Targeting Esophageal Cancer With Testing Protocols

• More information about the CAP Cancer Protocols
• For questions, please email us at CancerProtocols@cap.org.

Julie McDowell:

Implementing the CAP cancer protocols can help to ensure the completeness of pathology reports and higher-quality pathology evaluation. Further, using the Cancer Protocols can help to ensure pathologists are practicing consistent with current best practices.

In this episode, Yale pathologist Dr. Dhanpat Jain discusses how cancer protocols benefit his practice, particularly the protocol that guides the diagnosis of esophagus-related cancers. Dr. Jain, how have the Cancer Protocols impacted your day-to-day practice?

Dr. Dhanpat Jain:

As you know, the medical knowledge continues to evolve on a daily basis, and it is very difficult to keep track of all the changes that can potentially impact patient care, even for the experts. So with regards to the reporting of cancer specimens, it is well known that whenever a new version of AJCC manual comes out, there are often a lot of changes that impact how we sign out our cases.

The CAP Cancer Protocols are continuously updated by a team of experts so that it makes it easy for practicing pathologists to know what features to evaluate and report in a given type of cancer. This is very important. This allows the oncologist not only treat the patients appropriately as per the most current updated protocols, but also provides accurate prognostic information for a given cancer. So having the standardized and updated cancer protocols by the CAP makes it very easy for me to prepare a concise and complete cancer report without worrying about leaving out any important information in my sign-out.

Julie McDowell:

Now, April is Esophageal Cancer Awareness Month. The CAP has a protocol to guide diagnosis of esophagus related cancers. Can you share a bit about the protocol?

Dr. Dhanpat Jain:

Yes, indeed. April is Esophageal Cancer Awareness Month, and people should know some important facts about esophageal cancer. Esophageal cancer, for example, ranks seventh in terms of the incidences among all cancers worldwide and despite improving survival in recent years, it still remains the sixth leading cause of cancer-related deaths.

With five-year survival of about 20% it remains one of the deadliest forms of cancer, which is largely due to the fact that it is often diagnosed at a late stage. The esophageal cancer is also unique in many ways within the tubal gut. The main histologic type of cancer involving the tubal gut is adenocarcinoma, except in the anal canal. However, the esophagus in the tubal gut is unique as both squamous cell carcinoma and adenocarcinoma can arise at this location. The relative proportion and incidence of each histologic subtype varies by the location within the esophagus and also by patient's ethnicity and geographic locations.

The management of esophageal cancer has evolved over the years, and American Joint Committee on Cancer Staging Systems has taken a novel approach in designing the new staging system and stage groupings for the esophageal cancers, which reflects the changing practice and new data. The staging of esophageal cancers truly remains unique amongst various gastrointestinal cancers as it takes into account not only the location of the cancer, but also the histologic subtype, its grade and the status

of any new adjuvant therapy.

The other issue that is unique to esophageal cancer is that the preoperative neoadjuvant therapy is increasingly being used in the treatment of locally advanced esophageal cancers, which is followed by surgical resection. And it is now very clear that while it's certainly improves the survival, the therapy also leads to a variety of histologic changes in the esophagus that can be challenging for the pathologist to evaluate and report.

For example, following neoadjuvant therapy, sometime one can see pools of mucin in the tumor bed. These mucin pools may have viable tumor cells or be completely SSLR. Similarly, the lymph nodes may also show a variety of treatment related changes.

The CAP cancer protocol properly addresses these issues and helps you to correctly stage the cancer. In addition, endoscopic mucosal resection and dissection are also increasingly used in clinical practice and to treat early esophageal cancers. The esophageal cancer CAP protocol has now been modified to address all these changes.

Julie McDowell:

Can you share some helpful hints for those who may not have used this protocol before?

Dr. Dhanpat Jain:

Certainly, I would suggest that read the protocols from beginning to end at least once, to familiarize yourself with the various elements included. And especially read the associated footnotes as these include explanations that are not always intuitive, and also explain some of the controversies associated with the cancer staging.

I would also suggest that one should read the most recent AJCC cancer staging manual and its content which provides the rationale for staging different types of cancers, and also highlights various changes that have been made in the latest versions.

However, one should recognize that these cancer protocols are very brief and evaluations of some of the parameters or the provided explanations in the footnote may be not enough, especially to someone who is using it for the first time. In this situation I would suggest that one should not hesitate to seek advice or clarification from other colleagues who have been using these protocols for a longer period of time. In addition, one can also send their questions to the CAP Cancer Committee for clarifications. The CAP Cancer Committee uses this feedback to continuously improve the cancer protocols as well as to correct any errors.

Julie McDowell:

What are some of the common challenges for you as a practicing pathologist who uses this protocol?

Dr. Dhanpat Jain:

Certainly filling out the details to complete this synoptic summary according to protocols, takes more time and attention to details. However, once you become familiar with the protocols, with time it certainly gets easier and quicker. It also implies that individuals who are grossing the cancer specimens, whether it be PAs or residents, are also trained appropriately so that they can record all the important features accurately that are needed to complete the synoptic summary. In most of the training programs, initially, the residents compile the synoptic summary using the CAP cancer protocols, which not only helps in their education, but also reduces the burden on the attending pathologists.

Julie McDowell:

Finally, Dr. Jain, what are the potential benefits of using this protocol?

Dr. Dhanpat Jain:

The protocols are very, very helpful in our clinical practice. Pathologists use different language to report the same feature due to their personal biases or preferences, but this can sometimes create confusion for the treating physicians.

For example, while reporting normal tissues, some will say "Tissues are unremarkable." While others might say "No diagnostic abnormality identified." While in many situations such differences do not matter clinically, in some situations they do. The uniformity of language that is used in the CAP cancer protocols in reporting various parameters and standardization of this language that is used in reporting critical parameters in cancer specimens avoid such confusions.

In addition, the cancer protocols also standardize the pathology reports in such a way that anyone looking for a specific information within a case can often easily find it. More so standardization of the cancer reports as per the CAP protocols also helps each laboratory or the institution to keep track of cancer related data, which can be very useful in any quality improvement projects or research. Overall, I would say the standardization and uniformity of reporting cancer specimens avoids confusion and unnecessary clarification, which can be very useful in discussions at the tumor boards.

Julie McDowell:

Thank you, Dr. Jain. For more information about this CAP cancer protocols, click on protocols and guidelines at the top of cap.org. Thank you for listening to this CAPcast. Be sure to listen to our other CAPcasts from the CAP on our SoundCloud channel by downloading the SoundCloud app on your mobile device. And we're also on Apple Podcast and the Stitcher app. To find this podcast, search for the word CAPcast on these apps. Once you find our podcast, be sure to click the subscribe button so you don't miss new CAPcast episodes.

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