Treatment of Locally Advanced Esophageal Carcinoma Guideline

An interview with Dr. Manish Shah from New York Hospital Weill Cornell Medical Center on “Treatment of Locally Advanced Esophageal Carcinoma: ASCO Guideline.” This guideline provides evidence-based recommendations on treatment options for patients with locally advanced esophageal adenocarcinoma and squamous cell carcinoma. Read the full guideline at www.asco.org/gastrointestinal-cancer-guidelines Transcript The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Hello, and welcome to the ASCO Guidelines Podcast Series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at podcast.asco.org.   My name is Brittany Harvey. And today, I'm interviewing Dr. Manish Shah from New York Hospital Weill Cornell Medical Center, lead author on "Treatment of Locally Advanced Esophageal Carcinoma," ASCO guideline. Thank you for being here, Dr. Shah.   I'm so pleased to be here on this podcast for ASCO with you, Brittany. I'm very pleased to talk about this guideline and its significance to the oncologic community and to our patients.   First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. But Dr. Shah, do you have any relevant disclosures that are directly related to this guideline topic?   No, I have no conflicts as it relates to this topic. I do have research funding from Merck, Boston Biomedical, Oncolys, BMS, and Acelis, and no other conflicts and nothing specific to locally advanced esophageal cancer.   Thank you. Then let's dive into this guideline. First, can you give us an overview of what this guideline covers?   Sure. This guideline covers the management of locally advanced esophageal cancer, both adenocarcinoma and squamous cell cancer, because management of these diseases is very complicated, primarily as the epidemiology of this disease has shifted over the past several decades. About 20 to 30 years ago, squamous cell cancers of the esophagus was the predominant disease subtype. About 90% of patients that we would see with esophageal cancer were of squamous cell histology.   However, with the rise in Barrett's esophagus and adenocarcinoma of the distal esophagus and GE junction, now, about 50% of esophageal cancers are adenocarcinoma histology. This distinction is important because, while the two diseases have significant overlap and treatment options, there are differences in sensitivity to various therapies. The guideline attempts to tease out these distinctions to provide the best evidence-based practice recommendations for the community.   Great. So you mentioned that this covers both adenocarcinoma and squamous cell carcinoma. So what are the key recommendations of this guideline for patients with locally advanced esophageal adenocarcinoma?   Sure. So for both squamous cell cancer and adenocarcinoma of the esophagus, locally advanced disease, the first and key recommendation is that multimodality therapy is considered and offered to both disease histologies. It's very important that these patients are treated through a multidisciplinary approach that involves a surgeon, typically a thoracic surgeon, but sometimes a general surgical oncologist as well, as well as a radiation oncologist and a medical oncologist.   For adenocarcinoma of the esophagus, which is really becoming the most common type, the primary recommendation is that patients with locally advanced esophageal adenocarcinoma receive either preoperative chemotherapy with radiation or perioperative chemotherapy. Because there is no comparative study for these two options, we also provide a clinical vignette to help readers understand some of the key features that may sway one to one treatment versus another.   For example, large bulky tumors where an R1 resection is more likely may be better suited for chemoradiotherapy, followed by surgery. An R1 resection, of course, is where the microscopic margin might still be positive. Additionally, patients who may not have a three-hole or a thoracic surgery as part of their surgical plan may not have an adequate lymph node dissection. That might be another reason to consider chemoradiotherapy, followed by surgery.   And what is recommended for patients diagnosed with locally advanced esophageal squamous cell carcinoma?   Yes. For squamous cell cancer, we recognize that these tumors are much more sensitive to radiotherapy. So the options that are recommended here, based on the evidence available, is that patients who receive preoperative chemotherapy and radiation or definitive chemotherapy and radiation, meaning chemotherapy and radiation with or without surgery. These are the recommendations for squamous cell cancer.   So why is this guideline important, and how will it change practice?   So we hope that our guideline will provide some clarity on a very murky field. The study suggests that there are several options available for patients with locally advanced esophageal squamous cell cancer and adenocarcinoma. And the guideline helps us frame the question and frame how we think about these options in offering patients the best practice that we can with regard to the available data. Additionally, the guideline may help define future research questions as well, as the gaps in knowledge are clear based on the guideline.   For example, there are patients, a significant number of patients, who have a complete response to chemotherapy and radiation. Should all of these patients have immediate surgery, or can surgery safely be delayed? That's an ongoing question that is being examined in rectal cancers. And also, there is some data in esophageal cancer as well. And that might be an important question to ask, moving forward, for example.   Great. And then finally, how will these guideline recommendations affect patients?   We hope that through the guideline process and understanding the nuances of how to treat patients with locally advanced esophageal cancer, that based on histology, based on the size and bulk of the tumor, based on the likelihood of an R1 resection, or based on even the surgical approach, that patients will receive more uniform therapy and therapy that is more tailored to their particular condition and situation. In the end, we hope that patients will receive the right care and ultimately have better outcomes because their care is more uniform.   It sounds like these guidelines could have a real impact for patients. So thank you for your work on these treatment of locally advanced esophageal carcinoma guidelines and for taking the time today to speak with me, Dr. Shah.   Thank you. It's a pleasure to be here.   And thank you to all of our listeners for tuning into the ASCO Guidelines Podcast Series. To read the full guideline, go to www.asco.org/gastrointestinal-cancer-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO guidelines app, available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast. And be sure to subscribe so you never miss an episode.