Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.
Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting gastric cancer. Joining me is Dr. Annabelle Fonseca. She's an Associate Professor in the Department of Surgery at UAB Medicine. Dr. Fonseca, thank you so much for joining us today. I'd like you to give us a little bit of the evolution of gastric cancer and how the approach has changed when we think of treatments in recent years.
Dr. Annabelle Fonseca: Thanks so much for having me. It's an honor to be here. It's a great question. You know, the treatments of a lot of cancers have evolved over the last five, seven years. They keep evolving, and gastric cancer is one that has changed quite a bit. I think the changes throughout the whole spectrum, the whole sort of continuum of care from the workup once you're diagnosed, the things that we do. Staging laparoscopy, for instance, is something that we didn't do as routinely. And even the treatment has changed with some of the newer trials that we have seen good data for. So, lots of things have changed, and thank you for having me here to talk about them.
Melanie Cole, MS: And we will get into some of those changes. So, let's start with the workup and staging. What is the recommended workup and staging process for a patient with newly diagnosed gastric cancer?
Dr. Annabelle Fonseca: So yeah, you get a biopsy to start with which is often how patients get diagnosed. In terms of symptoms, patients will sometimes have weight loss or sort of the inability to eat or eat as much, or sometimes can present as anemic various different reasons. But regardless of what sort of the presentation is, the diagnosis usually starts with a biopsy. But that's sort of the beginning, right? And so, once you have the biopsy, you also do want to have a high quality upper endoscopy that may or may not be the same endoscopy that results in the diagnosis.
But we also want to know or to have the report document the exact location, what the extent is. Is it at one location or is it at more than one? Sometimes there's the ulcerated tumor, but how much does the abnormal tissue extend above and below? What the relationship to the GE junction is really important because proximal gastric cancer is different from a true GE junction or esophageal cancer. And so, we want to know what the location is specifically. But then, in addition to that, we get staging scans, so a CT of your chest as well as abdomen and pelvis with IV contrast. And those are the two things that we've done for a very long time.
And then, importantly, if you don't have evidence of metastatic disease or that it's spread on your staging imaging scans, then we want to get an EUS or an endoscopic ultrasound, especially to determine the depth of invasion because that depth of invasion changes how we manage the cancer.
The endoscopic ultrasound or EUS is also useful to know if there is evidence of lymph nodes that appear to be involved on EUS, because both those things would change how we manage patients. If your CT does not show obvious evidence of metastatic disease, we will often get a PET CT and we can talk about some of the indications for why we do some of those things.
And then, depending on the pathology, sometimes we have the pathology re-reviewed. Depending on what the stage is on the EUS, we may or may not do a staging laparoscopy. And so, if we have to break it up and the way I think about it is, is this a very early stage gastric cancer? Is it localized but perhaps more advanced, or is it metastatic? And the way we treat them is different as well.
So, for everything except the very early stage gastric cancer, so not the T1as. But especially if you're above a certain depth of invasion or if there are lymph nodes that are positive either on the CT or suspicious looking on the EUS, or if you have one of the more aggressive sort of histology, say it's a signet ring cell type of tumor, and that's something that is found on pathology, then all those things should raise concern for potential peritoneal disease even if you don't see it on a CT or on your PET-CT. And so, in those patients, we typically recommend a staging laparoscopy with peritoneal washings for cytology. So, that's kind of what I think about as the staging overall.
Melanie Cole, MS: So, that's so interesting now when we think of the staging. And you mentioned tumor location and histology. So, there's biomarker testing, all of these things together, Dr. Fonseca, how do they come together to help you determine whether the patient goes right to surgery, which we'll get into in a minute, or whether the adjuvant chemotherapies, immunotherapies combination, how do you put that all together in a multidisciplinary way to determine the treatment plan?
Dr. Annabelle Fonseca: In general, like I said, I try to think about it in a few different buckets. And so, there is the very early stage, and then the early stage or localized but more advanced, and then metastatic. So if we had to think about very early stage, so where the penetration into the wall of the stomach is very minimal, so what we call T1 lesions. Those, we can treat with either endoscopically sometimes alone, so for T1a lesions, or a surgery, but without chemotherapy or any other systemic therapy because the risk of involvement of lymph nodes is very low. So for T1, those patients typically will only get a localized treatment, either endoscopically if it can be removed safely and appropriately that way, so T1a lesions, or with a gastrectomy in a T1b.
