By Dr. Imran Siddiqui
Associate Chief Surgical Oncology and HPB Surgery
Hartford Healthcare
St. Vincent’s Medical Center (Bridgeport)
Cancer of the gastrointestinal tract encompasses a diverse group of cancers affecting the gastrointestinal system from the esophagus to the rectum.
Upper gastrointestinal cancers affect the digestive system, including the esophagus, stomach, duodenum, liver, pancreas and biliary system. These are difficult to diagnose and treat. Symptoms include weight loss, difficulty in eating, jaundice, pain and anemia, which can have a significant impact on your quality of life. These are difficult to diagnose early, so patients present typically in advanced stages, requiring a complex approach in their care.
Upper GI cancers are among the leading causes of morbidity and mortality, affecting more than 200,000 patients annually in the United States. Significant improvements in both diagnostic and therapeutic tools allow us to detect these cancers early, increasing the number of patients able to undergo surgery and potentially be cured. Advances in diagnostic techniques enable us to accurately diagnose cancers at an earlier stage. That increases the chances of complete surgical removal, the mainstay treatment for the cure of such cancers.
The majority of these cancers require a multidisciplinary team approach involving a surgical oncologist, medical oncologist, gastroenterologist and a radiation oncologist. The aim is to perform patient-centered care, allowing us to design individual treatment plans based on your unique cancer fingerprint as well as any other medical conditions and treatment preferences.
Among the advances in surgery are robotics and minimally invasive surgery. This has allowed us to perform complex operations via a keyhole approach, with significant improvement in operative techniques with minimal blood loss and complications. Patients recover quickly, discharged home after a brief hospitalization. We can perform surgeries on a larger pool of patients, including the elderly and patients with comorbidities who were once considered as not ideal surgical candidates.
Improvement in postoperative care has also contributed to this development. Early ambulation, multimodal pain management and implementation of enhanced recovery after surgery (ERAS) programs have been a game-changer in the perioperative care of cancer patients. Patients who once spent weeks in the hospital recovering from complex surgery are now discharged just a few days after surgery. Some patients with more advanced cancers may benefit from chemotherapy and possibly radiation therapy delivered prior to surgery to help shrink the tumor.
A unique aspect of gastrointestinal malignancies is the overall physical and psychological strain it puts on patients. This is a consequence of poor nutrition, weight loss, changes in bowel and dietary habits and overall motivation and energy levels. It significantly impacts quality of life as well as ability to tolerate treatment and overall outcomes and survival. It is imperative to address these needs throughout the journey of cancer care. The roles of an oncology nutritionist, counselor, social worker and physical therapist are vital in this regard.
With the rapidly evolving field of cancer genomics, we are increasingly able to accurately define GI cancer tumor targets and use precision medicine such as targeted therapy and immunotherapy. Advances in complementary surgical techniques, including ablation, electroporation and target drug delivery, have the potential to revolutionize GI cancer care.This enables an organ-preserving approach to cancer surgery with minimal side effects.
Attention to the patient’s overall status and wellbeing and addressing individual patients’ concerns has led to the concept called prehabiliation for surgical oncology patients. This is a comprehensive team-based approach that complements therapeutics in the form of surgery, chemotherapy or radiation. The overall goal is to improve the functional status of patients prior to undergoing complex surgery, leading to early recovery and improvements in quality of life in the post-treatment phase.
For patients over 65, a geriatric assessment may also help determine which treatment options might be appropriate and feasible given the patient’s physiologic status and comorbidities.
Finally, the role of survivorship and ongoing surveillance is critical in upper GI malignancies. Evaluating and addressing the long-term effects of treatment and addressing quality-of-life concerns of cancer survivors is an important aspect of cancer care. The emphasis on the long-term survival and quality of life starts at the initial diagnosis and treatment discussions. The prehab team allows this to be done in a comprehensive manner, addressing all the needs of cancer patients and allows for overall patient satisfaction as well as improved adherence to treatment and survival outcomes.
The future of cancer care involves establishing accurate and early diagnosis, evaluating the genetic fingerprint of tumors and using predictive analytic tools to create a unique treatment pathway for patients that aims at a cure with minimal effect on patient’s quality of life. Advances in surgery will lead to precision surgery that complements precision medicine. This means more teamwork, improvements in technology and a focus on a holistic approach to cancer care.
With this cancer care, the 21st century will truly be transformative.
Dr. Imran Siddiqui is Associate Chief of Surgical Oncology and HPB Surgery at St. Vincent’s Medical Center in Bridgeport.
