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Searching for the Optimal CRC Surveillance Test
About a third of the US population are eligible for colorectal cancer screening but aren’t up to date on screening.
Many patients are reluctant to test for colon cancer for a variety of reasons, said Jeffrey K. Lee, MD, MPH, a research scientist at the Kaiser Permanente Northern California Division of Research and an attending gastroenterologist at Kaiser Permanente San Francisco Medical Center.
“As a gastroenterologist, I strongly believe we should emphasize the importance of colorectal cancer screening. And there’s many tests available, not just a colonoscopy, to help reduce your chances of developing colorectal cancer and even dying from colorectal cancer,” said Dr. Lee.
Many patients prefer a test that’s more convenient, that doesn’t require them to take time out of their busy schedules. “We must educate our patients that there are some noninvasive screening options that are helpful, and to be able to share with them some of the benefits, but also some of the drawbacks compared to colonoscopy and allow them to have a choice,” he advised.
He is a recipient of the AGA Research Scholar Award, and has in turn supported other researchers by contributing to the AGA Research Foundation. In 2012, Dr. Lee received a grant from the Sylvia Allison Kaplan Clinical Research Fund to fund a study on long-term colorectal cancer risk in patients with normal colonoscopy results.
The findings, published in JAMA Internal Medicine, determined that 10 years after a negative colonoscopy, Kaiser Permanente members had a 46% lower risk of being diagnosed with CRC and were 88% less likely to die from disease compared with patients who didn’t undergo screening.
“Furthermore, the reduced risk of developing colorectal cancer, even dying from it, persisted for more than 12 years after the examination compared with an unscreened population,” said Dr. Lee. “I firmly believe our study really supports the ten-year screening interval after a normal colonoscopy, as currently recommended by our guidelines.”
In an interview, he discussed his research efforts to find the best detection regimens for CRC, and the mentors who guided his career path as a GI scientist.
Q: Why did you choose GI?
During medical school I was fortunate to work in the lab of Dr. John M. Carethers at UC San Diego. He introduced me to GI and inspired me to choose GI as a career. His mentorship was invaluable because he not only solidified my interest in GI, but also inspired me to become a physician scientist, focusing on colorectal cancer prevention and control. His amazing mentorship drew me to this field.
Q: One of your clinical focus areas is hereditary gastrointestinal cancer syndromes. How did you become interested in this area of GI medicine?
My interest in hereditary GI cancer syndromes stemmed from my work as a medical student in Dr. Carethers’ lab. One of my research projects was looking at certain gene mutations among patients with hereditary GI cancer syndromes, specifically, familial hamartomatous polyposis syndrome. It was through these research projects and seeing how these genetic mutations impacted their risk of developing colorectal cancer, inspired me to care for patients with hereditary GI cancer syndromes.
Q: Have you been doing any research on the reasons why more young people are getting colon cancer?
We recently published work looking at the potential factors that may be driving the rising rates of early onset colorectal cancer. One hypothesis that’s been floating around is antibiotic exposure in early adulthood or childhood because of its effect on the microbiome. Using our large database at Kaiser Permanente Northern California, we did not find an association between oral antibiotic use during early adulthood and the risk of early-onset colorectal cancer.
You have the usual suspects like obesity and diabetes, but it’s not explaining all that risk. While familial colorectal cancer syndromes contribute to a small proportion of early-onset colorectal, these syndromes are not increasing across generations. I really do feel it’s something in the diet or how foods are processed and environmental factors that’s driving some of the risk of early onset colorectal cancer and this should be explored further.
Q: In 2018, you issued a landmark study which found an association between a 10-year follow-up after negative colonoscopy and reduced risk of disease and mortality. Has there been any updates to these findings over the last 6 years?
We recently saw a study in JAMA Oncology of a Swedish cohort that showed a negative colonoscopy result was associated with a reduced risk of developing and even dying from colorectal cancer 15 years from that examination, compared to the general population of Sweden. I think there’s some things that we need to be cautious about regarding that study. We have to think about the comparison group that they used and the lack of information regarding the indication of the colonoscopy and the quality of the examination. So, it remains uncertain whether future guidelines are going to stretch out that 10-year interval to 15 years.
Q: What other CRC studies are you working on now?
We have several studies that we are working on right now. One is called the PREVENT CRC study, which is looking at whether a polygenic risk score can improve risk stratification following adenoma removal for colorectal cancer prevention and tailoring post-polypectomy surveillance. This is a large observational cohort study that we have teamed up with the Fred Hutchinson Cancer Center, Erasmus University, and Kaiser Permanente Northwest to answer this important question that may have implications for personalized medicine.
Then there’s the COOP study, funded by the Patient-Centered Outcomes Research Institute. This is looking at the best surveillance test to use among older adults 65 years and older with a history of polyps. The trial is randomizing them to either getting a colonoscopy for surveillance or annual fecal immunochemical test (FIT) for surveillance. This is to see which test is best for detecting colorectal cancer among older adults with a history of polyps.
Q: Do you think FIT tests could eventually replace colonoscopy, given that it’s less invasive?
Although FIT and other stool-based tests are less invasive and have been shown to have high accuracy for detecting colorectal cancer, I personally do not think they are going to replace colonoscopy as the most popular screening modality in the United States. Colonoscopy remains the gold standard for detecting and removing precancerous polyps and has the highest accuracy for detecting colorectal cancer.
Q: Besides Dr. Carethers, what teacher or mentor had the greatest impact on you?
Clinically it’s been Dr. Jonathan Terdiman from UCSF, who taught me everything I know about clinical GI, and the art of colonoscopy. In addition, Douglas A. Corley, MD, PhD, the Permanente Medical Group’s chief research officer, has made the greatest impact on my research career. He’s really taught me how to rigorously design a research study to answer important clinically relevant questions, and has given me the skill set to write NIH grants. I would not be here without these mentors who are truly giants in the field of GI.
Q: When you’re not being a GI, how do you spend your free weekend afternoons? Are you still a “Cal Bears” fan at your alma mater, UC Berkeley?
I spend a lot of time taking my kids to their activities on the weekends. I just took my son to a Cal Bears Game Day, which was hosted by ESPN at Berkeley.
It was an incredible experience hearing sports analyst Pat McAfee lead all the Cal chants, seeing Nick Saban from the University of Alabama take off his red tie and replace it with a Cal Bears tie, and watching a Cal student win a hundred thousand dollars by kicking a football through the goal posts wearing checkered vans.
Lightning Round
Texting or talking?
Text
Favorite breakfast?
Taiwanese breakfast
Place you most want to travel to?
Japan
Favorite junk food?
Trader Joe’s chili lime chips
Favorite season?
Springtime, baseball season
Favorite ice cream flavor?
Mint chocolate chip
How many cups of coffee do you drink per day?
2-3
Last movie you watched?
Oppenheimer
Best place you ever went on vacation?
Hawaii
If you weren’t a gastroenterologist, what would you be?
Barber
Best Halloween costume you ever wore?
SpongeBob SquarePants
Favorite sport?
Tennis
What song do you have to sing along with when you hear it?
Any classic 80s song
Introvert or extrovert?
Introvert
About a third of the US population are eligible for colorectal cancer screening but aren’t up to date on screening.
Many patients are reluctant to test for colon cancer for a variety of reasons, said Jeffrey K. Lee, MD, MPH, a research scientist at the Kaiser Permanente Northern California Division of Research and an attending gastroenterologist at Kaiser Permanente San Francisco Medical Center.
“As a gastroenterologist, I strongly believe we should emphasize the importance of colorectal cancer screening. And there’s many tests available, not just a colonoscopy, to help reduce your chances of developing colorectal cancer and even dying from colorectal cancer,” said Dr. Lee.
Many patients prefer a test that’s more convenient, that doesn’t require them to take time out of their busy schedules. “We must educate our patients that there are some noninvasive screening options that are helpful, and to be able to share with them some of the benefits, but also some of the drawbacks compared to colonoscopy and allow them to have a choice,” he advised.
He is a recipient of the AGA Research Scholar Award, and has in turn supported other researchers by contributing to the AGA Research Foundation. In 2012, Dr. Lee received a grant from the Sylvia Allison Kaplan Clinical Research Fund to fund a study on long-term colorectal cancer risk in patients with normal colonoscopy results.
The findings, published in JAMA Internal Medicine, determined that 10 years after a negative colonoscopy, Kaiser Permanente members had a 46% lower risk of being diagnosed with CRC and were 88% less likely to die from disease compared with patients who didn’t undergo screening.
“Furthermore, the reduced risk of developing colorectal cancer, even dying from it, persisted for more than 12 years after the examination compared with an unscreened population,” said Dr. Lee. “I firmly believe our study really supports the ten-year screening interval after a normal colonoscopy, as currently recommended by our guidelines.”
In an interview, he discussed his research efforts to find the best detection regimens for CRC, and the mentors who guided his career path as a GI scientist.
Q: Why did you choose GI?
During medical school I was fortunate to work in the lab of Dr. John M. Carethers at UC San Diego. He introduced me to GI and inspired me to choose GI as a career. His mentorship was invaluable because he not only solidified my interest in GI, but also inspired me to become a physician scientist, focusing on colorectal cancer prevention and control. His amazing mentorship drew me to this field.
Q: One of your clinical focus areas is hereditary gastrointestinal cancer syndromes. How did you become interested in this area of GI medicine?
My interest in hereditary GI cancer syndromes stemmed from my work as a medical student in Dr. Carethers’ lab. One of my research projects was looking at certain gene mutations among patients with hereditary GI cancer syndromes, specifically, familial hamartomatous polyposis syndrome. It was through these research projects and seeing how these genetic mutations impacted their risk of developing colorectal cancer, inspired me to care for patients with hereditary GI cancer syndromes.
Q: Have you been doing any research on the reasons why more young people are getting colon cancer?
We recently published work looking at the potential factors that may be driving the rising rates of early onset colorectal cancer. One hypothesis that’s been floating around is antibiotic exposure in early adulthood or childhood because of its effect on the microbiome. Using our large database at Kaiser Permanente Northern California, we did not find an association between oral antibiotic use during early adulthood and the risk of early-onset colorectal cancer.
You have the usual suspects like obesity and diabetes, but it’s not explaining all that risk. While familial colorectal cancer syndromes contribute to a small proportion of early-onset colorectal, these syndromes are not increasing across generations. I really do feel it’s something in the diet or how foods are processed and environmental factors that’s driving some of the risk of early onset colorectal cancer and this should be explored further.
Q: In 2018, you issued a landmark study which found an association between a 10-year follow-up after negative colonoscopy and reduced risk of disease and mortality. Has there been any updates to these findings over the last 6 years?
We recently saw a study in JAMA Oncology of a Swedish cohort that showed a negative colonoscopy result was associated with a reduced risk of developing and even dying from colorectal cancer 15 years from that examination, compared to the general population of Sweden. I think there’s some things that we need to be cautious about regarding that study. We have to think about the comparison group that they used and the lack of information regarding the indication of the colonoscopy and the quality of the examination. So, it remains uncertain whether future guidelines are going to stretch out that 10-year interval to 15 years.
Q: What other CRC studies are you working on now?
We have several studies that we are working on right now. One is called the PREVENT CRC study, which is looking at whether a polygenic risk score can improve risk stratification following adenoma removal for colorectal cancer prevention and tailoring post-polypectomy surveillance. This is a large observational cohort study that we have teamed up with the Fred Hutchinson Cancer Center, Erasmus University, and Kaiser Permanente Northwest to answer this important question that may have implications for personalized medicine.
Then there’s the COOP study, funded by the Patient-Centered Outcomes Research Institute. This is looking at the best surveillance test to use among older adults 65 years and older with a history of polyps. The trial is randomizing them to either getting a colonoscopy for surveillance or annual fecal immunochemical test (FIT) for surveillance. This is to see which test is best for detecting colorectal cancer among older adults with a history of polyps.
Q: Do you think FIT tests could eventually replace colonoscopy, given that it’s less invasive?
Although FIT and other stool-based tests are less invasive and have been shown to have high accuracy for detecting colorectal cancer, I personally do not think they are going to replace colonoscopy as the most popular screening modality in the United States. Colonoscopy remains the gold standard for detecting and removing precancerous polyps and has the highest accuracy for detecting colorectal cancer.
Q: Besides Dr. Carethers, what teacher or mentor had the greatest impact on you?
Clinically it’s been Dr. Jonathan Terdiman from UCSF, who taught me everything I know about clinical GI, and the art of colonoscopy. In addition, Douglas A. Corley, MD, PhD, the Permanente Medical Group’s chief research officer, has made the greatest impact on my research career. He’s really taught me how to rigorously design a research study to answer important clinically relevant questions, and has given me the skill set to write NIH grants. I would not be here without these mentors who are truly giants in the field of GI.
Q: When you’re not being a GI, how do you spend your free weekend afternoons? Are you still a “Cal Bears” fan at your alma mater, UC Berkeley?
I spend a lot of time taking my kids to their activities on the weekends. I just took my son to a Cal Bears Game Day, which was hosted by ESPN at Berkeley.
It was an incredible experience hearing sports analyst Pat McAfee lead all the Cal chants, seeing Nick Saban from the University of Alabama take off his red tie and replace it with a Cal Bears tie, and watching a Cal student win a hundred thousand dollars by kicking a football through the goal posts wearing checkered vans.
Lightning Round
Texting or talking?
Text
Favorite breakfast?
Taiwanese breakfast
Place you most want to travel to?
Japan
Favorite junk food?
Trader Joe’s chili lime chips
Favorite season?
Springtime, baseball season
Favorite ice cream flavor?
Mint chocolate chip
How many cups of coffee do you drink per day?
2-3
Last movie you watched?
Oppenheimer
Best place you ever went on vacation?
Hawaii
If you weren’t a gastroenterologist, what would you be?
Barber
Best Halloween costume you ever wore?
SpongeBob SquarePants
Favorite sport?
Tennis
What song do you have to sing along with when you hear it?
Any classic 80s song
Introvert or extrovert?
Introvert
About a third of the US population are eligible for colorectal cancer screening but aren’t up to date on screening.
Many patients are reluctant to test for colon cancer for a variety of reasons, said Jeffrey K. Lee, MD, MPH, a research scientist at the Kaiser Permanente Northern California Division of Research and an attending gastroenterologist at Kaiser Permanente San Francisco Medical Center.
“As a gastroenterologist, I strongly believe we should emphasize the importance of colorectal cancer screening. And there’s many tests available, not just a colonoscopy, to help reduce your chances of developing colorectal cancer and even dying from colorectal cancer,” said Dr. Lee.
Many patients prefer a test that’s more convenient, that doesn’t require them to take time out of their busy schedules. “We must educate our patients that there are some noninvasive screening options that are helpful, and to be able to share with them some of the benefits, but also some of the drawbacks compared to colonoscopy and allow them to have a choice,” he advised.
He is a recipient of the AGA Research Scholar Award, and has in turn supported other researchers by contributing to the AGA Research Foundation. In 2012, Dr. Lee received a grant from the Sylvia Allison Kaplan Clinical Research Fund to fund a study on long-term colorectal cancer risk in patients with normal colonoscopy results.
The findings, published in JAMA Internal Medicine, determined that 10 years after a negative colonoscopy, Kaiser Permanente members had a 46% lower risk of being diagnosed with CRC and were 88% less likely to die from disease compared with patients who didn’t undergo screening.
