Podcasts about FAP

Good morning from Pharma Daily: the podcast that brings you the most important developments in the pharmaceutical and biotech world. Today, we delve into a series of significant advancements and challenges shaping the landscape of these dynamic sectors. Starting with Ipsen's Dysport, which has made notable strides in its Phase 3 trials for migraine prevention. The trials covered both episodic and chronic conditions, marking a first in the neurotoxin market. Dysport's success positions it as a formidable competitor to AbbVie's Botox, expanding therapeutic options for individuals battling migraine disorders. This achievement showcases the potential efficacy of botulinum toxin-based therapies in neurology and pain management, offering promising new avenues for patient care. In regulatory news, Boehringer Ingelheim has received approval from the Medicines and Healthcare products Regulatory Agency (MHRA) for Jascayd, a small molecule PDE4B inhibitor with antifibrotic properties. This approval marks a significant milestone in the treatment of idiopathic and progressive pulmonary fibrosis. Jascayd's addition to the therapeutic arsenal offers new hope for managing this debilitating condition, emphasizing the ongoing efforts to improve patient outcomes through innovative treatments. The arena of business development sees HanChorBio partnering with InxMed to advance oncology research. By combining HCB101 with FAK inhibitors and FAP-targeted ADCs, this collaboration aims to leverage antibody and small molecule drug discovery techniques. The goal is to develop innovative cancer treatments that could redefine therapeutic approaches in oncology. Keenova Therapeutics has also reported success with Xiaflex for plantar fibromatosis. This enzyme injection therapy offers a novel approach by targeting collagen, thus providing an innovative solution for musculoskeletal conditions. Similarly, Fate Therapeutics' FT819, an off-the-shelf CAR-T therapy, has shown early promise in tackling treatment-resistant systemic sclerosis, underscoring the potential of cell therapies beyond oncology. Meanwhile, MindRank's successful Series B funding round of $52 million highlights the growing role of AI platforms in drug discovery. The funding will propel its AI-discovered oral GLP-1 obesity pill into Phase III trials, exemplifying how technology-driven solutions are gaining traction in addressing metabolic diseases like obesity. On the regulatory front, Saol Therapeutics has resubmitted SL1009 (DCA) to the FDA for pyruvate dehydrogenase complex deficiency. This submission underscores ongoing efforts to address rare metabolic disorders using small molecule therapies. Additionally, Sanofi's concessions to the EU regarding flu vaccine marketing illustrate the complexities of competitive dynamics and regulatory scrutiny within the vaccine market. However, not all developments are favorable. AstraZeneca and Ionis Pharmaceuticals faced a setback as their drug Wainua failed its Phase 3 trial for transthyretin-mediated amyloid cardiomyopathy. This outcome highlights the challenges inherent in developing effective treatments for complex cardiovascular conditions. Meanwhile, regulatory processes remain contentious as the FDA pauses its release of complete response letters amid debates over proprietary information disclosures. In another noteworthy development, GSK has terminated its $2.2 billion collaboration with Alector after underwhelming results from Alzheimer's drug trials. This decision highlights both financial implications and strategic shifts as companies reassess risk tolerance in neurodegenerative disease research. Conversely, Roche's success with its KRAS G12C inhibitor divarasib in Phase 3 lung cancer trials underscores the promise of precision medicine. Divarasib outperformed competitors Amgen's Lumakras and Bristol Myers Squibb's Krazati, positioning Roche to potentially redefine standards of care based on genetic profiles. In a move reflecting industry trends towards collaboration and innovation risk-sharing models, AstraZeneca has partnered with Sino Biopharmaceutical on respiratory disease research. This strategic alliance represents a substantial investment aimed at expanding AstraZeneca's pipeline in respiratory therapeutics. Lastly, amidst these developments, psychedelic drugs are experiencing a renaissance in psychiatric care. Companies like Compass Pathways are pioneering clinical validation for their use in treating depression, signaling a potential paradigm shift from traditional SSRIs to newer therapeutic classes pending safety and efficacy data. Overall, these stories illustrate a dynamic interplay of scientific progress and regulatory navigation within the pharmaceutical and biotech sectors. While challenges persist—particularly in neurodegenerative disease treatment—the breakthroughs in oncology and metabolic disorder therapeutics offer hopeful prospects for improving patient care. As these industries continue evolving, integrating advanced technologies such as AI will likely play a pivotal role in shaping future therapeutic landscapes.Support the show

