Additional Info
- Audio Fileuf_health_shands/ufhs008.mp3
- DoctorsSu, Li-Ming
- Featured SpeakerLi-Ming Su, MD
- Guest BioDr. Su is the David A. Cofrin Professor of Urologic Oncology and Chairman of the Department of Urology at the University of Florida College of Medicine. He completed his urology residency at the New York Presbyterian Hospital-Weil Cornell Medical College in 2000 and a fellowship in robotics and laparoscopic surgery in 2001 at Johns Hopkins Hospital. He served eight years on faculty at the James Buchanan Brady Urological Institute at Johns Hopkins before coming to the University of Florida in 2008 as the Chief of the Division of Robotic and Minimally Invasive Urologic Surgery. His clinical interests are in minimally invasive surgical therapies including robotic surgery for prostate and kidney cancer. Dr. Su’s research focuses on exploring image-guided surgery for prostate and kidney cancer as well as optical imaging for renal tumors, robotic simulation and virtual reality. He has authored over 90 peer reviewed manuscripts and multiple book chapters including chapters in both Campbell’s Urology and Smith’s Textbook of Endourology.
- TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome. I’m Melanie Cole. And today, we’re discussing Robotic Urologic Surgery Program at UF Health Shands Hospital. We’re going to examine how advancements in instrumentation and the rapid adoption of robotic surgery in urologic surgery is changing the landscape of urologic surgeries. We’ll touch on the advantages of robotic surgery over conventional open and laparoscopic surgery and how the multitude of urologic surgical procedures that robotic surgery is applied to include those applied to oncologic procedures, female urology and reconstructive surgery. Here to tell us about all of that today is Dr. Li-Ming Su. He’s a David A. Cofrin Professor of Urologic Oncology and the Chairman in the Department of Urology at UF Health Shands Hospital.
Dr. Su, it’s a pleasure to have you with us today. what was previously done for urologic issues and how have as I said in the intro, advancements in instrumentation given birth to this era of robotic surgeries? When was it first introduced into the field of urology?
Li-Ming Su, MD (Guest): Very good. Melanie, first of all, thanks for giving me this opportunity to be part of this podcast. I’m very excited to have this opportunity to speak on behalf of my team and the extraordinary changes that we’ve seen in our department and also nationwide with regards to the use of robotics in urologic surgery.
Really, if you look back over the last decade and a half, we’ve seen the implementation of robotic surgery in the field of urology. And in my career of almost two decades; this has probably been the most transformative change in our field with the rapid infusion of robotic surgery that in many ways has supplanted what we used to do by open surgery and even laparoscopic surgery. Whereby over 90% of surgeries at least the major operations we used to perform were by open surgical techniques; we’ve now seen in many different arenas within urologic surgery; this change to robotics because of advances of minimally invasive surgery.
Host: It is an exciting time to be in urologic surgery. Dr. Su, tell us about the new Da Vinci Surgical System and how it’s going to change the landscape of urologic surgeries that you are doing at UF Health Shands Hospital. What are you doing there and what conditions can you use it for?
Dr. Su: Absolutely. Our program in robotic surgery in our department at UF Health Shands Hospital began in 2007. And during that period of time, the most common operation that robotic surgery was applied to was that for prostate cancer and this is robot assisted laparoscopic radical prostatectomy. And this still remains the most common operation that we use the robot for, however, we have now seen expansion of robotic surgery into many different areas of cancer surgery specifically whether it’s the robotic partial nephrectomy or radical nephrectomy for kidney cancer, also radical cystectomy for bladder cancer. That is complete removal of the bladder and reconstructing a new urinary system.
So, I think that the robotic interventions have had it’s most significant impact in the area of cancer surgeries and really what this has translated to is much less invasive incisions but as good in some ways more precise surgical interventions done through tinier incisions leading to less transfusions, faster patient recovery and certainly patient satisfaction and outcomes.
But in addition to the cancer arena, we’re seeing a huge wave of interest in using robotic surgery for more advanced reconstructive procedures for both men and women.
Host: Well that certainly is exciting. So, as we’re speaking about the advantages over standard or laparoscopic surgery; what will it enable you to do? How is it different for the surgeon than performing these procedures using traditional surgical methods and while you’re telling us about that; speak about the learning curve a little bit.
Dr. Su: Sure. So, there are advantages to the surgeon, but there are also advantages to patients that I touched on briefly. For the surgeon, really this is a happy marriage in my mind between traditional open surgery and conventional laparoscopic surgery. And what I mean by that is urologic surgeons now can perform very complex operations within the human body without making a big incision. So, through small incisions, we can place robotic instruments that are essentially miniaturized wrists that we can then articulate, dissect, and retract in a very similar manner to what we would do in an open surgery but through eight millimeter instruments. So, you can imagine the size of your pinky finger having a very sophisticated terminal instrument that has the same maneuverability as the human wrist.
So, on top of that, so it’s an advantage of using both open surgical concepts and how we operate but with a minimally invasive approach as we see in laparoscopy but even beyond laparoscopy, we have three dimensional visualization and high definition images so that’s again, an advantage over conventional laparoscopy. So, it’s really a marriage of both techniques.
So, also, I can’t say enough about the magnification that is offered by robotic surgery being 12 to 15x greater than what we can see with our naked eye. And so a surgeon then is able to see the nuances of tissues and diseased versus normal tissues and making critical decisions while performing these complicated operations whether it’s a cancer operation or reconstructive operation.
For the patient, I alluded to the fact that smaller incisions equates to less pain, faster recuperation and back to the nuance of better visualization we are also seeing less blood loss because we can prospectively identify vessels and manage them, cauterize them or suture them before bleeding is encountered and thus reducing overall blood loss during the operation.
Host: Well thank you for that very comprehensive answer. Dr. Su, as we are talking about oncologic procedures, female urology, reconstructive surgery; does patient selection play a role in who can receive surgical procedures with robotics and who is it indicated for and why is that important?
Dr. Su: Absolutely. There are certain patients that are perhaps not well suited for robotic intervention and these are patients that have had very, very complex intraabdominal or pelvic surgeries where there’s a lot of scar tissue that would make establishment of a robotic environment with what’s called pneumoperitoneum, inflating the abdomen with carbon dioxide and placing our small instruments through our keyhole incisions very complicated. However, on the other hand, there are patients that we are able to do robotically that would be complicated if done by an open surgical technique. For instance, morbidly obese patients and we are unfortunately in our society, we are seeing that our body mass index has grown considerably year by year. Traditional open surgery can be a very morbid operation in those that are of high body mass index. They have higher complication rates, wound infection rates, and blood loss et cetera. But if we can do that surgery through smaller incisions; then we can steer clear of some of those associated morbidities that are encountered through open surgical incisions in these unique patient sets.
So, on one hand, patient selection is important and is limited by patients that have complex prior abdominal surgery or radiation treatments that would make scar tissue a problem. But it’s also opened up the opportunity to treat other patients that would be difficult through an open approach.
Host: Do you have any technical considerations or issues you’d like other providers to know when they are considering robotic surgery for urologic issues?
Dr. Su: Well I think as anything, this is all about experience. Just as we – as any surgeon learns a technique, it does require time, experience and exposure to a variety of different anatomic circumstances to really excel at what we do. What’s really unique about robotic surgery is the skill set is very, very different than open surgery and laparoscopy and even though as I said before, it’s a marriage of both techniques and taking advantage of the unique nature of each type of intervention. What different that we do robotically is no longer do we have tactile feedback as we perform these robotic surgeries.
And because of that, we have to rely more on our visualization to be able to appreciate the unique tissue planes as we do these operations. So, in many senses, we are relying upon a different sense, human sense if you will to perform these complex operations that we would otherwise have in open surgery which is tactile feedback. So, the analogy of that is you always hear about people that are born with one sense missing whether it’s the sense of sight for instance, but their other senses tend to take over. So, their sense of hearing may be better. Similarly here, is we do not have tactile feedback but then our visual sense is augmented by the 12-15X magnification and high definition quality images and so we are able to see those tissues and therefor perform as good and, in some ways better than open surgery because of that unique skill set.
Host: Very well explained. Dr. Su, as we wrap up, please tell other providers what you’d like them to know about the Robotic Urologic Surgery Program at UF Health Shands Hospital, when you feel it’s important that they refer and go ahead and tell us about your team.
Dr. Su: Absolutely. So, if I look at globally what’s happening at UF Health Shands Hospital, we have an extraordinary group of bright and talented robotic surgeons in many different disciplines, not only urology. Also gynecology, thoracic surgery, general surgery, ear, nose and throat surgeons as well and so we have – and colorectal surgery. So, we have a very multidisciplinary team involved in robotics. We have four Da Vinci Robotic Surgical Systems that have dual console capability and simulation for training of our residents, fellows and novice surgeons.
From a urologic standpoint, I’m proud to say that we have nine extremely well-trained and talented urologic surgeons. We began our program in 2007. We cover the disciplines of oncology, in that we perform robotic prostatectomy, partial nephrectomy, radical nephrectomy, cystectomy and then from a reconstructive standpoint; we do a lot of pelvic organ prolapse repair for female urology prolapse and incontinence work. We do pyeloplasty’s for kidney and ureteral obstruction and also, we are now delving into more complex urologic reconstructions that may involve substitution of the intestinal segments for bypassing ureteral strictures or some of the latest advances of using buccal mucosa as a platform to augment a repair for ureteral strictures.
So, I think the opportunities for robotics continues to challenge urologists and provide great opportunities to be very, very creative and we’re very excited about the future of robotics in urology and I’m proud to have a group of nine surgeons that offer a whole range of these types of operations for our patient population.
With regards to our urologic robotic team here at UF Health Shands Hospital, we have one of the most experienced programs here in the southeastern section of the United States. Certainly, with regards to our robotic prostatectomy and kidney cancer work, especially partial nephrectomy work; we perhaps have one of the highest volume practices in the state of Florida. As these cases can be very challenging and require a great deal of experience, for physicians who encounter cases that perhaps can be done robotically yet they don’t have those years of experience; we are happy to provide a second opinion and see these patients in our clinic. We are able to turn around our visit times quite rapidly as we have a very established nurse navigator approach to intake of our new patients coming in for evaluation. And even those that need a multidisciplinary approach to the cancer care; we have established clinics with medical oncology and radiation oncology as well as review of their pathology and radiology reports.
So, we are available to the community and the region and our referring physicians and we are happy to provide this service to these individuals.
Host: Well thank you so much Dr. Su for joining us today. What a fascinating topic. Thank you for sharing your expertise. And that wraps up this episode of UF Health MedEd cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates, please follow us on your social channels. I’m Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs007.mp3
- DoctorsChristman, Gregory
- Featured SpeakerGregory Christman, MD
- Guest BioDr. Christman joined the faculty in 2013 to direct the Division of Reproductive Endocrinology and Infertility at the University of Florida. He has a long-standing clinical research interest in the biology underlying the pathogenesis of uterine leiomyomas (fibroids) and for 2012-2013 he was chosen to chair the Fibroid Special Interest Group of the American Society of Reproductive Medicine. Dr. Christman is a Professor in the Department of Obstetrics and Gynecology and is board certified in both Obstetrics and Gynecology and the subspecialty of Reproductive Endocrinology and Infertility. His clinical interests include the care of women with polycystic ovarian disease, premature ovarian failure, endometriosis, leiomyomas, and infertility. His basic research interests include the study of apoptosis, gene therapy, and the development of prevention strategies to block the formation of uterine leiomyomas. He is currently involved in several clinical research studies in infertility management regarding the optimal use for medications used for ovulation induction, the use of GnRH analogs to prevent ovarian toxicity in women receiving alkylating chemotherapy, and the development and clinical application of novel non-hormonal treatments for endometriosis.
- TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome. I’m Melanie Cole and today we’re speaking to Dr. Gregory Christman. He’s a J. Wayne Reitz Professor of obstetrics & gynecology and Reproductive Biology and the Director of the Division of Reproductive Endocrinology and Infertility at UF Health Shands Hospital. We’re discussing the required characteristics and criteria to establish a diagnosis of polycystic ovarian syndrome. We’re going to address the various options available to address infertility secondary to poor or absent ovulation in women with PCOS and offering advice to best deal with the nonreproductive impact of PCOS on one’s health. Dr. Christman, it’s such a pleasure to have you with us. Explain a little bit about polycystic ovarian syndrome. Is it a gynecological or an endocrine disorder?
Gregory Christman, MD (Guest): Well to answer your question, it’s actually both. Okay. Most people are familiar with it based on what type of doctor they need to see. So, in the medical endocrine world, they embrace it as their disease and gynecology we embrace it as something that we have to help patients with. But in reality, it’s just a concern for the patient that sometimes has different presentations at different times of their lives.
Host: So, is this pretty common in young girls? Is there a genetic component to it? Tell us a little bit about what we know that causes it and what other providers should be aware of as far as conditions that may mimic PCOS and list associated physiologic causes and alterations with this common condition.
Dr. Christman: Well polycystic ovarian syndrome is incredibly common. Perhaps 10% of the population has some evidence of it if you look carefully. Fortunately most people it’s much less common to have a severe presentation with this. But in reality, when 10% of the population has something; it’s almost as if you are saying that being left handed is a concern because 10% of people are left handed. Polycystic ovarian syndrome has some characteristics and it’s important to remember that the name is that this is a syndrome.
It's not a disease. There probably are multiple diseases that can fall under this label of having polycystic ovarian syndrome. So, one of the first things we tell patients is it’s not all the same. I need to see what’s causing your PCOS because PCOS is just – is sort of a vague label and really to address the people’s needs, you really need to sort of focus on what exactly is the pathophysiology.
But to keep it simple, there’s a very common definition of polycystic ovarian disorder and what it is, it is stemmed from a meeting that was held in the Netherlands many, many years ago where the doctors who were studying this and taking care of patients decided that they really needed to come up with some criteria. So, the criteria now to be labeled as having polycystic ovarian syndrome is you have to have two of three things. You need to have one, symptoms of irregular menstrual cycles. So people who have regular 28 day cycles like clockwork probably do not have PCOS.
The second thing that you need to have is some evidence that your androgens or testosterone level are higher than what they should. And this could be as simple as someone just telling you geez, I think I have acne more than my friends or I have a little bit excessive hair growth on different parts of my body. And the third criteria is if you have an ultrasound done that you see multiple follicles more than 12 on either the right or the left side to have what we call a polycystic ovarian appearance. Hence the name, polycystic ovarian syndrome.
But there are many people who have normal ultrasounds who – you need two of the three. So, in that regard, it’s a group of symptoms and then the challenge to the doctor is to figure out what is underlying this cause and that’s how you really can sort of decide on the appropriate treatments for whatever the patient needs at the time.
Host: Well you mentioned ultrasound. Are there other lab tests that are performed? Because the diagnostic criteria are controversial and a little bit and so tell us a little bit about that and why it’s difficult to diagnose.
Dr. Christman: Okay I wouldn’t really say that the criteria are controversial. But I would have to admit that the definition that’s used in common practice or in the literature or in the newspaper is somewhat vague. The use of ultrasound is optional and there is no really specific lab tests. I think this is important for doctors to remember because sometimes we’re just looking for one test as physicians to document or confirm things. This is not a disease or a condition that where you have an ah ha moment, this laboratory test documents this. This is something you need to talk to the patient and say you have this constellation of symptoms where all these things are going on at once and now, I need to figure out what the cause is. So, ultrasound isn’t required and there’s really no specific lab tests. The reason why you would do lab tests is when you suspect that the person doesn’t have in this common condition because of other things you observe as a physician.
