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WINTER 2013

Insight and news from Johns Hopkins Medicine

Healthy Minds, Healthy Hearts Responding to a heart attack with the goal of renewal, not just recovery

Young people at risk for this cancer Get healthy and get back in the game Do you have facial pain?

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Contents W i n t er 2 013

4| Facing Pain 

Qu ic k Con s u lt

Discover what may be causing excruciating facial pain and how doctors are treating it.

et Back in the 5| GGame–and Stay There  Physical therapists are working to keep people free from injury.

10| Match Maker  F irst Pe rson

A father made sure a kidney was available when his son needed a new one.

Better Vision in Sight for Sufferers of Age-Related Eye Disease

11| Early Warning 

S econ d Opi n ion

As colorectal cancer affects younger people, know what to watch for.

ON THE COVER

6| Healthy Minds,

Healthy Hearts Be assured that the steps you take after a heart attack can lead to renewal as well as recovery.

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for Health Information from Johns Hopkins Get the latest news on health and wellness topics important to you and your family, all from the experts at Johns Hopkins Medicine. The Your Health e-newsletter is delivered straight to your inbox. Visit hopkinsmedicine.org/news/ e-newsletters for your free email subscription.

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If

you are suffering from age-related macular degeneration (AMD)—a disease that slowly destroys the eye tissue related to central vision—and think hope is lost for clearly seeing the faces of loved ones again, there might be a chance for regaining some of your independence and quality of life. The Johns Hopkins Wilmer Eye Institute is one of the first institutions in the country to offer an implanted miniature telescope that replaces the eye’s natural lens and can help certain people with AMD see better. “This device can enhance distance vision and improve clarity,” says Judith Goldstein, O.D., Wilmer’s chief of low vision and vision rehabilitation service. But she is cautious: “Careful screening of candidates is essential to ensure rehabilitation after surgery will maximize visual function and meet patient expectations.” This is an alternative to external telescopes, which some people find to be cumbersome and provide only a narrow field of vision.

Rather, the new implanted telescope could be life-altering. Oliver Schein, M.D., Wilmer’s vice chairman for quality and safety and a surgical investigator on the study that led to Food and Drug Administration approval of the device, says the implant can help many patients with facial recognition, television watching and social interactions, and allow them to track moving objects more easily than can be done with a conventional external telescope. Ideal candidates for the implant are people ages 75 and older who have stable AMD, aren’t undergoing active injection or laser treatment, haven’t had cataract surgery in at least one eye, and experience a measured benefit using an external telescope. According to a long-term safety study, the implant, which Medicare covers, improves vision an average of three lines on the eye chart. For more information, appointments or consultations, call 800-547-5182. 800-547-5182 | hopkinsmedicine.org

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healthinsights Before You Assume ADHD, Check Your Child’s Hearing

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hen a child exhibits behavior problems in school or doesn’t progress academically in line with peers, some parents might think of a developmental disability or attention deficit hyperactivity disorder (ADHD). First, says Margaret Skinner, M.D., consider getting the child’s hearing checked, especially if he or she has suffered repeated ear infections. “During an ear infection, there is fluid in the middle ear,” says Skinner, a Johns Hopkins pediatric otolaryngologist (ear, nose and throat surgeon). “The infection can resolve but fluid may remain. That fluid is associated with mild but typically reversible hearing loss.” Permanent hearing loss from a common infection is extremely rare. But, she says, “children who have chronic fluid in their ears can experience impacts on language and behavior development.” Skinner recommends all children with hearing loss be evaluated by a pediatric otolaryngologist to help determine the best intervention, before going to a psychiatrist to evaluate behavior problems or developmental issues. If hearing loss is a concern, parents can get children preferential seating in classrooms, ask for written instructions from teachers, or have the children fi tted with hearing aids. Surgery is also an option in certain circumstances, Skinner says. NOW HEAR THIS! Discover more about children’s hearing problems from Emily Boss, M.D., Johns Hopkins pediatric otolaryngologist, in the video “The ABCs of Pediatric ENT.” Visit bit.ly/ABCsofPedsENT.

