Peter Attia, MD: How to Detect Cancer Early - Before it Spreads

Name: Peter Attia, MD: How to Detect Cancer Early - Before it Spreads
Uploaded: 2023-05-04T14:34:57.000Z
Duration: 2 h 32 min 48 s

Introduction

Dr. Peter Attia discusses the most common causes of death and the importance of knowing them.

Leading Causes of Death

Chronic diseases are the leading cause of death in modern times.

The Four Horsemen of Death: cardiovascular and cerebrovascular disease, cancer, neurodegenerative disease, and metabolic diseases.

Lifespan is the length of life while healthspan is quality of life.

Medicine 2.0 is the current medical system while Medicine 3.0 focuses on optimizing healthspan.

Medicine 2.0 vs Medicine 3.0

Dr. Peter Attia explains the difference between medicine 2.0 and medicine 3.0.

Medicine 2.0

Developed from the late 17th century to early 20th century with scientific advancements such as antibiotics and vaccines.

Focused on treating acute illnesses rather than chronic diseases.

Medicine 3.0

Focuses on optimizing healthspan rather than just treating illness.

Uses data-driven approaches to personalize treatment plans for each individual patient.

Emphasizes prevention through lifestyle changes such as diet and exercise.

Personalized Health Optimization

Dr. Peter Attia discusses personalized health optimization.

Personalized Health Optimization

Personalized medicine involves using data to tailor treatments to individual patients.

Data can come from sources such as genetic testing, blood tests, and continuous glucose monitors (CGMs).

CGMs can provide valuable information about how different foods affect an individual's blood sugar levels.

Using this data, individuals can make lifestyle changes to optimize their healthspan.

Medicine 2.0 and the Need for Medicine 3.0

In this section, the speaker discusses how medicine has evolved from treating infectious diseases to chronic diseases. He introduces the concept of Medicine 2.0 and explains why it has been largely unsuccessful in treating chronic diseases.

The Playbook of Medicine 2.0

Medicine 2.0 uses a playbook that involves diagnosing a disease and then treating it pharmacologically or surgically.

This approach has been largely unsuccessful against chronic diseases because they are not as amenable to this strategy.

Life Expectancy and Early Successes of Medicine 2.0

Applying tactics and strategies from Med 2.0 to current problems has not been very successful.

Life expectancy today is almost the same as it was 120 years ago when you strip out the top eight infectious and communicable diseases.

Doubling life expectancy came almost exclusively through early successes of medicine 2.0.

Introduction to Medicine 3.0

The speaker introduces the concept of medicine 3.0, which involves a fundamental philosophical shift around prevention and very early prevention.

Challenges with Transitioning to Medicine 3.0 in the US

In this section, the speaker discusses why transitioning from medicine 2.0 to medicine 3.0 will be harder in the US than in other countries due to structural reasons related to financial incentives for healthcare compensation.

Preventive Strategies in Other Countries

Some countries in Europe have more preventive strategies due to their healthcare systems.

Financial Incentives for Treating Disease

The US healthcare system is not well geared up for medicine 3.0 due to financial incentives and remuneration for treating disease.

Financial incentives are geared towards getting paid to treat disease, especially early in life when care is private, not public.

Challenges with Single-Payer System

The speaker argues that a single-payer system is usually quite unsuccessful as well.

However, a single-payer system makes it easier to tweak the incentives towards prevention because there is no financial incentive to provide delayed treatment.

Structural Challenges with Transitioning to Medicine 3.0

Healthcare in the US is very portable, so insurance carriers may only own the risk of a person's life for five or six years.

There are many structural challenges with transitioning from medicine 2.0 to 3.0.

Cancer and Medicine 3.0

In this section, the speaker discusses cancer and how medicine 3.0 can help prevent it.

Introduction to Cancer

The speaker introduces cancer as one of the Horsemen and mentions his personal experience with Hodgkin lymphoma.

This transcript has limited content related to Medicine 3.0 and its benefits over Medicine 2.0. Most of the content focuses on why Medicine 2.0 has been largely unsuccessful against chronic diseases and why transitioning to Medicine 3.0 will be challenging in the US due to structural reasons related to financial incentives for healthcare compensation.

Approach to Cancer in Medicine 2.0

In this section, the speaker discusses his approach to cancer within the context of medicine 2.0 and highlights the importance of early and aggressive cancer screening.

