whatdoctorsknow.

com
On Call with Dr. Porter
Steve Porter, MD
Publisher and Chairman
October is Breast Cancer Awareness month and while
this is a great cause, we have to remember there are
many other health issues affecting people of all ages.
In reality, good health is a 24 hours a day, seven days
a week effort. This means good health requires every
single one of us to look carefully on a daily basis at
our own body and define what measures we need to take
for a longer and healthier life. Do we exercise? Do we
eat right? Do we visit our doctors on a regular basis?
As parents, we have the added responsibility to look at our
children and determine what tests, what immunizations
and what check-ups they need to live a healthy life.
Thats why, along with Breast Cancer Awareness,
we have included information and awareness this
month on Spina Bifida, Lupus, and more. There is
a great deal of support out there for so many.
While we make every effort to do our part in bringing
attention to the causes, I would like to acknowledge
the many volunteers, and the organizations that work
hard to make a positive difference. These groups and
these causes certainly face a daunting task, but if the
efforts change just one life, its a job well done.
I hope you enjoy this issue. And as always, if you have
any suggestions, questions or would like a specific feature,
drop us a line at: editor@whatdoctorsknow.com
whatdoctorsknow.com
WHAT DOCTORS KNOW
And you should, too!
P18
P34
Taking Control
09 New Hope for Women with Advanced Breast Cancer
17 The Psychology of Healing
18 Just the Facts: Spina Bifida
22 Treatment Advances for Hereditary Angioedema
26 CDC Vital Signs: Cancer Screening/Colorectal & Breast Cancer
Health Hints
34 HealthWatchMD: Combatting Fall Allergies
36 Breast Cancer: Not just for Women
38 Breathe Smarter
40 New Breast Imaging System
42 Reuniting Mended Hearts
whatdoctorsknow.com
Vol. 1 Issue 9
01 On Call With Dr. Porterr
04 Meet Our Doctors
06 Medicine in the News
26 CDC Vital Signs: Cancer Screening/
Colorectal & Breast Cancer
34 HealthWatchMD: Combatting
Fall Allergies
In Every Issue
P56
Contents
14 The Acceptance Letter
10 Understanding Lupus
44 Could Americas
Physicians Be Facing a
State of Emergency?
On The Cover
Inquiring Minds
52 Early Breast Tumors Deadly Path
54 A Hospitalist?
56 What We Dont Talk About When
We Dont Talk About Sex
58 Breast Cancers Journey to the Lungs
60 Colon Cancer. Genetics or Bad Luck?
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Meet Our Doctors
Copyright 2012 by What Doctors Know, LLC. All rights reserved. Reproduction of this magazine,
in whole, or in part is prohibited unless authorized by the publisher or its advertisers. The
Advertising space provided in What Doctors Know is purchased and paid for by the advertisers.
Products and services are not necessarily endorsed by What Doctors Know,LLC.
Vicki Lyons, MD
Founding member
and chairman of the
editorial advisory
board of What Doctors
Know, Dr. Lyons is a
board certified and fellowship trained
allergist and immunologist practicing in
Ogden, Utah. She has been practicing
for 20 years. Contact Dr. Lyons at
(801)387-4850 or www.vicki-lyonsmd.com.
Steven Porter, MD
Founder and
publisher of What
Doctors Know, Dr.
Porter is recognized
as one of the top
gastroenterologists in the country.
He is the medical director of the
endoscopy lab at a leading hospital in
Ogden, Utah and has been practicing
for more than 25 years. Contact
Dr. Porter at (801)387-2550.
Calling All Doctors. Our readers want to hear from you. What healthcare
issues do you want to address? What do you want to tell patients all
over the country? Whats new in your practice, in your specialty?
Drop us a line and let us know about any healthcare topic you want
to address in What Doctors Know. Remember, we want to inform and
educate our readers. We know, an informed reader has the opportunity
to live longer and happier. You can be part of that healing process.
Our readers look forward to hearing from you.
Send story ideas to: submit@whatdoctorsknow.com
Timothy J. Sullivan, MD
Contributing editorial
advisory board member of
What Doctors Know, Dr.
Sullivan spent 25 years
in full-time academic
medicine at Washington University,
University of Texas Southwestern
Medical School, and Emory University.
He currently has a full-time allergy
and immunology practice in Atlanta,
Georgia and is a clinical professor
at the Medical College of Georgia.
Contact Dr. Sullivan at (404)255-2918
or www.trittbreatheandsleep.com.
Carlo M. Croce, MD
World renowned Italian
physician-researcher.
Dr. Croce is currently
Director of Human
Cancer Genetics,
Chairman of Molecular Virology,
Immunology and Medical Genetics,
and Director of the Institute of
Genetics at The Ohio State University
Comprehensive Cancer Center.
Kathy Albain, MD
Professor in the
Department of
Medicine, Division
of Hematology/
Oncology at Loyola
University Chicago Stritch School
of Medicine. Dr. Albain has special
interests in Breast Cancer, Cancer
in Seniors, Cancer Survivorship,
Chemoprevention of Breast Cancer,
Chemoprevention of Lung Cancer,
Lung Cancer, and Mesothelioma
whatdoctorsknow.com
WHAT DOCTORS KNOW
And you should, too!
Published by
What Doctors Know, LLC
Publisher and Chairman
Steve Porter, MD
Editorial Advisory Board
Vicki J. Lyons, MD, Chairman
Editorial and Design Director
Bonnie Jean Thomas
Senior Designer
Suki Xiao
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Cayden Chan
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Birmingham, AL- New research from the University of Alabama at Birmingham casts
doubt on the long-standing belief that the vaccine for shingles should not be given
to patients taking biologics for auto-immune diseases such as rheumatoid arthritis.
The findings were published in the Journal of the American Medical Association.
Shingles, or herpes zoster, is a reactivation in adults of the varicella virus that causes
chicken pox in children. The U.S. Food and Drug Administration recommends a vaccine
for shingles for people older than 60, but not for individuals taking anti-tumor necrosis
factor therapies or other biologics commonly used to treat immune-mediated diseases.
The vaccine is a live attenuated vaccine, and the long-standing opinion in the
medical community is that patients with certain immune-related diseases receiving
immunosuppressive therapies like biologics are at increased risk of contracting varicella
from the vaccine itself, said Jeffrey Curtis, M.D., lead author of the study and associate
professor in the division of Clinical Immunology and Rheumatology in UABs School of
Medicine. However, that opinion has not been definitively bolstered by scientific studies.
Curtis and fellow researchers examined 463,541 Medicare patients 60 years and
older with five immune-related conditions: rheumatoid arthritis, psoriasis, psoriatic
arthritis, ankylosing spondylitis and inflammatory bowel disease. There were 633
patients who were exposed to biologics at the time of vaccination or within the next
42 days, the time normally associated with potential adverse reactions to a vaccine.
Curtis reports that none of the 633 patients developed shingles in that time period.
Shingles vaccine OK for people
with immune disorders
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Miami, FL- Miami Childrens Hospital (MCH) has received three 2012
Kids Crown Awards from South Florida Parenting magazine. The MCH
recognition includes: ?Best Pediatric Hospital in Miami-Dade County ?Best
Pediatric ER in Miami-Dade County ?Best in Special Needs in Miami-
Dade County, awarded to MCH Rehabilitation Services- Miami Lakes
Kids Crown winners are chosen annually by the readers of South
Florida Parenting. This year, the magazine received thousands of votes
identifying readers favorite places and things to do in South Florida. The
winners are broken up into five categories: Best-Kept Secrets, Family Eating, Family
Outings & Activities, Family Shopping & Services and Important Matters.
Chapel Hill, NC- New research
led by a medical geneticist at the
University of North Carolina School
of Medicine points to an increased risk
of autism spectrum disorders (ASDs)
among individuals whose parents or
siblings have been diagnosed with
schizophrenia or bipolar disorder.
The findings were based on a case-
control study using population registers
in Sweden and Israel, and the degree to
which these three disorders share a basis
in causation has important implications
for clinicians, researchers and those
affected by the disorders, according
to a report of the research published
online July 2, 2012 in
the Archives of
General
Psychiatry.
Autism, schizophrenia and bipolar disorder
may share common underlying factors
The results were very consistent in
large samples from several different
countries and lead us to believe
that autism and schizophrenia
are more similar than we had
thought, said Patrick F. Sullivan,
MD, FRANZCP, professor in the
department of genetics and director
of psychiatric genomics at UNC.
Sullivan and colleagues found that the
presence of schizophrenia in parents was
associated with an almost three times
increased risk for ASD in groups from
both Stockholm and all of Sweden.
Schizophrenia in a sibling also was
associated with roughly two and a half
times the risk for autism in the
Swedish national group
and a 12 times greater
risk in a sample
of Israeli military
conscripts. The
authors speculate
that the latter
finding from
Israel resulted
from individuals
with earlier onset
schizophrenia,
which has a higher
sibling recurrence.
Bipolar disorder showed a similar
pattern of association but of a lesser
magnitude, study results indicate.
Our findings suggest that ASD,
schizophrenia and bipolar disorder
share etiologic risk factors, the authors
state. We suggest that future research
could usefully attempt to discern risk
factors common to these disorders.
Study co-authors with Sullivan
are Cecilia Magnusson, MD,PhD,
Christina M. Hultman, PhD,
Niklas Langstrom, MD, PhD,
Paul Lichtenstein, PhD, Marcus
Bowman, BS, Christina Dalman,
MD, PhD, Anna C. Svensson, PhD
and Michael Lundberg, MPH,
Karolinska Institute, Stockholm,
Sweden; Abraham Reichenberg, PhD,
Kings College, London, England;
Michael Davidson MD, and Mark
Weiser, MD, Sheba Medical Center
and Tel Aviv University, Israel; Eyal
Fruchter, MD Israeli Defense Force
Medical Corp, Ramat Gan, Israel.
The study was funded in part by The
Swedish Council for Working Life
and Social Research, the Swedish
Research Council and the Beatrice
and Samuel A. Seaver Foundation.
Miami Childrens Hospital Receives
Three Kids Crown Awards
DRIVE4COPD, a public education and awareness program
of the COPD Foundation, invites you to participate in the
Tournament will take place at participating golf courses
around the country between August and November 2012.
You can participate by sponsoring a foursome at one of
the participating courses, by paying to play in a foursome
yourself, or by making a charitable contribution to the
COPD Foundation in support of the DRIVE4COPD
Tee-Time Tournament. Winners in local tournaments
tournament to be held at the Biltmore Golf Course in
Coral Gables, Florida on November 16, 2012.
Money raised by the DRIVE4COPD Golf Tournament will help the Foundation
to raise awareness, encourage risk screenings, increase research, and improve
the quality of life for individuals living with COPD.
Find an Event Near You and Register Online Today:
www.DRIVE4COPDGolfTour.com
Event Date Course Location
August 31, 2012 Eagles Landing Stockbridge, GA
September 7, 2012 The Crossings Golf Club Glen Allen, VA
September 14, 2012 Waters Edge Golf Club Worth, IL
September 21, 2012 Loudon Country Club Loudon, NH
September 28, 2012 Jonathans Landing Magnolia, DE
October 12, 2012 Cabarrus Country Club Concord, NC
October 19, 2012 Falcon Hills Basehor, KS
October 26, 2012 Chatmoss Country Club (pending) Chatmoss, VA
November 2, 2012 The Golf Club at Champions Circle Fort Worth, TX
November 9, 2012 Palm Valley Golf Club Goodyear, AZ
whatdoctorsknow.com
New
cancer.) Fulvestrant (brand name Faslodex) is given
by injection. It binds to estrogen receptors, thereby
blocking the effect estrogen has on cancer cells.
The study included 707 postmenopausal women
who had metastatic breast cancer that was hormone-
receptor-positive. About half the women were randomly
assigned to receive the standard regimen: treat first with
anastrozole, and after the disease progresses, switch to
fulvestrant. The other half were randomly assigned to
receive anastrozole and fulvestrant in combination.
Women who received the standard regimen survived a
median of 41.3 months. Women who received the two
drugs in combination survived a median of 47.7 months.
Among women who received the standard regimen, it
took a median of 13.5 months for the disease to progress.
Among those who received the drugs in combination,
it took 15 months before the disease progressed.
The combination treatment produced even
greater benefits among women who had
not previously taken tamoxifen.
Side effects generally were similar in both treatment
groups, although only the combination group
experienced the most severe side effects (one
stroke and two pulmonary embolisms). -This
information provided courtesy of Loyola Medicine
A

study co-authored by a Loyola researcher
and published in the New England
Journal of Medicine is offering new hope
to women with advanced breast cancer.
The study found that combining two
drugs that normally are given as single
agents significantly extended the lives of women
with metastatic breast cancer. Kathy Albain, MD, a
breast cancer specialist at Loyola University Medical
Center, is among the main authors of the study.
The study found that women who initially took the drugs
anastrozole and fulvestrant together lived more than six
months longer than women who took anastrozole alone,
with fulvestrant given later when the disease progressed.
"This study is the first to show that combination
hormonal therapy alone without chemotherapy
improves survival in advanced breast cancer,"
Albain said. "This most likely will change the
standard of care for how we treat these patients."
First author is Rita Mehta, MD, of the
University of California at Irvine.
Anastrozole (brand name, Arimidex) is a pill that
is taken daily. It is in a class of medications called
aromatase inhibitors. It works by decreasing the amount
of estrogen the body makes. (Estrogen fuels breast
Breast Cancer
For Women With Advanced
whatdoctorsknow.com 0
A
t least 1.5 million people in the United States have some
form of lupus, with more than 16,000 new cases of lupus
reported annually. Approximately five million throughout
the globe have some form of lupus. These numbers are
estimated because there have been no large-scale studies
to accurately show how many people are affected.
Overall, lupus strikes mostly women of childbearing age (15-44).
However, men, children, and teenagers can develop lupus.
People of all races and ethnic groups can develop lupus, but
women of color are 2-3 times more likely to develop lupus.
If you or a family member has been diagnosed with or are being
evaluated for possible lupus, you want to know as much as possible
about the disease. Here are answers to many frequently asked questions.
Lupus
Understanding
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What is Lupus?
Lupus is a chronic, autoimmune disease that can damage
any part of the body (skin, joints, and/or organs inside
the body). Chronic means the signs and symptoms tend
to last longer than six weeks and often for many years.
In lupus, something goes wrong with your immune
system, which is the part of the body that fights off
viruses, bacteria, and germs ("foreign invaders," like the
flu). Normally our immune system produces proteins
called antibodies that protect the body from these
invaders. Autoimmune means your immune system
cant tell the difference between these foreign invaders
and your bodys healthy tissues ("auto" means "self") and
creates autoantibodies that attack and destroy healthy
tissue. These autoantibodies cause inflammation,
pain, and damage in various parts of the body.
Lupus is also a disease of flares (the symptoms
worsen and you feel ill) and remissions (the
symptoms improve and you feel better). Lupus can
range from mild to life threatening and should
always be treated by a doctor. With good medical
care, most people with lupus can lead a full life.
Lupus is not contagious, not even through
sexual contact. You cannot "catch" lupus from
someone or "give" lupus to someone.
Lupus is not like or related to cancer. Cancer is a
condition of malignant, abnormal tissues that grow
rapidly and spread into surrounding tissues. Lupus
is an autoimmune disease, as described above.
