Medical Intel

PET-CT scans provide detailed information on where cancer is located, whether it's spreading and if treatments are working. Dr. Carlos Garcia explains how this test works, what to expect if you're having one and how your doctor uses the results.

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. Carlos Garcia, Medical Director of Nuclear Medicine at MedStar Washington Hospital Center. Today, we're talking about the benefits of PET CT scanner. Dr. Garcia, what is a PET CT scanner and when is it used?

Dr. Garcia: So, a PET CT scanner is kind of a gold standard for cancer imaging. Just like in the past it was called a CAT scan, now they're called CT scans, are for anatomic imaging of multiple causes, whether they're cancer or not. PET CT is 99.9 percent dedicated to cancer imaging. The difference between a PET scanner and a CT scanner is that a PET scanner will rely on the cells being alive and consuming a specific type of substance that makes them show up on the scan. This substance is normally either produced or it circulates in your body. And we add radiation to it and that's why we can see it on the images. So, it's a combination now of anatomic imaging from the CT portion of the exam and functional or metabolic imaging from the PET portion of the exam. PET stands for positron emission tomography. Positrons are just basically an energy source that will, you know, produce an amount of radiation that we can translate into images, and the more active a cell is--especially the cancer cells tend to be more active than normal cells--the more they're going to emit this type of energy, the more they're going to take up this type of radioactive substance that they would normally not, and that's how they show up in a more avid, or they light up on the scan, if you will.

Host: So, how is the substance introduced to this other substance that you mentioned in order for it to show up on the PET scan?

Dr. Garcia: So, what we do is we make the patient the source of the radiation. We inject the patient with a modified version of glucose, which is the most common one; that's why I am going to use that as an example. It's called fludeoxyglucose, or FDG for short. You'll see that many of our exams have acronyms for that same reason. It's kind of a hard, long word. So, we inject the patient with this glucose substance, and all the cells in the body normally will use glucose as energy. Cells that replicate faster or grow out of control, as cancer cells do, will use more glucose because they require more energy to sustain this growth pattern. So, the cells that take up more glucose will take up more of the radioactive glucose that we have injected into the patient, and that's why they will shine in comparison to the background of normal cells. These cells will look bigger, darker and brighter because they just take up more of the radioactive substance that we tricked the body into taking because it doesn't know it's radioactive; it just thinks it's glucose.

Host: So, what are the advantages of combining a PET scan with a CT scan for cancer?

Dr. Garcia: For many, many years, when we did not have PET images available, we only used CT imaging, which could provide us only with an anatomic version of whatever is going on inside the body. The problem with this is sometimes you can see a tumor—we'll just use that as an example, and only the inner portion of the tumor might be where all the cancer is, and the rest of it might be just inflammation resulting from the presence of that cancer or tumor. The PET scan can differentiate that sometimes. It can show you what is the actual size of the live tumor inside of a structure that might be, let's say for example, 5 cm larger, but it's not all tumor. This helps in many ways to guide the therapy. One of the main applications of knowing this difference between what is functional or what is metabolically alive versus just the anatomy, is that when you apply this to radiation purposes for treatment, for example, the radiation field that will be attached, I'm sorry, that will be used for that particular tumor will only be the size of the part of the tumor, or the part of the mass, that is actually alive, so you can actually make it a little more circumscribed and more directed. So that's one of the applications when you talk about it. Now it's called all hybrid imaging--that is the gold standard nowadays of all cancer or oncologic imaging. And now the new hybrid imaging scanners like the ones that we have here, will overlap these images, and they're called fused activity, and you can definitely see the background and over the background of anatomy overlap with the cells that are actively replicating that turn out to be cancer cells.

Host: So, having the fused images really provides a deeper layer and a deeper perspective for both the imaging team and the physician. Does the patient also get the chance to see those images?

Dr. Garcia: When we have the opportunity to show the images to the patients, by all means. Nine out of 10 times, the physicians that have ordered the tests are comfortable with the patients knowing the results. We always want to extend the courtesy of the referring physician to be directly involved with the patient and them communicate the results, but we have had scenarios in which the patients are very comfortable knowing and they are very, very well versed in their own disease process, as it should be nowadays, and we are happy to show them the images. The overlapping of the anatomic portion of it and the live cell, the metabolic portion of it, it completely takes away from having to even point at the screen. Everything becomes very, very obvious and you can use different color schemes to bring out certain cell types, so it makes a picture worth a million words instead of a thousand words. And all the physicians within the hospital, they have the opportunity to be able to see these images on Enterprise-wide imaging viewer that they have access to as well. So, that makes our job very easy. Even though they're always welcome to come to the reading room and have us show them the images directly, we can have phone conversations, them looking at the exact same images that we are looking at, and we can tell them slice number and position, and target everything they need to know.

Host: Are there certain cancer types for which PET CT scan is most applicable or certain body parts that are easier to do?

Dr. Garcia: That's an excellent question because, for a long time, PET CT imaging was considered to be the, you know, savior for all types of cancer, and that unfortunately is not true. It has limitations and then it has indications that make it much more favorable. So, off the top of my head, I can tell you the top three indications that we use it here at the hospital are for breast cancer, lung cancer and lymphoma. So, these tend to be tumors that are very metabolically active. When I say metabolically active, it means that they have a tendency to take up more glucose than normal cells would, than other types of cancer would, so as long as they take up this increased amount of glucose, they will be brighter on the images and they will really stand out from the background, making the ability to detect them much, much easier.

Host: It really makes the cancer sound like a living thing and like a living disease, if you will, as opposed to just this abstract.

Dr. Garcia: I'm going to actually start using that way of explaining it because that actually sounds exactly right. That is, it's a live being that has a mind of its own sometimes, and our job is to be able to detect it early, be able to apply what we see to a treatment program, and then, after the treatment program, be able to monitor the response to the therapy by seeing whether that activity that translates into a lot of glucose uptake, seeing if it went down, meaning the number of cells is going down based on the therapy. If you have less amount of cells, it'll be less glucose that will be taken up and the shine on the exam, if you will, will decrease over time. So, we measure, we have units to measure the intensity of this activity and we use them very specifically, you know, to monitor the response to therapy because those units should go down as the number of cells within the cancer start dying as a result of the therapy.

Host: If my doctor tells me that I would need a PET CT scan, what should I expect from that appointment? What will that process look like?

Dr. Garcia: So, the first thing that you're going to do is you'll be contacted by one of our staff members from the PET CT Center, and they're going to ask you to prepare your body to be able to absorb the glucose better, and that's going to require for you to be fasting for at least six hours prior to the examination. So, the first glucose that you will receive, meaning the first source of energy that your body that has now been without food or drink for six hours, it will be starving. So, you prepare the body to eat something, and then the first thing that it sees is the glucose. And like I said before, it doesn't know that it's radioactive. It just thinks it's glucose, so it'll latch onto it immediately, and that way you won't have any competition with glucose from your diet, I mean, which are carbs basically from your diet, competing for a space to latch onto certain cells. So, everything that you will have will be radioactive glucose it'll latch on. And you arrive to the center. We give you the injection. It's going to an intravenous injection in your arm. You'll sit in a quiet room for anywhere between 40 or 60 minutes, and the reason why you want the quiet room is because you don't want any stimulus to any organ in your body, so we'll get you in a nice warm-temperature room, you'll relax, and then about after 60 minutes from that, we will place you in the PET CT camera, and with the new cameras, the amount of time that you will spend under the camera is a lot less, so you're looking at anywhere between a 20 to 30-minute scan from the level of your eyes down to your mid thighs. And once you conclude that portion of the exam, then the images get sent over to the radiology reading room, to the nuclear medicine reading room, for interpretation.

Host: How does that doctor then use the imaging to suggest treatment for me?

Dr. Garcia: So, we use a staging system, and I'm going to just use cancer, you know, as an example, which is the majority of the reasons why you do a PET CT scan. There's a staging system to know how far or how advanced, your cancer is. And depending on how advanced your cancer is, the treatment modalities will change. Let's use, for example, if we have a patient with lung cancer and they have a small lesion in a very circumscribed area and nothing anywhere else because the PET scan did not show that there was spread to any other organ in the body, then, in these particular cases, one of the treatment modalities might be surgery, for example. You know, I'm not a surgeon, but this is, you know like, this is, you know, one of the treatment modalities, one of the treatment options would be surgery. If, for example, the same patient has that same spot in the lung, but also has spots in his liver, also has spots in his bones, surgery may no longer be an option and a more systemic approach is necessary, meaning something, a form of therapy that will apply to your entire body since there has been spread. So, it can guide the clinician to knowing what the treatment options are for the patient, and that opens the discussion, you know, with the patient that these are now your options and this is your staging, you know, this is what we consider it to be. Because nowadays patients will do a lot of research on their own, and they come in asking you, you know, like, what is my stage? Am I stage I or stage II? What are my options based on these stages? So, that's really, really what helps to kind of tell the patient where they are and what their options are.

Host: So, really mapping the progress of that tumor through the body and then the patient's progress, thereafter, is mapped by the images.

Dr. Garcia: Correct. Mapping is a good word to use specifically for this because you will do a PET scan in various clinical phases. One of them is going to be for initial diagnosis. If a patient comes in and has an x-ray and they see a small spot on his lung, that could qualify him for having a PET scan, and they'll isolate a nodule. Then, after that, they will apply whatever treatment option is available to the patient based on the images, and then you will have another PET scan after the therapy has been installed to monitor treatment response. So, there's an initial treatment strategy and then a subsequent treatment strategy. That's how PET scan is divided nowadays. So, it's early, it's a very important early on in the initial staging and diagnosis, and also in the monitoring treatment response phase to see if it all cleared up, if it's spread more, or if it's actually regressed completely. And we see patients that sometimes showed up in their doctor's office with a small tickle in their throat. And it turned out, then they went over to their ear, nose and throat doctor, and they saw a little growth--you know, a little something, a little bulging inside their throat. And when they ordered a PET scan for this, it turned out that it was not just in that little spot, but it was in many other areas within their neck or within their chest. And, like I said, you know, once you know that, it'll change the treatment options, but I can say definitely, this is something that I share with my colleagues, is that you sometimes, you know, you get, your day brightens up, when you compare it to a study before that showed a tremendous amount of disease, and after chemotherapy or radiation, it's all gone. So, it's always nice to have that dramatic effect when you see live cancer cells everywhere and all these cells are dormant--you know, they disappeared basically. We call them night and day scans.

Host: For many imaging tests, patients have asked questions about or have been concerned about the level of radiation to which they're exposed. How does the PET CT radiation dose compare to MRI or another imaging?

