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Audio File cgh_medical_center/cgh001.mp3
Doctors Reese, Scott
Featured Speaker Scott Reese, MD, FACC
Guest Bio Scott Reese, MD, is a Cardiovascular Disease (Cardiology) specialist. He attended and graduated from Boston University School Of Medicine in 1978, having over 41 years of diverse experience, especially in Cardiovascular Disease (Cardiology).

Learn more about Scott Reese, MD
Transcription Deborah Howell (Host): Question: what have you done for your heart lately? Welcome to our series, CGH about your health. I'm Deborah Howell and we're here today with Dr. Scott Reese; an interventional cardiologist at CGH Medical Center in the heart of the Sauk Valley in northern Illinois. This podcast is called Healthy Hearts: A Heart-to-Heart Talk. Thank you so much for joining us, Dr. Reese.

Dr. Scott Reese, MD (Guest): Thank you for having me.

Host: A pleasure. What is an interventional cardiologist and how does it differ from other cardiology?

Dr. Reese: Interventional cardiologists are heart specialists- medical heart specialists as opposed to surgical, who fix problems with the heart by going inside the body, being invasive to correct problems. The primary function of most interventional cardiologists is to fix blockages in the heart arteries that are either causing or felt to likely cause a heart attack. That's what the three of us here do. We also do general cardiology, which is diagnosing and treating all sorts of heart conditions with the tests that we have available and various medications.

Host: Let's talk about that. What are some of the conditions you typically treat?

Dr. Reese: We treat a very broad range of heart conditions, including things that often can lead to more serious heart problems, such as high blood pressure, high cholesterol, helping people quit smoking. These conditions often lead to blockages in the heart arteries which can cause chest pain and heart attacks. We treat heart rhythm disorders, we treat problems with heart valves and the heart muscle. It's pretty much the entire range of heart conditions. The advantage we have here is that if it's something that's beyond our capabilities, we have a number of higher level facilities that provide much more specialized care, including some interventions, some new valve procedures that are things that we don't do here.

Host: Got it. And what are some of the symptoms to look for?

Dr. Reese: The heart can be very sneaky, unfortunately. The classic symptoms to look for are very limiting shortness of breath, chest discomfort. Not necessarily pain, but discomfort, tightness, squeezing often in the center of the chest, often going into the neck or down the arm. These are some of the more classic heart attack or heart pain type symptoms called angina that we worry about. But it also could include passing out, being extremely dizzy, having excessive fatigue. It can even present sometimes as abdominal or discomfort high in the abdomen right below the rib cage. So unfortunately, the heart doesn't read any rule books regarding what symptoms it can have.

Host: So why do you think patients put off calling for help if they think they're having a heart attack?

Dr. Reese: Well, I wish I knew the answer to that. Part of the problem of course relates to what we just talked about that you don't know you're having a heart attack. At the same time, when people are concerned they might be having a heart attack, that's a hard thing to face and, be upfront with yourself and admit that, "I may have a serious problem." Most of us throughout our lives have ignored a multitude of symptoms and we've gotten away with it, and we'd like to think that we can potentially get away with it one more time. That obviously can be problematic because that may be the one time you get that symptom and that may be it. So we clearly wish that more people would come to the hospital or seek some sort of medical attention sooner for any symptoms that they feel are different, new, concerning, and most people get it pretty right. Most people know.

Host: That's good to know. Now what should people look for when finding a hospital to treat heart attacks?

Dr. Reese: Well, it depends. If it's an actual heart attack, then probably the closest hospital is the most important thing. To get the ambulance to your house, especially if you can't get to the hospital quickly on your own. But the standard recommendation is to call 911 and have an ambulance come. And then it's a little bit out of your hands. The ambulance services are all very good, and the majority of the time, they will go to the closest facility. On occasion, the ambulances will bring someone to a hospital that has interventional capabilities on a 24 hour a day, seven day a week basis, as we have here. If you have symptoms that you're concerned about enough to seek attention but not wanting to call the ambulance for whatever reason, then going to that type of facility is probably reasonable if it's close or very close as to the next closest hospital. But usually the general rule is closest facility.

Host: Got it. CGH was recently accredited a chest pain center from the American College of Cardiology. Can you tell me a little bit about that?

Dr. Reese: Sure. That encompasses more than just heart attacks. Lots of people have chest discomfort and fortunately a lot of them don't have heart attacks, but it's making that distinction in a quickly appropriate sort of way that makes a difference. And by being chest pain accredited, it means that we have met some fairly strict standards regarding that process so that we take consistent uniform care of people who might be having a heart attack, and it's not clear at the very beginning, and we then do all the right things to make sure that we keep those people safe. But at the same time, if it turns out that they are safe, that then many of them could go home and not have to stay in the hospital.

Host: Great. What are some of the things we can do to maintain a healthy heart?

Dr. Reese: Live right. I read somewhere once that mostly important lessons in life are learned in kindergarten.

Host: Yeah.

Dr. Reese: Such as taking naps, and sharing, and things like that, and some of that I think can be said for the heart. As a famous philosopher once said, I think we're born with good health, we just have to work to keep it. And most of us know when we do things that are not ideal for our health. You know, certainly smoking is right up there as one of the most unhealthy things that you can do. Getting enough appropriate exercise. They recommend about thirty minutes of exercise, five days a week. That's a reasonable rule to follow. Keeping our weight under control, eating the right portion size, eating the right things. Most of us can go down a list of food, a buffet or wherever, and identify probably what we should eat and probably what we shouldn't eat. I think that's where probably 70% to 80% of the heart problems come from; not following those simple rules.

Host: Easier said than done, but boy once you do it right and you're feeling so much better, it's even harder to go back to your bad ways. Right?

Dr. Reese: We hope so.

Host: I've just a couple more questions for you, Dr. Reese. Can you explain catheterization and how it might help diagnose heart disease?

Dr. Reese: Sure catheterization and the terms we use around it can be very confusing. Catheterization basically involves putting a tube into the body. And when we put tubes into the body, we put them either into the blood vessels of the arm or leg, into the veins or arteries, for the purposes of initially diagnosing heart conditions. The more specific example of this is to advance a tube or catheter through an artery from the wrist or the leg into the heart, and by the heart, to inject a dye and take pictures of the heart, which are called angiograms - that's the picture word - of usually the heart arteries, and the medical term we use for those heart arteries are called coronary arteries, and that's where we look for these cholesterol blockages that are the bad habits we just spoke about. That's where these blockages occur that can progress and cause the chest pain we talked about and the heart attacks we've talked about.

Host: I was just thinking- as you were saying that, it was so visual the way you were picturing it for me. I was thinking of Susan Lucci, who is such a thin, healthy, fit person, but she had a 90% blockage. So even if you're on the skinny side, it's always important to really still take care of what you eat and get that exercise in, correct?

Dr. Reese: Oh, absolutely. And doing all the right things helps enormously, but unfortunately it's not always everything. And that's why when you have these symptoms that you feel are concerning, even though you may be the picture of health, it bears looking into in order to be safe. Unfortunately with the heart, you may only get one warning. You may only get one strike, and we don't want to waste that opportunity.

Host: In your opinion, when is the right time to go through the catheterization process?

Dr. Reese: That's a very complex discussion and it varies very much from individual case to individual case. That's a circumstance where you need to talk to the physician who's caring for you and the circumstances of who you are, and your life, and your other medical circumstances. But generally when it is felt that you have a high likelihood of a blockage that has a high likelihood of causing or is causing a problem at the time, then that's when catheterization enters the discussion in order to evaluate that blockage or possibly multiple blockages, and decide the best way to take care of it, or hopefully find that in fact there are no blockages.

Host: Yeah. Okay, well that leads to my final question to you. Are cardiac devices like pacemakers also something patients should consider as a preventive measure?

Dr. Reese: Not really as a preventive measure. Pacemakers and most of the other electronic devices are primarily for heart rhythm problems, either heart rhythms that are too fast or too slow. They can be a consequence of heart attacks, they can occur on their own, but as a preventative measure, generally not. There are some circumstances where that's appropriate. If you had, for example, significant damage to your heart and your heart needs some electrical support, we might do that even in the absence of any symptoms. But pacemakers, for example, are pretty much always put in for people who have symptoms of, as we talked about at the very beginning, dizziness, light-headedness, or even fainting.

Host: Well thanks so much for clearing that up, and thank you also, Dr. Reese, for taking time out of your extremely busy day to be on the podcast with us. We do appreciate it.

Dr. Reese: My pleasure. I hope it helps.

Host: I'm sure it will. I'm Deborah Howell. Thank you for listening to this episode of CGH about your health. Head on over to our website at www.CGHMC.com to get connected with one of our providers. If you found his podcast helpful, please share on your social channels, and be sure to check back in soon for the next podcast. Have yourself a terrific day.
Hosts Deborah Howell

Nootropics: Performance Enhancing Drugs for the Brain or Snake Oil?

Additional Info

Audio File allina_health/ah147.mp3
Doctors Corry, Jesse
Featured Speaker Jesse Corry, MD
Guest Bio Jesse Corry, MD, is board certified in critical care and neurology, and serves as a neurologist at Allina Health’s United Hospital in St. Paul. His clinical interest is in the stroke continuum of care.

Learn more about Jesse Corry, MD
Transcription Melanie Cole (Host): Today’s topic is Nootropics, also known as smart drugs and cognitive enhancers. Are they performance-enhancing drugs for the brain or are they snake oil? My guest today, Dr. Jesse Corry, fan favorite, here on the Well Cast. He’s Board-Certified in Critical Care and Neurology and serves as a Neurologist at Allina Health United Hospital, Saint Paul. Welcome to the show, Dr. Corry. What is a neurotropic?

Dr. Jesse Corry (Guest): These are drugs – like you said, they’re cognitive enhancers. These are a class of drugs that actually date back to 7,000 years. There are texts in Ancient Indian and even Mesopotamian literature about different drugs that are meant to basically improve your memory, help with attention, help with creativity. What these drugs are meant to do is to do that very thing. It takes those components of how we think, how we perform mentally – memory, attention, creativity, and whatnot – and improves those inherent traits within us.

