Feb 23, 2023
Dr. Shannon Westin, Dr. Ezra Bernstein, and Dr. Nadir Arber discuss increasing cancer prevention and early detection with a one-stop-shop comprehensive cancer screening center.
TRANSCRIPT
The guest on this podcast episode has no disclosures to declare.
Dr. Shannon Westin: Hello, everyone, and welcome to another episode of JCO After Hours, our podcast where we get in-depth on manuscripts that have been published in the Journal of Clinical Oncology. I am your host, Shannon Westin, GYN oncologist and social media editor of the JCO. And I am thrilled to be discussing this very interesting paper entitled “Data From a One-Stop-Shop Comprehensive Cancer Screening Center,” focused on asymptomatic screening.
And this very important work was published by these two authors who are joining me today. We have Dr. Nadir Arber, professor of Medicine and Gastroenterology, head of the Integrated Cancer Prevention Center, head of the Cancer Prevention section of the European Society of Medical Oncology at Tel Aviv Sourasky Medical Center in Tel Aviv, Israel. And we're also joined by Dr. Ezra Bernstein, Fulbright fellow and researcher at the Integrated Cancer Prevention Center that we're going to be discussing today at Tel Aviv Sourasky Medical Center in Tel Aviv, Israel. And he's also, impressively, a resident in internal medicine at the New York University, so he's a gentleman of many talents and quite busy.
Welcome.
Dr. Ezra Bernstein: It's great to be here. I had a slow clinic day.
Dr. Shannon Westin: Oh, I was going to say I'm impressed you, as a resident, could find the time. So we're really excited to have you, and you certainly have a bright future ahead of you as an oncology practitioner.
So let's get started. I think certainly most of our listeners are quite familiar with the benefits of cancer screening. But I think it would be great if you all could level set and review the benefits at the patient level as well as at the healthcare system level.
Dr. Ezra Bernstein: Sure. So I think, kind of breaking it down, on the patient level, the scientific community has made incredible progress over the last several decades in not only the understanding of the biology of cancer, but also that's translated into the treatment of cancers, from genomic sequencing to targeted therapy, which you now have specific small molecule inhibitors for specific mutations in each cancer. But despite all these incredible improvements and advances and the ability to treat many cancers, the greatest prognostic factor is still often the stage of diagnosis because the chances of survival and the chances of complete cure increase dramatically if the disease is detected in its earlier stages. So earlier detection and diagnosis can greatly reduce mortality, it can increase treatment effectiveness, and ultimately improve the quality of life for the cancer patients.
On a healthcare system level, often when you're doing screening, you're discussing cost-effectiveness. And so the thing about the healthcare system, which we didn't really address in our paper–we initially were going to, but we think we're going to do a follow-up paper on this–the cost of cancer care is very high. In Europe, the total cost of cancer care in 2018 was $199 billion. And then I think the last data I saw was the US, in 2015, the total cost of cancer care was $183 billion. So, on a healthcare system level—and those are just the costs of cancer care; there's tons of other costs that go into when patients have cancer: lost wages… So I think that it's crucial not only for the patient but also for the healthcare system to help catch these cancers earlier.
Dr. Shannon Westin: Yeah, I completely agree. I think we have such great guidelines on how we should be screening our patients. I think there's a number of different areas where providers can look to understand what they should be doing with the patient in front of them. What do you think are some of the barriers of implementation of this guideline-based cancer screening?
Dr. Ezra Bernstein: That's a crucial question. We have the guidelines, especially in the US; we have our grade A recommendations: colon cancer, cervical cancer. We have our grade B recommendations: mammography. And lung cancer. So a big hurdle, especially in the US now with the recommended screenings at this point, is just getting people to do it. You look at the US, and for Pap smears, it's pretty good; 80% of the population is up to date with PAP smears. Mammography, a little bit less, low 70s. And then colon cancer screening, a little bit less. So how do we get these up, and what's the barriers? And that's kind of the idea behind the Integrated Cancer Prevention Center is it’s cost, it’s time, and it's also awareness.
And this kind of gets into a little bit of the theory for what kind of created the Integrated Cancer Prevention Center is the idea that if you do a one-stop-shop approach where patients come in in a single visit and they get screened for all the recommended cancers, so they don't have to do multiple appointments, they don't have to take off work multiple times, and they can get it all done at once, that automatically leads to 100% compliance for those screenings that they do during that day. So that was kind of the theory behind it is you're able to remove a lot of the barriers to the implementation of the guideline-based cancer screening.
