Latest / Becker’s Healthcare Podcast / Dr. Ajay Goel on Blood-Based Screening and the Next Frontier of Cancer Prevention

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Dr. Ajay Goel on Blood-Based Screening and the Next Frontier of Cancer Prevention · Becker’s Healthcare Podcast

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  - Hello. Thank you so much for tuning in
• 1:00
  - to the Becker's Oncology Leadership podcast.
• 1:04
  - I'm Elizabeth Gregerson, a reporter here at Becker's,
• 1:07
  - and today, I'm talking to doctor Ajay Goel.
• 1:10
  - Doctor Goel is a professor and chair of
• 1:13
  - the department of molecular
• 1:15
  - diagnostics and experimental
• 1:17
  - therapeutics at City of Hope. Doctor Goel, thank
• 1:20
  - you so much for time. Before I dive
• 1:22
  - into my questions, questions, I would love if
• 1:24
  - you could share just a bit about your
• 1:26
  - background and your role at City of Hope
• 1:29
  - for our listeners.
• 1:30
  - Absolutely happy to do so. So I'm Jay
• 1:33
  - Guel.
• 1:34
  - I wear multiple hats at City of Hope.
• 1:36
  - One of those you introduced already. I'm I'm
• 1:39
  - a department chair for the department of molecular
• 1:41
  - diagnostics and experimental therapeutics.
• 1:44
  - So within this department, we do a lot
• 1:46
  - of work around,
• 1:48
  - cancer diagnostics
• 1:49
  - and developing new treatments and therapies for this,
• 1:53
  - for different cancers. So that's one role. In
• 1:55
  - addition to that,
• 1:57
  - I also serve as
• 1:59
  - associate director
• 2:01
  - for
• 2:02
  - basic sciences
• 2:03
  - within the CDF Hope comprehensive
• 2:06
  - cancer center. So so I I participate in
• 2:09
  - all the basic,
• 2:10
  - basic sciences program within the institution.
• 2:14
  - And then the third title I wear is
• 2:16
  - I also serve as
• 2:17
  - director of biotech innovations
• 2:20
  - at the at this,
• 2:21
  - City of Hope Hospital.
• 2:23
  - So
• 2:25
  - so I've we had multiple roles,
• 2:27
  - but my own lab, my own research
• 2:30
  - team focuses heavily
• 2:33
  - on gastrointestinal
• 2:34
  - cancers only, which means cancers starting from
• 2:37
  - esophagus, stomach, colon, pancreas, liver, rectum.
• 2:42
  - So we do
• 2:43
  - a variety of things,
• 2:45
  - within the gastrointestinal
• 2:46
  - cancers or GI cancers in brief. Mhmm. But
• 2:50
  - a big emphasis of my research is on
• 2:52
  - cancer prevention.
• 2:53
  - And that's part of the reason we are
• 2:54
  - here together to discuss one of the recent
• 2:56
  - studies we have published today.
• 2:58
  - But we do a lot of work around
• 3:00
  - developing
• 3:01
  - molecular
• 3:02
  - minimally invasive, noninvasive
• 3:04
  - diagnostics
• 3:05
  - for the early detection of these cancers.
• 3:09
  - Perfect. Thank you for kind of setting the
• 3:10
  - stage for where you're coming from and and
• 3:13
  - teasing where why we're talking today.
• 3:15
  - So, yes, a study did come out,
• 3:19
  - for a blood test,
• 3:20
  - and your study found
• 3:22
  - roughly eight and ten
• 3:24
  - precancerous
• 3:25
  - lesions. So if you could go into, you
• 3:27
  - know, the background of this study, just briefly
• 3:29
  - for our listeners,
• 3:31
  - but I'd love to point out the distinction
• 3:34
  - that the test was able to catch precancerous
• 3:37
  - lesions, not just cancers that have already formed,
• 3:40
  - especially through that lens of prevention
• 3:43
  - and why that distinction matters so much for
• 3:46
  - how health systems should be approaching
• 3:48
  - cancer screening.
• 3:50
  - Yes. So I think this is what gets
• 3:52
  - us very excited about this particular study. So
• 3:55
  - this was essentially the key
• 3:58
  - central message of the study.
• 4:00
  - So early cancer detection and cancer prevention are
• 4:04
  - not the same thing.
