Dr. Walter Coyle discusses cancer prevention and detection as it relates to various gastrointestinal organs including new screening guidelines for colon cancer.
Back to Symposium Page » Dr Walter Coil is our next speaker. He's a gastroenterologist who treats most diseases the digestive track, as well as attached organs such as liver gall, bladder, bile ducts and pancreas. His clinical gastroenterology interests include the diagnosis and treatment of pancreatic diseases, comical bladder and biliary tract diseases, esophageal diseases, inflammatory bowel, such a Crohn's and all sort of colitis and other disorders. His expertise includes digestive disorders, all digestive related cancers, including pancreatic cancer. Acute and chronic. Pancreatitis is Senate Filic Esophagitis, Barrett's esophagitis and Self a jail cancer. He has a research interest in pancreatic cancer treatment of Barrett Esophagitis, using cryo ablation and all types of advance endoscopy. He's been active in gastroenterology research related to the epidemiology of colon and rectal cancer. He has been an active educator of medicine and gastroenterology trainees and is extensively published on training issues and gastroenterology. He believes that the best doctor patient relationships are developed through careful listening by the provider and open honest communication by both parties. In his spare time, he enjoys photography and diving any actively enjoys golf. Okay. Hey, everybody. This is well coil. Thanks for that introduction. Mike, Mike and I play golf quite a bit. That's one of my great pleasures. Um, we've got a lot to cover today, but I'll try to be nice on pace and the very end. We can skip through the questions that we need to. But we're going to cover all the GI cancers here. Um, hey, Scott, out there Advanced. Is this little delay these air My disclosures. I do speak for two pharmaceutical companies unrelated to any of the topics today. Yeah, it's not changing here. I mean, click again radio. I see. So we have ah lot to cover. So it's general cancer prevention. We'll talk about G. I cancer. Instance in general will go through all things we can look for people who may have cancer, and then we'll go through all the major GI cancers esophagus, stomach, pancreas, liver and colon cancer going through a new guidelines and new updates. So for general prevention, we all sort of practices. But we often forget to tell our patients some of these things. So obviously tobacco is huge for lung cancer, but also for Asafa Jill, cancer, stomach cancer, pancreas and colon. If you smoke, it triples your risk off pancreas, cancer, alcohol so if you stop alcohol decreases pancreas cancer via chronic pancreatitis, esophageal cancer, particularly squamous and liver cancers, weight loss improves survival and decreases all GI cancers. Exercise we know have solid data decreases colon cancer and diet, as you can imagine, with the gut interfacing with what you eat eyes a huge impact where less red meat, especially processed red meat, eyes important and diet should be hiring fresh fruit and vegetables. And the World Health Organization now lists process red meat as a carcinogen. So we have to counsel patients on alcohol. They always use those studies with one alcohol a day helps and always get this picture from Getty images, suspecting what some patients think is one alcohol per day. I threw this in here because it's very important, as you can see, if you look at all G I tract cancers combined 42% of all cancer deaths in this country, and both men and women are G I related colon and rectum about equal men and women. 9% Pancreases centuries equal between men and women. Men are much more likely to get bile, duct cancer and gall Bladder cancer created women 6% 8% and esophagus is dramatically different between men and women. And I'll show you that in the next slide. But you can see if you put all the GI cancers together. They're the most likely cause of death from cancer in this country. This is an annual port from 2018 and cancer, and I throw this in here to show the difference. So here's mail. Okay, this is desk 100,000. There's a soft exit 7.2 and their stomach at 4.3. I'm gonna jump the women now and you can see for women, esophagus is way down at 1.5 and stomach is also down to 2.3. So these are much more male related cancers, the esophagus and stomach, and we'll talk about that. So what are the general warning symptoms? This is all sort of, you know, stuff we learned in medical school, but it's important to learn thes air, the red flags that the gas serologist and every primary here that you should ask way loss. Obviously, dysplasia never ignored this aphasia, particularly it's a soffit yield. ISF Asia, as opposed to aural friend Jill dysplasia on this early satiety. It's very non specific. I chased this all the time, but it's something to think about. And there's any evidence of bleeding. Be iron deficiency anemia, especially through over 50. Or the woman is no longer man situating and any bleeding. Correct? Melania, of course. Hemet emphasis. Abdominal pain that's new and increasing it should be a worrisome finding. Change in bowel habits is new now. These last two are very important because we'll get into this in the future. We having a rise in rectal cancer and colon cancer and young people. So you really have to pick up