MBC Matters Meet Up: Blood Test Results- Understanding Your Laboratory Test Report

00:00:00:00 - 00:00:38:04
Unknown
Welcome to Share Embassy Matters. Video Presentation titled Blood Test Results Understanding Your Laboratory Test Report. I'm your host, Kate the Professor, the Metastatic Breast cancer program director at SHARE. And I'm Victoria Goldberg. I'm here to represent the podcast, our own Busy Life. And I really wanted to meet and talk to Dr. Torres, and I just wanted to let you know that this recording is going to be turned into a podcast episode.

00:00:38:05 - 00:01:06:07
Unknown
Before we begin, I'd like to tell you a little bit about Share. We're a national nonprofit that supports, educates and empowers anyone who has been diagnosed with breast or gynecological cancers and provides outreach to the general public about signs and symptoms because no one should have to face breast cancer, ovarian, uterine, cervical or metastatic breast cancer alone. For more information about upcoming webinars, our ABC Life podcast, a support group, our helplines.

00:01:06:09 - 00:01:25:06
Unknown
Please visit our website at Share Cancer Support Talk. Now I'd like to hand it over to Dr. Alfredo Torres to introduce himself. I thank you, Kate, and thank you, Victoria, for having me here. Very excited to be part of this webinar and to reach so many patients. I think it's a wonderful initiative and I wish you the best in your future endeavors.

00:01:25:07 - 00:01:48:21
Unknown
My name is Taurus. I'm a medical oncologist. I work at New York Cancer and Blood Specialists. I currently serve as assistant chief medical officer. I have other titles. I work with the American Cancer Society on Long Island. I sit in their board as well, and I'm currently nominated as a chief chair for a GI in one Oncology, which is a big umbrella group that we have for community practice.

00:01:48:23 - 00:02:15:09
Unknown
I'm certified as an internal medicine. I'm certified in medical oncology and medical hematology as well. One of the reasons we're meeting today is actually that we're going to go over some of the labs you will see as a patient. The labs that we commonly use for surveillance treatment of the cancer itself, and also possible side effects that can be encounter with some of the therapies that we use specially in the metastatic setting.

00:02:15:11 - 00:02:46:20
Unknown
So one of the things that has changed recently with the Transparency Act is that most of the patients have access to their medical information and almost immediately that in one hand is phenomenal because that will empower people to advocate for themselves in terms of knowing exactly what's happening and having that accessibility to their records easily. But it also creates a lot of confusion and anxiety because it's not just about what the lab and the number says is how to interpret it and put it in the right context.

00:02:46:22 - 00:03:08:13
Unknown
But the reality is that knowing when that value, if it's abnormal, is actually of clinical relevance, that becomes a little bit more challenging. But I'm hoping that during this 10 to 15 minute discussion, I can tell you at least some of the basic law works that we typically see. So you as a patient can advocate for yourself in case you're seeing any abnormalities.

00:03:08:15 - 00:03:49:15
Unknown
I would say the most commonly used lab is the CBC. That stands for complete blood count. And here we are actually going to see three big numbers. The firstly, the white blood cell, the level of cell usually ranges from 4 to 10, and it can tell you a lot when you're below that number. That's called neutropenia usually. And when those numbers are severely down, especially if your absolute neutrophil count, ANC for short is quite low, you're running a risk of having severe neutropenia and that makes you very immuno compromised, meaning that if you have a fever is quite on an emergency, actually you need I.V. antibiotics as soon as possible.

00:03:49:17 - 00:04:10:14
Unknown
When the white blood cell count is high. It could be that you are having an infection, but it also could be that you're having a normal response if you're having what we call growth factors. Sometimes when you're having chemotherapy, we give you an injection to avoid the neutropenia. And when those numbers are high, it could be a perfect natural response to the growth factors working.

00:04:10:19 - 00:04:33:02
Unknown
So again, seeing the number by itself doesn't mean anything. You have to put it in the right context. So that's in the white blood cell count space. Then the second big number that we would address is the hemoglobin. So the hemoglobin in a normal woman will be 11.5 or greater in a man can be a gram higher and also depends on the h what a hemoglobin when it's low, that's for anemia.