• 4:06
  - Finding a colorectal cancer at stage one
• 4:09
  - versus stage three
• 4:11
  - can make a big difference because if you
• 4:13
  - can find a stage one cancer,
• 4:15
  - it can clearly improve
• 4:18
  - the opportunity for successful treatment.
• 4:21
  - But if you can identify
• 4:23
  - advanced adenomas
• 4:25
  - or advanced polyps, which are essentially the precursors
• 4:29
  - which eventually can become into cancer, and if
• 4:31
  - you can treat them in
• 4:34
  - time, we can essentially prevent the disease from
• 4:36
  - happening in the first place. So it's a
• 4:38
  - big distinction.
• 4:39
  - Finding precancerous polyps, you treat them, you take
• 4:42
  - them out. These people will never ever probably
• 4:45
  - develop colon cancer to begin with. So it's
• 4:47
  - a big deal. So we have essentially prevented
• 4:49
  - the cancer. If you take out stage one
• 4:52
  - cancer versus stage three,
• 4:54
  - these people can live
• 4:56
  - probably their full lives. So it's not just
• 4:58
  - about early detection. It is
• 5:00
  - early detection at what stage. So that's why
• 5:03
  - it's important. So in other words, this is
• 5:06
  - distinction
• 5:07
  - is especially important in colon cancer because
• 5:10
  - screening already gives us a powerful opportunity for
• 5:15
  - prevention. Finding advanced adenomas
• 5:17
  - are clinically actionable lesion lesions.
• 5:20
  - So a blood test that does not remove
• 5:22
  - them but can find them can help
• 5:26
  - trigger
• 5:27
  - a preventative approach means if their test turns
• 5:30
  - positive, somebody has advanced polyp, now they can
• 5:33
  - go see their gastroenterologist,
• 5:35
  - and they can treat them very effectively.
• 5:37
  - So in this particular study, we call as
• 5:41
  - DANAB study. So in this particular study we
• 5:43
  - just published, we found that we could
• 5:46
  - identify
• 5:47
  - eighty one percent of advanced ad adenomas or
• 5:50
  - polyps
• 5:51
  - in addition to ninety one percent of colorectal
• 5:54
  - cancers
• 5:55
  - and almost ninety two percent of stages one,
• 5:58
  - two, three cancers.
• 6:00
  - So what makes this study more important? Because
• 6:02
  - we can find advanced adenomas and stage one
• 6:05
  - cancers at a very high degree of sensitivity
• 6:08
  - and specificity,
• 6:09
  - which is a game changer in a way.
• 6:12
  - From a health care system perspective, I think
• 6:15
  - the change that changes the question.
• 6:17
  - We should be asking for future screening technology.
• 6:20
  - We should not evaluate them only by how
• 6:23
  - many cancer does this find, but we should
• 6:25
  - also ask how many cancers
• 6:28
  - might this screening strategy ultimately help prevent. So
• 6:32
  - I think that's a biologically or clinically more
• 6:34
  - important question that how many cans cancers not
• 6:37
  - only we can find, but how many we
• 6:38
  - can prevent.
• 6:40
  - I love that kind of rephrasing of the
• 6:43
  - of the question. I think almost got goosebumps
• 6:45
  - when you said it, but, yeah, that is
• 6:47
  - such a a needle kind of moving,
• 6:50
  - statistic to think
• 6:51
  - you're not catching cancer, you're catching it before.
• 6:56
  - A key point of the study too is
• 6:58
  - the fact that this screening test is a
• 7:00
  - blood test.
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  - Nationally, colorectal cancer screening rates, you know, have
• 7:05
  - been stuck well below the goal for years.
• 7:09
  - And
• 7:10
  - anyone who, you know, reads news about cancer
• 7:13
  - knows that incidence is growing with young adults.
• 7:18
  - Where do you see a tool like blood
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  - based screening,
• 7:22
  - you know, actually moving screening numbers?
• 7:25
  - Is it able to?
• 7:27
  - Is it their cautious optimism?
• 7:29
  - Will they be will blood based tests, you
• 7:31
  - know, become as standard as colonoscopy? What's your
• 7:34
  - kind of
• 7:35
  - strategy or mindset when you're watching these types
• 7:38
  - of tests become more and more
• 7:41
  - used?
