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David Lieberman, MD, AGAF, spent much of his long career asking questions about everyday clinical practice in GI medicine and then researching ways to answer those questions.
“The answer to one question often leads to further questions. And I think that’s what makes this research so exciting and dynamic,” said Lieberman, professor emeritus with Oregon Health and Science University, where he served as chief of the Division of Gastroenterology and Hepatology for 24 years.
He was also instrumental in creating a blood and tissue repository for colorectal cancer (CRC) research, and a national endoscopic database.
His groundbreaking GI research in colorectal cancer screening earned him AGA’s Julius Friedenwald Medal, a top career honor. “We started off with some questions about the role of specific screening tests like colonoscopy and stool-based tests for screening,” he said. This led to the first large study about the value of screening with colonoscopy, which set the stage for current screening guidelines. Assessing more than 3,000 asymptomatic adults, Lieberman and colleagues determined that colonoscopy was more effective than sigmoidoscopy in detecting advanced colonic neoplasms.
The next phase of research focused on how well GI doctors were performing colonoscopy, asking questions about the quality of the colonoscopies being performed, and what course of action to take in polyp discovery. “We did some work related to polyp surveillance, what happens after we take out polyps and some recommendations for the appropriate length of follow up afterwards,” he summarized.
Most recently, Lieberman has centered his research on program effectiveness. “If you’re doing high quality colonoscopy and you’re doing appropriate surveillance, how effective is that? And what are the potential problems that might impair effectiveness?”
Adherence and participation remain significant challenges, he said. “If people don’t get the tests done, then they’re not going to be effective. Or if they get part of it done, there can be issues.”
In an interview, Lieberman discussed the reasons why people resist CRC screening, and the new technologies and research underway to make screening options more palatable for reluctant patients.
What do you think are the biggest deterrents to getting screened for CRC?
Dr. Lieberman: The whole idea of dealing with a stool sample is not appealing to patients. The second issue, and this has been shown in many studies, is patients who are referred for colonoscopy may resist because they have heard stories about bowel preps and about colonoscopy itself. But there are many other reasons. I mean, there are issues with access to care that are important. What if you have a positive stool test and you need to get a colonoscopy? How do you get a colonoscopy? There are barriers in moving from one test to the other in a different setting. There are issues with having to take a day off work that’s potentially a financial hardship for some patients. If you’re taking care of elderly relatives or children or if you need transportation, that’s an issue for people.
So, there are many potential barriers, and we’ve been trying to work at a national level to try to understand these barriers and then develop tools to mitigate these problems and improve the overall participation in screening.
How has the field of GI changed since you started practicing medicine?
Dr. Lieberman: I think there have been many exciting changes in technology. The endoscopes we used when I started my career were called fiberoptic scopes. These were scopes that contained tiny glass fibers that ran the length of the scope, and they were good, but not great in terms of imaging, and sometimes they would break down. We now have digital imaging that far surpasses the quality there. We’ve come a long way in terms of things like CT scans, for example, and MRI imaging. The other big technology change has been the development of minimally invasive treatments. For example, if you have a gallstone that’s in your bile duct, we now have ways to remove that without sending the patient to surgery.
The second big change has been the assessment of quality. When I started my career in gastroenterology, we were doing a lot of things, but we didn’t necessarily know if we were doing them well. Most of us thought we were doing them well, of course, but nobody was really measuring quality. There were no quality benchmarks. And so if you don’t measure it, you don’t know. Where we are today in gastroenterology is we’re intensively concerned about quality and measuring quality in various aspects of what we do. And I think that’s a positive development.
What key achievements came out of the U.S. Multi-Society Task Force on Colorectal Cancer?
Dr. Lieberman: This panel evolved because back in the early 2000s, each of the GI organizations were producing guidelines related to colon cancer screening and follow-up. And they were slightly different. This was an attempt to bring all the relevant groups together and try to align the guidelines and recommendations among the GI organizations so that there wouldn’t be a confusing message.
