Hi, I'm Dr.

Chrissa Quite, faculty member from the department of family medicine and behavioral health at the University of Minnesota Medical School Duth campus and family medicine actually internal medicine physician um at uh Aspire St.

Luke's here in Duth.

I'm your host for today's episode on cancer prevention, diagnosis, staging, and grading and treatment.

The success of our program is very dependent on you, the viewer.

So, please call in with any question you have.

Send them to our email address at askpbsnorth.org.

Our panelists this evening include Dr.

Sandy Stove from the Department of Family Medicine and Behavioral Health at UMD and Dr.

Matthew Braithweight, an oncologist from Essentia Health here in Duth.

Our UMD medical students, um, phone volunteers are Simon Boyagna from Ellsworth, Minnesota, and Jessica Loen from Hugo, Minnesota.

And now on to tonight's program on cancer prevention, diagnosis, staging, and grading, and treatment.

Welcome you guys.

Thanks for being here.

Good to be with you.

We always like to start with you telling us just a little bit about who you are and what you do.

So, uh, well, I'm Sandy Stove.

I I've had a career in the up the Northshore in primary care, so as a family doc, and now I have a chance to work with med students and do a little bit of of some clinical um, work supporting them.

Very good.

Uh, so my name is Matt Braithweight.

I'm a hematologist and medical oncologist at Essentia Health.

So, uh, I'm a cancer physician.

uh kind of what I do specifically is uh manage medications and drug therapies to treat cancer patients and also see folks with different blood related conditions both cancerous ones and non-cancerous ones.

So, thank you for having me tonight.

Oh, it's so fun to be here.

Hard topic though um and one that concerns many many of our viewers and our families and friends because cancer affects actually um so many people.

I think about 25 to 30% of people will encounter a cancer in their lifetime and maybe even more.

But um then often as we age I I once heard a statistic that nine out of 10 cancer patients are over the age of 50.

So it's a very common worry for those of us who are um entering the later parts of our life.

So I thought maybe we could talk a little bit about something that I've been hearing about in the news which is something called a liquid biopsy.

And I wondered if um maybe somebody in the audience has heard about this too, so we could just kind of tell them what what is on the horizon a little bit and what what it is used for and what maybe will will come in the future.

Do you want to field that one, Dr.

Baker?

Sure, I can start with that one.

So um liquid biopsies are blood tests that um can have a number of different uses um in cancer care.

uh for instance we use them in my clinic sometimes to detect small amounts of circulating tumor DNA in someone's bloodstream and we can use that information to look for mutations that might be amenable to certain targeted therapies or other kind of non- chemotherapy uh type medications.

I think the other area where we're seeing them um emerge is with uh cancer screening.

And so, you know, those same circulating fragments of tumor DNA that I might be looking for to look for drug targets, um, we could use those just to maybe find cancer to begin with.

And so, there are some, uh, commercially available tests now that can be used to kind of look for multiple different cancers with one single blood test.

And, um, I think that's something uh, Sandy, that you may be seeing, you know, more so in primary care.

And so, uh, I haven't seen a lot of it yet here in this area, but when I was a fellow, I was starting to see some patients that were coming in with tests that had been done by, you know, other providers.

I know it's there are some tests out there that are helpful in looking at people at higher risk because like with breast cancer, the BRCA testing can help to make it easier to know the people that we wanted to be a little more careful in terms of screening, right?

And Dr.

Stover and I would love to not have to talk everyone into a colonoscopy if it was as simple as a blood test.

Wouldn't that be easy?

Um although the the vit the colard which is one of the brand new one of the tests that's out there right now is actually pretty easy to do in a home setting and it actually it's increased the number of people that have gotten screening already but a blood test would be even even more so.

Yes.

If I can add one thing there though.

Um I mean these tests will oftentimes come back positive but then you have to go looking for the cancer.

So you you may still very much require that colonoscopy or other imaging tests or biopsies.

So often times that's just the start.

So there are some other implications I think of this testing that um the healthc care industry as a whole will have to figure out how to how to manage.

Probably behooves us to state that not every positive test is positively a cancer also.

So that's important to put in our message about this exciting um frontier on on medicine.

