Smilow Shares with Primary Care: Gastrointestinal Cancers

Transcript

• 00:00Um, thanks for joining tonight. We
• 00:02want to welcome you to smile
• 00:05shares with primary care tonight
• 00:07our focuses on GI cancers and
• 00:10we've got a great staff available,
• 00:12great faculty tonight that are going to.
• 00:16That are going to talk about issues around
• 00:19GI cancers and my name is Anne Chang,
• 00:22my partner in establishing this
• 00:25series is Karen Brown, and we are.
• 00:29Here to welcome you to this monthly
• 00:31lecture and many of you have been
• 00:33with us before this came about really
• 00:38through discussions between Karen and
• 00:40myself and others focusing on the
• 00:43primary care perspective on cancer.
• 00:45There are a lot of venues where
• 00:47you can get cancer information,
• 00:49but this is intended to really partner
• 00:51with primary care at and this cancer
• 00:54specialist to to focus on those issues
• 00:57that are most interesting to you.
• 00:59And most pertinent to you so.
• 01:03Well, it's a as you know a case
• 01:06based discussion.
• 01:07We have three cases tonight that we're
• 01:09going to try to get through and to
• 01:12highlight certain key clinical pearls
• 01:14and and and and certainly the advances
• 01:16for for you to know about.
• 01:19Umm, so we'll do our introductions
• 01:22first and then we will go into the case
• 01:25presentations and then we always like
• 01:27to have about 10 minutes available
• 01:29for your questions and answers.
• 01:31So either put them into the chat
• 01:33or else keep them for the end.
• 01:35That's always the really interesting
• 01:38and and important part. So we'll
• 01:41we'll definitely leave time for that.
• 01:43Karen, do you want to go ahead
• 01:47and introduce yourself and and?
• 01:49And. Start with the introductions.
• 01:52Sure. Thank you.
• 01:53So for those who don't know me,
• 01:55my name is Karen Brown.
• 01:56I'm an internist in in North
• 01:58Haven at the Divine St.
• 02:00Complex and the medical
• 02:02director of EMG Primary Care.
• 02:04I am thrilled to introduce
• 02:06two of my colleagues who have
• 02:09collaborated on in making this talk,
• 02:12something that will be really
• 02:14applicable to primary care,
• 02:16focusing on diagnosis and and
• 02:19the kind of intersections.
• 02:21Between primary care and oncology,
• 02:24Doctor Elizabeth Allard,
• 02:25who we call Beth,
• 02:27is originally from Wisconsin.
• 02:29She received her undergrad degree
• 02:31from Carnegie Mellon in Biology,
• 02:34and then she received both a
• 02:36PhD in Pathobiology and an MD
• 02:38from Brown University.
• 02:40She broke the usual MD, PhD,
• 02:42mold and completed her residency
• 02:44in Family medicine at UMass
• 02:46Medical School in Worcester at
• 02:48an inner city health clinic.
• 02:50She's been employed by a prior.
• 02:51Hospital owned family practice then
• 02:54spent 15 years in private practice
• 02:57and is now a very valued member
• 02:59of our Northeast Medical Group's
• 03:02primary care team and she runs an all
• 03:06female family practice in Waterford.
• 03:09She creates care with a thoughtful
• 03:12and scientific framework.
• 03:13She's a leader in her practice
• 03:15on in her geographic region,
• 03:16and she's a member of the
• 03:18primary care steering group,
• 03:19where her insight helps to guide all of
• 03:22us as we build systems of primary care.
• 03:26Doctor Scott Thornton attended
• 03:28University of Pittsburgh School of
• 03:31Medicine and completed his residency
• 03:33at UConn and in the colorectal surgery
• 03:36at Muhlenberg Regional Medical Center.
• 03:39He is also a northeast
• 03:41Medical Group physician.
• 03:42He's a colon and rectal
• 03:44surgeon in in Shelton, CT,
• 03:46right next to our walk in,
• 03:48which is a convenient location and he
• 03:50has a Bridgeport hospital affiliation.
• 03:53He's well respected by colleagues.
• 03:55He's cared for patients.
• 03:56With um colon and rectal
• 03:58cancer for nearly 30 years,
• 04:00his professional interests include
• 04:03laparoscopic colorectal surgery,
• 04:04rectal and hemorrhoidal issues
• 04:06and he is an avid golfer.
• 04:08When he is outside of the office,
• 04:10I'll turn it over to you and to
• 04:12introduce your smilow colleagues.
• 04:14Thank you. And I I should say I'm a medical
• 04:16oncologist and associate cancers director
• 04:19for clinical initiatives.
• 04:21So I'm going to
• 04:22start with Doctor Amit Khanna,
• 04:24who is an associate professor of
• 04:25surgery at Yale School of Medicine.
• 04:27And he's the director of colorectal
• 04:29surgery for the Bridgeport Hospital
• 04:31region and as such he's responsible
• 04:34for leading the provision of of
• 04:36colorectal surgical surgical services
• 04:38across the area in collaboration with
• 04:41the Digestive Health service line and
• 04:43Smile Cancer Hospital network teams.
• 04:45Doctor Khanna has more than 20
• 04:47years of experience the high volume
• 04:50surgeon and he specializes in the
• 04:52minimally invasive treatment and
• 04:54management of inflammatory bowel
• 04:56disease colorectal malignancies.
• 04:58Anorectal diseases.
• 05:01Doctor Pam Kunz is associate professor
• 05:05of medicine and director of the
• 05:09Center for Gastrointestinal Cancer
• 05:10at Yale Cancer Center and SMILO.
• 05:13She joined us at Yale from
• 05:15Smile from Stanford University,
• 05:17where she was the director of the
• 05:20Neuroendocrine Tumor program there
• 05:22and leader of in endocrine Oncology
• 05:25research group and the director of
• 05:28the Neuroendocrine Tumor Fellowship,
• 05:29but beyond her record of accomplishment.
• 05:31And GI oncology.
• 05:32Dr.
• 05:33Kunz is an international leader in
• 05:35the clinical care of patients with
• 05:38neuroendocrine tumors are called nuts.
• 05:40And she's also advancing the field
• 05:42through clinical trials and translational
• 05:44science that is really defining the
• 05:46next generation of therapies for
• 05:48patients with this rare diagnosis.
• 05:52And then finally,
• 05:53doctor Justin Persico is assistant
• 05:55professor of clinical medicine in
• 05:57the section of medical oncology,
• 05:59and he's the director of Smilow
• 06:01Cancer Hospital care centres in
• 06:03Trumbull and Fairfield.
• 06:04He focuses his clinic on the care
• 06:06of patients with GI cancers,
• 06:08and his specific interests
• 06:10include research on lifestyle
• 06:11factors that impact pathogenesis,
• 06:14treatment and survivorship of
• 06:16colorectal cancer patients.
• 06:17He attended Tufts University School
• 06:19of Medicine, where he also completed.
• 06:21This fellowship in hemlock,
• 06:22so our distinguished faculty.
• 06:24I'm going to hand it over to Doctor
• 06:27Allard to start with our first case.
• 06:30Thank you.
• 06:35Thank you so much, Shannon.
• 06:37So we want to begin with talking about cases.
• 06:42And it's probably a great surprise that
• 06:44this is colon Cancer month and that
• 06:46a lot of people are probably going
• 06:48to be expecting a colon cancer case.
• 06:50So I might as well just put
• 06:52it out there up front.
• 06:53But we're going to try to take each case
• 06:55this afternoon and focus on a different way.
• 06:57So we're going to focus on this
• 06:59one pretty thoroughly because
• 07:00we know colon cancer so common.
• 07:02So we begin our story with a 45 year
• 07:04old woman with a past history of
• 07:06arthritis and elevated cholesterol
• 07:07should prevent presents for a
• 07:09complete physical exam.
• 07:10She's a non-smoker who drinks 3
• 07:12glasses of wine per day and the
• 07:15question of the hour is does this
• 07:16patient need colon cancer screening?
