marin medicine winter 2012

Volume 58, Number 1 Winter 2012 $4.95

The magazine of the Marin Medical SocietyMarin Medicine

CancerCancer Screening in Primary CareColonoscopiesLymphoma UpdateMarin Women’s StudyPSA Test Controversy

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Volume 58 Number 1 Winter 2012

Table of contents continues on page 2.

Cover: “The crab and its mother,” by Wenceslas Hollar (c. 1650)

FEATURE ARTICLES

CancerINTRODUCTIONThe Topic of Cancer

“Unlike Miller’s novel, this issue of Marin Medicine is literally about cancer. Far from despairing, five local physicians offer mostly positive reports on medical progress against this pervasive killer.”Steve Osborn

CANCER SCREENINGFlickering Lights on the Christmas Tree

“The swing in cancer screening over the last 50 years is like putting hundreds of lights on a Christmas tree, then realizing that most of them don’t work and need to be removed.”Joan Pont, MD, FACP

COLORECTAL CANCER SCREENINGEnough With the Excuses!

“As a gastroenterologist, probably the single biggest question I get asked is, ‘Do I have to get a colonoscopy?’”Jeff Fox, MD

CANCER UPDATENew Treatments for Non-Hodgkin’s Lymphoma

“The past decade has brought tremendous progress in both diagnostic and treatment approaches for Non-Hodgkin’s lymphoma, but we still have a long way to go and face many challenges.” Jennifer Lucas, MD

BREAST CANCER RESEARCHThe Marin Women’s Study

“Odds are that every physician in Marin County encounters breast cancer in their practice, either in their patients or in their patients’ family members and friends.”Mary Mockus, MD

PROSTATE CANCERPSA Screening and the Patient-Doctor Relationship

“I believe the task force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease.”Peter Bretan, MD, FACS

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Marin MedicineThe magazine of the Marin Medical Society

Marin MedicineEditorial BoardIrina deFischer, MD, chairPeter Bretan, MDGeorgianna Farren, MDLori Selleck, MD

EditorSteve Osborn

PublisherCynthia Melody

ProductionLinda McLaughlin

AdvertisingErika Goodwin

Marin Medicine (ISSN 1941-1835) is the official quarterly magazine of the Marin Medical Society, 2901 Cleveland Ave. #202, Santa Rosa, CA 95403. Periodicals postage paid at Santa Rosa, CA.POSTMASTER: Send address changes to Marin Medicine, 2901 Cleveland Ave. #202, Santa Rosa, CA 95403.

Opinions expressed by authors are their own, and not necessarily those of Marin Medicine or the medical society. The magazine reserves the right to edit or with- hold advertisements. Publica- tion of an advertisement does not represent endorsement by the medical association.

E-mail:[email protected]

The subscription rate is $19.80 per year (four quarterly issues). For advertising rates and infor-mation, contact Erika Goodwin at 707-548-6491 or visit marin-medicalsociety.org/magazine.

© 2012 Marin Medical Society

2 Winter 2012 Marin Medicine

Marin MedicineThe magazine of the Marin Medical Society

LOCAL FRONTIERSKeeping Frequent Fred out of the ED

“Reliable data on the prevalence of frequent flyers is elusive, primarily because an established definition of frequent flyer does not exist.”Dustin Ballard, MD

PRACTICAL CONCERNSNew Hospital-Physician Alignments in Marin County

“Changes in reimbursement are making it extraordinarily difficult for private practice physicians to survive financially.”Jon Friedenberg

HOSPITAL/CLINIC UPDATEMarin General Hospital

“A year and a half after the Marin Healthcare District regained control of Marin General Hospital, the facility is thriving.”Susan Cumming, MD

CURRENT BOOKSCostly Grace

“I was drawn to this biography because I had heard of Dietrich Bonhoeffer in the context of the German Resistance but knew little about him.”Irina deFischer, MD

OUTSIDE THE OFFICEIn Search of the Vikings

“I have searched for my father’s family roots for years. Despite its size (338,000 square kilometers), Finland has less than 5.5 million inhabitants, some 40 of whom are my father’s family.”

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16 NEW MEMBERS27 CLASSIFIEDS

DEPARTMENTS Our Mission: To support MarinCounty physicians and theirefforts to enhance the health of the community.

Officers

PresidentPeter Bretan, MD

President-ElectIrina deFischer, MD

Past PresidentLori Selleck, MD

Secretary/TreasurerGeorgianna Farren, MD

Board of DirectorsLarry Bedard, MDAnne Cummings, MDScott Levy, MDBarbara Nylund, MD

Staff

Executive DirectorCynthia Melody

Communications DirectorSteve Osborn

Executive AssistantRachel Pandolfi

MembershipActive: 265Retired: 92

AddressMarin Medical Society2901 Cleveland Ave. #202Santa Rosa, CA 95403415-924-3891Fax [email protected]

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Steven Hao MD Cardiac Electrophysiology

Richard Hongo MD Cardiac Electrophysiology Robert Rho MD Cardiac Electrophysiology

Christine Jacobson MD Dermatology

Kara Reinke MD Dermatology

Hilarey Bhatt MD Internal Medicine

Rebecca Li MD Internal Medicine

Gyorgy Pataki MD Internal Medicine

Ellen Rosenthal MD Internal Medicine

Max Duncan DO Neurology

Richard Mendius MD Neurology

Smriti Wagle DO Neurology

Mary Burke MD Psychiatry

Ken Rosenberg MS LAc Acupuncture Bruce Roberts MD Integrative Medicine

Molly Roberts MD Integrative Medicine

Nikola Tede MD Pediatric Cardiology

Suruchi Bhatia MD Pediatric Endocrinology

Alison Reed MD Pediatric Endocrinology

Farhad Sahebkar-Moghaddam MD Pediatric Neurology

Regina Arvon MD Prenatal Diagnosis, Genetics & Ultrasound

Denise Main MD Prenatal Diagnosis, Genetics & Ultrasound

Carl Otto MD Prenatal Diagnosis, Genetics & Ultrasound

Kristin Pullen Williams MD Prenatal Diagnosis, Genetics & Ultrasound

Kimberlee Sorem MD Prenatal Diagnosis, Genetics & Ultrasound

Corte Madera 240 Tamal Vista Blvd. #190

Greenbrae 1100 S. Eliseo Drive #1

Novato 101 Rowland Way #220

San Rafael 750 Las Gallinas Ave. #210

Tareq Elqousy MD Internal Medicine

Steven Hao MD Cardiac Electrophysiology

Richard Hongo MD Cardiac Electrophysiology

Robert Rho MD Cardiac Electrophysiology

Christine Jacobson MD Dermatology

Timothy Davern MD Liver Disease Management and Transplant

Smriti Wagle DO Neurology

Tareq Elqousy MD Pediatrics

Alison Reed MD Pediatric Endocrinology

Anthony Yin MD Endocrinology

Jose Antonio Quiros MD Pediatric Gastroenterology

Farhad Sahebkar-Moghaddam MD Pediatric Neurology

Gregg Jossart MD Surgery: Bariatric/ Endocrine/Gastrointestinal

James McCurdy MD Psychiatry

Dongmei Yue MD Psychiatry

Katy Davis MD Pediatrics

Inessa Gofman MD Pediatrics

Albert Goldberg MD Pediatrics

Cindy Greenberg MD Pediatrics Shelley Palfy MD Pediatrics Sydney Sawyer MD Pediatrics



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Winter 2012 5Marin Medicine

The Topic of CancerSteve Osborn

I N T R O D U C T I O N

Mr. Osborn edits Marin Medicine.

Cancer can become all-consuming, but our departments cover a com-

pletely different range of topics, from frequent flyers to the German Resis-tance.

In “Keeping Frequent Fred out of the ED,” Kaiser emergency physician Dr. Dustin Ballard addresses the oft-returning patients who are placing an increasing burden on emergency departments. Like the patients them-selves, the problem is complex, but Ballard details several potential solu-tions. “Given that frequent flyers take up such a significant chunk of ED time and resources,” he writes, “they are potentially a high-yield population for intervention.”

Another problem long in search of solutions is the ever-changing land-scape of private practice. Jon Frie-denberg, the chief fund and business development officer for Marin General Hospital, describes several new hos-pital-physician alignments that he be-lieves will benefit everyone concerned.

Our rotating hospital update for this issue is also from Marin General. Dr. Susan Cumming, the hospital’s medi-cal director, reports that the facility has launched several new initiatives, includ-ing a transition to electronic records and an effort to reduce readmissions.

Far from the hospital, Novato gastro-enterologist Dr. Barbara Nylund writes about her recent journey to Sweden and Finland in search of her family’s roots.

Rounding out this issue is Dr. Irina deFischer’s review of the new biog-raphy of German Resistance leader Dietrich Bonhoeffer, whose struggles against the Nazis led to his eventual death in a concentration camp. He too was a victim of cancer, this one of hu-man origin.

Email: [email protected]

Henry Miller’s infamous novel Tropic of Cancer is not literally about the disease known as

cancer, but it does use cancer as a meta-phor for Miller’s own despairing view of the world. As he explained later when asked about the title, “To me cancer symbolizes the disease of civilization, the endpoint of the wrong path, the necessity to change course radically, to start completely over from scratch.”

Unlike Miller’s novel, this issue of Marin Medicine is literally about cancer. Far from despairing, five local physi-cians offer mostly positive reports on medical progress against this pervasive killer. They describe encouraging steps in the detection and treatment of breast cancer, colon cancer, prostate cancer and lymphoma.

We begin with internist Dr. Joan Pont’s overview of cancer screening from a primary care perspective. While acknowledging that screening has proved effective for cervical, colorec-tal and breast cancer, Pont (an assistant physician in chief at Kaiser San Rafael) also observes that more work is needed to improve screenings for other forms of the disease. Cancer screening over the last 50 years, she writes, “is like putting hundreds of lights on a Christmas tree, then realizing that most of them don’t work and need to be removed.”

Kaiser gastroenterologist Dr. Jeff Fox furnishes a helpful overview of the half-dozen commonly available tests for colorectal cancer. While none of them is perfect, the buffet of options has low-ered the incidence and mortality from colorectal cancer in the United States. Above all, Fox urges both patients and physicians to get screened. “There are few diseases,” he writes, “where mod-ern medicine has been more successful

than in preventing colorectal cancer.”Unlike colorectal cancer, the inci-

dence of Non-Hodgkin’s lymphoma con-tinues to increase, a trend made all the more complicated by the bewildering variety of the disease, which has more than 30 distinct subtypes. In her article on new treatments for Non-Hodgkin’s lymphoma, medical oncologist Dr. Jennifer Lucas, who practices at Marin Specialty Care, focuses on two main forms of the disease. The treatments are diverse, but many involve the latest research in biologic approaches, some of which is being conducted locally.

