Mole check technology for skin cancer screening: An Interview with MoleMap’s Chief Customer officer
In our previous post, our Founder Nick shared his personal experience with a detailed skin cancer check with the Australian based company Mole Map.
Mole Map is an innovative organisation who have more than 25 years of experience in skin cancer screening, and have pioneered new technology for imaging skin lesions (aka your moles) as well as a ‘surveillance’ system for tracking your skin continually over time.
Today, we’re following up on that content with an in-depth and exclusive interview with MoleMap’s Chief Customer Officer Vlad Mehakovic.
In this interview, we discuss the basics on how the service works, as well as Vlad’s own motivations for joining the company nearly two years ago.
With the basics covered, we dive into the details on how their ‘surveillance’ approach is enabling customers to manage their unique skin cancer longevity risk, and why the business model has been such a success.
Also, we ask Vlad a series of questions on where skin cancer surveillance is headed in the future.
This has some exciting answers, including emerging opportunities for the application of artificial intelligence to the skin cancer detection challenge, as well as a future where more of us are empowered to self-monitor our own skin using apps (some of which are freely available from Mole Map already).
There’s even a cool AI start-up company in the mix! There is plenty to learn about in this post, so without further delay, let’s chat with Vlad from MoleMap.
This interview was conducted on 20 May 2021, over Zoom and is an audio transcript with minor edits for clarity, brevity and correctness.
Our guest - Vlad Mehakovic, Chief Customer Office at MoleMap
Longevity Blog (LB):Vlad, thanks so much for joining us today. To kick things off - could you give us a brief history of MoleMap and its mission?
Vlad Mehakovic (VM): Thanks for having me!
MoleMap was started about 25 years ago by a group of medical entrepreneurs. Their key innovation was creating a system for better skin cancer diagnosis. Not only a set of hardware and software technologies, but also a system that took the dermatologist away from having to do the screening process themselves.
We see ourselves as pioneers within telehealth. What we've been doing is taking specialised photography and sending them to a remote dermatologist for review - and we’ve been doing that for 25 years.
How does skin cancer screening work?
LB: Those early medical entrepreneurs, they saw a specific ‘gap’ in the diagnostic capability. Could you comment on that gap? What was it?
VM: It comes down to standardisation. We've got a standardised way to map at your entire body, at a macro level. We then go micro and do diagnosis when there are lesions (medical term for all types of moles) of risk. These risky lesions are identified by a trained registered nurse (melanographer), they will take macro images of your skin followed by a micro, very close up, image of your skin. This is completed with a specialized camera (Molecam). [See the process yourself in Nick’s post about his MoleMap visit]
This camera can see under the first few layers of your skin. Those images are then passed on to a dermatologist who reviews them remotely. We've built one of the best dermatologist teams in Australia and New Zealand, some real leaders in dermatology.
A ‘melanographer’ use a ‘Molecam’ to image a mole on Nick’s foot!
This team-up between the melanographers and dermatologists with high quality images, allows people to track their body over time. This is the ‘surveillance system’ in action. It's not a one time solution, it's something that you repeat over time. This is important because skin lesions can change very quickly.
LB: MoleMap has clearly built a talented team, and have creatively structured the business so you can pull in the best dermatologists to review the images, leaving the technical side of assessing the skin and taking images to the melanographer. It’s a great model.
Speaking of talented people coming into the company, you're the Chief Customer Officer and have been in that role for going on two years now. Talk us through what drew you to MoleMap?
VM: I came onboard as a consultant initially and I saw lots of opportunities for growth. After a few months a new CEO (Tanya Houghton) came on board. Everything was working well, and I really liked the company. I was really honored when she asked me to keep on working with business.
LB: We like how you're talking about a team who is continuing to pioneer technology for skin cancer surveillance. It is quite a remarkable success story of applying a technology to cancer detection.
Does Skin Cancer Screening Save Lives?
LB: Can you tell us in the instance of skin cancer, why does early screening, save lives?
MoleMap provide extensive literature and supporting information about the many types of skin lesions, and the ones you need to watch out for
VM: It’s a pretty simple equation - the less cancerous tissue there is to remove, the less likely that cancer is getting into the bloodstream. The earlier you remove them, the higher the rate of survival. It's really that simple.
Again, it's not necessarily just the technology, it's the system that we offer, that really offers the step-change. There are a lot of different medical professionals, even with good technology, good dermascopes, but they don't necessarily get their education updated after attending med school. It is the application and the surveillance system that allows us to detect skin cancer systematically and comprehensively.
LB: In our Founder Nick’s personal experience with MoleMap, he reviewed the very technical way you map the entire body. It first calls out areas of interest, but then, of course, requires the user to come back.
It seems that this surveillance system has been remarkably successful. MoleMap have seen over 300,000 patients, mapped over 5 million moles. Can you take that a step further? What is the likelihood that this surveillance approach will save somebody's life?
VM: On average, we’ll see a bit more than 50,000 people a year, and that grows every year. About 30% will have some sort of recommended action. Most often, that is to continue monitoring a lesion closely.
We've started providing an increasing number of free tools for our patients & non-patients alike, to help support them. One of these is a web application that allows you to track your own lesions over time. This web app can also integrate that with the professionally taken photographs from our clinic.
So of those 30% where we advise continual monitoring, around 3% of people need urgent attention. We call them straight away and advise to see a dermatologist immediately.
If Skin Cancer Screening Reveals an Issue, What Next?
LB: In the case of a finding that is immediately actionable, talk us through what happens next for a patient.
VM: If there is a lesion requiring urgent attention, we'll call that patient to find out if they've got an existing dermatologist or GP whom we can send them a copy of our detailed report. If the patient gives permission, we send off the report and then the practitioner will understand what needs to be done and can act swiftly.
LB: In the case where there's an immediate finding we could argue the MoleMap visit has been a life saving intervention.
Should I Get a Skin Cancer Check?
LB: Coming back to those 50,000 or so people that come every year, nearly 40% of Australians have never had a skin cancer check, and many more of them fail to do it regularly. Why do you think it is such a difficult thing for people to manage? Why don’t more people complete regular skin cancer screenings?
