Breakthroughs in the Surgical Care of Thoracic Cancers and how Early Detection is Saving Lives

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:04Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:08with the director of
00:08 --> 00:10Yale Cancer Center, doctor Eric
00:10 --> 00:11Winer.
00:11 --> 00:14Yale Cancer Answers features conversations
00:14 --> 00:16with oncologists and specialists who
00:16 --> 00:17are on the forefront of
00:17 --> 00:18the battle to fight cancer.
00:19 --> 00:20This week, it's a conversation
00:20 --> 00:21about the surgical treatment of
00:21 --> 00:23thoracic cancers with doctor Dan
00:23 --> 00:24Boffa.
00:24 --> 00:26Doctor Boffa is a professor
00:26 --> 00:27of thoracic surgery at the
00:27 --> 00:28Yale School of Medicine.
00:29 --> 00:30Here's doctor Winer.
00:31 --> 00:32Maybe we can just start
00:32 --> 00:34off as I often do,
00:34 --> 00:36just asking you a little
00:36 --> 00:37bit about yourself.
00:38 --> 00:39How was it that you
00:39 --> 00:41became a doctor? And
00:41 --> 00:42probably, more importantly,
00:43 --> 00:44how was that you ended up
00:45 --> 00:45focusing on cancers of
00:49 --> 00:49the chest?
00:51 --> 00:53Well, I grew up in
00:53 --> 00:53Ohio
00:55 --> 00:56at a time when
00:57 --> 00:58I was
00:59 --> 01:00left to the television a
01:00 --> 01:02fair bit.
01:02 --> 01:03You and me both.
01:04 --> 01:06I was really
01:06 --> 01:08drawn to the television show
01:08 --> 01:09MASH and
01:11 --> 01:12more for the medical aspects
01:12 --> 01:14and the dynamics than
01:15 --> 01:16some of the mischief on
01:16 --> 01:17that show. But,
01:19 --> 01:20that really drew me to
01:20 --> 01:21surgery.
01:23 --> 01:24And it was only later in
01:24 --> 01:26life that I learned that
01:27 --> 01:29Hawkeye, who was the
01:29 --> 01:30character I most
01:30 --> 01:31identified with
01:32 --> 01:33on the show was a
01:33 --> 01:35thoracic surgeon, but that was
01:35 --> 01:36not what
01:36 --> 01:37drew me to the specialty.
01:42 --> 01:43When I was in New
01:43 --> 01:45York, as a surgery resident I
01:47 --> 01:49had a mentor who really
01:51 --> 01:52got me interested in thoracic
01:52 --> 01:54surgery and the anatomy and
01:56 --> 01:57it's one of the
01:57 --> 01:59few specialties where we
01:59 --> 02:00really go
02:01 --> 02:02in multiple different parts of
02:02 --> 02:03the body and treat
02:05 --> 02:06literally hundreds of different types
02:06 --> 02:08of diseases. And so it
02:08 --> 02:10it allows you to be a
02:11 --> 02:13physician as much as it
02:13 --> 02:14does a surgeon, and I
02:14 --> 02:15really like that.
02:15 --> 02:17There are thoracic surgeons who spend
02:17 --> 02:19less of their time
02:19 --> 02:21focused on cancer than you do?
02:22 --> 02:23Yeah.
02:23 --> 02:23I think
02:25 --> 02:26in the field of surgery,
02:27 --> 02:28the lines get a little
02:28 --> 02:30bit blurry, and it depends on
02:31 --> 02:33the size of the hospital
02:33 --> 02:35and the types, and complexity
02:35 --> 02:37of cases that come through.
02:38 --> 02:39I grew up in an
02:39 --> 02:41era where the thoracic surgeons
02:43 --> 02:45did cancer and noncancer,
02:46 --> 02:48and so I have continued
02:48 --> 02:49to have that as
02:49 --> 02:50part of my practice. But
02:50 --> 02:52there are I would say
02:52 --> 02:53the majority of thoracic surgeons
02:54 --> 02:55spend the majority of their
02:55 --> 02:55practice
02:57 --> 02:58dealing with at least
02:58 --> 02:59lung cancer.
02:59 --> 03:00Some of the more
03:01 --> 03:02less common cancers,
03:04 --> 03:05I think a lot of
03:05 --> 03:06the thoracic surgeons
03:07 --> 03:08tend to
03:09 --> 03:10refer those on to
03:10 --> 03:11larger centers,
03:12 --> 03:13such as Yale or some of
03:15 --> 03:16the other larger centers.
03:16 --> 03:18And other than lung cancer,
03:18 --> 03:20what other cancers do you
03:20 --> 03:20end up treating?
03:21 --> 03:23Esophageal cancer is probably the
03:23 --> 03:24second most common,
03:25 --> 03:27but really any tumor that
03:27 --> 03:28arises
03:28 --> 03:30in the chest and that
03:30 --> 03:30could be
03:31 --> 03:32tumors can arise from the
03:32 --> 03:32bones,
03:33 --> 03:34mesothelioma.
03:36 --> 03:36There are
03:38 --> 03:40tumors that can spread from other
03:40 --> 03:42parts of the body to
03:42 --> 03:43the lungs, and we can
03:43 --> 03:44help the
03:45 --> 03:47teams that manage colorectal
03:47 --> 03:48cancer, for instance,
03:49 --> 03:50by treating
03:50 --> 03:52some of the sites of
03:52 --> 03:53disease that spread to the
03:53 --> 03:53lungs.
