The Beam: Protons for esophageal cancers; benefits of mentorship among physicians; meet one of our patient care coordinators

Proton therapy for esophageal cancer

The esophagus is the organ in the throat that moves food from the mouth to the stomach.

Esophageal cancers make up approximately 1% of cancer diagnoses in the U.S., making them rare. Because many people who have esophageal cancer do not have any symptoms from the start, this cancer is often not diagnosed until at least stage 3, at which point the tumor is larger and may have begun to spread to lymph nodes.

“Esophageal cancers are hard to catch early,” said Jing Zeng, MD, who treats many patients with esophageal cancer at Fred Hutch Cancer Center – Proton Therapy. “Often the first noticeable symptom is that the tumor is causing a blockage, making it hard to swallow. Once it’s that large, it most likely has also spread to local lymph nodes, and if stage 4, to distant organs such as the liver.”

Some of the risk factors for esophageal cancer are smoking, heavy drinking, chemical exposure and uncontrolled gastroesophageal reflux disease (GERD). Patients who are being actively treated for acid reflux may find esophageal cancer early, because they may receive routine endoscopies. If caught early — when the tumor is tiny and superficial — treatment is easy and non-invasive through a method called endoscopic mucosal resection.

However, once the tumor is large enough to cause symptoms, treatment is extremely aggressive: chemotherapy with major surgery, or chemotherapy and radiation (chemoradiation) with or without the surgery.

“Usually, surgeons must remove the entire esophagus, which is a very delicate and thin organ that is challenging to operate on, and the stomach is moved up to the chest to connect to the throat,” said Zeng. “Having the surgery comes with the risks of any major surgery but can help with tumor control.”  

Chemoradiation for esophageal cancer treatment is challenging.

A patient’s appetite is already reduced from the cancer, and they usually have trouble swallowing because of the tumor. Chemotherapy can cause nausea and taste changes. Radiation can burn the esophagus, making it painful to swallow. Eating can become a full-time job, just to get the nutrition needed.

In terms of radiation, Zeng often recommends proton therapy for treating esophageal cancer. The esophagus is in a challenging location to treat — in front of the spine, behind the heart and between the left and right lungs. When using radiation to treat esophageal cancer, it is important to deliver enough radiation to the cancer without damaging the healthy organs around the esophagus.

“Where protons are beneficial is in reducing the short- and long-term side effects to the other organs nearby,” said Zeng. “Surgery and conventional radiation can cause lung problems such as pneumonia and heart problems such as arrythmia. Protons reduce the radiation dose to those organs and studies suggest that proton therapy may lead to decreased side effects from radiation treatment. That is why we often recommend protons as the preferred radiation treatment for esophageal cancer.”

If protons are not an option, it's often because of other circumstances, such as logistics, insurance denials or other medical conditions, said Zeng. In these circumstances, Fred Hutch has other ways to treat esophageal cancer.  

“Esophageal cancer is an aggressive cancer, but treatments are always improving,” said Zeng. “For example, immunotherapy after chemoradiation has shown promise, and new treatments are being developed.”  

The benefits of mentorship in radiation oncology

When you speak to a radiation oncologist, you might hear them refer to their mentor. In fact, they might have had more than one, each providing guidance in a different area of expertise, such as their disease site specialty or their research, according to Proton Therapy Medical Director, Annemarie Shepherd, MD. 

Shepherd recently recounted how she benefitted from her mentor, Ramesh Rengan, MD, PhD, who leads the radiation oncology department at Fred Hutch and UW Medicine.

“He was my research mentor in medical school. I was partnered with him by the department and he has significantly shaped the course of my career,” said Shepherd. “I knew about radiation oncology, but during this research fellowship, Dr. Rengan exposed me to the many different aspects of the field. He influenced my decision to go into radiation oncology, provided perspective on different residency programs, and offered guidance about how to connect with colleagues at different institutions. He was always open to giving me his time.”

