Welcome to Charting with Doctor McNeil.

Greetings, this is Doctor Patsy McNeil and this is Charting with Doctor McNeil.

Today we are really blessed to have a great physician with us. Today I have Dr. Kashif Firozvi with me. He is Assistant Medical Director of our Cancer Service Line and there's a lot going on in the cancer arena in medicine.

A lot of cutting edge things happening at Adventist HealthCare as well. We're going to talk about those things. As we start though, I'm going to have him introduce himself and have him tell us all a little bit about his journey through Adventist HealthCare. Go ahead, Kashif.

Hi, Doctor. McNeil. Thank you so much for inviting me here. My name is Kashif Firozvi. I'm a medical oncologist. I work at Maryland Oncology Hematology, and I have been with Adventist HealthCare now since two thousand and six, when I came out of fellowship at Georgetown, and I found a home at Washington Adventist Hospital. And since then, we have gone through a long journey of not only building a new hospital, but also consolidating our cancer programs between the two sites and bringing together through that collaboration, a partnership around radiation, a partnership around different disease types, such as breast cancer, as well as the launch of our new next generation sequencing testing, which we are doing as a partnership with Adventist HealthCare.

Exciting times. I know you said both sites. We have Aquilino Cancer Center on Shady Grove Medical Center's campus, not opened up in twenty thirteen. It was the first community based comprehensive cancer center in Montgomery County.

And then in twenty twenty, White Oaks Cancer Center opened, in in in following. So they have a second comprehensive cancer center. So Adventist HealthCare does have two full comprehensive cancer centers within its network, which is a great thing to have. And both of them are sitting right here in, Montgomery County as well.

So the cancer services that are offered by Adventist HealthCare are wraparound. It's not only that you could get your chemotherapy, it's not only that you get your plan, there's wellness, there's more. Could you walk us through the type of offerings that are existing within our cancer services?

Sure, absolutely. Cancer care is unique in that it's really truly a multidisciplinary approach to managing and caring for patients. When cancer comes, unfortunately it affects every aspect of a patient's being, including their health, their mental health, their socioeconomic condition, their family condition. And so in order to really do a comprehensive job of taking care of patients, we really need to have all of the services that are part of that cancer journey. And historically, when I first started in two thousand and six, the cancer program was great, but at the same time it was very fragmented. And what we found was that patients were really having to be their own navigator in terms of navigating all the different appointments, all the different multidisciplinary approaches to managing their care. And the result of that was not only patient frustration, but there were delays.

And what we found was that not only does it help to integrate and coordinate the program through a collaboration where all the clinicians and physicians, administrators are all working together, but there's even just value in having it co located all in one place. And so what we did in building the two centers in Nacolino, as well as the White Oak Cancer Center, is that we were able to bring all those services into one roof. And in some cases, not necessarily in one roof, but in one system. And the benefit of that is that patients now didn't have to spend all of their time traveling from one site to another site to get their care.

And so now with our comprehensive program through this partnership between Maryland Oncology and Adventist HealthCare, we're really able to address all aspects of care. So there's the diagnostic part where we have a full array of imaging modalities, including our breast screening program, as well as our lung cancer screening and all of the other aspects that are seen in our primary care offices. Then on top of that, we have the surgical approaches. We have a whole team of surgical oncologists, breast surgeons, gynecologic oncologists, colorectal surgeons, thoracic surgeons, all who can help with making that initial diagnosis or making that initial treatment.

From there, we have radiation oncologists at both sites with some of the, most advanced machines and equipment here in the region, which is able to provide patients who might not be eligible for surgery, the option of getting a radiation approach, which essentially provides the same outcome as the surgical approach because of the ability to provide intense pinpoint precise radiation to a lesion. And then from there, we also have our medical oncology part where we're able to provide the most advanced cutting edge systemic therapies, whether they be traditional chemotherapy or some of the new agents like, bispecifics, a targeted monoclonal antibodies and small molecule tyrosine kinase inhibitors, as well as some of the new immunotherapy approaches that are out there.

So all of that is brought together under one program. And the result is that patients are able to get a coordinated, comprehensive approach to their care. What's really unique also is that we're seeing more and more that genomic approach to understanding patients' cancer is essential in terms of being able to provide a more precise, customized, personalized approach to medicine. And we've historically referred all those tests, those patients out to different places all over the country.

And now we're able to bring that in house and hopefully improve care by getting that information to patients and their providers as soon as possible.

That's amazing. We're going to talk about that a little bit more. But what I'm hearing you say though, is that, you know, we have a lot of dense populated areas at Montgomery County, number one. And there's no reason for patients necessarily, unless it's a very unusual case or very specific types of cancers, there's no reason to leave their backyard.

They can come to Adventist HealthCare, they can come to, either Aquilino or White Oak Cancer Center and get wraparound types of care that is at the cutting edge. It's not behind in any way. It's not in any way compromised. Talk a little bit about research and what's offered and the scope of things there.

