[00:00:01] Speaker A: Welcome to the Spotlight edition of the Future of Medicine Podcast. I'm your host, Dr. Craig Wright. Join me as I have conversations with fascinating medical experts as we discuss a variety of compelling topics. We aim to not only inform you, but to empower you, instilling confidence along your journey toward optimal health.
This podcast is brought to you by Brentwood, md. Located just south of Nashville, Tennessee, Brentwood, MD Provides Best in Class Concierge Primary Care. To learn more about our innovative approach to primary care, visit our
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[00:00:38] Speaker B: this episode, I'm joined by Dr. Natalie Spradlin, an Assistant professor of Hematology and Oncology at Vanderbilt Ingram Cancer center. She has over 14 years of clinical experience. A Nashville native and a graduate of Vanderbilt University School of Medicine. She currently holds three board certifications, Internal Medicine, Hematology and Oncology.
She is deeply involved in physician development, currently holding the position of Co Director at Vanderbilt's Internal Medicine Miller Society. She's a dedicated educator, regularly teaching medical students, residents and fellows in clinic. In fact, for the 2024 academic year, she was given the Outstanding Clinic Home Preceptor Award. Her passion for education shows up today in how she communicates and educates her current patients with we hope you Enjoy our conversation,
[00:01:28] Speaker C: Dr. Spradlin. I look forward to continuing our conversation, kind of diving deeper into some of the advancements in screening, diagnostics and even therapeutics around kind of the general field of oncology. So as we start this part of our conversation, many of the members I work with are fearful of this conversation, a little health anxious and worried about ways that they can prevent cancers. So what are some of the ways that you would recommend a primary care doc counsel their patients on what are evidence based ways to reduce broad cancer risk?
[00:02:06] Speaker D: So 30% can be up as high as 50% of cancer diagnoses can be
[00:02:13] Speaker E: traced back to some sort of environmental or lifestyle risk factor.
[00:02:19] Speaker D: And so it's just continuing the good fight of trying to communicate the importance
[00:02:26] Speaker E: of taking care of yourself.
[00:02:29] Speaker D: The ones that have evidence behind them is tobacco use.
[00:02:34] Speaker E: It's estimated up to close to 18 19% of all cancers can link back to regular tobacco use, whether that's smoking or in the form of snuff. With head and neck cancers and cancer in the mouth, tongue, tonsils,
[00:02:51] Speaker D: a healthy weight is linked to decreased cancer risk. And it doesn't always kind of loosely say that.
[00:02:59] Speaker E: It doesn't mean you got to be skinny.
[00:03:01] Speaker D: But there is a calculator, an online
[00:03:03] Speaker E: calculator, BMI body mass Index. You can plug Your name, Google a
[00:03:08] Speaker D: BMI calculator, plug in your height and your weight. And unless a person is a big weightlifter, real, you know, large, human, they may never get a BMI under 30. So we have to take the information
[00:03:21] Speaker E: in the context of the person.
[00:03:23] Speaker D: Yes, But BMI under 30 is considered normal weight.
I think.
[00:03:28] Speaker E: Well, you'd know better than me doing primary care. I think actually under 25 is normal and then a little bit overweight is 25 to 30.
[00:03:35] Speaker D: But with cancer risk, BMI under about
[00:03:37] Speaker E: 30 has been shown to reduce certain cancer risks. Sun protection reduces skin cancer risk. Melanoma being the most scary of those.
Regular exercise has been shown to help with lots of chronic health conditions and then also reduce the risk for cancers.
Trying to think limiting alcohol. Alcohol has some association in liver cancer.
Depending on the amount used, alcohol could have links to some of the head and neck cancers. It's a carcinogenic. So those are some of the ways
[00:04:17] Speaker D: that we know can modify those. It's going to impact your lifetime risk
[00:04:23] Speaker E: of developing a malignancy associated to those factors.
[00:04:27] Speaker C: Yeah, I love that. When like we talked last episode, those are ways in this context so we can prevent cancers. But then should you get a cancer independent of that, that'll help your after story, help help your recovery.
So now let's transition into some of the, the early diagnostics and screening specifically. So the first place I'd like to start, which we also touched on last episode when you talked about the BRCA genes, genetic screening, does that have value outside of someone with a family history?
There's screen, there's, there's now broad genetic panels. I know we've run one here that I think test like 70 genes that have been linked to var cancer types. Is there a place for that to be done in someone who does not
[00:05:18] Speaker B: have a strong family history that they're aware of?
[00:05:21] Speaker E: Not usually.
[00:05:22] Speaker D: Usually it certainly there's a role for
[00:05:26] Speaker E: it if there is a family history of a particular type of cancer. And again we touched on it. But there are these syndromes that have
[00:05:36] Speaker D: this, this or this and that syndrome. So if there's a family history recognizing
[00:05:41] Speaker E: those syndromes, that might prompt one to get tested for that syndrome. So there's a syndrome called lynch syndrome and it's a cluster of cancers that a family tree could manifest if they carry the lynch gene.
[00:05:55] Speaker D: And so being aware of your family
[00:05:58] Speaker E: cancer history is important. And then talk about it with your doctor to know if that puts you in that higher risk category.
[00:06:05] Speaker D: There's also cancer genetics teams and to my understanding, doesn't. You don't have to be referred by
[00:06:13] Speaker E: a cancer oncologist, like an oncologist.
[00:06:16] Speaker D: So if as a primary care provider, if you recognize, hey, this is a
[00:06:20] Speaker E: really strong family history of cancer and these people are.
[00:06:23] Speaker D: This, this family tree is getting it
[00:06:25] Speaker E: younger in life, you can write a referral to cancer genetics and have the person talk to a genetic counselor, they'll do a family tree.
[00:06:34] Speaker D: Then that will give a statistical risk.