Lupus is not like or related to HIV (Human
Immune Deficiency Virus) or AIDS (Acquired
Immune Deficiency Syndrome). In HIV or AIDS
the immune system is underactive; in lupus, the
immune system is overactive.
What Causes Lupus?
Genes
No gene or group of genes has
been proven to cause lupus. Lupus
does, however, appear in certain
families, and when one of two
identical twins has lupus, there
is an increased chance the other
twin will also develop the disease.
Findings strongly suggest genes
are involved in the development of
lupus. Although lupus can develop
in people with no family history of
lupus, there are likely to be other
autoimmune diseases in some
family members. Certain ethnic
groups (people of African, Asian,
Hispanic/Latino, Native American,
Native Hawaiian, or Pacific Island
descent) have a greater risk of developing lupus, which
may be related to genes they have in common.
Environment
While a persons genes may increase the chance
he or she will develop lupus, it takes some kind
of environmental trigger to set off the illness
or to bring on a flare. Examples include:
ultraviolet rays from the sun
ultraviolet rays from fluorescent light bulbs
sulfa drugs, which make a person more sensitive
to the sun, such as: Bactrim and Septra
(trimethoprim-sulfamethoxazole); sulfisoxazole
(Gantrisin); tolbutamide (Orinase);
sulfasalazine (Azulfidine); diuretics
sun-sensitizing tetracycline drugs such as minocycline
(Minocin) penicillin or other antibiotic drugs such
as: amoxicillin (Amoxil); ampicillin (Ampicillin
Sodium ADD-Vantage); cloxacillin (Cloxapen)
an infection
a cold or a viral illness
exhaustion
an injury
emotional stress, such as a divorce, illness, death
in the family, or other life complications
anything causing stress to the body, such as
surgery, physical harm, pregnancy, or giving birth
Although many seemingly unrelated factors can
trigger the onset of lupus in a susceptible person,
scientists have noted some common features
among many people who have lupus, including:
exposure to the sun
an infection
being pregnant
giving birth
a drug taken to treat an illness
However, many people cannot
remember or identify any specific
factor or event before they
were diagnosed with lupus.
Hormones
Hormones are the bodys messengers
and they regulate many of the
bodys functions. In particular, the
sex hormone estrogen plays a role
in lupus. Men and women both
produce estrogen, but estrogen
production is much greater in
females. Many women have more
lupus symptoms before menstrual
periods and/or during pregnancy,
when estrogen production is high.
This may indicate estrogen somehow
regulates the severity of lupus.
However, it does not mean estrogen,
or any other hormone causes lupus.
whatdoctorsknow.com
Forms of Lupus
Systemic Lupus Erythematosus
Systemic lupus is the most common form
of lupus and it can be mild or severe.
Some of the more serious
complications involving
major organ systems are:
Inflammation of the kidneys
(lupus nephritis), which can
affect the bodys ability to
filter waste from the blood
and can be so damaging
that dialysis or kidney
transplant may be needed.
An increase in blood
pressure in the
lungs (pulmonary
hypertension).
Inflammation of the
nervous system and
brain, which can
cause memory
problems,
confusion,
headaches,
and strokes.
Inflammation in
the brains blood
vessels, which can cause high fevers,
seizures, behavioral changes, and
hardening of the arteries (coronary
artery disease), which is a buildup
of deposits on coronary artery walls
that can lead to a heart attack.
Cutaneous Lupus Erythematosus
Cutaneous refers to the skin, and this
form of lupus is limited to the skin.
Although there are many types of
rashes and lesions (sores) caused by
cutaneous lupus, the most common
rash is raised, scaly and red, but
not itchy. It is commonly known
as a discoid rash, because the areas
of rash are shaped like disks, or
circles. Another common example of
cutaneous lupus is a malar rash over
the cheeks and across the bridge of the
nose in the shape of a butterfly, which
is known as the butterfly rash. Other
rashes or sores may appear on the face,
neck, or scalp (areas of the skin that
are exposed to sunlight or fluorescent
light), or in the mouth, nose, or
vagina. Hair loss and changes in the pigment, or color,
of the skin are also symptoms of cutaneous lupus.
Approximately 10 percent of people who have
discoid lupus will develop systemic lupus. However,
it is likely that these people already had systemic
lupus, with the skin rash as their main symptom.
Drug-induced Lupus Erythematosus
Drug-induced lupus is a lupus-like disease caused by
certain prescription drugs. The symptoms of drug-
induced lupus are similar to those of systemic lupus,
but only rarely will any major organs be affected.
The drugs most commonly connected with drug-
induced lupus are hydralazine (used to treat high
blood pressure or hypertension), procainamide (used
to treat irregular heart rhythms), and isoniazid
(used to treat tuberculosis). Drug-induced lupus is
more common in men because they are given these
drugs more often; however, not everyone who takes
these drugs will develop drug-induced lupus. The
lupus-like symptoms usually disappear within six
months after these medications are stopped.
Neonatal Lupus
Neonatal lupus is a rare condition affecting infants of
women who have lupus and is caused by antibodies
from the mother acting upon the infant in the
womb. At birth, the infant may have a skin rash, liver
problems, or low blood cell counts, but these symptoms
disappear completely after several months with no
lasting effects. Some infants with neonatal lupus can
also have a serious heart defect. With proper testing,
physicians can now identify most at-risk mothers,
and the infant can be treated at or before birth. Most
infants of mothers with lupus are entirely healthy.
Treating Lupus
For most people with lupus, proper treatment can
minimize symptoms, reduce inflammation and pain,
and stop the development of serious organ damage.
Visiting www.lupus.org will help you understand
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the most commonly prescribed medicines today, and
other drugs under investigation for treating lupus.
Treatments for Lupus
Health professionals continue to search for better ways
to care for and treat people with lupus. Understanding
what causes the disease and why certain people are
more likely to develop it may one day lead to promising
new treatments for, or even prevention of, lupus. In
the meantime, researchers continue to look for new
treatments and ways to modify existing ones so they
can diminish or eliminate side effects and improve
the quality of life for people who have lupus.
Medications to Treat Lupus Symptoms
Medications are important for managing many
systemic lupus erythematosus (SLE) patients. An
array of drug therapies is now available, and this has
increased the potential for effective treatment and
excellent patient outcomes. The section Medications
to Treat Lupus Symptoms at www.lupus.org will
discuss the use of anti-inflammatories, corticosteroids,
antimalarials, immunosuppressives, and anticoagulants
in the treatment of your lupus symptoms.
Investigational Treatments for Lupus
People with serious illnesses who are not responding to
already available treatments sometimes enroll in clinical
trials to gain access to medical treatments that could be
helpful. In this section at www.lupus.org you will find
information on biologics, hormones, immunosuppressives
(immune modulators), monoclonal antibodies, organ
transplant anti-rejection drugs, stem cell transplantation,
and topical immunomodulators (TIMs) therapies.
The Best Approach to Taking Medications
Knowing your medications and being careful to take
them as prescribed can sometimes be a daunting task,
especially if the side effects seem to be worse then the
lupus disease itself. Visit this section at www.lupus.
org to find out how you and your health care team
can work to develop the best treatment plan for
you. Open communication and knowledge are
the best approaches to managing your lupus.
What Kind of Doctors Treat Lupus
The form of lupus and its symptoms
determine what type of doctor you will
see. Most people who have mild to
moderate disease will be treated by a
rheumatologist, who specializes in
the diseases of joints and muscles.
However, if your lupus causes
kidney problems, you will also
see a nephrologist, a specialist in
diseases of the renal system. If
you have rashes or lesions, you
will see a dermatologist, who specializes in diseases that
affect the skin (including the scalp and the mouth).
Because lupus can cause damage to any part of the
body, other specialists may be necessary, such as a
cardiologist, who specializes in heart problems, or a
neurologist, who specializes in problems that affect
the brain and nervous system, or a perinatologist,
who specializes in high-risk pregnancies.
Prognosis and a Hopeful Future
The idea that lupus is generally a fatal disease is
a big misconception. In fact, the prognosis of
lupus is much better today than ever before.
It is true that medical science has not yet developed
a method for curing lupus. And some people
do die from the disease. However, people with
non-organ threatening aspects of lupus can
look forward to a normal lifespan if they:
follow the instructions of their physician,
take their medication(s) as prescribed, and
know when to seek help for unexpected
side effects of a medication or a new
manifestation of their lupus.
Although some people with lupus have severe recurrent
attacks and are frequently hospitalized, most people with
lupus rarely require hospitalization. There are many lupus
patients who never have to be hospitalized, especially if
they are careful and follow their physician's instructions.
New research brings unexpected findings each
year. The progress made in treatment and diagnosis
during the last decade has been greater than that
made over the past 100 years. It is therefore a
sensible idea to maintain control of a disease that
tomorrow may be curable. -This information provided
courtesy of the Lupus Foundation of America
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The
Acceptance
Letter
Congratulations and Welcome
to Moores Cancer Center!
Maureen and Dr. Parker
M
aureen Roadman may well be
the first cancer patient on earth
to celebrate her diagnosis by
sending out an acceptance letter.
Indeed, upon finding out she had
inflammatory breast cancer, Roadman
who founded a non-profit college/career resource
organization for San Diego students wrote friends,
family and students saying, Great news! I got
accepted at UC San Diego Moores Cancer Center!
I felt comfortable the minute I met with Dr. Parker
and her team (on November 16, 2011), said Roadman.
The information she shared was clear, concise and
compassionate and that gave me confidence.
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Roadman wanted to share that
confidence in her diagnosis
with loved ones, without having
to endure long faces and sad
sympathy letters. Beanies! said
Roadman. Instead of flowers
or food, I asked them to bring
me their favorite beanie cap!
The first week, Roadman received ten
beanies. The second week, 20 more.
In less than a year, she collected nearly
200 beanie caps, modeled on everything
from Dr. Seuss Cat in the Hat to the
Union Jack and every college team youve
ever heard of and some you havent. But
it was what came with the beanies that
made Roadmans journey enjoyable.
Id open the door and there would stand a
friend in a crazy hat with a great story about
why they chose that beanie, said Roadman. I
didnt get a single sympathy card but hundreds
of laugh-out- loud notes and big smiles.
Roadman also tapped friends for help, built
her support system, by playing to each persons
strength. One friend is Roadmans researcher
who hunted down and explained in lay terms any
complicated medical ideas Roadman came across
during treatment. Another friend handled a weekly
soup offering not because Roadman asked her to,
but because when that friend said, What can I do?
Roadman chose something she knew her friend loved to
do. Yet another friend baked homemade scones weekly
for Roadman to take to her radiation treatments.
Everyone wants to help and if you dont have
an idea of what they can do or want to do, then
youre going to end up with a lot of lasagna
casseroles in the freezer, said Roadman.
Knowing Maureen, I knew she would beat this,
explained friend and co-worker, Cynthia Wilson. This is
going to sound like a Hallmark card, but its the humor
that got us through. Its genuine. Thats Maureens
spin on life: don't take yourself so darned seriously!
Even Roadman had an off day, now and then. She
refers to her worst day as an aggravated assault. I was
trying to put tissue paper in a gift bag for a presentation
at work and I couldnt manipulate the paper and
couldnt write. Id lost feeling in the tip of my finger
and I had a three hour melt down. Then it was over.
Roadman underwent chemotherapy followed by
a mastectomy and six weeks of radiation. Long
days. Lots of thinking. And thats when she
came up with ideas for a book and a party.
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The book will
contain photos of Moores
Cancer Center employees wearing a
beanie. Next to each beanie will be snippets of the
notes that came with each beanie. Friends, colleagues
and clients wrote to Roadman, sending her best wishes,
prayers for strength, and thanks to Roadmans request
each referenced their hunt for the perfect beanie.
One couple sent a beanie from Frostburg College,
Roadmans alma mater. Another pledged to knit her
a beanie of their own design. And one family sent a
beanie, a beanie baby and a bag of jelly beanies.
Almost every note in her stack of hundreds
referenced Roadmans attitude:
I wanted to let you know that your positive
attitude inspires me to face my day with a smile.
If you can face adversity with
courage, I can do the same.
You amaze me with your energy and
enthusiasm. Its so easy to feel sorry
for yourself. But you dont.
"If you ever find a way to bottle your
energy and share it with the rest of us mere
mortals, I call dibbs on first in line!
Roadman plans to put the books in
waiting rooms or treatment areas to keep
spirits up and laughter loud. Also, on a
Friday afternoon in September, she and
friends hosted Celebrate the Care, an
afternoon dedicated to honoring all 775
employees of Moores Cancer Center.
Maureen is truly inspirational, said
Roadmans oncologist, Barbara Parker,
MD, medical director of oncology
services at UC San Diego Moores
Cancer Center. She is really, incredibly
positive about everyone and everything,
and honestly grateful about every
day and every person she meets.
It was Dr. Parker who gave me
the direction I needed. She
immediately said, Dont give up
your day job. Keep on doing
what you do. So I did. I stuck
to my routing and tried to make
life as normal as possible.
The way Dr. Parker presented
it was so practical that I no
longer felt like I was the
only person with cancer.
Theyre researching, doing
their best so I decided to do my best.
When Roadman sent out her acceptance letter
announcing her diagnosis, one student wrote back,
saying, Congratulations. Good job. At first,
Roadman thought, She doesnt understand what Im
trying to say. Now, Roadman realizes that student
was on to something. Seriously, it is a privilege
to be treated here. Congratulations are in order!
-This information provided courtesy of University of
California at San Diego Moores Cancer Center
whatdoctorsknow.com
The Psychology
of
Healing
M
aureen Roadman
responded to her
cancer diagnosis
as she does most
moments of crisis:
with humor and
a positive attitude. Thats classic
Maureen. But many patients dont or
cant feel that way. Wayne Bardwell,
PhD, MBA, from UC San Diego
Moores Cancer Center a psychiatrist
with specialty in treating cancer
patients and cancer survivors who
is current president of the American
Psychosocial Oncology Society says
positivity only works if its real.
If the attitude coming from the
patient is organically, authentically
positive, thats good, explains
Bardwell. But do not feel bad about
feeling bad! I call that the Tyranny
of Positive Thinking. If you feel bad
about feeling less-than-positive, thats
only going to harm you. Each one of
us, because of our personalities, our
background and experiences will have
different emotions that come up and
well all deal with them differently.
The best thing you can say to a
cancer patient is Im here to support
you regardless of what or how you
feel, said Bardwell. Because
we all react differently, Bardwell
stresses that authenticity is most
important. If we feel free and
supported in sharing more difficult
feelings, it gives us the opportunity
to feel more optimistic and positive.
Individual therapy, group therapy,
music and art therapy are just a handful
of the various ways breast cancer
patients and survivors can fight back
and find some sense of control over
their disease. Bardwell says another
common way of coping with crisis
is through healthy denial. When
patients are in the midst of active
treatment, often they will grit their
teeth and bear it, and that denial allows
them to get through the treatment.
The value of this is that it really helps
the patient cope in the moment. The
downside is that the suppressed feelings
may come out at end of treatment. The
complication here is that its at the end
of treatment, the end of your support
systems duties. The people in your
system may think Youve made it!
and go back to normal life, just when
you, as a patient, are feeling terrible.