A Special Industry Update, With Jason Diamond and Mindy Diamond Jason and Mindy Diamond revisit how advisor due diligence is evolving—from AI and enterprise value to firm stability, ownership, and optionality—and why those questions matter more than ever. In Summary Due diligence has always been about finding the right fit. But what advisors are evaluating has expanded considerably. In this replay of an Industry Update, Jason Diamond and Mindy Diamond revisit The Advisor Transition Playbook to explore how advisor priorities continue to evolve. Beyond the traditional reasons advisors consider change, they discuss newer factors shaping decisions today—from artificial intelligence and enterprise value to ownership structure, firm stability, and long-term optionality. The conversation reinforces that while every advisor's motivations are personal, the evaluation process has become far more strategic. Today's advisors aren't simply comparing recruiting deals or platforms. They're considering how today's decisions may influence the value, flexibility, and future of the businesses they're building. The Storyline For years, advisor movement was largely driven by familiar themes: bureaucracy, management changes, technology frustrations, and the desire for greater independence. Those factors remain important. But the conversations Diamond Consultants has with advisors today increasingly include questions that rarely surfaced just a few years ago. How should AI factor into firm selection? What is the long-term value of building enterprise value instead of simply maximizing a recruiting package? How important is a firm's ownership structure? And how should advisors think about stability in a marketplace where acquisitions, recapitalizations, and private equity investment have become commonplace? Jason and Mindy revisit the transition framework introduced in Part 1, focusing less on the mechanics of making a move and more on the evolving criteria advisors are using to evaluate their options. The result is a broader discussion about due diligence—not simply as a transition exercise, but as an ongoing strategic process for advisors seeking to build their best business life. Topics Covered Advisor due diligence Traditional vs. emerging drivers of advisor movement Artificial intelligence in wealth management Enterprise value and advisor ownership Recruiting deals versus long-term economics Reverse due diligence Firm ownership and stability Private equity in wealth management Advisor optionality Building a long-term advisory business Blubrry Player > Download a transcript of this episode… Listen and Learn Highlights for Advisors Why are the traditional drivers of advisor movement still relevant? (4:00) Jason and Mindy revisit the longstanding push-and-pull factors that continue to influence advisor decisions, from bureaucracy and management frustrations to the desire for greater ownership and control. How has AI become part of the due diligence process? (13:50) The discussion explores why advisors increasingly expect firms to demonstrate a clear AI strategy—and why investment, integration, and vision may become meaningful competitive advantages. Why should advisors care about enterprise value, even if they don't technically own their business? (24:30) Jason and Mindy explain why more advisors are evaluating decisions through the lens of long-term business value rather than solely short-term economics. What does reverse due diligence really involve? (37:15) The conversation highlights why advisors should evaluate prospective firms with the same rigor firms use when evaluating advisors. How does firm ownership affect advisor optionality? (38:00) Private equity, acquisitions, and changing ownership structures have made it increasingly important to understand what happens if a firm's strategy changes after an advisor joins. Why has due diligence become more strategic than ever? (45:30) The episode concludes with a broader discussion about defining one's “best business life” and making decisions that align with long-term goals rather than reacting to short-term frustrations. Key Takeaways The reasons advisors evaluate change have expanded well beyond traditional frustrations such as bureaucracy and compensation. AI has become an increasingly important component of firm evaluation, not because it replaces advisors, but because it can enhance productivity and client service. Enterprise value is becoming a consideration even for advisors who currently work within employee models. Reverse due diligence is just as important as a firm's evaluation of an advisor, particularly when assessing ownership structure, capitalization, and long-term stability. The most effective transition decisions balance immediate economics with long-term flexibility, ownership, and optionality. Every advisor's definition of success is different, making clarity around personal goals the foundation of any due diligence process. https://youtu.be/WZbUZJZK1yc Quotable Moments “Every advisor deserves to live their best business life.” “Just because you're frustrated doesn't mean you should move. You need something worth moving toward.” “The question isn't simply what you're paid today. It's what you're building over time.” “Knowledge is power. Understanding what your business is worth should be part of every advisor's decision-making process.” FAQs Why are more advisors expanding their due diligence beyond compensation? While transition economics remain important, advisors are increasingly evaluating technology, AI capabilities, enterprise value, ownership opportunities, and long-term flexibility as part of the decision-making process. How should advisors evaluate a firm's AI strategy? Rather than looking for finished products, advisors should assess whether a firm has a clear vision, meaningful investment, and an integrated approach to using AI to improve advisor productivity and client experience. What is reverse due diligence? Reverse due diligence is the process of evaluating a prospective firm as thoroughly as the firm evaluates the advisor. It includes understanding ownership structure, financial stability, culture, technology, leadership, and long-term strategy. Why does enterprise value matter for employee advisors? Even advisors who do not currently own their businesses may benefit from understanding how different business models create opportunities for ownership, long-term value creation, and future monetization. How has private equity changed advisor due diligence? Private equity has introduced new opportunities for growth and capital, but it has also made it more important for advisors to understand ownership structures, investment horizons, and what future transactions could mean for their business. What does Diamond Consultants mean by an advisor's “best business life”? It refers to aligning an advisor's business model, goals, client experience, compensation, flexibility, and long-term vision in a way that best supports both the advisor and the clients they serve. While transition economics remain important, advisors are increasingly evaluating technology, AI capabilities, enterprise value, ownership opportunities, and long-term flexibility as part of the decision-making process. Rather than looking for finished products, advisors should assess whether a firm has a clear vision, meaningful investment, and an integrated approach to using AI to improve advisor productivity and client experience. Reverse due diligence is the process of evaluating a prospective firm as thoroughly as the firm evaluates the advisor. It includes understanding ownership structure, financial stability, culture, technology, leadership, and long-term strategy. Even advisors who do not currently own their businesses may benefit from understanding how different business models create opportunities for ownership, long-term value creation, and future monetization. Private equity has introduced new opportunities for growth and capital, but it has also made it more important for advisors to understand ownership structures, investment horizons, and what future transactions could mean for their business. It refers to aligning an advisor's business model, goals, client experience, compensation, flexibility, and long-term vision in a way that best supports both the advisor and the clients they serve. NOTE: The views and opinions expressed by the guests on this podcast are their own and do not necessarily reflect the views and opinions of Diamond Consultants. Neither Diamond Consultants nor the guests on this podcast are compensated in any way for their participation. Related Resources The Advisor Transition Playbook: The Latest on Due Diligence, the Move, and Everything In Between – Part 1 Annual Advisor Transition Report Top 10 Tips for a Strategic Due Diligence Process Should I Stay or Should I Go? View the transcript of this episode… The Advisor Transition Playbook: The Latest on Due Diligence, the Move, and Everything In Between – Part 2 A Special Industry Update with Jason Diamond and Mindy Diamond. Jason Diamond: Welcome to a replay of one of the most popular episodes from our podcast series for financial advisors, The Advisor Transition Playbook: The Latest on Due Diligence, the Move, and Everything In Between. It's Part 2 of a 2-Part Industry Update with Mindy Diamond. I’m Jason Diamond and this is the Diamond Podcast for Financial Advisors. Mindy Diamond: At Diamond Consultants, we help elite advisors identify the right environment for their businesses to thrive, whether that’s at a wirehouse, boutique, or independent firm. With nearly three decades of experience, we’ve guided thousands of advisors and represented more than a quarter of a trillion dollars in assets transitioned. And each year, one in four advisors managing a billion dollars or more who change firms are our clients. Our process is education driven and based on building relationships, starting as your strategic partner, well before you’re even thinking of a move. To schedule a confidential conversation, call us at 908-879-1002. Wondering why advisors change firms and where they’re headed? Are transition deals going up or down? Those very questions and more inspired us to create our Annual Advisor Transition Report. It’s the award-winning data-driven resource designed for advisors that connects the dots between the motivations around movement and the firm’s appetite for top talent. Arm yourself with the knowledge you need to make smart decisions. Download your copy at diamond-consultants.com/transitionreport. Jason Diamond: There’s been a noticeable shift in how advisors are approaching decisions about their business, not necessarily in whether they’re exploring change, but in what they’re focused on when they do. Mindy is back with me for a continuation of our earlier conversation on the Advisor Transition Playbook. Last time, we spent time on the mechanics, how due diligence works, what a move actually entails, and how to think through the process. What’s become more apparent since then is that the inputs into that process are evolving. The traditional drivers are still there, but layered on top are a set of considerations that didn’t carry the same weight before. AI is one of them, and not just as a tool, but as a differentiator that advisors are starting to diligence more seriously. Enterprise value is another. Showing up in conversations, even for advisors who don’t technically own their business, but are thinking more critically about what they’re building over time. And then there are questions around stability, ownership, and flexibility. What happens to the firm itself and whether advisors retain the ability to adapt again if circumstances change. None of this is theoretical. It’s showing up in real time conversations. What we want to do here is unpack those new triggers of advisor movement and what they suggest about how decisions are being made today. So let’s get to it. Mindy, the legend, thank you for joining me. So glad to have you on. Mindy Diamond: Thank you. I’m so happy to be here. Jason Diamond: Great. Let’s dive right in. I’ll set the stage really quickly one more time. When we spoke about this topic last, we talked about the drivers of movement, what we’ll call in this conversation as the old or the legacy drivers of movement, and we spoke about the mechanics of the move. Before we get into the new drivers of movement, which I want to be the meat of the conversation, remind us, when we talk about the legacy drivers of movement …. And by the way, by saying legacy, I by no means want to suggest that they’re not valid today, because they’re equally valid, if not more so today than they were then. But when you think of the classic drivers of movement in our industry, what are they? Mindy Diamond: Yeah. So I would say, first of all, let’s start by saying that for every advisor, they’ve got a unique set of needs. So the first thing to say is that while you and I can talk about the categories of frustrations or things that might bother an advisor, they show up differently in each advisor’s life. So it’s important to note that everyone is unique. But generally speaking, if I had to package them, I’d say it’s number one that shows up most of the time is too much bureaucracy. A feeling that a firm or a model is just too hypervigilant in terms of compliance and it’s too bureaucratic and too hard to get things done. Number two would be some sort of change in or frustration with management. Something is going on that the person or persons that are responsible for managing the business are just not … They’re not the wind at their back. They’re obstreperous. They’re causing difficulty and frustration. And probably the third one would be less about a pain point and more about the desire to be something that they couldn’t where they were. The notion that they want to be more independent, they want to be a business owner and they just can’t do that. That doesn’t exist within the model where they work. Those probably have been the three ones top of mind, but I bet you’ll have some … You’ll add to that. Jason Diamond: I’ll add a couple. But before I do, I’ve heard you talk about this topic, maybe said another way as pushes and pulls. Can you explain what you mean by that? Mindy Diamond: Yeah. So I think that we think about the pushes, the frustrations, the things pushing somebody out the door, the factors that make it less easy or less fluid to do business. And there’s almost always pushes that exist when somebody comes to us, where they’re frustrated to some degree or another about certain things. But we tell people all the time that just to be frustrated should never be enough, because if all you’re doing is running from one set of problems, you’re very likely to run into maybe a different set, but still problems elsewhere. So a move needs to be driven in equal part, if not more, by pulls. Being pulled toward an opportunity that can be needle moving enough or better enough than where you are now. Pushes and pull. Jason Diamond: I love it. So let me ask you a little bit of a pointed question. Is a recruiting deal a valid pull factor? Mindy Diamond: So look, it’s different for every person. We’ve had advisors come and say, “I just went through a divorce and the most important thing to me is to recapitalize. And so a recruiting deal is really important.” And while I would never be one to say that’s not valid, it can be … And by the way, any advisor should want to and expect to better their financial situation. There should be economic gain. But it shouldn’t be the only or the primary reason for the move. So you want to monetize. The notion of wanting to monetize in the short term should be a factor in what model you pick, but it shouldn’t be the primary driver for a move. Jason Diamond: I agree with that wholeheartedly. I was going to say something I think maybe would’ve surprised you a little, which is like, yeah, I think recruiting deal is a very valid pull factor because what we’re saying is, it shouldn’t be the only pull factor. And sometimes it is and it makes us a little bit sad, I think, when that’s the case. But all of these factors you mentioned, and the ones I would add, I think that maybe technology would be another kind of factor that drives movement, all of these factors are not one specific reason. If you did the exit interview, either actually conducted the exit interview with advisors or thought exercise exit interview, I think they would point to a confluence of all of these factors. Compliance was a headache. I wanted to launch a podcast. I wanted to be able to send a timely communication to my clients. We used to hear that one during COVID a lot, right? By the time compliance approved something to send to clients, it was already stale. So do you agree with that, that it’s generally a confluence or a combination of these? Or in your experience, is it advisors are like, “No, compliance or the tech is so bad, I’m out”? Mindy Diamond: Yeah. So most often there’s a straw that breaks the camel’s back incident or thing where they’re willing to put up with a series of minor paper cuts, if you will. And then almost always there’s something that happens. You and I got a call the other day from a team that said that they had split from their partner and the management of the firm was favoring the ex-partner, making it harder for them to stay or making it less fun or feel good for them to stay. So while they gave me a laundry list of things that were imperfect, I don’t know that any one of the things that were imperfect up until then would’ve been enough to drive them out. But when that one thing, that feeling that they were a second class citizen came up, that was the straw that breaks the camel’s back and went from a minorly frustrated to, “I’m out of here.” Jason Diamond: Yeah. And there’s probably a hundred examples you could walk us through. And I wanted to just highlight too, this concept is not limited to the wirehouse or employee or captive firm world, this is equally relevant for independent advisors. Granted, some of the pushes and pull factors, some of the triggers are not necessarily the same, but the idea that advisors outgrow a broker dealer or an RIA or either need or want or desire in some way, shape or form, greater autonomy, flexibility, freedom, control is certainly not limited to the employee space. I just wanted to make that point. Mindy Diamond: And I think that’s absolutely right. I think the notion of that frustrations or limitations or bureaucracy only existed if you were a W2 employee at a bulge bracket firm. That went out the window. As the industry landscape has expanded and there’s more and more valid ways to be a financial advisor, there’s more and more ways for a firm or a model or an infrastructure to frustrate an advisor. And that’s not being overly negative. It’s just to say there is no perfection anywhere. Jason Diamond: Yeah, 100%. And by the way, to play a little bit of devil’s advocate on that, and then we’ll move on, I would just say there are pain points that might come from a firm being small and subscale as well. My firm doesn’t have efficient technology. They don’t invest enough in the business. They don’t provide a lead mechanism. They don’t have a robust banking and lending or investment solutions platform. So this stuff cuts both ways. An advisor can be frustrated or limited and an advisor can be excited. Pushes and pulls I think touch on, we’ve heard from advisors in every single pocket of the market, this is a relevant concept. Mindy Diamond: The theme of this is that every advisor deserves to live their best business life. That’s what people are in search of when they reach out to us or when they engage with us. What they’re looking for more than anything, and this is irrespective of where they work or how long they’ve worked or how much they manage, every advisor is in search of their best business life. And what defines their best business life is having the best quality of work life, but also the best ability to do what they want to do with their business, to serve their clients without limitations, to grow the way they want, to be paid a fair wage, and ultimately set up to maximize the value of the business they’ve built. Those are the definitions of one’s best business life. Jason Diamond: I used an even simpler definition of best business life and I stole it from you, which is the true north concept, which is if your true north is maximizing enterprise value and chasing the dollar and trying to build something that’s scalable and saleable, then great. If your true north is to build a lifestyle practice, there’s plenty of advisors who are successful and happy and content in that regard as well. And I think that’s what we’re talking about, is finding your true north and then it’s possible. I mean, that’s the beauty of the landscape. We’re talking about this, a lot of this is pain points or things that advisors experience. The exciting part of this is there’s never been a better time to be an advisor because of the breadth of choice they have and the ecosystem that’s been born to support advisors, to your point, across the spectrum. Mindy Diamond: Yeah. And it’s also, I think, worth saying that it starts with really good crystal clear clarity around not only what’s frustrating you, but what you want ideal to look like. Because I can’t tell you, or I can tell you because … I can’t tell our listeners, I can’t stress enough how often we get calls from advisors that tell us where they think they want to be or tell us they want to move. They have clarity about what’s frustrating them or what they want to change, but they don’t really have clarity about what they want it to look like. And the less clarity you have, the less likely you are to be successful in finding the exact right solution. So our work, the thing we probably do best is really work with advisors to help them. It doesn’t take long. In an hour conversation, we can help them to really get crystal clear on what they’re looking to solve for. Jason Diamond: Absolutely. All right. Great appetizer. We set the table. Let’s dive into the main course now. I want to talk now about what I’m calling the 2.0 triggers or the new triggers of movement. And to be clear, it’s not that these are more important or better or more significant drivers of movement. In fact, you could argue they’re probably at present less significant than the ones we just listed. But I think what we’re saying is these are triggers that are starting to come up more and more in conversations and we expect them to only proliferate further. And in that regard, they’re noteworthy and important for advisors because advisors should be reconciling not just what are the things I need to be worrying about today, but also what are the things I need to be potentially worrying about five years from now. So with that in mind, let’s dive in. I think the first one we have to start with is AI. And I always chuckle a tiny bit when we mention AI, we used to have to specify what are we talking about. Are we talking about artificial intelligence or alternative investments? And now it’s very clear. Everybody knows we’re talking about artificial intelligence. So the direction of the industry, no over-dramatization to say is at stake here. It’s that important of a topic. Let me ask you just very simply first, is this coming up in conversations with advisors? Mindy Diamond: Oh, all the time, but it’s almost table stakes. So I think the way it comes up is that people assume, advisors assume, and by the way, have the right to assume that AI is part of the tech stack. The notion that if I’m evaluating a firm and part of what frustrates me or part of what’s really important to me is cutting edge, really robust technology, part of what I am expecting is that a new firm is going to have really robust technology. And part of that is really robust access to AI. And has honed the AI in a way that’s user-friendly, that really answers or delivers on making me a better … Not replacing me as an advisor, but making me a better, more efficient advisor. Jason Diamond: 100%. And I would also add, so as I think about this AI topic, I don’t want this to become a conversation around, is AI going to replace advisors, because I think we both agree that’s not going to be the case. Especially at the top end of the market for quality advisors, I think they’re not going anywhere. But in my view, when we think about the trigger of movement, AI has the potential to be transformative because a couple kind of use cases or trigger cases come to mind, and I’d love to hear your thoughts. One is, do you think advisors will potentially consider a move because they’re worried about this? So in other words, play this logic out with me. I’m 55 years old and I’m like, “Oh man, AI might be coming from my job.” And there’s firms offering 400% of revenue to move my book. Maybe I should take that check and kind of de-risk and monetize while I can. What are your thoughts on that? Mindy Diamond: I absolutely think we’re already working with that fall into that category, but to say that is the only reason for the move would be wrong. I’m grateful that people trust us enough to be transparent with us. So they let us know that underneath the notion that they want to better serve clients, they ultimately want better access to A, B, and C, they want to be able to do D, E and F with less restriction, is really the main reason for the move. But underneath it, the notion that my book, I want to protect myself. My book may well be the biggest it’s ever going to be. It is going to be worth more today than it could be in the future if things don’t go my way. And if I know I’m going to move and one of my goals is to monetize, I might want to do that now. Jason Diamond: I agree. And that’s where the top deal story comes in also. Firms paying a top deal is a part of that story. It’s what you just said, plus advisors know firms are willing to pay incredible multiples. I mean, as we speak, UBS is in market with one of the largest deals in history. So those two narratives side by side, I agree. I think this becomes more of a kind of catalyst or driver movement. It’s come up in my conversations on both sides of the spectrum. It’s the tech savvy, AI savvy advisors who are excited about this, who are like, “I want to be the most AI enabled version of myself I can be. It’s going to make me a rockstar and it’s going to widen the gap with my peers,” but it’s also come up with the people who are, I think, rightly scared and fearful about what this might mean for their job. Mindy Diamond: Let me ask you, what are examples of the way you’ve seen some of the best firms who have embraced AI? What is their narrative? What is it that they’re saying to advisors that if you come here from a tech or AI perspective, you’ll be better because we’re able to do … Fill in the blank. Jason Diamond: Yeah. So a couple that come up. First of all, I want to make the important point. Advisors do not expect that firms, either their current firm or firms that they are diligencing prospectively, have this figured out or solved. Everybody understands this is a fairly new area that firms are still very much kind of developing their strategies in. What advisors want to see is a few things. They want to see though leadership, they want to see investment, and they want to see a strategy, right? Effectively, they want to see a step in the right direction, really. So I’ll give you a couple examples. There are a number of tech savvy RIAs, very tech-enabled, AI-focused RIAs, because I think this is easier to be nimble. I think where you’ll see this quicker probably is in the independent space. That what they’re doing is things like this. An advisor logs on to their workstation in the morning and their system queues them proactively, Mr. and Mrs. Smith may be good candidates for a Roth IRA conversion. And then if the advisor decides to contact the client in some way about it, the system will of course help them draft the communication, but then it’ll take it a step further and actually help them to process and transact that conversion. So soup to nuts, ultimately driving efficiency. That’s the name of the game. That’s why firms, I think, are excited about AI, at least the good firms. Because what I think they realize it will do is, the stuff that’s a waste of time that could be automated that advisors, and probably even more so their associates, client associates are spending time on, that should be a massive time saver for advisors. And I think if you play that story out, what does that mean? It should mean bigger books of business and therefore more productive advisors because they have more time to prospect and focus on their clients. Thoughts? Mindy Diamond: Yeah. So I think you said it perfectly, but it raises the question then. You say that the RIAs can be more nimble. You’re right. I mean, the big story around the biggest firms was like moving a battleship, it takes a long time to turn it. It’s not as nimble. So what and how are the bigger firms competing against the RIAs with respect to AI? And second question, we still always get questions, and rightly so, about Morgan Stanley has more money to invest… Jason Diamond: That was going to be part of my answer. Mindy Diamond: … than fill in the blank RIA. So how does that all work? Jason Diamond: That is absolutely going to be part of my answer, is that I have heard this question posed almost presumptively both ways. “Oh, it’s got to be that the RIAs are going to be the clear winners in this.” And I’ve also heard, “Oh, it’s got to be that the wirehouses are going to be the clear winners in this.” I don’t think it’s going to be channel specific like that. I think it is going to be firm specific. I think there’s going to be firms that are going to do this well and firms that are going to not do this well. But there’s going to be winners in the wirehouse space. There’s going to be winners in the regional firm space, with firms like Raymond James who are clearly trying to be on the cutting edge of this. There’s certainly going to be winners in the broker-dealer space. LPL is investing heavily in this, as are many of their broker-dealer competitors. And then of course the RIA space, where sometimes they may not have the budgets, but they have a couple things. They have private equity backing, sometimes. They have the custodians that they’re built on, right, or the tech vendors that they’re built on. So Schwab and Fidelity or Orion and Addepar. They have other ways to access these innovations. One of the things that comes up with this that your question I think gets at is, a similar question that was raised around technology stacks, which is strength of offering versus integration. And that’s where I think a firm like Morgan Stanley really will shine, is they should … Because they don’t put anything out that’s not well integrated. The big firms have generally done a pretty good job of that. Versus the RIAs. Sometimes we’ve heard feedback where, yes, you have access to you name it, right? You dream it up, you can go and buy it. But the left hand may not speak to