WEBVTT

NOTE duration: "01:00:21.162"


NOTE Confidence: 0.99335945

00:00:00.719 --> 00:00:01.839
I'll go ahead and get

NOTE Confidence: 0.99335945

00:00:01.839 --> 00:00:02.500
us started.

NOTE Confidence: 0.8974304

00:00:03.360 --> 00:00:05.040
Good evening and welcome to

NOTE Confidence: 0.8974304

00:00:05.040 --> 00:00:07.540
Smilo Shares with Primary Care.

NOTE Confidence: 0.9905892

00:00:08.000 --> 00:00:09.840
Smilo Shares with Primary Care

NOTE Confidence: 0.9905892

00:00:09.840 --> 00:00:10.740
is a collaborative

NOTE Confidence: 0.9781203

00:00:11.759 --> 00:00:14.160
lecture series between, our primary

NOTE Confidence: 0.9781203

00:00:14.160 --> 00:00:15.940
care clinicians here at Yale

NOTE Confidence: 0.8777065

00:00:16.295 --> 00:00:18.235
and our SMILO Cancer Care

NOTE Confidence: 0.7974426

00:00:18.614 --> 00:00:19.114
Specialists.

NOTE Confidence: 0.9287624

00:00:19.655 --> 00:00:21.335
I'm Karen Brown, a primary

NOTE Confidence: 0.9287624

00:00:21.335 --> 00:00:22.155
care internist,

NOTE Confidence: 0.97914624

00:00:22.855 --> 00:00:24.135
and I will host this

NOTE Confidence: 0.97914624

00:00:24.135 --> 00:00:25.335
evening's talk with the help

NOTE Confidence: 0.97914624

00:00:25.335 --> 00:00:26.475
of Tracy Battaglia.

NOTE Confidence: 0.9982753

00:00:27.575 --> 00:00:29.035
This series highlights

NOTE Confidence: 0.98520154

00:00:29.500 --> 00:00:31.580
the primary care perspective in

NOTE Confidence: 0.98520154

00:00:31.580 --> 00:00:32.560
cancer care.

NOTE Confidence: 0.9929528

00:00:32.940 --> 00:00:34.780
Our primary care perspective is

NOTE Confidence: 0.9929528

00:00:34.780 --> 00:00:35.280
different.

NOTE Confidence: 0.9835997

00:00:35.739 --> 00:00:37.659
We're constantly providing advice to

NOTE Confidence: 0.9835997

00:00:37.659 --> 00:00:39.820
prevent cancer, testing to screen

NOTE Confidence: 0.9835997

00:00:39.820 --> 00:00:40.559
for cancer,

NOTE Confidence: 0.93157274

00:00:40.860 --> 00:00:43.505
testing for cancer, and fortunately

NOTE Confidence: 0.93157274

00:00:43.565 --> 00:00:45.085
less often finding a new

NOTE Confidence: 0.93157274

00:00:45.085 --> 00:00:45.585
cancer.

NOTE Confidence: 0.9569596

00:00:46.045 --> 00:00:47.245
But when we do, it's

NOTE Confidence: 0.9569596

00:00:47.245 --> 00:00:48.524
stressful and we want to

NOTE Confidence: 0.9569596

00:00:48.524 --> 00:00:49.985
get the handoffs right.

NOTE Confidence: 0.9435279

00:00:50.925 --> 00:00:52.604
And so that is the

NOTE Confidence: 0.9435279

00:00:52.845 --> 00:00:54.045
those are the sorts of

NOTE Confidence: 0.9435279

00:00:54.045 --> 00:00:55.824
topics that we deal with.

NOTE Confidence: 0.98435056

00:00:56.470 --> 00:00:57.830
During this talk, please feel

NOTE Confidence: 0.98435056

00:00:57.830 --> 00:00:59.110
free to enter questions into

NOTE Confidence: 0.98435056

00:00:59.110 --> 00:01:00.310
the Q and A. I'll

NOTE Confidence: 0.98435056

00:01:00.310 --> 00:01:02.230
monitor it and pose questions

NOTE Confidence: 0.98435056

00:01:02.230 --> 00:01:03.430
to our speaker during or

NOTE Confidence: 0.98435056

00:01:03.430 --> 00:01:04.069
at the end of the

NOTE Confidence: 0.98435056

00:01:04.069 --> 00:01:05.110
talk when we try to

NOTE Confidence: 0.98435056

00:01:05.110 --> 00:01:06.310
save time for questions and

NOTE Confidence: 0.98435056

00:01:06.310 --> 00:01:07.270
a bit of an open

NOTE Confidence: 0.98435056

00:01:07.270 --> 00:01:08.970
conversation between our speakers.

NOTE Confidence: 0.99348485

00:01:09.875 --> 00:01:12.375
Tonight's topic is colorectal cancer

NOTE Confidence: 0.9980078

00:01:12.755 --> 00:01:14.135
prevention and screening.

NOTE Confidence: 0.99882394

00:01:15.555 --> 00:01:16.694
We have a terrific

NOTE Confidence: 0.9707397

00:01:16.995 --> 00:01:18.935
panel. I'll start by introducing,

NOTE Confidence: 0.8564479

00:01:19.475 --> 00:01:21.255
Doctor. Piaal Alam.

NOTE Confidence: 0.9934721

00:01:22.560 --> 00:01:24.740
Pial is a board certified

NOTE Confidence: 0.9934721

00:01:24.880 --> 00:01:26.259
family medicine physician.

NOTE Confidence: 0.9629519

00:01:26.720 --> 00:01:28.659
He received his medical degree

NOTE Confidence: 0.9629519

00:01:28.720 --> 00:01:30.500
from the New York Institute

NOTE Confidence: 0.9629519

00:01:30.640 --> 00:01:31.140
Technology

NOTE Confidence: 0.82442874

00:01:32.319 --> 00:01:33.380
College of Osteopathic

NOTE Confidence: 0.93818915

00:01:33.680 --> 00:01:35.360
Medicine and he completed his

NOTE Confidence: 0.93818915

00:01:35.360 --> 00:01:37.520
family medicine residency at Northwell

NOTE Confidence: 0.93818915

00:01:37.520 --> 00:01:38.020
Health.

NOTE Confidence: 0.9892643

00:01:38.615 --> 00:01:40.235
He is a primary care

NOTE Confidence: 0.79051554

00:01:40.854 --> 00:01:41.354
physician,

NOTE Confidence: 0.948855

00:01:42.134 --> 00:01:44.375
a busy primary care physician,

NOTE Confidence: 0.948855

00:01:44.375 --> 00:01:45.895
for Northeast Medical Group here

NOTE Confidence: 0.948855

00:01:45.895 --> 00:01:47.174
at Yale in Rye Brook,

NOTE Confidence: 0.948855

00:01:47.174 --> 00:01:48.854
New York. In his spare

NOTE Confidence: 0.948855

00:01:48.854 --> 00:01:50.295
time, he is also an

NOTE Confidence: 0.948855

00:01:50.295 --> 00:01:51.975
executive Miles per hour candidate

NOTE Confidence: 0.948855

00:01:51.975 --> 00:01:53.015
at the Yale School of

NOTE Confidence: 0.948855

00:01:53.015 --> 00:01:55.200
Public Health focusing on health

NOTE Confidence: 0.948855

00:01:55.200 --> 00:01:55.700
policy.

NOTE Confidence: 0.9474705

00:01:56.400 --> 00:01:57.600
He serves as a co

NOTE Confidence: 0.9474705

00:01:57.600 --> 00:02:00.260
director for another lecture series,

NOTE Confidence: 0.9593296

00:02:00.720 --> 00:02:02.000
called Trust Your Gut on

NOTE Confidence: 0.9593296

00:02:02.000 --> 00:02:03.060
Digestive Health.

NOTE Confidence: 0.96283406

00:02:03.760 --> 00:02:04.900
He's very involved

NOTE Confidence: 0.94778436

00:02:05.360 --> 00:02:06.240
in what we call our

NOTE Confidence: 0.94778436

00:02:06.240 --> 00:02:07.460
care signature pathways,

NOTE Confidence: 0.94312024

00:02:08.035 --> 00:02:10.294
chairing and authoring several ambulatory

NOTE Confidence: 0.94312024

00:02:10.514 --> 00:02:12.195
pathways and sitting on the

NOTE Confidence: 0.94312024

00:02:12.195 --> 00:02:13.955
primary care and infectious disease

NOTE Confidence: 0.94312024

00:02:13.955 --> 00:02:14.455
councils.

NOTE Confidence: 0.9928781

00:02:14.755 --> 00:02:16.435
He also recently joined the

NOTE Confidence: 0.9928781

00:02:16.435 --> 00:02:18.055
Connecticut Department of Health

NOTE Confidence: 0.89099324

00:02:18.355 --> 00:02:19.575
outpatient antibiotic

NOTE Confidence: 0.9995752

00:02:20.035 --> 00:02:20.535
stewardship

NOTE Confidence: 0.98726666

00:02:20.915 --> 00:02:21.415
committee.

NOTE Confidence: 0.93080235

00:02:22.100 --> 00:02:23.220
I'm gonna turn,

NOTE Confidence: 0.9514923

00:02:23.620 --> 00:02:24.120
over,

NOTE Confidence: 0.97881335

00:02:24.660 --> 00:02:25.959
my virtual microphone,

NOTE Confidence: 0.9174115

00:02:26.260 --> 00:02:27.480
to Tracy Battaglia

NOTE Confidence: 0.94970864

00:02:28.020 --> 00:02:29.220
who joins me tonight as

NOTE Confidence: 0.94970864

00:02:29.220 --> 00:02:31.240
a cohost. She's the associate

NOTE Confidence: 0.94970864

00:02:31.380 --> 00:02:33.139
director of the Cancer Care

NOTE Confidence: 0.94970864

00:02:33.139 --> 00:02:33.639
Equity,

NOTE Confidence: 0.9564265

00:02:34.340 --> 00:02:35.860
at our Yale Cancer Center,

NOTE Confidence: 0.9564265

00:02:35.860 --> 00:02:37.400
and and she counts double

NOTE Confidence: 0.9960729

00:02:37.815 --> 00:02:39.275
because she's an internist,

NOTE Confidence: 0.96945393

00:02:39.974 --> 00:02:41.575
and a professor in our

NOTE Confidence: 0.96945393

00:02:41.575 --> 00:02:43.355
section of general internal medicine.

NOTE Confidence: 0.9932229

00:02:43.655 --> 00:02:45.095
And she will introduce our

NOTE Confidence: 0.9932229

00:02:45.095 --> 00:02:45.915
other speakers.

NOTE Confidence: 0.9696633

00:02:46.215 --> 00:02:47.974
Tracy? Thank you, doctor Brown.

NOTE Confidence: 0.9696633

00:02:47.974 --> 00:02:49.334
It's really a pleasure to

NOTE Confidence: 0.9696633

00:02:49.334 --> 00:02:50.630
be here this evening with

NOTE Confidence: 0.9696633

00:02:50.630 --> 00:02:51.750
all of you and to,

NOTE Confidence: 0.9998461

00:02:52.629 --> 00:02:54.150
introduce our esteemed panel. I'm

NOTE Confidence: 0.9998461

00:02:54.150 --> 00:02:55.430
excited to learn from this

NOTE Confidence: 0.9998461

00:02:55.430 --> 00:02:55.930
panel.

NOTE Confidence: 0.93222314

00:02:56.230 --> 00:02:57.750
Let me first, on behalf

NOTE Confidence: 0.93222314

00:02:57.750 --> 00:02:59.110
of the Cancer Center, introduce

NOTE Confidence: 0.93222314

00:02:59.110 --> 00:03:00.810
you to doctor Thayjal Shreekumar.

NOTE Confidence: 0.978174

00:03:01.510 --> 00:03:03.190
Doctor Shreekumar is an assistant

NOTE Confidence: 0.978174

00:03:03.190 --> 00:03:04.870
professor of medicine and medical

NOTE Confidence: 0.978174

00:03:04.870 --> 00:03:06.764
oncology and hematology, where she

NOTE Confidence: 0.978174

00:03:06.764 --> 00:03:08.044
cares for patients as part

NOTE Confidence: 0.978174

00:03:08.044 --> 00:03:09.825
of the Center for Gastrointestinal

NOTE Confidence: 0.9859445

00:03:10.285 --> 00:03:12.125
Cancers at Smilow Cancer Hospital

NOTE Confidence: 0.9859445

00:03:12.125 --> 00:03:13.725
and Yale Cancer Center here

NOTE Confidence: 0.9859445

00:03:13.725 --> 00:03:14.625
in New Haven.

NOTE Confidence: 0.9663743

00:03:15.885 --> 00:03:17.805
She completed her undergraduate degree

NOTE Confidence: 0.9663743

00:03:17.805 --> 00:03:19.105
in heart at Harvard

NOTE Confidence: 0.95731384

00:03:19.405 --> 00:03:20.685
and then received her medical

NOTE Confidence: 0.95731384

00:03:20.685 --> 00:03:22.159
degree from the University of

NOTE Confidence: 0.95731384

00:03:22.159 --> 00:03:24.000
Florida College of Medicine and

NOTE Confidence: 0.95731384

00:03:24.000 --> 00:03:25.139
completed her residency

NOTE Confidence: 0.9671353

00:03:25.680 --> 00:03:26.799
here at Yale, where she

NOTE Confidence: 0.9671353

00:03:26.799 --> 00:03:28.500
also served as chief resident.

NOTE Confidence: 0.9953083

00:03:29.040 --> 00:03:30.319
She went on to complete

NOTE Confidence: 0.9953083

00:03:30.319 --> 00:03:32.340
her medical oncology and hematology

NOTE Confidence: 0.9829085

00:03:32.720 --> 00:03:33.780
fellowship and,

NOTE Confidence: 0.990463

00:03:34.239 --> 00:03:35.920
chief year fellowship here at

NOTE Confidence: 0.990463

00:03:35.920 --> 00:03:36.420
Yale,

NOTE Confidence: 0.9461055

00:03:37.395 --> 00:03:39.075
which at the time she

NOTE Confidence: 0.9461055

00:03:39.075 --> 00:03:40.675
obtained her executive master of

NOTE Confidence: 0.9461055

00:03:40.675 --> 00:03:42.215
public health degree in epidemiology

NOTE Confidence: 0.9461055

00:03:42.355 --> 00:03:43.735
and health health informatics.

NOTE Confidence: 0.9079011

00:03:44.595 --> 00:03:46.194
We're very fortunate to have

NOTE Confidence: 0.9079011

00:03:46.194 --> 00:03:48.215
doctor Sri Kumar's clinical research

NOTE Confidence: 0.9079011

00:03:48.275 --> 00:03:49.955
efforts here centered around caring

NOTE Confidence: 0.9079011

00:03:49.955 --> 00:03:51.575
for young adults with gastrointestinal

NOTE Confidence: 0.8878251

00:03:51.880 --> 00:03:52.380
malignancies,

NOTE Confidence: 0.9974366

00:03:53.320 --> 00:03:54.920
and she's also quite passionate

NOTE Confidence: 0.9974366

00:03:54.920 --> 00:03:56.680
about medical education as she

NOTE Confidence: 0.9974366

00:03:56.680 --> 00:03:58.200
serves as our assistant program

NOTE Confidence: 0.9974366

00:03:58.200 --> 00:03:58.700
director

NOTE Confidence: 0.93040353

00:03:59.000 --> 00:04:00.620
for the Yale Medical Oncology

NOTE Confidence: 0.93040353

00:04:00.840 --> 00:04:02.920
Hematology Fellowship Program. Thank you

NOTE Confidence: 0.93040353

00:04:02.920 --> 00:04:04.540
for being here, doctor Sreekumar.

NOTE Confidence: 0.92987573

00:04:06.275 --> 00:04:07.875
I'm also here to introduce

NOTE Confidence: 0.92987573

00:04:07.875 --> 00:04:09.975
you to doctor Xavier Lohr,

NOTE Confidence: 0.9964653

00:04:10.755 --> 00:04:12.455
who received his MD

NOTE Confidence: 0.99357325

00:04:12.915 --> 00:04:14.435
degree from the University of

NOTE Confidence: 0.99357325

00:04:14.435 --> 00:04:14.935
Barcelona.

NOTE Confidence: 0.98963624

00:04:15.715 --> 00:04:17.235
Doctor Lohr is trained in

NOTE Confidence: 0.98963624

00:04:17.235 --> 00:04:19.154
basic research and internal medicine

NOTE Confidence: 0.98963624

00:04:19.154 --> 00:04:20.615
at the University of Chicago,

NOTE Confidence: 0.98963624

00:04:20.675 --> 00:04:22.330
where he also completed his

NOTE Confidence: 0.98963624

00:04:22.330 --> 00:04:23.310
GI fellowship

NOTE Confidence: 0.9983454

00:04:23.770 --> 00:04:25.390
at the University of Illinois

NOTE Confidence: 0.9983454

00:04:25.450 --> 00:04:26.190
at Chicago.

NOTE Confidence: 0.9834821

00:04:26.890 --> 00:04:28.570
He complemented his training with

NOTE Confidence: 0.9834821

00:04:28.570 --> 00:04:30.190
a PhD degree in molecular

NOTE Confidence: 0.9834821

00:04:30.330 --> 00:04:31.850
biology from the University of

NOTE Confidence: 0.9834821

00:04:31.850 --> 00:04:32.350
Barcelona.

NOTE Confidence: 0.9966001

00:04:33.130 --> 00:04:35.070
He's a very active clinical

NOTE Confidence: 0.9966001

00:04:35.290 --> 00:04:35.790
gastroenterologist

NOTE Confidence: 0.88421744

00:04:36.410 --> 00:04:37.904
where his research and clinical

NOTE Confidence: 0.88421744

00:04:37.904 --> 00:04:39.284
interests relate to gastrointestinal

NOTE Confidence: 0.9995513

00:04:39.664 --> 00:04:40.565
cancer prevention.

NOTE Confidence: 0.9801862

00:04:41.264 --> 00:04:42.464
He has an active basic

NOTE Confidence: 0.9801862

00:04:42.464 --> 00:04:44.805
science and translational research program,

NOTE Confidence: 0.9801862

00:04:44.865 --> 00:04:46.705
which focuses on several aspects

NOTE Confidence: 0.9801862

00:04:46.705 --> 00:04:47.444
of gastrointestinal

NOTE Confidence: 0.942975

00:04:47.904 --> 00:04:48.404
cancer,

NOTE Confidence: 0.99468756

00:04:48.784 --> 00:04:51.185
hereditary and familial forms, screening

NOTE Confidence: 0.99468756

00:04:51.185 --> 00:04:51.845
and prevention,

NOTE Confidence: 0.9994248

00:04:52.420 --> 00:04:53.160
and disparities.

NOTE Confidence: 0.9945959

00:04:53.940 --> 00:04:55.480
He is a well published,

NOTE Confidence: 0.9315694

00:04:56.100 --> 00:04:57.860
investigator in the field, making

NOTE Confidence: 0.9315694

00:04:57.860 --> 00:04:59.620
seminal contributions to the fields

NOTE Confidence: 0.9315694

00:04:59.620 --> 00:05:01.060
of Lynch Syndrome and other

NOTE Confidence: 0.9315694

00:05:01.060 --> 00:05:02.600
non polyposis syndromic

NOTE Confidence: 0.99940085

00:05:02.980 --> 00:05:04.520
colorectal cancer cases.

NOTE Confidence: 0.96283114

00:05:05.300 --> 00:05:06.680
He holds many leadership,

NOTE Confidence: 0.9392721

00:05:07.255 --> 00:05:09.415
positions nationally, most notably at

NOTE Confidence: 0.9392721

00:05:09.415 --> 00:05:10.055
the National,

NOTE Confidence: 0.97892666

00:05:10.455 --> 00:05:11.995
Colorectal Cancer Roundtable

NOTE Confidence: 0.98618925

00:05:12.775 --> 00:05:15.015
and, the National Comprehensive Cancer

NOTE Confidence: 0.98618925

00:05:15.015 --> 00:05:16.055
Network. So we're thrilled to

NOTE Confidence: 0.98618925

00:05:16.055 --> 00:05:17.435
have doctor Lohr here

NOTE Confidence: 0.99839216

00:05:17.895 --> 00:05:18.714
as a panelist.

NOTE Confidence: 0.98836

00:05:21.569 --> 00:05:23.089
I'll pass it off to,

NOTE Confidence: 0.98836

00:05:23.409 --> 00:05:24.610
our panelists to get us

NOTE Confidence: 0.98836

00:05:24.610 --> 00:05:25.110
started.

NOTE Confidence: 0.9541082

00:05:26.050 --> 00:05:27.250
Thank you to both Karen

NOTE Confidence: 0.9541082

00:05:27.250 --> 00:05:28.689
and Tracy for those wonderful

NOTE Confidence: 0.9541082

00:05:28.689 --> 00:05:29.889
introductions, and thank you to

NOTE Confidence: 0.9541082

00:05:29.889 --> 00:05:31.409
the entire smile team for

NOTE Confidence: 0.9541082

00:05:31.409 --> 00:05:32.770
hosting us here tonight. And

NOTE Confidence: 0.9541082

00:05:32.770 --> 00:05:33.650
also thank you to our

NOTE Confidence: 0.9541082

00:05:33.650 --> 00:05:35.565
audience for joining us. Before

NOTE Confidence: 0.9541082

00:05:35.565 --> 00:05:36.604
we get started, I'll give

NOTE Confidence: 0.9541082

00:05:36.604 --> 00:05:37.164
a little bit of a

NOTE Confidence: 0.9541082

00:05:37.164 --> 00:05:37.664
background.

NOTE Confidence: 0.9840997

00:05:38.205 --> 00:05:40.685
So with that, colorectal cancer

NOTE Confidence: 0.9840997

00:05:40.685 --> 00:05:42.365
is a relatively common disease.

NOTE Confidence: 0.9840997

00:05:42.365 --> 00:05:43.884
In the United States, over

NOTE Confidence: 0.9840997

00:05:43.884 --> 00:05:45.085
a hundred and fifty four

NOTE Confidence: 0.9840997

00:05:45.085 --> 00:05:46.845
thousand new cases of colon

NOTE Confidence: 0.9840997

00:05:46.845 --> 00:05:48.464
and rectal cancer are diagnosed

NOTE Confidence: 0.9840997

00:05:48.604 --> 00:05:49.104
annually.

NOTE Confidence: 0.9932703

00:05:49.770 --> 00:05:51.950
Colorectal cancer incidence and mortality

NOTE Confidence: 0.9932703

00:05:52.089 --> 00:05:54.010
rates vary markedly around the

NOTE Confidence: 0.9932703

00:05:54.010 --> 00:05:54.510
world.

NOTE Confidence: 0.98646414

00:05:54.970 --> 00:05:57.050
Globally, colorectal cancer is the

NOTE Confidence: 0.98646414

00:05:57.050 --> 00:05:58.890
third most diagnosed cancer in

NOTE Confidence: 0.98646414

00:05:58.890 --> 00:06:00.410
males, and the second most

NOTE Confidence: 0.98646414

00:06:00.410 --> 00:06:01.850
in females, according to the

NOTE Confidence: 0.98646414

00:06:01.850 --> 00:06:02.910
World Health Organization.

NOTE Confidence: 0.9681231

00:06:03.835 --> 00:06:05.275
Tonight, we will go into

NOTE Confidence: 0.9681231

00:06:05.275 --> 00:06:07.035
greater detail about some clinical

NOTE Confidence: 0.9681231

00:06:07.035 --> 00:06:08.955
presentations in the primary care

NOTE Confidence: 0.9681231

00:06:08.955 --> 00:06:09.455
setting,

NOTE Confidence: 0.9882307

00:06:09.755 --> 00:06:11.035
when and how to screen,

NOTE Confidence: 0.9882307

00:06:11.035 --> 00:06:12.395
and what history and red

NOTE Confidence: 0.9882307

00:06:12.395 --> 00:06:13.435
flags to keep an eye

NOTE Confidence: 0.9882307

00:06:13.435 --> 00:06:14.714
out for to best support

NOTE Confidence: 0.9882307

00:06:14.714 --> 00:06:15.375
our patients.

NOTE Confidence: 0.8261892

00:06:16.235 --> 00:06:17.214
Next slide, please.

NOTE Confidence: 0.95868397

00:06:18.180 --> 00:06:20.040
So the United States Preventative

NOTE Confidence: 0.95868397

00:06:20.180 --> 00:06:22.660
Services Task Force recommends that

NOTE Confidence: 0.95868397

00:06:22.660 --> 00:06:24.580
adults age forty five to

NOTE Confidence: 0.95868397

00:06:24.580 --> 00:06:26.339
seventy five be screened for

NOTE Confidence: 0.95868397

00:06:26.339 --> 00:06:27.560
colorectal cancer.

NOTE Confidence: 0.9903707

00:06:28.180 --> 00:06:29.779
Most people should be begin

NOTE Confidence: 0.9903707

00:06:29.779 --> 00:06:31.725
screening for colorectal cancer as

NOTE Confidence: 0.9903707

00:06:31.725 --> 00:06:33.585
soon as after turning forty

NOTE Confidence: 0.9903707

00:06:33.805 --> 00:06:35.404
five, then continue getting screened

NOTE Confidence: 0.9903707

00:06:35.404 --> 00:06:36.464
at regular intervals.

NOTE Confidence: 0.9663051

00:06:37.085 --> 00:06:38.205
However, you may need to

NOTE Confidence: 0.9663051

00:06:38.205 --> 00:06:39.885
be tested earlier than forty

NOTE Confidence: 0.9663051

00:06:39.885 --> 00:06:41.165
five or more often than

NOTE Confidence: 0.9663051

00:06:41.165 --> 00:06:43.585
this in certain, clinical scenarios.

NOTE Confidence: 0.9970331

00:06:44.205 --> 00:06:45.665
Some of which being inflammatory

NOTE Confidence: 0.9970331

00:06:45.964 --> 00:06:46.785
bowel disease,

NOTE Confidence: 0.9708302

00:06:47.500 --> 00:06:49.180
like Crohn's disease or ulcerative

NOTE Confidence: 0.9708302

00:06:49.180 --> 00:06:49.680
colitis,

NOTE Confidence: 0.9725123

00:06:49.980 --> 00:06:51.500
a personal or family history

NOTE Confidence: 0.9725123

00:06:51.500 --> 00:06:53.920
of colorectal cancer, or colorectal

NOTE Confidence: 0.9725123

00:06:54.220 --> 00:06:54.720
polyps,

NOTE Confidence: 0.924868

00:06:55.020 --> 00:06:56.940
or, genetic syndromes, such as

NOTE Confidence: 0.924868

00:06:56.940 --> 00:06:58.000
familial adenovitis,

NOTE Confidence: 0.8432276

00:06:58.300 --> 00:06:59.839
paleposis, or hereditary

NOTE Confidence: 0.78990805

00:07:00.625 --> 00:07:01.125
nonpulposis

NOTE Confidence: 0.9353473

00:07:01.505 --> 00:07:03.365
colorectal cancer, Lynch syndrome.

NOTE Confidence: 0.96724534

00:07:03.985 --> 00:07:05.745
And with that, I'd like

NOTE Confidence: 0.96724534

00:07:05.745 --> 00:07:07.265
to hand over to Javier

NOTE Confidence: 0.96724534

00:07:07.265 --> 00:07:08.145
to discuss a little bit

NOTE Confidence: 0.96724534

00:07:08.145 --> 00:07:09.125
more about this.

NOTE Confidence: 0.93777055

00:07:09.425 --> 00:07:10.625
Thank you, Biel. So,

NOTE Confidence: 0.93220204

00:07:11.105 --> 00:07:13.445
starting first with, colorectal cancer

NOTE Confidence: 0.93220204

00:07:13.665 --> 00:07:15.445
screening options. As we've,

NOTE Confidence: 0.96170396

00:07:16.010 --> 00:07:17.130
heard over the last few

NOTE Confidence: 0.96170396

00:07:17.130 --> 00:07:18.270
years, the armamentarium

NOTE Confidence: 0.9747454

00:07:18.650 --> 00:07:20.330
for colorectal cancer screening has

NOTE Confidence: 0.9747454

00:07:20.330 --> 00:07:22.090
grown. And with the growth,

NOTE Confidence: 0.9747454

00:07:22.330 --> 00:07:24.030
complexity has come with that,

NOTE Confidence: 0.9747454

00:07:24.170 --> 00:07:26.170
and, we'll really have to

NOTE Confidence: 0.9747454

00:07:26.170 --> 00:07:27.370
try to figure out what

NOTE Confidence: 0.9747454

00:07:27.370 --> 00:07:28.650
best suits our patients and

NOTE Confidence: 0.9747454

00:07:28.650 --> 00:07:29.955
how we handle that. This

NOTE Confidence: 0.9747454

00:07:29.955 --> 00:07:30.855
is a summary,

NOTE Confidence: 0.9897951

00:07:31.715 --> 00:07:32.855
slide from the NCCN,

NOTE Confidence: 0.9442782

00:07:33.955 --> 00:07:36.294
guidelines on colorectal cancer screening,

NOTE Confidence: 0.9442782

00:07:36.514 --> 00:07:37.955
and that shows, on the

NOTE Confidence: 0.9442782

00:07:37.955 --> 00:07:39.074
left side, you see all

NOTE Confidence: 0.9442782

00:07:39.074 --> 00:07:40.514
the different modalities starting with

NOTE Confidence: 0.9442782

00:07:40.514 --> 00:07:42.595
colonoscopy, which was has been

NOTE Confidence: 0.9442782

00:07:42.595 --> 00:07:43.255
the traditional,

NOTE Confidence: 0.9636055

00:07:43.875 --> 00:07:45.480
screening method in the US,

NOTE Confidence: 0.9636055

00:07:45.560 --> 00:07:47.260
then down the flexible sigmoidoscopy,

NOTE Confidence: 0.95822656

00:07:47.800 --> 00:07:48.540
CT colonography,

NOTE Confidence: 0.9841815

00:07:49.320 --> 00:07:50.220
then FOBT,

NOTE Confidence: 0.9546177

00:07:51.320 --> 00:07:53.080
and then now that mostly

NOTE Confidence: 0.9546177

00:07:53.080 --> 00:07:55.000
have been substituted that, by,

NOTE Confidence: 0.9958452

00:07:55.400 --> 00:07:55.900
FIT

NOTE Confidence: 0.89068586

00:07:56.520 --> 00:07:58.680
and then, multi target stool

NOTE Confidence: 0.89068586

00:07:58.680 --> 00:08:00.360
DNA test, the Cologuard test

NOTE Confidence: 0.89068586

00:08:00.360 --> 00:08:01.455
that and then you can

NOTE Confidence: 0.89068586

00:08:01.935 --> 00:08:03.615
see sensitivity and specificity for

NOTE Confidence: 0.89068586

00:08:03.615 --> 00:08:04.435
both colorectal,

NOTE Confidence: 0.97359055

00:08:05.534 --> 00:08:06.995
cancer and then for advanced

NOTE Confidence: 0.97359055

00:08:07.134 --> 00:08:07.634
lesions.