[00:06:37] Speaker E: There's different risk models, and then that helps to inform what should be tested for and covered by insurance and all of that.
[00:06:45] Speaker C: That's a great way. I think it is important to note that in many of those cases, it does change one's screening.
[00:06:52] Speaker D: Sure, absolutely.
[00:06:53] Speaker C: Where you kind of fall outside of the traditional age for mammograms or age for colonoscopies or even frequency of certain testing. And so it is something that in the right situations might be actionable and help someone kind of keep their foot to the pedal on cancer screening.
[00:07:08] Speaker D: Absolutely. I will say so. If there's a primary first degree relative diagnosed with breast cancer, the mammogram for
[00:07:17] Speaker E: the children need to come or the siblings, the first degree relatives needs to come 10 years before the age of the youngest person diagnosed.
[00:07:25] Speaker D: So if someone's diagnosed with breast cancer at 46, their child needs to start
[00:07:30] Speaker E: breast cancer screening no later than 36.
[00:07:34] Speaker B: Yeah.
[00:07:34] Speaker D: That's actionable. Because screening mammogram doesn't start to 40.
Colorectal cancer. We're seeing an increase in young people
[00:07:42] Speaker E: diagnosed with colorectal cancer. Someone's diagnosed in their 30s with colorectal
[00:07:46] Speaker D: cancer, their child, their sibling needs to
[00:07:49] Speaker E: start their screening colonoscopies 10 years before. So if they're diagnosed at 36, that child needs to start at 26 years old.
[00:07:56] Speaker C: Yeah.
[00:07:56] Speaker D: And needs to get a colonoscopy depending on the findings. But usually ballpark about every five years.
[00:08:02] Speaker E: Yeah.
[00:08:02] Speaker D: Autumn finitum. Whereas a normal risk person, you start
[00:08:05] Speaker E: at 45 years old and it's a colonoscopy every 7 to 10, if that's the screening modality chosen.
[00:08:11] Speaker D: So it changes. Yeah. And I think human nature is the one to stick her head in the
[00:08:15] Speaker E: sand and not know.
[00:08:17] Speaker D: But if you can identify cancer sooner, earlier, it's cur.
[00:08:21] Speaker E: It's more curable.
[00:08:22] Speaker C: Yeah.
[00:08:22] Speaker E: Than if you stick your head in the sand and you don't know till it's already stage four when it's diagnosed.
[00:08:28] Speaker C: So, um, when. I guess it is important to point out too. I was just thinking on, like, you know, some of the genetic cancer screening panels.
Is it, is it fair to say that those would be different than if you actually have a tissue diagnosis and you're looking at cancer genetics?
[00:08:43] Speaker D: Correct.
[00:08:44] Speaker C: I want to make sure I separate those terms for our list and they
[00:08:46] Speaker E: are two different things.
[00:08:47] Speaker D: So there's tumor genetics.
[00:08:49] Speaker C: Yeah.
[00:08:49] Speaker D: And then there's mine in your like
[00:08:51] Speaker E: genetics that we're born with. That's called germline.
[00:08:54] Speaker C: Yep.
[00:08:55] Speaker D: So the genetics were born with is germline. And then the two. Then there's tumor genetics.
[00:09:00] Speaker C: Yes.
[00:09:02] Speaker D: And so when you're sending. If somebody just wants a blood test to see if I'm going to get cancer one day, Doc, those are not as reliable because in just the average person.
But if you have somebody that's. You always want to test the person
[00:09:18] Speaker E: with cancer because that tells you what you're looking for.
[00:09:21] Speaker C: For. Yeah, yeah. And the cancer genetics, I would assume there's been probably a lot of advancements in more specific treatment based on cancer. The genetics.
[00:09:31] Speaker D: Tumor genetics really does speak to treatment options.
[00:09:36] Speaker E: Get into that whenever if you want to.
[00:09:38] Speaker D: But the.
So what we're talking about the person with cancer, what did they have test
[00:09:44] Speaker E: their genetics and that's how you know whether the. The family members should be tested.
[00:09:49] Speaker A: Yeah.
[00:09:49] Speaker C: I was just thinking as we're talking about, I want to make sure to separate those terms because using genetics and two kind of different methods is really important because, you know, a breast cancer with tumor genetics are going to. Is going to be different and possibly treated differently than someone who has the BRCA one or two or not. So it is separate process.
[00:10:10] Speaker E: Yes.
[00:10:10] Speaker C: There. So as we talk more about screening before we get into the therapeutics, one big thing that we see promoted now even online and television is these whole body screenings, whole body MRIs for cancer prevention. Kind of to get it. Not prevention, but to get ahead of cancer early diagnoses.
That's something I find myself talking about on a weekly basis with our members. I'm either bringing it up or receiving interest about it. How does that live in your world?
Give me some thoughts on how you view whole body MRI screening. Looking for cancer.
[00:10:48] Speaker D: So we live. I live in a world post diagnosis. So in terms of just somebody going. And I have had patients occasionally, maybe
[00:10:58] Speaker E: once a year, they'll message in and
[00:10:59] Speaker D: say, will you write for me a whole body scan? My answer is no, because it's never been proven.
[00:11:07] Speaker E: I think the number is the cancer detection rate is 1.6 per percent and the. It's never been shown to change mortality. There's Never been shown to have a mortality benefit. This is an asymptomatic individual.
[00:11:21] Speaker D: Just somebody who's anxious and wants to
[00:11:23] Speaker E: go get a scan.
[00:11:25] Speaker D: It's never, no study has ever shown
[00:11:27] Speaker E: that going and getting and finding changes of mortality benefit and that it only detects cancer. 1.6%.
[00:11:35] Speaker D: It also, there's some literature out there.
[00:11:37] Speaker E: There's a false positive rate of 16%.
[00:11:40] Speaker D: So you get a scan, I call them incidentalomas.
[00:11:43] Speaker C: Yeah, yeah.
