Inactive (722)

Segment Number 2
Audio File virginia_health/1607vh4b.mp3
Doctors Deal, Nicole
Featured Speaker Nicole Deal, MD
Guest Bio Dr. Nicole Deal is a board-certified orthopedic surgeon and hand surgeon whose specialties include caring for patients with hand, wrist, elbow and upper arm injuries.
Transcription Melanie Cole (Host): Tennis elbow is a painful condition of the elbow caused by overuse and, not surprisingly, playing tennis or other racquet sports can cause this condition. However, several other sports and activities can also put you at risk. So, what can athletes do to reduce their risk for tennis elbow? My guest today is Dr. Nicole Deal. She’s a board certified orthopedic surgeon and hand surgeon who specialties include caring for patients with hand, wrist, elbow and upper arm injuries at UVA Health System. Welcome to the show, Dr. Deal. Tell us a little bit about what tennis elbow is. People have heard this term for years. What exactly is it?

Dr. Nicole Deal (Guest): Well, thanks, Melanie. It’s an overuse injury, as you said. It’s a painful condition about the outside or the lateral part of the elbow which is really a tendonitis – an inflammation of where the muscles insert on bone in that region of the elbow.

Melanie: What are the causes of this injury? Is it strictly overuse?

Dr. Deal: In general, yes, it is overuse. It’s a myth that it’s always caused by tennis. In fact, I frequently see it in patients who don’t play tennis, although I do see it in tennis players also. It’s a really common condition.

Melanie: So, what other activities? Does golf cause this? What about the pitchers who now have pitching limits on how many times they can pitch?

Dr. Deal: Sure. That tends to be an unrelated thing in younger athletes. This is more of 30’s to 40’s to 50’s type of age range and sometimes we see it in people who go out and do an overuse activity--sort of a weekend warrior type of a thing. Another example is people who are taking up weight lifting. Golfers can get it but that tends to be more on the inside part of the elbow. It’s just when people don’t listen to their body and they try to push through an activity that’s really causing them a lot of discomfort.

Melanie: Let’s start with prevention, then. Is there anything that you recommend people can do to prevent this painful condition?

Dr. Deal: Sure. What I just said, I think, is the very most important and that is just to really listen to your body. If you’re going out and doing an activity that is actually painful--you know, we all get sore from time to time and we all want to be physically fit--but if you’re doing something that’s really bothering you and that lasts for a long time after the activity and limits your ability to do your daily activities, then you’re doing too much. You really need to back off and see someone and learn how to get fit without hurting yourself. I would say that’s number one. Number two is, really think about stretching before you do activities. If you’re feeling a little bit of discomfort after an activity, consider icing after activity and sometimes anti-inflammatory medications, like ibuprofen, can be really helpful on an intermittent type of basis. You don’t want to take those all the time but if you have a little flare up, sometimes those of us who are in that age range need a little help.

Melanie: You said stretching. People really don’t know to stretch the area and the tendons around the elbows. Give us some advice.

Dr. Deal: Sure. There are some good online resources about that. If you have tennis elbow, you’ll notice that tone of the most painful activities is holding your arm away from your body with your elbow straight and trying to raise your wrist. That really tends to hurt, so if you can get in a position where you’re doing that activity but you’re stretching the wrist down and pulling gently on those muscles and sort of warming those up before you begin to do your activities, that can really help quite a lot.

Melanie: Then, you mentioned icing afterward and we’ve seen the athletes with their elbow jammed into a bucket of ice and then, what? Some people like to brace Dr. Deal. What do you think about bracing?

Dr. Deal: Sure. So, a lot of people come in with what’s called a counterforce brace on their arm and you can get those over the counter. They are straps that go around just below the elbow to sort of hold your arm. What I see people do--and some people love those--but what I see people do that’s an error is wearing it extremely tight because that actually exacerbates the problem. I think if you’re going to use that particular type of brace, you should use it as a reminder to yourself how “my elbow’s a little sore. I better not do those extreme activities” but don’t wrap it so tightly that it’s really pinching that part of the elbow because that’s not helpful either. One brace that is helpful can be a wrist brace and that sounds strange but we talked at the beginning about how these muscles are the muscles that are on the outside part of the elbow, they actually don’t work they elbow, they work the wrist. If you can rest your wrist, you really rest those muscles that are constantly working to pull your wrist up.

Melanie: If they do some strengthening exercises like forearm exercising, flexion and extension of the wrist, do those help or are they counterproductive?

Dr. Deal: They can help. I think once you’re in the acute inflammatory phase, strengthening is not a good idea. You need to get out of the extremely uncomfortable phase before you can begin to strengthen. The first thing is to really stretch it out, rest it, let those tissues heal. You can think of this as a micro-tearing of the muscle, if you will. So, it’s actually an injury that needs to heal before we can begin to strengthen again.
Melanie: That’s such great advice and if it does become really, truly problematic and somebody is an athlete and they really need to kind of get through this, what treatments are available?

Dr. Deal: There are a few things. The first thing we do, even in athletes, is really have you see our therapist because they can educate you in ways to prevent this becoming a chronic problem and also begin strengthening you in safe ways. We brace your wrist when we see you the first time, too, for a few weeks, and put you on a course of anti-inflammatories. If those modalities fail to alleviate all your symptoms, we can consider doing cortisone injections into the region. That is not always beneficial for people. Some people have great relief and some people don’t.

Melanie: I’m glad you brought up cortisone because some people do want to come in for those more than is indicated. If they do work, how many are you willing to give somebody before you say “no more”?

Dr. Deal: Not more than a couple and not more frequently than a couple of times a year. If you’re having them more frequently than that, you can weaken the tissues and also it’s putting a band aid on something that you really should be trying to heal using other methods. Sometimes--very, very rarely--this does become a surgical problem and we do operate on this. I would say that’s a very uncommon thing to have to do.

Melanie: In just the last few minutes, kind of reiterate your best advice about maybe cross-training, resting and using flexibility and stretching it, ice. Kind of wrap it all up for us.

Dr. Deal: Sure. I think if you’re having symptoms of tennis elbow, you know, we all want to just push through and keep doing that activity. “Hey, I want to have stronger arms, etc.” Back off a little bit. Do a little more cardio, do your legs. Let your body have a chance to heal and then see someone. Let us help you figure out the way that you can achieve your physical fitness goals or get back to the level of activity you want in a safe way that you’re not going to consistently inflame this area and make it a chronic problem.

Melanie: Dr. Deal, why should patients come to UVA Orthopedics for elbow and other arm injuries?

Dr. Deal: Well, we have a great center called the “UVA Hand Center” and we have four specialty-trained upper extremity surgeons and two physician assistants on site who specialize in treatment of the arm, including tennis elbow. In additional, we have our therapists right on site with us. We can take x-rays if we need to and we can do injections right there in the UVA Hand Center also. So, it’s a one stop place to go to have all of your diagnosis and your treatment in one spot.

Melanie: That’s great information. Certainly very useable things people can do right now, today. Thank you so much, Dr. Deal, for being with us. You’re listening to UVA Health System Radio. For more information you can go to UVAHealth.com. That’s UVAHealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Who Can Receive a Stem Cell Transplant?

Additional Info

Segment Number 1
Audio File virginia_health/1607vh4a.mp3
Doctors Keng, Michael K.
Featured Speaker Michael K. Keng, MD
Guest Bio Dr. Michael Keng is board certified in internal medicine and specializes in hematology, including caring for patients with leukemia.

Learn more about Michael K. Keng, MD

Learn more about UVA Stem Cell Transplant Program
Transcription Melanie Cole (Host): Stem cell transplants can help patients with certain blood cancers, including leukemia. My guest today is Dr. Michael Keng. He’s board certified in internal medicine and specializing in hematology including caring for patients with leukemia at UVA Health System. Welcome to the show Dr. Keng. People hear this word in the media—“stem cells” and “stem cell transplants”. Please tell them what this means.

Dr. Michael Keng (Guest): Absolutely. Thank you for having me today. I want to first just begin saying that stem cell transplants are something that involves a huge medical team in that we are all here in regards to our patients. Stem cell transplant is basically deriving stem cells from a patient, whether that’s from the bone marrow or the blood itself or umbilical cord, and it’s the process of taking one of the stem cells from these sources and delivering them to a particular recipient that needs the stem cell transplant.

Melanie: Who would be a recipient? What type of patients would require stem cell transplantation?

Dr. Keng: That’s a great question. There are many types of indications for stem cell transplant. I usually think of them as patients that have malignant versus non-malignant diseases. What I mean by that are patients with malignant cancers such as leukemia, including acute myelo leukemia, acute lymphoblastic leukemia and also other special bone marrow disorders, such as myelodysplastic syndromes and also myeloproliferative disorders. If a patient has a relapse or a refractory disease in multiple myeloma and Hodgkin’s lymphoma or non-Hodgkin’s lymphoma, these patients can also proceed to stem cell transplant. Non-malignant cases, meaning cases that are not considered cancers, can also require stem cell transplant such as thalassemia, sickle cell anemia, aplastic anemia and other immunodeficiency syndrome.

Melanie: Dr. Keng, before I ask you about the people that are donating the stem cells, is there a pre-treatment that patients have to go through before they can have a stem cell transplant?

Dr. Keng: Absolutely. It honestly depends on what your baseline diagnosis is. For example, if you are a patient that has been diagnosed with leukemia, a patient must be in remission before heading to a stem cell transplant. Remission treatment usually involves chemotherapy or other targeted therapies to suppress or remove these cells altogether from your body. If you have specific non-malignant cases like I discussed earlier, these may not require intensive therapies but a stem cell physician would be able to tell you specifically when would be the best timing for a stem cell transplant.

Melanie: Where are you getting the stem cells? That’s been such a source of controversy both in politics and the media but it’s really not the same thing is it, what you’re talking about?

Dr. Keng: No. These stem cells are not embryonic stem cells that has created such controversy in the media. These stem cells are what we call “hematopoietic stem cells”. Hematopoietic basically means derived from the bone marrow. These stem cells only have the ability to grow into the common cells that we are concerned about such as white blood cells, red blood cells and platelets and other bone marrow cells. We get these cells from the bone marrow itself or the proliferal blood or umbilical cord blood.

