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| Daniel Coit, MD Professor Memorial Sloan Kettering Cancer Center, New York Oncology Frontier |
Oncology Frontier(肿瘤瞭望): There is still controversy regarding the anatomical location of EG-junction tumors. Do you have any updates on the EG-junction tumor location?
Dr Coit: I believe we can develop a staging system which embraces the entire range of presentations in the foregut from the esophagus through to the stomach. It is very clear that the prognosis for proximal tumors is worse than the prognosis for distal tumors, so I am not sure that a staging system should dictate treatment. I think that treatment should be risk-driven, not staging-driven. But there is a staging system that encompasses a general language to describe the entire foregut.
If we can embrace that staging system， then we can end this debate about whether the GE-junction is one centimeter above or below the Z-line， because otherwise， we will never agree on that. The first goal is to recognize the harmony and staging of the foregut tumors. The second goal is to recognize the differences within foregut tumors and to tailor treatment appropriately.
It used to be recommended that EG-junction tumors should follow TMN staging of gastric cancers if it is adenocarcinoma， and esophagus staging if it is squamous cell carcinoma. Do you have a preference， or an opinion as to why it is no longer recommended?
Dr Coit: My strong feeling is that adenocarcinoma of the GE-junction should be part of a uniform foregut staging system that embraces the GE-junction and the stomach. That staging system should be quite different from that of squamous cancer. They are very different cancers with different biologies. That doesn’t mean that we should treat all foregut tumors the same. It is increasingly clear that the treatment paradigms for the more proximal focal tumors in the GE-junction are different， largely for anatomic reasons compared to the more anatomically diffuse gastric cancers.
How does the epidemiology of EG-junction tumors in the US differ with that in Asian countries?
Dr Coit: I am not sure that we know that the epidemiology of GE-junction tumors in a given location is different in Asia to what it is in the West. I do think we are seeing an increased incidence of GE-junction cancers in Asia and that may be because of the fact that those risk factors that we have in the West are now becoming more prominent in Japan and Korea， for example. I am not sure that the epidemiology is different; I think it may be that the environment is changing and leading to differences in incidence.
What about the epidemiology of EG-junction tumors in the US? Do you have any new evidence to support your research?
Dr Coit: We are learning more about the epidemiology of GE-junction tumors in the US. Most of the epidemiologic studies now have been supplanted by molecular biology and genetics. I think what we are going to find is that there is enormous heterogeneity within gastric cancers and GE-junction tumors whose origins can be traced to the genetic drivers of the tumor.
For the most part, when we talk about epidemiology， we are talking about the view from 30000 feet, but what we really want to do is get down and look at the individual drivers in individual tumors. We have seen this with the HER2 story, where HER2 amplification is much more common in GE-junction cancer than in gastric cancer. We are going to start to have a much better understanding of the genetic drivers of cancers in all locations. So I think the issue of the epidemiology of those tumors is interesting because it does highlight some of the differences， but it is going to be supplanted by a much better understanding of the genetic heterogeneity of these tumors.
Do you have any suggestions for the treatment of EG-junction tumors? For example， would you recommend the multidisciplinary approach (MDT) for the treatment of EG-junction tumors?
Dr Coit: There are a number of cultural differences and almost geographic differences in the way that people assess the Level I evidence in treating GE-junction tumors. The data are the data. Do I believe that a multidisciplinary review and management of these patients is essential? Yes，I do. It would be ideal if every patient underwent review to take advantage of Level I evidence，new techniques and things like that，but from a practical standpoint， I don’t see that happening in places other than major cancer centers.
The Dutch has started the concept of regionalization of uncommon diseases that are technically demanding and potentially morbid and I think that is a model for the world. But not every society is prepared to do that. However，to be able to centralize care and have patients treated in a multidisciplinary setting, is far and away the ideal approach，mainly because it would help us answer some of the differences in opinion about management of a single disease.
(Reproduced from Oncology Frontier)
Reference:
[IGCC2015] 胃癌临床分期挑战--Daniel Coit教授访谈 肿瘤瞭望 June 24, 2015, WeChat video http://mp.weixin.qq.com/s?__biz=MzA4MDM4MzExMA==&mid=208557599&idx=2&sn=853ba23e36a3f719b6759f25bc97bb67#rd
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