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Segment Number 5
Audio File virginia_health/1340vh5e.mp3
Doctors Lim, Scott
Featured Speaker Dr. Scott Lim
Guest Bio Dr. Scott Lim is co-director of UVA's Cardiac Valve Center and is noted internationally for his expertise in novel percutaneous approaches to heart valve disease. He specializes in children and adults with congenital heart disease. Dr. Lim is also the co-director of the Adult Congenital Heart Disease Center at UVA.

Organization: Cardiac Valve Center
Transcription Melanie Cole (Host): Minimally invasive techniques for repairing heart valves are now available for patients who aren't necessarily candidates for traditional heart surgery. My guest is Dr. Scott Lim. He's the co-director of UVA's Cardiac Valve Center, and he's noted internationally for his expertise in novel percutaneous approaches to heart valve disease. Welcome to the show, Dr. Lim. Speak about what cardiac valve disease is with a little bit of a lesson for us on what valves do.

Dr. Scott Lim (Guest): Sure. First of all, I'm honored to be on this segment here. Now, as far as what heart valve disease is, all of us have four valves in our hearts. They help regulate the flow of blood through the heart and out to the body. Most commonly, two of the valves on the left side heart can, in certain people, strictly as we get older, cause problems. Now, the most common problem is either that the valve itself doesn't completely open, and as such, the heart is under a lot more stress and strain as it's trying to pump the blood past a narrowed heart valve. Most commonly, that's something called aortic stenosis, which can affect many people as they get older. Another common problem is a valve doesn't completely close so that the blood can leak backwards, particularly towards the lungs, giving a patient the sensation of increasing shortness of breath, particularly with activity. Those are probably the two of more the common types of heart valve issues plaguing people as they get older.

Melanie: So you certainly don't want blood backing up or going back into the lungs. We want it really strongly pushed out through that left ventricle out into the body. So the valves that you mentioned on the left side that typically have issues, what are some reasons that they would have these issues? Are there symptoms, Dr. Lim, that might signal that you've got some kind of -- you know, do you have shortness of breath? What might people feel?

Dr. Lim: Sure. From a patient's standpoint, the most common symptom that they would feel is increasing shortness of breath with activity, with exercise. Other potential symptoms can be chest pain or chest tightness or palpitations or raising heartbeat. Now, the most common reason why the valve is failing this way is related to age-type changes. For some Americans, as they get older, into their '70s and older, they can have degeneration of these valves as we're all living longer and, as a result, those valves start malfunctioning. Less commonly, it can also be due to an abnormality or a birth defect to the valve that was present since birth but then really starts to become more of a problem as the person gets older.

Melanie: People picture these valves, Dr. Lim, and I know that in graduate school that's how I pictured them, as something you might see on a car that prevents that back flow. They're these so important bit of our heart and bits of our body. Now, if somebody does have a problem with the valve and you need to help them, what are the treatment options available at UVA in the cardiac valve center? What are you doing for them?

Dr. Lim: Sure. Probably the most important thing is, first of all, the evaluation of it, because not everything has to require a replacement or repair, something more invasive. So when the patients first come to us, they get a multidisciplinary approach. They get to see cardiologists involved in imaging their heart valve through ultrasound or CAT scan or MRI and so forth. They also get to meet with specialists in deciding what's the proper therapy, as well as the surgeon or the cardiologist involved in doing that therapy. Now, if it turns out that the patient has a significant heart valve problem, in most cases, medicines are not effective for that. In most cases, you have to either repair the valve or replace the valve. Traditionally, that's been something that's only been done by a relatively invasive open-chest, open-heart surgery type of approach. More recently, we've done a lot of work allowing research, as well as coming into the forefront of medical care, of how to repair or replace valves through catheters. Small tubes are inserted into the blood vessels in either the leg to the side of the body. That's really allowed a less invasive approach for many people, allowing them to undergo such procedures that may not have been warranted for them in the past, as well as allowing them to heal up much quicker than a more traditional, more invasive approach.

Melanie: And minimally invasive in these trans-catheter procedures, what are you doing when you repair versus changing the whole valve?

Dr. Lim: When we're repairing a valve, a good example is a valve that's leaking. There is the traditional way, which involves opening up the chest and opening up the heart, stopping the heart, looking at the valve, and trying to figure out where and how we can put in a series of stitches on the valve. A less invasive way to doing it, or a trans-catheter based way to do it, is using tiny little metal clips called MitraClips that are introduced through a catheter and then placed onto the leaking part of the valve, clipping it back together. This is all done with the catheter while the heart is still beating, while the chest is still closed, and it's guided by the use of ultrasound so that we can see what we're doing.

Melanie: That is so cool. Is this a lifetime thing, or is there a possibility later that they might need the valve replaced?

Dr. Lim: The goal with this is a lifetime repair. However, many of these newer technologies have not been in existence for an entire lifetime. So we may have eight or 10 ten years of experience on it, but we certainly don't have 40 or 50 years of experience, so we don't really know that answer. We think it is a permanent repair, and we certainly hope so. That still has yet to be proven.

Melanie: Recovery time for the trans-catheter, more minimally invasive, and then we'll talk about a full replacement.

Dr. Lim: Sure. So in terms of a trans-catheter repair of a valve using some of these MitraClip type procedures, that's commonly done where the patient comes in, gets the procedure, we watch them one or two days in the hospital, and then they're able to head home and resume more normal activities. Now, instead of repairing the valve, we're replacing it. Much of the time, that depends on how we do it, but oftentimes the patients are in the hospital maybe three or four days on average compared to if they underwent a standard open-chest, open-heart surgical approach, where they'd be in the hospital a week or slightly longer.

Melanie: And if you have to replace the entire valve, then -- we only have a couple of minutes left, but what's involved in that?

Dr. Lim: Sure. What that is is we take almost the same valve that's inserted by a standard open-chest surgery. Instead, we compress it down so it can then go through that catheter from the blood vessel in the leg or the side of the body, and we spread that up into the heart, where, as it comes out of the catheter, we re-expand it into the normal size. It pushes aside the old malfunctioned valve and starts working right away.

Melanie: Wow. That is fascinating. And then recovery, if you've had a valve replaced, aortic valve, a mitral valve, what can they look for for the rest of their life? Is this something that really is a new lease—no more shortness of breath? Pretty exciting.

Dr. Lim: It is very exciting, and yes, that is the goal that the patient's main symptoms that got them there in the first place, be it shortness of breath or chest pain, that the patient has resolution of those symptoms.

Melanie: So give us your best advice for cardiac valve disease in the last one minute, Dr. Lim, if you would.

Dr. Lim: Sure. I think one of the most important things is that this whole field of heart valve disease is rapidly changing. There's a lot of really new, exciting things available and on the horizon. So it's very important for a patient with heart valve disease not only get an opinion from a cardiologist, a physician they trust, but in certain cases, it's worth seeking out a second opinion from a center that has a lot of experience in these newer things.

