Gastrointestinal Cancers: Scientific News for Patients

Gastrointestinal Cancers: Scientific News for Patients with Richard Schilsky, MD, Chat Transcript
Thursday, January 26, 2006, 2:00 – 3:00 PM ET

Moderator:On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net Ask the ASCO Expert chat on Gastrointestinal Cancers: Scientific News for Patients, a live question-and-answer session hosted by Richard Schilsky, MD.

During this hour, Dr. Schilsky will answer as many questions as possible. Due to an increasing number of chat participants and number of questions submitted for each chat event, time simply does not allow us to address all of your questions, and we encourage you to consult your doctor and cancer care team.

Some questions may be adapted so that Dr. Schilsky's answers can help as many people as possible.

Dr. Schilsky will take questions from 2:00 – 3:00 PM ET. As you prepare your questions, please keep in mind that Dr. Schilsky is unable to give individual medical advice in this setting, nor is he able to address questions that include information specific to one person's medical profile.

The information presented here is for informational and educational purposes only and is not intended to substitute the professional medical advice or treatment recommendations provided by your doctor.

This forum is neither intended nor appropriate to serve as a means of obtaining a second opinion on cancer diagnosis or treatment. In response to questions about specific drugs, Dr. Schilsky's comments will focus only on the state of current research and clinical trials.

It is advised that you do not delay seeking professional medical advice based on any information received during this chat event.

The chat is governed by all terms and conditions of the Cancer.Net website. Participation in this chat event means that you fully understand and agree to abide by the terms and conditions of the Cancer.Net website.

Good afternoon and welcome. Thank you for joining us. Dr. Schilsky will now begin taking questions.

Richard Schilsky, MD, is currently a Professor of Medicine and Associate Dean for Clinical Research of the Biological Sciences Division at the University of Chicago.

Dr. Schilsky is an international expert in gastrointestinal malignancies and cancer pharmacology and is currently an Associate Editor of Clinical Cancer Research and Cancer and a member of the editorial board of Seminars in Oncology and the Journal of Cancer Research and Clinical Oncology.

He has published more than 170 articles and book chapters in the medical literature.

Dr. Schilsky, thank you for taking the time to join us today.

Guest3: My 65-year-old father, a smoker with non-small cell lung cancer, has stage IV colon cancer that has metastasized to the liver. He has undergone surgery, received the usual chemotherapies, and received radiation treatment. His doctor is now recommending irinotecan (Camptosar). I am skeptical about having him start this new treatment. My father wants to enjoy what's left of his life and not be so sick.

Dr. Schilsky: Irinotecan is an effective treatment for colorectal cancer and should be seriously considered as a potential treatment. It does have serious side effects in a small proportion of patients. There is a new blood test available that can be used to determine if a patient is at high risk for severe side effects.

I would recommend that your father have the blood test done so that the chemotherapy dose can be adjusted to reduce the likelihood of severe side effects.

Guest41: Last month I had a colectomy. The tumor was malignant and two of 31 nodes were positive. The surgeon recommended contacting an oncologist. Are there oncologic specialists? Do I need to go to a cancer center for treatment, or can I work with a local oncologist?

Dr. Schilsky: When colon cancer has spread to the lymph nodes, postoperative chemotherapy is the recommended treatment. Most medical oncologists are familiar with this type of chemotherapy and are well qualified to administer it.

It is not necessary to go to a cancer center, but it would be important to see a board-certified medical oncologist to receive this treatment.

Guest33: I have stage III colorectal cancer. I have read that the rate of recurrence is very high for colorectal cancer. Is this true? I am finding it difficult to plan my future when my health seems to be so uncertain.

Dr. Schilsky: With currently available treatment, the prognosis for patients with stage III colon cancer is quite good. Overall, the likelihood of being successfully treated is about 70%.

There is an article on Cancer.Net called coping with the fear of recurrence that may also help.

Guest77: Is Barrett's esophagus considered precancerous? What are the chances of this condition turning into cancer?

Dr. Schilsky: Barrett's esophagus is a precancerous condition. It is a condition where cells in the lower esophagus potentially become cancerous through long-standing inflammation.