This is a critical point in patient
survivorship, says Bardwell. Mental
health professionals are the tie that
binds. We know you may be thinking
I just went through the mill! Or
I could have died! And we can
help you sort out those feelings.
Its also not uncommon for the cancer
patient/survivor to enter unexplored
territory. The cancer experience can
bring up unexpected feelings. Some
people may see the whole situation
as a catastrophe, thinking about
what lies ahead, what life will be like
after cancer. Bardwell recommends
contacting a psychologist or psychiatrist
who deals with these issues, to examine
your thoughts about what may
happen and why you feel that way.
A 75-year-old woman is going to
weather this storm in a much different
manner than a 25-year-old, noted
Bardwell. The older woman has
more experience to draw on. She
likely knows that shes faced tough
times and that she will do it
again. The younger woman
may not have had those tough
times yet. Her reaction is
likely to be much grimmer.
Patients with a strong family
and friend support system may
feel they have enough support.
For those living apart from
family or lacking that system,
Bardwell emphasizes there is
no shame in reaching out.
Crises generate distress and
theres nothing wrong with
seeking professional help. This
is not the time to act strong
or pretend to be positive.
Authenticity is the watch word.
For more information about
psychosocial counseling
and cancer treatment, visit
the American Psychosocial
Oncology Society
(APOS) Helpline: Toll
Free 1-866-276-7443 or
1-866-APOS-4-HELP.
Dr. Wayne Bardwell
whatdoctorsknow.com 8
Just the Facts:
Spina Bifida
A
ndrea is 12 years old and in the 6th grade. She likes to go swimming,
play with her dog, and have friends over. She's been in three dance
recitals, and she even received a standing ovation once. She's traveled
to Canada and many places in the United States, and next summer she
hopes to go to Scotland. When she's older, Andrea wants to be a chef.
Like you, Andrea is interested in many things and can do a lot of stuff.
What might be different from you, though, is the fact that Andrea can't walk. Andrea
has spina bifida (say: spy-nuh bih-fuh-duh) and uses a wheelchair to get around.
whatdoctorsknow.com
What Is Spina Bifida?
Someone born with spina bifida has an opening in
the spine. A healthy spine is closed to protect the
spinal cord, a bundle of nerves that sends messages
back and forth between your brain and the rest of
your body. The messages tell your muscles to move
so you can kick a soccer ball or pick up a pencil. The
messages also tell you about sensations on your skin,
so you know to pull your hand away from a hot pot.
When a baby is growing inside its mother, the spine and
spinal cord are developing. But sometimes part of the
spinal cord and spine don't grow the way they should,
leaving an opening where the spinal cord may protrude
outside the body. When this happens, a baby is born
with spina bifida, a term that means "split or open spine."
Because of the opening in the spine, the nerves of
the spinal cord may be damaged. A spinal cord that's
damaged may not be able to do the important job of
getting messages to and from the brain. Usually when
your brain says "kick the ball," the nerves of your spinal
cord carry that message that tells your leg to kick.
These messages may not be able to get through if
a person has spina bifida. The person may not be
able to move their muscles the way other people
do. This is called paralysis (say: puh-ra-luh-sis),
which means a person can't move some muscles
or to feel things on some parts of the body.
What Are the Different Types of Spina Bifida?
One kind of spina bifida can go unnoticed. With spina
bifida occulta (say: uh-kul-tuh), the opening in the
person's back is covered by muscle and skin and the spinal
cord is usually normal. There may be some problems
with the spine, or there may be no problems at all.
Another type of spina bifida is called meningocele
(say: meh-nin-jo-seel). This involves the meninges,
the membranes that cover the brain and spinal
cord. Meningocele is the name used when just the
meninges no nerves push through the opening
in the vertebrae. The meninges form a fluid-filled
sac that is usually covered with skin. The spinal cord
is normal and a person with a meningocele usually
has no problems. A person with meningocele will
need surgery to prevent any nerve damage later.
When most people talk about spina bifida, though, they
mean myelomeningocele (say: my-uh-low-meh-nin-jo-
seel), from words meaning "spine" and "swelling." In
this type, the baby is born with a sac protruding from
the opening in the spine. This sac contains nerves and
part of the spinal cord. About 1 in 1,000 babies born
in the United States has this type of spina bifida.
Because the spinal cord hasn't developed normally
and some nerves may have been damaged, a
person with myelomeningocele will have some
paralysis, as well as a loss of feeling in their legs.
The amount of paralysis will vary, depending on where
the opening is on the back. The lower down the back
the opening is, the fewer nerves are affected and the less
paralysis there is. This is why some kids with spina bifida
can walk and some can't. To help them get around,
kids might use crutches, leg braces, or wheelchairs.
Andrea, our dancer, was born with an opening
in her lower back, just below her waist. She can
move her legs but not her feet and ankles. Her
skin has feeling only down to her knees. When
Andrea was younger she walked with braces
and crutches, but now she uses a wheelchair.
Like many other kids with myelomeningocele, Andrea
also has hydrocephalus (say: hi-dro-seh-fuh-lus). This
happens when there's too much fluid in the brain.
Some people with spina bifida may have learning
problems, but most have normal intelligence.
whatdoctorsknow.com 0
Most kids with spina bifida have some problems
with their bowels and bladder. The nerves
that send and receive messages from the brain
can't do their job, so it's hard for kids to know
when they need to go to the bathroom.
Why Do Kids Have Spina Bifida?
No one is really sure why some kids are born
with spina bifida, but doctors and scientists
have found some possible reasons.
They've learned that folic (say: foh-lik) acid is very
important, especially when a baby is growing inside
its mother. Folic acid is one of the B vitamins found in
foods like broccoli, spinach, egg yolks, and oranges.
If a woman doesn't have enough folic acid in her diet
while she's pregnant, she may be more likely to have
a baby with spina bifida. Luckily, special vitamins
containing folic acid are available for pregnant women.
A woman who has a high fever early in her
pregnancy also may be at higher risk of having
a baby who has spina bifida. Scientists are also
studying the roles that genes, certain chemicals,
and medicines might play in causing spina bifida.
What Do Doctors Do?
From the moment Andrea was born, doctors have been
an important part of her life. When she was just a few
hours old, she had her first surgery. Doctors gently
pushed her spinal cord back inside her body through
the opening on her back, and then closed the opening.
When she was 2 days old, the doctors put in a shunt,
a device that drains the extra fluid in the brain.
Since then, Andrea has had several operations,
mostly to replace her shunt. In addition to surgery
to keep her shunt working, a kid with spina bifida
might need surgery on the feet, hips, or spine.
Kids like Andrea also need checkups a couple of times
a year and may see a team of medical people. This team
may include pediatricians, orthopedists, surgeons, physical
therapists, and occupational therapists. They want to help
the person to be healthy and as independent as possible.
What Is Life Like for Kids With Spina Bifida?
Living with spina bifida isn't exactly the same for
each kid who has it. But for most kids, it means
taking extra care of their bodies and paying attention
if something seems wrong. It can mean taking
longer to do things, because braces, crutches, and
wheelchairs just aren't as fast as walking and running.
But as Andrea has shown, that doesn't mean
she can't do exactly what she wants to do! -This
information was provided by KidsHealth, one of
the largest resources online for medically reviewed
health information written for parents, kids, and
teens. For more articles like this, visit KidsHealth.
org or TeensHealth.org. 1995- 2012 . The Nemours
Foundation/KidsHealth. All rights reserved.
Folic Acid
Supplementation before conception reduces the risk of Spina Bifda.
Although the exact causes of Spina Bifda are not yet
known, maintaining healthy levels of folate (called folic
acid when taken via a supplement) have been identifed
as a key factor in prevention.
What is folic acid?
Folic acid is a B vitamin that helps a womans body
produce healthy red blood cells. Taking folic acid before
and during the frst three months of pregnancy does not
guarantee the baby will not have SB, but it can signifcantly
reduce the risk. Research has shown that iF women who
could become pregnant were to take a multivitamin with
folic acid, the risk of neural tube defects like Spina Bifda
could be reduced by up to )o%.
Where can I get folic acid?
Folate occurs naturally in foods like green vegetables,
fruits and juices. Some cereal and bread have folic acid
added to them. A diet high in folate is good for you, but
most people do not get enough through food alone. The
best way to get the right amount is to eat a healthy diet,
and take a vitamin with folic acid every day.
How much folic acid do I need?
vomen who could become pregnant should take qoo
mcg {o.q mg) oF Folic acid through a vitamin.
Women who have Spina Bifda, a child with SB, or
had a pregnancy aFFected by SB should take qooo
mcg {q.o mg) oF Folic acid For one to three months
before pregnancy. This amount of folic acid is available
only through prescription, so high risk women must
carefully plan their pregnancies. Taking folic acid before
and during the frst three months of pregnancy does
not guarantee the baby will not have SB, but it can
signifcantly reduce the risk.
This information does not constitute medical advice for any individual. As specifc cases may vary from the general information presented here,
SBA advises readers to consult a qualifed medical or other professional on an individual basis.
www.spinabifdaassociation.org - qo MacArthur Boulevard Nv, Suite zo, vashington, DC zooo) - 8oo-6z-q
SBA National Resource Center:
800-621-3141
whatdoctorsknow.com
Treatment Advances for
Hereditary Angioedema
A
llergic reactions to foods, medications
and insect stings can be more than an
inconvenience; in some cases they can be
fatal if not treated promptly. Angioedema
is the medical term for sudden swelling
of the tissues just beneath the skin or
the tissues lining the cheeks, throat, or the intestinal
tract caused by an allergic reaction. The swelling can
cause temporary discomfort, disfigurement, and loss of
function depending on the site of swelling. Angioedema
also can cause abdominal pain and can be fatal if
swelling of the tongue or throat blocks the airway.
Allergic angioedema is sometimes referred to as
histaminergic angioedema, and is common during
acute allergic reactions to foods, medications,
or insect stings. Among the warning signs are
intense generalized itching and a visible rash
(hives, urticaria). Because the swelling is caused
by an allergic reaction, aggressive treatment with
antihistamines, epinephrine, and other anti-allergy
medications usually provides rapid and complete
resolution of the swelling. While this form of
angioedema can be fatal, allergy medications
are appropriate and usually very effective.
whatdoctorsknow.com
Degradation of bradykinin
by ACE and other enzymes
Bradykinin Receptors on Blood Vessels
ANGIOEDEMA
(Swelling)
BRADYKININ
Reactions leading to the
Formation of Bradykinin
from inactive precursors
There are other causes of angioedema that have nothing
to do with histamine and allergic reactions. The
angioedema looks like an allergic reaction, but does not
respond to allergy medications. Hereditary angioedema
and angioedema induced by Angiotensin Converting
Enzyme inhibitors (ACE inhibitors) commonly used to
treat high blood pressure are examples of angioedema
caused by a totally different substance called bradykinin
(Figure 1). Treating bradykinin-induced angioedema
with allergy medications is ineffective and has been
associated with tragic outcomes. Fortunately, we now
have medications that can suppress the formation
of bradykinin or block the actions of bradykinin.
HEREDITARY ANGIOEDEMA (HAE)
Hereditary angioedema is an uncommon but serious
genetic illness affecting roughly one in every 50,000
people. The clinical manifestations are episodes of
swelling of the skin, abdominal attacks, and potentially life
endangering swelling of the upper airway (from swelling
of the tongue or throat). Abdominal attacks usually are
painful and can be accompanied by nausea, vomiting,
Figure 1. The Mechanisms of
Bradykinin-induced Angioedema
or diarrhea. Episodes of swelling begin at an average of
11 years of age, but the diagnosis of the disorder often
is not made for years or even decades after the onset.
Episodes of swelling without the presence of itching
or hives (urticaria) are highly suggestive of HAE. The
episodes are very unpredictable in frequency, severity and
duration. Trauma, for example oral surgery, can induce
attacks in some patients. The onset of menstruation
or the use of oral contraceptives cause increased
frequency or severity of attacks in some women.
Recent studies have indicated that before the availability
of new, effective therapies for HAE, patients had an
average of 20 to 100 days of incapacitation per year
from HAE. Over the course of their illness, nearly
all patients have episodes of swelling, nearly all have
episodes of abdominal pain, and approximately
50% have an episode of upper airway obstruction.
Before current diagnostic and therapeutic methods
were developed, more that 25 percent of patients
with HAE died of upper airway obstruction.
whatdoctorsknow.com
The fundamental problem in
most forms of HAE is that a
defect in the genetic code for a
crucial control protein results in
a markedly increased tendency to
produce bradykinin. This protein
regulates several reactions in the
human body. The first recognized
effect involved a body system that
helps kill bacteria and viruses, the
complement system. As a result the
protein is called C1 esterase inhibitor
(C1 INH). We now know this
same protein regulates two crucial
reactions leading to the formation
of bradykinin. Without adequate
amounts of C1INH, a person is at
high risk for the sudden production
of bradykinin and then episodes of
swelling or abdominal problems.
The most common form of HAE,
Type I Hereditary Angioedema,
results from a genetic defect that leads
to the formation of a C1INH protein
that cannot be released into the blood
normally. Blood levels of C1INH
are low and unable to regulate
bradykinin production effectively.
This accounts for 85 percent of HAE.
Type II Hereditary Angioedema
accounts for 15 percent of HAE.
There are normal levels of C1INH
in the blood, but the genetic
defect results in a protein that does
not work properly. The effect is
the same; bradykinin formation
is not effectively controlled.
These two forms of hereditary
angioedema result in susceptibility to
making large amounts of bradykinin,
resulting in angioedema episodes (Figure 1, reaction #1).
Type III HAE is a very rare inherited disorder that
causes the same swelling, abdominal problems, and
airway obstruction risks, but with normal levels
and function of C1 INH. The mechanisms and
treatment of this form of HAE are being studied.
ANGIOTENSIN CONVERTING ENZYME
INHIBITOR INDUCED ANGIOEDEMA
The Angiotensin converting enzyme (ACE) is the
principal pathway for degrading bradykinin in
humans (Figure 1, reaction #2). The first known
function of this enzyme was to generate a protein
called Angiotensin, a normal substance in the body
that helps keep blood pressure up. Medications
were developed to inhibit this reaction to help
reduce abnormally high blood pressure, These ACE
inhibitors are widely used to treat hypertension.
Recent research has shown that this same enzyme is
the main way the human body degrades bradykinin.
When we use ACE inhibitors for hypertension, we
block the degradation of bradykinin. Approximately
1 in 500 patients treated with ACE inhibitors develop
swelling similar to HAE. Again, this swelling resembles
an allergic reaction, but there is no itching or hives,
and does not respond to allergy medications.
TREATMENT FOR HEREDITARY ANGIOEDEMA
Acute attacks. Before 2008, treatment for hereditary
angioedema attacks was very limited in effectiveness.
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whatdoctorsknow.com
Since that time we have new medications available to
us that can be used to arrest and reverse acute attacks.
Some of these medications act by suppressing the
production of bradykinin (purified human C1 INH
and Ecallantide (Kalbitor), reaction 1 in Figure1.
Another new medication, Icatibant (Firazyr) acts by
blocking the bradykinin receptor on blood vessels thereby
preventing the angioedema, reaction 3 in Figure 1.
