I first came to MD Anderson in August 2016. My physician, Dr. David Rice, carefully explained, in layman's terms, how he would remove the cancerous tissue in my esophagus and then pull up my stomach and attach it, along with part of my esophagus, to the other section. He told me about the risks and possible complications that could arise. Most important, he told me about the following blood work and CT scans, and that he would bring my case before a group of esophageal doctors. Once he had all the information, he would devise optimal cancer treatment plans.
This approach gave me a great deal of confidence that I could, and would, be cured of cancer and that I could begin to plan for my retirement years.
A few weeks later, I received a call. The group had come to the consensus that my cancer could be eliminated by either surgery or endoscopic treatments. I chose the latter and Dr. Rice's team readily turned me over to another team. I realized that patients are truly the biggest concern for doctors at MD Anderson.
Unfortunately, the endoscopic treatment did not eradicate my cancer. I was again turned over to Dr. Rice. He spent days following the first operation trying to understand what might have caused my inability to swallow. Again, he told me that he planned to consult with colleagues before making a final decision. I cannot emphasize enough how his attitude impressed me and gave me confidence that I was receiving world-class treatment.
These discussions led to a second operation that determined that Dr. Rice had figured correctly - my stomach had somehow twisted, cutting off the blood supply and causing it to die along with a length of my lower esophagus. Dr. Rice removed my stomach and most of my esophagus, and rerouted the remaining esophagus. A third operation in May reconstructed my digestive system. This 14-hour surgery required Dr. Rice and reconstructive surgeon Dr. Matthew Hanasono to connect the small intestine to the remaining esophagus and build a blood supply to keep the system and me alive for years to come.
Dr. Rice and his team personify what it means to be a hero whose actions, when surgeries do not go as planned, do not instill panic but rather lead to careful reflection and acquisition of more information that ultimately leads to actions that save patients' lives. It is precisely this scenario that I have experienced firsthand and that saved my life.
Promise invites cancer survivors to share their reflections. Email email@example.com.
As an 18-year-old, Lauren Rodriguez never suspected her lingering cough would turn out to be a lung cancer symptom.
“I was in shock,” Lauren says of her lung cancer diagnosis. “I never suspected something like that.”
Today, Lauren’s cancer-free, thanks to her MD Anderson care team. But cancer has changed how the now-19-year-old views life.
“I’ve been given a second chance,” she says.
The first lung cancer symptoms
In February 2017, Lauren developed a cough that wouldn’t go away. The then-high school senior knew it wasn’t asthma — like the doctors in her hometown of Mansfield, Texas, had said. She wasn’t sure what it was, but it kept getting worse. At times, she coughed up blood, or coughed so much she became sick to her stomach. Appointment after appointment left her with few answers.
In June 2017, she saw a pulmonologist in nearby Dallas, who ran a CT scan. The scan revealed a very small carcinoid tumor on one of her lungs.
Lauren had never smoked, and, aside from the cough, she’d never had trouble breathing. She had planned on starting classes the following month at Tarrant County College, but decided to delay her studies to focus on her lung cancer treatment.
Coming to MD Anderson for a second opinion
Lauren’s fears continued to grow after she saw a lung cancer surgeon in Dallas. There, the care team outlined a complicated surgery, which would require multiple incisions and chest tubes to help her breathe after surgery. While the chest tubes would only be temporary, she would still have to leave the hospital with them. She was nervous about the risk of infection or injury.
Spotting her daughter’s anxiety, Lauren’s mom suggested they seek a second opinion at MD Anderson. Lauren wanted to get the surgery over with, but she listened to her mom as she described the cancer center’s world-class reputation and finally agreed.
Choosing MD Anderson in Sugar Land for lung cancer treatment
“From the moment I met her, I knew this was the surgeon I needed,” Lauren says. “She was so nice and down to earth. She was easy to talk to.”
Antonoff outlined the surgery she planned to perform. She would use a surgical technique that only required one incision and one chest tube, which would be removed before Lauren left the hospital.