Melanie: So, when you’re getting these stem cells who are you getting them from? Are these willing donors? Are people, then, step up if it’s someone in the family? Do you have to be a match? How does the donation work?

Dr. Keng: All bone marrow donors are coming from volunteers. They are 100% volunteers that do not receive any payment for stem cell transplant. What we typically look for, depending on what type of transplant one condition needs; for example, if someone needs an autologous stem cell transplant, these are when stem cells are used from the patient themselves. There’s something called “allogeneic” stem cells where stem cells are from a donor that’s not the patient. An autologous stem cell transplant is probably the lease controversial because these are stem cells that are collected from the patient himself or herself and will be used and infused to the patient at some other time in the future when the disease is taken care of. However, in allogeneic stem cell transplant is when stem cells are derived from a donor other than from the patient himself or herself. These donors are all volunteer based, like I said, and what we prefer is a matched sibling donor. If a sibling is not available, we commonly look in the National Bone Marrow Registry to see if there is a non-related match available. However, if a non-matched donor is not available, we can look at umbilical cord blood and also newer technology involves using what we call “half-matched” donors that could provide stem cells for the donor himself.

Melanie: Dr. Keng, does it hurt to donate stem cells to someone that you love?

Dr. Keng: No. It does not hurt. Actually, it is something that will probably give you a lot of satisfaction and just meaning that you’ve donated life literally to a patient or to someone that you love. There are procedures that are done prior just to make sure that you are an adequate candidate to donate stem cells, meaning without infections or other disorders that would prevent you from donation. The actual donation process, depending on whether the source is from bone marrow or peripheral blood, can be tailored according to what is needed. There are various procedures that allow these stem cells to be received without any pain.

Melanie: What happens once you give the stem cells to a patient? How long does it take for them to start regenerating and helping this person to get better? Is this a permanent situation or do they have to have this kind of transplant on a regular basis?

Dr. Keng: When a patient needs to undergo a stem cell transplant, this is done in the hospital, in the in-patient setting. What I will be referring to is first autologous stem cell transplant--patients who need stem cells from himself or herself would undergo chemotherapy and/or radiation. This would allow the current bone marrow to be completely removed and allow stem cells to be infused back in. This process of bone marrow recovery would take approximately 10-14 days. However, if you are receiving an allogeneic stem cell transplant, meaning stem cells from another donor, this process can be a little bit longer. The preparatory regimen to remove the current bone marrow can be quite aggressive but the stem cells that are infused in should be able to begin recover in the time period of 14-20 days. Everyone is a little bit different but this is why everything is individually based when it comes to stem cell transplantation.

Melanie: UVA as received accreditation from FACT and from the National Marrow Donor Program. Explain a little bit, Dr. Keng, what those recognitions mean.

Dr. Keng: Absolutely. FACT is an accreditation that allows us to be able to obtain and to be able to appropriately process and to be able to deliver stem cells back to a particular recipient. This is given after many checks and balances that would allow us to do this successfully without any complications. It’s not given to all institutions. You have to show that you follow specific policies and protocols that are set forth by the FACT accreditation. The NMDP, which is the National Bone Marrow Registry Program, allows us to be able to access donors who are willing to provide stem cells for our patients. Once again, this is a particular accreditation that is not given to any program that wants to perform stem cell transplants. You must show that you have an appropriate team, that you have good quality measures to be able to perform stem cell transplants appropriately before receiving this accreditation.

Melanie: That’s fascinating, Dr. Keng. I applaud all the great work that you’re doing. How cool is that what you get to do? In just the last minute here, why should patients come to UVA Cancer Center for treatment for their blood cancers?

Dr. Keng: The University of Virginia is a growing program and it is amazing to see what is being done with acute leukemia and stem cell transplantation programs. We have a multi-disciplinary team including physicians, nurses, pharmacists, physical occupational therapists, nutritionists and also social workers who all come together to care for the individual patient. No one patient is the same for us and we love to be able to call each one of our patients family because they are with us through this process. Once you become a part of UVA as a patient, you are forever a patient with us and we love the privilege and the honor to be able to take care of all patients who chose UVA.

Melanie: How beautifully put, Dr. Keng. Thank you so much for being with us. You’re listening to UVA Health Systems Radio. For more information you can go to UVAHealth.com. That’s UVAHealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Gender / Sex Medicine, What Makes Women Different

Additional Info

Segment Number 5
Audio File florida/1605fl5e.mp3
Doctors Boardman, Lori
Featured Speaker Lori Boardman, MD
Guest Bio Learn more about Florida Hospital for Women.
Transcription Melanie Cole (Host): Men and women are alike in so many ways. However, there are such important biological and behavioral difference between the two different genders and they can affect the way we look and treat many widespread diseases and the approach to healthcare. My guest today is Dr. Lori Boardman. She’s the Executive Medical Director of the Florida Hospital for Women and a professor of obstetrics and gynecology at the University of Central Florida College of Medicine. Welcome to the show, Dr. Boardman. We hear about so many of the studies on heart disease always done on men. What’s going on now? Are women coming to the forefront of really good health advocacy?

Dr. Lori Boardman (Guest): Definitely women are becoming to the forefront of advocating for ourselves and our families. In terms of advocating for ourselves with respect to heart disease, more women are being enrolled in clinical trials which really gives us the evidence we need to know how to best manage women. For example, we know that women sometimes respond differently to medications. We need lower doses or we need different medications that work better for us than they do in men. So, from treatments to diagnosis there are definitely differences and they are increasingly coming to light.

Melanie: Why do you think women are so hesitant, as we’re the caregivers of society, Dr. Boardman, and we’re the ones who need to put our own mask on before we put the mask of our loved ones on. why do you think that we are so hesitant sometimes to take care of ourselves when we are so willing to shove our spouses to the doctor and take our kids to their well visits?

Dr. Boardman: Because I think exactly as you advise. We put the mask on everybody else before we bother to put the mask on ourselves. I think with the pressures of often working and taking care of a family or taking care of your parents puts the pressure on us to take care of those individuals and our health needs, our dental needs kind of go to the back of the pack.

Melanie: We also have so many things that mimic other things. We get chest pain that could be heart disease or could be anxiety and stress. We get bloating when we’re going through menopause. What do you tell women about all of these symptoms that we get all the time?

Dr. Boardman: I think we tell women that sometimes we present differently for heart disease, for example. Sometimes it’s not with chest pain. Sometimes it actually comes out as abdominal pain or pain that radiates that spreads to your back. We want women to be aware of how their symptoms may differ and to take those symptoms seriously. The other thing I see over and over again when I talk to women is, they pass over those items, pass over those symptoms they may be having and just attribute them to something else and, therefore, again, delay getting the care that they need.

Melanie: What do you think are the most important bits of testing that women should get such as PAP smears, mammograms? What should we be getting on a yearly basis?

Dr. Boardman: I think on a yearly basis, again, it depends on a woman’s age but routine testing that almost any age should get is a blood pressure check every year. We should have our body mass index, our BMI, our weight and our height checked every year. We should pay attention to heart disease when we get a little bit older and make sure that we’re getting our lipids tested. Make sure we know our cholesterol levels and the other levels that are a part of that panel. We should also be getting mammograms. There’s an argument about when to start this but certainly by the time you’re in your mid-40’s going up to your mid-70’s. Getting a mammogram, whether it’s every year or every other year. PAP tests have now had a new way of screening has been introduced with HPV testing depending on what combination, or if you pick HPV testing alone, will vary how often we need to go see the doctor. Certainly, one of the things that both men and women have a tendency not to get on a regular basis is colon cancer screening. That can be done with things like colonoscopy or other testing but people have been slow to pick up on those. Those are things that are really critical to making sure we stay well.

Melanie: Knowing our numbers, getting our annual physical so important and you mentioned prescription medications and how we sometimes differ in how we respond to them. So, when we are thinking of blood pressure medications or cholesterol medications or a daily aspirin, for that matter? How is it different for women?

Dr. Boardman: I’ll take the one you just mentioned, the daily aspirin. I think if you look in the media and, certainly, when you read at all about the daily use of aspirin, it’s often advocated to prevent heart disease. What we know is, that works in men but it doesn’t work in women. Interestingly, what the aspirin is doing for us is, it’s reducing our risk of stroke and it doesn’t have that impact in men. I think, as we become more and more aware of these differences and that women ask their physicians specifically, “Is this a medication that you know works in women? Are there any differences in how it works in men and women? Is this the best medication for me?” are questions that we should be asking.

Melanie: That’s really great advice. Now, where stress comes in. As we’ve mentioned, women--we put ourselves under so much stress. Is there a difference in the way our stress is treated or looked at as opposed to men? It used to be, Dr. Boardman, that men were the workers, men were under stress, men had to make the money but now, that’s not the case anymore. So, is our stress different than theirs?

Dr. Boardman: Our stress is often compounded by the fact that we’re really doing a couple of jobs. We’re not only taking care of our households, taking care of our aging parents, taking care of our children but trying to work or volunteer and I think that you get compounded stress with that. To your point, women have more heart disease, more women die each year in the United States of cardiac disease than do men. Whether that’s stress related or other things are at work, I think all of those things play a part in why we see some of these differences. We have to realize that this is a serious condition in women and take preventative measures seriously and see our physicians and have those conversations.

Melanie: Another thing I’d like to ask you is that we’re seeing more autoimmune disorders in women. Again, is this something because we are overrunning ourselves, overtaxing ourselves and our immune systems are breaking down? We just seem to be seeing more Crohn’s or Lupus and things and it seems to be more women that are getting these.

Dr. Boardman: That’s absolutely true, again. About 75% of autoimmune diseases occur in women. Whether it’s lupus, whether its rheumatoid arthritis, whether it’s even thyroiditis, other disorders do present more in women and we don’t quite know what the difference is but there’s clearly a different way in which our immune systems work. Just by virtue of our ability to have a baby, which is really a foreign body within ourselves and be able to have a baby does mean something else is going on a little bit different with our immune systems and maybe it could be tied to an increase of autoimmunity in the future. I don’t know if we have the answer to that but I think that could be one possible explanation.

