Episode Transcript
Interviewer: Cancer of the esophagus, what you need to know after diagnosis. That's next on The Scope.
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Interviewer: Dr. John Weis is an oncologist at Huntsman Cancer Institute. Dr. Weis, for a patient that was told they might have cancer of the esophagus, I'm sure it's pretty scary and they've got a lot of questions. So I wanted to dive into some of the questions that your patients might have, and I think the place to start first is how do they generally end up in your office?
Dr. Weis: They end up in my office in two fashions. The most common fashion is somebody that has symptoms. They have difficulty of swallowing solids or liquids. It may be they throw up blood, those kind of things. But mostly it's difficulty with swallowing and weight loss. The other way is people that are diagnosed by screening where they have known Barrett's esophagus or get endoscopies screening test.
Interviewer: And that is generally done by another physician. So they've found something and then they would refer them to you?
Dr. Weis: Right. The gastroenterologist would likely see them. If they're diagnosed with early stage esophageal cancer, limited to the lining of the esophagus, they would normally treat that themselves. If it's more advanced stage, they would refer them to myself, a surgeon, and a radiation therapist.
Interviewer: So by the time somebody comes to you, has it been pretty much just determined that they do have some form of cancer, or is that still up in the air?
Dr. Weis: When they come to me, generally, they have been told they have cancer.
Interviewer: Okay. And at that point, what is the discussion that you have with that patient?
Dr. Weis: There are certain principles of oncology that are important. In order to prognosticate, you start with a diagnosis. And then you stage. Staging may involve an endoscopic ultrasound or an ultrasound test, or CAT scans, or even a PET scan to find out how extensive it is. Generally, we try and divide the disease into several categories: superficial, local, regional, and distant.
Interviewer: And when it comes to esophageal cancer then, is it something that they did? Is that a question that you commonly get?
Dr. Weis: Well, that's an interesting question. It leads into a relatively long discussion. But I think I would like to talk about that.
Interviewer: Okay.
Dr. Weis: There are clearly things and I'm a bad example that being overweight, the highest quartile of weights in this country have about eight-fold risk of esophageal cancer. Smoking and alcohol are strongly associated with a type of cancer called squamous cell. Reflex esophagitis, Barrett's esophagus, hiatal hernias are more associated with adenocarcinomas. The squamous cell carcinomas, the smoking-alcohol-associated tumors, have been falling in incidence in this country. They're still very, very common in the east northern France, Eastern Europe, Asia. But in this country, adenocarcinomas are rapidly dominating the picture.
Interviewer: And when it comes to cancer of the esophagus, how serious is this type of cancer? Because some cancers . . .
Dr. Weis: Esophageal cancer is a lethal cancer. It's a very dangerous cancer.
Interviewer: Quick moving?
Dr. Weis: It's aggressive, but it's also . . . tends to be very difficult to treat in a curative fashion. There are about 16,000 cases of esophageal cancer in the United States each year and about 13 and half thousand deaths each year, which tells you that the incidence and the death rate are not that different.
Interviewer: So that must be very stressful for an individual that comes in your office when they've got that diagnosis because it is so aggressive and it can be so deadly?
Dr. Weis: Right. And the first question is, usually, can it be cured? That really is it the salient question. And that depends on the stage. If it's spread beyond local regional disease, disease confined to the area of the esophagus, then it's probably not curable. So the next question people usually ask me, what are the goals? And I think the important separation is whether your goal is cure and whether your goal is palliation either by keeping somebody alive longer or reducing their symptoms. The amount of toxicity you're willing to accept as a patient or doctor depends on what your goal is.
Interviewer: And what are the treatment options for cancer of the esophagus?
Dr. Weis: For the early stage, a mucosally-confined tumor, they can be simple things like a brachytherapy, mucosal resection, local radiation. All of those things have a potential to cure very early stages.
Interviewer: What are some common things that you see patients go through when they've been diagnosed with this type of cancer and you're having the conversation with them? Are there kind of any kind of common trends?
Dr. Weis: Well, they come to me for treatment. And so I can quote statistics to patients. The problems is statistics don't apply to a given individual. The given individual won't be 70% cured or 30% cured, he will be 100% cured or 100% not cured. And so the fundamental question is, "Do you want to treat aggressively to try and cure something, or do you not want to cure it?" And then, the question they will often ask me, "What is my lifespan if I don't do anything?"; And the problem is their lifespan if they don't do anything is likely to be short, in three to six months. And so it seems to me there's no downside to rolling a dice to try for a much longer lifespan.
Interviewer: Got you. Somebody's at the beginning of this journey. What would you like to make sure that they keep in mind or know at this point?
Dr. Weis: They should always know that they're in control and that the oncologist is not their mother and not God, so I don't get to tell them what they have to do. They should know clearly what the goal of therapy is, whether the goal is cure or palliation. They should know that the ultimate decision about how much toxicity they're willing to tolerate is theirs. My recommendations are my recommendations. When you treat a patient as a cancer specialist, you don't know what the outcome will be. You can make recommendations, but in the final analysis and if God wants you, He's going to get you whether I give you chemotherapy or radiation, or surgery. If it's not your time, you get to stay here. I think you use the tools that have been provided and try to make yourself live longer and healthier.
But as a general rule, you retain control of your life. I'm always a little uncomfortable when somebody says to me, "I'll do whatever you tell me to do." I would like them to know what they're doing. I do think the concept of informed consent for anything is sort of a misnomer though. I'm not sure anybody could know what they're getting into when they started this journey with chemotherapy, radiation, and surgery. I think the decision you make as a patient is do you trust the providers providing your care? You sign the document because it's medical-legally required. But the fundamental decision is not that you know all the side effects of chemotherapy. And so you trust that people are trying to help you.
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