Summary

In this episode, the hosts introduce Sitaram Chilakamarry, MD, a colorectal cancer specialist, and discuss his background and interest in medicine. They then delve into the topic of colorectal cancer, providing statistics on its prevalence and mortality rates. They explain the anatomy of the colon and rectum and how colorectal cancer develops from the innermost lining of these organs. The discussion also touches on the role of genetics, diet, and inflammation in the development of colorectal cancer. The hosts emphasize the importance of early screening and detection to prevent advanced stages of the disease. The conversation explores different screening methods for colorectal cancer, including stool-based tests and direct visualization tests like colonoscopy. The FIT test, which checks for blood in the stool, is the most popular stool-based test. Colonoscopy is considered the gold standard for screening, but it is expensive and carries risks. The conversation also highlights the importance of healthy lifestyle choices in reducing the risk of colorectal cancer. Tobacco use and obesity are significant risk factors. The incidence of colorectal cancer is higher in smokers, and smoking causes inflammation throughout the body. The conversation concludes with a discussion of different cases of colorectal cancer and the next steps in diagnosis and treatment. In this conversation, Sitaram Chilakamarry discusses the process of diagnosing and staging colon and rectal cancer. He explains the importance of MMR testing, staging with CT scans and blood tests, and the role of surgery and chemotherapy in treatment. He also highlights the significance of regular colonoscopies for early detection and the potential for non-operative management of rectal cancer. Additionally, he mentions the promising use of immunotherapy in treating rectal cancer in patients with Lynch syndrome.

Chapters

00:00 Introduction and Background

08:11 Understanding the Anatomy of the Colon and Rectum

13:08 The Development of Colorectal Cancer

24:49 The Importance of Early Screening and Detection

27:32 Exploring Different Screening Methods

36:29 The Pros and Cons of Colonoscopy

43:37 The Impact of Tobacco Use and Obesity

50:43 The Importance of Healthy Lifestyle Choices

53:49 Diagnosing Colorectal Cancer

59:28 The Significance of Screening Compliance

55:17 Staging and Blood Tests

56:45 Treatment Plan and Chemotherapy

01:04:00 Urgent Cases and Ostomy

01:08:49 Elective Cases and Surgery

01:14:07 Anemia and Colonoscopy

01:19:46 Polyps and Watchful Waiting

01:23:35 Immunotherapy and Lynch Syndrome

Takeaways

• Colorectal cancer is a common and serious disease, with approximately 150,000 new cases and 53,000 deaths in the United States each year.
• The colon and rectum are part of the gastrointestinal tract, with the colon absorbing water and the rectum acting as a reservoir for stool.
• Colorectal cancer arises from the innermost lining of the colon or rectum and is typically classified as adenocarcinoma.
• Genetics, diet, and inflammation are factors that contribute to the development of colorectal cancer.
• Screening for colorectal cancer is crucial, as early detection can prevent advanced stages of the disease. Stool-based tests like the FIT test are popular for colorectal cancer screening.
• Colonoscopy is considered the gold standard for screening but is expensive and carries risks.
• Tobacco use and obesity are significant risk factors for colorectal cancer.
• Smoking causes inflammation throughout the body, increasing the risk of colorectal cancer.
• Healthy lifestyle choices can help reduce the risk of colorectal cancer.
• Diagnosis of colorectal cancer involves checking for mutations and inherited syndromes.
• Screening compliance is important, especially for individuals with a family history of colorectal cancer. MMR testing (or mismatch repair testing) is important for diagnosing colon and rectal cancer.
• Staging involves CT scans, blood tests, and determining the depth of tumor invasion.
• Regular colonoscopies are crucial for early detection and treatment.
• Non-operative management may be an option for rectal cancer patients with a complete clinical response.
• Immunotherapy shows promise in treating rectal cancer in patients with Lynch syndrome.

[00:00] Intro and hello

[01:30] Guest - Eva Galka, M.D. FACS: personal background and path to Surgical Oncology.

