Wellness Wednesday | Panreatic Cancer and Melanoma: 5 Facts You Need to Know

hi everyone and welcome back to Wellness Wednesday where experts share insights on topics that are important to pancreatic cancer patients survivors and caretakers I'm Angela horn with Rolf Pancreatic Cancer Foundation and I'll be co- moderating this evening session with Savina Chacha and our partners at Cancer Wellness Center today we're thrilled to have Dr Allison dep Persia with us Dr depersia is a medical oncologist specializing in clinical cancer genetics at Endeavor Health she'll be sharing more insights on a topic that isn't discussed enough pancreatic cancer and melanoma for those of you joining us through Cancer Wellness Center I'd like to tell you a little bit about Rolf Pancreatic Cancer Foundation we're a local Chicago organization deeply connected to top pancreatic cancer hospitals and researchers in the Midwest and Beyond this year Rolf Foundation is celebrating 25 years of providing person personalized and tailored support to patients survivors and families in crisis we connect families with medical experts personalized resources and education we raise awareness about risks and symptoms and fund early detection research our hands on approach or as we like to say boots on the ground and hands on the back ensures no one has to face this journey alone our community has always been the heart of R foundation in June we hosted our 14th annual dash for detection and raised nearly $240,000 for early detection research a huge thank you to everyone who came out and supported us we have more exciting events coming up this year as we celebrate our 25th anniversary so grab your calendars and save these dates on September 9th we're back on the greens for the second annual drive for research at skoki Country Club in partnership with the Israel cancer research fund there are only a couple forom left for that event so don't miss out then get ready to celebrate 25 years of progress at our fall Gala on November 14th at venue West in Chicago we will soon share more details about these events our young professionals board events and our Pancreatic Cancer Awareness Month activities you can learn more at Rolf foundation.org and connect with us through our social channels we'll also put our links in the chat for more information and easy access now I'd like to welcome my partner today Savina Chacha from Cancer Wellness Center welcome Savina thank you so much um Angela and we're so grateful for our continued partnership with Ral good evening everyone my name is Savina Chacha I'm the program director at the Cancer Wellness Center and I'm so glad you could all join us tonight for those of you who are joining for the first time I would like to share a little bit more about the center the center was founded in 198 9 is a nonprofit organization with the mission to help anyone touched by cancer Find A Way Forward each year our free counseling services support groups health and nutrition programs serve over 1,800 community members of all ages and backgrounds people with cancer family members friends and caregivers all come to us to connect and cope our services which are both virtual um and in person include education programs like the one today that are aimed to help you navigate the very challenges that come with living with the cancer diagnosis Wellness classes like yoga meditation nutrition mindfulness and more that provide a holistic approach to Healthy Living and support services including counseling for individuals families couples children and those bereaved as well as support groups that are designed to help our participants manage the mental and emotional impact of cancer if you would like to learn more about the center and connect our free programs and services please visit cancer wellness.org and the link will be included in the chat now I would like to turn it back over to Angela who will introduce our presenter this evening thank you Savina now a few housekeeping items don't forget you can ask questions throughout the session in the comment section below we'll be saving all questions until the end to make sure we're able to get everyone if you prefer to if you prefer to submit questions anonymously you can absolutely email us at info@ r foundation.org we're so grateful to have Dr Allison dep Persia with us tonight Dr dep Persia is a medical oncologist specializing in clinical cancer genetics at Endeavor healths Mark R Neeman Center for personal for personalized medicine she is a member of the high-risk breast team at Endeavor and has expertise in hereditary cancer syndromes and cancer risk and screening Dr dep persa is board certified in medical oncology and Internal Medicine she earned her medical medical degree from New York University School of Medicine and completed her residency and fellowship at the University of Chicago hospitals welcome Dr dep Persia good evening everyone and thank you for that introduction I'm happy to be with you this evening to talk about this important topic um as I was introduced I'm a physician U my background is in medical oncology and I focus in genetics I read a high-risk Clinic where I do genetic testing um risk assessment and high-risk screening and prevention for individuals who are at increased risk of cancer either due to an inherited mutation or strong family history um so I'm going to go through a slide Tech today review important information around trary cancer specifically around melanoma and pancreatic cancer um and then we'll answer any questions at the end so um if yall um the team's assisting me with slides if you guys can go ahead and put up my slides then we can get started great uh next slide please so the goals for this evening we're going to talk about key insights on hereditary cancer syndromes some Basics around genetics and inherited risk um how genetics specifically affect risk for pancreatic cancer as well as risk of melanoma and then discuss a few genes that are specifically linked to inherited risk of pancreatic cancer and melanoma as well as some other Cancers and then discuss recommended screenings for individuals who are at increased risk due to these inherited mutations and pancreatic cancer risk in general next slide please um so just helpful to take a step back and talk a little bit about the basics of cancer incidents and cancer risk so um 40% of individuals will develop cancer in their lifetime most cancers are spaic so you don't need to have a family history or an inherited mutation to be at risk of cancer that's why all people do some level of cancer screening we know cancer is more common as we get older and so most cancer screening is recommended based on current age as well as risk factors and then many factors affect cancer risk um next slide please so um just briefly when we think about risk factors for cancer so like I said you don't need a specific risk factor to develop cancer which is why it's really important that we all do age appropriate population screen but there are specific aspects of our personal and family history that will inform our risk so there's environmental exposures occupational exposures for example lifestyle such as smoking increased alcohol consumption BMI then there's genetics so we think about specific inheritage genetic mutations which we'll talk a lot more about in a little while as well as just our general family cancer history and then sometimes our personal medical history can inform our risk and so specifically in the setting of pancreatic cancer for example a personal story of something like chronic pancreatitis would increase cancer risk as well next slide um so when we're thinking about cancer and risk so like I said the majority of cancer is spaic but some of it is due to inherited mutations um roughly 5 to 10% of cancers are thought to be related to an inherited change in a gene or mutation and this is when we say that someone has a hereditary cancer syndrome so having hereditary cancer syndrome is not a diagnosis of cancer it's not 100% risk but it is an increased risk of cancer where we specialize someone's screening and prevention so that's the blue part of the pie in this little image next slide some people have what we call a familiar risk so familiar risk could be due to um shared small genetic changes that are influencing risk as well as lifestyle or exposure history that we might share with our family so this is where we have a family history of cancer maybe don't have a specific inherited mutation but still have an increased risk due to that family history that's the green slice of the pie and then really important to understand that the gray is really the rest where we think most cancer is in fact sporadic and we all have that risk and that's why we all do screening and symptom awareness and follow with our doctors next slide okay so now we're going to really focus in on hereditary cancer syndromes next slide okay so just back to our basic genetics some of us think