RWJBarnabas Health
Keeping Your Liver Healthy: Cancer Prevention & Liver Health Strategies
The Cancer Center at Saint Barnabas Medical Center presents the A, B, C’s of liver health and cancer prevention. Learn how liver health is connected to other conditions, to improve liver health through diet, modern treatment for liver cancer and what tests you should ask your doctor for. Moderated by Angela McCabe, MSW, LCSW, OSW-C, Director of Patient and Family Services, Oncology Service Line, RWJBarnabas Health, this event features Su Wang, MD, MPH, Medical Director, Center for Asian Health &Viral Hepatitis Programs; Jill Kremer, RD, Registered Dietitian, Cancer Services – Patient and Family Services, Saint Barnabas Medical Center; and Russell Langan, MD, Chief of Surgical Oncology and Hepatopancreatobiliary Surgery, Saint Barnabas Medical Center and Surgical Oncologist, Rutgers Cancer Institute of New Jersey. Rutgers Cancer Institute of New Jersey is the state’s only NCI-designated Comprehensive Cancer Center. Together RWJBarnabas Health and Rutgers Cancer Institute offer the most advanced cancer treatment options close to home.
#LetsBeHealthyTogether
thank you for joining us this evening and i wanted to say that october is liver cancer awareness month we have three clinical experts who will address cancer prevention and liver health strategies how diet can improve liver health and modern treatments for liver cancer a few housekeeping issues before we start all of the participants will be on mute throughout the program if you have a question we're asking that you please type it in the chat box down at the bottom of your screen in the right hand corner we will try to answer as many questions as possible given the amount of time we have when all three presentations are completed i did want to also mention that tonight we will be covering general guidelines and recommendations if you have specific medical questions or concerns it's best to consult with your personal physician as they can address your individual needs and lastly for con the comprehensive bios on our speakers you can go to the handout section of our presentation and take a look at them it is now my pleasure to welcome dr su wong dr huang is the medical director of the center for asian health and the viral hepatitis programs please go ahead dr wong thank you angela i want to welcome everybody here it's so great to have everybody here i think this is such an important series we're doing for october which is liver cancer awareness month and it's a chance for us to really talk about how we can protect our liver keep our livers healthy and learn about some of the important liver diseases and what to do if you do have a liver condition so let me um start my slides all right great so today i'm going to talk about liver disease basics and what you can do to be an advocate for your own liver again i am an internist and i do have a interest and focus on viral hepatitis and preventing liver cancer and i work out of st barnabas medical center in florence park and i'm part of the rwj barnabas health medical group i also serve as the president of the world hepatitis alliance which is a non-profit organization which seeks to harness the power of people living with viral hepatitis to see its elimination all right so what does the liver do we all know the liver is an important organ and it's actually the largest solid organ in our body it weighs about three pounds and it's about the size of a football and you can see the picture of it here it hangs out under your lungs on the right side of your body above your colon and your intestines so it's got an important job it produces almost all the proteins that you need in your body it creates the clotting factors which helps stop bleeding it creates all the immune factors which protect you from infections and help you get well when you do get sick it also produces bile you see the gallbladder there the little green sack hanging underneath the liver and i it and those bile the the bile acid actually helps your body digest fats vitamins and nutrients it's also really important as a filtering organ it clears away in it and excretes toxins such as drugs alcohol and poisonous substances and also it stores and releases energy almost all the vitamins and minerals and carbohydrates proteins and fats are stored there and it slowly releases them as your body needs them and so what can happen to the liver there are a number of kind of like um attacks that can happen so we talk about acute liver disease um and what does that mean so that means that it's a transient insult so it's a insult that can cause transient hepatitis or inflammation it sometimes can cause an actual flare and rarely but but something to be concerned about it can cause actual liver failure some of these acute injuries so what can these injuries come from so can come from alcohol which is what we commonly can think about people who go into alcoholic hepatitis or go into alcoholic liver failure any of these hepatitis viruses can cause an acute infection so you can have acute hepatitis a acute hepatitis b and acute hepatitis c often when you first get the infection and then there are a number of drugs that can cause hepatitis in almost any drug but there are certain drugs that have a pretty predilection for the liver and one of those is tylenol or acetaminophen is the generic name at high doses it doesn't mean you can't take it but in high doses and sometimes in combination with other medications it's more likely to cause injury inh which is a tb medication um certain statins can cause a mild elevation of liver enzymes but not necessarily liver injury and that often goes away and then there are often herbals and supplements that have been tied to liver damage and so i always tell people that just because it's labeled as natural um or just a supplement doesn't mean that it can't do damage and so one of those things that we talk about make sure people know are like some certain kinds of green tea supplements not green tea in itself but in the supplements are highly concentrated amounts of green tea and every year there's a handful of people who go into liver failure because they've taken too many of these green tea concentrates in an effort to lose weight or whatever and as i mentioned there's often interactions with herbals and supplements with prescription medications it's really important to let your doctor know if you're taking any of these things because if they're prescribing you other medications it's important for them to know especially if they see any abnormalities in your liver enzymes they can then try to figure out if it's related to something else that you're taking so the good news is that the majority of these acute insults will self-resolve however acute severe acute hepatitis sometimes can require supportive care or hospitalization and if there is liver failure it may actually warrant a liver transplant so now we're going to go into chronic liver disease and what does this mean so chronic liver injuries can cause ongoing liver inflammation um and what happens here is that there's an ongoing cycle of damage and repair so um the the the liver is basically subjected to chronic damage and as it's trying to repair