Understanding Cancer

The majority of cancers arise from somatic mutations acquired over a person's lifetime.

Smoking and obesity are modifiable risk factors for cancer.

However, cancer is largely about bad luck as we have limited understanding of what drives it.

Importance of Early and Aggressive Cancer Screening

Early detection is key to effective treatment as the fewer cancer cells a person has in their body, the more effective the treatment.

As mutation burden rises, there is a greater likelihood that some cancer cells will be resistant to treatment.

There is no example where odds of eliminating cancer go down as tumor burden goes up.

Therefore, very early and aggressive cancer screening is essential in our fight against cancer.

Controversies Surrounding Cancer Screening

While early and aggressive screening is important, it remains a highly controversial topic.

The rationale for screening is straightforward based on data from colon and breast cancers where early detection leads to better outcomes.

However, there are concerns about overdiagnosis leading to unnecessary treatments with potential side effects.

Conclusion

While we have limited understanding of what causes cancer, early detection through aggressive screening can lead to better outcomes.

The Importance of Early Cancer Screening

In this section, the speaker discusses the importance of early cancer screening and how it can help fight cancer with the smallest burden possible.

Early Screening for Cancer

Regardless of how much we do individually to reduce our risk of cancer, every one of us is susceptible. Therefore, it's imperative that we at least consider what very early screening does to give us a chance to fight cancer with the smallest burden possible.

Lack of Progress in Cancer Treatment

Treatments over the last 50 years for metastatic solid organ cancers have not come along that far. There has only been an improvement in overall survival rate from cancers by 5% in 50 years.

Immunotherapy has shown promise in improving these numbers, specifically checkpoint inhibitors which work on any tumor provided they have a certain type of mutation. Approximately 8% of all tumors today are now responsive to immunotherapy.

The Power of Immunotherapy

Of all the things that have come along in the past 20 years, immunotherapy is by far the most interesting part of cancer treatment.

Types of Cancer Screening

In this section, the speaker discusses two big buckets for cancer screening: cancers that happen inside and outside the body.

Cancers That Happen Inside The Body

Everything from your mouth to your anus is technically outside your body because you can look directly at it. Colon cancer is particularly noteworthy as it is currently the third leading cause of cancer death in the United States.

Cancers That Happen Outside The Body

Skin cancers are exposed to air and everything on the outside vis-a-vis your skin is exposed to the outside world.

The Importance of Colonoscopy

In this section, the speaker discusses how colonoscopy can help identify and remove polyps that are a necessary first step towards the development of colon cancer.

Colonoscopy as a Screening Tool

Colonoscopy allows for direct visualization of the colon and identification of any polyps.

Development of a polyp is a necessary but not sufficient step for the development of cancer.

If screening is done at a high enough rate, nobody should die from colon cancer.

Screening typically begins at 40 years old for those with no other risk factors or family history.

Frequency and Risks Associated with Colonoscopy

Screening frequency depends on what is found during the colonoscopy.

Adequate visualization of the colon is important to wait three years before doing another screening.

Risks associated with bowel prep, sedation, bleeding, and perforation exist but are generally small.

Upper Endoscopy

No bullet points as there was no new information provided in this part of the transcript.

Pre-Cancerous Lesions in the Esophagus

In this section, the speaker discusses how pre-cancerous lesions can be found in people who only report occasional heartburn.

Risk Factors for Barrett's Esophagus

Occasional heartburn is a significant risk factor for Barrett's esophagus.

Upper endoscopy may be recommended during colonoscopy to check for pre-cancerous lesions.

Whether or not to perform an upper endoscopy depends on each individual case.

Bowel Prep for Colonoscopy

In this section, the speaker talks about bowel prep for colonoscopies and recommends a product called SUTAB.

SUTAB as a Better Alternative

SUTAB is a more pleasant alternative to other bowel prep products.

It involves taking 12 tablets with water twice before the procedure.

The volume of liquid required is much less than other products like GoLYTELY.

Choosing an Endoscopist

In this section, the speaker provides recommendations on what to look for when choosing an endoscopist.

Questions to Ask Your Endoscopist

Ask your endoscopist about their perforation rate, bleeding rate, cecal intubation rate, and typical endoscopy time.

These metrics can help you determine if they are a good fit for you.

Stool-Based Tests as Alternatives to Colonoscopies

In this section, the speaker suggests stool-based tests as alternatives to colonoscopies.

