Specialists Write In About Melanoma

Dr. Pendharkar is a practicing dermatologist (skin doctor) and Dr. Sivendran is a practicing Oncologist (cancer specialist). Please read their posts below for more information about a deadly type of skin cancer: Melanoma 

Melanoma 
By Dr. Ninad Pendharkar, Dermatologist

May is melanoma awareness month. Melanoma is a type of skin cancer that arises from melanocytes, which are the cells in the skin that create pigment. Unfortunately, the incidence of melanoma has been increasing. It is now the most common type of cancer in young adults aged 25-29. When identified early and treated, the cure rate is very high. However, a delay in detection increases the chance of it spreading to other parts of the body and being fatal.

Since early diagnosis is paramount in managing melanoma, it is important to examine your skin for any new or changing moles. The ABCDEs of melanoma can help in early detection.

      A-     Asymmetry (one half of the lesion looks different than the other half)

      B-     Border (irregular or poorly defined or scalloped boundaries of the lesion)

      C-     Color (varied color from one area to another; shades of tan, brown & black are present; sometimes white, red and blue)

      D-     Diameter (larger than the size of a pencil eraser)

      E-     Evolving (a lesion that looks like it has been changing in size, shape or color)

Another helpful detection tool is the “ugly duckling sign.” When examining your moles, look for the one mole or lesion that looks different than all the others. If you see any of these signs, it is important to see your doctor. Sometimes melanomas can itch, hurt or bleed. But most of the time there are no symptoms associated with melanoma.

Anyone can develop melanoma. However, people with fair skin, people who burn easily, and people with many moles are at an increased risk. Ultraviolet (UV) radiation is a major cause of melanoma. This could be from the sun, indoor tanning beds and sun lamps. Recent studies have shown that use of indoor tanning beds can increase your risk for melanoma by almost 75%.

If your doctor finds a spot that looks suspicious, the doctor will remove it or part of it and send it to the lab for analysis. This is called a skin biopsy and is typically a quick, safe and easy procedure to perform in the office. If the biopsy report states that the lesion is a melanoma, it will usually tell your doctor how deep the melanoma has grown into the skin. Based on this result, patients will require further surgery to remove skin cancer with a safety margin of normal skin around it. If the melanoma is deeper than a certain level, patients may need another type of biopsy called a sentinel lymph node biopsy. This helps doctors identify whether the melanoma has spread to nearby lymph nodes. If the melanoma has spread, then patient will need to see an oncologist (cancer doctor) for further testing and treatment.

As mentioned previously, early detection is the key for better outcomes. If the melanoma is early and only in the top layer of the skin, patients can be cured with surgical removal of the cancer. However, prevention is always better than cure. As a result, limiting UV sun exposure, using broad spectrum sunscreens of SPF 30 or higher, sun protective clothing, and avoiding the use of indoor tanning beds are critical in preventing melanoma.

Treatment of Advanced Melanoma: Perspective of a Cancer Doctor

By Dr. Shanthi Sivendran, Oncologist.

May is melanoma awareness month and important advances have been made in the treatment of advanced melanoma.  Stage IV or metastatic melanoma describes melanoma that starts in the skin and travels to some other part of the body such as the liver, lung, or brain.  When this occurs melanoma is rarely curative and the goals of treatment are to balance a patients quality and quantity of life.  

Historically, the average survival with someone with metastatic melanoma (spread beyond the skin) has been about six months.  For many years the only Food and Drug Administration (FDA) approved drugs were traditional chemotherapy and an immunotherapy called Interleukin 2.  Both were difficult therapies to tolerate.  Chemotherapy goes through the body and kills anything that grows fast.  That is potentially great for killing cancer but the price can be significant side effects from the temporary destruction of certain normal cells that also grow fast.  Chemotherapy has also not been very effective in the treatment of metastatic melanoma.  

Breakthroughs in research however have led to the FDA approval of two new medications in the treatment of metastatic melanoma - vemurafenib and ipilimumab.  These drugs are a significant break from chemotherapy because instead of killing anything that grows fast they only target specific pathways that drive the growth of melanoma.  For example, a mutation in BRAF pathway has been implicated in melanoma cancer growth.  Targeting BRAF with a drug that specifically inhibits it, vemurafenib, has been shown to improve overall survival from 6 months to 10 months.  Ipilimumab targets the immune system and has also improved survival in this disease.  Because these drugs are "targeted" drugs they come with a different potentially more tolerable set of side effects in comparison to traditional chemotherapy.  The introduction of these new drugs has provided new options for patients with this tough disease and have opened pathways for new research and clinical trials. 