NOTE Confidence: 0.93881506

00:08:08.574 --> 00:08:09.935
On the data on the,

NOTE Confidence: 0.93881506

00:08:10.175 --> 00:08:11.775
data on the Cologuard, that's

NOTE Confidence: 0.93881506

00:08:11.775 --> 00:08:13.455
gonna be updated soon because

NOTE Confidence: 0.93881506

00:08:13.455 --> 00:08:15.314
Cologuard is releasing a new

NOTE Confidence: 0.93881506

00:08:15.580 --> 00:08:17.100
version of their test with

NOTE Confidence: 0.93881506

00:08:17.100 --> 00:08:18.380
a a mark improved in

NOTE Confidence: 0.93881506

00:08:18.380 --> 00:08:18.880
specificity.

NOTE Confidence: 0.9473752

00:08:19.260 --> 00:08:20.540
So that's gonna make an

NOTE Confidence: 0.9473752

00:08:20.540 --> 00:08:22.060
important difference. And over the

NOTE Confidence: 0.9473752

00:08:22.060 --> 00:08:23.100
last couple of years, we've

NOTE Confidence: 0.9473752

00:08:23.100 --> 00:08:24.240
seen an approval,

NOTE Confidence: 0.9417554

00:08:24.620 --> 00:08:27.020
FDA approval of two new

NOTE Confidence: 0.9417554

00:08:27.020 --> 00:08:28.460
methodologies. One of them is

NOTE Confidence: 0.9417554

00:08:28.460 --> 00:08:29.600
a multi target,

NOTE Confidence: 0.9808462

00:08:30.754 --> 00:08:32.214
stool RNA test,

NOTE Confidence: 0.98991245

00:08:32.834 --> 00:08:34.214
that has similar

NOTE Confidence: 0.88452125

00:08:34.675 --> 00:08:36.355
performance to the newest test

NOTE Confidence: 0.88452125

00:08:36.355 --> 00:08:36.515
of,

NOTE Confidence: 0.89929026

00:08:37.554 --> 00:08:39.315
the multi target stool DNA

NOTE Confidence: 0.89929026

00:08:39.315 --> 00:08:39.815
test,

NOTE Confidence: 0.9399483

00:08:40.755 --> 00:08:42.515
maybe with the caveat that,

NOTE Confidence: 0.9399483

00:08:42.755 --> 00:08:43.993
failure rate is probably a

NOTE Confidence: 0.9399483

00:08:43.993 --> 00:08:45.220
little bit higher and and

NOTE Confidence: 0.9399483

00:08:45.220 --> 00:08:46.760
likely related to the,

NOTE Confidence: 0.93166864

00:08:47.380 --> 00:08:49.640
handling RNA instead of DNA,

NOTE Confidence: 0.93166864

00:08:49.779 --> 00:08:51.620
but, something that, something that,

NOTE Confidence: 0.92683804

00:08:53.700 --> 00:08:55.540
overall didn't seem to have

NOTE Confidence: 0.92683804

00:08:55.540 --> 00:08:57.140
a significant impact. But, again,

NOTE Confidence: 0.92683804

00:08:57.140 --> 00:08:57.960
it's a consideration.

NOTE Confidence: 0.9263743

00:08:58.325 --> 00:08:59.765
And finally, the blood based,

NOTE Confidence: 0.96791327

00:09:01.285 --> 00:09:02.964
cell free DNA test that's

NOTE Confidence: 0.96791327

00:09:02.964 --> 00:09:03.705
come about,

NOTE Confidence: 0.9656675

00:09:04.245 --> 00:09:05.625
again, the last year,

NOTE Confidence: 0.9759771

00:09:06.325 --> 00:09:07.925
with the caveat that the

NOTE Confidence: 0.9759771

00:09:07.925 --> 00:09:09.304
sensitivity is definitely,

NOTE Confidence: 0.95365226

00:09:09.925 --> 00:09:11.045
lower at this point,

NOTE Confidence: 0.9048048

00:09:11.525 --> 00:09:13.760
than the, those, stool tests

NOTE Confidence: 0.9048048

00:09:13.760 --> 00:09:14.660
that we mentioned

NOTE Confidence: 0.9739713

00:09:15.040 --> 00:09:15.540
before.

NOTE Confidence: 0.9843001

00:09:16.079 --> 00:09:16.579
And,

NOTE Confidence: 0.93822867

00:09:17.040 --> 00:09:18.339
and with that,

NOTE Confidence: 0.905826

00:09:18.959 --> 00:09:21.120
we've we've come a little

NOTE Confidence: 0.905826

00:09:21.120 --> 00:09:22.559
bit concerned about the fact

NOTE Confidence: 0.905826

00:09:22.559 --> 00:09:23.059
of,

NOTE Confidence: 0.81718445

00:09:24.480 --> 00:09:26.240
using this more of a

NOTE Confidence: 0.81718445

00:09:26.240 --> 00:09:26.740
generalized

NOTE Confidence: 0.89594805

00:09:27.120 --> 00:09:27.620
way,

NOTE Confidence: 0.95409477

00:09:28.265 --> 00:09:29.545
Particularly, this is going to

NOTE Confidence: 0.95409477

00:09:29.545 --> 00:09:31.385
substitute the other options that

NOTE Confidence: 0.95409477

00:09:31.385 --> 00:09:33.065
probably are better at this

NOTE Confidence: 0.95409477

00:09:33.065 --> 00:09:34.045
point. But, anyways,

NOTE Confidence: 0.9838499

00:09:34.505 --> 00:09:36.184
that's probably gonna get better,

NOTE Confidence: 0.9838499

00:09:36.184 --> 00:09:37.725
and it's gonna be another,

NOTE Confidence: 0.9989162

00:09:38.745 --> 00:09:40.105
important tool that we'll be

NOTE Confidence: 0.9989162

00:09:40.105 --> 00:09:40.925
using for

NOTE Confidence: 0.9774535

00:09:41.380 --> 00:09:43.300
colorectal cancer screening. So stay

NOTE Confidence: 0.9774535

00:09:43.300 --> 00:09:44.500
tuned because this is really

NOTE Confidence: 0.9774535

00:09:44.500 --> 00:09:45.540
a moving target, and there

NOTE Confidence: 0.9774535

00:09:45.540 --> 00:09:46.279
are more tests,

NOTE Confidence: 0.9628036

00:09:46.740 --> 00:09:48.420
coming up. And, hopefully, we'll

NOTE Confidence: 0.9628036

00:09:48.420 --> 00:09:49.220
be able to,

NOTE Confidence: 0.95607305

00:09:49.860 --> 00:09:50.360
altogether,

NOTE Confidence: 0.9864829

00:09:51.459 --> 00:09:53.459
manage the, this new world

NOTE Confidence: 0.9864829

00:09:53.459 --> 00:09:55.139
of different options and and,

NOTE Confidence: 0.9864829

00:09:55.459 --> 00:09:56.260
be able to, like,

NOTE Confidence: 0.98735785

00:09:57.035 --> 00:09:58.475
make sure that, at the

NOTE Confidence: 0.98735785

00:09:58.475 --> 00:09:59.275
end, what we do is

NOTE Confidence: 0.98735785

00:09:59.275 --> 00:10:01.135
screen better and more patients.

NOTE Confidence: 0.9426704

00:10:03.195 --> 00:10:04.554
Hundred percent agree, Shrav here,

NOTE Confidence: 0.9426704

00:10:04.554 --> 00:10:05.835
especially from the primary care

NOTE Confidence: 0.9426704

00:10:05.835 --> 00:10:07.835
side. Being able to advocate

NOTE Confidence: 0.9426704

00:10:07.835 --> 00:10:09.195
for our patients by giving

NOTE Confidence: 0.9426704

00:10:09.195 --> 00:10:10.015
them the options,

NOTE Confidence: 0.95468456

00:10:10.940 --> 00:10:12.300
and being up to date

NOTE Confidence: 0.95468456

00:10:12.300 --> 00:10:14.059
on those guidelines is so

NOTE Confidence: 0.95468456

00:10:14.059 --> 00:10:15.179
important for us. So thank

NOTE Confidence: 0.95468456

00:10:15.179 --> 00:10:16.540
you again for that. And

NOTE Confidence: 0.95468456

00:10:16.540 --> 00:10:18.059
on that note, a nice

NOTE Confidence: 0.95468456

00:10:18.059 --> 00:10:18.880
little segue.

NOTE Confidence: 0.96635073

00:10:19.820 --> 00:10:20.940
So for our health care

NOTE Confidence: 0.96635073

00:10:20.940 --> 00:10:22.380
system, we have something called

NOTE Confidence: 0.96635073

00:10:22.380 --> 00:10:23.900
the care signature pathways. Many

NOTE Confidence: 0.96635073

00:10:23.900 --> 00:10:25.100
of you may be familiar

NOTE Confidence: 0.96635073

00:10:25.100 --> 00:10:25.679
with this.

NOTE Confidence: 0.9845788

00:10:26.215 --> 00:10:27.755
What we do is essentially

NOTE Confidence: 0.9848684

00:10:28.375 --> 00:10:28.875
provide

NOTE Confidence: 0.9978656

00:10:29.255 --> 00:10:31.434
some clinical guidelines and clinical

NOTE Confidence: 0.9978656

00:10:31.495 --> 00:10:31.995
recommendations

NOTE Confidence: 0.99325955

00:10:32.535 --> 00:10:34.475
based off of expert consensus.

NOTE Confidence: 0.96679074

00:10:35.415 --> 00:10:37.015
Speaking of voice, Javier was

NOTE Confidence: 0.96679074

00:10:37.015 --> 00:10:38.295
the one of the chairs

NOTE Confidence: 0.96679074

00:10:38.295 --> 00:10:39.115
for this department.

NOTE Confidence: 0.9489518

00:10:39.630 --> 00:10:40.990
Doctor Karen Brown was also

NOTE Confidence: 0.9489518

00:10:40.990 --> 00:10:41.870
part of this. So it's

NOTE Confidence: 0.9489518

00:10:41.870 --> 00:10:43.490
a collaborative effort between

NOTE Confidence: 0.94363505

00:10:43.790 --> 00:10:46.270
primary care, experts and specialist

NOTE Confidence: 0.94363505

00:10:46.270 --> 00:10:46.770
experts.

NOTE Confidence: 0.95659655

00:10:47.630 --> 00:10:48.130
Multidisciplinary

NOTE Confidence: 0.98231053

00:10:48.590 --> 00:10:50.510
as well. We sometimes have

NOTE Confidence: 0.98231053

00:10:50.510 --> 00:10:52.270
lab or imaging part of

NOTE Confidence: 0.98231053

00:10:52.270 --> 00:10:53.470
the team as well, depending

NOTE Confidence: 0.98231053

00:10:53.470 --> 00:10:54.450
on the pathway.

NOTE Confidence: 0.98705566

00:10:55.005 --> 00:10:56.525
So it's an excellent resource

NOTE Confidence: 0.98705566

00:10:56.525 --> 00:10:57.805
that we have. So with

NOTE Confidence: 0.98705566

00:10:57.805 --> 00:10:58.845
that, would we actually be

NOTE Confidence: 0.98705566

00:10:58.845 --> 00:11:00.285
able to skip forward to,

NOTE Confidence: 0.98705566

00:11:00.605 --> 00:11:01.745
three more slides?

NOTE Confidence: 0.97975045

00:11:03.085 --> 00:11:04.045
Yes. This one right here.

NOTE Confidence: 0.97975045

00:11:04.045 --> 00:11:05.085
So this kind of gives

NOTE Confidence: 0.97975045

00:11:05.085 --> 00:11:06.925
you an impression of what

NOTE Confidence: 0.97975045

00:11:06.925 --> 00:11:08.625
these care pathways entail,

NOTE Confidence: 0.98330665

00:11:09.240 --> 00:11:10.700
essentially giving you

NOTE Confidence: 0.85344255

00:11:11.240 --> 00:11:13.559
guidance where what ages we

NOTE Confidence: 0.85344255

00:11:13.559 --> 00:11:14.620
may want to screen,

NOTE Confidence: 0.9947632

00:11:15.000 --> 00:11:15.500
what

NOTE Confidence: 0.87477916

00:11:16.200 --> 00:11:17.400
red flags to look out

NOTE Confidence: 0.87477916

00:11:17.400 --> 00:11:17.900
for.

NOTE Confidence: 0.9765063

00:11:19.240 --> 00:11:20.679
So it also provides lots

NOTE Confidence: 0.9765063

00:11:20.679 --> 00:11:22.360
of great patient education tools

NOTE Confidence: 0.9765063

00:11:22.360 --> 00:11:23.934
as well. So if we

NOTE Confidence: 0.9765063

00:11:23.934 --> 00:11:25.214
have access to this within

NOTE Confidence: 0.9765063

00:11:25.214 --> 00:11:26.255
our health care system, I

NOTE Confidence: 0.9765063

00:11:26.255 --> 00:11:26.755
would,

NOTE Confidence: 0.970488

00:11:27.214 --> 00:11:28.735
recommend our colleagues to please

NOTE Confidence: 0.970488

00:11:28.735 --> 00:11:29.695
take a look and and

NOTE Confidence: 0.970488

00:11:29.695 --> 00:11:30.355
give consideration.

NOTE Confidence: 0.8401516

00:11:31.054 --> 00:11:33.395
Okay? Thank you. So with

NOTE Confidence: 0.95564514

00:11:33.855 --> 00:11:35.455
that, we'll go on to

NOTE Confidence: 0.95564514

00:11:35.455 --> 00:11:37.135
our case based discussion of

NOTE Confidence: 0.95564514

00:11:37.135 --> 00:11:37.455
some,

NOTE Confidence: 0.9243185

00:11:38.290 --> 00:11:38.790
colorectal,

NOTE Confidence: 0.95395243

00:11:39.890 --> 00:11:40.870
cancer scenarios.

NOTE Confidence: 0.9854336

00:11:41.330 --> 00:11:42.770
And this first case will

NOTE Confidence: 0.9854336

00:11:42.770 --> 00:11:43.270
be,

NOTE Confidence: 0.9736168

00:11:44.130 --> 00:11:45.410
based off of a real

NOTE Confidence: 0.9736168

00:11:45.410 --> 00:11:47.410
patient with slight modifications for

NOTE Confidence: 0.9736168

00:11:47.410 --> 00:11:48.309
teaching purposes.

NOTE Confidence: 0.95504856

00:11:48.850 --> 00:11:50.130
So this one, I'll read

NOTE Confidence: 0.95504856

00:11:50.130 --> 00:11:51.634
it, Is a fifty seven

NOTE Confidence: 0.95504856

00:11:51.634 --> 00:11:52.675
year old male with a

NOTE Confidence: 0.95504856

00:11:52.675 --> 00:11:54.214
past medical history of hyperlipidemia.

NOTE Confidence: 0.93869543

00:11:54.675 --> 00:11:55.574
It's diet controlled,

NOTE Confidence: 0.9330079

00:11:55.954 --> 00:11:56.454
prediabetes,

NOTE Confidence: 0.9543918

00:11:56.915 --> 00:11:58.754
gout, skin tags, and external

NOTE Confidence: 0.9543918

00:11:58.754 --> 00:12:00.774
hemorrhoids, was presenting to establish

NOTE Confidence: 0.9543918

00:12:00.834 --> 00:12:02.774
care with an annual physical

NOTE Confidence: 0.9543918

00:12:02.834 --> 00:12:03.334
after

NOTE Confidence: 0.993001

00:12:03.714 --> 00:12:05.394
prior the prior PCP had

NOTE Confidence: 0.993001

00:12:05.394 --> 00:12:06.809
left the practice. It has

NOTE Confidence: 0.993001

00:12:06.809 --> 00:12:08.170
been over eighteen months since

NOTE Confidence: 0.993001

00:12:08.170 --> 00:12:09.070
the last examination.

NOTE Confidence: 0.987744

00:12:10.010 --> 00:12:11.530
On chart review, during prior

NOTE Confidence: 0.987744

00:12:11.530 --> 00:12:13.610
visit, patient had complained about

NOTE Confidence: 0.987744

00:12:13.610 --> 00:12:14.809
blood in the toilet bowl

NOTE Confidence: 0.987744

00:12:14.809 --> 00:12:16.030
and flares of hemorrhoids.

NOTE Confidence: 0.9991319

00:12:16.650 --> 00:12:18.030
During today's visit,

NOTE Confidence: 0.98752373

00:12:18.410 --> 00:12:20.650
the, this chief complaint still

NOTE Confidence: 0.98752373

00:12:20.650 --> 00:12:21.150
persists.

NOTE Confidence: 0.99629426

00:12:21.645 --> 00:12:23.165
Otherwise, patient is feeling at

NOTE Confidence: 0.99629426

00:12:23.165 --> 00:12:24.845
baseline and at relatively good

NOTE Confidence: 0.99629426

00:12:24.845 --> 00:12:25.345
health.

NOTE Confidence: 0.8498589

00:12:25.805 --> 00:12:26.305
Active,

NOTE Confidence: 0.9634776

00:12:26.685 --> 00:12:28.225
problems include hemorrhoids.

NOTE Confidence: 0.9732235

00:12:28.605 --> 00:12:30.365
Medication wise, nothing,

NOTE Confidence: 0.8928534

00:12:31.085 --> 00:12:31.825
too outstanding,

NOTE Confidence: 0.9594676

00:12:32.205 --> 00:12:34.845
colase, PRN for constipation, vitamin

NOTE Confidence: 0.9594676

00:12:34.845 --> 00:12:36.205
d, vitamin b twelve, and

NOTE Confidence: 0.9594676

00:12:36.205 --> 00:12:36.865
a multivitamin.

NOTE Confidence: 0.815516

00:12:38.149 --> 00:12:39.050
Social history,

NOTE Confidence: 0.9908222

00:12:39.509 --> 00:12:40.709
the patient is a former

NOTE Confidence: 0.9908222

00:12:40.709 --> 00:12:42.630
smoker, did quit around fourteen

NOTE Confidence: 0.9908222

00:12:42.630 --> 00:12:43.750
years ago, but does have

NOTE Confidence: 0.9908222

00:12:43.750 --> 00:12:45.050
a ten pack year history.

NOTE Confidence: 0.99551183

00:12:45.750 --> 00:12:48.069
Habits wise, social drinking, only

NOTE Confidence: 0.99551183

00:12:48.069 --> 00:12:49.110
about one to two shots

NOTE Confidence: 0.99551183

00:12:49.110 --> 00:12:50.410
of liquor per week.

NOTE Confidence: 0.99547863

00:12:50.774 --> 00:12:51.274
Occupation,

NOTE Confidence: 0.8419236

00:12:51.894 --> 00:12:54.154
no occupational hazard, really. Professional

NOTE Confidence: 0.8419236

00:12:54.214 --> 00:12:55.514
poker poker player.

NOTE Confidence: 0.99761945

00:12:55.975 --> 00:12:58.154
And, no known family history.

NOTE Confidence: 0.9915779

00:12:58.855 --> 00:12:59.834
Next slide, please.

NOTE Confidence: 0.9903968

00:13:00.454 --> 00:13:02.714
So the patient also patient

NOTE Confidence: 0.9371522

00:13:03.095 --> 00:13:04.615
only had a Cologuard done

NOTE Confidence: 0.9371522

00:13:04.615 --> 00:13:05.595
three years ago

NOTE Confidence: 0.95596987

00:13:05.960 --> 00:13:07.559
at this time and and

NOTE Confidence: 0.95596987

00:13:07.559 --> 00:13:08.600
also it was found to

NOTE Confidence: 0.95596987

00:13:08.600 --> 00:13:09.900
be negative at that time.

NOTE Confidence: 0.9400089

00:13:10.280 --> 00:13:11.960
However, patient has never had

NOTE Confidence: 0.9400089

00:13:11.960 --> 00:13:13.340
a colon formal colonoscopy.

NOTE Confidence: 0.98600656

00:13:14.280 --> 00:13:15.720
Patient had received a rectal

NOTE Confidence: 0.98600656

00:13:15.720 --> 00:13:17.160
exam during prior visit with

NOTE Confidence: 0.98600656

00:13:17.160 --> 00:13:17.820
the PCP.

NOTE Confidence: 0.95286787

00:13:18.280 --> 00:13:20.059
Stool guaiac was negative.

NOTE Confidence: 0.9404695

00:13:20.475 --> 00:13:21.995
Therefore, patient had declined a

NOTE Confidence: 0.9404695

00:13:21.995 --> 00:13:23.774
rectal exam on today's visit

NOTE Confidence: 0.9404695

00:13:23.915 --> 00:13:25.855
and wants hemorrhoid cream only.

NOTE Confidence: 0.9944435

00:13:26.554 --> 00:13:28.154
Patient is very apprehensive to

NOTE Confidence: 0.9944435

00:13:28.154 --> 00:13:28.654
colonoscopy

NOTE Confidence: 0.9397298

00:13:29.434 --> 00:13:30.415
and declines,

NOTE Confidence: 0.92890227

00:13:31.035 --> 00:13:33.515
and reluctant for, Cologuard again

NOTE Confidence: 0.92890227

00:13:33.515 --> 00:13:34.975
as it was already negative.

NOTE Confidence: 0.84482706

00:13:36.210 --> 00:13:37.410
So next slide, please.

NOTE Confidence: 0.9833808

00:13:38.130 --> 00:13:39.030
So I guess

NOTE Confidence: 0.9540191

00:13:39.410 --> 00:13:40.210
there's a few of these

NOTE Confidence: 0.9540191

00:13:40.210 --> 00:13:41.730
questions that we'll discuss with,

NOTE Confidence: 0.9540191

00:13:42.210 --> 00:13:43.510
our experts colleagues.

NOTE Confidence: 0.9487577

00:13:44.690 --> 00:13:45.809
This is a patient that

NOTE Confidence: 0.9487577

00:13:45.809 --> 00:13:47.080
I had actually encountered. So

NOTE Confidence: 0.9487577

00:13:47.330 --> 00:13:48.070
and we,

NOTE Confidence: 0.98403615

00:13:48.605 --> 00:13:50.704
as primary care clinicians, may

NOTE Confidence: 0.98403615

00:13:50.845 --> 00:13:52.605
have patients that are reluctant

NOTE Confidence: 0.98403615

00:13:52.605 --> 00:13:53.504
to screening,

NOTE Confidence: 0.9922949

00:13:54.365 --> 00:13:55.665
especially if

NOTE Confidence: 0.59866345

00:13:56.045 --> 00:13:56.545
one

NOTE Confidence: 0.97287184

00:13:57.004 --> 00:13:57.904
it was negative.

NOTE Confidence: 0.96711344

00:13:59.324 --> 00:14:00.524
You know, there's some health

NOTE Confidence: 0.96711344

00:14:00.524 --> 00:14:02.790
literacy concerns as well, I

NOTE Confidence: 0.96711344

00:14:02.790 --> 00:14:04.390
remember with this patient. So

NOTE Confidence: 0.96711344

00:14:04.390 --> 00:14:05.670
let's start answering these questions

NOTE Confidence: 0.96711344

00:14:05.670 --> 00:14:07.029
and get some, guidance from

NOTE Confidence: 0.96711344

00:14:07.029 --> 00:14:07.850
our, experts.

NOTE Confidence: 0.9695152

00:14:08.309 --> 00:14:09.750
So one question we ask

NOTE Confidence: 0.9695152

00:14:09.750 --> 00:14:10.890
as a primary care clinician,

NOTE Confidence: 0.9695152

00:14:11.029 --> 00:14:12.250
what are the next steps?

NOTE Confidence: 0.9695152

00:14:12.550 --> 00:14:14.070
So, Shavir, what would you

NOTE Confidence: 0.9695152

00:14:14.070 --> 00:14:14.809
say there?

NOTE Confidence: 0.9995349

00:14:15.264 --> 00:14:16.385
Sure. So I think the

NOTE Confidence: 0.9995349

00:14:16.385 --> 00:14:16.885
clear

NOTE Confidence: 0.9852296

00:14:17.345 --> 00:14:19.445
message here is when we

NOTE Confidence: 0.9852296

00:14:19.505 --> 00:14:20.865
have heard from our patient

NOTE Confidence: 0.9852296

00:14:20.865 --> 00:14:22.305
that there was a red

NOTE Confidence: 0.9852296

00:14:22.305 --> 00:14:23.204
blood per rectum,

NOTE Confidence: 0.9371387

00:14:23.505 --> 00:14:24.545
we are no longer in

NOTE Confidence: 0.9371387

00:14:24.545 --> 00:14:26.464
the screening realm. And so

NOTE Confidence: 0.9371387

00:14:26.464 --> 00:14:27.824
forget about doing more fit

NOTE Confidence: 0.9371387

00:14:27.824 --> 00:14:29.260
test or other things. And

NOTE Confidence: 0.9371387

00:14:29.260 --> 00:14:30.380
I've just seen a patient

NOTE Confidence: 0.9371387

00:14:30.380 --> 00:14:32.320
today who's has been describing

NOTE Confidence: 0.9371387

00:14:32.380 --> 00:14:33.500
just today in my clinic,

NOTE Confidence: 0.9371387

00:14:33.500 --> 00:14:35.120
which is describing brachycardia

NOTE Confidence: 0.9454046

00:14:35.500 --> 00:14:37.020
for a year, and the

NOTE Confidence: 0.9454046

00:14:37.020 --> 00:14:38.460
PCP did order a,

NOTE Confidence: 0.95578176

00:14:39.180 --> 00:14:40.635
fit test. And it's like,

NOTE Confidence: 0.9685353

00:14:41.195 --> 00:14:42.875
what's the purpose? We have

NOTE Confidence: 0.9685353

00:14:42.875 --> 00:14:44.315
gross blood. We then need

NOTE Confidence: 0.9685353

00:14:44.315 --> 00:14:45.355
to look for a cold

NOTE Confidence: 0.9685353

00:14:45.355 --> 00:14:46.795
blood. We already know. So

NOTE Confidence: 0.9685353

00:14:46.795 --> 00:14:47.915
that takes us to a

NOTE Confidence: 0.9685353

00:14:47.915 --> 00:14:49.275
different level that takes us

NOTE Confidence: 0.9685353

00:14:49.275 --> 00:14:51.195
to a diagnostic level. So

NOTE Confidence: 0.9685353

00:14:51.195 --> 00:14:52.635
forget about anything that applies

NOTE Confidence: 0.9685353

00:14:52.635 --> 00:14:54.075
to screening that's no longer

NOTE Confidence: 0.9685353

00:14:54.075 --> 00:14:55.695
applied to this patient, basically.

NOTE Confidence: 0.93020815

00:14:56.769 --> 00:14:58.270
In terms of the, what

NOTE Confidence: 0.93020815

00:14:58.270 --> 00:14:58.730
the,

NOTE Confidence: 0.944677

00:14:59.649 --> 00:15:01.010
if it was appropriate for

NOTE Confidence: 0.944677

00:15:01.010 --> 00:15:02.050
the patient to be screened

NOTE Confidence: 0.944677

00:15:02.050 --> 00:15:03.970
with Cologuard, that was three

NOTE Confidence: 0.944677

00:15:03.970 --> 00:15:05.010
years ago. So he would

NOTE Confidence: 0.944677

00:15:05.010 --> 00:15:05.670
be for

NOTE Confidence: 0.9527021

00:15:06.130 --> 00:15:07.649
do for next one because

NOTE Confidence: 0.9527021

00:15:07.649 --> 00:15:08.769
it's been approved after three

NOTE Confidence: 0.9527021

00:15:08.769 --> 00:15:09.824
years. So at that time,

NOTE Confidence: 0.9527021

00:15:09.824 --> 00:15:11.345
the patient had no family

NOTE Confidence: 0.9527021

00:15:11.345 --> 00:15:12.885
history of colorectal cancer.