An example would be if someone was incredibly tired which is not part of the syndrome, then maybe they are hypothyroid. If someone has conditions where you think that these androgen symptoms are simply far too excessive; you might want to order an ultrasound or get a testosterone level to sort of narrow things down. But in reality, this is not something that’s a complicated diagnosis to make. It can be made even by the patient themselves by just applying the criteria that I mentioned.
Host: Well thank you for clearing that up. So, let’s talk about treatment and is treatment different if a woman is trying to get pregnant or done with her reproductive years? Give us some of the options available for treatment.
Dr. Christman: Well when it comes to treating patients with PCOS basically people generally have one or two things that they would like assistance with. One of the common reasons for presenting to a doctor is that having irregular cycles and a history of not being able to conceive in a reasonable amount of time which for most patients that’s immediately but in medicine we usually feel like someone should have a chance to get pregnant within six months to a year. People present with either subfertility or the other concern people present with is increased acne or facial hair growth. And the treatment for those are exactly the opposite. Because when someone is having one or two menstrual cycles a year and only ovulating perhaps once or twice a year; by definition, it’s going to be harder to get pregnant because most women get thirteen opportunities a year to get pregnant and here, you are getting only one or two cycles or perhaps you are not even ovulating at all. So, the treatment to help women conceive is medicines to help them ovulate. When people have excessive hair growth or acne the opposite is true and usually the ovary is making too much testosterone or androgen, so you normally put them on pills, the most common one is birth control pills to just keep the ovary quiet so that the symptoms of excess testosterone go away.
So, the treatments depend on what the patient wants, and you can’t treat both unfortunately and the technology to help people conceive with medicines has really advanced tremendously in the last seven years and many of these advancements I was fortunate enough to participate as one of the key authors on several trials that the NIH did to help women conceive with this condition.
Host: Is there an issue with complications if it’s left untreated, if young women have those diagnostic criteria, maybe they’ve self-diagnosed or maybe they’ve seen their OBGYN. Are there any complications you’d like them to be aware of if there is not treatment available?
Dr. Christman: Well generally, fortunately, the answer is most of the time people live a full and health life with this condition because it’s so common. Like anything that’s going on, sometimes this condition can be associated with an increased incidence of developing diabetes, sometimes people do not ovulate on a regular basis and if this continues for years and years and years without treatment, sometimes that might predispose to precancerous conditions of the endometrium. But I always remind my patients that these consequences are incredibly rare, easy to look out for and even if they are noticed; are generally fairly easy for the doctor to treat and have people keep doing the things that they enjoy with very few reasons to show for a doctor.
So, like most patients, when they ask what do I really need. They really don’t need anything different than other patients other than a physician who is keeping an eye on them and addressing whatever needs they have at the time and if they are doing fine, they are doing fine.
Host: Are there any effective lifestyle changes in the treatment of PCOS?
Dr. Christman: There are. Okay. And again, the thing that I mentioned earlier is that there’s different versions of PCOS. One of the things that was very confusing at least when I was in my training many, many years ago; is that you would have wise faculty members pointing at patients and saying see that person has PCOS and another person who has PCOS. And at the time, as a naive medical student or resident, I’m going like well they look completely different. One person seems to have diabetes and concerns controlling their weight and the other person is thin as a rail and has none of these issues. How can they both have the same condition. And that’s because some people with PCOS it’s caused by how the brain communicates to the ovary. And in other people, who have concerns with their weight or increased facial hair growth; sometimes that’s due to a problem where they don’t use insulin efficiently and, in those patients, sometimes lifestyle changes are advantageous. So, certainly patients who have difficulty with weight gain and prediabetes; those patients can have benefit with exercise and weight regiment plan to keep their weight controlled or to lose weight.
So, again, all these treatments have to be individualized. So, if someone comes in and says my patient has PCOS, what do they need? I can never answer that question unless I ask more questions like what else is going on in their lives? What have you seen? What’s their weight? What are they doing? What are the kinds of problems they’ve had? So, it takes a conversation to really take care of patients with PCOS. Specific lab tests or labels aren’t really too helpful. You really have to engage the patient and figure out what exactly is going on and hear their story.
Host: Well thank you for that answer. Very comprehensive and I’m glad that you made that point about how individual it is. As we wrap up, Dr. Christman, please tell us what other providers can expect after referring a patient to the gynecology team at UF Health Shands Hospital and what you would like them to know about PCOS, diagnosing their patients, helping them with these symptoms and what you can do for them at UF Health Shands Hospital.
Dr. Christman: Well, one of the big advantages of sending your patients to UF Health Shands Hospital is that one of the concerns I guess in doctors sort of treating this condition is that they made perhaps tings more complicated or more risky than what they should be. One of my great passions in life is – and part of this is from having relatives because sometimes this does run in families with the same condition. When people have difficulty conceiving; at one time I took a big interest like how could we actually make these things work better so that people didn’t need complicated fertility therapies?
So, one of the things that we are very well-known for in the area and I was fortunate enough to be involved in the original NIH trials that pioneered the use of letrozole which is a very simple inexpensive medicine, costs perhaps $4 per dose and yet it really changed how we take care of patients because it’s 40% more effective, no side effects and the biggest complication of fertility therapy in young healthy women is if it works too well and they get twins. And letrozole cut that rate in half.
So, when it turned out that it was more effective, less risky and no side effects; shortly after we did the study which was published in the New England Journal of Medicine; it became the standard of care five years ago. And now there are so many patients who conceive with this very simple, inexpensive treatment who never get to all these advanced stages of treatment. So, my advice out there for someone with PCOS is that if you are just starting your therapy and you have trouble conceiving; you need to start with something very simple because the world has changed a lot in the last five years and these things are now effective or perhaps a decade ago, if people aren’t paying attention; have now made simple things actually effective where perhaps if you are still practicing old time sort of reproductive care; it would seem that people would need very expensive therapies like IVF which we usually find there’s a place for that, but that’s not how you start. The simple things really work really reasonably well.
Host: Well that’s a great ending. Thank you so much Dr. Christman for coming on and sharing your incredible expertise in this pretty common condition. Thank you so much. And that concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates please follow us on your social channels. I’m Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs006.mp3
- DoctorsHughes, Steven
- Featured SpeakerSteven Hughes, MD
- Guest BioSteven J. Hughes, MD, is a professor and chief of surgical oncology at the UF College of Medicine. He also serves as vice chair for the department of surgery.
Learn more about Steven J. Hughes, MD - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome. Today we’re talking to Dr. Steven Hughes, Professor and Chief of Surgical Oncology at the University of Florida and he practices at UF Health Shands Hospital in Gainesville. We’re going to identify limitations of current research models of pancreatic cancer with respect to immunity. We are going to understand the role of cell to cell communication within the pancreatic cancer microenvironment and describe potential mechanisms of tumor tolerance in pancreatic cancer. Dr. Hughes, I’m so glad to have you join us today. This is such a fascinating topic. Please just let’s set the stage a little with pancreatic cancer. Tell us a little bit about the incidence or burden of this type of cancer today. what are you seeing?
Steven Hughes (Guest): The frightening aspect of this cancer is that the incidence meaning the percentage of the overall population that’s being diagnosed with the condition is on the rise coupled with poor options for treatment; pancreatic cancer is predicted to be the number two cause of cancer related death by the time of 2025 or 2030. So, it’s become a very important cancer which we need to find more effective treatments for immediately.
Host: Well that certainly is true. So then, help us to identify limitations of the current research models of pancreatic cancer with respect to immunity. Please discuss for us, the evidence and unique properties of the tumor microenvironment in pancreatic cancer because that could contribute to its resistance towards immunotherapies as well as strategies to overcome some of those barriers.
Dr. Hughes: Oh indeed. And this is a big subject. So, I’m going to try to distill it down into a couple of simple concepts so that everybody on the line has an understanding of what we are trying to do in our particular research effort.
First and foremost, the standard paradigm for finding new treatments for cancer starts in a petri dish with cancer cells. Success there leads to experiments in vivo models, typically in mice or rats. And then ultimately when success is met there, it’s brought on to humans. We have had a huge failure particularly in pancreatic cancer where things that appear to be effective in a petri dish looking at cancer cells and then effective in the treatment of mice given models of cancer have been effective only to fail when we try these treatments in humans. And in fact, only one or two percent of those things that look very promising in the in vivo models ultimately proved to be effective in actual patients.
What we’re come to realize is that these models first and foremost, have not been human and that the human disease appears to be somewhat different than that we see in rodents or other models. As a surgeon, that’s given us an opportunity. We are actually engaging our patients to participate in our research, and they have been very generous in offering up a portion of their tumor that is not necessary for decision making regarding their treatment following surgery to be incorporated in models that we believe mimic the human condition much more effectively.
That’s allowed us to start to understand the role of not just the cancer cells, but the host and how it responds to the cancer. And where that’s become particularly relevant is the immune system. And I think most folks have seen commercials about Keytruda or check point inhibitors. They’ve proven to be incredibly revolutionary in lung cancer, melanoma, bladder cancer and other cancers that appear to have ability to elicit an immune response.
At the moment, pancreatic cancer is thought to be for the most part, incapable of eliciting immune response but it would appear that that’s largely driven by the fact that that stroma, the noncancerous response of the cancer within the pancreas actually leads the immune system to believe that it should be helping the cancer instead of fighting it.
Host: Isn’t that fascinating? So, help us to understand that role. You started to talk a bit about it of that cell to cell communication within the microenvironment of pancreatic cancer and also, while you’re talking about that, tumor tolerance. Tell us a little bit about that. And how this all ties together when you are looking at treatment.
Dr. Hughes: Let me do that in the context of some large theories about how our immune system surveys for the formation of new cancers. The role of the immune system in helping us heal injury and I think then it will all bring it together.
So, first and foremost, our immune system is broken down into two large components. What’s referred to as innate immunity and this is very fundamental immunity and it plays a particularly large role in the healing of wounds. If you get a cut, it would become immediately infected with bacteria and would never heal if it weren’t for innate immunity. That’s a very different issue than if you develop influenza, a viral infection. In that circumstance, the second component which is a more complicated component, called adaptive immunity; is brought in to help fight off that influenza. It is an adaptive immune response that is the foundation for all of our strategies for vaccination.
What you’re talking about then is about how the innate immune system tells the adaptive immune system to either engage to fight a particular problem or to not engage because the innate system is in the process of healing a problem. In that setting, for the last few decades; there has been this notion of what’s called an immune escape hypothesis for cancer. And what its foundation is is that the rate of cancer is actually much lower than it should be given our understanding about how frequently mutations of DNA and therefore damage to genes occurs. The rate of cancer is much lower than it should be.
And so, years ago, the notion that most cancers that arise were immediately eliminated by the immune system started to gain enthusiasm. Then some cancers obviously, succeed so some of those cancers are not immediately eliminated and they form what we call equilibrium where they actually are allowed to survive but the immune system keeps them in check until some of those tumors actually escape and ultimately start to threaten the overall survival of the host.
So, this is the context where check point inhibitors, drugs once again like I mentioned, Keytruda which I have no ownership in or whatnot. So, I just use it because I think it’s the one that people know the most; actually help the immune system to go from that I’m going to let you be and help allow the innate immune system to fix the situation to the no this is not okay, I’m going to help the immune system fight you. Lung cancer, bladder cancer, other cancers like melanoma seem to be quite prone to being one that that therapy will work in part because they have a large number of mutations. Lung cancer, because it’s tobacco smoke and the mutational burden that that smoke brings on. Melanoma because of the exposure to the sun and then once again bladder cancer because actually all of the carcinogens from tobacco smoke are excreted by the kidney and ultimately bathes the bladder.
Pancreas cancer is thought of differently because it has fewer mutational burdens, is less likely to be caused by cigarette smoking or other carcinogens. It appears that the immune system has a harder time recognizing it as being something that needs to be eliminated. And part of that is we circle back to what I mentioned earlier clearly is that this supportive stroma, the host, is trying to help the tumor actually because it misunderstands the tumor as something that needs to be fixed rather than fought.
What we are interested in is understanding how the cancer cell fools the immune cells into believing that this is something that needs to be left alone. And we’re able to grow up cancer cells separate of all those other immune cells. We can grow the immune cells separate of the cancer cells. And then we can reintroduce them together either in a petri dish or in an animal model and understand how those interactions, that cell to cell communication that you asked me about may actually influence whether the immune system is being turned on or turned off.
And our evidence right now is that there’s clearly some factors that we’re trying to discover that turn that immune system off and strongly turn it off. If we can figure out what those are and turn those signals down; we can turn pancreatic cancer from a tumor that the immune system just can’t recognize into a tumor that the immune system can aggressively attack.
Host: Wow. Really, it’s an exciting time to be researching this. Dr. Hughes, let’s briefly talk about the Whipple procedure itself and UF Health Shands Hospital’s expertise, as you teach this to other doctors; do you have any approach considerations that you would like to let other providers know and I’d also like you to tell us a little bit about your teaching process, how it’s influenced by your drive to improve healthcare in provide patient-centered care to all patients. Because I can hear it when you are describing this. I can hear the passion and your mission with this. So, describe that just a little bit for us.
Dr. Hughes: Sure. That’s a big question. I’ll do my best to boil it down for you. So, first and foremost, our top priority in our training programs is to open up the minds of young individuals to challenge what I’m teaching them, to think independently and to get outside the box and to circle back to what we’re trying to do here at the University of Florida within our surgical training program is to not teach people how to just do what we’ve been doing for the last few decades or even the last few years but to change how we’re going to do it five or ten years from now. To identify where’s there’s opportunities for us to be better and to do better for our patients than we do right now.
And we’re really lucky here. The culture at least certainly in Gainesville and the surrounding area. Our patients come very open to the notion of participating in our research. It is very rare for a patient to not want to at least hear how they could perhaps participate in the research and after they’ve heard that, because we are always very careful to make sure that we never compromise their own personal outcomes, very rarely do they not engage.
When it comes to the Whipple procedure, the biggest message I would send to folks is that the biggest challenge we have isn’t in how safe we made the operation; it’s changing the current understanding even amongst medical professionals that pancreatic cancer is a futile disease. We actually have evidence within the last ten years that up to 40% of patients who are candidates for surgery and who are diagnosed with pancreatic cancer while it’s still in a curable state; never ever seek treatment within intent to cure. Many of them are sent home by their physicians innocently misunderstanding that there actually are treatment options with wonderful success for pancreatic cancer. And just sent home with a death sentence. It’s a misperception. Up to 40% of folks who we might be able to cure never pursue that.
That’s okay if they choose not to. And that’s my patient-centered approach to the disease. But at least let me have the conversation about what we can and cannot do. As far as what we’re trying to do from a surgical perspective is first of all, get those patients into our office so that we can talk with you about your options. The next step is to reduce the complication mortality rate to the lowest possible levels and at the moment, the mortality rate for surgery on the pancreas has been dropped from 20%, in other words one in five patients that undergo the operation dying as a complication of the surgery to less than 2% meaning less than one in fifty.
