MS. KRISTIE KAHL:This is part one of the series focused on diagnosis and staging.I’m Kristie Kahl, editorial director of CURE.We’re pleased to bring you this webcast presented by CURE and in partnership with Debbie’s Dream Foundation, and our sponsors Bristol Meyers Squibb, Daiichi-Sankyo, and Merck.

We’ve a few important announcements before we begin.We encourage you to ask questions during the event which you can submit by typing them in the Q and A box.You will be receiving a survey via email tomorrow.As a thank you for watching the full webinar and completing the survey, you will be entered to win a $200 Visa gift card.

We’re pleased to be joined today by our moderator, Dr. Jaffer Ajani.Professor of Medicine in the Department of Gastrointestinal Medical Oncology in the Division of Cancer Medicine at the University of Texas, MD Anderson Cancer Center.

As well as Dr. Madappa Kundranda, Section Chief of Medical Oncology in the Division of Cancer Medicine and Director of the GI Cancer Program.A medical director of regional hematology/oncology practices at Banner MD Anderson Cancer Center.

Dr. Daniel Catenacci, Associate Professor in the Department of Medicine and Director of the Interdisciplinary Gastrointestinal Oncology Program and the Assistant Director of Translational Research in the Comprehensive Cancer Center at the University of Chicago Medical Center and Biological Sciences.

And Dr. Bassel El-Reyes, Professor and Vice-Chair for Clinical Research in the Department of Hematology and Medical Oncology, and Director of the Gastrointestinal Oncology Program at Winship Cancer Institute at Emory University.

Thank you for joining us today and I’ll now pass things off to our moderator to begin our discussion.

DR. JAFFER AJANI:Thank you, Kristie.I want to welcome all the participants, all the members in the audience, patients, and relatives.We’re really privileged to communicate with you today about very important questions we have.We have already formulated some questions.We hope that these are going to be very instructive for you.And if you have additional questions, of course, our panelists, a very experienced group of individuals will be answering that.

So we will begin.I’m going to ask Dan about our first question, which is understanding stomach cancer diagnosis and straight staging process.And this has multiple components like what does stomach cancer diagnosis mean?And explain this staging process.And whether this staging, once it is agreed upon, whether it has an influence on the treatment.Dan?

DR. DANIEL CATENACCI:Great.Thank you, Jaffer.And it’s a pleasure to be here today.I’ll start off with this question.It’s a very important question and it’s basically how we start our meetings when I’m meeting a patient for the first time and they’re newly diagnosed.

And so, the way I think about it, I always start with what’s the problem and why are you here?And usually, it’s due to some symptoms that led to a finding of a stomach cancer, usually by an upper endoscopy finding it in the stomach.At that point, we know there’s a stomach cancer, which means that there’s an abnormal growth in the stomach.And the next question we ask is what’s the extent of that problem, or something that we call what’s the stage?And the reason why that’s important, and Jaffer alluded to that, is because different stages are treated differently.And so, what’s involved in the staging includes a CAT scan.That’s of the chest, the abdomen, and the pelvis.What that’s looking for is to determine whether or not the cancer that started in the stomach has spread somewhere else.Some common places that it could spread to include the liver, the lungs, the belly cavity that we call the peritoneum, and the bone.Those would be some common places or lymph nodes that are far away from the stomach.

If the CAT scan is looking like it has not spread, then we would call that a localized cancer that doesn’t have evidence of metastatic spread or stage-four spread.And that would lead us to then do some other studies to do some more staging, which includes a PET scan, which is looking - - is not the cancer has spread outside but looking at it in a different way.CAT scans look at the size of things and PET scans look at the activity of the cancer in terms of how quickly it’s metabolizing and eating sugar.And so, together, they have a good sensitivity - - than either alone.And another test that we do is called an endoscopic ultrasound, which is like the first endoscopy, but it’s a specialized procedure looking to tell us how far through the wall of the stomach the cancer has grown and whether or not there are lymph nodes nearby that look abnormal or not.And that last endoscopic ultrasound is really helping us define whether or not the cancer is in early-stage, like a stage-one, or what we would call a more locally advanced stage, like a stage-two or a three.

And so after all of those procedures are performed, there may be one last staging procedure that we call a diagnostic laparoscopy.And that’s done if the CAT scan and the PET scan don’t look like there’s any spread distantly, and the ultrasound probe shows that there’s lymph nodes that look abnormal or that the cancer has grown through the wall of the stomach through into the third or fourth layer.Then we know that there’s a risk that the cancer could spread to the belly cavity that we call the peritoneal cavity that we just can’t identify well on CAT scans and PET scans.And so a laparoscopy, where a surgeon performs a very small incision in a surgery, that’s a same-day surgery, where they would go inside, look there and ensure that there’s no visible cancer that has spread.And they also spread fluid into that belly cavity and collect it and make sure it’s not in the fluid microscopically.

And so that’s all the staging procedures that one would do to really narrow down what’s the extent of the problem that we’re starting with.And as we’ve been talking about the treatments will be different based on the stage.And so for a stage-one cancer, typically we would recommend surgery alone and you wouldn’t be getting any therapies from me, the medical oncologist, with chemotherapy or with radiation therapy.On the other hand, if it was a stage-two or three cancer, we do know that surgery is not enough and that we do recommend chemotherapy before and after the surgery to enhance the cure rate.It improves the cure rate by helping to get rid of microscopic cells that we just can’t see despite all those staging procedures we just recommended to do.And then, unfortunately, if it’s stage-four, which means that it has spread outside of a surgical area, that means that at least today, in April of 2021, we don’t know how to eradicate the cancer from your body and surgery is not the recommended approach to deal with the issue.Rather, we treat with chemotherapy and other systemic therapies like immunotherapy and targeted therapies to help control the cancer, improve your symptoms, and to increase your survival time, but with the acknowledgment that it generally will not eradicate the cancer but rather just can keep it well controlled.

So I think that that’s a big topic and I tried to keep it as concise as I could to answer those questions.

DR. AJANI:That was very well done, Dan.Thank you for that.Are there any comments on this particular question from Bassel or Madappa?Any additional issues you want--

DR. BASSEL EL-REYES:[Interposing]I think Dan did a really excellent job in providing a very comprehensive review of staging.I think the one addition I would add is during the endoscopy we usually obtain biopsies as well to establish a what’s called a pathologic diagnosis where we look at those samples of the tumor under the microscope to characterize the tumor further in terms of its origin and more likely to look at also molecular profiles of the tumor that would help predict how it would behave or maybe how it would respond to certain treatments and we can elaborate on this more in the coming questions.

DR. AJANI:Okay.Any other--

DR. MADAPPA KUNDRANDA:No I agree with what Dan and Bassel had just said.Nothing more to add.

DR. AJANI:Okay.Very good.So I think we all acknowledge that this is a very stressful moment for our patient and their families because we all hope that it will be the lowest stage, so it’s a very important moment.A very important few days until we can finalize the stage, at least clinical stage.

Okay, so that’s very good.I think we can move on to the next question, which is completely related to the first question.So what one would do once the diagnosis is made in terms of patients and their family.What should they do?So the questions are after a patient receives the diagnosis, what is the next step? And as we all know, patients and families they want the treatments started the next day.What role does the caregiver play?This is also very, very important.And there many, many aspects to this particular issue about the loss of wages and all the stress that comes with sudden diagnosis of cancer.It never comes at the right time.Or I should say, there is never a good moment to have cancer.And should patient consider a second opinion?Bassel, would you like to make some comments about this important topic?

DR. EL-REYES:Of course.My pleasure.I think after the diagnosis is established, it’s very important that we start out treatment as quickly as we can, but also on the correct track.Because as Dan mentioned earlier, treatment options are complex.They could be ranged from surgery to chemotherapy plus surgery, or to chemotherapy alone, or immunotherapy, or immunotherapy plus chemotherapy.So there are many options for therapy and this is why it’s important after we establish the diagnosis to consult with a team of experts, especially in early-stage disease where multimodality therapy or treatments with chemotherapy radiation, and surgery from different specialties might come into play.It’s very important to put together a team and establish a right approach to manage the complex condition like this.

In addition to the medical specialties that are involved in managing these cancers like medical oncologists, like the people on the call today, surgeons, and radiation doctors, patients with stomach cancer need a number of people who support them with respect to nutrition, symptom management, and so on and so forth.This is why it is important to really after we establish the diagnosis to put together the team that will be able to deliver a complex care plan that is needed to take care of a complex problem like this.

In addition, more and more we learn that the stomach cancer is not one disease but actually many different kinds of diseases that can be classified by us testing what we call molecular features of the tumor or the things that make the tumor function in the way it does.And through that molecular testing, we are able to, number one, sometimes understand better how the tumor is going to behave.And more importantly, know more what is the best treatment for that specific tumor.Not everybody who walks to our offices with stomach cancer gets the same treatment if they have the same stage. The treatment is much more complex and is based on, in addition to the stage, on the molecular features of the tumor.So those are important next steps.