the right hand quite as well. Mindy Diamond: Yeah, that’s actually a really good point. And integration is probably one of the biggest … If you ask an advisor when they talk about technology as either being one of their pushes or pulls, probably what they’re referring to more than anything is not only having the capability, but having the integrated capability. So that’s a great point. And I think your point is right, that the final chapter on this has not been written. Nobody thinks that it has. And so whatever answers you and I can talk about today about who’s winning this race, or this tech race or this AI race, will be totally different tomorrow. We all know that. But I think for purposes of this conversation, to say that an advisor having an expectation that their technology be outstanding and that AI be on the table, that a firm is embracing it and heading in the right direction, if you will, has the right thought leadership and the right willingness to invest in it is what advisors are really looking for right now. Jason Diamond: Absolutely. And this is a question too from the firm’s perspective, if you are a firm of any size, you must be able to answer that. This has become question 1A. And again, I don’t mean to suggest that I think AI is the number one most important factor driving advisor movement today. It very well might be at some point down the road. I don’t think we’re there yet. But I do think it’s the topic du jour or the hot topic, where every advisor is asking about this. So that means if you’re a firm, you need to be prepared to tell the story or at least have the vision. And I think what we’re hearing from both advisors and from firms is this, AI is going to … What is right now a gap between the good and the bad, the quality and the non, is going to become an absolute chasm, right? An absolutely mountainous gap between the best firms and the firms who are able to adapt this technology or this AI. And the same thing at the advisor level, between the AI-enabled superpowered advisor versus those who are in the dinosaur ages, for lack of a better term. Mindy Diamond: Yeah. And we’ll move on, but it is worth saying that the day of the standalone independent, the one man or one woman band who hangs out a shingle, and to use your term, running a lifestyle practice, nothing wrong with that, but it would be near impossible to imagine a world where a standalone independent can compete with a private-equity-backed RIA or an RIA that has a big pool of capital behind them or to compete with the major firms. And our point is the ability to compete is probably more important with respect to this topic than just about any other. Jason Diamond: Totally agree. Thank you for tying a bow on that because I think that’s a good place to leave the AI topic, at least for now. I’m certain we’ll have more to say on this one. By the time we release this episode, we’ll probably have more to say on it. So we’ll have to do a follow-up again. But I want to talk now about enterprise value. And this is one where if you’re an RIA or if you’re an advisor at an independent firm, this might sound like a duh, but hear me out on this one. The idea is as follows, if I’m a wirehouse advisor or any sort of captive advisor, I don’t technically own anything. Agree? Mindy Diamond: Agreed. Jason Diamond: Okay. So if that’s true, that I don’t technically own anything, I technically don’t have any sort of enterprise value or ability to monetize. But my premise here and why I would argue that enterprise value has become a driver of movement is even wirehouse advisors know … They see teams like OpenArc, a massive RIA that launched last year. They see their corner office peers breaking away, starting independent firms. They see them selling to asset managers, private-equity-backed RIAs, private equity firms in their own right for these massive multiples. And what I guess I’m getting at, and I’m curious if you agree is, if a wirehouse advisor, let’s say, sees their colleagues sell to a private equity firm for 20X, doesn’t that have to become a little bit of a catalyst for movement in its own right? Mindy Diamond: Without a doubt. Historically … Actually, let me date myself. When I started this business now 32 years ago, there was zero way for an advisor who was a captive employee of a firm, of any firm, to monetize their business. It’s why there was so much movement, because the only way they could monetize was to get paid a big fat transition deal to move from one firm to the other. Jason Diamond: Yep. Mindy Diamond: Obviously, we all know that first it started with the big firms, and then just about every brokerage firm on the street began to offer a retire-in-place program. And that is the big firms or a traditional brokerage firm’s way of allowing advisor to monetize in place from their perspective to stave off attrition. And for an advisor that believes that the status quo serves them well, that finishing their career, that leaving their legacy, that leaving their team at their firm is the best thing to do, then those retire-in-place programs, like Merrill’s CTP or Morgan’s FAP or UBS’s Alpha or a name at every firm has them, is the best gift to advisors there is. But the problem is that the next generation at those firms are buying an asset they don’t own. And so when we talk about enterprise value or the desire to build enterprise value as a real driver of movement, what we’re talking about is not only that advisors want ownership of an asset, because ownership translates into more control and autonomy and agency over building it the way you want to, but it also translates into maximizing the value of the business that you’ve built. So that’s a long-winded way of saying that the OpenArc deal you are referencing, for anybody not familiar, is a Merrill Lynch team, a legacy Merrill Lynch team in Atlanta that was managing more than 120 billion in assets, part retail, ultra high net worth client assets, and part institutional consulting assets. And believe me, I don’t want to make it sound like it was a snap that one day they’re happy and the next day they’re going independent. Over a 10-year period became more and more aware, driven by the pushes and more aware of the pulse. But ultimately, while there was a long list of things they wanted to be able to do that they couldn’t to best serve clients and grow the business, the real driver at the end of the day, or I shouldn’t say the real driver, but a major driver was the notion of building and owning enterprise value. Yes, they could have all gotten very attractive deals and retired with your Merrill CTP, but they wanted to own the business, they wanted cap gains treatment. And so they went through the sweat equity big time of building what they’re calling OpenArc for the ability for probably five, 10, 20 years, because there’s partners with all different ages, so at all different times, to be able to really maximize the value of the business they’ve built. Jason Diamond: Can I push back on that for … It’s a super helpful example, but my one thought is, okay, yeah, of course, 130 billion in assets, they should be concerned with enterprise value at that size. And the delta between caring about enterprise value and not is too great because those guys have, by all accounts, a phenomenal business that is rivaled by very few in the industry. Most of our audience does not fit into that stratosphere. So what about advisors in, let’s call it the million to $10 million space? Should they still care about this concept? Mindy Diamond: Again, it’s an inside job. It’s a personal thing. Some don’t. But the answer is yes. And if I were them, I would. Why? Because whether I am generating a million a year in revenue or $10 million a year in revenue, at the end of the day, I’ve got an asset. I’ve built a valuable asset. And I have the choice at the end of the day or the middle of the day to decide a million things about that asset. How do I want to live my business life? How do I want to serve my clients? Where do I want to work? But one of the biggest factors to determining where and how they want to work is, ultimately, do I want to be able to maximize the value of the business that I’ve built? And while there are few things that are really definitive in this industry, the one thing that is absolutely indisputably definitive is that if you build an independent practice like the ex-Merrill Lynch churned RIA OpenArc team did, you will ultimately build enterprise value exponential multiples greater than any way you could monetize the business as a traditional employee. Jason Diamond: And that math absolutely still holds up even at numbers smaller than we’ve mentioned. I totally agree with that. I’ll give you one other reason why I think you should care. And I’d love your thoughts on this one. I’ll ask it two ways maybe. I’ll tell you my take and then I’ll ask you yours. Morgan Stanley, let’s use as an example. Who are Morgan Stanley’s competitors? In my opinion, the legacy answer to that is, well, of course the wirehouses are Morgan Stanley’s competitors. Merrill, UBS, Wells Fargo, what maybe used to be a longer list, but today those four. I don’t think that’s the answer anymore. I think those are the direct competitors. But because of this enterprise value conversation, I think Morgan Stanley’s competitors are anyone and everyone who recruits financial advisors with books of business. Because if you think about it, an advisor who has a $3 million business at a wirehouse, even if they’re not actually going to do this, they don’t have any entrepreneurial spirit, no desire to go independent, they still know that they could. This is an option and a viable option. And firms are even figuring out ways to cut out the middle step, right? Because this was historically a two-step process. You’re a wirehouse advisor or a W2 advisor. You break away, launch an independent business to establish your enterprise value, begin building it, and then you monetize it. If you could cut out the middle step, or even if you couldn’t, I still think it’s pretty clear that if you’re an advisor, this is important because the firms know … Like when Morgan Stanley’s writing a recruiting deal, they’re kept honest by RIAs and acquirers just the same as their direct peer set. Do you agree with that or do you think I’m reading too far into this? Mindy Diamond: Oh no, I agree a thousand percent. I think that it is naive for anyone recruiting for or on behalf of a traditional firm to think that the only competition is another traditional firm. The days of pomposity for a senior leader at a traditional firm to say, “We’ve got the best technology, the best everything fill in the blank. We have no competitors.” That’s just naive. Because even if it’s true, you’ve got the best platform infrastructure fill in the blank, there is a multitude of advisors that value things different than what you can provide. Beauty is in the eye of beholder is probably a good way to say that. But at the end of the day, what we’re really talking about is when I started the business, because there was no way, no really good way for an advisor to really monetize their life’s work, the only thing they could or were focused on from a personal financial gain perspective was the short-term deal. What are they paying? What’s the transition deal? Now, of course they’re concerned about that. But almost to a person, they’re equally concerned about what I can build and what will this allow me to build in terms of the value of the business I’m building in the long term. So let me ask you, if we’re talking about an advisor that has the ability to monetize in the short term for what could be 4X and in some cases more than that these days, and we’re talking about the ability to maximize enterprise value, and we talk about the concept of moving once and monetizing twice, what kind of numbers are we talking about? Fill in the blanks there. Jason Diamond: It’s such a hard question to answer because I do genuinely believe recruiting deals, when you talk about 300 to 400% revenue deals in the recruiting space, they vary a little bit, but I feel pretty comfortable quoting those types of numbers that most firms are somewhere in the 300 to 400% of T12 realm. There are some outliers, we mentioned UBS. But the multiple or EBITDA based or enterprise value M&A market where we’re doing these legitimate buyout transactions, the valuations do vary quite a bit. But here’s how I think about it. First of all, most firms are not purchased or sold at top line revenue. Most are sold at some sort of adjusted EBITDA number, which factors in local expenses, platform expenses, but also advisor compensation. And then that adjusted number is typically multipled. The multiples are anywhere from 8X for small kind of, let’s say, million dollar revenue businesses up to, we’ve seen deals struck at north of 20X for some of these mega cap RIAs. Typically, just back of the envelope, if I had to quote, I typically estimate around 5X top line at capital gains is a good kind of ballpark valuation. But there is quite a bit of nuance to it, more so than the traditional recruiting space. And I do think, shameless plug, part of the value in working with somebody who’s an expert on the entirety of the industry landscape is just that. It’s the idea that you need to run the horse race across multiple verticals. The good advisors who work with us typically are looking at a wire like a Morgan Stanley or a Merrill. They’re looking at a boutique firm like a Rockefeller, or they’re looking at a regional like an RBC or a Ray J. They’re looking at an independent firm like an LPL or a Sanctuary. They’re looking all across the spectrum. Mindy Diamond: I think that’s exactly right. But the topic of enterprise value, you can see how powerful it is and how wise it is. For an advisor today, when considering their personal economics to consider not just the short term, but to weigh in or add in or factor in, what could I be building and what ultimately will that business be worth at the end of the day? Jason Diamond: Yeah, 100%. Short of going out and selling your business, what can advisors do then? So I’m an advisor, okay, I’m curious about this. Or is it just as simple as, “Yeah, you should know what your business is worth if you’re an advisor”? Mindy Diamond: Definitively yes, because I mean, we always believe that knowledge is power. And just like it’s important for you to understand what your options are within your own firm, how can I ultimately retire out and monetize my business where I am, I think it’s really hard to make a decision in a vacuum without having other perspective. And getting other perspective doesn’t have to be that you have to go out and take 20 meetings. It’s not that hard for you to figure out what your business is worth to make it a data point for whether or not you’re ultimately best to retire in place or go elsewhere. Jason Diamond: Yeah, that I think is the main takeaway. And the education point is so important. I think because these are relatively new concepts for a lot of advisors that haven’t formally shopped a business before, there’s a lot of resources available. And we’ll certainly link some as well on the page for the episode. Let’s shift gears now, our kind of final trigger 2.0, which is stability and ownership structure of the firm. And this has been a little bit of a hot topic. It’s honestly been a hot topic every year because it seems like things pop up every year. And a lot of times advisors don’t reconcile the question of who owns the firm or how stable is the firm until something happens. The firm gets bought, the firm goes bankrupt, like the First Republic scenario. What should a good advisor do proactively about the idea that if you’re a W2 employee or even an employee who’s affiliated with a broker dealer, you saw this with Commonwealth, you just don’t really have control over what the firm decides to do. Give me your thoughts on this. I know it’s a big topic. Mindy Diamond: Yeah. First of all, using Commonwealth an example, it’s a good one. Because for those unfamiliar, Commonwealth is a boutique broker dealer that was privately owned and whose tagline was, “We love our privately owned status and we are never going to sell,” until one day they did. And not only did they sell, but they sold to the biggest independent broker dealer in the country, ala LPL. That’s not good nor bad, it’s just a fact. So if Commonwealth, who had definitively said we’re never up for sale, suddenly sells, any time you’re an employee of a firm, you never know what tomorrow brings in. You’re not in control over whether it’s sold. So that’s one example. But as you’re talking about this, I’m thinking about, I’m probably going back 20 years, so I’m 10 years into my career and I talked to someone who had been a very successful Merrill advisor. So I’m going to say he was probably generating around $5 million in revenue at the time. Going back 20 years, that’s a pretty significant book of business. He was courted for years by what he thought was a top RIA. And in those days, remember 20 years ago, the RIA space wasn’t nearly as mainstream as it is now. But the story the RIA told him was that ultimately, one, he was going to be a partner in the firm, that was very appealing to him. So he was going to have equity in the firm and much more freedom and control. And locally, by the way, the RIA was a really high quality brand. He worked on a lot of the economics, the short term and the long term with them. They did a ton of due diligence on his book of business. But he failed to ask … And I didn’t represent him. I just know this story. He failed to ask or do enough due diligence about the stability of the firm. What we think is really important, we talk about this expanded landscape. If you’re looking at Morgan Stanley, I don’t think you necessarily need to see Morgan Stanley’s balance sheet. If you are talking to a firm that is anything but a bulge bracket or anything but a large firm, it’s really important to do what we call reverse due diligence and to really understand if a firm expects you to open your kimono and show everything about your business to prove your worth, it is equally important that you do the same for them. In this new world order where private equity has come in and there are so many different ways for a firm to be owned and to be capitalized, it’s very important that an advisor understand what’s going on behind the scenes. And one of the questions around stability, if a firm is private equity backed, is it permanent capital? Is it patient capital? Is the private equity firm going to look to sell and monetize in five years? And then who would the likely buyer be and what does that mean for you? So the question is a big question and it’s really important. Jason Diamond: I love everything you just said, except I do think even the wirehouses, wirehouse advisors, honestly, as much as anybody should be asking these questions. And I’ll give you an example right now, UBS. And UBS, it’s not a story of balance sheet stability. I don’t think anybody has concerns that UBS is going to fail. But UBS management has been very publicly, “Oh, we’re cutting costs.” There’s been some rumors, I think for years, probably dating back 30 years to when you started the business about UBS’s commitment to the US wealth management business. I think those questions about stability and ownership structure are still valid. And to me, the implication of it is twofold. One, what you said, reverse due diligence, ask the questions, plan B. But also the concept of the exits or the off-ramps or how many bites of the apple do you get. So if you’re an advisor and you sell your business to somebody and you sign garden leave and non-competes and non-solicits, the question of ownership structure of that firm becomes less relevant because you have no off-ramps and no ability to exit that business anyway. A lot of times that’s how advisors get comfortable with this concept. And that’s what firms will tell them too, frankly, and we’re living through the middle of this, by the way, with Commonwealth and LPL, is vote with your feet, right? To the extent advisors can, the offer … And this is like, you used the example of private-equity-backed firms. This is how Rockefeller addresses the question of their private equity ownership. If we sell to UBS, all of our advisors will leave. They have that built-in put option. So knowing where the off-ramps are or how many bites of the apple an advisor gets, I think is a big concept that ties into that. But we’re absolutely seeing this pop up, probably largely because of those two examples, Commonwealth and UBS this year, more so Commonwealth, to your point. Janney’s another example last year or two years ago now where KKR comes in and buys Janney. So when these examples happen, it seems like it triggers advisors to say, “Is this something that could happen to me and should I be thinking about this?” Mindy Diamond: Yeah. So let me ask you a question. You’re talking, you’ve mentioned UBS offering this outsized deal. So how does the notion of stability and ownership factor in? If an advisor is considering an unprecedented deal from UBS, what are the caveats or concerns with respect to stability and ownership? Jason Diamond: It’s the same list of considerations you should and would ask of any other firm you’re diligencing, except I think amplified even more in the case … If I was counseling an advisor who was looking at UBS, that would be what I would say, is exactly that. You’re seeing all of these departures and defections, and I would want to have conversations with those advisors and understand exactly why and have guarantees or assurances that I’m not going to suffer from those same pain points that force them to leave. Or, and I say this a little bit flippantly, but it’s a little bit true, I understand the devil that I’m getting into bed with, but for 550%, or whatever the deal might be, I can suck it up. And that’s something that some advisors might well say as well. Mindy Diamond: Yeah. Jason Diamond: I don’t want to end on the negative note of overly large transition, not there’s anything wrong with large transition deals, but as you look out, is there anything that’s coming up in your conversation with advisors that you view as the next wave of this? I’ll give you one that maybe you could touch on, and if you have another one, feel free to offer it in conclusion, but do you think age or advisors starting to succeed out of the business will become more of a driver of movement, even though to your point, advisors can access sunset deals? Mindy Diamond: I do actually, because I think the more the average advisor age increases, the more likely that those advisors are going to want to move on to do something else to monetize the business. And so much of the wave of movement we see is driven not so much by the senior advisor, because many seed advisors are happy enough with the ability to monetize their business in place. Even though it may not maximize the value of the business, it’s a close enough approximation and it means I don’t have to disrupt the apple cart. So we support that 100%. But where we get the calls is from the next generation that says, “Yeah, but hold on a minute. It’s a good way for me to take on a book of assets that I not otherwise have access to. And it’s great for my senior partner, my father, my mother, my whatever to monetize the business. But I’m buying an asset again that I don’t own and I ultimately don’t have control over all these things we’re talking about, the AI investment, the ability to create enterprise value, the stability, the cost cutting, all of it.” So I think it’s all of the above. You say, “What else is there?” I think that’s it. It’s all of the above. It’s anything and everything that drives movement. One, it’s personal, it’s highly unique, it’s different for every advisor. There are certainly themes, and we’re talking about them, but there’s a million different things. It’s personal. And while there are an awful lot of pushes, things that can frustrate an advisor, it is the most exciting time in our view to be an advisor, particularly a high quality one, because the options abound, the ecosystem is big, because the ability to monetize both in the short term and the long term is big, mammoth, exponentially bigger than it ever was before. And the true ability to really build an enterprise has never been greater. And I think all of those things, the desire for an advisor to be the best that they can be and live their best business life is probably the biggest driver of all. Jason Diamond: It’s really true these days, if you can dream it, you can probably build it. And we’ve said in the past, if you build it, they will buy it. It’s a great place to end. This was a really fun topic. I think that’s a spot on kind of fourth trigger, by the way, too. This sort of next gen is almost like the force multiplier or the amplifier of like they see all this other stuff and they’re asking these questions even more so. Because if I’m 60 years old, none of this matters all that much. It matters, but I’m out of the business in five to 10 years. Versus the next gen advisors are the ones who often bear the brunt of this. So I think a lot of really smart stuff. Thank you for sharing your wisdom and expertise. In the episode page, we’ll be sure we have our Industry Transition Report. And we’ve also created a tool, the top 10 tips for a strategic due diligence process, which is a great kind of practical hand-in-hand companion for this topic for advisors looking for more pointed tips on the due diligence process. So Mindy, thank you again. This has been a blast. Mindy Diamond: My pleasure. Thank you. Jason Diamond: Thank you for joining us. We'll be back with a new episode next week, so be sure to listen in. Mindy Diamond: As a financial advisor, you hold yourself to the highest standards of integrity, honesty, and credibility. You are successful because you take your professional responsibility seriously and are dedicated to your clients. But are you living your best business life? Are your goals aligned with your firms or could a better option exist? Should I Stay or Should I Go? is a book written with you in mind. It’s a self-guided journey that walks you through the key steps that we take with our advisor clients. This strategic thought process and roadmap to professional self-discovery is designed to help you ask the right questions and think critically and objectively, whether you’re considering change or not. Learn how to get your copy at diamond-consultants.com/thebook. The Advisor Transition Playbook: The Latest on Due Diligence, the Move, and Everything In Between – Part 2 A Special Industry Update with Jason Diamond and Mindy Diamond. Jason Diamond: Welcome to a replay of one of the most popular episodes from our podcast series for financial advisors, The Advisor Transition Playbook: The Latest on Due Diligence, the Move, and Everything In Between. It's Part 2 of a 2-Part Industry Update with Mindy Diamond. I’m Jason Diamond and this is the Diamond Podcast for Financial Advisors. Mindy Diamond: At Diamond Consultants, we help elite advisors identify the right environment for their businesses to thrive, whether that’s at a wirehouse, boutique, or independent firm. With nearly three decades of experience, we’ve guided thousands of advisors and represented more than a quarter of a trillion dollars in assets transitioned. And each year, one in four advisors managing a billion dollars or more who change firms are our clients. Our process is education driven and based on building relationships, starting as your strategic partner, well before you’re even thinking of a move. To schedule a confidential conversation, call us at 908-879-1002. Wondering why advisors change firms and where they’re headed? Are transition deals going up or down? Those very questions and more inspired us to create our Annual Advisor Transition Report. It’s the award-winning data-driven resource designed for advisors that connects the dots between the motivations around movement and the firm’s appetite for top talent. Arm yourself with the knowledge you need to make smart decisions. Download your copy at diamond-consultants.com/transitionreport. Jason Diamond: There’s been a noticeable shift in how advisors are approaching decisions about their business, not necessarily in whether they’re exploring change, but in what they’re focused on when they do. Mindy is back with me for a continuation of our earlier conversation on the Advisor Transition Playbook. Last time, we spent time on the mechanics, how due diligence works, what a move actually entails, and how to think through the process. What’s become more apparent since then is that the inputs into that process are evolving. The traditional drivers are still there, but layered on top are a set of considerations that didn’t carry the same weight before. AI is one of them, and not just as a tool, but as a differentiator that advisors are starting to diligence more seriously. Enterprise value is another. Showing up in conversations, even for advisors who don’t technically own their business, but are thinking more critically about what they’re building over time. And then there are questions around stability, ownership, and flexibility. What happens to the firm itself and whether advisors retain the ability to adapt again if circumstances change. None of this is theoretical. It’s showing up in real time conversations. What we want to do here is unpack those new triggers of advisor movement and what they suggest about how decisions are being made today. So let’s get to it. Mindy, the legend, thank you for joining me. So glad to have you on. Mindy Diamond: Thank you. I’m so happy to be here. Jason Diamond: Great. Let’s dive right in. I’ll set the stage really quickly one more time. When we spoke about this topic last, we talked about the drivers of movement, what we’ll call in this conversation as the old or the legacy drivers of movement, and we spoke about the mechanics of the move. Before we get into the new drivers of movement, which I want to be the meat of the conversation, remind us, when we talk about the legacy drivers of movement …. And by the way, by saying legacy, I by no means want to suggest that they’re not valid today, because they’re equally valid, if not more so today than they were then. But when you think of the classic drivers of movement in our industry, what are they? Mindy Diamond: Yeah. So I would say, first of all, let’s start by saying that for every advisor, they’ve got a unique set of needs. So the first thing to say is that while you and I can talk about the categories of frustrations or things that might bother an advisor, they show up differently in each advisor’s life. So it’s important to note that everyone is unique. But generally speaking, if I had to package them, I’d say it’s number one that shows up most of the time is too much bureaucracy. A feeling that a firm or a model is just too hypervigilant in terms of compliance and it’s too bureaucratic and too hard to get things done.

