Liver Transplantation for the Treatment of Liver Cancer

December 01, 2021

Information

November 28, 2021

Yale Cancer Center

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00:00Funding for Yale Cancer Answers
00:02is provided by Smilow Cancer
00:04Hospital and AstraZeneca.
00:08Welcome to Yale Cancer Answers with
00:10your host doctor Anees Chagpar.
00:12Yale Cancer Answers features the
00:14latest information on cancer care by
00:16welcoming oncologists and specialists
00:17who are on the forefront of the
00:20battle to fight cancer. This week,
00:21it's a conversation about the care of
00:23patients with liver cancer with doctor
00:25Ariel Jaffe. Dr. Jaffe is an assistant
00:27professor of medicine and the section of
00:30digestive diseases at the Yale School
00:32of Medicine where Doctor Chagpar is
00:34a professor of surgical oncology.
00:37Ariel, maybe we can start off by
00:38you telling us a little bit about
00:40yourself and what exactly you do.
00:43Sure, so basically I specialize
00:45in the care of patients that have
00:48advanced liver disease and I work
00:50both in the transplant program,
00:53so patients who need to go on
00:55to have a liver transplant,
00:56and also patients
00:58that develop liver cancer,
00:59which is an extremely common
01:01complication in patients that
01:03have chronic liver disease.
01:05So let's talk a little bit about that.
01:08So when you're talking about
01:11patients who require transplant,
01:13what kinds of conditions
01:15require liver transplants?
01:17I mean, are these patients who
01:21have hepatitis, cirrhosis, tell
01:23us a little bit more about what
01:25kinds of conditions will lead
01:27you down the path of transplant?
01:31Most commonly, patients that develop
01:33end stage liver disease, which is
01:35what we commonly know
01:37as cirrhosis are the ones that we
01:39do evaluate for liver transplant,
01:41and that could be from a variety
01:43of different causes.
01:43Some which you alluded to.
01:45You know patients that
01:47have chronic viral disease.
01:49Certain toxins, like alcohol use,
01:51certain genetic disorders,
01:53patients with obesity and diabetes which
01:56can lead to fatty liver and
01:59go on to develop
02:00end stage liver disease.
02:02Once you start to have
02:03complications from that,
02:04we generally start to consider
02:06you for transplant.
02:08There are a subset of patients who may
02:10actually have really well preserved
02:12liver function and look and feel well,
02:15but in patients that develop liver cancer,
02:17which sort of as I mentioned,
02:18is an extremely common complication,
02:218 to 10% of patients with
02:23cirrhosis will develop cancer each year.
02:26That's another indication in which we
02:28go on to consider them for transplant.
02:31Because
02:31transplant will not only cure the cancer,
02:33but it will actually cure their
02:35underlying liver disease,
02:36which is the major risk factor
02:38for their cancer development.
02:41So tell us a little bit more
02:43about that in terms of cancer.
02:46Are all patients with liver cancer
02:48candidates for
02:51transplant or is it only those
02:53who have that underlying chronic
02:55liver disease that would make them
02:58potentially a candidate anyways?
03:01So not all patients are
03:04candidates for transplant.
03:05The majority of patients who
03:07develop liver cancer will have some
03:09form of chronic liver disease,
03:11but interestingly, we're actually
03:12seeing a unique population who don't
03:15have underlying advanced liver disease
03:17go on to develop liver cancer and it's
03:20a little bit of a controversial field
03:21if those patients should be
03:25considered for transplant or not.
03:27But in terms of those that
03:29may have chronic liver disease
03:30and develop liver cancer,
03:32there are certain criteria that need
03:33to be met for patients to be considered
03:36for transplant and some of that includes
03:38how extensive their liver cancer is.
03:41So for example,
03:42if it's spread outside of the liver,
03:45they would not be good
03:46candidates for transplant,
03:47or if they have a large amount
03:50of tumors within the liver,
03:52they would not be considered
03:54good candidates.
03:55We also sometimes like to look at
03:57patients if they have recurrent cancer.
04:01We're more likely to consider them
04:03for transplant or if their underlying
04:05liver is really very very sick so
04:07that they have other complications of
04:09liver disease in addition to cancer,
04:12then you know,
04:13we're more likely to want to pursue
04:15transplant in those patients.
