Inactive (722)

Segment Number 1
Audio File staying_well/1509sw1a.mp3
Featured Speaker James Beckerman, MD
Guest Bio Dr. James Beckerman is a cardiologist and medical director of the Center for Prevention and Wellness with the Providence Heart and Vascular Institute in Portland, Oregon. He graduated from Harvard College and Harvard Medical School and completed his medical training at the Massachusetts General Hospital and Stanford University.

Dr. Beckerman is the former chair of the Oregon Governor's Council on Physical Fitness and Sports and is the team cardiologist for the Portland Timbers Major League Soccer team.

In 2011, he published his first book, The Flex Diet, which gives readers 200 tools to design their own approach to wellness, weight loss, and heart health, and he just released his second book, Heart to Start, an "exercise prescription in a book," designed to motivate patients and physicians alike to be more active.
Hosts Melanie Cole, MS

Vaccinations: More Important Than Ever

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Segment Number 2
Audio File yakima_valley/1511yv3b.mp3
Doctors Bäcker, Martin
Featured Speaker Martin Bäcker, MD
Guest Bio Dr. Martin Bäcker is a family practitioner at Pacific Crest Family Medicine and Memorial Cornerstone Medicine. He was born and raised in Buenos Aires, Argentina, where he also attended medical school. He moved to the United States in 2003 to complete his residency and a combined fellowship in adult and pediatric infectious diseases. He is fluent in English and Spanish.
Transcription Melanie Cole (Host): Measles, whooping cough, vaccines, immunizations have been really a hot topic with recent disease outbreaks. The incidence rate for some of these diseases has declined as more people are vaccinating, but many are still at risk, which highlights the need for immunizations. My guest today is Dr. Martin Backer. He’s an internist and pediatrician specializing in infectious diseases at Pacific Crest Family Medicine and Memorial Cornerstone Medicine. Welcome to the show, Dr. Backer. Tell us a little bit about some of the vaccines and what you do when newborns are born. What vaccines do they get? And explain a little bit about the importance of them.

Dr. Martin Backer (Guest): Sure. Thank you, Melanie, for having me. From day one, we start with immunizations, and we start with hepatitis B vaccine. A lot of parents are like, “Oh, why does my child need that?” Actually, it’s one of the vaccines that can prevent cancer. Liver cancer can be caused by hepatitis B. Then most of the vaccines we give kids start at two months of age. We give vaccines against some of the most significant killers of kids for years, including polio, Haemophilus influenza, including pneumococcal vaccine. A lot of very important pathogens are prevented with the vaccines.

Melanie: When you give these new vaccines to a newborn, do parents ask you about giving more than one vaccine? Because I know even at two months, there’s a few. You get rotavirus or the second dose of hepatitis B, or the DTaP. Tell us about what parents ask you when there’s more than one vaccine at a time.

Dr. Backer: Absolutely. We do have, fortunately, vaccines against a lot of different agents. Fortunately as well, we’ve been able to combine those in fewer shots. No kid or parents like the shots, so combination means less shots at a time. Some parents do have concerns that am I not introducing too much at a time for my kid. Isn’t that too much for his or her immature defenses? The truth is, no, it’s not too much. Quite the contrary, what we’re doing is we are preventing actual infections, which would be much more burdensome for the defenses than what the vaccines are. Yes, we have antigens, which are almost like particles of viruses or bacteria against several bacteria or viruses, but in real life, kids get exposed to much more than that, tons of viruses that we don’t have any vaccines against that. This is not unnatural and not harmful, but quite the contrary. It helps prevent these infections, which can be serious and even deadly.

Melanie: For example, the pneumococcal vaccine, you have to have a few doses. And many of these vaccines need more than one dose. Why is that?

Dr. Backer: Absolutely, you are correct. The majority of vaccines we give to the young kids include a series of vaccines, a series of shots, because the defenses of the child are definitely developing and they are not as mature. First, we introduce the first vaccine, and then the body starts to learn how to respond to that. Then when we get re-exposed, then we get an anamnestic or memory response, and then we know how to respond against it much better. We do see that after one dose of vaccine, there often will be some response, but we think it might not be protective enough. But when we give more than one of those, that would have given the best response. What’s important to understand is that the number of vaccines that we give for a specific disease that we are preventing is not something random that somebody said, “Okay, let’s try three. Let’s try two. Let’s try five.” They did try different things. There’s been, first, in vitro studies, following by animal studies, usually, and then human studies that have supported the current schedule of immunization that they’ve recommended.

Melanie: Dr. Backer, I’d like to ask you about the measles, mumps, and rubella, the MMR vaccine, that receives a lot of press, especially lately. And measles has seen a recent [surgence], and we’ve seen measles cases breaking out all over the country. Tell us about the safety and efficacy of the MMR vaccine. Tell the listeners what you want them to know about this vaccine.

Dr. Backer: Absolutely. I’m glad you bring this up. Something good comes out of everything bad and vice versa. It’s tragic that we are having so many kids get measles in the United States when we have had an effective and safe vaccine for several decades. Most of the kids that have gotten measles—not all of them, but most—have been unvaccinated kids, and even the ones that have been vaccinated usually have been in a setting where unvaccinated kids have facilitated the introduction of the virus again in the community. The vaccine works very well. Typically, we recommend two doses. The first dose is given usually at the first year or thereabout, and the second one is typically given at four years of life, though it can be given at any time after one month after the first dose. We believe you get protection after the first one, but you get much better protection after two doses. In an outbreak setting, if your kid is between one and four and has only gotten one dose, they might benefit from getting a second dose, something to talk about with your child’s doctor. There has been a huge spread in the number of cases, many of these associated with one very large outbreak seen across the nation related to Disneyland. But there has been a number of other outbreaks. The cases of measles have been going up over the last few years, and that has to do with the number of parents choosing not to vaccinate their kids. Unfortunately, there have been some concerns raised about the safety of the vaccine, not based on any science whatsoever. There has been one study published 25 years ago, almost, that all of the authors in the medical journal except one of the authors have retracted in saying, “You know what? The data we had was no good,” or this was fraudulent. “We do not support this publication anymore,” Except one of the original author, which linked the vaccine with autism. There are more than a couple of dozen studies that have found no association between the measles, mumps, rubella vaccine and autism. The vaccine has been given to millions of kids worldwide and is considered to be very, very safe and effective. Measles can not only be serious, but as we suggested before, it can be deadly. It is a vaccine-preventable condition.

Melanie: Measles is a nasty disease. Is it ever too late to get the vaccine?

Dr. Backer: No, it’s never too late to get the vaccine. If somebody has not had the vaccine and has not gotten the disease, no evidence of having defenses, they can get it no matter young or old, even the really old. Typically, we’re seeing that people born before 1952 or ’57 are believed to be immune or have defenses just because it was so universal that it is pretty much everybody had been exposed to it back then. Since the vaccine became more common, then the disease became less common.

Melanie: There is so much information about vaccines, Dr. Backer. We could do a lot of topics on this. Now, talk about the HPV vaccine because that’s been in the news a bit lately too. This is now given to teenage or preteen girls and boys. Explain a little bit about this vaccine.

Dr. Backer: Sure. The HPV or human papillomavirus vaccine is a great vaccine. It’s not a live virus. It’s a very cool technology. And yes, we don’t have time to go into how they make it, but it’s a very safe vaccine that helps prevent infection with this virus that can cause not just genital warts but also cancer, cervical cancer, but also penile or anal cancer. The virus that causes these infections is a very, very common virus, and the vaccine works really well. Studies show that perhaps the best response is when we give it as young as nine years of age. The current vaccination calendar calls for giving the vaccine—it’s a series of three shots—at age 11, and that is because we are already having kids going to see their pediatricians or their doctors at the age of 11. For other shots, we combine it at that point. Also, because a lot of parents say, “Why do my kids need the vaccine for a virus that’s transmitted sexually at age 11? They are not having sex.” Certainly, we don’t think and we don’t hope that they’re having sex at that age, but precisely giving the vaccine way before they have exposure is the best way to make sure they are protected. If we wait until they’ve already had exposure, the vaccine does not work. We really want to give it clearly before they’ve had any exposure and the vaccine works best at a young age and it’s believed to have a very long-lasting immunity or defense. It’s important to bear in mind this really helps prevent cancer, and we can offer our kids the vaccine that prevents cancer and not have regrets that way down the road. Another thing many parents will say, “Well, this is a vaccine for a sexually transmitted infection. Will it encourage my child to have sex or unprotected sex?” There are many studies that have looked into this question and have shown that it doesn’t. It doesn’t make a difference in whether the child is having sex or not or having unprotected sex. It just protects them against one virus that can be acquired that way that can cause cancer.

