March 2014

March 2014

Volume 3Issue 3

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E TESTOSTERONE REPLACEMENT THERAPY: Clinical Considerations and ControversiesP. 7

TO SCREEN, OR NOT TO SCREEN: The Ongoing Mammography ControversyP. 12

EGG & EMBRYO BANKING:Frozen Embryo Transfers Can Be More Successful than FreshP. 15

Editorial CommitteeRuss Granich, MD, ChairSharon Clark, MDEdward Morhauser, MDGurpreet Padam, MDSue U. Malone, Executive DirectorShannon Goecke, Managing Editor

SMCMA Leadership

Amita Saxena,, MD, President; Vincent Mason, MD, President-Elect; Michael Norris, MD; Secretary- Treasurer; Gregory C. Lukaszewicz, MD, Immediate Past President

Alexander Ding, MD; Manjul Dixit, MD; Russ Granich, MD; Edward Koo, MD; C.J. Kunnappilly, MD; Susan Nguyen, MD; Michael O’Holleran, MD; Chris Threatt, MD; Kristen Willison, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Editorial/Advertising Inquiries

San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted.

Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

For more information, contact the managing editor at (650) 312-1663 or [email protected].

Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc.

© 2014 San Mateo County Medical Association

March 2014 / Volume 3, Issue 3

Columns

S A N M A T E O C O U N T Y

PhysicianPresident’s Message: Customer Satisfaction and Effective Communication ................................... 4Niki Saxena, MD

Executive Report: SMCMA Goes to Washington .......................................................................... 6Sue U. Malone

Feature Articles

Testosterone Replacement Therapy:Clinical Considerations and Controversies .................................................... 7Andrew Rosenberg, MD

To Screen, or not to Screen?The Ongoing Mammography Controversy ................................................... 11Harriet Borofsky, MD

Egg/Embryo Banking:Frozen Embryo Transfers Can Be More Successful than Fresh .................... 15Christo Zouves, MD

Of Interest

Upcoming SMCMA Events ............................................................................. 17

New SMCMA Members, Membership Updates, Index of Advertisers ......... 18

4 SAN MATEO COUNTY PHYSICIAN | MARCH 2014

Next time you’re looking for some lively conversation, just say the words “patient

satisfaction surveys” to a group of physicians. Press Ganey, a company from South Bend, Indiana, is the leading provider of patient satisfaction surveys for hospitals and physicians. And until the recent shift toward a more patient-centric model of healthcare, they may

have stayed in South Bend without making even a tiny ripple in the ocean of our healthcare system. But now government and healthcare administrators are embracing customer service as an integral part of American healthcare, and these surveys have become part of the daily issues many physicians face.

Kai Falkenberg’s article, “Why Rating Your Doctor May Be Bad for Your Health,” published in the January 2013 issue of Forbes, does an excellent job painting a chilling picture of what can happen when you travel down the road of unintended consequences:

President’s Message by Niki Saxena, MD

Customer Satisfaction and Effective Communication

I don’t know the key to success, but the key to failure is trying to please everybody. — Bill Cosby

The chief cause of problems is solutions.

— Eric Sevareid

The current system might just kill you. Many doctors, in order to get high ratings (and a higher salary), overprescribe and overtest, just to “satisfy” patients, who probably aren’t qualified to judge their care. And there’s a financial cost, as flawed survey methods and the decisions they induce, produce billions more in waste… researchers at UC Davis, using data from nearly 52,000 adults, found that the most satisfied patients spent the most on health care and prescription drugs. They were 12 percent more likely to be admitted to the hospital and accounted for 9 percent more in total health care costs. Strikingly, they were also the ones more likely to die. UC Davis authors posit that the most satisfied patients have a higher mortality rate because they receive more discretionary services–interventions that carry a risk of adverse effects.

ObamaCare’s “pay-for-performance” program is providing yet another boost…hospitals that perform poorly on quality measures forfeit 1 percent of their Medicare payments, a number that doubles by 2017,

putting some $2 billion at risk. Thirty percent of that determination will be based on the hospital rankings from mandated patient surveys.

It doesn’t take a huge leap to see how these surveys can lead to a culture of fear that can erode the doctor-patient relationship. I have heard similar statements from many local physicians:

“I can have lots of great reviews but just one bad review can drop me from the 99th percentile to the 1st percentile.”

“No one is having the conversations we are ‘supposed’ to have because no one wants to get bad satisfaction scores.”

