Medical Update (2003)

Volume1/2003_SummerUPdate University of Utah Health System Summer 2003 W H A T ' S I N S I DE Q ui 2 Surviving Melanoma page 4 Breast Cancer Surgery: Making an Informed Decision page 6 Continuing Medical Education Schedule page 8 Latest Surgery, Medication Help U Physicians Fight Glaucoma By Phil Sahm Curds Hancock lines up putts and splits the fairways from a little dif-ferent perspective when he plays golf these days. It's fair to say that Hancock, 37, looks at every aspect of life differently since learning three years ago that he has glaucoma, an insidious disease that steals sight and can cause permanent blindness. More than 2 million Americans have open- angle glaucoma- the most common form of the disease- and half of them may be undiagnosed. Hancock, married and the father of three children ages 18 months to 8 years, was at risk for losing his vision- but he and his doctors caught the disease before it caused major damage to his optic nerve. In May, the Ogden resident went to the University of Utah's John A. Moran Eye Center to undergo one of the latest advancements in glaucoma treat-ment- non- penetrating surgery. Hancock's surgeon, Norman A. Zabriskie, M. D., associate professor of ophthalmology and visual sciences at the U School of Medicine, made an incision wwi V. Glaucoma won't stop Curtis Hancock from enjoying golf or other activities since he underwent one of the latest surgical techniques at the U's John A. Moran Eye Center. continued on page 2 Fighting Glaucoma Patient Benefits from Latest Surgery, Medication ... continuedfrom cover to allow fluid to drain from his eye and relieve pres-sure on the optic nerve. In the past, such surgery involved a cut that penetrated the full thickness of the eye. But using the non- penetrating technique, Zabriskie cut only partly into Hancock's eye. The procedure not only provides fluid drainage to reduce pressure on the optic nerve, but also carries a lower risk of bleeding or infection compared with operations that use deeper incisions. The surgery worked. Pressure in Hancock's eye is dramatically lower and damage to his optic nerve has been stopped. " That was great to hear," Hancock said. Hancock is a rarity among people with glaucoma: He had forewarning of the disease. Glaucoma often develops from a medication he was taking for an inflamed iris, a condition called iritis. The medication also caused him to develop cataracts, which require surgery. Most people aren't on the lookout for glaucoma and don't know when they develop it because the disease occurs with no noticeable symptoms. But glaucoma is the second- leading cause of permanent blindness ( behind diabetes) in the country. Glaucoma is the second-leading cause of permanent blindness in the country. Fluid naturally flows in and out of the eye, but in open- angle glaucoma the fluid drains too slowly. The slow drainage forces pressure to build in the eye, which damages the optic nerve. When the optic nerve becomes damaged it reduces peripheral vision, and if the problem goes unchecked, blindness can occur. People over age 60 are at greater risk of develop-ing glaucoma, and African- Americans are particularly vulnerable to the disease. African- Americans over age 80 are five times more likely to get glaucoma and are four times likelier to be blinded by the disease as Caucasians. Glaucoma is the leading cause of blindness among African- Americans. The change in eye pressure and optic nerve damage occurs imperceptibly, and glaucoma often goes undetected until some peripheral vision is lost. Vision loss may be so slight at first that the individual doesn't notice. Ophthalmologists usually find the signs of glau-coma during a complete eye examination. If the eye pressure, also called ocular pressure, is above a reading of 22, or if the optic nerve looks suspicious, the patient should undergo further tests. High ocular pressure doesn't always signal glaucoma, but it often does. Conversely, some people with glaucoma don't have high eye pressure. After developing glaucoma, Hancock took daily eye drops to reduce the ocular pressure, but the drops eventually stopped working. " That's when I started to get nervous," Hancock said. Then, he took an oral medication to reduce the pressure. The medicine worked but had an intolerable side effect- it made him vomit. Finally, in