The other thing is awareness and just making sure that patients are aware. I think it's actually great timing with this paper. They haven't done it so much lately, but the NFL, the National Football League, they were actually running a campaign for the first few games of the season where—you know, you have millions and millions of American viewers—it was called Intercepting Cancer, and they were highlighting the importance of screening and prevention. They gave a link, which is great, but it really just links you to your providers in your area to then go ahead and screen individually. That initiative was important in getting more awareness, but still, there's the cost and the time issues that are still barriers.
Dr. Nadir Arber: Let me just emphasize what Ezra brilliantly says. He said that the best therapy of cancer is prevention, so increase early detections. I’m a gastroenterologist, so I'm fairly aware of preventions. I do colonoscopy, I found the polyp, I take it out, I prevent colon cancer. In other cancers, it's not that obvious, especially colon cancer. But then to detect it at an early stage, it means when the patients have no symptoms. When there are symptoms, mostly—not all, but mostly—it's too late. And then, when somebody feels good and well, it is not acceptable, it's not possible to go to all these different facilities and to have the referral. You want to go to screen for colon cancer, you go to your GP, who sends you to a gastroenterologist, you get the colonoscopy, then you come back, go to another GP, then you have to screen for prostate cancer. So you ask him, “Can you send me to a urologist?” They send you to a urologist. And they send him for a PSA and then free PSA and the rest of it. And then, if you do it on one stop, this is the only way that is feasible, for maybe the five major or six major cancer screening, there is no doubt and no questions.
But then, with Ezra, we have learned that there is more than that. It's not only screening, but it's also case finding. Patients come to me for different reasons. They came to the center to be screened for skin cancer, breast cancer, colon cancer. So let's just tell him, “Can you open your mouth?” And then five minutes, not more than that, an oral surgeon checks your mouth. It is not cost effectiveness to call the patients to come to check, but he's coming for another reason. This is what you call case finding.
People are not that aware about the difference between screening and case findings, and I would like to emphasize before I let the floor to you, so I'm not speaking about cost-effectiveness; I’m speaking about cost saving. It saves money. It does not cost; it saves. Actually, I was in Singapore when maybe I was invited to Singapore by the Singapore government. They heard about my concept and invited me to speak, and like we have just said, and that it's going to be published in the JCO, in the journal. And they told me—and they were very impressed—“We are going to do it because it's going to save money for us.” And I said, “But how you are going to implement it?” They said, “We are a democracy; we cannot force the people to do it, but we are going to offer them free of charge. Free, because we understand that if they do, the government are going to save money.”
But if they offer it free of service, free of charge, and then somebody does not want to do it and he has cancer, it is his problem. It's like somebody has a car, buying a new car. He's not obliged to make insurance for the car, but if he doesn't do it and something happened to the car, he cannot come to the government or the insurance company or his spouse and complain. It's his problem. I think when you understand it, and we understand that it's cost-saving and it's a win-win situation, then we can make a big step ahead, and this is the way to go.
Dr. Ezra Bernstein: I think Professor Arber brings up a very interesting point that I'm just going to make real quickly when he talks about kind of the case findings and the screening for something like oral cancer and skin cancer, which aren't currently grade A or grade B recommendations by the USPSTF, but in the context of a one-stop shop, it kind of changes the game a little bit. It's one thing to go to your dermatologist once a year in terms of screening for skin cancer, but if you're already at a one-stop-shop center screening for skin cancer, screening for thyroid cancer, and things which aren't currently—the thyroid is a little bit different, but screening for certain cancers aren't currently recommended for because they're not cost-effective, it changes the game a little bit in the concept of the unique setup that Professor Arber started.
Dr. Nadir Arber: And at the same times, we also measure blood pressure, we measure sugar, hemoglobin, A1Cs, and other things that are known, but not only for cancer, but the patient is scanned when he's there. And also, if we found something—and we have the data, between 1% to 2%, we do find cancers—then we can help the patient to solve it on the spot because he's in the hospital, so we can arrange whatever he needs. So the patients like it. They appreciate. They know that they're in safe hands. And if you like, “I need to do ultrasound. I have some very suspicious legion,” I can do it on the spot. Vaginal ultrasound, Pap smear, now we do it for HPV, DNA. So everything is on the spot, and we give solutions if something happens.