Melanie: What’s your best advice about bridging some of these gaps in women’s health and what do you tell women every single day about what you really want them to know about taking charge of their healthcare?

Dr. Boardman: I think taking it on a daily basis, spending some time thinking about what makes you feel more peaceful or making sure that you’re getting access to exercise if you want to do that; that you eat healthy; that we make healthy decisions when we go grocery shopping for ourselves and/or our families. I think taking that time, again, to kind of focus on stress and do things that help you, whatever it is that you do that makes you feel more energized by being able to relax and have that time to yourself. I think it’s really important to put into our schedules time to go see the physicians or dental care or whatever it is that we need to make sure that we stay healthy. And to take a list, make lists before you go to see anybody with questions that you have about what’s going on because, as we all know, often you go to the doctor’s office, you’re nervous and leave the doctor’s office realizing there’s ten things you forgot to ask that person. So, try to, when you’re in that state before you go, and you’re not feeling anxious about the appointment, make a list of questions you want to ask your physician. Don’t be afraid to ask those questions. There are no silly questions when it comes to your own health.

Melanie: What would you like to tell women listening in just the last few minutes about Florida Hospital for Women?

Dr. Boardman: I think Florida Hospital for Women is a great opportunity for women to come get a great experience with their obstetrical care but to also use our hospital and our community resources that we offer to take care of the whole person. We have services built into the new Towers at the Orlando Campus and many of the other campuses, to look at women a standpoint of breast cancer screening, cardiac screens which will be coming down the road in the future. Those kinds of things. Take advantage of what our hospital and our community resources are out there for you to enjoy good health.

Melanie: Thank you so much. What great information. So beautifully put, Dr. Boardman. Thank you so much for being with us. For more information about Florida Hospital for Women you can go to fhforwomen.com. That’s fhforwomen.com. You’re listening to Health Chat by Florida Hospital. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Painful Leg Cramps:You Could Have Peripheral Vascular Disease

Additional Info

Segment Number 3
Audio File florida/1605fl5c.mp3
Doctors Chauhan, Ketul K.
Featured Speaker Ketul K Chauhan, MD
Guest Bio Ketul K. Chauhan, MD specialties are Cardiovascular Disease and Interventional Cardiology.

Learn more about Ketul K. Chauhan, MD

Learn more about FloridaHeartExperts.org
Transcription Melanie Cole (Host): Pain in the legs can occur as a result of a myriad of conditions. However, conditions such as venous insufficiency or peripheral artery disease may be the problem. My guest today is Dr. Ketul Chauhan. He is an interventional cardiologist with Florida Hospital. Welcome to the show, Dr. Chauhan. Tell us a little about some of the physiology involving the arteries and veins in the lower limbs and how they sometimes get blocked up and we have these issues.

Dr. Ketul Chauhan (Guest): Thank you for having me on the show. The arteries of the legs are no different than arteries of the rest of the body. They are prone to just as much atherosclerosis and plaque build-up just as are all of the other arteries. Half of the physiology is always the same – its cholesterol and all of the stress on the body related. Over time, actually, the leg blockages are more likely to happen than blockage in other places, like the heart or the brain. It’s quite prevalent.

Melanie: Okay. What would somebody experience? What red flags? If we hear the words claudication, pain in the legs – but people can get pain in the legs just from musculoskeletal issues. What are some red flags that would signal there are some real issues going on here?

Dr. Chauhan: Absolutely. The biggest thing is decreased blood flow, mostly to the muscles. People start having cramps when they walk which is one of the most cardinal signs of having blockage in the legs. When people experience when they are walking and they experience pain or calf muscles or buttocks pain, that is a pretty good sign of having claudication. But, if people are undiagnosed and they don’t walk much, the peripheral vascular disease can advance. People start seeing color changes in their legs. Start seeing loss of hair and signs like those.

Melanie: Okay. So then, they go see a cardiologist-- someone such as yourself. What tests do you use to diagnose that they do have some vascular arterial issues?

Dr. Chauhan: At first, it just pure examination. By looking at it, a lot of times you can tell and just feeling the pulse in your legs. Beyond that, what we do in our office is a sonogram of the leg and that is a pretty good sensitive sign if there is decreased blood flow in the legs.

Melanie: That shows you whether somebody has some blockages or what. Then, what would be the first line of defense? Do you use medication, interventions? What do you do for somebody if they’ve got some of these issues?

Dr. Chauhan: It depends on two things. One, how affected they are with these blockages. Just because they have blockages doesn’t mean it always has to be fixed. A lot of times, we can get away with just exercise. The first line is always exercise. If you walk past the pain, you’ve forced the legs to make collaterals around the blockages. But, it is more of a supervised exercise – something we’ve prescribed. But, if that does not work, the next best line is that we physically do an angiogram of the legs to see where the blockage is. A lot of times, we can fix them with stents nowadays.

Melanie: Dr. Chauhan, if you tell them to exercise but then, pain limits their amount of exercise, does that limit the affects that it can have for them? What if they have trouble exercising because of the pain?

Dr. Chauhan: That’s why we have to prescribe them. What we tell them is to exercise beyond the pain for about 15 seconds, 30 seconds, and over time, you would be amazed at how much exercise capacity is improved. Exercise works better than any medicine, for the most part.

Melanie: If somebody does have to have a stenting procedure or an angioplasty and you go in, is this more permanent or is this something that maybe will come back and maybe you might have to redo the procedure?

Dr. Chauhan: That depends on two factors. One, the risk factor that led them to having blockages those have to be addressed. If patients smoke, they have to stop. Their diabetes has to be controlled. Their blood pressure has to be controlled. If they control the risk factors, their probability of having re-blockages is quite small. The second aspect is, the stent themselves have a certain amount of patency to it. Not just because you stent them every time do they stay open forever. There is about 85% patency over three years. There is a 10-15% chance the blockage is going to come back again just because of the nature of the stents.

Melanie: If somebody, then, has the situation and we have not discussed yet, doctor, risk factors. Are there certain things that predispose somebody to peripheral artery disease or venous insufficiency?

Dr. Chauhan: Peripheral vascular disease is the number one. Two and three reason we go to smoking, smoking, smoking. Those are the most common reasons. That’s what we see, the majority of the time people have peripheral vascular disease from.

Melanie: Is there a genetic component at all if your parents had it?

Dr. Chauhan: No, there is not a genetic component to this. The second most is because we have atherosclerosis which is a plaque build-up. Plaque build-up is related to cholesterol and your lifestyle habits. So, a combination of smoking and lifestyle habits is what really predominately drives PAD.

Melanie: When you speak about lifestyle habits, does diet fit into this at all? We hear about plaques and cholesterol and all these sorts of things: fish oils, Omega 3s. Do any of these figure into peripheral artery disease at all?

Dr. Chauhan: Yes, ma’am. Absolutely. It is a multi-factorial approach. When we start talking about risk factors, you have to address blood pressure. You have to address hyperlipidemia, cholesterol. When you are addressing cholesterol, obviously, it depends on what kind of cholesterol issues they have. If they have triglycerides, obviously, there have different treatments for it. LDL issues and then, statins come into play. There are all of these modalities. It is a multifactorial approach.

Melanie: What about things that they can try at home if they do have some issues with their legs or with arterial problems? Do you recommend compression stockings? Are people supposed to keep their legs up if they notice some edema, some swelling?

Dr. Chauhan: Now, we are developing into more venous issues. The PAD is what we talked about so far. The venous issue is a whole different story where you have a bad drainage of the legs. The blood flows to the legs but the blood doesn’t come back. Those are because of venous disease. People start out with having big varicose veins, initially, and then that leads to more blackening of the skin. The skin breaks down and there are a lot of edema and so forth. That’s where venous issues come into. The venous issues present themselves with edema as well and those are treated differently.

Melanie: Does that tend to get worse over time or does it pretty much stay the same?

Dr. Chauhan: Venous insufficiency is definitely progressive. It is heavily dependent on what happens pathophysiology-wise. The veins of the legs – they have valves in them. Because we are human beings, we stand all the time the blood that comes back from the leg depends on valves to bring the blood back against the gravity. If those valves in the veins go bad, the blood keeps pooling in the leg. The idea is to get rid of the bad veins. All the blood gets channeled to the proper veins. They are treated, most of the time, with something called ablasion where we put a laser inside the bad veins which is a big highway right underneath the skin. You get rid of the bad veins, all the blood gets back through the proper channels and the legs get better.

Melanie: Can you get rid of the bad veins? Don’t we need our veins?

Dr. Chauhan: There are two types of veins in the body the veins which are inside the muscle, which are the most important veins. There are a whole bunch of channels there. There are veins underneath the skin in the legs. Those are not the most important veins. If they are bad veins, they are not used for anything anyway. If they are good veins, then we sometimes harvest them for by-pass. But, if they have gone bad they are of little use regardless.

Melanie: When you get rid of them and you do this ablation, is it still in there? Or, do you actually physically take this vein out or does it just sort of disintegrate within the leg?

Dr. Chauhan: Correct. In the old days, to get rid of the bad veins, they used to do stripping. It used to be more of a procedure surgical issue. Now, we can do this in a more office based procedure where we put the laser inside of the vein and the vein is literally closed with this laser by a small radiofrequency ablasion. Over time, once that is closed the body, absorbs this closed vein.

Melanie: That is absolutely fascinating. In just the last few minutes, Dr. Chauhan, give us your best advice for people that might be suffering from peripheral arterial disease or peripheral vascular disease. What you would tell them is the best bit of advice and why they should come to Florida Hospital for their care?

Dr. Chauhan: Florida Hospital is really, truly at the cutting edge of medicine. That is a given. The second best advice I could give the patient is be vigilant about their symptoms. Look at your legs. See what bothers them. Most of the times, patients are aware if they live a bad lifestyle. If you have a bad lifestyle and you have risk factors and if you start experiencing things in your legs, it is better to get it checked out than not. The bigger implication here, what we’re missing is that if you do have a PAD, the PAD does not kill people. That implies that you are at very severe risk of having heart disease and that’s what hurts people. It’s better to get more vigilant and have it checked out so we can get you on the right track.