Shepherd herself has several mentees from her previous position in New York. She continues to give her mentees guidance and is looking forward to helping new ones at Fred Hutch, once a mentorship program is fully established for the radiation oncology department.

“Mentors are incredibly valuable to career development in radiation oncology. Without a mentor it’s hard to figure out the educational and career paths in the field,” she said. “You rely on people who’ve been through it before.”

Smith Apisarnthanarax, MD, professor and radiation oncologist who sees patients at the proton therapy facility, is currently expanding the mentorship program at Fred Hutch and UW Medicine. Right now, the program exists for junior providers on an academic track and for medical physicists. Other faculty will also be able to take part in mentorship in the future.

Mentorships are designed to facilitate the career development of junior faculty (assistant professors) by pairing them with senior faculty (associate professors or professors).

“The department stakes are pretty high,” said Apisarnthanarax. “You have six years to be promoted, or you leave. However, it isn’t just about promotion. We want to be able to foster the junior faculty members’ specific needs.”

The mentorship program was established about two years ago by pairing mentors with mentees. To create more focused pairings, Apisarnthanarax has developed surveys for both parties involved.

“I need to understand both sides in order to create good connections,” said Apisarnthanarax. “What are the strengths individual senior faculty members can offer, and what are the needs and desires that junior faculty members want to get out of the relationship?”

For example, if a junior faculty member is interested in clinical trials, Apisarnthanarax, among other considerations, will try to pair that person up with a physician who has extensive experience in designing, leading and running clinical studies. 

“Physicians with good mentorship often step into roles where they can lead, educate and innovate,” said Apisarnthanarax. “Mentors help young physicians define who they want to be in our field and to become well-rounded, compassionate and resilient physicians, which benefit patients.”

There is a lot of data behind the need for a mentorship program. But how much individuals get out of the program is up to them, said Apisarnthanarax. To really encourage them to make the most of it, he is also hoping to do some team-building activities that involve everyone in the program, to jump start their involvement.

Right now, about half the senior physicians and half the senior medical physicists have agreed to be mentors. But there have been requests to expand the program to include not just mentorship for junior faculty, but of mid-level faculty, especially those who have come from other institutions, and of clinical (non-academic) faculty as well.  The hope is to be able to meet the needs of all faculty so that they have the type of mentorship experience that Shepherd benefitted from.

Meet patient care coordinator, Erik Rummell

If you have had a consultation on proton therapy for prostate cancer at Fred Hutch, you may have spoken with patient care coordinator, Erik Rummell. He helps patients meet with one of our physicians to determine if proton therapy is an appropriate treatment option for them. He also collects medical and insurance information from patients to verify benefits and coverage so they can make informed decisions with their providers.

“My favorite part of the job is helping patients, and often their families as well, move through a period of time that can feel frightening, overwhelming and uncertain,” said Rummell. “Whether they’re an appropriate patient for proton therapy or not, I take pride in assisting them with as little stress or extra leg work on their end as possible.”

Rummell was raised in Silverdale, Washington, but has also spent a lot of time in Bellingham, Washington and Eugene, Oregon as he attended universities in both cities, pursuing undergraduate and graduate degrees in sociology and psychology. He knew he wanted to assist others for a living and he learned about the proton therapy facility through a network of friends who work at Fred Hutch.

Because he has a basic understanding of physics after classes taken in high school and college, he appreciates understanding how the technological marvel of proton therapy works, but what he especially enjoys is working with his colleagues.

“They are some of the funniest people I’ve met, yet diligent in their roles,” he said.

His biggest inspiration in life is his mother.

“She had me as a teenager yet always prioritized me,” he said. “If I become a quarter of the person that she is, I will be content, because she is truly remarkable.”

It may be because of his mother’s influence that Rummell has won several “Most Inspirational” awards in team sports and jobs, and why he feels joy seeing friends and family succeed.

Outside of work, Rummel is a huge fan of Pink Pantheress, an English singer, songwriter and producer. He likes to play video games and tennis, and to eat good food with friends. Make sure to say “hi” if you see him at the proton therapy facility!