Peter Attia, MD: How to Detect Cancer Early – Before it Spreads

Peter Attia, MD: How to Detect Cancer Early – Before it Spreads



Cancer is the 2nd leading cause of death in the U.S. and Dr. Peter Attia joins MedCram to explain optimizing cancer screening using various techniques: timing, imaging (full body MRI, etc.), liquid biopsies, and more.
Peter Attia, MD is the founder of Early Medical, a medical practice that applies the principles of “Medicine 3.0” (discussed in this interview) to patients with the goal of lengthening their lifespan and simultaneously improving their healthspan. Dr. Attia is the host of the popular medical podcast called The Drive, and the author of the #1 New York Times Bestseller, Outlive: The Science and Art of Longevity.

Dr. Peter Attia received his medical degree from Stanford, trained for five years at the Johns Hopkins Hospital in general surgery, and spent two years at the National Institutes of Health as a surgical oncology fellow at the National Cancer Institute.

Interviewer: Kyle Allred, Physician Assistant, Producer, and Co-Founder of MedCram.com

Topics covered in this video: How to Detect Cancer Early – Before it Spreads:

00:00:00 – Intro to Peter Attia, MD, and Outlive
00:00:45 – Summary of most common causes of mortality
00:01:29 – The 4 key chronic diseases: Cardiovascular, Cancer, Neurodegenerative, and Metabolic
00:02:07 – “Healthspan” vs Lifespan
00:03:41 – Medicine 2.0 vs Medicine 3.0
00:04:46 – Life expectancy changes over time
00:06:50 – Countries that focus more on prevention? Single-payer insurance?
00:09:48 – Kyle Allred shares his cancer diagnosis
00:10:31 – Dr. Attia's approach to cancer with his patients
00:11:43 – What is driving cancer: current understanding
00:12:27 – Somatic mutations and “bad luck”
00:13:19 – Very early and aggressive cancer screening rationale
00:16:15 – Metastatic cancer treatment remains largely unsuccessful
00:17:10 – Checkpoint inhibitors and other immunotherapy
00:19:03 – Inside the body vs outside the body cancers
00:21:03 – The power of direct visualization of colon and polyps
00:22:04 – Colon cancer screening specifics: age, frequency, etc.?
00:23:25 – Bowel prep for colon importance and tips
00:24:31 – Colonoscopy risks and upper endoscopy (Barrett's esophagus)
00:26:16 – Pills for colon bowel prep (Sutab) vs liquid prep
00:27:09 – Tips when choosing a GI specialist for a colonoscopy
00:28:08 – Blood tests for colon cancer screening (FOBT and Cologuard)
00:29:12 – How quickly can colon cancer develop?
00:30:26 – Breast cancer: Peter Attia's approach (age, modalities, etc.).
00:32:15 – “Stacking” screening modalities for breast cancer
00:32:36 – Mammography strengths and weaknesses (dense breast tissue)
00:33:13 – MRI and ultrasound for breast screening pros/cons.
00:34:16 – Stagger cancer screening modalities?
00:34:58 – Level 1 medical evidence and costs
00:35:53 – Genetic testing for breast cancer vs family history?
00:37:53 – Liquid biopsy for cancer detection
00:42:10 – The future of liquid biopsies for cancer screening
00:45:10 – Metal detector analogy for sensitivity vs specificity
00:48:25 – Prostate cancer: Dr. Attia's approach to PSA, imaging, and 4K tests
00:52:54 – Multiparametric MRI for prostate screening
00:56:59 – Empowering ourselves as patients with knowledge
00:57:41 – Incidence of prostate cancer. 80% in men of age 80?
00:58:40 – Lung Cancer increasing in never smokers
01:00:46 – Full body MRI screening for cancer?
01:07:45 – Aneurysm on MRI
01:08:59 – Exercise and cancer prevention?
01:11:05 – Possible impact of stress, immunity decline, etc.
01:12:32 – Other cancer screening: cystoscopy, lung, and more.
01:13:33 – Genetic testing recommended?
01:14:20 – Final thoughts on EARLY cancer screening and the future
01:15:50 – Where to find more of Peter Attia, MD

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FOLLOW DR. PETER ATTIA:

Websites: https://peterattiamd.com/ AND https://www.earlymedical.com/
Podcast “The Drive”: https://open.spotify.com/show/63AWQmsSnFNFHUqnRAOFtD?si=de25c7712d07424c
YouTube: https://www.youtube.com/@PeterAttiaMD

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Interview Produced and Edited by Kyle Allred with Daphne Sprinkle

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#cancer #earlydetection #medcram

I'm excited to be here with Dr Peter attia who is perhaps the leading expert on communicating what things were most likely to die from how can we prevent them and how can we use data-driven approaches to optimize our health now and for as many years as possible Dr Tia's medical degree is from Stanford he trained at Johns Hopkins general surgery and he also trained as a Surgical Oncology fellow at the National Cancer Institute he's the founder of a website called early medical the host of a popular podcast called the drive and the author of outlive a fantastic book just published we'll discuss several topics from it Dr Tia welcome yeah thank you so much for having me well we'll get to strategies and specific tools for optimizing our health and avoiding cancer and disease in a minute but first for someone watching this what are they most likely to die from and why is that so important to know well given that we're watching this in 2023 and not uh you know 1823 um it looks a lot different than it did historically at least for most of our evolutionary past uh today we're most likely to die from things that I call slow deaths uh whereas for virtually all of our existence we were more likely to die from Fast deaths fast deaths think of things like infections and Trauma uh but today we're going to die from chronic disease most likely and those chronic diseases uh in rank order approximate cardiovascular and cerebrovascular disease cancer and neurodegenerative disease we also have a whole host of metabolic diseases that while they don't directly result in loss of life at as high a frequency contribute overwhelmingly to the suite of chronic diseases I mentioned above so things like type 2 diabetes non-alcoholic fatty liver disease insulin resistance they don't show up directly on death certificates that often but their contribution to those other three is enormous so collectively I call those The Four Horsemen of death and in your book you talk a lot about the difference between lifespan and health span can you review what that difference is sure lifespan is I guess the easier of the two to understand because it's quite binary you know you're either alive or you're dead and you know you're breathing or you're not um and so uh lifespan is is is is essentially the length of your life and a part of longevity is asking the question can we extend that period of time um but an often overlooked component of longevity it's Health span and health span is quality of life and that's much harder to Define because it's you know medical definition is relatively useless the medical definition of Health span is the period of time for which we are free from disability and disease but you know I think most people would agree that even as you age even if you do so without disability or disease your physical and cognitive performance for example deteriorate also your emotional health which doesn't really fit into a disability and disease standpoint unless of course we're talking about it rising to the level of true mental health will clearly contribute to your quality of life as well so quality of life at least around these three areas of physical cognitive and emotional health contribute at least as much and probably more to the overall concept of longevity another concept that you mention a lot in your book is this difference between medicine 2.0 as you call it kind of the status quo what we have right now versus medicine 3.0 something that you talk about with your patients and practice yourself um yeah could you give us kind of an overview of the difference between these two sure medicine 2.0 is the system of medicine that we evolved to obviously for medicine 1.0 in the latter part or middle part of the 17th century with the kind of elucidation of the scientific method all the way into the latter part of the 19th century with the development of the light microscope and ultimately into the early 20th century with the development of antibiotics antimicrobial agents and of course vaccines and what medicine 2.0 then did was allow us to basically dramatically cull fast death so we took fast death which again for all of our existence for you know millions of years was effectively what was going to end our lives and that meant we were going to die somewhere in our 30s to 40s typically if we didn't if we managed to survive childhood and infant mortality was through the roof so mothers are you know based dying at an alarming rate every time they're they're giving birth to a child it basically allowed us to escape that and get to the point where we are now primarily dying of these chronic diseases that we talked about a minute ago so medicine 2.0 says look we're going to still use the same Playbook to go after those diseases different side of diseases so it's you know we've hit it out at the park with infectious diseases communicable diseases and Trauma so now let's ask the question what if we take the same Playbook and