Melanie: Thank you so much, doctor. It’s great information. You’re listening to Health Chats by Florida Hospital and for more information you can go to FloridaHeartExperts.org. That’s FloridaHeartExperts.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Innovations in Minimally Invasive Heart Surgery

Additional Info

Segment Number 2
Audio File virginia_health/1608vh3b.mp3
Doctors Ailawadi, Gorav
Featured Speaker Gorav Ailawadi, MD
Guest Bio Dr. Gorav Ailawadi is a board-certified surgeon whose specialties include minimally invasive heart surgery and treatments for heart valve disease.

Learn more about Dr. Gorav Ailawadi

Learn more about UVA Heart & Vascular Center
Transcription Melanie Cole (Host): Over the past decade, minimally invasive cardiothoracic surgery has grown in popularity and is, in large part, due to the benefits for patients such as decreased pain and reduced surgical trauma. My guest today is Dr. Gorav Ailawadi. He's a board-certified cardiothoracic surgeon whose specialties include minimally invasive heart surgery and treatments for heart valve disease with UVA Health System. Welcome to the show, Dr. Ailawadi. What are some of the newest breakthroughs? What's going on in the world of minimally invasive heart surgery right now?

Dr. Gorav Ailawadi (Guest): Melanie, first, thanks for having me on the radio. I think this is an exciting time for cardiac surgery. Things are really changing and have changed pretty dramatically in the last 3-4 years with so much more new innovation coming down the pike that we haven't seen before, and especially, since probably the 60's or 70's. So, much of the types of surgery that we have performed for the last 50 years are steadfast and true. Things like valve replacement surgery, valve repair surgery, or bypass surgery to try to improve blood flow to the heart. Those are really tried and true techniques that work but patients have long been asking for less invasive options to help them get back to recovery. That really is the benefit both for young patients who need to get back to work, provide for their families, as well as for elderly patients who are worried about what is the biologic toll that a big open-heart operation is going to take on their life and recovery and pain. So, really, approaches to minimally invasive span all types of patients. Where we started with this is we learned to perform similar types of operations that we do through an open chest, through the breastbone, through less invasive approaches, typically, through the side or through partial incisions to try to mimic the same operation, or do the same operation. Now, if a patient needs a lot of things done to their heart, they need more than one valve, they need multiple valves, they need bypasses plus valves, then it's not really feasible often to do that purely through a minimally invasive approach. But, if it is an isolated thing like a valve or a single vessel bypass, then most of those patients often can be evaluated an often can get a minimally invasive approach where we're doing the same operation through a smaller incision. What that means for the patient is, typically, the pain can be a little bit less but the recovery is dramatically less with often no broken bones. They get back to driving sooner; they get back to their normal life; they get back to work sooner. If they're elderly, they oftentimes don't even need to go to rehab or they can get out of rehab sooner, as well. Now, where we're headed is, really, in the last 3-5 years, we have been involved in a number of new trials, new valves, where we can replace the valve with no incision, or we can go through the groin. This is particularly true with the aortic valve. Each of us have four valves in our heart. The most common valve that is affected is the aortic valve. With the wear and tear, that valve becomes tight and narrow. It's not related to our diet or smoking. It's just wear and tear on the heart valve similar to our knees and our back. It gets bad. So, what we can do is go through the groin with a wire up to the heart using x-ray and a new valve is collapsed on a stent. We blow up a balloon which pushes the old valve out of the way and then we go ahead and blow up the new valve on a stent. The stent stays in place and the new valve starts working immediately. Now, those valves have been approved for very high-risk patients who cannot get open heart surgery and we've been performing trials in low-risk patients. We have a very new trial coming out in the near future where we'll be looking at any patient, regardless of how young or old they are, who could potentially get this type of approach. The benefit for that is, they often leave the hospital in two or three days with no incision and get back to the routine far quicker than with any open heart or even minimally invasive surgical approach. So, this same type of technology is now expanding beyond just the aortic valve. We have ways to repair the mitral valve. The mitral valve is the valve between the lungs and the heart, so when the heart squeezes, this valve is supposed to close to keep the blood from going back to lungs. This valve often can leak in certain types of patients and when it leaks, the blood goes back to lungs and the patients feel short of breath. So, we have ways, not only to fix it with open surgery, a common way is with minimally invasive surgery where we go through the side and we can repair and replace the valve. A third option now is also to go through the groin and put a small clip called the “mitral clip” that can clip the parts of the valve that are leaking. It's a good approach for the right type of patient and the beauty of it is that it is very minimally invasive and the patients often go home the next day or two days after. That is also approved for high-risk patients who have the right type of leaking valve anatomy that they can get that. Now, there are many new devices that are coming out, many of which that we're a part of at UVA, like devices that can replace the mitral valve .We can put rings on the valve to cinch it up. We can put new cords so the mitral valve actually is like two parachutes, side-by-side with little strings, or “cords” we call them. Those cords, in some patients, can become torn or elongated. There are new devices coming out where we can place a new cord through a small incision on the chest without the heart-lung machine, using ultrasound to guide us. So, there are lots of new things and this is a really exciting time in our field.

Melanie: Wow, that is absolutely fascinating and how well-spoken you are, Dr. Ailawadi. There are such interesting innovations that are going on today. Are there certain people who would not be candidates for minimally invasive type surgeries? Then, in which case, for them, they have to have what? The full open heart?

Dr. Ailawadi: Yes. I think there are multiple things that we're looking at when we're evaluating patients for any of these devices or approaches. I think one of the biggest benefits is that we do see patients as a team. So, oftentimes, we'll have multiple different specialties, not just a heart surgeon but also a cardiologist that specializes in valve disease. Oftentimes, we'll have a specialist cardiologist who focuses just on the imaging, see the patient together and decide together what's best for each individual patient. So, it's really a team approach kind of like you hear about for cancers--there's a tumor board. We literally have a valve board. Every week we meet and talk about all patients considering any of these options. So, for the aortic valve--I think we ought to split it up into the aortic and mitral valve. For the aortic valve, we traditionally had only been able to offer this for patients that are higher risk with new trials that we're going to be a part of. We're going to be able to offer this for lower-risk patients through a clinical trial. Essentially, some of the anatomy is important, meaning the size of the valve, the size of the arteries in the groin. We need a road to the heart and we have multiple different ways to get there. The groin artery is going to be the easiest for patients to recover but we have other approaches where we can go in between the ribs and go into the heart directly, if the groin arteries are too small. So, we're looking at a lot of things in terms of the anatomy, as well as a lot of things in terms of the patient, if it's a suitable candidate. There are subtle things, like how much calcium and things like, that that may weigh in on our decision one way or the other. For the mitral valve, it’s actually a bit more complex because the valve can leak in multiple different ways. For the aortic valve, it's pretty straightforward: it gets tight, we replace it, whether we do it with surgery—and we have multiple different ways to do it with surgery. We have valves that don't need stitches and we also have the valve through the groin called the TAVR. For the mitral valve, it's a bit more complex because the valve can leak in different ways and depending on how it's leaking, that will dictate how we want to fix it--whether we want to repair it, whether we want to replace it, how we would want to repair it. And so, those things all weigh into the decision as to what that patient can get ranging from traditional open heart surgery, to minimally invasive surgery, to the percutaneous through the groin, mitral clip or the new devices that are coming down the pike. Certainly, if their anatomy is suitable for a mitral clip, for example, and they meet the patient criteria, meaning they're typically high-risk and not good candidates for surgery, we can oftentimes offer that. That's also true with all the new technologies. In terms of minimally invasive, pretty much any patient that has just a valve problem, we really consider strongly for a minimally invasive approach and there are just a few things that may weigh on us and change our decision that we need to do it in a traditional approach. That's if they have a very weak heart or a lot of calcium around their heart, or calcium around their arteries in the groin--those types of things. Or, if they have more than just the valve, like if they have multiple valves or are needing a bypass plus a valve. Those things traditionally can't be done through a minimally invasive approach alone. Now, sometimes we do combinations or hybrid approaches where we may have our cardiologist stent some of the blocked arteries and then we would fix the valve, or vice versa. That's where that team approach is really important to figuring out what's best for each patient.

Melanie: So, Dr. Ailawadi, in just the last few minutes, and even if we're talking about the transcatheter aortic valve replacement, the outcomes for these, do they have to be replaced? Does minimally invasive surgery affect the outcome as far as how long they last or any of those kinds of benefits?

Dr. Ailawadi: Well, I think we probably need to probably compare two things. So, if we compare open heart to minimally invasive and then open heart to the percutaneous approaches. So, when we talk about open heart to minimally invasive certainly the goal should be we provide as good a correction of the problem, whether it's replacement or repair than through an open approach. It's just that it's done through a smaller incision and potentially without breaking bones, or breaking less of the bone, to help with recovery. So, really the goal should be the exact same type of operation. Sometimes, honestly, the procedure is better for the patient through minimally invasive because I think we do sometimes do a better job with repairing the valve in that approach. When we compare surgery to percutaneous approaches, I do think, right now, the bar changes meaning, patients and physicians will accept less effective therapy, meaning we don't get as good a result with a valve repair, with a mitral clip as we do with surgery. However, for the type of patient we're talking about, if they're just not a good candidate for surgery or have other things going on, that's probably okay. We don't want to put them through an operation that needs a lot of recovery if they're very frail. So, the bar does change depending on the approach but I think the team approach really will help guide the patient and, ultimately, the patient's decision as to what they think is best for them.

Melanie: Thank you so much. It's absolutely wonderful and fascinating information, doctor. Thank you so much for being with us today. You're listening to UVA Health Systems Radio and for more information, you can go to UVAHealth.com. That's UVAHealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Pulmonary Embolism: Surgery May Be Necessary

Additional Info

Segment Number 4
Audio File virginia_health/1606vh4d.mp3
Doctors Sharma, Aditya
Featured Speaker Aditya M. Sharma, MBBS
Guest Bio Dr. Aditya Sharma is board certified in internal medicine and specializes in vascular medicine, including aneurysms.