NOTE Confidence: 0.96757895

00:15:13.665 --> 00:15:15.584
And, therefore, if there's no

NOTE Confidence: 0.96757895

00:15:15.584 --> 00:15:17.445
family history of colorectal cancer,

NOTE Confidence: 0.96757895

00:15:17.505 --> 00:15:19.204
all these options, all guidelines

NOTE Confidence: 0.96757895

00:15:19.345 --> 00:15:20.305
seem to agree that all

NOTE Confidence: 0.96757895

00:15:20.305 --> 00:15:21.745
these options are reasonable including

NOTE Confidence: 0.96757895

00:15:21.745 --> 00:15:23.605
the cologuard every three years.

NOTE Confidence: 0.96757895

00:15:23.665 --> 00:15:24.165
Now,

NOTE Confidence: 0.9571651

00:15:25.140 --> 00:15:26.440
the patient is a smoker,

NOTE Confidence: 0.9571651

00:15:26.500 --> 00:15:28.120
and and he's a professional,

NOTE Confidence: 0.95250744

00:15:29.140 --> 00:15:30.839
player, so he may actually

NOTE Confidence: 0.95250744

00:15:30.980 --> 00:15:32.180
smoke them more than what

NOTE Confidence: 0.95250744

00:15:32.180 --> 00:15:33.240
we think, actually.

NOTE Confidence: 0.95690936

00:15:33.779 --> 00:15:35.540
So and that increases risk.

NOTE Confidence: 0.95690936

00:15:35.540 --> 00:15:36.040
Clearly,

NOTE Confidence: 0.96647197

00:15:36.444 --> 00:15:38.125
alcohol deaths, obesity, lack of

NOTE Confidence: 0.96647197

00:15:38.125 --> 00:15:40.125
physical exercise, those do increase

NOTE Confidence: 0.96647197

00:15:40.125 --> 00:15:41.964
risk, and and, and we

NOTE Confidence: 0.96647197

00:15:41.964 --> 00:15:43.404
may have some here. The

NOTE Confidence: 0.96647197

00:15:43.404 --> 00:15:44.524
issue, though, is that,

NOTE Confidence: 0.9909713

00:15:45.165 --> 00:15:46.444
in the guidelines, we really

NOTE Confidence: 0.9909713

00:15:46.444 --> 00:15:48.444
have not separated that increased

NOTE Confidence: 0.9909713

00:15:48.444 --> 00:15:50.589
risk from family history risk.

NOTE Confidence: 0.9909713

00:15:50.589 --> 00:15:52.029
So family history calls for

NOTE Confidence: 0.9909713

00:15:52.029 --> 00:15:52.529
colonoscopy.

NOTE Confidence: 0.9322271

00:15:54.270 --> 00:15:55.709
No no family history or

NOTE Confidence: 0.9322271

00:15:55.709 --> 00:15:56.529
other factors,

NOTE Confidence: 0.9690225

00:15:56.910 --> 00:15:58.350
would call for either one

NOTE Confidence: 0.9690225

00:15:58.350 --> 00:15:59.970
of these options, but,

NOTE Confidence: 0.96961963

00:16:00.430 --> 00:16:01.470
I think in the future,

NOTE Confidence: 0.96961963

00:16:01.470 --> 00:16:02.350
we may have to think

NOTE Confidence: 0.96961963

00:16:02.350 --> 00:16:04.190
about how, these factors that

NOTE Confidence: 0.96961963

00:16:04.190 --> 00:16:05.685
we're mentioning here do change

NOTE Confidence: 0.96961963

00:16:05.685 --> 00:16:06.405
the risk and how do

NOTE Confidence: 0.96961963

00:16:06.405 --> 00:16:07.925
we incorporate them in our,

NOTE Confidence: 0.9948469

00:16:08.245 --> 00:16:09.765
decision making about what we

NOTE Confidence: 0.9948469

00:16:09.765 --> 00:16:10.265
suggest,

NOTE Confidence: 0.97618127

00:16:11.125 --> 00:16:12.485
potentially for screening. But, again,

NOTE Confidence: 0.97618127

00:16:12.485 --> 00:16:13.685
we are beyond screening at

NOTE Confidence: 0.97618127

00:16:13.685 --> 00:16:14.645
this point, but we're just

NOTE Confidence: 0.97618127

00:16:14.645 --> 00:16:15.525
talking about the,

NOTE Confidence: 0.8677615

00:16:16.325 --> 00:16:16.805
and,

NOTE Confidence: 0.96917546

00:16:17.740 --> 00:16:19.280
the treatment of the hemorrhoid.

NOTE Confidence: 0.96917546

00:16:19.420 --> 00:16:20.300
At this point, what we

NOTE Confidence: 0.96917546

00:16:20.300 --> 00:16:21.340
really have to do is

NOTE Confidence: 0.96917546

00:16:21.340 --> 00:16:22.460
just look what's going on.

NOTE Confidence: 0.96917546

00:16:22.460 --> 00:16:23.660
And if there are hemorrhoids,

NOTE Confidence: 0.96917546

00:16:23.660 --> 00:16:24.780
we'll treat the hemorrhoids, but

NOTE Confidence: 0.96917546

00:16:24.780 --> 00:16:25.660
first we need to figure

NOTE Confidence: 0.96917546

00:16:25.660 --> 00:16:26.720
out what's going on.

NOTE Confidence: 0.9816714

00:16:27.260 --> 00:16:28.720
Absolutely. And I I love

NOTE Confidence: 0.9816714

00:16:28.780 --> 00:16:29.900
everything that you said. And

NOTE Confidence: 0.9816714

00:16:29.900 --> 00:16:30.860
one of the most take

NOTE Confidence: 0.9816714

00:16:30.860 --> 00:16:32.255
home points there is we've

NOTE Confidence: 0.9816714

00:16:32.255 --> 00:16:33.615
gone from the realm of

NOTE Confidence: 0.9816714

00:16:33.615 --> 00:16:35.295
screening to diagnostic now, and

NOTE Confidence: 0.9816714

00:16:35.295 --> 00:16:36.195
being able to,

NOTE Confidence: 0.94543266

00:16:37.055 --> 00:16:38.355
communicate that, especially

NOTE Confidence: 0.97883767

00:16:39.055 --> 00:16:41.055
with, kindness and grace, especially

NOTE Confidence: 0.97883767

00:16:41.055 --> 00:16:42.015
to a patient that may

NOTE Confidence: 0.97883767

00:16:42.015 --> 00:16:43.295
be a little more reserved

NOTE Confidence: 0.97883767

00:16:43.295 --> 00:16:44.435
and hesitant to,

NOTE Confidence: 0.9829691

00:16:45.135 --> 00:16:46.335
any type of procedure in

NOTE Confidence: 0.9829691

00:16:46.335 --> 00:16:47.710
the first place is very

NOTE Confidence: 0.9829691

00:16:47.710 --> 00:16:49.390
important. So I love everything

NOTE Confidence: 0.9829691

00:16:49.390 --> 00:16:50.830
that she says there. Thank

NOTE Confidence: 0.9829691

00:16:50.830 --> 00:16:51.330
you.

NOTE Confidence: 0.9758939

00:16:51.790 --> 00:16:52.910
And then with that, would

NOTE Confidence: 0.9758939

00:16:52.910 --> 00:16:53.470
we be able to go

NOTE Confidence: 0.9758939

00:16:53.470 --> 00:16:54.590
to the next slide, please?

NOTE Confidence: 0.9758939

00:16:54.590 --> 00:16:56.350
Thank you. And so what

NOTE Confidence: 0.9758939

00:16:56.350 --> 00:16:58.350
happened next? This patient was

NOTE Confidence: 0.9758939

00:16:58.350 --> 00:17:00.210
referred to colorectal surgeon.

NOTE Confidence: 0.9900382

00:17:00.575 --> 00:17:01.855
At this visit, the patient

NOTE Confidence: 0.9900382

00:17:01.855 --> 00:17:03.455
had a rectal exam, which

NOTE Confidence: 0.9900382

00:17:03.455 --> 00:17:05.855
demonstrated an ulcerating rectal mass

NOTE Confidence: 0.9900382

00:17:05.855 --> 00:17:07.455
that extended from the dentate

NOTE Confidence: 0.9900382

00:17:07.455 --> 00:17:09.295
line to eight centimeters above

NOTE Confidence: 0.9900382

00:17:09.295 --> 00:17:10.355
the anal verge.

NOTE Confidence: 0.99919444

00:17:11.055 --> 00:17:12.815
Arrangements were made immediately to

NOTE Confidence: 0.99919444

00:17:12.815 --> 00:17:13.855
have the patient have an

NOTE Confidence: 0.99919444

00:17:13.855 --> 00:17:14.675
urgent colonoscopy.

NOTE Confidence: 0.99192125

00:17:15.650 --> 00:17:17.570
As expected, the biopsy was

NOTE Confidence: 0.99192125

00:17:17.570 --> 00:17:18.789
consistent with,

NOTE Confidence: 0.9986558

00:17:19.090 --> 00:17:20.230
invasive adenocarcinoma.

NOTE Confidence: 0.9509786

00:17:21.650 --> 00:17:22.770
And with that, we'd like

NOTE Confidence: 0.9509786

00:17:22.770 --> 00:17:23.250
to set,

NOTE Confidence: 0.9931669

00:17:23.809 --> 00:17:25.010
give this next slide over

NOTE Confidence: 0.9931669

00:17:25.010 --> 00:17:26.150
to Tejal, please.

NOTE Confidence: 0.9797003

00:17:26.770 --> 00:17:28.424
Thank you so much. So

NOTE Confidence: 0.9797003

00:17:28.424 --> 00:17:29.625
I know this talk is

NOTE Confidence: 0.9797003

00:17:29.625 --> 00:17:32.605
focusing more on colorectal cancer

NOTE Confidence: 0.98813045

00:17:32.984 --> 00:17:34.744
screening and prevention, but I

NOTE Confidence: 0.98813045

00:17:34.744 --> 00:17:36.205
thought it would be helpful

NOTE Confidence: 0.98813045

00:17:36.264 --> 00:17:37.965
to do a big picture

NOTE Confidence: 0.98813045

00:17:38.024 --> 00:17:39.804
overview of what happens

NOTE Confidence: 0.99786437

00:17:40.184 --> 00:17:41.644
when that cancer diagnosis

NOTE Confidence: 0.9783125

00:17:42.105 --> 00:17:42.605
confirmed.

NOTE Confidence: 0.96865845

00:17:43.470 --> 00:17:45.150
So I the first thing

NOTE Confidence: 0.96865845

00:17:45.150 --> 00:17:46.429
that we always want to

NOTE Confidence: 0.96865845

00:17:46.429 --> 00:17:47.790
know is what is the

NOTE Confidence: 0.96865845

00:17:47.790 --> 00:17:49.170
stage of the cancer?

NOTE Confidence: 0.9996417

00:17:49.950 --> 00:17:52.210
The staging of colorectal cancer

NOTE Confidence: 0.9621276

00:17:52.670 --> 00:17:55.490
is done by the American

NOTE Confidence: 0.9621276

00:17:55.710 --> 00:17:57.785
Joint Committee on Cancer, the

NOTE Confidence: 0.9621276

00:17:57.785 --> 00:17:58.285
AJCC

NOTE Confidence: 0.9806579

00:17:58.825 --> 00:17:59.805
based recommendations,

NOTE Confidence: 0.99704885

00:18:00.744 --> 00:18:02.525
which is on the TNM

NOTE Confidence: 0.97493875

00:18:03.225 --> 00:18:04.285
staging system.

NOTE Confidence: 0.97906274

00:18:04.905 --> 00:18:07.005
The T stands for tumor

NOTE Confidence: 0.97906274

00:18:07.065 --> 00:18:08.765
or the depth of invasion

NOTE Confidence: 0.97906274

00:18:09.065 --> 00:18:10.665
into the wall of the

NOTE Confidence: 0.97906274

00:18:10.665 --> 00:18:11.885
colon or the rectum.

NOTE Confidence: 0.9524212

00:18:12.590 --> 00:18:14.670
N stands for lymph nodes

NOTE Confidence: 0.9524212

00:18:14.670 --> 00:18:15.950
or the number of lymph

NOTE Confidence: 0.9524212

00:18:15.950 --> 00:18:18.030
nodes that are involved local

NOTE Confidence: 0.9524212

00:18:18.030 --> 00:18:18.530
regionally.

NOTE Confidence: 0.93594587

00:18:19.150 --> 00:18:21.330
And M stands for metastasis.

NOTE Confidence: 0.9671313

00:18:22.190 --> 00:18:23.470
Whether or not there's any

NOTE Confidence: 0.9671313

00:18:23.470 --> 00:18:25.310
distant sites of disease involvement,

NOTE Confidence: 0.9671313

00:18:25.310 --> 00:18:26.750
for example, in the lung

NOTE Confidence: 0.9671313

00:18:26.750 --> 00:18:27.570
or the liver.

NOTE Confidence: 0.949183

00:18:28.174 --> 00:18:30.174
And by combining three these

NOTE Confidence: 0.949183

00:18:30.174 --> 00:18:31.775
three components, we come up

NOTE Confidence: 0.949183

00:18:31.775 --> 00:18:33.375
with a stage from one

NOTE Confidence: 0.949183

00:18:33.375 --> 00:18:34.195
to four,

NOTE Confidence: 0.93406856

00:18:34.494 --> 00:18:36.195
one being the the lowest

NOTE Confidence: 0.93406856

00:18:36.255 --> 00:18:38.015
stage and four being the

NOTE Confidence: 0.93406856

00:18:38.015 --> 00:18:40.275
most aggressive, the highest stage.

NOTE Confidence: 0.99658704

00:18:40.770 --> 00:18:42.930
Staging not only helps us

NOTE Confidence: 0.99658704

00:18:42.930 --> 00:18:44.530
determine how aggressive the cancer

NOTE Confidence: 0.99658704

00:18:44.530 --> 00:18:46.369
is, but it really does

NOTE Confidence: 0.99658704

00:18:46.369 --> 00:18:48.550
guide what our treatment options

NOTE Confidence: 0.99658704

00:18:48.690 --> 00:18:49.190
are.

NOTE Confidence: 0.9727249

00:18:49.730 --> 00:18:51.670
Now I should say that,

NOTE Confidence: 0.99370056

00:18:52.130 --> 00:18:53.030
this is our

NOTE Confidence: 0.951217

00:18:53.535 --> 00:18:56.015
staging system, as of, June

NOTE Confidence: 0.951217

00:18:56.015 --> 00:18:56.515
third,

NOTE Confidence: 0.9859852

00:18:57.055 --> 00:18:58.575
of twenty twenty five. But

NOTE Confidence: 0.9859852

00:18:58.575 --> 00:18:59.875
just this past weekend,

NOTE Confidence: 0.98240584

00:19:00.494 --> 00:19:02.195
we had our major oncology

NOTE Confidence: 0.98240584

00:19:02.415 --> 00:19:02.915
conference,

NOTE Confidence: 0.99968535

00:19:03.935 --> 00:19:05.855
and there are some new

NOTE Confidence: 0.99968535

00:19:05.855 --> 00:19:06.994
proposed changes

NOTE Confidence: 0.9220202

00:19:07.500 --> 00:19:08.960
to this staging system,

NOTE Confidence: 0.96617

00:19:09.260 --> 00:19:11.260
which might incorporate other elements

NOTE Confidence: 0.96617

00:19:11.260 --> 00:19:11.660
such as,

NOTE Confidence: 0.99091154

00:19:12.380 --> 00:19:13.840
tumor deposits and

NOTE Confidence: 0.99552613

00:19:14.140 --> 00:19:15.900
other factors of the biology,

NOTE Confidence: 0.99552613

00:19:15.900 --> 00:19:17.420
which may help us better

NOTE Confidence: 0.99552613

00:19:17.420 --> 00:19:19.340
predict how our patients will

NOTE Confidence: 0.99552613

00:19:19.340 --> 00:19:20.744
do based on their stage.

NOTE Confidence: 0.99552613

00:19:20.744 --> 00:19:21.865
But at this moment in

NOTE Confidence: 0.99552613

00:19:21.865 --> 00:19:22.905
time, this is what we

NOTE Confidence: 0.99552613

00:19:22.905 --> 00:19:23.965
use for our staging.

NOTE Confidence: 0.9969845

00:19:25.545 --> 00:19:27.645
Now when someone has that

NOTE Confidence: 0.9969845

00:19:27.705 --> 00:19:28.205
confirmation

NOTE Confidence: 0.9999109

00:19:28.585 --> 00:19:29.645
of cancer

NOTE Confidence: 0.99972576

00:19:29.945 --> 00:19:30.845
on the biopsy,

NOTE Confidence: 0.9802433

00:19:31.545 --> 00:19:32.265
there are a few more

NOTE Confidence: 0.9802433

00:19:32.265 --> 00:19:33.785
pieces of information that we

NOTE Confidence: 0.9802433

00:19:33.785 --> 00:19:34.285
need

NOTE Confidence: 0.99971837

00:19:34.919 --> 00:19:36.200
to determine all of that

NOTE Confidence: 0.99971837

00:19:36.200 --> 00:19:37.100
staging information

NOTE Confidence: 0.97287863

00:19:37.879 --> 00:19:39.080
and also to help us

NOTE Confidence: 0.97287863

00:19:39.080 --> 00:19:40.279
guide what the next steps

NOTE Confidence: 0.97287863

00:19:40.279 --> 00:19:40.779
are.

NOTE Confidence: 0.9654022

00:19:41.320 --> 00:19:42.299
From the colonoscopy,

NOTE Confidence: 0.9454318

00:19:43.240 --> 00:19:44.859
that bio but that biopsy

NOTE Confidence: 0.9454318

00:19:44.919 --> 00:19:46.679
will confirm the pathology, but

NOTE Confidence: 0.9454318

00:19:46.679 --> 00:19:48.940
we actually send more testing

NOTE Confidence: 0.9996063

00:19:49.555 --> 00:19:50.535
from that pathology

NOTE Confidence: 0.9967841

00:19:51.475 --> 00:19:52.375
to characterize

NOTE Confidence: 0.9806629

00:19:52.675 --> 00:19:54.455
something that we call mismatch

NOTE Confidence: 0.9806629

00:19:54.595 --> 00:19:55.655
repair proteins.

NOTE Confidence: 0.96499527

00:19:56.195 --> 00:19:57.315
And I put an asterisk

NOTE Confidence: 0.96499527

00:19:57.315 --> 00:19:58.675
there because I wanna come

NOTE Confidence: 0.96499527

00:19:58.675 --> 00:19:59.475
back to that. I'll put

NOTE Confidence: 0.96499527

00:19:59.475 --> 00:20:00.035
a pin in it and

NOTE Confidence: 0.96499527

00:20:00.035 --> 00:20:01.255
I'll come back to that.

NOTE Confidence: 0.96499527

00:20:01.395 --> 00:20:02.185
But that can actually have

NOTE Confidence: 0.96499527

00:20:02.185 --> 00:20:03.890
a lot of prognostic and

NOTE Confidence: 0.96499527

00:20:03.950 --> 00:20:06.290
treatment implications for our patients.

NOTE Confidence: 0.9948863

00:20:06.910 --> 00:20:08.210
In addition to the colonoscopy,

NOTE Confidence: 0.9638066

00:20:08.670 --> 00:20:10.830
we get CT scans of

NOTE Confidence: 0.9638066

00:20:10.830 --> 00:20:12.190
the chest, the abdomen and

NOTE Confidence: 0.9638066

00:20:12.190 --> 00:20:13.710
the pelvis to evaluate for

NOTE Confidence: 0.9638066

00:20:13.710 --> 00:20:14.609
distant disease.

NOTE Confidence: 0.9636687

00:20:15.165 --> 00:20:16.925
And we get labs including

NOTE Confidence: 0.9636687

00:20:16.925 --> 00:20:19.244
not only your, basic labs,

NOTE Confidence: 0.9636687

00:20:19.244 --> 00:20:20.605
which is the complete blood

NOTE Confidence: 0.9636687

00:20:20.605 --> 00:20:22.445
count and the comprehensive metabolic

NOTE Confidence: 0.9636687

00:20:22.445 --> 00:20:22.945
panel,

NOTE Confidence: 0.9966643

00:20:23.325 --> 00:20:24.685
but we also will send

NOTE Confidence: 0.9966643

00:20:24.685 --> 00:20:26.145
what we call a CEA,

NOTE Confidence: 0.9966643

00:20:26.365 --> 00:20:27.985
which is a tumor marker

NOTE Confidence: 0.97873163

00:20:28.390 --> 00:20:30.570
or, also known as, carcinoembryonic

NOTE Confidence: 0.9922938

00:20:31.190 --> 00:20:32.470
antigen, which is a protein

NOTE Confidence: 0.9922938

00:20:32.470 --> 00:20:33.669
that the cancer cells make

NOTE Confidence: 0.9922938

00:20:33.669 --> 00:20:34.710
and give us a sense

NOTE Confidence: 0.9922938

00:20:34.710 --> 00:20:36.150
of what the activity might

NOTE Confidence: 0.9922938

00:20:36.150 --> 00:20:37.369
be from the cancer.

NOTE Confidence: 0.9660136

00:20:38.309 --> 00:20:39.450
Now for

NOTE Confidence: 0.9468457

00:20:39.910 --> 00:20:41.690
rectal cancer specifically,

NOTE Confidence: 0.9998089

00:20:42.565 --> 00:20:44.005
we also want to get

NOTE Confidence: 0.9998089

00:20:44.005 --> 00:20:45.865
an MRI of the pelvis.

NOTE Confidence: 0.99680483

00:20:46.645 --> 00:20:48.165
So if you think that

NOTE Confidence: 0.99680483

00:20:48.165 --> 00:20:49.205
the patient just has a

NOTE Confidence: 0.99680483

00:20:49.205 --> 00:20:50.505
colon cancer, meaning,

NOTE Confidence: 0.98046625

00:20:50.885 --> 00:20:52.665
you know, from the cecum

NOTE Confidence: 0.98046625

00:20:52.725 --> 00:20:54.425
through the sigmoid or rectosigmoid,

NOTE Confidence: 0.9793776

00:20:55.125 --> 00:20:55.625
colonoscopy,

NOTE Confidence: 0.9541083

00:20:56.165 --> 00:20:57.660
CT scans in the labs

NOTE Confidence: 0.9541083

00:20:57.820 --> 00:20:58.560
should be sufficient.

NOTE Confidence: 0.98844814

00:20:59.660 --> 00:21:00.619
But this is a key

NOTE Confidence: 0.98844814

00:21:00.619 --> 00:21:03.760
point. We treat rectal cancer

NOTE Confidence: 0.9741379

00:21:04.140 --> 00:21:05.660
differently than how we treat

NOTE Confidence: 0.9741379

00:21:05.660 --> 00:21:07.180
colon cancer, and we need

NOTE Confidence: 0.9741379

00:21:07.180 --> 00:21:08.619
more information. So these were

NOTE Confidence: 0.9741379

00:21:08.780 --> 00:21:09.740
for these patients, we get

NOTE Confidence: 0.9741379

00:21:09.740 --> 00:21:11.020
the MRI, and I'll circle

NOTE Confidence: 0.9741379

00:21:11.020 --> 00:21:11.925
back to that too.

NOTE Confidence: 0.9984449

00:21:12.405 --> 00:21:13.205
I just wanna make a

NOTE Confidence: 0.9984449

00:21:13.205 --> 00:21:14.665
note that we don't typically

NOTE Confidence: 0.9811367

00:21:14.965 --> 00:21:17.045
or routinely get PET scans

NOTE Confidence: 0.9811367

00:21:17.045 --> 00:21:18.885
on our patients unless there's

NOTE Confidence: 0.9811367

00:21:18.885 --> 00:21:20.565
something concerning from our CT

NOTE Confidence: 0.9811367

00:21:20.565 --> 00:21:21.685
scan that would prompt us

NOTE Confidence: 0.9811367

00:21:21.685 --> 00:21:22.585
to do so.

NOTE Confidence: 0.98560816

00:21:22.965 --> 00:21:24.005
From getting all of this

NOTE Confidence: 0.98560816

00:21:24.005 --> 00:21:24.505
information,

NOTE Confidence: 0.9883103

00:21:25.365 --> 00:21:27.285
we wanna answer two main

NOTE Confidence: 0.9883103

00:21:27.285 --> 00:21:27.660
questions.

NOTE Confidence: 0.993002

00:21:28.460 --> 00:21:30.060
Number one, is this a

NOTE Confidence: 0.993002

00:21:30.060 --> 00:21:30.560
localized

NOTE Confidence: 0.9484334

00:21:30.940 --> 00:21:32.640
disease, or is it metastatic?

NOTE Confidence: 0.98311806

00:21:33.340 --> 00:21:34.859
And number two, is it

NOTE Confidence: 0.98311806

00:21:34.859 --> 00:21:36.320
colon, or is it rectal?

NOTE Confidence: 0.9779612

00:21:36.940 --> 00:21:38.460
We'll return to our case

NOTE Confidence: 0.9779612

00:21:38.460 --> 00:21:39.260
now to get some of

NOTE Confidence: 0.9779612

00:21:39.260 --> 00:21:40.400
those pieces of information,

NOTE Confidence: 0.9871762

00:21:40.700 --> 00:21:42.619
and then we'll circle back

NOTE Confidence: 0.9871762

00:21:42.619 --> 00:21:44.535
to what happens next. Next.

NOTE Confidence: 0.9871762

00:21:44.675 --> 00:21:46.195
Excellent. And I really love

NOTE Confidence: 0.9871762

00:21:46.195 --> 00:21:47.655
your, two main questions,

NOTE Confidence: 0.9753094

00:21:48.195 --> 00:21:49.234
because that's really the two

NOTE Confidence: 0.9753094

00:21:49.234 --> 00:21:50.275
main questions that a a

NOTE Confidence: 0.9753094

00:21:50.275 --> 00:21:51.395
lot of our patients ask

NOTE Confidence: 0.9753094

00:21:51.395 --> 00:21:52.055
us. Right?

NOTE Confidence: 0.9926699

00:21:52.595 --> 00:21:53.815
Most patients know,

NOTE Confidence: 0.94493014

00:21:54.195 --> 00:21:56.355
the term terminology metastatic now,

NOTE Confidence: 0.94493014

00:21:56.355 --> 00:21:57.395
so they really want to

NOTE Confidence: 0.94493014

00:21:57.395 --> 00:21:58.515
know, is it local or

NOTE Confidence: 0.94493014

00:21:58.515 --> 00:21:59.040
is it

NOTE Confidence: 0.9531898

00:21:59.440 --> 00:22:00.660
metastatic versus,

NOTE Confidence: 0.9244194

00:22:01.119 --> 00:22:02.400
the clinical pearl that you

NOTE Confidence: 0.9244194

00:22:02.400 --> 00:22:04.000
pointed towards, the colon versus

NOTE Confidence: 0.9244194

00:22:04.000 --> 00:22:05.760
rectal from our clinical perspective?

NOTE Confidence: 0.9244194

00:22:05.760 --> 00:22:06.880
That's important for us to

NOTE Confidence: 0.9244194

00:22:06.880 --> 00:22:07.700
know as well.

NOTE Confidence: 0.97471243

00:22:08.240 --> 00:22:09.359
So going back to our

NOTE Confidence: 0.97471243

00:22:09.359 --> 00:22:10.100
case again,

NOTE Confidence: 0.94633114

00:22:10.880 --> 00:22:11.619
the staging,

NOTE Confidence: 0.92996985

00:22:12.160 --> 00:22:12.960
CAT scan,

NOTE Confidence: 0.96347713

00:22:13.440 --> 00:22:14.744
showed no evidence of of

NOTE Confidence: 0.96347713

00:22:14.744 --> 00:22:16.925
distant metastasis for this patient.

NOTE Confidence: 0.97967654

00:22:17.545 --> 00:22:18.445
Rectal MRI,

NOTE Confidence: 0.99212575

00:22:19.225 --> 00:22:21.225
suggested tumor was t three

NOTE Confidence: 0.99212575

00:22:21.225 --> 00:22:22.984
or possibly t four rectal

NOTE Confidence: 0.99212575

00:22:22.984 --> 00:22:23.484
tumor

NOTE Confidence: 0.92463404

00:22:23.785 --> 00:22:24.845
with a suspicious

NOTE Confidence: 0.9795181

00:22:25.385 --> 00:22:25.885
mesorectal

NOTE Confidence: 0.99697584

00:22:26.345 --> 00:22:27.085
lymph node.

NOTE Confidence: 0.99040437

00:22:27.520 --> 00:22:29.280
The tumor also appeared to

NOTE Confidence: 0.99040437

00:22:29.280 --> 00:22:31.040
be extending to the anal

NOTE Confidence: 0.99040437

00:22:31.040 --> 00:22:31.540
sphincter.

NOTE Confidence: 0.9043311

00:22:31.920 --> 00:22:33.600
Clinically, he was staged at

NOTE Confidence: 0.9043311

00:22:33.600 --> 00:22:36.180
t three four, and one.

NOTE Confidence: 0.93029976

00:22:36.640 --> 00:22:38.900
PET scan showed, no distant

NOTE Confidence: 0.93029976

00:22:38.960 --> 00:22:39.460
metastasis.