apply it to chronic diseases The Playbook being you come up with a diagnosis you treat pharmacologically surgically or however once that disease is present and I don't need to State the obvious here but that approach has been largely unsuccessful against chronic diseases chronic diseases are not as amenable to that strategy and when you apply the tactics and strategy from Med 2.0 to the current Suite of problems we have we have not been very successful and that's it's it's so Stark that if you take a look at the life expectancy of people 120 years ago and you strip out the top eight infectious and communicable diseases you realize it's almost the same as it is today so yes it's true we have doubled life expectancy but that has come almost exclusively through the lens of those early successes of medicine 2.0 so the question then is what is medicine 3.0 and why would it be different and it basically comes down to a fundamental philosophical shift around the acceptance of prevention and very very early prevention many people watching this are going to be watching from the United States and they're familiar with this medicine 2.0 Paradigm where we like you said we wait till disease happens and then we we try to treat it are there any countries or places that have this better than we do and are are more on the path towards medicine 3.0 that you're aware of yes although only only sort of slightly right so there are definitely countries in in Europe that have a bit more of a preventive strategy it's largely a result of their Health Care system so the U.S Healthcare System is not really well geared up um for medicine 3.0 in fact the the the the transition to Medicine 3.0 will be harder in the U.S than in many other countries and one of the reasons for that is just a structural reason that has to do with the financial incentives and remuneration for how health care is compensated so in a system like ours where the majority of care especially early in life is private not public not single-payer the financial incentive is really geared towards you know getting paid to treat disease now I'm not advocating for a Single Payer system because I could argue with equal veracity why a single-payer system is usually quite unsuccessful as well so it really probably needs to be a hybrid but here is where the single-payer system does get a nod which is it is easier to tweak the incentives towards prevention because you don't have the financial incentive to provide delayed treatment in other words in a single-payer system the payer which is the government owns the risk of disease for the duration of your life conversely in a system like ours Health Care is very portable so who's your insurance carrier right now Moda which is just a local one in here in Oregon okay so I you know can't speak to them specifically but let's just assume you know they might only own a life meaning own the risk of that person's life for you know five or six years so are they really interested in putting the time effort and resources into prevention when you're in your 20s and 30s if those things are only going to reap rewards when you're in your 50s 60s 70s or 80s it's very unlikely um again this is one of many of the structural challenges with transitioning from medicine 2.0 to 3.0 but to your question countries that have a single-payer system have a much easier time making that transition because if you're in Canada or the UK or Australia or many of the European countries um you know the government is effectively backstopping your health care well I want to get into uh one of the horsemen that you mentioned uh cancer and this is a topic of particular interest to me because I was diagnosed with a type of cancer called Hodgkin lymphoma about six months ago fortunately it has a very high survival rate and a complete remission rate in someone my age so it's likely that the chemotherapy that I'll be finishing up soon will be the the only treatment I need for this but my personal interest in screening for cancers is higher than it was before because I've been reminded firsthand that cancer does you know can and does happen in 40 year olds like me without other medical problems or a strong family history of cancer so let's hear about your approach to cancer again within this kind of medicine 2.0 what we have now and what you would like to see and what you recommend with your patients regarding cancer well each of the horsemen has a slightly different Playbook to go down the medicine 3.0 route and truthfully when it comes to cardiovascular disease it's the easiest of the lot because we have both the greatest understanding of what causes it and the greatest set of tools to prevent it so in other words if we really know what's driving it you know we could we could go down that rabbit hole in detail and we happen to have all the tools in the world pharmacologically and non-pharmacologically to lay down the prevention Gauntlet decades in advance with let's take Alzheimer's disease we actually have quite a strong sense of what the drivers are some of them are not modifiable they are genetic but many of them are highly modifiable and we have some sense of what tools to use therefore to prevent it unfortunately we have very few tools to treat it once it's present so cancer occupies kind of a unique place in that landscape in that we frankly have hands down the least understanding of what is driving it we know a few things right we know that smoking dramatically increases the risk of cancer but I'm willing to guess you were not a smoker correct we know that the second leading environmental or modifiable risk factor for cancer is obesity which really isn't about obesity it's probably much more about the internal environment that tracks with obesity namely hyperinsulinemia and inflammation and again I'm guessing that that was not necessarily risk factors for you as well so what that leaves us with is at the end of the day cancer is very much about bad luck in other words cancer is a condition where the majority meaning 95 percent arise from what are called somatic mutations so these are not mutations in genes that you acquired from your parents these are genes that you inherited that were completely normal but over the course of your life and again in your life being so short to date that you've already had this bad luck of acquiring enough mutations to drive a cancer and the reality of it is if we were sitting here five years ago having this discussion before you had cancer I I could have told you everything under the sun to do to minimize that risk and maybe it would have but ultimately you could have still come down with cancer so why am I saying all of this well I'm saying all of this because what it does is it calls to our attention another tool that is essential in our fight if you will against cancer and that is the tool of very early and aggressive cancer screening now that's a highly controversial topic and we can I'm happy to talk about all the controversies but the rationale is is unambiguously straightforward uh based on the following there is no example that I am aware of of a cancer where the odds of eliminating it go down as the tumor burden goes up meaning the fewer cancer cells a person has in their body the more effective the treatment and I think the simplest explanation for this is that the more cancer cells you have the more heterogeneous the population of cancer cells and the more heterogeneous the mutation burden and as that burden of mutation Rises you have greater and greater chances for escape meaning you provide a systemic treatment like chemotherapy and you have a greater and greater likelihood that some cancer cells will actually be able to evade the therapy and go on to develop a new population of cancer cells that will be resistant to treatment and so you know the the easiest way to look at this is just to look at colon cancer or breast cancer for which we have so much data and I write about both of these in the book where if you take a patient with stage three colon cancer for whom you resect the colon and you resect the lymph nodes around but there is no gross or visible spread of the disease say to the liver or other organs and you give that patient a chemotherapy regimen their survival in five years is very high you know 60 70 percent if you take a group of patients with metastatic colon cancer so the exact same patient but now the cancer is also in the liver so you can actually see it and you give them the exact same chemotherapy none of them will be alive in five years again similar examples with with breast cancer and other forms of cancer so regardless of how much we do individually to reduce our risk of cancer and we can talk about all of those things the importance of exercise nutrition sleep probably and clearly mitigating factors like insulin resistance and smoking at the end of the day we are still every one of us susceptible and therefore I think it's imperative that we at least consider what very early screening does to give us a chance to if we do have cancer fight it with the smallest burden possible and another thing that you mentioned in your book that convinced me on the importance of early and aggressive screening is you point out that treatments over