Some people think that they have to go to Hopkins, go down into the city. It's always a little bit burdensome as far as travel is concerned. Talk about what's available here.

Sure. So we have right now about a hundred clinical trials available to our patients that range from phase one all the way to phase three. What that means is that for patients who have specific biomarkers that might be really rare and unique, and that may not have a lot of treatment options, we're able to access clinical trials to be able to provide patients with the appropriate access to therapies that they might not otherwise have access to. We're part of a star network of research trials, which basically means that even if there's a patient who has a rare mutation, we're able to turn on that trial pretty quickly, even if we don't have it available so that somebody doesn't have to travel to Texas or New York or wherever they may have to go to get access to that treatment.

But that's a really valuable benefit. So the other piece is that we work closely with all of the academic centers here. So there are some rare circumstances where a patient really should be at an academic center. Because we have these close relationships with all of the academic centers here, we're able to get patients seen quickly, identify the patients, and then refer them to an academic center if they are better served there.

I'll give you an example. The other day on Friday of last week, we started a new program called our Priority Cancer Pathway, where a patient who has a new diagnosis of cancer, where they really need to be seen right away can be seen in the same day. And so on a Friday afternoon, we got a message from one of the primary care doctors that I have a patient here who just had blood work and they had a white count of twenty five and there's some blast noted on their smear.

And so they're like, what do we do? It's Friday afternoon now.

What do blast mean?

Immature white blood cells that are oftentimes a sign of a really hyperactive bone marrow that's secreting these immature cells into the bloodstream, which can be oftentimes a sign of a really serious bone marrow disorder like leukemia.

So we got the phone call at four thirty. We did a telehealth visit with the patient. And talking to the patient identified that they clearly had something ominous going on, unfortunately.

So we had them come and see us on Saturday. We have a Saturday clinic. They got a bone marrow biopsy on Saturday.

By Tuesday, we had the results back and that it was acute leukemia. And when they came back and got some more blood work, the white kind of jumped up even higher.

With the holidays coming, we were like, this patient needs to start treatment right away. So we got them, we were not able to get to start here right away because of the holidays. So we got them connected at University of Maryland. And by Wednesday they were admitted and starting induction chemotherapy.

And after they finished their chemotherapy, they're going come back here and get their maintenance therapy with us. So that coordination and that relationship that we have with some of those centers is really helpful because a patient can get seen sooner here, get a diagnosis, and still if they need an access to an academic center, we can get them in there right away. So I think that convenience is really helpful because had they gone to somewhere else, an Atkins center, there'd been four weeks, five weeks, they would have ended up in the ER in crisis, probably bleeding to death in really bad situation.

So there is the benefit of being able to access cutting edge clinical trials, but also more importantly, to get access to convenient, immediate, comprehensive care.

That's amazing story actually, because I would think that the worst part of being, diagnosed with cancer is what is next. And to have to, which is common though, you feel a lump someplace, you go and you, you know, talk to your doctor. Doctor's like, I'll get you biopsied in, you know, two weeks. You get the biopsy and it's going to be a week till you get the results back.

You're going out of your mind. You really want to know what's going to happen. You have children, have a job, you have a life you want to know. And so that's really a great example of what wraparound patient centered care should look like.

And that is that is really exceptional, especially to be able to refer them to a cutting edge larger tertiary care place like University of Maryland or Hopkins or Georgetown or wherever, but then get them back. Because, you know, to go from your backyard in a suburb and then hit Baltimore and then hit DC, it is just a bear Well, absolutely. To to get that travel done. It's just the parking is expensive and confusing and you're not familiar with the places and this is going be a safe place for me to park.

It's just so much better for the patients to get the care here. So I know that we do great care, but we also do vocal care for cancer with breast, colorectal, GYN, head and neck, lung, prostate, thyroid, and urologic care. It sounds like we also do some of the blood borne kind of cancers as well, which I wasn't as clear about what we do and do not do. That was a point in the past we didn't do leukemia at all.

So this is a newer thing, even for me to know. Is there anything else you'd like to talk about as far as the scope of what we cover versus not cover and what would kind of drive a patient perhaps out to that tertiary care area?

Sure, sure. We also do CNS tumors. We have great surgeons who can provide access to some of the best surgical approaches for some of these, unfortunately, sprain tumors. So we pretty much cover most of all the tumor types.

Some of the things that we still refer to our academic centers for are from things like Whipple, and surgical approaches that we may not be able to do here, but we're able to do them in a coordinated fashion. A lot of patients now we're seeing more and more that they benefit from treatment, systemic therapy before surgery. So there's a general trend, just noting that with the advent of better and better therapies, that we can actually control the disease with systemic therapy and shrink it, make surgical approaches more effective. In the past, for certain cancers, there was always rolling the dice with chemotherapy, whether it going work or not work.