“Furthermore, the reduced risk of developing colorectal cancer, even dying from it, persisted for more than 12 years after the examination compared with an unscreened population,” said Dr. Lee. “I firmly believe our study really supports the ten-year screening interval after a normal colonoscopy, as currently recommended by our guidelines.”
In an interview, he discussed his research efforts to find the best detection regimens for CRC, and the mentors who guided his career path as a GI scientist.
Q: Why did you choose GI?
During medical school I was fortunate to work in the lab of Dr. John M. Carethers at UC San Diego. He introduced me to GI and inspired me to choose GI as a career. His mentorship was invaluable because he not only solidified my interest in GI, but also inspired me to become a physician scientist, focusing on colorectal cancer prevention and control. His amazing mentorship drew me to this field.
Q: One of your clinical focus areas is hereditary gastrointestinal cancer syndromes. How did you become interested in this area of GI medicine?
My interest in hereditary GI cancer syndromes stemmed from my work as a medical student in Dr. Carethers’ lab. One of my research projects was looking at certain gene mutations among patients with hereditary GI cancer syndromes, specifically, familial hamartomatous polyposis syndrome. It was through these research projects and seeing how these genetic mutations impacted their risk of developing colorectal cancer, inspired me to care for patients with hereditary GI cancer syndromes.
Q: Have you been doing any research on the reasons why more young people are getting colon cancer?
We recently published work looking at the potential factors that may be driving the rising rates of early onset colorectal cancer. One hypothesis that’s been floating around is antibiotic exposure in early adulthood or childhood because of its effect on the microbiome. Using our large database at Kaiser Permanente Northern California, we did not find an association between oral antibiotic use during early adulthood and the risk of early-onset colorectal cancer.
You have the usual suspects like obesity and diabetes, but it’s not explaining all that risk. While familial colorectal cancer syndromes contribute to a small proportion of early-onset colorectal, these syndromes are not increasing across generations. I really do feel it’s something in the diet or how foods are processed and environmental factors that’s driving some of the risk of early onset colorectal cancer and this should be explored further.
Q: In 2018, you issued a landmark study which found an association between a 10-year follow-up after negative colonoscopy and reduced risk of disease and mortality. Has there been any updates to these findings over the last 6 years?
We recently saw a study in JAMA Oncology of a Swedish cohort that showed a negative colonoscopy result was associated with a reduced risk of developing and even dying from colorectal cancer 15 years from that examination, compared to the general population of Sweden. I think there’s some things that we need to be cautious about regarding that study. We have to think about the comparison group that they used and the lack of information regarding the indication of the colonoscopy and the quality of the examination. So, it remains uncertain whether future guidelines are going to stretch out that 10-year interval to 15 years.
Q: What other CRC studies are you working on now?
We have several studies that we are working on right now. One is called the PREVENT CRC study, which is looking at whether a polygenic risk score can improve risk stratification following adenoma removal for colorectal cancer prevention and tailoring post-polypectomy surveillance. This is a large observational cohort study that we have teamed up with the Fred Hutchinson Cancer Center, Erasmus University, and Kaiser Permanente Northwest to answer this important question that may have implications for personalized medicine.
Then there’s the COOP study, funded by the Patient-Centered Outcomes Research Institute. This is looking at the best surveillance test to use among older adults 65 years and older with a history of polyps. The trial is randomizing them to either getting a colonoscopy for surveillance or annual fecal immunochemical test (FIT) for surveillance. This is to see which test is best for detecting colorectal cancer among older adults with a history of polyps.
Q: Do you think FIT tests could eventually replace colonoscopy, given that it’s less invasive?
Although FIT and other stool-based tests are less invasive and have been shown to have high accuracy for detecting colorectal cancer, I personally do not think they are going to replace colonoscopy as the most popular screening modality in the United States. Colonoscopy remains the gold standard for detecting and removing precancerous polyps and has the highest accuracy for detecting colorectal cancer.
Q: Besides Dr. Carethers, what teacher or mentor had the greatest impact on you?
Clinically it’s been Dr. Jonathan Terdiman from UCSF, who taught me everything I know about clinical GI, and the art of colonoscopy. In addition, Douglas A. Corley, MD, PhD, the Permanente Medical Group’s chief research officer, has made the greatest impact on my research career. He’s really taught me how to rigorously design a research study to answer important clinically relevant questions, and has given me the skill set to write NIH grants. I would not be here without these mentors who are truly giants in the field of GI.
Q: When you’re not being a GI, how do you spend your free weekend afternoons? Are you still a “Cal Bears” fan at your alma mater, UC Berkeley?
I spend a lot of time taking my kids to their activities on the weekends. I just took my son to a Cal Bears Game Day, which was hosted by ESPN at Berkeley.
It was an incredible experience hearing sports analyst Pat McAfee lead all the Cal chants, seeing Nick Saban from the University of Alabama take off his red tie and replace it with a Cal Bears tie, and watching a Cal student win a hundred thousand dollars by kicking a football through the goal posts wearing checkered vans.
Lightning Round
Texting or talking?
Text
Favorite breakfast?
Taiwanese breakfast
Place you most want to travel to?
Japan
Favorite junk food?
Trader Joe’s chili lime chips
Favorite season?
Springtime, baseball season
Favorite ice cream flavor?
Mint chocolate chip
How many cups of coffee do you drink per day?
2-3
Last movie you watched?
Oppenheimer
Best place you ever went on vacation?
Hawaii
If you weren’t a gastroenterologist, what would you be?
Barber
Best Halloween costume you ever wore?
SpongeBob SquarePants
Favorite sport?
Tennis
What song do you have to sing along with when you hear it?
Any classic 80s song
Introvert or extrovert?
Introvert
Giving the Smallest GI Transplant Patients a New Lease On Life
The best part about working with kids is that “I get to laugh every day,” said Ke-You (Yoyo) Zhang, MD, clinical assistant professor for pediatrics–gastroenterology and hepatology at Stanford Medicine in California.
Everyday life for them is a challenge.
Dealing with sick children is difficult. “But I think the difference between pediatrics and adults is despite how hard things get, children are the single most resilient people you’re ever going to meet,” she said.
Kids don’t always know they’re sick and they don’t act sick, even when they are. “Every day, I literally get on the floor, I get to play, I get to run around. And truly, I have fun every single day. I get excited to go to work. And I think that’s what makes work not feel like work,” said Dr. Zhang.
In an interview, she discussed the satisfaction of following patients throughout their care continuum and her research to reduce the likelihood of transplant rejection.
She also shared an inspirational story of one young patient who spent his life tied to an IV, and how a transplant exposed him to the normal joys of life, like swimming, going to camp and getting on a plane for the first time.
Q: Why did you choose this subspecialty of pediatric GI?
I think it’s the best subspecialty because I think it combines a lot of the things that I enjoy, which is long-term continuity of care. It’s about growing up with your patients and seeing them through all the various stages of their life, often meeting patients when they’re babies. I get pictures of high school graduations and life milestones and even see some of my patients have families of their own. Becoming a part of their family is very meaningful to me. I also like complexity and acuity, and gastroenterology and hepatology provide those things.
And then lastly, it’s great to be able to exercise procedural skills and constantly learn new procedural skills.
Q: How did you become interested in the field of pediatric intestinal and liver transplantation?
I did all my training here at Stanford. We have one of the largest pediatric transplant centers and we also have a very large intestinal rehabilitation population.
Coming through residency and fellowship, I had a lot of exposure to transplant and intestinal failure, intestinal rehabilitation. I really liked the longitudinal relationship I got to form with my patients. Sometimes they’re in the neonatal ICU, where you’re meeting them in their very first days of life. You follow them through their chronic illness, through transplant and after transplant for many years. You become not just their GI, but the center of their care.
Q: What challenges are unique to this type of transplant work?
Pediatric intestinal failure and intestinal transplant represents an incredibly small subset of children. Oftentimes, they do not get the resources and recognition on a national policy level or even at the hospital level that other gastrointestinal diseases receive. What’s difficult is they are such a small subset but their complexity and their needs are probably in the highest percentile. So that’s a really challenging combination to start with. And there’s only a few centers that specialize in doing intestinal rehabilitation and intestinal transplantation for children in the country.
Developing expertise has been slow. But I think in the last decade or so, our understanding and success with intestinal rehabilitation and intestinal transplantation has really improved, especially at large centers like Stanford. We’ve had a lot of success stories and have not had any graft loss since 2014.
Q: Are these transplants hard to acquire?
Yes, especially when you’re transplanting not just the intestines but the liver as well. You’re waiting for two organs, not just one organ. And on top of that, you’re waiting for an appropriately sized donor; usually a child who’s around the same size or same age who’s passed away. Those organs would have to be a good match. Children can wait multiple years for a transplant.
Q: Is there a success story you’d like to share?
One patient I met in the neonatal ICU had congenital short bowel syndrome. He was born with hardly any intestines. He developed complications of being on long-term intravenous nutrition, which included recurrent central line infections and liver disease. He was never able to eat because he really didn’t have a digestive system that could adequately absorb anything. He had a central line in one of his large veins, so he couldn’t go swimming.
He had to have special adaptive wear to even shower or bathe and couldn’t travel. It’s these types of patients that benefit so much from transplant. Putting any kid through transplant is a massive undertaking and it certainly has risks. But he underwent a successful transplant at the age of 8—not just an intestinal transplant, but a multi-visceral transplant of the liver, intestine, and pancreas. He’s 9 years old now, and no longer needs intravenous nutrition. He ate by mouth for the very first time after transplant. He’s trying all sorts of new foods and he was able to go to a special transplant camp for children. Getting on a plane to Los Angeles, which is where our transplant camp is, was a huge deal.
He was able to swim in the lake. He’s never been able to do that. And he wants to start doing sports this fall. This was really a life-changing story for him.
Q: What advancements lie ahead for this field of work? Have you work on any notable research?
I think our understanding of transplant immunology has really progressed, especially recently. That’s what part of my research is about—using novel therapies to modulate the immune system of pediatric transplant recipients. The No. 1 complication that occurs after intestinal transplant is rejection because obviously you’re implanting somebody else’s organs into a patient.
I am involved in a clinical trial that’s looking at the use of extracellular vesicles that are isolated from hematopoietic stem cells. These vesicles contain various growth factors, anti-inflammatory proteins and tissue repair factors that we are infusing into intestinal transplant patients with the aim to repair the intestinal tissue patients are rejecting.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
My husband and I have an almost 2-year-old little girl. She keeps us busy and I spend my afternoons chasing after a crazy toddler.
Lightning Round
Texting or talking?
Huge texter
Favorite junk food?
French fries
Cat or dog person?
Dog
Favorite ice cream?
Strawberry
If you weren’t a gastroenterologist, what would you be?Florist
Best place you’ve traveled to?
Thailand
Number of cups of coffee you drink per day?
Too many
Favorite city in the US besides the one you live in?
New York City
Favorite sport?
Tennis
Optimist or pessimist?
Optimist
The best part about working with kids is that “I get to laugh every day,” said Ke-You (Yoyo) Zhang, MD, clinical assistant professor for pediatrics–gastroenterology and hepatology at Stanford Medicine in California.
Everyday life for them is a challenge.
Dealing with sick children is difficult. “But I think the difference between pediatrics and adults is despite how hard things get, children are the single most resilient people you’re ever going to meet,” she said.
Kids don’t always know they’re sick and they don’t act sick, even when they are. “Every day, I literally get on the floor, I get to play, I get to run around. And truly, I have fun every single day. I get excited to go to work. And I think that’s what makes work not feel like work,” said Dr. Zhang.
In an interview, she discussed the satisfaction of following patients throughout their care continuum and her research to reduce the likelihood of transplant rejection.
She also shared an inspirational story of one young patient who spent his life tied to an IV, and how a transplant exposed him to the normal joys of life, like swimming, going to camp and getting on a plane for the first time.
Q: Why did you choose this subspecialty of pediatric GI?
I think it’s the best subspecialty because I think it combines a lot of the things that I enjoy, which is long-term continuity of care. It’s about growing up with your patients and seeing them through all the various stages of their life, often meeting patients when they’re babies. I get pictures of high school graduations and life milestones and even see some of my patients have families of their own. Becoming a part of their family is very meaningful to me. I also like complexity and acuity, and gastroenterology and hepatology provide those things.
And then lastly, it’s great to be able to exercise procedural skills and constantly learn new procedural skills.
Q: How did you become interested in the field of pediatric intestinal and liver transplantation?
I did all my training here at Stanford. We have one of the largest pediatric transplant centers and we also have a very large intestinal rehabilitation population.
Coming through residency and fellowship, I had a lot of exposure to transplant and intestinal failure, intestinal rehabilitation. I really liked the longitudinal relationship I got to form with my patients. Sometimes they’re in the neonatal ICU, where you’re meeting them in their very first days of life. You follow them through their chronic illness, through transplant and after transplant for many years. You become not just their GI, but the center of their care.
Q: What challenges are unique to this type of transplant work?
Pediatric intestinal failure and intestinal transplant represents an incredibly small subset of children. Oftentimes, they do not get the resources and recognition on a national policy level or even at the hospital level that other gastrointestinal diseases receive. What’s difficult is they are such a small subset but their complexity and their needs are probably in the highest percentile. So that’s a really challenging combination to start with. And there’s only a few centers that specialize in doing intestinal rehabilitation and intestinal transplantation for children in the country.
Developing expertise has been slow. But I think in the last decade or so, our understanding and success with intestinal rehabilitation and intestinal transplantation has really improved, especially at large centers like Stanford. We’ve had a lot of success stories and have not had any graft loss since 2014.
Q: Are these transplants hard to acquire?
Yes, especially when you’re transplanting not just the intestines but the liver as well. You’re waiting for two organs, not just one organ. And on top of that, you’re waiting for an appropriately sized donor; usually a child who’s around the same size or same age who’s passed away. Those organs would have to be a good match. Children can wait multiple years for a transplant.
Q: Is there a success story you’d like to share?
One patient I met in the neonatal ICU had congenital short bowel syndrome. He was born with hardly any intestines. He developed complications of being on long-term intravenous nutrition, which included recurrent central line infections and liver disease. He was never able to eat because he really didn’t have a digestive system that could adequately absorb anything. He had a central line in one of his large veins, so he couldn’t go swimming.
He had to have special adaptive wear to even shower or bathe and couldn’t travel. It’s these types of patients that benefit so much from transplant. Putting any kid through transplant is a massive undertaking and it certainly has risks. But he underwent a successful transplant at the age of 8—not just an intestinal transplant, but a multi-visceral transplant of the liver, intestine, and pancreas. He’s 9 years old now, and no longer needs intravenous nutrition. He ate by mouth for the very first time after transplant. He’s trying all sorts of new foods and he was able to go to a special transplant camp for children. Getting on a plane to Los Angeles, which is where our transplant camp is, was a huge deal.
He was able to swim in the lake. He’s never been able to do that. And he wants to start doing sports this fall. This was really a life-changing story for him.
Q: What advancements lie ahead for this field of work? Have you work on any notable research?
I think our understanding of transplant immunology has really progressed, especially recently. That’s what part of my research is about—using novel therapies to modulate the immune system of pediatric transplant recipients. The No. 1 complication that occurs after intestinal transplant is rejection because obviously you’re implanting somebody else’s organs into a patient.
I am involved in a clinical trial that’s looking at the use of extracellular vesicles that are isolated from hematopoietic stem cells. These vesicles contain various growth factors, anti-inflammatory proteins and tissue repair factors that we are infusing into intestinal transplant patients with the aim to repair the intestinal tissue patients are rejecting.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
My husband and I have an almost 2-year-old little girl. She keeps us busy and I spend my afternoons chasing after a crazy toddler.