the last 50 years for cancer haven't really come come along that far there's been certain uh kind of exceptional cases lymphoma leukemia for example but for the most part our overall survival rate from cancers is not much better than it was several decades ago is that right for metastatic solid organ cancers so that does not include leukemias and lymphomas especially Hodgkin's lymphoma where we've had the field has had remarkable success when you talk about uh epithelial tumors solid organ tumors it's been an improvement in overall survival of five percent uh in 50 years um now we're starting to see those numbers get better and better with immunotherapy and specifically a type of immunotherapy called checkpoint Inhibitors so I think we're probably getting to the point now where maybe that number is getting closer to a 10 percent improvement over where we were because approximately eight percent of all tumors today are now responsive to immunotherapy and immunotherapy has the advantage of when it works it is usually a very durable remission meaning that remission tends to stay it is effectively a cure so of all the things that I think have come along in the past 20 years I think immunotherapy is by far the most interesting part of cancer treatment um I was very fortunate in that just by luck that's what I did my research in so back as a medical student you know when I went over to the NCI the National Cancer Institute I spent time working there and then I went back again for a fellowship more formally uh when when I was in residency and the great pleasure of spending two years you know working in the lab and doing that type of work at the time it was pretty much exclusively a treatment for melanoma and a little bit of a kidney cancer called renal cell carcinoma but we were just starting to see the power of checkpoint Inhibitors which we used at the time in melanoma um and today we realized that these checkpoint Inhibitors can work on any tumor provided they have a certain type of mutation now the goal is what does it take to create and unleash the immune system on any type of cancer how do you do this when we know by the way that 80 percent of solid organ cancers have cancer antigens that are recognized by the immune system I want to talk about um each specific type of cancer screening that that we have available that you recommend and I think it's it's helpful the way that you organize kind of the the two big buckets of cancer screening into cancers that happen inside the body and Cancers that happen outside the body can you kind of go over that distinction yeah it is kind of funny because most people don't think of their colon or their stomach is outside their body and I understand why of course but you have to think about it through the lens of embryology right you sort of develop in these multiple layers three layers to be specific but the easiest way to think about it is can the air that you breathe or that's outside your body can it get to the tumor can it touch the tumor directly so for example when you consider all of the skin cancers the answer is yes right your every everything on the outside of your body via vis-v your skin is exposed to the outside world but what's a little more uh less intuitive is that everything from your mouth to your anus is also technically outside your body now the significance of this is primarily that you can look directly at it right it's that you can take a direct look at these cancers and where it gets particularly noteworthy at least in the United States is that colon cancer is the third leading cause of cancer death so you have the number one being uh lung cancer number two is kind of split between genders so if you're a man it's prostate cancer if you're a woman it's breast cancer and then number three straight across the board is colon cancer and interestingly colon cancer unlike the others that I mentioned lung which by the way lung doesn't occur in the air sac so what I said about being able to look at it directly doesn't really apply to lung um but what's amazing is that you can look directly at the colon as it transitions from being perfectly normal to developing something called a polyp and that transition is a necessary first step towards the development of colon cancer now most polyps do not become colon cancer but every colon cancer comes from a polyp this is a very important step means the development of a polyp is a necessary but not sufficient step for the development of cancer and we have a tool that allows us to look directly at the colon and identify any and all polyps and remove them and if you think about that the implication is really nobody should die of colon cancer if we accept screening at a high enough rate it should certainly be far less than it is today it shouldn't be the third leading cause of cancer death it shouldn't kill 50 000 people a year so on the topic of colon cancer what age if someone were to visit you as a patient what age do you recommend their first colonoscopy and that's assuming they're willing to you know pay out of pocket if needed for it so it depends on number of things it certainly depends on family history and other personal risk factors such as you know Crohn's disease ulcerative colitis and things of that nature but if we talk about a person who has no other risk factors and no family history we still take a very aggressive posture and typically begin screening at 40. which is five years ahead of the current recommendation and 10 years ahead of the last recommendation up until very recently the recommendation for first colonoscopy was 50 that has been reduced to 45 which I think is a very uh good first step when you consider how many people under the age of 50 were dying from colon cancer and then the frequency I imagine also depends on what's of course found in the colonoscopy yes although again here's where we are much more aggressive we typically recommend screening at no longer than every three years but also depending on what's found so if you find a certain type of polyp that is indeed pre-cancerous we would screen much more frequently it also depends on the adequacy with which the endoscopist was able to visualize the colon so when you do a colonoscopy as anybody listening to this will recall you go through something called a bowel prep now fortunately you know I'm 50 so I've already had three of these things just in the last 10 years the the bowel preps have become much much easier in fact the last one I did a year ago was at walk in the park relative to the first one in terms of you know I was able to do it using a product where you only take 12 or 24 pills over the course of a day and you have a much easier bowel prep but when the endoscopist is in there he or she basically makes a designation it's a scale it's a rating system I believe it's one to nine or zero to nine I think it's called the Boston bowel prep score or something to that effect but it's basically How well was I able to visualize the colon and so we're really looking for two things right to wait three years to do it again we want no polyps and we want a perfect visualization of the colon and if those conditions aren't met then we you know decide on what the next colonoscopy should be I would note that given that the biggest risks of colonoscopy are the bowel prep itself which for people our age is not really a risk at all just an inconvenience but for older people absolutely is a risk there's a risk of electrolyte abnormals and dehydration the sedation itself is a risk again all of these risks are small but none of them are zero so you have risks that are associated with you know not breathing and things like that and then finally there's a risk of bleeding and perforation from the colonoscope given that you're having a colonoscopy you're buying all of those risks we generally recommend our patients undergo an upper endoscopy so to look at the esophagus and the stomach as well because cancer from the esophagus to the duodenum while less common than cancer of the colon is still collectively a relatively high probability cancer when taken together from mouth to duodenum and therefore given that it poses no additional risk to the patient given that they've all the risk is baked into the colonoscopy we generally recommend doing that as well and surprisingly we do at times find pre-cancerous lesions in the esophagus in people who maybe only report you know occasional heartburn for example which is a significant risk factor for something called Barrett's esophagus which is a pre-cancer of the esophagus and you recommend that upper endoscopy at every colonoscopy if one can get it it depends you know I can't it's impossible for me to take a blanket state treatment even though I'm sounding like I'm sort of doing it now every case is different um but we're basically asking that question with every colonoscopy should we do the upper endoscopy at the same time as well got it what was that product that you had such a wonderful bowel prep with because my most recent colonoscopy was uh that anything that would that you know it wasn't a great experience yeah the last one that I've done and now this is what most of our patients do it's called stew tab I think it's s-u-t-a-b and I think just