Additional Info
- Audio Fileuab/ua061.mp3
- DoctorsBhatia, Smita
- Featured SpeakerSmita Bhatia, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4430
- Guest BioSmita Bhatia, MD, MPH, is the Director of the Institute for Cancer Outcomes and Survivorship in the University of Alabama at Birmingham (UAB) School of Medicine, as well as the Vice Chair for Outcomes in the Department of Pediatrics and Associate Director for Cancer Outcomes Research at the UAB Comprehensive Cancer Center.
Learn more about Smita Bhatia, MD
Release Date: January 23, 2018
Reissue Date: December 10, 2020
Expiration Date: December 10, 2023
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Smitha Bhatia, MD
Director, Institute for Cancer Outcomes and Survivorship
Dr. Bhatia has no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Today’s topic is breast cancer survivorship and the future of cancer survivorship, in general. My guest today, is Dr. Smita Bhatia. She’s an Oncologist and the Director of the Institute for Cancer Outcomes and Survivorship in the School of Medicine at UAB. Welcome to the show, Dr. Bhatia. Explain a little bit about breast cancer survivorship, the program at UAB. Tell us a little bit about the evolution of it and some of the overall past feelings about prognosis and what’s different now?
Dr. Smita Bhatia (Guest): Thank you, for giving me this opportunity. Good morning. Breast cancer is the most common cancer for women in the United States. With the treatments that patients have received, survival rates have improved tremendously. After completing treatment, many breast cancer survivors have questions about how cancer may affect their lives going forward. The UAB Medicine Breast Cancer Survivorship Clinic will answer these questions by helping survivors navigate these complex issues they face after treatment has ended.
Each survivor has unique needs and concerns while they find their new normal and the Breast Cancer Survivorship stands by, ready to assist them with these changes.
Melanie: What do you think has been accomplished in cancer survivorship over the last decade? Was there even survivorship back even a decade ago?
Dr. Bhatia: Well, survivorship was always the goal when oncologists treat. That has always been the goal, but increasingly, with these new treatments, with the improvements in supportive care strategies, there is increasing hope and longevity associated with breast cancer or with other cancers as well. As individuals – these women – live longer, they realize that they can now return to what they are calling their new normal. As part of that, they are also realizing that there are complications that result as a result of the treatment they received or the result of breast cancer. These survivorship clinics that we have developed, including the Breast Cancer Survivorship Clinic, offer them this unique opportunity for a single place to be able to assess, evaluate, and help manage all of the complications that they might be anticipating or having at that time.
Melanie: How are you identifying the needs of these cancer survivors, and what are some of the late and long-term effects that breast cancer survivors have?
Dr. Bhatia: Sure. The Breast Cancer Survivorship Clinic at the UAB is for patients who have a diagnosis of breast cancer who have reached at least twelve months since diagnosis and are not receiving active treatment, i.e., any chemotherapy or radiation. They could be receiving hormonal therapy. In this setting, we provide care – a nurse practitioner, who has expertise in breast cancer care and survivorship issues, leads these efforts. There is a yearly follow-up in this clinic, and this gives the patients an opportunity to discuss their cancer treatment, its impact on their health, and ways to stay as healthy as possible.
What do the Breast Cancer Survivorship Clinic patients receive? They receive monitoring for long-term effects of breast cancer treatment – and I’ll discuss those in a minute. They receive referrals for management of the problems that are identified if that is needed. And a survivorship care plan is given to the patent, which includes a personalized record of the details of cancer treatment, the guidelines for continued monitoring, recommendations for preventative care, and then information regarding available resources and services.
The survivorship care is done in collaboration with each patients’ primary treatment team, and that’s the most important thing. There’s communication – seamless communication between the primary oncologist, the radiation oncologist, and the survivorship clinic team. Now, what are the long-term effects that could possibly happen in this setting? The treatment needed for breast cancer can result in thinning of bone. If there is radiation, it can result in thyroid involvement, so that’s hypothyroidism or lower functioning thyroid gland. That can happen several years after the treatment. It can result in vitamin D deficiency. Sometimes, the treatment that is used can result and even have an effect on the heart.
What we do in the Survivorship Clinic is offer tailored evaluations or screening tests, which are needed in order to detect these complications early. The patients, we review their history and symptoms, we do a physical exam, we give health education, we review the survivorship care plan, and then we do these tests. These include the blood work, or the bone density scans, or the echocardiogram, that is needed only if they have received specific treatments that would place them at risk for these complications. And then, if there are abnormalities that are detected, we create referrals to specialists or resources or services based on their individual needs. Then we give them a summary to both the patient as well as the primary health provider if the patient requests that. That’s the summary of what we do in Survivorship Clinic.
Melanie: Speak about the coordination of care, Dr. Bhatia, because you mentioned a few of the other healthcare providers that might be involved. Who is involved, and how do you coordinate that care? Speak about some of the key elements of the program.
Dr. Bhatia: Right, the coordination of care is the key topic of this – a key element of this survivorship clinic. That coordination is provided by the nurse practitioner as well as the clinic coordinator. The survivorship clinic nurse practitioner identifies who the primary oncologist is – the radiation oncologist, the surgical oncologist, the primary healthcare practitioner – she summarizes all of the treatments that the patient has received. She creates a survivorship plan for the patient, and then sets up – schedules all of the screening evaluations for the patients, reviews the results, and then creates the referral to the various specialists as needed, but then communicates all of these results back to the primary oncologist – the surgical oncologist, the radiation oncologist, and the primary healthcare provider. Essentially, she is coordinating the care of the patient after completion of therapy in order to make sure the patient leads as healthy a life as possible.
Melanie: So, what about some of the challenges for adherence? If someone is a candidate for this program at UAB, how do you approach those challenges to adherence to those healthy lifestyles, to possibly prevent new cancer diagnoses, or keep track of the surveillance for recurrence, and that sort of thing?
Dr. Bhatia: Right, and that’s a very good question. What our hope is that inviting patients back for annual visits, and health education, and ensuring that they understand what is needed for health promotion, as well as having social services available, so that can remove the barriers to the best of our ability, so that the patients can adhere to these recommendations that we have and their primary oncologists have to help them adhere to these recommendations.
Quite often, the barriers are pretty tangible. The barriers could be lack of transportation. The barriers could be issues related to insurance. The social worker we have is at hand in order to help them navigate those issues.
Melanie: How are you evaluating the impact of these kinds of programs, and monitoring those barriers on the outcomes?
Dr. Bhatia: You ask fantastic questions. Our goal here is multifold. First, we’re looking to see are the patients satisfied with their care? Are they perceiving that they are getting additional benefits from this survivorship clinic? We ask them to help us understand if there are issues, so they can complete a satisfaction survey and give us comments about what they would like improved in this survivorship clinic. That’s one way of dealing with it.
The second thing that we are doing is we are very closely following whether we are identifying any new complications as a result of our screening efforts and whether we are making referrals and closing the loop in terms of making sure that the patients get the necessary care for the new complications that are identified. Those are the outcomes that we are monitoring. Are we picking up low bone density? Are we picking up low vitamin D3 levels? Are we picking up heart problems, or lung problems, or thyroid problems, which would go undetected if they had not visited the Survivorship Clinic? We are keeping very close tabs on that in order to see what benefits the patients are getting from this clinic.
Melanie: In summary, Dr. Bhatia, tell other physicians what you would like them to know about the Breast Cancer Survivorship Program at UAB, and where do you see the future of cancer survivorship going from here and when they should refer?
Dr. Bhatia: Right. Right, Breast Cancer Survivorship Clinic is at the Kirkland Clinic at UAB Hospital. We have a referral -- for more information or to schedule an appointment, the phone number is 205-801-0080. There’s convenient parking located near the clinic, and the patients can be referred either self-referred, or the physicians are taking care of them can refer the patients.
What’s important to know is that the patients have to have a diagnosis of obviously, breast cancer. They have to have reached at least twelve months since diagnosis, and they have to be not receiving active treatment other than hormonal therapy.
Where is survivorship efforts going from here on? By 2025, over 20 million individuals in the US will be cancer survivors. Cancer survivors carry a substantial burden of morbidity that is related to the treatments that were used to treat their primary cancer. In order to prevent fragmentation of care because of these cancer treatment-related complications, it is important for multidisciplinary efforts, such as the Survivorship Clinic that we are running, where there is expertise related to survivorship care issues as well as the ability to coordinate the care of the patient. We believe that the patients’ health would be tremendously improved if they were to attend such clinics.
Melanie: Tell us about your team. Why is UAB so great to work with?
Dr. Bhatia: UAB is the best place ever. That is my summary. We have a very strong collaborative team. We have a Nurse Practitioner, we have a social worker, a clinic coordinator, a chief Nurse Practitioner who manages – who directs the clinical services, and then I offer the content expertise in terms of survivorship-related issues. The breast oncologists partner with us so that if the Nurse Practitioner has issues, she has Dr. Andres Forero ready and at hand in order to address those issues if needed. It’s just a tremendous collaborative environment, and patients feel very welcomed and do believe that they gain something out of the Survivorship Clinic.
Melanie: Thank you so much, Dr. Bhatia, for being with us today. A physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MYST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua053.mp3
- DoctorsStraughn Jr., J. Michael
- Featured SpeakerJ. Michael Straughn Jr., MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4452
- Guest BioStraughn, J. Michael, Jr., MD is at UAB Medicine and practices Obstetrics & Gynecology, and Gynecologic Oncology.
Learn more about J. Michael Straughn Jr., MD
Release Date: January 8, 2018
Reissue Date: January 7, 2021
Expiration Date: January 7, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
J. Michael Straughn, Jr., MD
Professor; Gynecologic Oncology Fellowship Director
Dr. Straughn has no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionUAB MedCast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): In the world of electronic health records and an increase in this aging population; many physicians find themselves subjected to more intense scrutiny of quality and performance while they face an ever-increasing patient load. They can, like the rest of us, experience depression, burnout the way many professionals do; however, as physicians, they may be tempted to care for others before they care for themselves. My guest today is Dr. J. Michael Straughn Jr. He’s a gynecologic oncologist at UAB Medicine. Welcome to the show, Dr. Straughn. Explain a little bit about physician burnout. Are doctors supposed to be gods? Do they have fatigue, depression, family concerns just like the rest of us?
Dr. J. Michael Straughn Jr., MD (Guest): Yes, that’s an excellent question. Believe it or not, when medical students go through medical school; there just hasn’t been that much education on burnout and so I think when trainees finish up; the majority of their focus is on their patients and obviously many physicians and especially physicians that may take care of serious patients or cancer patients undergo a very strenuous and demanding career. But there has been a lot of focus over the last five to ten years that physician burnout is a major problem that has probably gone sort of underdiagnosed or not well appreciated, but people are finally figuring out that physician burnout is a very serious problem.
Melanie: Well, I think as you mentioned, in medical school, they may not get much education, but they certainly get initiated with residency and internship in those long hours and late nights and holiday and weekends. What do you think are some of the major causes of this? As I mentioned electronic health records and the aging population; what do you see as some of the major causes?
Dr. Straughn: You know I think the added stress of quality of care as we put more and more focus on the quality of care that we provide our patients. What comes with that, is this sort of overwhelming sort of feeling that everything must be perfect. All the emails must be answered. All the patients must be seen. And as you mentioned earlier; the electronic medical record probably has added many hours to the week for most physicians and so what has happened in order to get the work done; many physicians have taken that work home in order to work from the computer at home in order to get their work done. So, the added time that people are focused on their patients I think is one of the major contributors. You also mentioned the amount of time that both trainees and physicians spend with their patients. It has been difficult for physicians to turn it off and, so I think a lot of the focus has been on getting physicians to sort of dial back or turn off their practice both at night and on weekends.
Melanie: Dr. Straughn, do some physicians deny maybe that other doctors have this or does “first do not harm” only apply to their patients? Are you – do you feel in the workplace, are you seeing that doctors are hesitant to even address this subject of burnout because they have got patients to care for?
Dr. Straughn: Yeah, I think that there has been sort of – that sort of superman complex that many physicians have had through the years that patients require a physician who really doesn’t have any weaknesses and that’s probably a bad way to sort of set up your career. And so, I think most people now are realizing that you are going to experience some of the aspects of burnout which include things like emotional exhaustion, depersonalization, and reduced personal accomplishment and so those are sort of the factors that people are now talking about.
In our field, in 2015, there was a survey of almost 400 gynecologic oncologists and even in that survey, over a third of GYN oncologists admitted to experiencing burnout. And probably even more important is that the burnout rate does appear to be higher in women than in men which is certainly a concern.
Melanie: Wow, so if so many physicians are experiencing this and when we learn about concussion for example, Dr. Straughn, we learn that players on the field have to kind of keep their eye on each other to recognize those symptoms. Kind of a buddy system. Do you think that that is something that could be tried in the medical workplace and what symptoms would you like other physicians to be on the lookout for with their colleagues so that maybe they can address it or get each other help?
Dr. Straughn: Yeah, so I think the sort of the symptoms would be people who are having mood changes and so obviously depression has been well-associated with burnout. Certainly, signs of alcohol or drug abuse also have been tied to burnout and certainly in sort of the worst-case scenario would be thoughts of suicide, etc. And so, I think that coworkers need to be aware of those things and obviously if there appears to be a trend towards some mood issues then hopefully physicians can step in and take care of their own. I think many physicians now are trying to really turn their patients over when they are not on call or not working and so, even in my practice in the first five to ten years, when I was on vacation, I would still look at the electronic medical record and talk to people back at home. But I finally learned that when you are off you really need to be off and you have to trust your partners and trainees and other people who are working back at home to take care of your patients. To really turn it off and enjoy your time away from the hospital.
