Upcoming Research Could Address Disparities in Esophageal Cancer

Steven Sims, MD, discussed his upcoming research into how transnasal esophagoscopy could help address disparities in esophageal cancer diagnoses.

Aislinn Antrim: Hi, I'm Aislinn Antrim with Pharmacy Times and today I'm speaking with Dr. Steven Sims about upcoming research into how repurposing a diagnostic device for esophageal cancer could help tackle health disparities. And so, from my understanding, your upcoming research will be investigating the repurposing of a diagnostic device to address health disparities in esophageal cancer screening and outcomes. What diagnostic device is that's referring to? And can you talk about that a little bit?

Steven Sims, MD: Absolutely. First, thank you for the opportunity. I am always happy to talk about ideas and the work that I hope comes from them. I guess I'll start by giving a little background. Esophageal cancer really occurs in two forms, so one of them is adenocarcinoma. And that particular type of esophageal cancer is more common in caucasian males over age 50. That type is really linked to Barrett's esophagus, which is a terminology for changes seen in the cells and the esophagus. It's often associated with chronic reflux or untreated reflux. And if you look in the literature, there's already a fairly robust protocol to make sure those patients get screened for cancer. And this idea that if you have a scope—which the device itself is called the transnasal esophagoscopy, abbreviated TNE—and this is basically just a camera, a scope, that is small enough to go through the nose trans-nasally. And then we can go all the way down into the swallowing, too. And then it's long enough for us to get all the way into the stomach.

Now, one of the benefits of this is that it can be done with minimal sedation in an awake patient. So, in the office, we use a little bit of numbing medicine in the nose, and maybe in some patients spray a little bit in the back of the throat, and have them go to under really minimal anesthesia for this. And then we can have the patient swallow. And we just sort of follow the mechanics of what happens when one swallows and the muscles contract. And then the scope will go down into the swallowing. I don't want to minimize it, because that does feel kind of weird, you know, when you have it happen. And in order to see into the swallowing too, we do have to put little puffs of air in there. Because in its sort of natural state, the swallowing tube is collapsed. It's sort of flattened. And so it doesn't really open up unless you're swallowing, and there's something there to help hold it open. So, we need to use a little puff of air to help expand it enough for us to see it. And so that feels a little funny as well when it's going on. But patients actually tolerate this pretty well, and for a while now we've been able to do that in the office.

So, our concept, our idea is to just repurpose something that we're already using to look for squamous cell carcinoma and changes along the lining of the esophagus. And see if we can pick up some of those cases earlier using TNE. That is, if you look at the data, death from squamous cell carcinoma is highly prevalent in African American males. Like, that seems to be the group that suffers the burden of this the most. And a lot of the data and literature also shows that these patients tend to present with late stage disease. And so, knowing that there is already a screening paradigm in place for adenocarcinoma, part of what we're doing is saying well, let's you know, have a parallel to that, and initiate a screening paradigm for squamous cell carcinoma. And some of that is looking at and understanding the risk factors associated with it, which includes smoking and drinking and, in particular, that combination. And so some of this is just screening the community and looking for patients who are engaging in smoking and drinking at the same time.

One of the features of our project is that we also want to look sort of specifically at some of the products, because I think that that is reflective of a disparity as well. And when I say that, I mean this malt liquor, Cisco fortified wines, products like that, as well as methylated cigarettes. The data again bears out that these are rather targeted and specifically marketed in African American and Latino communities, and so we want to take a look at how many of the patients that may have these diagnoses also have a history of consuming these products. And is there a possibility that these products have sort of a qualitative effect in terms of their cancer risk. So that's, you know, another piece of how we want to do this investigation and use this screening to try to help improve survival, but also the treatment options available to the patient if we get them diagnosed at an earlier stage.

Aislinn Antrim: That’s very interesting. And it sounds like there are kind of a variety of issues, all going into these disparities. Can you talk about how specifically the diagnostic device could help address these issues?

Steven Sims, MD: So, I mean, the diagnostic device, I don't think will address the disparity per se. Meaning that having a scope is not going to mean that you don't live in a neighborhood where fortified wines and methylated cigarettes are marketed. But it does create a bit of balance if that neighborhood is experiencing those carcinogens. And by the way, often there's an overlap with that neighborhood also being the same one where you can't go to a grocery store and get fresh fruits and vegetables, which is going to also increase your cancer risk. And then I think the other layer of overlap is that neighborhood also may not have as ready access to medical care. And so, some of those things, well, I guess all of those things we can do something about. But just thinking in terms of what can we do, one of the things that we can do is improve the access to screening. And so that is the way in which we view ourselves as helping with part of the disparities that exist. And hopefully, we will have data to help educate the patients, and the community really, about the risk of using and consuming these products. Because the marketing campaign, you know, as this is true for most of the marketing of tobacco, has made it slick and sexy and appealing. And the way in which I think you can bet that is with the real evidence of what happens with long term consumption of these products and what the real risks are. So that's another just sort of piece of how we envision making a difference, is being able to share information about what happens with consuming these products and engage and be a part of, you know, some of the smoking cessation and reducing alcohol consumption issues.

Aislinn Antrim: Absolutely. And can you go into a little bit more about what specific disparities exist in screenings for esophageal cancer?