Como trabalhar o tema CX na área da educação!? Esse é o tema desse episódio com o nosso conselheiro. Neste episódio, o professor Doutor Fernando Coelho, diretor do Instituto Experiência do Cliente e autor de 7 livros, bateu um papo com Mateus Braga, Diretor da FAP. Dá o play e confere! Leve a Palestras Gestão de Vendas e Experiência do Cliente, do Professor Fernando Coelho, para sua empesa:https://www.institutoexperienciadocliente.com/

A daily low dose of aspirin could significantly reduce the risk of bowel cancer in people with Lynch syndrome, an inherited condition that increases the likelihood of developing certain cancers.   In this episode, we explore the findings from the landmark CaPP3 trial, hear from a participant living with Lynch syndrome, and discuss how genomics could help shift healthcare from treatment to prevention.  Our host, Sharon Jones is joined by:  Dr Katie Snape, Principal Clinician for Population Health at Genomics England  Professor Sir John Burn, Professor of Clinical Genetics at Newcastle University  Drew Hyde, participant in the Cancer Prevention Programme (CaPP3)  Links:  Listen to: How can genomics help us understand cancer?  "I think knowing is always a good thing. And obviously, I wish I'd known earlier, and then, I could have taken more measures earlier on. So I think knowledge is definitely a good thing. And it would be great if more people could be tested or could find out if they were carriers at an early age, I think."  You can download the transcript or read it below. [00:00:00] Sharon: Welcome to Behind the Genes. In today's episode, we'll explore the research which shows how a low dose of aspirin can halve the risk of bowel cancer in people with Lynch syndrome. We'll hear about the real-life impact of living with the condition, and look at how genomics can help shape a more preventative approach to care in the future. [00:00:20] I'm Sharon Jones, and to help us unpack all of that, I'm joined by our guests, Dr. Katie Snape, principal clinician for population health at Genomics England; Sir John Burn, professor of clinical genetics at Newcastle University; and Drew Hyde, a participant in the Cancer Prevention Programme, which is also known as the CaPP3 trial. [00:00:42] So to start with the basics, Katie, can you walk us through what cancer is in simple terms? [00:00:50] Katie: Sure, Sharon. So, our body is made up of cells. Those are the building blocks that, that make us as humans and other creatures and plants. And our cells need to keep dividing throughout our lifetime as our bodies are growing and working normally. [00:01:06] And so we need to have processes in place in our body where our cells can divide, but then also stop dividing when we don't need them to carry on dividing. What happens in a cancer cell is basically that cell becomes abnormal, and it doesn't follow the normal checks and balances and rules of cell division. [00:01:23] So it starts to divide and grow uncontrollably, and it can start to invade other tissues and obviously, that can cause serious consequences. [00:01:33] Sharon: We'll hear a lot more from Dr. Katie Snape in this episode. But before we move on, I just wanted to flag that there was an episode of our Genomics 101 explainer series with Katie dedicated to helping us get to grips with how genomics can help us understand and diagnose cancer. [00:01:47] Do go and check that out. We'll put a link to that in the episode description. [00:01:54] So the World Health Organization estimates between 30 to 50% of all cancers are preventable. So, Katie, when we talk about cancer being preventable, what does that actually mean? And what's an example of cancer prevention that people might already know? [00:02:11] Katie: Yeah. So some cancers are due to chance or just mistakes happening as our cells copy. [00:02:19] Other cancers are because there has been damage to the genetic information within the cell that can be caused by certain things that can cause damage to DNA. So for example, a sort of obvious answer would be skin cancer. Skin cancers can be caused by sunlight, the, the UV light in the sun, and particularly if we burn our skin or, or get sun damage to our skin, increases the chance of us developing a skin cancer. [00:02:44] So you can think of lots of other examples such as cigarette smoking and lung cancer, and so we know that there are a number of different risk factors that increase the chance of our cells developing damage and becoming abnormal cells and growing uncontrollably. So when we talk about prevention, we might think, well, could we reduce some of those risk factors and therefore reduce the chance of those cells getting damaged and becoming cancer cells? [00:03:10] So I gave the example of skin cancer. We might put sun cream on if we're going out in the midday sun, for example. That reduces the damage of the UV light onto our skin cells. Or we might help people to go into a smoking prevention programme or, you know, other risk factors, such as we know that being very overweight can increase the chance of cancer. [00:03:31] We might help people get into more exercise regimes or improve people's diets. So those are the sorts of things that we might do sort of for environmental risk factors. But we also know, particularly in this context, that sometimes people are born, they carry genetic changes within their cells that they're born with, that are inherited, that run through families, and those can also increase the chance of some cancers developing. [00:03:56] And for those people at higher genetic risk, then we might look to other ways that we might reduce that risk. We can't change the genetic changes in their cells, but we might be able to put things in place to reduce the risk for those individuals, and that might be medication, it might be surgery, or there could be other things that we might be able to offer. [00:04:15] Sharon: Yeah, and with that in mind, is there anything more, you know, that you can share about some of those risk factors that someone is more likely to develop cancer? [00:04:25] Katie: Yeah. So actually, the, the biggest risk factor for developing cancer is age. The older we get, the more times our cells have divided, the more chance there is of a copying mistake that, that, that can cause that cell to become abnormal and start growing uncontrollably. [00:04:41] And that's why cancer becomes more common the older we get. We obviously can't change our aging process. Then, as I've said, sometimes we're born with certain specific inherited factors that increase the risk. That might be one big high-risk genetic factor, such as having a cancer gene that's important for, for that process of cell division that isn't working properly. [00:05:04] Or it could be that we have multiple lower genetic risk factors that can kind of add up together to increase the risk. And those often interplay with some of those environmental factors that we've talked about, like smoking, for example, or weight, or alcohol or other things like that. So most cancers are due to aging, and then there's a sort of interplay of genetic factors, but environmental factors as well. [00:05:30] Sharon: That's really interesting to understand. And the focus of this podcast is sort of looking at kind of Lynch syndrome and what findings have come out around aspirin and having a low dose of aspirin. So I want to kind of explore what Lynch syndrome is and, and then bring in Drew to talk about his experience of having Lynch syndrome and how he got involved in the trials themselves. [00:05:49] So from what I understand, Lynch syndrome is a genetic condition that can make some people more likely to have the chances of developing into bowel cancer. And Drew, this is your opportunity to sort of talk about what that's been like living with Lynch syndrome. And, you know, I'd like to understand more about your story and how it came about that you discovered that you had Lynch syndrome, and to share with our listeners your journey. [00:06:13] Drew: Yep. So in my case, I discovered I had the colon cancer before I discovered I was a Lynch syndrome carrier Basically, at the age of 50, I noticed some change in my health. You know, I was becoming a little bit more tired. My bowel movements had changed or whatever. So, I went to the GP and the GP basically said, "Well, you're probably too young for cancer, so let's look at other alternatives." [00:06:37] And I had blood tests and I had low iron, so I was on iron tablets for three months and whatever. Then eventually I went back and finally the GP said, "Well, let's try a colonoscopy." And the colonoscopy revealed that I did actually have colon cancer. And then very quickly I had surgery and, uh, then following that, I kind of asked the question, "Well, why me?" [00:06:59] You know, I'm only 50, 51. Yeah. You know, why me? [00:07:02] Drew: And basically, I was told, "Well, it's probably genetics." And then I was referred to, you know, St George's and Katie and I had the test and discovered that I was actually a Lynch syndrome carrier, and that's why, you know, I'd got the colon cancer at the age of 50, so. [00:07:17] Sharon: I mean, that's quite a journey. I mean, how did you feel when you're already on one pathway and then having to kind of find out more, you know, what was your experiences? What was the impact on your life? How did you, how did you feel? [00:07:27] Drew: I think I was lucky in that I had a very good surgeon. I had surgery very quickly, so that was the first hurdle. [00:07:32] Then I had to go on to chemotherapy, and the chemotherapy obviously is far worse than any surgery or anything else that comes before or after. But having got through that, then I went through the St George's onto the Lynch syndrome system. So, the most important thing then really was to basically identify what that meant for me, but also because it was an inherited characteristic, what it meant for my family. [00:07:57] One thing that was interesting, and I say, you know, the, the GP was saying, "Well, you're too young to have cancer," is that there wasn't any history of cancer in my family, you know, looking at older relatives. So, you know, to be fair to the GP, that wasn't an obvious marker. So basically, yeah, it was let's, you know, find out what it means now going forward. [00:08:21] Sharon: So, can you just take us back to when you were diagnosed with Lynch syndrome? What sort of guidance were you given at the time about managing your cancer risk? [00:08:30] Drew: Well, following the surgery, I was given various statistics which were fairly grim on what your percentage survival rate were in three years, five years, 10 years based on the surgery, whatever. [00:08:39] And that was kind of a bit harrowing. But, you know, assuming I'd get through five years, I felt it was, my chances were quite good. As for myself living with, living with Lynch syndrome, that, you know, I was aware that having had the colon cancer, I then had increased risk of other cancers. So since then, I've been on a screening programme, and I have colonoscopies or gastroscopies every year or two years. [00:09:04] So that's been very good. So, I believe now that if any other cancers were to appear, I would probably know very early on because they would be detected through a screening process before they got to a point where they would be, you know, maybe too difficult to resolve, so. So that's-- I think the screening programme, has been very, very good. [00:09:23] The main issue for me was what it meant for my family, being a genetic thing. So very quickly, my children, who were teenagers at the time, were both tested, and they went through some counselling with Katie beforehand, you know, about what it would mean for them to get a positive or negative result. [00:09:42] Unfortunately, my daughter was tested as negative, but my son was tested as positive, so he's now on the same cancer screening programme, and has colonoscopies every two years. So yeah. The mystery really, though, is where I inherited it from because my father died when I was very young. My mother was in a care home at the time, and I wanted to get her tested. [00:10:07] And at the time, her GP wouldn't test her on the basis that she was unable to give consent. But fortunately, I had power of attorney, and we could persuade him to do the test. But she tested negative. So I'm assuming I inherited it from my father's side. But most of my grandparents on that side of the family lived into their nineties without any apparent cancers. [00:10:32] So it's still a bit of a mystery how I inherited it, but what was important for me was to know which side of the family I'd inherited it from because obviously with cousins and whatever on different sides of the family, I wanted to be able to tell them what the situation was. My brother also tested negative, which was a positive. [00:10:54] So at the moment, it's just my son and I that have the defective gene. [00:10:59] Sharon: I'm sorry to hear that about your son, but does it- [00:11:01] Drew: Well, well, I mean, he, you know, he has to go through a colonoscopy every couple of years, which, you know, obviously is not a pleasant experience. But at least he knows that, you know, the first sign of any problem, the medics will be aware of it, and he'll be able to react. [00:11:16] Sharon: Has it changed your outlook on life, having this window in possibly knowing stuff or not knowing stuff? How has that affected you and, and your son as well? [00:11:25] Drew: I think knowing is always a good thing. And obviously, I wish I'd known earlier, and then, I could have taken more measures earlier on. So, I think knowledge is definitely a good thing. And it would be great if more people could be tested or could find out if they were carriers at an early age, I think. [00:11:42] Sharon: Yeah. That is really important. And moving into about the trial more broadly, scientists have known that there's been a link between cancer and aspirin for some time, with fewer cancers observed in people who take aspirin. So coming to you, John, could you share a bit more about the history of inherited cancer research and how the focus of Lynch Syndrome came about? [00:12:02] Because this isn't new, is it? [00:12:06] John: No, absolutely, Sharon. And in fact, this story, my story in this space begins 40 years ago when I was one of the geneticists who set out to try and find the genes that we've just been talking about. At that time, the group of patients who were the most obvious to begin with were young people with a condition called familial adenomatous polyposis, or FAP for short. [00:12:26] And they'd get thousands of polyps in their bowel, and the only way to treat that was to actually remove the whole bowel when they reached adulthood, which is a fairly extreme intervention. And I was running, I was setting up a registry. We were trying to find the gene at that time, and we'd just found it, in fact, but we also were trying to find all the families. [00:12:44] And I'd taken over responsibility for all the genetic services in the north of England, in the North East and Cumbria. And we'd, I'd started identifying families with FAP, and we went to visit one of those families, and this was the kind of light bulb moment for me because I walked into the room and mum had had her colon removed, and her son, Jonathan, had just had his first colonoscopy at the age of 12, and it was clear. [00:13:07] And I was about to give them the good news, but as I walked in, I noticed that he had little bumps on his forehead called osteomas, little bony bumps. His mother had them just the same, and it was one of the features of this condition. So I knew he had the gene even though he hadn't yet got the polyps. [00:13:21] Sharon: Wow. [00:13:22] John: And it made me think, wouldn't it be nice if we could do something to prevent these things happening rather than just waiting for an operation? And as it happened at the time, I was leading the English end of a big study, which you'll probably be aware of, which we're, we're, we were doing the vitamin study on women with spina bifida babies, and we were just about to identify folic acid as a way of preventing spina bifida in pregnant women. [00:13:45] So I had these two thoughts in my head. Maybe we could set up a trial like this folic acid trial, and then one of my friends in Edinburgh said, 'Have you seen this paper from Melbourne?' Gabriel Kuhn had just done a big study looking at people with colon cancer. It seemed that people who took a lot of aspirin didn't seem to get as much bowel cancer in Melbourne as those who didn't. So that was the design set up. [00:14:08] We were applying to Europe for a concerted action, so we had to think of an acronym that began with CA. So I, I came up with Concerted Action Polyp Prevention. But then in 1993, just as we started that trial, we were involved in finding the first of the genes for Lynch syndrome. We had a big family in Northumberland where there were lots of people like Drew's family, and there were three generations of cancer in the family. [00:14:31] So CaPP2 was immediately born in my head. In 1999, we had our first recruit, and we recruited until 2005. We found, in total, 1,000 people in 16 countries to join in, and we gave them two aspirins a day or two dummy tablets. Two aspirins is quite a big dose, but back in my day when I was a junior doctor, we used to give many more tablets of aspirin to people with arthritis. [00:14:57] So two tablets wasn't such a big deal. Nowadays, it's seen as a very high dose. And it worked. Basically, to cut to the chase, when we looked in 2010, the people who were getting the aspirin were getting less bowel cancers. In fact, it was a 50% reduction. So the people who took two aspirins had half as many bowel cancers and fewer cancers of other types as well. [00:15:19] We realised, although, at this point, immediately we saw that it was working, we knew we'd need to do another trial to see whether a smaller dose of aspirin would be just as effective. So CaPP3 began, and the great news is that what we'll be reporting in the journals in the next few days when it gets published, is that the people who were taking  CaPP3 aspirin in any dose were tracking exactly the same as the 600-milligram group in CaPP2. [00:15:46] So we're pretty sure that it works. We're pretty sure that the small dose is just as good. And the great news was that we had fewer side effects in that group. And so in fact, no one had to go to hospital for a transfusion or anything, you know, like that. Whereas in the 600-milligram group, we had a few people who needed treatment because, as you know, and everyone knows, if you take aspirin, there's a higher chance of having an ulcer that causes a bleed. [00:16:10] And that was always the anxiety. But people like Drew were courageous enough to take the chance because they knew we needed to know the answer to this. And of course, when you compare it to the risk of getting cancer, taking an aspirin is a relatively small risk. [00:16:26] Sharon: So, what were your kind of considerations when you were designing the trial, having that knowledge? [00:16:32] John: Well, the first thing is it has to be fully informed consent, which means that you have to explain to people what that risk is. The important thing about aspirin is that doctors have a much worse opinion of it than it deserves because if you work in a hospital, you'll often see people coming in who've had a bleed. [00:16:48] It's not always caused by the aspirin. The thing is, if you're coming with a bleed and you're on aspirin, everyone blames the aspirin. Right. About half of them would've happened anyway. In fact, the, the irritation of the stomach is much more of a problem in older people So in fact, the average age of the people in CaPP2 and CaPP3 was about 45, 46 when they started. [00:17:08] Drew was a little bit older, but, but people in that sort of middle age group are much, much less likely to get into trouble than people in their 70s and 80s. And it's people also who've had a history of ulcers that have a bigger problem. We also knew that if you had a stomach infection called H. Pylori, which is itself a risk factor for cancer, and about one in six people carry that bug, and we knew that if we fixed that with antibiotics, that would significantly reduce the risk of bleeding as well. [00:17:37] So it was a manageable risk. It was something we could share with people. They knew they were taking a bit of a chance. But actually a good way of putting it in terms of the risk, for people in middle age, the risk of a low dose of aspirin is about the same as the risk of having a colonoscopy, which is very small, but it isn't completely without risk. [00:17:56] Sharon: Yeah, and Drew, kind of like hearing this sort of incredible, like, backstory about how we've got to these trials and where we are today What was your experience like as a kind of participant of this trial? [00:18:08] Drew: I understood I was going to be on 100, 300, or 600, but wouldn't know for at least three years, or was it five years? I can't remember. [00:18:15] And then sometime later in the post we got these packs, and it was ... I remember at the time thinking it was like a rather dull advent calendar - ... in that you'd have the days of the week- ... with the little, with the little windows, and you'd, you'd pop the tablets out three times a day and take them. [00:18:31] So I did that. I think, you know, I, I don't think I ever missed a day or whatever. Initially, I thought I must be on a really low dose, because I didn't actually notice any side effects. You know, I remember saying to my wife, I said, "Oh, I think I must be on the lowest dose, because I don't see any side effects." [00:18:46] It was a surprise years later when I was told actually I'd been taking 600, so. [00:18:51] Sharon: Wow. [00:18:52] Drew: It was quite an easy experience really. [00:18:54] John: We had a lot of problems. We had to pack the aspirin in six-month packs, because it was very expensive to pack this stuff up. It cost... We got the aspirin free from the Bayer company, but it cost us more than a million pounds to actually put it in, in the packs to satisfy the regulations. [00:19:10] Uh, and a lot of people complained that the packs were a bit big and awkward, but that was just, you know, a constraint. But it was not that big a deal once people got into it. But we did get a lot of complaints about the size of the packets, which we couldn't do anything about that. [00:19:24] Drew: They came regularly through the post, and, you know, so every three months or whatever I got another supply, and I just carried on taking them. [00:19:30] Yeah, so. [00:19:31] Sharon: What was going through your mind when you were kind of waiting for this potential outcome, Drew? Because you, like you say, it was, you know, it was a long time taking part. What was... Especially as you were opening your, you know, your package a day, knowing exactly what you were going to get. [00:19:44] Drew: Well, I, I kind of knew it would be a long-term thing. [00:19:47] I think I was committed for five years initially. But I carried on taking the aspirin for another probably five years after that. So yeah, I was just sort of happy to take the aspirin and then sort of wait to see what the results would be. As I say, that I didn't really notice any side effects, so I wasn't really worried that it was having any detrimental effect on me. [00:20:09] So I was curious to see what the, what the results would be. [00:20:12] Sharon: Yeah. John, the trial has provided like the evidence that, you know, low-dose aspirin can prevent bowel cancer. But are there any challenges that still exist with translating this research into clinic and ultimately patient care? [00:20:26] John: Well, yes, and I'm going to hand back to Katie, who's actually leading the charge on, on getting it into practice as well. [00:20:32] But just to say that I, I'm actually now literally on my other computer finalising my bid to go back to Cancer Research UK because we want to go for three more years. Wow. We said that we would follow people for 10 years after they'd finished their ... or after they'd started, so, you know, for at least 10 years. [00:20:50] So the last person to join didn't finish until 2024, so we won't get to that person. It's Robin and one of my patients. We won't get to Robin's 10-year anniversary until 2029. Oh, yeah. By which time, obviously, Drew will be even further on. But that will give us at least 10 years of follow-up because we know that there is this delayed effect, and that was seen right back at the beginning when people looked, for example, the nurses study in America, where they followed 86,000 nurses and just asked them if they took aspirin. [00:21:18] And nothing happened for 10 years, but those who were taking aspirin for more than 10 years saw a benefit. So in the general population, it probably takes that long to kick in. And so we need to keep going for just a while longer. It's not as expensive now because we're not giving people aspirin anymore. [00:21:33] Sharon: Yeah. [00:21:34] John: But one of the reasons we g- we made Drew's dose blind was because we wanted to know what the side effects would be when you didn't know how much you were getting There's a danger if you're getting a higher dose, you're more likely to complain. And actually, it did work out that the people on the lowest dose had the fewest side effects, even slight side effects. [00:21:51] The only thing we can't escape from is if you're taking aspirin, you get bruising more easily because it blocks the platelets, which are the little tiny blood cells which plug up little holes in your blood vessels when they leak. The good news is we now know that platelets turn out to be right, a major factor in triggering cancer. [00:22:09] And so the aspirin, by blocking the platelets, is actually reducing the risk of cancer, but also reducing the risk of cancer spreading in the body. So this is new research, and we've got another big research project in collaboration with a team in Cambridge who are, uh, pursuing this. Also, the other exciting news is that my other partner, Ruth Langley, is running a big trial of people with cancer, and those who are given aspirin as part of their treatment have less likelihood of getting spreading cancer later on. [00:22:39] So the aspirin is clearly doing something good at many levels in the system. Surprisingly, and we think it might be partly, partly because we used to have a lot of salicylate in our diet, which is what aspirin's made from. And we think that maybe we're putting back something that the body actually was used to having. [00:22:57] Yeah. But modern diets don't contain any, any salicylate because of the way we prepare our food. So it may well be that a little bit of aspirin's a good thing for everybody, but obviously, that's a choice that each person will have to make. [00:23:09] Sharon: Yeah. I mean, it's a real powerhouse of a, of a drug essentially, which you're finding out more about its benefits as, uh, as research goes on. [00:23:18] So Katie, can you just give us a bit of a broad overview of Genomics England's new adults program, which is kind of looking at this sort of area of work and, and what, how can it benefit people? [00:23:29] Katie: Yeah. Thank you, Sharon. So, the adults programme at Genomics England is being funded by government, and the government wrote about it in the 10-year NHS Health Plan, the Life Science Sector Plan to run a large-scale genomics population study. [00:23:44] So looking at how we can obtain genetic information from people in the population and look at more proactive and preventative healthcare, and can we generate evidence on where, how, and why the NHS should start applying genomics into kind of more population health measures. So, there's sort of two sides to this. [00:24:05] So the first is thinking about pharmacogenomics, which is basically about how genetic factors influence how we respond to drugs. So lots of people have had experiences of having side effects from drugs, we've just been talking about that with aspirin, or for drugs not working so well for them. And we know that there are certain drugs that genetic factors can influence whether you should take the drug at all, or if you do, what dose you should take, whether it's going to work for you or not, whether you might be more likely to get side effects or adverse reactions. [00:24:34] So part of the programme's looking at that. And then the other half of the programme will be looking at sort of is, are the genetic factors relevant for sort of serious and high-risk conditions in the adult population? So we could take bowel cancer as an example of that, a common condition, breast cancer, you know, common cancers or cardiovascular disease. [00:24:58] We know there are certain genetic factors for some people that have significantly increased their chance of developing those serious adult onset conditions. Can we find those people in the population and then put measures in place to prevent that? So, you know, even just thinking about Drew's story, he didn't have a family history of cancer. [00:25:16] The first time that he knew he had Lynch syndrome, he'd already developed bowel cancer. And we know that many people that have Lynch syndrome or other high-risk cancer genes are unaware of their status in the population, and so, um, the idea of this program is to really look at, well, if we were to, to look for some of these very high-risk genes in the general population, could we then put measures in place to reduce the chance of them developing the serious condition as a consequence? [00:25:44] So instead of Drew presenting with his bowel cancer, we'd actually already picked it up, despite the fact he doesn't have a family history, and we'd offered him, let's say, aspirin if we'd known the information at the time, and we could maybe have prevented him from developing bowel cancer. [00:25:58] So it's really exploring looking at that a little bit more. [00:26:02] Where can we get genetic information in the population? Where might there be a really well-evidenced, like all the work John's done over 40 years, is really well-evidenced now. Yeah. Yeah. Where are there these opportunities for us to turn the dial on some of these common adult onset conditions? [00:26:20] Sharon: What other challenges do you think with getting this out there do you see? [00:26:25] Katie: Uh, I think there's, there's lots of challenges. I think it's a really com- ... complex programme of work. The first thing is that the risks might be different for people in a population than have a family history. So where I've worked for, for years, and John as well in, in clinical genetics, we've seen the highest risk people, the people with lots and lots of cancer in their family because they're the people that are presented to healthcare services. So we've worked out the risks based on that population. It will be really different when we move to the population setting. We'll find fewer people, and the risks might be lower because there might be other factors that are giving them a lower risk. But that's not to say the risk is zero. [00:27:05] It's probably still raised. So then what we need to do is we need to consider, okay, well, what can we do to intervene, taking into account this change of context from people that we found through clinical services to people that we see in the population. And aspirin is a great example of this. [00:27:22] So, you know, if we find that someone has a Lynch syndrome gene, then taking aspirin, unless there's a really good reason for them not to take aspirin, is almost certainly going to be low cost to the NHS and really significantly reduce the chance of them developing bowel cancer with a low risk profile. So where are those opportunities? [00:27:41] And that isn't clear cut, and that's why we need a large scale research programme that can try to help the NHS answer some of those questions, so it can decide how best to spend its money in, in the people that are most likely to benefit from it with the least amount of risk or harm to them. [00:27:58] Sharon: That makes sense. And, and so, you know, going to you, Drew, what are your kind of thoughts on some of the challenges that Katie's highlighted? And is there anything else that you think needs to be improved in better supporting people living with inherited risk of cancer in the future? [00:28:14] Drew: In the brief sort of 10, 15 years or whatever since I've been s- suffering, awareness has increased greatly. [00:28:21] I mean, for example, my GP now knows about Lynch syndrome, whereas I don't think she did when I was first diagnosed, and I think there is a little bit more awareness out there, but I still think it's a lot less than there would be for, say, for breast cancer. So for example, when a high-profile personality reveals they've got breast cancer, you often get information about inherited risks. [00:28:44] You don't seem to get that with colon cancer. You know, when it's announced that so-and-so has died or is whatever, you don't get that same, you know, it, it might be a genetic thing. I mean, when I was first told people that I had bowel cancer, the response I got usually was, "Oh, poor diet, was it?" [00:29:04] And I always felt a bit upset, that, you know, actually my diet was fairly healthy. And that was the assumption that people had. So I think anything that gets the message out there that there is a risk, an inherited risk, I'm not sure what the statistics are now, Katie, is it one in 400 people might be a Lynch syndrome carrier or something like that? [00:29:24] You know, it's relatively high for something that is, if you know in advance you're at risk, you can do something about it. But like me, you know, I waited until it was too late, because I didn't know, and then had to have the surgery, so anything that promotes the message that there is a risk. I know some people don't want to know about their genetic makeup. Obviously, that's a choice. But I think to give people, as many people as possible, the choice must be a good thing. [00:29:54] Sharon: Yeah, absolutely. And I think one thing I've noticed through this thread is the sort of theme of funding and what gets funding and the amount of time it takes to, to kind of get that funding. [00:30:05] Is there anything you wanted to add around the kind of funding model, around why some things get funded, you know, uh, more prominent, like Drew's point, obviously, talks about if someone high profile kind of comes forward and says XYZ, that gets the spotlight shone on it, and there might be research going that direction compared to s- to, to other cancers. [00:30:23] John: So maybe I could speak at that. So partly because of my experience, I've now been made chairman of the grant committee at Cancer Research UK for prevention and population research. And there is a real drive to push more resource into prevention for the obvious reasons. [00:30:39] Katie: Yeah. [00:30:39] John: And also, it's got to be remembered, it's very difficult for the drug companies to fund this because it takes such a long time that the drug's- Mm [00:30:46] out of its patent before they actually get to use it. So, it's very difficult from a business point of view to fund research into prevention. But they are keen to help us, uh, but we really need sort of central government and the charities to focus on prevention if it's going to make a difference. [00:31:02] And just on Drew's point on diet, I mean, diet is still important even if you have Lynch syndrome. In our CaPP2 trial, the people who were overweight were more than double the risk of cancer. So it's not like an either/or. If you've got a higher genetic risk and you have a bad diet, then that's, you know, is going to contribute. [00:31:21] But the other exciting thing is, of course, we now have medical ways of treating obesity in, in people. So, one of the interesting areas is whether we should be, in the same way as we are for other high-risk populations with overweight, we should be giving overweight people with Lynch syndrome, help to lose weight because that will also reduce their risk. [00:31:41] It's also worth just dropping in at the last moment here is that this is also a good news story in terms of treatment and further prevention. We now have a new class of drugs called immune checkpoint inhibitors, which specifically target the types of cancer that Drew had and are much more effective in curing them And also, we've just been given funding to do a project called LynchVax, which I'll be helping with, but it's led by David Church in Oxford. [00:32:05] And this is developing a vaccine against cancers in people with Lynch syndrome. The great news is it'll probably work alongside aspirin because we know the aspirin is enhancing the immune response. So the two together may make this a curable condition. [00:32:18] Sharon: That's actually incredible. I mean, that, it gives so much hope for people. [00:32:23] And I just wanted to find out if you had any more kind of reflections as we close, because we're going to come to the end of our podcast today. If there's anything more that you wanted to share, anything that has been missed, or anything that you want our listeners to know, and I think I'm gonna come to you, Drew, first, because you're the person who's had to sort of live through this and, and go through this journey along the way. [00:32:41] Drew: I think just basically, if you're not sure, get tested. Obviously, there are financial constraints. I'm sure that running a DNA test is quite an expensive business. But I think if you've got any history of bowel cancer in the family, you've got any concerns about your health, speak to a GP and see if you can get tested as quickly as possible. [00:33:00] And then, to get a better message out there that there are risks of inherited colon and other similar cancers, so. [00:33:11] Sharon: Yeah, so it's getting that, messaging out, um, for people to understand more and make those informed choices. And Katie? [00:33:18] Katie: I mean, I would say that the power of, of our, you know, NHS and our academia and, and our healthcare system has been collaboration. [00:33:26] Sharon: Yeah. [00:33:27] Katie: There's so many moving parts. There's commissioners, there's funding, there's the evidence, there's research, there's healthcare implementation. The UK's a really amazing place to work in genomic medicine, and I think that's partly because of the amazing collaborations that we have, and the way that we can translate research into healthcare as John's team have done with this amazing study. [00:33:48] So let's all keep working together, please. [00:33:52] Sharon: Absolutely. And John, it feels like this is your lifetime's work. [00:33:58] John: Well, I've become aspirin man, it wasn't intended. But Katie's done fantastic work in her role as chair of the Cancer Genetics Group in the UK, so we've now implemented a, [00:34:06] we're the first in the world to really make this an absolute directive to the GPs and all, to all doctors to say, "People with Lynch syndrome need to be offered aspirin." And so that's a great step forward. But we also need to get it into the British National Formulary, and I'm working with their team so that the GPs are empowered to do this. [00:34:24] It's actually part of their care package. But I would just say we've still got a long way to go. We've now got a national list of all the people with Lynch syndrome, like Drew, to make sure we offer them all a colonoscopy, but there are only 14,000 people after several years of really pushing. [00:34:40] Sharon: Right. [00:34:40] John: We think in the national population in all ages, it's about 1 in 300. That's a lot of people. That means there's about 150,000 people like Drew in the country, and we've only found 10% of them. So we can't just rely on family history for all the reasons Drew explained. You know, I mean, Drew's dad probably died of Lynch syndrome, but we don't know because we've lost that record. [00:35:02] So now we're checking every bowel cancer to see if it might be caused by Lynch, and that programme is now kicking in, and we're picking up a lot more gene carriers as a result of that. But there's still a long way to go to get co- get people aware of Lynch syndrome, to think of it when someone presents with a cancer, not just of the bowel, but in the womb, in the kidney, in other parts of the body. [00:35:23] It's not just the bowel, but that's the most important group. [00:35:26] Sharon: Yeah. [00:35:26] John: So there's still a long way to go. [00:35:28] Sharon: Where you've come to now is still an incredible achievement, even though we've still got a long way to go, and I don't think we should ever lose sight of that. So we're going to wrap it up there. Thank you to our guests, Katie Snape, Professor Sir John Burn, and Drew Hyde, for joining me today as we discuss cancer prevention. [00:35:48] If you'd like to hear more like this, please subscribe to Behind the Genes on your favourite podcast app, and thank you for listening. I've been your host, Sharon Jones, and Behind the Genes is produced by Deanna Barac, Florence Cornish, Sophie McLachlan, and Dave Howard at Bespoken Media.  

Sarkome sind eine sehr heterogene Gruppe von Tumoren mit über 70 verschiedenen bösartigen Subtypen. Sie machen zusammen gerade einmal 1% aller Krebserkrankungen aus. Genau diese Seltenheit und Vielfalt macht sie zu einer der größten Herausforderungen der modernen Onkologie. In dieser Folge von O-Ton Onkologie spricht Dr. med. vet. Astrid Heinl, stellvertretende Chefredakteurin des Journal Onkologie, mit zwei Expert:innen auf diesem Gebiet: Privatdozentin Dr. Joanna Szkandera von der Universität Graz und Privatdozent Dr. Rainer Hamacher, Oberarzt am Westdeutschen Tumorzentrum des Universitätsklinikums Essen. Gemeinsam beleuchten sie, warum klassische systemische Therapien in der Sarkom-Therapie an ihre Grenzen stoßen und in welche Richtung die Forschung geht: hin zu präzisionsmedizinischen Strategien wie Antikörper-Wirkstoff-Konjugaten (ADCs), FAP-gerichteten Radioligantentherapien und Theranostik. Weiterführende Informationen: https://tumorforschung.uk-essen.de/spezialsprechstunden/sarkome-gist/ https://www.sarkome.de/kalender/sarkomkonferenz-2026-berlin https://www.medmedia.at/krebs-hilfe/krebshilfe/der-schluessel-zur-erfolgreichen-sarkomtherapie/ https://www.uniklinikumgraz.at/inneremedizin/onkologie https://www.myscience.at/news/wire/musculo_skeletal_oncology_praesidentin_joanna_szkandera-2023-medunigraz https://www.journalonko.de/sarkome/patienten-rundumblick https://bit.ly/3NJPbAC Diese Podcast-Staffel wird ermöglicht durch Fortimel - medizinische Trinknahrung. Wir danken unserem Partner für die Unterstützung der Produktion dieses Audio-Formats. Unsere Sponsoring-Partner haben keinen Einfluss auf die Inhalte. Fortimel Trinknahrungen sind Lebensmittel für besondere medizinische Zwecke (bilanzierte Diät). Zum Diätmanagement bei krankheitsbedingter Mangelernährung. Nur unter ärztlicher Aufsicht verwenden.