Melanie: That’s an excellent point. Now, this may be difficult to answer, but what can be done? Does leadership play a role in this, the CEOs of hospitals or somebody that’s running the practice and maybe it’s a multiple physician practice, so as you say you can give up your call time to other physicians? Do you think it’s more up to the physicians, Dr. Straughn or do you think that leadership really needs to step in and address this as they would any other employee workplace issue?
Dr. Straughn: Yeah, that’s a great question. Specifically, at UAB, I have been very impressed with the leadership as they have begun to address this problem over the last few years. Most of the surveys that have been sent to physicians have included questions about burnout, depression, support from your departmental leadership and so at UAB there has been a big focus on trying to assess how common this problem is. Additionally, UAB has the professional development office which basically provides counseling and coaching for students, residents, fellows and faculty so that now you have a place where you can call and be seen by someone trained in these issues. What’s pretty amazing is that you can be seen usually within 1-2 days. These appointments are free. This information is not in the electronic medical record, so this is a completely confidential counseling session or appointment with an MD to discuss many of the issues that we have talked about and so, hospitals and CEOs as you suggested really have to put the time, the money, the energy, the education into physician wellness and I think many of them are because this is a topic that can no longer go sort of unnoticed or not discussed. So, I have been impressed with many of the hospitals that are really addressing this.
Melanie: Well as workplace wellness is becoming so popular for the normal employee with workout rooms and massage therapists and even meditation times and yoga, all of that sort of thing; do you see as a possible solution something along those lines? Would you doctors even be willing to take time out and go workout or get a massage or do meditation? What do you see are some possible solutions for this?
Dr. Straughn: Yeah, you are right, those are things that the hospitals are offering. Obviously, you have to have the time to do it, so, when the services are offered, you still have to have the time away from your clinic or surgery or call and so the first step is to have those there, but then I think people are going to have to either have some time during the day to do that or people are going to have to cover for each other. Obviously, if you are in clinic 8-5 then you can do those things at home or on your own time, but I think if you could find some time to do that during your work day then those things are going to help. There have been some techniques taught which are sort of self-techniques which are basically taking a few minutes in your office whether that’s lying on the floor and stretching or meditation or just some sort of exercises to take a deep breath. I think this is kind of easy quick things to do when you are having a stressful day. But obviously, you can’t do that with patients or in the clinic and, so you do have to find a little bit of time to get away. Another important thing is that many people just won’t disconnect from the email or from the next project on their to do list and, so I think people are going to have to make an effort to sort of sign off during the day a little bit to take some time for themselves.
Melanie: So, in summary, Dr. Straughn, tell other physicians what you would like them to know about recognizing physician burnout and what you would like they themselves to be experiencing, what you would like them to let people know some possible solutions so that you don’t have maybe errors or medicational issues coming up or any of those kinds of things. Tell your colleagues what you want them to know about this physician burnout so that we can reduce early retirement of you much needed doctors.
Dr. Straughn: I think the first thing we have to recognize is that the research has been done. Surveys are coming out every year and so the problem is real. So, we have to accept that a very high number of physicians experience differing aspects of burnout. So, awareness and recognition I think is number one. The second is that there are resources to receive education and so in our specialty, we are actually participating in a beta course for GYN oncologists. So, we are actually teaching a four-month course on some different aspects of wellness to our trainees and so if those type of resources are available to you then my recommendation would obviously be to get involved with those things. And then the things that you can control, spending time with your family, getting away from work, the city, whether that’s going to the lake or to the beach, a place outside of your normal environment, travel, sporting events, concerts, those type things that are totally different from medicine. Everybody needs to have some hobbies or some things to do to get away from the things that we like because we obviously like our patients, we like taking care of patients; but everybody has got to have some hobby and people who have families and kids obviously focusing on them is a good way to think about something else, do something else.
Melanie: Well I think it’s so important everything you have stated to keep that engaged and resilient health professional workforce and thank you so much for being with us today, Dr. Straughn. You’re listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to www.uabmedicine.org/physician , that’s www.uabmedicine.org/physician. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua052.mp3
- DoctorsGreene, Benjamin;Hughley, Brian;Buczek, Erin
- Featured SpeakerDr. Benjamin Greene, | Dr. Brian Hughley, | Dr. Erin Buczek
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=2053
- Guest BioDr. Benjamin Greene is an ENT-otolaryngologist in Birmingham, Alabama and is affiliated with University of Alabama at Birmingham Hospital. He received his medical degree from University at Buffalo, School of Medicine and Biomedical Sciences and has been in practice between 6-10 years. He is one of 12 doctors at University of Alabama at Birmingham Hospital who specialize in Otolaryngology.
Learn more about Dr. Benjamin Greene
Dr. Brian Hughley is an ENT-otolaryngologist in Birmingham, Alabama and is affiliated with University of Alabama at Birmingham Hospital. He received his medical degree from University of Virginia School of Medicine and has been in practice between 6-10 years. He is one of 12 doctors at University of Alabama at Birmingham Hospital who specialize in Otolaryngology.
Learn more about Dr. Brian Hughley
Dr. Erin Buczek is an otolaryngologist-head and neck surgeon provides comprehensive medical and surgical care for patients with diseases and disorders that affect the ears, nose, throat, the respiratory and upper alimentary systems and related structures of the head and neck.
Learn more about Dr. Erin Buczek
Release Date: December 6, 2017
Reissue Date: December 4, 2020
Expiration Date: December 4, 2023
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Brian B. Hughley, MD
Assistant Professor in Otolaryngology,
Erin Buczek, MD
Assistant Professor in Otolaryngology,
Benjamin J. Greene, MD
Assistant Professor in Otolaryngology,
Drs. Buczek, Greene and Hughley have no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Through the hormones, it produces, the thyroid gland influences almost all of the metabolic processes in your body. As a result, thyroid disorders can be far-reaching and can range from nodules to hypothyroidism, to life-threatening cancer. Here today, in a panel discussion regarding thyroid cancer and thyroid disease are Dr. Benjamin Greene, Dr. Brian Hughley, and Dr. Erin Buczek. They are Head and Neck Surgeons at UAB Medicine. Welcome to the show, Doctors. Dr. Buczek, I’d like to start with you. Please explain a little bit about thyroid disease. How common is it, and what are the different types that you see?
Dr. Erin Buczek (Guest 1): Excellent question. There are several different types of thyroid disease. There are metabolic thyroid diseases such as Grave’s Disease or hyperthyroidism. Also, commonly, there is something called hypothyroidism, where the thyroid is less active and producing less thyroid hormone. There are also autoimmune diseases of the thyroid, such as Hashimoto’s Thyroiditis, which usually results in hypothyroidism long-term. Additionally, we see anatomic problems with the thyroid. Most commonly we see thyroid nodules, and you can also see thyroid cancers as well that start in the thyroid gland and can go elsewhere in the body.
Melanie: So, Dr. Greene, patients with abnormalities of the thyroid gland, function, or structure come to medical attention for several reasons. Give us some of those reasons.
Dr. Benjamin Greene (Guest 2): So, most of the time, to be honest, it’s found on routine labs because people don’t feel well for some reason. What they feel as – if people have an overactive thyroid gland, people tend not to be able to sleep, they’re losing weight; they’re always hungry, they have a tremor, they feel like they can never – they are restless, and things like that.
And people that have a low thyroid, kind of have the opposite. They’re having fatigue, weight gain – despite eating the same amount of food – their hair is falling out, their nails are becoming brittle. Those are things for metabolic thyroid problems that people usually complain about. And usually, they’re seeing their – they’re usually not coming to a head and neck surgeon for those kinds of complaints. They’re usually seeing their primary doctor and saying, “You know, Doc, I really just feel terrible, and I don’t know why,” and they ask a couple of questions, get some lab work, and find out that the thyroid is not functioning the way it’s supposed to.
Melanie: Dr. Hughley, what might some of those reasons be? Are we looking at lack of Iodine? You certainly have to have an understanding of thyroid disease and the interpretation of this function to get that basic understanding. What are you looking at?
Dr. Brian Hughley (Guest 3): Well, that is true. The lack of Iodine worldwide – worldwide, excuse me – is a very big cause of thyroid disease. However, we don’t see that much in the United States. There are certainly familial inherited thyroid diseases that run in certain families that can cause both cancers as well as benign, physiologic dysfunction.
Melanie: So, let’s talk about treatments now, and Dr. Greene, back to you for a minute. When we’re talking about clinical tests and diagnosis, then what would be the first line of treatment – because it’s not really always going to be surgical in nature – speak about some of the medicational intervention that you might encounter.
Dr. Greene: Well, mostly what you’ll see is people having low thyroid – having not enough thyroid hormone. That can be due to a number of reasons like Dr. Hughley said, or it can be – most commonly, in this country, it’s due to something called Hashimoto’s Thyroiditis, where people have an autoimmune reaction to the thyroid gland that causes it to produce not enough thyroid hormone. The treatment of that is just replacing the thyroid hormone. That’s one of the safest medications that you can give because it’s literally just the exact same hormone and replacing it. And so that’s usually done under the care of a family medicine, or an internal medicine doctor or an endocrinologist to make sure that they are giving enough but not too much thyroid hormone replacement therapy.
Now, there are some intricacies that come into it when people are producing too much thyroid hormone. There are medications that we usually start with, such a propylthiouracil to stop the thyroid from producing so much hormone and help with some of the feedback mechanisms that cause it to keep producing the hormone. Those are a little bit more tricky to give and are usually given under the direction of an endocrinologist to make sure that people are getting the correct amount, getting treated well, and also, it’s very difficult to treat patients with these medications if they’re planning on getting pregnant or things like that, so usually, those are directed by an endocrinologist for people who have Grave’s Disease or hyperactive thyroid hormone.
Melanie: Important points, all. Let’s veer off for a minute. Dr. Buczek, what about nodules – thyroid nodules? How are they treated? Specifically, when is a needle biopsy needed? When is observation indicated and when might surgery be indicated?
Dr. Buczek: That’s an excellent question. To start off with, thyroid nodules are extremely common. Among mixed studies, they are palpable in somewhere between 2 to 6% of the population, and thyroid nodules can be found on autopsy studies in up to half of the population, so they are extremely common. And most importantly, most thyroid nodules – up to 90 to 95% of them – end up being benign. The question as clinicians that we have been working on sorting out is exactly which nodules do we determine to be benign, and how do we figure that out and trying to avoid surgery? Surgery is the most definitive way to figure that out since we can send the entire nodule to the pathologist to look at, but the goal for us is to figure out who is safe to watch and who do we need to take to surgery?
One of the most important tools that we have is the ultrasound. Ultrasound is a noninvasive technique. It doesn’t involve any external radiation, and it allows us to evaluate the structure of the thyroid gland and the surrounding lymph nodes. There are a lot of characteristics on ultrasound as well as on palpation that can lend you to think that a nodule might be more concerning. Size is one of them. Traditionally, it used to be anything greater than a centimeter, but depending on the appearance of the nodule, we now say a centimeter and a half to two centimeters. Is the nodule cystic or is it solid? Does it have well-defined edges? Is it particularly vascular?
We use all of these different data points to grade these nodules, and depending on whether a nodule is concerning enough or not to meet what we call biopsy criteria. And so, if it meets criteria, we do a fine needle aspiration. Nodules that don’t meet that criterion, we consider to be very low-risk for malignancy, and those are considered safe for observation. Observation usually means an ultrasound within about a year, potentially less if they change.
The nodules that are deemed biopsy-worthy, we’ll do a needle biopsy. We send that off to the pathologist to look at and grade and tell us whether or not they are either benign, whether they are suspicious for malignancy, whether they are malignant, or whether they are uncertain. Now, we actually have some genetics testing tools to look at that uncertain category to tell us whether they have concerning molecular features that would make us think that they were more likely to be malignant or not. Based on the results of the biopsy determines whether or not we recommend further observation or whether or not we recommend surgical removal of the nodule.
Dr. Hughley: The one thing I would add is that occasionally, in the workup of a nodule, it’s actually too large to recommend a biopsy. If they are four centimeters or larger is the typical cutoff. Occasionally, the – or, not occasionally – we will recommend actually taking that side of the gland out -- assuming all other things are normal – to get a more accurate diagnosis rather than a needle biopsy.
Dr. Greene: And if I can add something, that makes a lot of sense because if something is larger than four centimeters and you’re just taking one, small, tiny needle sample of it the question is, is cancer hiding in there and you just didn’t hit it with this very small needle? It’s called a fine needle aspiration biopsy, and it is a very, very fine needle. But also, there’s something new in the line of ultrasound reporting that came in part out of UAB, and it’s based on the breast data. If you’ve heard any podcasts or talked to any people who have had breast biopsies done, there is something called BI-RADS, which stands for Breast Imaging Reporting and Data System. UAB was very influential – the Radiology Department – in developing something called TIRADS, which is Thyroid Imaging Reporting and Data System. TIRADS is based on ultrasonic features – and they have this huge grading system about how to grade thyroid nodules and whether or not to biopsy them, and not only whether or not they need a biopsy, but also if you can follow them up and when they should have follow-up. It’s a very helpful thing, and this is brand new. It came out -- I think the paper on this came out in April of 2017 or somewhere around that time. It’s very, very new.
Melanie: That’s fascinating. Dr. Hughley, thyroid cancer, is there a screening recommendation? Is this controversial? Tell us about it.
