Smilow Shares with Primary Care: Gastrointestinal Cancers

March 08, 2023

Information

March 7, 2023 | Hosted by Dr. Anne Chiang

Presentations from: Drs. Amit Khanna, Pamela Kunz, Justin Persico, and

Scott Thornton

ID9614

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