May, he came to the Moran Eye Center for surgery. Zabriskie, Alan S. Crandall, M. D., professor of ophthalmology and visual sciences and director of Glaucoma and Cataract at Moran, and Jason A. Goldsmith, M. D., assistant professor of ophthalmology and visual sciences, are the U's glaucoma experts. They offer the full range of the latest medications, laser tech-nology, and surgery. The first news any glaucoma patient receives is not good: nerve damage and vision loss from the disease are irreversible, meaning the only medical recourse is to prevent further damage, according to Zabriskie. " We don't kid ourselves that we can cure the disease," he said. " We just try to keep it from getting worse." Advancements in glaucoma treatment are helping in that effort. Glaucoma medications today are the best ever, according to Zabriskie. New eye drops reduce ocular pressure by increas-ing the fluid outflow from the eye through a second-ary route. These drops can be taken once a day, with the primary side effect of causing irritation or darken-ing of the eye. Oral medications also reduce eye Glaucoma often goes undetected until some peripheral vision is lost. pressure, but, as in Hancock's case, the side effects can be more pro-nounced. Drops are the most commonly prescribed medication for glaucoma. Newer medicines, used during an operation, also increase the chance of successful surgery, and biological agents are being developed that may further help surgical outcomes. If drugs don't decrease ocular pressure to stop damage to the optic nerve, laser surgery or invasive surgery are the next options. Laser surgery, in which high intensity beams of light are aimed at parts of the eye, changes the anatomy of the primary path where fluid drains, increasing the outflow and reducing pressure. In the past, once laser surgery was per-formed it couldn't be repeated in the same area. But new technology is making it possible to repeat laser surgery if necessary, according to Zabriskie. Many advances are coming in traditional surgery, in which incisions are made to cut new pathways in the eye and increase fluid drainage. New drugs also prevent scar tissue from forming over incisions made to keep fluid draining from the eye. " That has definitely increased our success," Zabriskie said. The non- penetrating surgery that Hancock underwent is particularly encouraging because of the lower risk of complications. As advances in technolo-gy, surgical technique, and drugs enhance the ability to stop the disease from progressing, researchers are learning more about glaucoma. Physicians and other researchers, for example, are learning that cornea thickness may indicate the likelihood of developing glaucoma: the thicker the cornea, the less likely the disease will occur. And- as in nearly every other aspect of medi-cine- genetics may hold the ultimate key to glaucoma as researchers look for a gene, or genes, that predispose people to the disease, according to Zabriskie. That would change the picture for millions of people. For the present, Curtis Hancock and others in Utah and the Intermountain West count on the U's Moran Eye Center for the best current knowledge and technology to stop an incur-able disease from taking their sight. That gives hope for the future and some peace of mind. " It's been a roller- coaster the past few years," Hancock said, " but I hope we're on the right track now." ® For more information, call the John A. Moran Eye Center, ( 801) 581- 2352. University of Utah Hospitals & Clinics toll- free referral and consultation: 1 - 8 0 0 - 4 5 3 - 0 1 2 2 in Utah, 1 - 8 0 0 - 6 6 2 - 0 0 5 2 outside Utah Surviving Melanoma DQ LJ I < H D O X D D Patient Joins " Gene Hunt" to Help Fight Disease By Cindy Fazzi When the death of Maureen Reagan, daughter of former President Ronald Reagan, made headlines almost two years ago, it struck Bonnie Myers in a very personal way. Reagan died of melanoma- a type of skin cancer- on Aug. 8, 2001, less than a month after a cancerous freckle on Myers' shoulder and another one on her stomach were surgically removed. " Maureen Reagan's death really hit me," said Myers, a 52- year- old wife and mother of two from Salt Lake City. " Here was a woman who was famous, well- educated, and had money. All of that did not save her from melanoma." Melanoma develops in the cells that produce