) is the third leading cause of cancer-related death despite only accounting for 3% of all new cancer diagnoses.

 Obesity is a well-known risk factor for multiple types of cancer, including PDAC. In fact, there exists a relative risk of PDAC of 1.10 for every 5-unit increment increase in body mass index (BMI).

 While bariatric surgery has been demonstrated to reduce overall cancer incidence and mortality, conflicting data exist regarding the effects of bariatric surgery on PDAC.

We performed a retrospective case-control study utilizing the National Inpatient Sample (NIS) database from October 2015 to December 2020. All adult subjects (age ≥18 years) with a BMI >40 kg/m2 or >35 kg/m2 with ≥1 metabolic comorbidity were identified and stratified into those with and without a history of bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy).

, Tenth Edition Clinical Modification (ICD-10-CM) codes were used to define variables of interest. Baseline characteristics and comorbidities among the 2 groups were compared using chi-squared and Wilcoxon rank-sum tests and logistic regression analysis was performed to assess the risk of PDAC after adjusting for multiple risk factors, including tobacco use, acute and chronic pancreatitis, diabetes mellitus and various stages of obesity.

Over 19 million subjects were included, 1,656,329 of whom had a history of bariatric surgery. Patients with a history of bariatric surgery were significantly younger, more frequently female (75% vs 58%), had higher rates of class 3 obesity (69% vs 52%) and lower prevalence of hypertension, hyperlipidemia, chronic kidney disease, Charlson Comorbidity Index (CCI) ≥3, tobacco use, acute and chronic pancreatitis and pancreatic cancer (0.1% vs 0.2%) while having a higher prevalence of OSA (

 <.001). Additionally, in-hospital mortality (0.5% vs 1.8%), total hospital charges and overall length of stay were lower in the bariatric surgery cohort compared to the nonsurgical cohort (

 <.001). After adjusting for multiple comorbidities and risk factors, history of bariatric surgery was demonstrated to significantly reduce the risk of PDAC on both univariable (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.44 - 0.56) and multivariable analysis (OR, 0.68; 95% CI, 0.61 - 0.77).

This is the largest analysis to date investigating the effects of bariatric surgery on pancreatic cancer risk reduction and serves to clarify previously inconclusive data. We have shown bariatric surgery to exhibit an independently protective effect against PDAC oncogenesis. It is reasonable to suggest that patients at increased risk of PDAC as well as other obesity-related malignancies may be recommended for surgically-assisted weight loss earlier and more frequently.

With advancements in minimally invasive bariatric procedures, expanding patient eligibility and indications for surgery, increasing utilization of bariatric surgery and endoscopic bariatric and metabolic therapies may help alleviate the growing burden of pancreatic cancer.

Surveillance, Epidemiology and End Result (SEER) Program. Surveillance Research Program, National Cancer Institute. 2023 Apr 25. https://seer.cancer.gov.

Aune D, Greenwood DC, Chan DS, et al. Body mass index, abdominal fatness and pancreatic cancer risk: a systematic review and non-linear dose-response meta-analysis of prospective studies. Ann Oncol. Apr 2012;23(4):843-52. doi:10.1093/annonc/mdr398

Schauer DP, Feigelson HS, Koebnick C, et al. Bariatric Surgery and the Risk of Cancer in a Large Multisite Cohort. Ann Surg. Jan 2019;269(1):95-101. doi:10.1097/SLA.0000000000002525

Adams TD, Stroup AM, Gress RE, et al. Cancer incidence and mortality after gastric bypass surgery. Obesity (Silver Spring). Apr 2009;17(4):796-802. doi:10.1038/oby.2008.610

Sjöström L, Gummesson A, Sjöström CD, et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncol. Jul 2009;10(7):653-62. doi:10.1016/S1470-2045(09)70159-7

Tee MC, Cao Y, Warnock GL, Hu FB, Chavarro JE. Effect of bariatric surgery on oncologic outcomes: a systematic review and meta-analysis. Surg Endosc. Dec 2013;27(12):4449-56. doi:10.1007/s00464-013-3127-9