on these warning symptoms and young folks to try to catch these cancers. And, of course, one time my liver, cancers and pancreas. Any abnormal or function tests need to be pursued mhm, so we'll move to a stop. The Jill Cancer. This is a classic 58 year old gentleman that I saw a couple years ago. This is classic Barretts esophagus we called salmon colored, but unfortunately, here on this side of the screen, it's an ulcerated mass, and it's just invasive T three and one cancer of the esophagus. So I put both cancers together. And if for years you're taking your boards again, this is very easy. Pneumonic. So screams Cancer is on the right adenocarcinoma, which is the most common assault. Your cancer in this country Scream is much less than I gave you a pneumonic staples. Okay, we're smoking this disease called Tylo Sis, where you have, um, thickened souls and hands actual Asia Plummer Vinson syndrome, which is iron deficiency anemia. Lie ingestion, which we see much less now, is much more common when I was in training. But that's a thousandfold increase for Stop Joe cancer, alcohol, celiac disease and scalding drinks, which is brand new. We'll talk about that and a carcinoma. It was increasing. Now it's like it's stabilized. It's generally a male disease. We think it's probably nearly 100% arising in barrettes. Reflects is usually part of that Caucasian in central obesity. Being older, family history is critical. We'll talk about that and tobacco. So here's the trends. For a while in men, you really saw this rise in a soft gel cancer, especially this is adding no, I now it seems to have stabilized, and women it's much less. It really has not changed significantly in women over the last decade or so. So what's new in a softball cancer is a couple things. One is what I did to this is hot consumptions of food, particularly alcohol. It was a number of trials, UH, 2015 18, to look into. This one was in the annals of internal medicine and the one in the British Medical Journal. They had 47 independent reports they reviewed and 32 of them's favored or showed that if you had consumed hot food and hot beverages, it increases your risk for a soft dough cancer. This is squamous. This is not add enough. So the working group addressed this image that in 2016, and they say that drinking very hot beverages at above for US 149 F was classified as probably carcinogenic to humans. This is class two A. So my comments is Gris was greatest in the Asian and South American population. They have a drink called Matt that they drink very hot down in South America on the best way to be cool less than 1 49. That should be sufficient. So in general, like to go to Starbucks, make sure you add some cream. So what are the newest guidelines? So they keep changing the guidelines for barrettes, the most recent ones that were working off of her 2019 in giant Tosca P. There's really not much new the LME's. They have complicated table such as this, and I'll break them down and for you here. So the bottom line is, if you have known barrettes, there is solid evidence to be saved lives. By survey. However, routine screening for all individuals is not recommending. They consider screening is a positive family history of barrettes, or you have reflux plus one other risk factor. So I pointed to this slide. This is the risk factors we talked about. It was interesting in this one. They dropped out Caucasian, which actually is an independent risk factor. I'm not quite sure what they did, but look at family history. If you illicit a family history of either esophageal cancer or barrettes in a patient, it's a 12 fold odds ratio so that recommend nation in a man or a woman. In my mind, they should have an endoscopy if their reflux disease just having reflux disease is a threefold risk, and you could see the others as you go down. Smoking modestly increases your risk at 1.42 Now the guidelines been using previously with the A C G guidelines, which were in the Red Journal for us, and they again said screening the general population is not recommended. What they said, however, though, if you have reflux disease and two or more risk factors, you should get screened. So the most current ones that only one risk factor. But these were two. So what does this all mean? So most people should not be screened. If they just have mild reflux disease, they do not need be screened by endoscopy. However, if you have any risk factors used to change that on, do at least a one time endoscopy. Once you find barrettes, surveillance does save lives. We used to put a time rage on that. Well, we won't screen above 85. Well, it's more likely an 85 year old will get a subject cancer, and now we have many endoscopic techniques. Even if the patients have bad COPD or heart disease or heart failure. Actually, I'm doing patients with neurotics. Now they're finding squamous cell and adenocarcinoma and changing them. Play the cryotherapy, weaken, burn! We can reset with yes D or E m. R. And now we have excellent eradication of dysplasia and barrettes, so generally have great tools. So now we'll move on to gastric cancer. This is actually the anthem of the stomach. This is the calm, most common location in the world for gastric cancer in the US We all have a lot of proximal gj cancers also, so it's incident. It's instant. The incidence rates of gastric cancer