Stomach Cancer Screening | How Asian and Latinx Patients Can Self-Advocate

Stomach Cancer Screening | How Asian and Latinx Patients Can Self-Advocate from Patient Empowerment Network on Vimeo.

How can Asian and Latinx patients self-advocate for gastric cancer screening? Expert Dr. Joo Ha Hwang from Stanford Medicine shares advice for how patients can discuss gastric cancer screening with their provider and how providers should be engaging with patients for better care.

[ACT]IVATION TIP

“…especially if you come from Korea, Japan, where they actually have instituted national screening, with endoscopy, we actually have U.S. guidelines that state that if you come from a country whose guidelines state you should have endoscopy, then you should also have endoscopy, we should be following your home of origins guidelines for you and so, those patients should also have endoscopy.”

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Transcript:

Lisa Hatfield:

So in the United States, we do have many people from the Asian and Hispanic communities who may be at higher risk for gastric cancer, do you suggest that they talk to their provider about getting screened? And how might they phrase that question? Can I get screened for the H. pylorI? So if you had a patient who wanted to be screened or is interested in getting screened, how might they approach their provider in asking for the screening for gastric cancer or H. pylori?

Dr. Joo Ha Hwang:

I think the first step is to get tested for H. pylori, and pretty much, everyone who is, an immigrant to the U.S. is at much higher risk for having H. pylori, in the past, we used to say that the people from Asia, immigrants from Asia had an 80 percent risk of having H. pylori, from Mexico, it was more like around 60 percent, United States, it was in the 20 to 30 percent, it’s probably less than that now.

So worldwide, prevalence of H. pylori is certainly going down but again, providers should know this is something that is taught in medical school, is areas that are, endemic with H. pylori and providers should also know that, H. pylori is a carcinogen, and so if a patient just comes up in and says I’m worried about having H. pylori, I come from a high-risk population, it really shouldn’t be difficult to get tested for H. pylori, furthermore, if they have any symptoms, especially any epigastric pain what we call dyspepsia that should also trigger the provider to go ahead and test for H. pylori, because that’s part of the algorithm. So I think that all of these, it shouldn’t be difficult to engage a provider on that particular issue.

Lisa Hatfield:

So it is okay and appropriate for a patient to approach their provider and ask that question? So I appreciate that.

Dr. Joo Ha Hwang:

I think it’s important and I think that patients need to be their own advocates, because I have heard of instances where providers have been reluctant and in certain systems they’re discouraged from further testing, because it’s a capitated system. I think H. pylori testing is not that difficult, sometimes if patients want endoscopy, it can be, more challenging but again, especially if you come from Korea, Japan, where they actually have instituted national screening, with endoscopy, we actually have U.S. guidelines that state that if you come from a country whose guidelines state you should have endoscopy, then you should also have endoscopy, we should be following your home of origins guidelines for you and so, those patients should also have endoscopy.

But the challenge with that is that they’re going to end up paying for it, because it’s not typically covered by insurance or it’s not fully covered by insurance so you’d probably have to pay a copay, for something like that at this time.

Lisa Hatfield:

I have a friend who’s dealing with her father who lives in Korea, she’s from Korea, has been here about two, five years. He has stomach cancer. So we’ve been having this discussion, and that’s why I thought I’d ask that last question. She said she sometimes is afraid to approach her provider…

Dr. Joo Ha Hwang:

If you’re afraid to approach your provider, you need a different provider.

Lisa Hatfield:

Well, that’s a good suggestion too.

Dr. Joo Ha Hwang:

No, no. We’re supposed to work with you and listen to you and again, I go around and give a lot of talks to patient groups, and I like engaging in these types of activities, because I think the more information patients have, the more that they can talk with their physicians, and oftentimes patients know more than their physicians do, because they’ve done a lot more research. And hopefully you have a physician with some hubris who will listen to the patient and if they don’t know, they’ll kind of look things up, so yeah.

Lisa Hatfield:

Yeah. I appreciate that, thank you.

Dr. Joo Ha Hwang:

My pleasure.


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Potential Impact of Artificial Intelligence on Stomach Cancer Detection and Care

Potential Impact of Artificial Intelligence on Stomach Cancer Detection and Care from Patient Empowerment Network on Vimeo.

What role might artificial intelligence take in stomach cancer detection and care? Expert Dr. Joo Ha Hwang from Stanford Medicine shares his perspective on how AI might be most impactful in stomach cancer detection and care, how the FDA will be involved in AI use, and protections that must be put in place to safeguard patient interests.

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Transcript:

Lisa Hatfield:

Dr. Hwang, what is the current role of artificial intelligence or AI in gastric cancer care? And how do you envision the role of AI in the future management of gastric cancer?