• 07:18And we all know that five years ago,
• 07:19three years ago we would have said
• 07:21probably not unless there was a risk.
• 07:23But now things have changed and
• 07:25before I go forward on this case
• 07:28let's look at pathways.
• 07:29So if we look closely now that we have.
• 07:32These wonderful pathways in our system at
• 07:34EPIC as ambulatory care continues to advance.
• 07:38We have three ways to look
• 07:40at colon cancer screening.
• 07:42The first one we'll look at in greater
• 07:43detail is obviously initial screening,
• 07:45but then there's screening for someone
• 07:47who has had a previous normal evaluation
• 07:49and then for someone who's had an abnormal.
• 07:52And we all know that the GI doctors come up
• 07:54with these recipes of how often to screen.
• 07:56But I think it's great to have access
• 07:58to all of this so we can look at it.
• 08:00Let's move on to our next slide.
• 08:03So once we're in pathways and we go
• 08:04to the initial screening pathway,
• 08:06this is what it looks like.
• 08:07So if you're seeing a patient
• 08:08and you're not certain what to do
• 08:10or whether they're eligible,
• 08:11you look up this pathway through
• 08:13the through the pathway system.
• 08:15And the colon cancer initial screening
• 08:17at the very top has two items.
• 08:19The first is asking whether or not this
• 08:21patient is a candidate for screening.
• 08:23And yes,
• 08:24in general,
• 08:25healthy patients between the
• 08:26ages of 45 and 75 are recommended
• 08:29screening or anyone with a life
• 08:31expectancy of greater than 10 years.
• 08:33On the flip side,
• 08:34you might be asking who isn't a candidate?
• 08:36And again, details are there,
• 08:38but anyone obviously with any
• 08:40chronic or terminal illness such
• 08:42as cancer and stage heart failure,
• 08:44we're not going to put them through
• 08:45a colonoscopy because we know that
• 08:47that's a significant risk to them.
• 08:49And likewise,
• 08:49if we're going to treat a colon
• 08:51cancer and they already have
• 08:52this concomitant illness,
• 08:53that may just be too much.
• 08:55Next step on the flow diagram is you know
• 08:58additional details of who is high risk.
• 09:00So we know people with the first
• 09:02degree relative with cancer of the
• 09:04colon or polyps of the colon is
• 09:05at higher risk as well as people with
• 09:08irritable bowel disease and people
• 09:09with certain genetic syndromes.
• 09:11Final step on the pathway, quick look,
• 09:14there are several ways we can screen.
• 09:16Before COVID we mostly focused
• 09:18on the colonoscopy since COVID,
• 09:21I myself and others have certainly considered
• 09:23more of the options that are available.
• 09:26Uh, that don't involve such an invasive
• 09:28procedure, particularly Cologuard.
• 09:30But for the purposes of this conversation,
• 09:33we're not going to go into
• 09:34more detail at this point.
• 09:36So let's move back to our
• 09:37case in the next slide.
• 09:39So the patient underwent
• 09:41her screening colonoscopy.
• 09:43I do want to note that it took a whole year
• 09:45and that brings up a point for us PCP's.
• 09:47Our job is to look at that health
• 09:49maintenance list all the time.
• 09:50And if you see someone who is due
• 09:52for something, talk to them about it,
• 09:54whether it's their, you know,
• 09:55preventative health maintenance visit or
• 09:57it might even be a visit for something else.
• 09:59We,
• 10:00it's our job to get these folks to screening.
• 10:02So she had the screening and it revealed
• 10:04a large tubular adenoma greater than 10
• 10:06millimeters and the patient was recommended.
• 10:09Repeat screening in three years.
• 10:11Going to turn to our next slide,
• 10:13which is going to show us in the pathways.
• 10:15If you've had an abnormal
• 10:17colonoscopy now what you do.
• 10:19So it may be hard to see
• 10:20this on all of your screens,
• 10:21but this basically goes through the details
• 10:24of depending on the what the findings are,
• 10:26how frequently the next
• 10:28colonoscopy needs to occur.
• 10:30And in her particular case,
• 10:31because it was a large adenoma,
• 10:33it's recommended that she undergo
• 10:35screening again in three years.
• 10:38But another little sub point here.
• 10:41This particular patient didn't listen to
• 10:43her PCP right away and again spent another
• 10:45year deciding whether or not to do this.
• 10:48But fortunately,
• 10:48when she saw her primary care
• 10:50physician one year later,
• 10:52she was willing to go forward with
• 10:54the procedure.
• 10:54So let's turn to our next slide.
• 10:59So here she's had the initial colonoscopy
• 11:01that reveals the tubular adenoma.
• 11:03It's four years later.
• 11:05She's finally going for that
• 11:06repeat screening. She feels great.
• 11:08She has no symptoms.
• 11:09She's not concerned.
• 11:10She undergoes repeat colonoscopy.
• 11:13And unfortunately a transverse
• 11:14mass was found in her colon.
• 11:16But pathology report revealed
• 11:18at a no carcinoma of the colon.
• 11:20And in a moment we're going
• 11:21to hear more from our surgeon
• 11:23about what the next steps are.
• 11:24I do want to stop for a minute and
• 11:26give a personal thanks to Doctor
• 11:27Rachelle Andre who assisted me with
• 11:29coming up with this particular
• 11:30case which we use today. OK, Amit.
• 11:32Phyllis in what do we need to do?
• 11:36Thanks so much.
• 11:37So you know this is a very common story.
• 11:41This is something that all of you see
• 11:44and and unfortunately our patients
• 11:46and I just want to talk a little
• 11:49bit about how to help with making
• 11:51that preoperative evaluation easier
• 11:52so that you can help guide your
• 11:55patience through this process as it's
• 11:57always a challenging one for them.
• 11:59But we also want to take out any of
• 12:01the mystery of helping us support your.
• 12:02Patients once they are diagnosed
• 12:04with colon cancer.
• 12:06So if we could go to the next slide.
• 12:09You know, if we just think about
• 12:11colon cancer broadly, you know,
• 12:13where does everyone fall?
• 12:14Well, about 65% of patients are
• 12:17going to have sporadic disease.
• 12:19And I think one of the most common
• 12:21questions I get from primary care doctors is,
• 12:23you know, do they need a genetics evaluation?
• 12:25How important is that family history?
• 12:27Well, most of our colon cancer patients
• 12:30are going to have sporadic disease,
• 12:32but a significant amount of them
• 12:34will have a familial component,
• 12:37which means that there isn't
• 12:38an actual germline.
• 12:39Mutation that we see,
• 12:40but but we know that it's running in a
• 12:42family and that they have a family history.
• 12:44And then the thing that we,
• 12:46we see you know sort of less commonly but
• 12:48but we do find more and more frequently
• 12:51are actual hereditary genetic defects.
• 12:54And I think the other part of it from
• 12:56a primary care perspective is how can
• 12:59we help our patients get the most
• 13:01efficient access to surgical care,
• 13:03how do we do that work up and I
• 13:06think it's helpful for our primary
• 13:08care colleagues to understand.
• 13:10Well,
• 13:10what is a complete workup and
• 13:11there's a few questions that that
• 13:13often get asked me and I think the
• 13:15one is you know do we need to do a
• 13:17genetics evaluation before surgery
• 13:19and I think in most cases we don't.
• 13:22But we will do that screening process
• 13:25when the patient gets referred in
• 13:27for their first surgical evaluation.
• 13:30And we're very lucky that we have
• 13:32a very robust genetics program at
• 13:35SMILO and and it's actually right
• 13:37on the campus where Doctor Persco.
• 13:40Myself certainly see patients and
• 13:42so we're able to get patients in
• 13:44quite efficiently.
• 13:45Sometimes we don't have the results back
• 13:48before patients need to go through surgery.
• 13:50But in most cases as you can see
• 13:53in you know talking about 95% of
• 13:56patients what we don't need the
• 13:58information ahead of time or we
• 13:59can make a decision based on the
• 14:01patient's previous history.