Melanie: Thank you so much. Dr. Scott Lim is the co-director of UVA's cardiac valve center, and he's noted internationally for his expertise in novel percutaneous approaches to heart valve disease. You're listening to UVA Health System Radio. For more information on the cardiac valve center at UVA, you can go to uvahealth.com. This is Melanie Cole. Thank you so much for listening.
Hosts Melanie Cole, MS

The Future of Cancer Care

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Segment Number 4
Audio File virginia_health/1340vh5d.mp3
Doctors Loughran Jr, Thomas P
Featured Speaker Dr. Thomas P. Loughran Jr
Guest Bio Dr. Thomas P. Loughran Jr. is director of the UVA Cancer Center. He comes to UVA after 10 years as the founding director of the Penn State Hershey Cancer Institute. Dr. Loughran discovered large granular lymphocyte (LGL) leukemia and has had his research published in numerous peer-reviewed journals, including The New England Journal of Medicine, Annals of Internal Medicine, Lancet, Journal of Clinical Investigation, Journal of Clinical Oncology, and Blood.

Organization: UVA Cancer Center
Transcription Melanie Cole (Host): Dr. Thomas P. Loughran Jr., the new director of the UVA Cancer Center, is here with us today to discuss his plans for enhancing the care available to patients at UVA. Welcome to the show, Dr. Loughran. Let's start about what attracted you to the UVA Cancer Center.

Dr. Thomas Loughran, Jr. (Guest): Sure. Well, I just arrived from Penn State, the medical school there, where I was founding director of the Penn State Cancer Institute. There were several reasons that attracted me. I think foremost in those is the University of Virginia is obviously well-known as a prestigious, outstanding institution. Within that, the cancer center has been one of the major centers in the country over the past 26 years, receiving a special designation from the National Cancer Institute and recognition on the tremendous work being done here. Second point was that even though UVA is great and the cancer center is great, there are still amazing opportunities to build programs and make them stronger. Lastly, Charlottesville is a very attractive feature of the entire package, if you will.

Melanie: So as great as UVA Cancer Center was before you got there, I'm sure that you have some goals, some things you'd like to see happen and to accomplish. So what are you looking for there?

Dr. Loughran, Jr.: Sure. There're only two major goals on my arrival. The first one is to connect the outstanding basic research better to what's going on in the clinic, with the obvious goal there to advance patient care. Secondly, kind of a longer-term goal is to achieve from the NCI, National Cancer Institute, recognition as a comprehensive cancer center.

Melanie: Which means what, for the listeners?

Dr. Loughran, Jr.: Yes. I was going to say an explanation there. There are right now about 68 cancer centers that are designated across country as outstanding and received this recognition from the National Cancer Institute. There are all kinds of different flavors of these centers. Some of them are basic research centers only. Others are more focused on clinical research. But the higher designation is this comprehensive status. So of the 68, 41 of them are comprehensive, and comprehensive means that, simply put, you take maximum advantage of all the strengths of your university to have a direct impact on the people that you serve.

Melanie: So you have a cancer treatment team there at the cancer center. As I understand, this involves nurses and surgeons and radiologists and, really, patient care advocates, all.

Dr. Loughran, Jr.: Yes. We refer to that as multidisciplinary care. Sometimes people call it multi-D, for short. The goal here is it's already well-established, but certainly can be improved. The whole focus is patient-centered, so we want to make it easier and for the patient, particularly, those who are just diagnosed with cancer, which can be a life-threatening diagnosis. So for example, we have strength in all the major cancers so that we can establish clinics just that specialize, for example, in breast cancer or colon cancer or lung cancer. So all the major kinds of cancer. The idea would be that a patient anywhere in Virginia or even outside of Virginia recently diagnosed, let's just say, with colon cancer, could come and see all the doctors that they needed to see. So that would be radiation therapists, medical oncologists, surgical oncologists, and then others that play a role in that care, such as primary nurses, social workers, and all the ancillary care.

Melanie: Along with all of these different types of cancer that you can help people deal with, and treating the patient as a whole patient -- and you even have a pediatric cancer, right?

Dr. Loughran, Jr.: Yes, mm-hmm.

Melanie: So you've got all of these different multidisciplinary or multi-D, and you're treating the patient, ,really as a whole patient with nurse navigators and all of that. How do you see cancer care in general, sort of the direction that it's moving now, different than maybe it was when you started in this business?

Dr. Loughran, Jr.: Okay. That's a good question. I started about 30 years ago, so it's quite some time. So really, there is a focus in all of medicine, but I think what really has had the most impact so far in the past 10 years certainly is something called targeted treatment. Other popular terms for this are personalized medicine or precision medicine. This basically means that the three previous main ways of treating patients were surgery—and I want to emphasize that it's still probably the best and most effective treatment for the most common cancers. In this whole area, it really relies on early detection. Secondly would be medical oncology, which is my field, where we treat patients with kind of a major assault type of approach with chemotherapy, and then lastly, radiation treatment, delivering x-ray treatment to patients. All of these treatments, particularly the last two, really, the idea there was to deliver the most treatments possible that the patient can tolerate to get rid of all the cancer cells, and then the normal cells would grow back. But that has a lot of side effects associated with that, and the treatment may not be that specific. So the newer concept—let's just call it targeted treatment—is with the knowledge of the underlying fundamental problems in cancer. Say one gene, for example—and it's a simplistic explanation—maybe one cancer is caused by one gene that's constantly turned on. We want to develop drugs that will turn that protein off. Since the cancer cells rely on that protein and normal cells don't, this is kind of the ideal type of treatment, because it would be potentially much better in terms of killing the cancer cell and then secondly, cause less side effects.

Melanie: So Dr. Loughran, explain a little bit about research going on, because research, as you're talking about genetic and turning it on and off and mutations, this is where the research is going. So discuss the importance a little bit. We only have about a minute and a half left, so give us a little bit about the research in providing this high-quality cancer care.

Dr. Loughran, Jr.: Okay, sure. The way we're organized is basic research, clinical research, translational research, and population research. This last category may be the most unfamiliar to your listeners, but it's very important because this means that our goal is to keep everyone in Virginia healthy and for them never to develop cancer. So cancer prevention and research in cancer prevention is extremely important. Perhaps it might be the single most important thing we could do. If we could just get patients to stop smoking, that would get a long way to preventing cancer. We have a lot of other research going on, the basic science area, the genetics and mutations of cancer you already highlighted. Clinical research, our goal here is to develop new therapies, develop new drugs for treatment of cancer. And translational cancer is about reach, which I mentioned in my introduction today, which is to speed up the discoveries in a lab to make sure that they are reaching the clinics as best as we can so it can benefit our patients.

Melanie: That's wonderful. In the last 20 second, wrap it up for us, Dr. Loughran, and give us your best, most enthusiastic words of wisdom about the cancer center at UVA.

Dr. Loughran, Jr.: Well, it's a great place to come. We provide steady care, and we also are developing new therapy for patients. We have a wonderful, relatively new outpatient cancer center providing state-of-the-art holistic care for patients with cancer.

Melanie: Thank you so much. You're listening to UVA Health System Radio. For more information, you can go to UVAHealth.com. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Spotting and Treating Asthma in Children

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Segment Number 3
Audio File virginia_health/1340vh5c.mp3
Doctors McDaniel, Lynn
Featured Speaker Dr. Lynn M. McDaniel
Guest Bio Dr. Lynn McDaniel is a board-certified pediatrician at UVA Health System. She provides general pediatric care as well as caring for children with chronic and special health needs, including children with asthma, allergies, ADHD, acid reflux, ear infections, hearing loss and heart murmurs..

Organization: UVA Children’s Hospital
Transcription Melanie Cole (Host): One in eleven children has asthma, according to the U.S. Centers for Disease Control. If your child is exhibiting certain symptoms, would you know what they are? Would you know the difference between seasonal allergies and asthma in your children? My guest is Dr. Lynn McDaniel, she is a board certified pediatrician at UVA Health System. Welcome to the show Dr. McDaniel. So, explain a little bit about asthma and what makes a child more likely to develop it.