basically twice the day before or like once the afternoon before and once you know a couple hours before bed you're taking like 12 tablets with a large amount of water you know probably 20 ounces of water or something like that and yes it's just a it's an infinitely more pleasant experience especially for people who don't like the taste of a lot of these things which again going back 10 years ago when you were drinking something called Go Lightly I mean that stuff was an Abomination and the volume you had to consume was unbearable I think that's what I had was the Go Lightly yeah yeah they should ban that stuff you had some specific for people that haven't had a colonoscopy before or you know are willing to change their their endoscopist um or GI specialist what what things should people be looking for in um you know someone that's going to do a perform a colonoscopy on them um I remember in the book you had some specific recommendations for things to look for yeah we have a whole bunch of recommendations in the book but I mean I think some of the big ones are I just I would always ask your endoscopist what's your perforation rate in other words it's it's nice to tell me globally what the perforation rate is but that's a very misleading number because it also involves all sorts of patients some of whom are very very sick so the real question is an outpatient elective colonoscopy what is your bleeding rate what is your perforation rate I would also ask what is your SQL intubation rate so how often are you getting into the cecum uh what is your typical endoscopy time so what is the total time of scope and I provide in the books of metrics on which you're kind of looking for what would be considered ideal for this purpose great any other thoughts on colon cancer screening before we move on to perhaps maybe breast and uh and prostate screening yeah I think the other thing I'd mention with that is that a really elegant thing to do on the off years of colonoscopy is to do a stool-based test so you can do uh like a fecal occult blood test although that's far less effective than the immunohistochemistry tests so let's just say you're getting a colonoscopy every three or four years if on the years you're not doing it you're doing a stool test that's looking for tumor DNA um you're at least looking for a signal in those off years now again that's nowhere near as effective as a colonoscopy but of course it poses no risk so it's it's in my mind kind of better than not doing anything in the off years and if the stool test is positive then you would go straight to a colonoscopy that's right okay yep because yeah you point out that despite maybe what people think colon cancer can develop in as little as six months in some patients right yeah it's a big controversial um there have been case reports of that nature of course the the alternative explanation for that is that that cancer was there six months earlier but somebody missed it so the truth of it is we actually don't know what the time is to develop a colon cancer right clearly it's a way way way less than 10 years so the idea that you would only do this every 10 years to me is absolutely insane um but you know maybe it's one year maybe it's two years maybe it's three years we just don't know uh what what it is um and when we see those case reports it's easy to be suspicious that it's not that you really developed a colon cancer in six months uh but it's possible that it was missed six months ago and either way it reinforces the need to be vigilant and for the stool test is there one in particular that you tend to recommend more than others I mean again it just comes kind of down to your budget but we probably like Colo guard the most and I can't even remember how much it costs let me put it this way they cost significantly less than getting a colonoscopy yeah let's talk about breast cancer and again maybe just start with your your approach to to breast cancer screening if if there's um you know a particular age I know every patient's different but um if there's not a strong family history of breast cancer is it a particular age that you recommend you know starting screening for breast cancer well again your breast cancer is is is pretty common a woman's lifetime risk of breast cancer at least in terms of having it not necessarily dying from it is is high enough that I think you have to approach every woman as though she's at risk and clearly family history here is a very valuable tool for at least a woman who has not been adopted right so if you have a woman who's not adopted and in whom we can look at her mom her grandmother both sides uh her aunts on both sides if we can start to get um some insights there that can really shape our thinking so if we're again let's say dealing with somebody who does not have a family history of breast cancer well I should say even more there's more detail to it that I I think is kind of maybe beyond the scope of our discussion but there's more Nuance around this right so sort of if breast cancer occurred in family members it's also important to understand if it was pre or post menopause so early life versus late life breast cancer kind of gives us a slightly different algorithm for how we screen we then look at some other very personal factors for example a woman's breast tissue how dense is it right so the denser the breast tissue the greater the likelihood that you're going to miss a breast cancer on screening I think the most important thing and I want to just be clear like you know there are people who for whom this is their specialty and I would think that they're far more knowledgeable about this than me so I'm only talking about this through the lens of how we think about it with our patients but you know I think there's there's no form of cancer screening where the idea of Stack stacking different modalities is more important than in the breast so to be clear I don't think there is any single modality that is sufficient for screening breast cancer every modality has a strength and weakness and the good news is they are opposing so for example mammography is very good at picking up calcified lesions so lesions that have you know little specks of calcium in them and certainly cancers can have little specks of calcium in in them that tends to be later in life so younger women don't necessarily get as many calcific breast cancers it also tends to struggle with dense breast tissue so you're going to get a lot of false negatives and a lot of false positives frankly in a low prevalence uh population of young women conversely if you look at something like MRI MRI has much more sensitivity to pick up breast cancer although it actually has kind of low specificity and it tends to miss all calcified lesions unless they're really really big so it has an enormous blind spot to the very thing that mammography is very good at and then ultrasound offers you know advantages and disadvantages as well so the first thing I would say is whenever you decide to start screening you have to be thinking about using at least two modalities so I think mammogram should be an automatic for every woman and then I think the question based on risk should be is ultrasound the right thing to do in concert with it or should it be MRI and even within MRI there's different ways to do it so the gold standard would be something called multi-parametric MRI where you're using contrast and something called diffusion weighted Imaging which I I think I explained in the book why that's such a special tool to enhance MRI when you stack those modalities do you typically stagger them out you know maybe get a mammography test done one year and then an MRI done the following year or do you tend to get them at the same time and do they complement each other um yeah kind of in real time yeah great question uh there's no right answer to this um it depends on the patient so for some patients we stagger everything by six months so they'll do an MRI every year and a mammogram every year but they'll be offset by six months so they're doing a form of screening every six months uh that that would be kind of a higher risk woman for other women you might do mammography every year an MRI every two years so there's an endless permutation in here and you know again we don't have level one evidence telling us what the right answer is but of course level one evidence don't really apply to this type of screening for the reasons I talk about in the book which is you know level one evidence are also going to concern themselves with cost societal cost or cost of screening um I think that's a totally valid concern but it's not one that I concern myself or my patience with which is we're asking the question that's slightly less constrained which is if you ignore cost what is the right approach to screening and there you only have to concern yourself with harm right false positives psychological harm um and you know opportunity cost but but you don't really need to think about monetary cost um which again it's important it absolutely matters at the societal level of somebody else is paying but I I think it's a personal choice for anybody who's going to pay for themselves along those lines um genetic testing for uh for genes that