• 7:42
  - Yes. I think this is a very relevant
• 7:44
  - question. So I think blood based screening has
• 7:47
  - a real potential to increase
• 7:49
  - participation
• 7:50
  - in screening. Mhmm. But I would view this
• 7:53
  - as an additional doorway to screening
• 7:57
  - Mhmm. Rather than replacing the doors we already
• 7:59
  - have. By that, what I mean is we
• 8:01
  - have colonoscopy. We have some other test. All
• 8:03
  - of them are there, but the participation, just
• 8:05
  - like you said, is lower. So what blood
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  - test do is they open another opportunity for
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  - us to increase
• 8:12
  - the cancer screening, bring more people into the
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  - fold, and help more people participate. And there
• 8:18
  - are decades of data that any kind of
• 8:21
  - cancer screening tool we can use. Whatever that
• 8:24
  - might be, every one of them help. So
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  - the goal is bottom line is, yes, it
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  - will help participation.
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  - So
• 8:32
  - our manuscript highlighted an important
• 8:35
  - operational problem. Just like you said, despite having
• 8:38
  - very effective screening methods, participation has not consistently
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  - reached the approximate target of eighty percent, you
• 8:44
  - know, screening,
• 8:46
  - population level,
• 8:47
  - wide.
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  - Blood testing offers a different type of access
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  - because it can potentially be incorporated
• 8:53
  - into an encounter that is already happening. People
• 8:56
  - are already going to the clinics. They are
• 8:57
  - going for different reasons.
• 8:59
  - So if a patient may come in for
• 9:01
  - annual physical, for example, a patient may be
• 9:03
  - coming in for diabetes monitoring. They may be
• 9:05
  - coming in for cholesterol testing or some other
• 9:09
  - blood draw.
• 9:10
  - And
• 9:11
  - they it presents the opportunity. Because once they're
• 9:13
  - already in the clinic doing some other workup,
• 9:15
  - they can the doctor can now
• 9:17
  - ask, hey. Would you be interested in getting
• 9:20
  - your risk for colon cancer estimated? And from
• 9:22
  - the same tube of blood, now we can
• 9:24
  - measure that as well. So, certainly, the patient
• 9:26
  - who did not come into the clinic for
• 9:28
  - colorectal cancer screening got screened for that particular
• 9:32
  - cancer,
• 9:33
  - and now they don't have to make a
• 9:35
  - special visit,
• 9:36
  - to get colon cancer screening. So it's very,
• 9:39
  - very important.
• 9:40
  - I think the greatest near term opportunity is
• 9:43
  - among people who are eligible for screening but
• 9:45
  - repeatedly do not complete colonoscopy
• 9:48
  - or stool based testing. They just
• 9:51
  - don't participate.
• 9:52
  - So I think that may be particularly relevant
• 9:54
  - for screening eligible adults
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  - in their late forties, early fifties who have
• 10:00
  - recently
• 10:01
  - become eligible but have not participated
• 10:03
  - in this kind of screening. So our study,
• 10:06
  - the DANF study
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  - itself does not establish that offering this test
• 10:10
  - will
• 10:11
  - increase participation. Everyone in our study underwent colonoscopy.
• 10:15
  - However, the question has to be answered prospectively.
• 10:19
  - Prior evidence, like I said, supports that any
• 10:22
  - kind of blood testing will help rescue can
• 10:25
  - function as a rescue strategy for screening
• 10:28
  - avoidant individuals, people who just don't feel the
• 10:31
  - need for it. So
• 10:32
  - will blood testing become as standard as colonoscopy?
• 10:36
  - I think it could eventually become a standard
• 10:38
  - component of colon cancer screening for sure, but
• 10:41
  - I would not frame these two as competing
• 10:44
  - technology. Colon colonoscopy remains unique because it can
• 10:48
  - diagnose
• 10:49
  - and remove precancerous lesions.
• 10:52
  - A positive blood test leads to colonoscopy. So
• 10:55
  - they both work
• 10:56
  - in hand hand in hand in that way.
• 10:59
  - So if I have to sum up, the
• 11:01
  - answer would be the future may not be
• 11:03
  - about choosing between colonoscopies,
• 11:05
  - stool testing, or blood testing.