“I was so relieved,” Lauren says.
Undergoing lung cancer surgery during Hurricane Harvey
On Aug. 25, 2017, Lauren underwent lung cancer surgery at MD Anderson’s Texas Medical Center Campus. The surgery went smoothly, and Lauren was declared cancer-free.
That same day, Hurricane Harvey made landfall. Lauren’s family members, who were staying at a local hotel, had to evacuate to another one nearby. Meanwhile, Lauren and her mom looked out onto Houston’s flooded streets from the observation deck on Floor 24 of MD Anderson’s Main Building.
“Outside of the hospital, it looked like chaos, but inside, everything ran smoothly,” Lauren says. “The staff was constantly checking to make sure we were comfortable.”
Seven days later, Lauren and her family returned home, happy to leave both lung cancer and Hurricane Harvey behind them.
Life after lung cancer treatment
Today, Lauren is taking classes at Tarrant County College and making plans to transfer to a larger school next year. She returns to MD Anderson every six months for follow-up scans.
Lauren says she feels lucky. Her cancer treatment seemed easy compared to some patients she’s known. But the experience has left her with more than just a scar.
“I have a better heart and a better head on my shoulders,” she says. “It’s changed who I am as a person.”
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
He’d sought medical attention after coughing up blood. But at age 42, he never suspected cancer.
The doctors near his hometown of Effingham, Illinois, weren’t optimistic about the diagnosis the X-rays and CT scans revealed: stage IIIA non-small cell lung cancer.
“It’s going to take a Herculean effort to survive this cancer,” his doctor told him.
Jason would need surgery, and because of the tumor’s location, it wouldn’t be easy. The doctor told him it was unlikely he’d get to go back to work and there was a 30% chance he might not make it off the operating table at all.
Jason thought of his wife and three children. He thought of the career he loved. He decided to look for other odds.
Finding hope at MD Anderson
It was a friend who worked in an emergency room that recommended MD Anderson.
“If I were you, I’d be in Texas,” he told Jason.
Jason loved the comradery and compassion among MD Anderson staff and the other patients. But most of all he loved the hope his doctors gave him.
Remembering the odds his doctor back in Illinois had given him, he asked his new surgeon, David Rice, M.D., what the chances were that he wouldn’t survive the surgery. Rice told him 3%.
“Look, you’ve got a difficult case, but it’s just another Monday for us,” Rice told Jason.
“That’s when I thought, I really like this guy,” Jason says.
Jason’s lung cancer treatment: chemotherapy and a lobectomy
Jason completed four cycles of chemotherapy at home in Illinois. This shrunk the tumor down to half its original size. Then, he returned to MD Anderson for surgery: a left lower lobectomy, in which they removed the tumor, along with a portion of his lung.
The surgery was successful, and Jason’s recovery was smooth.
“My pain was very well managed while I was in the hospital. On a scale, of one to ten, ten being very painful, I don’t think it ever got over a three,” he says.
He was discharged from the hospital five days later.
Jason’s radiation therapy
Given the location of Jason’s cancer, his radiation oncologist, Michael O’Reilly, M.D., told him it was best that he come to MD Anderson for his radiation therapy, so he returned in early November. This was going to be a longer stay than any of his previous visits, so he and his dad rented an RV and made the trip together.
Jason had heard stories about the difficult side effects that often accompany radiation, but he said he was fortunate that he didn’t experience any of them.
He finished his last round of radiation on New Year’s Eve 2014. His scans showed no evidence of disease.
Moving forward after lung cancer treatment
So far, Jason’s scans have all been clear. His doctors believe it’s very unlikely that the cancer will return. And while he could do his annual scans closer to home, Jason still returns to MD Anderson simply because he likes to visit.
As for going back to work, Jason returned Jan. 15, 2014 – just a few weeks after finishing up treatment. He can’t do everything he once did, but he’s grateful to continue serving.
