Introduction

0:28

Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller. This is part two of my conversation with Dr. Monica Esposito, founder of Ascend Concierge Medicine. In today's episode, we're focusing on cancer prevention and early detection. We discuss lung cancer screening, abdominal aortic aneurysm screening, colonoscopy recommendations, Barrett esophagus, and why preventative testing remains one of the most powerful tools we have in medicine. Many diseases are highly treatable when found early, and today's conversation highlights how screening Can help identify problems before symptoms develop

Kerry Reller 1:06

Yeah. So tell me about abdominal aortic aneurysms and screening and why we miss that sometimes

MonicaEsposito 1:14

So abdominal aortic aneurysms or triple As is what we typically shorten it, the colloquial version. It's basically a dilation of the large portion of the blood vessel that passes through your abdomen. And it's something that we typically, if we don't screen for it, you'll either find it if you're in the ER and getting

Abdominal Aortic Aneurysm (AAA) Screening

MonicaEsposito 1:34

a CT because of, a kidney stone or potentially if you're in the ER because you're having a dissection or something major and, big, bad problems. And with a triple A, this dilation basically causes that blood vessel to become more fragile, and over time it can become high risk for what we call dissection, where it starts to tear. And it can ultimately cause you to bleed out to hemorrhage. So any time that people are at increased risk for this, we tend to want to screen to at least evaluate if there are any signs of an early dilation. And if there are, then based on, how much of a dilation there is and how fast we see progression, the, the screening to follow is a little different, and it can a-adjust based on the patient's risk level. But typically we'll do this for anybody that's sixty-five and above that has any sort of history with tobacco whatsoever. I sometimes will also look at it for patients that have, high blood pressure issues because hypertension is another independent risk factor that can elevate risk for aneurysms, not only in the triple A, but anywhere else in the body. Think of it as, the added pressure is like blowing out a tire. So you can get aneurysms in that vessel, but you can also get aneurysms in more like the cardiac portion of the aorta, so up in your in ascending and descending aorta. And these are also high-risk areas, but they don't really have specific screening tools that are dedicated to those typically unless we find them incidentally or we have a specific concern.

Kerry Reller 3:05

Always, it's if you ever had one cigarette in your whole life, right? It's pretty crazy that is the,

MonicaEsposito 3:10

yep.

Kerry Reller 3:11

criteria to do the screening. And for some reason, I see it, in quality measures things, but I feel like sometimes it is overlooked and missed, and I think it's 'cause it's just that one cigarette thing. People could say they'd be a never smoker, but sure enough they

MonicaEsposito 3:25

Yeah. They're like, "Oh, when I was a teenager I smoked for a year." And I'm like that's still 12..."

Kerry Reller 3:30

Yeah, apparently it counts, right?

MonicaEsposito 3:33

Yeah. Which,

Kerry Reller 3:34

that's what I was thinking of when we were talking about cardiovascular screening. Before we go into any other types of screening I think, going off the cigarette stuff, what what are other types of screening for people who have smoked before that we often need to be doing? And sometimes I have actual trouble with some insurance companies with this one too

MonicaEsposito 3:54

Yeah, wild. So the other biggie, which, there, there are a lot of areas that we see increased cancer risk unfortunately with tobacco use, whether it's chewing tobacco or smoking. But specifically especially with smoking, the low-dose CT of the chest is a big one, and I've actually caught numerous early cancers on these screenings. So at this point the recommendation that it did update several years ago so they started as young as age 50, and it's for anybody who has

Lung Cancer Screening & Low-Dose CT Scans

MonicaEsposito 4:22

at least a 20 pack year history and is either actively smoking or stopped smoking within the last 15 years. And once you've had the one, then typically they will allow continuation, especially if there were anything finding those abnormalities. So usually it's something that we do annually in these patients. So in terms of the pack years, 'cause that's always a kind of a confusing things for my patients I know in the past pack year is where they multiply the number of packs per the number of years. So if you smoked one pack a day for 20 years, that would be 20 pack years. But if you smoked a half a pack a day for 40 years, that would also be the same 20 pack years. Or if you smoked for 10 years but you were, smoking two packs plus, you're still hitting that same landmark. Now, this is gonna unfortunately exclude people that were lighter smokers or more temporary, or people that smoked many years ago and, quit 30 years ago. The insurance companies will not cover it for those patients, and although they still are probably at increased risk, the insurance companies draw that line in the sand, which is a little bit of a nuisance. And sometimes we will say, "Hey, this might be worth doing the cash pay and get the cash pay rate to see what it is." Usually CT's between 200 and 300 bucks most places that we can get away with. So it's not great, but for somebody who's really high risk, we still may say, "Hey, it might be worth getting at least a one-time thing to keep an eye on things, and if there's nothing to worry about, then we won't do it as an annual." But, the, the low-dose CT chest is a tricky one, and the insurance companies also don't like it if they ever had any sort of nodule. 'Cause if you put that they had a lung nodule, then they're like we're not gonna cover it as a low-dose CT." Then you have to put it as just a regular CT chest, because it's not gonna be low dose because they have this history. So this-- it- talking about the whole red tape and trying to jump through all the hoops and, unfortunately, it's some extra nonsense, but ultimately, if we can capture some of those early lung cancers before they progress and spread, 'cause if you think about the times that we diagnose cancer in primary care, the ones that we catch early are typically the ones that are coming either incidental findings because it happened to pop up on something else we were looking at, or people that are getting screenings. Usually, if they're coming in 'cause they're symptomatic from cancer, typically it's gonna be stage III, stage IV most of the time. Before it really gets to the point that it's interfering with, blood counts or interfering with their daily living or they're having, they're coughing up blood in the case of this or they're turning yellow from liver. So doing things like this really helps us to catch things early enough that they have a much better chance at fighting and eliminating the cancer versus, having a very different conversation about trying to decide if when it's best to do chemo versus radiation versus surgery versus palliative care in some cases. So it's a very different scenario if we can catch these early.

Kerry Reller 7:18

And that's why we screen, right? That's the whole pur- purpose of the preventative medicine, right? Make a plan, do all the screenings, and, see you in one year, not a million, right? Unless

MonicaEsposito 7:27

Yep.