“We get audited at work, someone follows us around to make sure we stick to a script and don’t forget to say whatever key phrases we are supposed to say. If we don’t, we get dinged.”

...continued on page 10

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As you know, the American Medical Association advocates

for physicians before Congress and the Administration in the Nation’s capital. To assure that medicine has a cohesive voice in Washington and in order to achieve its legislative

goals, the AMA works with county, state and specialty organizations to develop positions, messages, and strategies on issues of shared concern.

Each year the AMA organizes a National Advocacy Conference in Washington, D.C., offering stimulating presentations and encouraging leaders with county and state medical organizations to go to Capitol Hill to meet with local legislators.

The SMCMA started sending representatives about seven years ago so that our leaders could gain in-depth knowledge about national health care issues and be an informed advocate when speaking with our representatives in the House and Senate, whether on the Hill or back in their district offices.

This year, Dr. Vincent Mason (PD), our President-Elect, joined me in attending the Conference. I

Executive Report by Sue U. Malone

SMCMA Goes to Washington

believe it is well worth the time to participate in this forum as the attendees are exposed to speakers one might never have an opportunity to hear in person. Further, being in Washington gives us the opportunity to meet with our representatives in their Hill offices.

During this year’s program we heard a Capitol Hill briefing by AMA Government Relations staff and AMA physician leaders; an address by Bob Woodward, Associate Editor of The Washington Post, who provided insight to what goes on inside the beltway; CMS Administrator Marilyn Tavenner, who spoke about the ACA and the Exchange programs, known to us as Covered California. An evening address was offered by Bob Schieffer, CBS television

journalist and moderator of the Sunday public affairs show Face the Nation. On another day we were treated to a point/counter point with Dana Perino, press secretary for President George W. Bush, and Robert Gibbs, the first press secretary for President Obama. They gave a fascinating account of life in the White House. Finally, we heard from Rep Michael Burgess, MD (R-TX), the author of H.R. 4015, the SGR repeal and Medicare Modernization Act of 2014. This bill, along with its companion bill in the Senate (S.2000), are the bills that all of medicine has been urging both Houses to pass.

...continued on page 10

AMA graph compares over a 20-year period the medical practice cost inflation factor compared to Medicare physician payment updates, showing the growing gap between what physicians should get paid vs. what they do get paid.

MARCH 2014 | SAN MATEO COUNTY PHYSICIAN 7

TESTOSTERONE REPLACEMENT THERAPYClinical Considerations and Controversies

by Andrew Rosenberg, MD

Direct-to-consumer marketing, extolling the

products available for erectile dysfunction in

general, and especially for “Low T,” has exploded

in every form of media. The erstwhile poorly-

understood and under-diagnosed condition of

male hypogonadism has become the darling

of the pharmaceutical industry, an increase in

prescription sales of more than 500% over the

past decade. Yet, urologists and endocrinologists

have been treating hypogonadism for decades,

safely and effectively.


The burgeoning number of patients banging on our doors demanding treatment has also led to a plethora of reports about the benefits and adverse effects of testosterone replacement therapy (TRT). Yet for a properly diagnosed male, treated with careful guidelines and a diligent monitoring system, TRT can improve the quality of life tremendously.

Testosterone (T) regulation (production and secretion) is controlled by the hypothalamus-pituitary-testes axis, much like a thermostat. T circulates either as an unbound molecule (free T), loosely bound to albumin or more tightly bound to sex-hormone binding globulin (SHBG). The free and albumin-bound T are the bioavailable forms responsible for the physiologic activity. SHBG, synthesized in the liver, increases with age and also certain disease states, such as hypogonadism, cirrhosis and hyperthyroidism, and decreases in hypothyroidism, acromegaly, Type II Diabetes Mellitus (DM) and obesity. T levels vary on a circadian rhythm, with the highest levels occurring in the early morning hours, thus testing should be performed before 10 a.m. As men age, however, the variation can be markedly reduced or absent.

Beginning in the third decade of life, men begin to experience a decline in testosterone averaging 0.4% per year. Up to 39% of men over the age of 45 have androgen deficiency as defined by low or low-normal testosterone levels, but only 6% present with symptoms. Low-T is identified in obese men 2.4 times the normal male population, 2.1 times in diabetics, and 1.8 times in hypertensive patients. The symptom that trumps all others as being the most common reason for referral is sexual dysfunction (low libido, erectile difficulties), though a patient may also complain of fatigue, depression, weakness, loss of muscle, low energy and stamina, and cognitive difficulties independent of sexual problems. Signs

include increased body fat (truncal), reduced muscle mass and strength, low bone density (osteopenia or osteoporosis) and loss of body hair. As a physician who gets to know

my patients over many years, I often identify the

insidious onset of signs and symptoms and initiate therapy

based on my clinical impressions supported by biochemical evidence.