[07:00] Pancreatic Cancer: typical patient

[13:35] Clinical Presentation: how does someone know they have pancreatic cancer?

[20:30] Referral: how do people show up in my office?

[33:20] What is the pancreas?

[45:00] Epidemiology of pancreatic cancer, and demographics

[48:00] Staging & Resectability

[1:04:00] Chemotherapy

[1:07:00] Breaking therapies & Studies on pancreatic cancer

[1:15:00] Thank you and closing

Key takeaways:

1. Pancreatic cancer (specifically adenocarcinoma of the pancreas) is a fairly common, and very serious diagnosis, worldwide, with three basic categories meaning early (stage 1), late (stage 4), and intermediate (stages 2-3). Different approaches to the disease are based on which of those categories it falls into, and how healthy / able to tolerate treatment the patient may be.

   2. Resection is one's only/best chance for cure; however many cases are beyond respectability at diagnosis; and some are questionably resectable (borderline or locally advanced) and require upfront treatment before any attempt at resection. Even after resection it can come back, so extra treatments such as chemotherapy is almost always recommended.

   3.  Pancreas located in center of upper abdomen, surrounded by important other organs and blood vessels, making resection of tumors from it a very complex and technically demanding procedure, with significant risks of complications, even --not often but sometimes-- death.

   4.  Chemotherapy and radiation are somewhat effective; frequently necessary, but not AS effective as they can be in some other tumors/cancers..

   5.  The condition (adenocarcinoma of the pancreas) is best treated in specialized centers by specialized teams.

  6.  New treatments (such as immunotherapy and tumor vaccines) are being explored; but need to discuss with academic centers if applies to you. If you think you might be interested in being part of a trial, ask your treating physician and also view the show notes links below.

[00:03] I. Intro and hello

[02:07] II. Guest - Farhan Shams, MD. Geriatrician & Palliative Care specialist

[02:49] III. What are Goals of Care?

[05:38] IV. What is Palliative Care?

[18:01] V. Who comprises a Palliative Care team, and what are their roles?

[31:00] Expectations, communication, and understanding where the patient is coming from.

[43:08] Change is the only constant in life

[47:04] Futility

[48:45] Closing

Key takeaways:

-- Palliative Care is a subspecialty and a team of professionals dedicated to improving the overall experience of a patient, family, and friends throughout the critically difficult moments of patient succumbing to disease.

-- Comprised of a physician, nurse practitioner, psychologist, social worker, and chaplain; all specialized and with a professional focus in the field.

-- Critical to establish "what are the goals of our treatment" and to ask "why are we doing what we are doing?"

--Understanding, communication, expectations, hope, reality, and process.

--Grief

--A Palliative Care doctor is a "Life Coach" for the end-of-life process

Timestamps:

[00:30] Intro to show and Guest Keith Bowersox, MD, PhD

[2:38] Overview on Lung Cancer

[5:55] Smoking & Lung Cancer

[7:40]  Lung Cancer Screening

[10:30] Radon, Vaping, Marijuana & Lung Cancer

[13:30] “If you’re honest with your doctor…”

[16:00] Lung Cancer workup

[20:00] Lung Cancer types:  Small Cell; Non-Small Cell.

[23:00] Lung Cancer stages and implications

[26:00] Radiation treatment

[32:45] Chemo, radiation, immunotherapy side effects and patient selection

[34:45] Cure or palliation

[35:50} Treating for cure:  patient selection & treatment options

[41:18] Post-op:  Medical Oncology assessment and treatment

[44:00] Wrap-up and thank you

Key takeaways:

-lung cancer is a heavy diagnosis; however great progress in its treatment has been made especially recently

-lung cancer is among the most common and lethal, yet among the most preventable of tumors: by quitting smoking, or never starting.

-new, powerful screening modalities in modern practices are low-dose Computed Tomography (“CT”) scans of the chest. Must meet specific guidelines and quit smoking to be able to benefit.