03:54 --> 03:57And in the abdomen, there
03:57 --> 03:58are various cancers
03:58 --> 04:00that we get involved with,
04:01 --> 04:01sometimes,
04:02 --> 04:03gastric cancers that are
04:05 --> 04:07close to the esophagus.
04:07 --> 04:09But, really, anything that
04:09 --> 04:10happens in the chest that
04:13 --> 04:14doesn't need a heart surgeon,
04:15 --> 04:16we're the people to call.
04:17 --> 04:18So maybe we can start
04:18 --> 04:20off talking a little about
04:20 --> 04:21lung cancer, and then we'll
04:21 --> 04:22move on to
04:23 --> 04:25talking about esophageal cancer. We
04:25 --> 04:25recently had
04:26 --> 04:28Roy Herbst on on the
04:28 --> 04:28show
04:29 --> 04:30and talked about some of
04:30 --> 04:32the medical aspects
04:32 --> 04:34of lung cancer treatment and
04:34 --> 04:36how it has just evolved
04:37 --> 04:38so much over the past
04:38 --> 04:39twenty years with
04:39 --> 04:40both immunotherapy
04:41 --> 04:43and various forms of targeted
04:43 --> 04:43therapy.
04:44 --> 04:46Tell us about your involvement
04:46 --> 04:48in patients with lung cancer
04:49 --> 04:49and,
04:50 --> 04:51in particular,
04:51 --> 04:53how the changes in the
04:53 --> 04:55medical therapies have affected what
04:55 --> 04:56you do?
04:56 --> 04:58So whenever we think about
04:58 --> 05:00cancer, we think about what
05:00 --> 05:01we see and what we
05:01 --> 05:04can't see. So surgery is a
05:05 --> 05:07treatment that's very effective
05:08 --> 05:09in sites of cancer that
05:09 --> 05:10we can see.
05:11 --> 05:12Unfortunately,
05:12 --> 05:13a lot of patients who
05:13 --> 05:15have their life shortened by
05:15 --> 05:17cancer, it's the disease we
05:17 --> 05:18can't see that gets them
05:18 --> 05:18into trouble.
05:19 --> 05:20And I would say what's
05:20 --> 05:22really exciting about
05:22 --> 05:24the current era of cancer is
05:25 --> 05:27we now have answers
05:27 --> 05:29for the disease we can't
05:29 --> 05:30see that we've never had
05:30 --> 05:31before. And so,
05:32 --> 05:34we're turning more patients into
05:34 --> 05:35curable
05:35 --> 05:37than we've ever seen.
05:37 --> 05:38And to be clear,
05:38 --> 05:40the not seeing,
05:40 --> 05:42which is what the
05:42 --> 05:43disease that ultimately can threaten
05:43 --> 05:44someone's life,
05:45 --> 05:46it's not seeing it at
05:46 --> 05:48diagnosis, but eventually it becomes
05:48 --> 05:49apparent.
05:49 --> 05:51That's right. So it's
05:51 --> 05:53the microscopic cancer that's either
05:53 --> 05:55living in the blood or
05:55 --> 05:56a vital organ
05:56 --> 05:58that has left the cancer
05:58 --> 06:00where it started and traveled
06:00 --> 06:01somewhere else. And it's just
06:01 --> 06:03too small to be seen
06:03 --> 06:04on a CT scan or
06:04 --> 06:05a PET scan or a
06:05 --> 06:06brain MRI,
06:06 --> 06:08and it's only over time
06:08 --> 06:10that cancer grows
06:10 --> 06:11and then becomes
06:12 --> 06:13apparent on the scans. But
06:13 --> 06:14at that point,
06:15 --> 06:17our ability to treat it
06:18 --> 06:20for a cure historically or
06:20 --> 06:21in the past has
06:21 --> 06:23been very low. But now
06:23 --> 06:24with some of these treatments
06:24 --> 06:26and lung cancer in
06:26 --> 06:26particular,
06:27 --> 06:29we're taking patients who
06:29 --> 06:31have always been thought
06:31 --> 06:32to be incurable
06:32 --> 06:33and actually,
06:34 --> 06:35curing them. And so it's
06:35 --> 06:36just a really exciting
06:36 --> 06:37time.
06:40 --> 06:41And while
06:42 --> 06:42ultimately,
06:43 --> 06:44maybe there'll be a
06:44 --> 06:46time when there's the magic
06:46 --> 06:47pill for all cancer,
06:48 --> 06:48at the moment,
06:49 --> 06:51as the pills and as
06:51 --> 06:52the infusions get better, it just
06:54 --> 06:56allows us to do that
06:56 --> 06:57much more in the way
06:57 --> 06:57of surgery,
06:58 --> 06:59because
07:00 --> 07:01as you said, people who
07:01 --> 07:02in the past wouldn't have
07:02 --> 07:03been curable,
07:04 --> 07:06now we can eradicate their
07:06 --> 07:07micrometastatic
07:07 --> 07:09disease, and that leaves you
07:10 --> 07:12dealing with the lung nodule
07:12 --> 07:13that's still left behind.
07:13 --> 07:15Absolutely. And I think
07:15 --> 07:17at the same time that
07:18 --> 07:19the treatments,
07:20 --> 07:21the chemotherapies
07:21 --> 07:23and the medications
07:23 --> 07:24that are given,
07:25 --> 07:26intravenously
07:27 --> 07:27have improved,
07:28 --> 07:30the surgical techniques have gotten
07:30 --> 07:31a lot better. And so
07:31 --> 07:33we used to make a
07:34 --> 07:36five to ten inch incision
07:37 --> 07:39to remove early stage lung
07:39 --> 07:40cancers. And now
07:40 --> 07:41ninety percent,
07:42 --> 07:43to ninety five percent of
07:45 --> 07:47lung cancers are removed
07:47 --> 07:48using minimally invasive techniques.