These are big operations. They are equivalent to open heart surgery, liver transplant. People are typically need to be in the hospital for a week to ten days in order to recover. But we – I think it’s going to be hard for us to do much better than a one or two percent mortality rate. It’s just a very complicated surgery with lots of opportunities for things to not go perfectly well. And so from that, the two things we’ve tried to do is we concentrate that experience into the hands of a small number of surgeons who are devoted to this particular disease and to this particular operation. So, everybody that’s involved in pancreatic cancer at the University of Florida is all in. This is what they do. This is what they are passionate about and they do it all day every day.
The next thing that we’ve been pursuing is how can we reduce the recovery period, the pain, the suffering of having to face the notion of an operation to try to overcome your cancer. And what we’ve done here, and I in particular have been focusing on is the use of minimally invasive surgery techniques. Others refer to that as Band-Aid surgery. Some may think of it as lap – it’s also referred to as laparoscopic surgery. An extension of that is with the robot. For the most part, when you talk about robotic surgery, you are talking about minimally invasive surgery or Band-Aid surgery but with the benefit of a robot.
All of those things are actively in practice here at the University of Florida and we apply them whenever possible mostly because it matters to our patients. They want smaller incisions. They want shorter hospital stays. They want fewer complications. And obviously we want that as well and so that is a wonderful partnership with our patients and our emphasis on the surgical treatment of cancer.
Host: Well that was an excellent explanation Dr. Hughes. And thank you for that. Please wrap it up with us. In summary, tell other physicians what you’d like them to know about the Whipple procedure program at UF Health Shands Hospital, when you feel it’s important to refer to the specialists at UF Health Shands Hospital.
Dr. Hughes: Absolutely. I think the biggest message I’d like to send to folks is that there are a number of centers that are engaged in high quality pancreatic surgery. There’s no question that there’s – I am not the only person that can do minimally invasive pancreatic surgery nor am I partners. I think what’s separate for us and what I’d like doctors to think about and patients is that we don’t just do good surgery, we use the opportunity to do good surgery on these patients to also figure out how we can do it even better five years from now. Or maybe not even have to do surgery because if you engage with us, you are going to participate in research that may discover the new cure to cancer.
But if you go to just a high quality center that is not actively engaged in the research of trying to cure pancreatic cancer; it’s a lost opportunity for us. The more patients we take care of, the better understanding we have of the disease, the more rapidly we can make progress.
Host: Well said Dr. Hughes. Thank you so much for coming on and sharing your incredible expertise in this very complicated but comprehensive topic today. Thank you again. That concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this an other healthcare topics at UF Health Shands Hospital please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advances and breakthroughs, please follow us on your social channels. I’m Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs005.mp3
- DoctorsFoote, Kelly;Okun, Michael
- Featured SpeakerKelly Foote, MD | Michael Okun, MD
- Guest BioKelly D. Foote, MD, is a graduate of the University of Utah, where he completed a BS degree in Materials Engineering as well as his Doctorate of Medicine. The U of U School of Medicine honored him with the Florence M. Strong Award in recognition of his outstanding qualities as a physician dedicated to patients. He did his general surgery internship at the University of Florida, where he also completed his residency in Neurological Surgery, including one year of dedicated training in Stereotactic and Functional Neurosurgery under the mentorship of Dr. William Friedman.
Learn more about Kelly D. Foote, MD
Michael S. Okun, MD, received his B.A. in History from Florida State University, and his M.D. from the University of Florida where he graduated with Honors. Dr. Okun completed an internship and Neurology residency at the University of Florida. Following residency he was trained at Emory University, one of the world’s leading centers for movement disorders research, in both general movement disorders and in microelectrode recording/surgical treatments.
Learn more about Michael Okun, MD - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Is your Parkinson’s patient a candidate for deep brain stimulation? Welcome to UF Health Med cast with UF health shands Hospital. In this panel discussion today, we have Dr Michael Okin, MD is a University of Florida chair of neurology; and executive direction of the Norman Fixel Institute for Neurological Diseases at UF Health; and a professor at UF and Dr Kelly Foote, MD is the Co-Director Norman Fixel Institute for Neurological Diseases at UF Health. Gentlemen, I’m so glad to have you join us today. Dr. Okun, I’d like to start with you. What is usually the first line treatment for tremors resulting from movement disorders such as Parkinson’s?
Michael Okun, MD (Guest): Well when we see patients who come to us and they have issues with shaking or with difficulty picking up objects or doing the types of things that they need to do to button buttons, and hand write and all the things you need to do to just get through your everyday life; we typically will do a full evaluation and look to see if there’s anything we can do with adding a medication. We want to see what type of tremor it is. There is actually a whole bunch of different subtypes of tremors. So, not all tremor is one thing and so we want to make sure we get the diagnosis right and once we’re sure we know what we are dealing with; we have a number of different medicines that we can try and we always want to try medications and if there are some behavioral treatments and some exercises and some things that might help that tremor as well, we’ll also prescribe those.
Host: Dr. Foote, based on what Dr. Okun just said, if your patient has not seen positive effects from medication, for other providers, other neurologists that are dealing with patients with Parkinson’s; give us some of the clinical indications for use of deep brain stimulation.
Kelly Foote, MD (Guest): Well, you sort of alluded to the issue there, when the medications are not solving the problem for appropriately selected patients; surgical intervention can actually be very helpful. And in the case of tremor as you brought up before, if it’s an essential tremor, which is very common and not to be confused with Parkinson’s Disease, which is a more complex problem that frequently involves tremor; either of those two problems can be addressed very effectively with deep brain stimulation.
Host: Dr. Okun tell us a little bit about it. What are some of the advantages and what are some of the risks?
Dr. Okun: Well so when we think about should we proceed with a surgical intervention for any individual patient; what we want to do is we want to meet with that patient and that family member and we want to be sure that we understand everything it is that will make their life better and what are the reasons that we may want to do a surgery. I mean even though we do this surgery through a tiny burr hole and we use a lot of computers and fancy devices; it’s still a risk to pass a probe into the brain and to try to stimulate through that probe and change the way in which a lot of these brain regions are talking to each other. And so, the first step is having that conversation with the patient and with the family about expectations and what is it that you want to improve? Is it tremor, is it stiffness, is it slowness? And so, we try to create that nice interaction where we can both be speaking the same language and then once we’ve done the first evaluation and usually patients see a neurologist, if they are being operated on for a neurological disorder or a psychiatrist if it’s a psychiatric disorder or a neuropsychiatric disorder.
Then we proceed with what is called a multidisciplinary workup. And so, that’s where a neurologist and a neurosurgeon and a psychiatrist and all the rehab specialists like physical therapist, occupational therapists and speech and swallow therapists as well as social workers and nutritionists, meet with the patient and then we do something that might sound a little unconventional and that’s that we talk behind the patient’s back and the best type of healthcare that you can hope for in the modern system is when a group of doctors and professionals and healthcare professionals get together and they are actually talking about you. And then once we do that, we can establish what might be the best approach whether surgery is the right approach for the patient. Have we tried everything?
And then if we are going to do surgery, then we want to have that discussion about do you need it on one side of your brain or on two, what brain target might be the best for your individual symptoms and then getting all the way back to that first question. What are your expectations and what expectations based on our experience, so at UF Health Shands Hospital, we’ve done over 2000 leads and so we have a lot of experience and so we can draw on that to try to give patients a sense of what may or may not get better with the operation.
Dr. Foote: I would add from a neurosurgeon’s perspective; that I approach this as a risk benefit analysis. And you might be surprised that the decision making process for deep brain stimulation is much more complex than that say for a patient who comes to me with a brain tumor. Even though the brain tumor is typically a much worse problem to deal with and the operation that your propose carries a substantially higher risk than deep brain stimulation; the decision making is relatively straightforward. Because that is an urgent or emergent operation and deep brain stimulation is sort of special in that it is an elective brain surgery.
Some might argue that elective brain surgery shouldn’t exist. Because any time you do brain surgery; there is the potential for an injury to the brain and of course an injury to the brain could leave you with new problems that may or may not be worse than the problems you came in with. So, we take that very seriously. And that’s what all this infrastructure is about that we’ve developed at UF Health Shands Hospital and the team approach that Dr. Okun described takes some of the pressure off of me in this decision making process.
I really like the way he said what are your expectations. I actually with every single patient when I first meet them, I talk to them about what affects your quality of life and they make a list for me in order of importance to them. These are the symptoms that most impair my quality of life in order of importance to me. And then based on our experiences with a couple of thousand people before them; we can give them realistic expectations and say look, this first thing on your list I think is very likely to respond well to surgery and we’ve found a way to do this operation that addresses that quite nicely. But perhaps this second thing on your list, I can tell you right now, that never gets better and you should know up front that that particular symptom is not something that we figured out a way to solve. The third and fourth things on your list, I’m pretty confident. The fifth thing on your list, sometimes it gets better and sometimes it doesn’t. And we don’t fully understand how to make that happen every time.
But at least, once we’ve finished this conversation, the patients can have very realistic expectations about what we can hope to achieve with this intervention.
Host: Well it certainly is a comprehensive multidisciplinary evaluation and as you say, patient selection criteria is so important for this. Dr. Foote, speak a little bit about the device programming itself. How does it work and tell us a little bit about the surgeon and the movement disorder specialist experience with this procedure.
Dr. Foote: Well, the devices involved – the implantation of in general, a single wire with multiple metal contacts that make contact with the part of the brain that we hope to stimulate in order to address the patient’s symptoms and as you might imagine; the position in the brain that we stimulate anatomically, determines the effect and the success or failure of the operation is completely dependent on delivering the electrical currents exactly where we want to deliver it and perhaps just as importantly, not delivering electrical currents to other structures or other circuitry surrounding the circuitry that we know we can stimulate for the patient’s benefit.
So, a big part of this operation is an investment in making sure that the DBS lead and those electrical contacts end up exactly where they need to be to help the symptoms. If they are a couple of millimeters in one direction or the other; then you may get stimulation induced side effects that are intolerable instead of the relief from your tremor or in the case of Parkinson’s Disease suppression of your dyskinesia or relief from stiffness and slowness and muscle cramping.
So, getting the DBS lead in precisely the right position and then programming to adjust where that current is going and how powerfully it gets there is the process that we use to delivery therapeutic stimulation and have what can be really dramatic effects on people’s symptoms and quality of life.
Host: Well thank you for that answer. Dr. Okun, how have been your outcomes? Have you seen sustained improvement in motor function and a reduction maybe in antiparkinsonian medication? Has that been stable? Have you seen any adverse effects of treatments? Tell us a little bit about your outcomes.
Dr. Okun: So, I think one of the most important lessons of running a really high quality deep brain stimulation program is making sure that you have both the right preoperative screening, that you do the procedure in a very careful way because the real estate in the brain matters. So, it matters whether you are a millimeter or two off can be like the distance between Florida and California. And so, it’s really important to get the leads in the right place but then maybe most important is to make sure you have the right team in place to follow the patients and so the follow up of these patients includes not only programming the device and so everybody thinks about okay you have this really fancy device that you’ve implanted, it’s going to be all about programming. But a lot of these patients have diseases like Parkinson’s Disease and so long term, it’s not just the programming of the device but it’s also management of the medications.
Now when the procedure is done and it’s successful which in most cases, it is and in fact, in almost all cases, it should be successful with low side effects and that’s part of the interdisciplinary screening process. So, part of the process of seeing all these people from different disciplines and assessing the risk and making sure that you are taking the right approach and you have the right follow up for patients ensures that you are going to have success in most of these cases.
Now can you get side effects, and can you get complications from deep brain stimulation? You certainly can and the ones that we worry the most about are bleeds or strokes because remember we might be pushing through a brain region and accidentally or unintentionally hit something that we don’t want to hit, and we worry about infection. Because we are putting a device into somebody and that device doesn’t have a blood supply so if maybe a little bit of dirt gets on that device or a little bit of bacteria gets on there; we don’t have the blood supply that even if we take antibiotics, we can clear that and so those are two of the things that happen less than 5% of the time. So, usually a few percent of the time in most major centers that do a lot of these procedures.
And so we watch out for that. Now in terms of motor benefits; it can be life changing. So, if you’re a Parkinson’s patient; it might capture your tremor and so it’s very good with tremor, it’s very good for another movement disorder called dyskinesia which are these extra dance like movements that you get from taking dopamine replacement therapy called levodopa. It’s very effective at suppressing those extra movements. It also improves the quality of life by doing things like reducing the amount of stiffness that you have and improving your speed of movement or your slowness of movement that happens with Parkinson’s and so you get to be faster and so you can do your activities of daily living in a faster way that you couldn’t do before because the movement was so slow and so labored.
And then many of our Parkinson’s patients, the meds are wearing off after a few hours and coming back on and so we call these fluctuations where the meds are wearing off and then as they wear off you get tremors, stiffness and slowness. And so you can imagine going through cycles of being on your meds and off your meds and one of the great things about deep brain stimulation is it really does smooth out those on and off fluctuations. And so, in summary, we think about improvements in tremor, we think about improvements in that other movement disorder caused by the medicines called dyskinesia and then stiffness and slowness improve and then these fluctuations that go up and done that can really make life difficult for patients.
And then finally, the other thing is that some patients but not all will also have a reduction in the medications that they take.
Dr. Foote: I would add that one sort of nice way to think about it is that deep brain stimulation does not cure Parkinson’s Disease. It doesn’t even necessarily make someone dramatically better than they are when they are at their best on their medications. But what it does quite nicely is get people at or near their best level of functioning and keep them there much more of the time. So, alleviating those motor fluctuations is one of the main indications for deep brain stimulation. And in most cases, as Parkinson’s Disease progresses, it becomes increasingly difficult even for very good movement disorder specialists to adjust the medications well enough to avoid those motor fluctuations because it gets more and more difficult as the disease progresses.
And so at some point, deep brain stimulation can have a beneficial effect in that regard.
Host: Dr. Foote, before we conclude this episode; tell us about some promising new therapies in regards to tremors and deep brain stimulation for other providers. Let them know what’s exciting in your field of neurosurgery and why you think it’s important that they refer to the specialists at UF Health Shands Hospital.
Dr. Foote: Well, there are a couple of different directions I could go with your question. The question about why I think it’s important to send patients to a place like UF Health Shands Hospital has to do with the specialization that is very effective. We talked about that interdisciplinary team approach and I think until you see it in action; it’s hard to appreciate how important that can be in making sure we get the optimal outcome. We have eight different specialists with various areas of expertise who are all let’s say we are dealing with a Parkinson’s patient. Each of these specialists is a Parkinson’s expert but they might be a physical therapist or an occupational therapist or a psychiatrist or a neuropsychologist, but all of these folks are focused on Parkinson’s Disease and know all the nuances of Parkinson’s Disease within their area of expertise.
So, they are Parkinson’s specialists but just as importantly, they are also deep brain stimulation specialists. And each one of them has evaluated hundreds of patients before and after deep brain stimulation and they have this wealth of understanding that they can share with me as we are making decisions. Let me give you an example just to illustrate what I’m talking about. Perhaps the Parkinson’s specialist who is a speech pathologist who focuses on speech and swallowing does her evaluation of a patient prior to surgery and says, you know what, this patient is aspirating. They have a dysfunctional swallow and they don’t even realize that some of their food is getting into their lungs and they are at high risk for getting pneumonia. And one of the possible temporary side effects of deep brain stimulation just from a little swelling in the brain around the DBS, the implanted DBS lead is that it can impair your swallowing function temporarily.
