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On the 200th episode of the Gaming News Canada Show presented by Bede Gaming, it felt like your humble host was playing a game of 200 Questions with the President and CEO of the Canadian Gaming Association, Paul Burns. Burns has been a familiar voice and face on Gaming News Canada's weekly audio show, going back to the early days when we gathered on Clubhouse every Thursday afternoon to talk about the soon-to-change Canadian gaming industry with the passing of Bill C-218 to legalize single-event sports betting in our home and native land. On this milestone episode, the CGA head honcho offered his thoughts on several recent happenings including: The recent actions taken by The Alcohol and Gaming Association of Ontario against both FanDuel and PointsBet Canada.The latest tete a tete between Loto-Québec and the Quebec Online Gaming Coalition.The iGaming Ontario hiring of former AGCO chief strategy officer Ben Valido as its first Chief Responsible Gaming Officer.The CGA's involvement and the feedback it has received from its membership on the rules placed by operators and suppliers to do business in Alberta's incoming open and competitive sports betting and gaming marketplace.Burns's recent op-ed on efforts within the Senate and federal government to create its own rules around sports betting advertising. And much more. Hosted on Acast. See acast.com/privacy for more information.
O estrategista de investimentos do BB Private, Richardi Ferreira, CGA, CNPI, analisa os principais fatos da última semana e reflete sobre as expectativas para a semana atual no Brasil e no mundo para te ajudar a tomar as melhores decisões de investimento: "No cenário internacional, os mercados reagiram à forte desaceleração do PIB dos Estados Unidos no quarto trimestre de 2025, à inflação ainda resistente e a uma comunicação mais dura do Federal Reserve, que sinalizou pouca disposição para cortes de juros no curto prazo. O aumento das tensões geopolíticas entre Estados Unidos e Irã também impulsionou o preço do petróleo. No Brasil, o destaque foi o IBC‑Br, que confirmou uma atividade econômica moderada em 2025, reforçando a expectativa de início do ciclo de cortes da Selic nos próximos meses. Para a semana, o foco recai sobre os dados de inflação e mercado de trabalho no Brasil e indicadores de atividade e inflação nos Estados Unidos."Confira agora o BB Private Highlights. Conheça também outros conteúdos produzidos por nossos premiados especialistas no hub BB Private Lounge: bb.com.br/lounge
Stando al rapporto della Cga di Mestre l'unica regione dove, negli ultimi dieci anni, le imprese di autotrasporto sono aumentate è il Trentino-Alto Adige. "Più che di nuove aperture però si tratta di delocalizzazioni", commenta Roberto Bellini, Confartigianato Trasporti Trento.Da quest'anno interi tratti delle ferrovie tedesche saranno interrotti per lavori di manutenzione. Di qui una riduzione del traffico merci lungo il corridoio del Brennero. Penalizzate le imprese del cargo ferroviario. Ne parliamo con Giuseppe Rizzi, direttore generale di Fermerci.
Confira a análise de Richardi Ferreira, CGA, CNPI, estrategista de investimentos do BB Private, sobre o cenário macroeconômico e as estratégias de investimentos para este mês.Para se aprofundar nas informações contidas neste vídeo, veja nosso relatório Estratégia de Investimentos: bb.com.br/docs/pub/voce/private/dwn/Relatestratinvest.pdfConheça também outros materiais dos nossos premiados especialistas em bb.com.br/lounge
O estrategista de investimentos do BB Private, Richardi Ferreira, CGA, CNPI, analisa os principais fatos da última semana e reflete sobre as expectativas para a semana atual no Brasil e no mundo para te ajudar a tomar as melhores decisões de investimento:"No cenário externo, o dólar perdeu força e o iene teve forte valorização em meio a rumores de possível ação coordenada entre Fed e Banco do Japão para reduzir a volatilidade da moeda; o movimento só se reverteu após Donald Trump confirmar Kevin Warsh como indicado para comandar o Fed, reforçando expectativas de postura mais hawkish, elevando Treasuries, pressionando bolsas e derrubando metais preciosos. O FOMC manteve os juros em 3,50%–3,75% e reiterou dependência dos dados. No Brasil, o IPCA‑15 subiu 0,20% e o Copom manteve a Selic em 15%, sinalizando início de cortes já em março; o IGP‑M avançou 0,40%, enquanto o Ibovespa subiu forte com fluxo estrangeiro, o dólar recuou para perto de R$ 5,20 e os juros futuros cederam acompanhando o tom mais construtivo do Copom"Confira agora o BB Private Highlights.Conheça também outros conteúdos produzidos por nossos premiados especialistas no hub BB Private Lounge: bb.com.br/lounge
Era actualitat dera Val d'Aran en aran
Before hopping on a plane to Spain for this week's ICE Barcelona, gaming industry veteran Ilkim Hincer hopped into the virtual studio for a new episode of the Gaming News Canada Show presented by Bede Gaming. The interview with Hincer, the Chair Emeritus of the Canadian Gaming Association who joined Integrity Compliance 360 in October as President, Canadian Operations & Managing Director, Global Advisory Strategy, took place just days after Alberta Gaming Liquor & Cannabis made registration available for the province's incoming legal sports betting and gaming market. Hincer, who joined gaming industry stakeholders on a call a week ago with Alberta minister Dale Nally and AGLC personnel, provided his thoughts and layers on the next Canadian jurisdiction to join Ontario in a competitive, regulated marketplace. Hincer, given IC360's involvement in U.S. college sports, was guarded in his response to our question about a point-shaving plot involving 39-plus players and 17 Division 1 teams in NCAA men's basketball. He also discussed with host Steve McAllister last week's announcement of an extended agreement between IC360 and the PGA Tour to incorporate the company's ProhiBet platform into the tour's gambling oversight. Finally, McAllister asked the former CGA chair if he had any words of wisdom for incoming Chair Scott Vanderwel. Hosted on Acast. See acast.com/privacy for more information.
O estrategista de investimentos do BB Private, Richardi Ferreira, CGA, CNPI, analisa os principais fatos da última semana e reflete sobre as expectativas para a semana atual no Brasil e no mundo para te ajudar a tomar as melhores decisões de investimento: "Nos EUA, a investigação contra Jerome Powell elevou o risco institucional, enquanto os dados de inflação e varejo reforçam a resiliência da economia americana. No Brasil, dados de atividade econômica surpreenderam positivamente, esfriando as apostas de um corte da Selic já agora em janeiro."Confira agora o BB Private Highlights. Conheça também outros conteúdos produzidos por nossos premiados especialistas no hub BB Private Lounge: bb.com.br/lounge
Era actualitat dera Val d'Aran en aran
Infosys Q3 results: Revenue jumps 8.9% to ₹45,479 crore; beats expectations Infosys reported a decline in profit for the December-ended quarter of FY26, with PAT falling 9.6% sequentially and 2.2% year-on-year (YoY) to Rs 6,654 crore. Despite the dip, the IT major raised its constant currency revenue growth guidance for FY26 to 3–3.5%, up from the 2–3% forecast issued in the previous quarter. Revenue rose 8.9% YoY and 2.2% quarter-on-quarter to Rs 45,479 crore. In constant currency (CC) terms, revenue grew 1.7% YoY and 0.6% QoQ. Large deal momentum improved, with total contract value (TCV) reaching $4.8 billion during the quarter, including 57% net new deals, up from $3.1 billion in the September quarter. PM Internship scheme falters as funds go unused Data from Controller General of Accounts (CGA) showed as against the budget allocation of over Rs 11500 crore, the Ministry spent little over Rs 500 crore. The allocation for the full year has a 94 per cent share, or over Rs 10,800 crore, for the PM Internship Scheme. During FY25, budget allocation was revised to around Rs 1,078 crore from Rs 2,667 crore. The ministry had admitted before the Standing Committee that it was largely because the funds were surrendered under the PM Internship Scheme. CGA data showed actual expenditure was around Rs 680 crore only. Maharashtra, Tamil Nadu top performers in Niti Aayog's export preparedness index 2024 Maharashtra has topped the Niti Aayog's Export Preparedness Index (2024) in the large States category followed by Tamil Nadu and Gujarat in the second and third places respectively. Uttarakhand, Jammu & Kashmir and Nagaland bagged the top three spots among small States, North East and Union Territories. The report was released by Niti Aayog CEO B V R Subrahmanyam on Wednesday. EPI 2024 assesses the export capabilities (performance and readiness) and potential of Indian States and Union Territories covering the period FY2022-FY2024 and has been prepared with the support of Deloitte. India steps up bunker construction along LoC after Operation Sindoor Following Operation Sindoor, the central government has intensified its focus on strengthening border infrastructure in Jammu and Kashmir. In north Kashmir's Uri sector, the government is constructing at least 500 new bunkers to protect civilians living along the Line of Control (LoC), officials said, as part of broader measures aimed at enhancing safety in border areas vulnerable to cross-border shelling. The lack of adequate bunkers in border areas across Jammu and Kashmir during the Operation Sindoor operation laid bare the risks faced by residents during periods of heightened tension along the 740-km-long LoC.
What does it really mean to leave Canada — and how do you know when you've crossed the line from spending time abroad to officially exiting?Host Gerry Scott sits down with Jennifer Reid CPA, CGA, TEP and Frank Casciaro of RSM, two cross-border tax specialists who advise Canadians navigating complex international lives — from snowbirds and dual citizens to executives, business owners, and globally mobile families.With deep experience in international tax and firsthand insight from working with clients before, during, and after a Canadian exit, Jen and Frank break down why leaving Canada is not just a lifestyle decision — it determines how your assets are taxed, what reporting obligations follow you, and where costly compliance mistakes often happen.Together, Gerry, Jen, and Frank unpack the realities behind some of the most misunderstood rules in Canadian departure planning, including why residency is rarely as simple as counting days or keeping a Canadian mailing address.In this conversation, they explore:Why more than 106,000 Canadians left the country in 2025 — and what's driving the trendThe difference between being a factual resident and a non-resident of CanadaWhy spending a few months abroad doesn't automatically mean you've exitedWhat departure tax and “deemed disposition” really mean in practiceWhich assets are subject to departure tax — including worldwide holdings, not just Canadian onesWhen deferring departure tax may be possible, and why it's becoming harder to doHow the Canada–U.S. tax treaty can help prevent double taxation — and where it falls shortWhy health care eligibility (including OHIP) is not tied to your tax returnThe compliance risks of keeping Canadian bank accounts, investments, or a family address after leavingTFSA, RRSP, and withholding tax issues that frequently catch departing Canadians off guardWhy planning before you leave is far less expensive than fixing mistakes afterwardIf you're living, working, retiring, or investing outside Canada — or considering a permanent move — this episode offers a clear, practical look at what truly defines a Canadian exit and the planning steps that can save you from expensive surprises down the road.