I do have some questions.

Are you ready?

Excellent.

All right.

Why do we screen for some cancers and not others?

Well, and I think that's that kind of goes to what what does what we were talking about?

What does a screening cancer look like?

And there are some cancers that will will um give some hints that there may be something going on like breast cancer.

The tissue of breasts can be looked at with either X-rays like a mimography or ultrasounds and you can see changes in the tissue in a different way than you could see something.

It doesn't work that way to do the special X-rays to the abdomen.

CT scans can be helpful, but they're not specific in terms of densities.

So, there's there's different kinds of things that respond differently and and have different outcomes.

And you probably have some input on that as well, I think.

No, I I agree with everything you said.

I think you know other uh reasons why you know some cancers might be easier to screen for or be more effective um to be screened for that uh you know you kind of have to think about what the downstream ramifications are.

So you know ideally a screening test for cancer is going to detect cancer at an early stage where um you can intervene on that and improve someone's outcome ideally their survival because we we all worry about you know dying of cancer that's that's people's ultimate concern and so we need to be able to intervene um to improve a patient's outcome.

So colonoscopy for instance, if you can find um a precancerous spot in someone's colon like a polip, you can do something to intervene on that and hopefully prevent them from having a cancer that might affect their health in in years to come.

If you take something like, you know, pancreas cancer for instance, it's it's maybe harder to find it in the first place and to deal with something that might be precancerous might be a big invasive surgery or something like that.

And so it gets more difficult, right?

I think that's a good point.

Some cancers we can find very early and treat and be effective at that screening tool and others we just can't figure it out fast enough.

And unfortunately, it's not probably cost-effective nor um with the numbers of folks that will have these cancers to to endorse a mass screening effort for them.

I think so.

There's some things like skin cancer though that people can be alerted to what to watch for, which is sort of like a screening.

It's not a a mandated or a a formatted sort of screening, but being aware of what does it look like when skin changes are normal with aging and which ones do you are more concerning and need to go in uh to be checked out.

Yeah, that sounds good.

I was I'm tempted to tell you tell you to tell the audience what they look like.

rapid change, anything that's uncomfortable, color change, irregular borders, uh uh increased risk in a family, people who have light skin are at higher risk, people are redheads are are at higher risk than than blondes are.

Um the shapes to some extent, irregularity, I think denser color, and variegated color service message, Sandy.

All right, I have a good one.

So, this is um they didn't leave a name, but um it's someone who wonders.

It's an environmental question.

So, such a good question.

His specific question is about uranium and how that causes cancer, but maybe we could talk about other things that are in our our environment in addition to uranium.

And what do you think about things like that and how they might be risk factors for cancer?

How should people consider that and where they live and how they test maybe their water, soil, environment?

In terms of environment, there's a number of things that we we do in terms of the foods that we eat that are they may be more helpful to in reducing cancer risk.

With colon cancer, a lot of more of the fresh fruits and vegetables are easier on the gut and more healthy for the gut than eating things that have more preservatives and more things like that.

So, higher fiber diets are are generally better for colons.

Um, I think the we're just talking about skin cancer.

some of the the radiation that we get from the sun.

The UV light is essentially a radiation form that can impact the genetics or the the how the cells turnover is going because cells are amazing.

They turn over rapidly.

They keep us um um healthy and and things working well.

But that that process of continuous division uh is relies on cells that are healthy and that the the genetic genes are the the the plan is basically I think about the the genetic materials like the the plans for how to make things in within the cell and if they're screwed up a little bit.

It's like when you get um that Christmas toy you're going to set up for your kid and you realize that the some of the pieces are missing or the pieces are not the right piece for the for the situation and it doesn't work then and so then you get abnormal turnover on the cells and grow growth happens that's not normal.

Dr.

Braithweight, do you want to comment about uranium environmental factors?

Sure.

Yeah.

like like Sandy was saying, um you know, different toxins or environmental exposures can sometimes damage the DNA in our cells.

And uh sometimes when the DNA gets damaged, these mutations that happen in our DNA can cause cells to gain some sort of survival advantage, which is kind of a paradox, but can cause them to grow in an unre unregulated way.