The diagnosis of hypogonadism, sometimes referred to as andropause, can be challenging as patients must have biochemical androgen deficiency (AUA standard is < 300 ng/dl) or low normal levels (<400 ng/dl) as well as signs and symptoms of androgen deficiency. The problem is that the signs and symptoms are non-specific and can be found in numerous other conditions, such as aging, obesity, DM, and chronic narcotic use, to name a few. Sexual dysfunction is a complex diagnosis of multiple contributing causes, taking into account the neurological, vascular, and psychological status of the patient, the medical and surgical history, and medications, alcohol and illicit drug use, not just the testosterone level. Proper sexual function depends on all these factors. Patients must have a current PSA, CBC, and chemistry panel before starting therapy, both as a baseline and also to identify conditions that may otherwise be undiagnosed to date, such as DM, hyperlipidemia and metabolic syndrome.

Injectable, transdermal and buccal formulations are available for clinical use in the Unites States. There are oral preparations, but these are rarely prescribed because of the risk of first-pass hepatotoxicity. The choice is dictated by both physician and patient preference, but the obvious driving factors are compliance, tolerability, efficacy, convenience and cost. There are benefits and disadvantages of each delivery method, but that discussion is beyond the scope of this article. I do not have a preference. Most patients choose injections, being the least costly, ranging from weekly to every six weeks, the timing of which is to prevent the sudden decline of testosterone

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levels toward the end of the injection cycle known as “testosterone crash,” which can be associated with a sudden and severe reoccurrence of hypogonadal symptoms. Besides routine monitoring of labs, patients are questioned as to their symptomatology, and reminded that TRT alone may not be enough to restore their sexual function. In addition, the benefits of TRT can take from one month (libido) to six months (bone density and muscle mass) to elicit improvement. I generally recommend the patient stay on the TRT at least for 6 months before making any decisions as to whether to continue the therapy. I do not gauge the success of the treatment by the new testosterone level but rather by the feedback from the patient. I have maintained some patients in the 300 range if they are feeling well and they started at very low levels, while others get up into the 7-800 level to receive the benefits desired. The upper level is 900 and adjustments are made frequently dependent on not just the T level but also the CBC. TRT must be individualized. In other words, the goal of treatment is not to treat a number (T level) but to treat the patients’ symptoms. I am not trying to get my patients to hit home runs out of AT&T Park. TRT duration is usually lifelong.

I have personally seen phenomenal changes in men of all ages with TRT. The great majority feel better than they have in years, with more energy, better strength and stamina, and, of course, improved sexual abilities. TRT also has shown to improve insulin sensitivity, fasting glucose and hemoglobin A1c levels. Bone densities improve and the interpretation would be to expect lower incidence of fractures, though trials supporting this claim have not been conducted to date. TRT is to these men like Miracle Grow is to plants. Used properly it can be a panacea for so many ailments plaguing so many men. These statements are supported by several quality-of-life studies in the literature.

Of course, the benefits of TRT must be weighed against the disadvantages. Let me first say that TRT DOES NOT CAUSE PROSTATE CANCER! In fact, many of my

TRT patients have been previously treated for

prostate cancer, and TRT is supported in the literature

as being safe as long as they are without evidence of disease.

Side effects of TRT often depend on the delivery mechanism, but include testicular

atrophy, infertility, erythrocytosis, skin reactions to transdermal agents, emotional lability issues, and infrequent incidences of acne/oily skin and gynecomastia. PSA elevation, BPH symptoms, lipid alterations and sleep apnea are rarely clinically significant.

Perhaps the most controversial topic in the ongoing discussion of TRT is the issue of risk. The belief that testosterone is a risk factor for cardiac disease is based on several studies revealing a higher incidence of cardiac events in patients receiving TRT. However, there are at least as many studies that suggest the exact opposite. There is no real scientific data to support a causal relationship, though the likely culprit is erythrocytosis and its potential for increasing blood viscosity, aggravating vascular disease in the coronary, cerebrovascular, or peripheral vascular circulation. The problems with most of the studies are that they are retrospective, non-randomized, often have imbalances in the cardiovascular-related comorbidities in the two treatment arms, and include patients who received as little as one shot over as many as three years as being in the treatment group. In addition, there is usually no mention of a stringent monitoring system in place, as described above. Currently, the FDA and the NIH have prospective studies in progress.

