[
  {
    "start": 0.0,
    "end": 4.2,
    "text": " - Hello everyone, welcome to this episode of the UUG Talks."
  },
  {
    "start": 4.2,
    "end": 5.28,
    "text": " It's Pradeep Munda here,"
  },
  {
    "start": 5.28,
    "end": 8.28,
    "text": " and I'm your host for the UUG Talks today."
  },
  {
    "start": 8.28,
    "end": 12.92,
    "text": " Now, gastric cancer is potentially preventable."
  },
  {
    "start": 12.92,
    "end": 16.32,
    "text": " And I have covered this aspect"
  },
  {
    "start": 16.32,
    "end": 19.38,
    "text": " with my very first podcast for UUG Talks"
  },
  {
    "start": 19.38,
    "end": 23.6,
    "text": " with Professor Marcis Lea nearly 18 months ago."
  },
  {
    "start": 23.6,
    "end": 25.84,
    "text": " We did discuss various things and basics."
  },
  {
    "start": 25.84,
    "end": 27.52,
    "text": " I felt go back to Pylori and things."
  },
  {
    "start": 27.52,
    "end": 32.24,
    "text": " And I would urge the listeners to listen to that episode."
  },
  {
    "start": 32.24,
    "end": 35.04,
    "text": " And this goes in conjunction with this episode."
  },
  {
    "start": 35.04,
    "end": 37.34,
    "text": " And one of the things in relation to this"
  },
  {
    "start": 37.34,
    "end": 41.36,
    "text": " that I often notice routinely in my clinical practice"
  },
  {
    "start": 41.36,
    "end": 46.36,
    "text": " is huge variability in the quality of upper genoscopy"
  },
  {
    "start": 46.36,
    "end": 51.12,
    "text": " in terms of reporting gastric pre-malangal lesions."
  },
  {
    "start": 51.12,
    "end": 54.0,
    "text": " And I find that these are often missed."
  },
  {
    "start": 54.0,
    "end": 57.12,
    "text": " And if sometimes they're reported,"
  },
  {
    "start": 57.12,
    "end": 59.48,
    "text": " they're reported very inadequately"
  },
  {
    "start": 59.48,
    "end": 63.36,
    "text": " in terms of the extent of the pre-malangal lesions"
  },
  {
    "start": 63.36,
    "end": 65.76,
    "text": " and everything else that comes with it."
  },
  {
    "start": 65.76,
    "end": 68.36,
    "text": " And this has huge implications"
  },
  {
    "start": 68.36,
    "end": 70.76,
    "text": " in terms of patient management."
  },
  {
    "start": 70.76,
    "end": 74.04,
    "text": " And often the offer of surveillance"
  },
  {
    "start": 74.04,
    "end": 78.64,
    "text": " or no surveillance for such patients ends up being potluck."
  },
  {
    "start": 78.64,
    "end": 81.96,
    "text": " So to say, depending on how the endoscopist describes"
  },
  {
    "start": 81.96,
    "end": 85.56,
    "text": " the findings or the clinician's interpretation"
  },
  {
    "start": 85.56,
    "end": 87.24,
    "text": " of the endoscopist's report."
  },
  {
    "start": 87.24,
    "end": 90.36,
    "text": " And I suspect the reason for this is lack of awareness."
  },
  {
    "start": 90.36,
    "end": 93.92,
    "text": " And previous guidelines had addressed this issue"
  },
  {
    "start": 93.92,
    "end": 97.52,
    "text": " but may not have been crystal clear"
  },
  {
    "start": 97.52,
    "end": 99.96,
    "text": " or crisp in guiding us clinicians."
  },
  {
    "start": 99.96,
    "end": 103.76,
    "text": " And on that note, the European Society of Gastrointestinal"
  },
  {
    "start": 103.76,
    "end": 107.36,
    "text": " Endoscopy have now updated their latest guidelines"
  },
  {
    "start": 107.36,
    "end": 111.76,
    "text": " on this topic called the MAPS Three Guidelines."
  },
  {
    "start": 111.76,
    "end": 115.32,
    "text": " And whilst we can't cover the entirety of the guidelines,"
  },
  {
    "start": 115.32,
    "end": 119.6,
    "text": " today's discussion is about the most important aspects of this."
  },
  {
    "start": 119.6,
    "end": 121.68,
    "text": " And to discuss this today,"
  },
  {
    "start": 121.68,
    "end": 123.84,
    "text": " we have none other than the lead author"
  },
  {
    "start": 123.84,
    "end": 127.72,
    "text": " for this guidelines, Dr. Mario Dinis-Riveru."
  },
  {
    "start": 127.72,
    "end": 130.68,
    "text": " Professor Dinis-Riveru is a full professor"
  },
  {
    "start": 130.68,
    "end": 134.2,
    "text": " at the Faculty of Medicine at the University of Porto,"
  },
  {
    "start": 134.2,
    "end": 138.64,
    "text": " Consultant Gastrointestinal at Porto Comprehensive Cancer Center"
  },
  {
    "start": 138.64,
    "end": 140.76,
    "text": " where he's the head of the department"
  },
  {
    "start": 140.76,
    "end": 144.76,
    "text": " and vice director of research center."
  },
  {
    "start": 144.76,
    "end": 147.6,
    "text": " - Welcome to UIG Talks, Mario. - Thank you."
  },
  {
    "start": 147.6,
    "end": 152.32,
    "text": " So, Mario, I've been looking at the MAPS Three Guidelines"
  },
  {
    "start": 152.32,
    "end": 153.96,
    "text": " in preparation for this."
  },
  {
    "start": 153.96,
    "end": 157.6,
    "text": " It's extensive compared to the previous ESG guidelines"
  },
  {
    "start": 157.6,
    "end": 159.8,
    "text": " and very amazingly succinct."
  },
  {
    "start": 159.8,
    "end": 162.92,
    "text": " And I have to give all kudos to your team"
  },
  {
    "start": 162.92,
    "end": 165.44,
    "text": " and you and your team to put this together."
  },
  {
    "start": 165.44,
    "end": 167.24,
    "text": " And it's 40 pages long."
