WSUS Women's Health Guide

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Kathleen Kobashi-Porter, MD

WSUS Women’s Health Chair

With the fast pace of life, it can be di� cult for many of us to � nd the time to take proper care of ourselves. Although there is a plethora of health-related information available on the Web and in the media, it is often challenging to identify helpful and precise information on which to base our healthcare decisions.

Several years ago, the Men’s Health Initiative created a Guide to Men’s Health that has been very well-received. Consequently, it seemed � tting to proceed with a women’s version of the Guide to provide brief and accurate information for the women in our com-munity. Contained in this booklet is information ranging from nutrition, alternative medicine, cancer screening and treatment options to treatment of urinary incontinence and pelvic prolapse.

� e goal of this “healthzine” is to provide women with a reliable abbreviated resource to which they can turn for important women’s health care issues. Authors from across the state of Wash-ington have been gathered to contribute in their respective � elds to provide a reliable and useful source of information.

Every couple of months a new article will be added to this on-line health guide to provide new material on an active basis until the entire guide is available. � e articles found within the guide are updated regularly representing a current per-spective on ongoing health issues facing women.

As October 2008 is Breast Cancer Awareness month, the breast cancer overview will be high-lighted as our introductory “chapter.”

We hope you � nd this guide a useful reference and would appreciate any feedback from our readers.

For additional information on this re-lease, please contact:

Kathleen Kobashi-Porter, MD

via Debi Johnson

[email protected] (425) 971-5822

INTRODUCTION

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Debra G. Wechter, MDVirginia Mason Medical CenterSeattle, WA

Breast cancer is the most commonly occurring cancer in women and will a� ect one in nine women in their lifetime. � e cause of the majority of breast cancers is unknown though risk factors which may be associated with the development of breast cancer include early age with � rst menstrual period, late age at menopause, late � rst pregnancy, nulliparity, no breastfeeding, and a family history of breast or ovar-ian cancer.

Only 5-10% of breast cancers are hereditary. � ere are two gene mutations, BRCA1 and BRCA2, which increase the lifetime risk of breast cancer up to 85% and ovarian cancer as high as 60% in a� ected wom-

en. Women (or men) who might be at risk of having a genetic mutation include those with:

• Early onset breast cancer

• Two primary breast cancers

• Family history of early onset breast cancer

• Personal or family history of male breast cancer

• Personal or family history of ovarian cancer

• Ashkenazi Jewish heritage

• Known BRCA mutation in the fam-ily.

In BRCA carriers, one of the options for prevention is prophylactic bilateral mas-tectomy. If not done, follow-up should include yearly mammogram, yearly breast MRI and twice yearly clinical breast exam. Prophylactic oophorectomy reduces the risk of ovarian cancer, and

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BREAST CANCER

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also reduces the risk of developing breast cancer by 50% in premenopausal women. Tamoxifen may also decrease the risk of breast cancer.

Screening for breast cancer includes breast self exam (BSE), clinical breast exam (CBE), and mammography. Although BSE is widely recommended, there is actually no compelling evidence to show that BSE a� ects prognosis. Although some women � nd it reassuring to become familiar with their breast exam, others may � nd it intimidating to try to assess a breast abnormality. Performing BSE is a personal choice that should be discussed with a woman’s primary care provider. CBE is recommended by the American Cancer Society every 3 years for women in their 20’s and 30’s, and annually for asymptomatic women who are 40 and older. Screening mammography is recommended yearly for women 40 and older by the Ameri-can Cancer Society. Screening breast MRI is reserved for women with a high lifetime risk of breast cancer and guidelines for its use have been published by the American Cancer Society (cancer.org; CA Cancer J Clin 2007;57:75-89).

If a breast mass is found on exam, mammogram and ultrasound may be used to assess the mass. If a mammogram is abnormal, additional mam-mographic views and ultrasound may be used. If

exam or imaging is suspicious, the preferred method of diagnosis is core needle biopsy which is performed under local anesthe-sia by a breast radiologist or surgeon using mammogram, ultrasound or palpation for guidance.