Melanie: Well, so where are these drugs? Are they a prescription medication? Do doctors use them for certain conditions? Where would they be found?

Dr. Corry: Great question. We kind of see them both in the form of supplements as well as medications that we prescribe. When we think of some pretty common ones – Nootropics – you would consider stimulants, a case of that. Children who are on medications for ADHD -- Methylphenidate – these medications would be considered in the class of Nootropics. They’re meant to improve attention. Memory – I’m sorry, medications like Namenda or Aricept we use for Alzheimer’s would be considered in that class of medication, as well. But more and more what we’re seeing is people who are otherwise healthy who don’t have problems with attention, problems with memory, trying to use these medications. Often times they’re taking them more in the form of supplements. There’s an increasing – about a $1 billion a year industry now in these supplements meant to improve how the people’s attention, memory, creativity, and intelligence.

Melanie: Is Adderall considered a Nootropic?

Dr. Corry: Many people who do not have ADHD do take Adderall for its Nootropic effects – for its ability to improve focus and attention. It’s not uncommon to find people who take this medication without a prescription.

Melanie: Now, you said that they’re in some supplements? Is this a particular active ingredient that’s legal over the counter so it can be used in supplements, but yet, it’s also used in drugs like Adderall and prescription medications?

Dr. Corry: Great question. Now, as far as stimulant medications like Adderall, those you do need a prescription for. Probably the most commonly studied medications that are Nootropic that is over the counter that doesn't require a prescription would be things like Ginkgo Biloba, which does have some weak evidence – but there is some evidence out there that Ginko Biloba does help with improving memory.

Probably the best-studied one is – this is a hard name to say – but it actually has about a 7,000-year track record is Bacopa Monnieri. This is a medication – this is a chemical that comes from a flower found in India, and this has a pretty long history with some smaller, but well-done trials that have shown that people who take this medication – or, I should say supplement, pardon me – if you take this supplement, do show, in fact, improvements in both attention as well as their ability to switch attention and remain focused. There has actually been a number of studies that have looked at this. Probably the best one to date was one where they looked at medical students who took this medication and found that the medical students who took the medication for six weeks did better than their counterparts who did not have this medication on board.

Melanie: So aside from the attentional, and the focus – like Bacopa Monnieri – what about a mood-enhancer. Do these things also help your mood and maybe your energy level, as well?

Dr. Corry: Yeah, some of them very much would help with things of that nature. When we look at the neurotransmitters that are helping with memory and attention -- the memory is stimulated through more of these acetylcholine network, but a lot of times, when you indirectly affect that acetylcholine, you will affect the neurotransmitters that help more with mood, like serotonin, as well as help maybe make you a little more prone towards being happy – things like dopamine. We do know there is some evidence that – again, mainly with Ginkgo, but also another medication called Panax Ginseng, which is also known as Asian Ginseng, which has been shown to help improve mood in many, many a person. It seems as though the overall push of this supplement-Nootropics market is more for the memory, attention, and creativity type focus. The mood-enhancers probably still typically are more in the realm of SSRIs and more in the prescription medications you would receive from a psychiatrist.

Melanie: Well, there’s one very popular Nootropic, Dr. Corry, and that’d be caffeine --

Dr. Corry: Yes.

Melanie: And people also hear about creatine, and that’s an energy supplement that plenty of athletes, and/or weightlifters, that sort of thing – they look to creatine to see if it’s going to enhance their energy formation for working out.

Dr. Corry: Right.

Melanie: Tell us what you want us to be careful of because we’ve heard of some of the dangers of overdoing caffeine – people get the jitters or of creatine as well – tell us some of the dangers, things people should really be on the lookout for.

Dr. Corry: Okay, with caffeine – caffeine is like you said, it’s a great medication. It helps with attention, helps improve memory. The thing with caffeine obviously, is the jitters. There are some folks that if they have a little too much, they can get a little jittery with it. The biggest thing to worry about with caffeine would be changes in blood pressure, particularly people who have high blood pressure, to begin with. They may be more prone towards developing hypertension as a result of the caffeine. However, a lot of times folks who take caffeine for a long time, their body gets used to that, and it mitigates that hypertension.

Another problem with caffeine would be intermittent changes in heart rhythm. If you’re a person who has a history of atrial fibrillation, caffeine may not be the thing that you want to be using. Now, you also bring up another great issue – is the creatine. Creatine, obviously, it’s in a lot of supplements. It’s being used by MMA athletes, et cetera, to help improve those energy stores within muscles. The biggest thing that folks need to be aware of when they’re taking something like creatinine is you need to drink enough water. If you take too little fluid intake with this particular supplement, it puts you at a huge risk of developing renal failure. The kidneys are similar to the brain in that once you start losing kidney tissue, you don’t have a – you often times do not recover that kidney tissue. It’s important then, people who are taking these supplements for improving their strength and explosiveness, that they take in plenty of water on top of that supplement.

Melanie: Well, and another point about supplements -- if people are looking to buy Nootropics, and they’re going to an all-natural store – supplement store – it’s not regulated, whereas Adderall is going to be regulated, caffeine you can get anywhere, but some of these others aren’t regulated, so you don’t know what you’re getting?

Dr. Corry: Exactly, and that’s a big point, and thank you for bringing that up. When folks take in those Nootropics, these are supplements – they’re at a very – at a completely different FDA set of standards by which that they have to comply with as opposed to medications that have to go through Phase I, Phase II, Phase II Trials, et cetera. When you’re taking supplements, you’re often times not knowing if you’re having maybe too much Mercury in them. You’re not sure if the dose is the same from dose to dose.

Why is this important? Particularly with medications that people are taking for those Nootropic effects – for those cognitive effects – is that when you start playing with neurotransmitters, you can develop a whole cascade of unintended side effects. If the person is on, let’s say an antidepressant, and they’re taking a Nootropic that may affect serotonin more or norepinephrine more, they can put themselves at risk for what’s called a serotonin syndrome. Basically, the body goes into mass muscle breakdown, becomes very febrile, very hyperthermic, and the person can develop all sorts of problems just from being encephalopathic and delirious to having muscle breakdown, to having irregular heart rhythms. It’s really important that if a person is going to invest the time into taking a Nootropic that they go and they do some research on it to make sure that the vendor of this particular drug is, in fact, held to standards.

Melanie: That’s really a very good point. Tell us, before we wrap up here, Dr. Corry, does it increase intelligence in the long-run, do you think? Or do you know, as a Neurologist, are you seeing any studies done on it?

Dr. Corry: When we look at right now at does it improve the person’s overall intelligence? The short answer is: probably not. It takes your attention, it takes your memory, and these things especially you can see, it improves what’s inherently within that individual, so it’s more of a performance enhancer. Over time, though, there is increasing evidence – it’s not huge, but just increasing – that these Nootropics, particularly the Bacopa Monnieri and some other medications, may, in fact, stave off some of the oxidative effects – some of those damaging effects that happen to our brain as we age, as we drink too much alcohol, et cetera, and over time, it may hopefully stave off things like Alzheimer’s. The final answer isn’t there yet, but in the long run, these medications may, in fact, let you be yourself longer than you otherwise would have been.

Melanie: So what do you want people to know? What do you want to tell people if they’re considering some of these – if they’re looking into them or if they’re a college student that’s saying they’re going to borrow their friend’s Adderall, what do you want them to know as a Neurologist, Dr. Corry –

Dr. Corry: I would say that –

Melanie: Because this is important to hear from an expert, like you.

Dr. Corry: Yeah, first and foremost, talk to somebody. Talk to a medical professional – a therapist, a neurologist, what have you. Identify are your problems more with mood? Are you having problems with anxiety and depression? That often times will affect things like memory, will affect things like creativity, behavior, and would be treated much differently than a person who just wants to go and improve what they already have – improve their memory, improve their attention. If you’re a person, who’s looking and saying, “My mood is fine. I feel great, but I want to retain more. I want to be able to focus better,” talk to a medical professional. Ensure that you don’t have the criteria for a true ADHD type phenomenon because the medications that they have for that are very good, but they need to be prescribed, so you can be followed under a doctor’s supervision. Many stimulants will affect things like blood pressure blood vessel health, and you want to be under the care of a medical professional if you’re taking these particular drugs so that you don’t develop side effects.

If you are a person who doesn’t have ADHD, but you’re interested in taking one of these supplements, then it’s important that you go on the web, research these places. When they cite different papers, review those papers, make sure that these medications do sound as good as they, hopefully, are portraying themselves to be. Start small, take breaks from the medication, and to be very objective in what you’re looking at. If you’re looking to say, “Okay, is my memory improving?” Find some way to – if your test scores aren’t improving, if you’re noticing you’re still needing to reread books, obviously it’s not working as well as it should have – or you would like it to do, then stop taking the medication.

Melanie: That’s good advice. I think that people also definitely need to do their research on them, and listen to the good advice that Dr. Corry is giving you about Nootropics – if you’re somebody who’s looking to, or if your teenager comes to you and asks you about things like caffeine and creatinine, make sure that they do research and that the listen to this podcast. Thank you, so much, Dr. Corry, for being with us today.

Dr. Corry: No problem.

Melanie: You’re listening to the Well Cast with Allina Health, and for more information, please visit AllinaHealth.org, that’s AllinaHealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Coping with Tragedies in The Media

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Audio File allina_health/ah146.mp3
Doctors McCallum, Ethan
Featured Speaker Ethan McCallum, PhD
Guest Bio Ethan McCallum, PhD is a psychologist with professional interests in borderline personality disorder, PTSD, trauma, Prolonged Exposure therapy, Dialectical Behavior Therapy and serious mental illnesses.