And so giving chemotherapy prior to surgery, there was always a chance, a gamble of whether or not it was going to work. And as a result of that, you might sometimes lose the opportunity to do surgery. And so as a result, we only in clear cut circumstances where neoadjuvant chemotherapy made a lot of sense, we didn't always pursue it. But now with some of these new therapies that we have, which are so effective, we're seeing more and more systemic therapy prior to surgery, which is a real paradigm shift because historically, I'll give an example.

My dad did his oncology hematology fellowship. Actually, did his hematology fellowship in 'sixty seven at University of Maryland. There was no oncology fellowship because oncology was a disease managed by surgeons.

And the only thing that a medical internist did was hematology because of leukemias, lymphomas. But really the management of solid tumors was a purely surgical approach. And so from that time to now, and even in my twenty plus years of practicing, the advances have been just tremendous to the point now that our therapies that we are providing are really changing not only approaches to managing patients, but also expectations for patients in terms of how how well they're going to live. Sometimes we can't cure patients, but they can live with it. And this goes back to your point earlier, which is that if patients are going to live years and years and years with their treatment, with their disease, it needs to be done in a convenient way so they can live with cancer and not have to sort of destroy their entire life and have to travel long distances to get that treatment for something that can ultimately work within the context of their day to day life.

Okay. Just on a really good point. I'll go back to one thing you said, then I'm gonna go on to the new kind of what I'll call spicy things in cancer care. But you said, you know, things that require a whipple. Now tell the audience in case they're not physicians what a Whipple is and what kind of cancer that treats.

Sure. For certain cancers, like pancreatic cancer, the surgical approach that can ultimately be curative is a surgery called the Whipple procedure, which is a very advanced complex surgery where the hepatobiliary sort of region is incredibly complex. It's like, imagine two seventy, four ninety intersection where all these roads are coming at one place and you get an accident right at the junction. In that situation, trying to extract a tumor is very complicated.

It requires the ability to essentially remove a part of the pancreas or in the context of all the different vessels and liver and everything else that's there. And it's really complicated. So that's typically done and the outcomes are best in places where you have a tremendous experience of doing that, which is not something we do on a regular basis here. And so that's where being able to get a patient to a surgeon who specializes in this is really helpful.

Now, problem is that most patients are diagnosed late.

And as a result, that opportunity, that window to get curative surgery is oftentimes not even available. The only times patients really get Whipple surgeries is they get a CAT scan for a kidney stone. They end up in the ER with a kidney stone and then lo and behold, oh, you got this spot in your pancreas. Did you know about it?

And we sort of serendipitously stumble upon it. And those are the patients that benefit from Whipples. Unfortunately, that's not often. And usually when they present with symptoms, that's too late.

But one thing we're going to talk about later is that some of these genomic tests that are out there now, which are making early detection, not just a chance, a game of chance, but a reality. And that will make some of these advanced surgical approaches probably go up in volume because we're hopefully going to be diagnosing patients with early stage disease more than we've done so historically with some of the multi cancer early detection screening tests that are available today through some of these new genomic assays.

So more to come, but it will have, it's even more important for us to be able to build those pipelines and those referral pathways for referrals to tertiary care centers when it's appropriate, because that time is coming where, in my humble opinion, I think primary care doctors and medical oncologists will be much, much more involved in the diagnosis of cancer than even surgeons.

I'm looking forward to the future in that regard. It's funny because remember sitting in biology class back in undergrad. I went to Washington University in St. Louis, for my undergraduate degree. And that was where a lot of the early sequencing of the genome occurred. They were talking about it and it seemed like it was otherworldly to even be able to start thinking about that.

Now you fast forward so many decades later, but still within a lifetime Not that many decades later.

It's more than one. More than two.

So it's, it's just like the late eighties, early nineties.

And so you fast forward even within the lifetime of a career and just look at what the human, you know, what human beings have done with that science. And let's talk about that going forward. And let's talk about next generation sequencing. Tell me about it, what it is, and then we'll branch off into more questions.

To echo what you said earlier, which is sort of where we were and where we are today, just to give you an idea. For those who remember, I think it was back in nineteen ninety something when Bill Clinton was president, there was this big announcement.

I woke up one day and there was like suddenly all these, you know, all this security in Rockville, right here in Rockville, because that's where they essentially cracked the human genome. And they're making a big announcement that, you know, we finally did it. And Bill Clinton was there and everybody was there and it was a big deal. Was all over the news.

And so just to think about that, it took three hundred dollars plus million in ten years to reach that point where they could basically say, we have sequenced the human genome.

Okay, that was a huge paradigm shift in how we take care of patients, because now we had the genetic blueprint to understand how diseases functioned. And we knew that that was the beginning of a whole new era of how we were gonna practice medicine. Again, I don't need to belabor this point, but again, my father was a doctor. And when he practiced, he did medical school in four years.

