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Cancer, Events, Genetics, Imaging, Stanford News, Surgery, Women's Health

Don't hide from breast cancer – facing it early is key

Don't hide from breast cancer - facing it early is key

cat_hiding-pgMy cat suffers from acute anxiety. Although she and I have lived together for more than 12 years, and the worst thing I’ve ever done to her was cut her nails, she’s terrified of me. (She’s also very smart – she runs from the sound of my car, but not my husband’s). During trips to vet, Bibs hides her eyes in the crook of my elbow.

It’s a strategy that’s only minimally effective. After all, what I can’t see, or don’t recognize, can still hurt me.

Take breast cancer. It terrifies most women. And if you don’t look for it, you won’t find it. But if you do look, and find it early, you might save your life and your breast, says Amanda Wheeler, MD, a Stanford breast surgeon. She joined other Stanford breast cancer experts at a recent public program sponsored by the Stanford Women’s Cancer Center called “The Latest Advancements in Screening and Treatment for Breast Cancer.”

“One of our biggest challenge is women are scared of breast cancer, but[we have to get] the word out that we have such great advances, we’ve just got to catch it early,” Wheeler said.

She pointed to a tiny dot on a screen. At that size, Wheeler said, breast cancer is almost 100 percent curable. She performs a small lumpectomy. If it’s a little bigger, she can still probably save the nipple.

And if the entire breast must be removed, surgeons like Rahim Nazerali, MD, come in. Nazarali explained the importance of choosing a reconstruction surgeon carefully: The doctor should be accredited by the American Society of Plastic Surgeons and have experience with microsurgery, preferably on the breast. There are different ways to remold a breast and doctors can use either a synthetic implant or a patient’s own tissue, from their abdomen, hips or thighs, Nazerali explained.

All of Wheeler and Nazerali’s artistry depends on expert imaging performed by specialists like Jafi Lipson, MD, whose message at the event was simple and encouraging.

Thanks to many new developments, mammography isn’t the only way to detect nascent breast cancers, Lipson said. Her team can employ 3-D mammography, or tomosynthesis, to reveal a layered look at a breast. And genetic screening, particularly for those with a history of breast cancer in the family, can provide the earliest warning signal of all, the breast cancer team said.

Women no longer need to hide their eyes from the risk, the experts emphasized. Women should take a peek – there’s help coping with what they may find.

Previously: Screening could slash number of breast cancer cases, The squeeze: Compression during mammography important for accurate breast cancer detection, Despite genetic advances, detection still key in breast cancer, NIH Director highlights Stanford research on breast cancer surgery choices, Breast cancer awareness: Beneath the pink packaging and Using 3-D technology to screen for breast cancer
Photo by Notigatos

Cancer, Events, In the News, Patient Care, Stanford News

A neurosurgeon's journey from doctor to cancer patient

A neurosurgeon's journey from doctor to cancer patient

image.img.320.highEarlier this week, I had the chance to hear Stanford neurosurgeon Paul Kalanithi, MD, discuss living with advanced-stage lung cancer in a conversation with palliative care specialist Timothy Quill, MD. The idea for the night’s event, which was held on the Stanford medical school campus, was to provide a good example of how the doctor-patient relationship can help improve quality of life for the very sick. On stage before a packed audience, Kalanithi, prodded by Quill’s gentle but pointed questions, told the story of how serious illness changed his life. As I wrote in an online story posted yesterday:

“Are there things in particular that you worry about now?,” asked Quill… a professor of psychiatry and medical humanities at the University of Rochester School of Medicine and an expert in end-of-life decision making. “Not really,” [Kalanithi] said. “I am sad at not seeing my daughter grow up, at probably not being here long enough for her to have a memory of me. I try to worry about things that are actually changeable. I worry about getting my book finished. I’d like to have that done for my daughter to know me.”

What surprised Kalanithi most about his life after being diagnosed with lung cancer was just how hard it was dealing with those “existential” questions, he told Quill:

“Having to deal with questions like, ‘What am I going to do with my life?’ was exceedingly difficult. After realizing I wasn’t going to die in weeks or months, figuring out what I was going to do with that time was a struggle.”