Fecal Occult Blood Test vs Immunohistochemistry Tests

A fecal occult blood test is less effective than immunohistochemistry tests.

Doing a stool test that looks for tumor DNA during off-years of colonoscopy is better than doing nothing.

If the stool test is positive, a colonoscopy should be scheduled.

Timeframe for Colon Cancer Development

The timeframe for developing colon cancer is unclear, but it can develop in less than 10 years.

Getting a colonoscopy every 10 years is not recommended.

Colon and Breast Cancer Screening

In this section, the speaker discusses colon and breast cancer screening. They talk about different types of stool tests for colon cancer screening and recommend Cologuard as their preferred option. For breast cancer screening, they discuss the importance of family history and personal factors such as breast tissue density. The speaker also emphasizes the need to use multiple modalities for breast cancer screening.

Colon Cancer Screening

Stool tests are a less expensive alternative to colonoscopy for colon cancer screening.

Cologuard is the speaker's preferred stool test, but the choice ultimately depends on budget.

Stool tests cost significantly less than getting a colonoscopy.

Breast Cancer Screening

Family history is an important tool for assessing breast cancer risk in women who have not been adopted.

Personal factors such as breast tissue density can affect how breast cancer is screened.

Mammography should be an automatic screening modality for every woman, but it may struggle with dense breast tissue in younger women.

Using at least two modalities is necessary for effective breast cancer screening, with mammography being one of them.

Using Multiple Modalities

There is no right answer to how often to use different modalities; it depends on the patient's needs and preferences.

Breast Cancer Screening

In this section, the speaker discusses the right approach to breast cancer screening and genetic testing for genes that may increase the risk of breast cancer.

Breast Cancer Screening

The right approach to screening is determined by ignoring cost and only considering harm such as false positives, psychological harm, and opportunity cost.

Genetic testing for genes that may increase the risk of breast cancer is recommended in select patients with a family history that comes up suspect. BRCA genes are usually quite obvious from family history but other non-deterministic genes require further investigation.

Genetic testing has significance in terms of planning and expectations around having kids. Women with these genes will be much more on guard if they have a child and can think through those things. If the risk is significant enough, a woman can elect to do something much more aggressive than screen which is prophylactically undergo a mastectomy and just eliminate the source of the tumor before a tumor forms.

Liquid Biopsy

Liquid biopsy is an emerging tool used for early detection of breast cancer. The sensitivity is very low while specificity is very high meaning if no tumor is there, you're going to get it right but if a tumor is there, you might not see it. However, when you look more closely at the data and segregate out the breast cancers by type, liquid biopsy becomes yet another tool that we should include in this process.

Liquid Biopsy and Galleri Test

In this section, the speakers discuss the liquid biopsy and Galleri test as a tool for detecting cancer.

Liquid Biopsy Detecting Aggressive Tumors

The liquid biopsy is over three times better at detecting triple-negative tumors at an early stage than it is for triple-positive tumors.

The liquid biopsy is much better at detecting more aggressive tumors that are already spreading by the time they're stage two.

Attaining the Galleri Test

The Galleri test has to be ordered by a physician. It's not available as a direct-to-consumer test.

The Galleri test requires two tubes of blood and returns results within two weeks or so.

Using Liquid Biopsies as a Screening Tool

While the liquid biopsy can be used as a pan-cancer tool, it should not be relied on solely by itself. It should be used in conjunction with other screening modalities.

False positives and false negatives have different implications when using biological tests like liquid biopsies compared to anatomical tests like colonoscopies or mammograms. We need to understand what these mean before relying on them exclusively for screening purposes.

Sensitivity and Specificity in Cancer Screening

In this section, the speaker discusses the concepts of sensitivity and specificity in cancer screening tests.

Sensitivity and Specificity of Different Tests

MRI has almost 100% sensitivity but its specificity is abysmal.

Liquid biopsies have almost 100% specificity but their sensitivity is abysmal.

The Mathematics Behind Adding Multiple Tests

When adding two tests, you cannot simply add their sensitivity and specificity. The mathematics behind it are more complicated.

However, adding more tests increases the number of shots on goal to pressure test what is being seen.

Metal Detector Analogy for Setting Test Sensitivity

A metal detector's sensitivity can be set higher or lower depending on how the test makers want to set them.

Tuning a screening test involves deciding whether to tune it more towards no false positives or no false negatives.