For patients who have Barrett's esophagus, the risk of developing cancer is now 0.2% per year. It is recommended that patients with Barrett's esophagus have an annual endoscopy to look for the presence of cancerous cells.

Guest238: There seems to be a sharp increase in the occurrences of gastric cancer over recent years. Are there any studies or theories underway to find out what is causing the increase? Are there any new drugs on the market or long-term effects of gastric cancer just now coming into play?

Dr. Schilsky: Over the past 20 years, there has been a sharp increase in gastric cancer, which affects the lower esophagus and first portion of the stomach. There are many theories that seek to explain this increase, including an increase in obesity, the use of tobacco and/or alcohol, as well as chronic inflammation from acid reflux.

There is no proof that any of these factors causes stomach cancer. At the present time, there are no drugs on the market known to be preventive for stomach cancer. There is some speculation that anti-inflammatory drugs may reduce the risk, but this is not yet proven.

Guest175: What sort of treatment do you recommend for gastrointestinal stromal tumors (GISTs) located in and around the lungs? I have been told this is a very rare type of cancer and have not found a lot of information about how to treat it.

Dr. Schilsky: GISTs are rare cancers that have a particular genetic abnormality that makes them very sensitive to treatment with a drug called imatinib (Gleevec). The majority of patients with metastatic GISTs will respond initially to imatinib therapy.

A number of new drugs are on the horizon that have been shown to be effective in treating GISTs after imatinib stops working.

Guest19: My father, who has colorectal cancer, always talks about his carcinoembryonic antigen (CEA) number. Can you explain what this is, and what is considered a good number?

Dr. Schilsky: CEA is a protein produced by colon cancer cells that circulate in the blood. The level of CEA is not as important as the trend in the CEA over time.

Doctors will usually use the CEA level over time as an indication whether the cancer is responding to treatment or progressing.

Guest26: I am four years post-treatment for colorectal cancer and have been diligent about follow-up screenings. My doctor says I no longer need to undergo computerized tomography (CT) scans or CEA tests. What are your thoughts?

Dr. Schilsky: The risk of recurrence of colorectal cancer is greatest the first two years after surgery. By five years after surgery, the risk of recurrence is quite low, although not zero. Annual CEA testing is recommended for the first five years after surgery for colorectal cancer.

After that point, the risk of recurrence is sufficiently low that annual testing may no longer be necessary.

Guest10: Gastrointestinal (GI) cancers seem to be common in my family. Both my grandfathers had colon cancer, and my aunt had pancreatic cancer. What can I do to lower my risk?

Dr. Schilsky: Most GI cancers are not hereditary. However, if GI cancer is common, it may seem that it runs in families. There are some specific hereditary colon cancer syndromes that are usually characterized by the onset of cancer at a young age, multiple generations in a family.

The best way to lower your risk of colon cancer is to follow a healthy lifestyle and to undergo annual screening with colonoscopy, beginning at age 50.

Guest339: My mother has anal cancer and is just starting radiation treatment. Can you explain this treatment and some of the side effects she may experience? Thank you.

Dr. Schilsky: The standard treatment for anal cancer is a combination of chemotherapy and radiation treatment. It is successfully treated in approximately 70% of patients. Side effects are often diarrhea, low blood counts, and damage to the skin, the groin and pelvic areas that can increase the risk of infection.

All of these side effects are reversible once the treatment is completed. However, there may be long-term side effects, such as chronic diarrhea or reduced bladder capacity, that results from the treatment.

Guest219: My mother underwent a gastrectomy six months ago for stomach cancer. Since then she has had constant problems with cramping, diarrhea, and sometimes nausea. Her doctor suggested taking smaller bites, chewing thoroughly, and increasing the time she takes to consume a meal. Are there any other options to help treat these side effects?

Dr. Schilsky: It sounds like your mother may have symptoms of what is called "dumping syndrome." This occurs when food passes rapidly into the small intestine. It is most likely to occur after a high-carbohydrate meal. Therefore, we usually recommend small, high-protein, low-carbohydrate meals.

After a gastrectomy, it may take up to a year for the GI tract to return to normal function.