• 14:03So the things that are really important
• 14:05to us are previous genetic syndromes,
• 14:07previous polyps,
• 14:08age at diagnosis of their.
• 14:11Colon cancer, obviously the CAT scans
• 14:14that that we perform usually chest,
• 14:17abdomen and pelvis.
• 14:18Sometimes physicians will ask me,
• 14:20do I really need a CT of the chest?
• 14:23Can I just use a chest X-ray?
• 14:25And we'll talk a little bit about
• 14:27why that's important in a second.
• 14:28And then I think the last point here
• 14:30that's important to make is the idea
• 14:32that we take care of patients as teams.
• 14:35And so early multidisciplinary involvement
• 14:37is something that we really emphasize.
• 14:40And care of our patients and
• 14:42that's not just the surgeon,
• 14:44the oncologist or or radiation oncology
• 14:47or genetics counselors that's that's our
• 14:50primary care partners and our specialist.
• 14:52So we really have a a lot of emphasis
• 14:54on making sure that we're optimizing
• 14:57these patients for surgery because
• 14:58that can really have a big impact
• 15:00on the approach that we might take.
• 15:02And also if there's any other interventions
• 15:05such as cardiac interventions or
• 15:06pulmonary interventions that that may
• 15:08add value on certainly management of.
• 15:11Anticoagulation around surgery is
• 15:12another big one. Next slide, please.
• 15:17And so just these are some some pearls
• 15:19I think that are helpful just to think
• 15:22about you know as your counseling
• 15:24your patients and I always tell our
• 15:27patients when they come to see me,
• 15:29you've known me for 10 minutes,
• 15:31you've known your primary
• 15:32care doctor a lot longer.
• 15:33So it's really important that
• 15:35you reach out to your primary
• 15:37care physician and ask questions,
• 15:40you know ask about your surgeon,
• 15:42ask about the approach the the options
• 15:44that you have and and we look at that.
• 15:46It's a very important partnership.
• 15:48So 1/3 of colon cancer patients may have
• 15:52you know some mutation and these are
• 15:55in the younger than fifty group CEA,
• 15:58which we will almost always do before
• 16:01surgery does have a significant
• 16:03predictive value of overall survival.
• 16:06And so if you have an elevated CEA
• 16:08at diagnosis you know your your
• 16:10hazard of death compared to patients
• 16:12with a normal CEA is,
• 16:14is is you know quite different.
• 16:17In terms of the chest CT,
• 16:19we still do it even though the
• 16:22risk of metastasis is quite low.
• 16:24The the yield allows us to see some
• 16:27indeterminate lesions that may need
• 16:29follow up and so that that's why we do it.
• 16:32And so universally we ask for chest CT's.
• 16:36Sometimes I get asked about a pet CT
• 16:38in the preoperative setting and there
• 16:40are a few situations where we might do that.
• 16:43But for the large number of patients
• 16:45that present to us with colon cancer
• 16:48that they're not undergoing pet
• 16:50CT's as a preoperative evaluation.
• 16:52So I'm generally not needed.
• 16:54Next slide please.
• 16:56And I think the other thing I just
• 16:59want to quickly go over is the idea
• 17:01of trying to figure out what the right
• 17:03approach for any individual patient is.
• 17:05And I,
• 17:06you know I often tell patients that
• 17:09customized care is quality care.
• 17:10We have guidelines and we have data
• 17:13that really helps us a ton to figure
• 17:16out which one of those custom roles
• 17:19is going to be most helpful and.
• 17:23And apologize for the background
• 17:26and that these can be customized
• 17:29to the patient's best interest.
• 17:32So a robotic approach,
• 17:34a laparoscopic approach or an open approach,
• 17:38all of those can be very appropriate
• 17:40and we really find that at least
• 17:43for right colon cancers,
• 17:44the the the outcomes are very similar.
• 17:47So oncologic outcomes here for robotic
• 17:50versus laparoscopic approaches they have.
• 17:53Stop improving one to be superior
• 17:55over the other.
• 17:56That being said, pain,
• 17:58postoperative recovery,
• 18:00length of stay,
• 18:01you know,
• 18:02those have definitely been shown
• 18:04to be slightly in the advantage
• 18:06of a robotic approach,
• 18:07but ontologically probably very similar.
• 18:11The last thing I want to talk
• 18:13about a little bit is just about
• 18:15Lymphadenectomy and the extent that
• 18:17we do not to belabor this too much,
• 18:19but the the importance of doing a.
• 18:23Adequate lymphadenectomy with
• 18:24getting over 12 lymph nodes,
• 18:26but there's been some discussion and
• 18:28you might hear this in the literature
• 18:30or hear patients ask you about this,
• 18:32the idea of a complete musicholic excision
• 18:36or an extended lymphadenectomy and
• 18:38you know that's become more and more.
• 18:43Employed in Europe and in Asia and
• 18:46right now in the United States,
• 18:49the American side of colorectal
• 18:51surgeons has not recommended that we
• 18:54do a routine extended lymphadenectomy.
• 18:57But if we see, you know,
• 18:58suspicious notes outside of the
• 19:00normal field of our dissection,
• 19:02that there does seem to be data that
• 19:04we should go ahead and remove those.
• 19:06And all that means is just doing sort
• 19:07of a little bit more of a lymph,
• 19:10lymph node dissection right on top
• 19:12of the superior mesenteric vein.
• 19:14But right now we're not,
• 19:15we're not advocating or at least our
• 19:17our our guidelines don't advocate
• 19:19for us to do that routinely.
• 19:21And then the last thing I would
• 19:22say is that we,
• 19:23we really work hard to integrate
• 19:25our eras on care signature pathways
• 19:28within our preoperative planning.
• 19:31So that really involves us
• 19:33making sure that you know,
• 19:35we've got our patients very well
• 19:38educated in the office on what they
• 19:40need to do before surgery and their
• 19:42expected discharge and what they need.
• 19:44To do when they get home and obviously
• 19:47all of this allows us to hopefully get
• 19:50our patients home and and back into
• 19:52your offices looking for the next steps.
• 19:55Thanks again for the opportunity to be here.
• 20:01So this is a Justin Persico.
• 20:03I'm going to take it from here to continue
• 20:05the discussion and I guess I should
• 20:07preface the discussion that we that we are
• 20:10talking about colon cancer patients here.
• 20:11We we do segregate rectal cancer patients
• 20:15into a different category and think
• 20:17about them a bit a bit differently in
• 20:19terms of you know how we approach it.
• 20:21But for for typical colon cancer patients,
• 20:24the paradigm is you know typically
• 20:26the stage and to do surgery and then
• 20:28they would be referred to the medical
• 20:30oncologist and I wanted to use.
• 20:32Is this opportunity to sort of highlight
• 20:35a couple of points that are sort of
• 20:39practice changes that have happened
• 20:40maybe in about the last five years
• 20:42that might be important for you to
• 20:44know as you send your your patience
• 20:45for a referral to us, umm, the this,
• 20:48this case in particular is a is a
• 20:51patient with a stage 3 colon cancer.
• 20:54So the the data is quite clear that
• 20:57those benefit those patients benefit
• 21:00from adjuvant chemotherapy.
• 21:02But how we give it as well as what we
• 21:04do with with earlier stage patients,
• 21:07particularly stage two patients
• 21:09has has changed a bit.
• 21:11I'll, uh,
• 21:12I'll first discuss stage two patients,
• 21:14even though that's a little
• 21:16different than this particular case.
• 21:18But in the past,
• 21:19you know,
• 21:20medical oncologists have used clinical
• 21:22pathologic features to decide,
• 21:24you know,
• 21:25which patients within that stage
• 21:26would be at the highest risk
• 21:28because studies have failed to
• 21:30show consistently that all stage,
• 21:32stage two patients benefit
• 21:34from adjuvant chemotherapy.
• 21:35But we do know there are a subset who
• 21:37are at a significantly higher risk and
• 21:40those patients really should get treatments.
