December 13, 2019

Medical Update Fall 2019

Tailored and Targeted


How breast cancer treatment has become more conservative and more effective
By Kasey Fuqua

 

Treatment for breast cancer has come a long way from mastectomies and broad-spectrum chemotherapy. Thanks to new research and clinical trials, treatment has become more personalized — and conservative — than ever, improving not only survival rates but quality of life throughout survival. For the nearly 235,000 people diagnosed with breast cancer in the United States each year, these advances can’t come soon enough.

Brian King, MD

“The ability to individualize the treatment plan to each patient and the biology of their tumors has been the biggest advance in breast cancer treatment in the last decade,” says Brian King, MD, breast surgeon at Sentara Surgery Specialists. “Patients are getting smaller operations and less treatment and still have great outcomes.”

Genetic Testing and Identification of Cancers
Like all cancer treatment, breast cancer therapies have become more individualized thanks to the availability and effectiveness of genetic testing. The American Society of Breast Surgeons recommends that every newly diagnosed breast cancer patient should be offered genetic testing, whether or not they are considered high risk for BRCA1 or BRCA2 genes.

“Genetic testing is critical for anybody who presents at a young age or with a strong family history for breast cancer,” says Michael Danso, MD, medical oncologist at Virginia Oncology Associates. “In that population of patients, there’s a significant chance of finding a gene mutation, particularly BRCA1 and BRCA2.”

Michael Danso, MD

Breast cancer treatment teams use two different tests to develop a genetic profile of cancer: Oncotype DX, which checks for more than 20 genes, and MammaPrint. Together, these tests help physicians determine who is at most risk for the development of metastatic cancer.

“These tests are being used more and more now to tell us who doesn’t need chemotherapy,” says George Kannarkat, MD, medical oncologist at the Peninsula Cancer Institute. “As scary as cancer is, I think chemotherapy is just as scary to most people. If we can avoid chemotherapy in more women, that would be great.”

Understanding gene mutations in breast cancer patients can shape their entire treatment strategy, Dr. Danso says. It can determine what type of chemotherapy they receive, whether they receive therapy before or after surgery, or even if they receive chemotherapy at all.

“On molecular level, knowing more about the particular disease somebody has allows us to give them the right type of therapy rather than the therapy that is for all patients,” says Dr. Danso. “There are sometimes molecular profiles that suggest a better outcome such that you don’t need to give chemotherapy.”

George Kannarkat, MD

Having specific gene mutations may also open the door to more treatment options. ADP-ribose polymerase (PARP) inhibitors are approved to treat patients with HER2 negative metastatic breast cancer if they have a BRCA mutation. These treatments prevent DNA repair in cancer genes, leading to cancer cell death. In clinical trials, including those offered at Virginia Oncology Associates, PARP inhibitors extended progression-free survival time by an average of three months.

Women with other gene mutations may also have access to more targeted therapies. For instance, women with PIK3CA mutations and estrogen receptor positive breast cancer benefit from both anti-estrogen therapy and newly approved PIK3CA inhibitors. In trials, these inhibitors extended progression-free survival by nearly six months.

“Our hope is that eventually we can find a targetable mutation in every breast cancer that we can exploit with some drug rather than using chemotherapy,” says Dr. Kannarkat. “We’re getting there slowly, perhaps one gene at a time.” 

“Individualized therapy is the future of breast cancer therapy,” says Dr. Danso. “Down the road, molecular profiling may be able to determine whether patients need radiation or even surgery.”

Researchers are also studying the benefits of other testing, such as circulating tumor cell assays. These tests check for tumor cells that are flowing through the blood, providing a less invasive sort of biopsy. They are still being studied and currently not available for routine use.

More Treatment Options for Metastatic Cancer
While targeted and hormonal therapies have been used in breast cancer treatment for several years, breast cancer patients have only recently had access to immunotherapy treatment options. 

“It’s hard for a new breast cancer drug to come out and show major improvement on the treatments we already have,” says Dr. Kannarkat. “Thanks to screenings, most of the time we are catching stage 1 or 2 cancers that will be cured 90 percent of the time.”

For patients with more aggressive subtypes of breast cancer or metastatic disease, however, immunotherapy has shown benefits. In patients with HER2 positive cancer, trastuzumab, given with neoadjuvant chemotherapy, increases the chance of a complete pathological response to up to 80 percent. Even after surgery, the use of trastuzumab and chemotherapy is better than chemotherapy alone.

“The most exciting clinical trial we’ve recently been involved in at Virginia Oncology Associates is the use of immunotherapy in triple negative breast cancer,” says Dr. Danso. “The combination of neoadjuvant chemotherapy and immunotherapy showed a significant improvement. The pathologic complete response rate almost doubled in a large randomized trial.”

Triple negative breast cancer is one of the most aggressive forms of breast cancer, with few treatment options until recently. It also affects a greater proportion of patients in Hampton Roads than nationally, “We are participating in multiple clinical trials to better understand and treat this cancer,” says Dr. Danso. “We appear to be making significant strides.”

In addition to immunotherapy, other drug classes are extending survival time for metastatic breast cancer. CDK4/6 inhibitors interrupt cell division and growth in estrogen receptor positive metastatic breast cancers. The oral drugs help patients avoid or delay chemotherapy altogether by stopping cancer progression.

“Patients can sometimes avoid harsher chemotherapy for several years,” says Dr. Kannarkat. “While these drugs have some side effects, they are not nearly as tough as chemotherapy usually is.”

These drugs can also prevent damage to bone marrow cells when patients do receive chemotherapy, allowing oncologists to deliver higher and more effective doses of chemotherapy drugs. Patients who received these drugs with chemotherapy had longer survival times, despite their metastatic or aggressive cancers.

Highly Targeted Radiation Therapy
It’s not just chemotherapy that has become more targeted; radiation therapy has changed dramatically over the past few decades to reduce side effects while boosting effectiveness.

