Cancers of the Gastrointestinal System

Cancers of the Gastrointestinal (GI) System Chat Transcript with Richard Schilsky, MD
Thursday, March 31, 2005, 3:00 – 4:00 PM ET

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

On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net Ask the ASCO Expert chat on Cancers of the Gastrointestinal System, 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 3:00 – 4:00 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.

Guest12: What are the adjuvant chemotherapy options that should be considered for Stage II colon cancer? Is there evidence that suggests that one option is better than the others?

Dr. Schilsky: Adjuvant chemotherapy for stage II colon cancer has not yet been proven effective in reducing the chances of recurrence. Patients with stage II colon cancer have a high likelihood of being cured with surgery only.

In some cases, the characteristics of the tumor might suggest a high risk of recurrence and adjuvant chemotherapy could be considered in such cases. The decision should be made after careful discussion between the patient and the physician about the risks and benefits of chemotherapy.

Guest173: Can you discuss the pros and cons of radiation in pancreatic cancer?

Dr. Schilsky: Radiation therapy is usually used in the treatment of locally advanced pancreatic cancer that has not spread to other organs. It is typically given together with chemotherapy to shrink the tumor and prevent spread.

Guest103: What can you tell me about small cell cancer in the descending bowel? The pathology report said it was advanced neuroendocrine.

Dr. Schilsky: Most bowel cancers are adenocarcinomas. Small cell tumors are rare types of bowel cancer. Depending on the portion of the bowel affected, the appearance of the tumor under the microscope, and whether the tumor has spread, chemotherapy treatment may or may not be recommended. Many patients with small cell tumors of the bowel live a very normal life for long periods of time without chemotherapy after surgery. However, some patients have a more aggressive tumor and require chemotherapy treatment.

Guest273: My mother died of pancreatic cancer; she was younger than 60, and her brother died a few years later. There are two more brothers, both well so far, and no pancreatic cancer known in their parents. We do not know about any other genetic diseases in the family. Am I at increased risk for pancreatic cancer? Can I test myself? Can I undergo some regular screening?

Dr. Schilsky: You may be at increased risk. There are rare hereditary pancreatic cancer syndromes. Unfortunately, there is no really good screening test for pancreatic cancer right now. Although, ultrasound study of the pancreas might be able to detect an early stage tumor. You should speak with your doctor about whether and how often you should undergo this testing.

Guest46: Could you please discuss some of the symptoms of esophageal cancer?

Dr. Schilsky: The most common symptom of esophageal cancer is difficulty swallowing. Usually this begins with difficulty swallowing solid foods, but may lead to liquids eventually. Other symptoms can be chest pain, weight loss, cough, or vomiting.

Guest10: How does a patient continue to eat and drink after the removal of the esophagus?

Dr. Schilsky: It depends on the kind of surgery that is done. If a portion of the esophagus is removed, the remainder can usually be reattached to the stomach. If the entire esophagus is removed, often a portion of the large intestine is transplanted into the chest to create a new esophagus.

Guest163: Does Gleevec prevent GIST from recurring after surgery?

Dr. Schilsky: We don't know yet whether Gleevec can prevent recurrence of GIST tumor after surgery. Several studies are testing this right now, but results are not yet available.

Guest163: I have GIST and my doctor gave me two options: Gleevec and other chemotherapy. Which is best?

Dr. Schilsky: If you have not yet had Gleevec, then that is certainly available treatment.

Guest155: Are there any dangers in getting a colonoscopy?

Dr. Schilsky: There are risks associated with any medical procedure. For colonoscopy, the risks can be pain; perforation of the colon; bleeding, if a biopsy is done; or, rarely, infection.

Guest412: My dad has cancer on the liver; he is vomiting a lot. How can I stop the vomiting? Please help.

Dr. Schilsky: The first thing to consider is the cause of the vomiting. If it is due to the chemotherapy treatment, then it may be necessary to make a change in the antinausea regimen that your father is receiving. Sometimes, combinations of several antinausea drugs work better than any drug individually.

Guest110: I need information on treatments for recurrence of colon cancer.

Dr. Schilsky: The appropriate treatment will depend on where the tumor is located, the patient's symptoms, and what treatment has already been given. There are a number of effective chemotherapy treatments that can be used, but the specific treatment that is best depends on what treatment has already been used and what side effects the patient has already experienced.

Guest52: I am 26 years old. My mother passed away seven years ago from colon cancer, and I am wondering what steps I should take to prevent colon cancer and at what age I should be tested.