Confira a análise de Richardi Ferreira, CGA, CNPI, estrategista de investimentos do BB Private, sobre o cenário macroeconômico e as estratégias de investimentos para o início de 2026.Para se aprofundar nas informações contidas neste vídeo, veja nosso relatório Estratégia de Investimentos: bb.com.br/docs/pub/voce/private/dwn/Relatestratinvest.pdfConheça também outros materiais dos nossos premiados especialistas em bb.com.br/lounge
What does it take to build a duck dog that other hunters respect?CGA member Shawn Dry joins Josh to share the real journey of training his own retriever—from first obedience reps to calm, steady work in the blind. They talk about “place,” early hunts done the right way, handling and casting, managing breaking around other dogs, and why consistency outside of training matters just as much as the sessions themselves.It's a story about earning trust, building a true partnership, and reaching the moment every handler hopes for—when someone in the blind says, “Bring that dog back.”Want to learn how to train your hunting dog with confidence?Visit: Cornerstone Gundog AcademyNeed gear for training your retriever, like collars, dog training dummies, and more?Visit: Retriever Training SupplyInterested in sponsoring the BuildFromHere Podcast?Fill out this form and tell us more about promoting your product, service, or brand.
O estrategista de investimentos do BB Private, Richardi Ferreira, CGA, CNPI, analisa os principais fatos da última semana e reflete sobre as expectativas para a semana atual no Brasil e no mundo para te ajudar a tomar as melhores decisões de investimento: "Nos Estados Unidos, o relatório JOLTS voltou a indicar aumento na abertura de vagas, enquanto o Fed promoveu mais um corte de 25 pb e sinalizou compasso de espera. No Brasil, o IPCA de novembro veio em linha com as projeções, o Copom manteve a Selic em 15% com tom cauteloso."Confira agora o BB Private Highlights. Conheça também outros conteúdos produzidos por nossos premiados especialistas no hub BB Private Lounge: bb.com.br/lounge
In this episode, Ben Azadi reveals the 7-day coffee experiment that transformed his metabolism, lowered insulin, flattened belly fat, and eliminated cravings—without changing workouts or counting calories. You'll learn how most people unknowingly drink coffee in a way that spikes cortisol, raises blood sugar, and leads to stubborn fat gain… and how a few simple changes can turn coffee into a powerful fat-burning tool. Ben breaks down:• The 3 biggest coffee mistakes ruining your metabolism• Why timing your caffeine is more important than you think• How chlorogenic acid (CGA) helps your body burn stored fat• What to add (and avoid) in your morning coffee• His exact 7-day step-by-step coffee and insulin reset• How to test your coffee's effect on glucose like a scientist• The fat-burning coffee recipe he used daily• Advanced strategies like the “Triple Insulin Reset” You'll also learn how to choose clean, mold-tested coffee beans, why sleep is a major insulin regulator, and how this simple morning shift can dramatically improve energy, cravings, and fat loss. Perfect for anyone wanting to fix their mornings, support metabolic health, and turn their daily coffee into a metabolic advantage. FREE GUIDE: https://bit.ly/3Y20AAG
From the very beginning of Cornerstone, Chad Duckworth has been part of the CGA family. In this episode, Chad shares one of the most powerful DIY retriever journeys we've ever featured—starting with his first dog, Moose, who was once labeled “not cut out” for gun-dog work after a rough pro-training experience. But instead of giving up, Chad rolled up his sleeves, trusted the process, and trained Moose himself through CGA—turning that dog into a steady, reliable hunting partner who accompanied him on countless incredible days in the field.Chad opens up about the highs, the heartbreak, and the unforgettable final hunt Moose made by his side. He then walks us through the new chapter with his pup, Winnie—a young, driven retriever whose journey has been built slowly, intentionally, and the right way. From foundational obedience to first hunts, swan retrieves, road trips, chapter meetups, and the lessons learned between dogs one and two… this episode is packed with wisdom for any handler who wants to build something special with their dog.Whether you're just starting out, rebuilding a dog, or navigating the roller coaster of training your first retriever, Chad's story will remind you why the journey matters, why patience pays off, and why doing it yourself creates a bond unlike anything else.Want to learn how to train your hunting dog with confidence?Visit: Cornerstone Gundog AcademyNeed gear for training your retriever, like collars, dog training dummies, and more?Visit: Retriever Training SupplyInterested in sponsoring the BuildFromHere Podcast?Fill out this form and tell us more about promoting your product, service, or brand.
professorjrod@gmail.comA single glowing dot in a glass tube changed how we understand the world. We follow that spark from Carl Ferdinand Braun's cathode-ray breakthrough to radar operators reading life-and-death blips, to living rooms lit by television and desktops shaped by GUI windows. Along the way, we show why screens didn't just display information—they taught humans to think in frames, patterns, and pixels.I walk through the interface pivots that mattered: when computers stopped spitting paper and started talking back visually; when text terminals gave way to Xerox PARC's icons and pointers; when Apple and IBM normalized monitors as the heart of personal computing with standards like CGA, EGA, and VGA. Then we dive into the flat panel turn: the physics of liquid crystals, the jump from passive to active matrix TFT, and the moment LCDs escaped laptops to conquer the desk. We weigh plasma's cinematic highs and practical lows, and how LED backlights, higher refresh rates, and HDR transformed clarity, contrast, and color.From there, we explore OLED's promise—self-emissive pixels with true blacks, flexible forms, and motion precision that redefined smartphones, TVs, and creative workflows. We compare Mini‑LED's local dimming advances and MicroLED's potential for brightness, longevity, and perfect blacks, while noting the manufacturing roadblocks. Finally, we look ahead: curved, foldable, and rollable designs that adapt to you; VR and AR that pull displays onto your eyes; and early steps toward holograms and light field systems that project depth without headsets. The through-line is simple and profound: as control over light improves, the screen fades and the experience takes its place.If this journey reshaped how you see your monitor, share it with a friend, subscribe for more deep dives, and leave a review to help others discover Technology Tap.Support the showArt By Sarah/DesmondMusic by Joakim KarudLittle chacha ProductionsJuan Rodriguez can be reached atTikTok @ProfessorJrodProfessorJRod@gmail.com@Prof_JRodInstagram ProfessorJRod
Josh sits down with longtime CGA member and founding supporter Marshall Anliker to talk hunting, dogs, and the power of community. Marshall shares how a blizzard goose hunt with his great-grandfather lit the fire for waterfowling, how that led him to British Labradors and Southern Oak Kennels, and why Cornerstone has been part of his last three dogs.From college days stacking classes around duck hunts to running a roofing company and training high-drive British Labs at a high level, Marshall opens up about genetics, discipline, reward timing, and what it really means to “train the dog in front of you.” If you're serious about building a steady, family-friendly hunting companion and you love hearing real stories from real CGA members, this episode is for you.Want to learn how to train your hunting dog with confidence?Visit: Cornerstone Gundog AcademyNeed gear for training your retriever, like collars, dog training dummies, and more?Visit: Retriever Training SupplyInterested in sponsoring the BuildFromHere Podcast?Fill out this form and tell us more about promoting your product, service, or brand.
Stephen Grootes speaks to Dr Boitshoko Ntshabele, CEO of the CGA about how Southern African citrus exporters smashed expectations this year, packing a record 203.4 million cartons for global markets, a 22% surge that signals major growth potential for SA agriculture. In other interviews, Donnavan Linley, one of the inquiry's Technical Leads unpacks Google and YouTube’s landmark R688 million commitment to support South African media producers following a Competition Commission report on unfair value sharing between global platforms and local publishers. The Money Show is a podcast hosted by well-known journalist and radio presenter, Stephen Grootes. He explores the latest economic trends, business developments, investment opportunities, and personal finance strategies. Each episode features engaging conversations with top newsmakers, industry experts, financial advisors, entrepreneurs, and politicians, offering you thought-provoking insights to navigate the ever-changing financial landscape. Thank you for listening to a podcast from The Money Show Listen live Primedia+ weekdays from 18:00 and 20:00 (SA Time) to The Money Show with Stephen Grootes broadcast on 702 https://buff.ly/gk3y0Kj and CapeTalk https://buff.ly/NnFM3Nk For more from the show, go to https://buff.ly/7QpH0jY or find all the catch-up podcasts here https://buff.ly/PlhvUVe Subscribe to The Money Show Daily Newsletter and the Weekly Business Wrap here https://buff.ly/v5mfetc The Money Show is brought to you by Absa Follow us on social media 702 on Facebook: https://www.facebook.com/TalkRadio702 702 on TikTok: https://www.tiktok.com/@talkradio702 702 on Instagram: https://www.instagram.com/talkradio702/ 702 on X: https://x.com/CapeTalk 702 on YouTube: https://www.youtube.com/@radio702 CapeTalk on Facebook: https://www.facebook.com/CapeTalk CapeTalk on TikTok: https://www.tiktok.com/@capetalk CapeTalk on Instagram: https://www.instagram.com/ CapeTalk on X: https://x.com/Radio702 CapeTalk on YouTube: https://www.youtube.com/@CapeTalk567 See omnystudio.com/listener for privacy information.
Stephen Grootes speaks to Dr Boitshoko Ntshabele, CEO of the CGA about how Southern African citrus exporters smashed expectations this year, packing a record 203.4 million cartons for global markets, a 22% surge that signals major growth potential for SA agriculture. The Money Show is a podcast hosted by well-known journalist and radio presenter, Stephen Grootes. He explores the latest economic trends, business developments, investment opportunities, and personal finance strategies. Each episode features engaging conversations with top newsmakers, industry experts, financial advisors, entrepreneurs, and politicians, offering you thought-provoking insights to navigate the ever-changing financial landscape. Thank you for listening to a podcast from The Money Show Listen live Primedia+ weekdays from 18:00 and 20:00 (SA Time) to The Money Show with Stephen Grootes broadcast on 702 https://buff.ly/gk3y0Kj and CapeTalk https://buff.ly/NnFM3Nk For more from the show, go to https://buff.ly/7QpH0jY or find all the catch-up podcasts here https://buff.ly/PlhvUVe Subscribe to The Money Show Daily Newsletter and the Weekly Business Wrap here https://buff.ly/v5mfetc The Money Show is brought to you by Absa Follow us on social media 702 on Facebook: https://www.facebook.com/TalkRadio702 702 on TikTok: https://www.tiktok.com/@talkradio702 702 on Instagram: https://www.instagram.com/talkradio702/ 702 on X: https://x.com/CapeTalk 702 on YouTube: https://www.youtube.com/@radio702 CapeTalk on Facebook: https://www.facebook.com/CapeTalk CapeTalk on TikTok: https://www.tiktok.com/@capetalk CapeTalk on Instagram: https://www.instagram.com/ CapeTalk on X: https://x.com/Radio702 CapeTalk on YouTube: https://www.youtube.com/@CapeTalk567 See omnystudio.com/listener for privacy information.