Michele Nedelka, MD

“The difference in the radiation oncology delivery systems of the past and now is the difference between a dial-up phone and the iPhone 10,” says Michele Nedelka, MD, radiation oncologist at Bon Secours Cancer Institute. “Radiation targeting today is far more technologically advanced and precise.”

The precision technology allows radiation oncologists to minimize the dose of radiation delivered to the heart and lungs while maximizing the dose delivered to the breasts. The patient can be tilted or moved millimeter by millimeter to ensure that when they receive treatment, they are perfectly aligned. Respiratory gating also uses special devices to recognize patient breathing and only deliver radiation while the breath is held, which is especially important when treating a left-sided breast cancer because of the proximity to the heart. These tools protect the heart from radiation, reducing a patient’s risk for radiation-related heart damage in the future.

Proton therapy also provides incredibly precise radiation treatment. Unlike external beam radiation, proton therapy does not have “exit doses” that deliver radiation energy along the path to the tumor and beyond. Proton therapy may be particularly beneficial for patients with cancer in their left breast, in order to reduce the risk of damage to the heart and lungs, or for patients with early stage, small breast tumors.

Allan Thornton, MD

“Proton therapy’s effectiveness in the treatment of breast cancer is rooted in the way the dosage is administered; the beam doesn’t penetrate the chest wall,” explains Allan Thornton, MD, Radiation Oncologist with the Hampton University Proton Therapy Institute. “This significantly decreases and oftentimes eliminates the chance that a patient will suffer from heart disease years after receiving treatment.”

Many patients undergoing proton therapy and even external beam radiation therapy for breast cancer can also receive fewer treatments than ever before. Many patients now undergo four weeks of treatment, instead of six weeks. Certain patients with earlier stage breast cancer may also qualify for brachytherapy, which delivers internal radiation to the biopsy cavity.

“For brachytherapy, you remove the tumor through partial mastectomy and then in the cavity that remains, you place a special catheter,” says Dr. King. “The radiation oncologist can send a radioactive seed down and deliver radiation inside that cavity.”

Brachytherapy patients receive radiation twice a day for just five days and then have the catheter removed. Dr. King says in addition to convenience, brachytherapy can have significant cosmetic benefits in women with darker skin. Brachytherapy removes the risk of hyperpigmentation without changing patient outcomes.

Another type of new brachytherapy offered at Bon Secours, MicroSeed, uses low dose rate radioactive seeds to destroy any remaining cancer cells in the breasts.

“They are small, radioactive pellets like the seeds used in prostate cancer,” says Dr. Nedelka. “We can implant them in one setting in our radiation operating room, and the patient returns home with the implanted permanent seeds.”

While patients must meet stringent criteria for this one-time treatment, it’s just another way targeted care makes treatment more convenient. 

More Conservative Surgical Treatment
Thanks to genetic testing, targeted therapies, and advanced radiation therapy, breast surgeons have also been able to change how they deliver treatment. Many patients can now undergo more conservative surgical treatment and experience the same survival and cure rates.

“Over the last decade, there have been more and more studies that show we have been overly aggressive with some of our therapies in how much tissue we removed and how many lymph nodes we removed,” says Dr. King. “What we’ve realized is in select patients, it is a safe option to do less surgery, and those patients do well.”

One of the largest areas of improvement for breast cancer surgery is a reduced need for lymph node dissection. Sentinel lymph node biopsy, which has been performed for many years, has lowered the number of complete dissections by helping surgeons identify which lymph nodes were most likely to be affected by spreading cancer cells. Surgeons now remove just two or three lymph nodes, if any, instead of ten to 12.

“For patients, there is significantly lower risk of lymphedema in the arm or breast, post-operative pain, and injury to any nerve structures that may lead to numbness in the arm or, in rare cases, some weakness,” says Dr. King.

Neoadjuvant chemotherapy has also reduced the need for lymph node dissection for patients with locally advanced cancer or large lesions.

Rachel Burke, MD

“Historically, surgery was always the first treatment,” says Rachel Burke, MD, FACS, breast surgeon with EVMS Medical Group. “Today, we’re doing a lot more neoadjuvant therapy in triple negative and HER2 positive breast cancers. While there’s no proven survival benefit to doing chemotherapy upfront, it can help people become candidates for breast conserving treatment.”

Biopsy techniques have also rapidly changed from excisional localized biopsies to core needle biopsies to image-guided biopsies with vacuum assistance.

“Instead of repeatedly sticking the needle in, new biopsy machines allow you to take multiple biopsies without withdrawing and reinserting the needle,” says Antonio Ruiz, MD, breast surgeon at Chesapeake Regional Medical Center. “That’s a great improvement in core biopsy techniques for the patient.”

Antonio Ruiz, MD

Improved surgical techniques are also allowing women to keep more of their own tissue than ever before, even in the case of mastectomies.

“In years past, we were taking large areas of skin with the breast tissue,” says Dr. Ruiz. “We started doing skin-sparing mastectomies. Now we’ve moved onto nipple-sparing mastectomies, saving essentially the entire breast envelope.”

These nipple- and skin-sparing surgeries provide both a cosmetic and emotional benefit to many women. Surgeons can also boost cosmetic results by carefully placing incisions in the axillary or intramammary creases, called hidden scar surgery, by using tunneling techniques to reach the surgical sites.

Beryl Brown, MD, FACS

“We are trending more towards nipple-sparing surgery almost exclusively,” says Beryl Brown, MD, FACS, breast surgeon and general surgeon with Coastal Surgical Specialists, a Bayview Physicians Group practice. “Not only is it cosmetically superior than building a nipple with 3D tattooing, it is preferable for patients to retain their own nipples. The cosmetic result is excellent, and the oncologic procedure is still superior.”