• 21:42In the past we use these factors
• 21:44I've listed here whether the patient
• 21:46presented with an obstructive tumor
• 21:47or a larger a T4 tumor or bathing
• 21:49through the cirrhosis of the colon,
• 21:51whether there's a risk factor like
• 21:53seeing Lymphovascular invasion even even
• 21:55though we don't see lymph node invasion yet.
• 21:57But this is largely I think going to
• 22:00be supplanted and this transition has
• 22:02already already happening in oncology with
• 22:04what we call circulating tumor DNA testing.
• 22:06So,
• 22:07so this is a a serum test,
• 22:09a blood test that we can do on
• 22:11patients when they are referred to us.
• 22:13Uh which would detect uh whether there
• 22:16is actually cancer tumor DNA in the
• 22:19bloodstream and and as you might expect
• 22:21this is this is a poor risk factor.
• 22:24I put in this recurrence free survival
• 22:27curve from this recent dynamic
• 22:29trial that was published in New
• 22:30England Journal Journal of Medicine.
• 22:32There's also other groups who have
• 22:34been working on on this technology
• 22:36and as you can see the patients who
• 22:38did have detectable circulating
• 22:39tumor DNA did did much worse.
• 22:41So these are stage two patients.
• 22:44And so those patients are likely
• 22:46the best candidates for for adjuvant
• 22:48chemotherapy and patients who
• 22:50tested negative had actually very
• 22:52excellent disease free survivals
• 22:53going out four years and
• 22:55beyond and those patients probably don't,
• 22:57won't won't benefit from chemotherapy.
• 23:01So. So this is the emerging more and
• 23:04more the main data that's still lacking
• 23:07here is just the confirmation that if
• 23:10these patients do test positive for
• 23:12circulating tumor DNA do they benefit from.
• 23:14Chemotherapy, uh, but we,
• 23:15we know like I said there's a
• 23:17high risk group and and this this
• 23:19actually this disease free survival
• 23:21curve is one of the better ones.
• 23:23When you look at some of the data from like
• 23:25what's what's called the circulate trial,
• 23:28there's a few of those
• 23:29going on across the world.
• 23:30The the outcomes are even worse
• 23:32in their studies compared to this.
• 23:34And we actually at Yale had one a clinical
• 23:37trial called the COBRA trial actually
• 23:40I think it might just be on pause,
• 23:43but it's an ongoing trial.
• 23:45Where we're looking at these stage two
• 23:47patients and then randomizing them to
• 23:48get treatment or not treatment depending
• 23:50on the presence of circulating tumor
• 23:52DNA to try to answer that question.
• 23:54So, so this is something your patients
• 23:57you know may may be coming across
• 23:59for stage three patients like I
• 24:01mentioned the data is quite clear
• 24:03that they benefit from chemotherapy.
• 24:05But what's happened in the last five
• 24:07to maybe 10 years now is there's been
• 24:10further work on trying to separate out.
• 24:15Patients that may not need the
• 24:17typical recommendation,
• 24:18which would be six months
• 24:21of adjuvant chemotherapy.
• 24:23There is this group called the ideal
• 24:27Sorry idea Trial Analysis Group
• 24:29that's taking the data from multiple
• 24:31adjuvant chemotherapy studies.
• 24:33And I've come with some pretty
• 24:37interesting results analyzing this
• 24:39and the most significant here is
• 24:42that they found patients who had.
• 24:45Lower earlier stage, stage three,
• 24:48Stage 3,
• 24:49eighth stage 3B with three or less
• 24:51lymph nodes have the same outcomes if
• 24:53they receive three months of adjuvant
• 24:56regimen where we use capacity and
• 24:58oxaliplatin compared to six months
• 25:00of traditional folfox chemotherapy,
• 25:02which is great because it's shorter
• 25:04duration and it helps reduce the
• 25:06most feared I think long term
• 25:08complication of these treatments
• 25:10which is peripheral neuropathy,
• 25:11rates of peripheral neuropathy with three
• 25:13months of chemotherapy are only about 10%.
• 25:15Compared to more than 60% with
• 25:17six months of of chemotherapy.
• 25:19So.
• 25:19So this is an example of how we've
• 25:22actually been able to to reduce the
• 25:24the treatment in certain circumstances.
• 25:27Now patients with more than three lymph
• 25:28nodes or other high risk factors like
• 25:31having two separate tumor deposits
• 25:32from the primary tumor T4 tumors.
• 25:34These types of things we still
• 25:36recommend you know they be treated
• 25:38more more aggressively as a high
• 25:40risk patient with with six months
• 25:42of of combination chemotherapy.
• 25:46So, so with that I think we can pass
• 25:48it back for discussion of case 2.
• 25:56All right. Justin and Anna,
• 25:58thank you so much for expanding on
• 25:59what we see as primary care doctors
• 26:01and bringing bringing us over to what
• 26:03happens when our patients leave our
• 26:05offices and start seeking care with
• 26:07the surgeons and medical oncologists
• 26:08that need to take care of them.
• 26:10Our next discussion is going to be a
• 26:12little bit different because we're going
• 26:14to spend some time talking about a case.
• 26:17We're going to talk a little
• 26:19bit about discussion points for
• 26:20us as primary care physicians,
• 26:22a little bit about the treatment
• 26:23of this disease,
• 26:24but we're going to bring it in a little
• 26:26bit of a different direction which I
• 26:27think will be brought up in another of
• 26:29the smile shares programs coming up.
• 26:31So case two, we have a 75 year old
• 26:34woman with a history of Type 2 diabetes,
• 26:37hypertension, spinal stenosis,
• 26:39peripheral arterial disease.
• 26:40She's a former smoker who presented to her
• 26:43PCP with a 2 month history of chest pain,
• 26:45epigastric pain, dysphagia,
• 26:47and 11 pound weight loss.
• 26:49She's very active and walks 2 miles per day,
• 26:52helps care for her grandchildren
• 26:54on physical exam.
• 26:55She's thin but otherwise looks good.
• 26:58Her lab work shows that her
• 27:01kidney functions are normal.
• 27:02LFT's are normal,
• 27:03except for a bump in her Lt.
• 27:04to 40, and her hemoglobin is only seven.
• 27:08So.
• 27:08Every day of our lives,
• 27:10people walk in our offices.
• 27:12They have a big gastric pain,
• 27:13they have chest pain.
• 27:14We're trying to figure out what
• 27:15to do with it.
• 27:16We use a lot of proton pump inhibitors
• 27:18and diet change and so forth.
• 27:20But what we need to learn is
• 27:21primary care physicians is to
• 27:23remember what are the symptoms
• 27:24in this case that raise concern.
• 27:26And what do we need to do when we
• 27:27see these warning signs that make us
• 27:29think that this isn't just another
• 27:31time to hand out the purple pill, so.
• 27:33First discussion point,
• 27:34what are the symptoms in this
• 27:36case that raised concern?
• 27:38Obviously,
• 27:38the 11.# weight loss is kind of a standout.
• 27:42And secondarily, the hemoglobin of seven,
• 27:44we think malignancy,
• 27:45right?
• 27:45We think something big and bad is
• 27:48happening if the body is so affected
• 27:50as to cause weight loss and anemia.
• 27:53And what we need to do at that point
• 27:54is these are the people that we're
• 27:56probably not going to be really
• 27:58doing the medication trials with.
• 27:59We may put them on a medication,
• 28:00but we might say you really need to
• 28:02see a GI specialist at this point.
• 28:05You really need to have some testing done.
• 28:07So if we could go to the next slide.
• 28:11So in our next slide,
• 28:12our patient did undergo testing.
• 28:15And her cat scan did show
• 28:16thickening of the GE Junction,
• 28:18multiple liver metastases,
• 28:20pulmonary embolus of the left lower lobe.
• 28:23Ultrasound also showed in the left
• 28:26lower extremity and occlusive DVT.