-“Staging” of lung cancer (“Local, regional, distant”) determines treatment options and potential outcomes; baseline health status / lung function important.

-Surgery, Chemotherapy, Immunotherapy, Radiation therapy are main treatment modalities

-Optimal / Essential to have a primary care physician, and maintain a positive relationship with them.

1  - Michael Riordan, Medical Oncologist Peter Schlagel, MD, Urologist Charlie Rinehart MD, and Surgical Oncologist Paul Roach MD embark on a full discussion of Prostate Cancer: what it is, how it happens, how it behaves, and how it's treated.

2  - Guest:  Charlie Rinehart, MD, a practicing Urologist and medical officer in the U.S. Navy, (formerly an officer in the USMC), undergraduate at Georgetown, Medical School at Columbia, and Urologic Residency at US Naval Medical Center, San Diego.  Currently practices at the Captain James A. Lovell Federal Health Care Center, in North Chicago, Illinois. This is his second time on the program; for full introduction to Dr. Rinehart please check out the episode on Bladder Cancer.

3  - Timestamps:

[00:4] - Intro & disclaimer

[01:00] Overview of Prostate Cancer: 

A. Incidence and broad description of the problem

B. What is a prostate? What is a PSA screening test? What does it mean to have an elevated PSA test? How is the PSA test done?

C. Clinical Presentation & who gets prostate cancer?

[10:50] Prostate Biopsy

[12:25] Shared decision making regarding prostate cancer screening

A. The good, the bad, the ugly

B. Risk reduction versus over treatment; the importance of age in the process

C. “Heterogeneity” and variability in prostate cancers

[20:00] Very Low risk, Low, Intermediate, High, Very High risk categories.

[26:15] The “Trifecta”

A. The goal:  Treat the cancer, preserve urinary continence, preserve sexual function.

B. Risks and benefits of treatment options, based off of estimates of baseline risk.

C. What is “active surveillance?” Impact of age, baseline health status on deciding which course of action to take.

[31:20] Active Surveillance & Radiation Therapy

A. Age, health issues, prior experiences and their influence in choosing Surveillance or Xrt.

B. External Beam, IMRT (Intensity Modulated Radiation Therapy), Brachytherapy

[34:03] Side Effects of Surgery, Radiation Treatment

A. Incidence and range of incontinence, erectile difficulties

B. Impact of baseline function, age at time of treatment, time from surgery

C. Sequencing Surgery and Radiation treatments

D. Antitestosterone therapy

[42:00] Staging tests for localized versus widespread cancer.

A. CT scan and bone scans - traditional

B.  MRI’s and PSMA tests - newer

[46:25] Michael’s questions on origin of the cancer: Genetic? Smoking? Diet? Exercise

A.  African American/Black individuals a clearly higher risk of developing prostate cancer and should consider PSA screening 10 years earlier (age

B.  Agent Orange exposure - Viet Nam Veterans.

C. Association with BRCA

i. What is it?

ii. Importance of Family Medical History (males & females)

[51:05]  Summary of points thus far, and Radioactive seeds treatment option

A. When to use which option?

B. Lower risk options and higher risk options

[54:45] Prostatectomy

[56:21] Advanced disease

A. Locally advanced (i.e. spread outside the capsule of the prostate, and/or spread into the local pelvic lymph nodes or organs) disease

B. Distant (i.e. metastatic) disease

i. Androgen deprivation

C. Microscopic disease

D. Survival and quality of life

E. Testosterone supplementation and (+/-) association with prostate cancer.

[1:03:50] How does prostate cancer cause a man to die?

A. “Go-go” phase, “slow-go” phase, “no-go” phase

B. Androgen deprivation

[1:09:22] Closing and thanks

4  - Key takeaways in bulleted format:

-- Prostate Cancer happens to Men alone, as only men have a prostate, and has about the same frequency and risks as breast cancer has for women.

