Like most patients with esophageal cancer, by the time Christopher began experiencing symptoms, his cancer had already progressed to an advanced stage.

The most common symptoms, difficulty swallowing or food getting stuck when eating, ultimately lead people to see their doctor.

Christopher had trouble swallowing from time to time. Starchy foods like rice were the worst and felt like they were expanding in his throat, he describes. His wife, Jill, encouraged him to talk to his doctor.

 “I was not worried,” he says. “I had a lot of heartburn, but there was nothing in my mind that led me to believe something was seriously wrong.” The busy architect did not feel ill. He was keeping a full schedule. Nonetheless, at his wife’s encouragement, he contacted his doctor, and an endoscopy was scheduled.

Patient Christopher and his wife Jill.

An endoscopy is a procedure in which a small flexible tube with a tiny camera is inserted through the mouth, down the throat and into the esophagus.

A few weeks after the procedure, Christopher was at work when he got a call from his wife. “We got the report,” Jill said. “You have cancer.” Christopher thought she must be kidding. “Cancer was the furthest thing from my mind,” he remembers. He realized it wasn’t a joke when Jill begin to cry. “It’s bad,” she said through tears. “We have to call the Kimmel Cancer Center at Johns Hopkins.”

Jill’s best friend was a cancer survivor and recommended the center to her.

The Multi-D

Most patients with esophageal cancer, upward of 80%, are treated with a combination of chemotherapy, radiation therapy and surgery, says thoracic surgeon Stephen Broderick, M.D. Immunotherapies — newly developed drugs that unleash the power of immune cells against the cancer — are also being studied in clinical trials.

The Kimmel Cancer Center’s Multidisciplinary Esophageal Cancer Clinic, nicknamed the Multi-D, brings together experts in medical oncology, radiation oncology, surgery, nursing, social work and all other patient care specialties for a one-day appointment for a patient with esophageal cancer. Each specialist meets with the patient, and the experts review imaging and pathology. At the end of the appointment, the patient receives a treatment plan.

As one of the first people who new patients with esophageal cancer meet, Jean Butler, the multidisciplinary clinic coordinator, is a source of comfort and direction.

“Newly diagnosed patients are scared,” Butler says. “We get them in right away to give them support and help relieve some of the anxiety.” Butler gives patients her phone number and invites them to call any time throughout their treatment with questions or concerns.

Rarely, more than a week passes before she hears from them. As part of their first appointment, patients attend a teaching session with Butler on the basics of their cancer and the treatments they may hear about when they meet with doctors. That way, she says, they are prepared and able to focus on questions about the treatment plan.

“We provide as much support upfront as possible so patients know they are surrounded by a care team concerned about their physical and emotional care,” says Butler, who consults with Russell Hales, M.D., the multidisciplinary clinic’s co-director, on every patient. Having that extra support makes a big difference. By the end of the day, patients say they feel well educated about their cancer. They understand their diagnosis, their individualized treatment plan and any anticipated side effects, she says, adding that about four new patients are seen in the clinic each week, she says.

A nutrition evaluation is also performed, since swallowing issues and weight loss are common among patients with esophageal cancer. They may have trouble eating, and some have feeding tubes. Patients who need nutritional support are identified and issues are addressed right away.

Before a patient’s first visit, Butler works with referral coordinator Margaret Clark to make sure the experts have the imaging and pathology needed to evaluate the cancer.

Treatment Plans

Christopher and Jill traveled from their home in Virginia to the Kimmel Cancer Center’s multidisciplinary esophageal cancer clinic.

His diagnosis was stage 3 esophageal cancer. This means the cancer had begun to spread outside of the esophagus. “The experts did all of the tests and X-rays and came up with a plan,” says Christopher. Christopher says that after listening to recommendations from each one, including Hales, who is a radiation oncologist, and Joy Feliciano, M.D., a medical oncologist, he felt comfortable and was ready to start treatment.

“I trusted them and was ready to do whatever they suggested,” he says.

“We work together as a team to get patients through efficiently from diagnosis to staging to treatment,” says Broderick. Treatment is challenging, he adds, but continued research and refinements to the surgery to remove the cancer are improving outcomes.

Christopher’s treatment began in spring 2019 with chemotherapy and radiation therapy, followed by surgery.

Complex Surgery

“For surgery, we have two primary goals,” Broderick says. “We want the most effective operation, one that provides the best chance of cure and one that allows the patient to return, as much as possible, to a normal quality of life.” Key to this goal, he points out, is a surgery that allows patients to resume a normal diet.