Mouth Swabs May Be as Effective as Blood Draws I T ’ S N O F U N getting stuck with a needle at the doctor’s office, but drawing blood is often the only way to detect illness, test the effectiveness of medicines and evaluate organ function. That may be changing, however, thanks to the research of Johns Hopkins University professor Doug Granger, Ph.D., who has spent the past 20 years looking at how to use a saliva swab as an alternative for blood collection. “In the early ’90s, when I was working with children who had to give blood samples,” Granger says, “I found the parents and kids just didn’t want to do it if blood had to be drawn.” Johns Hopkins researchers began a quest to discover that saliva, with its mix of proteins,

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hormones, enzymes and DNA, can be used in some instances for disease diagnoses and data collection. And it’s already making things easier for patients. Women receiving in vitro fertilization, for example, now can get their daily estrogen hormone levels tested with saliva as opposed to a blood sample, and a home saliva test kit for detecting HIV was approved by the Food and Drug Administration in 2012. “The diagnostic world has never thought of saliva as something that could help them very much,” Granger says. “We’ve just scratched the surface of the potential here.”

WANT TO REDUCE THE EFFECTS OF DIABETES? GET MOVING A new Johns Hopkins study shows that regular aerobic exercise provides great fuel (and efficiency) for the pumping heart. This is encouraging news for people who have type 2 diabetes, who also frequently have a high risk of heart disease. “Diabetic people have elevated glucose and fat in the blood,” explains lead researcher Miguel Aon, Ph.D. “They can have twice as much as a healthy person.” Each of these factors contributes to heart disease. Exercise breaks up stored fatty acids, giving the diabetic heart the extra fuel it needs to function normally. “To our surprise, the heart improved performance in the presence of hyperglycemia [high blood sugar] when there was a high energy demand,” Aon says. “If a person is exercising, the heart needs more energy, and energy is provided by fat.” In the study, researchers gave double the normal fatty acids to type 2 diabetic mice and then used an adrenaline-like substance to stimulate their hearts to beat faster, mimicking stress or physical activity. They found the diabetic mice’s hearts improved their function to the same level as normal mice and also counteracted the negative effects of too much glucose. This doesn’t mean you can eat whatever you want if you have diabetes, but it does mean regular biking, swimming, running or walking will improve your cardiovascular function and reduce your risk of heart failure. For more health news, research and events from Johns Hopkins Medicine, follow @HopkinsMedicine on Twitter.

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quickconsult

Facing Pain Intermittent yet excruciating pain in your face could be a sign of a nerve disorder. Michael Lim, M.D., a neurosurgeon at Johns Hopkins, explains the condition and the treatments that can bring relief How can I find relief? Recently I started experiencing sharp facial pain. What is going on? There are many causes of facial pain. One of them, trigeminal neuralgia, is characterized by episodic stabbing pain over the forehead and eyes or near the cheek, nose or jaw. Some people describe a sensation of electric shocks or ice picks. The pain, usually on one side of the face, can be triggered by eating, drinking, talking or feeling a slight wind or breeze.

What causes trigeminal neuralgia? No one is exactly sure, but many people believe the cause is an artery that rubs on the nerve near the brainstem. As people age, the insulation on the nerve wears down, much like wires in a home that cause electrical shocks when exposed.

The first line of treatment is usually medication. A majority of people respond well and their pain is well-controlled. If medication doesn’t work, there are three surgical options. Be sure to seek out a treatment center, like the Johns Hopkins Trigeminal Neuralgia Center, that has extensive experience and handles a high volume of cases.

Can you tell me about the surgical treatments? The first is called microvascular decompression. It’s an open surgery involving a small incision to lift the artery off the troublesome nerve and insert a cushion to eliminate rubbing. Although a short hospital stay is required, about 90 percent of people are completely cured. The second is called a rhizotomy, where a needle is used to insert medicine or apply other treatments to stop the pain. It’s an outpatient procedure, but the pain typically returns within a few years. For the third option, doctors deliver focused beams of radiation to the nerve. People return to work the same day, but the procedure doesn’t take effect right away and the pain can return a few years later.  n

Do You Experience Facial Pain? Watch a video of Michael Lim, M.D., Johns Hopkins neurosurgeon, to learn more about the symptoms, causes and treatment options for trigeminal neuralgia. Visit bit.ly/facingpain. For more information, appointments or consultations, call 800-547-5182.

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FREE ONLINE SEMINAR

Get Back in the Game– and Stay There

MASTER YOUR GOLF SWING BY IMPROVING YOUR MOVEMENT MECHANICS Tuesday, March 5, 7–8 p.m. Do you want to improve your golf game? Join Terrence G. McGee, P.T., Johns Hopkins clinical specialist and certifi ed golf fi tness and medical professional, to learn how you can improve your body motion to better your swing and prevent injuries. To register, visit

hopkinsmedicine.org/ healthseminars.

