Medically Speaking #10

Welcome to today's edition of Medically Speaking. Today I have two special guests with us from our cancer center. We have Dr. Ahmad Rahal and Dr. Clint Wood. In today's topic we're going to be talking about our cancer center at Self Regional. These two physicians are specialists in their areas. Dr. Rahal is a medical oncologist and Dr. Clint Wood is a radiation oncologist. We're going to have a really interesting conversation today around cancer, what is cancer, what are the treatments that we offer at Self Regional, and some really neat things that I want the community to know a little bit more about. So I thought we'd just start a little bit more with some introductions. So Ahmad, maybe just tell us a little bit about your background to start with, kind of where you're from, where you did your training, and how you ended up in Greenwood. Sure. So basically I was born in Colombia, South America, and then after that I moved to Lebanon, and I did my medical training there in Beirut. After that I moved to the States in about 10 years ago, in 2013. That's when I did my training in Kansas, in KU. I did my medicine, internal medicine training there. After that I did my oncology fellowship in Houston, in Baylor College of Medicine. Then after that I was looking for a job and looking around and then one of the oncologists, Dr. Yin, which is at Self Regional, I mean I kind of contacted her, and she was very happy here, and then it worked out. We have some family around, and then decided to give it a try, and been here for five years, and everything is going well. That's awesome. Yes, so I believe Dr. Yin, did she also train at Baylor? She did, yes. I think that's how we kind of, I knew about Self Regional, and then we decided to kind of, you know, she was very happy here. Yes. And you know, she and then Dr. Sedersky was here for a very long time, and I can, that made kind of my decision kind of to come here, and then everything has been going well since then. Awesome. Yeah, that's great. Yeah, Baylor, great reputation, great training in medical oncology, and we're super glad that you're here at Self Regional. Thank you. Yeah, thank you. And Clint, tell us a little bit about yourself. Okay, well, Columbia is a lot more interesting than where I'm from. I was born in a little town called Morehead, Kentucky, which is in the Appalachian Mountains in eastern Kentucky, and all my family lives in the same county, and born and raised there, and my dad was in the Army, so we moved around quite a bit, but started in Kentucky, ended in Kentucky, and I'm a Kentucky boy all the way through, and especially when it's basketball season, but I went to the University of Kentucky Medical School, and prior to that, I'd gone to grad school at the University of Wisconsin in Madison, and I was studying radiation physics, and I really didn't know what I wanted to do with my life, but I knew a little bit of medicine, a little bit of physics, and radiation physics kind of fit the two of those, and I got about halfway through that and decided to go to medical school and take those skills and apply them to radiation oncology, and I did my residency at the Medical College of Wisconsin in Milwaukee, Wisconsin. And how long have you been with Self now? This is my 13th year. Wow, yeah, that's awesome. Great. Well, super glad to have this conversation today. I thought we would just, maybe just talk a little bit about cancer in general. Maybe, Amai, we'll start with you. Just tell us, what is cancer exactly? Sure. So I think it's a disease, basically. I think you have to look at it, it's kind of, you know, the cancer starts from our own cells. And so normally, when you have a normal cell, it has a specific age where that cell will have to die, so there is a specific program inside you that will tell that cell to die at a specific time. So there are specific mechanisms that happen for that cell to be able to die, and then new cells will form. Let's say when you shave your, you know, you cut your hair or something, there's something growing back. So there's always that renewal that is going on. So what happens with cancer is that that particular cell, when it becomes of age and is supposed to die, the mechanism that will let that cell die, it just doesn't work anymore. So that cell doesn't die, it doesn't die anymore, and it just multiplies, and it starts growing and growing and becomes a tumor. And, you know, there is always a mechanism for that. And it's usually, there are some genes, the genes that we're usually born with, they are that control that mechanism for the cell to be able to die, and they just don't work. And that tumor starts growing and growing, and that's what's known as cancer. So it's basically a disease when there's an uncontrollable growth of, you know, your cells, where they multiply and multiply and they don't die anymore. And so, you know, there's of course different types of cancer, right? So like if it was like in an organ, it might grow like a tumor, but like blood cancers also are a little bit different. Maybe talk about blood cancers for a little bit. Right. So blood cancers are different in a way that you don't really see them on a scan, let's say. Or sometimes you don't really feel them as a tumor growing in some place of your body, like let's say. So they just run in the blood and a lot of the times they are, they come from the bone marrow and they just go and go in the blood and they multiply in the blood. So in this particular case, the mother cell in the bone marrow that's making those cells every day, it develops a mutation or something wrong in it. And instead of making a specific number of cells, it