Dr. Joo Ha Hwang:

Yeah, it’s a great question, very early day for AI but AI is really the hot topic, in the field of medicine, and AI will definitely play a role in, the detection of gastric cancer on probably many fronts, obviously the most straightforward one is during endoscopy, we can use AI to help identify early gastric cancer, and one of the issues in the United States is, since gastric cancer is a relatively rare finding, and it can be very subtle on endoscopy, a lot of endoscopists can miss an early gastric cancer or a precancerous lesion, and so we’re hoping to use AI to better identify, these lesions, since they’re not super common, and we’re really not taught to look for these lesions, this is an area that AI can be helpful. But the other, probably easier implementations of AI would be through just medical records and just using AI to help identify people who are at high risk.

And then flagging these patients for physicians to say, “Hey, this patient should be considered for H. pylori testing, this patient should be considered for endoscopic screening.” So I think that’s actually a simpler implementation of AI. So I think that AI will definitely help, it should help with outcomes, the challenge really is, working with the FDA to allow AI to be implemented in the clinical setting, that’s not a really simple task, because AI can also potentially be used for nefarious reasons and so we certainly have to protect patients’ identities, we have to protect patients’ information.

And so, there’s a lot of steps and a lot of responsibility that comes with AI. But I would say stay tuned, it will definitely, you’ll see more and more AI implementation over the years to come, and overall it should be very positive for patients for all disease processes, including gastric cancer.


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What Stomach Cancer Care Obstacles Do Asian and Latinx Patients Face?

What Stomach Cancer Care Obstacles Do Asian and Latinx Patients Face? from Patient Empowerment Network on Vimeo.

What kind of gastric cancer care barriers do some patient groups face? Expert Dr. Joo Ha Hwang from Stanford Medicine discusses key factors that impact gastric cancer care access, and recommendations for patients and providers to reduce disparities.

[ACT]IVATION TIP

“…if you have any influence with the members of Congress, kind of bring up the issues related to minority health and access to healthcare. I know there’s a, within the Department of Health and Human Services, there is a Department of Minority Health, this is something that I think that they’re working on, which is access to healthcare, but it’s a real problem.”

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Can Stomach Cancer Risk Be Reduced by Treatment and Lifestyle Changes?

Transcript:

Lisa Hatfield:

Dr. Hwang, what are the challenges faced by the Asian and Hispanic populations in accessing timely and appropriate treatment for stomach cancer? And what strategies could be implemented to address these challenges?

Dr. Joo Ha Hwang:

There are several questions or several challenges. Number one, I think, is patient awareness is educating these communities that they actually are at higher risk of developing gastric cancer. Number two, their access to healthcare oftentimes, is difficult sometimes because of language barriers, sometimes due to cultural issues, sometimes just due to regional geographic issues, and access to healthcare also insurance. A lot of the immigrant population, they even if they’re very successful and work quite a bit, oftentimes they’re, small business owners and they have high deductible, insurance plans. I had a friend who was an immigrant from Asia, and I told him you’re at high risk for developing gastric cancer, and you should have an endoscopy, we did an endoscopy on him and this was at a county hospital in Seattle.

He got a bill for $6,000 for his endoscopy, and I was personally appalled at that, and that’s actually kind of what got me into this field, was because I felt that that was very unfair, that this person who worked very hard and had insurance, but had a high copay, because he had high deductible insurance, was being treated like this when someone with Medicare, we’re charging only $200 for an endoscopy. And then if we had screening guidelines from the USPSTF such as for colon cancer, breast cancer, it would be completely free. And so there’s a huge disparity, and it is the Hispanic, it’s the Asian population, it’s the immigrant population that are at higher risk for gastric cancer.

And this is completely uncovered, and so, these are all inequities, in the system that we’re trying to address, what I would say, is that, if my activation tip for this would be, if you have any influence with the members of Congress, kind of bring up the issues related to minority health and access to healthcare. I know there’s a, within the Department of Health and Human Services, there is a Department of Minority Health, this is something that I think that they’re working on, which is access to healthcare, but it’s a real problem. The other side of it also is the education side and the empowerment side, and I think that we have to do a better job in terms of educating the populations who are at high risk for gastric cancer to go see their primary care physician to talk to them about what they need to do.

The other challenge really, actually is on the physician side, because, and I’ve been working at this as well, physicians don’t know, we’re taught in medical school that gastric cancer is rare, and it’s almost like an afterthought and we spend very little time on gastric cancer, but gastric cancer isn’t rare, and there are high risk populations, and there is something that we can do about it. So we really have a long way to go, but the good news is there is progress to be made, so if we just put in the effort, we can make a huge dent in outcomes for gastric cancer.