Dr. Lynn McDaniel (Guest): Well, we’re not really sure what causes asthma. We do know that certainly genetics play a part. So, it can be inherited…if there is a family member that has asthma, it is more likely that a child will develop asthma. We know that the immune system plays a role. We know that environmental factors, like cigarette smoking in the home or air pollution. We also know that viral infections play a role in children developing asthma. Asthma is a disease of the airwave and the smaller airwaves of the lung can become very inflamed and clogged with mucus, making it very difficult for a child to breath.

Melanie: Let’s talk about some of the symptoms, because certainly at this time of the year, with the leaves falling and things, you know, kids develop all kinds of sniffles and coughs and little dry sounding coughs. How do we know what we are hearing, as parents, is something that we really need to take them to the doctor about and look into asthma?

Dr. McDaniel: You know, sometimes it can be very difficult to tell the difference when you’re a parent and your child has a cough and a sneeze and when they breath sometimes it does sound whistley or wheezy. I think if a parent is certainly concerned that it is something more than a cold, they should always take them to their pediatrician and have them evaluated. Some of the common signs children will have will be coughing, a lot of times, even in the evening at bedtime. Shortness of breath, they may complain that their chest feels tight, they may have trouble sleeping, because they cough. All of these things should trigger a parent worrying whether their child may have asthma or not. The other thing is a cold that seems to linger for a long period of time or a cough that seems it should have gone away if it were a typical cold – those are things a parent should look at and go “Perhaps I need to have a doctor evaluate them.”

Melanie: OK, if we take them to the doctor and they are diagnosed, this is something a little bit more chronic we’ve caught, that it kind of doesn’t go away, it’s not really the same as a cold, which comes and goes, maybe lasts a week or whatever and you’ve determined that it is asthma, what treatments are there? Because, people and parents, we are panickers of course and we worry about ongoing medications and what that’s going to do to our child at school and is it going to make them lethargic? Speak about treatments that are out there right now.

Dr. McDaniel: Absolutely. Asthma is the most common chronic disease of childhood. We see a lot of this. It’s responsible for so many office visits, so many missed days of school, so we do want to treat them appropriately. A lot of things that parents want to stay away from medications, is to eliminate any triggers. If they are allergic to dogs or they’re allergic to dust mites, do the kind of things in the household that’s important…try to eliminate the things that will trigger their asthma. Get a flu shot – great time of the year to think about that. Everybody in the household needs to be immunized because, influenza and colds can trigger them. But, when it comes to medication, it is incredibly important to understand that asthma is a chronic disease. It really does need to be treated. Your child will not become hooked or dependent on these medications, but they can help to calm down the inflammation in the lungs and allow them to be a normal kid and not be limited in their activities. One of the big things that we rely on is what we call “quick reliever medications” and those are medications like Albuterol. Generally, they are delivered in an inhaler or a puffer. They are inhaled medications. And those are important for relieving symptoms. Parents should know, that if their children are having to rely on those quick reliever medications really frequently during the week, several times during the week, then perhaps they need more…a medication that they take every day to keep their asthma symptoms down, so they don’t have to rely on that quick reliever medication. Some of those long term controller medications are things like Inhaled corticosteroids. A lot of times with parents and steroids they are like “oh no, that’s a bad thing.” But, inhaled steroids can be great. It is not the same kind of antibiotic steroids you hear about in sports, this is a medication that really calms down the inflammation of the lungs and really helps the children to be active and grow normally without being restricted by their asthma.

Melanie: So, if they are on these controller medications, the Inhaled corticosteroids and their at school, is there any restrictions? You know, back in the day, children with asthma would have to sit out from gym. We understand there is a difference between exercise induced asthma and asthma that is normal. Do they have to sit out? Is physical activity limited? Do these controller medications help them be able to partake in the physical activity at school?

Dr. McDaniel: Great question. The whole purpose of treating asthma is so it doesn’t limit them. We want them to be active, because, actually exercise in children with asthma is shown to be very helpful. We want to be able to manage their medications in such a way that they are not limited in their activities. We want them to play sports, we want them to be active in gym class. Certainly having those quick reliever medications available them at school or at play is important, so if they have an attack, but it should not limit their everyday activity.

Melanie: Dr. McDaniel, when do we turn over care of this kind of thing to our children themselves? When do we put them and say “you know what, you know what your symptoms when if you are about to have an attack and you keep that rescue inhaler with you, but, make sure you’re taking your meds when you are supposed to.” When do you begin to give them a little autonomy there?

Dr. McDaniel: A lot of it depends on the maturity of your child and whether they truly are able to sensor symptoms. Some children are much better able to go “I’m having trouble” and others are sitting there coughing and wheezing and saying “I’m fine.” A lot of it is knowing your child’s ability. Generally, we start talking about turning over some of their responsibility too them when they are around 10, 12 or 14 depending on your child. Schools will allow children, with a written note from their doctor, to carry their reliever medications with them in their backpack at school, which is really important, because getting to a nurse sometimes is difficult in larger schools. I think that teaching and coaching your children to know when and how to deliver their medications. Most children when they’re using puffers may need a spacer device attached to the puffer to help them deliver all of the medication. Some of them want to stop using that if they get to be older and teenagers, but they need to continue to use that spacer device to get all of the medication in.

Melanie: I’ve seen that spacer device and it does help the children. In the last minute and a half, tell us a little bit about the steps you’re taking at UVA to improve asthma care.

Dr. McDaniel: We have the joint commission, which is the governing body of hospitals has asked that children’s hospitals look closely at how they handle inpatient asthma. It’s very important that we do three things; that we give them reliever medications to relieve their symptoms, that we treat them with steroids and that we give them a very detailed plan when they’re discharged to help them manage that asthma at home, so they don’t need to come back. As a team of doctors and nurses and respiratory therapists, we’ve worked very hard to make sure that we are able to do those three things and for the past five quarters, UVA has been a top performer in what we call UHC, which is a university health system consortium of leading academic centers. We are very proud of all the work that everybody has done. But, more importantly, teaching our families what they need to do at home, what kinds of things they can do to stay away from triggers, to get their flu shots, so that they don’t need to come back to see us. That parents can manage and their doctors can manage their medication at home.

Melanie: That is very exciting. For you parents listening, you can work with your pediatrician at UVA to control your child’s asthma, maybe turn over just a little bit of it to your children, so they understand their symptoms, signs they might be having an asthma attack. Teach them how to use their meds properly, make sure they get all of the meds in. And work with your school system. 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 for listening…have a great day.
Hosts Melanie Cole, MS

Detecting Breast Cancer Sooner

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Segment Number 2
Audio File virginia_health/1340vh5b.mp3
Doctors Rochman, Carrie
Featured Speaker Dr. Carrie Rochman
Guest Bio Dr. Carrie Rochman is a member of the UVA Breast Care Program, which offers advanced screening options for women who need mammograms and personalized care plans for women who need breast cancer treatment. Dr. Rochman specializes in breast imaging and is board certified in diagnostic radiology.

Organization: UVA Breast Care Program
Transcription Melanie Cole (Host): Early detection is the best defense against breast cancer, and we're going to learn today about something called tomosynthesis. My guest is Dr. Carrie Rochman. She's a member of the UVA Breast Care Program, and she is also a specialist in breast imaging and board-certified in diagnostic sadiology. Welcome to the show, Dr. Rochman. Let's speak a little bit about tomosynthesis. What is it, and how does it differ from standard mammography?