Kerry Reller 7:28

going on. So obviously we've alluded into the cancer realm. So I think we were having a fun, not a debate, but a discussion on some of the colon cancer screening stuff. So why don't we go over I guess those options and what is, recommended?

MonicaEsposito 7:43

My number one as a primary care doc, I'm always gonna recommend colonoscopy for pretty much everybody with very few exceptions. Really the only exceptions that I'd say, "Hey, if we, we... If it's high risk for them

Colon Cancer Screening Options Explained

MonicaEsposito 7:56

to do it. If they're really high risk for doing a colonoscopy because of the anesthesia or something," which it's a very small subset of patients that I would be that worried about that would still fall into the screening, criteria realm. Then those people, we would have a different discussion. Colonoscopy is the gold standard for a reason, it gives us the most information. It e- it enables the physician that's doing it to remove any polyps and actually get those tissue samples and diagnose on, on-site, and actually know exactly what they're dealing with versus just purely visualization or knowing, hey, something's wrong, but not knowing what. It's the gold standard for a reason. Getting a good prep and everything, making sure that people are doing all the stuff that they're supposed to prior is important. The current guidelines now say that even for average-risk people we wanna start at 45, which has been brought down from the age of 50, and that's a major deal because the fact that we have seen an uptick, and I'm sure you've seen this on your side too, of young people being diagnosed with colorectal cancers. It's definitely been on the rise. So I think that was a really good update that people are, reading the room and seeing, hey, maybe we need to escalate things a little bit more. And there are people that fall into even earlier screening categories that are high risk based on occupations, based on their genetics. So people like with Lynch Syndrome or things like that are very high risk for the polyposis as well as people with just very strong family history especially those in younger, you know, adults in their families. Outside of the colonoscopy, of course, you have the sigmoidoscopy, which is gonna be a little bit more limited version basically. And then you have the stool testing. So there's the FIT testing, FOBT, and Cologuard. I know a lot of the insurances will try to push, to get this stuff just because they wanna get at least something done for these patients. Colonoscopy is nice 'cause if it's totally clear, you're essentially good for 10 years in the absence of any sort of acute concerns. If you have, blood per rectum or, if you're having you know, thin caliber stools or unexplained weight loss or something along those lines, then of course we may do it sooner. But the 10 years is like that standard if everything looks good, you're cool. With FOBT, we typically do them annually. With the Cologuard, it's usually every three years. And then now there's a newer test that's on the kind of the rise that the American Cancer Society has rec- recognized now but USPSTF, the US Preventative Task Force, has not. But it's a blood test that can also be used for colorectal screening called SHIELD. And I, I have had it used in patients that absolutely refuse any other options. So for people that say, "I'm not doing anything that involves poop, and I'm not doing anything that involves anything going up in places where things come out," then I'm like, "All right. This is an option because at least it will give us some sort of data." Now that said, it has its limitations especially in terms of diagnosing polyps. With cancer diagnosis it's got a little better accuracy, but it's fairly low diagnostics when it comes to detecting polyps, which are oftentimes the pre-cancers, so those prodromes that l- end up leading up to cancer. So it's an option that will give us at least some element of, information, and we can use it in cases where the other things don't make sense. It's only recommended for patients that do not have any elevated risk. So for completely average risk, you would not use this in a patient that had increased genetic risk, increased risk because of, smoking or because of history of a bunch of polyps or anything along those lines. But for me, if I have the option to do nothing versus do something, I'll choose something. But if I have the ability to choose a colonoscopy, I'm always gonna choose the colonoscopy first

Kerry Reller 11:41

What were the occupational risks that you were referring to?

MonicaEsposito 11:45

So there are some jobs, depending on what you're doing in terms of dietary side, but like for example, fire department, they have increased risk of cancers almost entirely across the board,

Kerry Reller 11:53

Ja

MonicaEsposito 11:54

Because they're exposed to a lot of carcinogens in their line of work. So there are several, That's one of them that has a lot of higher risk in almost everything. There are some types of risk factors that are more specific. So like people that work in shipyards that have exposure to some of the pulmonary things, they have increased risk for lung cancers, and unfortunately, like that hasn't really picked up where they automatically have the screening included despite the fact that they may have that exposure. Same thing with military. I've had a lot of people that have come from like the veteran side, and they have increased risk because of exposures when they were overseas, and they don't have anything specific that's included on like the civilian side. But thankfully, if they're active with the VA, oftentimes the VA, if they recognize whatever exposure, then they can pick up some additional testing through that and get that covered, which is, nice. But for those that are not going through the VA, it can be a little bit of a, a challenge, a little bit of a hurdle.

Kerry Reller 12:50

But I think it's good unfortunately maybe, that mainstream media or pop culture, or you, if you will, because of all these famous people that have been diagnosed at such a young age, that I think it's becoming more, serious maybe taken by the patient side, that they're noting that, yes, it's now 45 and not 50, and actually going to want to get some sort of screening. And hopefully it is the colonoscopy, but, you can't... Not everybody is gonna wanna do the poop and then everything like that. I, so I don't know if you have any comment on that, but I do think that it's, people, the awareness is out there. I think it's improving for sure for

MonicaEsposito 13:28

Absolutely. I think it, it's almost like the relevance has improved because although people don't always like listening to doctors or trust doctors, unfortunately, which, we're trying to actively combat and, being approachable and having those good communication lines with patients is, rule number one to help combat that. I think having it out where people, even younger people that, may not be anywhere near needing this stuff, they're... it's on their minds already. They're like, "Oh yeah that's a thing." And that can happen, even in relatively young people or famous people or, it doesn't discriminate. These are things that can come up regardless of what your status is or what your job is or, what your age is. So I think that I agree, with that. And I do think that there has been some kind of data to support the fact that it suggests, anyway, that maybe some of the things that we're eating are contributing to the, that rise in colorectal cancer. There's a lot more additives in foods than, traditionally, 50, 100 years ago people were eating more things that were more generally natural. And people are consuming a lot more in the heavily processed foods. And some of them have actual proven carcinogenic effects. We see that with alcohol. We see that with, some of these cured meats and things that people love. And although they can be delicious, they can also be really terrible for your body. Being aware of what you're putting in your body and what the potential down-the-line implications are can make a difference, and, eating as cleanly as possible, at least for the majority of your eating. The occasional indulgence is like less likely to cause problems, but if you're eating a lot of high volume of these things, that definitely increases your risk for down-the-line problems, and it could be anywhere in your gastrointestinal tract, not just specifically colorectal.