I think the caregiver is key in this disease.Dr. Ajani spoke a little bit about the financial implications of having a diagnosis of gastric cancer.There are a number of other implications that come with this patient even in the earliest stage where they are going to be treated with surgery alone, still need a lot of support after surgery in terms of recovery from the surgery, nutrition, physical therapy, and so on and so forth.Needless to say, when treatment becomes more complex and entails things like chemotherapy, radiation, and surgery, the support that the patients need at home to go through such a procedure, such a complex treatment is quite taxing on the caregivers.And then there’s financial aspect.There’s the supportive aspect.And then there’s also the emotional or the stress of having a diagnosis and the uncertainty of dealing with a serious illness like this where the patient really would need the caregiver to support them through the journey, dealing with a disease of this nature.So caregivers play, I think, a key role in supporting patients and dealing with this diagnosis.

As far as second opinions are concerned, I do think second opinions are very important because really none of us know the field completely and sometimes having someone else look at a case will provide a point of view that your own oncologist did not consider.In addition, it becomes even more important if you are being taken care of in an institution that does not have a lot of track record in taking care of gastric cancer patients or stomach cancer patients.This is not an extremely common type of tumor, so unless you are in a larger center, your medical team may not have a lot of experience in managing this type of cancer.So it’s not wrong to get a second opinion, especially if you are being taking care of in a smaller institution.In addition to the fact that second opinion can provide access to a higher level of specialization, you may get also sometimes input about availability of clinical trials, which is another important part of the management of this disease, especially in the more advanced stage.Those are things that you could learn from a second opinion.So I feel like a second opinion, if available, is important.Of course, we have to balance the second opinion against the delay in treatment because we don’t want to delay treatment while we get multiple opinions, but we have to balance getting the treatment started on time while obtaining that second opinion to make sure that we’ve covered all the bases.

DR. AJANI:Okay.Wonderful.Thank you, that was very well done.I’d like to ask Dan or Madappa if you have any additional comments on this particular question.

DR. KUNDRANDA:I think the only comment I’ll make is that I think to Bassel’s point, the psychosocial component of this is just so important both to the patient and to the caregiver.That is where I think supporting them emotionally and physically during this whole thing cannot be reiterated enough because the caregiver, he or she who’s caring for a loved one is working, taking care of a--being a true caregiver and kind of bearing the burden of everything else that typically was two people were sharing that burden.So one of the things, at least, in my thing that I’ve seen happens often is there’s a lot of focus on the patient and then sometimes we tend to forget about the caregiver and therefore, that support the - - oncology support is extremely important.That’s one part of it.

The second thing is with regards to the second opinion, I truly think, especially, like Bassel mentioned, this is one of those wherein getting that second opinion in a timely fashion is just extremely important because sometimes we’ve had patients with locally advanced disease, and they go and they’re trying to get the second opinion and that takes almost a month.And we know time to treatment is a huge predictor in terms of survival and outcomes.

So those are the only two comments.I really think Bassel wrapped it up very nicely.

DR. CATENACCI:I would agree with all of that and with the caregivers is very critical. I would point out we encourage second opinions, even third opinions because it does help with the difficulty of understanding everything that is going on to hear consensus with major issues like stage and what the general therapy should be.At the same time too, you’re talking to academics here that are at, like, tertiary academic centers that are always trying to do better than the standard of care and we always have clinical trials that are looking at questions can we do better than what we do normally?And getting second and third opinions you can see what other treatment options on clinical trials there might be, and different centers have different studies.So by looking around at that, you sort of get a full picture of all the possibilities and treatment options, and then you have sort of all the things on the table and you can pick what you feel is right for you in collaboration with your doctor that’s acting as your consultant.I would also say, though, and what both of the others have said is that you have to balance that with at some point you have to start therapy.And you can’t wait too long doing all of that before you get going.So it is a balance, but at the same time rushing in and missing out on potentially good opportunities is also potentially not a good idea either.

DR. AJANI:Okay.Thank you very much.I think we will probably come back to some of these topics when we go into question and answers.Let’s go to question number three, which is another very important question which is how to recruit a treatment team and how can a patient learn more to ensure that they’re treated by somebody who has had experience with stomach cancer and not necessarily someone who treat stomach cancer occasionally?The question also includes the importance of multidisciplinary approach.And why is it so important that they’re getting the right treatment from the right team, it says.So Madappa, do you want to elaborate on some of the answers?

DR. KUNDRANDA:Absolutely.I think some of it is kind of repetitious in its own way, but I think it’s such an important question that I think it definitely bears repetition here.

So the first question is how can a patient learn more to ensure that they’re being treated by the right team?And that is a critical part of it because especially in early-stage cancers, going to a high-volume center, having that multidisciplinary approach--and when we say multidisciplinary approach, it is not just the surgeon, radiation oncologist, and the medical oncologist.It’s truly that entire team.So when we have that, one of two things that is important is when--and also figuring out or having a candid conversation with the physician that’s treating you, how many of these patients have you treated in a year?How often do you see this diagnosis?And that kind of alludes to some of the things that Dan brought up as well with regards to clinical trials.Ideally, with every stage, first option is a clinical trial.An appropriate clinical trial, I would say because all of our trials tend to have a randomized arm - -.At least you’ll be getting the standard of care.Which is where if you do not have any clinical trial options, then you - -, what is the standard of care?And going on to a clinical trial is that you have the option to get investigational therapies whether it is in an early-stage cancer or if it’s in a late-stage cancer.So I think that is an integral part of it in the context of when you’re trying to decide on the right team is to have that candid conversation with the physician who is treating you.

The second part of it is what is the role of a multidisciplinary team in this whole--or rather a multidisciplinary approach in this whole treatment of gastric cancer?This cannot be more important, especially in the resectable situation more because that’s when truly a trimodality treatment in certain cases or basically when you’re using radiation, you’re using surgery and you’re using chemotherapy to get the best outcomes can come into play.So it’s important to have all of these physicians sitting around a table looking at your scans trying to figure out, “Hey, we’ve had the laparoscopic thing, this is what we saw” and having that candid discussion one-on-one before they come up with this treatment plan per se.When you’re planning out the treatment plan also is part of this multidisciplinary approach, is basically involving the dietitian or the nutritionist because, in most of these cases or a significant number of these cases, weight loss and kikexia, cancer kikexia is a true entity.And you do not want to go into this--you want to go into this with everyone in your corner.And that’s the reason why having a dietician there, and occasional cases having genetic counselor.In these 1 to 3% of these genetic - - --because I think somebody asked us about stomach cancer in one of these questions below and we’ll go get into that later--becomes important.So gone are the days wherein it was chemotherapy, chemotherapy, chemotherapy alone, or just surgery upfront per se.One of the changes wherein we’ve seen that and the optic is almost two-thirds of the country does that as well, which is looking at therapies prior to surgery.Some of it has worked.Dan alluded to wherein you’re trying to make sure that you--the - - of the tumor has not spread at this point in time.You want to ensure that this micrometastatic disease has certainly controlled prior to going into a surgery to get the best outcomes.And all of these only rendered in an appropriate way when you have multidisciplinary team working together.

So if the question is why is it important for patients to make sure that they’re getting the right treatment at the right time, right, and from the right team.That is because you really can’t--once we get things started, very few times when, especially in the purest of setting, there are very few times when you can take a step back and say, “Yeah, it’s already done.Let’s move on.”And we tend to do it if the approach is not accurate.However, to get the best outcomes and trying to do it at the right time with the right team and I think that’s why large volume centers make sense, and people who are more comfortable treating this and the modalities makes sense.And even if it’s staging.I mean, if somebody’s doing an endoscopic ultrasound and staging and this is not somebody who does that on a regular basis, that can be inaccurate as well.So that is, yeah.So that I hope I answered all of those questions that were addressed, Dr. Ajani.

DR. AJANI:Yeah, thank you.That was very well done.We have a few more minutes to dwell on this particular question.So Bassel or Dan, any additional points you want to raise about multidisciplinary approach?Do stage-four patients really--do they need that, or we focus on earlier stages, and do we allow one of the team members to make the final decision, or is better to make a group decision?Some comments on that.

DR. EL-REYES:Well, I’ll go first.Oh, Dan, go ahead.Go ahead, Dan.I’ll go after you.

DR. AJANI:Okay.You may be muted because we can’t hear you.

DR. CATENACCI:Can you hear me now?

DR. AJANI:Yeah.Now we can.