La fondation pour le Logement des défavorisés, anciennement fondation Abbé-Pierre pour le logement des défavorisés (FAP), est une organisation créée en 1987 et reconnue d'utilité publique le 11 février 1992, qui a pour mission de permettre à toute personne démunie d'accéder à un logement décent et à une vie digne, quels que soient le montant de ses ressources et sa situation sociale.Réalisé par Claire.Site web : https://www.fondationpourlelogement.fr/Hébergé par Ausha. Visitez ausha.co/politique-de-confidentialite pour plus d'informations.

Advanced practice providers discuss biomarker testing in patients with colorectal cancer. Listen in to learn from Ann Marie Siney, RN, MSN, ANP-BC, and Kathleen Boyle, DScPAS, PA-C, about familial cancer syndromes associated with colorectal cancer and key biomarker testing often used in patients with colorectal cancer, including their thoughts on overcoming key barriers to testing, education of patients and caregivers, and improving equity in the application of biomarker for all patients. Presenters: Ann Marie Siney, RN, MSN, ANP-BC Division of Hematology/Oncology UCLA Health Santa Monica, California Kathleen Boyle, DScPAS, PA-C  Gastrointestinal Cancer Center Dana-Farber Cancer Institute Boston, Massachusetts Link to full program: https://bit.ly/4spkxiC Get access to all our new podcasts by subscribing to the Decera Clinical Education Oncology Podcast on Apple Podcasts, YouTube Music, or Spotify. Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

In dieser Folge meines Podcasts „Krebs als zweite Chance – Der Mutmacher Podcast“ spreche ich mit Anja, die seit vielen Jahren mit einer seltenen genetischen Erkrankung lebt. Mit 25 Jahren erhielt sie die Diagnose FAP – Familiäre Adenomatöse Polyposis, eine vererbbare Erkrankung mit stark erhöhtem Krebsrisiko. Aufgrund der Erkrankung wurde ihr bereits früh der Dickdarm entfernt und bis heute gehören regelmäßige Kontrolluntersuchungen zu ihrem Leben. Im Oktober 2023 kam eine weitere schwere Diagnose hinzu: Ein bösartiger Tumor in der Gebärmutter. Es folgten Operation und Chemotherapie – gleichzeitig musste sie weiterhin regelmäßig wegen ihrer FAP zu Magenspiegelungen ins Krankenhaus. Doch Anja hat sich entschieden, das Leben bewusst weiterzugehen. 2024 stand für sie unter dem Motto: „Raus ins Leben.“ Sie war viel unterwegs und hat nach 19 Jahren in wilder Ehe ihren Partner geheiratet. Gleichzeitig trägt sie eine große persönliche Geschichte in sich: Vor genau einem Jahr ist ihre Mutter gestorben – von ihr hat sie auch die genetische Erkrankung FAP geerbt. Im Gespräch erzählt Anja offen über: ✨ das Leben mit einer genetischen Krebsprädisposition ✨ die Diagnose eines bösartigen Tumors in der Gebärmutter ✨ medizinische Herausforderungen und regelmäßige Kontrollen ✨ Trauer, Familie und Neubeginn ✨ warum sie sich entschieden hat, bewusst zu leben Ihre Geschichte zeigt, dass das Leben trotz Krankheit weitergeht – manchmal sogar intensiver als zuvor. ⸻ ✍️ Mehr über Anja Über ihre Erfahrungen schreibt sie auch in ihrem Blog:

Originally Aired December 8, 2025: Rick's Cabaret girls in studio. Fap-sicles. Everything you wanna know about frost jacking. Listen & subscribe to the show on Apple Podcasts, Spotify or Amazon Music. For more, visit https://www.93x.com/half-assed-morning-show/Follow the Half-Assed Morning Show:Twitter/X: @93XHAMSFacebook: @93XHAMSInstagram: @93XHAMSEmail the show: HAMS93X@gmail.com See omnystudio.com/listener for privacy information.

This week we had a recommendation from Blue Jack from the FAP! Warnings on this movie, there are alot of topics/events in this movie that can trigger your or make you feel uncomfortable so please go in with that thought! Listen in to hear what we thought about this movie and what is coming next!Ratings: Artsy: 4/10Cj: 5/10

On this episode, Alyx, Flint & Ashleigh go over: The EHRC wanting to get out in front of any statements made by the Global Alliance of National Human Rights Institutions (GANHRI) with mixed success. Some social science, of the LGB Alliance. An NHS ICB threatening to close a group of GP's surgeries for continuing to support trans young people, in line with existing legislation. Lib Dem returning officers don't get off lightly after an encounter with the FAP committee. Stop sniggering! Yes you read that correctly! And for our meat, we find out what Your Party's Trans Liberation Group had to say about Alyx's recent article calling Your Party a waste of time... References: https://whatthetrans.com/ep144  

Send us a textA uniform shouldn't cost a parent their child. We sit down with retired Army officer, attorney, and parent advocate Erhan Bettistani to unpack how military service collides with family court—and why a little-known administrative process, the Family Advocacy Program's Incident Determination Committee (FAP IDC), can tilt custody decisions without basic due process. Erhan brings research published in Family Court Review and Military Law Review, plus firsthand stories from Warrior Family Advocacy, to show how “substantiated” findings spill into civilian courts, inflame stress, and even factor into veteran suicide risk.Across an hour, we trace four forces that often work against service members: media narratives of extremes, the stigma of deployments and constant PCS moves, assumptions around PTSD and mental health, and the shadow-court mechanics of FAP IDC. We compare FAP procedures to the old Title IX campus model—informal, opaque, and vulnerable to error—and highlight reforms that state courts and the Department of Education have already embraced: clear notice, access to the evidence file, counsel in the room, cross-examination, written findings, and recorded hearings. The takeaway is stark but hopeful: the Department of Defense can integrate these protections now, without waiting on Congress, and still support victims with clinical care while improving fairness for all parties.We also get practical. If you're navigating divorce or custody as a military parent, you'll hear strategies for documenting stability, addressing PTSD stigma, planning around deployments, and securing counsel early in the right jurisdiction. Erhan explains how Warrior Family Advocacy funds initial attorney consults and offers grounded guidance so you can breathe, plan, and protect your bond with your child. Abuse must be taken seriously—and so must process. Better rules mean better outcomes for families, for justice, and for the mental health of those who serve.If this conversation resonates, follow the show, share it with a military family, and leave a review with your biggest question about fixing FAP. Your voice helps push the right reforms forward.Resources & Links: •

Em mais um episódio do Conversas de Trabalho, Camila Cruz informa que a consulta ao FAP 2026 já está disponível.

With more than four decades of experience in oncology, cardiovascular imaging, ultrasound, and radioligand therapy, Dr. François Tranquart has helped shape the field of molecular imaging from both sides of the table—first as an academic physician and researcher, and later as an industry leader driving global clinical development.In this French-language episode of Fractals: Life Science Conversations, François joins host Paul Martinetti to share:Why the transition from academia to industry brought new opportunities for innovation.The critical role of collaboration and patient-centered thinking in clinical research.How emerging tools like AI, FAP tracers, and therapeutic ultrasound are transforming nuclear medicine.The biggest lessons he's learned across 40+ years of advancing imaging and therapeutic solutions.Listen to the full conversation on your favorite podcast platform, and connect with Bracken to learn how our cross-functional expertise can support your development strategy.

They say laughter is the best medicine - unless you're diagnosed with something that sounds like a meme.Mike lives with FAP, short for Familial Adenomatous Polyposis - a rare genetic disorder that guarantees colon cancer without drastic surgical intervention. In this unfiltered and laugh-out-loud conversation, Mike opens up about the brutal realities of living without a large intestine, the mental toll of life-altering surgery at 18, and the deeply personal decision to write a memoir titled A Bump in the Road. From rows of shark-like baby teeth to an ostomy bag that looked like Rudolph's nose, Mike takes us through the gritty details of his medical journey. But what starts as a conversation about disease turns into something much bigger: a story of resilience, perspective, and finding purpose on the other side of pain. Plus, a passionate pitch for bidets, because we all know bidets are for kings. Check out Mike's book!

They say laughter is the best medicine - unless you're diagnosed with something that sounds like a meme.Mike lives with FAP, short for Familial Adenomatous Polyposis - a rare genetic disorder that guarantees colon cancer without drastic surgical intervention. In this unfiltered and laugh-out-loud conversation, Mike opens up about the brutal realities of living without a large intestine, the mental toll of life-altering surgery at 18, and the deeply personal decision to write a memoir titled A Bump in the Road. From rows of shark-like baby teeth to an ostomy bag that looked like Rudolph's nose, Mike takes us through the gritty details of his medical journey. But what starts as a conversation about disease turns into something much bigger: a story of resilience, perspective, and finding purpose on the other side of pain. Plus, a passionate pitch for bidets, because we all know bidets are for kings. Check out Mike's book!

In this episode, hosts Robby and Sammi welcome Jenny Jones, an author and advocate for those living with chronic pain. Jenny shares her personal journey with familial adenomatous polyposis (FAP), a hereditary condition that significantly impacts her life and her experience writing a children's book aimed at educating young readers about FAP. The conversation also delves into Jenny's struggles with chronic pain, including abdominal migraines and the importance of physical therapy in her recovery. She discusses the impact of her condition on her mental health, and how she has worked towards healing. The conversation also touches on her reflections on life and death, emphasizing the peace she has found in accepting her journey. Buy "Life's a Polyp: with Zeke and Katie" on Amazon!Follow Jenny's journey on www.lifesapolyp.com and on social media @LifesaPolypFollow the show on Instagram @thepainfultruthpodcast, as well as Robby @robert1950studios and Sammi @thesam.a.lamCheck out their TikTok @1950StudiosYou can find Limitless Broadcasting on Instagram @limitlessbroadcasting.Rant Radio is LIVE! Call 844-857-7268 and leave your rant today. Check out LimitlessBroadcastingNetwork.com for all of our podcasts, subscriptions, and to pick up some awesome merch!

My guest today is Holly Yates, LCMHC. Holly has been in private practice in North Carolina since 2004. Her specialty areas are working with adults both individually and in groups as well as couples addressing depression, anxiety, mood disorders and life stressors through clinical intervention and skills training. Holly's practice centers on third wave therapies most specifically Functional Analytic Psychotherapy (FAP) and Acceptance and Commitment Therapy (ACT). She is a founding facilitator of the online ACT Peer Intervision Network sponsored through ACBS and a Certified FAP Trainer through University of Washington. Holly presents FAP and ACT workshops locally and around the world. Holly is Co-founder of North Wake Counseling Partners in Raleigh NC.Some of the topics we explore in this episode include:- Holly's background with ACT and how it led to learning about FAP- The importance of the therapeutic relationship- Clinically relevant behaviors for connection building in the therapy room- The importance of encouraging authentic relationships outside of therapy- The courage and vulnerability involved in intentional self-disclosure- How ACT and FAP naturally blend together—————————————————————————Thank you all for checking out the episode! Here are some ways to help support Mentally Flexible:Sign up for PsychFlex through the Mentally Flexible link! PsychFlex.com/MentallyFlexibleYou can help cover some of the costs of running the podcast by donating a cup of coffee! www.buymeacoffee.com/mentallyflexiblePlease subscribe and leave a review on Apple Podcasts. It only takes 30 seconds and plays an important role in being able to get new guests.https://podcasts.apple.com/us/podcast/mentally-flexible/id1539933988Follow the show on Instagram: https://www.instagram.com/mentallyflexible/Check out my song “Glimpse at Truth” that you hear in the intro/outro of every episode: https://tomparkes.bandcamp.com/track/glimpse-at-truthCheck out my new album, Holding Space! https://open.spotify.com/album/0iOcjZQhmAhYtjjq3CTpwQ?si=nemiLnELTsGGExjfy8B6iw

In episode 485 I chat with Jonny Say. Jonny is a UK based therapist and co-director at The Integrative Centre for OCD Therapy.  We discuss the importance of the therapeutic relationship, the benefits of it to outcomes, functional analytic psychotherapy (FAP), how compulsions can get in the way of the therapeutic relationship, how a good therapeutic relationship can help acceptance and commitment therapy (ACT) and exposure and response prevention therapy (ERP), the therapeutic relationship as a way of dealing with shame, rupture and repair, Jonny and I share our own experiences from therapeutic relationships, and much more. Hope it helps.  Show notes: https://theocdstories.com/episode/jonny-485 The podcast is made possible by NOCD. NOCD offers effective, convenient therapy available in the US and outside the US. To find out more about NOCD, their therapy plans and if they currently take your insurance head over to https://learn.nocd.com/theocdstories  FAP training for therapists: https://www.integrativecentreforocd.co.uk/live-trainings-therapists/fap-for-ocd  Join many other listeners getting our weekly emails. Never miss a podcast episode or update: https://theocdstories.com/newsletter   Thanks to all our patrons for supporting our work. To sign up to our Patreon and to check out the benefits you'll receive as a Patron, visit: https://www.patreon.com/theocdstoriespodcast 

In this powerful episode of It Happened To Me, hosts Beth Glassman and Cathy Gildenhorn are joined by author, advocate, and healthcare leader Laura Kieger, who shares her family's deeply personal journey with FAP (Familial Adenomatous Polyposis), a rare genetic condition that significantly increases the risk of colorectal and other cancers. Laura's memoir, Summer's Complaint, chronicles the emotional and medical challenges her family has faced across generations, from diagnosis and genetic testing to coping with loss and finding resilience. As someone who tested negative for the familial mutation herself, Laura also opens up about "survivor's guilt", the burden of watching loved ones endure cancer, and how her work in healthcare and leadership has informed her approach to caregiving and advocacy. Whether you're living with a hereditary cancer condition, supporting someone who is, or simply seeking to understand the human side of genetic risk, this episode offers insight, education, and compassion. Topics Covered: What FAP is and how it differs from other hereditary cancer conditions Laura's family's diagnosis journey and how it shaped their approach to screening and prevention The emotional experience of receiving a negative genetic test result when others in your family test positive The value of genetic counseling and early detection Misconceptions about FAP and what patients and families should really know How storytelling can raise awareness and build advocacy for rare diseases Highlights from Laura's memoir, Summer's Complaint, and what she hopes readers take away Laura Kieger is a healthcare human resources consultant, leadership coach, and author of Summer's Complaint. With decades of experience improving patient and employee experiences in healthcare settings, Laura brings both professional and personal insight to the conversation around rare diseases and inherited cancer risk. She's also a passionate advocate and speaker for organizations like the Ronald McDonald House and Care Partners.   Be sure to purchase your own copy of Laura's memoir Summer's Complaint; all proceeds go to continuing education credits for healthcare providers about hereditary cancer syndromes. During the episode Laura also mentioned a study about green bananas here and a private Facebook support group here.    Stay tuned for the next new episode of “It Happened To Me”! In the meantime, you can listen to our previous episodes on Apple Podcasts, Spotify, streaming on the website, or any other podcast player by searching, “It Happened To Me”.    “It Happened To Me” is created and hosted by Cathy Gildenhorn and Beth Glassman. DNA Today's Kira Dineen is our executive producer and marketing lead. Amanda Andreoli is our associate producer. Ashlyn Enokian is our graphic designer.   See what else we are up to on Twitter, Instagram, Facebook, YouTube and our website, ItHappenedToMePod.com. Questions/inquiries can be sent to ItHappenedToMePod@gmail.com.   

Subscriber-only episodeWhat drives men to constant masturbation and what's the real cost of this habit? The Chastity Queen cuts through the shame and embarrassment to explore why so many men fall into this pattern and—more importantly—how breaking free from it can transform your life.Sexual desire is natural, but constant release through masturbation depletes more than just physical energy—it diminishes your drive for achievement, relationship-building, and self-improvement. This episode exposes how the compulsion to masturbate weakens men mentally and emotionally, creating a cycle of addiction that's increasingly difficult to escape. "If I tell you to edge for one hour before being rewarded with release, that has more merit, more depth and meaning," explains the Chastity Queen, highlighting how structure and restraint create purpose.The most revolutionary concept? Denial actually increases desire and satisfaction. The growing "no FAP" movement among younger adults recognizes what the BDSM community has known for years—controlling sexual release channels that energy into productivity, confidence, and ultimately better connections with partners. Women can sense when a man has been "saving it" specifically for them, and this restraint becomes incredibly attractive. Ready to transform weakness into strength? Take the 7-day chastity challenge outlined in this episode, and discover how redirecting sexual energy into productive pursuits can change everything. Your key to breaking the cycle and experiencing true sexual fulfillment might be the opposite of what you've been taught.Subscribe now and use promo code CHASTITYQUEEN at lockedinlust.com for 15% off your first chastity device—because sometimes restraint is the most empowering choice you can make.Try to connect with your local BDSM community. Fetlife is a great way to see others in similar FLR and chastity lifestyles. You can check out Mine in Fetlife at Chastity-Queen. It's a free to join. Hugs, Chastity Queen Locked In Lust 15% OFF:CHASTITYQUEEN Use Discount Code:CHASTITYQUEEN for 15% OFF ANYTHING at www.lockedinlust.com LOVE SHOP 15% OFF Sex Toys & MORE Get 15% OFF sex toys, lingerie and more, using PROMO CODE: CHASTITY QUEEN Buzzsprout - Let's get your podcast launched!Start for FREE15% OFF Shoe Freaks-PROMO%CHASTITYQUEEN GET your 15% OFF ANYTHING when you buy SEXY Shoes, heels & Stripper Boots at Shoe Freaks Canada!www.SMBSM.com - Chastity Cages 10% OFFGet reasonably priced chastity cages, chastity belts, chastity wear, + chastity accessories.Disclaimer: This post contains affiliate links. If you make a purchase, I may receive a commission at no extra cost to you.https://www.linktr.ee/ChastityQUEEN

Dr Charlie Andrews talks to Dr John Leeds. John Leeds is a Consultant Pancreaticobiliary Physician and Endoscopist based at the Freeman Hospital in Newcastle and an Honorary Clinical Senior Lecturer based in the Population Health Sciences Institute at Newcastle University. He is involved in research in pancreaticobiliary disorders including benign and malignant conditions as well as outcomes from therapeutic/advanced endoscopy.John is a member of the British Society of Gastroenterology and Pancreatic Society of Great Britain and Ireland. He serves on the endoscopy and Pancreas committees for BSG and is the website lead for PSGBI.He is also a founder member of the BSG Pancreas Clinical Research Group which is coordinating research for the society.Key Learnings from this episode:Challenges in Early Detection of Pancreatic Cancer • Pancreatic cancer is often diagnosed at an advanced stage due to the deep location of the pancreas and the lack of early symptoms. • Tumors in the body and tail of the pancreas can grow significantly before causing symptoms, often invading major arteries or veins, making them inoperable. • Tumors in the head of the pancreas may present earlier due to bile duct obstruction, leading to jaundice, but even these are often detected late. Early Symptoms and Red Flags • Early symptoms are vague or absent, making early diagnosis difficult. • Possible early indicators include: • Weight loss (often a sign of advanced disease). • New-onset diabetes, particularly in individuals with a normal BMI or without typical risk factors for type 2 diabetes. • Jaundice, which is a significant red flag and often indicates a serious underlying condition. • Classic signs like painless jaundice and Courvoisier's sign (palpable gallbladder) are important but not always present. Limitations of Current Screening Methods • There is no reliable biomarker or screening test for pancreatic cancer: • CA19-9 is not suitable as a screening tool due to its lack of specificity (elevated in other conditions). • Imaging techniques like CT scans or MRIs are used but have limitations, including incidental findings that may lead to unnecessary anxiety (“scanxiety”) and over-investigation. • Screening is currently limited to high-risk groups, such as those with familial pancreatic cancer syndromes or hereditary pancreatitis. High-Risk Groups for Screening • Familial pancreatic cancer accounts for less than 10% of cases. Criteria for screening include: • Multiple family members with pancreatic cancer, especially diagnosed under age 50–60. • Genetic syndromes like BRCA mutations, familial adenomatous polyposis (FAP), and Peutz-Jeghers syndrome. • Hereditary pancreatitis patients have an increased risk but are harder to screen due to pre-existing pancreatic abnormalities. Emerging Research and Future Directions • Studies are exploring potential biomarkers, such as microbiome signatures in the pancreas, which might help identify high-risk individuals in the future. • Trials like the EuroPAC study focus on surveillance protocols for high-risk individuals using imaging techniques like MRI or endoscopic ultrasound. • Research into new-onset diabetes as a potential marker for pancreatic cancer is ongoing but currently has a low yield due to the high prevalence of type 2 diabetes unrelated to malignancy. Considerations for Screening and Surveillance • Screening should be carefully targeted to avoid over-diagnosis and unnecessary investigations. • The psychological impact of screening (e.g., anxiety from incidental findings) must be considered. • Smoking cessation is emphasized as smoking is a significant risk factor for pancreatic cancer. Advances in Treatment Approaches • PET-CT scans are increasingly used to detect systemic disease that might not be evident on standard CT scans. • Neoadjuvant treatments (therapy before surgery) are being... Chapters (00:00:00) - Ingest(00:00:53) - Pancreatic Cancer(00:04:03) - New diabetes and pancreatic cancer(00:08:01) - Pancreatic Cancer: Screening(00:15:42) - Determining breast cancer early is hard(00:16:03) - Pulmonary neuroendocrine tumors of the pancreas(00:22:26) - Pancreatic cancer 20, Management(00:29:00) - Pancreatic cancer, management principles(00:33:48) - Primary Care Take Home: Pancreas, pain(00:40:29) - Primary Care: Pancreas Cancer Episode 2