itself it's creating a lot of additional collagen and other things inside the matrix of the liver and over time that just causes fibrosis and that can lead to what we call that's basically essentially liver stiffness and over time that fibrosis can lead to cirrhosis or scarring you see a picture of that on the right with a really like bumpy irregular uh surface of the liver and cirrhosis um can come in different degrees too it's usually not reversible early cirrhosis can't have degrees of uh regenerating and improving um and people often are first in the stage of compensated cirrhosis where they're still able to maintain functions make enough proteins but at the end the really end stage of liver disease you get decompensated cirrhosis and you often have people who have a lot of swelling in their belly they may be jaundiced more likely a lot more likely to bleed um and that's really the the end stage of liver disease we're trying to avoid and cirrhosis itself can increase the risk of liver cancer um because of that ongoing inflammation uh you're basically causing a lot of cell turnover and you can get cancerous cells grow so i didn't go over what can cause chronic liver injuries but it's essentially the same thing that can cause acute hepatitis does although alcohol viruses what's different is that you have the metabolic associated fatty liver disease which i'm going to go into a little bit more detail next um there's also other conditions such as autoimmune hepatitis which is when the body develops antibodies to the liver and certain gallbladder disorders which are more rare but can also cause liver damage so how common is liver disease um so unfortunately there is low awareness of liver disease so we're really you know we think it's great that you're here and that you're trying to learn about liver disease because overall globally and even in america there's low awareness of liver disease october happens to be breast cancer awareness month and we've all heard about breast cancer and there's a number of toxins and things happening for breast cancer but liver disease is often not as celebrated or you know there's not a lot of education that happens with it so we are glad to be here and i'm glad that all of you guys are here so liver disease is common though and uh one of the most common conditions at this point is actually fatty liver disease we think that up to 25 percent of americans may have fatty liver disease and that comes out to like almost 100 million americans in terms of the other liver conditions hep c we think affects 3 million americans hepb 2.2 alcohol-related cirrhosis which is you know the more severe form of alcohol-related disease may affect up to two million individuals now the concerning thing is that liver cancer is the sixth most common most common cancer globally and also concerning it has a very high mortality rate and it's the highest third highest cause of cancer-related deaths so it's often diagnosed late in stage which is the problem if you diagnose earlier there's more interventions we can do but often it's not detected till much later and dr lingan will be talking more about liver cancer and as i mentioned the cases are going up in the u.s and globally liver cancer screening unfortunately is not done as regularly as breast colon cancer or prostate cancer and that's something that i hope can impress on you is really important as well in liver transplants in the u.s about 40 000 people um had liver transplants in 2019 so we're gonna talk about fatty liver disease and here's a picture of kind of what a fatty liver looks like you can see that basically there's been fatty infiltration of the liver it has that yellowish hue to it's not bright red and burgundy color like a healthy liver and this says in the medical terminology we call it non-alcoholic fatty liver disease and some of the main contributors are high fat high starch diet and the sedentary lifestyle that we often have here in the u.s our major contributors and what happens it can cause it can lead to this crime and path of chronic inflammation and over time non-alcoholic fatty liver a subgroup of people will develop nash which is non-alcoholic stato hepatitis and this is more likely to develop into cirrhosis this is now the most common liver disease in the u.s and quickly becoming unfortunately the number one cause of liver transplants which before were largely due to alcohol and hepatitis c so most of the people almost 90 percent of people have a metabolic risk factor so either obesity type 2 diabetes pre-diabetes even and high blood pressure high cholesterol majority people with fatty liver are overweight but lean fatty liver is an actual thing and it is quite common in asians so what are the interventions that work and this is study over study has really shown that it's all about lifestyle change that exercise weight loss even five to 10 percent of weight loss can actually lead to regression of the fatty liver and it's really important to control those other contributory conditions such as diabetes and high cholesterol so to be aggressive and make sure that you're actually on your medication and getting it checked and in good control of those conditions and what treatments work so there's no magic pill unfortunately right now oddly enough vitamin e is the one thing that's been shown to work and so we put a lot of patience on that there's been a recent medication an injection called semiglutive um which has been shown to reduce some nash cases and there are a number of others in clinical trials but nothing that's really proven to be very effective so it really does come down to lifestyle so what can you do to be an advocate for your liver and to be healthy so i like to tell people know your abcs and make sure your doctor has tested you for these conditions i think we often think that you go to the doctor they do a check at the kind of just check everything but it's not it's not necessarily the case there's not one box that checks off you know all the lab tests that you need so it's important to be an advocate and actually ask your physician if you've been screened for hepatitis a b or c and it can often seem like an alphabet soup but just to kind of do a quick overview hepatitis a you may have heard of recently and oftentimes there'll be reports of outbreaks in restaurants um because it happens through uh contaminated food during um food preparation or at time of harvest um it's basically fecal oral contamination so that's why so much emphasis on food preparers washing their hands there is a vaccine and it's now part of the childhood vaccine schedules schedule for adults however the vaccine was traditionally given for travel and so you may have gotten in if you were traveling but a lot of people have actually not been given the vaccine so what i tell people is get tested and if you're not immune get vaccinated past couple years the u.s has seen a number of epidemics which at first affected the homeless population but recently in new jersey it actually affected people who went to um certain delis um even at a certain country club people were affected so really doesn't um nobody's truly immune unless you are actually you actually have the antibody so in terms of hep b and hep c