Dr. Hughley: Not – there’s not screening for the general public that everyone can just have. It’s based on – basically, risk factors. We mentioned earlier thyroid nodules being concerning, and once a nodule is discovered whether a patient feels that, or much more commonly it’s being found incidentally on scans that are done for other reasons. As Dr. Buczek mentioned, if it’s not an ultrasound that it’s found on, often times we will then get an ultrasound to look for any of those concerning characteristics that she mentioned to determine if that nodule that was found incidentally needs to be biopsied, or, as we were discussing, removed surgically.
The amount of imaging that’s being done in the head and neck for other reasons -- whether it’s head and neck cancer, or neck pain, or before spine surgery – is much higher than it’s ever been, so a lot of these nodules – excuse me, PET scans, also are showing incidental thyroid nodules. A lot are being found without the patient even knowing that there is a nodule present. And it’s important to know that not all of those – just because they’re present – actually need to be biopsied. Even when nodules are found on other imaging, just like Dr. Buczek mentioned before, there’s a criterion to go on to determine if that needs to be worked up any farther, or can be observed.
Melanie: And Dr. Buczek, so let’s start with some treatments if thyroid cancer is detected -- so medicational or nonsurgical to begin -- whether you’re talking radioactive iodine therapy, or chemo, targeted, medicational – give us a little bit of that adjuvant therapy.
Dr. Buczek: Generally speaking, the treatment for thyroid cancer is going to be surgical in nature as a frontline therapy. Exceptions to that may include particularly advanced thyroid cancer if it’s involving the larynx or the airway, or a particularly aggressive – like a variant called anaplastic thyroid cancer – in which case the prognosis is extremely poor. It’s a very rare cancer, but we generally don’t operate on that. But generally speaking, for the more common thyroid cancers like papillary thyroid cancer, follicular thyroid cancer, and medullary thyroid cancer, the treatment modality is going to be, for the most part, total thyroidectomy with some exceptions. For instance, if the thyroid cancer is extremely small, like less than a centimeter, you do not necessarily have to remove the other half to the gland. You at least just have to remove the side of the gland that the cancer is involved with. But for most cancers, it's going to be a complete thyroidectomy, potentially removing some lymph nodes that could be at risk if they’re either clinically evident to have cancer in them or if the cancer itself in the thyroid is large enough, we often will recommend getting some of the lymph nodes taken out as well.
And then, adjuvant therapy for papillary and follicular thyroid cancer, it’s going to be radioactive iodine, and we usually recommend those for cancers that are at high risk. High risk means any cancer that’s grossly invaded outside of the thyroid gland into the surrounding structures, if it has metastasized to lymph nodes – either in the central neck around the thyroid or into the lateral neck nodes – we often recommend radioactive iodine, and then for any metastatic disease. Occasionally, we have used external beam radiation, but generally speaking, we don’t use that for thyroid cancer. Radioactive Iodine is the mainstay of adjuvant treatment.
Melanie: Dr. Greene – as Dr. Buczek got to my next question in that whether it’s metastatic or it’s become systemic, tell us a little bit about the support that’s available for those with thyroid cancer should they have to have a full-on total thyroidectomy.
Dr. Greene: Well, thyroid cancer is interesting to me in that it can be a very nonaggressive cancer, like a very small papillary thyroid cancer where the – in a young person, a very small papillary thyroid cancer, the five-year survival rate is almost 99 to 100%. I have even read studies that show that in young women, people who have thyroid cancer live longer than those who don’t because they see a doctor more commonly and things like that. It can be a very, very nonaggressive cancer, but then like Dr. Buczek said, anaplastic thyroid cancer is one of the most aggressive human malignancies there is and kills people faster than virtually any other type of cancer.
Thyroid cancer runs the whole spectrum of nonaggressive to extremely aggressive, so the support can vary significantly. A lot of the support needed for thyroid cancer is just understanding the risks that go with surgery. The risks that go with thyroid cancer surgery can be significant. There can be risks to the recurrent laryngeal nerve, which controls the voice. There’s risk to the parathyroid glands, which are near the thyroid gland and control calcium homeostasis in the body. There are bleeding risks; there’s risk to the tone of your voice. We see a lot of singers that have nodules, and any type of change in their voice has profound implications to their job and their lifestyle. There are support groups for that, but most of the support is done through our other head and neck cancer supports, and it’s for people who have had big neck dissections for cancer, and tracheal resection, or laryngectomies for cancer. People who have thyroid cancer and undergo thyroidectomy generally do really, really, really well for the most part.
Melanie: Dr. Hughley, what about things like targeted therapy? Give us your blueprint for what you see as the future for thyroid cancer, and treatments, and also, that support.
Dr. Hughley: There are specific drugs that are being used occasionally. It’s not standard treatment -- Tyrosine Kinase Inhibitors are one example that comes up. Our medical oncology friends are the experts with those and indications for when to use them, but one thing that almost all patients who will need that type of adjuvant therapy also need is multidisciplinary care. Just like with our other head and neck cancers, we’re fortunate at UAB, to participate in our multidisciplinary tumor board for head and neck tumors that includes endocrine tumors as well as the others. That’s meeting with the surgeons that take care of the head and neck tumors, as well as radiation when that’s indicated, and adjuvant chemotherapy -- including all of the newer, directed therapies, which are occasionally given as part of clinical trials and occasionally given as adjuvant treatment in very rare settings for the more aggressive types of diseases -- or sometimes, not necessarily invasive and aggressive, but if there is an indication of a small recurrence, but it’s in a very sensitive region, or in a patient who may not otherwise qualify or be a good candidate for surgery, that’s when those agents are being used for thyroid cancer more frequently.
Melanie: Dr. Greene, do you have anything to add to that?
Dr. Greene: No, I think Dr. Hughley hit it right on the head. It’s a very sensitive area, and recurrences or metastatic disease, we do rely heavily on our medical oncology colleagues and our nuclear medicine colleagues to help with delivering adjuvant therapies. Mostly, our adjuvant therapy for thyroid cancer is Radioactive Iodine. That is tagged Iodine that – with radioactive entities that goes to the thyroid tissue wherever it is in the body and kills it with the radiation because as we know, the thyroid uptakes Iodine. The Iodine will be drawn into the thyroid cells, whether it’s in the neck in the thyroid bed or even in the lungs, and in small amounts, the radioactive agents that are tagged with Iodine can kill it. We rely on our nuclear medicine, endocrinology, and medical oncology colleagues to totally help us out with treating that.
Dr. Buczek: Sorry, one thing that I just wanted to add on a little different tangent as far as new technology and moving to the forefront. On the front end, and detecting cancers, I think one of the exciting things that’s being currently developed right now, and a lot of new changes are in the genetic profiling of thyroid nodules. The testing there, that’s really giving us a lot better data preoperatively about whether or not these nodules are cancerous or not. They can take some of the tissue from the fine needle aspiration, send that off and run it for like 130 or 167 different transcription abnormalities, and basically, spit out the report that says whether or not the lesion is suspicious or not for cancer. Every year or two, they’re really improving that technology and making it a lot more specific, which I think helps everybody out in targeting who really needs surgery and who doesn’t.
Melanie: Dr. Buczek, tell other physicians what you’d like them to know about thyroid disease, thyroid cancer, and when to refer to a specialist.
Dr. Buczek: That’s a great question. I think thyroid nodules are extremely common and picked up by a lot of folks – family medicine practitioners. One thing I would say if a nodule or a thyroid mass seems symptomatic, which is something we haven’t talked a whole lot about, but if someone is complaining that they’re having a hard time swallowing, if they’re having hoarseness, if there’s a lot of pain in their neck and they have a big nodule, these are reasons to suspect that something potentially more aggressive is going on or potentially that they have a large, benign goiter that may need surgery. Those would be instances where I would recommend referring to an ENT Surgeon who does thyroid surgery.
On the other forefront, things I’d want people to know is making sure when they do thyroid ultrasounds, doing needle biopsies, that their institution is utilizing some of those tools for genetic testing – which is often a send-out test. Here at UAB, we end up sending it out to – actually, Texas, to get it tested, but it can be really valuable and helpful to know who needs surgery and who we can simply observe.
Melanie: Dr. Hughley, what do you like best about working with UAB and your team?
Dr. Hughley: Well, our team, as Dr. Greene mentioned earlier, we have a great time working with each other. The three of us here today all work great together, but we also, as we’ve said many times today already, really enjoy working with our colleagues in radiation oncology, medical oncology, endocrinology, nuclear medicine, radiology, pathology. It’s just really easy to pick up the phone and get in touch with somebody if there’s a specific question about an image or about the treatment plan. We have our head and neck multidisciplinary tumor boards that meet regularly, and we actually talk with our colleagues about the cases that are not straight-forward. There are a lot of experts around who – for lack of a better term, you can just either pick their brains or actually have them formally consult on patients. There are a lot of people around that do the same things that I do, and also very complimentary things to what I do that I can bounce ideas off of, learn things from, and share new ideas with.
Melanie: Thank you all, so much, for being with us today. It’s really great information. A community physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MYST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua051.mp3
- DoctorsGreene, Benjamin;Hughley, Brian;Buczek, Erin
- Featured SpeakerDr. Benjamin Greene | Dr. Brian Hughley | Dr. Erin Buczek
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=2049
- Guest BioDr. Benjamin Greene is an ENT-otolaryngologist in Birmingham, Alabama and is affiliated with University of Alabama at Birmingham Hospital. He received his medical degree from University at Buffalo, School of Medicine and Biomedical Sciences and has been in practice between 6-10 years. He is one of 12 doctors at University of Alabama at Birmingham Hospital who specialize in Otolaryngology.
Learn more about Dr. Benjamin Greene
Dr. Brian Hughley is an ENT-otolaryngologist in Birmingham, Alabama and is affiliated with University of Alabama at Birmingham Hospital. He received his medical degree from University of Virginia School of Medicine and has been in practice between 6-10 years. He is one of 12 doctors at University of Alabama at Birmingham Hospital who specialize in Otolaryngology.
Learn more about Dr. Brian Hughley
Dr. Erin Buczek is an otolaryngologist-head and neck surgeon provides comprehensive medical and surgical care for patients with diseases and disorders that affect the ears, nose, throat, the respiratory and upper alimentary systems and related structures of the head and neck.
Learn more about Dr. Erin Buczek
Release Date: December 6, 2017
Reissue Date: December 4, 2020
Expiration Date: December 4, 2023
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Brian B. Hughley, MD
Assistant Professor in Otolaryngology,
Erin Buczek, MD
Assistant Professor in Otolaryngology,
Benjamin J. Greene, MD
Assistant Professor in Otolaryngology,
Drs. Buczek, Greene and Hughley have no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole: (Host): Every year, approximately 100,000 people in the United States are diagnosed with head and neck cancer. Here today, in a panel discussion regarding the intricate nature of head and neck cancer, facial reconstruction, and how it affects the daily lives of patients, and their families are Dr. Benjamin Greene, Dr. Brian Hughley, and Dr. Erin Buczek. They are Head and Neck Surgeons at UAB Medicine. Welcome to the show, Doctors. Dr. Hughley, I’d like to start with you. Explain a little bit about head and neck cancer. How common is it, and are there different types?
Dr. Brian Hughley (Guest 1): Yeah, there are several different subtypes, mostly based on the area in which they occur. In my last reading, about the fifth most common cancer in the United States – so not very rare, but not nearly as common as some of the more common ones. We typically divide these up – there are several different ways to divide it up. Most people, when they think of head and neck cancer, think of the upper aerodigestive tract – basically the track starting from the lips going down to the voice box including mouth cancer, tongue cancer, throat cancer, voice box cancer or a lot of the other names that they go by, but they also include skin cancer of the head and neck and endocrine cancers of the head and neck, like thyroid cancers and salivary gland cancers.
Melanie: And Dr. Buczek, give us a little pathophysiology. What are some common conditions and factors that lead to head and neck cancer and who might be at risk?
Dr. Erin Buczek (Guest 2): Well, that’s a great question. Traditionally, most head and neck cancer are caused by squamous cell carcinoma, which is the most common histologic type of cancer that we see. In the aerodigestive tract, traditionally, the risk factors have been tobacco use, including cigarettes and smokeless tobacco, as well as heavy alcohol usage. In the recent couple of decades, we’ve noticed a sharp increase though, in HPV-mediated cancer – similar to cervical cancer, Human Papilloma Virus has been found to be associated with particularly oropharyngeal cancers, which are tonsil cancers and base of tongue cancers. We’ve seen that split of a group of tobacco and alcohol-related and then HPV-related cancers.
Additionally, we sometimes see skin cancers like Dr. Hughley mentioned, so they are associated with sun exposure, and then some of the endocrine cancers can be associated with a familial -- hereditary factors as well.
Melanie: And Dr. Greene, what is the clinical presentation of head and neck cancer? What would even send somebody to see a physician?
Dr. Benjamin Greene (Guest 3): That’s a good question because they can be masked as other – they can be easily missed because they can come up as a sore throat, they can come up as hoarseness of your voice, they can come up as ear pain, and they can also come up as just a lesion on the tongue that won’t go away or something like that. Somebody that has hoarseness for a long time may not think of that as being cancer, and their doctor may not think of that as being cancer either, and they won’t know that something is wrong until a lump comes up in their neck. And actually, a lump or a large lymph node in the neck is sometimes the first thing that we see with these. That’s why I always tell people that if you’re over 40 and you have a new lump in your neck, you have to come and see a head and neck surgeon or an ear, nose, and throat doctor to have that evaluated because we have to start thinking that that’s cancer until proven otherwise. And that’s because they can mask as so many other things. I’ve seen people who just have ear pain, some people who just have some pain in their throat and all of a sudden, they have a very large cancer back there that was just missed because of the seemingly benign nature of their symptoms.