  },
  {
    "start": 167.24,
    "end": 169.36,
    "text": " Can I ask you to begin with,"
  },
  {
    "start": 169.36,
    "end": 170.92,
    "text": " what is the scope of these guidelines"
  },
  {
    "start": 170.92,
    "end": 172.4,
    "text": " and how this was developed"
  },
  {
    "start": 172.4,
    "end": 175.4,
    "text": " and what all aspects have it covered in these guidelines?"
  },
  {
    "start": 175.4,
    "end": 178.28,
    "text": " Well, first of all, thank you again for inviting me"
  },
  {
    "start": 178.28,
    "end": 180.8,
    "text": " and I hope that we can have a discussion around,"
  },
  {
    "start": 180.8,
    "end": 183.24,
    "text": " we believe, a nice guideline"
  },
  {
    "start": 183.24,
    "end": 184.76,
    "text": " and a very comprehensive guideline."
  },
  {
    "start": 184.76,
    "end": 187.76,
    "text": " That was the main aim always of the team"
  },
  {
    "start": 187.76,
    "end": 191.24,
    "text": " that embarked on this adventure."
  },
  {
    "start": 191.24,
    "end": 195.36,
    "text": " So, as you said, this is the third edition for this guideline."
  },
  {
    "start": 195.36,
    "end": 199.76,
    "text": " And when we started in 2011, 2010,"
  },
  {
    "start": 199.76,
    "end": 202.44,
    "text": " when we kicked off the first guideline,"
  },
  {
    "start": 202.44,
    "end": 205.36,
    "text": " we joined forces with the European Helicobacter"
  },
  {
    "start": 205.36,
    "end": 207.0,
    "text": " and Microway of the study group."
  },
  {
    "start": 207.0,
    "end": 209.0,
    "text": " Well, it's obvious because the Helicobacter"
  },
  {
    "start": 209.0,
    "end": 211.8,
    "text": " is the main risk factor for gastric cancer"
  },
  {
    "start": 211.8,
    "end": 213.68,
    "text": " and also the European Society of Pathology"
  },
  {
    "start": 213.68,
    "end": 217.56,
    "text": " because finally it's all about merging the concepts"
  },
  {
    "start": 217.56,
    "end": 219.6,
    "text": " between endoscope and pathology"
  },
  {
    "start": 219.6,
    "end": 221.32,
    "text": " on managing these patients."
  },
  {
    "start": 221.32,
    "end": 225.04,
    "text": " But we will have the chance to go to that topic."
  },
  {
    "start": 225.04,
    "end": 228.52,
    "text": " So, every five years, approximately the guidelines,"
  },
  {
    "start": 228.52,
    "end": 230.76,
    "text": " they have to be updated and meanwhile,"
  },
  {
    "start": 230.76,
    "end": 232.92,
    "text": " of course, they are exposed to the community"
  },
  {
    "start": 232.92,
    "end": 235.88,
    "text": " and lots of discussions occur in conferences."
  },
  {
    "start": 235.88,
    "end": 240.04,
    "text": " And we felt along the line with the recent systematic review"
  },
  {
    "start": 240.04,
    "end": 243.32,
    "text": " that even though the guidelines have been uptaken,"
  },
  {
    "start": 243.32,
    "end": 246.08,
    "text": " there was somehow, sometimes some discrepancy"
  },
  {
    "start": 246.08,
    "end": 248.04,
    "text": " in the way they were read."
  },
  {
    "start": 248.04,
    "end": 251.48,
    "text": " This is on one side, so it's probably not anymore,"
  },
  {
    "start": 251.48,
    "end": 254.44,
    "text": " a lot of heterogeneity, but on the other side,"
  },
  {
    "start": 254.44,
    "end": 257.72,
    "text": " a lot of discrepancy in the way the different guidelines"
  },
  {
    "start": 257.72,
    "end": 261.56,
    "text": " from different parts of the globe, they were understood."
  },
  {
    "start": 261.56,
    "end": 264.76,
    "text": " Also, there were some areas that have not been covered"
  },
  {
    "start": 264.76,
    "end": 266.04,
    "text": " and there were some criticism"
  },
  {
    "start": 266.04,
    "end": 268.04,
    "text": " because of course you can manage a patient"
  },
  {
    "start": 268.04,
    "end": 271.64,
    "text": " when it comes finally to your outpatient clinics,"
  },
  {
    "start": 271.64,
    "end": 273.88,
    "text": " but what about enrolling the patient"
  },
  {
    "start": 273.88,
    "end": 276.8,
    "text": " at the very first moment to endoscopy"
  },
  {
    "start": 276.8,
    "end": 279.72,
    "text": " or how to deal with special situations."
  },
  {
    "start": 279.72,
    "end": 284.72,
    "text": " And finally, she decided also for other guidelines"
  },
  {
    "start": 285.16,
    "end": 287.8,
    "text": " that we would be more, even more comprehensive"
  },
  {
    "start": 287.8,
    "end": 288.76,
    "text": " in terms of organ."
  },
  {
    "start": 288.76,
    "end": 291.16,
    "text": " So, yes, she did that for merits"
  },
  {
    "start": 291.16,
    "end": 295.32,
    "text": " and we did this in terms of how to manage finally"
  },
  {
    "start": 295.32,
    "end": 297.2,
    "text": " if we find out the superficial reason"
  },
  {
    "start": 297.2,
    "end": 299.32,
    "text": " that would be respectable."
  },
  {
    "start": 299.32,
    "end": 304.32,
    "text": " And that's why at the end became quite a long guideline."
  },
  {
    "start": 304.32,
    "end": 309.24,
    "text": " In the top of that, we also aim to have the consequences"
  },
  {
    "start": 309.24,
    "end": 312.6,
    "text": " in terms of greener endoscopy."
  },
  {
    "start": 312.6,
    "end": 316.32,
    "text": " But we did not, of course, cover everything."
  },
  {
    "start": 316.32,
    "end": 318.44,
    "text": " So, the readers of the guideline"
  },
  {
    "start": 318.44,
    "end": 321.92,
    "text": " may miss also some technical and training concepts,"
  },
  {
    "start": 321.92,
    "end": 324.8,
    "text": " but this can be found elsewhere."