And so if we know that in advance; then the speech pathologist might in our meeting when we are talking about this patient’s case; say, heh you know what, this patient has this issue and in my experience with other patients like this, when we’ve done the deep brain stimulation operation this way, when you stimulate in this target; it turns out better than when you stimulate in this target and it’s a lower risk of having postoperative problems. And by the way, I think as a precaution, immediately after the operation, I want you to call me and I will come evaluate this patient’s swallowing function before you start giving the patient something to eat and drink just to make sure that we don’t cause a pneumonia during the hospitalization.
So, that’s one example. But I could give you 50 different examples of how this interdisciplinary approach can alter – it’s not just making the decision should this patient have a DBS operation. But how should we do the operation for this specific patient in order to maximize the predicted benefit and to minimize all of the risks and all different domains. And that infrastructure, I think is what makes a center like ours special and allows us to as Michael said, we expect essentially every patient who goes through this process of careful patient selection and tailoring the operation to their given needs and their risks; we expect every patient to have a good outcome and the patients who have bad outcomes should be very few and far between.
Host: Dr. Okun, please conclude for us what can a referring physician expect from your team after referral in so far as communication and your team approach. Just kind of summarize for us.
Dr. Okun: Yeah so, after referral to UF Health Shands Hospital, we consider ourselves to be partners with everyone. We see patients from every continent except for Antarctica. We haven’t had a patient from there but we’ve had patients from all over and so, our job is really to help to restore people’s lives and to make things easier for the referring docs and so if they need some help in evaluating a patient for deep brain stimulation and going through the process; we are happy to provide that help if the patient needs surgery and would like to be managed back in his or her community. Whether that’s locally, regionally, across the pond meaning in Europe or Australia or somewhere else; we work with physicians all over the world.
And so, out job is to really try to impact lives and try to help people with symptoms that can be modulated by this really cool and unique therapy and the number of indications for the therapy keep growing and we do a lot of research too. And so, we are involved in a lot of National Institutes of Health and other studies for other indications so not just Parkinson’s and tremor, but we operate on dystonia and obsessive compulsive disorder and Tourette’s Syndrome and so, the expectation from our end is how can we help. We are here to help. The answer is always yes. Not everybody is a surgical candidate but certainly if you can benefit from a surgery; we want to see what we can do to help you. And we also want to return you back to your communities and make it easy for management to happen there locally as well.
And so, we’ve really enjoyed the partnership we’ve had with various physicians and health practitioners all over the world.
Host: Thank you gentlemen for joining us. What a fascinating topic. Thank you so much for sharing your incredible expertise today. And that concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs, please follow us on your social channels. I’m Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs010.mp3
- DoctorsCrispen, Paul
- Featured SpeakerPaul Crispen, MD
- Guest BioPaul Crispen, MD, is board-certified in urology. He earned his medical degree and completed his urology residency at Temple University School of Medicine in Philadelphia and completed his fellowship in urologic oncology at the Mayo Clinic in Rochester.
At University of Florida Health, he is the associate chair of clinical affairs and an associate professor of urology. Dr. Crispen specializes in the treatment of cancers involving the kidney, bladder, testis and penis. His clinical interests focus on the surgical management of renal and bladder cancer, including minimally invasive techniques. He has extensive experience with bladder removal surgery and urinary diversion. While Dr. Crispen’s practice focuses on the surgical management of urologic malignancies, he places emphasis on multidisciplinary cancer care involving medical and radiation oncologists.
His research focuses on improving the evaluation and treatment of patients with urologic malignancies. Dr. Crispen is an advocate for enrollment of patients in clinical trials to enhance their own care, in addition to providing essential information for prospective patients who may benefit from such treatment in the future.
Dr. Crispen is an active member of the UF Health Cancer Center, and serves as the research leader for the Genitourinary Disease Site Group as well as chairman of the Scientific Review and Monitoring Committee. - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome. I’m Melanie Cole and today we’re talking about bladder preservation. We’re examining current indications for radical cystectomy when treating bladder cancer. We’re going to discuss BCG refractory disease and treatment options outside of radical cystectomy and patient and tumor characteristics that are associated with improved outcomes. Today with me, is Dr. Paul Crispen. He's an Associate Professor of Urologic Surgical Oncology at the University of Florida and he practices at UF Health Shands Hospital in Gainesville. Dr. Crispen, it’s a pleasure to have you join us. Please let’s start with the prevalence of bladder cancer and the incidence, the burden; tell us a little bit about this particular type of cancer.
Paul Crispen, MD (Guest): Bladder cancer is very prevalent in the United States. It’s the fourth most common malignancy in males and it’s in the top ten in females in our area around UF Health Urology. So, we have a lot of interest in this disease and would like to do a lot more better to improve the outcomes. The average age of patients that are diagnosed currently is 73 years old in the state of Florida. And there are going to be about 80,000 new cases of bladder cancer throughout the year in the United States.
Now when patients, when we first diagnose them with bladder cancer, the majority are going to have localized disease or stage one disease and then the other 30 to 40% of patients are going to have more locally advanced or even metastatic disease based upon their presentation.
Host: Well thank you for opening with that Dr. Crispen. So, help us to understand the current indications for radical cystectomy when treating bladder cancer and some of the outcomes associated with neoadjuvant chemotherapy.
Dr. Crispen: There are two main groups of patients who have indications to undergo bladder removal surgery. The first of which, are patients who have stage one bladder cancer that have not responded to standard therapy and that standard therapy is BCG in the United States. And those patients, the reason we move to cystectomy is really they have poor treatment options once we see that BCG is ineffective. And so, when we look at the medications or the current therapies beyond BCG currently, they are very limited with most having less than a 20% success rate at one year, thus a lot of these stage one patients will be offered cystectomy immediately when we consider them BCG refractory.
The second population of patients which are commonly recommended to undergo bladder removal surgery or cystectomy are those who are presenting with stage two and three disease. And that’s defined as patients where the cancer is invading into the deep musculature of the bladder or just going into the fat around the bladder and can be also in the lymph nodes in the pelvis.
For patients who have metastatic disease, we do not typically recommend bladder removal surgery. Now, with these patients, we expect the long term outcomes in patients with the stage one indications or the BCG refractory indications to do very well long term in terms of survival and we’d expect a high cure rate associated with those patients with the bladder removal surgery. Unfortunately, in the patients with stage two and three disease; those patients have a potentially deadly cancer where most patients who undergo even maximal therapy may not live beyond five years.
And that brings us to your question of neoadjuvant chemotherapy. We do know that if we give patients chemotherapy, usually it’s about three to four months’ worth before their surgery, they will have improved survival compared to patients who do not undergo chemotherapy. This improvement in survival can be quite dramatic. If you look at some of the clinical trials that evaluated this, if a patient on average would have just the bladder removal surgery alone; their average life expectancy would be about four years. If they get chemotherapy first, that could extend their life expectancy by about one and a half to two years. And so that’s the real important piece about neoadjuvant chemotherapy and when we like to give it while we can with our medical oncologists because we know patients will do better in the long run. It’s more treatment up front, however, I think the outcomes justify it.
Now with the neoadjuvant chemotherapy, the patients who do the best, are the ones when we take their bladder out after the chemotherapy; that they have no residual disease left in their bladder. And that’s something we have to be upfront with with patients right away. We have to prepare them to know we could take out their bladder and then they go – when we get the pathology report back, there’s no evidence of cancer, and that will often lead to patients saying well why did you need to take my bladder out if we got rid of it with the chemotherapy?
That’s how well the neoadjuvant chemotherapy can work. And that will happen in about 30 to 40% of patients who receive neoadjuvant chemotherapy prior to cystectomy.
Host: Wow that is so interesting Dr. Crispen. So, then based on what you just said, tell us about bladder preservation. When is this indicated or contraindicated? And tell us about the cancer-free and overall survival of patients in these populations.
Dr. Crispen: Certainly and again, I’ll start with the two separate populations. The BCG refractory stage one patients, then move on to the muscle invasive cancer patients. And so, for the stage one patients, we would like to avoid the bladder removal surgery as much as we can because we know that bladder removal is extremely complicated both short term and long term. And so, some of those immediate complications would be bleeding, infection, high 30 day readmission rates and it can also have very long term complications as well impacting patient’s quality of life. Some patients can have recurrent urinary tract infections, have a tremendous impact on their sexual function and their ability to work.
And so, when we look at all of these things when we talk to patients, it’s a really big deal. Especially if they have the BCG refractory stage one disease. And so for what it means in those patients, bladder preservation therapy would be discovering new medications or new techniques to replace BCG and to replace cystectomy all together. And that can be putting the medications directly into the bladder or putting medications into the vein where they go systemically. But again, as I pointed out earlier, these current medications are very limited with a low likelihood of success, however, they can be used to preserve the bladder in patients with this low stage disease. However, unfortunately, they are just not that successful at this time.
In regard to muscle invasive bladder cancer, there are several different options for those patients for bladder preservation. Those would include something called trimodal therapy where we combine maximal endoscopic resection and then concomitant chemotherapy and radiation therapy which is given over a six week period. And that’s probably the best form of bladder preservation therapy we have.
Other options would include maximal endoscopic resection, or chemotherapy alone.
Host: Well thank you for that explanation. So, as we’re talking about radical cystectomy, why is this one of the most challenging procedures performed by urologic surgeons and does it carry with it, significant risks of complications, hospital readmissions, things like that?
Dr. Crispen: Yes, absolutely. And that’s why I always tell my patients when counseling them about bladder removal surgery or cystectomy, that it’s a surgery that I do often, and I enjoy doing but only do it when it’s absolutely indicated because it has such a tremendous impact on a patient’s life. Now, the surgery is complex, however, there’s a very low mortality rate associated with it. And so, the surgery itself isn’t risky in terms of taking a patient’s life, but there are as you stated, multiple complications can occur commonly in patients.
If you look at for example, if you would look at the national rate of blood transfusions at the time or immediately after a cystectomy; it’s anywhere from 30 to 40%. And also, there’s a high rate of patients needing to go back and have secondary procedures to correct problems that were missed or occurred at the time of the first surgery. And as you alluded to, there is a high 30 day admission rate, up to 30% of patients will be readmitted after their discharge within 30 days of their hospitalization.
In regard to what makes the surgery this complex; most of these complications aren’t related to the bladder removal portion of the surgery; they are usually related to the portion of the surgery what you call urinary diversion where we have to use a segment of the patient’s bowel to eliminate the urine from their body after the surgery.
Host: It is such an interesting topic Dr. Crispen and when you discuss the surgery itself, yes, so complicated; so what is the role of BCG in bladder carcinoma in situ treatment and when you’re discussing that, tell us what BCG refractory disease is and some of the treatment options that you might consider outside of radical cystectomy.
Dr. Crispen: Certainly and so, for carcinoma in situ of the bladder, when patients first present with that, BCG is the best treatment we know for those patients. When you look at patients with a carcinoma in situ, their recurrence rate after a endoscopic resection, depending upon your series is going to be 70 to 90% of those patients are going to have the cancer come back. BCG is our best way of controlling that after their initial surgery, however, it only cuts that chance of recurrence in half. And so, if patients have an 80% chance of having the recurrence without the BCG; with the BCG, it only drops that to 40%.
So, we define BCG refractory disease based upon the total amount of BCG treatments a patient has received in their treatment course. So, all patients will have to have at least six weeks of induction BCG and if they recur then; they can get another six weeks of induction BCG before they would be considered BCG refractory. Another common definition of BCG refractory disease is if a patient would have the cancer come back after the initial six week induction course or another three weeks of maintenance therapy. If the cancer would come back within a set time.
Now the importance of this BCG refractory definition cannot be understated and having the key to understanding of what someone needs to become BCG refractory is very important because of the clinical trials being done out there which can give patients another option before going to cystectomy. But these definitions are very rigid for enrollment and so if the BCG isn’t given according to standard guidelines; patients may miss out on bladder preservation being offered through a clinical trial.
In regard to the options outside of going straight to bladder removal surgery in these patients with BCG refractory disease and particularly carcinoma in situ; there are a number of options for them, all of which involve the placement of chemotherapy directly into the bladder. Those chemotherapeutic agents include valrubicin, mitomycin, gemcitabine, thiotepa, docetaxel and there’s others I could add onto the list. And there’s others I could add onto the list. And so, while there’s a large number of those that can be offered; unfortunately, they do fairly poorly again, with success rates at one year of keeping the cancer at bay being less than 20%.
And so, often, patients will try that next step before going on to bladder removal surgery. However, those other options are not very durable at this point.
Host: Good points Dr. Crispen. So, let’s talk a little bit about patient selection. What patient characteristics are important when you are considering improved outcomes with that trimodal therapy for muscle invasive bladder cancer. Tell us how careful patient selection and extensive counseling are paramount to your successful intervention.
Dr. Crispen: Certainly. Yeah, it’s very important to get it right the first time with these treatments. Because secondary treatments can be more complex and so patient selection up front is critical. If we look at a patient to be considered for trimodal therapy; we know that there are certain tumor characteristics that will select patients for the best outcomes. And those would be only having a single tumor in the bladder that can be completely resected, not having carcinoma in situ in the bladder, not having any hydronephrosis or swelling of the kidneys, not having any variant histology on their bladder cancer. So, bladder cancer can come in different types and the pure bladder cancer or pure urothelial carcinoma tend to do better.
And so, when a patient has all of those options, certainly trimodal therapy is an excellent alternative for them compared to bladder removal surgery. However, we know that the recurrence rates in patients who even have been well selected, the recurrence rates of the bladder cancer can be 50 to 60%, at which time, we’d have to look at other agents like bladder removal surgery despite our initial attempt to keep the bladder in place.
Host: What about the tumor itself Dr. Crispen? What characteristics are associated with improved outcomes in that regard?
Dr. Crispen: Volume of disease, certainly has a lot to do with it. The more tumor we can resect and clear with the scope before they get chemotherapy or trimodal therapy; we know that will improve outcomes. There is evidence that tumors with certain genetic mutations will be more sensitive to chemotherapy and for those patients; there’s currently trials available including one here with UF Health Urology where if a patient has specific mutations within their tumor; and we believe that they will have a complete response based upon that; we can enroll them in the trial to see if we can give them chemotherapy and then not have to take their bladder out or not have to give them radiation as part of their treatment of their muscle invasive bladder cancer.
Host: Well as long as you brought up trials, doctor, tell us about some ongoing research being evaluated to improve bladder preservation therapy in patients with BCG refractory disease and muscle invasive disease. What research is going on? What would you like other providers to know that you are doing there?
Dr. Crispen: Certainly. And so, we kind of have a top down approach for trying to improve our outcomes with patients with bladder cancer. And that starts really in our labs. Part of a lab where I collaborate with, with Dr. Serge Kusmartsev, we are looking at things in the petri dish and in animal models trying to look at the tumor microenvironment or the way that the tumor or the cancer impacts cells around it, impacts the fluid around it to kind of push the immune system away or turn off the immune system at the level of the tumor. And we do know that immunotherapy can be successful in bladder cancer but it’s only successful for about 30% of patients and so what our research is looking at is looking at ways that we can change the tumor microenvironment, increase our understanding to then make these cancers more susceptible to currently available immunotherapy.