Melanie: Dr. Buczek, how important is early diagnosis as being crucial to improve the outcome prediction?
Dr. Buczek: Early diagnosis is extremely important, not only to catch cancers early and treat them when they’re small, but head and neck cancer is a rarity in the sense that treatment affects so many important different functions, so for instance, speech, swallowing, and even breathing can be severely affected if these cancers progress. If we can catch them early, a lot of times that will have a dramatic impact on folk’s functional outcomes as well as survival outcomes. Once you get to an advanced stage, local cancer, it can be pretty difficult to cure, even with aggressive surgery and radiation, and so early diagnosis is critical.
Melanie: Dr. Hughley, what are some valuable prognostic tools to aid in that early diagnosis?
Dr. Hughley: The very first thing we always start off with is a good, and thorough physical exam, but that includes in – like Dr. Greene was saying, in either an ear, nose, and throat physician’s, or specifically a head and neck surgeon’s office. We can look in the back of the throat and down at the voice box very easily with no sedation, no special equipment other than what we have in the office. We’re able to look at people and look at the back of the throat in the office and get our first impressions. After that, other things that we do very frequently as far as imaging is Commuted Tomography – or CT scans, occasionally MRIs, Ultrasounds, things like that that we can order based on what we see in person and on a patient’s symptoms. PET scans are another thing that is frequently used, and other diagnostic tools that we have -- occasionally in the office we can do biopsies or needle biopsies. Sometimes those have to be sent out and done by our radiology colleagues using some image guidance.
Melanie: Dr. Hughley, I’m going to stick with you for a minute – to the sensitivity of this cancer and the intricate nature, are there some non-surgical treatment options if you detect there’s something going on?
Dr. Hughley: There absolutely are. In some cases, surgery isn’t necessarily the first line treatment. We work in – every one of these cancers – or at least locations of cancers can be treated and is best treated in a place that has a multidisciplinary approach. The common ways to – there are basically three ways to come at the treatment of head and neck cancers. There’s surgery, there’s chemotherapy, and there’s radiation therapy. We work very closely with our medical oncology and radiation oncology colleagues to come up with the best treatment plan based on the location of the disease, the type of disease, and the extent of disease.
Melanie: Dr. Buczek, who is involved in the surgery, and the aftercare? Tell us a little bit about the cancer care team for head and neck cancers.
Dr. Buczek: Absolutely, it involves several different players. You have the head and neck cancer surgeon themselves. There are clinical care coordinators who are specifically specialized in cancer care who our patients will meet in the clinic when they are diagnosed with cancer. There’s an anesthesia team, which can be extremely important particularly from an airway standpoint – a lot of these cancers involve the airway, so they are a vital member of the team. Afterwards, there’s a whole team of surgeons and residents taking care as well as our amazing nursing staff. A lot of the surgeries that we do are fairly specialized and require things such as tracheostomies and feeding tubes, and that requires a lot of specialized nursing care as well. Here at UAB, we have a dedicated floor where our head and neck cancer patients go, and the nurses there are specialized in taking care of this type of patient.
After that, as Dr. Hughley mentioned, it’s a team approach when it comes to radiation therapy, possibly chemotherapy, and using our medical and radiation oncology colleagues. At the same time, we’re also utilizing our pathology colleagues as well, both in the operating room – we often will send samples of tissue from the tumor that’s removed to make sure that we completely excise it – and then afterwards, they’re evaluating the tumor that we send them as well as any lymph nodes or other structures that are resected.
And then last but not least, our radiology friends are helping us determine exactly where the tumor is on imaging and helping us plan surgically what needs to come out. It’s a big team effort.
Melanie: Certainly a multidisciplinary approach. And Dr. Greene, please start for us, with the goals of reconstruction for the patient, protecting vital structures, function, form, and the sensitivity of this procedure.
Dr. Greene: Reconstructing the head and neck is very difficult because – think of everything that you have to do using your throat, your mouth, it’s not only speaking or breathing but eating and all of these things – and cosmetics. All of these things are part of what makes us human beings. In my own personal social life, eating is basically 98% of what I do socially with my wife, my kids, my friends, everybody. If you take away somebody’s ability to eat, that’s a big deal for them and their quality of life. Breathing without a tracheostomy tube, that is – having to have a tracheostomy tube or feeding tube, and just your cosmetic appearance is extremely important to people.
When I talk to people about surgery, I say there are multiple goals of surgery. The first and most important goal is getting all of the cancer out safely. That’s the most important goal. But then we have to talk about the goals of reconstruction, and I always tell people, the first, primary goal of reconstruction is making a safe wound where you don’t die from the wounds that are created by taking the cancer out. I don’t say that lightly because these are wounds that are created where saliva could potentially be coming to the neck from a space where saliva is supposed to be – in the oral cavity – to a space where it’s not supposed to be in the neck. Saliva contains a ton of bacteria and also proteinases that dissolve proteins. If saliva leaks into your neck, you can have major infections, and if it erodes into your blood vessels you can have major bleeding and even death. The main goal of reconstruction is to seal the oral cavity from the sterile environment of the neck. That’s number one.
Number two is a functional recovery, which means getting people to eat without a feeding tube safely so that it doesn’t aspirate and go into their lungs. With that, breathing without a tracheostomy. Eating without a feeding tube, breathing without a tracheostomy. I tell people my last goal is cosmetics. Even though it is important, it is the least important goal of reconstruction because if you think about it, dying from the wounds is about as horrible as it could be. And then if you still have a feeding tube and a tracheostomy tube, those parts of your life become more important to you than cosmetics. While cosmetic recovery is a very, very large goal of what I do, it is probably – believe it or not – the least important. So that’s the goal.
We, as head and neck surgeons, are very comfortable understanding the anatomy of how people speak and swallow and we work very, very closely with our speech pathology and head and neck speech and swallowing team to make sure that they’re seen preoperatively, during their hospitalization, and followed postoperatively to make sure that their speaking and swallowing outcomes are as good as we could possibly get them.
Melanie: Dr. Hughley, you had mentioned some nonsurgical techniques and adjuvant therapies that might possibly go along. What about IORT, Brachytherapy, or Palliative Radiation Therapy? Speak about some of these adjuvant therapies and when would be the appropriate times to be using those?
Dr. Hughley: Nonsurgical therapy can occasionally be used as primary therapies, specifically in the oropharyngeal cancers, tongue base, and tonsils, as well as some of the early stage laryngeal cancers. Often times in large cancers, usually in more advanced stage cancers, after we have done surgery they’ll need adjuvant therapy – usually radiation, occasionally chemotherapy based on certain indications from the surgery to go along with that whether there is evidence that there is a potential for microscopic disease left behind, or if there are grossly positive margins and not all of the cancer is able to come out.
But more commonly, we think about postoperative adjuvant therapy as radiation used in addition to surgery to help with the more advanced stage three and stage four cancers.
Most of – you had mentioned IMRT. That’s the standard radiation protocol that I’m aware of in the modern era of head and neck cancers and has a big benefit to patients as far as the side effects that they have, which are usually much more – I’m sorry, not more – are less with IMRT. That’s another one of the advantages of coming to a place – or having your treatment at a place that has a high volume of the specific type of cancer you have.
Melanie: Dr. Buczek, as we’re talking about this intricate procedure and the adjuvant therapies, and then there is the patient to consider – and Dr. Greene mentioned a little bit about the self-esteem and the look after surgery, and all of these really important functions that the head and neck do – eating – and all that goes into that. How do you deal with the families? What are some of the effects in the daily life that you explain to these families, and you say this is how your new normal would be or how we’re going to deal with it? For other physicians, what do you recommend about discussing this type of treatment with families?
Dr. Buczek: That’s a very, very good, and complex question. I would say when we see a new patient and are discussing surgery; I think it’s very important to be honest with patients up front. It can be really terrifying for them to hear exactly what surgery is going to entail, but I have found that people that are well prepared do a little bit better than if they are surprised after surgery. Explaining to them exactly what’s going to need to come out and what things will look like after surgery, for instance, how their speech is going to be affected. Let’s say, for instance, the patient as a big tongue cancer, how are they going to talk afterward? I think explaining to them that how things are two days after surgery is very different than how things can potentially be three or four months after surgery in that a lot of folks with a lot of speech pathology and exercises can really regain a lot of function that they started off with depending of course on how big the tumor is. And then having our speech pathology colleagues see them in the clinic – like Dr. Greene said, before surgery – to really help explain how things are going to work.
One of the more common things we do here at UAB is something called a laryngectomy where we take out someone’s entire voice box. When someone hears that they’re going to lose their voice box, that’s fairly devastating news, but in reality, a lot of folks do pretty well long-term, and they’re able to communicate, just in a different way than what they were used to preoperatively. Taking the time to explain how it’s going to work, explain their new physiology because things are extremely different than what they’re used to, I think that really helps alleviate their fear that they’ll never be able to talk again when in reality they potentially can, it’s just going to be different. I think that makes people feel better.
And then from a more personal standpoint, we, here at UAB, have a head and neck cancer support group that meets every – I believe every other month. I feel like that’s a really great resource for a lot of our patients who can meet other patients who’ve gone through something similar. While we see a lot of this, it is not particularly common in the community and, so it can be really hard to reach out and find resources, but just knowing that they’re out there can be really helpful.
Melanie: Dr. Greene, as far as things that are so complex like mandibular reconstruction, what kind of additional training do you have to do these kinds of complex procedures, and what would you like other physicians to know about entering into this field?
Dr. Greene: There are a couple of different ways to become a head and neck reconstructive surgeon. I’m an ear, nose, and throat doctor, and so I did four years of medical school, five years of Otolaryngology – or ENT residency – and then one year of Head and Neck Cancer and Reconstructive Microsurgery Fellowship. Dr. Hughley and Dr. Buczek did the same. That’s one way – five years of an Ear, Nose, and Throat Residency plus a Head and Neck Cancer and Reconstruction Fellowship.
Now, there are other ways – Plastic Surgeons do this on a routine basis, and going into a Plastic Surgery Residency from medical school or doing a Plastic Surgery Fellowship after Surgery. Oral Surgeons can also do this, so Oral Surgery Residency plus a Reconstructive Head and Neck Cancer Fellowship after Oral Surgery Residency.
For the most part, in this country, the most head and neck cancer reconstructive surgery is being done by Ear, Nose, and Throat doctors who have specialized training in reconstructive surgery for the head and neck. That’s a shift over the past twenty years or so because otolaryngologists, for the most part, are the people who diagnose these problems that are sent because they have a sore throat, or they have a lump in their throat or a mass in their neck, we tend to see these people, treat them, and reconstruct their cancers as needed.
Melanie: Dr. Hughley, what does current research indicate for future developments and treatments? Give us a little blueprint of what you might see as future research and if there’s anything you’re doing at UAB that other physicians might not be aware of.
Dr. Hughley: As far as for reconstruction, some of the newer concepts or newer techniques being used involve 3D modeling of the actual reconstruction – particularly with the complex bony reconstruction. We can look beforehand at a CT scan of the patient and realize which parts are going to be removed with the surgery and which parts need to be reconstructed, and then can use computer software along with specialized engineers to design the shape of those bony reconstructions, whether it’s the mandible or the mid-face or even some cranial bone defects. That’s something that’s become almost standard now – we’re doing that fairly routinely.
Other advances that are being made – or newer things not related to reconstruction are the robotic surgeries that we’re doing. Actually, a lot of the initial research that was done on using the robotic surgical instruments for head and neck cancers was actually done here at UAB and was one of the institutions that helped pioneer that. We’re currently – all three of us who you’re speaking with today as well as our Chairman, Dr. Carroll, are doing robotic head and neck cancer surgery. We’re helping pilot a new training program for our residents along with – it’s a multidisciplinary training program for robotic surgery along with our gyn, and urology, and general surgery colleagues that we’re going to be one of the first institutions in the nation to institute this multidisciplinary residency robotic training program. Those are a few of the things that we’re going with head and neck cancer that are sort of – I guess you could say are on the cutting edge and things that are being pioneered here at UAB.
Melanie: Dr. Buczek, last word to you. Tell other physicians what you’d like them to know about head and neck cancer surgery, reconstruction, and when to refer to a specialist.
Dr. Buczek: I would say when to return to a specialist would be anytime you’re unsure – if someone has a neck mass, or a lesion in their oral cavity, or hoarseness that’s persistent, especially in an adult, I would refer to an ear, nose, and throat physician within at least a month or two if it’s still persistent and fails conservative management.
As far as head and neck surgery and what I would tell other physicians, I would say if you’re uncomfortable and you’re uncertain with the anatomy or with the particular disease, referring to a high-volume center is usually best. As we talked about in the last few minutes, there are so many different aspects to head and neck cancer, and it’s very complicated, and I think the best care can really be given in a place where they have all of those resources. I would suggest to anybody who is uncertain or may not feel like they may not have those resources, that’s the time where I would be sending that to a tertiary care center here, like UAB.
Melanie: Dr. Greene, what can a physician expect from your team after referral, insofar as communication with the referring physician and your team approach?
Dr. Greene: Well, basically, whenever somebody refers over to us, we like to keep an ongoing communication line with the people that sent it because when you’re at a place like UAB in Birmingham, we’re getting people from Tennessee, Georgia, Mississippi, the Florida Pan Handle five hours away. The aftercare – when folks go home from the hospital, we’re going to rely on the people who initially referred the patient to help us with the aftercare, whether it’s something simple like pulling out a drain, so they don’t have to make a five-hour trip for that, and also, taking care of people who have emergent problems in the Emergency Department.