Lisa Hatfield:

Are there any efforts underway right now to develop guidelines for those communities in the U.S. to do screening? Do you know?

Dr. Joo Ha Hwang:

Yeah. We’re actively involved on a national level to work with societies and working with societies to make guidelines. This helps educate providers and whatnot, the challenge really in terms of getting insurers to cover this. This is really cost-effective, but oftentimes when insurers look at something they need to see an immediate return, they want to say within one year, this is cost beneficial, where this is a long….Gastric cancer prevention, any cancer prevention is really a long-term, outlook and that’s why the USPSTF plays such an important role because their guidelines have immediate implications on insurers and what they need to pay for, and so really we need, guidelines from the USPSTF, to make a true impact on the outcomes of gastric cancer.

But this is proving to be challenging because, the population that’s affected is a relatively small population in the United States. But again, in this era of precision medicine and equitable medicine, my view is it shouldn’t matter, in terms of the size of the population, that’s at risk, it should be data that says these particular patients are at high risk, and this intervention should work to decrease the risk of gastric cancer, and so I think we need to start having dialogue and changing the way we think about, patient care and make this more personalized, precision individualized medicine as opposed to population-based medicine.


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How Can Gastric Cancer Patients in Rural Areas Access Specialists?

How Can Gastric Cancer Patients in Rural Areas Access Specialists? from Patient Empowerment Network on Vimeo.

How can rural gastric cancer patients gain access to specialists? Expert Dr. Jun Gong from Cedar-Sinai Medical Center discusses access to additional medical consults and a way to access more Asian and Hispanic patient groups.

[ACT]IVATION Tip

“…for challenges faced with timely access to Asian and Hispanic subgroups and all racial groups, in my opinion, is to seek…it’s always appropriate to seek second or third opinions particularly at larger comprehensive cancer centers for the availability of clinical trials or whether it’s about questions about standard of care therapies or actually just questions about can we have a supportive service that you may offer that our local community providers may not offer?”

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Transcript:

Lisa:

So there are maybe some patients who are in more rural communities or go to smaller cancer centers. You’re at a very large center that has a lot of these resources. Do you think there is some benefit to patients if they have the ability to have a consult done by a specialist like yourself who only see, or who sees mostly gastric cancer patients? Can they tap into that like as a one-time consult when they’re diagnosed, particularly if they have metastatic disease, and could they also tap into the resources of a larger center?

Dr. Jun Gong:

That is a great question, Lisa. And yes, we do do that. We, as part of a large urban medical center here, we have a great relationship with our community oncologist and primary care doctors and other subspecialists where we are often referred for a second opinion or a third opinion. Sometimes it’s really, is this the best treatment that I have? Or it’s simply a question of are there clinical trials because we would like to refer to an urban medical center, a larger comprehensive cancer center for clinical trial options.

And here what I would like to add is that the post pandemic period has really afforded, in my opinion, an easier way to do consultations. I know it’s specific to certain institutions and certain centers, but I actually am okay with virtual medicine consultations for those who are…who find it difficult to travel to an in-person visit, again, I can’t speak for all other cancer centers or oncologists, but we at least offer this ability to do that, to help with that barrier of transportation. And when they are connected with us sometimes if we are able to, we can even follow peripherally, almost like an extra care partner with the main local doctor who’s driving more of the day-to-day, and we’re providing our recommendations as an extension from an urban medical center.

Lisa:

Great. Thank you for that information. I know as a cancer patient and a patient advocate, I will always recommend seeking out a consult from another person just to have another set of eyes on, particularly if it’s a specialist like yourself who sees primarily that type of cancer. So, thank you.

Dr. Jun Gong:

My activation tip for challenges faced with timely access to Asian and Hispanic subgroups and all racial groups, in my opinion, is to seek…it’s always appropriate to seek second or third opinions particularly at larger comprehensive cancer centers for the availability of clinical trials or whether it’s about questions about standard of care therapies or actually just questions about can we have a supportive service that you may offer that our local community providers may not offer? Or can you help us in a later stage of our treatment? Not just a one-time consultation, really just raising awareness that we do have ancillary staff that are very, very, very helpful in terms of addressing a lot of these risk, healthcare access barriers.

The one thing I would’ve liked to add was I think involving church groups is a really, really great way for Asians and Hispanics, because they are so heavily invested in attending church services. And that’s one of the innovative approaches from the Cedars-Sinai perspective is that we actually have a disparity center, a center of community outreach where we are actually engaging both Asians and Hispanics and other racial groups with their leaders in the churches, the local churches, to actually educate and promote awareness.