Jennifer: Does the prognosis for metastatic colon differ by age? (I'm in my early 30s.) Do you still hold to the 8% to 15% five-year survival? Thanks.

Dr. Schilsky: The prognosis for metastatic colon cancer is not really related to age. It is more related to general health and fitness, other medical problems, and the patient's ability to tolerate treatment.

Guest155: I have heard that immunotherapy is being tested in the fight against cancer. Is this true, and how does it apply to GI cancers?

Dr. Schilsky: There are many types of immunotherapy that are being tested, including the use of drugs that stimulate the immune system and the use of vaccines to enhance the body's ability to fight cancer.

None of these approaches are proven yet to be effective in treating GI cancer.

Guest193: I was just diagnosed with stage IIIA liver cancer. I have an appointment for a second opinion next week. What is considered the best treatment for someone like me? What about clinical trials?

Dr. Schilsky: The best treatment for liver cancer is surgery. The ability to do surgery depends on the extent of the tumor in the liver and whether the patient has normal liver function. If surgery is not an option, clinical trials are available for patients with liver cancer.

Guest99: What is the best way for a patient to stay informed on the latest cancer research? How can we assure our doctors have the most up-to-date information?

Dr. Schilsky: Information about the latest cancer research from many sources, including ASCO, Cancer.Net, and the National Cancer Institute at www.cancer.gov. Another useful site is www.cancertrialshelp.org.

Guest304: What are your thoughts on screening for colorectal cancer using virtual colonoscopy and stool DNA testing?

Dr. Schilsky: Virtual colonoscopy and stool DNA testing are very exciting new approaches to screening for colorectal cancer. Virtual colonoscopy, which is a CT scan, seems to be as accurate as conventional colonoscopy in detecting colon polyps that are of a moderate or large size.

Stool DNA testing is still being evaluated, but it has the potential to be a better test than looking for blood in the stool because it is more specific for the presence of malignant cells.

Moderator: Transcripts of today's chat will be available January 27, 2006, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

Guest216: I have been diagnosed with gallbladder cancer. What sort of side effects can I expect if I have all or part of my gallbladder removed?

Dr. Schilsky: Many people have their gallbladders removed, usually for gallstones. After you recover from the surgery, you should not expect any other side effects. It is possible to live normally without a gallbladder.

Guest154: Is it true that people with diabetes may be more at risk for developing pancreatic cancer?

Dr. Schilsky: Recent onset of diabetes has been associated with pancreatic cancer, although there is no convincing evidence that people who have diabetes are at greater risk for developing pancreatic cancer.

Guest198: What are the limiting factors for duration of bevacizumab (Avastin) therapy for advanced colon cancer?

Dr. Schilsky: Generally speaking, bevacizumab is given together with chemotherapy for patients with advanced colon cancer. Most of the time, the bevacizumab treatment is stopped when the cancer progresses.

Bevacizumab can have many side effects, including high blood pressure and a risk of perforation of the bowel, and there is very little information on how long bevacizumab can be given safely.

Jennifer: What is the risk of infertility with chemotherapy? I stopped having periods after my second month of chemotherapy.

Dr. Schilsky: The risk of infertility after cancer chemotherapy is related to gender, age at onset of treatment, and the type of chemotherapy given. For women, the closer they are to their natural menopause, the more likely it is that chemotherapy will cause infertility.

The risk of infertility from drugs used to treat colon cancer has not been well studied, although fluorouracil (5-FU, Adrucil) is not associated with an increased risk of infertility.

Guest122: My husband has stage IV esophageal cancer and has lost much of his appetite due to the disease and treatments. Can you recommend foods that may be easy for him to swallow and digest, so he doesn't lose more weight?

Dr. Schilsky: I would recommend that you consult a dietitian or nutritionist to develop good diet plans for your husband. He might also consider taking nutritional supplements to add extra calories to his diet.

Diet programs need to be individualized depending on each patient's circumstances.

Guest212: Can you please address the issue of fatigue in people on chemotherapy? My husband is exhausted, and I would like to try and help him regain some of his energy.

Dr. Schilsky: Fatigue is a very common in patients receiving chemotherapy. It is often due to a combination of problems, such as symptoms from the cancer, side effects of the treatment, anemia, and poor appetite. Your husband should be evaluated to be sure that he is not anemic; there are specific medications that can be used to reverse that.