What I like to do is see the patients and send the doctor who referred them to me, a note saying what I’m thinking – or give them a call and say, “Hey, this is what I’m thinking. I think they need this type of big surgery or radiation,” so that they know. Once the surgery is done, I usually that night, when I finish the surgery, give them a call or give their office a call and say, “Hey, we’ve just finished Mr. X’s surgery. This is what we did. I expect him to stay about seven days in the hospital, and you might be hearing from him about a drain removal.” Or, if it’s something smaller, saying, “We’re going to send him home tonight. Would you mind taking out the drain in four or five days to make sure that everything – and doing a quick wound check.”
And we work together really well here. It’s not like that everywhere. Other places that I’ve been don’t have such a great relationship with the outside referring people as we do, but we are lucky that the people in Alabama and the surrounding areas are very, very helpful and very, very friendly. We work together as a team, not as competing entities, and so it’s really nice to be able to talk with these guys, get their ideas, and make sure that they’re okay with what we’re doing, how we’re doing it, and involving them in the aftercare so that they can not only see the patients for us afterwards but also help out as they can so that the patients don’t have to make a six-hour trip to have a five minute appointment to get a drain removed and things like that. It helps when you keep the referring doctors updated in the care.
Melanie: Thank you so much, all of you, for being with us today. A community physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MYST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua045.mp3
- DoctorsGunn, Andrew
- Featured SpeakerAndrew Gunn, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4280
- Guest BioAndrew Gunn, MD graduated magna cum laude from Brigham Young University in Provo, UT earning a BS in exercise physiology with a minor in sociology. He then returned home to South Dakota to attend medical school at the University of South Dakota. During medical school, he participated in the competitive Howard Hughes Medical Institute – National Institutes of Health Research Scholars Program and was awarded the Donald L. Alcott, M.D. Award for Clinical Promise. He graduated summa cum laude in 2009. He completed his diagnostic radiology residency at the Massachusetts General Hospital of Harvard Medical School in Boston, MA followed by a fellowship in vascular and interventional radiology at the Johns Hopkins Hospital in Baltimore, MD where he served as chief fellow.
Learn more about Andrew Gunn, MD
Release Date: November 20, 2017
Reissue Date: October 29, 2020
Expiration Date: October 29, 2023
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Andrew J. Gunn, MD
Assistant Professor in Diagnostic Radiology
Dr. Gunn has disclosed the following commercial interests:
Grants/Grants Pending/Research Support – Penumbra Inc.
Consulting Fee – Varian, Boston Scientific
Payment for Lectures, Including Service on Speakers Bureaus - Boston Scientific, Terumo
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Percutaneous ablation is a minimally invasive procedure where small needles are inserted through the skin under imaging guidance. These needles are directed towards tumors which can be in the liver, kidney, bone or lung. Once the needles are in the place, the tumors are destroyed by either heating or freezing the cancer cells. There treatments can be faster and safer than traditional surgery. My guest today is Dr. Andrew Gunn. He’s an interventional radiologist at UAB Medicine. Welcome to the show. Explain a little bit about ablation therapy. It’s typically been used in many different conditions such as AFIB or varicose veins. When did this become something that can be used to treat cancer?
Dr. Andrew Gunn (Guest): Thanks for having me on the podcast. Ablation therapy, as you said, has been around for a long time. In interventional radiologist, we’ve been using percutaneous ablation for kidney tumors and liver tumors for almost 30 years at this point. We've been able to have very good results with both liver and kidney tumors and be able to treat patients in a minimally invasive manner in which they can avoid the risk associated with traditional surgery.
Melanie: What kind of cancers can be treated with ablation therapy?
Dr. Gunn: We’re starting to find out that almost any type of cancer can be treated with ablation therapy. We have the longest history with renal tumors and with liver tumors, but we’re expanding ablative therapies into bone cancers and also into pancreatic cancers and into certain types of lung cancers as well. Even researchers actually are looking into percutaneous ablation for small breast cancers as an alternative to lumpectomies. Pretty much if there's a small tumor that we can see under imaging guidance and we can reach it with a needle, people are looking into ablating it. That being said, we have our best results and our best data with our kidney tumors and our liver tumors.
Melanie: What's the influence for clinical indications as their lesion size or comorbidities of the patient? Speak about some of these clinical indications?
Dr. Gunn: For kidney cancers, we have the best data for kidney tumors that are about three centimeters or less sized. Certainly, there are some patients – for example, patients who might not be surgical candidates because of other medical comorbidities or for patient preference that we’re certainly about to ablate large lesions than that – but for the most part, a lot of times we’re looking at these lesions that are about three centimeters in size. They often get referred to us because the patient’s either don’t want to undergo traditional surgery or because they're not good surgical candidates. In the liver, it’s the same. Our liver cancers are really managing a multidisciplinary conference, so we sit down with surgeons and medical oncologists and radiation oncologists and interventional radiology determine which tumors would be best for ablation versus intra-arterial therapy versus surgical resection. Again, even in liver tumors, we’re looking at the tumors that are about three centimeters in size, maybe up to three of those lesions in which we can do percutaneous ablation.
Melanie: Is there a need for a pre-ablation biopsy?
Dr. Gunn: That depends. For our liver cancer patients, we often don’t do a biopsy beforehand because these patients often just by imaging characteristics that’s diagnostic for liver cancer or some other type of cancer that they have, so we often don’t do a biopsy for our liver cancer patients. For our renal cancer patients, we often do a biopsy at the same time and that helps to influence the type of follow-up that they get, but usually by the time they get to us, people are pretty convinced by the imaging characteristics that they have either renal cancer or liver cancer.
Melanie: What are some current issues in procedural planning and technical considerations for radiofrequency ablation? Speak about the anatomic location of the kidney to the adrenal gland and as a consideration of all these things.
Dr. Gunn: Technically, there's still some debate about what type of ablative therapy is to be used. Certainly, as you just mentioned, radiofrequency ablation is the thing that has been around for the longest, but mostly physicians for renal tumors are moving away from radiofrequency ablation. The newer ablative technologies that are out there include microwave ablation, cryoablation – which is where you freeze the tumor – or irreversible electroporation, IRE – which destroys the tumor by destabilizing the cell. A lot of the research that’s out there is looking at different ablative technologies – which ones are better and which ones may kill the tumor better – so when you're talking about technical approaches, for us, you may want to use something like IRE if there's structures nearby that you don’t want to damage in the ablative zone like the aorta or the inferior vena cava or adjacent bowels. A lot of the times we’re using cryoablation and able to safely ablate by using things like hydro-dissection, which is where we instill fluid to protect adjacent structures from the ablative zone, or pneumo-dissection, where we put air in there to move the ablative zone away from any structures that we don’t want to damage.
When we sit down with a patient in our clinic, we go over these different kinds of issues whether or not they're safe for the percutaneous route – are we going to have to do any adjunctive measures and whether or not we think we can cover the whole lesion in one session or maybe will need to use two sessions. Those are the things technically that we’re really talking about as we consider renal tumors. For liver tumors, the biggest thing is for a lot of times, we’re using microwave ablation for these just because it’s quicker and we can get a bigger ablation zone with a single probe. Again, you want to make sure that you're not damaging any adjacent structures like the portal vein or the gallbladder or the biliary system. A lot of this for us is treatment planning where we can safely access and how much we can safely ablate without causing damage to any adjacent structures.
Melanie: What about follow-up imaging?
Dr. Gunn: It’s different for each tumor. For our renal tumors, we usually see them in about three months, and I think if you look around, institutional people and nationwide people easily use three or six months as a first follow-up after ablation for renal cell cancer. If things look good, they usually get scanned at three months and again at nine months and again at a year. If we don’t see anything at that point, we usually get yearly scans for anywhere from three to five years out. For our liver tumor patients, a lot of these patients are looking towards getting transplants for their liver, and so we follow them a little bit closer. We usually get a scan at about one month and again at three months, and if they're a transplant candidate, we usually get them about every three months, and if not, usually about every six months for the liver cancer patient.
Melanie: What does current research indicate for future developments in these types of treatments? Give us a little blueprint for future research.
Dr. Gunn: I think future research is going to focus on different ablative technologies. I think that’s one way, like we IRE versus radiofrequency ablation versus cryoablation. I think another area would be combined technologies. For example, for liver cancer patients, we can do intra-arterial therapy like chemoembolization or radioembolization and follow that up with percutaneous ablation and does that give patients better survival, longer progressive survival or time to progression? The same thing with renal cell cancer patients. We’re looking into if we do a combined trans-arterial therapy like embolization or radioembolization up front and then treat with percutaneous ablation and is that going to give us longer survivals. We don’t really know the answers to those things yet, but I definitely think those combined therapies are very interesting and exciting and things that people are going to be looking at going forward.
Melanie: In summary, tell other physicians what you'd like them to know about the ablation of kidney and liver tumors and when to refer to a specialist.
Dr. Gunn: One thing that I would like physicians to know is that we can do it. I think that there's a general lack of awareness of what interventional radiology can provide for patient care. Your patients have options, so if you see a patient and someone says their only option is surgery, you can send them over to us and maybe we can do a percutaneous ablation, have them avoid that bigger procedure and we can do something that’s more minimally invasive with a shorter recovery time, less hospital stays and may have just as good clinical results. Another thing I’d want people to understand is that we can do this and you should send them over to us to discuss this. The patients that they should be thinking about sending over to us would be patients that have lesions that are less than three centimeters in size, patients who may have multiple comorbidities where potentially they might not do well with general anesthesia or might not do well with a big surgery, and patients who just generally do not want to undergo a large surgery just because of their lifestyle. We see patients all the time that don’t want to be down for four to six weeks – they want to be down for a week – they don’t want to miss that much work, they don’t want to miss a vacation or Christmas or all these other things with their families. Those are the patients that we should be talking to because we have options for them.
Melanie: Tell us about your team. Why is UAB so great to work with?
Dr. Gunn: Our team is all board certified interventional radiologists. We’re the experts in this field and definitely in this area. Anything big and complicated comes to UAB and so we see everything. We have lots of experience in this area and also clinical trials that we’re rolling people for that might not be available at other centers. I think the fact that we treat patients with a wide variety of problems that we do so in a multidisciplinary manner with support from world class physicians from surgery, transplant, urology and gastroenterology and we collaborate so closely with them in the ability to enroll patients in clinical trials that aren’t available at other centers is a huge benefit for patients.
Melanie: Thank you so much for being with us today. A community physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UABMIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua047.mp3
- DoctorsOser, Rachel
- Featured SpeakerRachel Oser, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4382
- Guest BioRachel Oser, MD is an Associate Professor, Department of Radiology with UAB Medicine.
Learn more about Rachel Oser, MD
Release Date: November 17, 2017
Reissue Date: November 18, 2020
Expiration Date: November 18, 2023
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Rachel F. Oser, MD
Associate Professor in Radiology, UAB
Dr. Oser has no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Uterine fibroids are the most common benign tumors in women of childbearing age. Many women with uterine fibroids have no symptoms. However, fibroids can cause a number of symptoms depending on their size, location within the uterus and how close there are to adjacent pelvic organs. My guest today is Dr. Rachel Oser. She's an associate professor in the department of radiology at UAB Medicine. Welcome to the show. What are fibroids and is it inevitable that most women will get them?
Dr. Rachel Oser, MD (Guest): As you said in your introduction, which was very nicely said, they're a benign tumor. They are an abnormal growth that occurs in women uteruses, but they are benign, which means that they are not cancer and they typically do not turn into cancer. The most common tumor in women uteruses in about 50% of African American women, maybe 30% of other women, tend to develop fibroids during the course of their lifetime. It's an extremely common problem. It can run in families but often it does not, and they are in fact the number one cause for hysterectomy in the country right now. It's extremely common, they're found in all different groups of women, not cancer but can cause symptoms, which need to be treated because they could bother people and limit their lifestyles.
Melanie: Do we know how or why uterine fibroids develop? You mentioned just a bit about genetic contributions, so speak a little bit about the etiology.
Dr. Oser: Right now, we don't really know why women develop fibroids. There's a lot of research on that right now. There's a lot of research going into medications and other treatments, but currently, there aren't any good long-term treatments for women with fibroids that are not either surgical or interventional radiology based. What happens is that as the tumors grow, they can cause several different problems. In women who are of childbearing years, if they're adjacent especially to the cavity of the uterus, they can distort that cavity and they can cause problems with pregnancy that could include difficulty getting pregnant and can include difficulty carrying the pregnancy to term, so repeated early miscarriages, and also they can cause problems with delivery. If you have large fibroids, sometimes it can make deliveries more complicated and cause a required C section.
They also can cause problems with heavy periods. Sometimes women will have almost continuous periods, passing blood clots, extremely heavy cycles, things like that. They can also be associated if they're very large with mass symptoms. If you think about it, when you're uterus gets big, if you're pregnant for example, you have to pee all the time. You have to urinate frequently. You can have issues with constipation, you can have abdominal pain, you can have nausea on a full stomach, and all of these symptoms can be associated with fibroids if they become extremely large. They can range in size from small enough that you would never really feel them unless you're doing a pelvic exam to big enough that women can look like their eight or nine months pregnant. The symptoms can be related to where they are and to where the size of the fibroids are. Because they're benign, they don’t need to be treated unless they are in fact causing you symptoms, and that’s when women will typically come to either their gynecologist or to the interventional radiologist for their treatment options for the fibroid tumors.