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PODCAST: Gastric Cancer: How to Access the Best Care and Treatment for YOU

Advances in gastric cancer research have led to more personalized therapy for patients. Dr. Yelena Janjigian discusses how biomarker testing can help guide a patient’s prognosis and treatment path, reviews currently available gastric cancer therapies, and shares tips for self-advocacy.

Dr. Yelena Janjigian is Chief of Gastrointestinal Oncology Service at Memorial Sloan Kettering Cancer Center. 

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Transcript:

Katherine:

Hello and welcome. I’m your host, Katherine Banwell. Today’s program focuses on helping patients understand gastric cancer treatment options based on their individual disease. We’ll review the latest research and provide tips for self-advocacy to help patients access better care.  

Before we meet our guest, let’s review a few important details. The reminder email that you received about this webinar contains a link to a program resource guide. If you haven’t already, click that link to access information to follow along during the webinar. At the end of this program, you’ll receive a link to a program survey. Please take a moment to provide feedback about your experience today in order to help us plan future webinars.  

And finally, before we get into the discussion, please remember that this program is not a substitute for seeking medical advice. Please refer to your healthcare team about what might be best for you. Well, let’s meet our guest today. Joining me is Dr. Yelena Janjigian. Dr. Janjigian, welcome. Would you please introduce yourself? 

Dr. Janjigian:

Thank you so much, Katherine, for this opportunity. My name is Yelena Janjigian. I’m a medical oncologist. And I oversee the GI oncology service at Memorial Sloan Kettering Cancer Center in New York. We’re a large group of doctors, over 40 physicians who treat everything from esophagus cancer to rectal cancer. And my research focus and my passion has been in developing new treatments for patients with stomach cancer, so I personally focus on this disease clinically and from research perspective.  

Katherine:

Okay. Lovely.  

Well, thank you so much for joining us today. I’d like to start by learning about the latest research news. Are there recent advances in gastric cancer that patients should know about? 

Dr. Janjigian:

That’s a great question. The field of gastric cancer research has accelerated and evolved immensely over the last three years. We’ve had several important approvals for treatment of metastatic disease both for biomarkers selected population and immunotherapy targeted therapies. So, there’s been a lot of research, a lot of effort and some positive data that the patients and clinicians should be aware of.  

Katherine:

And what excites you about the research you’re involved with? 

Dr. Janjigian:

I’ve been focused on gastric cancer for nearly two decades. So, my recent advances have really helped to understand how we can improve patient’s survival better, potentially cure more patients, and understand the different subsets of cancer treatments and patients with gastric cancer understanding that not all gastric cancer is the same.  

So, I think being able to zoom in on different subsets and target personalized approaches for each individual patient is why I stay in research, why I stay in gastric cancer research because we’ve been able to make some major breakthroughs.  

Katherine:

That’s excellent news. How can patients stay up to date with treatment options? 

Dr. Janjigian:

That’s a great question. And recently there’s been a lot of resources online through both the big pharma really educating patients with patient-friendly handouts. And many of my big recent papers when we publish them in big journals like Lancet or Lancet Oncology, for example, or JCO, there’s always a patient-friendly handout that comes with that data that helps patients understand some of the endpoints, how do we describe why this study is positive? 

Or why is the FDA decided to approve the drug? So, there are many patient handouts that come with some of these papers. And it’s interesting, a lot of my patients come in. When they see me, they say, “Oh, it’s so good to finally meet you. I’ve watched a lot of your videos.” So, because of COVID actually, a lot of the scientific content that used to be just in in-person meetings behind doors for doctors, now it’s all online because a lot of these scientific presentations are now made for virtual content as well. So, patients have access to it. That’s double-edged sometimes. It’s a little bit of an information overload, and it may actually make patients feel more anxious than reassure them, right? Because it’s a lot of jargon and not too – but some patients find it helpful.  

Katherine:

Yeah, I can see that. It can be a double-edged sword.   

Dr. Janjigian:

Yeah.   

Katherine:

Well, thank you for that advice. So, now that we’ve heard what’s happening in research, let’s review some more basic information about gastric cancer. First, gastric cancer is sometimes referred to as stomach cancer. Is that the same thing, or are both terms correct?  

Dr. Janjigian:

Yeah. So, stomach is really where the cancer starts. But we can talk about stomach or abdomen. But gastric and stomach are the same tumor location basically. What’s interesting actually, some patients also have tumors that start at the bottom of their esophagus and extend into the stomach. So, biologically a lot of these cancers behave similarly. In fact, in United States the most common location for these cancers actually is in between the gastric esophageal junction and the stomach.  