04:18One of the things that
04:20people might be thinking about when
04:22we think about transplant is that
04:25oftentimes people
04:27may be under the impression
04:29that patients who have cancers,
04:31for example, may not be a potential
04:36recipient of organs,
04:39but it sounds like for liver cancer,
04:42that's not the case, that
04:44if you have liver cancer,
04:46even if it's recurrent liver cancer,
04:49you can still be on the organ
04:53recipient list.
04:54Is that right?
04:55Yes, actually
04:56it's a really unique cancer and
04:58you're very spot on with that.
05:00In that transplant is
05:02considered one of the curative therapies,
05:06and it really can't have spread outside
05:07of the liver or you can't have
05:09such an extensive tumor burden.
05:11But because you're really
05:13replacing the liver,
05:15you're not only treating the cancer,
05:16but you're sort of getting rid of
05:18the damaged organ because we like
05:20to think of liver cancer in
05:23particular as sort of a complication
05:25of a failing organ.
05:27I think it's an important perspective to have.
05:32Yeah, it does not mean that
05:34you're not a candidate.
05:34It's actually one of the most
05:36curative therapies and really
05:38currently in the United States,
05:39honestly,
05:40about a quarter of transplants
05:41are done for the indication
05:43of having liver cancer.
05:45Wow, so the other thing that we often
05:48think about when we think about transplant
05:52is the universal shortage of organs.
05:55Liver is one of those nice organs that there
05:59is a potential for a living related donor.
06:02How often is that used in
06:05patients who have liver cancer?
06:07Can you talk a little bit more about that?
06:09Definitely so the liver is
06:13just one of the most remarkable
06:15organs, and its ability to regenerate.
06:17So in certain patients who are
06:20candidates for a living donor organ,
06:23meaning that a part of the liver is taken
06:25from a donor and put into the recipient and
06:28it will actually grow to a normal size,
06:30usually in about 12 weeks time.
06:34To determine if someone is
06:36a candidate for a living donor,
06:37there's a few factors that we
06:39have to take into account.
06:41One is the size of the patient
06:43because there's a certain sort of
06:47massive liver that you would need
06:49to sufficiently
06:52do its job in a person.
06:54So if you're a really really
06:57big guy or big girl,
06:59your candidates might be limited.
07:01You would really need someone who is
07:03equally as tall or as large as you.
07:05The second thing is,
07:07if you're really incredibly sick and have a
07:10lot of complications from your liver disease,
07:12there's concern that you may not be able
07:14to tolerate just a piece of an organ.
07:16So it's actually something
07:18that we use quite often,
07:22and it varies based on programs and
07:24how large the programs are,
07:26but we definitely do a lot of
07:28living donors in our center here,
07:31and it's a really a great option
07:33for a certain subset of patients.
07:36And tell us a little
07:38bit more about how that works,
07:40because I think that for many people
07:43just the thought of having a relative
07:47or a loved one being diagnosed with
07:50a potentially treatable cancer,
07:52but that you can help with,
07:54you can help give them a new life,
08:01is really awesome in terms of the actual
08:04benefit that you can provide,
08:07but people may have some
08:09questions about that.
08:10Yes, so it's definitely a pretty
08:14grueling process
08:16and the way that it works
08:19is once we determine that someone
08:21is ineligible as a transplant candidate,
08:23they're then open to have either relatives
08:25or even just altruistic
08:28donors that can call in and be screened
08:31to see if they're compatible and
08:33usually it starts with
08:34just looking at blood typing to
08:36see if there is a compatibility.
08:38The rejection is a little bit different
08:40in the liver compared to other organs,
08:43so it's nice in that there's not
08:46so many factors that have to be
08:48directly matched to be
08:51considered a compatible donor.
08:52But once we think that there's
08:54not going to be overt rejection,
08:56and that really comes down a lot of
08:58times to compatibility and blood typing.
09:01We have a very strict process
09:03to make sure that the donor itself
09:05is someone who would do very well
09:07going to surgery, that they have
09:09no underlying liver disease,
09:11and that ultimately we
09:13feel would essentially come out
09:15unscathed should they decide to go
09:18forth with donating their liver.
09:20It's extremely rare in general to have any
09:24type of rejection from incompatibility.
09:26Just because our ability to screen
09:28and make sure that blood types and
09:30things match is so great now,
09:32so that's not generally a major
09:35major concern,
09:35but there's a lot of strict processes
09:38in terms of making sure the size is
09:41appropriate that the recipient,
09:43whatever portion was donated,
09:45that that would be enough for the patient
09:48not to have what we call post operative
09:50liver failure or liver insufficiency.
