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Upper gastrointestinal cancers

Upper gastrointestinal cancers. Dr Sue Darby Consultant Medical Oncologist Weston Park Hospital Sheffield. Introduction. What’s UGI? Terminology Treatment intent Treatment options Clinical trials. What’s upper GI?. Oesophagus GOJ Stomach (Small bowel). What sorts of cancers?.

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Upper gastrointestinal cancers

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  1. Upper gastrointestinal cancers Dr Sue Darby Consultant Medical Oncologist Weston Park Hospital Sheffield

  2. Introduction • What’s UGI? • Terminology • Treatment intent • Treatment options • Clinical trials

  3. What’s upper GI? • Oesophagus • GOJ • Stomach • (Small bowel)

  4. What sorts of cancers? • Mainly adenocarcinomas (lower oesophagus downwards) • Squamous cell carcinomas (usually upper or mid oesophagus) • Gastrointestinal stromal tumours (GIST) • Lymphoma • Metastatic tumours (follicular breast, renal)

  5. Treatment intentions • Neoadjuvant • (Downstaging) • Adjuvant • Curative • Palliative

  6. Treatment types • Chemotherapy • Radiotherapy • Chemoradiotherapy • Biological therapy • (Brachytherapy) • (Surgery)

  7. Curative treatments

  8. (Neo)adjuvant chemotherapy • SqCC • 2 cycles neoadjuvant chemotherapy • 2 drugs – cisplatin and 5 fluorouracil • OEO2 trial – increases 2 year survival from 35% to 45% (surgery vs chemo+surgery) • Surgery 4-6 weeks after chemo

  9. (Neo)adjuvant chemotherapy • AdenoCa • 3 cycles neoadjuvant and 3 cycles adjuvant chemotherapy • 3 drugs – epirubicin, cisplatin and capecitabine • MAGIC trial – increases 5 year survival from 23% to 36.5% (surgery vs chemo+surgery) • Surgery 4-6 weeks after neoadjuvant chemotherapy

  10. ST03 • ECX +/- biological therapy • HER2 positive • +/- lapatinib • potentially operable lower oesophageal, GOJ and gastric adenoca • HER2 negative • +/- bevacizumab • gastric adenoca only

  11. Side effects • Benefits outweigh risks (in majority) • GI – nausea, vomiting, diarrhoea, constipation, mucositis • Skin – hair loss, hand-foot syndrome • Neurotoxicity – peripheral, tinnitus/deafness • Renal toxicity • Fatigue • Haematological – thrombocytopenia, anaemia, neutropenia (neutropenic sepsis) • Cardiovascular – angina/MI, arrhythmias

  12. Contraindications/Cautions • Ischaemic heart disease • Renal disease • Perfomance status • Patient choice

  13. Chemoradiotherapy • SCOPE trial – 2 yr survival >50% • 2 cycles of neoadjuvant cisplatin and capecitabine • 5 weeks of daily radiotherapy concomitantly with a further 2 cycles of capecitabine • Side effects • odynophagia • fatigue • severe dysphagia (towards end of radiotherapy) • treatment related stricture (late effect) - may require dilatation or stenting • Advantages over surgery – can treat some surgically untreatable cancers (eg locally invasive) • Disadvantages – nodal disease/field size

  14. Palliative treatments

  15. Palliative chemotherapy – 1st line • SqCC • Cisplatin/5FU • AdenoCa • Oesophagus - EOX – epirubicin, oxaliplatin, capecitabine – adds few months on average • Gastric/GOJ • HER2 negative – EOX • HER2 positive – cisplatin, 5FU, trastuzumab (Herceptin) + maintenance trastuzumab • TOGA trial

  16. REAL2 • ECX/ECF/EOX/EOF • No significant difference in survival between arms • Around 9-11 months median survival • Trend towards best with EOX • Delivery issues • Led to change in practice from using ECF (PICC lines, continuous infusional chemo) to EOX (oral 5FU, no PICC)

  17. Palliative chemotherapy – 2nd line • SqCC – nothing • AdenoCa – docetaxel • COUGAR trial – adds 2 months on average • Symptomatic benefit/BSC • Early phase trials (Leeds)

  18. Palliative radiotherapy • Symptomatic benefit • If local disease only can offer some local control • Good for: • Dysphagia • Bleeding • Tumour pain • Side effects minimal and short-lived – odynophagia, increased dysphagia, fatigue

  19. Clinical trials • Only way to improve outcomes • What current treatments are based on • Form basis for future (better) treatments • Importance of introducing idea to patients at early stage • Early referral of patients • Opportunity • patients • doctors

  20. Questions?

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