may increase the risk of breast cancer do you typically recommend that we do it in select patients so if the family history comes up completely Stone Cold negative we typically do not do it um if the if it comes up a little suspect we certainly do obviously one of the genes everybody's looking for is the the family of bracket genes uh usually it's pretty obvious when that's the case just from the family history but you would absolutely want to confirm that genetically um but you know the the real edge cases are the ones that are probably more interesting which is not a bracket case which is usually quite obvious but sort of a non-bracket case when there are other um less you know further from being deterministic genes and bracket by the way is not necessarily deterministic but you have genes that are just more subtle increases in Risk again there are reasons to do this both from an a financial perspective right so once you have a gene that places you at greater risk obviously more of your care is covered so that's very important it also has significance in terms of you know planning and expectations around having kids you know if a woman has one of these genes she's going to be much more on guard uh if she has a child than can can sort of think through those things and of course ultimately if the risk is significant enough a woman can elect to do something much more aggressive than screen which is to prophylactically undergo a mastectomy and just eliminate the source of the tumor but for a tumor forms and interestingly there are a number of cases where women prophylactically do get mastectomies in breasts that otherwise appear normal only to find out that they actually do have microscopic Foci of tumor at the time of mastectomy any other thoughts on breast cancer screening before we move on to prostate cancer screening I think one other thing I would just say on breast cancer is the the other tool that we do use here and it's it's a very emerging tool is that of the liquid biopsy so liquid biopsies are still in their infancy but they are already showing promise and breast cancer is an example where um if you just look at the data superficially you would probably convince yourself that they're not very helpful but if you look at the data more deeply and I cite an example of this in the book I think you start to realize that liquid biopsy becomes yet another tool that we should include in this so superficially the data for early detection of breast cancer with uh a test called The Gallery test by a company called Grail suggests that the sensitivity is very low something on the order of 20 percent for stage one and stage two breast cancer while the specificity is very high north of 99 about 99.5 so low sensitivity High specificity means if a tumor is there you might not see it um but if no tumor is there you're going to get it right that's effectively what that means well again that doesn't seem like it's very helpful if you're trying to screen for a cancer but when you look more closely at the data and you segregate out the breast cancers by type and you divide them between hormone positive and hormone negative so in breast cancer a lot of the prognosis and treatment comes down to whether the breast cancer is positive for estrogen and progesterone receptors and another receptor called her2 new so if you look at the triple positive which is all three receptors positive versus the triple negatives you have a very different story the ability of the liquid biopsy to detect the triple negative at an early tiny stage tumor is over three times higher than it is for the Triple positive the implication here is the liquid biopsy is much better at detecting more aggressive tumors and therefore it might suggest that the stage one stage two triple positive tumors aren't going to kill you if you catch them at that stage which you're going to catch with other means because they aren't spreading these tests are looking for cell free DNA whereas you are catching the more aggressive tumors because they're already spreading by the time they're stage two so that's just another wrinkle that I think has to always be considered as we kind of think about how to incorporate liquid biopsies into this and for people that are new to that term um the the gallery test that you mentioned um if someone wanted to get that test done where what's the process of actually attaining that uh it has to be ordered by a physician to my knowledge I don't believe that they do a direct consumer I could be wrong I mean I have no affiliation with this company um so in our case you know when we choose to order that we we are the ones that order that for our patients and it's a blood test so it's a you know it's a test that takes two tubes of blood and returns a result in a relatively short period of time usually within two weeks or so yeah and you mentioned that it basically gives you information about a couple different things a do you have a cancer present potentially and B where is it coming from in the body and you also mentioned maybe you could speak to this a bit that it's um and correct me if I have this this right that your opinion is it's not a great just broad screening tool for cancer it should be used uh in general for for specific purposes or to stack with other screening modalities yeah I mean I would say that we do use it as a pan cancer tool but I'm generally not going to just rely on it by itself so I'm not going to just say we'll we'll do the test and if it comes back negative we don't have to do anything else um I I just I don't have enough confidence in any test to say that including a whole body MRI um so I view everything as a stacking you know optimization problem you see the technology advancing with the with liquid biopsies to the point where you know maybe we would be able to say with more confidence I guess that what really needs to happen is the false positive rate would need to drop significantly on the test right yeah I mean I think we have to I think the problem with liquid biopsies is is it it's a very important conceptual issue we have to wrap our heads around which is what is a false negative what is a false positive like what do they actually mean because when a person gets an MRI or a mammogram or a colonoscopy uh well let's take colonoscopy out of it so colonoscopy you are looking directly at something there is no false positive right there's no false positives in colonoscopies there's false negatives if the bowel prep isn't good or the endoscopus just missed it but there's no such thing as a false positive but like if you're looking at an MRI or a mammogram a false positive means you're looking at a set of pixels that are meant to represent something that is happening in the body that is an anatomic feature right it is purely an anatomic test a liquid biopsy is not an anatomic test in some ways I don't have a good word for it but it's it's a biological test maybe right it's testing the ability of that cell to escape its primary location such that it's shedding cell free DNA that we have to wrap our heads around what that means and what the implications are for screening and I don't think we fully have yet and that's why I don't think it will ever make sense to rely on a biological or functional assay in exclusion of an anatomical assay or vice versa I think we just want to come back to all of these things all of the time because it also increases the Fidelity of the test right what we don't want to do I mean we have to accept the fact that if we're going to be aggressively screening we're going to find a lot of false positives it's impossible to have 100 sensitivity and 100 specificity it's impossible so you can plug those numbers into a spreadsheet and it will tell you that for any prevalence of cancer even a cancer that only exists in one percent of the population you'll have a hundred percent positive predictive value and a hundred percent negative predictive value meaning every time it's positive it's truly positive every time it's negative it's truly negative but nothing comes close to that right so MRI has almost a hundred percent sensitivity but its specificity is abysmal liquid biopsy is the opposite its specificity is almost a hundred percent its sensitivity is abysmal now here's the thing it is not the case that when you add two tests you add their sensitivity and specificity so it's mathematics behind that are more complicated um but clearly the more tests you add the more shots you're getting on goal to pressure test what you're seeing speaking of sensitivity and specificity I like an analogy that you've used before of a medic a metal detector with regard to these tests that they can I mean they can really be set however the the test makers want to uh to set them so could you yeah could you kind of explain that analogy and how it fits with liquid biopsies for example sure so I'm sure people have experienced this all the time right it's like you know you go to you're passing through an airport metal detector and it goes off and you think to yourself dude I'm wearing the exact same thing I was wearing three days ago when I went to the metal detector at the other airport and it didn't go off how is that the case like did I some did I somehow