hep is the most common chronic blood-borne infection in the world it's transmitted through blood and bodily fluids so not through food like hepatitis a um in the world the the most common transition infection route is mother to child transmission during child child birth and that's why the happy birth dose for infants is really important um because we can stop that transmission if the babies all get vaccinated for adults a lot of us if you were born after 1990 i mean before 1991 um you were not given this as a childhood vaccine and so it's important for you to get tested and if you're not immune you can still get vaccinated so hep c is through blood transmission including unsafe injections drug use and transfusions and now the cdc as of last year recommends a one-time hepatitis c test for all adults it used to be just for um for uh for baby boomers it used to be for people born between 1945 and 1965 but we saw we were seeing a surge of infections in the millennials in the 20s and 30s largely driven by the opioid epidemic so it's now um recommended that all adults over 18 should have a one-time test and what's remarkable is we have cures now for hep c so it's a 8-12 week course of oral medication almost 100 cure rate so if you know you have hep c or you know somebody who's had it now is the time to get cured because we can stop that cycle of inflammation and decrease the risk of cirrhosis and liver cancer so what else can you do to be an advocate for your liver well obviously protect it so limiting alcohol is really important we know that there's a dose dependent uh rate for for damage related to alcohol beware of the herbals and supplements as i mentioned medication interactions do the things to help prevent fatty liver and control those conditions that can lead to fatty liver which i mentioned so your doctor does do routine blood work which includes liver function tests um they're often part of a complete metabolic profile um and those the liver enzymes we look at are what we call the amino transferases or the ast or alt which you might see on your lab results alkaline phosphatase is also produced by the liver ggt um and other tests that could be abnormal if there's liver disfunction you might see issue issues with the bilirubin it might be high and that's what causes the jaundice um your platelet count might be decreased so oftentimes that's a sign of really severe liver dysfunction when the platelet count is low prothrombin time that's a reflection of the clotting factors if you're not making enough of those your prothrombin time is long that means that you're not clotting in the right amount of time and then another test is lactate dehydrogenase or ldh now if you've already been diagnosed with the liver condition a chronic liver condition what's uh what should you do it's really important to see your physician for regular follow-up so if they tell you to get lab tests every six months every three months please do so sometimes i see patients who i told you know to follow up every six months they don't come back for another year or two years and we miss that window of time to intervene if i saw something that was abnormal imaging is really important so ultrasounds we often order and now we're also ordering fiber scans or elastographies and it's basically like an ultrasound but it also measures liver stiffness so it helps us look for fibrosis cirrhosis and actually the fiber scan can help look at fat content um so that helps us confirm a diagnosis of fatty liver and this ongoing imaging is really important so for my chronic uh patients with chronic liver disease people who are considered high risk for liver cancer need this every six months at six to 12 months in order to screen for liver cancer um and also liver cirrhosis so as i mentioned just follow the recommendations and treatments sometimes it doesn't feel like we're always doing things if we're not giving you medication but just know that your doctor is really paying close attention to your blood to your blood test and monitoring you obviously avoid other liver toxins and the insults that i mentioned and then make sure you prevent other liver disease so if you have fatty liver it's important to get screened for hep a and hep b because you can get vaccinated and prevent another potential insult to your liver and then i think it's really important to find peer support and resources to find people who are going through the same thing as you um and can be a support for you so and also learn you know i tell people to be active be proactive and learn about the conditions that you have there's a lot of resources out there the american association for the study of liver diseases a double a sld has a lot of patient facing educational materials and they have an annual liberal meeting in november and they're sure they actually have a patient track so it's a very reduced registration fee and there's a we're designing a lot of the educational program for patients and so i'll be a part of organizing those that patient that patient conference the american liver foundation has resources national viral hepatitis roundtable has patients do a lot of advocacy and then if you have hep b the happy foundation has some great resources as well so in just two seconds you know one of my um one of my passions is viral hepatitis and it's something that we now is really the time for us to do more in this just kind of showing that we've ignored hepatitis um and if you look at it basically the deaths from hepatitis now exceed hiv tb or malaria and so if we don't do what we know we need to do in terms of screening and treating patients with hep b and hep c we're going to be seeing uh the burden the number of deaths from heppy and hep c exceed tb hiv and malaria all combined and so it is time for us to uh to mount a global response to hepatitis as dr chan who used to direct the who said um and i just think it's important for us to cast this vision because we are all living in this era i think about you know i tell people how we were able to eliminate smallpox um you know through vaccines same thing with hepatitis we may be able to tell our kids that in our generation we eliminated hepatitis so that they would not have to to face it um and this is something that you know i think it's important for the general population to know because these screening tests are recommended by cdc they're actually covered by insurance um and uh so it's important to advocate for yourself and ask for those tests because the hep c is now curable um and it should all insurances cover it um there may be some pre-authorization involved but uh we work with closely with the pharmacist we have a pharmacist embedded in our practice who helps do all the the the pre-authorization work hepb as i mentioned is vaccine preventable it's also treatable and there are cures coming down the pipeline so we think in the next five to ten years we'll have options where we're able to cure hep b as well but really screening is the first step if we don't find the missing millions we won't be able to get people into care and sadly in the u.s more than 50 percent of people living with heppy and hep c are still unaware of the infection um and we we see that we see the the outcome of this