about this more regularly due to professions or interest and some of us maybe haven't really looked a picture like this since high school um but just to remind us that um that uh we have our DNA is present in every cell it helps direct the cell to carry out certain functions our DNA is made into proteins which help the cell carry out certain functions and so essentially certain proteins help protect us from developing cancer so we're thinking about inherited risk we're talking about a change in that DNA next slide okay so um our DNA is divided in so our DNA like I said is the manual it instructs the cell how to make proteins that control cell functions such as growth and replication and play a role in essentially um protecting our cells from developing into a cancer cell and then I think um the next part of this slide if you click again it may pop up yeah thank you um so our DNA is divided into genes which are sort of like chapters so tell our cell how to carry out specific functions um so we think about her inherited cancer syndromes we're talking about a specific Gene a specific part of our DNA that um has mutation and isn't doing its job as well as we would like next slide great um so it's important for people to understand that we all have two copies of every Gene and every cell in our body so in this picture you have a mom and a dad um each of them have two copies of a gene and then they're each going to pass on one copy to each of their children so I think there can be sometimes um misunderstandings or just confusing language used around inherited cancer syndrome so someone sometimes someone might say I have the braa 2 gene or I have the cdkn2a gene the bottom line is that we all have two copies of these genes as well as every other Gene and when we're talking about having an inherited risk or genetic mutation what we're saying is one of our two copies of these genes is not spelled correctly um and so when it's spelled correctly that's a mutation and then one of the two copies of the gene isn't able to do its job as well as we'd like we're talking about a gene that's playing a role and protecting us from cancer then we're not as protected from cancer as um ideally we would be if both genes were working properly uh next slide okay so like I had said um the way I think about a genetic mutation is just that our DNA um is essentially letter code so each chapter Gene is made up of sentences just sort of the same way a chapter in a book would be and mutation is a change in the spelling of that Gene so that it's not doing its job properly um and having a mutation like I said earlier is not cancer diagnosis it's not 100% risk certainly for someone who has a personal history of cancer and is sound of a mutation linked to that cancer we would say this mutation is part of the reason that you developed that cancer but for someone who is healthy with no cancer history we're not telling them that they will definitely develop cancer because of an inherited mutation but we're telling them that they have specific elevated risk of some types of cancer and then we're able to take action based on knowing that information to help um screen them better or or decrease their risk of developing that cancer so um that idea of an elevated risk but not 100% is what we call the penetrance of the gene the level of cancer risk next slide um and this is just a helpful visual that I think also just emphasizes that point so when I oftentimes when I talk about how most cancer sporadic patients are really surprised by that fact and they think that um you have to have a specific like known respector family history but um essentially in sort of a very uh basic sense of how cancer develops um we have normal cells which are constantly replicating themselves and sometimes when our cells replicate themselves and errors made and and if those errors aren't corrected then the cell can continue to collect errors or mistakes within its genetic material so that eventually the cells are growing out of control not to the benefit of the greater person and that's essentially when a tumor might develop or a cancer might develop so if you have hereditary cancer syndrome you're sort of starting with one of those spelling changes or mutations or errors in your DNA there's still many more errors that have to occur as your cells replicate and copy themselves which is why it's not a diagnosis of cancer but sort of think about it as being one step closer to developing cancer than someone who doesn't have that risk factor next slide please okay and then why would you want to know um if you have heriditary cancer syndrome certainly um it's a very personal choice if people pursue J testing or risk assessment it's maybe not something that everyone wants to know but certainly I have bias because this is my practice and I think there's a lot of benefits to pursuing risk assessment in genetic testing um so it can give more precise cancer risk estimates and if we understand someone's cancer risk and we know that it's significantly elevated then there there opportunities to be proactive um I think if you click again probably the other bullet points so um increased cancer screening is an opportunity we'll talk about that um as well as risk reduction so um in the setting of The cancers we're really focused on today obviously pancreatic cancer and melanoma um we're really thinking more about increased cancer screening um there's not necessarily surgical risk reduction or something like that but certainly there are risk reduction in the form of like lifestyle modifications so you know someone knows that there have a heightened risk of melanoma then they might be more cautious around sun exposure things like that than they might have been otherwise and then for someone who already has a cancer diagnosis and we learn that it is due to an inherited risk there are opportunities um to inform their treatments their targeted uh Cancer Treatments now that are available based on certain inherited mutations essentially the um error in the cell that um in the DNA that um caused that person or increase the risk of developing cancer is also an air in the cell that we can take advantage of with our treatments to try to Target the cancer cells and um um kill them while not affecting other healthy cells in the body potentially um next slide okay so um just a little review on the elevated risk of pancreatic cancer then we'll do elevated risk of melanoma and then we'll talk about um the specific genes that can link those so um when we're talking about hereditary pancreatic cancer risks today I just wanted to point out that specifically focused on pancreatic ductal adnoc carcinoma which is um 94% of pancreatic cancers are there are other types of rare neuro enderin tumors and things like that that we're not going to get in today but um in general when people are talking about pancreatic cancer this is often the type that we're talking about or thinking about um the general population lifetime risk of pancreatic cancer is somewhere around 1 to 2% um and someone is considered a high risk of developing pancreatic cancer if their risk as their lifetime risk is over 5% or roughly a fivefold or greater increased risk compared to the general population um someone can be at high risk of pancreatic cancer either due to um a hereditary um inherited syndrome oring mutation which is sort of the focus of our discussion today or um there also can be familial risk where you're looking to family history but there's not inherited mutation um in most instances that's defined as having at least two first relatives with pancreatic cancer or um sometimes it can be three relatives on the same side of the family in certain clusterings as well um next slide please um so thinking about um inherited syndromes causing increased risk of pancreatic cancer we know um up to about 10% of pancreatic cancers are due to an inherited genetic mutation that increases pancreatic cancer risk um the bottom sentence on this slide is the most important so all patients with pancreatic cancer should be offered genic testing and based on current guidelines all patients with a diagnosis of pancreatic cancer are recommended to do genetic testing because about one in 10 will have an inherited mutation and like I said it could inform their treatment it can also inform their family members risk and management um and certainly if the family member person who is affected with pancreatic cancer is no longer with us because they were diagnosed before this was a guidance or they had an opportunity to do genetic testing certainly close relatives also are eligible and appropriate for Gen testing um we're more suspicious that we might find an inherited mutation in someone with pancreatic cancer if they have a younger than average diagnosis have relatives of pancreatic cancer or have a personal St of other cancers or clustering of certain cancers that can be seen with some of these genes next slide please