Now while this type of research is in its very early stages and we’d be years away from being able to actually treat patients with these types of techniques that we are evaluating; we do have multiple clinical trials open for patients with both the stage one BCG refractory disease and for those patients presenting with muscle invasive disease. And so, with our patients with the stage one disease; one of the obvious ways that we would think to try to improve that is avoiding patients for becoming BCG refractory. So, is it giving better BCG, is it improving a patient’s immune system prior to giving them BCG so they have an improved response rate.
Currently, we are involved with a nationwide trial which we’ve been very good in. It will be over 900 patients at which we are one of the top three accruing sites to this trial where we are looking at bringing in a new type of BCG into the United States and helping to improve outcomes for all patients and helping to improve the availability of BCG to all patients. And so, that’s one method where we are trying to actually just prevent the patients forever needing to be considered for a cystectomy.
Another option we have for these patients is avoid offering patients unique treatments when they really are BCG refractory. We’ve been involved in a number of clinical trials there looking at immunotherapy that’s given systemically through an IV infusion and these medications have been shown to be very successful in patients with advanced bladder cancer. We’re just trying to move that type of therapy early in their treatment to try to keep their bladder in place.
Another fascinating area for clinical trials and what’s being used in bladder cancer now are the trials that we’ve helped complete in looking at putting an adenovirus, an altered adenovirus or the common cold virus in someone’s bladder, having that virus infect the cells of the bladder, then make those cancer cells kill themselves or secrete products that will lead to their death and be able to keep these patients away from having their bladder removed.
In regards to our clinical trials for muscle invasive disease; we look to again, improve current therapies by offering additional therapy after trimodal therapy. So, instead of getting that 50 to 60% chance of the cancer coming back after standard trimodal therapy; trying to offer additional medications after they have completed their radiation therapy to decrease that chance of recurrence maybe even as much as 25%.
And again, I mentioned one trial a little earlier where we are looking to avoid having to perform bladder removal surgery in patients who have a complete response to chemotherapy and developing other markers which can predict that complete response to help patients avoid cystectomy.
Host: So, exciting. Absolutely fascinating. Dr. Crispen as we wrap up, do you have any final thoughts or information you would like other providers to know about the bladder preservation program and what you are doing there at UF Health Shands Hospital?
Dr. Crispen: Certainly. I think that there’s other ways that we could improve our treatment of bladder cancer and again, within standard therapies, even outside of clinical trials; the one thing is just for us to do as best job we can to treat these patients up front. And example again, would be optimizing treatment in patients with stage one disease so they do not develop BCG refractory disease or not progress to muscle invasive disease. We always are looking at our quality and one quality measure is to make sure that patients get the proper chemotherapy placed in their bladder after their endoscopic resections because we know that that can decrease bladder cancer recurrences in the future.
And again, if you look at national numbers for the use of that type of what I consider standard therapy; less than 25% of urologists are using that routinely throughout the country and our rates are well over 70%. And again, that’s just our dedication to really try to avoid the need for bladder removal surgery.
Another, I think important component of this is keeping up with widely available technology. There’s new technology that has been approved for the last year for use in patients with a stage one bladder cancer called Blue Light Cystoscopy and we’re happy to be able to offer that to our patients with UF Health Urology. And what that technology consists of is us putting the medication in the bladder so when we look in the bladder with a cystoscope; we are going to be able to detect tumors with greater sensitivity. And studies have shown, when you use that on a routine basis; the time to recurrence increases and the total amount of recurrences decrease as well. So, again, that’s part of our strategy of doing the best job we can to get to the point we never even have to discuss bladder removal surgery with a patient.
Host: It is such an interesting topic. Dr. Crispen, thank you so much for great information. That concludes this episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about cancer clinical trials available at the UF Health Cancer Center, please visit www.ughealth.org/navigator. And to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital Podcasts. Until next time, I’m Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs009.mp3
- DoctorsRamnaraign, Brian;Hitchcock, Kathryn;Crispen, Paul
- Featured SpeakerBrian Ramnaraign, MD | Kathryn Hitchcock, MD, Ph.D. | Paul Crispen, MD
- Guest BioBrian Ramnaraign, MD is an assistant professor of medicine in the division of hematology and oncology at the University of Florida College of Medicine.
Learn more about Brian Ramnaraign, MD
Kathryn Hitchcock, MD, Ph.D. is an Assistant Professor, department of radiation oncology, University of Florida.
Learn more about Kathryn Hitchcock, MD, Ph.D.
Paul Crispen, MD, is board-certified in urology. He earned his medical degree and completed his urology residency at Temple University School of Medicine in Philadelphia and completed his fellowship in urologic oncology at the Mayo Clinic in Rochester.
Learn more about Paul Crispen, MD - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome. I’m Melanie Cole. And today we’re discussing the multimodal approach for treating bladder cancer. We will recount the natural history of bladder cancer and the most common path experienced by patients. We’ll explain the treatment options available to patients with muscle invasive bladder cancer, when each are appropriate and what approaches clinicals are attempting to bring in and we’re going to describe the experience of patients after cystectomy or bladder preservation and the cancer-free and overall survival of patients in these populations.
In this panel discussion today we have Dr. Kathryn Hitchcock. She’s an Assistant Professor in the Department of Radiation Oncology at the University of Florida. And Dr. Brian Ramnaraign. He’s an Assistant Professor of Medicine in the Division of Hematology and Oncology at the University of Florida and Dr. Paul Crispen. He’s an Associate Professor of Urologic Surgical Oncology at the University of Florida and they all practice at UF Health Shands Hospital in Gainesville.
Dr. Ramnaraign, I’d like to start with you. Please tell us about the natural history of bladder cancer. What’s the disease incidence and burden?
Brian Ramnaraign, MD (Guest): So, thanks for the question Melanie. Bladder cancer is actually one of the more common cancers of the genitourinary tract. It’s commonly seen in older men with a history of smoking. But it can happen really, in anyone of any age. Usually the patients present with blood in the urine and it’s usually a painless hematuria as we call it. And when patients present with these symptoms; it can be really multiple causes including having a kidney stone or even having a urinary tract infection. But usually at this time they would come and present to their primary care doctor or urologist who would do further testing including maybe a CAT scan or cystoscopy which Dr. Crispen I am sure will go into a little more detail. And at that time, we may see a tumor in the bladder which we may biopsy and which should return back as positive for cancer. And then from there, of course, further workup.
Host: Dr. Hitchcock, most people consider bladder cancer to be treated only by urologists but today, I’m joined by the three of you, different areas of providers. How important is this multidisciplinary care model for this type of cancer and specifically for patients with muscle invasive disease? How does the emphasis on a multidisciplinary approach change the patient’s treatment options and therapy received?
Kathryn Hitchcock, MD, PhD (Guest): I’m so glad you asked about that. That is something that’s changing pretty rapidly and even during my career, looks completely different than it did at the beginning. As late at the 1990s, my specialty radiation oncology didn’t come into bladder cancer treatment very much except in very advanced stages where it was used for palliation. These days, there’s a much greater emphasis on the trimodal approach to bladder cancer and for many patients, we are able to spare their bladder, keep it as a functioning organ and the way to do that is by treating it with radiation therapy as well as chemotherapy in patients who in an earlier era would have had their bladder surgically removed.
Host: Well Dr. Hitchcock, sticking with you, tell us about your role in bladder cancer care. As you are a radiation oncologist, tell us what you are doing specifically.
Dr. Hitchcock: So, for patients who are appropriate to keep their bladders, who have muscle invasive bladder cancer; I work closely with a doctor like Dr. Ramnaraign in medical oncology to give concurrent chemotherapy and radiotherapy to the bladder and to the lymph nodes of the pelvis.
Host: Dr. Crispen, let’s talk about clinical presentation and diagnostic criteria as well. What are some valuable prognostic tools to aid in early diagnosis? Tell us how important is accurate diagnosis, staging and grading.
Paul Crispen, MD (Guest): It’s extremely important. That’s an excellent point to bring up. Without accurate staging and grading in these patients, we will not be able to offer them the appropriate therapy or even all of the therapies offered within the appropriate stage after it’s identified. As you also commented on the diagnosis, one important point that Dr. Ramnaraign brought up is when patients are evaluated for say blood in the urine or hematuria; unfortunately, we will see a lot of women presenting with more advanced stage because their hematuria is credited to a urinary tract infection as opposed to having a cystoscopy done to make the diagnosis of bladder cancer.
Once we have a patient where we highly suspect bladder cancer; we perform a cystoscopy, look in the bladder and if we see a tumor, we will then remove it with the scope. That scope procedure gives us very valuable information about a patient’s stage but also, they’re candidacy for treatment, more importantly as with this discussion, the potential treatment with radiation therapy and chemotherapy as Dr. Hitchcock and Dr. Ramnaraign are discussing. One important part about this resection, is it needs to be complete. We want to remove all the visible tumor within the bladder. We know that that will increase the chance of a patient having a successful radiation and chemotherapy treatment.
In fact, that’s so critical that once we identify these patients with Dr. Ramnaraign and Dr. Hitchcock at UF Health Shands Hospital; we always take these patients back for a repeat resection and resect more tissue to do everything we can to make sure the bladder is as clean as possible for the radiation therapy. In addition to that, we will often put markers in the bladder to help Dr. Hitchcock focus additional radiation to the spot where we removed the tumor. And so this initial diagnostic step gives us valuable information for patient treatment selection and as you alluded to, even prognosis. As we know that there’s patients that we’ll find specific pathologic features on their tumor that won’t make them good candidates for trimodal therapy.
Host: Well along those lines then, as he’s talking about candidates for trimodal therapy, Dr. Ramnaraign, how does careful patient selection and extensive counseling, how are they paramount to successful intervention? Tell us a little bit about patient selection criteria.
Dr. Ramnaraign: So, that’s a really great question Melanie. The most important thing is that whenever we have one of these new patients, we always have a multidisciplinary discussion with our colleagues in all these fields, Dr. Hitchcock in radiation oncology and Dr. Crispen in Urology to determine whether or not a patient is a good candidate for bladder preservation or whether or not they have to undergo a cystectomy and have the bladder removed. There are a lot of factors that might influence one decision over the other and that would include the size of the tumor, the location of their tumor, if there’s any obstruction and hydronephrosis which is a swelling of the kidney related to the tumor. So, there’s multiple reasons why a patient might chose – why we may choose one option over the other.
Dr. Crispen: And I would just like to add another point here, is that despite with these known selection features as Dr. Ramnaraign is pointing out; unfortunately, very few patients nationally are offered this type of therapy. And if we look at large data series, less than five percent of patients are being offered this bladder preservation approach with the chemotherapy and the radiation therapy. And I think one of the reasons that is is patients are not being evaluated by doctors like Dr. Ramnaraign and Dr. Hitchcock upfront. They are only seeing those specialists following their bladder removal surgery which at that time, it’s too late.
Dr. Hitchcock: I’d like to also add that part of the selection of patients is related to their age. Many patients who are diagnosed with bladder cancer are senior citizens. They may have some other health issues going on that may not make them the best candidates for one therapy versus another and although before I saw it myself, I might not have predicted it; radiation therapy even at the same time as chemotherapy is surprisingly gentle, even fairly elderly patients who maybe aren’t at their best performance still get through the treatment pretty well. They don’t have a lot of pain. It doesn’t really affect their quality of life very much and so it can be a really good treatment that keeps them from starting down a bad path health wise.
Host: Well then Dr. Crispen, explain bladder preservation for nonmetastatic muscle invasive bladder cancer and tell us a little bit about some of the current population outcomes and ongoing studies for these patients.
Dr. Crispen: So, when we look at all choices of bladder preservation therapy; we have multiple modalities to choose from. You could look at a partial cystectomy or partial bladder removal surgery, a maximal endoscopic resection, chemotherapy alone or radiation therapy alone. However, the one bladder preservation therapy that works the best, that has the best data and that is our modality of choice at UF Health Shands Hospital is trimodality therapy which includes maximal endoscopic resection by a urologist, and then combined chemotherapy and radiation therapy with doctors like Dr. Ramnaraign and Dr. Hitchcock. With a carefully selected patient, and appropriate treatment; we see excellent outcomes here at our center. As with and is also documented at other centers which – and these outcomes approach those seen with bladder removal surgery. And that’s again in appropriately selected patients.
So, when we have a combined approach, we have multiple specialist involved; we can get the same results and the same survival as we do with bladder removal surgery. And in terms of percentages; what we’re looking at percentages in the 60 to 80% overall and cancer-free survival at five years in these patients.
Host: That’s fascinating. Dr. Ramnaraign, for patients that are undergoing cystectomy as Dr. Crispen was discussing, and you’re talking about preferred regimens for neoadjuvant or adjuvant chemotherapy in balder cancer; have there been trials demonstrating that neoadjuvant chemotherapy before removal of bladder does improve patient outcome? Is that something that’s going on right now?
Dr. Ramnaraign: So, we’ve studied this question in the past and it has been shown that neoadjuvant chemotherapy before cystectomy does improve outcomes and does improve overall survival. So, it is the standard of care now for us to prescribe neoadjuvant chemotherapy before cystectomy. And with regards to neoadjuvant chemotherapy; there are two choices that we have. One is a combination called MVAC which is four treatments and then there is a treatment called gemcitabine with some cisplatin. And here at UF Health Cancer Center, we prefer to give gemcitabine and cisplatin because it’s better tolerated than the MVAC treatment.
Dr. Crispen: I would also just like to add to Dr. Ramnaraign’s points that despite this overwhelming evidence that the neoadjuvant chemotherapy prior to bladder removal surgery is out there. It’s been out there for over 13 years now. Only about 30 to 40% of appropriate patients nationwide receive that type of therapy. And that can be for a number of reasons, but I suspect it may just be from patients not being offered their treatment and being evaluated in multidisciplinary care clinics as we have here. in fact, when we look at our rates of neoadjuvant chemotherapy use at UF Health Shands Hospital; our rates of neoadjuvant chemotherapy per use in select patients is 60 to 80% depending upon which year we look at.
Host: That is so interesting. Dr. Hitchcock, give us an example as we’re talking about all of this and putting it together to this multimodal therapy; give us an example of work you’ve done together.
Dr. Hitchcock: The most important work that we’ve done together is what Crispen described just a moment ago and that is working toward true trimodality therapy and even in cases where that’s not appropriate, true trimodality assessment of the patient before any major steps in their treatment are done, that’s an ongoing process. At UF Health Shands Hospital is a big medical center and it takes getting a lot of people on board into a system like that. But we’re meeting with a lot of success here and I think that other facilities, other practitioners could get in touch with us if they’d like to hear some tips about how to make that work.
Host: Well I think that is one of the most important points of a podcast like this, is for other providers to be able to see this multimodal approach that you are doing there at UF Health Shands Hospital. Dr. Crispen, how do you envision your research translating to patient care? As we start to wrap this up, what would you like other providers to know about the exciting technology and changes and advances in bladder cancer and bladder preservation?