“When you’re snatched from the jaws of death, some teeth marks are expected,” he says.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
Tim Orellano knew something was wrong when minimal physical activity made him short of breath. “Other than acid reflux, I considered myself very healthy,” says Tim, who has played tennis for decades.
So, in Feb. 2014, Tim went to his doctor in Little Rock, Arkansas. Bloodwork showed that his red blood cell count was very low, requiring blood transfusions.
An endoscopy found a bleeding ulcer, and a biopsy revealed the cause – esophageal cancer.
“I was in shock,” Tim says.
Choosing to take charge of esophageal cancer
Soon after receiving the news, Tim and his wife, Gina, focused on finding the best esophageal cancer treatment. “Cancer is probably even harder on a caregiver, but Gina was just awesome at offering support,” he says.
Tim knew he could feel sorry for himself, or he could take charge. “I decided I was going to attack this very aggressively,” Tim says. “I was going to own my cancer. It wasn’t going to own me.”
Tim created a binder with his health records and information pertaining to his esophageal cancer diagnosis. He wrote down questions, and began researching treatment options and seeking doctors’ opinions.
The search for a surgeon
While Tim knew he might need an esophagectomy, a surgical removal of his esophagus, he wanted to try an endoscopic mucosal resection procedure, which was less invasive and would potentially allow him to retain his esophagus.
Tim sought a specialist who was both knowledgeable and personable. But he wasn’t happy with many of the doctors he considered. “One surgeon didn’t seem to like me asking questions,” Tim says. Another scheduled him for an endoscopic mucosal resection without telling Tim that he hadn’t ever performed the procedure before.
When Tim cancelled that surgery, another doctor suggested he go to MD Anderson. Within three days, Tim had an appointment at MD Anderson with Wayne Hofstetter, M.D.
“My experience at MD Anderson was different,” Tim says. “Dr. Hofstetter encouraged me to ask questions. I wasn’t rushed, and I had all the information I needed. I even got to talk to other patients with the same diagnosis.”
Tim’s esophageal cancer surgeries
Hofstetter performed an endoscopic mucosal resection to remove the cancerous area in May 2014. But he wasn’t able to remove enough of the area around the cancer to declare Tim cancer-free. He gave Tim a choice: have an esophagectomy or return every six months to be screened for cancer.
“I decided that I didn’t want to keep looking in the rearview mirror or have it hanging over my head,” he says. So, Tim opted for an esophagectomy, which Hofstetter performed in June 2014. The surgery involved lifting his stomach to a higher position and forming a new esophagus out of a portion of his stomach.
Life after an esophagectomy
For 10 days after his esophagectomy, Tim stayed in the hospital, where he transitioned from a feeding tube to solid foods. Clinical dietitian Joan H. Elizondo helped Tim adjust to his smaller stomach and taught him to eat six small meals per day.
On a day he was feeling spry, Tim formed a conga line with the nurses on his floor for fun. He also had “Kicking cancer’s butt” buttons made for his care team. “I really felt like we all were on the same team. Everyone from Surgery to Clinical Nutrition worked together to help me get my health and strength back. They followed up with me even after I went home,” Tim says. “Our connection was just tremendous.”
Now, two-and-a-half years after Tim’s esophagectomy, Dr. Hofstetter often asks him to speak with his other patients. “I received so much that I felt an obligation to give back,” Tim says. “It’s really rewarding and has reinforced that cancer does not own me.”
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
At age 27, Nadine Beech was a picture of health and notably, a non-smoker. So when she was diagnosed with non-small cell lung cancer in 1997, she was in complete disbelief.
Nadine’s doctor also didn’t initially detect the disease. “I started spitting up blood after a water skiing accident, and my doctor thought I had a bruised lung,” Nadine says. She saw several doctors in Kansas City, Missouri, before one discovered the 8-centimeter tumor on the lower lobe of her left lung.