Melanie: Let’s speak about some of those treatment options. What's available to women if these fibroids are causing symptoms? As you said, they don’t necessarily need treatment, but if these symptoms are affecting the quality of a woman’s life or her ability to get pregnant or very heavy periods, what are some treatment options you might recommend?
Dr. Oser: One of the main treatment options, and the one that has been around the longest, is going to be a surgical option. Typically, there are two different ways that this can go. One of them is called a myomectomy and that is where you just remove the myoma, or the fibroid, so they actually do an open surgical procedure or sometimes laparoscopic or robotic assistance, and they can go in and try to remove the fibroid itself and leave the remainder of the uterus intact. That is also very effective if it's a solitary fibroid or if they're smaller fibroids, in women who are in childbearing years who really want to preserve fertility; that's often what gynecologists will suggest first. That has been fairly well studied and can be effective. The problem with it is that these fibroids tend to occur over the life of the woman, so even if you've had a myomectomy at a younger age, you could expect that later on in your life you will develop subsequent fibroids that might need treatment.
The ultimate treatment for fibroids is to do a hysterectomy where the uterus is entirely removed. The advantage to that is that once your uterus is gone, you are never going to have problems with your fibroids again. But for many women, that’s a very invasive option. There are many complications that can be associated with hysterectomy that women want to avoid, and obviously, if you're at all interested in preserving fertility, having a hysterectomy means that’s no longer an option for you, even with assistance. The newer option for treating uterine fibroids is uterine artery embolization and that's the procedure that I do. What this is, is a catheter-based procedure. We put a catheter in your artery just like when they do a heart cath to treat blockages in the heart, except instead of looking at the arteries that go into the heart, we're looking at the arteries going to the uterus. We actually get a little catheter all the way out to the uterus in these arteries. It’s a very small diagnostic catheter about the size of a piece of angel hair pasta that we can get way out there, and we put in small particles that block off the blood supply to the fibroid tumors in the uterus. Once they lose their blood supply, the tumors start to die and they shrink and scar down. They're not being removed entirely, but because we cut off their blood supply and they shrink and scar down, you can get extremely good resolution in the symptoms.
The advantage of this procedure is that it is minimally invasive. We do it through a little nick in your groin, probably a quarter-inch incision in your groin, just like a heart cath that you might have heard about, you end up with a Band-Aid when we're done instead of a big incision, and people can return to work within one to two weeks as opposed to an open surgery where you may be out for four to six weeks. It's much less debilitating and the results are extremely good. When we talk about treating the main symptoms that we see with fibroids like heavy bleeding, over 95% of women in large studies have a resolution of their symptoms after fibroid embolization.
Melanie: Have you been able to evaluate the long-term outcome of the uterine artery embolization as opposed to a surgical treatment?
Dr. Oser: The uterine artery embolization is a newer therapy. It has been around in live use since the early 2000s. There are tens of thousands of women in this country who have had uterine artery embolization and long-term people seem to do very well. They have good resolution of their symptoms, there is a lower recurrence rate than there is after a myomectomy, although it is not zero. Most people who present with symptomatic fibroids tend to be by the time they become really symptomatic in their 40s and 50s anyhow. At that point, you're looking at maybe 10 to 15 years until menopause at which point those symptoms are going to resolve. Many of these women who have this procedure can have a minimally invasive procedure, resolution of their symptoms and then they don’t really see a recurrence because by the time you might be starting to see some recurrence, they're already heading into menopause.
In younger women, we've also seen good results. It is possible to have a successful pregnancy after a fibroid embolization, although there isn't good data on what the percentage is. There's better data for a myomectomy on that. However, I know in my practice, I've had several women who've had successful pregnancies post uterine artery embolization. Those women tend to get good symptom relief and there is a small recurrence rate of fibroids as they age, but once again, overall it's lower than it is with a myomectomy.
Melanie: Are there any contraindications for the institution of it?
Dr. Oser: Typically for fibroid embolization, we prefer to not do it when individual fibroids are larger than about 12 centimeters or when your uterus is bigger than about a six-month pregnancy. The reason for that is that we are not removing the fibroids entirely as they do with surgery and it takes a while for that shrinkage to occur, and they never totally go away like they do if you scoop them out surgically. If you have an extremely large fibroid or a very large uterus because of multiple fibroids, although we will probably get good relief of some of your symptoms and the uterus will shrink, it’s not going to go back to normal. If your symptoms are mainly related to the size of the fibroids or the size of your uterus, it may be that in that case surgery is a better option. We have, however, women who really don’t want to have a surgical procedure, and as long as we all understand what the results are going to be or likely to be, I'm fine. We have embolized those women and they’ve had good results with it.
Melanie: What about medicational management? As you mentioned, some women don’t want to have a procedure. Is there some medicational management that can be used in this case?
Dr. Oser: Some of the symptoms can sometimes be managed by things like oral contraceptives with good results. Sometimes women can be treated with hormone suppression therapy to try to shrink the fibroids themselves. The problem with that is that the hormonal therapies have side effects and they tend to be temporary, so once you stop the medications, they fibroids are still there and your symptoms are going to return. They're not a therapy that you can take for six weeks and you're better; it’s something that is going to be more of a lifelong issue.
Melanie: Are there any current studies you'd like to discuss for other physicians that might make them more aware of the situation?
Dr. Oser: Uterine artery embolization at this point is really an accepted practice. In fact, the American College of Obstetricians and Gynecology considers it a level one evidence-based treatment for uterine fibroids. The studies that are going on right now are things looking more like long-term outcomes, pregnancy after uterine artery embolization things like that. Overall, the therapy has become fairly well accepted in practice of literature. It still is not as widely available in the community as we would like to see. Certainly, I don’t think it’s a replacement entirely for surgical options depending on the patient, but I really do think that something that I wish people would think of it and talk to their patients about as a potential option going forward. I think it really is nice to provide our patients with all the possible options.
Melanie: In summary, tell other physicians what you'd like them to know about uterine fibroids and when to refer to a specialist.
Dr. Oser: I think what I would say about uterine fibroids for other physicians is to know that there are nonsurgical options that are available. They're available in your community. I know that at UAB, we have an interventional radiology clinic that you can refer symptomatic patients to, and what we do when that happens is we sit down with them, we get an MRI to image their uterus and that gives us a really good idea of how many and the size of the fibroids they have, what kind of blood supply they have, and if they're a good candidate for the procedure. We then sit down with the patient and go over their potential treatment options, we show them their images, and we just give them the information. Many of the women I talk to go on to have a uterine artery embolization, some of them prefer a more definitive therapy and some of them are not good candidates for our procedure, but we’d really like to have that chance to inform the patient and let them be a partner in their medical care. Any symptomatic fibroid patient is a candidate to at least find out about what her options are.
Melanie: Tell us about your team. Why is UAB so great to work with?
Dr. Oser: We have a fantastic team here. All of our physicians who perform this procedure have trained in interventional radiology. Most of us have added certification in it and the ones who don’t have been doing it for over 30 years and have specialty training as well. We have a team of physicians, dedicated nurses, technologists, a physician assistant who all work with us to streamline our patient care. The clinic setting is great for talking to patients, letting them know what their options are, and then we do their procedure in the hospital. We work really hard to get good pain control after the procedure and most of the patients have been extremely happy with their care. I think we bring a lot of expertise of a diverse team of professionals to taking care of our patients in a really high tech environment that is unique in central Alabama.
Melanie: Thank you so much for being with us today. A community physician can refer a patient to UAB medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua044.mp3
- DoctorsMorgan, Sarah
- Featured SpeakerSarah Morgan, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4285
- Guest BioSarah Morgan, MD, MS, RD/LD, FADA, FACP, CCD, is Professor of Nutrition Sciences and Medicine in the Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham (UAB) School of Medicine.
Learn more about Sarah Morgan, MD
Release Date: November 6, 2017
Reissue Date: November 6, 2020
Expiration Date: November 6, 2023
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Sarah L. Morgan, MD, RD, FADA, FACP, CCD
Professor in Internal Medicine and Nutrition
Dr. Morgan has disclosed the following commercial interests:
Consulting Fee – Amgen
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): According to the National Osteoporosis Foundation, approximately 54 million Americans have osteoporosis and low bone mass; placing them at an increased risk for osteoporosis. Studies suggest that approximately one in two women and up to one in four men aged 50 and older will break a bone due to osteoporosis. My guest today is Dr. Sarah Morgan. She’s a professor of Nutrition Sciences and Medicine in the Division of Clinical Immunology and Rheumatology at UAB Medicine. Welcome to the show Dr. Morgan. So, explain a little bit about bone density and osteoporosis and why it’s important to measure this.
Dr. Sarah Morgan, MD, RC, FADA, FACP, CCD (Guest): Osteoporosis is a condition that can be caused by many things where the bones are thin and the problem with having osteoporosis is it predisposes you to have fractures. This is not fractures – traumatic fracture, this is a fall when you have a fall from a standing height, you might have a fracture, so we call that an insufficiency fracture. So, that’s the problem with having osteoporosis. A bone densitometry test which is also called DEXA, which is dual energy x-ray absorptiometry, right now is one of the state of the art measurements that help us to determine how thick your bones are. So, it’s a very nice test to help us to make the diagnosis and we use it for a lot of things; to follow you and also determine your fracture risk.
Melanie: So, tell us about some of those valuable prognostic tools to aid in early diagnosis of osteoporosis because that is so important. Are there different types of bone density tests?
Dr. Morgan: There is really one – there are probably two different types of bone density tests. There is a peripheral one where you might go to a screening health fair and you could stick your heel or your forearm into a machine. The one that we use in our clinic, is a table unit where we would measure bone density on the lumbar spine, the hip and we could also measure the forearm. We can also do total body evaluation which also can tell us about body composition analysis. For the most part, when you come to our clinic, we will be doing the DEXA scan of the hip, the spine, and sometimes adding on a wrist scan.
Melanie: So, are the any shortcomings of bone mineral density testing?
Dr. Morgan: I can’t think of many shortcomings. Really a bone mineral density test is more predictive of whether somebody will have a fracture that is a cholesterol level of whether somebody will have a heart attack or a stroke. That being said, there may be things that confound the bone density testing. For example, as we get older, in our spine, we may get degenerative arthritis in our spine and that will tend to overestimate bone mineral density in the spine. Therefore, that’s one of the reasons that we do other sites such as the hip and the forearm to provide us with other data.
Melanie: Well, as we are speaking about data, does denser bone necessarily mean stronger bone?
Dr. Morgan: We measure bone densitometry, we measure your bone mineral density which is in T-scores and in Z-scores and there is categorization of these T-scores and Z-scores. We use a T-score and Z-score which are standard deviations to give us benchmarks for diagnosis. A T-score that is in a postmenopausal woman for example, that is above -1 or above is normal bone mineral density. A T-score that is below -1 to just above -2.5 is osteopenia and a score of -2.5 is osteoporosis. To specifically address your question, we do have metabolic bone diseases that have thicker bones that necessarily may not be stronger bones, but in the context of osteoporosis; generally having higher bone mineral density means you are less likely to have a fracture.
Melanie: So, speak about patient selection criteria and some clinical indications for the institution of this test. Who should have it?
Dr. Morgan: Well, there are a wide variety of people that have come up with guidelines related to this for example, the National Osteoporosis Foundation. Generally, and I also will add, that Medicare/Medicaid has criteria for paying for that test. So, those are some of the benchmarks we use. But generally, I think that we do these studies in people who have had insufficiency fractures looking for their bone mineral density. We may do them for people that are on steroids because steroids are examples of medications that can lower bone mineral density. We often do them in postmenopausal women because we know women at menopause who chose not to continue to take hormones lose bone mineral density. So, there are some categories like that of people in whom we generally recommend that they have a bone density test. Another good example is hyperparathyroidism. In hyperparathyroidism, you lose bone mineral density. So, there are a whole host of reasons that your physician may decide to order a bone density test.
Melanie: So, what are some current issues in medical management, assess for us the appropriateness of specific treatments you might engage with the patient if you determine that they have osteopenia and on to osteoporosis.
Dr. Morgan: If somebody has osteopenia, that’s the category that is above osteoporosis, so generally the bone mineral density is higher than osteoporosis. One of the uses of bone mineral density is to use a tool called FRAX in osteopenia which is a fracture risk algorithm that gives somebody their ten-year risk of having a major osteoporotic fracture or a hip fracture. So, we can combine the information with bone mineral density, the bone mineral density generally at the femoral neck with risk factors in the patient and that can help us to determine their fracture risk. So, we oftentimes do that in somebody with osteopenia and the National Osteoporosis Foundation has established cutoffs for when the fracture risk is high enough to use medical therapies and the National Osteoporosis Foundation generally would certainly recommend therapy in somebody with an insufficiency fracture, if you have a T-score of -2.5 or below at the lumbar spine and in the hip.
Melanie: So, tell us about the UAB Osteoporosis Prevention and Treatment Clinic.
Dr. Morgan: I’m very proud of this clinic. This is a long-term clinic we have had is a multidisciplinary clinic. So, I feel that the best care of patients with metabolic bone disease is multidisciplinary. So, in ort clinic, we have a physical therapist, so a new patient may have a physical therapy screen. This helps me with fall prevention, gait analysis, back pain. We have nurses, nurse practitioners. We have physicians that are many different types of specialties; internal medicine, nutrition, endocrinology, rheumatology, geriatrics. We all practice together. We have a nurse practitioner that we all work together. We have a radiologist that works with us on our team to read bone densities. So, a new patient that would come to our clinic, might come in the morning and see the physical therapist first. They would then go on to have a DEXA scan completed and then we; one day of the week we have a two-hour class that our patient educator, who I should mention is a PhD level nutritionist, so we have dieticians that are part of our team. We have a two-hour class for all of our new patients. In this class, we discuss calcium, calcium stores, you learn how to read a label, we talk about fall prevention, we talk about how to read your DEXA scan and we talk about therapeutic options. Then all of us see our new patients, generally in the afternoons so all of our patients have been educated and our wonderful patient educator is there in the afternoon and she helps us to do calcium and vitamin D instructions. If I want to put somebody on a low sodium diet, because of hypercalciuria, she also would instruct people on how to take bisphosphonate medicine correctly, she would also instruct on how to give an injectable medicine like teriparatide.