There is no doubt that symptomatic hypogonadism is an important condition that merits attention and treatment. Of course, as in all treatments, the patient and the physician must partner into the decision to

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treat. However, the improved quality of life in treated patients cannot be denied, and the benefits outweigh the disadvantages and risks in the great majority of men. ■

About the Author

Andrew Rosenberg, MD, is a board-certified urologist with Mid-Peninsula Urology Group in Burlingame. A graduate of CMDNJ Rutgers Medical School, he completed a Urology residency program at Beth Israel Medical Center in New York and a urological oncology fellowship at

the University of Texas, Department of Urology, Anderson Cancer Center, in Houston.

...Continued from page 4

“I think these were supposed to make physicians better at communicating with patients, but I just feel blackmailed into doing whatever a patient wants because I don’t want to get in trouble with my department head, I don’t want to take a financial hit and I don’t want to lose my job.”

When I first started practice in 1996, I remember thinking that making a diagnosis and coming up with a treatment plan were sometimes the relatively easy parts of my day. Figuring out how to have the discussion with a parent was much more difficult. If I said too much about a diagnosis a parent might panic, if I said too little they might think I was condescending and uncaring, and if I tried to tell them an unpleasant truth in the “wrong way” they would just stop coming to see me. Many years later I think I have found a style that works for me and my patients, but I had the luxury of developing it in a mentored environment where I could try out different approaches.

The art of connecting with patients takes constant practice, and each of us has developed our own unique personal style. I’m not sure Press Ganey scores would motivate me to be a better communicator any more than the simple reality that in private practice, if your patients aren’t happy with you they just stop coming to see you. And that has very real financial consequences as well.

Customer satisfaction often boils down to effective communication, and effective communication is especially critical in medicine. Could we as a profession do a better job at it? Absolutely…but the only way to get better is to practice, and when you practice you are bound to make mistakes. Constructive feedback used in a supportive environment can help us refine and hone our skills. Introducing financial rewards or punishments into this process only de-incentivizes physicians from stepping out of their comfort zone and trying different ways of communicating. When we penalize honesty on the part of physicians, that can lead to devastating consequences for everyone.

Doctors and patients might be better served if we could get back to the original intent of such surveys: use the feedback to create a more efficient system, give physicians the concrete tools and support they need, and help patients find an effective voice. That sounds like a real win-win to me. ■

President’s Message by Niki Saxena, MD

Executive Report by Sue U. Malone

...Continued from page 6

With the knowledge we already had and the information gleaned from the Advocacy meeting, we were armed and ready to address the SGR and other issues when we meet with our House representatives, Congresswomen Anna Eshoo and Jackie Speier. Although we talked about other legislative issues as well, our main message was repeal of the SGR and an “ask” that they sign on as co-sponsors of H.R. 4015. We were thrilled to learn that both assemblywomen took our request to heart and the next day signed on as co-sponsors of H.R. 4015. It is pretty compelling when the House and Senate understands that, since 2003, Congress has enacted 16 patches to stop Medicare physician payment cuts. The cumulative cost of these patches is $153.7 billion, which exceeds the cost of simply repealing the SGR. According to the Medicare Payment Advisory Commission, Congress will never have a better opportunity to eliminate the formula than it does right now. ■

Congresswoman Jackie Speier and SMCMA President-Elect Vincent Mason, MD, in Speier’s DC office.


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TO SCREEN, OR NOT TO SCREEN?

The Ongoing Mammography Controversy

by Harriet Borofsky, MD

Mammography has been studied in greater detail and validated with greater scientific rigor than any other screening test, and yet the controversy surrounding its efficacy continues. Most recently, the British Medical Journal’s publication of the Canadian National Breast Screening Study (NBSS) spurred heated emotional and scientific debate last month. More than two decades of follow-up on the Canadian study showed no mortality benefit in women screened versus not screened, emboldening the opponents of screening mammography and making front page news of The New York Times: “Vast Study Casts Doubts on Value of Mammograms.”

The efficacy or “value” of screening for breast cancer is an important medical, as well as public health issue, with enormous implications regarding allocation of funds and resources for the benefit of reducing the

risk of dying from this common disease. It is critical for us, as physicians—who advise and consult women who are hearing confusing or conflicting messages in the media—to review and understand the science and rationale behind why and how we screen for breast cancer, the existing proof of benefit to patients and whether the Canadian study qualifies as a legitimate trial of modern mammographic screening.