In episode 475 I chat with Nate Gruner and Meaghan Cleary. Nate is a staff behavioural therapist at the obsessive-compulsive disorder institute at McLean hospital. Meaghan is a licensed mental health counselor and a registered dance and movement therapist. She is also a behavioural therapist and group facilitator at the obsessive-compulsive disorder institute at McLean hospital.  We discuss what is functional analytic psychotherapy (FAP), the rules of FAP, using the therapeutic relationship to create change in OCD, what FAP looks like in a session, case examples, the therapist training we are running through the centre I co-run, integrating FAP with exposure and response prevention therapy (ERP) and acceptance and commitment therapy (ACT), why I'm interested in FAP, and much more. Hope it helps.  Show notes: https://theocdstories.com/episode/nate-and-meaghan-475  FAP training for therapists: https://www.integrativecentreforocd.co.uk/live-trainings-therapists/fap-for-ocd The podcast is made possible by NOCD. NOCD offers effective, convenient therapy available in the US and outside the US. To find out more about NOCD, their therapy plans and if they currently take your insurance head over to https://go.treatmyocd.com/theocdstories Join many other listeners getting our weekly emails. Never miss a podcast episode or update: https://theocdstories.com/newsletter   Thanks to all our patrons for supporting our work. To sign up to our Patreon and to check out the benefits you'll receive as a Patron, visit: https://www.patreon.com/theocdstoriespodcast 

Dr. Navidi specializes in Hypnosis for GI Disorders and is a wealth of information that he shares with us on the podcast.  We talk about: ·       Underlying disorders ·       ARFID ·       How hypnosis works to help people feel better ·       Why some sessions are recorded and some are not ·       Interactive vs receptive hypnosis ·       Advanced hypnosis techniques ·       Apps like Nerva and whether they're helpful   About Dr. Ali Navidi Dr. Ali Navidi is a licensed clinical psychologist, one of the founders of GI Psychology and one of the founders and past president of the Northern Virginia Society of Clinical Hypnosis (NVSCH). Dr. Navidi has been helping patients with GI disorders, chronic pain and complex medical issues for over ten years for Kids, adolescents and adults Patients with Gastrointestinal (GI) Problems Patients with complex medical issues and chronic pain Clinical Hypnosis & Brief Therapy Cognitive Behavioral Therapy (CBT)   Get help through Dr. Navidi's practice for children, adolescents, and adults in the US at https://www.gipsychology.com/   Dr. Liz also offers Gut Directed hypnosis for adults in the US and Internationally. Contact her through her website https://www.drlizhypnosis.com   -------------- Support the Podcast & Help yourself with Hypnosis Downloads by Dr. Liz! http://bit.ly/HypnosisMP3Downloads Do you have Chronic Insomnia? Find out more about Dr. Liz's Better Sleep Program at https://bit.ly/sleepbetterfeelbetter Search episodes at the Podcast Page http://bit.ly/HM-podcast --------- About Dr. Liz Interested in hypnosis with Dr. Liz? Schedule your free consultation at https://www.drlizhypnosis.com Winner of numerous awards including Top 100 Moms in Business, Dr. Liz provides psychotherapy, hypnotherapy, and hypnosis to people wanting a fast, easy way to transform all around the world. She has a PhD in Clinical Psychology, is a Licensed Mental Health Counselor (LMHC) and has special certification in Hypnosis and Hypnotherapy. Specialty areas include Anxiety, Insomnia, and Deeper Emotional Healing. A problem shared is a problem halved. In person and online hypnosis and CBT for healing and transformation.  Listened to in over 140 countries, Hypnotize Me is the podcast about hypnosis, transformation, and healing. Certified hypnotherapist and Licensed Mental Health Counselor, Dr. Liz Bonet, discusses hypnosis and interviews professionals doing transformational work.

Episode 183: Colorectal Cancer in Young AdultsFuture Dr. Avila and Dr. Arreaza present evidence-based information about the screening and diagnosis of colorectal cancer and explain the increasing incidence among young adult and the importance to screen early in high risk groups.  Written by Jessica Avila, MS4, American University of the Caribbean School of Medicine. Edits and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.IntroductionJessica: Although traditionally considered a disease only affecting older adults, colorectal cancer (CRC) has increasingly impacted younger adults (defined as those under 50) at an alarming rate. According to the American Cancer Society, CRC is now the leading cause of cancer-related death in men under 50 and the second leading cause in women under 50 (American Cancer Society, 2024). Arreaza: Why were you motivated to talk about CRC in younger patients?Jessica: Because despite advancements in early detection and treatment, younger patients are often diagnosed at later stages, resulting in poorer outcomes. We will discuss possible causes, risk factors, common symptoms, and why early screening and prevention are important. Arreaza: This will be a good reminder for everyone to screen for colorectal cancer because 1 out of every 5 cases of colorectal cancer occur in adults between the ages of 20 and 54. The Case of Chadwick BosemanJessica: Many people know Chadwick Boseman from his role as T'Challa in Black Panther. His story highlights the worrying trend of increasing CRC in young adults. He was diagnosed with stage III colorectal cancer at age 39. This diagnosis was not widely known until he passed away at 43. His case shows how silent and aggressive young-onset CRC can be. Like many young adults with CRC, his symptoms may have been missed or thought to be less serious issues. His death drew widespread attention to the rising burden of CRC among young adults and emphasized the critical need for increased awareness and early screening efforts.Arreaza: Black Panther became a hero not only in the movie, but also in real life, because he raised awareness of the problem in young AND in Black adults. EpidemiologyJessica: While rates of CRC in older populations have decreased since the 1990s, adults under 50 have seen an increase in CRC rates of nearly 50%. (Siegel et al., 2023). Currently, one in five new CRC diagnoses occurs in individuals younger than 55 (American Cancer Society, 2024).Arreaza: What did you learn about the incidence by ethnic groups? Are there any trends? Jessica: Yes, certain ethnic groups are shown to have higher rates of CRC. Black Americans, Native Americans, and Alaskan Natives have the highest incidence and mortality rates from CRC (American Cancer Society, 2024). Black Americans have a 20% higher incidence and a 40% higher mortality rate from CRC compared to White Americans, primarily due to disparities in access to screening, healthcare resources, and early diagnosis. Hispanic and Asian American populations are also experiencing increasing CRC rates, though to a lesser extent.Arreaza: It is important to highlight that Black Americans have the highest rate of both diagnoses and deaths of all groups in the United States. Who gets colorectal cancer?Risk FactorsJessica: Anyone can get colorectal cancer, but some are at higher risk. In most cases, environmental and lifestyle factors are to blame, but early-onset CRC are linked to hereditary conditions. Arreaza: There is so much to learn about colorectal cancer risk factors. Tell us more.Jessica: The following are key risk factors:Modifiable risk factors:Diet and processed foods: A diet high in processed meats, red meat, refined sugars, and low fiber is strongly associated with an increased risk of CRC. Fiber is essential for gut health, and its deficiency has been linked to increased colorectal cancer risk (Dekker et al., 2023).Obesity and sedentary lifestyle: Obesity and physical inactivity contribute to CRC risk by promoting chronic inflammation, insulin resistance, and metabolic disturbances that promote tumor growth (Stoffel & Murphy, 2023).Gut microbiome imbalance: Disruptions in gut microbiota, especially an overgrowth of Fusobacterium nucleatum, have been noted in CRC pathogenesis, potentially causing tumor development and progression (Brennan & Garrett, 2023).Arreaza: As a recap, processed foods, obesity, sedentarism, and gut microbiome. We also have to mention smoking and high alcohol consumption as major risks factors, but the strongest risk factor is a family history of the disease.Non-modifiable risk factors:Genetic predisposition: Although only 20% of early-onset CRC cases are linked to hereditary syndromes such as Lynch syndrome and familial adenomatous polyposis (FAP), individuals with a first-degree relative with CRC are at a significantly higher risk and should undergo earlier and more frequent screening (Stoffel & Murphy, 2023).Arreaza: Also, there is a difference in incidence per gender assigned at birth, which is also not modifiable. The rate in the US was 33% higher in men (41.5 per 100,000) than in women (31.2 per 100,000) during 2015-2019. So, if you are a man, your risk for CRC is slightly higher. Protective factors, according to the ACS, are physical activity (no specification about how much and how often) and dairy consumption (400g/day). Jessica, let's talk about how colon cancer presents in our younger patients.Clinical Presentation and Challenges in DiagnosisJessica: Young-onset CRC is often diagnosed at advanced stages due to delayed recognition of symptoms. Common symptoms include:Rectal bleeding (often mistaken for hemorrhoids)Young individuals may ignore it, believe they do not have time to address it, or lack insurance to cover a comprehensive evaluation.Unexplained weight lossFatigue or weaknessChanges in bowel habits (persistent diarrhea or constipation)This may also be rationalized by dietary habits.Abdominal pain or bloatingIron deficiency anemia.Arreaza: All those symptoms can also be explained by benign conditions, and colorectal cancer can often be present without clear symptoms in its early stages. Jessica: Yes, in young adults, symptoms may be dismissed by healthcare providers as benign conditions such as irritable bowel syndrome (IBS), hemorrhoids, or dietary intolerance, leading to significant diagnostic delays. Arreaza: We must keep a low threshold for ordering a colonoscopy, especially in patients with the risks we mentioned previously. Jessica: We may also be concerned about the risk/benefit of colonoscopy or diagnostic methods in younger adults, given the traditional low likelihood of CRC. Approximately 58% of young CRC patients are diagnosed at stage III or IV, compared to 43% of older adults (American Gastroenterological Association, 2024). Early recognition and prompt evaluation of persistent symptoms are crucial for improving outcomes. Empowering and informing young adults about concerning symptoms is the first step in better recognition and better outcomes for these individuals.Arreaza: This is when the word “follow up” becomes relevant. I recommend you leave the door open for patients to return if their common symptoms worsen or persist. Let's talk about screening. Screening and PreventionJessica: Due to the trend of CRC being identified in younger populations, the U.S. Preventive Services Task Force (USPSTF) lowered the recommended screening age for CRC from 50 to 45 in 2021 (USPSTF, 2021). Off the record, some Gastroenterologists also foresee the USPSTF lowering the age to 40. Arreaza: That is correct, it seems like everyone agrees now that the age to start screening for average-risk adults is 45. It took a while until everyone came to an agreement, but since 2017, the US Multi-Society Task Force had recommended screening at age 45, the American Cancer Society recommended the same age (45) in 2018, and the USPSTF recommended the same age in 2021. This podcast is a reminder that the age of onset has been decreased from 50 to 45, for average-risk patients, according to major medical associations.Jessica: For individuals with additional risk factors, including a family history of CRC or chronic gastrointestinal symptoms, screening starts at age 40 or 10 years before the diagnosis of colon cancer in a first-degree relative. Dr. Arreaza, who has the lowest and the highest rate of screening for CRC in the US? Arreaza: The best rate is in Massachusetts (70%) and the lowest is California (53%). Let's review how to screen:Jessica: Recommended Screening Methods:Colonoscopy: Considered the gold standard for CRC detection and prevention, colonoscopy allows for identifying and removing precancerous polyps.Fecal Immunochemical Test (FIT): A non-invasive stool test that detects hidden blood, recommended annually.Stool DNA Testing (e.g., Cologuard): This test detects genetic mutations associated with CRC and is recommended every three years.Arreaza: Computed tomographic colonography (CTC) is another option, it is less common because it is not covered by all insurance plans, it examines the whole colon, it is quick, with no complications. Conclusion:Colorectal cancer is rapidly emerging as a serious health threat for young adults. The increase in cases over the past three decades highlights the urgent need for increased awareness, early symptom detection, and proactive screening. While healthcare providers must weigh the risk/benefit of testing for CRC in younger adults, patients must also be equipped with knowledge of concerning signs so that they may also advocate for themselves. Early detection remains the most effective tool in preventing and treating CRC, emphasizing the importance of screening and risk factor modification.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American Cancer Society. (2024). Colorectal Cancer Statistics, 2024. Retrieved fromhttps://www.cancer.orgAmerican Gastroenterological Association. (2024). Delays in Diagnosis of Young-Onset Colorectal Cancer: A Systemic Issue. Gastroenterology Today.Brennan, C. A., & Garrett, W. S. (2023). Gut Microbiota and Colorectal Cancer: Advances and Future Directions. Gastroenterology.Dekker, E., et al. (2023). Colorectal Cancer in Adolescents and Young Adults: A Growing Concern. The Lancet Gastroenterology & Hepatology.Siegel, R. L., et al. (2023). Colorectal Cancer Statistics, 2023. CA: A Cancer Journal for Clinicians.Stoffel, E. M., & Murphy, C. C. (2023). Genetic and Environmental Risk Factors in Young-Onset Colorectal Cancer. JAMA Oncology.U.S. Preventive Services Task Force. (2021). Colorectal Cancer Screening Guidelines.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

BELIEVING IN HOPE WITHOUT COMPROMISE. Dr Virgilio Sacchini is dedicated to caring for people with breast cancer at the Memorial Sloan Kettering Cancer Center in New York. He originally trained at Universita degli Studi di Milano (UNIMI, Milan, Italy) where he is Professor of Surgery, and cooperates with the European Institute of Oncology in Milan (IEO, Milan, Italy). Dr Sacchini is a 2023 and 2024 Castle Connolly America's Top Doctor, the peer nominated group of the top 7% of all US practicing physicians. His goal is to achieve the best possible cancer outcomes and cosmetic results for his patients. “The new concept is to target only cancer cells.” “To cure someone and give him or her a miserable life is terrible, so the target in this moment is both better survival and better quality of life, less side effects.” “Once we prove that the combination of the medication with the Avacta technique works, of course it is approved and you can be cured everywhere in the world.”

Dear men!Discover the transformative power of chastity as I challenge the norms of routine stress-relief mechanisms like porn addiction and masturbation. Join me, Chastity Queen, on this journey of self-reflection and empowerment, where we question whether these habits still add value to our lives or if they have become dull, repetitive chores. Learn how adopting chastity can lead to greater mindfulness, self-awareness, and a revival of excitement in your daily routine. Embark on a guided meditation that encourages you to reexamine your habits, explore their psychological and emotional roots, and consider new, healthier coping strategies. Together, we will navigate the boundary between routine and spontaneity, revealing surprising insights into your desires and stress-relief methods. This episode isn't just about restriction; it's about rediscovering freedom and joy in new ways. Join the conversation, redefine your boundaries, and embrace a lifestyle that serves your growth and happiness.Ultimately, I love seeing you happy!Chastity QueenTry to connect with your local BDSM community. Fetlife is a great way to see others in similar FLR and chastity lifestyles. You can check out Mine in Fetlife at Chastity-Queen. It's a free to join. Hugs, Chastity Queen Locked In Lust 15% OFF:CHASTITYQUEEN Use Discount Code:CHASTITYQUEEN for 15% OFF ANYTHING at www.lockedinlust.com LOVE SHOP 15% OFF Sex Toys & MORE Get 15% OFF sex toys, lingerie and more, using PROMO CODE: CHASTITY QUEEN Buzzsprout - Let's get your podcast launched!Start for FREE15% OFF Shoe Freaks-PROMO%CHASTITYQUEEN GET your 15% OFF ANYTHING when you buy SEXY Shoes, heels & Stripper Boots at Shoe Freaks Canada!www.SMBSM.com - Chastity Cages 10% OFFGet reasonably priced chastity cages, chastity belts, chastity wear, + chastity accessories.Disclaimer: This post contains affiliate links. If you make a purchase, I may receive a commission at no extra cost to you.Support the showhttps://www.linktr.ee/ChastityQUEEN

So that's how FAP does it. They compromise someone with an under age girl, that doesn't look it and they turn him into a snitch. - Phil Get weekly bonus content on our Patreon: www.patreon.com/kingmepod Email us at kingmepod@gmail.com

Historias de armamentos: Los EEUU nos donaron helicópteros (y en esta donación no se paga nada). La PNP tiene vehículos –donados y comprados– inservibles. Y la FAP comprará sí o sí aviones caza. MIENTRAS TANTO: La extraña mu3rt3 del policía descuartizador. Un video grabado por la propia PNP demuestra que los colegas del as3sin0 contaminaron la escena del crimen. Estos son los detalles. ADEMÁS: Lozano sale libre... pero se revelan los chats con su "presidente" Acuña. Y... ¿Necesitas un equipo de grabación para tu evento? ¿O quieres ir a una obra de teatro, a la presentación de un libro? Aquí tienes unas alternativas. **** Mira aquí la película “Rosa Chumbe”, dirigida por Jonatan Relayze https://www.tokyvideo.com/es/video/rosa-chumbe-2015-pelicula-completa **** ¿Te gustó este episodio? ¿Buscas las fuentes de los datos mencionados hoy? SUSCRÍBETE en http://patreon.com/ocram para acceder a nuestros GRUPOS EXCLUSIVOS de Telegram y WhatsApp. También puedes hacerte MIEMBRO de nuestro canal de YouTube aquí https://www.youtube.com/channel/UCP0AJJeNkFBYzegTTVbKhPg/join **** Únete a nuestro CANAL de WhatsApp aquí https://whatsapp.com/channel/0029VaAgBeN6RGJLubpqyw29 **** También estamos en TokyVideo https://www.tokyvideo.com/user/marcosifuentes/videos **** Para más información legal: http://laencerrona.pe