okay so now just a little bit around basics of melanoma and risk so um roughly 7 to 15% of individuals who develop melanoma while the family history of melanoma not all of those people certainly will have an inherited mutation in their family but potentially up to five to 10% of um diagnoses with melanoma could also be due to an inherited mutation and just notable that one of the genes we focusing on cdkn2a is um thought to um be responsible for up to 20 to 40% of um those inherited cases of melanoma based on what's currently available in the literature as far as research um and then there's also an entity of familial melanoma where maybe there's not a clear inherited mutation in a family but once again there's a stronger history than we might expect by chance and so someone might have a familial risk where they have multiple close relatives or multiple relatives on the same side of the family who've had melanoma and be considered at increased risk next slide um so as far as inherited um cancer predisposition syndromes that link specifically pancreatic cancer and melanoma um the main ones that we think about and that we're going to be talking about today are going to be cdk 2A gene mutations that are inherited which is associated with fam or famili atypical multiple mole melanoma syndrome um this is felt to be um the underlying genetic cause or of a pancreatic cancer diagnosis in almost a half percent of patients so it's um a relatively rare syndrome but certainly something that we see in our clinics and that is important to be testing for um and then brc2 which is one of the genes that can cause hereditary breast ovarian cancer syndrome um and based on what's currently known based on research um it it probably is the ideology of um a larger percentage of um pancreatic cancer patients so one of the main contributors to inherited genes that were going to be finding in people who are diagnosed with pancreatic cancer um next slide um so this slide is just to say that there are many other genes that can be linked to inherited risk of pancreatic cancer or inherited R risk of melanoma but um don't necessarily link the two aside from from brca1 is on this list so on the left side of the screen these are genes that are known to be linked to inherited risk of pancreatic cancer brc1 is probably the only one that may also be linked to melanoma but the the risk is not as strong as with brc2 for melanoma and pancreatic cancer specifically um there's a gene called ATM um uh I know there was a question submitted in advanced body Tams we can talk more about it at the Q&A if there are questions um palb 2 there's a syndrome called Lynch syndrome P Jagger syndrome leani syndrome and then heriditary pancreatitis genes and so um these are hereditary syndroms that include pancreatic cancer risk and then might have other cancer risks um so that's where when we're thinking about gen testing or evaluating a family if we're seeing clustering of pancreatic cancer with other types of cancers in a family then maybe we're not thinking about CD cvk Anda but maybe we're thinking about something like Lynch syndrome where we are mainly seeing coloral and uterine cancer um and addition to pancreatic cancers for example and on the right there's a few genes that can be linked to inherited risk of melanoma that um are not necessarily um linked to pancreatic cancer risk these genes are definitely going to be a little bit more rare less well known to the audience I would expect but mitf pot one back one int and certainly there are um probably other genes out there that are linked to inherited risk of pancreatic cancer melanoma and um those are ongoing areas of research there are families that have strong histories that are unexplained and we we realize there are probably other genetic changes that that need to be found to help identify at risk families next slide please okay so we're going to talk more about cdkn2a like I said related to fam syndrome um so the key characteristics of cdkn2a um inherited mutations or families that have this inherited mutation are going to be multiple millon AIC nevi so people have um multiple moles or freckles a lot of atypical moles sort of more than the average person might um maybe it's something that their primary care doctor or their um dermatologist has pointed out in the past um they're going to have an increased risk of melanoma the lifetime risk estimates of melanoma you can see this is a pretty wide estimate um 28 to 76% um either way this is much higher than the general population um and warant um specific followup but I I think there's more research to be done to understand exactly what the risk are risk is and and some of this is that um different people have other risk factors beyond just their mutation so that's why we can see a wide range of um of risk there um notably the age of onset for melanoma in individuals with CD cdk and 2A is definitely shifted to um a younger age than average so um youngest diagnoses in the literature can be um around the early teens is what I've seen um and uh and then the average diagnosis is going to be probably so with CD can a somewhere around 30 to 45 whereas it's shifted closer to like 50 or later in the general population as far as age average age of diagnosis and then um increased risk of pancreatic cancer so um once again there's sort of a range but uh the lifetime risk is about to be greater than 15% there's some estimates I think that were closer to 19 15% um there may be some variability here based on which specific mutation or what change within the gene a family has because sometimes that could affect the level of risk um and the age of onset um average age is going to be shifted long younger so potentially in the 50s versus the average age in the general population would be closer to age 70 um next slide please um and so what are the recommendations for individuals who have an inherited mutation in the cdk and to aging with um bam syndrome so um P pancreatic cancer screening is recommended to start at age 40 or 10 years younger than the youngest diagnosed relative which ever comes first and this is for all individuals who have a cdk and to amutation regardless of whether they actually have a known family history of pancreatic cancer or close relative so um even if a family doesn't necessarily look like a CD Anda family where we're seeing a cluster strain of melanoma or pancreatic cancer if we find this mutation in an individual then we would say they still have this increased risk why we don't see the history in in All Families even though you know I said the melanoma risk is you know potentially above 50% so you think you would see it um sometimes people are very small families so it's a truncated family or we don't know a lot about the family history people aren't sharing that history and so sometimes there's just limitations in what can be known and then there's probably sometimes um other genetic changes in a family that are somewhat protective and so maybe their risk doesn't look as higher as the the average risk that we're seeing with cdk 2A but we don't have really great ways to assess those other genetic factors influencing a mutation at this point so even if there's not a family history that pancreatic cancer screening um is is really important um how is screening performed so typically screening is done on a yearly basis with um something called mic magnetic resonance cangal pancreatography this is basically an MRI of the pancreas so contrast is given it's phased and focused on the pancreas um and then there's also an endoscopic ultrasound which is I tell patients basically like a colonoscopy from above where um when they it's like an EGD when they do the endoscopy they go all the way down to the start of the small intestine they're be basically able to look through the wall of the small intestine at the pancreas so both of these the goal is visualiz close visualization of the pancreas to see if there's any growth or changes that are abnormal or concerning and basically they're both good ways to visualize the pancreas and they um they complement each other so they can be rotated on an annual basis to be looking at the the pancreas um the E is um an invasive study although it's um you certainly a lowrisk study um M obviously is just a a radiology Imaging study where you're in the scanner for um you know 30 minutes to an hour um and then from a melanoma perspective we recommend Dermatology screening every six months um this would start as ear is age 10 so um in some instances it may be that younger Generations are not doing Dr testing yet in the family but they may just start the the melanoma screening recognizing that they have um a chance of having inherited the mutation but they're not ready or age appropriate to really be pursuing the genetic testing yet to see if they inherited the ctk into a mutation from one of their parents um next slide so this slide is really important and um really exciting