The Johns Hopkins stomach (gastric) cancer multidisciplinary team participates in an in-depth podcast about innovative research, a collaborative approach to stomach cancer treatment and the program’s benefits to patients.
Welcome to our panel discussion on a multi disciplinary approach to the treatment of stomach cancer from Johns Hopkins Medicine. I'm Elizabeth Tracy. I'm Catherine Bever. I'm a medical oncologist, Fabian Johnson. I'm a surgical oncologist on so winning, I'm lumping I'm a gastroenterologist. Thank you so much for joining me today. I think we'd like to start with the idea of a multi disciplinary approach to the treatment of stomach cancer. How long has this program been around? Well, this program is actually very new program, but we realized we needed something different. Gastric cancer is actually, um, not a very prevalent cancer is only about 30,000 cases per year. And with that, about 11,000 patients succumb to this disease. With that, we find it's kind of an orphan cancer in a lot of places. And so we wanted to do was bring together those experts across the enterprise that focus on this disease and provide a comprehensive way of managing thes patients. So they're really getting that holistic care. Since you've reviewed the statistics, isn't it true that gastric cancer or stomach cancer is also associated with a pretty poor prognosis? That's exactly right. It is often a poor prognosis, mainly because, as you can imagine, your stomach is kind of like a balloon a bag, and so patients don't often present until later on another disease. With that, unfortunately, many patients don't end up. Coming to me is a surgeon. They're usually being seen either by my colleagues and gastroenterology or medical oncology. But because of that, we wanna make sure for those patients that could have the best opportunities for cure and for a longer survival that we're all together in a room talking about these patients, providing the best care for themselves and their families. Can we talk just a little bit more about diagnosis and detection? Yes. First, the gastroenterologist who performed procedures need to be family with how the gastric cancer of stomach cancer look like at early stage because, as Dr Johnston mentioned, that this lesion generally present at advanced age, so a number off practitioner gastroenterologists are not familiar with how to detect early cancer, so in center of Excellence or in high volume center that family with the examination off gastric cancer, that would be the very important part off early detection. Also, the endoscope endoscopic examination need to be very detailed and systematic to prevent earlier or miss elation. Why would someone come, though initially, why would someone come to even ask if they might have stomach cancer? Actually, most early gastric cancer or early stomach cancer detected, incidentally, in the United States, because we don't have surveillance or screening guideline. But as I mentioned earlier that advanced cancer is more common, uh, diagnosis in the United States. So what we receive we follow most of the time is the lesion that not sure what it is. And we got referral toe. Did you mean what is the best approach in in terms off diagnosis and treatment? You said that it was important to take a very systematic approach to evaluating these lesions. Could you tell me a little more about that? Yes. So first, uh, examination, you need to spend enough time to examine every centimeter off the stomach. Uh, and then you special technique uses a special light or die to highlight the lesion and the endoscope that you use. It will be better if you use the endoscope with magnify function, toe highlight. Or, uh, you can see the margin off the leash in better, which is not widely available outside. I mean, to me, this highlights one of the benefits of this program. There's someone that's actually taking the time to focus on these lesions in the stomach, right? And also, when we think about it, some of these people are very incidental. Alright? Or they're asking their they're coming with reflux are very vague symptoms. And so certainly we're not looking for everybody that has a big belly pain to be seen by guessing urologist. But if they are and it's questionable, you have a group of pope folks or physician that's focused on that aspect. I'd like to follow up just a little bit on this idea of incidental findings, and certainly I'm familiar and I get. Lots of people are with the idea that you might be having CT for another reason, and oops, we find something that needs to be followed up. How does that happen with stomach cancers so that if you can see on the cat, scan most of these cancer advanced age. So the early early stage cancer you generally detect under endoscopic examination and if you, if you do see it, usually end up seeing either myself or my colleague first. And medical oncology is usually large enough at that point or less subtle right on the C T scan. To suggest we need to see a gastroenterologist, get a diagnosis and then see one of us, um, to help treat that patient. So let's talk about the surgical approach, then. Hmm. So surgical approach standard Lee the U. S. Most of time. It is an open operation, but