Nadine had a lobectomy, surgery to remove the cancerous lobe. Six weeks later, she jumped back into her fitness regime, earning three black belts, running a marathon and completing a triathlon.
Nadine also quit her job as a bar tender and became a personal fitness trainer. “I was back on top of my game,” she says.
But lung cancer returned two years later.
Nadine’s lung cancer recurrence
In 1999, Nadine visited her oncologist for a routine follow-up CT scan. But instead of leaving with a clean bill of health, she learned the non-small cell lung cancer had returned in her right lung.
A New Zealand native, Nadine was discouraged and unsure where to turn. Then, her friend told her about MD Anderson where her father was being treated for lung cancer. “She told me I had to go there for lung cancer treatment,” Nadine says.
At MD Anderson, under the care of Waun Ki Hong, M.D., Nadine learned she had three tumors in her right lung, each measuring less than 1 centimeter. Hong decided to not immediately treat her tumors, as they are known to grow slowly based on her cancer type. He also knew there was a drug soon-to-come to market that he thought could treat Nadine’s cancer better than currently available drug therapies.
So, Nadine was placed under surveillance. “We just had to wait and watch the tumors,” she says. Nadine returned to Kansas City and for seven years had CT scans with her local oncologist every six months.
Genetic testing reveals risk of more cancers
While monitoring her lung cancer, Nadine learned she was at increased risk for more cancers.
Because of her family history, Nadine underwent genetic testing in 2005. The blood test showed Nadine carries the BRCA1 mutation, increasing her risk of developing breast and ovarian cancers.
“Lung cancer was not the cancer I was supposed to get,” Nadine says. To prevent another cancer diagnosis, she had a double mastectomy and hysterectomy.
Tumor growth prompts another round of surgery for lung cancer treatment
In 2007, Hong started Nadine on the targeted drug therapy he’d been waiting for to treat her lung cancer. She took the drug Tarceva daily for nine years. And despite some unbearable side effects, including diarrhea, nausea, fatigue and acne, Nadine got very comfortable living with lung cancer.
Then, in April 2016, a nagging cough led Nadine to her local oncologist for an earlier-than-scheduled CT scan. It showed her tumors had grown slightly. Her oncologist thought she should change medications.
“The tumor growth did not sit well with me and my loved ones,” Nadine says. “It was time to go back to MD Anderson.”
Her gut instinct was right. Nadine’s tumors were now 8 centimeters and engulfing the upper and middle lobes of her right lung.
Here, thoracic and cardiovascular surgeon Mara Antonoff, M.D., reviewed Nadine’s case and performed a lung function test.
“The outcome of the test was phenomenal,” Antonoff says. “At age 46, Nadine was so fit and had such outstanding lung function that she could safely tolerate removal of two more lung lobes.”
So, Nadine underwent a bilobectomy, a type of surgery to remove two cancerous lobes. “Dr. Antonoff is an angel,” Nadine says. “She gave me so much comfort and strength. I had no doubt surgery was the right choice.”
Life lessons after 19 years of lung cancer
Six weeks after surgery, Nadine, once again, returned to her physically fit life.
“Living with cancer every day for 19 years felt like marathon training,” Nadine says. “I was constantly working hard to be the best I could be for when my cancer-free day would come. And finally, it’s here.”
Nadine calls MD Anderson her “office of cure.” And for the next two years, she’ll visit her office every three to six months for CT scans.
“I encourage people with cancer and their caregivers to take more time to de-stress,” Nadine says. “Stay patient and positive daily, live healthfully, have faith and rest assured, MD Anderson will destroy your cancer.”
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
With a family history of colon cancer, Brian Folloder has been getting regular colonoscopies since he turned 35. But in 2009, when he was 62 years old, a screening blood test for medical insurance showed a possible sign of cancer. So, Brian had a CT scan.
It showed no evidence of cancer. Yet, Brian’s son Justin, a physician assistant in Surgical Oncology at MD Anderson, insisted Brian get a six-month follow-up scan at MD Anderson.