00:04:33:04 - 00:04:54:08
Unknown
The the lower the hemoglobin, the more symptomatic the patient is expected to be. So shortness of breath, tachycardia, fatigue, headaches, pallor being pale, all or all of those symptoms are expected with anemia. And the lower the number, the more of symptoms you will see. However, the anemia has to be interpreted of its acute meaning that it happened weekly.

00:04:54:08 - 00:05:22:00
Unknown
So you're having normal anemia and then suddenly you have a big drop. Usually when that happens, patients are way more symptomatic and it probably has to do with either a bleeding or a more severe reaction to chemotherapy or if it's chronic, it's a more of a slow down trend in the hemoglobin. They're actually not symptomatic. And I have seen both cases of a patient, for example, with a hemoglobin of seven that is extremely short of breath winded and tachycardic and a patient with a hemoglobin of seven that is completely normal.

00:05:22:01 - 00:05:41:11
Unknown
Usually that happens when it's more chronic. So your body has time to accommodate. The last number that we see on the CBC is the platelet count. So we know is a cell that is in charge of helping with clotting. And that number can fluctuate bending if the patient is on chemotherapy. So that's where the CBC as a hemophilia in college is.

00:05:41:13 - 00:06:00:17
Unknown
We look a little bit deeper into the subtypes of white blood cell count, but that could be a little complicated. But as a rule of thumb, if you know what's happening with a white blood cell, count on the hemoglobin, the and the platelet count, that gives you a very good overall about what's happening. The next best that we use is called the CMB, and that stands for a complete metabolic profile.

00:06:00:22 - 00:06:26:18
Unknown
And the difference between the complete metabolic profile and the basic metabolic profile is the inclusion of the liver function tests. And we'll talk about that in the CMB and the BNP. We're usually going to see the electrolytes and the renal function. The electrolytes that we see are sodium, potassium chloride. Then we're also going to see the CO2 level glucose and the renal function, the renal function.

00:06:26:19 - 00:06:56:15
Unknown
This is usually presented as UN and creating and they will tell you how your kidneys are functioning. Very important to know that it can also be an indicator of dehydration. So for example, if you see a very high UN with a ratio to the UN to creating more than 20 is suggestive of dehydration and then sodium, potassium chloride, you can see them being higher low bending certain situations and they should be grossly within normal limits in terms of the CMB.

00:06:56:15 - 00:07:23:03
Unknown
So complete metabolic profile, if you're going to add the liver function test, left these for short liver function tests are going to be alt SD access and total bilirubin, and they're actually very helpful to see two things. The first one, if the liver is functioning well, and that could be because of therapy, chemotherapy, because again, a big portion of the chemotherapies are processed and metabolized by the liver.

00:07:23:05 - 00:07:42:01
Unknown
The second thing, breast cancer tends to go to the liver. Again, you have to put in the right context, but it could be suggestive of liver dysfunction by either therapy or that itself. It can also see sometimes if there's an obstruction in the biliary tract so your bilirubin can get elevated. So with that, we can actually see a lot.

00:07:42:01 - 00:08:06:19
Unknown
And alkaline phosphatase, of course, is something that is related to the liver and the liver functionality, but it also can be seen elevated in the setting of bone disease. So something that especially in breast cancer that tends to metastasize to the bone. So we pay close attention to and then electrolytes that we follow, there are calcium and magnesium because it is important, especially if you're getting a bone resort invasion.

00:08:06:19 - 00:08:31:05
Unknown
So diva or Prolia or Samatta, those agents need calcium to build up your bones so you can see Hypercalcemia if you are in treatment with those agents. Also that calcium is high, it could be an indicator that metastatic disease is going into the bones. And there's a thing called malignant hypocalcemia. So if the calcium level is extremely high, that could be considered also a medical emergency.

00:08:31:07 - 00:08:56:12
Unknown
Other tests that we like to order in breast cancer are vitamin D levels. We check them often. The majority of people actually have low vitamin D, especially when the winter comes. The sun exposure gets a little less. And I want to emphasize something very specific to breast cancer. We check what we call two more markers. So the tumor markers are labs that can help us see if there's activity of the disease happening.

00:08:56:14 - 00:09:15:00
Unknown
And the important thing about the tumor marker is not necessarily that number itself, but the trend. And I like to share a story with my patients. I think that a lab actually is a picture, and we don't want to see a picture of something frozen on time. We like to see a movie. So to me, the number itself doesn't tell me quite the whole story.