Bulsei J, Chierici A, Alifano M, et al. Bariatric surgery reduces the risk of pancreatic cancer in individuals with obesity before the age of 50 years: A nationwide administrative data study in France. Eur J Surg Oncol. Apr 2023;49(4):788-793. doi:10.1016/j.ejso.2022.11.013

Fan H, Mao Q, Zhang W, Fang Q, Zou Q, Gong J. The Impact of Bariatric Surgery on Pancreatic Cancer Risk: a Systematic Review and Meta-Analysis. Obes Surg. Apr 05 2023;doi:10.1007/s11695-023-06570-x

Wilson RB, Lathigara D, Kaushal D. Systematic Review and Meta-Analysis of the Impact of Bariatric Surgery on Future Cancer Risk. Int J Mol Sci. Mar 24 2023;24(7)doi:10.3390/ijms24076192

A history of bariatric surgery was associated with up to 50% reduced risk of PDAC among a national cohort.

Bariatric Surgery is Associated with Reduced Risk of Pancreatic Cancer: Analysis of a US National Database

Bailey Flora, MS, RD, ND

Anti-VEGF for RVO: The Gold Standard

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John W Kitchens, MD, bookends the discussion by highlighting the landscape of branch vein occlusion (BRVO) treatment options. 

Anti-VEGF for RVO: The Gold Standard 

Dante J. Pieramici, MD

Jennifer B. Green, MD: Implementation of Evidence-Based Therapies for T2D

22nd Annual World Congress Insulin Resistance Diabetes & Cardiovascular Disease (WCIRDC)

, Jennifer B. Green, MD, an endocrinologist and a clinical trialist at Duke University Medical Center, provided updated insight into the implementation of evidence-based therapies for high-risk patients with 

Green highlighted the success of the COORDINATE-Diabetes trial, which aimed to improve the adoption of essential therapies—high-intensity statins, ACE/ARB inhibitors, and sodium-glucose co-transporter 2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists—in cardiology clinics for patients with T2D and established atherosclerotic cardiovascular disease (ASCVD). The trial showed significant improvements in treatment adherence, addressing a critical gap where only 3-4% of patients were initially receiving all recommended therapies. Green also emphasized the importance of continuing medical education, noting that conferences like these help clinicians stay updated on evolving management strategies, particularly for managing cardio-renal complications in diabetes.

Reflecting on advancements in 2024, Green pointed to the expanding benefits of therapies like GLP-1 receptor agonists and SGLT2 inhibitors, which, beyond managing glucose and weight, are now shown to provide substantial cardiovascular and kidney-related outcomes. She expressed satisfaction in knowing that her prescribing practices are delivering broader benefits than initially expected, reinforcing the importance of implementing the latest evidence to improve patient outcomes.

Disclosures: Relevant disclosures for Green include Bayer, Boehringer Ingelheim, Eli Lilly, Merck, and others.

Green JB. From Research to Guidelines to Implementing Good Clinical Practice in the Management of Diabetes. Presented at the 22nd Annual World Congress Insulin Resistance Diabetes & Cardiovascular Disease (WCIRDC). Los Angeles, California. December 12-14, 2024.

Dr. Jennifer B. Green discussed the implementation of evidence-based therapies for high-risk type 2 diabetes patients at the WCIRDC. She highlighted the COORDINATE-Diabetes trial's success in improving adherence to essential therapies in cardiology clinics, addressing a significant treatment gap. Green emphasized the role of continuing medical education in updating clinicians on management strategies, particularly for cardio-renal complications. She noted the expanding benefits of GLP-1 receptor agonists and SGLT2 inhibitors, which now show substantial cardiovascular and kidney-related outcomes, underscoring the importance of applying the latest evidence in practice.

Jennifer B. Green, MD highlights the successful implementation of evidence-based therapies for high-risk patients with type 2 diabetes.