Dr. Garcia: That's an excellent question because that is the one thing that people will worry about a lot is radiation exposure. Yes, PET scanning alone will produce much higher radiation exposure than a chest X-ray, but you have to think about the amount of information that comes as a result of that, you know, slightly over, you know, the normal degree of exposure. People sometimes don't understand that you just by standing around, you know, are getting a little bit of radiation from nature. And living in Denver for a year, you actually get more radiation than by having a PET scan. So, it all depends, you know, like on what kind of information you get out of it. When you do CT imaging of certain parts of your body, depending on what part of your body you're going to image, that part of your body gets an amount of radiation. PET scanning is the injected dose that will distribute throughout your body, so the dose that you receive will be spread out through your entire body, and that is, in essence, less of a dose to each organ in your body than if you only imaged one particular area at a time. So, it is a little bit more than CT alone if you only did CT imaging, but again the risk, benefit, and the amount of information you get for only a small amount of extra radiation, which is very, very below what the maximum amount of radiation you can receive in a year is, you know, is a wealth of knowledge.

Host: Are there any patients for whom PET CT scan just is not an option because of either the radiation dose or another complication?

Dr. Garcia: Actually, I can't think off the top of my head of a case in which you could not use a PET scan. We more, we more will see it in cancers that either don't take up glucose, radioactive glucose, so it's not the appropriate test for that particular type of cancer. Other limitations, of course, are that it has been proven through many, many studies that it is not the best examination for that particular type of cancer. There are some types of diseases that we wish we could use them on there, for those, but it's not approved to be used for those cases.

Host: Thank you so much for joining us today.

Dr. Garcia: Oh, it's my pleasure. 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.

Most thyroid cancer is small and slow-growing. Dr. Kenneth Burman shares why it's best to remove the cancer surgically before it has a chance to spread.

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: Today I am joined by Dr. Kenneth Burman. Thanks for joining us today.

Dr. Burman: Thank you very much for the invitation. I've been here about 20 years. It's really been a great experience. I've enjoyed it. We've had great support and we see a large number of thyroid patients and we have a big group so that gives us a lot of insight and experience regarding various thyroid issues.

Host: And you've probably seen a lot of change in 20 years, I would think.

Dr. Burman: Yes. Our ability in all of medicine to diagnose and treat diseases, especially cancer, has changed dramatically, and that applies to thyroid cancer as well.

Host: For, especially, low-risk thyroid cancer, what shall we do? Should we have surgery, or should we do active surveillance? What, what do we mean by active surveillance, to begin with?

Dr. Burman: You, you happen to hit a very controversial area. So, until about 5 or 10 years ago, we would treat most thyroid cancers the same and specifically I am talking about papillary thyroid cancer and not talking about other types of thyroid cancer such as medullary cancer and anaplastic cancer, which are totally different diseases. So, focusing on papillary thyroid cancer which accounts for about 90 percent of all thyroid cancers, in general, it's an indolent disease that's picked up by identifying a nodule in a patient's thyroid, biopsying it, showing that it's likely cancer or is cancer, and then recommending surgery. The surgery could be either removing the whole thyroid gland or a portion of the thyroid gland and then, in some cases, administering radioactive iodine therapy. And those have been the time-honored treatments and assessments for papillary thyroid cancer. But what's happened in the last five to 10 years is that it's recognized that the vast majority of patients with papillary thyroid cancer do well, the mortality rate is low, probably less than 3 to 5 percent over 10 to 20 years, and it's especially low in most younger individuals.

So, we don't want to expose people to unnecessary diagnosis and treatment modalities that they may not need. So, the issue is, or isn't, that there are a group of patients with slow-growing indolent thyroid cancers that we could just watch? The answer to that question is unknown at the present time. There are various clinical trials around the country, especially in New York, where they're taking the patients with small papillary thyroid cancers, doing a biopsy and not operating and just monitoring those patients. But the outcome of those results will take many years, maybe decades, to determine whether that's the appropriate course. In summary, the answer to your question is if we can identify a young, healthy patient with no other risk factors for thyroid cancer that would make it grow, and the thyroid cancer is small, meaning less than one centimeter, and the patient is willing to be monitored, there are some physicians, especially in a clinical trial, that would just monitor that patient with sonograms every 3 to 6 months for an indefinite period of time and follow it and if the nodule increased in size by about 20 percent or 30 percent or more they would then re-biopsy and then consider surgery. The standard of care, however, in the United States at the present time is to identify a thyroid cancer and to perform surgery. If it's a small papillary cancer that appears to be indolent, it's perfectly appropriate to do a lobectomy alone and leave the other lobe intact. If it's more aggressive cancer you might want to (or larger cancer) you might want to do a total thyroidectomy.

Host: So, what would be the advantages to not do surgery?

Dr. Burman: Well, first of all, with regard to surgery, surgery must be performed by an experienced thyroid surgeon. And it's an interesting observation that approximately 90 to 95 percent of thyroid surgeries in the United States are performed by surgeons who do 5 or less a year. So, you certainly want to go to an established institution with experienced thyroid surgeons. The risk of complications of thyroid surgery, even of taking out one lobe, include permanent or temporary low calcium and permanent or temporary hoarseness as the two most common complications that are still relatively uncommon. In experienced hands, they occur in less than 5 percent of patients, but in less experienced hands, the risk is much higher. So, for the population of the United States as a whole, if you find a small papillary thyroid cancer, and you don't have access to an experienced surgeon, the question is, is it safer to just monitor those patients and if the nodule grows and may cause more impingement of surrounding tissue, to then operate. That isn't the standard of care in the United States at the present time, but some physicians are doing that and there are active monitoring clinical trials.

Host: And what's your stand? Do you typically recommend surgery since it's the standard of care, or do you ever recommend monitoring?

Dr. Burman: In the vast majority of cases, our approach is to note that the mortality rate from thyroid cancer under present treatment and diagnosis regimens is really good. The prognosis is really good. The mortality is very low. The morbidity is relatively low as well of recurrent disease, so it makes most sense to us to, once you diagnose thyroid cancer, to recommend a lobectomy, but especially in patients who are otherwise relatively healthy and have a nodule that is more than 5-10 millimeters. Of course, there are exceptions. If a patient is 80 years old and has metastatic cancer from another cause, or heart problems, you're going to temper your advice appropriately.

Host: So, just to clarify, you do recommend, typically, the more surgical approach, correct?

Dr. Burman: Correct.

Host: Yup. And how do you talk about this with patients? Do you give them the options?

Dr. Burman: Well, first off, you have to have a great relationship with your surgeons. We have 3 excellent endocrine surgeons who do approximately 700 to 800 thyroid cases a year in total. So, they're very, very experienced and very interactive, and we present most of our complicated patients in a conference where there's a multidisciplinary approach. So that is optimal in this circumstance helping to make a decision about the appropriate course of therapy. It's the surgeon themselves and the patient that make the final decision whether it should be lobectomy or total thyroidectomy, but it's the whole team, including endocrinologists, that decide whether the patient should be sent for surgery in the first place.

Host: What other things should people consider?

Dr. Burman: I think the most important thing is the experience of the surgeon and interaction with the endocrinologists and surgeon with a full discussion of the advantages and disadvantages of each approach of monitoring versus lobectomy.

Host: Thank you so much for coming on the show today and sharing your knowledge on low-risk thyroid cancer options.

Dr. Burman: Thank you for the invitation.

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.

Can talcum powder cause ovarian cancer? Dr. Louis Dainty discusses why he recommends women not use the product on their genital area.

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. Louis Dainty, Regional Director of Gynecologic Oncology at MedStar Washington Hospital Center. Welcome, Dr. Dainty.

Dr. Dainty: Thank you. It's great to be here.

Host: Why don't we begin by telling us a little bit about yourself. Why did you go into medicine, and how did you come to be at MedStar Washington Hospital Center?

Dr. Dainty: My interest in medicine began as a, as a kid. I knew I wanted to be a doctor and going the long way to get there, I went in the military, went to medical school after spending some time in infantry and just retired from the military a physician after 26 years just last year.

Host: What led you into women's health and women's oncology?

Dr. Dainty: I fell in love with women's health as soon as I rotated on my OBGYN rotation as a medical student. Initially I thought I was going to be interested in orthopedics but then it was much easier working with women—they were a lot tougher than men.

Host: Today we are talking about ovarian cancer and talcum powder, or baby powder. So, a jury in August 2017 awarded a woman $417 million in a case against Johnson and Johnson. The woman claimed that her terminal ovarian cancer was caused by the company's baby powder, which she said she'd used for decades. And this isn't the first time that talcum powder has been blamed for causing ovarian cancer. So, Dr. Dainty, what does science say about whether baby powder can cause ovarian cancer?

Dr. Dainty: The first concern about the possible link between the use of talcum powder and ovarian cancer dates back to 1960s, and that sprung from the initial contamination of talcum powder with asbestos. For some time now, there hasn't been any asbestos in talcum powder, but still the question remained whether or not there was an association between the use of talcum powder on a female perineum and risk of developing ovarian cancer. The data has been studied, mostly not in a prospective manner but in an observation manner, and the data is mixed—most studies showing that there is no association between the use of talcum powder and ovarian cancer, and others showing that there is a small increased risk of ovarian cancer with the use of talcum powder. When scientists have gone back and looked at the data in total, it seems that statistically there is a very small increased risk of ovarian cancer with the use of talcum powder on the perineum, with specifically a single type of ovarian cancer, and that's the most common type which is papillary serous carcinoma of the ovary.

Host: What do the studies suggest about a woman's risk for developing ovarian cancer if she's used talcum powder?

Dr. Dainty: Your lifetime risk of developing ovarian cancer is about 1.6 percent of all women, so slightly less than two women out of 100 will get ovarian cancer during their life. And the majority of women die from that cancer because it usually doesn't present until it's very advanced. Some of the studies suggest slight increase of a risk of ovarian cancer where, if the baseline risk was 1.6 percent, some studies have shown that it might be as high as 1.8 percent. Now that doesn't sound like it's a lot, but instead of 14 women out of a thousand, 16 women out of a thousand would develop ovarian cancer. So those two additional women would certainly not feel that that's not a significant increased risk from talcum powder. So, while statistically it seems like a very small increase, anything we can try to do to try to decrease your risk of developing ovarian cancer, especially something as simple as not applying talcum powder to your bottom, is worth the effort.

Host: So, would it be fair to say that you do recommend that women who use talcum powder stop doing so, or use it less frequently?

Dr. Dainty: Yeah, I would recommend that they don't apply it directly to their perineum because the vagina is interesting in that there is a communication, obviously, physiologic communication, between the outside world and the inside of your body by means of the vagina and the cervix. And so, in theory, talcum powder could be transported from outside of your body into your vagina and up through your cervix because that's where sperm travel. Talcum powder certainly also could be transported that way, physiologically. So, yes, I'm recommending that if you're going to use talcum powder that you use it sparingly around your bottom and not apply it directly to your perineum or your vagina. Cornstarch, without any other additives, seems to do some of the same functions as talcum powder without, the, any obvious risks or any clear association between risk and, so if you have to use something, maybe a more natural subject like cornstarch would do. But again, so just avoid using talcum powder.

Host: Why do women use talc in these areas, and are there certain groups of women who use it more often?