DR. CATENACCI:Okay.So I was going to agree with what said and pertinent to the questions that Jaffer just asked. I think that the multidisciplinary approach which generally typically means like looking with surgeries, with radiation oncologists, with gastroenterologists and pathologists, many of our centers have weekly meetings that review cases that are complex, including gastric cancer patients, to go over all of the information, the staging, the pathology, et cetera, and to weigh in on what we think is the best approach as a consensus opinion.However, Jaffer pointed out, like, is this happening with every stage-four patient?What other types of patients that this is going on for?Generally, it’s for earlier-stage patients that are, you know, stage-two or three that are going to have multidisciplinary approach to their care.But that said, almost all patients are at least reviewed there at the first meeting just to ensure that we agree on the staging, especially if it’s not clear to review the imaging, et cetera.So I think, as Madappa was mentioning, is that you really want the staging component can have a lot of subjectivity and in places that don’t have high volumes of this cancer, they may have different, sort of, stage in terms of what they’re calling a certain cancer.So that’s a very important point.

And then the other part of multidisciplinary care that was mentioned outside of that is very important even, and probably more so, for the stage-four setting in terms of having palliative care physicians and teams and nutritionists involved in their treatment.Maybe the multidisciplinary team is slightly different in each of those stages, but multidisciplinary care is always welcomed in having more, sort of, minds addressing a given problem together.I would just extent what was already said in a certain way.

DR. AJANI:Bassel?

DR. EL-REYES:I agree with Dan and with what he just said.I think in stage-four the multidisciplinary team component may be a little bit different than what it is in stage-two or stage-three, but definitely, we do benefit from having input on nutrition as many times as a major issue in these patients.Supportive care in terms of pain control, control of other symptoms that come sometimes with treatment.That is an important aspect.Psychosocial component of taking care of these patients.Also, that’s part of the multidisciplinary team that’s involved.And occasionally when you have these unusual molecular features in the tumor engaging pathology and your molecular tumor board to sort of figure out what the best approach.Also, in management of certain unique molecular profile tumors is also important.So there are many aspects and complexities to the management of stage-four that require a little bit different type of multidisciplinary team, but still a multidisciplinary team.Maybe a little bit less for surgery and radiation, but more for those other partners who work with us on the care of these patients.

DR. AJANI:Okay.Thank you so much.So we’re going to the last question and I’m going to ask all of you to help me with this particular question.The question itself is the key questions patients should ask their doctors and healthcare team.And this is a big one.It’s about diagnosis, treatment, side-effects, schedule, additional issues that they don’t discuss is the co-pay, and whether they will be able to get medication or not.One thing I want to mention as providers, we recognize that the patient and family are under huge amount of stress.The amount of information they can really absorb and, also the amount of information we give them is just enormous.So in that context, how do you transfer important information to the patient and caregivers?I used to say before that I would explain the toxicity such as management of diarrhea, or nausea/vomiting to the caregiver rather than to the patient because the patient wants to know what is their longevity, curability, and they want to know the toxicity.But how to manage toxicity sometimes is best done by the caregiver so they can learn some of the algorithms that we mentioned.Can all of you just mention a couple of points that I may have missed as to what do you think is really important for families and patient to learn from the treating team that sometimes they will come back and say, “You never mentioned that or never explained that.”And, of course, you can’t really explain everything because there is so much information out there.How do you balance all that?Any comments?

DR. KUNDRANDA:Okay, I’ll jump in since both Dan and Bassel are not jumping into this.But the way I look at this is almost breaking it up into four different categories.One is--and then you are absolutely right, Jaffer.This is one of those where when the patient comes in for the first time, most of them, although we try to fragment it up, what I tell them is, “I’m just going to give you the big picture here.”And then we’ll delve into a couple of things and on the subsequent visits, that’s when we go into and basically give it piece by piece, so to speak.Because it can be overwhelming on the first day.So I try to hit on the highlights of each of those things.

So the way I break it down is, I mean, it’s basically four different categories that I’m looking at.At the time of the initial diagnosis, what are those questions that are key questions of importance for them in terms of the stage, in terms of the type of tumor, whether curative or not.

And the second part of it is when they come to treatment planning, and that’s the second part when we discuss clinical trials, we say this is the stage, this is what we’re thinking about, these are the multidisciplinary people that you need to meet within the team, and kind of talk to them about the risks and all of this in the context of the therapy, how the side-effects would be, and basically how--some of them are still working--so how would it affect their day to day life?And so that’s when you talk even the financial part of it, the commuting, just coming here to get their chemotherapy.Do they have somebody who can drive them?And then that’s when I get the navigator and - -, as well.

The third part of it is the actual treatment itself and on treatment, that’s when there’s a much more extensive discussion with regard to the side-effects, how often do we get scans, and what is the goal of treatment that is almost an ongoing discussion.Then the other things such as exercise, such as nutrition, all of those are kind of discussed at that point.

And then on the curative is after treatment, then what?Because some of them still end up having--if they have a feeding tube or any of that, and then stop talking about those.So that’s the way I break it down only because it can get overwhelming for patients when they come in if you just give them everything.And, yeah.

DR. AJANI:Okay, thank you.Bassel?

DR. EL-REYES:Yeah, I think one aspect that you both touched on is the definition of success.Like, what is successful treatment?What’s the goal of treatment because that’s not always the same in stage-one, in stage-two, in stage-three, and stage-four of stomach cancer.Not just what is success from our point of view, but also what is success from the patient’s point of view.And that’s, of course, also becomes, I think, more complex when you’re dealing with stage-four disease.And especially if you’re dealing with a lot of patients that we see in our practices.Patients who have stage-four and have gone through treatment and are coming for second opinion in second-line or third-line setting.I think it’s important to understand what is success, what are we trying to achieve.And to ensure that we have our definition of success and the patient’s definition of success are matched.That the goals that we are setting from this treatment are really the goals that are meaningful for the patient as well.And again, sometimes I think this is not as straightforward as it sounds to be.And I do think that can influence many times the choice of therapy, the duration of therapy, the starting time of therapy, and so on and so forth.

DR. AJANI:Okay.Thank you.Dan?

DR. CATENACCI:Yeah, I would really agree with everything that was said and really emphasize what Bassel was just saying in terms of setting the goals and what is the definition of success from the point of view of the patient because, especially in the stage-four setting, that can be very subjective in terms of what the goal of therapy is and what we’re willing to concede in order to try and achieve that in terms of side-effects and other inconveniences of the therapies.So that’s really critical.

I’d also just, sort of, point out that because the question included how do we deal with all this information and how do we relay it and what questions should patients ask?I will say that a patient who has already had a consult or two and now seeing me as a second or third opinion, there’s already a lot of information that’s been relayed to the patient and generally, usually.And they’ve always, typically, had some time for it to sink in and they’ve even maybe gone and done some reading on their own.So those meetings I think that we can go a little bit further and go into more depth.

But in the truly newly diagnosed and this is the first time the patient is seeing the physician or medical oncologist, then I think that it’s really challenging to get much of that through because we’re just, sort of, facing the first shock of what’s going on.And in those instances, I think that, as Kundranda said, that we just sort of hit the high-level points that are really important like we need to know the stage.Sometimes we don’t have the full stage and the first meeting, and we have to do some more tests.And so, we sort of indicate we need to know that first before we can be more definitive in what the next steps are.And so, it’s through a period of multiple visits in the first couple of weeks, where we continue to build on what we’ve learned from the previous meetings in order to get all of the picture across to something that’s very foreign, and new, and scary to the patient and their families.I think that these are all points and then patients--for me, I always give them my email and other doctors have different ways of communicating with the patient because we know that you have questions that will come up after the meeting that you didn’t think of at the time or whatever.All of us, I think, want to make ourselves available to answer those questions when they come up, and either at next visits or even in between, I think many physicians are willing to do that.I think that’s all I would add to what was already said.

DR. AJANI:Okay.Thank you so much.I think very important point.Just to elaborate on what Dan said in a very short manner, is that we are not expected to give all the education and information in one setting.I think it would be impossible to absorb that.It will become ineffective.So I think it has to be done stage-wise.And sometimes I tell the family and the patient that let’s wait a little bit longer until we are sure until the treating team is sure what to recommend rather than hypothetically mention three/four treatments.It creates a big confusion later on.

Okay, so I want to remind the patients and families to start typing your questions.We have a couple of questions to start with.But, please add your questions in the Q and A box so we can answer them.

So let’s go to question number one.Since my father died of stomach cancer in 1995, how often should I get an endoscopy and/or colonoscopy?I think this is a very, very important question.Let’s see who wants--Bassel, do you want to answer that?

DR. EL-REYES:Sure.So I think it’s important in these settings to know if there’s an established familial syndrome like, for example, Lynch Syndrome or a syndrome that is known to cause inherited risk for stomach cancer and to know that you would need to do genomic testing, but not on the cancer but genomic testing on the blood or the normal tissue like from the mouth swab.And the screening plan would depend on the risk which is partly dependent on whether you have those familial trends or not.And many of those familial types of cancers carry risk for more than one cancer also, so knowing that may impact also types of cancers you need to screen for, not just the frequency.