Jennifer B. Green, MD

I think we've gone through a litany of different ideas about the drugs and how we use them. One of the concerns that many people have when anything new comes out is, is it reliable? I know, certainly, when drugs come out, is it effective, is it safe, and then can my patients get it? We ask the same questions with laboratory tests. Is it effective? Is it reliable? Can my patients get it for free or covered through insurance? With that, I think I'd like to get the last part. I'm going to hear from both of you. What advice do you have for your colleagues treating rheumatoid arthritis in the community setting? Joy?

I think we've come a long way. I think rheumatologists need to commend themselves. First of all, rheumatologists are still the subspecialty that still listens to patients. We still examine our patients. We use all of our clinical tools, we don't rely just on testing alone. However, we are probably the group of subspecialists that question and ask those questions on how this test is going to benefit our patients. And so I think that we do look at science, and the fact that we are getting these studies that are showing us consistently that looking at the signaling and whether a patient is going to have a response or not have a response to certain medications, and as we get into more precision medicine, and we see that these tools are going to help us to get our patients into low disease activity quicker and get to that treat to target quicker, I think we're going to rely on them more. Like Bob has said, it's going to take us a few years. There's going to be our early adopters that are going to look at this and look at that science and study it and say, ‘This is a tool in my toolbox, I’m going to use it with my clinical exam. I’m going to use it with all my laboratory testing, and I’m going to move into that direction quicker, and I’m going to see the response probably in my patients a little bit quicker.’ Then there are going to be the early adopters. There are going to be our colleagues that are going to take a little bit more time. But I think over the next few years you're going to see a big change in how we approach our patients. We're going to be commended for how quickly we take care of the patient journey and get these patients in low disease activity, and maybe at some point, rheumatoid arthritis will not have the stigma that it has had over the last several years, at least in my career, that this is a "crippling" disease process. Thank you.

Joy said it very nicely, and I would like to add that this technology has great potential. We're only scratching the surface based on the data on looking at the signal of nonresponse to TNFs [tumor necrosis factor], and hopefully getting more patients involved and more data collected will strengthen the argument that this is a reliable piece of information that will really help us guide therapy. Second, I look forward to the day that the adoption by CMS [Centers for Medicare & Medicaid Services] and adoption by the commercial insurance carriers will help us guide therapy and allow us to have this be an affordable option for us to use and not have the worry of large out-of-pocket expenses and concerns about that. Then, I just think that this really has the opportunity to help guide our patients to get to those treat to target goals, low disease activity, remission. That would ultimately lead to getting our patients to our goals as providers, as doctors, and also to the patient goals of improving those quality-of-life and patient-reported outcome things that we measure.

I think both of you hit the nail right on the head. We need more tools. We need more information. We need more accessibility to these tools because although we've had a tremendous explosion of therapeutic options, we haven't had any real guidance. To have a test that may guide our hand in therapy, even for just the first decision or even beyond that, because as we both and all know here, the therapy selection right now comes down to what are we most comfortable with? What came first? Maybe comorbid conditions, but mainly insurance mandates. Use this, then that, then this because that's our formulary. That's our sequence. I think many of us are feeling choked by this because as scientists, as rheumatologists, we are data-driven. We know better, and we know that as this science evolves in the 21st century, precision medicine is the way we can learn from our oncology colleagues. With that, I'd like to give a thanks to all of you for this rich and informative discussion. Before we conclude, I'd like to get final thoughts from each of you. Joy?

I wholeheartedly agree with everything that has been said here today. We're in a very rich environment that we have a lot of potential, a lot of hope, down the line by having a good collaboration with the science, with the testing, to give our patients that precision medicine that we want to achieve and to get these patients into the remittive state that they should be able to get into. By using good science and showing insurance companies that we are scientists, that we use evidence-based medicine to make some of our decisions. I hope through the work of the CRSO [Clinical Research Support Office], Bob, and my other colleagues, and I know myself I've tried to work in that area as well, that we'll be able to convince our insurance payers that this is the way to go for our patients and to get them into low disease activity in remission as quickly as possible.