Melanie: So, how can someone schedule a bone density test?
Dr. Morgan: A bone density test in our health system; can be scheduled by any physician. It’s part of the radiology order set and you just click on the bone densitometry and you can order it.
Melanie: And what can a physician expect from your team after referral, if they refer someone to you, insofar as communication with the referring physician and your team approach?
Dr. Morgan: With our team approach, let me talk about clinic first; we would generate a report of our consultation and that would be sent to a physician who requested the consultation. It would be available on our electronic medical record. A DEXA scan we rotate reading DEXA scans, all of the physicians within the clinic and our radiologists and those are reported out and one of the things I will mention is that DEXA quality is very important and our DEXA facility is accredited by the International Society for Clinical Densitometry. We are one of about 50 or 60 in the country right now. And so, I’m very proud of that, because that means we do all of the quality control and you can also count that our report that we generate about the DEXA scan has all of the recommended required elements that the International Society for Densitometry deems to be important in communicating our DEXA results.
Melanie: So, to wrap up in summary Dr., tell other physicians what you would like them to know about quality in bone densitometry and when to refer to a specialist.
Dr. Morgan: Quality is extremely important in bone densitometry. The clinician who reads a bone densitometry report should be certified. I have the letters CCD after my name, which means Certified Clinical Densitometrist, this is through the International Society for Clinical Densitometry. And my bone density, my DEXA technologists, are radiographic technologists who have the letters CBDT, they are certified bone density technologists. And so, I think that is very important to have people that have been educated about correctly doing the test, correctly reading the test and evaluating the test. So, that’s one thing I’d like to leave with everybody is that quality in DEXA scans is very important and so you want to make sure that the facility that is performing the DEXA scan has certified individuals and also is hopefully accredited.
Melanie: Thank you so much Dr. Morgan for being with us today. And a community physician can refer a patient to UAB Medicine by calling the Mist line at 1-800-UAB-MIST. That’s 1-800-822-6478. You are listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to UABmedicine.org/physician. That’s UABmedicine.org/physician. This is Melanie Cole. Thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua041.mp3
- DoctorsHuh, Warner
- Featured SpeakerWarner Huh, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=1958
- Guest BioWarner Huh, MD is Professor and Director of the Division of Gynecologic Oncology, his areas of expertise include Gynecologic oncology, cancer vaccine, robotic surgery for gyn/onc, ovarian cancer, endometrial cancer.
Learn more about Warner Huh, MD
Dr. Huh has the following financial relationships with commercial interests:
Merck - Consulting Fee
Dr. Huh does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): The mission of the UAB Medicine comprehensive ovarian cancer program is to improve the lives of women affected by or at risk for ovarian cancer. My guest today is, Dr. Warner Huh, he’s the division director in the division of gynecologic oncology, in the department of OBGYN at UAB Medicine. Welcome to the show, Dr. Huh, tell us a little bit about the UAB comprehensive ovarian cancer program, and how did this come about?
Dr. Warner Huh (Guest): Well, first off, thank you for having me. So, the genesis of the program was based around our realization and understanding that ovarian cancer patients really require multiple resources well beyond just surgery and chemotherapy, but what they really need is really sort of a comprehensive package of care that focuses on multiple aspects that are relevant to their treatment and also on their quality of life.
And I’ll give you an example, some of that might be access to experts that are counselling and testing about 15% are women with ovarian cancer, have a hereditary or high-risk component, and so, it’s important for them to understand whether or not they have a specific gene that may related to their ovarian cancer. That’s important because of novel drug therapy that’s currently available for these women, but not only that, it might affect their future risk of breast cancer, and also, it might affect the future risk of their families. That’s one component. Other components include things like nutritional counselling, expert support of care, counselling, access to alternative therapies, access to clinical trials, but what we essentially have learned is that there needs to be sort of this programmatic approach to caring for these women, well past just basically providing surgery and chemotherapy.
Melanie: And why is that, Dr. Huh? What makes ovarian cancer that much different than, and they’ve called it the silent cancer, and it certainly is a tough one to detect. So, why is this so different than say breast cancer or cervical or any of these other women cancers that would necessitate a program devoted entirely to it?
Dr. Huh: Well, it’s not that… not that so much that it’s different. Matter of fact, what I would argue is, in many ways, the program that we built, I’m hoping will service a future template for other cancers that might benefit from a similar comprehensive program with multiple facets that focus around basically the patient and the family. The reason why I think that ovarian cancers important is that, it’s just from the simple observation that we wind up tapping into multiple resources, that are ultimately really important for the management of women for ovarian cancer. It’s a very difficult disease to treat, and what we know is that, patients require a lot of support, and what we’re trying to do is to try to create an expert program that really revolves around the patient. And so, I think most people who treat ovarian cancer will argue that it requires a certain level that’s expertise. And what we’re trying to do is bring all that expertise under one roof.
Melanie: So, let’s speak about ovarian cancer for a minute, Dr. Huh, what do you want other physicians to know about being able to identify it? To speak to their patients about the risk factors, the hereditary factors involved, the genetics. Since it is so hard to detect, what should other physicians be on the lookout for if there an obstetrician, gynecologist, what should they be helping their patients to understand?
Dr. Huh: Well, to your point earlier. Ovarian cancer has been often labeled or in some says maybe mislabeled as the silent killer. Unfortunately, unlike other malignancies like breast cancer, colon cancer, cervical cancer, there’s no screening tests for ovarian cancer, and so, what we recommend to women, as well as we counsel to their providers is that they need to be aware of symptoms. The patients that have chronic bloating, nausea, vomiting, abdominal pain, difficulty urinating, difficulty using the bathroom. These may all be ultimately signs of ovarian cancer, and what we’re more interested in is sort of chronicity of the symptoms. I think everyone on this, who’s listening to this program realize a lot of things I just mentioned, nausea and vomiting could be caused by a multitude of different things that’s non-specific, but it’s really paying attention to those symptoms and going to doctor, and saying, “Listen, I’ve had multiple weeks of nausea, vomiting, and bloating, and I’m worried about this.” And making sure that they’re properly evaluated. So, it’s really about heightened symptom awareness.
Melanie: So, while there are no screening tools, are there some valuable prognostic tools to aid in diagnosis if you do suspect something?
Dr. Huh: Yeah, I think that in a woman like that who might this chronic symptoms, and OBGYN’s may elect to get an ultrasound of their pelvis, to see if there’s something going on with their ovaries or uterus or perhaps maybe they have increased fluid within their abdomen. Another option would be to check for something called the, CA125, which is commonly used to kind of help guy clinicians in terms of ordering additional testing. Some providers might use…order a CAT scan if they’re really concerned or have a really tightened suspicion of ovarian cancer. So, there are multiple tests that we use, but over and over again, what people recognize, and this has been published in the scientific literature is that referral to a gynecologic oncologist, another word, an oncologist who’s specifically trained to take care of women that have ovarian cancer, both from the surgical perspective, as well as the treatment perspective. That those women actually have much, much better outcomes, overall.
Melanie: So, when we were speaking before about the program, and you were talking about genetics. Tell us what’s going on in the world right now of gene expression and genomics for ovarian cancer. What are you seeing, Dr. Huh?
Dr. Huh: Yeah, this is a really hot area. The area that is of great interest to myself, my division, the ovarian cancer program, as well as the patients. So, the two levels or two types of testing that is done. Right now, we offer pretty much all of our ovarian cancer patients largely, basically, genetic testing or what we call, a gene panel testing, and what we’re looking for are specific mutations. For instance, like the BRCA1 and BRCA2 mutation that put women at considerable risk for developing ovarian cancer and breast cancer, but there actually multiple other genes, 20 plus other genes, that are actually epidemiologically linked to ovarian cancer, that might have great impact. Not only on the management of that individual women, but also an impact on the management of their family, for instance their daughters, and so, what we’re seeing now is what we call cascade testing, where if a woman with ovarian cancer has a genetic mutation, then we’ll talk about with their family members, like for instance, their daughters, their sons. Whether or not they need to be tested, as well, so that we can risk produce their future risk of getting cancer in the future. Now there’s another type of testing that’s done, where we do, what’s known as, next generation sequencing off of their actual tumor, where we try to figure out whether or not they might be candidates for drug therapy in the future, that might actually have a positive impact on their outcome.
So, what are those drugs? That’s really fascinating, and there’s been a lot of attention paid toward it, is from they’re called PARP inhibitors. So, in the United States, there’s three commercially available PARP inhibitors, that are used sort of in different settings for ovarian cancer, but what we know is that women who have, let’s say, a mutation for BRCA1 or 2. That those women actually have a really, very significant positive response to those drugs. So, what we’re doing now, is that we’re trying to understand these genetic mutations much earlier on in the course of their therapies, so that can look at this drug therapy. Not only that, understand what the risk is to the patient and their family as well.
Melanie: Wow, that’s fascinating, Dr. Huh, so in summary, tell other physicians what you’d like them to know about recognizing ovarian cancer, and when you feel it’s very important for them to refer, as you said, to a gynecologic oncologist.
Dr. Huh: Well, one is like you just said, that the scientific evidence clearly indicates that referral of these patients to a gynecologic oncologist or particularly to a Center, that does a relatively high volume of ovarian cancer surgery and treatment, that those are made definitely have a better outcome. And two, to realize that management of ovarian cancer patients, as I said, at the beginning of this interview, is more than just giving chemotherapy and operating. It’s about utilizing multiple resources to really provide, what I call, patient-centric care, that revolves around, not just on cancer outcomes, like survival, but also on quality of life, feeling things to the spirituality, feeling things with how to reduce the risk of their family members getting cancer, and to do that in a truly expert experienced way, that generally just benefits the patient and their families. And I think that, that is the main driver for why we created this program.
Melanie: Thank you so much, Dr. Huh, for being with us today. It’s really great information and so important for women and for other providers to hear, and a community physician can refer a patient to UAB Medicine by calling the MIST line, at 1800 UAB MIST, that’s 1800 822 6478. You’re listening to UAB Med Cast, for more information on resources available at UAB Medicine, you can go to, UABMedicine.org/Physician, that’s UABMedicine.org/Physician. This is Melanie Cole, thanks so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua032.mp3
- DoctorsRichter, Holly
- Featured SpeakerHolly Richter, PhD, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4217
- Guest BioHolly Richter, MD, PhD, J. Marion Sims Endowed Chair in Obstetrics and Gynecology.
Learn more about Holly Richter, PhD, MD
Release Date: 10/3/2017
Reissue Date: 10/5/2020
Expiration Date: 10/5/2023
Faculty:
UAB MedCast: Urinary & Bowel Incontinence
UAB MedCast: Vaginal Prolapse
Holly E. Richter, PhD, MD
Director, Division of Women's Pelvic Medicine and Reconstructive Surgery
Dr. Richter has disclosed the following commercial interests:
· Royalties - UpToDate
· Grants/Research Support/Grants Pending - Allergan, Renovia
· Other - DSMB Member: BlueWind Medical
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Nearly 40% of women will experience some form of pelvic organ prolapse. It most often occurs in women beyond the age of 40 and in relation to or following childbirth, menopause, or a hysterectomy. My guest today, is Dr. Holly Richter. She’s the Director of the Division of Urogynecology and Pelvic Reconstructive Surgery at UAB Medicine. Welcome to the show, Dr. Richter. Explain a little bit about pelvic organ prolapse including vaginal prolapse, and what are some common conditions and factors that lead to this?
Dr. Holly Richter (Guest): Sure. First of all, thank you, so much, for letting me come in today and talk about this very impactful condition that women can develop over time. Just to start off and provide perspective, approximately 10% of all women in the US may have surgery for pelvic organ prolapse and/or incontinence, and/or both of these conditions during the course of their lifetime. About 1 in 3 of those women may have a second surgery for these conditions. It’s really something that we really see a lot of in the post-reproductive health lifetime of a woman. Pelvic organ prolapse results from weakening of the support structures in the pelvis which lead to the woman feeling or seeing a vaginal bulge. One day she’ll be going to the bathroom and wiping, and she starts to feel something coming out of the vagina.
There are numerous risk factors for this including having babies. It makes sense when a big head and shoulders come down through the small vaginal canal that it may injure supportive structures such as muscles or ligaments and other types of connective tissue. Increases in weight can lead to this. Medical conditions such as a chronic cough, high physical activity that really puts chronic stress on the pelvic floor, changes in hormones, all of these things may contribute to the development of this condition. In fact, as you know, this is a condition which is multifactorial. There also may be intrinsic genetic predispositions to the development of prolapse. In fact, genetic studies that are going on, most of them are going on in the area of prolapse at this time.
Melanie: Do you have some valuable prognostic tools to aid in early diagnosis for a woman, or is there a history? What goes on with the diagnosis?