When he was in medical school, they hadn't discovered DNA. Just to think about it. When he was in medical school, was completely, he was like making fun of me one day when was in medical school, because I was like struggling with biochemistry. And I was like, dad, they didn't even have DNA when you were in medical school, give me a break.

Mean, so, I mean, this is how fast we're moving, how quickly things have changed and how the diseases are being defined differently. And if you don't have the genetic understanding of how that disease is defined, it's like, how do you take care of a patient without a pathologist to make a diagnosis? Likewise, how do you treat a patient if you don't know the genomic blueprint of their disease? And so what they did in that time when they cracked the human genome back in nineteen ninety something, I forgot the year.

Historically, what we've done is we knew that there was a gene, we know there was a mutation, and we would use a flashlight to find that one gene, like PCR testing. We're all familiar with PCR testing. That PCR testing requires a knowledge of the gene in question, and then it allows you to search for it. So it's a very, very narrow, precise approach to testing for one particular mutation.

What next generation sequencing does is it takes a small amount of material, some nanograms of DNA, and it takes that DNA and you you get the DNA through tissue, like whatever it may be, you create a DNA library of basically sequences, And then you run it through the sequencing machine, which basically looks at the entire DNA of that sample and identifies every single mutation, every single genomic alteration, rather than just, specifically looking for that one mutation through a PCR, and it gives you the entire comprehensive blueprint, the entire genome, which is in essence ultimately what drives the mutations or drives the cancer pathogenesis.

So this is a complete different approach. And that next generation sequencing approach requires sort of different pieces. You need the assay itself, the kit itself that is used to sort of identify the tissue in particular. Then you need the sequencer.

The sequencer basically takes that assay and that blood sample or that tissue sample and runs it over a four or five day period of time to identify all the different mutations. And then you need a bioinformatics platform to take all of that information and to match it and correlate it with known information around mutations to be able to come up with a report. So those are the three key pieces. Again, this was three hundred million dollars before, now it's under a thousand dollars in four days, five days.

So again, ten years, three hundred million to one thousand dollars four or five days. That is what has happened in these past twenty plus years, that has allowed this testing and this information to become more available to all of us.

You know, it's so funny because you mentioned that with your dad and and I had had a conversation with, one of my parents who'd gotten their master's degree, and they were older when they had me before Watson and Crick even discovered DNA. Right. And there was a time where, like, could you please explain DNA to me? And I'm like, what?

Because it just was a whole different thing. But look, you know, nineteen fifty two, Watson and Crick. It's not even been a hundred years, and look how far we've gone. And things are about to take a vertical climb as far as even further developments.

So it's a whole new world. And to be able to have that kind of personalized medicine, especially for something as for patients, frightening, complicated, and sometimes very kind of unique to a patient, depending on the type of cancer. That's just a whole new world.

If I can add one piece, that this information has been around for about, commercially available for our patients for about twenty years. It's gotten better and better every But right now what happens is when a patient is diagnosed with cancer and we need to do what call a comprehensive genomic profiling, CGP, comprehensive genomic profiling of their tumor to be able to identify the mutations that might be present in their cancer that can ultimately become targets for their therapy. Today, what we've had to do is we've had to essentially send that off to a centralized lab throughout somewhere in the country.

So there's three or four major labs that do this on a regular basis. The problem with that is that it takes a lot of time. It can take three plus weeks to get that, sometimes even longer to get that information back. And so built into our actual cancer pathways is recognition that sometimes you're not going to have that genomic blueprint of information at the time of making your decision as to what to give to the patient.

So it'll oftentimes say, give treatment X until you get the genomic profiling back, and then you can switch. So we build into our pathways inefficiency because we know that that process of getting the genomic information can take three, four or five weeks sometimes. And because we sometimes can't wait for the patient to start to get that information, we sort of accept the fact that we might give treatment that may not work, that might have toxicity as a way of holding things at bay until we get the right information. So one of the reasons why we've really tried to do this, recognizing the fact that the macro level, testing has become more feasible, we decided to embark on whether or not it made sense to do it in house.

And that's kind of what we've been working on now for the past, I guess, eighteen to twenty four months.

So, you know, in doing this, you have shortened the timeline toward treatment and gotten people closer to wellness basically by having this now in house.

Right. The goal is hopefully five to seven days. We should hopefully have, instead of three to four weeks, it'll be five to seven days.

What is the next closest lab of this sort to Adventist HealthCare? What are we the next closest, like you said, the three or four in the country, what's the next geographic closest one?

Yeah, so, you know, a lot of, academic centers looked at bringing it in house, and they've tried. They tried to bring it in house. And in some cases they did, some cases they didn't. And in many cases they determined that, you know what, it's not really feasible.

Let's just partner with a major central lab. And that was a calculated decision. Some places say, you know what, we'll still do it, but they may do a very limited profile. Like they might look at forty six genes or seventy genes, what have you.

