What can I do to help prevent heart disease?

Denise M. Dietz, MD, MS, FACC
Cardiology Associates of Richmond

According to the American Heart Association, Heart disease – also called cardiovascular disease and coronary heart disease – is a simple term used to describe several problems related to plaque buildup in the walls of the arteries, or atherosclerosis. As the plaque builds up, the arteries narrow, making it more difficult for blood to flow and creating a risk for heart attack or stroke.

Men and women experience similar symptoms for heart attack, with the most common being chest pain and discomfort. Classic angina, or chest pain due to low blood flow to the heart muscle, is typically described as uncomfortable pressure, fullness, squeezing or heaviness over the left anterior chest.  It can radiate to the left arm or jaw, and is usually brought on by exertion.  It can last for several minutes, it may come and go.

Women can experience a heart attack without these typical symptoms.  Instead, they may experience atypical symptoms such as pain or discomfort in both arms, back, neck, and stomach. They may develop shortness of breath, with or without chest discomfort.  Other signs may include breaking out in a cold sweat, nausea, or lightheadedness.  Their symptoms may be more subtle.  Diabetic women are more likely to present with atypical symptoms.

There are many steps you can take to help prevent heart disease, but they all require being proactive and taking action to control your risk factors. Start with the following activities:

1.   If you smoke, quit. Smoking is one of the strongest risk factors, and thereby strongest predictors of not only heart disease, but almost all vascular disease, including peripheral vascular disease. Talk with your primary care doctor about programs and products that can help you quit. Also, try to avoid secondhand smoke.

2.   Manage your blood pressure. Hypertension, or elevated blood pressure, is a risk factor for heart disease.  Seeing your primary care doctor for routine wellness checks will provide screening blood pressure readings.  If your blood pressure is elevated talk to your doctor about treatment – which will include therapeutic lifestyle changes and can include pharmacologic treatment.

3.   Know your cholesterol. Hyperlipidemia, or elevated cholesterol numbers, is a strong risk factor for heart disease.  Get a screening lipid panel and talk to your primary care doctor about the results.  Based on your results and risk factors, your doctor will decide if you warrant further treatment. 

4.   Avoid diabetes. Diabetes patients are at high risk for developing heart disease, so much so that diabetes is considered a heart attack equivalent. Get screened for diabetes.  If you have already been diagnosed with diabetes, manage your condition collectively with lifestyle changes (diet and exercise) as well as pharmacologic treatment. A diagnosis of diabetes brings about unique indications for pharmacologic treatment of cholesterol and blood pressure. 

5.   Know your family history.  Family history of heart disease, particularly at younger ages, puts you at risk for developing heart disease yourself, and is taken into consideration by your doctor to determine your overall risk for heart disease.

6.   Maintain a healthy and nutritious diet. A healthy diet includes a variety of vegetables and fruits. It also includes whole grains, fat-free or low-fat dairy products, and protein foods, such as lean meats, poultry without skin, seafood, processed soy products, nuts, seeds, beans, and peas.

7.   Reduce stress, as stress can bring about heart disease. Find ways to manage your stress, by engaging in activities that you enjoy.

8.   Exercise. Regular exercise will help prevent heart disease, and it will help prevent you from developing risk factors that are associated with heart disease. 

For further inquiries about heart disease or cardiovascular health, contact Denise M. Dietz, MD, MS, FACC, of CardiologyAssociates of Richmond, at 804.560.8880, or visit their website at cardiologyrichmond.com.

I Feel a Breast Lump - Now What Do I Do?

Eric P. Melzig, MD
Richmond Surgical

One of the scariest moments for a woman is when she feels a lump in her breast, with the human nature of fearing the worst taking over. Thoughts of a cancer diagnosis become the immediate concern; anxiety then enters the picture, along with the perception of a negative outcome. The good news is the vast majority of breast lumps are benign and harmless. A similar scenario plays out when a woman is informed that her mammogram is abnormal and further imaging is indicated, with the vast majority of mammogram abnormalities being benign.