DR. AJANI:I think that’s a very important point because if the patient themselves are young then they may have inherited something from their parents that led to the cancer. Not just that but always there is interaction between the genes and the environment.But suppose the patient is 65, do we think their children need to be vigilant about themselves getting the same type of cancer?Are there any recommendations for them?Dan?

DR. CATENACCI:I think it’s an important question and some of the follow-up questions I see there are what are the symptoms that I would be looking for early on?And so I think, as Bassel mentioned, and also Jaffer too, unless a patient had a known germline, we call that germline or inherited gene that is known, and then family members are tested for that and they have essentially a 50% chance of getting that gene or not from their parent.Then they would be at risk and potentially recommended to get early screening.But the majority of the cancers that we see that are stomach cancer are not known to be germline.And the patient that got cancer in the family wasn’t young, which we define as less than 40 or at least less than 50.Jaffer’s patient at 65 generally would not be recommended - - any specific screening other than routine healthcare that would be considered follow on with a primary care doctor, et cetera, and getting screening for other cancers that we do routine screening like colon cancer.That said, it should be noted that Bassel has been talking a lot about doing gene sequencing of the cancer cells in patients.And we do that so we can identify treatments for patients.But these days, some companies do parallel sequencing of not only the cancer cells but also the patient’s normal cells that we get from the blood.And so we do that for multiple reasons because it helps to be sure that the mutations are real, et cetera.But at the same time, as an extra now, we’re getting inherited gene sequencing back.And sometimes we identify a gene that looks like it’s a problematic gene but even in the normal cells.This can happen even in patients who would go under the radar from what we normally might recommend to go to a genetic counselor and talk about this.This is becoming more prevalent now with this type of this sequencing now it should be known.And that’s the case, and something like that is identified, then patients and their families might be recommended to go discuss with a genetic counselor.But overall, my impression is that it’s relatively rare that there’s a known inherited problem.

DR. AJANI:Okay.Thank you.We are getting a number of questions now, which is great.So I urge you to keep your answers shorter so we can get through all of them.

So there is another question. It’s about original symptoms, so very briefly we can mention that.But the second following sentence is why should someone decide to seek a stomach cancer treatment.This is a more profound question.So Madappa, you want to take this question and give us a brief answer?

DR. KUNDRANDA:Are we talking about the symptoms or are we talking about both of these questions?

DR. AJANI:Would you mind dealing with both?

DR. KUNDRANDA:Oh, absolutely.So, yeah, so the symptoms, I mean, that’s one of those wherein it can be very vague symptoms.You could come in weight loss.You could have problems swallowing.You could--especially if it’s more of a proximal stomach tumor.And then you could have nausea, vomiting, just the feeling of fullness per se.And occasionally patients sometimes come to my clinic with a GI bleed which is picked up by a PCP because they’re having anemia.So all of these are very non-specific symptoms.One of the things that I think is important for patients to recognize is the fact that when you have a symptom that’s persistent, and you can’t attribute it to something else, that’s when you need to come to a health care provider and be evaluated.

Now coming to the second question that Dr. Ajani mentioned.Yes, this is a pretty profound question if you’re talking about why seek treatment.And I think, over here, the way I would approach this, at least in my practices, what are your goals of treatment?And is it curative or is more in the context of prolonging survival.And if you’re prolonging survival, what are you giving up from the context of toxicities.And there is a fine line.If it’s a curative setting, then I think that where everything else that’s we’ve spoken about, multimodality, treatment planning, and all of that.So I’m just going to spend a minute on the stage-four disease wherein at that point the way I would look at it is to balance your quality of life and your quantity of life.And that’s where talking to your physician and saying, “Okay, you’re giving me these treatments.What are the alternates?”Basically, if I don’t do it, what am I going to experience and having that candid conversation and then making the decision at the end of if you want treatment or not would be important.And, again, what your goals are.If it’s six months that you’re trying to get to a life event and then trying to be able to close - -.

DR. AJANI:Okay.Thank you.Next question is--so we have, I think, another three/four questions and only five minutes.Next question, is intestinal metaplasia treatable successfully?Dan?

DR. CATENACCI:If patient has intestinal metaplasia that was found because they had symptoms that were just described like upset stomach or acid reflux or something like this and they’ve found intestinal metaplasia, particularly we see that in the far end of the esophagus, and that’s called Barrett’s esophagus, then patients like that would be screened and surveilled with periodic endoscopy to ensure that metaplasia, which is a precancer in a way, doesn’t progress to a more invasive cancer.The majority of them do not.So that’s the challenge is because most patients’ tumors will not progress to become an invasive cancer--most patients’ intestinal metaplasia.But we do know that that’s a precursor lesion before it becomes cancer.So in terms of trying to treat it, other than just surveilling it, sometimes for stomach cancers specifically, the reason why that’s there is because of an infection, which is a common cause of stomach cancer, like H. pylori.And so we would treat that infection with antibiotics and potentially the intestinal metaplasia would improve as well as with antacids.But the endoscopist would be the one doing the surveillance and sometimes they do do procedures to it, like the foreign - - where they can ablate it with various procedures.But it’s a little bit outside of the medical oncologist’s jurisdiction, so to speak.

DR. AJANI:Okay.Thank you.Bassel, if we have to say the word surgery, do you mean removal of the entire stomach or part of the stomach?How do you communicate that?

DR. EL-REYES:So there isn’t, unfortunately, one answer for that.The goals for surgery are number one, to try and get rid of the cancer.And number two, to try and preserve as much of the organ as we can.Of course, the number one priority is to get rid of the cancer and whenever feasible, surgeons usually would do a partial gastrectomy.If they can remove the cancer completely without removing the whole stomach, they would do a partial gastrectomy.If removing the cancer requires the removal of the whole stomach, then, of course, we would go with total gastrectomy because the number one priority is to remove the cancer.But I would say majority of cases, it’s more likely that you end up with partial than total gastrectomy.But, again, it’s a case-by-case decision and with a priority to removing the cancer completely as our number one goal.

DR. AJANI:Okay.Thank you.The next one is about Barrett’s esophagus with frequent burning, discomfort.So how often should I get endoscopy?I think Dan already addressed some of this and I can just elaborate on that.

So if you have established Barrett’s, it’s better to remain in contact with your gastroenterologist because many times it be inconsequential, but sometimes it can turn into cancer.It can deteriorate into what is called dysplasia.So I think there is no fixed endoscopy schedule.It’s better to remain in touch with an informed gastroenterologist and they can really help you.

So let me go to the next question, which is to say you used the word tumor, I thought gastric cancer was diffuse.Dan, very quickly, what is your answer?

DR. CATENACCI:So there are two main, sort of, types of stomach cancer.One is the diffuse type as you refer to here and one is non-diffuse or what we refer to as intestinal type.Diffuse type, you’re right, is not a mass per se.But the cancer cells diffusely, sparsely sort of scatter through the stomach and often can involve the whole stomach wall.Something that we call linitis plastica.And so, you know, as the question about surgery, for example, that Bassel was talking about, really the type of surgery depends on the type of cancer, intestinal type or diffuse type and where the primary mass is.So if it’s an intestinal type, it would be at the far end of the stomach or in the middle of the stomach, et cetera.And that will dictate what surgery is done.Diffuse type, on the other hand, is one that is throughout the stomach.There’s no mass often even visualized on endoscopy, often can be missed with a routine endoscopy, yet it’s a very aggressive form of stomach cancer.You’re right, we wouldn’t be using the word tumor per se because it’s not forming a mass for diffuse-type but that’s one subset of the disease.

DR. AJANI:Okay.Thank you.So we have time only for one last question.And this is a question--it’s a long text, but they’re not happy really with our approach of generalizing for all patients how we should inform them about their diagnosis, treatments, side-effects, caregiver.So, you know, obviously, I think they’re right that we cannot have a cookie-cutter approach and we don’t.But I think generally what we see, and we should, we didn’t respond to that, to be appropriate, appropriately helpful is that there is a lot of anxiety.So when I see a newly diagnosed--not newly diagnosed--a newly arriving patient to my clinic, there is a lot of stress.The patient really is very scared.They don’t know what I’m going to say about their cancer.And when you start up talking about treatment, there’s a lot of information.But the person asking the question, they’re absolutely right that we cannot treat every patient and family in the same manner because they are not.Their needs can be very, very different.So I apologize if we came through like there is only one way we deal with every gastric cancer patient and their family.It is not like that.

MJH LIVE EVENTS

EDUCATED PATIENT® Stomach Cancer 101 Series Webinar  April 12, 2021

EDUCATED PATIENT® Stomach Cancer 101 Series Webinar

MS. KRISTIE KAHL:This is part one of the series focused on diagnosis and staging.I’m Kristie Kahl, editorial director of CURE.We’re pleased to bring you this webcast presented by CURE and in partnership with Debbie’s Dream Foundation, and our sponsors Bristol Meyers Squibb, Daiichi-Sankyo, and Merck.