Era actualitat dera Val d'Aran en aran
In this episode, Ben Azadi reveals the simple but powerful 7-day morning routine that helps you burn belly fat, balance hormones, and boost energy — without long workouts or restrictive diets. Each day builds a new habit to reprogram your metabolism and align your body with its natural fat-burning rhythm:
In this episode, Ben Azadi reveals the simple but powerful 7-day morning routine that helps you burn belly fat, balance hormones, and boost energy — without long workouts or restrictive diets. Each day builds a new habit to reprogram your metabolism and align your body with its natural fat-burning rhythm:
JCO PO author Dr. Bryson Katona at the University of Pennsylvania Perelman School of Medicine shares insights into his article, “Areas of Uncertainty in Pancreatic Cancer Surveillance: A Survey Across the International Pancreatic Cancer Early Detection (PRECEDE) Consortium” Host Dr. Rafeh Naqash and Dr. Katona discuss how, given differing guidelines as well as lack of detail about how PC surveillance should be performed, approaches to PC surveillance across centers often differs. TRANSCRIPT Naqash: Hello and welcome to JCO Precision Oncology Conversations, where we bring you engaging conversations with authors of clinically relevant and highly significant JCO PO articles. I am your host, Dr. Rafeh Naqash, podcast editor for JCO Precision Oncology and Associate Professor at the OU Health Stephenson Cancer Center at the University of Oklahoma. Today, I am thrilled to be joined by Dr. Bryson Katona, Director of the Gastrointestinal Cancer Genetics Program and Director of the Lynch Syndrome Program at the Penn Medicine's Abramson Cancer Center, and also lead author of the JCO PO article entitled "Areas of Uncertainty in Pancreatic Cancer Surveillance: A Survey Across the International Pancreatic Cancer Early Detection or PRECEDE Consortium." Bryson, thanks for joining us again. Dr. Bryson Katona: Well, thank you so much for having me. I appreciate the opportunity. Dr. Rafeh Naqash: It is exciting to see that this work will be presented concurrently with the upcoming CGA meeting. Dr. Bryson Katona: Yes, it has been a fantastic partnership between JCO PO and the CGA-IGC and their annual meeting. And for those who may not be familiar, the CGA-IGC is the Collaborative Group of the Americas on Inherited Gastrointestinal Cancer. It is basically a professional organization dedicated to individuals who have hereditary GI cancer risk and focusing on providing education, promoting research, and really bringing together providers in this space from not just throughout the US but from across the globe as well. Dr. Rafeh Naqash: That is exciting to hear the kind of work you guys are doing. These are definitely interesting, exciting things. Now, going to what you have published, it is an area that is very evolving in the space of cancer screening, cancer surveillance, especially for a very aggressive cancer such as pancreatic cancer. Could you tell us currently, what are the general consensus? I know there are a lot of differences between different guidelines or societies, but what are the some of the commonalities if we were to start there first for pancreas cancer screening? If you are not a GI oncologist, you may not be aware that there is something with regards to pancreas cancer screening. Could you give us an overview and a background on that? Dr. Bryson Katona: Yeah, I think that pancreatic cancer screening really is one of the most controversial areas of all cancer screening. Part of that controversy is just because all the guidelines, the many different guidelines that are out there, do not always match up with one another, which I think leads to a lot of confusion, not just for providers but for patients who are trying to go through this, and then also the insurance companies in trying to get these screening tests covered. You know, when we think about who is eligible for pancreatic cancer screening, you know, it is important that these are not average-risk individuals. So really, we are only offering screening to high-risk individuals. And those can include people that have a strong family history of pancreatic cancer without a germline genetic susceptibility that has been identified. And those individuals we refer to as having familial pancreatic cancer. And the other big cohort is those individuals that carry hereditary pancreatic cancer predisposition. These are due to cancer risk mutations in many different genes, including many of the breast cancer risk genes like BRCA1 and BRCA2, as well as ATM and PALB2, but then other genes such as the Lynch syndrome genes, and then some of the higher risk genes such as those leading to Peutz-Jeghers syndrome as well as FAM, which is due to CDKN2A mutations. Dr. Rafeh Naqash: Thank you for that. Again, another practical question, and this may or may not be exactly related to your specific topic here, but perhaps to some extent there might be an overlap. If I get a patient from a colleague, and I see people in the early-phase clinical trial setting, so many different tumors for novel drugs, and I find an individual with, let us say, lung cancer who has a pathogenic BRCA2, which is somatic, should I be worried about pancreas cancer screening in that individual? Or have we not met that threshold yet in that circumstance? Dr. Bryson Katona: A lot of times these variants or these genes that are associated with pancreatic cancer risk get picked up on the somatic tumor profiles. Now, you know, whether or not those are truly germline variants typically requires the next step of referring the patient for germline genetic testing. So you know, I would not screen or make any kind of screening choices based on a somatic variant alone, but nowadays germline testing is so easy, so efficient, and relatively cheap that it is easy enough to confirm whether or not these somatic hits are in fact just somatic or may confer some germline risk in addition. Dr. Rafeh Naqash: So from what I understand from what you have said, there is debate about it, but it is something that should be done or is important enough that you need to figure out a path moving forward. Was that one of the reasons why you performed this project through this very interesting consortium called the PRECEDE Consortium? Dr. Bryson Katona: Yeah, that was one of our main reasons for doing this. And for those who do not know about the PRECEDE Consortium, this is a very large international, multi-institutional organization really focused on reducing death and improving survival from pancreatic cancer, primarily through increased and more effective use of screening and early detection strategies. This is an international consortium. There are over 50 sites now with nearly 10,000 patients who are enrolled in the consortium. So it really is at this point the largest prospective study of individuals who are at high risk for pancreatic cancer who are undergoing screening. And you know, I think amongst all of us in the consortium, just amongst discussions between colleagues and then, you know, often times when I see patients that are transferring their care to Penn who maybe had their screening done in another center before, what we were realizing is that, you know, although we all do a lot of screening, it seems that people are doing it slightly differently. And it does not seem that there is a real consensus approach across all centers about how pancreatic cancer screening should really be done. And it is one thing if you are thinking comparing, okay, well, maybe in the US we do it differently than, you know, in Europe or in other locations, but even among centers within the United States, we were still seeing very large differences in how pancreatic cancer screening in high-risk individuals were done. And so that led us to really pursue this survey of pancreatic cancer screening practices across the PRECEDE Consortium. So for this survey, we actually have 57 centers who the survey was sent out to. As you know, surveys are oftentimes very difficult to get good response rates back on, but we were fortunate to have 54 of the 57, or 95% of the centers, actually get back to us about their screening practices for this particular project. Dr. Rafeh Naqash: That is good to know. I hope you did not have to use any kind of gift cards for people to respond to the survey. But nevertheless, you got the information that you needed. Could you tell us what are some of the common denominators that you did identify and some of the differences that you identified? From your perspective, it sounds like there is no established consensus guidelines. There are different societies that have different perspectives on it. So I am sure some of what you found will probably have implications in maybe creating some guidelines. Is that a fair statement? Dr. Bryson Katona: Definitely a fair statement, and we found some very interesting results. I think one important result is really just the heterogeneity in the consortium. And so even before we got into pancreatic cancer screening practices, we also, we were asking consortium sites, “At your particular site, who is the individual that is leading these in-depth discussions about pancreatic cancer screening?” And while about 50% of the sites had a gastroenterologist leading it, about a quarter of the sites had a medical oncologist, a quarter had a surgeon leading these discussions as well. And we also found heterogeneity in who is the physician or the provider actually ordering these screening tests, again, with multiple different specialties across the different sites. But really one of the main areas that we wanted to hone in and focus on was how the different pancreatic cancer screening guidelines were actually utilized in each of the particular centers. The biggest controversial area in the field is for the gene mutation carriers, whether or not we should be requiring that a family history of pancreatic cancer be present in order for those individuals to qualify for pancreatic cancer screening. And the reason that is so controversial, let us take an example of BRCA1 and BRCA2 carriers. Currently, if you look through the guidelines, NCCN and the ASGE guidelines recommend that really all BRCA2 carriers undergo pancreatic cancer screening regardless of whether or not there is a family history, starting at age 50. However, other guidelines such as the AGA guidelines, or the AGA Clinical Practice Statement, as well as guidelines from the CAPS consortium, do recommend that a family history of pancreatic cancer be present in order to qualify for screening. But then we have different things for other genes. So for BRCA1 carriers, in fact, it is the ASGE guidelines that recommend all BRCA1 and 2 carriers undergo screening, whereas NCCN and the other guidelines that are out there do not recommend those individuals undergo screening. Again, this huge heterogeneity in guidelines is quite striking. And so when we assessed all the sites in the PRECEDE Consortium, we found some really interesting results with respect to these particular genes. For BRCA2 carriers specifically, we found that about half of the sites required a family history for recommending pancreatic cancer screening, but about half of the sites would offer it to all BRCA2 carriers regardless of if there was a family history of pancreatic cancer screening. Rates for BRCA1, PALB2, and ATM carriers were a little bit lower, where about a third of sites would offer screening really regardless of whether or not there is a family history of pancreatic cancer. And for Lynch syndrome, those rates were very, very low, with only about 13% of sites offering screening to Lynch patients in the absence of a family history. But I think, you know, we are all in the same consortium, but there is still just a lot of heterogeneity in how our own individual practices are run. Dr. Rafeh Naqash: Definitely different thoughts, different practices. But from what you saw, did it matter as far as outcomes are concerned whether it was a gastroenterologist doing the screening, or it was a medical oncologist, or a geneticist? Or is it a combination of all of these that actually makes the most difference? Dr. Bryson Katona: So I think we do need to get some more information about specialty-specific screening preferences. We just had one response per site in this particular survey, and so I think we are going to need a larger sample size in order to get that data. But I think that is certainly possible that, you know, certain subspecialties may prefer, you know, screening more aggressively or not including family history. That is definitely a question that we will be asking in future studies. Dr. Rafeh Naqash: Definitely more gift cards that will be needed as well. Moving on to another aspect of the implications for early detection, from a breast cancer, colon cancer standpoint, there is health economics research that shows it saves cost in the bigger picture. Has there been anything for pancreas cancer where early detection, early identification, early treatment actually ends up saving a lot more versus detecting metastatic pancreas cancer later? Dr. Bryson Katona: It is a great question. And of course, for any screening modality, you know, we would ultimately want it to be a cost-effective measure. In pancreas cancer screening, the jury is still a little bit out about whether or not pancreas cancer screening is truly cost-effective or not. There have been several different studies that have assessed this. And I think in general, the thought is that it is a cost-effective endeavor. But I think most of these cost-effectiveness estimates are actually related to what is the risk of pancreatic cancer in the population you are studying. And so when you have very, very high-risk individuals that have over a 10% lifetime risk of pancreatic cancer, it is almost a certainty that pancreatic cancer screening is going to be cost-effective. However, you know, if you have, say for example, BRCA1 carriers where lifetime risk of pancreatic cancer may be less than 5%, likely around like 3%, those individuals, I think it is going to be a tougher sell to say that it is cost-effective. But as we get more data on pancreatic cancer screening, that will be a very important question to ask. And you know, when you mentioned how does it save money, our goal at least in pancreatic cancer screening is to really downstage pancreatic cancer at the time of diagnosis and allow someone to undergo, you know, ideally a curative-intent surgery. There is data out there showing that we can downstage the cancers, that survival after the time of diagnosis is substantially increased after detection in a pancreatic cancer screening program. But again, these are studies that are based on fairly small numbers of converters. And so I think we need more data in that space as well, which is one of the main questions that the PRECEDE Consortium is trying to answer with all of our prospective data. Dr. Rafeh Naqash: Excellent. Well, I hope we see more interesting, exciting work from the PRECEDE Consortium at meetings as well as as a publication in JCO PO. I would like to shift gears briefly for a minute or two, Bryson, to you as an individual, your career. How have you evolved over the last 5, 7 years? How did you end up doing cancer genetics? What were some of the lessons that you learned along the way and some of those that you would want to share with our listeners, especially trainees and early-career faculty? Dr. Bryson Katona: Just to give you and others listening a little bit of background, but I am a physician-scientist, gastroenterologist, but a physician-scientist. And so my clinical practice is exclusively focused on individuals with hereditary GI cancer risk. I run a basic science lab where we do a lot of studies in organoids and mouse models of these hereditary GI cancer risk syndromes. And then I also have a clinical research group where we do early-phase clinical trials and screening and early detection trials, again in these same individuals with hereditary GI cancer risk. I think probably the most important thing that kind of allowed me to get to this stage in my career where I am trying to, you know, essentially try to juggle all three of these balls at the same time is that I absolutely love what I do. And I am so incredibly interested in what I do. And I think for young individuals that are coming through the pipeline and going through training, you know, I mean, finding a specialty and a clinical niche where you truly just enjoy the work and you enjoy the patients and you enjoy your colleagues is by far the most important thing. I ended up getting into the hereditary GI cancer space because a lot of my work earlier on in my career during my PhD and then in my postdoc work in the lab really focused on colorectal cancer. And I thought that focusing on cancer genetics could allow me to really continue to think from the molecular side of things while simultaneously being a gastroenterologist and taking care of patients with hereditary cancer risk. Dr. Rafeh Naqash: Well, thank you so much for giving us a sneak peek of your journey and insights on what perhaps works best, especially when you love what you do. I think that is one of the most important reasons a work tries to keep you going and keep you interested, keep you passionate. So thank you again. Thank you for listening to JCO Precision Oncology Conversations. Do not forget to give us a rating or a review, and be sure to subscribe so you never miss an episode. You can find all ASCO shows at asco.org/podcasts. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.
