ACG MAGAZINE | Vol. 2, No. 1 | Spring 2018

Page 1

ACG MAGAZINE Spring 2018

MEMBERS. MEDICINE. MEANING.

Resolved to

BEAT

COLON

CANCER


ACG MOBILE: ACCESS KEY RESOURCES

at the point of care

STAY ON-THE-GO with ACG’S MOBILE APP An exclusive ACG Member benefit that provides access to valuable resources for your practice and your patients, from your mobile device. ACG Guidelines GI Anatomical Diagrams IBD Vaccination Guide

Medical Calculators powered by MDCalc and more

DOWNLOAD THE ACG MOBILE APP Download the app via Google Play or Apple App Store.


SPRING 2018 // VOLUME 2, NUMBER 1

FEATURED CONTENTS COVER STORY

RESOLVED TO BEAT COLON CANCER

Lawrence Meadows' cancer journey and his efforts to raise CRC awareness with his brother Craig Melvin, of NBC and MSNBC. PAGE 22

FROM PERSON TO PATIENT

Dr. Dennis Laffer on being diagnosed with Stage IV CRC at age 53. PAGE 20

HOW'D YOU DO THAT?

Q&As with SCOPY Award winners Dr. Darrell Gray and Matthew Paul Mewhorter.

Left to right: Ryan Melvin, Lawrence Melvin, Betty Jo Melvin, Craig Melvin, Lindsay Czarniak, Lawrence Meadows. Photo courtesy of Craig Melvin.

PAGE 31

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Attend an upcoming

2018 ACG POSTGRADUATE COURSE 2018 ACG/FGS Annual Spring Symposium Hyatt Regency Coconut Point Resort & Spa | Bonita Springs, FL March 16–18, 2018

2018 IBD School and ACG Eastern Regional Postgraduate Course Seaport Hotel | Boston, MA April 13–15, 2018

2018 Hepatology School and ACG Midwest Regional Postgraduate Course Sheraton Indianapolis City Centre Hotel | Indianapolis, IN August 24–26, 2018

2018 IBD School and ACG/VGS/ODSGNA Regional Postgraduate Course Williamsburg Lodge | Williamsburg, VA September 7–9, 2018

ACG 2018 Annual Meeting and Postgraduate Course Pennsylvania Convention Center | Philadelphia, PA October 5–10, 2018 • • • • •

Practice Management: October 5 GI Pharmacology: October 5 Pathology and Imaging: October 5 ACG’s Postgraduate Course: October 6–7 ACG’s Annual Meeting: October 8–10

FOR MORE INFO, VISIT: GI.ORG/ACG-COURSE-CALENDAR


SPRING 2018 // VOLUME 2, NUMBER 1

CONTENTS

“I can't pastor people, encouraging them and sharing with them to be able to lean and depend upon their faith in God, and then I'm a reed shaken in the wind when I have some issue come my way”­ —Lawrence R. Meadows, “RESOLVED to Beat Colon Cancer,” PG 22

6 // MESSAGE FROM THE PRESIDENT

20 LESSONS LEARNED Dr. Dennis Laffer reflects on his patient experience when he was diagnosed with Stage IV colon cancer at age 53.

39 // EDUCATION

Dr. Irving Pike on the diversity of contributions to this ACG MAGAZINE special issue on colorectal cancer.

7 // NOVEL & NOTEWORTHY

22 // COVER STORY

45 // INSIDE THE JOURNALS

CRC awareness initiatives, professional achievements, and an ode to holiday screening.

13 // PUBLIC POLICY Recognizing 20 years of the Medicare colorectal cancer preventive screening benefit.

17 // GETTING IT RIGHT 17 BUILDING SUCCESS Dr. Louis Wilson and attorney Gary Herschman offer strategic options for independent GI practices to consider.

RESOLVED TO BEAT COLON CANCER The cancer journey of Lawrence Meadows, who shares his approach to battling colon cancer and efforts to raise awareness with his brother Craig Melvin, of NBC and MSNBC.

31 // ACG PERSPECTIVES 31 HOW'D YOU DO THAT? SCOPY Award winners Dr. Darrell Gray and Matthew Paul Mewhorter discuss their CRC awareness efforts in separate Q&As. 37 CRC SCREENING IN NATIVE AMERICANS Dr. Ramon Generoso on CRC disparities and cultural barriers to screening for Native Americans.

EDGAR ACHKAR VISITING PROFESSORS Taking ACG's commitment to GI training on the road.

46 AJG Five rules of thumb for when to stop surveillance colonoscopy in older adults. 47 CTG Increased frequency of KRAS mutations in African Americans, a striking dysbiosis in IBD. 48 ACGCRJ Treatment of Cannabinoid Hyperemesis Syndrome with topical capsaicin.

50 // REACHING THE CECUM A LOOK BACK: LAXATIVE MINERAL WATER The evolution of mineral water, from a mere appreciation for it during the Roman Empire to its commercial production and sale today.

Cover photo, left to right: Lawson Meadows, Angela Meadows, Lawrence Meadows, Addie Meadows. Cover photo courtesy of Lawrence Meadows. Photo top, left to right, Angela Meadows, Lawrence Meadows, Dr. Scott Kopetz. Photo courtesy of The University of Texas MD Anderson Cancer Center.

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ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG

Executive Director Bradley C. Stillman, JD

youtube.com/ACGastroenterology

Editor in Chief; Vice President, Communications Anne-Louise B. Oliphant Managing Editor; Senior Writer Brian C. Davis Copy Editors; Staff Writers Jenny Dunnington, Sarah Richman, Lindsey Topp

facebook.com/AmCollegeGastro

twitter.com/amcollegegastro

instagram.com/amcollegegastro

bit.ly/ACG-Linked-In

Art Director Emily Garel Graphic Designer Antonella Iseas

BOARD OF TRUSTEES President: Irving M. Pike, MD, FACG President-Elect: Sunanda V. Kane, MD, MSPH, FACG Vice President: Mark B. Pochapin, MD, FACG Secretary: Samir A. Shah, MD, FACG Treasurer: David A. Greenwald, MD, FACG Immediate Past President: Carol A. Burke, MD, FACG

CONTACT IDEAS & FEEDBACK We'd love to hear from you. Send us your ideas, stories and comments.

ACGMag@gi.org

CONTACT ACG American College of Gastroenterology 6400 Goldsboro Rd., Suite 200 Bethesda, MD 20817 (301) 263-9000 | gi.org

Past President: Kenneth R. DeVault, MD, FACG Director, ACG Institute: Nicholas J. Shaheen, MD, MPH, FACG Co-Editors, The American Journal of Gastroenterology: Brian E. Lacy, MD, PhD, FACG

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

Brennan M. R. Spiegel, MD, MSHS, FACG Chair, Board of Governors: Costas H. Kefalas, MD, MMM, FACG Vice Chair, Board of Governors: Douglas G. Adler, MD, FACG Trustee for Administrative Affairs: Delbert L. Chumley, MD, FACG

TRUSTEES William D. Chey, MD, FACG Immanuel K. H. Ho, MD, FACG Caroll D. Koscheski, MD, FACG Paul Y. Kwo, MD, FACG Jonathan A. Leighton, MD, FACG Amy S. Oxentenko, MD, FACG Daniel J. Pambianco, MD, FACG David T. Rubin, MD, FACG John R. Saltzman, MD, FACG

4 | GI.ORG/ACGMAGAZINE

American College of Gastroenterology is an international organization with more than 14,000 physician members representing some 85 countries. The College's vision is to be the pre-eminent professional organization that champions the evolving needs of clinicians in the delivery of high-quality, evidence-based and compassionate health care to gastroenterology patients. The mission of the College is to advance world-class care for patients with gastrointestinal disorders through excellence, innovation and advocacy in the areas of scientific investigation, education, prevention and treatment.


CONTRIBUTING WRITERS

Ramon S. Generoso, MD Dr. Generoso, of Kalispell Gastroenterology in Kalispell, MT, is a member of the ACG Minority Affairs and Cultural Diversity Committee.

Gary W. Herschman, JD Mr. Herschman is a health care attorney and member of the national law firm Epstein, Becker & Green, PC in Newark, NJ and New York, NY. He advises medical groups across the country on strategic transactions with hospitals, private equity companies, national health care companies, and mega-groups.

Robert E. Kravetz, MD, MACG Dr. Kravetz is passionate about the history of medicine and the history of the College. He is Past Chair, ACG Archives Committee, and was instrumental in the publication of the ACG 75th Anniversary history in 2007. Read about ACG’s History: gi.org/about-acg/#Anniversary

Dennis R. Laffer, MD, FACG Dr. Laffer earned his medical degree at the University of Michigan School of Medicine. He served an internship in General Surgery and a residency in Internal Medicine at William Beaumont Hospital in Royal Oak, MI, and completed a Fellowship in Gastroenterology at the Cleveland Clinic Foundation. He began practicing in Tampa Bay, FL in 1982.

Louis J. Wilson, MD, FACG Dr. Wilson is a gastroenterologist and the managing partner of Wichita Falls Gastroenterology Associates, a seven-physician single-specialty group. He is the current Chair of the ACG Practice Management Committee and a frequent author and speaker for ACG on practice management.

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MESSAGE FROM THE PRESIDEN

COLORECTAL CANCER SPECIAL ISSUE: THE INTERSECTION OF CLINICAL EXCELLENCE AND PUBLIC AWARENESS The rich perspectives featured inside this special issue of ACG MAGAZINE dedicated to colorectal cancer bring to life ACG’s longstanding commitment to action at the intersection of clinical excellence and public awareness. The College is dedicated to advancing CRC screening in terms of technical performance, policy challenges and patient and public education. As you read about the scientific findings, community education, legislative advocacy and clinical expertise of ACG members—and the powerful stories of survivors who share so generously about their experiences—I hope you will be both inspired and motivated. Although this issue revolves around the common theme of CRC, what strikes me is the diversity of contributions and experiences.

COURAGEOUS CRC SURVIVORS WITH LESSONS TO SHARE

The College is indebted to siblings Lawrence Meadows and Craig Melvin (of NBC News and MSNBC), who opened up in interviews with ACG MAGAZINE about Mr. Meadows’ ongoing battle against Stage IV CRC (pg. 22). We deeply appreciate their time, their willingness to tell this important story, and especially the photos of their beautiful family. I am grateful to Dr. Dennis R. Laffer, who approached me last fall because he wanted to share a reflection of his experience as a gastroenterologist diagnosed with Stage IV CRC in 2004, at age 53. He shares his experience with great humility and candor (pg. 20). Original artwork by Matthew Paul Mewhorter, a talented illustrator and Stage II CRC survivor, graces the pages of ACG MAGAZINE. Mr. Mewhorter won the 2017 “SCOPY Inspiration and Impact Award” for chronicling his CRC journey in a cartoon entitled, “Cancer Owl” (pg. 34).

“I hope that

in this special issue of ACG MAGAZINE you will find ideas that INSPIRE your work today, IGNITE your dedication to preventing CRC in the future, and SUPPORT you as you care for patients every day.” 

Research published in Clinical and Translational Gastroenterology offers new understanding of genetic mutations that may explain higher mortality from certain CRCs among African Americans (pg. 47). A video of Dr. Mark B. Pochapin’s 2017 Emily Couric Memorial Lecture, “Colon Cancer: Polyps, Prevention and Progress,” provides an outstanding overview on the state of the science for CRC prevention and can be accessed via ACG’s Education Universe (pg. 8). The ACG special lecture named for Emily Couric honors her role as a state senator who was instrumental to Virginia becoming the first state in the United States to enact a law requiring insurance companies to cover colonoscopy as a screening modality. For practical tips and insights on community engagement and outreach to promote CRC screening among underserved patients, we invited another SCOPY winner, Dr. Darrell M. Gray from The Ohio State University Wexner Medical Center, to answer the question: “How’d You Do That?” His revealing and useful answers will inspire you (pg. 31).