have really trended down over the decades. Now this is inching. It started before H. Pylori probably has to do with the quality of our food and refrigeration. This is an American cancer society in 2020. So about 21,000 patients or diagnosed in the U. S. With gastric cancer, about half of those are expected to die, but it's the second leading cause of death worldwide. One million cases per life, and that's probably mostly due to poor food storage conditions, and he'll go back to polarize. So we think Explorer is a big player in that, but it's not the only one, and smoked foods and foods that are poorly, uh Stewart, or have a flat tokens probably make a big difference. So what are the risk factors I told you before? It's more common in Men versus Women H. Pylori infection. You have any chronic gastric disease, pernicious anemia, gastric atrophy and then the diet that's high in Nitro Sabine's. Um, so this is why we I recommend against grilling and charring your food and smoked foods should be limited. Tobacco, obesity, smoking alcohol and a diet that's low and fruit and vegetables. It's interesting. Blood Type A is an infant risk factor, but each floor I loves people with blood type A, and that's probably why that's an important risk factor. Let's talk about H. Pylori. You know it's been around for since the start of dawn with man lives in the stomach, um, usually acquired as a child, and it definitely probably anywhere between a 4 to 6 fold lifetime risk for stomach cancer. Eso I put you to the treatment guidelines, which I'm not going to go through, since that's not the point of the talk. But if you need to treat someone, these were the guidelines, and we'll go through there in a second. So we talked about childhood, um, acquisition of the disease. It increases your risk for ulcers, iron deficiency, anemia, stomach cancer, but particularly malt lymphoma, which is probably the number one calls the malt lymphoma in the world. And we now know if you find an infected patient, you should be treated. Um, So who should be tested? Anyone who has pastor Active ulcer disease. Definitely. Patients. Malt lymphoma, sometimes treating the h polarized enough to eradicate the malt lymphoma without any chemotherapy radiation. And those were superficial gastric cancer. We find a very small lesion. You take, you remove the lesion and then repeat the age. Pollari. Let's see. E didn't change. It froze on me. Here. Let's see. Yeah. Hey, Scott, I can't advance the slide. Mhm. Mhm. Um, that's the slide for me, Scott. You know which slide do you want to be on, Doc? Just the next one. Yeah. Yeah, sorry about that. So the next two slides, I believe, show about treatment, and I'm not gonna go through the different regiments. There's a treatment regimen for salvage and ex treatment regimen for those folks who the first up. Remember, when you treat H. Pylori? The most important thing is the first regimen is your best chance for cure. If the patient stops for therapy after three days because of, um, they can't tolerate it. Um, then the chance they're going to be untreatable or have resistant organism is extremely high. I'll be doing there, Scott. I can see the slide stock, you know, on current trends since 2000. Well, I ch poor. All I see is h pylori infection on mine. I'm still stuck on my slide. Mhm. Yeah, we're behind Scott. No system. Sorry about that. It were way ahead, so keep going back. Let's see. Keep going back. There we go. Okay. Now, do you Are you controlling this or not? Mhm. Mhm. One more Scott, you can collect to control dog. Say mhm. Uh huh. There you go. Okay. So this is if you're positive, treat the four drug regimens of the best there also the hardest to take, and you can look through their regimen. Mhm. So mhm. I think we skipped a couple there. Their radio and this is salvage regiments. This is the regimen. If you fail on again. These are very difficult. I always add bismuth toe all my treatment regimens. It's very well tolerated and helps increase your percentage. So in general, this is what's good for you. That's just bad for you. And I love how they feel this this orange slice on here to make this pound of protein more powerful. But essentially, that's what we should be teaching our patients and ourselves. So and there's not much current data on diet. Billion of exalt, preserve and smoked or the worst alcohol is insufficient, but processed red meats or bad as I said, vitamin C is very protective fresh fruit and vegetables, green teas and, like opinion, which is high and tomatoes. So now we move on the liver cancers, so HCC and climbed across Sonoma are tremendously increasing in this country. Here's the trends more. It's more common in man again as we moated, but it's a steady increase, always through 2017, Um, and it's 70% more likely in a man than a woman, particularly if you're over age 65. If you look at the graph of thistles, have had a separate question, and without the country California, we were. Most of us think we're from has 30% of all liver cancer in the United States. Baby boomers have the highest incidents and those from Asia having been higher incidents most related to hepatitis B. And then if 54% of those individuals are in that 50 to 65 year age group. So who is at risk? Or we just mentioned it. Any cirrhosis of any type Hep B piping more so than hep C heavy drinkers. People