• 28:28She underwent EGD and biopsy,
• 28:32which showed a mass poorly
• 28:35differentiated adenocarcinoma.
• 28:36Her two negative MSSP DL1
• 28:39CPS greater than five.
• 28:41And this patient obviously is just
• 28:43a little bit more of an advanced
• 28:45situation that our last case,
• 28:46but let's hear from our oncologist, Dr.
• 28:49Pam Koons about what she
• 28:50would do for this patient.
• 28:52Thank you, Pam.
• 28:54Great. Thanks, Beth. Hi everybody.
• 28:55So you know when I'm first meeting
• 28:58with a patient in a new patient visit,
• 29:01I try to go over and be really
• 29:03clear about what we're defining in
• 29:05terms of the stage of the disease.
• 29:08So this is a stage four or metastatic
• 29:11GE junction adenocarcinoma
• 29:12with liver metastases.
• 29:15Defined to the patient really what that
• 29:17means and what our goals of care are.
• 29:19So if even in that first meeting
• 29:20I would say the goals of care
• 29:22are to control the disease,
• 29:24we we will not be able to
• 29:26get rid of the disease.
• 29:27And then we talk about next steps in
• 29:30terms of what the treatment options are.
• 29:32This patient is robust enough to
• 29:35consider doing first line chemotherapy.
• 29:38And before we get into that I do want
• 29:41to define some of the acronyms that
• 29:43are used in this because I think it's.
• 29:46Just to for the you may see
• 29:48these in pathology reports.
• 29:50So her two is and MSS are both
• 29:55standardly done now for most GI cancers.
• 29:59So her two is in the family of epidermal
• 30:02growth factor receptor is about 15 to 20%
• 30:05of patients will be her two positive.
• 30:08This is more common probably in
• 30:09the language of breast cancer that
• 30:11you may be familiar seeing this.
• 30:13But we do have targeted therapies for
• 30:16this for patients who are her two
• 30:18positive including something called.
• 30:20S2 is amab or her septum.
• 30:22MSS refers to microsatellite stability
• 30:26or microsatellite instability.
• 30:27We see this commonly.
• 30:29We see microsatellite instability with
• 30:31Lynch syndrome which was mentioned in
• 30:33the earlier case where again testing
• 30:36this now routinely in all GI cancer.
• 30:38So this patient was microsatellite stable,
• 30:41therefore unlikely to have Lynch
• 30:44syndrome and we use this some to
• 30:47think about immunotherapies and
• 30:48then the third category or the third
• 30:51item listed in the pathology report.
• 30:53Is PDL one.
• 30:55It's the combined positivity score
• 30:57of greater than or equal to five.
• 30:59That CPS score is actually the
• 31:01number of PDL 1 staining cells.
• 31:04So this is an immune marker
• 31:07that includes the tumor cells,
• 31:08the lymphocytes and the macrophages
• 31:11in a combined score.
• 31:13And this is a little debatable as
• 31:16to what positive is in this case,
• 31:18but it really indicates there's a
• 31:20specific indication for the use of
• 31:22nivolumab in the first line setting so that.
• 31:24For a CPS score of greater than
• 31:26or equal to 5.
• 31:27So when I so this patient a
• 31:29standard first line treatment would
• 31:31be the combination of folfox and
• 31:34nivolumab full foxes,
• 31:355 FU and oxaliplatin again talked about
• 31:37by the way on a multiple choice test,
• 31:40full foxes often the right answer
• 31:43for most GI cancers.
• 31:44So that was already discussed in
• 31:47colorectal cancer and nivolumab is
• 31:51one of our checkpoint inhibitors,
• 31:52it's a PD1 antibody.
• 31:54This is becoming pretty common language.
• 31:57Really across specialties if thinking
• 31:59about checkpoint inhibitors because we
• 32:01see a lot of immune related side effects,
• 32:04many of you have may have taken
• 32:06care of patients
• 32:06with some of these.
• 32:08So as I start talking about
• 32:10treatment and goals of treatment,
• 32:12I also will mention sometimes
• 32:14patients will ask, well,
• 32:15what's my prognosis?
• 32:17I don't often kind of bring
• 32:19that up on my own.
• 32:20During the first visit,
• 32:21I will talk about again,
• 32:23palliative versus curative treatments.
• 32:24But if a patient asks me,
• 32:27we will sometimes talk about
• 32:29median overall survival.
• 32:30And for this audience,
• 32:32the median overall survival
• 32:34is probably 12 to 14 months.
• 32:36It was about 14 months in this clinical
• 32:38trial with FOLFOX and nivolumab.
• 32:40But it can certainly be less and I
• 32:42tell patients that the first few
• 32:44months is really a test of biology
• 32:46of their cancer as we learn a little
• 32:48bit more about how they tolerate
• 32:50the treatment and how they respond.
• 32:52So I'll pass to Beth for the next slide.
• 32:57Thanks, Pam. So our patients as we just
• 33:00discussed a moment ago did end up receiving
• 33:04the palliative chemotherapy of the
• 33:06combination of folfox in the volume NOB.
• 33:09She saw improvement of her dysphagia
• 33:11reduction, the size of her liver lesions.
• 33:14She was also started on Lovenox
• 33:16obviously to treat the fact that she
• 33:18was hypercoagulable from her cancer
• 33:20and had the PE and DVT at diagnosis.
• 33:23Unfortunately, after about nine months
• 33:25the CAT scan showed some progression
• 33:27and she did develop worsening dysphagia.
• 33:30Her performance status deteriorated and
• 33:32she needed a G2 for nutrition and spent
• 33:35a fair amount of time in the hospital.
• 33:37She insisted on continuing chemotherapy
• 33:40until she became bed bound due
• 33:43to weakness and recurrent DVT.
• 33:45And this is one of those moments
• 33:46I wanted to insert into this talk
• 33:47which I think is so important for us,
• 33:49this primary care doctors,
• 33:50how do we talk to our oncology
• 33:52partners with our patients?
• 33:53When do we in you know interact.
• 33:56And I think it's important for
• 33:58us first to hear kind of from the
• 34:00oncologists how Pam do you direct
• 34:02the care at end of life and then I'll
• 34:04talk a little bit more after you've,
• 34:06you've told me how you do things.
• 34:09Sure, absolutely.
• 34:10I mean I think this is a really
• 34:12great opportunity for something
• 34:13we could really do better.
• 34:15Is the partnering between oncology
• 34:16and primary care physicians,
• 34:18particularly if PCP's have a long trusting
• 34:21relationship with their patients.
• 34:23I think that can be really valuable
• 34:25to have these conversations.
• 34:27I I think that usually when someone is
• 34:30deteriorating or if we get a scan like this,
• 34:32it's really important to talk
• 34:34about their goals of care.
• 34:36You know if this patient is robust enough,
• 34:39we may consider additional treatment,
• 34:40but this patient has really been deteriorated
• 34:43significantly and if they are bed bound.
• 34:46They would be,
• 34:47we use something called a performance
• 34:48status or the ECOG performance status.
• 34:50If they're in bed more than half the day,
• 34:52they would be an ECOG performance status
• 34:55of three and we generally would not
• 34:57continue chemotherapy at that point.
• 34:59And so I start talking about
• 35:01palliative care often.
• 35:02We will have started palliative care in the
• 35:04outpatient setting even before Hospice.
• 35:06That's often probably a good time,
• 35:07Beth,
• 35:08for us to be communicating with you.
• 35:10Umm, patients often get confused
• 35:13as to who they go to with questions
• 35:15really throughout their oncology.
• 35:17Journey,
• 35:17but I would say especially
• 35:19when they're needing,
• 35:20when they're more symptomatic.
• 35:21And I think having open lines
• 35:24of communication between UNC and
• 35:26palliative care is important.
• 35:28And then I would say 1 Pearl that I
• 35:30have around end of life and goals
• 35:32of care communications is that if
• 35:34you can do it early and often,
• 35:36it's really helpful.