The scan revealed Brian had a pancreatic neuroendocrine tumor that would require surgery.
“My son just kept telling me, ‘Dad, you’re going to be fine.’” Brian says. And Justin was mostly right.
Finding life through surgery at MD Anderson
When Brian arrived at MD Anderson for surgery, he was scared. “I was crying like a baby because I thought people came here to die,” he says.
Brian quickly found the opposite to be true.
After a nearly eight-hour surgery with Jason B. Fleming, M.D., to remove the tumor, his gallbladder and lymph nodes, Brian was pancreatic cancer-free. But he would need to be followed for Barrett’s esophagus, a condition that made him more likely to develop esophageal cancer. The condition was incidentally discovered during the biopsy of his pancreas.
“My care was managed by an amazing team of doctors. And you know what they did?” Brian says. “They gave me more time to live.”
A second round of cancer
In September 2010, Brian had an endoscopy as part of his surveillance under gastroenterologist Jeffrey H. Lee, M.D. It showed cancer. Following a biopsy, Brian was diagnosed with esophageal adenocarcinoma.
Wayne Hofstetter, M.D., director of MD Anderson’s Esophageal Surgery Program, was consulted for Brian’s care. “He was thorough,” Brian says. “He presented me with two treatment options and was clear that the choice was mine.”
Brian could opt for a novel technique known as endoscopic mucosal resection, which allowed Dr. Hofstetter to preserve his esophagus. The procedure uses an endoscope with an attached device to reach and then remove the tumors. The alternative option was an esophagectomy – surgery to remove part of his esophagus.
“Choosing between the two was not an easy decision,” Justin says.
Choosing endoscopic mucosal resection surgery
An endoscopic mucosal resection would require aggressive surveillance post-procedure – serial endoscopies and scans for an indefinite amount of time. “This can be a bit riskier for managing the disease,” Justin explains. “An esophagectomy is a more aggressive approach to remove the cancer, but causes permanent lifestyle changes and has its own set of risks.”
Brian made his decision after connecting with other patients through myCancerConnection, MD Anderson’s one-on-one support program for patients and caregivers. After speaking with four patients, Brian says he found his cure.
He choose an endoscopic mucosal resection, followed by serial radiofrequency ablation with Marta Davila, M.D., to manage residual disease.
A new perspective after cancer
Since the endoscopic mucosal resection, Brian has remained cancer-free. “I know not everyone has a success story – my mother died of colon cancer when I was 15 years old,” Brian says. So at 69 years old, with a wife of 25 years, six kids and 10 grandkids, he feels grateful to be alive.
“MD Anderson gave me life -- twice,” Brian says. “And now, I am focused on maintaining a healthy lifestyle and giving back.”
The scan that showed Pamela Bowman's broken pelvis -- the painful
result of an afternoon of ice skating with her grandchildren -- also
revealed the tumor inside her lung.
Years earlier, Pamela had undergone adrenal surgery at MD Anderson. So when she received her lung cancer diagnosis, there was no doubt in her mind where she would go for lung cancer treatment.
"There's no place like MD Anderson," she says. "When you've got cancer, you need to go to the best."
Pamela's lung cancer treatment: Finding a home away from home
Pamela's local doctors in Jackson, Miss., had warned her that her surgery would be difficult and that her lung cancer prognosis wasn't good. At MD Anderson, though, she got a different message.
"This is something that you'll carry to your grave, but it's
not going to put you in your grave," said her doctor, Wayne
Hofsetter, M.D., professor of thoracic and cardiovascular
Pamela had surgery at MD Anderson before returning home to Mississippi for chemotherapy. Once her chemo treatments were complete, she traveled back to Texas for twenty-seven proton therapy treatments.
"I actually looked forward to going to my treatments each night," she says. "The staff and other patients all became like a big family to me."
She grew especially close to one of the radiation therapists, Stephanie Bazille. Stephanie was one of the first people Pamela met after starting her treatment.