Kerry Reller 15:16

You mentioned the prep and things like that. I think that's also something the patients are very scared about. And do you know anything about the options for prep or anything? 'Cause I see a lot more of that Sutab thing being prescribed now by the gastroenterologist before it, and I don't know if that is sufficient on the clean out. Do you have any idea?

MonicaEsposito 15:36

I don't know a lot about the really specific versions, and I know that most of these docs have a certain thing that they tend to go for unless they've had a poor prep in the past. But I think one of the problems is that people fear it, and they're like, "I don't wanna be, having all the diarrhea issues and everything that lead up to it." And I think that's, from what I've heard from ev- every patient, that's the most unpleasant part. The actual colonoscopy, you pick a dream, you go have a nice little rest, and then you wake up and it's done, and you're like, "Oh, okay, that wasn't so bad." But the prep part can be miserable, and you can't really be working or doing things much when you're getting it because you're not eating, it's all, liquid diet. You have certain restrictions to make sure, 'cause like they don't want you to be drinking anything that's red because it can discolor and cause problems, and they can think that they're seeing blood, so there are definitely restrictions. Some of the preps cause a cleaner, release than others, and obviously it does make a difference and, this is something and part of the reason why people need to see their actual col- like the, the gastroenterologist prior to doing the scope because if they have a history of problems with constipation, they may need a little bit longer prep to really clean everything out thoroughly. Because unfortunately, if you go in and you get the colonoscopy and there's still a bunch of stool on exam, although they may be able to see certain areas really well, if it's limited visibility in certain areas, they can't definitively say that they're clean. And although, they can use a little bit of the stuff with the tools to try to help clean out if there's something specific they wanna look at, it's not like they can do a clean-out while they're in there. So ultimately, that can make a big difference, and ultimately that is one instance where even if you didn't have abnormalities, they may say, "Hey, we need to repeat your colonoscopy sooner because your prep wasn't adequate." And so making sure that people are following the instructions, they're taking the full amount even if they feel like they're pooping more than they should, it's probably what they need to be doing to clear everything out thoroughly so that the test is gonna be the best possible diagnostic test.

Kerry Reller 17:38

It's interesting the way that you frame that they have to have that initial appointment because that's another thing I feel like that limits people, right? You need an initial appointment, at least in Florida and how we kind of practice, which I

MonicaEsposito 17:48

Yeah

Kerry Reller 17:49

Like, you can't just go get the colonoscopy. It's see the doctor, the GI doctor, then do the colonoscopy, then do a follow-up. They make it a little bit more harder to go in. But that's an interesting point that you said, "Okay, maybe because of the history of constipation or some other thing," then they maybe, would do different in their prep or whatever it is. I don't know. So that's a good way I can use to frame it to say why you need three appointments to get your colonoscopy done. But,

MonicaEsposito 18:14

Yeah

Kerry Reller 18:15

I hadn't thought of that previously, it is another barrier of getting it done, and that is because they, multiple appointments and k- taking time off work and it's a challenge.

MonicaEsposito 18:24

I totally get it. And

Kerry Reller 18:25

Yeah

MonicaEsposito 18:25

actually spoken to some of my colleagues about that in the GI realm, and they said one of the other things is that sometimes they'll evaluate if, number one, they're at increased risk for cancer for something specific, but number two, sometimes they'll actually do an endoscopy at the same time. So if they have a reason like, oh, they're having a lot of reflux and it's unexplained and they've been on omeprazole for six months and nothing's changed, they might say, "Hey, listen, while you're under, we're gonna do an upper endoscopy and evaluate to make sure there's nothing going on with your stomach or esophagus too." And ultimately, although nobody wants to deal with that, and I get a lot of jokes when people are talking about getting both done. They're like, "Make sure you do the, the endoscopy first," all jokes aside it can save them the extra trip. It ultimately ends up being usually less expensive 'cause they're getting anesthesia once, and it's lower risk because they're getting anesthesia once. So although it's kind of a nuisance it does make sense I think in a lot of ways to have that direct contact with the doc beforehand to make sure that everybody's on the same page, any risk ra- factors are identified ahead of time, and hopefully they can eliminate the extras. And in my side of things, I've also dealt with getting cash pay rates. So like I know, where the cheapest option in town is, that if my patient needs a colonoscopy done, that they can get their full colonoscopy including, the, any biopsies and anesthesia and everything done for like $1,250 all out, in, in and out done. So although it sounds like a big number, sometimes you can spend more than that on, dental work. So if somebody that hasn't ever had it done and they're hoping they won't have it for 10 years, it might be worth still doing that if they don't have insurance to get at least that initial thing done and out of the way and know that everything looks clean and that there's one less thing to worry about. So you know we do keep that in mind as well and, try to keep the cost and mitigate it where we can as much as we can.

Kerry Reller 20:17

It's also maybe important to be the bad guy here, whereas, okay, so maybe they're on omeprazole and they need an evaluation. I think that's a good idea, but of course that part is not a screening test, so it's probably gonna have some sort of co-pay deductible or anything like that, right?

MonicaEsposito 20:31

Yeah

Kerry Reller 20:31

they'll get off the medicine because they don't need to be taking, which is, had its own, has its own issues, right?

MonicaEsposito 20:37

Downline osteoporosis, all the fun things.

Kerry Reller 20:39

Yeah.

MonicaEsposito 20:40

has a side effect.

Kerry Reller 20:41

Yep. So interestingly, we were talking about Cologuard as one of the tests, i... Real quick before I segue into the next thing, but I have found that the insurance companies sometimes are just ordering them on behalf of my patients without my permission just to meet these quality measures, and I find that very, I don't know if the word's unethical in this camp, but I don't know. But it made me very upset when that happened. But

MonicaEsposito 21:06

Mhm

Kerry Reller 21:07

to change the subject to Cancer Guard because that is the same company that has another, screening thing. Now, this thing is not covered by insurance yet. I don't know if it will be, but tell us about that and what other kind of advanced cancer screenings that you use in your practice.