• 11:07
  - It may be about making every patient has
• 11:09
  - a screening pathway that are actually willing to
• 11:13
  - complete. So one way or the other, we
• 11:15
  - need to bring people who are not participating
• 11:17
  - into the screening programs.
• 11:19
  - Absolutely. And I'd love to kind of pick
• 11:22
  - your brain as well. When we're looking towards
• 11:25
  - the future and seeing all these different screening
• 11:27
  - options that will be available,
• 11:29
  - what should health system and hospital leaders know
• 11:32
  - about the current state of kind of coverage
• 11:34
  - and reimbursement
• 11:36
  - when it comes to these types of screening
• 11:38
  - tools?
• 11:39
  - So this is an extremely important issue because
• 11:42
  - the screening technology
• 11:43
  - cannot
• 11:44
  - have population level impact
• 11:47
  - if it is scientifically impressive but financially or
• 11:51
  - logistically inaccessible. So it's in it's very important
• 11:54
  - that we keep that in mind.
• 11:56
  - For Deneb specifically,
• 11:57
  - we are not at the reimbursement stage, so
• 12:00
  - I would like to clarify that. The essay
• 12:02
  - remains in a research setting. The current study
• 12:05
  - establishes
• 12:06
  - diagnostic potential, but we still need large prospective
• 12:10
  - phase four validation study before we consider routine
• 12:14
  - clinical implementation, but that's where we are heading
• 12:17
  - now. Mhmm. Our study also did not perform
• 12:20
  - a formal
• 12:21
  - cost effectiveness analysis.
• 12:23
  - We did note that Deneb uses very simple
• 12:26
  - PCR
• 12:27
  - based essay,
• 12:28
  - which can which is routinely available in almost
• 12:31
  - every diagnostic lab,
• 12:33
  - and they could ultimately
• 12:36
  - help in scalability
• 12:38
  - and reimbursement
• 12:40
  - should be fairly straightforward.
• 12:42
  - However,
• 12:44
  - all of the reimbursement framework
• 12:46
  - emerging from this category,
• 12:49
  - exist because we do this kind of PCR
• 12:52
  - based approach for many other things. Medicare currently
• 12:55
  - covers
• 12:55
  - qualifying blood based biomarkers for colon cancer
• 12:59
  - screening once every three years for eligible
• 13:02
  - asymptomatic
• 13:03
  - average risk beneficiaries
• 13:05
  - ages between 45 to 85. So the the
• 13:08
  - the the reimbursement
• 13:09
  - program is already in place, and Medicare also
• 13:12
  - covers follow-up colonoscopy
• 13:15
  - as a screening service after a positive blood
• 13:18
  - based biomarker
• 13:20
  - has been tested.
• 13:21
  - So
• 13:22
  - CMS's national coverage framework also includes requirements related
• 13:26
  - to FDA authorization and test performance. So coverage
• 13:29
  - should not be assumption
• 13:30
  - simply because it essays a blood test. So
• 13:33
  - so in other words,
• 13:35
  - all the elements are in place for health
• 13:37
  - care system leaders. I think the bigger point
• 13:39
  - is to
• 13:40
  - look beyond the price of the lab test
• 13:42
  - yourself. The relevant economics includes
• 13:46
  - entire screening pathway.
• 13:48
  - Who gets offered the test? I think that's
• 13:50
  - very important. How many additional pause previously onscreened
• 13:53
  - patients
• 13:54
  - are can participate in such a testing program?
• 13:57
  - What proportion of tests are turned positive? How
• 14:00
  - many follow-up
• 14:01
  - colonoscopies are generated? What is the completion rate
• 14:04
  - for those colonoscopy? So there's so many other
• 14:05
  - questions, but I think this is exactly the
• 14:08
  - point where we need to be. The issue
• 14:10
  - is particularly relevant because the specificity of the
• 14:13
  - test we just published is very high. It
• 14:16
  - is almost eighty five percent specific
• 14:19
  - for finding advanced neoplasia or advanced polyps in
• 14:22
  - our cohort, which is really import impressive because
• 14:25
  - in a true population screening strategy
• 14:28
  - where advanced polyps is relatively uncommon,
• 14:31
  - that could generate meaningful number of follow-up colonoscopies.