We’ve a few important announcements before we begin.We encourage you to ask questions during the event which you can submit by typing them in the Q and A box.You will be receiving a survey via email tomorrow.As a thank you for watching the full webinar and completing the survey, you will be entered to win a $200 Visa gift card.

We’re pleased to be joined today by our moderator, Dr. Jaffer Ajani.Professor of Medicine in the Department of Gastrointestinal Medical Oncology in the Division of Cancer Medicine at the University of Texas, MD Anderson Cancer Center.

As well as Dr. Madappa Kundranda, Section Chief of Medical Oncology in the Division of Cancer Medicine and Director of the GI Cancer Program.A medical director of regional hematology/oncology practices at Banner MD Anderson Cancer Center.

Dr. Daniel Catenacci, Associate Professor in the Department of Medicine and Director of the Interdisciplinary Gastrointestinal Oncology Program and the Assistant Director of Translational Research in the Comprehensive Cancer Center at the University of Chicago Medical Center and Biological Sciences.

And Dr. Bassel El-Reyes, Professor and Vice-Chair for Clinical Research in the Department of Hematology and Medical Oncology, and Director of the Gastrointestinal Oncology Program at Winship Cancer Institute at Emory University.

Thank you for joining us today and I’ll now pass things off to our moderator to begin our discussion.

DR. JAFFER AJANI:Thank you, Kristie.I want to welcome all the participants, all the members in the audience, patients, and relatives.We’re really privileged to communicate with you today about very important questions we have.We have already formulated some questions.We hope that these are going to be very instructive for you.And if you have additional questions, of course, our panelists, a very experienced group of individuals will be answering that.

So we will begin.I’m going to ask Dan about our first question, which is understanding stomach cancer diagnosis and straight staging process.And this has multiple components like what does stomach cancer diagnosis mean?And explain this staging process.And whether this staging, once it is agreed upon, whether it has an influence on the treatment.Dan?

DR. DANIEL CATENACCI:Great.Thank you, Jaffer.And it’s a pleasure to be here today.I’ll start off with this question.It’s a very important question and it’s basically how we start our meetings when I’m meeting a patient for the first time and they’re newly diagnosed.

And so, the way I think about it, I always start with what’s the problem and why are you here?And usually, it’s due to some symptoms that led to a finding of a stomach cancer, usually by an upper endoscopy finding it in the stomach.At that point, we know there’s a stomach cancer, which means that there’s an abnormal growth in the stomach.And the next question we ask is what’s the extent of that problem, or something that we call what’s the stage?And the reason why that’s important, and Jaffer alluded to that, is because different stages are treated differently.And so, what’s involved in the staging includes a CAT scan.That’s of the chest, the abdomen, and the pelvis.What that’s looking for is to determine whether or not the cancer that started in the stomach has spread somewhere else.Some common places that it could spread to include the liver, the lungs, the belly cavity that we call the peritoneum, and the bone.Those would be some common places or lymph nodes that are far away from the stomach.

If the CAT scan is looking like it has not spread, then we would call that a localized cancer that doesn’t have evidence of metastatic spread or stage-four spread.And that would lead us to then do some other studies to do some more staging, which includes a PET scan, which is looking - - is not the cancer has spread outside but looking at it in a different way.CAT scans look at the size of things and PET scans look at the activity of the cancer in terms of how quickly it’s metabolizing and eating sugar.And so, together, they have a good sensitivity - - than either alone.And another test that we do is called an endoscopic ultrasound, which is like the first endoscopy, but it’s a specialized procedure looking to tell us how far through the wall of the stomach the cancer has grown and whether or not there are lymph nodes nearby that look abnormal or not.And that last endoscopic ultrasound is really helping us define whether or not the cancer is in early-stage, like a stage-one, or what we would call a more locally advanced stage, like a stage-two or a three.

And so after all of those procedures are performed, there may be one last staging procedure that we call a diagnostic laparoscopy.And that’s done if the CAT scan and the PET scan don’t look like there’s any spread distantly, and the ultrasound probe shows that there’s lymph nodes that look abnormal or that the cancer has grown through the wall of the stomach through into the third or fourth layer.Then we know that there’s a risk that the cancer could spread to the belly cavity that we call the peritoneal cavity that we just can’t identify well on CAT scans and PET scans.And so a laparoscopy, where a surgeon performs a very small incision in a surgery, that’s a same-day surgery, where they would go inside, look there and ensure that there’s no visible cancer that has spread.And they also spread fluid into that belly cavity and collect it and make sure it’s not in the fluid microscopically.

And so that’s all the staging procedures that one would do to really narrow down what’s the extent of the problem that we’re starting with.And as we’ve been talking about the treatments will be different based on the stage.And so for a stage-one cancer, typically we would recommend surgery alone and you wouldn’t be getting any therapies from me, the medical oncologist, with chemotherapy or with radiation therapy.On the other hand, if it was a stage-two or three cancer, we do know that surgery is not enough and that we do recommend chemotherapy before and after the surgery to enhance the cure rate.It improves the cure rate by helping to get rid of microscopic cells that we just can’t see despite all those staging procedures we just recommended to do.And then, unfortunately, if it’s stage-four, which means that it has spread outside of a surgical area, that means that at least today, in April of 2021, we don’t know how to eradicate the cancer from your body and surgery is not the recommended approach to deal with the issue.Rather, we treat with chemotherapy and other systemic therapies like immunotherapy and targeted therapies to help control the cancer, improve your symptoms, and to increase your survival time, but with the acknowledgment that it generally will not eradicate the cancer but rather just can keep it well controlled.

So I think that that’s a big topic and I tried to keep it as concise as I could to answer those questions.

DR. AJANI:That was very well done, Dan.Thank you for that.Are there any comments on this particular question from Bassel or Madappa?Any additional issues you want--

DR. BASSEL EL-REYES:[Interposing]I think Dan did a really excellent job in providing a very comprehensive review of staging.I think the one addition I would add is during the endoscopy we usually obtain biopsies as well to establish a what’s called a pathologic diagnosis where we look at those samples of the tumor under the microscope to characterize the tumor further in terms of its origin and more likely to look at also molecular profiles of the tumor that would help predict how it would behave or maybe how it would respond to certain treatments and we can elaborate on this more in the coming questions.

DR. AJANI:Okay.Any other--

DR. MADAPPA KUNDRANDA:No I agree with what Dan and Bassel had just said.Nothing more to add.

DR. AJANI:Okay.Very good.So I think we all acknowledge that this is a very stressful moment for our patient and their families because we all hope that it will be the lowest stage, so it’s a very important moment.A very important few days until we can finalize the stage, at least clinical stage.

Okay, so that’s very good.I think we can move on to the next question, which is completely related to the first question.So what one would do once the diagnosis is made in terms of patients and their family.What should they do?So the questions are after a patient receives the diagnosis, what is the next step? And as we all know, patients and families they want the treatments started the next day.What role does the caregiver play?This is also very, very important.And there many, many aspects to this particular issue about the loss of wages and all the stress that comes with sudden diagnosis of cancer.It never comes at the right time.Or I should say, there is never a good moment to have cancer.And should patient consider a second opinion?Bassel, would you like to make some comments about this important topic?

DR. EL-REYES:Of course.My pleasure.I think after the diagnosis is established, it’s very important that we start out treatment as quickly as we can, but also on the correct track.Because as Dan mentioned earlier, treatment options are complex.They could be ranged from surgery to chemotherapy plus surgery, or to chemotherapy alone, or immunotherapy, or immunotherapy plus chemotherapy.So there are many options for therapy and this is why it’s important after we establish the diagnosis to consult with a team of experts, especially in early-stage disease where multimodality therapy or treatments with chemotherapy radiation, and surgery from different specialties might come into play.It’s very important to put together a team and establish a right approach to manage the complex condition like this.

In addition to the medical specialties that are involved in managing these cancers like medical oncologists, like the people on the call today, surgeons, and radiation doctors, patients with stomach cancer need a number of people who support them with respect to nutrition, symptom management, and so on and so forth.This is why it is important to really after we establish the diagnosis to put together the team that will be able to deliver a complex care plan that is needed to take care of a complex problem like this.

In addition, more and more we learn that the stomach cancer is not one disease but actually many different kinds of diseases that can be classified by us testing what we call molecular features of the tumor or the things that make the tumor function in the way it does.And through that molecular testing, we are able to, number one, sometimes understand better how the tumor is going to behave.And more importantly, know more what is the best treatment for that specific tumor.Not everybody who walks to our offices with stomach cancer gets the same treatment if they have the same stage. The treatment is much more complex and is based on, in addition to the stage, on the molecular features of the tumor.So those are important next steps.