07:49 --> 07:51Here, mostly using the robot.
07:51 --> 07:53So your biggest incision is
07:53 --> 07:53about
07:54 --> 07:55an inch and a half,
07:55 --> 07:57maybe two inches, and everything's
07:57 --> 07:57done
07:58 --> 08:00minimally invasively. And that
08:00 --> 08:01really speeds up recovery and
08:01 --> 08:03allows people who
08:03 --> 08:04maybe weren't as healthy,
08:05 --> 08:06to get through
08:07 --> 08:08an operation,
08:08 --> 08:09a lot more easily and
08:09 --> 08:11get back to their life
08:11 --> 08:12much faster.
08:12 --> 08:14And those ten to fifteen
08:14 --> 08:16inch incisions for early stage
08:16 --> 08:17lung cancer,
08:17 --> 08:19that was being done how
08:19 --> 08:19long ago?
08:20 --> 08:22Twenty years? Ten years? How
08:22 --> 08:23long has it been?
08:23 --> 08:25I would say
08:25 --> 08:26a ten inch incision is
08:26 --> 08:28something I've seen,
08:29 --> 08:30maybe twenty five years ago.
08:30 --> 08:31Even when I
08:31 --> 08:32have to do what we
08:32 --> 08:34call a traditional incision,
08:34 --> 08:36it's now like a five
08:36 --> 08:37inch incision, and we don't
08:37 --> 08:39usually cut big muscles. So
08:39 --> 08:40if somebody ever
08:41 --> 08:42says you're not a candidate
08:42 --> 08:44for a minimally invasive approach,
08:45 --> 08:47that still is way better
08:47 --> 08:49than what patients used to be
08:51 --> 08:52subjected to
08:52 --> 08:54twenty five, thirty years ago
08:54 --> 08:55where it was a
08:55 --> 08:56much bigger cut and
08:57 --> 08:58ribs were commonly
08:59 --> 09:00taken.
09:01 --> 09:02Now the vast majority
09:02 --> 09:03of patients who even get
09:03 --> 09:05a traditional incision,
09:05 --> 09:07the recovery is actually much
09:07 --> 09:08faster than when we were
09:08 --> 09:10making those really big incisions.
09:10 --> 09:11No. I think it's really
09:11 --> 09:13remarkable. It's been true across
09:13 --> 09:14the whole surgical field.
09:16 --> 09:17I'll share that, you know,
09:17 --> 09:18I recently had
09:19 --> 09:20a hip done.
09:21 --> 09:23And the day of surgery, they tried
09:23 --> 09:24to get you up walking.
09:25 --> 09:26You know, there was a
09:26 --> 09:27time years ago
09:28 --> 09:29when whether it was a
09:29 --> 09:30hip or whether it was
09:30 --> 09:32a lung cancer, people
09:32 --> 09:34were put in their beds for
09:35 --> 09:36you know, a long time.
09:38 --> 09:39I think that
09:40 --> 09:40medicine
09:41 --> 09:42tends to improve
09:44 --> 09:46in one area and pull
09:46 --> 09:48other areas along. And so
09:48 --> 09:50I would say that the
09:50 --> 09:53patient experience now benefits from
09:53 --> 09:55better anesthesia. So people are
09:55 --> 09:57less nauseous people wake up
09:57 --> 09:59faster, their pain is much
09:59 --> 10:00better controlled at the same
10:00 --> 10:01time. We're
10:02 --> 10:04making smaller incisions. We're better
10:04 --> 10:05at controlling
10:05 --> 10:06pain.
10:06 --> 10:07And, because of
10:08 --> 10:09the opioid
10:10 --> 10:11pandemic,
10:12 --> 10:13we really
10:13 --> 10:15try to minimize narcotics, and
10:15 --> 10:16we have all of these
10:16 --> 10:17different
10:17 --> 10:19techniques that we can keep
10:19 --> 10:20people
10:20 --> 10:22active and doing the things
10:22 --> 10:23we need them to do
10:23 --> 10:24to recover,
10:25 --> 10:26yet doing it in a
10:26 --> 10:27way that their pain is
10:27 --> 10:28controlled,
10:28 --> 10:29and they're not getting
10:30 --> 10:32a lot of narcotic medication.
10:33 --> 10:34Yeah. I mean, it is
10:34 --> 10:36fairly dramatic how
10:36 --> 10:38the concern about opioids
10:38 --> 10:40and the abuse of
10:40 --> 10:40opioids
10:41 --> 10:42has led to far more
10:42 --> 10:43creativity
10:43 --> 10:45about how we use them
10:45 --> 10:47in people who have
10:47 --> 10:49significant pain and how
10:50 --> 10:51we don't let people
10:51 --> 10:53remain in pain, but we
10:53 --> 10:54come up with other ways
10:54 --> 10:56of approaching the pain. So,
10:56 --> 10:57you know, I'm not sure
10:57 --> 10:58I've ever asked anyone this
10:58 --> 10:59question, but I'm sure
11:02 --> 11:02occasionally
11:03 --> 11:04when you're doing a bigger
11:04 --> 11:05surgery,
11:05 --> 11:07you're in the operating room
11:07 --> 11:09for quite a number of
11:09 --> 11:09hours.