09:54So I would say technology and our
09:56screening strategies are just so
09:58remarkable now that those
10:00factors are really very well detailed
10:03before we would proceed with any
10:05type of living donor liver transplant.
10:09And then after the transplant,
10:11does the recipient stay on
10:14immunosuppressive therapy for life?
10:16Or how does that work?
10:18Yeah, so there's variations
10:21in the quantity of immunosuppression
10:24in liver transplant recipients.
10:26Generally within a year after transplant
10:29you can get patients down to an extremely
10:31low level of immunosuppression which
10:34again is slightly different than
10:36other organs where rejection rates
10:37are much higher and it's interesting
10:40because there are certain reports
10:43of patients being able to completely
10:45come off of immunosuppression.
10:48And we've actually had a few patients
10:50within our center that we've done that on.
10:52It's a little bit higher risk,
10:54and it requires some more close monitoring,
10:56but I would say the vast majority of
10:59patients are usually on at least one
11:01medication for the duration of their life,
11:04but it's again incredibly low
11:07dose compared to the majority of
11:09other organ transplant recipients.
11:12And they quote cured?
11:16Yeah, so that's
11:17exactly the hope is
11:20that from liver transplant,
11:23you're essentially replacing the
11:25entire organ, and so whatever the
11:28etiology of that patients,
11:30liver diseases is essentially cured.
11:33Of course, there's a risk if
11:36patients redevelop viral infections,
11:38or if some of the risk factors
11:40that led initially to their
11:42liver disease are still present.
11:44And I think a lot in our population
11:46the common things are patients
11:49who develop fatty liver disease
11:51in the post transplant setting,
11:53if they continue to
11:55have diabetes or obesity,
11:57you can develop recurrent
11:58disease in the organ.
11:59But if patients mitigate their risk
12:03factors and go on to live a healthy life,
12:06then yes, liver transplant is
12:08curative not only for the cancer,
12:10but again for the initial
12:12cause of their cirrhosis.
12:14And so for patients who have liver cancer
12:18is transplant one of the things that
12:20you think of first or do people have
12:23to kind of go through chemotherapy?
12:25At least in assessment of
12:27surgical resection and so on?
12:29Kind of the more commonplace
12:31cancer therapies before you think
12:33about transplant or is transplant
12:35something that is now first line?
12:39So it definitely is extremely
12:41independent on each patient's case.
12:44If we see a patient who has a single tumor,
12:48that's very small in size,
12:50and we think that we can cure them
12:52with a local resection, meaning,
12:54just cutting out a portion of that liver,
12:57that's generally the first line
12:59therapy that we would actually go to.
13:01In patients that have more
13:03advanced liver disease and other
13:05complications from their liver,
13:07if they develop a cancer
13:08on top of that, we know that a transplant
13:10would cure both of those aspects,
13:12so I would not say it's often firstline,
13:15but it's a curative approach that we
13:18definitely have in the back of our heads
13:20for a subset of patients that
13:21would be good candidates.
13:23Terrific, we're going to learn
13:25a lot more about liver cancer and
13:28transplant hepatology right after we
13:30take a short break for a medical minute.
13:33Please stay tuned to learn more
13:34with my guest doctor Ariel Jaffe.
13:37Funding for Yale Cancer Answers
13:39comes from AstraZeneca, dedicated
13:41to advancing options and providing
13:43hope for people living with cancer.
13:45More information at AstraZeneca Dash us.com.
13:51Genetic testing can be useful for
13:53people with certain types of cancer
13:55that seem to run in their families.
13:56Genetic counseling is a process that
13:59includes collecting a detailed personal
14:01and family history or risk assessment and
14:04a discussion of genetic testing options.
14:06Only about 5 to 10% of all cancers
14:09are inherited, and genetic testing
14:11is not recommended for everyone.
14:13Individuals who have a personal and
14:15or family history that includes
14:17cancer at unusually early ages,
14:20multiple relatives
14:20on the same side of the family
14:23with the same cancer,
14:24more than one diagnosis of
14:26cancer in the same individual,
14:28rare cancers or a family history of a
14:31known altered cancer predisposing gene
14:33could be candidates for genetic testing.
14:36Resources for genetic counseling and
14:38testing are available at federally
14:40designated comprehensive cancer
14:41centers such as Yale Cancer Center
14:44and at Smilow Cancer Hospital.