Steven Sims, MD: I think that there is sort of this global idea that a lot of times lower socioeconomic status, which often happens to overlap with African American and Latino communities, is less likely to have a primary care provider, they're less likely to have regular primary care visits. So I think a lot of the baseline in general patient education and screening is more lacking in certain zip codes. And so, we are designing this to partner with a lot of the community health organizations so that we strengthen our presence and our alignment with their mission, and hopefully, make it easier for the patient to get access to us.

Aislinn Antrim: How were some of these disparities exacerbated by the COVID 19 pandemic?

Steven Sims, MD: Well, I don't know that specifically esophageal cancer was exacerbated, although I would say like in this global onset, global sense. We have patients who just weren't coming in because of fear. And so that delays diagnosis and tends to show up, as with late stage, later stage disease at the time of diagnosis. But I think it’s, just again, in the more comprehensive sense.

I have a different project that is actually looking at the COVID-19 pandemic specifically. And where patients got information and whether or not they thought they had a medical home and whether or not there was somewhere they need to go. Particularly early on in the pandemic, people didn't know where to go to get tested. They didn't know whether or not they needed to wear a mask, they didn't know very early on, like what the social distancing policies were, and a lot of the information coming out changed daily. And it was very confusing. Absolutely. Remember, in the very, very early stages, there was this narrative that if you hadn't traveled, you were less likely to have experienced or been exposed to this. And so we had a large cohort of patients who would, if they had not been on a cruise, they had not been on a plane, and felt like they probably weren't at any risk of developing it. And that turned out to be completely not true. And I'm not saying that anyone misled because we all use the information that we have, at the time that we have it, to try and give the best advice and recommendations that we can give. But I definitely understand that, from the perspective and vantage point of a lot of our patients, it just seemed very confusing, and the messaging did not feel consistent. And I think that a lot of that is related to the fact that underlying relationships with health care providers had not been there.

And the other just organizational things, we have people who have jobs where they are considered or deemed essential, and we say that you shouldn't go to work—except for you, because you do have to go. And a lot of those people who are essential, we tell them don't ride public transportation, but there's no other way for them to get to work. You know, and so I think that there are just a lot of systemic issues, the pandemic has highlighted and helped us face that. You know, we ask for the impossible, and are not always as aware as we could be about, really, what the constraints are. And so, I think, you know, it's terribly unfortunate, the way in which we have highlighted and learn some of these lessons. But I certainly hope moving forward, we see a bit more clearly some of the underlying disparities that have always been there and how the pandemic exacerbated them.

Aislinn Antrim: Absolutely. And you mentioned earlier that your study will engage community based organizations. Can you talk about how that will work? And what you hope to accomplish with these collaborations?

Steven Sims, MD: Oh, absolutely. So, one of them is that we are doing this through community health centers, here at USC, they are called Mile Square Community Health Centers, and we are partnering with them. But there are also other organizations. There's something called The Shared Project and Brothers Helping Brothers, which specifically engages African American males, in terms of community education, health care, literacy. And it's sort of out of the box thinking, like a lot of the locations for intervention and community building are barber shops, or places where we know black men congregate, because you may not have a large number of African American males who are going to come to the community health outreach, per se, particularly if there's this history of it feeling like it's not inviting, not welcoming, then you may not have people show up. And that's just reality. And so what has to happen, I think, to combat that, is you have to go where they are, and sit down and have conversations and talk about, you know, what, what you can do, and I think more importantly, listen to what people need, and what helps them feel comfortable, what way of receiving information is best for them. And I think once you establish relationship and partnership with the community, you do a much better job of so.

Aislinn Antrim: Absolutely. From my understanding, your research hasn't begun yet and it just recently got funded, I think late last year. But is there kind of a timeline? What's the plan for everything?

Steven Sims, MD: You know, we are ready to go. We're raring to go. But we're also cognizant of the fact that we are still finalizing IRB approval, I've had a few questions and clarifications about some of the things. And obviously, we are 100% on board with being as transparent as we can and protecting our patients. And explaining everything to really anyone who asked in as much detail as we can to have this project fully approved and everyone on board with what we're doing. But those are some of the things that we are waiting on. Now, I just had a meeting this morning, actually, to finalize our relationship and commitment with Mile Square. I have worked with them before with other projects. So again, as you build these relationships, it just makes it easier to do this work. But it also is very rewarding to have those relationships and sort of walk into the clinic and have people already know who you are. So, yeah, we are hoping to be able to begin at least administering our survey within the next six weeks. Our first scope may be a little more delayed than that, but hopefully not too much.

Aislinn Antrim: I'm certainly looking forward to hearing more about it in the future. Is there anything that you want to add or anything that I didn't think to ask about?

Steven Sims, MD: I mean, I guess I'll add that part of this is this idea, in a way at least, has been floating around in my head for a long time. But I think that this is one of the reasons why I am such an advocate for a diverse group of researchers, because I don't think someone who has not had great interface in certain communities would even pick up on the fact that like Cisco, Mad Dog 2020, those types of products, you really only see those in certain local locations, or certainly with the amount of access and how prevalent they are. That's only in certain zip codes. And it takes seeing that to even begin asking the question, I wonder if that's related to the fact that these same zip codes have a higher predominance of later stage disease? And I don't know, you know, for a fact, that that will be what I find. But I feel like you won't know if you don't ask. And if you are not someone who has experienced it, you don't even know to ask. And so I think that’s the way in which we determine what which projects are funded and who is a researcher. We would all do well to expand that.

Aislinn Antrim: Absolutely. Well, thank you so much for talking with me about this.

Steven Sims, MD: Oh, it's my absolute pleasure. Thank you.