if people aren't diagnosed then um or treated then basically what we see is that we get more people with liver cancer or the end the end outcome so 65 percent of living liver cancer in the u.s is still due to hep b and hep c um and this is something that the us has now said we can eliminate and this was actually the conclusion um announced by dr brian strom who's the chancellor of rutgers as you guys as many of you know um he was the chair of the u.s hepatitis elimination committee and he said we now have the tools to eliminate hepatitis b will require significant resource allocation commitment and strategy um and so we just want everybody to know at st barnum's medical center we're committed to this vision um our hospital uh both in the ed and inpatient is doing hepian hep screening for those who qualify um and we're getting everybody we find who's positive into care into our practice and at this point we've actually cured almost 100 people of hep c um and a number of people with hep b were taken care of so and i just say everybody who's on this talk has been a really big important part of this teamwork and really honored to to be here with you all and i'm happy to pass the baton on to jill now thank you dr wong for that terrific and informative overview on liver health and prevention strategies i'm delighted to now welcome jill karima registered dietitian for our cancer program at the saint barnabas medical center and jill please go ahead with your presentation do you have it there is it there you got it okay good thank you angela um i'm going to speak to you tonight about keeping your liver healthy with good nutrition okay a key component to liver health is having a clean whole food anti-inflammatory diet we're going to talk tonight about what dietary changes you could make to help lessen the inflammation in your system and keep your liver healthy we are going to eat to beat inflammation what do we want to limit we want to limit our processed foods processed foods have added preservatives chemicals toxins in it such examples are canned foods prepared foods bacon sausages cold cuts and all that adds stress to our liver in terms of metabolizing those we want to limit our simple carbohydrates simple carbohydrates break down very quickly in our system which can lead to a spiking glucose which can lead to a increase in insulin and which can lead to fatty liver as well such examples would be candies you know juices sodas frappuccinos really if you're looking on an ingredient list what you're looking for you want to avoid anything that says high fructose corn syrup as well that goes directly to the liver and can create fatty liver we want to limit our red meat so red meat is defined as any animal that walks on four legs so not only is that cows but that's also our pork and lamb as well and there's a few reasons for this the heme iron that is found in red meat has been shown to have a direct link to colorectal cancer in addition we know that red meat is an abundance of saturated fat and cholesterol which can increase our cholesterol and increase our ldl and add to fatty liver we want to limit our saturated fats in our trans fats saturated fats you'll find in fried foods meats high fat dairy products and trans fats have been added to foods to increase the shelf life so many of our processed foods can often have trans fats in them and what you're looking to look what you're looking on the ingredient list for that is if you see partially hydrogenated oils at all it's a kind of a key to you that there might be trans fat and then you might want to put it back on the shelf and alcohol if you don't drink don't start and if you do please keep it in moderation but it's not all about what to take out of the diet what can you add to the diet to kind of make it a little bit more anti-inflammatory well we definitely want to increase our complex carbohydrates we want to increase our fiber we're looking at about 30 grams of fiber a day is what we want and the typical american diet can gets only about half of that fiber does a few things a it helps us feel full longer so that helps if we're trying to control our weight it helps us metabolize carbohydrates so that they break down a little bit more slowly in our diet and it also helps us normalize our lipid levels so it can help us reduce our cholesterol reduce our ldl and increase hdl which is that good cholesterol on our good numbers we're going to increase our fresh fruits and vegetables we're going to talk about how you can you know we're asking you to kind of limit some of your meat but we're going to talk about how you can now increase your plant-based proteins and very important is cooking with fresh herbs and spices not the pill form fresh herbs and spices we know that there are many out there that do have some anti-inflammatory uh responses to them we have turmeric cinnamon garlic ginger just to name a few and you really want to cook with them to get the the most the most benefit and the safest uh way to do that so that could be soups or stews or you can throw a little turmeric in your morning smoothie a little cinnamon in your steel cut oats are just examples of where you can start the day that way so we do want to choose some complex carbohydrates now what does that mean we shouldn't be afraid of carbohydrates but you want to choose the right ones what you're looking for is 100 whole wheat if you're looking out on the label um in terms of a bread choice a great option is a sprouted grain bread i think most people probably have heard of the brand ezekiel bread but many uh companies out there now make their own and basically what they do is they take organic lentils and legumes and they sprout them so they they put them in a very temperature and moisture controlled environment and then they sprout and then they blend them into their bread product and what the result is is really a very hearty high fiber high protein rich in omega-3 fatty acid type of bread so next time you're at the store take a look for those now we when we're looking at our complex carbohydrates let's say at dinner we might be used to having white rice white potatoes regular pastas and we really want to try and swap those out a little bit so brown rice is a great option barley couscous wheat berries there's many many out there you can try you want to swap maybe that baked potato you know swap in a sweet potato for the baked potato for some added fiber and nutrition and quinoa quinoa is really a superfood it is a complex carbohydrate it offers you fiber protein omega-3 fatty acids it is a complete protein which means it has all the essential amino acids in it and it is gluten free so just to speak about gluten for a moment gluten is the protein found in wheat products and it has been shown that diets high in gluten can maybe have a result in a high inflammation in your system so many of my patients come to me and they're look they're looking to either reduce or eliminate a lot of gluten in their diet and quinoa is a wonderful opportunity to do that plant-based pasta i tell all my patients slow down when you go down the pasta aisle we got very used to kind of what pasta we grew up on but there really is a wonderful variety um that is offered now in terms of