VM: Compliance is a difficult thing, full stop. The number one barrier we talk about is apathy, as in, it won't happen to me. The main driver we see that finally gets people to act is when someone close to them - a loved one, a close friend - is diagnosed with skin cancer or dies from it. In the case of males, it's usually a spouse that drives them in to get screened. To be honest, guys don't tend to come in of their own accord.
LB: This is where we wanted to pivot to next - these objections: apathy, time, budget, nerves - what are some elements of the MoleMap service that help people get past those barriers and into a regular screening program?
VM: Our core service is going to cost what it's going to cost. So really, when people talk about cost, they're talking about value. What we're trying to do is support people in and around the visit, even before the visit.
Software management tools are a great example. First, risk assessment - we've got an online risk assessment. We also provide a free service where you can talk to one of our melanographers for 15 minutes to assess your risk and find the right service fit for your needs. We have a free online body map tracker, which allows you to actually track your own moles for a period of time.
“The number one barrier we talk about is apathy, as in, it won’t happen to me.”
Skin Cancer Screening with your GP?
LB: We understand there is currently an effort to get your technology directly into the GP room. In this model, GPs are provided the same system you offer and you train their nurse staff to complete the assessment. Tell us about the maturity of this strategy - Is it a pilot project? Or is this something you're in the process of going more widely?
VM: The pilot is well and truly done, and we've validated that it makes sense. It's got a lot of interest. We've rolled it out successfully in a number of practices across Australia, and we're beginning to roll that out in in New Zealand as well. It's going extremely well
LB: Is this something Australian’s should be asking their GP about - saying “Hey, have you heard about the MoleMap technology? I'm interested”.
VM: Look, that would be lovely. A significant number of GP visits are already skin related, and GPs are increasingly, in the last decade becoming increasingly educated around skin diagnosis. It's an already growing aspect of general practice. We're coming in with a holistic solution that hopefully, increases the patient outcome while decreasing the workload on the practice.
Artificial Intelligence for Skin Cancer Screening
LB: Continuing down the technology angle, looking into the future, MoleMap have created a very large database of skin lesions. Upon each visit, there is an opportunity for patients to opt in to allow their moles to be part of R&D.
Let's talk about MoleMaps R&D a bit, specifically where skin cancer detection technology is going in the future. As a starting point - explain what happens when one of your patients opts-in to allows their anonymous mole/lesion images to be sent off to improve the detection technology? What's happening there? What is their contribution, so to speak?
VM: Our vision is a world where all skin cancers get diagnosed and treated. That means we need to have a variety of options and solutions. The more lesion images that we can capture and categorise, the better that we can achieve that outcome. So that means we've got to look a lot further than just our own clinics.
MoleMap operates the biggest database of high resolution skin lesion images in the world. Perfect for training Artificial Intelligence algorithms. Picture: one of Nick’s moles that he needs to track!
We're starting to do that by offering that service to GPs and we are in the talks with a couple of big pharmacies. We have a workplace program where we come into your office.
About three years ago, we kicked off a process with IBM, because we have the biggest database in the world of high quality dermatologist diagnosed and categorized skin lesions approved to be used for research and development.
“Our vision is a world where all skin cancers get diagnosed and treated”
LB: That is a highly valuable and unique asset. So, what are your plans for this database?
VM: For the last three years, we've been using that imagery to train an artificial intelligence algorithm. Specifically, a convolutional neural network. And we’re continuing to optimise its ability to categorise skin cancers correctly.
We’ve also been working with Monash University, which has progressed to the stage where we've been comfortable enough to really want to invest in the commercialization of that technology. About six months ago, we formed a start-up company. It’s a stellar team of both technical business people, but also scientists within AI that have applied AI commercially in medical imaging in the past.
The team is now in the process of regulatory approval, which means, number one, being able to use that AI as a medical device. Secondly, the team needs to figure out how it makes sense to take it to market.
LB: Is this company currently in stealth mode, or can we know its name?
VM: Oh, it's called. It's called kāhu, named after a large hawk known for its sharp vision. The only thing that’s really stealth is what exactly the product is going to be. We've got some tight time pressures on that team and are expecting to get it to market quickly.
How Might AI Change The Skin Cancer Screening Process?
LB: When it does come to market, what is the vision for how that might change diagnosis or the surveillance process for catching potentially cancerous lesions?
AI will assist dermatologists by reducing the time they need to spend assessing each skin lesion.
VM: Well, again, if we go back to our global vision of the business, we're trying to get more images diagnosed. So this potentially helps that happen. It's unlikely that it's going to be the case where there is no human intervention. If you look at a lot of the best applications of AI, it's assisting an existing professional in the decision making rather than taking over the decision making process.
The AI technology would most likely be running alongside an already trained healthcare professional. It’s main potential is to deliver a higher level outcome to a wider audience - in other words, deliver the same level of diagnosis and categorization and patient outcomes, without having to have as much specialist contribution for every single lesion.
The Future of Skin Cancer Screening is Based on enabling patients to self-manage risk
LB: That's a great answer. Just as an aside to that, it was actually announced just today that Google had launched an AI health tool for skin conditions, including skin cancer. So that is another signal that artificial intelligence and good data sets in skin health is part of the future.
Pulling from your insights and some of the things you just talked about, what is your vision for how skin cancer diagnosis and treatment is going to change in the next 5 to 10 years?
VM: I think the key thing is, we've got to think about how to enable the patient to better manage risk themselves. There's a couple of levels of triage that happen. A patient goes to see a doctor, when they've got an issue, usually it is their family GP. They go and see that person for advice.
MOBILE APPS FOR SKIN CANCER?
Longevity Blog will soon be reviewing a selection of DIY options for skin cancer screening, be sure to subscribe below to get notified when that new content arrives!
Now, the nature of that is changing somewhat. There are now a number of mobile applications that are claiming various things that you can do by taking a photo of your skin with your phone and performing self-tracking. But the truth is the quality of those images and the ability of those people to really do the same job as a trained professional - there's quite a gap.
What we need to be able to do is get the best system and solution in as many doorways where patients are already visiting, as possible. The intent for us is really Australia and New Zealand as a testbed, before we begin to export globally. But we want to prove the case, really solidly here first, before we start to look at those options.