• 35:37So that the slow drip of information
• 35:39around goals of care and around
• 35:42definitions of palliative care
• 35:44and Hospice and destigmatizing,
• 35:46all of that is critical and it often.
• 35:48Takes multiple visits.
• 35:52Yeah. I totally agree and
• 35:54appreciate your thoughts.
• 35:55I think that sometimes there's an
• 35:57extreme stereotype that an oncologist is
• 35:59always going to want to treat a patient
• 36:01regardless of where they are at stage.
• 36:04And I think hearing and obviously
• 36:05knowing that all of us have hearts
• 36:08and are realizing that patients have
• 36:10functional status and family members
• 36:12can appear to see what's going on.
• 36:14And I think you're right,
• 36:15the more we plant seeds of conversation
• 36:16and sometimes for our patients like if
• 36:18they have other health problems and
• 36:19you're seeing them and then you're like,
• 36:21how is their cancer treatment?
• 36:22Knowing you can kind of nicely
• 36:24insert you know what's going on.
• 36:26But I think what's great about
• 36:27us and having epic,
• 36:28which I didn't have as I was in private
• 36:30practice is that I can communicate
• 36:32with all of these oncology staff
• 36:34members either through an annoying
• 36:35instant message or just a regular
• 36:37message or see seeing a note to them.
• 36:39And so we can really improve
• 36:41our conversations that way.
• 36:42And then if we need to have a real
• 36:44phone conversation and talk to
• 36:45them about like what do you think
• 36:47for this patient and should I try
• 36:49to counsel them about end of life
• 36:51issues or Hospice or palliation?
• 36:53That, you know,
• 36:54we're all moving towards that
• 36:55in the same way.
• 36:56And my final point on this was
• 36:58obviously when everyone is on the
• 37:00same page and the the patients
• 37:02hearing things from the oncologist,
• 37:04but you have these options and
• 37:06they're hearing something similar
• 37:07from their primary care doctor.
• 37:08It can only go better because if you've
• 37:10ever spent time in a Hospice care
• 37:12setting like I have as a medical student,
• 37:14I loved it.
• 37:15The nurse said the perfect moment is
• 37:17when everyone is at the same decision
• 37:19point at an end of life situation.
• 37:21So when we've decided that
• 37:22treatment is no longer valuable.
• 37:24But we can get every person in that
• 37:26person's family as well as the
• 37:27patient and the team all saying,
• 37:28yes, this is where we are.
• 37:30We're in a good place.
• 37:31We're in a good place.
• 37:38Thank you for allowing us to have
• 37:39that different discussion, Pam.
• 37:41I really appreciate it.
• 37:43So our last case kind of at first I
• 37:45was like well is this really a case
• 37:46we're going to do and of course it
• 37:48is because it's still part of GI
• 37:50cancer and this is another case that
• 37:53I wanted to make everyone aware of.
• 37:57I have a 56 year old woman who
• 37:59presented to a surgeon actually
• 38:00she had a few month history of
• 38:02increasing rectal pain and bleeding.
• 38:05And of course, we need to think
• 38:07about what those things could be.
• 38:08But I want to insert my thoughts,
• 38:10which is that so many of us,
• 38:11as primary care doctors say,
• 38:14must be a hemorrhoid.
• 38:15Oh, you know,
• 38:16maybe it's a fissure if it's painful,
• 38:18but if it's really a lump down there,
• 38:19it's got to be a hemorrhoid.
• 38:20I don't need to see it.
• 38:21I don't need to look at it.
• 38:23You know, let's just talk about 6 fast and
• 38:26let's talk about avoiding Constipation.
• 38:28But obviously this case is a is
• 38:30a GI cancer case.
• 38:31So that's not where we're going.
• 38:33Where we're going is a basic concept
• 38:34that I want to emphasize to all of you.
• 38:36When your patient feels a lump
• 38:38in their ****** area,
• 38:39we need to do that exam.
• 38:41We need to actually take a step further.
• 38:43In this situation,
• 38:44the patient mentioned that her pain
• 38:46was worse with bowel movements.
• 38:48On exam,
• 38:48she had a 2 by 3 centimeter anal mass.
• 38:52A biopsy of the mass did reveal
• 38:54squamous cell carcinoma.
• 38:55Its P 16 positive.
• 38:57She underwent full staging and fortunately
• 39:00didn't have evidence of metastasis.
• 39:03Her treatment has involved
• 39:05chemotherapy as well as radiotherapy.
• 39:07But in a moment I'm going to you're
• 39:09going to see some graphic images.
• 39:12But I requested this of our surgeon,
• 39:14Scott,
• 39:14and so appreciative that he wants to
• 39:16take a moment to tell us a little bit
• 39:18about what is a hemorrhoid look like
• 39:20and what does an anal cancer look like.
• 39:22So,
• 39:22as it says here,
• 39:23warning graphic images on their way.
• 39:27Thank you so much.
• 39:29Hi guys. First I want to
• 39:32basically demystify the ****.
• 39:35The **** is just a part of your body,
• 39:36like everybody, like everything else.
• 39:39And looking at and evaluating the unit should
• 39:41be done just like any other piece of skin.
• 39:44In order to look, you have to have an
• 39:46assistant to kind of hold the cheeks apart.
• 39:48And if you lay the patient on their left hand
• 39:51side and you kind of hold the cheeks up,
• 39:52you'll be able to see the
• 39:55entire anal area carefully.
• 39:56If you look at these,
• 39:57they're 5 pictures here, the anal cancer one,
• 40:01you can look and say it's almost looks
• 40:03like a hemorrhoid, but if you touched it,
• 40:04it would be firm and irregular.
• 40:07Anal cancer is in the anal area.
• 40:08Skin cancer the anal area are just
• 40:10like skin cancer is in other places.
• 40:11They're generally firm, irregular,
• 40:14discolored doesn't look normal.
• 40:18So if you just think about that and you
• 40:20think about anything that's abnormal.
• 40:22More likely that that's the thing they have
• 40:24to worry about in the send to a specialist.
• 40:26But look and feel.
• 40:28If you look and feel,
• 40:29you will not make mistakes frequently.
• 40:33If you look at the pictures of the right,
• 40:34these are anal warts.
• 40:35Warts look relatively the same
• 40:37in multiple different areas.
• 40:39The middle one at the bottom are hemorrhoids.
• 40:41Now if you touch all of these different
• 40:42things, they will be all different.
• 40:46But the annual cancer is firm,
• 40:48irregular, discolored.
• 40:51Next slide.
• 40:54So I just want to talk briefly
• 40:56about anal squamous cell cancer.
• 40:57So it's a relatively faster growing cancer
• 41:00especially in the immune compromised group.
• 41:03Now that people have been
• 41:05living much longer with HIV,
• 41:06they are now getting secondary and tertiary
• 41:08diseases and this is a very common one.
• 41:10Anal squamous cell cancer is analogous to
• 41:13cervical and vaginal squamous cell cancer.
• 41:16It's similar tissues involving the
• 41:19similar HPV source just to remind
• 41:22everybody if you test 20 to 30 year old.
• 41:25Kids the day you test them 80%
• 41:28have HIV have HPV virus on their
• 41:31body the day you test them.
• 41:33So it's very common high risk groups,
• 41:36men who have sex with men,
• 41:37HIV positive patients and or people
• 41:40who have immune compromised,
• 41:42we're getting more and more immune
• 41:44compromised patients with liver transplants
• 41:46and kidney transplants etcetera.
• 41:48And also anybody who has a history
• 41:50of HPV disease not infection but
• 41:51disease which are warts both in
• 41:53the front and the back genital.
• 41:55As well as dysplasia of the
• 41:57cervix or the vagina.
• 41:58So there's a large group of people
• 42:00who are at high risk and I put
• 42:03anal pap smear as prevention here
• 42:05because as analogous tissue prior
• 42:07to the papilloma testing,
• 42:09cervical cancer had something like a 90%
• 42:12mortality rate and we've significantly
• 42:14dropped death rates because we're
• 42:17finding cancer in the pre cancer stage.