plant-based pastas from red lentil to edamame to quinoa to chickpea pasta and i always tell them i said just try a new one every week to see what you like but portion size does matter you can have too much of a good thing so about a half a cup cooked rice potato or pasta was really the serving size that you're looking for so we've now asked you to kind of limit some of those animal based proteins so where are we going to get a protein from well we're going to look really towards our plant-based proteins i'd say the most common one that people think of is our legumes and our lentils right our our beans our chickpeas our soybeans our black beans red beans you do want to have the non-canned version you want to have them fresh and you want to rotate them you're going to get a different nutrition profile from each different bean you also don't have to think about them just in terms of like a dinner option they're a great snack option as well so i often i love hummus i think hummus is a great plant-based protein high in fiber there's tahini in it which is a rich source of vitamin e which has been shown to help lower inflammation your system as well i take chickpeas and i will roast them about 400 degrees for about 20 25 minutes i put a little garlic powder a little cayenne pepper and they're a great substitute for those highly processed croutons that we like to put in our salad so i'll keep them and i'll throw maybe a third cup into my salad and it gives me some fiber some protein and a healthier crunch than the crouton did nuts and seeds are a good option again similar to that of the beans you want to rotate those you're going to get different nutrition from different nuts and seeds for example in terms of almonds you're a good source of calcium omega-3 fatty acids are going to be very rich in your walnuts your flax seeds your chia seeds your hemp seeds vitamin e and selenium you can find in sunflower seeds magnesium and manganese which can be difficult to find you can find in brazil nuts so you really do want to kind of rotate them to really get all the nutrition you can but portion size matters and you're looking for about an ounce is considered the portion size and we have nut butters as well you know we grew up maybe just on peanut butter but now we know that there's cashew butter sunflower butter almond butter the serving size is about a tablespoon and that would go great with that sprouted grain bread as an afternoon snack we did talk about quinoa we um we did talk about the plant-based protein pastas but i also encourage you to think not just about dinner time with those um because they're great options to make a meatless dinner option but i tend to make a little extra then i'll put them in my fridge and i'll keep they keep about up to four days pretty pretty nicely in the refrigerator and i'll when i'm having my salad at lunch i'll take maybe a third cup cooked and i'll kind of toss it in in my salad for a nice plant-based approach to to your salad let's see so dairy-free alternatives this is similar to the gluten the protein that is found in cow's milk specifically casein has been linked to increase inflammation in our system so again many of our patients come to us and they're looking to either eliminate or significantly lower the amount of dairy in their diet it is much easier now there are many many options and they're really easily available in most stores in terms of the beverage side you're looking at almond milk cashew milk milk pea plant protein milk almond oat milk i have you do want to choose the unsweetened variety because many of these can have added sugars which obviously we are trying to avoid because increased sugar will lead to the increased inflammation um you know we grew up and i think we always sort of you know you have to have milk you know two three times a day to get your calcium keep your bones strong but what you learned is that almond milk has twice the amount of calcium so you have two glasses of that a day and uh you've pretty much almost met your calcium requirements um they're great for cereal coffee smoothies it's a great option if you're having a morning smoothie and cooking as well it can be substituted in uh for like any type of heavy cream i also tell you that you can take this a step further um the yogurt varieties in there too there are so so many um when you when you head to the yogurt area they have uh you know the almond version the coconut burger and the pea plant version as well and even a little further is you know most people have a hard time letting go with cheese you know but we know specifically with the with the sodium in it and the saturated fat content of it um they do now have dairy-free cheeses out there and there are quite a few different companies that will make them as well fresh fruits and we're talking about carbohydrates and complex carbs we need fruit in our diet um we do metabolize it fairly well uh because of the fiber content in it you want fresh fruit or frozen fruit not candor juiced when we're looking at what fruits to kind of choose you might have heard of the lower glycemic index especially if you're diabetic or pre-diabetic lower glycemic index speaks to the how quickly the fruit or the food will break down in our system so the higher the glycemic index the quicker uh the food breaks sound which can result in that spiking glucose which we're trying to avoid so we do tend to encourage lower glycemic index fruits some examples would be apples strawberries blueberries um raspberries cherries but regardless of the glycemic index i think most importantly with fruits is that you have to really take care of the portion size for example bananas are kind of dense so it's about a half a half a banana or about a four inch portion berries you can get a little more volume with they're about a cup uh edible fruits you know if you're looking at apples or oranges nectarines or pears you want to compare to the size of about a tennis ball so not a softball but about a tennis ball so um all fruits are good for you but you do really want to pay attention to the portion size you also want to enjoy the protein you know enjoy your fruit with a protein for the best metabolic effect in our system so in other words have that apple maybe with that tablespoon of nut butter we'll metabolize that even a little bit more slowly again preventing that spike in blood sugar that we're trying to avoid vegetables the anti-inflammatory diet focuses centers around our vegetable intake you've probably heard the expression follow the rainbow and that really speaks to the fact that you need a variety of colored vegetables to really meet all of your knees every color is going to give you a different you know phytonutrient phytochemical that can be helpful in your system for example the greens like the swiss chard the kale the spinach the dandelion greens they're going to be a really good source of you know calcium iron b complex folate uh your your oranges and your yellows you know those are going to be your beta carotenes that's your you know your your peppers and your and your carrots um your purples and your blues are very important as well so you're looking at blueberries beets pomegranates um those are those are going to be very