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An informative look at the Cancers you help diagnose › Prior to 1953, what product was advertised with the slogan, “Just what the doctor ordered?” Estimated Deaths in 2015: 158,040 men and women - 221,200 New Cases Diagnosed 2015 › 65 – 75% of diagnosed Lung Cancers are INCURABLE at time of diagnosis - HALF of those diagnosed will DIE within 1st year of diagnosis › Survival is based on Stage at time of diagnosis - Overall 5 year Survival Rate for ALL Stages of Lung Cancer is 15-18% 5 year survival rates Lung – 17.8% Colon – 65.4% Breast – 90.5% Prostate – 99.6% Average age at diagnosis – 70 y/o - 2 of 3 are > 65 y/o Only 2% diagnosed are under 45 y/o Age adjusted death rate greater in men – (56.1 vs. 36.4/100,000) Women on average 2 years younger than men at time of diagnosis 90% OF DIAGNOSES ATTRIBUTABLE TO SMOKING OTHER CAUSES: › Radon – accounts for 10%; estimated 21,000 deaths/year › Occupational Exposures - 9-15%, includes Asbestos, Uranium and Coke >the combination of asbestos and smoking greatly increases risk >non-smoking asbestos workers are 5x more likely to develop lung cancer › Outdoor Air Pollution – accounts for 1-2% Up until a few years ago, people with lung cancer were relegated to the coffin. We’re going to bring this under control. - David Grant (author) › Lung Screening - based on National Lung Screen Trial findings - Low Dose CT’s for 3 consecutive years decreased the lung cancer mortality be 20% (with 5 year follow up) - High Risk Population only › Other Diagnostic Tools (some still in research phase) - Blood Tests - Breath Tests - Sputum Cytology - Cell Sampling from Airway via Bronchoscopy › Targeted Therapies – interferes with way cancer cells function & reduces damage to normal cells › Immunotherapies – utilizes bodies own immune system to fight cancer - A devastating disease usually detected in an advanced incurable stage › 2015 Estimated New Cases – 16,980 MEN – 13,570 WOMEN – 3410 Accounts for 1% of all new Cancer cases › 2015 Estimated Deaths – 15,590 MEN – 12,600 WOMEN – 2990 Accounts for 2.6% of all Cancer deaths › 7th Most Common Cancer Death in Men › Overall 5 year survival (all stages) – 18% › Age: 45-75 years old at highest risk › Gender: Men>Women; men 3-4 times more likely to be diagnosed › Race: Blacks 2x greater than Whites to develop Squamous Cell type › Age 65 or greater › › › › Male Smoker Heavy Alcohol use Diet lacking fruits & vegetables › Obesity › Acid Reflux › Barrett’s Esophagus › Achalasia – on average Esophageal Cancer diagnosed 15-20 years after diagnosis of achalasia › Tylosis – rare dz, includes small papillomas in esophagus; high risk of squamous cell cancer › Plummer-Vinson Syndrome – webbing of esophagus; 1 in 10 will develop squamous cell carcinoma › Difficulty/Pain with Swallowing › Pressure/Burning in Chest › Indigestion/Heartburn › Emesis › › › › Choking on Food Unexplained Weight Loss Coughing, Hoarseness Pain behind Sternum or in Throat Esophageal wall has several layers Knowing these layers helps to understand how these cancers start and how they grow Upper esophageal sphincter – senses food and opens allowing food to pass Lower esophageal sphincter – allows food into stomach; stops acid reflux › In United States, NO regular screening tests in asymptomatic patients › Patients with known Barrett’s Esophagus may have regular endoscopic evaluations to monitor › Possible benefit of early diagnosis in these patients › 54 y/o male present to office with c/o chronic indigestion with meals over last 3 months. › Additional symptoms include change in appetite secondary to discomfort, occasional emesis, 15lb weight loss over last 5-6 months › PMH – Hypertension, recent treatment for Pneumonia › PSH – unremarkable › Social History – previous smoker, quit 1 year ago; drinks 2-3 beers daily, sometimes more on weekends; married & employed in HVAC services › Family History – positive for gastric cancer in father › Physical Exam - unremarkable › Barium Swallow – aka Upper GI Series -shows abnormal areas of normally smooth lining of inner esophageal surface - can also identify complication known as tracheo-esophageal fistula At this point suspicion for cancer is very high! › Stage of cancer determines appropriate treatment planning › Multi-disciplinary work-up - Medical Oncologist - Radiation Oncologist - Surgeon - Gastroenterologist › History & Physical – to help detect gross evidence of metastatic disease › CT chest/abdomen with contrast to better evaluate for disease spread › Bronchoscopy - if airway involvement suggested on CT studies - all surgical candidates should have airway assessed prior to treatment › Better assessment of primary tumor and depth of invasion into esophageal wall › Assess for lymph node involvement, distant metastasis and other structures outside of esophagus › Perform biopsies › Includes: - flexible bronchoscopy - upper endoscopy - diagnostic laparoscopy peritoneal lavage any indicated biopsies Jejunostomy tube › Stage “0” – high grade dysplasia, pre-cancer; close follow up › Stage I – grown into deeper layers of esophagus, no lymph node involvement T1 – surgery; chemo/radiation after if indicated T2 – invades into mucosa propria; chemo/radiation then surgery * if near stomach, chemo only then surgery * if upper portion of esophagus, chemo/rads, restage, if no signs residual disease, close follow up › Stage II – grown into main muscle layer of esophagus or into connective tissue outside; 1-2 nearby lymph nodes may be involved › Stage III – includes cancers that grown thru wall to outer layer of esophagus as well as grown into nearby organs or tissues; also includes spread to nearby lymph nodes *if patients are healthy, chemo/radiation then surgical resection *if Adenocarcinoma & near GE junction, chemo only then surgery › Stage IV – spread of disease to distant organs or lymph nodes; usually only chemotherapy, other treatments for palliation > Radiation therapy for pain or trouble swallowing > Dilation or Stent placement to help with strictures > Laser Ablation of tumor (only temporary) > Feeding Tubes › Recurrence – local vs distant? If local surgical resection; chemo +/- radiation › Aimed at specific molecular targets found in tumor that affect cell growth, angiogenesis, inflammation, resistance to radiation and chemotherapies › Have specifically found makers in esophageal squamous carcinoma and adenocarcinoma near GE junction > EGFR, HER2/Neu ( growth factor receptors) > VEGF (angiogenesis) > COX-2 (inflammation) › HER2 +: Stage I > use Herceptin (Ca near GE jxn, Stage II > use Transtuzunab no Rads) - Remove part or all of esophagus - Create Neoesophagus utilizing stomach - Lymph Node dissection - Feeding Tube postoperatively - May be performed using Robotic Technique As with most malignancies, complete accurate staging, multidisciplinary evaluation and the use of standard guidelines for stage specific treatment is critical in giving esophageal and lung cancer patients the best outcomes.