Dr. Carrie Rochman (Guest): Hi. Good morning. We are very excited about breast tomosynthesis. It's also known as a 3D mammogram, and it's basically a different way of taking a mammogram image. The mammogram machine moves slightly during the test, and what we are able to create is the 3-dimensional image. And the great benefit of tomosynthesis is that we're able to see through the different layers of normal tissue to get better detail of the breast.

Melanie: Wow. That is exciting. Women, especially first timers, are sometimes afraid to go for their mammograms. Would you do tomosynthesis on somebody right from the get-go, or is it used diagnostically?

Dr. Rochman: Tomosynthesis is showing benefit across all groups of women, all ages, all different types of breast density. The benefit is that it's more sensitive, which means that we find more breast cancers. It's also more specific, which means that we find fewer things that turn out not to be cancer. So it's an overall more accurate test, and the benefits apply to all women.

Melanie: Is it something that you can foresee that we're going to be switching to over standard mammography, or is there still a place for that?

Dr. Rochman: We're gaining more data all the time. The data that has come in so far really shows that it is a more accurate test. In my opinion and with our experience so far, I think that we will be using more and more tomosynthesis in the future, absolutely.

Melanie: Is there anything different that women do? We're told not to use deodorant for our mammogram, and we're told soap, that sort of thing. Is there anything different that you do?

Dr. Rochman: No. For the patient experience, it's actually quite similar. The machine looks identical to a standard mammogram machine. There's just a subtle movement in the top part of the machine during the test, but the test is about the same length of time, and it should be very similar from a patient's perspective.

Melanie: Pain-wise, does it compress the same?

Dr. Rochman: Yes. There is some compression of the tissue. The benefit of that is that it really helps the tissue spread out so that we can see through and find those cancers when they're very small and the earliest detection possible.

Melanie: So you know the dreaded sit and wait, Dr. Rochman, that every woman just really, really hates. You have your mammogram, and then you go sit in the lobby and you wait to make sure that they got the pictures all proper, then you can go home and wait for the results. Is this the same, or do you have results a little quicker? Can you tell right there in the room? Any difference there?

Dr. Rochman: The waiting time is about the same. For a screening exam, the patient will have the pictures taken, and then the patient goes home and the screening exam then is read within a day or so. In the diagnostic setting though, those are for women who have had an abnormal screening or if they have any kind of a breast problem, those are read immediately, while the patient is still there, and all the results are given to her before she leaves our department.

Melanie: Now, because you specialize in breast imaging, tell us what the difference is. I've gone around after my mammogram and stood there with the tech and looked and seen. I can't really tell what's going on there; you look around, you see a bunch of dots and you say, "Oh my goodness," they say, "No no, that's not anything." What would you see that looks different than the standard mammogram? What's the picture like for you?

Dr. Rochman: The picture is that the normal tissue is almost blurred out, and so the normal structures melt away into the background. The abnormal structures, the breast cancers, stand out as a very mass-like finding. As well, what tomosynthesis is great is to see any kind of architectural distortion, where the normal architecture of the breast has been disrupted. Tomosynthesis is just superior at letting the imager see that.

Melanie: That's so exciting. What about radiation? Is there any more or less than standard mammography?

Dr. Rochman: Tomosynthesis or 3D mammogram does have an increased radiation dose relative to your standard digital mammogram. It's about two times the dose, but it's a very low dose. Even though it's two times, it's still two times a very tiny dose, and it's still well within what the FDA allows for screening mammograms. The levels of radiation are similar to what we used to have with mammography about 10 or 15 years ago when we were using analogs. When we switched to digital, we got the dose down, and now, tomosynthesis brings it back up to those levels that we had several years ago. Now, there's a lot of research, though, being done about how to get that dose back down, and I really think within about the next year or so, we'll get it back down to the levels we're at with a standard digital mammogram.

Melanie: And this is something that you can have once a year, just like our standard digital mammogram, and you're hoping, maybe, that this will be what we're using?

Dr. Rochman: Yes, once a year screening. I do. I really think that patients will benefit. I recommend it to all of my friends, family members, and patients. It's just a great test.

Melanie: Now, let's speak about women doing a self-exam. If you're teaching women how to do this and you're telling them, "I really think it's important," when is the best time for women to check their own breasts and to kind of get to know them?

Dr. Rochman: The best time is to do it the same every month. We want to check your breast when your hormone levels are at their lowest. If a woman is still having a menstrual cycle, the hormones are at their lowest in the week after her period, not the time when there'll be fewer areas that are tender, fewer things that are a little bit slow and just because of hormonal influences. So that week after your period is the best time to check your breast, and do it consistently that same time every month.

Melanie: Some of us have dense breasts and cystic, and it's hard to know what you're feeling.

Dr. Rochman: Absolutely. The best thing to do is kind of get an idea with your healthcare provider when you go in for a clinical breast exam and have them help explain to you the areas that feel normal, why they feel normal, and then get a good idea about what you're looking for. And then once you have an idea of what your own baseline exam is, how your normal tissue feels, it gives you a starting point to then look for something that's different.

Melanie: Because I think that's the hardest point that women don't actually do a self-exam is because they don't know what they're supposed to be feeling for, plus we all dread feeling that pea-sized bump if we were going to feel anything. Would it be something that moves around in there? Would it be something that is stationary on the back wall? What would we feel?

Dr. Rochman: The things that we're looking out for on a physical exam is we're looking for an area that feels hard. Breast cancers tend to feel hard like marbles. The other thing that we're looking for is that the tissues around the lump don't slide around it very easy, so we call it a fixed lump. The skin doesn't slide easily back and forth across it, or the tissue doesn't slide back and forth against your chest wall very easily. The other things that we look for are a change. Somebody might say, "You know, this spot was always soft, and now it just feels a little bit thicker." Any of those things would be a red flag. There can be changes on the skin. If there's redness or swelling of the skin or any kind of dimpling of the skin, all of those things should be evaluated. I want to stress, too, if there are ever any concerns that a patient feels or that her doctor feels and that she is concerned about, always come in and get it checked out. We're always happy to see women if there's any concern.

Melanie: The UVA Health System is the first hospital in the region to use tomosynthesis. In the last minute or so, 30 seconds or so, Dr. Rochman, please wrap it up for us about tomosynthesis and the advantages in using this 3D type of screening for breast cancer.

Dr. Rochman: Again, I just really want to stress that it's more sensitive, that it finds more cancers, and then also that it's more specific, that there's fewer recalls for things that turn out to be nothing, so there's fewer false positive. We have a more accurate test, and it's overall just great news for women.

Melanie: And it can certainly help the UVA doctors detect breast cancer sooner. You are listening to University of Virginia Health System Radio. That's UVA Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks for listening.
Hosts Melanie Cole, MS

What Every Woman Needs to Know About Breast Cancer

Advances in breast cancer treatment have paved the way for treating many types of cancer—today, treatments are individualized to each patient's unique tumor and cancer type.

