Colonoscopy versus CTC remains controversial
Presidential Profile
Plenary sheds light on liver repair, regeneration
Future of HCV therapies examined in AASLD lecture
Hands–on course explores advanced endoscopic techniques
A new view of sedation and monitoring
Endoscopy standard, but indications remain for surgical treatment of upper GI bleeding
Panel to address ethical dilemmas raised by genetic testing



Colonoscopy versus CTC remains controversial

The controversy continues over whether traditional optical colonoscopy or computed tomography colonoscopy (CTC), also known as virtual colonoscopy, will emerge as the preferred screening procedure for colorectal cancer.

This oft–debated question was the topic of two presentations during Sunday's AGA Clinical Symposium: Colonoscopic Cancer Screening in 2009.

Jason A. Dominitz, MD, MHS, VA Puget Sound Healthcare System, Division of Gastroenterology, University of Washington, Seattle, addressed "Should Colonoscopy Be the Standard of Care?"

"Colonoscopy is the criterion standard for the diagnosis of colorectal neoplasia," Dr. Dominitz said, "but that does not necessarily make it the standard of care."

The U.S. National Cancer Institute defines "standard of care" as "treatment that experts agree is appropriate, accepted and widely used."

Colonoscopy has been found to lower colorectal cancer mortality but CTC has highlighted that colonoscopy also has "blind spots," Dr. Dominitz said. Colonoscopy complications also include a risk for perforation bleeding.

Quality improvement processes, such as slower withdrawal and better polyp removal technique, are critical in colonoscopy screening, he added, and technological advances also are needed in the areas of improved bowel preparation, optics and contrast.

While earlier studies show that patients preferred colonoscopy and flexible sigmoidoscopy, a soon–to–be released study will show that patients now prefer CTC to colonoscopy, Dr. Dominitz said. "But there is still some debate," he added.

Don C. Rockey, MD, professor, department of medicine, gastroenterology, Duke University Medical Center, Durham, NC, asked the question, "Is CTC the Screening Test of Choice?"

CTC is a quick, non–invasive procedure, requires no sedation and has a very low risk of perforation. Like traditional colonoscopy, it requires bowel preparation."Sensitivities for large lesions (>8 mm) are likely to be in the 90 percent range, perhaps close to colonoscopy, but sensitivities are low for smaller lesions. And, in my opinion, sensitivities for flat lesions remain problematic," said Dr. Rockey.

A lot of controversy exists about the amount of radiation used in the procedure, Dr. Rockey added, but studies have shown the level is low in comparison with other radiologic screening tests.

CTC also cannot remove polyps or biopsy anything suspicious, is an uncomfortable procedure, and reimbursement remains an issue.

CMS recently finalized its decision not to cover CTC as an option for colorectal cancer screening because "the evidence is not sufficient to conclude that (CTC) screening improves health benefits for asymptomatic average–risk Medicare beneficiaries." However, given that more than 20 states mandate coverage by commercial payors, it's likely that CMS will consider this issue again in the future.

CTC is not the screening test of choice today, concluded Dr. Rockey, "but it could become a player."

"I think the major potential advancement is minimally prepless CTC," he said. "I propose that the best CRC (colorectal cancer) mechanism or mechanisms have yet to be elucidated. And each patient should be offered options and providers should be proficient."

Dr. Rockey is also professor, department of cell biology and director of the Liver Center, Duke University Medical Center, Durham, NC.

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When Robert S. Sandler, MD, MPH, assumed the position of AGA Institute president one year ago, he was quoted as saying, "The chance to serve as president of the AGA Institute is likely to be the greatest professional privilege of my life." It is a privilege he has used well.

"During the past year, I have had the privilege to work with an amazingly talented staff and a dedicated group of volunteers," Dr. Sandler said. "By working together, members of our organization help advance the field and make AGA the trusted voice of the GI community. I believe that I have benefitted the organization by focusing squarely on the mission, enlisting the help of our volunteers and staff, and working with our sister organizations."