00:09:15:06 - 00:09:44:00
Unknown
I like to see the trend. If the trend is going up, especially if it's going up rather quickly, there's a fast doubling time that's actually very suspicious and very worrisome for activity of the disease. And the opposite is also true. The numbers are going down is actually it tells you that the patient is responding to that therapy when you're going through chemotherapy because you are going through processes of losing a little bit of blood, decreasing the production, and then you're trying to ramp up that production in the bone marrow.

00:09:44:02 - 00:10:02:08
Unknown
We like to test for folic acid, B-12 and iron levels, which are the main components of hemoglobin. So we check on iron panel. Every so often that iron panel will have the iron that the ABC, which is a total iron binding capacity, which if it's high, that means that you're in need of iron and we check it with ferreting.

00:10:02:08 - 00:10:22:10
Unknown
So if this very thing is usually less than 100, that means that you don't have enough iron in terms of B12 and folic acid. If they're low, we like to replace because you are going to need those vitamins in order to make sure that you have a normal production of hemoglobin that will help to expedite the recovery of the anemia.

00:10:22:12 - 00:10:50:02
Unknown
So those are usually the main labs. If you're having a specific medication that can have some specific side effects. For example, we have some medications that can affect your cholesterol. We like to check a lipid profile every three months. Or if you have a medication that can affect your glucose. We like to check the A1. See also every three months or every so often, depending on if it's controlled or not, to make sure that those labs are not getting out of hand.

00:10:50:04 - 00:11:13:21
Unknown
Again, the most important thing when we see these labs is actually the interpretation of where the labs are. Sometimes one doesn't tell you the whole story. Being outside of the normal ranges is not an indicator to panic or to be extremely concerned, but to have a fair discussion with your doctor. And with the exception of, for example, hypercalcemia and neutropenic fever, most of them are not under emergency.

00:11:13:23 - 00:11:42:10
Unknown
I tell my patients that treating and living with metastatic breast cancer is more like a marathon, not a sprint. When you are talking about normal range, you had mentioned mostly normal range. A lot of us in the community, we're trying to stay on top of our labs and we're looking at things and they really honed in on the interpretation and we should not be our own doctors and interpret this stuff.

00:11:42:12 - 00:12:05:19
Unknown
But there are so many questions when it comes to normal range. A lot of times we hear patients say it's within normal range, but I'm seeing a trend and it's going up or sometimes it's up and it's a high upper range and sometimes it's low lower range and they're trying to analyze it. And what does that mean? It would be wonderful to hear your take on what a normal range is and what do you mean by mostly.

00:12:05:19 - 00:12:33:15
Unknown
No, absolutely. So you're not a doctor. You are not responsible to make decisions based on those numbers. But the more that you know about them, the better a conversation we can have. So what is a normal range? A normal range is exactly what the lab decides to be within normal limits. And usually those labs were that their mean when they study thousands of people and they need a pretty much a bell curve and you have a minimum and a maximum of normalcy all those lab values you mentioned something very important.

00:12:33:17 - 00:12:49:13
Unknown
So just normal ranges doesn't get you out of the woods, but most of the time it is okay to be within normal range if you are hitting those normal ranges every time you get bloodwork, that's usually a good indicator Things are going to be okay and they're stable. But let's talk about some of the numbers in more detail.

00:12:49:13 - 00:13:11:18
Unknown
Like you mentioned. So the white blood cell, we said usually a normal range will be like 4 to 10 if you're below or above, that's something to address. For the hemoglobin less than 11.5, you're usually going to see other patients anemic. The lower the number, the more symptomatic and the worse it is. And then for platelet counts, for us in hematology, we pay more attention when the planets are starting to be below 100.

00:13:11:20 - 00:13:42:22
Unknown
When they're below 50, we say, okay, we probably need to do some medication modification. If they're taking antiplatelet therapy and anticoagulation and IV, there is some 30 or is there bleeding, then we really have to address it with something else that will be platelet transfusion or medication, depending on whatever the case will be. If you go on the CMB, usually when the electrolytes, sodium, potassium are abnormal, we tend to address it, but it could be something as simple as the sodium is low for the patient to do it a little bit more salt or to hydrate better if the kidney function is a little abnormal.