Additional Info

Segment Number 4
Audio File managing_cancer/1338ct4d.mp3
Doctors Citrin, Dennis
Guest Bio Dr. Citrin earned a medical degree and PhD at the University of Glasgow in Scotland. He also completed an internal medicine residency and fellowship in academic medicine at the university. He then completed a human oncology and medicine fellowship at the University of Wisconsin-Madison. Dr. Citrin is a member of several professional associations, including the American Society of Clinical Oncology, American Association for Cancer Research and the Chicago Medical Society. His research has been published extensively over the years in journals such as Cancer and the Journal of Clinical Oncology.
Transcription Melanie Cole (Host): After skin cancer, breast cancer is the most common cancer diagnosed in women in the United States. My guest is Dr. Dennis Citrin, he is a medical oncologist with Cancer Treatment Centers of America. He is also the author of the book Knowledge is Power: What Every Woman Should Know About Breast Cancer. Welcome to the show Dr. Citrin. Let's talk about what every woman should know about breast cancer, especially in this awareness month. First, give us some of the risk factors, genetic or controllable and then some of the symptoms we might experience that will send us to you.

Dr. Dennis Citrin (Guest): Thank you. The most important risk factor for developing breast cancer is being a woman. Breast cancer, unlike lung cancer where there is a clearly single defined cause factor like smoking, we don't have that in breast cancer. One woman in eight will develop breast cancer during her lifetime. So, this is a disease that affects women of all sizes and shapes, of all sorts of different background. There are several risk factors however, that are clearly identified, those would include family history of breast cancer or cancer of the ovary. Alcohol use is also associated with an increased risk of breast cancer and the use of hormone replacement therapy, particularly combined estrogen and progesterone in post-menopausal women. These are risk factors that have been defined. But, for many women there's no clearly obvious risk factor other than the fact that she's a woman.

Melanie: So symptoms. Now, we know we are supposed to get our mammograms and we get them every year. Is there something a woman can do to catch it earlier, then maybe her yearly mammogram?

Dr. Citrin: Well, we do advise women to check their breasts regularly. I tell women, you should be familiar with how your breasts feel. You know, the breast changes during a woman's monthly cycle because of estrogen stimulation. The best advice is simply this, check your breasts regularly, if you feel anything in the breast that is different or feels strange to you, different from the rest of the breast tissue or the other breast, then go see a knowledgeable doctor. See a knowledgeable doctor because it's very important to recognize that sometimes breast cancer usually produces a lump in the breast that sometimes can produce very subtle changes only. So, it's as well to see someone, a doctor who is really familiar with breast disease.

Melanie: Now, when we've done that, we've had our mammogram, we go then for that dreaded diagnostic mammogram after maybe they've seen something suspicious. You know, then the doctor says "ok, you know, this is what we're thinking." Maybe there is a needle biopsy or a core biopsy, stereotactic, whatever involved. So, once the diagnosis is made, then Dr. Citrin, then what? What is going on in treatment for breast cancer today?

Dr. Citrin: The first piece of advice to give any woman who is newly diagnosed with breast cancer is this, do not panic. The vast majority of woman diagnosed with early stage breast cancer today can confidently expect to be cured of their disease. That's very important to recognize that fact. I say, don't panic because sometimes doctors will almost rush patients into making decisions regarding treatment and that is not in a woman's best interest. There has been a huge change in how we approach breast cancer. I've seen a paradigm shift. The old concept was, diagnosis of breast cancer, do surgery immediately and then after surgery, either lumpectomy or mastectomy will decide what else has to be done. That has all changed. You mentioned a core biopsy before. A core biopsy gives us enough breast tumor tissue that we can accurately assess the disease. Not only the stage of the disease, in other words, how much cancer is present and where is it, but also the type of breast cancer. Because, there have been tremendous advances in our understanding of the different types of breast cancer. And very often, surgery is not the first treatment which is required. So my advice is this, do not panic. By all means see a surgeon, but before any treatment is given the patient should also see a medical oncologist, particularly, if possible, a medical oncologist who specializes in breast cancer. Because treatment today is very very different from what it was even five years ago.

Melanie: So speak about what the treatment is that is different from five years ago. So, you know, you mentioned lumpectomy and not rushing into surgery, not panicking, seeing a doctor that you trust, a medical oncologist that has plenty of experience with breast cancer...then what? If you've done the core biopsy, you've gotten the information that you need, what then are some of the treatments available? So they are not so scary for the women listening Dr. Citrin.

Dr. Citrin: There is really two different forms of treatment. There is what we call local treatment, which means treatment for the tumor in the breast and also to check the lymph nodes in the armpit, in the axilla. There's also a need for what we call systemic treatment, which is treatment for the rest of the body. Now, that may be as simple as taking a hormone blocking pill or may involve chemotherapy. And in each of these areas; surgery, radiation and drug treatment, there have been tremendous advances over the last five to ten years. If I had to characterize it, I'd say the following, "The approach now is, we want to do everything to cure the patient, but we don't want to over-treat the patient." And secondly," the buzzword is kind of personalized medicine." We now recognize that each and every patient and every tumor is different. And so the treatment has to be tailor made to the individual patient and her disease. There is no longer one size fits all.

Melanie: You know, people are afraid of things like mastectomies. Obviously, women have been seeing women with scarves on their heads for years. Are there changes in the types of surgery and in the chemotherapies that are received?

Dr. Citrin: Yes. There's been advances in all three different basic forms of treatment; surgery, radiation and drug treatment. It's hard in nine minutes to try and describe them all to you, but let me just say this...most women diagnosed with early stage breast cancer today do not require mastectomy. There are some special cases where mastectomy is still required. For example, if there's multiple tumors in the breast, or if there's a very large tumor, or if the patient has the breast cancer gene, the BRCA gene. But, outside those kind of special kind circumstances, mastectomy is generally not required. A lot of women seem to think "Well, if the whole breast is removed my chances of cure are much better." That is not true. The cure rate for limited surgery, a lumpectomy, the cure rate in most women is exactly the same as for mastectomy. And obviously, cosmetically and functionally and psychologically it is much more acceptable. So, that's surgery.

Melanie: Now, Dr. Citrin, in just twenty seconds...wrap it up for us. Give us your best advice and hope for the advances in breast cancer.

Dr. Citrin: Best advice is, if a woman feels anything abnormal in her breast, she should not panic. She should seek medical treatment immediately. Before starting treatment, at the very least, she should see a surgeon and a medical oncologist. And finally, when the specialists who are treating her develop a treatment plan, she should stick with that plan and make sure that she follows the treatment recommendations.

Melanie: Thank you so much Dr. Dennis Citrin. You're listening to Managing Cancer. For more information you can go to cancercenter.com, that's cancercenter.com. This is Melanie Cole, thanks for listening.

Navigating a Diagnosis of Lung Cancer

Lung cancer is the leading cause of cancer death in the US. Understanding lung cancer risk factors and symptoms can help you make a more informed treatment decision.

Additional Info

Segment Number 3
Audio File managing_cancer/1338ct4c.mp3
Doctors Gershenhorn, Bruce
Guest Bio Dr. Gershenhorn is board certified in medical oncology, hematology and internal medicine. He earned an osteopathic medical degree from the Philadelphia College of Osteopathic Medicine. He completed an internal medicine residency at Beth Israel Medical Center in New York, New York. In addition, Dr. Gershenhorn completed a fellowship at Montefiore Medical Center in Bronx, New York, where he served as Chief Fellow in the Department of Hematology/Oncology. He was honored with an award for his accomplishments as Chief Fellow. Before pursuing an education in medicine, Dr. Gershenhorn completed a bachelor's degree in biology at Lehigh University in Bethlehem, Pennsylvania. Among the types of cancer he treats are thoracic cancers, gastrointestinal cancers (e.g., cancer of the esophagus, stomach, pancreas), renal cell cancer and prostate cancer.
Transcription Melanie Cole (Host): Lung cancer is the leading cause of cancer death in the US. Understanding lung cancer risk factors and symptoms can help you make a more informed treatment decision, my guest is Dr. Bruce Gershenhorn, he's a medical oncologist with Cancer Treatment Centers of America. Welcome to the show Dr. Gershenhorn. Let's start. We are going to be talking about navigating the diagnosis of lung cancer, but I'd like you to give us a little bit of risk factors. Who is at risk lung cancer? And tell us some of the symptoms that might send us to the doctor.