When he assumed office, Dr. Sandler embraced a leadership philosophy detailed in the nonfiction book, "The Wisdom of Crowds," written by James Surowiecki on "why the many are smarter than the few." Throughout his year in office, he sought to harness efforts of talented AGA staff and passionate volunteers to achieve core goals of the AGA's strategic plan.

"The wisdom of this crowd of individuals working on behalf of the AGA helped the organization execute its plan and achieve its goals," he said. "The organization achieves its mission because a large number of volunteers work tirelessly. They serve on committees and task forces. They review papers and grant applications, provide advice on issues facing our field, and advocate on our behalf to their legislators."

These collective efforts, Dr. Sandler said, have resulted in innovative services for all members of the GI community – clinicians and the patient care team, researchers, trainees and practice managers.

"Of particular note, we held a successful Clinical Congress, which we hope will become an annual event to provide clinicians with an outstanding educational program," he said. "We used our new guidelines process to issue a medical position statement and technical review on GERD that exemplifies the highest standards of guideline development. We also launched the AGA Institute Press with two practice management handbooks, 'The No–Diet Obesity Solution for Kids' and 'The EMR Field Guide.'"

It was also a busy year for AGA on the political front. AGA's political action committee – AGA PAC – participated in its first election cycle, raising and contributing nearly $90,000 to winning candidates, including the first gastroenterologist elected to Congress.

Since the inauguration, AGA has continued to be active on behalf of GIs, Dr. Sandler said.

"At the behest of the Obama transition team, we provided guidance on NIH and research–related issues, and recently I had the privilege of representing the AGA at a White House meeting on health–care reform," he said.

AGA also has continued its diligent efforts on behalf of both GI clinicians and GI researchers.

"For clinicians, we helped to avert a 10.6 percent Medicare physician fee cut and are advocating for a new payment system as part of health–care reform. We expanded our online educational offerings through GI Learn.org, published a GERD guideline and measures for hepatitis C, and endoscopy and polyp surveillance, and continued to prepare the field to expand GI practice to include CT colonography and nutrition and obesity," he said.

"We support researchers with more than $3 million in grants each year through our Foundation for Digestive Health and Nutrition. The AGA Institute has assumed all of the administrative costs of the foundation, which means every penny that is raised by the foundation goes for research. The foundation places special emphasis on funding researchers at the most vulnerable period of their careers – the transition from fellowship to faculty and the early years of their faculty positions."

The AGA also witnessed completion of the National Commission on Digestive Diseases final report and prioritized top research questions. The commission report was particularly timely given the influx of stimulus bill money received by NIH.

"We have been working with the NIH to develop funding mechanisms for the high–priority areas," Dr. Sandler added. "On behalf of researchers we also have fostered international research exchange through the Research Scholar–Rising Star program at DDW® and the United European Gastroenterology Federation. Through the work of the AGA Institute Council, we put on a single topic symposium and a comprehensive program at DDW."

The "wisdom of crowds" philosophy also helped create and nurture synergies between AGA and its "sister societies."

"During my presidency, I was very eager to find ways for the GI organizations to work together on common goals, a sentiment that was shared by the presidents of all of the organizations," he said. "During the year, we issued several joint letters to the Centers for Medicare & Medicaid Services and worked together on RUC/CPT issues. We also convened a task force on GI training that will transform the way that we train gastroenterologists and hepatologists in the future."

While Dr. Sandler's year as AGA Institute president is coming to an end, his commitment to the success of the organization and the field of gastroenterology will not. He will continue to serve as a member of the board and work with staff and volunteers to help realize the strategic plan of the organization.

"During the next year, we intend to update the strategic plan," he said. "I hope that my perspective as an officer of the organization, and experience as a researcher, clinician and teacher in the field over the past 30 years, will help to inform that new plan."

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Plenary sheds light on liver repair, regeneration

Sunday's AASLD Plenary in the basic sciences featured two animal studies that shed light on techniques to repair liver injury in mice and stimulate liver regeneration after massive hepatectomy.