The best treatment however for melanoma is prevention and early detection.  Talk to your family doctor and dermatologist about ways to reduce your risk of melanoma including wearing sunblock, avoiding excessive sun exposure, and wearing sun protective clothing.  If you have any moles you are concerned about bring it to the attention of your doctor.  As Ben Franklin said "An ounce of prevention is worth a pound of cure."

 Photo of asymmetrical melanoma Click here to go to National Cancer Institute website

Vaccinations: "I Cannot Tell a Lie," Said Our Founding Father

According to the College of Physicians in Philadelphia, in 1777, George Washington ordered mandatory vaccination for his troops in the Continental Army if they had not previously survived smallpox earlier in life. (Interesting timeline of vaccines- Click here). Some historians believe that a British commander in the revolutionary war may have intentionally spread small pox (just 1 example of early bio-warfare).

Vaccinations in some form or another were used as far back as 900 CE (or maybe earlier).

Many deadly illnesses have been eradicated or reduced due to vaccination.  For example, the crippling disease polio is virtually unheard of due to vaccination in children.  
Photo of president Franklin D Roosevelt with Polio complications. Click to hear NY Times audio clip.

There seems to be many conspiracy theories against vaccination. Some of these theories were fueled by the infamous report by Andrew Wakefield in The Lancet in 1998 that the measles, mumps and rubella vaccine (MMR) in children can cause autism. The Lancet retracted this article in 2010 and Wakefield et al have been found guilty of deliberate fraud. Read more at the US library of Medicine- Click Here. 

Vaccines are generally safe and can greatly reduce the chance of severe, disabling illness and death.

Talk to your doctor to be sure you are up to date on your vaccines to prevent serious illness. There are some reasons to avoid a few vaccines and your doctor can explain to you which ones you may need to avoid.

In general, the following are recommended for adults: Influenza or FLU shot (every year); Tetanus with pertussis (once) followed by tetanus EVERY 10 years; Chickenpox (once- if born after 1980- talk to your doctor); Shingles (once-for adults over age 60); Pneumococcal (once for adults over 65 OR every 5-7 years for adults over age 18 with breathing problems such as asthma); HPV (to prevent a sexually transmitted virus that can cause cervical cancer); MMR (measles, mumps and rubella); Meningitis vaccine (especially college or military individuals); Hepatitis A and B. There are a few other vaccines that may pertain to you which can be addressed by regular checkups with your primary care provider.

If you have questions about the above vaccines feel free to post a question below.

Diabetes Mellitus: "Honey Sweet Passer Through"

Diabetes is a very prevalent illness affecting some 290 million people in the world. In the United States alone 26 million people (8% of the population) have diabetes.  The disease cost the United States $245 billion in 2012. (source: diabetes.org)

What exactly is diabetes? What are some symptoms? Why is diabetes so serious and costly?

Diabetes mellitus is a term loosely translated from Latin and Greek meaning "honey sweet urine". Ancient Greeks, Chinese, Egyptians, Persians and Indians had noticed the sweet taste of urine (called glycosuria) in people with what we now call diabetes.

There are 2 basic types of diabetes: insulin dependent and non insulin dependent. Another way to classify it is called Type 1 and Type 2 diabetes. Type 1 diabetics don't make insulin and need to take insulin to use the sugar (glucose) in their blood as energy for cells. I like the analogy of the lock and key. Insulin is the key to get sugar into our cells for energy. Without insulin one becomes very sick and cannot metabolize sugar to make the energy necessary to sustain life. Type 2 diabetics make insulin, however their cells become RESISTANT to insulin. Think of the key 'not working well' to get the sugar into our muscle cells to produce energy. If Type 2 diabetics become severely resistant to insulin they need supplemental insulin (given as an injection) to convert the sugar in the blood to useful energy in cells. Many Type 2 diabetics can take a pill to help with this problem and avoid the need for insulin in the early stages of diabetes.