Dr. Bruce Gershenhorn (Guest): Sure, first of all it's great to be here and thanks for having me. As far as risk factors for lung cancer, it's smoking, smoking, smoking. Prior to the advent of cigarettes being around, lung cancer was a very rare cancer. Since the advent of cigarettes, smoking has risen to a point where it's actually the leading cause of cancer death in the United States amongst men and women. There are some other risk factors that are associated with lung cancer, such as specific exposures, like asbestos exposure, other environmental exposures, but those are much less common. Cancer is a disease that happens to smokers and outside of smoking it's very unlikely to get the disease.

Melanie: But, are there non-smokers that do get lung cancer?

Dr. Gershenhorn: There are, there are. That population is slowly on the rise, but the vast majority of people who develop lung cancer are smokers. So, it is clearly the leading risk factor for developing this disease.

Melanie: Now, what about symptoms? Some people are coughers, some people are not. Some people have chest pain, but it could be anxiety. How do you know? And, when do you come see someone?

Dr. Gershenhorn: You know, that's a great question. Sometimes lung cancer develops in an asymptomatic person, meaning a person who develops no symptoms. But, the common presenting symptoms with lung cancer are cough, sometimes people even cough up little bits of blood. Sometimes people develop a little bit of weight loss. Shortness of breath or episodes of difficulty breathing and sometimes just an overall feeling of not well-being...people feel somewhat sick. But, the major symptoms at presentation are related to cough and shortness of breath.

Melanie: OK, so now if somebody gets that hideous diagnosis, that they don't want to get, but, they've gotten this diagnosis...they've gone to see you. You've determined this is what they have. Then, what's the first beginning treatment? Because, it's not necessarily a no hope situation that everyone thinks it is...is it?

Dr. Gershenhorn: No, no no. Symptoms and the disease management has changed dramatically over the past five to ten years. The first thing I would say, is when someone has a cancer diagnosis, is that obviously, the stress and the fear and the anxiety associated with it needs to be addressed, but you need to be educated. You need to understand what options are out there. Specifically, what type of lung cancer you have, because there are different types. The more we learn about the disease, the more we are subtyping this disease into different population. You need to know the stage. You need to understand exactly how advanced this is and what your options are based on the stage. So, you need to educate yourself and find a team of professionals around you that can give you the guidance and guide you through this difficult situation.

Melanie: Once you've staged it. Stage 1 being the earliest stage. Then, you look at the courses of treatments, so what treatments are out there for lung cancer?

Dr. Gershenhorn: For the first stage of lung cancer, the treatment revolves around surgery. Removing the tumor from the body, usually via a technique called a lobectomy. For the second stage of lung cancer, which is a little more advanced than the first stage, when the glands near the tumor become swollen with cancer, the treatment also revolves around surgery. Usually, after surgery for the second stage we do give chemotherapy, which will lower the risk of the cancer coming back. For the third stage of lung cancer, which is when the tumor usually involves some of the lymph nodes a little further away from the tumor called the mediastinum, the treatment mainly revolves around radiation and chemotherapy given together. The role for surgery in the third stage is a little bit more questionable and you have to address that with your specific medical provider. For the fourth stage, which is when the lung cancer actually spreads outside the lung to distant sites. For example, if the lung cancer spreads to the liver or if it spreads to the other lung, or the bones, or sometimes even the brain, the treatment revolves around chemotherapy.

Melanie: OK. So, targeted treatments. You know, there have been a lot of new advances. In lung cancer treatment, it's pretty exciting the things you can do now. Speak about some of the targeted treatments and targeted therapy.

Dr. Gershenhorn: You know, this is a great question. This is actually the key involving paradigm in lung cancer right now and where a lot of the advances are being made. There are specific driver mutations, as we call it in oncology. Which are basically the gas pedal, that make these cancers spread, that make them divide, that make them go to other places and makes them hurt people. There is cutting edge technology now, to try to determine what are the driver mutations in the cancer and are there drugs out there that are different from the typical chemotherapy drugs that kill cells that are undergoing cell division. They can actually target the driver and shut down the driver or put the brakes on and stop the cancer from growing and be much more targeted in that specific to the cancer in minimizing side effects. So, for example EGFR has been a huge advance. It's a mutation that is present in the cancer and predominantly this actually happens in non-smokers. I know we talked a little about smoking as a risk factor. But, in the non-smokers who develop lung cancer, EGFR mutations are actually fairly common. These mutations are again, what's driving the cancer and there's pills for example, Erlotinib or Tarceva is a pill that can shut down that driver and could profoundly affect someone's prognosis from the lung cancer. There are other drivers that have been determined now that also have targets, such as, ALK or alk as it's called. There are other ones, such as ROS1, such as B-RAF, such as HER2, there's a lot of other drivers that are being picked up, that are really sub-stratifying lung cancer into many different cancers. And, if we could find the driver that targetable via a drug, then we can do a lot to help these patients, rather than just use standard chemotherapy, that affects cell division and has the side effects that most people think of when they think of chemotherapy.

Melanie: Well, you segued beautifully into the next thing, Dr. Gershenhorn. Side effects, and when you talk about EGFR and ALK and people hear these things and they are terrified of the treatments side effects, not always only the treatment itself. We don't have a lot of time left, but can you please speak about dealing with those side effects.

Dr. Gershenhorn: Yeah. At Cancer Treatment Centers of America, we have a very integrative model, where we feel like naturopathic medicine, nutritional care, mind-body therapy, lots of other support services can help enable someone and get them more involved in dealing with some of the side effects from drugs. The typical chemotherapy side effects which include nausea, and sometimes hair loss and a poor appetite, low blood counts or risks of infection. We have newer and newer treatments available to target those side effects, to make the treatments more palatable.

Melanie: More palatable. That's so important and in the last twenty seconds, Dr. Gershenhorn, can you please just wrap it up , give the people listening some hope about the advances in lung cancer treatments.

Dr. Gershenhorn: So, I think that being an oncologist now that specializes in lung cancer, I'm very excited about the future. I think that learning more about specific targets that we can attack via certain drugs, learning more about the immune system and how to harness the power of the immune system to help fight cancer holds great hope for people that are fighting this difficult disease.

Melanie: You're listening to Managing Cancer. For more information you can go to cancercenter.com, that's cancercenter.com. This is Melanie Cole for Cancer Treatment Centers of America.

What is Orthopedic Oncology?

Orthopedic oncology specializes in the treatment of men and women with bone cancer, sarcoma or cancer that has spread to the bone from other areas of the body.