THE MEDICARE CRC SCREENING BENEFIT AT 20 Thanks to the vision of the ACG Archives Committee, historic photos from the College’s collection provide a glimpse of some of the ACG leaders and Members of Congress whose efforts laid the groundwork for the law covering CRC preventive screening in Medicare that was implemented on January 1, 1998 (pg. 13). The 20th anniversary of the Medicare CRC screening benefit is an opportunity to remember ACG’s concerted effort in the early 1990s to educate lawmakers about the importance of preventive screening for Medicare patients and the role of colonoscopy. Many ACG physician leaders visited Washington, DC to speak with legislators, but special recognition goes to Past Presidents Dr. Lawrence J. Brandt, Dr. William D. Carey, Dr. Sarkis J. Chobanian, Dr. Seymour Katz, Dr. Joel E. Richter and Dr. Marvin M. Schuster for their leadership. As we consider the challenges currently facing medicine, there is much to learn from their example of persistence and principled dedication to the best interests of patients. The Archives Committee plans an historical display about this chapter in ACG’s history next fall, when we gather in Philadelphia for the 2018 Annual Scientific Meeting. While there is much to learn reflecting on ACG’s past, I hope that in this special issue of ACG MAGAZINE you will find ideas that inspire your work today, ignite your dedication to preventing CRC in the future, and support you as you care for patients every day.

INSIGHTS AND ADVANCES IN THE CRC FIGHT

While the College has guideline recommendations on CRC screening and surveillance, not as much guidance exists on when to stop screening in elderly patients. The Editors of the AJG Red Section invited guidance from Dr. Jennifer Maratt and colleagues (pg. 46).

6 | GI.ORG/ACGMAGAZINE

Irving M. Pike, MD, FACG


N wotoerthy ACG MAGAZINE is a forum for College news—a place to showcase the interests and accomplishments of ACG members, as well as notable GI news and innovation. In this special issue, we highlight colorectal cancer awareness, members receiving accolades within their communities and from the GI community, new video on the state of colon cancer prevention and treatment, and an ode to screening during the holidays. Email your news and any ideas for future issues of ACG MAGAZINE to ACGMag@gi.org

Novel & Noteworthy | 7


N&N [AWARDEES] [SPECIAL LECTURER]

POLYPS, PREVENTION AND PROGRESS

Mark B. Pochapin, MD, FACG, ACG Vice President, was the invited speaker for the College’s 2017 Emily Couric Memorial Lecture. Dr. Pochapin’s insightful talk, “Colon Cancer: Polyps, Prevention & Progress,” shed light on the state of the science for colorectal cancer screening while weaving in his perspective on key milestones in the national effort to increase CRC screening rates in the United States. This distinguished annual lecture at the ACG Annual Scientific Meeting honors the late Virginia State Senator Emily Couric and was endowed by the Virginia Gastroenterological Society and the Old Dominion Society for GI Nurses and Associates.

RITU WALIA, MD, MBBS The South Asian Pediatric Gastroenterologists presented Dr. Ritu Walia with its “Founder Award” in late 2017. The award is “in appreciation of her unwavering commitment, passion and contributions” to the founding of the organization. In October 2014, Walia founded the organization, which is a special interest group helping promote public education and serving the minority community. Walia currently works for the Navicent Health Department of Pediatrics in Macon, GA.

Listen to Pochapin’s Lecture: bit.ly/PochapinLecture17

LEARN MORE Organization information:  bit.ly/SA-Peds-GIs  bit.ly/FB-SA-Peds-GI

[ACCOLADES]

NICHOLAS J. TALLEY, MD, MBBS, PhD, MMEDSci, FACG

Virginia State Senator Emily Couric received the College’s Distinguished Service Award in 2001, the year of her death from pancreas cancer.

Professor Nicholas Talley earned the distinction of Australia’s top researcher, according to Google Scholar. According to the Newcastle Herald, Google Scholar determines the rankings based on researchers’ “productivity and citation impact on the web giant's academic collection of scholarly literature.” The list consists of 1,000 scientists from Australia. Talley is Pro Vice-Chancellor of Global Research at the University of Newcastle. READ MORE The distinction in the Newcastle Herald: bit.ly/Talley-Tops-List

8 | GI.ORG/ACGMAGAZINE

[AWARDEES]

MARCH E. SEABROOK, MD, FACG Columbia Metropolitan magazine recognized Dr. Seabrook as one of four honorees in the “The 2017 Best of Philanthropy Awards,” given to Columbia, SC residents who are “making their mark” in philanthropy.

Seabrook and his practice, Consultants in Gastroenterology, are credited for initiating and shepherding a program that provides no-cost screening colonoscopies for the uninsured and underinsured. The program, created roughly 15 years ago under the name Friday At Noon or Nine (FANNi), is now part of the South Carolina Colon Cancer Prevention Network, under the purview of the University of South Carolina Center for Colon Cancer Research (CCCR). Since its inception, more than 1,500 people have been screened with colonoscopy; Seabrook’s

practice has performed 350+ of these colonoscopies. Nearly one half of South Carolina’s 160 gastroenterologists participate in the program. “When you find pathology and pre-cancerous polyps in someone who has been screened, it’s so gratifying to know that they have just prevented themselves from getting this disease,” Seabrook told the magazine. Read more about Seabrook’s efforts in Columbia Metropolitan magazine: bit.ly/Seabrook-17


[MILESTONES]

SAMIR A. SHAH, MD, FACG, ACG SECRETARY The February 2018 issue of the Rhode Island Medical Journal features a Letter to the Editor titled “Importance of screening for prevention, early detection of colorectal cancer,” written by Dr. Shah, of the Alpert Medical School of Brown University, The Miriam Hospital, and Gastroenterology Associates, Inc. The letter highlights efforts by the Rhode Island Colorectal Cancer Advisory Committee to address the disparity in the state-level colorectal cancer screening rate—nearly 75%— versus the rate for the state’s eight Federally Qualified Health Centers—44.7%—which serve an ethnically diverse population. The Committee is establishing a program mirroring the Screening Colonoscopies for Underserved Populations program created in 2009 by Joseph D. DiMase, MD, FACG, which offered hundreds of screening colonoscopies to uninsured and underinsured Rhode Islanders. Shah and his co-authors call on providers, health systems, insurers, elected officials, employers and RI citizens to join this new effort. They write:

“As Rhode Islanders, we already have the tools at our disposal to overcome colon cancer,” READ MORE Shah's Letter to the Editor and accompanying fact sheet: bit.ly/RI-Med-Shah Full issue of the Journal: bit.ly/RI-Med

[AWARENESS]

HOLIDAY SCREENING

This Christmas tree is dressed in blue, ready to fight colorectal cancer. Photo courtesy of Bruce R. Cameron, MD, FACG.

ACG PARTNERS WITH AMERICAN COLLEGE OF PHYSICIANS IN OKLAHOMA Colorectal Cancer Screening Message to ACG and ACP Members Thanks to the leadership and vision of ACG Governor for Oklahoma Tauseef Ali, MD, FACG, the College and the ACP Chapter in Oklahoma collaborated to bring attention to the public health challenges of colorectal cancer. In a letter to all ACG and ACP members in the state, Dr. Ali and Dr. Michael S. Bronze, Governor of the ACP Oklahoma Chapter, joined forces to let their colleagues know:

“The situation in Oklahoma is serious. Our state has one of the lowest rates of colorectal cancer screening in the United States—ranking among the bottom 13 states. According to the CDC, approximately 58 percent of Oklahomans received colorectal cancer screening in 2013, and the number increased to barely 59 percent by 2016.” The letter offered ACG educational resources and key messages for physicians to use in conversations about screening with their patients. Tauseef Ali, MD, FACG, ACG Governor for Oklahoma (left) and Michael S. Bronze, MD, MACP, FIDSA, ACP Governor for Oklahoma.

Novel & Noteworthy | 9


ACG CALENDA

MARCH

16–18

ACG/FGS ANNUAL SPRING SYMPOSIUM  Bonita Springs, FL Topics covered will include colon cancer screening, therapeutic endoscopy, esophageal conditions, functional and GI motility, hepatology, and IBD.

26

ACG 2018

Register: meetings.gi.org

Call for Abstracts APRIL

APRIL

MARCH

13

14–15

IBD SCHOOL AT EASTERN REGIONAL

EASTERN REGIONAL POSTGRADUATE COURSE

 Boston, MA

 Boston, MA

More info: gi.org/regional-meetings

More info: gi.org/regional-meetings

MAY 31

Scopy Award

SUBMISSION DEADLINE More info: gi.org/SCOPY

Submit your abstract: conferenceabstracts.com/acg2018.html

MARCH 31 MIPS DEADLINE LAST DAY to submit CY 2017 data

AUGUST

24

HEPATOLOGY SCHOOL AT MIDWEST REGIONAL

 Indianapolis, IN More info: gi.org/regional-meetings

SEPTEMBER

7–9

AC G 2O18 O CTO B E R 5 – 1 O, 2 O 1 8 The Premier GI Clinical Meeting & Postgraduate Course

IBD SCHOOL AND ACG/VGS/ODSGNA REGIONAL POSTGRADUATE COURSE  Williamsburg, VA More info: gi.org/regional-meetings

ACG 2018

ANNUAL SCIENTIFIC MEETING & POSTGRADUATE COURSE Pennsylvania Convention Center Philadelphia, PA

acgmeetings.gi.org

AUGUST

25–26 ACG MIDWEST REGIONAL POSTGRADUATE COURSE

 Indianapolis, IN More info: gi.org/regional-meetings

DECEMBER 2018 HEPATOLOGY SCHOOL AND SOUTHERN REGIONAL POSTGRADUATE COURSE

 Location TBD

10 | GI.ORG/ACGMAGAZINE


IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution. INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECGs should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy. STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2017 Braintree Laboratories, Inc.

HH13276B-U

May 2017


1 MOST PRESCRIBED,

#

BRANDED BOWEL PREP KIT1

A CLEAN SWEEP

EFFECTIVE RESULTS IN ALL COLON SEGMENTS2

· SUPREP® Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 · >90% of patients had no residual stool in all colon segments2* †

These cleansing results for the cecum included 91% of patients2*

SUPREP Bowel Prep Kit also achieved ≥64% no residual fluid in 4 out of 5 colon segments (ascending, transverse, descending, and sigmoid/rectum)2* †

Aligned with Gastrointestinal Quality Improvement Consortium (GIQuIC) performance target of ≥85% quality cleansing for outpatient colonoscopies.4

*This clinical trial was not included in the product labeling. †Based on investigator grading. References: 1. IMS Health, NPA Weekly, May 2017. 2. Rex DK, DiPalma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc. 2010;72(2):328-336. 3. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2012. 4. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2017 Braintree Laboratories, Inc.

HH13276B-U

May 2017


PUBLIC

POLICY

MILESTONES

Medicare’s Colorectal Cancer

PREVENTION Benefit Marks 20 YEARS ENACTED INTO LAW ON AUGUST 5, 1997, the Medicare colorectal cancer (CRC) preventive screening benefit is now celebrating its 20th anniversary. The law went into effect on January 1, 1998.

The ACG Archives Committee, under the leadership of Stephen W. Landreneau, MD, FACG, wanted to share a glimpse of College history through photos documenting the legislative fight for CRC preventive screening for Medicare beneficiaries. This look back captures some of the many ACG physician leaders and congressional champions whose work on Capitol Hill helped create momentum for change. 

ACG President Dr. William D. Carey (center) set the stage for later legislative efforts to advance CRC screening in testimony on October 26, 1993 before the House Ways and Means Committee on behalf of the Gastroenterology Leadership Council, comprised of AASLD, ACG, AGA and ASGE.