Lightning Round
Texting or talking?
Huge texter
Favorite junk food?
French fries
Cat or dog person?
Dog
Favorite ice cream?
Strawberry
If you weren’t a gastroenterologist, what would you be?Florist
Best place you’ve traveled to?
Thailand
Number of cups of coffee you drink per day?
Too many
Favorite city in the US besides the one you live in?
New York City
Favorite sport?
Tennis
Optimist or pessimist?
Optimist
The best part about working with kids is that “I get to laugh every day,” said Ke-You (Yoyo) Zhang, MD, clinical assistant professor for pediatrics–gastroenterology and hepatology at Stanford Medicine in California.
Everyday life for them is a challenge.
Dealing with sick children is difficult. “But I think the difference between pediatrics and adults is despite how hard things get, children are the single most resilient people you’re ever going to meet,” she said.
Kids don’t always know they’re sick and they don’t act sick, even when they are. “Every day, I literally get on the floor, I get to play, I get to run around. And truly, I have fun every single day. I get excited to go to work. And I think that’s what makes work not feel like work,” said Dr. Zhang.
In an interview, she discussed the satisfaction of following patients throughout their care continuum and her research to reduce the likelihood of transplant rejection.
She also shared an inspirational story of one young patient who spent his life tied to an IV, and how a transplant exposed him to the normal joys of life, like swimming, going to camp and getting on a plane for the first time.
Q: Why did you choose this subspecialty of pediatric GI?
I think it’s the best subspecialty because I think it combines a lot of the things that I enjoy, which is long-term continuity of care. It’s about growing up with your patients and seeing them through all the various stages of their life, often meeting patients when they’re babies. I get pictures of high school graduations and life milestones and even see some of my patients have families of their own. Becoming a part of their family is very meaningful to me. I also like complexity and acuity, and gastroenterology and hepatology provide those things.
And then lastly, it’s great to be able to exercise procedural skills and constantly learn new procedural skills.
Q: How did you become interested in the field of pediatric intestinal and liver transplantation?
I did all my training here at Stanford. We have one of the largest pediatric transplant centers and we also have a very large intestinal rehabilitation population.
Coming through residency and fellowship, I had a lot of exposure to transplant and intestinal failure, intestinal rehabilitation. I really liked the longitudinal relationship I got to form with my patients. Sometimes they’re in the neonatal ICU, where you’re meeting them in their very first days of life. You follow them through their chronic illness, through transplant and after transplant for many years. You become not just their GI, but the center of their care.
Q: What challenges are unique to this type of transplant work?
Pediatric intestinal failure and intestinal transplant represents an incredibly small subset of children. Oftentimes, they do not get the resources and recognition on a national policy level or even at the hospital level that other gastrointestinal diseases receive. What’s difficult is they are such a small subset but their complexity and their needs are probably in the highest percentile. So that’s a really challenging combination to start with. And there’s only a few centers that specialize in doing intestinal rehabilitation and intestinal transplantation for children in the country.
Developing expertise has been slow. But I think in the last decade or so, our understanding and success with intestinal rehabilitation and intestinal transplantation has really improved, especially at large centers like Stanford. We’ve had a lot of success stories and have not had any graft loss since 2014.
Q: Are these transplants hard to acquire?
Yes, especially when you’re transplanting not just the intestines but the liver as well. You’re waiting for two organs, not just one organ. And on top of that, you’re waiting for an appropriately sized donor; usually a child who’s around the same size or same age who’s passed away. Those organs would have to be a good match. Children can wait multiple years for a transplant.
Q: Is there a success story you’d like to share?
One patient I met in the neonatal ICU had congenital short bowel syndrome. He was born with hardly any intestines. He developed complications of being on long-term intravenous nutrition, which included recurrent central line infections and liver disease. He was never able to eat because he really didn’t have a digestive system that could adequately absorb anything. He had a central line in one of his large veins, so he couldn’t go swimming.
He had to have special adaptive wear to even shower or bathe and couldn’t travel. It’s these types of patients that benefit so much from transplant. Putting any kid through transplant is a massive undertaking and it certainly has risks. But he underwent a successful transplant at the age of 8—not just an intestinal transplant, but a multi-visceral transplant of the liver, intestine, and pancreas. He’s 9 years old now, and no longer needs intravenous nutrition. He ate by mouth for the very first time after transplant. He’s trying all sorts of new foods and he was able to go to a special transplant camp for children. Getting on a plane to Los Angeles, which is where our transplant camp is, was a huge deal.
He was able to swim in the lake. He’s never been able to do that. And he wants to start doing sports this fall. This was really a life-changing story for him.
Q: What advancements lie ahead for this field of work? Have you work on any notable research?
I think our understanding of transplant immunology has really progressed, especially recently. That’s what part of my research is about—using novel therapies to modulate the immune system of pediatric transplant recipients. The No. 1 complication that occurs after intestinal transplant is rejection because obviously you’re implanting somebody else’s organs into a patient.
I am involved in a clinical trial that’s looking at the use of extracellular vesicles that are isolated from hematopoietic stem cells. These vesicles contain various growth factors, anti-inflammatory proteins and tissue repair factors that we are infusing into intestinal transplant patients with the aim to repair the intestinal tissue patients are rejecting.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
My husband and I have an almost 2-year-old little girl. She keeps us busy and I spend my afternoons chasing after a crazy toddler.
Lightning Round
Texting or talking?
Huge texter
Favorite junk food?
French fries
Cat or dog person?
Dog
Favorite ice cream?
Strawberry
If you weren’t a gastroenterologist, what would you be?Florist
Best place you’ve traveled to?
Thailand
Number of cups of coffee you drink per day?
Too many
Favorite city in the US besides the one you live in?
New York City
Favorite sport?
Tennis
Optimist or pessimist?
Optimist
In a Parallel Universe, “I’d Be a Concert Pianist” Says Tennessee GI
She also relishes opportunities to think, to analyze, and solve problems for her patients.
One of her chief interests is inflammatory bowel disease (IBD). It’s reassuring to focus on a field of work “where I know exactly what’s causing the issue, and I can select a therapeutic approach (medication and lifestyle changes) that help a patient achieve remission,” said Dr. Pointer, co-owner and managing partner of Digestive and Liver Health Specialists in Hendersonville, Tenn. She’s also the medical director and a principal investigator of Quality Medical Research in Nashville, and currently serves as chair of the AGA Trainee and Early Career Committee.
Starting her own practice has been just as challenging and rewarding as going through medical school. Medical training does not prepare you for starting your own practice, Dr. Pointer said, so she and her business partner have had to learn as they go. “But I think we’ve done very well. We’ve taken the ups and downs in stride.”
In an interview, Dr. Pointer spoke more about her work in IBD and the ways in which she’s given back to the community through music and mentoring.
Q: Why did you choose GI?
I knew from a very young age that I was going to be a physician. I had always been interested in science. When I got into medical school and became exposed to the different areas, I really liked the cognitive skills where you had to think through a problem or an issue. But I also liked the procedural things as well.
During my internal medicine residency training, I felt that I had a knack for it. As I was looking at different options, I decided on gastroenterology because it combined both cognitive thinking through issues, but also taking it to the next step and intervening through procedures.
Q: During fellowship, your focus was inflammatory bowel disease. What drew your interest to this condition?
There are a lot of different areas within gastroenterology that one can subspecialize in, as we see the full gamut of gastrointestinal and hepatic disorders. But treating some conditions, like functional disorders, means taking more of a ‘trial and error’ approach, and you may not always get the patient a hundred percent better. That’s not to say that we can’t improve a patient’s quality of life, but it’s not always a guarantee.
But inflammatory bowel disease is a little bit different. Because I can point to an exact spot in the intestines that’s causing the problem, it’s very fulfilling for me as a physician to take a patient who is having 10-12 bloody bowel movements a day, to normal form stools and no abdominal pain. They’re able to gain weight and go on about their lives and about their day. So that was why I picked inflammatory bowel disease as my subspecialty.
Q: Tell me about the gastroenterology elective you developed for family medicine residents and undergraduate students. What’s the status of the program now?
I’ve always been interested in teaching and giving back to the next generations. I feel like I had great mentor opportunities and people who helped me along the way. In my previous hospital position, I was able to work with the family medicine department and create an elective through which residents and even undergraduate students could come and shadow and work with me in the clinic and see me performing procedures.
That elective ended once I left that position, at least as far as I’m aware. But in the private practice that I co-own now, we have numerous shadowing opportunities. I was able to give a lecture at Middle Tennessee State University for some students. And through that lecture, many students have reached out to me to shadow. I have allowed them to come shadow and do clinic work as a medical assistant and watch me perform procedures. I have multiple students working with me weekly.
Q: Years ago, you founded the non-profit Enchanted Fingers Piano Lessons, which gave free piano lessons to underserved youth. What was that experience like?
Piano was one of my first loves. In some parallel universe, there’s a Dr. Pointer who is a classical, concert pianist. I started taking piano lessons when I was in early middle school, and I took to it very quickly. I was able to excel. I just loved it. I enjoyed practicing and I still play.
The impetus for starting Enchanted Fingers Piano lessons was because I wanted to give back again to the community. I came from an underserved community. Oftentimes children and young adults in those communities don’t get exposed to extracurricular activities and they don’t even know what they could potentially have a passion for. And I definitely had a passion for piano. I partnered with a church organization and they allowed me to use their church to host these piano lessons, and it was a phenomenal and rewarding experience. I would definitely like to start it up again one day in the future. It was an amazing experience.
It’s actually how I met my husband. He was one of the young adult students who signed up to take lessons. We both still enjoy playing the piano together.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
I’m a creative at heart. I really enjoy sewing and I’m working on a few sewing projects. I just got a serger. It is a machine that helps you finish a seam. It can also be used to sew entire garments. That has been fun, learning how to thread that machine. When I’m not doing that or just relaxing with my family, I do enjoy curling up with a good book. Stephen King is one of my favorite authors.
Lightning Round
Texting or talking?
Talking
Favorite junk food?
Chocolate chip cookies
Cat or dog person?
Cat
Favorite vacation?
Hawaii
How many cups of coffee do you drink per day?
I don’t drink coffee
Favorite ice cream?
Butter pecan
Favorite sport?
I don’t watch sports
Optimist or pessimist?
Optimist
She also relishes opportunities to think, to analyze, and solve problems for her patients.
One of her chief interests is inflammatory bowel disease (IBD). It’s reassuring to focus on a field of work “where I know exactly what’s causing the issue, and I can select a therapeutic approach (medication and lifestyle changes) that help a patient achieve remission,” said Dr. Pointer, co-owner and managing partner of Digestive and Liver Health Specialists in Hendersonville, Tenn. She’s also the medical director and a principal investigator of Quality Medical Research in Nashville, and currently serves as chair of the AGA Trainee and Early Career Committee.
Starting her own practice has been just as challenging and rewarding as going through medical school. Medical training does not prepare you for starting your own practice, Dr. Pointer said, so she and her business partner have had to learn as they go. “But I think we’ve done very well. We’ve taken the ups and downs in stride.”
In an interview, Dr. Pointer spoke more about her work in IBD and the ways in which she’s given back to the community through music and mentoring.
Q: Why did you choose GI?
I knew from a very young age that I was going to be a physician. I had always been interested in science. When I got into medical school and became exposed to the different areas, I really liked the cognitive skills where you had to think through a problem or an issue. But I also liked the procedural things as well.
During my internal medicine residency training, I felt that I had a knack for it. As I was looking at different options, I decided on gastroenterology because it combined both cognitive thinking through issues, but also taking it to the next step and intervening through procedures.
Q: During fellowship, your focus was inflammatory bowel disease. What drew your interest to this condition?
There are a lot of different areas within gastroenterology that one can subspecialize in, as we see the full gamut of gastrointestinal and hepatic disorders. But treating some conditions, like functional disorders, means taking more of a ‘trial and error’ approach, and you may not always get the patient a hundred percent better. That’s not to say that we can’t improve a patient’s quality of life, but it’s not always a guarantee.
But inflammatory bowel disease is a little bit different. Because I can point to an exact spot in the intestines that’s causing the problem, it’s very fulfilling for me as a physician to take a patient who is having 10-12 bloody bowel movements a day, to normal form stools and no abdominal pain. They’re able to gain weight and go on about their lives and about their day. So that was why I picked inflammatory bowel disease as my subspecialty.
Q: Tell me about the gastroenterology elective you developed for family medicine residents and undergraduate students. What’s the status of the program now?
I’ve always been interested in teaching and giving back to the next generations. I feel like I had great mentor opportunities and people who helped me along the way. In my previous hospital position, I was able to work with the family medicine department and create an elective through which residents and even undergraduate students could come and shadow and work with me in the clinic and see me performing procedures.
That elective ended once I left that position, at least as far as I’m aware. But in the private practice that I co-own now, we have numerous shadowing opportunities. I was able to give a lecture at Middle Tennessee State University for some students. And through that lecture, many students have reached out to me to shadow. I have allowed them to come shadow and do clinic work as a medical assistant and watch me perform procedures. I have multiple students working with me weekly.
Q: Years ago, you founded the non-profit Enchanted Fingers Piano Lessons, which gave free piano lessons to underserved youth. What was that experience like?
Piano was one of my first loves. In some parallel universe, there’s a Dr. Pointer who is a classical, concert pianist. I started taking piano lessons when I was in early middle school, and I took to it very quickly. I was able to excel. I just loved it. I enjoyed practicing and I still play.
The impetus for starting Enchanted Fingers Piano lessons was because I wanted to give back again to the community. I came from an underserved community. Oftentimes children and young adults in those communities don’t get exposed to extracurricular activities and they don’t even know what they could potentially have a passion for. And I definitely had a passion for piano. I partnered with a church organization and they allowed me to use their church to host these piano lessons, and it was a phenomenal and rewarding experience. I would definitely like to start it up again one day in the future. It was an amazing experience.
It’s actually how I met my husband. He was one of the young adult students who signed up to take lessons. We both still enjoy playing the piano together.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
I’m a creative at heart. I really enjoy sewing and I’m working on a few sewing projects. I just got a serger. It is a machine that helps you finish a seam. It can also be used to sew entire garments. That has been fun, learning how to thread that machine. When I’m not doing that or just relaxing with my family, I do enjoy curling up with a good book. Stephen King is one of my favorite authors.
Lightning Round
Texting or talking?
Talking
Favorite junk food?
Chocolate chip cookies
Cat or dog person?
Cat
Favorite vacation?
Hawaii
How many cups of coffee do you drink per day?
I don’t drink coffee
Favorite ice cream?
Butter pecan
Favorite sport?
I don’t watch sports
Optimist or pessimist?
Optimist
She also relishes opportunities to think, to analyze, and solve problems for her patients.
One of her chief interests is inflammatory bowel disease (IBD). It’s reassuring to focus on a field of work “where I know exactly what’s causing the issue, and I can select a therapeutic approach (medication and lifestyle changes) that help a patient achieve remission,” said Dr. Pointer, co-owner and managing partner of Digestive and Liver Health Specialists in Hendersonville, Tenn. She’s also the medical director and a principal investigator of Quality Medical Research in Nashville, and currently serves as chair of the AGA Trainee and Early Career Committee.
Starting her own practice has been just as challenging and rewarding as going through medical school. Medical training does not prepare you for starting your own practice, Dr. Pointer said, so she and her business partner have had to learn as they go. “But I think we’ve done very well. We’ve taken the ups and downs in stride.”