Bulk Billed Skin Cancer Checks
LB: Your answer actually flows on really nicely to an Australian specific question - when can we expect ‘bulk billed’ skin cancer checks to become available? It’s a legitimate question, given the prevalence of the disease in Aussies.
Is there a future for bulk-billed skin cancer checks in Australia? Not anytime soon, unfortunately
VM: We haven't heard any plans, even of it being reviewed. We don't go out and lobby or do anything like that. For us it's a step by step approach. We know that Medicare coverage for these checks would be hugely powerful. It would be good for Australians, it would be good for skin cancer diagnosis.
The first step that we can take, and we’re making some headway with, is working with major private insurance providers. More than one of the major private insurance companies in Australia are interested, and we're talking things through. We’re hoping to launch some partnerships very soon. That would be a really good first first step.
LB: At least there's some hope in the future with private health cover!
VLAD’s Personal Approach to Longevity
LB: We're gonna wrap this interview up now, Vlad, but before you go we always like to ask interviewees a little bit about what they do for their own longevity and health. To start, do you use the MoleMap technology yourself?
VM: Yeah, of course! I believe in proactive health management. I have an annual week of bloods, gut, dentistry, skin health that I personally go through. It's almost that via negativa process of ruling out the worst conditions. I totally believe in proactive health management to increase longevity and quality of life.
LB: Great to hear that! What have you learned from that week of focus that could be valuable to our readers in terms of putting together their own longevity strategy?
Establishing a good working with your personal doctor is a key longevity tip from Vlad. (GP = general practitioner, the same as Primary Care Physician in the US).
VM: I've got a great holistic GP, and I've started educating myself around the importance of gut health, more so than anything else. I know that skin cancer is bad, of course, and I need to be monitoring it. I know that heart attacks and strokes are bad, and I should be monitoring them. Putting it all together makes sense.
LB: So a good relationship with a high quality doctor has been one of the most important parts of that journey for you, as well as taking initiative to educate yourself on longevity risks.
VM: Yeah, totally!
LB: Thank you so much for contributing today, Vlad. We really appreciate it!
VM: Thanks mate!
FDA & TGA DISCLAIMER
This information is intended for educational purposes only and is not meant to substitute for medical care or to prescribe treatment for any specific health condition. These blog posts are not intended to diagnose, treat, cure or prevent any disease, and only may become actionable through consultation with a medical professional.
How Does Skin Cancer Screening Work
Skin Cancer Screening Saves Lives
“Don’t worry, be happy”
Getting a Skin Cancer Check “Mole Map”
“What are your plans for the day?” the tall brunette asked, as she rung up my Lulu Lemon shopping spree (I needed some new running shorts! They didn’t disappoint).
“I’m actually headed around the corner for a ‘mole mapping’, have you heard of that technology?”, I offered, excited to hear her reply.
Anxiously, she replied “Yes, you must be nervous! I’d be so scared of what they might find!”
I chuckled, “Well, actually I’m a bit used to it by now”, pointing to my Health Nucleus jacket and explaining this wasn’t my first cancer screening experience, quite the opposite in fact!
“Well, I’m sure you’ll be fine”, she offered.
“Actually, that’s what the appointment is for”, my somewhat cheeky reply.
In her polite laugh, I could see the point had landed.
“The clinic is just around the corner, you should check it out sometime”, my closing remark, as I headed off to a comprehensive skin cancer screening service, in search of that ‘sure you’ll be fine’ level of certainty - but not on a whim, instead, at the guiding hand of longevity technology.
Skin Cancer Spreads and Kills
Bob Marley - legendary musician, skin cancer victim
When Bob Marley, one of the most influential musicians of his time, collapsed during a run around Central Park, his first thought was not likely to fault skin cancer for the scare.
But further analysis revealed that a known cancerous growth in the skin under his big toenail had metastasised, spreading to his brain, liver and lung. He was dead only a few months later at age 36.
His death shook the world in a way not unlike that of Chadwick Bosemen, who died a similarly tragic death at the age of 43 from colorectal cancer last year, raising awareness of the disease, which has unfortunately continued to reek havoc on the lives of millions of people each year.
In my home country of Australia, skin cancer is particularly rife. 2 out of every 3 Australians will get some form of skin cancer by age 70. On average, an Australian dies every 5 hours from melanoma, the most aggressive and dangerous form of skin cancer.
However, it is not just older folks who are affected. Skin cancer is one of the most common cancer diagnoses for younger people in the ages of 25-44.
And while the 1970s did not offer the types of advanced skin cancer screening technologies that could have saved Bob Marley’s life - 2021 proves much different.
You don’t have to leave your skin cancer risk up to chance. You can manage the risk.
Let’s look at how.
Skin Cancer Screening Saves Lives
As I explain in the above video, my visit to a MoleMap clinic in the Sydney CBD was to provide a comprehensive skin cancer screening, leveraging imaging technology to make a ‘map’ of my skin, forming a baseline for future tracking.
The MoleMap clinic utilised a few key pieces of technology to complete this screening.
An example of one of the 26 high resolution images taken of my body.
Step 1: Full Body Images
The first was a series of high resolution photos, where, stripped ‘down to me undies’ (said in the lovely Irish accent of my melanographer Kathy).
In a series of coordinated movements, using a reference chart on the floor for my foot positions, I posed for more than 25 images.
These were taken with a Nikon DSLR, set for maximum focus on the skin of the body.
Each image was then mapped onto a virtual avatar in a specialised computer system.
Unfortunately the avatar was much more ripped than I, perhaps I will equal his masculinity next visit?
Step 2: Head to Toe Examination
After the full body images were taken, the melanographer (who was a registered nurse, specially trained by the Australiasian College of Dermatologists) reviewed my body from head to toe.
Side Note: I wasn’t asked to take off the underwear, unless I had a mole or skin issue I wanted them to track. Ladies - bra is optional, but recommend that you go without! Your female melanographer will be sure to make you comfortable and there is a robe you can use to cover up.
The dermatoscope in action. This tool is used after a mole has been marked by visual inspection, to further screen its shape, colour and size.
In this head to to review, Kathy would look at each of my moles using a Dermatoscope
This handy gadget uses a LED lighting and a magnifying lens to assess the surface features of a mole (more broadly referred to as ‘lesions’).