Setting the Stage

Public Policy | 13


PUBLIC POLICY: MILESTONES

A strong champion for CRC screening, Dr. Seymour Katz was ACG President from 1995 to 1996. During his term, Dr. Katz helped the College skillfully navigate contentious issues on the Hill. His guiding principle was always to put the best interests of patients first when dealing with the “sausage making” that goes into passing legislation in the U.S. Congress.

A CHAMPION in the HOUSE A meeting in 1993 with U.S. Rep. Ben Cardin (D-MD) (center). Congressman Cardin has a deep appreciation for CRC screening because of family members. ACG Executive Director Tom Fise (left), ACG lobbyist Thomas Scully, Esq., and Dr. Marvin M. Schuster (right) were part of this meeting, at which Mr. Cardin pledged to help.

1993

1995

Putting

PATIENTS FIRST 1995-1996

JANUARY 1997

WAYS & MEANS

An Influential

REPUBLICAN SURGEON in the SENATE L to R, U.S. Sen. Bill Frist (R-TN), ACG Executive Director Tom Fise, Dr. Seymour Katz, and Dr. Joel E. Richter at the ACG Annual Scientific Meeting in 1995. Sen. Frist is a surgeon who in 1995 co-sponsored S. 1178, the Cancer Screening and Prevention Act, which was the Senate companion to Rep. Cardin’s proposed bill in the 104th Congress, H.R. 922, to amend the Social Security Act to provide coverage of CRC screening.

14 | GI.ORG/ACGMAGAZINE

U.S. Rep. Bill Thomas (R-CA) chaired the powerful Ways and Means Committee in January 1997, when President Bill Clinton was inaugurated to begin his second term as President, with the GOP in control of both Houses of the new Congress. Mr. Thomas supported Rep. Cardin in introducing a bill to expand preventive services in Medicare, including CRC screening, mammography and prostate cancer screening.


A LEGISLATIVE

Vehicle

In the first days of the 105th Congress in 1997, Rep. Cardin introduced H.R. 15, a bipartisan bill providing a preventive benefits package for Medicare beneficiaries including CRC screening. The provisions of H.R. 15 were the basis for language ultimately enacted into law as part of the Balance Budget Act of 1997.

JANUARY 1997

ACG President Dr. Marvin M. Schuster (center) in March 1997 testifying before the House Ways and Means Committee. Dr. Schuster practiced at Johns Hopkins Bayview Medical Center in Baltimore. His personal and professional connections to Rep. Cardin from Baltimore, who served on the Ways and Means Committee, gave ACG an opportunity to have a voice on the Hill to champion important screening benefits for Medicare patients.

1997

A VOICE on the HILL

MARCH 1997

PERSONAL RECOLLECTIONS:

ACG and the FIGHT for Medicare CRC SCREENING Senate

SUPPORTER

U.S. Sen Edward Kennedy (D-MA) was a champion of CRC screening who, in his role as Chair of the Senate Committee on Health, Education, Labor and Pensions, endorsed provisions relating to a Medicare preventive CRC screening as part of the Balanced Budget Act of 1997.

Sharing their memories of the legislative fight for Medicare’s colorectal cancer screening benefit, ACG’s former Executive Director Thomas Fise and three of the College’s Past Presidents, Dr. Edgar Achkar, Dr. Luis Balart and Dr. Seymour Katz, bring their unique perspectives to a chapter in ACG’s history. Read their account: bit.ly/Med-CRC-Screen-20th

Public Policy | 15


Accessible. Relevant. Practical.

The information you need to improve your practice. The ACG Practice Management Committee’s mission is to equip College members with accessible tools to overcome management challenges, improve operations, enhance productivity, and support physician leadership in their private and physician-led clinical practices. Learn from practicing colleagues through monthly articles on topics important to you. Articles include a topic overview, suggestions, examples, and a list of resources or references.

Toolbox topics will include

• Alternative Payment Models (APMs)

• Patient Satisfaction Surveys & Engagement

• Merit-Based Incentive Program Systems (MIPS)

• Reviewing & Updating Informed Consent

• Medicare Compliance & Preparation for RAC Audits

• Developing an Infection Control Plan

• Reviewing & Maximizing Revenue Cycle Efforts

• Professional Society Opportunities & Involvement

• Reviewing & Negotiating Insurance Contracts

• Quality Improvement Projects in Your Practice

"Pressures are high as gastroenterologists make important management decisions that profoundly affect their business future, their private lives, and their ability to provide care to patients." —Louis J. Wilson, MD, FACG

Start Building Success Today. GI.ORG/TOOLBOX


it Right GETTING

GETTING

IT

Considering BUILDING SUCCESS

STRATEGIC OPTIONS

THE BIG PICTURE FOR YOUR INDEPENDENT GASTROENTEROLOGY PRACTICE

Louis J. Wilson, MD, FACG, Wichita Falls, TX

Gary W. Herschman, JD, Epstein, Becker & Green, PC, Newark, NJ and New York, NY

BUSINESS PRESSURES ARE HIGH FOR MANY IN THE INDEPENDENT PRIVATE PRACTICE OF GASTROENTEROLOGY. Major trends affecting gastroenterology groups include increased

consolidation, alternative payment systems focusing on value rather than fee-for-service, risk-sharing contracts that increase the need for care coordination across specialties, and population health management. The independent practice of medicine and physician leadership in health care are under severe pressure. Many groups are partnering with hospitals and integrated health care systems, joining other groups to form larger partnerships, and even selling controlling interest to private equity (PE) platform companies or public health care companies. While your group currently may be financially successful and remaining independent may be your best strategy, it may be beneficial for your group to actively consider other strategic options that may be available before making conclusions on the best course for future success. 

Getting it Right | 17


GETTING IT RIGHT: BUILDING SUCCESS

S

trategic planning involves an assessment of your current market environment and challenges, prioritizing the organization’s needs and goals, and then evaluating available options. Not surprisingly, there are a great many variables to consider. These include market challenges such as competition and changes in referral networks, management problems like staffing or revenue cycle performance, and partnership problems such as recruiting or senior member retirements. Capital investment may be needed for the addition of ancillary service centers or facility construction. Lifestyle choices are also always an important consideration. Remaining fully independent remains an excellent option in many markets, and there is not one “ideal” business structure for every market. However, it is becoming increasingly necessary for medical professionals to thoroughly meet the needs of their given patient population. Gaps in service will usually invite competition and create uncertainty for the future. Even if your analysis results in changing nothing about the current structure of your practice, failing to evaluate your current business strategy and to consider strategic options could be a costly mistake. Timing may be crucial in making these decisions, as changes in the competitive marketplace continue at a fast pace, and certain current options may not be available on the same terms in the future. Many thought leaders in practice management believe that maintaining physician leadership and independence remains an important goal for the future of gastroenterology. Some strategic options discussed in this article involve large, well-capitalized organizations that are currently investing substantial capital to strategically position themselves and their partners to be profitable as the industry undergoes transformation. Gastroenterologists should consider these options carefully and with experienced legal counsel and financial advisers.

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The following are

FOUR STRATEGIC OPTIONS for gastroenterology groups to consider:

JOINING, OR BEING ACQUIRED BY, A HOSPITAL OR HOSPITAL-AFFILIATED MEDICAL GROUP Hospital employment has attracted many physicians in recent years. These agreements often begin with lucrative initial salary guarantees but generally do not result in any ownership equity. Although there may be some comfort in becoming part of and being managed by a large health care organization, some complaints of groups that have pursued this option include: (a) some hospitals are not good at managing physician practices; (b) hospitals generally do not pay a lot to acquire medical groups due to regulatory limitations; and (c) physician leadership in these systems is usually very limited. Hospital employment agreements usually include restrictive covenants that will restrict your mobility if the arrangement ends for various reasons.

JOINING, OR BEING ACQUIRED BY, A MEGA-PHYSICIAN GROUP (MULTI-DISCIPLINARY OR SINGLE-SPECIALTY) Very large gastroenterology groups that include dozens or even hundreds of members have been forming in many areas. These groups allow for expert management, increased leverage in contracting, and investment in professional information systems management. Single-specialty groups have tended to meet the specific needs and opportunities of gastroenterologists better than multi-specialty groups, but the built-in referral networks and opportunities for risk-sharing contracts i.e., alternative payment models, of a multispecialty group may have an advantage in some markets. Although there may be comfort in becoming part of a well-run "mega-physician group" and being managed by fellow physicians, if you are looking for significant financial "upside" (both short term and long term), this option may not fit your goals. Also, the group’s total size may not be as important as how well it meets the demands of the specific market or service area. Small independent groups may be able to meet the needs of smaller markets.

BEING ACQUIRED BY A PE PLATFORM COMPANY FOCUSED ON GASTROENTEROLOGY AND DIGESTIVE HEALTH This may be a lucrative option to consider if you and your physician owners are looking for both significant short-term and long-term financial upside. The potential benefits or risks of this strategic option include: • All physician owners of the group may reap initial financial benefit in the short term when the transaction is completed. They usually also obtain "roll-over equity" in the PE platform company going forward. The amount of this equity should be negotiated based on the time horizon of the various physicians. • These PE companies usually plan to "exit" or sell the company to a larger national health care company in a three- to seven-year timeframe. This could create some uncertainty for physicians with a long time horizon. When the exit event occurs, the physicians who own roll-over equity stand to reap additional financial profits, sometimes at the same level or above that which they were paid in the initial transaction, when they partnered with the PE company.


• The financial rewards should be lucrative to all owners of the group, both for: (a) founder or more-senior physicians, who might otherwise receive a very minimal buyout of their ownership interest in the practice when they retire; and (b) more-junior and middle-age physicians. Younger members have often used the initial transaction to fund their retirement early. They also will not be burdened with buying out senior physicians, the risks of uncertainty in the health care market, and capital requirements that may be needed to compete effectively in the future. Further, they likely will continue to earn market-based compensation for their ongoing services.

CONCLUSION

• Physicians do not generally need to lose substantial control over their medical practices when entering into a strategic transaction with a PE-backed company. This is because PE companies do not want to take over management of medical groups but, rather, want to invest in groups that already have solid management teams. They want the current management team to remain in place and use the PE partner's capital to expand and improve the practice (e.g., new equipment, new ancillaries, new locations, adding new groups, etc.).

Louis J. Wilson, MD, FACG, is a gastroenterologist and the managing partner of Wichita Falls Gastroenterology Associates, a seven-physician single-specialty group. He is the current Chair of the ACG Practice Management Committee and a frequent author and speaker for ACG on practice management. His group has not pursued any of the strategic options discussed in this article.

It is important that physician groups obtain professional valuation advice before entering these agreements, and should consider competitive bids from multiple companies. Physicians seeking to partner with a PEbacked company may take into consideration a variety of non-monetary factors as well. For more information on how PE investments in gastroenterology groups are structured and valued, as well as related legal issues, a free webinar is available at: bit.ly/PE-PPT-WEB

In summary, gastroenterology group practices should, at a minimum, be exploring potential strategic options for their future success and for the financial well-being of their physician owners. Independent physicians should consider pursuing group structures and strategies that meet as many of their goals and objectives as possible. Several strategies that preserve physician leadership and practice independence remain viable. The best structure will take into consideration your group’s unique set of professional challenges and personal goals.

ABOUT THE AUTHORS

Gary W. Herschman, JD, is a health care attorney and member of the national law firm Epstein, Becker & Green, PC. He advises medical groups across the country on strategic transactions with hospitals, PE companies, national health care companies, and mega-groups.

BEING ACQUIRED BY A NATIONAL HEALTH CARE COMPANY There are numerous national physician services companies that are in the market seeking to partner with and invest in medical groups—some are public companies, some are private, and others are affiliated with large national payers or providers. Transactions usually are not as lucrative as PE investments (but can be), and usually do not involve roll-over equity (although there may be some exceptions to the foregoing). Investments by these national health care companies are usually much more long term focused and strategic, as opposed to investments by PE-backed companies, which invariably will seek a financially lucrative exit in medium-term horizon.

