About Dr. Fontaine
Dr. Jacques Fontaine is board certified by the American Board of Surgery and the American Board of Thoracic Surgery. He currently practices Thoracic and GI Oncology at H. Lee Moffitt Cancer Center in Tampa, Florida.Make an Appointment
Esophageal cancer is a relatively rare malignancy that forms in the lining of the esophagus. It can complicate swallowing and cause chest pain. Trust Dr. Fontaine and Moffitt to find the best treatment options for you.
The esophagus is composed of several layers of tissue where cancer can form. Typically, it develops on the inner lining of the esophagus and, over time, spreads to the outer layers as the cancer progresses.
The two most common types of esophageal cancer are:
- Adenocarcinoma: It is most prevalent in North America and usually associated with chronic heartburn (GERD) and Barrett’s esophagus. It often forms near the lower esophageal sphincter, which is the valve between the esophagus and stomach.
- Squamous cell carcinoma: This is less common in North America, and it can form anywhere in the esophagus, but it’s mostly found in the upper and middle portions of the organ.
The American Cancer Society estimates that 18,170 new cases of esophageal cancer will be diagnosed in the U.S. in 2014, making it the 8th most common cancer. Diagnosis in men is three to four times more likely than in women. The experienced oncologists at Moffitt Cancer Center in Tampa, Florida, can help patients determine if they are at risk for esophageal cancer.
Symptoms and Diagnosis of Esophageal Cancer
The most common symptoms of esophageal cancer are:
- Difficulty or painful swallowing
- Pain, burning or pressure in the chest
- Weight loss
If you are experiencing any of these symptoms — especially trouble swallowing — schedule an appointment with Dr. Fontaine immediately. The patient support team at Moffitt can help you make travel arrangements if you are from a community surrounding Tampa Bay such as St. Petersburg, Fort Myers, Naples or Lakeland. Moffitt has ties with several accommodations surrounding the Tampa-based hospitals to offer discounted or free lodging while patients are receiving treatment.
While diseases other than cancer may cause some of these symptoms, Fontaine can perform tests to detect esophageal cancer and establish a diagnosis. It is essential to get an accurate diagnosis as soon as possible.
Detecting Esophageal Cancer
Although a barium swallow (X-ray with special oral contrast) may detect cancer of the esophagus, the most reliable way to diagnose the disease is with an endoscopy (EGD). During this procedure, doctors insert a thin, tube-like camera through the mouth to examine the esophagus and obtain a sample for testing, also called a biopsy.
Biopsies can confirm a cancer diagnosis, but may also reveal abnormal changes in the lining of the organ. One of those abnormalities is Barrett’s esophagus, an inflammation caused by chronic irritation of the lining of the esophagus from chronic reflux (heartburn or GERD) which may lead to cancer. It is considered a pre-cancerous condition. Patients with a diagnosis of Barrett’s esophagus should be followed closely by their doctors, especially if dysplasia is found in the biopsy sample.
Staging Esophageal Cancer
When cancer is discovered, the first step doctors take is performing more tests to determine its stage or the extent of the cancer’s spread. By international convention, all cancers are staged using the TNM classification;
- T: Size or depth of invasion of the cancer
- N: Lymph node involvement
- M: Presence of metastasis (spread to distant organs)
Based on the TNM classification, cancers are then grouped into four stages. Stage I refers to very early tumors while stage II and III are intermediate-staged tumors. Stage IV represents advanced cancers where the disease has already spread or metastasized to other organs.
The tests necessary to determine the TNM classification (stage) include the following:
- CT scan of the chest and abdomen
- Endoscopic Ultrasound (EUS)
- PET scan
What is an Endoscopic Ultrasound (EUS)?
An endoscopic ultrasound (EUS) is a special endoscope that has a small ultrasound probe at its tip, in addition to the camera. This allows the doctor to measure the thickness (T stage) of the tumor, as well as evaluate the surrounding lymph nodes (N stage).
What is a PET scan?
A PET scan is a CT scan with a special radioactive glucose (sugar) dye that is injected in a patient’s vein. This glucose, a fuel source for cells, is absorbed more rapidly by cancer cells as they replicate, causing them to show up brighter on a PET scan. This helps determine the location of the cancer and if it has spread to other areas or organs (M stage). Although very precise, PET scans are not 100 percent accurate.
If you have been diagnosed with esophageal cancer, finding a medical team specialized in this disease can greatly improve the outcome of your treatment.
Doctors in the Gastrointestinal Oncology Program at the H. Lee Moffitt Cancer Center in Tampa treat more esophageal cancer patients than any other center in the Southeast. This unique specialization allows them to offer the latest advances in treating this disease.
Based on National Cancer Institute (NCI) data, esophageal cancer patients treated at Moffitt have higher survival rates than the national average.
Trust Moffitt and Dr. Fontaine to Treat Your Cancer
The NCI recognizes H. Lee Moffitt Cancer Center as a Comprehensive Cancer Center for its resources, research and specialists. In fact, it’s the only one to carry that designation in Florida. Because of its recognition, patients from Clearwater, St. Petersburg, Sarasota and other nearby cities prefer Moffitt over other cancer hospitals.
The total focus on cancer has allowed Moffitt to provide the latest, cutting-edge treatment, including immunotherapy and access to the world’s latest clinical trials to better target the cancer. The goal is to provide the finest care in the world.