A great breast surgery begins with careful planning during the biopsy stage thanks to new tools like the SAVI scout electromagnetic reflector. This non-radioactive seed can replace guidewires and radioactive seeds in helping guide the surgeon to the surgical site.

“You can place a reflector in the area of interest, place a hidden scar, which can be in the location of the surgeon’s choosing, and tunnel to the cancer area using lighted retractors,” says Dr. Brown. “This technology enables you to tell how many millimeters you are away from the cancer site so you can get a good margin and decrease the need for a second surgery.”

Even as surgical techniques and technologies improve, the need for breast surgery may be declining.

“The future of surgery in breast cancer is less and less surgery,” says Dr. Ruiz. “With these huge advancements in the medical field, the hope is that need for surgery is going to decrease more and more.”

In Europe, several clinical trials are underway to use more minimally invasive approaches to destroying breast cancer cells. These trials use heat or cryotherapy to destroy tumors without surgical removal. Others are using ultrasound technology to break up cancer cells. Still, most patients in these trials are undergoing surgery after the trial is complete to see how much cancer remains.

“One problem with these techniques is how to prove that you’ve completely destroyed the tumor,” says Dr. Ruiz. “These procedures are primarily being performed through research studies at this time.”

Advances in Reconstructive Breast Surgery
In addition to hidden scar surgeries, advances in plastic surgery techniques have helped patients achieve better cosmetic results after mastectomy or lumpectomy. The early involvement of a plastic surgeon in treatment planning gives patients more cosmetic treatment choices, including skipping reconstructive surgery altogether.

“When we are doing lumpectomy, there are some more basic techniques we can use to improve the cosmetic outcome and wouldn’t necessarily get a plastic surgeon involved,” says Dr. Burke. “We can rearrange breast tissue after lumpectomy to offer breast conservation and give them a good cosmetic result as well.”

For the opposite breast, women may have a small breast reduction or breast lift to maintain symmetry.

In women who receive mastectomies, newer techniques, such as a deep inferior epigastric perforators (DIEP) flap, allow for natural-feeling breasts while preserving muscle tissue in the abdomen and back. These procedures reduce a woman’s future risk for hernias. Women who undergo skin- and nipple-sparing procedures may also benefit from the use of expanders and implants instead of transfer of their own tissue.

From genetic testing to surgical techniques, each aspect of breast cancer treatment has dramatically improved in just a few years. Patients, even those with advanced and aggressive cancers, are seeing extended survival and improved quality of life during survivorship. And thanks to ongoing research, more treatment options are likely only months away.

“We do a great job of curing breast cancer,” says Dr. Nedelka. “My hope, and my strong belief, is that in my lifetime we are going to move metastatic breast cancer from something people die of, to something people die with. I believe that hope is on the horizon.”

 

Thomas A. Pincus, MD

Peninsula Radiological Associates; Medical Director Radiology, Riverside Regional Medical Center

 

When Dr. Thomas Pincus was a medical student two decades ago, many of the patients he treats today would have had no chance of survival – or at least not without devastating health complications. 

With dramatic advances in imaging technologies, rapid stroke interventions and radiation therapies, Dr. Pincus has seen his subspecialties of Neuroimaging and head and neck imaging evolve rapidly. He also has helped guide the growth of Riverside Regional’s neurosciences program into the Comprehensive Stroke Center it is today.

Yet to Dr. Pincus, the most rewarding part of being a physician is helping put his patients at ease on a daily basis, guiding them through common-yet-frightening procedures such as biopsies, drainages, barium swallows and MRIs. 

“All physicians are busy, but the bottom line is we’re always treating a human being,” he says. “I like taking the extra time to explain what we plan to do together, step by step. My goal is to support them through a difficult time with as little discomfort and anxiety as possible, and with a high degree of safety.”

While always keeping the big picture in mind, Dr. Pincus also encourages his patients to take each phase of treatment as it comes: “Otherwise, it’s too easy for them to get overwhelmed and discouraged.” 

Not surprisingly, Dr. Pincus has been named a Hampton Roads “Top Doc” by Coastal Virginia Magazine five times and is a popular lecturer for medical residents. He also is a respected leader at his practice as well as at Riverside, where he directs weekly neuroscience case conferences and has served on the hospital’s stroke, MRI safety and surgical quality and performance committees. 

A Hampton native, Dr. Pincus grew up as the third youngest of 12 siblings. By the time he was a student at Hampton High School, he had decided to follow an older brother, an ENT physician, into medicine. 

After majoring in biology at the University of Dallas, Dr. Pincus earned a medical degree from University of Texas Health Science Center at Houston. He completed a general radiology residency and a neuroradiology fellowship at University of Texas Medical Branch at Galveston. 

Dr. Pincus has worked with Peninsula Radiological Associates since 2002. Board certified by the American Board of Radiology, he holds medical licenses in Virginia, North Carolina and Texas and enjoys collaborating with his partners and a variety of specialists in the region.  

“Radiology allows for interaction with many fields of medicine, and I’ve always found the anatomy and function of the brain and spine especially interesting,” he says. “The ability to use MRI and CT to clearly see the type of pathology and plan treatments is very powerful.”

CT angiography, for example, is a critical part of diagnosing and treating ischemic or hemorrhagic stroke. Scans taken within 15 minutes of a patient’s arrival at Riverside’s emergency room now can clearly image blood vessels from the top of the heart into the brain, including the carotid and vertebral arteries, in isolation from other structures. 

That ability to precisely visualize blockages, blood clots and arterial damage, as well as unexpected findings such as tumors or lesions, has led to much quicker decisions on effective interventions.

“We are seeing very good outcomes – limited damage or complete resolution – for what easily could have been a devastating or fatal stroke,” Dr. Pincus notes.   

Many brain cancer patients, meanwhile, qualify for gamma knife therapy, a minimally-invasive procedure to pinpoint and often destroy metastatic lesions without remissions. That can eliminate repeated doses of whole brain radiation, a threat to mental capacity over time. 