So, it’s in the location in of the cancer that’s at the very top of the stomach. But in short, stomach cancer and gastric cancer are interchangeable. And as I mentioned, for many of our viewers, actually gastro-esophageal junction is also part of the same disease.  

Katherine:

Could you tell us what tests are used to diagnose gastric cancer? 

Dr. Janjigian:

Most of our patients, when they come in to see me, by then the diagnosis of cancer has been made because I’m on oncologist.  

In clinical practice, patients often present with vague symptoms or no symptoms at all. And that’s an important point for our clinicians to understand. In patients who have chronic acid reflux or have, for example, other risk factors such as H. pylori infection, often they end up getting endoscopy at the time, for example, for their first colonoscopy. So, the age of colonoscopy, the first colonoscopy has is getting earlier and earlier with each update, because colon cancer is increasing in incidents in younger adults. So, sometimes patients present and get first endoscopy, for example, which is an upper test with a camera when they’re getting their colonoscopies. In other patients, unfortunately, they present with more progressive symptoms. Often, it’s difficulty swallowing, regurgitation of food, and weight loss, which is obviously very dramatic.  

And so they end up getting an endoscopy because of that and referred by their doctors.   

Katherine:

How is gastric cancer staged? And what do the stages mean? 

Dr. Janjigian:

Yeah. So, the most important part of the staging of gastric cancer and what patients ask me, “What is my risk of cancerous recurrence? What is my stage?” Really what it comes down to is the depth of invasion. So, it’s not only the size of the tumor, but how deep is it going into the muscle of the stomach, because stomach and your esophagus are basically a muscular bag, right? And so how deep is the invasion of the tumor into the wall? And also how likely are the lymph nodes to being involved? So, we assess it based on clinical symptoms such as swallowing difficulty and so forth. But in some patients, because the tumor is lower down in their stomach, they may not have very many symptoms, because there’s a lot more give in this muscular bag that our stomach is.  

And so we test the endoscopic ultrasound to look at the depth of an invasion and also other X-ray type imaging such as a PET scan, a P-E-T scan or a CAT scan, which gives us a sense of tumor location whether or not we think the lymph nodes may be involved. And ultimately the final way to assess, especially in patients who are undergoing surgery, is their microscopic involvement of the lymph nodes? Because that often drives the likelihood of cancer coming back after surgery.  

Katherine:

And how do the stages work for gastric cancer? 

Dr. Janjigian:

So, in gastric cancer it’s either early, intermediate, or late stage. And this goes from stage I to IV. So, stage IV  tumors is where most of the cancers are present. Over probably 50 percent of our patients present already at the time of diagnosis with more advanced stages. 

Biologically this cancer just tends to move quickly. So, even in between endoscopies in patients who get endoscopies frequently, often it goes from 0 to stage III or IV because of the lymph node involvement and also spread of microscopic cells, right? Tiny, tiny cells before we even see them, they spread through the bloodstream to other organs or lymph nodes outside of your abdomen. So, that’s considered to be stage IV. And then early, early stage disease is stage I. Those usually that we can just scoop them out using endoscopic procedures. They don’t even need to have full surgery. And then stage II and III is usually if there’s some involvement of the tumor through the muscle or into the muscle of the stomach and also some lymph node involvement. But that’s how we stage it.  

Katherine:

Okay. I’d like to move onto current gastric cancer treatment options. Can you provide an overview of what’s available now?  

Dr. Janjigian:

Right. So, in patients with intermediate or early-stage tumors, really surgery is the main way to cure patients. Occasionally when we have an amazing response to chemotherapy or chemotherapy with immunotherapy or just immunotherapy, we can avoid surgery. But in most patients, surgery in early-stage disease is a gold standard for cure. Of course, it can be a very jarring thing to say to someone. “We have to take out. your stomach.” But patients do live without either fully their stomach removed or partially removed. And that’s the gold standard. We do additionally other treatments to help maximize chances of cure, but surgery is the main state. As I mentioned earlier, most of our patients, however, present with later stages where surgery is not feasible.  

And when I say it’s not feasible, we would only attempt an operation if we thought there was a possibility of removing the cancer completely. Leaving some of the tumor behind, even if it’s only 1 percent of the cancer behind, makes patients unwell. They may not be able to tolerate additional chemo, so we do not recommend doing suboptimal surgery unless cancer can be completely removed. So, in those patients, we always explain the situation. And the disease is not potentially as curable, but it’s absolutely always treatable. And since the development of our immunotherapy options, really, we’ve changed the trajectory and the course of those cancers. We won’t know the stage or the final response to therapy until we’ve start it. But in those patients, usually a form of long-term therapy. Chronic treatment is very important.  