JCO PO author Dr. Asaf Maoz at Dana-Farber Cancer Institute shares insights into article, “Causes of Death Among Individuals with Lynch Syndrome in the Immunotherapy Era.” Host Dr. Rafeh Naqash and Dr. Maoz discuss the causes of death in individuals with LS and the evolving role of immunotherapy. TRANSCRIPT Dr. Rafeh Naqash: Hello, and welcome to JCO Precision Oncology Conversations, where we bring you engaging conversations with authors of clinically relevant and highly significant JCOPO articles. I'm your host, Dr. Rafeh Naqash, podcast editor for JCO Precision Oncology and Associate Professor Medicine, at the OU Health Stephenson Cancer Center. Today, I'm super thrilled to be joined by Dr. Asaf Maoz, Medical Oncologist at Dana-Farber Cancer Institute, Brigham and Women's Hospital, and faculty at the Harvard Medical School, and also lead author on the JCO Precision Oncology article entitled "Causes of Death Among Individuals with Lynch Syndrome in the Immunotherapy Era." This publication will be a concurrent publication with an oral presentation at the annual CGA meeting. At the time of this recording, our guest's disclosures will be linked in the transcript. Asaf, I'm excited to welcome you on this podcast. Thank you for joining us today. Dr. Asaf Maoz: Thank you so much for highlighting our paper. Dr. Rafeh Naqash: Absolutely. And I was just talking to you that we met several years back when you were a trainee, and it looks like you've worked a lot in this field now, and it's very exciting to see that you consider JCOPO as a relevant home for some of your work. And the topic that you have published on is of significant interest to trainees from a precision medicine standpoint, to oncologists in general, covers a lot of aspects of immunotherapy. So, I'm really excited to talk to you about all of this. Dr. Asaf Maoz: Me too, me too. And yeah, I think JCOPO has great content in the area of cancer genetics and has done a lot to disseminate the knowledge in that area. Dr. Rafeh Naqash: Wonderful. So, let's get started and start off, given that we have hosts of different kinds of individuals who listen to this podcast, especially when driving from home to work or back, for the sake of making everything simple, can we start by asking you what is Lynch syndrome? How is it diagnosed? What are some of the main things to consider when you're trying to talk an individual where you suspect Lynch syndrome? Dr. Asaf Maoz: Lynch syndrome is an inherited predisposition to cancer, and it is common. So, we used to think that, or there's a general notion in the medical community that it is a rare condition, but we actually know now from multiple studies, including studies that look at the general population and do genetic testing regardless of any clinical phenotype, that Lynch syndrome is found in about 1 in 300 people in the general population. If you think about it in the United States, that means that there are over a million people living with Lynch syndrome in the United States. Unfortunately, most individuals with Lynch syndrome don't know they have Lynch syndrome at the current time, and that's where a lot of the efforts in the community are being made to help detect more individuals who have Lynch syndrome. Lynch syndrome is caused by pathogenic germline variants in mismatch repair genes, MLH1, MSH2, MSH6, or PMS2, or as a result of pathogenic variants in EPCAM that cause silencing of the MSH2 gene. Dr. Rafeh Naqash: Excellent. Thank you for that explanation. Now, one of the other things I also realized, similar to BRCA germline mutations, where you require a second hit for individuals with Lynch syndrome to have mismatch repair deficient cancers, you also require a second hit to have that second hit result in an MSI-high cancer. Could you help us understand the difference of these two concepts where generally Lynch syndrome is thought of to be cancers that are mismatch repair deficient, but that's not necessarily true for all cases as we see in your paper. Can you tease this out for us a little bit more? Dr. Asaf Maoz: Of course, of course. So, the germline defect is in one of the mismatch repair genes, and these genes are responsible for DNA mismatch repair, as their name implies. Now, in a normal cell, we think that one working copy is generally enough to maintain the mismatch repair machinery intact. What happens in tumors, as you alluded to, is that there is a second hit in the same mismatch repair gene that has the pathogenic germline variant, and that causes the mismatch repair machinery not to work anymore. And so what happens is that there is formation of mutations in the cancer cell that are not present in other cells in the body. And we know that there are specific types of mutations that are associated with defects in mismatch repair mechanisms, and those are associated a lot of times with frameshift mutations. And we have termed them ‘microsatellites'. So there are areas in the genome that have repeats, for example, you know, if you have AAAA or GAGA, and those areas are particularly susceptible to mutations when the mismatch repair machinery is not working. And so we can measure that with DNA microsatellite instability testing. But we can also get a sense of whether the mismatch repair machinery is functioning by looking at protein expression on the surface of cancer cells and by doing immunohistochemistry. More recently, we're also able to infer whether the mismatch repair machinery is working by doing next-generation sequencing and looking at many, many microsatellites and whether they have this DNA instability in the microsatellites. Dr. Rafeh Naqash: Excellent explanation. As a segue to what you just mentioned, and this reminds me of some work that one of my good friends, collaborators, Amin Nassar, whom you also know, I believe, had done a year and a half back, was published in Cancer Cell as a brief report, I believe, where the concept was that when you look at these mismatch repair deficient cancers, there is a difference between NGS testing, IHC testing, and maybe to some extent, PCR testing, where you can have discordances. Have you seen that in your clinical experience? What are some of your thoughts there? And if a trainee were to ask, what would be the gold standard to test individuals where you suspect mismatch repair deficient-related Lynch syndrome cancers? How would you test those individuals? Dr. Asaf Maoz: We do sometimes see discordance, you know, from large series, the concordance rate is very high, and in most series it's over 95%. And so from a practical perspective, if we're thinking about the recommendation to screen all colorectal cancer and all endometrial cancer for mismatch repair deficiency, I think either PCR-based testing or immunohistochemistry is acceptable because the concordance rate is very high. There are rare cases where it is not concordant, doing multiple of the tests makes sense at that time. If you think about the difference between the tests, the immunohistochemistry looks at protein expression, which is a surrogate for whether there is mismatch repair deficiency or not, right? Because ultimately, the mismatch repair deficiency is manifested in the mutations. So if the PCR does not show microsatellite instability and now NGS does not show microsatellite instability, the IHC may be a false positive. At the end of the day, the functional analysis of whether there are actually unstable microsatellites either by PCR or by NGS is what I would consider more informative. But IHC again is an excellent test and concordant with those results in over 95% of cases. Now there is also an issue of sampling. It's possible that there's heterogeneity within the tumor. We published a case in JCOPO about heterogeneity of the mismatch repair status, and that was both by immunohistochemistry, but also by PCR. So there are some caveats and interpreting these tests does require some expertise, and I'm always happy to chat with trainees or whoever has an interesting or challenging case. Dr. Rafeh Naqash: Thanks again for that very easy to understand explanation. Now going to management strategies, could you elaborate a little bit upon the neo-adjuvant data currently, or the metastatic data which I think more people are familiar with for immunotherapy in individuals with MSI-high cancers? Dr. Asaf Maoz: Yeah, that's an excellent question and obviously a very broad topic. Individuals with Lynch syndrome typically develop tumors that are mismatch repair deficient or microsatellite unstable. And we have seen over the last 15 years or so that these tumors, because they have a lot of mutations and because these mutations are very immunogenic, we have seen that they respond very well to immunotherapy. And this has been shown across disease sites and has been shown across disease settings. And for that reason, immunotherapy was approved for MSI-high or mismatch repair deficient cancer regardless of the anatomic site. It was the first tissue-agnostic approval by the FDA in 2017. And so there are exciting studies both in the metastatic setting where we see individuals who respond to immunotherapy for many years, and one could wonder whether their cancer is going to come back or not. And also in the earlier setting, for example, the Cercek et al. study in the New England Journal from Sloan Kettering, where they showed that neoadjuvant immunotherapy can cause durable responses for rectal cancer that is mismatch repair deficient. And in that series, the patients did not require surgery or radiation, which is standard of care for rectal cancer otherwise. And there's also exciting data in the adjuvant space, as was presented in ASCO by Dr. Sinicrope, the ATOMIC study, and many more efforts to bring immunotherapy into the treatment landscape for individuals with MSI-high cancer, including individuals with Lynch syndrome. Dr. Rafeh Naqash: A lot of activity, especially in the neo-adjuvant and adjuvant space over the last two years or so. Now going to the actual reason why we are here is your study. Could you tell us why you looked at this idea of patients who had Lynch syndrome and died, and the reasons for their death? What was the thought that triggered this project? Dr. Asaf Maoz: As we were talking about, we now know that immunotherapy really has changed the treatment landscape for individuals with Lynch syndrome, and that most cancers that individuals with Lynch syndrome do have this mismatch repair deficiency. But we also know that individuals with Lynch syndrome can develop tumors that do not have mismatch repair deficiency, and we call them mismatch repair proficient or microsatellite stable. And there was a series from Memorial Sloan Kettering showing that in colorectal cancer, about 10% of the tumors that individuals with Lynch syndrome developed did not have mismatch repair deficiency. In addition to that, we anecdotally saw that some of our patients with Lynch syndrome died of causes that were not mismatch repair deficient tumors. We wanted to see how that has changed since immunotherapy was approved in a tissue-agnostic manner, meaning that we could look at this regardless of where the cancer started, because we would anticipate that if the tumor was mismatch repair deficient, the patient would be able to access immunotherapy as standard of care. Dr. Rafeh Naqash: Thank you. And then you looked at different aspects of correlations with regards to individuals that had an MSI-high cancer with Lynch syndrome or an MSS cancer with Lynch syndrome. Could you elaborate on some of the important findings that you identified as well as some of the unusual findings that perhaps we did not know about, even though the sample size is limited, but what were some of the unique things that you did identify through this project? Dr. Asaf Maoz: The first question was what cause is leading to death in individuals with Lynch syndrome? And we had 54 patients that we identified that had died since the approval of immunotherapy in 2017, 44 of which died of cancer-related causes. And when we looked at cancer-related causes of death, we wanted to know how many of those were due to mismatch repair deficient tumors versus mismatch repair proficient tumors or MS-stable tumors. And we found, somewhat surprisingly, that 