11:10 --> 11:12What's that like to
11:12 --> 11:13be just standing over
11:15 --> 11:17a patient and
11:17 --> 11:19it is standing. It's not
11:19 --> 11:20sitting most of the time.
11:22 --> 11:23How do you get through
11:23 --> 11:24all that?
11:24 --> 11:25It is
11:26 --> 11:27amazingly
11:27 --> 11:27compelling
11:28 --> 11:29when you are
11:30 --> 11:32in charge of a patient's
11:32 --> 11:33life and not just
11:36 --> 11:38whether something big
11:39 --> 11:40happens in the operating room,
11:41 --> 11:41but
11:42 --> 11:43when somebody
11:43 --> 11:44trusts you to take them
11:44 --> 11:45to the operating room, they're
11:45 --> 11:46trusting you
11:48 --> 11:49to fight that battle for
11:49 --> 11:52them. And so you are
11:52 --> 11:54looking for any site of
11:54 --> 11:55disease. You are
11:55 --> 11:57so focused on getting
11:58 --> 11:59every part of that tumor
11:59 --> 12:01out as cleanly as possible,
12:02 --> 12:04and it really commands your
12:04 --> 12:06attention so much that the
12:06 --> 12:08time really flies by.
12:08 --> 12:09I do a lot of
12:09 --> 12:11surgeries that are three hours,
12:11 --> 12:11but I do a lot
12:11 --> 12:13of surgeries that are
12:14 --> 12:16seven hours. And
12:17 --> 12:18I would consider
12:18 --> 12:21myself to have a pretty
12:21 --> 12:23short attention span outside of
12:23 --> 12:24the OR. But when you're
12:24 --> 12:25in the OR,
12:26 --> 12:27that responsibility
12:27 --> 12:28is so compelling
12:29 --> 12:30that the time just absolutely
12:30 --> 12:31flies by.
12:32 --> 12:34Well, I'm not
12:34 --> 12:35a surgeon, and I have
12:35 --> 12:37never been in a seven
12:37 --> 12:39hour operation in the OR.
12:41 --> 12:42I can tell you that
12:43 --> 12:44the times when I feel
12:44 --> 12:46most centered and focused are
12:46 --> 12:47when I'm in a room
12:47 --> 12:48with a patient,
12:49 --> 12:50and in fact, the door
12:50 --> 12:52closes and nothing else in
12:52 --> 12:53the world is happening for
12:53 --> 12:54me.
12:55 --> 12:56I would hope that I
12:56 --> 12:57would have the attention to
12:57 --> 12:58do that for seven hours,
12:58 --> 12:59but you obviously do.
13:01 --> 13:03And I was a carpenter before medical
13:03 --> 13:04school, and when
13:06 --> 13:07you're in the thick of
13:07 --> 13:09things, it's problem
13:09 --> 13:11solving, and
13:11 --> 13:13when you're concentrating on something
13:13 --> 13:14that is stimulating and you
13:14 --> 13:16care a lot about,
13:16 --> 13:18time just flies by.
13:21 --> 13:22And I suppose when you
13:22 --> 13:24saw that in medical school,
13:25 --> 13:27that's one of the things
13:27 --> 13:28that drew you to become
13:28 --> 13:28a surgeon.
13:29 --> 13:31Hundred percent.
13:31 --> 13:33Well we're gonna need to take
13:33 --> 13:34just a brief break.
13:34 --> 13:35When we come back, we're
13:35 --> 13:36gonna talk about
13:36 --> 13:38esophageal cancer and
13:39 --> 13:41what has evolved in
13:41 --> 13:42that area,
13:42 --> 13:43and we'll talk a little
13:43 --> 13:44bit about
13:44 --> 13:45lung cancer screening.
13:46 --> 13:48Funding for Yale Cancer Answers
13:48 --> 13:50comes from Smilow Cancer Hospital,
13:50 --> 13:51where their hematology
13:51 --> 13:53program offers comprehensive
13:53 --> 13:55diagnosis and treatment of blood
13:55 --> 13:57cancers including lymphoma, leukemia, and
13:57 --> 13:58myeloma.
13:59 --> 13:59Smilowcancerhospital
14:00 --> 14:01dot org.
14:03 --> 14:04There are many obstacles to
14:04 --> 14:06face when quitting smoking as
14:06 --> 14:08smoking involves the potent drug
14:08 --> 14:08nicotine.
14:09 --> 14:10Quitting smoking is a very
14:10 --> 14:13important lifestyle change especially for
14:13 --> 14:15patients undergoing cancer treatment as
14:15 --> 14:16it's been shown to positively
14:17 --> 14:18impact response to treatments,
14:19 --> 14:20decrease the likelihood that patients
14:20 --> 14:22will develop second malignancies,
14:22 --> 14:24and increase rates of survival.
14:25 --> 14:27Tobacco treatment programs are currently
14:27 --> 14:28being offered at federally designated
14:29 --> 14:31comprehensive cancer centers, such as
14:31 --> 14:32Yale Cancer Center and
14:32 --> 14:34Smilow Cancer Hospital.
14:35 --> 14:36All treatment components are evidence
14:36 --> 14:38based and patients are treated
14:38 --> 14:40with FDA approved first line
14:40 --> 14:41medications
14:41 --> 14:43as well as smoking cessation
14:43 --> 14:45counseling that stresses appropriate coping
14:45 --> 14:46skills.
14:46 --> 14:48More information is available at
14:48 --> 14:50yale cancer center dot org.
14:50 --> 14:52You're listening to Connecticut Public
14:52 --> 14:52Radio.