with Nash and National now have it automate hepatitis hemochromatosis and primary biliary cholangitis. If you have hepatitis B and not cirrhosis, there's still a chance 0.5% per year that you will get iPad a cellular carcinoma. So this study has not been has been validated. Several new one. This is the landmark one in 2002. This should if you survey people, you prolong survival. Now, with our newer therapy and therapies, aggressive surgery and transplant, these numbers are even better. So the guidelines now have come out eso every guideline and this is throughout. Dina through the world recommends screening the A S L D. Which the U. S. Society says just ultrasound every six months. The European say the same. But other ones say you add outfit approaching. It's very controversial, but it doesn't really matter. Sent you. A lot of us do. Is will alternate, you know, essentially twice a year are once you're being an officer protein. In every six months, I'm doing an ultrasound, so screening we just need to do it. You know who is at risk. Anyone has liver disease. Surveillance saves lives. And, if any questions, just contact your guests and artists or liver colleagues. And, of course, if any lesion is seen, they radiology says this is suspicious. Should be pushed on to either one of the liver colleagues or G ay colleague. This is one of most important things that come out lately. This is first one was in gastro in 2015 that coffee intake reduce the incidence of liver cancer and all deaths from liver disease. It was a large prospective trial. Ah, lot of folks from California why you were in it. It was retrospective data looking at their diet and then looking forward where they got cancer or not, death and liver disease and parasites carcinoma. If you drank 2 to 3 cups per day. It dropped your chance of dying from liver disease by 38%. If you drank, too. The cups today it dropped your cancer dying from chronic liver disease by 46%. So liver cancer was down 38% which is three cups and 46% from liver disease. You conceiving four more cups today, your chances from chronic liver disease was 71%. So Carrie Fernet I transmitted Pathologist is drinking coffee all the time and interesting enough, it doesn't matter where it it's decaffeinated, a caffeinated, and it really was equal between all ethnic groups and gender. So it's a simple, easy way. Most people enjoy drinking coffee, the guidelines and European Easel Society 2018. They now say coffee consumption has been shown to decrease, and they recommend or encourage it in your patients. So it's an easy thing to recommend, so I'm pretty heavy with the cancer stuff, so I get a little lighter stuff now. So this is, uh, I'm an empty nester and my kids around successful except with Kobe that came home, Um, and I'm really not sufficient for my wife's and my wife grabs his cage and she tells me I'm gonna go check out some puppies at the Corgi Farm. You never goto a farm with the cage in the back of the car. Okay, so then this comes home. Okay, so this guy comes home to live with us. Bilbo's his name tried color corgi and essentially takes over the house. The kids don't come home to see us anymore. They come home to see Bilbo and a walks. I'm anonymous. And are you Bilbo's dad? Yes. I am Bilbo's dad. Our daughter works for Google Marketing. They noticed Bilbo, and now Bilbo has an international following. He's on people, even in People magazine has been on the verge, and they're doing a second promotion at a Google. And now Bilbo's faces being used yet again. And so now the future for Bilbo is his own Facebook page, His own dog to line. He's gonna visit the queen. I am sure because you know the core keys of the queen's dogs. If we get to the dog, I'm gonna put my foot down, though, about what he needs to be called photo. Um and essentially I know who rules the roost and the worst is my daughter who's you has stolen his image for Google gives me no royalties. Gets nothing because, Dad, if you want to use, get royalties, then we'll have to find another dog. So Bilbo has his own world. So let's go to a world that I live in, which is pancreas cancer, which is a tough world, let me tell you, but it's getting better. So here's some cancer images. This is what I do is endoscopic ultrasound. You can see the tumor right here. This is a needle going into this tumor here. And then here is the C. T. You never want to see this this hypo dense area in the middle of your pancreas so the Cancer Society guidelines 2020 Rex Show this graph. Or maybe there's a slight upward trend in pancreas cancer. Um, but not dramatic. But the problem is, we've done really very little to change the trend. Deaths. Essentially, the new cases and deaths are fairly equal. 