good sources of polyphenols which have shown to have significant anti-inflammatory assistance in our in our bodies so what you're looking for is the number five you want five cups total of fruits and vegetables a day and that's pretty much about a cup cup and a half of those fresh fruits and about three and a half to four cups of fresh vegetables a day and to do that you almost you really can't just think about it at dinner you have to kind of wake up and start thinking about it at that first first meal of the day at breakfast so if you're having maybe an egg or egg white scramble you really want to throw some tomatoes in it peppers in it some veggies from the night before is fine if you're having that smoothie throw a cup of organic spinach in there you'll know you'll get a serving there as well maybe then you head into lunch so you have that nice hearty salad and now even snacks so if you're having that hummus you want to do it maybe with some cut up fresh vegetables as well so you really have to kind of think about it throughout the day and then dinner time half your your plate should be either fresh or frozen vegetables um you do want to choose non-starchy ones that's asparagus broccoli cauliflower spinach you know your your greens i will talk to you a second about about salads i think we kind of get very used to the salads that we just kind of used to have in like maybe romaine but really slow down when you're in the produce section because they have some wonderful super green bags out there well that will combine kale um brussels sprouts in there you know dandelion greens really that combination of vegetables that can give you a lot more nutrition than just the romaine that maybe we're used to having now if you're looking to reduce your caloric intake and lose some weight the rice cauliflower and rice broccoli as well as zucchini spirals are a fabulous opportunity to do it they have such a high water content that they will really pull in any sauce or spices that maybe you're cooking around that um so i highly encourage you to to give that a try as well same and then lastly we're talking about fats healthy fats are very important part of your diet they're good for brain health they help us absorb our fat soluble vitamins the ade and the k's they help us feel full but the type of fat really really matters um you really want to increase your monounsaturated fatty acids that's your you know your your olives your avocado your avocado oils polyunsaturated fatty acids right that's your omega-3s that's your chia seeds your flax seizure hemp seizure your walnuts a great oil to use you know in terms of even salads if you're trying to really increase your omega-3 fatty acids would be to use either flax or walnut oil as well you can cook with avocado oil so i think you know using the right amount of fats in your diet is very important in addition to fatty fish if you choose to have fish in your diet wild alaskan salmon albacore tuna mackerel are all good sources and you'd want to do that about twice a week but be careful because serving size matters for this too about a about a teaspoon of oil is equivalent to 45 calories so that can add up pretty quickly and then lastly some helpful resources so eatright.www.eatright.org is the american dietetic association um this is you can go to for a whole bunch of great nutrition information and specifically you can search out um a dietitian in your area i highly recommend if you're looking to make these dietary changes that you sit with a health professional a registered dietitian he or she then can actually go through your past medical history any medications you're on take a look at your lab values maybe any hurdles that you've had in the past um and together make an individualized plan that will work for you cookie and cake.com is a great website i sent all my patients to um kate is the chef and cookie's her dog that's where the name comes from and she has a wonderful uh they're all anti-inflammatory vegetarian-based recipes out there and she updates them every other day so they're it's really a great it's where i get most of my recipes truthfully and then two really good books the skinny liver book i find is very good it's user friendly it builds upon what you know we're speaking about today not even just the nutrition side of it how to reduce you know on everyday toxins in your system to lower your inflammation it talks about exercise which is very very important you're looking for at least 45 minutes five times a week of some type of good aerobic exercise but she also does speak about the benefits of de-stressing in terms of even like yoga so i think it's a fantastic book that was really user friendly and then eating clean so eating clean is a little step further that is a vegan book anti-inflammatory vegan book but for example if you wanted to maybe learn how to make some of those dairy free beverages at home in your own kitchen or dairy free cheeses you can do that in your own kitchen which will be always the least processed way to do it so those are just some for helpful resources to help you further what we've talked about today thank you thank you jill for that wonderful overview and for those very specific nutrition guidelines it's always inspiring to hear you talk about food and how easy it is and i i think everybody out there would agree with me that it is always a challenge so those resources are great thank you it's now my pleasure to welcome dr russell langlin dr lang in his chief surgical is chief of surgical oncology and hepatopancreobiliary surgery at st barnabas medical center and is a surgical oncologist at rutgers cancer institute of new jersey please go ahead dr langan hello good evening thank you so much for taking some time uh to learn more about liver disease and now we're going to move into uh treatments for liver cancers i do leave the surgical program on this particular campus we do have a affiliation with the rutgers cancer institute in new jersey and i hold a professorship through rutgers i do have two disclosures i sit on advisory boards for medical technology companies so the first thing i wanted to uh really address is the fact that here on this campus at st barnabas medical center we truly have a comprehensive liver center and that means that we have surgeons one that can complete complex liver surgeries and at times use minimally invasive techniques like laparoscopic surgery or robotic surgery we have an intimate relationship with their liver transplant team that's based out of university hospital those surgeons are on this campus often as well we have hepatologists and interventional gastroenterologists that focus on liver patients interventional radiologists to do complex liver procedures and patients that do not move towards liver transplant or liver surgery radiation oncologists that can now use cyberknife focused into the liver medical oncologists that have based their careers around treating gastrointestinal and liver malignancies and of course nutritional and psychosocial support services we are a comprehensive liver center and our group really is the highest volume liver surgery group for the state of new jersey our surgical team here on this particular campus on the livingston campus