—It typically happens in the more advanced ages, but can happen in younger men (40’s for Black men, 50’s for other demographics)

-- Frequently, Prostate Cancer does not present with symptoms; one needs to have a screening test performed (called PSA) but should discuss risks/benefits with physician prior to embarking on that.  

-- There are a variety of different risk categories for diagnosed prostate cancer (very low, low, intermediate, high, very high) with different risk of progression into advanced disease and death.  The risk categories can change (from less risky —> more risky) over time, so a physician-patient relationship must be maintained over time.

—Multiple treatment options; these are based on stage of disease, risk category of the disease, patient age and health, and patient preferences.  Patient and physician must work with one another to decide which therapy to employ, and when, and why.

5  - Relevant links for the episode:

https://www.cancer.gov/about-cancer/treatment/clinical-trials/disease/prostate-cancer/treatment

https://www.cancerresearchuk.org/about-cancer/prostate-cancer

https://www.cdc.gov/cancer/prostate/

https://www.cancer.gov/types/prostate

https://www.radiologyinfo.org/en/info/imrt

6  - Follow us on your favorite Podcast program, and learn more through the homepage at  https://paulbryanroach.com/so-its-cancer/

7  - Coming up next month:  “Lung Cancer"

8 - Follow us on your favorite podcast platform, please contact me/us via webpage https://paulbryanroach.com, and direct link to show website is here: https://paulbryanroach.com/so-its-cancer/

Timestamps:

[00:01] Intro: Paul Roach, MD; Peter Schlagel, MD; Michael Riordan, Man of the People

[01:30] Short definitions of What is Cancer?

[04:30] Framing:  What is life?

[04:37] Shout out to Lex Fridman's awesome Podcast- Thanks, Lex

[06:40] What is a Cell?

[07:15] Long definition of or exploration of “What is Cancer?”

[19:00] Mutations of cell signaling, growth, and, differentiation

[30:00] Detecting Cancer

[43:00] Tumor markers

[46:00] Hereditary mutations

[53:30] Genetic Testing & Counseling

[1:02:00] Genetic Signatures

[1:04:00] Smoking, Age, Obesity, Heredity

[1:10:00] The Basics

[1:12:00] Targeted Therapy

[1:16:50] Where cancer cells go wrong

[1:23:02] Benign versus Cancerous

[1:29:27] Summary and Closing

Links:

https://www.nasa.gov/vision/universe/starsgalaxies/life's_working_definition.html

https://www.quantamagazine.org/what-is-life-its-vast-diversity-defies-easy-definition-20210309/

https://youtu.be/yyBosLx7bbM

https://youtu.be/NXU_M4030nE

https://www.cancer.gov/publications/dictionaries/cancer-terms/def/cell

https://www.cancer.gov/about-cancer/understanding/what-is-cancer

References:

https://www.goodreads.com/book/show/18442853-the-molecular-basis-of-cancer?from_search=true&from_srp=true&qid=Sw4zWg3ZSp&rank=1

https://www.goodreads.com/en/book/show/61048190-devita-hellman-rosenberg-s-cancer

Key Takeaways:

“Life” as we know and accept it is the product of an intricately organized set of self-sustaining bio-chemical processes working harmoniously, with memory and the ability to carry-on over time and over new generations (Paul’s best crack at the question of “what is life?”).

Biological life is comprised of individual cells, which are extremely tiny and have three main parts:  cell membrane wall around it; cytoplasm filling it up; and a nucleus as the main office or command center of the cell containing the DNA / genetic code, which determines the structure and the behavior of the cells and the tissues. 

In life, that DNA/genetic code acquires (or sometimes is born with) “defects” or “mutations” which alter the shape, function, and behavior of the cell; some types of mutations [particularly those responsible for the processes/jobs of cell signaling, cell growth, and cellular differentiation] result in derangements and loss of proper cellular function —which brings its own set of problems— and also, aggressive behaviors of local invasion and distal metastasis —which, untreated, can produce organ system failure and death.

