Medical Update (1999)

Volume1/1999_AutumnAutumn 1999 Mapping Moles To Detect Melanoma Melanoma Detection Digital Camera, Computer Offer Sophisticated Mole Mapping The admonition to check moles regularly for changes that may indicate melanoma, a deadly skin cancer, seems easy enough to follow. But, dermatologist Glen M. Bowen, M. D., says, " Some people have so many abnormal- looking moles on their bodies, it is very difficult for them to tell which ones are changing and which are stable." In order for patients and physicians to better monitor atypical moles for changes that may signal a malignant growth, a sophisticated mole- mapping technique is being introduced as part of the newly formed multidisciplinary melanoma program at the Huntsman Cancer Institute ( HCI) at the University of Utah. The program begins Nov. 22. The objective of mole mapping is twofold: to diagnose melanoma as early as possible, and to reduce the number of unnecessary biopsies. " If caught early, melanoma is one of the easiest cancers to cure; if it escapes early detection, it is one of the deadliest," said Bowen, co-director of the new program ( with dermatology department chair John J. Zone, M. D.) and assistant professor of dermatology at the University of Utah School of Medicine. Mole mapping consists of digital photographs of moles taken with a surface microscope con-nected to a computer. It provides extremely close- up images of an individual mole that can be fol-lowed over time for subtle changes that may signal abnormal growth. In addition, patients will be given photographs of their moles and encouraged to examine their skin at home once a month and compare Glen Bowen, M. D., assistant professor of dermatology, says mole- mapping objectives are early melanoma detection and avoidance of unnecessary biopsies. their moles to the photographs to make sure there have been no changes or development of new abnormal moles. " For some patients with a large number of atypical moles and a strong family history of melanoma, the question is not whether mela-noma may appear but when and where, " Bowen said. Studies have shown that patients who use photographs to monitor changes in their moles are nearly as effective as their doctors at picking up the early changes that may signal melanoma, according to Bowen. For patients with large numbers of moles, it is difficult to remember what each one looked like the preceding month, but with photographs, the self- exam becomes much less subjective. Spouses and family members are encouraged to help patients compare the moles they see ( particularly on the back, where most melanomas occur) to the appearance of the moles in the baseline photos. " Patients and family members are often intimi-dated by the self- exam at first, but with the photographs, they find that it is a cinch," Bowen says. If Bowen identifies a mole he is worried about in a high- risk patient ( who will be seen every six months), a new photograph will be taken with the digital microscope/ camera and compared to the baseline photograph. A biopsy is performed only if changes are seen. " This technique has greatly reduced the number of unnecessary biopsies because unchanged moles are stable and can be left alone," Bowen said. Leslie Osborne had a melanoma removed from her right forearm six years ago. The malignant mole on her arm concerned her because it seemed to appear overnight and it didn't look like her other moles. During a scheduled appointment with her physician, she asked about it, but was told it was nothing to worry about. When her husband said he also thought the mole looked strange, she saw a derma-tologist, who diagnosed a mela-noma. Since then, she's had three other moles removed because they looked suspicious, but none was malignant. She has recently undergone mole mapping to ease her mind about the number of other moles on her body. She checks her moles regularly and thinks the photographs definitely will help her determine whether they have changed. Osborne, with green- eyes, blond hair and " freckly" light skin, fits the profile of people who are most susceptible. Individuals with dark hair and dark skin are not so prone to the disease, Bowen said. The mole- mapping service will cost between $ 100-$ 300, depending on the number of images taken. Because the technique is so new, it is not clear how reimbursement from third-party payers will play out. " In the long run, this technique will save insurance companies a great deal of money since these patients typically end up with multiple biopsies over their lifetimes, sometimes as many as 50 or more, most of which can be avoided with mole- mapping compari-sons," Bowen said. In addition to the mole-mapping clinic, a multidisciplinary clinic for patients newly diagnosed with melanoma is being formed. Dermatology, medical oncology, surgical oncology, otolaryngology, plastic surgery and pathology specialists, as well as nurses and social workers, will be involved, and patients also will have access to state- of- the- art clinical trials. Referred patients will first receive a total body skin examina-tion by dermatologists, then be referred to the appropriate subspe-cialty the same day. When a patient leaves the clinic a compre-hensive work- up with all the necessary tests will have been completed and appropriate follow-up treatment scheduled. For patients who want to receive subsequent care closer to home, the recommended treatment