When facing a frightening new cancer diagnosis, some people ask their doctors, “What would you do if you were me?” Here, our Curious Dr. George asks gastrointestinal cancer expert Sarbajit Mukherjee, MD, MS, how he would handle his own case of advanced esophageal cancer. Dr. Mukherjee is Assistant Professor in the Department of Medicine—GI Medical Oncology and Co-Leader of the GI Translational Research Group at Roswell Park Comprehensive Cancer Center in Buffalo, NY.
Curious Dr. George: Imagine a hypothetical scenario in which, as a relatively young clinical oncologist, a lifelong non-user of tobacco, and not an alcohol abuser, you did not imagine that you might be afflicted by a gastrointestinal malignancy. You have experienced some epigastric discomfort and have taken antacids from time to time. But recently, sometimes your solid food does not go down as easily as usual, and you have lost five pounds. Your primary care physician suggests esophageal endoscopy, which finds an obstructing distal esophageal mass. Biopsy reveals a poorly differentiated adenocarcinoma, and chest CT shows a widened distal esophagus, three suspicious mediastinal lymph nodes, and a single 2 cm pulmonary mass. When you learn of this unfortunate situation, how do you proceed?
Sarbajit Mukherjee, MD, MS: Esophageal cancer is the eighth most common cancer globally. As of 2022, the lifetime risk of developing esophageal cancer was 1 in 125 men and 1 in 417 women for the U.S. population. Recent studies have shown that young-onset esophageal adenocarcinoma (age at diagnosis under 50 years) is rising. Unfortunately, young-onset cases often present at an advanced stage, resulting in poor survival.
Over the last few years, we have had several new approvals in esophageal cancer, but the prognosis for metastatic cancer remains poor. Each patient’s treatment is individualized, and specific information about the tumor’s molecular characteristics helps guide a treatment decision.
Initially, I would complete the staging work-up with a CT scan of the abdomen and pelvis with contrast. I would check for biomarkers, particularly HER2, PD-L1 CPS score, and MSI-H status. I would also consider doing next-generation sequencing testing of the tumor tissue. To confirm the metastatic disease, I recommend a CT-guided biopsy of the pulmonary nodule.
I would ensure that an expert medical oncologist sees me at a tertiary care center. I would also ask my oncologist if any clinical trials are available for me in an upfront setting. If I were not enrolled in a clinical trial, I would receive a 5-fluorouracil-based chemotherapy with or without trastuzumab and an immune-checkpoint inhibitor (pembrolizumab or nivolumab), depending on the results of the biomarker status. Before starting any treatment, I would want to ensure my nutritional status is adequate and see a nutritionist.
There are several other factors to consider while caring for a young-onset esophageal cancer patient. Firstly, symptom management during cancer therapy is extremely important. Therefore, I would seek a referral to palliative care. I would also ensure a living will or an advanced directive is in place. Research has shown that early interdisciplinary supportive care improves survival in metastatic esophageal cancer. A new cancer diagnosis could be devastating for any family, and I would seek a psychology referral to help my family cope with the diagnosis.
Secondly, fertility preservation should be discussed with every cancer patient in the reproductive age group. If the patient wishes to, they should be referred to an oncofertility specialist to discuss some of the established means of fertility preservation before starting systemic treatment.
Finally, I would also seek a genetic counseling referral to determine if my cancer is potentially inheritable so my children can be screened accordingly.
In summary, young-onset esophageal cancer is on the rise and often presents at an advanced stage. Biomarker testing is important for making a personalized treatment plan. Patients should be offered participation in clinical trials whenever possible. Early supportive care, genetic counseling, and fertility preservation should be considered for this unique population.
Dr. Mukherjee can be reached at firstname.lastname@example.org.
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