"I trusted her," Pamela says. "She explained the procedures to me and my family. She made me feel like we had almost come home."
Stephanie even came back hours after her shift had ended to watched Pamela ring the gong at the graduation ceremony, signifying the end of her treatment in August 2013.
Life after lung cancer treatment
Pamela's family was also there to support her throughout her treatment. Her husband traveled to Houston with her, and their children and grandchildren visited a few times as well. One of her grandsons, Key, sent her a text message each day during her lung cancer treatment.
With her treatment complete and her scans clear of signs of cancer, Pamela went back to Mississippi. Pamela's life was like it had been before cancer, but somehow everything was different now.
"Everything changes after cancer," she says. "I just live in the moment. I just live for the special times."
Lung cancer is one of the cancers MD Anderson is focusing on as part of our Moon Shots Program to dramatically reduce cancer deaths. Learn more about our Lung Cancer Moon Shot.
I'm a 58-year-old lung
A great thoracic surgeon at MD Anderson, Ara Vaporciyan, M.D., removed my large tumor by doing a lobectomy of my upper left lobe in August 2009.
I participated in a clinical trial for two-and-a-half years after surgery. It involved some painful injections and side effects, but nothing as bad as what many patients go through.
Now, I'm training for my first triathlon.
Lung cancer in my family
Three of my immediate family members have had lung cancer.
I was my oldest sister's primary caregiver until she died peacefully in my arms in 1995. So, I know what caregivers go through. How it changes the direction of their lives.
My next sister helped me a great deal with our oldest sister. Like me, she's now a lung cancer patient at MD Anderson.
The power of "I can"
"You can." Those are the two most important words for family and friends to say to patients.
Early in my journey, I decided the two most important words for me to say to myself are "I can."
I have the same fears as you, the same uncertainties, the same depression. I dread scans like you. I sit with you to get my IV inserted and in all those places we feel our special, but unfortunate, bond. It has become ever-present in my life, too.
But saying "I can" has done so much for me.
Physically, it kept me from questioning whether I could and, instead, I just did - after checking with my doctors, of course. To be able to do things, to not feel helpless, to believe I can survive -- that significantly improved my quality of life.
In fact, I ran a half-marathon in February in honor of all patients and their families.
It was difficult and took me a long time, but not because I had
cancer. I'm not a good runner. I've never done any endurance
challenges, and I've had back and neck surgery.
Being "normal" feels really good, even if it means I'm not going to win any races.
Doing something I've never done
Now I want to do something I've never done, and for which I really have no skill. That way, no one can say, "He spent a lifetime doing this; of course, he can do this."
I also wanted to do something unique for a lung cancer survivor. Something others might not think possible for a person missing part of their lung.
So, on May 5, I will do a triathlon. I'm told it will be the first time a triathlon of any distance has been done by a lung cancer survivor.
I've done some swimming (like 40 years ago), but I am no runner or cyclist. My coach is visibly nervous when he rides next to me. I really stink at bike riding.
People ten years older pass me when I run. My good friend and sometimes trainer can run backwards faster than I can run straight ahead. But, I train a lot now. I can get better.
Have faith that you can
You are my inspiration. I think about all of you, my fellow patients -- my mother, sisters and the tireless caregivers at MD Anderson during every run, every swim (but not every bike ride because I'm too busy trying not to crash).
People who know me look at me as a cancer survivor, not a victim. That gives me hope.
This hope and belief in survival, combined with faith, family and friends, has made my journey one of hope and now confidence.
My wish is for you to know you can have hope and confidence like me. Do what you can. You can do something to impact your outcome. You can live a wonderful life.
I believe you can. Your family believes you can. You must believe you can. Faith is being sure of what you hope for and certain of what you do not see.
Have faith that you can.