And our cells have these mechanisms that tell them that they should live for a certain amount of time and then die just like our own bodies.

And sometimes those mechanisms can get affected by things like well uranium or other things that um cause some ionizing radiation or other toxins in our diet.

And so um yeah, I think we need to be mindful of of the things that we put in our bodies.

It's it's a really hard thing to study.

Um, so, uh, you know, figuring out what things are bad for us and and what, uh, what isn't is sometimes a difficult question.

So many things, but I do remember studying in medical school about radon, for example, and it's linked to lung cancer.

And of course, you'll have a radon test when you buy a new home, and that's what's happening there is like to look to see if your environment is a risky environment in which to live.

We also have lead in in water systems that can sometimes get there.

They're left over from from decades of of even lead and gasoline that's still around.

Right.

Right.

That's right.

Especially for you know Duth in particular being a older city with with some lead service line still and infrastructure.

Well, you use some words and you know Chrissa loves her history of medicine so we might as well go into that.

And so I warned these people my guest that we were going to talk a little bit about PTO's paradox.

And so that is um you know, do you ever sit around and think like why do we get cancer and why do some living things not get as much cancer?

And I've mentioned elephants before.

It's my favorite organism to talk about on the show.

So for example, humans have um a higher risk of cancer than elephants, but one wouldn't think that would be the case because elephants have more cells.

And if you have more cells, like Dr.

Stove was saying each cell can have a mutation and it can like mutate into a cancer.

So why don't elephants who have more cells have more cancer and that is a there's something called PTO's paradox.

So do you want to maybe talk to the audience about why humans have more cancer and certain things like el beings like elephants do not but mice for example have a lot more cancer.

Maybe that's a interesting that's a great question and and uh I was reminiscing on the fact that someone asked me that question when I was interviewing for my oncology fellowship and it kind of took me by surprise because sometimes we're thinking more about what what are we going to do about this cancer rather than some of these questions about its biology.

But um what you're alluding to is interesting.

Yeah.

Animals that are larger have more cells.

There's more cell turnover in the body so more chance for mistakes to be made.

you'd think more cancer would happen, but that doesn't seem to be the case.

I don't think anyone truly knows all the reasons why, but we do know that some really large animals like elephants have more genes in their body that can suppress cancer.

So, um, most living organisms have this gene called p-53, which encodes a protein that helps our cells die if there are errors in its DNA that things that could lead to cancer.

And we have two copies of that gene in our bodies, one that we received from our mom and one that we received from our dad.

Elephants have 20.

And so they have a genetic um protection against cancer because of that.

And there might be other things that contribute that too.

But that's something that I think scientists have pointed to as an explanation for that.

Thank you.

I just think that's so interesting that elephants have less cancer than we do.

And you're right.

It's all because of that p-53 gene suppression gene.

Fun fun medicine.

So okay this is a really specific question about a part of the body from Trice from Duth asks with a new diagnosis of Barrett's esophagitis what is my likelihood of getting cancer and maybe I would even we could talk about how to how to monitor that to try and prevent cancer so anybody want to field that one so be esophagus is a change in the cells at right where the esophagus meets the stomach and the most likely reason for it to happen is irritation ongoing inflammation which increases cell turnover which you know is problematic for cells that that some of those those turnovers may result in abnormal uh appearing cells and the so so constant irritation on that from reflex or from other things.

Uh if cancer were to develop there it's hard to see it.

So the the b the benefit of doing regular endoscopies or where a tube goes down you can you can look and potentially take biopsies of that tissue is very helpful.

So the the risk is is one of those things that that to say risk for an individual is difficult to say risk for a group of people um is less precise but a little um a little bit more likely and it kind of depends on the degree of the Barrett.

I don't have that in my head and exactly what it is but we generally see people with with Barretts are are have regular surveillance.

So that's another good word that's kind of good to describe is there's screening where we're looking for anything that could be happening in a number of different organ systems.

So mammograms, colon screening, um there's lung screening at at this point, particularly for people who've been have a history of smoking.

But when we're doing surveillance, we have something where we know there is already a change where growth may be impacted and some abnormal um cells are showing up.