43% of patients in our cohort actually died of tumors that were microsatellite stable or mismatch repair proficient, meaning of tumors that are not typically associated with Lynch syndrome. This is not entirely surprising as a cause of death because we know that immunotherapy does not typically work for tumors that are microsatellite stable. And so in the metastatic setting, there are much less cases of durable remissions with treatment. But it was helpful to have that figure as an important benchmark. There are previous studies about causes of death in Lynch syndrome, and particularly from the Prospective Lynch Syndrome Database in Europe. Those have provided really important information about cause of death by cancer site, but they typically don't have mismatch repair status and are more difficult to interpret in that regard. They also don't include a large number of individuals who have PMS2 Lynch syndrome, which is the most common, but least penetrant form of Lynch syndrome. Dr. Rafeh Naqash: As far as the subtype of pathogenic germline variants is concerned, did you notice anything unusual? And I've always had this question, and you may know more about this data, is: In the bigger context of immunotherapy, does the type of the pathogenic germline variant for Lynch syndrome associated MSI-high cancers, does that impact or have an association with the kind of outcomes, how soon a cancer progresses or how many exceptional responders perhaps with MSI-high cancers actually have a certain specific pathogenic germline variant? Dr. Asaf Maoz: That's an excellent question, and certainly we need more data in that space. We know that the type of germline mutation, or the gene in which there is a germline pathogenic variant, determines to a large degree the cancer risk, right? So we know that individuals who have germline pathogenic variants in MLH1 or MSH2 have a much higher colorectal cancer risk than, for example, PMS2. We know that for PMS2, the risks are more limited to colorectal and endometrial, and may be lower risk of other cancers. We also know that, you know, the spectrum of disease may change based on the pathogenic germline variants. For example, individuals who have MSH2 associated Lynch syndrome have more risk of additional cancers in other organs like the urinary tract and other less common Lynch-associated tumors. The question about response to therapy is one where we have much less information. There are studies that are trying to assess this, but I don't think the answer is there yet. Some of the non-clinical data looks at how many mutations there are based on the pathogenic variant and what the nature of those mutations are, whether they're more frameshift or others. But I think we still need more clinical data to understand whether the response to immunotherapy differs. It's also complicated by the fact that the immunotherapy landscape is changing, especially in the metastatic setting, now with the approval of combination ipilimumab and nivolumab for first-line treatment of colorectal cancer that is microsatellite unstable. But in our study, we did find that, as you would expect, there is an enrichment in MS-stable cancers among those with PMS2 Lynch syndrome. Again, our denominator is those who died, right? So this is not the best way to look at the question whether this is overall true, that is more addressed by the study that Sloan Kettering published. But we do see, as we would anticipate, that there are more microsatellite stable cancers among those with PMS2 Lynch syndrome that died. Dr. Rafeh Naqash: A lot to uncover there for sure. This study and perhaps some of the other work that you're doing is slowly advancing our understanding of some of these concepts. So I'd like to shift gears to a couple of provocative questions that I generally like to ask. The first is, in your opinion, and you may or may not have data to back this up, which is okay, and that's why we're having a conversation about it. In your opinion, do you think the type or the quality of the neoantigen is different based on the pathogenic germline variant and a Lynch syndrome associated MSI-high cancer? Dr. Asaf Maoz: I think there are some data out there that, you know, I can't cite off the top of my mind, but there are some data out there that suggest that that may be the case. I think the key question is the quality, right? I think that whether these differences that are found on a molecular level also translate to a clinical difference in response is something that is unknown at this moment. Some people hypothesize that if the tumor has less neoantigens, there's less of a response to immunotherapy. But I think we really need to be careful before making those assertions on a clinical level. I do think it's a really important question that needs to be answered, among others because, you know, in the colorectal space, for example, where we have both the option of doing ipilimumab with nivolumab and the option of doing pembrolizumab, we don't really know which patients need the CTLA-4 blockade versus which patients can receive PD-1 blockade alone and avoid the potential excess toxicity of the CTLA-4 blockade. There are a lot of interesting questions there that still need to be answered. And of course, individuals with Lynch syndrome are just a fraction of those individuals who have MSI-high cancer. So there's also the question about whether non-Lynch syndrome associated MSI-high cancer responds differently to immunotherapy than Lynch syndrome associated MSI-high cancer. A lot of very interesting questions in the field for sure. Dr. Rafeh Naqash: Absolutely. My second question is more about trying to understand the role of ctDNA, MRD monitoring in individuals with Lynch syndrome. If somebody has a germline, you know, Lynch syndrome MSI-high cancer, when you do a tumor-informed ctDNA assessment, what do you capture generally there? Because, and this question stems from a discussion I've had with somebody regarding EGFR lung cancer, since I treat individuals with lung cancer, and the concept generally is that even if the tissue showed EGFR, but for MRD monitoring, when you do a barcoded sequence of different tumor specific mutations, it's not actually the EGFR that they track in the blood when they do ctDNA assessment. But from a Lynch syndrome standpoint, if you have a germline, right, which is the first hit, and then you have the somatic in the tumor, which is the second hit, are you aware or have you tried to look into this where what is exactly being followed if one had to follow MRD in a Lynch syndrome MSI-high colorectal cancer? Dr. Asaf Maoz: I think a lot of the MRD assays are proprietary, and so we don't receive information about what the mutations that are being tracked are. In general, the idea is to track mutations that we would not expect to disappear as part of resistant mechanisms. We want these to be truncal mutations. We want these to be mutations in which resistance is not expected to result in reversion mutations. But what specifically is being tracked is something that I don't know because these assays, the tumor-informed ones, are proprietary, and we don't get the results regarding specific mutations. When it's circulating tumor DNA that is not necessarily tumor-informed, we do get those results, but that is less so about the specific selection of mutations. Dr. Rafeh Naqash: Thank you for clarifying that question to some extent, of course, as you said, we don't know a lot, and we don't know what we don't know. That's the most important thing that I've learned in the process of understanding precision medicine and genomics, and it's a very fast-paced evolving field. Last question related to your project, what is the next step? Are you planning any next steps as a bigger multicenter study or validation of some sort? Dr. Asaf Maoz: There are two big questions that this study raises. One, is this true across multiple other sites, right? Because this is a single center study, and we really need additional centers to look at their data and validate whether they are also seeing that a substantial portion of deaths in individuals with Lynch syndrome are attributable to mismatch repair proficient cancer. The other question is whether we can look at specifically MSI-high cancer versus MS-stable cancer and understand what the mortality rate for each of those are. From a clinical perspective, it's important to counsel individuals with Lynch syndrome about general cancer screening outside of mismatch repair deficient tumors and to understand that there is also a risk of mismatch repair proficient tumors and that treatment for those tumors would be different. There's a lot of work to be done in the future. Another major area of need is to see whether tumors that are microsatellite stable can be sensitized to immunotherapy, and that is beyond the Lynch syndrome field, but that is something that certainly would benefit these individuals with Lynch syndrome who develop mismatch repair proficient cancer. Dr. Rafeh Naqash: That's very interesting to hear, and we'll look forward to seeing some of those developments shape in the next few years. Now, I'd like to spend a minute, minute and a half on you specifically as a researcher, clinician, scientist. Could you briefly highlight - because I remember meeting you several years back as a trainee, with your interest in genomics, computational research - could you briefly tell us what led you to hereditary cancer syndromes based on your research and work? What are some of the things that you learned along the way that other early career investigators can perhaps take lessons from? Dr. Asaf Maoz: Big questions there, thanks for asking. I got interested in the field of hereditary cancer syndromes when I came to the United States and started doing lab research in Stephen Gruber's lab at the time at USC. He's now at City of Hope. And my interest was originally looking at immunotherapy and immunology, but I went to the case conferences where we were learning about individuals with hereditary cancer, and those were kind of earlier days where we were still trying to figure out how to test and what the implications for these individuals would be. And through fellowship, I was also very interested in that, and I did my senior fellowship years with Dr. Yurgelun here at Dana-Farber, who is the director of the Lynch Syndrome Center. And I I think it's the combination between being able to treat individuals based on precision medicine and what the germline mutation is, but also the ability to prevent cancer and to develop strategies to intercept cancer early that is really appealing to me in this field. It's also a great field to be in because it's a small field. If you come to the CGA-IGC meeting, you'll be able to interact with everyone. Everyone is super collaborative, super nice, and I really recommend it to trainees. The CGA-IGC annual meeting is really a great opportunity to learn more and experience some of the advancement specifically in the GI hereditary space. Lessons for trainees. I think there are a lot of lessons that I could think about, but I think finding strong and supportive mentors is one of the things that has helped me most. I think that just having close relationship with your mentor, having frequent discussions and honest discussions about what is feasible, what is going to make a difference for your patients and your research and what you want to focus on is really important. And so I think if I had to choose one thing, I would say choose a mentor that you trust, that you feel you have a good relationship with, and that has the availability to support you. Dr. Rafeh Naqash: Thank you so much for those insightful comments, and thank you for sharing with us your journey, your project, and some of your interesting thoughts on this concept of hereditary cancers. Hopefully, we'll see more of this work being published in JCOPO through your lab or work from others. Dr. Asaf Maoz: Thank you so much. I appreciate the opportunity to be here. Dr. Rafeh Naqash: Thank you for listening to JCO Precision Oncology Conversations. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all ASCO shows at ASCO.org/podcasts. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.