57 vs 47 per 1000 per year. Here's the trend immortality. It was a big rise in the 19 seventies, and now we sort of stabilized here, but a fairly high rate. This is what's concerning here is a judge. If we look at those between 40 and 64 there has been a dramatic rise in pancreas cancer in that age group s. So it's the same thing that happened in rectal cancer. So we're just not sure why this rise is taking place. We can do some question Q and A on that at the end. And here's the sobering data for American Cancer Society in 2020 to be like at all stages of pancreas cancer. The five year survival is 9%. If someone presents with, um distant metastases like liver disease like Alec Trebek did, his five year survival is 3%. We're doing better with localized people have localized tumor that's not spreading and operated on them. Be aggressive. We're now up to over 30% survival, Um, at five years, and that's really what we wanna be want to detect these patients right here so they can improve survival. So then the U. S Preventive Task Force came out in 2019 saying, Okay, let's make our recommendation about screening for average risk patients, and we do it for colon cancer for breast cancer. What about for pancreas cancer? No, they recommend against screen for pancreas cancer in asymptomatic adults. The reason is you have to use so much. Resource is so much radiation, and we have no survival benefit in any study shows. So even though it's a deadly cancer and it kills almost 50,000 Americans of the year, we do not recommend routine screening. Having said that, that's an average risk. People who are asymptomatic. So what about people who have increased risk? Where there's been a couple studies? One was in 2020. Looking at this exact question and who are at high risk, we'll go through some of these. There's a bunch of genetic mutations that associated with it. And then there's the family cancer by heart. This is the most common okay. Most patients, like my mother died of pancreas cancer will have only one family member. A single family member is not considered a family cancer. Cohort has to be more than one, and one should be a first degree relative of you. So this is a complex slide. I'll break this down later. This is in the guidelines and the paper and essentially what they say is the biggest ones. I don't know how many of you folks have puts Yeager's than these fan patients. I'm getting a lot more patients referred to. You have this c D. K into a genetic risk. They recommend surveillance during at age 40. Most others require family history, so they have the other risk factors, like I Bracha one and to the A t M Lynn Johnston jump. If you have a family history, you start at age 45 or 50 or 10 years younger. If you're a family cancer kindred, which I said remember, that's at least two members with cancer. You started 50 to 55 or 10 years younger than family history. So how do you scream at baseline? We think Marie M. R, C P and endoscopic ultrasound is that I do are better than CT scan. If the patients some reason can't afford the insurance won't pay for a memory than a C T is sufficient. So about that lights in your hand with this s o. The family history, um, is important in these folks, and I've had some problems getting insurance to pay for it, But usually when I send them this paper, I've been able to get screening eso they recommend every 12 months if there's no lesion scene. But I'll often spread it out if there are low risk and I get no risk factors, Um, now we're recommending there's data that if you have new onset glucose intolerance, that's a risk factor. So I recommend routine screening with either hemoglobin, a one C or fasting much sugar. I was not doing that to this year. Another papers coming out that supports routinely screening people at risk and if they developed diabetes or the criteria for Lucas intolerance, check their pancreas. So the goal of surveillance is very clear. We want to detect those patients who have vory early tumors. If you have a T one n zero tumor, we can cure those folks. And if you want to find a high risk lesion, these I p m. Ends of these pancreas assists, then refer to surgery stunner. Refer to me. We'll take care of them. I'm while these people don't need surgery, that it seemed very in close, intense follow or I'll doing endoscopic ultrasound and biopsy the cysts or the lesion and decide what we should do anything further. So we talked briefly about the risk factors. There's a hereditary pancreatitis were all talked about in our med school days. If it's calcification and frequent bouts of pancreatitis, there's a dramatic increased risk in pancreas cancer in these folks. There was one study that showed at 70 years half the people Frederick pancreatitis get pancreas cancer. Eso these patients thievery close, follow up and I'd recommend Emery every year. Puts Yeager's on. I have had, like, I have a half dozen patients who have this mutation. It's the STK 11. They have a significant reason. Many cancers, but essentially almost a one third lifetime risk of getting pancreas cancer. Any other patients have multiple moles. You should think about this mutation a C D. K. Into a mutation. It's extremely, uh, we used to think it is very rare. The mutation is more common than the full manifestation of the syndrome. If you get this, they should be screened for pancreas cancer. They also have a one third lifetime risk getting pancreas cancer, so please screen those patients. They have a lot of moles and several melanomas, and it's by worthwhile least getting a genetic testing or sent him to counseling. So most patients have no family history, no mutation, and they should not be screened. Secondary screening for those patients who have risk factors is promising. We're still a long way to go, and patients with precursor lesions these assists in the pancreas. This is chronic pancreatitis and other lesions. They need more aggressive follow, and we're certainly available