Purified human C1INH can be used for simple
intravenous replacement of the missing regulatory
protein. In the doses currently recommended C1
INH can begin to affect the swelling within as little
as 30 minutes and lead to complete resolution much
faster than in patients given no active treatment
(placebo). By giving adequate amounts of the natural
control protein, bradykinin production is suppressed
and the angioedema resolves. Adverse effects have
been minimal and usually related to complications
from the need to give the drug intravenously.
Ecallantide (Kalbitor) is a medication that inhibits
the chemical reaction that generates bradykinin
from its inactive precursor, high molecular weight
kininogen. This drug also leads to more rapid
onset of relief and full resolution when compared
to placebo. Ecallantide must be injected in three
subcutaneous sites, and must be given in a medical
facility because approximately three percent of
patients have a severe allergic reaction to the drug.
Icatibant (Firazyr) is a drug that blocks the bradykinin
receptor on blood vessels. Bradykinin may be present
in large amounts, but by blocking the receptor
the angioedema is suppressed. Again, the onset of
relief and time to resolution of the angioedema is
significantly faster than in patients given placebo.
The drug has no known serious side effects, but 90
percent of patients have transient local pain, swelling,
and redness at the injection site. This drug is approved
for self-administration for treatment of all attacks.
PREVENTION OF ATTACKS OF HAE. Some patients
have frequent attacks and are candidates for
continuous treatment to try to prevent attacks.
Danazol is a modified androgen (related to testosterone)
that can increase the level of normal C1INH in patients
with HAE. People with HAE have the capacity to
make normal as well as genetically damaged C1INH.
Danazol activates the gene for normal C1INH and
can bring the levels of normal C1 INH into an
effective range. Because this is an anabolic steroid,
there are many possible adverse effects. The drug can
be considered in patients over 16 years of age, who
are not pregnant, and are not lactating. The drug
is not recommended if serious side effects appear
or if the effective dose exceeds 200 mg per day.
Human C1INH. Doses of 1000 units twice a week
have been shown to reduce attack rates by 50 percent.
The doses for this approach to prevention need to be
adjusted according to the individual patients response.
SUMMARY. Recognition of the molecular basis of
HAE and the central role of bradykinin has led to the
development of powerful new medications. We now
have much better ability to control the incapacitation,
pain, and life-endangering effects of HAE. Initial
studies indicate that ACE inhibitor angioedema also
may respond to the bradykinin receptor antagonist. We
have moved from struggling to keep HAE patients alive
and out of the hospital, to learning to abort attacks and
greatly increase the quality of life for HAE patients.
-Timothy J. Sullivan, MD and Vicki J. Lyons, MD
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1
www http://www.cdc.gov/mmwr
www http://www.cdc.gov/vitalsigns
www http://www.cdc.gov/cancer
36%
Only 36% of uninsured adults
aged 5075 are up-to-date with
colorectal cancer screening.
56%
Only 56% of uninsured women
aged 5074 are up-to-date
with mammography screening.
Cancer
Screening
Colorectal Cancer
Breast Cancer
22M
22 million adults aged 5075
need to be screened for colorectal
cancer, and 7 million women aged
5074 need to be screened for
breast cancer.
Most adults are getting recommended breast and
colorectal cancer screenings. Yet a new CDC report
says more than 22 million adults have not had
screening tests for colorectal cancer, and more than
7 million women have not had a recent mammogram
to screen for breast cancer as recommended. This
CDC report also points out why more people need
to get tested for colorectal and breast cancer and
what can be done to increase screening.
Want to learn more? Visit
National Center for Chronic Disease Prevention and Health Promotion
Division of Cancer Prevention and Control
1
www http://www.cdc.gov/mmwr
www http://www.cdc.gov/vitalsigns
www http://www.cdc.gov/cancer
36%
Only 36% of uninsured adults
aged 5075 are up-to-date with
colorectal cancer screening.
56%
Only 56% of uninsured women
aged 5074 are up-to-date
with mammography screening.
Cancer
Screening
Colorectal Cancer
Breast Cancer
22M
22 million adults aged 5075
need to be screened for colorectal
cancer, and 7 million women aged
5074 need to be screened for
breast cancer.
Most adults are getting recommended breast and
colorectal cancer screenings. Yet a new CDC report
says more than 22 million adults have not had
screening tests for colorectal cancer, and more than
7 million women have not had a recent mammogram
to screen for breast cancer as recommended. This
CDC report also points out why more people need
to get tested for colorectal and breast cancer and
what can be done to increase screening.
Want to learn more? Visit
National Center for Chronic Disease Prevention and Health Promotion
Division of Cancer Prevention and Control
Colorectal Cancer
Colorectal cancer screening 1.
prevents cancer and saves lives.
Colorectal cancer is cancer of the colon or rec-
tum, and is often called simply colon cancer.
It is the #2 cause of cancer deaths in the
United States and kills more nonsmokers than
any other cancer. African American men and
women are particularly at risk of dying from
colon cancer.
In 2006, more than 139,000 people learned
they had colon cancer, and more than 53,000
people died of it.
At least 6 of every 10 deaths could be pre-
vented from colon cancer if every adult 50 years
or older got tested regularly.
Screening tests can fnd precancerous polyps
(abnormal growths) in the colon or rectum.
These growths can be removed before they
turn into cancer. In this way, you can prevent
colon cancer. The earlier colon cancer is found
during a screening, the easier it is to cure.
What screening tests look for 2.
colon cancer?
At age 50 and until age 75 (sometimes young-
er or older, if your doctor recommends it), men
and women should have one or more of three
tests to check for colon cancer. In particular,
adults aged 5059 years should get screened
because their testing rate is so low. The maxi-
mum beneft is expected when people in their
50s are informed and start getting tested.
22 Million Adults Aged 5075
Still Need to Be Tested
Problem
Colon cancer tests are
A stool test , also called a fecal occult blood
test (FOBT) - every year. FOBT is done in the
privacy of your home.
Flexible sigmoidoscopy - every 5 years. This
takes place at a doctors offce or other medi-
cal setting. If any unusual growths are found,
they can usually be removed at the time. Some
people will need a follow-up colonoscopy.
Colonoscopy - every 10 years. This test takes
place at a doctors offce or other medical
setting under light sedation. If any unusual
growths are found, they can be removed at the
time.
About a third of people are not get- 3.
ting screened for colon cancer accord-
ing to national recommendations.
As of 2008, about a third of adults between the
ages of 50 and 75 (about 22 million people)
are not up-to-date with colon cancer screen-
ing.
Why dont more men and women get 4.
tested for colon cancer?
They dont know that anyone can develop colon
cancer as they get older.
They didnt get recommendation from a
health care provider.
They dont have health insurance or a health
care provider.
0
10
20
30
40
50
60
70
80
50-59 years - 60 69 years - 70 75 years
Percentage of Colorectal Cancer Screening, by Age
Percentage of Colorectal Cancer Screening,
by Annual Income
0
10
20
30
40
50
60
70
80
< $15,000 $15,000
- - - $34,999
$35,000
$49,999
$50,000
$74,999
$75,000
%
%
Whos at Risk?
Who needs to get tested for 5.
colon cancer?
People of all racial and ethnic groups aged 50
to 75 years should get tested.
Some groups of people dont get tested at all
or as often as their doctors recommend. The
following people should be especially encour-
aged to get tested
African Americans. This group has the highest
death rate for colon cancer.
Hispanics.
People with low income.
People with low education levels.
People who dont have health insurance.
People who have a family history of colon
cancer. One in five people has a family his-
tory of colon cancer and should speak with a
doctor about getting tested earlier and more
often than others.
Some people may be at especially high risk be-
cause of a personal history of having polyps or
having several close family members (parent,
grandparent, sister, brother) who have had
polyps or colon cancer.
Risk is higher for people with certain con-
ditions including Crohns disease, infam-
matory bowel disease, and some genetic
disorders. People with these conditions
should talk with their health care providers
about getting tested at younger ages or more
frequently.
0
10
20
30
40
50
60
70
80
90
Insured
Uninsured
Source: Behavioral Risk Factor Surveillance System (BRFSS)
%
Mammogram Colorectal Cancer Test
U.S. State Info
Percentage of People Screened Among
Insured and Uninsured in 2008
The number of people who get screened for colon or
breast cancer is very different from state to state.
The highest number of people who get tested are in
the northeastern United States.
Alabama
Arizona
Arkansas
California Colorado
Connecticut
Delaware
Florida
Georgia
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Nebraska
New
Hampshire
New Jersey
New York
North Carolina
North
Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South
Carolina
South
Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Idaho
Montana
Nevada
New Mexico
Wyoming
Hawaii
Alaska
Alabama
Arizona
Arkansas
California Colorado
Connecticut
Delaware
Florida
Georgia
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Nebraska
New
Hampshire
New Jersey
New York
North Carolina
North
Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South
Carolina
South
Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Idaho
Montana
Nevada
New Mexico
Wyoming
Hawaii
Alaska
Colorectal Cancer Screening:
Fecal occult blood test use within past year or lower
endoscopy (either sigmoidoscopy or colonoscopy) in
past 10 years, adults aged 5075 years, United States,
BRFSS 2008
Mammogram: Mammogram use in past 2 years,
women aged 5074 years, United States, BRFSS 2008
53%60%
72%78%
>60%67%
>78%84%
>67%74%
>84%90%
The percentage of people up-to-date with colorectal cancer screening ranged
from 53.2% in Oklahoma to 74.1% in Massachusetts. States with the highest
number of screenings were in the northeastern United States.
Mammography screening use varied by state, with the highest mammography
use in the northeastern United States.
Breast Cancer
Screening for breast cancer 1.
prevents cancer and saves lives.
Breast cancer is the most common cancer
among adult women in the United States and
second leading cause of death from cancer
among women.
One of every eight adult women will get
breast cancer in her lifetime. The risk of can-
cer increases with age.
In 2006, more than 190,000 women were dis-
covered to have breast cancer, and more than
41,000 died of the disease.
Although white women are more likely to get
breast cancer, African American women are
the most likely to die of it. Minority women
are most likely to have advanced breast cancer
when the cancer is frst discovered.
If a close family member (mother, grand-
mother, sister, and father or brother) has
had breast cancer, the risk for other family
members getting breast cancer may be higher.
If you think you may be at increased risk, ask
your doctor if you should be tested earlier or
more often than other women.
What test looks for breast cancer? 2.
The best way to fnd breast cancer is by having
a mammogram. A mammogram is an X-ray of
the breasts.
Mammograms can fnd breast cancer early, be-
fore it is big enough to feel or cause symptoms
and when it is easier to treat.
Women are not getting screened for breast 3.
cancer as often as recommended
In 2008, about one of fve adult women be-
tween the ages of 50 and 74 never had a mam-
mogram or were not up-to-date with getting
screened.
Overall, mammography screening rates in the
United States have not improved since 2002.
Getting a mammogram every 2 years should
be a priority for women aged 5074 years.
Screening can fnd breast cancer at an early
stage, when treatment is most effective.
7 Million Women Still Need to
Be Screened for Breast Cancer
Problem
Percentage of Mammography Screening, by Age
Percentage of Mammography Screening, by Annual Income
0
10
20
30
40
50
60
70
80
90
100
79
80
81
82
83
50-59 years - 60 69 years - 70 74 years %
% < $15,000 $15,000
-$34,999 -
$35,000
$49,999 -
$50,000
$74,999
$75,000
Who needs to get screened for breast 4.
cancer?
All women aged 50 to 74 should have a mam-
mogram every 2 years. Women between 40
and 50 years should talk with their doctor
about when to start getting mammograms.
Some women are less likely than others to be
up-to-date with breast cancer screening.
They include women aged 5074 years who
Are uninsuredonly 56% of uninsured
women had a mammogram in the past
2 years, while 84% of women with health
insurance had a mammogram.
Are American Indian and Alaska Native.
Have a low income.
Have less than a high school education.
How effective are mammograms in 5.
preventing death from breast cancer?
Getting screened for breast cancer beginning
at age 50, or earlier if you have a family his-
tory of the disease or your doctor recommends
it, helps fnd this cancer early, when treatment
can be most effective.
Why dont more women get screened for 6.
breast cancer?
The #1 reason women say they didnt get a
mammogram is that their health care provid-
er didnt tell them to get one.
Some women dont get a mammogram
because they dont have health insurance and
cant afford it. In the future, health care re-
form may help reduce this problem.
Some women are not aware of, or convinced
of, the benefts of screening.
Whos at Risk?
8
www Want to learn more? Visit http://www.cdc.gov/mmwr
For more information, please contact
Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov
Publication date: 07/06/2010
What Can Be Done
Health departments can
Inform people about who should be
screened and about test options.
Explain the benefts of screening for
colon and breast cancer.
Identify groups in the community
who are not getting screened.
Make sure tests are done correctly.
Work with minority and other hard-to-
reach groups to encourage and facilitate
screening.
Identify problems (barriers) that keep
people from getting screened.
Create programs to solve these prob-
lems and increase screening such as
using patient navigators. Patient
navigators can guide people through
the screening process, making it easier
to get screened, learn test results
promptly, receive appropriate follow-
up care, and fnd support networks.
Encourage medical practices, especially
those with low screening rates, to
remind patients to be screened, track
who has been screened, and follow
up with patients who have not been
screened or who need additional tests
or treatment.
Doctors, nurses, and other
health care providers can
Inform patients about who should be
screened, when screening should be
done, and why it is important.
Establish standing orders for nurses so
they can request tests themselves.
Make sure patients who cannot afford testing know about free
cancer screening services in their area.
Establish systems that make screening automatic, such as re-
minding patients when theyre due for a recommended cancer
screening by sending cards or e-mails or calling them.
Ensure patients receive test results promptly and that those
with positive results quickly get an appointment for diagnosis
and treatment.
Systematically monitor and improve screening rates.
People can
Talk to their health care providers about their risk of getting
cancer and ask which screening tests they should have, at
what age to begin, and how often to be screened.
Get screened regularly for colon cancer at age 50 or older,
using either one or a combination of tests, including a fecal
occult blood test, fexible sigmoidoscopy, or colonoscopy.
Get a mammogram every 2 years if you are a woman aged
50 or older. Women younger than 50 should talk with their
health care provider about breast cancer risk and when to
begin getting a mammogram.
Talk to their health care provider about whether they should
be tested at an earlier age or more often than other people if
they have a family history of colon or breast cancer.
Contact their local health department about free or low-cost
screening if they cant pay for colon or breast cancer testing
or if their insurance doesnt cover it. Call 1-800-CDC-INFO or
visit www.cdc.gov/cancer to fnd a local program.
See a doctor promptly to determine the next steps needed if
a screening test shows there might be a problem.
What can be done to help more people get screened for
colon and breast cancer?
whatdoctorsknow.com
HealthWatchMD
with Dr. Randy Martin
Provided courtesy of Piedmont Healthcare
Dr. Randy Martin: I dont know about
you, but Im bothered big-time by fall
allergies. We typically think of allergies as
occurring in the spring, but fall allergies can
have a large impact on your health as well.
These autumn allergens are caused by what
I like to call The Rock Band: RMD. RMD
stands for ragweed, mold and dust mites.
Combatting Fall Allergies
Starts at Home
T
here are several things you can do in your
home to minimize the effects of two of
these allergens, mold and dust mites.
