The Role of Surgical Pathology

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers with
00:08 --> 00:10your host Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:14latest information on cancer care by
00:14 --> 00:16welcoming oncologists and specialists
00:16 --> 00:18who are on the forefront of the
00:18 --> 00:20battle to fight cancer. This week,
00:20 --> 00:22it's a conversation about the role
00:22 --> 00:24of surgical pathology in certain
00:24 --> 00:25cancers with Doctor Marie Robert.
00:25 --> 00:27Doctor Robert is a professor
00:27 --> 00:29of pathology and of medicine at
00:29 --> 00:30the Yale School of Medicine,
00:30 --> 00:32where Doctor Chagpar is a
00:32 --> 00:34professor of surgical oncology.
00:35 --> 00:37Marie, maybe we can start off by
00:37 --> 00:39you telling us a little bit about
00:39 --> 00:41yourself and what it is that you do.
00:41 --> 00:44Sure, so I am a surgical pathologist
00:44 --> 00:48and this is somebody who goes to
00:48 --> 00:51medical school and does a residency
00:51 --> 00:53in the specialty of pathology.
00:53 --> 00:57And that specialty involves looking
00:57 --> 01:01at diseases in the tissues in
01:01 --> 01:05biopsy samples and and surgical
01:05 --> 01:08resection samples from patients.
01:09 --> 01:11And we look at that very
01:11 --> 01:13deeply under both with our naked
01:13 --> 01:15eye and under the microscope,
01:15 --> 01:19and then inform the surgeon or the
01:19 --> 01:21clinician oncologist
01:21 --> 01:23who's taking care of the patient
01:23 --> 01:25about what we're seeing and what
01:25 --> 01:26their disease process might be?
01:27 --> 01:29Yeah, you know I I often tell patients
01:29 --> 01:31that there's only two people who
01:31 --> 01:33can tell you anything for sure.
01:33 --> 01:36God and the pathologist because we
01:36 --> 01:39rely so heavily on the diagnosis
01:39 --> 01:41that's rendered by pathologists.
01:41 --> 01:45So you know, tell us a little bit
01:45 --> 01:47more about what got you interested in
01:47 --> 01:49pathology and what got you interested
01:49 --> 01:53in GI and liver pathology in particular.
01:53 --> 01:55So that is an easy question
01:55 --> 01:57to answer and no secret.
01:57 --> 01:58If you know my family at all,
01:58 --> 02:05so I am the daughter of a French Canadian.
02:05 --> 02:07Nurse and physician scientist.
02:07 --> 02:10My father Andre Robert,
02:10 --> 02:13who was a basic scientist studying
02:13 --> 02:14gastrointestinal diseases so
02:14 --> 02:17he had both the clinical side
02:17 --> 02:19MD and the scientific training.
02:19 --> 02:22And so I grew up visiting his lab
02:22 --> 02:25and seeing and actually, you know,
02:25 --> 02:28he would let me do a little help in the
02:28 --> 02:30lab in in participating in his experiments.
02:30 --> 02:35And so this is when I went to college and.
02:35 --> 02:38Medical school, I thought that medicine
02:38 --> 02:41was this the study of disease.
02:41 --> 02:43And so when I it was,
02:43 --> 02:46you know, not a far.
02:46 --> 02:48Challenge for me to decide that
02:48 --> 02:51pathology was where my heart really lay.
02:51 --> 02:51And of course,
02:51 --> 02:54the apple doesn't fall far from the tree
02:54 --> 02:55and I was immediately drawn towards
02:55 --> 02:58all things of the gastrointestinal tract,
02:58 --> 02:59liver, and pancreas.
03:00 --> 03:03So tell us a little bit more
03:03 --> 03:06about kind of what you do.
03:06 --> 03:08day-to-day. I mean, because one of
03:08 --> 03:11the things that is frustrating.
03:11 --> 03:15Anxiety provoking for patients is the wait.
03:15 --> 03:17They have the biopsy done and
03:17 --> 03:20then we say we need to wait and
03:20 --> 03:23I always tell patients you know,
03:23 --> 03:26never rush the pathologist because.
03:26 --> 03:29You you don't necessarily want a fast answer.
03:29 --> 03:30You want the right answer,
03:30 --> 03:32because everything that we
03:32 --> 03:35do rests on what you say.
03:35 --> 03:39So can you give us a little bit more
03:39 --> 03:41granularity in terms of what happens in
03:41 --> 03:44terms of that black box while we wait?
