The Peter Attia Drive - July 26, 2021


#170 - AMA #25： Navigating the complexities and nuances of cancer screening


Episode Stats

Length

12 minutes

Words per Minute

171.70575

Word Count

2,177

Sentence Count

134


Summary

In this episode of the Ask Me Anything podcast, Dr. Peter Atiyah sits down with Dr. Bob Kaplan to discuss how he thinks about cancer screening and how he and his team approach it. They cover everything from how to understand cancer screening, what you need to understand it, how to do it, and how to improve it.


Transcript

00:00:00.000 Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.
00:00:16.500 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can
00:00:20.460 access the AMA episodes in full, along with a ton of other membership benefits we've created,
00:00:25.440 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.
00:00:31.140 So without further delay, here's today's sneak peek of the ask me anything episode.
00:00:39.180 Hey everyone, welcome to this week's episode of the drive. Today is an AMA with Bob Kaplan. And
00:00:45.400 in this episode, we go super deep on cancer screen. And we've had so many questions about this and we
00:00:50.140 kind of lumped them all into one episode. So we get into kind of the, what you need to understand
00:00:54.900 cancer screening, sensitivity, specificity, positive, negative, predictive value, all those
00:00:58.660 things. And then kind of go through the different modalities, i.e. how you would actually go about
00:01:03.860 doing these screens and how you can improve their predictive value by stacking them on top of each
00:01:08.380 other. So hopefully you enjoy this one and check it out. This is probably a really good one to check
00:01:12.640 out on video because we use a lot of visuals, including a spreadsheet that you can manipulate
00:01:17.200 to better understand the concepts. So if you're a subscriber and you want to watch the full video
00:01:22.040 of those podcasts, remember, you'll want to see it on the show notes page. And if you're not a
00:01:25.540 subscriber, you can at least watch the first part of this video on our YouTube page. So without further
00:01:30.320 delay, please enjoy AMA number 25. Hey Bob, that's a lot of books behind you, man. Have you read all of
00:01:42.500 them or most of them? Thanks for noticing, Peter. I'm a voracious reader. Sometimes my appetite is too big.
00:01:48.780 I have to admit, I haven't read all of them. Maybe 90%, I think at this point.
00:01:53.140 It's impressive. Everything, the classics, literature, science.
00:01:57.240 Mostly the classics. You can probably tell by the book binding on some of those.
00:02:02.040 Yeah. Hard to get them out of the shelf, to be honest, to pull those things out. They're in
00:02:05.680 there so tight. Yeah. And it's good too. Your kids can do little projects, flattening leaves and
00:02:10.200 stuff like that. Yes. We've got more of those going on. It's fun for the whole family.
00:02:14.300 All right. Well, what do we have on the docket today for AMA number 20 something, 25?
00:02:21.260 25. In a similar vein as some of the previous AMAs, I consolidated a bunch of questions around
00:02:26.480 a particular topic. And this one is cancer screening. We've gotten a bunch of different
00:02:31.980 questions related to cancer and cancer screening. So you've got, I'll give you a flavor of some of the
00:02:36.200 questions that we've received. How do you think about cancer screening? Why and or when should I be
00:02:42.120 screened? Which tests are worth getting? What do you think of liquid biopsies? How do you interpret
00:02:48.420 sensitivity and specificity of tests? What do those actually mean? What are some screening tools
00:02:54.740 for cancer you use in your practice? There's another one. I don't know if this was a question
00:02:59.060 from someone, but I found this very interesting. And this question is, can you discuss how you
00:03:03.340 categorize cancers and how you screen for each? So I remember you told me this too, and it was pretty
00:03:07.340 interesting. I don't know if everybody would suspect this answer, but cancers outside the body
00:03:11.680 versus cancers inside the body. So we'll get into that a little bit, but I think it probably makes
00:03:16.180 sense to start off with sort of in general. I know you're a, you're a strategy person. I know
00:03:20.400 you love tactics too. Now, just to be clear, Bob, do we have three or four hours set aside for this
00:03:25.700 podcast? Hopefully it's the latter. Yeah. I think this could be a long one. Where would you like to
00:03:32.880 begin? I think we should begin from the top. The first question was, how do you think about cancer
00:03:37.620 screening? I guess putting this in the context of what we're interested in clinically is,
00:03:41.680 probably sounds repetitive, but longevity has these two components and they're not independent,
00:03:46.700 but sometimes it's helpful to think about them in isolation. Lifespan, healthspan. How do you live
00:03:52.860 longer? And then how do you live better? In many ways, cancer versus the other major chronic diseases
00:04:00.440 that rob a person of lifespan, namely the atherosclerotic diseases and the diseases of dementia
00:04:06.340 and neurocognitive decline. The latter two tend to go more hand in hand with the reduction in
00:04:13.160 healthspan. In other words, by definition, when a person has Alzheimer's disease, their quality of
00:04:19.420 life, i.e. their cognition is also deteriorating. So they're experiencing both the slide in quality of
00:04:25.380 life and eventually length of life. And similarly in people that have advanced atherosclerosis, while of