suddenly take on a whole bunch of metal no the sensitivity of that metal detector has just been set to be higher or lower depending on how you want to think about it so in other words it's it's going to kick off at a lower threshold okay so let's now play the thought experiment right so put yourself in the minds of TSA so you get to set the sensitivity on the uh on the device you get to say what is a positive so sensitivity is the definition of the true positive rate so if you set that thing to be very very Twitchy the likelihood that anybody will get through who actually has metal um is you can you can make that number exceedingly low but what's the problem with that the problem with that is that most of the people going through who don't have metal are still getting stopped so you know you basically create a log Jam problem where you're creating a whole bunch of distress for no reason but In fairness no bad guys are getting through conversely you can say all right fine fine fine let's set the bar really really high so anyone that we catch is a bad guy and the you know we're not going to create any distress or false positive but the problem is there's absolutely going to be some bad guys that get through so if you said it such that I'm going to catch anybody carrying an 18-inch knife or a gun that's fine but maybe somebody walking through with you know a six inch knife isn't doesn't have enough metal to trigger it so that's basically as you say kind of the decision everybody has to make as they work through how to tune a screening test are you tuning it more towards no false positives or more towards no false negatives and sometimes that's the nature of the test so for example an MRI because of the resolution that it can produce it's generally geared towards higher sensitivity it's going to over call things especially in glandular tissue like the thyroid gland and the pancreas and things like that but in a liquid biopsy it's a hundred percent at the discretion of the scientists as they tune the algorithm makes sense okay getting back to prostate cancer screening um this is one that you know most people watching this have heard the PSA test for for prostate but could you explain what PSA is and how we can do better than just look at at the PSA number alone for prostate screening so PSA stands for prostate specific antigen and it's a protein that is made or an antigen that's made by cells in the prostate and obviously it's not made by other cells that's why it's prostate specific and the value this this this is a biomarker that you can measure in the blood and this value is proportional to the size of the prostate gland but it also comes out disproportionately when a person has prostate cancer so we tend to think of the prostate in either you know milliliters or grams we can estimate the size of it pretty well on an ultrasounder on an MRI so if you took two people who had the same size prostate so let's say a 25 gram prostate which is a normal size prostate um you know you would expect them both to have a relatively low PSA you know probably at or below one let's just say it's one but if one of those people all of a sudden has a PSA of four or five even though his prostate isn't significantly larger you would certainly be worried about the risk of prostate cancer because again once those cells make the transition to becoming cancer cells they're going to secrete more and more of this prostate specific antigen and historically prostate specific antigen or PSA was a screening test that was done for men um it was always one that created a lot of consternation within the community because it was a test that when used by itself had a lot of false positives and frankly a lot of false negatives so false positives meant there were a lot of men who were you know showing up with a PSA value that was higher than you would have expected based on you know their age for example and the next step was to do a biopsy of their prostate gland to make sure they didn't have cancer and lo and behold they wouldn't have cancer and you you just subjected them to a pretty aggressive procedure uh you know a trans rectal biopsy of the prostate is not a benign procedure uh not having had one but certainly having spoken to many people who have I've never heard anybody say that was pleasant so um and not without complications by the way so so the question is how could you make the predictive value of the PSA better this by the way is another question of where do you set the bar so let's go back and think about this through the lens of your metal detector you could say we are not going to biopsy anybody below a PSA of 10. and if that's the case outside of guys with prostatitis you're only going to be biopsying people with cancer but you're going to miss a lot of people with cancer too you're not going to have false positives you're going to a lot of false negatives if you say okay we're going to biopsy everybody who's over three oh my God you're probably not going to miss many cancers but there's a lot of people getting biopsies who shouldn't get them so today what we do is we don't just look at the PSA we look at several other metrics we look at something called free PSA which is the percent of PSA that is Unbound it's not being bound to other carrier proteins and so the percent free also gives us a clue as to whether or not this is a prostate cancer or not we look at something called PSA density which is the PSA value normalized to the size of the prostate we look at something called PSA velocity which is the rate of change of PSA value over time all of these things so higher PSA velocities higher PSA densities differences in percent free PSA add color Beyond just PSA and will you know give us a much earlier indication as to whether something is significant in which case we can depending on the PSA value either move to another type of blood test called a 4K test which is kind of like another liquid biopsy for prostate but it's specific to prostate or move directly to a multi-parametric MRI which is very similar to that multi-parametric MRI I talked about for breast tissue where you're looking at these different types of pictures so different types of images of the MRI T1 T2 diffusion weighted Imaging Etc with and without contrast so where we basically are now is very few men are undergoing unnecessary biopsies in fact I don't think in the last 10 years I've had a single patient undergo a prostate biopsy that did not find cancer so the implication is by the time we're sending a patient for a biopsy today we know he has cancer it's just a question of how aggressive now some of those men come back with a cancer that is not very aggressive and the collective decision of the urologist and the patient is to wait a year in biopsy again and in one of those cases I can you know I just think about a patient very recently there was enough of a change in the histology over a year that they said enough is enough we're going to do surgery now in other cases the answer is let's wait another year and do it um and or compare it to you know other characteristics of the MRI so so the point is you know this has largely become an issue where we are less you know doing these biopsies with low probability uh you know thinking in terms of outcomes these additional PSA blood tests that can be done the PSA velocity density and free PSA um or what was it the yeah 4K yeah and then the 4K as well well so the so when you order a PSA test a lab will typically default into a free PSA they'll reflex a free PSA test if it's over three typically so I don't I forget is it three or four but usually with a high enough PSA I think over three you can automatically just get the free PSA the other ones you actually have to manually calculate the lab won't tell you the density you have to have had an ultrasound or some other Imaging of the prostate to know its size to then calculate the prostate density and similarly you have to keep track of the PSA values and plug them into they have online calculators that'll do this for you where you put in historical PSA data with time and it will tell you the PSA velocity got it so that gets that my next question is I know this is something that you do at your practice with your patients is is any are any of these additional parameters Beyond just this the simple PSA test mainstream in Family Medicine clinics across the United States for example to your knowledge or is this it's a good question I mean unfortunately we know that there are lots of people who are falling through the cracks so uh you know someone who works with me actually meaning one of my colleagues his dad was at his doctor and you know they uh he had a PSA level and it wasn't particularly alarming and his doctor wasn't concerned and the colleague of mine said well let me do a double check on that and ran it through the PSA velocity check and actually the PSA velocity was higher than 0.45 so that's generally the cutoff meaning anything that's growing more than 0.5 the the units aren't important but 0.5 you know 0.45 units per year anything that's growing at a rate beyond that is alarming and even though the absolute value of his PSA wasn't that high the velocity was and so he went back to his dad and said