00:13:43:00 - 00:14:03:19
Unknown
But in general, we want to address the electrolytes because when they're far away from the normalcy, they can actually have problems with the heart and those could be serious. The renal function to be under the grant I was mentioning usually doesn't change drastically. And when that happens, that's something more acute that is happening like an obstruction, for example, in the bladder or the urethra.

00:14:03:21 - 00:14:30:05
Unknown
The most common abnormal lab that we see is a difference between the UN and the CARIAD, and that usually is a sign of dehydration, which is seen after chemotherapy because of the inability to drink, maybe secondary to nausea. So I'm always emphasize to my patients that you have to maintain adequate hydration after chemotherapy, and if they cannot achieve that, then I have the patients get hydration I.V. just to make sure that we're healthy and preventing dehydration.

00:14:30:05 - 00:14:50:02
Unknown
So now, because of the numbers, because of how people feel when they're dehydrated and then the side effects are usually worse, the liver function tests are very similar to the kidney function. They usually don't jump too high. And you have a lot of wiggle room because the liver is a very noble organ. And the only way like 10% of the liver, it will still function well.

00:14:50:04 - 00:15:12:20
Unknown
So normal would be like 30 or less. But if you're seeing that 30 to 100, roughly speaking, you still find there's not a lot of things to do. But if you're starting to see like the numbers being 3x5x ten x, the normal limit of normal, that's not good, especially if it happens acutely. So that means that the liver is being overwhelmed either by a side effects from the medication and infection or disease.

00:15:12:22 - 00:15:31:08
Unknown
So that does something to pay attention to. For the tumor markers that we mentioned. The number itself doesn't mean much usually depending on which tumor marker in which we are using, that number is usually less than 30. For example, for some of the tumor markers that we follow. If you're following CTA for a nonsmoker is usually less than five.

00:15:31:11 - 00:15:53:15
Unknown
The number itself to me is not super relevant. Is the trend for that number that we actually follow. Vitamin D that we touch upon is usually 30 or above. If it's less than 30, you're actually low in vitamin D, and one important one will be calcium. The calcium is usually below ten if is great, and then it is dangerous if it's below eight, that's also not doing as well.

00:15:53:16 - 00:16:15:18
Unknown
We had another question regarding the liver enzymes, because that's something that can sometimes go up and we wonder why is it going up? Is it the treatment that we're on? Perhaps maybe a dose needs to be change or maybe it's liver progression because that's an area of concern for us with metastatic breast cancer. That's something triggers and said, you know what?

00:16:16:00 - 00:16:33:15
Unknown
What would you do? We don't treat numbers, we treat people. So if you give me numbers colon dry and you show me a picture, I will probably won't be able to tell what's happening. But if you tell me more information when I examine the patient, I know their patient history. I might be able to have a better deduction about what's causing what.

00:16:33:15 - 00:17:02:08
Unknown
For example, if I have a patient that I know is getting therapy that is actually metabolized by the liver and the patient had normal liver function tests, and then the week after I give the chemotherapy, those numbers went up. I can almost assure you that was a side effect from the medication that was worth telling me, that a patient has liver disease and has the liver function that is slowly trending up and up and up and up and then suddenly has a little bit more of a jump and that patient is taking therapy.

00:17:02:08 - 00:17:31:10
Unknown
That is not what we call toxic to the liver. And that patient, for example, the alkaline phosphatase going up. And I do know that they have baseline liver disease. I would say, okay, this is probably more of the disease than the medication. When you have the two situations, when you have liver dysfunction because the patient has a baseline metastatic disease to the liver, but you also have a medication that is affecting the liver, you have to see when the patient started the medication, what dosage is the patient taking.

00:17:31:16 - 00:17:47:15
Unknown
And you have to see that Beijing business. Any new medication that was included on there are so not even over the counter stuff or herbal stuff. I had a patient recently. She was taking a medication that was toxic to the liver, but she was doing great for months. The left is suddenly had a jump and I couldn't make a lot of sense out of it.

00:17:47:20 - 00:18:06:13
Unknown
So I start asking her if she took anything and she actually went on a borderline. So there was a medication that she read was great for the therapy and she didn't tell me it was an over-the-counter medication and her liver enzymes then from where she was. Well, I had told her not to take the medication. So you have to get the story.

