Esophageal & Gastric Cancer Program

INCIDENCE AND PREVALENCE

The National Cancer Institute estimates that 17,290 individuals in the U.S. will be diagnosed with esophageal cancer in 2018, and an estimated 26,240 individuals will be diagnosed with gastric cancer. Both esophageal and gastric cancers are more common in men than in women.

PROGRAM OVERVIEW

From early detection and prevention to multidisciplinary, leading-edge treatment, Hoag Family Cancer Institute’s Esophageal & Gastric Cancer Program provides the full continuum of esophageal and gastric cancer care. Under the leadership of John Lipham, M.D., program director for Hoag Esophageal & Gastric Cancer Program, James & Pamela Muzzy Endowed Chair in GI Cancer, and professor of surgery at Keck School of Medicine of USC, the program combines the best of academic and community medicine through Hoag’s collaboration with the USC Norris Comprehensive Cancer Center. Specialists in surgery, medical oncology, radiation oncology, gastroenterology, interventional gastroenterology, pathology, and radiology work as a team to provide expert and coordinated treatment.

DIAGNOSTICS

Hoag’s interventional gastroenterologists are experts in advanced endoscopy techniques including endoscopic ultrasound for the most accurate staging. Dedicated GI pathologists at Hoag add unique pr oficiency in the right diagnosis, staging, and lymph node count. In addition, Hoag’s Radiology Department provides MRI, CT and PET CT imaging for staging and evaluation of both primary and recurrent disease.

TREATMENT

Tumor Board

Every esophageal and gastric cancer case is presented at the GI Cancer Program bi-weekly multidisciplinary tumor board, a practice that has improved patient outcomes (complication, mortality, and survival rates). It is attended by GI surgeons, GI medical oncologists, gastroenterologists and advanced interventional gastroenterologists, radiation oncologists, pathologists, radiologists, palliative care specialists, and the GI cancer nurse navigator.

GI Tumor Board is held on the 2^nd and 4^th Monday of every month at 12:30 p.m. at the Patty & George Hoag Cancer Center Newport Beach and via videoconferencing at Hoag Cancer Center Irvine. It is moderated by John Lipham, M.D., James & Pamela Muzzy Endowed Chair in GI Cancer.

To submit a case for the GI Tumor Board, contact the GI Cancer Nurse Navigator, Diane Eadie, R.N., at 949-764-8267 or [email protected] or Rosana Figueroa at 949-764-7044 or [email protected]

Surgery

Over 95% of the esophagectomies and gastric cancer surgeries at Hoag are performed using a minimally invasive approach, a statistic that sets our program apart from many community and academic programs. The Hoag-USC team conducted and published a research study comparing minimally invasive esophagectomies to open en bloc esophagectomies.¹ The results showed the minimally invasive approach improved complication rates, decreased length of stay, decreased blood loss, and reduced the need to transfuse patients while providing the same cancer outcome.

The program’s GI surgeons bring a depth of experience that is advantageous to patients. The average 30-Day Mortality Rate After Esophagectomy at academic hospitals is 3% and often higher at community hospitals. Hoag’s is 0%.

In 2017, Hoag purchased the Spy Fluorescence Imaging System, an intraoperative tool that gives GI surgeons real time assessment of the blood supply to the stomach during esophagectomy, helping reduce complications and often, the need for additional surgeries.

Two clinical fellows per year train at Hoag and USC through the GI Surgical Fellowship Program. The program not only benefits the fellows who engage in patient care, learning and engaging in research at Hoag and USC, it also benefits the patients whose specialized surgical team is extended through the fellows’ participation.

Medical Oncology

Skilled medical oncologists, including a subspecialized GI medical oncologist, add unique expertise, and achieve improved response rates with neoadjuvant chemotherapy. Patients who have a favorable response to neoadjuvant therapy have a 60-70% survival rate after surgical resection.

Patients with advanced gastric and esophageal cancers benefit from a precision medicine approach as part of Hoag’s program. A sample of the patient’s tumor is sent for comprehensive tumor genomic profiling at the start of treatment to help guide clinical decisions based on reported genomic mutations or alterations. Liquid biopsies are sometimes done during treatment for additional molecular genomic profiling to determine if there are new resistance mechanisms developing in the tumor. Considerations for additional options for treatment are available through Hoag’s clinical trials portfolio.

Radiation Oncology

Hoag Radiation Oncology offers image guided radiation therapy and 3D conformal radiation therapy (3DCRT) using state-of-the-art linear accelerators – TomoTherapy®, Elekta Versa HD™, and Elekta Agility™ – when radiation therapy is warranted for patients with esophageal and gastric cancers.

Under daily CT image guidance, TomoTherapy uses hundreds of pencil beams of radiation, rotating in a spiral around the tumor and hitting it with varying intensity from all directions, providing incredible precision. The radiation can be sculpted to fit the shape of the tumor, improving accuracy, precision, and efficiency.