to help you. So we still have a lot of questions about pancreas screening and pancreas cancer. We still don't know, actually, how often. How early. For a lot of these patients, it's It's very expensive. If you say from age 45 we're gonna memory every year or two years. That's extremely expensive for a small disease, and we also don't know when to stop screening. Most of us stop 85 because most of the treatment for pancreas lesions is surgery. Imagine. Can your patient get a whipple, your patient? Get additional plan. Protect me. If not, usual, price should stop screening. So colon cancer, something also near and dear to my post. Here's to cancers in the colon, I found in the last two years, Um, and the polyps surveillance. We all know this in med school. In the pop surveillance, here's a small Cecil Adenoma. Here's a big lesion words, not ulcerated. Here's another one Cecil Illustrated Adenoma, which so they went to cancer here. The good thing about colon cancer is it takes a long time, we think, probably anywhere from 7 to 10 years, from a polyp to form to develop into cancer. So that's a perfect for screening, because then we can intervene anytime. The good news days because we're now screening the death trend is going the proper direction. We're dropping the death cancer rate, but in this country we have about 150,000 cases of colon cancer, and we about 50,000 deaths. And the mortality matches hit male. I mean males and females. Mortality is dropping together, and here's the survival risk. So if we get someone early Stage one, it's 88% cure rate. If we wait to Stage four, they have symptoms and and present poorly. Um, then it's 12%. So in the first two stages we can make a huge difference and save lives. That's why screening makes such a huge difference. We find those early precursor lesions. So where some of the risk factors. This is very important for counseling. Your patient's family history is critical. If you have one first three relatives, I tell my patients. Then it's it. Doubles your risk for colon cancer. Lifetime. If you have to, it doubles it again. So now it's four fold. If it's just a second, the relative, it's still about twice, and the adenoma is about twice. Of course, inflammatory bowel disease and maybe even diabetes. Increase your is what can we modify if you get less than three drinks per day? Have you will lose weight, particularly men. That makes a big difference more than women. Red meat. Maybe slightly process red meat. That's why the World Health Organization came against processed red meat and then smoking. Of course. What can you decrease? We know dairy, which is the vitamin D, and I'll show you that data later and then. Physical activity being active so exercise in several large prospective oppositional trials has been shown to decrease risk for colon cancer. On, of course, we all know about Chadwick Boseman. It's now striking young people, and I was funny my my accounts just blew up when his announcement was made. You know about his death and he was diagnosed at age 39. Unfortunately, he was staged for diagnosis and he died four years later. Um, so here's this trend. So these are Caucasians here, the most dramatic arises and Caucasians. It's always been higher in blacks, but it's also rising slightly in them. Now the question is, is why we really don't know. That's the problem. We think it has to do with diet to take the same cohort. Let me go back here. If you take the cohort who turned 50 here, you're almost, um, not quite doubled your risk of getting rectal cancer in the same cohort when you're you hit age 40 to 50. So it's very important for the primary care doctors to recognize this. Don't blow off any lower tract symptoms that the patient comes to your bleeding. It's 95% hemorrhoids, but I think your suspicion for cancer should be higher. They all need a rectal exam or flex sig. Um, if they have a change in bowel habits, where they pain or certainly weight loss, you need to get them to have your flexible sigmoidoscopy or colonoscopy. So what does the task force recommendations? There's There's dozens of recommendations. I'm going to go over the ones that I use that Avery helpful. This is from the U. S. Threat of task force. And what they say here is in the average risk population age 50 to 75. Everyone should be screened. We'll talk about what? How to screen in a second at age 76. 85. You talk with your patient. If you have this very healthy, vigorous 82 year old, he or she should be screened. If they're very frail, you know 80 year old heart failure then probably don't need to get screened. The other thing that task force came out to that 16 is aspirin makes a difference for primary prophylaxis. Astra makes a huge difference, so I recommend that my patients, but talk to them also about the risk factors for G. I tract bleeding before you do that. So the newer guidelines from one of my societies, which is the multi, especially task force, who took all the special radiology surgery g I. And they made recommendations. I like it because it makes it very easy. They developed a clinical approach to tears. Tier one is colonoscopy every 10 years or a fit test, and the fit test is interesting. The fit test is better than the old guy act that we grew up with because it's a text, the globe in chain of hemoglobin, and it's specific to humans, so you