14:46More information is available at
14:49yalecancercenter.org. You're listening
14:51to Connecticut Public Radio.
14:53Welcome
14:53back to Yale Cancer Answers.
14:55This is doctor Anees Chagpar and I'm joined
14:58tonight by my guest doctor Ariel Jaffe.
15:00We're talking about patients with liver
15:03cancer, and before the break we talked
15:06about the whole aspect of transplant
15:09as a potential curative modality for
15:12patients with liver cancer. But Ariel,
15:14just as we were heading to the break,
15:16you mentioned that there are a
15:18lot of other things that go into
15:20thinking about liver cancer as well,
15:22so I wanted to take a step back
15:24and talk a little bit about
15:26how common is liver cancer?
15:30Primary liver cancer is actually
15:33a quite significant global burden.
15:35There's over 800,000 new
15:37cases diagnosed each year,
15:39and actually in the US in particular,
15:41it's the fastest increasing cause
15:43of cancer and the fastest increasing
15:45cause of cancer related death.
15:48When we talk about
15:50primary liver cancer we mean cancer
15:52that has originated and developed
15:54in the liver from the beginning.
15:56There are two main types that we think about,
15:59so hepatocellular carcinoma,
16:00probably accounts for 80 to
16:0490% of primary liver cancer,
16:06but another common type that we see
16:08that often develops in patients with
16:10chronic liver disease is something
16:13called cholangiocarcinoma and
16:14that arises in the biliary cells,
16:16and these are the cells that line
16:18the little lakes
16:20and channels within the liver
16:22that sort of drain and modify the
16:24substance that the liver makes,
16:25called bile.
16:26When you think about
16:28secondary liver cancer,
16:30a lot of times what we're talking
16:31about is metastatic disease,
16:33so cancer that may have spread to the liver,
16:36but that's really treated and
16:38managed extremely differently
16:39than primary liver cancer.
16:42And so that's really fascinating.
16:44I didn't realize that liver
16:46cancer in the United States was the
16:48the fastest growing in terms of
16:50incidence and mortality. Why is that?
16:53What are the risk factors that
16:55predispose to liver cancer that
16:58are factoring into this equation?
17:00Or is it the risk factors?
17:03Yes, so there's definitely been a shift
17:05sort of in the risk factors globally where
17:08prior the major causes of liver disease
17:10used to really be chronic viral disease.
17:13And mainly we're talking about
17:15chronic hepatitis B and hepatitis C,
17:18but with the ability to treat
17:20hepatitis C and control hepatitis B,
17:23and even prevent that with vaccinations
17:27really in the Western world,
17:28what we're seeing as the major cause of
17:31liver disease is definitely what we call
17:33Fatty liver disease or non-alcoholic
17:36fatty liver disease, and
17:38as we see a rise in the obesity epidemic,
17:42we're seeing more and more patients that
17:45develop complications such as diabetes,
17:47high cholesterol,
17:50central adiposity,
17:52meaning
17:53a lot of belly fat, which is inflammatory
17:55bad fat that the body does not like,
17:58and high blood pressure.
18:01As we're seeing more patients
18:03develop those complications,
18:04we're seeing a rise in the
18:06incidence of fatty liver disease.
18:08It is certainly true that there's just
18:11this exponential rise in obesity in
18:14America and in the world quite frankly.
18:17So let me ask you this, is it possible
18:21to reverse that, if you lose weight,
18:24do you reduce your risk of fatty
18:27liver and therefore reduce your
18:30risk of hepatocellular carcinoma?
18:33Absolutely,
18:34generally when patients have
18:36developed cirrhosis which is really
18:38advanced scarring within the liver,
18:40we do say that you can't
18:43reverse completely to having
18:44a normal healthy liver,
18:45but for a lot of patients who
18:47are not quite yet cirrhotic,
18:49or who may be cirrhotic but have active,
18:52ongoing inflammation, which is a
18:54big risk factor for
18:56the development of cancer,
18:57you can absolutely reduce the risk of
19:00developing complications from liver disease,
19:03and the development of liver cancer.
19:05So in particular for fatty liver disease,
19:08really the only kind of approved
19:11therapy at this time is the
19:13recommendation to lose weight.
19:15And generally we say 5 to 10% of
19:18weight loss has been associated
19:20with reduction in inflammation
19:22reduction in scarring of the liver,
19:25and even reduction in the
19:27potential to develop liver cancer.