Dr. Dainty: Historically, generations past, I think that a lot of women were taught to put a sanitary pad on, and prior to application of the sanitary pad on their vaginas, they would put talcum powder just to absorb moisture and to also combat bad smell. I think a lot of women, especially older women, grew up doing that. I think younger women, there's very few women that do that anymore. And so, that's why people started using talcum powder in the first place.

Host: And when you say that it affects the perineum of the woman, could you explain what that body part is, for individuals who might not know.

Dr. Dainty: So, the perineum is anything, the vagina, the labia, external genitalia basically, between your thighs, from your pubic bone down to your anus.

Host: Are there other products a woman may use, internally or externally, such as petroleum jelly, that may raise her risk for ovarian cancer?

Dr. Dainty: Yeah, that's an interesting question and the bottom line is there is no evidence to date that there is any increased risk with those, at least not that I am aware of, but you bring up a good point—any petroleum-based product that's applied to your perineum could have, theoretically have, a risk. The bottom line is what I tell most of my patients is when people ask me, you know, "should I use douching or anything like that," I say "no" and basically that God designed the vagina just the way it's supposed to be and you shouldn't mess with that—mess with it as little as possible. So, I don't recommend using any foreign products, that are artificial products, that you don't have to. Obviously, people that need artificial lubricant in order have comfortable intercourse, the products with the least number of additives, either color or perfumes or anything like that, are, are, going to be the safest.

Host: Is it safe to use baby powder on a baby's bottom?

Dr. Dainty: We don't know what that risk is, but certainly the use of baby powder for babies is pretty common, and we don't know whether or not that increases risk. It'd be hard—it's hard to design a study where you take a hundred babies and expose half of them to talcum powder and the other half you hold back, so all you're left with is recollection of whether or not a mother said that she used talcum powder on her baby's bottom or not. So, it's difficult to get at those kind of exposures through scientific investigation. If I had babies again, I would probably not use talcum powder on their bottoms.

Host: If you have a woman who's used talcum powder for years or for decades, should she be concerned, or should she see her doctor more frequently?

Dr. Dainty: No. There is no—there's no call for alarm and there's no call for increased testing or surveillance. There is no current routine screening that is recommended for the prevention or diagnosis of ovarian cancer in people that are at baseline risk. That means a lifetime risk of 1.6 percent, perhaps, in the United States. So, no, I wouldn't say that anybody who has used talcum powder in the past should do anything different except maybe stop using talcum powder.

Host: When you're talking about screening for ovarian cancer, there is really no great test, like mammography for breast cancer or pap smears for cervical cancer. What does screening look like, then, for ovarian cancer?

Dr. Dainty: There is no routine screening. As you just said, there is no routine screening for baseline risk, women at baseline risk for ovarian cancer. There are some screenings that we recommend for women who fall into the category of familial or hereditary ovarian cancer, which is a different topic altogether. But for the baseline-risk, general population, there is no routine screening. The only thing that, as an individual and/or a provider, that you may ask a patient to look for are symptoms. So, early satiety, bloating, increased abdominal girth, abdominal pain that occur more days than not—if that's a new finding, that's something you need to bring up to your OB GYN. And so that's really the only screening that I would recommend for all folks.

Host: So, you alluded to this a little bit before. What are those main risk factors for ovarian cancer?

Dr. Dainty: Probably the biggest is age. So, the average age for ovarian cancer is about 63. So, the older you get, the higher risk you are of developing ovarian cancer. Obesity is the number one modifiable risk factor. If you are 25 pounds overweight, which we all are, you are at 400 percent risk of having endometrial cancer. So, we talk about talcum powder because it increases your risk by 20 percent, and being overweight by 25 pounds, you increase your risk by 400 percent. If you are 50 pounds or more overweight, the risk goes up to 10 times the baseline risk. Certainly—and let's not even talk about smoking, right? So, yes, talcum powder is real, but it's not, the data is not so strong. Certainly, the most common talked about risk of ovarian cancer is familial risk. Now, right now, familial risk accounts for maybe 15 or 20 percent of all ovarian cancers. So, most are sporadic or just happen spontaneously. Family history is certainly, though, very important. So, if you have other family members who have breast or ovarian cancers, especially those that have had those cancers prior to age 50, those are folks that may need to be referred to a geneticist for testing.

Host: Does that include both sides of your family—so my mother's side of the family or my father's—or does that run more prevalently in one or the other?

Dr. Dainty: No, it includes both sides. That's an excellent point. It's all first-degree relatives. So, if your father's sister had ovarian cancer early or your father had breast cancer, that would be something that would be very concerning and something that would possibly warrant referral to see a geneticist.

Host: This has been very insightful and eye-opening so thank you again, Dr. Dainty, for joining us to discuss this very delicate but also very important women's health topic.

Dr. Dainty: I appreciate the invitation. Thank you.

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.

An adult can bleed to death in less than five minutes from a severe wound. Bystander intervention is critical to survival, but many people are afraid to help in the moment. On this anniversary of the 9/11 attacks, Dr. Jack Sava discusses the Stop the Bleed campaign, a national movement to teach people simple steps to save lives.

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. Jack Sava, Chief of Trauma at MedStar Washington Hospital Center. Welcome, Dr. Sava.

Dr. Sava: Well, thank you.

Host: So, today we're talking about the Stop The Bleed campaign, a national effort to encourage bystanders to become trained and empowered to help in a bleeding emergency before professional help arrives. Dr. Sava, why is it so important that bystanders know what to do if they see someone bleeding?

Dr. Sava: Well, I think that the Stop The Bleed campaign has become important in a couple different ways. This campaign grew out of a tragedy, a mass shooting, and so the original idea of the Stop The Bleed campaign is that first responders, specifically police officers, should be able to stop bleeding with direct pressure and a few other means. But, quickly everybody realized that this doesn't just apply to a police officer in a mass shooting. It applies to all of our lives. We've all become accustomed to the idea that if we're on a subway platform and somebody has a cardiac arrest, that it would be great if we knew how to do CPR and save their life. So, the fact that everybody now is getting on board with doing CPR, but many people don't understand the very basics of how to stop bleeding, is a bit of a mismatch. And I think that's part of the impetus for the Stop The Bleed campaign is to bring the care of bleeding patients up to what we're trying to achieve with the care of patients who have had a cardiac event.

Host: What's the danger if somebody is bleeding--how fast can that person die from blood loss?

Dr. Sava: Well, people can die in seconds or they can die in hours, and some of the people who die in seconds are not going to be saved by pressure on the subway platform, and maybe, you know, some of the other people have time to get to the hospital, but what we're after is this big middle ground of people who have severe bleeding and what happens in the first hour is going to make a difference between them living and dying. I've seen over the years footage, as we all do nowadays, of people who have been bleeding from an arm or a leg, and have been in a crowd of people who didn't know what to do, and you can watch these people bleed to death. And it's a very moving experience for anybody, but for a trauma surgeon it's torture to watch people who are well intentioned, but don't understand that if they did one or two simple things, they could save that person. It's very hard to watch, and we see this play out in people who come in who probably had an opportunity to have somebody stop the bleeding before arrival in the hospital.

Host: I think as a population people are just almost trained to panic when they see blood, you know, worrying about their own safety. What are the precautions that an individual might be thinking about or what's going through their mind when they're watching this individual bleeding?

Dr. Sava: Well, I think that's a great point. I think we've all gotten messages about what matters over the years, and people, even at their best, might have a hard time balancing those different things about priorities, about what matters, and when they're under a lot of stress, they're not going to be thinking that clearly. So, what do I mean by what matters? Well, first of all, infection matters. In a very general sense, I think we all think that wounds have to be treated with sterile stuff, with certain types of gauze and medical equipment, other than that there's going to be an infection. So, first of all, one of the important things that we need to train people is if you're about to bleed to death, infection doesn't matter at all. It literally should be the furthest thing from your mind. Another thing that matters is pain. So, if I tell you, and we don't often talk about this, but if you see, uh, somebody with a big wound on their arm, the last thing, as an empathetic human being, that you're going to be inclined to do is to press on it. We're trying to say that as if it's common sense, but it's actually very counterintuitive to press on a wound. It seems cruel, but that requires, some, uh, some discipline, some, you know, some training, maybe some mental preparation because it can be hard to do. I think that's something that we in the medical profession get good at. We're used to thinking of pressing on a wound as a nice thing to do for somebody, even if it's uncomfortable for them. We, you know, we feel good about that, but I think to the bystander, that connection might not have been made, and so now you picture somebody--well, what if it's your child? Many of us have been through situations like giving a child medicine where you have to hold them down, and you all know that sometimes in a marriage there is one partner who can do that because they feel like they're doing something good, even though it's unpleasant, but some people just can't torture their own child that way, so that's something that is not so much a fact that they need to learn, but something they need to mentally rehearse, and they need to really embrace the idea that this has to happen, despite the fact that it could lead to an infection weeks later that could easily be treated with antibiotics, but also despite the fact that it might be very painful. Now, in the military, you know, they have protocols. In many cases, if somebody has a gunshot wound to the leg, the medic might be kneeling on it or standing on it. I mean, those are things again that are not in our normal course of activities.

Host: I can only imagine what that would feel like - you come up on somebody and they're already in pain, and putting additional pain on them - it's the right thing to do. So, if I were walking through a subway, for example, and I see an individual bleeding out of their arm or leg, walk me through what I should do for that individual.

Dr. Sava: Well, the first thing to do, the immediate response, should be to press on it hard and to press on it with whatever you can find. One of the things that I see is that people like to use a lot of cloth, for lack of a better word--a lot of gauze, a lot of, you know, giant shirts and so forth, and what that can tend to do is spread out the force well beyond where it's needed and diminish the actual pressure at the right, at the point where it's needed, so you need to, uh, get an idea of where the actual cut is, and obviously, if somebody had a whole pant leg soaked in blood, it's very easy to be very wrong about that, so in some cases it means cutting off a piece of clothing or removing clothing, or if other people have sort of layered on dressings and cloth all over the place, you've got to kind of figure out where the actual wound is if you're going to successfully manage it with pressure. So, first step is to apply pressure. Now, in many cases that stops the bleeding. Now, I think that usually a person pushing on a wound does a better job than a dressing. My advice would be, if you're pressing on something and it stops the bleeding, don't be in a hurry to try to turn that into a bandage that's wrapped. Just take a moment and be happy with your success, and keep your hand on there until help arrives.

Host: Dr. Sava, what should a person do if that direct pressure doesn't stop a person's bleeding?

Dr. Sava: If the direct pressure doesn't stop the bleeding, another alternative that you may have available to you is to use what we call a hemostatic dressing. That means a dressing that's built to stop bleeding. So, nowadays over the last 10 years we've developed gauze dressings that are coated with special substances that stop bleeding, and so if you have those, those can be very effective to put on or into the wound, and then reapply the direct pressure. Now, if those things don't work, on an arm or a leg, the next step is a tourniquet. Tourniquets have been around for a long time. There are commercially available tourniquets, and one of the missions of the Stop The Bleed campaign is to try to make these very readily available. Just like there's defibrillators now everywhere, we want there to be tourniquets, you know, in glass cases at every school and everybody's glove compartment, and so forth. The key thing about a tourniquet is it has to be above or upstream of where the wound is, so if you have a wound on your thigh and you put a tourniquet on your knee or on your calf, then that's obviously not going to help. So, tourniquets are very effective when there's room to get them between the wound and the torso.

