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Kathleen Kobashi-Porter, MD

WSUS Women’s Health Chair

With the fast pace of life, it can be di� cult for many of us to � nd the time to take proper care of ourselves. Although there is a plethora of health-related information available on the Web and in the media, it is often challenging to identify helpful and precise information on which to base our healthcare decisions.

Several years ago, the Men’s Health Initiative created a Guide to Men’s Health that has been very well-received. Consequently, it seemed � tting to proceed with a women’s version of the Guide to provide brief and accurate information for the women in our com-munity. Contained in this booklet is information ranging from nutrition, alternative medicine, cancer screening and treatment options to treatment of urinary incontinence and pelvic prolapse.

� e goal of this “healthzine” is to provide women with a reliable abbreviated resource to which they can turn for important women’s health care issues. Authors from across the state of Wash-ington have been gathered to contribute in their respective � elds to provide a reliable and useful source of information.

Every couple of months a new article will be added to this on-line health guide to provide new material on an active basis until the entire guide is available. � e articles found within the guide are updated regularly representing a current per-spective on ongoing health issues facing women.

As October 2008 is Breast Cancer Awareness month, the breast cancer overview will be high-lighted as our introductory “chapter.”

We hope you � nd this guide a useful reference and would appreciate any feedback from our readers.

For additional information on this re-lease, please contact:

Kathleen Kobashi-Porter, MD

via Debi Johnson

djmgmt@gmail.com (425) 971-5822

INTRODUCTION

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Debra G. Wechter, MDVirginia Mason Medical CenterSeattle, WA

Breast cancer is the most commonly occurring cancer in women and will a� ect one in nine women in their lifetime. � e cause of the majority of breast cancers is unknown though risk factors which may be associated with the development of breast cancer include early age with � rst menstrual period, late age at menopause, late � rst pregnancy, nulliparity, no breastfeeding, and a family history of breast or ovar-ian cancer.

Only 5-10% of breast cancers are hereditary. � ere are two gene mutations, BRCA1 and BRCA2, which increase the lifetime risk of breast cancer up to 85% and ovarian cancer as high as 60% in a� ected wom-

en. Women (or men) who might be at risk of having a genetic mutation include those with:

• Early onset breast cancer

• Two primary breast cancers

• Family history of early onset breast cancer

• Personal or family history of male breast cancer

• Personal or family history of ovarian cancer

• Ashkenazi Jewish heritage

• Known BRCA mutation in the fam-ily.

In BRCA carriers, one of the options for prevention is prophylactic bilateral mas-tectomy. If not done, follow-up should include yearly mammogram, yearly breast MRI and twice yearly clinical breast exam. Prophylactic oophorectomy reduces the risk of ovarian cancer, and

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also reduces the risk of developing breast cancer by 50% in premenopausal women. Tamoxifen may also decrease the risk of breast cancer.

Screening for breast cancer includes breast self exam (BSE), clinical breast exam (CBE), and mammography. Although BSE is widely recommended, there is actually no compelling evidence to show that BSE a� ects prognosis. Although some women � nd it reassuring to become familiar with their breast exam, others may � nd it intimidating to try to assess a breast abnormality. Performing BSE is a personal choice that should be discussed with a woman’s primary care provider. CBE is recommended by the American Cancer Society every 3 years for women in their 20’s and 30’s, and annually for asymptomatic women who are 40 and older. Screening mammography is recommended yearly for women 40 and older by the Ameri-can Cancer Society. Screening breast MRI is reserved for women with a high lifetime risk of breast cancer and guidelines for its use have been published by the American Cancer Society (cancer.org; CA Cancer J Clin 2007;57:75-89).

If a breast mass is found on exam, mammogram and ultrasound may be used to assess the mass. If a mammogram is abnormal, additional mam-mographic views and ultrasound may be used. If

exam or imaging is suspicious, the preferred method of diagnosis is core needle biopsy which is performed under local anesthe-sia by a breast radiologist or surgeon using mammogram, ultrasound or palpation for guidance.

Once a diagnosis of cancer is made, a mul-tidisciplinary team including providers with expertise in radiation oncology, medical oncology, breast surgery, plastic surgery, and genetic counseling guides evaluation and treatment.

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� e clinical stage of the tumor is based on tumor size, lymph node status, and presence or absence of metastases. Lab tests and imag-ing such as chest x-ray, breast MRI, PET/CT scan, bone scan, and CT scan are chosen to help de� ne the stage based on NCCN guidelines (cancer.org).