Why and how we screen for breast cancer

Breast cancer fulfills the three main criteria for screening appropriateness: it is common, it causes significant morbidity and mortality, and it is progressive. The American Cancer Society estimates that in 2014, 232,340 new cases of invasive breast cancer and another 55,000 cases of ductal carcinoma in situ (DCIS) will be diagnosed in women in the United States and that approximately 39,620 women will die of this disease. Excluding skin cancer, breast cancer is the most common malignancy among American women and is the second leading cause of cancer related deaths (second only to lung cancer). Early detection, through screening, offers an opportunity to halt its natural progression before metastatic disease occurs, to increase treatment options and, ultimately, to save lives.


Mammography is the accepted imaging test for evaluating a population of asymptomatic women in an effort to detect unsuspected breast cancer at an earlier stage and smaller size than would otherwise be found by other means. As a screening test, it has been proven to be safe, well tolerated and amenable to population-based, widespread utilization.

Radiographic imaging of the breast was first attempted in the 1960s using high-dose, industrial film studies. It was soon upgraded in the 1970s to xeromammograms, which had significantly improved exposure latitude and resolution. Modern mammography, using dedicated, film-screen combinations, was introduced in the 1980s and both significantly improved contrast resolution and reduced radiation dose. Digital mammography, in the 2000s, replaced film with digital detectors and computer generated images, further improving contrast resolution, reducing radiation dose, and increasing efficiency of image acquisition, display, and storage. Digital mammography also created the platform for the most recent and possibly most impactful advance in mammography, Digital Breast Tomosynthesis (DBT). The new ability to generate tomographic, 1 mm-thin images through the breast tissue improves upon the main limitation of mammography: overlapping tissue. Several observational trials and a prospective screening trial of this technology have already shown that it increases overall mammographic accuracy, leading to an increase in breast cancer detection rate, while reducing false positives.

Proof of benefit

While it is an undisputed fact that mammographic screening in the modern era detects small, early stage disease, the primary scientific proof of benefit is to determine whether this results in a decrease in breast cancer deaths that can be attributed to screening. Between 1940 and 1990, the death rate from breast cancer remained unchanged in the United States. According to the NCI, since mammographic screening reached widespread utilization in the 1990s, the death rate from breast cancer in women 40 and older began a sudden and sustained decrease by 2.2% per year, leading to an overall decline of 30%.

Population-based, randomized controlled trials (RCTs) are considered the gold standard in evaluating the overall benefit of any screening test. If randomly

screened women in a population have fewer cancer specific deaths compared to unscreened women, and if that difference is statistically significant, then efficacy is validated. While it would no longer be medically ethical to conduct a screening trial for mammography, there have been seven published RCTs performed in the United States, Europe, and Canada in the 1960s through 1980s. All, with the exception of the Canadian study, showed a significant reduction in breast cancer mortality in screened women, ages 40-74, ranging from 20%-44% (Table 1). Given the marked improvement in mammographic technology since these studies were conducted, and given the known, inherent contamination in the study groups ( i.e., some women invited to be screened chose not to be screened and some women not invited to be screened underwent screening), the mortality benefit due to screening is estimated to be in the 30%-65% range.

Table 1: Summary of Randomized Controlled Trials, 1963-1980

Trial Year Participants Ages Mortality Reduction

HIP (Health Plan of NY)

1963 62,000 40-64 23%

Swedish 2-County

1977 162,981 40-74 34%

Malmo 1976 42,000 45-69 20%

Stockholm 1981 38,525 40-65 21%

Gothenburg 1982 52,000 39-59 30% (ages 50-59);44% (ages 40-49)

Edinburgh 1978 45,130 45-64 29%

Canadian NBSS 1980 90,000 40-59 None

Canadian National Breast Screening Trial (NBSS)

The Canadian study ran from 1980 through 1985 and enrolled women ages 40-59 in 15 centers in six Canadian provinces. It was designed to determine the efficacy of screening in women ages 40-49 with mammography and clinical breast exam versus routine follow-up; and to compare the relative contribution of mammography versus clinical breast exam in women ages 50-59. The study recruited approximately 50,000 women, ages 40-49, and 40,000 women, ages 50-59, and


reported its initial five year results in 1992. Screened women, ages 40-49, had a poorer overall survival from breast cancer (of 75%), compared to non-screened women, who had an overall survival of greater than 90%. The 25-year update, recently published in the British Medical Journal, showed no breast cancer mortality difference in women screened versus the control group.