Dr. Schilsky: Screening for colon cancer can save lives. People at average risk should begin screening at age 50 with a colonoscopy examination. People who have a family history of colon cancer should generally begin screening at an age that is 10 years younger than the age at which the family member developed colon cancer.

Colonoscopy is the best available screening tool because it allows both detection and treatment of colon polyps, which are the precursor lesions of colon cancer.

Guest84: My friend has a non-functioning pancreatic cancer. What is the difference between non-functioning and functioning?

Dr. Schilsky: The term functioning usually refers to a kind of pancreatic tumor known as an islet cell tumor. These tumors are different from pancreatic carcinomas. Islet cell tumors may or may not produce various hormones that can cause symptoms, such as flushing, diarrhea, or low blood sugar.

Tumors that produce these hormones are usually referred to as functioning pancreatic tumors.

Guest16: I have cancer of the gallbladder and my doctor wants to remove it. What are the side effects of this surgery, and do I need to do anything special to survive without a gallbladder?

Dr. Schilsky: You do not need a gallbladder to survive. After surgery, the bile duct will be connected directly to the intestine, so no gallbladder is necessary.

The side effects of the surgery are primarily related to healing from the incision, but other risks of surgery can be bleeding or infection.

Guest463: What is the difference between upper gastric cancer and lower gastric cancer?

Dr. Schilsky: The difference relates to the location of the tumor in the stomach. Upper gastric cancers usually originate at the junction of the esophagus and the stomach. While, lower gastric cancers originate where the stomach joins the intestine. There may be differences in the cause of these two types of stomach cancer, and differences in the treatment approaches that are used for each.

In both cases, surgery is the primary form of treatment.

Guest63: My brother's doctor mentioned that with chemotherapy, a common side effect is low white cell count? What is this and are there treatments available? Are there any types of chemotherapy that do not cause this?

Dr. Schilsky: There are many kinds of chemotherapy and different drugs have different side effects. Low white cell count is a common side effect of many chemotherapy drugs. It is dangerous because it increases the chances of getting an infection.

Patients on chemotherapy should avoid crowds and people who are ill. If a patient on chemotherapy develops a fever, they should have their white cell count checked by their physician as soon as possible.

If it is low, they will usually need intravenous (IV) antibiotic treatment. Some drugs are available to prevent the white blood cell count from going too low, and these drugs are best used to prevent an episode of infection.

Moderator: Transcripts of today's chat will be available Friday, April 1, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

Guest373: Is there a way to tell the difference between inflammatory bowel disease (IBD) and cancer?

Dr. Schilsky: They are very different conditions, although they may have similar symptoms, particularly abdominal pain or bleeding in the stool. Patients with IBD are at increased risk for developing cancer. It is usually possible to tell the difference by a colonoscopy examination.

Tom: How do I find and choose a doctor to operate on my stomach cancer? How do you know if you need to see a specialist?

Dr. Schilsky: Generally speaking, cancer operations should be performed by specially trained surgeons called surgical oncologists. The most important thing to consider, in addition to training, is the doctor's experience in doing the kind of operation that is necessary.

So, things to ask the doctor about are whether they are trained in surgical oncology and how often they have operated on patients with stomach cancer.

Guest35: My father died of liver cancer with probable origination in the small bowel. He was exposed to asbestos many years ago. Can asbestos cause this type of cancer?

Dr. Schilsky: There is no evidence that asbestos causes small bowel cancer. However, it does cause a rare abdominal tumor called peritoneal mesothelioma. It is possible that your father actually had mesothelioma rather than a small bowel cancer.

Guest41: I have read that if you have polyps in your stomach that this can lead to colon/intestinal cancer. During my last endoscopy, I was told that I had more than 40 polyps in my stomach, but the biopsy taken of a few of them came out negative. My paternal grandmother died of colon cancer, and I have irritable bowl syndrome. Your comments, please.

Dr. Schilsky: Stomach polyps do not cause colon cancer, but they could be sign of a hereditary syndrome that involves polyps in both the stomach and the colon. Since you have stomach polyps and a family history for colon cancer, you should speak with your doctor about having a colonoscopy performed.

Guest2: How much interaction is there internationally between cancer treatment specialists? Can one assume that a specialist in France or in the United States has all of the relevant information for the best treatment?

Dr. Schilsky: GI cancer specialists around the world frequently interact at professional meetings, such as the GI Cancer Symposium recently organized by ASCO. This meeting and others provide opportunities for GI cancer specialists around the world to exchange information about the latest treatment options. So, it is reasonable to assume that a GI cancer expert anywhere in the world will be pretty up to date on what is going on everywhere.

