There was no way Kevin Schmidt was going to let doctors remove his esophagus — even if it might mean it would also remove his cancer.
“Sleeping in a recliner the rest of my life and eating saltine crackers the rest of my days — for me that was not an option,” said Schmidt, who was diagnosed with stage 3B esophageal cancer three years ago, at age 55. “So I asked my doctors, ‘What’s plan B?’ and they said, ‘Let’s get outside the box,’ and that is what we did.”
The esophagus connects the throat to the stomach with 10 to 13 inches of muscular tube comprised of layers. Esophageal cancer, of which there are two kinds, starts in the inner layer and grows outward. Common treatment is an esophagectomy with gastric pull-up, a surgical procedure in which the stomach is used to replace the esophagus.
Schmidt had a large tumor at the base of his esophagus that had spread to seven of his lymph nodes. And in 2013, he was diagnosed with adenocarcinoma esophageal cancer.
Esophageal adenocarcinoma commonly starts in the lower esophagus and is often the result of Barrett’s esophagus — which Schmidt also had. “Barrett’s esophagus is a precancerous condition in which the normal tissue lining in the esophagus changes to tissue that resembles the lining of the intestine. This is thought to be a complication of longstanding gastroesophageal reflux disease,” said Dr. Michael Nosler, a therapeutic gastroenterologist with UCHealth in northern Colorado. Barrett’s esophagus increases the chance of esophageal cancer thirty-fold, but only 1 percent of Barrett’s patients develop the cancer each year.
Radiology oncologist Dr. Joshua Petit and oncologist Dr. Ross McFarland decided to attack Schmidt’s cancer with an aggressive chemotherapy and radiation strategy.
“Any time you use chemo and radiation together it’s more toxic than either alone — and this was a sensitive area,” McFarland said. “The chemotherapy is used to kill the tumor, but also makes the radiation more effective on the tumor. Unfortunately, it also makes it more effective on normal cells as well.”
Because Schmidt’s lymph nodes were at risk, a large area of radiation was necessary, which caused a lot of pain, McFarland said. Schmidt was on a feeding tube and lost a lot of weight.
“I lost about 70 pounds in five months,” Schmidt said. “I was a wreck. It was bad, but I bounced back and I got healthier. These guys did a good job. They definitely saved my life.”
To make sure Schmidt continued to enjoy his life, doctors had to eliminate the cancer’s precursor: Barrett’s.
“Because we were treating the cancer without removing the esophagus, we needed to do something about his Barrett’s,” Nosler said. “We needed to take away that cancer risk as well as the cancer.”
Nosler had been following cryotherapy’s use and effectiveness to eliminate tumors and cancerous cells.
“Cryotherapy has a good tissue-depth effect,” he said. “When you are applying it to a large portion, it has a lower risk of forming scars inside the esophagus than radiofrequency ablation (heat and radio-wave treatment). … It was consistent with the broader treatment plan that he [Schmidt] was looking for.”
Cryotherapy uses liquid nitrogen to spray and destroy cells without much damage to the esophagus. Under general anesthesia, a scope the size of a pinky finger is directed down the esophagus, and a ventilation tube in the stomach vents the gas as liquid nitrogen is sprayed through the scope. Nosler freezes a small area for about 20 seconds, lets it thaw for about two minutes, and then repeats the process — typically two cycles for each site. “It is the thawing that destroys the bad cells,’’ he said. “Over time, the body regenerates that area with healthy cells — similar to what happens with a blister.’’
“This was a patient-directed idea,” Nosler said. “It was consistent with doing something that may possibly be effective but minimizing the side effects.”
So far, the treatment is working. Nosler has been able to reduce the portion of Schmidt’s esophagus affected by Barrett’s — which started at 9 centimeters — at the rate of about 2 centimeters per visit. After each visit, Schmidt is sore for a few days and on a diet of mostly liquids. The next few days he experiences no pain, but then as the new skin forms, the tenderness in his throat returns for a few more days. Sessions are about eight weeks apart.
“It’s important that we educate patients about all the treatment choices available to them,” Nosler said. “Cryotherapy is an alternative for those who have a high surgical risk or who decide to opt out of surgery. The difference is one surgery, with higher risk versus multiple smaller treatments that equal a few years of treatment. For Kevin, cryotherapy reflects the vision of how he saw his health care.”