Mold loves dark, damp, hot conditions. With the hot
summer and all the moisture weve had, mold can
grow in many places in your house. To combat mold:
Keep the temperature cool in your house.
Keep the air as dry as possible consider using a dehumidifier.
Use exhaust fans in bathrooms and the laundry room.
Keep surfaces as clean as possible. A good cleaning
solution is 5 percent bleach and a quart of water.
Make sure you have a filter in your air conditioning and heating units.
Dust mites are eight-legged little creatures
that look like little spiders when placed
under a microscope. They love to feed on
dead skin cells and can be found in beds,
mattresses and pillowcases. However, dust
mites are not bedbugs. To reduce dust mites:
Wash your bedding at least once a week
in water that is 140 degrees or higher.
Vacuum furniture and carpets
with a HEPA filter vacuum.
Follow these tips and you can help reduce
the impact of falls allergens on your health.
Combatting Fall Allergies
Starts at Home
whatdoctorsknow.com
whatdoctorsknow.com
Breast Cancer:
Not Just for Women
M
ale breast cancer occurs when malignant cells form
in the tissues of the breast. Any man can develop
breast cancer, but it is most common among men
who are 6070 years of age. About 1% of all
breast cancers occur in men. About 2,000 men
are diagnosed with breast cancer annually, with
about 450 deaths due to male breast cancer occurring each year.
Many men may be surprised to learn that they can get breast
cancer. Men have breast tissue that develops in the same way as
breast tissue in women, and is susceptible to cancer cells in the
same way. In girls, hormonal changes at puberty cause female
breasts to grow. In boys, hormones made by the testicles prevent
the breasts from growing. Breast cancer in men is uncommon
because male breasts have ducts that are less developed and
are not exposed to growth-promoting female hormones.
Male Breast Cancer Symptoms
Male breast cancer symptoms
can be similar to those
experienced by women
and may include:
Lumps in the breast,
usually painless
Thickening of the breast
Changes to the nipple or
breast skin, such as dimpling,
puckering or redness
Discharge of fluid
from the nipples
whatdoctorsknow.com
Just like in women, breast cancer in men can begin
in the ducts and spread into surrounding cells. More
rarely, men can develop inflammatory breast cancer or
Pagets disease of the nipple, which happens when a
tumor that began in a duct beneath the nipple moves
to the surface. Male breasts have few if any lobules, and
so lobular carcinoma rarely, if ever, occurs in men.
Men should also be aware of gynecomastia, the
most common male breast disorder. Gynecomastia
is not a form of cancer, but does cause a growth
under the nipple or areola that can be felt, and
sometimes seen. Gynecomastia is common in teenage
boys due to hormonal changes during adolescence,
and in older men, due to late-life hormonal shifts.
Certain medications can cause gynecomastia, as
can some conditions, such as Klinefelter syndrome.
Rarely, gynecomastia is due to a tumor. Any such
lumps should be examined by your doctor.
Detecting Male Breast Cancer
Male breast cancer is typically found through a
clinical breast exam. If your doctor feels any lumps, a
mammogram or ultrasound may then be used to look for
any abnormalities within the breast. If you have nipple
discharge, your doctor can examine the fluid to look for
cancerous cells. A biopsy is used to make a definitive
diagnosis of breast cancer, including the type and stage.
Male Breast Cancer Treatments
Male breast cancer is treatable, and
usually involves the following:
Surgery: Most men with breast cancer undergo a
modified radical mastectomy. In this procedure,
all of the breast tissue and some underarm
lymph nodes are removed. Your doctor may also
recommend a sentinel lymph node biopsy to
determine if cancer has spread to the lymph nodes.
Radiation Therapy: Following surgery, radiation may be
used to destroy any remaining cancer cells in the body.
Chemotherapy: Your doctor may recommend
chemotherapy after surgery. Like radiation,
chemotherapy may kill any cancer cells that have spread
outside the breast. Chemotherapy is also a treatment
option for men who are diagnosed with advanced
breast cancer that has spread beyond the breast.
Hormone Therapy: Most men with breast cancer
have tumors that are hormone-dependent; that is, the
cancer cells are supported by hormones in the body.
Hormone-dependent cancer may be treated with
hormonal therapy medications such as tamoxifen.
Targeted Therapy: In targeted therapies,
the drug attacks a specific abnormality
or process within cancer cells.
Anti-HER2 Therapy: Some breast cancer is fueled by
an excess of HER2, a protein that helps cancer cells
grow and survive. When cancer cells contain HER2,
they may be treated with anti-HER2 drugs such as
trastuzumab and lapatinib. -This information provided
courtesy of Cancer Treatment Centers of America
Male Breast Cancer Risk Factors
Any man can develop male breast cancer. Factors that may increase risk include:
Age: Male breast cancer is most common among men age 6070.
Alcohol: Excessive consumption of alcohol may increase risk.
Exposure to radiation: Men who have undergone radiation treatment to the chest,
such as for the treatment of cancer, are more likely to develop breast cancer.
High estrogen levels: Having a disease connected to increased amounts of estrogen
in the body, such as cirrhosis or Klinefelter syndrome (a genetic disorder).
Family history: Having several female relatives who have had breast
cancer, especially those with a mutation of the BRCA2 gene.
Weight: Men who are obese may be at greater risk for male breast cancer. Fat cells
convert the male hormone androgen into the female hormone estrogen, which may
lead to an increased amount of estrogen in the body, possibly triggering breast cancer.
If you have several male breast cancer risk factors, talk with your doctor
to ensure he or she can monitor your health appropriately.
whatdoctorsknow.com 8
American Lung Association Releases "Breathe Smarter" PSA
Campaign Featuring New Air Quality Smartphone App
A
n edgy public service advertising (PSA)
campaign featuring provocative television,
online and out-of-home components
was released by the American Lung
Association in June 2012. The PSA
campaign encourages people to download
the charitys new State of the Air smartphone
application, a valuable resource for people living with
lung disease like asthma and chronic obstructive
pulmonary disease (COPD), people with heart disease or
diabetes, as well as older adults and children. This is the
first time that a charity has included an app download
as the call to action in a nationally distributed PSA.
Despite continued improvements in improved air
quality across the country, unhealthy levels of air
pollution still exist across the nation. According
to the Lung Associations 2012 State of the Air
report, more than 127.2 million people live in U.S.
counties with dangerous levels of ozone or particle
pollution, the two most widespread air pollutants.
The State of the Air app enables users to enter their
zip code or use the geo-locator functionality to get
current and next-day air quality conditions. The
app also provides levels of both ozone and particle
pollution, and pushes out alerts if local air quality is
code orange or worse. Depending on the severity of
the days air pollution, the app will provide vital health
recommendations advising that outdoor activities
should be rescheduled or that people who work
outdoors should limit extended or heavy exertion.
"Breathe Smarter"
whatdoctorsknow.com
This air quality information is based on
data made available to the public by the U.S.
Environmental Protection Agency (EPA). The
American Lung Association app is available
for Apple in iTunes and for Android in Google
Play or at www.lung.org/stateoftheairapp.
The Breathe Smarter PSA campaign is targeted
to individuals between the ages of 18 and 40 but
the app is a valuable tool for all age groups with
smartphones. The campaign includes television,
online and out-of-home PSAs that promote the app
as a valuable health resource to individuals, especially
those at most risk from breathing unhealthy air.
According to Jeff Boal with Plowshare Group, a company
that is responsible for placing hundreds of millions
of dollars in donated media: The American Lung
Associations new campaign represents a unique shift in
thinking for social issue communications. Humor is a
great way to reach all audiences and its sometimes tough
to be funny when it comes to health charity messages.
The television/online PSAs feature a fictional air
collector named Alvin Grimes, who is incredibly
passionate about his love of air. He loves air so much
he takes samples in glass jars from everywhere he visits
and even from his own backyard. Alvins character
is meant to be quirky and endearing as evidenced
by his passion for the air and all things air-related,
e.g. dirigibles, sailboats, balloons, pinwheels, etc.
Our new PSAs are meant to be funny in order to
capture viewers attention. But theyre also meant to
convey the underlying message that it is important
to be aware of your air, said Carrie Martin Munk,
Vice President of Communications and Marketing
for the American Lung Association. We hope
Alvin gets people to laugh, stop and think about
what theyre breathing and then download the app
to monitor local air quality on a daily basis.
Alvin has his own Facebook and Twitter accounts
where he will post and tweet about air. There are
four additional online videos that are available on
Alvins YouTube page. Find Alvin online here: www.
facebook.com/theaircollector, www.twitter.com/
theaircollector, and www.youtube.com/theaircollector.
The PSAs will be distributed to national cable and to
television stations in markets across the country, and
the Lung Association will also be placing the television
ads in movie theaters, and online on health and fitness
related websites. The out-of-home ads will be placed
in a few select markets and will appear in shopping
malls, bus shelters, and train stations, along with
highway/neighborhood billboards. -This information
provided courtesy of the American Lung Association
whatdoctorsknow.com 0
New
Breast Imaging
System
whatdoctorsknow.com
T
he U.S. Food and
Drug Administration
today approved the first
ultrasound device for use
in combination with a
standard mammography
in women with dense breast tissue
who have a negative mammogram
and no symptoms of breast cancer.
Breast cancer is the second leading
cause of cancer-related death
among women. This year an
estimated 226,870 women will be
diagnosed with breast cancer, and
39,510 will die from the disease.
The National Cancer Institute
estimates that about 40 percent
of women undergoing screening
mammography have dense breasts.
These women have an increased
risk of breast cancer, with detection
usually at a more advanced
and difficult to treat stage.
Dense breasts have a high amount
of connective and glandular tissue
(fibroglandular tissue) compared
with less-dense breasts, which have
a high amount of fatty tissue. A
physician determines if a woman
has dense breast tissue with a mammography exam.
Mammography is a low-dose X-ray imaging
method of the breast. However, mammograms
of dense breasts can be difficult to interpret.
Fibroglandular breast tissue and tumors both appear
as solid white areas on mammograms. As a result,
dense breast tissue may obscure smaller tumors,
potentially delaying detection of breast cancer.
Ultrasound imaging has been shown to be capable
of detecting small masses in dense breasts. During
an ultrasound exam, a device called a transducer
directs high-frequency sounds waves at the portion
of the body being examined. Software analyzes the
differences in how the sound waves are reflected off
different tissues and back to the transducer to create
an image a physician can review for abnormalities.
The specially shaped transducer of the somo-v
Automated Breast Ultrasound System (ABUS) can
automatically scan the entire breast in about one
minute to produce several images for review.
As part of the approval process, the FDA reviewed
results from a clinical study in which board-certified
radiologists were asked to review mammograms alone
or in conjunction with somo-v ABUS images for 200
women with dense breasts and negative mammograms.
Biopsies were performed on masses detected with
the somo-v ABUS to determine if they were cancer.
The results show a statistically significant increase
in breast cancer detection when ABUS images
were reviewed in conjunction with mammograms,
as compared to mammograms alone.
A physician may recommend additional screening
using ultrasound, for women with dense breast
tissue and a negative mammogram, said Alberto
Gutierrez, Ph.D., director of the Office of In Vitro
Diagnostic Device Evaluation and Safety at FDAs
Center for Devices and Radiological Health. The
somo-v ABUS is a safe and effective breast ultrasound
tool when such screening is recommended.
The somo-v ABUS is approved for use in women who
have not had previous clinical breast intervention,
such as a surgery or biopsy, since this might alter
the appearance of breast tissue in an ultrasound
image. -This information provided courtesy of
the US Food and Drug Administration
FDA approves the first breast ultrasound
imaging system for dense breast tissue.
The device is designed to help health
care providers detect smaller tumors.
whatdoctorsknow.com
A
pproximately 200 children receive specialized surgery to correct
congenital cardiac defects at N.C. Childrens Hospital each year.
The Childrens Hospital commemorates the lives saved by reuniting
pediatric heart patients and their families to reminisce and
celebrate with their care teams at its Healthy Hearts Reunion.
More than 250 people attended this year's 22nd anniversary reunion,
sponsored by the Carolina Parent Network, on September 15, 2012, in Durham, N.C.
Patients and families enjoyed family-oriented entertainment, including carnival games,
face painting, balloon animals and the likebut more than that, the event provided a
rare opportunity for patients and families to connect, or reconnect, with one another and
their caregivers, fostering much-needed social support for this unique patient population.
Six-year-old patient, Charleigh Reese, attended the reunion and articulated her excitement
as perhaps only a 6 year old can. Im glad, she said. All these kids really, really, really,
really care about this, and they care about all the families and all the other stuff they do
care about. -This information provided courtesy of North Carolina Children's Hospital
Reuniting
"Mended Hearts"
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Reuniting
"Mended Hearts"
whatdoctorsknow.com
Could America's
Physicians Be Facing
A State of Emergency?
I
f the current trend continues, doctors in America
wont be able to afford to practice medicine.
And since 25 percent of the Gross Domestic
Production (GDP) comes from healthcare and
23 percent of the population works in healthcare,
what affects doctors, affects you and me.
Physicians have seen a 50 percent reduction in
compensation over the past 25 years and hospitals have
seen a downward spiral of reimbursement per patient.
Yet, insurance companies have seen major increases in
their bottom line, physician reimbursement has decreased
and the cost of office staff has risen nearly 100 percent.
Physicians are getting the blame, but they arent the
cause of rising healthcare costs or the crisis. Heres
why. The typical family practice doctor in the United
States bills about $1 million per year. He will collect
about $500,000 after discounts imposed by insurance
companies. Of that $500,000 received, he will pay
about half ($250,000) in overhead. Approximately
$200,000 will go back to office operations (this
is the cost to collect what is owed to him). That
leaves $250,000. Since it is all earned income, he
will pay about half in state and federal taxes, leaving
about $125,000 after tax. In essence, doctors
take home about 15 percent of what they earn.
whatdoctorsknow.com
What other industry would accept
a 15 percent take home pay?
But then, what other industry would be subjected to
the business model of a typical medical practice?
To provide a proper perspective, lets plug in a
grocery store into the payment/collection process of
a medical office and walk through the procedure.
You are a grocery store owner. A customer buys $100
worth of your product but when he gets to the register
and pays with a credit card. The credit company
tells you the allowed amount for these groceries is
only $50. Next, the credit card company tells you
in order to collect the agreed upon $50, you have
to fill out a host of forms. If any of the forms are
misfiled or incorrect, they will be rejected and any
payment will be refused until they are corrected.
Because this credit card company often refuses your
claims, you are forced to hire a staff to insure collection.
But the cost of hiring a staff to chase every $50
increases your cost another $35. That means that $100
purchase now nets you $15. Can you stay in business?
Heres another factor. If you happen to have a number
of unpaid claims from your customers you somehow
cant collect, unlike other businesses that can claim a
bad debt write off your industry has been targeted and
you cant write off bad debt on your taxes. Less to the
bottom line. Again, can you afford to stay in business?
Being a physician today is financially difficult.
Healthcare costs are rising seemingly out of
control with physician incomes decreasing. Still,
the government thinks the answer to rising costs
is to reduce the healthcare providers income even
more. The government way of thinking will
shut down a lot of practices and hospitals.