melanin, the pigment that gives skin its color. Melanoma is the deadliest type of skin cancer because it's more likely than other skin cancers to spread to different parts of the body. However, if caught early, it's almost entirely curable. Other common kinds of skin cancer are basal cell carcinoma and squamous cell carcinoma. The Skin Cancer Foundation says occurrence of melanoma is rising faster than any other cancer. In 1935, only one in 1,500 Americans developed melanoma, but today the rate is one in 71. Myers, a skilled horsewoman and an avid skier, was first tested for melanoma in June 2001. A month later, R. Dirk Noyes, M. D., a surgical oncologist and co- director of the Multidisciplinary Melanoma Clinic at the University of Utah's Huntsman Cancer Institute ( HCI), removed Myers' melanoma. Today she's cancer- free, but by no means complacent. Myers and her 72- year- old mother, Catherine Ziegenbalg, are participating in a clinical investigation being conducted at HCI's Tom C. Mathews Jr. Familial Melanoma Research Clinic ( FMRC). Like her daughter, Ziegenbalg had melanoma but is now cancer- free. The FMRC is devoted to studying the genetic causes and inheritance patterns of familial melanoma. It also serves as an educational resource for individuals at high risk for the cancer. The research focuses on the role of genes in the development of melanoma. About 15 years ago, U researchers localized the first gene- now called pi6- which is known to increase the likelihood of developing melanoma. " PI6 is a gene that frequently is mutated and is passed on within a family, from generation to generation," said Sancy A. Leachman, M. D., Ph. D., FMRC director and assistant professor in the U's Department of Dermatology. Melanoma: Facts and Figures Skin cancer is the most © For more information, call HCFs melanoma program, ( 801) 585- 9427. Leachman said the current research builds on the previous study by trying to understand why p l 6 causes melanoma and how it interacts with environmental factors, such as sun expo-sure. " Just because you have a mutation in the p l 6 gene doesn't mean you'll automatically get melanoma. It simply means that your chance of getting it is significantly enhanced, especially if you happen to be living in a really sunny place," she said. Leachman said p l 6 is mutated in only about 25 percent of familial melanoma patients, which implies that the majority may have other genes that make them susceptible to melanoma. FMRC wants to investigate these other genes. " Basically, we're doing a gene hunt," said Leachman. Myers and her mother became part of this " gene hunt" in March. Myers said their participation involved giving blood sample, a thorough body skin exam, and photographing their freckles and moles for close monitoring. They also completed an extensive questionnaire about such things as how often they were outdoors and for how long. All clinical services within the research program are free, but Leachman said it's not a replacement for immediate care. For Myers and Ziegenbalg, their participation helped them keep tabs on their condition. In fact, Leachman did a biopsy of a suspicious lesion on Ziegenbalg's shoulder. It turned out to be basal cell cancer, a slow- growing cancer that seldom spreads to other parts of the body. Ziegenbalg had the lesion removed in Florida, where she lives. Not every melanoma patient is qualified to par-ticipate in the clinical study, but Myers was a logical candidate. She has light, freckled skin, blue eyes, and red hair- some of the physical charac-teristics typical-ly associated with melanoma patients. Myers loves being outdoors and her mother also had melanoma. Myers grew up in New Jersey, where her family had a summer home by the beach. " I spent a lot of time at the beach or riding horses and generally staying out-doors," said Myers. " Growing up, nobody ever told me about the danger of skin cancer or the impor-tance of sunscreen and other forms of protection from the sun." Although Myers no longer spends as much time outdoors as she used to, she's more vigilant in protecting herself when she does. She wears long sleeves and a hat as much as possible, applies sunscreen daily, and checks her skin very closely. She also makes sure her two teen- agers do the same. Myers said a major advantage of participating in the study is access to