19:28And it's why we like to really tell
19:31patients that a lot of the risk factors
19:33to develop liver disease and liver
19:35cancer are really preventable.
19:36And you see and
19:40treat patients with liver disease who may
19:44be at risk of developing liver cancer,
19:47and you also see patients who
19:49have developed liver cancer.
19:51You know if you tell them to lose weight,
19:53that's often easier said than done.
19:57Are there any specific recommendations
19:59that you give patients?
20:01I'm just thinking that our listeners
20:03might be thinking, yeah,
20:04I'd love to lose 5 to 10% of my body weight.
20:08How exactly do I do that?
20:10Yeah, so it is definitely
20:12easier said than done,
20:14and I think especially in the COVID era
20:16where a lot of people were really
20:18confined to their home,
20:20it's been an even bigger challenge,
20:22so oftentimes what I say to patients is,
20:24we kind of go through what
20:26they're eating and their physical activity.
20:28And sometimes their food choices.
20:30They may think that they're eating healthy,
20:32but when we actually breakdown the calories
20:34or the amount of sugar they're eating,
20:37it's a lot more than they're aware of so
20:39off the bat,
20:40I always offer patients to speak with
20:43nutrition because I think to have someone
20:45hold you accountable and really go through
20:48the target of each food
20:51group and macro and micro nutrients
20:53you should be hitting is very helpful.
20:56We also have specific fatty liver
20:58clinics and weight loss clinics here,
21:00so there are definitely patients
21:02even if they're dieting or exercising,
21:05they're just really stuck in this
21:07challenging place and they can't
21:09get to an ideal body weight.
21:10And in that situation there are
21:12medications that are available to
21:14sort of assist in weight loss.
21:16So we have a lot of programs
21:18and a lot of
21:20ancillary help for patients that
21:21really struggle.
21:22Alright, so the news flash
21:24there is talk to your doctor,
21:27because there likely is
21:29help available and we can
21:31all get through this
21:33and hopefully reduce our risk.
21:35But Ariel, I want to just kind
21:37of switch gears a little bit.
21:39Let's suppose it's a little too late.
21:41And we develop liver cancer.
21:45How do you know that you
21:47have developed liver cancer?
21:49So how is that diagnosis made?
21:51Are you going to have signs and symptoms?
21:54Are you going to go yellow or is this
21:56something that is picked up
21:58incidentally?
22:00That's a great question.
22:01You know, the majority of patients
22:04that develop liver cancer are really
22:06asymptomatic until it becomes very advanced.
22:09So at the time that someone may have
22:11pain or start to have
22:14some vague symptoms like weight
22:16loss or significant fatigue or even
22:18jaundice or yellowing of the eyes,
22:21which suggests that there's either a
22:23blockage in the liver or that the tumor
22:26has spread so much in the liver that it's
22:28just kind of taken over any remaining
22:31normal tissue, that's often too late.
22:32So really, what's incredibly important is
22:35to identify patients that have chronic liver
22:39disease or risk factors for liver cancer.
22:42Some which include
22:44poorly controlled diabetes,
22:45heavy alcohol use, obesity,
22:47and make sure that we're
22:49screening those patients.
22:51So really all major societies recommend
22:53in patients with chronic liver disease
22:56that every six months you're actually
22:58screened for liver cancer with the
23:00hopes that if you develop a cancer,
23:02you can actually pick it up early.
23:05And it's interesting because liver
23:07cancer is the only solid organ tumor
23:10that could actually be diagnosed
23:12based on imaging alone,
23:14so it has very unique features when we
23:18do a CAT scan or an MRI that basically
23:20allow us to definitively tell if this
23:23is a hepatocellular carcinoma and
23:25oftentimes we don't even have to do
23:28a biopsy to confirm the diagnosis.
23:31So people who have those risk factors
23:34should have a CT or MRI every six months.
23:38So we always recommend an ultrasound.
23:40That's the first
23:42step for screening,
23:45and that's really just based
23:46on sort of cost effectiveness,
23:48and you know the fact that it is
23:50fairly sensitive, but in some patients,
23:52if their liver is very scarred down,
23:55so you can't get a good look at that tissue,
23:57or if there's a lot of obesity, because
24:00a lot of fat in the belly can limit how
24:02good of a look you can get.