Learn more about Ethan McCallum, PhD
Transcription Melanie Cole (Host): Parents and children learning about tragedies that are all over the media may find it difficult to process and to discuss. Many young likely hear about these attacks through social media and have formed opinions, impressions and questions. This can leave parents and other adults struggling with what to say and share amid the frightening news. Here to speak with us about coping with those tragedies is Dr. Ethan McCallum. He’s a licensed psychologist at Allina Health Hopkins Clinic. Welcome to the show. How can tragedies in the world in the media affect individuals mentally and psychologically?

Dr. Ethan McCallum (Guest): Thanks for having me on. Over the last decade or so, there's been quite a lot of research on how these strategies affect us after 9/11 and started paying a whole lot more attention to this. Surprisingly, these types of high profile situations can be really impactful, even for people who aren’t directly involved. Part of that may have to do with the level of media exposure that we get now. We absolutely can be affected by hearing about things on the news or through social media and many people do have a reaction to those types of high profile events.

Melanie: Have we become numb, do you think, and can these tragedies be more sensitive or alarming for individuals with existing mental health conditions?

Dr. McCallum: There is maybe some truth to people getting numb to it, or at least habituating to these types of events. I think that something like the Vegas shooting would have been a whole lot more shocking to the nation 10 or 15 years ago than it is today, but that doesn’t mean that it’s not affecting people. In terms of people with preexisting issues, that’s absolutely the case that they are more vulnerable to reactions. It’s particularly true of individuals who experience trauma, so if somebody’s been exposed to combat or has been exposed to a mass shooting event or some other type of interpersonal trauma, they may be more vulnerable to experiences like that. Even going beyond trauma-related reactions, people who have a history of depression or anxiety issues may find themselves to have stronger reactions to these types of events.

Melanie: Let’s really get into some techniques to practice for coping with these. Along with that, I would like to discuss how you will discuss this with your children. First, self-coping. When we hear these stories in the news, what do you want us to do?

Dr. McCallum: I think taking care of yourself is really important and probably one of the best ways to cope with these types of events is to really make sure that you're still living your life. One of the things that can have a cumulative negative effect is when people start to withdraw, whether they withdraw from the world or from their social connections, so make sure you're getting out of the house, make sure that you're reaching out to friends and family, particularly for people who feel unsafe in the wake of an incident like this – somebody who feels like they don’t want to be in a crowded area or don’t want to be going out to a concert or something like that. Now is the time to try to get back up on the house with that kind of thing. Beyond that, focus on the things that you can control, get good sleep, make sure you're exercising and eating well – all those things will help to get people through the immediate discomfort that comes with this type of event.

Melanie: That’s really good advice, to really get back out there and make sure that even if you are afraid that you involve yourself and get involved. How do we discuss these things with our children, especially kids under 10, and then even with our teenagers? I’ll tell you when we heard about the Las Vegas shooting and then there was a possibility that he was in Chicago and had gotten some rooms by Lollapalooza, which my son was at for all four days, it’s a tough discussion to have. Speak about having that discussion for under 10 and then over 10.

Dr. McCallum: It is a really tough discussion to have. Age does really matter so the way we talk about this is going to vary depending on how old your kids are. I will say talking about it with your kids regardless is pretty important. We like to think that our kids are pretty sheltered from this sort of thing, but with social media, it’s becoming less and less true. Maybe when we were kids, there were discussions that happened in the back of the bus, but these days with Twitter and Facebook and everything, kids often times know as much, if not, more than we do. Trying to keep them sheltered actually can backfire in the sense that it communicates a message to kids that they can't talk to you about these things, and the best way to combat that is to be open. That being said, you want to pay attention to where they're at in development.

A child under 10 is really not ready to talk about the types of details that maybe a teenager would be aware of. I think in terms of working with the younger kids, you want to stick to just really basic facts – who, what, where, when – in terms of what happened, and really emphasize with the younger kids that you're going to be there to keep them safe and that this type of thing, even when it gets talked about a lot, even when we can look back in the past couple of years and see examples of this, it’s a very uncommon experience. With the teenagers, they're going to know the details anyway, so pretending like they won't is just probably counterproductive, and the older kids may want to talk about more details and being okay and opened to that makes sense.

Melanie: People often want to do something to feel better about tragedies and even to help our children cope if this kind of thing upsets them, whether they're young kids or teenagers or even other family members and friends. Some people take these things to heart more than others. What can we do to feel better about these tragedies and can we do something to give back? There's the “text $10 to the Red Cross” and all those things, but they have a bit of a disconnected feel. Are there some other things that we can do to help our children, our loved ones, ourselves copes that makes us feel like we are making a difference?

Dr. McCallum: That is a really good way to combat or counteract some of the negative effects of these high profile tragedies. Obviously, when we’re dealing with something straightforward like a hurricane, there's a lot of different ways we can directly provide relief, and there are some charities and donation lines set up for the Las Vegas victims. That is one way to give back. Honestly, giving back at all to a community or to a group in need is helpful, even if it’s not directly related to the tragedy. Doing things like volunteering at a food shelter or a meal preparation place like Feed My Starving Children or something like that is going to help people to feel connected. It’s going to help them feel more hopeful and like they can make a positive difference in the world.

Melanie: Wrap it up for us with your best advice on reminding kids, ourselves, our loved ones, that there is more joy in life than sorrow, how we can focus on the positive and really what you want them to know about tragedies like this and seeing it all over the media and all the upsetting news and what we can do to turn it around for ourselves so that it doesn’t become all-encompassing and really put a drain on the rest of our lives.

Dr. McCallum: This is definitely relevant when we’re talking about the media because the media tends to focus on the negative and we can get to a place where it feels like tragedies like this are all around us all the time. With our kids, it’s really important that we supplement and go out of our way to identify positive experiences, joyful experiences, share those experiences together. For ourselves, I think it’s important to remember that even though with these 24/7 news cycles, something like Las Vegas can seem like it’s all around us all the time, that the reality is most places are safe. Most concerts are safe, most malls are safe and we need to go out and live our lives.

Melanie: We absolutely have to and it’s great advice for listeners to hear. Thank you so much for being with us today. This is the Well Cast with Allina Health. For more information, please visit allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Your Brain 101: Social Media and the Brain – Is It Addiction or Just Good Marketing?

Additional Info

Audio File allina_health/ah145.mp3
Doctors Corry, Jesse
Featured Speaker Jesse Corry, MD
Guest Bio Jesse Corry, MD, is board certified in critical care and neurology, and serves as a neurologist at Allina Health’s United Hospital in St. Paul. His clinical interest is in the stroke continuum of care.

Learn more about Jesse Corry, MD
Transcription Melanie Cole (Host): Have you ever felt a sense of unease if you weren’t able to check your phone regularly or had a little burst of pleasure when friends and colleagues liked something you posted online? How and why you feel that way is no accident. Here to talk with us about brain hacking, is Dr. Jesse Corry. He’s a Neurologist at Allina Health’s United Hospital. Welcome to the show, Dr. Corry. What does that mean, brain hacking? We hear about it a little bit in the media, what does that mean?

Dr. Jesse Corry (Guest): Well, thanks for having me, Melanie. Brain hacking is this term that has been used to describe the engineering practice of technologists, software developers, to try to – in short, get you hooked on the application. They do things in order to help make you want to come back to use that phone -- to feel a little nervous if you don’t use the phone through different times when they would release the likes or the little bells and whistles they’ll put on there to make you nervous or happy with your phone use.

Melanie: Wow, so this was sort of engineered as a way to get us to really need to do that or want to do that because that’s how they sell their apps?

Dr. Corry: Correct, it’s – there’s actual conditioning that’s going on, on behalf of these developers of software. There is – over the last several months and years there’s been more and more evidence that people are trying to engineer these things to make you feel more stressed or to make you feel happy or to make you have more of a reward sensation when using that application. We need to keep in mind when we go, and we’re using a social media platform, it’s almost as though we’re going to use it for free because the real commodity is our eyeballs. The people who advertise on these things really want us to see their advertisements. The more we’re on that social media platform, the more we’ll see, the more we’re likely to purchase those items.

Melanie: That’s amazing, so they leveraged our brains --

Dr. Corry: Um-hum, yeah.

Melanie: To work -- to provoke that neurological response – that desire – almost the bell-meat thing?

Dr. Corry: Correct, there are actually a number of firms in technology right now, and they focus on how to better manipulate through neuroscience, technology, and software. You can go online – there are a number of articles in the Wall Street Journal, CBS News, et cetera, that talk about this interface now, between neuroscience and technology.

Melanie: How would someone know if they’ve got a social network addiction? What does that look like, and are we – do we want to do something about it? Is it similar to an addiction to anything else?

Dr. Corry: Okay. I think the first thing to start is – okay, is there a diagnosis of social media addiction? Right now, it falls under the covering of what we call behavioral addiction. The Diagnostic Manual of Psychiatric Diseases at this time does not have a firm Facebook or social media addiction diagnosis, but it’s considered in the category of behavioral addiction.

And like many other addictions, the things we look for in individuals are: are they starting to use that technology in a way that’s beyond volitionally – maybe almost subconscious use. Are they almost in need of that technology in order to have them feel pleasure? Do they use the technology more and more? Are they developing a tolerance to this? When they cut themselves off from technology, is there kind of a relapse – when they take some time off, when they relapse they start using it more and more. I think the most important thing is, is there a conflict? Is that person because of technology, missing out on those offline experiences – those offline relationships? Is it causing difficulty for the individual using the technology and the people in their life who they have relationships with?

Melanie: So it’s really – basically, as you’re saying, Dr. Corry, it’s the same parameters as really any addiction. Is it affecting your life – the quality of your life? I-E are you checking Facebook while you’re trying to reach your child a bedtime story?

Dr. Corry: Correct.

Melanie: And for our teens and our kids, what do you recommend? I mean, you’re an expert in so many things, and you’re a neurologist. What do you recommend for our teens? I’m asking you not only as the person interviewing you but as the mother of two teenagers, how do we break this cycle as if they were starting to drink and do drugs? Is there a way to kind of break this up a little bit?