Those are, I would say, the smallest proportion of patients, unfortunately. But the vast majority will have either localized but more advanced disease versus metastatic disease. So for the patients who have localized disease that has not spread to other locations like peritoneal spread, do not have peritoneal or liver spread or other things, most often we think of gastric cancers as best served with a multimodal treatment, because we think of it as a systemic disease. And so, for those patients, the recommendation is to do perioperative systemic therapy. So, it used to be just chemotherapy, so systemic therapy before and after. Historically, we used FLOT as the regimen which is, you know, a four-drug regimen, 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel. But a four-drug regimen of which you got half, so four cycles. You got four cycles before surgery and four cycles after surgery. So, it's kind of a chemotherapy sandwich. You get half the chemotherapy, you have your operation, and then you recover, and then you go back to finish the rest of the chemotherapy.
Now, following the Matterhorn trial, we often will do perioperative FLOT plus durvalumab. So, that's a little bit of a change, but it's still the same idea and the same sort of chemotherapy backbone. And then, you know, once you finish your perioperative, your systemic therapy before, then you go on to surgery, which would be a gastrectomy that's essentially oncologically appropriate. Sometimes that's a partial gastrectomy, sometimes that's a total gastrectomy with an appropriate lymphadenectomy.
And then, you know, your third bucket is metastatic disease. And so, here, systemic treatment is the primary therapy. It does depend on tumor biology. We mentioned biomarkers.
In general, there are so many and broad next gen sequencing is something we do in most patients and should be considered. But the things to remember are HER2, because patients can benefit from HER2-directed therapy; PDL1, which helps to guide immunotherapy decisions in advanced disease, your MMR status. Those are the sort of the three big ones I would think about, HER2, PDL1, and your MMR status.
But for those patients, chemotherapy is the mainstay of treatment for patients with metastatic disease.
Melanie Cole, MS: Dr. Fonseca, it's really an exciting time in your field. Speak a little bit about high-quality gastric cancer operations. What do they involve, and when in this course, where do they fit in?
Dr. Annabelle Fonseca: Yeah. So, even for patients where we know an operation would help, it's not just the operation, right? So, which is why the best way to treat patients is in a multidisciplinary fashion. So, it's not you have the medical-oncologist, the surgical-oncologist, sometimes the radiation-oncologist, but also the advanced endoscopist, your nutrition is really important, prehab. All those things matter to how we deliver high-quality care. And so, surgery is a very important part of that high-quality care, but the whole sequence matters.
And so once we finish staging, and let's say patients get chemotherapy before, so the neoadjuvant portion of their perioperative chemotherapy in terms of the actual operation so the extent of the operation is determined by the location. And so, the tumor location and our ability to achieve adequate margins, because you always want to have a margin negative resection, meaning you have resected it completely in that location. And then, we also do a lymphadenectomy, which is generally considered a D2 lymphadenectomy.
So, a D1 lymphadenectomy is what was traditionally done. But for many, many years now, we've been doing more than that. A D1 would remove the perigastric lymph nodes, so the lymph nodes just around the stomach, along the greater and lesser curves. But a D2 lymphadenectomy takes those out, plus also sort of what we think about as the second-tier regional lymph nodes. So, they're along the major arterial blood supply to the stomach, so the left gastric, the common hepatic, the celiac, the splenic arteries.
So, it's constructing an operation based on the location such that we would obtain negative margins, as well as taking out all the draining lymph nodes up to sort of the second order. In addition to that, the quality beyond the operation would include the things that we touched on briefly, so nutrition, prehabilitation, as well as all the appropriate perioperative management.
Melanie Cole, MS: Doctor, after all of the evaluations and the staging and the workup and possible surgery, are there some indications that a patient may have more advanced disease, you mentioned metastatic earlier than initially suspected? And what would lead you to that? And if that's the case, does that change the course and the direction?
Dr. Annabelle Fonseca: We always like it if we see a patient who has what we think is localized disease on a CT, for example. And that is good. We always prefer to not see evidence of metastatic disease on a CT, but it's important to not let a seemingly reassuring CT provide, false reassurance.
