Although T2,N0,M0 esophageal adenocarcinoma is grouped with other locoregional disease by NCCN, no consensus exists about how it should be treated. One of the inherent complexities of treating T2,N0,M0 esophageal adenocarcinoma is the inaccuracy of the clinical staging. In addition, conflicting evidence exists about whether neoadjuvant therapy adds any benefit to esophagectomy. A 52-year-old patient recently seen at the Robert H. Lurie Comprehensive Cancer Center illustrates the complexity of these issues.
Ariel Polish and Mary F. Mulcahy
Mary F. Mulcahy and Al B. Benson III
The past 5 years have seen significant developments in the treatment of colorectal cancer (CRC). New chemotherapy agents with activity in CRC have demonstrated an improvement in survival for patients with advanced CRC. Studies now are focusing on combinations and sequences of chemotherapy agents to prolong survival in second- and even third-line therapies. Oral agents have been developed and are being studied in combination chemotherapy regimens. Development of oral combinations should maintain a survival advantage with the added benefit of convenience for the patient. Drugs designed to act on specific cellular protein targets have also shown activity and are being explored further. Researchers continue to pursue immunotherapy and vaccine therapy. Studies are now focusing on how best to use the available agents. These new agents and new combinations of agents and of approaches have led and should continue to lead to improved outcomes in the treatment of patients with CRC.
Mary F. Mulcahy, Andrew O. Wahl, and William Small Jr.
Pancreas cancer is the fourth most common cause of cancer deaths. Even for the small percentage of patients who can undergo surgical resection of the primary tumor, the risk of recurrence remains unacceptably high. For patients with localized disease that is not amenable to surgical resection, pain related to the primary tumor can significantly impair quality of life. Attempts to improve the duration and quality of life for these patients have included both chemotherapy and radiotherapy. The addition of chemotherapy to radiation may enhance the local effects of radiation or provide treatment of disease outside the radiation field. The results of clinical trials evaluating the appropriate therapy for locally advanced or resected disease have been inconsistent. In some instances, the methods used in these studies became outdated before the results were available. Hopefully, advances in radiation techniques and systemic drug therapy will provide more durable and clinically relevant results. Meanwhile, treatment decisions should be tailored to the clinical situation, including consideration of treatment toxicity and therapy goals. Recognizing which patients are likely to benefit from combination therapy or systemic therapy alone is a subject of future and ongoing clinical trials.
Presenters: Crystal S. Denlinger, Kristina A. Matkowskyj, and Mary F. Mulcahy
For the treatment of gastric and esophageal cancers, several pivotal trials—especially those evaluating immune checkpoint inhibitors (ICIs)—have altered the treatment landscape and led to changes in the NCCN Guidelines. In addition to pembrolizumab and nivolumab, new treatment options include trastuzumab-deruxtecan (T-DXd), ramucirumab, and trifluridine/tipiracil. These agents convey varying degrees of benefit depending on treatment line, PD-L1 expression, HER2 expression, and tumor histology. Recently, ICIs have been incorporated into the first-line treatment of HER2-negative advanced esophageal, gastroesophageal junction (GEJ), and gastric cancers, in addition to second-line treatment of advanced esophageal and GEJ cancer of squamous histology. T-DXd is another new second-line option for HER2-positive esophageal, GEJ, and gastric adenocarcinomas. ICIs are now moving into the adjuvant setting as well, and a new recommendation is nivolumab use after preoperative chemoradiation and surgery in patients who have residual disease identified at the time of their R0 resections.
Sheetal M. Kircher, Mary Mulcahy, Aparna Kalyan, Christine B. Weldon, Julia R. Trosman, and Al B. Benson III
The first confirmed case of coronavirus disease 2019 (COVID-19) in the United States was reported on January 20, 2020. As of September 17, 2020, there were more than 6.6 million confirmed cases and 196,277 deaths. Limited data are available on outcomes of immunocompromised patients, but early published reports from China indicate that those with cancer have a 3.5 times higher risk of ICU admission, mechanical ventilation, or death than those without cancer. Because of the uncertain behavior of COVID-19, it has become imperative for practices to limit exposure to vulnerable patients. Telemedicine has been one of the cornerstones of caring for patients with cancer during the COVID-19 pandemic. This review provides an overview of reimbursement policy by public and private payers before and during the COVID-19 pandemic, describes implications in cancer care, and offers considerations for future reimbursement policy.
Robert E. Glasgow, David H. Ilson, James A. Hayman, Hans Gerdes, Mary F. Mulcahy, and Jaffer A. Ajani
The clinical spectrum of esophageal cancer has changed dramatically over the past couple of decades. Most notably, a profound rise in esophageal adenocarcinoma and decrease in the incidence of squamous carcinomas have occurred. An understanding of the factors that influence survival for patients with localized esophageal cancer has evolved concomitantly with these changes in epidemiology. Significant advancement in endoscopic and radiographic staging allows for more selective use of treatment modalities. The treatment of localized esophageal cancer mandates a multidisciplinary approach, with treatment tailored to disease extent, location, histology, and an accurate assessment of pretreatment staging. Despite these improvements in the staging and use of multimodality therapy, only modest improvements in patient survival have been observed. This article summarizes these modern approaches to localized cancer of the esophagus.