In an interview, Dr. Pointer spoke more about her work in IBD and the ways in which she’s given back to the community through music and mentoring.
Q: Why did you choose GI?
I knew from a very young age that I was going to be a physician. I had always been interested in science. When I got into medical school and became exposed to the different areas, I really liked the cognitive skills where you had to think through a problem or an issue. But I also liked the procedural things as well.
During my internal medicine residency training, I felt that I had a knack for it. As I was looking at different options, I decided on gastroenterology because it combined both cognitive thinking through issues, but also taking it to the next step and intervening through procedures.
Q: During fellowship, your focus was inflammatory bowel disease. What drew your interest to this condition?
There are a lot of different areas within gastroenterology that one can subspecialize in, as we see the full gamut of gastrointestinal and hepatic disorders. But treating some conditions, like functional disorders, means taking more of a ‘trial and error’ approach, and you may not always get the patient a hundred percent better. That’s not to say that we can’t improve a patient’s quality of life, but it’s not always a guarantee.
But inflammatory bowel disease is a little bit different. Because I can point to an exact spot in the intestines that’s causing the problem, it’s very fulfilling for me as a physician to take a patient who is having 10-12 bloody bowel movements a day, to normal form stools and no abdominal pain. They’re able to gain weight and go on about their lives and about their day. So that was why I picked inflammatory bowel disease as my subspecialty.
Q: Tell me about the gastroenterology elective you developed for family medicine residents and undergraduate students. What’s the status of the program now?
I’ve always been interested in teaching and giving back to the next generations. I feel like I had great mentor opportunities and people who helped me along the way. In my previous hospital position, I was able to work with the family medicine department and create an elective through which residents and even undergraduate students could come and shadow and work with me in the clinic and see me performing procedures.
That elective ended once I left that position, at least as far as I’m aware. But in the private practice that I co-own now, we have numerous shadowing opportunities. I was able to give a lecture at Middle Tennessee State University for some students. And through that lecture, many students have reached out to me to shadow. I have allowed them to come shadow and do clinic work as a medical assistant and watch me perform procedures. I have multiple students working with me weekly.
Q: Years ago, you founded the non-profit Enchanted Fingers Piano Lessons, which gave free piano lessons to underserved youth. What was that experience like?
Piano was one of my first loves. In some parallel universe, there’s a Dr. Pointer who is a classical, concert pianist. I started taking piano lessons when I was in early middle school, and I took to it very quickly. I was able to excel. I just loved it. I enjoyed practicing and I still play.
The impetus for starting Enchanted Fingers Piano lessons was because I wanted to give back again to the community. I came from an underserved community. Oftentimes children and young adults in those communities don’t get exposed to extracurricular activities and they don’t even know what they could potentially have a passion for. And I definitely had a passion for piano. I partnered with a church organization and they allowed me to use their church to host these piano lessons, and it was a phenomenal and rewarding experience. I would definitely like to start it up again one day in the future. It was an amazing experience.
It’s actually how I met my husband. He was one of the young adult students who signed up to take lessons. We both still enjoy playing the piano together.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
I’m a creative at heart. I really enjoy sewing and I’m working on a few sewing projects. I just got a serger. It is a machine that helps you finish a seam. It can also be used to sew entire garments. That has been fun, learning how to thread that machine. When I’m not doing that or just relaxing with my family, I do enjoy curling up with a good book. Stephen King is one of my favorite authors.
Lightning Round
Texting or talking?
Talking
Favorite junk food?
Chocolate chip cookies
Cat or dog person?
Cat
Favorite vacation?
Hawaii
How many cups of coffee do you drink per day?
I don’t drink coffee
Favorite ice cream?
Butter pecan
Favorite sport?
I don’t watch sports
Optimist or pessimist?
Optimist
Patient Navigators for Serious Illnesses Can Now Bill Under New Medicare Codes
In a move that acknowledges the gauntlet the US health system poses for people facing serious and fatal illnesses, Medicare will pay for a new class of workers to help patients manage treatments for conditions like cancer and heart failure.
The 2024 Medicare physician fee schedule includes new billing codes, including G0023, to pay for 60 minutes a month of care coordination by certified or trained auxiliary personnel working under the direction of a clinician.
A diagnosis of cancer or another serious illness takes a toll beyond the physical effects of the disease. Patients often scramble to make adjustments in family and work schedules to manage treatment, said Samyukta Mullangi, MD, MBA, medical director of oncology at Thyme Care, a Nashville, Tennessee–based firm that provides navigation and coordination services to oncology practices and insurers.
“It just really does create a bit of a pressure cooker for patients,” Dr. Mullangi told this news organization.
Medicare has for many years paid for medical professionals to help patients cope with the complexities of disease, such as chronic care management (CCM) provided by physicians, nurses, and physician assistants.
The new principal illness navigation (PIN) payments are intended to pay for work that to date typically has been done by people without medical degrees, including those involved in peer support networks and community health programs. The US Centers for Medicare and Medicaid Services(CMS) expects these navigators will undergo training and work under the supervision of clinicians.
The new navigators may coordinate care transitions between medical settings, follow up with patients after emergency department (ED) visits, or communicate with skilled nursing facilities regarding the psychosocial needs and functional deficits of a patient, among other functions.
CMS expects the new navigators may:
- Conduct assessments to understand a patient’s life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors.
- Provide support to accomplish the clinician’s treatment plan.
- Coordinate the receipt of needed services from healthcare facilities, home- and community-based service providers, and caregivers.
Peers as Navigators
The new navigators can be former patients who have undergone similar treatments for serious diseases, CMS said. This approach sets the new program apart from other care management services Medicare already covers, program officials wrote in the 2024 physician fee schedule.
“For some conditions, patients are best able to engage with the healthcare system and access care if they have assistance from a single, dedicated individual who has ‘lived experience,’ ” according to the rule.
The agency has taken a broad initial approach in defining what kinds of illnesses a patient may have to qualify for services. Patients must have a serious condition that is expected to last at least 3 months, such as cancer, heart failure, or substance use disorder.
But those without a definitive diagnosis may also qualify to receive navigator services.
In the rule, CMS cited a case in which a CT scan identified a suspicious mass in a patient’s colon. A clinician might decide this person would benefit from navigation services due to the potential risks for an undiagnosed illness.
“Regardless of the definitive diagnosis of the mass, presence of a colonic mass for that patient may be a serious high-risk condition that could, for example, cause obstruction and lead the patient to present to the emergency department, as well as be potentially indicative of an underlying life-threatening illness such as colon cancer,” CMS wrote in the rule.
Navigators often start their work when cancer patients are screened and guide them through initial diagnosis, potential surgery, radiation, or chemotherapy, said Sharon Gentry, MSN, RN, a former nurse navigator who is now the editor in chief of the Journal of the Academy of Oncology Nurse & Patient Navigators.
The navigators are meant to be a trusted and continual presence for patients, who otherwise might be left to start anew in finding help at each phase of care.
The navigators “see the whole picture. They see the whole journey the patient takes, from pre-diagnosis all the way through diagnosis care out through survival,” Ms. Gentry said.
Gaining a special Medicare payment for these kinds of services will elevate this work, she said.
Many newer drugs can target specific mechanisms and proteins of cancer. Often, oncology treatment involves testing to find out if mutations are allowing the cancer cells to evade a patient’s immune system.
Checking these biomarkers takes time, however. Patients sometimes become frustrated because they are anxious to begin treatment. Patients may receive inaccurate information from friends or family who went through treatment previously. Navigators can provide knowledge on the current state of care for a patient’s disease, helping them better manage anxieties.
“You have to explain to them that things have changed since the guy you drink coffee with was diagnosed with cancer, and there may be a drug that could target that,” Ms. Gentry said.
Potential Challenges
Initial uptake of the new PIN codes may be slow going, however, as clinicians and health systems may already use well-established codes. These include CCM and principal care management services, which may pay higher rates, Mullangi said.
“There might be sensitivity around not wanting to cannibalize existing programs with a new program,” Dr. Mullangi said.
In addition, many patients will have a copay for the services of principal illness navigators, Dr. Mullangi said.
While many patients have additional insurance that would cover the service, not all do. People with traditional Medicare coverage can sometimes pay 20% of the cost of some medical services.
“I think that may give patients pause, particularly if they’re already feeling the financial burden of a cancer treatment journey,” Dr. Mullangi said.
Pay rates for PIN services involve calculations of regional price differences, which are posted publicly by CMS, and potential added fees for services provided by hospital-affiliated organizations.
Consider payments for code G0023, covering 60 minutes of principal navigation services provided in a single month.
A set reimbursement for patients cared for in independent medical practices exists, with variation for local costs. Medicare’s non-facility price for G0023 would be $102.41 in some parts of Silicon Valley in California, including San Jose. In Arkansas, where costs are lower, reimbursement would be $73.14 for this same service.
Patients who get services covered by code G0023 in independent medical practices would have monthly copays of about $15-$20, depending on where they live.
The tab for patients tends to be higher for these same services if delivered through a medical practice owned by a hospital, as this would trigger the addition of facility fees to the payments made to cover the services. Facility fees are difficult for the public to ascertain before getting a treatment or service.
Dr. Mullangi and Ms. Gentry reported no relevant financial disclosures outside of their employers.
A version of this article first appeared on Medscape.com.
In a move that acknowledges the gauntlet the US health system poses for people facing serious and fatal illnesses, Medicare will pay for a new class of workers to help patients manage treatments for conditions like cancer and heart failure.
The 2024 Medicare physician fee schedule includes new billing codes, including G0023, to pay for 60 minutes a month of care coordination by certified or trained auxiliary personnel working under the direction of a clinician.
A diagnosis of cancer or another serious illness takes a toll beyond the physical effects of the disease. Patients often scramble to make adjustments in family and work schedules to manage treatment, said Samyukta Mullangi, MD, MBA, medical director of oncology at Thyme Care, a Nashville, Tennessee–based firm that provides navigation and coordination services to oncology practices and insurers.
“It just really does create a bit of a pressure cooker for patients,” Dr. Mullangi told this news organization.
Medicare has for many years paid for medical professionals to help patients cope with the complexities of disease, such as chronic care management (CCM) provided by physicians, nurses, and physician assistants.
The new principal illness navigation (PIN) payments are intended to pay for work that to date typically has been done by people without medical degrees, including those involved in peer support networks and community health programs. The US Centers for Medicare and Medicaid Services(CMS) expects these navigators will undergo training and work under the supervision of clinicians.
The new navigators may coordinate care transitions between medical settings, follow up with patients after emergency department (ED) visits, or communicate with skilled nursing facilities regarding the psychosocial needs and functional deficits of a patient, among other functions.
CMS expects the new navigators may:
- Conduct assessments to understand a patient’s life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors.
- Provide support to accomplish the clinician’s treatment plan.
- Coordinate the receipt of needed services from healthcare facilities, home- and community-based service providers, and caregivers.
Peers as Navigators
The new navigators can be former patients who have undergone similar treatments for serious diseases, CMS said. This approach sets the new program apart from other care management services Medicare already covers, program officials wrote in the 2024 physician fee schedule.
“For some conditions, patients are best able to engage with the healthcare system and access care if they have assistance from a single, dedicated individual who has ‘lived experience,’ ” according to the rule.
The agency has taken a broad initial approach in defining what kinds of illnesses a patient may have to qualify for services. Patients must have a serious condition that is expected to last at least 3 months, such as cancer, heart failure, or substance use disorder.
But those without a definitive diagnosis may also qualify to receive navigator services.
In the rule, CMS cited a case in which a CT scan identified a suspicious mass in a patient’s colon. A clinician might decide this person would benefit from navigation services due to the potential risks for an undiagnosed illness.
“Regardless of the definitive diagnosis of the mass, presence of a colonic mass for that patient may be a serious high-risk condition that could, for example, cause obstruction and lead the patient to present to the emergency department, as well as be potentially indicative of an underlying life-threatening illness such as colon cancer,” CMS wrote in the rule.
Navigators often start their work when cancer patients are screened and guide them through initial diagnosis, potential surgery, radiation, or chemotherapy, said Sharon Gentry, MSN, RN, a former nurse navigator who is now the editor in chief of the Journal of the Academy of Oncology Nurse & Patient Navigators.
The navigators are meant to be a trusted and continual presence for patients, who otherwise might be left to start anew in finding help at each phase of care.
The navigators “see the whole picture. They see the whole journey the patient takes, from pre-diagnosis all the way through diagnosis care out through survival,” Ms. Gentry said.
Gaining a special Medicare payment for these kinds of services will elevate this work, she said.
Many newer drugs can target specific mechanisms and proteins of cancer. Often, oncology treatment involves testing to find out if mutations are allowing the cancer cells to evade a patient’s immune system.
Checking these biomarkers takes time, however. Patients sometimes become frustrated because they are anxious to begin treatment. Patients may receive inaccurate information from friends or family who went through treatment previously. Navigators can provide knowledge on the current state of care for a patient’s disease, helping them better manage anxieties.
“You have to explain to them that things have changed since the guy you drink coffee with was diagnosed with cancer, and there may be a drug that could target that,” Ms. Gentry said.
Potential Challenges
Initial uptake of the new PIN codes may be slow going, however, as clinicians and health systems may already use well-established codes. These include CCM and principal care management services, which may pay higher rates, Mullangi said.
“There might be sensitivity around not wanting to cannibalize existing programs with a new program,” Dr. Mullangi said.
In addition, many patients will have a copay for the services of principal illness navigators, Dr. Mullangi said.
While many patients have additional insurance that would cover the service, not all do. People with traditional Medicare coverage can sometimes pay 20% of the cost of some medical services.
“I think that may give patients pause, particularly if they’re already feeling the financial burden of a cancer treatment journey,” Dr. Mullangi said.
Pay rates for PIN services involve calculations of regional price differences, which are posted publicly by CMS, and potential added fees for services provided by hospital-affiliated organizations.
Consider payments for code G0023, covering 60 minutes of principal navigation services provided in a single month.
A set reimbursement for patients cared for in independent medical practices exists, with variation for local costs. Medicare’s non-facility price for G0023 would be $102.41 in some parts of Silicon Valley in California, including San Jose. In Arkansas, where costs are lower, reimbursement would be $73.14 for this same service.
Patients who get services covered by code G0023 in independent medical practices would have monthly copays of about $15-$20, depending on where they live.
The tab for patients tends to be higher for these same services if delivered through a medical practice owned by a hospital, as this would trigger the addition of facility fees to the payments made to cover the services. Facility fees are difficult for the public to ascertain before getting a treatment or service.
Dr. Mullangi and Ms. Gentry reported no relevant financial disclosures outside of their employers.
A version of this article first appeared on Medscape.com.
In a move that acknowledges the gauntlet the US health system poses for people facing serious and fatal illnesses, Medicare will pay for a new class of workers to help patients manage treatments for conditions like cancer and heart failure.
The 2024 Medicare physician fee schedule includes new billing codes, including G0023, to pay for 60 minutes a month of care coordination by certified or trained auxiliary personnel working under the direction of a clinician.
A diagnosis of cancer or another serious illness takes a toll beyond the physical effects of the disease. Patients often scramble to make adjustments in family and work schedules to manage treatment, said Samyukta Mullangi, MD, MBA, medical director of oncology at Thyme Care, a Nashville, Tennessee–based firm that provides navigation and coordination services to oncology practices and insurers.
“It just really does create a bit of a pressure cooker for patients,” Dr. Mullangi told this news organization.