It allows up to 2.5x magnification and allows for the colour, shape and size to be reviewed in more detail.
Any more that ticks the boxes of being at increased risk (more on that in a moment), would have its location ‘tagged’ on my virtual avatar.
Kathy reviewed me thoroughly, including within my hairline, in a highly professional and considerate way.
Step 3: Enter the MoleCam
For any mole displaying any of the characteristics of skin cancer (basal cell carcinoma, squamous cell carcinoma or melanoma), further imagery was take using specialised device aptly named the “MoleCam”.
The dermatoscope identifies a mole with asymmetry and irregular border on my leg.
To be clear - this is not to say these moles are likely to be cancerous.
Instead, they match known characteristics of skin cancer risk are best remembered by the “ABCDs”:
Asymmetry (irregular shape)
Border (ragged or uneven)
Colour (more than two shades)
Diameter (greater than 6mm)
For each at risk mole, the MoleCam was used to capture two images.
The first, at a set distance and focal length - you can see the ‘slide’ extended from the device.
Second, with a ‘contact’ dermascopic image, where a dab of alcohol is placed on the lens, and the MoleCam is placed directly against the skin.
In the below 3x images, from left to right, we can observe the process.
The first image at extended focal length. The second ‘contact’ image. And finally, the contact image of the mole on my left foot is displayed on the device - you can see that Kathy rightly spotted its irregular shape, border and colour.
Step 4: Teledermatologist Review
In total, I had 26 moles of interest tagged and submitted for further review.
This is above average, and does suggest that my longevity is at elevated risk for skin cancer.
In general the moles were present all over my body, including the back, chest, abdomen, legs, arms and feet.
In some areas, sun exposure did appear to play a role, but in others, my naturally ‘mole-y’ complexion likely drove their prevalence.
Each of the detailed images that were taken by the MoleCam will now head off for a review by a ‘teledermatologist’, which is pretty much a fancy way of saying that a skin cancer expert will review each of the moles.
After this review, there will effectively be a ‘ranking’ of the risk each of the moles represents.
I will then receive customised advice on the MoleMap online patient platform, about 7 days or so after the appointment.
In most cases, the actionable information will be - watch & wait.
This is because the 5th aspect of the ABCDs of skin cancer is actually an E, standing for Evolution, or changes over time.
Cancerous moles, due to unregulated growth driven by DNA damage, generally have an inability to heal and fast cell turnover.
Whereas normal skin/moles will be steady-state, skin cancers will be changing. This is why your first MoleMap visit is so important - you form a baseline by which to assess the Evolution of your unique mole makeup.
This brings us to Step 5!
Step 5: Monitoring for Skin Cancer
The brilliant aspect of this mole mapping longevity technology is the ability to track changes in your moles over time.
New moles, quick changing moles or any areas of the skin which begin to react to excessive sun damage, need to be re-assessed over time.
Your MoleMap appointment will provide you with valuable reference material for self-assessment and tracking at home.
Depending on your individual risk factors (age, sun exposure, existing moles, genetics), MoleMap will provide you with guidance on how often you should re-assess with a follow-up appointment.
By the way - you can check your personal risk with this handy tool on the MoleMap website.
This of course also depends on your budget, and is one reason why you should form a personalised longevity strategy, and include skin cancer screening as a part of your approach to life a long and healthy life.
For me, this will be an annual visit (every 12 months), supplemented by a self-exam every 3 months.
Since I now know where each of my moles on interest are, and have been provided with some handy tools by the MoleMap team.
This includes a thorough information sheet, which I’ve uploaded here (see image).
However, one interesting fact to keep in mind - you can only ‘see’ about 40% of your skin - so be prepared to ask for some help!
Skin Cancer Screening - the Future
Coming up in our next post, Longevity Blog will interview MoleMap’s Chief Customer Officer Vlad Mehakovic.
We’ll dive deeper into how you can use skin cancer screening technology to manage your longevity risk, as well as chat about where this longevity technology will go in the future!
Be sure to subscribe below, so you won’t miss it!
FDA & TGA DISCLAIMER
This information is intended for educational purposes only and is not meant to substitute for medical care or to prescribe treatment for any specific health condition. These blog posts are not intended to diagnose, treat, cure or prevent any disease, and only may become actionable through consultation with a medical professional.
Adding Colon Cancer Screening to Your Longevity Strategy
Early Disease Detection is Essential for Longevity
As regular readers of the Longevity Blog will know - we stand on the precipice of incredible advances in the technologies available for measuring, halting and even reversing the aging process.
As the fusion of AI and computational power with healthcare and biological data marches forward, rapid improvements can be expected over the coming decades.
Therefore, if you’re keen on leveraging these advances, you’d better have a plan to stay healthy in the mean time!
[Timesaver Tip: If you’re not big into reading a blog post - you can skip the details and order your own at-home colon cancer test here! ]
Searches for ‘Colon Cancer Testing’ surged to a 5-year high after Chadwick Boseman’s death in August 2020. Source: Google Trends
Thankfully, modern medicine has become exceptionally proficient at treating life-threatening diseases - so long as they are caught early at the so-called ‘treatable stage’.
However, what is not entirely obvious is who is responsible for managing your access to the technologies ensuring early disease detection.
While, as we’ll discuss below, healthcare systems have begun to take on the role of providing some early screening services, you’d be quite naive to think leaving your health up to them is a bulletproof strategy.
Quite the opposite is true, in fact - ensuring your longevity requires a radical level of personal accountability and a proactive attitude.
This is to say, that longevity strategy is yours to lead, and while it should absolutely include your doctor and the broader healthcare system, it should not entirely depend upon them.
You need to know your risk factors, educate yourself on the many resources available and stay on top of the emerging technologies available for your personal risk management.
Thankfully, Longevity Blog is here to help. In this post, we carve out a segment of that risk management strategy - focusing in on colorectal cancer - and will present some newly available resources at your disposal.
Early Detection of Colon Cancer is a Lifesaver
Hear more about Aaron’s journey of colon cancer survivorship on the Pelatonia podcast “One Goal”. Pelatonia is an organisation who have raised over $218M for cancer research through the sport of cycling. Pictured: Aaron Conley
Colorectal cancer is both one of the most common and most deadly (in terms of total lives lost) forms of cancer in the developed world.