Melanie: In just the last minute if you would, Dr. Backer, give the listeners your best information and advice what you tell your patients every day about the importance of vaccinations.

Dr. Backer: Yes, those vaccines have been around for several decades, many of them. Some of them are new ones. They are very safe, given to millions of patients. And the healthcare community, as a whole, it’s unanimous in its recommendations. They save lives. They prevent diseases. They keep us healthy. They work and they are safe. Everything has risks, but we need to think not just the risk of doing but the risk of not doing. The risk of giving vaccines is exceedingly low. Serious consequences are almost unheard of, while our risk of not giving them are quite common. If you have questions, I encourage everybody to talk to his or her doctor and ask those questions to help keep us safe. It not just keeps me and my family safe but you and your family. We help protect each other.

Melanie: Thank you so much, Dr. Backer. You are listening to Healthy Yakima. For more information, you can go to yakimamemorial.org. That’s yakimamemorial.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Surviving Cancer: What Do I Do Now?

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Segment Number 3
Audio File city_hope/1512ch2c.mp3
Doctors Meyering, Elizabeth Lynn
Featured Speaker Elizabeth Lynn Meyering, MD
Guest Bio E. Lynn Meyering, M.D., is an Assistant Clinical Professor in the in the Department of Medical Oncology & Therapeutics Research at City of Hope’s Simi Valley location. Dr. Meyering joined City of Hope from North Valley Hematology and Oncology Group, located in Simi Valley, California. Prior to that, she was appointed as faculty at UCLA-Olive View Medical Center as a Assistant Clinical Professor, and she continues her services now as a Volunteer. Dr. Meyering completed her undergraduate degree in microbiology at California State Polytechnic University, and medical school at Albany Medical College in New York. Following medical school, she completed her internship and residency in internal medicine at UCLA-Olive View Medical Center in Sylmar, California. Dr. Meyering is board certified in medical oncology, hematology and internal medicine, and is an accomplished and experienced clinician and teacher. She has a particular interest in breast cancer and survivorship issues.

To learn more about Dr. Meyering
Transcription Melanie Cole (Host): Life after cancer treatment can sometimes present both physical and emotional challenges, and that’s why City of Hope developed the Center for Cancer Survivorship, a long-term followup program that’s designed to create a bridge between cancer treatment and community medical care. My guest today is Dr. Elizabeth Lynn Meyering. She’s an assistant clinical professor in the department of medical oncology and therapeutic research at City of Hope. Welcome to the show, Dr. Meyering. Tell us a little bit about life after cancer. How does it affect the survivors and also their families?

Dr. Elizabeth Lynn Meyering (Guest): That’s such a great question, and it comes up all the time in my office. When people are treated for cancer, there are so many issues that come up. Their first task is to be cured from their cancer. They are goal oriented. They want to get through it. But then what happens when they’re done? They feel very lost. Sometimes they have a lot of fear. They don’t know if the cancer is coming back. They have all kinds of issues that come up, and it’s not just physical issues. They have so many emotional problems that come up as well, including grief. And like I said, the statistics are a little bit terrifying because when we think about the statistics of cancer, there are about 12 million people surviving with a history of either chronic cancer or cancer that they have faced in the past in the United States today. A lot of those people are concerned that their cancer is going to come back.

Melanie: I would think that’s one of the biggest fears. How do you deal with that? Some of us think we’re going to get cancer. But if you’ve already had it, then that fear of recurrence would seem to be even greater.

Dr. Meyering: Well, that’s interesting. I think that’s very true. It is a greater fear. And I think I was a little naïve when I was a young fellow and I thought, well, shoot, if you get your cancer, maybe that’s it. You pull that card out and you’re done. As it turns out, there is an increased risk for another cancer when you have cancer in the first place. A lot of that has everything to do with whether or not you are carrying a genetic mutation, which truly, that is the minority. Most people do not have a mutation. However, we know there is more than mutations that cause us to have increased risk for cancer. It’s just everybody has different coping skills and trying to help patients find how to put cancer in the rear-view mirror is a different journey for every person and it’s not a simple one, certainly.

Melanie: When you think of the side effects of treatment, chemotherapy, losing your hair, fatigue, general weakness, and you think, “Oh, I’m not even gonna be able to work. What am I gonna do for money?” all these fears and stress start building up, Dr. Meyering. What about after the fact and maybe you can go back to work? What are some of the after side effects that might limit your ability to do the things you always want to do?

Dr. Meyering: That’s a great question. I usually characterize this for my patients in two different ways. One, I explain there’s going to be temporary side effects, just like you mentioned—the hair loss and all of those different side effects. Then the long-term things, which I think the biggest problem that people have is a problem with short-term memory and focus as well as self-esteem. These things are very, very difficult to combat, and they happen to all patients with cancer, and not only if they’ve had chemotherapy. We certainly have seen patients, particularly breast cancer patients, who never even had chemotherapy. Maybe they had surgery. Maybe they did or did not have radiation. However, they have the same cognitive problems that we see in patients who have received chemotherapy. We know there is a lot more to this than just the medications we’re providing and strategies to do these. I sometimes try to help my patients by exploring what exactly is their problem. Is it memory issues? Because there are go-rounds for everything. Sometimes I have them keep little notebooks where they can put buzz words and things in there to just sort of help them feel like they’ve got control and to reassure them that there is life after cancer. They can do whatever strategies we need to do to help get back into the workforce because they’re going to survive and we know with our five-year survival now approaching 70 percent, that they really are going to have an improved quality of life if they’re able to go back to work.

Melanie: If they are and that improved quality of life you’re talking about, what can they do to promote more of a healthy lifestyle at home? And when we talk about that fear of recurrence, do you need to keep checking again? I would think that some cancer survivors would want to go have scans every three months, make sure it’s not coming back. What do you recommend for healthy lifestyle, things they can do, and followup care?

Dr. Meyering: For healthy lifestyle, the most important things that I recommend is a very well-balanced diet. And I do not recommend fad diets for anybody. Lots of fruits and vegetables, must have fatty acids, must have healthy fats and enough protein. Exercise has been shown time and time again to help with the physical and the mental effects of cancer treatment. It seems to improve mental acuity. It improves reduced joint pain. There are a million and one reasons that exercise is beneficial. A lot of times my patients come to me and they say, “Oh, I am just way too tired.” The truth of the matter is that moving your body, just your strength and your stamina is improved by exercise in general. You’re right. A lot of patients do come in and want scans because they’re so concerned about their cancer coming back. There’s a lot of different reasons that we don’t do these things. For one thing, repeated scans is not good for us. This increases our risk to have exposure to ionizing radiation, plus it finds a lot of incidental things that really have no bearing on our health whatsoever, and that can result in many unnecessary procedures and surgeries and biopsies that we don’t really need. The other thing that’s important is that in most cases, a scan is going to find cancer in which it’s already past the point where we can cure it. Honestly, really what we need to be focused on is the ones that we can do something about, and that means continuing to do the routine screening. For breast cancer patients, that’s going to be histories and physicals and breast exams and looking for local recurrence, which we can do an awful lot for. If there is something that is outside of the breast, it presents with a symptom. People will have a pain related to wherever it is. Doing multiple scans doesn’t typically find that sooner. In some of my patients, however, in those patients we often do heightened surveillance because we can often do things to interact with it or to change the cure rate. I have to explain these things to the patients, and they’re usually very amenable once they understand what the limitations of the imaging is and how it can offer a negative impact on their health.

Melanie: Now, what about family relationships? As we talked so much about that fear of recurrence, the family must be terrified as well—children, spouses, parents, anybody who is dealing with cancer in a loved one. How do you work with, and what do you recommend for family relationships so that people can live a little bit less stressed life when they’re dealing with someone who’s surviving cancer?

Dr. Meyering: That is such a good question and it is so tricky because it depends on which relationships we’re talking about. The first concern is when there are children involved, and the age of the child certainly has a lot to do with it. Very often parents are afraid to let their children know that they are fighting a cancer battle because they’re afraid that their child will have fear. What we do see is that children have a remarkable ability to be understanding, and they feel rejected if they are not told what’s going on. “Why is dad feeling sick all the time?” or, “Why is mom losing her hair?” Most of the time, it is a better strategy to have the child part of the process in the beginning so that they have that ability to ask questions and to feel that they are not being kept in the dark from this. That is actually probably easier than some of the other problems that I come across in my office. A lot of times, this puts an unusual amount of strain on marriages. A lot of this is because of changes in body morphology. Sometimes people have had surgeries. Maybe they have ostomies where they have a bag for going to the bathroom. Sometimes they’ve had breast reconstruction, and all of these things cause problems both in the spouse but also in the patient themselves, because they look at themselves and they’re like, “Well, I’m not the person I was. I’m never gonna be the person I was. I’m something different. I have a new normal,” and it’s sometimes very difficult to accept that and that itself puts strain on it. The healthy relationship typically will survive a cancer diagnosis, but if the relationship is already strained, often it results in a failure in the relationship, which is adding additional problems to the patient who already is struggling to feel like they can move forward. The other thing that comes up is parents who have not children but adult children who have a diagnosis of cancer. No one feels that they want to see their child go through cancer treatments, but typically these relationships are preserved and supportive, and I don’t see nearly the problems for those. I think the body image is huge in a relationship, and the problem is often within the patients themselves. Counseling is often very helpful for those, and I usually recommend this for most of my patients.