The evaluation of a new breast lump should begin with a visit to one's primary care physician or gynecologist. Your physician will perform a dedicated history and physical examination with emphasis on factors influencing breast health. Key features of the history include the presence or absence of nipple discharge, pain, or lymph node swelling. Is there redness of the breast associated with the lump? This may indicate mastitis. If one is premenopausal, has the breast lump changed in size and texture over time, and does this correlate to the timing of the menstrual cycle? If nipple discharge is present, is it clear or bloody, and is it spontaneous? Much information can be gleaned from a detailed history, which can be segmented into the below parts:

Risk Assessment

A detailed personal risk assessment will not necessarily dictate treatment of the newly discovered lump but can add perspective. Risk analysis is helpful in planning a long-term approach to breast health and a screening strategy. The salient risk factors, in order of importance, are:  1) personal history of familial genetic mutations (Angelina Jolie's BRCA1 and BRCA2 mutation, for example); 2) personal history of previous breast cancer; 3) personal history of non-malignant proliferative benign disorders (sclerosing adenosis, ductal hyperplasia or atypical ductal hyperplasia, for example); 4) breast density on mammography; 5) family history of breast cancer; and 6) previous radiation therapy to the chest (for example, Hodgkin's disease treatment). The risk factor generating the greatest misconception is a positive family history of breast cancer, with women automatically suspecting doom when they feel a breast lump. Conversely, women with negative family history tend to feel bullet proof. Both concepts are incorrect, as the status of the family history is an important factor, but breast cancer is multifactorial and family history is only one of many risk components. Ultimately, most breast cancer patients have a negative family history of breast disease and the majority of patients with breast cancer (60%) have no identifiable risk factors.

Physical Examination

The breast exam alone can lead to a benign diagnosis without imaging or biopsies. Findings such as mastitis, fibrocystic changes with associated breast thickening, waxing and waning masses associated with one's menstrual cycle, and lesions that are actually in the skin and not in the breast can all be readily diagnosed as benign entities. If the palpable lesion is indeed a true mass on physical exam, then breast ultrasound is the preferred method of evaluation. Ultrasound will distinguish a benign simple cyst from complex cysts and solid lesions. This distinction can lead to an ultrasound-guided cyst aspiration and resolution of this benign lump or it can point to the need for further investigation with additional imaging.

Diagnostic Mammogram

After intake of a patient’s history and a physical exam, a diagnostic mammogram is the next tool for patients aged 35 and older. If less than 35 years of age, the accuracy of a diagnostic mammogram significantly decreases due to the natural breast density of a young woman, as breast density naturally decreases with age. For those under 35, a solid lesion can best be diagnosed with an ultrasound-guided needle biopsy. At this young age, the high percentage diagnosis is a benign fibro-adenoma.

For those over 35, the diagnostic mammogram will yield important information concerning the nature of the mass. Is it smooth or are the borders irregular? Does it create architectural distortion? Are there any other lesions present that are too small to be palpated? The recent introduction of 3D tomosynthesis with mammography adds detection sensitivity. Needle biopsy using mammogram imaging is called a stereotactic biopsy. Imaging with breast MRI is very sensitive in detecting breast abnormalities and is especially helpful in patients with dense breasts. If a lesion is not visualized on mammography, 3D tomosynthesis or ultrasound, then a needle biopsy using MRI image guidance is the preferred diagnostic option.

Multiple well-controlled, large, randomized studies document that annual screening mammography saves lives. As a cancer is evolving, mammography leads to early detection. If the malignant process is diagnosed earlier in its natural history, we are lead to higher cure rates and less severe treatments. Despite some controversy, mammography lowers the risk of dying from breast cancer and should be a mandatory component of every woman's healthcare plan.

It is important to note that men are not exempt from breast cancer. While women account for 99% of breast cancer diagnoses, men are still at risk and 2,000 men per year in the United States are diagnosed. Therefore, men must fight their usual reluctance to seek medical attention and have any breast lumps examined by their physicians.

Do not panic if you find a breast lump on self-exam. Benign diagnoses far surpass malignant diagnoses. Remain calm and consult with your treating physicians. Personal history, physical examination, imaging, and, if required, image-guided needle biopsy will most likely lead to a benign diagnosis, ruling out malignancy.