Photo from: asweetlife.org (labeled on original website as a courtesy of Eli Lily)




 Dr. Elliott Joslin considered the father of diabetes care.


Symptoms of diabetes include excessive thirst, urination and fatigue. If your blood sugar is very high it can cause blurred vision and tingling in your hands and feet. There are many things that can cause the above symptoms so just because you are thirsty doesn't necessarily mean you have diabetes.  Often times diabetes can be silent without symptoms in the early stages. 

Complications of untreated diabetes include heart disease, stroke, foot ulcers and amputations, blindness and nerve pain and damage. Fortunately, today, people with diabetes can avoid these complications by good care and close followup with their primary care provider or endocrinologist (diabetes specialist).

If you have a family history of diabetes, talk to your doctor and ask how you can be tested for diabetes and what things you can do to reduce your risk of developing diabetes and the complications of diabetes.

Sleep apnea, Charles Dickens & Pickwick papers

Charles Dickens may be one of the greatest novelists of the Victorian period.  Dickens is famous for his humor, satire and keen observation of character.   Dickens started with an 1836 publication known as the "Pickwick papers."

The main character, Samuel Pickwick is a kind and wealthy old gentleman and founder of the Pickwick club.  He is usually portrayed "as a round-faced, clean-shaven, portly gentleman wearing spectacles." Another character, Joe, known as the "Fat boy" "consumes great quantities of food and constantly falls asleep in any situation any time of the day."  Joe's sleep problem is the origin of the medical term Pickwickian syndrome which ultimately led to the development and subsequent description of obstructive sleep apnea syndrome.    (From the article: Literature, Sleep and Dreams in).

What is Sleep Apnea?

Sleep apnea is a condition of interrupted sleep caused by pauses in breathing (apnea). These pauses lead to low oxygen levels in the blood and elevated carbon dioxide levels in the blood. This causes one to wake up briefly and then fall back to sleep. This constant interruption of sleep throughout the night can manifest itself as symptoms of fatigue, daytime sleepiness, falling asleep easily during the day, morning headaches, poor memory and attention and lack of feeling refreshed after a night of sleep.

Risk factors for sleep apnea include being overweight and crowding of the airway (from large tonsils or a large tongue relative to your windpipe). The aging process can also cause abnormal signals from the brain and trigger another type of sleep apnea.

Take a test to see if you are at risk.  You can also take THE SNORE SCORE.  

Untreated Sleep apnea can lead to high blood pressure and increase your risk of heart and lung disease. It can increase your risk of a heart attack if left untreated for many years. Take the above tests and talk to your doctor to see if you might suffer from Sleep apnea.

Strong Bones

Brittle Bones, Calcium/Vitamin D & Bisphosphonates

Many patients have asked me excellent questions about bone health and osteoporosis. Below is some brief information on bone health. You should always discuss new symptoms and concerns with your personal doctor.

Osteoporosis increases your risk of hip, spine and other fractures.  Osteoporosis is a condition that affects older individuals or those who take steroids on a LONG term basis (such as prednisone). Postmenopausal women are at highest risk for osteoporosis.

There is much written in the popular press about bone health. More recently there has been a media scare about a class of drugs known as bisphosphonates (one example is alendronate or the brand name Fosamax). Fosamax (alendronate) is just one of the medications prescribed to treat osteoporosis.  It can significantly reduce your chances of a fracture IF you have osteoporosis. The media has hyped up reports of fractures and jaw bone necrosis. Both of these are very serious but rare. The risk of osteonecrosis of the jaw is between 1 in 10,000 and 1 in 250,000 and this was in doses 10x higher than prescribed for osteoporosis.  Talk to your doctor and your pharmacist about your individual risk and the benefit of taking any medication to treat a disease.

In general women are at higher risk then men for osteoporosis. If you are a woman over the age of 65 talk to your doctor about a BONE DENSITY test known as DEXA.  You might need the test before age 65 if you smoke cigarettes or have a family history of osteoporosis. Talk to your doctor about the best time to have a DEXA test to screen for osteoporosis.

There is an online calculator to help you and your doctor calculate your risk of osteoporosis. Click on this link to calculate your score. Talk about your score with your doctor to determine if you simply need periodic monitoring or treatment for osteoporosis.

 

WHAT CAN I DO NOW?