JCO PO author Dr. Michael J. Hall, Professor of Medicine, Chairman of the Department of Clinical Genetics, and Co-Leader of the Cancer Prevention and Control Program at Fox Chase Cancer Center in Philadelphia, PA, shares insights into the JCO PO article, “Uptake of aspirin chemoprevention in patients with Lynch Syndrome.” Host Dr. Rafeh Naqash and Dr. Hall discuss the finding that only about 1 in 3 patients with Lynch Syndrome use aspirin for cancer chemoprevention. 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 JCO PO articles. I'm your host, Dr. Rafeh Naqash podcast editor for JCO Precision Oncology and Assistant Professor at the OU Health Stephenson Cancer Center at the University of Oklahoma. Today, I'm excited to be joined by Dr. Michael J. Hall, Professor of Medicine, Chairman of the Department of Clinical Genetics and co-leader of the Cancer Prevention and Control Program at the Fox Chase Cancer Center in Philadelphia, and also the lead author of the JCO Precision Oncology article entitled, “Uptake of Aspirin Chemo Prevention in Patients with Lynch Syndrome.” At the time of this recording, our guest disclosures will be linked in the transcript. Dr. Hall, welcome to the podcast and thank you for joining us today to explain and help the listeners understand your interesting research that was just published in JCO Precision Oncology. Dr. Michael J. Hall: Thank you so much for having me and really thanks for the interest in our work. I think it's an important subject and I hope people will also find it as interesting as we do. Dr. Rafeh Naqash: Absolutely. I think your research touches upon a few things. One, obviously, touches upon Lynch syndrome germline assessments of individuals. It also touches upon chemo prevention, prevention in general, and it also touches upon the knowledge and understanding of chemo prevention aspects. So to start off, I would like to ask you, for the sake of our listeners, many of whom who may not necessarily fully understand the length and breadth of Lynch syndrome, maybe perhaps some residents or trainees out there, could you tell us what Lynch syndrome is, what some of the mutations are, what the implications are, and then we can try to go and delve more into the research topic. Dr. Michael J. Hall: Sure, I'd be happy to. Lynch syndrome is probably, in the hereditary cancer genetics world, one of the most common hereditary risk syndromes we encounter. Recent estimates are that probably roughly about 1 in every 280 individuals in the population is a carrier of a pathogenic variant, one of the Lynch syndrome genes, there are roughly four. There's sort of a fifth gene that is also involved with Lynch syndrome, but really, we largely think about four genes in Lynch syndrome, MLH1, MSH2, MSH6, and PMS2. Over time we've begun to learn, and I'll say that the guidelines that we develop have become more specialized for each of those genes. They are not sort of all the same in the cancers they cause and the way they behave. But roughly, what is Lynch syndrome? It's a syndrome of DNA mismatch repair. So, individuals who have Lynch syndrome have some degree of deficiency in their ability to repair DNA via the mismatch repair system. Depending on the pathogenic variant that is within a family, that may be related to a more severe deficiency of mismatch repair, repair, editing, or for instance, with the PMS2 gene, we've learned over time that actually the degree of DNA repair deficiency is actually a milder phenotype. These individuals over a lifetime are at risk of a variety of different kinds of cancers, the most common being colon cancer. And the risk of that is variable by gene. With MLH1 and MSH2, it's close to 50% over a lifetime. With MSH6 and PMS2, somewhat lower. There are also risks of endometrial cancer, gastric cancer, ovarian cancer, pancreas cancer, a number of other ones. But they're all related again to the same underlying molecular deficiency, and that's this deficiency of being able to repair mistakes made in the DNA accurately. And so, mutations accumulate in the genome of cells in various tissues of the body. Dr. Rafeh Naqash: Thank you for that very simplified version of a very complicated topic otherwise. So, as you mentioned, these different genes have different implications. Perhaps some have higher risks for colorectal cancer than others. What are some of the current standardized approaches for screening or following these individuals over the course of their journey until perhaps either get detected with cancer or while they're being monitored? Dr. Michael J. Hall: Sure. It's a great question, because this is very much a moving target in this disease. I'm going to give you a quick second of history that up until maybe about six or seven years ago, we had uniform guidelines, really, that any Lynch syndrome pathogenic variant carrier should start colorectal cancer screening. Usually, we were recommending between the age of 20 and 25, and this was usually annual colonoscopy. And for years that was the standard. In more recent years, we've stuck to that tight interval, particularly in the higher risk genes, MLH1 and MSH2, although the guideline now reads every one to two years, because we recognize people need some degree of flexibility to live their lives. And there are people in the population who are more risk averse, and there are those who want a colonoscopy every year because they want to stick to that schedule. For MSH6, we recommend a somewhat later start at age 30, and that can be every one to three years for colon screening and for PMS2, similar recommendations, although I think there is a chance in the coming years, we may actually expand the screening interval even more, again, because the risks are somewhat lower. We still have ways to go in terms of screening for the other cancers in Lynch syndrome. I'll say that, for instance, endometrial cancer, which is the second most common cancer in this disease, we still struggle with what is the best way to screen women for a risk of endometrial cancer. Our guidelines in the past were always somewhat draconian, that once women sort of finish childbearing, they should immediately have a total abdominal hysterectomy and oophorectomy. And I'll say that with greater input from the gynecologic and GYN ONC community, we have somewhat softened those recommendations, especially for the endometrial cancer and also the age at oophorectomy, because we recognize that there were compensatory risks of taking the ovaries out too early in some women, risks of bone loss and cardiovascular disease. So those are the most common. For other tumors in Lynch syndrome, for instance, gastric cancer and pancreas cancer, the guidelines are still really evolving, and different groups have put out guidance for clinicians. And I'll say NCCN, which I participate in and help write those guidelines, has very good recommendations for docs. But I'll say that it is again, back to the idea that it's a moving target. And as we learn more, hopefully, we'll have better recommendations. Dr. Rafeh Naqash: I completely agree as far as a moving target is concerned, and we often look at the disconnect between the recommendations and then what's implemented or followed in the real-world setting. So I have a question in that context, and my question is, when you identify these individuals with Lynch syndrome, perhaps let's talk about academic settings, and then we can try to delve into how this might work in the real world community oncology settings, where the real world population actually exists, 60, 70% of individuals get treated in the community. So, when you talk about an academic center, what is the flow of the individual? Does the individual stay within the geneticist when they're diagnosed? Does the individual go to the primary care and the geneticist makes the recommendation and the primary care follows the recommendation? How does it work for you and what are some of the models that you've seen work best perhaps at different academic centers? Dr. Michael J. Hall: I think you get at a really great question. And I'll say there is really no one model. And I think models have to be fluid these days because people with Lynch syndrome are really being identified in more and more diverse settings, and by diverse means. I'll say at my own center, we are more of a traditional practice. So, we do the pre-test and the post-test counseling. Once we have counseled individuals identified Lynch syndrome, we will usually make referrals. If folks don't have a gastroenterologist that they have interacted with before, we keep them in our own group and follow them. But their Lynch syndrome home really sits both in a continuity clinic that I run for patients to come back and circle around every one to two years just to review guidelines and review their screening results. However, I do really make an effort to, first of all, keep primary care docs involved, because I think some of the things we recommend, it is critical that the primary care doc is aware so that patients are keeping up with some of the recommendations. For instance, we often recommend skin screening to make sure that folks have had at least one good skin exam somewhere in the 40s. And I think the primary care doc can be very helpful in making sure that happens. It is somewhat different, I think, in the community where many more patients with Lynch syndrome are being identified these days. I suspect that much more of the burden of making sure Lynch syndrome patients are well hooked in with a gastroenterologist and with a dermatologist and maybe a urologist probably does fall on that primary care doctor. In my experience, some primary care physicians have really kind of jumped up in and taken hold of this and really know their Lynch syndrome well, and I think that's amazing. I do, however, as kind of an expert in this area, I do get a lot of referrals in from the community as well, from docs who just feel that they may not have quite that expertise that they can get at a comprehensive center. So, someone may come in to me just for a consult to review what my recommendations would be, hear about research, hear about what's going on in the field, and those folks will often touch base with me again every couple year or so. Often, another thing I've started to experience is that I may meet people once or twice early on in their diagnosis, and then they go back to their primary docs and I may not hear from them again until something more profound happens in the family or into the patient and they get their screening colonoscopy and a stage 1 cancer is found. Often then, that's the patient who, after four or five years, will contact me again and say, “We haven't talked in a while, but something has happened, and can we re-consult about what would be the best way to do things?” Dr. Rafeh Naqash: Again, like you said, lots of moving targets, moving aspects to this whole care of these individuals. Do you think, in your experience, nurse navigation, maybe some centers have already implemented that perhaps you might have that, do you think nurse navigation could play a certain level of role? You know how in the multidiscipline care we have nurse navigators that coordinate care between radiation oncologists, medical oncologists, thoracic surgeons. So that's something that is being implemented. My second part of that question is telehealth in this case, maybe it's a little more difficult for somebody to drive three hours to come to you for a visit just to check in versus maybe virtually talking to you or your team getting a sense of where things are at in terms of their screening and their follow ups. Dr. Michael J. Hall: I think both are great, great questions and absolutely, we use both of those pieces in our model. And I know from colleagues that they do as well. So, in terms of navigation, we do have an embedded nurse navigator within our department. She joins and kind of helps facilitate all of our high risk follow up clinics. Mine, for GI, we have a high-risk prostate clinic, we have several high-risk breast clinics and those are populated by providers. We have a couple of nurse practitioners in my genetics group and a PA they are sort of the main provider in those clinics, but they are very much supported by that nurse navigator who, as you well point out, really helps with the coordination of the care. Telehealth as well, I do 100% support because you're absolutely right, if you look at a map of the United States and you first of all look at where there are good counseling services available, of course, there's ample counseling in the major metropolitan areas all over the U.S., but the minute you get outside of those counseling and then other management expertise, then– So we do have a model where particularly for folks who are from central Pennsylvania and sometimes more towards western Pennsylvania, I do have some individuals who've been identified with Lynch syndrome who telehealth in, again, for that follow up. A sort of side notes on telehealth, I think we learned a lot from the pandemic about how to use telehealth more effectively. And thank goodness, we've all gotten up to speed in medicine of how to be better telehealth providers. Unfortunately, I feel like with the pandemic kind of waning, there's been a little bit of a regression of the telehealth laws. So now if I want to do telehealth with someone who is from New Jersey, even though New Jersey sits very close to where I practice, it's more complicated now. Again, I have to get a license and same thing with New York and same thing with Delaware. I sort of wish we had a little bit of a better and welcoming system in the states where you could have easier ability to practice, especially when states were quite close using telehealth. But nonetheless, that's for another podcast, I think. Dr. Rafeh Naqash: Well, thank you again for some of those interesting aspects to this whole topic. But let's dive into the thing that we are here to talk about, which is aspirin in these individuals. So can you give us some context of why aspirin, what's the biology there and what's the data there, and then talk about why you did what you did. Dr. Michael J. Hall: So, we've known for many years that aspirin has preventive properties in terms of preventing colorectal cancer. Many observational studies and some interventional studies have shown us that aspirin has benefits for reducing the risk of colon cancer in an average risk population. There was even an interventional trial a number of years ago that looked at individuals who made polyps, and this looked at particularly adenomas, which we know are the precancerous polyps and adenoma prevention using aspirin. And that study clearly showed that aspirin had benefits for lowering risk of recurrent polyps and adenomas. Particularly even a lower dose of aspirin, 81 milligrams, was effective in that setting. Aspirin's also been studied in other hereditary risk syndromes, the most visible one being FAP, where data have shown that aspirin does help reduce polyp count in FAP, although is certainly not a perfect chemo prevention for that disease. So, in that background of knowing that aspirin has many benefits for colorectal cancer prevention, a study was initiated in the UK a number of years ago called the CAPP2 study, with its lead investigator being John Burn. And in this study, it was a two-arm factorial study that was not just aspirin, but they were also looking at resistant starch, which there was a lot of excitement about resistant starch back then. But in this study, they looked at using aspirin as a way of lowering risk of colorectal cancer in patients with Lynch syndrome. And that study, which was initially reported in The New England Journal, the initial outcomes did not actually show benefits in its first analyses of adenoma risk and colon cancer risk. But what they found over time was that there was a delayed effect and, in a follow, up paper looking at 10 plus years of follow up, they showed a substantial reduction in risk of colon cancer, about 40% risk reduction, which was really striking and exciting in the field to see such a large benefit from aspirin. Now, one caveat was in the analyses they performed, it was those individuals who were able to stick to the aspirin dose in that study, which was 600 milligrams a day. I always say to folks that back in the day, that was not a lot of aspirin, although I think these days we're much more skeptical about taking larger doses of any drug. So, 600 milligrams is roughly about two adult aspirin in the U.S. So those folks who were able to stick to that dose for at least two years were the ones who gained benefit from being on aspirin. And what was interesting is that benefit endured for really 10 years after those two years of being able to take aspirin. So, this was striking and it really changed our thinking about whether there may be chemo prevention options for folks with Lynch syndrome. However, and I think what formed the background of our study here was that there was a somewhat equivocal endorsement of aspirin by the major guidelines committees, mainly because, as we all know in oncology, we love one first big study, but we always really love secondary studies that solidify the finding of the first study. And so, because this was such a niche group and no one else out there was doing big aspirin studies when this result came out in 2011, we've sort of been waiting for many years for some follow up data. And the NCCN guidelines have always been a little bit equivocal that people could consider using aspirin to lower risk in their patients with Lynch syndrome, but without that kind of strong, “Everyone should do this.” And so, this has kind of formed the background of why we performed the study that we did. Dr. Rafeh Naqash: Interesting. And then you had a bunch of observations. One of the most important ones being that use of aspirin was pretty low. Could you dive into that and help us understand what were some of the factors surrounding those low implementation aspects? Dr. Michael J. Hall: Of course. So, what we were interested in then again in that background was, here's a high-risk population, docs are getting somewhat maybe ambiguous information from the guidelines, but what actually is going on out there in practice? How many patients are actually using aspirin? What doses are they using, and what are some of the factors that drive it? So, we performed a survey that actually occurred in two parts. One started at Fox Chase in our population here, and then we expanded it online to a convenience sample. Overall, we had 296 respondents. And yeah, what we found actually was the uptake of aspirin was only about roughly 30%, 35% or so among patients who were eligible to take aspirin. When you actually drill down to those people actually taking aspirin because they wanted to prevent Lynch syndrome, it was even lower. It was in the range of 25% to 30%. This somewhat surprised us. And then when we looked at the doses that people were using, of course, thinking back to that 600-milligram dose that was tested in the study, we found actually that more than half of folks were taking low dose aspirin, like an 81 milligram, and only about 8% of our study participants were using that 600-milligram range. So, again, I would say this somewhat surprised us because we thought it might be higher than this. I'll say as a somewhat caveat to this though, is that back to my comment about we always like another study that confirms our findings, and at a meeting earlier this year, there was a study performed in a New Zealand population by a medical oncologist named Rebecca Tuckey. And she actually found almost the same identical results that we did in the New Zealand population - very, very similar uptake rates of aspirin in the New Zealand population with Lynch syndrome, so kind of confirming that something we've stumbled upon appears to be true. But how do we understand why some folks use aspirin and why others don't in this condition? Dr. Rafeh Naqash: You had a very robust question there from what I saw in the paper. And some of the questions that I had around that was, did you or were you able to account for demographics, education level of the individuals? Were you also able to assess whether these individuals felt that they had been counseled appropriately when they met with either a primary care physician or of any provider on the genetic side, physician or non-physician? So how did you get an assessment of whether it was an apples-to-apples comparison or were there a lot of confounders. Dr. Michael J. Hall: Very good question. And of course, in the setting, unfortunately, we weren't interviewing people, which we could have gotten much richer data in some ways. And there were other things we were looking at in this survey as well, so our aspirin questions, we had a number of them, but perhaps in retrospect, it would have been nice to even have more. We did have some common covariates, age, sex, ancestry, marital status, which gene was affected, whether they had a history of cancer. We did not have education, unfortunately. And I think your question is a great one, but we did not actually ask folks about whether they had been counseled by their provider or their genetic counselor or someone else about whether they should use aspirin or not. We simply wanted to see whether folks were using it. We did ask them again whether they were using it because they wanted to lower their risk of a Lynch syndrome cancer or whether they were using it for another reason or a combination of both. So, yes, in retrospect, we actually do have another study plan to kind of drill deeper into these questions of is it more of a hesitancy question? Is it more of a question of just not as much awareness? Are there other reasons? I think there's a lot to answer, and I think answering these questions is really important because we both want to make sure we're talking about interventions that we think can help people, but we need to understand also some of the barriers they may face. And if people do have barriers to some forms of chemo prevention or I think about some of the vaccine research that's going on right now, if the kinds of things that we're working on to develop are actually not going to be palatable to the patient, the population, then I think we kind of need to step back and say we need to maybe understand what people want so that we can have a good meeting of what's going to work and what's going to fit the needs and lifestyles of our patients. Because these are things they might have to do for many, many years and starting maybe even in their 20s or 30s. So, it makes a difference. Dr. Rafeh Naqash: From what you learned in the study, are you thinking of any subsequent interventional approaches, whether they involve a simple phone call to the patient regularly or perhaps, even though I'm not a big fan of EMR prompts, like an EMR prompt of some sort, where they talk, where they're instructing the provider, whoever is seeing the patient physician or the APP or the geneticist that, “Hey. Did you counsel the patient?” And its sort of a metric how in the oncology side they say, “Well, your metric is you should stage all patients and you should talk about toxicities from a reimbursement standpoint and also from a quality improvement metric standpoint. “Is that something you're thinking of? Dr. Michael J. Hall: 100%. So, when we looked at the barriers, many of the kind of the things that were the strongest predictors of who used aspirin versus who didn't were really patients' perceptions of whether aspirin would cause side effects or whether aspirin would be burdensome to take on a daily basis, also, just how much benefit they thought would come from taking aspirin. So, I think there's, number one, I think an intervention and our next delve into this as an interventional study would be both education about the delta prevention benefit that you get from aspirin, the safety profile of aspirin, which is really quite excellent. And also, I think the data that are so important that in this study by Burn et al, it was actually only two years of intervention that then paid off for 10 years down the line, right? So, I think that's important. The other thing that we actually learned as an aside in this study was actually the kind of intervention that patients wanted the most was actually not a drug and was not a vaccine and was not another kind of special scope to stick somewhere. What they actually were most interested in were interventions related to diet. People really see diet as being an important part of health, or I should say diet and nutrition. And so, I think a subsequent study would perhaps wed both a nutritional intervention of some kind with a chemo prevention in some sort of time limited fashion, so that folks felt like they were both focusing on something that was more important to them, but also, something that was related to the study that we wanted to look at. So that's kind of my idea of where we're going to go in the future with this. Dr. Rafeh Naqash: Excellent. Sounds like the next big RO1 for your group. Dr. Michael J. Hall: Let's hope so. Dr. Rafeh Naqash: Well, I hope the listeners enjoyed talking about the science and learning about aspirin Lynch syndrome. The last couple of minutes are about you as an individual, as an investigator. Can you tell us what your career journey has been like, how you ended up doing what you're doing, and perhaps some advice for early career junior investigators on what this whole space looks like and how you pace yourself and how they can learn from you? Dr. Michael J. Hall: I really got interested in oncology during my residency training. I really found that I really liked oncologists. I found them to be a bit more of a science focused group. They liked research, but you're in oncology because you understand the fears and the challenges of cancer. And so, it's both a combination of that love of science, but also that real human touch of taking care of people. The thing I always tell my fellows as well is the other thing I love about oncology is if you tell people they don't have cancer, they don't want to come back to you. Now, of course, that's modified in the prevention setting. But I really like that when people come to me in my GI oncology clinic, it's because they have a diagnosis and if I say you actually don't have cancer, they go off to their life, and so you're really spending your time on real subjects. The person who really got me most interested in Lynch syndrome and this kind of prevention research was a mentor from University of Chicago, Funmi Olopade, who really has been an enormous mentor for many, many people in the field. Actually, three people in my fellowship class all went on to careers related to genetics and genomics. So, she's been highly influential and continues to mentor me even in my mid-career. I think in terms of pearls or what keeps this interesting for me, I think as much as oncology treatment and new drugs and trials is super exciting, I love being able to step away from that into my genetics and prevention population and kind of focus on treating people in a different format. Patients who are healthy but are worried about cancer because of a family history or carrying a gene or otherwise, and I feel that that's where I can have also an important impact, but on a different level in educating people and helping them understand how genetics works in an understandable and simple way, but also giving them some tools. And one reason for this study, and the reason I study preferences related to prevention is, again, I don't want to just develop something and spend 10, 15 years of my life developing some intervention that everyone looks at and is like, “I don't really want to do that.” I want to really understand what it is that is important to the patients so that we can hopefully work together to develop things that can not only have impact but have impact on a wide scale. Dr. Rafeh Naqash: Awesome. You mentioned Dr. Olopade. I crossed paths with her actually at an international medical graduate community of practice session earlier this year at ASCO where she talked about her journey as an immigrant, talked about how she started, the kind of impact that she's had. It was obvious evident in the picture that she showed with all her mentees who have kind of gone all over the world. So that was very phenomenal. And it's surprising how small of a world we live in. Everybody knows everybody else. Dr. Michael J. Hall: It's crazy. More so than anyone I think I've met in my career; she is really a huge believer in mentorship and spending that extra time with your mentees. And she has been someone who has continued to promote me as an investigator and build me up and get me involved in things. And like I said, I've been in oncology now for quite a few years. But having that person who I think is always thinking about their trainees and people who have learned and grown under them, because what it does is it gives you that fire as well as an investigator to do the same thing for the people that you are a mentor for and train. So, I try to be just as good of a mentor to my genetic counselors and the fellows who come through me and my APPs to give them opportunities to get them excited about research and when they have these big moments to do that. So, yeah, I know Funmi just has had a huge impact on the field of genetics. I still remember some of our early conversations on the wards when she said to me, “Oh, this is such an interesting case. We don't really have anyone who's studying Lynch syndrome so much right now and you should really get into this area.” And I remember thinking, “Okay, I want to develop a niche and here's a niche that's waiting.” Dr. Rafeh Naqash: Clearly it paid off big time and you're paying it forward with your mentees. So, thank you again for joining us. This was an absolute pleasure. Hopefully, the listeners learned a lot about the science and also your journey and how you're trying to impact the field. 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 opinion, 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.      

How long were we off since the last episode? When did we first start recording Fetch a Pail? Is it Bad Rap or Bad Rep, or either? MDITF? Is gazpacho the only other cold soup? Is coffee soup? Is hottub soup? All these questions and more were written down hastily as Jill edited the episode but none of them are answered in this week's FAP. Tune in to find out why she asked them, but not what the answers are! It's like Jeopardy except instead of the questions being answers and the answers being questions, everything is just questions. Is questions soup? Email questions to fetchapailpodcast@gmail.com  Follow us on Instagram: https://instagram.com/fetchapail

FAP-301 Aesthetica of a Rogue Hero - That PLOT is really something with #TokyoTreat In this episode, we dive into the chaotic world of "Aesthetica of a Rogue Hero." With its wild plot and unconventional power scaling, this anime takes the isekai genre in a fresh direction. Did it hit the mark or miss it completely? Tune in to find out! Next Up: "Love Tyrant" Got thoughts on this or past selections? Share them with us! We'd love to hear your opinions or get suggestions for future picks. Submit your feedback here! Deals for Our Listeners: CrunchyRoll: Get 15% off your first order! TokyoTreat: Use code "FEATUREDANIME" for $5 off your first box! Our Merch Store: Show your support with exclusive merch! Watch Anytime, Anywhere! Stream your favorite anime with Crunchyroll. Start Your Free Trial Support Us on Patreon Enjoy bonus content and ad-free episodes by joining our Patreon community. Become a Patron Connect with Us: Anime List: Check Out Our Rankings Twitch: Join our live discussions every Monday at 10pm EST Discord: Be part of our community! Twitter: @ThoseAnimeGuys Facebook: Featured Anime Podcast Contact Us: Email: info@featuredanimepodcast.com Website: www.featuredanimepodcast.com About "Aesthetica of a Rogue Hero" Producers: Genco, Lantis, Media Factory, AT-X, Showgate Studio: Arms Aired: July 2012 - September 2012 Genres: Action, Fantasy, Ecchi, Harem, Isekai Source: Light Novel Episodes: 12 Our Ratings: Jack: 5/10 Rick: 6/10 Don't forget to follow us for more anime reviews and discussions. See you next episode! --- Support this podcast: https://podcasters.spotify.com/pod/show/featuredanimepodcast/support

This week, we stick the butter fork up the anal ca-nay-nal, FAP our way through "You All Everybody," and Lacy is a Debby Downer Bomb Dropper - get ready! Email us here (it may make it onto a video pod!) --- https://www.spacebearmedia.com/contact All our other links! --- https://linktr.ee/spacebearmedia *PLEASE RATE & REVIEW!*

This week we wrapped up Trigun Stampede and just like we thought, we enjoyed the last 6 episodes more, me much more and Artsy a little more! The breakdown Knives and Vash's history was done well, and finally seeing Vash stand up for himself was very enjoyable to see. There was loss, some triumph, and some big cliffhangers/callbacks to characters from Trigun 98. Next week we have a recommendation from Jack from FAP! Join us for No Game No Life!Want to join us live? Head over to twitch.tv/crazyjam where we live record each episode Wednesday night at 8:30 pm EST! If you want to recommend an anime to us, please use the following linktree to see our “recommend us an anime!” page and also every other way to interact with us! https://linktr.ee/xAnimeAnonymousxRatings:Artsy:9/10Cj:7/10 Hosted on Acast. See acast.com/privacy for more information.