Dr. Pincus’ job is to perform and interpret MRI scans before neurosurgeons and radiation therapists take over. “By quantifying and identifying the exact locations of cancerous lesions to target, we can save patients we couldn’t save in the past,” he states. Emerging chemotherapy methods that deliver drugs directly to tumors will rely on such detailed imaging, too. 

The future looks promising for even more types of patients. MR magnets, for instance, can produce images of spinal tracts, or the pathways for sensory or motor nerve impulses within the spinal cord’s white matter. 

“We now can determine where nerve tracts are disrupted, or if a tumor is very nearby,” Dr. Pincus says. “That gives neurosurgeons an amazing capacity to remove tumors without disturbing nerve tracts, or for alternatives such as radiosurgery to prevent sensory or motor/muscular damage.” 

In head and neck imaging, modalities such as PET/CT, CT perfusion/angiography and Diffusion MRI aid in cancer diagnosis and staging, along with rapid evaluation of infections and traumatic injuries to the head and neck. In nuclear medicine, improvements in radiotracers used in PET scans may be helpful in identifying patients with Alzheimer’s and Parkinson’s diseases sooner. 

For cancer patients, minimally-invasive ablation of tumors with heat, electrical energy or extreme cold is providing an alternative for people who don’t qualify for surgery. Again, imaging tests are critical to properly positioning a needle probe into a tumor. 

Outside the office, Dr. Pincus has been married for 13 years to wife Stephanie and has five children, ages 2 through 11. His hobbies include surfing, fishing and playing tennis.  

Dr. Pincus remains committed to developing local neuroimaging capabilities to give his patients the best chance of a positive outcome. All the while, he’ll be an advocate by their side. 

“The less people understand about what’s happening to them, the more scared they will be,” he says. “They’re not used to being in a hospital, and they deserve to have my time and encouragement. They always deserve to know what to expect.”

Jeffrey D. McTavish, MD

President, Hampton Roads Radiology Associates 

 

As advanced imaging technology allows radiologists to find ever-smaller cancerous growths, Dr. Jeffrey McTavish also is thinking big. 

Radiology shouldn’t end at reading scans and reporting suspicious growths, he feels. Instead, Dr. McTavish is leading a system-wide Sentara Healthcare effort to ensure that every patient who needs follow-up clinical action receives that care.  

“We want to extend the reach of radiology in a really powerful way,” he says. “We plan to take more ownership in care after imaging, so not even a single patient falls through the cracks.”   

The project is just one that Dr. McTavish has spearheaded this decade to improve patient care throughout the region. He was physician lead on Sentara’s drive to drastically shorten wait times between screening mammograms and tissue biopsies; is principal investigator on a push to identify malignant pulmonary nodules earlier; and is physician lead on an electronic decision support system to help physicians prescribe the correct radiology studies. 

At Hampton Roads Radiology Associates, a large regional practice that services Sentara and Bon Secours hospitals, Dr. McTavish is a specialist in abdominal imaging – diagnosing ailments that historically might have required a scalpel. 

“Modern CT and MRI allow us to accurately stage very small tumors and to avoid exploratory surgery in the vast majority of acute abdominal processes,” he says. “When I was in training, people had to hold their breath for up to 45 seconds for abdominal MRI. Today we can obtain much higher-quality images in as little as 5 seconds, which has opened the door to imaging practically everything in the abdomen.” 

Magnetic Resonance Spectroscopy, which can identify biochemical markers in cancerous tissues, is an exciting advance in abdominal imaging, he adds: “Most of our imaging has been anatomic up to this point, but this gets us to the molecular level.” 

Dr. McTavish grew up in a small town outside Toronto, where physicians were community role models. He decided on a medical career by high school, although he also was a gifted piano player and earned an associate degree in piano performance from Toronto’s Royal Conservatory of Music. 

At the University of Toronto, Dr. McTavish completed a medical degree and residency in Diagnostic Radiology, followed by a fellowship in Body MRI at Harvard Medical School/Brigham and Women’s Hospital. He chose radiology due to rapid progress in imaging technology that have turned CT and MRI into the crucial diagnostic tools now taken for granted. 

After three years as an Attending Radiologist at Brigham and Women’s and Harvard Medical School, Dr. McTavish moved to Hampton Roads in 2002 to work at Hampton Roads Radiology Associates. He has been President of the practice since 2009.  

In 2014, Dr. McTavish worked with a team to help Sentara patients with suspicious mammogram findings spend fewer anxious days before diagnostic mammograms and biopsies. By 2016, thanks to better communication with radiologists, surgeons and referring physicians, the median wait had dropped from 16 days to 6, one of the best timetables in the country. 

Dr. McTavish’s current passion is an effort to confirm closed loop communication in 100 percent of radiology results that require clinical action or imaging follow-up. Follow-up failures can occur for a variety of reasons, from technology glitches to physician retirements. 

As an example, Dr. McTavish cites a patient with acute appendicitis whose scan shows a small pulmonary nodule as a secondary finding. A radiologist might advise a follow-up CT in six months. Yet quite often, that never happens due to the focus on the acute problem, especially if a patient hears – truthfully – that a growth is likely benign. 

Dr. McTavish’s team is creating a virtual patient database with a three-step plan: sending a letter or email to the ordering physician, having a radiologist call that doctor directly, and mailing a registered letter to the patient. “We see hundreds of actionable findings across our system every day,” Dr. McTavish notes. “This would be a huge step forward.” 

Simultaneously, Dr. McTavish is leading a grant project for the Eastern Virginia Medical School-Sentara Healthcare Analytics and Delivery Science Institute to identify barriers to follow-up compliance for small lung growths. This is important for improving survival rates, as lung malignancies in the region are identified at later stages than the national average. 