NOTE Confidence: 0.9219856

00:22:40.320 --> 00:22:41.380
Next slide, please.

NOTE Confidence: 0.97608507

00:22:42.234 --> 00:22:44.234
Thank you. Yeah. So before

NOTE Confidence: 0.97608507

00:22:44.234 --> 00:22:44.955
I go on to the

NOTE Confidence: 0.97608507

00:22:44.955 --> 00:22:45.994
next slide, I'll I'll just

NOTE Confidence: 0.97608507

00:22:45.994 --> 00:22:47.294
make a note here. So,

NOTE Confidence: 0.96208423

00:22:47.914 --> 00:22:49.514
as you as I had

NOTE Confidence: 0.96208423

00:22:49.514 --> 00:22:50.554
mentioned, so we looked at

NOTE Confidence: 0.96208423

00:22:50.554 --> 00:22:51.755
the t stage and the

NOTE Confidence: 0.96208423

00:22:51.755 --> 00:22:52.894
n stage here.

NOTE Confidence: 0.9976111

00:22:53.755 --> 00:22:55.355
So with the t stage,

NOTE Confidence: 0.9976111

00:22:55.355 --> 00:22:56.490
it goes from one to

NOTE Confidence: 0.9976111

00:22:56.570 --> 00:22:57.690
four in terms of the

NOTE Confidence: 0.9976111

00:22:57.690 --> 00:22:59.309
depth of invasion. So

NOTE Confidence: 0.9874262

00:22:59.609 --> 00:23:01.710
having both the deeper invasion

NOTE Confidence: 0.9874262

00:23:01.850 --> 00:23:03.130
as as well as nodal

NOTE Confidence: 0.9874262

00:23:03.130 --> 00:23:03.630
involvement

NOTE Confidence: 0.99616754

00:23:04.410 --> 00:23:05.609
means that he's what we

NOTE Confidence: 0.99616754

00:23:05.609 --> 00:23:07.609
call locally advanced. There's no

NOTE Confidence: 0.99616754

00:23:07.609 --> 00:23:09.475
distant disease, but it's also

NOTE Confidence: 0.99616754

00:23:09.475 --> 00:23:11.635
not necessarily the smallest tumor

NOTE Confidence: 0.99616754

00:23:11.635 --> 00:23:12.674
either. He's kind of in

NOTE Confidence: 0.99616754

00:23:12.674 --> 00:23:13.975
that middle road.

NOTE Confidence: 0.99836224

00:23:15.315 --> 00:23:15.815
So

NOTE Confidence: 0.9578306

00:23:16.195 --> 00:23:17.794
in terms of his next

NOTE Confidence: 0.9578306

00:23:17.794 --> 00:23:18.855
steps in treatment,

NOTE Confidence: 0.9982015

00:23:19.875 --> 00:23:21.315
as I mentioned, we treat

NOTE Confidence: 0.9982015

00:23:21.315 --> 00:23:22.914
colon cancer different than how

NOTE Confidence: 0.9982015

00:23:22.914 --> 00:23:24.695
we treat rectal cancer.

NOTE Confidence: 0.9918948

00:23:25.130 --> 00:23:26.330
And to give you a

NOTE Confidence: 0.9918948

00:23:26.330 --> 00:23:28.030
big picture overview,

NOTE Confidence: 0.98580253

00:23:28.810 --> 00:23:30.430
when someone has a nonmetastatic

NOTE Confidence: 0.98187476

00:23:30.810 --> 00:23:33.050
colon cancer, typically, the standard

NOTE Confidence: 0.98187476

00:23:33.050 --> 00:23:34.430
of care is to

NOTE Confidence: 0.9527896

00:23:34.730 --> 00:23:36.270
take them for surgical resection

NOTE Confidence: 0.9527896

00:23:36.330 --> 00:23:38.510
upfront. And then depending on

NOTE Confidence: 0.9527896

00:23:38.804 --> 00:23:41.125
the final stage and the

NOTE Confidence: 0.9527896

00:23:41.125 --> 00:23:43.044
features of the pathology from

NOTE Confidence: 0.9527896

00:23:43.044 --> 00:23:44.904
the surgical resections specimen,

NOTE Confidence: 0.97250336

00:23:45.445 --> 00:23:46.565
that will help us determine

NOTE Confidence: 0.97250336

00:23:46.565 --> 00:23:47.524
whether or not they need

NOTE Confidence: 0.97250336

00:23:47.524 --> 00:23:49.044
any more treatment after the

NOTE Confidence: 0.97250336

00:23:49.044 --> 00:23:50.424
surgery such as chemotherapy.

NOTE Confidence: 0.9778259

00:23:51.820 --> 00:23:52.800
In contrast,

NOTE Confidence: 0.99710244

00:23:53.580 --> 00:23:54.960
for rectal cancer,

NOTE Confidence: 0.97055185

00:23:55.580 --> 00:23:57.340
we've actually moved a lot

NOTE Confidence: 0.97055185

00:23:57.340 --> 00:23:59.760
of that other treatment upfront

NOTE Confidence: 0.8927789

00:24:00.300 --> 00:24:01.360
before surgery,

NOTE Confidence: 0.956822

00:24:01.820 --> 00:24:03.280
and we call that treatment

NOTE Confidence: 0.956822

00:24:03.340 --> 00:24:05.280
strategy total neoadjuvant

NOTE Confidence: 0.95648146

00:24:05.580 --> 00:24:07.275
therapy or TNT.

NOTE Confidence: 0.9994785

00:24:08.535 --> 00:24:09.815
The more recent studies have

NOTE Confidence: 0.9994785

00:24:09.815 --> 00:24:12.395
shown that doing both chemotherapy

NOTE Confidence: 0.9993486

00:24:12.934 --> 00:24:13.434
and

NOTE Confidence: 0.9013467

00:24:13.815 --> 00:24:14.715
chemo radiation

NOTE Confidence: 0.99867857

00:24:15.575 --> 00:24:16.635
before surgery

NOTE Confidence: 0.97774714

00:24:17.335 --> 00:24:19.255
can actually not only decrease

NOTE Confidence: 0.97774714

00:24:19.255 --> 00:24:20.695
the shrink of shrink the

NOTE Confidence: 0.97774714

00:24:20.695 --> 00:24:22.054
tumor and decrease the size

NOTE Confidence: 0.97774714

00:24:22.054 --> 00:24:23.990
of it before the surgery

NOTE Confidence: 0.97774714

00:24:23.990 --> 00:24:24.650
to help

NOTE Confidence: 0.8697371

00:24:25.030 --> 00:24:26.549
decrease the morbidity of a

NOTE Confidence: 0.8697371

00:24:26.549 --> 00:24:27.609
sir a surgery,

NOTE Confidence: 0.9979461

00:24:28.390 --> 00:24:29.669
and, you know, decrease the

NOTE Confidence: 0.9979461

00:24:29.669 --> 00:24:30.730
chances of needing

NOTE Confidence: 0.9650116

00:24:31.030 --> 00:24:32.570
something like a permanent ostomy.

NOTE Confidence: 0.9807469

00:24:32.950 --> 00:24:34.150
But moving all of this

NOTE Confidence: 0.9807469

00:24:34.150 --> 00:24:35.990
treatment upfront has actually also

NOTE Confidence: 0.9807469

00:24:35.990 --> 00:24:37.305
shown to have a benefit

NOTE Confidence: 0.9807469

00:24:37.305 --> 00:24:38.685
for overall survival.

NOTE Confidence: 0.9480669

00:24:39.865 --> 00:24:41.545
So typically, these patients will

NOTE Confidence: 0.9480669

00:24:41.545 --> 00:24:42.045
have

NOTE Confidence: 0.96939754

00:24:42.345 --> 00:24:44.744
chemotherapy, chemo radiation, and then

NOTE Confidence: 0.96939754

00:24:44.744 --> 00:24:45.565
go to surgery.

NOTE Confidence: 0.99890816

00:24:45.945 --> 00:24:47.885
But what we're also finding

NOTE Confidence: 0.9991859

00:24:48.185 --> 00:24:48.925
is that

NOTE Confidence: 0.99054146

00:24:49.225 --> 00:24:51.540
we might actually be curing

NOTE Confidence: 0.99054146

00:24:51.540 --> 00:24:53.060
some of these patients with

NOTE Confidence: 0.99054146

00:24:53.060 --> 00:24:55.240
chemotherapy and chemo radiation alone.

NOTE Confidence: 0.98431534

00:24:55.700 --> 00:24:57.060
This is a small subset

NOTE Confidence: 0.98431534

00:24:57.060 --> 00:24:58.180
of patients, and we're still

NOTE Confidence: 0.98431534

00:24:58.180 --> 00:24:59.220
trying to figure out who

NOTE Confidence: 0.98431534

00:24:59.220 --> 00:24:59.880
that is,

NOTE Confidence: 0.95280266

00:25:00.260 --> 00:25:01.220
but we are doing a

NOTE Confidence: 0.95280266

00:25:01.220 --> 00:25:02.600
lot of work in studying

NOTE Confidence: 0.95280266

00:25:02.660 --> 00:25:04.275
the watch and wait strategy.

NOTE Confidence: 0.95280266

00:25:04.275 --> 00:25:06.115
So treating with chemo and

NOTE Confidence: 0.95280266

00:25:06.115 --> 00:25:06.935
chemo radiation,

NOTE Confidence: 0.9987203

00:25:07.635 --> 00:25:08.295
and then

NOTE Confidence: 0.9884644

00:25:08.675 --> 00:25:10.775
delaying surgery and just following

NOTE Confidence: 0.9884644

00:25:10.915 --> 00:25:12.915
with scans and scopes very

NOTE Confidence: 0.9884644

00:25:12.915 --> 00:25:14.595
closely to see whether or

NOTE Confidence: 0.9884644

00:25:14.595 --> 00:25:15.795
not there's a recurrence of

NOTE Confidence: 0.9884644

00:25:15.795 --> 00:25:16.455
this disease.

NOTE Confidence: 0.9898739

00:25:17.100 --> 00:25:18.140
So let's circle back with

NOTE Confidence: 0.9898739

00:25:18.140 --> 00:25:19.340
our patient and see what

NOTE Confidence: 0.9898739

00:25:19.340 --> 00:25:21.100
happened with him. So our

NOTE Confidence: 0.9898739

00:25:21.100 --> 00:25:23.179
patient did begin this total

NOTE Confidence: 0.9898739

00:25:23.179 --> 00:25:25.200
neoadjuvant therapy or TNT

NOTE Confidence: 0.99941945

00:25:25.660 --> 00:25:26.160
strategy

NOTE Confidence: 0.8078652

00:25:26.859 --> 00:25:28.240
starting with chemoradiation,

NOTE Confidence: 0.9991546

00:25:28.940 --> 00:25:30.815
meaning that while he was

NOTE Confidence: 0.9991546

00:25:30.815 --> 00:25:31.315
getting

NOTE Confidence: 0.9991824

00:25:31.775 --> 00:25:33.695
radiation doses, he was also

NOTE Confidence: 0.9991824

00:25:33.695 --> 00:25:34.595
taking a chemotherapy

NOTE Confidence: 0.9799625

00:25:34.895 --> 00:25:36.195
pill called Xeloda.

NOTE Confidence: 0.97690266

00:25:36.895 --> 00:25:38.195
When he finished the radiation,

NOTE Confidence: 0.97690266

00:25:38.255 --> 00:25:39.695
they got some scans, which

NOTE Confidence: 0.97690266

00:25:39.695 --> 00:25:41.055
showed that he had a

NOTE Confidence: 0.97690266

00:25:41.055 --> 00:25:41.795
good response,

NOTE Confidence: 0.9939626

00:25:42.250 --> 00:25:43.529
and they moved to that

NOTE Confidence: 0.9939626

00:25:43.529 --> 00:25:45.230
next part of the TNT

NOTE Confidence: 0.9939626

00:25:45.369 --> 00:25:46.990
strategy, which is the chemotherapy.

NOTE Confidence: 0.9894888

00:25:48.010 --> 00:25:49.869
He received our standard chemotherapy

NOTE Confidence: 0.9894888

00:25:50.010 --> 00:25:51.850
regimen, which is called FOLFOX,

NOTE Confidence: 0.9894888

00:25:51.850 --> 00:25:52.809
and I won't get into

NOTE Confidence: 0.9894888

00:25:52.809 --> 00:25:54.169
more details about that right

NOTE Confidence: 0.9894888

00:25:54.169 --> 00:25:54.645
now.

NOTE Confidence: 0.9996164

00:25:55.125 --> 00:25:56.345
But after completing

NOTE Confidence: 0.9997625

00:25:56.645 --> 00:25:58.025
both of those components,

NOTE Confidence: 0.90259475

00:25:58.565 --> 00:25:59.765
his PET scans show that

NOTE Confidence: 0.90259475

00:25:59.765 --> 00:26:01.785
he had no residual disease.

NOTE Confidence: 0.9990302

00:26:02.325 --> 00:26:03.545
He got MRIs

NOTE Confidence: 0.9580998

00:26:04.085 --> 00:26:05.685
as well, and this continued

NOTE Confidence: 0.9580998

00:26:05.685 --> 00:26:06.645
to show that he had

NOTE Confidence: 0.9580998

00:26:06.645 --> 00:26:08.505
a com an excellent response

NOTE Confidence: 0.9580998

00:26:08.565 --> 00:26:09.465
to the TNT.

NOTE Confidence: 0.99777585

00:26:10.460 --> 00:26:12.060
And based on discussing with

NOTE Confidence: 0.99777585

00:26:12.060 --> 00:26:14.000
the oncologists and the colorectal

NOTE Confidence: 0.99777585

00:26:14.220 --> 00:26:14.720
surgeons,

NOTE Confidence: 0.97670764

00:26:15.180 --> 00:26:16.460
they decided to proceed with

NOTE Confidence: 0.97670764

00:26:16.460 --> 00:26:17.840
this wash and wait strategy,

NOTE Confidence: 0.9850757

00:26:18.540 --> 00:26:21.100
with, proceeding without surgery and

NOTE Confidence: 0.9850757

00:26:21.100 --> 00:26:22.320
having close surveillance.

NOTE Confidence: 0.940509

00:26:23.135 --> 00:26:24.415
So first, as of right

NOTE Confidence: 0.940509

00:26:24.415 --> 00:26:25.235
now, surveillance,

NOTE Confidence: 0.98470116

00:26:25.615 --> 00:26:27.635
for colorectal cancer upon,

NOTE Confidence: 0.99831235

00:26:28.335 --> 00:26:28.835
completing

NOTE Confidence: 0.97237045

00:26:29.375 --> 00:26:30.835
curative intent treatment

NOTE Confidence: 0.9899743

00:26:31.215 --> 00:26:33.535
is following for five years

NOTE Confidence: 0.9899743

00:26:33.535 --> 00:26:34.035
with,

NOTE Confidence: 0.9309565

00:26:34.575 --> 00:26:36.975
physical exams and HMPs as

NOTE Confidence: 0.9309565

00:26:36.975 --> 00:26:39.230
well as labs, imaging, and

NOTE Confidence: 0.9309565

00:26:39.230 --> 00:26:39.730
endoscopies

NOTE Confidence: 0.9981739

00:26:40.190 --> 00:26:40.850
as well.

NOTE Confidence: 0.96993273

00:26:43.230 --> 00:26:44.430
There's just one more point

NOTE Confidence: 0.96993273

00:26:44.430 --> 00:26:45.230
that I wanna make, and

NOTE Confidence: 0.96993273

00:26:45.230 --> 00:26:46.030
this is going back to

NOTE Confidence: 0.96993273

00:26:46.030 --> 00:26:47.470
the asterisk that I had

NOTE Confidence: 0.96993273

00:26:47.470 --> 00:26:48.770
discussed about earlier.

NOTE Confidence: 0.989503

00:26:49.150 --> 00:26:50.350
And that's about the role

NOTE Confidence: 0.989503

00:26:50.350 --> 00:26:51.250
of immunotherapy

NOTE Confidence: 0.92018354

00:26:51.915 --> 00:26:52.895
in localized

NOTE Confidence: 0.89717215

00:26:53.435 --> 00:26:55.215
and locally advanced rectal cancer.

NOTE Confidence: 0.84462154

00:26:55.595 --> 00:26:57.775
So you might've seen these,

NOTE Confidence: 0.91151077

00:26:58.475 --> 00:27:00.155
major articles come out in

NOTE Confidence: 0.91151077

00:27:00.155 --> 00:27:01.435
the New York Times and

NOTE Confidence: 0.91151077

00:27:01.435 --> 00:27:02.575
other new sources,

NOTE Confidence: 0.78880966

00:27:03.755 --> 00:27:04.675
showing some dramatic responses that

NOTE Confidence: 0.78880966

00:27:04.675 --> 00:27:05.535
we've seen for a subset

NOTE Confidence: 0.96468323

00:27:05.835 --> 00:27:07.869
of responses that we've seen

NOTE Confidence: 0.997135

00:27:08.409 --> 00:27:09.470
for a subset

NOTE Confidence: 0.9933853

00:27:09.929 --> 00:27:11.450
of patients who have rectal

NOTE Confidence: 0.9933853

00:27:11.450 --> 00:27:13.529
cancer that are deficient in

NOTE Confidence: 0.9933853

00:27:13.529 --> 00:27:15.309
what we call mismatch repair

NOTE Confidence: 0.9933853

00:27:15.369 --> 00:27:15.869
proteins.

NOTE Confidence: 0.98169523

00:27:16.570 --> 00:27:17.769
This means that they have

NOTE Confidence: 0.98169523

00:27:17.769 --> 00:27:19.769
more DNA damage in their

NOTE Confidence: 0.98169523

00:27:19.769 --> 00:27:20.269
cancers,

NOTE Confidence: 0.9732356

00:27:21.005 --> 00:27:22.765
and therefore, they might be

NOTE Confidence: 0.9732356

00:27:22.765 --> 00:27:25.085
more likely to respond to

NOTE Confidence: 0.9732356

00:27:25.085 --> 00:27:26.145
an immunotherapy

NOTE Confidence: 0.88413405

00:27:26.605 --> 00:27:26.925
based,

NOTE Confidence: 0.9657569

00:27:27.805 --> 00:27:28.305
approach.

NOTE Confidence: 0.999761

00:27:29.005 --> 00:27:30.845
And there was this really

NOTE Confidence: 0.999761

00:27:30.845 --> 00:27:32.945
remarkable trial that came out

NOTE Confidence: 0.9951695

00:27:33.245 --> 00:27:34.750
that showed that of the

NOTE Confidence: 0.9951695

00:27:34.750 --> 00:27:36.429
forty nine patients who had

NOTE Confidence: 0.9951695

00:27:36.429 --> 00:27:38.289
rectal cancer with this mismatch

NOTE Confidence: 0.9951695

00:27:38.350 --> 00:27:39.890
repair protein deficiency,

NOTE Confidence: 0.99866104

00:27:40.669 --> 00:27:42.049
they all had a clinical

NOTE Confidence: 0.99866104

00:27:42.190 --> 00:27:43.890
complete response to the immunotherapy

NOTE Confidence: 0.973215

00:27:44.590 --> 00:27:46.289
alone, and that is without

NOTE Confidence: 0.973215

00:27:46.429 --> 00:27:47.730
having any chemotherapy,

NOTE Confidence: 0.94431275

00:27:48.615 --> 00:27:49.355
any radiation,

NOTE Confidence: 0.965371

00:27:50.055 --> 00:27:50.795
or any,

NOTE Confidence: 0.996082

00:27:51.255 --> 00:27:53.175
surgery on, to remove their

NOTE Confidence: 0.996082

00:27:53.175 --> 00:27:55.035
initial rectal cancer tumor.

NOTE Confidence: 0.95883596

00:27:55.494 --> 00:27:56.775
So I think that this

NOTE Confidence: 0.95883596

00:27:56.775 --> 00:27:58.215
has been a really exciting

NOTE Confidence: 0.95883596

00:27:58.215 --> 00:27:59.895
finding and is just a

NOTE Confidence: 0.95883596

00:27:59.895 --> 00:28:01.415
a taste of what's next

NOTE Confidence: 0.95883596

00:28:01.415 --> 00:28:03.050
to come. But this comes

NOTE Confidence: 0.95883596

00:28:03.050 --> 00:28:04.490
back to the fact that

NOTE Confidence: 0.95883596

00:28:04.490 --> 00:28:06.190
on our initial diagnosis

NOTE Confidence: 0.99880284

00:28:06.570 --> 00:28:07.869
of rectal cancer,

NOTE Confidence: 0.9995093

00:28:08.170 --> 00:28:09.450
we want to get that

NOTE Confidence: 0.9995093

00:28:09.450 --> 00:28:10.970
information to know whether or

NOTE Confidence: 0.9995093

00:28:10.970 --> 00:28:11.690
not they might be a

NOTE Confidence: 0.9995093

00:28:11.690 --> 00:28:12.910
candidate for immunotherapy.

NOTE Confidence: 0.94248277

00:28:15.585 --> 00:28:17.025
Excellent points, Dejal, and thank

NOTE Confidence: 0.94248277

00:28:17.025 --> 00:28:18.325
you so much. And just

NOTE Confidence: 0.98106116

00:28:18.865 --> 00:28:20.065
to gently wrap up this

NOTE Confidence: 0.98106116

00:28:20.065 --> 00:28:20.565
case,

NOTE Confidence: 0.9260497

00:28:21.105 --> 00:28:22.565
some key points again,

NOTE Confidence: 0.97504014

00:28:23.025 --> 00:28:24.625
do not dismiss mild rectal

NOTE Confidence: 0.97504014

00:28:24.625 --> 00:28:27.289
bleeding, needs, close follow-up. Again,

NOTE Confidence: 0.97504014

00:28:27.289 --> 00:28:28.590
this is where we're transitioning

NOTE Confidence: 0.97504014

00:28:28.650 --> 00:28:30.270
from just screening to diagnostic.

NOTE Confidence: 0.97504014

00:28:30.490 --> 00:28:30.990
Right?

NOTE Confidence: 0.9950423

00:28:31.929 --> 00:28:33.450
Ensure patients are screened at

NOTE Confidence: 0.9950423

00:28:33.450 --> 00:28:34.350
adequate intervals.

NOTE Confidence: 0.9525329

00:28:34.890 --> 00:28:36.890
Thankfully, this patient was. But,

NOTE Confidence: 0.9525329

00:28:36.890 --> 00:28:38.409
again, we need to change

NOTE Confidence: 0.9525329

00:28:38.409 --> 00:28:39.789
our modality to diagnostic.

NOTE Confidence: 0.9782725

00:28:41.015 --> 00:28:42.855
Collaborate with our specialist colleagues

NOTE Confidence: 0.9782725

00:28:42.855 --> 00:28:44.375
if there are suspicious findings

NOTE Confidence: 0.9782725

00:28:44.375 --> 00:28:45.034
or history,

NOTE Confidence: 0.98261726

00:28:45.335 --> 00:28:47.034
and early detection of colorectal

NOTE Confidence: 0.98261726

00:28:47.095 --> 00:28:48.534
cancer is key for treatment

NOTE Confidence: 0.98261726

00:28:48.534 --> 00:28:49.595
options and survival.

NOTE Confidence: 0.8059466

00:28:50.375 --> 00:28:50.875
Okay.

NOTE Confidence: 0.9939048

00:28:51.335 --> 00:28:52.774
And with that, we'll move

NOTE Confidence: 0.9939048

00:28:52.774 --> 00:28:53.894
on to our next case,

NOTE Confidence: 0.9939048

00:28:53.894 --> 00:28:54.394
please.

NOTE Confidence: 0.987595

00:28:55.450 --> 00:28:57.050
So case two will be,

NOTE Confidence: 0.987595

00:28:57.530 --> 00:28:58.730
based more so on a

NOTE Confidence: 0.987595

00:28:58.730 --> 00:29:00.110
suspicious family history.

NOTE Confidence: 0.9404484

00:29:00.810 --> 00:29:02.170
So here we have a

NOTE Confidence: 0.9404484

00:29:02.170 --> 00:29:03.470
twenty five year old female,

NOTE Confidence: 0.9404484

00:29:03.530 --> 00:29:05.210
well, with no significant past

NOTE Confidence: 0.9404484

00:29:05.210 --> 00:29:07.630
medical history, except mild GERD,

NOTE Confidence: 0.9554417

00:29:08.010 --> 00:29:08.510
controlled,

NOTE Confidence: 0.9953284

00:29:08.914 --> 00:29:10.434
presents for a routine physical

NOTE Confidence: 0.9953284

00:29:10.434 --> 00:29:10.934
appointment.

NOTE Confidence: 0.9722953

00:29:11.635 --> 00:29:13.414
As far as active problems,

NOTE Confidence: 0.9722953

00:29:13.554 --> 00:29:14.054
none.

NOTE Confidence: 0.9809519

00:29:14.355 --> 00:29:16.455
Medication wise, PPI, PRN,

NOTE Confidence: 0.9507372

00:29:17.154 --> 00:29:19.335
no social history, no habits,

NOTE Confidence: 0.82158136

00:29:19.794 --> 00:29:20.855
smoking or

NOTE Confidence: 0.9987581

00:29:21.570 --> 00:29:22.070
alcohol

NOTE Confidence: 0.6917003

00:29:22.529 --> 00:29:24.549
occupational wise, teacher.

NOTE Confidence: 0.9866668

00:29:25.010 --> 00:29:26.210
But, we do see there's

NOTE Confidence: 0.9866668

00:29:26.210 --> 00:29:27.649
a family history of multiple

NOTE Confidence: 0.9866668

00:29:27.649 --> 00:29:29.730
colonic polyps in mother diagnosed

NOTE Confidence: 0.9866668

00:29:29.730 --> 00:29:30.870
at age forty.

NOTE Confidence: 0.98829144

00:29:32.769 --> 00:29:34.309
So at this point,

NOTE Confidence: 0.9666459

00:29:34.929 --> 00:29:35.970
some questions, if we could

NOTE Confidence: 0.9666459

00:29:35.970 --> 00:29:37.095
go to the next slide,

NOTE Confidence: 0.9666459

00:29:37.174 --> 00:29:37.575
please, is,

NOTE Confidence: 0.96593386

00:29:38.934 --> 00:29:40.715
what what are some outstanding

NOTE Confidence: 0.96593386

00:29:40.934 --> 00:29:42.294
parts from our history that

NOTE Confidence: 0.96593386

00:29:42.294 --> 00:29:43.335
are standing out to us?

NOTE Confidence: 0.96593386

00:29:43.335 --> 00:29:44.455
So, Shavir, I'd like to

NOTE Confidence: 0.96593386

00:29:44.455 --> 00:29:45.255
hand off to you for

NOTE Confidence: 0.96593386

00:29:45.255 --> 00:29:46.695
this, please. Yeah. I think

NOTE Confidence: 0.96593386

00:29:46.695 --> 00:29:48.135
the first, thing they would

NOTE Confidence: 0.96593386

00:29:48.135 --> 00:29:49.015
like to say is that

NOTE Confidence: 0.96593386

00:29:49.015 --> 00:29:49.835
we, gastroenterology,

NOTE Confidence: 0.9338315

00:29:50.215 --> 00:29:51.095
should be a better job

NOTE Confidence: 0.9338315

00:29:51.095 --> 00:29:52.800
many times at saying,

NOTE Confidence: 0.94279027

00:29:53.660 --> 00:29:55.020
polyps and how many polyps

NOTE Confidence: 0.94279027

00:29:55.020 --> 00:29:56.240
we find. We often

NOTE Confidence: 0.9602797

00:29:56.540 --> 00:29:58.620
describe multiple, and multiple for

NOTE Confidence: 0.9602797

00:29:58.620 --> 00:30:00.140
everyone, it mean may mean

NOTE Confidence: 0.9602797

00:30:00.140 --> 00:30:01.740
a different number. So really,

NOTE Confidence: 0.9602797

00:30:01.740 --> 00:30:02.860
it's not the same to

NOTE Confidence: 0.9602797

00:30:02.860 --> 00:30:04.860
have seen, seven polyps, which

NOTE Confidence: 0.9602797

00:30:04.860 --> 00:30:06.400
for someone can be multiple

NOTE Confidence: 0.9602797

00:30:06.695 --> 00:30:08.155
over the years versus,

NOTE Confidence: 0.9830866

00:30:08.855 --> 00:30:09.995
twenty five polyps.

NOTE Confidence: 0.977505

00:30:10.695 --> 00:30:11.895
So we really have to

NOTE Confidence: 0.977505

00:30:11.895 --> 00:30:13.434
be much more specific.

NOTE Confidence: 0.9647586

00:30:13.815 --> 00:30:15.575
It'll be important because the

NOTE Confidence: 0.9647586

00:30:15.655 --> 00:30:16.855
our patient really has not

NOTE Confidence: 0.9647586

00:30:16.855 --> 00:30:18.054
had anything. It's all based

NOTE Confidence: 0.9647586

00:30:18.054 --> 00:30:19.175
on family history. It'll be

NOTE Confidence: 0.9647586

00:30:19.175 --> 00:30:20.429
important to know that did

NOTE Confidence: 0.9647586

00:30:20.429 --> 00:30:22.029
mom have also colorectal cancer,

NOTE Confidence: 0.9647586

00:30:22.029 --> 00:30:23.309
just polyps, how many and

NOTE Confidence: 0.9647586

00:30:23.309 --> 00:30:24.590
all that? Did she have

NOTE Confidence: 0.9647586

00:30:24.590 --> 00:30:25.490
genetic testing?