For further inquiries about breast cancer management and advancements, or HCA Virginia’s Breast Care Network, contact Eric P. Melzig, MD, of Richmond Surgical, at 804.285.9416, or visit their website at richmondsurg.com.

The Pill - Still Not Just for Birth Control!

Catherine Bagley, DO
Commonwealth Ob/Gyn Specialists

In 1957, the medication now known as “the pill” was approved by the FDA for menstrual disorders. Coincidentally (or not), when the pill became available, thousands of women suddenly developed menstrual disorders. Three years later, the FDA officially approved the combined estrogen and progesterone pill for contraception. Today, over 100 million women are taking the pill worldwide and the question remains, are we taking full advantage of the benefits the pill has to offer?

The pill was the first medication approved by the FDA for long-term use in healthy patients and it still functions as a go-to drug for many different clinical situations. The pill works primarily through influencing the hormones that cycle in women naturally, estrogen and progesterone. There is a progesterone-only pill that works somewhat differently than the combined hormone pills and is an appropriate clinical choice for patients unable to take estrogen.

Estrogen stabilizes the uterine lining, reducing breakthrough bleeding and significantly lightening bleeding for each month that patients are on the pill. Eventually, researchers discovered that estrogen also inhibits the development of eggs and helps to prevent ovulation. This combination of effects resulted in a treatment for menstrual disorders as well as providing contraception. Today, there are many different combinations of the amount of estrogen as well as the amount and type of progesterone available in different medications, including a combination transdermal patch and a removable vaginal ring.

In the development of the pill, a hormone-free week was built into each month in order to provide the patient with reassurance that she was not pregnant. During this week, a patient may take placebo pills or no pills at all.  Typically, she will bleed during this week, and some patients will mistake this for a period, when it is not. The hormones in the pill prevented ovulation and stabilized the lining of the uterus; the bleeding that may occur is merely the uterus responding to the withdrawal of the hormones. When I counsel adolescent patients about the use of the pill, I often answer questions from patients’ mothers about the safety of continuous dosing, i.e. avoiding the week of inactive pills built into a typical four week pill pack. Historically, that week of bleeding was considered normal, but continuous dosing is very safe and is an excellent option for many patients. Some of the newest versions of combined pills are designed to minimize bleeding, representing a shift toward recognizing not only the safety of continuous use, but the importance of giving women more control over their cycles. 

For many women, periods interfere with school, life, and/or social activities.  Whether a woman suffers from heavy bleeding, painful periods, fatigue due to chronic anemia (because of heavy bleeding), headaches, or mood changes, the pill can often help alleviate those symptoms. Pelvic pain, either because of painful periods or other conditions, such as endometriosis or fibroids, is one of the leading causes of women missing school and work. Many patients who are treated with the pill are able to function at the level they were accustomed to prior to the pain. Continuous use of pills can resolve the symptoms of pre-menstrual dysphoric disorder for many patients.

Beyond controlling reproductive cycles, there are other benefits to the pill. These include: the potential to slow excess hair growth and acne because they suppress production of the male hormone, prevention of menstrual migraines, improving bone mineral density, normalizing irregular periods, and allowing women to avoid having their period at inconvenient times, such as during a business trip, vacation, or honeymoon.

The scientific evidence shows that the longer a woman uses the birth control pill, the lower her risk for developing endometrial and ovarian cancer later in life, up to 20 years after discontinuing use. The pill also seems to offer some short-term protection against colorectal cancer among current or recent users. Women using the pill for non-contraceptive benefits, generally return to fertility soon after discontinuing the medication. On the opposite side of the coin, women who have completed child bearing and may be entering the perimenopausal state can benefit from the hormone balance the combined pill provides. Because of recent legislative changes, most every financial barrier to the pill has been eliminated, which is terrific news for our patients.