Medicare has for many years paid for medical professionals to help patients cope with the complexities of disease, such as chronic care management (CCM) provided by physicians, nurses, and physician assistants.
The new principal illness navigation (PIN) payments are intended to pay for work that to date typically has been done by people without medical degrees, including those involved in peer support networks and community health programs. The US Centers for Medicare and Medicaid Services(CMS) expects these navigators will undergo training and work under the supervision of clinicians.
The new navigators may coordinate care transitions between medical settings, follow up with patients after emergency department (ED) visits, or communicate with skilled nursing facilities regarding the psychosocial needs and functional deficits of a patient, among other functions.
CMS expects the new navigators may:
- Conduct assessments to understand a patient’s life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors.
- Provide support to accomplish the clinician’s treatment plan.
- Coordinate the receipt of needed services from healthcare facilities, home- and community-based service providers, and caregivers.
Peers as Navigators
The new navigators can be former patients who have undergone similar treatments for serious diseases, CMS said. This approach sets the new program apart from other care management services Medicare already covers, program officials wrote in the 2024 physician fee schedule.
“For some conditions, patients are best able to engage with the healthcare system and access care if they have assistance from a single, dedicated individual who has ‘lived experience,’ ” according to the rule.
The agency has taken a broad initial approach in defining what kinds of illnesses a patient may have to qualify for services. Patients must have a serious condition that is expected to last at least 3 months, such as cancer, heart failure, or substance use disorder.
But those without a definitive diagnosis may also qualify to receive navigator services.
In the rule, CMS cited a case in which a CT scan identified a suspicious mass in a patient’s colon. A clinician might decide this person would benefit from navigation services due to the potential risks for an undiagnosed illness.
“Regardless of the definitive diagnosis of the mass, presence of a colonic mass for that patient may be a serious high-risk condition that could, for example, cause obstruction and lead the patient to present to the emergency department, as well as be potentially indicative of an underlying life-threatening illness such as colon cancer,” CMS wrote in the rule.
Navigators often start their work when cancer patients are screened and guide them through initial diagnosis, potential surgery, radiation, or chemotherapy, said Sharon Gentry, MSN, RN, a former nurse navigator who is now the editor in chief of the Journal of the Academy of Oncology Nurse & Patient Navigators.
The navigators are meant to be a trusted and continual presence for patients, who otherwise might be left to start anew in finding help at each phase of care.
The navigators “see the whole picture. They see the whole journey the patient takes, from pre-diagnosis all the way through diagnosis care out through survival,” Ms. Gentry said.
Gaining a special Medicare payment for these kinds of services will elevate this work, she said.
Many newer drugs can target specific mechanisms and proteins of cancer. Often, oncology treatment involves testing to find out if mutations are allowing the cancer cells to evade a patient’s immune system.
Checking these biomarkers takes time, however. Patients sometimes become frustrated because they are anxious to begin treatment. Patients may receive inaccurate information from friends or family who went through treatment previously. Navigators can provide knowledge on the current state of care for a patient’s disease, helping them better manage anxieties.
“You have to explain to them that things have changed since the guy you drink coffee with was diagnosed with cancer, and there may be a drug that could target that,” Ms. Gentry said.
Potential Challenges
Initial uptake of the new PIN codes may be slow going, however, as clinicians and health systems may already use well-established codes. These include CCM and principal care management services, which may pay higher rates, Mullangi said.
“There might be sensitivity around not wanting to cannibalize existing programs with a new program,” Dr. Mullangi said.
In addition, many patients will have a copay for the services of principal illness navigators, Dr. Mullangi said.
While many patients have additional insurance that would cover the service, not all do. People with traditional Medicare coverage can sometimes pay 20% of the cost of some medical services.
“I think that may give patients pause, particularly if they’re already feeling the financial burden of a cancer treatment journey,” Dr. Mullangi said.
Pay rates for PIN services involve calculations of regional price differences, which are posted publicly by CMS, and potential added fees for services provided by hospital-affiliated organizations.
Consider payments for code G0023, covering 60 minutes of principal navigation services provided in a single month.
A set reimbursement for patients cared for in independent medical practices exists, with variation for local costs. Medicare’s non-facility price for G0023 would be $102.41 in some parts of Silicon Valley in California, including San Jose. In Arkansas, where costs are lower, reimbursement would be $73.14 for this same service.
Patients who get services covered by code G0023 in independent medical practices would have monthly copays of about $15-$20, depending on where they live.
The tab for patients tends to be higher for these same services if delivered through a medical practice owned by a hospital, as this would trigger the addition of facility fees to the payments made to cover the services. Facility fees are difficult for the public to ascertain before getting a treatment or service.
Dr. Mullangi and Ms. Gentry reported no relevant financial disclosures outside of their employers.
A version of this article first appeared on Medscape.com.
SVS Now Accepting Abstracts for VAM 2017
Abstracts for the 2017 Vascular Annual Meeting are now being accepted. The submission site opened Monday, Nov. 14 for the meeting, to be held May 31 to June 3, 2017, in San Diego. Plenary sessions and exhibits will be June 1 to 3.
Participants may submit abstracts into any of 14 categories and a number of presentation types, including videos. In 2016, organizers selected approximately two-thirds of the submitted abstracts, and this year the VAM Program Committee is seeking additional venues for people to present their work in, including more sessions and other presentation formats.
Click here for abstract guidelines and more information. Abstracts themselves may be submitted here.
Abstracts for the 2017 Vascular Annual Meeting are now being accepted. The submission site opened Monday, Nov. 14 for the meeting, to be held May 31 to June 3, 2017, in San Diego. Plenary sessions and exhibits will be June 1 to 3.
Participants may submit abstracts into any of 14 categories and a number of presentation types, including videos. In 2016, organizers selected approximately two-thirds of the submitted abstracts, and this year the VAM Program Committee is seeking additional venues for people to present their work in, including more sessions and other presentation formats.
Click here for abstract guidelines and more information. Abstracts themselves may be submitted here.
Abstracts for the 2017 Vascular Annual Meeting are now being accepted. The submission site opened Monday, Nov. 14 for the meeting, to be held May 31 to June 3, 2017, in San Diego. Plenary sessions and exhibits will be June 1 to 3.
Participants may submit abstracts into any of 14 categories and a number of presentation types, including videos. In 2016, organizers selected approximately two-thirds of the submitted abstracts, and this year the VAM Program Committee is seeking additional venues for people to present their work in, including more sessions and other presentation formats.
Click here for abstract guidelines and more information. Abstracts themselves may be submitted here.
Atypical Antipsychotics Tied to Adrenal Issues
NEW ORLEANS — It is important to recognize the potential for atypical antipsychotics to cause adrenal insufficiency to ensure that the condition is managed appropriately, according to Dr. Violeta Tan and Dr. Natalie Rasgon.
They described the case of a 54-year-old man with a history of depression and posttraumatic stress disorder who was admitted to the hospital after complaining of malaise 9 days after a previous admission for a urinary tract infection that had been treated with ciprofloxacin.
At the first admission, the patient was restarted on 225 mg/day of bupropion and 300 mg/day of quetiapine (Seroquel), both of which he had discontinued 6–8 months prior, said Dr. Tan and Dr. Rasgon, who presented the case in a poster session at the American Psychiatric Association's Institute of Psychiatric Services.
Symptoms at the time of the second admission included fatigue, warmth, chills, loose stools, mild headache, and reproducible chest wall pain. Laboratory findings showed that previously normal eosinophil levels were elevated (6.5%–8.3%), reported Dr. Tan and Dr. Rasgon, both of Stanford (Calif.) University.
A work-up for infection, malignancy, and rheumatologic conditions was negative, and primary adrenal insufficiency was ruled out based on the findings of a cosyntropin stimulation test. However, adrenocorticotropic hormone (ACTH) levels (less than 5 pg/mL) indicated secondary or tertiary adrenal insufficiency, and a review of the patient's medications alerted the authors to the possibility of quetiapine-associated ACTH and cortisol reductions.
Atypical antipsychotics such as quetiapine can reduce cortisol levels—often in association with improved psychopathology. Thus, although the cortisol-lowering effects of such drugs may ameliorate negative symptomatology, the reduction could be detrimental, they wrote.
However, adrenal insufficiency caused by such agents has not been specifically studied, and although it might seem appropriate to discontinue the “offending agent,” the risks of discontinuing antipsychotics should be weighed against the benefits of preventing adrenal insufficiency sequelae, they added.
In the current case, which also demonstrated that quetiapine administration, particularly under precipitating circumstances such as an infection or stress, can contribute to reductions in ACTH and cortisol secretion, the patient's condition improved after quetiapine, a standard treatment for adrenal insufficiency, was administered at 20 mg every morning and at 10 mg at bedtime.
Atypical antipsychotics can cause adrenal insufficiency, which presents ambiguously, and awareness of this can be key in preventing false diagnoses, they said.
Adrenal insufficiency can present ambiguously, which can lead to false diagnoses. DR. RASGON
Spotting Adrenal Insufficiency
Dr. Tan and Dr. Rasgon say determining whether a patient has developed adrenal insufficiency requires an investigation into four areas:
▸ Symptoms. Look for weakness and fatigue, abdominal distress, anorexia, nausea, vomiting, myalgia or arthralgia, postural dizziness, salt craving, headache, impaired memory, and depression.
▸ Physical findings. Some factors to look out for are increased pigmentation, postural hypotension, tachycardia, fever, decreased body hair, vitiligo, amenorrhea, and cold intolerance.
▸ Laboratory findings. Red flags include hyponatremia, hyperkalemia, hypoglycemia, eosinophilia, and elevated thyroid stimulating hormone.
▸ Clinical problems. Watch for hemodynamic instability, ongoing inflammation, multiple-organ dysfunction, and hypoglycemia.
NEW ORLEANS — It is important to recognize the potential for atypical antipsychotics to cause adrenal insufficiency to ensure that the condition is managed appropriately, according to Dr. Violeta Tan and Dr. Natalie Rasgon.
They described the case of a 54-year-old man with a history of depression and posttraumatic stress disorder who was admitted to the hospital after complaining of malaise 9 days after a previous admission for a urinary tract infection that had been treated with ciprofloxacin.
At the first admission, the patient was restarted on 225 mg/day of bupropion and 300 mg/day of quetiapine (Seroquel), both of which he had discontinued 6–8 months prior, said Dr. Tan and Dr. Rasgon, who presented the case in a poster session at the American Psychiatric Association's Institute of Psychiatric Services.
Symptoms at the time of the second admission included fatigue, warmth, chills, loose stools, mild headache, and reproducible chest wall pain. Laboratory findings showed that previously normal eosinophil levels were elevated (6.5%–8.3%), reported Dr. Tan and Dr. Rasgon, both of Stanford (Calif.) University.
A work-up for infection, malignancy, and rheumatologic conditions was negative, and primary adrenal insufficiency was ruled out based on the findings of a cosyntropin stimulation test. However, adrenocorticotropic hormone (ACTH) levels (less than 5 pg/mL) indicated secondary or tertiary adrenal insufficiency, and a review of the patient's medications alerted the authors to the possibility of quetiapine-associated ACTH and cortisol reductions.
Atypical antipsychotics such as quetiapine can reduce cortisol levels—often in association with improved psychopathology. Thus, although the cortisol-lowering effects of such drugs may ameliorate negative symptomatology, the reduction could be detrimental, they wrote.
However, adrenal insufficiency caused by such agents has not been specifically studied, and although it might seem appropriate to discontinue the “offending agent,” the risks of discontinuing antipsychotics should be weighed against the benefits of preventing adrenal insufficiency sequelae, they added.
In the current case, which also demonstrated that quetiapine administration, particularly under precipitating circumstances such as an infection or stress, can contribute to reductions in ACTH and cortisol secretion, the patient's condition improved after quetiapine, a standard treatment for adrenal insufficiency, was administered at 20 mg every morning and at 10 mg at bedtime.
Atypical antipsychotics can cause adrenal insufficiency, which presents ambiguously, and awareness of this can be key in preventing false diagnoses, they said.
Adrenal insufficiency can present ambiguously, which can lead to false diagnoses. DR. RASGON
Spotting Adrenal Insufficiency
Dr. Tan and Dr. Rasgon say determining whether a patient has developed adrenal insufficiency requires an investigation into four areas:
▸ Symptoms. Look for weakness and fatigue, abdominal distress, anorexia, nausea, vomiting, myalgia or arthralgia, postural dizziness, salt craving, headache, impaired memory, and depression.
▸ Physical findings. Some factors to look out for are increased pigmentation, postural hypotension, tachycardia, fever, decreased body hair, vitiligo, amenorrhea, and cold intolerance.
▸ Laboratory findings. Red flags include hyponatremia, hyperkalemia, hypoglycemia, eosinophilia, and elevated thyroid stimulating hormone.
▸ Clinical problems. Watch for hemodynamic instability, ongoing inflammation, multiple-organ dysfunction, and hypoglycemia.
NEW ORLEANS — It is important to recognize the potential for atypical antipsychotics to cause adrenal insufficiency to ensure that the condition is managed appropriately, according to Dr. Violeta Tan and Dr. Natalie Rasgon.
They described the case of a 54-year-old man with a history of depression and posttraumatic stress disorder who was admitted to the hospital after complaining of malaise 9 days after a previous admission for a urinary tract infection that had been treated with ciprofloxacin.
At the first admission, the patient was restarted on 225 mg/day of bupropion and 300 mg/day of quetiapine (Seroquel), both of which he had discontinued 6–8 months prior, said Dr. Tan and Dr. Rasgon, who presented the case in a poster session at the American Psychiatric Association's Institute of Psychiatric Services.
Symptoms at the time of the second admission included fatigue, warmth, chills, loose stools, mild headache, and reproducible chest wall pain. Laboratory findings showed that previously normal eosinophil levels were elevated (6.5%–8.3%), reported Dr. Tan and Dr. Rasgon, both of Stanford (Calif.) University.
A work-up for infection, malignancy, and rheumatologic conditions was negative, and primary adrenal insufficiency was ruled out based on the findings of a cosyntropin stimulation test. However, adrenocorticotropic hormone (ACTH) levels (less than 5 pg/mL) indicated secondary or tertiary adrenal insufficiency, and a review of the patient's medications alerted the authors to the possibility of quetiapine-associated ACTH and cortisol reductions.
Atypical antipsychotics such as quetiapine can reduce cortisol levels—often in association with improved psychopathology. Thus, although the cortisol-lowering effects of such drugs may ameliorate negative symptomatology, the reduction could be detrimental, they wrote.
However, adrenal insufficiency caused by such agents has not been specifically studied, and although it might seem appropriate to discontinue the “offending agent,” the risks of discontinuing antipsychotics should be weighed against the benefits of preventing adrenal insufficiency sequelae, they added.
In the current case, which also demonstrated that quetiapine administration, particularly under precipitating circumstances such as an infection or stress, can contribute to reductions in ACTH and cortisol secretion, the patient's condition improved after quetiapine, a standard treatment for adrenal insufficiency, was administered at 20 mg every morning and at 10 mg at bedtime.
Atypical antipsychotics can cause adrenal insufficiency, which presents ambiguously, and awareness of this can be key in preventing false diagnoses, they said.
Adrenal insufficiency can present ambiguously, which can lead to false diagnoses. DR. RASGON
Spotting Adrenal Insufficiency
Dr. Tan and Dr. Rasgon say determining whether a patient has developed adrenal insufficiency requires an investigation into four areas:
▸ Symptoms. Look for weakness and fatigue, abdominal distress, anorexia, nausea, vomiting, myalgia or arthralgia, postural dizziness, salt craving, headache, impaired memory, and depression.