Dr. Corry: When I think about this, I kind of start thinking what’s going on in the brains of the people they studied who have these social media addictions or these bad habits. They find that the part of the brain that drives impulse, right – that desire to go and do that – that is kind of accentuated. That is made to be more powerful than it should be. And why that’s concerning, particularly with young people, is that as we get older, we learn both the cure and the stick. As we get older, we learn the consequences of our actions, but children and teens, in particular, their brains are wired to learn best from positive feedback, right? If they’re getting those likes and they’re getting them in those bundles, right, where they’re getting 30 likes at a time, that is going to be a very positive experience for them. They are going to go ahead and -- that’s going to be a more potent reinforcement than punishing the child and saying, “Hey, we’re going to ground you on this.”

When I look at that, I realize that okay, there’s almost that sugar high that young people are going to get. I think the first thing that people really need to – your children need to do is to set boundaries, right? There are applications on phones people can use to say how much time they’re spending, but to set boundaries. We all have to use the internet for whether it be research, or school, or work, what have you, so making sure that you’ve got goals when you go on the internet and what you’re going to do. You try not to deviate from those goals, and yeah, if you make your goals then reward yourself with some online time. In my family, my kids, they actually have to do chores around the house, and go to activities, and do well in school. We have this little gold coin game where the kids can then – if they get so many gold coins they get so much screen time then for Facebook, or YouTube, or what have you. That’s one mechanism.

The other thing is – and this is part of when people do have an addiction, one of the things they can use – the tools they can use to help get themselves off of the addiction or try to rehabilitate is rationalized why you’re using this. Understand why you’re trying to put this post or that post on your social media platform, and think about the consequences of that use.

Melanie: Do you think that it will – if we’re able to cut back on constantly checking in and this need that we have – and even for people who have to answer their e-mails right away and that sort of thing. Do you think that this could help us reduce our stress levels -- cortisol, all these anxiety hormones that we get? Or do you think that it will cause more if we cut back?

Dr. Corry: No, I think we definitely need to cut back, and the reason I say this is kind of two-fold. Number one, there has been a number of studies over the last year that has looked at the connection between the brain and stress and the development of heart disease, stroke, blood vessel, hardening, and whatnot. They found that people who are more stressed, who have a higher metabolic activity of a part of the brain called the amygdala, which is kind of the stress-driven in people. When that little part of your brain – when that amygdala is more active, you’re more prone towards the hardening of the arteries and the consequences thereof, such as heart disease, stroke, and what have you.

We know, too, from other studies that people who are higher on that social media addiction spectrum, they have larger amygdalas.

Melanie: Really?

Dr. Corry: Does larger necessarily mean more active? Not necessarily, but we see that people who have this part of the brain more active, larger, will have more stress. They’re going to be more risk for complications of stress like heart disease and stroke.

Melanie: Wow.

Dr. Corry: That’s the first thing to be really concerned about. The other thing is in medicine and many other fields; people are trying to cut down on the beeps and whistles because people become immune to them. They don’t respond to them like they should. If it’s causing stress and it’s not really improving the situation, and people are ignoring them for the beeps and whistles we don’t want to have like you have an e-mail or something. That I think requires to sit back and say, “Okay, how do we make technology work for us as opposed to us working for technology?”

Melanie: That’s a great way to think about it. Dr. Corry, for those who do feel that social media is taking up too much time whether it’s Instagram, or Snap Chat, or Facebook, or Twitter, or any of these other things, what do you want them to do to start reducing the amount and to really kind of whine themselves off of some of these things?

Dr. Corry: Yeah, and I think that we can take some advice from other forms of behavioral addiction like internet addiction and whatnot, and look at the things like – number one, justify what you have to do and why you have to do it, so you have a very clear goal, and what your purpose is to be on the internet, so you don’t stray from that. Number two, social media – this is a very – this is an awesome thing we have. We can keep in contact with friends now; we made as children. That’s the real driver of a lot of social media is to maintain those offline relationships, so use it for that. Don’t go lurking on people’s Facebook trying to find different things about the person. If you want to use it to maintain a relationship, use it like you would a regular relationship. Use it to say something positive about this person.

The other thing people can do is they can talk to people who their Facebook use or their social media use affects. If a person is in a relationship with somebody else and that partner is saying, “Your use of social media is really affecting the time between us,” talk with that person, understand why they feel that way. That kind of feedback, which is oftentimes missing from social media platforms, is invaluable for a person to understand the consequences of their actions. There is some evidence that certain medications may be of help to people who things like rationalization and therapies aren’t enough for, but still in the very early stages of the study.

Melanie: What are some of your final thoughts on the healthy use of social media? And also for our teens, is there anything really good about it?

Dr. Corry: I think social media is there to help us maintain those offline relationships. I think that’s great. It should be used for things of that nature. I think for people who are industries upon themselves – celebrities, athletes, and whatnot – it’s good to help maintain that positive image. It’s good to help promote causes that you feel passionate about. I think these are all great things that social media can be useful for. We need to be mindful that all actions have consequences, and we need to make sure that when we want to post something or say something, we do so in a way that’s mindful of how it reflects on us as well as how it will affect other people. I think as we, as a society, move forward, there’s going to be – we need to start having a little better etiquette as far as how we use social media and how we interact with people on this medium on this platform.

Melanie: I think you’re absolutely, 100% right, and so it’s definitely something that as individuals, we can work with our family and friends, right?

Dr. Corry: Um-hum.

Melanie: And try and convince them of these positive things and play this podcast for them because you’ve just explained it so well.

Dr. Corry: Oh, thank you, so much.

Melanie: Thank you so much, Dr. Corry, for being with us, today. You’re listening to the Well Cast with Allina Health. For more information, you can go to AllinaHealth.org, that’s AllinaHealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Advances in Local Treatment for Breast Cancer

Additional Info

Audio File city_hope/ch110.mp3
Doctors Jones, Veronica C.
Featured Speaker Veronica C. Jones, MD
Guest Bio Specializing in breast cancer surgery, the much-honored Veronica C. Jones, MD, joined City of Hope in 2015 after serving as an Assistant Professor of Surgery at Emory University School of Medicine in Atlanta, GA.

Learn more about Veronica C. Jones, MD
Transcription Melanie Cole (Host): Physicians and research scientists are on the front lines looking for better ways to care for patients with cancer. Clinical trials are a great way to make scientific advances using the latest technology and resources. A relatively new technique could make breast cancer patients’ post-surgery lives much easier. Intraoperative Radiation Therapy or IORT is a new form of radiation therapy that replaces weeks of traditional radiation therapy. My guest today, is Dr. Veronica Jones. She’s a Breast Surgeon in the Division of Surgical Oncology in the Department of Surgery at City of Hope. Welcome to the show, Dr. Jones. Tell us about some of the exciting advances and localized treatment for breast cancer including IORT.

Dr. Veronica Jones (Guest): Sure. Traditional breast cancer treatment includes breast conservation therapy, which is where we remove a portion of the breast and then traditionally give radiation for up to six weeks after the surgery is performed. It’s every day, Monday through Friday. Intraoperative Radiation Treatment is a newer technique in which radiation is given directly to the surgical bed for anywhere from ten to fifteen minutes during the surgery, and then the patient is done. They do not need to return daily for six-weeks to have radiation therapy. It’s all completed during the surgery.

Melanie: How can that be? Is it a higher level? Is it a higher dose of radiation? How does that work?

Dr. Jones: We actually have found that if a cancer is to come back, it’s most likely to come back right in the area where it originally occurred, and so we discovered that if we give radiation directly to the area where the cancer was, it’s actually as effective as giving radiation to the entire breast. It’s a more concentrated dose of radiation directly where it’s needed most.

Melanie: Tell us a little bit about how the clinical trials were working for IORT and then we’ll talk about Cryoablation and really what that is, but are there still clinical trials or is this now a pretty much standard course of treatment?

Dr. Jones: This is still a clinical trial. There were clinical trials previously done on intraoperative radiation therapy, but there have been newer machines that have come out, and we are testing those machines. This is a clinical trial -- even though previous clinical trials have been done, we are still exploring this area, trying to expand which patients are eligible and following all of the patients long-term because we want to see how these patients are doing ten years from now, twenty years from now. Even the earlier clinical trials that were done are still being followed – those patients are still being followed. It’s not technically standard of care in that we are still learning more and more about this technique as patients progress into survivorship.

Melanie: Speak a little bit about patient selection criteria and who might be a candidate for this particular procedure.

Dr. Jones: Right, so we’re typically looking at patients that have stage one disease, so it’s a very localized disease. We usually like for the span of cancer to be less than two centimeters in size. These are stage one patients who do not have any lymph node involvement. We also primarily look at postmenopausal patients and favorable disease. What I mean by favorable disease, are diseases that are responsive to hormones, what we call estrogen receptor positive disease – diseases that are less likely to come back.

Melanie: So then tell us a little bit about Cryoablation. What is that and how is it different than what you’ve been discussing?

Dr. Jones: Intraoperative Radiation Treatment is radiation that’s given after surgery has been performed. We surgically remove the cancer and then we give radiation to the area where the cancer was. In Cryoablation, we actually do not remove the cancer. We don’t even do surgery. We make a very small incision on the breast, about four millimeters in size, and instead of removing the cancer, we actually just freeze it with a liquid nitrogen gas. That is supposed to kill the cancer cells and stop them from replicating and progressing. We are treating the cancer without a surgery completely.

Melanie: And are there certain candidates for this particular thing too?

Dr. Jones: Yes, so the candidates for this type of procedure are actually pretty similar to the candidates for the Intraoperative Radiation Therapy Treatment. We’re looking for patients who have favorable disease – again, who respond to estrogens, who have less than two centimeters of disease. We also are looking for patients with a certain type of breast cancer. There are typically two main types of breast cancer, invasive ductal cancer, and invasive lobular cancer, and this Cryoablation technique is for the invasive ductal cancers. That just has to do with the way the cancer grows.

Melanie: And with both of these procedures, Dr. Jones, what are you seeing in terms of success rate? Are you noticing that the patients are happier as a result also because it’s more convenient for some of these things and maybe they’re having better outcomes?

