Monday, October 27, 2014

Early Detection is the Best Medicine


Susan Uhle, CNP
Richmond Surgical
Henrico Doctors' Hospital
Early detection is currently the cornerstone of the arsenal in the war against Breast Cancer.  This is accomplished through annual Mammographic Screening, and, at times, other imaging methods such as Ultrasound and Breast Magnetic Resonance Imaging (MRI). Combined with genetic screening, we look to identify signs of the disease early and improve the chances for a favorable patient outcome.

Screenings and tests tell us many things about a patient’s overall risk, and findings from Mammography can lead to Needle Biopsy, where results can range from benign, to benign but abnormal, to cancer.  These results dictate the next action, which may include surgery or closer surveillance.  The results also allow us to better stratify individual risks, and determine next steps for investigation or treatment.

There are many paths that further tests and detection can take. As an example, Christina undergoes a Screening Mammogram, leading to a Needle Biopsy; results show Atypical Ductal Hyperplasia (ADH), which is a benign lesion of the breast that indicates an increased risk of Breast Cancer.  Her risk of developing cancer is now known to be four times that of a woman her age without those findings.  There are certain measures she can take to decrease that risk, including lifestyle modification, surveillance, and chemoprevention (the use of natural, synthetic, or biologic substances to reverse, or prevent the development of cancer).

Family history plays a significant role in incidence of Breast Cancer, and there are individuals with a personal or family history, who should be further evaluated at the time of Mammography or during the office visit.  We know that a family history in a first degree relative (mother, sister, or daughter) confers an increased risk for development of Breast Cancer. 

There are many available options to pursue if unfavorable results are found after Mammography or other screening activities. If we find that there is a malignant tumor, and the Breast Cancer was one of several types (early onset, two separate Breast Cancers, Male Breast Cancer, Ovarian Cancer, Multi-Generational), we would consider whether there is an inherited mutation in the family. Although this is present in only 5 to 10% of individuals, the Breast and Ovarian Cancer risk is as high as 87% and 44%, respectively, in the patient’s lifetime, depending on many factors.

Fortunately, there are many options for treatment and future preventive activity. Preventive Mastectomy and removal of ovaries is the choice of many, but not all, women. This reduces the risk of Breast and Ovarian Cancer, but not to zero. This prevention, one form of risk management, was chosen by Angelina Jolie after she discovered she carries a mutated copy of the BRCA1 gene, with wide media coverage after the announcement. This is a personal decision, to be made with all facts in place and with information from a health care provider with extensive knowledge in this area. For those at a lesser risk, at the opposite end of the continuum, one would start with lifestyle changes and medication.

Because more data allows us to make informed decisions regarding the next steps in the path to prevention, early detection is the most important piece of the puzzle, and options have never been more readily available for preventive care.


For further inquiries about breast cancer and genetics, or to set up a consultation for a breast health screening, contact Susan Uhle, CNP, of Richmond Surgical, at 804.285.9416.

Wednesday, October 22, 2014

Tapering for Your Big Race

Jonathan Wilson, DPT
HCA Virginia Sports Medicine
Chippenham Hospital
Runners are good at listening and following instructions. We are especially good if these instructions include running more, longer, or harder. If the work-out seems almost impossible, we are excited to push out bodies to complete it. However, runners are quick to stop everything and wait, as if they are waiting for a punchline to a joke, when we are told to taper.

Taper?

Taper, as in running less? That cannot be right. Tapering is just another word for resting, right?

No. Tapering has been shown in many research studies to help improve performance on race day. Research has shown tapering has improved performance from on average 3 to 5 percent, with a high of 16 percent! A 5% increase, would take a 4:00 hour marathon and improve it by 12 full minutes, to give you a 3:48 marathon. Just by tapering and resting, you could run faster by 12 minutes. Not too shabby.

The goal of tapering is to find the balance between maintaining the cardiovascular fitness level you have obtained through hard work, and resting to reduce fatigued muscle and stressed tissue from training. If you taper for too long, you could risk losing the cardiovascular fitness level you gained. However, if you do not taper long enough your body and muscles will be fatigued and not at optimal performance level come race morning.

So, how do you taper?

Tapering is individualized like running programs, shoes, and styles. However, there are general rules you can follow to find a good tapering plan for you.

The overall length of your taper is based on the distance of your race. This is pretty simple. Research supports the below as the optimal number of days to taper for specific races:


Cut back on mileage, NOT intensity or frequency. Reference the below chart for percent of weekly mileage to decrease:


The overall goal of tapering is to allow your body to rest and heal from your training, while not losing the cardiovascular gains you have worked so hard to obtain. It is also important to mentally feel like you are not getting "out of shape” while cutting back from running before your big race.

By maintaining the amount of times you run (frequency) and running at your target race pace (intensity), but cutting down on the overall mileage, you should mentally feel like you have maintained your current fitness level as your body rests. In other words, you are gaining speed on your race day from running less. It simply does not get better than that.