just multiplies and make millions of cells. And then it has to go out of the bone marrow to the blood. And you know, depending on what type of blood cancer you're talking about, it can grow in the lymph nodes and that's sometimes when you can see the growth there. Or you're talking about leukemias when people start becoming sick from the problems from that growth. Thank you for that. That's good information. So Clint, maybe for you, I know there's sometimes some confusion about, let's say a diagnosis, like someone hears, oh, I have stage two cancer or I have stage three cancer or I have stage four cancer. Could you just walk us through just the basics of what that means, like the staging of how cancers are staged? Yeah, I'll try to. Staging of cancer is a way that we can classify or categorize the progress of the cancer, how far has it grown. What I like to tell my patients is really cancer comes down to three questions for me. And so we have to be able to answer three questions. And question number one is what you just asked is what is it? What is cancer? What is it called? Where did it come from? And question two is where is it? And the where is it question is the staging question. And so where did it originate? Has it invaded other structures? Has it spread into the lymph nodes? Has it metastasized or spread throughout the body? And the staging system typically goes from a stage one to a four with one being the most early stage and four meaning that the cancer has spread throughout the body. And so it's a way that we can categorize and a way that we can also have different treatments that will apply to different stages of cancer. So stage ones are typically the best and the most favorable. You've caught them the earliest. And the treatment may be different for a stage one versus a stage two or a stage three. And then stage four is when we really rely on our medical oncology colleagues when the cancer now has spread throughout the body and the treatment has to be able to do the same thing. And that's where their therapies come into play. Absolutely. So, you know, of course, there's a lot of different treatments for cancers. I thought maybe you guys can touch on, you know, you know, what's what's the difference between like chemotherapy or radiation treatment or immunotherapy or just those different types of cancer treatments? And like what may what are some factors that may make one cancer like better treated by one modality versus another? Sure. I think that's a very important question because, you know, I think and we have to be careful because let's just start with the basic chemotherapy. I think that's what most of the people are familiar with. So chemotherapy, think about it as a chemical. So it's a toxin that you put in your body. And then the idea of that chemotherapy is to work on anything that's multiplying fast. So as we talked earlier, the cancer, they grow very fast and then the chemotherapy will go and try to kill anything that multiplies fast. The problem with chemotherapy, it doesn't really differentiate between a cancer cell and a normal cell. So when you give that toxin, you will have side effects because that chemo is intended to kill anything that multiplies fast. So you're talking about, for example, your hair cells, which multiply every day. The chemo can kill those hair cells. You can have hair loss. There are cells in your stomach and your in your intestines that kind of multiply every day. So the chemotherapy can damage those cells. And that's why patients have nausea and vomiting. And you can have any rash or basically and with many years ago, I mean, they didn't really know which chemotherapy will work for what type of cancer. So they they tried different trials. For example, the colon cancer, they tried this type of chemo and it works. So that's how it's approved. And there are many types of chemotherapies and the other types of treatments. Let's say there is a. Immunotherapy immunotherapy is different than chemotherapy. Immunotherapy is an infusion and it works by activating your own immune system. So it activates your immune system to recognize the cancer, because what has happened is that your immune system didn't really recognize the cancer to the point that the cancer has started growing inside you. And the immunotherapy will go in and try to prevent so that the way cancer works. It will put some some brakes on the immune system. So the immunotherapy will break that break and unleash that immune system. That way, the immune system will be able to kind of recognize the cancer and attack it. So there are the problems with immunotherapy is that sometimes we can over activate your immune system and the immunotherapy will go ahead and attack your own body. And that's what we know as autoimmune disease. So when you have an overactive immune system. Patients have autoimmune diseases. So if things like this happen, we usually treat side effects from immunotherapy by giving medications that suppress your immune system. Let's say prednisone or steroids. They basically are they kind of calm your immune system down. And that's that's immunotherapy. So chemotherapy, it's a toxin. It doesn't differentiate between good and bad, and it tries to kill anything that's multiplying fast. Immunotherapy, it's an infusion that helps activate your immune system for your own immune system to fight the cancer. I will let Clint talk about radiation, but there's one important treatment is called targeted therapy. Sometimes you see patients kind of get treatment for cancer with a pill. So what happens is when we were talking in the beginning, I was talking about the cancer growth and there is a problem in the