Over the history of this task force, which started around 2002, it’s been remarkably productive. The task force has really examined all aspects of colorectal cancer, including things like the bowel prep, quality of exams, high risk management, hereditary syndromes that can lead to the higher likelihood of developing colon cancer, polypectomy and polypectomy techniques, and screening and surveillance recommendations, which have evolved over time. It’s been, in my opinion, a remarkably productive task force and continues to this day. I’m so very proud of that group.
Could you give a status update on the blood and tissue repository you created for CRC research?
Dr. Lieberman: Our initial studies were part of a Veterans Affairs cooperative study, which is a mechanism of funding within the VA that allows us to work with multiple VA centers to collect data and information. At the very outset of this study, we were performing screening colonoscopies in individuals, and we decided to create a bio-repository that included blood samples, polyp tissue, and normal rectal tissue. The thinking was at some point we might be able to do some genomic studies that might help us predict which patients are most likely to develop colon polyps and colon cancer. All that happened in the 1990s. It was supported by the National Cancer Institute. We created this repository, which sat for a long period of time while we were waiting for the technology to develop and so that we could perform genomic studies in a cost-effective way.
We’re now at that point, which is really exciting. We’re beginning to look at this tissue and perform some genomic studies. Some of this data has been presented at national meetings. This was a precursor to creating a similar type of bio-repository in a larger VA cooperative study. CSP #577 Colonoscopy vs. Fecal Immunochemical Test in Reducing Mortality from Colorectal Cancer (CONFIRM) is a randomized study comparing two forms of screening, a fecal immunochemical test versus a colonoscopy. We’re in the process of enrolling 50,000 patients in that study. We have also created a blood and tissue repository, which we hope will be useful for future studies.
You lead the AGA CRC Task Force, which advances research and policy initiatives to improve screening rates and patient outcomes. What would you like to see in future GI research, particularly in colorectal cancer?
Dr. Lieberman: We have new blood tests coming along that are going to be very attractive to both patients and physicians. You can obtain a blood sample at a point of service and patients won’t have to deal with stool samples. We need to understand how those tests perform in clinical practice. If the test is abnormal, indicating a patient has a higher risk of colon cancer and should get a colonoscopy, are they getting that colonoscopy or not? And what are the barriers? And if it’s normal, then that patient should have a repeat test at an appropriate interval.
We know that the effectiveness of screening really depends on the participation of individuals in terms of completing the steps. We’ve published some work already on trying to understand the role of these blood tests. We expect that these tests will continue to improve over time.
We’re also working on trying to develop these risk stratification tools that could be used in clinical practice to help figure out the most appropriate test for a particular individual.
Let’s say you go to your doctor for colon cancer screening, and if we could determine that you are a low-risk individual, you may benefit best from having a non-invasive test, like a blood test or a stool test. Whereas if you’re a higher risk individual, you may need to have a more invasive screening test like colonoscopy.
This falls into a concept of personalized medicine where we’re trying to use all the information we have from the medical history, and maybe genomic information that I mentioned earlier, to try to determine who needs the most intensive screening and who might benefit from less intensive screening.
I think the most recent work is really focused on these gaps in screening. And the biggest gap are patients that get a non-invasive test, like a stool test, but do not get a colonoscopy that renders the program ineffective if they don’t get the colonoscopy. We’re trying to highlight that for primary care providers and make sure that everyone understands the importance of this follow-up. And then, trying to develop tools to help the primary care provider navigate that patient to a colonoscopy.
What do you think is the biggest misconception about your specialty?
Dr. Lieberman: If there’s a misconception, it’s that GI physicians are focused on procedures. I think a good GI provider should be holistic, and I think many are. What I mean by holistic is that many GI symptoms could be due to stress, medications, diet, or other aspects of behavior, and the remedy is not necessarily a procedure. I think that many GI physicians are really skilled at obtaining this information and trying to help guide the patient through some uncomfortable symptoms.
It means being more like an internist, spending time with the patient to take a detailed history and delve into many different possibilities that might be going on.