Dr. Jones: Right, with intraoperative radiation therapy, the patients are extremely happy. They love their cosmetic results. With traditional radiation therapy that’s given over a course of multiple weeks every day, the patients can get a lot of skin changes, and they notice a sunburn type of appearance to the breast. The breast can also get dramatically larger or smaller than it was previous to the radiation therapy, and they can have chronic pain from the radiation treatment even after the acute side-effects of the skin changes have resolved.

With intraoperative radiation therapy, they do not see the changes that are typically associated with radiation. They may have a little bit of redness, but that typically goes away in a few weeks. They do not have the sunburn changes on the breast. They don’t notice the dramatic change in the size of the breast, and they typically have less pain. All of that is in addition to not having to come to the hospital every day for several weeks. The intraoperative radiation therapy patients are extremely happy with their results.

Melanie: And where do you see this going in the future? Give us a little blueprint for future research, and what you want to tell the listeners they can look forward to down the line.

Dr. Jones: I think that we are getting so much better at treating breast cancer and in the past, we did a lot of surgery for breast cancer treatment. Years and years ago, we actually would remove the whole breast, the muscle, the lymph nodes, everything in the area, and women were left with a significant deformity on the side of the breast cancer. Over time, we have gotten less and less invasive with our treatments. We’re able to do less surgery especially as the medicines that we develop for breast cancer have gotten so good. I think that we are headed toward doing less and less surgery on patients, causing less deformity, and less problems after surgery. I think that this is just part of it – Cryoablation is part of it, Intraoperative Radiation Therapy is part of it. As our medicines get better, as our detection techniques get better, I think we’re going to see less and less surgery being done.

Melanie: What an exciting time to be in the research end of breast cancer. Thank you so much, for being with us today. You’re listening to City of Hope Radio, and for more information, you can go to CityofHope.org, that’s CityofHope.org. This is Melanie Cole. Thanks so much, for listening.
Hosts Melanie Cole, MS

Dense Breasts and Screening Indications

Additional Info

Audio File city_hope/ch109.mp3
Doctors Tumyan, Lusi
Featured Speaker Lusi Tumyan, MD
Guest Bio Lusi Tumyan, M.D., is an assistant clinical professor in the Department of Diagnostic Radiology. Dr. Tumyan received her undergraduate degree in biochemistry from Occidental College in Los Angeles where she was elected to Phi Beta Kappa, and went on to obtain her medical doctorate from the David Geffen School of Medicine at UCLA. She completed a medicine internship at Huntington Memorial Hospital in Pasadena, CA, and went on to complete her training as a general radiology resident at the LAC+USC Medical Center in Los Angeles, CA. Dr. Tumyan also completed a fellowship in breast imaging at the Iris Cantor University of California, Los Angeles Women’s Health Center.

Learn more about Lusi Tumyan, MD
Transcription Melanie Cole (Host): Mammograms have long been the gold standard for breast cancer detection, but they are not perfect. They can be less effective in women with dense breasts which contain more glandular and connective tissue than fat. Many states now require women to be notified when dense breast tissue is seen on a mammogram. Some states also require supplemental screening like ultrasound even if the mammogram found no cancer. My guest today is Dr. Lusi Tumyan. She is a radiologist in the department of diagnostic radiology and the Chief of Breast Imaging at City of Hope. Welcome to the show Dr. Tumyan. So, what are dense breasts?

Dr. Lusi Tumyan, MD (Guest): Our breasts and just like everything else about us is different from one person to another. So, our breast parenchyma, what is composed of our breasts, whether it is connective tissue, whether it is fibro glandular tissue or whether it is fat; we all have different compositions. Some people have a lot more fat than they have other connective tissue or fibro glandular tissue. Other people will have a lot more fibro glandular tissue and connective tissue and less fat. On a mammogram, fibro glandular tissue and connective tissue shows up as white. Unfortunately, cancer also shows up as that white. So, if patient has a lot more fibro glandular tissue than fat, sometimes the fibro glandular tissue will mask the cancer which means that the radiologist is unable to pick up the cancer because there is a lot of tissue overlap and we just cannot see it on mammogram. In those patients, the mammogram is less sensitive than in patients that majority of their breasts composed of fatty tissue. About 50% of our population, is patients that do have dense breast parenchyma and in those cases, mammogram becomes less sensitive in detection of breast cancer.

Melanie: So, how does a woman know if she has dense breasts?

Dr. Tumyan: In the state of California, the woman will get a letter when they have a mammogram which will tell them the results of the mammogram. In that letter, when the patient does have dense breasts; we are required to notify our patients. In that letter will state that you have dense breasts parenchyma and it is something to be discussed with your referring clinician. You may look into supplemental screening modalities and examination.

Melanie: So, if someone receives that letter, and it can be worrisome; you have already stated how many people have it so it is not abnormal. Does it increase our risk for breast cancer?

Dr. Tumyan: It is extremely worrisome and it is extremely anxiety provoking, especially since this is a new law that went into effect a couple of years ago. So, previously, women did not get that notification. Once the law was enacted, women were getting new notifications and once you see that; you become very anxious about it. There have been several studies that have shown that patients with dense breasts do have slightly increased risk of breast cancer compared to populations that do not have dense breasts. So, yes, the risk of breast cancer is slightly, not a lot, likely higher in dense breasted women.

Melanie: So, do women still need to get their mammogram or should they discuss with their doctor some of these adjuvant imaging techniques?

Dr. Tumyan: Women should always get mammograms because mammogram has been shown to decrease mortality and mammogram is the gold standard for detection of breast cancer. Also, mammogram is the best modality to find breast calcifications and breast calcifications, some of breast calcifications are associated with early breast cancer. So, mammograms should always be part of their regimen. However, in patients that do have dense breast parenchyma, it is worth talking to your clinician and determining your risk factors for breast carcinoma. For patients that do have dense breast parenchyma, there are supplemental imaging that could be performed. These would include either an ultrasound of the breasts or MRI. If a woman is determined to be average risk for breast cancer based on their overall risk factors; ultrasound is a great supplemental examination in addition to mammogram to screen for breast cancer. For patients that have high risk of breast cancer based on their overall profile; MRI is a great supplemental technique. It is very sensitive and it is very good to catch early breast cancer in addition working as a compliment with mammogram.

Melanie: So, Dr. Tumyan, if a woman is doing her self-exams every month; does dense breast tissue affect what we feel?

Dr. Tumyan: Yes. Having dense breast tissue sometimes will mask smaller lesions, so small cancers that develop because there is so much fibro glandular tissue and so much connective tissue; detecting very tiny cancers is harder when they are doing breast self-exams. For patients that have fatty tissue, you can detect these easier.

Melanie: So, does insurance recognize those supplemental tests, like MRI or ultrasound if a woman has received that letter, does she then check with her insurance company? Are they recognizing this?

Dr. Tumyan: Some states, when asked for, as for requiring the insurance companies to pay for the supplemental examinations. California has not gone that far. California law says that we have to let the patient know, however, it is not requiring the insurance companies to pay for supplemental examinations. Majority of our insurance companies will pay for ultrasounds. We haven’t seen too much difficulty with getting whole breast ultrasounds, however, insurance companies it is becoming extremely difficult to get breast MRIs. Breast MRIs are really reserved for patients that have increased risk of breast cancer and just having dense breasts, majority of our patients do not qualify for breast MRI and the insurance companies will not pay for that.

Melanie: Is there a difference in the view if someone goes for 3-D or tomosynthesis? Is there a difference with dense breasts?

Dr. Tumyan: Three-D or tomosynthesis is better for dense breast parenchyma because we are able to actually see the breast in three dimensions and we can scroll back and forth within the breast parenchyma and detect more lesions.

Melanie: And what about breast feeding? Does this affect that at all?

Dr. Tumyan: Breast feeding definitely affects the breast density. In fact, when patients do breast feed, we advise them to get their mammograms after they are done breastfeeding. While they are breastfeeding, our glands, fibro glandular tissue, everything increases, so our density – the breast density becomes extremely dense. It is extremely difficult to find cancers in those patients. So, yes, breastfeeding does affect it.

Melanie: So, summarize it for us Dr. Tumyan. What would you like women to know about the laws about getting the letter that informs them that they have dense breast tissue and there may be slightly increased risk of cancer but still getting those mammograms on a regular basis? What would you like to tell them?

Dr. Tumyan: I want to let them know that for patients in California, when they do get the dense breasts letter; it is just something to consider and talk to your doctor and individualize your personal breast cancer screening with your physician. It should be a conversation to this and it should be a balanced discussion with your clinician to determine your overall risk factors for breast carcinoma. Once you determine your overall risk factors; then determine what additional supplemental, if any, examinations would be appropriate for you. If you are average risk; consider ultrasound, always consider 3-D tomography because that is really good for dense breasts. If you are high risk; then consider adding MRI to your screening mammogram.

Melanie: Thank you So much Dr. Tumyan for being with us today. You are listening to City of Hope Radio and for more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Falls Prevention: How You Can Avoid a Fall

Additional Info

Audio File allina_health/ah144.mp3
Doctors Wellner, Chris
Featured Speaker Chris Wellner, PT, MPH, Courage Kenny Rehabilitation Institute
Guest Bio Chris Wellner, PT, sees clients at Courage Kenny Rehabilitation Institute – Abbott Northwestern Hospital. She specializes in fall prevention and has a special interest in public health.

Learn more about Chris Wellner, PT
Transcription Melanie Cole (Host): Falls are not a normal part of aging; yet one out of every four adults aged 65 and older falls every year and most have significant health and lifestyle consequences as a result. The good news is, falls can be prevented. My guest today is Chris Wellner. She’s a physical therapist and sees clients at the Courage Kenny Rehab Institute at Abbott Northwestern Hospital. She specializes in fall prevention and has a special interest in public health. Welcome to the show Chris. So, falls are a huge problem. Are they, as I said in my intro, they are not a normal part of aging, so I mean what do you tell people about the possibility of preventing falls when people think oh, I’m just going to have a fall at some point?