Getting it Right | 19


GETTING IT RIGHT: LESSONS LEARNED

MY METAMORPHOSIS FROM

“PERSON” to “PATIENT” By Dennis R. Laffer, MD, FACG, Tampa, FL

I

Top: Dr. Laffer with his wife and children. Right: Dr. Laffer. Photos courtesy of Dr. Laffer.

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t all began with a persistent cough from an upper respiratory infection. After this went on for several weeks, my wife suggested that I see a physician. I hate going to doctors. At the time, I had been a a solo GI practitioner for approximately 20 years, so I paid a visit to an internist on my floor. I simply wanted him to listen to my lungs for any sign of pneumonia. The chest was clear, but a complete blood count demonstrated a microcytic anemia; a subsequent ferritin was 23 ng. My medical history was unremarkable with the exception of well-controlled irritable bowel syndrome. There were not any alarm symptoms. A Hemoccult was negative. The clinician region of my brain concluded that I had colon cancer. I was 53 years old, a husband, father of 15- and 13-year-old daughters, and a physician. The clinical plan was obvious: colonoscopy followed by surgery. Now I was faced with a major dilemma: did I tell my spouse of 18 years that I knew I had a malignancy? I decided to wait until the completion of the endoscopy, so en route to the hospital I simply said I hoped that they would not find anything that required surgery. After all my years as a physician, this was my first real experience on the other side of the proverbial bed. My transition from individual to patient to object began slowly but quickly accelerated as my individuality was lost in the progression of paperwork, finger printing, photograph, and name band with date of birth, allergies, and medical record number. The colonoscopy demonstrated nine tubular and tubulovillous adenomas of varying sizes distributed along the length of the colon. However, a two-cm, moderately differentiated adenocarcinoma was also detected. When the effect of the sedation resolved, I was informed of the findings but was not surprised or overly alarmed. I anticipated imaging followed by laparoscopic surgery and a six-week recovery time. However, a preoperative CT scan, confirmed by a PET exam, demonstrated a fourcm left hepatic lobe metastasis. Stage IV disease—not an uplifting finding. At this point, the game changed dramatically. I realized that the situation had become more serious and complicated, but I never doubted my survival. Surgery was going to be more extensive, followed by six months of chemotherapy. The hardest thing to face at that time was telling my daughters of the results in a manner that allayed any fears. I also wondered whether I was going to return to my practice—my alter ego—following surgery, and during and after chemotherapy. As it turned out, I did not return. A permanent peripheral motor-sensory neuropathy from oxaliplatin forced my involuntary retirement. The years of building up a practice from the ground up seemingly vanished overnight. My professional identity was


lost. The landscape of those affected by my disease grew larger and compelled my office “family” to seek employment elsewhere. This last change was for me a profound example of how an illness reverberates and impacts those connected with the patient. I decided to have the surgery performed at a nearby cancer center with very experienced colorectal and liver surgeons. Again, I went through the same impersonal admission process and headed off to the operating suite on September 1, 2004, where a colonic resection and left hemihepatectomy were performed. When I awoke, I had IV and arterial lines and tubing galore, accompanied by incisional pain. An anesthesiologist advised me preoperatively to have an intra-epidural catheter placed for administration of fentanyl, claiming this provided better pain control, decreased ileus, and promoted earlier mobilization. It wasn’t true. The anticipated hospital stay was five to seven days, but lasted much longer. The nasogastric tube was discontinued on day one, followed a few days later by removal of suture line staples. When asked, the surgeon told me that this resulted in a better cosmetic effect. One night, at approximately 0400 hours, a nurse came to change the PCA pump’s fentanyl bag. After she left the room, I pushed the button for a dose and lost consciousness. When I woke up in the intensive care unit, I was intubated on a ventilator with an internal jugular catheter in place. An unremarkable head CT had been obtained en route to the ICU. Somehow, a respiratory arrest occurred secondary to narcotic overdose, complicated by aspiration pneumonia. Coughing induced a one-cm dehiscence of the wound, prompting a surgical resident to open half of the incision due to the possibility of an infection. There wasn’t. When the time came to be transferred back to a regular room, the ICU nurse began removal of the internal jugular catheter. Without warning, he rapidly began lowering the head of the bed causing marked abdominal pain. I asked him to stop, but he ignored my complaint. Ice chips, drinking and eating precipitated severe oral pain. I was diagnosed with oral candidiasis and placed on intravenous Diflucan. A week and a half passed without improvement. I finally looked in a mirror

"I realized during my metamorphosis from husband, father, friend, physician and employer of four long-term and dedicated office staff, into a patient, that my humanity was lost. I felt objectivized and regarded principally as a 'Stage IV colon cancer' in a hospital bed–a diagnosis on a list of rounds to make. "

and recognized the hallmarks of a viral infection and requested an infectious disease (ID) consult, which confirmed my impression; parenteral acyclovir was prescribed. When the ID professor and his entourage came to the room for a several-minute visit, he asked how I was feeling. When I told him there hadn’t been any improvement, he turned around and started to walk out. I said to him, “Don’t you want to look?” He gave a cursory glance and was on his way. The stomatitis resulted in an inability to consume food or fluid for three weeks, precipitating significant weight loss. Eventually, an allergist friend visited and noted that the maintenance dose of acyclovir was being administered rather than the therapeutic amount. When the liver surgeon made rounds for the colorectal surgeon, he would stop at the doorway, make a joke to my family and me, and leave. Two neurology fellows came to my room, stood at a distance, and declared that I needed an MRI of my brain to exclude a CVA or brain metastases. I advised them that my respiratory arrest was the consequence of a fentanyl overdose and that I did not require an MRI, nor could I lie flat for the examination due to the degree of pain. It was noteworthy, to me, that neither of these physicians in training performed a neurological examination. To complete the saga of my hospitalization, I need to mention that the nasogastric tube was reinserted around day eight, and during its placement, every fascial suture “popped,” one after the other, resulting in evisceration, a second surgery, and a significantly longer hospital stay. The repair produced a large symptomatic ventral hernia, which necessitated a third abdominal operation following completion of a six-month course of chemotherapy. I’m describing my experiences for a variety of reasons. I realized during my metamorphosis from husband, father, friend, physician and employer of four long-term and dedicated office staff, into a patient, that my humanity was lost. I felt objectivized and regarded principally as a “Stage IV colon cancer” in a hospital bed—a diagnosis on a list of rounds to make. It is critically important for health care providers to recognize that we are not treating an ICD-10 code in a gown but rather, first and foremost, a person who happens to have a medical malady; an individual with a host of people attached to him or her. My experience as a patient helped me appreciate the great deal of stress that hospitalizations and illnesses create for the patient and their family. From my time in the hospital, I saw how limited or absent engagement by the physician and staff with the patient and the family, as people with lives outside of a health care facility, significantly interferes with communication, proper delivery of care, and fosters a disconnected and unfeeling environment. Failure to actively interact with the person, increasingly without the laying on of hands, compounds this sense of estrangement. In this age of escalating reliance upon electronic medical records and technology, when time is at a premium and reimbursements are falling, there is a danger that the art of medicine will degrade or be lost. I try to teach residents under my charge to always remember that they are dealing with a human being and a family who have entrusted them with their medical care and lives. This is a unique and awesome responsibility that must not be taken lightly. As physicians, we have a duty owed to those we are given the privilege to serve. William Osler once said: “The good physician treats the disease; the great physician treats the patient (the person) who has the disease.”

Getting it Right | 21


COVER STORY

Resolved to

BEAT

COLON CANCER By Brian C. Davis

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Cover Story | 23


COVER STORY

He couldn’t keep down any food. His stomach didn’t feel normal. He kept shedding weight. “My clothes were fitting like grocery bags,” he says. His primary care physician told him it was constipation. It was not constipation. He was certain. 24 | GI.ORG/ACGMAGAZINE

Now seven months after his diagnosis, he momentarily laments that he was not more aggressive in pinpointing the problem once his clothes began to sag. Almost immediately he relents, giving himself a warranted break. "But who actually knew” about his diagnosis, he rhetorically asks. As he engages in the first of a series of interviews with ACG MAGAZINE, he is two days away from starting his 15th round of chemo treatment. He is fully aware of the formidable challenge ahead. Lawrence Meadows, 39, husband to Angela and father to Addie, eight, and Lawson, four, is battling Stage IV colon cancer.

ARRIVING AT A DIAGNOSIS It was August 2016 when Meadows first visited his physician in response to his symptoms. The physician advised that Meadows take constipation medication. He continued to experience the symptoms and knew he was confronting something more significant. “I kept going back until he finally referred me to a specialist,” says Meadows, who saw the physician four times before he was referred to a colorectal surgeon locally in Spartanburg, SC, where he lives and serves as a Baptist Pastor and funeral home co-owner. Unearthing the issue had been a slow process, but it accelerated the moment Meadows saw the surgeon. Two days after undergoing a CT scan, on October 13, 2016, the surgeon told Meadows there was a baseball-sized mass on his abdomen that he believed to be cancerous, and that they should schedule surgery immediately. “Numb.” That’s how Meadows felt when he heard the news. But, true to his nature, he grew optimistic. “I’m thinking…‘Alright, once he removes [the mass], we’re home free,’” Meadows says. The surgeon performed the surgery two days later, removing the mass and 16 inches of the colon. The news following surgery didn’t match Meadows’ optimism. While in the recovery room, the surgeon told him he could see that the cancer had metastasized to the abdominal linings of his stomach, and that there were small spots on his hip bone and upper chest cavity. “Of all the people who could get a diagnosis like this, I was flat out stunned it was him,” says Craig Melvin, Meadows’ brother, during the May 2017 interview. Throughout his life, Meadows has generally made sound health choices, which made the diagnosis more confounding.

Photos on pages 22-29 courtesy of Lawrence Meadows and Craig Melvin. Pages 22-23, front left to right, Ryan Melvin, Craig Melvin, Lawrence Meadows; Lawrence Meadows, Craig Melvin. Photo top, left to right, Lawson Meadows, Angela Meadows, Lawrence Meadows, Addie Meadows. Photo at right, left to right, Addie Meadows, Lawrence Meadows, Lawrence Melvin, Craig Melvin, Ryan Melvin, and Jasmine Melvin. Pages 26-27, top to bottom, left to right, Craig Melvin, Lawrence Meadows, Addie Meadows; Craig Melvin following his colonoscopy; Angela Meadows, Addie Meadows, Lawrence Meadows, Lawson Meadows. Pages 28-29, Addie Meadows, Angela Meadows, Lawrence Meadows, Lawson Meadows.


“No cigarettes. No alcohol. I've never seen him drink a whole beer or a glass of wine,” says Melvin, who is Co-Anchor, NBC News’ “Weekend TODAY,” National Correspondent, “TODAY,” and MSNBC Anchor. The surgeon counseled that the next steps were to allow the body to heal and then to see an oncologist to determine the plan of action, since this was Stage IV colon cancer. Not knowing much about cancer, Meadows asked how many stages there are in cancer. “'Oh, this is the final stage,’” the surgeon replied.