It also strikes a personal chord with the Longevity Blog.
While our Founder Nick’s wife was awaiting her surgery for the treatment of appendiceal cancer in late 2013, one his closest friends (Aaron, see image) was besieged by this disease at the young age of only 27 years old.
The shock of these diagnoses evoked strong motivations for exploring the ways we might contribute to the end of late stage disease diagnosis, once and for all.
And while that is a big dream, the ambition of reducing human suffering through the early detection of disease is very much at the core of the Longevity Blog mission.
We believe we already have most of the technologies required to ensure the long-term health of everyone who chooses to dedicate their resources to a comprehensive longevity strategy.
Colorectal cancer screening is one such resource. Let’s explore this topic - starting with, what is ‘screening’ exactly?
Cancer Screening - A Key Component of Your Longevity Strategy
The highly detailed, full body MRI available at the Health Nucleus is a key pillar of the ‘screening’ component of my personal longevity strategy - this is a very high tech form of cancer screening & where the Longevity Blog got started!
The concept of cancer screening is quite topical for the Longevity Blog. It forms one of the pillars of our shared longevity strategy - detect disease early, while it remains treatable.
Longevity Blog believes this can be accomplished through the *right* combination of medical technologies.
This of course includes detailed, full body MRI imaging as central to this objective.
However, full body MRI imaging has limitations with respect to its sensitivity to certain disease types - chiefly with respect to gastrointestinal cancers, and specifically esophageal and colorectal cancers.
Therefore, in order to comprehensively screen, one must turn to alternative strategies to minimise risk with respect to the diseases not sampled. Thankfully, colorectal cancer has several screening technologies at our disposal…
Colon Cancer Screening
Outside of advanced facilities like the Health Nucleus, cancer screening is most often disease specific. Australia’s most common cancer - breast cancer - can be screened via mammogram, for example.
And thankfully, the same is true for the 2nd most common cancer in Australia (and 4th most common in the United States) - colorectal cancer.
Colorectal cancer is the result of uncontrolled growth of abnormal colon or rectal cells, which grow to form a tumour.
However, most such cancers do not immediately begin in the tumour phase, originating instead as small abnormal tissue growths (called lesions) and/or polyps.
Source: Harvard Health
The process of forming a lesion and/or polyp, followed by possible malignancy, is often associated with the release of small amounts of blood into the stool, as well as low levels of tumour DNA material in more advanced cases/recurrence.
It is from this blood and/or DNA, that currently available cancer screening technologies can detect this potentially malignant activity. Let’s dive into how that works.
Colon Cancer Screening Technologies
Direct visual inspection of the colorectal (nether?) regions (e.g. colonoscopy) with biopsy (direct tissue sample) remains the gold standard for colon cancer screening.
However, over the past few years, test kits which can be completed at home have become widely available, as well as generally accepted by the broader medical community (For more, read this JAMA article).
These kits are so popular and effective, that governments in many countries have rolled out widespread test by mail kits.
Such a move has created strong market forces for driving the supply of these kits up, and the associated cost per unit downward - to the point where purchasing such kits out of pocket has become possible (we’ll come back to this point shortly!).
In the ‘test at home’ market offering, there are three primary technologies in use today. Two are tests which detect blood in the stool (known as a faecal occult blood tests [FOBT]), and the third tests for tumour DNA directly.
Review of Three ‘Test at Home’ Technologies
The current standard of care uses FOBT tests as ‘first-line screening’. These can be either the ‘guiac-based form (gFOBT)’’ or the ‘immunochemical form (FIT).”
gFOBT tests look for haemoglobin (an important oxygen carrying protein in the blood) in the stool, however it has been shown to be sensitive to diet and medications (e.g. red meat or high vitamin C intake). The requisite chemical reaction can however occur locally, meaning the test kits don’t have to be shipped back to a laboratory for the results. For example, one of these kits might involve dropping a tablet into your toilet and seeing if it turns a signalling colour.
FIT methods use an antibody reaction instead, which removes any complications from the diet (or medications), identifying human haemoglobin directly. These kits must be sent back to the lab for processing. FIT tests have become the ‘go to’ testing method for widespread use.
A third, emerging testing option is the ability to detect tumour DNA directly, with a high degree of accuracy (92%). These kits have not yet become directly available to consumer, and I won’t mention them again here.
For further reading, you can find a detailed list of pros/cons of the above three methods here
Who Should Get Tested for Colon Cancer?
The age at which the general population is recommended a colorectal cancer screening varies by who you ask. However, one trend is clear - the recommended screening age keeps getting younger.
For example, longstanding recommendations from the American College of Gastroenterology state “Men and women at average risk for colorectal cancer should be screened starting at age 50”, but go onto several caveats (45 for heavy smokers or African Americans), and even ≤ 40 years anyone with:
A first-degree relative who has had colorectal polyps or cancer
Crohn’s disease or ulcerative colitis
Lynch syndrome or familial adenomatous polyposis (FAP)
More recently, the general testing age was also dropped to 45 by two influential bodies in the US. The American Cancer Society changed its recommended screening guidelines in 2018, from 50 to 45 years citing “rising rates of bowel cancer in young and middle-aged populations.” Furthermore, the US Preventive Services Task Force also changed the age of screening to 45 quite recently (October 2020).
Should You Get Tested for Colon Cancer?
Depending on your age bracket, you may already qualify for free or subsidised colorectal cancer screenings. If this is the case - the answer is obvious, you should definitely test according to the recommended guidelines.
But what about folks under the standard age in their region of care? Should they get a test? Well, there a few factors to consider when answering this question - let’s address them.
#1 Colon Cancer Screening Tests are Inexpensive and Easily Available
With a bit of digging around online, you will likely be able to find commercially available test kits in your country. The price point on these kits is pretty outstanding, costing the user only a few bucks a month to test every year or so. Let’s take a look at four options, all available for under $70 (3x United States, 1x Australia):
Our Top Choice: LetsGetChecked
Let’s Get Checked at Home ($69 USD)
Technology: FIT
Second Generation FIT ($25)
Technology: FIT
[Alternative Link] (CVS)
EZ Detect ($12)
Technology: gFOBT
[Alternative Link] (Walgreens)
ColoVantage ($42AUD)
Technology: FIT
#2 The recommended screening age is falling
As was briefly discussed before, the recommended screening age has been on a downward trend over the past decade.