Additionally, Hoag’s Elekta machines deliver Volumetric Arc Therapy (VMAT), an advanced technology that delivers radiation in single or multiple arcs around the patient under 3D image guidance. The Hexapod iGuide Couch (6D) of the Elekta Versa HD machine adjusts the patient during each treatment into the exact location with submillimeter accuracy.

Palliative Care

The team is proactive in integrating palliative care to improve quality of life during treatment as well as extend and enhance life for patients who are not candidates for curative treatment. In addition to advanced endoscopy for palliation of advanced cancers, the team works closely with Hoag’s Palliative Care team, CARES, to address pain and discomfort at all disease stages.

CLINICAL RESEARCH

Several early phase clinical trials testing novel agents that apply to esophageal and gastric cancer patients are available at Hoag, which expands treatment options for a number of patients, especially those with advanced disease. The following clinical trials have opened for patients with gastric or esophageal cancer. For a list of trials currently open, please contact Leila Andres, M.S., at 888-862-5318.

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(155-17) 0C 17-1: Phase I Multi-center Study of the Safety of Pharmacokinetics and Preliminary Efficacy of CBT- 101 in Subjects with Advanced Solid Tumors and C-Met Dysregulation (Phase 1 clinical trial, appropriate for patients with advanced solid malignancies.)

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(187-17) 0C-17-11: Phase 1 trial of ZW25 in patients with locally advanced (unresectable) and/or metastatic HER2- expressing cancers (Phase 1 clinical trial, appropriate for patients with HER2 expressing cancers.)

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157-17/0C-18-2: A Phase I Study of FID-007 in Patients with Advanced Solid Tumors

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(211-17) 0C-17-14: An Open-Label, Non-Randomized, Multicenter Study to Determine the Pharmacokinetics and Safety of Niraparib Following a Single Oral Dose in Patients with Advanced Solid Tumors and Either Normal Hepatic Function or Moderate Hepatic Impairment (Phase 1 Clinical trial appropriate for patients with advanced solid tumors)

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181-17/0C-14-2: An Open-Label, Phase 2 study of Neratinib in Patients with Solid Tumors with Somatic Human Epidermal Growth Factor Receptor (EGFR, HER2, HER3) Mutations or EGFR Gene Amplification

SCREENING AND HIGH RISK SERVICES

Early detection and prevention of esophageal cancer is a major focus of the program. Barrett’s Esophagus, caused by long term gastroesophageal reflux disease (GERD), is the precursor to esophageal cancer. The team is aggressive in screening for Barrett’s using Hoag’s sophisticated endoscopic and imaging equipment. Interventional gastroenterologists treat early cancers (carcinoma in situ) using endoscopic mucosal resection followed by an ablation to remove the Barrett’s precancerous tissue, sparing the patient an esophagectomy. Beginning in 2017, endoscopic submucosal dissection (ESD) is also available at Hoag for the treatment of very early esophageal and gastric cancers localized to the mucosa. The technique requires a high degree of expertise and is not widely available.

Hoag’s GI Lab is one of only a few with WATS 3D® technology, acquired in 2017. The two-part technology is comprised of a special brush that samples a wider area and targets only the layer of the esophagus where dangerous cells develop and a computer imaging system that forms a 3D image. It has been shown to increase detection of Barrett’s or early cancer by 40%.

In addition, Hoag’s GI surgeons are experts in surgical techniques that treat GERD including traditional nissen fundoplication, partial fundoplication, laparoscopic implantation of the LINX® Reflux Management, transoral incisionless fundoplication, and repair of large hiatal hernieas, which help prevent Barrett’s Esophagus and esophageal cancer.

Cryoablation was also added to the program in 2017 and serves as an additional tool to remove pre-cancer or early cancer without the need for surgery. Following radiofrequency ablation, 10-20% of patients will have some residual Barrett’s Esophagus, which can be eradicated with cryoablation.

SUPPORT AND EDUCATION

Diane Eadie, R.N., is the GI cancer nurse navigator. She helps patients connect the dots of their multidisciplinary treatment plans, answers questions, and helps in addressing other issues that arise during their care. Diane’s ability to offer emotional support and education is a key benefit to patients and their families. The GI Cancer Support Group meets monthly at the Hoag Cancer Center in Newport Beach.

In addition to Hoag Family Cancer Institute’s range of patient support services, classes, and workshops, esophageal and gastric cancer patients benefit from the integration of two oncology dietitians who assist with nutrition needs during and after care. Their role is especially crucial during neoadjuvant chemotherapy to ensure the patient’s weight and nutrition are optimal for surgery.

The team puts on several GERD education programs and seminars throughout the year in Orange County to provide awareness and education on esophageal cancer risk factors and prevention. Thanks to funds from the James & Pamela Muzzy Endowed Chair in GI Cancer, Hoag annually hosts a half-day GERD Symposium open to anyone in the community. Approximately 60 community members attended the 2017 event.

_{1 *Cash JC, Zehetner J, Hedayati B, Bildzukewicz NA, Katkhouda N, Mason RJ, Lipham JC. Outcomes following laparoscopic transhiatal esophagectomy for esophageal cancer. Surg Endosc. 2014 February}

For more information call: 949-722-6237