00:18:06:13 - 00:18:30:04
Unknown
And sometimes it is hard. But we have other ways of complementing that information. We do physical exam. We asked you a couple of questions, which I highly value, and I think you'll get a lot of information. And then lastly, we actually can do imaging as well to see if we can sort out what's what. But again, on a patient that comes to me and shows me a lab results, only a lab result without anything else will be a little challenging.

00:18:30:09 - 00:18:55:22
Unknown
I just wanted to jump in for a second dose using some acronyms that maybe people don't know what they mean, including me. F t. I think the other one was s t. What do they stand for and what do they measure? Lefties is a short acronym for liver function tests. In the liver function, as you have what we call the SD and alt, they're part of the liver enzymes.

00:18:56:00 - 00:19:20:02
Unknown
And there's another way of of mentioning these TGT, which is also functionality of the liver and you have bilirubin and alkaline phosphatase the Sure way that we referred to is of course as well. So those are where we call liver function as the AC stands for Aspartate Aminotransferase and A and B using that on a regular basis. Thank you.

00:19:20:04 - 00:19:48:20
Unknown
yeah, that's what we short and the LP is alanine. Transforming is by the way we never use those name. We use SD enabled for short. I think we will stick to that as well. Yeah. Will stick to those. That's a lot easier. So most of us and I don't know if it's true for every regimens for people who are doing I.V. chemo and I.V. targeted therapies, we get our C because every time before the treatment.

00:19:48:20 - 00:20:09:00
Unknown
And I think people who are on the pill get it a little less often, maybe once a month. I wanted to ask you the other test that you had mentioned. How often are those prescribed? How often do you do the other two tests that you talked about? And should they be done on a regular basis or only if there is something wrong with the CBC?

00:20:09:02 - 00:20:30:12
Unknown
So CBC, which is complete Blood Count and CMB, which is a complete metabolic profile or a basic metabolic profile, which is a CMP without the liver function tests or like AES, they should be done quite routinely, especially if the patient is on therapy. I will say in an active patient, usually once a month we tend to run those tests that sub growth estimate.

00:20:30:12 - 00:20:50:06
Unknown
But for some chemotherapies you need to do it a little bit sooner for tumor markers every three months it will be sufficient for a1c, which is the hemoglobin like oscillator, which is the one that we use for diabetes, or to see how the glucose or sugar is the same as lipid profile. We tend to do that every three months.

00:20:50:12 - 00:21:19:00
Unknown
Give the medication that we're using can cause some reaction to the lipids, which is a cholesterol or to the sugar, which is the glucose. I remember something that I wanted to communicate as well. Knowing the numbers and knowing what normal parameter is is important. But I say more importantly, it's actually to know what to do with them. So for example, a lot of the medications that we give, they could be what we call natural toxic, meaning toxic to the kidney, or a lot of them could be toxic to the liver.

00:21:19:02 - 00:21:37:07
Unknown
So when we see that the renal function does being at normal, and when we see that the liver function does being abnormal, if that's a consequence of the medications that we're giving, we have to adjust that medication. There's actually protocols that say you have to dose reduce the medication if you're seeing X or Y or C organ being affected.

00:21:37:08 - 00:21:56:13
Unknown
And it is just a job of the oncologist. But I want to make sure that people can advocate for themselves. They have to say if my renal function is being compromised or my liver function is being compromised, is any of my other therapies, my hypertension medication, my diabetes medication, my blood thinners, do I have to modify any of them?

00:21:56:18 - 00:22:19:07
Unknown
And sometimes the answer is no. But I think it's very important for the patient to communicate with the doctor saying, listen, I think we need to revise my medication list, make sure that there's nothing that needs to be modified. Also, over-the-counter medications, even though you don't have to get a prescription and they could be the most natural, they can definitely modify your renal function and your liver function test.

00:22:19:12 - 00:22:39:21
Unknown
So before you start anything, just communicate to your doctor. You will be surprised. Most of the people are willing to incorporate what we call holistic or alternative medication if they're not interacting or if they're not posing any threats to the patient. So the key here is listen to your doctor, talk to to your doctor, have an open communication.

00:22:39:21 - 00:23:06:12
Unknown
But I wanted to go back to the three numbers. We like numbers, the three numbers that seem to be the most important ones that we get from the CBC. Right. And that's the read counts, the white cell counts and the platelets. So I want to ask you about a topic that's very dear to my heart, the anemia, as far as I know, and correct me if I'm wrong, all anemia is not the same.