Worse yet, the current federal administration is
promising to add three million medical office staff
jobs in the next two to three years. In addition,
they are making promises to fund the training of
this additional office staff. Three million additional
employees, averaging $40,000 per year, will create
a 120 billion dollar price tag. Doctors and hospitals
already being affected by payment reductions and
continually rising costs to provide healthcare, have been
targeted to pay for this multi-billion medical jobs bill.
The governments answer always seems to either tax
or regulate a problem. In the case of healthcare,
part of the solution lies in the inefficiencies in which
medicine is practiced. Our government has never
been known for its efficiencies, so recognizing the
inefficiencies of medicine is a bit much to ask.
There are a number of ways to cut
down on the cost of healthcare, but
perhaps one of the most immediate
is to control the inefficiencies
of the mountains of paperwork
required to run a medical practice.
And while it sounds simple, the solution requires a
system that can interact with insurance companies,
understand complicated medical coding, be able to
translate physician orders, coordinate labs, prescriptions,
patient medical and family history, and keep track
of appointments, referrals and follow-up visits.
Until now, such a system never existed.
When the federal government realized the need
for such a system they had another agenda. They
wanted to create a national record sharing system to
insure better communication within the healthcare
community. If such a system could be realized,
the medical practice would benefit as well from the
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efficiencies. As expected, the government mandated
for all medical practices and hospitals integrate an
electronic health records (EHR) system. With the
country on such a system, physicians could access
patient records, patients would be able to review their
own records, and efficiencies would be created.
In theory.
There is a common misconception in the world today
that when it has healthcare associated with it, there is an
unlimited source of revenue. Or, when its healthcare,
money is no object. So when the government mandated
EHR systems for medicine, almost anyone who could
spell computer or software became an expert on EHR
systems. And the systems were launched in droves
promising salvation, but delivering nightmares.
Medical practices were required to buy expensive and
unreliable hardware and software. Medical support staff
who were used to paper charts and checkmarks were
now required to practically become software engineers.
Office training time stretched to months and years,
offices were crippled by software glitches and hardware
crashes. Closets were being converted into trash piles
when frustrated staffers started pulling plugs, discarding
these promising systems and going back to paper charts.
It was common for a physician to complain that
these systems promise of cost savings and efficiencies
actually turned into outrageous expenditures
for hardware and software and the hiring of
additional staff to learn and understand these new
systems. Not only did they actually cost more,
but they simply didnt deliver as promised.
Not surprising, the government pushed back
its mandatory conversion date for medical
practices. Even they realized that the
industry wasnt ready. Until recently.
Of the emerging EHR companies, one has taken
advantage of cloud based technology to eliminate
hardware and software purchases by the practice, is
simple to use and best yet, has been created by doctors.
Frankly, the technology has been available for a
workable, comprehensive system but the holdback has
been the people behind the design of the program.
There are some amazing programmers in the industry
today, but a majority of them have never set foot
in a physicians office to understand the need. The
downfall is programmers or engineers trying to
design a system to correct inefficiencies when they
dont understand the impact of the inefficiencies.
One EHR that could change the
landscape is called NetMedai.
HOW IS IT DIFFERENT?
Perhaps the greatest advantage of NetMedai is
its history and how it was developed and why it
works like no other system available today. Unlike
programmers designing a system and trying to
educate physicians and medical staff on how to
use and adapt it for their practice, NetMedai was
designed by physicians and office staffers who
told programmers and system engineers what
they needed in a real world medical office.
It was a painstaking procedure that took nearly
20 years to create, but the end result is impressive.
Better yet, its easily and seamlessly integrated,
easy to understand, is offered at a fraction of
the cost of other systems, and it works.
What separates NetMedai from
other systems is its ease of use as
well as its comprehensive nature.
Unlike other systems who offer
an ala carte for the practice,
NetMedai takes in every aspect of
the medical practice. Thats why
Dr. Steven Porter, MD, calls it the
first truly comprehensive medical
practice management system.
Dr. Porter should know. Hes been testing
the system in his own gastroenterology
practice for the past ten years.
There was a great deal of concern from my
programmers because they kept watching other systems
being introduced. Porter points out. But I knew
they were premature and I while I could have joined
the melee and roll out NetMedai along with the rest, in
my heart I didnt think we had thoroughly tested the
system. I wanted to offer a system that would deliver as
promised. I was already hearing horror stories from my
colleagues about systems they called expensive junk.
Maybe thats why only about 20 percent of the
practices out there have ventured into the EHR
market. Word spreads fast in the medical community.
In the words of one office manager who had researched
EHR systems for more than a year: there are a lot
of systems out there, and every one has issues. I
suppose you have to find the lesser of the evils.
When I heard that story, I was convinced more than
ever that I wanted to be sure our system was fully
tested and ready to go before rolling it out, Porter
added. Im happy to say, our system is ready.
whatdoctorsknow.com 8
Dr. Porter isnt the only one
convinced NetMedai is ready.
The number of physicians
testing and using the system
daily agree and having nothing
but positive feedback.
NetMedai is based on the
concept of simplicity, ease of
integration, and dependability.
Because every aspect of the
system was developed with
important input from end users,
there is a surprisingly high
familiarity with the system.
Even the basic functions such
as the appointment scheduling
benefitted from front desk
staff members using, evaluating,
reviewing and testing. Each
step of the way, appropriate
staff members provided input
looking for familiarity, ease of use and more.
Perhaps the most interesting and important
aspect was the actual physician interface. Once
again, efficiencies revolved around using the
latest and most effective technology available.
We knew we had to take the pen and pencil away
from the physician, D. Porter added. Physicians are
notorious for their horrible penmanship. So it should be
of no surprise when there are so many errors in trying to
decipher a doctors notes or orders. A misinterpretation
could be the cause of a bad code, wrong diagnosis, etc.
We solved the problem with a voice recognition system.
Voice recognition is not new, but a voice recognition
system for the physician presents a challenge. Medical
terminology can be difficult. That means a voice
recognition system has to not only be able to transcribe
and understand the doctor, but also the terminology
and the codes (more than one million) for accurate
diagnosis, accurate ordering of prescriptions, labs and
more. A mistake in the transcription can be problematic
for the patient and costly for the billing aspect (if a code
is misinterpreted, the insurance company wont pay).
The goal of NetMedai is to streamline the medical
practice and hold the insurance companies
accountable effectively lowering the cost of
healthcare for the providers. NetMedai is more
comprehensive, can be fully integrated and
operational in less than a week in most practices.
The goal of NetMedai is to have every doctor, every
hospital, every medical practice institute and reap the
benefits of NetMedai and all its features to improve the
quality of healthcare and to reduce the cost of providing
healthcare for the physician. In the
long run, a system such as NetMedai
could help stabilize healthcare costs.
NetMedai can make an
impact on healthcare
The first step is to make the system
affordable and obtainable for any
size practice. The system can
provide an immediate reduction
in costs to run a medical practice
while making the overall practice
more efficient, because it offers:
Ease of integration
Ease of use
State of the art technology
Support
Opportunity for the
physician to spend more
quality time with patients
Minimum investment in
equipment and other resources
Why Is NetMedai Different?
Imagine a world without a doctor or staff writing
out or calling in a prescription. Imagine a world
without a doctor or staff member calling in labs.
Imagine not having to call a physicians office to
make an appointment or to call for lab reports.
Imagine doing all this with an efficient, automated
online system backed up by state of the art cloud
technology. Physicians have long dreamed of a
national, shared automated Electronic Health
Records (EHR) system. Diagnosis, treatments,
and patient histories would be available at the
touch of a button anywhere, at any time.
An estimated one-third of the EHR systems in physician
offices arent being used because they are either too
difficult to use, extremely user unfriendly, ineffective
or too expensive to maintain. NetMedai, a total office
management system, eliminates the fear of EHR because
it is easy to understand, user friendly, cost effective and
can be implemented quickly and easily oftentimes the
system can be up and running in less than a week.
Perhaps the most impressive feature of the NetMedai
system is the ability to purchase a medical practice AR
at the end of each business day. No other program
has this ability, perhaps a testimony of the NetMedai
efficiency and accuracy. Thats why NetMedai
has targeted medical practices (estimated to be 80
percent of the active medical practices) without an
EHR system that is waiting for a system offering
all the benefits and features of Netmedai because it
is designed by doctors, not marketers which means
a better understanding of the medical practice.
whatdoctorsknow.com
A Breakdown of the Medical Practice
The medical practice is broken down into a
number of segments which makeup the overall
management process. These areas include:
Transcription
Medical records
Coding
Billing
Collections
AR (accounts receivable)
Service
Transcription
NetMedai eliminates the need for pens, pencils and
paper. Most medical practices are burdened by a
paper chart system. The physician writes notes on
a chart which are transcribed, transferred, etc. As
the notes are transcribed, transferred, etc., there is
an opportunity for human error. NetMedai features
a voice recognition system, which is virtually 100
percent accurate, and can be immediately corrected.
Using a hand held microphone, android phone, lapel
microphone or other device, the physician or medical
provider dictates diagnosis, orders, labs, prescriptions
and more. Voice recognition software translates the
orders and every element of care is dispersed, recorded
and ordered electronically and systematically.
Because NetMedai is a cloud based software system,
there is no need for a practice to invest in expensive
hardware or software. Updates are automatic,
continuous and seamless. The majority of EHR
systems available require the purchase of expensive
hardware and software. It is not unusual for a
practice using a system other than NetMedai system
to spend nearly $250,000 or more in start-up costs.
Medical records
Once again, medical records become part of the
NetMedai magic. Beginning when the patient
registers either online or in person the electronic
trail begins. Totally integrated and instituted,
a patient can log on and view his or her records
online including labs, prescriptions, etc. NetMedai
eliminates the need for volumes of paper. NetMedai
features low, or no cost medical record storage with
the patient in charge of his or her medical records.
Coding
Coding is perhaps one of the most critical aspects
of the medical office accounting system. Erroneous
codes cost medical offices billions of dollars every
year. Insurance companies who receive claims with
incorrect codes can refuse to pay. No explanation
is offered, the claim is merely rejected.
After the patients medical information has been entered
into the system, the data still has to be coded. This means
conversion of the text data dictated by the physician into
proper codes. This conversion is required to transfer
the data from the physicians dictation format into a
language to bill the respective insurance companies.
This highly specialized process requires the expertise of
highly skilled employees who can read the medical record
and convert the data into the correct format, which in
turn is interpreted by the insurance company. Without
proper coding, the payment is rejected by the insurance
company. NetMedai eliminates the need for specially
trained coding personnel because it is 99 percent accurate.
The NetMedai, word recognition software literally reads
the physicians notes and generates the appropriate coding
accurately and automatically without the human error that
costs healthcare providers billions of dollars every year.
whatdoctorsknow.com 0
Billing
Once the patient record has been transcribed and
properly coded it moves to the billing stage. Again,
traditional practices without an EHR run the risk
of having the billing information incorrectly entered
before it is sent to the insurance company. Providing
another opportunity for the practice to lose money
by having a claim rejected due to a clerical error.
With NetMedai, the computerized and highly
accurate coding a billing process continues virtually
eliminating the possibility for clerical error and
rejected claims. Current estimates indicate that human
coding error is the cause of up to 35 percent form
rejection. The resulting cost can be astronomical.
Collections
Collections are perhaps the single most money-losing
element of the medical practice. When a claim is
improperly coded and improperly billed, insurance
companies gladly reject the erroneous claim. Rejected
claims highlight the typical medical office inefficiencies
because these rejected claims often find their way to
a less than priority file. Office staff, already taxed
for time and resources, rarely find the time to review
and correct these rejected claims. Oftentimes, the
rejected claims expire and never get corrected or re-filed.
NetMedai, submits claims, codes and billing
for collection. Rejected claims are re-processed
in seconds. Furthermore, because the overall
system is more efficient, the staff has more time to
address faulty claims a rarity with NetMedai.
Accounts receivable
Medical offices using traditional paper and less
comprehensive systems are subject to claim rejection
in several areas. Because of the numerous rejected
claims due to the many human error opportunities,
the average medical practice has no ability to estimate
daily income. At best, there is an educated guess.
The lack of this important information makes it very
difficult for a practice to project income and/or loss.
Because of the confidence of the NetMedai system,
not only is the physicians office able to project
its daily receipts, loss and/or income, the office
has the ability to sell its receivables, less a small
processing fee back to NetMedai. In short, not only
is the practice more efficient and more profitable,
the physician has an accurate evaluation of his
income on a daily basis. In addition to a better
understanding of the practices financial health, there
is the ability to take his or her profit to the bank.
Service.
Because the NetMedai system is cloud based with
instantaneous hot back up of all data, there is virtually
no down time or loss of productivity. There is no
need for on-site IT employees or on-site maintenance
since the heart of the system is the cloud. If one of
the inexpensive support computers breaks down,
it is simply replaced by another. The replacement
machine is plugged in and the office continues as usual.
There is no expensive configurations, set-up, etc.
Cost/Pricing
Implementation cost:
Because NetMedai is cloud based, there is no need for
the practice to buy expensive hardware or software
to implement the system. The only up front charge
is for desktop computers dedicated to the NetMedai
system with the number of computers required
dictated by the size of the practice/clinic/hospital. The
estimated cost for each computer is set at under $300.
Once the system is in place, the practice will
be charged a small monthly cloud fee.
Training will be offered as part of the system set
up. Because NetMedai mirrors a typical paper
chart system, integration and training is minimal.
With NetMedai, the physicians
office benefits from decreased
overhead, increased profit, a more
efficient office environment and
better care for the patient. The
system cant control government
regulations or the increased
profit margins from insurance
companies, but it can streamline
the practice management system
and increase the bottom line
by as much as 50 percent.
NetMedai gives the medical
practice the tools to survive.
-Steve Porter, MD
whatdoctorsknow.com
R
esearchers have discovered a
restricted pattern of molecules
that differentiate early-stage
breast tumors from invasive,
life-threatening cancer.
They also found a similar
molecular signature that correlated with the
aggressiveness of invasive tumors, and with
the time to metastasis and overall survival.
Researchers at the Ohio State University
Comprehensive Cancer Center Arthur
G. James Cancer Hospital and Richard J.
Solove Research Institute (OSUCCC
James) who led the study say the findings
could offer new strategies for treating
breast cancer by blocking progression
to life-threatening invasive cancer.
The researchers investigated a common type
of early-stage breast cancer called ductal
carcinoma in situ (DCIS). DCIS tumors are
confined to the milk duct, and, though small,
they are detectable by mammography. They
can sometimes grow and spread beyond the
milk duct into surrounding healthy tissue,
a stage called invasive ductal carcinoma.
The study, reported in the Proceedings of the
National Academy of Sciences, compared the
pattern of molecules called microRNAs in
DCIS to the pattern present in invasive ductal
cancer. It identified nine microRNAs that
distinguished invasive cancer from DCIS.
The transition from DCIS to invasive ductal cancer is
a key event in breast cancer progression, but it remains
poorly understood, says principal investigator Dr.
Carlo M. Croce, director of Ohio States Human Cancer
Genetics program and a member of the OSUCCC James
Molecular Biology and Cancer Genetics Program.
This study has identified a
small pattern of molecules
that highlights important
differences between early-
stage breast tumors and
invasive, deadly ones.
Some early-stage breast cancers are potentially
harmless, but others invade surrounding
healthy tissue and become deadly.