24:05In those cases,
24:05you may then need to do more advanced
24:08imaging, but generally once we see
24:10something abnormal on an ultrasound,
24:13the next step is to do a cross sectional
24:16scan with either a CT or an MRI.
24:19And so it's interesting
24:21that liver cancers are one of
24:24the few where you don't need a
24:26biopsy to make that diagnosis.
24:28So let's suppose you see that,
24:31tell us about some of
24:33the medical management,
24:34some of the things that are coming
24:36down the Pike short of transplant
24:37that might be helpful in these patients.
24:42Whenever someone has a new
24:44diagnosis of liver cancer,
24:45we always want to make sure that
24:47it hasn't spread outside the liver.
24:48So that's a big step,
24:49because once it has spread,
24:51your treatment is a little bit different,
24:54and it's very important to look at a
24:56patient's underlying liver function,
24:58because that plays a major role in
25:00understanding if they're eligible or
25:02would tolerate certain treatments.
25:04And outside of transplant,
25:05we really do think of
25:08liver cancer treatment in either
25:10a curative approach or what's
25:12called a palliative approach, and
25:14transplant is one of the curative therapies,
25:18but other curative therapies include
25:20local resection and that's
25:22when we cut out a small
25:24piece where that tumor is
25:26and of course,
25:27someone has to be a good candidate
25:29to undergo surgery and so if
25:31they have really advanced liver
25:32disease that would not be
25:34an ideal treatment choice,
25:36but other curative therapies
25:39include something called ablation which
25:42is really where you destroy the tumor and
25:45that can be either through
25:47thermal techniques,
25:48radiation techniques,
25:49electrical injury,
25:50and then we think of some of our
25:55palliative treatments which include
25:57what we call local regional
26:00therapies or transarterial therapies,
26:02and that's basically where you can
26:05either induce radiation damage
26:07or locally give chemotherapy to
26:10the tumor to kind of cut off the
26:13blood supply and kill that tumor,
26:15and then for patients
26:16that either are just not responding
26:18to those or where the cancer has
26:20spread outside of the liver,
26:21we start to think about systemic
26:24therapy or chemotherapy.
26:27And so you know,
26:28I can imagine that no patient wants
26:31to go through chemotherapy and
26:33everybody has heard horror stories
26:36about what chemotherapy is like.
26:38But very often on this show we've been
26:41talking about some of the newer advances,
26:43especially in systemic therapy,
26:45where we really are looking
26:48towards personalized medicine,
26:50sometimes immunotherapies.
26:51Is there anything like that
26:54going on in primary liver cancer?
26:57Absolutely, so I think probably the
27:00management for patients with liver cancer
27:02that's more advanced has been one of the
27:06most innovative
27:08fields within liver cancer.
27:10And that's because there have been so many
27:13new advancements in systemic therapies.
27:14Just a few years ago,
27:17we just had one or two medications,
27:20and now we have 10 FDA approved therapies.
27:23And as of May 2020, so just a
27:27little over a year ago,
27:29a new combination therapy.
27:32One of the components
27:34was an immune checkpoint inhibitor,
27:36which is one of our immunotherapy
27:39medications that actually proved to
27:41be the best first line therapy,
27:42so it had improvement in overall
27:45survival and disease
27:46free progression compared to what our
27:49prior first line was and is actually
27:52now what we try to use for our patients.
27:55And I think it's also important to know that
27:58oftentimes,
27:58when our patients hear that they're going
28:01to go on systemic therapy or chemotherapy,
28:04they kind of think of
28:06the movies or loved ones that they've
28:09seen have gotten really very sick.
28:11Or their hair has fallen out or their
28:13immune system is completely wiped out,
28:16and the medications that we use to
28:18treat liver cancer are definitely
28:20much more tolerable
28:22with significantly reduced side
28:24effects compared to
28:25what a lot of patients think about
28:28for sort of standard chemotherapy
28:29for other tumors.
28:31Doctor Ariel Jaffe is an assistant
28:33professor of medicine in the
28:35section of digestive diseases
28:36at the Yale School of Medicine.
28:38If you have questions,
28:40the address is cancer answers at
28:42yale.edu and past editions of the
28:44program are available in audio and
28:47written form at yalecancercenter.org.
28:48We hope you'll join us next week to
28:51learn more about the fight against
28:53cancer here on Connecticut Public Radio.
28:54Funding for Yale Cancer
28:56Answers is provided by Smilow
28:57Cancer Hospital and AstraZeneca.