14:54 --> 14:55Good evening again. This is
14:56 --> 14:56Eric Winer
14:57 --> 14:58with Yale Cancer Answers.
14:59 --> 15:01And I'm joined tonight by
15:02 --> 15:04Dan Boffa, who is a
15:04 --> 15:05thoracic surgeon
15:06 --> 15:07and leads our
15:08 --> 15:09division of
15:11 --> 15:12thoracic surgery.
15:13 --> 15:14Dan, let's
15:15 --> 15:16shift gears a little bit.
15:16 --> 15:18We talked about
15:18 --> 15:20lung cancer, and we talked
15:20 --> 15:21about surgical techniques
15:22 --> 15:22a bit.
15:23 --> 15:25Let's talk about esophageal cancer.
15:25 --> 15:26And esophageal cancer,
15:27 --> 15:28I think, is one of
15:28 --> 15:30those cancers that people are
15:30 --> 15:32pretty frightened of.
15:33 --> 15:33And,
15:34 --> 15:35while it's not the most
15:35 --> 15:37common cancer, it's by no
15:37 --> 15:38means uncommon.
15:38 --> 15:40So tell us a little
15:40 --> 15:40bit about
15:41 --> 15:43esophageal cancer.
15:44 --> 15:45So esophageal cancer
15:46 --> 15:48is a dangerous cancer that
15:48 --> 15:50we don't have a great
15:50 --> 15:51way to screen for yet.
15:51 --> 15:53And I think because of
15:53 --> 15:53that,
15:54 --> 15:55we're not finding it until
15:55 --> 15:56people
15:56 --> 15:57have symptoms.
15:58 --> 15:59And once you have symptoms,
16:00 --> 16:02it is not necessarily,
16:03 --> 16:05spread to vital organs, but
16:05 --> 16:06it is not typically
16:07 --> 16:08at its earliest stage and
16:08 --> 16:10not the point where we're
16:10 --> 16:11best able to cure people.
16:13 --> 16:14Can you just comment
16:14 --> 16:15for a minute on those
16:15 --> 16:16symptoms?
16:16 --> 16:18So if you notice that
16:18 --> 16:21you're having difficulty swallowing, that
16:21 --> 16:22food is getting stuck, particularly
16:23 --> 16:25in the mid to lower
16:25 --> 16:27part of your chest. Even
16:27 --> 16:28if it just happens
16:28 --> 16:30more than once, you really
16:30 --> 16:32need to let your
16:32 --> 16:34primary know about it
16:34 --> 16:35and see a gastroenterologist.
16:37 --> 16:37A lot of people
16:40 --> 16:40have heartburn,
16:41 --> 16:42and that's one of the
16:42 --> 16:43things that makes
16:44 --> 16:45esophageal cancer
16:46 --> 16:49difficult to identify because the
16:51 --> 16:53way that screening works is to find
16:53 --> 16:55dangerous things before they do
16:55 --> 16:56dangerous things.
16:57 --> 16:57And
16:58 --> 16:59the symptoms
17:00 --> 17:01and the people at risk
17:01 --> 17:03for esophageal cancer are generally
17:04 --> 17:04people
17:04 --> 17:06who have heartburn,
17:06 --> 17:08who are over the age
17:08 --> 17:08of fifty,
17:09 --> 17:10who are overweight.
17:12 --> 17:14White males tend to have
17:14 --> 17:15a higher risk.
17:15 --> 17:16Well, that's a lot of
17:16 --> 17:18us. And I've described this
17:18 --> 17:19in the past as kind
17:19 --> 17:20of like a tornado.
17:21 --> 17:22So tornadoes
17:22 --> 17:24often happen when the conditions
17:24 --> 17:25are right for a tornado.
17:26 --> 17:27But most of the time
17:27 --> 17:29that conditions are favorable for
17:29 --> 17:29tornadoes,
17:30 --> 17:31you don't get any. And
17:31 --> 17:33sometimes tornadoes happen
17:33 --> 17:35when the conditions aren't favorable.
17:35 --> 17:36So it's really hard to
17:38 --> 17:39pin down who you would
17:39 --> 17:40do upper endoscopies,
17:42 --> 17:43instead of a colonoscopy,
17:43 --> 17:44which goes from the bottom.
17:44 --> 17:46This is an upper endoscopy,
17:46 --> 17:47which goes from your mouth
17:47 --> 17:49into your esophagus. And so
17:49 --> 17:50it's hard to screen for and
17:52 --> 17:53we miss that opportunity to
17:55 --> 17:56find it at its earliest
17:56 --> 17:57stage.
17:57 --> 17:58But if you do have
17:58 --> 17:59heartburn,
18:00 --> 18:01and it's not well controlled
18:02 --> 18:03with an over the counter
18:03 --> 18:03medication,
18:04 --> 18:06and you're
18:06 --> 18:07over the age of fifty,
18:07 --> 18:08I would talk to your
18:08 --> 18:09primary about having an upper
18:09 --> 18:10endoscopy.
18:10 --> 18:12And then there are certain
18:12 --> 18:14conditions that are associated with
18:14 --> 18:15a higher risk of
18:15 --> 18:16esophageal
18:16 --> 18:17cancer, things like
18:18 --> 18:19Barrett's esophagus.