  },
  {
    "start": 324.8,
    "end": 327.04,
    "text": " - So, you covered screening here,"
  },
  {
    "start": 327.04,
    "end": 332.04,
    "text": " surveillance, identification of pre-meding lesions,"
  },
  {
    "start": 332.04,
    "end": 334.24,
    "text": " management of such lesions,"
  },
  {
    "start": 334.24,
    "end": 337.88,
    "text": " and treatment of alcovacter pylori and all that."
  },
  {
    "start": 337.88,
    "end": 341.28,
    "text": " I guess for the benefit of audience, Mario,"
  },
  {
    "start": 341.28,
    "end": 346.24,
    "text": " they probably focus less on treatment of displace here"
  },
  {
    "start": 346.24,
    "end": 348.16,
    "text": " and we will cover some of it,"
  },
  {
    "start": 348.16,
    "end": 350.36,
    "text": " but I think predominantly we'll cover screening surveillance,"
  },
  {
    "start": 350.36,
    "end": 353.12,
    "text": " which is more important to our colleagues"
  },
  {
    "start": 353.12,
    "end": 355.2,
    "text": " 'cause management of displace here as such"
  },
  {
    "start": 355.2,
    "end": 357.36,
    "text": " is dealt in by specialists."
  },
  {
    "start": 357.36,
    "end": 360.72,
    "text": " And although we'll touch, we'll cover less on that,"
  },
  {
    "start": 360.72,
    "end": 361.8,
    "text": " hopefully, let's see."
  },
  {
    "start": 361.8,
    "end": 364.12,
    "text": " Now, let's start off, Mario,"
  },
  {
    "start": 364.12,
    "end": 368.44,
    "text": " with screening for gastric cancer and pre-medicine lesions."
  },
  {
    "start": 368.44,
    "end": 372.68,
    "text": " And in the guidelines, you mentioned"
  },
  {
    "start": 372.68,
    "end": 375.2,
    "text": " three different domains of screening."
  },
  {
    "start": 375.2,
    "end": 378.56,
    "text": " Can you expand on that"
  },
  {
    "start": 378.56,
    "end": 380.12,
    "text": " and briefly explain what this means"
  },
  {
    "start": 380.12,
    "end": 382.56,
    "text": " and how it's best done?"
  },
  {
    "start": 382.56,
    "end": 385.8,
    "text": " - Of course, there is always some differences in taxonomy"
  },
  {
    "start": 385.8,
    "end": 387.88,
    "text": " if you speak with different groups,"
  },
  {
    "start": 387.88,
    "end": 391.24,
    "text": " but at least within the guideline we aim"
  },
  {
    "start": 391.24,
    "end": 395.88,
    "text": " that's a discussing population-based screening"
  },
  {
    "start": 395.88,
    "end": 400.2,
    "text": " when we refer to an entire population solely defined"
  },
  {
    "start": 400.2,
    "end": 403.2,
    "text": " as the setting end or the age,"
  },
  {
    "start": 403.2,
    "end": 407.12,
    "text": " like we can discuss for others, the screenings,"
  },
  {
    "start": 407.12,
    "end": 409.8,
    "text": " or target screening."
  },
  {
    "start": 409.8,
    "end": 414.8,
    "text": " That would mean that you further define a subsetting again,"
  },
  {
    "start": 414.8,
    "end": 417.96,
    "text": " like for instance, if we would be defining screening"
  },
  {
    "start": 417.96,
    "end": 421.04,
    "text": " for barrens or for other diseases"
  },
  {
    "start": 421.04,
    "end": 423.36,
    "text": " like pancreatic cancer, et cetera."
  },
  {
    "start": 423.36,
    "end": 428.12,
    "text": " And then lastly, a screening/opportunistic diagnosis"
  },
  {
    "start": 428.12,
    "end": 432.68,
    "text": " that we suggested that in every gastroscopy should be done,"
  },
  {
    "start": 432.68,
    "end": 434.68,
    "text": " that is probably a chance"
  },
  {
    "start": 434.68,
    "end": 437.36,
    "text": " when the citizen come to the health system"
  },
  {
    "start": 437.36,
    "end": 440.72,
    "text": " for the first time and it's probably a lost moment"
  },
  {
    "start": 440.72,
    "end": 443.52,
    "text": " if you don't care about looking carefully to the stomach"
  },
  {
    "start": 443.52,
    "end": 445.8,
    "text": " and detect what you should be detecting."
  },
  {
    "start": 445.8,
    "end": 447.24,
    "text": " Of course, if the first two,"
  },
  {
    "start": 447.24,
    "end": 449.28,
    "text": " meaning the population and the target,"
  },
  {
    "start": 449.28,
    "end": 452.2,
    "text": " would be more, let's say, more or less to be defined"
  },
  {
    "start": 452.2,
    "end": 456.36,
    "text": " by policy makers and when and how to implement"
  },
  {
    "start": 456.36,
    "end": 458.52,
    "text": " and maybe we can discuss further this."
  },
  {
    "start": 458.52,
    "end": 462.44,
    "text": " The last is for everyday clinicians to decide"
  },
  {
    "start": 462.44,
    "end": 466.48,
    "text": " and that should be applying what we suggest in the guidelines."
  },
  {
    "start": 466.48,
    "end": 470.16,
    "text": " - Okay, let's briefly dwell into population-based screening"
  },
  {
    "start": 470.16,
    "end": 472.64,
    "text": " and you do make some statements about this"
  },
  {
    "start": 472.64,
    "end": 473.92,
    "text": " in the guidelines."
  },
  {
    "start": 473.92,
    "end": 478.2,
    "text": " Can you briefly tell us how this is done,"
  },
  {
    "start": 478.2,
    "end": 479.6,
    "text": " where this should be done"
  },
  {
    "start": 479.6,
    "end": 482.36,
    "text": " and when it should be done, how frequently?"
  },
  {
    "start": 482.36,
    "end": 486.92,
    "text": " - Yeah, well, some of the answers are not, let's say, there yet."
  },
  {
    "start": 486.92,
    "end": 491.76,
    "text": " So, for instance, there is some evidence to suggest"
  },
  {
    "start": 491.76,
    "end": 494.04,
    "text": " that in Eastern countries,"
  },
  {
    "start": 494.04,
    "end": 496.48,
    "text": " that of course we are discussing mostly for Europe,"
  },
  {
    "start": 496.48,
    "end": 498.28,
    "text": " even though this guideline has been taken"
  },
  {
    "start": 498.28,
    "end": 501.4,
    "text": " by others in different parts of the globe."