Kalanithi has reorganized his priorities since his diagnosis in May 2013, setting new priorities for a much shorter lifespan than he once expected – planning for years instead of decades. He and his wife got their finances in order, they had their first child July 4. Kalanithi said he has found solace in his love of poetry, and through his writing. Kick-starting a writing career that he had planned to start in 20 years was one of those changes.

In January, he wrote an op-ed piece for the New York Times about his cross over from physician to patient titled: “How long have I got left?” He told the audience how surprised he was at the overwhelmingly positive response he received to the story. “My own thoughts on something very personal, really resonated with people. I still get an email every other day in response to the New York Times piece. It’s a great inspiration to me to remember why writing is important.” [Editor’s note: Kalanithi’s recent Q&A here on Scope has also drawn massive attention; it’s already one of our most popular posts of the year.]

Kalanithi’s final message, particularly to those young physicians and medical students in the audience, was to listen to your patients. Take time to get to know them. Remember why it is that you went to medical school. When asked if he treats his own patients differently since his diagnosis, he was characteristically thoughtful. “I think I felt a depth that I didn’t before… But I had excellent role models. I was trained you don’t just go over what are the risks and benefits. You really try to convey as much as you can about what it’s going to feel like.” He told his favorite example of a pediatric oncologist who he observed talking to parents whose daughter had just been diagnosed with a brain tumor. The doctor’s advice: “You need to support each other. You have to prepare your patients as much as you can for that larger emotional experiential landscape. You have to get enough sleep.”

Previously: “Stop skipping dessert:” A Stanford neurosurgeon and cancer patient discusses facing terminal illness and No one wants to talk about dying but we all need to.
Photo by Norbert von der Groeben

Cancer, Events, Patient Care, Public Health

"Stop skipping dessert:" A Stanford neurosurgeon and cancer patient discusses facing terminal illness

"Stop skipping dessert:" A Stanford neurosurgeon and cancer patient discusses facing terminal illness

terminally_ill

Updated 10-23-14: Dr. Kalanithi spoke about this topic on campus earlier this week; more on the event, and his insights, can be found here.

***

10-20-14: When Paul Kalanithi, MD, a chief resident in neurological surgery at Stanford, was diagnosed at age 36 with stage IV lung cancer he struggled to learn how to live with conviction despite a prognosis of uncertainty. He found comfort in seven words from writer Samuel Beckett, “I can’t go on. I’ll go on.”

That mantra has given Kalanithi the strength to face his own mortality and have tough conversations with his wife and loved ones about the future. Tomorrow evening, he’ll join palliative-care specialist Timothy Quill, MD, for a discussion about end-of-life decision-making. The campus event is free and open to the public; no registration is required.

As a preview to the talk, Kalanithi talked with me about his experience as a patient and about the importance of end-of-life decisions.

How has your prognoses changed the way you talk to patients and their loved ones about grim news?

In large part, the way I talk to patients and their families hasn’t changed, because I had excellent role models in training. I remember witnessing a pediatric neurosurgeon talk parents through the diagnosis of their daughter’s brain tumor. He delivered not just the medical facts, but laid out the emotional terrain as well: the confusion, the fear, the anger and – above all – the need for support from and for each other. I always strove to emulate that model: to educate patients on the medical facts isn’t enough. You have to also find a way to gesture towards the emotional and existential landmarks.

Seeing it from the other side, it’s really hard, as a patient, to ask the tough questions. It’s important for the doctor to help initiate these conversations. I think it’s worth addressing prognosis and quality of life with patients, asking them what they think. My own assumptions about my prognosis were way off base. As a doctor, you can’t provide definite answers, but you can remove misconceptions and refocus patients’ energy.

Finally, I think, if you are the oncologist, it’s important to establish yourself as a go-to for any questions. Patients are bombarded with well-meaning advice, from dietary recommendations to holistic therapy to cutting-edge research. It can easily occupy all a patient’s time, when you ought to also spend time thinking about the priorities in your life. Physicians can also advise patients, as my dad would insist, that they can stop skipping dessert.

What is your advice to patients who are struggling with the certainty of death and the uncertainty of life?

I’ve written a little bit about facing terminal illness in The New York Times and The Paris Review. I found the experience difficult. I still find it difficult. It is a struggle. The problem is not simply learning to accept death. Because even if you do come to terms with finitude, you still wake up each morning and have a whole day to face. Your life keeps going on, whether you are ready for it to or not.