[00:11:44] Speaker D: You see something but you don't know what it is and it leads to anxiety, leads to increased cost burden and invasive procedures to figure it out. Now if it, if you're the 1.6%,
[00:11:54] Speaker E: you're glad you chased that. But the 98.4% of people, it's not going to wind up being.
[00:12:01] Speaker D: Yeah, so, so I don't order whole body scans just to assuage somebody's anxiety. Yeah, you know, we can talk through the anxiety. We can talk through.
[00:12:13] Speaker E: Is there something that is more evidence
[00:12:15] Speaker D: based that we could do something more proactive that we could do?
[00:12:18] Speaker E: Are they up to date on their
[00:12:19] Speaker D: age appropriate things that are known to
[00:12:22] Speaker E: help age appropriate cancer screenings, but just
[00:12:25] Speaker D: to make somebody try to feel less anxious?
[00:12:28] Speaker E: A whole body MRI has not been shown to be supported by the data.
[00:12:32] Speaker D: Yeah, I also read it increases outpatient
[00:12:36] Speaker E: health care costs by 11.6% over two year time period.
[00:12:41] Speaker D: And then also one of the cons to it is there's certain parts of our body where depending on this, the imaging modality, it doesn't pick it up well. So you can, you can be falsely reassured. Yeah, like a whole body scan is
[00:12:53] Speaker E: not how you scream for colorectal cancer.
[00:12:57] Speaker D: So if you got, if you were to get one of these scans and all is good.
[00:13:01] Speaker E: Well, it may not be.
[00:13:02] Speaker D: You may have a tumor growing in your colon. But there's certain parts of our body
[00:13:05] Speaker E: that are not well visualized depending on the modality.
[00:13:08] Speaker C: I think that's a great insight because you do think whole body. You have that kind of connotation of. Okay, this is comprehensive and at minimum it should only be done in my opinion, on top of recommended guidelines. So you're up on your pap, your mammogram, your colon, your prostate, you're up on all of those. And then this is kind of an additional thought, but I found myself, I don't know if this would resonate with you, but I kind of call it instead of worst case scenario, kind of mid case scenario with these, where I'm often counseling patients well before they get this test of okay, what are we going to do with the results?
And obviously worst case is it finds a cancer that is the worst case. It finds something that is a mass tissue diagnosis. And that's what the purpose of these tests are, is to catch those early.
But many people fall in that mid case. And how are you going to live in the middle? How are you going to live in the gray zone? I've yet to see a whole body MRI that said thumbs up, all normal. There's always something whether it's in the spine, whether it's in a, in a, in a gland somewhere and it's uncertainty. And so before I'm even thinking about ordering this test, I'm thinking of how are we going to mentally live there.
And some people I think can handle it. And some people it may be inviting more worry.
[00:14:25] Speaker E: Yeah.
[00:14:26] Speaker C: Which can then spiral into being counterproductive to some of the actual cancer prevention you want to see with stress management and sleep inflammation and so forth. So I think, I think you worded it really well where there may be a use case for it but the stats aren't overwhelming and it could incite a lot more worry compared to the likelihood of it picking up something that's
[00:14:50] Speaker E: actionable for the average risk people person.
[00:14:53] Speaker C: Yeah.
[00:14:53] Speaker D: Now there are some exceptions. If someone is considered high risk for breast cancer and high risk based off of one of these cancer genetic risk tools that are validated, statistically validated.
If someone were to fall into that
[00:15:08] Speaker E: category, there's absolutely precedent for changing how you screen that person. Yeah.
[00:15:13] Speaker D: If low dose chest CT scan, low dose radiation chest CT scan for smokers that absolutely have to try to look
[00:15:23] Speaker E: here and remind myself it's ages 50 to 80 years old and if you smoked greater than or equal to 20 pack years.
[00:15:30] Speaker C: Yeah.
[00:15:30] Speaker D: Then you should get a low dose
[00:15:32] Speaker E: chest CT once a year. It doesn't require any contrast. It's covered by insurance and screen yearly for lung cancer development.
[00:15:41] Speaker D: That's proven. So we're just talking about the anxious person or the person who's just wanting to go get a scan.
[00:15:47] Speaker C: Yeah.
[00:15:47] Speaker E: You know, whether they're not when I
[00:15:49] Speaker C: think that points back to the fact that yeah for lung MRI is not the best CT scans have more, more data around them. So you want to be thoughtful on, hey, if I'm going to go looking at or for something, let's do it the right way.
[00:15:59] Speaker D: Yeah, absolutely.
[00:16:02] Speaker C: Last thing on the kind of advancing in the diagnostic world. Is there any use that you see or see on the horizon for AI and being involved in diagnostics yeah, it's on the horizon.
[00:16:15] Speaker D: I mean change is constant.
[00:16:17] Speaker C: Yeah.
[00:16:18] Speaker D: Change will always be here.
[00:16:20] Speaker E: So right now there's a lot of change in medicine around AI and AI tools.
So we just have to figure out how to best apply them.
[00:16:28] Speaker D: Yeah, I think there's absolutely going to be a role. I think the most, the literature, the studies that are furthest along is using
[00:16:36] Speaker E: AI in mammography
[00:16:39] Speaker D: and there, but, but right now there's no like long term outcomes data.
[00:16:46] Speaker C: Yeah.
[00:16:47] Speaker E: So right now the national recommendation from the different radiology groups, breast radiology groups across the world is that it's not a replacement for a breast radiologist by any means. But it's, it's complimentary too. Yeah.
[00:17:02] Speaker D: But using AI to pick up a small. Where, where it seems to make, where it seems to be reliable is in
[00:17:10] Speaker E: an early detection breast cancer. That's lymph node negative.
[00:17:16] Speaker D: An AI could review more mammograms than potentially a human could maybe flag them
[00:17:23] Speaker E: to go to the human breast radiologist to then verify. Yes, no, something like that.
