Jonathan A. Leighton | Professor of Medicine, Mayo Clinic, Phoenix, Arizona, USA; Immediate Past President of the American College of Gastroenterology (ACG)
Citation: EMJ Gastroenterol. 2024; https://doi.org/10.33590/emjgastroenterol/PHOO3308
What inspired your particular interest in gastrointestinal conditions such as inflammatory bowel disease (IBD) and colorectal neoplasia?
I have always been fascinated by inflammatory pathways, and IBD is a direct result of uncontrolled inflammation in the body. Other factors, like genetics and the environment, also contribute, but uncontrolled inflammation is certainly the key one. In addition, early in my career, I became involved with the Crohn’s and Colitis Foundation. I think both factors led to my focus on the care of patients with IBD.
Colorectal neoplasia is basic to what we do as gastroenterologists in terms of colonoscopy and colorectal screening. My group had a lot of curiosity and interest in how we could improve colonoscopy, and so we mainly focused on issues of adenoma detection rates and colon prep quality.
So, those were two areas that made sense to me in terms of building an academic and clinical career.
As Immediate Past President of the American College of Gastroenterology (ACG), what have been your proudest achievements in this position? What would you like to see ACG achieve in years to come?
At Mayo Clinic, Phoenix, Arizona, USA, where I worked for the last 34 years, one of my areas of priority was leading the office of joy and wellbeing. I realised that burnout and issues around wellbeing were critical in the healthcare workforce, including gastroenterology. It was clear that burnout was causing physicians and other allied health staff to leave their jobs or retire early, and I thought this was a significant issue that needed to be addressed in gastroenterology.
One of my goals was to educate our members about the issues of burnout, and how to improve their wellbeing. We spent a lot of time on this. The professionalism committee also worked on this issue and created an ACG website, and we had two ACG virtual Grand Rounds. One of the ACG magazine publications focused on wellbeing, and we worked hard on bringing this issue to the forefront. I am proud that we were able to achieve that. I hope we will continue to address burnout.
Another priority was revising our strategic plan. We developed a very broad strategic plan that incorporates multiple areas relevant to gastroenterology today, with some fantastic tactics that we are going to attach to those strategic priorities. We are very excited about the future, and the ACG Board of Trustees will continue to work on this for the next several months. I am confident that it will make us a better organisation.
The third achievement focused on innovation and endoscopy. One of our priorities was to have a bigger endoscopic footprint as part of the ACG, and we’ve worked extensively on expanding our endoscopy and education programming. In fact, we now have a Friday Endoscopy School at some of our regional courses, and we renamed our hands-on workshop ‘Endoscopy School’ as well. We’re now continuing to look for opportunities to help with innovation in endoscopy.
The fourth achievement dealt with international outreach and global health learning, and I am a strong proponent of this. We know that the world we live in now has become so global, and healthcare is no different. Although the ACG mainly focuses on the USA, we are already doing quite a bit of international outreach, but there is even more we can do. I am involved with the World Gastroenterology Organization (WGO), where there is really an opportunity for our members to benefit from international outreach programmes and global health learning. It has the potential to offer our members other ways to get more involved with research and education. Again, I hope that we will continue to look at ways to expand our international footprint.
Last but not least, I did have a priority around environmental issues and sustainability in endoscopy. We have a task force on sustainability, and I asked them to develop a simple strategic plan that we could move forward with that focused on education, research, and partnering with industry to improve sustainability. They were able to accomplish that, and we will continue to work on this.
So, those are the five areas that I focused on, and I think we have made considerable headway.
A key focus of your work is developing new devices for small bowel imaging. Can you elaborate on your research in capsule endoscopy and balloon enteroscopy?
Capsule endoscopy was truly a disruptive technology that I had the opportunity to get involved with early on. Disruptive technologies do not come along very often. One of the gaps in gastroenterology was the diagnosis and management of small bowel disorders: we didn’t have a good way to visualise the mucosa of the small bowel because it is long and tortuous, and there wasn’t any technology available that could accomplish that. I was fortunate to be at the right place at the right time when capsule endoscopy came along.
Capsule endoscopy allowed us to explore the small bowel in a complete way, which was unprecedented. It was an exciting time because this new technology was being studied around the world. It was a unique opportunity for me to be exposed to global issues surrounding small bowel diseases and learn how to improve diagnosis and management. I was able to spend most of my academic career studying capsule endoscopy and determining which diseases it would be most useful for, including IBD and small bowel bleeding.