MonicaEsposito 21:24

Yeah. So there's two kind of like big screening names out there. Cancer Guard is one of the, the newer ones that we see from the same makers of the Cologuard. And then there's the Galleri testing which is from Grail.

Multi-Cancer Blood Tests: Galleri & CancerGuard

MonicaEsposito 21:36

And they both do the same general thing, and basically it is that they do blood testing and in essence can detect a lot of these cancers within the bloodstream versus having to do the full, body screenings or all the different other tests. And the general idea is to use them in addition to the normal recommended tests, not in lieu of them for multiple reasons. But number one is that they are not equal across the board in their likelihood to detect some of these cancers. So some of them, they have really great rates of detection even in early cancers, and then some of them, they're eh. And, in certain cases we can use this as an added tool for people that we would deem high risk for cancer, whether it be for genetic reasons or history, and it can help in a non-invasive kind of way to detect if there's anything that needs to be worked up further. Now one of the delineations between those tests is that with Cancer Guard it can give you a positive test, but it doesn't actually tell you the specific location of the concern. So if it detects something that it seems like there's an active cancer, it recommends doing like the basically the full body imaging to evaluate and look at that. Whereas with the Grail it gets a little more specific. But that said, oftentimes if you do identify an area of concern with cancer, usually these people do end up getting a lot of the full body imaging, but it's not like the full body MRIs. It's more like, PET scan or the PET CT or a brain MRI or things to help with staging and things along those lines. So it's a little different. But it's interesting and, it's not something that I by any means recommend for every patient because number one, the, the cost like for me with I know with... I don't off the top of my head know what the cost is for the Cancer Guard, but I think it's relatively in the same general neck of the woods. But, I get a discounted rate for my patients on the Galleri, and it's like I think $749 for the test. And they're relatively similar. They both test for a lo- a high number of cancer. I want to say it's in the 80s. So it's a lot of different things they screen for. Some of them are going to be more, efficacious than others, and some of them it's going to find, typically later stage. But one thing that I've seen is that in terms of the ones that are the highest risk that we don't have screening tests for, a lot of those are the ones that the tests are the most beneficial for. So like the ovarian and the pancreatic, and some of these things that we don't have a dedicated screening test for that maybe somebody might be high risk for. So if they had a family history of some of these things, and they had a specific concern, this is a way that they could, include this and potentially, depending on their really identifiable risk, if they had genetic testing or something and they're BRCA positive or things like that, then we would do different things based on what their specific risk factors were. But it's an added tool that people that are higher risk for developing cancer can get this periodically. It's definitely not something that's typically recommended for an annual thing. I think typically they say, if you're going to do it, you consider doing this as part of your thing every five years or something. But it's an added tool that we can use to help identify areas of concern in hopefully the earlier phases. Like I said, some cancers it's better at detecting earlier than others, but it's still an added tool in our arsenal, and the, the risk of false positive is relatively low, so obviously there's still always any of these tests, they always have flaws. There's always going to be that possibility, but it's fairly unlikely, and, it's a way that we can help reassure patients sometimes if there is elevated concern in those particular people. That being said- Sometimes to help identify risk and be a little more focused, we also consider including some of the genetic testing that predisposes you to certain cancers. So this is something that I find relevant in people that have, themselves had cancers, especially multiple cancers but also people that have, a really extensive family history of people developing cancers, especially early cancers or young cancers. So you know, it can help identify specific risk factors that may qualify them even through the insurance company to get some of this testing earlier. So if you identify that, you came from a line and you have Lynch syndrome, you're extremely high risk for colorectal cancer, and you need screening young. They start with people in their teens and 20s sometimes because it's just really high-risk disease. So insurance companies will cover when you have these identifiable risk factors. Same thing with doing some of these breast screenings and people that are BRCA positive. Breast-- that's one that we can see with breast cancer or ovarian cancer. I also might be prone in, depending on which BRCA gene, to be looking at male patients and also, ovarian concerns and, keeping an eye on things like that. Because unfortunately, that's an area that we really haven't seen the screening updates. Like there, there's not a whole lot out there that really delineates any actual recommendations for those patients. And so we have to rely on, good faith medicine and maybe the, the guidance of our gynecologic oncology friends and specialists and everything outside. Some of these things, it's a disservice to patients. And ultimately, the more we have knowledge on their risk factors, the more we can still sometimes cut through the red tape and get them what they need and what's most indicated to catch things early again, versus, lumping them with all of the average-risk people. That is really what the guidelines are there for

Kerry Reller 27:19

I had a male patient come in today, the other day with, a- someone in the family was BRCA positive, but it wasn't like a direct relationship. And I'm like I guess I'll still, try to, at least order the test." I didn't order the whole genetic panel, but at least just the BRCA testing. And, it's, I hope the insurance covers it, but I don't, know exactly what will happen from that. But it's nice that you have those options. Now, do you do full body MRI at all for any of your patients?

MonicaEsposito 27:47

So I use them from time to time. It's not something that I typically will automatically go for because MRI does have its limitations. And, we do-- we, we call them our incidentalomas. We find things that people are like, "Oh, what's that?" And then, it gives them added health anxiety for stuff that really n- need not be legitimately addressed. But that said, I think they can be useful in, again, that, that subset of higher risk patients. They can identify certain vascular anomalies, and they can identify

Full Body MRI: Is It Worth It?

MonicaEsposito 28:15

cancers. But ultimately they're high cost. They're not actually, attainable for the majority of patients. It's really gonna be for the, wealthier subset that have the money to do it and want the added information. And it's one of these things that if they really wanna do it, I'm happy to interpret it and help guide them through the results. But I think in terms of the general population, it's not something that I would necessarily automatically recommend. When you look at some of the radiology colleagues and stuff, getting imaging with CT is much better. For example, in the chest versus an MRI. It's just a, it's better technology for that area. So depending on what you're looking for, Or contrast versus non-con it makes a difference. So for me, generally speaking, I tend to err on the side of getting things that are more directed at what we're looking for if we have an area of concern versus that, that kind of blanket covering everything. It's not to say that they can't be useful and they can't be interpreted and they can't catch things. Of course, they can. But it's definitely not right for every patient.