Until recently, patients with esophageal cancer were treated with esophagectomy, or removal of the affected part of the esophagus and surrounding lymph nodes, followed by reconstruction. Barrett esophagus with high-grade dysplasia, which carries a substantial risk of progressing to cancer, was treated the same way. However, esophagectomy leads to significant lifestyle changes, including diet limitations and an inability to sleep horizontally; and the operation itself can be dangerous for some older patients. Now, an increasing number of patients with early-stage esophageal cancer or dysplastic Barrett esophagus can be effectively treated with esophagus-sparing surgery and/or ablation.
Physicians at The University of Texas MD Anderson Cancer Center are incorporating new modalities in the diagnosis, treatment, and prevention of esophageal cancer. Among the new treatments is the use of local therapy administered endoscopically to remove early-stage tumors or dysplastic cells while preserving the esophagus.
“Around 2007, we began a program here at MD Anderson of performing local therapy for early esophageal disease,” said Wayne Hofstetter, M.D., a professor and the director of the esophageal surgery program in the Department of Thoracic and Cardiovascular Surgery. “We perform ablation for precancerous conditions and endoscopic mucosal resection followed by ablation for early-stage cancers.”
To determine the appropriate course of treatment, patients with suspected esophageal cancer or dysplastic Barrett esophagus are given a thorough staging workup. This workup usually includes endoscopic ultrasonography to identify tumor tissue, determine how deep the tumor extends into the esophageal wall, and determine whether the disease involves the lymph nodes.
If needed, advanced endoscopic imaging techniques are used to identify areas of dysplasia within an esophageal segment affected by Barrett esophagus, a precancerous lining that develops owing to exposure to acid or bile. One such method is confocal endomicroscopy. “Confocal endomicroscopy is like doing a live pathological exam; you insert a probe through the endoscope, and you can see the actual cells,” said Marta Davila, M.D., a professor in the Department of Gastroenterology, Hepatology, and Nutrition. Another such method is volumetric laser endomicroscopy, which visualizes metaplastic glands (i.e., Barrett glands) buried under normal mucosa in the esophagus.
Endoscopic mucosal resection
Patients with esophageal tumors that appear superficial on workup can undergo endoscopic mucosal resection (EMR), a definitive resection in which the esophagus is accessed via the mouth and pharynx.
EMR avoids a full-thickness injury to the esophagus and is easier for patients to withstand than open surgery. Whereas open esophagectomy is a 6-hour operation that requires a significant amount of physiological reserve and several days of postoperative recovery in the hospital, EMR is an outpatient procedure that requires patients to tolerate only 45 minutes of anesthesia and is associated with a better quality of life.
About half of patients who undergo tumor resection for early-stage non–small cell lung cancer (NSCLC), the most common type of lung cancer, experience recurrence and/or progression to metastatic disease. While immune checkpoint inhibitors have been shown to benefit some patients with metastatic NSCLC, it is not known whether giving such drugs before surgery can reduce the risk of recurrence and metastasis in patients with early-stage disease. In hopes of achieving such risk reduction, a new clinical trial at The University of Texas MD Anderson Cancer Center will offer preoperative therapy with checkpoint inhibitors to patients with early-stage NSCLC.
“In trial after trial, the checkpoint inhibitors have yielded more and longer responses than standard chemotherapy for metastatic NSCLC,” said William N. William Jr., M.D., an associate professor and chief of the Head and Neck Section in the Department of Thoracic/Head and Neck Medical Oncology. “But only about 20% of these patients have a durable response to the checkpoint inhibitors. We believe that the checkpoint inhibitors could be much more effective in patients with earlier stage NSCLC who have not yet developed metastatic disease.”
Dr. William is the principal investigator of the new trial (NEOSTAR), which will be among the first clinical studies of neoadjuvant checkpoint inhibitor therapy in patients with early-stage NSCLC. The trial is expected to begin enrolling patients in May/June 2017. Eligible patients are those with recently diagnosed, operable stage I–IIIA NSCLC. Patients who have received immunotherapy or chemo-radiation therapy are not eligible. In this trial, patients will receive one or two checkpoint inhibitors before resection. All patients will receive the PD-1 (programmed cell death protein 1) inhibitor nivolumab, and some will receive nivolumab plus the CTLA-4 (cytotoxic T lymphocyte antigen 4) inhibitor ipilimumab.