Youngmi Jung, PhD, from the division of gastroenterology at Duke University, Durham, NC, presented an abstract showing that when the inhibitor kappa B kinase (IKK) complex subunit IKKβ gene is deleted from hepatocytes in mice, the deletion promotes apoptosis and inhibits proliferative activity, which leads to repair of liver injury.

The IKK complex regulates nuclear localization of the transcription factor NF–κB (nuclear factor–kappa B), which induces expression of hepatocyte viability factors, Dr. Jung said. Deletion of IKKβ from hepatocytes after injury forces expansion of the Hedgehog (Hh) signaling pathway, which regulates compensatory proliferation of progenitor cells to regenerate injured livers. Expansion of Hh–responsive progenitor cells induces epithelial–mesenchymal transition of the progenitor cells and promotes liver regeneration.

To induce liver injury, Dr. Jung and her colleagues at Duke fed a methionine choline–deficient, ethionine–supplemented diet to mice with hepatocyte–specific deletion of IKKβ. The diet induced injury and increased the weight of the mice. Although the livers of these mice appeared normal at baseline, Western blot analysis revealed high levels of an activated apoptotic marker, caspase–3, and other analyses showed more apoptotic hepatocytes in these mice versus control mice.

The mice also had significantly more progenitor cells, greater proliferation of ductular cells, and increased Hh signaling. The progenitor cells uniformly tested negative for annexin V, a protein that indicates apoptosis.

"Inactivating IKKβ in live progenitors inhibits nuclear localization of NF–κBp65 and increases an alternative survival pathway – Hedgehog – that promotes viability," Dr. Jung said.

Presenting the other study, Zhi Zhong, MD, assistant professor of pharmaceutical and biomedical sciences, Medical University of South Carolina, Charleston, SC, said that massive hepatectomy leads to failure of the remaining liver, and added that her study investigated whether blocking the mitochondrial permeability transition (MPT) after a 90–percent partial hepatectomy with N–methyl–4–isoleucine cyclosporine (NIM811), a non–immunosuppressive analog of cyclosporin A, could decrease injury and improve regeneration of the remnant liver.

She and her colleagues found that NIM811 minimizes liver injury and restores liver regeneration after the massive hepatectomy and, at least in part, prevents the onset of MPT and subsequent compromise of energy supply for regeneration.

"Massive hepatectomy causes onset of the MPT and mitochondrial depolarization in vivo, which is associated with necrosis, apoptosis and suppression of regeneration," Dr. Zhong said. "Inhibition of the MPT by NIM811 attenuates hepatic injury, improves liver regeneration and increases survival. Thus, the MPT plays an important role in liver failure after massive hepatectomy."

The apoptosis that occurs after major liver resection is in part due to MPT–induced mitochondrial cytochrome c release. Cytochrome c is a small protein associated with the inner membrane of the mitochondria that plays a role in apoptosis. NIM811 partially blocked the release of this protein.

For the study, Dr. Zhong and her colleagues gave C57BL/6 mice 10 mg/kg NIM811 two hours before surgery and then 5 mg/kg daily afterwards. The mice underwent either the 90–percent partial hepatectomy or a sham operation. Caspase–3 activity was 50 percent lower in the NIM811–treated mice compared with controls, indicating decreased apoptosis. Improved liver regeneration was indicated by a 30–fold higher incorporation of 5–bromo–2'–deoxyuridine in the NIM811–treated mice.

NIM811 decreased the number of hepatocytes with depolarized mitochondria by 66 percent. It also decreased cell death by approximately 60 percent three hours after hepatectomy, Dr. Zhong said.


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Future of HCV therapies examined in AASLD lecture

More than 130 million cases of hepatitis C (HCV) have been diagnosed worldwide, leading to a wealth of research into the most effective treatments for this disease, which were explored Sunday during the AASLD State–of–the–Art Lecture.

Donald M. Jensen, MD, discussed the success of combination therapies, the length of treatment and the potential of new regimens during his lecture, HCV Therapy Advances: Today and Tomorrow. Dr. Jensen is a professor of medicine and director of the Center for Liver Diseases at the University of Chicago Medical Center, IL.