don't address the diet. The patients could be huge red meat eaters that will not alter the task. And it's only one test. Artistas. You mail it in the patient's pick it up in a mail it back. They don't have to bring it back to the hospital, and it's fairly accurate on git costs about 25 to $35 to or too, it's CD philosophy, the fit DNA test and the Flex Sig. Every 10 years, two or three is not recommended. That capsule colonoscopy. We're just not there yet, and there's a blood test called except in nine. It's not recommended. It's a performance. Characteristics are not good enough for screening at this point. So there was an update, though, that caused some controversy in the G I world. This is from the American Cancer Society in 2018, and they said, Hey, we think we should definitely screen 50 to 75 which validated all the other ones They said we have a qualified recommendation that those between 45 50 should be screened. That was based on modeling, not an actual real world data, but that's very interesting. The problem is, I don't think we have enough colonoscopy. Resource is just colonoscopies on everyone from 45 to 50 so they do not recommend how the screening should be done. So the problem is, there are too many recommendations. So what's my opinion? So first of all, it's like the Nike thing. Just do it Screening Definitely save lives. Okay, I like Tier one. Colonoscopy or fit Testing is probably best for 50 year older patients, and both are good, and we can argue the benefits of coronavirus fit. That's not the point of this talk for 45 to 50 year olds. In the absence of any concerning symptoms, I think fit test is probably most certifications and certainly the most cost effective. But if you have ah, 40 I've been, say, 40 to 50 year old who has any symptoms doc. I see blood on the toilet paper. Hey, my stools have changed over the past two years. I have this pain. Now I write Laura Quandary that patients should probably get a colonoscopy on. If that had happened with Chapter Bozeman, who knows would still be alive today? I don't know. So what about we find a pile up? These change? All these new guidelines just came out in gastroenterology in 2020 because I think, personally, we were always doing too many colonoscopies and these folks and I think the evidence now support it. So they went back and looked at the data on when we actually should go back. And so screening remains every 10 years by the current guidelines, if you have one or two small polyps used to be every five years. Now, they said, you go 7 to 10 years. You have three or four polyps. They say 3 to 5 years. It used to be every three years. If you have one polyp observer 10 millimeters or as bad histology, which is considered Phyllis, it's three years that didn't change. You have more than 10 adenomas. Even if they're small, they say every year the rest of your life, and that's new. And a lot of times when it's a big pile up, I have to take it off in pieces. We call it piecemeal resection. We look again in six months, and it really wasn't a change, either. Now, this is also know you're seeing more of these hyper plastic and the Cecil serrated politics very confusing. They sort of looked at the data. I've always started treating the same as adenomas, and they essentially due to, however, if you have left less than these 20 of these and there on the Left Colon, you could do 10 years, which is a big change. Okay from actually not from this guideline, but from what you guys were taught in medical school. Now the Cecil Polyps that they're very small. It's 5 to 10 years. That's new. If you have 3 to 4 the Cecil straight of polyps, it's 3 to 5 years, and that's new. Also, it's more than five. It's the same, which is three years and again, if you piecemeal respected okay, even though it's hyper plastic or Cecil survey, did they recommend six months follow? And that's to make sure we got it all, so I won't. We'll go through these slides. Have time for questions. Essentially, here's the high quality. Colonoscopy should be done to screen. Here's the 10 years, and this makes it very easy. I have this up in my endo unit, so when we have our pops, like I told the patient, right now, this is where you are and we should look again. A tous this time frame. So circulating vitamin D I told you I was going to discuss this. There's a large trial looked at vitamin D. They had 5700 colon cancer patients and over 7000 controls. They looked at each increment of 25 for vitamin D and in women, it was significant. Colon cancer decreased by 19% and those who were taking vitamin D okay and it decreased each court tile. So if you had during the 25th, it was better than the 50th better and up 100%. There was a risk production of 7% in men but just didn't meet statistical significance. It didn't matter. Age, race, region. It didn't matter engender like we talked about and in pushing the dose over 100 to get over 100 level for your vitamin D made no difference. So how? What Star General Prevention? We'll go through some of the things and add the new things we just talked about. Stop smoking increases the cancers we talked about stopping alcohol decreases pancreas, esophageal, squamous and liver weight loss increases all GI cancers exercise. We have solid data increases. Colon cancer, a diet, it's higher and fresh fruit and vegetables. Um, is