Early Breast Tumors
Deadly Path
A Small Group Of Molecules Might Hold The Answer
whatdoctorsknow.com
These findings suggest that this micro-signature
might be used to identify DCIS tumors that are
at high-risk for becoming invasive cancer.
MicroRNAs are a class of molecules that help control
the types and quantity of proteins cells make. Work by
Croce and others has shown that microRNAs are often
dysregulated during cancer development, and it has
suggested that the molecules offer new biomarkers of
disease, and that restoring key microRNAs to normal
levels might offer a new approach to cancer treatment.
First author and cancer researcher Dr. Stefano Volinia
notes that high expression of one of those molecules,
called miR-210, correlates with tumor aggressiveness
and with time to metastasis and overall survival.
If we could inhibit the few miRNAs associated
with tumor invasiveness, perhaps we could
arrest tumor progression at the harmless, pre-
invasive state, says Volinia, an assistant professor
of molecular virology, immunology and medical
genetics and of biomedical informatics.
For this study, Croce, Volinia and their colleagues
studied microRNA profiles from data collected
using whole-genome deep sequencing. They
examined 80 cases of invasive ductal carcinoma,
eight of DCIS, and six of normal breast biopsies.
Comparing DCIS and invasive cancer samples showed
nine microRNAs that formed an invasiveness
micro-signature. Three of these miRNAs (let-
7d, miR-210, and -221) showed the most extreme
changes in expression levels. Relative to their levels in
normal breast tissue, the three were down-regulated
in DCIS, then up-regulated in invasive cancer.
That told us that progression from in-situ ductal cancer to
invasive cancer involves a reversal of miRNA expression,
Croce says. -This information provided courtesy of The
Ohio State University Comprehensive Cancer Center
whatdoctorsknow.com
A Hospitalist?
whatdoctorsknow.com
Y
ou may be hearing a new term or name
when you visit your local hospital. Hospitals
across the country are providing a team
of physicians on its medical staff, called
hospitalists or inpatient care providers,
who specialize in treating hospitalized
inpatients specifically. These hospitalists are on site
around the clock, caring for patients throughout the
day and night, making decisions quickly as situations
arise and following up on test results more quickly.
Hospitalists provide a more efficient stay for the
patient, said Jeffrey Astbury, M.D., internal medicine
physician and the new medical director of Inpatient
Care Unit at Baylor Waxahachie. Hospitalists can
provide improved patient safety, improved outcomes
and shorter stays for the patient. They are onsite
making treatment decisions, being available to talk
with patients and family members, and admitting
and discharging patients in a timely manner.
As defined by the Society of Hospital Medicine, a
hospitalist is a physician who specializes in the practice
of hospital medicine. Hospital medicine is a medical
specialty dedicated to the delivery of comprehensive
medical care to hospitalized patients. These physicians
are usually board certified in internal medicine or family
practice. More than 30,000 hospitalists are currently
practicing in more than 3,000 hospitals nationwide,
according to the Society
of Hospital Medicine.
Baylor Waxahachie has
five hospitalists on its
medical staff, as well as
several others on its medical
staff that provide services
on an as-needed basis.
For example, at Baylor
Waxahachie, hospitalists use
evidence-based protocols
for managing common
illnesses, such as pneumonia,
heart failure and stroke.
The hospitalists on our
medical staff regularly follow
proven treatment plans for
common conditions which
lead to improved patient
safety and outcomes,
said Dr. Astbury.
Hospitalists work closely
with patients primary
care physicians, providing
updates and consulting with referring physicians as
needed. The result is an efficient system for staying
connected with primary care physicians, alerting them
when patients are admitted and providing them with
the patients discharge orders when they go home.
The model of using hospitalists to care for
hospitalized patients has been around for more
than a decade. The trend has evolved due
to a number of factors, including increased
efficiencies, financial strains on primary care
physicians, patient safety and the need for more
coordinated care for hospitalized patients.
Published studies show the positive impact of
hospitalists. A Press Ganey study in 2010 found
that facilities with hospitalists had significantly
higher nurse and patient satisfaction than those
without hospitalists. A 2008 study found that
hospitalists at a community hospital reduced the
risk of patient readmissions by 41.8 percent and
increased coordination of care by 13.2 percent. A
study published in the Journal of American Medical
Association in 2002 showed that implementation
of hospitalist programs decreases hospital costs by
13.4 percent and length of stay for patients by 16.6%
while improving quality and patient satisfaction.
-This information provided courtesy of Baylor Health
H
ow often does your doctor ask
about your sexual life?
Unfortunately, the answer may be: not
often enough. Leaving the subject off the
check-up checklist could mean missing
an important link to overall wellness.
Results of a comprehensive national survey of U.S.
obstetrician-gynecologists regarding communication
with patients about sex have found that too
often doctors aren't having "the talk" with their
patients. And when the topic of sex does find its
way into a doctor's office or exam room, chances
are the discussion only skims the surface.
The report, "What We Don't Talk about When
We Don't Talk about Sex," uncovers the
shortfalls in doctor-patient communication
around sexual matters and examines the
barriers that may be limiting the range
of dialogue in a typical evaluation
of a woman's general health. The
study is being published today in
the Journal of Sexual Medicine.
The survey, conducted by a
team of University of
Chicago researchers,
found that
while nearly two-thirds of OB-GYNs routinely
inquire about patients' sexual activity, other aspects
of female sexuality are not routinely addressed. Only
40 percent of those surveyed routinely ask questions
to assess for sexual problems or dysfunction. Far
fewer, 29 percent, routinely ask patients about
satisfaction with their sexual lives and 28 percent
routinely confirm a patient's sexual orientation.
Given the well-established link between a sexual
function and overall health, the study's authors say their
findings point to a clear need for stronger guidelines
for doctors on conducting a thorough sexual history.
"As a practicing OB-GYN, many of my patients
say I'm the first physician to talk with them
about sexual issues," said Stacy Tessler Lindau,
MD, associate professor of obstetrics and
gynecology at the University of Chicago
Medicine, and the study's lead author.
"Sexuality is a key component of a
woman's physical and psychological
health. Obviously, OB-GYNs are well
positioned among all physicians to
address female sexual concerns.
Simply asking a patient if
she's sexually active
does not tell us
whether she
Sex
What We Don't Talk About
When We Don't
Talk About
First national survey of OB-GYN sex history
screening practices confirms narrow focus
whatdoctorsknow.com
whatdoctorsknow.com
has good sexual function or changes in her sexual
function that could indicate underlying problems."
There is strong evidence of a high prevalence of
sexual function concerns among women. Recent
studies estimate that roughly a third of young and
middle-age women and about half of older women
experience some sort of sexual problem such as low
desire, pain during intercourse or lack of pleasure.
For most, the concerns go beyond physical -- in
fact, the impact of sexual dysfunction can be far
reaching. In addition to strained relationships, many
women experience worry, shame, guilt and feelings
of isolation. If the doctor doesn't ask, patients often
assume the topic is not welcome for discussion.
"Many women are suffering in silence," Lindau
said. "Patients are often reluctant to bring up
sexual difficulties because of fear the physician
will be embarrassed or will dismiss their concerns.
Doctors should be taking the lead. Sexual history
taking is a fundamental part of gynecologic care.
Understanding a patient's sexual function rounds
out the picture of her overall health and can reveal
underlying issues that may otherwise be overlooked."
The study also takes a close look at whether factors
such as gender, age, race, medical school location,
immigration status, religious affiliation or type of
practice play a role in the likelihood an OB-GYN
will broach sexual matters. Not surprisingly, female
doctors are more likely to address sexual activity
with female patients. Doctors who see more patients
for gynecology versus prenatal care tend to screen
for sexual dysfunction more frequently than their
colleagues. OB-GYNs age 60 and older are less likely
to delve into a patient's sexual orientation or identity.
Generally, less than a third of all OB-GYNs surveyed
routinely ask patients about their sexual orientation.
Assuming heterosexuality can alienate a lesbian or
bisexual patient and result in misinterpretation of
symptoms and misdiagnosis. The report suggests this
remains an important area for further research.
"One explanation for the findings may be a deficit in
physician training about diagnosis and treatment of
female sexual problems," said first author Janelle Sobecki,
MA, a second-year medical student at Wayne State
University. "Like patients, physicians may worry that
raising the topic could offend or embarrass the patient.
Physicians, especially OB-GYNs, are better positioned
than patients to open the door for discussion."
For many women grappling with a sexual problem,
the underlying cause may be treatment for another
medical condition. Drugs regularly prescribed for
conditions from depression to breast cancer can have
a negative effect on sexual function in some women,
including low libido. Patients may be better able to
tolerate these side effects if they know to expect them.
An emerging area of concern for Lindau -- a
specialist in maintaining sexual function in cancer
survivors -- is prevention measures for patients
at high risk for developing breast cancer. Drugs
such as aromatase inhibitors and tamoxifen, which
interfere with the activity of estrogen and therefore
reduce breast cancer risk, are becoming more
widely used, including among younger women.
"Women are not being counseled on the potential
sexual side effects of these treatments, and we have
limited data to appropriately counsel them," Lindau
said. "For men with prostate cancer, in comparison,
the impact of treatment on sexual function is typically
discussed as part of deciding which therapy to try."
One reason doctors may feel more comfortable discussing
sex with men is the availability of FDA-approved
treatments for erectile dysfunction, while medical
treatments for female sexual dysfunction are limited.
The good news is that women are seeking and
demanding more information about their personal
health, oftentimes turning to the anonymity of
the Internet as a first resource. Ideally, Lindau
adds, these women are empowered by reputable
online and other media sources to know that they
are not alone in their concerns and will gather the
courage to begin a conversation with a physician.
"If you have a doctor you trust who has not brought this
topic up, give it a try," Lindau adds. "If you are waiting
for the doctor to start the conversation, it may never
happen. Communication is key." -This information
provided courtesy of The University of Chicago Medicine
whatdoctorsknow.com 8
Digitalis can reduce lung metastases
T
he spread of breast cancer is responsible
for more than 90 percent of breast cancer
deaths. Now, the process by which it
spreads -- or metastasizes -- has been
unraveled by researchers at Johns Hopkins.
Reporting in two papers, the researchers
have discovered the switch that enables breast cancer
cells to travel to and be received in the lungs.
The results appear in two separate papers, one in the
September 12, 2011 issue of the Proceedings of the
National Academy of Science Early Edition and the
other in the August 22, 2011 issue of Oncogene.
"Metastasis transforms breast cancer from a local, curable
disease, to one that is systemic and lethal," says Gregg
L. Semenza, M.D., Ph.D., the C. Michael Armstrong
Professor of Medicine, director of the Vascular Program
in the Institute for Cell Engineering and a member of
the McKusick-Nathans Institute of Genetic Medicine at
Johns Hopkins. "Metastasis was long thought a late event
in cancer progression, but we have now shown metastasis
to be an early event that is dependent on HIF-1"
Discovered by Semenza's team nearly 20 years ago,
the HIF-1 protein controls genes that enable cells
to survive in low oxygen, like cells in solid tumors.
More recently, others have found that in patients with
breast cancer, an increase in HIF-1 activity correlates
with increase in metastasis and decreased survival.
To uncover the role of HIF-1 in breast cancer metastasis
to the lungs, the research team first looked at the lung,
which is prepared for the arrival of metastatic cells
by enzymes that are produced by the breast cancer
cells. Using human breast cancer cells, the research
team examined the genes that encode these enzymes
and found regions where HIF-1 could bind to the
DNA. Since HIF-1 is active in low oxygen, the team
genetically engineered and reduced the amount of
HIF-1 the cells could make, then examined how active
the enzyme-producing genes were in cells grown in
normal or low oxygen levels. They found that the cells
were unable to produce these enzymes without HIF-1.
The team next implanted some of these same human
breast cancer cells -- some that made normal amounts
of HIF-1 and some that made reduced amounts -- into
mice and examined the lungs after 45 days. Compared
with breast cancer cells that made normal amounts of
HIF-1, those making less HIF-1 resulted in smaller
tumors and fewer changes in the lung, leading them
to conclude that HIF-1 is critical for lung metastasis.
In order for breast cancer cells to spread to lungs,
they must leave the breast, enter blood vessels that
lead to the lungs, and exit those same vessels. "Blood
vessels are pretty tight, a cell has to work pretty hard
to get through the vessel wall," says Semenza.
"Since HIF-1 triggers the lung to prepare for arriving
breast cancer cells, we wondered if HIF-1 also is
involved in getting cells into and out of blood vessels."
Breast Cancer's
Journey to the Lungs
whatdoctorsknow.com
Semenza's team used breast cancer cells grown in low oxygen to
examine the activity of 88 genes known to play a role in metastasis.
Looking for genes that are turned on in response to low oxygen,
they found one called angiopoietin-like 4 and one called L1
cell adhesion molecule, known as ANGPTL4 and L1CAM for
short. Further examination of the DNA around these genes
revealed regions where HIF-1 could bind, and removing HIF-1
from cells rendered them unable to turn on the two genes.
When breast cancer cells turn on ANGPTL4, it helps them
travel through blood vessel walls, the team found
by injecting these cells either with normal or
"knocked-down" levels of ANGPTL4 into
mice and examining their lungs. Cells
lacking HIF-1 and containing extra
ANGPTL4 were better
able to invade the
lungs than cells
without extra
ANGPTL4;
the researchers
concluded that
ANGPTL4
promotes cell
exit from blood
vessels. And they
found the same to
be true for L1CAM.
Lastly, a few years ago,
Semenza's team found that
digitalis/digoxin, commonly
used to treat irregular
heartbeats, can block HIF-1
production and can stop
liver and prostate cancer
cells from growing.
To see if digitalis could do
the same with metastatic
breast cancer, the researchers
transplanted human breast
cancer cells into mice.
After two weeks, they gave the
mice daily injections of digitalis
or saline. They found both fewer
and smaller lung metastases in
mice treated with digitalis.
"This is really exciting," says Semenza.
"The therapeutic range for digoxin is well
established, and our findings warrant clinical
trials to determine if these doses are enough to
sufficiently block HIF-1 and slow breast cancer
growth and metastasis." -This information
provided courtesy of Johns Hopkins Medicine
whatdoctorsknow.com 0
Before you read any
further, be warned. What
you are about to read
is in-depth, scientific,
specific and detailed
information about
cancer. If you prefer
your reading to be less
technical stop now. For
those of you who want
the nitty gritty read on.
whatdoctorsknow.com 0
T
here is a common expression: "the acorn
never falls far from the oak " In plain speak,
this means as your ancestors went, you will
follow. We use this principal in medicine
everyday. Among the first things we want
to know about you is your family history.
If your grandparents lived into their nineties and were
in good health, we expect the same from you. This is
because with most disease there is a significant genetic
component. If your family history is littered with
prostate cancer, breast cancer, heart disease, hypertension
and type 2 diabetes, we assume you are at high risk
for these problems. If none of your grandparents
lived past 60, we don't think you're condemned to
die by 60, but making it to 90 might be a stretch.
There are lifestyle variables such as smoking,
excessive alcohol consumption, sedentary lifestyle
and obesity due to excessive caloric intake, affecting
different outcomes. Still, if you have a family history
of these illnesses, the odds are against you.
Colon cancer is an exception to the rule. Approximately
1 in 4 patients who develop colon cancer have either
an inherited tendency or a genetic predisposition
for the development of the disease. However,
this represents a minority of those affected.
