Health Connection - October 2022

Mammography Q&A: Early Detection Is Your Best Protection

As October is Breast Cancer Awareness Month, we sat down with Natalya Lvoff, MD, Medical Director of MarinHealth’s Breast Health Center, to discuss the importance of focusing on breast health.

According to Breastcancer.org:

• In 2022 in the United States, it’s estimated that 43,780 people — 43,250 women and 530 men — are going to die from breast cancer
• According to the CDC, about 9% of all new cases of breast cancer in the U.S. are found in women younger than 45; breast cancer risk increases as women get older
• Black women are less likely to be diagnosed with breast cancer than white women, but are 41% more likely to die from the disease
• About 170,000 people in the United States are living with metastatic breast cancer

In response to these sobering statistics, Dr. Lvoff pioneered the use of MRI-guided breast biopsy at MarinHealth. She is involved in research, has published multiple articles, presented at numerous national radiology conferences, and has served as a representative of the Mammography Education Task Force for the American College of Radiology.

Question: Screening guidelines seem to vary depending on the source. What is MarinHealth’s official position on when to start mammography and how often to screen?

Dr. Lvoff: MarinHealth recommends annual screening mammography starting at age 40, because this is the regimen that saves the most lives. This recommendation is supported by The American Congress of Obstetricians and Gynecologists, the American College of Surgeons, the American College of Radiology, the National Comprehensive Cancer Network, and the Society of Breast Imaging.

Mammography is the only test proven to reduce mortality from breast cancer. According to the National Cancer Institute, since screening mammograms became widespread in the mid 1980’s, the death rate from breast cancer in the U.S. decreased by over 30%.

Question: What type of screening equipment does MarinHealth’s Breast Health Center offer?

Dr. Lvoff: Our Breast Health Center is on the cutting edge of technology. We were the first program in Marin to offer tomosynthesis, the most sensitive type of mammogram. Tomosynthesis is a 3-dimensional mammogram that acquires multiple images of the breast at different angles. Images are reconstructed into thin slices, allowing the radiologist to see through overlapping structures—like reading the pages of a book, rather than just looking at the cover. This provides increased cancer detection, less additional imaging, fewer biopsies, and less anxiety. Our breast center has four brand-new, state-of-the-art tomosynthesis machines, so all of our patients benefit from this technology.

We are also the first community hospital in the Bay Area to use 3D Quorum technology for processing mammograms. This technology produces the clearest images of the breast using the lowest amount of radiation. We also offer a prone 3D stereotactic biopsy table, which allows for greater patient comfort and optimized accuracy. And we are one of the first programs doing pre-operative seed localization for increased patient comfort.

All of our mammography machines are now equipped with curved compression paddles, which are curved to mimic the contour of a breast, making the mammogram as comfortable as possible. I have received so much positive feedback about these paddles. Patients have said that this was the most comfortable mammogram they have ever had. They have said that they will tell their friends, some of whom have been reluctant to get a mammogram, how much better it is now.

Question: What are the most common barriers to mammography screening?

Dr. Lvoff: Some patients fear the discomfort of mammography, but our new curved paddles reduce this fear. Some patients fear radiation, but in reality, the radiation associated with mammography is minimal. Our Breast Health Center uses the minimal amount of radiation possible, well below the established national guideline. Our new image processing equipment allows us to lower the amount of radiation even further.

Our patients’ main fear is breast cancer. The best way to combat this fear is to get annual screening mammograms beginning at age 40. This is the approach that saves the most lives. Our team is here to help each patient through the screening process: To hold a hand, to offer guidance and reassurance, and to provide fast and accurate mammography results.

Question: Take us through the Breast Health Center’s process if a routine mammogram turns up a suspicious area. What should a woman expect?

Dr. Lvoff: Screening mammograms can be associated with a lot of anxiety. Our team is here to make the process as easy and stress free as possible. Screening mammograms are interpreted within several days, often on the same day of the study. Thanks to our new electronic medical record, the result is available immediately to the patient. A small group of patients will be called back for additional pictures or an ultrasound to get a closer look at an area. These patients receive results at the end of their exam.

Less than 2% of patients will need a biopsy. A nurse and radiologist guide the patient through every step of the process. Pathology is processed accurately and efficiently and we call the patient directly with the results as soon as they are available. Our patients never go through this process alone.

A team of specialists, including breast surgeons, oncologists, radiation oncologists, radiologists, plastic surgeons, nurses, navigators, and therapists, discusses each new breast cancer diagnosis to come up with a treatment plan that is individually tailored to each patient.

Are you due for a mammogram?

MarinHealth's Breast Health Center offers appointments for screening mammograms Monday – Friday from 7:30 am – 6:30 pm and Saturdays from 8:00 am – 4:30 pm. Request an appointment online or call our scheduling team at 1-415-925-7301.