03:46 --> 03:48So delighted to talk about this
03:48 --> 03:51because we are believe it or not,
03:51 --> 03:53even though we are not meeting
03:53 --> 03:54your patient first hand,
03:54 --> 03:57we are constantly mindful of the fact
03:57 --> 04:00that there is a wonderful human being on
04:00 --> 04:03the other end of this specimen and we
04:03 --> 04:06are working as fast as we can to provide.
04:06 --> 04:08As you say the right answer.
04:08 --> 04:09So what does this entail?
04:09 --> 04:12So take a biopsy.
04:12 --> 04:16It is put in a fluid called.
04:16 --> 04:19Formalin, usually that is allowed that
04:19 --> 04:22sort of hardens the tissues so that we can
04:22 --> 04:25then put them through an overnight process.
04:25 --> 04:26And we actually.
04:26 --> 04:27This may sound crazy.
04:27 --> 04:32We actually take the small samples or large
04:32 --> 04:35samples and put them into paraffin wax.
04:35 --> 04:38Melted paraffin wax that then
04:38 --> 04:40hardens in a small little box.
04:40 --> 04:43If you will, we call it a tissue cassette.
04:43 --> 04:45And believe it or not,
04:45 --> 04:47old fashioned thing like paraffin wax
04:47 --> 04:50is what holds the tissue in place.
04:50 --> 04:54While we then apply a very sharp knife,
04:54 --> 04:56it's called a microtome to the
04:56 --> 04:59sample and we're actually taking
04:59 --> 05:01small slices of the sample.
05:01 --> 05:05We take that put it on a microscope slide.
05:05 --> 05:07Remember from science class.
05:07 --> 05:09And that microscope slide is then
05:09 --> 05:12with the tissue section on it is
05:12 --> 05:14stained with some very pretty colors.
05:14 --> 05:16Purples and pinks really.
05:16 --> 05:19Pathology is like looking at beautiful
05:19 --> 05:22art under the microscope and these dyes.
05:22 --> 05:25If you will are stains adhere to the
05:25 --> 05:27cells and we during our residency
05:27 --> 05:30have learned how to recognize cells
05:30 --> 05:33with these dyes under the microscope
05:33 --> 05:35so that whole process of just
05:35 --> 05:37getting to the glass slide takes.
05:37 --> 05:41At least one day so you know one day gone.
05:41 --> 05:45Now depending on the type of sample it is,
05:45 --> 05:47we can then grab it quickly,
05:47 --> 05:49begin our process of looking
05:49 --> 05:50under the microscope,
05:50 --> 05:52and in some situations we are
05:52 --> 05:54able to give an immediate answer
05:54 --> 05:56doing nothing else to the sample.
05:56 --> 05:58Just looking at the microscope for
05:58 --> 06:00three or four minutes and we're
06:00 --> 06:02able to assess everything and give
06:02 --> 06:05a give the the surgeon, oncologist,
06:05 --> 06:06whomever gastroenterologist,
06:06 --> 06:08and then the.
06:08 --> 06:10Patient the answer they need,
06:10 --> 06:13but in especially in cancer there
06:13 --> 06:16are often other steps we need to
06:16 --> 06:19take to get the best possible answer
06:19 --> 06:22with the greatest amount of detail.
06:22 --> 06:25And nuance that will really help the
06:25 --> 06:28person just treating the patient next
06:28 --> 06:32to know exactly what therapy to apply.
06:32 --> 06:34So these extra steps include things like
06:34 --> 06:37we we use these terms called special stains,
06:37 --> 06:39so if you think of a stain,
06:39 --> 06:42think of like paint or or these
06:42 --> 06:45colors I mentioned and there are a
06:45 --> 06:47variety of very technical and highly,
06:47 --> 06:48you know,
06:48 --> 06:50honed technologies that we can
06:50 --> 06:52apply to the tissue.
06:52 --> 06:54This is getting more and
06:54 --> 06:55more finessed every day.
06:55 --> 06:59We can now even do molecular and
06:59 --> 07:02genetic analysis and and put what we
07:02 --> 07:05call biomarker stains and approaches
07:05 --> 07:08so we can really get much further
07:08 --> 07:11now to helping to guide the even
07:11 --> 07:14the exact medication one might use.
07:14 --> 07:16But this does take time,
07:16 --> 07:18so sometimes there's a first answer.
07:18 --> 07:20And then there's another more detailed
07:20 --> 07:23answer that comes a day or a week later.
07:23 --> 07:25Sometimes we have to hold up the whole
07:25 --> 07:27thing for four or five days just to
07:27 --> 07:29get the right answer from the start,
07:29 --> 07:30so that's sort of a long answer to
07:30 --> 07:32your question, but it is complete.