Host: So, the goal of the tourniquet--could you explain a little bit about that?

Dr. Sava: What the tourniquet does is it stops all blood flow to the arm or to the leg. And you might think, oh, that sounds bad to not have any blood flow to your arm or your leg, and actually, yeah, if you had no blood flow to your arm or to your leg for 8 or 10 hours, that would be a problem for that arm or leg. And that gets us back to the question of pain because putting a tourniquet on effectively is not comfortable, so you have to kind of push through that. And basically, you have to tighten that tourniquet until it stops the blood flow, so there's a good kind of feedback about whether or not your tourniquet is working because the wound should stop bleeding. It's very simple and satisfying physics. We see patients very frequently now who have probably had their lives saved by tourniquets. And it's interesting because tourniquets were not as commonly used 15 years ago, so really one of the major lessons of the war and the conflicts recently has been that tourniquets really are lifesaving and it really is OK to have them on for a reasonable period of time. So, thankfully, we're now, over the last 5 or 10 years, seeing the emergency medical services providers putting on tourniquets in the field, and it's even trickling down to citizens, so we're seeing workplace accidents where somebody at the job site has applied a tourniquet, and people are coming in awake and alert and surviving, whereas before that they would have come in soaked in blood and perhaps dying.

Host: It seems so antiquated to, you know, to be a newer technology, you know, like people have done this for centuries. And how did it fall out of practice?

Dr. Sava: Yeah, it's interesting. There's a lot of things that are cyclical like that, but the reason it fell out of practice was the concern for having no blood flow to a limb for a period of time, so, you know, there were a number of cases where there were consequences because they were left on too long. And the fact is also sometimes you might put a tourniquet on and it might turn out not to be necessary, and so between some of them not being necessary and some of them being left on too long, there was a period of time where people became anti-tourniquet, but the war changed all that.

Host: How are you and your team here at MedStar Washington Hospital Center working to promote the Stop The Bleed campaign or these initiatives, globally or nationally?

Dr. Sava: Well, the Stop The Bleed campaign is great because it's organized into some very simple messages, um, what we're trying to teach. And so now there's a course of materials, there's a simulation mannequin leg that we use to teach the skills, and there's ... it's all been put together into a product or course that we can teach very quickly, in an hour or two of time, so we are now going out into the community, um, to teach this course to all types of people. I'm teaching it to my kids' school this fall, which has raised the interesting discussion of how young can you be to learn these skills. Now, my kids were … I was yelling at my kids about bleeding management probably from the age of 4 maybe? I mean, they ... I used to get a cut on my finger, and I am not, of course, very freaked out by minor cuts, so I would just let it bleed and call my kids and then say 'this is going to bleed until you stop it,' and then my wife would tell me that's inappropriate. So, but anyway, for the school kids, I think the country is trying to decide what age is appropriate. Now, first aid skills and CPR go down into middle school and beyond sometimes, but this is, you know, a little more scary, and so everyone's trying to decide that.

Host: So, if I want this training for myself, how would I contact you or what are the resources available?

Dr. Sava: You can google Stop The Bleed and you can find courses through the website. You can also contact any local trauma center will likely be teaching the course. This has become a big push on the part of the trauma surgeons of the country, so most trauma folks either are putting on courses or know about them.

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.

Health organizations' guidelines about PSA screening for prostate cancer can be confusing. Dr. Ross Krasnow discusses how he advises men about the test.

TRANSCRIPT

Introduction: 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: Welcome, everybody, and thanks for joining us today. We're talking to Dr. Ross Krasnow. He is a urologic oncologist at MedStar Washington Hospital Center. Welcome, Dr. Krasnow.

Dr. Krasnow: Thank you for having me.

Host: So, we're going to talk about PSA testing for prostate cancer. In 2016, Ben Stiller, the actor, made waves with a blog post titled, "The Prostate Cancer Test That Saved My Life," in which he encouraged men to learn more about PSA testing, and it was something that he had gone through personally. And, the article also renewed a debate between medical professionals and organizations about the effectiveness of this test. Please explain to us a little bit more about what PSA testing is. Why is there so much debate surrounding this test?

Dr. Krasnow: PSA stands for prostate specific antigen. It is a substance that the prostate actually secretes into the ejaculate. The prostate is a sexual organ. It's not really supposed to be in the bloodstream, but it does leak into the bloodstream in small amounts. When a patient has prostate cancer, PSA will be secreted into the bloodstream at a higher level. Because of how PSA can be elevated in the bloodstream, it can be used as a screening test for prostate cancer, and it has been used successfully as a screening test for prostate cancer. Unfortunately, some of the data that demonstrates the efficacy, or lack thereof, of PSA testing for prostate cancer, is controversial. Specifically, in 2012 the US Preventative Task Force gave PSA testing a grade D recommendation. What that means is that they thought that the benefits of testing did not outweigh the harm, and they did not recommend PSA testing in men. In May of 2017, the US PTF, the US Preventative Task Force, revised their recommendation, and upgraded the recommendation to a grade C recommendation in men between the ages of 55 and 69.

What this grade C recommendation means is that the test should be offered based on the professional judgment of the clinician and patient preference. Prostate cancer screening works when used properly, but there are harms. That's why the Preventative Task Force came out with their recommendation in 2012. And those harms are a false positive rate of 15 percent. That means that 15 percent of men with an elevated PSA may not have prostate cancer at all and undergo unnecessary testing. When I say unnecessary testing, that primarily means a prostate biopsy, and a prostate biopsy can have complications. Also, there is a real risk of overtreatment. Most of the prostate cancer that's diagnosed with the prostate biopsy ends up being low-grade prostate cancer, also what we call indolent prostate cancer. Yes, under the microscope, the cells are abnormal, and it's technically called prostate cancer, but it's unlikely to negatively impact that man's life in any way. Also, there's a risk of over-detection of prostate cancer in men who are older with a lower life expectancy. Prostate cancer is a very slow-growing cancer, and it takes 10 to 15 years for it to progress, and maybe even longer for it to cause death. So there's not a lot of utility in screening and treating older gentlemen.

Host: So, what do current screening guidelines say about PSA tests then? So, for example, like the US Preventative Services Task Force or American Cancer Society?

Dr. Krasnow: As I mentioned, the updated recommendations from the US Preventative Task Force give it a grade C recommendation for men between the ages of 55 and 69. This means that a conversation needs to take place between the physician or advanced practice provider ordering the PSA test and the patient to understand the risks and benefits associated with PSA screening. And really, the American Cancer Society and American Urological Association guidelines have a similar emphasis on shared decision-making. The American Cancer Society updated their recommendations in 2016. They recommended that screening should start at the age of 50 after a conversation using shared decision-making takes place. They also recommend screening, specifically African-American men, starting at the age of 45, and they recommend screening patients with a family history of prostate cancer at the age of 40. The American Urologic Association has similar recommendations. They recommend starting screening a little bit later at the age of 55, but again they emphasize the importance of the patient understanding the benefits and harms of screening before undergoing PSA testing. The American Association of Family Physicians hasn't revised their recommendations in some time, but they do not recommend screening at this time.

Host: As a younger male, how is a man supposed to know which guidelines to follow?

Dr. Krasnow: There really is no right or wrong guideline to follow. The key is that the patient themselves has to engage in the decision-making process with their provider to decide whether they should undergo PSA testing or not. They need to understand the benefits of PSA testing, that PSA testing can lead to a decrease in the risk of a prostate cancer mortality, but they also need to understand that you have to screen a lot of patients before you save even one person, and the treatment for prostate cancer has its own risks associated with it. One person may feel that they don't want to undergo that type of test for what they find to be minimal benefit. Another person may say, "You know what? I want to know if I have cancer, and if I have it, I want to treat it, because I don't want to face the long-term consequences of having a cancer down the line." The other thing to mention is that the detection of prostate cancer with PSA testing may not impact survival as much as we would expect, but there is a lot of benefit to preventing patients from having progressive prostate cancer that either invades into local structures or becomes metastatic. I've certainly seen patients in my practice who have advanced prostate cancer that spreads to other organs and they feel that, had they had testing at an earlier stage, an intervention could have been offered sooner.

Host: That makes me wonder, you know, have you seen patients like Ben Stiller, who is a younger male than I guess what is presented in those guidelines to follow, in which this test found the cancer really at the really early stage of their lives, or have you seen patients who went through a biopsy and it turned out that the test was false positive?

Dr. Krasnow: I've definitely seen both of these types of scenarios. I have a specific patient in mind that I treated. He was a very young gentleman. He was less than 50 years old, who ended up getting a PSA test because he had some urinary symptoms. In reality, based on the strict screening guidelines, he may not have needed a PSA test at all because he was less than 50, but it was warranted because he had some urinary symptoms. His PSA was very, very high. At that point, we did a prostate biopsy on him and it showed only a very small focus of low-risk cancer, but something didn't make sense. His PSA should not have been that high for having such a low, small focus of cancer on the biopsy. So we had a long discussion about what the next step should be. Should we continue PSA testing? Should we treat? Should we do an MRI? We ended up doing an MRI, which showed an area that was of concern for a higher-risk cancer. We then discussed the potential treatment options, and he elected to undergo a radical prostatectomy using the robotic platform. And at the end of the day, his final pathology was a very high-grade cancer that left unchecked would likely have led to a lethal prostate cancer, so I was very relieved that he had had that PSA test and that we had intervened. On the other side of the spectrum, I'm often referred patients in their 70s, mid-70s or patients who have a lot of medical, what we call comorbidities. That means they have a lot of other medical problems—heart problems, lung problems, vascular problems, and they end up being referred to me for elevated PSA and for a biopsy. And when I meet with them, I say, "You know what? We should not biopsy you because we're likely to find prostate cancer or likely to find an indolent prostate cancer, but it's unlikely to ever affect you in your lifetime. So, I feel that I have avoided overtreatment in many patients as well. I think the key is to be smarter about testing, being more selective.

Host: How do you advise men regarding prostate cancer screening and do you find the test valuable, or do you think more men are harmed than helped because of false positives?

Dr. Krasnow: Let's not forget that prostate cancer is by far the most common cancer in men. Over 160,000 men are diagnosed with prostate cancer each year, and it's the number 2 cause of cancer death in men with 26,000 men dying of prostate cancer each year. This number is really comparable to breast cancer in women. Since the inception of PSA testing, there has been a sharp decrease in prostate cancer mortality. Approximately 1 out of 7 men in the US will be diagnosed with prostate cancer during their lifetime, and nearly 2.8 percent of men will die from the disease. We've discussed how PSA testing can decrease prostate cancer mortality and that treatment is associated with better survival over just watching it, so yes, I think that we definitely can help patients through PSA testing, but we can cause harm if we test the wrong patients. So, we really need to engage in smarter PSA screening.