Dealing With Kidney Stones

By Harry Neuwirth, MD

Every year, the excruciating pain of kidney stones sends more than half a million Americans to the Emergency Department. One in eleven people will have a kidney stone at some time in their lives, usually between the ages of 30 and 60, and the incidence appears to be increasing. After you’ve had one stone, you are at high risk to have more unless you make changes, so it is worthwhile to review causes and treatment.

The kidneys are fist-sized organs located on either side of the spine below the rib cage. They filter roughly 200 quarts of fluid every 24 hours to remove waste products and excess fluid through urination. While waste management is their primary function, the kidneys also help regulate blood pressure, red blood cells, salt, calcium, and potassium, and produce a form of vitamin D.

What Causes Kidney Stones?

During urine production, crystal deposits collect on the inner surface of the kidney. These are mostly excreted in the urine. However, in some patients they will enlarge, break from the kidney walls and form a stone. Stones in the kidney are usually asymptomatic. However, stones can also slip into the ureter, a narrow tube that carries urine from the kidney to the bladder, and cause a blockage. The result is severe pain, or “renal colic.”

Symptoms of Kidney Stones

The symptom that sends people to the Emergency Department is sharp, cramping lower back pain, sometimes radiating to the side, abdomen, and groin. This comes and goes until the stone passes, but at its peak, it is so severe that some women who have given birth describe it as “worse than childbirth.” Other symptoms include nausea, vomiting, fever, and chills. People may feel an intense urge to urinate and experience a burning sensation when they do. Urine may have a foul odor and be brown, red, or pink, indicating the presence of blood. Some men also feel testicular discomfort and/or pain at the tip of the penis.

Risk Factors for Kidney Stones

• Gender: According to the National Kidney Foundation, the lifetime risk for developing kidney stones is about 19% for men and 9% for women. However, several studies indicate that the gap is closing, with rates increasing in women. Experts suspect this may be due to dietary changes and rising levels of obesity.
• Dehydration: Kidney stones are caused by too much mineral and not enough water. The easiest way to lower stone risk is to stay hydrated. Almost nobody can keep track of urine volume, so I recommend that you have water available in your surroundings, drink as soon as you feel thirsty and try to have clear urine at least once during the day. Many of our patients enjoy endurance sports. Running, cycling, even tennis, deplete your body’s water and runners train themselves to ignore thirst. If you work out for an hour you should keep drinking over the next hour to replenish lost fluids. I also see “stones of self-denial,” mostly in moms and teachers, where they have trained themselves to ignore thirst. Staying hydrated helps reduce your risk of developing kidney stones.
• Excess salt drives your kidneys to put out more calcium, so watching salt intake can be helpful.
• Diet: Animal protein in particular (meat, chicken, fish, cheese) increases stone risk. Consuming more plants and less animal protein reduces your stone risk.
• Supplements: There is a huge fitness industry geared to selling supplements, which very effectively promote kidney stones.
  • It is possible that Olympic level athletes working at the limits of human performance need protein bars and shakes. You and I, however, working out a few hours a week, certainly do not.
  • Megadose Vitamin C has been completely disproven as a treatment for any condition. Nevertheless, it remains popular as a supplement. Vitamin C over 200 mg/day, which you get in a balanced diet or a multivitamin, is metabolized to oxalic acid which promotes kidney stones. Do not take this.
  • Smoothies. There are fad diets with spinach and chard in smoothies. These are loaded with oxalate and can cause stones.
  • What about calcium? Your gut is designed to reject most of the calcium you ingest, so I continue to encourage taking recommended doses of calcium and Vitamin D, particularly in women and older patients. We can monitor urine calcium and moderate dosages if needed.

Diagnosis

Kidney stones mostly go unnoticed as long as they don’t cause symptoms. Once a person experiences pain, the first step is imaging, preferably a high-resolution CT scan known as a Kidney-Ureter-Bladder, or KUB scan. The severity of pain is not an indicator of the stone’s size, but imaging will reveal the size, allowing urologists to assess whether the stone is likely to pass or not and whether it is suitable for shock wave treatment to break it up.

Treatment

Most stones under 5 mm in size will pass on their own, and doctors will prescribe pain medications, anti-inflammatories, and plenty of fluids to help ease the process. Larger stones can be treated through a variety of minimally invasive procedures:

• Shock-wave lithotripsy uses high-energy sound waves to blast stones into fragments that are then more easily passed out in the urine.
• Ureteroscopy involves inserting an endoscope through the ureter to retrieve or destroy the stone.
• Percutaneous nephrolithotomy/nephrolithotripsy is reserved for the largest kidney stones. The surgeon inserts a catheter into the kidney through a small incision in the patient’s back. A miniature fiberoptic camera and tiny instruments are threaded through the catheter to operate. The stone can be directly removed through the tube (nephrolithotomy) or broken up into smaller pieces first, and then removed (nephrolithotripsy).