This is because colorectal cancer occurrence in young adults is on the rise, as a part of a global trend in developed countries (read more).
Consider this startling statistic: People born in 1990 onwards have double the risk of colon cancer and quadruple the risk of rectal cancer compared with people born in 1950 (source).
Concerningly, when the disease is detected in young adults, it is often at a late stage. You need only scroll back up to the top of this blog post to read about 27 year old cycling enthusiast Aaron for an example.
In his case, a fairly late (stage III) diagnosis, following him experiencing extreme fatigue on his regular rides. Chadwick Boseman was only 43 years old when he passed away, after battling colon cancer for four years (age of stage III diagnosis ~38-39 yrs).
While its not yet settled why later diagnosis is common among young adults, it is surmised they are more likely to write off early warning signs, and are also less likely to have health insurance.
None of these details are particularly important to the point being made here - individual young adults are still at risk for developing colon cancer, even if the average risk of this population is low.
Source: Bowel Cancer Australia
#3 Colon cancer screening tests are accurate and highly effective
Test at home colon cancer screening technology is highly developed, and so effective, that is has become the standard of care for early screening.
So useful in fact, the biggest challenge healthcare systems have with colon cancer screening is increasing compliance (link). Imagine that - a healthcare service where increased demand is viewed positively!
Why? Because the tests are cheap, save lives and reduce downstream costs. That’s a rare win-win for healthcare!
#4 False positive downsides are small
Positive FIT tests are about 80% accurate for detecting cancer, and positive findings only occur in about 5-8% of people.
If your test comes back positive, your doctor will likely recommend you for a colonoscopy. Colonoscopies (as Aaron addresses in the podcast) are not as unpleasant as they might first sound.
Aside from the inconvenience of missing work, and the potential costs (check your insurance policy carefully), there is very little downside ‘false positive’ test result.
Furthermore, if there is blood in your stool, but no cancer or pre-cancerous legions/polyps, there may be other health related issues revealed in the process (e.g. hemorrhoids).
One could perhaps think of these tests more broadly as a ‘blood in the stool’ test, in that regard.
Colon Cancer Screening Conclusions
The Longevity Blog can’t make any healthcare recommendations to you, full stop. However, following the logic of the previous four points brings me to a fairly obvious, personal conclusion:
Colon cancer screening tests are accurate, effective, commercially available without a prescription at low cost, with very little downside to a false positive result (miss work, potential out of pocket costs, anxiety for some). Risk rates for adults below the screening age are not negligible. There are very high costs to late stage diagnoses.
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FDA & TGA DISCLAIMER
This information is intended for educational purposes only and is not meant to substitute for medical care or to prescribe treatment for any specific health condition. These blog posts are not intended to diagnose, treat, cure or prevent any disease, and only may become actionable through consultation with a medical professional.
Early Cancer Detection and Big Data - Health Nucleus Interview Part 1
Shaking hands with Dr. Duchicela (left) during my January 2020 visit to the Health Nucleus!
In this post you’ll learn:
Dr. Duchicela’s background
Big Data & healthcare
The definition of ‘Healthy’
Early detection of Cancer
Part 1 - Intro, Cancer Detection, What is Healthy?
In a series of three posts, Longevity Blog interviews Dr. Keegan Duchicela, Medical Director at the Health Nucleus in San Diego, California. Dr. Duchicela received his medical degree from UCSF in 2007. Since the completion of his residency, he has served as the Lead Physician at the Google Wellness Center (Google’s on-campus medical facility), and over the past three years has held several roles at the Health Nucleus including Clinical Director, Medical Director and Physician.
This interview, from the 24 January 2020, walked through a series of pre-written questions with Dr. Duchicela, and is presented in the form of a transcribed audio conversation.
Longevity Blog:
Q: What motivated you to become the medical director at the Health Nucleus? That’s a pretty cool job!
Dr Duchicela:
A: It is pretty cool! My training is in family medicine, so from the get go I have felt there is great value in preventing and detecting disease before it happens and having actual relationships with the patients to really delve into things other than just normal lab values and imaging. I think you really need to get to know the patient, their family, their socioeconomic context, and their culture, as well as where they live to really get a general sense of their health risks, because there are so many other things besides just labs that determine how healthy you are.
Corporate wellness centers, like those run by Premise Health, are becoming more common at big tech companies, like Google. And they recruit top-notch medical practitioners like Dr. Keegan to run them. Source
I come from a different perspective, I didn’t go into medicine to learn about genetics or advanced imaging or even precision medicine, my focus was more on getting to know the person holistically to really enable them to take care of their body, their mind and their family. I looked at health in that context. But as I went through training and through the kinds of places I’ve worked over my career; I worked for a few years at Google helping lead their onsite primary care clinics where I encountered a lot of interesting individuals, engineers who were doing some amazing things with Big Data, I started to really see the value in having a large data set on health metrics and what you can do with that sort of information and the impact you can achieve. I began thinking that the future of medicine for physicians is as good data scientists with excellent bedside manner.
If we could offer this testing at a very inexpensive price point to millions of people, how much better would our health improve overall? I think it could be pretty dramatic to be honest with you.
I really think that’s where we’re heading. And so as a physician I feel like it’s really important to grasp the implications of using Big Data and what it really means and how we can use these analytical tools to predict where we’re going with our health.
after I left Google, I was looking for a company that was doing innovative things
So after I left Google, I was looking for a company that was doing innovative things in this space and really Human Longevity was the only place that I found that’s using imaging, genetics, peripheral blood biomarkers, plus family history and past medical history and putting it all together and getting a comprehensive view of health. So that’s what attracted me to the position. It’s been a wild ride and very interesting to see how the company has evolved and progressed and I think we have a pretty bright future. It’s exciting to be the medical director and that’s kind of how I ended up here.
Looking at this from a primary care perspective, if we could offer this testing at a very inexpensive price point to millions of people, how much better would our health improve overall? I think it could be pretty dramatic to be honest with you.