The breakdown for colon cancer development is as
follows: Out of 100 patients who will be diagnosed,
75 will have sporadic colon cancer. This means
there is no family history. Twenty of the 100 will
have a family history of colon cancer in one or more
family members and they will have an inherited
predisposition. Five of the 100 will be members of
families genetically linked to colon cancer disorders.
There are two major pathways for colon cancer. The
first pathway is a series of mutations in gene expression
within the colon cells resulting in colon cancer. This
subset comprises 100% of FAP patients and about 80%
of sporadic and inherited colon cancer. The mechanism
leading to cancer expression in these individuals is a
problem called APC (adenomatous polyposis coli gene).
In the FAP syndrome this gene is congenitally absent
and the probability of colon cancer development over
a lifetime is 100%, with most patients undergoing
cancer development by the time they are in their mid-
Colon cancer.
Genetics or Bad Luck?
whatdoctorsknow.com
20s. This group of patients is easily identified because of pronounced
family colon cancer history at a young age along with the presence of
hundreds or thousands of colon polyps on sigmoidoscopy or colonoscopy
at a very young age. Eighty percent of sporadic colon cancer sufferers
will acquire abnormality of the APC gene over the course of a lifetime.
Usually, this genetic mutation occurs in the patients 40s and requiring
about 20 years for complete transformation to colon cancer -- usually by
age 65. This will lead to cancer in about 80 percent of affected individuals.
The APC gene mutation results in cellular overgrowth cancer. From
this point, mutation of a second tumor-suppressing gene called
K-ras, results in conversion from simple cellular overproduction to
a condition known as aneuploidy. This causes disorganized division
within the cells, marking the transition from overgrowth of tissue
to adenomatous polyp, which is the precursor for colon cancer.
Beyond this, another mutation is necessary in a gene known as the DCC
gene (deleted in colorectal cancer). This is another mutation, or turn off, of
a suppressor gene required for the actual transformation from adenomatous
polyp to colon cancer only after the final step, deactivation of the p53 gene.
These mutations must occur in the proper sequence to result in cancer.
Why do we get colon cancer?
"When a mommy and daddy love each other very much and get married, something
magical happens in the mommy's tummy, and 9 months later a tiny baby is born."
What actually happens is this. With fertilization, there is
a joining of genetic material from both parents.
Immediately after fertilization, the result is a zygote and it begins a rapid
series of cellular divisions eventually leading to an adult human body
containing about 14 trillion cells in a highly specialized matrix. Early
in the development process, all cells are basically stem cells. This means
they are pluripotent (can become any type of tissue), because every cell
within the human body contains all of the genetic code for the human
body to be completely reproduced -- totaling about 25,000 genes. We
see most genes turn off with further and further cell specialization.
Cells specialize through a process known as differentiation.
Differentiation leads to specialization of cell types divided
into three subsets of cellular specialization early on.
The initial three cell specialties are:
1. Ectoderm which gives rise to the skin, eyes, hair and central
nervous system, as well as peripheral nerves.
2. Mesoderm, which gives rise to muscles bones and cartilage.
3. Endoderm, which gives rise to the internal organs.
This is an oversimplification, but this is not an article on embryology,
but rather gene expression and its role in cancer development.
The early pluripotent stem cells bear a striking resemblance
to the traits identified with cancer. These include:
1. Rapid cellular growth and division.
2. Angiogenesis or growth of blood vessels into the newly developing
tissue to carry oxygen and nutrition to the developing cells.
3. Invasiveness, which implies the ability to migrate through other tissues.
As we go from pluripotent cells of the embryo, to the completely specialized
cells of the adult, we go through a pattern of gene turnoff. Shut down of the
primitive genes and focus on genes necessary for the specialized cell function.
FAP
100%
APC Gene missing at birth.
Cancer can start by mid 20s
LYNCH
100%
MMR Leads to MSI
whatdoctorsknow.com
The development of cancer involves a process known as dedifferentiation.
This is a process in which there is a regression to a more primitive cell
type through mutations affecting genes turned off during specialization
that are reactivated. This will result in repeat expression of primitive
or primordial traits, which leads to the aggressive pluripotent cell type
behavior responsible ultimately for the development of cancer.
The biochemistry of gene shutdown
Gene shutdown usually comes from a process in biochemistry known as hyper
methylation. This involves the addition of the methyl group to the 5 prime
carbons of cytosine nucleotides in the DNA chain. Methyl groups are thought
to serve as signaling sites, but with excessive methylation of the gene, it will no
longer be read or produced by the cell. In the case of differentiation, this is the
mechanism for gene turnoff. In the case of colon cancer development, it involves
the turnoff of suppressor genes, including the APC gene, the K-ras-gene and p53.
Gene activation is restarting of genes turned off during specialization, by
methylation described above, but in the presence of free radical hydroxy
groups, which are part of the free radical cascade. These free radical hydroxy
groups will cause a process called hydroxylation in which the hydroxy group
becomes attached to the methyl group as an unintended consequence leading
to activation of the gene once again. This enables re-starting of the gene
formerly shutdown to express primitive traits and the type of pluripotent
cell activity of division and invasiveness attributed to cancer cells.
Cells with a high metabolic rate tend to have a rapid turnover. This is because of
the hydroxylation in the presence of hydroxy free radicals, leading to corruption
of the genetic code, which leads to activation of the p53 gene, causing apoptosis
or cell death. For this reason, we see frequent mutations in cells with a high
turnover rate that are also induced by errors in the copying of the cell genetic
code. It is thought that it takes about 1000 cycles of cell division to result in
mutation, which is why we see cancer expression at a very young age in patients
with congenital APC mutation, leading to familial polyposis and in a more rare
subset of cancer patients born without K-ras gene, a condition called Li-Fraumeni
syndrome. These patients have very high rates of cancer development at a very
young age. This makes sense, since rapidly developing cells turning over every
3 days will have about 10 years before significant mutations begin developing.
The sequence of mutations leading to most cases of familial
polyposis related colon cancer as well as most cases of
sporadic and inherited colon cancer includes:
First. The loss of the APC gene function either acquired
or congenital leads to rapid cell overgrowth.
Second. Either congenital or acquired loss of the K-ras
gene leads to disorganized division in the nucleus. The
growth now becomes an adenoma (pre-cancer).
Third. Loss of the DCC gene is further loss of control of the cell life cycle.
Fourth. Permanent loss of the function of the p53
gene. Conversion from adenoma to cancer.
The second pathway to cancer development affects the patients with Lynch
syndrome and the 20 percent of the sporadic colon cancer patients. These
patients will develop colon cancer because of gene regulation failure,
however the failure comes from a slightly different process. This failure
is from a defect in the genetic mismatch repair system "MMR ". This is
an error within the cell affecting the fidelity of the DNA copying during
cell division. Failure of the MMR system can result in what is termed
microsatellite instability or "MSI ". This causes either shortening or
lengthening of the code and leads to improper gene expression, resulting in
failure to recognize the gene properly and subsequent cancer development.
ALL Colon Cancer
Inherited 30%
LYNCH 4%
FAP 1%
SPORADIC 75%
75%
1%
4%
30%
Sporadic Cancers(75% of all Cancers)
APC Gene lost around age 40.
MMR repair gene defect leads
to Microsatelite instability.
Leads to cancer in the 40s
25%
75%
whatdoctorsknow.com
Of those patients with Lynch syndrome, about 80 percent
will develop colon cancer in their mid 40s. This genetic
defect is also the culprit in approximately 20 percent of
the populations sporadically occurring colon cancer.
The sequence of mutations leading to development of
colon cancer in patients with Lynch syndrome includes:
First. Abnormality of MMR, the mismatch
repair system which allows for:
Second. Microsatellite instability resulting in
abnormal gene expression and copying, then:
Third. Failure of p53 gene to kill off the abnormal, resulting
cells with chromosomal defects (this remains controversial).
The Expected age of colon cancer development
based on pathway to development.
1. Sporadic colon cancer and acquired APC mutation usually presents
with polyp around age 50 with cancer shortly after age 60.
2. Lynch syndrome typically with polyps starting around
mid-20s with colon cancer by the mid 40s.
3. FAP 100% certainty of colon cancer development by the mid 20s.
It is possible that both the failure of the MMR system and the APC
gene loss are actually separate pathways mediated by the same final
common pathway, which is p53 gene turn off, since anywhere along
the way the p53 gene can activate the cell kill switch to stop the
developing problem. For this reason, it may not be that important
how we get to the point of the p53 failure, but that the failure
occurs. The major clinical importance of how we get there has more
to do with treatment strategies. Let it suffice to say, no matter how
we arrive at the permanent turn off of p53, it is the point of no
return. In fact, this is the final common pathway in approximately
50 percent of all human malignancies, not just colon cancer.
The role of the p53 gene in healing, similar to cancer development
The human body is a fairly steady system. Without injury or
infection, the production of cells within the body is driven
primarily by the rate of cell turnover in the given organ system.
We are born with the same number of brain cells we will have for
the rest of our lives. We may have enlargement of muscles cells,
but for the most part, they do not die rapidly or turnover. The
same is true of our bones and other connective tissue. Much of
our cell turnover comes in the skin, the hair, the lining of the
digestive system and glandular tissue such as the breast or prostate.
And finally, production of blood and immune system cells.
We see an interruption of this body stability in an injury or
infection. When this happens, an aggressive assault is triggered by
the immune system to repair the affected area tissue and to allow
rapid cellular development growth and repair. Your immune system
is composed of a number of different types of inflammatory cells
circulating throughout the blood stream. These cells are responsible
for looking for any abnormality within our bodies and attacking
that abnormality. These cells include neutrophils, lymphocytes,
and monocytes. They produce a number of chemical mediators
such as lymphokines and cytokines, allowing for the following:
1. Movement of cells through blood vessel walls and across tissue planes.
2. Growth of new blood vessels into the affected area.
3. Turn off of cell suppressor gene p53 to allow rapid growth of
new cells to replace injured, damaged, or destroyed cells.
STEM CELL
Methylations
turns Off
primitive
need genes
Hydration from
free Radical
overload.
Re-activates
aggressive genes
Turn off APC
by Hyper-
methylation
overgrowth of
normal cells
Normal
cell rapidly
producing
Turn off K-RAs
Primitive
genes allow
clonal growth
invasiveness
spread.
Specializes Cell.
Stable cells do only
assigned work.
Normal
suppressor genes
(k-ras,APC,P53)
cell kills itself
by triggering
cell death.
Aneuploidy.
Abnormal
chromosomes
in various stages
of development.
Adenomateous
polyps.
Damage cell
becoming
more
primitive.
whatdoctorsknow.com
If this sounds familiar remember, these are the same
traits seen in stem cells prior to differentiation and
in cells after mutations allowing dedifferentiation
of stable differentiated cells to become cancer.
Interestingly, it is the p53 gene that is modulated at
the time of injury or infection, allowing the alteration
of the cell life cycle with rapid cloning of individual
cells for the repair process. This is probably achieved
through a process called hyper methylation, which
refers to the addition of methyl groups to the 5 prime
carbons on cytosine molecules within the sequence
of the p53 gene genetic code, which has a silencing
effect. This silencing of p53 permits the aberration of
the cell lifecycle and even of cell death development.
The difference between cancer and healing is
simply reversible versus irreversible P53 turn off.
With resolution of the infection or inflammation, or
with treatment with anti-inflammatory medications
such as aspirin, we can see normalization of the
p53 gene function resulting in a return to normal
cell cycle, the stoppage of rapid growth cells,
and a return to normal life cycle of the cells.
Yes, you did read that aspirin has the ability to reverse
inflammation, and at the same time restart the p53
gene. This raises the question of whether aspirin can
be used to treat cancer. We know it cant, but we also
do know there is a role for aspirin in the prevention of
cancer. Its use is already recommended for patients over
50 for prevention of stroke and heart attack. But study
after study has shown a correlation between regular
aspirin usage and the decrease of polyp development for
the type necessary for colon cancer development. There
is no current recommendation for the use of aspirin
for colon cancer prevention because current wisdom
suggests the risk of ulcer development with aspirin could
outweigh the potential benefit. Another way to look at
it is if aspirin is already recommended for adults over
50 for other purposes, the benefits could be derived,
even in the absence of a specific recommendation.
How aspirin can reduce cancer risk
A good example of the inflammatory response effects
on colon cancer development may be seen with a
brief review of ulcerative colitis. Ulcerative colitis is
a type of autoimmune inflammatory bowel disease.
This condition results from a mistake in the immune
recognition system, "the body recognizes the lining of
the colon cells as being foreign, or transplanted and tries
to destroy the colon cells through the immune pathway.
This is an example of the friendly fire mechanism
whatdoctorsknow.com
or self-destruction of the body through immune
recognition errors characterized by an enormous
amount of human pathophysiology, a recurring theme
in medicine. "This results in a chronic inflammatory
state and raises the lifetime cancer risk from about
4 percent to around 16 percent. It is now becoming
accepted that treatment of ulcerative colitis with low
dose derivatives of aspirin will reduce the risk of colon
cancer and chronic colitis patient's from 16 percent back
down to a more manageable 8 percent lifetime risk.
Role of inflammation in cancer
It is worth mentioning the contribution to cancer
development and proliferation provided by the
body's immune system to cancer development. We
have already seen how inflammation causes changes
resulting in cellular reactions similar to cancer onset.
It should be noted, the body has a significant immune
response to cancer cells, which can actually result in
reversal of a tumor and even complete stoppage of
cancer development. It is not yet clear whether the
defect is in the immune system, which allows some
types cancer to develop while stopping others.
Possible future treatment through p53 activation
Much attention is being given to the p53 gene, both in
its normal function, its healing and fighting infection
ability and its ability to restore the body to its normal
state and finally, its final and complete suppression
that results in the development of cancer in so many
situations. We will update any new changes in colon
cancer treatment, not only during colon cancer screening
month, but any time new information becomes available.
Where do we go from here?
I would summarize by saying progression from normal
cells to cancer cells involves activation of primitive growth,
promoting genes in combination with the turnoff of
tumor suppressing genes. It is the combination of these
two factors that leads to most colon cancer development.
We are now standing at the threshold of what I think
will be a great age of discovery and hope. The first
chemotherapeutic agents were derived from mustard
gas in the chemical warfare labs of World War I. The
principal was to kill cells that developed rapidly, giving
these poisons at a dosage that would hopefully kill the
cancer cells without killing the human host. We are
still using chemical warfare with 5-FU and leucovorin
as the primary mainstays in the war on colon cancer.
That is changing with a better understanding of the
genetic abnormalities involved and the development
of more targeted therapies, including monoclonal
antibody therapies. I do not pretend to know where this
will lead, but I think that we are on the right path.
This is small consolation to those already
afflicted with colorectal cancer, but it holds out
great hope that eventually we may see an end
to the war on cancer. -Steve Porter, MD
Hes one
more reason
air standards
matter.
Big polluters and their allies cant ignore the facts:
more pollution from power plants means more childhood
asthma attacks. Mercury, arsenic, dioxin and other deadly
toxics threaten the air we breathe and the health of our
children. Theres technology that makes the air cleaner,
but too many plants dont use it.
We cant waitEPA must update power plant standards
to protect our kids.