07:32 --> 07:35Yeah, yeah, so I mean,
07:35 --> 07:37so This is why I think it's good
07:37 --> 07:39information for people who are listening
07:39 --> 07:41and potential patients to kind of
07:41 --> 07:44understand why it can take so long,
07:44 --> 07:46because sometimes we expect these days
07:46 --> 07:49to to get an answer instantaneously.
07:49 --> 07:52And and that's just not
07:52 --> 07:54practical or or feasible.
07:54 --> 07:56So I want to dig a little bit more into some
07:56 --> 07:58of the things that you mentioned, Marie.
07:58 --> 08:01So one is that you know in
08:01 --> 08:03medical school and in residency,
08:03 --> 08:07you, as a pathologist got very
08:07 --> 08:10good at recognizing patterns,
08:10 --> 08:12understanding what looks benign
08:12 --> 08:15under a microscope and what looks
08:15 --> 08:18malignant under a microscope.
08:18 --> 08:20But can you tell us a little bit more about
08:21 --> 08:23the secrets that go into that pattern?
08:23 --> 08:23Recognition?
08:23 --> 08:26Because that's another piece that
08:26 --> 08:29people don't really understand.
08:29 --> 08:29I mean,
08:29 --> 08:32how can you tell the difference between.
08:32 --> 08:35You know a benign polyp,
08:35 --> 08:38something that then is perhaps a
08:38 --> 08:43carcinoma in situ, a precancer.
08:43 --> 08:46And then something that is truly
08:46 --> 08:49cancerous that for many people is a
08:49 --> 08:51nuance that we don't really understand.
08:51 --> 08:52How.
08:52 --> 08:54How do you make that distinction?
08:55 --> 08:59So thank you for these wonderful
08:59 --> 09:01pathology type questions.
09:01 --> 09:04The the answer is it all starts
09:04 --> 09:06with knowing what is normal,
09:06 --> 09:10what is normal tissue appearance?
09:10 --> 09:12We use the term Histology,
09:12 --> 09:13it doesn't matter,
09:13 --> 09:15but it's just what are you expecting to see.
09:15 --> 09:16That is normal.
09:16 --> 09:19So in anything that you look at and
09:19 --> 09:21in looking at, you know anything
09:21 --> 09:23around your house or in your workplace.
09:23 --> 09:25Your desk is something out of place.
09:25 --> 09:28Were first to understand what is normal
09:28 --> 09:30tissue, so you want to talk about,
09:30 --> 09:31say, a colon polyp.
09:31 --> 09:33We first have to learn,
09:33 --> 09:35and this is actually, you know,
09:35 --> 09:37at least a four year training
09:37 --> 09:38process and residency,
09:38 --> 09:41and then often today one or two years
09:41 --> 09:43of specialty fellowship training,
09:43 --> 09:45we learn very quickly what is normal in
09:45 --> 09:47our first couple of years of residency,
09:47 --> 09:49training and normal means,
09:49 --> 09:52how in health are the this
09:52 --> 09:54wonderful machine that is?
09:54 --> 09:56Our body is organized at the cellular
09:56 --> 09:59level so that you know you look at
09:59 --> 10:02your skin and you see your skin.
10:02 --> 10:03You might.
10:03 --> 10:05The freckles or some blood vessels
10:05 --> 10:07underneath under the microscope
10:07 --> 10:10we learn what all those layers
10:10 --> 10:12from the outside of the skin to
10:12 --> 10:15underneath the skin down into even
10:15 --> 10:18the muscles and the bone look like.
10:18 --> 10:21So once we have that template,
10:21 --> 10:24sort of that pattern if you will
10:24 --> 10:25pattern recognition in our mind.
10:25 --> 10:28Then we begin very slowly to build
10:28 --> 10:31to learn abnormal and the one of
10:31 --> 10:33the first things we start with is.
10:33 --> 10:34Inflammation,
10:34 --> 10:36you know you get a cut and you
10:36 --> 10:39notice that there are bee sting and
10:39 --> 10:41you notice swelling right away.
10:41 --> 10:41Redness.
10:41 --> 10:41Well,
10:41 --> 10:43we learn what that looks like
10:43 --> 10:45under the microscope with,
10:45 --> 10:45you know,
10:45 --> 10:47too much fluid and and inflammatory
10:47 --> 10:49cells from the immune system
10:49 --> 10:51being called to that area.
10:51 --> 10:53The same is true when we
10:53 --> 10:54start talking about cancer.
10:54 --> 10:57There's often a process starting from
10:57 --> 11:00an early, let's say, neoplastic,
11:00 --> 11:03meaning that the cell is stopped.