[00:17:27] Speaker D: So it may cut down on the
[00:17:30] Speaker E: number of normal mammograms that a breast radiologist has to see it. It may kick an abnormal or flag. It's just like a lab result.
[00:17:37] Speaker D: If automated lab machine kicks out a lab because it's not quite as out of parameter, then the lab tech has
[00:17:44] Speaker E: to go over and take a look and see if it triggers a smear
[00:17:47] Speaker D: review or something like that. Or does it mean that the qi, the quality check is out and they got to replace the reagent or whatever, but it flags a human to come
[00:17:56] Speaker E: over and problem solve.
[00:17:57] Speaker C: Gotcha.
[00:17:58] Speaker D: So I do think we're going to see it. And the breast in the breast screening world is where I think the data
[00:18:06] Speaker E: is the most advanced, but we still don't have long term outcomes.
[00:18:09] Speaker D: But I think it's going to be there.
[00:18:11] Speaker E: I don't think it's.
[00:18:12] Speaker D: I, it's my personal opinion that a
[00:18:14] Speaker E: computer is never going to be able to replace a human's ability to synthesize the information.
[00:18:18] Speaker C: Yes. Yeah.
[00:18:21] Speaker D: So, but I think it can help
[00:18:22] Speaker E: flag and look for things that are outside of parameters so that you save humans the work of maybe going through all the normals. Does that make sense?
[00:18:31] Speaker C: Absolutely. Yeah. And, and I think it sounds like, like you say, change is constant and we're still as far as AI has come in the last few years in the medical world. I'm sure it's still the tip of the iceberg with getting some of that data that can help Support adoption of these. And it takes years to get modalities. Yeah. So it takes time and it can't
[00:18:52] Speaker B: rush time, for sure.
[00:18:53] Speaker D: And people that are outside of the medical world or a world where you
[00:18:56] Speaker E: have to run studies for long period
[00:18:58] Speaker D: years, it can feel so slow.
[00:19:02] Speaker E: My world, five to six years is quick.
[00:19:05] Speaker D: If you get a change in five
[00:19:06] Speaker E: to six years, whoa. Things are moving swiftly. Yeah.
[00:19:09] Speaker D: You know, so it just takes that
[00:19:10] Speaker E: long for the data to mature.
[00:19:11] Speaker C: Yep.
Well, thanks for going over kind of those early details.
Let's transition to talking about therapies. And I know we're talking general oncology today, so we're not talking specifics about any particular type of cancer. But you know, when somebody hears cancer, they're going to think surgery, radiation, chemo.
They may be curious, what am I going to get? What am I going to have? What's going to be indicated for my cancer.
I'm just going to release you to talk about therapeutics, how, you know, tell me a little bit about each one, what type of things it's used for, and any new or advancing things outside of those kind of three bullet points.
[00:19:51] Speaker E: Okay.
[00:19:52] Speaker D: So classically, the way we treat cancers is either single modality, meaning one thing, just radiation, just some sort of systemic
[00:20:02] Speaker E: treatment like by vein or a pill that you swallow, or surgery.
[00:20:07] Speaker D: Okay, so those are the three major modalities.
[00:20:10] Speaker E: A localized treatment with radiation, a surgical treatment where you cut it out, or
[00:20:16] Speaker D: a more systemic treatment where you take something, you ingest something by your mouth
[00:20:21] Speaker E: or through a vein IV that goes throughout your system.
[00:20:26] Speaker D: That's where staging of a cancer is very helpful, because if something is localized, you have.
You can at least have more of the opportunity to think about a localized
[00:20:34] Speaker E: treatment strategy, whether that's radiation or surgery,
[00:20:38] Speaker D: if something is sort of more advanced. So using an example of a mass in the colon. And then on scans, it looks like
[00:20:48] Speaker E: lymph nodes are involved.
[00:20:49] Speaker D: We would call that local regional spread. So it's still. It's not distant, it's not far and wide, but it's bigger, it's more involved
[00:20:57] Speaker E: than just the singular mass where it all started.
[00:21:01] Speaker D: So then you start to need more
[00:21:02] Speaker E: of a larger treatment focus or a wider treatment focus.
[00:21:06] Speaker D: So that's when you're going to get well. We might need a combination of these
[00:21:09] Speaker E: three large group modalities. So you might have some radiation in your treatment plan.
[00:21:13] Speaker D: You might have surgery first, then some chemo along with radiation, or you might have chemo, then chemo, radiation. Then there's all these ways we can
[00:21:24] Speaker E: sequence the three major groups of modalities.
[00:21:27] Speaker D: So radiation treats locally, surgery treats locally,
[00:21:31] Speaker E: and systemic therapies, treat systemically. So that's where the stage is important to know.
[00:21:38] Speaker D: And then just we throw around the term chemotherapy to a cancer doctor.
Chemotherapy is the old school chemotherapy where
[00:21:49] Speaker E: it's technically called cytotoxic.
[00:21:51] Speaker D: So it's killing cells.
[00:21:52] Speaker E: Chemotherapy, that's your old.
[00:21:53] Speaker D: That's what. When people hear chemotherapy, that's the mental
[00:21:56] Speaker E: picture that most people are getting.
[00:21:58] Speaker D: The losing your hair, the sick at your stomach, you know, systemic therapies or loosely chemotherapy, meaning drugs that treat cancer has exploded. So we've got the old school type
[00:22:11] Speaker E: of drugs that have been around for decades.
[00:22:13] Speaker D: The cytotoxic chemo.
[00:22:15] Speaker E: Cyto means cells, psy cy means cells,
[00:22:18] Speaker D: therapies that kill cells.
[00:22:20] Speaker E: That's the old school.