▸ Physical findings. Some factors to look out for are increased pigmentation, postural hypotension, tachycardia, fever, decreased body hair, vitiligo, amenorrhea, and cold intolerance.
▸ Laboratory findings. Red flags include hyponatremia, hyperkalemia, hypoglycemia, eosinophilia, and elevated thyroid stimulating hormone.
▸ Clinical problems. Watch for hemodynamic instability, ongoing inflammation, multiple-organ dysfunction, and hypoglycemia.
Beyond Weight Loss: The Expanding Role of GLP-1s in Oncology
Beyond Weight Loss: The Expanding Role of GLP-1s in Oncology
This transcript has been edited for clarity.
Coral Olazagasti, MD: Hi, everyone. Good afternoon. My name is Dr Coral Olazagasti, and I’m a medical oncologist from the University of Miami. I’m excited to be here with my colleague and my friend, Carolina. Dr Bernabe, Can you please introduce yourself?
Carolina Bernabe, MD: I am Dr Carolina Bernabe. I’m one of the gastrointestinal (GI) oncologists at Montefiore Einstein Comprehensive Cancer Center. Thank you for having me today.
Olazagasti: We’re excited because we know that there has been excitement and interest in GLP-1s in cancer. You would think, like, “Hmm, let’s just combine a GI oncologist with a thoracic oncologist to talk about GLP-1s.”
I wanted to bring the conversation to the GLP-1s because we know that it’s been becoming a boom. You see it in your home because your husband is an endocrinologist, and many people are on these drugs. It’s been remarkable, the use and the benefits that we’ve seen so far. Then to know that they might have a benefit in cancer, I think it’s wonderful and very interesting.
What are your thoughts?
Bernabe: When looking at the data on how many patients are using this medication, you’re talking about 12% of the whole US population, which is, like, 44 million people. That’s crazy. Looking at the abstracts that were presented here at ASCO, they looked at these numbers and looked at these patients with cancer, which is around 1000 patients, and then they were evaluating what is the benefit of GLP-1s. You had a chance to look at the abstract, I think?
Olazagasti: Yeah. We have a retrospective study where the authors review a database. There were around 1000 patients, like you said, on GLP-1s with a history of cancer, and the benefit was profound. They found at 24 months there was an overall survival benefit, not only for breast but also prostate cancer, in patients on GLP-1s. Granted, I know that we’re looking into retrospective studies, but I think it makes you wonder if we’re seeing these trends in a retrospective fashion in breast and prostate, where else are we seeing it? I think it’s just a matter of looking at the data.
Bernabe: Even though it was a retrospective analysis, they also did this propensity score where it’s like matching, and that tries to create kind of a randomized clinical trial.
Olazagasti: After adjusting, it was for age and other factors.
Bernabe: Correct.
Olazagasti: The benefits were sustained, so I think it’s wonderful.
What about the other abstract? There was also another abstract. This one was in patients that had a history of cancer and were on GLP-1s, but they also were on immune checkpoint inhibitors. This database covered more patients. I think it was around 3800 patients that were in this particular retrospective study. That study found that not only were the patients having benefits of survival those patients on immune checkpoint inhibitors and GLP-1s, but also we’re seeing that the patients had lower rates of immune-related adverse events. It’s just mind-blowing to me.
Bernabe: Completely agree with you. We are seeing the benefit not only in the survival, who knows, maybe some decrease in the inflammatory component on cancer and tumor microenvironment, but also we’re seeing less events related to immunotherapy and less immune toxicity, right, that we’re always worried about and the patients need to start using a steroid. Maybe in the future, this can be used as a steroid-sparing agent. It’s wonderful news.
Olazagasti: Yeah, I know. We’ve been seeing data from rheumatologic disorders that GLP-1s help with that inflammation, so you’re right. Sometimes autoimmune diseases are our limiting factor to be able to offer these patients immunotherapy, and oftentimes our only choices are chemotherapy.
Bernabe: It opens a window.
Olazagasti: It may be allowing them a possibility of controlling their autoimmune disease while also being able to challenge them. I’m so excited. I think we’re going to start seeing these studies planned and designed in a prospective fashion, so I wonder how these data are going to look in the long term.
Bernabe: I think this is just the tip of an iceberg and will open up the opportunities to further prospective studies and trials.
Olazagasti: There’s a large amount of excitement also for patients, at least in the thoracic space, where with many of these drugs — especially TKIs, like lorlatinib for ALK-positive lung cancer — you have a large amount of edema. Even in patients with docetaxel, too, you have some swelling. With that agent that I mentioned, lorlatinib, patients also had high cholesterol levels, and that’s really a challenge.
I’m interested to see what the role will be of GLP-1s in these cohorts of patients. Is this going to be something where not only do they hopefully derive a survival benefit, but also in the side effect profile and in quality of life?
I’m excited to see. It’s crazy to be an oncologist in 2026, and so it’s honestly such a pleasure for me to see science advancing. At the end of the day, we want to make sure that the studies and the discoveries that we have are applicable to our patients and are something that we can incorporate outside of clinical trials and into the real world.
Bernabe: Especially this drug that is already popular, right? Now we’re seeing an extra benefit on top of all the weight loss and decrease in inflammation in general.
Olazagasti: Thank you for this wonderful discussion, and thank you for watching our video. Have a great day.
Bernabe: Thank you for having me.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Coral Olazagasti, MD: Hi, everyone. Good afternoon. My name is Dr Coral Olazagasti, and I’m a medical oncologist from the University of Miami. I’m excited to be here with my colleague and my friend, Carolina. Dr Bernabe, Can you please introduce yourself?
Carolina Bernabe, MD: I am Dr Carolina Bernabe. I’m one of the gastrointestinal (GI) oncologists at Montefiore Einstein Comprehensive Cancer Center. Thank you for having me today.
Olazagasti: We’re excited because we know that there has been excitement and interest in GLP-1s in cancer. You would think, like, “Hmm, let’s just combine a GI oncologist with a thoracic oncologist to talk about GLP-1s.”
I wanted to bring the conversation to the GLP-1s because we know that it’s been becoming a boom. You see it in your home because your husband is an endocrinologist, and many people are on these drugs. It’s been remarkable, the use and the benefits that we’ve seen so far. Then to know that they might have a benefit in cancer, I think it’s wonderful and very interesting.
What are your thoughts?
Bernabe: When looking at the data on how many patients are using this medication, you’re talking about 12% of the whole US population, which is, like, 44 million people. That’s crazy. Looking at the abstracts that were presented here at ASCO, they looked at these numbers and looked at these patients with cancer, which is around 1000 patients, and then they were evaluating what is the benefit of GLP-1s. You had a chance to look at the abstract, I think?
Olazagasti: Yeah. We have a retrospective study where the authors review a database. There were around 1000 patients, like you said, on GLP-1s with a history of cancer, and the benefit was profound. They found at 24 months there was an overall survival benefit, not only for breast but also prostate cancer, in patients on GLP-1s. Granted, I know that we’re looking into retrospective studies, but I think it makes you wonder if we’re seeing these trends in a retrospective fashion in breast and prostate, where else are we seeing it? I think it’s just a matter of looking at the data.
Bernabe: Even though it was a retrospective analysis, they also did this propensity score where it’s like matching, and that tries to create kind of a randomized clinical trial.
Olazagasti: After adjusting, it was for age and other factors.
Bernabe: Correct.
Olazagasti: The benefits were sustained, so I think it’s wonderful.
What about the other abstract? There was also another abstract. This one was in patients that had a history of cancer and were on GLP-1s, but they also were on immune checkpoint inhibitors. This database covered more patients. I think it was around 3800 patients that were in this particular retrospective study. That study found that not only were the patients having benefits of survival those patients on immune checkpoint inhibitors and GLP-1s, but also we’re seeing that the patients had lower rates of immune-related adverse events. It’s just mind-blowing to me.
Bernabe: Completely agree with you. We are seeing the benefit not only in the survival, who knows, maybe some decrease in the inflammatory component on cancer and tumor microenvironment, but also we’re seeing less events related to immunotherapy and less immune toxicity, right, that we’re always worried about and the patients need to start using a steroid. Maybe in the future, this can be used as a steroid-sparing agent. It’s wonderful news.
Olazagasti: Yeah, I know. We’ve been seeing data from rheumatologic disorders that GLP-1s help with that inflammation, so you’re right. Sometimes autoimmune diseases are our limiting factor to be able to offer these patients immunotherapy, and oftentimes our only choices are chemotherapy.
Bernabe: It opens a window.
Olazagasti: It may be allowing them a possibility of controlling their autoimmune disease while also being able to challenge them. I’m so excited. I think we’re going to start seeing these studies planned and designed in a prospective fashion, so I wonder how these data are going to look in the long term.
Bernabe: I think this is just the tip of an iceberg and will open up the opportunities to further prospective studies and trials.
Olazagasti: There’s a large amount of excitement also for patients, at least in the thoracic space, where with many of these drugs — especially TKIs, like lorlatinib for ALK-positive lung cancer — you have a large amount of edema. Even in patients with docetaxel, too, you have some swelling. With that agent that I mentioned, lorlatinib, patients also had high cholesterol levels, and that’s really a challenge.
I’m interested to see what the role will be of GLP-1s in these cohorts of patients. Is this going to be something where not only do they hopefully derive a survival benefit, but also in the side effect profile and in quality of life?
I’m excited to see. It’s crazy to be an oncologist in 2026, and so it’s honestly such a pleasure for me to see science advancing. At the end of the day, we want to make sure that the studies and the discoveries that we have are applicable to our patients and are something that we can incorporate outside of clinical trials and into the real world.
Bernabe: Especially this drug that is already popular, right? Now we’re seeing an extra benefit on top of all the weight loss and decrease in inflammation in general.
Olazagasti: Thank you for this wonderful discussion, and thank you for watching our video. Have a great day.
Bernabe: Thank you for having me.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Coral Olazagasti, MD: Hi, everyone. Good afternoon. My name is Dr Coral Olazagasti, and I’m a medical oncologist from the University of Miami. I’m excited to be here with my colleague and my friend, Carolina. Dr Bernabe, Can you please introduce yourself?
Carolina Bernabe, MD: I am Dr Carolina Bernabe. I’m one of the gastrointestinal (GI) oncologists at Montefiore Einstein Comprehensive Cancer Center. Thank you for having me today.
Olazagasti: We’re excited because we know that there has been excitement and interest in GLP-1s in cancer. You would think, like, “Hmm, let’s just combine a GI oncologist with a thoracic oncologist to talk about GLP-1s.”
I wanted to bring the conversation to the GLP-1s because we know that it’s been becoming a boom. You see it in your home because your husband is an endocrinologist, and many people are on these drugs. It’s been remarkable, the use and the benefits that we’ve seen so far. Then to know that they might have a benefit in cancer, I think it’s wonderful and very interesting.
What are your thoughts?
Bernabe: When looking at the data on how many patients are using this medication, you’re talking about 12% of the whole US population, which is, like, 44 million people. That’s crazy. Looking at the abstracts that were presented here at ASCO, they looked at these numbers and looked at these patients with cancer, which is around 1000 patients, and then they were evaluating what is the benefit of GLP-1s. You had a chance to look at the abstract, I think?
Olazagasti: Yeah. We have a retrospective study where the authors review a database. There were around 1000 patients, like you said, on GLP-1s with a history of cancer, and the benefit was profound. They found at 24 months there was an overall survival benefit, not only for breast but also prostate cancer, in patients on GLP-1s. Granted, I know that we’re looking into retrospective studies, but I think it makes you wonder if we’re seeing these trends in a retrospective fashion in breast and prostate, where else are we seeing it? I think it’s just a matter of looking at the data.
Bernabe: Even though it was a retrospective analysis, they also did this propensity score where it’s like matching, and that tries to create kind of a randomized clinical trial.
Olazagasti: After adjusting, it was for age and other factors.
Bernabe: Correct.
Olazagasti: The benefits were sustained, so I think it’s wonderful.
What about the other abstract? There was also another abstract. This one was in patients that had a history of cancer and were on GLP-1s, but they also were on immune checkpoint inhibitors. This database covered more patients. I think it was around 3800 patients that were in this particular retrospective study. That study found that not only were the patients having benefits of survival those patients on immune checkpoint inhibitors and GLP-1s, but also we’re seeing that the patients had lower rates of immune-related adverse events. It’s just mind-blowing to me.
Bernabe: Completely agree with you. We are seeing the benefit not only in the survival, who knows, maybe some decrease in the inflammatory component on cancer and tumor microenvironment, but also we’re seeing less events related to immunotherapy and less immune toxicity, right, that we’re always worried about and the patients need to start using a steroid. Maybe in the future, this can be used as a steroid-sparing agent. It’s wonderful news.
Olazagasti: Yeah, I know. We’ve been seeing data from rheumatologic disorders that GLP-1s help with that inflammation, so you’re right. Sometimes autoimmune diseases are our limiting factor to be able to offer these patients immunotherapy, and oftentimes our only choices are chemotherapy.
Bernabe: It opens a window.
Olazagasti: It may be allowing them a possibility of controlling their autoimmune disease while also being able to challenge them. I’m so excited. I think we’re going to start seeing these studies planned and designed in a prospective fashion, so I wonder how these data are going to look in the long term.
Bernabe: I think this is just the tip of an iceberg and will open up the opportunities to further prospective studies and trials.
Olazagasti: There’s a large amount of excitement also for patients, at least in the thoracic space, where with many of these drugs — especially TKIs, like lorlatinib for ALK-positive lung cancer — you have a large amount of edema. Even in patients with docetaxel, too, you have some swelling. With that agent that I mentioned, lorlatinib, patients also had high cholesterol levels, and that’s really a challenge.
I’m interested to see what the role will be of GLP-1s in these cohorts of patients. Is this going to be something where not only do they hopefully derive a survival benefit, but also in the side effect profile and in quality of life?
I’m excited to see. It’s crazy to be an oncologist in 2026, and so it’s honestly such a pleasure for me to see science advancing. At the end of the day, we want to make sure that the studies and the discoveries that we have are applicable to our patients and are something that we can incorporate outside of clinical trials and into the real world.
Bernabe: Especially this drug that is already popular, right? Now we’re seeing an extra benefit on top of all the weight loss and decrease in inflammation in general.
Olazagasti: Thank you for this wonderful discussion, and thank you for watching our video. Have a great day.
Bernabe: Thank you for having me.
A version of this article first appeared on Medscape.com.
Beyond Weight Loss: The Expanding Role of GLP-1s in Oncology
Beyond Weight Loss: The Expanding Role of GLP-1s in Oncology
Proton Therapy for Prostate Cancer: What Should Clinicians Do With the Latest Evidence?
Proton Therapy for Prostate Cancer: What Should Clinicians Do With the Latest Evidence?
For years, proton beam therapy has been marketed as the next evolution in radiation oncology—offering extraordinary precision, reduced radiation exposure to surrounding tissues, and the promise of fewer adverse effects.
For prostate cancer, however, the most important question has never been whether proton therapy is technologically impressive.
The question is whether patients experience better outcomes.
The latest evidence suggests that for most men with low- and intermediate-risk localized prostate cancer, the answer is probably no.
The Biggest Takeaway: Outcomes Matter More Than Technology
The debate surrounding proton therapy often focuses on physics.
Protons deposit radiation differently than photons, theoretically reducing exposure to healthy tissue. On treatment planning software, proton therapy frequently appears superior.