As these results are alarming in suggesting that mammography may be an ineffective tool in reducing deaths from breast cancer and are strikingly different from those found in six other trials and observational data, the methodology, the quality of the screening process, and the overall validity of the Canadian study must be examined and questioned. While randomized control trials are widely accepted as the standard for demonstrating the efficacy of an intervention, if not designed properly, results can be misleading or faulty.

Random assignments of patients to screened and control groups are critical to the accuracy and validity on any screening trial. Unlike the other RCTs, where large numbers of women in a given population randomly received invitations to be screened, the Canadian study participants were volunteers, recruited to participate by their physicians or through publicity/marketing campaigns. This introduces a selection bias whereby women with breast symptoms and potentially more advanced disease than a random sample of the population, may choose to enroll. Unlike other RCTs, the Canadian study participants received breast exams by trained physicians and nurses prior to being placed in the screened versus not screened (control) group. This fact introduces a randomization bias whereby women with palpable findings and potentially more advanced disease may be assigned to the screened group.

These biases are reflected in the outcome analysis of study participants. Tumors in the screened arm of the study were larger in size and more advanced than would be expected in an asymptomatic population of women. The mean tumor size in mammography arm was 19 mm, compared to 21 mm in the control group. Lymph node positivity in the screened group, which would be expected to be less than 25% (according to American College of Radiology benchmark, and ranging from 5%-11% in our screening experience), was 30.6%, compared to 32.4% in the control arm. More advanced than expected tumors in the screened group

likely explains the poorer survival statistics initially reported in women, ages 40-49, and explains the lack of overall mortality benefit in screened women.

Results of the mammography arm of the study also raise serious concerns about the quality of the screening exams and expertise of the interpreting radiologists. Only 32% of cancers in the mammography arm were detected by mammography, a surprisingly low number compared to an expected mammographic breast cancer detection rate of at least 85%. Flawed and widely discredited, the Canadian study is not a legitimate trial of modern mammographic screening and should not be used to make any policy decisions about screening utilization.

To screen, or not to screen?

Screening for breast cancer has become a hotly debated public health issue. Most opponents of mammographic screening argue that the enormous allocation of resources and costs, both financial and human, in terms of stress and anxiety, outweigh the degree of benefit to the individual woman. The undisputed scientific facts, including six RCTs and three decades of screening experience, are that mammography, especially with current technology, reduces the size and stage of most breast cancers at detection, increases opportunity for less invasive surgeries and effective targeted treatment options, and saves lives. If we want to continue the significant progress that has been in reducing breast cancer deaths over the past two decades, we need to recommend annual screening mammograms in women 40 and older. ■

About the Author

Harriet Borofsky, MD, is medical director of breast imaging at Mills-Peninsula Women’s Center, the first of its kind in the region to provide expert diagnosis, treatment and education for health issues that are specific to women. She attended Brown University and Harvard Medical

School, and completed her residency and fellowship at Stanford Medical Center.


by Christo Zouves, MD

Until recently, the prospect of storing gametes, whether they are eggs or embryos, was great in theory but not in practice because the method of freezing that has been used for the last 25 years resulted in the loss of up to 30% and produced eggs or embryos that were significantly devitalized by the process. As a result, a frozen transfer was always a bonus, but the success rates were lower than with a fresh transfer.

This all changed over the last six to ten years with the development of the ultra rapid cryopreservation method called vitrification, developed and perfected in Japan.

With the introduction of vitrification, the survival rates for both eggs and embryos has risen to better than 95% and the resulting gametes appear to be almost as good as they were in the fresh state. This single innovation allows us to consider the option of banking either eggs or embryos without compromising success when these gametes are ultimately used. This allows young women to bank their eggs while they are still in the prime of reproductive life and return many years or even decades later to use these vitrified eggs to have a family with their own genetics. Without the ability to “stop the clock,” they would otherwise have been looking at a much lower chance of success or even the option of having to do in vitro fertilization (IVF) with egg donation.

The availability of vitrification also allows us to increase the chances of success for patients with decreased ovarian reserve (DOR) or patients over age 40 who are not yet ready to pursue egg donation. By setting out to do multiple cycles of stimulation with the banking of unfertilized eggs, one can do two or three stimulations with egg retrieval in rapid succession, bank these eggs unfertilized and then thaw them at one time in the future, allowing for one single fertilization procedure and one single procedure of preimplantation genetic screening (PGS), which permits the selection of embryos that are then chromosomally normal and of good quality for transfer. If there are more normal embryos available than are transferred, these can be revitrified for future use.