experts such as Leachman. Moreover, the study gives Myers the satisfaction that she's doing something to help fight the disease. Myers even ventured down to sunny Mexico in June. " I used to be petrified. I didn't want to do anything outdoors anymore, but Dr. Leachman told me develop-ing melanoma does not mean my life is over," she said. " Now I'm slowly getting over my fear." common type of cancer in the U. S., according to the National Cancer Institute. It says 40 per-cent to 50 percent of Americans who live to age 65 will have skin cancer at least once. The American Cancer Society estimates that 54,200 Americans will be diagnosed with melanoma this year. Out of that, 29,900 are men and 24,300 women. The organization says 7,600 people will die of skin cancer this year. Sancy A. Leachman, M. D., HCI researcher and assistant professor in the U's Department of Dermatology, is studying the genetic causes of familial melanoma. University of Utah Hospitals & Clinics toll- free referral and consultation: 1 - 8 0 0 - 4 5 3 - 0 1 2 2 in Utah, I - 8 O O - 6 6 2 - O O 5 2 outside Utah Breast Cancer Surgery: Making an Informed Decision By Cindy Fazzi Kari Ellingson and Kathy Howa aren't related. They don't even know each other. But they have a lot in common. Both are 40- something. They live and teach in the Salt Lake City area. Each woman was diagnosed with breast cancer and they both turned to the same University of Utah Hospital surgeon for help. While they both agreed that surgery was the best treatment for breast cancer, they did not choose the same type of surgery. In Ellingson's case, a biopsy showed that most of the microcalcifications scattered throughout her right breast were pre- malignant, a change called ductal car-cinoma in situ. But she also had a small area of true invasive breast cancer, proven by a needle biopsy. She had been advised to have a lumpectomy, a type of surgery that removes only the part of the breast where the tumor is located. Not satisfied with the information she had at hand, Ellingson decided to get a second opinion. She sought the help of Edward W. Nelson, M. D., professor and chief of the U medical school's Division of General Surgery. Nelson thought Ellingson had too many microcalcifications for lumpectomy to be as effective as a mastectomy with reconstruction. " I knew nothing about breast can-cer, but after my diagnosis, I learned in a hurry," said Ellingson, assistant vice president for Student Development and clinical associate professor in edu-cational psychology at the U. After doing her own research, the 48- year-old wife and mother of two chose to have her right breast removed, a proce-dure known as simple mastectomy. Nelson was her surgeon. She also decided to have breast reconstruction at the same time as her mastectomy. W. Bradford Rockwell, M. D., associate professor and chief of the U's Division of Plastic and Reconstructive Surgery, performed that surgery. Ellingson's mastectomy lasted two hours and the breast reconstruction, six hours. Howa had braced herself for cancer diagnosis because of her family history. Although she's the first in her family to have breast cancer, her grandmother, mother, and sister all had uterine cancer. The tumor in Howa's right breast was small ( 1.5 millimeters), but it was invasive cancer. " At first I wanted a mastectomy. But I told Dr. Nelson I was willing to do whatever he thought was best for me," said Howa, 42, of Midvale. Nelson ultimately performed a lumpectomy and sentinel procedure under Howa's right arm. A sentinel node is the first place where cancer is likely to spread. Howa's surgery lasted four hours and she went home after two days. She returned to her job as a physical education teacher at Rowland Hall- St. Mark's School just a few days after surgery. She then began chemotherapy, which lasted six months. " I would have chosen mastectomy, but Dr. Nelson was absolutely right about a lumpectomy. He helped me take the right path," she said. Team Approach Actually, Nelson's recommendation reflected not just his opinion, but the consensus of an entire team. In a Breast Cancer Care Conference held every other week, doctors involved in treating breast cancer patients- surgeons, radiolo-gists, pathologists, plastic surgeons, oncologists, and radiation oncologists- meet to discuss options available to patients. " My