So, the things that would raise my suspicion about the cancer being more aggressive would include various things. For example, the histology. So, say, we have a signet ring histology, or certain things that may raise your suspicion based on the presentation. So for example, linitis plastica is a type of gastric cancer where you have diffuse gastric wall thickening. It is associated with signet ring histology. And sometimes the stomach essentially doesn't move very much. So, patients may have a long history of just not being able to eat. It almost appears to be like gastroparesis where the stomach is not moving, that makes me concerned. If the endoscopy report or the endoscopist says that the stomach didn't really insufflate very well, that would make me concerned. Finding either sort of bulky or nodal disease that looks suspicious or T3 and T4 disease, meaning the cancer's grown into the wall more deeply or for even having ascites or a little bit of fluid in the abdomen on CT or a little bit of thickening of the peritoneum.
All those things kind of make me concerned that you might have metastatic disease even if you don't see it on the CT scan. And so, in those patients, it's important to do a staging laparoscopy. So, the thing that we talked about was part of the staging. I would do it for all recommended reasons, meaning if it's T3, T4 disease or if there's nodal disease. But also, if you have one of these other histologies that's concerning or something about the presentation that makes you worried, if you see an ovarian mass in a woman, for example, that's another reason because sometimes gastric cancer can go to the ovaries. You can have drop metastasis there.
So, all those things would be reasons to do a staging laparoscopy where you make a small incision, we look on the inside with the laparoscope, and we're looking for evidence of disease that you cannot see on a CT scan. For something to be visible on a CT scan, it has to be at least a half a centimeter or so for us to be able to see it on a CT. But a staging laparoscopy will find things that are smaller.
And then, the other thing we do there is peritoneal washings for cytology. So, we put fluid into the abdomen and we let it rest there for a little bit. We suction it out, and fluid is spun down, and we look for cancer cells in it. And so, that will sometimes show you evidence of disea se that is microscopic that we can't see with the naked eye as well. And it matters because having even microscopic peritoneal disease or positive peritoneal cytology is considered stage IV disease. So, it is metastatic disease.
In some situations, we can manage it differently based on how it responds, but it's important to know and it's important for the patient to know, because prognosis implications are different.
Melanie Cole, MS: This is such an interesting discussion. Dr. Fonseca, as we wrap up, what are some of the most important takeaways for other physicians deciding when and where to refer a patient with gastric cancer? And if you were to look into the future, what do you see on the horizon for treatments for gastric cancer?
Dr. Annabelle Fonseca: So, I think as far as referring, it's important to refer early, ideally before treatment starts. And it's not just because of the operation, it's the whole sequence. And so, you need to determine whether the patient needs additional staging, whether we should do a staging laparoscopy or not. So, the endoscopic ultrasound tells us whether the treatment should begin with systemic therapy, whether the staging laparoscopy should be performed, whether we should do systemic therapy or not, what operation will ultimately become necessary. And starting from day one, how do we optimize the nutrition? How do we optimize functional status to get patients to be in their best potential state of health as they receive these treatments?
So, it's not necessary to finish staging before referring. I think if the biopsy shows gastric cancer, it's the appropriate time to involve a multidisciplinary cancer team. And that team can be spread out across multiple institutions, but it's important to involve and communicate across the whole gastric cancer team. And gastric cancer, it's an operation where experience matters. And so, because it's not only removing a portion of the stomach, it has to be an oncologically appropriate operation with the appropriate lymphadenectomy while improving nutrition and preserving quality of life as much as possible.
The goal is not to get patients to surgery as quickly as possible, but we want to get through the right sequence of treatments and get patients in their best health possible while they get the best treatment possible.
In terms of on the horizon, it's a good time. It's an exciting time in that we have so many new treatments and so many trials that are giving us more information every day. Like, the Matterhorn trial changed how we managed patients with essentially resectable disease, but we manage them slightly differently. And so, it feels like every few months, we have some new potential targeted treatment in various cancers. So, it's an exciting time to be here and to be helping patients with this disease.
Melanie Cole, MS: Thank you so much, Dr. Fonseca, for joining us and sharing your incredible expertise today. And for more information, you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.
Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting gastric cancer. Joining me is Dr. Annabelle Fonseca. She's an Associate Professor in the Department of Surgery at UAB Medicine. Dr. Fonseca, thank you so much for joining us today. I'd like you to give us a little bit of the evolution of gastric cancer and how the approach has changed when we think of treatments in recent years.
Dr. Annabelle Fonseca: Thanks so much for having me. It's an honor to be here. It's a great question. You know, the treatments of a lot of cancers have evolved over the last five, seven years. They keep evolving, and gastric cancer is one that has changed quite a bit. I think the changes throughout the whole spectrum, the whole sort of continuum of care from the workup once you're diagnosed, the things that we do. Staging laparoscopy, for instance, is something that we didn't do as routinely. And even the treatment has changed with some of the newer trials that we have seen good data for. So, lots of things have changed, and thank you for having me here to talk about them.
Melanie Cole, MS: And we will get into some of those changes. So, let's start with the workup and staging. What is the recommended workup and staging process for a patient with newly diagnosed gastric cancer?
Dr. Annabelle Fonseca: So yeah, you get a biopsy to start with which is often how patients get diagnosed. In terms of symptoms, patients will sometimes have weight loss or sort of the inability to eat or eat as much, or sometimes can present as anemic various different reasons. But regardless of what sort of the presentation is, the diagnosis usually starts with a biopsy. But that's sort of the beginning, right? And so, once you have the biopsy, you also do want to have a high quality upper endoscopy that may or may not be the same endoscopy that results in the diagnosis.
But we also want to know or to have the report document the exact location, what the extent is. Is it at one location or is it at more than one? Sometimes there's the ulcerated tumor, but how much does the abnormal tissue extend above and below? What the relationship to the GE junction is really important because proximal gastric cancer is different from a true GE junction or esophageal cancer. And so, we want to know what the location is specifically. But then, in addition to that, we get staging scans, so a CT of your chest as well as abdomen and pelvis with IV contrast. And those are the two things that we've done for a very long time.
And then, importantly, if you don't have evidence of metastatic disease or that it's spread on your staging imaging scans, then we want to get an EUS or an endoscopic ultrasound, especially to determine the depth of invasion because that depth of invasion changes how we manage the cancer.
The endoscopic ultrasound or EUS is also useful to know if there is evidence of lymph nodes that appear to be involved on EUS, because both those things would change how we manage patients. If your CT does not show obvious evidence of metastatic disease, we will often get a PET CT and we can talk about some of the indications for why we do some of those things.
And then, depending on the pathology, sometimes we have the pathology re-reviewed. Depending on what the stage is on the EUS, we may or may not do a staging laparoscopy. And so, if we have to break it up and the way I think about it is, is this a very early stage gastric cancer? Is it localized but perhaps more advanced, or is it metastatic? And the way we treat them is different as well.
So, for everything except the very early stage gastric cancer, so not the T1as. But especially if you're above a certain depth of invasion or if there are lymph nodes that are positive either on the CT or suspicious looking on the EUS, or if you have one of the more aggressive sort of histology, say it's a signet ring cell type of tumor, and that's something that is found on pathology, then all those things should raise concern for potential peritoneal disease even if you don't see it on a CT or on your PET-CT. And so, in those patients, we typically recommend a staging laparoscopy with peritoneal washings for cytology. So, that's kind of what I think about as the staging overall.
Melanie Cole, MS: So, that's so interesting now when we think of the staging. And you mentioned tumor location and histology. So, there's biomarker testing, all of these things together, Dr. Fonseca, how do they come together to help you determine whether the patient goes right to surgery, which we'll get into in a minute, or whether the adjuvant chemotherapies, immunotherapies combination, how do you put that all together in a multidisciplinary way to determine the treatment plan?
Dr. Annabelle Fonseca: In general, like I said, I try to think about it in a few different buckets. And so, there is the very early stage, and then the early stage or localized but more advanced, and then metastatic. So if we had to think about very early stage, so where the penetration into the wall of the stomach is very minimal, so what we call T1 lesions. Those, we can treat with either endoscopically sometimes alone, so for T1a lesions, or a surgery, but without chemotherapy or any other systemic therapy because the risk of involvement of lymph nodes is very low. So for T1, those patients typically will only get a localized treatment, either endoscopically if it can be removed safely and appropriately that way, so T1a lesions, or with a gastrectomy in a T1b.