David Lieberman, MD, AGAF, spent much of his long career asking questions about everyday clinical practice in GI medicine and then researching ways to answer those questions.
“The answer to one question often leads to further questions. And I think that’s what makes this research so exciting and dynamic,” said Lieberman, professor emeritus with Oregon Health and Science University, where he served as chief of the Division of Gastroenterology and Hepatology for 24 years.
He was also instrumental in creating a blood and tissue repository for colorectal cancer (CRC) research, and a national endoscopic database.
His groundbreaking GI research in colorectal cancer screening earned him AGA’s Julius Friedenwald Medal, a top career honor. “We started off with some questions about the role of specific screening tests like colonoscopy and stool-based tests for screening,” he said. This led to the first large study about the value of screening with colonoscopy, which set the stage for current screening guidelines. Assessing more than 3,000 asymptomatic adults, Lieberman and colleagues determined that colonoscopy was more effective than sigmoidoscopy in detecting advanced colonic neoplasms.
The next phase of research focused on how well GI doctors were performing colonoscopy, asking questions about the quality of the colonoscopies being performed, and what course of action to take in polyp discovery. “We did some work related to polyp surveillance, what happens after we take out polyps and some recommendations for the appropriate length of follow up afterwards,” he summarized.
Most recently, Lieberman has centered his research on program effectiveness. “If you’re doing high quality colonoscopy and you’re doing appropriate surveillance, how effective is that? And what are the potential problems that might impair effectiveness?”
Adherence and participation remain significant challenges, he said. “If people don’t get the tests done, then they’re not going to be effective. Or if they get part of it done, there can be issues.”
In an interview, Lieberman discussed the reasons why people resist CRC screening, and the new technologies and research underway to make screening options more palatable for reluctant patients.
What do you think are the biggest deterrents to getting screened for CRC?
Dr. Lieberman: The whole idea of dealing with a stool sample is not appealing to patients. The second issue, and this has been shown in many studies, is patients who are referred for colonoscopy may resist because they have heard stories about bowel preps and about colonoscopy itself. But there are many other reasons. I mean, there are issues with access to care that are important. What if you have a positive stool test and you need to get a colonoscopy? How do you get a colonoscopy? There are barriers in moving from one test to the other in a different setting. There are issues with having to take a day off work that’s potentially a financial hardship for some patients. If you’re taking care of elderly relatives or children or if you need transportation, that’s an issue for people.
So, there are many potential barriers, and we’ve been trying to work at a national level to try to understand these barriers and then develop tools to mitigate these problems and improve the overall participation in screening.
How has the field of GI changed since you started practicing medicine?
Dr. Lieberman: I think there have been many exciting changes in technology. The endoscopes we used when I started my career were called fiberoptic scopes. These were scopes that contained tiny glass fibers that ran the length of the scope, and they were good, but not great in terms of imaging, and sometimes they would break down. We now have digital imaging that far surpasses the quality there. We’ve come a long way in terms of things like CT scans, for example, and MRI imaging. The other big technology change has been the development of minimally invasive treatments. For example, if you have a gallstone that’s in your bile duct, we now have ways to remove that without sending the patient to surgery.
The second big change has been the assessment of quality. When I started my career in gastroenterology, we were doing a lot of things, but we didn’t necessarily know if we were doing them well. Most of us thought we were doing them well, of course, but nobody was really measuring quality. There were no quality benchmarks. And so if you don’t measure it, you don’t know. Where we are today in gastroenterology is we’re intensively concerned about quality and measuring quality in various aspects of what we do. And I think that’s a positive development.
What key achievements came out of the U.S. Multi-Society Task Force on Colorectal Cancer?
Dr. Lieberman: This panel evolved because back in the early 2000s, each of the GI organizations were producing guidelines related to colon cancer screening and follow-up. And they were slightly different. This was an attempt to bring all the relevant groups together and try to align the guidelines and recommendations among the GI organizations so that there wouldn’t be a confusing message.