And so you watch for them to get to that point where you want need to intervene because as you had said earlier, sometimes if we go in and intervene too soon, the the the the method we use to do that can be more damaging than the cancer itself.

So going and removing a pancreas because you might have pancreatic cancer someday.

Well, pancreas is pretty important in the body.

So you don't want to do something that causes significant injury to the those kind of major organs.

Yeah.

And yet I would say those who have genetic predisposition sometimes we do do things like ovaries removing ovaries or doing a prophylactic removal of a breast or people have the BRCA.

Yeah.

Such good conversation.

This is another great question from Tom from Duth.

He asks, "Why would CT scan MRI be beneficial for watching for or screening for cancer?"

Yeah, I can take a stab at that one.

Um, so in general, um, a cancer might show up as an abnormality on an imaging test, like a CT scan or an MRI.

Um, you know, so a couple examples of that would be, um, using a CT scan to screen someone for lung cancer.

You know, that's something that we do uh commonly in patients that are at high risk for it.

So, namely people that have a strong smoking history and the rationale of that is that you might find a cancer in early stage and it appears maybe as a small nodule on that CT scan.

And if that can lead to a biopsy, then that that proves that it's a cancer.

It could be operated on or radiated at an early stage before it becomes more advanced.

Um, similarly with an MRI test, that's something we may use in in certain patients that are at higher risk for breast cancer.

It's a bit more sensitive than uh a mammogram.

So, some some patients that have a high um risk based on family history or genetics like a BRCA mutation like you were mentioning, an MRI of the breast might find a very small or early breast cancer that could be intervened on early.

Good.

Um, on occasion I will have a patient refuse a test because of their concern about exposure to radiation and we use radiation to screen.

And so I've always find myself in this predicament of trying to explain like the amount of radiation exposure might be worth the risk for trying to detect an early cancer.

An example of that would be regular mamography or the lowd dose CT scanning.

Could we speak maybe a little bit to radiation exposure and how much to worry about that?

Sometimes as a hospitalist I um I think whoa this person had a CT scan a month ago.

Should I do another one?

How much radiation should I expose them to?

Can we have a little conversation maybe about that?

I I I talk to people a little bit about relative risk and what that means is what's the risk of doing something versus the risk of not doing something.

And it it's interesting that we receive radiation every day from the world around us.

The particularly from the sun, but there's other sources.

And so when we go on an airplane and fly across the country, it's it's about as much radiation as a as a just CT if I remember the correlation something like that.

And so it's like but I don't you know we do we also don't want to do so much exposure in a natural world that that we you know that you have to take that into account too.

But I think that the the balance is an individual decision relative to the risks an individual has and the the benefits of doing an intervention is is the big thing.

I think it's also important to understand that radiation frequent radiation at a younger age where the the gen the um ability to form eggs and sperm and and those kinds of things would be more impacted than radiation at an older age.

Although at an older age we've had more acred radiation.

So, it's one of those u I I my the students that I work with get tired of me saying this, but it kind of depends.

There's individual choices and that's something though to understand that in in that balance it may be better for you to have some radiation to inter to understand the disease better.

Um even though there's some risks associated with, right, everything we do, right?

We really value life and we're just trying to prevent an illness.

And so sometimes the risk is worth it.

If we catch things early, why else would you come to the doctor?

And and sometimes it's just understanding it better.

If people understand what's going on, that can be so valuable uh and to have a better grasp of of the choices that they have.

Right.

Exactly.

Here's one about prostate cancer.

This is a fun cancer to talk about.

And in in truth, like this whole topic is so vast.

We could spend a week.

A week.

We could be on TV for a week.

Anyways, wouldn't everybody love that?

Okay.

It says, "Among cancer patients, even though they have the same disease, why do they have different treatment regimens?"

So, I'm gonna let you answer that.

Sure.

So, uh, can cancers that arise from different parts of the body oftentimes have different biology.

There's different things that drive the growth of those cancers.

Um, and because of that, you know, they may be more sensitive to certain types of treatment.

I think you had alluded to prostate cancer.

You know, we know that the biology of prostate cancer is such that testosterone in particular seems to feed the growth of that cancer, at least early on in its disease course.

