Medical Intel

Bladder cancer is the 4th-most common cancer among men, but when detected early, it can be managed and often cured. Dr. Lambros Stamatakis discusses how we find and treat this disease, and what we do if it comes back.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents medical intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. In today's episode, we talk to Dr. Lambros Stamatakis, Director of Urologic Oncology at MedStar Washington Hospital Center about bladder cancer. Dr. Stamatakis discusses bladder cancer symptoms, how treatment has advanced over the years, including techniques unique to MedStar Washington Hospital Center and what patients can expect during treatment and recovery.

Host: Thanks for joining us today.

Dr. Stamatakis: Thanks for having me.

Host: So, let's get started on bladder cancer. How common is it, what do people need to know?

Dr. Stamatakis: So, bladder cancer is often considered a bit of an orphan cancer because it doesn't get as much press as some of the other cancers out there. But it's actually the fourth most common cancer in men. So if we compare this to prostate cancer, there's about 160,000 new cases estimated to occur in 2017, bladder cancer we're estimating around 60,000 to 65,000 in men. So, it's a relatively common cancer in men, overall about 78,000 cases a year. So, it's less common in women and the reason for that is a bit unclear, but it is something that we predominantly see in men.

Host: And how common is it in the D.C. area? How many cases do you see in a month or year?

Dr. Stamatakis: Estimates from the National Cancer Institute suggest that there are around 3,000 total new cases in the D.C. metropolitan area, so I'm including Maryland and Virginia in those numbers. I usually, because I am a referral center for bladder cancer, I often see around 10 to 20 cases a month. We do more bladder cancer than any other institution in the District of Columbia. So, being a high-volume center, we're very experienced in the nuances of the surgical treatment of this disease, which is paramount for how you manage bladder cancer. Because of that, we also have higher expertise in knowing how to stage the disease and also how to manage it moving forward. We also have a multidisciplinary clinic where surgical folks like myself work with medical oncologists and our partners from Lombardi Cancer Institute over at Georgetown to provide systemic therapy in patients that need it or require that. Also, again, clinical trials are another option for some of our patients who are interested, and that can provide therapies that are not otherwise available as standard-of-care yet.

Host: And, what are the most common symptoms?

Dr. Stamatakis: So, blood in the urine is the number one symptom that typically prompts referral to a urologist. Blood in the urine can also be caused by other benign conditions. For example, somebody having a kidney stone or an enlarged prostate. But for the urologists, we need to make sure that we rule out bladder cancer or other malignant causes of blood in the urine. So that's certainly something that most of our patients won't present with, but not all. Other patients can have irritating voiding symptoms, meaning they're going to the bathroom more frequently or they're having a sense of extreme urgency and that's not getting better with the traditional therapies that we give for those types of symptoms. Every once in a while now, with modern day imaging, we're also able to pick these things up incidentally. So, a patient gets a cat scan for another reason and the radiologist sees a little tumor in the bladder that then prompts the referral to us.

Host: So typically, when somebody comes in and they had blood in their urine, is that a sign that it's usually already advanced a little ways?

Dr. Stamatakis: Not necessarily. Not necessarily. But what it will signal to the urologist is that a specific workup needs to be completed. So, that includes getting imaging of the kidneys and upper urinary tract, so that includes the tubes that connect the kidneys to the bladder, called the ureters. And that's most typically done using a CT scan and specifically something called a CT urogram. In addition, a cystoscopy will often be offered to the patient and that's a procedure where we stick a small camera inside the patient's bladder to directly visualize the surface of the bladder; make sure that they don't see anything that's abnormal.

Host: And, most bladder cancers are diagnosed relatively late though, correct? Or …

Dr. Stamatakis: Not necessarily. About 75 percent of them actually are present in the quote non-muscle invasive state. So, that's a big differentiator when we talk about bladder cancer staging is whether the disease is muscle invasive or non-muscle invasive. And, to go back a little bit, the bladder is essentially a muscular sac that just stores urine. The bladder itself has multiple layers and these cancers derive from the inner layer of the bladder, known as the urothelium. So as these tumors grow, they tend to grow from the urothelium towards the outside of the bladder. And right sandwiched in between is the quote muscle or detrusor muscle of the bladder. So, when we see a bladder tumor on a cystoscopy on somebody who's been worked up for blood in the urine, the next step will be to take them to the operating room to resect that tumor. That procedure will accomplish two goals. Number one, it's diagnostic, so we get it out, the pathologist does their exam under the microscope, tells us what it is and how deep it's invading into the bladder. And then the second thing is that it's potentially therapeutic. So if it's non-muscle invasive, often we can then watch those patients very closely and may offer select patients intravascular therapy, which basically means different types of drugs inside the bladder to prevent further recurrence or treat any remaining microscopic disease that's left behind. If it's muscle invasive, then we're a little bit more aggressive.

Host: And how has bladder cancer treatment, how has it advanced over the years?

Dr. Stamatakis: In many different ways. Initially, the treatment of bladder cancer, or traditionally, has, for muscle invasive disease, has been removal of the entire bladder with a urinary diversion. And a urinary diversion basically means being able to figure out a way to somehow get the urine out, for that particular patient. The most common thing that's done in the United States is something called an ileal conduit urinary diversion, or otherwise known as a urostomy, where, essentially, we plug the kidney tubes into a small piece of intestine which then gets tunnelled through the abdominal wall and creates a small stoma, and the urine will then basically drain into a bag. But as time has gone on, we've now developed other methods for urinary diversions. We can even create what's called a neobladder, using a much longer piece of intestine but being able to connect that pouch that we create to the patient's native urethra, so then they can basically void through their natural orifice. So, that does help to prevent the need for an external appliance and is more cosmetically pleasing for select patients. In addition, another thing that's really changed is the kind of something that I eluded to before, was a multidisciplinary approach to treating these cancers, and that is no better highlighted than in the use of chemotherapy up front before radical surgery for these conditions. In a big randomized control trial done by the Southwest Oncology Group in the early 2000s, getting upfront chemotherapy actually was shown to confer an overall survival advantage compared to patients who went to cystectomy directly or bladder removal directly. So, that is something that we do offer all of our patients, upfront chemotherapy, and ultimately, hopefully, be able to confer that survival advantage for them. One thing that we do differently is something called blue light cystoscopy. Blue light cystoscopy is an enhanced cystoscopic technique and essentially what it involves is the administration of a dye into the bladder about an hour prior to going back to the operating room for a bladder biopsy. And what will happen is that this dye essentially gets preferentially retained within the cancer cells as opposed to the normal bladder tissue.

So, when we shine a specific wavelength of light, which looks blue, the areas of abnormality will appear to fluoresce. It almost looks like a fluorescent pink little spot on the screen. So, the benefit is that—is several. First off, we are able to identify tumors that otherwise you may miss on traditional cystoscopy. And it's not that you have a bad urologist that misses it, it's just the fact that some of these lesions can be so small that they're really hard to perceive with the naked eye. In addition, when you have a tumor in place, we have a theory that when you end up excising that tumor through that procedure that perhaps you may be leaving some tumor behind. So, using this technique, we can actually evaluate the edges of the tumor resection site and make sure that we got everything out. And, if we need to, we resect a little bit more to make sure that we have a negative margin, meaning that we got all the tumor out as we possibly can. So, this doesn't really add that much to the patient experience, other than the fact that they have to have this dye put inside their bladder about an hour before, and we really feel that it adds an additional piece of information to us when we're making the diagnosis and performing these procedures for these bladder tumors.

Host: When a patient comes in, what should they expect?

Dr. Stamatakis: So, again, I'll kind of break this up into sort of the non-muscle invasive and the muscle invasive group. So, in patients with non-muscle invasive, otherwise known as superficial, bladder cancer, the one thing that patients need to understand is that recurrence is unfortunately the rule with bladder cancer. These tumors, depending on the stage and the grade, which is something that's determined by the pathologist, the recurrence rates can be quite high. So, in order to identify those recurrences, we have to routinely perform cystoscopies, again looking inside their bladder, to be able to identify those recurrences early. So, a patient that is being treated for non-muscle invasive bladder cancer needs to realize that they're going to be getting occasional procedures to look inside their bladder. And often that can be just done in the office as an outpatient procedure with relatively little discomfort to the patient, if any at all. In addition, there are multiple therapies that we use inside the bladder to, again, in certain patients, to help prevent these tumors from coming back. In patients with muscle invasive disease, again, that's when we get our multidisciplinary folks involved and we'll have them work together with our medical oncologists to select a therapy that's personalized to their particular disease state and also for their preferences. And often we will offer radical surgery, and, when it's appropriate, do it through a minimally invasive approach. I typically use the DaVinci robot for bladder removal, and that's something that will be offered to many of our patients in our practice. So, those are the sort of, the things that we, that we end up offering to our patients.

Host: What can a survivor expect during recovery and beyond?

Dr. Stamatakis: So, after radical surgery for bladder cancer, again for muscle invasive or locally advanced disease, the surgery itself is a big surgery. I mean, usually, typically, four to five days in the hospital and often it can be several months before they feel really back to normal. And after that, we will be very vigilant about performing imaging studies to make sure that their bladder cancer doesn't come back. If they have not received chemotherapy up front, we may offer it to them after the surgery, depending on the results from pathology from the bladder removal. And that's something, again, that we'll get our medical oncologists involved with. For non-muscle invasive bladder cancer, again, it's really just being vigilant about seeing each other over and over again and making sure that they get the surveillance that they need with periodic cystoscopies.

Host: As a final thought, maybe, with bladder cancer being so prevalent, why do you think it's not top-of-mind as much as other cancers?

Dr. Stamatakis: Yeah. Well, again, it hasn't gotten as much press and also, I think, because the symptoms that we discussed that are associated with bladder cancer are the same symptoms that patients often get with many benign urologic diseases. Again, if somebody has blood in the urine, the first thought to a primary care provider isn't bladder cancer. It's "Is the patient having a kidney stone? Do they have a urinary tract infection?" And often, I think our primary care providers don't like to jump to conclusions because you don't want to create fear within your patients. We see this a lot in women. Women are more prone to urinary tract infections. They'll come to their doctor and have blood in the urine and they'll treat them for a urinary tract infection almost reflexively. And the blood keeps coming back, and they keep throwing different antibiotics at them. It's often part of the reason why, despite the fact that bladder cancer occurs less frequently in women, it actually presents at a more advanced stage in women compared to men. And that's because, we think, that primary care providers often will be misdiagnosing them.