11:03 --> 11:05Just minding its own business and
11:05 --> 11:08staying put where it should be
11:08 --> 11:10to maintain the normal but is now
11:10 --> 11:12dividing and growing and and we can
11:12 --> 11:15see that under the microscope by
11:15 --> 11:19changes and actually how the cell looks.
11:19 --> 11:23Over overtime that growth.
11:23 --> 11:25Can then.
11:25 --> 11:27Disrupt the normal to the point
11:27 --> 11:30that there is disruption of the
11:30 --> 11:32the little little boxes of the the
11:32 --> 11:34little alleys and lanes that that
11:34 --> 11:37cells need to stay in and they invade.
11:37 --> 11:40We talk about invasive cancer.
11:40 --> 11:42It's because those cells actually
11:42 --> 11:44go into a compartment that they have
11:44 --> 11:46no business being like an epithelial
11:46 --> 11:48cell which should be on the surface.
11:48 --> 11:50So if you look at your skin,
11:50 --> 11:52it's lined by a certain kind of cell.
11:52 --> 11:54We call it an epithelial cell,
11:54 --> 11:55just the lining.
11:55 --> 11:57Now if it becomes a tumor,
11:57 --> 12:01it can then go down into the soft tissues,
12:01 --> 12:03even the muscle and bone,
12:03 --> 12:03et cetera.
12:03 --> 12:07And we can see this all under the microscope.
12:07 --> 12:09So recognizing cancer or recognizing
12:09 --> 12:12an abnormal process is recognizing
12:12 --> 12:14that the normal has been disrupted.
12:15 --> 12:19And so so you know, one of the
12:19 --> 12:21questions that people often ask is.
12:21 --> 12:23You know how important is it?
12:23 --> 12:26Or is it important to get a second
12:26 --> 12:29opinion with regards to your pathology?
12:29 --> 12:32So very often you may have your
12:32 --> 12:35biopsy done at one place if you go
12:35 --> 12:37to another place to get treatment,
12:37 --> 12:40they'll say, well, we need our
12:40 --> 12:42pathologist to look at the slides.
12:42 --> 12:44So is it that you know a
12:44 --> 12:46pathologist is a pathologist,
12:46 --> 12:48is a pathologist and this is a black
12:48 --> 12:50and white answer and everybody is going
12:50 --> 12:53to say the same thing, in which case.
12:53 --> 12:54Why repeat it?
12:54 --> 12:57Or is there some nuance there and
12:57 --> 12:59and how important or not important
12:59 --> 13:01is it to get a second opinion
13:01 --> 13:03on your pathology slides?
13:05 --> 13:06So another great question.
13:06 --> 13:09I am a big fan of second opinions
13:09 --> 13:12and I recommend that when folks
13:12 --> 13:14are getting impactful diagnosis.
13:14 --> 13:16Like a cancer diagnosis,
13:16 --> 13:19that's going to change their life and
13:19 --> 13:22start a train in motion of serious
13:22 --> 13:25therapeutics and operations that a
13:25 --> 13:28second opinion should always be obtained.
13:28 --> 13:31And I'm not offended if someone would
13:31 --> 13:34like to get a second opinion on a
13:34 --> 13:37pathology diagnosis that I have made it.
13:37 --> 13:40You know it many times as you sort of
13:41 --> 13:44allude to probably 90% or more of the time.
13:44 --> 13:46There will be no disagreement
13:46 --> 13:48in an original diagnosis.
13:48 --> 13:50But sometimes there is either a
13:50 --> 13:52really a complete disagreement,
13:52 --> 13:53very, very rarely,
13:53 --> 13:55a complete disagreement between hey,
13:55 --> 13:55you know, I actually,
13:55 --> 13:57I'm not sure this is cancer.
13:57 --> 13:58I know that.
13:58 --> 14:00This was thought to be cancer,
14:00 --> 14:02but actually I'm doing a little more
14:02 --> 14:04extra work on it and I'm finding that
14:04 --> 14:05maybe it might be just a precancer,
14:05 --> 14:08or it may some nuance about that.
14:08 --> 14:10In addition,
14:10 --> 14:14in tertiary care centers tend
14:14 --> 14:16to have specialized pathologists
14:16 --> 14:20that are only doing one thing.
14:20 --> 14:24So in my case I'm only doing
14:24 --> 14:25gastrointestinal pathology,
14:25 --> 14:27whereas in other centers there's
14:27 --> 14:29a group of wonderful general.
14:29 --> 14:33Pathologists who are looking at all all
14:33 --> 14:36all specimens from all parts of the body,
14:36 --> 14:38and they are all all outstanding
14:38 --> 14:40and and this is a good system.