Another local research effort is de-scribed by Dr. Mary Mockus, a Kaiser surgeon who serves as one of the princi-pal investigators of the Marin Women’s Study, which includes representatives from the entire medical community. The study grew out of the discovery in the 1990s that Marin County had the highest rate of breast cancer in the United States. To date, more than 14,000 Marin women have participated in the study, whose first results were published in 2010. The study, writes Mockus, “is an example of the power of cooperation and collaboration.”

We conclude our cancer articles with Dr. Peter Bretan’s perspective on the ongoing controversy surrounding the PSA test for prostate cancer. A urolo-gist in private practice in Novato (and president of MMS), Bretan urges con-tinued use of the PSA test, despite the recent U.S. Preventive Services Task Force draft recommendation against the screening. While acknowledging that false positives on the test can lead to overtreatment, Bretan observes that, “Failing to administer the PSA test would sacrifice patients with unde-tected high-grade cancer, unbeknownst to them.”

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corn prepared with alkali, or fruits and vegetables, or fortified foods—all simple maneuvers with great clinical benefit.

Cancer screening involves a little of both. There are huge endeavors involving technology and people for detection, screening, treatment and follow-up; but there are also simple steps we take every day in the office. The evaluation of symptoms or signs suggestive of cancer is very different from cancer screening. Weight loss, fever, bleeding, and new and increas-ing localized pain require a diagnos-tic workup independent of screening recommendations. When a man has a breast lump, he may be evaluated for breast cancer. However, it would be of very limited value to screen all men for breast cancer.

My recommendations for cancer screening are aligned with programs that have shown aggregate benefit to the defined population. They are sum-marized in the U.S. Preventive Services Task Force recommendations.1

Cervical cancer screening for women between 21 and 65 years old reduces cervical cancer mortality. Colorectal cancer screening is estimated to in-crease aggregate life of adults over 50 by eight months compared with an un-screened population. Some people may have life extended, but many get tested and derive no benefit. That is where sophisticated risk/benefit calculations based on multiple studies boil down to practical recommendations.

The swing in cancer screening over the last 50 years is like putting hundreds of lights on

a Christmas tree, then realizing that most of them don’t work and need to be removed. With current technology, screening is effective in very few dis-eases. Physicians want the repertoire extended, and we await new advances in accurate serology and imaging.

The structural concept of screen-ing is that a disease begins. We use a modality to detect its presence, and we do something to avoid death from that particular disease in the future, i.e., find it at a curable stage.

We also need to consider balancing factors, such as not causing an equal amount of unintended morbidity or mortality in treating patients with false positives (no cancer altogether) or in-dolent disease that would not become manifest if left untreated (lead time bias). Specifically, knowing a patient has a disease eight years before death versus two years before death might make you think that treatment or detec-tion lengthened survival time, whereas the natural history might be identical, and the six-year apparent difference is from acknowledging the disease’s pres-

ence at different times.The idea of cancer

screening goes back to

1928, when Dr. George Papanicolaou first reported cervical cancer cell detec-tion. Careful follow-up brought this concept into a functional and mature state, leading to the publication in 1943 of Papanicolaou’s landmark book, Di-agnosis of Uterine Cancer by the Vaginal Smear. The book launched widespread dissemination of the Pap smear and led to a dramatic reduction in deaths from cervical cancer.

To physicians, the Pap smear must have been a jolt, like landing on the

moon or curing pellagra with niacin. Yet these advances are diametrically opposed. Landing on the moon takes the efforts of many smart people and loads of money to create a machine safe and powerful enough to get there and back. Avoiding pellagra takes eating

Flickering Lights on the Christmas Tree

Joan Pont, MD, FACP

C A N C E R S C R E E N I N G

Dr. Pont, an internist, is

an assistant physician

in chief at Kaiser San

Rafael.


Breast cancer screening with mam-mography every 1-2 years for women 50-75 years old reduces breast cancer mortality. We generally extend screen-ing to women 40-75 years of age, ac-knowledging a delayed benefit. Lung cancer screening in ever-smokers is being better defined as research con-tinues.

Those are the blinking lights on the Christmas tree. Other screening

modalities have been explored, but with the technology available, they remain unproven. Ovarian cancer screening with ultrasound and serology did not diminish mortality from that dreaded disease. Prostate cancer screening with PSA may well represent a near-neutral balance of risk and benefit. Skin, pan-creatic and esophageal cancers have not yielded their biologic destiny to being plucked out just in time. Essentially, by the time we can see them, it is too late for meaningful intervention.

Much research is ongoing. We need version 2.0 of the PSA test to exclude indolent disease not requiring surgery or radiation therapy. Thus we could use those tools only on cancers that are destined to progress.

If used correctly, streamlined cancer screening recommendations free up many health care personnel. Cervical cancer screening is a beautiful example of a win-win situation. Dropping down the frequency of testing to every three years and stopping at 65 years of age means primary care physicians, gyne-cologists and cytologists can address other health issues.

Cancer screening is an exciting subject. It is full of possibilities. Great technical challenges remain that we hope will lend themselves to efficacious solutions in the future.


Reference1. USPSTF, “Recommendations for Adults:

Cancer,” www.uspreventiveservices-taskforce.org/adultrec.htm#cancer (2011).

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tests: high-sensitivity fecal occult blood testing annually, flexible sigmoidoscopy every five years, and colonoscopy every 10 years. The other available tests (CT colonography, double-contrast barium enema and fecal DNA testing) were not supported by both task forces.

The pros and cons of all six tests are reviewed below.

Occult blood testingPROS: Evidence-based means of re-

ducing colorectal cancer incidence and mortality (i.e. randomized, controlled trials proving effectiveness). Conve-nient, inexpensive, well-tolerated by patients, zero risk. Fecal immunochemi-cal testing (FIT) improves sensitivity for colorectal cancer to 60-90%. FIT is the form of occult blood testing used in most settings now, including at Kai-ser Permanente, and the only kind that was recommended by both USPSTF and MTF.

CONS: High false positive rate. Re-quires serial testing to show benefits.

Flexible sigmoidoscopyPROS: Evidence-based means of re-

ducing colorectal cancer incidence and mortality. Able to detect polyps/cancer in the distal (left) colon and biopsy/remove at the same time. Convenience, cost and risk to patient are intermediate, relative to other modalities.

CONS: Patient discomfort when unsedated; sensitivity poor for proxi-mal (right) colon disease as a stand-alone test.

As a gastroenterologist, probably the single biggest question I get asked is, “Do I have to get

a colonoscopy?” In fact, many of my col-leagues and friends confess that when they pass me on the street, they think of the colonoscopy they had, were sup-posed to have, or never got around to having. To them, I am like Katie Couric, “the face of colon cancer screening.” Embarrassed, am I? Absolutely not! There are few diseases where modern medicine has been more successful than in preventing colorectal cancer.

Efforts to prevent colorectal cancer (CRC) include many well-documented successes. In just the last 25 years, the incidence of CRC in the United States has been reduced by 33%, and death from CRC has dropped by 40%. Over half the mortality reduction is thought to be attributable to screening. Addi-tionally, overall 5-year survival from CRC during the last 25 years has in-creased from 50% to 66%, largely due to early detection and improved treat-ments. Finally, more and more people are getting screened every year. At Northern California Kaiser Perman-ente, for example, nearly 80% of patients in the target 50-75 age range will have recorded up-to-date CRC screening in

2011, an all-time high. To approach this high level of adherence for CRC screening was

once unheard of. Physicians should be very proud of these efforts.

Though some observers have attrib-uted the declines in CRC incidence to an increase in colonoscopy screening, the procedure has only been used widely for screening during the last 10 years. The rise in colonoscopy screening oc-curred precisely when Medicare began reimbursing for colonoscopies for pa-tients with average CRC risk. Yet, CRC mortality had been steadily declining well before that policy change. Physi-cians have been screening for colorectal cancer for more than 20 years, though earlier efforts were mostly by occult blood testing and flexible sigmoidos-copy, with colonoscopy reserved for positive tests only. In other words, the successes in CRC screening aren’t just attributable to colonoscopies. Instead, they are successes of population-based screening with all available modalities.

So which modality should be used in which patient? I believe that ev-

ery patient who is reasonably healthy and is in the appropriate screening age range (50-75 years, older than which the overall risk of screening outweighs the benefits) with at least a 5-year life ex-pectancy should be offered CRC screen-ing. In 2008, both the U.S. Preventive Services Task Force (USPSTF) and a multispecialty task force comprised of gastroenterologists, radiologists and oncologists (MTF) published lists of recommendations for colorectal cancer screening. Three screening modalities made both lists as “recommended”

Enough With the Excuses!Jeff Fox, MD

C O L O R E C T A L C A N C E R S C R E E N I N G

Dr. Fox is a gastroen-

terologist at Kaiser San

Rafael.


ColonoscopyPROS: High sensitivity and specific-

ity for polyps and cancer. Able to detect polyps/cancer in both proximal and distal colon and biopsy/remove at same time. Patient must be sedated.

CONS: Safety—has 10 times the per-foration risk of a sigmoidoscopy (1/1000 vs. 1/10,000). Costly. Inconvenient. Use of colonoscopy is supported only by surrogate outcomes, not by random-ized trials.

Colonoscopy is used to investigate positives from other modalities, but it appears to be limited in screening the proximal colon. Efforts to sharpen optics, prolong the examination time and improve bowel preparation could increase the sensitivity of colonoscopy in the proximal colon.

Other testsCT colonography (virtual colonos-

copy). Similarly high sensitivity as colonoscopy for polyps and cancer. Concerns about radiation exposure risk (i.e., iatrogenic malignancies) and missed “flat polyps” make CT colonog-raphy a less than ideal screening tool (and not reimbursed by many insurance companies). However, CT colonography is a good alternative to colonoscopy as a reasonably accurate test when colo-noscopy is not feasible.

Double contrast barium enema. Poor sensitivity and radiation exposure make this a less favored choice for screening when other modalities are available.