[00:22:23] Speaker D: And then you can have targeted therapy
[00:22:25] Speaker E: options where we were talking about the
[00:22:27] Speaker D: cancer, the tumor genomics.
Does the tumor have a mutation that's only in the tumor. It's not in your body. It's only in the tumor cells. And then do we have a drug
[00:22:38] Speaker E: that's manufactured that targets just that specific.
[00:22:42] Speaker D: So I always think about, I always.
Dumb little examples like a dollar. Does it all have red hair?
[00:22:49] Speaker E: Brown hairs all have freckles, no freckles.
[00:22:51] Speaker D: You know, you get your, you get your tumor genomics. What is the tumors?
[00:22:55] Speaker E: What's its signature?
[00:22:56] Speaker D: What is it? Does it have freckles? Does it have red hair? You know, what is, what is its features? Then do we have a drug that
[00:23:03] Speaker E: targets one of those features?
[00:23:04] Speaker D: That's called targeted therapy. Because when you take that drug. Now no drug is perfect.
Every drug that you take for treating a cancer is going to have some side effects. But the side effect profile can be very different depending on if you're getting old school cytotoxic chemo versus targeted therapy.
And then there's immune therapy or immunotherapy. That's where you try to get your immune system, that the therapy gets your immune system to fight the cancer cells.
[00:23:37] Speaker E: I always explain to people, you know,
[00:23:39] Speaker D: it makes sense that if we get a transplanted kidney or a transplanted heart for a transplant patient, makes sense that our body would want to reject the transplant because it's not native to us and our body rejects foreign things. If we get a virus, our immune
[00:23:53] Speaker E: system fights the virus. If we get a bacterial infection, our immune system fights that invader, that foreign invader.
[00:23:59] Speaker D: If we get a transplanted organ, we have to take medicines to suppress our immune system.
[00:24:04] Speaker E: Our immune system Will reject that transplant.
[00:24:08] Speaker D: So then the notion was, well then why does the body. Why does the immune system not reject cancer cells? Because they're not our native cells. They're an abnormal cell. Always think about an army.
[00:24:18] Speaker E: You've got star wars and you get this rogue sect.
[00:24:21] Speaker D: Yeah, sect.
And you get this sect of cells that's now, they used to be normal, and now it's.
[00:24:28] Speaker E: It's cells behaving in an abnormal fashion. That's one of the definitions of malignancy.
[00:24:33] Speaker D: So then why does the immune system not see that and fight that? And so that's kind of the genesis in a very basic way of immunotherapy and trying to get the immune system to recognize the cancer cells are bad
[00:24:46] Speaker E: and form and attack them.
[00:24:48] Speaker D: And so what immunotherapy does. There are certain cancers where it is shown to work.
[00:24:53] Speaker E: There are certain cancers where immunotherapy just does not seem to work.
[00:24:57] Speaker D: So it's not a one size fits all. It's not everybody diagnosed with cancer can be a candidate for immune therapy.
[00:25:03] Speaker E: But there are certain cancers where we can particularly melanoma is very sensitive to immunotherapy, kidney cancers. Immunotherapy.
The immune system is important.
[00:25:17] Speaker D: Urothelial, things like that. So it depends on the cancer. But then basically what the immunotherapy drug does is I always say, if you got a cancer cell and it has,
[00:25:27] Speaker E: it's called PD L1, but it has this ability to hide from the immune system.
[00:25:31] Speaker D: And so the immunotherapy drugs that we give take away the hide. So it's almost like a double negative.
So the cancer system is camouflaged or
[00:25:40] Speaker E: the cancer cell is camouflaging itself.
[00:25:42] Speaker D: We give a drug that takes the camo away or takes
[00:25:48] Speaker E: the ability to evade the immune system detection.
[00:25:50] Speaker D: And then we want the immune system
[00:25:52] Speaker E: to attack that cancer cell.
[00:25:54] Speaker D: And so that's immunotherapy in a very broad sense.
And then there's even newer drugs like CAR T where you.
You take out some of your native
[00:26:06] Speaker E: immune system cells, but you've also got your cancer cells. These are in more blood based cancers.
[00:26:12] Speaker D: And you see what the signature is
[00:26:15] Speaker E: of the cancer that you have.
[00:26:17] Speaker D: Specifically you, not your next door neighbor. So if two people have the same
[00:26:20] Speaker E: blood cancer, if CAR T works in the cancer, in this type of cancer,
[00:26:25] Speaker D: yours is going to look a little bit different to the person sitting next
[00:26:29] Speaker E: to you has the same type of cancers.
[00:26:31] Speaker D: So you pull your cancer cells out,
[00:26:32] Speaker E: you label the T cells to fight your specific ones, and then you infuse it back in. That's car T. And then your immune system will attack the cancer.
[00:26:41] Speaker D: So car T is just a different, higher level way of targeted immune therapy.
But that's the cutting edge right now in cancer care is immunotherapy. And then These, they're called ADCs, antibody drug conjugates.
[00:26:57] Speaker E: And this is maybe too granular, but those are.
[00:27:00] Speaker D: These are very.
Have a lot of excitement around them. So if I'm a cancer cell and
[00:27:07] Speaker E: let's just say I have C on my surface, think of like a circle with a C, you.
[00:27:16] Speaker D: You take a chemo drug, a regular cytotoxic chemo drug, and then you pair it with an antibody that hooks into C.
And so then I give you this antibody drug, conjugate and locates to any cell that expresses C, which is the cancer cell.
[00:27:32] Speaker B: Okay.
[00:27:33] Speaker C: Yeah.
[00:27:33] Speaker D: Takes it up, takes it in, and then the chemo is directly delivered inside
[00:27:37] Speaker E: the cancer cell only.
[00:27:38] Speaker C: Wow.
[00:27:38] Speaker D: Does that make sense?
[00:27:39] Speaker C: It does, yeah.
[00:27:40] Speaker D: So it's a. It's almost like a combination of a targeted.