So, it is something that I think, from our perspective as educators, to be able to educate the future generations of primary care physicians to understand the appropriate workup for blood in the urine and I think that will help to increase awareness. The other thing that's also changed is that there's more advocacy groups out there now, particularly something called the Bladder Cancer Advocacy Network, that actually started in the D.C. metropolitan area. They are now doing a lot to increase awareness of bladder cancer and become advocates for patients and their families. And that's something that never really existed before and we've really been following suit and the folks that have created these sorts of organizations for prostate cancer and breast cancer, which are really the more popular, or more well-known, cancers out there. So, we're hoping that bladder cancer is going to become something that, really, people know more about as time goes on.

Host: Great. Thank you so much for joining us.

Dr. Stamatakis: Yeah, no problem. Thank you so much.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Surgery is the gold-standard breast cancer treatment, but some techniques leave women flat-chested or with lopsided breasts. Dr. Patricia Wehner discusses how many women can benefit from oncoplastic surgery, which offers a more natural breast shape so women can look and feel more confident after surgery.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We're speaking with Dr. Patricia Wehner, a surgeon with fellowship training in breast surgical oncology and MedStar Washington Hospital Center. Today we're discussing breast oncoplasty. Welcome Dr. Wehner.

Dr. Wehner: Thanks for having me today.

Host: What is breast oncoplasty?

Dr. Wehner: Oncoplasty in and of itself, what that actually means is it just means removing the area of cancer with attention to cosmesis. So, it's really removing the area of cancer by doing a partial mastectomy and figuring out a way to cosmetically and acceptably close the defect that you've created and making certain that you leave the patient with a very reasonable size and shape breast. So, the goal is always to make it so patients don't necessarily need to ever remember that they've had surgery because you're trying to make them look how they looked before or at least minimize the disruption that you've caused. So, , I trained at USC, so University of California, and it is a huge oncoplastic program there. So, there I learned a lot of various plastic surgery techniques to employ in my daily operative time. So, because of that, I don't need to have a plastic surgeon come in for most cases. Unless, again, we're doing sort of a larger reduction or larger reconstructive surgery. Every single patient who undergoes a partial mastectomy, really is a candidate for breast oncoplasty. And again, the point of breast oncoplasty really is to just pay attention to cosmetics. So, what I tell patients is cancer surgery first, because obviously we're all here to get rid of their cancer and to treat their cancer, but cosmetics is still really important for women undergoing breast surgery because anybody who has to deal with the loss of breast tissue or even the loss of the breast, while they're going through it they obviously feel it. If they're undergoing chemo, if they're undergoing radiation, then obviously it's something that's very much on their mind. But five years later, when they've completed all of their treatment, and they've completed the chemo and they've completed the immediate surgery and they've completed everything that needed to be completed right around the time of their diagnosis, I want them to not have to look at their body and also be forced to remember day in and day out. I want them to get back to where they were beforehand, meaning, I feel good, I look good and I don't want to stare at something that's going to remind me on a daily basis of what I went through. So, any type of breast surgery, breasts are not twins, they're sisters, so no matter what they're going to look a little bit different and the goal is just to minimize that difference. So, you're never gonna reconstruct or recreate what you had prior to surgery. There's just no way around that. But we want to at least keep it as close to that as possible and to minimize those differences.

Host: If a woman has this procedure and then they have oncoplasty at a younger age, say in her 30s, so the breasts change as we age--how does that compare as their other breast that might be healthy?

Dr. Wehner: With oncoplasty, really you're taking the patients natural tissue and just sort of rearranging it to fill in the defect. So, I'm not adding anything, meaning I'm not placing an implant in there or I'm not placing something foreign within the breast. So, it's still the exact same tissue you had before, just maybe a little bit less of it. But, with that, the density of that tissue can change as you get older. You're breast, as you get older, if you gain weight or lose weight, your breast can gain weight or lose weight and so the same thing with that area of reconstruction can gain weight or lose weight. So, it's really still retaining everything that you had before it's just kind of moving it around in a different location. Now, there's a lot of discussion about skin and nipple sparing mastectomy. So, a mastectomy is different than a partial mastectomy because the goal of a mastectomy is to remove all of the breast tissue. Previously when we did a mastectomy, we would make an incision, we'd remove the nipple, we'd remove the areola complex, we'd remove a good majority of the skin and try to close it as flat as we could. Then we kinda sort of started saving some skin and placing an implant in there and so creating a decent or reasonable breast. And now for certain patients that are fairly well selected, we can actually preserve the entire breast envelope, meaning the nipple, the areola complex, and the skin and still remove all of the breast tissue that's living underneath of that and then reconstruct it with an implant or even an autologous tissue, so tissue from someplace else. It's a very technical surgery because it's a large amount of real estate, I guess for lack of a better term, of what you need to get to in order to remove it.

So, we go through an inframammary fold incision, meaning the incision is at the very bottom of the breast. And through that incision we reach the very top of the breast and remove all of the breast tissue. So, anything that lives above the pectoralis muscle and underneath the skin gets removed. Overall outcomes, so what a patient look like afterwards then tends to be very favorable because you still retain the nipple and you still retain the areola complex. Now they don't function like they did before surgery, but they still look good because they're there. So, I kind of liken it to the earrings that you would put in an ear. So, while it maybe loses its function, it still looks good, so we leave it there for cosmetics and we know that there's no increased risk of cancer recurring at that location. This doesn't hold true for each and every patient because some of this depends on size of the natural breast, shape of the natural breast before reconstruction and just overall body habitus. But for certain patients it really is a great option.

Host: Is there a general criteria that you have for women who would quality for nipple sparing surgery?

Dr. Wehner: So for skin and nipple sparing surgery, most of these women do tend to be a little bit thinner and that's just because patients who do best with an implant reconstruction tend to be a little bit thinner so they don't have a very wide chest and they're beasts have to be a little bit smaller, so generally we say A through C cup. Now we have started doing a two-stage approach for patients who have a large breast, so those who have Ds, DDs, even maybe a little larger than that. Or we actually do a surgery where we reduce the size of the breast first, so we reduce it down to a B or a C cup, let that heal and then after that's healed then we go back and then do the skin and nipple sparing mastectomy. So, we do have options, it's just again not a one size fits all type of option and it really kind of depends on the patient and what the patient looks like and even the type of cancer the patient has.

Host: Why is it that how the woman feels afterwards and how she feels about her self-image has become so important?

Dr. Wehner: So, losing a breast is the same as losing an appendage. Even though it doesn't function like an arm, it's still an appendage, it's still an organ and for most women it has a lot to do with who they are as a women, it has a lot to do with their sensually, it has a lot to do with their body image, it has a lot to do with just how they feel about themselves. So, when they put a shirt on, do they feel normal? Do they look normal to the outside world? And that is what the goal of some of this reconstruction is. Is when a patient gets dressed and they go out, how can they give and portray sort of their best self-confidence to the world and nobody's gonna want to do that if they don't feel self-confident. So if they feel very anxious about how they look, if they feel very worried or afraid or if they've lost a breast and now it's flat and not reconstructed and so it's really obvious because they're other breast is very large and now the other side clearly have tissue loss--does that make them feel sort of uncomfortable and not want to go out in public. So there's lot to do with just body image that goes along with this type of surgery and there's a lot to do with sensuality that has to do with this surgery and that's why it's really important that when you have a breast cancer diagnosis that you find a provider that you trust and a provider that really can understand that. All cosmetic follow-up procedures are not cosmetic because they are done under the purview of reconstruction operations in the setting of a cancer diagnosis. So, they are considered oncoplastic. And that's onco meaning oncologic or cancer and plastic meaning cosmesis. So, everything covered by insurance. This is a not a paid out of pocket. We're not trying to augment you or place implants just because you want them. We're doing it because this is a legitimate cancer diagnosis and so you should be able to undergo treatment and surgery and come out on the other side feeling good.

Host: What is the oncoplastic surgery recovery like compared to say if they hadn't had a reconstruction?

Dr. Wehner: So oncoplastic surgery in a partial mastectomy is the same recovery time as a regular partial mastectomy. There's not really any difference. Now if we do oncoplasty in a setting of a reduction surgery, meaning a patient has really, really large breast and they're heavy and they cause strap indentations on their surgery or they cause them back pain and we chose to reduce the size of their breast all while removing the cancer, that recovery is a little bit different because it's a more extensive surgery. But even those patients go home the exact same day.

Host: Why is MedStar Washington Hospital Center the best place to seek oncoplastic surgery?

Dr. Wehner: Each and every breast cancer patient that is treated at MedSTar Washington Hospital Center will have oncoplasty employed in their surgery. And whether that's done by the main surgeon, which I do most oncoplasty myself, or whether that's done with the aid of a plastic surgery, which is done by my partner here always employs the help of a plastic surgeon. Every patient still will have oncoplasty and still will have the opportunity to have some of these types of procedures brought into their regular partial mastectomy procedure. Historically anybody who underwent a partial mastectomy came out looking essentially like a shark bit off part of their breast. I mean, part of their breast was removed, the skin was closed and that was just it. So, a lot of patients who were treated many years ago have a lot of indentation, a lot of asymmetry and they don't feel good about it. They really don't want anybody to see. Whereas now, there's plenty of patients who come and again are just like oh right, I don't remember where that scar is.

Host: Is there anything that can be done for those women now that had surgeries maybe ten, fifteen years ago when techniques weren't so good?

Dr. Wehner: So, there is some plastic surgery options. Some involve reconstruction. Some involve something that's called fat grafting which is done by our plastic surgeons where they can actually suck fat from one part of the body and inject it within the breast to fill in some of that area. So, there's options, but it really just depends on what surgery they had, what treatments they had and kind of what they look like now.

Host: Thanks for joining us Dr. Wehner.

Dr. Wehner: Absolutely.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Breast cancer is one of the most daunting diseases in women's health, as it affects about one in eight U.S. women at some point during their lives. Dr. Ami Chitalia discusses four lifestyle changes women can make to reduce their risk of developing breast cancer.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We're speaking with Dr. Ami A. Chitalia, a breast medical oncologist at MedStar Washington Hospital Center. Welcome, Dr. Chitalia.

Dr. Ami A. Chitalia: Thank you for having me.

Host: Today we're discussing general best practices to reduce breast cancer risk. While breast cancer can have a genetic component, there are things that women can do to prevent the disease altogether or improve the chances that, if breast cancer develops, it'll be detected at an earlier, more treatable stage. Dr. Chitalia, is there a number one thing women can do to reduce their risk for developing breast cancer?