Fecal DNA testing. Initial promise was thwarted by relative costliness and nearly identical sensitivity to the much less expensive fecal immunochemical testing. Still primarily investigational.

The current buffet of screening op-tions exists because there is no

“perfect” screening test for CRC. The ideal test would be something as sim-ple, tolerable and inexpensive as the occult blood test with the accuracy of colonoscopy (or better). This perfect test unfortunately does not appear to be on the near horizon, so I expect we will be making do with what we have

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for at least the next few years.Nevertheless, with the buffet ap-

proach, we are continuing to improve screening rates nationally. And it’s working—colorectal cancer incidence and mortality continue to decline. The important message that I advise physicians to give to patients is: Get screened. Don’t get too bogged down on the details, and certainly don’t let indecision or excuses prevent you from getting screened.

Here are the most frequent excuses I hear, along with sample responses:

EXCUSE: “I’m too busy to have a colonoscopy/sigmoidoscopy.”

RESPONSE: “FIT takes five minutes and can be performed in the comfort of your own home.”

EXCUSE: “Won’t FIT or sigmoidos-copy miss something?”

RESPONSE: “No test is perfect, in-cluding colonoscopy. Despite those lim-itations, both occult blood testing and sigmoidoscopy are proven to reduce your risk of colorectal cancer and death. If you are willing to acknowledge the additional risk and inconvenience of a colonoscopy, it is an acceptable method of screening.”

EXCUSE: “I don’t want to know.”RESPONSE: “Colon cancer is pre-

ventable without surgery or chemo-therapy when caught early or in the pre-cancerous stage. You can’t find it in those stages unless you get screened.”

EXCUSE: “I don’t have any symp-toms, so why bother?”

RESPONSE: “Colon cancer and pre-cancerous polyps are usually asymp-tomatic until it’s too late.”

EXCUSE: “The prep sounds hor-rible.”

RESPONSE: “FIT requires no prep. And there are lower-volume sigmoidos-copy and colonoscopy preps available through many providers.”

So tell your patients what I tell them: “Enough with the excuses! Get screened. Period.” I don’t mind being the face of colorectal cancer screening because I could save your life.


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Marin Medicine Winter 2010 15

emphasizing separate functions and expertise, the entire department had to be restructured. The providers were asked to choose an area of expertise, practice only that area of expertise, and follow the inmate/patients to wher-ever they were housed. This denotes a signi�cant departure from the typical institutional treatment model where a clinician is assigned to a unit. In San Quentin’s restructured model, the mul-tidisciplinary treatment team is not assigned to a location, but to their in-mate/patients. We now have individual clinicians practicing in their areas of strength, rather than trying to provide every service.

Working within an institution, local custody administration is an invaluable ally in the delivery of mental health services. Each peace of�cer—including the warden, chief deputy warden, as-sociate wardens, captains, lieutenants, sergeants and of�cers—plays a critical role in our success. Local San Quentin custody ensures a safe working envi-ronment while serving as our access to providing care. Absent this safety or this access, our working environment would be much less efficient and ef-fective. In part, our success is derived from our ability to provide services, and this function is uniquely tied to custody operations.

Finally, our professional relation-ship with various administrative bodies has led to our success via their unwavering support, including work-ing relationships with the Secretary’s Of�ce, the Of�ce of the Receiver, and the Division of Correctional Health Care Services. □

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New biologic approaches such as adding bortezomib or lenalidomide to the R-CHOP regimen are being evalu-ated in clinical trials. Lenalidomide (a relative to thalidomide) is an immu-nomodulatory agent that has a broad spectrum of anti-cancer activity and as a single agent has significant activity in relapsed DLBCL.

At Marin Specialty Care, where I practice, we are evaluating a novel compound, RAD001, as maintenance treatment for patients who achieve re-mission with standard immunochemo-therapy. As an mTOR inhibitor, RAD001 interferes with a cell-growth signaling pathway that is dysregulated in lym-phoma cells and is key for cell survival.

Another area of research worldwide is the identification of different sub-types of diffuse large-B-cell lympho-mas based on gene-expression profiles. Gene-expression profiling measures the activity of thousands of genes at once, to create a global picture of cel-lular function. These profiles can, for example, distinguish between cells that are aggressively dividing and grow-ing, or show how the cells react to a particular treatment.

Subtypes within DLBCL can now be categorized by gene expression into germinal center B-cell-like (GCB) and nongerminal center B-cell-like (non-GCB). Patients diagnosed with non-

Non-Hodgkin’s lymphoma (NHL) consists of a diverse group of malignant tumors

of the lymphoid tissues derived from the clonal expansion of B-cells, T-cells and natural killer cells or precursors of these cells. The incidence of NHL in the United States is over 65,000 cases per year. The average annual increase in incidence is approximately 2.7%, with an 82% rise in annual incidence since 1975. NHL has been extensively studied, yet the causes and increasing incidence of most forms of NHL are unknown.

The past decade has brought tre-mendous progress in both diagnostic and treatment approaches for NHL, but we still have a long way to go and face many challenges. The WHO Clas-sification system characterizes over 30 distinct subtypes of NHL, a quantity that can lead to much confusion for both patients and physicians. Meanwhile, hundreds of lymphoma clinical trials are under way, and more than 40 new investigational agents are being studied worldwide.

This article summarizes advances in treatment for the two most common forms of NHL: diffuse large B-cell lym-phoma and follicular lymphoma, which together represent more than half the diagnoses of NHL in North America.

Diffuse large B-cell lymphoma Diffuse large B-cell lymphoma (DL-

CBL) is an aggressive B-cell malignancy that requires immediate treatment, without which survival is typically measured in weeks to months. With combination immunochemotherapy, however, up to 70% of DLCBL patients can be cured. The addition of rituximab, a monoclonal antibody that targets the CD20 antigen expressed on most B-cell lymphomas, has made the single biggest impact on improving survival rates in the last decade when combined with standard chemotherapy (R-CHOP).

Other strategies for improving out-comes over R-CHOP are under vigorous investigation. Both bone marrow trans-plant and maintenance rituximab have been studied in patients who achieve a remission, but clinical trials to date have not shown a definitive advantage to either approach. The current consensus is that cure rates will only be improved by adding new biologic agents to in-duction immunochemotherapy or as maintenance treatment after remission has been achieved.

New Treatments for Non-Hodgkin’s Lymphoma

Jennifer Lucas, MD

C A N C E R U P D A T E

Dr. Lucas is a medical

oncologist and

hematologist at Marin

Specialty Care in

Greenbrae, which is

affiliated with the Marin

Cancer Institute.

Winter 2012 13Marin MedicineMarin Medicine Summer 2010 23

APP functions as a molecular switch, and its switching appears to be gov-erned by its interaction with ligands. When APP interacts with netrin-1, an axonal guidance ligand, it mediates process extension. When APP inter-acts with Abeta, however, it mediates process retraction, synaptic loss, and programmed cell death. During this interaction, Abeta begets more Abeta (one of the Four Horsemen) by favor-ing the processing of APP to the Four Horsemen. In other words, Alzheimer’s disease is a molecular cancer. Positive selection occurs not at the cellular level but at the molecular level. Furthermore, Abeta itself is a new kind of prion, since it is a peptide that begets more of itself. We believe that all of the major neuro-degenerative diseases may operate in an analogous fashion.

One of the interesting ramifica-tions of our new model of AD is that we should be able to screen for a new kind of drug: “switching drugs” that switch the APP processing from the Four Horsemen to the Wholly Trinity,

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thus preventing the synaptic loss, neu-rite retraction, and neuronal cell death that characterize AD. Indeed, we have identifi ed candidate switching drugs and are now testing these in transgenic mouse models of AD. We are also test-ing the effects of netrin-1 on this system, and fi nding similar effects.

A corollary of the switching prin-ciple is that we should now be able to screen existing drugs, nutrients, and other compounds not just for their car-cinogenicity (as is done using the Ames test) but also for their Alzheimerogenic-ity. We rarely stop to think that we are likely exposed to many compounds that have positive or negative effects on the likelihood that we will develop AD, and it would be helpful to have such information. We hope that our new model of AD may provide new insight into the pathogenesis of this common disease and offer new approaches to therapy. h

E-mail: [email protected]

Marin Medicine Summer 2010 23

APP functions as a molecular switch, and its switching appears to be gov-erned by its interaction with ligands. When APP interacts with netrin-1, an axonal guidance ligand, it mediates process extension. When APP inter-acts with Abeta, however, it mediates process retraction, synaptic loss, and programmed cell death. During this interaction, Abeta begets more Abeta (one of the Four Horsemen) by favor-ing the processing of APP to the Four Horsemen. In other words, Alzheimer’s disease is a molecular cancer. Positive selection occurs not at the cellular level but at the molecular level. Furthermore, Abeta itself is a new kind of prion, since it is a peptide that begets more of itself. We believe that all of the major neuro-degenerative diseases may operate in an analogous fashion.

One of the interesting ramifica-tions of our new model of AD is that we should be able to screen for a new kind of drug: “switching drugs” that switch the APP processing from the Four Horsemen to the Wholly Trinity,

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thus preventing the synaptic loss, neu-rite retraction, and neuronal cell death that characterize AD. Indeed, we have identifi ed candidate switching drugs and are now testing these in transgenic mouse models of AD. We are also test-ing the effects of netrin-1 on this system, and fi nding similar effects.

A corollary of the switching prin-ciple is that we should now be able to screen existing drugs, nutrients, and other compounds not just for their car-cinogenicity (as is done using the Ames test) but also for their Alzheimerogenic-ity. We rarely stop to think that we are likely exposed to many compounds that have positive or negative effects on the likelihood that we will develop AD, and it would be helpful to have such information. We hope that our new model of AD may provide new insight into the pathogenesis of this common disease and offer new approaches to therapy. h


GCB type have a poorer prognosis and significantly reduced survival rates. Studies are now being designed to in-corporate new drugs with standard treatment in an effort to overcome the inferior outcomes seen in patients with the non-GCB subtype. For example, bortezomib (a proteasome inhibitor) may be effective in non-GCB DLBCL because of its ability to inhibit nuclear factor kappa B, a well-described sur-vival pathway that is upregulated in non-GCB subtypes.