Learn more about Dr. Aditya Sharma

Learn more about UVA Heart & Vascular Center
Transcription Bill Klaproth (Host): This is Bill Klaproth in for Melanie Cole. A pulmonary embolism is a blockage in one of the pulmonary arteries in your lungs. Could this happen to you? Dr. Aditya Sharma is the Director of the Vascular Medicine program at UVA Health Systems and is here to talk with us today. Dr. Sharma, thanks so much for joining us today. How does a pulmonary embolism develop?

Dr. Aditya Sharma (Guest): Thank you very much. So, pulmonary embolism is basically a blockage of the blood vessels in the lungs where, typically, the blockage occurs from blood clots that usually form in the blood vessels in the legs and then go up to the lungs. So, how does it occur? Through many different means. One of the things is that it typically occurs after surgery or in someone that has been immobilized for a long period of time and that immobilization can be because they just drove 6-8 hours straight in the car or because they broke their ankle and now they cannot move for some reason or the other. When these things happen, usually, the blood tends to be stagnant for a long period of time in the legs and that causes a clot to form there which then breaks off and goes to the lung. The other ways it can happen is that some people just have some kind of blood clotting disorder which can be genetic and, in some situations, if somebody has cancer, cancer can make the blood a lot more clottable or hypercoagulable and these people also can develop blood clots. Those are the more common ways of getting blood clots.

Bill: So, a pulmonary embolism isn’t necessarily age-specific. This can happen to young people and old people alike?

Dr. Sharma: That’s a good question. Very interesting question. No, actually there is a difference and typically pulmonary embolism is more likely to occur in older people than younger people. If it happens in a young person, we will look for blood-clotting disorders more frequently. One of the reasons behind why older people are more likely to get pulmonary embolism more is from the fact that the inside of the blood vessels, which is the [inaudible 02:43] after years and years of being exposed to irritants such as smoke and so on, can actually become damaged. I think that’s one of the reasons why they are more at risk of getting blood clots.

Bill: When you say “inactivity”, it’s basically sitting, right? It’s sitting for long periods of time. We hear about people on airplanes and really long flights of this happening, too. So, it’s basically in a sitting position? Not laying down?

Dr. Sharma: Yes. So, it can be either way. It can be in a sitting position or lying down also. It’s any position in which you’re not using your calf muscles for a long duration of time. This typically tends to be 6 hours or greater, although sometimes people can have it sooner also. Typically, it’s 6 hours or so. Often you’ll hear the case of pulmonary embolisms typically occurring in somebody who takes a trans-Atlantic flight and immediately after the flight is over, their legs are swollen and then they may break a blood clot from their legs which goes into their lungs and causes the pulmonary embolism. But, often, it could be also somebody who has broken their ankle or just had a major surgery and has been lying in bed for hours and hours. Typically, they tend to get blood clots in the legs which can break off and go to the lungs, too.

Bill: So, how do you know if you have one? Do you get like a pain in the chest or do you feel the blood clot traveling? Are their common symptoms that somebody should be watching out for?

Dr. Sharma: Yes. Typical symptoms that help people recognize that they may have a blood clot in the lung are: chest pain which will be, usually, sudden onset of chest pain; sometimes it might just be severe chest heaviness; it could be shortness of breath. A lot of times, it’s just severe palpitations. Those would be the typical symptoms. Another thing to look out for is a lot of these people will have sudden onset of swelling in the legs as the blood clot will typically form varicose before it goes to the lungs.

Bill: Would there be any pain at all in the legs if a blood clot was forming?

Dr. Sharma: Yes. If the swelling is severe, a lot of times people will have pain in the legs, too, but it’s not there always. So, the absence of it does not always rule out pulmonary embolism or a blood clot in the leg.

Bill: So, this is a serious thing. You can die from this, right?

Dr. Sharma: Yes, it’s true. In fact, it’s considered to be, actually, the 4^th leading cause of cardiovascular death in most developed nations and, in fact, pulmonary embolism is thought to be the most leading cause of death in the hospital. So, certainly, it’s a major big problem. It’s a major concern worldwide right now.

Bill: Wow. I did not know that. Is there any way to prevent this at all? Exercise as you grow older? Exercise? Diet? Does anything help prevent this from happening?

Dr. Sharma: Certainly, so one of the things, in talking about prevention, that the patient can do for themselves or we can do for ourselves is to make sure that we delay the damage within the blood vessels, the endothelial damage. That, typically, can be delayed by not smoking. Smoking, typically, tends to cause that damage and I think, overall, puts people at risk of getting pulmonary embolism in the long run. The other thing that we always advise is that if you are taking a long flight or if you’re driving a long distance, always stop every couple of hours, get out, walk a little bit, flex your calves and then sit back and continue with your flight or your drive. Those are the things we typically suggest. During surgery, now most major centers have standard protocols where we have devices called “sequential compression devices” which constantly pump blood in the leg immediately after surgery and even sometimes during surgery. We tend to give them low-dose blood thinners while they are in the hospital to help them avoid getting blood clots, too.

Bill: If you do develop a pulmonary embolism, what is the treatment for it if it’s caught in time?

Dr. Sharma: If a pulmonary embolism is caught in time, the most commonly used treatment is blood thinners. We used to have just one blood thinner for many years—almost for the last 50 years, we had only one blood thinner called Warfarin but now, we actually have 4 new blood thinners on the market that we can use, all of which are FDA approved for the treatment of pulmonary embolisms. So, it’s definitely that we have a lot of advances when it comes to that. Beyond that, it depends upon how bad the pulmonary embolism is but, often, at a big center as the University of Virginia, when we have somebody with sort of a high-risk pulmonary embolism as in the blood clot burden is so much that it’s causing stress on the heart and we are worried that this could cause death in the near time, we often will have a multidisciplinary discussion of such patients between the cardiovascular medicine group, interventional radiology group as well as the cardiovascular surgery group and discuss what would be the best option, whether just treating them with blood thinners is fine or should we go in and suck the clot out—a thrombectomy—or break down the clot with lytic agents or actually to open surgery and remove the clots. Often, it’s a fairly complicated solution for the patient and that is something we achieve through more of a multi-disciplinary approach.

Bill: So, with treatment you’re generally able to get rid of the clot?

Dr. Sharma: If we just use the standard treatment which is blood thinner therapy, over 30% of the time the clot will go away. About 30% of the time, half of the clot goes away. The role of blood thinners is not to take the clot out, but just to keep the blood thin enough so new clots don’t form and, in that period of time, the body actually takes down the clots on its’ own. That’s one of the reasons why, when we have patients with too much blood clot that’s causing stress on their heart, we will often think about going in and actually sucking the clot out with sort of devices or actually doing open surgery and removing the clot.

Bill: What is the general prognosis, then, for recurrence if you are unfortunate enough to develop one of these?

Dr. Sharma: The likelihood of recurrence depends a lot on under what conditions a person gets a blood clot. If there’s somebody who had a blood clot after major surgery or had a severe fracture and they couldn’t move their leg for a long period of time and then they get those blood clots, their chances of having another blood clot is very low in the long term. It could be less than 10% in their entire lifetime because people usually have a reason why they developed the blood clot. Clearly, they couldn’t move their leg for a long period of time and ended up getting a blood clot in the leg which went to the lung. On the other hand, we will have people who just suddenly get a blood clot because they may have a genetically predisposed condition to get blood clots or it could be that we don’t even find anything genetic and then they just suddenly got a blood clot for no clear reason at all. In those people, the risk of getting another blood clot is very high and it can be, sometimes, up to 30% in the next 10 years of their life. So, typically, for those people, we tend to keep them on blood thinners for the rest of their lives to avoid getting another blood clot.

Bill: Why should patients come to UVA for their vascular health needs?

Dr. Sharma: One of the things that we do at UVA in a very nice way is we have a very collaborative environment when it comes to vascular care. Vascular care can be provided by vascular surgery; it can be provided by cardiovascular medicine; it can be provided by even vascular interventional radiologists. Often, all of these groups provide a certain amount of care. At UVA, we all actually work together to provide what could be possibly the best care that we could give for our patients with vascular disease. That’s what I think is one of the positive things about being at UVA because you have the top level surgeons; you have the best interventional radiologists you could potentially find in the country. So, we have all the skill sets, all the techniques and all of us actually come together and decide what would be optimal and treat patients that way. So, that’s why I think it’s one of the best places to get vascular care in the country.

Bill: Well, Dr. Sharma, thank you so much for your wonderful work and thanks for being on with us today. For more information, you can go to UVAHealth.com. That’s UVAHealth.com. This is UVA Health Systems Radio. Thanks for listening.
Hosts Bill Klaproth

When Should You Get a Colonoscopy?

Additional Info

Segment Number 3
Audio File virginia_health/1606vh4c.mp3
Doctors Yoshida, Cynthia
Featured Speaker Cynthia M. Yoshida, MD
Guest Bio Dr. Cynthia Yoshida is a board-certified gastroenterologist whose specialties include colon cancer and colonoscopies.

Learn more about Dr. Cynthia Yoshida

Learn more about UVA Digestive Health Center
Transcription Bill Klaproth (Host): This is Bill Klaproth in for Melanie Cole. So, when should you have your first colonoscopy and how often should you have one? Dr. Cynthia Yoshida is a board certified gastroenterologist whose specialties include colon cancer and colonoscopies. Dr. Yoshida, thanks for being on with us today. Now, I am of the colonoscopy age. I am over 50 and I’ve got to tell you, I have friends that say, “I’m not getting that. I don’t have colon cancer in my family. I don’t need to do that thing. I’ve heard it’s horrible.” Can you explain to us why it’s so important to get a colonoscopy?

Dr. Cynthia Yoshida (Guest): Sure. Absolutely. I hear this all the time. People, even at cocktail parties, will stop me and say, “Why should I have a colonoscopy? I don’t have any symptoms. I feel great. I’m only 50. No big deal.” The real reason that we do this is just about screening. We know that all colon cancers, or the vast majority of colon cancers, start as little polyps which are benign growths. If we do a colonoscopy beginning at age 50, in the average risk population, we can actually find these polyps before they are going to turn into something bad—cancer. We can take them off before they do that. The colonoscopy is really the only screening test that we have out there that can find the pre-cancerous lesions before it turns into cancer.