In IVF centers with access to advanced laboratory facilities and vitrification, frozen embryo transfer procedures now yield the same or even better success rates compared with the transfer of fresh embryos when the egg provider has herself been stimulated and undergone egg retrieval.

As the success rate with frozen/thawed embryos approaches and surpasses the pregnancy rate in fresh cycles, more and more cycles of conventional IVF, where a woman provides the eggs and carries the embryos herself, will now become cycles where embryos are banked by vitrification, the patient returns the following month for a frozen embryo transfer, either with natural ovulation, if this is predictable, or else with a controlled frozen transfer, where natural estrogen and progesterone are supplied in sequence allowing for a planned frozen embryo transfer.

EGG/EMBRYO BANKINGFrozen Embryo Transfers Can Be More Successful than Fresh


The innovation of vitrification of eggs and embryos allows us to consider increasing the chances of ultimate success for patients with DOR by allowing the banking of unfertilized eggs over two or three retrievals followed by the selection of normal and good quality embryos for subsequent frozen embryo transfer. There will also be cost savings due to discounted multiple retrieval plans and the performance of a single fertilization by intracytoplasmic sperm injection (ICSI) and a single PGS procedure.

We have analyzed the first year of doing multiple retrievals followed by a single fertilization and CGH testing, and it appears as though the patients who benefit most from the double retrieval are patients with a resting count of less than six with high FSH and very low AMH levels. These patients generally

produce fewer than six eggs in a cycle and often only two or three. When we looked at the patients with better reserve, it appears as though a single cycle with fertilization and testing of blastocysts is better and may shorten the process and make the second retrieval unnecessary.

Experts from Aberdeen University reviewed 11 previous studies that followed to birth more than 37,000 pregnancies resulting from the transfer of either fresh or frozen thawed embryos. When frozen embryos were used, there was a 30% lower risk of bleeding during pregnancy, 30-40% less chance of the baby being born underweight, 20% lower chance of premature delivery and 20% less likelihood of dying in the neonatal period. The study by Dr. Abha Maheshwari, “Obstetric and Perinatal Outcomes in Singleton Pregnancies Resulting from the Transfer

of Frozen Thawed Versus Fresh Embryos Generated Through in Vitro Fertilization Treatment: A Systematic Review and Meta-Analysis,” was published in the journal Fertility and Sterility and was presented at the British Science Festival in Aberdeen in 2012. Dr. Maheshwari said, “We found pregnancies arising from the transfer of frozen thawed embryos seem to have better outcomes both for mothers and babies when compared to those after fresh embryo transfer.”

“If pregnancy rates are equal and outcomes in pregnancies are better, our results question whether one should consider freezing all embryos and transfer them at a later date, rather than transferring fresh embryos,” Maheshwari said. The practice has already been adopted by some clinics in Japan, where the process of vitrification was first developed. ■

About the Author

Christo Zouves, MD, is medical director of Zouves Fertility Center in Foster City. He studied medicine at the University of Cape Town in South Africa and completed residencies and fellowships in OB/GYN and General Surgery at Royal Colleges in London, England.

Prior to opening Zouves Fertility Center in 1999, Dr. Zouves was the Medical Director of Pacific Fertility Center in San Francisco for seven years.

In IVF centers with access to advanced laboratory facilities and vitrification, frozen embryo transfer procedures now yield the same or even better success rates compared with the transfer of fresh embryos when the egg provider has herself been stimulated and undergone egg retrieval.


“The Times They Are A-Changin.’” There are many practice opportunities for physicians to consider for the future. Will you remain in solo practice? Merge with others to form a bigger single specialty, multi-specialty group or ACO? Join a Foundation or University Affiliation? This workshop will present a balanced discussion of options and issues for physicians to consider before making these important practice decisions.

Topics Include:

Is solo or small group practice viable for the future?

• How to survive and thrive by savvy management and marketing

• Is the “concierge” model right for me?

Merger Mania – Should you merge with others?

• Single Specialty or Multi-Specialty – pros and cons

• Important elements in merging - deal makers and deal breakers

• Can merging reduce expenses/increase net income, maintain independence, increase contracting power to remain in private practice?

• Will merging position the group for future acquisition?