“Culturally, eating is an important part of who we are,” Broderick says. “We gather for family meals, go out to dinner, so this is essential to quality of life.”

The surgery to remove the cancer is called an esophagectomy. Surgeons take out the diseased part of the esophagus, pulling the stomach up and connecting it to the remaining esophagus.

Kimmel Cancer Center experts, led by Richard Battafarano, M.D., Ph.D., regional director of general thoracic surgery, worked to reduce the most serious complication of esophageal cancer surgery—leaks where esophageal and stomach fluids escape through the incision where the esophagus and stomach are joined together during surgery—and for good reason. Leaks, he says, increase the risk of death and long-term complications. They also impact the immune system, making it more likely that the cancer will come back, Battafarano explains.

There are other complications. Pneumonia and pleural effusions—a dangerous buildup of fluid—are among the common ones, and they are more manageable than leaks, he says. 

Nationally, leak rates range from 10% to 21%. Battafarano and his team reduced that rate to an incredibly low 2% at Johns Hopkins.

Combination Therapy

For most patients whose cancers, like Christopher’s, are diagnosed after the cancer has begun to spread, the first course of treatment is chemotherapy and radiation to knock the cancer back and stop the spread.

“It’s tough,” Christopher recalls. He turned to his love of music and art, and played his guitars and created artwork to help cope with the intensive, life-saving therapy.

Feliciano, his medical oncologist, understands. She wears gold, glittery shoes on clinic days to lift her patients’ spirits of. This small gesture caught on, and now much of the clinical team and many patients and family members don sparkly shoes. During Christopher’s infusions, friends and family members provided encouragement, texting him photos of themselves wearing their own shiny footwear.

Christopher drew on this support in the months ahead, as he prepared for major surgery amid the global COVID-19 pandemic.

In August 2019, after completing chemotherapy and radiation therapy, he underwent an extensive, 11-hour surgery to remove any remaining cancer in his esophagus and lymph nodes, which the spreading cancer had begun to invade. Christopher remained in the surgical intensive care unit for eight weeks, having four more surgeries to address complications.

With the support of his wife and five children, he recovered and was discharged in November 2019. The long stay in the hospital took its toll, but Christopher was determined to regain his strength. After about a month of recovery, he returned to work and began walking and running.

He and Jill were very careful during the pandemic. They went to the small rural town of Deep Creek Lake in Garrett County, Maryland, during his recovery and remained there through June 2020, returning to the Kimmel Cancer Center for quarterly appointments, imaging and bloodwork. He met with his doctors via telemedicine.

Immunotherapy

Christopher was also part of a clinical study of immunotherapy, a new type of cancer treatment that uses drugs that prompt the immune system to attack the cancer and reduce the risk of cancer recurrence. He received immunotherapy before surgery, chemotherapy and radiation therapy.

Studying the benefit of immunotherapy before surgery also gives researchers the opportunity to study all of the molecular inner workings of tumor samples and immune cells to pinpoint what drives response and resistance.

“We think this will provide unique insights about why immunotherapy works in some esophageal cancer patients and not in others,” says Valsamo Anagnostou, M.D., Ph.D. (see story on page 11), who is leading the study in collaboration with Feliciano and Lam.

The results of this study are not yet available, says Feliciano, so she doesn’t know if immunotherapy helped Christopher, but data from ongoing studies is being evaluated, and overall

“All I know is I have a clean bill of health,” says Christopher, who returns to the Kimmel Cancer Center every six months to see Feliciano and to make sure his cancer remains in check.

A similar clinical trial for patients with esophageal cancer explored the benefit of immunotherapy with the drug nivolumab, after chemotherapy, radiation therapy and surgery, to prevent the cancer from coming back. Cancer cells block the natural immune response to cancer, and this drug re-ignites the immune response. Results of this study were published last year in TheNew England Journal of Medicine, and the treatment was found to reduce recurrence of esophageal cancer by 31% and nearly double disease-free survival. In May 2021, the findings led to the first approval by the Food and Drug Administration of the immunotherapy drug for esophageal cancer.

Immunotherapy is showing promise as a new way to combat this cancer by stimulating the immune system to monitor for and eliminate any returning cancer cells, says Feliciano. This type of advance in treatment, she adds, offers hope to patients battling esophageal cancer.