Kerry Reller 29:18

Yeah, I had an MRI recently, and I can't imagine staying in there that long for a full body MRI. That would be the worst. That would be the breaking point for me. I would not do it. It was so long

MonicaEsposito 29:29

So I recently had people come in. They said I think it was like between 35 and 45 minutes or something for the full thing, which really surprised me 'cause I was like, man, how do they do it that fast? 'Cause I would have thought automatically based on what like the normal MRIs and how f- how long they take, I would've thought it would've been a lot longer. I was like, man, they're gonna be sitting in there for hours. They might as well turn on a movie,

Kerry Reller 29:47

that's what I thought. I had an elbow MRI and I think it was 30 minutes long. That sounds

MonicaEsposito 29:52

Yeah, you're like, "Oh my gosh."

Kerry Reller 29:53

then.

MonicaEsposito 29:53

Yeah, I don't know. It's interesting. But I, if it, probably to some degree depends on the specific scanner and everything like everything else. But yeah, I thought that was really interesting

Kerry Reller 30:01

that the... There was, there's these companies that you into their program and want you to do these full body scans and things like that, and they do find stuff. So it is exciting, the life-saving things they do, but then, cost and all those things associated with it. So it seems

MonicaEsposito 30:17

a big cost

Kerry Reller 30:17

targeted

MonicaEsposito 30:18

most people

Kerry Reller 30:19

really good. Yeah. So I know we've been discussing a while, but, there's all these other imaging studies, and you mentioned women's health as kind of one thing that you like to favor as well. And I... We were talking earlier about how Omeprazole can cause reduced bone mass, and typically, which I find ridiculous, the screening for osteoporosis doesn't begin till 65. So

MonicaEsposito 30:42

Yeah.

Kerry Reller 30:42

do in your practice, and why is that, and what is the screening tool for it?

MonicaEsposito 30:47

We can sometimes get things covered before 65 just because if they have specific risk factors. So things like malabsorption syndromes or people that are, like, status post gastric bypass, people that have had a recent fracture, sometimes we can get the insurance to cover it for those subsets. But I agree. It's really limiting, and ultimately

Osteoporosis & Bone Density Screening

MonicaEsposito 31:10

we're catching people so late in the game. And it's something that we're seeing in higher rates now because with the whole fad of everybody being on the weight loss medications, we see some of this muscular atrophy in patients that aren't adequately, you know, doing protein and strength training and everything to adapt with the medication that they're on. And I think we're gonna see overall an uptick because of that phenomenon, that we're gonna see more people that are younger developing osteoporosis, honestly

Kerry Reller 31:39

darn. I thought it was gonna be the opposite now that we are using more hormone therapy,

MonicaEsposito 31:45

But the hormones are helpful. Yeah, I guess it's like kind of one offsets the other, right?

Kerry Reller 31:48

I didn't think about the GLP-1 approach, but so I feel like that whole population that's 65 and above now missed like the hormone window, right? So

MonicaEsposito 31:56

I know

Kerry Reller 31:56

osteoporosis. It's very, almost everybody that I s- gets a DEXA scan on is like osteopenia, osteoporosis. Now, I will say I don't usually wait till 65, and I haven't had... Maybe one or two patients had some issue with getting theirs covered, and it-- I use just the menopause diagnosis, and then, I'll do it

MonicaEsposito 32:14

yeah.

Kerry Reller 32:15

as 50,

MonicaEsposito 32:15

Push it through

Kerry Reller 32:16

really haven't had... Only I can think of one or two, and they-- honestly, their insurance companies were not the best. It doesn't surprise me. But I find it ridiculous that the, the guidelines are until 65. We are not gonna do any favors

MonicaEsposito 32:28

I agree

Kerry Reller 32:29

just like, "Here's your pharmacy," be- you know, because now it's too late to have lifestyle recommendations to prevent

MonicaEsposito 32:36

Yeah, the bone's already gone

Kerry Reller 32:36

It's b- it can happen, and I usually still focus on that, but it's very unlikely. So I feel like we're-- that whole thing needs to be totally revamped. What help is it to diagnose someone with, at 65 with osteoporosis?

MonicaEsposito 32:50

I know. I totally agree. And ultimately, when you look at the morbidity and mortality rates for a hip fracture for somebody over 65, it's staggering. It's insane. So you would think that more energy and effort would be put forth to update these guidelines, but unfortunately we're not seeing that just yet. But now that the hormones I do agree. I think that having some of those people getting hormone replacement therapy in the earlier days, it can have that preventative effect, and hopefully on that side at least, that will help and maybe offset some of the other issues that I was talking about. And we have some places will offer the bone density scans cash pay, and they'll include the body composition testing and things like that. And I know some patients do like that anyway, and they'll get them early, and it'll help as a guide to say, "Hey, if you're getting this, we're seeing, you do have a little bit of this bone resorption already, and we need to make some adjustments." And it can also give us a little bit more information. So you know, people like having values to show, "Oh, hey, these changes that you're making in your diet and your exercise and whatever, look what you did now versus, when we repeat this a couple years from now." Your muscle mass has improved, your visceral fat has gone down. Your bone strength is still going strong, this and that. So in those patients that have to cash pay sometimes, it's nice that at least we can say, "Hey we can get you some additional information that may help as a guide," and also help to put a little fire under them, I think, 'cause they see, "Oh, okay that number, yeah, that's a bad number. But I really wanna improve that." And then they have something that they can quantify rather than just the numbers on the scale. 'Cause I routinely, whenever we're talking about weight loss, I'm like, "Listen. It's not all about the scale. It's about how you're feeling. It's about, where your weight is coming from. Is it muscle? Is it fat? Is it visceral fat? What are you actually looking at?" And The BMI and weight, which that's a whole other story for another day, that doesn't tell the full picture anyway

Kerry Reller 34:44

That's a great point. And I mi- might as well say, if they are able to do, 'cause the de- bone density is like gold standard for the or the DEXA, I'm sorry, is gold standard for bone density, but it's also, I think, other than MRI, gold standard right now for body composition, so Think using that in combination is a great idea. We have a InBody in our office and I don't put everybody on it, but I wish I did. And I think especially that older age group for the same reasons. I will find plenty of women or men who are a normal weight with the, inappropriate body composition. Not inappropriate, but visceral fat and

MonicaEsposito 35:21

Higher risk

Kerry Reller 35:22

Yeah, and almost borderline sarcopenia, therefore, their risk of, once again, osteoporosis, falls, and all that stuff just keeps climbing. So that in and of itself, if we're talking about preventative screening measures, that should be, and maybe they sh- if it's one test, one screen, I actually don't know how it's done. If, if they have to do it twice or whatever, the DEXA twice to get both informations, I don't know. But that would be great if they just did it at the same time so we can have all of that information, right?