14:40 --> 14:44But if it's a really impactful diagnosis,
14:44 --> 14:45it's not a bad idea to have a
14:45 --> 14:47very impactful diagnosis reviewed
14:47 --> 14:49by someone who is a recognized
14:49 --> 14:51specialist and they exist all over
14:51 --> 14:53the country and all over the world,
14:53 --> 14:55perfect, well, we're going to
14:55 --> 14:57pick up the story learning more
14:57 --> 14:58about surgical pathology right
14:58 --> 15:01after we take a short break.
15:01 --> 15:02For a medical minute,
15:02 --> 15:03please stay tuned to learn more
15:03 --> 15:05with my guest Doctor Marie Robert.
15:06 --> 15:08Funding for Yale Cancer answers
15:08 --> 15:10comes from Smilow Cancer Hospital,
15:10 --> 15:12where you can view videos from their
15:12 --> 15:14survivorship team by searching for the
15:14 --> 15:16smilo survivorship playlist on YouTube.
15:18 --> 15:20The American Cancer Society
15:20 --> 15:22estimates that more than 65,000
15:22 --> 15:24Americans will be diagnosed with
15:24 --> 15:27head and neck cancer this year,
15:27 --> 15:30making up about 4% of all cancers
15:30 --> 15:32diagnosed when detected early.
15:32 --> 15:34However, head and neck cancers are
15:34 --> 15:36easily treated and highly curable.
15:36 --> 15:38Clinical trials are currently
15:38 --> 15:40underway at federally designated
15:40 --> 15:42Comprehensive cancer centers such
15:42 --> 15:44as Yale Cancer Center and Smilow
15:44 --> 15:46Cancer Hospital to test innovative new
15:46 --> 15:49treatments for head and neck cancers.
15:49 --> 15:51Yale Cancer Center was recently awarded
15:51 --> 15:53grants from the National Institutes
15:53 --> 15:56of Health to fund the Yale Head and
15:57 --> 15:59neck Cancer Specialized program of
15:59 --> 16:01Research Excellence or SPORE to
16:01 --> 16:03address critical barriers to treatment
16:03 --> 16:06of head and neck squamous cell
16:06 --> 16:08carcinoma due to resistance to immune
16:08 --> 16:10DNA damaging and targeted therapy.
16:10 --> 16:13More information is available at
16:13 --> 16:15yalecancercenter.org you're listening
16:15 --> 16:16to Connecticut Public Radio.
16:18 --> 16:20Welcome back to Yale Cancer Answers.
16:20 --> 16:22This is doctor Anees Chagpar and I'm joined
16:22 --> 16:25tonight by my guest Doctor Marie Robert.
16:25 --> 16:27We're talking about the important role
16:27 --> 16:29that pathology plays in cancer and
16:29 --> 16:31right before the break we were talking
16:31 --> 16:33about the role that pathology plays
16:33 --> 16:35in actually making the diagnosis.
16:35 --> 16:38Like you go for a biopsy and is
16:38 --> 16:41this cancer or is this not cancer?
16:41 --> 16:44That distinction is actually made by
16:44 --> 16:47a pathologist whom you may never meet,
16:47 --> 16:50but that your team really relies on.
16:50 --> 16:54Now Marie, the other thing that
16:54 --> 16:56pathologists often really provide
16:56 --> 17:00is some of the genomic information.
17:00 --> 17:02Whether that comes in the form
17:02 --> 17:04of special stains like you were
17:04 --> 17:06telling us about before the break,
17:06 --> 17:07or whether it comes in.
17:07 --> 17:10Actually you know doing things like
17:10 --> 17:12sequencing and telling us about
17:12 --> 17:14genetic and genomic mutations,
17:15 --> 17:16can you talk a little bit more
17:16 --> 17:18about how that's done and and the
17:18 --> 17:20importance that that plays in various?
17:20 --> 17:21Answers
17:22 --> 17:25yes, delighted so I would say so.
17:25 --> 17:27I've been practicing for,
17:27 --> 17:30you know about 3 decades now and.
17:30 --> 17:32Over the course of my career
17:32 --> 17:35there has been really in the past.
17:35 --> 17:3910 to 15 and I would say even in the past
17:39 --> 17:42five an explosion of new technologies
17:42 --> 17:45and new information that help,
17:45 --> 17:47especially in cancer, help,
17:47 --> 17:50oncologists and surgeons fine tune
17:50 --> 17:53and find a very specific therapies
17:53 --> 17:56for a specific patients tumor.
17:56 --> 17:58How is this done?
17:58 --> 18:01And it comes under the general
18:01 --> 18:05heading of molecular pathology and.