Dr. Richter: In terms of diagnosis, I think many people that do a gynecologic physical exam may see that with Valsalva or with – when a woman presses down on the pelvic floor, they may see mobility of the anterior vaginal wall, or the apex of the vagina, or even posteriorly. Many women remain asymptomatic, and that’s okay. The problem typically comes to the level of needing help when the protrusion starts coming outside of the vagina or beyond the hymenal ring. That’s typically when a woman will come and start to seek some information regarding what’s going on here. Many women may think this is a cancer. Seeing something come down like this is very scary. This is where docs that do pelvic exams can really help allay a woman’s fear that this is not a cancer. It’s something that’s quite prevalent in women and that there is help for it.
Melanie: Are there any complications if it’s left untreated?
Dr. Richter: Really great question. If left untreated, any kind of tissue that’s protruding down and is somewhat in an abnormal position, the blood supply to that area can be impaired. When the bladder starts coming down, it kinks off the urethra so a woman may have symptoms of incomplete bladder emptying. The same thing when there’s weakening in the posterior vaginal wall. A woman may have symptoms of inability to complete bowel movements, or just feeling really a lot of heaviness and pressure after a day of walking around. I’m confining – I’ve only mentioned urinary incontinence, but along the same lines, these same types of symptoms of prolapse can also predispose to bowel incontinence and bowel issues as well.
Melanie: What are some of the clinical challenges in the management of prolapse?
Dr. Richter: Well, I would say that -- first off, in managing – if a woman is coming for treatment, you want to make sure that you understand all of the weaknesses that are occurring in the vagina. You want to optimize lower urinary tract genital tissue health, and estrogen is a very important part of this. I’m a big believer in the use of vaginal estrogen. It helps thicken the vaginal epithelium, the underlying connective tissue. It just makes things healthier down in that area for a woman seeking treatment. Treatment really comes from two main areas. There’s nonsurgical treatment with the use of devices called pessaries that can be placed in the vagina, and then there are surgical treatment options for women.
Melanie: Is it a challenge for surgeons, Doctor, that you want the successful quality of life outcome for your patient --
Dr. Richter: Sure.
Melanie: but you also mentioned incontinence, so the associated symptoms of prolapse, and then do you have to deal with those as well while you’re dealing with the prolapse itself?
Dr. Richter: Absolutely. When you’re dealing with prolapse, because the urethra can be kinked, the woman, if she has her prolapse fixed, may actually develop urinary leakage. That needs to be assessed before surgery for prolapse. Quite often, we’ll also take a look down in the posterior compartment area to ensure that if she – typically, in the posterior compartment area, if she presents with fecal incontinence type symptoms, we evaluate that more fully before surgery because if there’s something we can fix there – we’ll want to take care of all of these things in one surgery.
Melanie: Are there some treatments and research that you’re doing at UAB that other physicians may not be aware of?
Dr. Richter: Yeah, we’re actually one of currently seven sites in the NIH-sponsored pelvic floor disorders network. We do multisite research. A lot of that has been in the area of surgical treatment of pelvic organ prolapse. We are currently looking at a trial in women who have a pelvic organ prolapse after having had a hysterectomy. We’re looking at three surgical treatment approaches for the management of this type of prolapse and which one – and if one of them is better than one of the others, and if one may be associated with an increased risk of recurrence versus another. It’s really an exciting area of research going on right now.
Melanie: And how do you make that decision with your patient on which type of surgery to have?
Dr. Richter: That’s awesome. Awesome question. If I have a 90-year-old who has a total procidentia, she’s not sexually active, the pessary won’t stay in -- we’ll talk about doing an obliterative type of repair. Getting the prolapse up, but also really making things very tight down below, so it doesn’t come back out, but it essentially obliterates the vagina. That’s as opposed to doing a reconstructive surgery, say in a woman who’s still sexually active – these are some of the considerations that we make.
Further, we can look at the type of approach to the surgery, whether we’re going to do everything vaginally – maybe she’s had a previous surgery before that’s failed and we may think about doing something from above with the use of mesh. Typically, in initial surgery, we’ll do what’s called a native tissue repair where we use the woman’s own tissue. All of these types of issues we discuss in an individualized fashion before doing a surgery for pelvic organ prolapse.
Melanie: And what about a pessary? Are these something that – you mentioned for a certain age woman they won’t stay in, but is this a good option – a non-surgical intervention for a younger woman? Is it something that comes out or stays in?
Dr. Richter: Yeah, great questions. Again, many younger women use a pessary. For the most part, they probably aren’t going to use it for the rest of their lives, but they may want to use it if they have some weakening of the pelvic floor and symptoms associated with this when they’re doing physical activity. They may want to have another child in the future so don’t want to take the uterus out at this time. For younger women, it’s typically a stop-gap measure.
Then there are older women that just don’t want to have surgery. Maybe they’ve got medical comorbidities that keep them from going to the operating room, or they have no desire to have surgery. A pessary can be used chronically. It can be used for several years where we will fit a particular pessary for her needs, teach her how to put it in and take it out. Again, this is where vaginal estrogen is very important to maintain the health of the vagina.
A pessary is a – and sometimes a woman just wants to try a pessary before moving on to surgery. I always offer every woman a nonsurgical treatment option. Now, she may not go for it. She may just want to get it fixed and move on, but it certainly is something that everybody should be offered.
Melanie: In summary, Doctor, tell other physicians what you’d like them to know about recognizing prolapse in their patients and when they should refer to a specialist.
Dr. Richter: Yeah, I think – well, prolapse is something that is managed by a specialist in female pelvic medicine and reconstructive surgery. Although, I would say that there are generalist Ob/Gyns that know how to place pessaries, and that’s a good thing because we need partners in the area of treating women with prolapse. But I think if a woman is really thinking about having surgery to treat the prolapse and cure the prolapse that she should be sent to a specialist for evaluation.
Melanie: And how can a community physician refer a patient to UAB Medicine?
Dr. Richter: Yeah, that’s a great question. We do have health finders. That is a service – I think that primarily patients are able to call and talk to a nurse specialist who can get them into the right doctors – to the right group. Doctors out in the community can call the UAB MIST Line at 934-MIST to contact any of the urogynecology docs here at UAB.
Melanie: And a community physician can refer a patient to UAB Medicine using the MIST Line at 1-800-822-6478, that’s 1-800-822-6478. And tell us about your team, Dr. Richter, why is UAB so great to work with?
Dr. Richter: We’re all board-specialized female pelvic medicine and reconstructive surgery specialist, and we’ve been doing this for twenty years, plus. In fact, one of my partners has been working in this area for thirty years. We’re training our future. We have an ACGME-Certified, three-year fellowship program. We not only take good clinical care of women, we’re trying to improve the care of women with prolapse through research initiatives as well as educational initiatives. This is all I do. This is all I – I don’t deliver babies; we don’t do pap smears. This is an area that’s very emotional for women, so you really want someone who takes the time to explain things, who has experience and expertise in all aspects and can offer a full spectrum of treatment options for women with this condition.
Melanie: Thank you, so much, for being with us today. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician. This is Melanie Cole. Thanks, so much for listening. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua033.mp3
- DoctorsRichter, Holly
- Featured SpeakerHolly Richter, PhD, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4221
- Guest BioHolly Richter, MD, PhD, J. Marion Sims Endowed Chair in Obstetrics and Gynecology.
Learn more about Holly Richter, PhD, MD
Release Date: 10/3/2017
Reissue Date: 10/5/2020
Expiration Date: 10/5/2023
Dr. Richter has the following financial relationships with commercial interests:
UpToDate - Royalties
Pelvalon - Grants/Research support/Grants Pending; Consulting Fee
Dr. Richter does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): As life expectancy in developed countries gradually increases, obstetrician/gynecologists are encouraged to be familiar with disorders of the elderly population. Half of all women are likely to experience some incontinence in their lifetime, and about 10% will have surgery for incontinence and/or prolapse. Fortunately, most incontinence problems can be successfully treated. My guest today, is Dr. Holly Richter. She’s the Director of the Division of Urogynecology and Pelvic Reconstructive Surgery at UAB Medicine. Welcome to the show, Dr. Richter. Explain a little bit about urinary incontinence and the etiology of it. What are some of the most common causes?
Dr. Holly Richter (Guest): Okay, so for all women – if we take a look at all women in the US 20 years of age and older, almost 20% of these women will have symptoms of urinary incontinence. Urinary incontinence is a condition where a woman loses the ability to control urine. There are a couple of different types of urinary leakage. Stress urinary leakage is the type of urine leakage when a woman undergoes activities such as running, jumping, coughing, sneezing. There’s an increased pressure transition to the pelvic floor, and this results in urinary leakage.
Along with stress urinary incontinence, there’s another type called urgency urinary incontinence. That’s a type of incontinence where a woman has a strong urge to go to the bathroom that she cannot defer. She can’t get to the bathroom in time, and she will leak. And probably the biggest group of the type of incontinence is mixed urinary incontinence, and that’s where a woman has both stress and urgency urinary incontinence.
Melanie: How important is early diagnosis as being crucial to improve the outcome prediction? Do you take a thorough history, and is that essential to the evaluation of incontinence?
Dr. Richter: A thorough history is very important because you want to get the correct diagnosis – the correct type of urinary leakage. Typically, for all urinary incontinence, the primary approach to its treatment is behavioral – the use of pelvic muscle exercises, watching the water and other fluid intake, staying away from caffeine, these types of issues. Some of these types of strategies work better for stress incontinence as opposed to urgency incontinence. There are also medications that we can use in women that have urgency incontinence that won’t help women that have stress leakage. The diagnosis is very important.
Melanie: Dr. Richter, since many women – almost half the women won’t report it to their doctor, whether it’s embarrassing or they don’t think that anything can be done, should physicians take an active approach and ask specific questions such as onset, symptoms? Should this be something that physicians just do as a regular thing?
Dr. Richter: That’s a great question. I do think that as a part of a normal review of systems when a woman presents to her primary care provider regarding her yearly checkup that he or she should ask whether she has symptoms of urinary leakage, bowel leakage, or if she feels or sees a bulge coming down from the vagina. All of these conditions are considered pelvic floor disorders and can be helped.
Melanie: And you mentioned management – speak about your nonsurgical intervention, what you do when you talk about the exercises and behavioral lifestyle -- how do you encourage women to follow these? Do you teach them how to do something like the Kegel, for example?
Dr. Richter: We have a specialist that we partner with in Urogynecology Care Clinic and they essentially provide strategies including how to isolate the pelvic muscles, how to use them, when to use them – when a woman is doing various types of activities – to help close off that urethra so that when she’s doing activities or when she has a strong urgency to go to the bathroom she can keep that urine from passing from the bladder to the urethra. Along with that is thinking about the types and amounts of fluids that a woman may take in during the course of the day as well as things like regular voiding throughout the day.
Melanie: And what about medicational intervention? People hear these things on television late at night and in the media, what do you tell women when they ask you about all of these different treatments?
Dr. Richter: Medications that are out there are essential medications for women with urgency urinary incontinence. The meds to help calm the bladder muscle. When a woman has a strong urge to go to the bathroom, that bladder muscle is trying to contract when she’s not typically in a socially acceptable position to be able to act on that. Therefore, the medications typically will give her a bit of time to be able to get to the bathroom.
Now, the problem with the use of medications is that they also have side effects. They cause dry mouth. They can cause constipation. They can cause dry eyes. It’s nice if a woman can have a behavioral therapy approach such as using her pelvic muscles, such as watching her fluid intake – not only amount of fluid intake, but the type of intake – so that she may not have to depend on medication to control this condition.
Melanie: And what about other interventions, Dr. Richter, such as Botox, or SNS?
Dr. Richter: Yes, prior to even going to Botox and SNS for stress leakage the use of pessaries exists. These are devices that are put into the vagina. They help support the bladder neck. There’s even some data which suggests that a pessary may also help with urgency urinary incontinence. Once a woman has exhausted these nonsurgical approaches, these behavioral approaches including pelvic muscle exercises, strategies, the use of medications. Then for urgency, urinary incontinence Botox and Sacral Nerve Stimulation are options that are available for women.
Melanie: What about the psychosocial impact of untreated incontinence?
Dr. Richter: Oh, that’s an immense issue. Untreated incontinence keeps women from going out, from exercising, from interacting with her friends, even family. It is a condition where it can cause social and psychological isolation for women, so it’s very important to proactively ask about this condition and to help a woman get treatment for it.
Melanie: Is it likely to worsen with time? Are there any studies about the menopausal transition? Does that seem to be the age that it starts to worsen?
Dr. Richter: That is a very insightful question. As women go from the reproductive to the post-reproductive time of life, as many of you all know, the ovaries start to shut down. Systemic estrogen levels go down. Associated with this is vaginal dryness, increasing bladder irritability. These things go hand-in-hand with the menopausal transition. Vaginal estrogen is very important to manage these symptoms.
Melanie: Wrap it up for us and let other physicians know what you’d like them to know about treating urinary and bowel incontinence and when they might refer to a specialist.
Dr. Richter: In terms of urinary incontinence, I think a generalist could talk to a woman, see what her pelvic muscles are like, and encourage her to use her muscles to help urine leakage. If this is not something that is successful for her on her own, she should be sent to a specialist for treatment.
Similarly, with bowel incontinence -- which is probably an order of magnitude of higher impact compared to urinary incontinence -- we have many strategies, many treatments for this including, again, behavioral therapy, the use of other strategies, perianal injections, vaginal devices and anal devices, as well as Sacral Nerve Stimulation, which treats bowel incontinence.
Melanie: Thank you, so much for being with us today, Dr. Richter. That’s great information. A community physician can refer a patient to UAB Medicine using the MIST Line at 1-800-UAB-MIST, that’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician. This is Melanie Cole. Thanks, so much for listening. - HostsMelanie Cole, MS
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