Once a diagnosis of cancer is made, a mul-tidisciplinary team including providers with expertise in radiation oncology, medical oncology, breast surgery, plastic surgery, and genetic counseling guides evaluation and treatment.

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� e clinical stage of the tumor is based on tumor size, lymph node status, and presence or absence of metastases. Lab tests and imag-ing such as chest x-ray, breast MRI, PET/CT scan, bone scan, and CT scan are chosen to help de� ne the stage based on NCCN guidelines (cancer.org).

Surgical options for treatment of the breast are partial mastectomy (lumpectomy) and mastec-tomy. Partial mastectomy is usually performed as an outpatient procedure and involves re-moving the cancer with a rim of normal tissue around it. If the mass is not palpable, either wire localization with mammogram or ul-trasound, or ultrasound alone, identi� es the cancer for the surgeon. With wire localization, a mammogram or ultrasound is performed to identify the cancer and a skinny wire is inserted through a needle toward the cancer under local anesthesia. In the operating room, an inci-sion is made using the wire as a guide and the cancer is removed with a rim of normal breast tissue around it. An x-ray is taken of the tissue to prove the cancer has been removed and that there is a clear margin.

A mastectomy removes the entire breast and nipple-areolar complex, but not the muscle un-derlying the breast. A skin-sparing mastectomy removes the entire breast and nipple, but leaves a small rim of skin around the nipple, allowing more skin to be used in reconstruction. Recon-struction by a plastic surgeon can be performed at the same time (immediate) or at any point in

the future (delayed). � e two primary options include implant reconstruction, or autologous reconstruction using one’s own tissue from the abdominal wall, buttock or back.

One of the � rst places that breast cancer can spread is to the lymph nodes under the arm. With invasive cancer, the lymph nodes are as-sessed with sentinel lymph node biopsy (SLNB) unless the lymph nodes have already been shown to have cancer by biopsy or imaging. � is technique removes the � rst node or nodes draining the cancer through microscopic lymph channels from the breast to the axillary nodes.

To � nd the sentinel node, a small amount of radioactive tracer is injected into the breast using local anesthesia the afternoon before or the day of the operation. In the operating room, sometimes a blue dye is injected into the breast as well. � e radioactive or blue sentinel node is removed using a gamma probe (a small Geiger counter) and evaluated by the pathologist. If the sentinel node has cancer, an axillary node dissection may be performed. � is involves removal of the lower level lymph nodes in the fatty tissue under the arm.

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Additional treatment after operation may include radiation therapy, chemotherapy and hormonal therapy. Women who under-go partial mastectomy also require radiation treatment to the breast to reduce the risk of recurrence. Without radiation, the chance of cancer coming back in the breast may be up to about 30%, though with radiation the risk is at most up to 10-15%. Whole breast radiation begins a few weeks after opera-tion and is given over approximately 6 weeks for a few minutes each weekday. A newer technique called accelerated partial breast radiation may be appropriate in selected patients. It is not yet considered the stan-dard of care because we do not know that the long term risk of breast recurrence is as low as with whole breast radiation. � e area of cancer is treated twice daily for � ve con-secutive working days using external beam radiation, placement of an intracavitary balloon catheter (MammoSite®), or, least commonly, insertion of interstitial wires through the breast tissue. Some women will require radiation therapy after mastectomy to reduce the risk of chest wall recurrence if the invasive cancer is 4 cm or larger in size, if there are 4 or more lymph nodes involved with cancer, or if the cancer is close to the skin or chest wall.

� e use of hormonal therapy may be consid-ered in women whose tumors test positive

for estrogen and/or progesterone receptors depending upon tumor size, lymph node sta-tus, and other factors. � ese oral medications are usually taken for up to 5 years.

� e primary purpose of chemotherapy is to treat or prevent metastasis (spread to lymph nodes, liver, lung, bone or other organs). Recommendations are based on tumor size, lymph node status and other factors such as age and coexisting medical conditions. Che-motherapy is usually given intravenously every one to three weeks for a period of 3-6 months. In women with “HER-2 positive” tumors, Herceptin (trastuzumab), a mono-clonal antibody, may be considered for treat-ment. HER-2/neu is a tumor oncogene that is “overexpressed” or positive in some tumors.