I think an important key is the shared decision-making so that patients really understand the benefits and risks associated with testing. I think we need to be smarter about screening patients who are at an increased risk of prostate cancer, such as African-American and those who have had a close family member with prostate cancer. I think that it's reasonable to start screening even at an earlier age, such as 50 or below, and I think that there is now data that suggests that a low PSA at the age of 50 may suggest that you don't need any further testing, and so I think that is something that's coming down the line. It's important that we don't test patients who have a life expectancy of less than 10 years because they're really unlikely to derive any benefit from the testing and any further workup or treatment could definitely result in harm. I really advocate for stopping screening at the age of 70, except in only rare situations where someone is extremely healthy for their age, has a long life expectancy and, for whatever reason, is extremely burdened about the health of their prostate. I think it's important that we check PSA in men with urinary symptoms, especially before procedures or treatment of benign prostatic hyperplasia, like the young gentleman I told you about earlier.

Host: Dr. Krasnow, are there certain men who are at risk for prostate cancer and should be screened earlier or more frequently?

Dr. Krasnow: Absolutely. There are populations of men who are at increased risk of prostate cancer. Race is strongly correlated with prostate cancer mortality. African-Americans have at least double the incidence of prostate cancer compared to white men. And it's not only that the incidence is higher. They have an increased risk of high-risk prostate cancer and they have a 2 to 3 times increased risk of dying from prostate cancer, so not only is this a population that's underrepresented in the medical literature, but they're at increased risk of having an adverse outcome from prostate cancer, so it's more important that we screen in that population. Another important population that I talked about earlier is men with a family history of prostate cancer, and when I say family history I specifically mean those who have a father or a brother with prostate cancer. They have a much higher risk of developing prostate cancer, and again, more importantly, a higher risk of dying from prostate cancer. And studies suggest that screening in those patients with a family history may decrease prostate cancer death by 50 percent. We are also developing a better understanding of those who may have an increased genetic predisposition to prostate cancer. For example, one of the most common causes of breast cancer is a gene mutation called the BRCA gene, associated with breast and ovarian cancer in women. And what we're learning now is that men who have this mutation also have an increased risk of prostate cancer and an increase in lethal prostate cancer. Now we know that men who have a family history of breast cancer in the women in their family should also be more aggressively screened for prostate cancer.

Host: So, to me it sounds like the PSA test and the screening, it's effective. What's the future for prostate cancer screening? Are there better methods coming down the pipe?

Dr. Krasnow: I definitely think that PSA testing is effective when used in a smart fashion in patients who are younger and in patients who are more likely to die from prostate cancer. But the test could definitely be improved. Also, we're understanding that just because a man has a diagnosis of prostate cancer doesn't mean that we have to treat them for prostate cancer. We can effectively prevent prostate cancer death by watching the cancer closely. But, there are better methods coming down the pipeline. There's a lot of interest in earlier screening for prostate cancer, but not yearly screening. There was recently a publication by my colleague, Mark Preston, in the Journal of Clinical Oncology that showed that by essentially screening with a single PSA test at a younger age, if your PSA value is below a certain cutoff, you may never need PSA screening again for the rest of your life, and I think that's a very exciting proposition to say, OK, at the age of 45 we are going to do one PSA test. If it looks OK, we never have to do it again. That would certainly prevent screening in a large amount of patients, but we're not there yet. Also, we're better integrating advanced imaging into the diagnosis of prostate cancer. Specifically, I mean MRI for prostate cancer—magnetic resonance imaging. This type of imaging has increasingly been used in men who had an elevated PSA and have had a negative biopsy, but a scary high-level PSA, and it can be used to see prostate cancer that you can't see on the ultrasound and detect by routine biopsy. Now there is data that suggests that we may be able to push the MRI into an earlier phase and use it in the screening process, so instead of the process being an elevated PSA leading to a negative biopsy, leading to an MRI, leading to another biopsy, maybe a smarter way to do it is an elevated PSA, leads to an MRI, and then if there is something suspicious on the MRI, then we do the biopsy. This is new because up until recently the MRIs haven't had a high enough resolution to really see prostate cancer. There's also better biomarkers for prostate cancer. One is called the 4K score. It uses not just PSA, but PSA that's found in the blood and PSA that's further broken down by the body, and it may also be useful in screening patients who have an elevated PSA prior to biopsy to better detect those who may just have a lethal prostate cancer. And, in fact, MRI and these new biomarkers, like the 4K score, have recently been integrated into the NCCN guidelines. So, we've made a lot of progress in how to intelligently use PSA testing for the screening of prostate cancer. I think that we have more work to do, but it's looking even more promising, and I'm hopeful that we can further reduce the burden of screening and the harms of screening through these new technologies.

Host: That is really great news. I especially liked the part where you were telling us about how we can do it just one time at the age of 45 or so, and then never have to do it again. Hopefully, that time will come soon.

Dr. Krasnow: I hope so. It's early data now, but it's looking like that may be promising.

Host: Thank you very much for joining us today.

Dr. Krasnow: It was my pleasure.

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.

Digital rectal exams for prostate cancer can be a little uncomfortable, but they're vital for early cancer detection as part of regular screening. Dr. Ross Krasnow explains why a digital rectal exam is important and what to expect.

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. Ross Krasnow, a urologist who specializes in urologic oncology at MedStar Washington Hospital Center. Welcome, Dr. Krasnow.

Dr. Krasnow: It's great to be here. Thanks for having me.

Host: Today we're talking about the digital rectal examination used to check for abnormalities of the lower rectum, particularly prostate cancer. Doctor Krasnow, what can a man expect when he gets a digital rectal examination?

Dr. Krasnow: So, I think that most people, when I tell them they need a digital rectal examination, get pretty nervous about it. And they also don't always understand why they need it. So, the first thing I do is try to explain, "Why are we doing it? Why do I need to put my finger in your rectum?" And typically, I'll…I'll grab a mannequin and I'll show them where the prostate is. And we do the digital rectal exam because the prostate sits right next to the rectum, right in front of it actually, and the best way to access the prostate through an examination is through the rectum. You can't feel it on the outside of the body.

Host: When might a man get this test - at what age should they start and how often?

Dr. Krasnow: So, there is a lot of controversy surrounding prostate cancer screening. But for the most part, men who choose to undergo prostate cancer screening, which should occur around the age of fifty, should have both a PSA test along with a digital rectal exam. There is some controversy as to whether the digital rectal exam adds anything to the blood test called the PSA that we use to screen for prostate cancer, but I think it's an important part of screening.

Host: So, in both of those tests, what exactly are you looking for?

Dr. Krasnow: So, when we talk about screening for prostate cancer there are really two components. One is a blood based test called the PSA. PSA is a substance that's secreted into the ejaculate by the prostate, but a small amount of it leaks into the bloodstream. When a prostate has prostate cancer in it, more of that substance can leak into the bloodstream, and that number becomes elevated and can be a signal of prostate cancer. That's why we use that as a screening test. The digital rectal exam is pretty crude, really. We're just feeling for any nodules, lumps on the prostate and any evidence of a prostate cancer extending into nearby organs like the rectum.

Host: So, you mentioned around age fifty - are there any other recommendations for men, perhaps men that are at higher risk for prostate cancer because of family history of the disease?

Dr. Krasnow: Absolutely. So, there are different guidelines as to when prostate cancer screening should start. The American Cancer Association recommends screening for prostate cancer starting at age 50. And in men with a family history of prostate cancer, specifically in men with a first relative who had prostate cancer - that would be a brother or a father with prostate cancer, screening should start earlier. Also, men of African American descent should start screening earlier because not only are those men at an increased risk of prostate cancer, specifically they're…they are at an increased risk of lethal prostate cancer. I believe that African Americans with a history of prostate cancer are supposed to be screened at age forty-five and men with a first relative who had prostate cancer should be screened at age forty.

Host: So, with the advent of PSA tests and those becoming more and more popular, what do you recommend for patients? Do you still continue to recommend different tests depending on their specific risk, their family history and so forth? Should all men have both the digital rectal exam and the PSA?

Dr. Krasnow: So, the problem with the digital rectal exam is that it's not a really good test for prostate cancer at the end of the day. In men who have an abnormal digital rectal exam, only about three maybe four percent of those patients will actually have prostate cancer. In men who have an abnormal PSA, it's about six to seven percent of those men will have prostate cancer. Really, I view a digital rectal exam as an adjunct to PSA testing to learn more about the size of the prostate and the anatomy of the prostate to understand the interpretation of either their PSA or…or biopsy.

Host: What are a couple of the…the most common concerns that men will ask you about this test, or the most common fears?

Dr. Krasnow: I think for the most part, most men are concerned about it being painful. I think men also wonder if it's even necessary. So, when I talk to them about it, I try to reassure them that it's certainly awkward but it's not painful, and I also tell them the rationale for why I'm doing it. Often when I see men for prostate cancer screening, very rarely am I only seeing them for prostate cancer screening. More often than not, men who are coming to me regarding prostate cancer screening are in their 50s, 60s and 70s, and they have associated urinary symptoms. They are getting up to go to the bathroom at night, they feel like they are not emptying their bladder completely, so when I am talking to these men, I'm not just focused on prostate cancer and prostate cancer screening. I'm focused on other aspects of a man's health - sexual function and urination - and so the digital rectal exam helps me treat those aspects of their life as well.

Host: Do you feel like there's still work to be done to educate men about the importance of prostate cancer screening and what do you think the future of that looks like in DC?

Dr. Krasnow: So, Washington, DC is very interesting in terms of prostate cancer. It has some of the highest incidents of prostate cancer compared to the rest of the United States. And the risk of prostate cancer mortality is higher in the DC area than in the rest of the United States. So…so certainly prostate cancer screening seems to be important in this area. That being said, there has been a lot of controversy regarding the efficacy of prostate cancer screening. So, recently the US preventative task force upgraded their recommendation for prostate cancer screening from a grade D recommendation to a grade C recommendation. The grade D recommendation essentially recommended against prostate cancer screening but newer and more robust data has shown that prostate cancer screening can be effective in lowering prostate cancer mortality. So, the grade C recommendation means that the patient and the clinician should have a discussion regarding prostate cancer screening and after weighing the risks and benefits of the screening, they can be offered PSA testing. Urologists are to blame for over-diagnosis and over-treatment of low-risk prostate cancer that would otherwise not affect a man in their lifetime, leading to toxicity – treatment-related toxicity, such as urinary problems and sexual problems. I think that now we're doing a much better job of screening more intelligently. Selecting who is at risk for prostate cancer and screening just men in the right age category or the right risk category that would benefit from screening, and often, even if we make a diagnosis of prostate cancer, we may not treat it if that cancer is low-volume and low-grade cancer, and this is a paradigm shift compared to what we used to do, which was treat everyone indiscriminately.

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

Dr. Krasnow: Thank you so much 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.

