34: Are We Closer to a Cancer Breakthrough? – The Truth About Liquid Biopsies & MRIs with Dr. Aaron Hartman

The false positive rate is about 58%. So what does that mean? It means if you do the test and it's positive, 58% of the time, it's not a true positive, it's a false positive. So if it pops positive for a colon, breast, lung, prostate, pancreas, whatever, 58% of the time after additional screening, CT scan, MRI, maybe a biopsy, who knows? The results are negative. Welcome back, everybody. We're going to start doing some of these short little mini episodes, maybe 10 minutes, where we'll talk about some interesting topics. Today we're going to talk about some cutting edge screen tools, like liquid biopsies for cancer, like whole body MRIs. Let's talk about how useful they are. Are they, are they amazing? Are they as advertised? Or is this just the string of our attempts? That advanced screen that just isn't quite ready for prime time? And that's today's topic, but we'll be doing more of these and just let us know if this is helpful. One of our team members actually recommended doing this and some patients have asked for it. So just let us know if there's a topic you'd like us to talk about. Take a deep dive in. You can put it below where on social media, wherever you're seeing this, or on our podcast. And we'll be releasing these probably on Thursday or Fridays on our podcast, just our usual topics. And these are kind of like little deep dives on different interesting things. So in the precision medicine world, the personalized medicine world, we've always wanted to be able to screen for cancer. Screen for heart disease. Earlier we had, back in 2000 when I was doing my training, the IVA cholesterol panel, LDL, HDL, triglycerides. Oh my gosh. We can now screen for other things. When the A1C first came out in like 19, it was 1996. Actually. An endocrinologist I was training with at that point in time was so excited about this thing called a 1C. It was super fancy. It took like 20 years for Medicare to start paying for it. We've always wanted to find early screening tests. One of those actually was virtual colonoscopies. Back in 2007 and 8 when I came back to Richmond, there's some local groups doing virtual colonoscopies screening for colon cancer. Hey, guess what? You don't need scope and you can screen for colon cancer. It didn't pan out for a lot of reasons. There was a lot of radiation exposure. Screening for pancreatic cancer, abdominal ultrasound not covered by insurance doesn't always work the best. How about blood tests checking for CA99 alpha feta protein, other tests for screen for cancers. We've always been trying to find cutting edge things to help us find stuff earlier. And when I was doing some trauma surgery training when I was in the military, I came across this thing called bombit syndrome. Victims of modern imaging techniques, they talked about this in the hospital, the trauma surgery world. And the idea is that because we have cool technologies, we want to use them and we don't always appreciate the errors in them, the accuracy. And there's a thing called the number needed to treat which is how many people do you have to do this procedure on to actually save a life? And sometimes those numbers need to treat a pretty, pretty bad for example is using Zocor to prevent cardiovascular death in high risk individuals. The number need to treat to treat over five years is 40. So you have to treat 40 people who've had a heart attack or coronary risk equivalent for five years to prevent one. When you say it like that, it's not super impressive doing ET scans for cancer. So the point is, is that we've always been on this quest how can we find cancer earlier? It's not new. Sometimes we have these little screening things we have in the Richmond here, the life lying screening where you can get an aortic aneurysm screen done. Well actually that was beneficial. Now Medicare will pay for a screening abdominal ultrasound to rule out an aneurysm in men who smoked, not for women, but men who smoked. We started doing CT scans unofficially screening for lung cancer and actually could find it earlier and actually save lives. And eventually we got some guidance that actually allow for low energy CTs for screening for lung cancer. So there are some things or coronary calcium scores, There are some things that are out there, some are paid for insurance and some are not. But two of the newer things right now are liquid biopsies for cancer. There's a couple different tests out there. I'm not going to mention names because I don't want to draw too much hate, but that's a new thing. And the liquid biopsies, the concept is in the one particular test is using this thing called cpgs. It's methylation sites on cells and you can actually through these actually figure out about 50 different cancers people may have. And just the next generation of, of cancer screening, we've been using things like alpha feta protein for ovarian cancer, colon cancer, an extra testicular cancer and then We've been using PSAs for prostate cancer, CA99s, CA for colon cancer. The thing with some of these tests is that they're not really good for screening. If someone had cancer and it was positive, then you could actually use it to track treatment, but it's not really good. And so the newest generation are these liquid biopsies, which are now the rage.

