Onco-hepatology with Tamar Taddei

Transcript

• 00:16Welcome back, this session is
• 00:18being recorded. Thank you.
• 00:22Welcome everybody, and I'm sorry
• 00:23we're running just a little bit late.
• 00:25Had a little I had a little
• 00:26trouble getting from one talk to
• 00:28the other after the first talk,
• 00:29but I'm pleased to introduce
• 00:33Tamar Taddei who is a professor of
• 00:36internal medicine digestive diseases.
• 00:38And director of the Regional Liver
• 00:40Center at the VA and associate program
• 00:42director of the Yale, MD PhD program.
• 00:45And tomorrow we'll be speaking
• 00:47to us on Onco hepatology.
• 00:53Thank you Cliff for the introduction.
• 01:01All right? Hopefully you can all
• 01:05see my slides. Looks great good,
• 01:09now they're going without
• 01:10order here, so one moment.
• 01:15OK, so First off, I'd like to thank doctors,
• 01:19Nathanson and Strazza Bosco for
• 01:21the honor and opportunity to speak
• 01:23with you today on the path ahead.
• 01:24And I'll go hepatology.
• 01:27Before I talk about the path ahead,
• 01:29perhaps we ought to define
• 01:31Ancol hepatology and I have to
• 01:33say it's a personal definition.
• 01:34I define Uncle Hepatology as a
• 01:37burgeoning multidisciplinary field
• 01:38in which the HEPATOLOGIST serves
• 01:40as the anchor for the patient.
• 01:42The interpreter and optimizer
• 01:44of liver function,
• 01:45and the steward of multidisciplinary care
• 01:48for patients with primary liver cancer.
• 01:51As we think about the path ahead,
• 01:53it's important to understand perhaps
• 01:54why the road has been long and winding,
• 01:57and like many roads in Connecticut,
• 01:59it will be long and winding into the future.
• 02:01The field is extremely complex in
• 02:03just the last five years we've seen
• 02:06shifting epidemiology with the advent
• 02:08of direct acting antivirals for the
• 02:10treatment of hepatitis C and with
• 02:12global efforts at hepatitis B vaccination,
• 02:15while viral hepatitis remains a
• 02:17significant driver of liver cancer,
• 02:19fatty liver disease.
• 02:20Is emerging as a key risk factor
• 02:22for the development of liver cancer.
• 02:24Depending upon where you live on the globe,
• 02:26the epidemiology of liver cancer
• 02:29may differ he there.
• 02:31There are a multitude of stakeholders
• 02:33and disciplines involved in liver care
• 02:35along the continuum of prevention,
• 02:37detection, diagnosis, staging,
• 02:40treatment and survivorship.
• 02:42Not only are there many medical and
• 02:44surgical disciplines that we've
• 02:46heard earlier in the day involved
• 02:47in the care of liver cancer,
• 02:49each with their own governance
• 02:51and guidelines,
• 02:51there are many other services integral
• 02:53to care delivery such as nurses,
• 02:56care, navigators, social workers,
• 02:58and health psychologists, just to name a few.
• 03:01How these disciplines come together is
• 03:03pivotal for patient engagement and care.
• 03:06Finally, because of this clinical complexity,
• 03:09it's vital that clinical data,
• 03:11for example, on underlying ideology,
• 03:13stage of disease and treatment
• 03:16cascade be structured in such a
• 03:18way that they can inform and enrich
• 03:21basic and translational science.
• 03:23As we've heard earlier,
• 03:24the liver Center is a global endeavor.
• 03:27Recruiting scientists and
• 03:28trainees from around the world,
• 03:30and HCC is a global problem.
• 03:32It's the leading cause of death in
• 03:34cirrhosis and the second leading
• 03:35cause of global cancer deaths.
• 03:37Claiming an estimated 800,000
• 03:39deaths annually with over 1,000,000
• 03:42projected annual deaths by 2025,
• 03:44HCC takes 90% of the share of primary
• 03:47liver cancer with intrahepatic
• 03:50bile duct cancer,
• 03:51claiming the majority of the remaining.