18:05 --> 18:07This means that so we talked
18:07 --> 18:08about looking at the microscope,
18:08 --> 18:10the light microscope and we
18:10 --> 18:12can determine a lot from there.
18:12 --> 18:15Now we're getting inside the cell
18:15 --> 18:17and specifically the cell nucleus.
18:17 --> 18:19For the most part.
18:19 --> 18:22And so every cell I should say has
18:22 --> 18:25a central brain called a nucleus,
18:25 --> 18:27and then something called the cytoplasm,
18:27 --> 18:29which is where all the working
18:29 --> 18:31parts of the cell that do what
18:31 --> 18:32they're supposed to do reside.
18:32 --> 18:35But the nucleus is where the chromosomes are.
18:35 --> 18:39The genetic material that are the,
18:39 --> 18:40you know,
18:40 --> 18:42the blueprint for what that cell
18:42 --> 18:44should do all over the body.
18:44 --> 18:47Tumors tend to occur when those
18:47 --> 18:50genes or chromas or the chroma,
18:50 --> 18:52the genes on the chromosomes.
18:52 --> 18:54The chromosome is divided up
18:54 --> 18:56into a gazillion genes,
18:56 --> 18:59each one doing something and tumors
18:59 --> 19:04happen when what we call mutations occur.
19:04 --> 19:07Or deletions or other types
19:07 --> 19:10of fusions and other damage.
19:10 --> 19:13Overall damage to the genes and the
19:13 --> 19:16genetic structure on the chromosomes.
19:16 --> 19:18When this happens,
19:18 --> 19:21when there's an alteration for the bad.
19:21 --> 19:23Several things can happen.
19:23 --> 19:26One is that a cell just recognizes that.
19:26 --> 19:26Oh,
19:26 --> 19:28you are no longer functioning normally
19:28 --> 19:29and the body's going to sort of
19:29 --> 19:31take you right out of Commission
19:31 --> 19:33and you're you're off the assembly
19:33 --> 19:35line and actually kills the cell.
19:35 --> 19:36That's a good thing.
19:36 --> 19:40Unfortunately, other times the cell,
19:40 --> 19:42the mutations or genetic
19:42 --> 19:45alterations give the cell power.
19:45 --> 19:46To divide,
19:46 --> 19:49make more cells with those same problems
19:49 --> 19:53and that is the beginning of a tumor.
19:53 --> 19:56We can now detect very smart
19:56 --> 19:57scientists have created technologies
19:58 --> 20:00that allow us to look even from
20:00 --> 20:02the biopsy that you gave us the
20:02 --> 20:05same piece of tissue that we made.
20:05 --> 20:08The diagnosis of a tumor on.
20:08 --> 20:10We can take the rest of that sample
20:10 --> 20:13and apply something called next
20:13 --> 20:15generation sequencing and other.
20:15 --> 20:18Techniques. Why is this important?
20:18 --> 20:20This is important because these days
20:20 --> 20:24there are more and more specific therapies.
20:24 --> 20:27How do you know when you say this doesn't
20:27 --> 20:29apply to every patient and to every tumor?
20:29 --> 20:32How do you know whether your tumor should
20:32 --> 20:35have all of those fancy shmancy tests done,
20:35 --> 20:38or whether simply looking at
20:38 --> 20:41that pink and purple dyes under
20:41 --> 20:43the microscope is sufficient?
20:43 --> 20:46So maybe you had your biopsy done.
20:46 --> 20:50At a given institution and you were told
20:50 --> 20:53that this was a particular kind of cancer.
20:53 --> 20:57Should patients know which particular types
20:57 --> 21:02of cancer should get advanced kind of
21:02 --> 21:06diagnostics done that might help their care.
21:06 --> 21:08How do people figure that out?
21:08 --> 21:10How do you know which cancers and
21:10 --> 21:12which patients need to have more
21:12 --> 21:14studies done and which ones don't?
21:14 --> 21:17So that is a terrific question.
21:17 --> 21:21I think that every patient and I hope every
21:21 --> 21:23patient listening who has a some sort of.
21:23 --> 21:26Tumor or cancer diagnosis and is
21:26 --> 21:30beginning down that path of getting
21:30 --> 21:32treated should ask the question.
21:32 --> 21:35Does my sample? Will my sample?
21:35 --> 21:39Will this tumor benefit from genetic testing,
21:39 --> 21:40molecular testing or whatever
21:40 --> 21:42phrase you want to use?
21:42 --> 21:45And it is the oncologist who knows best,
21:45 --> 21:48so if you're not talking to an oncologist,
21:48 --> 21:50talk to an oncologist.