Bill: So, this is really a great form of preventative medicine. I mean, the way I look at it, the technology we have today, you’re not allowed to get colon cancer.

Dr. Yoshida: That’s exactly right. It’s my job to make sure my patients don’t get colon cancer. It’s really though. There are sometimes, obviously, when polyps can be missed, but we work hard to find those polyps and take them off before they turn into anything bad.

Bill: So, you mentioned the guidelines are starting at age 50. Are there any exceptions to that general rule?

Dr. Yoshida: Sure. So, there are a number of exceptions. In African Americans, the American College of Gastroenterology actually recommends that African Americans start at the age of 45 because the risk is a little bit higher. People always think that there’s a difference between the sexes—between men and women. There isn’t. The risk is 50. If you have a family history of colon cancer, if you have somebody who is a first degree relative—so, somebody who is a child or parent or a sibling; a brother or sister who has colon cancer—you’re going to start 10 years before their age of when they were diagnosed with cancer. So, say your brother was diagnosed with colon cancer at age 46. You’re going to start screening at age 36.

Bill: Alright, Dr. Yoshida. So then, how often should you get a colonoscopy?

Dr. Yoshida: So, it’s different for different people. For most people who have no family history of colon cancer, if you have a great prep and we do the colonoscopy and don’t find any polyps, you don’t have to come back for 10 years. The reason for that is because from the start of a polyp to the formation of cancer, it takes a long time. It usually takes a number of changes for it to happen and it takes well beyond a decade for colon cancers to form. So, a ten-year window is absolutely fine for many people. If you have a family history of colon cancer in a first degree relative, say, a parent or a sibling or a child, then you need to come back every 5 years. If we find pre-cancerous polyps, it depends upon the number and the size of the polyp. For most people, it’s a 5 year window but sometimes if we find many polyps or bigger polyps, we could bring you back anywhere between 1 or 3 years.

Bill: And, if you find a polyp, do you remove it right then and there?

Dr. Yoshida: Yes. That’s the beauty of colonoscopy as opposed to other screening tests. There are a number of screening tests that are out there that they can look and see the polyps but with colonoscopy, we can actually see the polyps and we can also take it out at the same time.

Bill: That’s terrific. For many people, really, the prep is worse than the test, right?

Dr. Yoshida: That’s exactly right. That’s what I tell people. When we’re doing the consent, I usually say to people, “You could back out now, but you’ve done the hardest part.” For the most part, having the colonoscopy is really just getting sleepy and comfortable and it really is a good nap and then somebody take you out to lunch.

Bill: So, tell me, what can you expect before, during and after the colonoscopy? Take me through the day?

Dr. Yoshida: So, the day before the colonoscopy, you have the prep. That really is the hardest part. We ask that our patients eat or drink only clear liquids for breakfast that day before. Then, that evening, you’ll take a prep. The prep is something called “go lightly”. It doesn’t always go lightly but it is a liquid that stays within your GI tract. So, you drink it. People have this misconception that we have to drink gallons and gallons of fluid. For most people, it’s 4-6 glasses the night before and then 4 hours before your test the next morning, it’s 4 glasses of prep. So, you usually start at about 6:00 pm and you’re going to drink about 4-6 glasses of the prep slowly. Then, it will start to clear your bowels. Then, you go to bed and the next morning, you wake up prior to 4 hours before your procedure. You take another 4 glasses and then not eat or drink anything 2 hours before the test. It’s really important to remind your listeners that they really have to have a driver. It’s important that they have somebody who can drive them home because they will be getting sedation and then, in order to make them comfortable, they’ll get sedation through the veins. So, most people will arrive at UVA at our endoscopy unit. They’ll register out in front and will be taken to the back to the endoscopy pre-procedure area where they’ll be met by a nurse and they’ll get basic vital signs. They’ll get your blood pressure and your pulse and you’ll get undressed. They’ll put you in a patient gown and we’ll start an IV. Then, usually, the physician comes in and will tell you all about the procedure; tell you about the risks and the benefits and tell you why we’re doing the procedure and what we’re doing for that day. Then, we actually get you back into the endoscopy room itself. In that procedural area, again, we get you all connected to our blood pressure monitors, our heart monitors and our oxygen saturation monitors so that we can really closely watch you and monitor you during the procedure while you’re getting the sedation. The colonoscopy itself takes anywhere from 15-30 minutes on average depending upon what you have to do. Then, after the procedure, you go into the recovery area. Usually, in that area, you’re waking up and the nurses have some cookies and some juice and we get you fully awake and make sure that you’re tolerating what you’re eating and drinking. That’s the time that I come back and tell you exactly what we found, describe what we did and if there were any polyps found, what the follow up would be. Oftentimes, we send all the polyps to pathology. So, we’re going to need to mail you those results. I can usually tell by looking at them what I think they are and what the follow up is going to be.

Bill: So, you can eat right after you’re done? You don’t have to have any special diet? You just normally after the procedure?

Dr. Yoshida: Most people actually can. I have a number of patients who head out and have a hamburger right after. It depends on your tummy and how your belly responds to things but most people can eat pretty much back to normal.

Bill: Alright. This may sound like a silly question, but maybe not. What if somebody has hemorrhoids or an anal fissure or something? Is that problematic?

Dr. Yoshida: Those are common—for people to have hemorrhoids and they don’t interfere at all for our ability to do the colonoscopy. Oftentimes, what I tell people is the prep itself—because you’re going so much and wiping so much—that you may actually make your hemorrhoids a little worse during that period of time. After the procedure, we tend not to go for a day or so. So, it all makes up for it and they usually get better after that.

Bill: Are there any complications ever? I’ve never heard of one—not that I would. But, are there any complications that arise during this?

Dr. Yoshida: Sure. You know, the complications from colonoscopy are rare but it’s really important that people understand that this is an invasive procedure and that, I mean, you have to find somebody who is competent and excellent at this; somebody who has done a number of procedures. So, the risks of the procedures, though, are really: bleeding, infection, poking a hole through the bowel; missing a lesion; a reaction to the sedation that we give you. They are very rare. The chances of them happening are extremely unlikely especially in the hands of somebody who has done a number of colonoscopies but it’s important—and this will be the part that the doctor will talk to you about before doing the procedure to get consent and to make sure that every patient understands what they’re having and what the possibilities are.

Bill: Well, thank you so much for this great overview. You really explained it well. I really appreciate it. And, speaking of the great people at UVA, can you tell us why patients should come to UVA for their digestive health needs and their colonoscopy needs?

Dr. Yoshida: I think for their colonoscopy needs, the reason that they should come to UVA is that we have excellent, trained physicians who really care about colon cancer and colon health. We have a multispeciality group of people who are going to make sure that you have a great experience for your colonoscopy and if you have colon cancer or an issue that needs to be taken care of, we have a great group and great team of people that can take good care of you.

Bill: Dr. Yoshida, thank you so much, again. I really appreciate it. For more information, you can go to UVAHealth.com. That’s UVAHealth.com. This is UVA Health Systems Radio. Thanks for listening.
Hosts Bill Klaproth

What You Need to Know About Lung Cancer

Additional Info

Segment Number 4
Audio File city_hope/1605ch4d.mp3
Doctors Rajurkar, Swapnil
Featured Speaker Swapnil Rajurkar, MD
Guest Bio An active member in the American Society of Clinical Oncology and the American Society of Hematology, Swapnil Rajurkar, M.D. has published in the Journal of Clinical Oncology and presented at several major clinical conferences. As an oncologist, Rajurkur is especially interested in lung, prostate and ynecological cancers. His goal is to provide compassionate and individualized treatment for his patient’s through the use of evidence based medicine, access to the best technology and enrollment in clinical trials.

Learn more about Swapnil Rajurkar, MD
Transcription Melanie Cole (Host): If you have been recently diagnosed with lung cancer or are looking for a second opinion, you and your family may be facing a lot of difficult questions. City of Hope’s lung cancer specialists can walk you through the treatment process, address your concerns and create a personalized plan designed to give you the best possible results. My guest today is Dr. Swapnil Rajurkar. He’s a thoracic oncologist at City of Hope. Tell us about lung cancer and the world today. Are you seeing more lung cancer than you used to? Or less?

Dr. Swapnil Rajurkar (Guest): First of all, Melanie, thank you for having me on your show and, yes, you’re absolutely right. We are seeing lung cancer. It happens more frequently and I am seeing a lot of new cancer patients, especially women, who never even smoked. So, there is clearly something going on that we do not understand at this time.

Melanie: Okay. So, if somebody has been a smoker or if they are somebody whose family--is there a genetic component doctor?

Dr. Rajurkar: At this time the genetics are really not important for lung cancer. There could be some new information coming out soon but, at this time, there really isn’t a genetic test that can help us guide and see if any person is at a higher risk for getting lung cancer.

Melanie: Okay. So, then, back to the question I was going to ask you. If somebody is a smoker, and we’ve heard lately about lung cancer screening, who can get this screening and is it helping you docs to detect lung cancer earlier?

Dr. Rajurkar: Absolutely. There are very specific criteria as to who should get lung cancer screening. First of all, this is a low dose CT scan and these CT scans should be ordered in people between the ages of 55-74 who have smoked at least 30 pack years and, if they are a former smoker, have quit within the last 15 years.

Melanie: What does 30 pack years mean? People hear those terms and they’re not sure what that even means.

Dr. Rajurkar: If a person smokes one pack a day of cigarettes for about 30 years, that would be called a 30-pack year smoking history.

Melanie: If someone has been that, then this is the criteria and is this something they ask their doctor if they can have this screening and at what age?

Dr. Rajurkar: This is approved to be done between the ages of 55 and 74 years, first of all. Secondly, whenever we see a new patient, we get this history in their initial paperwork and if a person thinks he’s at a high risk of getting lung cancer because of the high risk of smoking, they should bring this up with their primary care physician so that this scan can be ordered for them.

Melanie: So, you do the screening. What are the symptoms of lung cancer doctor that people might, if they haven’t been screened, or if they’ve been a smoker or they just feel something’s not right, what are some red flags for lung cancer?