  },
  {
    "start": 501.4,
    "end": 503.2,
    "text": " But of course, if the country as a whole"
  },
  {
    "start": 503.2,
    "end": 507.0,
    "text": " has a very high incidence for gastric cancer,"
  },
  {
    "start": 507.0,
    "end": 510.64,
    "text": " probably justifies to implement even a standalone screening"
  },
  {
    "start": 510.64,
    "end": 513.2,
    "text": " procedure for gastric."
  },
  {
    "start": 513.2,
    "end": 516.8,
    "text": " That all means that that individual would be recommended"
  },
  {
    "start": 516.8,
    "end": 519.8,
    "text": " to make an endoscopy or any other matter for screening,"
  },
  {
    "start": 519.8,
    "end": 523.96,
    "text": " such as seronpicepepsinogen or other measures,"
  },
  {
    "start": 523.96,
    "end": 525.8,
    "text": " such as primary prevention,"
  },
  {
    "start": 525.8,
    "end": 528.8,
    "text": " such as screening and treating forage pylori."
  },
  {
    "start": 528.8,
    "end": 533.64,
    "text": " If we move to Europe, we may not have such areas"
  },
  {
    "start": 533.64,
    "end": 535.08,
    "text": " with a very high incidence"
  },
  {
    "start": 535.08,
    "end": 539.56,
    "text": " and we discuss mostly intermediate and low areas."
  },
  {
    "start": 539.56,
    "end": 542.6,
    "text": " So, the suggestion that we make is that if,"
  },
  {
    "start": 542.6,
    "end": 546.08,
    "text": " for that specific area, it's finally shown"
  },
  {
    "start": 546.08,
    "end": 549.12,
    "text": " that it's cost effective to have screening"
  },
  {
    "start": 549.12,
    "end": 552.08,
    "text": " for gastric cancer, then it should be implemented."
  },
  {
    "start": 552.08,
    "end": 554.08,
    "text": " So, of course, it's a circular suggestion,"
  },
  {
    "start": 554.08,
    "end": 558.52,
    "text": " but we open the door to the projects that are ongoing,"
  },
  {
    "start": 558.52,
    "end": 561.08,
    "text": " like Togas, it's a European consortium"
  },
  {
    "start": 561.08,
    "end": 563.36,
    "text": " that will address these topics."
  },
  {
    "start": 563.36,
    "end": 566.56,
    "text": " And we may find out different answers in different parts,"
  },
  {
    "start": 566.56,
    "end": 569.0,
    "text": " depending on facilities."
  },
  {
    "start": 569.0,
    "end": 570.52,
    "text": " And finally, the cost, of course,"
  },
  {
    "start": 570.52,
    "end": 573.16,
    "text": " I will not go into detail on cost effective studies,"
  },
  {
    "start": 573.16,
    "end": 577.08,
    "text": " but our suggestion is that if in a specific area,"
  },
  {
    "start": 577.08,
    "end": 581.0,
    "text": " it's finally shown that it's cost effective to go"
  },
  {
    "start": 581.0,
    "end": 582.8,
    "text": " for screening, we should go."
  },
  {
    "start": 582.8,
    "end": 587.68,
    "text": " The suggestion is also made in a previous position statement"
  },
  {
    "start": 587.68,
    "end": 591.76,
    "text": " and also based even for the states"
  },
  {
    "start": 591.76,
    "end": 593.84,
    "text": " in some cost effectiveness there,"
  },
  {
    "start": 593.84,
    "end": 595.44,
    "text": " that it may be cost effective"
  },
  {
    "start": 595.44,
    "end": 598.96,
    "text": " to synergistically approach the population"
  },
  {
    "start": 598.96,
    "end": 601.04,
    "text": " together with the correct cancer screening."
  },
  {
    "start": 601.04,
    "end": 604.36,
    "text": " How, well, we could go for fit based"
  },
  {
    "start": 604.36,
    "end": 606.68,
    "text": " plus seeking for H. pylori,"
  },
  {
    "start": 606.68,
    "end": 610.52,
    "text": " I guess that Mars is already alluded to that in this talk,"
  },
  {
    "start": 610.52,
    "end": 613.8,
    "text": " or if the patient finally comes to prognoscopy,"
  },
  {
    "start": 613.8,
    "end": 617.12,
    "text": " either from primary colonoscopy towards screening"
  },
  {
    "start": 617.12,
    "end": 620.88,
    "text": " or fit based programs, we could add up the upper GI."
  },
  {
    "start": 620.88,
    "end": 624.2,
    "text": " This was shown to be cost effective almost one decade ago"
  },
  {
    "start": 624.2,
    "end": 626.52,
    "text": " and also recently, when we addressed"
  },
  {
    "start": 626.52,
    "end": 629.0,
    "text": " by our group also the role of AI"
  },
  {
    "start": 629.0,
    "end": 631.92,
    "text": " in intermediate regions in Europe,"
  },
  {
    "start": 631.92,
    "end": 635.32,
    "text": " such as Portugal, Romania, some parts of Spain"
  },
  {
    "start": 635.32,
    "end": 636.8,
    "text": " and Italy, et cetera."
  },
  {
    "start": 636.8,
    "end": 639.12,
    "text": " So these were the suggestions."
  },
  {
    "start": 639.12,
    "end": 641.84,
    "text": " In Europe, I think we could differentiate"
  },
  {
    "start": 641.84,
    "end": 645.88,
    "text": " between intermediate regions and risk areas"
  },
  {
    "start": 645.88,
    "end": 648.56,
    "text": " for the first synergistic approach"
  },
  {
    "start": 648.56,
    "end": 650.4,
    "text": " could be cost effective."
  },
  {
    "start": 650.4,
    "end": 652.4,
    "text": " - So to summarize, Mario, within Europe,"
  },
  {
    "start": 652.4,
    "end": 654.12,
    "text": " there's no high risk regions."
  },
  {
    "start": 654.12,
    "end": 656.72,
    "text": " - Yeah, we can define Europe in different ways."
