As you gather information to better understand your gastric or esophageal adenocarcinoma diagnosis, expert advice is invaluable. Your cancer is unique to you, but many of the questions about it are universal. How treatable is it? What can you expect in the future? Here to share his experience and insight into these cancers and their treatment is Jaffer Ajani, MD, a gastrointestinal medical oncologist at University of Texas MD Anderson Cancer Center.
What are the earliest signs of gastric and esophageal adenocarcinomas?
An important thing to realize about gastric and esophageal cancers is there’s no early detection strategy. There’s a premalignant condition called Barrett's esophagus that raises your risk. People who have that, or reflux disease, end up having an endoscopy because they’re having such severe symptoms. Often, that’s how we catch cancer. But there’s no formal national strategy to detect it early. We’re hoping things will change when we have a blood test for early detection of a variety of cancers.
So right now, gastric and esophageal cancers are diagnosed when patients already have pretty advanced symptoms. When they finally make it to a gastroenterologist and we do further testing, we typically find it’s already in stage IV.
What are the symptoms of these cancers?
The most common symptom is difficulty eating. If the cancer is at your gastroesophogeal junction (GEJ) or higher, you have a hard time swallowing because of the tumor narrowing the passage. And in your stomach, you may get what’s called early satiety. In other words, your brain wants you to eat but your stomach has no room. So you feel full, but you're still hungry. These symptoms cause weight loss. Sometimes, you also have bleeding. But after we identify all of these symptoms, diagnose you, and start treatment, there's more than 50% chance your initial major symptoms will reduce considerably.
Is there a first-line treatment for gastric and esophageal adenocarcinomas?
Yes, and there are two components to it. One is chemotherapy. For advanced disease, we use a platinum drug called oxaliplatin (Eloxatin). And there's another group of drugs called fluoropyrimidines. These are pills like Xeloda or 5-FU, which is the IV version that has to be given through a pump. Those make up the chemo component. Then there’s a biologic component based on your biomarkers, which are specific proteins or molecules on your cancer cells.
When we do an endoscopy as part of your diagnosis, we also take some tissue of the tumor, and from that diagnostic tissue we ask the pathology department to test for four primary biomarkers. This is important for deciding treatment because we have drugs that interrupt those proteins. So we must know which of the four biomarkers you have. These are the ways we determine the best treatment plan. We look at your biomarkers, the advancement of your cancer, and where you are in your treatment, and make a plan from there.
When should I expect to feel a difference in my symptoms?
Everyone’s cancer develops from genes they get from their mom and dad, so every case is different. There are some commonalities, but there’s a lot of diversity. Treatment can work within 10 days for some people. I have patients who take treatment and the next week, when we talk to them before their second dose, they're already feeling a lot better. And then for others it can take three or four weeks. But if we don't see improvement in four weeks—that means you’ve already received two doses at least—then it becomes a problem because the chemo itself confers so many bad side effects and you're already feeling bad from the cancer. So that can be very difficult.
What are the challenges with gastric and esophageal adenocarcinomas treatment?
Some treatments are very difficult. For example, one of the relatively new drugs, zolbetuximab (Vyloy), which is targeting the biomarker claudin 18.2, has a very long infusion time of five to six hours and can cause significant nausea and vomiting. So there are some treatment combinations that are tougher and others that are easier. But we have a few principles for managing side effects. First, the treating team has to know what your side effects are. We counsel people to tell us as soon as they start having side effects like significant nausea, vomiting, diarrhea, or fever so we can intervene as quickly as possible. The next thing is to follow up and modify your treatment if needed. Following these steps can help reduce your side effects considerably.
How do you determine if treatment is working?
We use a lot of tools to figure that out. First is the objective method, like a scan. We get a baseline scan at the beginning of treatment, and then two months later we do another scan, and compare them side by side. Second, your symptoms — are they getting better? Third, there are tumor markers. These are proteins made by your tumor, like CEA or CA 19-9 and many others. We take all this information and put it together. Often, it's not difficult to figure out whether the current treatment is working.
How can I understand my prognosis?
When my patients ask for a number or percentage, I tell them, "This is the number from our database, this is not your number.” You start this journey with cancer, and if things go in the right direction, you may be the one who lives five or even 10 years. Or we’ll be asking you not to come back because your scans are negative. It’s important to remember everyone’s cancer is different, and responsiveness to treatment is also different. When we talk about prognosis, we talk about these cancers in general. We use previous cases as a framework, but your prognosis is unique to you and your cancer. Your oncologist can help you better understand what your most realistic outcome may be.