After your race, if you would like a consultation on your results, how to improve performance, or to schedule a comprehensive Biomechanical Gait Video Analysis, contact Jonathan Wilson, DPT, at hcavasportsmed.com, or HCA Virginia Sports Medicine’s Boulders location at 804.560.6500.

Monday, October 20, 2014

Women’s Health at Every Age


Julie H. Ladocsi, MD
Richmond Women's Specialists
Johnston-Willis Hospital
Everyone recognizes Breast Cancer Awareness Month in October, but did you know there are many things you can do throughout the months and years to reduce your risk and stay generally healthy? It's important to stay connected to your overall health as a woman, as preventive care is often the best medicine.

Gynecological care emphasizes women’s health maintenance in ways that primary care visits do not. We assist in early detection of diseases 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 JulieH. Ladocsi, MD, of Richmond Women’s Specialists, at 804.267.6931, or visit their website at richmondwomens.com.

Wednesday, October 15, 2014

Obesity and Infertility are Linked - Surgery May Relieve Both Conditions


Mohammad Jamal, MD, FACS
Surgical Weight Loss Center at Spotsylvania Regional
Obesity has been linked to infertility and studies show bariatric surgery may treat one of its most common causes - polycystic ovarian syndrome (PCOS), a hormonal imbalance that affects up to 10% of women of child-bearing age – 33-50% of whom are overweight or obese.

Not many patients come to a bariatric surgeon to treat infertility problems, but women with morbid obesity, who are infertile secondary to PCOS, may have a surgical option. Many other studies have shown bariatric surgery can improve or resolve a multitude of diseases and conditions, and now infertility appears to have joined the list.

Recent clinical research from the University of Iowa Hospitals and Clinics showed that nearly all morbidly obese women enrolled in the study, who were diagnosed with PCOS-related infertility and desired children, became pregnant within three years following gastric bypass surgery. Doctors advise women not to try to conceive until at least 18 months after bariatric surgery due to surgery-related changes that could affect fetal development.

Before surgery, the women had an average body mass index (BMI) of 52, and after surgery had an average excess weight loss of nearly 60%. Menstruation corrected in 82% of the women and nearly 80% no longer had Type 2 diabetes. In addition to infertility, PCOS increases the risk of obesity, insulin resistance and Type 2 diabetes, heart disease, irregular menstrual cycles and miscarriage. Obese women who become pregnant may suffer from a complication of gestational diabetes, which passes on an increased risk for early diabetes and obesity to their children.

Significant weight loss also reduces the risk of pregnancy related complications, which is another important consideration. Though this is a small study, it has a big result and should be an area for more investigation and should be discussed with morbidly obese women who are having difficulty conceiving – especially those who have failed conventional methods of conception including hormonal treatments and in-vitro fertilization.

Bariatric surgery has been shown to be the most effective and long lasting treatment for morbid obesity and many related conditions. People with morbid obesity have BMI of 40 or more, or BMI of 35 or more with an obesity-related disease such as Type 2 diabetes, heart disease or sleep apnea.

According to the American Society for Metabolic and Bariatric Surgery (ASMBS), more than 15 million Americans have morbid obesity. Studies have shown patients may lose 30-50% of their excess weight 6 months after surgery and 77% of their excess weight as early as one year after surgery.

The most common methods of bariatric surgery are laparoscopic gastric bypass and laparoscopic adjustable gastric banding (LAGB). Bariatric surgery limits the amount of food the stomach can hold, and/or limits the amount of calories absorbed, by surgically reducing the stomach’s capacity to a few ounces.


If you have more questions about obesity-related infertility, metabolic disease, or bariatric surgery, contact Dr. Mohammad Jamal with the Surgical Weight Loss Center at Spotsylvania Regional at 540.423.6600 or visit their website at fredericksburgweightloss.com

Quick Question - Why Is a Patellar Tendon Tear So Bad?

Source: Associated Press
Last night, during Sunday Night Football, the New York Giants faced a heavy loss to the Philadelphia Eagles. Their loss, though, involved so much more than a football game. Victor Cruz, the Giants’ standout wide receiver, suffered a torn patellar tendon in his right knee, a season-ending injury.

The patellar tendon connects the patella (kneecap) to the tibia (lower leg “shin” bone). This tendon is what allows for extension and movement of the lower leg. Surgical reconstruction is complicated because not only does the tendon need to be properly reconnected, but the tension must also be accurately reinstated.

In Cruz’s injury, early reports tell us that it has been a complete tear, which will require surgery, extensive rehabilitation, and a minimum of 4-6 months before active participation.

For more questions about sports injuries, contact Dr. Doug Cutter of HCA Virginia Sports Medicine at 804.560.6500, visit online at hcavasportsmed.com, or like us at facebook.com/hcavasportsmedicine.

Monday, October 13, 2014

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

Eric P. Melzig, MD
Richmond Surgical
Henrico Doctors' Hospital
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 CareNetwork, contact Eric P. Melzig, MD, of Richmond Surgical, at 804.285.9416, or visit their website at richmondsurg.com.

Monday, October 6, 2014

40 Years of Breast Cancer Treatment

George A. Knaysi, MD
Richmond Surgical
Henrico Doctors' Hospital
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.