I think the caregiver is key in this disease.Dr. Ajani spoke a little bit about the financial implications of having a diagnosis of gastric cancer.There are a number of other implications that come with this patient even in the earliest stage where they are going to be treated with surgery alone, still need a lot of support after surgery in terms of recovery from the surgery, nutrition, physical therapy, and so on and so forth.Needless to say, when treatment becomes more complex and entails things like chemotherapy, radiation, and surgery, the support that the patients need at home to go through such a procedure, such a complex treatment is quite taxing on the caregivers.And then there’s financial aspect.There’s the supportive aspect.And then there’s also the emotional or the stress of having a diagnosis and the uncertainty of dealing with a serious illness like this where the patient really would need the caregiver to support them through the journey, dealing with a disease of this nature.So caregivers play, I think, a key role in supporting patients and dealing with this diagnosis.

As far as second opinions are concerned, I do think second opinions are very important because really none of us know the field completely and sometimes having someone else look at a case will provide a point of view that your own oncologist did not consider.In addition, it becomes even more important if you are being taken care of in an institution that does not have a lot of track record in taking care of gastric cancer patients or stomach cancer patients.This is not an extremely common type of tumor, so unless you are in a larger center, your medical team may not have a lot of experience in managing this type of cancer.So it’s not wrong to get a second opinion, especially if you are being taking care of in a smaller institution.In addition to the fact that second opinion can provide access to a higher level of specialization, you may get also sometimes input about availability of clinical trials, which is another important part of the management of this disease, especially in the more advanced stage.Those are things that you could learn from a second opinion.So I feel like a second opinion, if available, is important.Of course, we have to balance the second opinion against the delay in treatment because we don’t want to delay treatment while we get multiple opinions, but we have to balance getting the treatment started on time while obtaining that second opinion to make sure that we’ve covered all the bases.

DR. AJANI:Okay.Wonderful.Thank you, that was very well done.I’d like to ask Dan or Madappa if you have any additional comments on this particular question.

DR. KUNDRANDA:I think the only comment I’ll make is that I think to Bassel’s point, the psychosocial component of this is just so important both to the patient and to the caregiver.That is where I think supporting them emotionally and physically during this whole thing cannot be reiterated enough because the caregiver, he or she who’s caring for a loved one is working, taking care of a--being a true caregiver and kind of bearing the burden of everything else that typically was two people were sharing that burden.So one of the things, at least, in my thing that I’ve seen happens often is there’s a lot of focus on the patient and then sometimes we tend to forget about the caregiver and therefore, that support the - - oncology support is extremely important.That’s one part of it.

The second thing is with regards to the second opinion, I truly think, especially, like Bassel mentioned, this is one of those wherein getting that second opinion in a timely fashion is just extremely important because sometimes we’ve had patients with locally advanced disease, and they go and they’re trying to get the second opinion and that takes almost a month.And we know time to treatment is a huge predictor in terms of survival and outcomes.

So those are the only two comments.I really think Bassel wrapped it up very nicely.

DR. CATENACCI:I would agree with all of that and with the caregivers is very critical. I would point out we encourage second opinions, even third opinions because it does help with the difficulty of understanding everything that is going on to hear consensus with major issues like stage and what the general therapy should be.At the same time too, you’re talking to academics here that are at, like, tertiary academic centers that are always trying to do better than the standard of care and we always have clinical trials that are looking at questions can we do better than what we do normally?And getting second and third opinions you can see what other treatment options on clinical trials there might be, and different centers have different studies.So by looking around at that, you sort of get a full picture of all the possibilities and treatment options, and then you have sort of all the things on the table and you can pick what you feel is right for you in collaboration with your doctor that’s acting as your consultant.I would also say, though, and what both of the others have said is that you have to balance that with at some point you have to start therapy.And you can’t wait too long doing all of that before you get going.So it is a balance, but at the same time rushing in and missing out on potentially good opportunities is also potentially not a good idea either.

DR. AJANI:Okay.Thank you very much.I think we will probably come back to some of these topics when we go into question and answers.Let’s go to question number three, which is another very important question which is how to recruit a treatment team and how can a patient learn more to ensure that they’re treated by somebody who has had experience with stomach cancer and not necessarily someone who treat stomach cancer occasionally?The question also includes the importance of multidisciplinary approach.And why is it so important that they’re getting the right treatment from the right team, it says.So Madappa, do you want to elaborate on some of the answers?

DR. KUNDRANDA:Absolutely.I think some of it is kind of repetitious in its own way, but I think it’s such an important question that I think it definitely bears repetition here.

So the first question is how can a patient learn more to ensure that they’re being treated by the right team?And that is a critical part of it because especially in early-stage cancers, going to a high-volume center, having that multidisciplinary approach--and when we say multidisciplinary approach, it is not just the surgeon, radiation oncologist, and the medical oncologist.It’s truly that entire team.So when we have that, one of two things that is important is when--and also figuring out or having a candid conversation with the physician that’s treating you, how many of these patients have you treated in a year?How often do you see this diagnosis?And that kind of alludes to some of the things that Dan brought up as well with regards to clinical trials.Ideally, with every stage, first option is a clinical trial.An appropriate clinical trial, I would say because all of our trials tend to have a randomized arm - -.At least you’ll be getting the standard of care.Which is where if you do not have any clinical trial options, then you - -, what is the standard of care?And going on to a clinical trial is that you have the option to get investigational therapies whether it is in an early-stage cancer or if it’s in a late-stage cancer.So I think that is an integral part of it in the context of when you’re trying to decide on the right team is to have that candid conversation with the physician who is treating you.

The second part of it is what is the role of a multidisciplinary team in this whole--or rather a multidisciplinary approach in this whole treatment of gastric cancer?This cannot be more important, especially in the resectable situation more because that’s when truly a trimodality treatment in certain cases or basically when you’re using radiation, you’re using surgery and you’re using chemotherapy to get the best outcomes can come into play.So it’s important to have all of these physicians sitting around a table looking at your scans trying to figure out, “Hey, we’ve had the laparoscopic thing, this is what we saw” and having that candid discussion one-on-one before they come up with this treatment plan per se.When you’re planning out the treatment plan also is part of this multidisciplinary approach, is basically involving the dietitian or the nutritionist because, in most of these cases or a significant number of these cases, weight loss and kikexia, cancer kikexia is a true entity.And you do not want to go into this--you want to go into this with everyone in your corner.And that’s the reason why having a dietician there, and occasional cases having genetic counselor.In these 1 to 3% of these genetic - - --because I think somebody asked us about stomach cancer in one of these questions below and we’ll go get into that later--becomes important.So gone are the days wherein it was chemotherapy, chemotherapy, chemotherapy alone, or just surgery upfront per se.One of the changes wherein we’ve seen that and the optic is almost two-thirds of the country does that as well, which is looking at therapies prior to surgery.Some of it has worked.Dan alluded to wherein you’re trying to make sure that you--the - - of the tumor has not spread at this point in time.You want to ensure that this micrometastatic disease has certainly controlled prior to going into a surgery to get the best outcomes.And all of these only rendered in an appropriate way when you have multidisciplinary team working together.

So if the question is why is it important for patients to make sure that they’re getting the right treatment at the right time, right, and from the right team.That is because you really can’t--once we get things started, very few times when, especially in the purest of setting, there are very few times when you can take a step back and say, “Yeah, it’s already done.Let’s move on.”And we tend to do it if the approach is not accurate.However, to get the best outcomes and trying to do it at the right time with the right team and I think that’s why large volume centers make sense, and people who are more comfortable treating this and the modalities makes sense.And even if it’s staging.I mean, if somebody’s doing an endoscopic ultrasound and staging and this is not somebody who does that on a regular basis, that can be inaccurate as well.So that is, yeah.So that I hope I answered all of those questions that were addressed, Dr. Ajani.

DR. AJANI:Yeah, thank you.That was very well done.We have a few more minutes to dwell on this particular question.So Bassel or Dan, any additional points you want to raise about multidisciplinary approach?Do stage-four patients really--do they need that, or we focus on earlier stages, and do we allow one of the team members to make the final decision, or is better to make a group decision?Some comments on that.

DR. EL-REYES:Well, I’ll go first.Oh, Dan, go ahead.Go ahead, Dan.I’ll go after you.

DR. AJANI:Okay.You may be muted because we can’t hear you.

DR. CATENACCI:Can you hear me now?

DR. AJANI:Yeah.Now we can.

DR. CATENACCI:Okay.So I was going to agree with what said and pertinent to the questions that Jaffer just asked. I think that the multidisciplinary approach which generally typically means like looking with surgeries, with radiation oncologists, with gastroenterologists and pathologists, many of our centers have weekly meetings that review cases that are complex, including gastric cancer patients, to go over all of the information, the staging, the pathology, et cetera, and to weigh in on what we think is the best approach as a consensus opinion.However, Jaffer pointed out, like, is this happening with every stage-four patient?What other types of patients that this is going on for?Generally, it’s for earlier-stage patients that are, you know, stage-two or three that are going to have multidisciplinary approach to their care.But that said, almost all patients are at least reviewed there at the first meeting just to ensure that we agree on the staging, especially if it’s not clear to review the imaging, et cetera.So I think, as Madappa was mentioning, is that you really want the staging component can have a lot of subjectivity and in places that don’t have high volumes of this cancer, they may have different, sort of, stage in terms of what they’re calling a certain cancer.So that’s a very important point.