21:50 --> 21:53The oncologist will know best that,
21:53 --> 21:54Oh yes, this tumor,
21:54 --> 21:56if it has this mutation,
21:56 --> 21:58we have these three drugs that
21:58 --> 22:00we might want to try, and this is
22:00 --> 22:02certainly true in many tumors of the.
22:02 --> 22:04Of the gastrointestinal tract,
22:04 --> 22:06liver and pancreas.
22:06 --> 22:09And the oncologist will also know well today.
22:09 --> 22:11As things stand,
22:11 --> 22:13we don't have anything that we're
22:13 --> 22:15giving based on genetic analysis,
22:15 --> 22:17and so they may say at this
22:17 --> 22:20moment in time we know what to do.
22:20 --> 22:20This is.
22:20 --> 22:22This is exactly what we should do,
22:22 --> 22:24and we don't need further information.
22:24 --> 22:27I will also share that at many
22:27 --> 22:30academic centers there is a philosophy
22:30 --> 22:32that really we want to sequence.
22:32 --> 22:35Every tumor and we want to start
22:35 --> 22:37moving towards a world where every
22:37 --> 22:39diagnosis of malignancy, cancer,
22:39 --> 22:43type of tumor will automatically
22:43 --> 22:46have a gene you know.
22:46 --> 22:49Sequencing of the genetics of that tumor,
22:49 --> 22:51and this is for two reasons.
22:51 --> 22:52One is that.
22:52 --> 22:55We want to continue learning about
22:55 --> 22:58tumors because we we we are continuing
22:58 --> 23:00to develop medicines based on the
23:00 --> 23:03information we're finding and the second
23:03 --> 23:06reason is that sometimes a tumor of 1 type.
23:06 --> 23:08May have a mutation that we
23:08 --> 23:10weren't expecting and hey,
23:10 --> 23:11you know there's a drug out here.
23:11 --> 23:13We usually use this drug to
23:13 --> 23:15treat to treat another tumor.
23:15 --> 23:17Usually not this tumor,
23:17 --> 23:19but now that you tell us this tumor
23:19 --> 23:21surprisingly has this mutation.
23:21 --> 23:21Well,
23:21 --> 23:22you know,
23:22 --> 23:23now we've got another thing to
23:23 --> 23:24put in the toolkit.
23:25 --> 23:27And so one of the questions
23:27 --> 23:29that people may be asking as
23:29 --> 23:31they're thinking about this is,
23:31 --> 23:33you know. Oftentimes,
23:33 --> 23:35when patients think about genetics,
23:35 --> 23:38they think about their family history
23:38 --> 23:40and whether they need to have a
23:40 --> 23:42blood test or a saliva test to
23:42 --> 23:45look for genetic mutations that may
23:45 --> 23:47predispose them to certain cancers.
23:47 --> 23:49So, for example, you know the one
23:49 --> 23:51that is most often talked about,
23:51 --> 23:55at least in my sphere is BRC A1 and two,
23:55 --> 23:57which will increase your risk
23:57 --> 23:59of breast and ovarian cancer.
23:59 --> 24:02How is that different from the
24:02 --> 24:04work that you're talking about?
24:04 --> 24:06Where you're looking at the
24:06 --> 24:08genetics of the cancer itself?
24:09 --> 24:13Yeah, that is super and these things
24:13 --> 24:16go actually hand in hand so the
24:16 --> 24:19the the thing we just discussed
24:19 --> 24:22was any particular tumor that one
24:22 --> 24:25might have and that is something
24:25 --> 24:28that an oncologist and discussion
24:28 --> 24:31with their patient may may initiate.
24:31 --> 24:34But in addition, the patient their
24:34 --> 24:36physician oncologist and sometimes
24:36 --> 24:38the pathologist will discover that
24:38 --> 24:40there's something about the patient
24:40 --> 24:42as they walk in the door with
24:42 --> 24:44their first diagnosis of cancer.
24:44 --> 24:46That, or even they don't have it yet.
24:46 --> 24:49But there's a family history should be
24:49 --> 24:53at something in them should be analyzed
24:53 --> 24:56for a specific genetic disorder.
24:56 --> 24:59Like bracca as you discuss or like in
24:59 --> 25:01the GI tract, familial polyposis syndrome,
25:01 --> 25:04or something called Lynch syndrome,
25:04 --> 25:08which are colon cancer syndromes and
25:08 --> 25:10endometrial and other cancer syndromes.
25:10 --> 25:12So in these scenarios,
25:12 --> 25:16there may or may not be a cancer
25:16 --> 25:18diagnosis yet in the patient,
25:18 --> 25:20but they may on their annual visit
25:20 --> 25:22to their you know physician,
25:22 --> 25:24discover that, Oh yeah, well,
25:24 --> 25:25you know my mom,
25:25 --> 25:27dad and three uncles had colon cancer.