  },
  {
    "start": 656.72,
    "end": 661.12,
    "text": " So there may be some specific regions"
  },
  {
    "start": 661.12,
    "end": 663.24,
    "text": " that I don't know by heart in different countries,"
  },
  {
    "start": 663.24,
    "end": 664.4,
    "text": " where it may be just a file,"
  },
  {
    "start": 664.4,
    "end": 666.84,
    "text": " but in general, there are no high risk areas."
  },
  {
    "start": 666.84,
    "end": 670.32,
    "text": " - Okay, so the intermediate risk regions,"
  },
  {
    "start": 670.32,
    "end": 672.04,
    "text": " you can consider the screening"
  },
  {
    "start": 672.04,
    "end": 674.84,
    "text": " as long as cost effective is what you said."
  },
  {
    "start": 674.84,
    "end": 678.28,
    "text": " And most European countries are low risk"
  },
  {
    "start": 678.28,
    "end": 682.56,
    "text": " except for is that Portugal and Eastern European countries"
  },
  {
    "start": 682.56,
    "end": 686.64,
    "text": " and screening is not advised based on the guidelines."
  },
  {
    "start": 686.64,
    "end": 687.48,
    "text": " Is that correct?"
  },
  {
    "start": 687.48,
    "end": 690.32,
    "text": " - Yeah, that is our suggestion."
  },
  {
    "start": 690.32,
    "end": 694.04,
    "text": " And also, for instance, if we discuss the low regions"
  },
  {
    "start": 694.04,
    "end": 696.52,
    "text": " that are more frequently in Europe,"
  },
  {
    "start": 696.52,
    "end": 699.4,
    "text": " one topic that is also important to mention here"
  },
  {
    "start": 699.4,
    "end": 701.84,
    "text": " is that we didn't include this in our definitions."
  },
  {
    "start": 701.84,
    "end": 702.92,
    "text": " When you speak about screening,"
  },
  {
    "start": 702.92,
    "end": 704.72,
    "text": " public should be organized,"
  },
  {
    "start": 704.72,
    "end": 707.8,
    "text": " meaning that it can address all the population"
  },
  {
    "start": 707.8,
    "end": 709.24,
    "text": " like we were discussing before,"
  },
  {
    "start": 709.24,
    "end": 713.2,
    "text": " or eventually, even if for low risk countries,"
  },
  {
    "start": 713.2,
    "end": 715.8,
    "text": " to be organized means that probably"
  },
  {
    "start": 715.8,
    "end": 719.44,
    "text": " either first degree relatives or some ethnicities"
  },
  {
    "start": 719.44,
    "end": 723.96,
    "text": " or some immigrants should be probably proposed to screening."
  },
  {
    "start": 723.96,
    "end": 726.0,
    "text": " For instance, the result of a cost effective study"
  },
  {
    "start": 726.0,
    "end": 728.72,
    "text": " is also in the USA."
  },
  {
    "start": 728.72,
    "end": 731.2,
    "text": " And there is a sub task in targets"
  },
  {
    "start": 731.2,
    "end": 733.92,
    "text": " that will address these kind of questions."
  },
  {
    "start": 733.92,
    "end": 736.36,
    "text": " Because even if it is not cost effective"
  },
  {
    "start": 736.36,
    "end": 737.76,
    "text": " for the entire population,"
  },
  {
    "start": 737.76,
    "end": 740.68,
    "text": " there is a nice manuscript published by the Dutch group"
  },
  {
    "start": 740.68,
    "end": 742.96,
    "text": " alluding to the ethical aspects"
  },
  {
    "start": 742.96,
    "end": 746.24,
    "text": " of not going for a general population"
  },
  {
    "start": 746.24,
    "end": 748.08,
    "text": " and going only for some segments."
  },
  {
    "start": 748.08,
    "end": 749.52,
    "text": " That on one side, of course,"
  },
  {
    "start": 749.52,
    "end": 752.24,
    "text": " you increase paradoxically equity"
  },
  {
    "start": 752.24,
    "end": 755.0,
    "text": " by proposing to those that are probably lost."
  },
  {
    "start": 755.0,
    "end": 758.68,
    "text": " But you can also bring some prejudice to those that are,"
  },
  {
    "start": 758.68,
    "end": 762.28,
    "text": " let's say, the target of a specific screening such as these"
  },
  {
    "start": 762.28,
    "end": 767.4,
    "text": " because they can be, let's say, identified as such a group"
  },
  {
    "start": 767.4,
    "end": 769.2,
    "text": " with a high risk, et cetera."
  },
  {
    "start": 769.2,
    "end": 772.96,
    "text": " So you can consider screening for high risk population"
  },
  {
    "start": 772.96,
    "end": 777.44,
    "text": " within a low risk region, kind of technically speaking."
  },
  {
    "start": 777.44,
    "end": 778.72,
    "text": " Exactly."
  },
  {
    "start": 778.72,
    "end": 783.32,
    "text": " Okay, now, once a patient develops a pre-malignant changes"
  },
  {
    "start": 783.32,
    "end": 789.0,
    "text": " within the stomach, does geography or ethnicity"
  },
  {
    "start": 789.0,
    "end": 791.64,
    "text": " play a role in progression towards cancer?"
  },
  {
    "start": 791.64,
    "end": 793.52,
    "text": " Or any other factor that plays a role?"
  },
  {
    "start": 793.52,
    "end": 795.44,
    "text": " That's a very, very important question."
  },
  {
    "start": 795.44,
    "end": 797.92,
    "text": " And I think this is a very practical question."
  },
  {
    "start": 797.92,
    "end": 803.78,
    "text": " practical one and that this was one of the reasons that motivated the systematic review"
  },
  {
    "start": 803.78,
    "end": 811.9,
    "text": " that we were able to publish in God last year, that where we systematically review the guidelines"
  },
  {
    "start": 811.9,
    "end": 821.26,
    "text": " and all of them tend to say that when we detect such changes, first of all, we will not surveil"
  },
  {
    "start": 821.26,
    "end": 826.88,
    "text": " everyone and we will have to select those that merit surveillance. Then there are some"
  },
  {
    "start": 826.88,
    "end": 832.26,
    "text": " differences in the schedule of that surveillance that we can come back. But in principle, the"
  },
  {
    "start": 832.26,
    "end": 840.22,
    "text": " answer is no. It doesn't matter if you are Portuguese or Dutch or Norwegian or German."