• 14:35
  - We explicitly identify that as a issue. This
• 14:38
  - is a issue,
• 14:39
  - requiring prospective and health economic evaluation. So so
• 14:44
  - we are there, but we still need to
• 14:45
  - do a stage four test, stage four clinical
• 14:48
  - trial to answer some of the questions. But
• 14:50
  - I think these are all relevant things, and
• 14:53
  - and the value proposition will depend upon whether
• 14:56
  - such a blood test can bring more people
• 14:58
  - into a screening,
• 14:59
  - program and ultimately help prevent cancers, which will,
• 15:02
  - in the end, you know, trump the cost
• 15:06
  - for managing these patients if they were missed
• 15:08
  - during screening and have advanced cancer.
• 15:12
  - Absolutely. Thank you for kinda laying that out,
• 15:15
  - as well. I think it's such crucial information
• 15:17
  - to have, especially as, you know, these types
• 15:20
  - of studies
• 15:21
  - continue to come out showing, you know, how
• 15:24
  - different tests can screen and and change numbers
• 15:26
  - like you said.
• 15:28
  - Before I let you go, I always like
• 15:30
  - to end my conversations with oncology leaders about
• 15:34
  - what's exciting them the most
• 15:36
  - when it comes to the future of cancer
• 15:37
  - care. And feel free to take this in
• 15:39
  - any direction if you don't, you know, just
• 15:41
  - wanna talk about the blood test, if you
• 15:42
  - wanna talk about something else as well, but
• 15:44
  - I always love to end with that kind
• 15:45
  - of note of optimism
• 15:47
  - about the future. So what's exciting you right
• 15:50
  - now, doctor Goel?
• 15:52
  - Yes. I think what excites me most is
• 15:54
  - the possibility that we are now beginning to
• 15:56
  - move from a model centered primarily on treating
• 15:59
  - cancer after it has happened to the one
• 16:03
  - that increasingly helps in earlier interception of the
• 16:06
  - biological process where we can possibly
• 16:10
  - prevent the cancer
• 16:11
  - or maybe cure it if we can find
• 16:14
  - it at a early enough stage. So I
• 16:16
  - think this is very, very important. For decades,
• 16:18
  - most of the cancer medicine has
• 16:20
  - focused on developing better treatments for established disease.
• 16:25
  - And as advances in therapy,
• 16:28
  - you know, targeted therapy, immunotherapy, precision oncology
• 16:31
  - have improved, but still, I think there's a
• 16:34
  - big window of opportunity there
• 16:36
  - to to intercept these cancers at much earlier
• 16:39
  - biological stage. So technologies such as liquid biopsies
• 16:43
  - for blood test and others,
• 16:45
  - they can help
• 16:46
  - overcome that
• 16:48
  - challenge that we cannot only find these cancers
• 16:51
  - early, but possibly we can find them much,
• 16:54
  - much, much, much earlier where we can either
• 16:56
  - prevent or possibly cure these patients from having
• 16:59
  - these diseases.
• 17:00
  - So I think the next frontier in cancer
• 17:03
  - care is simply
• 17:04
  - not treating the cancer more precisely
• 17:06
  - once it has developed,
• 17:08
  - but it is learning
• 17:09
  - how to recognize the biological process early enough
• 17:12
  - that for some patients,
• 17:14
  - we can prevent cancers from happening,
• 17:17
  - from becoming their diagnosis
• 17:19
  - at all. So, essentially, this is gonna be
• 17:21
  - the next frontier. This is gonna be the
• 17:22
  - future of cancer care.
• 17:25
  - Amazing. Well, thank you so much. I I
• 17:27
  - love leaving it on that note, and I'm
• 17:29
  - excited to see
• 17:30
  - what comes out next, from City of Hope.
• 17:34
  - Doctor Guell, thank you so much for coming
• 17:36
  - on the podcast, taking the time to share
• 17:37
  - your insights. I know our audience really appreciates
• 17:40
  - it. Thank you so much for having me.
• 17:42
  - Enjoyed it.
• 17:43
  - And thank you to our listeners for tuning
• 17:45
  - in to Becker's Oncology Leadership podcast.
• 17:48
  - I invite you all to check out even
• 17:50
  - more of Becker's Healthcare podcasts
• 17:52
  - at beckerspodcast.com.
• 17:55
  - Thank you again to doctor Goel for joining
• 17:57
  - me today and to our listeners. Have a
• 17:59
  - good one.