is myself and dr jason maggie we are both surgical oncologists we are fellowship-trained and board-certified in surgical oncology and have practices that focus on liver as well as some other gastrointestinal cancers and then there are three liver transplant surgeons that spend time on this campus dr james guerrera dr flavio paterno and dr will boyne based out of the liver transplant center at uh university hospital so treatments for liver cancer um you heard earlier in this session about preventative measures for liver cancer and nutritional method measures to protect your liver but what if a patient does develop a liver cancer well the way we look at liver cancer when i say liver cancer i mean a cancer that actually started within a liver cell not a cancer that started in another part of the body and spread to the liver i will address that later in this talk but what if you had a cancer that started in the liver we call that hepatocellular cancer or liver cancer well first and foremost we assess whether a patient is a candidate for transplantation so just because you're seeing myself or one of my partners here on this campus we will ensure that if a patient meets transplant criteria we set them up for formal transplant evaluation we have a direct relationship with the transplant team and we consider ourselves to be one liver surgery team for the state and for the healthcare network if a patient is not a liver transplant candidate or whether or if they're not interested in undergoing liver transplantation we then offer surgical resection meaning to bring the patient to the operating room and remove that liver tumor if we're not going to operate if the disease is too extensive uh or surgery just is is not safe for that particular patient the next thing that we can offer here on this campus uh is embolization and that is done through our interventional radiologists they are part of our comprehensive liver center they can do chemo embolization where small catheters are placed through an artery in the groin up into the liver into the tumor and the deliver beads that have chemotherapy then directly to the tumor we can do radiation embolization which is a more modern form of using beads that have radiation in them into the tumor and then we could also just stop blood supply into liver tumors which we call bland embolization we can also do ablation that would mean putting a needle into a liver tumor and heating it to kill that tumor nowadays we use a microwave machine for that or cryo-ablation at times either done in the operating room or performed by our interventional radiologists as i mentioned earlier we can use cyberknife therapy delivered by our radiation oncologists into the liver to focus radiation in a modern way to treat a liver cancer and then of course we have uh expert medical oncologists to deliver medical therapeutics for liver cancer believe it or not we do not use chemotherapy for liver cancer there are newer agents there are immunotherapy agents or drugs which we call tyrosine kinase inhibitors that stop the pathway of a liver tumor and we are one team and address each patient in a multi-disciplinary fashion to go through each of these options and find the option that is best for that particular patient we also have access to novel clinical trials this is one particular trial that is currently open it's based out of the rutgers cancer institute of new jersey accruing on both the new brunswick as well as this campus and it's called the emerald 2 trial it is a clinical trial for patients that have a liver cancer that either had that liver cancer removed or burned and then giving them new novel modern drugs to prevent recurrence currently within the guidelines there are no approved therapies to treat patients to try and prevent recurrence of liver cancer it is something that is just absolutely needed we use it in other areas of the body and this clinical trial offers patients a very novel and exciting way to prevent recurrence of liver cancer after it has been treated i'm going to briefly now just move into a different disease site colorectal cancer and the reason i'm doing that is within the united states you can see from this particular table which is a new table colon and rectal cancers represent a significant portion of new cancer diagnoses and a significant portion of cancer deaths in the u.s the national cancer institute estimates that 150 000 new colorectal cancer cases will be found here in the united states in 2020 20 of those cases will have disease that has already spread at the time they are found and half of all patients 50 percent of patients um will have the liver involved from from colon cancer and the question we ask as oncologists is can we cure these patients and interestingly um for for colon cancer that has spread to the liver there is a chance for cure it's absolutely amazing and it's exciting and you can cure a patient with stage four metastatic colon cancer with liver metastasis to briefly overview how we would look at a patient with metastatic colon cancer within the liver we again use multidisciplinary teen-based tumor board conferences and assess that patient as an individual and look to see whether it can be surgically removed i'm also going to touch on a therapy called hepatic arterial infusion pump therapy that is the therapy that was popularized by memorial zone kettering cancer center my former institution and um saint barnabas medical center and robert wood johnson university hospital in coordination with the rutgers cancer institute of new jersey we will be the two only centers uh in the state of new jersey to offer this particular therapy this coming year um we can burn tumors uh in the liver uh when there are colon origin and of course we can use chemotherapy and at times radiation embolization all of those offered here on our campus um i just have to show this every time i give a liver talk it's just fascinating this is a picture of uh prometheus from um from greek god times and this is a picture of prometheus who is being punished by zeus in the form of an eagle that would come down daily and eat his liver and his liver would regenerate and this is amazing that thousands of years ago the theory of liver regeneration um was around and that's very important for liver surgeons because for us to perform large complex liver surgeries we have to have the liver grow after surgery this is a picture you'll see on the screen of a pre-operative segment of liver that was planned to be left behind and then six weeks after surgery it grew into this large healthy piece of liver surgical resection removing tumors from the liver is the recommended choice by the national comprehensive cancer network for patients with colon cancer that spread into the liver so why is that statement made well this is a publication by a former mentor of mine from sloan kettering cancer center that found that patients can be cured cure is something that you can strive for in this patient population that in patients that had colon cancer spread into their liver and they were stage four patients if we were able to remove those tumors 55 percent of those patients were alive at five years and 25 were cured they were alive at 10 years and they had no recurrence