Melanie: In just the last minute or so, Dr. Meyering, your best advice for families and loved ones and the people going through cancer and surviving it.

Dr. Meyering: Well, my best advice is cancer is not the definition of the person. It is something that happens to someone. It does not define you. It is only something that has happened. To move forward and be yourself and start the whole trip anew and turn the page and look forward, we now have to accept the new normal and to do it with gusto. I think that’s my best advice.

Melanie: Thank you so much. That’s great information. You’re listening to City of Hope Radio. For more information on the Center For Cancer Survivorship at City of Hope, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

FAQs on IUDs

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Segment Number 2
Audio File allina_health/1512ah1b.mp3
Doctors Ketelsen, Addie
Featured Speaker Addie Ketelsen, CNP - Family Medicine and Obstetrics
Guest Bio In addition to pursuing her passion to make a healthy difference with her patients, Addie Ketelsen is a wife and mother to three young children. She savors precious every day moments with her family and looks forward to exercising more together with her children. Her love of people and building relationships brought her to a career as a nurse.
Transcription Melanie Cole (Host): The use of IUDs as birth control has been increasing greatly recently, and in the 1970s and ‘80s, certain faulty IUDs caused bad side effects and understandably caused most women to avoid even considering them as an option. My guest today is Addie Kettleson. She’s a certified nurse practitioner. Welcome to the show, Addie. Tell us a little bit about an IUD. What is it? How does it work?

Addie Kettleson (Guest): Well, an IUD is a device that’s placed in the uterus by a healthcare provider for contraception. There are three IUDs available at this time. There’s a copper IUD, and that is known as ParaGard. There are two that can contain a progestin, Mirena and Skyla. The copper IUD works by inhibiting and interfering with the movement of the sperm and egg fertilization, and the hormonal IUDs work by thickening the cervical mucus and keeping the uterine lining thinner.

Melanie: When we talk about IUDs, for a little while there in the ‘70s and ‘80s, women were afraid of them. Now, these do release hormones, correct? Are they safe for all ages, including teens, or is this something that you do in your little bit later life?

Addie: Generally, IUDs are safe for women and teenagers and they’re actually recommended by the American Academy of Pediatrics, American College of Obstetrics and Gynecology as well for birth control for women of all ages. They don’t protect against STDs, so we still recommend your traditional screenings and exams. There can be disruption in the normal menstrual cycle. As I mentioned before, the progestin-only [IUDs] keep the lining thin. Sometimes with those they’ll see lighter periods, or with Mirena, sometimes no periods at all. Pediatricians might not have as much experience with IUDs, so if the teen is interested, they should talk to an OB/GYN provider.

Melanie: Are they permanent? Do they go in and out very easily? Are they something that’s difficult to use?

Addie: No, not at all. They’re not permanent. We place them here in the office depending on which type of IUD you get. The copper is effective for 10 years. The two progestin-only IUDs are effective for five and three years. They can be removed sooner if the patient chooses to have them removed sooner. Or if they’re trying to conceive, we can take them out sooner. So, not permanent.

Melanie: Now, what’s changed since the ‘70s and ‘80s, Addie? Why is use increasing?

Addie: I think that in the 1980s there were a lot of issues with IUDs causing infertility, injury, infections, and lots of problems. They kind of got a bad rap. But since then, they’re much safer. They are approved by the US Food and Drug Administration and are considered very safe and effective for birth control. Currently, I think the trend is definitely increasing for IUD use.

Melanie: How long can you use one?

Addie: The ParaGard can be in place for 10 years, and the Mirena is five years, and the Skyla is three years. They all can be removed sooner if the patient desires removal or desires to conceive.

Melanie: Is there ever a time when they fall out?

Addie: They can. There is a small risk of them falling out of the uterus. In that case, I would think that the woman would have some cramping, irregular bleeding, and may notice the IUD itself come out. It doesn’t happen a lot. There’s also the risk that the IUD could perforate the uterus, meaning move through the uterine wall and out of the uterus itself. That doesn’t happen a lot, and usually, it doesn’t cause any permanent damage.

Melanie: Now, because these have hormones involved, when a woman does want to get pregnant—and you said they can be removed easily—how far in advance should she have it removed before she can then safely try and get pregnant?

Addie: With all of them, they can be removed and you can try immediately to conceive. There is no window of time that you have to wait. What’s really nice about them is you can conceive immediately following removal.

Melanie: What are the disadvantages to them? It doesn’t sound like there’s really very many at all.

Addie: Not a lot. I’m a big fan of the IUDs. But cost could be an issue. But I think a lot of insurance companies are covering them well now. I would encourage people to check with their insurance company prior to having an IUD placed. There’s also, during placement and maybe for the day after placement, you could have some moderate cramping, some initial bleeding. With the Mirena and the Skyla IUDs, you may have a couple of months of irregular bleeding as that lining thins. But once the lining thins, especially with Mirena, we see a lot less bleeding, and sometimes no periods. So that is nice for a lot of people. I would say the initial cramping plus irregular bleeding at first could be a disadvantage, but it’s usually worth it once you get past that first few months.

Melanie: Then, what would be the disadvantage over other types of birth control—the pill or other methods out there, diaphragm?

Addie: I would say convenience. For patients, there’s nothing that they need to remember. Once it’s placed, some come back in about a month just to make sure everything is going okay, and we do a quick string check in the office. But you don’t need to go to the pharmacy to pick up refills. It’s just kind of a… you get it placed and you don’t have to think about it. That’s really nice. It’s very effective, over 99 percent effective, which is higher than other methods that are available. It’s surgeon-free. For women who have side effects, they can’t have estrogen due to other medical conditions, it’s a good option for them. It really delivers a low dose of progestin just to the uterus, so we don’t really believe that it has a systemic effect at all. It’s reversible. And right away, when you pull it out, it’s reversible immediately. Then I would say the fact that it can be used long-term is an advantage. Mirena is also used to treat heavy periods. For people who are having heavy bleeding, just heavy periods, crampy periods, it’s a good option to treat them as well.

Melanie: What symptoms should women who use an IUD be on the lookout for? And when they have their annual exams, is that affected at all when they’re using an IUD?

Addie: No. There are a few things that -- if they were having persistent abdominal pelvic pain, heavy bleeding, bad cramping, that sort of thing, I would encourage people to come back into the office for. Most people do very well, and after that first initial four-week visit after placement, as long as they come back for their annual exam, we just kind of do a string check when we’re doing their annual exam, and that’s usually sufficient as far as followup.

Melanie: What’s your best advice for women that are looking, Addie, at all the different types of contraception out there and your best advice on women considering an IUD?

Addie: I would encourage people to talk with their provider about which method they feel is best for them and which method would work the best for them and consider the pros and cons of all the methods. And you can decide that with your provider, and… I think though that an IUD is a great option if you want a long-term, reversible option.

Melanie: Thank you so much for great information. You’re listening to the WELLcast with Allina Health. For more information, you can go to allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Latest Advancements in The Treatment of Bile Duct Cancer

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Segment Number 2
Audio File city_hope/1512ch2b.mp3
Doctors Fong, Yuman
Featured Speaker Yuman Fong, MD
Guest Bio Esteemed liver and pancreatic surgeon, researcher and author, Yuman Fong, M.D., is one of today’s most respected and recognizable physicians in the treatment of the liver, bile duct, gallbladder and pancreas disease. He has pioneered and enhanced many surgical, laparoscopic, robotic and ablative, therapies now widely used around the world to treat these difficult cancers. Especially notable is his track record of launching human clinical trials of genetically modified viruses with the potential to fight cancer.
Transcription Melanie Cole (Host): Highly experienced at diagnosing and treating bile duct cancer, City of Hope brings an aggressive multidisciplinary approach to caring for people with this disease, offering them and their loved ones the most positive outcomes possible. And through their clinical trials program, one of the most extensive in the nation, bile duct cancer patients can often access promising new anti-cancer drugs and technologies that are not available anywhere else. My guest today is Dr. Yuman Fong. He is one of today’s most respected and recognizable physicians in the treatment of liver, bile duct, gallbladder, and pancreatic cancer. He’s also the chair of the department of surgery at City of Hope. Welcome to the show, Dr. Fong. Thank you so much for being with us. Tell us a little bit about bile duct cancer. Is this a very common cancer? Is it a very scary cancer?