Chris Wellner, PT (Guest): Right. Yes, we try to really emphasize that it is not a normal part of aging and that they definitely can be prevented. To help prevent falls among older adults, the American and British Geriatric Societies developed a clinical practice guideline which recommends that a fall risk screening be done once a year for adults ages 65 and older. And at Allina Health and Courage Kenny, we are working to educate our older clients and providers about falls, conduct fall risk screenings and provide follow up resources that can help people prevent a fall.

Melanie: So, what are the most common causes of a fall?

Chris: Well some of the risk factors are related to changes that our bodies just experience as we age. We start to lose muscle strength and flexibility which leads to issues with balance and endurance. Our eyesight also changes which increases the risk for falling and certain commonly prescribed or over the counter medications that make us sleepy or dizzy; can also increase the risk. Then in our homes, going up and down stairs, navigating a dark room or a hallway, or an uneven throw rug or an electrical cord in the wrong place; can all lead to a fall.

Melanie: Sure, and even little animals around if you have got a dog, sometimes they walk right in front of you or a cat or something for older people, now tell us about a fall risk screening. What’s involved in that?

Chris: Well, the United States Centers for Disease Control developed a tool kit called the STEADI which stands for Stopping Elderly Accidents, Deaths and Injuries. And the goal of the STEADI is to help primary care clinics and providers incorporate fall prevention screening into the annual physical for people over the age of 65. And the simple STEADI assessment can be completed during one office visit and it recommends that providers do the following things. First ask the person if they feel unsteady on their feet or if they are worried about falling or if they have fallen in the last year. And next the person’s medications should be reviewed and any dosages of drugs that could increase the risk of falls should maybe be switched or reduced. Also, MDs should recommend daily vitamin D supplements to help improve bone and muscle and nerve health and also perform a quick balance and gait assessment which can show if a person is low, medium or high risk for falls and then the doctor can provide recommendations for follow up based on the person’s risk level. And this simple common-sense approach has been estimated to reduce falls by 24%.

Melanie: Wow. You know and like you say, it is simple and common-sense, now not every doctor is going to address this situation with their older patients. So, if somebody is with their mom or dad at an appointment or someone over 65 is having their doctor; how do you recommend they mention this to their doctors without sounding like they are you know asking for something that is maybe not necessary?

Chris: Right, well I would say, if you are 65 and older, and your doctor doesn’t discuss fall prevention with you; that you should feel empowered to just ask about it, especially if you are fearful of falling and maybe just share with your doctor why you are afraid or if you have had a fall, definitely share that with them and just engage in a conversation about maybe some of the things you can do. And you might be appropriate to see a physical therapist or attend a community class and your doctor could recommend those things.

Melanie: So, then what do you tell people are some ways, if you are found to be at high risk for falls; what are some ways that you can re, you mentioned carpets and electrical cords and medications and eyesight. You mentioned all of these things; but what do we do about all those things? How do we kind of walk around our house and look at the medications and see what is going on so that we can prevent falls?

Chris: Right, well I have lots of ideas. So, number one would be to look at your home and one thing that is really important in the home is to keep the lighting in the home consistent and to make sure you have lights in dark areas or use nightlights so that when you are getting up and going to the bathroom at night, that that path is lighted up. You could also have your doctor or your pharmacist look at the medications you take including your over-the-counter medications and if any of them leave you sleepy or dizzy, that can increase your risk, so there is maybe potential for those medications to be adjusted. Wearing proper shoes that give you good support and traction is important and people should avoid wearing socks only or smooth soled shoes or slippers especially if you are on stairs, wood floors or any slippery surfaces, having your eyes and ears checked every year is important just to catch any changes in your vision or your hearing and sometimes people get dizzy when they stand up really fast from a seated position, so it is important just to get up slowly after you have been sitting for a while or even lying down and just make sure you have your bearings before you start walking and then certainly using a cane or another walking aid if you have been directed to do so is important. Also, important to keep emergency numbers in your cell phone contacts or a list near your home phone and if you have a cell phone to keep it with you and close by in case you do a fall so you can call for help. And one of the most important things a person can do to decrease their risk for falling, which is probably one of the hardest, but is to get regular exercise, especially exercise that focuses on improving strength and balance. It has been shown that people can gain strength all the way up into their 90s, if they are challenged appropriately. So, this is really important to keep your fall risk low. And Courage Kenny offers a seven-week class called Stepping On at several locations around the metro area which works on just this; improving a person’s strength and balance as well as instruction and all the fall risk factors we have talked about today, and how to make changes to keep a person safe from falling. Another exercise that has been shown to be very good to help reduce a person’s risk is Tai Chi or Tai Chi Chuan, which are ancient Chinese meditation forms that can also help improve strength, balance and flexibility and is also offered through Courage Kenny.

Melanie: So, that’s some great information Chris and also, the fact is that those kinds of exercise and the American College of Sports Medicine does recommend these for older people, Tai Chi and they are so great. And what about functional exercise, I mean people have a risk of falling just from stepping off the curb and so, you know those kinds of classes are great but what can they also do at home to practice those kinds of same exercises like would balancing in the doorway, standing on one leg, does that carry over? Would that help?

Chris: Definitely. So, we often instruct people to work on balance exercises, maybe standing at the kitchen sink, so that if you do become unsteady, you have something to hold onto. So, just work on standing with your feet close together or work on standing on one leg and holding on if you need to, but just trying to let go as you can so that you are really working your legs on keeping your balance. And also, just practicing sitting to standing from a chair is an excellent exercise to increase strength. And just doing that ten times in a row, like during a commercial break if you are watching TV is a great exercise.

Melanie: Well you will see people too when especially older people and as a trainer, I see this all the time; when people get up from a chair or you are having them do that exercise you have just described off a bench or a chair; they waver a little as they are getting up and that strength and then they have that little balance issue so you can see how really applicable that kind of an exercise is. So now wrap it up for us with your best advice about fall prevention and what you really want people to know about these classes available at Allina.

Chris: Yeah, first I would say talk to your doctor and really be honest about your fear if you have a fear of falling and then really look on getting regular exercise and look for our classes within Allina, talk to your doctor about them. They are on the website, Allinahealth.org, so if your doctor doesn’t’ know about them, they may be able to look there and find them for you.

Melanie: Thank you so much for being with us today, it is great information. Thanks so much. You are listening to the Well Cast with Allina Health and for more information, you can go to allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Living with Diabetes

Additional Info

Audio File doctors_laredo/dl015.mp3
Doctors Reyes, Mateo
Featured Speaker Mateo Reyes, MD
Guest Bio Mateo Reyes, MD works in Laredo, TX and specializes in Family Medicine and General Practice, and is a member of the medical staff at Doctors Hospital of Laredo.

Learn more about Mateo Reyes, MD
Transcription Melanie Cole (Host): According to the Centers for Disease Control and Prevention, as many as 29 million people in the United States have diabetes, but up to 8 million may be undiagnosed and unaware of their condition. My guest today is Dr. Mateo Reyes. He’s a family medicine physician and a member of the medical staff at Doctors Hospital of Laredo. Welcome to the show. What is diabetes type 2?

Dr. Mateo Reyes (Guest): Type 2 diabetes is a problem with the body having what we called insulin resistance or the body’s inability to use insulin appropriately in order to be able to transfer sugar from the blood into the cells to be used for energy.

Melanie: Are there certain people who are predisposed to type 2 diabetes? We’re distinguishing between type 1 and type 2 because type 1 is something that really can be a lifelong thing, but diabetes type 2, which used to be called adult onset, now we are seeing in children. Just give us a little physiology lesson of the difference between the two.

Dr. Reyes: Type 1 diabetes was always known as insulin dependent diabetes – the pancreas doesn’t produce insulin and therefore they require insulin to manage their sugars. In type 2 diabetes, it’s actually the opposite – there's a lot of insulin but there's insulin resistance and therefore the person builds up high levels of sugar in the blood. One requires insulin and the other one does not require insulin. Sometimes type 2 diabetics however with time people start using insulin doesn’t make them a type 1 diabetic unless they deplete their insulin levels in their body and enter something that’s called diabetic ketoacidosis, at which point a type 2 can become a type 1.

Melanie: I'm glad you made that distinction between insulin resistance and the pancreas being damaged or destroyed for type 1. Who’s at risk for type 2? Are there lifestyle things that can be involved that can help cause it?

Dr. Reyes: One of the biggest risk factors is ethnicity. I think somewhere around 16% of American Indians have type 2 diabetics. Now it is something like 13% of non-Hispanic African American people have type 2 diabetes and also about 13% of Hispanics, 9% of Asian Americans, so that tends to be a big risk factor, and of course the other one would be obesity. Particularly the people that have the centripetal obesity or the pear shaped distribution type of fat. Around the belly, that one produces more insulin resistance than the people that carry it more on their thighs, etc.

Melanie: What would be your first best piece of advice? If someone is told that they have pre-diabetes, that they're on the edge of full blown diabetes, what would you want them to know and what would you want them to do?

Dr. Reyes: The biggest thing that we always start with is lifestyle modifications. Of course, there has been some studies that show that losing up to 10% of a person’s body weight at the diagnosis of prediabetes will keep them from becoming a full blown diabetic, at least in that short period of time. Somebody who’s on the verge of becoming a diabetic, you tell them to lose 10% of your body weight, you encourage a low carb diet, you encourage exercise and of course the weight loss. You can keep them from becoming a diabetic so long as they maintain that lifestyle modification. If they go back to their old ways, then risk comes right back.

Melanie: If they are diagnosed, you’ve mentioned the lifestyle modifications a little bit, and then what about nutrition and then medicational intervention? Nutrition, people hear carbohydrates and right away they say ‘I'm not allowed to eat those anymore, now I'm a diabetic.’ Certain vegetables are carbohydrates and things that are not necessarily so bad for you, so what do you tell people about their nutritional requirements?