Dr. Rajurkar: Sure. So, shortness of breath, chest pain, cough, coughing up blood, losing weight significantly without trying to lose weight. These are all possible symptoms of lung cancer.

Melanie: You mentioned coughing up blood, does every lung cancer patient cough or sometimes it cannot have a cough accompanying it?

Dr. Rajurkar: That’s correct. Not every lung cancer patient has a cough or even has shortness of breath. Sometimes, lung cancers are diagnosed incidentally. Say, for example, a patient is going to have a surgical procedure and the surgeon orders a pre-operative chest x-ray. That, incidentally, picks up a mass in the lung. A lot of patients who have lung cancer don’t even have any symptoms. That’s the scary part.

Melanie: Wow. That’s the scary part. Now, if somebody hears that diagnosis--and what a scary diagnosis it would be--but it’s not always the death sentence that it used to be 50 years ago. Tell us what’s going on in the world of lung cancer treatment now.

Dr. Rajurkar: Sure. Say a person has a CT scan which shows a mass in the lung. The first step is to get a biopsy of that mass. It’s usually done by putting a needle in the mass from outside or through a bronchoscopy where a camera is passed in the airway. One of these ways we get a biopsy and confirm if it is lung cancer or not. Once it is confirmed to be lung cancer, we get a full body scan called a PET scan and we also get a MRI of the brain to make sure the cancer has not spread anywhere else in their body. Once we have these results, we know the exact stage of the lung cancer. There are four stages. Stage I, II, III, IV and the treatment of the cancer depends on the stage of the cancer. Also, it is important to know that there are two major types of lung cancer. One is a small cell lung cancer and the second is the non-small cell lung cancer and they are treated slightly differently. For small cell lung cancer, typically surgery is not recommended because by the time the patient is diagnosed, it’s too late for surgery. For non-small cell lung cancer we try to do surgery whenever we can. If a person has a bad emphysema, COPD because of the smoking and they cannot have surgery, they can have local radiation therapy to the cancer in the lung and that can cure those patients also. But, say, the person is not lucky enough to have an early stage lung cancer. In that situation, we do a combination of chemotherapy and radiation or, if it’s Stage IV lung cancer, it is chemotherapy alone.

Melanie: What are some general outcomes that you can give hope to people about the outcomes with these type of treatments?

Dr. Rajurkar: Lung cancer still continues to be a very aggressive and deadly type of cancer. Yes, the survival has improved over the last 20-30 years but we still have a long ways to go. For Stage I lung cancer, there is a 90% chance of curing the cancer with the surgery. For Stage II, it’s about 70%. For Stage III, about 40-50% and for Stage IV the chances of surviving five years are less than 5%. So, obviously, Stage IV lung cancer is bad news. However, for Stage IV lung cancer, over the last year or two we have had new treatments that have been developed and are FDA approved, that have improved the outcomes and survival as compared to what we had before. A lot of these treatments are immunotherapy based treatments where we use the patient’s immune system to fight the cancer cells. That’s definitely the most exciting part of treatment at this time.

Melanie: What else are you doing that’s really exciting there at City of Hope?

Dr. Rajurkar: We have a lot of clinical trials for patients whose cancers have grown despite FDA approved treatment. So, that is definitely something that we at City of Hope are able to offer that other facilities are not able to. We also have a very strong laboratory based research program where our scientists are working really hard to find the next best treatment so it can be studied in clinical trials in the future. We have amazing surgeons, radiation oncologists and medical oncologists, like myself, who are dedicated to be associated with the treatment of lung cancer and give the best outcomes for them.

Melanie: That’s fascinating and it’s such great information, doctor. Thank you so much for being with us today. You’re listening to City of Hope Radio. 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

How to Deal with Menopause Symptoms

Additional Info

Segment Number 2
Audio File virginia_health/1606vh4b.mp3
Doctors Pinkerton, JoAnn V
Featured Speaker JoAnn V Pinkerton, MD
Guest Bio Board certified in obstetrics and gynecology, Dr. JoAnn Pinkerton is Division Director of UVA Health System’s Midlife Health Center and executive director of the North American Menopause Society.

Learn more about JoAnn V Pinkerton, MD

Learn more about UVA Midlife Health Center
Transcription Melanie Cole (Host): Well, it’s not a disease, but it is certainly a condition that every woman is going to go through at some point in her life but what are some of the most common symptoms of menopause? How do you know that that’s the time that you’re in and what are some potential options for dealing with them? My guest today is Dr. Joann Pinkerton. She’s board certified in obstetrics and gynecology and she’s the division director of UVA Health Systems Mid-life Health Center and the executive director of the North American Menopause Society. Welcome to the show, Dr. Pinkerton. When do menopause symptoms typically start? How does a woman know that we’re starting perimenopause and heading towards that change?

Dr. Joann Pinkerton (Guest): Well, first of all, thank you so much for giving me a chance to talk about something I’m so passionate about which is about menopause and the decisions women get to make as they move through it. Most women start to know that something has changed, their cycles are not coming as regular as they normally do. They might come a little bit closer; they might start to skip; they might be heavy one cycle, light one cycle; or they might start to notice that they’re having a few hot flashes a week before their period, more migraines, more PMS, even to where they start to feel a little road rage or even fatigue a week before their period. But, they will start to notice changes and they may start to have hot flashes or night sweats that occur at night. All of those lead up to an average age of menopause at about 52. So, any time around that sort of 45-55 can be the perimenopause. Menopause is when you’ve had a year without periods which means you can only determine it when you look backwards.

Melanie: Is there a genetic component to when you’re going to start? Do you look at your sisters and your mother?

Dr. Pinkerton: It has been shown that family occurrences of menopause run together. So, if your mother and your sister had an early menopause, you want to be prepared that you might have an early menopause. If they had a late menopause, you might also have a later menopause. There are other things that might affect it. Like, if you smoke, you might have an earlier menopause. Or, if you’ve had an ovary removed or a hysterectomy, you might have an earlier menopause but, in general, you can look to your mother or your sister for a guideline for when you might go through it.

Melanie: All of these things you mention Dr. Pinkerton, heavy periods, irregular, maybe road rage or insomnia, hot flashes, any of these things, do women want to do something to alter these or deal with these symptoms or is it something we’re just supposed to settle for and let happen to us?

Dr. Pinkerton: So, for 75% of women, the hot flashes and night sweats occur, they’re bothersome, they last 30 seconds or maybe their mild. They’re not a major issue. For 25 % of women, they are pretty bad. They might be happening for lasting 10 minutes, eight times a day. They might have soaking sweats where they have to change their sheets or their beds. They might have flooding periods. If you have anything than is more than a minor nuisance, you want to talk about what are your options. For the bleeding, we might use birth control pills around the time of menopause. For somebody with hot flashes, we are going to be thinking about either hormones or non-hormonal options.

Melanie: Okay. So, the hormonal options: some women are, you know, for a lot of years now we’ve heard various controversies such as “you’re trading one problem for another,” “you’re increasing your risk of breast cancer but yet helping your bone density,” and “your risk of heart disease goes down.” So, what do you tell women when they ask all these questions about hormone treatment?

Dr. Pinkerton: Well, what’s really exciting is we are working on our 2016 NAMS Position Statement, so I’ve looked at all the data that’s out there including the study that came out in 2012 that scared us so much. That’s the study that said that hormones cause breast cancer and heart disease and dementia and stroke and blood clots and everybody went off of them. We’ve learned a lot since then. Now, we know if you’re under 60 or within 10 years of menopause and you’re having moderate to severe bothersome symptoms, that estrogen not only can help your symptoms but it’s probably good for you. It may actually help your heart. It may help your brain and you will have fewer sleep disturbances, your dreaming will come back. So, we can not only improve your hot flashes but we can help your health risks if you’re young and you’re under 60. We also have low doses. We have different ways of giving it. So, if a women has a lot of symptoms, she just needs to sit down with her provider and say, “Here’s my health risks; what can I do? What’s the safest thing for me?” But, the mantra that you shouldn’t use hormones is gone and even low dose for only a couple of years might be wrong. It might be what’s the right dose for you and how long should we be using it for you? Even women who want to stay on it longer because they keep having hot flashes when they go out or when they try to stop, we may talk about using the hormones even longer for those women.

Melanie: What are bio-identical hormones? That’s been thrown around a lot lately, too.

Dr. Pinkerton: Well, a bio-identical hormone is a marketing term. It really means the hormones that you used to make before menopause. Primarily estradiol and progesterone. What happened when that scary study came out was that everybody said, “Well, FDA approved hormones must be bad so we’ll go get something compounded and that will be safe.” But, if you remember the 64 deaths from the contaminated intrathecal steroids, compounding is not always safe. There’s a MORE magazine article that showed that compounding had underdosing and overdosing risks. We have many FDA Approved bio-identical hormones which means that they are hormones that are the same that you used to make before menopause and we can give them as a pill, as a patch, a gel, a lotion, lots of creative ways to give you hormones that match what you used to give.

Melanie: So, speaking about gels and things, women hear about hormones and they mostly think of estrogen and estrogen replacement but there are some other hormones that you’re replacing for us and some of them help with various dry…They have intercourse that could be painful, so what do you do for those and are there certain creams that you can use as opposed to taking an oral steroid, or an oral hormone?

Dr. Pinkerton: Yes, so we divide the hormone therapy into systemic, which could be oral patch or gel but it’s giving you a systemic level. So, we have to look at risk for your heart and your brain as well as the benefits of helping your hot flashes. For women who have dryness, though, we have estrogen cream, tablets, and ring that are low dose, go in the vagina, prevent the vaginal dryness, prevent the pain with intercourse without giving you the same systemic risks. In fact, we just went to the FDA, came from UVA and from NAMS to ask them to remove the box warning from these very low dose vaginal products because so little gets into your system that your blood levels are the same as in a normal post-menopausal woman so that you can safely use these products and treat that painful sex. There’s also a new oral, what we call a designer estrogen, it’s called ospemifene or sold as Osphena. It’s an oral tablet that is a combination estrogen/anti-estrogen that actually treats pain with intercourse. So if women are having pain with intercourse please, please come see us. Talk to your doctor, find out what you can do. If the over-the-counter lubricants and moisturizers don’t work, we can use these creams. For women who haven’t had sex for a long time, we can use dilators with the estrogen creams so that for many, many women we can restore a part of their life that they’ve lost.