Exercise, quitting smoking and a diet rich in calcium and Vitamin D can reduce your chances of osteoporosis and fracture. Try to get about 1,000mg to 1,200mg of calcium in your diet everyday. Also try to get about 600-800 IU of Vitamin D. Read food labels for totals in your foods. Supplement with an over the counter supplement with calcium and vitamin D available at your pharmacy.

"Obama Care"

Access for Millions

I have been asked by my patients, "As a doctor how do you feel about 'Obama-Care'?" This is a difficult question to answer.  I believe it is good that 40,000,000 uninsured people now have access to health care.  It was unacceptable that so many Americans did not have coverage for basic health care.

Without access, people will wait until their disease process is out of control to seek help. From a financial perspective it costs MORE money to treat a disease after many complications have developed than to catch something in the early stages. With access, hopefully the newly insured will be able to get the care they need.

The Affordable Care Act (known as "Obama Care") has been criticized as an entitlement program and a program that will add to our national debt. I am curious to hear YOUR thoughts on this law (Please post comments below). The supreme court upheld the constitutionality with respect to the requirement for an individual mandate "as a tax" by a 5-4 vote.

The American Medical Association (AMA) has supported the ACA. Click to read about the AMA views on the law.

The Press has reported extensively on the matter click to view a New York Times article.
(Please post an article that comes from another source). There is a hotly bipartisan divide with Republicans wanting to repeal the law and Democrats supporting the law.

I recognize we are at a critical juncture in our nation and spending must be controlled, however, this cannot be done at the sacrifice of human lives and their access to quality health care. I believe there are going to be new challenges that arise from this law: the financial burden & the shortage of primary care doctors to treat the new patients (just to name a few). Hopefully with time the law can be amended to meet the needs of all Americans.

Brainwave Symphony, Patient Safety & Primum Non Nocere

Primum non nocere

First do No Harm 

As I write this post, I am listening to Dr. Jeffrey Thompson's Brainwave Symphony- Energize and Focus. For my heavy metal fans, try Symphony & Metallica for the hard rock edge! 

NOTE: (click on links to explore)

Last night I listened to a Webinar by Jaan Sidorov, M.D., MSHA, FACP titled: Basics of Medical Malpractice Insurance and Minimizing Chances of a suit. As I listened to the statistics that 12% of a physician's career is spent in litigation and 100% of physicians will be named in a suit at some point I realized the truth behind his comment, " It is the price of doing business and a sacrifice we make as doctors.

Several excellent points were brought up that I will open for discussion:

1) Tort reform.

2) Apology Laws- Do they work? Short answer: yes.

3) Use curbside consults appropriately and respect your colleagues?

4) We are all responsible to do our best to ensure patient safety. Patient safety takes priority above all else.

5) GOOD, THOROUGH patient hand offs from shift to shift for all providers.

6) Safety, Safety, Safety.

7) No finger pointing.

8) Tickler systems as part of the electronic medical records for reminders and safety.


3 good books I encourage people to read:  "How Doctor's Think," by Dr. Jerome Groopman; "Who Killed Healthcare?" by Regina Herzlinger & "Complications- A Surgeon's Note on an imperfect Science," by Dr. Atul Gawande.

Website

My website is up and running. Visit: www.dradamalbert.com

I'm not 100% certain what my goals for it are going to be. Some thoughts:

1) sounding board for discussion amongst colleagues regarding relevant health care policy topics.

2) A guide for patients to use for common problems seen by internists.

3) A personal space to share thoughts on wellness and health.

4) I am open to any ideas- please post them in the comments.

I will be attending the American College of Physicians conference in San Francisco in April. I look forward to the conference and hope to have some new ideas to share with everyone.

Welcome

Welcome to my first adventure with blogging.

I hope to write some interesting thoughts, comments and ideas to encourage knowledge discovery as well as healthy debate in various areas of healthcare, medicine and wellness.

The medical field is a sea of seemingly endless information. I hope to post links and ideas that are solidly grounded in what the science community calls "Evidence based Medicine." This will help assist the reader in the process of sorting out quality information from nonsense.

Check back weekly for blog updates. You may contact me at adamjalbertmd@gmail.com with questions or comments.

Disclaimer: The information in this blog is not meant to be a substitute for regular medical care. Always discuss health concerns and new symptoms with your personal health care provider and never try to diagnose yourself.