So I think in terms of community practices or a practice or a community center that's doing, there's only three in the country, or I think the third. In terms of academic centers that doing it, it's hit or miss. Some like the local centers that we have here, some of them do it in a limited way. Some of them have said, you know what, it makes more sense to partner with another central lab.

And so they've decided to do it that way. From our perspective, we had the benefit of just being pretty large because of our partnership with Maryland Oncology and Pathology. We have access to about eight thousand new cancer patients a year, probably closer to nine. And that sort of creates the ability to have the volume to pull something like this off.

Because if you don't have the volume, even if the time it takes is less, it's just such a costly process that you won't be able to do it in house. So that volume is a prerequisite to be able to do it.

And we now have that volume to be able to do One of only three though, it's still really And will we be getting volume outside of that just for this lab, do you believe?

Not at the moment. We're still looking at structure of how to do this, if it's a reference lab versus a physician owned lab. And I think right now we're set up as a physician owned lab, which means that we'd only be able to do it for our own tests that are part of the practice. But that's something we are exploring.

There's some regulatory compliance issues that we have a lawyer that we're looking at to see if it makes sense to consider that reference model, which would allow us to bring in other samples. Right now, it's a little bit complicated where this is the problem with sometimes starting something new. You kind of have to experiment and learn the guardrails of what you can and can't do a regulatory So as of right now, we'll probably start off with just doing the testing in house of our system. And then gradually, if things from a compliance and regulatory standpoint, become more feasible, we could look at expanding.

But at the moment it's just going be an asset. Still though, for patients, who would be within the catchment area, Montgomery County or MOH, it's really a great thing to Absolutely.

All right. Next questions. What kinds of mutations or biomarkers are most critical in guiding cancer treatment today?

It's interesting.

I'm going to answer that question, but do you mind if I go a long windy road to answer that Do what necessary.

I have a tendency to do that. So don't laugh.

So the audience is laughing at me. So basically there's different types of genomic testing. I'll start off by saying that. You you always think about, you've got the somatic testing, which is looking at the mutations in the cancer itself.

You've got the germline testing, which is the mutations identified in a patient and a person that they've inherited from their family members that may make them more prone to developing cancer. We think about that all the time, like BRCA mutations and for breasts and so on. It's a very different type of mutation than somatic mutations. So one is looking at the person, one is looking at the tumor.

So you've got this germline and you've got somatic. Then on top of that, you've got also this multi gene expression tests, which are looking at twenty or forty or seventy genes to help predict, responsiveness to treatment and prognosis. That's a third type. Then you've got circulating DNA, which is a whole new aspect, which is where we're looking at the shedded DNA in the blood.

That still brings back the somatic testing information, but it's done as opposed to a tissue biopsy, it's done through liquid. Then you've got pharmacogenomic testing. Pharmacogenomics basically you're looking at the germline mutations that might impact how a person metabolizes drugs, which would be extrapolated to all patients, not just cancer patients. And then lastly, you've got this multi cancer early detection test, which is a whole new thing.

It's not approved by insurances yet, but I think it's coming, where a simple blood test will screen for forty six cancers. And, you know, that's a whole different way to do things than we've done historically.

So those are like the different types of genomic tests that we have. Now, when we talk about the different somatic tests, somatic mutations we do, there are some classic ones that we're all familiar with or that we've heard about. So that might be like your BRAF mutation, your EGFR mutations in lung cancer, HER2 mutations, your NTRK mutations. These are all different mutations that we have identified that are what we call oncogene addiction.

They're basically, they drive the cancer. So we know there's lots of different mutations. Some are silent, some are really loud. When I say loud, that means that basically they're the ones driving the cancer.

And so we've been able to identify lots and lots and lots of mutations when we start doing this testing. The problem is a lot of these mutations are really not that important, but then other mutations are extremely important. And so this is a rapidly changing area because we're learning more and more about the different mutations that are oncogenic drivers.

And with that, more and more pharmaceutical companies are looking for that information. So they're actually reaching out to us and saying, give us this information in mutations, give us your outcome data so we can identify patients and identify mutations that might be a good target for a drug.

And so there's lots of different biomarkers and each cancer has its own sort of different one. So for example, lung cancer, we have KRAS mutations, EGFR mutations, BRAF mutations, NTRK mutations, ROS mutations, and the like. And you really can't make a treatment plan for a lung cancer patient without that information. I mean, it's so funny because lung cancer historically was just like non small cell and small cell. Was it.

And now it's like, there's so many mutations and it's not just non small cell, it's non small cell, ROS, ALK, KRAS, whatever it may be.

There's all these different mutations and you have to know them. And the other thing that's kind of interesting is that it's not a static picture in time. So you'll have a patient who's a breast cancer patient, who's HER2 negative.

Six years later, they relapse and now they're HER2 positive. So the mutations change.