Longevity Blog (LB): I love that vision and one of the things that attracted me to HLI (Human Longevity Inc.) was one of your founders Peter Diamandis. He’s one of my… ‘heroes’, I’ll call him, a mentor, somebody I look up to. He shapes my thinking a lot and that idea of inexpensive testing for millions and reaching and impacting people positively is a mission that I believe in. The Longevity Blog is me playing my small part in helping to accomplish that.
There’s a really interesting kind of dichotomy that we find between the healthcare industry and the Health Nucleus - and that’s thinking proactively about health care. If I were to go into my doctor’s office, my traditional GP here in Australia and didn’t have any acute symptoms of any sort and told them I was there to optimise my health, they would probably tell me to get outta there because they are there to take care of somebody who’s sick.
Q: So, I was curious what you think the Health Nucleus definition of “healthy” is and how might it be different from a traditional one?
From the Health Nucleus website
Dr Duchicela:
A: I think right now we are in version one of this, in that we are trying to create a suite of testing modalities. We are trying to detect the things that prematurely end people’s lives very early on. The broad categories of these would be things like cancer, metabolic diseases like aneurysm or heart disease, and neurodegenerative disease like alzheimer's. And right now our testing packages or testing suites are set up where we’re looking for those big categories of disease.
When we have enough data and we have enough people go through, and we are able to create advanced risk prediction tool kits and algorithms, that’s when the real promise of a company like this can come to fruition. We do get pretty rigorous metrics from things like genomics and also from the imaging biomarkers like liver fat and visceral fat, but what we really want to do and what we’re currently working on and what really excites me is taking your genomics - let’s say dementia or Alzheimer’s - taking your ApoE status and taking your hippocampal volume metrics from your imaging and also taking into account these other genomic variants that may not contribute to risk in such a large way as for example ApoE does, but on their own could tilt the needle one way or the other and putting this all together with your alcohol consumption, your BMI, your visceral fat levels and everything else and using machine learning and AI to come up with a ten year risk prediction for Alzheimer’s disease.
An example of the brain imagery data collected by MRI at the Health Nucleus, to compute metrics like hippocampal volume. Pictured: my own brain!
That’s where I think the true promise of this testing lies, but those algorithms need to be developed and it really does take a large data set to develop those algorithms. So right now I’d say in terms of our testing modalities we have a really good screening test for these five big categories of disease, but we really want to evolve into becoming the crystal ball for alzheimers, the crystal ball for metabolic disease, the crystal ball for prostate cancer or breast cancer by putting these algorithms or data modalities together and really deriving some good inferences from them, but we need a large data set first. I think that’s the biggest challenge with this.
LB: Right and so that kind of definition of healthy is actually shifting perspective out ahead of time almost, not just are you healthy now, but will you be healthy in the future and what can we do to minimise your risk and hopefully be able to be more predictive with more data and better algorithms that you’re continuing to develop.
Dr Duchicela:
it’s tricky to give a one size fits all definition of health. You really have to take in the context of the individual and see what their values and priorities are and what they want out of their life
A: Yeah and everyone really has their own definition of healthy, because different people have different values. For example I had a patient the other day who is a wine entrepreneur. This is his business, this is how he supports himself and his family, and to tell him, “Hey listen, if you really want to optimise your health and be quote-unquote completely healthy, you may want to avoid the amount of alcohol you’re drinking, because alcohol is a carcinogen.” For him, that would actually negatively impact his lifestyle. He wouldn’t necessarily be living a happy life if he gave up his profession. So, I think it’s tricky to give a one size fits all definition of health. You really have to take in the context of the individual and see what their values and priorities are and what they want out of their life.
And if you ask people about this, it’s not one size fits all. I think that’s the art of this, figuring out what drives them, what motivates them to come in to get assessed; Is it a family member who was recently diagnosed? Is it because they have a grandchild now and they want to be able to be healthy and active for when they get older?
And, at least as a physician that’s what I’m trying to focus on, how do we judge success? I don’t think it’s necessarily just not dying at an early age. It’s essentially living a fulfilling life and accomplishing the goals that you want to accomplish, whether that be having your own wine business and doing that as a profession or living to 100 and being cancer free the entire time. So, I think what we like to do here at the Health Nucleus is focus on the goals of the patient and really try to tailor our recommendations and counseling towards their goals.
LB: That’s great and I love that individual nature of it and the reflection of values and goals that the individual has. You’re right that the definition of healthy has to sit in that spectrum. That’s an encouraging answer and one I definitely agree with.
You just mentioned at the end of your talk there, cancer. Cancer is actually something that has personally impacted me, even directly in my own wife who has had to have two big peritonectomy surgeries for appendix cancer, thankfully she’s in remission now.
I think about the widespread availability of Health Nucleus technologies and MRI scanning etc. and think about if we had had routine access to something like that, how might that outcome have been different.
Q: Now, I don’t want you to go into theoretical outcomes for my specific case, but I’m really interested in helping to share with folks how the Health Nucleus can detect the actual presence of cancer, not just cancer risk but the actual presence of cancer at an early stage.
Dr Duchicela:
A: That’s a great question. When looking at our testing modalities, we have the imaging which is almost like a point-in-time disease test. We’re looking for disease right now, or early early disease, that’s the hope. With the genetic testing, it’s more your disease risk five years, ten years down the road. So the imaging is really powerful in that we can tell you within a few hours after a scan, if there is something concerning, a soft-tissue mass or an aneurysm even.
our goal is to develop a test that doesn’t use radiation, that we can give safely to many many people, that covers most cancers and then have a suite of tests to fill in the gaps essentially.
With our imaging, that’s really the goal, we cover some cancers pretty well, but we also have some gaps in our cancer coverage, just to be completely transparent. We don’t pick up colon cancer or certain other GI cancers very well, the MRI results are limited because we don’t have people do a bowel prep ahead of time, so we would still recommend a colonoscopy or a Cologuard test for that.
Certain pulmonary cancers you can’t get too well just yet with MRI but we’re working on that. No screening test is perfect, and you can’t catch every cancer with one single test, but our goal is to develop a test that doesn’t use radiation, that we can give safely to many many people, that covers most cancers and then have a suite of tests to fill in the gaps essentially.
My own Health Nucleus MRI scan (pictured), from 2018.