Dr. Chitalia: Well, I think there are a few things that women can do to decrease their risk of breast cancer. There are lifestyle modifications, such as having a healthy diet, exercising and maintaining a normal weight. Also, limiting alcohol intake has been shown to decrease risk of breast cancers. And, of course, screening mammograms will not reduce a woman's risk of developing a breast cancer, but they may help to find a cancer at an earlier stage, where treatment may be easier to go through. And when there's a better chance of curing the cancer.

Host: So many cancers have been linked to healthy eating, exercise and weight management. How do these factors affect a woman's breast cancer risk?

Dr. Chitalia: Yes, these have certainly all been linked to breast cancer risk. I counsel my patients with breast cancer on maintaining a healthy and balanced diet. So, this includes a focus on whole grains, fruits, vegetables and lean meats. However, all foods are okay in moderation. So far there's no clear link between breast cancer and red meat intake or sugar intake. In terms of exercise, I recommend 30 minutes, at least, of any exercise that will make you sweat or breath faster, so aerobic exercise, 4 to 5 times per week. By maintaining a healthy diet and exercising, a woman can maintain a healthy weight, and this has certainly been shown to decrease their risk of breast cancer.

Host: How are unhealthy habits, such as tobacco use and alcohol consumption, associated with an increased risk of breast cancer?

Dr. Chitalia: So, tobacco use is an interesting question. There has been a study that shows an increased risk of breast cancer with smoking, but in premenopausal women only - so, in younger women. Other studies have not shown this to be true. So, we don't really have a clear answer for how tobacco use is linked to breast cancer but, either way, tobacco use clearly does increase risk of many other cancers and diseases and can certainly impact healing after breast surgery. Excess alcohol intake - which, for women, is more than four drinks per week - has been associated with an increased risk of certain types of breast cancer as well.

Host: What should women, who are at increased risk because of family history or genetics, do differently to reduce their risk of breast cancer?

Dr. Chitalia: So, women with a family history of breast cancer should seek guidance from their primary care physician on when to begin screening mammograms, as depending on their family history, or the genetics, screening may be recommended at an earlier age than an average woman. Women who carry a genetic mutation with an increased risk of breast cancer should be under the care, ideally, of a breast surgeon or medical oncologist to determine the best screening strategy for them, as well as for monitoring. In addition, these women should be counselled on the risks and benefits of risk-reducing surgeries, such as mastectomies or oophorectomies.

Host: Should all women perform breast self-exams?

Dr. Chitalia: Although self-breast exams have not been shown to have a clear benefit in finding a breast cancer earlier, I think it is important that women maintain a breast awareness so that they're aware of any changes to their breasts, either in feeling or in appearance.

Host: If women chose to do self-exams, how often should they do them?

Dr. Chitalia: If women chose to perform self-breast exams, I think a monthly basis is a good idea. Typically, at the time when their breasts are the least tender is also a good idea, and when there are less changes such as from a menstrual cycle, if that's applicable to a woman.

Host: Do you have any stories you could share about patients who successfully found a lump on their own and came in?

Dr. Chitalia: Sure. So, we do have a number of women that come in, usually at first to their primary care doctor or their OB-GYN, saying that they felt a lump. And this, you know, was either while they were showering or while they were performing their monthly self-breast exam. Typically, then, their doctor has referred them to a diagnostic mammogram, an ultrasound, and skipped the screening mammogram in order to expedite their work up. And then they usually get referred to one of us in the practice. So, that has definitely happened a number of times.

Host: If a woman finds a lump, why is MedStar Washington Hospital Center the best place to seek breast care?

Dr. Chitalia: So, I think, for a number of reasons, MedStar Washington Hospital Center is the best place for women to seek breast cancer screening. We offer state-of-the-art equipment and imaging techniques, including MRI-guided biopsies, which are sometimes needed and are only offered at selected imaging centers. In addition, we offer comprehensive care so that in case something is found, such as a breast cancer, we have a large multidisciplinary team, including nurse navigators, radiologists, surgeons, radiation doctors and medical oncologists who focus on breast cancers, such as myself. We also have dedicated breast radiologists who have expertise in reading breast imaging, such as mammograms and ultrasounds. And, above all, I think our nurses, technicians, and staff are kind and caring and really aim to make sure that a patient's experience is as smooth and comfortable as possible.

Host: Thanks for joining us today, Dr. Chitalia.

Dr. Chitalia: Sure! Thanks again for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Human papillomavirus (HPV) is the most common sexually transmitted infection in the U.S., and this virus is behind a surge in head and neck cancers among young people. Dr. Matthew Pierce discusses who is at risk, warning signs and how we treat these cancers.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today. We're talking with Dr. Matthew Pierce, an otolaryngologist and head and neck surgeon at MedStar Washington Hospital Center. Welcome, Dr. Pierce.

Dr. Pierce: Thank you. Thanks for having me.

Host: The human papillomavirus, or HPV, is one of the most common sexually transmitted infections. In most people, the virus courses through the body and leaves without causing any health problems, though HPV is known to cause cervical cancer in women. However, men and women in their 30s and 40s are developing head and neck cancers at an alarming rate as a result of HPV infection. In the U.S., HPV is thought to cause 70% of cancers in the oropharynx, which is the back of the throat, the base of the tongue, and the tonsils. Dr. Pierce, why is this virus that was once associated solely with cervical cancer now so strongly associated with head and neck cancer?

Dr. Pierce: We don't really know the answer to that at this point. Uh, it's only recently, and I say recently in the past 20-25 years, been associated with cancers of the oropharynx, or the back of the throat. These cancers may have always been associated with HPV, and we're just now realizing it and newly diagnosing these types of cancers. The majority of people have been exposed to HPV at some point in their life. And the vast majority, 90% of the people, clear this without any effects whatsoever. There's a small population that, for whatever reason, harbors the HPV virus, either in their tonsils, cervix or elsewhere. And there are over 100 types of HPV, but there's only a very small few percentage of those different strains that actually cause or are related to cancer. And that small percentage, and even smaller percentage who are infected with what we call those high-risk types of HPV, actually develop cancer. And again, we don't really know why some people develop cancer and why some people don't, but there's a lot of good research going into that now. But, uh, there are those high-risk type of HPV infections.

Host: Nearly everyone who has had at least one sexual partner has been exposed to HPV. How do you discuss that with patients?

Dr. Pierce: HPV is a sexually transmitted disease. I don't really have that conversation with them once they're diagnosed. You know, it's a big deal being diagnosed with head and neck cancer, and they really want to know kind of what to do about it. And so, I think it's good to discuss treatment options and where we go from here. With, uh, head and neck cancer, it's a very morbid type of cancer to get, and it can really affect patients' appearance as well as their swallowing and speech, and so it really affects a lot of different parts of their day to day lives. Uh, and so, getting the correct diagnosis and getting a good treatment plan is essential. The interesting thing about HPV head and neck cancers is that they actually respond better to treatment and they have a better prognosis than most other cancers of the head and neck. It's kind of the silver lining of this new...new wave of cancers.

Host: Why do HPV-related head and neck cancers respond a little bit better to treatment than other head and neck cancers?

Dr. Pierce: Uh, we actually don't know why these patients respond better to treatment as of yet. There's a lot of studies going into that, and there's actually a lot of studies that are looking at what we call a de-escalation or actually trying to reduce the amount of treatment that we actually have to give these patients while maintaining the same results and the same outcomes.

Host: So, on the one hand you have a cancer that's quote/unquote "relatively easy to treat", but it can also can be quite destructive. Can you talk about the effects or the symptoms of HPV-related head and neck cancer?

Dr. Pierce: So, HPV head and neck-related cancer is--I wouldn't say it's necessarily easy to treat but I would say that it responds better to treatment. Whether that is radiation or chemotherapy, or even surgery, these patients tend to do better after treatment, and they have a better prognosis. Cancers of the head and neck can very frequently affect the patient's swallowing function and speech, as well as the outward appearance, and so, depending on what type of treatment and where the cancer is located. You can have some scarring from... if the patient has surgery or radiation. Uh, the side effects of treatment can often cause issues with swallowing, or speech, or other aspects of day to day life. I think with head and neck cancer, the best outcomes are when we catch these cancers early on. And the reason that they are very morbid is because of one, their aggressiveness, and two, because of the location. And, you know, anytime you have a tumor that requires treatment in the mouth, in the neck or the throat, it can affect multiple organ systems, including swallowing, speech, uh, and as you can imagine, appearance as well. And so, it is something that we recommend, if you are suspicious, just come in and be seen, and see a specialist if you're concerned about anything in the head and neck area.

Host: What symptoms might a person experience if they have head and neck cancer that might cause them to go see their doctor?

Dr. Pierce: The symptoms can…can be very subtle, but it's very important that patients go, if they have any concern at all, to go and see a specialist and get checked out. And some of the major symptoms that most people present with are a mass in the neck or a lesion in the oral cavity that does not heal or an ulcer that persists and doesn't go away. Other more subtle symptoms can be difficulty swallowing or pain with swallowing. It can be changes in your voice, hoarseness, ear pain, or coughing up blood or blood from the nose. Usually if a symptom lasts for more than 2 or 3 weeks, and it's not getting better, it's good to go see a specialist and…and get it checked out.

Host: Do you recommend that any of your young adult patients receive the HPV vaccine, or is that reserved for younger folks?

Dr. Pierce: Absolutely. I think that the HPV vaccine is very important for young teenagers, and the current recommendation is for, uh, children who are 11 to 12 years old, both male and female, to get the HPV vaccine. Children as young as 9 years old, as well as adults up to the age of 26 for women and…and 21 for men, uh, are currently recommended to get the HPV vaccine. Currently, there's no recommendation above that age, uh, and the reason for that is the majority of people have already been exposed to HPV at that time, and so it's not gonna have any benefit to the patient once they've already been exposed, but for younger patients, it is something that is invaluable. And even though we don't know the benefit at this time, we do know that it can prevent from an infection, and the prediction is that it will decrease the amount of cancers that we see in the future.

Host: Because HPV is so common, is there anything aside from the vaccine that parents can teach kids to do, or that young adults can do, to reduce their risk?