Over the history of this task force, which started around 2002, it’s been remarkably productive. The task force has really examined all aspects of colorectal cancer, including things like the bowel prep, quality of exams, high risk management, hereditary syndromes that can lead to the higher likelihood of developing colon cancer, polypectomy and polypectomy techniques, and screening and surveillance recommendations, which have evolved over time. It’s been, in my opinion, a remarkably productive task force and continues to this day. I’m so very proud of that group.
Could you give a status update on the blood and tissue repository you created for CRC research?
Dr. Lieberman: Our initial studies were part of a Veterans Affairs cooperative study, which is a mechanism of funding within the VA that allows us to work with multiple VA centers to collect data and information. At the very outset of this study, we were performing screening colonoscopies in individuals, and we decided to create a bio-repository that included blood samples, polyp tissue, and normal rectal tissue. The thinking was at some point we might be able to do some genomic studies that might help us predict which patients are most likely to develop colon polyps and colon cancer. All that happened in the 1990s. It was supported by the National Cancer Institute. We created this repository, which sat for a long period of time while we were waiting for the technology to develop and so that we could perform genomic studies in a cost-effective way.
We’re now at that point, which is really exciting. We’re beginning to look at this tissue and perform some genomic studies. Some of this data has been presented at national meetings. This was a precursor to creating a similar type of bio-repository in a larger VA cooperative study. CSP #577 Colonoscopy vs. Fecal Immunochemical Test in Reducing Mortality from Colorectal Cancer (CONFIRM) is a randomized study comparing two forms of screening, a fecal immunochemical test versus a colonoscopy. We’re in the process of enrolling 50,000 patients in that study. We have also created a blood and tissue repository, which we hope will be useful for future studies.
You lead the AGA CRC Task Force, which advances research and policy initiatives to improve screening rates and patient outcomes. What would you like to see in future GI research, particularly in colorectal cancer?
Dr. Lieberman: We have new blood tests coming along that are going to be very attractive to both patients and physicians. You can obtain a blood sample at a point of service and patients won’t have to deal with stool samples. We need to understand how those tests perform in clinical practice. If the test is abnormal, indicating a patient has a higher risk of colon cancer and should get a colonoscopy, are they getting that colonoscopy or not? And what are the barriers? And if it’s normal, then that patient should have a repeat test at an appropriate interval.
We know that the effectiveness of screening really depends on the participation of individuals in terms of completing the steps. We’ve published some work already on trying to understand the role of these blood tests. We expect that these tests will continue to improve over time.
We’re also working on trying to develop these risk stratification tools that could be used in clinical practice to help figure out the most appropriate test for a particular individual.
Let’s say you go to your doctor for colon cancer screening, and if we could determine that you are a low-risk individual, you may benefit best from having a non-invasive test, like a blood test or a stool test. Whereas if you’re a higher risk individual, you may need to have a more invasive screening test like colonoscopy.
This falls into a concept of personalized medicine where we’re trying to use all the information we have from the medical history, and maybe genomic information that I mentioned earlier, to try to determine who needs the most intensive screening and who might benefit from less intensive screening.
I think the most recent work is really focused on these gaps in screening. And the biggest gap are patients that get a non-invasive test, like a stool test, but do not get a colonoscopy that renders the program ineffective if they don’t get the colonoscopy. We’re trying to highlight that for primary care providers and make sure that everyone understands the importance of this follow-up. And then, trying to develop tools to help the primary care provider navigate that patient to a colonoscopy.
What do you think is the biggest misconception about your specialty?
Dr. Lieberman: If there’s a misconception, it’s that GI physicians are focused on procedures. I think a good GI provider should be holistic, and I think many are. What I mean by holistic is that many GI symptoms could be due to stress, medications, diet, or other aspects of behavior, and the remedy is not necessarily a procedure. I think that many GI physicians are really skilled at obtaining this information and trying to help guide the patient through some uncomfortable symptoms.
It means being more like an internist, spending time with the patient to take a detailed history and delve into many different possibilities that might be going on.