And usually it involves a combination of chemotherapy and some targeted agents, biologic agents, meaning that they were designed in the lab to target the cancer specifically. And usually, they involve some sort of immunotherapy.  

Katherine:

Excuse me. Can you go into some detail about the targeted therapies and immunotherapies that you use?  

Dr. Janjigian:

Sure. So, conventional chemotherapy works on any rapidly dividing cell. And these are chemotherapies that have been tried and true in the clinic for decades, right? And they work still in gastric. And in  particular they’re very important. And then over the last 10 years or so, we’ve started developing target agents in the lab that target the specific biologic tumor biomarkers. And when you think about tumor biomarkers, I would think about them as almost ZIP codes, right? How do you direct the cancer cell to die? 

And how do you inhibit the cancer cell for the thing that is uniquely what’s making it grow as opposed to normal cells, right? So, that’s the difference between chemotherapy because chemotherapy can affect any rapidly dividing normal cell and cancer cell, while biologic agents ideally only affect the target, cancer, the cell. So, that’s why it’s very appealing to do both to help maximize response and survival on treatment. So, the biologic therapies that are available in and already approved in our disease for stomach cancer are something called HER2 directed treatments. And that’s been my focus in the lab. And then in my group has really spearheaded a lot of this research for HER2-positive tumors. In gastric cancer it occurs in up to 20 to 30 percent of tumors, but we have drugs such as trastuzumab or Herceptin, T-DXd, trastuzumab deruxtecan-nxki (Enhertu) or in HER2 that target these agents.  

And furthermore, our work here at Memorial Sloan Kettering demonstrated the combination therapies really for HER2-positive disease has helped improve outcomes in those patients. So, that’s biologic therapy. Other biologic therapies that’s approved in gastric cancer is something called VEGFR-2 inhibitor. These are drugs that target blood vessel formation around the tumor to help the chemotherapy drugs work well and better. Those drugs are called ramucirumab or Cyramza. And that’s used in a combination of chemotherapy in second-line treatment. And there’s other drugs such as regorafenib (Stivarga) and other inhibitors that maybe have some targetable activity in our disease. And last but not the least is immunotherapy. So, immunotherapy’s a completely different class of drugs.  

We think about immunotherapies, really the fundamental problem with cancer, right? The cancer issues that it started as a normal cell. So, at some point, it was a normal cell that then became and went awry and went rogue. And the body did not recognize that there was a problem. And the immune system did not eliminate that cancer cell. Before it started to metastasize and give us problems in their body, right? So, the fundamental question is why is the body’s immune system, why did it not recognize it as a abnormal cell? Well, because it really acts and looks like a normal cell from the immune perspective. Our immune system is trained not to hurt us, right? And that’s why in patients with rheumatoid arthritis or other autoimmune disorders, what happens is the immune system goes awry. So, what the immune checkpoint blockade or immunotherapy for cancer does, is it helps take some of those brakes off our immune system and help our immune system recognize the cancer and give it permission to say, “Hey, you know what?  

You thought it was a normal cell. It’s not. It’s a cancer cell. Please help us eliminate it.” And that’s worked well because I think in for some of our patients, the immune system actually knows how to target and suppress the cancer much better than any of the fancy drugs we can design in the lab. And that’s why in some patients, immune checkpoint blockade immunotherapy has been such a game changer if you do respond, your duration and durability of response is so much more better than anything that would go to just done on our own in the lab or with other chemotherapies. So, it really is a nice way to think about it. And the patients feel like they’re part of the solutions. It’s always nice for them to have that.  

But it’s been a real game changer for both HER2-positive and HER2-negative disease in combination with chemotherapy. I’ve had the pleasure of leading some of these studies. And it’s nice to be able to update the three or the four or the five-year survival rate from these studies in a disease where in the past most patients died within a year.   

Katherine:

Dr. Janjigian, I’d like to talk about what goes into deciding on a best treatment for a patient. Is there testing that helps you understand a patient’s individual disease? 

Dr. Janjigian:

One is an important factor about this disease, and when the patient comes in, the number one factor that helps us decide, what treatment to assign, is how well is the patient feeling? What are their nutritional deficits? How functional they are. Are they able to tolerate the treatment?