All medications carry some degree of risk and it is important for patients to know whether or not the pill is safe for them. Early formulations of the pill contained high levels of hormones; the pills available today have approximately one third the amount of estrogen as the first version of the pill. Estrogen carries very specific risks that are increased in certain patient populations. Patients with a history of any bleeding disorders, especially venous thromboembolism (VTE), deep venous thrombosis (DVT), and/or pulmonary embolism (PE), are not candidates for combined pills. Patients who are over the age of 35 and are smokers are also not candidates for combined pills.  For these patients, the estrogen in the pill increases their risk of developing blood clots.

In addition to the medical risks that medications carry, there are typically side effects that can dictate whether or not someone is able to tolerate a medication that has been deemed clinically appropriate and safe for that patient.   Side effects of the pill are interesting because some of them are the very symptoms that the pill helps to improve.  They can include: nausea, vomiting, hypertension, headaches, mood changes, and alterations in libido. If patients fail therapy with the pill, there are other options. With advances in minimally invasive operative technology, in addition to procedures that have been performed for many years, definitive surgical treatment is available to some patients. However, not every patient is an ideal surgical candidate; for those patients as well as the patients who want to avoid surgery, a different version of the pill (or a different delivery method of the combined hormones) may be a viable alternative.  

For further inquiries about the pill, contraception or general gynecology, contact Catherine Bagley, DO, of Commonwealth Ob/GynSpecialists at 804.285.8806, or visit their website at commonwealth-obgyn.com.

Menopause: What’s New, What’s True, and What do I Do?

Karen Knapp, MD
Commonwealth Ob/Gyn Specialists

Laura (not her real name) visits every year for her annual gynecologic exam. We have known each other for many years, but today, she is not herself. Laura’s periods have become less regular, and she has hot flashes some nights that disrupt her sleep. Some months she feels like her old self with regular periods, but other months, her periods are accompanied by severe cramps and breast tenderness. Laura is understandably distressed and wants to know what is happening.

Laura is experiencing the typical symptoms of perimenopause. This is when her periods become less predictable before eventually stopping at full menopause. This lack of predictability is from her brain’s response to the aging of the remaining eggs in her ovaries. To have a period and ovulate (pass an egg), a woman’s brain must send stimulating hormones to her ovaries. With ovulation, the ovary makes estrogen and progesterone, but as the ovaries age, the brain has to issue increasingly higher levels of its stimulating hormones, with the ovary not always responding. All of Laura’s symptoms are explained by this “waxing and waning” of her ovarian function. How do we help with her symptoms?

She needs to understand that it’s all normal, but understanding what may not be normal is just as important. Periods every 21-35 days during perimenopause are normal, while bleeding at intervals less than 21 days or bleeding more than eight days at a time is not normal, and indicates a need for further evaluation by a gynecologist.

Laura must also remember she is still at risk for pregnancy during perimenopause. Low-dose birth control pills or a progesterone intrauterine device are good choices for contraception as they also help regulate bleeding. If contraception is unnecessary, bioidentical progesterone can be used to regulate periods while soy and black cohash can help alleviate hot flashes. Laura decided she would just ride it out and see what happens.

Laura came back 8 months later having had no periods. Hot flashes, sleep disturbances, mood changes, and irritability had really begun to interfere with the quality of her life. Information from the internet and bookstores just confused her more. What does Laura do now?

Menopause can be divided into “early” menopause (no period for six months) and “late” menopause (no period for one year). Laura is between, having had no periods for eight months. We know her stimulating hormones are elevated as her brain tries to get her ovaries to work, but they no longer produce eggs and only make low levels of estrogen. This combination affects the body’s “thermostat” and causes the hot flashes, leading to sleep disruption, fatigue, irritability, and mood changes. Low estrogen can also cause mood changes and increase susceptibility to anxiety and depression, with accompanying physical changes. Vaginal dryness, pain with intercourse, decreased libido, joint pain, and decreased elasticity of the skin can also be experienced. Fortunately, there are a variety of options to help alleviate Laura’s symptoms.

Hormone replacement therapy was once the most commonly prescribed treatment, but we now know it can increase the risk of heart attack, blood clots, stroke, and breast cancer, regardless of the type of therapy used or its route of administration. Furthermore, contrary to popular belief, both bioidentical and non-bioidentical preparations carry these risks. Despite this, hormone replacement therapy is still the most effective way to alleviate menopausal symptoms, but it must be used with caution and with the understanding that the symptoms will return when the hormone replacement is stopped.