And so that also is important why we have to do this testing in house, because you can't just do one test and you're done. You got to do the testing on a regular basis to check for changes in their mutation status that might make a new target available that can change how you approach the therapy. So it's really complicated, but it's really fascinating because with that testing available, we're able to not only use the genomic testing to in essence quantify the shedded DNA that's being produced by the cancer, which then serves as a barometer of responsiveness, but you can then take that DNA that's shed and identify different mutations and new mutations, which might make a patient that was not responding to therapy before suddenly start responding to a new therapy. So it requires constant vigilant, you know, assessment of the genomic alterations. And that requires that ability to have the testing quickly available.

I don't if that answers the question, but so on. Doesn't more.

You know, it's so funny. I'm trying to contain myself because this is a wholesale change.

It is.

Based on what I learned, for instance, in medical school or residency.

And it's just so exciting because it allows you to do essentially bespoke medicine in ways that for a patient population that at some point, you know, may have been somewhat hopeless at times, depending on the cancer and depending on the diagnosis, you now can really not only kind of cater to treatment to them at this moment, but then you know to go back again, even if it's a year later, you may have to do this again and cater it even more. So that's just fascinating to me. That's a wholesale change. It used to be throw everything toxic you could at the patient.

They suffer, they suffer, they suffer, they get better or not.

This is different what you're Totally different. I'll give you another example of this. So not too long ago, maybe a year or two ago, I forgot how many years ago it was, FDA approved a drug for mutation, not for a disease. So just to give you an idea, historically what happens is you apply to FDA for approval for a drug in the treatment of breast cancer or the approval of drug in the treatment of lung cancer.

In this case, they approved the drug for the treatment of this mutation, regardless of what tumor type. So they realized that the mutation was more important than the anatomic origin of the cancer. And so that is almost, it's a really great example of how this is so different today than what we've done before. And this also creates a bit of a problem too, because, you know, the science is moving faster than our ability to pay for it.

And that's a big problem from an insurance perspective because, you know, it's growing so fast. But what we realize also is that when you give the right treatment to the right patient at the right time, actually in the long run, they do better and it costs less. Absolutely. But that realization hasn't necessarily made its way there yet.

So we're getting there. I think we'll get there, but you have to spend a little bit more money to do the testing and it might feel a little bit off from an insurance perspective. But the reality is a long run, the patients will live longer. They'll require less unnecessary therapy, they'll have less toxicity and the grand scheme of things, they'll pay less.

We just haven't been able to necessarily prove that in all cases yet.

They'll catch up though, because the moment that they understand that there's an ROI on that, they'll jump right in because cancer is such an expensive undertaking for insurance companies anyway. They're going to catch on relatively quickly, was what I would predict.

What cancers benefit most from this type of approach?

Right now, this type of going back to the somatic testing approach, somatic testing is really on pretty much any patient with stage four cancer, we're doing testing because you never know what you might find. You might find some PIK3CA mutation, which might make somebody who's got no options suddenly have therapy options. So we do it really pretty much on almost all stage four cancer patients with the hopes that we'll find something that could be a potential target. Now, are certain cancers that are clearly, we have much more experience and where we know it's much more beneficial.

So for example, breast cancer. We know breast cancer has certain mutations, which are not only important at the front end in terms of when you're making your initial treatment decisions, might sort of, know, ESR1, PIK3, all these different mutations are really important in an advanced setting. So the importance of testing that is really essential. As I mentioned before earlier, lung cancer, I mean, nowadays, if you don't do genomic testing on a lung cancer patient, I mean, you're doing a disservice.

That's really inadequate management because you just can't manage lung cancer patients without that genomic information. I'd say colon cancer. Colon cancer is a big one with BRAF mutations, HER2, KRAS mutations. We know a lot about colon cancer now such that we really need to have that information when we're approaching patients, even with rectal cancer patients.

And, we know that some of these patients have had dramatic responses with immunotherapy. And so we really just need to, we need to have that information while we're making the treatment decisions. I'd say beyond that, those are the big ones. I think, you know, other ones, gastric cancers, even pancreatic cancers are becoming increasingly more useful, know, head and neck cancers, you know, so I think pretty much all cancers, but the ones that I mentioned earlier are probably the most commonly.

Even, I'm sorry, I forgot to mention brain tumors also, where there's a lot of mutations, EGFR mutations, which we know affect prognosis and outcome.

Does this mean that the chemotherapeutic options are less toxic?

Yes, but also different.

Yes, but different.

Think, you know, chemotherapy is basically shotgun approach. You know, you sort of hit, you throw this drug at a patient and you hope you get the cancer, but yeah, we're going get a lot of collateral damage. With some of these targeted therapies, we are really able to avoid hitting healthy tissue, healthy cells, And we're able to minimize some of the toxicities that we typically think of, you know, hair loss, nausea, vomiting, low blood counts. I mean, remember when was in fellowship, I mean, how many patients were getting admitted for neutropenia fever? It was all the time. I mean, that doesn't happen as much anymore. A combination of both using better therapies and avoiding sort of that neutropenia, but also some of the new supportive agents have really helped make that a thing of the past.