• 03:5310%.
• 03:54Here you can see the age standardized
• 03:57incidence rates of HCC across the globe,
• 03:59with the darkest areas on the
• 04:01map having the highest rates.
• 04:03The most prominent risk factors
• 04:05for HCC are hepatitis B,
• 04:07especially in most parts of
• 04:09Asia and Mongolia.
• 04:10Hepatitis C in Western Europe,
• 04:12North America and Japan,
• 04:14and alcohol in Central and Eastern Europe.
• 04:17Non-alcoholic steatohepatitis depicted
• 04:19in yellow is becoming the facts
• 04:22fastest growing etiology of HCC.
• 04:24Particularly in the West,
• 04:27this shifting and differing epidemiology
• 04:29is important to understand as it
• 04:32drives public health policy funding
• 04:35and the scientific agenda.
• 04:37To forecast the future,
• 04:38we have to understand the past.
• 04:40Our understanding of HCC has grown
• 04:42exponentially in the last 40 years.
• 04:45While we've seen tremendous
• 04:46strides in the treatment of
• 04:48advanced HCC such that we can now
• 04:50offer multiple lines of therapy,
• 04:52we see continued challenges in our
• 04:54efforts just to screen patients
• 04:56at risk to be able to diagnose
• 04:58this cancer at early stages.
• 04:59When a cure is achievable,
• 05:01we see tremendous potential to
• 05:03understand the molecular classification
• 05:05and landscape of mutations in HTC.
• 05:07But this has yet to inform
• 05:09clinical guidance and we continue
• 05:11to marvel at the complexity of
• 05:13this heterogeneous cancer and the
• 05:15interplay between underlying liver
• 05:17disease tumorigenesis and the liver
• 05:19and the tumor microenvironment.
• 05:23So let's talk a little bit about
• 05:26milestones and liver cancer at Yale.
• 05:28The growth and evolution of our
• 05:30programs and liver cancer have
• 05:31fostered scientific discovery in the
• 05:33liver in the in the liver center.
• 05:35Dr Shaza Bosco returned to Yale
• 05:38in 2005 and implementing the
• 05:40successes of his program in Bergamo.
• 05:42He established a multidisciplinary
• 05:44liver tumor conference in early 2006.
• 05:47While Hepatology and transplant surgery
• 05:49clinics have been colocalized since then,
• 05:532011 marked the first colocalized
• 05:55hepatology and oncology clinic to serve
• 05:58the needs of advanced HCC patients.
• 06:00The integration of care across the
• 06:02continuum from early to advanced HCC is
• 06:05a focus for the future so that patients
• 06:08identify with an integrated team.
• 06:10Over the years,
• 06:12outreach efforts have increased our
• 06:14catchment such that we see the majority of
• 06:16liver cancers in the state of Connecticut.
• 06:19As the Liver Center's clinical
• 06:21core has grown,
• 06:22we have developed a biorepository
• 06:23of blood and tissue samples.
• 06:25However,
• 06:26we aspire to participate in coordinated
• 06:28university wide efforts to develop a
• 06:30robust repository that can serve as
• 06:32a shared resource for investigators,
• 06:35and I'm sure Doctor Lou will
• 06:36speak more on this.
• 06:38In partnership with pathology,
• 06:40radiology, and interventional radiology,
• 06:42we've developed a database of
• 06:44carefully annotated phenotypes,
• 06:46dovetailing clinical,
• 06:47histological,
• 06:47and imaging phenotypes with the
• 06:50aspirational goal of developing a
• 06:52robust informatics core that can
• 06:54facilitate deep learning and other
• 06:56analytical methodologies to advance
• 06:58our understanding of the pathogenesis
• 07:00of HCC and the care of our patients.