Dr. Crispen: Well, we have a special interest in bladder preservation therapy at UF Health Shands Hospital. And that involves all of our cancer providers, chemotherapy, radiation therapy and surgical therapy. And with this, we are trying to have every possible clinical trial available to our patients to try to increase the number of patients who can undergo bladder preservation therapy and improve the success of patients who are undergoing select types of bladder preservation therapy.
I can give you two examples of this. We’ll start with the one with trying to improve on our success of trimodal therapy is one particular trial where patients will under go the standard trimodality therapy as we offer all patients who are appropriate but then offer them additional therapy after they’ve completed their radiation to further decrease the chance of the cancer coming back.
Another example is in patients who may be going down the path for bladder removal surgery is that we give them chemotherapy with Dr. Ramnaraign and his partners in medical oncology and then evaluate those patients for specific mutations within their tumor. And in patients with select tumors, we’ll then evaluate for a complete treatment response and if they would have a complete treatment response, based upon their chemotherapy alone; we would follow them closely and avoid bladder removal surgery all together in those patients.
And so, those are just two examples of our current trials and we’ll evaluate other trials in the future to make sure we’re doing everything we can to avoid the need to remove bladders in these patients.
Host: Dr. Ramnaraign, do you have some final thoughts on bladder cancer and the multimodal approach that you are doing there at UF Health Shands Hospital and what you’d like other providers to know about referral.
Dr. Ramnaraign: So, I think the most important part about bladder cancer care is that there really should be a multidisciplinary approach towards managing these patients. I think it’s really important for patients to see a urologist like Dr. Crispen, a radiation oncologist like Dr. Hitchcock and a medical oncologist such as myself in order to make sure that they are getting the appropriate care and that they are being evaluated by all the physicians who may or may not play a role in their care in the future. And here at UF Health Shands Hospital, we are planning to start a multidisciplinary clinic where patients can come in and in one day see all three of us as opposed to having three separate clinic appointments. So, the most important thing is that it’s a teamwork and it takes a team to manage a patient with bladder cancer or any kind of bladder cancer.
Host: Well absolutely it does. And Dr. Hitchcock, last word to you. What would you like other providers to know about this multidisciplinary care and how important it is for their patients that they are referring that you have this ability to work together and that you are doing fascinating clinical trials and really advancing the field of bladder cancer.
Dr. Hitchcock: Well I guess when I think about the big picture here, I think about my grandparents’ generation that included people who went from driving horse drawn carriages to seeing people in outer space. We are experiencing exactly that kind of surgeon technology in the medical world right now. And it would be a real shame for patients not to have access to the best that our modern technology can offer. The best way for that to happen as we’ve said, is for all of the different physicians on the team to be able to contribute and make their recommendations. And so, I would just encourage doctors in other places who are thinking about referring patients to really get in touch with the people they are referring to if they want to refer their patients for multimodality care, make sure that they are sending them to a facility that practices treatment in this way for bladder cancer.
Host: Thank you so much doctors, for joining us today, sharing your incredible expertise and what an exciting time for you to be studying bladder cancer and bladder preservation in this multimodal approach. Thank you again for joining us. This concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about cancer clinical trials available at the UF Health Cancer Center, please visit www.ufhealth.org/navigator and to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates please follow us on your social channels. Until next time, I’m Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs004.mp3
- DoctorsMachuca, Tiago
- Featured SpeakerTiago Machuca, MD, PhD
- Guest BioTiago Machuca, MD, PhD, is an assistant professor of surgery at the University of Florida College of Medicine. Dr. Machuca joined the division of thoracic and cardiovascular surgery after completing clinical fellowships in thoracic surgery and lung transplantation at the University of Toronto, the premiere center in the world for his specialty. He was also a postdoctoral research fellow at the Latner Thoracic Surgery Research Laboratories at the University of Toronto.
Learn more about Tiago Machuca, MD, PhD - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): The use of robotic assisted techniques is growing fast in several surgical disciplines, now including thoracic surgery. Today, we’re talking to Dr. Tiago Machuca. He’s a Thoracic Surgeon and Surgical Director of the Adult and Pediatric Lung Transplant Program at the University of Florida in the Division of Thoracic and Cardiovascular Surgery. Dr. Machuca practices at UF Health Shands Hospital in Gainesville. Today, we will aim to understand the current treatment algorithms for early stage lung cancer, identify the potential benefits from minimally invasive thoracic surgery to treat lung cancer and recognize expected quality metrics that lead to improved outcomes.
I’m so glad to have you join us today Dr. Machuca. Before we get going, let’s set the stage. What are you seeing as far as incidence and prevalence of lung cancer? Do you feel that there’s more awareness and are people getting the message?
Tiago Machuca, MD, PhD (Guest): I think that there is an increasing awareness on the problem that lung cancer represents nowadays and not only that, but I think that the utilization of more consistent lung cancer screening programs and also the use or increased use of imaging techniques such as chest CT scans for unrelated reasons, I think we end up seeing an increasing number of early stage lung cancers. But certainly I think there’s a lot that needs to improve if you look back and just understanding that lung cancer continues to be the – amongst all cancers, one of the highest mortality, we still need to do a lot to get to a better spot.
Host: Let’s talk a little bit about screening. So, the screening now, there are guidelines. Tell us a little bit about low dose CT screening for early stage lung cancer.
Dr. Machuca: Yes, so CT screening now is validated after an extensive clinical trial that was run here in the United States and also counterparts in Europe. And that has shown that there is a significant benefit of implementing low dose CT screening to patients that are in the highest incidences of lung cancer. So, that is something that is validated but unfortunately, we still don’t see a widespread use of these protocols if you look at the general patient population.
Host: Well then please help us to understand the current treatment algorithms for early stage lung cancer, whether you are starting at initial evaluation and clinical stage and pretreatment evaluation. Give us a little understanding of these algorithms.
Dr. Machuca: Correct. So, I think that a lot of the treatment options and more importantly the prognosis of lung cancer is going to be dictated by the stage. Right, so what’s the stage of that lung cancer. Are we talking about stage one, two, three or four? And when we talk about screening for lung cancer, when we talk about using surgical therapies for curative intent in lung cancer; we are talking more about cancers in the stage one and two. So, these are small lesions for stage one up to three centimeters and for stage two up to five centimeters that do not have any spread to other areas such as mediastinal lymph nodes or metastasis to adrenal glands or liver or bones or the brain which are the most common sites of metastasis from lung cancer.
So, when you are talking about these types of lesions, they are usually smaller than five centimeters with no metastasis to mediastinal lymph nodes or to other organs; you are talking about curative intent, local therapy added or not by systemic therapy depending if there’s any regional spread to hilar lymph nodes or let’s say intrapulmonary lymph nodes.
When you start talking about let’s say more advanced stages such as stage three or four, when there is spread to those areas mentioned before, mediastinal lymph nodes or other organs; then the treatment focus starts to be more like systemic therapy with chemotherapy and now we have seen a boom in immunotherapy for lung cancer with improved outcomes. I think that that’s how you stratify what are your treatment options and algorithms to do further investigation on patients with lung cancer and also to come with a therapeutic plan.
Host: Well thank you for that very comprehensive answer. So, as we are working on identifying the potential benefits for minimally invasive thoracic surgery to treat lung cancer; on the surgical side, Dr. Machuca, the field has moved, are there many more cases being managed through minimally invasive and newer kinds of techniques? Give us a little bit of an overview of some of the techniques and surgeries that you perform.
Dr. Machuca: Yes. If you look back five, ten, fifteen years; a lot of the surgical therapy of lung cancer was centered on open surgery. So, let’s say conventional standard open thoracotomy to resect portions of the lung, most often a lobectomy. That’s how it was done and that’s how it’s still done in some circumstances. But the problem with that is that it involves a large incision and especially spreading the ribs. So, with spreading the ribs through an open large incision, later on patients will have increased pain, a longer postoperative recovery course and also that was all tied with increased rates of complications and that’s mainly respiratory complications.
So, even though we knew that surgical therapy for lung cancer involved removing a portion of it with the lymph nodes most often through a lobectomy; it was being done through open incisions and with that, I think that we were seeing an impact on the postoperative course of our patients. So, luckily, with the addition of new technologies, with the utilization of videoscopes and more recent with the addition of robotics; nowadays we have been able to perform these operations through small incisions usually three or four incisions about eight to twelve millimeters and more importantly, we do not spread any ribs. There’s no fracture on the ribs, there is no pressure on top of the intercostal nerves and with these newer techniques through small incisions; we are seeing that the surgical trauma on our patients is a lot improved.
So, with that, the patients tend to recover faster. They report less pain on the incisions and with less pain, they are able to take deeper breaths. They have a more effective cough. They avoid atelectasis or need for bronchoscopies for bronchial toilet or mucus plugging. So, with all of that what we see is that there is improved outcome in patients with lung cancer with the utilization of these newer techniques for treatment of lung cancer.
Host: Wow, it is amazing the technology. Dr. Machuca how are you recognizing the expected quality metrics that are leading to these improved outcomes and while you are telling us that, how have advances in radiologic imaging significantly augmented your diagnostic and therapeutic capabilities in surgery?
Dr. Machuca: Yeah, I think it’s very important to look into quality metrics for lung cancer and I think that nowadays because of all the advantages that I just mentioned to you; one of the quality metrics is the utilization of minimally invasive techniques. So either with the use of a video thoracoscope or use of a robotic surgery; I think if you can increase the rate of lung resections being done with minimally invasive techniques you are certainly adding quality to your patients who are undergoing lung cancer surgery.
Other important quality metrics that we see nowadays that are recognized are obviously the negative margins on the pathology examination so that’s crucial to have a good quality lung cancer surgery. The resection of lymph nodes on the mediastinum stations and also in the hilar stations and specifically usually a number of more than eight to ten lymph nodes involving the mediastinal and hilar stations need to be present because that’s going to lead to improved staging of lung cancer and also the identification of patients that will benefit from adjuvant therapy.
And then on top of that, additional quality metrics that we have are the time for operations. So, by the time that the patient is diagnosed with lung cancer; usually there is has got to be a timeframe of four weeks for the patient to be undergoing surgery. So, these are metrics that you look at when you are thinking of early stage lung cancer treatment.
Host: That’s absolutely fascinating and as you say, so important. As we wrap up, tell us about some of the latest advances in lung cancer treatment. What are some of the most exciting things that you are doing and that other oncologists should know that could be practice changing?
Dr. Machuca: The way I see lung cancer treatment is that you need to provide let’s say excellent surgery to your patients with decreasing morbidity, decreasing mortality. What we are seeing with minimally invasive techniques is that we are opening a therapeutic window to patients that were not considered for surgery before. So, if you take other patients or patients that have limited lung function or more comorbidities, these were the patients that had the highest complication rates with open lung cancer surgery. So, I do think that there has been a complete shift in paradigm when you consider these patients nowadays for surgery, you really need to make your referring physicians, pulmonary physicians, medical oncologists aware that this new era of lung cancer surgery has completely changed.
So, nowadays with the use of these advanced techniques, we are able to offer surgery for patients that we would be very hesitant in the past because these patients would have a higher rate of respiratory complications, higher mortality. So with all of that, I think that we are seeing more and more patients that can be considered for therapeutic surgical treatment of lung cancer with improved outcomes. So, I think that this is a number one that we are certainly seeing this shift and then number two, I think that there has been also a higher consideration for lung sparing procedures. So, just think that patients that have limited lung function, if you can provide a oncologically sound resection but on the same time, preserve lung; I think that that patient is going to have a big benefit.
So, nowadays with the use of let’s say segmental resection, so anatomical segmentectomy that can be performed robotically or bronchoplastic procedures so let’s say instead of performing a pneumonectomy, removing the entire lung; you would perform a resection of a lobe of the lung and then reconstruct the airway performing a bronchial anastomosis. So, with these lung sparing procedures I think it illustrates very well in other let’s say window in lung cancer surgery that we can consider. So, patients that have borderline lung function that we can still offer the ideal oncological procedure, therapeutic procedure but on the other hand, we will also be able to preserve lung instead of removing the entire lung or the entire lobe; we can preserve lung so that the patient is going to have a lower impact on his postoperative lung function and tied to that, better quality of life.
Host: It is great information and Dr. Machuca, do you have any final thoughts? What would you like other providers to know about the importance of understanding and giving lung cancer patients better results with robotic surgeries and innovative techniques and when you feel it’s important that they refer to the specialists at UF Health Shands Hospital?
Dr. Machuca: Yeah, so what I think is really important is consider a team approach. If you think of let’s say our internal lung cancer group here, but we also partner with outside medical oncologists, radiation oncologists to try to provide the best let’s say recommendations for the management of lung cancer of any given patient. So, whenever you have this team approach with unbiased views, and everyone is aligned to get the best outcome for the patient; I think that’s when you are truly impacting lung cancer care.
So, what I think is truly important is whenever you are seeing a patient with lung cancer, really seeing if there is any value in adding a thoracic surgeon in the decision making. So, let’s say denying an operation to a patient with a potential curable lung cancer based on previous assumptions or previous experiences I think that the patient will benefit a lot if you can change that view. So, if you can consider involving a surgeon and we always have a team approach and talk back to our referring physicians to come up with what’s the best plan for that patient.
So, I oftentimes receive patients that are borderline or considered high risk for resection and a lot of these patients we end up being able to take to the OR and do a curative intent lung cancer surgery and they do very well. But on the other hand, when I feel that a patient is not a good surgical candidate; we just circle back with the referring physician and come up with an alternative plan. So, I think that considering that team approach so you can come up with the best therapeutic plan for your patient is very important. And by team approach, oftentimes, considering involving a dedicated thoracic surgeon on that algorithm.
Host: Thank you so much Dr. Machuca for coming on. It’s a fascinating topic and thank you so much for sharing your expertise with us today. And that concludes this episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs please follow us on your social channels. I’m Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs003.mp3
- DoctorsHoh, Brian
- Featured SpeakerBrian Hoh, MD
- Guest BioBrian Hoh, MD is the Chair Lillian S. Wells Department of Neurosurgery James and Brigitte Marino Family Professor University of Florida College of Medicine
Brian Hoh, MD, MBA, FACS, FAHA, FAANS, is an internationally known expert in the treatment of brain aneurysms, brain arteriovenous malformations, and ischemic and hemorrhagic stroke. In July 2018, he was named the chair of the Lillian S. Wells Department of Neurosurgery at the University of Florida College of Medicine. Dr. Hoh graduated from Stanford University with a Bachelor of Arts and Science degree in biology and political science. He attended medical school at Columbia University in New York, where he graduated with Alpha Omega Alpha honors. Dr. Hoh completed his internship in surgery, residency in neurological surgery and fellowship in interventional neuroradiology at Harvard University at Massachusetts General Hospital. He graduated with an MBA from the University of Florida Hough Graduate School of Business with Beta Gamma Sigma honors. Dr. Hoh is board-certified by the American Board of Neurological Surgery. He is president-elect of the Congress of Neurological Surgeons, past-chair of the Joint American Association of Neurological Surgeons/Congress of Neurosurgical Surgeons Cerebrovascular Section, a member of the Society of Neurological Surgeons, a senior member of the Society for Neurointerventional Surgery (formerly the ASITN), a member of the American Association of Neurological Surgeons and a member of the Florida Neurosurgical Society. In 2014, Dr. Hoh was elected to the prestigious American Academy of Neurological Surgery. Dr. Hoh is a past co-chair and member of the editorial board of the Journal of Neurosurgery and a past member of the editorial board of the Journal World Neurosurgery. Dr. Hoh is an NIH-R01-funded principal investigator of basic science research investigating the biologic mechanisms of cerebral aneurysm formation and rupture, as well as innovative tissue engineering technology to improve the treatment of cerebral aneurysms. He is also an investigator on national and international clinical trials focused on stroke, cerebral aneurysms, carotid stenting and endarterectomy, and vasospasm. Dr. Hoh is a leader in neurosurgical education. He is the past director of the UF residency program and the UF endovascular surgical neuroradiology fellowship program, both ACGME-accredited training programs. In these roles, he was responsible for the training of 21 neurosurgery residents and endovascular surgical neuroradiology fellows. - TranscriptionMelanie Cole, MS (Host): Today we’re discussing the latest clinical guidelines for the management of stroke. We will exam prehospital management of acute ischemic stroke and stroke systems of care, the management of acute ischemic stroke in the emergency department, and the evaluation of acute ischemic stroke patients for mechanical thrombectomy. My guest is Dr. Brian Hoh. He's the James and Brigitte Marino Family Professor and the chair in the department of neurosurgery at the University of Florida and UF Health Shands Hospital. Dr. Hoh, it’s a pleasure to have you join us today. Please start by telling us the prevalence of people effected by stroke in the United States.