Learn more about the leading-edge kidney stone treatments at MarinHealth.

Reducing your Risk for Kidney Stones

• Stay hydrated. The more water you drink, the less concentrated your urine will be. If you are well-hydrated, your urine will be a very light yellow. Choose water as opposed to sugary beverages and soda.
• Eat more fruits and vegetables. They make the urine less acidic, which is less conducive to stone formation.
• Reduce salt and sugar. In general, try to eat fewer processed foods and always read the labels. Processed foods can contain a surprising amount of sodium and sugar.

The combination of too much salt and insufficient fluid intake increases the levels of oxalate and calcium in your body. Your doctor can order blood and urine tests to help determine what types of dietary changes would be most helpful in your case.

Learn more about kidney stones and the latest treatment options by listening to this short podcast.

Harry Neuwirth, MD is a board-certified urologist practicing at MarinHealth Urology | A UCSF Health Clinic.

The Lymphatic System and Lymphedema Treatment

By Mindy Zimmerman, CLT, BCTMB, CMT

The lymphatic system works alongside the blood system to help filter and transport waste products out of the body. A wide network comprised of lymph capillaries, collectors, vessels, nodes, ducts, and organs: spleen, thymus gland, and tonsils. Unlike our circulatory system, where the heart transports blood throughout the body with a central pump, the lymph system transports water, large proteins, cells, and fat through the body with the movement of adjacent muscles.

The lymphatic system has multiple functions:

• Fluid balance throughout the body. The lymphatic system removes and transports excess fluids and large proteins that have accumulated in various places in the body.
• Intestinal function. The lymphatic system facilitates the absorption of fats and fat-soluble vitamins and transports these substances from the digestive system to the circulatory system.
• Immune system function. Lymph nodes located all around the body act as filters, using white blood cells called lymphocytes to attack and destroy infectious agents and damaged or cancerous cells. Lymph fluid then carries these waste products back into the bloodstream to be disposed of through the liver, kidneys, and digestive system.

When the lymphatic system is not able to adequately drain lymphatic fluid from an area of the body, the accumulation of fluid and accompanying swelling is known as lymphedema. There are two types of lymphedemas. Primary lymphedema is due to a congenital or hereditary lymphatic system abnormality. Symptoms of this rare condition, which affects one in 100,000 Americans, can occur at any time over the course of a lifetime. Secondary lymphedema is much more common, affecting one in 1,000 people in the United States. This type of lymphedema is caused by damage to the lymphatic system. The most common causes of secondary lymphedema include the surgical removal of lymph nodes due to cancer, radiation, trauma, infection, malignant tumors, or chronic venous insufficiency. Watch this short video to learn more about the lymphatic system and how to reduce your risk of lymphedema.

Treating Lymphedema

Starting treatment and symptom management early prevents lymphedema from progressing, improves limb shape and skin condition, and reduces the risk of infection. Treatment is personalized based on the location of the issue, the condition of the affected tissue or joint, and the patient's general health. Other variables to consider include the time elapsed since surgery, precautions recommended by the surgeon, and the patient’s goals and functional requirements. Treatment starts with patient education to explain risk reduction and the importance of healthy habits, including at home lymphatic drainage techniques. Other treatment may include:

• Manual lymphatic drainage, a specific muscle movement technique that helps direct lymphatic fluid from the swollen area to functioning, undamaged lymph channels.
• Therapeutic exercises to encourage lymph circulation and address range of motion, strength, and stability deficits
• Compression bandaging and/or garments
• Specialized skin care
• A home compression pump for long-term management

Learn more about lymphedema and treatment options by listening to this short podcast featuring MarinHealth’s Certified Lymphedema Therapists (CLTs).

Lymphedema Treatment at MarinHealth

MarinHealth has been the North Bay’s primary resource for the treatment of lymphedema and cancer-related dysfunction for more than 30 years. Treatment is offered at our outpatient Physical Therapy Department and our Integrative Wellness Center. Our experienced, highly skilled Certified Lymphedema Therapists work closely with each patient’s medical team of physicians, nurses, patient navigators, physical therapists, and integrative wellness clinicians to provide personalized care and education for every patient. Patients who follow through with their therapists’ instructions usually experience decreased swelling, improvements in range of motion, strength and stability, reduced pain, improved function and mobility, and a reduction in scar tissue.

We’re pleased to offer Manual Lymphatic Drainage Massage at our Integrative Wellness Center. This highly specialized and gentle massage is especially useful for people who have had surgeries, radiation, or are currently undergoing Complete Decongestive Therapy with a Physical Therapist or dealing with the side effects of cancer. This treatment relaxes the entire body, reduces pain and stiffness, and opens up pathways for lymph fluid to move more freely and reduce swelling. For more information or to schedule an appointment, call MarinHealth’s Integrative Wellness Center at 1-628-336-7689.

Mindy Zimmerman, CLT, BCTMB, CMT, is a nationally certified massage practitioner with more than 20 years of experience. She practices at MarinHealth Integrative Wellness Center.

Added Sugar: Not So Sweet for Your Heart

By Beth Gonzales, RDN

It can be tempting to give in to those tricks and treats this time of year, and a little trick here and a little treat there might seem harmless, but the truth is, sweets can be scary for your heart. A diet high in sugar can lead to weight gain and over time, obesity. Excess weight raises your heart disease risk in several significant ways:

• Your body stores extra calories as triglycerides, a type of fat that increases heart disease risk.
• Consuming too much sugar raises your levels of LDL cholesterol which accumulates in your arteries in the form of plaque.
• Obesity contributes to high blood pressure, which can increase the risk of heart disease.
• Excess sugar consumption can lead to insulin resistance, pre-diabetes, and eventually, diabetes.
• A diet high in sugar leads to chronic inflammation which stresses the heart and blood vessels.
• If you are eating a lot of sugar and processed foods, you are likely not getting enough heart-healthy whole grains, fruits, and vegetables.

Natural Sugars vs. Added Sugars

Many healthy foods contain natural sugars which can be part of a healthy diet. For example, the fructose in fruit and lactose in milk products are natural sugars. What can get you into trouble is consuming added sugars. The table sugar, maple syrup, or honey you use in your coffee, tea, or oatmeal are added sugars. Added sugars are found in all kinds of processed foods, and not just in your favorite sweet treats like cookies or ice cream. Perhaps surprisingly, excess sugar can lurk in canned food, breads, fruit yogurt and peanut butter. The American Heart Association recommends limiting your consumption of added sugar.

Read the label!

Knowing how to read food labels can protect you from stealth sources of excess sugar. Pay attention to these common phrases:

• Sugar-free means the product has less than 0.5 grams of sugar per serving.
• Reduced sugar means at least 25% less sugar compared to what the product typically contains.
• No added sugars indicates that no sugar containing ingredient is added during processing.
• “Total sugars” means just that: A total of the natural and added sugars contained in the food.

Added sugars may be listed on a label as “added sugars” or as a specific type of sugar. Each of the below ingredients may be featured as an added sugar on a food label:

• Agave nectar
• Brown sugar
• Cane juice or cane syrup
• Corn sweetener
• Corn syrup
• Fruit juice concentrates
• High-fructose corn syrup
• Honey
• Invert sugar
• Malt sugar
• Molasses
• Raw sugar
• Rice syrup
• Sugar
• Dextrose, fructose, glucose, lactose, maltose, and sucrose
• Syrup

Tips for Cutting Back on Sugar

According to the American Heart Association, the average American has a whole mouthful of sweet teeth, consuming about 17 spoonfuls of added sugar a day! What’s more, nearly half of that added sugar comes from sweet beverages. If you insist on adding sugar, the American Heart Association recommends limiting the amount to 9 teaspoons a day for men and 6 teaspoons a day for women and children over two. But it’s a good idea to further reduce your sugar consumption.

• Don’t add sugar, syrup, honey, or molasses to anything you eat or drink.
• Get your sweet fix from fruits of all types and colors.
• Switch from sodas to sparkling water with a squeeze of lemon.
• Eat your fruit fresh. Avoid canned fruit in sweet syrup.
• Do a little comparative shopping–different brands of peanut butter, for example, can contain various amounts of added sugars.
• Try fresh or dried fruit instead of sugar on your oatmeal or cereal.
• Edit your recipes — When you bake, cut the amount of sugar in the recipe by a third or even a half or substitute unsweetened apple sauce for sugar. Dates are also a great option to replace added sugar in baked goods, offering sweet flavor along with fiber, antioxidents, vitamins, and minerals.
• Experiment with replacing added sugar in recipes with flavorful almond, vanilla, lemon, or orange extract, or try a sprinkling of ginger, allspice, cinnamon, or nutmeg.

If you are disciplined about cutting back on the sugar in your diet, you will eventually find that a lot of your formerly favorite foods now taste too sweet. That’s a sure sign you’ve finally tamed your sweet tooth.

(Watch the above video to learn more about the impacts of sugar on your body, from Beth Gonzales, RDN)

Beth Gonzales is a Registered Dietitian Nutritionist at MarinHealth Cardiovascular Medicine | A UCSF Health Clinic.