• 42:20Now best as I can tell there's
• 42:21only a couple ways to do that.
• 42:22That's with polyps and colorectal
• 42:24cancer you prevent.
• 42:26Answer If you find people who have
• 42:28dysplasia on anal or cervical pap smears,
• 42:31you can keep them from getting cancer.
• 42:33So in the back of your mind you
• 42:34have to remember HIV, HIV positive,
• 42:36low immune system.
• 42:38Men who have sex with men or who
• 42:41have previous HPV disease should
• 42:43have anal pap smears once a year.
• 42:46I'm done.
• 42:52Justin, sorry, just just
• 42:54unmuting there. Thanks Scott.
• 42:55So just to finish up the discussion
• 42:57because I'm going to change the discussion
• 42:59a little bit here with this slide.
• 43:02But with you know with one
• 43:04comment I'll make about anal,
• 43:06anal squamous cell carcinoma is,
• 43:07is that's because these patients
• 43:08are often immunocompromised,
• 43:09doesn't mean that they're not
• 43:11candidates for aggressive therapy,
• 43:13chemotherapy and radiation actually
• 43:15plenty of studies show that.
• 43:17They do just as well and tolerate
• 43:19it just as well with few exceptions
• 43:21and it is a disease that we
• 43:23can cure with chemotherapy and
• 43:25radiation and and and avoid surgery.
• 43:27So.
• 43:27So that's always the goal and you
• 43:29know surgery is used more as a
• 43:31salvage technique for these patients.
• 43:32Should they not fully respond and go
• 43:35into complete remission with with
• 43:37their chemotherapy and radiation or
• 43:38should they recur later on because
• 43:41you know radiation can really
• 43:42only be given once and at that
• 43:44point you're you're really reliant
• 43:46on what the surgeon can do.
• 43:48And I want to use this opportunity as
• 43:50we're talking about rectal bleeding
• 43:51to highlight something I think most
• 43:53primary care doctors have already
• 43:55have noticed and are aware of.
• 43:56You know in both the medical literature
• 44:00and the literature that there has been
• 44:03a rise in diagnosis of colorectal
• 44:06cancer and specifically I'm talking
• 44:08about rectal cancer here in younger patients.
• 44:11This is part of the reason why the
• 44:14screening age has been reduced from 50 to 45,
• 44:17but.
• 44:18But you know this,
• 44:19this slide is just to sort of highlight,
• 44:21this is also something you
• 44:23should be thinking about.
• 44:24You know if you're seeing a patient
• 44:26who has symptoms you maybe you do a
• 44:28rectal exam and you don't really see
• 44:30anything on the on the rectal exam
• 44:33that we we still have to to to think
• 44:36about you know rectal cancer as a as
• 44:39a potential reason for bloody stools.
• 44:42The current estimation is that there's
• 44:45about 18,000 new cases each year.
• 44:48And people under the age of 50 and
• 44:52the colorectal cancer has been
• 44:54rising in terms of the leading
• 44:56causes of death and cancer death I
• 44:59should say and patients age 20 to
• 45:0149 as you can see this data from
• 45:04the SEER database showing in men,
• 45:06it is actually the number one
• 45:08now and women #3 so high high up
• 45:11on the list for for both.
• 45:13Additionally we've we've known for
• 45:15some time now that that African
• 45:18Americans black patients are are
• 45:20more at risk for rectal cancer
• 45:22but there have been recently more
• 45:25spikes in incidents in whites,
• 45:27Native Americans and Alaskan natives.
• 45:30So that gap is is closing.
• 45:31So we have to be thinking about
• 45:33it you know pretty pretty evenly
• 45:35across our patient population.
• 45:37The reason for this is still unclear
• 45:39a lot of smart people looking into
• 45:41this every conference I go to I'm.
• 45:43Always interested in what research
• 45:45is going on in terms of the causes
• 45:48for this and what what they found
• 45:50it is really nothing definitive,
• 45:52this is. A very complex subject with a
• 45:57lot of variables involved, but but some.
• 46:02Up there.
• 46:10The other factor?
• 46:15Because there's of course been
• 46:17a rasterized kind of physical
• 46:20activity that we've also had.
• 46:22Some young face young folks in particular.
• 46:28Diets more prosthetic, you know,
• 46:32being used less, less, you know,
• 46:35cooking and less Whole Foods
• 46:37are being zoomed and a lot of
• 46:39interesting data in terms of the
• 46:42changes that are happening. Buy it.
• 46:46It's very complex.
• 46:51That that could be linked here,
• 46:54but not, not, not yet. A lot more
• 46:58to to come over the coming years.
• 47:00So, so, so keep your eye out for that.
• 47:06So that concludes the formal part
• 47:09of our talk, but I hope that
• 47:12you are thinking of questions.
• 47:14I see one has popped up.
• 47:16Please enter them.
• 47:18Before we answer,
• 47:20I just want to put in a plug
• 47:23for another medical education
• 47:26opportunity called trust your gut.
• 47:29We're on March 16th, Chavier lore and.
• 47:33Two, Kaship will present on colon
• 47:36cancer screening with an update
• 47:38and and this will involve a lot
• 47:41of details that Beth did not have
• 47:44time to cover when she covered the
• 47:47care signature pathway on you know,
• 47:50stool based screening when it's
• 47:54appropriate and reclassification
• 47:56of colon cancer screening to a
• 47:59two step screening when a non
• 48:01invasive tool is used and.
• 48:03One of the most exciting developments
• 48:05the fact that that's now covered
• 48:08equally by insurance as screening
• 48:09if a Cologuard is positive.
• 48:11So we will leave that up as well
• 48:16as kind of the announcement of next
• 48:19month where we will have palliative
• 48:22care and a more extensive discussion.
• 48:26So I am going to move on to questions.
• 48:29We have one from Doctor Breyer.
• 48:31Before we answer that.
• 48:33Beth as one of the panelists,
• 48:35do you have any additional questions
• 48:37for our SMILO colleagues at this time?
• 48:44Yeah, I do have a few,
• 48:46one of them and I think it it got
• 48:48brought up with the GYN cancer screening.
• 48:50But I know you touched a little
• 48:52bit about using tumor markers like
• 48:54CEA is an indicator of things.
• 48:56So again sometimes patients
• 48:57get kind of hung up on things.
• 49:00I haven't had one of these lately,
• 49:01but I get the sense that we're only going
• 49:03to be doing tumor marker assessments
• 49:05after we have a positive diagnosis.
• 49:07But I wanted your thoughts on
• 49:09patient comes to me Doctor Allard,
• 49:11you know my so and so has colon cancer.
• 49:13Can we just do this? EA level?
• 49:16What's your thinking about that?
• 49:17Should I say no, and if so, why?
• 49:26No, I don't want
• 49:28to take that one.
• 49:30Take that at all but but yes, no.
• 49:32So you're exactly correct that this
• 49:33is really a post you know diagnosis
• 49:35test that there has not been a
• 49:37study showing that this is a good
• 49:39screening test for colon cancer.
• 49:40So. So that's what I usually advise
• 49:42patients that with you know without
• 49:44a diagnosis we've never really shown
• 49:46that that this test is going to detect
• 49:48if you have colon cancer or tell us
• 49:50if you're at a higher risk of colon
• 49:51cancer or any of that information.
• 49:53So, so that's usually you know how
• 49:56how I advise I think in in in my
• 49:58experience you know the the CA 125.
• 50:01And the gynecologic malignancies because
• 50:03it's used, you know, so, so much.
• 50:07It's more commonly the question
• 50:09that that comes up but but CEA
• 50:11may come up from time to time and
• 50:12everybody's familiar with PSA which
• 50:14is a completely different story.
• 50:16And I would you tell patients that
• 50:18there are you know studies showing
• 50:19that that can be an effective screening
• 50:21test although that is as you know
• 50:22it's primary care doctor still that's
• 50:24a matter of somewhat debate so.
• 50:27Yeah, go ahead.