TRAINING TIPS

Therapy programs help people of all activity levels perform at their peak

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I T H S P R I N G fast approaching, you might be eager to get back out on the golf course or the running trail. Make sure you’re ready to resume your outdoor fitness regimen safely and effectively. “The majority of sports injuries are due to training errors, improper technique or a biomechanical imbalance,” says Dorianne Feldman, M.D., MSPT, a physiatrist with Johns Hopkins Medicine and Rehabilitation. “Lack of conditioning is another factor, especially for people who don’t play a sport year-round.” Perfecting the right form and technique for your pastime can reduce the risk of injury. Or if you’ve been sidelined, combining skill refinement with rehabilitation can help prevent future problems. That’s the idea behind a series of Johns Hopkins programs designed to help people of all activity levels perform at their best while learning to prevent or recover from injuries. “We place highly trained clinicians in direct oversight of each area based on their skills and personal experience,” says Ken Johnson, P.T., clinical manager of the Johns Hopkins Rehabilitation Therapy Services Clinic. “For example, we have therapists who are runners working with our running hopkinsmedicine.org | 800-547-5182

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Put these simple steps into your routine to keep pulls and strains at bay: ◗

rehab program and therapists with a professional background in ballet working in our dance rehab service.” Using high-tech equipment that captures detailed body movements in real time, therapists analyze each patient’s form and technique. For instance, they measure the mechanics of a golfer’s swing at three points: address, top of backswing and impact. “What we’re doing is identifying the particular joints or muscles that may be causing pain or performance issues,” says Terrence G. McGee, P.T., a fellowship-trained clinical specialist at the Rehabilitation Therapy Services Clinic. “Through manual therapy techniques and corrective exercises, we improve the biomechanics at particular joints that help them build muscle memory and improve the consistency of their performance.” If a runner tends to be a hard heel striker, for example, therapists can help prevent or reduce heel pain through coaching, injury prevention tips, strengthening or rehabilitation, based on each person’s needs. “When you think about it, the body’s like a machine,” Johnson says. “We study the machine for mechanical failures and weak links, and then we apply our therapy knowledge and experience to improve the function of that machine.” ■

Check with your doctor. Even if you’ve worked out in the past but stopped for a significant amount of time, it’s a great idea to make sure you’re still good to go. Start smart. Don’t overestimate your abilities. Whatever you think you can do, take it down a notch in the beginning. Warm up 15 minutes before starting an activity. This routine prepares the body by elevating the core temperature, loosening the muscles and raising the heart rate. Stretch, but only after a short cardiovascular activity, when muscles have had a chance to warm up. Drink plenty of water—before, during and after exercise—to prevent dehydration and fatigue. Increase the pace and intensity of your workout over time. Consider a 10 percent boost per week. Rest. It’s critical to help your body recover from the strain of exertion. Call in the pros. If you are having aches and pains that won’t go away, schedule time with a physiatrist or a sports medicine physician, who can refer you to a physical therapist as needed. For more information, appointments or consultations, call 800-547-5182.

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Healthy Minds, Responding to a heart attack with the goal of renewal, not just recovery

Healthy Hearts ew things in life are as scary as a heart attack. And then, after surviving one, a person must take many steps to resume a normal life and, in most cases, a more healthy lifestyle. What can be just as surprising as the heart attack itself are the unexpected, nonphysical effects, which are equally threatening to one’s quality of life. Although these effects might make the road to full recovery somewhat bumpy, experts at Johns Hopkins are proving that life after a heart attack not only goes on, but it can get better.

Facing Down Challenges

“A heart attack is a major life change. All of a sudden, someone has a wake-up call and it’s as if, ‘I’m not healthy anymore,’ ” says Shellee E. Nolan, M.D., a Johns Hopkins cardiologist. “Patients perceive themselves as being ill, and so they start to think about their future and how long their life is going to be. Many feel depressed, defeated, weakened.” Though some people develop depression, for most it’s anxiety that dominates their lives, largely in the form of worries about behaviors they believe might trigger another cardiac event, such as climbing stairs, having sex or drinking a glass of wine.  >

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So while they recover from an attack—attending rehabilitation and working to establish healthy habits—they struggle with the possibility of future heart problems. Rehabilitation, too, is challenging. It can take several weeks to several months or more, and people’s day-to-day lives change so much as to be barely recognizable. Some cannot resume work right away, especially if they have physically demanding jobs or their employers insist on an extended leave. And strain on relationships with spouses and caregivers, who themselves frequently have questions and fears, may also hinder recovery. For many individuals, however, time is of the utmost imporFREE SEMINAR tance, as people learn about CARDIOVASCULAR their health through the HEALTH— course of their recovery. A HEART TO HEART Nolan calls this carWednesday, March 20, 7–8:30 p.m., in Towson diac awareness. Join Johns Hopkins cardiologist Nancy “You don’t know Strahan, M.D., as she discusses the whether the symptom important steps you can take to reduce you’re having is signifiyour risk factors for heart disease. Learn more about what you can do to take cant versus really nothcharge of your cardiovascular health, make ing at all,” she says. healthier choices and identify key warning “But with time, you signs. The presentation will be followed learn what is a real conby a question-and-answer session. Refreshments will be served. cern or not a concern, and Call 800-547-5182 to register. a lot of worries pass.”