Dr. Yuman Fong (Guest): Melanie, thank you again for having me on the show. Bile duct cancer is actually a relatively rare cancer in this country. There are parts of the world where it’s actually very common, and I’ll go through why that’s so. But it is a very scary cancer simply because the diagnosis is usually associated with very complex treatment plans that have to be put together in order to allow the patient to survive their disease.

Melanie: What is the bile duct, Dr. Fong?

Dr. Fong: Well, the bile duct is just a pipe that carries bile around the liver and outside the liver into the intestines. The way the digestive system works is the liver makes bile that help digest food. This is the chemicals that are produced in the liver that comes down to digest our fats, our proteins, and many of the nutrients so that they can be absorbed by the intestines. And it’s made in the liver; it’s carried around the liver in a series of pipes called bile ducts. Then they’d all collect down to a very large bile duct, a large pipe that carries it directly into the small intestine right outside the stomach. Cancer can occur anywhere along these pipes. We segregate bile duct cancer into three parts. The ones that are inside the liver, those are called peripheral cholangiocarcinoma. That’s a fancy medical word for the tumors of the bile duct that happen inside the liver. Then there are the ones that occur right outside the liver. Those are called hilar cholangiocarcinoma—again, just fancy medical words for the tumor that happens right where the main bile duct comes out of the liver before it enters into the intestines. Because the bile duct passes through the pancreas before it enters the intestine, that’s the third type. The bile duct tumor that happens in the very bottom of the large bile duct before it enters into the intestines, those are oftentimes confused with pancreatic cancer, even though it behaves much better than a pancreatic cancer. Those are the three types of bile duct tumors and bile duct cancers that happen in men, and we segregate them anatomically because, again, the treatments of the three are very, very different.

Melanie: Why is it more rare in this country, you started to mention, and maybe more prevalent in other countries?

Dr. Fong: It’s because bile duct cancer is actually associated with three signs. One is hepatitis. Hepatitis B or hepatitis C virus, which are viruses that attack the liver, can actually cause the bile ducts inside the liver to form cancers. In parts of the world where hepatitis B and C are more common, the bile duct cancers are also more common inside the liver. Those parts of the world are China and Africa for hepatitis B. Those parts of the world are Italy—particularly Sicily—and Japan for hepatitis C. So it’s really the inflammation from the virus there that causes the cancers that form in the bile ducts inside the liver. For other types of bile duct cancers, they are associated with chronic inflammatory conditions, meaning diseases where the body actually causes an autoimmune reaction against its own tissues. Those are related to a kind of disease called sclerosing cholangitis, where for whatever reason, the body decides that the bile ducts are foreign to itself and starts attacking with its the immune system. You hear about that in very famous cases like -- remember Walter Payton, the football player? He actually formed one of these bile duct tumors inside his liver simply because his body was attacking his bile ducts. The third way in places where bile duct cancers are very common are chronic infections of some type. There is a worm in Southeast Asia that actually crawls up into the liver and causes inflammation. Those worms are called flukes. And it’s quite common in Northern Thailand, for example, and in those areas where people are chronically infected with this worm that they catch from raw fish. They end up having bile duct cancer, and therefore, in those regions, it’s much more common.

Melanie: What would someone experience? Because as you said, it might mask or be similar to pancreatic cancer, which is much more common in this country. And so what would you experience that would -- this isn’t something you obviously screen for, so why would someone even go see the doctor to get checked?

Dr. Fong: Well, we actually do screen for it. In fact, the screening for bile duct cancer is actually very straightforward. It is the annual physical. When somebody gets an annual physical and their liver enzymes, which are the blood test that tell us how our livers are working, are abnormal, one of the things that we look for is whether somebody has a bile duct cancer. The more common reasons that the liver enzymes are abnormal are either somebody has just had a few too many alcoholic drinks a few days before or that they have gallstones. If we don’t find that somebody is actually having troubles with gallstones or with a few too many drinks, then we start looking for bile duct cancer. Because when those liver enzymes are elevated, we worry about tumors like this. But the more common presentation for bile duct tumor is really somebody who presents with jaundice, or that they turn yellow. The reason this happens is because, again, the bile is actually made in the liver and meant to pass down these bile duct intubation tests and help digest food. When the bile duct is blocked in any way, then the bile backs up into the blood, then it deposits on the skin, and the skin takes on a yellowish hue because of the fact that bile is yellow. Then the urine turns very dark. The common presentation for a tumor like this is really that somebody suddenly turns yellow, the urine is really dark, and their stools are very light colored because bile no longer makes it down into the intestines, so pretty much the same presentation as someone who has pancreatic cancer. But when we go looking for the pancreatic cancer or gallstones and we don’t find gallstones and we don’t find a big lump in the pancreas, then we start suspecting bile duct cancer, because again, that would be the alternative in terms of what blocks the bile duct and causes jaundice.

Melanie: You explained everything so beautifully, Dr. Fong. Now, we only have a couple of minutes left. Tell us about some of the cutting-edge treatments you’re doing there at City of Hope.

Dr. Fong: Well, the most important treatment for bile duct cancer if possible is go remove it. For the ones that happen way down at the bottom of the bile duct, it is to go and do something called a Whipple Procedure. The medical term for this pancreaticoduodenectomy. It’s a big operation that removes that front part of the pancreas just as if it was a pancreatic cancer. What has been definitely shown is that kind of big operation is better done at places where a lot of it is being done. Around the country, it’s been very well accepted now that having such surgery at a major center decreases the risk of complications and even death from such operations. Again, over the last 20 years, we’ve gotten pretty good at taking those tumors out down there. If it’s inside the liver, or right outside the liver, in the main bile duct way up high, there are many operations that have now been perfected to go remove those, and some of those could even be done using a robot or using a laparoscope, operations where we can actually reach in with a small incision with multiple small instruments and take out cancer for someone without causing them a big recovery without making a huge incision. Many times, we catch these tumors after it’s already spread. That’s where the research comes in. Until about 10 years ago, our chemotherapy for this disease was terrible. Less than 10 percent of the people would even have any shrink to tumor based on chemotherapy. But over the last decades, because of work by pretty amazing chemotherapists and researchers, our chemotherapy has gone much, much better. Now we have good chemotherapy that we can give that has a fairly good chance of putting disease back into control and even some chance of sometimes shrinking the tumors enough so that the patients can become potential surgical candidates for removal and potential cure of the disease even after it’s spread. I think we’ve come a long ways over the last decade or in two decades. Our surgery is better. Our chemotherapy is better. Here is a disease that three decades ago would have been considered almost uniformly fatal that we are really making headways on. I’m just glad to be working at a place like City of Hope where we can actually use these therapies.

Melanie: Dr. Fong, thank you. You’ve given hope to so many and your information is so beautifully put. Thank you so much for being with us. You are listening to City of Hope Radio. For more information on bile duct cancer and Dr. Yuman Fong, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

Genetic Counseling for Cancer

Additional Info

Segment Number 3
Audio File virginia_health/1512vh5c.mp3
Doctors Thomas, Martha
Featured Speaker Martha Thomas
Guest Bio Martha Thomas is a genetic counselor at the UVA Cancer Center who meets with patients to discuss their family history of cancer and determine their level of risk.

UVA Cancer Center
Transcription Melanie Cole (Host): Which patients should consider genetic counseling to gauge their risk for cancer and what can you expect when you meet with a genetic counselor? My guest today is Martha Thomas. She’s a genetic counselor at the UVA Cancer Center who meets with patients to discuss their family history of cancer and determine their level of risk. Welcome to the show, Martha. When should patients or anybody consider receiving genetic counseling to measure their cancer risk? That’s the biggest question.

Martha Thomas (Guest): Sure. I think there are really two categories of patients that I tend to see. The first are patients that have actually been diagnosed with cancer, and when they first meet with the doctor to get that diagnosis, they say, “Gosh! There’s a lot of other cancers in the family. Could my cancer be caused by an underlying genetic reason?” Also, when individuals are diagnosed with cancers at young ages, we don’t expect to see colon cancers and breast cancers when people are in their 30s and 40s. That can raise a red flag as well. The other are healthy individuals that might come to me and say, “My grandma had breast cancer, my mom had breast cancer, and my sister just got diagnosed with breast cancer. Am I myself at increased risk of developing breast cancer?” Those are really the two categories of patients that I tend to see the most of.