"It is estimated that the number of patients with advanced liver disease will peak in 2019," Dr. Jensen said, with the number of patients expected to reach almost 200 million. "The number will peak because of the population of baby boomers."

With the increase in the number of HCV patients, research has led to advances in HCV therapy that include making treatment more cost–effective, confirming the importance of ribavirin, defining genotypic and racial responses, and developing response–guided therapy.

But challenges and unknowns that must be addressed are poor tolerability to some treatments, the great number of patients who have not been identified, and inadequate results in patient groups such as those in genotype 1 and those who have cirrhosis, symptoms of metabolic syndrome and obesity, he said.

Despite the increased knowledge of HCV, many questions remain unanswered, particularly the role of ribavirin.

"Ribavirin has been around the since the 1950s, but we still don't know why it works," Dr. Jensen said, adding that some of the other unknowns in the treatment of HCV include why some patients relapse, why other patients are null responders and if higher doses of ribavirin could improve the sustained viral response (SVR) in slow–responding patients.

Dr. Jensen presented a "roadmap to future therapies" that covered research into some of those unknowns that could lead to individualized, response–guided therapy, the use of protease and polmerase inhibitors in treatment, the evaluation of adjuvant biological therapies, and the removal of interferon and ribavirin from therapies. In the end, HCV could be treated with highly effective oral therapies, he said.

For now, researchers have been working to learn more about existing therapies, many of which have focused on increasing doses of interferon and ribavirin, as well as increases in adherence and treatment duration.

Much of that research has examined the length of treatment, and prospective data suggest that 24 weeks of ribavirin therapy may be adequate when rapid viral response (RVR) is achieved, Dr. Jensen said.

This is most true in genotype 1 patients, while data about those in genotype 2 or 3 is inconclusive, but suggest that shorter treatments with ribavirin leads to a greater chance of relapse, he said.

While most research has looked at reducing the duration of treatment with ribavirin, another study took the approach of expanding treatments with greater amounts ribavirin to improve results. In the study, patients received 2,540 mg of ribavirin daily, almost three times the normal dose.

"The result was a 90–percent sustained response," Dr. Jensen said. "It is intriguing, and can overcome a lot of negative predictors of response."

Other studies examined the effectiveness of an induction dose of pegylated interferon with ribavirin. Again, duration of treatment was a question, and researchers found that 12–week treatments did not maintain the desired RVR, he said.

Another study of treatment with a combination of high doses of pegylated interferon with ribavirin for up to 72 weeks showed benefits for slow–responding patients. The question that arose, though, was when to label a patient as a slow–responder and switch to the longer treatment, Dr. Jensen said.

"When do you decide? Four weeks, eight weeks, 12 weeks? We need more data before deciding," he said.

Dr. Jensen concluded his review of HCV therapy by looking at the development of new drugs used in combination with pegylated interferon and ribavirin. Studies show promise for boceprevir and telaprevir when they are used in combination with pegylated interferon and ribavirin.

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Hands–on course explores advanced endoscopic techniques

Endoscopy continues to evolve into an increasingly complex therapeutic modality. An ASGE hands–on course, "Advanced Endoscopic Techniques," drew an enthusiastic audience ready to learn Sunday.

What they learned was a logical progression of skills. Gastroenterologists who are comfortable with polypectomy can move on to endomucosal resection (EMR), the removal of small tissue masses. Next comes endoscopic submucosal dissection (ESD), the en bloc removal of larger lesions. Techniques such as endoscopic intraluminal suturing and intraluminal pouch reduction are still in the development and pilot study phases.

"Expertise comes with time and experience," said Jennifer Chennat, MD, assistant professor of medicine at the University of Chicago Center for Endoscopic Research and Therapeutics, IL. "Start slowly, and build your expertise and volume deliberately over time."

EMR is an effective technique to remove superficial carcinomas or premalignant lesions, said Massimo Conio, MD, director of gastroenterology at Sanremo Hospital, Sanremo, Italy. Therapeutic results with EMR are comparable to surgery, but morbidity and mortality rates are extremely low. And unlike ablative therapy, EMR offers the removal of lesions with specimens for histologic evaluation.