Follicular lymphoma Follicular lymphoma (FL) is an indo-

lent B-cell malignancy that to date still does not have a universally accepted first-line treatment strategy. Patients typically present with asymptomatic peripheral lymphadenopathy and ad-vanced stage disease. Fifty percent of patients have bone marrow involvement at diagnosis. To date, FL is considered a treatable but invariably relapsing dis-ease with long survival times, typically measured in years. Survival times have

continued to improve in recent decades, but FL is still considered incurable.

Depending on the clinical presenta-tion, FL patients have treatment options that range from watchful waiting to bone marrow transplants! A modified prognostic scoring system, the Follicu-lar Lymphoma International Prognostic Index (FLIPI), incorporates patient age, stage, number of involved nodal areas, serum lactate dehydrogenase, and he-moglobin. The resulting FLIPI index has helped oncologists take a risk-stratified treatment approach for FL.

While the FLIPI score is prognostic, the best predictor of outcome is again seen through gene-expression work (not yet commercially available). For instance, a predominance of inflamma-tory T-cells has a strong and favorable impact on survival and denotes that the patient’s own immune response is critical in keeping the lymphoma in check. Having a prognostic tool that can accurately predict which patients can safely be observed versus which patients should start immediately on

14 Winter 2012 Marin MedicineSpring 2010 7Marin Medicine

been adopted and modi� ed by Kaiser Permanente and Sutter Health.

IMPACT dovetails with the concept of the “medical home” outlined above. It provides a one-stop solution for pa-tients with mild to moderate mental health needs in a primary care setting. Eventually, mental and physical health providers will come to share record keeping, laboratory facilities, and even physical facilities to provide a seamless integrated home for the vast majority of our clients. Exchange of medical, psy-chiatric, and laboratory findings be-tween providers will be instantaneous. Substance users will also � nd a home in these centers, since both medical and psychiatric providers recognize that a large percentage of our clients have substance problems. Administrative overhead and costs could be combined and reduced as well.

One of the principles of IMPACT is to start small. The vision outlined above may not occur in the immediate future, and will certainly not be real-ized by our modest trial proposals. But as our clinical sophistication grows, the vision of a fully integrated mental and physical health center with rapid and seamless communication and consul-tation between treating professionals is becoming not only desirable, but inevitable. □


References1. Unützer J, et al, “Collaborative-care man-

agement of late-life depression in the primary care setting,” JAMA, 288:2836-45 (2002).

2. Hunkeler EM, et al, “Long term out-comes from the IMPACT randomized trial for depressed elderly patients in primary care,” Brit Med J, 332:259-263 (2006).

3. Callahan CM, et al, “Treatment of depres-sion improves physical functioning in older adults,” J Am Ger Soc, 53:367-373 (2005).

4. Areán PA, et al, “Improving depres-sion care for older, minority patients in primary care,” Medical Care, 43:381-390 (2005).

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treatment could be invaluable.Treatment approaches for FL are di-

verse, and treatment choice is highly de-pendent upon clinical presentation, the biases of the physician, and the goals and expectations of the patient. Mono-clonal antibodies, such as rituximab, are used either as a single agent or with chemotherapy (typically alkylators or purine analogues) and have become the cornerstone of therapy. Radioimmuno-therapy, an antibody conjugated to a radioactive isotope, is another effective

treatment option for patients with FL. Bendamustine, a newer chemothera-peutic agent, has shown excellent activ-ity, even in the refractory setting.

Despite a wide range of therapeutic options for FL, there is a great need for developing new molecularly targeted treatment approaches, such as drugs that target unique biologic abnormali-ties in FL. The characteristic cytoge-netic alteration in FL, for example, is a translocation involving the Bcl-2 gene t(14;18). This translocation, which is

present in approximately 85% of FL cases, places Bcl-2 under the control of an immunoglobulin heavy chain enhancer on chromosome 14, result-ing in constitutive overexpression of Bcl-2. These Bcl-2 genes are extremely important in regulating apoptosis (cell-programmed death) and have become an attractive target for developing new agents. There are currently several anti-bcl-2 molecules in clinical trials.

The ubiquitin-proteasome pathway plays a key role in the degradation of misfolded or unwanted intracellular proteins in cells and is a key mecha-nism in determining the activity of cell-cycle regulatory proteins. Pre-clinical studies have demonstrated encourag-ing results with bortezomib, a protea-some inhibitor in NHL cell lines, and early clinical studies indicate impres-sive activity in FL.

A large number of novel agents po-tentially useful in FL patients—includ-ing chemotherapeutics, monoclonal antibodies, apoptosis-inducing agents and immunomodulators—are in the clinical trial pipeline. Marin Specialty Care is participating in two such trials. One is measuring various combina-tions of rituximab and other drugs for high-risk FL, and the other is evaluat-ing a new antibody (ofatumumab) vs. rituximab for patients with relapsing lymphoma.

Despite the impressive biological and therapeutic progress made in deal-ing with FL over the last decade, there is still tremendous room for improving treatment. We need to develop therapies that extend the duration of remission without adding any additional toxicity. Therapy for FL also needs to be adapted to the patient’s individual status while relying on a continuously growing rep-ertoire of salvage therapies.

I am excited to see what the next decade of treatment offers our patients. Perhaps the opportunity to cure fol-licular lymphoma is right around the corner.


Summer 2010 35Marin Medicine

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patient who has sustained a gunshot wound to the head. The procedure re-quires an open craniotomy, and Coppola has to take care “to avoid suctioning up normal brain tissue” during the de-bridement.

Coppola recalls “soldier’s sweat un-der layers of armor in the Iraqi’s 130 de-gree heat” and is stricken by the death of a female National Guardswoman. He writes, “I’ve treated many women who have suffered non-combat trauma before. Some made it, some did not. But I cannot wrap my mind around the cold reality of a woman being killed at war.”

Confl icts are numerous for Coppola. As a military surgeon at a combat sup-port hospital, his fi rst responsibility is to troops injured in the fi eld. However, in treating children, he makes decisions to prioritize their care, at times soliciting the participation of other staff members. In the case of a child with biliary atre-sia, for example, Coppola fi nds a way to perform the surgery successfully, despite tense arguments to let the child die of a “non-combat” surgical disease.

Despite saying “We’re not winning, we’re not losing,” President Bush

inaugurated the Surge in 2007, ordering the deployment of more than 20,000 sol-diers, and extending the tours of 4,000 Marines, to provide additional security to Baghdad and Al Anbar Province. Coppola notes that while the Surge has been beneficial, it has inspired a countervailing effect on Iraqis: “Now that Al Qaeda can’t get to the troops easily, they’ve been targeting civilians. It’s frightening.”

Coppola points out that the Iraqi Medical Association prewar member-ship was about 34,000. By April 2006, 2,000 members had been killed, 250 kidnapped, and 12,000 had fled the country, leaving less than 20,000 physi-cians. This is but one of many statistics that Coppola shares. Here’s another: only 1.5% of the U.S. population is in the Armed Forces, but 67% of our $1.1 trillion budget goes to National Security and Defense.

Military lingo runs throughout the book. A “combat shower” is 30 seconds

to get wet and lather up, then 60 sec-onds to rinse. A military base is called “Mortaritaville,” and an oxymoron is “Army Intelligence.”

This book is a must read, not just for physicians, but for the general public. As a physician I was humbled by the grace and humanitarian acts that a fel-low surgeon exhibits in war. We should all be proud to have Dr. Coppola as a colleague and fellow American. h


Wendell Butler, MDInternal Medicine2250 Tennessee St.Vallejo 94591707-644-7277Case Western Reserve Univ 1955

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sible associations between hormones, reproductive history and increased breast density—a known risk factor for breast cancer. A second phase of the Avon study aims to develop a new risk model that links genes and the environ-ment to other known cancer risk factors.

The f irst publication of Marin Women’s Study results appeared in the October 2010 issue of BMC Public Health.1 Our research team found that a dramatic decrease in postmenopausal hormone replacement therapy during the 2000s was followed by a 33% decline in breast cancer cases. The real rates of breast cancer in Marin during the 2000s were about 50 cases per year less than the rates seen in the late 1990s, while at the same time the mammography rate remained unchanged.

The adjunct Avon study has shown that certain reproductive risk factors seem to affect breast density but not hormone levels. Gestational hyperten-sion in particular—along with age at first pregnancy and nursing—were as-sociated with breast density, but not with changed hormone levels (based on our saliva analysis). These findings suggest that the risk factors mentioned above may be creating persistent mor-phologic changes in the breast tissue that can be related to breast cancer risk.

Our next focus in data analysis will be on breast density as it relates to lifestyle factors such as life-course alcohol use, exogenous hormone use, and socioeconomic status. SNP (single nucleotide polymorphism) data from the saliva samples will be examined to see if genetic changes can explain the

Odds are that every physician in Marin County encounters breast cancer in their practice,

either in their patients or in their patients’ family members and friends. Breast cancer strikes one in seven women in Marin (compared to one in eight women nationally) and is of great concern to our patients.

When the final numbers from the 1990 census were applied to Marin’s breast cancer rates, we stood out as a community with the highest rate of breast cancer in the United States. The media soon labeled Marin as the “breast cancer capital of the world.” All this at-tention led to town hall meetings, the hiring of epidemiologists at the Marin County Department of Health and Hu-man Services (DHHS), and a Centers for Disease Control award of $217,000 to fund community breast cancer projects.

These efforts were followed by the formation of a National Scientific Advi-sory Committee that included national experts, members of the Marin General and Kaiser medical staffs, and local community groups such as Zero Breast Cancer. The committee addressed the meaning and validity of the data on breast cancer in Marin County. A thor-ough analysis of several decades of data established that the elevated rates of

breast cancer in Marin were real and could not

be explained by the age of the popu-lation, mammography rates, or other known risk factors in Marin women.

In April 2005, DHHS obtained more than $400,000 in federal research money to launch the Marin Women’s Study, a prospective effort to link individual risk factors with biospecimens and breast cancer outcomes. A local steering committee and 15 community groups partnered to plan the study; I serve as one of the principal investigators. The goal of the study was to obtain de-tailed risk factor information that could yield potentially immediate results as well as long-term, longitudinal data. Researchers developed an exhaustive questionnaire for Marin women on lifestyle, medical and personal history and paired the findings with screening mammography results.

The Marin Women’s Study began in fall 2008 and accrued participants

for about 18 months. To date, 14,100 sur-veys have been received and analyzed. In addition, 8,000 of those participants have provided saliva samples to create a biorepository, which is processed and stored at the Buck Center. Specimens are available for hormone analysis and DNA testing, with results that can be paired with risk factor information and mammography results.