FAITH AND FAMILY

WATCH THE VIDEO War on Cancer: Craig Melvin shares his brother’s colon cancer battle, TODAY: bit.ly/TODAYFeb17

You might not guess Meadows is fighting colon cancer if you turn down the volume and only watch his facial expressions during the story on NBC’s “TODAY,” in which he shares his cancer story, his brother posing the questions to him. You see Meadows confidently speaking from the front of his church, inducing head-nods from parishioners. You see him grinning as he quips Cover Story | 25


COVER STORY

FINDING A HOME FOR TREATMENT

about the irony of receiving this diagnosis despite his healthy lifestyle. He is comfortable making jokes while recounting his diagnosis, as Melvin points out in the story. In his interviews with ACG MAGAZINE, he is the same way—his wit and charm emanate. When asked how his diagnosis affects his work, he explains that his funeral home work came to a necessary halt because of the link between formaldehyde—used for embalming—and cancer. “I'm just not rushing over to the office,” Meadows jokes. “I don't want to add insult to injury.” Accompanying his humor are his optimism and drive, which are readily apparent. His maternal grandparents raised him on a 90-area farm in Moore, SC. He started working on the farm as soon as he was able to carry a bucket of water to water the plants and gardens. “My grandparents just worked us like there was no tomorrow,” says Meadows, who credits them for instilling in him a work ethic that he has carried through his education—including walking on to the football team at Wofford College—and into his career. The importance of faith was also ingrained in him by his grandparents. “They just insisted that there's nothing too hard that God can't handle, whether it be sickness, suffering or whatever the issue,” Meadows says. All these years later, Meadows, who is Senior Pastor and Teacher at the New Bethel Baptist Church and co-owner of The First Family Funeral Home, maintains that conviction and believes that he must be strong for his family and his church community. “I can't pastor people, encouraging them and sharing with them to be able to lean and depend upon their faith in God, and then I'm a reed shaken in the wind when I have some issue come my way,” Meadows says.

26 | GI.ORG/ACGMAGAZINE

“I can't pastor people, encouraging them and sharing with them to be able to lean and depend upon their faith in God, and then I'm a reed shaken in the wind when I have some issue come my way.”

Following his surgery, Meadows heeded the surgeon’s advice and saw an oncologist, who recommended that Meadows be kept comfortable and that he get ready for palliative care. “That wasn't the diagnosis and the prognosis that I wanted to hear,” Meadows says. Seeking a second opinion, he did some research and saw a reference to The University of Texas MD Anderson Cancer Center (MD Anderson) as “the best adult cancer facility in the country.” It is there—under the direction of Associate Professor Scott Kopetz, MD, PhD—that Meadows has been receiving care ever since, traveling the nearly 1,000 miles from Spartanburg to Houston. Every other Wednesday, Meadows flies to Houston and begins treatment the following day. He consults with Kopetz and is administered a three-hour chemo treatment. Next, he leaves the hospital with a chemo pump and retreats to the home of a mutual friend with whom he has taught at the National Baptist Student Union Retreat. After 46 hours, he returns to the hospital, is disconnected from the pump, and flies back home on Saturday night. The traveling has been challenging for the family, particularly Meadows’ children. During his first interview with ACG MAGAZINE, he says he will be missing his daughter Addie’s dance recital that upcoming weekend. His son, Lawson, expects him to be there when he gets ready for bed each night. “[He] just insists that every night my responsibility is to tuck him in bed and say prayers,” Meadows says. “When I'm out of town, I'm derelict in those duties.” His mom, brothers, aunts and uncles, and Angela’s family form the backbone of a strong support system, making sacrifices to help out when he travels to MD Anderson. The treatment in Houston has yielded “aboveaverage results,” as the cancer on his liver and hip no longer exist, Meadows says during the first interview, relaying the latest news from Kopetz. Meadows appreciates that Kopetz is “straight up” in explaining his prognosis. Channeling Kopetz, he describes: “He says, 'Lawrence, there is no quote unquote cure... but it's kind of like mowing your grass. The more you mow it, the more you mow it, and the lower you get it, the lower you get it, 'till eventually it just of course, you know, dies.' So we're in the process of just mowing the grass.”

KNOWING—AND SHARING—ONE’S FAMILY HISTORY In his funeral home work, Meadows has witnessed sons and daughters and nephews and nieces first learning about a family member’s chronic health condition when they read the cause of death on their death certificate. “They, of course, would be just flabbergasted,” says Meadows, who then roleplays how the ensuing conversations would go: “‘Oh gosh, we had no idea Mom, or Dad, or Auntie or Uncle had those issues.’”


This became somewhat of an irony for Meadows. While he was in the hospital, Meadows discovered that both of his paternal grandparents had colon cancer. “I found out more about the [family] cancer trail while I was in the hospital recuperating,” Meadows says. “When you have family reunions and birthday parties,” he says, “You just don't sit around and talk about it.” Meadows seems determined to change that. He’s told his family and his church community to ensure they have a primary care physician, be informed about their family cancer history and, if there is a family cancer history, to share that information with their physician. “Cancer is a silent killer,” Meadows says.

SPREADING THE WORD Meadows is not going to be mum about colon cancer and the important lifesaving messages he can share. "I definitely want to keep everyone informed,” says Meadows, describing why he chose to share his story. “I want as many people to get screened as possible.” In Melvin, Meadows had the right partner to help tell his story. Melvin was a little nervous, he says, and found the story was harder to tell because it was about his brother. “I spend a fair amount of my time telling stories that are pegged to the ‘news of the day,’” but this story was not, Melvin says. “This was one that hit pretty close to home.” The TODAY story was the first of several opportunities Meadows and Melvin have publicly taken to share colon cancer awareness messages, including speaking at an MD Anderson patient advocacy meeting and the Colon Cancer Alliance’s annual Blue Hope Bash, which Melvin emceed. Melvin has imparted messages on his Twitter account, including that his colonoscopy revealed he had no polyps. “Peace of mind is a powerful thing. And the fact that I’ve got some peace of mind for awhile now, yeah, it’s a good thing,” Melvin says during an interview. In addition to family history, Meadows focuses on paying attention to one’s body and potential symptoms—whether it’s weight, diet or simply feeling different— and visiting both primary care physicians and specialists, if possible. In a December 2017 interview, Kopetz recommends that those younger than

“Peace of mind is a powerful thing. And the fact that I’ve got some peace of mind for awhile now, yeah, it’s a good thing.”

recommended screening ages be “aggressive” if they experience symptoms such as changes in bowel habits and blood in the stool. He encourages patients wanting to be proactive to “make sure that their concerns are being heard, and that they're getting appropriate evaluations for recurrent symptoms.” Meadows feels that recommended screening ages need to be reviewed, particularly given the early-onset indicators in the African American community. “My case being case in point,” he says. As it relates to screening ages, Kopetz believes in unifying behind

—Craig Melvin, on his colonoscopy revealing no polyps.

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COVER STORY

the recommendation that African Americans be screened at age 45. He says that while there is a “long-standing recognition” of earlier onset in the African American community, all guidelines do not unanimously recommend African Americans be screened at age 45. ACG’s colorectal cancer screening guidelines have included this recommendation since 2005. “Because it's not universal in its recommendation in the guidelines, I think it's not as well practiced in the community,” Kopetz says.

LIFTING UP OTHERS IN #EVICTINGCANCER ACG MAGAZINE interviewed Meadows again in September 2017, a few days after he completed his 22nd chemo treatment. About two weeks prior, a surgeon had performed laparoscopic surgery to remove tissue from his abdomen, which was to be used to create a personalized immunotherapy vaccine that would then be re-inserted into Meadows leg, which Kopetz says will probably happen in 2018. The purpose is to “re-educate the immune system to attack the cancer cells,” Kopetz says.

28 | GI.ORG/ACGMAGAZINE

As Meadows fights his battle, his approach ignites others. Following the TODAY story’s airing, Melvin continually heard from viewers who were moved to action, being screened themselves and prompting others to be screened. “That's precisely what we both wanted,” says Melvin, who attributes the story’s resonance to Meadows’ honesty and the access he provided—to the treatment, to Kopetz, and to his wife, Angela. “I am using your brother’s words because I love it! I am working on #evictingcancer,” one person tweets to Melvin, referencing Meadows saying that his sole goal is “evicting cancer” from his body. In another tweet, a woman expresses thanks for the story, saying it makes her husband “see how serious” it is that he go in for the colonoscopy he has been delaying. Polyps were found in the colonoscopy he underwent at age 50.

Meadows’ impact is even felt at MD Anderson. The team enjoys interacting with him, appreciates his insights into the disease, and, unsurprisingly, “his willingness to roll his sleeve up and tackle any problems that come up.” His message really resonated when he spoke at the patient advocacy meeting at MD Anderson, says Kopetz, who describes Meadows’ attitude and perspective as “refreshing.” Rest assured, Meadows will remain perpetually optimistic, unbroken and resolved to beat colon cancer. “If we read in the New Testament over and over and over those 35 miracles that Christ performed…he is still performing miracles still today, in modern times,” Meadows says.


“[He] just insists that every night my responsibility is to tuck him in bed and say prayers,” Meadows said. “When I'm out of town, I'm derelict in those duties.”

Cover Story | 29


2018 ACG AWARD 2018 ACG AWARD NOMINATIONS NOMINATIONS Honor Honor Your Your Colleague Colleague Honor ColleagueNomination with an withYour an ACG ACG Award Award Nomination with an ACG Award Nomination

The ACG Awards Committee is seeking nominations from all members for the The ACG Awards Committee is seeking nominations from all members for the following distinguished awards. The ACG Awards Committee is seeking nominations from all members for the following distinguished awards. following distinguished awards. Berk/Fise Clinical Achievement Award Berk/Fise Clinical Achievement Award The intent of the Berk/Fise Clinical Achievement Award is The intent of the Berk/Fise Clinical Achievement Award is Berk/Fise Achievement Award to recognizeClinical an individual who has provided distinguished

to recognize individual who has provided distinguished The intent ofan the Berk/Fise Clinical Achievement Award is contributions to clinical gastroenterology, which could include: contributions toindividual clinical gastroenterology, which could include: to recognize an who has provided distinguished (a) clinical medicine, (b) technology application, (c) health care (a) clinical medicine, (b) technology application, health care contributions to related clinical gastroenterology, which(c) could delivery, and (d) factors such as humanism and include: ethical delivery, and (d) related factors suchapplication, as humanism and ethical (a) clinical medicine, (b) technology (c) health care concern. It is not intended that this award be given in honor of concern. and It is (d) notrelated intended that this award be givenand in honor of delivery, factors such as humanism ethical one’s laboratory research accomplishments. one’s laboratory research accomplishments. concern. It is not intended that this award be given in honor of

Community Service Award one’s laboratory research accomplishments. Community Service Award The Community Service Award is bestowed upon an ACG The Community ServiceAward Award is bestowed upon an ACG Community Service Member who has initiated or has been involved in numerous Member who hasService initiated or hasis been involved in an numerous The Community Award bestowed upon ACG volunteer programs/activities or has provided significant volunteer programs/activities or has provided significant Member has initiated or has been involved numerous volunteerwho service post-training. The service mustinhave been service post-training.orThe service must have been volunteer programs/activities has provided significant performed on a completely voluntary basis and not for the performedservice on a completely voluntary basis and forbeen the volunteer post-training. The service mustnot have completion of training or position requirements. completion of training or position requirements. performed on a completely voluntary basis and not for the

International Leadership Award completion of training or position requirements. International Leadership Award The International Leadership Award is given to a Fellow The International Leadership Leadership Award is given to a Fellow International Award or Master of the ACG in recognition of outstanding and

or Master of the ACG in recognition ofgiven outstanding and The International Leadership Award is totoa the Fellow substantial contributions to gastroenterology, College, substantial contributions to gastroenterology, to the College, or Master of the ACG in recognition of outstanding and and to the international gastroenterology community. and to the international community. substantial contributionsgastroenterology to gastroenterology, to the College, and to the international gastroenterology community.