In some ways, having a terminal illness makes you no different from anyone else: Everyone dies. You have to find the balance – neither being overwhelmed by impending death nor completely ignoring it.

You have to find the things that matter to you, in two categories. The first is of ‘the bucket list’ sort. My wife and I always imagined revisiting our honeymoon spot on, say, our 20th wedding anniversary. But I didn’t realize how important to me that was until we decided to go back earlier (on our 7th anniversary, instead, about four months after I was diagnosed).

The second is, as all people should be doing, figuring out how to live true to your values. The tricky part is that, as you go through illness, your values may be constantly changing. So you have to figure out what matters to you, and keep figuring it out. It’s like someone just took away your credit card, and now you really have to budget. You may decide that you want to spend your time working. But two months later, you might feel differently, and say, you really want to learn saxophone, or devote yourself to the church. I think that’s okay – death may be a one-time event, but living with a terminal illness is a process.

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Events, History, Medical Education, Medical Schools, Stanford News

A trip down memory lane: Stories from the early days of the School of Medicine

A trip down memory lane: Stories from the early days of the School of Medicine

When Philip Pizzo, MD, came to interview for the position of dean of Stanford’s medical school in 2000 he stayed in a nearby hotel. Taking a cab each day to campus for interviews, Pizzo would ask the driver to take him to the School of Medicine. Not one driver knew where to go, recounted Drew Bourn, PhD, while leading a recent architectural tour of the School of Medicine.

At the time the dean’s office was buried in a courtyard of the Stone Building and hidden from street view. But now the medical school has a face, the stately Li Ka Shing Center for Learning and Knowledge, which will soon have a twin to the east. Within a decade or so, a new, matching building will replace the research building currently beside it.

This was just one of the many stories Bourn shared about the first medical school on the West Coast, which has its roots in Illinois, where physician Elias Samuel Cooper, MD, diced up cadavers of executed criminals to teach surgery.

The Gold Rush brought him west, and soon the Cooper Medical College sprouted up in San Francisco, before aligning with Stanford and moving south to the Farm in the 1950s.

Its first building was the current hospital, known as the Stone Building not for its construction material, but for its architect, Edward Durrell Stone, a famous midcentury architect who designed Radio City Music Hall, among many other national and international works.

Lest I steal all of Bourn’s best bits — including how Stone met an Italian fashion writer on a plane, and before landing convinced her to marry him — I’ll leave it to you to enjoy the experience on your own. Local readers: Bourn offers tours regularly — the next is Nov. 12 at 2 PM — free and open to all. All who want to spend an enjoyable hour learning, that is.

For more fun photos, check out the Stanford History Medical Center’s Flickr collection.

Previously: Stanford building houses one of the world’s largest medical simulation facilities, Stanford’s Clark Center, home to Bio-X, turns 10 and A new era in education at Stanford’s Medical School
Photos from Stanford History Medical Center

 

Ebola, Events, Global Health, Infectious Disease

Experience from the trenches in the first Ebola outbreak

Experience from the trenches in the first Ebola outbreak

512px-Ebola_virus_emNoted infectious disease expert Donald Francis, MD, PhD, was “a quiet doctoral student” at Harvard when he was called in to fly into the remote bush of southern Sudan in 1976 to help with one of the world’s first documented outbreaks of Ebola. The federal Centers for Disease Control and Prevention dispatched him for a two-week assignment that stretched into two months, as he saw villages demolished by the virus and helped bury some 274 bodies, he told a group of 70 science writers earlier this week in San Francisco.

Like today’s epidemic in West Africa, most people who contracted the disease were caregivers, either at home or at the make-shift tent hospital, or people assisting at funerals, where bodies were literally dripping with blood, he said. A single drop contains many thousands of viral particles, so all it took was a simple scratch of the nose with a contaminated finger to become infected.

Remarkably, none of his team members became infected, though they took risks, including storing viral samples in unsafe vials, and flying in and out of the treatment area when they were supposed to be in quarantine, he said.

Unlike today’s epidemic, the outbreak burned itself out because it took place in the remotest of areas.