In 2013, the Food and Drug Administration (FDA) approved paroxetine (Brisdelle), a serotonin reuptake inhibitor anti-depressant, for the treatment of hot flashes. Neurotonin or gabapentin, long used for the treatment of chronic pain, can be helpful as well, but may be overly sedating at undesirable times. With mood changes, again, paroxetine may help, both as an anti-depressant and in promoting restful sleep. There’s a good chance that a full night’s sleep will help Laura’s mood improve.

Vaginal dryness, pain with intercourse, and decreased libido are also common during perimenopause. Bioidentical estrogen preparations for the vagina and vulva dramatically relieve the dryness and decrease libido by keeping estrogen levels in balance, and Osphema, an oral medication for vaginal dryness, has recently also been approved by the FDA.

Non-pharmacologically, numerous other treatments for the symptoms of menopause have been widely studied, but with varying results. These include vigorous aerobic exercise, yoga, hypnosis, paced breathing, mindfulness meditation, and acupuncture. As mentioned earlier, herbal supplements such as soy and black cohash may help, but dong quai, ginseng, kava, and evening primrose have not been found effective and can instead have serious side effects.

Laura decided to try a local estrogen supplement for her vaginal dryness and an anti-depressant for her hot flashes, and she increased her exercise. Six weeks later, her symptoms were not entirely gone, but she was managing them well and was much happier.

Over the past 20 years, a better understanding of the physiologic changes of aging in women has led to vast improvements in menopausal medicine and the treatment of disruptive symptoms. To find the latest information on menopause and to locate a certified menopause practitioner, visit the North American Menopause Society website at www.menopause.org.

For further inquiries about menopause management or general gynecology, contact Karen Knapp, MD, of Commonwealth Ob/Gyn Specialists at 804.285.8806, or visit their website at commonwealth-obgyn.com.

Minimally Invasive Surgery – What Every Woman Needs to Know

Prescott W. Prillaman
OB/GYN Specialists of Richmond

Traditional abdominal surgery uses a single large incision to accomplish a goal. In obstetrics and gynecology, removing a large uterus or cancer treatments have historically been performed with these “open” surgery methods, as some procedures can only be accomplished with a larger incision. Modern technology has progressed and now allows for better visualization with cameras. Laparoscopy allows for the surgeon to use a small telescope and a camera to visualize the abdominal cavity through a 1 centimeter or less incision. Instruments that can better mimic the human hand have been developed, and newer methods allow many surgeries previously requiring a prolonged recovery and more post-operative pain to be accomplished through smaller incisions with less pain and a fraction of the recovery time. The most experienced surgeons are usually involved with programs that have a commitment to surgical innovation and forward thinking.

The development of laparoscopy in the 1980s led to innovations that allow surgeons to perform minor surgeries such as diagnostic laparoscopies and tubal ligations. The 1990s ushered in hysterectomies that were assisted with laparoscopy. The 2000s started robotic-assisted surgery and single-site surgeries that now allow for most gynecologic surgeries to be performed using minimally-invasive techniques. In 2011, the first single-site robotic-assisted total hysterectomies in the Mid-Atlantic were done in Richmond.

Most laparoscopic surgical procedures use one or more 8-12 millimeter incisions. Some surgeons feel that this method is the best for most procedures, but it usually requires more than one incision. The diverse instrumentation has been developed over many years, and most outpatient abdominal and gynecologic surgery can be accomplished with this method.

Single-site surgery elevates general laparoscopy to an approach that only uses one 20-25 mm incision. This method usually requires a specialized port that allows for the camera and several instruments to be inserted from the same site.  Benefits of this method include a single surgical site and less post-operative pain, with some patients able to return to their daily lives sooner, as well as a better cosmetic result.