"It would be nice to have an en bloc resection in all patients," Dr. Conio said. "But because of endoscopic limitations, we can only resect sections of tissue up to about 20 mm using EMR."

EMR is most often used for Barrett's esophagus with high–grade dysplasia or intramucosal cancer, he said. Other common EMR applications include esophageal cancers and sessile, or flat, lesions of the duodenum and colorectum.

Lymph node involvement can be expected in about 12 percent of submucosal esophageal cancers and up to 15 percent of submucosal stomach cancers, Dr. Conio said. He advised referring patients with lymph node involvement for surgery.

The two keys to successful EMR are appropriate patient selection, and submucosal injection to isolate tissue to be resected and to insulate underlying tissue. Saline is most commonly used, he said, but solutions that dissipate more slowly may offer improved results.

Alternatives include hyaluronic acid, hydroxypropyl methyl cellulose, 50–percent dextrose and glycerol. EMR is also being used with radiofrequency ablation (RFA) to perform complete Barrett's mucosectomy. Obvious lesions are removed using EMR, and the remaining Barrett's is ablated with RFA.

Dr. Chennant said early results show 98 percent complete eradication of Barrett's esophagus and no recurrence during a 22–month follow–up.

Other advances have broken through the en bloc size limitations of EMR. ESD routinely resects tissue blocks up to 3 cm, reported Irving Waxman, MD, FASGE, professor of medicine and surgery, Center for Endoscopy Research and Therapeutics, University of Chicago, IL.

"These are very long cases, two to three hours," he said. "But ESD means that cancer is no longer a contraindication of endoscopic treatment."

The procedure is conceptually straightforward. The endoscopist first marks the margins of the lesion to be removed using a cauterizing tool. The next step is to cut a resection margin around the circumference of the lesion slightly outside the marks. Then comes the time–consuming step of cutting under the lesion, lifting tissue away until the entire block has been cut lose. The block is then removed and sent for pathological examination.

"ESD is practical to remove even large or fibrous lesions," said Naohisa Yahagi, MD, director of gastroenterology and endoscopy, Toranomon Hospital, Tokyo, Japan. "If the lesion is completely removed, we do not see local recurrence. That means we can avoid follow–up surgery and preserve organ function."

Experience is the key barrier to ESD, he said. Dr. Yahagi suggested becoming expert in polypectomy and EMR before attempting ESD. The most effective training cycle begins with observation, then assisting and practicing in ex vivo pig stomachs.

In clinical practice, gastric ESDs are generally the easiest procedures, followed by esophageal, colorectal and duodenal procedures.


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A new view of sedation and monitoring

Questions surrounding sedation and the monitoring of sedated patients still raise debates among endoscopists and beyond. The question is not whether endoscopists can or should sedate and monitor patients, but how to do it.

"Gastroenterologists and anesthesiologists are already improving the safety and efficacy of sedation in endoscopy," said Daniel Pambianco, MD, FACG, CPI, medical director and Charlottesville medical research director of GI endoscopy/motility, Martha Jefferson Hospital, Charlottesville, VA. "But we don't have any standards in GI endoscopy. The use of sedation varies from person to person and from practice to practice; we need standards."

Dr. Pambianco made his remarks Sunday during the ASGE Clinical Symposium Endoscopic Sedation and Monitoring Issues in 2009.

Surveys indicate that more than 98 percent of all routine endoscopies are performed under sedation, said Thomas Cutter, MD, professor of anesthesia and critical care, University of Chicago, IL. In most cases, there is no anesthesiologist present and no anesthesiologist is needed.

"We are all busy people," he said. "I want to be there when you need me, but I don't want to be there for the routine stuff that you can handle on your own."

The problem is that gastroenterologists need help more often than they realize. Blinded surveys of endoscopic procedures have found that oxygen saturation routinely drops below 90 percent for sedated patients without anyone in the endoscopy suite noticing, Dr. Cutter said. And growing numbers of lengthy, complex and painful procedures, such as endoscopic mucosal resection and endoscopic retrograde cholangiopancreatography (ERCP), mean more patients need deeper sedation.