People need—they found something or anything, so we can do everything. For this is the way of modern medicine. Ezra and myself have been working for many years. But eventually, it's going to catch up because this is the right things to do. The modern medicine, the way we see it in the future, is turning from sick care to health care. This is the way to go. This is one of these when we are advancing the technology and everyone is health conscious.
Dr. Shannon Westin: I really appreciate you kind of giving that laundry list of all the things you're doing because I do think you're exactly right, that people are doing a better job around the kind of the most common screening tests. I'm a gynecologist by trade, so Pap smears are part of my daily activity. But I think mammograms, Pap smears, colon—I think that's more common. But this is a great way to kind of get screening for all of those other things. Like, I know a friend who just got diagnosed with an oral cancer, and it's like nobody's screening for those things. And you're right, Ezra, where they say that it's not cost-effective to have a visit just for that, but if you can encompass it all in one visit, it just makes so much sense.
So I think that that takes us into the current study. Can you kind of just take us through briefly the design and your outcomes that you looked at?
Dr. Ezra Bernstein: Yeah. So it was a retrospective analysis of over 17,000 patients that have visited the ICPC, the Integrated Cancer Prevention Center, between 2016 and 2019. And as Professor Arber was saying, patients come in, they're mailed a questionnaire beforehand, they ideally fill it out before, but they'll then meet with an internist or an oncologist. And they'll go over the questionnaire, they'll go over family history, risk factors, and then it will be really a tailored screening exam for that. They'll get the classic recommended screenings based on if they're due for a mammogram, if they're due for a Pap smear, and then from there– Do you want me to go through in detail or just kind of overall?
Dr. Shannon Westin: I think overall is fine, yeah.
Dr. Ezra Bernstein: Overall? Okay. So they do their screening test, they’ll get some blood work done, and then if there's anything abnormal, then as Professor Arber was saying, the great thing is you get worked up right there. So they'll get TFTs, thyroid function tests. If those are abnormal, then they'll indicate a thyroid ultrasound needs to be done. They do all their screenings, all their testings. Most of it is done there. Professor Arber, do they do the biopsies there too if there needs to be a biopsy?
Dr. Nadir Arber: Yes, obviously. But what is Ezra also referring, we are trying to do precision medicine. When somebody is coming to us, like you said, the woman, so we are measuring her Tyrer-Cuzick score and to see, if it is high, then we send her to do an MRI, if it is above 20%.
Dr. Shannon Westin: So what were the outcomes that you measured in the study?
Dr. Ezra Bernstein: So, after they did all the screening, our main outcomes were the number of malignant lesions detected and then also what stage were they detected. Basically, if the cancer was found within a year of a visit to the ICPC and it was found as a direct result of the screening done that day or if there were recommendations for follow-up that then led to a successful detection, we counted that as a malignant cancer that was successfully detected through the ICPC.
Dr. Shannon Westin: What about the results? Were they as expected? How did your detection rates compare to kind of, say, the general population?
Dr. Ezra Bernstein: A successful cancer screening program is always going to have a shift in detection of cancer to earlier stages, which is exactly what we saw, which was great. We then compared it to the Israeli general public over a similar time period, and the percentage of cancers found at a metastatic stage at the ICPC, that was lower for all cancers. Just going through: Colon was 20% versus 46.2% in the general populations. There was no metastatic, cervical, or uterine cancer found. Prostate was 5.6 versus 10.5, lungs 6.7 versus 11.4, as well as renal, which isn't recommended we screen for, but that was 7.7 versus 10.3.
Dr. Shannon Westin: That's so incredible. I guess the other thing I thought was really nice that you did is looking at patient satisfaction and making sure—we're very much focused on patient experience and satisfaction right now in medicine. So what were your findings there? Were the patients satisfied with the process?
Dr. Ezra Bernstein: Yeah, so this is something that we started doing towards the end of the study period. So we really had respondents from 2019. There was about 1300 patients who responded on a Likert scale, 1 to 10. The average response was 8.35. So it's really good response. I try to go back there whenever I can, and it's always bustling. People are coming back. Professor Arber can speak—he's interacting with the patients every day. But talking with just friends who have heard of it, every time I bring it up, “Oh, that's amazing. We love that program.”
