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Focus on Quality: Gastrointestinal Cancer Treatment at St. Luke's Hospital
A 2013 Outcome Study on Esophageal, GE Junction and Gastric Carcinomas

By: Albert Van Amburg, MD
Physician Members of the Oncology Steering Committee

Study Assistants:
Julia Kang, CTR
Madonna Henning, RN

Since the St. Luke's Hospital reference date of January 1, 2004, there have been a total of 84 analytic esophageal cancers and 119 stomach cancers. A sharp increase of 38 percent from 2011 to 2012 was noted in the number of esophageal cancers diagnosed and/or treated at St. Luke's Hospital. This increase prompted the recommendation to review our experience with the treatment of esophageal cancer.

The average number of cases for esophageal cancer is 9.3 cases per year and the average number of cases for stomach cancer is 12.2 cases per year. The highest volume of esophageal cancer was noted in 2012 with thirteen cases, which is an increase from the five cases diagnosed and treated in 2011.

The demographic profile of cases shows 73 percent of patients coming from Missouri and 27 percent coming from Illinois. Comparison of distribution between the sexes revealed a higher number of male patients having GI cancers over females. This same distribution pattern is reflected in the National Cancer Data Base (NCDB) population as well. The average age for GI cancers at St. Luke's Hospital is 74. NCDB comparisons are similar with the St. Luke's Hospital age groups, however, the overall patient population at St. Luke's Hospital is significantly higher for the 80-89 age group when compared to the NCDB. Longevity is apparent in the St. Luke's Hospital data group.

Table 1: Comparison of St. Luke's Hospital demographics at diagnosis to NCDB Benchmark data

Stage at Diagnosis
Stage at diagnosis used the Collaborative Derived AJCC Stage for comparison purposes. A significant number of the St. Luke's Hospital cases were diagnosed at Stage I and Stage IV which exceeded the percentages identified by the NCDB. Improvement was noted in the diagnosis of Stage IV from 56 percent of the cases in 2006 to 33 percent of the cases in 2011. This reflects an improvement in the diagnosis of earlier stage cancers from 2006 to 2011.

Table 2: Comparison of St. Luke's Hospital stage at diagnosis to NCDB Benchmark data

Figure 1: Stage distribution of 2006, 2011 and NCDB 2000 to 2010 comparison data.

Treatment at Diagnosis
According to current National Comprehensive Cancer Network (NCCN) treatment guidelines for esophageal/GE Junction tumors, patients who are determined to be medically fit, T1-T3 tumors are resectable even with regional nodal metastases (N+). T4b tumors with involvement of the heart, great vessels, trachea or adjacent organs including liver, pancreas, lung and spleen are unresectable. Surgery is the most common treatment for esophageal cancer.

Initial treatment choice is a decision shared between the clinician and patient, taking into consideration adverse effects of treatment and other factors. Quality of life and life expectancy is the foremost component of this discussion.

In both 2006 and 2011, 50 percent of the Stage I cases were treated with surgery. Remaining patients were treated with combination therapies of radiation and/or chemotherapy. Optimal treatment was performed in all cases based on comorbid conditions and according to NCCN guidelines.

The treatment of esophageal cancer is currently evolving as new molecular information becomes available. In light of our experience with this study, a clinical trial was opened to accommodate enrollments for patients with esophageal adenocarcinoma. All physicians are encouraged to consider placing esophageal patients on this trial: RTOG 1010 A Phase III Trial Evaluating the Addition of Trastuzumab to Trimodality Treatment of Her2-Overexpressing Esophageal Adenocarcinoma.

Survival by Stage
Observed survival is not adjusted for age or other causes of death. St. Luke's Hospital has a 50 percent five-year survival of the Stage I cases and 14 percent overall five-year survival for all stages combined. According to the NCDB, five year survival for Stage I cases is 48 percent. Overall, NCDB five-year survival for all stages combined is 18 percent.

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