Yet patients do not experience treatment plans—they experience outcomes.
The landmark PARTIQoL trial directly addressed this distinction by comparing proton therapy and intensity-modulated radiation therapy (IMRT) in 450 men with localized prostate cancer.
The results were strikingly straightforward:
- Five-year progression-free survival was about 93% with both treatments.
- No meaningful differences emerged in bowel function.
- No meaningful differences emerged in urinary outcomes.
- No meaningful differences emerged in sexual function.
- No meaningful differences emerged in hormonal adverse effects.
For clinicians, this means the theoretical dosimetric advantages of proton therapy did not translate into measurable clinical advantages.
The Counseling Conversation Is Changing
Historically, patients interested in proton therapy often arrived with a simple assumption:
"More advanced technology must mean better outcomes."
The current evidence allows physicians to have a more nuanced discussion.
Patients should understand that:
- Proton therapy is an effective treatment.
- IMRT is an equally effective treatment.
- Current randomized evidence shows similar cancer control.
- Current randomized evidence shows similar quality-of-life outcomes.
This shifts the conversation away from "Which treatment is better?" toward "Which treatment is most appropriate and accessible for this patient?"
The Financial Toxicity Question Cannot Be Ignored
One of the most important implications of the PARTIQoL findings may involve cost rather than clinical efficacy.
Proton therapy frequently costs substantially more than IMRT.
For some patients this may result in:
- Higher out-of-pocket expenses
- Insurance appeals
- Treatment delays
- Significant financial stress
The NCCN's inclusion of financial toxicity in its latest guidance reflects a growing recognition that treatment value includes both clinical outcomes and economic burden.
If 2 therapies produce similar disease control and similar toxicity profiles, cost becomes an increasingly relevant component of shared decision-making.
What Patients Are Really Asking
Many patients are not asking about hazard ratios, dosimetry, or progression-free survival curves.
They are asking:
- Will I live longer?
- Will I have fewer adverse effects?
- Will treatment affect my quality of life?
Based on current evidence, clinicians can confidently explain that proton therapy has not demonstrated superiority in any of these areas for the average patient with localized low- or intermediate-risk disease.
That message may actually reduce decision anxiety for many patients.
Rather than feeling pressured to pursue the newest technology, patients can focus on receiving high-quality radiation treatment from an experienced multidisciplinary team.
Are There Patients Who May Still Benefit?
Importantly, the proton therapy story is not necessarily over.
Several areas remain under investigation:
Higher-Risk Disease
Some experts speculate that differences may emerge in patients requiring treatment of larger target volumes, including regional lymph nodes.
At present, however, evidence remains limited.
Reirradiation
One area where proton therapy may offer meaningful advantages is retreatment.
For patients who have previously received pelvic radiation, minimizing additional radiation exposure to normal tissues becomes increasingly important.
Many radiation oncologists believe this may ultimately represent one of the strongest indications for proton therapy in prostate cancer.
Future Technologies
Advances in treatment planning, image guidance, adaptive therapy, and proton delivery techniques could potentially alter the risk-benefit equation in the future.
But those benefits remain hypothetical until demonstrated in prospective clinical trials.
The "So What?" for Clinical Practice
For most physicians, the practical implications are surprisingly simple.
When counseling men with low- or intermediate-risk localized prostate cancer:
- Present proton therapy and IMRT as highly effective treatment options.
- Explain that randomized evidence shows comparable cancer control.
- Discuss similar bowel, urinary, and sexual side-effect outcomes.
- Include cost and insurance coverage as part of shared decision-making.
- Focus on treatment quality, physician expertise, and patient preferences rather than technology alone.
Bottom Line
The proton therapy debate has evolved from a question of technological superiority to one of clinical value.
The strongest evidence available today suggests that proton therapy works extremely well for localized prostate cancer—but so does IMRT.
For most patients, the key message is not that proton therapy is ineffective. Rather, it is that the anticipated advantages have not translated into better outcomes compared with modern standard radiation therapy.
Until evidence demonstrates otherwise, the most important factor may not be whether radiation is delivered with protons or photons, but whether patients receive high-quality care through a well-executed treatment program tailored to their individual needs.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article first appeared on Medscape.com.
For years, proton beam therapy has been marketed as the next evolution in radiation oncology—offering extraordinary precision, reduced radiation exposure to surrounding tissues, and the promise of fewer adverse effects.
For prostate cancer, however, the most important question has never been whether proton therapy is technologically impressive.
The question is whether patients experience better outcomes.
The latest evidence suggests that for most men with low- and intermediate-risk localized prostate cancer, the answer is probably no.
The Biggest Takeaway: Outcomes Matter More Than Technology
The debate surrounding proton therapy often focuses on physics.
Protons deposit radiation differently than photons, theoretically reducing exposure to healthy tissue. On treatment planning software, proton therapy frequently appears superior.
Yet patients do not experience treatment plans—they experience outcomes.
The landmark PARTIQoL trial directly addressed this distinction by comparing proton therapy and intensity-modulated radiation therapy (IMRT) in 450 men with localized prostate cancer.
The results were strikingly straightforward:
- Five-year progression-free survival was about 93% with both treatments.
- No meaningful differences emerged in bowel function.
- No meaningful differences emerged in urinary outcomes.
- No meaningful differences emerged in sexual function.
- No meaningful differences emerged in hormonal adverse effects.
For clinicians, this means the theoretical dosimetric advantages of proton therapy did not translate into measurable clinical advantages.
The Counseling Conversation Is Changing
Historically, patients interested in proton therapy often arrived with a simple assumption:
"More advanced technology must mean better outcomes."
The current evidence allows physicians to have a more nuanced discussion.
Patients should understand that:
- Proton therapy is an effective treatment.
- IMRT is an equally effective treatment.
- Current randomized evidence shows similar cancer control.
- Current randomized evidence shows similar quality-of-life outcomes.
This shifts the conversation away from "Which treatment is better?" toward "Which treatment is most appropriate and accessible for this patient?"
The Financial Toxicity Question Cannot Be Ignored
One of the most important implications of the PARTIQoL findings may involve cost rather than clinical efficacy.
Proton therapy frequently costs substantially more than IMRT.
For some patients this may result in:
- Higher out-of-pocket expenses
- Insurance appeals
- Treatment delays
- Significant financial stress
The NCCN's inclusion of financial toxicity in its latest guidance reflects a growing recognition that treatment value includes both clinical outcomes and economic burden.
If 2 therapies produce similar disease control and similar toxicity profiles, cost becomes an increasingly relevant component of shared decision-making.
What Patients Are Really Asking
Many patients are not asking about hazard ratios, dosimetry, or progression-free survival curves.
They are asking:
- Will I live longer?
- Will I have fewer adverse effects?
- Will treatment affect my quality of life?
Based on current evidence, clinicians can confidently explain that proton therapy has not demonstrated superiority in any of these areas for the average patient with localized low- or intermediate-risk disease.
That message may actually reduce decision anxiety for many patients.
Rather than feeling pressured to pursue the newest technology, patients can focus on receiving high-quality radiation treatment from an experienced multidisciplinary team.
Are There Patients Who May Still Benefit?
Importantly, the proton therapy story is not necessarily over.
Several areas remain under investigation:
Higher-Risk Disease
Some experts speculate that differences may emerge in patients requiring treatment of larger target volumes, including regional lymph nodes.
At present, however, evidence remains limited.
Reirradiation
One area where proton therapy may offer meaningful advantages is retreatment.
For patients who have previously received pelvic radiation, minimizing additional radiation exposure to normal tissues becomes increasingly important.
Many radiation oncologists believe this may ultimately represent one of the strongest indications for proton therapy in prostate cancer.
Future Technologies
Advances in treatment planning, image guidance, adaptive therapy, and proton delivery techniques could potentially alter the risk-benefit equation in the future.
But those benefits remain hypothetical until demonstrated in prospective clinical trials.
The "So What?" for Clinical Practice
For most physicians, the practical implications are surprisingly simple.
When counseling men with low- or intermediate-risk localized prostate cancer:
- Present proton therapy and IMRT as highly effective treatment options.
- Explain that randomized evidence shows comparable cancer control.
- Discuss similar bowel, urinary, and sexual side-effect outcomes.
- Include cost and insurance coverage as part of shared decision-making.
- Focus on treatment quality, physician expertise, and patient preferences rather than technology alone.
Bottom Line
The proton therapy debate has evolved from a question of technological superiority to one of clinical value.
The strongest evidence available today suggests that proton therapy works extremely well for localized prostate cancer—but so does IMRT.
For most patients, the key message is not that proton therapy is ineffective. Rather, it is that the anticipated advantages have not translated into better outcomes compared with modern standard radiation therapy.
Until evidence demonstrates otherwise, the most important factor may not be whether radiation is delivered with protons or photons, but whether patients receive high-quality care through a well-executed treatment program tailored to their individual needs.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article first appeared on Medscape.com.
For years, proton beam therapy has been marketed as the next evolution in radiation oncology—offering extraordinary precision, reduced radiation exposure to surrounding tissues, and the promise of fewer adverse effects.
For prostate cancer, however, the most important question has never been whether proton therapy is technologically impressive.
The question is whether patients experience better outcomes.
The latest evidence suggests that for most men with low- and intermediate-risk localized prostate cancer, the answer is probably no.
The Biggest Takeaway: Outcomes Matter More Than Technology
The debate surrounding proton therapy often focuses on physics.
Protons deposit radiation differently than photons, theoretically reducing exposure to healthy tissue. On treatment planning software, proton therapy frequently appears superior.
Yet patients do not experience treatment plans—they experience outcomes.
The landmark PARTIQoL trial directly addressed this distinction by comparing proton therapy and intensity-modulated radiation therapy (IMRT) in 450 men with localized prostate cancer.
The results were strikingly straightforward:
- Five-year progression-free survival was about 93% with both treatments.
- No meaningful differences emerged in bowel function.
- No meaningful differences emerged in urinary outcomes.
- No meaningful differences emerged in sexual function.
- No meaningful differences emerged in hormonal adverse effects.
For clinicians, this means the theoretical dosimetric advantages of proton therapy did not translate into measurable clinical advantages.
The Counseling Conversation Is Changing
Historically, patients interested in proton therapy often arrived with a simple assumption:
"More advanced technology must mean better outcomes."
The current evidence allows physicians to have a more nuanced discussion.
Patients should understand that:
- Proton therapy is an effective treatment.
- IMRT is an equally effective treatment.
- Current randomized evidence shows similar cancer control.
- Current randomized evidence shows similar quality-of-life outcomes.
This shifts the conversation away from "Which treatment is better?" toward "Which treatment is most appropriate and accessible for this patient?"
The Financial Toxicity Question Cannot Be Ignored
One of the most important implications of the PARTIQoL findings may involve cost rather than clinical efficacy.
Proton therapy frequently costs substantially more than IMRT.
For some patients this may result in:
- Higher out-of-pocket expenses
- Insurance appeals
- Treatment delays
- Significant financial stress
The NCCN's inclusion of financial toxicity in its latest guidance reflects a growing recognition that treatment value includes both clinical outcomes and economic burden.
If 2 therapies produce similar disease control and similar toxicity profiles, cost becomes an increasingly relevant component of shared decision-making.
What Patients Are Really Asking
Many patients are not asking about hazard ratios, dosimetry, or progression-free survival curves.
They are asking:
- Will I live longer?
- Will I have fewer adverse effects?
- Will treatment affect my quality of life?
Based on current evidence, clinicians can confidently explain that proton therapy has not demonstrated superiority in any of these areas for the average patient with localized low- or intermediate-risk disease.
That message may actually reduce decision anxiety for many patients.
Rather than feeling pressured to pursue the newest technology, patients can focus on receiving high-quality radiation treatment from an experienced multidisciplinary team.
Are There Patients Who May Still Benefit?
Importantly, the proton therapy story is not necessarily over.
Several areas remain under investigation:
Higher-Risk Disease
Some experts speculate that differences may emerge in patients requiring treatment of larger target volumes, including regional lymph nodes.
At present, however, evidence remains limited.
Reirradiation
One area where proton therapy may offer meaningful advantages is retreatment.
For patients who have previously received pelvic radiation, minimizing additional radiation exposure to normal tissues becomes increasingly important.
Many radiation oncologists believe this may ultimately represent one of the strongest indications for proton therapy in prostate cancer.
Future Technologies
Advances in treatment planning, image guidance, adaptive therapy, and proton delivery techniques could potentially alter the risk-benefit equation in the future.
But those benefits remain hypothetical until demonstrated in prospective clinical trials.
The "So What?" for Clinical Practice
For most physicians, the practical implications are surprisingly simple.
When counseling men with low- or intermediate-risk localized prostate cancer:
- Present proton therapy and IMRT as highly effective treatment options.
- Explain that randomized evidence shows comparable cancer control.
- Discuss similar bowel, urinary, and sexual side-effect outcomes.
- Include cost and insurance coverage as part of shared decision-making.
- Focus on treatment quality, physician expertise, and patient preferences rather than technology alone.
Bottom Line
The proton therapy debate has evolved from a question of technological superiority to one of clinical value.
The strongest evidence available today suggests that proton therapy works extremely well for localized prostate cancer—but so does IMRT.
For most patients, the key message is not that proton therapy is ineffective. Rather, it is that the anticipated advantages have not translated into better outcomes compared with modern standard radiation therapy.
Until evidence demonstrates otherwise, the most important factor may not be whether radiation is delivered with protons or photons, but whether patients receive high-quality care through a well-executed treatment program tailored to their individual needs.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article first appeared on Medscape.com.
Proton Therapy for Prostate Cancer: What Should Clinicians Do With the Latest Evidence?
Proton Therapy for Prostate Cancer: What Should Clinicians Do With the Latest Evidence?
Antidiabetic Therapies May Help Comorbid Pulmonary Hypertension in Veterans
Antidiabetic Therapies May Help Comorbid Pulmonary Hypertension in Veterans
Metabolic modulation may represent a viable therapeutic strategy in pulmonary hypertension (PH), report researchers from the Veterans Affairs Atlanta Healthcare System. Metformin and thiazolidinedione (TZD) were associated with significantly improved survival in their recent retrospective study of 41,670 veterans with PH and diabetes mellitus (DM). Insulin, on the other hand, was associated with increased mortality.
PH is a complex condition that may combine pulmonary vascular disease, heart disease, lung disease, and chronic thromboembolism. More than one-third of veterans with PH also have DM. Veterans are more likely than nonveterans to have chronic cardiopulmonary disease, which may make them particularly susceptible to PH. Moreover, those who served in Iraq and Afghanistan may have respiratory issues that predispose them to PH.
Another study from the same researchers assessed the influence of DM and weight, both potentially modifiable risk factors, on PH outcomes in 110,495 veterans. Veterans with PH survived an average of 3.9 years after PH diagnosis. Roughly one-third had DM, which increased risk of death by 31%. The analysis showed that lower weight and DM were strong risk factors for mortality in PH.
The most striking finding in the current study, according to the researchers, was a consistent reduction of about 20% in mortality risk associated with metformin and a similar association of 18% lower risk with TZD. The contrast with the 28% higher mortality with insulin “likely reflects fundamental differences” in how these medications influence cellular energy metabolism, they reported.
Interactions were observed between drug effects and both renal function and PH comorbidities, with metformin's protective effect enhanced in patients with lower estimated glomerular filtration rate but attenuated in those with lung disease. The associations remained “robust across multiple analytical approaches,” the researchers note.