Dr. Reyes: The whole key to that is just having a healthy well balanced meal because you being diabetic does not mean you have to eliminate carbohydrates – of course you have to go on a low carb diet. The body still needs some carbohydrates for energy – the body uses glucose for energy and if you totally deplete it, then you're going to start going into glucose starvation mode and then you start breaking down fat, which at some point it can be desirable such as the Atkins diet or something like that, but the brain in particular doesn’t do very well without glucose. The low carbohydrate diet is good. Obviously, you're going to want to go on a low fat diet because most people with diabetics also have issues with fat metabolism or cholesterol. You do want to eat your vegetables. You do want to eat your greens. The huge thing here is moderation and portion size. For example, if you're going to have some rice, it has to be whatever fits in the palm of your hand, but that doesn’t mean you cannot have any rice. Obviously, you want to stick more to the lean proteins, more veggies and a little bit of carbs and the portion size. If you look at the food pyramid that dieticians talk about, that’s a healthy well balanced meal. You want to decrease your fat intake, your carb intake, but you don’t want to totally eliminate them.

Melanie: What about if you do have to look towards medication? Are there some medications that can help reduce your glucose levels? Are there oral medications? What are you doing today for people that are having trouble with those lifestyle modifications and they have to turn toward medicational intervention to help them with this?

Dr. Reyes: There's a lot of medicines available now for diabetes and there's a lot of good medications nowadays that make the body function in a more normal way. Still, the #1 medicine used in type 2 diabetes is probably one of the older ones called Metformin and it allows the body to utilize its own insulin as opposed to having to use insulin. There's some medicines that work by eliminating sugar in the guts, some by eliminating sugar in the kidneys, some that help the pancreas in a more normal fashion. There's a broad spectrum of medications – oral medications, then you have to go to insulin – or if you're diagnosed with a very high level of sugar on presentation, your doctor might even opt to start you on insulin right off the bat with the medication like Metformin to bring your sugar levels down, and then if you do really good, then maybe take you off the insulin and keep you on oral medications.

Melanie: What about exercise? Where does that fit into this picture? It’s really important as exercise can have an insulin like effect. How often would you like people to exercise? What would you like them to do?

Dr. Reyes: In all diabetics, you have to make sure you get an okay from your doctor to exercise at first to begin with. Like I said earlier, the body uses sugar for energy so the more your exercise, the lower your sugar levels go in your blood. If you're a diabetic and you're going to be in an exercise program, it’s going to be important that you check your sugar before you exercise to make sure you're not too low because obviously if you exercise and your sugar is in a low normal range, then you're going to bottom out. The other thing is when you exercise too much and you push your body way too much, then the body starts getting stressed and the adrenaline, the cortisol mechanism of the body starts pushing out more sugar into the bloodstream so your sugar is going to go high. Typically, exercise 30 minutes a day, most days of the week, is recommended – 150 minutes of cardiovascular exercise per week. After your exercise, if you're a diabetic, it’s important to make sure you check your feet, make sure you didn’t get any blisters or ulcers from the exercises and that’s pretty much it as far as exercise goes.

Melanie: What about self-monitoring? Those glucose kits that you can get at the pharmacy – are those what you want them to use to keep track of their blood sugar levels – and how often would you like them to check those?

Dr. Reyes: It depends. If you're a person that has been controlled – your sugars have been very well controlled – then you don’t need to monitor it every day. I tell my patients to monitor it if they don’t feel well or they're getting any signs or symptoms of low blood sugar or high blood sugar. Somebody who’s on insulin three times a day, they require much more frequent monitoring when they wake up, before meals and at bedtime. It depends on where you fall in, but typically somebody on pills shouldn’t be monitoring more than once a day unless they're feeling bad or they're having episodes of their sugars dipping too low or going up too high. Somebody on insulin probably needs to check at least twice a day and sometimes even three or four times a day.

Melanie: In just the last few minutes, what would you like people to know about diabetes and living with and managing their symptoms?

Dr. Reyes: Diabetes doesn’t have to be a dead sentence as people thought before. Diabetes is actually something that’s very manageable and it’s very important that people take care of themselves. A big thing is people always say ‘I don’t feel bad, therefore I skip medication here and there, and I don’t care my sugar’s high because I'm totally okay, you tell me numbers look good,’ and that can happen early on, but with time, diabetes will eventually catch up to you, and 15 or 20 years of uncontrolled diabetes can do a lot of damage. Of course, if you're a 30-year-old with type 2 diabetes or a 20-year-old with type 2 diabetes, then you're looking at problems at a very young age. Diabetes is the #1 cause of blindness in the United States, #1 cause of amputations in the United States, #1 cause of renal failure in the United States, it’s associated with an increase in strokes and an increase in heart attacks. If you take care of yourself, then you minimize your risk of a complication and a better outlook and quality of life later on in life. Don’t wait until you have a problem to start taking care of yourself because a lot of the damage that diabetes does is irreversible – you got to start taking care of yourself the minute you're diagnosed with it.

Melanie: Thank you so much for being with us today. You're listening to Doctors Hospital Health News with Doctors Hospital of Laredo. For more information, please visit ichoosedoctorshospital.com. That’s ichoosedoctorshospital.com. The physicians are independent practitioners who are not employees or agents of Doctors Hospital of Laredo. The hospital shall not be liable for actions or treatments provided by physicians. Doctors Hospital of Laredo is directly or indirectly owned by a partnership that includes physician owners, including certain members of the hospital medical staff. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Robotic Surgery for Urologic Disorders

Additional Info

Audio File texoma/tm013.mp3
Doctors Ruddell, Timothy J.
Featured Speaker Timothy J. Ruddell, MD
Guest Bio Dr. Tim Ruddell, is a Urologist and a member of the medical staff at Texoma Medical Center. He is trained to perform urologic procedures using the daVinci Surgical System at the Center for Robotic Surgery.
Transcription Melanie Cole (Host): Using minimally invasive robotic surgery to treat urological disorders has rapidly grown as an option for many patients and it may reduce pain and recovery time. My guest today, is Dr. Timothy Ruddell. He is a urologist and a member of the medical staff at Texoma Medical Center. Welcome to the show Dr. Ruddell. So, what urological procedures and be performed using robotic technology?

Dr. Timothy J. Ruddell, MD (Guest): There are a number of different procedures that can be performed using the da Vinci robot. Most of our intrabdominal surgeries that we do, that we perform as urologists can be performed robotically; most commonly, these would be robotic prostatectomies for men who have prostate cancer and desire definitive surgical therapy of their prostate cancer. Other things that could be done are various kidney surgeries including kidney removal for cancer or nonfunctioning kidney for whatever the cause may be. We also perform partial removal of kidneys for example, if the patient has a tumor in their kidney that is small enough that we can resect only the tumor itself rather than the whole kidney, we can actually remove just the tumor robotically. We also can perform various reconstructive surgeries on the kidney and ureter whether that be through scarring from passage of kidney stones or reconstructive surgeries on congenital abnormalities of the way the kidney and ureter join together.

Melanie: So, how is this different than performing these procedures using traditional surgical methods?

Dr. Ruddell: So, the difference is the minimally invasive nature of this. Traditionally, all of these surgeries that I previously mentioned, were performed through large open intraabdominal incisions, so a large incision down the midline of the abdomen or under the ribcage. So, these are done through small incisions. How it compares to plain laparoscopic surgery is it gives you a third dimension of imaging whereas traditional laparoscopic surgery only has two dimensions. It is like watching a television in two dimensions. There is no depth perception. So, robotic surgery gives you a third dimension and gives a surgeon the ability to perform laparoscopic surgery in three dimensions and gives them better depth perception in doing so. Also, the robotic technology, the motion of the instruments is extremely precise. It gives what we call a wristed technology where it actually mimics the degrees of motion that your wrists have and there is really no other laparoscopic technology that has this.

Melanie: So, what are some of the benefits to the patient besides what you have just described as the difference with the traditional surgical methods? What are some of the other benefits to the patient?

Dr. Ruddell: The benefits to the patient most definitely probably that they will appreciate the most is the shorter hospital stay. The hospital stay for example, for an open prostatectomy done through a low abdominal incision traditionally was 5-7 days. Most patients are out of the hospital within 24-hours of their robotic prostatectomy. This corresponds to much less blood loss during the surgery because the blood vessels around the surgical field can be visualized and controlled earlier which therefore correlates with shorter hospital stays. Patients have less pain from the smaller incisions and this all boils down to a quicker recovery for the patient to get them back to doing their normal daily activities much more rapid than through traditional surgical techniques.

Melanie: And what about benefits to the surgeon, Dr. Ruddell, you mentioned is it more precise and sensitive and maybe it can spare delicate nerves. Tell us about, as a surgeon, why you find this so appealing.

Dr. Ruddell: Absolutely, so, for example, during the robotic prostatectomy, which I do a very large number of; there are delicate nerves that control erectile and sexual function postoperatively. There are also muscle fibers in the area that control urinary continence. So, traditional side effects of prostatectomy are erectile dysfunction and urinary incontinence. Using the robotic technology, these nerve bundles and muscles are much more easily spared, therefore correlating to better rate in nerve sparing prostatectomy, better erectile function, and better sexual function following prostatectomy and in my opinion, better continence rate and less urinary incontinence after the procedure. These nerves can be visualized, they can be easily separated off of the capsule of the prostate, whereas doing open prostatectomies, there is usually a large amount of blood in the field, these nerves are barely visualized and are much more difficult to take the care to spare them completely compared to the robotic technique.

Melanie: Dr. Ruddell, are there some patients for whom they are not a candidate for this type of surgery and they must undergo the open traditional type?