Moffitt’s relationships with cancer specialists across Florida allow patients to combine treatment at home with surgery in Tampa, providing an almost seamless relationship in receiving the best possible care. This makes it easier for patients from nearby cities, such as Clearwater, Vero Beach or Sarasota, to travel to Moffitt is Tampa for treatment.
Fontaine’s unique mix of innovative thinking and more than a decade of experience in esophageal cancer make him the thoracic surgeon of choice at Moffitt. In fact, Fontaine says nearly one-third of all his patients are diagnosed with esophageal cancer.
He is also a big believer in Moffitt’s Experimental Therapeutics Program and often encourages patients to participate.
Esophageal Cancer Treatment Options
Once your cancer is diagnosed and staged, your doctor will discuss your options for treatment. The primary treatment options for esophageal cancer include one or a combination of:
- Radiation therapy
At Moffitt, patients benefit from an individualized approach to treatment. Several of the world’s leading esophageal cancer experts, including Fontaine, will assess your unique situation as a team, discuss it in a multidisciplinary tumor board, and suggest a treatment plan associated with the highest survival rate and greatest improvement to quality of life. This makes Moffitt a top cancer center for Florida residents.
The choice of treatment depends on the stage of the cancer.
Stage I (Early stage): Removal of the esophageal cancer with surgery is called an esophagectomy. It offers the best chance of a cure. Chemotherapy or radiation are not required. Rarely, some very thin tumors may be completely removed without formal surgery by shaving off the inner lining of the esophagus using an endoscope and a technique called endomucosal resection (EMR).
Stage II/III (Intermediate stage): A combination of six weeks of chemotherapy and radiation followed by surgery is the best esophageal cancer treatment option in this situation. The rationale for administering chemotherapy and radiation upfront is to shrink the tumor and make it more likely for the thoracic surgeon to remove it completely as well as decrease the risk of the tumor recurring (coming back) after surgery. Most patients receive weekly chemotherapy and 28 doses of daily radiation during six weeks. They are then given 6-8 weeks to recuperate, and a repeat PET scan is performed to assess if the tumor responded to treatment and shrank. In 90 percent of cases, the tumor has remained the same or shrank. If this is the case, and patients have recuperated sufficiently from their chemotherapy and radiation, then surgery is recommended. In 10 percent of patients, where the tumor spread despite initial chemotherapy and radiation, surgery is not a good option as it would not increase their chance of a cure.
In some instances, after initial chemotherapy and radiation, the tumor may appear to have completely disappeared on a repeat PET scan or even on endoscopy. However, although not visible on tests, microscopic tumor cells are that still present and alive despite a “negative” repeat PET scan or endoscopy in more than 70 percent of cases. It is therefore imperative that all patients be physically and mentally fit enough to undergo surgery after chemotherapy and radiation. Waiting to see if the tumor comes back before deciding to have surgery is a risky option because the tumor may recur in other organs (metastasis). The risk of complications from “salvage” surgery also is much higher because of the long-term effects and scar tissue from radiation. However, this major surgery may not be advisable or safe if patients have not been able to fully recuperate from the initial six weeks of chemotherapy and radiation.
Stage IV (Advanced stage): If the tumor has already metastasized to other areas or organs, surgery is not an option. Chemotherapy alone is most often the recommended treatment. Although the chance of a cure in this situation is very low, chemotherapy may shrink and slow the growth of the tumor, allowing patients to swallow food more easily and live longer with a decent quality of life.
Referred to as an Ivor Lewis esophagectomy, this major cancer surgery involves removal of two-thirds of the esophagus as well as the surrounding lymph nodes. Once the section of the esophagus is removed, the surgeon shapes the stomach as a cylinder, pulls it into the chest and connects it to the remaining esophagus in the upper chest. The six-hour surgery requires patients to remain in the hospital approximately one week. Complications are common, but most are minor and temporary. The recuperation is long and can be challenging. The road to recovery can sometimes be bumpy. However, the surgery offers the best chance of a cure.
An Ivor Lewis esophagectomy is a high-risk surgery, and multiple scientific studies have proven the experience of the surgeon and of the medical center changes the outcome in terms of complications and success rates. Fontaine and his colleagues at Moffitt Cancer Center are leaders in esophageal cancer surgery and pioneers in robotic esophagectomies.
At Moffitt Cancer Center, Fontaine and his team of thoracic surgeons perform more robotic esophagectomies than any other center in the United States. This experience allows them to have better results, and it gives patients an even greater reason to travel to Tampa for the innovative procedure.
Minimally invasive or robotic surgery offers many advantages to cancer patients requiring surgery as part of their treatment. Through a few small cuts with the aid of a magnifying 3-D camera and miniaturized, precise instruments, surgeons can perform surgery with fewer complications and less trauma, blood loss and pain.
The recuperation after an esophagectomy is a long process that may take up to six months. The recuperation is often two steps forward, one step back. Some patients experience fatigue, poor appetite, diarrhea, reflux or vomiting. These symptoms improve over time. Walking 20 minutes twice a day and staying active is key. The patient and their family must remain optimistic after surgery. Once fully recuperated, patients may eat any food they like, drink alcohol in moderation and return to all their regular activities.
If a patient hits a bump on the road to recovery, they need to be able to get right back up and continue fighting.
Cancer patients must be monitored after their treatments to confirm they remain cancer-free. A PET or CT scan is recommended every 4-6 months as well as an endoscopy every year for at least the first five years after surgery. Moffitt staff can help patients make travel arrangements to Tampa from their hometown for these follow-up appointments.