On the front end of care, Dr. McTavish has helped implement an electronic tool that offers real-time feedback to medical providers as they order radiology studies. The system aims to ensure patients get the best scans – and nothing unnecessary – based on established guidance from the American College of Radiology. 

“The computer will automatically send an alert if the imaging study isn’t a good match for a clinical problem,” Dr. McTavish explains. “It also will provide links to literature detailing the reasons why, along with better options.” 

Finally, Dr. McTavish has served as chair and physician lead of Sentara’s Imaging High Performance Team, a collaborative initiative to standardize advanced reporting, radiation dose, technology assessment and patient experiences across 12 hospitals in Virginia, one in North Carolina, and eight radiology practices.   

In his off-hours, Dr. McTavish enjoys spending time with his wife, Andrea, a fellow radiologist, and their three college-aged children. He likes playing ice hockey, skiing and hiking; last year, his family climbed Africa’s Mount Kilimanjaro.  

In the future, Dr. McTavish expects radiology will become increasingly sub-specialized, making more experts available 24/7. Already, he considers the level of expertise in Hampton Roads to be on par with major teaching systems. 

“We all push each other to work at the highest level,” he says. “We’re always ready to tackle the next new challenges in radiology.”

A. Janae Johnson, MD

Diagnostic Radiology, TPMG Imaging and Breast Center

 

Breast imaging is a unique field, both highly technical and incredibly intimate. Specialists must pivot from analyzing digital images for tiny changes in patterns to walking patients through a diagnosis that often alters their views of themselves. 

Dr. Janae Johnson has embraced that challenge, building a patient-focused practice that can often offer same-day needle biopsies to women who need them, alleviating the added anxiety of waiting for days or weeks for a follow-up. In fact, pathologists often are able to report results within 48 hours.

A fellowship trained breast imaging specialist, Dr. Johnson also is a hands-on physician who performs her own physical exams and ultrasounds. She loves supporting patients from diagnosis through treatment, forming close relationships with each of them. 

“The hardest part of my job is telling someone she has breast cancer,” Dr. Johnson says. “It’s also the most important part, because my goal is to transition them from the initial panic of a cancer diagnosis to focusing on the plan for treatment. Far and away, this is a very treatable disease, and most of them will do beautifully.”   

Increasingly, advances such as 3D mammography and breast MRI are leading to earlier diagnosis of cancer and fewer callbacks for patients due to asymmetric tissue or superimposed tissue layers. 

3D technology provides a much clearer view of tissue slices than standard two-dimensional mammography. “Instead of just seeing the top and side of a book, you’re able to leaf through all the pages,” Dr. Johnson explains. 

Breast MRI enables the radiologist to look inside the breast, mapping out blood flow and generating detailed images that help more accurately determine the extent of cancer before surgery. It is also an additional screening tool for women with a lifetime risk of 20 percent or greater, based on factors such as family history, genetic mutations, previous precancerous breast changes or radiation treatments.  

Dr. Johnson hopes these improved technologies will soon reach even more women, as insurance coverage expands and MRI testing becomes shorter and less expensive. She also stresses that annual screening mammograms are critical from age 40 until a woman reaches a point in life where she would no longer treat a cancer if diagnosed. Randomized control studies have found up to a 40 percent decrease in mortality rates with regular screening.  

“We can find cancer sometimes years before it would be palpable, often before there’s any nodal disease,” she says. “This may eliminate the need for chemotherapy and also increases the surgical treatment options – for example, a patient may have a lumpectomy instead of a mastectomy.” 

No matter what the diagnosis, Dr. Johnson works hard to build trust with her patients, carefully explaining biopsy results, arranging appointments with surgeons and scheduling MRI tests as necessary. 

“I love to be in the forefront of finding cancers early, but I also love the personal conversations I get to have – hearing about people’s families, travels, books they’re reading,” she says. “It’s a special opportunity to guide them through a difficult time.” 

Surprisingly, Dr. Johnson didn’t consider medicine as a career until after college. The child of a military father, she moved to Williamsburg in grade school and graduated from Walsingham Academy. She studied psychology at the College of William & Mary, getting a taste for medicine as a cardiac technician and EMT for the Williamsburg Volunteer Rescue Squad and a behavioral counselor at Cumberland Hospital for Children and Adolescents in New Kent County. 

After college, Dr. Johnson lived in Washington, D.C., while taking prerequisite classes for medical school at George Mason University. Upon completion, she worked as a clinical research coordinator with an infectious disease expert at a Newport News HIV Clinic as she filled out medical school applications. That experience cemented her desire to go into healthcare.  

While waiting to start medical school, Dr. Johnson completed a master’s degree in Anatomy at Virginia Commonwealth University School of Medicine. She wrote her thesis on depression and apathy in brain tumor patients and volunteered at the Fan Free Clinic in Richmond.  

Through this, radiology was not even on her radar. Wanting to interact directly with patients daily, she thought she would choose a specialty such as internal medicine. “I literally said in my medical school interview, “I know I can knock radiology off my list,” she recalls with a laugh. 

Continuing at VCU for medical school, Dr. Johnson gravitated toward specialties that focused on women, including OB/GYN and internal medicine with a women’s health track. She discovered breast imaging during a third-year rotation. 

“I knew immediately that was exactly what I wanted to do,” she says. “I went into radiology just to do breast imaging.” 

Dr. Johnson completed a year-long internship at Riverside Regional Medical Center, followed by a four-year residency in Diagnostic Radiology and a year-long fellowship in Diagnostic Breast Imaging at VCU’s Department of Radiology. She came to TPMG Imaging and Breast Center, which has offices in Newport News and Williamsburg, in 2011. 

Dr. Johnson has been married to Dr. Raj Sureja for 15 years; they have four children, ages 5 to 11. She enjoys traveling, cooking, running, skiing, surfing, playing golf – albeit badly – and especially spending time with family and friends. 

Work, though, is a pleasure too. 