Melanie: Okay. So, when we talk about sexual intercourse and things women think, “Oh, I’m in perimenopause. I’m in menopause. I can have sex now I don’t have to worry about finally getting pregnant.” Is that a myth?

Dr. Pinkerton: If you are a year without a period and you’re around your 50’s, you don’t have to worry about pregnancy. But, the second highest unintended pregnancy rate is women in their 40’s because you’re cycles are irregular, then you might ovulate when you’re bleeding, you might ovulate early or late, so we actually worry more about pregnancy prevention in the 40’s and for women who are having a late menopause into the 50’s. The oldest spontaneous conceived delivered baby was in Ireland in at age 57. So, if you have a late menopause you might be able to have a late child. So, we have to think about pregnancy.

Melanie: Wow. So many good things for us to think about. What else do you tell women every day, Dr. Pinkerton about menopause, about this change of life that we’re all going to go through and give us some of your best advice.

Dr. Pinkerton: Everyone goes through this. This is something that we’re all going through and everybody goes through it a little different and everybody has different health risks. We want to sit down and figure out, what’s your breast cancer risk? Have you had a mammogram? Did your mother have breast cancer? How bad are your symptoms? We need to think about your bones. Are you taking calcium? Do you get it in your diet? Do you drink milk? Are you taking a calcium supplement that’s got some Vitamin D? What about avoiding that weight gain? Menopausal women can gain 12-15 pounds and we don’t want that. We don’t want that extra belly fat. They’ve shown that if you exercise, if you avoid being sedentary, that you can actually make going through menopause better. Your hot flashes will be less intense and your mood will be better. Now we’re looking at are you sleeping? Do we need treatment for hot flashes? Are we preventing bone loss? What about your heart? How are you doing with your cholesterol? Are you getting enough aerobic exercise for your cholesterol? And then, sleep. Women need 7 hours of sleep a night. I don’t know very many women who are getting that much sleep. They’re worried about their kids. They’re worried about their parents. They’re worried about their jobs. It’s hard to fit it all in. There is a lot of evidence that we can help our brains as we age if we not only exercise and eat right, but if we also sleep. I look at menopause as a time to say, “Okay, here are your health risks. Here’s where you’ve gotten off track. What can we do to get you back on track?” Someone says, “Well, I can’t do an hour of exercise three times a week.” But, you could do ten minutes three times a day and you could take that extra set of stairs; you could eat a more Mediterranean diet, a more healthy diet; you could work on getting to sleep earlier. If you have significant symptoms, if you’re having really bothersome hot flashes, we can talk about hormone therapy but we’ve also got non-hormonal therapy that can work. We can use cognitive behavioral therapy – things like dream therapy or hypnosis has shown to help hot flashes. Acupuncture helps some women. All of the anti-depressants – a medicine called Gabapentin can help hot flashes. We have so many choices for hormone therapy if people need it that going through menopause ought to be something that you do with your doctor so that you can make the decisions as you go along. You know, you make a birth plan but you know that real life sometimes gets in the way of your birth plan. Same thing for menopause. You can decide how you’re going to handle it and then, you have to wait and see what nature throws at you.

Melanie: In just the last minute here, why should women come to UVA’s Mid-Life Health Center for their care?

Dr. Pinkerton: The beauty of our physicians here is that we’re specialists. We’re actually credentialed menopause specialists. We’re very active in our organization called the North American Menopause Society and we believe in looking at women as an individual, looking at health risks, getting tests that we need to do and in helping women navigate this process. If someone wants to navigate it without any medications, we will do our best to help them do that. If people want to navigate with medications, we’ll try to pick and choose the best medicines and also continue following them, help them go off and then watch them as they age. We want those vibrant 90-year-old women who are still serving on boards, who are still active, who are still in great health. Our goal is you go through menopause is to get you set so that’s who you become.

Melanie: Wow. So beautifully put. Great information, Dr. Pinkerton. Thank you so much clearing so much of that up for us and being with us today. You’re listening to UVA Health Systems Radio. For more information you can go to uvahealth.com. That’s uvahealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

How to Better Understand Lymphoma

Additional Info

Segment Number 3
Audio File city_hope/1605ch4c.mp3
Doctors Upadhyaya, Gargi
Featured Speaker Gargi Upadhyaya, MD, FACP
Guest Bio Specializing in hematology and medical oncology, Dr. Upadhyaya is board certified in internal medicine. She received her medical degree from Government Medical College, Surat, India. Her residency and hematology and oncology fellowships were completed at Los Angeles County USC Medical Center and City of Hope National Medical Center. She also served as a research fellow in the Hematology and Oncology Division of the Internal Medicine Department of the University of Michigan Medical Center. Dr. Upadhyaya has published articles in the Journal of Clinical Investigation, Blood, and Leukemia and is an active member of the American Society of Clinical Oncology (ASCO).

Learn more about Dr. Upadhyaya
Transcription Melanie Cole (Host): If you’ve been diagnosed with lymphoma or looking for a second opinion, you and your family may be facing a lot of difficult questions. City of Hope’s lymphoma specialists can walk you through the treatment process, address your concerns and create a personalized plan designed to give you the best possible results. My guest today is Dr. Gargi Upadhyaya. She specializes in hematology and medical oncology at City of Hope. Welcome to the show, doctor. Tell us about lymphoma. People hear these words, about non-Hodgkin’s and Hodgkin’s. They don’t know what all of these are. Tell us about lymphoma and the different types.

Dr. Gargi Upadhyaya (Guest): The different types of lymphoma are divided into Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. Hodgkin’s lymphoma is one of the diseases that occurs at two extremes at life. They can occur at a younger age and then at the older age between 50-60 years old. It is a very treatable and curable disease. Non-Hodgkin’s lymphoma are different types of lymphomas. They occur usually at a later age in life and are divided into high-grade and low-grade lymphomas. Hodgkin’s lymphoma is treated with chemotherapy every two weeks and we get a very good response. People are cured of that lymphoma. They go through treatment with not much difficulty. The non-Hodgkin’s lymphoma, the low-grade lymphomas, do respond very well to treatment; however, they are not cured. Having said that, non-Hodgkin’s lymphomas that are low-grade, even though they are not cured, they are very treatable and are not life-threatening. High-grade lymphomas are a little bit of difficulty to respond; however, people who respond to therapy live a very long and fruitful and happy life. If the patients do not respond to chemotherapy, we, at City of Hope, have secondary options of going through bone marrow transplants. City of Hope is known to be one of the best places in the world for bone marrow transplants.

Melanie: People hear lymphoma and because breast cancer, prostate cancer, these things are detectable, they are at one place but lymphoma is more of a systemic. It can be running through your blood stream. So, that scares people just a little bit more. How is lymphoma detected? Are there any symptoms or red flags that you would have sent up? Is there any screening available?

Dr. Upadgyaya: There’s no screening for lymphoma; however, there are symptoms that we all can look for and look out for. Number one is weight loss. If you lose more than 10% of your body weight without trying in a short amount of time, by saying short amount of time it would be 4-6 weeks or you have unexpected fevers, night sweats, which are drenching that you have to either change your sheets or shirt or clothes at night because of sweating or you have reoccurring infections meaning you have sinus infections and, two weeks later, you end up having a urinary tract infection. Any of those things that happen, you would get suspicious and you would go to see your doctor. Also, if you have any glands that are growing and you don’t have any symptoms, you still need to go see your doctor. Usually, you would see glands in the neck or in the armpit area that would be suspect that something is going on in your body.

Melanie: Do you ever remove those glands? Is it possible to have these glands removed and, thereby, stop the spread or is this usually a type of cancer that spreads pretty rapidly?

Dr. Upadgyaya: The treatment is not removal but we do remove one gland. That’s called an “excisional biopsy of the lymph node” to establish the diagnosis. Once diagnosis is confirmed, then chemotherapy is the mainstay of treatment. We do not treat lymphoma with surgery. When we start chemotherapy, the medication goes through the blood stream and helps kill the cancer cells and get the rapid response. Therefore, we do not need to have a surgical approach.

Melanie: So, doctor, is there a genetic component? What puts someone at risk and are there any preventive measures that they can do to protect themselves from lymphoma?

Dr. Upadgyaya: It is known to run in families but there are no genetic tests for lymphoma. Like breast cancer, we do not have the BRCA-1 or two genes or any other gene telling us that you are at high risk. However, if your family members--mother or father--have been diagnosed with lymphoma at a younger age, it would be a good idea to you have yourself checked out and have a regular physical exam once a year. Look out for enlarged nodes. If you notice that you have trouble swallowing or you have trouble breathing, get medical attention right away and do not delay it.

Melanie: Would something show up on a routine blood test?

Dr. Upadgyaya: There is no blood test. There is the suspicion on a blood test to tell us whether a person has lymphoma if their white count is low or they are anemic but that does not confirm it. We have to confirm it with further testing and a biopsy.

Melanie: And, doctor, tell us what’s exciting. What are you doing at City of Hope for lymphoma patients?

Dr. Upadgyaya: There are lots of new treatments that are coming out at this point. There is immunotherapy where patients are responding with minimal side effects and also we have maintenance therapy which prevents the risk for reoccurrence. That is after a person has responded completely to therapy, they can be treated with maintenance therapy and the risk of reoccurrence decreases. People who don’t respond well and about 20-30% are patients with lymphoma who either reoccur or do not respond .In the first line therapy, we have bone marrow transplants and we treat with high dose chemotherapy followed by autologous bone marrow transplant.

Melanie: In just the last few minutes, and its great information, tell patients why they should come to City of Hope for their lymphoma care.

Dr. Upadgyaya: It is one of the nation’s largest clinical hospitals for bone marrow transplants. We have expert doctors like Dr. Forman and Dr. Alexandra Levine who are would renowned in the treatment of lymphoma. They would get the best of care with the best nursing staff and the best facility ever.

Melanie: Thank you so much, doctor, for being with us today. You’re listening to City of Hope Radio. 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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