I'm going to throw one out there. I'll put on my advocacy hat for a minute and just say that we've been really trying to improve formulary construction based on efficacy and safety. That flies in the face of the payers and the PBMs [pharmacy benefit managers] who basically construct formularies based on what's most profitable to them and not at all what's related to safety or effectiveness. I see this being a real tool that we can use from the advocacy standpoint in fighting the PBMs, in other words, being a PBM buster. That it could blow up their whole paradigm. I'm doubly excited, not only based on the science and how patient outcomes can be affected by utilizing this, but also utilizing it as maybe a cajole against the payers and against the PBMs who are unfortunately in control of what we prescribe and getting in the way of the doctor-patient relationship.

Well, Bob and Joy, thanks to you and our audience for this rich and informative discussion. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming peer exchanges and other great content right in your inbox.

Nehad Soloman, MD; Joy Schechtman, DO; and Robert Levin, MD, share final thoughts and takeaways on the treatment of rheumatoid arthritis in the community setting.

Clinical Pearls for RA Management

Joy Schechtman, DO

Andrea Nguyen, PA, shares her clinical pearls on taking care of patients with AD.

Clinical Pearls on AD Management

This is a video synopsis/summary of a panel discussion involving Melodie Young, NP, and Andrea Nguyen, PA.

In this segment, the discussion centers on providing advice and encouragement for healthcare professionals, particularly those entering the field or adjusting their approach to adhere to newer guidelines for managing atopic dermatitis (AD). The speakers acknowledge the increasing prevalence of AD, emphasizing the substantial number of patients with significant body involvement who may require more than just topical therapies.

The advice includes a systematic approach to learning about the various therapeutic categories, such as monoclonal antibodies, biologics, oral Jack inhibitors, and topicals. The recommendation is to start with a focused exploration of one category to build confidence before expanding knowledge across all therapy options. Anticipating continuous development in the next 5 to 10 years, there is emphasis on creating an efficient workflow and clinic template to streamline the prescription process for these complex therapies.

The conversation concludes with the suggestion of possible future discussions on using telemedicine for AD management, highlighting its effectiveness in treating chronic diseases like AD.

Video synopsis is AI-generated and reviewed by HCPLive editorial staff.

Clinical Pearls on AD Management 

Melodie Young, NP

The panel discusses the mechanism of treatment-emergent hypophosphatemia that occurs following the administration of certain intravenous iron formulations.

Treatment-Emergent Hypophosphatemia Following Administration of Intravenous Iron

Video content above is prompted by the following:

Treatment-emergent hypophosphatemia is now widely recognized as a phenomenon that can occur following administration of certain IV iron formulations and within the first 2 weeks after administration. Can you discuss the mechanism of treatment-emergent hypophosphatemia?

Michael Auerbach, MD

Vice Chief of Education, Fellowship Program Director

Division of Gastroenterology and Hepatology at UNC Health Care

Experts discuss the recent use of biosimilars like inolimomab as treatment for ulcerative colitis (UC).

Biosimilar Treatment Options for Patients With UC

Millie Long, MD, MPH

The panel concludes the discussion with key takeaways on the evolving treatment landscape for COPD.

Key Takeaways on the Evolving COPD Treatment Landscape

Video content above is prompted by the following question:

What are your key takeaways on the evolving COPD treatment landscape?

Nicola Hanania, MD, MS

Dr Linda Stein Gold, Dr Mona Shahriari and Dr Seemal Desai share advice for improving psoriasis care for patients with skin of color.

Advice for Dermatologists in Treating Psoriasis in Patients With Skin of Color

This is a video synopsis/summary of a panel discussion involving Linda Stein Gold, MD; Mona Shahriari, MD, FAAD; and Seemal Desai, MD.

The discussion focuses on the implications of research findings for patients with skin of color in psoriasis treatment. The speakers emphasize the importance of utilizing data-driven approaches to guide treatment decisions and advocate for increased diversity in clinical trial participation to ensure representative study populations.