Dr. Pierce: The only sure way to completely avoid any risk is for complete abstinence, which is not a realistic expectation. Even for people who are in a monogamous relationship still have the risk of being exposed, um, either from their partner's past partners or even from open-mouth kissing can even potentially spread HPV. And so, there is currently no recommendation specifically for reducing the risk of HPV transmission, uh, other than the standard safe sexual practices that are already recommended for decreasing the chance of STD transmission. The interesting thing about HPV-related cancers are that they typically involve a younger and healthier population. We typically see these in males more than females, about 3 to 1, and there's usually males in their 50s to 60s, whereas tobacco-related cancers of the head and neck usually present about 10 to 15 years after that, so that is one of the differences that we have seen in the epidemiology of head and neck cancers and HPV cancers is they're typically in a younger, uh, population.

Host: Could you talk about your team approach to head and neck cancer care at MedStar Washington Hospital Center?

Dr. Pierce: Absolutely. So here at MedStar Washington Hospital Center we have a multidisciplinary approach to cancer care, including HPV-related cancers. We talk about and present all of our new patients as well as our follow-up patients in a team approach, discussing with multiple ENT and head and neck cancer surgeons as well as chemotherapy doctors and radiation doctors. And we approach every patient in this multidisciplinary style of cancer care, uh, which has been shown and proven to be the best form of developing plans for cancer patients. We have a state of the art approach, both surgically and using other modes of treatment for head and neck cancer patients.

Host: Typically, are you having to do surgery on all of these patients, or is it rare that you'd have to do surgery?

Dr. Pierce: These patients respond well to all types of treatment. And depending on each individual patient, if it's an early stage and a small cancer, these patients can undergo surgery. And one of the benefits that we have here at Washington Hospital Center is we offer a minimally invasive type of surgery to resect these cancers. And that's in the form of either robotic surgery or transoral laser surgery. And these surgeries offer a minimally invasive way to cure and treat these patients. Fortunately, not everybody needs to have surgery and a lot of these patients respond very well to chemotherapy and radiation. And this… it's usually, a discussion that has to be made with the patient as well as the tumor board.

Host: Thanks for joining us today.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Typical symptoms of the flu, which affects up to 20 percent of Americans annually, can take a toll on one's health in their own right. However, there's an even more serious concern to consider. Dr. Allen J. Taylor explains how the flu can increase heart attack risk.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We're speaking with Dr. Allen J. Taylor, Chair of Cardiology at MedStar Heart & Vascular Institute. Welcome, Dr. Taylor.

Dr. Allen J. Taylor: Thank you.

Host: Today we're discussing how the flu can affect a person's risk of heart issues, particularly heart attack. It's widely known that the flu can be dangerous, and it kills thousands of otherwise healthy people each year in the U.S. Increasing the concern, a 2018 study published in the British Medical Journal suggests that a patient's risk of heart attack might be six times higher within the first week of a lab-confirmed diagnosis of influenza. Dr. Taylor, is this another scary media story or is the flu a real concern for patients when it comes to heart attack risk?

Dr. Taylor: This really is not a scary media story. This is the impact of the flu on health in total. People think the flu is a self-limited illness. They'll feel bad for a few days. And while that's true, each year the flu causes over 130,000 hospitalizations; 62,000 deaths. And those deaths include deaths from heart attacks - six times more likely after the flu. It's a real issue.

Host: How can the flu, which many people consider a sinus or respiratory illness, affect heart attack risk?

Dr. Taylor: Yeah, it might seem hard to connect. But, in fact, the flu triggers a host of inflammatory reactions that activate problems throughout the body and activate chronic conditions and inflammation is an important part of heart risk. And, we believe that that's the mechanism, that through the inflammation triggered by the flu, heart attack risk is six time higher in the week after the flu.

Host: Why is the flu such a concern when vaccinations are available for infants through seniors?

Dr. Taylor: Right. The CDC recommends that all healthy adults receive the flu shot. And the problem we're having is that folks aren't getting vaccinated. Fewer than half of individuals get vaccinated, for a variety of reasons and concerns and it's unfortunately too little. And so, many of those adults that are not getting vaccinated, in fact, are subjecting themselves to the risk of not just the flu but of many conditions, including heart attack. My recommendations at this point would be to first, get a flu shot and have your family members and other loved ones get flu shots. Even if you think you're healthy, the flu is a risk for you. If you have a chronic condition, even high blood pressure, you particularly need to get a flu shot. And they're simply easy to get. Every drug store now provides flu shots and they're inexpensive and typically covered by insurance companies. So, DO vaccinate yourself. And then, stay as healthy as you can. And if you are unlucky enough to contract the flu, look for these other symptoms, and if you experience them, get prompt medical attention.

Host: So, when we think of the flu as a risk, we tend to think of older adults. Could you discuss why this population's also at increased risk for heart attack?

Dr. Taylor: Well, problems from the flu can affect any otherwise healthy person. There is a group that's at increased risk and that's a middle-aged and older group of individuals who have at least one chronic health condition, which could include simply high blood pressure. So, there's many middle-aged and older adults with chronic health conditions and they're the ones at most increased risk. So, with the low rates of vaccination and this heightened risk, we really need to do a better job of getting the word out of "get vaccinated, protect yourself and protect others by protecting yourself." This idea of more immunizations reducing the transmission of flu during flu season is an important one. By your getting a flu shot, you could help somebody else.

Host: Aside from older adults, are other patient populations at increased risk for heart attack after catching the flu?

Dr. Taylor: The increased risk of heart attack seems to affect all people, so it's not just older individuals but it's the older individuals with chronic health conditions that are at the greatest risk. But, again, the CDC recommends that ALL adults receive the flu shot.

Host: When an individual has the flu, what sort of symptoms might they watch out for if their heart is becoming damaged?

Dr. Taylor: We commonly think of things like joint aches and muscle aches and fevers and respiratory symptoms. But if you have the flu and you're experiencing chest discomforts or unusual breathing problems is when I would become particularly concerned. The flu can increase risk for pneumonia, can inflame the lungs, and then, chest pains, either from inflammation around the heart or heart attack. Any worsening symptoms or new symptoms, besides what you'd otherwise expect from the flu, that you'd experience, I'd seek prompt attention for.

Host: Is this a year-around concern or is it just during flu season?

Dr. Taylor: That's an interesting question. Obviously, there's flu season, and the flu season for us runs from the fall into the late spring. We do see individuals, though, that travel to other parts of the world and, realizing there's a South American group, we've seen patients that have gone to vacation in the summer, say in the Bahamas, and folks that winter in the Southern Hemisphere will also go to those locations, and bring the flu with them. So, we've, in fact, had several recent cases of people contracting the flu and serious problems from it in the summer.

Host: What can patients do, aside from getting the flu vaccine, to reduce the risk?

Dr. Taylor: Well, the first thing is, in the flu season, being very attentive to things like hand washing. And if they're around sick contacts, to make sure that they're being particularly attentive. Folks with the flu should be careful about transmission—you know, the way they sneeze, touching objects, also washing their hands. And then, staying as healthy as possible. The more vulnerable populations are folks that are stressed, fatigued, chronic illnesses. So, as always, proper diet, proper rest, good exercise. It could be all part of a healthy lifestyle that could protect one from problems from the flu. But, that said, vaccination is the most important thing. And, right now, we're simply not vaccinating enough of Americans.

Host: Why is MedStar Heart and Vascular Institute the best place for people who want to reduce their risk of heart-related issues because of the flu?

Dr. Taylor: The heart consequences of the flu can be many, not just heart attack. We see cases of serious heart inflammation, for example, that can be very life threatening. And, we've successfully cared for those patients - identifying the flu, treating it, and supporting them through the illness. Properly supported patients usually do well, but prompt identification, aggressive treatment, is essential. So, we really serve as a regional resource for this and patients in our entire region, if they become very, very sick from the flu, we take excellent care of them. We've really had some great patient outcomes - folks that, for instance, travelled into the Bahamas and got sick, or in the flu season, and really have been fortunate that they've been able to survive.

Host: Could you share a treatment success story from your practice?

Dr. Taylor: I can think of several, but one that was particularly dramatic, was a perfectly healthy middle-aged woman who had gone out of the area to vacation. It was flu season and came back and started feeling poorly and started experiencing chest pains. And, what she had was serious inflammation of the heart muscle and a rapidly failing heart muscle. And in the course of just 12 hours, basically her heart could no longer support her body. So, she actually went on to artificial circulation, outside of her body, for a period of days while her heart recovered. Eventually that was removed and she's back to full-functioning. And, we had literally hours to act, to identify the problem and to put her on artificial circulation. But today she's alive and well and really is a great success story.

Host: Thanks for joining us today, Dr. Taylor.

Dr. Taylor: Thank you very much.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Lymphedema can cause painful, uncomfortable arm swelling for people who have been treated for breast cancer. Dr. David Song discusses how we can reduce or eliminate these symptoms with advanced surgery.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. In today's episode, we talk to Dr. David Song, Regional Chief for MedStar Plastic Surgery and a nationally recognized specialist in treating people who have lymphedema. Lymphedema is a condition in which fluid accumulates in the body causing pain and swelling in the areas where the fluid builds up. About 20 percent of patients diagnosed with breast cancer will develop lymphedema. Compression garments, physical therapy and massage techniques used to be the only treatment options for lymphedema symptoms. Now we can treat the root cause with surgery, and Dr. Song is one of the only doctors in Washington D.C. and the east coast who offers these advanced surgeries.

Host: Thanks for joining us.

Dr. David Song: Thanks for having me.

Host: So today we're talking about lymphedema surgery. Lymphedema surgery is actually fairly new.

Dr. Song: That's right.

Host: And what does that mean—fairly new?

Dr. Song: So probably within the last decade it's become more of an explosive sub-arena of plastic surgery and microsurgery, where we're able to see long term results now—five, ten year results and the impact that we're having on patients with lymphedema can be very profound in a positive way, and it can really change their lives around. So, it's something that's very exciting. I've been doing it for several years now.

Host: And how many hospitals in the D.C. area perform this?

Dr. Song: So, as of now, my understanding is I'm the only one in the greater D.C. area that does this. There's not many people that do this in the country, so it's a new field, it's in its infancy and there's just not a lot of people that do this.

Host: And who are some of the patients that do get lymphedema surgery?

Dr. Song: So primarily they're patients after breast cancer surgery. So, a mastectomy, radiation or lumpectomy with lymph node biopsy and radiation—those are the patients that can develop lymphedema. Approximately 20 percent of all patients with breast cancer that get mastectomy and radiation and lymph node biopsies can develop lymphedema, so it's a disease that's not uncommon and it can be rather debilitating. It can limit one's function, motion, quality of life. So, if you think about, you know, the tens of thousands of women that get breast cancer a year, that get mastectomy and radiation, and 20 percent of those every year can develop lymphedema, you're talking about, again, tens of thousands of women that are walking around with lymphedema.