plan will be sent to the referring physician. In addition to the mole map-ping and the new patient melanoma clinics, a high- risk melanoma clinic, free of charge, is planned for people who have a family history of melanoma in two or more relatives. This clinic will help assess an individual's personal risk for melanoma and offer guidelines for follow- up. $ F° r information about the melanoma program, call the melanoma program nurse coordina-tor, Huntsman Cancer Patient Center, 801- 585- 0100. On the cover... Glen Bowen, M. D. photographs a mole on the arm of Leslie Osborne, using a digital surface microscope/ camera. Sophisticated mole- mapping program is beginning at University of Utah's Huntsman Cancer Insititute. A Different Message From Promontory Point There's a message for sun worshipers in the photograph of the driving of the golden spike at Promontory Point, dermatologist Glen Bowen believes. The people are dressed in long- sleeved clothing and are wearing hats- in the desert- in the summer. In short, cover up when you're in the sun. Bowen personalizes the increase in melanoma incidence: In 1916, when his father was born, the incidence was 1: 2000; in 1960, when he was born, it was 1: 600; in 1996, when his daughter, Quincy, was born, it was 1: 87. The incidence of melanoma is projected to be 1: 75 by 2000. He advises: • Don't go out in the sun between 10 a. m. and 3 p. m. • Children must wear hats- and shirts, too. • Wear sunscreen. Remember these simple concepts about sunscreen: • It filters some sun, but not all. • It must be on the skin 30 minutes before it works. • It is spent after two hours, so it must be reapplied before the time runs out. • Buy sunscreen with a high sun protection factor ( SPF), and one that blocks both UVA and UVB rays. 3 Women and Heart Disease Symptoms Differ, Standard Tests Are Less Reliable Gertrude Goldsberry credits University of Utah cardiologists with helping her recover from a severe heart attack two years ago. Gertrude Goldsberry, 82, vividly remembers the heart attack she had two years ago. " It was like someone stabbed me," she recalled. " I don't want to have another one." Within an hour of being admitted to University Hospital, she underwent angioplasty; less than a year later, she needed double bypass surgery. " The doctors said they couldn't do any more patch-ing. They told me I could go home and live the best I could or have a bypass. I chose the bypass," she said. Heart disease is the leading cause of death for women in the United States, according to Jeffrey L. Anderson, M. D., professor and chief of the Division of Cardiology at the University of Utah School of Medicine. He says that while men normally develop symptoms in their 50s and 60s, most women don't show signs of the disease until their 70s and 80s. " The impact of heart disease on women is greater than breast cancer," he said, " but because it strikes later in life, less attention is given to it." Ruth Ann Smith, M. D., assistant professor of cardiology, says that is changing. " While heart disease is very prevalent in older women, it appears to be largely preventable, just as in men. If a postmenopausal woman has increased risk for developing coronary heart disease, the use of cholesterol- lowering medications will reduce the risk of heart attack significantly. And, if a woman has already developed evidence of coronary disease, cholesterol-lowering medications will decrease the chance of heart attack or death." Anderson says much of what is known about the disease is based on research that involved men. " What we've found, however, is that the disease often presents differently in women than in men. Standard diagnostic tests also are less reliable for women," he said. Symptoms of heart disease in women include fatigue, shortness of breath, nausea or abdominal discomfort, uncom-fortable pressure in the chest, and throat or jaw pain. Risk factors for heart disease also reflect gender differences, recognized in a set of new preven-tive guidelines for women published in the May 11, 1999, issue of the journal Circulation by the American Heart Association ( AHA) and American College of Cardiology ( ACC). The report provides recommendations on physical activity, nutrition, weight manage-ment, smoking, psychosocial factors, blood pressure, lipids and lipoproteins, diabetes, and pharma-cological intervention such as hormone replacement therapy, oral contraceptives, antiplatelet agents/ anticoagulants, beta- blockers and ACE inhibitors. The guide is available on the internet at www. circulationaha. org. The report presents new guidelines for the use of estrogen. Based on the results of the recent multicenter Heart Estrogen/ progestin Replacement Study ( HERS), the AHA and ACC recommend that estrogen not be started in women who have evi-dence of coronary disease. Instead, the report says, physicians should use cholesterol- lowering agents more aggressively and work closely with patients to reduce risk factors. According to Smith, the HERS study placed women who had clear-cut evidence of coronary disease on either estrogen or a placebo, expecting that the estrogen would dramatically lower the incidence of heart attacks over a four- year period. To everyone's surprise, the incidence of heart attacks and coronary disease death did not change. " Results of the HERS study present an interesting dilemma," said Smith. " When you break down numbers from the first