Hemoglobin A1c was not associated with outcome, suggesting that these therapies' association with outcome may be irrespective of their glycemic effects. The researchers say this emphasizes the complex interplay between DM and PH pathobiology, known differences in mechanisms of action of antidiabetic medications, and potentially off target impacts of these metabolically active therapies.
Metabolic modulation may represent a viable therapeutic strategy in pulmonary hypertension (PH), report researchers from the Veterans Affairs Atlanta Healthcare System. Metformin and thiazolidinedione (TZD) were associated with significantly improved survival in their recent retrospective study of 41,670 veterans with PH and diabetes mellitus (DM). Insulin, on the other hand, was associated with increased mortality.
PH is a complex condition that may combine pulmonary vascular disease, heart disease, lung disease, and chronic thromboembolism. More than one-third of veterans with PH also have DM. Veterans are more likely than nonveterans to have chronic cardiopulmonary disease, which may make them particularly susceptible to PH. Moreover, those who served in Iraq and Afghanistan may have respiratory issues that predispose them to PH.
Another study from the same researchers assessed the influence of DM and weight, both potentially modifiable risk factors, on PH outcomes in 110,495 veterans. Veterans with PH survived an average of 3.9 years after PH diagnosis. Roughly one-third had DM, which increased risk of death by 31%. The analysis showed that lower weight and DM were strong risk factors for mortality in PH.
The most striking finding in the current study, according to the researchers, was a consistent reduction of about 20% in mortality risk associated with metformin and a similar association of 18% lower risk with TZD. The contrast with the 28% higher mortality with insulin “likely reflects fundamental differences” in how these medications influence cellular energy metabolism, they reported.
Interactions were observed between drug effects and both renal function and PH comorbidities, with metformin's protective effect enhanced in patients with lower estimated glomerular filtration rate but attenuated in those with lung disease. The associations remained “robust across multiple analytical approaches,” the researchers note.
Hemoglobin A1c was not associated with outcome, suggesting that these therapies' association with outcome may be irrespective of their glycemic effects. The researchers say this emphasizes the complex interplay between DM and PH pathobiology, known differences in mechanisms of action of antidiabetic medications, and potentially off target impacts of these metabolically active therapies.
Metabolic modulation may represent a viable therapeutic strategy in pulmonary hypertension (PH), report researchers from the Veterans Affairs Atlanta Healthcare System. Metformin and thiazolidinedione (TZD) were associated with significantly improved survival in their recent retrospective study of 41,670 veterans with PH and diabetes mellitus (DM). Insulin, on the other hand, was associated with increased mortality.
PH is a complex condition that may combine pulmonary vascular disease, heart disease, lung disease, and chronic thromboembolism. More than one-third of veterans with PH also have DM. Veterans are more likely than nonveterans to have chronic cardiopulmonary disease, which may make them particularly susceptible to PH. Moreover, those who served in Iraq and Afghanistan may have respiratory issues that predispose them to PH.
Another study from the same researchers assessed the influence of DM and weight, both potentially modifiable risk factors, on PH outcomes in 110,495 veterans. Veterans with PH survived an average of 3.9 years after PH diagnosis. Roughly one-third had DM, which increased risk of death by 31%. The analysis showed that lower weight and DM were strong risk factors for mortality in PH.
The most striking finding in the current study, according to the researchers, was a consistent reduction of about 20% in mortality risk associated with metformin and a similar association of 18% lower risk with TZD. The contrast with the 28% higher mortality with insulin “likely reflects fundamental differences” in how these medications influence cellular energy metabolism, they reported.
Interactions were observed between drug effects and both renal function and PH comorbidities, with metformin's protective effect enhanced in patients with lower estimated glomerular filtration rate but attenuated in those with lung disease. The associations remained “robust across multiple analytical approaches,” the researchers note.
Hemoglobin A1c was not associated with outcome, suggesting that these therapies' association with outcome may be irrespective of their glycemic effects. The researchers say this emphasizes the complex interplay between DM and PH pathobiology, known differences in mechanisms of action of antidiabetic medications, and potentially off target impacts of these metabolically active therapies.
Antidiabetic Therapies May Help Comorbid Pulmonary Hypertension in Veterans
Antidiabetic Therapies May Help Comorbid Pulmonary Hypertension in Veterans
Wrist Air Samplers Detect Virus Exposure in Kids With Asthma
Wrist Air Samplers Detect Virus Exposure in Kids With Asthma
A novel wearable wrist device was feasible and effective for identifying exposure to respiratory viruses in children with asthma, based on new data presented at the American Thoracic Society 2026 International Conference.
Upper respiratory infections are the main trigger of asthma exacerbations in children, and documented racial and ethnic disparities in upper respiratory infections likely contribute to similar disparities in asthma exacerbations, noted Darlene Bhavnani, PhD, MPH, of The University of Texas at Austin, et al in their abstract.
“Understanding differences in personal exposure to upper respiratory viruses in children with asthma may help to inform these differences in the risk of viral infection and viral-associated asthma exacerbations,” Bhavnani said.
The researchers hypothesized that the use of a wearable passive air sampler could monitor respiratory virus exposure as a way to identify children at increased risk for asthma exacerbations.
Wrist devices to measure respiratory virus exposure are an emerging technology and have not been tested in children, the researchers noted. In their study, the researchers identified 25 children aged 6 to 17 years with persistent asthma who were enrolled in the TexHALE study. Participants were given a Fresh Air Clip to station in their homes and were asked to wear a wristband with a Fresh Air Clip for about 5 consecutive days. The median age of the participants was 12 years, and 64% were male.
At the end of the study period, families reported the number of days the wristband was worn, and the researchers used droplet digital polymerase chain reaction tests to quantify exposure to rhinovirus, respiratory syncytial virus (RSV), influenza A, and influenza B.
A total of 24 clips and 24 wristbands were distributed; 23 clips and all 24 wristbands were recovered for analysis. A total of 22 participants (92%) wore the wristband over a median of 6 days. Overall, approximately one-third of the wristbands (33%) tested positive for any respiratory virus, defined as > 6 copies of viral RNA, with 5 positive tests for rhinovirus, 5 for influenza B, 2 for RSV, and none for influenza A. None of the stationary home-based clips tested positive for any respiratory virus.
The researchers were not sure what to expect from the study, as personal exposure to upper respiratory viruses has not been well studied in children, said Bhavnani.
“One third of the children in our pilot study were exposed to one or more upper respiratory viruses in their personal environments, which is a substantial portion of the population studied,” she noted. “Given that viral exposure is the first step in the pathway leading to a viral infection and viral-associated asthma exacerbations, understanding differences in viral exposure could help us to learn more about how to prevent viral infection and viral-associated asthma exacerbations in children with asthma,” she said.
The study was limited by the small sample size, and larger studies are needed. However, the finding the one-third of wristbands and zero stationary clips tested positive for upper respiratory viruses suggests that clips stationed in homes may not be optimal to detect household exposures, or and that exposure outside the home may be more important for monitoring exposure to respiratory viruses in this population, and the results support the feasibility of the devices, the researchers wrote.
“Fresh Air Clips in the form of wearables can be used to understand differences in personal viral exposure and to target interventions that ultimately, would reduce the burden of viral infection and viral-associated asthma exacerbations,” Bhavnani said.
New Role for New Technology
“New technology now allows us to quantitate exposure to specific respiratory viruses on wearable and stationary devices,” said Tim Joos, MD, who practices internal medicine and pediatrics at a community health center in Seattle.
The current study findings suggest that the majority of the exposure to respiratory viruses occurs outside the home, said Joos, who was not involved in the study. Consequently, technology that can detect community exposure could be useful, although the role it may play in public health and clinical practice is yet to be determined, Joos said.
The wristbands and clips were easy to deploy and recover, which supports their value, and potential applications include testing the effectiveness of infection control strategies such as social distancing, masking, and isolation in lowering viral exposures, Joos noted.
The study received no outside funding but was supported by core funds from the Dell Medical School at the University of Texas at Austin. The researchers had no financial conflicts to disclose. Joos had no financial conflicts to disclose.
A version of this article first appeared on Medscape.com.
A novel wearable wrist device was feasible and effective for identifying exposure to respiratory viruses in children with asthma, based on new data presented at the American Thoracic Society 2026 International Conference.
Upper respiratory infections are the main trigger of asthma exacerbations in children, and documented racial and ethnic disparities in upper respiratory infections likely contribute to similar disparities in asthma exacerbations, noted Darlene Bhavnani, PhD, MPH, of The University of Texas at Austin, et al in their abstract.
“Understanding differences in personal exposure to upper respiratory viruses in children with asthma may help to inform these differences in the risk of viral infection and viral-associated asthma exacerbations,” Bhavnani said.
The researchers hypothesized that the use of a wearable passive air sampler could monitor respiratory virus exposure as a way to identify children at increased risk for asthma exacerbations.
Wrist devices to measure respiratory virus exposure are an emerging technology and have not been tested in children, the researchers noted. In their study, the researchers identified 25 children aged 6 to 17 years with persistent asthma who were enrolled in the TexHALE study. Participants were given a Fresh Air Clip to station in their homes and were asked to wear a wristband with a Fresh Air Clip for about 5 consecutive days. The median age of the participants was 12 years, and 64% were male.
At the end of the study period, families reported the number of days the wristband was worn, and the researchers used droplet digital polymerase chain reaction tests to quantify exposure to rhinovirus, respiratory syncytial virus (RSV), influenza A, and influenza B.
A total of 24 clips and 24 wristbands were distributed; 23 clips and all 24 wristbands were recovered for analysis. A total of 22 participants (92%) wore the wristband over a median of 6 days. Overall, approximately one-third of the wristbands (33%) tested positive for any respiratory virus, defined as > 6 copies of viral RNA, with 5 positive tests for rhinovirus, 5 for influenza B, 2 for RSV, and none for influenza A. None of the stationary home-based clips tested positive for any respiratory virus.
The researchers were not sure what to expect from the study, as personal exposure to upper respiratory viruses has not been well studied in children, said Bhavnani.
“One third of the children in our pilot study were exposed to one or more upper respiratory viruses in their personal environments, which is a substantial portion of the population studied,” she noted. “Given that viral exposure is the first step in the pathway leading to a viral infection and viral-associated asthma exacerbations, understanding differences in viral exposure could help us to learn more about how to prevent viral infection and viral-associated asthma exacerbations in children with asthma,” she said.
The study was limited by the small sample size, and larger studies are needed. However, the finding the one-third of wristbands and zero stationary clips tested positive for upper respiratory viruses suggests that clips stationed in homes may not be optimal to detect household exposures, or and that exposure outside the home may be more important for monitoring exposure to respiratory viruses in this population, and the results support the feasibility of the devices, the researchers wrote.
“Fresh Air Clips in the form of wearables can be used to understand differences in personal viral exposure and to target interventions that ultimately, would reduce the burden of viral infection and viral-associated asthma exacerbations,” Bhavnani said.
New Role for New Technology
“New technology now allows us to quantitate exposure to specific respiratory viruses on wearable and stationary devices,” said Tim Joos, MD, who practices internal medicine and pediatrics at a community health center in Seattle.
The current study findings suggest that the majority of the exposure to respiratory viruses occurs outside the home, said Joos, who was not involved in the study. Consequently, technology that can detect community exposure could be useful, although the role it may play in public health and clinical practice is yet to be determined, Joos said.
The wristbands and clips were easy to deploy and recover, which supports their value, and potential applications include testing the effectiveness of infection control strategies such as social distancing, masking, and isolation in lowering viral exposures, Joos noted.
The study received no outside funding but was supported by core funds from the Dell Medical School at the University of Texas at Austin. The researchers had no financial conflicts to disclose. Joos had no financial conflicts to disclose.
A version of this article first appeared on Medscape.com.
A novel wearable wrist device was feasible and effective for identifying exposure to respiratory viruses in children with asthma, based on new data presented at the American Thoracic Society 2026 International Conference.
Upper respiratory infections are the main trigger of asthma exacerbations in children, and documented racial and ethnic disparities in upper respiratory infections likely contribute to similar disparities in asthma exacerbations, noted Darlene Bhavnani, PhD, MPH, of The University of Texas at Austin, et al in their abstract.
“Understanding differences in personal exposure to upper respiratory viruses in children with asthma may help to inform these differences in the risk of viral infection and viral-associated asthma exacerbations,” Bhavnani said.
The researchers hypothesized that the use of a wearable passive air sampler could monitor respiratory virus exposure as a way to identify children at increased risk for asthma exacerbations.
Wrist devices to measure respiratory virus exposure are an emerging technology and have not been tested in children, the researchers noted. In their study, the researchers identified 25 children aged 6 to 17 years with persistent asthma who were enrolled in the TexHALE study. Participants were given a Fresh Air Clip to station in their homes and were asked to wear a wristband with a Fresh Air Clip for about 5 consecutive days. The median age of the participants was 12 years, and 64% were male.
At the end of the study period, families reported the number of days the wristband was worn, and the researchers used droplet digital polymerase chain reaction tests to quantify exposure to rhinovirus, respiratory syncytial virus (RSV), influenza A, and influenza B.
A total of 24 clips and 24 wristbands were distributed; 23 clips and all 24 wristbands were recovered for analysis. A total of 22 participants (92%) wore the wristband over a median of 6 days. Overall, approximately one-third of the wristbands (33%) tested positive for any respiratory virus, defined as > 6 copies of viral RNA, with 5 positive tests for rhinovirus, 5 for influenza B, 2 for RSV, and none for influenza A. None of the stationary home-based clips tested positive for any respiratory virus.
The researchers were not sure what to expect from the study, as personal exposure to upper respiratory viruses has not been well studied in children, said Bhavnani.
“One third of the children in our pilot study were exposed to one or more upper respiratory viruses in their personal environments, which is a substantial portion of the population studied,” she noted. “Given that viral exposure is the first step in the pathway leading to a viral infection and viral-associated asthma exacerbations, understanding differences in viral exposure could help us to learn more about how to prevent viral infection and viral-associated asthma exacerbations in children with asthma,” she said.
The study was limited by the small sample size, and larger studies are needed. However, the finding the one-third of wristbands and zero stationary clips tested positive for upper respiratory viruses suggests that clips stationed in homes may not be optimal to detect household exposures, or and that exposure outside the home may be more important for monitoring exposure to respiratory viruses in this population, and the results support the feasibility of the devices, the researchers wrote.
“Fresh Air Clips in the form of wearables can be used to understand differences in personal viral exposure and to target interventions that ultimately, would reduce the burden of viral infection and viral-associated asthma exacerbations,” Bhavnani said.
New Role for New Technology
“New technology now allows us to quantitate exposure to specific respiratory viruses on wearable and stationary devices,” said Tim Joos, MD, who practices internal medicine and pediatrics at a community health center in Seattle.
The current study findings suggest that the majority of the exposure to respiratory viruses occurs outside the home, said Joos, who was not involved in the study. Consequently, technology that can detect community exposure could be useful, although the role it may play in public health and clinical practice is yet to be determined, Joos said.
The wristbands and clips were easy to deploy and recover, which supports their value, and potential applications include testing the effectiveness of infection control strategies such as social distancing, masking, and isolation in lowering viral exposures, Joos noted.
The study received no outside funding but was supported by core funds from the Dell Medical School at the University of Texas at Austin. The researchers had no financial conflicts to disclose. Joos had no financial conflicts to disclose.
A version of this article first appeared on Medscape.com.
Wrist Air Samplers Detect Virus Exposure in Kids With Asthma
Wrist Air Samplers Detect Virus Exposure in Kids With Asthma