Because as an oncologist, the first rule is do no harm. Most patients come in when they’re first diagnosed are pretty well functional. They’re still able to eat. And so, they’re really up for the most aggressive. And that’s probably the number one wish I have from patients. I just want us to stay well and stay alive. So, we can be very aggressive with them, at least folks that come to see us in New York. And so, then the decision fork is really do you want only standard therapy, or are you interested in clinical trials? And I think what I am able to really explain to the patients, which is great, is that the benefit of trials – and, of course, you can never guarantee that a trial will be successful, right? Because that’s by definition – a clinical trial is experimental therapy. But for gastric cancer and stomach cancer where we need as many treatment options as possible, a clinical trial gives you an opportunity to try something different, and then go back to standard therapy, and then try experimental therapy, and then go back to standard therapy.  

So, it gives you as many options as possible. The way that I help our patients visualize this is you’re trying to cross a very wide and somewhat turbulent river. And you need as many stepping stones as possible. And a clinical trial, if it makes sense for you and if you’re able to do it physically, it gives you that other option. The most important other factor is to understand which subset of stomach cancer you have, right? Because biomarker testing has helped us tremendously to advance this disease. If you look at and if you watch any of my talks, I usually have this timeline of therapeutic development in stomach cancer until really this past year.  

We’re 2022, 2021. There was over a decade of negative trials, right? And the reason why I think is because the design of the trial really focused on targeting all the patients the same way. And now the trials are becoming more and more sophisticated. So, when we talk about the biomarker testing of the tumor, the patient’s specific tumor.  

It’s important for the patient to ask their physician. “What is the status of my tumor?” And the four critical biomarkers are microsatellite instability, HER2, PD-L1, and Claudin-18.2. So, those four biomarkers have really helped us transform this field especially in patients with metastatic disease. And in all of the tertiary cancer centers, certainly here at Memorial Sloan Kettering,  for each of the subsets we have a full research portfolio.  

So the patients have both standard and experimental options available to them.             

Katherine:

Well, how can test results like biomarker testing affect the patient’s prognosis and treatment options? 

Dr. Janjigian:

It will depend on the treatment and how it is paired to the biomarkers. So, for example, a certain subset of tumors such as microsatellite and stable tumors are patients with PD-L1 high tumors or even patients with HER2-positive tumors. Now in clinical trials, we see that those patients have an outstanding dramatic response to combination therapies often with chemotherapy or immunotherapy together or even HER2 directed therapy with immunity therapy. So, it really will impact how likely your tumor is to shrink. And if the tumor is shrinking, and if you’re feeling better, obviously that translates to better survival.  

Katherine:

Yeah. What questions should patients be asking about their test results? 

Dr. Janjigian:

I think it’s important for patients to be very clear with their providers about their willingness to undergo repeated biopsies if needed.  

I think the number one misunderstanding or misnomer that I see when patients come in to see me as a highly trained specialists, and they’re seeking me out for expertise and second and third and fourth opinions is that when the biomarker test is not done, often the answer in the community from the physician was, “Well, there was insufficient tissue or the tissue quality was not great, and that’s we’re going to do it. And it turns out the patient is perfectly willing and able to undergo a second biopsy. They really do not mind because a lot of times it’s just as simple as having a repeat endoscopy. Or even on treatment off and the problem is it’s a constantly evolving cancer. So, for example, if you receive first-line treatment and then you progressed and you need additional treatment, often it’s important to get a second biopsy to understand what your biomarkers are at that point. 

And I described this to my patients. We can’t get into a battle with outdated maps. We need to know. And sometimes when there’s a misunderstanding, the doctors think, “Maybe the patient wouldn’t be willing to do it. Or they are risk-averse.” And the patient’s more than willing to do it. So, I think communicating your wishes and your intent clearly with your doctors and not being shy to ask questions, and also not being shy to seek out clinical trials, right? So, yesterday I was in clinic. I see a lot of this disease. I often see 30 patients at clinic. I had an 80-year-old patient in my clinic, right? And before you meet the patient, most doctors would think, “Well, it’s an elderly patient. They wouldn’t even be interested in clinical trials. What are we trying to accomplish here?” 

Katherine:

Right.  

Dr. Janjigian:

But this patient clearly is – he exercises five days a week. He’s extremely active. He wants the best options for him.  

So, I am not an ageist, so I asked him. I said, “What are your sort of goals of this therapy? And how interested are you in clinical trials?” And him and the family were extremely enthusiastic. And, “We’re going to go for it, and we’re going to try.” So, I think having those conversations with your doctors – because you remember gastric cancer is very rare. In my clinic I see 30 patients, but in most normal sort of oncology practices, it’s lung, breast, and colon, the big three that sort of saturate the schedule of the oncologists. So, if they see one or two gastric cancers a month, they may not be thinking along the same lines of your disease. So, then you have to ask the questions of, “Are there any clinical trials? Should I see a specialist?” Did you do all of my biomarkers? 