what we like to do first, for many patients who present in the U. S. Is something called a diagnostic laparoscopy. What that is is a simple surgery takes less than one hour. But we want to do that to see if there's any cancer that has spread outside of the stomach. The reason being is about 3 to 4 out of 10 patients in Western countries. Us being one of them will actually have that. The disease has already progressed farther than we had liked. And so with that, we're able to then focus on which road do we go down because there are options in those situations and their surgeries and what we call multi modality management, meaning myself and another colleague manage those patients. Um, if it's spread on that Stage four disease or if it's not, then we know. Okay, we're going to enter this other paradigms. Other treatment algorithm after that. Usually, chemotherapy is the mainstay of therapy in the U. S. Followed by surgery. Surgery is either open, meaning you have a incision from kind of the bone. You first bone you feel in your belly, is called his iPhone to about your belly button. Or we do it laparoscopically or robotically, which means we do it with the cameras, and they're small incisions for those patients. Is it possible toe locally resect in the stomach? Or do we normally have much bigger kinds of operations? So, usually, if it's a gastric, cancer is usually going to be a major operation and respecting that major component of the stomach, mainly because of the risk of what we call nodal spread, meaning that it's going into the wall of stomach and it's spreading into the lymph nodes in that area. So for our best prognosis and help those patients, yes, then respecting that major part of stomach is important in early stages, and this is why we're together. Some patients can have a local resection, and that would be someone provided by Dr Nam, which may be curative in those situations. So they're really selected a group of patients that, after careful examination with endoscopy and a scoping out of sound and cast can. We did not detect metastases or spread then that some of those patients might be illegible for endoscopic resection, and it can be curative can be considered as an alternative treatment for surgery. But that should be discussed with the patient and that our group before we decided decision. You identify that medical oncology, of course, very important and the management of this disease. So talk to me a little bit more about that. Yeah. So, as my colleagues mentioned, chemotherapy is a big part of the paradigm for the treatment of most stages of gastric cancer. With the exception of the earliest stages, Um, and it can be either in localized disease. Thio uh, combined with surgery to reduce the risk of recurrence, or it can be used in the more advanced settings to control the disease and, um, in metastatic cancer we have at our disposal chemotherapies as well as targeted therapies and and you know therapy as well for some patients, of course. I think everyone has been hearing an awful lot about immunotherapy. Would you like to explore that a little bit more? Eso immunotherapy has been a very exciting new development in the field of oncology. It eyes basically this category of drugs that targets your bodies own immune system to try to help it thio recognize the cancer as foreign and destroy it. Um, this is based on what we've learned about cancer that it expresses signals on its surface that, um basically shut the immune system down so way now have drugs that can block those signals. And in some cases, people can have really, um, long term benefit from these types of treatments. So, um, in gastric cancer, we have one drug currently, which is approved. It's called Pemper Eliza Mob, or keytruda. And it's available toe patients with metastatic disease who either have a tumor that over expresses pd l one. Which is that signal that were blocking or that have a defect in their tumor called mismatch repair. Micro satellite instability. Um, so for those patients immunotherapy, maybe a a good option for treatment. Um ah, lot of our research is focused on how to get immunotherapy into the remainder of patients and how to make it work better in in, ah, larger group of gastric cancer patients. And so that's what Ah lot of the clinical trials were doing in Other research is focused on. It sounds like there's a lot of success using this particular agent. What percentage of people with gastric cancer will have the appropriate markers that will enable them to be patients? Eso for PD l one over expression. Um, it's a subset of patients, probably in the range of a third of patients. Or so who are eligible for this. Um, in the other marker that I mentioned Mismatch repair deficiency is a much smaller group of patients. So it's it's not, ah, large group. And within that subset that is eligible, there's a smaller group that will respond eso again. Ah, lot of our work is trying thio improve those numbers. Are there other Asians that are on the horizon you're excited about? I think there are a lot of new immunotherapy drugs in the pipeline. S o uh you know, we have a number of trials exploring different ways to combine these agents and, ah, lot of