Lost time = lost brain function when it comes to patients who have had a stroke. Dr. Rocco Armonda discusses mechanical thrombectomy, a minimally invasive procedure that can provide lifesaving treatment for strokes caused by large blood clots.

TRANSCRIPT

Introduction: 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. Today, we're talking about mechanical thrombectomy with Dr. Rocco Armonda, Director of Neuroendovascular Surgery and Surgical Co-Director of the Neuro Intensive Care Unit, MedStar Washington Hospital Center. Mechanical thrombectomy is a breakthrough procedure to quickly and effectively remove blood clots from the brains of stroke patients using a stent retriever device. The procedure often is used when the patient is suffering a large-vessel occlusion.

Host: Dr. Armonda, what is a large-vessel occlusion?

Dr. Armonda: Right, so what this refers to is basically the major conductance vessels of the brain, the major vessels that basically bring blood into the brain, so we're talking about mainly the carotid artery, the middle cerebral artery and the posterior circulation—it's primarily the vertebral artery and the basilar artery. These are the major conducting vessels that we're looking at, and what studies have shown of recent is that mechanical intervention with the use of catheters, a combination of mechanical devices called stent retrievers and aspiration techniques, have actually dramatically changed outcomes to the point where we basically are seeing a success rate of on the order of 70 to 90 percent if we can get to patients early enough. And, we're talking about huge life savings in terms of preventing paralysis, preventing them from death, preventing them from being bedridden, maintaining their independence, their ability to speak, communicate, relate to their families. An individual who is typically in the prime of their life or just post-retirement, and they go from being paralyzed on one side of their body and unable to speak, to basically speaking and moving and walking and back to their normal baseline, and that's pretty dramatic. But it takes a well-organized system to do this. And, it really took a number of studies that basically showed at the highest level of evidence dramatic changes in terms of outcome. With those vessels who have large-vessel occlusion, you can get to them in a very rapid fashion, and in fact, the core of the infarct was smaller than the tissue at risk.

Host: One of the better-known stroke treatments is tPA, which is a medication given through an IV to help dissolve blood clots. Is mechanical thrombectomy a replacement for tPA?

Dr. Armonda: You know, when IV tPA first came out, the clot-busting medication was given through the IV. That was the only FDA-approved intervention. And now, you know, the paradigm has shifted, so it's not that mechanical thrombectomy replaces IV tPA; we actually do both in a lot of cases. There's three different scenarios. There is one scenario in a patient where we'll start the IV tPA and you might shift them to a place that does mechanical thrombectomy. There's another scenario where you start the IV tPA while you're ongoing doing the mechanical thrombectomy. And, then there's a third scenario which is a patient who can't qualify for IV tPA. Let's say they have had recent surgery. Let's say because of other time-window reasons you can't exactly place the onset of the stroke. So, it's beyond perhaps the 4.5-hour period, so those patients will go straight to mechanical thrombectomy. So, the idea is that mechanical thrombectomy is not competitive with IV tPA; it is complemented. You know, there's some cases where, honestly, we started the IV tPA, we do the mechanical thrombectomy, and given the fact that they started the IV tPA, the clot suctions up much quicker, and/or we'll do an angiogram and the clot's now gone, in rare cases. But, you know there's situations where you don't want to stop and wait and see if the patient gets better because you're already putting into that situation of 20 percent-plus decline in their outcome. IV tPA is usually given earlier, typically under three hours, but up to 4.5 hours, but if you have a patient who is beyond that 4.5-hour period, but whose imaging shows evidence of a large-vessel occlusion, but still preservation of a large portion of brain, and that the core of the infarct doesn't exceed a certain volume, those patients may not be able to get tPA, but we can do a thrombectomy. And, then you have another group of patients who may have just woken up from a stroke. Those wake-up strokes beyond the typical 6 hours may also benefit from mechanical thrombectomy.

Host: Is six hours the typical window for a patient to receive mechanical thrombectomy?

Dr. Armonda: The sooner, the better. The way it works, basically, is that the best outcomes are those patients treated under three hours. Time is brain here. Each 30-minute period of time lost is 10 percent loss of good outcome. So, if you compare outcomes in patients who are treated within a three-hour period versus patients within a five-hour period, the difference could be as much as 70 percent good outcome versus 50/50 percent good outcome, and maybe even lower. So that means that you start at 50 percent and then it decreases from there at the five-hour mark. Beyond five hours, it may actually get lower and lower, so five hours is usually, you know, the optimal time period that we really shoot for. But, the idea here is that you want to be able to get to patients as quickly as possible. And, you know, there's a couple areas of delay. You know, one of the areas of delay is in patients and families just recognizing signs of a stroke. Does the patient have problems with their speech? Does the patient have a problem with a paralysis? Does the patient have asymmetry in terms of their face? Is it arm weakness? Is it leg weakness? Is this something new compared to before?

Sometimes, it could be a level of consciousness problem, and if they have problems speaking, they may not necessarily be able to communicate this, especially for elderly patients who may live alone. The other problem is that we're also seeing an increase in stroke in the young. There's been some reports on this just recently. And, the problem with stroke in the young is that, two things. One is that the individual is young and he may actually deny or she may deny that they are actually having a stroke. They may attribute it to, you know, a muscle spasm or problem with overexertion. The other problem is that because they are in the younger ages, when they present to the emergency room, they may not get as rapidly triaged because an ER physician may not be thinking of a stroke in a young person. But again, sudden-onset symptoms involving a paralysis, you know, the evidence of eye preference where they may be looking to one side, paralysis of their arm, leg, and/or face asymmetry should make, you know, ER physicians, family members, EMS think of a large-vessel occlusion. And it's different. You know, there's not many hospitals in this area that have the ability to do emergency thrombectomy. You know, emergency thrombectomy is a very specialized procedure that is best done by practicing neurointerventionalists, people who are using the tools, the devices in that circulation, day in and day out. It's not appropriate for a peripheral interventionalist or cardiologist, or someone who dabbles in peripheral vascular to now be trying to attempt mechanical thrombectomy in the delicate vessels of the brain. They're at much more risk for causing damage. So, it demands a lot from a hospital system.

Host: How do the specialist teams work together to treat people who need mechanical thrombectomy?

Dr. Armonda: So, it's a—it's a critical balance of multiple different team members. We're a comprehensive stroke center, the first one in DC. We've had this ability to sort of bring the expertise and scientists from NIH Stroke Team together with the neurointerventionalists and with our capacity to do this emergency work, and it transfers from emergency work from trauma to emergency work to stroke care, and it goes hand-in-hand. It means that the hospital system has to be very well streamlined in terms of the efficiency of receiving patients, rapidly imaging patients and being able to have a whole team of individuals to treat this individual. So, it's not just the neurointerventionalist. It's also, you know, the stroke team, neurologists who are screening these patients. It's the imaging team in terms of CT or MR personnel from radiology who are screening them. It's the anesthesia team who is supporting the anesthetic during that patient's neurointerventional procedure. And, then the follow-on care in terms of management in the ICU is absolutely critical. You know, you can win the battle in the angio suite and open up the vessel, but if you can't control the blood pressure, you know, you're at risk for that patient converting this dry stroke into a hemorrhagic stroke, and that could be fatal. You know, a lot of patients don't know the difference between a primary stroke center and a comprehensive stroke center. And, they see a sign that says "stroke center," so they bring their loved one to the closest hospital, and that might be a block away, a mile away, but they realize that that patient can't get – their loved one can't get an emergency thrombectomy at that hospital, and then they have to be transferred. So when they look at studies where patients had to be transferred, it was a minimum of 1 hour in the best of scenarios for that patient to then make it to another hospital, so that's already at least a minimum of a 20 percent decline in outcome. So that's why it's so important in terms of, you know, getting the message out there to EMS, getting the message out there to other clinicians to ensure that, you know, rapid transfer is made and rapid evaluation is made, patients are brought to the right place.

Host: So, it's really a combination of fast action and the hospital team working together?

Dr. Armonda: The idea is, once you see the patient in terms of early warning systems throughout your network, you want to start mobilizing the neuro-rescue. You want to start mobilizing the thrombectomy team. That means, you know, a team of nurses, technologists, anesthesia and the neurointerventionalist. And the unique thing about what we have here is that we have radiologists, neurologists, neurosurgeons all working together in the same procedure. So, there might be a patient who presents with a stroke and it might be a neurosurgeon doing the thrombectomy because he's on call that night. Or it might be a radiologist doing it, or it might be a stroke neurologist who is neurointerventional-trained because all of us, from different specialties, work together in the same arena, and we work together day in and day out, so we have a very comprehensive team approach.

Every single step of the treatment care has to be the most efficient workflow. It's like a car pulling in for a pit stop. You know, you have to work in parallel. You can't work in series. Everybody has to have a job and they have to sort of approach at the same time. So, in trauma, we do the same thing. We have to be able to rapidly get the patient from the door to imaging, and then from imaging, if they're a candidate, to the interventional suite. You know, and our interventional suites here are state-of-the-art. We have two biplane machines. What biplane means is that you're imaging both from the frontal plane and the lateral plane. You know, these are basically endovascular operating rooms. And, both are set up for anesthesia, so we could literally run two thrombectomy cases at the same time. There's very, very few institutions around the country that could do that, and we have the personnel to do that. So, it's not just, you know, have the rooms because an x-ray machine can't run itself. It's having the nurses, it's having the technologists, it's having the anesthesiologists. And, the beauty of our anesthesiologists, they are very adept to patients with multiple comorbidities. They are very adept of emergency airway, you know, from all their experience with cardiac patients, all their experience with trauma patients. Anesthesia is one of the most solid services that we have here. And you have to have that because while you're busy trying to get access into their arterial system and get your catheters up there, you want someone who is maintaining the patient's blood pressure, who's securing the patient's airway, who's ensuring that the patient remains immobile so that you're not dealing with a moving target. You know, and that's a difficult situation because these patients are not intrinsically healthy patients. These patients usually have problems with their lungs, usually cardiac problems as well, variations of all kinds of blood pressure problems, kidney problems, and so forth. So, it takes a real level of sophistication and team approach.

Whenever I see a patient come back in a clinic or a patient who, and family, comes in my office and thanks me, I try to redirect those patients back up to the ICU so they could visit with the nurses who took care of them. They could thank the PAs who were part of their care, and the nurse practitioners, because we never do anything here as a single individual. Everything that we do is as part of the team. And, the best things we do are with the best teams, and I think we really have one of the best teams here.

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

No one knows why stones and tumors sometimes form in salivary glands. Most are not cancerous, but if they aren't treated promptly, they can be big trouble. Dr. Matthew Pierce discusses the risk factors and how advances in technology make treatment easier than ever.

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.

Host: Today, we're talking about salivary gland disease, which is a grouping of conditions that affect oral health. The salivary glands produce saliva, which helps digest food and protect the teeth from decay. Salivary gland diseases can cause discomfort and can lead to serious health concerns that affect the mouth and lips. Dr. Pierce, what are some of the more common salivary gland diseases you treat?