And then the other part of multidisciplinary care that was mentioned outside of that is very important even, and probably more so, for the stage-four setting in terms of having palliative care physicians and teams and nutritionists involved in their treatment.Maybe the multidisciplinary team is slightly different in each of those stages, but multidisciplinary care is always welcomed in having more, sort of, minds addressing a given problem together.I would just extent what was already said in a certain way.

DR. AJANI:Bassel?

DR. EL-REYES:I agree with Dan and with what he just said.I think in stage-four the multidisciplinary team component may be a little bit different than what it is in stage-two or stage-three, but definitely, we do benefit from having input on nutrition as many times as a major issue in these patients.Supportive care in terms of pain control, control of other symptoms that come sometimes with treatment.That is an important aspect.Psychosocial component of taking care of these patients.Also, that’s part of the multidisciplinary team that’s involved.And occasionally when you have these unusual molecular features in the tumor engaging pathology and your molecular tumor board to sort of figure out what the best approach.Also, in management of certain unique molecular profile tumors is also important.So there are many aspects and complexities to the management of stage-four that require a little bit different type of multidisciplinary team, but still a multidisciplinary team.Maybe a little bit less for surgery and radiation, but more for those other partners who work with us on the care of these patients.

DR. AJANI:Okay.Thank you so much.So we’re going to the last question and I’m going to ask all of you to help me with this particular question.The question itself is the key questions patients should ask their doctors and healthcare team.And this is a big one.It’s about diagnosis, treatment, side-effects, schedule, additional issues that they don’t discuss is the co-pay, and whether they will be able to get medication or not.One thing I want to mention as providers, we recognize that the patient and family are under huge amount of stress.The amount of information they can really absorb and, also the amount of information we give them is just enormous.So in that context, how do you transfer important information to the patient and caregivers?I used to say before that I would explain the toxicity such as management of diarrhea, or nausea/vomiting to the caregiver rather than to the patient because the patient wants to know what is their longevity, curability, and they want to know the toxicity.But how to manage toxicity sometimes is best done by the caregiver so they can learn some of the algorithms that we mentioned.Can all of you just mention a couple of points that I may have missed as to what do you think is really important for families and patient to learn from the treating team that sometimes they will come back and say, “You never mentioned that or never explained that.”And, of course, you can’t really explain everything because there is so much information out there.How do you balance all that?Any comments?

DR. KUNDRANDA:Okay, I’ll jump in since both Dan and Bassel are not jumping into this.But the way I look at this is almost breaking it up into four different categories.One is--and then you are absolutely right, Jaffer.This is one of those where when the patient comes in for the first time, most of them, although we try to fragment it up, what I tell them is, “I’m just going to give you the big picture here.”And then we’ll delve into a couple of things and on the subsequent visits, that’s when we go into and basically give it piece by piece, so to speak.Because it can be overwhelming on the first day.So I try to hit on the highlights of each of those things.

So the way I break it down is, I mean, it’s basically four different categories that I’m looking at.At the time of the initial diagnosis, what are those questions that are key questions of importance for them in terms of the stage, in terms of the type of tumor, whether curative or not.

And the second part of it is when they come to treatment planning, and that’s the second part when we discuss clinical trials, we say this is the stage, this is what we’re thinking about, these are the multidisciplinary people that you need to meet within the team, and kind of talk to them about the risks and all of this in the context of the therapy, how the side-effects would be, and basically how--some of them are still working--so how would it affect their day to day life?And so that’s when you talk even the financial part of it, the commuting, just coming here to get their chemotherapy.Do they have somebody who can drive them?And then that’s when I get the navigator and - -, as well.

The third part of it is the actual treatment itself and on treatment, that’s when there’s a much more extensive discussion with regard to the side-effects, how often do we get scans, and what is the goal of treatment that is almost an ongoing discussion.Then the other things such as exercise, such as nutrition, all of those are kind of discussed at that point.

And then on the curative is after treatment, then what?Because some of them still end up having--if they have a feeding tube or any of that, and then stop talking about those.So that’s the way I break it down only because it can get overwhelming for patients when they come in if you just give them everything.And, yeah.

DR. AJANI:Okay, thank you.Bassel?

DR. EL-REYES:Yeah, I think one aspect that you both touched on is the definition of success.Like, what is successful treatment?What’s the goal of treatment because that’s not always the same in stage-one, in stage-two, in stage-three, and stage-four of stomach cancer.Not just what is success from our point of view, but also what is success from the patient’s point of view.And that’s, of course, also becomes, I think, more complex when you’re dealing with stage-four disease.And especially if you’re dealing with a lot of patients that we see in our practices.Patients who have stage-four and have gone through treatment and are coming for second opinion in second-line or third-line setting.I think it’s important to understand what is success, what are we trying to achieve.And to ensure that we have our definition of success and the patient’s definition of success are matched.That the goals that we are setting from this treatment are really the goals that are meaningful for the patient as well.And again, sometimes I think this is not as straightforward as it sounds to be.And I do think that can influence many times the choice of therapy, the duration of therapy, the starting time of therapy, and so on and so forth.

DR. AJANI:Okay.Thank you.Dan?

DR. CATENACCI:Yeah, I would really agree with everything that was said and really emphasize what Bassel was just saying in terms of setting the goals and what is the definition of success from the point of view of the patient because, especially in the stage-four setting, that can be very subjective in terms of what the goal of therapy is and what we’re willing to concede in order to try and achieve that in terms of side-effects and other inconveniences of the therapies.So that’s really critical.

I’d also just, sort of, point out that because the question included how do we deal with all this information and how do we relay it and what questions should patients ask?I will say that a patient who has already had a consult or two and now seeing me as a second or third opinion, there’s already a lot of information that’s been relayed to the patient and generally, usually.And they’ve always, typically, had some time for it to sink in and they’ve even maybe gone and done some reading on their own.So those meetings I think that we can go a little bit further and go into more depth.

But in the truly newly diagnosed and this is the first time the patient is seeing the physician or medical oncologist, then I think that it’s really challenging to get much of that through because we’re just, sort of, facing the first shock of what’s going on.And in those instances, I think that, as Kundranda said, that we just sort of hit the high-level points that are really important like we need to know the stage.Sometimes we don’t have the full stage and the first meeting, and we have to do some more tests.And so, we sort of indicate we need to know that first before we can be more definitive in what the next steps are.And so, it’s through a period of multiple visits in the first couple of weeks, where we continue to build on what we’ve learned from the previous meetings in order to get all of the picture across to something that’s very foreign, and new, and scary to the patient and their families.I think that these are all points and then patients--for me, I always give them my email and other doctors have different ways of communicating with the patient because we know that you have questions that will come up after the meeting that you didn’t think of at the time or whatever.All of us, I think, want to make ourselves available to answer those questions when they come up, and either at next visits or even in between, I think many physicians are willing to do that.I think that’s all I would add to what was already said.

DR. AJANI:Okay.Thank you so much.I think very important point.Just to elaborate on what Dan said in a very short manner, is that we are not expected to give all the education and information in one setting.I think it would be impossible to absorb that.It will become ineffective.So I think it has to be done stage-wise.And sometimes I tell the family and the patient that let’s wait a little bit longer until we are sure until the treating team is sure what to recommend rather than hypothetically mention three/four treatments.It creates a big confusion later on.

Okay, so I want to remind the patients and families to start typing your questions.We have a couple of questions to start with.But, please add your questions in the Q and A box so we can answer them.

So let’s go to question number one.Since my father died of stomach cancer in 1995, how often should I get an endoscopy and/or colonoscopy?I think this is a very, very important question.Let’s see who wants--Bassel, do you want to answer that?

DR. EL-REYES:Sure.So I think it’s important in these settings to know if there’s an established familial syndrome like, for example, Lynch Syndrome or a syndrome that is known to cause inherited risk for stomach cancer and to know that you would need to do genomic testing, but not on the cancer but genomic testing on the blood or the normal tissue like from the mouth swab.And the screening plan would depend on the risk which is partly dependent on whether you have those familial trends or not.And many of those familial types of cancers carry risk for more than one cancer also, so knowing that may impact also types of cancers you need to screen for, not just the frequency.

DR. AJANI:I think that’s a very important point because if the patient themselves are young then they may have inherited something from their parents that led to the cancer. Not just that but always there is interaction between the genes and the environment.But suppose the patient is 65, do we think their children need to be vigilant about themselves getting the same type of cancer?Are there any recommendations for them?Dan?