Melanie: You’ve mentioned colon cancer and breast cancer. Are there other particular cancers that you can identify with genetic counseling their risk?

Martha: Really, any type of cancer can be connected to an underlying genetic predisposition. Breast cancer, colon cancer, ovarian cancer, and uterine cancers tend to be the big ones. Pancreatic cancers, I also see a lot of those. A lot of times, people don’t realize that certain cancers can actually be connected. For instance, a family history of pancreatic cancer and then having a woman diagnosed with breast cancer does raise some suspicions in my mind for a genetic predisposition, where a lot of people might not realize that breast cancer and pancreatic cancer can be connected.

Melanie: I didn’t realize that either. Now, people hear about genetic counseling. They get scared. We’ll talk about what you do with the information that you get, but what do you do for testing? If we’re testing, we hear about the BRCA gene for breast cancer. What is the test like itself?

Martha: Sure. Doing genetic testing is actually very straightforward. It’s just a blood draw. Testing actually radically changed in June 2013 after a Supreme Court decision that de-patented genes. There’s also been brand new technology that’s come out called next-generation sequencing, and this allows us, instead of just looking at one or two genes at a time, we can look at 10, 20, 100 genes all at the same time and get those results back within a month or so. Testing has really now moved from just one or two genes to looking at larger panels of genes to get a broader idea of what might be going on in an individual.

Melanie: What kind of questions do you get from patients during a meeting? If they’ve already had the test or they’re considering it and you’re doing the family history evaluation, what are they asking you?

Martha: A lot of people want to know what their risk of developing cancer is, particularly if they haven’t had a cancer. That’s a big question and sometimes we can’t answer that to the point that people are satisfied, just because that information doesn’t always exist. People also want information on how to interpret their results. A negative result is not always a clinically negative result. Sometimes walking through those fine details of “what was your result and was does this mean to you in your particular situation” can be really helpful for people.

Melanie: Now, the big question, Martha, what do they do with the information? If they get that you have a genetic risk for breast cancer and we found the BRCA gene, how do you counsel them on making this really difficult decision on what to do with it? I don’t know that I’d want to know. Or can you change the outcome if you do have a positive result by prevention and other means?

Martha: Sure. That’s the million-dollar question really. I do always emphasize that genetic counseling is not the same as genetic testing. If you want to come for genetic counseling just to learn about your risks and the options that are available for you but decide that ultimately you’re not interested in testing, that’s a completely fine decision. You don’t have to get testing just because you’ve come for the counseling. In terms of what to do with the information, we’re really in an exciting period in genetics that our knowledge is growing extremely rapidly, but we don’t have all the information that, again, a lot of people want. Yes, we can tell individuals that they are at increased risk of developing cancer, but a lot of times outside of surgeries or increased surveillance, there’s not much that we can do to really reduce the risks of developing cancer. There are some interesting trials going on with using aspirin and how it reduces the risk of developing colon cancer and there are some certain drugs that can be used to reduce a woman’s risk of developing breast cancer, but a lot of it is just giving people the information so that they can be more diligent about their screening and asking their doctors questions and making sure that they’re getting the preventative care that is really appropriate for them.

Melanie: There’s been some news in the media recently about preventive surgeries, prophylactic mastectomies and things along those lines. What do you tell people when they ask you, “Well, now if I’ve got this BRCA gene, should I have a double mastectomy?”

Martha: Those are 100-percent personal decisions, and that’s actually what I think makes my job so interesting is I could have two different patients who tested positive for the exact same mutation in a gene and one patient might get her results and say, “Great! What’s the next opening in the OR? I want to do surgery this afternoon if I can.” Another patient might say, “Okay, that’s fine. I’m not ready to act on this yet,” or, “I’m not ready to act on this ever.” Those are really individualized decisions and I always emphasize, there is no wrong decision. As long as the patient has all of the information that they need to make the right decision for themselves, whatever decision they make is the right decision.

Melanie: Do you involve the families in that counseling session? Do you want the spouses to sit there and listen to these results? I know that it could be individual and personal, but you as a counselor, do you want the family to hear all these things?

Martha: When it comes to genetics, I always say the more, the merrier. Genetics is unlike any other area in medicine because a person’s result doesn’t just affect them. It’s not like getting a cholesterol level or a CBC. Your genetic testing results have implications for your children, for your siblings, for your parents, so on and so forth. The more ears that can hear this information and the more open families are about sharing this information, I think the better. With spouses being involved when talking to their children or something like that, I do encourage that as much as people are comfortable with, because you do walk that fine line. We still obviously observe HIPAA and it’s not like if a patient’s sister calls me and says, “Well, what was my sister’s genetic testing result?” I can’t give that out to them, even though it could potentially have implications for their own health. It’s a really interesting ethical area to work in.

Melanie: In just the last minute or so, Martha, give the listeners your best advice for those considering genetic counseling and maybe even genetic testing, and why should patients come to UVA Cancer Center for their genetic counseling?

Martha: The number one thing that I tell people before appointments is to get as much information as possible. A lot of times, there’s the “Oh, grandma died of some cancer in her stomach.” If we can really pinpoint what that cancer is, or even what treatment she had, sometimes that can be helpful for me. Gathering as much information as you can about the family history is really my number one advice. UVA is just such a cutting-edge institution. We really are on the forefront of doing testing on tumors that can give us indications for genetic predisposition syndrome. We are looking at new drugs and therapies that can potentially reduce individual’s risks of developing cancer. It’s just such an exciting innovating place to come, and with genetics, you want to be at an exciting innovating place because this stuff changes truly on a daily basis.

Melanie: Thank you so much, Martha. It’s absolutely fascinating. You are 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

Advances in Vascular Surgery

Additional Info

Segment Number 2
Audio File virginia_health/1512vh5b.mp3
Doctors Tracci, Margaret
Featured Speaker Margaret Tracci, MD
Guest Bio Dr. Margaret Tracci is a board-certified vascular surgeon and president of Virginia Vascular Society who provides comprehensive treatment and care for a range of vascular conditions.

UVA Heart & Vascular Center
Transcription Melanie Cole (Host): The vascular system is a complex system in the body, but certain things can go wrong with it. My guest today is Dr. Margaret Tracci. She’s a board-certified vascular surgeon and president of Virginia Vascular Society who provides comprehensive treatment and care for a range of vascular conditions. Welcome to the show, Dr. Tracci. What are some of the most common vascular conditions that you encounter?

Dr. Margaret Tracci (Guest): Thank you for having me. The most common disorders that we treat are disorders of both the arteries and the veins. In the arterial system, really much of our practice is centered around the treatment of atherosclerosis. This is very closely related to coronary artery disease. What we most commonly see is atherosclerosis of the carotid arteries which can be associated with stroke, and atherosclerosis of the arteries of the legs which can be associated with a range of symptoms from cramping of the legs with exercise to failure to heal ulcers, longstanding persistent sores in the legs, to even loss of limb.

Melanie: Dr. Tracci, people are always worried about symptoms of vascular disease, peripheral vascular disease, heart disease. They’re always looking for those red flags to give them a better sort of chance. When you mentioned the legs, hot feeling, blood clots, tell us some symptoms that we might come up with for any of these vascular conditions that people really need to be aware of when they’re exercising and when they’re at rest.

Dr. Tracci: Absolutely. As I said, the most commonly treated condition for us in the legs is atherosclerotic disease. What people notice is essentially the symptoms of angina in the legs. When they exercise, the muscles demand more oxygen, the body is not able to deliver that, and they feel a cramping or “Charley horse” sensation in the leg with exercise. People will tell you, “I get 50 yards and my legs cramp up on me.” In more severe cases, people will find that they have ulcers that won’t heal or constant pain in their feet and those can both be associated with bad atherosclerotic disease of the legs. We also get inquiries about venous disease. People will see varicose veins or notice that they have swelling or bulging of veins in their legs. We then screen them for either occlusive disease which would be blood clot, or what we call reflux disease which is badly functioning valves in the vein.

Melanie: If people are experiencing this claudication or pain in their legs when they’re exercising or any of these other conditions, do you recommend vascular screening? Who should be screened?

Dr. Tracci: We absolutely do. There are a number of different screening tests available and each one of them has slightly different criteria. I think one of the most important screening initiatives that vascular surgery has supported is screening for abdominal aortic aneurysms. Unlike all of the other conditions that we’ve described, aneurysms are really insidious because they don’t come with symptoms typically. People will sometimes have a family history of aneurysm, but more often not. So we do recommend that people have a simple ultrasound screening for men over the age of 65, or 55 if they have any family history of aneurysm; and for all women over the age of 65 who have either a family history of aneurysm or a smoker. For peripheral arterial disease, anybody who has got significant atherosclerotic disease in other areas, known coronary artery disease, known carotid artery disease, ought to be screened. Certainly anybody who is having symptoms potentially of claudication or noticing that they’re having sores on their feet that won’t heal. With regard to carotid artery disease, again, this tends to be a condition that’s insidious. It’s not symptomatic until somebody has a stroke. Again, we do tend to recommend that people undergo simple ultrasound screening for this if they have other significant atherosclerotic disease, either coronary artery disease or known peripheral artery disease.