18:22 --> 18:23Barrett's esophagus
18:23 --> 18:25is a change in the
18:25 --> 18:27esophagus where the lining
18:28 --> 18:30changes from its normal lining
18:30 --> 18:31to the lining that the
18:31 --> 18:33intestine has on the other
18:33 --> 18:34side of the stomach. In
18:34 --> 18:35a lot of ways, that
18:35 --> 18:37makes sense because the
18:37 --> 18:39downstream side of the stomach
18:39 --> 18:40sees acid all the time.
18:41 --> 18:43And so its lining is
18:43 --> 18:44designed to protect it,
18:45 --> 18:45whereas
18:46 --> 18:47acid shouldn't be going backwards.
18:48 --> 18:49And so that lining is
18:49 --> 18:50designed
18:50 --> 18:52to help things pass through it.
18:52 --> 18:54And so Barrett's esophagus
18:54 --> 18:55sounds like a good thing
18:55 --> 18:57because the acid is
18:57 --> 18:59turning the lining into something
18:59 --> 19:00that should be protecting it.
19:00 --> 19:02The problem is once it
19:02 --> 19:03makes that change, it loses
19:03 --> 19:05its ability to control
19:05 --> 19:06what it does and what
19:06 --> 19:07it looks like, and
19:07 --> 19:09a series of changes
19:09 --> 19:10can happen, and it can
19:10 --> 19:12turn into a cancer. But,
19:12 --> 19:13again, most Barrett's
19:14 --> 19:15does not turn into cancer.
19:16 --> 19:18So it's hard to
19:18 --> 19:19nail down who is
19:19 --> 19:21really at highest risk.
19:21 --> 19:23And what about the role of
19:24 --> 19:27tobacco use and alcohol in
19:27 --> 19:28esophageal cancer?
19:28 --> 19:30Both have been associated
19:30 --> 19:32with an increased risk of
19:32 --> 19:33esophageal cancer.
19:34 --> 19:35So I think there's
19:35 --> 19:37a lot of people who associate
19:37 --> 19:39tobacco use with lung cancer,
19:39 --> 19:40but really,
19:40 --> 19:41most
19:41 --> 19:43or many cancers,
19:43 --> 19:45have an association
19:45 --> 19:47with tobacco use. And we're
19:47 --> 19:48increasingly
19:49 --> 19:51finding signals that moderate
19:52 --> 19:53to heavy alcohol use
19:54 --> 19:55increases,
19:55 --> 19:56to some degree, your risk
19:56 --> 19:58for cancer in multiple parts
19:58 --> 19:59of the body, including the
19:59 --> 20:01esophagus and stomach.
20:01 --> 20:03And with esophageal cancer,
20:04 --> 20:05my recollection
20:05 --> 20:06is that
20:07 --> 20:08if you think of smoking
20:08 --> 20:10and drinking as one each,
20:10 --> 20:12that one plus one doesn't
20:12 --> 20:13equal two. It equals three.
20:14 --> 20:16Yeah. I think that
20:17 --> 20:18in many cancers,
20:19 --> 20:20risk factors tend to
20:20 --> 20:23stack into a
20:23 --> 20:24greater risk.
20:25 --> 20:26You know, I commonly,
20:27 --> 20:27describe
20:28 --> 20:30risk factors like smoking
20:30 --> 20:31as a bad thing.
20:31 --> 20:33Choosing to swim in gasoline
20:33 --> 20:34is a bad
20:34 --> 20:36thing. Doing both of them
20:36 --> 20:37is a really, really bad
20:37 --> 20:39thing. And so I think
20:39 --> 20:40that's a fair point. I
20:40 --> 20:42think that describes it quite
20:42 --> 20:44well.
20:45 --> 20:45How has esophageal cancer
20:46 --> 20:48treatment changed over the years?
20:48 --> 20:51Because this is one of
20:51 --> 20:53those tumors where our success
20:53 --> 20:54rate is going up.
20:58 --> 20:59The mainstay
20:59 --> 21:02of cure for esophageal cancer
21:02 --> 21:05has been removing the esophagus
21:05 --> 21:07and reconstructing the esophagus,
21:08 --> 21:10typically by bringing the stomach,
21:10 --> 21:11making it into a tube,
21:12 --> 21:13and replacing the esophagus.
21:14 --> 21:16So several things have happened.
21:17 --> 21:19One is the earliest stage
21:19 --> 21:21esophageal cancers can now be
21:21 --> 21:22treated successfully
21:23 --> 21:23endoscopically.
21:24 --> 21:24So,
21:25 --> 21:26you come and go the
21:26 --> 21:27same day. You have an
21:27 --> 21:28upper endoscopy and
21:30 --> 21:31either by
21:31 --> 21:32cooking
21:32 --> 21:34with heat or freezing or
21:34 --> 21:35scraping,
21:36 --> 21:37you can
21:38 --> 21:40remove the earliest stage esophageal
21:40 --> 21:42cancers, which we used to
21:42 --> 21:43do an esophageectomy
21:43 --> 21:44for.
21:44 --> 21:46Now for the people we
21:46 --> 21:48do offer an esophagectomy for,
21:48 --> 21:49it is
21:49 --> 21:51a much less invasive operation.
21:52 --> 21:53Ninety percent of
21:53 --> 21:55the esophagectomies I do now
21:55 --> 21:57are done with a minimally
21:57 --> 21:58invasive approach, and the biggest
21:58 --> 21:59incision,
22:00 --> 22:01which used to be two
22:01 --> 22:03eight inch incisions, is now
22:03 --> 22:04the biggest incision is a
22:04 --> 22:05single two inch incision. And
22:05 --> 22:06so,
22:06 --> 22:08the recovery is much faster,
22:08 --> 22:09and people get back to
22:09 --> 22:09their
22:10 --> 22:12routines much faster.