very helpful. Less red meat, especially the process red meat. And the World Health Organization has now listed red meat as a class two carcinogen specific preventions. Avoid hot beverages and food. That's where squamous cell esophagus avoid processed red meats and red, making some general decreases going cancer that low dose aspirin or regular ass per day Do cases. Colon cancer. Vitamin D decreases colon cancer data. Solid women Not quite a solid as in men, but it still was Trend coffee use. Recommend coffee your patient with all liver diseases and decreases the risk of dying from that liver disease and decreases the just of dying from the Paterson across the number. What about screening tests? What we talked about colonoscopy and still test save lives. It's harder in the young population. Maybe we should be a little more aggressive. Esophagus Selected Barrett screening Um, in those patients, Always check and treat for H. Pylori. If you find HP Laura, you really obligated to eradicate it. I gave you the screen through what doses to use. What medications? Uh, ultrasound and outfielder protein for screening for liver cancer, past or current cinema and image in the pancreas, pancreas, assistant highways, patients. Emery is probably the better tool and follow the guidelines of not sure contact any of us to take care of pancreas cancer. Andi. That's all I've got. And now we're open to questions. So I Doctor bandmaster put a question and when to stop aspirin for prevention we actually have. The data is actually fairly light for starting the aspirin, and to my knowledge, there's no data about stopping it. I would view it is when the patients our risk for bleeding. If they're reading list, their best reading goes way up. Let's say they get started on drug like eloquence. Xarelto. Then I would stop the aspirin, of course, unless you felt it was also good for cardiac and stroke prevention. So question to please clarify all new answer anti to better should be screened for pancreatic cancer. That is a great question. There is no solid recommendation on that yet. We've all known that a lot of time Station gets a new diagnosis of diabetes, and then two years later we're diagnosing them with pancreas cancer. There's a study I just reviewed that's not been published yet that actually looked at that and said that it definitely the trend of fasting blood sugar starts before the diagnosis of cancer. And so the guidelines not out and you might have a hard time getting an Emory in a patient who has a new diagnosis of diabetes. But I think it's reasonable thing to dio what I would do if you have a new diabetic assess the risk factors. Are they a smoker? Their family history. They have any other gene mutation that could make it. If so, use that as your fuel than to get the screening test. There was another question that popped up. I missed it. E thought there was a third question. What does that vitamin D is recommended her up to what vitamin D level shy obtained. We talked about the court tiles. So, you know, a lot of times you're getting into 33 or 35 vitamin D. It turns out over 100 made no difference. So it's not like these vitamin C people who say, I'm gonna push my dose of vitamin C. The sky high excess doses of vitamin D made no difference. And of course, they may be harmful, so I don't set a dose. I just started 1 to 2000 units, you know, per day. That's why does that usually daily. And then I checked the level in three or six months, and as long as they were 50 or above, that's perfect. If they're still hanging around, you know, 25 or 30 or low normal, I might push him, particularly if they're at risk for colon cancer. Then I would push the dose, but you don't need to go to the super physiologic doses, but I would keep a nigh on it. Check at least one time. So this is another one. So, um, I to start ordering ctm rye for all my diabetic patients, that is a a great question, I think No, I think we don't have the data yet, and that's expensive. It's the new onset, so but having had diabetes long term, they have a higher risk for pancreas cancer. But it's not a huge risk. So right now, I'd be reluctant to say all my diabetic patients should get screened again. I would look at any other risk factors then I absolutely would. If they have a family history, a second to refinement history, they have a break of one gene. You know where there are smokers, then I think I would. But I think just the screen, all your diabetics, I don't think we have the data. You have to say that and we're very, very expensive. Good question there. The planet pancreas cancer screening is even the data we have. A lot of times we find these cancers and they're not. We find them. We can't cure them. But you find them earlier. You do seem to prolong survival little longer. All that could be lead time bias, as we talked about it on 40 is not like colon cancer. Where universe to stage three. We can cure their stage three or four pancreas cancer. We don't cure those folks. E don't see any of the questions, Mike. What do you think? I thank you very much. We'll Great. Okay? Yeah, My pleasure. Alright, take everybody. All right. Bye bye, e Just wanna tell everybody we're going to take a break until 10. 30. Don't forget Thio. Check out the exhibit hall. Um are virtual exhibits during the break time and we'll see you back at 10. 30.