“Gastrointestinal cancers can occur anywhere from the esophagus to the rectum. This includes cancers of the esophagus, stomach, small intestine, colon, rectum and anus, as well as the bile duct, pancreas and liver,” said Robert C.G. Martin, M.D., Ph.D., surgical oncologist with Norton Cancer Institute. “They include the second- and third-deadliest cancers in the United States.”

Excluding skin cancers, colon cancer is the third most diagnosed cancer in the U.S. and the second deadliest; and the prevalence of colorectal cancer is increasing. People born in 1990 have double the risk for colon cancer and four times the risk for rectal cancer as someone born in 1950.

“We’ve seen a huge increase in colorectal cancer in the under-50 population,” said Douglas A. Nelson, M.D., gastrointestinal medical oncologist with Norton Cancer Institute.

National guidelines now recommend colonoscopy screenings starting at age 45, instead of 50, for people with average risk.

Colonoscopy remains the gold standard for detecting colon cancer, because a biopsy can be taken and polyps can be removed during the procedure, while noninvasive tests still can play a role in screening for colon cancer in patients who can’t or won’t undergo a colonoscopy, according to Dr. Nelson.

Pancreatic cancer

Pancreatic cancer ranks 10th for men and eighth for women in terms of estimated new cancer diagnoses in the United States, according to the American Cancer Society. But pancreatic cancer is third in cancer deaths in women and fourth for men, and it’s expected to pass colorectal cancer to become the second-leading cause of cancer death in the next 10 years.

In the U.S., there are no national screening guidelines for pancreatic cancer. However, individuals with a significant family history of the disease or known genetic mutations associated with pancreatic cancer may be eligible for screening, often available at specialized cancer centers.

A multidisciplinary setting is critical for the optimal care of patients with pancreatic cancer.

“The current treatment challenges for pancreatic cancer include late-stage diagnosis, the cancer’s aggressive nature, surgical complexity, resistance to chemotherapy, side effects from treatments and the underlying health of the patient,” Dr. Martin said. “These are why a team-based approach to multidisciplinary care is crucial for success in treating pancreatic cancer.”

New combinations of chemotherapy drugs appear to be more successful than single agents, but even when pancreatic cancer is caught early, a large percentage of patients will have a recurrence despite treatment.

Gastric cancer

The prognosis for gastric cancer is closely related to the stage of diagnosis. Early gastric cancer is limited to mucosa and submucosa and often has a greater than 90% survival rate.

There are no national screening programs or recommendations for gastric cancers. Clinicians should be on the lookout for concerning symptoms, including a history of ulcers or unexplained abdominal pain that doesn’t respond to treatment with proton pump inhibitors, and unexplained weight loss.

Infection with the intestinal bacteria H. pylori is a significant risk factor for gastric adenocarcinoma and gastric lymphomas.

“Patients with a history of ulcer disease, with unexplained dyspepsia, with a history of lymphoma or with a very early gastric cancer should be tested for H. pylori,” Dr. Nelson said.

With esophageal and gastric cancers, immunotherapy has shown recent success and is now well accepted as first-line treatment, often in combination with chemotherapy.

Esophageal cancer

In recent years, there has been a marked increase in gastroesophageal adenocarcinoma. Typically, esophageal cancer was thought of as a smoking- and drinking-related phenomenon, and was predominantly squamous cell carcinoma. The reason for the increase in gastroesophageal adenocarcinoma is not clear.

“Some people think it’s related to increasing obesity. Reflux can certainly play a role, along with perhaps other dietary factors that have not been identified,” Dr. Nelson said.

Treatments traditionally have been the same for adenocarcinoma and squamous cell carcinoma — radiation and chemotherapy, though the combination tends to be more successful in squamous cell carcinomas.

Genomic testing now plays an important role in the pathological workup of gastroesophageal cancers, and molecular findings can determine the treatment approach.

For example, with gastroesophageal cancer, a small percentage of patients have a feature of pathology known as microsatellite instability, a marker not only for a better prognosis but an extreme sensitivity to immunotherapy. PDL1 (programmed death-ligand 1) status is another marker for the likelihood of benefiting from immunotherapy.

HER2 (human epidermal growth factor receptor 2) status, which has been used in breast cancer treatment, also has been identified as a key factor in gastroesophageal cancers. Patients with HER2-positive gastroesophageal cancers often will receive HER2-directed therapy along with chemotherapy.

Liver cancer

With primary liver cancers, the main risk factor is cirrhosis, which produces chronic scarring and liver inflammation that provides the appropriate background for the cancer to form.

“These are folks who actually have two very serious medical conditions, either one of which could potentially be a threat to their life,” Dr. Nelson said.

For example, a small lesion in a healthy liver can be surgically resected. The same patient with advanced liver disease needs to be considered for a transplant.

Cirrhosis classically is related to alcohol use, viral infections, hepatitis B and hepatitis C. More recently, there has been a higher incidence of nonalcoholic steatohepatitis (NASH), which also is called nonalcoholic liver disease and often is associated with obesity. In rare cases, NASH has led to chronic inflammation of the liver and hepatocellular cancer.

Treating hepatocellular cancer is challenging due to chronic liver disease, which can limit options for systemic therapies. For such patients, liver-directed treatments, such as transarterial chemoembolization (injecting chemotherapy directly into the tumor’s blood supply) and radioembolization (delivering radioactive spheres into the tumor’s arterial circulation), are viable alternatives. Immunotherapy commonly is used as a first-line treatment for advanced liver cancer.

Collaborative focus on stomach and digestive cancer care

The Norton Cancer Institute team recognizes the importance of the relationship patients have with their referring providers. We view referring providers as a vital member of our team.

Our goal is to have newly diagnosed cancer patients meet all potential providers who could be part of their cancer care. Many patients require the care of a team of providers at the same time. Multiple specialists provide services at one multidisciplinary location so patients can receive their care in one place during one appointment. For patients traveling long distances, this can be a huge benefit.

Our diverse team includes medical oncologists, radiation oncologists, surgical oncologists, interventional radiologists, an interventional gastroenterologist, pathologists, radiologists, researchers, geneticists, dietitians and patient navigators. These specialists work together to create a coordinated plan for your patient, including treatment, care and follow up.

Providers within the Norton Healthcare system can refer through Epic using order REF54 Ambulatory Referral to Oncology. Community providers can make a referral online or by phone. Visit NortonEpicCareLink.com, place an order for Link Referral to Oncology (EREF122). Or call (888) 4-U-NORTON/(888) 486-6786.