Most endoscopic procedures are performed under light or moderate sedation, the state that used to be called "conscious sedation." But the boundary between moderate and deep sedation is flexible – depending on the patient, the procedure and other factors. Sedative doses intended to produce moderate sedation can easily induce deep sedation or general anesthesia. More powerful agents can be under–dosed and induce lighter sedation than expected.

Patient factors such as physical condition or underlying morbidities can also affect the degree of sedation. The American Society of Anesthesiologists (ASA) has compiled a list of potentially complicating conditions such as sleep apnea, physical deformities to the airway or morbid obesity that require a higher level of care for sedated patients. But ASA recommendations are not a good fit with the daily realities of endoscopic practice.

"The ASA says GERD (gastroesophageal reflux disease) is a serious condition that requires special attention," said Jennifer Lightdale, MD, MPH, pediatric gastroenterologist at Children's Hospital, Boston, MA. "GERD is normal for GI endoscopists. And a basic GI procedure on an obese patient is hardly out of the ordinary."

Endoscopists and anesthesiologists need to focus on their common interests, not their differences, Dr. Cutter said. For both professions, that means focusing first on patient safety.

The key change for endoscopists is the recognition of a key belief for anesthesiologists: sedation is a continuum, not a series of discrete states.

"When you make that leap, you realize that endoscopists need better algorithms for risk assessment in sedation," Dr. Lightdale said. "We need to embrace sedation as a specific skill set and we need to embrace better training. The reality is that when you administer sedation, you don't know where the patient will end up. You always need to be prepared to rescue them."

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Endoscopy standard, but indications remain for
surgical treatment of upper GI bleeding

Endoscopic treatment is the standard of care for upper gastrointestinal tract (GI) bleeding, but there are still indications for the surgical management of this common problem, according to speakers Sunday during the SSAT Postgraduate Course, Acute Care Gastrointestinal Surgery: Thinking on Your Feet.

"Nonvariceal upper GI bleeding remains a significant problem despite our potent medications," said Brian Dunkin, MD, director of the endoscopy unit at Methodist Hospital, Houston, TX, who discussed the surgical approach to treatment. Each year 300,000 new cases are reported, he said.

Although peptic ulcers are the source of upper GI bleeding in 50 percent of cases, SSAT has no guidelines for the surgical management of peptic ulcer disease, he said, adding, "We don't do surgery much for this problem anymore."

Factors that affect whether to perform endoscopy or surgery include the severity of bleeding, volume status and comorbidities. The risk of recurrent bleeding relates to the modified Forrest criteria for stigmata of recent hemorrhage. The five stigmata, in declining order of rebleeding risk, are: active bleeding, visible vessel, adherent clot, flat spot and clean base.

Other predictive factors for recurrent bleeding include pre–endoscopy hypotension, age 60 years or older, and an ulcer larger than 2 cm.

"For large ulcers, maybe you should bypass a second endoscopy and go right to surgery," Dr. Dunkin said.

Patients should go right to surgery after initial endoscopy if the endoscopist cannot find or cannot stop the bleeding and when the patient's anatomy does not allow visualization of the bleeding source, such as in morbid obesity, he said.

Goals of surgical therapy are to stop the bleeding and, if the lesion is a gastric ulcer, to rule out cancer, Dr. Dunkin said.

In cases of rebleeding, a second endoscopy usually should be performed before surgery, according to Dr. Dunkin and Loren A. Laine, MD, professor of medicine and director of the endoscopy unit at the University of Southern California School of Medicine, Los Angeles.

Dr. Laine, who spoke on the nonsurgical management of upper GI bleeding, said, "Three–fourths of the time, endoscopic therapy can prevent the need for surgery."

Indications for endoscopic therapy due to peptic ulcers are an actively bleeding ulcer, a nonbleeding ulcer with a visible vessel or an adherent clot, he said. The patient should receive constant intravenous (IV) infusion of a proton pump inhibitor (PPI).

"There is beginning to be encouraging data that intermittent oral or IV PPIs may work also," Dr. Laine said.

