Healthcare is no longer one-size-fits-all, but a personalized journey. Advancements in technology and our understanding of human biology allow us to predict and prevent disease. Hear our WellSpan experts discuss the future of medicine.
James, how are you? I am good, Nick, how are you? I heard you had a big birthday this year. I did have a big birthday. I heard you had a big birthday as well. It is the anniversary of my 40th birthday. I got you. I got you. So all of a sudden, you know, I listen to my doctor more. Um you know, imagine walking into your doctor's office and the treatment you receive there is tailored specifically for you and it's based on your genetic makeup, your lifestyle and even your preferences. We are entering a world where health care is not just one size fits all, but a personalized journey that understands that things like cancer and heart disease aren't single diseases but rather distinct conditions that are driven by unique factors. So I agree. And first off, I'd like you to realize that we have 100 years of collective wisdom on this stage. So I was thinking about I was doing the math but we are as you know, we are on the brink of a revolution in medicine where advancements in technology, our understanding of human biology allows us to really go for merely reacting to diseases to actively start proactively predicting them and preventing them. Yes. And when I think about personalized medicine, you know, where we started and where we are now, it makes me so excited about where we're going. We are truly in the midst of a transformative change as we go through personalization and precision medicine. That is exactly right. And I know, you know, this, but the idea of precision medicine isn't new. It's been around for millennia. Actually, in fact, Hippocrates, the father of western medicine 2500 years ago said it's better to understand the patient who the disease has, the person who the disease has rather than the disease the person has. And if you think about that, really, I believe our, our journey into precision medicine is actually the journey of medicine itself where we really have gone historically, for a long time, from focusing on the problem to focusing on the disease to being able to focus on the patient. Yep, you know, each step gets us a little bit closer to Hippocrates, ideal. Um you know, not long ago, as a profession, we would treat problems as they came up. So patients would come to us sick with clear evidence of disease and we would treat what we found. So in the oncology world, that often meant that disease was presenting at a late stage where patients were harder to help, the disease was harder to control and often our only tool was a one size fits all chemotherapy regimen that couldn't distinguish between healthy cells and cancerous cells leading to lots of side effects and varying efficacy. So I hear you and you are not alone. The same is true in the heart and vascular world. At least for a long, long time. The number one killer of Americans right now is heart and vascular disease. This is predominantly in the form of heart attacks. And for really the history of the world until relatively recently, we learned that you had heart and vascular disease or were having a heart attack when you showed up with a heart artery that has been blocked, so blocked with what we now know to be clear, they starved off blood to the heart muscle. Your heart muscle began dying. Your heart function got worsened and you were ultimately leading to a lot of things like death. And yes, in the relative past few decades, we got to where we could do some stuff, pretty heroic stuff. Actually, heart catheterizations we could put in stents, we could do bypass surgery and they were way, way better than nothing, but they were also still too late. I mean, we showed up there and yes, we arrived at the active crime scene and yes, we stopped the active ongoing crime, but the crime had been committed nonetheless. And so thankfully, we've moved on from there. We began to learn how to treat, not just the problem. But the disease, yeah. And this was kind of our first crack at personalized medicine medicine that took the patient's factors into account. We began to understand how certain diseases behaved, you know, what their risk factors were, what their natural histories were and how we could intervene to benefit. So we even began to understand that some of the things that drove these diseases were actually molecular signatures of the tumor. So in the cancer world, this meant things like screening, you know, mammograms, colonoscopies, chest cts, for example, to identify patients at risk. It also meant things like advanced imaging techniques, advanced interventional techniques to stage patients and advanced pathology techniques to determine the molecular drivers of a patient's cancer. So we went from treating cancers based on their site of origin to treating cancers based on their histologist, for example, adenocarcinoma or squamous cell carcinoma to really treating cancers based on the tumors. They the uh the tumor markers and the mutations they express are truly getting the molecular fingerprint of the of the tumor and uh acting on it from there. That's fascinating. And I'll tell you we've learned a lot from oncology on that there's a lot of similarities in the heart and vascular world. So, you know, for us, it began really wanted to understand the disease like what caused the heart attack and we began learning that plaque. What we now know is cholesterol got between the ol and the medial of the vessel. And we knew that that blocked blood flow. And we learned that these things called radio nucleotides actually tagged molecules. We could put them in your bloodstream and they would go to the heart muscle preferentially like blood does. And they'd send out a photon and we'd catch it on a detector. And we, and from that, we could learn where the blood weren't and went and more importantly where it didn't go. And this is what we now call a nuclear stress test. And really, this is one of the first time we could start actively, not always, but we could sometimes predict the problem before it happened and actually treat the disease. We could preemptively intervene, we could put a stent in there or a bypass surgery or something like that. And