You should also consult a dietitian to be certain that his diet is optimal. Patients often neglect to tell their doctors about their fatigue. Please speak with your doctor about this problem.

Other contributing factors may be sleep deprivation, depression, or anxiety, all of which are treatable with appropriate medication.

Guest259: I recently had a 1,991-gram GIST removed, and I am taking imatinib. How long will I need to take this, and what is the prognosis for people with GISTs?

Dr. Schilsky: Studies are ongoing to evaluate the effectiveness of imatinib in preventing the recurrence of GISTs after surgery. Until these studies are completed, it is difficult to recommend the optimal duration of imatinib treatment, although it is likely to be in the range of six to 12 months.

Guest147: My mother was diagnosed with gallbladder cancer that has metastasized to the liver and regional lymph nodes, and it cannot be removed completely. She has been invited to participate in a clinical trial. How can we determine if the clinical trial or perhaps a promising new treatment is best for her?

Dr. Schilsky: Clinical trials are the mechanism by which we develop new cancer treatments. Generally speaking, patients receive excellent medical care by participating in clinical trials. The best way to determine if a clinical trial is a good choice is to talk with your oncologist.

Please read more about clinical trial on Cancer.Net.

Guest136: I am being treated for colon cancer. Thankfully my outlook is good. Are there any long-term effects associated with colon cancer treatment? I am 59 years old.

Dr. Schilsky: It is difficult to answer that question without knowing the details of your treatment program; however, most of the commonly used colon cancer treatments have not been associated with long-term side effects.

Oxaliplatin (Eloxatin) may be associated with mild nerve damage that takes a year or longer to resolve but should be completely reversible.

Guest394: Can any GI cancers be treated with laparoscopic surgery?

Dr. Schilsky: Laparoscopic surgery may be an alternative to standard surgery, particularly for colon cancer. A clinical trial has shown that laparoscopic surgery is safe and effective treatment for colon cancer.

For other kinds of GI cancer, laparoscopic surgery would be considered experimental.

Jennifer: Does exercise improve prognosis for colon cancer?

Dr. Schilsky: A recent analysis of adjuvant chemotherapy for colon cancer has shown that patients who exercise regularly reduce the risk of colon cancer recurrence. There are many health benefits of exercise, even for patients with metastatic disease. Patients should talk with their oncologist about the appropriate level of exercise.

Guest276: Is there any connection between irritable bowel syndrome and gastric cancers?

Dr. Schilsky: There is no increased risk of GI cancer in patients with irritable bowel syndrome. However, this should be distinguished from inflammatory bowel disease that is associated with an increased risk of small bowel and colon cancer.

Guest271: Should someone going through chemotherapy avoid certain foods?

Dr. Schilsky: Generally speaking, it is important to maintain good nutrition and a well-balanced diet while receiving chemotherapy. There are no specific dietary restrictions for most chemotherapy, but you should talk with your oncologist about your particular treatment program.

Guest319: My father passed away from stomach cancer, and I am concerned about my risk of developing stomach cancer. What are early signs or symptoms of this type of cancer?

Dr. Schilsky: Stomach cancer can be difficult to diagnose in the early stages because it may not have symptoms or symptoms may be easily confused with more common problems such as indigestion.

Persistent abdominal pain, weight loss, or anemia are things to pay particular attention to.

Moderator: The chat is now ending. Thank you for your thoughtful questions.

We hope this discussion has been valuable, and we regret not being able to answer every question. We want to thank Dr. Schilsky for lending us his time and expertise.

TRANSCRIPTS: The full text of today's chat will be available on Cancer.Net (www.cancer.net) January 27, 2006, by 12:00 PM ET. To receive a copy of the transcript by e-mail, please send a message to contactus@cancer.net.

SAVE THE DATE: Please join Cancer.Net for a live chat about Prostate Cancer: Important News for Patients on February 24, 2006, from 2:00 – 3:00 PM ET.

The featured expert is Eric Small, MD, of the University of California, San Francisco.

The chat room is now closed. Thanks again for joining us.

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