The generous participation of so many Marin women in the study has created a valuable resource that has caught the interest of cancer research-ers worldwide. An adjunct to the study funded by the Avon Foundation includes specific analysis of the pos-

The Marin Women’s StudyMary Mockus, MD

B R E A S T C A N C E R R E S E A R C H

Dr. Mockus, a surgeon

at Kaiser San Rafael, is

a principal investigator

for the Marin Women’s

Study.


reproductive risk factors for increased or decreased breast density.

The Mar i n Women’s St udy i s a n example of t he power of

cooperation and collaboration. The local steering committee includes Dr. Chris Benz of the Buck Institute; Rochelle Ereman, Dr. Mark Powell, Lee Ann Prebil and other members of the DHHS staff; Dr. Francine Halberg of Marin General; Fern Orenstein of Zero Breast Cancer; myself at Kaiser Permanente; and all Marin mammography centers regardless of hospital affiliation. We are all grateful to the 14,100 women of Marin County who have so generously given of their time.

As a physician investigator on this study, I feel a tremendous personal re-sponsibility to the women of Marin, and I look forward to finalizing our data and sharing what we have learned with our wonderfully supportive com-munity. More details and results of the Marin Women’s Study can be found on our website, marinwomensstudy.org.


Reference1. Ereman RR, et al, “Recent trends in hor-

mone therapy utilization and breast can-cer incidence rates in the high incidence population of Marin County, California,” BMC Public Health, 10:228 (2010).

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Raymond Bonneau, MDOrthopaedic Surgery*165 Rowland Way #100Novato 94945898-4211 Fax [email protected] San Francisco 1974

Amanda Doherty, MDAnatomic & Clinical Pathology*1615 Hill Rd. #BNovato 94947925-7174 Fax [email protected] Univ 2005

Tareq Elqousy, MDInternal Medicine*Pediatrics*101 Rowland Way #220Novato 94945878-7200 Fax [email protected] Univ 1986

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pute that PSA testing detects cancer, but they do claim that the test leads to widespread overtreatment, which to them outweighs the benefits of early detection. By averaging data over the entire population, the task force con-cludes that there is no net gain from PSA testing and perhaps substantial damage to patients, ranging from need-less worry, to impotence and inconti-nence, and even to death.

Therein lies the dilemma for the older-than-50 male for whom averages mean little. Without PSA testing, if a high-grade prostate cancer is present, the disease might not be found until it is fatal. Although the five-year sur-vival rate for localized prostate cancer is 100%, once the cancer reaches distant organs, the rate falls to 29%.

In tallying the damage from PSA testing, the task force makes some rela-tively small problems seem very big. For example, they suggest that biopsies can be painful. In reality, the use of lo-cal anesthesia during biopsies makes pain an uncommon experience. Major complications after biopsies are rare. Even if prostate cancer is found and the patient elects to have the prostate surgically removed, the complications of urinary incontinence and erectile dysfunction are usually temporary and highly treatable. They’re also preferable to metastatic cancer and death.

As articulated by Cleveland Clinic urologist Dr. Andrew Stephenson, “None of us would dispute that there are harms with screening for prostate

In October 2011, the U.S. Preventive Services Task Force released draft recommendations against prostate-

specific antigen (PSA) screening for prostate cancer, asserting that there is “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” The task force further discouraged use of the PSA test by giving it a Grade D rating.

I am a board-certified, fellowship-trained urologist and professor of urol-ogy. I have been treating men with diseases of the prostate, both benign and cancerous, for the past 26 years. Along with my specialty society, the American Urological Association (AUA), I strongly oppose the task force’s recommendations. I believe the task force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease.

In 2009, the AUA issued a PSA Best Practice Statement finding that, when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients.1 Not all prostate cancers are life-threatening, and the decision

to proceed to active treatment or use sur-veillance for a patient’s

prostate cancer is one that men should discuss in detail with their urologists.

Following the release of the task force’s recommendations, AUA Presi-dent Dr. Sushil Lacy released a state-ment urging men to speak with their physicians about the value of prostate cancer screening.2 The AUA is also coor-dinating a sign-on letter for lawmakers to send collectively to U.S. Health and Human Services Secretary Kathleen Sebelius, urging her to reject the task force’s recommendations. In addition, the AUA is convening an expert panel that will submit formal comments to the task force.

Despite data from the National Can-cer Institute showing decreasing

mortality from prostate cancer since PSA testing began in the 1980s (see graph), the task force argues that the test can lead to harm. They don’t dis-

PSA Screening and the Patient-Doctor Relationship

Peter Bretan, MD, FACS

P R O S T A T E C A N C E R

Dr. Bretan, a urologist

in private practice in

Novato, is president of

MMS.

Prostate Cancer Death Rates(per 100,000 males)

1987 1992 1997 2002 2007

35.1139.22

34.15

28.1823.50

Source: National Cancer Institute


cancer, just as there are for screening for any other cancer, but the task force fails to acknowledge the benefits, which are clear.”3 The PSA test is painless, in-expensive and the only way to detect prostate cancer—the most common male cancer—before symptoms turn up.

What disturbs me most about the task force is that they recommend against gathering the information that leads to overtreatment, rather than re-forming the treatment itself. The chair of the task force, Virginia Moyer, claims that once patients hear they have can-cer, human nature drives them to de-mand aggressive action, necessary or not. While she has a point, the use of ignorance to help protect patients is not bliss, nor a medical practice I can condone.

Failing to administer the PSA test would sacrifice patients with unde-tected high-grade cancer, unbeknownst to them. The fact that such patients’ death prevention might be statistically offset by someone who receives un-needed treatment seems to be a cold-

hearted practice of pure bureaucracy and not the compassionate practice of medicine. Depriving people of infor-mation that empowers them to make choices is disturbing.

With the cost of American health care rising rapidly, the rationale

to reduce unproductive treatments is well appreciated, but not at the ex-pense of practicing ethical, transpar-ent and compassionate medicine. The task force’s recommendation against PSA testing, like their equally contro-versial suggestion in 2009 to do fewer mammograms, is a measure of how cost needs to be addressed—but cost control should not come at the expense of informed consent with the patient.

I believe that men older than 50 should continue to receive the PSA test, then get balanced information about prostate cancer and its treatment. That puts decision making back to patients, in close consultation with their physi-cians. I have always advocated for my patients and defend the patient-doctor

Communication between physicians can be inefficient at times, and pa-tient care can be delayed, resulting in frustration for everyone. These frustra-tions, however, may be short-lived. Two physicians from Texas have created a tool to help solve these communication delays: DocBookMD—a smartphone app that is free for MMS members.

“We wanted to change the way physicians communicate. We wanted to make it easier, more efficient, and more secure,” said orthopedic surgeon and DocBookMD cofounder Dr. Tim Gueramy. “We created a program that allows physicians to talk to one another with new technology.”

DocBookMD is a physicians-only iPhone, iPod and Android app that al-lows physicians to:•SendHIPAA-complianttextmessages

and photos

•Assignanurgencysettingtooutgoingtext messages

•Searchalocalpharmacydirectory•SearchtheMMSdirectoryandsort

by specialty“DocBookMD allows you to look up

another doctor at the point of care,” Gueramy explained. “You can then ei-ther call the physician or send a text message with room numbers, medi-cal record numbers, even pictures of wounds and x-rays. And all of this is sent securely and in a way that meets HIPAA requirements.”

MMS members can download their free copy of DocBookMD by visiting docbookmd.com/med_socs/marin. Not a member? The MMS website at www.marinmedicalsociety.org has details on DocBookMD and other member benefits, as well as an online application form.

relationship as the backbone of medical practice. Physicians are messengers and educators for their patients, in the elu-cidation of the risks, complications and alternatives of all therapeutic options.

For many of my patients, I rec-ommend no immediate therapy for low-volume, medium-grade prostate cancer. Can we all do better in this standard of care? Absolutely. Unfor-tunately, the task force implies that patients cannot make this decision be-cause it is too emotionally laden, and that urologists are all going to push for interventional therapies that may be inappropriate or injurious to patient. This is simply not true. Academic urol-ogists are constantly studying ways to fine-tune the selection of patients for specific therapies.

The task force’s recommendations would restrict the patient-doctor re-lationship by holding back the results of a simple test that has been shown to save lives, because “on the average” they see the benefits to society as “mar-ginal.” Perfect is often the enemy of good, but in this case “doing nothing” is the enemy.

We improve our way of living with science, not with denial, which has never helped anyone. There isn’t an “av-erage” cookie-cutter template that fits all patients. If there were, there would be no need for the practice of medicine, only algorithms and protocols. Recom-mending against a valuable and simple screening test to “save” the general pub-lic from their perceived incapacity for making a rational decision is neither rational nor beneficial.


References1. AUA, “Prostate-Specific Antigen Best

Practice Statement: 2009 Update,” www.auanet.org (2009).

2. AUA, “AUA responds to new recom-mendations on prostate cancer screen-ing,” www.auanet.org (Oct. 7, 2011).

3. Simon N, “Should you have a PSA test for prostate cancer?” AARP Bulletin (Oct. 12, 2011).

DocBookMD offers improved communications for MMS physicians


ED frequent flyers have been labeled as “unscrupulous” and “uninsured,” and are accused of “unnecessarily clog-ging EDs by presenting with primary care complaints better treated else-where.” But, as the authors of the An-nals meta-analysis note, evidence does not support these stereotypes. Frequent flyers are actually a diverse group of people who are much more likely to be insured than not. Their variety makes one-size-fits-all solutions ineffective. From poorly controlled congestive heart failure, to paroxysmal atrial fibrilla-tion, and from chronic pain to migraine syndrome—there are many reasons why someone might develop an ED habit. Besides, skeptics argue, even if we find a way to “fix” the Frequent Freds and Everyday Eddies, dozens of other frequent flyers will simply take their spots. According to some estimates, up to 75% of ED frequent flyers will be replaced within one year.