Those are, I would say, the smallest proportion of patients, unfortunately. But the vast majority will have either localized but more advanced disease versus metastatic disease. So for the patients who have localized disease that has not spread to other locations like peritoneal spread, do not have peritoneal or liver spread or other things, most often we think of gastric cancers as best served with a multimodal treatment, because we think of it as a systemic disease. And so, for those patients, the recommendation is to do perioperative systemic therapy. So, it used to be just chemotherapy, so systemic therapy before and after. Historically, we used FLOT as the regimen which is, you know, a four-drug regimen, 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel. But a four-drug regimen of which you got half, so four cycles. You got four cycles before surgery and four cycles after surgery. So, it's kind of a chemotherapy sandwich. You get half the chemotherapy, you have your operation, and then you recover, and then you go back to finish the rest of the chemotherapy.
Now, following the Matterhorn trial, we often will do perioperative FLOT plus durvalumab. So, that's a little bit of a change, but it's still the same idea and the same sort of chemotherapy backbone. And then, you know, once you finish your perioperative, your systemic therapy before, then you go on to surgery, which would be a gastrectomy that's essentially oncologically appropriate. Sometimes that's a partial gastrectomy, sometimes that's a total gastrectomy with an appropriate lymphadenectomy.
And then, you know, your third bucket is metastatic disease. And so, here, systemic treatment is the primary therapy. It does depend on tumor biology. We mentioned biomarkers.
In general, there are so many and broad next gen sequencing is something we do in most patients and should be considered. But the things to remember are HER2, because patients can benefit from HER2-directed therapy; PDL1, which helps to guide immunotherapy decisions in advanced disease, your MMR status. Those are the sort of the three big ones I would think about, HER2, PDL1, and your MMR status.
But for those patients, chemotherapy is the mainstay of treatment for patients with metastatic disease.
Melanie Cole, MS: Dr. Fonseca, it's really an exciting time in your field. Speak a little bit about high-quality gastric cancer operations. What do they involve, and when in this course, where do they fit in?
Dr. Annabelle Fonseca: Yeah. So, even for patients where we know an operation would help, it's not just the operation, right? So, which is why the best way to treat patients is in a multidisciplinary fashion. So, it's not you have the medical-oncologist, the surgical-oncologist, sometimes the radiation-oncologist, but also the advanced endoscopist, your nutrition is really important, prehab. All those things matter to how we deliver high-quality care. And so, surgery is a very important part of that high-quality care, but the whole sequence matters.
And so once we finish staging, and let's say patients get chemotherapy before, so the neoadjuvant portion of their perioperative chemotherapy in terms of the actual operation so the extent of the operation is determined by the location. And so, the tumor location and our ability to achieve adequate margins, because you always want to have a margin negative resection, meaning you have resected it completely in that location. And then, we also do a lymphadenectomy, which is generally considered a D2 lymphadenectomy.
So, a D1 lymphadenectomy is what was traditionally done. But for many, many years now, we've been doing more than that. A D1 would remove the perigastric lymph nodes, so the lymph nodes just around the stomach, along the greater and lesser curves. But a D2 lymphadenectomy takes those out, plus also sort of what we think about as the second-tier regional lymph nodes. So, they're along the major arterial blood supply to the stomach, so the left gastric, the common hepatic, the celiac, the splenic arteries.
So, it's constructing an operation based on the location such that we would obtain negative margins, as well as taking out all the draining lymph nodes up to sort of the second order. In addition to that, the quality beyond the operation would include the things that we touched on briefly, so nutrition, prehabilitation, as well as all the appropriate perioperative management.
Melanie Cole, MS: Doctor, after all of the evaluations and the staging and the workup and possible surgery, are there some indications that a patient may have more advanced disease, you mentioned metastatic earlier than initially suspected? And what would lead you to that? And if that's the case, does that change the course and the direction?
Dr. Annabelle Fonseca: We always like it if we see a patient who has what we think is localized disease on a CT, for example. And that is good. We always prefer to not see evidence of metastatic disease on a CT, but it's important to not let a seemingly reassuring CT provide, false reassurance.