actually, this is a major step, a significant step in the right direction of personalized care that being said it was still too late. This happened after there was a problem and after there was already a disease there. So what's really exciting is that, you know, as the like precision medicine is really advanced, we are now increasingly able to do the most critical part of this to actually start focusing on the most important element of care, not the process of the disease, not the disease factors, but the patient factors treating us from changing us from treating the patient, the disease to the patient. So in the cardiology, in the world. What did it mean? Well, we learned, we knew that not everybody gets acros. We wanted to know why we knew about risk factors. But we started learning about this cholesterol hypothesis in the fifties and sixties. Well, we got a little more nuanced and we learned that not all cholesterol is created the same. You've got low density lipoprotein. We call that the bad cholesterol, high density lipoprotein. As it turns out this cholesterol is good when it's around. And we started learning about different players, triglycerides, lipoprotein little A. We started to understand all these things. But what we really understood was everybody's cholesterol panel was different. That meant we could treat you differently to prevent the disease from occurring. We started to understand this a lot better and we didn't stop there. We actually started learning that not even all bad cholesterol. LDL was the same. If you take the same amount, the same concentration of LDL cholesterol in the bloodstream, but it's in small particles versus big particles, your odds of having a heart attack are way, way, way, way more. But again, what we learned is we had to treat people differently. And while at the time, we really didn't have a heart and vascular like anticholesterol or anti lipid target specific drugs like you did in oncology, we did learn about this thing called H coa reductase, an enzyme in the liver that makes the bad cholesterol. We learned, we could block it with drugs, most of us now know, called statins. And really, we learned that we could prevent, slow down, greatly reduce the number of strokes and heart attacks people have and sometimes even reverse it. And this was a, this was really the first time in history, we were able to do this and this was about two decades ago, only two decades ago, we really started to understand how to do this. What does this mean in the oncology world? That's amazing. Um You know, I think oncology though is another space in which we're seeing some of the most important applications of personalized medicine. Uh We're taking detailed information on what a tumors molecular markers are. And we're combining that with knowledge of the medications that work that work best for an individual patient based on their pharmacogenomic profile. So we're moving from an era in which randomized controlled trials would tell us what's best for an average patient to an era in which we can tailor individual treatments to the patient in front of us with fewer side effects and greater efficacy and all that's happening today. But there's more, there's always more well span has some critical partnerships that are allowing us to go even further into our future. Through our collaboration with Johns Hopkins, we're connected with cutting edge research such as cancer vaccines that are developed using a patient's own tumor cells. Through our partnership with Helix, we've offered all of our patients in South Central Pennsylvania sequencing of their entire genome, which allows them to learn about things like Lynch syndrome, hereditary breast and ovarian cancers and other critical uh medical conditions that can uh impact both the patient and their families. And it's really allowing us to move away from an era in which we simply offer preventative medicine and towards an area where we can practice predictive medicine and is awesome. Like it's actually truly amazing. but I will admit even I, so this sounds a little bit like pie in the sky kind of stuff. So let's give a shot. Let's tell our friends and colleagues here at the leadership forum, what this really means. Now, what you're doing, what are you doing now in oncology and your service line right now compared to like how are we treating people different than we did, let's say a generation ago. Great question, but it's actually not how we're treating patients differently than we did a generation ago. It's treating patients how we're treating patients differently than we did five years ago or 10 years ago. So precision medicine is part of just a whole, a whole ecosystem of how well span is continuing to make care, more effective, safer and easier to access with greater value. So let's take the example of a breast cancer patient. Um First, she may have access mammography at one of our mobile units that Kim Brister showed us earlier. Uh Secondly, the pathway we've created in our, in our Comprehensive Breast program, uh may have allowed that patient to go from a suspicious finding to a diagnostic biopsy in a single day, which as you can imagine, not only gets her to definitive care more quickly but also tremendously cuts down on the anxiety associated with having to wait. Uh And now the precision part, let's say her first treatment was an operation. Well, that excise tumor is going to be sent for the molecular profiling that I've talked about a couple of times. And that's gonna tell us whether the patient is eligible, for example, for treatment with the P I three KSE inhibitor or a checkpoint inhibitor. And that's all based on the tumor's molecular fingerprint or let's say she's eligible for an estrogen receptor modulator like tamoxifen. Well, some patients do not metabolize that drug normally, which may make it ineffective and or more likely to cause side effects. So, genomic testing through our gene health project will allow the patient's oncologist to know in the office at the point of care whether the patient has that kind of mutation, one that's gonna make the drug ineffective or likely to cause side effects. And if so to prescribe an alternative, which potentially avoids weeks, months or even years of treatment with a drug that just isn't working. Our partnership with