Robotic surgical procedures help the surgeon to perform with greater precision due to advances in optical magnification and a development that enables the “robotic arm” to move with the same flexibility of the human wrist. Three to five incisions are usually required to perform the surgeries. Visibility using magnification is 10 times greater than regular laparoscopy. The improvements with robotics allow the surgeon to evaluate and work on areas that cannot be accessed with traditional surgery.

The combination of single-site surgery and robotics has provided the opportunity to perform standard laparoscopic surgeries with better visibility and dexterity through a 25-35 mm single incision, allowing the surgeon to have more precise movement and less tissue trauma. This method also allows for less post-operative pain and faster recovery.

All of the above methods require substantial education and experience to perform.

If you are in need of surgery, it is very important that you are aware of all available options. Most patients are not as concerned about the surgeon’s technique as they are for the concerns of going to sleep and waking up, worrying about what might be found during surgery, and how much the surgery will hurt.  Your doctor should explain the risks, benefits and alternatives of the surgeries.

To get prepared for surgery, there are several online resources that can help you better understand the methods.  Sites will discuss the particular methods and blogs can help you explore previous patient experiences. Unfortunately, it is difficult to determine if the information you receive on the web is accurate and reliable. Web rating sites for physicians can also be helpful but their information can sometimes be outdated or incorrect. Be informed. You and your physician are a team with the same goal working toward the best outcome.

For further inquiries about minimally invasive surgery, contact Prescott W. Prillaman, MD, of OB/GYN Specialists of Richmond at 804.673.8791, or visit their website at ob-gyn-specialists.com.

Women’s Health at Every Age - Prevent Illness and Stay Healthy

Julie H. Ladocsi, MD
Richmond Women's Specialists

Gynecological care emphasizes women’s health maintenance in ways that primary care visits do not. We can assist in early detection of diseases, preventive medicine, and develop a customized care plan that facilitates total health based on family history, lifestyle, nutrition, and current risk factors for illness.

There is significant overlap of medical care between age ranges for women, and we try to understand your total health picture so we can develop a long-term care plan.

In your teens… You should establish a relationship with an OB/GYN with whom you feel comfortable and can discuss health issues honestly. We will address concerns regarding menstrual issues, contraception, and prevention of sexually transmitted diseases. We will discuss appropriate vaccinations, including prevention options for HPV, the virus that causes cervical cancer. Internal pelvic exams are unnecessary at this stage unless needed to address a specific problem. Open and honest dialogue with parents or guardians is encouraged at this time.

In your 20s… PAP smear screening for cervical cancer begins. Clinical guidelines recommend PAP smears every 3-5 years; however, gynecologic exams should still be administered annually. We will also discuss the HPV vaccine with you if you haven’t already been vaccinated. We will continue to work with you on contraception management and STD prevention and screening. This is also normally the time when we will begin pre-conception planning and even reproductive management, if you’re starting to have children.

In your 30s… We will focus on many of the items we’ve discussed in prior years, but this is when many women will be having children and managing the accompanying physical changes. Contraception and reproductive management are still a priority, as well as managing routine screenings. Pelvic and menstrual problems can surface during this decade, and we will develop a care plan for those if necessary.

In your 40s… Screening mammograms for breast cancer begin with regularity and we will discuss menstrual changes related to age. HCA Virginia has a robust imaging network and multiple options for screening locations. We will also continue reproductive planning and post-partum issues as appropriate.

In your 50s… We continue to focus on breast health with annual screening mammograms and clinical breast exams. Colorectal screening begins in earnest in this decade, as well as management of perimenopausal and menopausal physical changes. For some women, urinary health can also be an issue and we will address that as necessary.

In your 60s… We will screen for breast and pelvic abnormalities and begin bone density testing (earlier for high-risk patients). Menopause management can still be a concern and we will address those issues accordingly.

In your 70s and beyond… Our priority will be prevention of osteoporosis and reducing fracture risks. We will continue to screen for pelvic and breast abnormalities, as well as manage gynecologic and urinary health.

Women’s health and preventive medicine is a fluid dialogue over many years between the practitioner and the patient. We hope to develop a longstanding relationship with you so we can effectively manage the continuum of your health in a way that promotes great communication and overall well-being.