Melanie: Now tell us some of the latest advances in the treatment of some of these common vascular conditions.

Dr. Tracci: Sure. Vascular surgery has been one of the most exciting areas in medicine over the last 10 or 15 years, primarily in the area of minimally invasive treatment of each of these categories of disease. With regard to arterial aneurysms, particularly aortic aneurysm, virtually all of these can be treated with stents now rather than open surgery. We’re just becoming more able to treat aneurysms of the mid-portion of the aorta, the branch portion of the aorta, with stents. This was an area that historically we hadn’t had the technology to manage this one. It’s incredibly exciting. In the area of peripheral artery disease, new technology such as drug-eluting stents or balloons that actually chemically treat the lesions while we’re ballooning them or stenting them seem to be effective in reducing the rate of re-narrowing over time. We’re very excited about this as well. Finally, in a similar fashion, endovascular or minimally invasive catheter-based treatment has revolutionized the treatment of venous disease. A lot of people remember the old-fashioned vein stripping, which could be fairly extensive surgery and painful. For the vast majority of patients, that’s been transformed into in-and-out day procedure that essentially requires a single Band-Aid for a dressing.

Melanie: That’s fascinating. Can you give the listeners some of your best advice on prevention of vascular disease so maybe they don’t need any of these treatments?

Dr. Tracci: Absolutely. And thanks for asking. That’s a wonderful question. Part of the reason that we’re so supportive of screening is that the most important thing about identifying vascular disease, particularly atherosclerotic disease, is that early management with exercise, aspirin, cholesterol management, blood pressure management, and in the case of those who are diabetic, blood sugar management, not only can slow or reverse the progression of disease, but ultimately the most significant impact is on the rate of heart attacks and strokes. They really have an opportunity to impact not just the symptoms from this particular manifestation of the problem, but actually extends people’s life times and quality of life.

Melanie: Why should patients come to UVA for their vascular care?

Dr. Tracci: We’ve got a wonderful group of fellowship-trained, board-certified vascular surgeons who are national and international experts in all areas of vascular surgery, and these are folks who are writing the textbooks and traveling nationally and internationally to teach other people about this. As a result, we really do have access to the latest techniques and technology, including access to technologies that are really only available through clinical trials. At this point, we’re a part of a number of large trials sponsored by the NIH, sponsored by industry, and have quite a bit to offer. We also have a great multidisciplinary team and we really view this as a cardiovascular center of excellence that involves having a certified top-quality vascular lab with technicians and equipment to do the best diagnostics, and a wonderful interdisciplinary relationship with cardiology, cardiovascular medicine, interventional radiology, cardiac surgery, endocrinology, and other specialties that really need to be involved in the 360-degree treatment of vascular disease. We also have an absolutely wonderful team of nurse practitioners and physician assistants who are specifically trained in vascular disease and incredibly dedicated to the care of our patients.

Melanie: In just the last minute, Dr. Tracci, if you would, give your best advice for people that might already be suffering with vascular disease, peripheral vascular disease, and just really give them your best advice about things that they can do, lifestyle management.

Dr. Tracci: Absolutely. I think that it absolutely makes sense to approach your physician about treating and managing peripheral arterial disease. Like all atherosclerotic disease, the management depends on exercise, which encourages your body to build up its own collateral system or other branch vessels to relieve symptoms. In management of atherosclerosis, really the mainstays of that are: medication such as aspirin, frequently statins in the management of high cholesterol, and the management of hypertension or high blood pressure and blood glucose or blood sugar in diabetic patients. All of these things are routine portion of that and absolutely things that can typically be managed by your regular primary care physician. It makes sense to involve a vascular surgeon, a cardiovascular expert because we can actually quantify the disease and in most instances, we can actually help get you feeling better. There are treatments for this. There are options for this. We can all work together to make sure that we’re doing absolutely everything we can do to offer you the longest, healthiest, most symptom-free life that we can, and all of that depends on really early lifestyle changes and, again, a 360-degree approach to this.

Melanie: Thank you so much. What great information! You are 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

The Changing Face of Stroke Care

Additional Info

Segment Number 1
Audio File virginia_health/1512vh5a.mp3
Doctors Evans, Avery
Featured Speaker Avery Evans, MD
Guest Bio Dr. Avery Evans is a board-certified radiologist who specializes in interventional neuroradiology procedures to treat strokes, cerebral aneurysms and arteriovenous malformations.

UVA Neurosciences
Transcription Melanie Cole (Host): With recent studies confirming the benefits of some newer stroke treatments, how is the field of stroke care changing? My guest today is Dr. Avery Evans. He’s a board-certified radiologist who specializes in interventional neuroradiology procedures to treat strokes, cerebral aneurysms and arterial venous malformations. Welcome to the show, Dr. Evans. Tell us a little bit about some of the major developments in stroke care recently and describe them for the listeners.

Dr. Avery Evans (Guest): Well, as you mentioned, there have been some very exciting recent changes in stroke care. For a few years, we’ve had the ability to go in and treat some of the most devastating kinds of stroke, which is the ability to go in and remove a blood clot from a blood vessel in the patient’s brain. But up to now, we haven’t really been sure that this is the best thing for the patient, but four trials have recently come out that showed that unequivocally, this is a benefit to patients and more patients will get better if we do this than if we don’t.

Melanie: So that’s what it means for patients. Tell us a little bit about who could benefit from these developments.

Dr. Evans: Well, anyone can develop a stroke. It’s generally a disease of older patients, but it can happen in younger patients as well, but anybody can develop a stroke. The people who will benefit from this most are people who are having what we call ischemic strokes. This is a stroke that occurs because there has been blockage of a blood vessel in the brain.

Melanie: Tell us a little bit about ischemic stroke and what you’re doing. Is there a revascularization? Are we talking about first responder, what’s happening in the emergency room? Kind of go through it for us.

Dr. Evans: Well, one of the things I want to do is frame this for the people who are listening. Stroke is an incredibly important disease. Most people don’t realize that. It is the third leading cause of death in this country and it is the leading cause of disability. I think it’s sort of underappreciated by the general public. It’s a very important disease. What happens is a patient has signs and symptoms of a stroke and we can talk about what they are, and if we must, we’ll talk about them now. If you or a loved one is having weakness or numbness on one side of the body, if you’re having difficulty speaking or understanding speech, if you’re having a facial droop or difficulty seeing or blindness in one eye or the other or both, these are all very common symptoms with stroke, and the most important thing is that if you or a family member or a friend is having any of those symptoms, it’s incredibly important that you immediately call 911 or get that patient to the nearest emergency room because we have a saying among those of us who treat this disease, and that is, “Time is brain.” The longer you wait, the less likely it is that you’ll be able to have a good outcome if you’re having that kind of stroke. So it’s imperative that patients get to the hospital immediately. It’s the kind of thing, I think, because it doesn’t hurt—everybody understands if you have chest pain, you need to get to the emergency room—but stroke is not painful, and so I think because it doesn’t hurt, people think, “Well, Grandma doesn’t look exactly right. She’s a little weak, but we’ll just let her sleep it off.” That’s the wrong thing to do. If people are having signs and symptoms of stroke that I described, they need to get to the emergency room immediately. That’s the most important thing people listening to this need to hear.

Melanie: When we think about identifying it then, so time is brain, they spot some of these red flags you’ve described, they get to the emergency room, what do those people do to identify rapidly and accurately that it is a stroke and how fast can they start treating it?

Dr. Evans: We can start treating it very quickly. One of the great things about being here at the UVA is that we have all the pieces of the puzzle to make this happen properly. Make no mistake: it takes a team of people to make this happen. First off, you have to have the complex imaging equipment that it takes to diagnose the disease. Then you have to have people like me and some of my colleagues who have the ability to go in and remove the blood clot from the brain. Most importantly, it takes a team of specialized stroke neurologists which we have here at University of Virginia. We have a team of stroke neurologists who are on call 24/7/365. The minute the patient like this comes to the hospital, they jump into action and make the diagnosis. What happens is the patient comes in, the ER doctor identifies that the patient is having a stroke. The stroke neurology team jumps into action; they go and examine the patient. The patient very quickly is taken to the CT scanner. We do imaging of the brain and we’re looking to make sure that there is not already a completed stroke. We have to make sure that the damage hasn’t already been done. We also make sure that there hasn’t been bleeding because some kinds of stroke can present with bleeding. Then the stroke neurologist makes the determination whether they are going to give a clot-busting drug through the IV, that’s a clot-busting drug called tPA, so frequently they’ll give that. Then at that time, or before or after, we’ll do a specialized imaging study to find out if one of the large blood vessels in the brain is being blocked by a blood clot. If we determine that that large blood vessel is being blocked by a blood clot, then we can go in with some specialized tools, some catheter, some very long plastic tubes and some other specialized tools. With a high degree of success, we can remove the blood clot that’s blocking the blood vessel and restore flowing blood to the brain and hopefully prevent further damage. In a nutshell, that’s how it works, but it starts with a team. You’ve got to have a team of people who are experts in how to do this. No one physician group has all the expertise that it takes to do this.