It is, it's a targeted therapy with
[00:27:46] Speaker E: the old school chemo.
[00:27:48] Speaker D: So it's a way to get the
[00:27:49] Speaker E: cytotoxic chemo only inside cancer cells.
[00:27:51] Speaker D: Wow. So there's just all these, all this movement, all this, the dynamics around trying to get the chemotherapy drugs only into
[00:28:00] Speaker E: the cancer cells and to leave the rest of the cells alone. If that makes sense.
[00:28:05] Speaker C: It does. When I feel like just having this conversation here at this time and, you know, you've been practicing probably 15 years, give or take.
I'm thinking of how many tools you have in your toolbox now that you didn't even have trained.
[00:28:21] Speaker E: Yeah, absolutely.
[00:28:22] Speaker C: That, that. I loved how you kind of walked us through the general chemo. It's like that's still a thing. Now you have targeted chemo and these immunotherapies which can really just get to the cells that are the problem.
[00:28:35] Speaker D: So there's targeted and then there's immune and then there's some cancers that are sensitive to hormones.
So like an estrogen positive or hormone
[00:28:43] Speaker E: positive breast cancer, we want to just block the hormone. We want to block estrogen.
[00:28:47] Speaker D: Estrogen. There's no. It's chemo in that it's treating breast cancer, it's treating cancer, but it's not chemo.
[00:28:53] Speaker E: Like what we think of chemo, if that makes sense.
[00:28:56] Speaker C: Yeah.
[00:28:56] Speaker D: So to a cancer doctor, it's chemo in that it's treating cancer, but it's
[00:29:00] Speaker E: not chemo like cytotoxic chemo that makes you sick, lose their hair, all that. Yeah, that makes sense.
[00:29:05] Speaker C: When I appreciate you giving the overview because thinking through the lens of our listeners, this might give them a little word bank of things to look out for when they have that visit with their oncologist making the plan that when they're proposed with immunotherapy, they're like, oh, yeah, I've heard of that. I know kind of generally what that is. Or radiation, oh, I guess I've got a localized cancer. You know, they can have a little more power to walk into those visits with a word bank of the vocabulary that might be used by the doctor.
[00:29:35] Speaker D: Yeah, yeah.
[00:29:36] Speaker C: And obviously the nuances become exponentially more complex based.
[00:29:41] Speaker D: Absolutely. And so it's certainly not cookbook.
[00:29:43] Speaker C: Yeah.
[00:29:43] Speaker D: That's why every case is different and that's why somebody down the street or always keep referencing it, but people want to come compare their cancer stories, and
[00:29:51] Speaker E: it may or may not apply to
[00:29:52] Speaker D: you, depending on what stage it is
[00:29:55] Speaker E: and all of that and what your options are versus somebody else's options. So it really is personalized every time to the person and the stage and the location and just all of the, all the factors that go in.
[00:30:06] Speaker C: Yeah, well. And as we kind of wrap up this part of our conversation, research trials, you know, those may be proposed by doctors or, you know, a part of someone's treatment plan. How should someone navigate kind of the. The whole realm of research trials? What's the good, what's the downside? How should someone kind of be thinking through that process if that's an option for them?
[00:30:30] Speaker E: Yeah.
[00:30:30] Speaker D: So it's my opinion, and it's my
[00:30:32] Speaker E: recommendation that you always be open to a clinical trial.
[00:30:37] Speaker D: It does not mean that there'll be a good one for you at that moment.
But our next best treatment will come
[00:30:45] Speaker E: first in a clinical trial.
[00:30:47] Speaker D: Right. So it has to go through a trial before it becomes. Oh, yes, it works, it helps.
[00:30:51] Speaker E: And then it becomes mainstream and everyone can write for it.
[00:30:54] Speaker D: So I think that everybody should be
[00:30:57] Speaker E: open to a clinical trial.
[00:30:59] Speaker D: I do think the reputation of a clinical trial is, oh, you don't have
[00:31:02] Speaker E: any options, like, left, you're now on clinical trial, you're an experiment.
[00:31:05] Speaker C: Yeah.
[00:31:06] Speaker D: And that is just not the case.
[00:31:07] Speaker C: Yeah.
[00:31:08] Speaker D: Okay. So the, the primer on clinical Trials is there's 10 plus years, many times of research that goes into a drug, a therapy that is ever before it's
[00:31:23] Speaker E: tried in a human, whether it's in
[00:31:25] Speaker D: a culture cell, culture disch, in a lab, whether it's in a mouse model, if it's a monkey, I mean, you know, whatever it is, there's usually eight to 10 years on average of research
[00:31:36] Speaker E: and development that goes into a drug
[00:31:37] Speaker D: before it ever even is thought to, hey, can we, can we use this in humans?
So then when a human is proposed with a clinical trial, there's four phases of trial.
[00:31:48] Speaker E: There's phase one, there's phase two, phase three, and then phase four.
[00:31:54] Speaker D: Obviously phase four is the most advanced information, phase one.
[00:31:59] Speaker E: So I'm walk through it because I think it's important.
[00:32:01] Speaker D: Phase one is first in humans.
So it's not, does it work?
It's, it's, can we give this drug safely? What are the safety markers we need to watch? What are the toxicities? What dose seems to be, what's the tolerated dose, where we get some efficacy
[00:32:22] Speaker E: or we get some results, but it's not too toxic.
[00:32:25] Speaker C: Yeah.
[00:32:25] Speaker D: And then what are our, what are our side effects?
[00:32:27] Speaker E: What are we looking at?
[00:32:28] Speaker D: That's phase one.
Phase two is okay, we think we've got the dose.
We see at least the most frequent side effects and they're not prohibitive, meaning it's not unethical to go ahead and
[00:32:42] Speaker E: continue testing this drug.