work going on in the background to understand who might respond to which one better than another. So, um, there's a lot of effort being put into this right now. All of this, of course, points to the underpinnings of genetics and how they interact in the development of cancer. So I'd like to hear from all of you actually about what genetics are involved, if you will, in the development of stomach cancer. So I'll start. I think you know, one of the things that one of the common things we think about in terms of genetics is something called a C. D. H one mutation, and this is a small group of patients. But it's, uh, that have a high propensity, high risk of developing gastric cancer in the future. And so often it begins with a family member that's gotten it gastric cancer early in their life. And then they're screened by a genetic counselor and found to have this and then subsequently their siblings on their progeny, their Children or screen on def. That does occur, and we find that often they undergo surgery well, first, usually screening until a certain age. And then they undergo surgery with a certain, like myself, what was called a prophylactic gastrectomy, meaning removing the stomach to prevent having gastric cancer in the future. Okay, the other thing that we think about is something called familial adenoma polyp. Post F A p. That's another group of patients under CDH one mutation that have now large polyps or that develop in the stomach, that have a another risk of gastric cancer being developed. And so that's usually something that, between the genetic counselor, three gastroenterologists and ultimately the surgeon removing that stomach with the gastro neurologist screening early on, uh, to help us NFL, When is that that right time? If it's gonna be earlier and a number of other genetics condition like lynch syndrome, Um or, uh, brcm mutations. So if if patients have family history off this higher condition, they should discuss with their physician whether there will be, uh, benefit from gastric cancer screening on I outside of genetics, we mentioned that, um, how are we gonna select which patient we should examine patient and have a risk factor like H. Pylori infection or certain ethnicity coming from high incident countries, Uh, or if they have a family history off gastric cancer, even though they're not fulfilled criteria off military syndrome, they should discuss with their physician whether they should receive a screening. I'd like to explore the h pylori that Helicobacter pylori infection just a little bit more and maybe some of the other infections and how they might play a role in the development of stomach cancer. S. O H. Pylori infection is common. Uh, in the U. S. Is not as common as a country from sorry, the in Asia or South America. But this infection can cause chronic information. And this can lead toe, uh, intestinal metal pleasure, which is a pre cancel isolation. So if they develop intestinal middle pleasure, they should discuss with their physician whether they should undergo screening, even though after you treat H pile early, it may not reverse a risk off developing gastric cancer. In fact, this is such a robust link in some parts of the world that does it suggest to you that we should screen for H. Pylori infection. I saw no, not in the United States, because we we do have especially, but the incident is not that high, so it's not. Cannot be recommending all patients. E think you know the corollary to that. One of the issues that we have is there is a high propensity within certain populations. But those populations aren't necessarily seen on enough studies to to say in the US We should do that. Certainly. Hispanic communities, African American, Native American communities, higher rates of gastric cancer overall. But we're not seeing enough. Native Americans say we need to screen all those folks or African Americans or Hispanic patients say we need to screen them. And so certainly folks who, if you're coming from South America and you have some other risk factors, make sense. Um, if you're you know, um, you know of Africa, certain countries, you know, But we don't have enough to say we should screen all these people. Is it okay if we turn to the multi disciplinary approaching? And I'd like to hear from all of you what you perceive as the advantages and the re sources that are available as a part of that, I think, you know, as we've all touched on to some extent, the treatment of gastric cancer is highly individualized And so we carefully consider each case as a team in terms of the optimal treatment approach. Um, and a lot of those decisions depend on very accurate staging. So having excellent, um, endoscopy and excellent surgery at our disposal to help us with gathering the correct information and then discussing as a group how to approach these patients is is very critical, I think, for the best outcomes for patients, I think from a practical expect some of it is. You have world class experts here focusing on the disease. But one of the things that we like to pride ourselves on is, you know, when I tell people when they come to my clinic is cancer is a family disease? Um, and often again, as I said earlier on, folks Aer