Let’s set aside this “regression to the mean” phenomenon for a moment and assume that the problem of frequent fly-ers is worth addressing. First, however, we need to consider an important and related question: Should EDs be in the business of treating non-emergency conditions? Considering that close to 50% of all ED visits are for non-emer-gent conditions, this is a valid question indeed. (The 50% estimate is based on both a New York University study that employed exhaustive chart review to associate certain diagnosis codes with non-urgent ED visits and on a Kaiser study using data from millions of ED visits.2,3)

I’m certain every veteran emergency physician has had a thought pro-cess like this one: “Oh cripes, not

Frequent Fred again? Back for chest pain … non-cardiac chest pain? … Could there be something new going on? . . . Apparently not. … Is it possible that something’s been missed? … No, doesn’t seem like it. … Is there anything new I can offer? … Hmmm—perhaps not. … Soooo, how do I get Fred out the door?”

During my residency training at a county emergency department in Cen-tral California, thoughts like this often centered on a frequent flyer I’ll call Vin-cent. He was a self-declared COPDer who was always short of breath, but never for a discernible reason. His lungs were always clear, and he consistently registered 100% on pulse oximetry. We tried every approach—paper bags, oxy-gen, inhalers, Valium, steroids, even serial arterial blood gases—but Vincent always came back to the ED, sometimes four or five times a day. Clearly, Vincent had profound needs, but despite our best efforts (including psychiatric and social work consultations), we could not adequately address them.

“Kim” also visited us in the county ED. Many times. She was also short of breath without a discernible reason and

was way too young to be in the hospital so of-

ten. Her family would drop her off on Friday afternoons for a “vacation.” Hers or theirs, we’d wonder. They wouldn’t answer their phone all weekend and then would show up on Monday to find Kim no better and perhaps worse (from “therapeutic” meddling). After several years of well-intentioned interventions, Kim ended up with a tracheostomy.

I’m quite certain Kim’s tracheostomy was preventable, but how? Looking back, I don’t think ED care could have prevented this unfortunate outcome, because the ED is just not a good place to pursue in-depth, multi-dimensional, long-lasting therapy. It’s too hectic for that. Fluctuations in patient volume, staffing considerations, and the acuity of patients with time-sensitive illnesses combine to make ED care of frequent flyers less than optimal. Yet, frequent flyers continue to place an increasing burden on EDs.

Reliable data on the prevalence of frequent flyers is elusive, primar-

ily because an established definition of frequent flyer does not exist. Nonetheless, a 2010 meta-analysis from the Annals of Emergency Medicine (using a “frequency” definition of four or more visits per year) found that frequent flyers make up 4.5% to 8% of American ED patients and ac-count for 21% to 28% of all ED visits.1 These figures are attention-grabbing; frequent ED users clearly place a sig-nificant burden on our safety net sys-tem. But, after a deep breath or two, one wonders whether this is a problem we can fix. And if we were to try, would the effort be worth the cost?

Keeping Frequent Fred out of the EDDustin Ballard, MD

L O C A L F R O N T I E R S

Dr. Ballard, an emergency

physician at Kaiser San

Rafael, writes a medical

column for the Marin Independent Journal.


People come to the ED for all kinds of non-urgent conditions, from toe-nail fungus to big, black, ugly mole-itis. There are plenty of reasons why someone might choose ED care over other options for non-urgent medical problems—including convenience, lack of insurance, and timely access to spe-cialists and specialized imaging.

As medical professionals, I think we all know that the ED—although expensive and sometimes insufferably slow—can accomplish most work-ups more thoroughly than most other ven-ues. And, quite honestly, non-urgent visits keep some EDs in business. But by the time you reach the point, as we have in California, where 20% of patients leave the ED without being seen, your safety net is getting awfully frayed and in need of repair. So, approaches to pro-viding alternate means for non-emer-gent care, like urgent care and Rapid Care pathways (as in our San Rafael Kaiser) will help. However, given that frequent flyers take up such a signifi-cant chunk of ED time and resources, they are potentially a high-yield popu-lation for intervention. Recognizing that managing frequent flyers is not easy, let’s nonetheless explore some options.

Case ManagementWhat if we used ED visit data to

identify frequent flyers and then imple-mented a multidisciplinary approach to manage them with personalized care plans? This type of preventive care, called “case management,” deploys a team of nurses, social workers and phy-sicians to design and manage outpatient care and social support. With this type of team in place, perhaps Charlie COPD gets his exacerbation picked up earlier and is started on prednisone before he needs to come to the ED (for the seventh time this year).

Different forms of case management are in place across numerous locales and health systems. Within Kaiser’s Marin County facilities, for example, multiple programs exist to provide sup-port, advice and medical management to patients who have been identified as high risk or high utilizers. With

Medicare incentives now in place to reduce readmission rates, more such programs are surely on the way, but im-portant questions remain inadequately addressed. Can this type of approach work on a consistent basis? Is it cost-effective?

A recent meta-analysis in the An-nals of Emergency Medicine reviewed 11 studies of interventions designed to reduce adult ED frequent flyer utiliza-tion.4 Of these, seven studies were of case management programs, two were randomized controlled trials that com-pared case-management intervention vs. usual care groups, and two were not case-management based. Results across the studies were mixed, with a consistent decrease in ED visits in the intervention groups, offset by the observation that in one of the random-ized trials there was also a significant decrease in ED visits for the control group. (There’s that vexing “regression to the mean” problem again.)

The three studies that included cost-effectiveness analysis suggested that case management saved hospital costs—but only enough to pay for the case management program. The studies did not try to account for non-hospital societal costs, including charity care. This consideration is noted by Maria Raven in her companion editorial: “To be sustainable in the long term, any intervention model must demonstrate the ability to pay for itself in reduced health and social care expenditures, including, but not limited to, those of the ED.”5 Thus, while clearly promising, further work is needed to evaluate how best to design and study case manage-ment for ED frequent flyers.

Community ParamedicsThis approach is in its infancy. What

if we used pre-hospital providers, such as paramedics, to enroll and deliver pre-hospital case management? Could this supplement existing health sys-tem programs? Perhaps. As described in a recent New York Times article, the underlying thesis of the community paramedic is that “emergency workers should not wait around for crises to

happen, but rather go out and prevent them.”6 Thus paramedicine becomes a version of case management provided by paramedics, who have the added benefit of the resources and on-scene expertise of the pre-hospital provider.

Who better to prevent unnecessary transport than the transporters them-selves? A homeless outreach program implemented by the San Francisco Fire Department, for example, reduced emergency call volume among the homeless by about 75% in 18 months and saved an estimated $12 million. Unfortunately, the program has been on hiatus since 2009, a victim of federal reimbursement structures that reward pre-hospital transport rather than pre-ventive care. Nonetheless, other munici-palities are looking at different angles of the same model.

Alameda County has proposed a pilot program that would offer free pri-mary and preventive care to the public at five county fire stations. Called the Fire Station Health Care Portal, the ef-fort envisions stations staffed by a fire-fighter paramedic, a care coordinator and a nurse practitioner. The stations would provide non-emergency care, 48-hour ED visit follow-up, and 911/211 phone advice and response. If every-thing goes well, the program could be up and running by next year, but it may not be sustainable without outside or philanthropic funding.

That funding dilemma captures the current challenge of community para-medicine. Nonetheless, if incentives evolve, we may see a rapid blossoming of paramedicine. Ted Peterson, EMS battalion chief for the Novato Fire Pro-tection District, believes this can and should happen. “The fire service,” he says, “has a long history of both stand-ing ready to respond to emergencies as well as working to prevent them from ever happening. This same philosophy can and should be applied to medical care. The fire service is here 24/7/365 with paramedic firefighters that have the training, equipment, resources and access to help people. It is only logical that they be used in the prevention of medical emergencies. Once the high-


risk patients have been identified and protocols established, the community paramedics can ‘check in’ on this popu-lation and interject preemptively with treatment or referrals to help patients stay out of the hospital. Not only is this possible, it is the right thing to do for our neighbors.”

Predictive ModelsAs already mentioned, ED fre-

quent flyers are a diverse group with significant turnover, which makes retrospective-based identification and management problematic. Is it really possible to efficiently “react” when most frequent flyers will resolve their frequency issues on their own? Why not use multi-variable models to predict who will become a frequent flyer?

Some evidence suggests that we can predict frequent flyers. Several studies from the UK have derived and vali-dated algorithms to predict hospital admissions and readmissions. One of those studies found that strong predic-tors of non-elective admission to UK

References1. LaCalle E, Rabin E, “Frequent users of

emergency departments: The myths, the data, and the policy implications,” Ann Emerg Med, 56:42-48 (2010).

2. Billings J, et al, “Emergency department use: The New York story,” Commonwealth Fund Issue Brief (November 2000).

3. Ballard DW, et al, “Validation of an al-gorithm for categorizing the severity of hospital emergency department visits,” Med Care, 48:58-63 (2010).

4. Althaus F, et al, “Effectiveness of in-terventions targeting frequent users of emergency departments: a systematic review,” Ann Emerg Med, 58:41-52 (2011).

5. Raven MC, “What we don’t know may hurt us: Interventions for frequent emer-gency department users,” Ann Emerg Med, 58:53-55 (2011).

6. Johnson K, “Responding before a call is needed,” New York Times (Sept. 18, 2011).

7. Donnan PT, et al, “Development and val-idation of a model for predicting emer-gency admissions over the next year,” Arch Intern Med, 168:1416-22 (2008).


hospitals included age, male gender, history of previous visits, and the quan-tity of certain types of prescriptions such as analgesics, antibiotics, diuretics, inhalers, and nitrates.7 To date, such work has not been extended to the American frequent flyer population, but it is certainly possible and theoreti-cally helpful.

Here’s one possible scenario for a predictive case management model. Electronic medical records run regu-lar reports based on an algorithm or identified risk factors and create a list of at-risk patients. A hospital-based case management team reviews these pa-tients and selects some for intervention. A multi-disciplinary team, including community paramedics, implements the interventions, which might include medication and home safety reviews.

Such a model will surely not elimi-nate the frequent flyer problem, but maybe it will help soften the burden. And that would be good news not just for Frequent Fred, but also for everyone involved.

The town of Visby on Gotland Island, Sweden. Photo by Dr. Barbara Nylund (see page 28).


cover the rent, billing, collections—all the operational and management tasks for local physicians serving these offices. We can free them up to focus more on medical care and less on ad-ministration.

Recognizing that expanded capa-bilities are critical to our future, the hospital launched its own Spine & Brain Institute in collaboration with the Mt. Tam Spine Center and the UCSF De-partment of Neurosurgery. We have also developed a co-management agreement with physicians in Marin Specialty Care for their oncology and urology services, and we are in dis-cussion with several other physician groups about aligning with the hospital via either Prima or our 1206(b) clinics.