Host: How do you help patients understand if the surgery is a good option for them?

Dr. Song: Yeah, so surgery, a surgery, one of these options is good for virtually everybody. Uh, so it's a matter of consultation, it's a matter of having frank discussions about what patients are willing to undergo, optimizing their nutritional status, their body weight status prior to surgery, stopping smoking—all the things that can help our success rate. So, it's a lengthy discussion with a patient, and so that's the way to find the best individualized treatment plan for each and every patient that we see.

Host: So what types of lymphedema surgery do you offer and how do they work?

Dr. Song: So, the whole gamut, starting from lymphovenous bypasses, which are actually rerouting the lymphatic channels to the veins in the extremities. And that requires a technique called super-microsurgery. These vessels are beyond paper-thin and they're, on average, less than .8 millimeters in diameter, down to as small as .3 millimeters in diameter. So, the suture that we use is exceptionally small and thin. It's a specialty ordered suture. So, rerouting the lymphatics into the veins helps to drain the entire arm and it bypasses the blocked pathways that patients with lymphedema have. So that's one. The other option is to transplant lymph nodes from an area in the body that there's a redundancy of lymph nodes, like your back or the inguinal region where you pick the right lymph nodes, sparing the important ones—and there's a technique to do that—then transplant them into the arm or leg that's affected by lymphedema. That acts as a natural pump. So, combining those two techniques, lymph node transplantation with lymphaticovenous or lymphovenous bypass, seems to be the preferred method of choice with the longest outcomes of success. There are other aspects of lymphedema surgery that we can go into, as well. For those that are severely affected - years and decades they get more like an elephantiasis-type of outcome, where the skin is thickened and changed. Those patients are more amenable to what's called the Charles' Procedure - it's an old procedure where we're actually removing all the subcutaneous tissue, the fat around the affected leg or arm and then regrafting it with skin grafts. It's a pretty radical procedure, but that's really reserved for the very advanced patient with lymphedema.

Host: And how long will it take to actually see results?

Dr. Song: So, we can see results right away because of the scar release that we get. And the lymphaticovenous bypass works right away. But, the lymph node transplantation, it takes a while for the lymph nodes to grow and to start pumping again, and so that sometimes takes upwards of six to nine months to see some results from a lymph node transplantation. But you can see immediate results from the lymphaticovenous bypass and liposuction and the methods can be tailored to each and every patient.

Host: And recovery time is how long?

Dr. Song: Typically, for a lymphaticovenous bypass, it's sometimes an outpatient procedure. When you add a lymph node transplantation, we usually like to keep patients for 2 days, sometimes 3, depending on their pain level. So, it's a one to two-day, possibly three-day admission, and the recovery time back to work is, you know, maybe a week or so thereafter. So, it's a very short period of recovery.

Host: And, once they leave, they have to wear a compression garment?

Dr. Song: That's right. So, this is not a panacea for all lymphedema. It is an adjunct. Occasionally we get complete resolution, but most of our patients see improvement, sometimes dramatic, but they still have to keep up with their lymphedema therapy, their manual lymphatic drainage and their sleeves, especially when they fly.

Host: What else can we share about it? Is there anything else we didn't discuss already that people should be aware of?

Dr. Song: I just think the answer for patients with lymphedema, that's present now, is something that I hope everyone at least hears about and knows that there's an option for them. You know, ten years ago this was rather new—it was a concept—and I'm hoping that with efforts like this to get the word out with patient advocacy efforts, insurance companies will start to recognize this as something that's proven and that's, not, no longer experimental, because it clearly isn't.

Host: Well, thank you so much for joining us.

Dr. Song: Absolutely. Thank you for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

DCIS is sometimes called "stage zero breast cancer." It's contained to the milk ducts, and the primary concern is whether it comes back after treatment. Dr. Patricia Wehner discusses how we diagnose and treat this disease.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We're speaking with Dr. Patricia Wehner, a breast surgeon with fellowship training in surgical oncology for the MedStar Regional Breast Health Program. Today we're discussing ductal carcinoma in situ, or DCIS, breast cancer. Welcome, Dr. Wehner.

Dr. Patricia Wehner: Thank you!

Host: What is ductal carcinoma in situ, or DCIS, breast cancer?

Dr. Wehner: So, ductal carcinoma in situ, which is referred to DCIS for short, is a stage 0 type of non-invasive breast cancer. And what that means is DCIS really is a type of breast cancer that's confined to just the milk ducts of the breast. So, if you think of the composition of a breast, a breast is composed of multiple milk carrying pipes or tubes of the breast that come through the breast and join up at the nipple. DCIS is a cancer that's contained just within those milk ducts.

Host: Is DCIS life-threatening, if it doesn't spread?

Dr. Wehner: So, ductal carcinoma in situ, or DCIS, in and of itself is a non-invasive cancer. And that's why we call it a Stage 0 cancer. Stage 0, again, meaning just confined to the milk ducts of the breast. If treated, then DCIS is not necessarily life-threatening. The concern for DCIS is in the recurrent form of DCIS, meaning after it's treated, will it come back? And the concern there is if it comes back, will it come back as an invasive cancer? The difference is invasive cancers have the potential to spread. So, they have the potential to go to other places of the body and that could be anywhere – the lungs, the liver, the brain. DCIS, in and of itself, does not have that ability but when it morphs into an invasive cancer, that's when it has the ability to spread to these other locations.

Host: How is DCIS detected if it's just in the milk ducts?

Dr. Wehner: DCIS is generally just detected with screening mammography. So, within the United States, there's about 55 million annual screening mammograms that are performed on a yearly basis. And, of those mammograms, about 1 in 1300 will show ductal carcinoma in situ. For the majority of patients, when we look at a screening mammogram, what we're looking for is are there any new lumps or what we consider to be nodules or asymmetries that have shown up on mammograms. Or, are there new areas of calcium or calcifications that have showed up on mammograms. DCIS, in the majority of times, shows up as new calcium or calcifications. So, essentially, when we look at a mammogram, there are new little white dots that show up on the mammogram. White dots on a mammogram don't necessarily equate to a cancer and that's why, when we see them, we kind of ask a couple questions. And that is, "Are they new? Are they increasing in size or number? Are they fine and tiny or are they big and chunky?" If they're big and chunky, then generally we don't have to worry about them. But if they're small and fine and kind of clustered or grouped together, that's when we get concerned and will recommend to have a minimally invasive needle biopsy done to determine - is this DCIS or is this something that maybe we don't need to worry about and it's just representative of normal changes that we can see on the breast? Whenever we recommend a core needle biopsy, what is involved is coming into an imaging center. We take pictures, with the help of a mammogram machine. And then we place some local or some numbing medicine within the breast. Then a small needle's placed within the breast, around the area where the calcium or calcifications is located, and a little bit of tissue is removed. That tissue is then looked at by the pathologist, under the microscope, and that's what can give us our diagnosis of cancer or not cancer. So, going back to the number of annual screenings, about 1 in 1300 patients that get screened with a mammogram throughout the year will actually end up positive for DCIS. So, there's about 51,000 new diagnosis of DCIS, or stage 0 breast cancer, each year.

Host: Do all women with DCIS require treatment, if they're at average risk?

Dr. Wehner: So, when DCIS is found, so when you have a new diagnosis of ductal carcinoma in situ, the standard recommendation does require or recommend to have a multidisciplinary approach to the treatment of this. This may include surgery, it may include radiation therapy, and it may include a pill that's considered essentially an anti-hormone pill, or an endocrine therapy. Chemotherapy is not something that we will ever use for ductal carcinoma in situ. And chemotherapy is what everybody thinks of when they think of cancer treatment, because chemotherapy is the stuff that can make you feel kind of sick and make your hair fall out, make you kind of sick to your stomach. We don't use that for DCIS. Standard, if it's small – so the area of calcifications or the area of known cancer is small - then we can generally remove it by doing something that's called a partial mastectomy. Now, a partial mastectomy – there's a lot of terms that mean the same thing, and so you may hear it called as a lumpectomy or as removal of just the cancer or as breast conservation therapy. All of those terms mean the exact same thing. And, that just means the goal is to remove where the cancer cells are living and to get a little bit of healthy, non-cancerous tissue around them. Whenever we remove just part of the breast and we leave the rest of the breast behind, then generally we do recommend radiation therapy to be followed. Radiation generally doesn't start 'til a month or so after the completion of surgery and after healing, and then that can be anywhere from 3 weeks to 6 weeks, on a daily basis. That's not standard for each and every patient but that's the general guideline we use. Now currently, we do have a clinical trial that has just opened that's actually looking at observation alone for certain ductal carcinoma in situs, rather than moving forward with surgery. And that particular trial is called the COMET trial. And so, for certain patients that have fairly favorable DCIS, and favorable just refers to various things that we see under the microscope, for some of those patients now rather than moving to a surgery first, those patients can be observed with mammograms every 6 months. And, as long as nothing is changing on the imaging, then we can continue to observe them.

Host: Why is radiation therapy preferred over chemotherapy for DCIS?

Dr. Wehner: So, radiation therapy and chemotherapy treat cancer in very different ways. When we talk about cancer treatments, we talk about treatments that are local/regional treatments or we talk about treatments that are systemic treatments. And what that means is certain treatments are given just to the breast and the surrounding breast tissue and other treatments are given to the entire body. The point of both of those treatments is the same, which means the point of both of those treatments is to treat the breast cancer. They just go about it in a different way. So, for stage 0 ductal carcinoma in situ, to give a systemic treatment or a whole-body treatment through chemotherapy we know doesn't work. It doesn't affect the recurrence of this stage 0 cancer and it doesn't affect the overall lifetime survival of this type of breast cancer. That's not true for other invasive cancers, but for DCIS, chemotherapy just has no real added benefit, which is why we don't use it. Radiation therapy, however, is a treatment that's directed just to the breast and the surrounding breast tissue. And the point of radiation is to reduce the risk of recurrence. So, what we want to do is reduce the risk of DCIS coming back because we know when it comes back, about half of the time it comes back as that invasive form. And, it's the invasive form that we worry about the most because that's the form that can spread to other parts of the body.

Host: There've been discussions for several years about the over or under treatment of DCIS. What is your opinion about whether it should be treated and how do you help women make that choice?