[00:32:44] Speaker D: Now let's try it in a specific cancer type. Let's try it in breast, let's try it in skin, let's try it in pancreas.
So phase two is the first time a drug, we think we know the dose. We have a pretty good feel for
[00:32:57] Speaker E: safety signal, but we're still going to monitor that data.
[00:33:00] Speaker D: Now we're going to try it in
[00:33:01] Speaker E: a specific cancer primary site.
[00:33:05] Speaker D: And then if that has success and
[00:33:07] Speaker E: shows efficacy and safety, then phase three
[00:33:11] Speaker D: is okay, we're going to keep using this dose. We still feel like this safety profile is worth continuing to try this, that it's not too risky of a drug.
And this phase two data makes it look like it works in these cancer
[00:33:24] Speaker E: types, whatever it is, or this one cancer type, whatever.
[00:33:27] Speaker D: Phase three, you now give it, you give it in.
[00:33:30] Speaker E: I'm just going to use the example of pancreas.
[00:33:32] Speaker D: You give it in pancreatic cancer, you know, your dose, you think is still safe enough that the benefit outweighs the risk.
Now you're going to compare it against one of two things. Either usually it's standard of care. So if we've always given drug A, the trial might be, well, what if we DO drug A investigational drug B?
So is the doublet better than what we do already?
So phase three, there's usual. Sometimes there can be a placebo in a phase three, but not usually. Usually it's going to be against whatever
[00:34:06] Speaker E: is current standard of care.
[00:34:10] Speaker D: And there's some little like, nuance that
[00:34:12] Speaker E: you're checking or
[00:34:15] Speaker D: maintenance therapy might. Could we use a doublet or a single? We've always done a single, but it's a doublet better. So it's a finesse point.
[00:34:22] Speaker C: Yeah.
[00:34:23] Speaker D: Sometimes it's to just generally establish this, this regimen is superior to what we've always done. But in general, in phase three, you're comparing it against the standard in some way, but something about the investigation arm is different.
Phase threes, you might get randomized to
[00:34:38] Speaker E: the standard, you might get randomized to
[00:34:40] Speaker D: the investigational arm, but either way you're getting therapy. So there's nothing. It's not like somebody who might be curable is being deprived of potentially curative therapy because that's unethical. Does that make sense?
[00:34:50] Speaker C: It does, yeah.
[00:34:51] Speaker D: So.
So if a person ever has the option for a phase three trial, I'm always very gung ho. But hey, that's, you know, because the investigate, you're still going to get good therapy no matter what. You might get therapy that we know is better, might prove that it only adds toxicity and it's really not gives you enough extra benefit by adding the
[00:35:11] Speaker E: investigational agent that it beats out the current status or status quo. Does that make sense?
[00:35:16] Speaker D: Yeah, standard of care. But it might. And you're getting it earlier than five
[00:35:21] Speaker E: years from now when we let the
[00:35:22] Speaker D: data mature and we see, oh, this actually is better.
[00:35:25] Speaker E: Now the ship, we shift to the new regimen.
[00:35:28] Speaker D: That makes sense.
[00:35:29] Speaker C: It does, yeah. This is great.
[00:35:30] Speaker D: Yeah. Phase four is aftermarket. So phase three goes to the fda, the committee, yes, we're going to approve
[00:35:36] Speaker E: this in the United States or.
[00:35:37] Speaker D: No, we're not.
[00:35:38] Speaker E: This data is not good or the cost is too much or whatever.
[00:35:41] Speaker D: Phase four is after market survey, after approval surveillance. So sometimes in the phase four, that's when they may pull a drug off the market.
[00:35:50] Speaker C: Got it.
[00:35:51] Speaker D: Oh, we've noticed now, three years into this, that this, which is too rare to have seen in the early studies, but we're seeing it enough now. We don't think the benefits are outweighing
[00:36:00] Speaker E: this new risk that we're recognizing the safety signal and they pull a drug from the market.
[00:36:04] Speaker D: That's phase four data.
[00:36:05] Speaker C: Yeah.
[00:36:06] Speaker D: So.
So I don't think a new diagnosis, human who has a potentially curable cancer, usually a phase one is not a great idea for them. Right. Because phase one, there's, it's just dose finding and toxicity. You don't even know if it works or not. You don't, that's not ethical to give a person that has a potentially curable cancer a therapy that you have no
[00:36:28] Speaker E: idea if it's going to work or not. Does that make sense?
[00:36:33] Speaker D: And then the other thing about a so clinical trial, it should never be worse than what we could give you
[00:36:38] Speaker E: off of trial, if that makes sense.
[00:36:40] Speaker D: Now, it is true that as a person progresses and progresses and progresses with their cancer and they run through option
[00:36:47] Speaker E: one and then option two, option three, option four, however many options there are,
[00:36:50] Speaker D: at some point a phase one might be your quote, only option because we don't have used all the standard of care therapies and we don't have any left to try.
So then that is where that reputation comes, where, oh, it's your last, it's
[00:37:03] Speaker E: your worst or it's your last shot type.
[00:37:06] Speaker D: That's where. Like a phase one. Does that make sense?
[00:37:08] Speaker C: It does, yeah. This has been great because I didn't, I've never been involved in clinical trials and so I wasn't sure how to navigate somebody to even understand, okay, well, what part of the trial is this and would it be beneficial to you? Or maybe not as much.
[00:37:23] Speaker D: So it depends how advanced or how rare is it?
[00:37:25] Speaker B: Sure.
[00:37:25] Speaker D: It's a very, very rare cancer. Number one, they should probably be at a center. The primary center should not, should be
[00:37:32] Speaker E: somewhere where it's not super rare, if possible.
[00:37:34] Speaker C: Yeah.
[00:37:34] Speaker D: You know, there are orphan diseases, meaning
[00:37:37] Speaker E: they're just so uncommon and so rare, they're called orphan diseases.