Dr. Ruddell: Yes, there are a few reasons why patients would not be an ideal candidate for this. Typically, body mass index of greater than 40, it is difficult to ventilate patients in the position that we have them in for robotic prostatectomy. The position that the patient is required to be in, we actually put them in what is called Trendelenburg which is where the feet are actually elevated in the air and the head is down, so they are sloping downward toward the head. Carrying excess abdominal weight puts weight on the lungs and it is difficult for the anesthesiologist to adequately ventilate patients. Other than that, specific to the robot, that is really the only reason they would not be a candidate for it. Of course, there are other reasons why patients are not ideal surgical candidates in general. If they have severe cardiac disease, have had numerous heart surgeries, do not have good heart or lung function that they are just not healthy enough for an anesthetic, but that would be to any surgery, not specific to the robotic surgery.

Melanie: And Dr. this is just a question that some patients might want to know. Is it difficult to learn how to use the da Vinci Surgical System? I mean obviously, we have great respect for surgeons and everything that you guys do, but is this a difficult process? Does it take a lot of additional training to learn how to use these new techniques?

Dr. Ruddell: Yes, it takes a great deal of training to learn how to use these. The learning curve has been well-studied through the urologic procedures that are done in addition to the various other surgical specialties that use the da Vinci robot and across the board, the learning curves are very high, so the bottom line is you want to have a da Vinci robotic surgical procedure performed by someone who has had specialized training in that. It is very difficult to learn that without having specialized training and it is difficult to get the volume necessary to overcome that learning curve of performing these surgeries.

Melanie: So, in summary, what would you like people to know about urologic issues and disorders and the treatment options available through robotic surgery?

Dr. Ruddell: The robotic surgery has really revolutionized the way we practice urology. It is a great benefit to the patient. The da Vinci robot was really designed for the robotic prostatectomy, but now we have found many different reasons to use it and ways we have improved our surgical outcomes. Patients do so much better having the da Vinci robotic surgeries performed. A patient, when they are being evaluated for surgical therapy, they should always do their due diligence and research that the options that are delivered to them are the – are all the options available, because there are many surgeons, urologists, etc. that may not offer if because they were never trained on it. But that doesn’t mean that you can’t find someone that is trained on it and those options are widely available in the United States now. Here at Texoma Medical Center, we do a very large number of robotic surgeries. There are several different surgeons that use it. I am the only urologist in the area that currently uses the robotic technology, so if you are facing prostate surgery, kidney surgery, you should always look at your options and evaluate them and I am happy to see you to come talk about the robotic surgery if necessary.

Melanie: Thank you so much, Dr. Ruddell for being with us today. You are listening to TMC Health Talk with Texoma Medical Center. For more information, please go to texomamedicalcenter.net. That’s texomamedicalcenter.net. Physicians are independent practitioners who are not employees or agents of Texoma Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if robotic surgery is right for you. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Metastatic Triple Negative Breast Cancer

Additional Info

Audio File city_hope/ch108.mp3
Doctors Yuan, Yuan
Featured Speaker Yuan Yuan, MD, PhD
Guest Bio Yuan Yuan, MD., Ph.D. is an assistant professor specializing in breast oncology in the Department of Medical Oncology & Therapeutics. Prior to joining City of Hope in 2012, she was an assistant professor at Loma Linda University Medical Center in the Division of Medical Oncology and Hematology, and a principal investigator for multiple breast cancer trials.

Learn more about Yuan Yuan, MD., Ph.D
Transcription Melanie Cole (Host): Although breast cancer is often referred to as one disease; there are actually many different types. The differences can help guide treatment and provide information on prognosis. Certain characteristics make some breast cancers more aggressive than others. One such breast cancer is metastatic triple negative breast cancer. My guest today is Dr. Yuan Yuan. She is an assistant professor specializing in breast oncology in the Department of Medical Oncology and Therapeutics at City of Hope. Welcome to the show Dr. Yuan. What is metastatic triple negative breast cancer?

Dr. Yuan Yuan, MD, PhD (Guest): Thank you. Triple negative breast cancer is defined by lack of three receptors; estrogen receptor, progesterone receptor and HER2 receptors. So, that defines the triple negative breast cancer and so called the metastasis meaning the tumor had traveled beyond the local, went to other organ systems. So, triple negative breast cancer of course is one of the most challenging and aggressive disease.

Melanie: So, when we hear the word metastases, we think that as you say, it has traveled to other areas, but people tend to think of that as something that you find later in a cancer. So, is this something that happens very quickly in this cancer?

Dr. Yuan: Yes. The tumor is characterized by dividing really fast. We use the jargon called a proliferation means the tumor grows, they divide from one to two, two to four really fast. So, that it gets higher chance of spread beyond local and the most common sites of metastases can be liver, lung, brain. So, these are the really vital organs that we survive on.

Melanie: So, who would be a risk for this type of breast cancer?

Dr. Yuan: Any woman, but it tends to happen in certain ethnic backgrounds such as African Americans, Hispanics and also it happens in younger women.

Melanie: It happens in younger women? So, that’s a little bit more rare, now as we are getting our mammograms and some women don’t start until thirty five or forty, then is this a breast cancer that might have a genetic component that might signal that you want to start getting those mammograms earlier?

Dr. Yuan: Yes. Anyone who has family history of early onset breast cancers, I would encourage them to look for genetic counseling and often triple negative breast cancer is tied into the connection between the BRCA1 mutation and nowadays because of what we have much more comprehensive genetic testing panels we are able to identify gene mutations beyond the BRCA1 and 2.

Melanie: So, then what is treatment like? Are we in the clinical trial phase? Are there a lot of things that you are doing? Or is there a standard course of treatment that has been set out for this particular type?

Dr. Yuan: Yes, so over the past years, there has been a lot of effort to look into treatment options beyond chemotherapy. But unfortunately, at this moment of time, there is no FDA approved target therapy beyond conventional chemo. There has been a lot of efforts in research, such as identifying newer targets, identification of immunotherapies, so at this moment of time, we do have multiple clinical trials in triple negative breast cancer and as you mentioned earlier, breast cancer is heterogenous and in triple negative breast cancer, it is also a very heterogenous disease including a multiple of subset types, that is based on a MRNA expression panel, so at this time, we are working hard to identify a subset of triple negative breast cancer and treat them accordingly. We have multiple clinical trials for example, one of the trials we are leading is to target androgen receptor positive triple negative which accounts for about 10% of triple negatives and we combine immunotherapy with a checkpoint inhibitor and with the androgen receptor targeting drug which is an oral agent. So, that is one of the efforts that we are leading right now. We have multiple other studies and trying to identify targets, but the disease has been very challenging to treat especially in the metastatic setting because of the previous therapies they have received; so, the tumor often becomes chemotherapy resistant.

Melanie: And what about hormone therapy? Is it as resistant to that as it might be to chemo?

Dr. Yuan: Yes, because of a lack of receptors, ER and PR so hormonal therapy conventionally was not offered and here in this clinical trial, I mentioned earlier, we are looking at androgen receptors which is a male hormone receptor we can identify in about 10% of triple negative patients and we are hoping to see signals. Now there are some earlier trials utilizing drugs such as enzalutamide which we use to treat prostate cancer because of the prostate cancer cells expressed androgen receptors. So here in this clinical trial, we are using that concept and that concept has been tested but the signal is not super robust. For example, response rate is around 15-20% when you are just giving patient hormonal therapy. So, here in this clinical trial, we are combining hormonal therapy, antihormonal therapy and antiandrogen receptor with antiPD1 inhibitors. So, we are hoping to see some synergies between these two.

Melanie: So, as far as immunotherapy goes and seeing what is going on out there, is there – there is a new medication that might be effective in shrinking the tumors? Are you working on that immunotherapy as well?

Dr. Yuan: Yes. So, one of these agents being tested is called pembrolizumab or Keytruda. Earlier clinical trial has demonstrated a single agent activity meaning by offering just the single agent, Keytruda, alone in triple negative breast cancer, the response rate is around 8-15% of the time and one of the trials it is actually 19%, but we think it is not good enough and often our patients do have very aggressive disease and you need a much more effective therapy in order to help them relieve the symptoms and to prolong the survival. So, that is why the combination strategy has been utilized here. So, beyond the androgen receptor targeting drug, we also have a combination using Keytruda in combination doxorubicin, one of my colleagues is leading that study. Another trial is using Keytruda in combination with a stem cell inhibitor called Axl, A-X-L, axl inhibitor, so that is an ongoing study we just opened and looking forward to seeing some positive signals.

Melanie: So, what about recurrence and survival? We don’t always like to talk about prognosis and survival on this show, however, this one sort of warrants that. Is it a highly, does it recur quite often and then when it does, is it much harder to treat?

Dr. Yuan: Yes. So, the recurrence rate for stage by stage comparing the ER positive disease or HER2 positive disease to what is triple negative, the triple negative patients have a much higher rate of recurrence and once patients were diagnosed stage four or metastatic, the overall survival is really pretty bad in a way that average survival is about 13 months.

Melanie: So, what can you tell women Dr. Yuan, if they are either at risk for this type of breast cancer or if they have been diagnosed, what would you like them to know that might give them some hope and things that you are doing there at City of Hope?

Dr. Yuan: Yes. So, for women who have a diagnosis with any type of breast cancer, I think the key is to keep a very close follow up on a regular basis with their oncologist and certainly for triple negative, the challenge is that we don’t have a good adjuvant therapy, so although there are some clinical trials that are looking into giving women immunotherapy in the adjuvant setting, but that is not a proven strategy but a woman can certainly do several things to reduce their risk of recurrence. One such strategy is exercise and weight reduction has in some areas has shown benefit, but most important thing is that to keep a close follow up with your oncologist. And at this time, for the adjuvant patient, we are bringing some newer clinical trials to try to help for high risk women to offer them different options. Outside of that setting, we don’t have a lot of effective strategies. But for recurrent or metastatic cases, I think certainly looking for immunotherapy combinations would be something probably the most promising area in treating metastatic breast cancer – triple negative breast cancer, in addition at City of Hope, we are doing robust research including the preclinical translational and early phase clinical trials in an effort to try to change the current status of lack of therapy for triple negative breast cancer. So please do consider participating in one of our studies.

Melanie: Thank you so much Dr. Yuan for being with us today. You are listening to City of Hope Radio and for more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

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