For further inquiries about women’s health contact Julie H. Ladocsi, MD, of Richmond Women’s Specialists, at 804.267.6931, or visit their website at richmondwomens.com.

Changes in Breast Cancer Management in the Last 40 Years – Evolution to Revolution

George A. Knaysi, MD
Richmond Surgical

All cancers are caused by abnormalities in a person’s genes.  Some of these abnormalities (mutations) are inherited and some are acquired by life activities, like smoking. While breast cancer has become more common in the forty years since I began to practice breast surgery in Richmond, the cause for the increasing incidence is unclear.  For example, we know that the risk is elevated in women who are obese or who drink alcohol, but the increased risk is small. Every week we see someone with breast cancer who has a negative family history, but seems to do all of the right things relative to diet and lifestyle. Why does this happen? Unfortunately, we still don’t know.

It takes multiple genetic abnormalities to eventually result in cancer.  These do not happen all at once, and some of the changes might begin many years before the cancer actually develops.  While it appears there are four major types of breast cancer, there is significant genetic variation even within each type. When we have a clearer understanding of this, drugs can be designed to stop the abnormalities from developing or progressing.  When that happens, breast cancer will become a medical, not surgical illness. That scientific breakthrough will change everything – and eventually it will happen.

While we wait for a revolution based on a better understanding of cancer genetics, I would like to emphasize multiple significant evolutionary changes which have taken place in the last forty years.  When considered together, they have allowed us to increase survival and in most cases, decrease pain and deformity:

Earlier Detection

Early detection is the single most significant reason for increased survival. In 1973, there was essentially no mammography, and what was available was of poor quality. Patients presented with larger masses and more involvement of lymph nodes, and as a result, survival rates were lower. With digital mammography, and now tomosynthesis (3-D mammography), tiny cancers can be detected.  This allows for more surgical options and increased survival.  While a recent Canadian study refutes that, in my view, that study is flawed, and also contradicts the results of multiple other studies. If the quality of the mammogram is poor, early cancers will be missed and the survival advantage of mammography is lost.

Another advance is that almost all breast biopsies can now be done in an office with a needle rather than surgery.  When I started practice, a breast biopsy meant an operation under a general anesthetic with two nights in the hospital!

Increasing Surgical Options

Forty years ago, the standard operation for cancer was the Radical Mastectomy. The breast, underlying muscles, and many lymph nodes were removed along with the overlying skin. A skin graft was frequently used, making this surgery more painful, and extending the hospital stay. Because of the extensive lymph node removal, arm swelling (lymphedema) was common. During the 1970’s, the Modified Radical Mastectomy became the standard and is still performed today. This procedure removes the breast but leaves more of the overlying skin and all of the underlying muscle. By the 1980’s, surgeons began doing Lumpectomies if the tumor was small enough and the patient preferred to avoid a mastectomy. This procedure involves removing the lump and some normal surrounding tissue and is followed by radiation.

There have been two other significant advances. One is the Sentinel Node Biopsy, where dye is injected into the breast before and during surgery. This demonstrates which underarm lymph nodes would most likely have cancer.  We remove those (usually 1-3 range) and if they are negative, we leave the remaining, presumably normal nodes alone. This diminishes the chance of arm swelling if the nodes are negative.

Another increasingly common operation is a unilateral or bilateral Skin Sparing Mastectomy. Here, all of the breast tissue is removed through a very small incision, occasionally even sparing the nipple. This is followed by reconstruction of varying types, the excess skin allowing for better cosmetic results. This is frequently chosen by women with a small cancer, a large family history, prior worrisome biopsies, or a high risk of cancer because they carry the BRCA gene mutation. The results with reconstruction are usually excellent, and outcomes continue to improve.

More Focused Radiation

When I trained, radiation was only used for large tumors which were considered inoperable. Now it is a part of the local therapy in lumpectomy cases. Radiation can be administered to the entire breast or just to the area where the tumor existed (where the risk of recurrence is highest). In terms of recurrence, both methods seem equally effective.  Each has advantages and disadvantages. The biggest change in radiation is the increased precision with which it is delivered, thereby minimizing damage to adjacent normal tissues.