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But there are a couple issues with these. The first thing is that the false positive rate is about 58%. So what does that mean? It means if you do the test and it's positive, 58% of the time, it's not a true positive, It's a false positive. So if it pops positive for a colon, breast, lung, prostate, pancreatic, whatever, 58% of the time, after additional screening, CT scan, MRI, maybe a biopsy, who knows? The results are negative. The other thing is that 70%. It's 70% false negative mal cancer. So. So if someone has a stage 1, 2, 3, 4 cancer, 70% of the time, it's false negative in all those cancers. Now, where the utility comes in is in stage stage 3 and 4 cancer, the stage 1 sensitivity is about 16%, which means if you're, you have cancer, it's positive in stage 1 16% of the time, which is when you want to catch cancer. So that earliest cancer that you want to catch, it's positive 16% of the time. And as you go on to stage four cancer, the sensitivity is up to 90%. So this is a great screen for stage four cancer, but then the question is stage four, that's usually when spread like are you actually saving lives? So the advantages are they can look for 50 different types of cancers, but it's not really quite yet ready for prime time. I understand people wanting to have a screen test. If it's negative, I mean you get peace of mind. But again it's, if you people are found to have cancer and they look back, 70% of people, stage one, two, three and four would have a false negative. If you have stage one, 16% of the time it's picked up. If you have stage four, 90%. And so again, not, not super amazing. There's another thing called a whole body MRI which has become really popular. And in Richmond right now where I'm at, there's only one, one way, one group you can actually get that with. Otherwise you have to drive to D.C. to get it. But the thing about whole body MRIs which have been around for maybe eight or 10 years, is that it picks up absolutely everything. About 40% of women in their 40s or early 50s will have a cyst on their liver if you do an MRI, about 40, 50% of adults over 50 will have a cyst on their kidney. So if you start adding up cysts, liver, kidney, gallbladder, pancreas, you'll see a lot of people have these things, these normal abnormals that aren't cancer, that didn't result. Again, vomit victims of mining imaging techniques. You do a test and comes back positive, then what's next? I want early cancer screening just like everybody else does, but at what cost? You know, I always refer back to the, the mammogram example because it's not amazing, it's not a prevention, it's, it's early diagnosis. Because by the time you've, most women you've already had cancer anywhere from one to two years by the time it pops up on a mammogram. So it's not the best breast MRI is amazing for picking up. That's, that's actually a true screen test, but it picks up everything. So you can have even more false positives and even more biopsies done. So the question becomes, at what point in time does a screen test actually save lives? And that's where the whole process of vetting the utility of colonoscopy is the utility of immigrant pap smears. I mean pap smears are an example of something that in the 1950s, the most common cause of death, the middle aged women was silver coin answer. And in my career I've never had a patient die from cervical cancer. And the Difference has been Pap smear. So there are screening things we have are absolutely amazing. If you can deal with the uncertainty, if you can deal with the stress of knowing that you had a PSA for. I think it's a great example. I have patients who have a PSA 5, 6 or 7, they get a biopsy. It's Gleason 4. 5 early prostate cancer. Just watch it. Because 60% of men that are 65 or older and 80% of men that are over 80 will have prostate cancer. They die with it, not of it. And so we're getting used to this in certain situations, but like with a lot of female cancers. BRCA genes, for example, is another great example. Why don't we screen everybody for the BRCA gene? Well, in the 1950s, if you had the BRCA gene, you had 20% risk for cancer. Now it's slightly over 80%. And so now if you have a BRCA gene, the treatment is bilateral mastectomy, preventively bilateral ectomy. They cut off your ovarian tubes. It's pretty aggressive. And so you also have to weigh the risks and benefits. And I talked about this earlier, that medical error is the third most common cause of death. And so when you start thinking about things we do to prevent, you have to take that into account. That's the reason why you have to work with someone who's really educated, who's trained, who understands all these nuances. Doctors, we're clinical scientists, we like using fancy new technology, but it's not always the best thing for you. So just keep that in mind. As you're reading about liquid biopsies, as you're reading about whole body MRIs and other screen tests, take a deep dive and really talk with your practitioner, your physician. Are these things useful? Is this actually going to help save your life? There are things like screening A1Cs blood pressure, doing advanced lipid panels, looking at your LP, looking at particle number and size. There are so many things that can be done that actually have utility. Looking for inflammatory markers, sedate CRPs. There's so many things that can be done to have homocysteine levels, nutrient levels, omega 3 levels. Taking fish oil lowers your risk of sudden cardiac death. And you start looking at people. I routinely check this on patients and they, probably half of my people right now have low levels. There's so many things you can do to have a big bang for your buck. You don't always need to do the most recent fancy thing to get the benefit. Hopefully this information was helpful. We loved it. We love your comments. Please share us with friends. If you have other things you'd like to hear us talk about, please let us know below and we'll talk to y' all soon.