gene. Sometimes it's not like the cancer cell is not good. The cell is not dying. Sometimes there is a problem, a mutation in that gene that lets the cancer multiply very fast. So throughout the years, they have been able to kind of find specific medications that block that mutation. And when you block what's kind of triggering that cell to grow, you're basically killing the way or stopping its growth and the cancer will die. In order to be able to be a candidate for that treatment, that's it's called targeted therapy. So you really have to have that mutation. So nowadays, when most of the patients that have a cancer that is a stage four, it has a spread. We kind of take that cancer and then send it for a DNA analysis. So we try to look at that cell that was a normal cell and change to a cancer cell. Look into what happened in that DNA. Once we find that mutation, we will go back and see if we have a pill that blocks that mutation. If that's the case. We usually try to treat it with that targeted therapy to that mutation and block that. There is another example. For example, you have breast cancer where some of the cancers, they grow through estrogen and we have pills that block the estrogen. In that case, you're targeting that estrogen receptor, which basically lets the cancer grow. And if you're doing that, basically you're targeting what is kind of making that cancer grow and multiply. And that's what we call targeted therapy. So in the medical oncology field, we talk about chemo therapy, immunotherapy and targeted therapy. That's kind of big. That's a good way to think about it. Kind of those three big categories of medicines. And Clint, maybe touch on radiation therapy a little bit. Like, how do you decide if someone needs that or not? All right. So I'm glad you guys asked Dr. Rahal to come because he just went through a lot of topic and spoke very eloquently. I couldn't have explained it like that. Radiation is a little more simple. So radiation is actually an X-ray. X-rays that go through the body and can cause damage at the DNA level in tumor cells that are rapidly multiplying. And so from one cancer cell to become two, that has to make a copy of itself. It has to make a copy of its DNA and then split apart to make two and then make four and then make five. And then make eight. And so that replication process where the cancer cell multiplies itself, the DNA has to be copied. And the radiation causes damage at the DNA level that prevents that cell from rapidly or multiplying and growing. And so radiation therapy, in the most common sense that we use the most, is an external radiation X-ray source that gets directed at a tumor and goes through the body and gives direct damage to the DNA. Of those tumor cells, which causes them to die. Radiation therapy comes in a lot of different flavors. The most common that I just mentioned is called external beam radiation, where radiation X-rays are generated from a really large machine and it gets targeted and directed at a certain area in the body. If there's something called external radiation, so there must be something called internal, the opposite of that. And so internal radiation goes by the name of brachytherapy. Brachy in Latin means close. So you bring the therapy in close to the patient. And so there are surgical procedures that can put devices inside the patient, inside a tumor where the radiation can be given from the inside out versus from the outside in. And then lastly, there are actually radiation drugs called radiopharmaceuticals that can be given intravenously where much like targeted therapy that Dr. Rahal mentioned, we can have a particle of radiation that emits radioactivity. We can connect it to a molecule of your choosing. And that molecule can circulate through the body and park itself, is what I tell patients, where the tumor is located. And so a common one would be in the bone. So we have molecules that sort of look like calcium and they take a radiation particle along for the ride. And they park themselves inside the bone and gives radiation off from the inside out. And so external beam radiation, internal brachytherapy, and radiopharmaceuticals are the big three for us. Got you. That's a good explanation. You know, one thing I think might be interesting for the community or just at a high level, what do you guys see as the most common cancers that we see in our community? I think the most, the top three that we see are probably breast cancer, prostate cancer, and lung cancer, and maybe colon cancer would be the — I agree. I think that's what we usually see, the most common. Mm-hmm. And in and around prevention. What do you guys — what do you all recommend for prevention for like those significant community cancers? Yeah, prevention's a huge part. Yeah. So we like to think of the cancer program — I mean, we're blessed and fortunate to be a part of it. We're just one little small piece. Yeah. Cancer affects everybody. And all sorts of physicians are involved in the care of a cancer patient, from the primary care physician to all kinds of specialists to the oncologist to radiology, pathology. I mean, it just — it touches everybody in the hospital system. And in the cancer center, we like to think of three sort of main components, the first being prevention and screening, the second would be treatment and dealing with the cancer, and the third is survivorship. So how do you live after a cancer diagnosis? But prevention and screening is a huge topic, and there are multiple cancers which have different screening protocols to try to catch the cancer at an early state. And that's a pretty big topic, but lung cancer, prostate cancer, breast