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Multiple Subgroups Needed to Properly Treat Patients With GEJ Cancers

Laura Panjwani
Published: Tuesday, Aug 30, 2016

Richard J. Bold, MD

Richard J. Bold, MD

Categorizing subgroups of patients with gastroesophageal junction (GEJ) cancers, particularly proximal GEJ cancers, is key in the proper management of patients, explains Richard J. Bold, MD, professor, chief of Surgical Oncology at the UC Davis Comprehensive Cancer Center.

“We had traditionally rolled all of the gastroesophageal junction cancers into one group, and the treatment was left up to sometimes personal expertise, sometimes personal experience with regimens, or sometimes just regional preferences,” says Bold. “The development, and more, the adaptation of the Siewert classification systems that subdivide GEJ cancers, really in the field of adjuvant therapy, has really made a difference. Because the surgeon is ultimately the one that is going to end up with these patients on our hands, this matters to us.”

In an interview with OncLive, Bold discusses the reasoning to break GEJ cancers into multiple subgroups and why it is important for treatment and surgical decisions. He also sheds light on the challenges that come with treating patients with gastric cancer, due to the low incidence of the disease.

OncLive: Why is it important for GEJ cancers to be properly classified?

Bold: For those cancers that are considered more the proximal gastroesophageal junction cancers, we group them more into esophageal cancer, even though there may be some gastric component, and we will often treat those preoperatively with chemotherapy and radiation. If we move to Siewert-I, maybe even the same extent of disease, but more on the gastric side than the esophageal, those patents were getting treated with chemotherapy, omitting the radiation therapy. That will ultimately link into our surgical therapy, and this is where that preoperative and pretreatment multidisciplinary planning is critical.

We need to determine if we consider a patient more esophageal, where the operation is going to be an esophagectomy for definitive surgical therapy, or if it is more of a Siewert-III, where we think we can just do a total gastrectomy for their surgical therapy. That is really important because if those 2 treatment plans aren’t aligned at the beginning, we often end up in some kind of ambiguity as to what the true extent of the disease was, and what the right therapy was.

What prompted this subdivision?

For cancers that have more extent of disease in the stomach, the biology of disease behaved a little bit more like gastric cancer. Their nodal spread was usually along the stomach and an intra-abdominal metastasis, whereas those who were more esophageal, their nodal spread was into the mediastinum with a different pattern of metastasis. Even though it is really the same organ—gastroesophageal junction—the biology of disease dictating where the dominant fraction of the disease is, is important in terms of us beginning to separate those out for both treatment surgically, as well as treatment with preoperative therapy.

The other thing that has really compounded this in my mind, is that the esophageal cancer that we were seeing in the distal esophagus really was not the same esophageal cancer that people were seeing 20 years ago related to smoking. There is a lot more adenocarcinoma related to reflux. That kind of predisposition was not really the same as the gastric cancer that we saw that was extending to the esophagus. The precipitating biology seemed to be different in terms of these 2 entities and so did the biologic behavior in terms of disease risk.

Does this approach require more of a multidisciplinary treatment plan?

Yes, absolutely. Those things are really critical in terms of a team-based pre-treatment; it’s not just pre-operative planning or pre-chemotherapy. All 3 people—the radiation oncologist, if he or she is needed, the medical oncologist, and the surgical oncologist—really need to decide upfront and define what is the cancer type, and therefore, that will really dictate what the appropriate therapy is.

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