David Lieberman, MD, AGAF, spent much of his long career asking questions about everyday clinical practice in GI medicine and then researching ways to answer those questions.
“The answer to one question often leads to further questions. And I think that’s what makes this research so exciting and dynamic,” said Lieberman, professor emeritus with Oregon Health and Science University, where he served as chief of the Division of Gastroenterology and Hepatology for 24 years.
He was also instrumental in creating a blood and tissue repository for colorectal cancer (CRC) research, and a national endoscopic database.
His groundbreaking GI research in colorectal cancer screening earned him AGA’s Julius Friedenwald Medal, a top career honor. “We started off with some questions about the role of specific screening tests like colonoscopy and stool-based tests for screening,” he said. This led to the first large study about the value of screening with colonoscopy, which set the stage for current screening guidelines. Assessing more than 3,000 asymptomatic adults, Lieberman and colleagues determined that colonoscopy was more effective than sigmoidoscopy in detecting advanced colonic neoplasms.
The next phase of research focused on how well GI doctors were performing colonoscopy, asking questions about the quality of the colonoscopies being performed, and what course of action to take in polyp discovery. “We did some work related to polyp surveillance, what happens after we take out polyps and some recommendations for the appropriate length of follow up afterwards,” he summarized.
Most recently, Lieberman has centered his research on program effectiveness. “If you’re doing high quality colonoscopy and you’re doing appropriate surveillance, how effective is that? And what are the potential problems that might impair effectiveness?”
Adherence and participation remain significant challenges, he said. “If people don’t get the tests done, then they’re not going to be effective. Or if they get part of it done, there can be issues.”
In an interview, Lieberman discussed the reasons why people resist CRC screening, and the new technologies and research underway to make screening options more palatable for reluctant patients.
What do you think are the biggest deterrents to getting screened for CRC?
Dr. Lieberman: The whole idea of dealing with a stool sample is not appealing to patients. The second issue, and this has been shown in many studies, is patients who are referred for colonoscopy may resist because they have heard stories about bowel preps and about colonoscopy itself. But there are many other reasons. I mean, there are issues with access to care that are important. What if you have a positive stool test and you need to get a colonoscopy? How do you get a colonoscopy? There are barriers in moving from one test to the other in a different setting. There are issues with having to take a day off work that’s potentially a financial hardship for some patients. If you’re taking care of elderly relatives or children or if you need transportation, that’s an issue for people.
So, there are many potential barriers, and we’ve been trying to work at a national level to try to understand these barriers and then develop tools to mitigate these problems and improve the overall participation in screening.
How has the field of GI changed since you started practicing medicine?
Dr. Lieberman: I think there have been many exciting changes in technology. The endoscopes we used when I started my career were called fiberoptic scopes. These were scopes that contained tiny glass fibers that ran the length of the scope, and they were good, but not great in terms of imaging, and sometimes they would break down. We now have digital imaging that far surpasses the quality there. We’ve come a long way in terms of things like CT scans, for example, and MRI imaging. The other big technology change has been the development of minimally invasive treatments. For example, if you have a gallstone that’s in your bile duct, we now have ways to remove that without sending the patient to surgery.
The second big change has been the assessment of quality. When I started my career in gastroenterology, we were doing a lot of things, but we didn’t necessarily know if we were doing them well. Most of us thought we were doing them well, of course, but nobody was really measuring quality. There were no quality benchmarks. And so if you don’t measure it, you don’t know. Where we are today in gastroenterology is we’re intensively concerned about quality and measuring quality in various aspects of what we do. And I think that’s a positive development.
What key achievements came out of the U.S. Multi-Society Task Force on Colorectal Cancer?
Dr. Lieberman: This panel evolved because back in the early 2000s, each of the GI organizations were producing guidelines related to colon cancer screening and follow-up. And they were slightly different. This was an attempt to bring all the relevant groups together and try to align the guidelines and recommendations among the GI organizations so that there wouldn’t be a confusing message.