Melanie: That’s absolutely fascinating. In addition to acting fast and your ability to go in there and get these blood clots and the medications, what are you seeing as outcomes and what can we do to prevent stroke in the first place?

Dr. Evans: Well, the outcomes from stroke with this new technique are better than they have ever been. The particular kind of stroke that we’re targeting with this is what we call a large vessel occlusion stroke. These are the strokes of large blood vessels of the brain that lead patients most to devastated. These are the kinds of strokes that just really totally devastate the patient. Now, sort of for the first time – well, we’ve been able to do it as I said for several years – but for the first time, we have absolute proof that it helps a lot of people, a lot more than we could have. It’s very exciting in that sense. It’s the biggest development we’ve had in stroke care in 20 years, it’s easy to say. As far as prevention is concerned, prevention mainly has to do with good medical care. You need to have a relationship with your primary care doctor. You need to make sure that if you need blood pressure medicine, that you’re taking it appropriately. You need to make sure that if you have high cholesterol that you’re treating that either through diet or through meds. So stroke care begins with patients taking good care of themselves, and that has to do with making sure that you get your annual checkups with your primary care doctor.

Melanie: Tell us in just the last minute your best advice for people listening who are worried about stroke, and what are the benefits of coming to UVA for their stroke care?

Dr. Evans: Well, as I said earlier, it takes a team to do this and we have all the pieces of the puzzle right here. Not very many hospitals in the country have all of that and we have it. We’ve got excellent primary care doctors. As I said, we’ve got a team of absolutely fantastic stroke neurologists on call 24/7 who will be there immediately the patient needs them, and we have a complex imaging equipment and also doctors like me who, if needed, can go in and remove these blood clots if they’re present. We have it all here. But it all begins with patients taking care of themselves, getting their annual checkups and making sure that they reduce their stroke risk factors as best they can.

Melanie: It’s great information. Thank you so much. You are 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

Obesity and Cancer Risk

Additional Info

Segment Number 1
Audio File city_hope/1512ch2a.mp3
Doctors Karimi, Misagh
Featured Speaker Misagh Karimi, MD
Guest Bio Dr. Karimi has previously practiced at UC Irvine medical center, as well as Oregon Health and Science University as an assistant professor in hematology and oncology. Dr Karimi headed the clinical research unit of OHSU Community Oncology program and was intimately involved in bringing the cutting edge clinical trials in medical oncology to treat cancer patients. His research background is in several areas in GI oncology but he also has interest in lung cancer, breast cancer, prostate cancer and other general medical oncology and hematology diagnoses.

To learn more about Dr. Karimi
Transcription Melanie Cole (Host): Multiple studies have shown correlations between obesity and a risk of cancer recurrence. My guest today is Dr. Misagh Karimi. He’s a staff physician specializing in hematology/oncology at City of Hope. Welcome to the show, Dr. Karimi. Tell us a little bit about how obesity affects cancer risk and what you’re seeing in the country today as we have this obesity epidemic going on.

Dr. Misagh Karimi (Guest): Thank you for having me. I think obesity is an epidemic in this country. There have been multiple studies that have been done, epidemiological studies and also studies that look at the patients who have had cured early- stage cancers that have links to obesity with either recurrence, risk of a cancer or incidence of having a new primary cancer. Look at multiple studies that have been done in colorectal cancer, in breast cancer, which are two of the most common types of neoplastic diseases in this country and you see a direct correlation with obesity with people who have a higher body mass index having a higher chance of developing those cancers. But also if you look at other types of less common cancers such as the esophageal, pancreatic, and also looking at gallbladder and urinary bladder cancers also have been shown to have increased risk of disease with a higher body mass index.

Melanie: With certain cancers, Dr. Karimi, when you mentioned breast cancer and colorectal cancer and we linked that and looked at obesity, where is that link? Colorectal would seem to make sense because maybe it means that you’re eating a lot of junk and your colon gets filled up with that, but what about breast cancer or esophageal cancer, stomach cancer, how are these related to obesity?

Dr. Karimi: Looking at the breast cancer, if you look at the risk factors that have been studied in the past and have been shown to be important in increasing the chance of developing breast cancer, hormones seem to have a major play. Estrogen replacement has been linked very well to developing breast cancer with very large women studies that was eventually finalized about 10 to 15 years ago. If you look at estrogen, basically synthesis in the body after menopause, it’s linked to peripheral adipose tissue: The higher the content of adipose tissue or the fat tissue in the body, the higher chance of having a high level of estrogen and estrogen-like compounds in the body. That’s one way of linking the risk of developing breast cancer in the patients who have higher body mass index. But that doesn’t stop there. There are a lot of other issues that come up. Having a higher body mass index in general also is linked to lower exercise and perhaps not very healthy eating that also affects your immune system. If you want to think of this, perhaps in all of us, we develop one type of cancer or another on a regular basis. Our immune system keeps these under check, finds these cancer cells and removes them from the system. Now, if your immune system is not working very well, then we run to this problem that some of these go unchecked and eventually develop into advanced disease that the body cannot take care of any longer. So it is a constellation; I mean we look at several things. It’s really healthy habits, living habits, that all come together and one part is the obesity.

Melanie: Here’s the big question, Dr. Karimi. If you lose the weight, does that then decrease your risk of developing these specific cancers? Because I imagine that when you’re overweight, you worry about diabetes and heart disease, but you don’t always think about that link between obesity and cancer. If you lose the weight and you lose that body mass index, then are you decreasing your risk of cancer or is it already there?

Dr. Karimi: That’s an excellent question. We discuss this all the time. I discuss this all the time with my patients who have had early stage of cancer, for example, breast cancer, and we see them in follow-up. I do try to make this point every time I see my patients that it’s very, very important to try to follow some rules. We have studies that show reduction of body mass index of obesity would reduce the chance of developing a primary cancer that may be hard to show. These are again epidemiologic studies, very hard to perform a study that will actually do this and have an adequate control for it. But we have plenty of data in women who have had the cancer and have been followed afterwards. In other words, let’s say women who’ve had breast cancer early-stage disease have been cured with surgery, chemotherapy, radiation hormonal blockage and so on. Then they are randomized to either a healthy diet, if you want to call it, the prudent diet, Mediterranean diet, regular exercise; versus the other group, the control group that was left to continue their lifestyle as before. There is very good data that these patients had a much lower chance of recurrence of their breast cancer. Interestingly the study did not try to promote weight loss, but on average, women did have significant weight loss when they were on the experimental group that were followed closely by dietitian and encouraged to exercise and so forth. There is an indirect correlation, at least in this study, that weight loss by itself reduces chance of recurrence. There is no question that a healthy diet and exercise also adds to that.

Melanie: In just the last few minutes, give your best advice in what people can do to prevent obesity and their increased cancer risk and why they should come to City of Hope for their care.

Dr. Karimi: That’s a very tall order, but that’s also an excellent question. I think there are several things that fit into this. We talk about diet. We talk about exercise. I think we need to also talk about how much time we’ve spent sleeping at night. I think these are all important. People who in general sleep less, a fewer hours on average, tend to have more problems with obesity, with high blood pressure. It is a really healthy lifestyle that’s important to discuss. When we talk about exercising, generally most of the studies have shown that daily routine is recommended. Not to do two to three times a week, but try to do that on a regular basis, on a daily basis, to do an aerobic type of exercise. When we talk about diet, in general, it’s recommended to have a higher amount of fruits and vegetable intake and less amount of dietary protein that are basically originated from meat, especially red meat. So protein that comes from plant-based food is also recommended to be more beneficial, perhaps more legumes, more not in those general categories, and less red meat, and less dairy product.Again, finally, just the practice of trying to live a stress-free life as much as possible and getting enough sleep at night.