Helix will also allow that patient to know whether she has a mutation for the hereditary BRCA gene. And if so let her know that family member should also be tested and if they too test positive to be plugged into our enhanced screening program in our genetic counselors. So to me, this is kind of the farthest reaching uh application of precision medicine. Uh it's allowing us to have that ripple effect, not only for the patient, we're we're talking to but also for his or her family uh to truly change the way we practice. So that's the first a while, right? Like that's actually unbelievable. That's actually like literally almost unbelievable what you're doing. I would say. Secondly, that's kind of hard to follow like Holly and note to self, I'd like to go first next time because that's, that's really going to be a hard one. I'll give it a try though, you know, I'll give it a try. So what does this mean in a heart and vascular standpoint? There is no doubt that oncology is leading a lot away that we're learning about molecular fingerprints, that we're learning about personalized precision medicine on a genetic level, on a, on a cellular level and heart and vascular. And truthfully every service line, every subspecialty is, is learning a lot from this. In fact, right now, with, with our associates with Helix, we are able right now, right now with our genetic testing to identify people who have AAA strong like predilection, a strong impetus towards having very early, very premature atheros. We call this familial hypercholesterolemia. And the neat thing about that by identifying this genotype. We're finding people right now in their twenties and in their thirties and their family members, uh, we're finding out we're finding them when we know about the risk before their symptoms, before there's even significant disease. Now, why is this a big deal? Because like, five years ago, we were finding them in their forties and fifties with massive heart attacks for five, like five years ago. And before we're finding with massive heart attacks, now we're finding them in their twenties and thirties and their family members before they have them. This is unbelievable, but it really doesn't stop there because we know that most people who come in with heart attacks don't present in their forties and their fifties, they come in their sixties, they come in their seventies and eighties. Why is that? Because most people don't have what we know to be genetics associated acros. At least not yet. We might figure that out with Helix. We might learn the next seventies, but right now they're nongenetic associated factors for AOSS. And so what can we do about that? Well, right now, right now, we can do a, what's called a AC T coronary angiogram. We can do a four DC T, we can do that in all of our regions west, central East. Soon to be north, we can do a Coronary CT A four DC T scan where we can find and identify early early, early disease before there are symptoms before there's plaque before there's heart, before there's significant plaque before there's heart attacks. In fact, this is an example of one right here. This isn't just an example that we didn't pull this off the internet. This is actually a Wells Span patient. This is a Wells Span employee. This is a Wells Span employee who at the time was like 4849. He was an interventional cardiologist and he was thinking about being a CMO of the Hard Master service line. Yeah. Watch what I'm doing here. You want to talk about personalized medicine? That's me. So, and think about this before we had this, we actually had to do an invasive. I'm an interventional cardiologist. We had to do an invasive procedure to definitively know if acros was there or not. We had to go in and put a, not a big deal, but go in and take pictures to tell you you were free of disease or with disease. And now we can diagnose it with submillimeter accuracy, we can diagnose it. And so if you look at this example here, what do we see? Well, I'll tell you it's kind of subtle but right there, right from the proximal and mid led, there's about a 30% 20 to 20 30% plaque in the led and it's subtle. And don't you want to find it subtle? Yes, I didn't want to find it at all. I didn't want to find it at all. That's a little bit of a bummer. But at the same time I found it asymptomatic completely before there was a real problem completely before there was disease. And I found it, unlike my uncles who we found it with massive heart attacks in their fifties. Unlike my granddad, we found it at a heart attack in his sixties, we found it when it was silent. By the way, this, the order that the movies love to tell you is the widow maker. I'd like that not to be the case, but it doesn't stop there, it doesn't stop there. We've gotten more savvy. We've learned a lot like oncology has learned about how to target stuff. We've gone beyond just statins. We actually now have monoclonal antibodies, specific targets to go to your LDL respess, targeted to your LDL receptors to pull them out. Now for the first time we can drive, I'm on one. It's called Eucom PCSK nine inhibitors. We can actually drive cholesterol levels down low enough that we don't believe atherosclerosis can exist. I want you to think about that a minute. We're sitting here on the precipice of possibly the number one killer in America being eradicated in like a decade. We've got work to do. But the reality is like this is where we are right now. And so, so if you want to talk about, about precision medicine, if you want to talk about this is where we are, this is where we are right now. This is where right now um in, in our treatment of these things. And so I will tell you that we really are at the forefront of precision medicine and in the forefront of this revolution that we're about to do. And I can speak for both of us when I can say that we are really proud to be able to say that we are not only leaders compared to our peer institutions, we are leaders of large, amongst large academic institutions right now. Yeah, this is uh it's truly an exciting time to be taking care of patients and we're having impact in ways that was just an unimaginable 10 or 15 years ago. Uh This is not science fiction, this is happening and this is happening now and this is happening now. Well spent. Thank you stuff, man.