“I absolutely love what I do,” she says. “I get to talk with amazing women all day. They are part of my journey and I am part of theirs. It’s my privilege to help them get past what will hopefully just be a temporary hurdle in a long life.”

Advanced Practice Providers

Congratulations, it is an Honor to Feature
Michael Mitchell, PA-C
Sports Medicine & Orthopaedic Center, Suffolk

 

Beyond his rewarding job as a Physician Assistant, Michael Mitchell is an athlete, a husband and father of four, and a man dedicated to community service.

As a fellowship-trained, general PA orthopaedist, Mitchell handles cases from simple fractures to severe arthritis. He is grateful for the chance to watch his patients heal while still having time to spend with his family and on volunteer work, including fundraising for a domestic violence shelter and multiple projects through his beloved fraternity the Omega Psi Phi Fraternity, Inc.

“Being a PA gives me the freedom to practice cutting-edge medicine and be the family man and community member that I need to be,” he says. “The ability to help restore patients’ quality of life and see those results, especially if someone struggled with significant pain, is awesome.”

Mitchell has wanted to practice medicine since his childhood in rural Mississippi, where his mother, Mary, worked as a renal dialysis technician. Seeking the challenges and respect that come with a career in medicine, he joined the Navy after high school and served as a hospital corpsman and operating room technician for 10 years.

As his career advanced, Mitchell earned a bachelor’s degree in Behavioral and Social Sciences from the University of Maryland University College, followed by bachelor’s and master’s degrees in Physician Assistant Studies from the University of Nebraska Medical Center.

After four years as a Navy primary care PA, Mitchell followed a mentor’s advice and applied for an orthopaedic physician assistant fellowship at Naval Medical Center Portsmouth, the last duty station of his 24-year Navy career.

Mitchell graduated from the NMCP Bone and Joint Sports Medicine Center in 2008, with rotations in hand, foot and ankle, fracture and trauma, adult reconstruction, pediatrics, sports, podiatry and spine. While he now partners with Dr. Bryan Fox, a spine specialist at SMOC, Mitchell has put that wide training into good use.

“With the autonomy that Dr. Fox gives me, I’m able to treat all types of patients, from neck to foot cases,” he notes. “I can either take care of non-surgical issues myself or send them to a specialty surgeon as needed. I enjoy the variety, and I’m able to offload work from our surgeons. Having the surgical training, they really trust my judgement.”

Advances such as kyphoplasty for compression fractures and radiofrequency ablation for arthritic joints have transformed many patients’ lives, Mitchell notes. He recalls one older woman who was in excruciating pain after a fall in her home, had an in-office kyphoplasty treatment for a spinal compression fracture and felt great by her one-week follow-up.

A former high school baseball player, longtime recreational softball player and avid golfer, Mitchell fully understands the desire to return to action. He fractured his hand in baseball and has recovered from ankle sprains and shoulder bursitis.

“I understand the rehabilitation process,” he says. “I love working to restore patients’ anatomy and function to get them back to where they want to be.”

Being a role model also is important to Mitchell. He has assisted in fundraising for the Help and Emergency Response (H.E.R.) Shelter in Portsmouth and, through his fraternity, distributed holiday baskets to needy families, mentored youth with absent fathers, connected students with college scholarships, and participated in blood drives and highway cleanups.

“Our young black males should see people who look like them succeeding professionally and giving back,” he says. “That way, they know they can be something other than what tends to be portrayed in movies, television shows or music.”

Mitchell and his wife, Toni, live in Chesapeake and are devoted parents to four children, ages 13, 19, 24 and 27. As a PA, he aims to recreate that same family atmosphere.

“Anyone in pain needs – and deserves – to feel welcomed and encouraged,” he says. “All my patients should know that I’m committed to do everything I can to help them recover.”

 

Lackey Free Clinic

Jon H. Swenson, MD, FAAOS,
Hampton Roads Orthopaedics Spine & Sports Medicine

 

The patients referred to Dr. Jon Swenson from Lackey Clinic often have suffered from joint pain for months, if not years, putting off doctors’ visit for lack of health insurance or financial resources. For many people, the only remaining option is a total joint replacement. 

For nearly 20 years, Dr. Swenson and his partners have found joy in bringing them much-needed relief. 

“It’s sometimes easy to forget that there are people who don’t have the ability to go to a primary care physician or urgent care every time they want to – or even truly need to,” he says. “It feels good to help people who have had a lot of doors closed to them.” 

Located in upper York County, Lackey Clinic is a Christian-based health center that provides free or reduced-cost medical, dental and mental health care to low-income and uninsured residents of Newport News, Poquoson, greater Williamsburg and James City and York counties. 

Funded by donations and charitable foundations, Lackey offers primary care services; chronic care for conditions such as asthma, diabetes and hypertension; brand-name and generic formulary medications; spiritual counseling; and, on the dental side, checkups and cleanings, lab and X-ray services, fillings and crowns, root canals and gum disease treatment.  

Dr. Swenson is one of 172 clinical volunteers, including physicians, nurse practitioners, registered nurses, pharmacists and dentists, and contributes to the center’s wide range of specialty services. That list covers dermatology, ENT, gynecology, nephrology, neurology, physical therapy, psychiatry, rheumatology, urology and more. 

Lackey refers its orthopedic patients to HROSM for everything from arthroscopic procedures to rotator cuff repairs to total hip, knee and shoulder replacements. All have incomes between 139 to 300 percent of the federal poverty level – $35,535 to $77,250 for a family of four, for example – and are not eligible for Medicare, Medicaid or veterans’ benefits. 

“Often their pain has reached a point where it is impossible to ignore,” Dr. Swenson notes. “They are less likely to present with a partially-worn joint, which we might be able to treat with more conservative measures.” 