“We believe,” said Boris Sepesi, M.D., an assistant professor in the Department of Thoracic and Cardiovascular Surgery and lead surgeon in the NEOSTAR trial, “that checkpoint inhibitors given during the 6-week period before tumor resection can induce a major pathological response in a substantial proportion of patients. Moreover, our hope is that this treatment paradigm can train the patient’s immune system to recognize the tumor antigens while the tumor is still present and potentially induce a durable response.” Although the ability of neoadjuvant checkpoint inhibitor therapy to produce durable responses in NSCLC patients remains hypothetical, such responses could prevent recurrences that tend to occur even when a complete tumor resection is achieved.
Blood samples will be collected during checkpoint inhibitor treatment to monitor the immune response, and the tumor size will be monitored with imaging. As in all neoadjuvant therapy, the goals are to shrink the tumor before resection and to eliminate any existing micrometastatic disease, thus yielding a better outcome for the patient by reducing the risk of recurrence and metastasis.
The NEOSTAR trial will be available only at MD Anderson. However, the trial is designed to be as patient-friendly as possible by clustering treatments, doctor visits, and tests together so that only three visits, spaced 2 weeks apart, are required before resection. After surgery, patients will be offered standard therapy appropriate for their disease, if indicated.
In metastatic NSCLC and other cancers, checkpoint inhibitors are not effective in all patients. One aim of the NEOSTAR trial is to determine the characteristics of tumors that respond to the checkpoint inhibitors. Such knowledge could expand the numbers of patients who benefit from these agents while avoiding exposure for patients who are unlikely to benefit.
Tumor and tissue specimens and blood samples from patients in the NEOSTAR trial will be analyzed using methods modeled after the ongoing Immunogenomic Profiling of Non–Small Cell Lung Cancer (ICON) project. “In the ICON project, we are conducting an in-depth molecular analysis of resected tumors, surrounding tissues, and blood from patients with early-stage NSCLC and integrating those findings with clinical and outcome data to develop a comprehensive immunogenomic profile of these tumors,” said Dr. Sepesi, a co-leader of the project along with Don Gibbons, M.D., Ph.D., an associate professor in the Department of Thoracic/Head and Neck Medical Oncology. “This profile will generate a list of biomarkers—mutation or aberrant expression of specific genes and proteins—and an immune profile that can be used to learn more about how immunotherapy works in NSCLC.”
The ICON project and NEOSTAR trial aim to expand understanding of the immune response to NSCLC and how it could be harnessed to fight the disease. “The ICON project and NEOSTAR trial are efforts to thoroughly characterize immune cell activity in and around the tumor,” Dr. William said. “Armed with this information, we can develop novel therapies that narrowly target that activity. Eventually we hope to engineer T cell receptors that target specific tumor antigens, which will zero in on the tumor with minimal systemic effects or development of resistance.”
Dr. William continued, “The way we are looking at tumors in NEOSTAR goes beyond traditional staging and histologic criteria to develop new ways of identifying individuals who respond to specific therapies and of understanding what that response looks like.” And even as researchers use immunogenomic profiling to develop future treatments, the neoadjuvant immunotherapeutic approach offered by the NEOSTAR trial may give current patients with early-stage, operable NSCLC a better chance at long-term survival.
For more information, contact Dr. Boris Sepesi at 713-753-0131 or firstname.lastname@example.org or Dr. William N. William Jr at 713-792-6363 or email@example.com. For more information about clinical trials for patients with lung cancer, visit www.clinicaltrials.org. The NEOSTAR trial and ICON project are part of MD Anderson’s Lung Cancer Moon Shot program. For more information, visit http://bit.ly/2nKbOLF.
OncoLog, May-June 2017, Volume 62, Issue 5-6