cancer, everybody knows you get mammograms, you do colonoscopies, you do — now for lung cancer, you can do CT scans for patients who are at high risk. But catching the cancer early is a huge part of increasing a patient's chance at success. I think I agree. I just want to clarify a few points. That's an excellent overview, just kind of from the — I mean, community, people would like to know, hey, well, so when I should do those tests? Mm-hmm. From a mammogram's perspective, I would start usually at the age of 40. Mm-hmm. And, you know, how often to do them, usually the standard is to do a mammogram every year. Mm-hmm. And there are different societies that recommend to do it every other year, but I think doing it every year is usually covered by insurance, and it's usually a peace of mind that, you know, if anything will grow, within a year you should be able to catch it in a good time. Mm-hmm. As Clint said, colonoscopy, I think we used to start at the age of 50. But now we're seeing much younger people that are just, you know, being diagnosed with colon cancer, and they are only 30 years old or 35 years old without any family history. So that being said, now we're start screening at the age of 45. Mm-hmm. So when you're 45, I would just consider doing colonoscopy. Now, if someone in your family had a colon cancer, then you probably start at the age of 40 or 10 years before when they were diagnosed. So let's say if your father was diagnosed at the age of 45, then you start at 35. Or you can do — or 40 probably is the minimum. And then regarding the PSA, it's kind of a little bit of a tricky topic because initially there was a recommendation against doing a PSA because a lot of the times there was kind of — sometimes you might have a high PSA, and then you will have to go and do a biopsy. So really there should be a very good discussion between the patients. And the family members regarding the PSA, when to do it, and if you have a family member. So if you are African-American or if you have a family member with prostate cancer, usually your risk is higher, and I do recommend considering doing that. Mm-hmm. And CT scan, I think we're doing it at the age of 50. I have to double-check that. But you have to be smoking for more than 20 years. Mm-hmm. And then we will do a CT scan of the lungs. So right now, the screening options that we have, we have a CT scan. We have a CT scan for lung cancer. We have mammogram for breast, colonoscopy. We have PSA for prostate cancer, and obviously we have pap smears for cervix cancer. Mm-hmm. That's for now. We don't really have any others. Sometimes patients will come to my office and say, "Well, I need a blood test to tell me if I do have cancer or not." We're not ready yet. We might get to the point that you will do a test, and they will tell you if you have cancer or something, but not at this point. Mm-hmm. I have heard some folks talking about that, that blood test. Do you feel like that's coming in the future sometime, where you can get a blood test and kind of screen? It could be. I think we're in a time where we're being able to kind of take the blood and check for the cancer DNA in the blood. Mm-hmm. So I feel like we're getting there, and there are a lot of companies out there. But we have to be very cautious, because once you do that, it's very expensive. And a lot of the times, they will bring those results to their primary care doctors, and it's hard for the PCP or the primary care doctors to be able to look at the results, because there is no standard on what you should do if you have something positive or not. Mm-hmm. So when you don't really have a standard way of analyzing a specific result, it's better not to do it at this point. Mm-hmm. Got you. You know, one thing I wanted to also just ask, maybe Dr. Hall, you can help answer this a little bit. I know, not just in Greenwood, but throughout the whole United States, perhaps the whole entire world, there's been a decrease in the age of onset of cancer. And I've done a little bit of reading about this. I was just curious, from your perspective, any insights into why that might be? Why are people getting cancer at younger ages? Well, I think I might not be right, but I think when we talked at the beginning about the cancer, usually what happens with the cancer, you're born with normal genes, and the genes will function normal. So when people get cancer, there are three big categories why they can get cancer. One of them is age. As anything that ages after 80 or 90 years of working, that machine or something will get weaker and older, and eventually that gene, which is working every day for 80 or 70 years, you just get damaged, and people get cancer. And that's why we say sometimes patients come to us, "Why did I get cancer?" We tell them it's from age, you know, the fact that you're more than 70 years, your risk of getting cancer. Your risk of getting cancer is high. The other risk is genetic. You're sometimes born with a genetic mutation. There are some family members that have, for example, an example would be a BRCA mutation. A BRCA is BRCA mutation. If you're born with that mutation, your risk of getting breast cancer is 80%. So patients that have that mutation, they need to kind of have their both breasts removed and their ovaries removed. The other one is what we call environmental things like smoking, alcohol use. But right now we're seeing a lot of patients that don't drink or smoke that still have cancer, and it's what we eat. I think it's in the diet. So a lot of things, you know, in the diet basically will affect the microenvironment in your intestines. I think they did a study one time in places like so remotely,