Dr. Wehner: So, breast cancer is no longer a 'one size fits all' approach. So, historically, when we treated breast cancer, way back when, we used to treat it with a modified radical mastectomy. So, everybody lost their breast, most patients got chemotherapy, and most patients got radiation therapy, regardless of the type of breast cancer they had. In today's era, we are much more specific about the types of treatments that we recommend and that's because it's not a 'one size fits all' criteria any longer. DCIS, we know, is a non-invasive type of breast cancer that has a chance of turning into an invasive type of breast cancer. And so, historically, we have always treated DCIS with at least a minimum of surgery. Current trials do show us that treating it with surgery and then adding radiation will decrease the risk of recurrence but doesn't necessarily change the overall survival. And so, with that type of data, is where people start to say, 'well maybe we're overtreating this.' So maybe we don't need radiation therapy. Or maybe we don't even need surgery. Radiation, for certain patients with DCIS, is no longer a standard recommendation. So, if patients are a little bit older, if patients have a really low-grade type of breast cancer that seems favorable, for those patients we are potentially not recommending radiation therapy. There's also a new genetic test that has recently come on the market that's given us sort of a discussion point as to what somebody's risk of recurrence of the DCIS is. And, that may help us decide adjuvant treatments. But again, this also goes back to the current clinical trial that we have open, which is the COMET trial, and that's really trying to answer that question of - are there certain patients that we don't need to treat with radiation and don't even need to treat with surgery? And are these patients that we choose to just follow with imaging, such as mammography, do they do okay overall? And there's no real way for us to answer that question without enrolling patients on this trial. And so, we have a lot of high hopes that we can get patients to enroll in this trial and then we can really have a good answer to that question.

Host: Could you tell us a little bit about your patient population – what are the ages of women that you're seeing with DCIS?

Dr. Wehner: So, women with DCIS can be any age. So, they can be as young as in their 30s and we can see them up to the age of 103, I think is the oldest patient I've treated. So, it's not that it is necessarily an age criterion that we see for patients. We do know that the number one risk factor for developing breast cancer is age. So, the older we get, the more likelihood we have, or we become, to develop a breast cancer. And, there's nothing you're going to do about that because nobody can magically become younger. So, we do see it throughout a wide variety of patients.

Host: Have you ever had a patient who was maybe on the fence or had a cancer that you felt needed to be treated and she just wasn't sure? Could you tell us about that experience with her and how you helped?

Dr. Wehner: So, we have a lot of women who come in that are very anxious about their diagnosis of cancer, and rightfully so. However, what I try to explain to patients is breast cancer is a very different cancer compared to something like a brain cancer or a pancreatic cancer. And that just is because breast cancer is very, very treatable. So, most patients with a DCIS treatment, are alive and well five years, ten years later. And that's just partially the nature of the disease and partially because our treatment options have gotten so good at treating this, that while nobody wants to say that they have a cancer and they have to undergo therapy for a cancer, it really has become very streamlined and fairly minimal. For most patients that have a lumpectomy or a partial mastectomy - the two mean the same thing - it's actually an outpatient procedure. It only takes us really about one to two hours in the OR to perform this procedure. For most patients, we don't even have to put them fully to sleep for this procedure, meaning – we give them anesthesia but not so much anesthesia where we have to put a breathing tube down. And then, patients go home the same day. So, patients really do incredibly well from this sort of surgery and they recover very, very quickly. And so, I find a lot of anxiety and fear of treatment is because they just don't understand what's really involved with the treatment of it.

Host: Is there anything that women need to know about selfcare and recovery? What does the recovery look like for DCIS, if you have a procedure?

Dr. Wehner: So, for a partial mastectomy, I send everybody home essentially with just a small band aid that covers the incision and then we send them home in a tight, supportive bra. The key that I tell everybody is they should wear this supportive bra at least for a week after surgery – that includes sleeping in the bra – and that's just because we do use some deeper sutures within the breast. And so, it's just more comfortable to provide support to your breasts via this compression bra. And that can be the one we send you home in, that can be one that you have at home – it's just something that provides compression and support. Patients are allowed to shower the day after surgery. It's completely fine to get it wet with warm soapy water and then just kind of pat it dry and put your bra back on. There's not a lot of restrictions. Patients can use their arms. They can brush their hair. They can cook meals. They're not allowed to drive if they're taking narcotic pain medicine or if they cannot sit comfortably in a car with the seatbelt on. But, the recovery time actually is pretty minimal. And that's what most patients end up coming back in to the hospital saying, "You know, I only really needed a pain medicine for maybe one evening and then extra strength Tylenol worked just fine for me." And patients are pretty surprised at how well they feel afterwards. So, to do a mastectomy is a very different procedure than a partial mastectomy and that's because a mastectomy, the goal of that is to remove all of the breast tissue, whereas the goal of a partial mastectomy is just to remove part of the breast instead of the entire breast. When we remove an entire breast, then things become a little bit more complicated when we start talking reconstruction, meaning rebuilding another breast. And that can come in the form of an implant-based reconstruction or autologous reconstruction, which really just means we're taking tissue from someplace else on your body and moving it to where your former breast used to be. Those surgeries are very different and much more complex and much more involved. Those surgeries, some of them, means a hospital stay of four or five days. It really just kind of depends on what type of reconstruction is going on. To do a very simple mastectomy, where the goal is to make it flat and not reconstruct, those patients stay in the hospital one night and go home the next day.

Host: Why is MedStar Washington Hospital Center the best place to seek DCIS expertise?

Dr. Wehner: So, all breast cancer needs to be treated in a very multidisciplinary approach. And, as I alluded a little bit earlier, we have a lot of different treatment options for the way we treat breast cancer. Here, at MedStar Washington Hospital Center, we have a very active and very robust multidisciplinary team. And part of that is because our patient population here just isn't always the healthiest. And they have a lot of comorbidities and social factors, things that inhibit them from being able to come to the hospital to get treatments. And so, when you come here to have your breast cancer treated, you really come here to have everything treated and everything looked at. When we meet on a weekly basis, which we do as a multidisciplinary team every Wednesday morning, we have about thirty practitioners that come to our meeting. And that includes breast surgeons, breast medical oncologists, breast radiation oncologists, breast imagers, physical therapists, nutritionists, social workers, nurse navigators. We have a lot of just additional people that really take part in your care that you don't even realize are working behind the scenes. And that really is just to make certain that you, as a person, is taken care of and not just you as a breast cancer patient.

Host: Thanks for joining us today, Dr. Wehner.

Dr. Wehner: Absolutely.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Every year in the U.S., 20 per 100,000 people experience sudden hearing loss, a medical emergency commonly caused by upper respiratory tract infection. Dr. Selena Briggs discusses how early, specialized treatment can help restore hearing.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today, we're talking to Dr. Selena Briggs, a neurotologist skull base surgeon within the Department of Otolaryngology at MedStar Washington Hospital Center. Welcome Dr. Briggs.

Dr. Selena Briggs: Thank you, thanks for having me.

Host: Tell us a little about yourself, why did you go into medicine, and how did you come to practice at MedStar Washington Hospital Center?

Dr. Briggs: I've had an interest in going into medicine, I think, from my youth. It actually stemmed from my pediatrician, Dr. Frank Newburger who practiced here in Silver Spring, and he was a great mentor, and a great pediatrician and that spurred my interest, and then later I developed an interest in music and dance, I was a ballerina, and I loved ballet. And while I was younger, there was a miss America who was deaf and a ballerina, and that sparked my interest in understanding more about deaf culture and hearing loss. So, throughout my career it's just kind of moved in that direction of hearing health and this direction.

Host: Today we're talking about upper respiratory infections that can lead to hearing loss. Dr. Briggs, how can an upper respiratory infection cause hearing loss?

Dr. Briggs: That is an excellent question. Most people are unaware of the association between upper respiratory tract infections and hearing loss. It's not uncommon for an individual to wake up in the morning after experiencing an upper respiratory tract infection and state that they can't hear out of one ear. They'll commonly call their primary care provider and try to get an appointment to be seen, and nothing gets seen on examination. That is the main concern. That is of pinnacle concern, in fact. Those individuals may be suffering from something called sudden idiopathic sensorineural hearing loss or simply sudden hearing loss. That's most commonly associated with upper respiratory tract infections or the common cold.

Host: So, I know when I have colds or even allergy problems and anything really affecting my sinuses I get that kind of clogged feeling in your ear—what are some symptoms patients tell you about when they get this hearing loss going on?

Dr. Briggs: The clogged sensation in the ear and the sudden sensory no hearing loss actually are two separate entities. Both cause hearing loss and both have similar symptoms of presentation, but the source of it is very different and the treatment for it is very different as well. So, when you have an ear infection or even pressure in your ear from a sinus infection, that's usually caused by something called your Eustachian tube. I don't know if you've ever been on a plane and your ears popped and you feel that sensation? It's your Eustachian tube opening and closing that allows you to equalize your pressure while you're on a plane. But when you have a sinus infection, oftentimes that Eustachian tube becomes plugged, and doesn't open and close normally. That causes pressure, muffled sensation, and sometimes can even cause fluid to develop in your ear. That typically is a short-lived, self-limited process. The sudden sensorineural hearing loss or sudden hearing loss is a completely different process, where it doesn't cause a pressure problem, but it actually causes injury to your nerve. It may cause permanent damage to your ear. It's not something that you should take lightly. It can be a long term even permanent issue for individuals. So, if one wakes up with sudden hearing loss, from the sudden sensorineural hearing loss, the nerve type of damage, about one out of three people it will resolve on its own, one out of three people it'll improve but not go back to its normal, and one out of three people it won't change at all. There are interventions that we can do to make your likelihood of returning back to normal greater, but the key thing is that you have to get in and be seen within three days to three weeks. Outside of that window, the likelihood of it becoming permanent loss is significantly greater.

Host: How many people experience this?

Dr. Briggs: So, on an annual basis, so every year within the United States, it's speculated that approximately five to twenty out of 100,000 individuals experience sudden sensorineural hearing loss.

Host: So, since this is suspected to be caused by viral problems or a virus, what can the doctor do either that primary care doctor, and then at what point do you need to be transitioned over to a specialist?