Brian Hoh MD, MBA, FACS, FAHA, FAANS (Guest): Stroke occurs in about 900,000 people in the U.S. each year. It’s the fifth leading cause and the leading cause of disability in the U.S. On average, about every 40 seconds someone in the U.S. has a stroke. One of every 18 deaths in the U.S. is from a stroke.
Host: Wow. Well it certainly is prevalent. So Dr. Hoh, does the chain of events favoring good functional outcomes from an acute ischemic stroke, does that being with the recognition of stroke when it occurs? Does the data show that the public knowledge of stroke warning signs is adequate?
Dr. Hoh: The outcome after an acute stroke starts with well-timed recognition and then care for the patient happening as soon as possible. That starts in the prehospital setting when EMS arrives where the patient is in the field.
Host: Well then even before we get into the importance of a designated stroke center, let’s talk about stroke systems of car and the role of that prehospital provider situation. So please begin with the prehospital management and field treatment? What's important as far as EMS? Why is it so important that a patient or if someone suspects that they or a loved one are having a stroke that they call 911?
Dr. Hoh: It’s extremely important because when an EMS arrives to take care of a patient, they need to recognize that a stroke may be occurring. The reason why this is important is because time is brain. Every minute that treatment for acute stroke is delayed results in a worse outcome for the patient. Essential to that treatment is getting that patient to a center that can provide the appropriate stroke care.
Host: Dr. Hoh, please tell us about the importance of a designated stroke center and stroke care in the quality improvement process. How does a center achieve that designation and tell us about the designation at UF Health Shands Hospital.
Dr. Hoh: A stroke center designation is critically important. This is because EMS taking care of that acute stroke patient in the field will need to know where to take that patient for appropriate stroke care. IV alteplase is the first line treatment for acute stroke. So obviously a patient needs to go to a hospital that can provide IV alteplase, but if there's a hospital that’s equally close by or not that much further away that can offer endovascular mechanical thrombectomy then that would be the preferred destination for that patient because then a comprehensive treatment paradigm can be offered for that patient.
There are several certifications and designations for stroke hospitals, but the highest possible designation is a joint commission comprehensive stroke center. UF Health Shands Hospital is a joint commission comprehensive stroke center, which represents the top 2% of hospitals in the country taking care of stroke. In order to qualify as a joint commission comprehensive stroke center we had to demonstrate through rigorous metrics that provide an interdisciplinary treatment approach to stroke patients and qualify by rigorous metrics for door to needle times, door to endovascular times, and outstanding outcomes for our stroke patients.
Host: Well, I understand that you're one of the authors of the stroke guidelines. How were you chosen to be on the writing group for those guidelines?
Dr. Hoh: The American Heart Association and American Stroke Association publishes their clinical guidelines for the early management of patients with acute ischemic stroke. They gathered a number of writing authors who were considered experts in the field for acute stroke care.
Host: That is so interesting. As we learn about those guidelines, do you feel that the development of an organized protocol and stroke team, that that speeds that clinical assessment, the performance of diagnostic studies and decisions for early management? Please explain emergency evaluation and diagnosis of acute ischemic stroke and the latest clinical guidelines.
Dr. Hoh: Standardized treatment protocols for acute stroke are critical. At certified stroke centers, standardized protocols dictate eligibility for patients to receive IV alteplase, which is the first line treatment for acute stroke. Also, these guidelines can aid providers in choosing the best blood pressure management, blood glucose management, and other parameters for optimizing patients for the best possible outcome after an acute stroke. For large vessel occlusion, which is the severest type of acute stroke, patients might be eligible for mechanical thrombectomy and standardized protocols for getting these patients to endovascular treatment can be critical to their outcome.
Host: So Dr. Hoh before we get into mechanical thrombectomy and even tPA use, once in the emergency department what imaging should an acute ischemic stroke patient have? What tests should be performed? Please speak about some of the imaging and what’s new and exciting in the area.
Dr. Hoh: Once the diagnosis of acute ischemic stroke versus hemorrhagic stroke has been established by the non-contrast head CT scan, if the patient is eligible for IV alteplase, he or she should receive that. Then it will be essential to determine whether the patient has a large vessel occlusion. That can be determined by imaging called CT angiogram or MR angiogram, which shows the blood vessels of the brain and can aid in the diagnosis of a large vessel occlusion. This is important because large vessel occlusion can be treated by endovascular treatment called mechanical thrombectomy.
Host: Then tell us about the use of tPA and the implications for rapid response treatment. Tell us about the time window for its use and some concerns with using it and managing these patients.
Dr. Hoh: Patients with acute ischemic stroke who are eligible should definitely receive IV alteplase if they present within three hours of ischemic stroke symptom onset. That’s a level 1A recommendation in the AHA/ASA guidelines, but it’s also recommended that patients within three to four and a half hours of ischemic stroke also be candidates eligible for IV alteplase. That’s supported by a number of European clinical trials that showed it’s benefits in these patients. That’s a level 1B-R recommendation in the current AHA/ASA guidelines.
Host: Then what about the use of endovascular interventions such as mechanical thrombectomy? Tell us the latest clinical guidelines for indications for use?
Dr. Hoh: The current AHA/ASA guidelines recommends strongly with a level 1A recommendation that patients with a large vessel occlusion in the anterior circulation who have a prestrike modified Rankin score of zero to one, meaning they are not disabled at baseline, who are age 18 or older who have a severe stroke—meaning an NIH stroke score of six or greater—and have CT imaging demonstrating an ASPECTS score of six or greater should receive mechanical thrombectomy within six hours of symptom onset. However, if patients present between the time windows of six to 16 hours or even 16 to 24 hours and they meet the eligibility criteria including profusion imaging on CT profusion or MR profusion that they receive mechanical thrombectomy as well.
Host: Well, thank you for that comprehensive answer. So after diagnosis, speak about general support of care and treatment of acute complications. For example, blood pressure and the role of aspirin or dual anti-platelet medications after stroke. Tell us about some of the things that go on after the stroke and the multidisciplinary care that a patient usually needs to receive?
Dr. Hoh: So the guidelines give recommendations that blood pressure be maintained at less than 180 systolic and 105 diastolic after an acute ischemic stroke and during and for the 24 hours after a mechanical thrombectomy procedure. It’s recommended that patients receive aspirin within 24 to 48 hours after the onset of an acute ischemic stroke. For those treated with IV alteplase, aspirin is generally delayed until 24 hours later. Aspirin is also recommended for patients that undergo mechanical thrombectomy.
Host: So interesting. The technology, right now, is really amazing. Dr. Hoh, tell us about some promising new therapies. If you were to look forward to the next 10 years in the field, what do you feel will be some of the more important areas of research for stroke care?
Dr. Hoh: Well, there are always continuing evolution and development in the endovascular devices and techniques we use for mechanical thrombectomy. Certainly the current generation of endovascular devices that we use are much better than the first devices that we used in the past and were developed, and we’re getting much better outcomes for our patients. So I see in the future continued evolution and development of better and more innovative endovascular devices and techniques. Also there are currently no pharmacologic or non-pharmacologic neuroprotective treatments to treat patients with acute stroke, but there’s always the hope that in the future that a neuroprotective agent will be found that will also aid our acute ischemic stroke patients.
Host: Wow, what an exciting time. Dr. Hoh, as we wrap up what else would you like other providers to know about UF Health Shands Hospital at the University of Florida stroke program and when they should consider a transfer or referral to this program.
Dr. Hoh: UF Health Shands Hospital is a joint commission comprehensive stroke center, which means that it is one of the top two percent of hospitals in the country taking care of stroke. As a comprehensive stroke center, we obviously offer IV alteplase and other stroke treatments, but also have 24/7 365 endovascularly mechanical thrombectomy providers that can provide this essential treatment for patients with large vessel occlusion as well as other types of ischemic and hemorrhagic stroke.
Host: Please end by telling us about your team.
Dr. Hoh: We are fortunate to have an interdisciplinary team of emergency medicine physicians, EMS, vascular neurosurgeons, vascular neurologists, neurocritical care physicians, nursing, physical therapy, occupational therapy, speech and swallow, case management, as well as a multitude of other services that are skilled and certified to take care of stroke patients.
Host: Wow. That certainly is multi-disciplinary and such a comprehensive stroke program. Thank you so much, Dr. Hoh, for joining us and sharing your incredible expertise today. That wraps up this episode of UF Health Med Ed Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs, please follow us on Facebook and Twitter. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs002.mp3
- DoctorsMassoomi, Michael
- Featured SpeakerMichael Massoomi, MD
- Guest BioDr. Michael Reza Massoomi grew up in Atlanta, GA. He completed his undergraduate degree at Georgia Tech and medical school at the Medical College of Georgia. He completed his residency in internal medicine at Emory University then moved to Gainesville, FL, to complete his general and interventional cardiology fellowships at University of Florida, where he also served as chief cardiology fellow.
Learn more about Michael Massoomi, MD - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category one credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Melanie Cole (Host): There’s so much buzz about the new wearable technology that can monitor heart health and here to tell us why that matters is my guest, Dr. Michael Massoomi. He’s an Interventional Cardiologist at the University Of Florida and he practices at UF Health Shands Hospital in Gainesville. Dr. Massoomi, I’m so glad to have you with us. This is such a great topic. As personal health tech is already common independently at home, sleep studies, Holter monitors; please tell us about this new wave of wearable monitoring devices. What are you seeing?
Michael Massoomi, MD (Guest): Very excited to talk about this. Right now, somewhere around 13% of the people in the United States have a Smart watch and I have a special interest in trying to incorporate use of these devices in daily clinical care in the clinic. And so, I’m seeing a wide variety. I’m seeing patients who wear the devices and don’t really know much about what they can do for them and I see other patients on the other end of the spectrum; who use these devices to try to monitor their activity levels, or who come to me stating that they got an irregular rhythm notification and they want to know what it means.
Host: It really is amazing what’s happening today. So, what are some of the various metrics that can be obtained from a Smart watch and what are the most important ones to track?
Dr. Massoomi: Right now, we can obtain a wide variety of data and it’s available on different devices and it can be – the common devices these days being Fitbits, Garmins, Apple watches, and a few other ones. And some of the basic information can be obtained on any of those. And so, one of the common ones is energy expenditure or just kind of general activity level. And that’s probably one of the ones where I’m most careful and studies that we have which try their best to validate this information show that there’s a lot of variability. And so energy expenditure for example would be the metric that tries to show how many calories a patient has burned in a given day or with a given activity.
And what we find when we try to control using calorimetric studies is that these devices are very – there’s a lot of variability in what they present, and they are typically overestimating the energy expenditure. Sometimes at a margin of around 25%. So, I’m always really cautious when it comes to energy expenditure. I try to specifically tell patients not to use the information about how many calories they’ve burned to make any dietary decisions because I think that’s what will lead you down a dangerous path of probably weight gain.
But I do think it’s important to look at that because the trends can still be meaningful. So, don’t focus too much on what the exact number is, I’ve burned this many calories. But over time, if that’s going up, then that’s probably a good indication that you’ve become more active.
Host: Well certainly it is. And so as far as heart conditions, what can it help to possibly detect whether it’s AFib or O2 saturation, blood pressure, diabetes, glucose levels? I mean we’re hearing so much today doctor. Tell us what heart conditions it can help with.
Dr. Massoomi: Most of these watches now even the base models that start at around a price point of around $100, they have heart rate detection and they do that using a pleth so that’s not ECG, that’s just using the pleth signal like we would do with a pulse ox in the hospital to measure heart rate. Most of the watches don’t do oxygen saturation. But we can use the pleth and get pretty accurate data on heart rate and so, they’ve done a few different studies looking at the accuracy of the information and it turns out most of the Smart watch devices are pretty accurate, typically between five or ten percent of the values that we would obtain if we did a simultaneous ECG which is kind of the reference standard for heart rate.
And so, what this is telling us is that using a pleth based heart rate sensor, is an accurate way to have a watch on what somebody’s heart rate is doing. And so, there’s an additional are which is even more exciting and that’s limited right now to the Apple watch series 4 and now the newly released series 5 which offer the same health features. And the really neat thing there is that there’s two big health features that are available only on those devices and not on any others today.
Number one would be fall detection which is a neat algorithm that the device uses joining the accelerometer with other sensors to determine if someone has had what feels like is an unplanned descent, right, a dangerous fall. And then, it will give you notification and say did you fall, are you okay. And if you say yes, I’m okay then it dismissed it. If you don’t respond to the notification; it will assume that you have fallen and are either unconscious or unable to get up and it can automatically call 9-1-1. And so, that’s a really nice feature especially in the elderly population.
And then the second feature which I’m most excited about would be its ability to detect atrial fibrillation and do single lead ECG recording. And so, I’ll just try to clarify a portion of this here. So, you can use an Apple watch series 1, 2, 3, 4 or 5 to do pleth based heart rate detection and it can apply the algorithm to try to determine irregular heart rhythms. And that’s what they did with the Apple heart study, which is a great study, big, big study looking at the ability of a watch that the common folks are wearing to detect AFib. The series 4 and series 5 really add on to that by improving the accuracy because now, if you get a notification that says you have an irregular rhythm, you can immediately on the watch, take a single lead ECG recording which can then confirm or show that maybe it was artifact that this is atrial fibrillation.
And so I think that’s just groundbreaking and it’s something that so many patients already are wearing and with the growth of these devices, it’s only going to become more and more common.
Host: Well absolutely it is and as you say, really it is amazing what they are doing with this technology. Do you feel that it might cause false positive tests which could cause unnecessary tests and anxiety for patients if they notice something or they question something? Do you think that it can maybe not always be terrific as far as that?