MonicaEsposito 35:48

I think there are certain places that will do it, including the body composition. It just depends on the place you go. 'Cause some of them will just do that alone. But there are places that will do it all together, and I agree. I think that catching these things and identifying areas of risk, and I see it with the elderly, I see it, some with people that are on the weight loss medications. And, even just people that are generally sedentary. We see that muscle loss, and it happens so fast. Even just if you were in the hospital for an extended stay for something, you can lose muscle so rapidly, and it increases your risk of the osteoporosis. It increases your risk of falls, and ultimately morbidity and mortality tremendously. So identifying these areas and getting these people either in their own routine or physical and occupational therapy to help them or with a physical trainer or something that will help offset and get them on that right path towards building up some strength and stability, long game you can see really amazing benefits with that. And the correlation between muscle tone and strength and longevity and quality of life is a very well-defined one. So it's definitely something that we don't officially define in our preventative care guidelines, but it's something that should be paid attention to in the long game, and it's not something that's snake oil medicine. This is basic standard stuff.

Kerry Reller 37:11

I feel like after this conversation, I'm ready to go work for USPSTF, the task force,

MonicaEsposito 37:16

You're like, "Let's take pictures."

Kerry Reller 37:17

these guidelines." Yeah.

MonicaEsposito 37:18

Oh gosh.

Kerry Reller 37:19

I know we've been talking for a while, but did you wanna talk about mammography or mammograms or breast cancer screening?

MonicaEsposito 37:26

Absolutely. Yeah. So with the breast cancer screening, that's one of the areas that I kind of joke it's like a gray area because the different governing bodies, if you will, don't have like a, a really clear agreement. There's not really a consensus on the timelines for those. Which can make it harder to explain and really push patients to do whatever,

Mammograms & Breast Cancer Screening

MonicaEsposito 37:47

method you're trying to follow because they're like I don't understand. When I look it up online, it's saying this and, you're telling me this." And, it undermines to some degree, our authority and expertise, and we have to explain, what this means and why we do what we do. With-- we look at the three main like governing bodies that we see are, ACOG, which is the American College of Gynecology the USPSTF, which we referenced before, and then the American Cancer Society. And these three don't fully agree in this area. So with trip- traditionally through ACOG, they tend to be a little bit more aggressive in wanting the more frequent screenings, especially in those younger patients and getting more annual. And then after that, then it can be annual or biannual. But USPSTF is more oh, biannual is okay. And then y- the American Cancer Society kind of splits between the two. So when you're looking at trying to identify how frequently these people need it, number one, you have to say, "Okay I'm gonna preface this by saying I like annual mammograms," but these different things say, you can do it one to two years. So ultimately it's up to you and, this is why I recommend it But it also, again, we touched on this earlier, it doesn't identify anything for the higher risk patients typically, and then they have their own little stuff, but it doesn't fully identify guidelines consistently across the board there either. So for example, with our patients that have fibrocystic breasts, they're traditionally harder to really image and get good quality data on with mammography alone. So typically, radiology wants to have the ultrasound. The problem is that the insurance companies don't like paying for the ultrasound, even though it's recommended. So having those guidelines up to date and reflex to recommend these things will help to actually get these patients the testing that is genuinely recommended by the experts in the field. We don't see that consistently in almost every patient, unless I order it upfront advance and just hope for the best, I end up having to send them back for ultrasonography afterwards, and it's an extra day, and then it's extra time, and then they get nervous because they're like, "Oh, BI-RADS 0, what does that mean? Am I at risk?" Is there something that they're worried about? And I'm like not really," but we're, we have that gray area where the-- we're like we can't really identify it well because your breast tissue obscures, and it doesn't get imaged. The, the pictures aren't pretty, so we can't really tell." And even worse, for people that are really high risk for breast cancer, trying to deal with the MRIs and then making sure that we can get the MRIs covered. And then some people, they want to just do MRIs instead of mammography, but we have to look back and say, "Okay ultimately, MRIs are great, but it's not recommended to eliminate mammography." It's still the gold standard for a reason, and we actually recommend staggering between mammography and the MRI or potentially mammography with ultrasound and MRI. It definitely-- it makes it complicated, and if you're not up to date constantly and your patients have questions, it just, it builds that distrust. And, there are so many people that want to avoid radiation and avoid all this stuff, and they already are nervous and tend to be worrisome about this. And, I've had people ask for, the thermography and things like that, which I do not recommend for the record. But having that knowledge on the different areas and different recommendations based on their individual risk- And based on these different governing bodies, it helps at least to lend some clarity and, helps when you're trying to convince these patients, "Hey, this is ultimately what's recommended for you to get." And for me, I always keep it with the annual 'cause, I remember distinctly I had a patient that skipped one of her annual mammograms because of COVID, and she was just-- So it was like a two-year gap instead of a one-year gap, but she usually was one that was on the money annual. And she came in, got her mammogram, and we diagnosed her with breast cancer. And it was one of these things that she had to have a mastectomy and everything, whereas it could have been a smaller thing. It could have been that they just had to do a lumpectomy. It could have been something that was less involved had we caught it sooner. But because of COVID and everything getting pushed back, she unfortunately missed one of her normal routine things. But we see stuff like that, and unfortunately, statistics say that usually patients are not gonna feel a lump until it's around two centimeters in size. And obviously, it depends on the depth and where it's located and everything. But, self-breast exams are not alone going to catch these things, and especially the earlier, smaller things that, are less advanced. So getting those routine mammograms can help that even if you get a more aggressive form of breast cancer, you're catching it in those smaller stages where it's a lot more treatable and less likely to have the metastasis where it's going outside of that one breast.

Kerry Reller 42:40

Yeah, I'm, I don't know if I'm agreeing with you or not because I'm on team annual because I've seen too many patients who've gone away more than one year, even just, like they s- like you said, they missed one year and have come back with breast cancer.