00:04:31.780 course it's true that people die suddenly of heart attacks who are otherwise totally healthy, a lot of
00:04:36.200 times the reduction in the ability to carry out activities of daily living kind of moves more hand
00:04:42.300 in hand with that. I would say that's a little less the case with cancer. Obviously, cancer is still a
00:04:48.420 disease whose primary risk factor is age. So age is the greatest risk factor for cancer, just as it is
00:04:53.480 for the other two diseases. But it's also in some ways a little bit easier to think of cancer in
00:04:58.820 isolation from the healthspan stuff, the decline in physical and mental and emotional state.
00:05:05.420 So if you're trying to imagine a world in which you can live longer, as we've discussed many times
00:05:11.240 previously, that means living in a world where we delay the onset of chronic disease and or have better
00:05:16.740 tools to live longer with chronic disease. But you know that I much favor the former option
00:05:22.940 medicine because we basically spent most of the history of modern medicine working on the latter
00:05:29.320 option with very, very limited success. Let's now posit for a moment that one of the pillars of
00:05:35.660 longevity is minimizing mortality from cancer. So where does screening fit into this? Well, screening is one
00:05:43.240 of three pieces that you would envision, right? The first piece would be how do you prevent cancer?
00:05:48.700 The second thing would be how do you screen for cancer and detect it early? And I'll explain why
00:05:54.860 I think that's necessary. And the third is how do you treat it when you have it? We can talk a lot
00:05:59.760 about the former. How do you prevent cancer? We've had many podcasts and we have many podcasts coming up
00:06:05.840 where we're going to get into the treatments of cancer. But I want to focus this one on the prevention
00:06:10.420 piece. So why do I believe that? Well, this is a controversial topic I want to say first. So not all people
00:06:16.160 believe that screening matters. But I think the simplest explanation for why screening matters
00:06:23.500 is the evidence that suggests that a cancer that is caught earlier is easier to treat than a cancer
00:06:30.980 that is caught later. In other words, if you catch a breast cancer or a colon cancer when there are tens of
00:06:39.480 millions or hundreds of millions of cancer cells, your odds of treating that successfully are better
00:06:46.100 than if you catch the same cancer years later when there are billions of cells. And the evidence for
00:06:53.200 that basically comes from examining how patients respond to the exact same drugs in the adjuvant setting
00:07:01.060 versus in the metastatic setting. What does that mean? So the adjuvant setting is when a drug is given
00:07:08.900 to a patient who has no visible cancer. So these are patients that may have had the visible cancer
00:07:15.580 removed. You believe that they have microscopic disease that remains and you give them a drug
00:07:22.000 like Herceptin for a HER2 new positive breast cancer. And if you compare the outcomes of those patients to
00:07:28.700 the outcomes of patients who are given the exact same drug for the exact same phenotype and genotype of
00:07:34.660 the cancer, but in the metastatic setting, there's no comparison in the outcomes. And one explanation
00:07:39.060 for that may be that the more mature cancers, the ones that have been around longer, have developed
00:07:45.380 more mutations. They are more difficult to treat. So it is therefore my belief that the more we can do to
00:07:54.180 screen for cancer and catch it earlier, the better we will be. But we do pay a price for that. We pay a
00:07:59.960 financial price for that. In other words, it costs money to screen early. And we pay potentially an
00:08:05.400 emotional price from that because as we'll get to, and you alluded to, we have to now get into
00:08:10.840 false positives and false negatives. But at a high level, Bob, that's how I think about this topic
00:08:16.140 around cancer screening. Yeah. It's telling too, if you look at statistics on five-year survival. So
00:08:23.460 what are the odds of you surviving a cancer? And then if you look at specific cancers like breast cancer,
00:08:28.280 you're talking about, you catch it early and it's a local cancer. It hasn't metastasized. And the
00:08:32.340 statistics on that is the five-year survival rates are 99%. And then you go to a, like a distant cancer.
00:08:39.640 So a metastatic breast cancer, and it's closer to about 25% in terms of the five-year survival.
00:08:46.100 Also what you alluded to as well, the false positives, false negatives. I said, I alluded to that. So that
00:08:50.760 gets into sensitivity, specificity, and I didn't mention this, but positive predictive value,
00:08:56.600 negative predictive value. And I think it probably would be helpful to go into that. And I think
00:09:01.180 pictures are probably worth a thousand words in this case, in terms of looking at how good a
00:09:05.760 screening tool is and determining that stuff, sensitivity, specificity, et cetera.
00:09:10.440 You want to just start explaining those things?
00:09:12.180 Sure.
00:09:12.920 We've got some slides that we use with our patients. So go ahead and pull these up and we'll walk
00:09:18.380 through that. Because I think if you want to take ownership over your own understanding of cancer
00:09:24.140 screening, you'll definitely want to get to a point where you're really facile with these terms.
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