In this episode, we uncover why successful practices plateau and how to break free from the comfort zone that holds growth back. Drawing on Dr. Joe Dispenza's research and our field experience, we reveal the emotional patterns that keep revenue stuck at the same level.You'll learn which habits to reassess, why continuous growth is non-negotiable, and practical steps to adopt the mindset of a higher-level practice. Discover the growth paradox and how to step into a new identity so you can scale your healthcare practice to the next level.Welcome to the Clinic Growth Secrets Podcast where we give an insider's look into what the top 1% of clinic owners are doing differently to get more patients, make more profit per patient, and keep them longer. Inside, you'll find actionable tips, tricks, and strategies that you can implement into your personal clinic to create massive growth that allows you to help as many people as possible.
In this episode of Build From Here, Joshua Parvin talks with CGA member Russ Freehling about a lifetime of waterfowling, finishing the 41-species North American quest, and the rewards of training his own retriever—from backyard drills to seasoning a pup on real hunts. Tune in for practical training tips, creative urban adaptations, and the joy of building a true hunting partnership.Want to learn how to train your hunting dog with confidence?Visit: Cornerstone Gundog AcademyNeed gear for training your retriever, like collars, dog training dummies, and more?Visit: Retriever Training SupplyInterested in sponsoring the BuildFromHere Podcast?Fill out this form and tell us more about promoting your product, service, or brand.Want to learn more about the Ultimate Waterfowl Challenge?Visit the website here: https://waterfowlerschallenge.com/
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Era actualitat dera Val d'Aran en aran
Era actualitat dera Val d'Aran en aran
Following in the footsteps of a legend is never easy to do, but Andy Priest is ready for the challenge. With Jack Nance stepping down as executive director of the Carolinas Golf Association after 40 years, Priest actually returns to the CGA after serving as the leader of the Alabama Golf Association for nine years. Priest started his golf career in 1997 under Nance and returns with a vision for the future of the organization. In this episode of Paradise in the Pines, Priest talks about his golf career path, his vision for the CGA and how he plans to fill the shoes of a legend.
Dr. Cris Bergerot and Dr. Enrique Soto join the podcast to discuss the new global guideline on geriatric assessment. This guideline provides evidence-based, resource-stratified recommendations across the basic, limited, and enhanced settings. Dr. Bergerot and Dr. Soto discuss who should receive a geriatric assessment, the role of geriatric assessment, which elements of geriatric assessment can help predict adverse outcomes, and how a geriatric assessment is used to guide care and make treatment decisions. They comment on the importance of this guideline worldwide, and the impact of this guideline for a wide range of clinicians, patients, researchers, policymakers, and health administrators. Read the full guideline, “Geriatric Assessment: ASCO Global Guideline” at www.asco.org/global-guidelines." TRANSCRIPT This guideline, clinical tools, and resources are available at www.asco.org/global-guidelines. Read the full text of the guideline, view clinical tools and resources, and review authors' disclosures of potential conflicts of interest in the JCO Global Oncology, https://ascopubs.org/doi/10.1200/GO-25-00276 Brittany Harvey: Hello, and welcome to the ASCO Guidelines podcast, one of ASCO's podcasts delivering timely information to keep you up to date on the latest changes, challenges, and advances in oncology. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today I'm interviewing Dr. Cris Bergerot from OncoClínicas & Co and Dr. Enrique Soto from the University of Colorado, co-chairs on “Geriatric Assessment: ASCO Global Guideline”. Thank you for being here today, Dr. Bergerot and Dr. Soto. Dr. Cris Bergerot: Thank you. Dr. Enrique Soto: Thanks for the invitation, Brittany. Brittany Harvey: And then before we discuss this guideline, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The disclosures of potential conflicts of interest for the guideline panel, including Dr. Bergerot and Dr. Soto who have joined us here today, are available online with the publication of the guideline in JCO Global Oncology, which is linked in the show notes. So then to jump into the guideline here, Dr. Soto, could you start by providing an overview of the scope and the purpose of this global guideline on geriatric assessment? Dr. Enrique Soto: Of course, Brittany. So, this guideline comes from a request from the global oncology community and from the geriatric oncology community, who is very interested in making sure that geriatric oncology recommendations that are used in the United States can be adopted and used globally. So, this was a very highly rated topic when we had our call for proposals for guidelines, and that's why we decided to do this. The idea of this guideline is to provide resource-stratified recommendations for the use of geriatric assessments and interventions in older adults with cancer across different settings, right? And that these guidelines can be applied by clinicians working in low- and middle-income countries, but also, in a way, by clinicians working in community settings where the availability of resources may be limited. And the idea of these recommendations is to help clinicians evaluate older people with cancer better and also understand which interventions can be implemented with the resources they have and which interventions have a bigger bang for the buck, so to speak. And as all evidence-based, stratified guidelines that ASCO conducts, we stratified resources as basic, limited, or enhanced. And that means resources that go from those that provide the greatest benefits for patients in terms of outcomes to those that are evidence-based but provide additional additive benefits. And those resource-stratified recommendations can be found in the ASCO website as to how these guidelines are developed, and that's pretty standard for most resource-stratified guidelines. Brittany Harvey: Great. I appreciate that background and the impetus for this guideline, and thank you for providing that resource-stratified framework of basic, limited, and enhanced. I think that helps provide context for the guideline recommendations here. So then, Dr. Bergerot, I'd like to next review the key recommendations of this guideline across the four clinical questions that the guideline addresses. So, across those settings, the basic, limited, and enhanced settings, what is the role of geriatric assessment in older adults with cancer to inform specific interventions? Dr. Cris Bergerot: I think this is one of the most important points, so let's break it down. First off, who should actually receive the geriatric assessment? And the recommendation is clear. All patients aged 65 and older who are being considered for systemic cancer therapy should undergo a geriatric assessment. Now, depending on the available resources, for example, in basic setting, a quick screening may be enough, but in enhanced setting, a comprehensive geriatric assessment is encouraged. And for our next question, in which elements of the geriatric assessment can help predict poor outcomes, the core domains to focus on include things like physical function, comorbidities, polypharmacy, cognition, nutrition, social support, and psychological health. And there are also validate tools like the G8, the CGA, and the CARG that can be used depending on the setting and resources available. Now, talking about how we actually use the geriatric assessment to guide care, the assessment results can guide interventions to reduce treatment-related toxicities and maintain the patient functions. So, even in basic settings, the result can help guide those adjustments or identify the need for supportive care. And in more resource settings, we can implement more tailored intervention based on those findings. And finally, for our fourth question: How can geriatric assessment help guide treatment decisions? So, GA can influence decisions about how aggressive treatment should be, help clarify goals of care, and determine whether a curative or palliative approach makes the most sense. And again, even in settings with limited resources, a simplified GA can still provide meaningful guidance. Brittany Harvey: Great. Thank you, Dr. Bergerot, for that high-level overview of the recommendations of this guideline. So then, following that, Dr. Soto, which geriatric assessment tools and elements should clinicians use to predict adverse outcomes for older patients receiving systemic therapy across the basic, limited, and enhanced settings? Dr. Enrique Soto: Yeah, so that is an excellent question because it's something that people want to know, right? When people start developing a geriatric oncology clinic, one of the first things they want to know is which tools should I use. And we hope that this guideline will provide some clarity regarding this. So, our overarching recommendation is that every patient, regardless of the level of resources, should receive some sort of geriatric assessment. And that geriatric assessment can go from a simple screening tool, such as the G8 tool, which is available online and very easy to do, and that can be done in basic settings, to a more sophisticated geriatric assessment. The important thing, and what we emphasize in the guideline, is that regardless of the tool you use, it should include those high-priority domains that are associated with outcomes in older adults with cancer. And those include an assessment of physical function, of cognition, emotional health, comorbidities, polypharmacy, nutrition, and social support. In addition to that, an important thing that the guideline does is endorse the recommendation from our parent guideline, the guideline from high-income settings, the practical geriatric assessment, which is a tool that was actually developed by the ASCO Geriatric Oncology Group, which is a self-administered tool that people can use to evaluate their patients in a prompt and fast manner. And what we actually did for this guideline is include the validation of the various tools included in the practical geriatric assessment in the five most widely spoken languages in the world, including Hindi, Chinese, Spanish, and French, and Portuguese. And so, most of these tools are validated in these languages. So, we believe that the practical geriatric assessment is a tool that can be utilized across settings and that doesn't require a lot of resources. I think an important future step is making sure that we get the practical geriatric assessment translated into various languages, and we're working with the ASCO team in getting that done. Brittany Harvey: That's an excellent point. And yes, we'll hope to have the practical geriatric assessment translated into more languages. And that tool is available linked in the guideline itself, and we'll also provide a link for listeners in the show notes of this episode (Practical Geriatric Assessment). So then, following that, Dr. Bergerot, in resource-constrained settings, what general life expectancy data should clinicians use to estimate mortality and inform treatment decision-making? Dr. Cris Bergerot: So, in basic and limited resource environments, you might not have access to every tool or specialist, but you can still make informed and thoughtful decisions. So, what the guideline recommends is to start with population-level life expectancy tables. These are available through the WHO Global Health Observatory, and they offer useful starting points. And if available, clinicians should also look for country-specific or regional survival data. That kind of local information can be even more relevant to your patient population. The clinical judgment is also key here, and it becomes even more powerful when it's guided by the patient's geriatric assessment results. And when possible, use age- and comorbidity-adjusted models, like the Lee index or tools from the ePrognosis. This can help refine estimates of mortality risk and also inform how aggressive treatment should be. Brittany Harvey: Absolutely. I appreciate you providing those specifics as well. So then, following that, Dr. Bergerot mentioned this a little bit earlier, but Dr. Soto, how should geriatric assessment be used to guide management of older patients with cancer across the basic, limited, and enhanced settings? Dr. Enrique Soto: Yeah, and again, that's another important focus, right? Because if we assess things and then don't do anything about them, then why even assess them, right? And in many settings, people say, “Well, I don't have the tools to provide the interventions that these patients actually need.” And a very significant part of building this guideline was coming up with a resource-stratified and evidence-based way in which to prioritize which interventions provide most benefits for older adults with cancer. And so, for each level and each domain, we have a series of interventions that have been stratified according to importance and evidence base, and that is actually one of the coolest features of the guideline. We included a table, and then we have for each of the domains, including falls, functional status, weight loss, et cetera, what are the interventions that oncologists can do in their clinical visit without needing a lot of resources, including providing some specific information, giving some recommendations to patients, to more high-level things that can be done when the healthcare system allows it, such as working with a nutritionist, providing supplements, testing