“This was a very good place to control an outbreak – very rural, very isolated,” said Francis, co-founder and executive director of Global Solutions for Infectious Diseases.

Francis is the former director of the CDC’s AIDS Laboratory Activities and was among the first to suggest that AIDS was caused by an infectious agent. He has worked in epidemics around the world and helped eradicate smallpox from Sudan, India and Bangladesh before he became involved in the AIDS epidemic.

But his early work was in Ebola. During that first outbreak in Sudan, his five-member team worked with local nurses, some of whom were sickened by the virus but recovered. “I had patients who were so sick that the whole skin of their feet would slough off,” he said. And though the survivors were in a weakened state, losing as much as 20 percent of their body weight, they were determined to continue caring for their fellow villagers, he said.

He said today’s epidemic in West Africa presents a number of “worrisome challenges,” as it is occurring in a part of the world beset by political and social chaos.

“You have social chaos, socio-economic lack of resources, and hospitals that are just set up for transmission of the virus,” he said.

He said Ebola “can be controlled, but once it becomes so broad (as is currently the case), you lose that capability.” He expressed little hope that the current epidemic could be contained anytime soon: “I expect it will play out very badly for at least a year.”

Previously: Ebola: A look at what happened and what can be done,  Dr. Paul Farmer: We should be saving Ebola patients, Ebola panel says 1.4 million cases possible, building trust key to containmentShould we worry? Stanford’s global health chief weighs in on Ebola and Biosecurity experts discuss Ebola and related public health concerns and policy implications
Photo by CDC/ Dr. Frederick A. Murphy

Emergency Medicine, Events, Imaging, Medical Education, Stanford News

Ultrasound has its day – and evangelists galore

Ultrasound has its day -  and evangelists galore

ULTRAfestUltrasound isn’t just for babies anymore.

“We use it for everything from head to toe and skin and organs,” emergency medicine instructor Laleh Gharahbaghian, MD, recently told writer Sara Wykes for an Inside Stanford Medicine story. “It’s become an essential tool at  the bedside we apply to immediately rule out — or rule in — medical conditions.”

That’s why Gharahbaghian and her colleagues are hosting ULTRAfest, a full day of ultrasound instruction open to all medical students on Oct. 18. Last year, more than 300 students from across the western United States attended.

Ultrasound uses sound waves that are too high pitched for our ears to detect. The waves bounce off material in the body, providing a glimpse inside.

ULTRAfest2What’s so great about ‘Sound (as Gharahbaghian calls it on her Twitter page)? It’s relatively cheap — new scanners start at $90,000 — non-invasive and portable. Ultrasound has also moved beyond mere diagnostics. For example, Stanford radiologist Pejman Ghanouni, MD, PhD, uses ultrasound to treat uterine fibroids.

Although the technology isn’t new, researchers are finding new uses for ultrasound. As detailed in that Inside Stanford Medicine piece:

More recently, the use of ultrasound has crossed into another part of the anatomy long thought to be immune to its imaging prowess: the lungs. In the air-filled environment of the lungs, the sound waves that are the basis of ultrasound have nothing to ping against. However, in lungs where disease has produced fluids, ultrasound has proven more accurate than a chest X-ray and faster than CT scan to diagnose common lung conditions, including pulmonary edema, pneumonia and pleural effusions.

Other doctors and medical students, including U-fest volunteer William White aren’t shy about touting ultrasound’s benefits: “I just fell in love with the technology, picking up a probe and looking into the body in real time.”

Previously: New technology enabling men to make more confident decisions about prostate cancer treatment, Listening to the stethoscope’s vitals, Plane crash creates unexpected learning environment for medical students 
Photos by Teresa Roman-Micek

Ebola, Events, HIV/AIDS, Infectious Disease, Public Health, Stanford News

Dr. Paul Farmer: We should be saving Ebola patients

Dr. Paul Farmer: We should be saving Ebola patients

The photo says it all: A very slender, ailing man sits on the floor with his head bent, completely alone in the dark in what used to be an Ebola treatment center in West Africa.

Paul Farmer, MD, PhD, the brilliant physician and humanitarian, flashed the photo on a screen to a rapt Stanford audience last Friday to show the emaciated state of health care systems in West Africa, incapable now of treating the most basic ailments.