kind of orphaned in the gastric cancer world. And so when you have a comprehensive group of people that are focusing on this and then also saying, What are those other things that are important to you? Is your family so having an RN that understands who's who's coordinating our program? That's gonna help follow people along their journey, having genetic counselors who are available that understand you know all the issues that go on when you have a diagnosis. If you have a genetic syndrome having dieticians available to help people because, you know they tell my patients take out if I have to take out all of the stomach kind of feast or famine, it could be really easy or really difficult and having someone to lean on that understand those aspects and also acknowledging Hey, listen, you're not suffering this alone. Um, you know, I think that's really important. And if you have one individual focusing and it's kind of disjointed, but when it's all together, it really goes a long way to providing the care that the patient really wants on. And because we all have expertise in each of what we do, we can also ah, lot of other things like, for example, like Doctor, Dr Johnson mentioned robotic surgery that not very, very available outside outside, uh, institution or advanced resection off early gastric cancer. That's also really limited, um, in specialized center. So I think it's very important toe that you, uh, see the center toe care for you in in this condition. Another other aspect. For example, pathologist who read, uh, pathologic specimen. Need to also understand how to interpret and give important information. Toe the group because they're very important to decide what is the best treatment. Some of those cancer can be treated endoscopic lee or can be tree surgery or need certain chemotherapy regiment based on what the pathologies interpret. So it might not be only among three of us, but many other, uh, group. That will be, uh, help with making decisions. And I think one last thing. We don't have everybody here on sitting with us, but we can't forget our radiation oncologist. We can't forget their surgeries that are very proximal in the stomach. And that may mean myself and harassed IQ surgeon that may need to go higher into into the chest to do something. And so there are other folks that air there and having all of us sitting at a table, you know, on a regular basis, talking about folks and providing the right care not just to care that we can do I think, is really important. Three other thing, of course, that we have here are clinical trials. Are there any clinical trials you'd like to mention specifically that are underway. So I'll start. We have, ah, clinical trial that's gonna be opening soon for patients with Stage four disease that's spread to the para Tinian or the abdomen again. As I said earlier, three or four of page 3 to 4 to 10 patients present like this. And until recently most of those patients were basically, um, just giving chemotherapy, and they had a pretty dismal overall survival. And so now what we're looking to do is do something called bi directional therapy. Essentially, what that means is they're getting chemotherapy via the ivy or port, which is standard and also in the abdomen and the peritoneum, um, and alternating weeks. And what we found is that what happens is chemotherapy doesn't always penetrate very well to those parents. Neil, though the linings. And so, by providing direct chemotherapy, those patients were hoping that that will give them prolong survival. Number one. Bring them all to getting surgery with me on Ben again, give them also give them better quality of life. Overall, I'll say, in medical oncology, we also have a number of trials looking as I mentioned that different combinations of immunotherapy for patients who may not necessarily be eligible for, um, that type of treatment who have advanced cancer. So they're they're definitely a lot of options. Yes, So we are working with Translational Research Group to identify the way toe, detect early cancer without endoscopic examination. For example, obtain gastric stomach fluid or just grab a superficial sales off stomach lining in order area to see whether we can detect which patient eventually developed cancer. But it's in, uh, in the in in progress, so hopefully we'll see promising restart in the near future. What have I not asked about that you'd like to talk about? So one other thing that I think I would add is for again those patients with Stage four disease we also provide I provide a surgery called cider reductive Surgery and high peck. Again. This isn't a limited population, but essentially what that means is I'm going to remove all the visible tumor those patients that have spread, removed the stomach and then do chemotherapy in the operating room what we found. So this is not a trial. We've had trials that have shown significant benefit of this, uh, surgery for patients, and so we provide that operation here in concert with our colleagues. Thio, make sure we identify the right patient. That's gonna be the best benefit. Excellent. Thank you so very much for joining me. Thank you. Thank you. Thanks for having us really appreciate this opportunity.