Examples of Sensitivity and Specificity in Prostate Cancer Screening

PSA stands for prostate-specific antigen, which is a protein made by cells in the prostate. It's not made by other cells, making it prostate-specific.

Understanding PSA Testing

In this section, the speaker discusses how prostate-specific antigen (PSA) testing is used to screen for prostate cancer and the limitations of using PSA testing alone.

The Limitations of PSA Testing

Two people with the same size prostate would be expected to have a relatively low PSA, probably at or below one. However, if one person has a significantly higher PSA value than expected, it could indicate an increased risk of prostate cancer.

Historically, PSA testing had a lot of false positives and false negatives when used by itself. False positives led to unnecessary biopsies while false negatives missed many cases of cancer.

Looking at several other metrics in addition to PSA can improve its predictive value. These include free PSA, PSA density, and PSA velocity.

Improving Predictive Value

By looking at additional metrics beyond just the level of PSA in the blood, doctors can better predict whether someone has prostate cancer or not.

If there is concern about prostate cancer after reviewing these additional metrics, doctors may order a 4K test or multiparametric MRI to further evaluate the patient's condition.

Biopsy Procedures

False positives from using only a single metric like PSA often led to unnecessary biopsies. A transrectal biopsy of the prostate is not a benign procedure and can lead to complications.

Today very few men undergo unnecessary biopsies because additional metrics are used alongside the level of PSA in their blood. By the time someone undergoes a biopsy today, they likely already have cancer; it's just a question of how aggressive it is.

Conclusion

In this section, the speaker concludes by discussing how additional metrics have improved the predictive value of PSA testing and reduced unnecessary biopsies.

By using additional metrics alongside PSA testing, doctors can better predict whether someone has prostate cancer or not. This has led to fewer unnecessary biopsies and a better understanding of how aggressive someone's cancer is.

Additional PSA Blood Tests

In this section, the speaker discusses additional PSA blood tests that can be done beyond the standard test.

Types of Additional PSA Blood Tests

The additional PSA blood tests include PSA velocity, density, and free PSA.

When ordering a PSA test, a lab will typically default into a free PSA. They'll reflex a free PSA test if it's over three. With a high enough PSA, you can automatically just get the free PSA. The other ones, you actually have to manually calculate.

To know the prostate size to calculate prostate density, one has to have had an ultrasound or some other imaging of the prostate.

There are online calculators that'll do this for you where you put in historical PSA data with time and it will tell you the PSA velocity.

Mainstream Use of Additional Parameters

In this section, the speaker discusses whether any of these additional parameters are mainstream in family medicine clinics across the United States.

Use of Additional Parameters in Family Medicine Clinics

It is unclear how common it is for family medicine clinics to use these additional parameters beyond just the simple PSA test.

Unfortunately, there are lots of people who are falling through the cracks when it comes to detecting prostate cancer early on.

Importance of Early Detection

In this section, the speaker emphasizes how important early detection is when it comes to detecting prostate cancer.

Importance of Early Detection

Even a well-meaning doctor can miss something or maybe just isn't keeping up with this literature. So, everybody has to kind of take ownership over this problem for themselves.

Virtually every man will die with prostate cancer, fortunately not too many die from it, but it is still the second leading cause of cancer death in a man, only behind lung cancer.

Because so many men get prostate cancer and even though the lethality is not that high, the absolute numbers are pretty devastating.

Lung Cancer in Women

In this section, the speaker discusses the disproportionate incidence of lung cancer in women over men and how non-smoking women are the fastest-growing segment for lung cancer growth.

Disproportionate Incidence of Lung Cancer in Women

Women have a higher incidence of lung cancer than men.

Non-smoking women are the fastest-growing segment for lung cancer growth.

Non-smoking women appear to have a susceptibility to adenocarcinoma of the lung.

Possible Explanations for Disproportionate Incidence

The reason behind this trend is not clear.

Some possible explanations include estrogen or exposure to different types of gases.

Importance of Screening for Lung Cancer in Non-Smokers

It is not common practice to screen healthy non-smoking women for lung cancer.

Early detection can be life-saving, as demonstrated by a patient who survived an aggressive adenocarcinoma due to early detection through a calcium scan.

MRI Screening for Cancer

In this section, the speaker discusses MRI screening for cancer and its strengths and weaknesses.

Strengths and Weaknesses of MRI Screening

MRI has no radiation and high sensitivity, making it useful for detecting certain types of cancers.