  },
  {
    "start": 840.22,
    "end": 845.38,
    "text": " Once you have that phenotype at risk, then you should be surveilled. And it's the same"
  },
  {
    "start": 845.38,
    "end": 851.14,
    "text": " of having a denomination in the colon for our merits. So this is an important message that"
  },
  {
    "start": 851.14,
    "end": 859.54,
    "text": " sometimes eventually we may think that the same reasons that led us to implement a screening"
  },
  {
    "start": 859.54,
    "end": 865.34,
    "text": " procedure would affect then the decisions towards surveilling or not. And this is a"
  },
  {
    "start": 865.34,
    "end": 869.34,
    "text": " different, let's say, moment in the pathway of managing an individual."
  },
  {
    "start": 869.34,
    "end": 875.42,
    "text": " Mario, some of the audience may, I'm sure everyone knows, we describe pre-malignant changes in"
  },
  {
    "start": 875.42,
    "end": 879.34,
    "text": " the stomach. For the benefit of audience, can you describe what they are?"
  },
  {
    "start": 879.34,
    "end": 886.06,
    "text": " Yeah, within this scope, mostly, we are discussing trophic changes in the stomach and the presence"
  },
  {
    "start": 886.06,
    "end": 892.46,
    "text": " of in testament to pleasure. Of course, it's a marker of a trophy, but it's a step. So"
  },
  {
    "start": 892.46,
    "end": 899.94,
    "text": " the paleo-carea cascade, the perfect cascade, suggests that from a normal mucosa, there"
  },
  {
    "start": 899.94,
    "end": 905.62,
    "text": " is a progression from gastritis, then trophic changes, then in testament to pleasure and"
  },
  {
    "start": 905.62,
    "end": 911.54,
    "text": " final dysplasia. What we understood is that this is not, let's say, this does not occur"
  },
  {
    "start": 911.54,
    "end": 918.58,
    "text": " in 100% of the patients, of course. And from step to step, there are some, let's say, markers"
  },
  {
    "start": 918.58,
    "end": 923.98,
    "text": " of further increase in the risk. For instance, if the trophic changes and testament to pleasure"
  },
  {
    "start": 923.98,
    "end": 930.14,
    "text": " are more frequent in the stomach, meaning they are seen in several parts of the stomach,"
  },
  {
    "start": 930.14,
    "end": 934.22,
    "text": " those are the individuals that merit surveillance rather than the others. We will come back for"
  },
  {
    "start": 934.22,
    "end": 938.54,
    "text": " sure for this to discuss about this. One thing that struck me, probably a bit"
  },
  {
    "start": 938.54,
    "end": 944.34,
    "text": " of practice changing, or at least have not come across this in any of the previous guidelines,"
  },
  {
    "start": 944.34,
    "end": 950.82,
    "text": " you make two statements on the relatives of patients with gastric cancer. You just alluded"
  },
  {
    "start": 950.82,
    "end": 956.74,
    "text": " to just now that ethnicity in things may not matter, but family history does matter in"
  },
  {
    "start": 956.74,
    "end": 961.3,
    "text": " terms of value-added risk. You mentioned two things. You mentioned about the helicobacterpylori"
  },
  {
    "start": 961.3,
    "end": 968.18,
    "text": " screening and you mentioned about endoscopy screening for such individuals. Can you explain"
  },
  {
    "start": 968.18,
    "end": 976.54,
    "text": " what recommendation the Guideline Committee made and how strong is the evidence for making"
  },
  {
    "start": 976.54,
    "end": 978.82,
    "text": " such recommendation?"
  },
  {
    "start": 978.82,
    "end": 985.66,
    "text": " So just to stress, and this is nice to have this chat, so what I've said is that for determining"
  },
  {
    "start": 985.66,
    "end": 990.82,
    "text": " if the patient has to be surveilled or not, in principle, ethnicity does not matter. But"
  },
  {
    "start": 990.82,
    "end": 997.5,
    "text": " for instance, when defining an organized screening program in a low risk country, it may matter."
  },
  {
    "start": 997.5,
    "end": 1004.1,
    "text": " Coming to the first degree, relatives of family, of patients with gastric cancer, well, first"
  },
  {
    "start": 1004.1,
    "end": 1011.82,
    "text": " of all, it's an easy marker. So all the commissions should have the family history of their patients."
  },
  {
    "start": 1011.82,
    "end": 1018.38,
    "text": " Secondly, patients, they know that marker and eventually they can be empowered to seek"
  },
  {
    "start": 1018.38,
    "end": 1023.98,
    "text": " health care and health resources. The evidence is not that strong, but it's not that strong"
  },
  {
    "start": 1023.98,
    "end": 1030.46,
    "text": " and also for the colon, where we anticipate the screening based on an increased risk for"
  },
  {
    "start": 1030.46,
    "end": 1035.58,
    "text": " colorectal cancer of a certain magnitude. So for gastric cancer and also for premillian"
  },
  {
    "start": 1035.58,
    "end": 1042.18,
    "text": " conditions, what we observed is that family, first degree relatives of patients with gastric"
  },
  {
    "start": 1042.18,
    "end": 1047.54,
    "text": " cancer, and it doesn't matter too much if it's from the intestinal type or diffuse type,"
  },
  {
    "start": 1047.54,
    "end": 1053.42,
    "text": " they do have an increased risk for gastric cancer and for premillian changes. So based"
  },
  {
    "start": 1053.42,
    "end": 1061.54,
    "text": " on this, and also consistently with other, I'd say, panels, we suggested that we should"
  },
  {
    "start": 1061.54,
    "end": 1068.38,
    "text": " go for an anticipation of, or eventually only for this, the primary prevention moment, where"
  },
  {
    "start": 1068.38,
    "end": 1074.86,
    "text": " we seek for H. pylori and we eradicate, if we speak with patients, this is what we say,"
  },
  {
    "start": 1074.86,
    "end": 1082.02,
    "text": " that is, what can I do to avoid what my brother had or my father? And of course, we are discussing"
  },
  {
    "start": 1082.02,
    "end": 1088.9,
    "text": " outside genetic syndromes. And then there is a second moment of secondary prevention."