After initial treatment, women who have had breast cancer are followed with regularly scheduled exams and mammograms to look for evidence of recurrent cancer in the breast or elsewhere in the body. Follow-up guidelines may be found on the National Comprehensive Cancer Network website (nccn.org).

For additional information on this release, please contact:

Debi Johnsonwww.wsus.org

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COLORECTAL CANCER PREVENTION AND SCREENING

COLON CANCER

Richard P. Billingham, MD

Swedish Medical Center (Seattle, WA)

Women are usually quite well informed about methods of early detection and prevention for cancer such as breast and cervical cancer. However, the risks of development of colorectal cancer, and the methods of prevention of this deadly disease, are less well known. Colorectal cancer is the second leading cause of cancer death for both men and women in the United States. This year, more than 153,000 people in the U.S. will be diagnosed with colorectal cancer; more than 52,000 will die from their disease.

Colorectal cancer is one of only three cancers which

can actually be prevented by regular screen-ing examinations (the other two cancers which can be prevented are cervical cancer and skin cancer). Therefore, it is important for women to understand A) that colorectal cancer ispreventable; B) the methods by which colorectal cancer can be prevented; and C) how and when these methods should be used based on certain risk factors such as age, family history, personal history of other cancers and history of other related disease.

Nearly all colon and rectal cancers come from “polyps”, which are small, benign (non-cancerous) growths on the lining of the colon and rectum which may progress to cancer. Approximately 20% of all people will develop polyps. When they are small, polyps almost never cause symptoms and most people are unaware that they have them. While not every polyp will turn into a cancer, many polyps will become cancerous if not removed. If polyps are present and found early, before they can become cancerous, it is

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possible to remove these, preventing their develop-ment into cancer.

Screening is designed to detect polyps and to elimi-nate them before cancer develops. Prevention of can-cer is the #1 goal, but even if cancer should already be present, early detection, before cancer has had a chance to spread, is also an important factor in lead-ing to a cure and saving lives.

How does a person get screened?

The American Cancer Society recommends colonos-copy as the best method for screening.

When should I be screened?

The timing and frequency of colonoscopy is based on risk of developing this kind of cancer and is usu-ally categorized as average, moderate, or high risk.

Average Risk

The average risk of developing colorectal cancer for both men and women over the age of 50 is approxi-mately 1 in 20 if no screening is done. For those at average risk, the American Cancer Society recom-mends colonoscopy every 10 years beginning at age 50.

Moderate Risk

People are at moderate riskfor colorectal can-cer if they have either:

· a personal history of polyps or colorectal cancer themselves;

· a family history (sister, brother, parents or children) of colorectal cancer or polyps;

· a personal history of breast, ovarian or endo-

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metrial cancer, or

· a personal history of infl ammatory bowel disease, such as ulcerative colitis.

The risk of developing colorectal cancer in this group is three times greater than the average risk group or 1 person in 6, if no screening is done. Most women in the moderate risk category should have colonoscopy every 3 to 5 years beginning at age 40. For those with infl ammatory bowel disease involving the colon, specifi c recommendations for screening vary widely and should be discussed with your physician.

High Risk

People at high risk for colorectal cancer include those that have either:

· a family history of “familial adenomatosis polyp-osis” (a genetic disorder causing cancer to develop at an early age in 100% of those), or

· a family history of “hereditary nonpolyposis colon cancer” (HNPCC) (a genetic disorder with several other family members, especially under the age of 50, having colorectal cancer). Those in ei-ther of these risk groups should have colonoscopy every 1 to 2 years beginning no later than age 21.

These recommendations are based on guidelines published by the American Cancer Society, the American Society of Colon and Rectal Surgeons, the American College of Gastroenterology and

other interested groups. Your doctor may offer you other options for screening and surveillance based on your state of health and risk factors.

Now, about that colonoscopy…

A colonoscopy is an examination of the entire co-lon and rectum using a lighted fl exible instrument. This test requires clearing the bowels with laxa-tives on the day before the test. Colonoscopy has the advantage of viewing the complete lining of the colon and is very accurate in detecting polyps. Polyps can be removed without discomfort at the time of the examination.