00:23:06:12 - 00:23:45:23
Unknown
There are different types of anemia. Can you go quickly over that so people would understand that not everything is related to our own depletion? Correct. So as a hematologist, the first lab that we check when we have an anemia patient, so they're ridiculous, like count, they're ridiculous. Like count is the baby red blood cells. The way that I explained that is that when you have the bone marrow and you have to to start ramping up the production to respond to anemia because your body being so smart saying the hemoglobin is low, we have to ramp up that production is going to spill like a couple of baby red blood cells into the bloodstream.

00:23:45:23 - 00:24:06:10
Unknown
That's actually good when we see those numbers, when we see their ridiculous count being high, that means they are bone marrow is working well. So when your mare is working well, the anemia is usually secondary to hemolysis, which is an outing immune phenomenon of your own body, destroying your red blood cells or bleeding. Sometimes you can bleed through the stool and not see it.

00:24:06:14 - 00:24:27:13
Unknown
The stool is normal. You can still be bleeding. So that is anemia. But with a normal functioning marrow now, going back to the ridiculous account, if you don't see it in the blood stream, doesn't mean that your mouth is not producing enough red blood cells. And when that happens, we check a second number and see V that stands for mean CORPUSCULAR volume.

00:24:27:15 - 00:24:49:06
Unknown
That is the difference in size between the cells that red blood cells. So when the MKV is low, that's iron deficiency or thalassemia those are iron deficiency by the way is the most common anemia. That's what people automatically reflect to thinking about iron deficiency when they see anemia. But it's not the only one, not when that MCV is normal, meaning that is between 80 to 100.

00:24:49:08 - 00:25:13:23
Unknown
That is what we call normal like anemia and is usually secondary to anemia, chronic disease, more commonly renal dysfunction. And when that MCV is greater than 100, we call that macro acetic anemia is usually B12, folic acid deficiency alcohol. And there's a lot of diseases as well, like AMD. Yes, that could be part of that. So we use that to help us sort out what type of anemia the patient is having.

00:25:13:23 - 00:25:35:07
Unknown
Thank you so much. You put you've explained it so well that now I actually understand it. But I have a question. And you mentioned that it's not about the numbers. It's about what do these them. So what do you do when you are anemic? As far as I know, and I might not be right about that, that the blood transfusion is the only way to fix it.

00:25:35:07 - 00:25:59:07
Unknown
Maybe not. And how often is it safe to do blood transfusions? Absolutely. Great question. So the reality is diagnosis, stage and then treatment. I want to know why the anemia is happening. I want to see if I can fix that underlying issue and by the way, transfusions are not the only way that you can use for anemia. So I'm going to talk very basically B12 deficiency.

00:25:59:09 - 00:26:21:19
Unknown
You get vitamin iron deficiency. I'll give you iron if you have problems with your kidney function or if it's secondary to chemotherapy, I can give you an injection that is called EPO, erythropoietin, analogs that does the same thing that the kidney to bring the hemoglobin up. Okay. So there's things that can be done and there's more things, of course, but I just want to keep it a little short.

00:26:21:21 - 00:26:46:19
Unknown
Now, transfusions, either the hemoglobin is below seven or there is vital sign compromised, meaning your blood pressure is too low, your oxygenation is going low. Then that patient needs transfusions. Having a lot of transfusion is not necessarily bad. Well, we try to avoid it because the more transfusions that you get, your body will start seeing a lot of antibodies and then it will be harder for you to actually get compatible blood.

00:26:46:20 - 00:27:10:05
Unknown
So we try the best as possible within our means to avoid really low levels of anemia. If we have to modify the chemotherapy, if we have to dosimeter up and we have to postpone one cycle and move it up a little, or if we have to give you growth factors such as like the one that I was mentioning for the give me the EPO analogs, we can do all that to actually try to maintain a better level of glowing.

00:27:10:10 - 00:27:37:21
Unknown
It is fairly normal to see a little bit of anemia. We call that mild anemia during therapy. So your hemoglobin is 910. You should be functional, you should be feeling okay. You are not in transfusion territory. Okay. Well, that's wonderful. It's good to know because 20 years ago when I had my early stage cancer, I told Kate that I got appropriate shot at the time that they used to give, but I think they don't do it anymore.