um so you know the goal of pancreatic cancer screening specifically is to diagnose pancreatic cancer when it's presymptomatic and years ago even when I started my own independent clinical practice um uh we didn't really have good reliable pancreatic cancer screening there were studies around MRCP and e but just not a lot of data and and so often people were told you're at increased risk but there's really not a lot we can do for you or your insurance is going to cover these screenings and they're expensive um so we now have a lot of good data to show that um pancreatic cancer Imaging surveillance is very beneficial so um there was actually a publication that just came out in July so there's a few groups that study pancreatic cancer screening there's the perceived Consortium which is um something that endeavor health is part of and then there's also the Caps Consortium which is a smaller group of Institutions that's been doing screening for the longest period of time um there's not any sites in the Chicago land area but it's um a few institutions all over the US um and what they've been able to demonstrate is that uh individuals who are diagnosed with pancreatic cancer based on screening um are usually asymptomatic and much more likely to be early stage so it's sort of um a flip whereas um uh screen based pancreatic cancer diagnoses about 70% in this most recent publication from the Caps group or either stage one or two versus when they compareed to a historical coher from The Seer database of just general people being diagnosed with pancreatic cancer so presumably based on symptoms um oft times unexplained weight loss jaundice significant epigastric or back pain um only 30% of these individuals were going to be stage one or two so sort of a flip there um this means that people who are diagnosed on screening are much more likely to be surgically re receptable or candidates for surgery which is going to where the where we have the best chance of um uh good treatment and um prolonged survival and then also less likely to be metastic so um in this most recent publication um when it was screen detected it was um you know about one in four people where they might have a distant metastases where as in the general population if it's symptom based it's more than 50% of people are going to have um an image detected metastases so um at diagnosis um and then what's important is that um we've now been doing the screening for I think the cap cap Studies have been going on for over 10 years now so they have follow-up data and large numbers to be able to say that they have improved three and fiveyear survival um so for example the median overall survival in the um screen detected pancreatic cancers was um 62 months whereas for um uh symptom based diagnosis um it was um a 8th month median survival so that is a meaningful difference I tell my patients that it's meaningful three and five year survival where yes someone might have a big surgery and they need treatment but they they have meaningful improved quality of life for many years and certainly can be longer than three to five years but this is just looking at what we have datawise we haven't been doing this long enough to say whether um we have people who are cured of the dis disease or living for decades after but that is certainly the hope and something that just Wars more study to be able to to figure that out um next slide please okay um so the other Gene we were going to talk about um is the brca gene which is linked to hereditary brast and ovarian cancer syndrome like I said the main genes link to hereditary breast ovarian cancer syndrome are going to be brca1 and brca2 um I tell patients that the risks are pretty similar between the two genes they're linked to inherited risk of breast ovarian pancreas prostate cancer and melanoma um but there are some differences between the two genes as far as which risks are higher for each gene so um specifically for brca2 is where the risk is going to be um slightly higher specifically for pancreatic cancer or melanoma which is why that's sort of what the gene we're focusing on today um so brc2 um the highest risk for females is going to be the breast cancer risk it's greater than 60% in one's lifetime the varying cancer risk I usually say around 20% but there's a range of risk here um the pancreas cancer risk is somewhere between five and 10% um whereas H bc1 risk is thought to be equal to or less than 5% just remembering that 5% is traditionally the cuto off we use to consider someone high risk where we might consider screening for them um prostate cancer risk estimates are pretty broad but probably closer to that 60% number number and then melanoma there's not good um published lifetime risk estimates but there definitely um is an observation of an increased risk of melanoma and more so in brc2 than brc1 um next slide please um so just reviewing all of the screening recommendations for brc2 cares um and uh most of this would also apply for brc1 but brc2 for breast cancer for female risk um we start we do annual mamogram and MRI we start the MRI at age 25 the mamogram at age 30 and then there's Al also the option of risk reducing mastectomy given that level of risk um ovarian cancer we don't have good screening so we recommend risk reducing removal of the tubes and ovaries which is where the majority of ovarian cancers start the age 40 to 45 for brca2 for brc1 that's shifted a little bit it's 35 to 40 because we see slightly younger ovarian Cancers and slightly higher risk um next slide and then the cancerous that we're most interested today in our discussion um so for pinkis cancer screening and risk so screening typically starts around at age 50 um if there's a family history or 10 years younger than the youngest diagnosis should there have been a young diagnosis then you move up that screening age um and once again the screening um the data I shared when I was sharing CD k2a that comes from a group of patients who met those high-risk criteria so it was brc2 and cdk Anda patients as well as others so we know MRCP and E are very effective for these patients too I think one thing that's really notable and important to point out and something that um I've been talking a lot with my patients about is that um uh the traditionally the guidelines for pancreas screening for BRC 2 have said that you screen if there's a family history and a close relative the thought being that there's some families with brc2 mutations where we're seeing pancreatic cancer and some where we're not and was there something um that increased the risk in those families that had the history versus those that don't um but then when we look at people being diagnosed with pancreatic cancer brc2 mutations it's a lot of the people didn't have a family history and so um based on that there are some newer guidelines by um ASG which is um one of the societies around Advanced endoscopy who said we should consider screening um for all brc2 carers who are 50 and above regardless of family history um what's Difficult about this is that um many societies who put out guidelines around screening and so caps which I mentioned which is probably the biggest group who has the history of doing pancreatic cancer screening and then nccn which is the national Comprehensive Cancer Network which is where most of our cancer risk and screening guidelines come from still say you need to have a family history to qualify for screening for pancreatic cancer with a brc2 mutation whereas this ASG says all patients so um and there's a lot of debate among specialists in my field about what the right fit is like if you don't have a family history is your risk truly 5 to 10% or is it only those with a family history in B orca2 who have it so I've been telling all patients to talk to their providers talk to their family members about how they could be doing screening um regardless of family history recognizing that uh not all Insurance um companies are acknowledging that ASG guideline and they're going based on the caps and nccn guidelines which say you need a family history to be doing screening um and then like I said the screening out comes the same data that I had shared with k2a applies um to to this population as well as far as it being very effective um prostate cancer screening we start PSAs at age 40 um and then for melanoma like I said it's an association um but we don't have precise risk estimates um but we do recommend hand annual whole body skin exam or at least a baseline exam and then follow up with the dermatologist as they feel prop appropriate every one to two years given that we can see a higher um incidence of melanoma and BRC two carers and then of course um lifestyle modification too um next slide okay so that was um my last slide I guess the only other thing I wanted to mention which I didn't have a slide around but is important to say um so for pancreatic cancer and for melanoma there isn't like a surgical procedure um or medication at this point that we can give patients who have a genetic increased risk to decrease their risk but we know know that there are certain lifestyle factors that certainly contribute so for example smoking contributes to increased risk of many types of cancers but we know with pancreatic cancer there is definitely a strong link there so smoking sociation is really important and um it's true with many cancers that are smoking linked like lung cancer for example that um even if you have ay and you quit like you you have some risk but you can still benefit from having quit and more distant you are from it the more your body sort of is healing from that damage that was done from the smoking so it's never too late to quit smoking um and then alcohol consumption we know it increased cancer risk there's some really good data around breast cancer risk and alcohol consumption and how there's like a dose dependency so even moderate or appropriate drinking you know what's considered like safe levels of drinking could still be increasing cancer risk and so alcohol presumably contributes to pancreatic cancer risk as well certainly someone who drinks excessively or has pancreatitis or things like that where there's damage the pancre we know it's increasing pancreatic cancer risk but also just thinking about um moderating alcohol consumption in general and then around melanom skin cancer we know that um thinking about our sun exposure um protecting our skin avoiding Burns um you know a lot of that damage is sometimes when we're younger we're not as wise to these things that trying to raise awareness in younger Generations as well and um use sun protection is really important um this last slide just includes um uh where I'm located which is the Neiman Center for first medicine at Endeavor Health um so we do hereditary cancer gen tusting um I run a high-risk cancer screening clinic so patients who have inherited mutations or strong family histories who warrant screening and then counseling around risk reduction surgical referrals or medications like for breast cancer for example we can give medications to reduce risk and then our practice also includes uh General Medical genetics too so some of my colleagues are General Medical geneticist who might do cancer testing or other testing and then we specifically have a high-risk pancreas Clinic um at Endeavor one of the sure Legacy sites that's run by um myself I identify patients and refer them over and then Dr Melissa hog who's one of our pancreas surgeons helps run the screening Clinic with a nurse practitioner colleague where they're doing that annual Imaging with um MRCP and then also incorporating e with one of our Interventional GI doctors um and then my uh physical office Clinic I patients is in evinston and our phone number is there as well but um those that was really the basic outline of what I wanted to cover and then I'm happy to answer questions that people have around brc2 cdc2a or other inherited genes link to pancreas cancer risk or um Basics around cancer genetic screening Etc perfect thank you so much Dr dep Persia that was excellent excellent information um now we are going to open up for questions uh several have come through during the talk but if you have additional questions please continue to ask again if you don't feel comfortable doing so in the chat you can email us at infoworld foundation.org also one final note before we get rolling uh we understand that this topic is very personal and while we want to answer everyone's questions we unfortunately must refrain from questions targeting individual medical advice so with that said the first question we have here for you Dr dep persa is what is the difference between using blood and saliva for genetic testing is one better than the other sure good question um so both blood and saliva are reasonable sources of DNA for Gen tusting so historically we did blood-based testing what you do when we do gen tusting so if it's blood um we're essentially removing the white blood cells um removing the DNA from those cells and then the lab is sequencing or looking at the spelling of specific parts of the DNA or the genes that we care about so we can also take cells from our saliva which includes blood cells and other cells and extract the DNA from those cells too so the um the quality of a Jun testing result from saliva or blood is equivalent um historically we use blood and then honestly during the pandemic when going to a lab was a risk that patients didn't need to take and we were practicing virtual tele Health almost entirely um that's where we really shifted to saliva because we could ship the kits to the patients's homes they could do a swab or spit into a test tube and then mail it off and it's totally reli in rare instances um saliva has a slightly higher likelihood of failing just because sometimes when people spit into the test tube like the bubbles don't really count I tell them it's like that you actually need like the liquid spit to get like enough cells and enough DNA so sometimes it fails because they don't get enough genetic material from saliva but if you get a result then it's good result so um sometimes if it's urgent testing like new breast cancer patient or something that's going to guide someone's therapy in the very near future we usually prefer to do blood just because there's a low likelihood of it failing or not getting enough sample but they're both totally reliable right that's good to know I was actually curious about that too um can you explain what a genetic variant of Uncertain significance means yes yeah so um a variant of Uncertain significance or as we call it the US and sort of medical abbreviation lingo um so basically when we do genetic testing um what we're doing is we're I think of like I said our DNA as like a letter code and we're again at specific areas of the DNA specific genes where there's a correct way to spell the Gene and um we're sequencing the gene to see if it's correctly spelled sometimes we see a misspelling in the gene but every misspelling is not necessarily mutation so a misspelling in a gene that makes the gene not be able to do its function not be able to make that protein that then carries out whatever job the cell needs to do that's a mutation when the spelling change affects the protein sometimes there's a spelling change where we say this is just probably this or this could be normal variation so we have haven't done genetic testing on every person and we're a diverse population so there's not just one way right way to spell a gene but as far as like the reference code or what the labs use to say how the gene should be spelled they only have you know a certain number let's say 10 correct ways to spell the gene but we know that doesn't reflect population diversity so sometimes we see a change in spelling in someone and we haven't seen it enough to say this is definitely a problem where the gene isn't going to work and it's mutation um we just don't know it could be normal variation and once we see it in enough people we study it and we prove that it's normal variation then we downgrade it to say this is benign and we wouldn't even tell people about the spelling change because it's just a normal variation of how you spell the gene or in some instances we study it enough and we say this is actually um a spelling change that is a problem the gene isn't doing its job making the right protein and we call a mutation um so uh it's something that we tell patients the more genes you test the more like you are to get a us because we all have some rare changes in our genetic code that are not like exactly the same spelling as the reference code but that doesn't mean it's a wrong spelling or a problem um and usually what we do in those instances is we tell patients we're not going to make a change based on a vus or variant of Uncertain significance we're going to um make an assessment of your cancer risk based on your family history so if someone has a v in a gene that's linked to colon cancer and they have a family history of colon cancer that does not mean this V is a mutation um we're going to still put the V aside and say okay you have a history of colon cancer is that family history strong enough that we should be changing your screening so we just um I always tell patients the labs are I say we but it's reallyit Community the labs are constantly updating the information they have in VES and if they learn that it's either benign shouldn't even have mentioned it or yes mutation increased we need to do something about it then what they do is they let your ordering team know about it and your ordering team should update you so it's really important that wherever you had your initial J testing you keep your contact info up to date with so if you move out of state or to a different Health System you still want to make sure they have your contact info or you're seeing a genetics provider every few years to just check on that V us because if we don't have a way to contact you then we can't tell you if if there is an upgrade and it is now considered a mutation okay um I think thises into the next question here uh speaking of family risk if your family doesn't have a history of cancer that's known of right that's known now should you still consider getting tested or save the money it's a really good question and I think you could ask um a lot of different um experts in my field and you might get different answers so historically genetic testing was done for people with very strong family cancer histories or personal histories where we said this is more cancer than we expect by chance based on population incidents and suspicious that there's something that's increasing your risk maybe it's genetic risk um and part of it was that when genetic Su first rolled out it was time consuming it was expensive and there were limited genetic provider so it wasn't something we could offer to every patient um and what we've learned over time is that family stre is informative and it does tell us about some families that are increased risk but like I said um I think when I was talking about how you could have a CV to a mutation that of any family pancreatic cancer family St pancreatic cancer melanom and you sort of say how is that with these risk being that high well some of it is people didn't talk about cancer St as much in some families or you have a really small family so even though there's a high risk you know even if it's an 80% risk if there's only two people the generations above you in that family might not see a cancer history so we know now that family history is not always informative and we do find mutations in people who don't have family history so certainly anyone can pursue this testing from a guidelines and insurance coverage perspective the recommendations still are around family history and certain criteria that are met based on personal family history for endurance coverage but um there are ways to get testing with sort of capped out of pocket costs we have a program at Endeavor Health that's called the genetic Wellness assessment and the breast health assessment that basically patients um complete questionnaires around their personal and family cancer prior to their Primary Care appointment or their annual screening mamogram and based on those answers they're told whether they might meet criteria to be recommended for genic testing but they're also told that even if they don't meet criteria if they're interested in do genic testing they certainly can because the cost of testing can often be kept at um usually around $200 to $250 if not built through insurance so it's certainly someone something anyone can pursue I think the one thing that um causes pause among experts in my field is that a lot of the cancer risk estimates for genes so like the risk of pancreatic or for CD canu most of the studies that looked at that Gene they looked at families who had strong histories of pancreatic cancer and got tested for cdk and 2A and so they they came up the lifetime risk estimates based on those families with strong histories so the thing is if you come from a family doesn't have a strong history and we find a can to a mutation in you are those risk estimates correct they're the best we have so yes we'd manage you based on that but maybe there's something about your family that makes that was a little bit productive so maybe your risk is a little bit lower other genetic changes so there is this idea of like a polygenic risk score for example which looks at small genetic changes throughout our genes that maybe um lay over the one inherited mutation to shift the risk a little bit so so sometimes the risk estimate is not maybe as applicable to someone who has no family history but it's still the best we can do and we should still screen you and treat you at increased risk even if you don't have a family history but just recognize that maybe your risk number is slightly different and and we'll learn that over time and as we learn that maybe we can differentiate screening a little bit more based on family history and other genetic factors next question is I didn't know there was a connection between pancreatic cancer and melanoma why do you think more people don't know the connection and is it a newer Discovery good question um you know I think genetics in general uh cancer genetics is just a newer field so the genes that I think have gotten media attention in that most people know about brocco one and two for example because of um well-known people in the PO you know in the media who've been affected or what have you those genes have been studied and been available for clinical testing since you know they were sequenced in the mid 90s for example clinical testing in its earliest fashion was in the late 90s early 2000s but weren't really accessible to the general population until closer to 2010 2012 and so um and historically when we tested we were only testing like one or two genes at a time so genes like CDJ I can't tell you exactly when it was sequence it's probably been around for some time in research setting but as far as it being clinically accessible and there being like reasonable fast tests that are costeffective where we can test CD CD that has not been the case for that long so um and then I you know don't think it's gotten the same media attention you know there's we do these hereditary common hereditary cancer panels and you know usually those panels have around 40ish genes but um you know most people don't know the names of a lot of those genes so um it's a pretty specialized SK pretty nich and um but it's definely something that's been studied for quite some time and so the the data around CD K is good data yeah if someone has already had cancer should should they still consider getting tested yes 100% um there's a few reasons so um we have a lot of cancer survivors who should do genic testing because they were diagnosed with cancer when Gen testing wasn't common B and um just because you've had one cancer doesn't mean you're not at risk for additional Cancers and if we you have a genic mutation that thinks um you know breast cancer and pancreatic cancer like brca and you've had a breast cancer history and you've been treated for that and um you're doing other cancer bance then we'd want to know if you have an increased risk of pancreatic cancer so we can screen you for that because otherwise we wouldn't be um if you have a cancer history and you have advanced disease or recurrence or something like that then um inhered mutation could inform your treatment like I said the same genetic changes that increased one's risk of cancer sometimes make that cancer more susceptible to certain drugs because of basically the mutation within the DNA so we can sometimes do targeted therapy or know patients are more sensitive to certain types of therapies and then even if that's not of Interest like sometimes um you know everyone sort of has different um preferences and goals around screening as they get into older years and so sometimes they'll have a young patient who comes in and I'm like you know your grandmother should really do the testing they had breast cancer and they're like you know my my grandmother's in her 80s and she's not looking to do more cancer screening and I understand and I respect that and it's not always the right fit for someone based on their life expectancy their goals but for that that grandmother to do the testing then if she has IM mutation then we know that all of her kids need a test and then we know which grandkids need to test so if it's not done for the person who has the cancer history it's still really important for their family members and sometimes you know you want to check with your family members first and say do you want to know about this do you want me to do Jank testing um you know maybe not everyone wants to know but I think even if it's not for yourself um it makes sense to pursue the J testing if you have a cancer history and you're recommended to do it absolutely um forgive me if this was already covered but if someone had um or has stage four pet p NE P NE um does that kind of cancer have genetic implications related to melanoma melanoma so um Panet is a pancreatic neuroendocrine tumor so it wouldn't be linked to like CD or B or C2 we're talking about pancreatico carcinoma so um that's sort of the different topic in some instances there are um instances where we do jet testing around neuroendocrine tumors for example but that wouldn't um fall into like this topic of CD k2a or P C2 for examp um a question submitted here says my husband passed away from pancreatic cancer what should my adult children know uh what should my adult children know about it and be aware of um so I think the most important thing that the adult children can do is go get their own um genetic testing so presumably um if the person who's asking this