From there, balloon enteroscopy was developed: initially double balloon, and then single balloon enteroscopy. This was exciting to study because it complemented capsule endoscopy. Before this, you could perform capsule endoscopy to diagnose small bowel disease, but you didn’t have any therapeutic capabilities, and you couldn’t always confirm the diagnosis. With the invention of balloon enteroscopy, we were able to take it to the next level and perform biopsy and therapeutics in the small bowel. We were then able to study the impact of balloon enteroscopy on the management of these disorders, whether it was treating angiodysplasia in bleeding, diagnosing Crohn’s disease, or dilating a stricture in the small bowel.
Initially, we did capsule endoscopy, followed by balloon enteroscopy, and then we also had radiologists perform CT and MR enterography. These were three modalities that came around in the early 2000s; they all complemented each other, and they allowed us to better diagnose and manage small bowel diseases. I was very fortunate to be able to participate in the research and education dealing with this unique and exciting technology.
Are you currently exploring any novel therapeutics for Crohn’s disease and ulcerative colitis? How do you see biomarker discovery shaping the future of IBD diagnosis and management?
At Mayo Clinic, we are fortunate to have three different sites in Rochester, Arizona, and Florida, and we were able to develop a three-site IBD biobank where we store the serum and stool from patients with IBD. Having that biobank has allowed us to do some interesting work in terms of biomarker discovery, looking for biomarkers that not only can diagnose IBD earlier, and differentiate Crohn’s disease from ulcerative colitis, but might also give us profiles on which drug would work best in any given patient. We still have a ways to go in this area, but being a part of this biomarker discovery in collaboration with other academic centres has been very exciting.
Besides biomarker discovery, AI is also a fascinating area of research in the diagnosis and management of patients with IBD. The use of AI to improve trial design and recruitment in randomised clinical trials, as well as the overall management of patients, is expanding rapidly in the research domain. In addition to that, I had the opportunity to be a part of many clinical drug trials, starting with some of the anti-TNF agents, but involving the anti-integrins and other interleukin drugs. Seeing this explosion of new biologics and small molecules, all with different mechanisms of action to help our patients, has been very exciting. The challenge is that we do not know which drug is ideal for which patient, but with the development of better biomarkers and AI, I am optimistic we will make progress in this area.
Having worked with the Crohn’s and Colitis Foundation for many years, their current mission and vision is to not only find better treatments, but also discover new ways to prevent disease. Advances in medical therapy are critical, but preventing and curing the disease is the ultimate goal.
What are the long-term research goals in improving the early detection and management of colorectal cancer?
I have not always been directly involved in this work, but many of my colleagues have been particularly interested in the area of non-invasive screening. My colleagues at Mayo Clinic Rochester pioneered the use of stool DNA testing, which is now in practice for colorectal cancer screening, and has robust data supporting its effectiveness. Now, in addition to the stool-based screening tests, there is evidence that blood-based screening tests will also be available. Again, I think that this technology will transform our ability to screen more individuals, particularly from underserved and underrepresented minorities.
Another exciting area with great potential is AI. AI is progressing at warp speed and will help with colorectal screening and surveillance, and to identify the right populations to screen. One of the big challenges that I have recently become more interested in is access to care for underserved and underrepresented minorities. In some of these areas, patients cannot even get screening tests, and when they do get screening tests, they don’t have access to colonoscopy, which is the next best test. I am currently working with a group that is trying to solve this issue and improve access for these individuals, so that if they do have a positive screening test, we can make sure that they then get a colonoscopy.
What do you feel are some of the biggest challenges in gastroenterology as we look to the future?
As ACG President, I was able to talk with many of our members, including the ACG Board of Governors. It is very clear to me that that the biggest challenges are changes in our workforce, and the warp speed of new technology advancement.
Our workforce is changing, partly because of burnout. There is evidence that the workforce will be more mobile and demand more flexibility, but more importantly, it looks like there are going to be workforce shortages, both in physicians and allied health staff. We have to be prepared for this and search for innovative ways to address these issues. There are many potential solutions, and the ACG is looking into these. We will have to be very nimble and flexible in the way that we deal with the workforce in the future.
Another key challenge is the rapid advancement of new technology, including robotics and AI, which will need to be carefully integrated into the gastroenterology practice. Specifically, we will have to determine how to balance human connection with machine interaction. Some have labelled this the “bionic workforce”. We do want this new technology to help us, but we have to remember that medicine is still about that human-to-human connection. We must figure out how to preserve this human interaction while allowing technology to help us improve the efficiency of care, reduce costs, and improve clinical outcomes while improving patient and physician satisfaction. If we can do that, then we will be much more successful.