Dr. Pierce: So, I treat a multiple array of salivary gland diseases, everywhere from benign diseases to cancers of the salivary glands. Um, some common ones that I treat are stones of the salivary gland using a multiple array of techniques, including sialoendoscopy, which is small scopes in the salivary glands. In addition to stones, I also treat patients who have had chronic infections or inflammation of the salivary glands, as well as tumors of the salivary glands, including the parotid gland and the submandibular gland. And those can both be cancerous or benign tumors of the salivary glands.

Host: How many salivary glands does the average person have?

Dr. Pierce: So, everybody has four major salivary glands. They have the parotid glands on either side of the cheek as well as submandibular glands below the mandible, below the jawbone, as well as multiple minor salivary glands throughout the mouth - in the palate, underneath the tongue, and in the cheek mucosa itself.

Host: So, you have scopes that are small enough to fit within those glands?

Dr. Pierce: We have scopes that can fit into the major salivary glands, in the ducts that drain the major salivary glands. The scopes are very small and they can go in through those glands and we can look for strictures, or narrowing, of the ducts as well as...we can look for stones and potentially even remove some small stones from those ducts.

Host: What would cause a stone to form in the salivary glands?

Dr. Pierce: So, we don't really know the exact way that these stones are formed. We do know that patients that are dehydrated, that don't drink enough fluids, are more prone to it, as well as patients that have an increased amount of exogenous calcium or taking calcium for other reasons sometimes can lead to stones, but not for everybody. So, the shorter answer is that we don't really know what causes these in certain people.

Host: So, if someone has a salivary gland disease, what symptoms would prompt them to come to the doctor?

Dr. Pierce: The major symptom that most people notice is swelling in the area. So, swelling in the cheek or swelling just beneath the jawbone, and that could be in the form of a lump, it could be in the form of an infection, or it could also be associated with pain. Stones often present with recurring swelling and pain that then resolves and then comes back. This can be diagnosed through physical exam as well as certain x-rays and imaging techniques.

Host: So, you mentioned a couple of reasons why doctors think somebody might develop a salivary gland disease. What are some of the things that patients can do to perhaps reduce their risk for this happening to them?

Dr. Pierce: Well, as I mentioned, uh, one of the best things that you can do is staying well hydrated. But, other than that, there's not much that one can do to prevent stone formation, or tumor formation, either. There are some rare tumors of the salivary glands that can be associated with smoking, but in general, most of the tumors of the salivary glands are not associated with smoking or any other…other type of lifestyle changes or anything like that.

Host: So, we're talking about a very small gland. How large...how large are the tumors that you find within the salivary glands?

Dr. Pierce: The average size of tumors that I take out of the salivary glands are usually about the size of a marble. Sometimes, they can be as large as a golf ball size, but they're not usually very big. Sometimes, they can get very large and cause discomfort, but the majority of tumors of the salivary glands actually don't cause many symptoms. Um, and they're actually quite small and often they're found incidentally when getting imaging for other illnesses or other issues.

Host: So, compared to the size of a normal or a healthy salivary gland, how big would the marble-sized tumor be compared to that regular gland?

Dr. Pierce: So, the average-sized gland--obviously, it varies from person to person, but it could be as much as double in size. Or, you know, you may just feel a small little nodule in your cheek or just underneath your jawbone. They typically don't increase the size of the gland itself. Again, as I mentioned, maybe you might feel a little nodule inside your cheek or your neck there.

Host: What are some of the risks to an individual if they don't get this treated or if it goes undetected?

Dr. Pierce: Uh, the vast majority of tumors in the salivary glands are benign, meaning they are not cancer. However, there are certain ones that if you don't treat, they continue to enlarge and even can turn into cancer if you don't treat them and…and take care of them in a timely fashion. So, there are risks to not doing anything. There's also the risk of, uh, stones or other tumors causing obstruction, causing recurrent infections and inflammation, and causing swelling of the actual gland.

Host: So, all of that would affect, you know, what…what body functions?

Dr. Pierce: So, it doesn't really obstruct blood flow. It doesn't really...it wouldn't really affect any body functions. Even if you do have an obstruction of one gland, usually it does not cause enough decrease in flow. You have enough accessory glands to where it's not gonna really cause dry mouth unless you have some other type of disease causing decreased salivary flow in your other glands as well.

Host: Could you talk a little bit about your patient population? Are you usually seeing this in younger folks, older folks?

Dr. Pierce: The majority of salivary gland diseases are...are seen in older people in their 40s, 50s, 60s, and above. And the reason for that is it takes a while for these tumors to grow as well as the stones to form. This is something that happens over the course of many years, um, for salivary gland stones. And, uh, certain tumors are seen mostly in the elderly. However, it varies depending on what type of tumor it actually is. But we usually see these in the adult population.

Host: How do you work with other members of your team or other colleagues are MedStar Washington Hospital Center to care for patients with these diseases?

Dr. Pierce: So, we work very closely together, especially with the endocrinology team. A lot of patients who have received radioactive iodine may be more prone to developing strictures and salivary gland diseases. And so, we work very closely with them to find these patients that may be suffering from post-radiation salivary dysfunction. We also work closely with the radiation oncologists in finding these patients and help treating these patients. Uh, certain patients that have cancers of the salivary glands often require further treatments in addition to surgery, and this may be radiation and/or chemotherapy, and so we work closely with our colleagues there as well.

Host: If a person undergoes radiation for any type of cancer, you know, in the chest or the neck or the head area, is the dry mouth or are those salivary issues pretty common?

Dr. Pierce: So, patients that receive radiation to the head and neck area often do have problems producing saliva and they often have dry mouth afterwards. It's a common side effect of radiation treatment. Radiation in other areas does not cause that same type of dry mouth. It's pretty unique to patients who have had neck cancer and receiving radiation to that specific area. And the reason for that is because the radiation dose is actually concentrated in the area that has the cancer, and, unfortunately, the salivary glands are in that area. And so, in order to get rid of the cancer completely, a lot of times the salivary glands are affected. And this does not happen in all patients that undergo radiation, but a good portion of them it does.

Host: Is there any, uh, medication therapy that you would give these patients to control the size of the tumor?

Dr. Pierce: Um, initially, there is not a medication to treat cancers or tumors of the salivary glands. These are typically treated with surgery up front. For patients who have dry mouth, there are certain mouthwashes and medications that we can give to these patients to help saliva production. In patients that have salivary gland stones or strictures, again there's not really an oral medication that we can prescribe that's going to help with these conditions. These are typically surgically treated in the right patient population.

Host: Why should a patient choose MedStar Washington Hospital Center over maybe another physician in the community?

Dr. Pierce: MedStar Washington Hospital Center is a tertiary referral center and we have a very unique capacity to collaborate with our colleagues in other specialties. And we treat everything from the most simple to the most complex salivary gland diseases. And, by coming to one center where you get very comprehensive type of care, you avoid delays in care as well as you get the most state of the art treatment for, um, whatever salivary gland disease you may have.

Host: Could you talk about any patient success stories that you might have from your population?

Dr. Pierce: Um, I've had quite a few good success stories, uh, both salivary gland stones or patients who have had recurrent inflammation of the salivary glands, uh, using this endoscopic technique. I had a patient that had a tumor of his parotid gland and he elected to undergo surgery to remove this, and he underwent a successful surgery. He was sent home on the first day after surgery. Um, and he is extremely happy with his result and fortunately, it was not a cancer and he is done with treatment.

Host: What is the technique that you use to do these scoping procedures in patients? Are they under anesthesia? How does that work?

Dr. Pierce: The sialoendoscopy, which is the scope for salivary gland diseases such as stones, is typically done with the patient asleep. There are some physicians that will do this with the patient awake. And a lot of times it depends on the patient preference. It's a relatively straightforward and low-risk procedure, but usually the patient requires some type of sedation for comfort.

Host: And is it typical that they would have that similar result, where they can go home the next day?

Dr. Pierce: The patients that have the scope, uh, for either a salivary gland stricture or salivary gland stone usually go home the same day. Uh, the patients that require excision of a salivary gland usually stay one night in the hospital.

Host: Do they have any recovery time for stitches or anything like that?

Dr. Pierce: For removal of the salivary glands, they require an incision in either the neck or right in front of the ear. The incision is usually well hidden and the scars are kept to a minimum in the patients that require excision of the gland or excision of a tumor. Uh, the patients that have stones or the patients that have the, uh, sialoendoscopy procedure do not require stitches.

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.

Everyday choices affect our colorectal cancer risk – even what we eat and drink. Dr. Brian Bello discusses how eating a high-fiber diet and cutting down on certain beverages can help reduce your risk of developing colorectal 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: Thank you for joining us today. We're talking with Dr. Brian Bello, a colorectal surgeon at MedStar Washington Hospital Center. Welcome, Dr. Bello.

Dr. Bello: Thank you very much for having me.

Host: Nutrition and dietary factors have been tied to a wide range of diseases in the past decade, including colorectal cancer. The choices we make every day about what we eat and drink can have a dramatic effect on our current and future health. Dr. Bello, what food and beverage options are most alarming to you as a colorectal surgeon?

Dr. Bello: Well, as a colorectal surgeon, we tell them to try to avoid processed meats, like bacon, sausage, ham and jerky, beef jerky. Unfortunately, the bacon and ham and sausage are the things that people love and like to eat, especially and also red meat, so we just try to tell them to substitute leaner meats or skinless poultry or fish, and that usually can help them.

Host: What is it about the red meat, specifically, is it more harmful as compared to leaner meats?

Dr. Bello: Yeah, scientists don't know for sure. It's probably the way that the meat is processed and preserved - maybe some chemicals there, it's unclear.

Host: So I know we talked about food, are there any drinks that may contribute to a person's risk?

Dr. Bello: We know that obesity and diabetes are risk factors for colon cancer. So, we know that people that drink a lot of these high sugar beverages may get diabetes. So, we usually tell people when we're counseling them about their diet, to try to avoid those high sugar drinks, those energy drinks, those fruit drinks, and tell them to drink water, low dairy.

Host: And what about alcohol?

Dr. Bello: Alcohol, if consumed in a mild or moderate fashion's okay, but we tell people not to drink excessive amounts of alcohol.

Host: Are your patients ever surprised when you mention diet and nutrition as a factor in colorectal cancer risk?

Dr. Bello: Yeah, people seem to be surprised, and many people don't even realize that their diet is not a healthy one. So, usually we go over their usual daily intake and figure out what they can do better. We try to give them a lot of education about this. We try to give them menus and lists of things that they can do and eat so that they can have a better diet. We also find it helpful that, if they come with a family member, specifically the person that cooks for them, that they're involved in that discussion.

Host: Now you mentioned some of the things that you recommend that your patients avoid. What would you consider an ideal nutrition plan, say for a lunch or a dinner, for someone at average risk of colon cancer?