They discuss the significance of cultural sensitivity in patient interactions and highlight the need for continued investment in research and development to generate data that can inform clinical practice effectively. The transcript concludes with a call to action for dermatologists to play a critical role in improving outcomes for all patients with psoriasis, underscoring the value of sharing knowledge and fostering collaboration within the medical community.

Overall, the conversation emphasizes the importance of evidence-based approaches, cultural competence, and ongoing research efforts in addressing the needs of diverse patient populations with psoriasis.

Seemal R. Desai, MD

It’s important for us to understand that we treat the whole patient, and we treat the whole patient in the circumstances that surround us. And the circumstance that surrounds us now is COVID-19. Sometimes, it brings families closer together because they’re sheltering in place, and that helps with their support group. But sometimes, it’s the opposite. Sometimes, an older parent can’t be around their kids because their kids are sick, or their kids have little kids who are sick. And they don’t have the support. It’s good to keep all those factors in mind when we’re prescribing things. Sometimes an infusion is better, and sometimes a self-injection, for instance, like a repository corticotropin injection, might be easier than coming in to get an infusion. And in some ways, it may be more effective. We have to take into account all the factors with our patients, their support systems, their ability to come in and get treatment, their ability to get the monitoring that they need. All those are important things. Any comments you want to make on that?

 I totally agree. I tell my patients if you want black and white, then this is not the specialty for you. We are many shades of gray, and our decisions are individualized and based on our best opinion.

: I like to say, that absence of evidence is not evidence of absence. Just because you’re paranoid, doesn’t mean that people are out to get you. My professor used to say, “I don’t know what he’s got, but he’s got something.” And sometimes what we have to do is use the information available and go with it. I had a patient who had a bad inflammatory myopathy, early in the pandemic. I wanted to get a muscle biopsy on her, and there were no elective procedures, so I couldn’t do it. I had to go ahead and treat her. And now, doing the muscle biopsy isn’t going to be that helpful because we’re pretty far along. I’m having some trouble tapering her off of her oral prednisone. And I’ve found that repository corticotropin is a good way to help taper because of its effect on melanocortin type 2 receptors in the adrenal cortex. It’s sort of helping the adrenal cortex to work, and to wake up and do its job, so you can give fewer oral steroids.

 It has both, like you mentioned, direct and indirect properties. The percentage of engagement with the adrenal cortex is minimal. That’s the other special sauce, as you might want to call it.

: Yes. Well, we’ve covered a lot of ground today about treatment options for systemic lupus erythematosus and idiopathic inflammatory myopathies. What advice would you have for community physicians treating rare systemic autoimmune rheumatic diseases?

 Don’t be afraid to say, “I don’t know.” These are rare conditions, and even we’re not seeing them every day. But a good physical history, there are some serologies that are available, that anyone can order, and try to connect the dots with other subspecialties. If it doesn’t make sense, and if they’re having multiple organs involved, and you can’t quite tie a diagnosis, rheumatologists might be the missing link.

: I like that, the rheumatologist might be the missing link. That sounds great. I say exactly the same thing, that we’re here to help. Please use us as a resource. And we want to work with you and help you to work with things that are rare. I completely agree that common things are common, and not much of what we do is. And certainly, since we don’t have necessarily a light switch that says on and off for our diseases, it takes a lot of clinical judgment, and it takes a lot of working with the patient, following the patient. And sometimes it evolves over time. We might think it’s one thing, and it turns out that it’s something else. I completely agree with everything you have to say. And I think that’s great advice for community physicians. Do you have any final comments before I make closing remarks?

 I look forward to the good old days, where we can all get together in person, and not have to socially distance ourselves and not worry about unvaccinated individuals. And I wish everyone health and the very best.

Well, this has been delightful, and I’ve really enjoyed talking with you. I hope we get to do this again sometime. I want to thank all those out there who are watching this 

. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming programs and other great content right in your inbox.

Closing out their discussion, experts highlight practical advice for caring for patients with SARDs in the current treatment landscape. 

Authors