NOTE Confidence: 0.9872161

00:30:25.870 --> 00:30:26.110
And,

NOTE Confidence: 0.8704047

00:30:26.830 --> 00:30:28.850
key quick key key questions

NOTE Confidence: 0.8704047

00:30:28.990 --> 00:30:29.950
is, again, is like how

NOTE Confidence: 0.8704047

00:30:29.950 --> 00:30:31.230
many polyps, what type of

NOTE Confidence: 0.8704047

00:30:31.230 --> 00:30:32.835
polyps, whether some of them

NOTE Confidence: 0.8704047

00:30:33.154 --> 00:30:34.595
advanced was the patient young

NOTE Confidence: 0.8704047

00:30:34.595 --> 00:30:36.515
at, or mother, young at

NOTE Confidence: 0.8704047

00:30:36.515 --> 00:30:39.154
diagnosis of, those polyps. And,

NOTE Confidence: 0.8704047

00:30:39.154 --> 00:30:40.434
again, did she have genetic

NOTE Confidence: 0.8704047

00:30:40.434 --> 00:30:41.414
testing? Really,

NOTE Confidence: 0.9554564

00:30:42.115 --> 00:30:43.715
getting information from mom may

NOTE Confidence: 0.9554564

00:30:43.715 --> 00:30:44.995
be very, very important on

NOTE Confidence: 0.9554564

00:30:44.995 --> 00:30:46.054
how we address

NOTE Confidence: 0.959555

00:30:47.580 --> 00:30:49.040
next steps for this patient.

NOTE Confidence: 0.9798488

00:30:51.660 --> 00:30:53.340
If we're looking at, someone

NOTE Confidence: 0.9798488

00:30:53.340 --> 00:30:54.780
who's developed at least ten,

NOTE Confidence: 0.9798488

00:30:54.780 --> 00:30:55.280
fifteen,

NOTE Confidence: 0.97467566

00:30:56.300 --> 00:30:57.900
adenomas or other types of

NOTE Confidence: 0.97467566

00:30:57.900 --> 00:30:59.685
polyps, then we really have

NOTE Confidence: 0.97467566

00:30:59.685 --> 00:31:01.305
to, rule out a hereditary

NOTE Confidence: 0.97467566

00:31:01.365 --> 00:31:03.225
condition. Now we we have

NOTE Confidence: 0.90880364

00:31:03.765 --> 00:31:04.565
a a a list of

NOTE Confidence: 0.90880364

00:31:04.565 --> 00:31:05.945
genes that have been associated

NOTE Confidence: 0.90880364

00:31:06.165 --> 00:31:06.905
and beyond,

NOTE Confidence: 0.97252667

00:31:07.525 --> 00:31:09.305
the the very first one

NOTE Confidence: 0.97252667

00:31:09.365 --> 00:31:11.545
described, like, which was APC.

NOTE Confidence: 0.97252667

00:31:11.605 --> 00:31:12.885
Now we have a variety

NOTE Confidence: 0.97252667

00:31:12.885 --> 00:31:13.685
of them, and some of

NOTE Confidence: 0.97252667

00:31:13.685 --> 00:31:14.185
them,

NOTE Confidence: 0.978666

00:31:14.650 --> 00:31:16.270
are inherited in an autosomal

NOTE Confidence: 0.978666

00:31:16.490 --> 00:31:17.850
recessive manner. So you do

NOTE Confidence: 0.978666

00:31:17.850 --> 00:31:19.210
need two copies of,

NOTE Confidence: 0.93509305

00:31:19.690 --> 00:31:21.130
mutated gene, and and in

NOTE Confidence: 0.93509305

00:31:21.130 --> 00:31:22.410
that case, mom and dad

NOTE Confidence: 0.93509305

00:31:22.410 --> 00:31:24.250
usually won't have polyposis and

NOTE Confidence: 0.93509305

00:31:24.250 --> 00:31:26.010
cancer. So it may seem

NOTE Confidence: 0.93509305

00:31:26.010 --> 00:31:27.690
like it skipped generations. So

NOTE Confidence: 0.93509305

00:31:27.690 --> 00:31:29.370
important that, yeah, we're not

NOTE Confidence: 0.93509305

00:31:29.530 --> 00:31:30.225
we may not,

NOTE Confidence: 0.98549294

00:31:30.705 --> 00:31:31.765
we may have these

NOTE Confidence: 0.87461793

00:31:32.225 --> 00:31:33.424
situations with,

NOTE Confidence: 0.97017884

00:31:33.985 --> 00:31:34.485
with,

NOTE Confidence: 0.9760468

00:31:35.265 --> 00:31:37.125
the generation just above having

NOTE Confidence: 0.9760468

00:31:37.424 --> 00:31:40.065
no polyposis, no colorectal cancer

NOTE Confidence: 0.9760468

00:31:40.065 --> 00:31:41.345
history at all. So, again,

NOTE Confidence: 0.9760468

00:31:41.345 --> 00:31:42.225
we do have,

NOTE Confidence: 0.9146848

00:31:42.625 --> 00:31:43.265
many more,

NOTE Confidence: 0.9794588

00:31:44.190 --> 00:31:45.389
situations that are not the

NOTE Confidence: 0.9794588

00:31:45.389 --> 00:31:45.889
typical,

NOTE Confidence: 0.953669

00:31:46.510 --> 00:31:47.710
one that are associated with

NOTE Confidence: 0.953669

00:31:47.710 --> 00:31:49.630
an autosomal dominant pattern. And,

NOTE Confidence: 0.953669

00:31:49.630 --> 00:31:51.389
also, there are, some de

NOTE Confidence: 0.953669

00:31:51.389 --> 00:31:53.070
novo mutations in APC up

NOTE Confidence: 0.953669

00:31:53.070 --> 00:31:54.590
to twenty five percent. So

NOTE Confidence: 0.953669

00:31:54.590 --> 00:31:55.870
may have no family history

NOTE Confidence: 0.953669

00:31:55.870 --> 00:31:56.750
at all, and all of

NOTE Confidence: 0.953669

00:31:56.750 --> 00:31:58.225
a sudden, here we have

NOTE Confidence: 0.953669

00:31:58.225 --> 00:31:59.905
a new polyposis case. If

NOTE Confidence: 0.953669

00:31:59.905 --> 00:32:00.705
we can move on to

NOTE Confidence: 0.953669

00:32:00.705 --> 00:32:01.525
next one,

NOTE Confidence: 0.9722947

00:32:02.625 --> 00:32:04.465
besides those genetic ones, and

NOTE Confidence: 0.9722947

00:32:04.465 --> 00:32:05.664
I would skip the CPU

NOTE Confidence: 0.9722947

00:32:05.664 --> 00:32:06.625
one, we can,

NOTE Confidence: 0.93345946

00:32:07.025 --> 00:32:09.025
with, it's important also to,

NOTE Confidence: 0.7348595

00:32:10.145 --> 00:32:11.525
notice about the

NOTE Confidence: 0.9367051

00:32:12.090 --> 00:32:13.950
potential prior history of

NOTE Confidence: 0.96652

00:32:14.490 --> 00:32:16.750
chemotherapy and or radiation therapy,

NOTE Confidence: 0.96652

00:32:16.809 --> 00:32:18.730
particularly during childhood and young

NOTE Confidence: 0.96652

00:32:18.730 --> 00:32:21.049
adulthood, and that's been, associated

NOTE Confidence: 0.96652

00:32:21.049 --> 00:32:22.170
with what we call therapy

NOTE Confidence: 0.96652

00:32:22.170 --> 00:32:24.375
associated polyposis, which often is

NOTE Confidence: 0.96652

00:32:24.375 --> 00:32:26.055
a, kind of mixed pattern

NOTE Confidence: 0.96652

00:32:26.055 --> 00:32:27.835
of adenomas and serrated polyps.

NOTE Confidence: 0.96652

00:32:27.895 --> 00:32:29.015
So important to ask for

NOTE Confidence: 0.96652

00:32:29.015 --> 00:32:29.755
that information.

NOTE Confidence: 0.98182184

00:32:30.535 --> 00:32:31.995
Next one is serrated polyposis

NOTE Confidence: 0.98182184

00:32:32.055 --> 00:32:33.515
syndrome. Most of the time,

NOTE Confidence: 0.9284704

00:32:34.375 --> 00:32:34.855
not,

NOTE Confidence: 0.82953626

00:32:35.255 --> 00:32:36.555
associated with known,

NOTE Confidence: 0.96320045

00:32:38.130 --> 00:32:40.130
genetic conditions, and this is

NOTE Confidence: 0.96320045

00:32:40.130 --> 00:32:41.670
more, based on clinical

NOTE Confidence: 0.83878505

00:32:41.970 --> 00:32:42.470
criteria.

NOTE Confidence: 0.97290593

00:32:42.850 --> 00:32:44.150
But it does have implications

NOTE Confidence: 0.97290593

00:32:44.290 --> 00:32:45.570
in terms of cancer risk

NOTE Confidence: 0.97290593

00:32:45.570 --> 00:32:46.770
for the patients, but also

NOTE Confidence: 0.97290593

00:32:46.770 --> 00:32:48.690
so for first degree family

NOTE Confidence: 0.97290593

00:32:48.690 --> 00:32:50.130
members. So it's important that

NOTE Confidence: 0.97290593

00:32:50.130 --> 00:32:51.410
we understand what types of

NOTE Confidence: 0.97290593

00:32:51.410 --> 00:32:52.625
polyps there are and make

NOTE Confidence: 0.97290593

00:32:52.625 --> 00:32:54.385
sure, is it a serrated

NOTE Confidence: 0.97290593

00:32:54.385 --> 00:32:55.825
polyposis or not. And going

NOTE Confidence: 0.97290593

00:32:55.825 --> 00:32:56.645
back to the,

NOTE Confidence: 0.9126413

00:32:56.945 --> 00:32:59.665
first scenario, CPOE, that's that's,

NOTE Confidence: 0.9126413

00:32:59.905 --> 00:33:01.985
colonic polyposis of known etiology,

NOTE Confidence: 0.9126413

00:33:01.985 --> 00:33:03.585
and we call those once

NOTE Confidence: 0.9126413

00:33:03.585 --> 00:33:04.485
we've really seen

NOTE Confidence: 0.9746408

00:33:05.640 --> 00:33:07.480
an individual with polyposis with

NOTE Confidence: 0.9746408

00:33:07.480 --> 00:33:10.220
really no evidence of, any

NOTE Confidence: 0.9746408

00:33:10.280 --> 00:33:11.880
genetic mutations in the genes

NOTE Confidence: 0.9746408

00:33:11.880 --> 00:33:13.400
that are commonly associated with

NOTE Confidence: 0.9746408

00:33:13.400 --> 00:33:15.400
polyposis and colorectal cancer. In

NOTE Confidence: 0.9746408

00:33:15.400 --> 00:33:16.920
all those cases too, family

NOTE Confidence: 0.9746408

00:33:16.920 --> 00:33:17.420
members

NOTE Confidence: 0.97591203

00:33:17.800 --> 00:33:19.035
do have a higher risk.

NOTE Confidence: 0.97591203

00:33:19.115 --> 00:33:20.395
So it is important that

NOTE Confidence: 0.97591203

00:33:20.395 --> 00:33:21.915
we kind of, label these

NOTE Confidence: 0.97591203

00:33:21.915 --> 00:33:23.675
cases as appropriate as possible

NOTE Confidence: 0.97591203

00:33:23.675 --> 00:33:25.055
because it does have implications

NOTE Confidence: 0.9514333

00:33:25.515 --> 00:33:26.635
not only for our patients

NOTE Confidence: 0.9514333

00:33:26.635 --> 00:33:28.155
but for family members. So

NOTE Confidence: 0.9514333

00:33:28.155 --> 00:33:29.355
important to gather all that

NOTE Confidence: 0.9514333

00:33:29.355 --> 00:33:30.875
information if we know, if

NOTE Confidence: 0.9514333

00:33:30.875 --> 00:33:31.195
we,

NOTE Confidence: 0.9713364

00:33:31.675 --> 00:33:33.035
want to understand better how

NOTE Confidence: 0.9713364

00:33:33.035 --> 00:33:34.950
to address the, the patient

NOTE Confidence: 0.9713364

00:33:34.950 --> 00:33:36.250
that we're talking about.

NOTE Confidence: 0.9465657

00:33:38.150 --> 00:33:40.070
And and, very, very important,

NOTE Confidence: 0.9465657

00:33:40.070 --> 00:33:41.190
and I think that skips

NOTE Confidence: 0.9465657

00:33:41.190 --> 00:33:42.490
so many of us,

NOTE Confidence: 0.99950045

00:33:42.870 --> 00:33:43.929
which is that

NOTE Confidence: 0.9548108

00:33:44.549 --> 00:33:45.590
even if there are not

NOTE Confidence: 0.9548108

00:33:45.590 --> 00:33:46.789
that many polyps, but if

NOTE Confidence: 0.9548108

00:33:46.789 --> 00:33:48.495
there was an advanced polyp.

NOTE Confidence: 0.9548108

00:33:48.495 --> 00:33:49.695
And how we what we

NOTE Confidence: 0.9548108

00:33:49.695 --> 00:33:51.375
call advanced is, having an

NOTE Confidence: 0.9548108

00:33:51.375 --> 00:33:52.275
adenoma that's

NOTE Confidence: 0.98117644

00:33:52.735 --> 00:33:54.035
larger than one centimeter,

NOTE Confidence: 0.82924926

00:33:54.415 --> 00:33:56.035
adenoma with high grade dysplasia

NOTE Confidence: 0.82924926

00:33:56.175 --> 00:33:58.515
or villous bill tubular adenoma,

NOTE Confidence: 0.84047705

00:34:00.540 --> 00:34:01.600
traditional serrated,

NOTE Confidence: 0.9282068

00:34:02.060 --> 00:34:04.060
adenoma, or advanced sal serrated

NOTE Confidence: 0.9282068

00:34:04.060 --> 00:34:05.820
polyps. All those ones, just

NOTE Confidence: 0.9282068

00:34:05.820 --> 00:34:07.580
having a first degree relative

NOTE Confidence: 0.9282068

00:34:07.580 --> 00:34:09.340
who has had at least

NOTE Confidence: 0.9282068

00:34:09.340 --> 00:34:10.700
one of those put it

NOTE Confidence: 0.9282068

00:34:10.700 --> 00:34:11.739
as a higher risk, and,

NOTE Confidence: 0.9282068

00:34:11.739 --> 00:34:13.605
actually, guidelines are calling for

NOTE Confidence: 0.9282068

00:34:13.765 --> 00:34:15.525
starting colorectal cancer screening at

NOTE Confidence: 0.9282068

00:34:15.525 --> 00:34:16.585
an earlier age,

NOTE Confidence: 0.9563581

00:34:16.885 --> 00:34:18.405
age forty, or whenever the

NOTE Confidence: 0.9563581

00:34:18.405 --> 00:34:19.685
diagnosis was made in that

NOTE Confidence: 0.9563581

00:34:19.685 --> 00:34:21.225
family member. So that's

NOTE Confidence: 0.9341919

00:34:21.605 --> 00:34:22.965
how important it is that

NOTE Confidence: 0.9341919

00:34:22.965 --> 00:34:24.405
we know even if our

NOTE Confidence: 0.9341919

00:34:24.405 --> 00:34:25.950
family member has had just

NOTE Confidence: 0.9341919

00:34:25.950 --> 00:34:27.070
two polyps and is like,

NOTE Confidence: 0.9341919

00:34:27.070 --> 00:34:28.349
okay. Well, big deal. Well,

NOTE Confidence: 0.9341919

00:34:28.349 --> 00:34:29.969
no actually can have implications

NOTE Confidence: 0.9341919

00:34:30.109 --> 00:34:31.630
on how we approach screening

NOTE Confidence: 0.9341919

00:34:31.630 --> 00:34:33.730
for our family members. So

NOTE Confidence: 0.9341919

00:34:33.869 --> 00:34:35.310
very, very important, number one,

NOTE Confidence: 0.9341919

00:34:35.310 --> 00:34:36.910
as physicians to provide that

NOTE Confidence: 0.9341919

00:34:36.910 --> 00:34:38.450
information to our patients

NOTE Confidence: 0.99560624

00:34:38.864 --> 00:34:40.145
and and make them understand

NOTE Confidence: 0.99560624

00:34:40.145 --> 00:34:41.665
that that has implications for,

NOTE Confidence: 0.99560624

00:34:41.985 --> 00:34:42.585
for their,

NOTE Confidence: 0.9967702

00:34:43.665 --> 00:34:44.165
relatives.

NOTE Confidence: 0.966663

00:34:47.665 --> 00:34:49.185
Ben, thank you so much,

NOTE Confidence: 0.966663

00:34:49.265 --> 00:34:50.625
Javier. As you're saying that,

NOTE Confidence: 0.966663

00:34:50.785 --> 00:34:51.505
you know, I was writing

NOTE Confidence: 0.966663

00:34:51.505 --> 00:34:52.864
down notes as well. I

NOTE Confidence: 0.966663

00:34:52.864 --> 00:34:54.325
feel like such an important

NOTE Confidence: 0.9978027

00:34:54.650 --> 00:34:56.010
key clinical pearl that you

NOTE Confidence: 0.9978027

00:34:56.010 --> 00:34:57.450
shared right there was not

NOTE Confidence: 0.9978027

00:34:57.450 --> 00:34:58.730
to miss those high risk

NOTE Confidence: 0.9978027

00:34:58.730 --> 00:34:59.230
polyps.

NOTE Confidence: 0.99633455

00:35:00.090 --> 00:35:00.590
Again,

NOTE Confidence: 0.9603627

00:35:01.130 --> 00:35:03.450
we're seeing, colorectal cancer and

NOTE Confidence: 0.9603627

00:35:03.450 --> 00:35:05.150
polyps much earlier,

NOTE Confidence: 0.9859163

00:35:06.010 --> 00:35:06.830
in younger

NOTE Confidence: 0.7458111

00:35:07.210 --> 00:35:08.295
patients. So,

NOTE Confidence: 0.99258167

00:35:08.775 --> 00:35:10.375
not dismissing just polyps in

NOTE Confidence: 0.99258167

00:35:10.375 --> 00:35:11.015
the family,

NOTE Confidence: 0.98814505

00:35:11.335 --> 00:35:12.454
is very important. So in

NOTE Confidence: 0.98814505

00:35:12.454 --> 00:35:13.275
this case,

NOTE Confidence: 0.96635634

00:35:13.974 --> 00:35:15.255
getting a lot more history

NOTE Confidence: 0.96635634

00:35:15.255 --> 00:35:16.555
from the patient if they

NOTE Confidence: 0.96635634

00:35:16.775 --> 00:35:17.575
can share it, like,

NOTE Confidence: 0.94995993

00:35:19.575 --> 00:35:21.255
it would be so, vital

NOTE Confidence: 0.94995993

00:35:21.255 --> 00:35:21.915
and important.

NOTE Confidence: 0.97654486

00:35:22.410 --> 00:35:24.250
And then from the primary

NOTE Confidence: 0.97654486

00:35:24.250 --> 00:35:25.770
care side, I guess what

NOTE Confidence: 0.97654486

00:35:25.770 --> 00:35:26.730
I would want to ask

NOTE Confidence: 0.97654486

00:35:26.730 --> 00:35:28.270
our specialist colleagues is,

NOTE Confidence: 0.99883014

00:35:28.969 --> 00:35:30.329
how would we want to

NOTE Confidence: 0.99883014

00:35:30.329 --> 00:35:31.069
go about

NOTE Confidence: 0.99317455

00:35:31.369 --> 00:35:32.890
managing this patient? Like, after

NOTE Confidence: 0.99317455

00:35:32.890 --> 00:35:33.849
we get, like, a more

NOTE Confidence: 0.99317455

00:35:33.849 --> 00:35:34.670
thorough history,

NOTE Confidence: 0.9994172

00:35:35.335 --> 00:35:35.835
would

NOTE Confidence: 0.9917427

00:35:36.135 --> 00:35:37.094
we refer them to our

NOTE Confidence: 0.9917427

00:35:37.094 --> 00:35:38.695
GI colleagues or want to

NOTE Confidence: 0.9917427

00:35:38.695 --> 00:35:39.815
touch base and coordinate with

NOTE Confidence: 0.9917427

00:35:39.815 --> 00:35:41.515
our, genetic colleagues?

NOTE Confidence: 0.99905497

00:35:42.215 --> 00:35:43.435
Where would you recommend?

NOTE Confidence: 0.9404336

00:35:45.495 --> 00:35:46.855
Yeah. I think definitely when

NOTE Confidence: 0.9404336

00:35:46.855 --> 00:35:48.075
we get that information

NOTE Confidence: 0.9610066

00:35:48.375 --> 00:35:49.950
from, from mom, that would

NOTE Confidence: 0.9610066

00:35:49.950 --> 00:35:51.250
really help us understand.

NOTE Confidence: 0.9915181

00:35:51.630 --> 00:35:52.910
If we do have a

NOTE Confidence: 0.9915181

00:35:52.910 --> 00:35:54.350
suspicion that mom can have

NOTE Confidence: 0.9915181

00:35:54.350 --> 00:35:55.410
a genetic syndrome,

NOTE Confidence: 0.9750894

00:35:55.869 --> 00:35:57.150
the appropriate thing would be,

NOTE Confidence: 0.8624127

00:35:57.710 --> 00:35:58.989
seeing if mom could actually

NOTE Confidence: 0.8624127

00:35:58.989 --> 00:36:01.730
have that, assessment because she's

NOTE Confidence: 0.8624127

00:36:01.950 --> 00:36:02.450
that.

NOTE Confidence: 0.9548237

00:36:02.830 --> 00:36:03.795
I I think that'd be

NOTE Confidence: 0.9548237

00:36:03.795 --> 00:36:05.555
number one. If what, if

NOTE Confidence: 0.9548237

00:36:05.555 --> 00:36:06.355
at the end what we

NOTE Confidence: 0.9548237

00:36:06.355 --> 00:36:08.295
have is, mom had several

NOTE Confidence: 0.9548237

00:36:08.435 --> 00:36:10.135
polyps, none of them advanced

NOTE Confidence: 0.9548237

00:36:10.355 --> 00:36:11.395
or whatever, we can take

NOTE Confidence: 0.9548237

00:36:11.395 --> 00:36:12.295
another approach.

NOTE Confidence: 0.98812234

00:36:12.755 --> 00:36:13.875
And, and,

NOTE Confidence: 0.9447366

00:36:14.435 --> 00:36:16.295
so really, having that information

NOTE Confidence: 0.9447366

00:36:16.435 --> 00:36:17.610
will make a difference. And,

NOTE Confidence: 0.9447366

00:36:17.610 --> 00:36:18.810
again, if we do think

NOTE Confidence: 0.9447366

00:36:18.810 --> 00:36:19.130
it's,

NOTE Confidence: 0.92332476

00:36:19.930 --> 00:36:21.370
it could be genetic as

NOTE Confidence: 0.92332476

00:36:21.370 --> 00:36:22.810
need, to be ruled out

NOTE Confidence: 0.92332476

00:36:22.810 --> 00:36:24.490
that case, always try to

NOTE Confidence: 0.92332476

00:36:24.490 --> 00:36:25.230
get mom,

NOTE Confidence: 0.969573

00:36:26.090 --> 00:36:27.370
because, you know, she's the

NOTE Confidence: 0.969573

00:36:27.370 --> 00:36:28.810
affected one. If there's no

NOTE Confidence: 0.969573

00:36:28.810 --> 00:36:30.570
possibility, then we could definitely

NOTE Confidence: 0.969573

00:36:30.570 --> 00:36:32.125
test her. And nowadays, panel

NOTE Confidence: 0.969573

00:36:32.125 --> 00:36:33.805
testing allows for testing all

NOTE Confidence: 0.969573

00:36:33.805 --> 00:36:34.845
all the genes that we

NOTE Confidence: 0.969573

00:36:34.845 --> 00:36:35.985
were showing here

NOTE Confidence: 0.9469045

00:36:36.364 --> 00:36:37.805
at a with a single

NOTE Confidence: 0.9469045

00:36:37.805 --> 00:36:39.905
test, so something that's relatively

NOTE Confidence: 0.9469045

00:36:39.965 --> 00:36:40.785
easy to do.

NOTE Confidence: 0.97756153

00:36:41.325 --> 00:36:42.545
Absolutely. We oftentimes,

NOTE Confidence: 0.9751858

00:36:43.165 --> 00:36:44.864
get partial history and fragmented

NOTE Confidence: 0.9751858

00:36:45.005 --> 00:36:46.650
history sometimes, and we may

NOTE Confidence: 0.9751858

00:36:46.650 --> 00:36:48.089
end up having to test

NOTE Confidence: 0.9751858

00:36:48.089 --> 00:36:48.329
our,

NOTE Confidence: 0.9046647

00:36:48.969 --> 00:36:50.809
actual patients. Thank you again

NOTE Confidence: 0.9046647

00:36:50.809 --> 00:36:52.030
for your clinical insights.

NOTE Confidence: 0.9814276

00:36:53.289 --> 00:36:54.489
With that, I think we'll

NOTE Confidence: 0.9814276

00:36:54.489 --> 00:36:56.010
move on to case number

NOTE Confidence: 0.9814276

00:36:56.010 --> 00:36:56.510
three.

NOTE Confidence: 0.9524023

00:36:57.289 --> 00:36:57.789
And

NOTE Confidence: 0.9765281

00:36:58.089 --> 00:36:59.289
with that, this one will

NOTE Confidence: 0.9765281

00:36:59.289 --> 00:37:00.809
be more so an early

NOTE Confidence: 0.9765281

00:37:00.809 --> 00:37:01.869
onset colorectal

NOTE Confidence: 0.9879909

00:37:02.454 --> 00:37:03.655
cancer. So I'll read this

NOTE Confidence: 0.9879909

00:37:03.655 --> 00:37:04.315
as well.

NOTE Confidence: 0.9683392

00:37:04.694 --> 00:37:05.575
We have a thirty nine

NOTE Confidence: 0.9683392

00:37:05.575 --> 00:37:06.934
year old female with no

NOTE Confidence: 0.9683392

00:37:06.934 --> 00:37:08.934
significant past medical history except

NOTE Confidence: 0.9683392

00:37:08.934 --> 00:37:10.315
iron deficiency anemia

NOTE Confidence: 0.9527595

00:37:10.614 --> 00:37:12.454
and IBS who presents to

NOTE Confidence: 0.9527595

00:37:12.454 --> 00:37:14.214
her PCP for a routine

NOTE Confidence: 0.9527595

00:37:14.214 --> 00:37:15.194
physical appointment.

NOTE Confidence: 0.9823946

00:37:15.910 --> 00:37:17.670
Active problems wise, she has

NOTE Confidence: 0.9823946

00:37:17.670 --> 00:37:18.969
iron deficiency anemia,

NOTE Confidence: 0.96287626

00:37:19.510 --> 00:37:20.010
menorrhagia,

NOTE Confidence: 0.99679494

00:37:20.310 --> 00:37:22.150
and IBS. Medication wise,

NOTE Confidence: 0.9925636

00:37:22.550 --> 00:37:23.770
takes an iron supplement,

NOTE Confidence: 0.98193246

00:37:24.150 --> 00:37:25.770
oral contraceptive pill.

NOTE Confidence: 0.9589413

00:37:26.150 --> 00:37:27.670
Social history wise, she's a

NOTE Confidence: 0.9589413

00:37:27.670 --> 00:37:29.675
single mother of two, young

NOTE Confidence: 0.9589413

00:37:29.675 --> 00:37:30.175
children.

NOTE Confidence: 0.96135837

00:37:30.875 --> 00:37:32.475
Habits wise, never a smoker,

NOTE Confidence: 0.96135837

00:37:32.475 --> 00:37:34.015
denies alcohol as well.

NOTE Confidence: 0.9736487

00:37:34.635 --> 00:37:36.575
Occupational wise, is a waitress.

NOTE Confidence: 0.9736487

00:37:36.795 --> 00:37:38.635
And family history, no significant

NOTE Confidence: 0.9736487

00:37:38.635 --> 00:37:39.535
family history.

NOTE Confidence: 0.9761473

00:37:41.289 --> 00:37:43.450
Continuing on, on review of

NOTE Confidence: 0.9761473

00:37:43.450 --> 00:37:45.369
systems, she reports over the

NOTE Confidence: 0.9761473

00:37:45.369 --> 00:37:46.969
last eight months feeling more

NOTE Confidence: 0.9761473

00:37:46.969 --> 00:37:48.969
tired, and her IBS symptoms

NOTE Confidence: 0.9761473

00:37:48.969 --> 00:37:50.569
of bloating and diarrhea are

NOTE Confidence: 0.9761473

00:37:50.569 --> 00:37:52.410
worse, which she attributes to

NOTE Confidence: 0.9761473

00:37:52.410 --> 00:37:53.385
work related stress.