Complementing our physician align-ment strategy is our hospital alignment effort. To that end, we have signed a management services and affiliation agreement with Sonoma Valley Hospi-tal, which is also served by the Prima Medical Group. Our partnership will enable both administrations to share more physicians, and possibly reduce our IT, billing and marketing services costs. By doing so, we strengthen our ability to compete with corporate gi-ants. We also can develop an integrated model of care that shares capabilities—whether management or medical—to make us more cost-effective through economies of scale, while increasing patient services. We hope to reach simi-

Major changes in healthcare are inevitable—and soon. But no one knows exactly

what those changes will look like. That’s why Marin General Hospital (MGH) is pursuing new physician and hospital alignments that we hope will strengthen our ability to deliver high quality, cost-effective care in any en-vironment, while helping ensure that patients and physicians still have the choices they want.

In 2010, for example, MGH formed the nonprofit Prima Medical Founda-tion with Marin IPA and Sonoma Val-ley Hospital. The Foundation (which contracts exclusively with the locally owned Prima Medical Group) enhances the stability of the local medical com-munity. Equally important, it allows Marin physicians to maintain autonomy and practice medicine in the way they want while continuing to put the pa-tient first when making decisions.

Prima Medical Foundation is one of the cornerstones of our hospital-physician alignment strategy. While the original goal was to provide a so-lution to the ever-growing shortage of primary care in our area, the Founda-tion soon realized there was an equally important need to address the full spectrum of medical and preventive

care. Today, Prima Medical Group has more than 60 physicians in Marin and Sonoma counties, and that number is expected to grow. Specialties include family medicine, internal medicine, pediatrics, obstetrics & gynecology, pulmonary & critical care medicine, and general surgery.

Proof that Prima is having the desired effect is the Foundation’s en-hanced ability to bring new physicians into the community, such as the recent addition of three new surgeons to Pri-ma’s general surgery practice. Prior to the recruitment of this multispecialty team, much of the trauma coverage at Marin General Hospital was provided by an out-of-county physician group. Scheduling follow-up care was difficult, and such care was often delivered by a physician other than the operating sur-geon. Now, the new surgeons and oth-ers based in Marin provide full trauma coverage for the hospital.

The economics of private medical practice—particularly in Marin—

have become a key driver of our strat-egy. Changes in reimbursement are making it extraordinarily difficult for private practice physicians to survive financially. The fact is the current reim-bursement model is broken for primary care physicians, and even special-ists find the economics challenging. Through 1206(b)clinics and the Prima Medical Foundation, MGH can help

New Hospital-Physician Alignments in Marin County

Jon Friedenberg

P R A C T I C A L C O N C E R N S

Mr. Friedenberg is the chief fund and

business development officer for Marin

General Hospital.


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lar agreements with other hospitals in the future.

These initiatives improve access to care and reduce costs, and they offer the possibility of enhancing the qual-ity of care. Overall, quality in Marin is already high, but that doesn’t always extend to the quality of the patient ex-perience. Here, we see huge opportu-nity for improvement. Ensuring that everyone can access the same infor-mation in real time—results of tests as well as bedside observations—means patients and providers spend less time repeating the same tests and chasing paper records. Shared information en-sures stronger physician collaboration, including multi-disciplinary consults, without requiring the patient to travel from office to office repeatedly.

The changes described above aren’t unique to Marin. They are occur-

ring all over the country as hospitals and providers race to prepare for the na-tional and statewide changes ahead. All over the Bay Area, physicians and hos-pitals are aligning to achieve economies of scale, better integration and quality of care, and the ability to offer patients the care they want without leaving their home communities. Throughout the country, private practice physicians and community hospitals are fight-ing to remain independent from giant corporate networks. The transition of Marin General Hospital to local control has accelerated these changes locally.

I believe the best healthcare in the United States is provided by those who are accountable solely to the commu-nity they serve—and our community is no exception. Whatever the future holds, Marin General is committed to providing both local physicians and patients with that choice. Physicians who align with us can get the benefits of being part of a larger organization without losing their autonomy and the ability to run their practices as they see fit. Likewise, their patients can continue to access high quality care without hav-ing to leave their community.



gon charting application allows bed-side entry of clinical information and seamlessly interfaces with other clinical applications already in use at the hospi-tal. Because patient handover between nurses at shift change can now occur in the patient’s room, the new system will allow for increased patient involve-ment and better communication. The medication bar-coding application is integral to preventing medication er-rors. And no more chasing down the chart on morning rounds!

The implementation of Clinical Care Station is the first step toward demon-strating “meaningful use” of electronic records under federal regulations. The next step, computerized provider or-der entry, will be implemented during 2012. MGH is also working on protocols needed to create a health information exchange, a central database that can be shared by all providers involved in a patient’s care, regardless of the site of care. Such an exchange will offer a patient-centered approach to accessing clinical information.

Recent technology purchases at MGH include a PET/CT scanner and new breast imaging equipment, both made possible through funding by the MGH Foundation. The new, state-of-the-art scanner provides detailed 3-D images, especially useful for cancer and cardiovascular care, and has an open

Note: Each issue of Marin Medicine

includes a self-reported update from one

local hospital or clinic, on a rotating basis.

A year and a half after the Marin Healthcare District regained control of Marin General

Hospital, the facility is thriving. As a full-service, acute-care hospital, MGH provides a trauma center, comprehen-sive cardiac and neurological surgery programs, labor and delivery services, and a nationally recognized cancer care center.

Under our new leadership, MGH is pushing forward. With new industry awards and certifications, expansion of services, deployment of electronic health records, retention of nurses, staff and physicians, and significant com-munity donations of nearly $9 million to date, this past year and a half have brought great change and activity.

Key to the hospital’s future are ex-panded capabilities, including elec-tive neurosurgery at the new Spine & Brain Institute, the only program of

its kind in Marin. The launch of the institute is just one example of

a broader strategy to align with our physician community for the benefit of our patients.

Many of our services have been rec-ognized at a national level. In 2010, we earned the Joint Commission’s Gold Seal of Approval for both our hospital and behavioral health services, and we were designated a Breast Imaging Center of Excellence by the American College of Radiology. We also received accreditation from the American Col-lege of Surgeons’ breast-center accredi-tation program, and our Marin Cancer Institute was awarded eight out of eight possible commendations by the ACS’s cancer commission.

We are also the first hospital in Marin County to receive full accredi-tation for percutaneous coronary in-tervention from the Society of Chest Pain Centers for our treatment of acute coronary syndrome. Finally, our stroke program has been certified by the Joint Commission and has received a quality achievement award from the American Heart and Stroke associations.

In September 2011, MGH took a big step towards eliminating paper chart-

ing and enhancing patient safety. We deployed a new application, Clini-cal Care Station, to enable electronic charting, electronic clinical records and medication bar coding. The Para-

Marin General HospitalSusan Cumming, MD

H O S P I T A L / C L I N I C U P D A T E

Dr. Cumming, a senior fel-

low in hospital medicine,

is medical director of

Marin General Hospital.


design that makes scanning more com-fortable for patients. In September 2011, we opened a new electrophysiology lab, which will allow faster, safer abla-tions and device implantations. Plans are underway for a second 64-slice CT scanner and upgraded MRI equipment.

As an independent community hos-

pital, collaborat ion with other organiza-tions and with commu-nity partners is critical for MGH. The most sig-nificant recent example of our collaborative efforts is our work on reducing hospital read-missions. In September 2010, I attended the first meeting of the Avoid-ing Readmissions Col-laborative, an initiative supported by the Gor-don and Betty Moore Foundat ion. ARC’s goal is to help partici-pating organizations reduce 30- and 90-day readmissions by 30% by 2013.

Early in 2011, with funding from ARC, we established a cross-con-tinuum work group, the Care Transitions Collaborative (CTC), which included repre-sentatives of hospital departments and lead-ership, Marin County Health & Human Services, Prima Medical Foundation, Hospice by the Bay and Palliative Care, Sutter Care at Home, Marin Community Clinics, Marin-Sonoma IPA, and a patient rep-resentative. The CTC team identified four key areas for intervention: patient education, medication management, team communications (both within the hospital and post-discharge), and post–discharge support systems, especially for older adults.

The CTC team is still developing

plans to address those four areas, but MGH has already adopted an innova-tive technology for team communica-tions: Carebook, a multidisciplinary care collaboration tool. Care providers inside and outside the hospital can use Carebook to form multidisciplinary care teams, collaborate on safe transi-

tion plans for their patients, coordinate care across the teams, and engage pa-tien ts and caregivers with a patient-centered after-care map. MGH will deploy and administer Carebook and also make it available to community partners.

Our work with readmissions has evolved into a new initiative, the Collaborative for Older Adults Safe Transmissions Program. In late Octo-ber 2011, we received a $750,000 grant from the Gordon and Betty Moore

Foundation to implement the program, recognizing the need and our innova-tive community based approach. The work is just beginning, but we are op-timistic the program will offer a new paradigm for improving not only the health of our patients, but also their experience of care.

We are grateful for the generous

contributions received from the Marin County community since the hospital’s transition to publ ic control—nearly $9 million to date. Our fundraisers during 2011 have in-cluded the “Night in Marin Gardens” gala, which raised more than $400,000, and the “Taste of Tokyo” golf tourna-ment at the Meadow Club, which raised more than $300,000. Both will become an-nual events.

Wit h t h e s e a nd other contributions, we have been able to launch the Spine & Brain Institute, pur-c h a s e t h e PET/C T scanner, begin major expansions and up-grades to our emer-gency department, and update our breast im-aging equipment. We also plan to launch an

outpatient diabetes program. It has indeed been a busy year and a

half for all of us at MGH, and the pace is unlikely to slow down in the near future. Change creates challenges, but it also creates opportunity. I believe this past year and a half have demon-strated that MGH remains strong. We are continuing to focus on our patients as we work to raise the bar on health-care in Marin.


Marin General HospItal


ture readings. Because Karl was an agnostic, the family did not attend church regularly.

When Dietrich and his twin sister Sabine were 6 years old, the family moved to Berlin, where Karl had accepted an academic appointment. Berlin in 1912 was an intellectual and cultural cen-ter, with one of the world’s finest universities. The family lived in an elite community near the univer-sity and enjoyed an active social life. Many of their friends were Jewish. Karl taught his children fairness and intellectual rigor.