Since its 1995 founding by Dr. Jim Shaw and his wife, Cooka, Lackey has evolved from three volunteers in a church Sunday school room to a 10,000-square-foot facility with 24 full-time and 10 part-time staff, along with 441 medical and non-medical volunteers. 

After two moves and a series of expansions, the clinic space now includes 10 exam rooms, five dental operatories and two group education rooms. In fiscal year 2019, Lackey treated 1,400 patients during 9,420 visits, providing clinical services valuing more than $465,000. 

Dr. Swenson first connected with Lackey in 2000 through his wife, Dr. Christina Swenson, an internal medicine specialist who was one of the clinic’s first board members. After treating referred patients on his own for about two years, Dr. Swenson got his partners at HROSM involved. Last year, the practice handled 27 patient visits. 

The partnership runs both ways: HROSM also sends some of its patients to Lackey for financial analyses to determine if they qualify for free or low-cost care. That often allows patients to get needed lab work, X-rays and appointments with other local physicians, which in turn helps Dr. Swenson and his partners deliver the best results. 

A good number of Lackey patients are members of the working poor, holding demanding jobs but receiving low salaries and/or limited to no benefits, Dr. Swenson stresses.  

“They are so deserving of our help, and so grateful and happy to get it,” he says. “It’s a wonderful way to give back to our community.”  

To learn more, visit lackeyclinic.org or call (757) 886-0608 

Understanding the Virginia Birth-Related Neurological Injury Compensation Program

By Douglas E. Penner

 

The Virginia Birth-Related Neurological Injury Compensation Act, which created the Program, was passed by the Virginia General Assembly in 1987. The Act was intended to remove malpractice lawsuits from the court system and to provide an alternative way of compensating patients for medical expenses related to birth injuries. To be eligible for the program, an infant must meet the specific definition for birth-related neurological injury and the obstetrical services must have been performed by a physician or at a hospital that specifically participates in the birth injury program.  

The Program is administered by the Virginia Workers’ Compensation Commission (not the courts) and is designed as a no-fault system of compensation. Therefore, it does not require a finding of malpractice in order to provide compensation. By opting to deliver a baby at a participating hospital and/or with a participating physician, the baby’s family automatically waives the right to bring a medical malpractice lawsuit against the participating physician and/or hospital if the baby incurs a birth injury that meets the applicable definition. The benefits offered by the Program are potentially greater than what could be recovered in a medical malpractice award, as malpractice damages are capped under Virginia law. The Program is intended to help take care of the injured child for life.

There are three requirements for acceptance into the Program.
First, the licensed physician or nurse midwife and/or the hospital where delivery takes place must be participating providers. Among other things, this means they must have in force an agreement with the Board of Medicine whereby the physician and/or hospital agrees to submit to a review by the Board of the obstetrical services. In addition, they must have paid the participation assessment for the period of time in which the birth-related neurological injury occurred.

Second, the participating physician and/or hospital must give written notification to the obstetrical patient indicating whether or not they participate in the Program. The timing and details of the disclosure are not prescribed by law, but a brochure entitled “A lifetime of help” has been created by the Program for use by participating hospitals and physicians to explain the Program and the Virginia law establishing it. For a printable copy of the brochure, please see: 

https://vabirthinjury.com/wp-content/uploads/2012/06/Patient_Materials_english2.pdf.

Finally, the injury must meet the definition for the particular type of birth-related neurological injury that qualifies for the Program. Specifically, an injury to the brain or spinal cord of an infant caused by the deprivation of oxygen, or mechanical injury occurring in the course of labor, delivery or resuscitation necessitated by a deprivation of oxygen, or mechanical injury that occurred in the course of labor or delivery in a hospital, which renders the infant permanently motorically disabled and developmentally disabled, or, for infants sufficiently developed to be cognitively evaluated, cognitively disabled, meets the definition of a qualifying injury.

Failure to comply with each of these requirements could jeopardize a provider’s participation in the Program and/or the chances that a particular claim will be accepted for compensation. Please consult legal counsel for legal advice specific to your question.

Douglas Penner is an attorney with the law firm of Goodman Allen Donnelly. He specializes in hospital risk management, medical malpractice defense, health care law, and State Board licensing and credentialing matters. www.goodmanallen.com

Should Your Patients Be Seen by a Podiatrist or a Foot and Ankle Specialist?

“Podiatrist” and “Foot and Ankle Orthopaedic Surgeon” seem to be interchangeable titles to patients and referring physicians as they search for a specialist to address a specific need. What factors determine which may be the appropriate choice? We’d like to explain the similarities and differences when it comes to determining which specialist to see. 

Podiatrist
A podiatrist is a Doctor of Podiatric Medicine (DPM). These specialists train for four years at a podiatric medical school, with specific training in the diagnoses and treatments of the foot and ankle. That is followed by an internship and residency, which may be up to four more years of training specifically in treatment of the foot and ankle. While podiatrists aren’t fellowship trained, their specialized focus throughout their schooling is dedicated to those areas.

 Podiatry is typically associated with routine foot care, such as warts, bunions, and cutting toenails. However, many of the services that podiatrists are capable of have changed over the last 10 to 15 years. Today’s podiatrists do a lot of orthopaedic work. For example, if a patient has a broken ankle, they should be referred to a podiatrist. Diversity in podiatric care may include bunions, arthritis, joint replacements, ligament surgery and flat feet. 

Foot and Ankle Orthopaedist 
Foot and ankle specialists/orthopaedists are trained as a Doctor of Medicine (MD) in orthopaedics first, before subspecializing in the foot and ankle. These specialists attend medical school and complete an internship, followed by four years of residency for general orthopaedics. They may also complete a fellowship, where they are trained for a full year in their subspecialty: foot and ankle. Foot and ankle specialists are trained as orthopaedic doctors, so they are prepared to care for the whole body medically and musculoskeletal- wise. In fact, there are 10 years of full body training before they subspecialize in foot and ankle. Cases can vary between reconstructive and surgical cases, such as bunion deformities. A foot and ankle surgeon/orthopedist also may offer services such as ankle ligament reconstruction, total ankle replacement, and arthroscopies.  