• 07:05If you build robust clinical programs on
• 07:07a background of a strong legacy of basic,
• 07:09translational, and clinical science,
• 07:11the collaborations and publications
• 07:13follow over the past 20 years,
• 07:15we've seen a steady growth of
• 07:17publications on primary liver cancer
• 07:18among liver center members and the
• 07:20broader Yale Scientific community.
• 07:22And here you see HTC and
• 07:25Colangelo carcinoma publications.
• 07:26Over the past 20 years.
• 07:30What we should aspire to is
• 07:32an integrated value based,
• 07:33patient centered approach,
• 07:35while multidisciplinary tumor board is
• 07:37a very important piece of the puzzle.
• 07:41To provide aspirational cure,
• 07:42we need a programmatic approach
• 07:44that fosters the simultaneous
• 07:46practice of medicine and science,
• 07:48and this requires central team based intake.
• 07:52Truly integrated clinics and informatics.
• 07:55A learning practice across all
• 07:57disciplines with prospective electronic
• 07:59health record based data capture
• 08:02and ongoing outcomes assessment.
• 08:03A proactive approach to the clinical
• 08:06trial landscape tackling fundamental
• 08:08questions suitable to our population.
• 08:11And measuring patient reported outcomes.
• 08:14To have point of care,
• 08:15study enrollment in biobanking
• 08:17and a team based appraisal of the
• 08:19Gray areas where we have consensus
• 08:22driven center specific approaches.
• 08:23We examine our practices and
• 08:25we use scientific protocols.
• 08:29So what will it take to
• 08:32realize the path ahead?
• 08:33It will take a vision that
• 08:35transcends the disciplines.
• 08:36Objectivity, trust, collaboration,
• 08:38breaking down silos,
• 08:41investment prioritization, data management,
• 08:44informatics and a lot of hard work.
• 08:49But the future really is now,
• 08:51as we all feel the technological
• 08:54advances that facilitate discovery.
• 08:55Currently we're sitting on a gold
• 08:58mine of historical and future data,
• 09:00clinical, genetic,
• 09:02histological, and radiographic.
• 09:04We're in an era where high
• 09:06throughput analysis facilitates the
• 09:07acquisition of thousands of features,
• 09:09many of which we may not predict
• 09:12that may have risk, prognostic,
• 09:14and therapeutic relevance.
• 09:17The research agenda is vast,
• 09:19one that should take us from bench to
• 09:21bedside and back in an environment
• 09:23that attracts and trains a strong
• 09:25pipeline of physician scientists.
• 09:27We need to keep the patient front
• 09:30and center as an integral member
• 09:32of a culture of team science
• 09:34with the objective of providing
• 09:36personalized medicine in all domains,
• 09:38particularly access to care
• 09:40for prevention and screening.
• 09:42Early diagnosis with imaging liquid
• 09:45biopsy and tissue prospects.
• 09:47Clinical blood based imaging and
• 09:49tissue biomarkers for detection,
• 09:51prognosis and response to treatment
• 09:54mechanisms of pathogenesis and tumor
• 09:56behavior order and timing of treatments
• 09:59and sequential classification across
• 10:01stage migration and stage shift
• 10:04and delivery of value based care.
• 10:08In addition to all the departments and
• 10:09sections in the School of Medicine that
• 10:12are represented in the Yale Liver Center,
• 10:14we have great current and future
• 10:16opportunities for synergy with
• 10:17the Yale School of Public Health,
• 10:19the VA,
• 10:20the Department of Public Health
• 10:22and patient advocacy groups.
• 10:24With that,
• 10:25I'd like to again thank Michael
• 10:26and Maria for organizing this event
• 10:28and giving me this opportunity
• 10:30at the Yale Liver Center.
• 10:31Nothing is impossible,
• 10:32which is one of Michael's favorite sayings,
• 10:35and here's to the next 75 years of dreaming.
• 10:38Big thinking,
• 10:39big and letting our patients
• 10:41be our inspiration. Thank you.
• 10:46Thanks very much.