Colonoscopy can be performed either by a gas-troenterologist (those trained in the diagnosis and medical treatment of disorders of the esophagus, stomach, small intestine and large intestine), or by a colon and rectal surgeon, (those trained in the di-agnosis, as well as medical and surgical treatment, of disorders of the colon, rectum and anus).

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In summary…

Know your risks, talk to your doctor, and follow the recommended timelines for screening. It could save your life.

For additional information on this release, please contact:Richard P. Billingham, MDPhone: DEBI JOHNSON (425) 971-5822Email: [email protected] Source: Richard P. Billingham, MD Website: N/A

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CORONARY ARTERY DISEASE

John Holmes, MD

Virginia Mason Medical Center (Seattle, WA)

Coronary artery disease has been widely considered a “man’s disease” and not a major concern for women. Yet cardiovascular disease is the leading cause of death in adult women in the United States. It is also a leading cause of disability among women. Women’s age-adjusted mortality rates from coronary artery dis-ease are four to fi ve times higher than their mortality rates from breast cancer.

Coronary artery disease is caused by the gradual buildup of plaque (made of fat, cho-lesterol and other substances) on the inside wall of the coronary arteries, which supply oxygen-rich blood to the heart. Over time, the plaque deposits grow large enough to narrow the arteries inside channel, decreasing blood fl ow to the heart muscle. If the plaque be-comes unstable and ruptures, a blood clot can form at the rupture site and block blood fl ow altogether, resulting in a heart attack.

The risk factors for developing coronary artery disease in women are the same as in men; they are elevated blood cholesterol, high blood pressure, smoking cigarettes, diabetes mellitus, obesity, physical inactivity and a family history of coronary heart disease at a young age. In many coronary artery pa-tients, central obesity, hypertension, impaired glucose metabolism and hyperlipidemia are clustered in what has become known as the “metabolic syndrome”.

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WSU

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DIAGNOSIS AND MANAGEMENTHope Druckman, MD

Overlake Medical Center (Bellevue, WA)

Osteoporosis is a common and silent disease primarily affecting women, particularly in the postmenopausal years. This is a costly problem of enormous public health proportions. It is important to focus on screen-ing and treatment of this condition, so that we can prevent serious fractures. Hip fractures in the elderly can be particularly debilitating, resulting in loss of independence, nursing home placement, and in some situations can lead to death because of complications such as blood clots to the lungs. Fortunately, accurate, cost effective, and safe testing is now available to diagnose osteoporosis.

The defi nition of osteoporosis is based on measure-ments of bone density, or the strength of the skeleton. By using a machine called a DEXA scan, it is possible to look at an individual’s bone density and compare it to those who are of the same age and gender. This is

called the Z score. Comparison is also made to young adults of the same gender and is termed the T score. A BMD or bone mineral density between -1 and -2.5 standard deviations below the young adult mean bone density is defi ned as osteopenia, or low bone mass. A BMD which is less than- 2.5 is the defi nition of osteoporosis. As BMD decreases, the relative risk of developing fracture increases. Bone density is measured in both the spine as well as the hip. In people with signifi cant degenera-tive arthritis, particularly in the spine, this can falsely elevate the score and not give a true picture of an individual’s bone density.

There are a number of factors associated with fracture risk. Many fractures occur in women who do not have osteoporosis, but osteopenia, because there are so many more patients who fall into this category. Factors which have been shown to affect fracture risk and are independent of BMD include ad-vanced age, previous fracture, low body weigh less than 127 pounds, cigarette smoking, ex-cessive alcohol intake, chronic treatment with steroids and also family history of hip frac-ture. The most signifi cant of these risk factors are increasing age and previous fracture.