So, the things that would raise my suspicion about the cancer being more aggressive would include various things. For example, the histology. So, say, we have a signet ring histology, or certain things that may raise your suspicion based on the presentation. So for example, linitis plastica is a type of gastric cancer where you have diffuse gastric wall thickening. It is associated with signet ring histology. And sometimes the stomach essentially doesn't move very much. So, patients may have a long history of just not being able to eat. It almost appears to be like gastroparesis where the stomach is not moving, that makes me concerned. If the endoscopy report or the endoscopist says that the stomach didn't really insufflate very well, that would make me concerned. Finding either sort of bulky or nodal disease that looks suspicious or T3 and T4 disease, meaning the cancer's grown into the wall more deeply or for even having ascites or a little bit of fluid in the abdomen on CT or a little bit of thickening of the peritoneum.
All those things kind of make me concerned that you might have metastatic disease even if you don't see it on the CT scan. And so, in those patients, it's important to do a staging laparoscopy. So, the thing that we talked about was part of the staging. I would do it for all recommended reasons, meaning if it's T3, T4 disease or if there's nodal disease. But also, if you have one of these other histologies that's concerning or something about the presentation that makes you worried, if you see an ovarian mass in a woman, for example, that's another reason because sometimes gastric cancer can go to the ovaries. You can have drop metastasis there.
So, all those things would be reasons to do a staging laparoscopy where you make a small incision, we look on the inside with the laparoscope, and we're looking for evidence of disease that you cannot see on a CT scan. For something to be visible on a CT scan, it has to be at least a half a centimeter or so for us to be able to see it on a CT. But a staging laparoscopy will find things that are smaller.
And then, the other thing we do there is peritoneal washings for cytology. So, we put fluid into the abdomen and we let it rest there for a little bit. We suction it out, and fluid is spun down, and we look for cancer cells in it. And so, that will sometimes show you evidence of disea se that is microscopic that we can't see with the naked eye as well. And it matters because having even microscopic peritoneal disease or positive peritoneal cytology is considered stage IV disease. So, it is metastatic disease.
In some situations, we can manage it differently based on how it responds, but it's important to know and it's important for the patient to know, because prognosis implications are different.
Melanie Cole, MS: This is such an interesting discussion. Dr. Fonseca, as we wrap up, what are some of the most important takeaways for other physicians deciding when and where to refer a patient with gastric cancer? And if you were to look into the future, what do you see on the horizon for treatments for gastric cancer?
Dr. Annabelle Fonseca: So, I think as far as referring, it's important to refer early, ideally before treatment starts. And it's not just because of the operation, it's the whole sequence. And so, you need to determine whether the patient needs additional staging, whether we should do a staging laparoscopy or not. So, the endoscopic ultrasound tells us whether the treatment should begin with systemic therapy, whether the staging laparoscopy should be performed, whether we should do systemic therapy or not, what operation will ultimately become necessary. And starting from day one, how do we optimize the nutrition? How do we optimize functional status to get patients to be in their best potential state of health as they receive these treatments?
So, it's not necessary to finish staging before referring. I think if the biopsy shows gastric cancer, it's the appropriate time to involve a multidisciplinary cancer team. And that team can be spread out across multiple institutions, but it's important to involve and communicate across the whole gastric cancer team. And gastric cancer, it's an operation where experience matters. And so, because it's not only removing a portion of the stomach, it has to be an oncologically appropriate operation with the appropriate lymphadenectomy while improving nutrition and preserving quality of life as much as possible.
The goal is not to get patients to surgery as quickly as possible, but we want to get through the right sequence of treatments and get patients in their best health possible while they get the best treatment possible.
In terms of on the horizon, it's a good time. It's an exciting time in that we have so many new treatments and so many trials that are giving us more information every day. Like, the Matterhorn trial changed how we managed patients with essentially resectable disease, but we manage them slightly differently. And so, it feels like every few months, we have some new potential targeted treatment in various cancers. So, it's an exciting time to be here and to be helping patients with this disease.
Melanie Cole, MS: Thank you so much, Dr. Fonseca, for joining us and sharing your incredible expertise today. And for more information, you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.