22:12 --> 22:14And now just like in
22:14 --> 22:15lung cancer,
22:16 --> 22:16there are
22:18 --> 22:19different types of chemotherapies
22:20 --> 22:21and immunotherapies
22:21 --> 22:22that are starting to show
22:22 --> 22:23promise
22:23 --> 22:25in esophageal cancer. So, again,
22:26 --> 22:27trying to address
22:28 --> 22:29the cancer we can't see
22:29 --> 22:31on CT scans and PET
22:31 --> 22:33scans, the microscopic cancer,
22:34 --> 22:34using
22:35 --> 22:36the novel treatments
22:36 --> 22:38is showing great promise in
22:38 --> 22:40esophageal cancer as well.
22:40 --> 22:40immunotherapy,
22:42 --> 22:43presumably with chemotherapy,
22:44 --> 22:45is now a standard for
22:45 --> 22:47many patients with esophageal cancer?
22:48 --> 22:49For many patients.
22:49 --> 22:51Not all, but for
22:51 --> 22:53many patients. I think because
22:53 --> 22:54there's less of them,
22:55 --> 22:57than than, say, lung cancer,
22:57 --> 22:59we're still trying to learn
22:59 --> 23:01who would be best served,
23:01 --> 23:03by these by immunotherapy and
23:03 --> 23:04some of the more novel
23:04 --> 23:05treatments.
23:05 --> 23:06And what are the kinds
23:06 --> 23:08of problems people with esophageal
23:08 --> 23:10cancer have after surgery?
23:11 --> 23:13Well, if you have
23:13 --> 23:14your esophagus
23:15 --> 23:17removed and reconstructed,
23:18 --> 23:19the biggest thing is
23:22 --> 23:23everybody walks around with about
23:23 --> 23:25a Coke cans worth of
23:25 --> 23:26fluid in your stomach, which
23:26 --> 23:28is now in your chest
23:28 --> 23:29as opposed to your belly.
23:29 --> 23:31And so that means that
23:31 --> 23:32you can't lie flat.
23:32 --> 23:33Now we have
23:34 --> 23:35people that
23:36 --> 23:37are competitive triathletes,
23:38 --> 23:40people who swim, and
23:41 --> 23:43I have a woman who
23:43 --> 23:43bikes
23:44 --> 23:45in Europe.
23:45 --> 23:46Actually, we have a lot
23:46 --> 23:47of bikers.
23:48 --> 23:49So you can get back
23:49 --> 23:51to a very normal
23:52 --> 23:53quality of life, but there
23:53 --> 23:54are some considerations,
23:55 --> 23:56for sure. And so do
23:56 --> 23:57people have to sleep
23:58 --> 23:59on an incline?
23:59 --> 24:00Yeah. So you have to
24:00 --> 24:01sleep
24:02 --> 24:02with your head of the
24:02 --> 24:03bed thirty degrees,
24:04 --> 24:05either with a wedge or
24:05 --> 24:07a mechanical bed.
24:07 --> 24:09And if not, the problem
24:09 --> 24:11is that there's aspiration
24:11 --> 24:12of fluid into your lungs.
24:12 --> 24:14There's no valve
24:14 --> 24:16anymore that separates the stomach
24:16 --> 24:17from the esophagus. So if
24:17 --> 24:19you were to lie completely
24:19 --> 24:21flat, that Coke cans worth
24:21 --> 24:22of fluid can go
24:22 --> 24:23into the back of your
24:23 --> 24:24mouth and you could choke
24:24 --> 24:25on it. And so
24:25 --> 24:27it's really an important thing
24:27 --> 24:29that you keep your head
24:29 --> 24:29of bed elevated
24:30 --> 24:31at all times. It sounds
24:31 --> 24:33like a challenge for biomedical
24:33 --> 24:34engineers.
24:35 --> 24:37Well, I think there's
24:37 --> 24:38a lot of opportunities
24:38 --> 24:39for innovation, and I think that
24:43 --> 24:45both in the engineering world, but
24:45 --> 24:46also in sort of the
24:46 --> 24:47data science world to try
24:47 --> 24:49to figure out who are
24:49 --> 24:50the best people for
24:50 --> 24:51which treatment.
24:51 --> 24:52Sure.
24:54 --> 24:55Can we talk a little
24:55 --> 24:57bit about lung cancer screening?
24:57 --> 24:58I had promised to do
24:58 --> 25:00that on a
25:00 --> 25:00previous
25:01 --> 25:03episode or previous show
25:05 --> 25:07and we didn't quite get
25:07 --> 25:08into all the details that
25:08 --> 25:10I had hoped to.
25:10 --> 25:11But,
25:11 --> 25:13lung cancer screening is potentially
25:14 --> 25:15really lifesaving,
25:15 --> 25:17potentially very important.
25:18 --> 25:20Yeah. So lung cancer screening
25:21 --> 25:22in my lifetime
25:22 --> 25:24will probably be the single
25:24 --> 25:25most impactful
25:26 --> 25:27medical discovery
25:28 --> 25:29for the cancers I treat.
25:29 --> 25:30Lung cancer screening
25:31 --> 25:33reduces a person's chances of
25:33 --> 25:35dying of lung cancer by
25:35 --> 25:36more than twenty percent.
25:37 --> 25:39It's a CT scan
25:39 --> 25:40that happens
25:41 --> 25:42once a year
25:42 --> 25:44and looks for anything that
25:44 --> 25:46could be a precancer or
25:46 --> 25:46a cancer,
25:47 --> 25:48and then leads to the
25:48 --> 25:50various evaluations.