Dr. Massoomi: It’s a very good point that you are bringing up. And certainly there’s a difference in patients, right, there are some patients that are highly anxious and it could be anxiety provoking for them and then not the case in other patients. I think this is a good time to kind of discuss our responsibility as physicians in educating ourselves about this information so that when patients do come to us; we feel comfortable enough to look at their phone, to look at their tracings and help make sense out of this.
Now as far as false positives, I can share some specific data that came from the Apple heart study and in that study, they basically had a good level of positive predictive values so there was an 84% positive predictive value for patients having an irregular rhythm notification on their watch for them to have had AFib at the same time. So, these were patients that were earing the watch and wearing an event monitor at the same time to validate. And so 84% of the time that the watch said this is an irregular rhythm; that was indeed atrial fibrillation. And so that’s a good number to know and then also I think we should account for the fact that this was done only up to the series 3 device and the series 4 and 5 devices which are becoming more and more common, actually allow patients to take an ECG right then and so that would increase your sensitivity and specificity, I don’t want to say to 100%, because the tracings can have artifact, but to the highest level that we can really obtain aside from doing a 12 lead ECG.
And so, what I have patients do is I say for those who have a 4 or 5 watch, I say if you get an irregular rhythm notification; I want you to take a recording on your watch immediately. And then when they come in and show me those recordings; then I can confirm okay this atrial fibrillation and as far as I’m concerned; if they show me a recording from their watch and it looks like a clean recording and I see atrial fibrillation; I will use that as diagnostic information to put AFib in their chart and to start them on anticoagulation if it’s indicated.
Host: Wow. But since this is a healthcare device, do you see approval being needed from federal regulators. I mean if you are going to be using it as a diagnostic criterion then do you think that there will have to be some sort of regulation? What’s going on in that department?
Dr. Massoomi: The ECG portion of the watch is actually FDA approved for single lead ECG recording. And really what it comes down to is us being aware of it and recognizing it and actually using the information that’s there. It’s low hanging fruit. This information is already there. We just have to start using it.
Host: Absolutely. As we wrap up, doctor and what an interesting topic. How do you feel this will transform patient care? Tell us where you see the clinical application of this data for other providers and really what you’d want them to know about the accuracy, the metrics and using this wearable technology with their patients.
Dr. Massoomi: A few points of I will try to share with people listening is that we can use this information on practically a daily basis. I mean part of my physical exam when patients come in has become to look at their wrist and see if they have a Smart watch. And if they do, I ask for their telephone and I will review their health related apps. I look at their activity level and if I notice that their step count is on the lower side, I try to encourage them to make reasonable goals and to increase it and I show them how to look it so they can track their progress.
So, that’s one good use. I look at their heart rate data and I try to see if they have any strange outliers to suggest that there might be some kind of an underlying dysrhythmia. I look if their watch provides that, if they have an Apple watch, I look to see if they have any AFib notifications and I even use it in patients who have known AFib especially in the Apple watch, it has different heart rate metrics and it can actually give you an average heart rate while walking. So, the watch knows when you are walking and when you are still, and it will give you a separate heart rate average during times of walking which is an important metric for heart rate control in patients who have AFib.
And so I also will look at the resting heart rate and I use the combination of those two pieces of data to titrate drugs like metoprolol or Cardizem that these patients are commonly going to be on for controlling their heart rate. So, I think those are really, really great easy uses for these devices. I also try to take a look at their sleep and just sort of on that and try to get a rough idea of how much they are sleeping and the quality of their sleep. We’re learning more and more about sleep. I like to refer to sleep as the forgotten vital sign and I think there’s just a lot of good correlation with sleep quality and chronic diseases and chronic inflammatory states and we know that poor sleep is a risk factor for obesity, diabetes, and cardiovascular disease including heart attack and stroke. And so I try to use that to open the door and refer people for sleep studies if I think it’s appropriate.
I think there are many, many uses that we can do right now and then I think the door is just open for an expanding area here of more and more uses as we learn more about how to apply this information.
Host: I couldn’t agree more and thank you so much Dr. Massoomi for joining us today and sharing your incredible expertise. What a fascinating topic. That concludes today’s episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs please follow us on your social channels. Until next time, I’m Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs001.mp3
- DoctorsDziegielewski, Peter
- Featured SpeakerPeter Dziegielewski, MD
- Guest BioPeter T. Dziegielewski “Dz,” MD, FRCSC, is board-certified in otolaryngology-head and neck surgery. Originally from Canada, Dr. Dz received his medical degree and residency training in otolaryngology-head and neck surgery at the University of Alberta in Edmonton, Canada. He then completed a fellowship in head and neck oncologic surgery, certified by the American Head and Neck Society, at The Ohio State University in Columbus.
Learn more about Peter Dzieglielewski, MD - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of .25 AMA PRA category one credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Melanie Cole (Host): Today we’re talking to Dr. Peter Dziegielewski. He’s an Associate Professor and Chief of the Division of Head and Neck Oncologic and Microvascular Reconstructive Surgery at the University of Florida. And he practices at UF Health Shands Hospital in Gainesville. Our topic today, is robotic surgery in head and neck cancer treatment. Dr. DZ, thank you so much for joining us today. I’d like to just set the stage for other providers. Explain a little bit about the prevalence of head and neck cancer and some common conditions and factors that can lead to it.
Peter Dziegielewski, MD (Guest): The fifth or sixth most common cancer in the United States depending on the year. It accounts for probably less than 5% of all cancers but the incidence of it has increased in the last two decades and that’s mainly because of the incidence of the human papilloma virus and infections of the oropharynx or the tonsils and base of the tongue. So, it’s not the most common cancer, but it’s certainly one that’s becoming much more known and talked about in the news.
Host: Then let’s talk about the clinical presentation and how important early diagnosis is as being crucial to improve outcome prediction.
Dr. Dziegielewski: So, head and neck cancers encompass the cancers of the head and neck including the oral cavity. So, sites like the tongue, the forward mouth, the jaw, oropharynx, so cancers of the tonsils and base of the tongue. Also cancers of the larynx, the hypopharynx and so, depending on where the cancer starts will dictate how the patient may present. So, this can present as a sore or an ulcer inside the mouth that’s not going away after a few weeks. Patients can present with a growth inside the mouth or the throat. Some will present with just a neck mass as the first place that these cancers tend to spread to are lymph nodes in the neck.
And then others can have more extreme presentations such as difficulty swallowing, difficulty breathing, change in voice, or unexplained weightloss. So, there’s kind of a spectrum of presentations that patients may come to their doctor with. Early diagnosis is absolutely crucial because the earlier you can diagnose one of these cancers, the better the patient’s survival. And because these cancers are in such a very intricate area of the body; the treatment can have certainly devastating affects on the patient. And the smaller the cancer, the earlier the stage; the less side effects patients are going to have from treatment. So, ideally, you catch the cancer early; you can save the patient’s life and still maintain an excellent quality of life and functional outcomes.
Host: Well thank you for that Dr. DZ. So, due to the sensitivity of this type of cancer and it’s intricate nature; tell us about some of the advancements that have been made in the treatment as far as minimally invasive technology, robotics, that could allow surgeons to access hard to reach areas of the mouth and throat.
Dr. Dziegielewski: So, one of the technologies that’s developed over the last 15 years is robotic surgery. And in the past, whenever we’d have to cut out a tumor in the back of the mouth or the throat; we would have to do maximally invasive approaches meaning we would have to cut the patient’s jaw open and cut through their lip and get to the cancer, remove it and then reconstruct the area. A lot of these surgeries would take a dozen hours or so to finish and patients would have very morbid long-term affects from this including difficulty swallowing, speaking and poor quality of life.
Now with the use of the robot; what we are able to do is put a camera in the patient’s mouth as well as two robotic arms that we can control remotely from another console in the room. And by doing this, we can get into the back of the mouth and the back of the throat and cut out and resect tumors that we otherwise could not get to very easily. So, this allows us to preserve normal structures such as parts of the tongue, the muscles in the mouth and tongue as well as the nerves in that area and so this allows patients to heal quicker and return to functions of swallowing and speech which is something, they may not have been able to do in the past.
Also, it’s given us an opportunity to treat certain tumors such as those of the tonsils and the bade of the tongue surgically whereas before, we would rely much more on radiation therapy which can have a lot more long-term side effects. So, the idea here is that we want to minimize patients’ long-term side effects by minimizing exposure to more toxic treatments such as high doses of radiation and chemotherapy. So, with the use of robotic surgery, we are able to give the patients more options with similar or better cure rates and much less toxicity in the future.
Host: For the surgeons, the benefits. How is endoscopic instrumentation coupled with improved intraoperative imaging helping you to reach those areas? Speak about the benefits for the surgeon.
Dr. Dziegielewski: The robotic instrumentation gives us seven degrees of freedom. We can move the robotic instruments in every direction that our wrists and our fingers can move. And we can adjust how much movement we want in those instruments. We can magnify our movements, or we can minimize them so that we can eliminate hand tremor, or we can make the robotic instruments move quicker, faster depending on the movements we need. And we couple that with high definition endoscopes, and we can get a very close up view of the anatomy that now we are operating around. So, this lets us identify structures much sooner than we would normally so we can preserve normal anatomy. Also it lets us get a great view of the tumor so we can stay away from the margins of the tumor and it’s just a much more comfortable for us to operate in small areas by essentially making ourselves down to the size of a nickel or smaller and being able to operate in a very small area. And that’s what the high definition cameras let us do.
Host: Technology is amazing for what you’re doing and what an exciting time for the advancements in head and neck cancer. You mentioned the daily lives of patients because of this type of cancer whether it’s eating, self-esteem, speech, appearance; all of those things. Speak for us Dr. DZ about after surgery and the after care cancer team and the multidisciplinary approach that might be needed.
Dr. Dziegielewski: So here at UF Health Shands Hospital, we have a very large multidisciplinary team for patients undergoing head and neck cancer treatment. And that all starts with our surgical team. so, we have surgeons, fellows and residents looking after patients and then after the patients get through surgery, we have subspecialized nurses and nurse practitioners, nurse navigators who help patients get through their entire treatment plan. Because a lot of these patients will need additional treatment in the future and that may be radiation or chemotherapy and so we have physicians that treat patients based on those treatment modalities. And then after patients go through all of that; their treatment is not done. Now they have to recover. And so that involves intensive speech and swallowing therapy, physical therapy, consultations with the dietician, consultations with dentists and prosthodontists and so there’s a huge team looking after patients to try to get them back to looking as normal as possible, feeling as normal as possible and functioning as normal as possible.
And that functioning can be very simple things such as being able to lift one’s arms above one’s head to wash your hair or comb your hair to being able to eat out in public, to being able to speak over the phone. Lots of things that we just take for granted that are completely changed with these patients forever. And so, there is a long term dedication of these patients need to be part of and that’s not just their treatment but their long term rehabilitation. And here at UF Health Shands, we have a functional outcomes clinic where we follow our patients long-term and try to improve all of these functions that we possibly can. The earlier we do that, the better the patients do for the rest of their lives.
Host: Well that certainly is a comprehensive approach. Tell us a little bit about current research. What does it indicate for future developments in treatments? Give us a little blueprint and while you’re doing that, are there some treatments or research that you’re doing at UF Health Shands Hospital that other physicians may not be aware of?
Dr. Dziegielewski: So, a lot of research that we’re doing at UF Health Shands Hospital involves clinical research as well as basic science research. So, on the clinical sides of things; we’re looking at utilizing newer technologies to improve reconstruction in head and next surgery. So, for example, one of the things that we do is surgical planning on the computer where we can take a patient’s CT scan and we can upload that and get a three dimensional image of their craniofacial skeleton and then we can also take a image of another part of their body such as a bone in their leg, like the fibula or the scapula from their back and we can plan exactly how we are going to remove their tumor.
So, if we are going to cut out part of their jaw, we can plan that exactly, what we are going to do on the computer. And then we can also plan the reconstruction on the computer. And from that, we can print out a three dimensional model of the patient’s jaw with our reconstructive plan on that. And we can also print off cut guides that we can use in the OR so that we can make the exact cuts we’re planning to make. So, we can put those onto the jaw, cut out the cancer; we can put the cut guides on the leg bone, the fibula for example, make our cuts on there and put dental implants into the bone at the same time and then we can do the whole reconstruction on the same day of surgery.
And then once the patients heal, we can uncover their dental implants and give them teeth. Which is something we weren’t able to do ten to twenty years ago and this is something that we are starting to use more and more and more. And almost every patient that goes through one of these operations, we’re able to do this virtual planning on ahead of time. And what that means for the patient is more precise reconstructions, faster OR times and by decreasing the patient’s time under anesthesia; we help them heal faster and that decreases their chance of complications. And what this translate to in the short term is quicker recovery, quicker time to additional treatments and then what it translates to in the long-term is just better appearance and better functional outcomes which essentially translates to better quality of life in the future.
So, that’s one of the big areas that we’re focusing on. Other areas in the basic science domain include research on using nanoparticles in the treatment of head and neck cancers and developing targeted treatments. Over the last ten years or so, there have been newer and newer technologies being developed to promote drugs that attack various cancer targets at the molecular level. And it seems that almost every month a new target is being developed and we are very involved in developing tumor vaccination treatments and nanoparticle treatments that focus on attacking those molecular markers in head and neck cancers.
And the goal is to develop drugs that eventually would be able to fight head and neck cancer without having to use any toxic treatments. So, we are working on that. We have a lab that’s dedicated to that. And that’s one of the other exciting areas that we are focusing on.
Host: Well thank you for that answer. So, interesting. As we wrap up, tell other physicians what you’d like them to know about head and neck cancer surgery, reconstruction and when you feel it’s important that they refer to the specialists at UF Health Shands Hospital.
Dr. Dziegielewski: So, I think one of the biggest points is that head and neck cancer is a very potentially devastating disease for patients. However, we have come a very long way in the last 30 years. Surgeries are not nearly as disfiguring and dysfunctioning as they once were. We have a lot of technology that’s enabled us to use minimally invasive methods to remove cancers and much more improved technologies to reconstruct patients so that they can function afterwards. And one of the most important things is that patients see someone who is the leader of the head and neck cancer team at their institution and that’s often going to be a surgeon who can direct the patient to the appropriate treatment.
One of the things that we really value at UF Health Shands is a multidisciplinary comprehensive approach and that all starts at our head and neck cancer tumor board. And so patients are often referred to myself or one of my colleagues who is a surgeon and we bring the case to our tumor board and we discuss the case and we plan what we think will be the best option for the patients to maximize their survival and balance that with quality of life and functional outcomes.
And so, I think one of the most important things is making sure that the patients get referred to the appropriate clinic and to the appropriate person who is an expert in head and neck cancer. This isn’t one of those disease types that can be dealt with just by anybody. These patients really need a whole team looking after them. And so, here at UF Health Shands, that starts with myself or one of my colleagues a head and neck cancer surgeon.
Host: Wow, such great information. What a fascinating topic. Dr. DZ, thank you so much for joining us today and sharing your expertise. That concludes this episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about cancer clinical trials available at the UF Health Cancer Center, please visit www.ufhealth.org/navigator. You can also learn more about this and other healthcare topics at UF Health Shands Hospital if you visit www.ufhealth.org/medmatters to get connected with one of our providers. For more health tips and updates on the latest medical advancements and breakthroughs please follow us your social channels. I’m Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
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