Normal cellular machinery is so complicated that there are 10,000 ways (my made up number) in which it can break down, which in short accounts for the great variability of ways in which cancer can evolve and manifest.

These multiple pathways make it impossible to treat with a “one size fits all” approach, but these days we’re learning how to identify and target with a variety of clever treatments many of those various pathways, and thereby individualize treatment to that specific, unique tumor.

Advice: Cancer happens, but to minimize your risk of cancer / advanced cancer, take the best care of your own health with diet, exercise, moderation of things like tobacco / food / alcohol that you can, and keep a regular relationship with your physician for periodic check ups, screening exams, and the sharing of your family medical history. Don’t live in fear of cancer, but do take these reasonable steps against it.

Parting:

Follow the show! www.paulbryanroach.com parent website.

Send us mail: [email protected]

1  - Mike Riordan, Charlie Rinehart MD, and Paul Roach MD embark on a full discussion of Bladder Cancer: what it is, how it happens, how it behaves, and how it's treated.

2  - Guest: Charlie Rinehart, MD, a practicing Urologist and medical officer in the U.S. Navy, (formerly an officer in the USMC), undergraduate at Georgetown, Medical School at Columbia, and Urologic Residency at US Naval Medical Center, San Diego. Currently practices at the Captain James A. Lovell Federal Health Care Center, in North Chicago, Illinois

3  - Timestamps:

[00:24] - Intro & Charlie Rinehart, MD

A. Disclosure

B. Dr. Rinehart background & training.

[06:22] Overview of Bladder Cancer:

A. Incidence and Epidemiology

B. Clinical Presentation

C. Urinary system

[14:10] Hematuria and how is bladder cancer causing me problems?

A. Hematuria & its workup

B. Male / Female incidence & etiology.

i. Smoking Factors

ii. Occupational factors

iii. Low, Medium, High Risk

[21:06] Initial Workup of Bladder Cancer

A. Cystoscopy & Biopsy

B. CT Scan

[26:45] Tumor Grades and Depth of Invasion

A. Tumor Grades

B. Tumor Depth: Muscle Invasive and Non-Muscle Invasive

[36:00] Treatment & Surveillance of Non-Muscle Invasive Disease

A. Treatment

B. Surveillance

C. Why not bladder screening for everyone?

[40:50] Local Invasion & Metastasis

A. Pelvic organs

B. Lymph Nodes

C. Metastatic Behavior

D. Bladder removal (Cystectomy) and reconstruction

[50:00] Preventing progression from Non- to Muscle-invasive disease

A. BCG

B. Chemotherapies and Radiotherapy

[54:00] Bladder Cancer Endemic to East Africa & Middle East

A. Squamous Cell Cancer: Chronic Inflammation

i. Chronic Indwelling Urinary Catheter

ii. Parasite: Shistosoma

[57:45] Transitional Cell, Squamous Cell, AdenoCarcinoma Cell types

[59:30] Prevention

[1:01:30] Advanced Disease and Clinical Trials

[1:05:00] Closing

4  - Key takeaways in bulleted format:

-- Bladder Cancer happens to Men and Women, typically beginning in the more advanced ages.

-- Blood in the urine (either visible to naked eye, or only under the microscope) is a common feature.

-- Smoking (and some industrial exposures) important factors in its development

    -- "Transitional Cell" the most common type in USA and Europe; Squamous Cell (caused by a parasite called Shistosoma) also common in East Africa and Middle East

    -- Non-Muscle Invasive and Muscle Invasive frequently treated quite differently

    -- Chemotherapy, Radiotherapy, Immunotherapies available for Advanced Disease

    --  Important to not smoke, or quit smoking, to lower risk of disease.

-- In East Africa and Middle East, a type of bladder cancer can occur because of a parasitic infection.