Dr. Shannon Westin: Were there any limitations or weaknesses to the mechanism?
Dr. Ezra Bernstein: The main limitations and weaknesses were that it was a one-arm study; it was not a randomized controlled trial, whereas randomization would control for generalizability as well as other confounders. And as with all cancer screening, there's the issues of the lead time bias, the concept that cancer is detected earlier through screening, but the length of time a person survives with the cancer does not. So survival time is falsely lengthened. There's also time bias, which is the idea that more indolent and less aggressive diseases with longer survival times are more likely to be detected through screening, artificially inflating survival time. So that's always present in cancer screening.
In addition, the most reliable measure for determining the efficacy of a screening program is cancer-related mortality rates, and that's from the time of randomization as opposed to the time of diagnosis. And given the study design, that's just something that we weren't able to do. And any successful screening program such as ours is going to have the natural shift in the incidence of cancer to an earlier stage. But some of that can be attributed to overdiagnosis, the diagnosis of indolent diseases that are never going to actually cause harm, which has been heavily studied in the case of breast cancer with mammography. But it's not something that can be really proven; it's just more—overdiagnosis is more of a theory, and it can be hypothesized. So you're going to have overdiagnosis, you're going to have lead time bias, you're going to have a length time bias with any screening program, but in particular with ours, I think it's mainly the randomized control trial aspect, which is the gold standard.
Dr. Shannon Westin: Yeah, that makes sense. Okay, well, and then the final—let's give a call to action here. So how do we implement this more broadly? What's kind of necessary to get something like this up and running? Infrastructure, personnel, yeah?
Dr. Ezra Bernstein: So to implement this intervention more broadly, you really need the want from the general public and whoever's going to help implement this. And I think we're starting to see that with, as I mentioned, the recent program that the NFL is running about intercepting cancer. And then, to actually implement it, I'm going to leave some of it to Professor Arber, who did an amazing job setting up this program. But I think it makes the most sense setting it up within a hospital setting because you'd need certain imaging modalities within a clinic. And then, depending on which specific cancers you're screening for, you're going to need specialists able to screen for those cancers. Primary care, they can screen for skin cancer, but really, it should be someone with more training, dermatologists, to do that kind of screening. But Professor, I don't know if you want to jump in and talk about what you think it would take to set it up. I know you did an amazing job setting it up. Can't imagine the amount of work and coordinating. Because at the clinic in Tel Aviv, you have many different specialists coordinating every day. It has got to be quite difficult. So I don't know if you have anything to add, professor.
Dr. Nadir Arber: I think everything in medicine, in order to be successful, has to be simple. We are physicians. We are simple people. And this is a way that you are able to do this screening. Because first, from economy, it's cost saving. It doesn’t cost money for the government, for the health providers, but also for the patients. If somebody feels well, there is no way that he will go all this saga of going to the GP and have this referral to five, six specialists. And when we understand also the issue of cost and case finding on top of the screening, then we understand that this is the only way that this screening program—when people are feeling healthy, no symptoms, the only way that once a year, they can afford it. If I break my leg or have a rectal bleeding or have a chest pain, I go to the special physician because I have symptoms. But if I have no symptoms, then only once a year, I would like to go to a special place which has all the expertise which the GP cannot provide and then to implement it. This is the only way, and this is simple. And we are happy that you took the lead, and with this initial project, that should be multiplied everywhere. This is the only way. Now we understand that the best therapy of cancer is prevention or at least early detections. And also, Ezra maybe mentioned that we also teach for lifestyle modifications. If needed, we are doing genetic testing; that is going to be very important. I don’t know if Ezra mentioned that we are checking for this polymorphism in the APC genes that we have shown in the [inaudible]. Carriers of this APC can have double the risk of having cancer.
Dr. Shannon Westin: Well, this has been such a fascinating discussion, and I'm just so glad that you both had the time to spend with us today to review this. I think this is an incredible intervention, and I really do hope that we can mimic this across the States and across the world.
So, again, listeners, this has been JCO After Hours. We're discussing “Data from a One-Stop-Shop Comprehensive Cancer Screening Center,” focused on asymptomatic screening. We're so glad that you joined us today. Please do check out our other podcasts on the JCO website. Be well.
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