for particular cognitive impairments, et cetera. So, I encourage people to take a look at that table. It was really a lot of work putting that table together, and that table has specific recommendations for each setting, and I think people will find it very useful. Brittany Harvey: Absolutely. That table certainly contains a lot of information that's very helpful for clinicians. I think it's important to call out those tailored interventions to improve care and quality of life for every patient. So then, we've just reviewed all of the recommendations in this guideline. So, I'd like to ask you, Dr. Bergerot, in your opinion, what should clinicians know as they implement these recommendations across resource levels? Dr. Cris Bergerot: I would say that clinicians should remember that even a brief geriatric assessment can make a meaningful difference. You don't need a full suite of tools to improve quality of care, but clinicians should tailor all the tools that are available in their local context and always keeping in mind the core geriatric domains that we have mentioned in the very beginning of our podcast. And let's be clear, the goal of the assessment isn't just to gather data, as Enrique mentioned; it's to use this information to guide treatment decision and also to improve outcomes. And whenever possible, clinicians should engage interdisciplinary teams that might include nurse, psychologist, social workers, community health workers, or anyone who can help address the patient's broader needs. And flexibility really matters. So, especially in settings with limited access to specialists or diagnostics, we should prioritize what is feasible and what will truly help our patients during their journey. And above all, we should keep this in mind that equity in care delivery is essential. Just because resources are limited doesn't mean we can't deliver age-sensitive and even patient-centered care. Brittany Harvey: Definitely. That multidisciplinary care that you mentioned is key, and also thinking about what is feasible across every resource level to provide optimal care for every single patient. So then, to expand on that just a little bit and to wrap us up, Dr. Soto, what is the impact of this guideline for older adults with cancer globally? Dr. Enrique Soto: Well, what we hope this guideline will lead to is to a boom in geriatric oncology worldwide, right? That is our final goal. And what we want is for clinicians interested in starting a geriatric oncology program or setting up a geriatric oncology clinic to use these guidelines in order to justify the interventions that they're going to do, to pick the important partners they need for their multidisciplinary team, to choose the tools that they're going to implement. And then, with that, to present this to leaders in their hospitals, leaders in their healthcare system so that they can start these clinics that will ultimately lead to better outcomes for older adults with cancer. So, I encourage people to view this as high-quality, evidence-based recommendations that are done by a group of experts and with a thorough review of the literature and also based on our parent guidelines. The fact that these guidelines are resource-stratified does not by any mean signify that they're of less quality or that the recommendations that are included in those are not proven to improve outcomes, cancer-specific and also general outcomes, in older adults with cancer. Another thing that I think these guidelines could do in the future is motivate researchers in low- and middle-income countries to fill in the gaps that we have identified in these guidelines. We've made it very clear across the guidelines where evidence is lacking. And I think that this should prompt researchers across the globe to start trying to fill in these gaps with high-quality research. And finally, I also think that this is a call for policymakers, health administrators, and people interested in public health to start scaling up resources so that places with basic resources can eventually become places with more sophisticated resources. And I think this does not only apply to low- and middle-income countries, but also to community oncologists in the US who may be facing resource constraints. And I think that these guidelines can help them stratify and understand what things should be implemented first and how to scale up. So yeah, that's the dream that with this guideline, more people will start implementing geriatric oncology around the globe and that ASCO will continue to be a leader in setting the stage for what should be done in geriatric oncology and for improving care to older adults with cancer, regardless of where they live. Brittany Harvey: Absolutely. This guideline is wide-reaching and has important impacts worldwide. So, I want to thank you both so much for the huge amount of work you took to develop this evidence-based guideline, and thank you for joining me on the podcast today, Dr. Bergerot and Dr. Soto. Dr. Cris Bergerot: Thank you so much. Dr. Enrique Soto: Thank you for the invitation. It was a pleasure. Brittany Harvey: And finally, thank you to our listeners for tuning in to the ASCO Guidelines podcast. To read the full guideline, go to www.asco.org/global-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, which is available in the Apple App Store or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.
In today's podcast we talk with Eric Wong, geriatrician-researcher from Toronto, and Thiago Silva, geriatrician-researcher from Brazil, about the comprehensive geriatrics assessment. We spend the first 30 minutes (at least) discussing what, exactly is the comprehensive geriatric assessment, including: What domains of assessment are essential/mandatory components of the comprehensive geriatrics assessment? Who performs it? Is a multidisciplinary team required? Can a geriatrician perform it alone? Can non-geriatricians perform it? Who is the comprehensive geriatrics assessment for? Who is most likely to benefit? Eric Widera suggests not as much benefit for very sick and very healthy older adults, more benefit in the vast middle. Why do the comprehensive geriatrics assessment? What are the interventions that it leads to (we cover this more conceptually, rather than naming all possible interventions) How does the comprehensive geriatrics assessment relate to the 4Ms (or 5 Ms)? How long does it take to conduct a comprehensive geriatrics assessment? What's the evidence (BMJ meta analysis) for the comprehensive geriatrics assessment? What are the outcomes we hope for from the comprehensive geriatrics assessment? That final point, about outcomes, bring's us to Eric Wong's study, published in JAGS, which evaluates the cost effectiveness of the comprehensive geriatrics assessment performed by a geriatrician across settings (e.g. acute care, rehab, community clinics). As an aside, as the editor at JAGS who managed this manuscript, I will say that we don't ordinarily publish cost effectiveness studies at JAGS, as the methods are opaque to our clinical audience (e.g. raise your hand if you understand what ‘CGA provided in the combination of acute care and rehab was non-dominated' means). We published this article because its bottom line is of great interest to geriatricians. In Eric's study, geriatricians performing CGA were more cost effective than usual care in Every. Single. Setting. And of course cost effectiveness is only one small piece of the argument for why we do the comprehensive geriatrics assessment in the first place (no patient in the history of the world has ever asked for a test or treatment because it's cost effective for the health care system). I'll close with a couple of “mic drop” excerpts from Thiago's accompanying editorial: Finally, it is instructive to compare the cost-effectiveness of geriatric services and CGAs with other interventions. A recent analysis of lecanemab for early-stage Alzheimer's disease found that gaining one QALY would cost approximately $287,000 (USD). In contrast, Wong et al. estimated that adding community-based CGA would cost about $1203 (CAD) per quality-adjusted life month (QALM) (equating to roughly $10,105 (USD) per QALY, using $1 USD = $0.7 CAD), making geriatrician-led CGA nearly 30 times more cost-effective. Put simply, for each dollar spent to improve quality of life for a year through CGA, one would need to spend almost $30 to achieve the same benefit with lecanemab. Ultimately, the question is not whether geriatricians represent a worthwhile investment (they are) but how healthcare systems can ensure that every older adult requiring specialized, comprehensive care can access it. Wong et al.'s modeling study provides a valuable contribution by showing that geriatricians placed in acute and rehabilitation settings offer the most cost-effective deployment given current workforce limitations. Despite some caveats, the overarching message remains clear: geriatric expertise not only enhances care quality but can also align with health-economic objectives, especially in high-acuity environments. However, we cannot allow an inadequate geriatric workforce to become a permanent constraint, forcing painful decisions about which older adults and which settings will miss out on optimal geriatric care. Instead, we should continue to strive to increase the number of geriatricians through robust training programs and payment model reform to ensure that cost-effective care can be provided for this large and growing vulnerable population. -Alex Smith
In this episode of The Metabolic Freedom Podcast, Ben Azadi reveals a 7-day belly fat flush that targets the real root causes of stubborn belly fat — liver overload, insulin resistance, and hidden inflammation — rather than just calorie restriction. You'll learn daily, actionable steps including olive oil shots, high CGA coffee, apple cider vinegar, strategic walking, hydration protocols, fasting, and powerful mindset affirmations. Each day builds on the last to detoxify your body, balance hormones, activate fat-burning, and reset your metabolism. Ben also answers listener questions on repeating the protocol, adapting it for post-menopausal women, exercising during a fast, and tracking carbs vs. calories. Free Resources & Links Mentioned: Free 30-Day Belly Fat Plan: https://bit.ly/455tKmT Olive Oil: http://ketokampoliveoil.com Coffee: http://ketokampcoffee.com (Code: KETOKAMP for 15% off) Electrolytes & Salt: http://ketokampsalt.com (Code: AZADI) Protein: https://www.equipfoods.com/benazadi Urolithin A: http://timeline.com/azadi (Code: "AZADI" for 20% off) Events: http://BenAzadi.com/events Cronometer App: http://cronometer.com/Ketokamp
Most practices waste 30–50% of leads by ignoring those who aren't ready to buy right away.In this episode, learn how to warm up cold leads, maximize every marketing dollar, and grow through new patient generation, better conversions, and strong clinical results.Win long-term by giving so much value that your practice becomes impossible to ignore.Welcome to the Clinic Growth Secrets Podcast where we give an insider's look into what the top 1% of clinic owners are doing differently to get more patients, make more profit per patient, and keep them longer. Inside, you'll find actionable tips, tricks, and strategies that you can implement into your personal clinic to create massive growth that allows you to help as many people as possible.
We continue our Recruit Reflection series with a perspective we haven't heard before — the parent perspective! Erin Lang is the mother of Olivia Lang, an incoming freshman at the University of Maryland. Olivia was a Level 10 gymnast at CGA and is a four-time national qualifier. She visited five schools during her recruiting process — all within the Big Ten — and ultimately found her home at Maryland, where she committed in October 2023.Erin joins us today to talk about navigating the recruiting process alongside her daughter and shares some valuable advice for athletes and their parents who are going through the journey. Thank you to our monthly Patreon supporters: Lee B, Cookiemaster, Christa, Happy Girl, Erica S, Semflam, Amy C, Maria L, Becca S, Cathleen R, Faith, Kerry M, M, Derek H, Martin, Sharon B, Randee B, MSU, Kimberly G, Robert H, Lela M, Mara L, Jenna A, Alex M, Mama T, Kelsey, Lidia, Maria P, Alicia O, Cristina K, Bethany J, Diane J, Kentiemac, Marni S, Betny T, Emily C, Cathy D, Lisa T, Libby C, Thiago, Taryn M, Dana B, Jamie S, Chuck C, Je_GL, Kaitlin, Susan P, Katertot, Mallory D, LFC_Hokie, Ella, Debbie, Megan F, Kay, Diane J, Julie B,, Austin K, Jane, Sarah, Amy, Stephen S, Johanna T, Alison S, Kristina T, Abigail W, Becky, Ola S, Jennifer K, Kate M, Claudia, Siona, Erin L, Sarah A, Kennedy B, Thomas B, Lauren D, Kihika N, Beth C, Amy, Renee PM, Ryan V, Brandon H, Tyler, Hayley B, Ben S, Kate & Landon, Danielle, ALittleUnderRotated, Dana C, Grace, Pat G , Lexi G, Laura N, Kathy, Katie A, Ruby B,, Róisín, Becca, Megan J, Emily D, Britton, Ry Shep, Reyna G, William A, MB, MJ L, Jackson G, Brittany A, Stella, Ulo F, Noah C, Melissa H, Alexis, William M, Trish, Susie, Leslie G, Catherine B, Karlin, Laura L, Katy S, J'nia G, Kathy M, Kathy S, Okcaro, Caroline P, JD B, Cookiecutter, Ailish D, Wil D, BC & Caroline M!
In today's news: The Michigan Department of Transportation has made a presentation to the Berrien County Board of Commissioners to explain its planned reconstruction of Main Street in downtown St. Joseph in 2027. St. Joseph City Commissioners have recommended that Berrien County make some changes to the Brownfield plan for properties near Harbor Shores so new housing developments planned on those parcels can proceed. The Southwest Michigan Regional Chamber has announced the hiring of a director for the new Central Berrien Chamber Growth Alliance, or CGA. See omnystudio.com/listener for privacy information.