5  - Relevant links mentioned in the episode:

https://www.cancer.gov/about-cancer/treatment/clinical-trials/disease/bladder-cancer/treatment

https://www.cancerresearchuk.org/about-cancer/bladder-cancer

https://www.cdc.gov/cancer/bladder/index.htm

https://www.cancer.gov/types/bladder/patient/bladder-treatment-pdq

6  - Follow us on your favorite Podcast program, and learn more through the homepage at https://paulbryanroach.com/so-its-cancer/

https://www.cancer.gov/types/bladder

7  - Coming up next month: "What Is Cancer?"

8 - Follow us on your favorite podcast platform, and link to show website is here: https://paulbryanroach.com/so-its-cancer/

I. Intro and hello

II. Rohit Sharma, MD, FACS

III. Sunscreens - thorough explanation of the ins/outs of sprays, lotions, creams for cancer prevention; rash guard clothing; wide brimmed hats; collective measures. 

IV. Moles and blemishes: bad and good.

V. Interpreting the biopsy report 

VI. Tumor thickness and surgical margins

VII. Lymph nodes and “Sentinel lymph node biopsy.”

VIII. Horizontal and vertical growth phases; four types of melanoma.

IX. How to talk skin with your General Practice Physician or Clinician.

X. Staging the disease: Local, Regional, Metastatic.

XI. Impact and utilization of Immunotherapy & Targeted Therapies.

XII. Predicted survival of different Melanoma stages

XIII. How do I self-advocate?

XIV.  Clinical Trials explained

XV. Closing and Thank you

Key takeaways:

1. Ounce of prevention… learn your sunscreen options, how they complement one another, and use them from childhood on!

       2. Moles that are uniform and unchanging are safer; moles that are irregular and changing are more dangerous

       3.  Thicker and ulcerated melanomas are more problematic

       4.  In certain patients, harvesting a sentinel lymph node gives important prognostic and treatment-related information.

       5.  Be clear and upfront with your doctor about your moles and blemishes

       6.  New types of treatments exist that are powerful and important.

       7.  Stick with established, well-known websites (such as American Cancer Society) when starting your self-education on Melanoma

       8. Clinical Trials are fundamental to the advancement of Medicine, but they may or may not be what you’re looking for

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1. Introduction: Paul, Peter, Mike (Courtney out this month)
2. Guests:  No guests today
3. Case of the day:  Lymphoma patient. Workup, Treatment, & Result.
4. Lesson of the Day: Lymphoma: Hodgkins & Non-Hodgkins.
5. Cancer Questions: From Paul:  what is Car-T therapy?
6. Cancer News:  None today
7. Sign out 

1 - Intro Three cancer specialists and a graphic design artist discuss cancer.

2 - Bio's: Pete Schlegel, MD (Medical Oncology)

Courtney Coke, MD (Radiation Oncology)

Mike Riordan (Graphic Design Artist)

Paul Roach, MD (Surgical Oncology)

3 - Timestamps:

[00:05] Courtney, Pete, Mike, and Paul introduce themselves

[06:00] Case of the Day - Esophageal Carcinoma

[28:00] Lesson of the Day- Esophageal Carcinoma

[35:10] Cancer Questions: How do you tell a patient they've got cancer?

[41:32] Question: What do I do if my doc doesn't present me with a plan?

[51:45] Cancer News: Keynote 811 Trial; dual PD-1 & HER2 blockade in HER2(+) Gastric Cancer.

4 - Key Takeaways:

Causes of esophageal cancer (e.g. smoking, alcohol, gastroesophageal disease)

Signs and symptoms of esophageal cancer (e.g. difficulty swallowing, painful swallowing).

Immediate actions (e.g. contact Primary Care Physician; seek family, friends, trusted help)

Workup is pretty involved, so don't be surprised.

Treatment frequently involves endoscopic or surgical procedures, chemotherapy, radiation therapy, and now sometimes new kinds of medicines (anti-Her2, anti PD-1 medications, etc).

Don't be shy! Reach out. Get help. Treatment is available!

5 - Sign out: write [email protected] with ideas, thoughts, questions for next episodes