after that traditionally uh resection criteria were limited um to only a few tumors small tumors only had to get a big margin with no disease outside the liver but data uh and and medical technology and publications that that has shown all those things should not be true the way we approach the liver now really is different than dogma and historical controls so the way we approach the liver now is to assess whether we can leave a healthy segment of liver can we clear the tumor from the liver and can we leave a large enough uh you know segment of the liver for that patient to have a healthy life um at times patients have too much tumor in the liver to take them immediately to the operating room so we use novel strategies of giving them chemotherapy first or giving them chemotherapy through a hepatic arterial infusion pump this is an example of a patient that had very large tumors within the liver that you can see here that are in the dark gray the normal livers and the lighter gray and after significant chemotherapy on the lower portion of the screen you can see those tumors drastically came down in size and those were removed this is an image of the hepatic arterial infusion pump therapy again this institution and our sister institution in new brunswick will be placing these in in the coming year this is an image of the liver with tumors within it this is the artery that supplies blood into the liver and there is a sister artery that lives off of this we're able to place a catheter into that smaller artery that then can deliver chemotherapy um directly into the liver and directly to liver tumors liver tumors are supplied solely by the artery the pump itself is about the size of a hockey puck and is placed in the abdominal wall the catheter then moves into the abdominal cavity into the hepatic artery and will deliver chemotherapy directly in to the liver and those tumors this is a seminal publication by dr kemeny from sloan kettering that showed okay this is called a waterfall plot i know i'm getting a little technical but i'm going to do this for a minute in this waterfall plot that patients that were treated with hepatic arterial infusion pump therapy this represents a complete response their tumor being completely gone okay and you can see through this a just a dramatic tumor effect uh when when hepatic arterial infusion pump therapy is given to a patient with metastatic colorectal cancer to the liver um this is an example of a former patient of mind where we did this and they had large volume tumor within the liver they were given hepatic arterial infusion pump therapy and came down to have almost no tumor in the liver this is something that truly does work here's another example of what i call multidisciplinary care putting a team together in combination with chemotherapy hepatic arterial infusion pump therapy we can take large tumor burden like these large gray areas here and treat them and these livers can have dramatic responses and then we can remove the residual tumor and cure those patients of their disease so colon cancer remains prevalent with the united states metastatic colon cancer stage four colon cancer to the liver um remains a rate limiting step to patient survival we have to be aggressive with it and we need to be modern with it we can cure it and we are working on improving those cure rates with newer therapies such as immunotherapies we offer all modern therapies here on this particular campus and within our healthcare network and we actually had an immunotherapy clinical trial open that i was the principal investigator on that recently just closed due to the sponsor so we are looking into modern uh ways to to treat liver disease this is the team we have teams based here the rutgers cancer institute of new jersey and then university hospital is our liver transplant center and there's my information thank you thank you so much dr langan for that wonderful presentation and such comprehensive overview of all the services that we can provide here at st barnabas for the treatment of liver cancer i'm looking now at the chatroom and we have a few questions one question that came in and i think we'll ask dr wong and then maybe you dr langen if you have anything what does liver cancer screening consist of and i know we touched on it briefly but maybe if we could revisit that angela that's a great question um so i think of it a little bit like um mammograms where we recommend people get yearly mammograms after a certain age you may not feel anything you don't have symptoms your lab results may be fine you know if you have a liver condition but we recommend liver cancer surveillance for people who are considered high risk and i talked about the imaging but there's also a test called alpha feta protein which is not perfect but it's some indicator that we have and so it's a combination of getting the afp plus your liver imaging modality every six months we generally do ultrasound but in certain conditions if you already have fatty liver sometimes it's difficult to see new changes or nodules and so we may recommend a ct or mri every other year or um instead of the ultrasound uh and so those are so then this is something you would work with your doctor to to decide on the best um the best modality how about you dr lange did you want to add anything yes i'll just um uh take a little bit of a different spin on it so um if you've had um a cancer and and there are certain cancers that require surveillance and there are surveillance guidelines given to us by um national uh comprehensive guidelines uh your liver needs to be watched and typically we do that with imaging cat scans mri at times pet scan um in particular of course colon cancer is one there are other cancers of course that require surveillance i just use as an example um but yes if you have risk factors as dr wang mentioned those livers should be surveyed patients should you know seek to be part of our surveillance uh you know program and certainly if you have a cancer they need to be followed per guidelines thank you and i have a question for you jill yes if you don't like many veggies will supplements be sufficient um no i really feel like you got to get out there and try them i just gave you a whole bunch uh you're not going to get get all the same benefits from a pill form as you will from the fiber and the phytonutrients there's a synergy that those fresh fruits and vegetables will give you when you're you're consuming them fresh to be honest with you and you have to be careful with some of the pill forms because you don't really know all the time what's in them so they can interact with any type of medication or treatment that you might be on thank you thank you so unfortunately we are coming to the end of the hour i did want to thank our speakers again dr su wong jill creamer and dr russ langen for their well thought and informative presentations if you have questions or concerns related to the information that was presented tonight we encourage you to reach out to the liver center by calling 973-322-6777 and we thank you for participating tonight and have a wonderful evening
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Very informative video, thank you for the education on the liver.