Scott Webb (Host): Diagnosing cancer early is one of the keys to survival. And my guest today is here to emphasize the importance of cancer screenings for all of us, especially if we have a family history of cancer. I'm joined today by Dr. Marc Rappaport. He's a medical oncologist with Montefiore St. Luke's Cornwall.

This is Doc Talk presented by Montefiore St. Luke's Cornwall. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to talk about the importance of cancer screenings, and you're the right doctor to have here. And, Doctor, I know that a lot of people put off cancer screenings either out of fear or maybe the belief that they feel healthy enough maybe not to worry. So, I want to ask you, like, what do survival rate statistics tell us about who's actually at risk or who's more at risk because they've delayed being screened?

Dr. Marc Rappaport: I have seen in the last few months more and more of my patients be highly resistant to cancer screenings, specifically colonoscopies, even some with internal exams and, you know, Pap smears with their gynecologists. And the data is significant. Those that get routine screenings have a better long-term outcome, decreased risk of having advanced disease at time of diagnosis versus finding something early.

And that's really the point of the cancer screening, is to find something early so that it can be easily managed versus having something be advanced and then not even be curable. So yeah, there is a lot of concern about the procedures. They've heard stories from friends, this and that. So, it's sort of a public opinion issue.

Host: Yeah, for sure. Yeah, as you say, early diagnosis leads to early treatment and higher survival rates, all of that, really important things, of course. And I guess, Doctor, like, there's just so many types of cancer, right? It feels a little overwhelming, like where do we start? But maybe which screenings would you, you know, encourage adults—

Dr. Marc Rappaport: Yeah.

Host: Yeah, what should we prioritize? What ages should we start those screenings and so forth?

Dr. Marc Rappaport: So, let's start with GI, which I think is the most important. We do recommend starting colonoscopy at 45, the screening. We also do have, you know, other modalities for screening. We have the Cologuard, which the gastroenterologists would be using in their office. They'll have it sent to the patient's house, and they actually just came out with a blood test, as well that people can have done. But that was just reviewed by the AGA, which is like the gastroenterological organization, and it's sort of not recommended for first or second line. It's recommended for third line. So, most recommended, of course, is to look.

So, next would be, you know, gynecology. So for the women, mammograms starting at age forty, and if there was a family history, it can be earlier. And then, of course, you know, your Pap smears. I do think there's been a lot of changes in terms of older women and how insurance companies, Medicare has changed that now they can only go every two years instead of yearly, Which I don't really agree with. I think all women should still have their yearly Pap smears, because you just never know. I am seeing women with HPV positive vaginal cancers and cervical cancers at a later age. So, they're definitely out there. So after that, there is lung cancer screenings, and lung cancer screenings have been around for a number of years, and we're getting better.

And there's a certain, you know, demographic that is recommended for high-risk smokers. I believe it's could be starting age 35 or 40 up to maybe 65, and they have to have at least a 10 or 15, 20-pack-year history. And then, whatever finding there is from their initial, they have recommendations for subsequent scans. And if they do find something that is normally found, like I said early, normally, there's a stage I. So, those are the three big screening tests that oncologists recommend.

Host: Right. Yeah. And let's talk barriers, if you will, the systemic barriers, be that cost, lack of insurance, geography, cultural stigma, whatever it might be. Like, what are the barriers that you're encountering with patients, and what can we do to address them?

Dr. Marc Rappaport: So, I think in this area where I practice, there's certainly an issue with cost. I don't think a lot of patients are very educated on their insurance, deductibles, co-insurance, so they think that everything should be covered. They don't really realize that. So, I think cost is a huge barrier. And then, of course, what we had just addressed earlier was patient's concern for complication, especially with colonoscopy, and then access to care.

I think there's a tremendous need for more education, especially more in the inner city areas, as to the importance of the screening and why it's necessary. So, I think those really are, you know, the main barriers.

Host: Yeah, it does feel like education is so important. So, I'm glad we're doing things like this, like this podcast. And you know, Doctor, I think I've even said this myself, "Well, I'll get checked if something feels wrong," right? So, why is that approach problematic? And maybe what makes cancer particularly deceptive? Like, cancer's really good at being deceptive, right? So, there may be early warning signs, there may not be. Folks may be ignoring the warning signs. What's wrong with the "I'll get checked if I feel bad" approach?

Dr. Marc Rappaport: So, that's a great question. I hear that all the time. And the reason is that, once you start to notice, it's probably already advanced, and then it's too late. So, the whole point is find it early for cure. Don't wait until you have symptoms, because that can lead to poor outcome.