Melanie: It’s great information and these are such important points and such interesting topic. Thank you so much, doctor. You are 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

The Ins-and-Outs of IBS

Additional Info

Segment Number 1
Audio File allina_health/1512ah1a.mp3
Doctors Pieper-Bigelow, Christina
Featured Speaker Christina Pieper-Bigelow, MD – Gastroenterology and - Internal Medicine
Guest Bio Dr. Pieper-Bigelow loves working on cars, riding horses, spending time outdoors and travelling in her spare time. Her favorite 'gut healthy' tip is to eat a high fiber, low fat diet. She sees patients at the Allina Health Hastings First Street Clinic.
Transcription Melanie Cole (Host): Have you sat in the bathroom countless times wondering why me? Well, know that there are 58 million Americans who feel the same way. Irritable bowel syndrome isn’t a simple illness because everybody’s IBS is just a little bit different. My guest today is Dr. Christina Pieper-Bigelow. She’s a gastroenterologist and she sees patients at the Allina Health Hastings 1^st Street Clinic. Welcome to the show, Dr. Pieper-Bigelow. Tell me a little bit about IBS. What is it and what are the risk factors for it?

Dr. Christina Pieper-Bigelow (Guest): IBS is irritable bowel syndrome. What I think it is to be known right away is that it’s not a disease. It’s a constellation of symptoms and I often say it’s like a diagnosis of exclusion. In other words, we make sure there is nothing organically wrong with the colon. IBS is a constellation of symptoms like diarrhea, constipation (sometimes alternating between the two), abdominal bloating, gas, mucus in the stool, and intestinal cramping. The risk factors we know that it tends to be more common in women more than men. It tends to be a disorder of young people. Typically, before the age of 45, a person will start to have symptoms of IBS. There are also some risk factors associated with psychological issues. People who tend to have more anxiety, depression, and this surprises a lot of patients that I see, but people that have had some type of abuse in their past. They’ve been sexually abused or perhaps they’re in a situation of domestic abuse. Sometimes when I ask really personal questions like that, a person will look at me like, “Why are you asking me that when I’m here because of my diarrhea.” The fact is it is a risk factor.

Melanie: People who have bloating, women especially, we get upset stomachs. Whether it’s from stress or just that time of the month, so how do you know the difference? What would be some red flags that would send you to the doctor to get this checked out?

Dr. Pieper-Bigelow: That’s what’s really difficult. I know that. Because we do have bloating around the menses and sometimes even normally the bowels may change around menses. Women are forever going, “What do I do? Do I even talk to anybody about this?” There are red flags. The red flags would be bleeding. If one has seen blood in the stool, black tarry stools, blood mixed into the stools, unexplained weight loss or trouble with your appetite and then some other things like fatigue, just unexplained fatigue, if the doctor says, “Gee, you’re a little anemic,” or you go to donate blood and they say, “We can’t take blood. You’re anemic. You seem to be low on iron.” Those are the things that you would say, “Gee, I better go in and just get this checked out.”

Melanie: How do you diagnose it, Dr. Pieper-Bigelow? As someone who had it when I was in my 20s and now don’t have it anymore, they did a colonoscopy on me at the time, just to check because Crohn’s runs in my family. How would you normally diagnose somebody? Do you always do a colonoscopy to check and make sure it’s not something else or are there just history and things you can do?

Dr. Pieper-Bigelow: Yeah. There are certain criteria. There’s one called the Rome, R-O-M-E, Rome criteria that people can satisfy. Just with those criteria, if they meet that and the symptoms are very compatible with IBS, we can sort of put it to rest because there aren’t alarm symptoms, the ones that I told you about that were the red flags. Not everybody gets a colonoscopy. That would be an overuse of healthcare dollars, quite honestly, because there are millions and millions of people with IBS that do not have to go through colonoscopy. Now, if somebody comes in with just daytime symptoms, they know, “Gee, if I eat, I get all this bloating, I might have some diarrhea. Now I’m better.” They can sleep through the night. They’re not having weight loss. It’s a pretty typical symptom complex and it’s fairly safe to just try some lifestyle changes first. But clearly if there is some family history like you described, or perhaps a really strong family history of colon cancer, stomach cancer, then someone may be put through the ringer a little bit more as we say. Oftentimes, just some very simple blood tests can be done. We look for anemia. We look for signs of inflammation. If the symptoms are stable and not progressive, not associated with the Lime symptoms, we often just treat it with lifestyle changes. Clearly, if things change or those other things start to crop up, or if someone’s older, if someone’s over 45 and starts having these symptoms out of the blue, those people typically go through the whole workup. They have perhaps a colonoscopy, an upper endoscopy. We look for everything that could cause it. When it’s all negative, then we say, “Okay, this is IBS.” I think the other thing that I would be remiss if I didn’t mention, a lot of times I will order a pelvic ultrasound in a woman with kind of a lower abdominal pain and bloating to make sure there’s nothing going on with the ovaries because that can kind of overlap. It can be really tough to tell them apart.

Melanie: Now, tell us about some of those things we can do to manage those symptoms. It can be very uncomfortable. What things can we do in our diet? Also, speak about some of the alternative things like probiotics that are cropping up all over the media.

Dr. Pieper-Bigelow: Sure. Some people respond to some probiotics. I’m not pushing any particular brand, but the one called Culturelle has the probiotic that actually has gone through some testing to show that in some people, it is beneficial. The thing is, it’s not everybody. There is not a dietary prescription that you can receive from the doctor and that’s going to take care of all of your symptoms because everybody is so different. I would say one of the most common food intolerance is actually milk, or lactose intolerance. Quite honestly, once you’re over the age of two or three, the enzyme which digests milk, that level starts decreasing in our intestines over time. As we get older, we actually have less and less of that enzyme available. Undigested milk or partially digested milk causes more bloating and can cause diarrhea and gas. Other things, high gas foods, so carbonated beverages like pop, things like cabbage or broccoli, cauliflower, raw fruits. A lot of these are really good for you, maybe not the pop, okay? The other things are really good for you so I don’t think you should just like eliminate everything at once. Now, there is this big fad on the Internet right now where everybody is getting rid of gluten and studies are showing that it actually is not getting rid of gluten that’s making them feel better, but in fact, something called FODMAP and that’s an acronym and I’m not going to list it out, it’s a big long name. Anyway, it includes things like high fructose corn syrup, wheat, onions, garlic, lactose, mannitol, sorbitol, like all those artificial sweeteners that people have in their chewing gum and their soda pops and things like that. Those are things that one can kind of work at eliminating. Not from a dietary standpoint but from just an overall health standpoint is just relaxation, dealing with stress, and if there are some underlying psychological issues, dealing with that with perhaps some counseling.

Melanie: Now, what about things that they might try that are over-the-counter? If they’ve got diarrhea from this, trying some of those antidiarrheal medications or fiber supplements. You see Metamucil and all these things on the market. Do we try any of those to regulate your bowels?

Dr. Pieper-Bigelow: Yeah, I think that a lot of people who tend to have more of a constipation-predominant irritable bowel syndrome do better when they take like psyllium husk, which has been –yes, the name brand is Metamucil, but there are lots of generics out there. There’s also something called methyl cellulose, which is Citrucel, and then of course, there is Benefibre. There are a lot of fiber supplements. I usually tell people, “Get the generic, it’s cheaper. Just see if it even works for you.” Sometimes people complain that it makes them gassier, but honestly those fiber supplements tend to be less gassy and bloaty than the food that have more fibers such as beans and things. The antidiarrheal medications—that’s like Imodium or loperamide is the generic for that—that can be really helpful and it’s not unsafe to use it. You don’t want to use more than six to eight tablets a day, but it’s not unsafe if a person has a lot of diarrhea. Then, there are of course prescribed medications, but that’s not exactly what you asked me.

Melanie: That’s okay. In just the last couple of minutes, Dr. Pieper-Bigelow, please give us your best advice about IBS and what to do really to keep those symptoms at bay and still be able to eat healthy and get the best quality of life.

Dr. Pieper-Bigelow: I think it really is important to eat regular meals, smaller meals, low fat, high fiber, and just learn to look at it and go, “Okay, this is my idea. This isn’t terrible. I can deal with this and relax through it.” I see people who just get incapacitated because they’re so afraid of the symptoms because they’re worrying that it’s something more than it is. This is very important to eat a healthy diet and avoid the junk food, the fatty foods, going through fast food, drinking pop and things like that. It’s important to avoid some of these alternative things that are out there. There are people recommending cleanses and herbal teas and colonic enemas. A lot of the products that are sold from alternative practitioners have laxatives in them that can be detrimental. I think a lot of patients don’t even realize that.

Melanie: Thank you for such great information. It’s very important information. You are listening to the WELLcast with Allina Health. For more information, you can go to allinahealth.org. That’s allinahealth.org. This is Melanie Cole. Thanks for listening.
Hosts Melanie Cole, MS

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