Master of the American College of Gastroenterology Master of the American College of Gastroenterology Masters of the American College of Gastroenterology shall Masters of the College of Gastroenterology shall Master ofFellows theAmerican American College ofrecognized Gastroenterology have been who, because of their stature and

have been who, because recognized stature and Masters of Fellows theinAmerican College of of their Gastroenterology shall achievement clinical gastroenterology and because of their achievement in clinical gastroenterology and becausestature of theirand have been Fellows because of their recognized contribution to the who, College in service, leadership, and education, contribution to the College in service, leadership, and education, achievement in clinical gastroenterology because of their have been recommended for designationand as Masters. have been recommended as Masters. contribution to the Collegefor indesignation service, leadership, and education,

Minority Digestive Health Care Award have been recommended for designation as Masters. Minority Digestive Health Care Award The ACG Minority Digestive Health Care Award is an The ACG Minority Digestive Health Care Award is an Minority Care Award achievementDigestive award thatHealth will recognize an ACG Member or

achievement awardDigestive that will recognize an Award ACG Member The ACG Minority Health Care is an ororclinical Fellow whose work in the areas of clinical investigation Fellow whoseaward work in thewill areas of clinical investigation achievement that recognize an ACG Memberoror orclinical practice has improved the digestive health of minorities other practicewhose has improved theareas digestive healthinvestigation of minoritiesororclinical other Fellow work in the of clinical underserved populations of the United States. These efforts can underserved populations of the United States. These efforts can practice the digestiveactivities health ofthrough minorities or other be shownhas by improved community outreach clinical or be shown by community outreach activities through clinical orcan underserved populations of the United efforts educational programs, or research in anStates. area ofThese digestive disease educational programs, oroutreach research activities in an areathrough of digestive disease be shown by community clinical or that negatively impacts minority populations such as colorectal that negatively impacts minority populations such as colorectal educational programs, another area of cancer, hepatitis B and or C,research cirrhosis in and GIdigestive cancers. disease cancer, hepatitisimpacts B and C, cirrhosis and othersuch GI cancers. that negatively minority populations as colorectal

Samuel S. Weiss Award cancer, B and C, cirrhosis and other GI cancers. Samuelhepatitis S. Weiss Award The Samuel S. Weiss Award is granted in recognition The Samuel S. WeissAward Award is granted in recognition Samuel S. Weiss of outstanding service to the American College of

of outstanding serviceAward to theisAmerican College of The Samuel S. Weiss granted recognition Gastroenterology over the course of aninindividual’s career. Gastroenterology overto thethe course of anCollege individual’s of outstanding service American of career. Gastroenterology over the course of an individual’s career.

deadline deadline for for all all nominations: nominations: April April 16, 16, 2018 2018 deadline for all nominations: April 16, 2018 Nominations for all awards must: Nominations should be sent to: Nominations for allbyawards must: • Be accompanied two letters of recommendation ••Nominations Be accompanied by two letters of recommendation all awards Include the for nominee’s CV must: •• •• ••

Include the CV Be accompanied by two letters of recommendation Conform to nominee’s the specific requirements listed Conform to the specific requirements listed Include the nominee’s CV Be unsolicited by the nominee Be unsolicited the nominee Conform to thebyspecific requirements listed

Nominations should be sent to: William D. Carey, MD, MACG William D. Carey, MD, MACG Nominations should be sent to: Chair, ACG Awards Committee

Chair, ACG Awards Committee William D. Carey, MD, MACG 6400 Goldsboro Road, Suite 200 • Bethesda, MD 20817-5842 6400 Goldsboro Road, Chair, ACG Awards Committee Email: awards@gi.org Suite 200 • Bethesda, MD 20817-5842 Email:Goldsboro awards@gi.org 6400 Road, Suite 200 • Bethesda, MD 20817-5842

for nomination requirements. • Be unsolicited visit by thewww.gi.org/awardees-and-special-lecturers nominee Email: awards@gi.org visit www.gi.org/awardees-and-special-lecturers for nomination requirements. visit www.gi.org/awardees-and-special-lecturers for nomination requirements.

30 | GI.ORG/ACGMAGAZINE


HOW’D YOU DO THAT?

 WATCH Dr. Gray’s SCOPY presentation: bit.ly/DrGraySCOPY

Q&A with

DARRELL M. GRAY, II, MD, MPH

THE OHIO STATE UNIVERSITY (OSU)

IN LATE 2017, ACG CAUGHT UP WITH DR. DARRELL GRAY to learn how, exactly, he orchestrates his vast, comprehensive and consistent colorectal cancer (CRC) awareness initiatives. Dr. Gray leads the Provider and Community Engagement (PACE) Program for Health Equity in Colorectal Cancer Prevention at the OSU Wexner Medical Center. He has earned a SCOPY Award in each of the three years since the Awards’ inception, and this year delivered a speech about his efforts at the SCOPY Award Ceremony & Workshop. 

ACG Perspectives | 31


ACG PERSPECTIVES: HOW'D YOU DO THAT?

WHAT DID YOU DO?

Screening Saturdays: These are Saturdays during the months of March and April during which volunteer physicians, nurses and endoscopy technician staff provide highquality screening colonoscopies at low-to-no cost to uninsured and underinsured patients. We work closely with primary care providers in Central Ohio as well as patient navigators, financial counseling, and scheduling personnel at OSU to ensure that we are providing timely and equitable services. Nutrition Education: We partnered with Kroger grocery store to host a Walk With a Doc Grocery Store Tour for local residents, in which they to learned about making healthy food choices on a budget and about unlocking the nutritional power of fruits and vegetables to aid in cancer prevention. We partnered with WBNS-10TV News to broadcast this experience. Additionally, we partnered with the local Healthy Parents, Healthy Families Initiative to provide a health food cooking demonstration and tasting for >100 African American adults with Chef Jim Warner. Light the Town Blue: The AEP Building in downtown Columbus and the OSU Hospital East tower were lit blue during the month of March in recognition of CRC Awareness Month. Dress in Blue Sunday: We partnered with local churches to provide information about CRC prevention on select Sundays in March. During one Sunday event, I provided guided tours through a giant inflatable colon and answered questions about colon health. 10TV Commit to Be Fit Expo: Physicians, nurses, medical center staff and students provided interactive, guided tours through our inflatable colon. We also had a cooking demonstration by Chef Jim Warner. Third Annual Cancer Disparities Conference: Closing the Gap from the Bench to the Bedside and Beyond: This CME conference is designed for health care providers, health advocates, community organization leaders, and students. The keynote speaker was Samir Gupta, MD, Associate Professor at University of California, San Diego. Educational sessions included the following topics: Updates from the Hill, Place Matters in Eliminating Cancer Disparities, Cancer and the LGBTQ 32 | GI.ORG/ACGMAGAZINE

 WATCH Dr. Gray’s SCOPY presentation: bit.ly/DrGraySCOPY

community, The Role of Genetic Testing in Reducing Cancer Disparities, Challenges and Opportunities in Engaging Minority Populations in Cancer Clinical Trials and Biobanking, and Religion and Disparities. WBNS-10 TV News Live Phone Bank: During a live broadcast, Ohio residents called in to the news station to speak with OSU GI, Oncology and Surgery experts about CRC. One hundred and fifteen calls were answered, and 57,000 households were reached by the TV segment. Online and Community Education: We leveraged social media and news to extend our reach in spreading awareness about prevention, screening and early detection. From January-April 2017, I did the following:

• Published an article in The Hill titled, “As US Healthcare Changes, Preventative Screenings Can’t Stop,” which to date has more than 450 shares from the website; • Was quoted in the Huffington Post article, “Colorectal Cancer Rates are Rising Sharply Among Young Americans;” • Shared my educational colonoscopy video, “Colonoscopy: A Journey through the Colon and Removal of Polyps,” which now has over 200,000 views from people in all 50 states, as well as DC and Puerto Rico, and 125 countries outside of the US;


• Partnered with 10TV News to post two videos on YouTube in their “Toward a Cancer Free World Segment”; • Posted targeted messaging that has generated over 30,000 impressions on Twitter; and • Started a #CraigTheColon campaign on Twitter, Instagram and Facebook.

HOW DID YOU DO IT? Establishing meaningful partnerships, which is the core of community engagement, was the key. None of this would have been possible without the commitment of many community partners and colleagues and friends from the Division of Gastroenterology, Hepatology, and Nutrition at OSU, The OSU Comprehensive Cancer Center, and The James Cancer Hospital. They believe in the mission and vision, are champions of both, and give their time and, in some cases, money to support them.

WHAT RESOURCES DID YOU NEED? The main resources I needed were time and wo(man) power. Building relationships with community partners, creating a sense of urgency among team members and collaborators, and coordinating free colonoscopy sessions and educational experiences took a significant amount of time.

WHAT WAS THE COST? The cost was negligible, namely because of the generosity of our community partners, who donated space for events, services such as cooking demonstrations, a grocery store tour, as well as the generosity of the leadership of OSU Wexner Medical Center and Comprehensive Cancer Center, who ensured that uninsured and underinsured patients could receive patient navigation and CRC screening services. We’ve also worked closely with community and industry partners to cover expenses of the Cancer Disparities Conference.

HOW DID YOU PROMOTE IT? Through all available outlets. I advertised our activities on social media, including Twitter and Facebook, requested that our community partners inform those on their email lists, sent emails and letters to clinics across Central Ohio about our “Screening Saturdays,” and worked with our marketing team on a media campaign, including print media, radio and live TV.

WHAT TIPS OR LESSONS LEARNED DO YOU HAVE FOR YOUR COLLEAGUES?  TEAMWORK IS THE KEY Engage the community and all stakeholders at every stage, from planning to execution and evaluation.

 TRY TO FIND PARTNERS who are doing similar work and/or share your interests and passion. Do not try to “reinvent the wheel” if you don’t have to. If it’s possible, piggyback on existing reputable community events—be sure to explore those routes.

 DO NOT BE AFRAID TO ASK FOR HELP For example, I didn’t know that Walgreens would be willing to donate bowel prep for Screening Saturdays until I asked.

 YOU DON’T NEED A LOT OF MONEY TO MAKE A DIFFERENCE Photos courtesy of Dr. Darrell Gray.

You need a mission and people who believe in it and who will help you to achieve it.

ACG Perspectives | 33


ACG PERSPECTIVES: HOW'D YOU DO THAT?

Q&A with

MATTHEW PAUL MEWHORTER SCOPY AWARD WINNER ON HIS CANCER JOURNEY AND HIS COMIC, CANCER OWL

MATTHEW PAUL MEWHORTER HAS THE UNIQUE GIFT OF STORYTELLING. His vehicle for

storytelling—drawing comics—and the stories he tells—his and others’ cancer journeys—are similarly unique and impactful. Mewhorter, a Stage II colorectal cancer (CRC) survivor, won the “SCOPY Inspiration & Impact Award.” The University of Virginia Department of Gastroenterology, which treated Mewhorter, credited him for serving as the initial inspiration for its 2017 CRC awareness project, which also won a SCOPY Award. In this Q&A with ACG MAGAZINE, Mewhorter, who was diagnosed at age 35, talks about his cancer story, young-onset CRC, and his comic, Cancer Owl.

Could you describe when and how you discovered you had CRC? In November 2014, I had a colonoscopy to find out why I had been bleeding for the prior year. I put it off for a while because I thought maybe it was my stressful job at the time, or maybe my diet. When nothing seemed to work and the bleeding was getting worse every time I went to the bathroom, I decided to go to a doctor, who told me I had classic colitis and put me at the bottom of the list to get a colonoscopy. About four months later, the gastroenterologist almost completely missed the tumor at the bottom of my rectum.

34 | GI.ORG/ACGMAGAZINE

"I like to tell people that once you're diagnosed with cancer, it is very possible that so much of what you thought was important all melts away at that very moment. You will be left with only the things that truly matter..."

What are the lasting lessons you learned from your CRC diagnosis? There are so many lessons that I took from the experience. For one, I learned that even "healthy people" can get a serious, life-threatening cancer. I would say that the lasting lessons are how important it is to get screened as soon as you're seeing problems, even if you don't feel like you fit the mold for something like CRC. I learned that cancer in general does not care how old you are, how healthy you are, what your race is... it really just doesn't care. And while I understand there are risk factors, of course, and there are direct things scientists are finding that cause CRC, there are still people like me for whom the causes will always be a complete mystery. I like to tell people that once you're diagnosed with cancer, it is very possible that so much of what you thought was important all melts away at that very moment. You will be left with only the things that truly matter, and, if you let it, that realization could change your life.