That's a ten year change then. That's not even a twenty year change.

That's a ten year change at the Absolutely.

And so those new treatments are having less classic side effects, but they're having new side effects too. So like immunotherapy is causing these weird rashes. I'm having to become a dermatologist and I have to work closely with my dermatologist. I'm not really good at dermatology.

It's just required us to sort of change our expectations. Cardiotoxicity, there's a whole field of cardio oncology now because some of our drugs are known to cause heart failure or arrhythmias. And so, nowadays we used to not really work with cardiologists that much, but now we're working a lot with them, which is kind of cool. So, I mean, really it's Cool you.

I'm sure it's that great patient, but better than other things that used to be by far. Yeah. By far. So that's really interesting though, that evolution and the change, you must be constantly learning, groaning.

It's great to have that as a career. It is. It requires a lot of work to sort of stay up to date because things change rapidly in oncology. It's just really hard to stay up with everything that's happening.

I'm gonna bring this back to a human kind of a case again. Can you share an example where genomic testing has really changed a particular patient's life? Like maybe one of those stage four patients or somebody, you know, any case that you can share that's within compliance of privacy.

Sure, sure. I mean, it happens a lot actually. So I'll give it go back to very early on when I started. I had this patient, I gave two cases.

I had this one patient showed up one time in my office with, it looked like a chipmunk, these big massive lymph nodes in her neck. This is this woman who never smoked before. She had non small cell lung cancer. And was fresh off that we had just learned about sort of these EGFR mutations.

And so said, Oh my God, I've got the drug for you. And so I put her on drug and I had her come back a week later and the things had almost gone in one week. Within a few weeks, it was completely gone. Mean, how do think about that in lung cancer management? So, I mean, I still remember that patient to this day. I have another patient who presented in the ER with a seizure.

Oh, I've got so many cases here. I could go down forever in this one. I'll try to think of two or three and I'll stop after that because I'll bore you. But I had this one patient who presented in the ER with a seizure and found to have a brain lesion, came back as lung cancer.

You know, back in the day, remember when we were in training, they used to say, when you get diagnosed with cancer, you know, just buy a ticket to Bahamas and- Pretty much.

I mean, that's why I'm just mouth of gag over here because of all the choices now.

That's what we used to say. I mean, a lot of primary care doctors didn't even refer the patients to oncologists.

That's crazy.

Because they were like, oh, you you're going to die. Just go enjoy your life. And so this patient, I saw him, he was like, oh, I live, my family's from Jordan. I want to go back to Jordan and be with my family.

So no problem. Said, No, just let me send you, you've got a mutation, let me just send you the drug and maybe you get some extra time. Anyway, I kept on getting these requests for refills year after year after year after year for this patient. Seven years later, he came back and saw me and was like, Hey, I just thought I'd come back and visit my family.

I'm still alive. Thanks for sending me all these refills. But it's amazing. I mean, that's a patient who presents with brain mets.

Because we had the right mutation, they developed. But it really is dramatic how things have changed. These are just some cases, but it's really, once you know the mutation, and if it's, I said earlier that oncogene addiction, we call it, where that oncogene is the driver for the cancer.

If you have that situation, and if you have a drug that targets that, you can turn a cancer either cured or you can make it a chronic disease where people can live a completely normal life for many, many years to come.

It's really great because we've changed from, you know, this is one of the areas of medicine now that instead of it being symptom management and waiting for the body to heal itself, it's really targeted root cause medicine, which is really, like I said, a wholesale change.

Is that case you are mentioning now would have been a death sentence even fifteen years ago?

Yeah. I mean, that's just wild. I'm just gonna pivot to one last set of a couple of questions because everything you walk through, it's not a miracle, it's science. It's research, it's dedication, it's investment as well.

And we all know that there are things like this that make you look forward to the future in cancer. And I want to talk about that a little bit and you kind of think through what's cutting edge and what really is coming in the next two to five years that you're excited about. But, you know, the world right now is changing in a way that is somewhat de investing, if that's a word, in science and research and medicine a bit. And I want to talk about what your concerns may be.

So think about what's coming and what the future makes us think brightly. And what things do you wanna put a pin in for the public to just think through that they should consider as they talk to their congressmen or whoever in the future.

Yeah, you hit a point that's really hits home for all of us as physicians. So much of what we do is tied to trust. And I'm going to tell you about what's exciting and then I'm going try to come back to sort of macro level thesis of what's happening and why I have a little bit of hope, even though it can be depressing at times. So what's exciting, one thing that's exciting that I think is going to come in the next few years that we're all going to be seeing on a regular basis goes back to what I said earlier, which is that primary care doctors and medical oncologists are going to be in the field of diagnosing cancers and not relying on surgeons in the future as much.