question I'm guessing that their partner um didn't did not have access to genic testing before they passed away from their disease and so basically we'd say there's you know roughly a 5 to 10% chance that that individual had an inherited mutation and since we can't test them because they're no longer with us we'd recommend that their close relatives so their adult children and siblings um you know or potentially parents pursue genetic testing to understand if any of them carry inherit mutation and if they did then um you know the Assumption might be that it came from their father if it's link to pancreatic cancer but there are ways to figure that out by testing other paternal relatives for example to see what it's tracking within that side of the family so certainly the um adult children should do genic testing in general I say adult children because um many of their hereditary cancer syndrome don't have um uh relevant cancer risk or screening recommendations until adulthood so we usually prefer to test people for these types of genetic mutations once they're 18 or older so that they decisional adults versus Asen miners we want them to want to have this information and make that decision for themselves since it's not going to change their medical care until adults obviously there are exceptions to that as I mentioned with cdc2a melanoma screening would be appropriate in younger individuals in the family but because seeing a dermatologist is a you know quote pretty easy thing to do um you don't necessarily need to test the minors in a family you can just have them start skin scre skin cancer screening and then when they're older um and they're sort of ready to make that decision and understand the other implications then they might pursue the actual Jack testing to see if they share this can into a mutation or not not and if they don't then um you know maybe they can stop going to the dermatologist too if their screens were all clear and there were other concerns you until I had active concerns again yeah great um okay is it possible to get reoccurring melanoma after one instance uh for reference this individual is post- Whipple and six months cancer-free so um so right there's I think sometimes uh like terminology around cancer can be using so there's uh recurrence and then there's a new primary cancer so um someone with a cdk and mutation for example who had an inherited risk of melanoma could have a melanoma be treated with it for with like local excision it's an early melanoma and their doctors say you're you're treated for this you know you're cured obviously you're going to cons continue screening there's always some small chance of recurrence or that cancer coming back but based on the stage it might be very low but they still need screening because they can have a risk of a second Prim AR melanoma it's like just because you've had a melanoma doesn't mean you can't get another new melanoma in another part of your skin and if you're at an increased genetic risk certainly um in cdk Anda individuals and families is where you might be more likely to see someone who's more than one melanoma diagnosis in their lifetime and so also if you have a CD K into mutation and you like get pancreatic cancer it doesn't mean you can't also get melanoma you don't like get one of the Cancers and you're cleared it you know it's not as common or as likely that we see patients who've had multiple of cancers Associated but you do sometimes right like you certainly see people with brca2 mutations who've had breast and ovarian cancer or things like that and that's what makes us suspicious they have that history so you need to screen for the other cancers even if you've had one of them okay super helpful um you suggested a dermat a Dermatological screening every six months but my insurance only covers one per year do you have any advice to get two screen ings covered um you know I I um in most instances what happens is these are rare relatively rare inherited syndromes and oftentimes I don't know exactly how Insurance works but there's like General guidelines that insurance follows and then they don't always know the more nuanced or specific guidelines so in my clinical practice if there's an Imaging study or something I order for a patient that gets denied there's usually an appeal process that I can pursue as a physician and certainly an instance like this where I know there is a published um you know expert opinion or something that I can reference to say twice a year would be appropriate then I will often do that usually the appeal has to come from the provider who's providing the care so I would assume in this instance it would need to be like a dermatologist who was appealing to get a second um whole body skin exam covered per year you know if you have concerning skin lesions I think there's a lot of reasons people see a dermatologist more than once a year so I I um you know sometimes there might be another way to get that appointment covered for you for example but um I run into this more for example like I Wasing with BRC to P gratic canc risk and screening all BRC two cares and over even if they don't have a family history I have a lot of ures that deny me and um I will appeal it and sometimes if I tell them about this other guideline that's published they'll um overturn that appeal and they'll cover it and sometimes they'll say look we're following the cast guidelines which are the most well regarded guidelines and so we recognize other guidelines are out there but until there's more data behind them we're not going to cover it so but I think an appeal is always worthwhile it's it's time consuming for the physician but hopefully they are able to do that for patients okay great the next question I think ties into that but I just want to make sure um they have a question concerning screening since the specific test that was recommended is not covered by insurance they have P pb2 all these acronym you're good they have that gen mutation and what do they advise for next steps does that cover yeah um so palb2 yeah pal2 is associated with an inherited risk of pancreatic cancer as well as primarily breast and ovarian cancer that we think of um the current nccn and caps guidelines recommend screening for age 50 and over if there's a family history in a close relative which be a first or second degree relative um the asge guidelines that I reference do include um screening even if there's not a family history for brc1 2 and po B2 so there is like a reference out there that potentially an ordering provider could use to appeal the guidelines but like I said um so I think a provider could order an MRCP if it were denied they could try to do a peer to peer but it if it doesn't work it's not the physician's fault they didn't it's not that they didn't get the right info I've referenced the headlines and been denied and sometimes I referen them and been successful so um but it could be considered yeah great um and I just want to be cognizant of time here I know that we're technically over time we just have so many questions coming in so I am so thankful for everybody's time as we're we're going to continue on here for a little bit longer just because there's so much interest we're so thankful um so next on the docket would be um what kind of doctor do you need to visit to get these screenings done would an internist request them for us it's a good question and every clinical practice is different so um I'm really fortunate that I get to practice um heriditary cancer like genetic testing and for my entire practice um a lot of people this is part of their practice so um you know there are a lot of um uh sometimes like a pancreas surgeon might also do the high-risk pancreas screening or breast surgeon might do the high-risk breast surgeon my practice is sort of unique that I can cover all the I know all the cancer and do all the screen I refer out for specific needs I tell patients that they often leave genetic testing with like a list of their risks and recommendations um not every intern is to comfortable carrying out that screening understandably it's very nuanced um knowing what to do the results knowing the guidelines knowing how to get the the screens covered because diagnosis code so I don't want to speak for any one internist I certainly have some patients whose internist do their screening for them and they check in with me every few years I have some patients who see me for the screening so um it just sort of depends where one's located I tell patients as far as what I tell them to tell their family members who aren't local and I can't see them I'd say I'd start with a genetics provider because the people who do the testing and I identify the muans are going to be the ones who are referring out to specialist so they probably know the specialists in their area who are doing this screening so that they can find whoever that person is whether their background's oncology or surgery or