Katherine:

Yeah, yeah. That’s really great information to have.  

Are there other decision factors involved in deciding on treatment options? You mentioned age, comorbidities. What else do you look at? 

Dr. Janjigian:

Yeah, the other important factor as I said is nutrition. Being able to stay fit and stay independent is very important. Some of my patients ask me, and then they feel like what they eat is so important that as soon as they get their diagnosis, they restrict their diet. And then they start losing weight. And that’s not good. The number one negative prognostic factor is if you lose more than 10 percent of your body weight within the first few months of the diagnosis – because you get really weak, and then you can’t tolerate the chemotherapy. So, I tell the patients, “Your body will take from you whatever it wants. The cancer will take from you, from your body. So, you need to support yourself nutritionally.” So, if you don’t feel like eating a salad, but you are craving a cookie, it’s okay.  

Have that cookie; just don’t lose weight. And I think that’s the number one. And also, the other factor is how do you communicate your diagnosis and your prognosis to your family and your friends? Because then everybody’s asking and making you in some ways anxious, your job. And what I tell patients is, “It’s on need-to-know basis.” If you find love and support, then you can tell people. Otherwise, you can just loosely kind of mention that you need some help, and you’re going through treatment without specific details. And the great part about these combination immunotherapies is that a lot of our functional patients actually continue to work through this. And so, we fill out whatever forms they need for their jobs and so forth. But we have lawyers that are continuing to work, teachers, and sometimes even construction workers. So, really, I would say make decisions as they come up.  

Don’t run too far ahead and sort of assume that you’re going to not be well. But if you want to take some time off, that’s okay too. And so, I think the treatment paradigm for this disease has evolved so much that there’s a lot of misconceptions. And I think the job of a good oncologist is to let the patient live their life in as normal a fashion as possible. So, we work the chemo schedules around their schedule. Some of these immunotherapies you can give once a month. So, I have patients who will fly into see me, for example, get the dose, and then go back home. So, I think don’t be afraid to ask for what you need.  

Katherine:

Yeah. Well, that leads us very smoothly into self-advocacy. And it’s really important that patients advocate for themselves. So, if a patient has a question or they’re unsure about a decision, why is it so important for them to speak up?  

Dr. Janjigian:

What I always tell my patients and I explain to them, that often the doctors know a lot of information. But there’s so much information that it’s almost impossible to – and we only have 15 to 20 minutes together. So, it’s almost impossible to communicate everything that we know to you. So, you need to drive a bit of what the focus is of priorities in each visit and get as much information as you can. But also in some ways, follow the doctor’s lead. So, it’s a balance of information exchange. Use the portal as much as possible as well. The patient portal is often for follow-up questions. Write questions down. We have our nurse practitioners, our nurses, our fellows that continue to educate the patients because as things come up, and the field is so complicated that there  are just so many things that you can ask at one single appointment.  

So, it’s okay to forget something, but just write it down. In the end like anything else, you only have one sort of chance to do this in a way that you want it to be done. And as treatment progresses and you’re not feeling well, and maybe you don’t want to keep coming in for appointments and would rather go spend time in Aruba or Florida or somewhere sunny as opposed to – that’s okay. I think a lot of times it’s your life. You only have one. And I strongly believe in anything to try to get as much out of every interaction as possible using all the resources that are available to you.  

Katherine:

Well, I’d like to close today with getting your thoughts on how you feel about the state of gastric cancer care. Are you hopeful about treatment options? 

Dr. Janjigian:

I’m extremely hopeful. And usually, I finish all of my scientific talks. I’m a physician scientist.  

I travel a lot to meetings. And my goal now in my career is to attract more and more young talent and scientists that will help us make the next wave of breakthroughs for this difficult disease. I think we’ve made a lot of progress, but the reality is: We’re still not curing enough patients. And so, our next wave is not just to stabilize and help people live longer but cure them definitively and permanently. And so, I finish every single presentation I have by how much the possibility and how fruitful this field has been. Personally, for my work and career of those that I’ve mentored throughout the years all over the world. So, I’m very hopeful for the next five, 10 years in this field. It will continue to get better.   

Katherine:

It sounds very promising. Dr. Janjigian, thank you so much for joining us today.  

Dr. Janjigian:

Thank you. Great question.  

Katherine:

And thank you to all of our partners.   

If you’d like to watch this webinar again, there will be a replay available soon. You’ll receive an email when it’s ready. And don’t forget to take the survey immediately following this webinar. It will help us as we plan future programs. To learn more about gastric cancer and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Kathrine Banwell. It’s good to have you with us today.