NOTE Confidence: 0.94102746

00:37:54.425 --> 00:37:55.945
Labs wise, she shows a

NOTE Confidence: 0.94102746

00:37:55.945 --> 00:37:56.445
hemoglobin

NOTE Confidence: 0.99324137

00:37:56.745 --> 00:37:58.265
of nine from down from

NOTE Confidence: 0.99324137

00:37:58.265 --> 00:37:58.765
eleven.

NOTE Confidence: 0.98540044

00:37:59.225 --> 00:38:01.225
Iron studies show persistent iron

NOTE Confidence: 0.98540044

00:38:01.225 --> 00:38:01.725
deficiency.

NOTE Confidence: 0.99423295

00:38:02.825 --> 00:38:04.105
She has not been taking

NOTE Confidence: 0.99423295

00:38:04.105 --> 00:38:05.705
iron because she feels it

NOTE Confidence: 0.99423295

00:38:05.705 --> 00:38:06.445
makes her

NOTE Confidence: 0.99624676

00:38:06.745 --> 00:38:08.125
abdominal symptoms worse.

NOTE Confidence: 0.87805444

00:38:08.890 --> 00:38:11.050
A lab somewhat improved after

NOTE Confidence: 0.87805444

00:38:11.050 --> 00:38:11.850
IV iron,

NOTE Confidence: 0.9899691

00:38:12.330 --> 00:38:12.830
repletion,

NOTE Confidence: 0.9821522

00:38:13.290 --> 00:38:14.650
but her symptoms continued to

NOTE Confidence: 0.9821522

00:38:14.650 --> 00:38:15.690
get worse, and she was

NOTE Confidence: 0.9821522

00:38:15.690 --> 00:38:16.750
referred to GI.

NOTE Confidence: 0.9972413

00:38:17.130 --> 00:38:17.630
Colonoscopy

NOTE Confidence: 0.9487316

00:38:18.170 --> 00:38:20.010
was done, which showed a

NOTE Confidence: 0.9487316

00:38:20.010 --> 00:38:22.410
sigmoid mass, and biopsy showed

NOTE Confidence: 0.9487316

00:38:22.410 --> 00:38:22.910
adenocarcinoma.

NOTE Confidence: 0.97088146

00:38:27.145 --> 00:38:28.744
So at this point, what

NOTE Confidence: 0.97088146

00:38:28.744 --> 00:38:30.585
parts of our history is,

NOTE Confidence: 0.97088146

00:38:30.905 --> 00:38:32.585
standing out? What are some

NOTE Confidence: 0.97088146

00:38:32.585 --> 00:38:34.665
special considerations for young adults

NOTE Confidence: 0.97088146

00:38:34.665 --> 00:38:36.025
who are diagnosed with cancer?

NOTE Confidence: 0.97088146

00:38:36.025 --> 00:38:36.825
And with that, I'd like

NOTE Confidence: 0.97088146

00:38:36.825 --> 00:38:38.265
to, hand it over to

NOTE Confidence: 0.97088146

00:38:38.265 --> 00:38:39.165
Tejal, please.

NOTE Confidence: 0.9992771

00:38:39.549 --> 00:38:40.930
Yeah. Thank you so much.

NOTE Confidence: 0.98316646

00:38:41.230 --> 00:38:43.069
I think, this is, one

NOTE Confidence: 0.98316646

00:38:43.069 --> 00:38:45.069
of our greatest fears is

NOTE Confidence: 0.98316646

00:38:45.069 --> 00:38:46.210
that we're seeing

NOTE Confidence: 0.9995331

00:38:46.829 --> 00:38:49.390
younger and younger people being

NOTE Confidence: 0.9995331

00:38:49.390 --> 00:38:49.890
diagnosed

NOTE Confidence: 0.9752584

00:38:50.510 --> 00:38:52.269
with not only colorectal cancer,

NOTE Confidence: 0.9752584

00:38:52.269 --> 00:38:53.630
but other cancer types as

NOTE Confidence: 0.9752584

00:38:53.630 --> 00:38:54.130
well,

NOTE Confidence: 0.9943122

00:38:54.645 --> 00:38:55.625
every single day.

NOTE Confidence: 0.99478406

00:38:56.325 --> 00:38:56.825
And

NOTE Confidence: 0.95542264

00:38:57.364 --> 00:38:58.185
this is,

NOTE Confidence: 0.8949742

00:38:58.725 --> 00:38:59.225
you

NOTE Confidence: 0.984146

00:38:59.525 --> 00:39:00.885
know, based on a patient

NOTE Confidence: 0.984146

00:39:00.885 --> 00:39:02.585
who I've seen recently

NOTE Confidence: 0.95525014

00:39:03.285 --> 00:39:04.165
and a story that we're

NOTE Confidence: 0.95525014

00:39:04.165 --> 00:39:05.525
hearing over and over again.

NOTE Confidence: 0.95525014

00:39:05.525 --> 00:39:07.625
Someone who was otherwise healthy

NOTE Confidence: 0.98596156

00:39:08.000 --> 00:39:10.180
has no family history, really

NOTE Confidence: 0.92164564

00:39:10.640 --> 00:39:11.839
not much in terms of

NOTE Confidence: 0.92164564

00:39:11.839 --> 00:39:12.739
risk factors,

NOTE Confidence: 0.99910754

00:39:13.040 --> 00:39:13.540
and

NOTE Confidence: 0.9988925

00:39:14.319 --> 00:39:14.819
they

NOTE Confidence: 0.9801624

00:39:15.119 --> 00:39:16.319
had been doing well until

NOTE Confidence: 0.9801624

00:39:16.319 --> 00:39:17.619
they weren't. And

NOTE Confidence: 0.9822097

00:39:18.480 --> 00:39:19.599
they come to this complete

NOTE Confidence: 0.9822097

00:39:19.599 --> 00:39:21.299
shock of getting a diagnosis

NOTE Confidence: 0.9822097

00:39:21.359 --> 00:39:22.480
of cancer at such a

NOTE Confidence: 0.9822097

00:39:22.480 --> 00:39:23.295
young age.

NOTE Confidence: 0.97471327

00:39:24.255 --> 00:39:25.474
So, I think,

NOTE Confidence: 0.9871739

00:39:26.974 --> 00:39:28.094
that the fact that we're

NOTE Confidence: 0.9871739

00:39:28.094 --> 00:39:29.295
seeing these trends and what

NOTE Confidence: 0.9871739

00:39:29.295 --> 00:39:30.734
we'll be talking about more

NOTE Confidence: 0.9871739

00:39:30.734 --> 00:39:31.234
is

NOTE Confidence: 0.98956525

00:39:31.775 --> 00:39:33.234
when you are having

NOTE Confidence: 0.9992338

00:39:33.694 --> 00:39:34.674
these unexplained

NOTE Confidence: 0.97927797

00:39:35.055 --> 00:39:36.755
and these persistent symptoms,

NOTE Confidence: 0.98553896

00:39:37.750 --> 00:39:38.790
even in our younger and

NOTE Confidence: 0.98553896

00:39:38.790 --> 00:39:40.710
healthier patients, we need to

NOTE Confidence: 0.98553896

00:39:40.710 --> 00:39:41.830
be acting on them. We

NOTE Confidence: 0.98553896

00:39:41.830 --> 00:39:42.870
need to be picking them

NOTE Confidence: 0.98553896

00:39:42.870 --> 00:39:43.910
up and we need to

NOTE Confidence: 0.98553896

00:39:43.910 --> 00:39:45.210
get further evaluation

NOTE Confidence: 0.9974994

00:39:45.750 --> 00:39:46.250
promptly.

NOTE Confidence: 0.8854172

00:39:47.350 --> 00:39:47.850
So,

NOTE Confidence: 0.99523044

00:39:49.110 --> 00:39:50.010
as I mentioned,

NOTE Confidence: 0.9993365

00:39:51.350 --> 00:39:52.730
we've been seeing

NOTE Confidence: 0.98798585

00:39:53.265 --> 00:39:54.545
data over and over again,

NOTE Confidence: 0.98798585

00:39:54.545 --> 00:39:55.664
and you've probably read in

NOTE Confidence: 0.98798585

00:39:55.664 --> 00:39:56.244
the news

NOTE Confidence: 0.98951024

00:39:56.625 --> 00:39:58.065
that we're seeing rising rates

NOTE Confidence: 0.98951024

00:39:58.065 --> 00:40:00.065
and increasing incidence of what

NOTE Confidence: 0.98951024

00:40:00.065 --> 00:40:01.184
we term as early onset

NOTE Confidence: 0.98951024

00:40:01.184 --> 00:40:02.325
colorectal cancer.

NOTE Confidence: 0.9971717

00:40:03.025 --> 00:40:03.984
When I say the term

NOTE Confidence: 0.9971717

00:40:03.984 --> 00:40:06.005
early onset, I'm specifically

NOTE Confidence: 0.9998254

00:40:06.625 --> 00:40:07.125
referring

NOTE Confidence: 0.96107787

00:40:07.550 --> 00:40:09.170
to adults who are diagnosed

NOTE Confidence: 0.96107787

00:40:09.230 --> 00:40:10.430
under eight under the age

NOTE Confidence: 0.96107787

00:40:10.430 --> 00:40:12.430
of forty nine, although that's

NOTE Confidence: 0.96107787

00:40:12.430 --> 00:40:13.650
not a strict definition.

NOTE Confidence: 0.9860867

00:40:14.590 --> 00:40:17.010
And as this graph depicts,

NOTE Confidence: 0.96438354

00:40:17.469 --> 00:40:18.590
not only are we seeing

NOTE Confidence: 0.96438354

00:40:18.590 --> 00:40:19.969
an increasing incidence,

NOTE Confidence: 0.9994275

00:40:20.705 --> 00:40:22.485
but we're also seeing that

NOTE Confidence: 0.98551613

00:40:22.945 --> 00:40:23.844
while mortality

NOTE Confidence: 0.99950737

00:40:24.225 --> 00:40:25.125
had been decreasing

NOTE Confidence: 0.9937191

00:40:25.505 --> 00:40:27.445
for a very long time,

NOTE Confidence: 0.999492

00:40:27.825 --> 00:40:29.525
we then saw the mortality

NOTE Confidence: 0.999492

00:40:29.585 --> 00:40:31.045
in this young adult population

NOTE Confidence: 0.9319029

00:40:31.665 --> 00:40:33.425
plateau and now actually looks

NOTE Confidence: 0.9319029

00:40:33.425 --> 00:40:34.965
like it's starting to increase.

NOTE Confidence: 0.97843176

00:40:35.610 --> 00:40:36.570
I think one of our

NOTE Confidence: 0.97843176

00:40:36.570 --> 00:40:38.730
biggest questions is why is

NOTE Confidence: 0.97843176

00:40:38.730 --> 00:40:39.470
this happening?

NOTE Confidence: 0.9985437

00:40:40.090 --> 00:40:41.530
And we don't have a

NOTE Confidence: 0.9985437

00:40:41.530 --> 00:40:43.370
great explanation. The reality is

NOTE Confidence: 0.9985437

00:40:43.370 --> 00:40:44.430
that it's probably

NOTE Confidence: 0.99896413

00:40:44.970 --> 00:40:47.370
multiple different factors that are

NOTE Confidence: 0.99896413

00:40:47.370 --> 00:40:47.870
interacting.

NOTE Confidence: 0.9915969

00:40:48.730 --> 00:40:49.850
It might be, you know,

NOTE Confidence: 0.9915969

00:40:49.850 --> 00:40:51.305
the fact that we are

NOTE Confidence: 0.9915969

00:40:51.305 --> 00:40:53.644
having increasing rates of obesity

NOTE Confidence: 0.9915969

00:40:53.864 --> 00:40:55.944
and sedentary lifestyle. There's maybe

NOTE Confidence: 0.9915969

00:40:55.944 --> 00:40:57.385
something in the environment, what

NOTE Confidence: 0.9915969

00:40:57.385 --> 00:40:58.684
we're eating, what we're drinking,

NOTE Confidence: 0.9586831

00:40:59.144 --> 00:41:00.744
something that we're exposed to,

NOTE Confidence: 0.9586831

00:41:00.744 --> 00:41:02.025
all of these things that

NOTE Confidence: 0.9586831

00:41:02.025 --> 00:41:03.005
might be changing

NOTE Confidence: 0.9964979

00:41:03.660 --> 00:41:04.799
our gut microbiome

NOTE Confidence: 0.98609364

00:41:05.420 --> 00:41:06.940
and may lead to more

NOTE Confidence: 0.98609364

00:41:06.940 --> 00:41:07.920
of an inflammatory

NOTE Confidence: 0.888993

00:41:08.460 --> 00:41:08.960
phenotype,

NOTE Confidence: 0.9846188

00:41:09.260 --> 00:41:10.460
which might be increasing our

NOTE Confidence: 0.9846188

00:41:10.460 --> 00:41:11.520
chances of cancer.

NOTE Confidence: 0.9825535

00:41:11.980 --> 00:41:13.819
But we don't have any

NOTE Confidence: 0.9825535

00:41:13.819 --> 00:41:15.680
sort of slam dunk explanation,

NOTE Confidence: 0.9741083

00:41:16.434 --> 00:41:17.395
And there's a lot of

NOTE Confidence: 0.9741083

00:41:17.395 --> 00:41:18.515
research that's going on and

NOTE Confidence: 0.9741083

00:41:18.515 --> 00:41:19.974
trying to figure this out.

NOTE Confidence: 0.74204624

00:41:20.835 --> 00:41:21.335
Now,

NOTE Confidence: 0.9736682

00:41:22.515 --> 00:41:23.015
what's

NOTE Confidence: 0.94891465

00:41:23.875 --> 00:41:25.714
I think challenging, not only

NOTE Confidence: 0.94891465

00:41:25.714 --> 00:41:27.395
about the fact that we're

NOTE Confidence: 0.94891465

00:41:27.395 --> 00:41:28.295
getting the diagnosis

NOTE Confidence: 0.9586462

00:41:28.950 --> 00:41:30.250
of cancer in these younger,

NOTE Confidence: 0.8809481

00:41:30.790 --> 00:41:31.290
people,

NOTE Confidence: 0.99311966

00:41:31.910 --> 00:41:32.890
but oftentimes

NOTE Confidence: 0.98948956

00:41:33.670 --> 00:41:35.210
we're catching them late.

NOTE Confidence: 0.99938536

00:41:35.830 --> 00:41:36.650
We're seeing

NOTE Confidence: 0.99452096

00:41:36.950 --> 00:41:39.290
young people present with advanced

NOTE Confidence: 0.99452096

00:41:39.430 --> 00:41:40.790
disease by the time that

NOTE Confidence: 0.99452096

00:41:40.790 --> 00:41:41.609
they're diagnosed.

NOTE Confidence: 0.9998179

00:41:42.575 --> 00:41:43.714
Some of it might

NOTE Confidence: 0.98783165

00:41:44.094 --> 00:41:44.974
be the fact that the

NOTE Confidence: 0.98783165

00:41:44.974 --> 00:41:46.575
biology of the cancer itself

NOTE Confidence: 0.98783165

00:41:46.575 --> 00:41:47.055
might be,

NOTE Confidence: 0.91832405

00:41:47.535 --> 00:41:48.734
some, a little bit more

NOTE Confidence: 0.91832405

00:41:48.734 --> 00:41:49.234
aggressive.

NOTE Confidence: 0.9994801

00:41:49.694 --> 00:41:50.654
But there are a lot

NOTE Confidence: 0.9994801

00:41:50.654 --> 00:41:52.275
of other factors as well.

NOTE Confidence: 0.99200857

00:41:52.575 --> 00:41:53.315
There are,

NOTE Confidence: 0.98735

00:41:53.855 --> 00:41:55.214
factors related to the patients

NOTE Confidence: 0.98735

00:41:55.214 --> 00:41:56.894
themselves. They might be ignoring

NOTE Confidence: 0.98735

00:41:56.894 --> 00:41:58.230
symptoms they have. They might

NOTE Confidence: 0.98735

00:41:58.230 --> 00:41:59.690
think, oh, I'm healthy otherwise.

NOTE Confidence: 0.9876457

00:42:00.070 --> 00:42:01.590
I'm just not feeling great

NOTE Confidence: 0.9876457

00:42:01.590 --> 00:42:02.250
right now.

NOTE Confidence: 0.9914879

00:42:02.630 --> 00:42:03.989
And so that might mean

NOTE Confidence: 0.9914879

00:42:03.989 --> 00:42:06.230
that they are not looking

NOTE Confidence: 0.9914879

00:42:06.230 --> 00:42:07.350
for care. A lot of

NOTE Confidence: 0.9914879

00:42:07.350 --> 00:42:08.950
young people don't have primary

NOTE Confidence: 0.9914879

00:42:08.950 --> 00:42:10.310
care doctors. And so by

NOTE Confidence: 0.9914879

00:42:10.310 --> 00:42:11.510
the time they something is

NOTE Confidence: 0.9914879

00:42:11.510 --> 00:42:12.485
wrong, it takes them a

NOTE Confidence: 0.9914879

00:42:12.485 --> 00:42:13.525
long time to actually get

NOTE Confidence: 0.9914879

00:42:13.525 --> 00:42:14.745
in to see someone.

NOTE Confidence: 0.99553686

00:42:15.205 --> 00:42:16.245
There's also a lot of

NOTE Confidence: 0.99553686

00:42:16.245 --> 00:42:18.085
fear around this diagnosis, some

NOTE Confidence: 0.99553686

00:42:18.085 --> 00:42:19.465
embarrassment as well.

NOTE Confidence: 0.97122526

00:42:19.765 --> 00:42:21.364
There's also factors that might

NOTE Confidence: 0.97122526

00:42:21.364 --> 00:42:22.825
be related to the physicians

NOTE Confidence: 0.97122526

00:42:22.885 --> 00:42:24.245
that lead to to to

NOTE Confidence: 0.97122526

00:42:24.245 --> 00:42:25.465
the delay. They might

NOTE Confidence: 0.9700431

00:42:25.869 --> 00:42:27.390
miss symptoms, or they might

NOTE Confidence: 0.9700431

00:42:27.390 --> 00:42:27.890
attribute

NOTE Confidence: 0.9977393

00:42:28.349 --> 00:42:29.710
some of the symptoms to

NOTE Confidence: 0.9977393

00:42:29.710 --> 00:42:31.010
other more common

NOTE Confidence: 0.9292119

00:42:31.550 --> 00:42:32.050
diagnoses.

NOTE Confidence: 0.9951997

00:42:32.510 --> 00:42:33.550
A lot of these presenting

NOTE Confidence: 0.9951997

00:42:33.550 --> 00:42:35.070
symptoms can be vague. It's

NOTE Confidence: 0.9951997

00:42:35.070 --> 00:42:35.730
it's not

NOTE Confidence: 0.97568524

00:42:36.430 --> 00:42:37.550
most of the time, it's

NOTE Confidence: 0.97568524

00:42:37.550 --> 00:42:38.290
not clear.

NOTE Confidence: 0.97473764

00:42:38.895 --> 00:42:40.655
And this might mean that

NOTE Confidence: 0.97473764

00:42:40.655 --> 00:42:42.175
there are delayed referrals and

NOTE Confidence: 0.97473764

00:42:42.175 --> 00:42:43.075
further examination.

NOTE Confidence: 0.97194123

00:42:43.935 --> 00:42:45.375
And then ultimately, there are

NOTE Confidence: 0.97194123

00:42:45.375 --> 00:42:46.815
a lot of system related

NOTE Confidence: 0.97194123

00:42:46.815 --> 00:42:48.035
days delays,

NOTE Confidence: 0.9822426

00:42:48.335 --> 00:42:50.335
limited resources in terms of

NOTE Confidence: 0.9822426

00:42:50.335 --> 00:42:51.555
providers, particularly

NOTE Confidence: 0.9863762

00:42:51.855 --> 00:42:53.075
in rural areas.

NOTE Confidence: 0.9715404

00:42:53.610 --> 00:42:55.770
The appointments are delayed. We're

NOTE Confidence: 0.9715404

00:42:55.770 --> 00:42:57.770
needing more and more help

NOTE Confidence: 0.9715404

00:42:57.770 --> 00:42:58.910
to take care of this

NOTE Confidence: 0.987264

00:42:59.850 --> 00:43:01.450
population, but we just aren't

NOTE Confidence: 0.987264

00:43:01.450 --> 00:43:02.250
able to meet it with

NOTE Confidence: 0.987264

00:43:02.250 --> 00:43:03.710
the resources that we have

NOTE Confidence: 0.987264

00:43:04.010 --> 00:43:05.390
available to us.

NOTE Confidence: 0.9559491

00:43:06.885 --> 00:43:08.585
Now when a young adult

NOTE Confidence: 0.9559491

00:43:08.805 --> 00:43:11.465
is diagnosed with colorectal cancer,

NOTE Confidence: 0.9994581

00:43:12.085 --> 00:43:13.925
there are some unique things

NOTE Confidence: 0.9994581

00:43:13.925 --> 00:43:15.844
to consider that may not

NOTE Confidence: 0.9994581

00:43:15.844 --> 00:43:16.344
be

NOTE Confidence: 0.9957777

00:43:16.645 --> 00:43:18.005
necessarily as much in the

NOTE Confidence: 0.9957777

00:43:18.005 --> 00:43:20.425
forefront in our older patients.

NOTE Confidence: 0.9979244

00:43:21.190 --> 00:43:21.930
For example,

NOTE Confidence: 0.96450907

00:43:22.710 --> 00:43:24.230
you know, this young woman,

NOTE Confidence: 0.96450907

00:43:24.230 --> 00:43:25.830
she might still be wanting

NOTE Confidence: 0.96450907

00:43:25.830 --> 00:43:27.190
to have more children. So

NOTE Confidence: 0.96450907

00:43:27.190 --> 00:43:28.570
fertility is a consideration.

NOTE Confidence: 0.98368835

00:43:28.950 --> 00:43:29.989
And how do the treatment

NOTE Confidence: 0.98368835

00:43:29.989 --> 00:43:31.030
options that we have for

NOTE Confidence: 0.98368835

00:43:31.030 --> 00:43:32.170
colorectal cancer

NOTE Confidence: 0.9639866

00:43:32.790 --> 00:43:34.070
relate to that and have

NOTE Confidence: 0.9639866

00:43:34.070 --> 00:43:34.570
impact

NOTE Confidence: 0.80361766

00:43:35.495 --> 00:43:37.435
that. Their unique family dynamics.

NOTE Confidence: 0.98094016

00:43:37.815 --> 00:43:39.594
This young adult population oftentimes

NOTE Confidence: 0.98094016

00:43:39.735 --> 00:43:41.915
will have young children, toddlers.

NOTE Confidence: 0.9577568

00:43:42.215 --> 00:43:43.575
They might also taking care

NOTE Confidence: 0.9577568

00:43:43.575 --> 00:43:45.415
of their elderly parents as

NOTE Confidence: 0.9577568

00:43:45.415 --> 00:43:45.915
well.

NOTE Confidence: 0.91620505

00:43:46.695 --> 00:43:48.215
Sometimes they are the primary

NOTE Confidence: 0.91620505

00:43:48.215 --> 00:43:49.435
care the primary,

NOTE Confidence: 0.960413

00:43:49.895 --> 00:43:51.090
breadwinners in the family in

NOTE Confidence: 0.960413

00:43:51.090 --> 00:43:52.370
terms of their career. They

NOTE Confidence: 0.960413

00:43:52.370 --> 00:43:53.090
might be the only one

NOTE Confidence: 0.960413

00:43:53.090 --> 00:43:53.750
in their family

NOTE Confidence: 0.99097234

00:43:54.290 --> 00:43:56.050
who is making money, and

NOTE Confidence: 0.99097234

00:43:56.050 --> 00:43:56.930
so they may not be

NOTE Confidence: 0.99097234

00:43:56.930 --> 00:43:58.530
able to be taking the

NOTE Confidence: 0.99097234

00:43:58.530 --> 00:43:59.730
time off to actually get

NOTE Confidence: 0.99097234

00:43:59.730 --> 00:44:00.470
their treatments.

NOTE Confidence: 0.9615184

00:44:01.730 --> 00:44:02.770
They also might feel more

NOTE Confidence: 0.9615184

00:44:02.770 --> 00:44:04.805
isolated because other people who

NOTE Confidence: 0.9615184

00:44:04.805 --> 00:44:06.005
are their same age aren't

NOTE Confidence: 0.9615184

00:44:06.005 --> 00:44:08.184
dealing with these serious diagnoses.

NOTE Confidence: 0.9615184

00:44:08.325 --> 00:44:10.184
So that's even more of

NOTE Confidence: 0.9615184

00:44:10.405 --> 00:44:12.344
a psychosocial stress on them.

NOTE Confidence: 0.9962613

00:44:12.645 --> 00:44:14.005
And they're more likely to

NOTE Confidence: 0.9962613

00:44:14.005 --> 00:44:15.065
have a genetic,

NOTE Confidence: 0.9834831

00:44:15.605 --> 00:44:17.864
reason for having their colorectal

NOTE Confidence: 0.9834831

00:44:17.924 --> 00:44:19.500
cancer diagnosed, which also has

NOTE Confidence: 0.9834831

00:44:19.500 --> 00:44:20.480
its own implications.

NOTE Confidence: 0.96183425

00:44:21.260 --> 00:44:22.140
And so I think for

NOTE Confidence: 0.96183425

00:44:22.140 --> 00:44:23.500
all of these reasons, there's

NOTE Confidence: 0.96183425

00:44:23.500 --> 00:44:24.080
a real,

NOTE Confidence: 0.99988353

00:44:24.700 --> 00:44:25.200
opportunity

NOTE Confidence: 0.9805693

00:44:25.500 --> 00:44:27.820
here for our oncologists to

NOTE Confidence: 0.9805693

00:44:27.820 --> 00:44:30.480
partner with, primary care who

NOTE Confidence: 0.9805693

00:44:30.540 --> 00:44:32.460
know these patients the best

NOTE Confidence: 0.9805693

00:44:32.460 --> 00:44:34.545
and have followed them for

NOTE Confidence: 0.9805693

00:44:34.545 --> 00:44:36.005
much longer than the oncologist

NOTE Confidence: 0.9805693

00:44:36.145 --> 00:44:36.645
has

NOTE Confidence: 0.9827345

00:44:37.025 --> 00:44:38.484
to work through the holistic

NOTE Confidence: 0.88039154

00:44:38.785 --> 00:44:39.285
picture.

NOTE Confidence: 0.9641965

00:44:39.744 --> 00:44:40.565
At Yale,

NOTE Confidence: 0.9894727

00:44:41.025 --> 00:44:42.625
we've started an early onset

NOTE Confidence: 0.9894727

00:44:42.625 --> 00:44:44.225
cancer program to do just

NOTE Confidence: 0.9894727

00:44:44.225 --> 00:44:45.265
this and to help to

NOTE Confidence: 0.9894727

00:44:45.265 --> 00:44:46.859
address all of these issues

NOTE Confidence: 0.98637384

00:44:47.160 --> 00:44:48.520
in addition to their cancer

NOTE Confidence: 0.98637384

00:44:48.520 --> 00:44:49.340
care specifically.

NOTE Confidence: 0.9884602

00:44:51.640 --> 00:44:52.859
And then just to,

NOTE Confidence: 0.9540662

00:44:53.560 --> 00:44:54.680
share a little bit, like,

NOTE Confidence: 0.9540662

00:44:54.680 --> 00:44:56.940
I love those, unique considerations

NOTE Confidence: 0.9540662

00:44:57.080 --> 00:44:58.440
that you spoke about, Dejal.

NOTE Confidence: 0.9540662

00:44:58.440 --> 00:44:58.875
It's,

NOTE Confidence: 0.9661183

00:44:59.355 --> 00:45:00.875
very challenging with such a

NOTE Confidence: 0.9661183

00:45:00.875 --> 00:45:02.395
young diagnosis. And that's really

NOTE Confidence: 0.9661183

00:45:02.395 --> 00:45:04.015
where our primary care clinicians

NOTE Confidence: 0.9661183

00:45:04.075 --> 00:45:05.755
can be that bridge with

NOTE Confidence: 0.9661183

00:45:05.755 --> 00:45:07.355
our oncology specialists and be

NOTE Confidence: 0.9661183

00:45:07.355 --> 00:45:08.715
there for that holistic care,

NOTE Confidence: 0.9661183

00:45:08.715 --> 00:45:10.175
holistic approach. So,

NOTE Confidence: 0.96142113

00:45:10.475 --> 00:45:12.175
again, really, really important.

NOTE Confidence: 0.97910005

00:45:12.955 --> 00:45:14.075
Going back to the case

NOTE Confidence: 0.97910005

00:45:14.075 --> 00:45:14.575
now,

NOTE Confidence: 0.9720931

00:45:14.930 --> 00:45:16.530
the patient was diagnosed with,

NOTE Confidence: 0.9720931

00:45:16.850 --> 00:45:19.110
stage three sigmoid colon cancer,

NOTE Confidence: 0.98751986

00:45:19.570 --> 00:45:21.910
and she successfully underwent treatment

NOTE Confidence: 0.98751986

00:45:21.970 --> 00:45:23.170
with surgery and,

NOTE Confidence: 0.94563586

00:45:23.570 --> 00:45:24.070
adjuvant,

NOTE Confidence: 0.9711665

00:45:24.850 --> 00:45:25.350
chemotherapy.