Or maybe they can go through their traditional medical provider to do the colon cancer screening if we don’t have a good option for it here. So in terms of developing a test for cancer, it’s tricky because we don’t want to say that if you have a completely clear scan you’re cancer free, there are gaps and limitations with the current technology. But over time as we are able to get more patients through, we’re able to do better processing on the images, so hopefully we will start to fill in those gaps with better early detection of cancer.
LB:
Q: You’ve made very clear caveats on the limitations there, but where does your technology excel and succeed? There would definitely be some anecdotal examples of detecting certain types of cancer at an early stage. You certainly have some excellent technology in that space, could you elaborate a bit further on that?
Dr Duchicela:
I think where it excels is that we’re able to get really good images without having to use contrast and that’s really important if we’re trying to scale this and bring it to many people at a low price point, we want to make it safe too. We do have pretty good post processing.
Let’s take prostate cancer for example, most men will die with prostate cancer, rather than from prostate cancer. So the trick is, how do we know which prostate cancer is going to be an issue and is going to prematurely end your life and which is so slow growing that they will most likely pass away from other things instead of the prostate cancer. With the post processing that the computer scientists and radiologists, people much smarter than myself, have developed, they’re able to light up and differentiate with the software these higher grade lesions in the prostate that have a higher chance of being a concern and being more aggressive and truly cancerous.
Image Credit: UC London. Prostate cancer screening by MRI is becoming more widely accepted. That’s very good news for early detection and treatment. Source
So that kind of differentiation on the back end is really powerful. We don’t want to be detecting things that won’t really harm someone in the long run. If you’re familiar with prostate cancer screening in general, it’s pretty controversial just because if we find something, we are almost obligated to biopsy it and there can be complications with biopsy. So we really want to make sure that we are finding things that are meaningful, and I think with the post processing that we do with our scans we can make that differentiation and better guide them to say alright this a lesion that is at a much higher risk, so we would suggest you get a biopsy, as opposed to alright this is lower risk lesion based on our scans and it may be more reasonable to watch and wait, get a serial PSA, that sort of thing.
LB: That makes a lot of sense, and you’re right in terms of wanting to minimise false detection or follow up treatment or biopsy to the really significant or possibly progressive forms of the cancer. That’s really fascinating.
We’ve talked a little bit about cancer, another big killer and one that is kind of a function of how old you are and how long you’ve been alive and a number of genetic risk factors is actually cardiovascular disease and in particular atherosclerosis.
I understand my risk as a man in his thirties is low for an acute event now, but that it’s really decade on decade buildup of plaque and inflammation and wear and tear on the arteries that increases the risk…
Q: So how does coming to the Health Nucleus help inform someone about their risk as they get older and what they can do as a young person to minimise the risk of atherosclerosis and cardiovascular disease?
I’ve split this interview into four parts, due to its length! Part 2 is coming soon :)
Note: the Health Nucleus has recently appointed a new Medical Director - Dr. Pamila Brar. Dr. Duchicela has transitioned to a role as full-time physician at the Health Nucleus, working directly with patients to optimise their healthcare!
Follow us on Twitter for the latest #Longevity news!
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Comprehensive Health Screening: Health Nucleus
Health screening is the future of healthcare
In this short 5-minute video, our founder shares personal thoughts on the future of healthcare, and why it is proactive. The technologies to prevent disease are at your disposal, will you choose to access them?
medical screening in great socks
The Future of Healthcare
includes great socks 🧦
The future of healthcare is based on health screening that is proactive & preventative!
Today, we have all of the medical technology required to detect and treat the most common life-threatening diseases, provided that we can detect them early on.
This includes common killers such as cardiovascular disease (heart-attack, stroke, thrombosis), the chronic illnesses of metabolic disease (diabetes) and, of course, most cancers.
Even health screening and early detection of diseases of the brain (alzheimer's or parkinson’s) can result in extended healthspan, and slow the rate of disease progression (although a cure for these maladies will likely require changing the ageing process itself!)
Health Screening Gets Personal
As our founder shares, health screening is part of a personal motivation for creating Longevity Blog. “In my late 20s, I had three people quite close to me, also in their late 20s, be diagnosed with cancer. In fact, one of them, was my own wife (appendix cancer)!”
“Another had stage III colon cancer. The third, stage IV testicular cancer that nearly took his life.”
In each of these cases, treatments came well after the onset of the disease, which brought on deeper thoughts on the very nature of how we detect and treat these diseases.
Health Screening is how Healthcare catches up to the 21st CenturY
New longevity technologies are being developed and deployed at an increasing pace. Some forward thinkers, including our Founder, observe this trend to be exponential in nature.
This is particularly true for health screening technologies which are directly coupled with progress in computing capabilities (processing power, network communication speeds, memory availability).
However, your personal experience in the healthcare system does not make these changes immediately evident. The healthcare system has made great strides in responsive medicine - treating disease at later stages, after an acute event or advance systems are present.
comprehensive regular health screening is available now
All of the health screening technologies required to detect diseases at an early, highly treatable stage exist NOW (at the time of writing, late 2019).
It is not technological limitations which prevents your access to these technologies. Instead, the limitations are based on 1) knowledge of alternatives, 2) financial means to access them, and 3) your personal demand for access to them.
This foundational post from the Longevity Blog will be followed by all of the information you’ll require to learn about proactive healthcare technologies and how to access them.
It will include our Founder’s personal foray into this technology space, where we’ll use his experience to thoroughly vet and explore these new technologies, to help you decide which to add to your own personalised longevity strategy.
FULL BODY HEALTH SCREENING: the Health Nucleus
Full Body 3D MRI - on the cutting edge of proactive healthcare
As you’ll soon learn, many forward thinking technologists, scientists and medical professionals have already begun to create a healthcare system worthy of the 21st Century.
Where this adventure will start, is at one of the most comprehensive health screening treatment centres in the world: Human Longevity Inc’s Health Nucleus.
Based in San Diego, California, our Founder first visited the Health Nucleus in May 2018. Where he underwent the following:
a wide-reaching blood panel
microbiome sequencing (💩)
What followed on from this visit was a complete transformation in his approach to health and wellness. It’s precisely this type of self-experimenting that helps us create unique content to guide you on your own wellness journey.
Read more about the Health Nucleus in the following posts:
