Health Connection - October 2021

Your Primary Care Provider

It’s Open Enrollment time! Now is the time to evaluate your healthcare insurance plan and make changes to meet your needs. This is also the time to pick the right Primary Care Provider, or PCP. Your PCP is the point person and chief advisor for all your healthcare issues—the doctor who specializes in you. Selecting the right PCP is one of the most important things you can do to take charge of your own health. This is the doctor who:

• Treats the majority of your medical issues, from strep throat to GERD
• Serves as your “healthcare quarterback,” referring you to specialists when needed and coordinating with those specialists to optimize your overall health
• Helps you manage chronic conditions like high blood pressure, elevated cholesterol, or type 2 diabetes
• Makes sure you keep up with regular exams and essential screenings
• Keeps you on schedule for immunizations or booster shots
• Advises you on healthy lifestyle choices to help you stay well

There are several types of Primary Care Providers. Their focus or training may vary, but all are qualified to serve as your go-to physician.

Internal Medicine

Internal Medicine doctors are specially trained in the prevention and treatment of adult diseases. An internal medicine physician is considered a generalist in adolescent medicine, allergy and immunology, cardiology, endocrinology, gastroenterology, hematology, infectious disease, nephrology, oncology, pulmonology, rheumatology, and sports medicine. Internal Medicine doctors typically see patients 16 and older.

Pediatric Care

Pediatricians are trained in childhood development. They keep track of important developmental milestones and focus on diseases and disorders that are common during childhood and adolescence, from asthma and allergies to ADHD and other behavioral health disorders. Pediatricians treat patients from birth through age 21. Some teens, once they reach 16, may prefer to switch to a doctor who specializes in adults rather than continuing to see a pediatrician.

Family Medicine

Whereas an internal medicine doctor cares for adults, and a pediatrician specializes in children, family medicine doctors see patients of all ages, from newborn to elderly. Because they treat the whole family, these doctors have a unique perspective on your family’s relationships, lifestyle, culture, and health history. Some families find it especially convenient to receive care from a single expert in the same location. Family medicine physicians receive three years of specialty training in inpatient and outpatient medicine, including procedural and pediatric training with an emphasis on behavioral science and patient communication.

Osteopathy

Doctors of Osteopathic Medicine (DOs), also known as osteopaths, are fully licensed physicians. They emphasize a whole-person approach to care with a strong lifestyle focus. DOs attend Colleges of Osteopathic Medicine and go on to complete internships, residencies, and fellowships, just like MDs. DOs are specially trained in the musculoskeletal system, the body’s interconnected system of nerves, muscles, and bones. As part of their training, osteopaths, learn to practice Osteopathic Manipulative Treatment, or OMT, hands-on techniques used to diagnose, treat, or prevent illness and injury. OMT is just part of an osteopath’s medical tool kit and DOs can do everything other PCPs do, such as prescribe medicine or refer you to a specialist.

Nurse Practitioner

Nurse Practitioners (NPs) are nurses with a master’s or doctorate in advanced practice nursing and extensive clinical experience. They are trained to diagnose and manage acute and chronic conditions, with an emphasis on wellness and disease prevention. Like physicians, NPs can conduct and interpret diagnostic and lab tests and write prescriptions for medication and non-pharmacological therapies.

Geriatric Medicine

Geriatricians are specially trained to work with patients ages 65 and up. Medical needs often increase with age, and geriatricians are highly familiar with the common challenges patients face during this part of life. A skilled geriatrician can help patients address some of the typical health concerns that people face as they get older, such as arthritis, cardiovascular disease, joint replacement surgery, hearing loss, and dementia.

Open Enrollment for Medicare runs from October 15 – December 7. Commercial Open Enrollment begins November 1 and ends January 31, 2022. Don’t miss this opportunity to review your healthcare choices and ensure you have selected the right primary care physician.

With MarinHealth | UCSF Health primary care clinics located throughout Marin and Sonoma counties, you can easily find a doctor close to work or home. To start your search, click here if you’re a Medicare patient or here if you’re commercially insured.

Breast Cancer: From Awareness to Action

By Natalya M. Lvoff, MD

October is Breast Cancer Awareness Month, and it is hard NOT to be aware of a disease that strikes one in eight women. According to the American Cancer Society, 281,550 women will be diagnosed with breast cancer in 2021. The earlier that a cancer is diagnosed, the more treatable it is. This is why early detection is the best protection.

Yearly mammography starting at age 40 is the screening regimen that saves the most lives. Unfortunately, women often put off their annual mammogram.

Many women worry about pain with breast compression. To reduce discomfort, the MarinHealth Breast Health Center is implementing a new curved paddle, designed to mimic the shape of a woman's breast.

Another potential fear is radiation. However, the amount of radiation of mammography is minimal, equal to approximately three months of natural background radiation. Our Breast Health Center uses the minimal amount of radiation possible, well below national guidelines.

The most common fear women report is what her mammogram might reveal. It is important to understand that the odds are on your side. Of the 10 percent of women who get called back for additional imaging, only 0.5 percent are found to have cancer.

MarinHealth’s Breast Health Center uses 3D digital mammography with computer assisted detection. Unlike traditional mammography, this low-radiation imaging technology produces a 3D view of the breast. 3D digital mammography makes it easier to see through dense breast tissue. Small tumors can be detected earlier, with fewer false positives. Learn more about screening and early detection at Marin Health Breast Health Center.

If you are called back for additional imaging after a screening mammogram, additional testing can include one or more of the following:

• Diagnostic Mammography, which uses the same technology as screening mammography, but with a zoomed-in look at the area in question.
• Breast Ultrasound, where sound waves create an image of breast tissue without the use of radiation. This test can help the radiologist determine whether a lump is a fluid-filled cyst or a solid mass. Ultrasound also helps determine the size and location of the lump and evaluate the surrounding tissue.
• Breast MRI, which creates detailed images of the breast using a magnetic field and radio waves.
• Breast Biopsy, a test that samples breast tissue to determine if the area in question is cancer. It is important to remember that 80% of women who have a breast biopsy do not have breast cancer.
• Tumor markers are evaluated when a breast cancer is diagnosed. These markers look for the presence of estrogen and progesterone receptors in the cancer cells. These receptors use hormones to fuel the growth of cancer. Such tumors often respond well to hormone therapy. The HER2/neu test looks for a human gene called growth factor receptor 2 and the protein it produces. If this gene is not functioning properly, it can cause breast cells to grow and divide. Tumor makers affect treatment options.

Breast Cancer Treatment

If cancer is diagnosed, patients are referred to a breast cancer specialist. The results of the pathology report and other tests will help stage the cancer and arrive at the optimal treatment plan for each individual patient.

There are a variety of ways to treat breast cancer, and doctors often take a multi-disciplinary approach. A treatment plan is developed based on individual factors, including:

• The stage of the cancer
• The type of tumor and the nature of the cancer cells, such as whether they contain certain proteins or hormone receptors
• The woman’s overall health and other medical conditions
• The woman’s personal preferences
• Whether or not the woman has reached menopause
• How fast the tumor is growing

Surgery

Most breast cancer patients will have surgery as part of the treatment plan. Surgery is used to remove the cancer. Most patients undergo a lumpectomy, where only the breast cancer is removed. Mastectomy is the removal of the entire breast. Women who choose mastectomy, meet with a plastic surgeon to discuss breast reconstruction. Surgery also serves a diagnostic purpose, to determine the full extent of the cancer and whether it has spread to the lymph nodes under the arm.

Radiation

After a lumpectomy, radiation can be recommended to reduce the chance of recurrence.

Chemotherapy

Given intravenously or orally, chemotherapy may be prescribed at different times in the treatment process:

• Neoadjuvant chemotherapy is used before surgery to shrink larger tumors so that surgery can be less extensive.
• Adjuvant chemotherapy is used after surgery to target any remaining cancer cells and reduce the risk of recurrence.

Hormone Therapy

Certain types of breast cancers contain proteins called receptors that attach to the hormones estrogen and progesterone and promote tumor growth. Hormone therapy, which can be used both before and after surgery, prevents the hormones from attaching to the receptors, thereby slowing, or stopping tumor growth. Hormone therapy is a long-term treatment that is taken for 5-10 years.

Targeted Drug Therapy

Targeted drug therapies are a product of the emerging field of “Precision medicine”, a type of medicine that uses information about a person’s genes and proteins to prevent, diagnose, and treat disease. These drugs work by interfering with specific molecules involved in the growth and survival of cancer cells.

Immunotherapy for Breast Cancer

Immunotherapy uses drugs to boost the immune system’s ability to recognize and destroy cancer cells more effectively.

Overdue for your mammogram? Schedule your screening mammogram at the MarinHealth Breast Health Center today.

Dr. Lvoff is a fellowship trained Breast Imager, Board Certified Radiologist, and Medical Director of the Breast Health Center at MarinHealth.

Common COVID Questions, Answered

By Karin Shavelson, MD, FAAP, Gregg Tolliver, MD, MPH, and Susan Cumming, MD

This month, we asked a panel of MarinHealth experts to answer some of the most pressing questions you may have about COVID-19 and the latest vaccination news. Read on for insights from Karin Shavelson, MD, FAAP, Chief Medical Officer; Gregg Tolliver, MD, MPH, Medical Director of Infection Control; and Susan Cumming, MD, SFHM, Medical Director of Quality at MarinHealth Medical Center.

• If the vaccine is so effective, why do we keep hearing about breakthrough cases?
  
  Breakthrough cases have always been expected for the approved COVID vaccines. In January and Feb. 2021, the vaccines worked really well against the strains circulating then, and they did often prevent breakthrough infections. However, with some waning of immunity over several months and the emergence of the highly transmissible Delta variant, breakthrough infections became more common. Vaccines are designed to prevent severe disease, not prevent infection. Rarely, while trying to make the best vaccine possible, a vaccine is created that does seem to stop infection. This is called sterilizing immunity, which is really more a goal for a vaccine, rather than an expectation. Vaccines against polio and measles offer something close to sterilizing immunity.

• Are some vaccinated people more at risk for breakthrough COVID than others?
  
  Yes, age has a lot to do with infection risk, as does time since last infection. There is also data that those who had COVID, then get vaccinated, have more robust protection from severe disease. Those with blood cancers often don’t make enough antibodies, even after a booster dose.

• Am I supposed to get a booster shot? I’m not sure who’s eligible.
  
  As of this writing, booster shots are only approved for those who completed both doses of the Pfizer vaccine more than six months ago and are either age 65 or older, or age 18 and older and at risk of severe COVID due to a health condition or their work environment. This week, the FDA also amended the emergency use authorizations (EUA) to allow Moderna boosters for those same groups, as well as Johnson & Johnson boosters for those who received the Janssen vaccine at least two months ago, and are age 18 & older. Before the Moderna and Johnson & Johnson boosters can be authorized for local use, they must also receive approval from the CDC, as well as the Western States Scientific Safety Review Workgroup (WSSSRW). Both of these additional authorizations will likely come within the next week. Check Marin County’s boosters webpage for updates on local availability.

• What do we know about the Mu variant? Should we be concerned?
  
  Although the Mu variant had some concerning characteristics that suggested the possibility of some degree of immune system evasion, the Mu is being outperformed by the Delta in terms of spread to vulnerable persons. The CDC data tracker now says the percent of Mu COVID strains circulating in the US is zero. However, viruses mutate. We expect to see more variants of concern, but vaccination is likely to provide some protection.

• Will a booster shot eventually be necessary for everyone?
  
  There is general consensus among experts that COVID will become endemic, like influenza, and that vaccination to boost immune responses to prevent severe disease will likely be recommended for everyone.

• I already had COVID. How long does natural immunity last?
  
  In general, natural immunity isn’t quite as strong as a full vaccine series. The silver lining is that if you had COVID, a full vaccine course will really boost your antibody levels to levels that are several times higher than with just vaccine alone.

• Should I wait a certain amount of time after having COVID before getting the vaccine?
  
  Wait 90 days.

• I’ve been vaccinated but got a breakthrough case – should I still get a booster when I’m eligible?
  
  Congratulations. Your breakthrough case significantly boosted your immunity to SARS-CoV-2. You can wait at least 90 days to get a booster, probably longer. Check the CDC webpage guidance when your 90 days is up.

• I’m pregnant. Should I get the vaccine?
  
  Yes. Yes. Yes. Evidence about the safety and effectiveness of COVID-19 vaccination during pregnancy has been growing. These data suggest that the benefits of receiving a COVID-19 vaccine FAR outweigh any known or potential risks of vaccination during pregnancy. If you are not vaccinated, you are likely to become symptomatically infected, and possibly severely ill, even using masks and social distancing. Pregnant people are at increased risk for severe COVID disease compared to non-pregnant people. Don’t trust what you read on social media regarding vaccines. Trust the CDC.

• What about if I was vaccinated more than 6 months ago – should I get a booster while pregnant, or wait until after I deliver?
  
  Get a booster. Pregnancy is considered one of the “Certain Medical Conditions” that qualify you for a booster.

• A lot of COVID symptoms are similar to the flu, cold, or allergies. Should I get a COVID test anytime I’m feeling a little sick?
  
  If you have cold and flu symptoms, you should get tested ASAP. Allergy symptoms are similar to cold symptoms, but do differ. In home, rapid Antigen COVID testing will be more available in the next few months, so you might want to have that option at home before symptoms start. Even if you test negative for COVID, if your illness persists, call your doctor. MarinHealth's Adult Acute Care Clinic provides drive-through testing for patients exhibiting COVID-19 symptoms. To make an appointment, call 1-628-336-5205.

• My kids are back in school but not old enough to be vaccinated. Is it OK for them to be around their vaccinated grandparents?
  
  Kids have strong immune systems, so are less likely to have severe disease. However, they can transmit virus, even if they have no symptoms. Grandparents over 65 and with certain medical conditions can get boosted, which really makes them much safer. You can also test your kids at home to be sure, if you want. Most transmission happens at home.

• Of course hand washing is always a good idea, but do scientists still believe COVID can be spread through touch?
  
  Only about 1% of infections are thought to be from contact with infected surface.

• Is it safe to get your flu shot at the same time as your COVID shot or booster?
  
  YES.

• Has COVID treatment evolved since the start of the pandemic? Are there any new treatments that are being used in the hospital?
  
  Yes, treatment had evolved quite a bit. We use remdesivir if the infection is early on, and high flow nasal cannula oxygen if needed. Anti-inflammatory medicines like steroids are used later in severe disease.

• I understand the rules change as the pandemic evolves and scientists learn more about COVID. How often do you recommend checking the state regulations?
  
  Read your local newspaper, and go to your County COVID website as needed.

• How safe is it to fly on a plane right now? What about eating in an indoor restaurant or attending a sporting event?
  
  If you are fully vaccinated, you are still unlikely to get severe disease. You can decrease your risk by following the guidelines, masking, social distancing, frequent testing, vaccination, and avoiding risky situations. Pay attention to case rates where you might travel. Travel in October and November in the US is looking safer than in August and September.

Hip Replacement: A Life-Changing Procedure

By Derek Ward, MD

In 1891, Professor Themistocles Glück performed the first documented hip replacement in Berlin, Germany. Both the procedure and prostheses have come a long way since then. By the end of the 1900s, hip replacement was known as “the surgery of the century” for its high success rate and positive impact on quality of life.

Today, hip replacement is a common procedure with a very low complication rate. According to the Agency for Healthcare Research and Quality, more than 450,000 total hip replacements are performed each year in the US alone. Patients are amazed at how quickly they can get back to everyday activities they enjoyed before arthritis set in.

Osteoarthritis is a progressive disease. At first, you may have trouble pinning down the source of your pain, which may be experienced in the groin, upper thigh, buttock, side of the hip, or even the knee. Eventually, a hip x-ray reveals a damaged arthritic hip. As hip arthritis progresses, you may have trouble taking the stairs, walking—even putting on your shoes. Hip pain continues when you are at rest and may wake you up in the middle of the night. You can treat the pain and discomfort with physical therapy, anti-inflammatory drugs, or injections, but the impact on your quality of life just gets more pronounced. That’s when you and your doctor may want to discuss the next step: hip replacement surgery.

Despite the huge advances in hip replacement techniques and technologies, people still hold some major misconceptions. Some assume there will be many things they won’t be able to do with their new hip. However, in most cases hip replacement recipients can return to all the activities they used to enjoy before pain took over their lives. Others worry about whether the implant will wear out in 10 or 15 years. Fortunately, today’s implants are built for the long haul. Patients in their 50s can usually expect their prosthesis to last for decades, if not for life.

There are two basic surgical approaches to hip replacement: the classic posterior approach, and the newer anterior approach. The anterior approach has its advantages:

• It is intermuscular, meaning the surgeon can go through natural spaces between muscles without cutting, making for an easier first six weeks of recovery
• Because patients are on their back for the procedure, it’s easier to do real-time imaging and recreate their original anatomy

However, outcomes are equally good with either approach and it’s best to make your decision based on the surgeon rather than the technique.

Hip implants, or prostheses are comprised of four parts:

• The stem is inserted into the femoral bone and is usually made of titanium, an inert metal over which bone can grow, stabilizing the implant
• The head, made of metal or ceramic, which replaces the head of the femoral bone, and serves as the ball in the hip’s ball joint
• The liner, which covers the head so that it moves more smoothly, and is made of highly cross-linked polyethylene, an especially strong plastic engineered for a low rate of wear
• The cup-like socket, which fits into the pelvis, is also made of titanium, and holds the ball in the ball joint

Each part of the hip prosthesis comes in multiple sizes. Your surgeon will use pre-operative software to size the implant to your individual bone structure. In addition, a range of sizes for each part of the implant are available during surgery, allowing the surgeon to make any necessary tweaks to restore your hip joint’s original “geometry” as specifically as possible.

Studies have shown that “prehab”—physical therapy to prepare for surgery—is unnecessary and can in fact be painful. The best way to prepare is to understand your procedure. MarinHealth offers a free virtual Joint Replacement class that covers everything you need to know. Surgery is performed under regional anesthesia, with patients unconscious but breathing on their own. Most people can leave the hospital the same day or the day after their procedure. Many factors influence this decision including the person’s age, general health, and how easily they will be able to navigate their home environment.

Post-surgery, pain management is multimodal, involving a combination of anti-inflammatories, acetaminophen, and a periarticular cocktail injected directly into the hip. Most people need some opioids but are off those within a week or two. It usually takes just two or three months to feel completely normal. Learn how hip replacement surgery helped Randy Ichihana regain his active lifestyle.

Physical therapy (PT) is provided in-hospital before the patient is released. After that, needs vary widely. Some people have in-home PT, some have outpatient PT, some a combination, and some don’t need any physical therapy at all!

Learn more about MarinHealth’s hip replacement expertise.

Derek Ward, MD is an Orthopedic Surgeon at UCSF Health and Medical Director of Orthopedic Surgery at MarinHealth.