25:27 --> 25:29Before the age of 50,
25:29 --> 25:31that person that will be a series
25:31 --> 25:33of things set in motion like early
25:33 --> 25:35screening in the 1st place with
25:36 --> 25:37a colonoscopy and possibly some
25:37 --> 25:40blood tests in it with a genetic
25:40 --> 25:42counselor that might go on where
25:42 --> 25:43a pathologist might be.
25:43 --> 25:45The first one to initiate something
25:45 --> 25:47is that when we get a sample.
25:47 --> 25:50From someone of of the right age group,
25:50 --> 25:51or maybe a young person,
25:51 --> 25:55or that they have for example on colonoscopy,
25:55 --> 25:58have you know 10 or more types of
25:58 --> 26:01polyps that are all precancerous polyps?
26:01 --> 26:03We will raise our hands and say,
26:03 --> 26:04hey, here's your diagnosis,
26:04 --> 26:05and oh, by the way,
26:05 --> 26:07please sign this patient up for
26:07 --> 26:09some for genetic screening,
26:09 --> 26:10because they they have too many
26:10 --> 26:13polyps at age 50 that you know
26:13 --> 26:14that's the we want to make sure
26:14 --> 26:16it doesn't mean something more.
26:17 --> 26:20Right and but, but there's a clear
26:20 --> 26:22difference in terms of, you know,
26:22 --> 26:24in the one instance when we're
26:24 --> 26:26talking about molecular diagnostics,
26:26 --> 26:28we're really talking about
26:28 --> 26:30doing these tests to look for
26:30 --> 26:33mutations in the cancer itself,
26:33 --> 26:36whereas when we're looking at
26:36 --> 26:38predispositions and genetic screening,
26:38 --> 26:41for example, we're really talking about
26:41 --> 26:44cells that are baseline that are in
26:44 --> 26:47your blood or in your saliva that.
26:47 --> 26:49All of your cells carry versus in.
26:49 --> 26:50The tumor itself.
26:50 --> 26:51Is that right?
26:51 --> 26:52That's absolutely right,
26:52 --> 26:55and it's such a good, nuanced point.
26:55 --> 26:58And and so this again,
26:58 --> 27:03it's all good tools that physicians at
27:03 --> 27:06all levels of interacting with folks.
27:06 --> 27:10So in the in the you know, annual physical
27:10 --> 27:13exam at that level by family history,
27:13 --> 27:17personal and family history, the physician.
27:17 --> 27:19Can can begin the process and say, yeah,
27:19 --> 27:22we probably want to check into this.
27:22 --> 27:25And at the same time finding finding
27:25 --> 27:27early lesions that the pathology level,
27:27 --> 27:31in addition to finding a truly already
27:31 --> 27:34invasive cancer as they walk in the door.
27:34 --> 27:36Someone walks in the door at
27:36 --> 27:37age 45 with colon cancer.
27:37 --> 27:38They already have it.
27:38 --> 27:39We're going to work on that.
27:39 --> 27:41They're going to get testing of the
27:41 --> 27:43tumor itself to see what might work,
27:43 --> 27:45but because they're young,
27:45 --> 27:47this will, with all the clinicians,
27:47 --> 27:48will say, Oh yes.
27:48 --> 27:50And by the way, we want to screen
27:50 --> 27:51your family members now too.
27:51 --> 27:53We want to just make sure this is.
27:53 --> 27:56Not just an isolated thing.
27:56 --> 27:56Right,
27:56 --> 28:00so Marie, in our last kind of 30
28:00 --> 28:01seconds here, where do you think
28:01 --> 28:03the field of pathology is going?
28:03 --> 28:05Should we be expecting more of these
28:05 --> 28:07kinds of genetic and genomic tests?
28:08 --> 28:13Yes, I think it's going to go further
28:13 --> 28:14and further and deeper in this
28:14 --> 28:16direction with hopefully much more
28:16 --> 28:18useful information down the line.
28:18 --> 28:21I believe we are also poised to enter
28:21 --> 28:24the digital era and with artificial
28:24 --> 28:26intelligence to apply to samples.
28:26 --> 28:29To improve even further,
28:29 --> 28:32our ability to glean treatable information.
28:33 --> 28:35Doctor Marie Robert is a professor
28:35 --> 28:37of pathology and of medicine
28:37 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu
28:43 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public
28:55 --> 28:56radio. Funding for Yale Cancer Answers
28:56 --> 29:00is provided by Smilow Cancer Hospital.

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July 31, 2022

Yale Cancer Center

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