Surgical options for treatment of the breast are partial mastectomy (lumpectomy) and mastec-tomy. Partial mastectomy is usually performed as an outpatient procedure and involves re-moving the cancer with a rim of normal tissue around it. If the mass is not palpable, either wire localization with mammogram or ul-trasound, or ultrasound alone, identi� es the cancer for the surgeon. With wire localization, a mammogram or ultrasound is performed to identify the cancer and a skinny wire is inserted through a needle toward the cancer under local anesthesia. In the operating room, an inci-sion is made using the wire as a guide and the cancer is removed with a rim of normal breast tissue around it. An x-ray is taken of the tissue to prove the cancer has been removed and that there is a clear margin.

A mastectomy removes the entire breast and nipple-areolar complex, but not the muscle un-derlying the breast. A skin-sparing mastectomy removes the entire breast and nipple, but leaves a small rim of skin around the nipple, allowing more skin to be used in reconstruction. Recon-struction by a plastic surgeon can be performed at the same time (immediate) or at any point in

the future (delayed). � e two primary options include implant reconstruction, or autologous reconstruction using one’s own tissue from the abdominal wall, buttock or back.

One of the � rst places that breast cancer can spread is to the lymph nodes under the arm. With invasive cancer, the lymph nodes are as-sessed with sentinel lymph node biopsy (SLNB) unless the lymph nodes have already been shown to have cancer by biopsy or imaging. � is technique removes the � rst node or nodes draining the cancer through microscopic lymph channels from the breast to the axillary nodes.

To � nd the sentinel node, a small amount of radioactive tracer is injected into the breast using local anesthesia the afternoon before or the day of the operation. In the operating room, sometimes a blue dye is injected into the breast as well. � e radioactive or blue sentinel node is removed using a gamma probe (a small Geiger counter) and evaluated by the pathologist. If the sentinel node has cancer, an axillary node dissection may be performed. � is involves removal of the lower level lymph nodes in the fatty tissue under the arm.

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Additional treatment after operation may include radiation therapy, chemotherapy and hormonal therapy. Women who under-go partial mastectomy also require radiation treatment to the breast to reduce the risk of recurrence. Without radiation, the chance of cancer coming back in the breast may be up to about 30%, though with radiation the risk is at most up to 10-15%. Whole breast radiation begins a few weeks after opera-tion and is given over approximately 6 weeks for a few minutes each weekday. A newer technique called accelerated partial breast radiation may be appropriate in selected patients. It is not yet considered the stan-dard of care because we do not know that the long term risk of breast recurrence is as low as with whole breast radiation. � e area of cancer is treated twice daily for � ve con-secutive working days using external beam radiation, placement of an intracavitary balloon catheter (MammoSite®), or, least commonly, insertion of interstitial wires through the breast tissue. Some women will require radiation therapy after mastectomy to reduce the risk of chest wall recurrence if the invasive cancer is 4 cm or larger in size, if there are 4 or more lymph nodes involved with cancer, or if the cancer is close to the skin or chest wall.

� e use of hormonal therapy may be consid-ered in women whose tumors test positive

for estrogen and/or progesterone receptors depending upon tumor size, lymph node sta-tus, and other factors. � ese oral medications are usually taken for up to 5 years.

� e primary purpose of chemotherapy is to treat or prevent metastasis (spread to lymph nodes, liver, lung, bone or other organs). Recommendations are based on tumor size, lymph node status and other factors such as age and coexisting medical conditions. Che-motherapy is usually given intravenously every one to three weeks for a period of 3-6 months. In women with “HER-2 positive” tumors, Herceptin (trastuzumab), a mono-clonal antibody, may be considered for treat-ment. HER-2/neu is a tumor oncogene that is “overexpressed” or positive in some tumors.

After initial treatment, women who have had breast cancer are followed with regularly scheduled exams and mammograms to look for evidence of recurrent cancer in the breast or elsewhere in the body. Follow-up guidelines may be found on the National Comprehensive Cancer Network website (nccn.org).

For additional information on this release, please contact:

Debi Johnsonwww.wsus.org

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COLORECTAL CANCER PREVENTION AND SCREENING

COLON CANCER

Richard P. Billingham, MD

Swedish Medical Center (Seattle, WA)

Women are usually quite well informed about methods of early detection and prevention for cancer such as breast and cervical cancer. However, the risks of development of colorectal cancer, and the methods of prevention of this deadly disease, are less well known. Colorectal cancer is the second leading cause of cancer death for both men and women in the United States. This year, more than 153,000 people in the U.S. will be diagnosed with colorectal cancer; more than 52,000 will die from their disease.

Colorectal cancer is one of only three cancers which

can actually be prevented by regular screen-ing examinations (the other two cancers which can be prevented are cervical cancer and skin cancer). Therefore, it is important for women to understand A) that colorectal cancer ispreventable; B) the methods by which colorectal cancer can be prevented; and C) how and when these methods should be used based on certain risk factors such as age, family history, personal history of other cancers and history of other related disease.