MonicaEsposito 42:52

100%.

Kerry Reller 42:53

I don't know about the guidelines. I thought that American Cancer Society was 40 and annual. I actually don't know the ACOG ones, but you made it sound like it

MonicaEsposito 43:00

they're all on four- they're all on 40, but a lot of the stuff it's, it talks about biannual, which I found,

Kerry Reller 43:05

I know the USPSTF is 50 in buy-in, or you said they moved to 40, but they... I know they're buy-in. Yeah. So I'm on annual at 40 unless you have a higher risk factor, for sure. And then I think to be clear what you said, Earl, you don't recommend... Was it thermography, right? That's

MonicaEsposito 43:22

Yeah

Kerry Reller 43:23

Just making sure I heard you correctly so we're all on the... It was not that you don't recommend mammography, it's thermography,

MonicaEsposito 43:29

Thermography.

Kerry Reller 43:29

to go into that. But,

MonicaEsposito 43:31

Yeah, for him

Kerry Reller 43:32

I agree. I have difficulty in patients, they... because you said the insurance won't wanna pay for the ultrasound or they have to go back and, it's constant fighting. And some don't wanna do the mammogram at all, especially if they are the ones with fibrocystic breasts because, they're always gonna have to go do the ultrasound or they

MonicaEsposito 43:48

Or people with implants, I have issues with

Kerry Reller 43:51

as well. Yep. So there's all these, limiting things. But overall, it is very preventable and treatable cancer As long as you do your screenings, right?

MonicaEsposito 44:01

100%.

Kerry Reller 44:02

yeah. So highly encourage that. So are there any other screening tests that maybe we didn't touch on that you wanna touch on? I know we're probably not touch- touching on every single screening test there is,

MonicaEsposito 44:13

Oh, I feel like

Kerry Reller 44:14

screening,

MonicaEsposito 44:14

they're like unlimited practically. There's like a million. One of the things that I found interesting that-- this is not for everybody in average risk. But one of the things that I think is frequently missed is anybody with a hepatitis C history that's 50 and above, they're recommended to actually get ultrasonography of the right upper quadrant because they're increased risk for hepatocellular carcinoma, HCC. And it's something that,

Other Often-Missed Preventive Screenings

MonicaEsposito 44:42

believe it or not, I actually I've caught in a couple of patients over the years, and it's-- I don't think that most of us are even like aware of that guideline. I think it's one of these things that it's a little bit more obscure, and unless you've specifically encountered those patients. But as we see more patients coming through that don't have active hep C and cirrhosis necessarily, but have some of the liver disease, and they don't have active hep C, it's been treated, but they still, the, the liver changes, and they still are recommended to be getting the screening because their risk level persists even after clearance of the virus. I thought that was

Kerry Reller 45:19

okay.

MonicaEsposito 45:19

interesting

Kerry Reller 45:20

after being treated for hep C with the Harvoni or whatever the new ones are they are still recommended to get the right upper quadrant ultrasound?

MonicaEsposito 45:26

Yeah. It's based on if they have the liver disease. So like people that have the cirrhosis or the damage that was done, even if they're not having active issues. So like they don't need to have, the yellowed skin, like the jaundice, the ascites where they're building up fluid in their belly. It doesn't need to be where they're having end-stage signs of the cirrhosis. But if they have the cirrhotic changes in their liver, then they would still qualify. And it- it's something that like it's a very significant elevated risk for that hepatocellular carcinoma for these patients even outside of their initial window, which I thought was really interesting. so it's one of those things that it's preventable and it's not something-- you're not automatically going to be looking at liver ultrasounds all the time. So unless you have a specific reason I, I think a lot of these patients, if anything, they tend to get like the elastography because they're looking to see if there's progression of the fibrosis or, the hepatic steatosis, the fatty changes. So that's a whole different animal. But this looks more specifically for the signs of the actual, like the masses, the cancer

Kerry Reller 46:27

That's actually where I was gonna go with the topic, because I feel like I'm doing more and more, liver-type tests, whether it's, the fiber scan or getting like a FibroScan or getting like a Fib-4 test or, lab tests because of, I guess it's MASH these days, right? Metabolic associated steatohepatitis. So therefore, had I not known there was some sort of Hep C diagnosis, we might be uncovering something if we found that. But I, we're, I think the liver's being imaged more, but I don't even know if I was aware of that guideline, so thank you for the continuing medical education.

MonicaEsposito 46:58

It's always fun learning from our peers. I feel like it's constant CME. Our little things from our different friends and colleagues and everything. It's amazing what we can learn from one another. That's why I like all these interactions. It's great.

Kerry Reller 47:10

Absolutely. That's, I learned so much from, hosting and having guests on this podcast, for

MonicaEsposito 47:15

I can imagine

Kerry Reller 47:16

much more educational for me than me just speaking on my own, for sure.

MonicaEsposito 47:21

Oh, yeah. And it's probably fun.

Kerry Reller 47:23

Yeah, it is fun. Is there any other screening tests or preventative things that you wanted to discuss today?

MonicaEsposito 47:29

I think one of the other things that we see sometimes overlooked, and it's more specific, again, patient populations, is the getting the routine eye exams done.

Kerry Reller 47:39

Standing up straight. Yeah

MonicaEsposito 47:40

oh, hearing is relevant, too. Yeah 'cause actually hearing loss is strongly correlated with development of early Alz- Alzheimer's dementia or any of the dementia issues. We see hearing loss being a major risk factor that can actually be modifiable, so it's, again, an interesting one for my geriatric population. But in terms of the ocular screenings, we see a lot of people overlooked when they have hypertensive disease or issues with diabetes, type 1 or type 2. But also people that have autoimmune diseases that are on these different medications, they need to have their eyes checked routinely. And I have caught melanomas in the eyes because things hide. So even for the average-risk people that don't have anything specific, they should still be getting at least periodically routine eye exams to keep an eye on... Pun intended, right? To keep an eye on things and make sure that nothing is being missed and overlooked. And it's one of those things that if they're not having active vision changes, I think people tend to forget about it and be like, "Ah, whatever, I'm fine." But you don't want to wait until you're already progressing to the point that your vision is being, like, substantially impaired. It's better to catch these things ahead of time, so your, glaucoma, that early progress and, mediating your ocular pressures. If you're having signs of, macular edema or retinopathy, you wanna catch things early and medicate or mediate the risk factors that are causing it before you get to the point that it's more problematic. Or even seeing the papilledema from, pressures within the brain. There's so much that you can see in regards to a picture of your overall health just from looking in the back of the eye. It's really wild.