• 50:30I'm sorry I was just going to chime
• 50:31in and and support Justin as well.
• 50:33And I think that's a that's that's
• 50:36a very realistic I think thing
• 50:38because often even when you know
• 50:40you do a screening colonoscopy you
• 50:41know sometimes patients have read
• 50:43on the Internet and or whatever and
• 50:45they'll say well should I just get
• 50:47the CEA as well at that time and and
• 50:50the answer there obviously is no.
• 50:52I mean there are very rare
• 50:54circumstances well where we will do
• 50:56it without a diagnosis sometimes.
• 50:57And this is rare.
• 50:58If we have a patient who's sort of got,
• 51:01you know, this diverticular disease
• 51:03that doesn't get better and and they may
• 51:06have a small Abscess at the same time.
• 51:08And imaging is sort of you know,
• 51:10maybe concerning a little bit for more of a,
• 51:13you know, a thickening or a mass like lesion.
• 51:16We might do it in that setting,
• 51:18you know, before a colonoscopy.
• 51:21And I think that,
• 51:22you know there are very rare circumstances
• 51:24where we might use it and I think the
• 51:26other thing that's important to note.
• 51:28Is when patients come in and they have
• 51:32verified colon cancer by pathology and on
• 51:35colonoscopy amass and their CA is normal.
• 51:38It's important to tell patients
• 51:39at that time as well.
• 51:41But not all colon cancers make CEA
• 51:43and that that's an important thing
• 51:45because it's not always you know,
• 51:48it doesn't always portend a great
• 51:51prognosis and so you know these
• 51:53nuances are important and and
• 51:55I I love that question,
• 51:56it's such a great question.
• 51:59Well, sometime we'll bring back a group
• 52:02to talk about what is being referred to
• 52:05as liquid biopsy in the late literature.
• 52:08That is will be on our minds.
• 52:10I'm going to move to Doctor Breyer.
• 52:13There's question who points out
• 52:15that there was a wonderful lecture,
• 52:17this was at a general internal medicine
• 52:19grand rounds, about the care of patients
• 52:21living with developmental disorders.
• 52:23And as these patients are living longer,
• 52:26is there a recommendation about screening
• 52:30them or those who are conserved,
• 52:33for example, with mental illness?
• 52:37I feel like this might be as much
• 52:39primary care as anything else.
• 52:41I don't know that.
• 52:42Do you have a?
• 52:43A thought about that.
• 52:47I think I kind of look at like what the
• 52:49guideline says and say how functioning is
• 52:51that individual and if we detect the cancer,
• 52:53what is it we're going to do afterward,
• 52:54right. So if there's an anticipated
• 52:56process by which that person's going
• 52:58to be supported through their cancer
• 53:00diagnosis and could under undergo
• 53:02surgical procedure and so forth,
• 53:04then I would lean towards it versus someone
• 53:07that has a lot more limited functioning.
• 53:10So I think it's hard.
• 53:11Also, the first thing that pops
• 53:12into my little head is Cologuard.
• 53:14I'm like, oh, let's screen some
• 53:15of these folks that way because.
• 53:17It's just so much of an easier
• 53:19process than preparing for the
• 53:21colonoscopy and that might feel
• 53:22like a cheap out to some of you.
• 53:25But I look at the whole patient and
• 53:27say let's not put them through things
• 53:30that aren't unnecessarily complicated.
• 53:32I think that's a great point.
• 53:33I mean I've had a lot of patients,
• 53:36you know, you know,
• 53:37I think we have a lot of patients that
• 53:40are autistic and you know doing a
• 53:42prep requires a whole family effort.
• 53:45It's not an easy thing to do.
• 53:48Um to support a patient through that process.
• 53:50And so I wholly agree with you,
• 53:52it's got to be a conversation
• 53:55between the family the caregivers,
• 53:58the primary care team about really
• 54:00trying to find what that you know
• 54:03I always say you know on screening
• 54:05talks you know the people ask me well
• 54:07what's the best test the screening
• 54:09test for colon cancer and it's the
• 54:12one that you're able to get and so
• 54:14you know if you if you're able to
• 54:16get multiple ones then getting.
• 54:18You know, a colonoscopy or Cologuard,
• 54:19you know those are great things
• 54:21but I don't think we can be overly
• 54:23judgmental when we're looking at
• 54:25these sorts of special circumstances
• 54:27because it's a better situation to do
• 54:29a test that is practical to be able
• 54:31to get done then not do anything at all.
• 54:34Because we all know of patients
• 54:36that just say, well you know,
• 54:37I'm not going to do it at all
• 54:39because it's just too hard for this
• 54:41individual patient to be able to
• 54:42go through that process.
• 54:43So they, you know,
• 54:44I think it's a really great question.
• 54:46You know, it's, it's a really.
• 54:49Now I,
• 54:49I and I I will just chime in one step
• 54:52of just remember with Cologuard if
• 54:54it's positive it leads to colonoscopy.
• 54:56So you did the same decision making
• 54:59applies to even a non invasive stool
• 55:02based test and and Doctor Breyer
• 55:05was also happy with the answer.
• 55:07Thank you for that follow up.
• 55:09So I have another one from Doctor Banatski.
• 55:13When we order an anal pap do
• 55:16we order cytology and HPV?
• 55:19Every time if the cytology is
• 55:21negative and the HPV is positive,
• 55:24can you talk about frequency of
• 55:26follow up and where to refer?
• 55:27So we have a a lot of guidelines
• 55:30for Pap smear and HPV as far as
• 55:33our recommendations to repeat,
• 55:35but I there there is less for anal PAP.
• 55:40Scott, is this you?
• 55:43So first of all, there are few
• 55:44people who do anal pap smears.
• 55:45It's not. I've taught my
• 55:47multiple gynecologists to do it.
• 55:49It's not a hard thing to do,
• 55:50no reason to test for for
• 55:53the the serology, the virus.
• 55:55Either they have dysplasia or they don't.
• 55:57If they do have displays,
• 55:58that leads to a high resolution
• 56:00anoscopy which is a 5 minute
• 56:03outpatient with anesthesia exam,
• 56:05kind of like a a colposcopy,
• 56:08so similar to similar.
• 56:11We follow up similar to GYN pathology
• 56:15after after a high resolution anoscopy
• 56:18and treatment repeat Pap smear in a year.
• 56:21Again low grade lesions tend to not
• 56:23be as important as high grade lesions.
• 56:25But this simple thing for primary care docs,
• 56:27just think about one thing,
• 56:29if you have patients who are high risk,
• 56:31get them as someone who can do a pap smear.
• 56:33A Pap smear is basically a Q-tip
• 56:35in the **** and I can teach anybody
• 56:38to do it and takes 15 seconds.
• 56:40So again.
• 56:41Just get it to somebody who can
• 56:42do a pap smear will will follow
• 56:43up the patients after that.
• 56:47But I think we're actually at time it is 559.
• 56:54And wow, do I ever want to thank each
• 56:56of our panelists for their preparation
• 56:59and their really great presentations.
• 57:02And I definitely thank everybody who
• 57:04tuned in at the end of a work day at
• 57:085:00 o'clock to listen, because I
• 57:10know we've made it worth your while.
• 57:13But that also definitely is
• 57:16something to inspire gratitude.
• 57:18So thank you
• 57:19and I want to thank you as well.
• 57:21And and just Renee if you can put that
• 57:24last slide up if folks can can answer or or.
• 57:30I log in. For the CME piece and if you
• 57:35want to have any feedback, some of you
• 57:38have provided really great feedback,
• 57:40which we're actually looking for as we
• 57:43think about extending this for next year.
• 57:45So if you enjoyed the program,
• 57:46please put your comments on several of you,
• 57:49put really interesting questions
• 57:50and have a little bit of an e-mail
• 57:52conversation around that as well.
• 57:54So thank you all for joining
• 57:55us and thanks to our faculty.
• 57:58Everybody have a great night.
• 57:59Thank you. Thank you.