00:27:37:21 - 00:27:59:22
Unknown
Right? We don't do it for early stage, but we do it for metastatic and that is a very important topic. The reason for that is that there is some thought that in the early stage that can stimulate the growth of the tumor, but in the metastatic setting, actually it's okay and it's approved. So that's a great question. So all the EPO analogs, including procreate, are safe to use in the metastatic setting.

00:28:00:00 - 00:28:24:00
Unknown
You talked a lot about communication and how important it is to have good patient doctor communication when patients see their results on the portal when they come back abnormal. What are the next steps? Usually on the oncology side, what do colleges typically do when they see that in life? Your world? And you know, we're not living in a perfect world by the time that you get those results, we already went through them.

00:28:24:00 - 00:28:44:11
Unknown
Okay. And they're publicly released. If there were to be an emergency, there are actually systems that are check and balances to minimize the possibility of any of those labs slipping through. So when we see them, we get alerted, especially if it's a critical lapse. So there's normal abnormal and then critical. So when we have a critical lab, then we usually get notified and we have to address it right away.

00:28:44:11 - 00:29:01:04
Unknown
It is New York state law that whenever the lab releases that critical value, a doctor has to be notified even if it's in the morning. And I know that because I'm on call sometimes and I get them. So I have to address it. If it's critical. If it's not critical, we usually have time to actually sit down and review it.

00:29:01:04 - 00:29:22:23
Unknown
If we see you're having an appointment to come and see me soon, we can actually do it in person. If it's something that is still abnormal and needs to be addressed sooner, you should be expecting a phone call from your physician or the nurse. And whenever none of those things are happening, you always can advocate and call the number that you have to contact your physician office and ask them, Listen, I'm concerned about this lab.

00:29:22:23 - 00:29:45:14
Unknown
Is there something that I need to address? Again, it goes back in full circle in terms of advocating for yourself. Medicine in the US is best not just from a medical standpoint, but also nurses and front desk. And it is tough for us to handle the volume sometimes, so nothing is perfect. There's only one of you that that takes care of you and I have to take care of 6000 patients.

00:29:45:16 - 00:30:12:02
Unknown
I do my best not to miss anything. But you want to. We're human, so always advocate for yourself. We want to reiterate it again, advocate for yourself. But do keep an open conversation with your doctor. Very important. Now, I do want to ask you specifically this question, because we hear all the time, we know that you're human. We know that oncologists are very busy.

00:30:12:04 - 00:30:43:18
Unknown
Communication is hard. Patients have questions and sometimes they feel dismissed. The oncologists will say, it's okay. So I always love to hear your advice on how a patient could maybe ask the right question to their provider so that they actually get the answer that they need and they don't feel that that's a very smart question. I think a doctor and a patient, they have a relationship and that relationship needs to be built, but there's different personalities and different ways.

00:30:43:18 - 00:31:03:00
Unknown
But I think as a general rule of thumb, if you are polite and useful, maybe you say, I need to get an answer about X, Y and Z, for example. Doctor, why do you think that my liver function test is progressively getting worse? Every time that we check the number, it keeps getting higher. I know you mentioned in the past that it's normal, but why you might think that that's happening.

00:31:03:00 - 00:31:18:18
Unknown
I want to pick your brain so an open question instead of saying, is this okay because you give them an easy way out of saying, is this normal, yes or no? The same thing we get in training for a medical school if we want to get information from you, I want to ask you a yes or no question.

00:31:18:18 - 00:31:34:04
Unknown
I will ask an open question. I will say, how are you feeling? What has changed since the last time I saw you? If I want to get information, I'll do open ended question. So I think an open ended question to your provider could be a solution. Why do you think this is happening? My fatigue has been getting worse over the past couple days.

00:31:34:04 - 00:31:52:20
Unknown
What is the main culprit or what can I do to try to fix those liver function tests? Do you think that there's anything that I could be eating differently or is something related to any of the medications? But open ended questions, I think is the way to go. So much to talk about still. And liquid biopsy is on the top of everyone's mind.

00:31:52:20 - 00:32:14:22
Unknown
So if you're up to it, we love to have you back. Dr. Torres, we want to thank you so much for sharing your time and your expertise with us today. We really, really appreciate it. It was an honor sharing with you guys.