Over the history of this task force, which started around 2002, it’s been remarkably productive. The task force has really examined all aspects of colorectal cancer, including things like the bowel prep, quality of exams, high risk management, hereditary syndromes that can lead to the higher likelihood of developing colon cancer, polypectomy and polypectomy techniques, and screening and surveillance recommendations, which have evolved over time. It’s been, in my opinion, a remarkably productive task force and continues to this day. I’m so very proud of that group.
Could you give a status update on the blood and tissue repository you created for CRC research?
Dr. Lieberman: Our initial studies were part of a Veterans Affairs cooperative study, which is a mechanism of funding within the VA that allows us to work with multiple VA centers to collect data and information. At the very outset of this study, we were performing screening colonoscopies in individuals, and we decided to create a bio-repository that included blood samples, polyp tissue, and normal rectal tissue. The thinking was at some point we might be able to do some genomic studies that might help us predict which patients are most likely to develop colon polyps and colon cancer. All that happened in the 1990s. It was supported by the National Cancer Institute. We created this repository, which sat for a long period of time while we were waiting for the technology to develop and so that we could perform genomic studies in a cost-effective way.
We’re now at that point, which is really exciting. We’re beginning to look at this tissue and perform some genomic studies. Some of this data has been presented at national meetings. This was a precursor to creating a similar type of bio-repository in a larger VA cooperative study. CSP #577 Colonoscopy vs. Fecal Immunochemical Test in Reducing Mortality from Colorectal Cancer (CONFIRM) is a randomized study comparing two forms of screening, a fecal immunochemical test versus a colonoscopy. We’re in the process of enrolling 50,000 patients in that study. We have also created a blood and tissue repository, which we hope will be useful for future studies.
You lead the AGA CRC Task Force, which advances research and policy initiatives to improve screening rates and patient outcomes. What would you like to see in future GI research, particularly in colorectal cancer?
Dr. Lieberman: We have new blood tests coming along that are going to be very attractive to both patients and physicians. You can obtain a blood sample at a point of service and patients won’t have to deal with stool samples. We need to understand how those tests perform in clinical practice. If the test is abnormal, indicating a patient has a higher risk of colon cancer and should get a colonoscopy, are they getting that colonoscopy or not? And what are the barriers? And if it’s normal, then that patient should have a repeat test at an appropriate interval.
We know that the effectiveness of screening really depends on the participation of individuals in terms of completing the steps. We’ve published some work already on trying to understand the role of these blood tests. We expect that these tests will continue to improve over time.
We’re also working on trying to develop these risk stratification tools that could be used in clinical practice to help figure out the most appropriate test for a particular individual.
Let’s say you go to your doctor for colon cancer screening, and if we could determine that you are a low-risk individual, you may benefit best from having a non-invasive test, like a blood test or a stool test. Whereas if you’re a higher risk individual, you may need to have a more invasive screening test like colonoscopy.
This falls into a concept of personalized medicine where we’re trying to use all the information we have from the medical history, and maybe genomic information that I mentioned earlier, to try to determine who needs the most intensive screening and who might benefit from less intensive screening.
I think the most recent work is really focused on these gaps in screening. And the biggest gap are patients that get a non-invasive test, like a stool test, but do not get a colonoscopy that renders the program ineffective if they don’t get the colonoscopy. We’re trying to highlight that for primary care providers and make sure that everyone understands the importance of this follow-up. And then, trying to develop tools to help the primary care provider navigate that patient to a colonoscopy.
What do you think is the biggest misconception about your specialty?
Dr. Lieberman: If there’s a misconception, it’s that GI physicians are focused on procedures. I think a good GI provider should be holistic, and I think many are. What I mean by holistic is that many GI symptoms could be due to stress, medications, diet, or other aspects of behavior, and the remedy is not necessarily a procedure. I think that many GI physicians are really skilled at obtaining this information and trying to help guide the patient through some uncomfortable symptoms.
It means being more like an internist, spending time with the patient to take a detailed history and delve into many different possibilities that might be going on.