  },
  {
    "start": 1088.9,
    "end": 1093.74,
    "text": " And for that, the suggestion that we've made is not with a strong evidence because we don't"
  },
  {
    "start": 1093.74,
    "end": 1098.58,
    "text": " have trials, we don't have many studies suggesting that we should do what we suggest, but on"
  },
  {
    "start": 1098.58,
    "end": 1103.38,
    "text": " the other side, it's the best we can suggest to someone that has a relative that is to"
  },
  {
    "start": 1103.38,
    "end": 1110.42,
    "text": " anticipate somehow an endoscopic screening procedure for detecting exactly what I said."
  },
  {
    "start": 1110.42,
    "end": 1116.86,
    "text": " We hope also, by suggesting this, that eventually either it's consolidated by the community,"
  },
  {
    "start": 1116.86,
    "end": 1121.54,
    "text": " by further studies, or it's contradicted and then we need to adapt the recommendation."
  },
  {
    "start": 1121.54,
    "end": 1127.3,
    "text": " But this is kind of consistent, also for practice in most countries and also in some of the guidelines"
  },
  {
    "start": 1127.3,
    "end": 1133.74,
    "text": " that use, this is probably the most consistent marker, even for instance, in Europe for the"
  },
  {
    "start": 1133.74,
    "end": 1140.78,
    "text": " Spanish guideline that somehow does not suggest there's as commonly the surveillance for some"
  },
  {
    "start": 1140.78,
    "end": 1146.9,
    "text": " of these patients, the family risk is there, and also for the surveillance of the treatments."
  },
  {
    "start": 1146.9,
    "end": 1152.26,
    "text": " Yeah, I think you recommend two things. You recommend Helicobacter pylori testing for"
  },
  {
    "start": 1152.26,
    "end": 1159.1,
    "text": " first-aid relatives between the ages of 20 and 30, and OGD at the age of 45 or 10 years"
  },
  {
    "start": 1159.1,
    "end": 1163.7,
    "text": " before the age of diagnosis of the affected relative. I think this is something I think"
  },
  {
    "start": 1163.7,
    "end": 1168.58,
    "text": " people should be aware because this is not something we have traditionally done in clinical"
  },
  {
    "start": 1168.58,
    "end": 1175.7,
    "text": " practice and it came as a completely new knowledge to me, which I have not been offering, although"
  },
  {
    "start": 1175.7,
    "end": 1181.86,
    "text": " it was in the back of my mind. Of course, there are many health problems that we need to deal with,"
  },
  {
    "start": 1181.86,
    "end": 1186.5,
    "text": " and of course, there will be priorities. But if you think along the an ageing population in"
  },
  {
    "start": 1186.5,
    "end": 1194.42,
    "text": " Europe, also with some immigrants with an eye in between countries, and also other risk factors"
  },
  {
    "start": 1194.42,
    "end": 1201.94,
    "text": " that prevail like smoking, obesity, assault intake, so all of those makes probably this"
  },
  {
    "start": 1201.94,
    "end": 1209.82,
    "text": " measurement of family history so easy that it may lead to a screening procedure and an early"
  },
  {
    "start": 1209.82,
    "end": 1216.18,
    "text": " diagnosis because again, there is also a notion that I think it's all important to disseminate"
  },
  {
    "start": 1216.18,
    "end": 1222.1,
    "text": " this, even though the incidence, so the number of new cases over those that are at risk has been"
  },
  {
    "start": 1222.1,
    "end": 1228.34,
    "text": " decreasing year after year in Europe, we face an increase in the number of cases because of what"
  },
  {
    "start": 1228.34,
    "end": 1234.82,
    "text": " I said before. So in Europe, what is expected is that the number of cases will increase during the"
  },
  {
    "start": 1234.82,
    "end": 1241.62,
    "text": " next decades, and if we don't do anything in terms of early diagnosis, these small prognoses will"
  },
  {
    "start": 1241.62,
    "end": 1248.5,
    "text": " continue to be absurd. What I see lately, the number of endoscopies that we do is significantly"
  },
  {
    "start": 1248.5,
    "end": 1256.18,
    "text": " gone up, and the number of patients, older patients we're subjecting endoscopy to has gone up,"
  },
  {
    "start": 1256.18,
    "end": 1262.26,
    "text": " and more and more we do this by refining pre-malignant lesions in the stomach in older patients."
  },
  {
    "start": 1262.26,
    "end": 1269.54,
    "text": " Does the guideline can't you make any recommendation of either not doing some, is there any age cut"
  },
  {
    "start": 1269.54,
    "end": 1273.38,
    "text": " off or not offering surveillance for these patients? Again, of course, we need to take"
  },
  {
    "start": 1273.38,
    "end": 1280.98,
    "text": " care of all patients. On the other side, we first do no harm. So this is the other side"
  },
  {
    "start": 1280.98,
    "end": 1289.54,
    "text": " of the coin that we were discussing before. That is, is it reasonable for someone with 88 years old"
  },
  {
    "start": 1289.54,
    "end": 1297.06,
    "text": " asymptomatic patients to suggest to that patient screening procedure for any disease"
  },
  {
    "start": 1297.06,
    "end": 1306.5,
    "text": " in the luminal GI tract? No. So we set a bar at 80 years because life expectancy in Europe"
  },
  {
    "start": 1306.5,
    "end": 1312.18,
    "text": " is now increasing, or if for that specific individual, it doesn't make sense in terms"
  },
  {
    "start": 1312.18,
    "end": 1317.78,
    "text": " of life expectancy because of other comorbidities. I think this is bringing to the stomach what has"
  },
  {
    "start": 1317.78,
    "end": 1323.54,
    "text": " been said in the column and also in Barrett's recently, but at a certain stage it should not only"
  },
  {
    "start": 1324.34,
    "end": 1330.34,
    "text": " let's say we should stop. It's not giving up of that individual. It's allowing that individual not"
  },
  {
    "start": 1330.34,
    "end": 1336.18,
    "text": " to be submitted to procedures that probably will not affect finally their life expectancy."