This week's episode will be focusing on the second part of genetic syndromes with risk of malignancy. Last week we covered Li Fraumeni, Lynch, FAP, BRCA ½ and Cowdens. This week we are going to cover the syndromes associated with RCC as well as MEN 1 and 2 and a few others. 

This week's episode will be focusing on genetic syndromes with increased risk of malignancies. In Part 1 we discuss Li-Fraumeni, Lynch Syndrome, FAP, BRCA 1 and 2, and Cowden's syndrome.

On this week's episode we discuss the highly contentious and taboo topic of masturbation(?!) to explore if there are any physical, mental or spiritual benefits to either extreme abstinence or uninhibited indulgence. We talk about the popular no-fap movement, government psyops and folk superstitions before digging into the hard science behind some of the claims commonly made of either extreme. What happens in the brain during orgasm anyway? Ted Bundy and Marquis De Sade then make an appearance to discuss their thoughts about pornography. In the extended version of the show we discuss semen retention as a traditional occult practice, the physiology of orgasm (male and female) and what any of this could possibly do with the Qabalistic Tree of Life. Aleister Crowley then shows up to the party to explain to us how to achieve Eroto-Comatose Lucidity and what the Ancient Egyptians thought about the topic of sex and sanctity. As a warning, we talk quite a bit about sex in this episode so it's not safe for work or kids. This episode might also be offensive to people who feel strongly polarized on the issue because we're exploring the nuance behind a lot of big claims from all sides. We also decided it was probably best to proclaim that we are not kink shaming anyone and are advocates of sexual freedom and as long as all parties involved are capable of and do consent. Thank you everybody and enjoy the show! On this week's episode we discuss: The Power of The Orgasm The No Fap MovementBenefits of Semen Retention?Mainstream Media Chamber of Echoes Folk Superstition Psychological WarfareYour Brain On OrgasmsWhat The Science SaysIs Pornography… bad? In the extended show available at www.patreon.com/TheWholeRabbit we take the discussion way further and discuss:Semen Retention as an Occult PracticeYogaThe Physiology of Many Orgasms Occult Significance of Bodily FluidsEroto-Comatose LucidityThe Qabalah of OrgasmAncient Egyptian Beliefs Each host is responsible for writing and creating the content they present. In the notes: red sections are written by Luke Madrid, green sections by Malachor 5, purple written by Heka Astra and blue by Mari Sama…Where to find The Whole Rabbit:Spotify: https://open.spotify.com/show/0AnJZhmPzaby04afmEWOAVInstagram: https://www.instagram.com/the_whole_rabbitTwitter: https://twitter.com/1WholeRabbitMusic By Spirit Travel Plaza: https://open.spotify.com/artist/30dW3WB1sYofnow7y3V0YoSources:2001 Abstinence Studyhttps://pubmed.ncbi.nlm.nih.gov/11760788/1998 Male Neuroendocrine Studyhttps://pubmed.ncbi.nlm.nih.gov/9695139/More sources available on Patreon. Support the Show.

SEASON 5 is (almost) HERE!! This is your one week warning... as the KREWE is BACK on Friday, March 8th, 12 noon CST.  Here's a sneak peek & preview of gusts & episodes to come:- The History & Evolution of Godzilla ft. Dr. William Tsutsui- Witness Fukushima's Recovery through Educational Tourism ft. William McMichael- Japanese Self-Study Strategies ft. Walden Perry- Visit Miyagi Prefecture ft. Ryotaro Sakurai & William Woods- Japanese Homes, Architecture & Aesthetic ft. Azby Brown- A Glimpse into the World of Geisha ft. Peter Macintosh- Japanese Music Scene ft. Patrick St. Michel- Pioneering Louisiana's Only High School Japanese Program ft. Dr. Tara Sanchez- Scoping Out Shojo Anime & Manga ft. Taryn of Manga Lela- as well as some other returning guests like Matt Alt, Rob Dyer, & Kate KitagawaGet Hyped! Subscribe today on your favorite podcast app! See you on March 8th!------ About the Krewe ------The Krewe of Japan Podcast is a weekly episodic podcast sponsored by the Japan Society of New Orleans. Check them out every Friday afternoon around noon CST on Apple, Google, Spotify, Amazon, Stitcher, or wherever you get your podcasts.  Want to share your experiences with the Krewe? Or perhaps you have ideas for episodes, feedback, comments, or questions? Let the Krewe know by e-mail at kreweofjapanpodcast@gmail.com or on social media (Twitter: @kreweofjapan, Instagram: @kreweofjapanpodcast, Facebook: Krewe of Japan Podcast Page, TikTok: @kreweofjapanpodcast, LinkedIn: Krewe of Japan LinkedIn Page, Blue Sky Social: @kreweofjapan.bsky.social, & the Krewe of Japan Youtube Channel). Until next time, enjoy!------ Support the Krewe! Offer Links for Affiliates ------Use the referral links below & our promo code from the episode (timestamps [hh:mm:ss] where you can find the code)!Liquid IV Offer Link  to save 20% Off your Entire Order! (00:12:38)Zencastr Offer Link - Use my special link to save 30% off your 1st month of any Zencastr paid plan!  (00:13:54)------ JSNO Upcoming Events ------JSNO Event Calendar2024 Matsue Exchange Program ApplicationJoin JSNO Today!

In the this episode,  hosts Drs. Temara Hajjat and Peter Lu talk to Dr. Neha Santucci, an Associate Professor of Pediatrics and the Director of the Disorders of Gut-Brain Interaction Program at Cincinnati Children's. They discuss how to identify and manage functional abdominal pain in children with pre-existing organic GI disorders.  Learning Objectives:Learning how to diagnose functional abdominal pain  in patients with existing GI conditions Learning how to manage functional abdominal pain in patients with existing GI conditionsLearning when to utilize IB-Stim in patients with FAP.  Editor: Temara HajjatSupport the showThis episode is eligible for CME credit! Once you have listened to the episode, click this link to claim your credit. Credit is available to NASPGHAN members (if you are not a member, you should probably sign up). And thank you to the NASPGHAN Professional Education Committee for their review!As always, the discussion, views, and recommendations in this podcast are the sole responsibility of the hosts and guests and are subject to change over time with advances in the field.Check out our merch website!Follow us on Twitter, Facebook and Instagram for all the latest news and upcoming episodes.Click here to support the show.

Life often takes us on unexpected journeys, some that test our mettle and foundational beliefs. But it's within these challenges that we unearth the depth of our resilience and the capacity to impact others profoundly.  Mary welcomes Mike Caprio, a young man whose early encounter with a rare health condition led him to genuine introspection and personal growth. Initially met with isolation and despair, Mike's diagnosis of familial adenomatous polyposis spurred a transformation that not only impacted his physical well-being but also redefined his purpose in life. His narrative is one of courage and transformation, offering listeners a deep dive into the realities of grappling with a life-altering diagnosis. The conversation navigates through Mike's medical journey, starting with the absence of symptoms and the shocking discovery of his genetic condition, and advancing to the critical surgeries that saved his life. Mike and Mary explore the emotional toll of facing mortality at a young age, shedding light on the power of family support and the internal battles that accompany health crises. About Mike: Mike Caprio is a remarkable individual who has demonstrated immense resilience and strength in the face of a rare genetic condition known as familial adenomatous polyposis (FAP). Despite being diagnosed with FAP at just 18 and undergoing a series of complex surgeries right after high school, Mike turned his struggle into a powerful message of hope and determination. He candidly shares his journey of recovery and the lessons learned along the way, emerging as an inspirational figure and author of the book "A Bump in the Road," where he documents his experiences and the positive outlook that guided him through adversity.   Get His Book: https://www.amazon.com/Bump-Road-Medical-Potholes-Gratitude/dp/1636763626     Get Mary's New Book Today! https://marycraftsinc.com/ iTunes: https://podcasts.apple.com/us/podcast/crafting-a-meaningful-life-with-mary-crafts/id1336191892 Follow Mary on Instagram: https://www.instagram.com/marycrafts Follow Mary On Facebook: https://www.facebook.com/mary.crafts4   #crafting a meaningful life, #gratitude practices          

Episode 7 - Thriving without a colon, Kristly Bartlett, diagnosed with FAP at an early age, faces a rare inherited condition due to a defect in the denomatous polyposis coli (APC gene). Disclaimer: Please note that all information and content on the UK Health Radio Network, all its radio broadcasts and podcasts are provided by the authors, producers, presenters and companies themselves and is only intended as additional information to your general knowledge. As a service to our listeners/readers our programs/content are for general information and entertainment only.  The UK Health Radio Network does not recommend, endorse, or object to the views, products or topics expressed or discussed by show hosts or their guests, authors and interviewees.  We suggest you always consult with your own professional – personal, medical, financial or legal advisor. So please do not delay or disregard any professional – personal, medical, financial or legal advice received due to something you have heard or read on the UK Health Radio Network.

To quote Kevin Costner from the Postman - "is stuff getting better" for you in your recovery? In today's episode Vern explores a number of ways that we can determine if we are growing and moving forward in our recovery - or stalled out and stuck.To connect with Vern you can email him at bandofbrothers.care@gmail.com or check out the website for further resources https://www.bandofbrothers.care

One of our favorite parts of bringing The Health Detective Podcast to our listeners and viewers is that we get to highlight guests who deal with conditions that many of us would otherwise never hear about. Today's guest on the show, Michael Caprio, deals with a genetic condition that you very likely haven't heard of. At just eighteen years old, author Michael Caprio was diagnosed with Familial Adenomatous Polyposis, a rare genetic form of colorectal cancer that accounts for only 0.5 percent of all colorectal cancer cases in the United States. After enduring two life-saving operations, Michael has since made a full recovery and has become an author, advocate, leader, change-maker, and podcast guest in the spaces of mental health and colorectal cancer. Although this story is bit different than the ones we would typically bring on the show, we think it is important to not only give a spotlight for those dealing with conditions such as FAP in silence, but for the listeners and viewers to find inspiration in the incredible resiliency and determination that people like Michael display. We hope you enjoy this episode, and if you have an questions, you can always reach out to us directly @fdntraining on Instagram.    Where to find Michael: Facebook: A Bump in the Road  Instagram: @mikecaprio_author  Website: https://www.mikecaprioauthor.com/   Where to find FDN! Youtube: https://www.youtube.com/@FDNtraining/featured Instagram: www.instagram.com/fdntraining Facebook: https://www.facebook.com/FunctionalDiagnosticNutrition LinkedIn: https://www.linkedin.com/company/san-diego-natural-health-&-fitness-ctr  

Gap Inc. recently released its earnings report where CEO Richard Dickson revealed promising signs of revitalization as seen in the third quarter performance. This is particularly the case for the brand Old Navy, which according to Dickson, has witnessed a positive shift thanks to the launch of a women's marketing campaign and enhancement in site execution. Per the earnings call, the company states that these changes demonstrate their ability to adapt to evolving trends in consumer preferences and a competitive retail environment. In its effort to stay attuned to customer demands, Gap has focused heavily on creating more relevant marketing campaigns and maintaining insightful brand touchpoints. Fortifying the importance of offering trendy products, the company also reinforced its drive to curate an engaging omnichannel customer experience, which directly aligns with their objective of revitalizing each brand and boosting overall revenue. While the company grappled with a drop in net and digital sales, they recognized Old Navy's resilience in gaining market share and showing continued growth. Other brands under Gap Inc., specifically Banana Republic and Gap, are in the midst of strategic brand repositioning, a clear sign of the company's determination to triumph over existing obstacles. As for financial performance, Gap purportedly has taken strides to instill operational and financial discipline, which lead to an improved working capital situation, stronger balance sheets, and expanding margins. Conversely, with the drop in revenue and comparable sales, the company has been encouraged to reevaluate and refine its marketing, merchandising, and pricing strategies aiming to generate improved outcomes. Gap Inc. disclosed its plans for launching further campaigns, like women's marketing, improving site execution, invigorating in-store presentations, and reinforcing partnerships. Company highlighted the impact of these plans on key brands such as Old Navy, which include compelling gifting options and a redirected focus on core categories. To sustain its growth, Gap Inc. is reportedly resolute in maintaining financial stringency, rejuvenating its brand portfolio, bolstering operational platforms, and revitalizing corporate culture. As the company leaders declared on the earnings call, this comprises maintaining streamlined operations, optimizing investment in technology, and enhancing marketing and media strategies. Gap is also dedicated to offering trendy product lineups, fostering interactive omnichannel experiences and leveraging creative marketing to drive revenue growth and achieve long-term success. GPS Company info: https://finance.yahoo.com/quote/GPS/profile For more PSFK research : www.psfk.com  This email has been published and shared for the purpose of business research and is not intended as investment advice.

Continuing our conversation with warrior, Jenny Jones from S1E27. Jenny lives with two rare, chronic conditions called Familial Adenomatous Polyposis (FAP) and Short Bowel Syndrome and more recently was diagnosed with Post-Concussion Syndrome, Fibromyalgia, and Esophageal Dysmotility. Due to FAP, she underwent a total colectomy at age nine. Complications resulted in six additional surgeries and an eighth surgery to remove her gall bladder. Her genetics and additional factors led Jenny to decide not to have biological children. As fate would have it, she ended up becoming a very involved auntie to her twin nieces and stepmom to her bonus son. Listen to Part Two as Jenny discusses when and how she shares a health crisis with her bonus kid, how she addresses the challenges from her health limitations and being a stepmom and auntie, and more. To learn more about Jenny Jones, her blog, YouTube vlog, children's book, Life's a Polyp with Zeke and Katie or to support The National Organization for Rare Disorders Familial Adenomatous Polyposis Research Fund, go to her website at https://www.lifesapolyp.com. 

Let's catch up with warrior, Jenny Jones from S1E27. Jenny lives with two rare, chronic conditions called Familial Adenomatous Polyposis (FAP) and Short Bowel Syndrome and more recently was diagnosed with Post-Concussion Syndrome, Fibromyalgia, and Esophageal Dysmotility. Due to FAP, she underwent a total colectomy at age nine. Complications resulted in six additional surgeries and an eighth surgery to remove her gall bladder. Her genetics and additional factors led Jenny to decide not to have biological children. As fate would have it, she ended up becoming a very involved auntie to her twin nieces and stepmom to her bonus son. Tune in to Part One as Jenny fills us in on her health journey, shares her decision on kids and how she manages her many conditions as a stepmom and auntie. To learn more about Jenny Jones, her blog, YouTube vlog, children's book, Life's a Polyp with Zeke and Katie or to support The National Organization for Rare Disorders Familial Adenomatous Polyposis Research Fund, go to her website at https://www.lifesapolyp.com.

No solo en España: el fútbol femenino peruano también tiene una denuncia de acoso que incluso ha llegado a la fiscalía. Juana Acevedo comenta el duro panorama para las jugadoras. MIENTRAS TANTO: Guillermo Bermejo se llevaba el 1,5% de obras de la reconstrucción, según un colaborador eficaz. ADEMÁS: El escándalo de los "packs" con IA en un colegio de Lima. Y... La verdad está allí afuera: accedimos a los reportes oficiales de la FAP sobre avistamientos OVNI en el Perú. **** ¿Te gustó este episodio? ¿Buscas las fuentes de los datos mencionados hoy? Entra a http://patreon.com/ocram para acceder a nuestros grupos exclusivos de Telegram y WhatsApp. También puedes UNIRTE a esta comunidad de YouTube aquí https://www.youtube.com/channel/UCP0AJJeNkFBYzegTTVbKhPg/join **** ¿Quieres que tu emprendimiento sea mencionado en La Encerrona? Regístrate aquí para postular: https://encerroners.club

Let's talk all about p***y pumps VR porn, no fapping?! and a whole lot more with Layla from the Curious Girl Diaries podcast. How do you use a use a p**** pump? Is VR porn everything it's cracked up to be? How many fingers is best when fingering? And, do guys really FAP??? Tune in to find out plus hear Kathy and Layla talk all about their experience with a p**** pump and how Layla felt about the one Kathy bought for her, the pros and cons about VR porn and their experiences with it, how and why finger size is important to Kathy when fingering, how Layla learned to squirt while fingering herself and how she figured it out, an update on Layla's girl on girl action as well as find out whether or not she's pegged her sub, how and why she's currently obsessed with a guy who has “the biggest d*** in the world,” how and why the amount of jizz a guy produces is important to Layla, how much they think guys masturbate and why Layla believes no fapping is in style and why Kathy disagrees plus a whole lot more. Make sure to listen in and then chime in on our debate. You can find Layla's private podcast here: https://www.thecuriousgirldiaries **To see anonymous pics LAYLA plus see anonymous pics of my female guests + gain access to my PRIVATE Discord channel where people get super naughty + get early access to all episodes + hear anonymous confessions, + gain access to my Discord channel, join my Patreon. It's only $5 a month and you can cancel at any time. You can sign up here: https://www.patreon.com/StrictlyAnonymousPodcast Want to be on the show? Email me at strictlyanonymouspodcast@gmail.com or go to http://www.strictlyanonymouspodcast.com and click on "Be on the Show" Have something quick you want to confesss? Call the hotline at 347-420-3579. Want a private convo with me that won't be aired on the show? All calls are private, confidential and anonymous. Click here: https://calendly.com/strictlyanonymouspodcast/45min Sponsors: Get a generous sign-up bonus at MyBookie Casino https://mybookie.website/StrictlyAnonymous Want to have better S-E-X?! Who doesn't?! Use Promescent! https://promescent.com/strictlyanon Hear the hottest stories on Dipsea! 30 day FREE TRIAL https://www.dipseastories.com/strictlyanon Follow me! Instagram https://www.instagram.com/strictanonymous/ Twitter https://twitter.com/strictanonymous?lang=en Youtube https://www.youtube.com/c/StrictlyAnonymouspodcast Everything else https://linktr.ee/Strictlyanonymouspodcast Learn more about your ad choices. Visit megaphone.fm/adchoices

In episode 379 I chat with Nate Gruner. Nate is a staff Behavioral Therapist at McLean OCD institute.  I chat with Nate about functional analytic psychotherapy (FAP), the history of FAP, what is FAP, the 5 rules of FAP, why FAP may be helpful for people with OCD, content vs process, the principles of awareness, courage and love. Nate shares some client examples where he has used FAP with OCD, and much more. Hope it helps.  Show notes: https://theocdstories.com/episode/nate-379  The podcast is made possible by NOCD. NOCD offers effective, convenient therapy available in the US and outside the US. To find out more about NOCD, their therapy plans and if they currently take your insurance head over to https://go.treatmyocd.com/theocdstories Thanks to all our patrons for supporting our work. This podcast episode is available as a video recording on our Patreon. To sign up to our Patreon and to check out the other benefits you'll receive as a Patron, visit: https://www.patreon.com/theocdstoriespodcast

In this episode, Drs. Temara Hajjat and Jason Silverman talk to Dr. Miranda van Tilburg about the behavioral treatment of functional abdominal pain. We discuss issues of pain perception, pain coping and maladaptive responses to pain. We also discuss some research-informed behavioral interventions to help treat children with FAP.Dr. van Tilburg needs is a psychologist and researcher who has worked extensively on the behavioural explanations for and treatment of functional GI disorders, including work supported by the NIH and the Rome Foundation. She is currently a Professor in the Department of Medicine at Marshall Health in Huntington, WV and was recently named Chair of the Ethics Committee at NASPGHAN. This episode is eligible for CME credit!  Once you have listened to the episode, click this link to claim your credit.  Credit is available to NASPGHAN members (if you are not a member, you should probably sign up).  And thank you to the NASPGHAN Professional Education Committee for their review!Learning Objectives:Understand the relationship of pain perception and pain coping to symptoms experienced by children with functional abdominal pain. Understand the importance of an appropriate framework to explain functional abdominal pain to children and their parents in a way that validates their experiences.Name 3 possible behavioral treatment options that may be useful in children with FAP.Produced by: Jason SilvermanSupport the showAs always, the discussion, views, and recommendations in this podcast are the sole responsibility of the hosts and guests and are subject to change over time with advances in the field.Follow us on Twitter, Facebook and Instagram for all the latest news and upcoming episodes!