Host: Right. Right. And if you have the risk factors, if it's—

Dr. Marc Rappaport: If you're a smoker, if you drink, you know. And the high-risk factor patients are the following: smokers, drinkers, strong family history. I mean, those are the people that should really be, you know, heavily engaged in thinking about screenings.

Host: Yeah. And I'm glad you mentioned family history there because we can't outrun, unfortunately, our family history and genetics. So, how should we factor in those types of factors of family history, personal risk factors like smoking when we're trying to decide when and how often to get screened? Should we really just listen to the docs, Doc? You know, like should we listen to the recommendations from our providers? Is that best?

Dr. Marc Rappaport: Yeah. When it comes to any kind of history of smoking, then whichever doctor they see should really refer them to the screening program for lung cancer. In terms of family history, that's a well-defined, you know, niche population that if the patient comes up and says, "Yes, I have X, Y, and Z in my family, you know, should I be tested for any kind of genetics?" Then, they should be referred to either a genetic counselor or us to then do the testing. And if they do have a formal positive family history, genetic positive, that's a dedicated process that patients will be referred into for very close observation.

Host: You know, Doctor, I feel like there's this sort of head-in-the-sand mentality that many of us may be guilty of, right, when it comes to seeing our doctors or being screened, whatever it might be, because we just don't want to know, you know, what a screening might reveal. And it can be probably paralyzing for folks. Like, they know they need it, they know they should, but they don't want to know, right? So, how do you counsel patients who maybe are afraid to find out, or how do you reframe maybe the conversation around, let's say, hope rather than fear?

Dr. Marc Rappaport: So, denial and fear is probably one of our biggest barriers as well that I talk about in people on a daily basis. I'm actually very upfront with people. You know, my job is to educate. So, what I do is I say, "I recommend X, Y, Z for these following reasons." And I say to them, "Look, for what I do for a living, I'd rather see you when I can cure you instead of saying I can't. And the,n we're in a different situation." And I think that kind of gives patients a little bit more understanding that not all cancer is just easily removed or, you know, chemo, radiation, it's deadly. So, it's much better to find this earlier than, of course, later.

Host: Right. I'd rather have you here to talk to you about things than to have that end-of-life sort—

Dr. Marc Rappaport: Than to have an end-of-life palliative care discussion.

Host: Of course, yeah. It's been really good stuff today. So great to have your time and your expertise, and I know there's a lot of cool stuff, doctor, right? So, liquid biopsies, AI-assisted imaging. So much cool stuff, lasers, you name it. But in terms of the new technologies and through this lens, we're talking about detecting cancer, of course. What advances are you most excited about? How close are they to becoming widely accessible and maybe even more affordable for folks? That sort of thing.

Dr. Marc Rappaport: I think we have, you know, personalized medicine, we have genomic assays. We're looking at how these mutations in patients' tumor DNA can then lead to a very focused targeted therapy. We have new assays looking at circulating tumor cells by a blood test to show how patients are responding and/or lack of response to chemo.

There, of course, is AI integration, which I think I'm in favor of. I don't think AI is ever going to replace the human doctor, but I think it will help us with diagnosis and a treatment plan. But of course, that knowledge of experience is not there with AI. But yes, I think that AI will be the future in medicine, and it will be more of a supportive role than a takeover role.

Host: Yeah, much the way, you know, we don't want AI writing college essays and college papers, but assisting perhaps. And in this case of detecting and treating cancer, if it will ultimately, you know, help patients save time, save money, all of that, why not? Appreciate everything today, Doctor.

Dr. Marc Rappaport: Can I just say one last thing?

Host: Sure. Yeah.

Dr. Marc Rappaport: There's actually certain practices right now, there are certain pulmonology offices, groups, hospitals that are using AI during their procedures to help diagnose and find lung cancers during the procedure that are helping to assist the doc in getting to the actual location. So, it's really been a very, you know, exciting kind of supportive integration.

Host: Right. Right. AI-assisted, right? We still need the doctors. We still need the experts, much like with some of the robots and things that I've talked to experts about. It's like the robots aren't doing the surgery, right? The doctor's still doing the surgery. The robot's helping them to do the surgery.

Dr. Marc Rappaport: Exactly.

Host: Yeah. So, it's all good stuff. Thank you so much.

Dr. Marc Rappaport: You're welcome.

Host: And to schedule your next cancer screening, reach out to MSLC's patient navigation team at 845-458-4444. And visit montefioreslc.org to learn more about our oncology services.

And if you found this podcast to be helpful, please be sure to share it on your social channels and be sure to check out all the other Doc Talk episodes. This has been Doc Talk, the podcast from Montefiore St. Luke's Cornwall Hospital. I'm Scott Webb. Stay well.