Joining a Foundation, University Affiliation or Hospital Outpatient Clinic Model

• When to consider an offer and How to assess an offer

• Will goodwill or intangible asset value be included or excluded and how will this be valued?

• How will tangible assets including equipment be valued?

• How many years should the contract be guaranteed?

• Governance and decision making ability?

• Compensation models including base salary and $ per WorkRVU – How this works

• What will it be like being an employee?

• What if I want to leave?

This seminar will be taught by Debra Phairas, president of Practice & Liability Consultants in San Francisco. Ms. Phairas is an experienced practice management consultant who has appraised more than 350 medical practices of all specialties and assists physicians in valuing, buying, selling, merging, evaluating position opportunities and transitioning from training to practice. Learn more at www.practiceconsultants.net.

DATE & TIMEWednesday, April 16, 2014

Appetizers: 6:15 P.M.

Program: 6:30-7:45 P.M.

LOCATIONSan Mateo County Medical Association

777 Mariners Island Boulevard

Suite100

San Mateo

COST$99 SMCMA Members

$249 Non-members

Light refreshments will be provided.

PRACTICE OPTIONS: SELF EMPLOYMENT VS. GROUP AFFILIATION?WHAT IS YOUR STRATEGY FOR THE FUTURE?

San Mateo County Medical Association

- EDUCATIONAL SEMINAR -

Physician Name:

Name and Address of Medical Practice:

Phone: Fax: Email:

Payment Method: Check Enclosed Charge my Visa/Mastercard/Discover (please circle your card type)

Card Number: Expiration: 3-Digit Security Code:

Please fax your completed registration form to (650) 312-1664, email to [email protected] or mail to SMCMA, 777 Mariners Island Boulevard, Suite 100, San Mateo, CA 94404.


INDEX OF ADVERTISERS

First Republic Bank ........................................................................ 5

The Magnolia of Millbrae ....................... Inside Back Cover

Marsh ...............................................................Inside Front Cover

Medical Insurance Exchange of California (MIEC) ...... 11

NORCAL ....................................................... Outside Back Cover

Tracy Zweig Associates ............................................................ 18

For advertising information, please contact Shannon

Goecke at (650) 312-1663 or [email protected].

The following SMCMA members have recently

retired from practice:

Michael Mainardi, MD

and

Laurie Yang Marsh, MD

Tracy Zweig AssociatesA R E G I S T R Y & P L A C E M E N T F I R M

INC.

[email protected]

www.tracyzweig.com

Voice: 800-919-9141 or 805-641-9141

FAX : 805-641-9143

Locum Tenens

Permanent Placement

Physicians Nurse Practitioners

Physician Assistants

SMCMA MEMBER INFORMATION UPDATE

Please note: The following information was not received in time to be included in the 2014 SMCMA Membership Directory and Desk Reference. Please update your records to indicate that Alberto Bolanos, MD, practices at two addresses:

Alberto Bolanos, MD/*ORSOrthopedic Institute of the Bay Area

NEW SMCMA MEMBERS

David Wanderman*PD/S San Francisco

d dJulie Hersk, MD*EM/San Mateo

l kTeresita Degamo*IM/Daly City

Carina Baird, MD*PD/Burlingame

* Board-certified by the American Board of Medical Specialties

100 S. San Mateo DriveSuite 424San Mateo, CA 94401262-4262 Fax: 262-5862

1850 Sullivan AvenueSuite 150Daly City, CA 94015991-5880 Fax: 991-5886

Has your information changed since the Membership Directory was published? Please let us know by calling(650) 312-1663, faxing to (650) 312-1664, or emailing [email protected].


THE PENINSULA’S PREMIER RETIREMENT COMMUNITYRCFE# 415600154

201 Chadbourne Avenue | Millbrae, CA 94030

(888) 862-6915(650) 697-7700

www.themagnolia.com

GET A NEW TAKE

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BUCKET LIST.

777 Mariners Island Boulevard, Suite 100San Mateo, California 94404

ADDRESS SERVICE REQUESTED

NORCAL Mutual is owned and directed by its

physician-policyholders, therefore we promise

to treat your individual needs as our own. You

can expect caring and personal service, as you

are our first priority. Visit norcalmutual.com, call

877-453-4486, or contact your broker.

PROUD TO BE ENDORSED BY THE SAN MATEO COUNTY MEDICAL ASSOCIATION

A N O R C A L G R O U P CO M PA N Y

March 2014

Documents

Transcript of March 2014