hey you need to go and get more testing done you probably need a biopsy or at least an MRI and his doctor said no he doesn't you know this is totally fine and so you know this colleague of mine just told his dad we're going to go around your Dock and just go and pay and get an MRI they did the MRI indeed showed that he had a cancer he got a biopsy he was cancer he's already had his prostate taken out wow um so you know his son saved his life um and it's disappointing that the doctor was completely unwilling to even acknowledge this um so you know I'm guessing if that happened once it's going to happen a few times and unfortunately I think what the lesson is there is you as the patient probably have to be the owner of this process and you really can't rely on anybody else now um I think that particular doctor had an arrogance about him that's sort of deplorable um but the reality of it is even a well-meaning doctor I think can can miss something or maybe just isn't keeping up with this literature so I think you know everybody has to kind of take ownership over this problem for themselves which is unfortunate because in an ideal world that's why you know I shouldn't have to take ownership of my car when I take it to a mechanic that's why I'm taking it to a mechanic um but unfortunately I think you know that might be the case how common is prostate cancer in men and um you know I think many watching this have heard that many people die with prostate cancer not necessarily from it so how do you explain the the overall risk of prostate cancer to your patients yeah no I think that's exactly what I say is virtually every man will die with it fortunately not too many die from it but it is still the second leading cause of cancer death in a man only behind lung cancer so you know it's not a particularly lethal cancer compared to say pancreatic cancer or you know certain types of brain cancer or lung cancer I mean those are incredibly lethal meaning once you get it you're very likely to die that's not the case with prostate cancer but because so many men get it and even though the lethality is not that high the absolute numbers are pretty devastating the thing about covid right virtually nobody who got coveted died of it but because everybody got it the total death toll actually was pretty high you mentioned lung cancer there being the number one killer we know it's uh it's a huge risk for for people that smoke but what is the risk for people that don't have never smoked yeah sadly it's not zero right so 15 of people who develop lung cancer are never smokers and uh sadly we see that disproportionately in women over men and we see that women non-smokers are the fastest segment of cancer of lung cancer growth that's again that's a very sobering statistic for which we have no great explanation I wrote an article on this uh you know on in our blog newsletter several months ago if people are interested they can go back I mean uh Catherine who's the analyst that I worked on this with uh you know I think we went kind of back and forth on some of the whys you know is it something to do with estrogen is it something to do with you know different types of gases that women might be more exposed to I mean the short answer is I don't think we really have a great answer there's clearly some difference uh either genetic or otherwise that is pointing to this susceptibility that non-smoking women appear to have and um and again they disproportionately it's an adenocarcinoma of the lung that is afflicting them and it's very frightening because again nobody's thinking about lung cancer screening in a non-smoker it wouldn't cross your mind to take a healthy 40 year old woman who's never smoked and Screen her for lung cancer that's just the furthest thing from your mind and we have a patient who um has survived an aggressive adenocarcinoma of the lung only because she was so lucky in that she had a CT a calcium scan a CT a special CT of the heart to to look for calcification in the heart and it just happened to pick up a small cancer and I think had that cancer been caught a year later uh I you know I think it uh there's a good chance it would have been too late this kind of ties in with lung cancer potentially you mentioned uh earlier MRI screening for cancer taking someone who doesn't have signs or symptoms of cancer and putting them on an MRI scanner using a special technique that you mentioned diffusion weighted Imaging can you explain your recommendations around that to your patients uh the value that you see in that type of screening so again MRI is is you know has it has its strengths and its weaknesses and its greatest strengths are it has no radiation so pose is no harm to the to the individual unlike say a CAT scan or a pet scan which have tons of radiation and should never be used for General screening purposes with one exception that we can talk about later um and it has a very very high sensitivity meaning if a cancer is there an MRI is pretty likely to see it now there's things that'll miss this is only within the types of cancers that it can see it's not great for any of those outside the body cancers so by the time a MRI is picking up a colon cancer or an esophageal cancer it should have been picked up years ago on an endoscopy so you do not want to rely on this for diagnosing cervical cancer or endometrial cancer where you can that's those are other examples by the way of outside the body cancers right you can look directly at the cervix directly at the uterus Etc so anything that can be looked at outside the body we're going to do that but if you take away those cancers um yeah it's a high sensitivity test but it's a very low specificity test meaning it's just not good at differentiating between Cancer and non-cancer in certain tissues namely glandular tissue so again MRI is the metal detector that's beeping all the freaking time it just doesn't stop beeping it's the most annoying metal detector you're ever going to see so you're stopping a whole lot of people that are posing no threat to the airplane so in an effort to make that better a technique that was developed to look at Strokes is now being applied to the whole body this technique is known as diffusion weighted Imaging with background subtraction but we just abbreviate it to DWI what this technique does and it's I will not explain this in great detail because to do so I would actually need to explain how MRIs work and how the pulsing of the magnets makes protons move and I honestly just think most people don't want to get into that level of detail but if you sort of just try to suspend disbelief for a moment the way an MRI is basically working is it's working by detecting the movement of protons that's effectively what an mri's schtick is so a CT scan totally different stick right a CT scan is shining electrons through something and on the back side of that thing it's collecting how many electrons hit it and it's imputing the density of the thing it went through based on the collection of electrons MRI totally different it's power using powerful very powerful magnets and making protons move and depending on how it pulses the protons it's measuring different aspects of the movement of protons so protons of course are ubiquitous in fat and water proton is hydrogen right so H2O and the CH group in a fat molecule so we're full of protons it's you know most ubiquitous atom in our body and the diffusion weighted Imaging trick is to pulse water and basically look to see how long it takes to move again and this works really well to determine how firm a piece of tissue is so in the brain when a person's potentially had a stroke you can take a look and see the firmness of the tissue even if there's no bleeding in the area now this works in the brain because the head doesn't move the head is the easiest thing to stabilize in an MRI scanner and so the frequency with which they would ping these things was typically you know 50 microseconds and that was quick enough that they could still see the artifact or the movement artifact to do that in the body is much harder 50 microseconds is not fast enough to actually get a good signal in the body because you can't limit the movement of the body as much the body won't stay as still as the head so there are companies that are working on using faster and faster software to get that time down to 20 and even 10 microseconds and at that rate the diffusion weighted Imaging is starting to work pretty well in the body and it's you can sort of think of it as a visual lump detector it's able to concentrate the signal the darkness of the digital signal around the firmness of the tissue and that is serving as an effective way one effective way to increase the specificity of an otherwise High sensitivity low specificity test well I'll reveal that I am thankful for this technology because that's what actually caught my cancer that caught my my Hodgkin lymphoma company called pernuvo I know is offering them are they the only one right now that offers the full body screening for for this purpose pronuvo is probably the best MRI today at doing this detection now there are other companies that do it but they're just used like they're licensing the pernuvo technology but yeah at