DR. CATENACCI:I think it’s an important question and some of the follow-up questions I see there are what are the symptoms that I would be looking for early on?And so I think, as Bassel mentioned, and also Jaffer too, unless a patient had a known germline, we call that germline or inherited gene that is known, and then family members are tested for that and they have essentially a 50% chance of getting that gene or not from their parent.Then they would be at risk and potentially recommended to get early screening.But the majority of the cancers that we see that are stomach cancer are not known to be germline.And the patient that got cancer in the family wasn’t young, which we define as less than 40 or at least less than 50.Jaffer’s patient at 65 generally would not be recommended - - any specific screening other than routine healthcare that would be considered follow on with a primary care doctor, et cetera, and getting screening for other cancers that we do routine screening like colon cancer.That said, it should be noted that Bassel has been talking a lot about doing gene sequencing of the cancer cells in patients.And we do that so we can identify treatments for patients.But these days, some companies do parallel sequencing of not only the cancer cells but also the patient’s normal cells that we get from the blood.And so we do that for multiple reasons because it helps to be sure that the mutations are real, et cetera.But at the same time, as an extra now, we’re getting inherited gene sequencing back.And sometimes we identify a gene that looks like it’s a problematic gene but even in the normal cells.This can happen even in patients who would go under the radar from what we normally might recommend to go to a genetic counselor and talk about this.This is becoming more prevalent now with this type of this sequencing now it should be known.And that’s the case, and something like that is identified, then patients and their families might be recommended to go discuss with a genetic counselor.But overall, my impression is that it’s relatively rare that there’s a known inherited problem.

DR. AJANI:Okay.Thank you.We are getting a number of questions now, which is great.So I urge you to keep your answers shorter so we can get through all of them.

So there is another question. It’s about original symptoms, so very briefly we can mention that.But the second following sentence is why should someone decide to seek a stomach cancer treatment.This is a more profound question.So Madappa, you want to take this question and give us a brief answer?

DR. KUNDRANDA: Are we talking about the symptoms or are we talking about both of these questions?

DR. AJANI:Would you mind dealing with both?

DR. KUNDRANDA: Oh, absolutely.So, yeah, so the symptoms, I mean, that’s one of those wherein it can be very vague symptoms.You could come in weight loss.You could have problems swallowing.You could--especially if it’s more of a proximal stomach tumor.And then you could have nausea, vomiting, just the feeling of fullness per se.And occasionally patients sometimes come to my clinic with a GI bleed which is picked up by a PCP because they’re having anemia.So all of these are very non-specific symptoms.One of the things that I think is important for patients to recognize is the fact that when you have a symptom that’s persistent, and you can’t attribute it to something else, that’s when you need to come to a health care provider and be evaluated.

Now coming to the second question that Dr. Ajani mentioned.Yes, this is a pretty profound question if you’re talking about why seek treatment.And I think, over here, the way I would approach this, at least in my practices, what are your goals of treatment?And is it curative or is more in the context of prolonging survival.And if you’re prolonging survival, what are you giving up from the context of toxicities.And there is a fine line.If it’s a curative setting, then I think that where everything else that’s we’ve spoken about, multimodality, treatment planning, and all of that.So I’m just going to spend a minute on the stage-four disease wherein at that point the way I would look at it is to balance your quality of life and your quantity of life.And that’s where talking to your physician and saying, “Okay, you’re giving me these treatments.What are the alternates?”Basically, if I don’t do it, what am I going to experience and having that candid conversation and then making the decision at the end of if you want treatment or not would be important.And, again, what your goals are.If it’s six months that you’re trying to get to a life event and then trying to be able to close - -.

DR. AJANI:Okay.Thank you.Next question is--so we have, I think, another three/four questions and only five minutes.Next question, is intestinal metaplasia treatable successfully?Dan?

DR. CATENACCI: If patient has intestinal metaplasia that was found because they had symptoms that were just described like upset stomach or acid reflux or something like this and they’ve found intestinal metaplasia, particularly we see that in the far end of the esophagus, and that’s called Barrett’s esophagus, then patients like that would be screened and surveilled with periodic endoscopy to ensure that metaplasia, which is a precancer in a way, doesn’t progress to a more invasive cancer.The majority of them do not.So that’s the challenge is because most patients’ tumors will not progress to become an invasive cancer--most patients’ intestinal metaplasia.But we do know that that’s a precursor lesion before it becomes cancer.So in terms of trying to treat it, other than just surveilling it, sometimes for stomach cancers specifically, the reason why that’s there is because of an infection, which is a common cause of stomach cancer, like H. pylori.And so we would treat that infection with antibiotics and potentially the intestinal metaplasia would improve as well as with antacids.But the endoscopist would be the one doing the surveillance and sometimes they do do procedures to it, like the foreign - - where they can ablate it with various procedures.But it’s a little bit outside of the medical oncologist’s jurisdiction, so to speak.

DR. AJANI:Okay.Thank you.Bassel, if we have to say the word surgery, do you mean removal of the entire stomach or part of the stomach?How do you communicate that?

DR. EL-REYES:So there isn’t, unfortunately, one answer for that.The goals for surgery are number one, to try and get rid of the cancer.And number two, to try and preserve as much of the organ as we can.Of course, the number one priority is to get rid of the cancer and whenever feasible, surgeons usually would do a partial gastrectomy.If they can remove the cancer completely without removing the whole stomach, they would do a partial gastrectomy.If removing the cancer requires the removal of the whole stomach, then, of course, we would go with total gastrectomy because the number one priority is to remove the cancer.But I would say majority of cases, it’s more likely that you end up with partial than total gastrectomy.But, again, it’s a case-by-case decision and with a priority to removing the cancer completely as our number one goal.

DR. AJANI:Okay.Thank you.The next one is about Barrett’s esophagus with frequent burning, discomfort.So how often should I get endoscopy?I think Dan already addressed some of this and I can just elaborate on that.

So if you have established Barrett’s, it’s better to remain in contact with your gastroenterologist because many times it be inconsequential, but sometimes it can turn into cancer.It can deteriorate into what is called dysplasia.So I think there is no fixed endoscopy schedule.It’s better to remain in touch with an informed gastroenterologist and they can really help you.

So let me go to the next question, which is to say you used the word tumor, I thought gastric cancer was diffuse.Dan, very quickly, what is your answer?

DR. CATENACCI:So there are two main, sort of, types of stomach cancer.One is the diffuse type as you refer to here and one is non-diffuse or what we refer to as intestinal type.Diffuse type, you’re right, is not a mass per se.But the cancer cells diffusely, sparsely sort of scatter through the stomach and often can involve the whole stomach wall.Something that we call linitis plastica.And so, you know, as the question about surgery, for example, that Bassel was talking about, really the type of surgery depends on the type of cancer, intestinal type or diffuse type and where the primary mass is.So if it’s an intestinal type, it would be at the far end of the stomach or in the middle of the stomach, et cetera.And that will dictate what surgery is done.Diffuse type, on the other hand, is one that is throughout the stomach.There’s no mass often even visualized on endoscopy, often can be missed with a routine endoscopy, yet it’s a very aggressive form of stomach cancer.You’re right, we wouldn’t be using the word tumor per se because it’s not forming a mass for diffuse-type but that’s one subset of the disease.

DR. AJANI:Okay.Thank you.So we have time only for one last question.And this is a question--it’s a long text, but they’re not happy really with our approach of generalizing for all patients how we should inform them about their diagnosis, treatments, side-effects, caregiver.So, you know, obviously, I think they’re right that we cannot have a cookie-cutter approach and we don’t.But I think generally what we see, and we should, we didn’t respond to that, to be appropriate, appropriately helpful is that there is a lot of anxiety.So when I see a newly diagnosed--not newly diagnosed--a newly arriving patient to my clinic, there is a lot of stress.The patient really is very scared.They don’t know what I’m going to say about their cancer.And when you start up talking about treatment, there’s a lot of information.But the person asking the question, they’re absolutely right that we cannot treat every patient and family in the same manner because they are not.Their needs can be very, very different.So I apologize if we came through like there is only one way we deal with every gastric cancer patient and their family.It is not like that.

So I think we are almost done.And I want to thank the panelists for being so useful in formulating the answers and collaboratively helping gastric cancer patients, particularly, and their families.Kristie, anything else we need to do before we close?Okay, so we’re going to wrap it up and I know there are more questions, but unfortunately, we are out of time.So I would like to just mention that this has been recorded and this is available to you on our webinar.There is a webinar on-demand page on curetoday.com.So please visit that website and you can see our answers.I want to thank our panelists, as I mentioned, the audience for participating today.I think this truly is a good set of information that will be helping next generation of patients and families and we want to acknowledge the CURE Foundation, Debbie’s Dream Foundation, Bristol Meyers Squibb, Daiichi-Sankyo, and Merck for helping to put this together.There will be an email coming to all the participants tomorrow that will be for the survey and you can win the gift card. Take care, everybody. Get vaccinated. All the best.