[00:37:41] Speaker D: But you still want to go to
[00:37:42] Speaker E: a center that sees a fair number of those.
[00:37:45] Speaker D: Those are where a clinical trial really
[00:37:47] Speaker E: may make all the difference. Yeah.
[00:37:49] Speaker D: So if somebody has a rare sarcoma, let's say if there's a trial at Miami or somewhere where they have access
[00:37:57] Speaker E: to a drug that's showing a whole lot of promise and a very rare
[00:38:00] Speaker D: cancer, I'm going to say, hey, we can always come back to these standard of care options. But this data is looking really good. Why don't you go try that and
[00:38:09] Speaker E: then if it doesn't work, you can
[00:38:10] Speaker D: come back and we can do these
[00:38:12] Speaker E: standard FDA approved screen.
[00:38:14] Speaker D: But if you know the FDA approved option is just way better than the trial, then. And of course there's an element of unknown with the trial. So that's, that is a risk. But again, it's important to know you should never not be getting anything unless
[00:38:28] Speaker E: a You know, you're not getting it. And then B, you didn't have any other options left.
[00:38:31] Speaker C: Yeah.
[00:38:31] Speaker E: Does that make sense? It does.
[00:38:33] Speaker C: It does now. Thanks for going through. This has been a great episode, I think, full of a lot of great info, from being preventive to screening to treating, and then even, you know, advancing therapies with research trials moving forward.
[00:38:47] Speaker D: So I want to say something really quick about colorectal cancer screening options.
So there's the fit test. Have you heard of the fit test?
And then there is the.
[00:38:58] Speaker E: I'm trying to look here. I've got it written down.
[00:39:02] Speaker D: There's the stool DNA test.
[00:39:04] Speaker E: Right.
[00:39:05] Speaker D: So the stool DNA is approved for every three years, and the fit test is.
[00:39:14] Speaker E: I think you can do that one year.
[00:39:17] Speaker D: And then there's colonoscopy. So these are ways to screen for colorectal cancer. There's the traditional colonoscopy, which many people
[00:39:23] Speaker E: are afraid of and just frankly don't want to go have a colonoscopy.
[00:39:26] Speaker D: So then their options are the. The fit test yearly or the stool
[00:39:31] Speaker E: DNA test, the cologuard test every three years.
[00:39:36] Speaker D: In general, the stool test. The cologuard is felt to be to pick to find more cancers than the yearly fit tests.
[00:39:44] Speaker E: So its sensitivity is higher.
[00:39:50] Speaker D: Colonoscopy is still the gold standard. Yeah, but if it's the difference between somebody getting screened and not getting screened, the cologuard is good. The fit test is good. Just if it brings somebody in to getting screened that otherwise would never have
[00:40:04] Speaker E: been screened, those are very reasonable ways to screen for colorectal cancer.
[00:40:09] Speaker D: So I just wanted to comment on
[00:40:10] Speaker E: that because we're getting more and more options.
[00:40:12] Speaker D: So there's the colonoscopy still, the primo best test, and then the next, the most sensitive.
[00:40:17] Speaker E: So finding true cancers would be the cologuard.
[00:40:20] Speaker D: But then a yearly fit is also
[00:40:23] Speaker E: very reasonable to do.
[00:40:25] Speaker D: It has a little bit lower sensitivity, meaning a little bit lower finding actual cancer.
[00:40:29] Speaker E: Yeah, but it's still very reasonable to do if. If a person's not going to get screened otherwise.
[00:40:35] Speaker C: Yeah, that's a great reminder. We. You may use phrases like this, too, but I often say, you know, the best test is the one that gets done.
[00:40:41] Speaker D: Yes.
[00:40:41] Speaker C: You know, so there may be statistical differences among. But as long as you're. You're putting your eyes and putting science around, you know, especially cancers that have broad guidelines like breast and colon, prostate and cervical, you got to stay on top of those. There's a reason that they're recommended for the general population.
So now thank you.
[00:41:04] Speaker D: So you're welcome.
[00:41:05] Speaker C: Dr. Spradlin.
[00:41:06] Speaker D: Yes.
[00:41:07] Speaker C: As we truly wrap up here, I just want to give you an opportunity to just tell how an interested listener who may have either a family member or a personal circumstance and what you've said resonates with them. How can they connect with you at Vanderbilt?
[00:41:20] Speaker D: Well, so me personally, I'm general hematology
[00:41:23] Speaker E: oncology with Vanderbilt, have offices in Franklin and then Spring Hill, Tennessee.
But Vanderbilt has what we call an access center.
[00:41:31] Speaker D: The your primary care can refer you
[00:41:34] Speaker E: or your specialist if a GI needs to refer you.
[00:41:36] Speaker D: Some people's insurance payers will allow them to self refer but the number is 615-936-8422.
[00:41:46] Speaker A: Cool.
[00:41:47] Speaker C: Awesome.
[00:41:47] Speaker D: 936-8422 and that gets that goes straight
[00:41:50] Speaker E: to our cancer center access center and a phone conversation can be held that way.
[00:41:56] Speaker C: Yeah.
[00:41:56] Speaker E: So yeah.
[00:41:57] Speaker C: Well you have like we started our last episode with a beautiful calling and I know you personally so I know you've impacted many lives well beyond what you even realize.
And so I encourage you to continue.
And I'm just so thankful for the partnership that we've had over the years.
[00:42:18] Speaker E: Absolutely.
[00:42:19] Speaker C: And as this will will live in digital form for a while, it'll be able to provide a good frame of reference for even patients who you might never see their face.
It'll really empower them with a a little more confidence in their health journey. So thanks for your time.
[00:42:36] Speaker E: You're welcome. Happy to do it.
[00:42:39] Speaker A: Thank you for listening to this conversation. I truly hope you found it useful. You can find out more about today's episode and discover additional
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