Every time someone dies, it’s a failure to diagnose and deliver the imperfect tools we have

“The primary determinant of outcomes is the strength of health care systems. And if this is what ETU’s (Ebola Treatment Units) look like, there are going to be a lot of fatalities,” he told the crowd of some 400 people at Stanford’s Graduate School of Business. “We should be saving most of these patients. Every time someone dies, it’s a failure to diagnose and deliver the imperfect tools we have.”

But this vast inequity in care need not exist, said Farmer, MD, PhD, a Harvard professor. He pointed to examples from his own experience, in which he and the group he co-founded, Partners in Health, helped build robust health systems in Haiti and more recently, Rwanda, saving thousands of lives.

Farmer started working in Haiti while he was a student at Harvard Medical School nearly 30 years ago. In 1998, during the peak of the AIDS epidemic there, he established the HIV Equity Initiative, which relied on community health workers to visit the homes of patients daily to check on their status and ensure that they took their antiretroviral and/or tuberculosis medications. The approach proved remarkably successful, as people rose from their deathbeds to return to normal, functioning lives.

More recently, after the 2010 quake in Haiti, his group helped to build a medical center and teaching hospital in rural Haiti; he showed a photo of the modern, expansive new facility to the Stanford audience, which applauded the work.

“This is what I think of for rural Liberia, rural Sierra Leone,” he said. “This is not rocket science. Just think what we could do if we had a lot of help with systems and partners. It just requires sticking with some of these problems for a long time.”

Previously: Ebola panel says 1.4 million cases possible, building trust key to containmentExpert panel discusses challenges of controlling Ebola in West Africa, Should we worry? Stanford’s global health chief weighs in on Ebola and Biosecurity experts discuss Ebola and related public health concerns and policy implications

Behavioral Science, Events, Mental Health

Learning to forgive with Fred Luskin, PhD

283888330_71b4084e22The long, wooden conference table was surrounded by 12 women, including me. We giggled a bit: Where were the men?

“All over the world, it’s almost always women,” said the first and only man to enter the room, Fred Luskin, PhD, the instructor of a four-week “Forgive for Good” class (presented by the Stanford Health Improvement Program) and founder of a movement to forgive – for your own health. He looked every bit the professor — gangly, with disheveled hair and a shirt sporting an equation.

“Even in northern Ireland?,” one woman asked.

“Even in northern Ireland,” Luskin responded.

I came to watch, to record as an observer, just as I have covered hundreds of events in the past. But in Luskin’s class, everyone must forgive. Even journalists.

It hurt to darken my laptop and separate my fingers from its well-worn keys. I bristled during the initial relaxation session, where we were directed to focus on our breathing. He’s saying things and I’m missing them! Grrrrrr. My heart raced.

“You can’t forgive if you don’t relax,” Luskin said. “You have to quiet down and open.”

I tried to pretend I was in yoga class. I took in a breath. Open. Breathe. Then, the relaxation session was over and I relaxed, once again reunited with my trusty Mac.

But then, as Luskin was mentioning that many women had taken his classes to forgive their ex-husbands – “There’s lots of terrible ex-husbands running around,” he joked – I looked around the table. Here were 11 women, driven to spend four evenings letting go of a hurt that was tearing them up inside. Instantly, my aggravation slipped away. My teensy anger was nothing compared to the real wrongs of the world.

“It’s quick and difficult to be a human being,” Luskin said. “You don’t get a do-over.”

Grieving and suffering are normal, he said. Yet make sure the harm doesn’t dampen the rest of your life. A jerk cuts you off on the freeway? Fume for a second, but one exit later it should be forgotten, Luskin said. A drunk driver leaves you crippled? That takes a bit longer, maybe five years. Dreadful childhood? No one in their 50s should still be stewing about their harsh lot.

“Life is very challenging,” Luskin said. “Do you want to spend years holding on to your part of that challenge? Or can you accept your portion of portion of pain?”

Once the grieving is done, stop talking about the hurt, Luskin said. “We used to call this shut-up therapy…  Just shut up and stop driving yourself nuts.”

Then, he said, you can love again, without hiding your heart. That’s a message worth parting from my computer.