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In the United States, many experts are recommend-ing bone density screening in postmenopausal women 65 and older. Screening recommendations for women under the age of 65 are not as clear, and are based on risk factor assessment. Individuals should be coun-seled about reducing risk factors, most importantly smoking cessation. They should also be encouraged to limit alcohol intake and participate in regular exercise with a focus both on weight-bearing as well as muscle strengthening. Any weight-bearing exercise regimen, including walking is helpful. Exercises which help with balance are important because this can help to prevent falls. It is also important to assess the home for any potential fall risks, such as loose throw rugs and clutter on the fl oor. All adults should be consum-ing at least 1200 mg. of calcium per day as well as 400 to 800 units of Vitamin D per day. For those women without risk factors for accelerated bone loss, follow up DEXA scans should be performed every three to fi ve years. In women who have just gone through the menopause, since the most pronounced bone loss oc-curs during the fi rst fi ve years, screening DEXA scans might be recommended more frequently, depending upon other risk factors.

According to the National Osteoporosis Foundation, pharmacologic therapy is recommended for postmeno-pausal women with T-scores less than -2.0, regardless of risk factors for fracture, and with T-scores less than -1.5 if risk factors are present. The most commonly used medications are called bisphosphonates. These medications stimulate growth of new bone. Newer

preparations of this category of drug can be administered either once a week or once a month. Patients need to take this medication on an empty stomach with a large glass of water, and must remain upright for an hour, in order to prevent the relatively unlikely prob-lem of the pill being lodged against the wall of the esophagus and causing esophagitis.

Another category of medication used for the treatment of osteoporosis is the selective estrogen receptor modulator (SERM). Raloxi-fene has been shown to increase bone mineral density and reduces the risk of vertebral frac-tures. This drug also appears to lower the risk of breast cancer. Tamoxifen, which is another SERM that is used for the prevention and management of breast cancer, is not specifi -cally prescribed for treatment of osteoporosis, but has been shown to protect bones.

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Estrogen and progesterone therapy had been previously used as a fi rst-line treatment for osteo-porosis, but since the Women’s Health Initiative Study showed a small but real increase in the risk of breast cancer, stroke, thrombophlebitis, or blood clots, and heart disease, this is no longer the case. Hormone replacement therapy (HRT) is still used in women with menopausal symptoms and for women with an indication for treatment with the bisphosphonates who are unable to tolerate this category of medication.

Calcitonin, which is a hormone that stimulates bone growth, is a less effective treatment for osteo-porosis, but is sometimes prescribed. It is admin-istered nasally, with one spray per day, alternating nostrils. Calcitonin can also be used in an inject-able form in the setting of an acute compression fracture of the spine, helping to ease pain in the healing of the fracture.

There is currently no consensus on the optimal approach to monitoring therapy for osteoporosis. Up to one-sixth of women on bisphosphonate or hormone therapy continue to lose bone. Most experts are recommending rechecking the bone density within one to two years of starting therapy to document either improvement or stability of the bones, with less frequent monitoring subsequently.

Individuals who sustain a fracture secondary to osteoporosis and are not on osteoporosis medica-tion should be started long term pharmacologic therapy. In the United States and Europe, the majority of patients who sustain such fractures are

not started on medication despite convincing data demonstrating their benefi t in reducing the risk of developing a second fracture. Men are less likely than women to be evaluated or treated for osteo-porosis after having such a fracture. As men age, they are at risk for development of osteoporosis, although less so than women. Clinicians as well as patients need to be educated about the importance ofosteoporosis treatment after any osteoporotic fracture.

In summary, osteoporosis is a signifi cant public health problem. Prevention of this disease starts at a young age, with adequate calcium and Vita-min D intake. Smoking cessation, modest alcohol intake, as well as regular exercise all contribute to bone health. Women should be screened for os-teoporosis after their menopause, with those who are in a high risk category being screened earlier and more frequently. Those individuals who show substantial bone loss with a T-score of less than -2.0 should begin pharmacologic therapy, prefer-ably a bisphosphonate if tolerated. Our goal is prevention of fractures which not only improves quality of life but also will save billions of dollars in health care costs.

For additional information on this release, please contact:Hope L. Druckman, MDPhone: DEBI JOHNSON(425) 971-5822Email: [email protected]

Source: Hope L. Druckman, MD Website: N/A

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