Additional Info

Segment Number 2
Audio File managing_cancer/1338ct4b.mp3
Doctors Schmidt, Richard
Guest Bio Dr. Schmidt graduated from Pennsylvania State University College of Medicine in 1980. He completed an internship, orthopedic residency and fellowship in orthopedic research at the Hospital of the University of Pennsylvania in 1985. Additionally, Dr. Schmidt completed an orthopedic oncology fellowship at Shands Hospital at the University of Florida in Gainesville. Dr. Schmidt specializes in sarcomas, which includes cancer of the bone and soft tissue. He also has significant experience in treating metastatic bone cancer. He is known for his expertise in the surgical management of limb salvage surgery.
Transcription Melanie Cole (Host): Orthopedic oncology specializes in the treatment of men and women with bone cancer sarcoma or cancer that has spread to the bone from other areas of the body. My guest is Dr. Richard Schmidt. He's the medical director of orthopedic oncology. Welcome to the show, Dr. Schmidt. Why is it important to even have a Department of Orthopedic Oncology?

Dr. Richard Schmidt (Guest): Well, Melanie, it's a great question. It's important because patients with bone or soft tissue cancers deserve a specialist. Today, we have many specialists, so people have been programmed and taught that if they have a sports injury, they need a sports orthopedic surgeon; if they have a back problem, a neurosurgeon. We really need to get there with patients with bone cancer as well. They need to have specialists in orthopedics who deal with that particular problem, because those patients are different than the patient with ordinary orthopedic needs.

Melanie: When cancer has spread to the bone, it doesn't typically start there, does it?

Dr. Schmidt: No. That's right. Most of the time, when you see someone with bone cancer, it's because it has spread from what we call the paired midline structures, which is thyroid, breast, lung, prostate, and kidney.

Melanie: When it has spread to the bone, people often feel hopeless at that point, Dr. Schmidt,
but that's not really the case, because even metastatic cancers that have spread to the bone, there are certainly plenty of treatment options. Explain a little bit about the treatment of bone cancer and some pain management as well.

Dr. Schmidt: Certainly. You bring up a very good point. It's a shame that often patients will get diagnosed with metastatic or stage 4 cancer and they'll look upon that as a quick terminal illness. It is not unusual for many healthcare providers still to convey that impression. But we know today that patient with stage 4 breast cancer can live for many, many years, and they really shouldn't look upon this as an acute illness but more of a chronic condition. Years ago, when patients got diabetes, right before insulin, insulin pumps, it was considered a very short lifespan. But nobody looks today at diabetes as a terminal illness. It's a chronic condition, and that's particularly applicable to patients with breast cancer. The treatment modalities have absolutely skyrocketed today in terms of hormonal manipulation, targeted therapies, and that's why many more women today are developing metastatic lesions. So it sounds like bad news, but it's actually because they're living longer because they're now out there getting treatment. They're living 10 to 15 years. They develop a bone met and those can be treated with a combination of many modalities—radiation therapy, medical oncology, and then orthopedic stabilization type of procedure. What we don't want to have happen is a patient to get disconnected from their care, develop a lesion in their bone, develop a hole in their bone, and then break that bone. We aim for what is called prophylactic fixation. We've all heard the saying "a stitch in time saves nine" with things like that, and it couldn't be truer for the patient with, for instance, metastatic breast cancer to bone.

Melanie: So the pioneering advances in the treatment of bone cancer—radiation, surgery, chemotherapy—these are all treatments that you can do. Are these treatments, Dr. Schmidt, ways to get rid of the cancer? Is this a cancer that can go into remission and you can, as you said, live many years with?

Dr. Schmidt: Yes. Because of a lot of the hormonal therapies that we have today and a lot of the bone-stabilizing drugs—we call them bisphosinates—we can actually put patients with metastatic bone cancer, particularly classic breast, for example, into a state of remission and stabilize them so that they can enjoy their life and their children and maintain a very active lifestyle.

Melanie: So you're treating it more like a chronic condition rather than a terminal illness?

Dr. Schmidt: Exactly.

Melanie: Now, what about pain management? Because bones can be very painful. As you said, you don't want to get to the point where someone does fracture or break a bone, and I know that bone pain is painful. What do you do for people while they're going through these treatments?

Dr. Schmidt: If we identify a patient with metastatic, let's say breast cancer to bone, and we identify it early, the doctor and the patient are vigilant, it shows up on a bone scan or an x-ray, typically, those patients can be treated with radiation therapy. Or, if they have sizeable lesions in their bone which put them at risk for fracture, we want to do what is called a prophylactic stabilization of their femur using an intramedullary rod. We do many of those surgeries at Midwestern Regional Medical Center, and those surgeries can be done in less than an hour to two small incisions under x-ray guidance, and this prevents the patient from breaking. It also relieves them of their pain.

Melanie: That's wonderful, because it takes the pressure off the bone having to support itself if it's got a lesion on it or something. You've talked about radiation and the rod that you can use and some prophylactic things. Now, what if they're suffering from some other issues at the same time, bone-related, arthritis? There are so many things that we get as we age. How do all of these tie together?

Dr. Schmidt: That's a great question. Often we'll see patients who have metastatic cancer to bone who develop conditions such as arthritis who are often turned away from getting a joint replacement because they're kind of looked as a patient with a stigmata, they're too complicated. And often, we will see patients here at Midwestern -- for example, I just saw a lady with myeloma. She's apparently in remission. She needs a total hip because of arthritis. But the doctors in her area would not do her total hip arthroplasty because they've looked upon her as too much of a risk, too much of a complicated patient. So here we have a patient who can enjoy the quality of their life even though their cancer has been successfully treated because they are looked upon as more of a complex patient, more of a risk situation. Often, we'll see patients with arthritis and do their joint replacements as well even though that arthritis is not cancer-related. But as a whole, they should still be considered as a cancer patient but still get the treatments that everyone else can get to maintain independence.

Melanie: And that's really what's so important is that quality of life. Now, talk about the importance of bone scans for a minute. What do those show us?

Dr. Schmidt: Bone scan is basically a very simple test. What it does is it lights up an area of abnormality in your bone. I'd liken it to the oil light in your car. For example, when you're oil light comes on, it just tells you that you have an oil problem. It doesn't say exactly what the problem is, but it obviously means that you should get your oil checked out, get your car checked out. The bone scan is like an early warning system with the presence of early metastatic disease. In this situation with our patients, it's so much better to be proactive. Know that there is a problem even before it becomes clinically apparent with pain so that you can follow up an x-ray or an MRI study. Often, patients who get a bone scan and will see an area of abnormality, and it turns out to be nothing. But you follow it. At least you know what's going on. You have an idea of what their bone scan looks like as a baseline study so that you can then compare to other studies down the road. I like bone scans very much. It's an early warning system. It maintains a proactive approach to cancer care. I lean heavily on patients getting regular bone scan studies.

Melanie: In the last minute that we have, Dr. Schmidt, your best advice and most important info you'd like the listeners to hear.

Dr. Schmidt: I would tell patients, be your own advocate, be vigilant in your own cancer care. Don't be a passive traveler in your cancer journey. If you have a problem, tell your doctor. If you develop bone pain, don't let yourself be put into a situation where, "Well, don't worry about it." Demand an x-ray, demand a bone scan, demand an MRI. Be proactive, be vigilant, be part of your cancer care, and just stay in touch with your physicians but be involved as the champion of your own diagnosis.

Melanie: Patient advocacy, self-advocacy is certainly wonderful advice. Thank you so much, Dr. Richard Schmidt, medical director of orthopedic oncology. The cancer experts at Cancer Treatment Centers of America have extensive experience in properly staging and diagnosing the diseases and developing a treatment plan that's tailored to your specific types of cancer. This is Managing Cancer with Cancer Treatments Centers of America. I'm Melanie Cole. Thanks for listening.