NOTE Confidence: 0.98574615

00:45:25.970 --> 00:45:27.570
She followed with oncology for

NOTE Confidence: 0.98574615

00:45:27.570 --> 00:45:29.170
five years without evidence of

NOTE Confidence: 0.98574615

00:45:29.170 --> 00:45:31.325
disease recurrence, but has ongoing

NOTE Confidence: 0.98574615

00:45:31.545 --> 00:45:32.045
challenges?

NOTE Confidence: 0.97795665

00:45:34.185 --> 00:45:35.965
So as I mentioned earlier,

NOTE Confidence: 0.97795665

00:45:36.105 --> 00:45:38.265
surveillance for colorectal cancer per

NOTE Confidence: 0.97795665

00:45:38.265 --> 00:45:39.484
our national guidelines

NOTE Confidence: 0.9810573

00:45:40.025 --> 00:45:41.305
is recommended to follow for

NOTE Confidence: 0.9810573

00:45:41.305 --> 00:45:42.045
five years.

NOTE Confidence: 0.942138

00:45:42.425 --> 00:45:44.160
But it, the buck doesn't

NOTE Confidence: 0.942138

00:45:44.160 --> 00:45:46.080
stop there. The impacts of

NOTE Confidence: 0.942138

00:45:46.080 --> 00:45:48.239
having a cancer diagnosis, both

NOTE Confidence: 0.942138

00:45:48.239 --> 00:45:50.580
physically, but also mentally, emotionally

NOTE Confidence: 0.78422606

00:45:51.520 --> 00:45:52.020
far

NOTE Confidence: 0.9005871

00:45:52.400 --> 00:45:52.900
outlast

NOTE Confidence: 0.9662372

00:45:53.200 --> 00:45:54.820
that five year time mark.

NOTE Confidence: 0.953666

00:45:55.645 --> 00:45:57.105
There are multiple considerations

NOTE Confidence: 0.9881012

00:45:58.045 --> 00:45:58.545
that,

NOTE Confidence: 0.9742903

00:45:59.085 --> 00:46:00.065
that should be,

NOTE Confidence: 0.99950284

00:46:00.765 --> 00:46:01.505
thought about

NOTE Confidence: 0.9747032

00:46:02.125 --> 00:46:03.645
when the care of this,

NOTE Confidence: 0.9747032

00:46:03.965 --> 00:46:05.105
patient shifts

NOTE Confidence: 0.9939585

00:46:05.645 --> 00:46:07.825
more primarily or almost completely

NOTE Confidence: 0.9939585

00:46:07.885 --> 00:46:09.265
back to the primary care

NOTE Confidence: 0.99505574

00:46:09.690 --> 00:46:11.130
doctor at that five year

NOTE Confidence: 0.99505574

00:46:11.130 --> 00:46:11.869
time point.

NOTE Confidence: 0.97331303

00:46:12.329 --> 00:46:13.609
It's not only the physical

NOTE Confidence: 0.97331303

00:46:13.609 --> 00:46:15.869
consideration. So there might be,

NOTE Confidence: 0.99545395

00:46:17.369 --> 00:46:18.650
multiple things to consider in

NOTE Confidence: 0.99545395

00:46:18.650 --> 00:46:20.010
terms of the physical aspect

NOTE Confidence: 0.99545395

00:46:20.010 --> 00:46:21.290
of it. Maybe they have

NOTE Confidence: 0.99545395

00:46:21.290 --> 00:46:22.349
a permanent ostomy.

NOTE Confidence: 0.9998476

00:46:22.815 --> 00:46:24.515
Maybe they have permanent neuropathy

NOTE Confidence: 0.99448663

00:46:24.815 --> 00:46:26.675
from the chemotherapy they had,

NOTE Confidence: 0.99448663

00:46:26.974 --> 00:46:27.855
or they might be at

NOTE Confidence: 0.99448663

00:46:27.855 --> 00:46:29.375
higher risk for another cancer

NOTE Confidence: 0.99448663

00:46:29.375 --> 00:46:30.494
because of the chemo they

NOTE Confidence: 0.99448663

00:46:30.494 --> 00:46:32.335
had. They might look different.

NOTE Confidence: 0.99448663

00:46:32.335 --> 00:46:33.535
They might feel different. They

NOTE Confidence: 0.99448663

00:46:33.535 --> 00:46:34.275
might have

NOTE Confidence: 0.9996338

00:46:34.575 --> 00:46:35.714
fertility impact.

NOTE Confidence: 0.98269284

00:46:36.255 --> 00:46:38.035
There's countless things physically,

NOTE Confidence: 0.9020375

00:46:38.415 --> 00:46:39.690
but but it goes beyond

NOTE Confidence: 0.9020375

00:46:39.750 --> 00:46:41.050
that too. Psychologically,

NOTE Confidence: 0.99292964

00:46:41.989 --> 00:46:43.590
there's trauma from having the

NOTE Confidence: 0.99292964

00:46:43.590 --> 00:46:45.450
diagnosis in the first place.

NOTE Confidence: 0.9970685

00:46:45.830 --> 00:46:47.030
And we hear from our

NOTE Confidence: 0.9970685

00:46:47.030 --> 00:46:48.730
patients that sometimes

NOTE Confidence: 0.9885679

00:46:49.030 --> 00:46:50.310
when the five year mark

NOTE Confidence: 0.9885679

00:46:50.310 --> 00:46:52.070
is done, they sometimes feel

NOTE Confidence: 0.9885679

00:46:52.070 --> 00:46:53.130
forgotten about.

NOTE Confidence: 0.9928178

00:46:53.445 --> 00:46:55.445
But the truth is that

NOTE Confidence: 0.9928178

00:46:55.445 --> 00:46:56.645
experience that they have is

NOTE Confidence: 0.9928178

00:46:56.645 --> 00:46:57.605
gonna shape them for the

NOTE Confidence: 0.9928178

00:46:57.605 --> 00:46:58.665
rest of their lives.

NOTE Confidence: 0.9926098

00:46:59.205 --> 00:47:00.565
And, again, this may have

NOTE Confidence: 0.9926098

00:47:00.565 --> 00:47:01.925
longer term impacts in their

NOTE Confidence: 0.9926098

00:47:01.925 --> 00:47:03.045
social life in general as

NOTE Confidence: 0.9926098

00:47:03.045 --> 00:47:04.505
well. Maybe they need accommodations

NOTE Confidence: 0.9926098

00:47:04.725 --> 00:47:06.069
at work now. Maybe they

NOTE Confidence: 0.9926098

00:47:06.069 --> 00:47:07.609
had to interrupt their education.

NOTE Confidence: 0.99220973

00:47:07.910 --> 00:47:10.069
It's certainly impacted the relationships

NOTE Confidence: 0.99220973

00:47:10.069 --> 00:47:11.190
of their friends and family

NOTE Confidence: 0.99220973

00:47:11.190 --> 00:47:12.549
around them. So we have

NOTE Confidence: 0.99220973

00:47:12.549 --> 00:47:13.670
to be thinking about all

NOTE Confidence: 0.99220973

00:47:13.670 --> 00:47:14.569
of these things

NOTE Confidence: 0.97717535

00:47:14.950 --> 00:47:16.890
for long into the future

NOTE Confidence: 0.97717535

00:47:16.950 --> 00:47:18.545
when taking care of all

NOTE Confidence: 0.97717535

00:47:18.545 --> 00:47:19.445
of our patients,

NOTE Confidence: 0.97379845

00:47:20.065 --> 00:47:21.505
but in particular for our

NOTE Confidence: 0.97379845

00:47:21.505 --> 00:47:22.945
young adults who do have

NOTE Confidence: 0.97379845

00:47:22.945 --> 00:47:24.785
that lead time and that

NOTE Confidence: 0.97379845

00:47:24.785 --> 00:47:26.305
that long runway ahead of

NOTE Confidence: 0.97379845

00:47:26.305 --> 00:47:28.165
them beyond their cancer diagnosis.

NOTE Confidence: 0.9742915

00:47:31.370 --> 00:47:32.969
Hundred percent echo everything that

NOTE Confidence: 0.9742915

00:47:32.969 --> 00:47:34.650
you're saying. And then just

NOTE Confidence: 0.9742915

00:47:34.650 --> 00:47:35.850
a few just key,

NOTE Confidence: 0.92807907

00:47:36.330 --> 00:47:38.350
discussion points. You know, colorectal

NOTE Confidence: 0.92807907

00:47:38.489 --> 00:47:40.250
cancer incidence is increasing in

NOTE Confidence: 0.92807907

00:47:40.250 --> 00:47:41.450
young adults less than an

NOTE Confidence: 0.92807907

00:47:41.450 --> 00:47:43.404
age fifty years old even

NOTE Confidence: 0.92807907

00:47:43.404 --> 00:47:45.085
with though those without clear,

NOTE Confidence: 0.972321

00:47:45.805 --> 00:47:47.744
risk factors or family history.

NOTE Confidence: 0.972321

00:47:47.884 --> 00:47:49.265
And vigilance is needed,

NOTE Confidence: 0.97595006

00:47:49.805 --> 00:47:51.565
to diagnose early. So getting

NOTE Confidence: 0.97595006

00:47:51.565 --> 00:47:52.704
a thorough history

NOTE Confidence: 0.9177354

00:47:53.164 --> 00:47:54.625
and not not dismissing,

NOTE Confidence: 0.9650703

00:47:56.239 --> 00:47:58.000
symptoms, vague symptoms in young

NOTE Confidence: 0.9650703

00:47:58.000 --> 00:47:59.599
adults is very important for

NOTE Confidence: 0.9650703

00:47:59.599 --> 00:48:00.559
us from the primary care

NOTE Confidence: 0.9650703

00:48:00.559 --> 00:48:01.059
side.

NOTE Confidence: 0.9855624

00:48:01.760 --> 00:48:03.440
Oncology and primary care can

NOTE Confidence: 0.9855624

00:48:03.440 --> 00:48:05.059
partner to help provide holistic

NOTE Confidence: 0.9855624

00:48:05.119 --> 00:48:06.020
care to patients,

NOTE Confidence: 0.9556851

00:48:06.960 --> 00:48:08.739
and, again, especially that aftercare,

NOTE Confidence: 0.9556851

00:48:08.800 --> 00:48:10.079
right, so that patient doesn't

NOTE Confidence: 0.9556851

00:48:10.079 --> 00:48:10.819
feel forgotten

NOTE Confidence: 0.950982

00:48:11.195 --> 00:48:12.635
and are being being followed

NOTE Confidence: 0.950982

00:48:12.635 --> 00:48:13.455
through afterwards.

NOTE Confidence: 0.96014315

00:48:14.955 --> 00:48:16.315
And then with that, I

NOTE Confidence: 0.96014315

00:48:16.315 --> 00:48:17.355
think I was gonna share

NOTE Confidence: 0.96014315

00:48:17.755 --> 00:48:19.135
hand over to Tejal again.

NOTE Confidence: 0.96014315

00:48:19.355 --> 00:48:21.515
Yeah. So, doctor Yore has

NOTE Confidence: 0.96014315

00:48:21.515 --> 00:48:22.015
already,

NOTE Confidence: 0.9662226

00:48:23.035 --> 00:48:23.994
brought this up, but, you

NOTE Confidence: 0.9662226

00:48:23.994 --> 00:48:25.114
know, the question is what's

NOTE Confidence: 0.9662226

00:48:25.114 --> 00:48:26.840
next? What's happening now, And

NOTE Confidence: 0.9662226

00:48:26.840 --> 00:48:27.800
where are we looking for

NOTE Confidence: 0.9662226

00:48:27.800 --> 00:48:28.540
in the future?

NOTE Confidence: 0.9841525

00:48:28.920 --> 00:48:30.700
And I think that's where,

NOTE Confidence: 0.83482

00:48:31.719 --> 00:48:33.880
these novel technologies such as

NOTE Confidence: 0.83482

00:48:33.880 --> 00:48:35.320
the blood test blood piece

NOTE Confidence: 0.83482

00:48:35.320 --> 00:48:36.700
testing that was already discussed

NOTE Confidence: 0.97293013

00:48:37.160 --> 00:48:38.200
has a lot of promise

NOTE Confidence: 0.97293013

00:48:38.200 --> 00:48:39.340
and a lot of excitement.

NOTE Confidence: 0.9672761

00:48:40.535 --> 00:48:41.815
You know, the idea that

NOTE Confidence: 0.9672761

00:48:41.815 --> 00:48:42.855
someone can just get a

NOTE Confidence: 0.9672761

00:48:42.855 --> 00:48:43.975
blood test the same time

NOTE Confidence: 0.9672761

00:48:43.975 --> 00:48:44.855
as they get all their

NOTE Confidence: 0.9672761

00:48:44.855 --> 00:48:46.055
other labs and have that

NOTE Confidence: 0.9672761

00:48:46.055 --> 00:48:46.775
be a part of their

NOTE Confidence: 0.9672761

00:48:46.775 --> 00:48:48.614
colon cancer screening as well

NOTE Confidence: 0.9672761

00:48:48.614 --> 00:48:50.235
as other cancer screenings eventually

NOTE Confidence: 0.9921546

00:48:50.775 --> 00:48:52.560
is really exciting and might

NOTE Confidence: 0.9921546

00:48:52.800 --> 00:48:54.480
help to overcome some of

NOTE Confidence: 0.9921546

00:48:54.480 --> 00:48:56.000
those barriers that we are

NOTE Confidence: 0.9921546

00:48:56.000 --> 00:48:56.500
facing

NOTE Confidence: 0.99657744

00:48:57.040 --> 00:48:58.500
from a systematic standpoint

NOTE Confidence: 0.99642897

00:48:58.880 --> 00:48:59.860
for our patients.

NOTE Confidence: 0.99833757

00:49:00.480 --> 00:49:01.940
But as was already addressed,

NOTE Confidence: 0.99833757

00:49:02.080 --> 00:49:03.780
you know, our current technology

NOTE Confidence: 0.9945828

00:49:04.080 --> 00:49:05.780
is limited. So I think

NOTE Confidence: 0.9945828

00:49:05.945 --> 00:49:07.065
there's a lot more that

NOTE Confidence: 0.9945828

00:49:07.065 --> 00:49:08.585
is undergoing in terms of

NOTE Confidence: 0.9945828

00:49:08.585 --> 00:49:09.945
research right now and and

NOTE Confidence: 0.9945828

00:49:09.945 --> 00:49:10.744
a lot more to look

NOTE Confidence: 0.9945828

00:49:10.744 --> 00:49:11.965
forward to in the future.

NOTE Confidence: 0.9945148

00:49:14.825 --> 00:49:15.325
Excellent.

NOTE Confidence: 0.98866963

00:49:15.625 --> 00:49:16.905
And then with that, we'd

NOTE Confidence: 0.98866963

00:49:16.905 --> 00:49:18.105
like to share a few

NOTE Confidence: 0.98866963

00:49:18.105 --> 00:49:19.625
final, key points to take

NOTE Confidence: 0.98866963

00:49:19.625 --> 00:49:20.765
away from this lecture.

NOTE Confidence: 0.9735302

00:49:21.810 --> 00:49:23.570
One being consider all types

NOTE Confidence: 0.9735302

00:49:23.570 --> 00:49:24.790
of screening options.

NOTE Confidence: 0.99818075

00:49:25.090 --> 00:49:26.130
If we think back to

NOTE Confidence: 0.99818075

00:49:26.130 --> 00:49:27.190
our first patient,

NOTE Confidence: 0.9767012

00:49:27.570 --> 00:49:29.330
they were appropriately screened with,

NOTE Confidence: 0.9767012

00:49:29.650 --> 00:49:30.150
Cologuard.

NOTE Confidence: 0.9713099

00:49:30.610 --> 00:49:32.210
They were due for another

NOTE Confidence: 0.9713099

00:49:32.210 --> 00:49:33.650
Cologuard because they were at

NOTE Confidence: 0.9713099

00:49:33.650 --> 00:49:35.489
around, the year three year

NOTE Confidence: 0.9713099

00:49:35.489 --> 00:49:36.310
mark. Right?

NOTE Confidence: 0.97782326

00:49:36.645 --> 00:49:37.844
However, it was a case

NOTE Confidence: 0.97782326

00:49:37.844 --> 00:49:39.364
of rectal bleeding. Right? So

NOTE Confidence: 0.97782326

00:49:39.364 --> 00:49:41.145
that's when we shifted from

NOTE Confidence: 0.97782326

00:49:41.285 --> 00:49:42.905
screening to more diagnostic,

NOTE Confidence: 0.99797416

00:49:43.205 --> 00:49:44.425
and that's where the colonoscopy

NOTE Confidence: 0.99797416

00:49:44.645 --> 00:49:46.344
was more appropriate. So being

NOTE Confidence: 0.99797416

00:49:46.485 --> 00:49:47.625
able to identify

NOTE Confidence: 0.9941904

00:49:47.925 --> 00:49:49.545
the different types of modalities

NOTE Confidence: 0.9762945

00:49:50.420 --> 00:49:51.940
and, when to use what

NOTE Confidence: 0.9762945

00:49:51.940 --> 00:49:53.320
is very important for us.

NOTE Confidence: 0.9582315

00:49:53.700 --> 00:49:55.380
Do not dismiss mild rectal

NOTE Confidence: 0.9582315

00:49:55.380 --> 00:49:57.080
bleeding, needs close follow-up.

NOTE Confidence: 0.9956765

00:49:57.620 --> 00:49:59.940
Early detection of colorectal cancer

NOTE Confidence: 0.9956765

00:49:59.940 --> 00:50:01.460
is key for treatment options

NOTE Confidence: 0.9956765

00:50:01.460 --> 00:50:02.120
and survival.

NOTE Confidence: 0.99491537

00:50:02.934 --> 00:50:04.454
Taking a very thorough family

NOTE Confidence: 0.99491537

00:50:04.454 --> 00:50:06.234
history is key wherever possible.

NOTE Confidence: 0.97974795

00:50:07.174 --> 00:50:09.414
Colorectal cancer incidence is increasing

NOTE Confidence: 0.97974795

00:50:09.414 --> 00:50:10.315
in young adults,

NOTE Confidence: 0.97601974

00:50:10.694 --> 00:50:12.694
even without clear, risk factors.

NOTE Confidence: 0.97601974

00:50:12.694 --> 00:50:13.734
So we have to be

NOTE Confidence: 0.97601974

00:50:13.734 --> 00:50:15.174
vigilant to try to make

NOTE Confidence: 0.97601974

00:50:15.174 --> 00:50:16.155
an early diagnosis.

NOTE Confidence: 0.9346004

00:50:16.790 --> 00:50:18.469
And then very importantly, partnering

NOTE Confidence: 0.9346004

00:50:18.469 --> 00:50:20.150
with our colleagues, our GI

NOTE Confidence: 0.9346004

00:50:20.150 --> 00:50:22.250
specialists, our oncology specialists,

NOTE Confidence: 0.9826595

00:50:22.950 --> 00:50:24.330
especially when there's ambiguity

NOTE Confidence: 0.93376696

00:50:24.950 --> 00:50:26.230
or we have any suspicion

NOTE Confidence: 0.93376696

00:50:26.230 --> 00:50:27.750
for red flags is, very

NOTE Confidence: 0.93376696

00:50:27.750 --> 00:50:28.250
important.

NOTE Confidence: 0.9863821

00:50:28.550 --> 00:50:30.070
Taking a team based approach

NOTE Confidence: 0.9863821

00:50:30.070 --> 00:50:31.750
is, key for our patient

NOTE Confidence: 0.9863821

00:50:31.750 --> 00:50:32.250
care.

NOTE Confidence: 0.9259692

00:50:32.685 --> 00:50:33.645
With that, I'd like to

NOTE Confidence: 0.9259692

00:50:33.645 --> 00:50:35.344
open up to our colleague,

NOTE Confidence: 0.9259692

00:50:35.485 --> 00:50:37.165
specialist colleagues. Is there any

NOTE Confidence: 0.9259692

00:50:37.165 --> 00:50:37.905
other final,

NOTE Confidence: 0.97051656

00:50:38.685 --> 00:50:40.205
thoughts or wisdom pearls that

NOTE Confidence: 0.97051656

00:50:40.205 --> 00:50:41.344
you would like to share?

NOTE Confidence: 0.9809157

00:50:45.520 --> 00:50:47.040
Thanks, Pia. I think you

NOTE Confidence: 0.9809157

00:50:47.040 --> 00:50:48.080
really hit the nail on

NOTE Confidence: 0.9809157

00:50:48.080 --> 00:50:48.960
the head there in terms

NOTE Confidence: 0.9809157

00:50:48.960 --> 00:50:49.940
of this is

NOTE Confidence: 0.99916065

00:50:50.320 --> 00:50:50.980
a collaboration

NOTE Confidence: 0.9997669

00:50:51.840 --> 00:50:52.340
between

NOTE Confidence: 0.962765

00:50:53.280 --> 00:50:54.880
multiple different groups. And I

NOTE Confidence: 0.962765

00:50:54.880 --> 00:50:55.380
think

NOTE Confidence: 0.9967505

00:50:56.160 --> 00:50:56.660
communication

NOTE Confidence: 0.9987206

00:50:57.440 --> 00:50:57.940
between

NOTE Confidence: 0.9798161

00:50:58.320 --> 00:50:59.655
the, you know, patients and

NOTE Confidence: 0.9798161

00:50:59.655 --> 00:51:00.855
their providers is so important.

NOTE Confidence: 0.9798161

00:51:00.855 --> 00:51:01.835
But the communication

NOTE Confidence: 0.9996816

00:51:02.135 --> 00:51:02.635
between

NOTE Confidence: 0.9884418

00:51:02.935 --> 00:51:04.455
the different providers from different

NOTE Confidence: 0.9884418

00:51:04.455 --> 00:51:06.055
specialty groups is just as

NOTE Confidence: 0.9884418

00:51:06.055 --> 00:51:06.555
important.

NOTE Confidence: 0.9754402

00:51:07.094 --> 00:51:09.355
And building that relationship, increasing,

NOTE Confidence: 0.99072874

00:51:09.655 --> 00:51:11.094
you know, the education, not

NOTE Confidence: 0.99072874

00:51:11.094 --> 00:51:12.875
only among our medical community,

NOTE Confidence: 0.9780387

00:51:13.390 --> 00:51:15.090
but going out there and

NOTE Confidence: 0.9780387

00:51:15.150 --> 00:51:16.590
seeing meeting our patients where

NOTE Confidence: 0.9780387

00:51:16.590 --> 00:51:18.510
they're at, understanding where their

NOTE Confidence: 0.9780387

00:51:18.510 --> 00:51:20.350
barriers are, hearing from them,

NOTE Confidence: 0.9780387

00:51:20.350 --> 00:51:21.890
meeting with community stakeholders.

NOTE Confidence: 0.9996052

00:51:22.590 --> 00:51:24.369
I think that is so

NOTE Confidence: 0.9996052

00:51:24.430 --> 00:51:24.930
important

NOTE Confidence: 0.96056294

00:51:25.230 --> 00:51:26.130
to understand,

NOTE Confidence: 0.97592914

00:51:27.734 --> 00:51:29.815
you know, what what truly

NOTE Confidence: 0.97592914

00:51:29.815 --> 00:51:31.654
are the the challenges that

NOTE Confidence: 0.97592914

00:51:31.654 --> 00:51:33.494
our patients are facing and

NOTE Confidence: 0.97592914

00:51:33.494 --> 00:51:34.714
hearing from their voices

NOTE Confidence: 0.98078185

00:51:35.335 --> 00:51:36.775
can really help us as

NOTE Confidence: 0.98078185

00:51:36.775 --> 00:51:38.454
well, not only with the

NOTE Confidence: 0.98078185

00:51:38.454 --> 00:51:39.494
barriers that we know about,

NOTE Confidence: 0.98078185

00:51:39.494 --> 00:51:40.535
but those that we may

NOTE Confidence: 0.98078185

00:51:40.535 --> 00:51:42.180
not know, and also to

NOTE Confidence: 0.98078185

00:51:42.180 --> 00:51:43.859
help the disparity in care

NOTE Confidence: 0.98078185

00:51:43.859 --> 00:51:45.080
that we see as well.

NOTE Confidence: 0.9806643

00:51:45.460 --> 00:51:46.820
You're you're preaching to the

NOTE Confidence: 0.9806643

00:51:46.820 --> 00:51:48.340
choir. I echo everything that

NOTE Confidence: 0.9806643

00:51:48.340 --> 00:51:49.080
you say.

NOTE Confidence: 0.9911088

00:51:51.219 --> 00:51:52.680
I just wanna remind

NOTE Confidence: 0.91990536

00:51:53.380 --> 00:51:55.239
attendees, you can enter questions,

NOTE Confidence: 0.9989155

00:51:55.700 --> 00:51:57.160
in the q and a

NOTE Confidence: 0.9989155

00:51:57.435 --> 00:51:58.335
as we continue

NOTE Confidence: 0.9365188

00:51:59.675 --> 00:52:00.955
to have a discussion amongst

NOTE Confidence: 0.9365188

00:52:00.955 --> 00:52:01.695
our panelists.

NOTE Confidence: 0.9244159

00:52:02.155 --> 00:52:03.675
Tracy, I didn't know, Doctor.

NOTE Confidence: 0.9244159

00:52:03.675 --> 00:52:04.795
Battaglia, I didn't know if

NOTE Confidence: 0.9244159

00:52:04.795 --> 00:52:06.235
you had any questions. You

NOTE Confidence: 0.9244159

00:52:06.235 --> 00:52:07.515
have a huge interest in

NOTE Confidence: 0.9244159

00:52:07.515 --> 00:52:09.355
disparity in cancer screening. What

NOTE Confidence: 0.9244159

00:52:09.355 --> 00:52:10.475
what are some of the

NOTE Confidence: 0.9244159

00:52:10.475 --> 00:52:12.075
questions that you had, for

NOTE Confidence: 0.9244159

00:52:12.075 --> 00:52:13.055
the panel? Yeah. I mean,

NOTE Confidence: 0.9866987

00:52:13.650 --> 00:52:14.930
I think that first of

NOTE Confidence: 0.9866987

00:52:14.930 --> 00:52:15.809
all, thank you for that

NOTE Confidence: 0.9866987

00:52:15.809 --> 00:52:18.049
wonderful discussion and dialogue. And,

NOTE Confidence: 0.9866987

00:52:18.450 --> 00:52:19.109
I think

NOTE Confidence: 0.9115028

00:52:19.489 --> 00:52:21.329
fear is my first emotion

NOTE Confidence: 0.9115028

00:52:21.329 --> 00:52:22.690
that I'm having in listening

NOTE Confidence: 0.9115028

00:52:22.690 --> 00:52:23.589
to this presentation

NOTE Confidence: 0.97244537

00:52:24.369 --> 00:52:25.650
for two reasons. Two of

NOTE Confidence: 0.97244537

00:52:25.650 --> 00:52:26.950
the cases that you presented,

NOTE Confidence: 0.9891867

00:52:27.645 --> 00:52:28.145
you

NOTE Confidence: 0.9980003

00:52:28.445 --> 00:52:29.645
know, common things are common

NOTE Confidence: 0.9980003

00:52:29.645 --> 00:52:30.705
in young people.

NOTE Confidence: 0.99700147

00:52:31.245 --> 00:52:33.025
Right? And so, you know,

NOTE Confidence: 0.9997392

00:52:34.285 --> 00:52:34.785
constipation

NOTE Confidence: 0.99565506

00:52:35.325 --> 00:52:36.385
and rectal bleeding

NOTE Confidence: 0.9103544

00:52:36.844 --> 00:52:38.285
one time. Like, what does

NOTE Confidence: 0.9103544

00:52:38.285 --> 00:52:39.965
close follow-up mean, and how

NOTE Confidence: 0.9103544

00:52:39.965 --> 00:52:40.465
much

NOTE Confidence: 0.999811

00:52:41.130 --> 00:52:42.029
do we tolerate

NOTE Confidence: 0.99581367

00:52:42.329 --> 00:52:42.829
clinically

NOTE Confidence: 0.9755572

00:52:43.210 --> 00:52:44.250
before we sort of pull

NOTE Confidence: 0.9755572

00:52:44.250 --> 00:52:45.549
the trigger on a diagnostic

NOTE Confidence: 0.9755572

00:52:45.769 --> 00:52:47.049
test? And similarly, in a

NOTE Confidence: 0.9755572

00:52:47.049 --> 00:52:48.809
young menstruating female who has

NOTE Confidence: 0.9755572

00:52:48.809 --> 00:52:49.309
IBS,

NOTE Confidence: 0.97832984

00:52:50.089 --> 00:52:50.989
like, wow.

NOTE Confidence: 0.9759061

00:52:51.690 --> 00:52:52.969
Like, can you just speak

NOTE Confidence: 0.9759061

00:52:52.969 --> 00:52:53.930
a little bit more about

NOTE Confidence: 0.9759061

00:52:53.930 --> 00:52:54.705
that? Because I think this

NOTE Confidence: 0.9759061

00:52:54.705 --> 00:52:56.225
is our worst nightmare as

NOTE Confidence: 0.9759061

00:52:56.225 --> 00:52:57.665
a primary care physician is

NOTE Confidence: 0.9759061

00:52:57.665 --> 00:52:59.425
missing something like this. But

NOTE Confidence: 0.9759061

00:52:59.425 --> 00:53:00.625
yet every day in our

NOTE Confidence: 0.9759061

00:53:00.625 --> 00:53:02.305
practices, we're hearing these kinds

NOTE Confidence: 0.9759061

00:53:02.305 --> 00:53:03.045
of symptoms.

