Healthcasts Events

The Changing Landscape of Cancer Care

David Draper, MD
Director, Gastrointestinal Oncology
TriHealth Cancer Institute
Cincinnati, OH

I think one of the biggest changes that we’ve seen in cancer care over the past decade is that most cancers require what we call a multidisciplinary or a team approach to care. The days of being able to just go to surgery and think that is sufficient for curative therapy are gone for a majority of locally advanced cancers— stage two and stage three cancers. We know a number of cancer types, including gastric cancer, that require a team approach in which individuals may require chemotherapy, they may require radiation, and they may require surgery, and how we sequence those different therapies depends on the cancer type, it depends on the patient, the patient’s health, what we call the patient’s performance status, how many medical comorbidities that patient has, and it depends on what symptoms the patient is having from that particular cancer.

The data on cancer care and outcomes is changing. It’s been a slow change over the past decade, but most cancer types are seeing an uptick in improvement in overall survival. And that does include gastric cancer as well. It’s important to remember that stomach cancer is a rare cancer in the United States, and the incidence of gastric cancer has been going down over the past decade. The flip of that is the incidence of esophageal cancer, especially at the area where the esophagus meets the stomach, is going up. So the two are kind of inverse to each other. With that said, we know from our colleagues over in Asia, gastric cancer is very common and we’re getting emerging data to show that not only can we change outcomes in locally advanced disease, but also in stage four or metastatic or spread cancers.

For instance, in individuals who have locally advanced disease, we have new combination chemotherapy regimens that are showing an improvement in overall survival so we can give those treatments, in what we call kind of a sandwich therapy, both before and after the patient’s surgery. And what’s interesting is when we give this chemotherapy before surgery, about 10% of patients will have a complete pathologic response, meaning they go to surgery and after two or three months of chemotherapy ahead of time, we’re not seeing any signs of cancer. We look in the lymph nodes, we look in the resected tissue, and the cancer is completely gone. And those individuals obviously have a very, very good five-year survival rate. So new combinations of standard chemotherapies are being developed, which are really showing exceptional responses.

Regarding new drugs that are on the horizon, we know that gastric cancers may have certain mutations associated with them and we can use certain mutation directed therapy. So for instance, about 20% of gastric cancers will be associated with a specific mutation called HER2. People may have heard of this in breast cancer, it’s much more common in that disease, but a number of gastric cancers can be what we call HER2 positive and we have intravenous drugs that can target those specific mutations and subsequently improve response rates. As of right now, those drugs are used in the stage four setting, the metastatic setting, however we have clinical trials that are running currently that are trying to use these drugs up front to see if we can’t elucidate better responses.

Immunotherapy is now being used as well. We know that there are certain genetic mutations within the tumor cells. Things like micro satellite instability for instance, which is a small percentage, only about 5% of gastric cancers, but individuals who harbor those mutations respond extraordinarily well to immunotherapy. In fact, certain immunotherapies such as pembrolizumab have been FDA approved for individuals who harbor very specific mutations within their tumor cells. We can also look for tissue markers such as programmed cell death ligand-1 and when we find that individuals harbor a high percentage of these tissue markers, we know that they are very likely to respond to these novel treatments.

What’s really exciting about drugs such as anti-HER2 agents and immunotherapy, is we are seeing some individuals who have very, very long response rates, and actually in immunotherapy, a very small but statistically significant percentage of people will go into what I’m going to tell your audience is sort of a long term remission. I think you have to be very cautious of using the word cure, but even in the metastatic, even in the stage four spread setting, we are seeing a small but real group of individuals who are alive five years out and their disease is under control.

The Multi-Disciplinary Approach to Care

Cancer of course does not occur in a bubble, and as I often tell my patients, “Just because you have cancer does not mean that you are not at risk of other medical problems or that your comorbidities may not act up during treatment for your cancer care.” Going back to gastric cancer for instance, we know that the etiology, the underlying causes of gastric cancer are various. There are a myriad of different causes. However, one of the causes is lifestyle. Things like obesity, high salt intake, kind of a poor diet, the sort of standard American diet, nitroso compounds which are found in processed meats, lack of vegetables, smoking, alcohol, and of course individuals who have this lifestyle often also have other comorbidities. They may be diabetic, they may have cardiovascular disease, so not only do they have these underlying disorders, but the therapies that we use sometimes can exacerbate those underlying medical problems.

And it’s crucial to monitor those comorbidities. Here at the TriHealth Cancer Institute, when we work in a multidisciplinary clinic, we always have to have the patient’s primary care physician involved because if we start to see signs that one of those comorbidities is exacerbating, we need to get the primary care doctor involved rapidly in order to quell any subsequent problems that can occur. There’s nothing more devastating than starting a patient on a treatment and then they have, say a heart attack during therapy, and that certainly changes how that patient is going to be able to subsequently get further therapy and certainly changes whether or not that patient can go to surgery. We always try to mitigate other comorbidities as best as we can and it’s so important that patients know that keeping in touch with their primary care doctor through their cancer care is integral.

The TriHealth Approach to Patient Care

We have developed this multidisciplinary center and we’re the first in Cincinnati to do so. And actually in gastrointestinal oncology, we are the only multidisciplinary cancer clinic, not only in GI cancers, but also in skin cancers such as melanoma, breast, and lung cancer. The diagnosis of any cancer can be devastating and one of the most difficult things that our patients have to go through is to hear, “You have this diagnosis, we need you to see person A, person B, person C, we need you to get this scan, we need you to do this test, and we need you to have this procedure done,” and it’s going to take two to three weeks in order to get all of that accomplished. In the interim, the patient is sitting there wondering, “What’s my prognosis? What is my treatment going to be like? I’m doing all of this testing and yet I don’t have answers.”

When you have a multidisciplinary setting, in our clinic, when you come in, you come to one room and you see everybody that is going to be involved in your care. As an example, if you had a rectal cancer that has a metastasis to the liver, those individuals need the care of a medical oncologist, a radiation oncologist, a colorectal surgeon, and a surgical oncologist. That’s four different consults that can take two to three weeks to set up, even in a major academic institution. But when you can come to TriHealth and see all four of those physicians at the same time, now admittedly that’s a very long day for our patients, however it really takes some of the stress off of them. And we have already prospectively obtained all the imaging or testing that is required, all of the procedures that are required, and we pre-presented their case in a meeting called a multidisciplinary tumor board.

We sit there with about a hundred individuals in different specialties and subspecialties, we look at the patient’s pathology, we look at all of the appropriate imaging, so when that patient is coming into a multidisciplinary clinic, not only are they seeing everybody that needs to be involved in their cancer care, but they’ve heard the same story from each of those individuals. They’re not hearing, “Well, I think this is probably what we should do, but let me talk to the surgeon first.” I’ve already talked to the surgeon. We already have a plan in place and you’re hearing a dedicated plan.

Furthermore, in our multidisciplinary clinic, we have genetics, we have nutrition, we have wound care, we have great counseling and psychological services, and we have the ability to take care of every aspect of that patient. Patients come in and they know this is going to cost a lot. We have a social worker right in our office that can come in and start to work through some of those economics and it’s really beneficial for our patients and that allows us to get started on therapy sooner. There is a window of opportunity in which you can get started on treatment to obtain the best outcomes and this multi-disciplinary approach that we have incorporated at TriHealth really makes a difference.


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