Guest217: Do you have any advice on using grape seed extract, selenium, and shark cartilage tablets along with chemotherapy for my 74-year-old father with stage IV stomach cancer? Are there any other new treatments to use?

Dr. Schilsky: Sure. There is no medical evidence that any of these compounds are effective in treating advanced stomach cancer.

There is some evidence that selenium might be effective in preventing several kinds of cancer, and it is now being tested for prevention of both prostate cancer and colon cancer.

If your father is receiving chemotherapy, you should consult with his physician before giving him any of these other agents because some might negatively interact with the chemotherapy treatment.

Guest24: I had the Whipple procedure; a cancer tumor was removed from my pancreas. My biggest problem is that I'm not gaining weight. I weighed 180 lb, and now I am 146 lb. I have a great appetite, but I am dumping most of my food with the number of bowel moments I have, which is about seven a day. Is there any way that I can stop the numerous bowel movements? I would appreciate any help you can give.

Dr. Schilsky: One possible explanation is that you are not digesting fat properly after the operation. This can result in more frequent bowel movements.

The best treatment for that problem is to take pancreatic enzymes supplements with your meals.

Another possible problem is diarrhea caused by foods that are high in carbohydrates. The best solution for this problem is to eat a high-protein, low-carbohydrate diet, and to eat small amounts of food frequently during the day.

You should speak with your doctor about which approach is best for you.

Moderator: Transcripts of today's chat will be available Friday, April 1, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

Wai: Is post-surgery chemotherapy absolutely necessary for stage I/II colon cancer in elder patients?

Dr. Schilsky: No. Post-operative chemotherapy is not necessary for any stage I colon cancers or for the majority of stage II colon cancers.

Patients with these early stage tumors have a high probability of being cured just with surgery.

Guest163: Is GIST a terminal cancer? Can GIST be cured?

Dr. Schilsky: Like most kinds of cancer, GIST can be cured if it is diagnosed early. GIST does not respond to most standard chemotherapy drugs, but imatinib (Gleevec) has been shown to be a highly effective treatment for many patients.

The likelihood that imatinib will help depends on whether the tumor has a particular mutation that increases its sensitivity to imatinib.

Guest312: What is Barrett’s esophagus, and can it cause a swollen neck? Is there any relationship to lymphoma?

Dr. Schilsky: Barrett's esophagus is a condition in which the lining of the end of the esophagus becomes inflamed and changes its appearance under the microscope.

Barrett's esophagus increases the risk of developing esophageal cancer. Symptoms of Barrett's are usually those of acid reflux and indigestion. It should not cause a swollen neck.

There is no known relationship to lymphoma.

Guest463: My brother was recently diagnosed with gastric cancer; he's confused about treatment options, and I am interested in finding information on treatment options for him. Can you recommend where I should go? Are there any websites in addition to Cancer.Net?

Dr. Schilsky: You can look at the NCI website, www.cancer.gov, or call 1-800-4CANCER for some additional information.

Tim: There are several new agents in the news—oxaliplatin (Eloxatin), bevacizumab (Avastin), cetuximab (Erbitux); how do you decide the best treatment option for newly diagnosed or recurrent colon cancer?

Dr. Schilsky: This is a complicated but important question. Oxaliplatin is given with fluorouracil (5-FU) in a regimen called FOLFOX. This chemotherapy is the most effective treatment for metastatic colorectal cancer as initial therapy.

Bevacizumab is a monoclonal antibody that prevents the growth of blood vessels. It has been shown to improve the survival of patients when given with a different chemotherapy regimen in the first-line setting or with FOLFOX in the second-line setting.

Many physicians are now using FOLFOX plus bevacizumab as first-line treatment. Second-line treatment usually involves the drug irinotecan (CPT-11, Camptosar) given with or without cetuximab.

Cetuximab is an antibody against a receptor for epidermal growth factor on cancer cells, and can slow the growth of the tumor.

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) Friday, April 1, by 12:00 PM ET. To receive a copy of the transcript by e-mail, please send a message to contactus@cancer.net.

April Q&A: In April 2005, visit Cancer.Net (www.cancer.net) for a question-and-answer (Q&A) forum on Cancers in Children, Teens, and Young Adults.

The featured experts are Gregory Reaman, MD, of the Children's Oncology Group and Doug Ulman of the Lance Armstrong Foundation.

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

Last Updated: March 31, 2005