ACG Perspectives | 35


ACG PERSPECTIVES: HOW'D YOU DO THAT?

What do you want people close to your age to know about young-onset CRC? Most importantly, this is no “old person disease” anymore. To the best of my knowledge, adults under the age of 40 are actually being diagnosed with more-serious stages of CRC than elderly adults. If you are bleeding out of your bottom, then, for the love of God, go get screened. The sooner, the better. The earlier you catch it, the greater the chance that you will survive it. You may even be able to avoid having an ostomy bag like I did. Also, you get to know poop in a whole new way. That part of your life may never be the same.

Can you tell us about Cancer Owl? How did you start it, and what do you hope to accomplish? I started drawing my comic, called Cancer Owl, when I was in the hospital after my first resection surgery. I started drawing after a terrible night in the hospital, where I hiccupped for more than three hours and walked up and down the hallways in the middle of the night to push the gas out of my body. But after those horrible three hours, I started feeling so much better, and my recovery was very quick after that. I sat upright in my bed, and I started drawing. My therapist at the time suggested that I journal and put it out in the public as a way to cope, and I thought it was a great idea. I just put out a handful of cartoons as a way to tell my story, but I really did want to reach people. I really hoped it would do something positive, but I did not know how the public was going to take what I put out there. Many of my cartoons—especially the early ones—were really bold and straight from the gut. I didn't want to hold back at all. I told my story for a year and a half and decided it was time to start telling other cancer patients’ stories. So now I hope people can find humor through their cancer experience. I hope that I can educate others who do not have the cancer experience. And I really just want to tell great stories from great people who have had to deal with terrible things in their cancer experience and have found hope and strength through it.

Do you have a story (or two) you would be willing to share about the impact Cancer Owl has had on readers? I have so many heartfelt stories that have driven me to tears that it is hard to pick one. One reader wrote to tell me that he 36 | GI.ORG/ACGMAGAZINE

was sitting in the hospital by his dying mother’s bedside for two weeks straight. He told me he read my comics to cope and to better understand what she had been going through for the last few years. He told me that my comics were one of the only things that got him through that time. I had one woman tell me that reading my comic convinced her to go to the doctor to see about a complication and, because she got screened in time, she was able to get the help that she needed right before it was too late. I could go on and on. Those stories are easily the best part of doing the comic.

What did it mean to you to be recognized with a 2017 SCOPY Award? It was quite an honor to be recognized by the SCOPY Awards, and a confirmation that my comic is heading in the right direction. Honestly, there have been times I thought I might hang the comic up, because there is a fair amount of time devoted to creating comics. Getting this award made me aware of what kind of impact it's truly having, and that it's only just beginning.


Ramon S. Generoso, MD, Kalispell Gastroenterology, Kalispell, MT, ACG Minority Affairs and Cultural Diversity Committee

COLORECTAL CANCER SCREENING in NATIVE AMERICANS

While practicing on the East Coast, we were working toward the goal of 80% of eligible adults screened for colorectal cancer (CRC) by 2018. Moving to Montana in 2016 brought me to grips with the alarming disparity in CRC screening rates that exists among certain ethnic subgroups in the United States. Disproportionately higher rates of CRC have been reported for American Indians and Alaskan Natives (AI/ANs), whose screening rates have been estimated to range from as low as 4% to as high as 32%. Diagnosis of CRC occurs later for AI/ANs, who also have a higher CRC-specific mortality rate compared with the rest of the U.S. population. One study showed that AI/ANs were diagnosed with CRC at a younger age, and at a more advanced stage. In addition, while incidence of CRC has been declining for white Americans, it has remained unchanged among AI/ANs.

Photo top: the Indian Health Service facility in Browning, MT. Photo courtesy of Dr. Ramon Generoso.

LEARNING FROM THOSE WITH FIRST-HAND KNOWLEDGE I had the opportunity to interview Dr. Ernest Gray, Clinical Director of the Indian Health Service (IHS) in Browning, MT, whose facility provides medical services to the residents of the Blackfeet Reservation in northern Montana. Remoteness and lack of transportation are significant obstacles to obtaining access to medical care, according to Gray. The nearest hospital is a two-anda-half-hour drive away in good weather, and usually requires an airplane or helicopter ride during Montana’s long winter months, when mountain passes may be closed for extended periods of time. For the same reasons, recruiting doctors and other medical personnel has also proven difficult.

CULTURAL BARRIERS TO SCREENING Not only is lack of access to screening colonoscopy a problem, social and cultural barriers to screening exist. One patient confided that several of the nurses at the local IHS are either family members or neighbors. She did not feel comfortable with them “knowing her business." Another anonymous patient complained that it was difficult to obtain a referral, such as for screening colonoscopy, at an outside facility. “There are so many forms to fill up and so much red tape. Relatives of officials or tribal elders are usually given priority,” the patient said. As a whole, there is a “lack of a sense of urgency” when it comes to CRC screening, Gray states, “unless a family member was cured or died of colon cancer.” Gray also describes certain gender-specific differences. “Women,

"The men usually only have bloodwork for PSAs, and are a harder sell. There is also the Native American equivalent of machismo, and anything to do with violating the rectum, or even talk of it, is not socially acceptable to many." — Dr. Ernest Gray

who may be accustomed to more-invasive forms of screening like mammograms and PAP smears, tend to be more compliant with CRC screening. The men usually only have bloodwork for PSAs, and are a harder sell. There is also the Native American equivalent of machismo, and anything to do with violating the rectum, or even talk of it, is not socially acceptable to many.” Similar barriers have also been described by several investigators. Perhaps due to the lack of access to screening colonoscopy, it has been shown that the practice of screening for fecal occult blood in stool specimen obtained during digital rectal examination seems to remain prevalent among providers in the IHS, a practice shown to detect fewer than 5% of patients with CRC or advanced adenomas. Fecal immunochemical testing for hemoglobin and multi-target stool DNA test may be effective and acceptable modalities for CRC screening, particularly for more-remote Native American populations.

ACG Perspectives | 37


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38 | GI.ORG/ACGMAGAZINE


Photo top: Ikuo Hirano, MD, FACG, and Aasma Shaukat, MD, MPH, FACG, during Dr. Shaukat's visit to Northwestern.

EDUCATION

THE ACG EDGAR ACHKAR “The biggest impact was that I could see participants applying the information to their everyday practice and asking questions in the context of their specific practice ‘What does this mean to me’?” —Dr. Shaukat

VISITING PROFESSORSHIP PROVIDING NOTEWORTHY SPEAKERS FOR TRAINING IN YOUR COMMUNITIES

THE GOAL OF THE ACG EDGAR ACHKAR VISITING PROFESSORSHIP PROGRAM is to enable GI fellowship programs to have high-quality visiting professors to bolster the training program by providing lectures, small group discussions, and one-on-one visits with trainees and faculty. This issue of ACG MAGAZINE unveils confirmed dates for 2018 visiting professors and features the final four visiting professors of 2017: Aasma Shaukat, MD, MPH, FACG, at Northwestern University; Andrew Y. Wang, MD, FACG, at the University of Michigan; Nicholas J. Shaheen, MD, MPH, FACG, Director, ACG Institute for Clinical Research and Education, at California Pacific Medical Center; and Miguel D. Regueiro, MD, FACG, at UT Southwestern Medical Center. 

Education | 39


EDUCATION

“I found their learners to be enthusiastic, inquisitive, bright, energetic, and fun to be around. The fellows were full of great questions, and we spoke about a lot of stuff that is less well-covered in most GI curricula.” —Dr. Nicholas Shaheen

“Great reemphasis on careful upper endoscopy to evaluate for early precancer and cancer in the stomach. Since we do very little ESD, opportunity to see expert in action was invaluable.” —Dr. James Scheiman

40 | GI.ORG/ACGMAGAZINE


2018 ACG EDGAR ACHKAR VISITING PROFESSORSHIPS

NICHOLAS J. SHAHEEN, MD, MPH, FACG February 1–2 University of Minnesota PETER D.R. HIGGINS, MD, PHD, MSC February 21–23 UCLA David Geffen School of Medicine SATISH S.C. RAO, MD, PHD, FACG February 22–23 Virginia Commonwealth University

“The biggest impact...was learning about how Dr. Regueiro developed the IBD Specialty Home at University of Pittsburgh and the significant impact it has played in his patients' care. It was encouraging to see the intricacies of a multidisciplinary approach be streamlined so effectively to address each patient's unique needs.” —Dr. Anh Nguyen

KRIS V. KOWDLEY, MD, FACG March 1-2 University of Arizona College of Medicine STEPHEN B. HANAUER, MD, FACG March 5–6 Cleveland Clinic Florida SAPNA SYNGAL, MD, MPH, FACG March 26-27 Emory University School of Medicine SACHIN B. WANI, MD April 12-13 University of Nebraska DAVID T. RUBIN, MD, FACG May 2 UConn Health MILLIE D. LONG, MD, MPH, FACG May 16 Beaumont-Botsford Campus CHRISTOPHER C. THOMPSON, MD, MSC, FACG June 12 University of Alberta SUNANDA V. KANE, MD, MSPH, FACG September 13 SUNY Downstate STAY TUNED. More Visiting Professorships to be announced!

Education | 41


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A peer-reviewed, open-access journal edited exclusively by gastroenterology and hepatology fellows.

AC GORTS

EP CASE JRO URN L I.ORG EPORTS.G ACGCASER

/ ISSUE 4 VOLUME 3

Apply Now for 2018-2019 Editorial Board Openings • Gain valuable editorial experience • Eligible if starting 2nd, 3rd, or 4th fellowship year in July 2018 • One-year terms start July 1, 2018 • Submit applications to acgcasereports@gi.org

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• Completed applications are due April 23, 2018

Download an application and more information at acgcasereports.gi.org 44 | GI.ORG/ACGMAGAZINE


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STUDIES THAT DIRECTLY MEASURE PATIENT REPORTED OUTCOMES (PROs) and emphasize the patient’s experience of their disease are at the heart of the “Putting Patients First” issue of The American Journal of Gastroenterology. The theme of AJG’s January 2018 issue is research using PRO as the primary measure of treatment success. A Red Section contribution from Jennifer Maratt and colleagues addresses when and how to stop surveillance colonoscopy in older adults. Acknowledging that there are no clear recommendations, the authors propose five rules of thumb for clinicians. Clinical and Translational Gastroenterology published the first systematic literature review and meta-analysis investigating the mutational differences in sporadic colorectal cancer (CRC) between African Americans and Caucasians. Staudacher, et al. identified an increase in KRAS mutations in sporadic CRC in African Americans, which may contribute to worse prognosis and increased mortality. Using metagenomics data from a well-characterized cohort of IBD patients and healthy controls, researchers report in CTG on the presence of a striking dysbiosis in IBD based on diversity indices for bacteria. Their study reveals novel associations between host genetic risk, stool microbiome, and clinical features of IBD, demonstrating the power and value of technological advances in sequencing. ed by

Inside the Journals | 45


INSIDE THE JOURNALS: THE AMERICAN JOURNAL OF GASTROENTEROLOGY

HOW I APPROACH IT When and How to Stop Surveillance Colonoscopy in Older Adults: Five Rules of Thumb for Practitioners Jennifer K. Maratt, MD, MS, Audrey H. Calderwood, MD, MS, and Sameer D. Saini , MD, MS

“Post-polypectomy surveillance is an increasingly common indication for colonoscopy in the United States. As screening uptake increases and our population ages, we will see growing numbers of older adults who are due for surveillance. For many, the balance of benefits and harms will be uncertain. In addition, unlike average-risk screening, for which there are clear recommendations for when to stop, there is no specific guidance on when to stop surveillance. We therefore propose five ‘rules of thumb,’ to guide gastroenterologists in making decisions about stopping surveillance in older adults.”