However, it is not good at differentiating between cancer and non-cancer in certain tissues, namely glandular tissue.

Diffusion-weighted imaging with background subtraction (DWI), originally developed to look at strokes, is now being applied to the whole body to improve MRI screening.

Limitations of MRI Screening

MRI is not effective for diagnosing outside-the-body cancers such as cervical or endometrial cancer.

It is a high sensitivity test but has low specificity in certain tissues.

DWI can help improve the specificity of MRI screening.

MRI and Diffusion-Weighted Imaging

In this section, the speaker explains how MRI works and how diffusion-weighted imaging is used to determine the firmness of tissue.

How MRI Works

MRI uses powerful magnets to make protons move.

It measures different aspects of the movement of protons by pulsing them.

Protons are ubiquitous in fat and water, making it easy to measure their movement.

The frequency with which they ping these things was typically 50 microseconds for brain scans.

Diffusion-Weighted Imaging

Diffusion-weighted imaging is a trick that pulses water and looks at how long it takes to move again.

It determines how firm a piece of tissue is, even if there's no bleeding in the area.

This works well in the brain because the head doesn't move as much as other parts of the body.

To do this in the body is much harder because 50 microseconds is not fast enough to get a good signal due to body movement.

Visual Lump Detector

Diffusion-weighted imagining can be thought of as a visual lump detector that concentrates the signal around the firmness of tissue.

It serves as an effective way to increase specificity for an otherwise high sensitivity, low specificity test.

Importance of Whole Body MRI Scans

In this section, the speaker discusses whole-body MRI scans and their importance in detecting potential health issues.

Detection Technology

Whole-body MRI scans are important because they can detect potential health issues early on.

Prenuvo is probably one of the best companies offering whole-body screening using MRI technology.

Other companies license the Prenuvo technology.

Out of Pocket Expense

Whole-body MRI scans are 100% out of pocket and not covered by insurance.

Patients should be willing to deal with the high probability that something will be found that is not cancer but will require additional work.

Catch Rate

All comers have a 0.7% aneurysm catch rate, which can be lethal if not caught.

Clinically insignificant other artifacts are also detected, which need to be chased and pursued.

About 15% of patients elect not to do a whole-body MRI due to uncertainty as these other things are chased down.

Cancer Screening and Prevention

In this section, the speaker discusses cancer screening and prevention strategies. The importance of having a discussion before undergoing any type of screening is highlighted. Exercise is identified as the greatest longevity drug with evidence suggesting that it can help prevent cancer. The metabolic benefits of exercise are discussed, including its ability to reduce chronic inflammation and enhance the immune system.

Exercise as a Cancer Prevention Strategy

Exercise has been shown to have metabolic benefits beyond weight loss.

Muscle is the most important sink for glucose, making insulin-sensitive muscles equivalent to insulin-sensitive people.

Maintaining true insulin sensitivity requires exercise, particularly as we age.

Exercise creates myokines which reduce chronic inflammation throughout the body and enhance the immune system.

Other Cancer Prevention Strategies

Immune system exhaustion may be responsible for the exponential increase in cancer risk as we age.

Stress may play a role in cancer through hypercortisolemia and excessive glucocorticoids on the immune system.

Manipulating T-cell epigenome to turn old T-cells into younger ones could have a profound impact on cancer treatment.

Additional Cancer Screening Modalities

Cystoscopy may be recommended for individuals with a history or family history of bladder cancer or personal history of smoking.

Low-dose CT scan or MRI with diffusion-weighted imaging may be added for former smokers to screen for lung adenocarcinoma.

Genetic Testing and Cancer Screening

In this section, Dr. Attia discusses the benefits of genetic testing for cancer screening and prevention.

Benefits of Genetic Testing

Genetic testing has its place in cancer screening and prevention.

A thorough family history can accomplish a lot when it comes to cancer.

Prevention and screening are the main strategies for cancer today.

Limitations of Genetic Testing

The treatment landscape is still lacking relative to cardiovascular disease.

80% of solid organ tumors have novel neoantigens that a person's own immune system can recognize, but not enough immune cells can recognize them.

Increasing the number of T-cells that can expand to meet the need once they recognize a cancer cell is crucial.

Final Thoughts

Immunotherapy holds great promise for expanding the capacity to fight cancer.

Check out Dr. Attia's podcast "The Drive" and his website PeterAttiaMD.com.