If you're a holistic healthcare provider working 40+ hours a week but still stuck under $20,000/month, you're likely in what we call the "infancy stage." In this episode, we break down the most common mistakes clinic owners make early on and share the key shifts needed to create consistent, sustainable growth.Welcome to the Clinic Growth Secrets Podcast where we give an insider's look into what the top 1% of clinic owners are doing differently to get more patients, make more profit per patient, and keep them longer. Inside, you'll find actionable tips, tricks, and strategies that you can implement into your personal clinic to create massive growth that allows you to help as many people as possible.
This episode reveals a systematic strategy that moves patients from pain relief to transformation, preventing churn while building trust through objective health facts.Learn how Maslow's Hierarchy revolutionizes marketing by targeting pain, safety, and survival needs for maximum impact, using the "painkiller vs. vitamin" framework that creates viral advertising.Welcome to the Clinic Growth Secrets Podcast where we give an insider's look into what the top 1% of clinic owners are doing differently to get more patients, make more profit per patient, and keep them longer. Inside, you'll find actionable tips, tricks, and strategies that you can implement into your personal clinic to create massive growth that allows you to help as many people as possible.
“If you disappeared for 30 days, would your clinic survive?”Most clinic owners are trapped working 50+ hours a week because they're thinking like practitioners instead of entrepreneurs. The harsh truth: you can't scale past $100-200K per month when the business revolves entirely around you.Start building a machine that generates wealth while you sleep.Welcome to the Clinic Growth Secrets Podcast where we give an insider's look into what the top 1% of clinic owners are doing differently to get more patients, make more profit per patient, and keep them longer. Inside, you'll find actionable tips, tricks, and strategies that you can implement into your personal clinic to create massive growth that allows you to help as many people as possible.
Prospects today have less trust in business promises than ever before, creating inconsistent closing percentages, unpredictable sales cycles, and missed revenue opportunities.Discover the five framing strategies that transform skeptical prospects into eager patients before they walk through your door. Learn how to control the patient's mindset from first contact to final conversion through confirmation pages, pre-education sequences, and phone scripts that build rapport and create curiosity.Welcome to the Clinic Growth Secrets Podcast where we give an insider's look into what the top 1% of clinic owners are doing differently to get more patients, make more profit per patient, and keep them longer. Inside, you'll find actionable tips, tricks, and strategies that you can implement into your personal clinic to create massive growth that allows you to help as many people as possible.
"If you're serious about hitting record months, you need to know your metrics like the back of your hand."Most clinic owners are flying blind when it comes to the numbers that actually drive growth. We break down the essential business KPIs every successful clinic must track - from Patient Visit Average (PVA) and Collection Visit Average (CVA) to calculating your true Lifetime Value and Cost of Acquisition.Stop guessing and start measuring what matters - because the clinic that understands their numbers wins every time.Welcome to the Clinic Growth Secrets Podcast where we give an insider's look into what the top 1% of clinic owners are doing differently to get more patients, make more profit per patient, and keep them longer. Inside, you'll find actionable tips, tricks, and strategies that you can implement into your personal clinic to create massive growth that allows you to help as many people as possible.
Vitalism isn't just a philosophy, it's your advantage in the healthcare marketplace.If you want patients who stay, refer, and believe in what you do, stop selling care plans and start creating Vitalists. In this episode, Dr. Stephen and Dr. Pete unpack how Vitalism creates deep alignment between your message, your mission, and your market - and their unique IDENTITY as a Vitalist.Anchoring your patient journey to “Vitalism” as your unique position in healthcare, this conversation maps out how to build conversion, retention, community, referral and legacy around something much bigger than symptom relief. This is more than a mindset, it's a movement.In this episode you will:See how vitalism bridges the gap between conversion and retention.Learn why identity—not information—drives patient behavior.Understand how vitalistic branding builds community and loyalty.Discover how to use belief systems to scale your business.Walk away with the case for claiming “vitalist” as your market niche.Episode Highlights3:39 – The idea of taking a 150-year generational perspective for your clinic4:39 – Authenticity as the most powerful vibrational force in patient education6:32 – Calling vs. job: how perspective reshapes your team's engagement7:49 – Chiropractic's unique success proposition in today's healthcare market8:43 – How effective marketing creates urgency, relevance, and identity10:32 – Why vitalism matters and why chiropractors should claim the term now12:28 – Defining the vitalist and how they see chiropractic as a lifestyle success strategy15:41 – The story behind the “Make America Healthy Again” campaign and Vitalistic Party18:22 – Anchoring retention and identity: how vitalism helps patients stay21:55 – Vitalism as a belief in life force and its business implications22:43 – Identity shapes behavior: how lifestyle drives decisions like regular chiropractic23:52 – Vitalism, fitness, and personal routines as expressions of identity24:31- Dr. Eric is joined by Success Partner, Jeff Van Kampen from Clinic Growth Accelerator (CGA), a company that helps chiropractic clinics attract and convert new patients with digital marketing. Jeff explains how CGA specializes in paid social media ads and lead qualification, sharing practical insights on tracking ROI and maximizing new patient appointments. They also discuss the future of digital marketing in chiropractic, including AI-driven nurture sequences and the importance of building trust online. Resources MentionedTo learn more about the REM CEO Program, please visit: http://www.theremarkablepractice.com/rem-ceoFor more information about Clinic Growth Accelerator please visit: https://growyourclinic.com/Schedule a Brainstorming call with Dr. PeteFollow Dr Stephen on Instagram: https://qr.me-qr.com/l/riDHVjqt Follow Dr Pete on Instagram: https://qr.me-qr.com/I1nC7Hgg Prefer to watch? Catch the podcast on YouTube at: https://www.youtube.com/@TheRemarkablePractice1To listen to more episodes visit https://theremarkablepractice.com/podcast/ or follow on your favorite podcast app.
#72 What happens when the digital world of retriever training transforms into face-to-face connections? The answer lies in the groundbreaking Nashville Chapter event – the very first Cornerstone Gundog Academy chapter gathering that's changing how retriever owners train, learn, and build community.Kevin Wright returns to the podcast to share the remarkable success story of organizing and hosting this inaugural chapter event. As a passionate CGA member who took the initiative to bring fellow retriever enthusiasts together, Kevin offers valuable insights into how the Nashville Chapter came together, what made their first gathering so special, and why this model represents the future of retriever training communities.The Nashville experience demonstrates how the supportive online CGA community translates perfectly to in-person gatherings. Members who previously knew each other only through screens instantly connected on a deeper level when meeting face-to-face. Dogs and handlers alike benefited from the collaborative training environment where mistakes weren't just accepted but viewed as valuable learning opportunities. From basic obedience to water retrieves, every dog received plenty of work while handlers exchanged knowledge, encouragement, and friendship.Beyond the training itself, what stands out most is the genuine community being formed. Several members brought their families, transforming retriever training into a wholesome activity everyone can enjoy together. After the formal training concluded, participants stayed for an additional hour and a half simply enjoying each other's company – proof that these chapters are about much more than dog training alone.Looking to the future, Kevin shares exciting plans for monthly Nashville Chapter gatherings and even group hunting trips. He also reveals details about the upcoming CGA app that will further enhance chapter communications and community building. For those inspired to start their own local chapter, Kevin offers this encouragement: "Just get one other person. If it's just two of you, it doesn't have to be the biggest event, just start something... if you build it, they will come."Whether you're already a CGA member wondering how to connect with local retriever enthusiasts or someone considering joining this supportive community, this episode offers an inspiring glimpse into how the retriever training journey becomes infinitely more rewarding when shared with others who understand and support your goals.
Welcome to Vatican Insider on another hot summer weekend in Rome and so many parts of the world! Relax, enjoy a cool drink and let me bring you the news and a great interview! After the news segment, stay tuned for Part II of my conversation with Catherine Wiley and Marilyn Henry of the Catholic Grandparents Association as we continue our talk about the first international conference that CGA recently held in Rocca di Papa, near Rome, attended by grandparents from Ireland, England, Australia, the U.S., Malta, Gibraltar and the Philippines.
#070 Wade Skeen's path from Air Force serviceman to Kansas waterfowl guide extraordinaire reveals how passion, community, and proper training methods can transform both careers and gundogs. As a longtime Cornerstone Gundog Academy member before becoming a professional outfitter, Wade brings a uniquely valuable perspective that bridges the worlds of retriever training and professional hunting.Growing up in Mississippi with a focus on whitetail and turkey hunting, Wade's move to Kansas in 2012 opened his eyes to an underappreciated waterfowl paradise. What began as occasional hunts with friends evolved into Skeen Outfitters, now one of the premier guided waterfowl experiences in the Midwest. Against all odds, Wade launched his business in March 2020 just as COVID hit, yet through determination and a foundation of strong relationships, particularly within the CGA community, his operation has flourished.The conversation delves deep into Wade's transformation as a dog trainer, contrasting his experience with traditional methods versus the methodical approach of Cornerstone training. His position as both guide and trainer offers rare insights into what truly matters in hunting dogs: "Your dog's demeanor when not retrieving birds is actually much more important than how it retrieves birds." This perspective reinforces how proper foundation training creates adaptable, steady companions that enhance rather than detract from hunting experiences.Wade and Josh recount several memorable hunts together, including an extraordinary day filming for television where everything aligned perfectly—dog work, hunting conditions, and camaraderie. These stories highlight the unpredictable nature of waterfowl hunting that keeps enthusiasts coming back season after season.As the conversation closes, Wade shares his most valuable advice for dog trainers: "Throw expectations out the window. Enjoy the process itself—the wins, the losses. Just focus on each 15-minute training session, day in and day out, and your dog will far surpass what goals you ever had in mind anyway." It's a powerful reminder that in both dog training and life, the journey often matters more than the destination.Connect with Wade at SkeenOutfitters.com or find him on social media to experience one of the best waterfowl hunts available—with the added bonus of bringing your Cornerstone-trained retriever along for the adventure.
If you're stuck at a fat loss plateau or struggling with belly fat, this episode breaks down 5 science-backed morning drinks that can ignite fat-burning, balance blood sugar, and shrink your waistline—fast.
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No episódio de hoje temos Bruno Contesini, engenheiro químico de formação, pesquisador em biocombustíveis pela USP, com passagem pela Petrobras Distribuidora e vasta experiência no mercado financeiro. Sócio-fundador da Neit Asset, hoje é diretor no Ipê Bank, Index Core Investments e presidente do Grupo Glannos. Possui certificação CGA da ANBIMA, MBA pelo Ibmec e formação em Inovação e Design Thinking pelo MIT. Atua também no campo social, com livro publicado em apoio ao GRAACC e liderança na Associação Glannos. Uma conversa impressionante sobre superação e capacidade de fazer acontecer. ....................................................................................................................................................................
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