Focused Drug Therapy

The field of medical oncology barely existed until 1970. There were only two drugs for breast cancer, and no way to determine which was best to use. There was no anti-estrogen therapy except removal of the ovaries. Since then, there have been huge changes. A better understanding of cancer cells on the molecular level has led to targeted therapy with the many new drugs.  Some are effective against cells which are stimulated by estrogen, and others are specific for a group of cancers (about 25%) which have overexpression of a specific growth factor. There have also been advances to reduce the side effects of the drugs, but we still have plenty of room for improvement. Modern chemotherapy has definitely improved survival in breast cancer patients.

I’ve noticed that at cancer conferences, the medical oncologist usually speaks last, following the surgeon. I think it’s because we surgeons know that we’d better speak now, because as the genetic revolution evolves, the field of medical oncology will render us obsolete. That day can’t come soon enough.

For further inquiries about breast cancer management and advancements, or HCA Virginia’s Breast Care Network, contact George A. Knaysi, MD, of Richmond Surgical, at 804.285.9416, or visit their website at richmondsurg.com.

Allergies Are in the Air – How to Cope and Enjoy Springtime in Richmond

Thomas Veech, MD, JD
Richmond Family Practice

Ahh, Central Virginia in the springtime... the days are longer, the weather is warmer (usually), the birds are singing, the flowers and trees are in bloom... and my car is green.  Mind you, my car is supposed to be black.  Welcome to pollen season.  Runny noses and itchy eyes are as common around here as dogwoods and daffodils.

As Virginians, you know that allergy season is not limited to spring.  In fact, the milder winters (this past one being an exception) and long humid summers contribute to the Richmond area’s perfect recipe for a year-round allergy problem, noted frequently as one of the nation’s worst.

Allergies, sometimes referred to as allergic rhinitis, are a very common health problem involving an inappropriate response of our immune systems to allergens, substances which can induce allergic reactions.  There are both outdoor and indoor allergens.  Aside from different types of pollens and molds, allergens can include animal dander and dust mites.

Allergies can negatively impact quality of life, as well as decrease productivity in our daily jobs.  Allergies can also worsen other health problems like asthma.  Common symptoms include nasal congestion, runny nose, and itchy, watery eyes.  Thankfully, there are many effective treatments. 

For mild to moderate allergies, steroid nasal sprays are the medications of choice. These sprays block the release of certain chemicals that cause inflammation in the nasal cavity. Steroid nasal sprays can begin working in as little as 30 minutes, but it usually takes several hours to several days to notice an improvement in all-around symptoms.  Some of the more common side effects of these sprays include nasal irritation, like drying or stinging, and occasionally, nosebleeds.  In general, nasal steroids are quite safe and they are now available over-the-counter.

For more severe allergies, antihistamines are often needed along with nasal steroids. These medications block histamine, a substance released by the body in response to allergens.   Some oral antihistamines, such as diphenhydramine, can cause drowsiness and may be best when taken at night.  For daytime use, consider loratadine (Claritin), fexofenadine (Allegra), or cetirizine (Zyrtec).  Antihistamines in the form of a nasal spray are only available by prescription and typically used to treat more severe allergy symptoms.  Compared with oral antihistamines, nasal antihistamines directly target the nasal passages, but may cause a bitter taste and/or headache.

Over-the-counter decongestants may also be helpful in treating the stuffy noses that often go along with allergies.  Pseudoephedrine and phenylephrine are common oral over-the-counter decongestants.  Some asthma medications can also be used to treat allergies, but they are generally not as effective as nasal steroids or antihistamines. 

If you, like many Virginians, have allergy problems, your primary care physician can help develop a treatment plan that works for you.  In some instances, an evaluation by an allergist may be needed. These specialists can determine which allergens are causing your symptoms and provide appropriate therapies. 

Enjoy the spring and grab some tissues!

For further inquiries about allergies, asthma, or other chronic respiratory symptoms, contact Thomas Veech, MD, of Richmond FamilyPractice, at 804.358.0248, or visit their website at richmondfamilypractice.com.