this time we are only having our patients get scanned in a pernuvo scanner either at pronuvo or at a facility that uses a pronuvo scanner and hopefully someday insurance will cover this type of of screening because as you mentioned there's there's potentially a lot of value in it but right now as far as you know uh this has to be out of pocket for it for probably 100 out of pocket yeah and what I tell patients is don't do this if you're not willing to deal with the very high probability that something will be found that is not cancer but will require additional work um so you know I I don't have the exact numbers but it I would say at least 20 percent of the time we send a patient for one of these scans we you know get the news that yeah there's almost assuredly nothing here but there's this other thing there's this potential and by the way sometimes these are important things like you catch aneurysms that you know an aneurysm in the brain or in the pancreas can be lethal if not caught so sometimes you catch these other things and you go ahead and you fix them so all comers were seeing you know about a point seven percent aneurysm catch rate now probably a number of those will go on to be just fine if you did nothing about them but a subset of those have lethal potential but more likely you're catching these kind of clinically insignificant other artifacts that you do need to Chase and pursue and as a result of that I don't know I would say maybe 15 of our patients just elect not to do a whole body MRI for that reason which is they just they don't feel like their constitution is is gonna you know deal well with the following months of uncertainty as these other things are chased down and so I think that's a wise and informed decision for them and I think that's that I just want to make sure we don't get to the point where people are doing this type of screening without having that discussion right and understanding that hey you know there's there's a chance we're going down a rabbit hole here if you're not ready to go down that rabbit hole don't get on the ride yeah okay shifting to and you already mentioned this briefly but um you mentioned cancer is probably the least well understood as far as what we can do to prevent it um but you also mentioned that exercise is perhaps the greatest longevity drug um so do we do we have uh evidence at this time that exercise can help prevent cancer um and and that's decoupling exercise from you know the benefits it might have on someone's um you know weight uh if you know taking someone from obese to to not obese I mean we know that that can be helpful for cancer but just can exercise alone help prevent cancer to our knowledge yeah I think it I think there's very good evidence that it can right when you think about some of the things that exercise is doing so so if you think about the metabolic benefits of exercise uh it's certainly far transcends weight loss uh you know muscle is by far the most important sink for glucose and so insulin sensitive muscles are equivalent to insulin sensitive people you can't be insulin sensitive without having insulin sensitive muscles you can't have insulin sensitive muscles without exercising once you reach a certain age I mean you know a youngster maybe but but certainly by the time you're in your 20s and 30s you have to be exercising to maintain insulin true insulin sensitivity and that may be the single most important factor there is but going beyond that you know exercise does a lot of things right it creates a lot of myokines a lot of chemical signals that do various things throughout the body including reducing chronic inflammation and I think chronic inflammation is one of the impediments of the immune system and so if being insulin sensitive cuts down on the growth factors having less inflammation enhances the immune system and you could certainly make the case and I would make the case that those are probably two of the most important things at our disposal when it comes to reducing our risk of cancer excellent any other cancer prevention strategies besides the ones that you've already highlighted that that one should consider of course avoiding detrimental things like smoking aside yeah I think those are really the big ones I mean there's things we don't understand you know we probably don't understand exactly the role that stress is playing on cancer but I just have to think that there is a legitimate risk there through the the mediation of hypercortisolemia and excessive glucocorticoids on the immune system as well so so I think you know just some level of immune system and immune cell exhaustion as we age is probably equally responsible for the exponential increase in cancer as we age right I mean part of that I think is more time to accumulate mutations and mutations are the core thing that are driving cancer but I also think at least half of the equation is that our immune system is getting weaker as we age and that's actually one of the things where you know if I think about all of the Sci-Fi things that are going on out there the one that I would most want to see come to fruition um would be you know addressing the exhaustion of the immune system so if we could sort of manipulate the epigenome of T cells specifically and turn old T cells into younger T cells again that that would have a profound impact I believe on cancer treatment any other cancer screening modalities that we we missed we we talked about lung colon breast prostate um you mentioned screening for cervical cancer briefly skin checks you mentioned any other any other ones that were missing that we have the opportunity to screen for yeah I mean there there certainly are and it's always going to be Case by case right so for example in a person with a history or a family history of bladder cancer or in someone who has a personal history of smoking where you know we would even recommend cystoscopy uh for people who are former smokers we also add low dose CT scan to the lung MRI the MRI of the lung is with diffusion weighted Imaging is is equal probably to the low dose CT for adenocarcinoma but when you're talking about small cell carcinoma squamous cell carcinoma or large cell which are more common in smokers I think you're getting more benefit from the low-dose CT scan so we're doing a low-dose CT of the chest annually in former smokers as well and then what about just genetic testing for your patients getting their their whole genome sequenced with something like 23andMe or one of those companies I mean I think every one of these things has its place but they they you have to know what you're kind of looking for before you do it I mean again if a person's been adopted then I think there might be some benefit in doing it you might come up with something that you really didn't know but you'd be amazed what a very thorough family history can accomplish for a person and um at least when it comes to cancer uh you know I think we get we probably get more insight genetic testing on on some of the other diseases but uh with cancer at this point in time we generally don't routinely screen and we use the screening selectively based on an individual's history okay well to finish up any other final thoughts on cancer screening or or prevention no I think unfortunately um you know prevention and screening have to be our main strategies today I think the the treatment landscape is uh you know still kind of lacking relative to cardiovascular disease though it's further ahead than neurodegenerative disease um but you know personally I remain incredibly optimistic about what's going to come as far as you know expanding the capacity of immunotherapy again I said something at earlier that that might have gone over some people's heads because I just sort of mentioned it in passing but we now know that 80 of solid organ tumors have novel neoantigens meaning 80 of the cancers that people think about when they think about getting cancers that kill have enough antigen that a person's own immune system can recognize it the problem is not enough of the immune cell can recognize it and that's why ultimately the cancer wins so we're playing a game of tug and War right now and the good news is we at least have some guys that can hold on to the Rope the problem is we don't have enough in most cases so we have to figure out a way to increase the number of cells the number of T cells that can expand to meet that need once they recognize a cancer cell because I do believe that ultimately there is no therapy that's going to rival that of immunotherapy well Dr Tia thanks so much for your time uh today thanks for your fantastic book um I really enjoyed reading that and it's uh you systematically go through uh many of the things that we talked about today so really appreciate you all the time you spent on that and uh for people that haven't already please check out Dr Tia's podcast the drive and uh is you can find them online at Peter attia.com is that correct yep uh Peter Tia MD actually I think every I think everything is early medical too which is an exciting uh new website that you're working on so yeah thanks again thanks so much yeah appreciate you having me [Music]

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