job is to educate a patient about all her options, not necessarily to change her mind about a procedure," said Nelson, who presides over the conference. " But when 1 do make a recommendation, she can be sure that she's getting the best thinking of the entire Breast Cancer Care Conference." He said that for most patients, getting the opinion of several doctors at once boosts their confidence and helps them make a decision. Ellingson and Howa said they definitely welcomed the input of the group. At a recent conference, 21 doctors, residents, nurses, and clinical researchers discussed the options available to five patients. Detailed medical histories were presented, including everything from mammogram results to evaluations of a patient's psycho-logical and emotional readiness to undergo surgery. Nelson said the Hospital's Tumor Board used to evaluate all types of cancer patients, but the increase in breast cancer patients and the particular issues they face merited a separate conference. Ellingson agreed that breast cancer is unique because it's inherently linked to a woman's self- esteem and identity. " This is not like any other disease," she said. " 1 can understand that some women are very attached to their breasts." Lumpectomy vs. Mastectomy Given this context, counseling breast cancer patients on surgery can be downright difficult. " The problem is that breast conservation is not for everyone," said Nelson. " For some women, there's no other choice but mastectomy." But Nelson also expressed concern that many women assume removing an entire breast is better than other treat-ments. He said there are women with family history of breast cancer who want to remove both breasts as a preventive meas-ure even before they get the disease. " I let patients know that national studies have shown that the local recurrence rate is the same for both mastectomy and lumpectomy when the patient receives the procedure appropri-ate for her situation," said Nelson. Ellingson said if she were to advise a woman diagnosed with breast cancer, she would tell her to look at the big picture. " It's important to get a second opinion," said Ellingson. " Take the conservative approach if you can, but if not, take advantage of what science and technology has to offer." Howa believes that if the cancer is small enough, lumpec-tomy might be the answer. " I didn't always think this way," she said. " But now I know that lumpectomy is very effective and mastectomy is not necessarily better." A year after breast cancer surgery, both women say they're happy with their choices. " I'm lucky that I had top- notch surgeons in a top- notch hospital. It's as good as it gets," said Ellingson. As for Howa, she said: " I feel great. I've never felt better." ifj For more information on breast cancer surgery, call the Division of General Surgery, ( 801) 581- 7738. For information on breast reconstruction, call the Division of Plastic and Reconstructive Surgery, ( 801) 585- 6839. , M. D., professor and chief of the U general surgery division, attended a meet-evaluate options available to patients. University of Utah Hospitals & Clinics toll- free referral and consultation: 1 - 8 0 0 - 4 5 3 - 0 1 2 2 in Utah, 1 - 8 0 0 - 6 6 2 - 0 0 5 2 outside Utah U N I V E R S I T Y OF U T AH S C H O O L O F M E D I C I NE C O N T I N U I N G M E D I C A L E D U C A T I ON September 12: Ophthalmology Clinical Faculty Day October 3- 4: Western Intermountain Neurological Site: John A. Moran Eye Center, Organization Meeting University of Utah, Salt Lake City, UT Site: University Park Marriott, Chair: Mark D. Mifflin, M. D. Salt Lake City, UT Credit: 7 AMA Category 1 hours Chair: Kathleen Digre, M. D. Contact: Elaine Peterson Credit: 8 AMA Category 1 hours ( 801) 585- 3719 ( phone) Contact: Carrie Allen ( 801) 581- 3357 ( fax) ( 801) 359- 0700 ( phone) elaine. peterson@ hsc. utah. edu ( 801) 359- 5799 ( fax) carrie@ insiteevents. com September 20: Refugee Health Overview Site: Huntsman Cancer Institute Auditorium, University of Utah, Salt Lake City, UT March 12: Ophthalmology Residents/ Alumni Day Conference Chair: Cynthia Willard, M. D., M. P. H Site: John A. Moran Eye Center, Credit: 6.5 AMA Category 1 hours University of Utah, Salt Lake City, UT Contact: Bernadette Kiraly, M. D. Chair: Mark D. Mifflin, M. D. ( 801) 581- 2000 ( phone) Credit: 7 AMA Cate