Dr. Briggs: The key thing first is being evaluated by your primary care provider or even urgent care and having an ear examination. Making sure your ear drum looks normal, there's not wax that's occluding or plugging up the ear canal, and make sure there's not fluid behind the ear drum, as we talked about before associated with allergies or sinus problems. It sounds strange, but a normal ear exam is an emergency. So, if you have a normal ear exam, and hearing loss, you need to be seen and have a hearing test right away

Host: What about those individuals who do put it off? Is it damaged to the point where they can never get that back then if they wait too long?

Dr. Briggs: There is a time window, and there is a time urgency. A few days, ot so much out of the window of treatment. Typically, we state 21 days is when medical therapy is most effective, and those therapies tend to be steroids either taken orally or via an injection through the eardrum into the middle ear space.

Host: Once the patient has had this hearing test, how quickly do they receive that treatment, and how long does that treatment take?

Dr. Briggs: So once an individual has a hearing test that documents sudden sensorineural hearing loss, they should be seen by an otolaryngologist or a neurotologist within 24-48 hours. The treatment is started rather urgently, because it gives them the best opportunity for the best outcome. So the treatment, depending on the patient's associated comorbidities such as diabetes or hypertension, may include oral steroids vs injection steroids in the middle ear space vs a combination of the two, and that's started immediately. There are other therapies that are recommended within the literature or can be used, such as hyperbaric oxygen therapy for restoration therapy as well.

Host: What's the hyperbaric oxygen therapy?

Dr. Briggs: Essentially it simulates diving, scuba diving. So, it puts you in a chamber where you have increased oxygenation or oxygen levels, to increase the oxygen to your nerve, in a hope that increasing its oxygenation it'll help it to heal faster.

Host: And what do the steroids do to help mend the hearing loss?

Dr. Briggs: It decreases inflammation on the nerve similarly, helping to increase blood flow and hopefully improving the hearing

Host: So, the more blood that's flowing through the ear in a healthy way of course the better you're able to hear.

Dr. Briggs: Right, exactly.

Host: So aside from that sudden sensation of not being able to hear, are there any other symptoms that an individual should be aware of or talk to their doctor about?

Dr. Briggs: Oftentimes individuals who have this sudden hearing loss may experience other symptoms that can prompt them to know it is the sudden nerve type of loss vs the conductive type of hearing loss with the fluid and the sinuses. Some of those symptoms include ringing in the ears, so if you have a high-pitched sound or even a sound of white noise like when you turn the radio between stations, that's another indicator that you may have a nerve type of damage in your ear. Vertigo or dizziness in association with the hearing loss is another indicator that it may be a nervous type of loss.

Host: Are there other conditions aside from respiratory infections that might cause that sudden hearing loss? I know you think about construction workers and the loud noises and things, is that the same, or is that different?

Dr. Briggs: That's a different entity, that's noise induced hearing loss, and that can cause a sudden we call it a sudden threshold shift, so sudden changes in your hearing. For example, if you're exposed to a loud sound or a blast, that too can cause a sudden hearing loss. It's similarly treated, interestingly, however. There is a host of disease processes that can cause hearing loss in addition to the viral ideology, and that's why it's even more important for you to come in and be seen and evaluated. Individuals with diabetes can have it associated with neuropathy, it can be an early sign of strokes, it can be a sign of tumors of the skull base, thyroid disorders, autoimmune disorders, there's a whole list.

Host: So really since upper respiratory, obviously, probably one of the more common causes of hearing loss but since there are so many things that could cause it, it's really about getting to the root of that issue. Could you talk a little bit about how you do that and how your team works together to do that?

Dr. Briggs: Yeah, definitely. So, the patients will come in and be evaluated with a physical examination and a history, and that largely directs which direction we'll go in terms of diagnosis and treatment. It's very common for individuals who have a sudden hearing loss to have an MRI of their brain and their inner ear to evaluate for any changes of the hearing and balance nerve, or any lesions that might be compressing the hearing and balance nerve. And then based upon the patient's other history and family history and comorbidities, they may undergo various laboratory testing to assess for diabetes or other autoimmune disorders that might be contributing as well as Lyme disease and other infectious processes.

Host: Could you talk about a compelling story that you've had come in with that upper respiratory problem and how that treatment looked for that patient

Dr. Briggs: There is one individual who is a clinician as well, who presented with bilateral involvement so most often individuals come in and it's involving one ear. In exceptionally rare cases it involves both ears. This individual needed their hearing in order to perform their work, and so we were able—he got in almost immediately after onset of symptoms, started oral steroids, and inter-tympanic steroids, and hyperbaric oxygen therapy and remarkably had restoration of his hearing. At his initial visit we had to communicate via typing on his computer and him speaking back, because he couldn't hear at all.

Host: He couldn't hear at all? It wasn't just a decrease?

Dr. Briggs: No, and that's the other thing to understand with a sudden hearing loss, it's not always just a sudden decline in hearing, some people actually wake up and be deaf in one ear.

Host: What's the emotional or the mental state of people when they come into the office?

Dr. Briggs: Completely scared, definitely. It's life changing and life altering. I think we often take for granted our hearing, and then once we lose it, or lose some aspect of it, we realize how important it can be to your life. It can be jarring, and it can be life altering and scary for patients to experience, but as long as an individual's gotten in early, the opportunity for treatment is significant. Without treatment, yes, one third may have no change, one third will have some change, and one third will improve somewhat. But with treatment that can dramatically improve the odds of improving the hearing back to their baseline.

Host: Is there anything an individual maybe that's prone to those upper respiratory infections can do to reduce their risk?

Dr. Briggs: Unfortunately, not. There's no treatment, there's no preventative therapy that's been identified in the literature to reduce your risk of developing sudden sensorineural hearing loss from these upper respiratory tract infections.

Host: Could you talk a little about the importance of an individual coming to an otolaryngologist

Dr. Briggs: It's critical for patients to come in and be seen by otolaryngologists or a neurotologist because of the specialized care and therapy that can be provided. We work as a team with primary care providers, with urgent care providers and with emergency department providers to get the patients in early and provide them with the treatment that's necessary, but it is important that they are ultimately referred to an otolaryngologist who could provide them with that inter-tympanic steroid therapy injection which is a very specialized procedure, only performed mostly by neuro-otologists, but also by some otolaryngologists. In addition, it's important that they be evaluated for those other disease processes that might be mimicking the sensorineural hearing loss, the idiopathic type.

Host: Thank you for joining us today Dr. Briggs.

Dr. Briggs: Thank you for having me

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Mammogram screening guidelines can be hard to follow, as organizations tend to change them every few years. To keep women up-to-date on best practices, Dr. Ami Chitalia says it's important that doctors reiterate the guidelines and personalize them to patients.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We're speaking with Dr. Ami A. Chitalia, a breast medical oncologist at MedStar Washington Hospital Center. Welcome, Dr. Chitalia.

Dr. Ami Chitalia: Thank you for having me.

Host: Today we're discussing the current recommendations for mammography, which is a recommended screening test for breast cancer. The 2018 guidelines from the American Cancer Society suggest that women at average risk for breast cancer have yearly mammograms starting at age 45, and they can switch to every other year at age 55. But, the ACS also notes that women should have a choice to start screening as early as age 40. Dr. Chitalia, with guidelines that seem to change every few years, do you find that women have trouble keeping their screening schedule straight?

Dr. Chitalia: Yes. So, they definitely do have trouble and I don't blame them. I think it's important that physicians reiterate the guidelines to their patients often so that they are aware of any important updates or changes to them.

Host: What's your opinion on when women at average risk for breast cancer should start having annual mammograms?

Dr. Chitalia: So, there are a lot of different answers to this question. Depending on which society's guidelines you follow, such as the USPSTF, which is the United States Preventive Services Task Force, or the ACS, which is the American Cancer Society, and a few others as well. The answers range from starting at age 40 to starting at age 50. Above all, I think it's important to use shared decision making with a physician helping the patient to weigh pros and cons and come to an informed, value-based, individualized decision. That is the model that is recommended by most guidelines, especially between ages 40 and 45. ACS recommends annual screening beginning at age 45 and then, either annually or every other year after age 55. So, shared decision making is again recommended after age 75, as well.

Host: When you have a woman come in, what sort of questions do you ask her or what kind of discussions do you have to help her decide what's best for her?

Dr. Chitalia: Sure. So, that's a great question. So, one of the biggest things is family history, so really getting a good family history of not only breast cancers but maybe also ovarian cancers and other cancers as well. Also, just asking the patient herself if she's ever had any abnormal mammograms in the past, if she's ever had any breast biopsies in the past. That may change your recommendation and make it more specific to her.

Host: What do the 2018 guidelines mean for women at increased risk, such as those with a family history of breast cancer or genetic factors?

Dr. Chitalia: So, if a woman carries a family history of breast cancer, that may mean she is recommended to undergo screening at an earlier age than an average woman. An example of genetic factors may be a BRCA 1 or 2 mutation, which are the most common mutations associated with hereditary breast cancers. So, for the majority of these women, the recommendation is to have their first screening mammogram at the age of 30.

Host: Do women need to do anything special to prepare for a mammogram?

Dr. Chitalia: So, it's suggested that women schedule their mammogram at the time when their breasts are the least tender, which usually tends to be the week after their menstrual cycle, but this can be somewhat different for each woman. If they've had mammograms at another facility is the past, it's usually a good idea to bring those images and reports in with them so that the radiologist reading their current mammogram can use them as a comparison. They should also let the technician know if they have had previous biopsies or if they have breast implants. And also, it's recommended that deodorants, perfumes, and lotions be avoided under the arms or on the breast area during the morning of the mammogram.

Host: Could you describe what a woman should expect at her mammography visit?

Dr. Chitalia: Sure. So, she'll be asked to remove clothing from the waist up as well as a necklace, if she's wearing one. She will be standing, and she'll be asked to place each breast, one at a time, on a platform on the machine and the technician will help to place her arms and head so that they don't block the breast and so that they can take the best images possible. The machine will then compress the breast in order to take pictures. So, the reason that that's done, it's important for breast tissue to be spread out, as much as possible, so that the x-ray can go through all of the tissue and the most complete and detailed set of pictures can be taken. The whole process should take no more than 20 to 30 minutes. So, I know a lot of women do have some anxiety related to their mammogram - fear of sort of discomfort or pain, and so, you know, I always tell patients that it is okay to take a mild pain medication, such as Tylenol or an Ibuprofen product, as long as it's approved by their physician, maybe an hour before the mammogram to alleviate some of that discomfort, if they've experienced that before.

Host: What sort of questions do women ask about getting their mammogram?