For patients with active and acute variceal bleeding, ligation is the treatment of choice, with the addition of a long–term beta blocker to prevent recurrent bleeding, Dr. Laine said.

"The addition of octreotide should be the standard of care, as it reduces further bleeding," he said, recommending infusion for two to five days.

When endoscopic therapy fails, generally a transjugular intrahepatic portosystemic shunt (TIPS) procedure is performed. However, he said the use of coated stents is decreasing the need for reintervention with TIPS.


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Panel to address ethical dilemmas raised by genetic testing

The role of genetics in the treatment of colon cancer and the ethical dilemmas that can arise in the use of genetic information will be addressed by three speakers during Tuesday's SSAT Public Policy Panel presentation, Genomics and Cancer Care: What Every Clinician Should Know.

"We are learning more and more about the genetic influences on all the disease states we treat. The Human Genome Project has been a major breakthrough and it is early in the game, but we are beginning to utilize different aspects of molecular genetics in the things that we do both diagnostically and therapeutically," said Thomas Howard, MD, session moderator. "We thought that this panel would be a timely public policy issue to grapple with."

Much of the discussion will focus on patients with hereditary colon cancer syndromes because genetic testing is firmly established to help identify patients and families at risk, said Dr. Howard, professor in the department of surgery at Indiana University School of Medicine, Indianapolis.

The three speakers in the session will discuss the use of genetic testing to identify patients with germline mutations in the clinic, the use of genetic information to guide the choice of adjuvant chemotherapy and post–treatment surveillance in patients with colon cancer. They also will discuss whether current health–care policies ensure third–party reimbursement for genetic testing and confidentiality for patients with hereditary colorectal cancer syndromes and their families.

In his presentation, "Impact of Genetic Testing on the Cancer Patient," C. Richard Boland, MD, will discuss recommendations for genetic testing in hereditary colorectal cancer syndromes. Dr. Boland is chief of the division of gastroenterology at Baylor University Medical Center, Dallas.

"Dr. Boland has been interested in trying to identify markers that influence the course of treatment of patients who have colon cancer and how their genetics change what you do for specific patients, particularly patients with familial adenomas, polyposis and Lynch syndrome," Dr. Howard said. "He will talk about the nuts and bolts of identifying these patients in a clinical setting, who you test, how you test them, and the pros and cons of getting those tests for people."

Accurately identifying patients at risk for colon cancer could lead to improved screening of those at risk, better surveillance of patients with the disease, and earlier diagnosis and treatment of malignancies, he said.

In his presentation, "Treatment Guidelines and Management Implications for Patients with HCCS," Kenneth C. Micetich, MD, will discuss adjuvant chemotherapy treatment guidelines and how genetic testing now influences treatment in patients with colorectal cancer and hereditary colon cancer syndromes. Dr. Micetich is professor of medicine, hematology/oncology at Loyola University Stritch School of Medicine, Chicago, IL.

"Part of what Dr. Micetich will talk about is microsatellite instability for different types of colon cancers or if the patients have epidermal growth factor receptor (EGFR)–positive versus EGFR–negative tumors. We now have drugs that address these differences in cancer types, and they can be used clinically in patients we know have these genetic abnormalities," Dr. Howard said.

Dr. Micetich also will discuss the growing concern about how germline genetic mutations influence the care of patients, their families and future generations.

The final speaker, Kimberly A. Quaid, PhD, professor of medical and molecular genetics at Indiana University School of Medicine, Indianapolis, will discuss whether health–care policies related to genetic testing are adequate to provide protection for patients and their families.

Her presentation, "Ethical Considerations for Genetic Testing," will review the Genetic Information Nondiscrimination Act of 2008, Dr. Howard said.

Dr. Quaid is a medical ethicist with a research interest in ethical considerations surrounding genetic testing.

"Some patients may hesitate to undergo important genetic testing because of how this information might impact their future employment and ability to get health insurance. This recent law has been crafted in an effort to ensure genetic information remains confidential and cannot be used against patients or their families. We will hear her perspective on how this new legislation is impacting the use of genetic testing in our clinics," he said.


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