year of the study, patients on estrogen had an increase in coronary events. But in the last three years, they had fewer heart attacks. This seems to suggest that while estrogen poses some early risks in women who already show evidence of coronary disease, if they are on it long enough, their risk of a heart attack and death is lower than otherwise." She says further follow-up of the patients in the study and additional research is necessary to clarify the role of estrogens, in both secondary and primary prevention of coronary disease. One link doctors are more certain about is the relationship Sean Tuckett, R. N., left and Mike Morgan, RCIS, prepare a patient for angioplasty in one of University Hospital's recently renovated heart catheterization labs. between diabetes and heart disease in women. According to Smith, women with diabetes have a three to seven times greater chance of developing coronary heart disease than do men with diabetes. " My message right now for both women and men with diabetes is that they should work with their doctors to reduce their risks for coronary disease in every possible way. New research study data is coming out all the time," she said. Two years ago, Bonnie Clinical Studies Infectious Disease: Late- stage HIV patients, with a CD4< 50, are sought for a one- year, double- blind, placebo- controlled study evaluating the safety and efficacy ofWFlO ( TCDO) Intravenous Solution. The goal of the study is to decrease opportunistic infections to which late- stage HIV patients are susceptible. Qualified participants must be willing to undergo five consecutive days of a 90- minute infusion for four cycles. Call Susan Bracken, Center for Clinical Studies, 801- 585- 9228. Endocrinology: Men and women with inadequately controlled type two diabetes who are at least 60 years of age are needed for a two- year, double-blind study to evaluate rosiglitazone in combination with glipizide. Quali-fied participants must be using 1/ 4- 1/ 2 the maximum dose of their current sulfonylurea and still finding their self- monitored blood sugar level is greater than 126 mg/ dL. Contact Maureen Brinkman, R. N., at 801- 585- 6745. Bruening, 47, went to University of Utah Hospital's Emergency Depart-ment after five days of severe chest pain. Because of her diabetes and increased risk for heart disease, doctors ordered a stress echo-cardiogram. Later that day, she was admitted for angiograms and angioplasty. Since then, she also has had bypass surgery. " I never had any indication that I had heart problems," said Bruening. " I expected that I would have to deal with it at some point because of my diabetes and family history, but I never thought it would be so early." She now controls her heart disease through medication and by watching her diet and exercise. " After my angioplasty, the orthope-dic doctor I work for told me that 15 years ago women didn't have angioplasty or bypass surgery," she recalled. " So I asked him what happened to women with heart disease. ' They died,' he replied. ' We didn't look for it in women.'" $ For more information about cardiology services at the University of Utah, contact the Division of Card-iology, 801- 581- 7715. Vascular Surgeons Provide Newest Circulatory Treatments Ira Pollock, 73, knew his arteries were " clogging up." Retired from the Air Force, where he had done fire crash rescue, and from Utah's Tooele Army Depot, Pollock had been diagnosed with atherosclerosis many years earlier, but it had been worsening steadily over the past decade. The West Valley City, Utah, resident was told by his family physician that the sore on his heel wouldn't heal until the circula-tion in his foot improved. The surgeon he went to initially " was afraid to operate... said that just touching the arteries could cause them to crumble, told me I could lose one or both limbs." Referred to the University of Utah for a second opinion, Pollock received several; his case was evaluated in the medical school's six- member Division of Vascular Surgery by a team that also in-cluded radiologists and other experts in circulation disorders. Surgeon Larry W. Kraiss, M. D., ordered an angiogram for Pollock, which revealed an abdominal aneurysm that was repaired at University Hospital last February. This operation helped open up the arteries in Pollock's left leg, but the sore on his right heel remained unhealed, so in April Kraiss per-formed bypass surgery, in which 23 inches of vein were taken out of Pollock's arms and put into his leg. " Before the surgery, I couldn't walk a block without stopping at least a couple of times because of the pain," said Pollock. " I can cut my own grass and everything now." Pollock's lower extremity revascularization- bypass surgery in the legs to increase the circulation of diabetics and patients suffering from atherosclerosis- is a major focus of the U of U vascular surgery group. But it's far from the only one. Venous problems, both debili-tating and cosmetic, account for approximately half of the division's workload, " but we're also the court of last resort for emergency vascular problems, such as ruptured abdomi-nal aneurysms, vascular trauma and acute arterial blockage," said Kraiss. Over time, the global field of vascular surgery has been divided into two distinct parts, and each member of the division faculty might define the specialty with a slightly different nuance: " There is heart surgery, generally referring to