genetics who who's carrying out the screening if the internist isn't comfortable with it internists also have a lot else that they're covering so I don't expect them to be experts in rare hereditary cancer syndromes understood um where is back pain typically located with pancreatic cancer I did CT scan and doctors found nothing wrong but I still have gastric pain sometimes and back pain on the left side of the body what specialist would I see for pancreatic concerns a heptologist um so I don't you know I think if someone has back pain that's persistent or concerning them and they haven't found an good explanation then I think it's good to continue discussing with the doctor CT scan is like a very good way to evaluate the pancreas um but the type of Doctor Who specifically deals with a pancreas so hepatologist is like um an internist who does GI and focuses on the liver so someone like a a pancreas surgeon for example might be the person who focuses on the pancreas within a practice um if someone wanted to have further evaluation or inene um certainly in our practice for people who are at increased risk or doing screening like I said we have them see our pancre surgeon um but there are a lot of causes of back pain so um I don't you know by mentioning some of the symptoms that we might see in advanced pagis cancer I think they're also very non-specific when you talk about weight loss or EP gastric pain or back pain um but just if you have symptoms or concerns you want to tell a doctor and if you're at specific risk for cancer or something like that you want to make sure they know that when they're evaluating you so that they're not um you know not thinking about those scenarios as well when they're thinking about causes okay great um how far into a person's family tree should they be looking for familiar for famili risk yeah um so the guidelines talk about uh close relatives which is either to find a second or third degree relative so first degree is um your parents your children your siblings um second degree would be like your grandparents um uh third degree would be like great-grandparents for example so um it's I think it's sometimes harder with older generations to know just because if we think about our great-grandparents and how medicine was practice then family history is not as reliable um whereas like third degree relatives or maybe cousins maybe that's more reliable because they're medical history is like in contemporary medicine so we usually go out to third degree relatives but I often when I'm hearing histories around like you know great-grandparents great aunts and uncles um depending on what decade their care was sometimes you know that's not as reliable history but we still do go out to that third degree level okay great um next question would be uh you mentioned the high-risk pancreas Clinic is that meant for people already diagnosed with pancreatic cancer or for people who have a family member with pancreatic cancer and want screening for themselves our yeah our highest pancreas Clinic is run by Dr hog who's also a pancreas surgeon so she sees pancreas cancer patients for surgical consultation and care but um the high-risk Clinic specifically for people who are at increased risk of pancreatic cancer but don't have a personal so theose relatives um of people who've had pancreatic cancer or people who have inherited mutations or the type of patients that we're seeing in the high-risk pancreas Clinic to talk about screening and and Implement their screening for them great um and again thank you for everybody for hanging on we're still just going to continue on all this good data if we are if we are good to continue um for individuals that had previous genetic testing are there instances where updated testing may be indicated definitely um I don't have a year or specific cut off because um gen testing is sort of just devolved naturally as far as the technology and the genes that we test for but I certainly can say that if a family member did testing um you know 10 15 years ago then it's definitely most likely that it wasn't what we call a broad panel probably didn't include all the currently known pancreas cancer genes for example and update testing would be warranted um if it were more recent testing sometimes it's still not as broad because there's just different practice preferences um as far as of people are testing for the highest risk genes versus more moderate risk genes so unfortunately I have like my medical colleagues ask me this a lot like um what year you know after what year should we be doing update testing and I don't have a good cut off but if um if there's a family history and it was only BRC one and two testing or was very limited number of genes wasn't a panel then it's very possible there's a role for update testing for newer genes that were um identified linked to hereditary cancer risk a visitor a little cha okay just a few more questions here am I understanding correctly that the link is between adenocarcinoma and melanoma and not pets and pets and melanoma yeah cdk 2A is Rel related to pancreatic ductal Artic adnoc carcinoma and melanoma okay perfect um and is MRI better than CT scan for early detection of pancreatic abnormality um so CT is another good way to evaluate the pancreas um the reason we don't use CT scanning for screening in general is because CTS have radiation and M don't so for individuals who have a need for recurring Imaging on an annual basis or every other year MRI is preferred because then you're not getting that radiation exposure um usually CT is the DI the test of choice if it's more of a diagnostic evaluation so someone who's symptomatic or um having fall for um treatment like a ptic cancer that's being treated with chemotherapy and they're looking to see disease response often times it is a CT that we're using but in the screening setting for most hereditary cancer syndromes um CT or MRI might be a good way to evaluate a lot of organs but we often choose MRI because it doesn't have that radiation exposure right um I think we are down to the final question here um final question for you Dr Persia what are three key takeaways you'd like our viewers to leave with tonight um every person who has been gred cancer should have genetic testing because it can inform their treatment inform their family members cancer risk and inform their own future cancer risk and if you have a relative who has passed away from pancreatic cancer then you can pursue the direct testing if we can't test them um pancreatic cancer screening does exist because I think a lot of people don't think it exists or they were told five or 10 years ago that it didn't exist and when they were told that it was pretty accurate and that we didn't have good data around it and Med Insurance didn't cover it now we have good screening with meaningful improvements and outcomes as far as group three and fiveyear survival and those outcomes May in fact be even better but there's some limitations because we just haven't been studying it for that long um and then really anyone who wants um a genetic risk assessment or um you know cancer testing can do it and should have access to it there's you know some people who are more suspicious um based on family histories and we think that their you know pre-test probability their likelihood of finding mutation going into testing is higher but we certainly can find mutation sometimes in people who don't have a family history so um if if people want to pursue J testing they can do it and um you know and in that vein that is in part because it can be done for it's not inexpensive but um it's not the thousands of dollars that I think a lot of people think genetic testing is in this day and age out- of pocket cost can be capped at $200 to $250 and if you meet criteria then often times it's covered entirely although one's deductible can certainly play a role in in that cost but the labs are really great at working with people around cost of testing so um finances should not be a barrier foric testing in the St AG absolutely couldn't agree more thank you so much Dr Allison to Persia for such extended and informa informative discussion on this important topic and thank you to Savina and Cancer Wellness Center for partnering with us to learn more about Cancer Wellness Center please click the link in the chat and I would also like to thank you all everyone for joining us tonight if you're catching this on replay be sure to write Replay in the comments and ask your questions so we can get back to you we will be announcing details for our next Wellness Wednesday soon and if if you have any ideas for future Wellness Wednesday topics and speakers please email us at info@ Rolf foundation.org on behalf of everyone here at Rolf Pancreatic Cancer Foundation thank you for joining us this evening we can't wait to continue celebrating with you throughout this exciting year until next time stay healthy and take good care good night