NOTE Confidence: 0.94422185

00:53:04.225 --> 00:53:05.445
I'll just say, you know,

NOTE Confidence: 0.94422185

00:53:05.665 --> 00:53:07.045
when we had iron deficiency

NOTE Confidence: 0.94422185

00:53:07.185 --> 00:53:07.685
anemia,

NOTE Confidence: 0.96933913

00:53:08.230 --> 00:53:09.270
you know, being a a

NOTE Confidence: 0.96933913

00:53:09.270 --> 00:53:10.710
premenopausal woman was like a

NOTE Confidence: 0.96933913

00:53:10.710 --> 00:53:11.750
get out of jail free

NOTE Confidence: 0.96933913

00:53:11.750 --> 00:53:13.190
call. Right? That meant you

NOTE Confidence: 0.96933913

00:53:13.190 --> 00:53:14.890
did not need to investigate

NOTE Confidence: 0.96933913

00:53:15.030 --> 00:53:16.710
colorectal. That's right. Source of

NOTE Confidence: 0.96933913

00:53:16.710 --> 00:53:18.550
blood loss, and it's just

NOTE Confidence: 0.96933913

00:53:18.550 --> 00:53:21.130
no longer true. Mhmm.

NOTE Confidence: 0.9357368

00:53:22.585 --> 00:53:23.965
I I think our threshold

NOTE Confidence: 0.9357368

00:53:24.025 --> 00:53:25.965
has gone down dramatically responding

NOTE Confidence: 0.9357368

00:53:26.185 --> 00:53:27.945
precisely to that, and we

NOTE Confidence: 0.9357368

00:53:27.945 --> 00:53:28.905
should. And and,

NOTE Confidence: 0.9653641

00:53:29.465 --> 00:53:31.545
and, yeah, we could be

NOTE Confidence: 0.9653641

00:53:31.545 --> 00:53:33.864
extremely sensitive and overload our

NOTE Confidence: 0.9653641

00:53:33.864 --> 00:53:34.364
system.

NOTE Confidence: 0.9599419

00:53:34.809 --> 00:53:36.890
But a close follow-up on

NOTE Confidence: 0.9599419

00:53:36.890 --> 00:53:38.170
on things that are not

NOTE Confidence: 0.9599419

00:53:38.170 --> 00:53:40.010
that clear, a very close

NOTE Confidence: 0.9599419

00:53:40.010 --> 00:53:40.510
follow-up

NOTE Confidence: 0.93036264

00:53:41.049 --> 00:53:42.489
and and whenever we don't

NOTE Confidence: 0.93036264

00:53:42.489 --> 00:53:44.089
feel comfortable just going ahead

NOTE Confidence: 0.93036264

00:53:44.089 --> 00:53:45.690
with the diagnostic test for

NOTE Confidence: 0.93036264

00:53:45.690 --> 00:53:46.730
sure. I think we all

NOTE Confidence: 0.93036264

00:53:46.730 --> 00:53:48.089
have responded to that, and

NOTE Confidence: 0.93036264

00:53:48.089 --> 00:53:49.210
probably we just have to

NOTE Confidence: 0.93036264

00:53:49.210 --> 00:53:50.625
be more sensitive because what

NOTE Confidence: 0.93036264

00:53:50.625 --> 00:53:51.905
was say was saying. I

NOTE Confidence: 0.93036264

00:53:51.905 --> 00:53:52.725
mean, the the

NOTE Confidence: 0.8599405

00:53:53.425 --> 00:53:54.245
see, everyone

NOTE Confidence: 0.9533822

00:53:54.625 --> 00:53:56.145
born after nineteen sixty has

NOTE Confidence: 0.9533822

00:53:56.145 --> 00:53:57.745
a much higher risk of

NOTE Confidence: 0.9533822

00:53:57.745 --> 00:53:58.864
not only colon but other

NOTE Confidence: 0.9533822

00:53:58.864 --> 00:54:00.705
cancers. So we can approach

NOTE Confidence: 0.9533822

00:54:00.705 --> 00:54:01.205
things

NOTE Confidence: 0.9733783

00:54:01.585 --> 00:54:03.250
business as usual. We have

NOTE Confidence: 0.9733783

00:54:03.250 --> 00:54:04.690
to be much more vigilant

NOTE Confidence: 0.9733783

00:54:04.690 --> 00:54:06.130
and more aggressive, to tell

NOTE Confidence: 0.9733783

00:54:06.130 --> 00:54:07.989
you truth, with with symptoms.

NOTE Confidence: 0.9560486

00:54:08.450 --> 00:54:09.730
Yeah. And then I was

NOTE Confidence: 0.9560486

00:54:09.730 --> 00:54:11.010
just thinking for that third

NOTE Confidence: 0.9560486

00:54:11.010 --> 00:54:12.050
case, would we want to

NOTE Confidence: 0.9560486

00:54:12.050 --> 00:54:13.330
get, like, a serial h

NOTE Confidence: 0.9560486

00:54:13.330 --> 00:54:14.790
and h? Like, how frequent

NOTE Confidence: 0.9560486

00:54:14.930 --> 00:54:15.910
would we check

NOTE Confidence: 0.8866983

00:54:16.370 --> 00:54:17.910
the the hemoglobin there?

NOTE Confidence: 0.9808362

00:54:19.674 --> 00:54:20.395
Yeah. I mean, I think

NOTE Confidence: 0.9808362

00:54:20.395 --> 00:54:22.555
it really depends on on

NOTE Confidence: 0.9808362

00:54:22.555 --> 00:54:24.255
the the context, but,

NOTE Confidence: 0.99758565

00:54:25.515 --> 00:54:26.015
exactly

NOTE Confidence: 0.90791637

00:54:26.315 --> 00:54:27.614
what we have been discussing,

NOTE Confidence: 0.996048

00:54:28.075 --> 00:54:29.055
you know, if

NOTE Confidence: 0.9923509

00:54:29.355 --> 00:54:31.535
there's anything that is persisting

NOTE Confidence: 0.97802764

00:54:31.835 --> 00:54:33.840
or anything that's not just

NOTE Confidence: 0.97802764

00:54:33.840 --> 00:54:35.520
doesn't feel right, if they

NOTE Confidence: 0.97802764

00:54:35.520 --> 00:54:36.880
aren't responding the way that

NOTE Confidence: 0.97802764

00:54:36.880 --> 00:54:38.980
that you'd expect them to,

NOTE Confidence: 0.99825215

00:54:39.520 --> 00:54:41.220
I think there should be

NOTE Confidence: 0.99825215

00:54:41.360 --> 00:54:42.660
a very low threshold

NOTE Confidence: 0.99747205

00:54:42.960 --> 00:54:43.700
to just

NOTE Confidence: 0.97879505

00:54:44.239 --> 00:54:46.320
ask, to just get checked

NOTE Confidence: 0.97879505

00:54:46.320 --> 00:54:47.440
out. And, of course, that's

NOTE Confidence: 0.97879505

00:54:47.440 --> 00:54:48.260
much easier

NOTE Confidence: 0.9945157

00:54:48.905 --> 00:54:50.744
said than done for the

NOTE Confidence: 0.9945157

00:54:50.744 --> 00:54:52.025
reasons that we've already discussed

NOTE Confidence: 0.9945157

00:54:52.025 --> 00:54:53.085
as well in terms

NOTE Confidence: 0.96215475

00:54:53.385 --> 00:54:55.484
of systems limitations and provider

NOTE Confidence: 0.96215475

00:54:55.545 --> 00:54:56.765
limitations and,

NOTE Confidence: 0.8957065

00:54:57.305 --> 00:54:58.425
all the barriers there are

NOTE Confidence: 0.8957065

00:54:58.425 --> 00:54:59.464
to get care in the

NOTE Confidence: 0.8957065

00:54:59.464 --> 00:55:00.825
first place. But I think

NOTE Confidence: 0.8957065

00:55:00.825 --> 00:55:02.445
that's when, again, the communication

NOTE Confidence: 0.8957065

00:55:02.665 --> 00:55:03.484
between providers can be very,

NOTE Confidence: 0.72070885

00:55:05.250 --> 00:55:05.750
very

NOTE Confidence: 0.9252709

00:55:06.050 --> 00:55:07.330
helpful. You know, you make

NOTE Confidence: 0.9252709

00:55:07.330 --> 00:55:08.530
a great point there, Dejal.

NOTE Confidence: 0.9252709

00:55:08.530 --> 00:55:09.489
I'm just thinking back to

NOTE Confidence: 0.9252709

00:55:09.489 --> 00:55:11.590
another case I had, earlier

NOTE Confidence: 0.9252709

00:55:11.730 --> 00:55:13.410
last week where I didn't

NOTE Confidence: 0.9252709

00:55:13.410 --> 00:55:15.650
formally, consult oncology, but just

NOTE Confidence: 0.9252709

00:55:15.650 --> 00:55:17.090
having a relationship with one

NOTE Confidence: 0.9252709

00:55:17.090 --> 00:55:18.944
of our, heme oncologists in

NOTE Confidence: 0.9252709

00:55:18.944 --> 00:55:20.704
Greenwich Hospital, Doctor. Montanari, I

NOTE Confidence: 0.9252709

00:55:20.704 --> 00:55:21.744
was able to do, like,

NOTE Confidence: 0.9252709

00:55:21.744 --> 00:55:22.944
a soft consult and come

NOTE Confidence: 0.9252709

00:55:22.944 --> 00:55:23.844
up with a strategy.

NOTE Confidence: 0.98115903

00:55:24.625 --> 00:55:25.904
And then we ended up

NOTE Confidence: 0.98115903

00:55:25.904 --> 00:55:27.265
going a different route than

NOTE Confidence: 0.98115903

00:55:27.265 --> 00:55:29.765
going straight to, heme oncology

NOTE Confidence: 0.98115903

00:55:29.984 --> 00:55:31.825
to, make it more effective

NOTE Confidence: 0.98115903

00:55:31.825 --> 00:55:33.125
for the patient. So,

NOTE Confidence: 0.9204787

00:55:33.719 --> 00:55:35.340
just to summarize our relationships,

NOTE Confidence: 0.9204787

00:55:35.400 --> 00:55:36.940
collaborating with our colleagues,

NOTE Confidence: 0.9857988

00:55:37.560 --> 00:55:38.920
it's so important. It's an

NOTE Confidence: 0.9857988

00:55:38.920 --> 00:55:40.360
investment for patient care, right,

NOTE Confidence: 0.9857988

00:55:40.360 --> 00:55:42.060
to give better patient care.

NOTE Confidence: 0.9541904

00:55:43.960 --> 00:55:45.239
I wonder if I can

NOTE Confidence: 0.9541904

00:55:45.239 --> 00:55:46.380
follow-up on that,

NOTE Confidence: 0.8742919

00:55:47.395 --> 00:55:48.935
sort of this line of

NOTE Confidence: 0.8742919

00:55:49.075 --> 00:55:49.975
sort of discussion.

NOTE Confidence: 0.96626765

00:55:50.435 --> 00:55:51.475
It relates to sort of,

NOTE Confidence: 0.96626765

00:55:51.475 --> 00:55:52.675
like, how long is too

NOTE Confidence: 0.96626765

00:55:52.675 --> 00:55:54.275
long to, like, wait in

NOTE Confidence: 0.96626765

00:55:54.275 --> 00:55:55.795
terms of delay. Mhmm. And

NOTE Confidence: 0.96626765

00:55:55.795 --> 00:55:57.235
we know that access in

NOTE Confidence: 0.96626765

00:55:57.235 --> 00:55:57.895
our system

NOTE Confidence: 0.9766606

00:55:58.275 --> 00:56:00.250
across the country is far

NOTE Confidence: 0.9766606

00:56:00.250 --> 00:56:01.850
from perfect. And sometimes we

NOTE Confidence: 0.9766606

00:56:01.850 --> 00:56:03.290
have to advocate as primary

NOTE Confidence: 0.9766606

00:56:03.290 --> 00:56:04.750
care physicians to make sure

NOTE Confidence: 0.9865175

00:56:05.050 --> 00:56:07.290
that colonoscopy gets prioritized or

NOTE Confidence: 0.9865175

00:56:07.290 --> 00:56:08.110
that consultation,

NOTE Confidence: 0.9808676

00:56:08.570 --> 00:56:10.030
you know, with whatever specialty

NOTE Confidence: 0.9808676

00:56:10.090 --> 00:56:12.570
gets prioritized. And, unfortunately, we

NOTE Confidence: 0.9808676

00:56:12.570 --> 00:56:13.790
don't necessarily have

NOTE Confidence: 0.9681475

00:56:14.664 --> 00:56:15.944
safety net systems in our

NOTE Confidence: 0.9681475

00:56:16.025 --> 00:56:17.224
all of our practices to

NOTE Confidence: 0.9681475

00:56:17.224 --> 00:56:18.585
be be sort of managing

NOTE Confidence: 0.9681475

00:56:18.585 --> 00:56:19.805
all of that. And so,

NOTE Confidence: 0.9681475

00:56:20.025 --> 00:56:20.744
you know, is it, like,

NOTE Confidence: 0.9681475

00:56:20.744 --> 00:56:22.424
a three month mark? Like,

NOTE Confidence: 0.9681475

00:56:22.424 --> 00:56:23.644
that was just, like,

NOTE Confidence: 0.8579825

00:56:24.025 --> 00:56:24.844
just unacceptable?

NOTE Confidence: 0.95188427

00:56:25.464 --> 00:56:27.144
Or I mean, obviously, I

NOTE Confidence: 0.95188427

00:56:27.144 --> 00:56:28.744
understand your index of suspicion

NOTE Confidence: 0.95188427

00:56:28.744 --> 00:56:30.480
is gonna sort of dictate

NOTE Confidence: 0.95188427

00:56:30.480 --> 00:56:31.600
that. But, like, in that

NOTE Confidence: 0.95188427

00:56:31.600 --> 00:56:33.120
case, for that that young

NOTE Confidence: 0.95188427

00:56:33.120 --> 00:56:34.719
woman, she's a stage three.

NOTE Confidence: 0.95188427

00:56:34.719 --> 00:56:35.540
Is that right?

NOTE Confidence: 0.99665385

00:56:37.680 --> 00:56:39.840
Yes. So, like, was there

NOTE Confidence: 0.99665385

00:56:39.840 --> 00:56:41.300
a long delay in her

NOTE Confidence: 0.9260171

00:56:41.600 --> 00:56:42.660
diagnostic workup?

NOTE Confidence: 0.9252219

00:56:44.705 --> 00:56:46.645
I mean, that probably developed

NOTE Confidence: 0.9252219

00:56:46.785 --> 00:56:48.565
over the course of months.

NOTE Confidence: 0.9252219

00:56:48.705 --> 00:56:50.385
And, I would say, although

NOTE Confidence: 0.9252219

00:56:50.385 --> 00:56:51.344
she might have had a

NOTE Confidence: 0.9252219

00:56:51.344 --> 00:56:51.844
precancerous

NOTE Confidence: 0.9993452

00:56:52.225 --> 00:56:52.725
lesion

NOTE Confidence: 0.96763456

00:56:53.505 --> 00:56:55.025
over a year or more

NOTE Confidence: 0.96763456

00:56:55.060 --> 00:56:56.085
Right. Than that.

NOTE Confidence: 0.9305739

00:56:57.440 --> 00:56:57.940
So,

NOTE Confidence: 0.9806967

00:56:58.640 --> 00:56:59.219
I think,

NOTE Confidence: 0.9659748

00:57:00.719 --> 00:57:02.400
it's it's it's truly challenging.

NOTE Confidence: 0.9659748

00:57:02.400 --> 00:57:03.059
And I think

NOTE Confidence: 0.9983031

00:57:03.359 --> 00:57:04.339
this is where

NOTE Confidence: 0.98771495

00:57:04.799 --> 00:57:05.859
I'm really excited

NOTE Confidence: 0.9998246

00:57:06.239 --> 00:57:06.739
about

NOTE Confidence: 0.9926732

00:57:07.200 --> 00:57:07.700
the

NOTE Confidence: 0.9950745

00:57:08.000 --> 00:57:09.140
developing technology

NOTE Confidence: 0.9997635

00:57:09.984 --> 00:57:10.645
to see

NOTE Confidence: 0.9920342

00:57:10.945 --> 00:57:12.165
what can we

NOTE Confidence: 0.96064025

00:57:12.945 --> 00:57:14.545
take, you know, have as

NOTE Confidence: 0.96064025

00:57:14.545 --> 00:57:15.905
a pressure release valve from

NOTE Confidence: 0.96064025

00:57:15.905 --> 00:57:16.565
our system.

NOTE Confidence: 0.9994912

00:57:17.025 --> 00:57:18.405
Can we transition

NOTE Confidence: 0.987624

00:57:18.785 --> 00:57:20.065
some of these really time

NOTE Confidence: 0.987624

00:57:20.065 --> 00:57:20.724
and resource,

NOTE Confidence: 0.84972835

00:57:21.744 --> 00:57:22.244
intensive,

NOTE Confidence: 0.9994346

00:57:23.540 --> 00:57:24.440
screening methodologies

NOTE Confidence: 0.9488091

00:57:24.900 --> 00:57:26.020
to things that are more

NOTE Confidence: 0.9488091

00:57:26.020 --> 00:57:26.520
accessible?

NOTE Confidence: 0.9542263

00:57:27.060 --> 00:57:28.500
And can that improve equity

NOTE Confidence: 0.9542263

00:57:28.500 --> 00:57:29.700
in the care there, not

NOTE Confidence: 0.9542263

00:57:29.700 --> 00:57:30.660
only in terms of access,

NOTE Confidence: 0.9542263

00:57:30.660 --> 00:57:32.520
but actually delivery as well.

NOTE Confidence: 0.9991735

00:57:32.820 --> 00:57:34.119
But we're not there yet.

NOTE Confidence: 0.94613624

00:57:34.500 --> 00:57:35.540
Doctor Iohr, do you have

NOTE Confidence: 0.94613624

00:57:35.540 --> 00:57:37.055
thoughts? Well, I'm I'm it

NOTE Confidence: 0.94613624

00:57:37.055 --> 00:57:38.174
just comes up to my

NOTE Confidence: 0.94613624

00:57:38.174 --> 00:57:39.375
mind right away at the

NOTE Confidence: 0.94613624

00:57:39.375 --> 00:57:40.434
screening level,

NOTE Confidence: 0.9958984

00:57:41.135 --> 00:57:43.234
how we our data nationwide

NOTE Confidence: 0.9958984

00:57:43.295 --> 00:57:45.234
in terms of follow-up colonoscopy

NOTE Confidence: 0.9341854

00:57:45.694 --> 00:57:47.234
after a positive stool

NOTE Confidence: 0.98246175

00:57:47.535 --> 00:57:48.974
based test, which is about

NOTE Confidence: 0.98246175

00:57:48.974 --> 00:57:50.674
sixty percent over a year.

NOTE Confidence: 0.9984339

00:57:50.974 --> 00:57:51.474
So

NOTE Confidence: 0.9964852

00:57:52.200 --> 00:57:53.099
that's not good.

NOTE Confidence: 0.972333

00:57:53.880 --> 00:57:54.760
That has a lot to

NOTE Confidence: 0.972333

00:57:54.760 --> 00:57:56.200
do because for a lot

NOTE Confidence: 0.972333

00:57:56.200 --> 00:57:57.160
of reasons, one of them

NOTE Confidence: 0.972333

00:57:57.160 --> 00:57:58.200
is that we have not

NOTE Confidence: 0.972333

00:57:58.200 --> 00:57:59.880
fully developed a system that

NOTE Confidence: 0.972333

00:57:59.880 --> 00:58:00.380
prioritizes

NOTE Confidence: 0.97000533

00:58:00.680 --> 00:58:01.660
things appropriately.

NOTE Confidence: 0.9794293

00:58:01.960 --> 00:58:02.839
And if we do have

NOTE Confidence: 0.9794293

00:58:02.839 --> 00:58:04.520
a positive stool test, that's

NOTE Confidence: 0.9794293

00:58:04.520 --> 00:58:05.020
not,

NOTE Confidence: 0.9925385

00:58:05.560 --> 00:58:06.839
no longer an elective thing.

NOTE Confidence: 0.9925385

00:58:06.839 --> 00:58:08.175
That's something that needs to

NOTE Confidence: 0.9925385

00:58:08.175 --> 00:58:08.575
happen,

NOTE Confidence: 0.89267886

00:58:08.975 --> 00:58:10.575
within six months, and there

NOTE Confidence: 0.89267886

00:58:10.655 --> 00:58:11.695
and the six months is

NOTE Confidence: 0.89267886

00:58:11.695 --> 00:58:12.175
no,

NOTE Confidence: 0.9329786

00:58:12.575 --> 00:58:14.335
no soft number is that

NOTE Confidence: 0.9329786

00:58:14.335 --> 00:58:15.695
we know that really after

NOTE Confidence: 0.9329786

00:58:15.695 --> 00:58:17.615
six and and more after

NOTE Confidence: 0.9329786

00:58:17.615 --> 00:58:18.435
nine months,

NOTE Confidence: 0.99628127

00:58:19.055 --> 00:58:21.235
prognosis does change. Therefore,

NOTE Confidence: 0.971251

00:58:22.250 --> 00:58:23.369
this is something you have

NOTE Confidence: 0.971251

00:58:23.369 --> 00:58:25.369
to to deal with, and

NOTE Confidence: 0.971251

00:58:25.369 --> 00:58:26.569
I think it does call

NOTE Confidence: 0.971251

00:58:26.569 --> 00:58:28.990
for that system wide reorganization

NOTE Confidence: 0.9421441

00:58:29.690 --> 00:58:31.849
and and calling more on

NOTE Confidence: 0.9421441

00:58:31.849 --> 00:58:33.470
on really risk stratifying.

NOTE Confidence: 0.96804416

00:58:33.770 --> 00:58:34.970
If we have a low

NOTE Confidence: 0.96804416

00:58:34.970 --> 00:58:35.950
risk person,

NOTE Confidence: 0.9399902

00:58:36.885 --> 00:58:38.085
maybe those were the people

NOTE Confidence: 0.9399902

00:58:38.085 --> 00:58:39.205
who are who can benefit

NOTE Confidence: 0.9399902

00:58:39.205 --> 00:58:40.505
the most from the non,

NOTE Confidence: 0.75907385

00:58:41.045 --> 00:58:41.545
nonaggressive

NOTE Confidence: 0.95888025

00:58:42.485 --> 00:58:44.085
screening options and then make

NOTE Confidence: 0.95888025

00:58:44.085 --> 00:58:45.125
sure that we have the

NOTE Confidence: 0.95888025

00:58:45.125 --> 00:58:45.625
availability

NOTE Confidence: 0.9769698

00:58:46.245 --> 00:58:47.685
for all these positive stool

NOTE Confidence: 0.9769698

00:58:47.685 --> 00:58:49.205
tests and for everyone who's

NOTE Confidence: 0.9769698

00:58:49.205 --> 00:58:51.205
at higher than average risk.

NOTE Confidence: 0.9769698

00:58:51.205 --> 00:58:52.680
So I think it does

NOTE Confidence: 0.9769698

00:58:52.680 --> 00:58:54.060
take us to think,

NOTE Confidence: 0.97163254

00:58:55.080 --> 00:58:56.599
in a more global way.

NOTE Confidence: 0.97163254

00:58:56.599 --> 00:58:57.640
As we were talking about

NOTE Confidence: 0.97163254

00:58:57.640 --> 00:58:58.920
this, Tejal was talking to

NOTE Confidence: 0.97163254

00:58:58.920 --> 00:59:00.280
us about the early onset

NOTE Confidence: 0.97163254

00:59:00.280 --> 00:59:02.280
cases, we can't just work

NOTE Confidence: 0.97163254

00:59:02.280 --> 00:59:03.800
on silos here because the

NOTE Confidence: 0.97163254

00:59:03.800 --> 00:59:05.000
the needs of our patients

NOTE Confidence: 0.97163254

00:59:05.000 --> 00:59:06.425
are much more complex than

NOTE Confidence: 0.97163254

00:59:06.425 --> 00:59:07.545
that. And so we need

NOTE Confidence: 0.97163254

00:59:07.545 --> 00:59:08.205
to understand

NOTE Confidence: 0.9986098

00:59:08.744 --> 00:59:09.145
our,

NOTE Confidence: 0.97789

00:59:09.625 --> 00:59:09.785
our,

NOTE Confidence: 0.99672115

00:59:10.585 --> 00:59:12.365
capacity and our availability

NOTE Confidence: 0.98918897

00:59:12.744 --> 00:59:14.025
to really make sense of

NOTE Confidence: 0.98918897

00:59:14.025 --> 00:59:15.545
it to care for patients

NOTE Confidence: 0.98918897

00:59:15.545 --> 00:59:16.925
in the most proper way,

NOTE Confidence: 0.97993135

00:59:17.385 --> 00:59:18.985
and not everyone getting the

NOTE Confidence: 0.97993135

00:59:18.985 --> 00:59:20.525
same thing because not everyone

NOTE Confidence: 0.97993135

00:59:20.810 --> 00:59:21.930
is gonna benefit the same

NOTE Confidence: 0.97993135

00:59:21.930 --> 00:59:22.810
way if we give them

NOTE Confidence: 0.97993135

00:59:22.810 --> 00:59:23.550
the same things.

NOTE Confidence: 0.9715933

00:59:24.170 --> 00:59:25.530
Yeah. There's two key things,

NOTE Confidence: 0.9715933

00:59:25.530 --> 00:59:26.890
you know, Shavira, from having

NOTE Confidence: 0.9715933

00:59:26.890 --> 00:59:28.570
participated in other talks with

NOTE Confidence: 0.9715933

00:59:28.570 --> 00:59:29.450
you. I mean, it's it's

NOTE Confidence: 0.9715933

00:59:29.450 --> 00:59:30.270
really clear

NOTE Confidence: 0.88148797

00:59:30.570 --> 00:59:31.630
that having a system

NOTE Confidence: 0.9887006

00:59:32.090 --> 00:59:33.609
for cancer screening. Right? It

NOTE Confidence: 0.9887006

00:59:33.690 --> 00:59:34.970
it's not just whether they're

NOTE Confidence: 0.9887006

00:59:34.970 --> 00:59:36.330
behind closed doors with any

NOTE Confidence: 0.9887006

00:59:36.330 --> 00:59:36.705
one

NOTE Confidence: 0.9603048

00:59:37.185 --> 00:59:39.105
clinician. The whole organization works

NOTE Confidence: 0.9603048

00:59:39.105 --> 00:59:39.925
on a system

NOTE Confidence: 0.9651523

00:59:40.305 --> 00:59:41.585
for making sure that people

NOTE Confidence: 0.9651523

00:59:41.585 --> 00:59:43.425
get screened and then adding

NOTE Confidence: 0.9651523

00:59:43.425 --> 00:59:44.565
in risk stratification,

NOTE Confidence: 0.9731872

00:59:45.825 --> 00:59:47.185
you know, for most proper

NOTE Confidence: 0.9731872

00:59:47.185 --> 00:59:48.545
use of resources, I think,

NOTE Confidence: 0.9731872

00:59:48.545 --> 00:59:50.145
is is is really good.

NOTE Confidence: 0.9731872

00:59:50.145 --> 00:59:51.780
And we have drawn to

NOTE Confidence: 0.9731872

00:59:51.780 --> 00:59:53.320
the end of our hour.

NOTE Confidence: 0.96925247

00:59:54.100 --> 00:59:55.460
And, you know, we almost

NOTE Confidence: 0.96925247

00:59:55.460 --> 00:59:56.580
went over because this was

NOTE Confidence: 0.96925247

00:59:56.580 --> 00:59:58.740
pretty interesting and incredibly well

NOTE Confidence: 0.96925247

00:59:58.740 --> 01:00:00.260
presented. So thank you so

NOTE Confidence: 0.96925247

01:00:00.260 --> 01:00:00.760
much,

NOTE Confidence: 0.9779571

01:00:01.060 --> 01:00:02.200
to each of our panelists,

NOTE Confidence: 0.97767705

01:00:03.060 --> 01:00:04.680
for all of your words

NOTE Confidence: 0.97767705

01:00:04.740 --> 01:00:05.320
of wisdom

NOTE Confidence: 0.9091647

01:00:07.055 --> 01:00:08.195
to us tonight.

NOTE Confidence: 0.9558848

01:00:09.055 --> 01:00:10.575
And, thank you, Tracy, for

NOTE Confidence: 0.9558848

01:00:10.575 --> 01:00:11.935
co hosting with me, and

NOTE Confidence: 0.9558848

01:00:11.935 --> 01:00:13.635
thank you everybody who attended

NOTE Confidence: 0.9558848

01:00:13.695 --> 01:00:14.815
or who is watching this

NOTE Confidence: 0.9558848

01:00:14.815 --> 01:00:15.315
later.

NOTE Confidence: 0.9996462

01:00:16.015 --> 01:00:17.375
Thank you. Thank you so

NOTE Confidence: 0.9996462

01:00:17.375 --> 01:00:17.875
much.

NOTE Confidence: 0.99072933

01:00:18.255 --> 01:00:19.555
Bye. Take care.