Advances in Prostate Cancer Treatments

For most men diagnosed with prostate cancer, there are many treatment options. How do you decide which one is best for you?.

Additional Info

Segment Number 1
Audio File managing_cancer/1338ct4a.mp3
Doctors Pisick, Evan
Guest Bio Dr. Pisick earned a bachelor's degree in biology at the University of Rochester; he earned a medical degree from Boston University. Thereafter, Dr. Pisick completed an internship and residency at Mount Sinai Medical Center in New York City, followed by a fellowship at Tufts Medical Center in Boston. His extensive research on small cell and non-small lung cancer, as well as malignant mesothelioma, has been published in a variety of scientific journals, including Hematology/Oncology Clinics of North America, Anticancer Research and the Journal of Experimental Therapeutics and Oncology.
Transcription Melanie Cole (Host): We're talking today about advances in prostate cancer treatments, and my guest is Dr. Evan Pisick. He is a medical oncologist. Welcome to the show, Dr. Pisick. Can you tell us a little bit about prostate cancer? Give us a working definition.

Dr. Evan Pisick (Guest): Prostate cancer obviously is cancer of the prostate and also one of the most common non-melanoma skin cancers in men. In 2013, upwards of 240,000 men will be diagnosed with prostate cancer of all stages.

Melanie: Are there certain risk factors that men and their wives should be aware of that might predispose them to getting prostate cancer?

Dr. Pisick: Yes. One of the most common risk factor includes age. The older you get, the more likely you are to have prostate cancer. In fact, over the age of 60, one in 15 will be diagnosed. Also race is important. African-American men develop prostate cancer about, on the average, 10 years younger than Caucasian or Hispanic men. Family history is also very important so men who have brothers, fathers, uncles, sons with prostate cancer may be at higher risk for developing prostate cancer as well as obesity, diets high in saturated fat. There are other genetic syndromes as well, but they are much rarer.

Melanie: If somebody is going to see their doctor on a regular basis, which is what we certainly would encourage, but they are having some symptoms that they haven't really had before, let the listeners know what they might be experiencing that would send them to their doctor.

Dr. Pisick: Symptoms that men can look for include frequent urination, incomplete voiding of the bladder, urinating a lot at night while sleeping, erectile dysfunction, blood in the urine, blood in the semen. Those are some of the symptoms that if men are developing, they should be seeing their physicians about. The other issue with these symptoms is that they can come on very slowly. So they will not happen overnight. It is something that men will notice over time but may get used to, so they have to be more aware of their urinary habits.

Melanie: And it's important for men to see their doctor regularly, isn't that true, Dr. Pisick? Because as men age, their prostate does grow. And so that goes along with it, and they see their doctor on a regular basis.

Dr. Pisick: Correct. A lot of these symptoms that I described aren't only associated with prostate cancer. They're also associated with a benign enlargement of the prostate, which is treated in very different ways.

Melanie: So then, how would cancer be diagnosed?

Dr. Pisick: Prostate cancer is diagnosed by biopsy of the prostate, where parts of the prostate are removed that we can look at under the microscope. The men who do have prostate biopsies are usually men in which high suspicion is noted, including elevated PSAs, clinical histories, family histories, as well as physical exam of the prostate on what's called the digital rectal exam if the prostate is noted to be hard, irregular, swollen, or even if nodules are palpated.

Melanie: Dr. Pisick, if you would, please explain the PSA test. What are the normal ranges? Men get these numbers; they don't quite always know what they mean. And explain the Gleason score and the clinical staging, if you would.

Dr. Pisick: PSA is a blood test which stands for prostatic-specific antigen, which is a prostate noted in the blood made by prostate cells, both normal cells as well as cancer cells. This number, the range changes as men age. The range you use for a 50-year-old may not be the same range you use for an 80-year-old. The Gleason score is a pathologic diagnosis. When we do a biopsy and our pathologist looks at the cancer under the microscope, they basically determine its pattern from what they can see. It's based on a scale of 2 to 10. You have two scales of one to five. The primary growth pattern, which is the most common pattern you see within the specimen, gets a number of one to five. What we call the secondary pattern, which is the second most common pattern that is under the microscope, also gets a score under one to five. Those numbers are added together. Gleasons of six and lower are considered low risk, while Gleasons 8 to 10 are considered more of a high-grade tumor. The clinical staging of prostate cancer is based on digital rectal exams—how does the prostate feel under an exam with a finger itself. We also can use ultrasound to the prostate as well as MRIs of the prostate to get a picture of what the prostate looks like. Can we see cancer invading from the prostate into nearby structures such as bladder or rectum? Are there enlarged lymph nodes? Are the seminal vesicles involved? Is the cancer going through the capsule, which is the lining of the prostate? By using PSA, Gleason score, and clinical staging, we can develop a clinical risk in which patients can be low risk, intermediate risk, or high risk. For patients who have localized disease within the prostate, it helps us to better stratify when discussing treatment options moving forward.

Melanie: For most men, they'll have many treatment options, and the tricky part is then how to come to the decision that's best for them. So speak about some important developments in prostate cancer treatment.

Dr. Pisick: Many of the advances that have recently come in prostate cancer treatment apply mostly to men with metastatic prostate cancer. So that's cancer that has already spread beyond the prostate to lymph nodes, bones, in other internal organs. These are also men who, in their initial treatment, will receive what's called androgen deprivation therapy, which is very commonly referred to hormonal therapy. What we are accomplishing there is we give medications to get men to stop making testosterone. Low testosterone levels don't allow the prostate cancer to grow. But over time, these cancers learn to grow in low-testosterone environment, and thus we have to use other therapies. In the last several years, several have been developed, such as Provenge which is a vaccine therapy some people refer to as immunotherapy, in which white blood cells are removed from the body and actually conditioned to go back and fight prostate cancer. A new drug called Xofigo or radium-223, which is a radioactive drug that is infused into the patient on a monthly basis and actually binds into bone in areas in the bone where prostate cancer likes to grow. The only downside to this drug is that it does not fight cancer that is in lymph node or other organs, only in bone. But it is also a great drug.

Melanie: Dr. Pisick, let me ask you about surgery for a minute, because many men think that if they're diagnosed with prostate cancer, they're going to have to have their prostate removed. Surgery has advanced quite a bit these days, so tell us a little bit about surgery for prostate cancer.

Dr. Pisick: Men who have clinically localized disease, we have the surgical option. One is an open prostatectomy, where, as it says, it's an open procedure. Men are opened up, prostate and lymph nodes are removed by a trained urologist. They also have the new robotic and laparoscopic procedures, where small holes are made into patients, where probes and other devices are inserted, and the prostate and lymph nodes are removed as well.

Melanie: Can you please tell us the most important information that you would like men listening to hear about prostate cancer?

Dr. Pisick: I think the most important thing for men to know about prostate cancer is to be encouraged to talk with their doctors about their risk for prostate cancer and whether they should or should not be tested; second, to encourage men to know that they have options about prostate cancer treatment should they be diagnosed with either early disease or late-stage disease; and that the Cancer Treatment Centers of America are committed to finding the right treatment for them and offers an integrated approach to care that many men may benefit from.

Melanie: You're listening to Managing Cancer with Cancer Treatment Centers of America. Thanks for listening. This is Melanie Cole. Have a great day.

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