Kerry Reller 49:17

Do you do the hearing in your office or anything like that, or do you have them go to get screened elsewhere?

MonicaEsposito 49:23

I have them for now I have them go to get screened elsewhere. I look at the ears, and that's something that I routinely will check because you'd be amazed at how often I get people with perforated eardrums coming in. They don't even know that they have a hole which is a whole issue in and of itself. But, I think going somewhere where they can do that and where they can make all the specific recommendations for hearing aids or things if they're indicated it makes more sense to get them set up that way. But yeah it's interesting. There's a large subset of people that have hearing impairment, and, with respect to quality of life and overall risk and dementia and aging in a healthy way, hearing is highly relevant. We have so many things that we can do that help, again mitigate risk and help ourselves to age, in a more healthy and positive way. And it can come down to obviously the hearing, socialization exercise, stress management, getting sleep, which people constantly underestimate how much sleep they actually really need or should get. And I think probably most people are chronically getting less than what they really need or should get, but, that's another story for another day. But there's so much that we can do for our bodies to help overall improve our health and our outlook of our health and longevity even without getting into all of the, the really specific, all the mitochondrial medica- all that kind of stuff.

Kerry Reller 50:47

Yeah,

MonicaEsposito 50:48

That's a different animal, but you don't have to go into all that to still be looking at longevity and looking at long-term quality of life and aging in a healthy way.

Kerry Reller 50:58

Yeah. Now my head is just spinning with all the other types of screening that we do, like obstructive sleep apnea screening, depression screening, anxiety

MonicaEsposito 51:05

Oh gosh.

Kerry Reller 51:06

screening. We do,

MonicaEsposito 51:08

Limitless

Kerry Reller 51:08

so many other things that I didn't, we didn't even go over or talk about. But there's a lot, and there's a lot you could do as, a preventive medicine doctor in a concierge practice. So why don't you tell us about your practice? Where can they find you, if they wanna follow you or be your patient?

MonicaEsposito 51:24

Sure. So we're located in North Tampa. Our office is in the Magdalene Center. It's just north of Berens and just south of Lake Magdalene on North Florida Avenue. We're in suite 170. And it's a beautiful space. We have lots of space, lots of welcoming room and everything, and it's ADA compliant, so we, of course, welcome any of our patients that have, restrictions in being able to get in. We have patients that come in scooters and everything. We always make sure we're accommodating. With my practice, we always do complimentary

Ascend Concierge Medicine & Final Takeaways

MonicaEsposito 51:52

consultations. So for anybody that was interested in the model and learning more, they of course can call in and speak with my lovely office manager, Madeline and she's happy to provide some insight and, pricing and everything else. But also, if they have specific questions and they wanted to speak with me I'm happy to contact people directly if they wanted to have a one-on-one. And typically we'll have people come in and do a meet and greet. This way, they can check and see how they feel with me, make sure that it's a comfortable fit, 'cause I do think that having that real connection and feeling comfortable with your primary care doctor especially, is so important because ultimately you need that good, honest line of communication to make sure that there's mutual respect and that they feel comfortable and confident sharing everything with me about their life. Because, we're trusted with so much for these people, and it's an, it's a privilege. But ultimately, there has to be that trust in order for us to do our job the best, and I think that this helps to cultivate that early on because they essentially they're choosing me or they're choosing you. They're going in with a choice knowing that the person that they're going to is somebody that they're deliberately, they're making that decision on their own. And I really try to make sure that my patients maintain their autonomy and that I'm here as a guide and to help them be the best possible healthiest version of themselves and really optimize without feeling like they're being micromanaged, ultimately, and I'm treating adults, it's all 18 and above, and they're treated as such. And

Kerry Reller 53:19

Yeah

MonicaEsposito 53:20

it's a field of mutual respect where they can hopefully grow and evolve and, really feel more comfortable and confident in the medical system and what we can provide. And having that time to really establish that I think has been wonderful for me and for them. And, obviously everybody is welcome to explore this model. I have nothing but positive things to say about it, so It's been wonderful.

Kerry Reller 53:42

Awesome. Yeah. I love that you're able to give that, meet and greet and make sure they're ready for that long-term relationship, 'cause hopefully that's what it is, right? So

MonicaEsposito 53:49

Of course

Kerry Reller 53:50

a, it is a beautiful model, and I, I do think it's nice that medicine is evolving to have all these options as well. But,

MonicaEsposito 53:57

100%. It's nice for especially those uninsured people too, because if you... ultimately insurance shouldn't be a barrier for you to be able to get, the high quality care, and this allows people that, maybe choose not or, whatever, for whatever reason, whether it be personal or otherwise, to still establish with somebody that will take care of them and make sure that all their stuff is up to date and,

Kerry Reller 54:17

Mhm

MonicaEsposito 54:18

look out for their best interest, and that's important.

Kerry Reller 54:21

Absolutely. Anything else you'd like to share with our listeners today?

MonicaEsposito 54:25

If they wanna call our number is 813-859-7260, and you can find us at ascendconciergemedicine.com. But otherwise I hope that anybody that's been listening to this episode comes out with a renewed faith in medicine and, knowledge base and stuff with preventative care. And, make sure if you're not seeing somebody who's actively asking about these things, feel free to advocate for yourself. As a patient, don't be afraid to ask questions. It's okay to ask your doctor about things if you- if there's something that you're curious about or that you think might be beneficial. And, in most cases we're happy to take questions and to ultimately help to guide you on the right path to make sure that you're getting what you need, and you're not getting things that you don't or maybe could be harmful. And, that's our job to help be this guide through your process to make sure that you live your healthiest life, and it's an honor to do so

Kerry Reller 55:23

Awesome. Thank you so much for being on the podcast today. This was a really great conversation, and I think listeners would, will love it, so this is awesome. And everybody, please stay tuned next week for next week's episode.

MonicaEsposito 55:35

Wonderful. Thank you for having me