  },
  {
    "start": 1336.18,
    "end": 1341.14,
    "text": " Yeah. I guess that boils down to this career cascade that you mentioned, that you go to"
  },
  {
    "start": 1341.14,
    "end": 1348.74,
    "text": " stepwise and this takes often years to change. And even if it is an early gastro-cancer by the time"
  },
  {
    "start": 1348.74,
    "end": 1354.58,
    "text": " that kind of progresses and causes harm to the patient, it may take some time, right?"
  },
  {
    "start": 1354.58,
    "end": 1360.58,
    "text": " And it leads then to difficult decisions because then, okay, if finally you detect the lesion,"
  },
  {
    "start": 1360.58,
    "end": 1365.62,
    "text": " and then how to say to that patient that I will not treat you because, well,"
  },
  {
    "start": 1365.62,
    "end": 1371.7,
    "text": " probably finally exactly what you say, you will not suffer from this specific disease. So it's,"
  },
  {
    "start": 1371.7,
    "end": 1376.98,
    "text": " I think that the message is regardless of the screening program that you organized,"
  },
  {
    "start": 1376.98,
    "end": 1383.78,
    "text": " there will be an age limit. Or at the individual that is in front of you, don't start making"
  },
  {
    "start": 1383.78,
    "end": 1390.26,
    "text": " procedures that finally may lead to diseases that you were not, let's say, interested in managing"
  },
  {
    "start": 1390.26,
    "end": 1396.18,
    "text": " or the patient was not interested at all in knowing that, that phase of their life. This is"
  },
  {
    "start": 1396.18,
    "end": 1400.18,
    "text": " difficult, but I think it's an important recommendation. Of course, there is no evidence"
  },
  {
    "start": 1400.18,
    "end": 1405.62,
    "text": " about this. There is some scattered evidence of showing that then finally, for instance,"
  },
  {
    "start": 1405.62,
    "end": 1409.62,
    "text": " if even if you treat the cancer, but this is non-curity, you don't send the patient to surgery."
  },
  {
    "start": 1409.62,
    "end": 1412.98,
    "text": " So it's very questionable."
  },
  {
    "start": 1412.98,
    "end": 1418.58,
    "text": " Mario, we discussed earlier that what I see in clinical practice is huge variation in terms"
  },
  {
    "start": 1418.58,
    "end": 1424.18,
    "text": " of reporting of pre-malignant lesions. And that the main reason for this is lack of awareness"
  },
  {
    "start": 1424.18,
    "end": 1432.18,
    "text": " by the endoscopers. And certainly when I see our trainees, most of the education they get is from"
  },
  {
    "start": 1432.18,
    "end": 1438.82,
    "text": " peers, from their trainers, who are also not so much of recognizing these lesions and describing"
  },
  {
    "start": 1438.82,
    "end": 1445.14,
    "text": " these lesions. Is there any resource that we can refer to? I don't know, could be just videos and"
  },
  {
    "start": 1445.14,
    "end": 1451.46,
    "text": " things for our listeners to get some training in recognizing and describing these gastric"
  },
  {
    "start": 1451.46,
    "end": 1457.06,
    "text": " pre-malignant lesions. So this was probably the only thing in terms of, let's say, technical"
  },
  {
    "start": 1457.62,
    "end": 1463.7,
    "text": " perspectives that we brought to this guideline that were some hopefully considered nice pictures."
  },
  {
    "start": 1463.7,
    "end": 1471.3,
    "text": " And in fact, the descriptors that we may use to describe the presence of a trophy, but mainly"
  },
  {
    "start": 1471.3,
    "end": 1476.9,
    "text": " testament to pleasure that is quite more reliable, even among observers that are considered to be"
  },
  {
    "start": 1476.9,
    "end": 1485.22,
    "text": " experts, are similar to that to those that we observed in various. So for most of the European"
  },
  {
    "start": 1485.22,
    "end": 1491.3,
    "text": " endoscopers, if they are used to describe bearers, they will be able easily to learn how to"
  },
  {
    "start": 1491.3,
    "end": 1498.5,
    "text": " assess the gastric mucosa. Regardless of this, there are some educational tools delivered by ESC,"
  },
  {
    "start": 1498.5,
    "end": 1507.38,
    "text": " of course, reserved for ESC individual members. And we will have a course coordinated by EU,"
  },
  {
    "start": 1507.38,
    "end": 1512.58,
    "text": " within a consortium that is called You Can Screen, that will have three editions during the next"
  },
  {
    "start": 1512.58,
    "end": 1520.58,
    "text": " two years, two in Portugal and one in Lithuania, where at least 30 participants, 30 train the"
  },
  {
    "start": 1520.58,
    "end": 1526.18,
    "text": " trainers, will be able to participate and learn more about this. So be aware of this and be ready"
  },
  {
    "start": 1526.18,
    "end": 1533.78,
    "text": " to register in those courses. I think for those, the guidelines are amazing. The way, you know,"
  },
  {
    "start": 1533.78,
    "end": 1539.7,
    "text": " the pictorial representation of the tables in the guidelines are really good. And if people"
  },
  {
    "start": 1539.7,
    "end": 1545.22,
    "text": " want to refer to those, I really suggest. And that's the best way to know. And it's very"
  },
  {
    "start": 1545.22,
    "end": 1550.82,
    "text": " simplified in the guidelines, so I have to say. So we've had some wonderful conversation for the"
  },
  {
    "start": 1550.82,
    "end": 1556.5,
    "text": " last 30 minutes. There's still a lot more to cover and we'll be discussing this. But as we've"
  },
  {
    "start": 1556.5,
    "end": 1562.42,
    "text": " gone past 30 minutes, we thought we should end this as the first part. There's still lots to"
  },
  {
    "start": 1562.42,
    "end": 1569.54,
    "text": " discuss in the second part, which will be discussed in a week on the 9th of July. So there"
  },
  {
    "start": 1569.54,
    "end": 1575.86,
    "text": " we continue our discussion on maps three, the recommendations on the use of artificial intelligence,"
  },
  {
    "start": 1575.86,
    "end": 1581.7,
    "text": " the management of early gastric cancers and identification of pre-malignant lesions."
  },
  {
    "start": 1581.7,
    "end": 1589.22,
    "text": " And of course, what the acronym MAPS stands for, which has been a bit of mystery so far for me."
  },
  {
    "start": 1589.22,
    "end": 1592.74,
    "text": " Be sure to tune in again next week. Goodbye."
  }
]