25:51 --> 25:52For reasons that we don't
25:52 --> 25:53fully understand,
25:54 --> 25:56only about ten percent of
25:56 --> 25:57the people who are eligible
25:57 --> 25:58for screening, so those are
25:58 --> 26:00people who are fifty years
26:00 --> 26:02or older and who've smoked
26:04 --> 26:06only about ten percent of
26:06 --> 26:07the people who are eligible
26:07 --> 26:08actually participate.
26:10 --> 26:11We've tried to understand why
26:11 --> 26:13this is, and we've done
26:13 --> 26:15some research here at Yale.
26:15 --> 26:16One of the things we
26:16 --> 26:17found that was a bit
26:17 --> 26:19surprising is that the
26:19 --> 26:22primary care clinician is pretty
26:22 --> 26:23important in the lung cancer
26:23 --> 26:24screening process,
26:24 --> 26:25and one out of three
26:25 --> 26:26people in the United States
26:26 --> 26:27does not actually have a
26:27 --> 26:29primary care clinician.
26:30 --> 26:31We tried to call hospitals
26:31 --> 26:32to see if they could
26:32 --> 26:33help, and, actually,
26:34 --> 26:35only ten percent of the
26:35 --> 26:37hospitals can actually help if
26:37 --> 26:38you call them directly. And
26:38 --> 26:38so
26:39 --> 26:40we're working with the
26:41 --> 26:43big organizations
26:43 --> 26:44and primary care clinicians to try
26:46 --> 26:48to alleviate that barrier
26:48 --> 26:49to screening. But I also
26:49 --> 26:50think patients
26:52 --> 26:52have legitimate
26:53 --> 26:55concerns about screening.
26:56 --> 26:58a lot of people feel
26:58 --> 27:00that there's no hope if
27:00 --> 27:01you find things. Nobody wants
27:01 --> 27:03to look for something you
27:03 --> 27:04don't wanna find.
27:06 --> 27:07But I think that when
27:07 --> 27:09you participate in screening,
27:09 --> 27:11you're gonna find a cancer
27:11 --> 27:12at its earliest
27:12 --> 27:14stage when the treatment is
27:14 --> 27:15a lot easier on you.
27:15 --> 27:16And so I do think
27:16 --> 27:17that
27:18 --> 27:19it's such an important thing.
27:21 --> 27:22And anybody who's
27:22 --> 27:23listening to this, if you
27:23 --> 27:24know somebody who's fifty years
27:24 --> 27:26or older and has a
27:26 --> 27:27history of smoking,
27:28 --> 27:29either reach out or
27:30 --> 27:30have them reach out to
27:30 --> 27:32their primary or call us
27:36 --> 27:36and we can hook you
27:36 --> 27:38up with screening.
27:38 --> 27:39And do you think some
27:39 --> 27:41primary care doctors just don't
27:41 --> 27:42buy into it yet?
27:44 --> 27:46There was a recent study.
27:46 --> 27:47And I've had conversations
27:48 --> 27:48with
27:49 --> 27:50leaders of the primary care
27:50 --> 27:51organizations,
27:51 --> 27:52and there's just such a
27:52 --> 27:54shortage of primary care
27:55 --> 27:57clinicians right now that
27:57 --> 27:58if you had a primary
27:58 --> 28:00care clinician do everything
28:00 --> 28:02that's recommended as a best
28:02 --> 28:02practice,
28:03 --> 28:04they would have to work
28:04 --> 28:05eight or nine days a
28:05 --> 28:07week, which is obviously impossible.
28:08 --> 28:09I think that
28:10 --> 28:11a lot of the
28:11 --> 28:11primaries
28:13 --> 28:14trust that the screening works.
28:14 --> 28:16It's justthey're so overwhelmed
28:16 --> 28:17in many parts of the
28:17 --> 28:19country. They just don't have
28:19 --> 28:20the bandwidth
28:21 --> 28:22to chase down all of
28:22 --> 28:23these things. So I do
28:23 --> 28:24think it's a
28:24 --> 28:25responsibility
28:25 --> 28:26that we have to put
28:26 --> 28:28on patients as well
28:28 --> 28:30as their primaries,
28:30 --> 28:32because it's so powerful,
28:33 --> 28:34and such an
28:34 --> 28:35important thing to do.
28:35 --> 28:37Dr. Dan Boffa is a professor
28:37 --> 28:38of thoracic surgery at the
28:38 --> 28:40Yale School of Medicine.
28:40 --> 28:42If you have questions, the
28:42 --> 28:43address is cancer answers at
28:43 --> 28:45yale dot e d u,
28:45 --> 28:46and past editions of the
28:46 --> 28:48program are available in audio
28:48 --> 28:49and written form at yale
28:49 --> 28:51cancer center dot org.
28:51 --> 28:52We hope you'll join us
28:52 --> 28:53next time to learn more
28:53 --> 28:54about the fight against cancer.
28:55 --> 28:57Funding for Yale Cancer Answers
28:57 --> 28:58is provided by Smilow Cancer
28:58 --> 28:59Hospital.

Information

Breakthroughs in the Surgical Care of Thoracic Cancers and how Early Detection is Saving Lives with guest Dr. Dan Boffa March 30, 2025

Yale Cancer Center

visit: https://www.yalecancercenter.org

email: canceranswers@yale.edu

12949

Guests

Dr. Dan Boffa

To Cite

DCA Citation Guide