And so we find that taking away testosterone can prevent those tumors from growing.

That might be very different from someone with lung cancer or somebody with pancreatic cancer where different things are driving the biology or the growth.

And so in in general it's it's this biology or these genetic changes within the cancer that are driving it.

And we sometimes need to use different treatments.

Um because of that I've found in my career I've seen the evolution go from trying to target the cell the malfunctioning cell killing that to trying to enable our own immune system to fight the cancer.

And so it's been a very exciting change over time I feel like with in terms of what we're seeing as far as options go to treat.

And so each patient is unique.

We certainly study them genetically.

We look at the cancers and how they're made and and try and formulate the right concoction to beat the cancer.

So um well that's very good.

Let's see.

I'm trying to think of other commentary about about that.

Um I'm sure as a Go ahead.

Well well I think what you touched on about amunotherapy I think that's one of the more exciting things in our field right now.

Something that's really revolutionized cancer care in the last decade or so is our understanding of what the immune system does to both prevent and and uh how we can utilize those aspects of the immune system to treat cancer.

Um because we see for example that people that are immunosuppressed have higher rates of cancer.

Um so for instance you know folks that have had maybe an organ transplant they're on imunosuppressive drugs um because of that they have higher rates of cancer.

So we've known about this correlation for a long time but currently we have some medications that allow our immune system to better recognize cancer as something that shouldn't be in our body.

basically helping the immune system do its job and go after cancer cells and try to get rid of them.

It is definitely part of our job that is um up and coming.

Some of the most interesting new treatments that we have in medicine surround cancer.

Um I'm from a small town and I've often heard questions from friends, family about whether we have a cure for cancer and we're just withholding it.

You've got to love a good conspiracy.

I know that sounds a little crazy, but I've heard that more than I've than I could believe.

And no, we don't have that.

And I wish we did.

I'm sure if we did, we would give it to everyone because in medicine, we're I think it does bring up that we have reached a point where there's vaccines that can really help reduce some of the cancers that are triggered by certain viruses like the HPV virus.

Yes.

And so, hepatitis B. Hepatitis B. Yep.

Yep.

Thank you for that.

That's a good memory um thing to remember I guess when we're so we have prevention, we have screening and then we have detection and and like surveillance I guess.

So well we're nearing the end of our show and I just want to first of all invite you back.

You are wonderful guests, very interesting and I enjoyed your commentary.

Um do you have any final thoughts for our our audience today on our cancer screening treatment?

I think the big thing is there's lots of changes and it's because we're getting better and better evidence on what to do.

So it's not that we change our minds about something, but it's about there's something better to do.

Uh and so the recommendations do change over time.

The the screening that you your doctor will talk with about might be a little different than what you heard a couple years ago because we're getting better at it.

Yeah.

Yeah.

Thank you for having me this evening.

I' I' I'd maybe for a parting thought just say that uh please come see doctors like Dr.

over in primary care so that you can prevent the cancer and maybe not see me in my clinic and need my services.

But cancer is a an unmet need that we all need to continue to work on to take care of patients in the best way we can.

Thank you for that.

I want to thank our panelists, Dr.

Matthew Braithweight and Dr.

Sandy Stove.

Please join doctors on call next week where Dr.

Dr.

Ryden Harden will discuss care and treatment of the upper extremity, shoulder, and neck, including muscle and tendon conditions, joint replacement options, and prevention with a panel of experts from around this region.

And if you're looking for more tips, tricks, and conversation around health and wellness in the Northland, make sure to check out Northland Balance on the PBS North YouTube channel.

Thank you for watching and joining us for season 44 of Doctors on Call.

Good night.

Happy holidays.

promos.

I are Are they just like broadcast?

I guess I know some of the nurses and thanks you guys.

so much.

What a wonderful discussion.

Yeah, it should be an hour one easily.

So, especially if you kind of We didn't get as many questions as we normally do, but you did a nice job.

Phone lines died I think halfway through from what I was hearing.

Really?

Yeah.

So, Jason was going back and forth just Oh, shoot.

Okay, that makes sense because we normally have more.

They were great questions, but um yeah, I just sort of punt and Joe, I think