Nearly all colon and rectal cancers come from “polyps”, which are small, benign (non-cancerous) growths on the lining of the colon and rectum which may progress to cancer. Approximately 20% of all people will develop polyps. When they are small, polyps almost never cause symptoms and most people are unaware that they have them. While not every polyp will turn into a cancer, many polyps will become cancerous if not removed. If polyps are present and found early, before they can become cancerous, it is

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possible to remove these, preventing their develop-ment into cancer.

Screening is designed to detect polyps and to elimi-nate them before cancer develops. Prevention of can-cer is the #1 goal, but even if cancer should already be present, early detection, before cancer has had a chance to spread, is also an important factor in lead-ing to a cure and saving lives.

How does a person get screened?

The American Cancer Society recommends colonos-copy as the best method for screening.

When should I be screened?

The timing and frequency of colonoscopy is based on risk of developing this kind of cancer and is usu-ally categorized as average, moderate, or high risk.

Average Risk

The average risk of developing colorectal cancer for both men and women over the age of 50 is approxi-mately 1 in 20 if no screening is done. For those at average risk, the American Cancer Society recom-mends colonoscopy every 10 years beginning at age 50.

Moderate Risk

People are at moderate riskfor colorectal can-cer if they have either:

· a personal history of polyps or colorectal cancer themselves;

· a family history (sister, brother, parents or children) of colorectal cancer or polyps;

· a personal history of breast, ovarian or endo-

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metrial cancer, or

· a personal history of infl ammatory bowel disease, such as ulcerative colitis.

The risk of developing colorectal cancer in this group is three times greater than the average risk group or 1 person in 6, if no screening is done. Most women in the moderate risk category should have colonoscopy every 3 to 5 years beginning at age 40. For those with infl ammatory bowel disease involving the colon, specifi c recommendations for screening vary widely and should be discussed with your physician.

High Risk

People at high risk for colorectal cancer include those that have either:

· a family history of “familial adenomatosis polyp-osis” (a genetic disorder causing cancer to develop at an early age in 100% of those), or

· a family history of “hereditary nonpolyposis colon cancer” (HNPCC) (a genetic disorder with several other family members, especially under the age of 50, having colorectal cancer). Those in ei-ther of these risk groups should have colonoscopy every 1 to 2 years beginning no later than age 21.

These recommendations are based on guidelines published by the American Cancer Society, the American Society of Colon and Rectal Surgeons, the American College of Gastroenterology and

other interested groups. Your doctor may offer you other options for screening and surveillance based on your state of health and risk factors.

Now, about that colonoscopy…

A colonoscopy is an examination of the entire co-lon and rectum using a lighted fl exible instrument. This test requires clearing the bowels with laxa-tives on the day before the test. Colonoscopy has the advantage of viewing the complete lining of the colon and is very accurate in detecting polyps. Polyps can be removed without discomfort at the time of the examination.

Colonoscopy can be performed either by a gas-troenterologist (those trained in the diagnosis and medical treatment of disorders of the esophagus, stomach, small intestine and large intestine), or by a colon and rectal surgeon, (those trained in the di-agnosis, as well as medical and surgical treatment, of disorders of the colon, rectum and anus).

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In summary…

Know your risks, talk to your doctor, and follow the recommended timelines for screening. It could save your life.

For additional information on this release, please contact:Richard P. Billingham, MDPhone: DEBI JOHNSON (425) 971-5822Email: djmgmt@earthlink.net Source: Richard P. Billingham, MD Website: N/A

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CORONARY ARTERY DISEASE

John Holmes, MD

Virginia Mason Medical Center (Seattle, WA)

Coronary artery disease has been widely considered a “man’s disease” and not a major concern for women. Yet cardiovascular disease is the leading cause of death in adult women in the United States. It is also a leading cause of disability among women. Women’s age-adjusted mortality rates from coronary artery dis-ease are four to fi ve times higher than their mortality rates from breast cancer.

Coronary artery disease is caused by the gradual buildup of plaque (made of fat, cho-lesterol and other substances) on the inside wall of the coronary arteries, which supply oxygen-rich blood to the heart. Over time, the plaque deposits grow large enough to narrow the arteries inside channel, decreasing blood fl ow to the heart muscle. If the plaque be-comes unstable and ruptures, a blood clot can form at the rupture site and block blood fl ow altogether, resulting in a heart attack.

The risk factors for developing coronary artery disease in women are the same as in men; they are elevated blood cholesterol, high blood pressure, smoking cigarettes, diabetes mellitus, obesity, physical inactivity and a family history of coronary heart disease at a young age. In many coronary artery pa-tients, central obesity, hypertension, impaired glucose metabolism and hyperlipidemia are clustered in what has become known as the “metabolic syndrome”.