And the reason is because this multi cancer early detection test, which is a very unique test and the story in it, I don't know how much time we have, but the story in it is that it came actually in sort of genomic testing, looking for pregnant women who, they were trying to see if the patients, if their fetuses had Down syndrome or other things. They would do these blood tests to look at the fetus' DNA and see if they had different mutations. And what they did is they collected all these samples over the years and years and years, and they found some weird signals they didn't know what to make of it.

And to their credit, they kept on following these patients with the weird signals, and it turned out those patients had cancer. And so what they found was that the cancer cells create a different genomic profile than the normal person. And so when you identify those genomic profiles that are in the shed in the blood, you can basically find cancer early.

And so that test called the GRAIL study initially, were part of that study. Now the most commercially available test is the Gallery test, which is screens for forty six or so cancers, but there's more and more of these tests coming. Basically, it's a blood test and it essentially identifies shed DNA that can pick up a cancer before it's even manifested as a lesion, in some cases. More so in the cancers that tend to be more active and loud, like pancreatic cancer, cancers that we don't have a real means of screening for. So we screen for breasts, we screen for colon, prostate, lung, in some cases.

So we're pretty good at that. And we do a good job of that and that's not going away per se. But there are other cancers that we don't have a means of testing for, screening for. You're kind of just like sucks to be you because you get diagnosed late stage.

Those are the cancers that really shed a lot of DNA really fast. And those are the ones that we're able to pick up on if you start embarking on this testing on a regular basis so that those patients are picked up at stage one as opposed to stage four. So that's the really exciting stuff. I think that's coming very soon.

It's readily available today. You can get it now. It's not covered by insurance. It costs about five hundred dollars to nine hundred dollars Some people are saying, I'll do it once a year.

I mean, there's really no guidelines at this point. We're trying to figure that out. Actually have a meeting today with the company, to talk about building a clinic that focuses on that. And so it is coming.

The insurance has lagged behind. But what that also does is it also asks our patients to trust us.

Trust us, you got this signal, you might have a cancer coming out. We also have to get through the whole false positives and get the assays to be a little bit more accurate, is why maybe it's not available today. But we're going to get there. And when we do, we're going to be telling patients, trust us, you may have a sign of a cancer. And in a world today where trust is basically becoming eroded between physician and patient, it gets harder and harder. It gets harder and harder to tell your patient, take a vaccine. It gets harder and harder to tell your patient to say, Hey, we got to get a scan done.

You just want me to know this cancer so you can bill more or do something.

Yeah, exactly. Have no investment in it. Let's assume that we have some malicious intent. And so I think that's really difficult. It makes it harder and harder to do what we do. And I think it also means that what makes a good physician will not be how much you know, because knowledge is now a commodity.

In the day of AI, everyone and anyone can have access to knowledge.

So knowledge is no longer what separates us And so what will make a great physician is their ability to connect and communicate and build trust. I think that ability to build trust and that ability to demonstrate empathy is really going to be the best quality of a physician. And I think also with AI, we now have an objective validator. Now, obviously it depends on the LLM models and where they get the information from and all of that.

But that being said, if they don't believe me, they say, look, go check ChatGPT. And ChatGPT will verify what we're saying. So sometimes doctors feel a little intimidated by it. Like what's this, you know, ChatGPT is making my life harder.

I think it's making it better in some ways because now we don't have to worry so much about that trust issue because patients can validate what we're So I think it's a very different world we're in.

We'll have to figure out exactly how to navigate through this. It's moving fast and changing fast, it is exciting for sure.

Well, would argue that empathy and the trust have always made the best decisions.

Absolutely.

It's you a great position.

It makes a lot of the positions at Advanced HealthCare a great physician. It's more than what you know. It always is and always has been. Alright.

We're gonna wrap it up, I guess. That's been a huge amount of information for for our listeners to to absorb. I am very excited. I'm trying to contain myself in this seat because, as an emergency medicine physician at CORE, this is not the type of information I generally follow.

And I'm just holding onto my hat like my head's about to blow up.

This is a wholesale change, for patients and in a better way, in a improved And it's going to come to other specialties too.

It's not just oncology. So I think this will hit cardiology, neurology, psychiatry, primary care. Mean, pharmacogenomics, every patient will get a pharmacogenomics test and they'll know which drugs they interact with and what they don't interact with. So this is coming to everyone.

And coming not in twenty years. Yeah. It's not like the Watson and Crick change of fifty two to This is two, three years at Oh yeah, So that's really exciting.

Well, thank you for joining us.

Thank you. Thank you for having me. It's a This is great.

It's a new world.

Yes.

And a new world here at Adventist HealthCare.

Exciting times. Charting with doctor McNeil.