Previously: Practicing forgiveness to sustain healthy relationships, A conversation with Stanford psychologist Fred Luskin on forgiveness and its health benefits and Teaching children the importance of forgiveness
Image by Ian Burt

Cardiovascular Medicine, Events, Patient Care, Stanford News

A ssathi (partner) to thwart heart disease in South Asians

A ssathi (partner) to thwart heart disease in South Asians

heart-66892_1280S.S., a 44-year-old male South Asian engineer, visited Rajesh Dash, MD, PhD, at his Stanford clinic not long ago.

“He had come to see me almost as a third option,” Dash told a crowd of 25-or-so listeners at a presentation on South Asians and heart disease sponsored by the Stanford Health Library last week. Dash didn’t mention why S.S. originally visited a doctor. But he said S.S. exercised three times a week and ate relatively healthy food. He smoked socially. His blood pressure was only slightly elevated. He didn’t appear to be at high risk for heart disease.

One doctor had left S.S. with little more information than he had before the visit after the results of a standard diagnostic questionnaire were inconclusive. Another doctor recommended an angiogram. S.S. balked – why, he asked.

So he came to see Dash, who directs SSATHI, or the Stanford South Asian Translational Heart Initiative, a clinical program that specializes in coronary disease and insulin resistance in South Asians, which is defined to include people from India, Pakistan, Bangladesh, Nepal, Bhutan, Maldives and Sri Lanka.

Dash asked S.S. a question no one else had: What about your family? “Well,” S.S. responded, “my older brother, who is 46, had a heart attack recently. My mother has four stents in her arteries. Three of my mother’s brothers died of heart attacks before they were 60.”

Now, no medical degree was needed to see that S.S. was clearly at high risk for heart disease. Dash prescribed a coronary CT scan that revealed that one of S.S.’s heart vessels was 99 percent blocked. In other words, S.S. was a walking time bomb. Doctors treated his condition aggressively with a combination of drugs, surgery, recommended lifestyle changes and follow-up care.

S.S. had three questions for Dash: Why did this happen to me? How can I prevent it from happening again? And, how can I prevent it from happening to my children?

Dash doesn’t have the answers to all the questions — yet. But his SSATHI team (Ssathi also means companion or partner in Hindi) is working to figure them out – and to keep S.S. healthy for decades to come. The team surrounds patients with experts — cardiologists, nutritionists, surgeons and others. And they provide social-media tools and encourage around-the-clock commitments from patients. The program is no cake walk.

Dash also shared some startling statistics: More than half of all South Asians who suffer heart attacks get them before age 50. In California, South Asians have four times more heart attacks than other ethnic groups. South Asians also have a high rate of diabetes and heart disease is now the top cause of death in India, Dash said.

Ssathi hopes to treat South Asians of all ages, but they’re particularly looking for new patients from ages 20 to 55 because heart disease in South Asians begins at young ages. The SSATHI program is focusing South Asians in California, but Dash said they also plan to introduce programs in India.

Previously: Global community must do a better job of managing risk of Nipah virus, expert says, A closer look Asian American health and Gap exists in women’s knowledge of heart disease
Image by geralt

Events, Neuroscience, Stanford News

Open Office Hours: Stanford neurobiologist taking your questions on brain research

Open Office Hours: Stanford neurobiologist taking your questions on brain research

Newsome

Last year Stanford launched the new Stanford Neurosciences Institute, led by visionary neurobiologist William Newsome, PhD. Part of his job over the past year has been to inspire faculty to think beyond their own labs and to dream about what they could accomplish if they work together. He called this the Big Ideas in Neuroscience.

This week, Newsome will be taking questions about your Big Ideas (or Big Questions) in brain research as part of a Stanford Open Office Hours event on Facebook. Are you curious how we learn and remember? What technologies might allow us to peer into the brain and even manipulate its function? How a deeper understanding of the brain could influence public policy, education and the law? Go to the Facebook page for the event and submit your questions by tomorrow (Oct 1).

Previously: “Bold and game-changing” federal report calls for $4.5 billion in brain-research fundingDinners spark neuroscience conversation, collaborationBrain’s gain: Stanford neuroscientist discusses two major new initiatives and Co-leader of Obama’s BRAIN Initiative to direct Stanford’s interdisciplinary neuroscience institute
Photo from Stanford News Service

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