Summary of the five rules of thumb for

MAKING SURVEILLANCE COLONOSCOPY DECISIONS IN OLDER ADULTS

RULE OF THUMB: KNOW THE DATA RATIONALE: Knowing the data on CRC* risk and colonoscopy-related harms is essential if we are to make sound recommendations and have meaningful discussions with our patients.

RATIONALE: Incomplete information on prior colonoscopy quality and findings creates unnecessary ambiguity.

EXAMPLE: Know the lifetime risk of CRC in patients with LRAs versus HRAs.

RULE OF THUMB: INDIVIDUALIZE BENEFITS AND HARMS RATIONALE: Benefits and harms vary widely between patients, especially as they get older.

RULE OF THUMB: GET THE FULL HISTORY

EXAMPLE: Use decision support tools (e.g., screeningdecision.com) and validated life expectancy calculators (e.g., ePrognosis).

RULE OF THUMB: WORK WITH YOUR COLLEAGUES

EXAMPLE: Obtain prior colonoscopy and pathology reports.

RULE OF THUMB: ENGAGE THE PATIENT RATIONALE: Understanding patients’ perspectives can guide decisionmaking, especially in cases that are not clear cut.

EXAMPLE: Ask patients about their preferences and values, including worry about cancer and the burdens of colonoscopy.

 Read the full article bit.ly/When-To-Stop-Screening

 Listen to the Podcast bit.ly/AJGFeb18Pod

RATIONALE: PCPs* know their patients’ current medical and functional status and often have greater insight into their values and preferences.

EXAMPLE: Act as a consultant, providing clear guidance with appropriate qualifications that provide the PCP with flexibility.

Read the Putting Patients First digital edition: bit.ly/AJG-Jan18

*CRC, colorectal cancer; HRA, high-risk adenoma; LRA, low-risk adenoma; PCP, primary care provider. 46 | GI.ORG/ACGMAGAZINE


CLINICAL AND TRANSLATIONAL Increased Frequency of KRAS Mutations in African Americans Compared with Caucasians in Sporadic Colorectal Cancer

INSIDE THE JOURNALS: CLINICAL AND TRANSLATIONAL GASTROENTEROLOGY

Highlights

Jonas J. Staudacher, MD, Cemal Yazici, MD, Vadim Bul, MD, Joseph Zeidan, MD, Ahmer Khalid, MD, Yinglin Xia, PhD, Nancy Krett, PhD, Barbara Jung, MD

What is New Here  This is the first meta-analysis specifically designed to compare the differences in the most commonly seen somatic mutations in colorectal cancer (CRC) between African Americans and Caucasians.  African Americans have higher incidence of KRAS mutations compared to Caucasians.  No statistical differences were seen between African Americans and Caucasians in regards to BRAF or PI3CA mutations. Funnel plot of studies that reported data on mutational frequencies in KRAS

Translational Impact  Frequency of KRAS mutations should be compared in future studies investigating racial disparities in CRC between African Americans and Caucasians.  Since African Americans with CRC have higher incidence of KRAS mutations, testing this population for KRAS mutation during initial work up may provide tailored treatment strategies.

“As activating KRAS mutations are strongly correlated with worse prognosis in sporadic CRC, the increased frequency of KRAS mutations in AAs may contribute to the higher mortality observed in AA CRC patients. Importantly, our results remained significant after controlling for possible confounders such as age, gender, stage, or cancer site.”

 Read the full article: bit.ly/CTG-KRAS-AA

Genetic Risk, Dysbiosis, and Treatment Stratification Using Host Genome and Gut Microbiome in Inflammatory Bowel Disease

Host Genetics Genetic risk affects treatment

Ahmed Moustafa, PhD, Weizhong Li, PhD, Ericka L. Anderson, PhD, Emily H. M. Wong, PhD, Parambir S. Dulai, MD, William J. Sandborn, MD, FACG, William Biggs, PhD, Shibu Yooseph, PhD, Marcus B. Jones, PhD, J. Craig Venter, PhD, Karen E. Nelson, PhD, John T. Chang, MD, FACG, Amalio Telenti, MD, PhD, Brigid S. Boland, MD Highlights: Genetic risk may have a role in early risk stratification in the care of IBD patients and expression of virulence factors in a dysbiotic microbiome may contribute to pathogenesis in IBD.

 Read the full article: bit.ly/CTG-IBD-18

Dysbiosis

Microbiome Composition

Lower Diversity

Virulence factors Recent advances in sequencing and data analysis have transformed our understanding of the human genome and microbiome, and the complex interaction with clinical phenotype is slowly being unraveled.

Cohort

Ctrl

UC

CD

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PC2

Using whole genome sequencing and shotgun metagenomics, the authors studied the clinical features, host genome, and stool microbial metagenome of 85 IBD patients, and compared the results to 146 control individuals. Genetic risk scores, computed on 159 single nucleotide variants, and human leukocyte antigen (HLA) types differentiated IBD patients from healthy controls. Genetic risk was associated with the need for use of biologics in IBD and, modestly, with the composition of the gut microbiome. As compared with healthy controls, IBD patients had hallmarks of stool microbiome dysbiosis, with loss of a diversified core microbiome, enrichment and depletion of specific bacteria, and enrichment of bacterial virulence factors.

Clinical Profile

Microbiome correlates with genetic risk

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−2.5

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PC1 Analysis of microbiome taxonomic abundance. Principal component analysis was used to characterize the microbial populations across controls, UC and CD. (a). PC1 on the x-axis explains 26% of the variance and PC2 on the y-axis explains 10% of the variance.

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n PC1

CTG is a free, fully open-access journal, available to all readers worldwide. Read the journal: nature.com/ctg

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Inside the Journals | 47


Making theCASE INSIDE THE JOURNALS: ACG CASE REPORTS JOURNAL

Successful Treatment of Cannabinoid Hyperemesis Syndrome with Topical Capsaicin Andrew M. Moon, MD, MPH, Sarah A. Buckley, MD, and Nicholas M. Mark, MD

Proposed pathophysiology of cannabinoid hyperemesis syndrome. Transient receptor potential vanilloid subtype 1 (TRPV1) is expressed in area postrema of the medulla, along gastric enteric and vagal nerves, and on cutaneous receptors in the dermis and epidermis. Prolonged exposure to cannabinoids inactivates TRPV1, potentially resulting in central nausea, altered gastric motility, and abdominal pain. Exposure to nociceptive heat, such as with compulsive hot-water bathing, may transiently augment cutaneous TRPV1 firing and restore gastric motility, temporarily mitigating symptoms. Use of another TRPV1 agonist, capsaicin, may also provide relief. Cessation of marijuana use gradually leads to normalization of TRPV1 function and fully ameliorates symptoms.  Read the full case: bit.ly/ACGCRJ-CHS

 View more images and all published cases without a subscription: acgcasereports.gi.org

48 | GI.ORG/ACGMAGAZINE


PREVENTING COLORECTAL CANCER American College of Gastroenterology | Patient Education & Resource Center

Digestive health specialists from the American College of Gastroenterology urge you to be screened for colorectal cancer.

For additional information: patients.gi.org/colorectal-cancer GENERAL INFORMATION What you need to know about colorectal cancer, and reliable patient resources to help you understand why colorectal cancer screening is important.

RECOMMENDATIONS Everyone, beginning at age 50, should be screened for colorectal cancer. African Americans should start screening at age 45.

BASICS Colorectal cancer is the second leading cause of cancer death for men and women. It is expected to cause over 50,000 deaths a year in the U.S. alone. The majority of patients diagnosed with colon cancer do not have a family history. Screening can reduce the risk of developing colon cancer in the majority of cases. Early detection can achieve close to 90% cure.

QUICK FACTS Many colon cancers can present with vague or no symptoms. However, symptoms can also include rectal bleeding, change in bowel habits, abdominal pain or bowel obstruction. Colonoscopy is a procedure that allows a physician to look at the entire colon. It is effective in the diagnosis and/or evaluation of various GI disorders. It is also used to screen for colorectal cancer. One advantage of colonoscopy is that it allows for identification and removal of precancerous growths or polyps before they become cancerous.

PODCASTS Podcasts exploring various aspects of colorectal cancer including some of the myths and realities of colonoscopy, common risks factors, how to ensure you get a good colonoscopy, and genetic- and ethnicity-based risk factors. Visit: bit.ly/crc-podcasts

RESOURCES See videos, brochures, and related patient resources at: bit.ly/crc-resources

BROCHURES A brochure about colorectal cancer screenings is available at: bit.ly/crc-brochure

Visit: patients.gi.org/colorectal-cancer

Inside the Journals | 49


M CECUM THE CECU HING THE REACHING REAC By Robert E. Kravetz, MD, MACG Scottsdale, AZ

A LOOK BACK

LAXATIVE MINERAL WATER This archival reflection originally appeared in The American Journal of Gastroenterology in February 2003.

T

he origin of the use of mineral waters created by the flow of the water through rocks and soil is unknown. In approximately 400 BC, Hippocrates wrote a treatise entitled Airs, Waters & Places. During the period of the Roman Empire, springs and spas in Europe and England were popular because of the miraculous cures attributed to their waters. By the late 1700s, spas were frequently visited for the therapeutic effect of the waters and the curative benefits that drinking them provided. The first recorded report of the water being bottled in the United States was in 1767 from the Jackson Spa in Boston. The most popular bottled water was from Saratoga Springs Spa, NY; it was sold

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from 1820 until the early part of the 20th century. Today, mineral waters are made commercially by adding the mineral ingredients under careful chemical supervision. Many mineral waters had a strong laxative effect and were specifically sold for the purpose of treating constipation. The contained mineral salts were the carbonates of chlorides, phosphates, sulfides and sulfates of calcium, iron, lithium, magnesium, potassium, and sodium. This attractive broadside from circa 1900 advertised a "natural laxative water." It was imported from Hungary and sold in this country. Imported mineral waters were very popular during the early part of the last century. Liquid laxative waters continue to be sold today in drug stores.


IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution. INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECGs should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy. STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2017 Braintree Laboratories, Inc.

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1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT1 #

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FIVE-STAR EFF1CACY WITH SUPREP ® Distinctive results in all colon segments • SUPREP Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 • 98% of patients receiving SUPREP Bowel Prep Kit had “good” or “excellent” bowel cleansing2* †

• >90% of patients had no residual stool in all colon segments2*

These cleansing results for the cecum included 91% of patients2*

Aligned with Gastrointestinal Quality Improvement Consortium (GIQuIC) performance target of ≥85% quality cleansing for outpatient colonoscopies.4 *This clinical trial was not included in the product labeling. †Based on investigator grading. References: 1. IMS Health, NPA Weekly, May 2017. 2. Rex DK, DiPalma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc. 2010;72(2):328-336. 3. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2012. 4. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2017 Braintree Laboratories, Inc. All rights reserved.

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ACG MAGAZINE ARCHIVE 2017 Volume 1, Number 1

ACG MAGAZINE Members. Medicine. Meaning.

Striking

Gold

ACG MAGAZINE Summer 2017

MEMBERS. MEDICINE. MEANING.

FINDING DISCOMFORT

ACG MAGAZINE Fall 2017

MEMBERS. MEDICINE. MEANING.

ACG MAGAZINE Winter 2017

MEMBERS. MEDICINE. MEANING.

THE RACING LIFE OF DR. FRED POORDAD

Role Models

gi.org/acgmagazine

Vol. 1 No. 1 // Spring 2017

Vol. 1 No. 2 // Summer 2017

Vol. 1 No. 3 // Fall 2017

Vol. 1 No. 4 // Winter 2017