operations that require cardiopul-monary bypass machines, and there is peripheral vascular surgery- now simply called vascular- which is everything else," said Kraiss. Colleague Mark R. Sarfati, M. D., put it another way: " Vascular surgery deals with any circulation problems not directly related to the heart or brain." And Spencer W. Gait, M. D., summarizes: " We deal with everything beyond the aortic arch." The three assistant professors and their colleagues in the division perform 100- 150 lower extremity revascularizations annually to treat peripheral vascular disease, the leading cause of amputations in the U. S. Nearly two million Americans, like Pollock, suffer from advanced forms of it, and most are treated with the conventional saphenous vein bypass technique, requiring a long incision in the patient's leg. For the past three years, how-ever, the U of U and 10 other centers throughout the nation have participated in a trial of a new method for treating peripheral vascular disease, an angioscopically guided endovascular system that Lawn mowing's no longer a painful chore for Ira Pollock, following lower extremity revascularization, bypass surgery in his right leg. requires only two minor incisions. The study, reported on at last June's joint annual meetings of the Society for Vascular Surgery and International Society for Cardiovas-cular Surgery, showed that side branch occlusion is comparable in effectiveness to conventional bypass, but had significantly fewer wound complications and cut the patients' hospital stays by more than half, to 3.2 days. The new technique was used last spring at Utah on a woman who had ulcers in her legs from bad veins, but could not be treated conventionally because of blocked arteries. " My incision is gorgeous," reports the 79- year- old Salt Laker, upbeat and back to her regular shopping mall excursions. " I show it to everybody." Noting that University Hospital is the only one in the Intermoun-tain area to perform this minimally invasive bypass alternative, Kraiss said " vascular surgeons at the U of U can provide services that are not widely available in the community. As less and less invasive methods are developed for abdominal aneurysm procedures, carotid endocardec-tomy and lower extremity revascularization, they are tested here." Currently, newer medications designed to treat blood vessel disease are being tested, as well as new drugs for claudication, a condition which causes patients to have leg pain when they walk. Gait says the multidisciplinary research emphasis in academic medicine is another bonus for patients. His primary research interest is in the mechanisms causing acute arterial thrombosis; other vascular surgery faculty are involved in research with specialists in pulmonary, cardiology and genetics. Clinical collaboration is common, too, and in some opera-l \ I Like primary care physicians, vascular surgeons Larry Kraiss, Spencer Gait and Mark Sarfati follow patients over time. tions, vascular and cardiovascular surgeons both play a role. Univer-sity Hospital is the only one in the Intermountain area that has done side branch occlusion, endoscopic surgery and aortic stent grafts, a less invasive method of treating aneu-rysms. " Vascular disease can be managed, but not cured," according to Sarfati. " Because of the chronic-ity of the disease, vascular surgeons are required to build and maintain lifelong relationships with their patients." Another factor operating here is that vascular surgery has no coun-terpart in internal medicine. " For cardiothoracic surgeons there is cardiology and for neurosurgeons there is neurology. This is a surgical specialty that requires a lot of ongoing primary care." ^ p For a vascular surgery consulta-tion call 801- 585- 1425. University of Utah Hospitals & Clinics toll- free referral and consultation numbers: in Utah 1- 800- 662- 0052 outside Utah 1- 800- 453- 0122 www. med. utah. edu University of Utah School of Medicine Continuing Medical Education Oct. 18- Nov. 22: Medical Humanities Seminar Series: Physicians and Patients in Literature Audience: All specialties Site: Spencer S. Eccles Health Sciences Library Planned by: Division of Medical Ethics Meeting chairs: Jay Jacobson, M. D., Joseph Cady, Ph. D. Mtg. id# l999- 050; No Fee 2 AMA Category 1 hours per session Nov. 13: Update in Cardiology for the Millennium Audience: Primary care practitioners Site: Thanksgiving Point, Lehi, Utah Planned by: Division of Cardiology Meeting chairs: Sanjeev Trehan, M. D., Jeffrey Anderson, M. D. Mtg. id# 1999- 052; Fee: free for University Health Network employees; $ 50, others 4 AMA Category 1 hours 4 hours AAFP prescribed credit Feb. 7- 12, 2000: Advances in Internal Medicine Feb. 18- 22: 45, h Annual Postgraduate Course in Anesthesiology: Cardiovascular Disease Audience: Practicing anesthesiologists and nurse anesthetists Site: Cliff Lodge, Snowbird Planned by: Department of Anesthesiology Meeting chair: Theodore Stanley, M. D. Mtg. id# 2000- 008; Fee: $ 500 18.5 AMA Category 1 hours Feb. 26- March 4: 41s t Annual Obstetrics/ Gynecology and Gynecologic Oncology Updates Audience: Obstetricians, family practitioners Site: Yarrow Hotel, Park City, Utah Planned by: Department of Obstetrics and Gynecology Meeting chairs: Neil Kochenour, M. D., Mark Dodson, M. D. Mtg. id# 2000- 009; # 2000- 010 Fee: $ 395 each 13 AMA Category 1 hours each 13 hours AAFP prescribed credit each 13 cognates eac