Dr. Bello: We always recommend our patients be on a high fiber diet. So, when people come in and they tell me they're eating a lot of red meats and processed meat, I immediately try to give them some education. I tell them what foods are rich in fiber which include raw fruits, like apples and bananas; vegetables, especially raw vegetables, like lettuce and spinach; legumes, like beans, all have a lot of good dietary fiber which has been associated with less colon cancer risk. So, it's always good to have a variety of food, specifically a variety of fruits and vegetables, whole grains. I mentioned a high fiber diet - usually about 25 to 30 grams a day. Skinless poultry and fish are good. Nuts and beans. And we try to tell them to limit these things that aren't good for you, so fatty food, fried food, sweets, foods that are high in sodium - those are the key things to limit.

Host: Should patients who admittedly make poor nutrition choices, or just really enjoy junk food, be screened more often for colon cancer than say an individual with a healthier diet?

Dr. Bello: That's a good question. I'd say we haven't had enough data to make that choice yet. I think we still take in account the other risk factors where the patient symptoms, are they having symptoms like bleeding or abdominal pain, change in their bowel movements. I think poor nutrition alone, we don't recommend that they get screened more often than other people. That would probably lead to unnecessary tests. But I think we take the whole picture and see what their other issues are and what their other risk factors are.

Host: Could you discuss your team approach to care when it comes to balancing nutrition with colon cancer screening and awareness?

Dr. Bello: Yeah, so here at MedStar Washington Hospital Center, we have different experts in different fields. So, not only do we have surgeons and oncologists, we have nutritionists that can help patients find a good balance of what's healthy and what tastes good. That's an advantage that we have at Washington Hospital Center.

Host: So, why is MedStar Washington Hospital Center the best place to seek that colon cancer screening and guidance?

Dr. Bello: Yeah, I think we see a lot of colon cancer - we're a high-volume center. So, a lot of us do primarily colon cancer and rectal cancer - those are our primary patients, such as myself and my colleagues. We do present any new colon cancer at a multidisciplinary tumor board, where there's a lot of experts from different fields weighing in. With that, we come up with the very individualized treatment plan for each patient. So, because of that, we've shown that those patients have better outcomes.

Host: Could you share any success stories from your patient population, perhaps an individual with a very poor diet or a cancer risk that maybe turned their diet around?

Dr. Bello: Yeah, I think I get the most satisfaction when I'm seeing patients for a long time. For example, if I do a colon surgery on them, I usually follow them for several years, up to five years after surgery. And then I see that they're following my recommendations of leading a good, healthy lifestyle. They've stopped smoking. They're eating better. They're eating more fiber in their diet. And they're exercising. Those are the patients I feel that we've helped.

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

Dr. Bello: Thank you very much. My pleasure.

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.

An overactive bladder isn't just part of getting older. Dr. Andrew Sokol, a female pelvic medicine and reconstructive surgeon, discusses the symptoms and causes of overactive bladder, as well as what we can do to treat 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. In today's episode, we talk to Dr. Andrew Sokol, a female pelvic medicine and reconstructive surgeon at MedStar Washington Hospital Center, about overactive bladder. Dr. Sokol discusses why this very common condition is not a normal part of aging and how it can be treated with both lifestyle changes and more advanced treatments. He also talks about why that 8 glasses of water you've been told to drink may be doing more harm than good.

Host: Thanks for joining us.

Dr. Sokol: Thanks so much for having me.

Host: Why is this topic top-of-mind today? What's important to know?

Dr. Sokol: Right, so, overactive bladder is this constellation of symptoms that is incredibly common. The term really refers to the urge, the need to run to the bathroom, urgency, frequency, which is going to the bathroom more than normal, with or without leakage, and it's the type of leakage where you can't get your key in the door or get your pants down fast enough. So, the prevalence or the amount of people who have this in the community is incredibly high. Actually, incontinence or leakage of urine is the second most common reason for admissions to nursing home facilities, but a lot of younger people also experience these symptoms.

Host: So, when we say younger people, in this case, how young can this happen?

Dr. Sokol: Yeah, I mean the, the, symptoms can occur even in children, of course, but oftentimes they're looking for different sources, so I'd say when we're talking about younger women, it tends to be women ages 18 through menopause, and then women who are after the age of menopause being the older women.

Host: And how many, how many, people have overactive bladder symptoms?

Dr. Sokol: So, I mean the absolute numbers are very high. I think that we can't come up with an absolute number because it's underreported. People think it's a part of, normal part of aging, but I can tell you that by the time a woman turns 80, there is a 20 percent chance that she'll have surgery for a pelvic floor disorder. So pelvic floor disorders, of which overactive bladder is one, are more prevalent than breast cancer. So, it's incredibly common and the, the, amount of people who get them increases as age increases, so there's a prediction that there will be a doubling of these types of issues by 2050 and that surgeries for pelvic floor disorders will double by 2050 as well, so it's very, very common.

Host: And the increase would be? What's the reason for the increase?

Dr. Sokol: Mostly due to aging. So, we do, we do, also know that the symptoms of urgency and frequency in overactive bladder are more common in women who are postmenopausal or whose ovaries have stopped producing the female hormone estrogen because the skin that's around the opening of the urethra, the tube that you urinate through, is estrogen responsive, and so that dryness and irritation and the shift of the flora make women more prone to those symptoms.

Host: Can you share some of the most common causes?

Dr. Sokol: Right, so unfortunately the most common cause is over-consumption of fluid. There's a broad misconception that one needs to drink a certain amount of water and it is typically quoted at 8 glasses of water, which is based on absolutely no research, but has become almost dogma. And then the second most common would be the over-consumption of bladder irritants and diuretics like coffee, tea and soda. Really, eliminating those things, cutting down on the fluids and having good toileting habits can take care of a lot of the symptoms of urgency and frequency, sometimes decrease leakage or the need to wake up at night, which is called nocturia. And, so I'd say those are the most common causes of overactive bladder. Actually, 90 percent of overactive bladder is called idiopathic, meaning that there's no underlying anatomical or neurological cause, 10 percent as an underlying cause.

Host: So, in those 90 percent of cases, what are some tips?

Dr. Sokol: So, yeah, so it turns out that there's a lot of good tips for this area. And so, because so much of this is behavioral, the first step is always behavioral. That's actually what's recommended by the guidelines of the groups that treat these disorders. So, the first step, I would always tell someone to cut the fluids down and I really say there is no magic number for the amount you drink, just drink when you are thirsty. I always would advocate for people who are having urgency to run to the bathroom, timed urination, so just go to the bathroom regularly, 6 to 8 times a day. Stopping fluid intake within three hours of going to bed is a very effective way of decreasing the need to wake up to go to the bathroom, and then pelvic floor squeezing exercises, which are called kegels, which have been around forever because they actually work. That's a great way to defer the urge. In other words, someone who's trying to get into the door, get the key in the door and is having the overwhelming urge oftentimes can squeeze those pelvic floor muscles and the urge will pass and it'll give them time to calmly walk to the bathroom. So that's really – those are the first steps that we always take.

Host: And then, how about the other 10 percent?

Dr. Sokol: Yeah, so 10 percent of women who, who have symptoms may have an underlying problem. The most common is, of course, urinary tract infections or bladder infections. So, as a provider or physician, when someone comes to me, my job is to, of course, rule out the uncommon things that can cause it; they're generally easy to rule out. The first thing that we'd always make sure is that there is no infection, not only urinary tract infections, but often sometimes making, make sure there are no vaginal infections which can cause these symptoms. Another area that we have to rule out is voiding dysfunction, the inability to empty the bladder completely, which in women is, of course, more uncommon than in men because women don't have prostates, but it can happen when there's vaginal relaxation or prolapse, which is something that I treat for a living. It can happen in women who have underlying disk disease, like lower disk disease in their spine. It can happen in women who have had strokes. It can happen in multiple sclerosis. It can happen if there's something obstructing the urinary system, like prior surgery for urinary leakage. And so these are the less common things that a specialist would rule out in someone who's got persistent symptoms that didn't get better with the behavioral stuff and some of the other simpler things we do.

Host: What are the most common ways to treat overactive bladder?

Dr. Sokol: Right, so, the recommendations, the guideline recommendations, start with behavioral therapy. That's everything that I just said. That's the fluid management, the toileting and the kegels. The second step is often female pelvic floor physical therapy. We have a whole network, particularly in this greater Washington region, of physical therapists who help defer the urge, train the pelvic floor muscles so that the muscles are strong, and help someone have time to get to the bathroom. And, then the third step is, there is a whole class of medication that's used to treat the symptoms of urgency, frequency or urgency incontinence. And these medications have been around for a long time, so this class of medications for overactive bladder is called anticholinergics. They're reasonably effective, but they're most effective when they're done with the other treatments. And, then there's a newer medication that was recently released over the past 5 to 7 years that gets around some of the annoying side effects of some of these medications. The medications used to relax the bladder can also cause dry mouth and dry eyes and constipation, and so that's sometimes sort of a stumbling block for people using these medications. I'd say most people do not start medications right away. We would always start the conservative things first, and then, if those things fail, then we would institute an evaluation of the urinary tract or other causes. And, if there was nothing found, there's lots of newer things available as well, so that includes acupuncture of the ankle, which has been shown to work as well as the medicines, and then Botox, which is very effective. It is done right in the office. It's a medicine that's put right in the bladder to relax the bladder wall. And, then finally, there's something called an InterStim. Which is, basically, it's an outpatient placement of a bladder pacemaker, which can be used for people who have failed other therapies as well. So, lots of things we can do for overactive bladder symptoms nowadays.

Host: So, how do you help women get around some of the emotional issues, right? I mean if you have to run to the restroom all the time, at some point.

Dr. Sokol: Right. So, yeah, women with overactive bladder sometimes feel really socially isolated. They don't – try not to go out so much because they find themselves being the person that has to get up from dinner three times. So, I mean, I think the most, the best way of sort of allaying their fears is, first of all, just letting them know how common this problem is. I think if people talk to their friends they'll—It's unbelievably common. The second is letting them know that there are things that can be done to treat the symptoms—there are effective treatments. And so, one of the, I think, most common things that we battle with, as urogynecologists, is this thought that it's a normal part of aging, which is completely untrue, not only for overactive bladder, like we're discussing, but also for leakage of urine with physical activity, which is called stress urinary incontinence. And there are very effective treatments. It's not a normal part of aging and someone who's experiencing these symptoms should/can see someone who can help them with their symptoms. That's really reassuring to people because a lot of people, and even primary care providers, sometimes don't understand that there are very effective treatments for a lot of these symptoms. I think the, sort of the takeaway point, maybe, would be that, that these symptoms of urgency, frequency and sometimes urgency incontinence, can't make it to the bathroom, are incredibly common, but simple behavioral things are sometimes effective in treating those symptoms. If those symptoms persist despite moderation, then seeking care can be very fruitful because there are a lot of things that are available nowadays that can treat these symptoms and really decrease suffering, decrease the need to use pads, and really help people with these symptoms.

Host: Thank you for joining us.

Dr. Sokol: Thanks 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.