Podiatrists and foot and ankle orthopaedic surgeons are specialists trained with similar principles, but with different approaches in training and education. Podiatrists spend most of their schooling and training specifically in the ankle and foot, while foot and ankle surgeons take a wider approach and focus not only on the foot and ankle but the body as a whole. There is significant overlap in what both specialties can and are willing to treat. The choice to choose either for any ailment may be dependent on its cause, the placement and severity of the injury, or whichever specialist the patient and/or referring physician feels the most comfortable consulting.

John Duerden, MD

Jeremy Walters, DPM

John Duerden, MD is a Board certified Orthopaedic surgeon practicing with Sports Medicine & Orthopaedic Center in Chesapeake. Jeremy Walters, DPM is a Board certified Foot Surgeon practicing with SMOC in Franklin. Smoc-pt.com

Diabetic Eye Disease Awareness

As vitreoretinal surgeons and ocular oncologists, we have the privilege of intervening as guardians of sight every single day. While this proves to be an incredibly rewarding vocation, it comes with the supreme responsibility of being the final bastion defending against aggressive pathology trying to wreak havoc on the ever-so-delicate retina, which interfaces images of the outside world to the brain. Easily, no pathology has been more humbling through this journey than has been diabetic retinopathy. Inevitably, when witnessing someone’s vision deteriorate swiftly from this disease, the other eye is losing ground just a step behind. The bilaterality of diabetic retinopathy is often most challenging for younger type 1 diabetics who form aggressive scar tissue at the retinal surface that insists on stealing vision. Far too often, we are left putting together the pieces of a missed opportunity – the opportunity to avert vision loss if we could have met that patient just months earlier. 

So, Diabetic Eye Disease Awareness Month is a great time to pause and review a few details:

• Blindness is the number one disabling complication of diabetes.

• More diabetics fear going blind than any other complication of diabetes, including going on dialysis, having a stroke, or even suffering a heart attack. 

• An additional 50,000 Americans will go blind this year, and diabetic retinopathy will be the leading cause of preventable blindness overall and the leading cause of blindness in working-age adults. 

Now here are the real kickers:

• Nearly 60% of Americans with diabetes do not get an annual eye exam. 

• 95% of vision loss from diabetes is preventable just by taking that one step. 

One of the real challenges with diabetic retinopathy is that the overwhelming majority of patients who develop it have absolutely zero symptoms until the very late stages. By the time symptoms actually develop, the rate of progression and risk of permanent visual loss can accelerate quite rapidly. It is a unique entity from many other eye diseases, in that consistent annual surveillance needs to be considered an intrinsic component of its management. 

As we approach the month of November, let’s commit to being more cognizant of this gap, partner together to eradicate diabetic blindness, and commit in making the coming year 2020 the year we take the big stride forward in eradicating diabetic blindness here in Hampton Roads.

Kapil G. Kapoor, MD  is a Board certified ophthalmologist specializing in vitreoretinal surgery.   wagnerretina.com

Low-dose CT Scan for Lung Cancer Screening

By Jeffrey A. VandeSand, MD

 

Over the years, the use of low-dose CT (LDCT) scans has proven an effective method of screening for lung cancer, improving outcomes and reducing mortality for smokers. With evidence that only 15 percent of lung cancer cases are diagnosed at an early stage, an LDCT scan, a non-invasive method to detect abnormalities or nodules in the lungs, is currently the only recommended screening method for lung cancer.  

According to a study performed by the U.S. Department of Health and Human Services, patients receiving LDCT scans showed an overall reduction in mortality, with approximately five in 1,000 fewer total deaths compared to screening with chest X-ray. Crucial to the success of this screening protocol is the education provided by PCPs on risks, benefits and associated costs, often starting with smoking cessation counseling and a comprehensive overview of the screening process. 

When counseling patients, it’s important to advise them of the risks, including the cumulative nature of radiation exposure, the potential for false-positives, and overdiagnosis. While concerns over radiation exposure should be carefully considered, the potential for overdiagnosis and false positives has been largely mitigated by continued improvements to the algorithm used by radiologists. 

Regarding benefits, screening increases the likelihood that a cancerous nodule will be detected at an earlier stage, often allowing for less invasive treatments. The likelihood of curative treatment compared to a more progressive stage is also greater, and discovery of a nodule may serve as a “teachable moment” for reiterating the importance of smoking cessation.

Prior to screening, patients should check with their carrier about any copays, deductibles or associated fees. For most private insurers, the criteria for screening include those who have smoked the equivalent of at least one pack a day for 30 years or 2 packs a day for 15 years, are ages 55 to 80, and are currently smoking or have quit within the last 15 years. 

Qualified Medicare, Medicaid and privately insured patients within network should expect full coverage of this test as an annual screening exam. However, results necessitating follow-up exams in three or six months, or additional diagnostic testing, may require copays or additional charges. Medicare and Medicaid age guidelines differ from private insurers and only cover annual testing up to the age of 77.  

The United States Preventive Services Task Force (USPSTF) has issued a grade B recommendation for the screening, indicating a high certainty of moderate to substantial benefit. Applicable to approximately 8.7 million people in the U.S., this screening could help avoid as many as 12,000 lung cancer-associated deaths if implemented, according to the 2010 National Health Interview Survey. One in 320 high-risk patients screened will avoid death over five years, ​thereby reducing the cumulative​ risk by 20 percent. Again, as an LDCT scan is the only recommended screening test for lung cancer, primary care providers should be at the forefront of educating patients about its success and benefits.

Jeffrey A. VandeSand, MD, is a Board certified radiologist at TPMG Imaging and Breast Center in Williamsburg and Newport News. MyTPMG.com