Dr. Chitalia: So, typically, by the time they've come to see me, they've already had their mammogram so, of course, they are somewhat anxious to hear their results, especially if they've had some abnormality in the past. It depends on what type of mammogram is ordered. There are screening mammograms and there are diagnostic mammograms. The screening mammograms - they do not get results right away. It usually takes about a week or so, depending on the institution. So, for those, I think they tend to be a little bit more nervous because, if all is normal, usually it's a letter in the mail and, if not, they get a phone call to come back. For the diagnostic ones, they're actually told of their results there and then, that same day, before they leave from their mammogram. So, I think for those, they've already been told and that's ok. And a lot of my patients are getting diagnostic mammograms since they're coming to me, usually for some sort of a breast abnormality.

Host: So, the guidelines that we've been talking about are regarding screening mammograms where you're getting checked for a potential breast cancer. What happens if something is found that's perhaps abnormal during that screening mammogram?

Dr. Chitalia: So, it depends on the abnormality. And, that can range from repeating the mammogram in 6 months, which is earlier than the usual annual repeat. It could also mean getting additional views, so if it's a screening mammogram that caught something that needs additional views, that should be done right away, within, you know, days to a couple of weeks. And THAT would be a diagnostic mammogram. In addition, usually a targeted ultrasound to that region is done. Sometimes, depending on the woman and her history, it could mean an MRI of the breast. So, it sort of depends on what the abnormality is. If it's clear that it's a benign abnormality, such as a cyst seen on the ultrasound, then usually that's just followed in a bi-annual or annual basis. And sometimes, depending on the woman, they can have a biopsy if it's something benign like a fibroadenoma and usually that's it and then they resume their usual screening. So, the answer is it really depends on the abnormality that is found, the grade or the score that it's given by the radiologist, and then the recommendation that's given following that.

Host: Why is MedStar Washington Hospital Center the best place for women to seek breast cancer screening?

Dr. Chitalia: MedStar Washington Hospital Center does a great job in a lot of different areas, you know, so we do offer state-of-the-art equipment and imaging techniques, including MRI guided biopsies, which are only actually offered at certain selected imaging centers. And we do offer comprehensive care so if there is an abnormality, they can see a large multidisciplinary team, including nurses, radiologists, surgeons, radiation doctors and medical oncologists, such as myself, all, you know, in the same building, which is nice for them. We also have dedicated breast radiologists who have sort of expertise in reading mammograms. And, you know, I think also our nurses, our technicians, the staff are really kind and caring and just kind of aim to make sure that their experience is smooth and comfortable. So, I really feel that MedStar Washington Hospital Center is a great place to go for a woman to have their mammogram.

Host: Could you share a screening success story from your practice?

Dr. Chitalia: So, I've had a few patients recently who were found to have a pre-invasive cancer, which is sort of a pre-cancer before it takes its next step to becoming a true invasive breast cancer. This was actually found on their very first screening mammogram in their forties. So, both patients felt lucky to find it at this stage where it was actually a stage 0 cancer and the treatments, at that point, are much easier to take.

Host: If you could summarize the screening guidelines and how those are followed at MedStar Washington Hospital Center, what would you recommend to a woman at average risk for breast cancer about the importance of getting her mammograms every year?

Dr. Chitalia: Yeah, so, I think, you know, once we've had the discussion and they've reviewed their medical history, their family history, any personal breast history with their primary care physicians and a decision has been made to proceed with mammogram, I think it's important that they do so because if an abnormality is caught, it can be treated promptly and followed promptly. So, I think that sticking to, you know, that annual screening is important because it can catch something early and it can be taken care of in an expedited manner.

Host: Thanks for joining us today, Dr. Chitalia.

Dr. Chitalia: Sure! Thanks again for having me.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.

Nearly 25 percent of all heart attacks might be silent myocardial infarctions, or silent MI. These heart attacks can cause serious, long-term damage without any noticeable symptoms. Dr. Allen Taylor discusses who is at risk for this condition and how to prevent it.

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thank you for joining us today. We're talking with Dr. Allen J. Taylor, Chief of Cardiology at MedStar Heart and Vascular Institute at MedStar Washington Hospital Center. Today we're talking about silent myocardial infarction, or silent MI, which is a heart attack that goes unnoticed by the person who has it. Silent MI might have no symptoms, or the symptoms might be so mild that they're mistaken for muscle pain or heartburn. But the lack of symptoms is deceiving. Research has found that Silent MI, without a history of traditional heart attack, increases a patient's risk of heart failure, heart attack, and death in general. Dr. Taylor, how can a condition that feels and seems harmless be so dangerous?

Dr. Taylor: Silent MI is an unrecognized problem. It's the same as a recognized heart attack, in terms of its risk. Seems surprising, how can something silent be so dangerous. And it's not just the recognition that's the problem, in terms of risk, but it's the fact that when not recognized, we don't have an opportunity to apply the right treatments that improve outcomes. So, silent MIs are risky and they're just as risky as MIs that patients recognize. So, it's important that we find them and get patients on the right treatment.

Host: Are silent MIs common?

Dr. Taylor: So, about a quarter of heart attacks are thought to be silent. And I think that when we use the word silent, we have to explain a little bit. Cause some MIs are truly silent - the patient never even has a symptom. Some MIs are unrecognized and so, silent to the patient, although there was a symptom that the patient didn't recognize as being typical for a heart attack. Patients may mistake their symptoms - for instance, they may say "Oh, that's just heartburn", or they may experience heart pain as back pain. Or, in older patients in particular, they may simply have no symptoms at all or simply be feeling down or fatigued or just "off" a particular day. We hear all these stories and, whether it's truly silent or unrecognized, it's about 1 in 4 heart attacks that occur in the community.

Host: How are silent MIs detected if they cause no symptoms?

Dr. Taylor: Detection of unrecognized or silent MI can be a problem because it takes a test to detect it since the patient didn't experience warning symptoms. Some ways we'll identify them are using a simple test such as an electrocardiogram, that if it shows the changes of a heart attack, that we would then do further investigations to confirm if the electrocardiogram was true or not. Electrocardiograms can be very useful tests in detecting heart attacks that have been unrecognized, although it's important to note that there's both false positive test as well as negative tests. So, the electrocardiogram is not perfect, but it's our primary tool to detect them. Another test that is very common in use is a heart function test called an echocardiogram. It's a test using sound waves that looks at the heart function and if an area of the heart was shown to be not functioning properly, we might suspect that it had been impaired by an unrecognized heart attack. And that might lead to further investigations to determine if that was true or not. But the detection is difficult. And so, it takes going to your doctor and having one or two of these tests to see if your heart's in really good shape.

Host: What happens after you discover that a patient has experienced a silent MI?

Dr. Taylor: Well, the first thing I say is "Don't panic." Let's dive a little deeper into this. But, what happens then is we'll just basically use the same evaluation as someone that had a known heart attack and run them through generally simple tests to see. For example, if the EKG or ECG electrocardiogram was abnormal, we'd perhaps get an echocardiogram to see if the heart function was ok. And then maybe a stress test - having somebody walk and then lightly jog on a treadmill while placed on an electrocardiogram to see if that shows any signs of heart stress when being active. And, if that's not enough, we have very sophisticated tests that we can really dive very deep into heart function and to make sure the arteries are in good shape or, if not, what the depth of the problem is. So, it's really the same evaluation as someone who has a known heart attack. And if we find there's truly an abnormality, what then begins, after it's assessed, is pick the right treatments. Does someone need an artery treatment right up front, and clearly then we'll move them on to the right preventative treatments to prevent anything further from happening.

Host: Who's at risk for silent MI and should patients worry?

Dr. Taylor: It really can be anyone because if it's truly silent or unrecognized, any of us could mistake, say back pain, for back pain when it was really truly a heart attack. But there's a few patient populations we've really focused on. One would be patients with diabetes. The patients with diabetes often don't feel pain in the same way. And, they truly can be silent, or they may even experience a heart attack in a day when they simply don't feel well and maybe their blood sugar control gets worse all of a sudden and they can't figure out why. In an older patient, particularly in older females, the heart attacks can also be truly silent or unrecognized because they present in odd ways like back pain or a day in which they feel tired or just simply off. But it's important to know that if anyone is feeling any symptoms that are unexplained - heartburn that's just a little different than the usual heartburn they've experienced and longer lasting - they shouldn't assume it's heartburn, but get seen promptly to make sure that, nothing's going wrong with their heart.

Host: What can patients do to reduce their risk of silent MI?

Dr. Taylor: In terms of reducing the risk for it, well it comes down to the core risk factors for heart disease. That is, high blood pressure, high cholesterol, diabetes, tobacco use, and then leading an optimal lifestyle, regular exercise 30 to 60 minutes most days of the week, avoiding tobacco, eating a diet that's low in fat and low in sugars. So, it's a lifestyle approach. Really, knowing your numbers and leading a healthy lifestyle to prevent it. But then not taking symptoms that you think are a little funny for granted.

Host: Why is MedStar Washington Hospital Center the best place to seek heart care?

Dr. Taylor: Well, I'm very proud of what we do at MedStar Washington Hospital Center and MedStar Heart and Vascular Institute because we simply can take care of anything from the most simple to the most incredibly complex. And we have every possible diagnostic tool to help uncover heart disease and every possible tool then to treat it. No matter the severity, we have a team that can help and that's another unique aspect of MedStar Heart and Vascular Institute is that when you see one person, you're really seeing an entire team. An entire team of experts that work together for making your care optimal.

Host: Could you share some success stories from your patient population?

Dr. Taylor: I have an interesting case - a young man, he's very overweight but he had come in the hospital in terrible shape and things weren't quite right. And in fact, in looking at his electrocardiogram, we noticed that there were signs of an old heart attack. And, in fact, what we indeed found in investigating it, was in fact he had an artery that was totally blocked, and it really had helped contribute to this whole illness that started with just a little breathing difficulty and retaining fluid. And by diagnosing the artery blockage, now we're on a completely different course of care and now we're seeking some really novel ways to restore blood flow past the total artery blockage. And while it's unusual for a 30-year-old to have a blocked artery, it was the EKG that tipped us off and it's really changed the way we're caring for him. And, while I don't want to alarm every 30-year-old person out there to say, "Oh my goodness, I could have a totally, artery totally blocked", it raises the point of leading an optimal lifestyle. Good diet, exercise, maintaining good body weight, avoiding tobacco are the real ways to preserve your artery health.

Host: Thank you for joining us today, Dr. Taylor.

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