The children spent idyllic summer holidays at their coun-try home in the Harz Mountains, reading and playing outdoors. Their holidays where cut short in 1914, when Germany declared

war on Russia. The family was patri-otic to some extent and followed the progress on the front with interest. The war really came home to them when two older sons were drafted and one of them, Walter, was killed in 1918. Paula was devastated and withdrew into her-self for the better part of a year. Diet-rich’s childhood ended, and Germany changed: the Kaiser abdicated and the Weimar Republic came into being.

Life went on. Dietrich entered high school, and at the age of 14, though

he was a talented musician, declared his intention to study theology. The de-cision was met with some resistance. His brother Klaus, who had chosen a

Bonhoeffer: Pastor, Martyr, Prophet, Spy, by Eric Metaxas, 624 pages, Thomas Nelson (2011).

I was drawn to this biogra-phy because I had heard of Dietrich Bonhoeffer in the

context of the German Resistance but knew little about him. Eric Metaxas—who wrote the best-selling Amazing Grace: William Wilberforce and the Heroic Cam-paign to End Slavery—uses ex-tensive research to paint a vivid portrait of Bonhoeffer in the set-ting of his family and early 20th century Germany. Metaxas also attempts to explain the evolution of Bonhoeffer’s theology, which has often been misunderstood. What is certain is that, unlike most of his countrymen, Bon-hoeffer was not afraid to stand up against the Third Reich.

The ethical challenges of Bonhoef-fer’s era were famously summarized by one of his contemporaries, Pastor Martin Niemöller:

First they came for the communists, and I didn’t speak out because I wasn’t a communist.Then they came for the trade union-

ists, and I didn’t speak out because I wasn’t a trade unionist.

Then they came for the Jews, and I didn’t speak out because I wasn’t a Jew.Then they came for me, and there was no one left to speak out for me.

Dietrich Bonhoeffer was born in Bre-slau, Germany, in 1906, the sixth of

eight children of an upper-middle-class family. His father, Dr. Karl Bonhoeffer, who had studied under Wernicke, was a renowned neurologist and psychia-trist, and his mother, Paula von Hase, was a university-educated teacher who counted among her forebears theolo-gians, artists and musicians. Paula ran the household and home-schooled the children in their early years. She taught them religion through hymns and scrip-

Costly Grace Irina deFischer, MD

C U R R E N T B O O K S

Dr. deFischer, a Petaluma

family physician and geri-

atrician, is president-elect

of MMS


career in law, accused the church of being “a poor, feeble, petty bourgeois institution,” to which Dietrich replied, “I shall have to reform it!”

In 1923, Dietrich entered the Univer-sity of Tübingen. At the time, Germany was going into a financial free-fall. Meals cost a billion marks! Hitler led his first Beer Hall Putsch and began writing Mein Kampf. After a year at the university, Dietrich decided to travel with his brother to Rome for a semester abroad. The stay in Rome opened his eyes to the diversity and universality of the Catholic Church and sparked his interest in the ecumenical movement.

Upon his return to Germany, Diet-rich transferred to the University of Ber-lin and began his theological studies in earnest. The leading theologians of the day were extremely liberal, and though Dietrich held his teachers in high re-gard, he differed from them in his more literal interpretation of the scriptures. He contrasted the prevailing attitude of “Cheap Grace” (in which believers could live their lives as they pleased as long as they attended church services and received absolution periodically) with “Costly Grace,” which involved devoting one’s entire life to following the teachings of Christ as expressed in the Sermon on the Mount.

By the age of 21, Bonhoeffer had suc-cessfully defended his doctoral thesis and graduated summa cum laude. Too young to be ordained, he accepted a position as the assistant pastor of a Ger-man congregation in Barcelona, Spain. His sermons challenged the congrega-tion both spiritually and intellectually, and attendance at the services increased during his year-long tenure. Back in Berlin, he returned to the ivory tower and became a university lecturer. Soon afterward he was offered a Sloan Fel-lowship at Union Theological Seminary in New York.

Bonhoeffer’s stay in New York had a profound influence on him, particularly because of his exposure to the revival-ist preaching of the Abyssinian Baptist Church in Harlem and the piety and spirituals of the former slaves. He be-came interested in the racial issues in

America and travelled extensively on the East Coast and the South, and as far as Cuba and Mexico. During this time, he became a pacifist and got more in-volved with the ecumenical movement, which eventually led to his activities during the German Resistance.

Back in Berlin once again, Bonhoeffer resumed his work as a university

lecturer and author. He became more and more troubled by the German church establishment, which was be-ing co-opted by Hitler and the National Socialists. Bonheoffer’s brother-in-law, Hans von Dohnanyi, a lawyer at the German Supreme Court with access to privileged information, reported to Bonhoeffer the atrocities of the Third Reich that were not known to the gen-eral public. Another brother-in-law, Gerhard Leibholz, was subject to sanc-tions because he was of Jewish descent. Bonhoeffer eventually helped Leibholz and others escape to relative safety in England. He also helped found the Confessing Church, which pledged to take a stand against the Nazis and was eventually driven underground. Bonhoeffer lobbied his friends in the ecumenical community outside Ger-many to support the opposition, but he made little headway. Hitler’s power increased, and his critics were silenced through execution or imprisonment.

In 1938, Bonhoeffer learned that war was imminent. His friends, afraid for his safety, arranged for him to take a visiting professorship in New York, but after a brief stay Bonhoeffer returned to Germany, feeling he couldn’t abandon his country in its time of need. “I shall have no right,“ he wrote to a colleague, “to participate in the reconstruction of Christian life in Germany after the war if I do not share the trials of this time with my people. … Christians in Germany will face the terrible alterna-tive of either willing the defeat of their nation in order that Christian civiliza-tion may survive, or willing the victory of their nation and thereby destroying our civilization.”

Bonhoeffer was forbidden to speak in public, or to print or publish his

works, and he was required to report his movements to the police. He was able to avoid conscription by joining the Abwehr, a branch of the military intelligence service, and he became a double agent and co-conspirator with his brother-in-law von Dohnanyi in the failed plot to assassinate Hitler. As a pacifist, joining the plot was a difficult decision for Bonhoeffer, but he felt it was the only way to stop Hitler, and he was willing to assume the guilt for his action. As he said, “It is not only my task to look after the victims of madmen who drive a motorcar down a crowded street, but to do all in my power to stop their driving at all.”

In 1943, Bonhoeffer was arrested along with Dohnanyi and spent a year and a half in a military prison in Berlin awaiting trial. When his connection to the conspiracy was discovered, he was transferred to the Buchenwald con-centration camp and later to the Flos-senburg camp, where he was executed just a month before the capitulation of Nazi Germany. He left a legacy of both finished and unfinished works, includ-ing The Cost of Discipleship, Ethics, and Letters and Papers from Prison.


C L A S S I F I E D S

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How to submit a classified adTo submit a classified ad for Marin Medicine or MMS News Briefs, contact Erika Goodwin at [email protected] or 707-548-6491. The cost is one dollar per word.


(see photo). These communi-ties were founded in the 13th century as sanctuaries for the many women (Beguines) left single or widowed by the Crusades. Although a deeply pious residence, the beguinage was not a con-vent. The Beguines could leave to marry. They could also take their inheritance to the beguinage and work outside in the community.

From Belgium we traveled north to Sweden and Finland, spending time in both Visby and Jakobstad. Like Bru-ges, Visby is a well-preserved medieval town. It is surrounded by a long stone wall, and its skyline is dominated by the St. Nicolaus church ruin (see photo on page 21).

Farther north is Jakobstad, which was founded in 1652. Russians sacked the town twice in 1714. Despite the re-peated drubbings, it became the lead-ing shipping town in Finland during the 18th century. In 1844, Finland’s first round-the-world sailing expedition started from Jakobstad harbor. Today, Nautor, the manufacturer of the world’s most elegant, fastest production boat, the Swan, calls the port home.

Beyond Jakobstad, the countryside of Finland is forest and lakes and vast wilderness. There are more than 180,000 lakes and a nearly equal number of is-lands. The name Finland is thought to derive from fen (a swampy land), or from the French fin de lande, meaning “the end of the world.” For my father’s family, it was home.


I had to write a family history in the eighth grade and wrote to my

“far mor” (Swedish paternal grandmother) to help me. She was born in the town of Visby on Gotland Island, off the southwest coast of Sweden. She told me that her uncle was the Lutheran bishop of Gotland and that her father was the military commander of the island’s fort.

My “far far” (paternal grandfather) was raised in Jakobstad, Finland. When my father was in his teens, my grand-father gave him The Tales of Ensign Stål, by Johan Runeberg, the national poet of Finland. My father gave the book to me when he thought I was old enough, and I will pass it on to my only living nephew. It is the epic poem of Finland.

I have searched for my father’s family roots for years. Despite its size (338,000 square kilometers), Finland has less than 5.5 million inhabitants, some 40 of whom are my father’s fam-ily. My dear cousins, Anna Britta and Nils Sundqvist, allowed me to live with them for several months in 1975 while I did an internal medicine rotation at Malmska Hospital in Jakobstad, whose Finnish name is Pietarsarri. All towns on the west coast of Finland have Swed-ish and Finnish names. Swedish is the

predominant language, but Finnish is required at work. My cousins

speak Swedish, Finnish, English, Span-ish and French.

In September 2011, I returned to my father’s homeland via Belgium with my good friend, Wendy. After several days in Brussels, we were joined by an old friend from Vienna, Felicitas, with whom I had done medical relief work in Central America over 20 years ago. We all took the train to Bruges, one of the most perfectly preserved medieval cities in western Europe.

Wendy, who is an artist, led us to the Church of Our Lady (Onze-Lieve-Vrouwekerk), where the celebrated Madonna and Child sculpture is the only Michelangelo to have left Italy dur-ing the artist’s lifetime. Construction of the church itself began in the 1200s and continued for three centuries, with occasional renovations since then. The interior is Gothic, but there are Baroque flourishes to its statues and extravagant pulpit. The cathedral’s art collection in-cludes “Supper at Emmaus,” a painting that was once ascribed to Caravaggio but is rather flat and uninspired when compared to true Caravaggios.

Bruges is also home to one of several beguinages found in the Low Countries

In Search of the VikingsBarbara Nylund, MD

O U T S I D E T H E O F F I C E

Dr. Nylund, a gastroenter-

ologist in private practice

in Novato, serves on the

MMS board of directors.


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