Success Begets Success

Though it is said that time heals all wounds, what can people recovering from a cardiac event do to fast-track their success? “To some extent, part of [recovery] comes just from asking your doctor about the different issues you’re facing, but this is where cardiac rehabilitation can also truly be beneficial,” says Stuart Russell, M.D., chief of heart failure and transplantation at the Johns Hopkins Heart and Vascular Institute. “You’re with people who are going through the same thing as what you’re going through, which is probably by far the best therapy.” If heart health were for sale, cardiac rehabilitation would be considered one-stop shopping. It is designed primarily to help restore physical functioning by means of supervised exercise training. And the benefits don’t end there. “It helps people cope with their illness in terms of dealing with stress and depression and improving quality of life,” says Kerry J. Stewart, Ed.D., director of clinical and research exercise physiology at Johns Hopkins Bayview Medical Center. “It also educates them about what lifestyle changes they may need to make, as people who have had some |

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type of cardiac event are certainly at a high risk for having another one.” Cardiac rehabilitation is considered a standard of care after heart attack, coronary artery bypass surgery and angioplasty (blood vessel repair), and both of Johns Hopkins’ cardiac rehabilitation programs, at Bayview Medical Center and at Green Spring Station, are certified by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). But just as important, research at Johns Hopkins has helped the AACVPR set the bar for excellence. “We were involved in the first studies demonstrating that the use of resistance exercise is not only safe but also effective in people with heart problems; that has now become part of the standard of care,” Stewart explains. “We have also been a member of the American Heart Association’s writing committees that created the standards for cardiac rehabilitation.” Along with exercise, cardiac rehabilitation at Johns Hopkins includes nutritional counseling, smoking cessation, stress reduction and basic education about topics such as medication adherence. And even when people don’t elect to pursue all options, Stewart observes, “by performing exercise where they are monitored and get feedback that says ‘you’re OK,’ people regain a level of confidence about their ability to do things, which in turn leads to them doing more when not in the program.” Bill Fusting, one of Nolan’s patients, experienced a heart attack in January 2012 and, after placement of a stent (a mesh tube that will keep his artery 800-547-5182 | hopkinsmedicine.org

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but when I finish, I just feel so good,” he says. “It absolutely builds your confidence and clears your mind, which keeps you from worrying. And when you feel good, you can do more in life.”

Knowing Is Half the Battle

open) and a brief hospitalization, was immediately referred to cardiac rehabilitation. Fusting was somewhat skeptical about how three days of exercise each week could make such a difference, but he trusted Nolan’s recommendation. “She introduced me to the fine people at cardiac rehab, and I’m glad she did,” says Fusting, who saw improvements in his blood pressure, cholesterol levels, weight and mood shortly after starting the program. “Even now, sometimes I don’t want to go,

or decades, men were thought

to suffer from heart disease and heart attacks more so than women. But, sadly, women have narrowed the gap, and cardiovascular disease is now the No. 1 killer of both genders. Hormonal and anatomical disparities between the sexes, however, mean some differences do exist. For instance, women generally report higher rates of depression after a heart attack than men—an unfortunate finding because depression increases the risk of mortality in heart disease and heart attacks. Whether this is attributable to women’s unique physiology is unclear, but Marlene Williams, M.D., director of the cardiac care unit at Johns Hopkins Bayview Medical Center, is trying to unravel the mystery, which could prove useful for preventing and treating depression in all heart attack patients.

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Just as exercise strengthens the mind as well as the body, education plays an important role in nonphysical healing. Optimal recovery from a heart attack is more likely when people understand why the event occurred and the nature and purpose of the treatment. Nolan says it’s more than just sharing facts; people also must be taught how to return to healthier lifestyles and avoid the habits that likely contributed to their problems in the first place. This is yet another way in which cardiac rehabilitation is beneficial, providing a form of self-care, as in Fusting’s case. “He had this heart attack, but now he has embraced a new life, fully and happily,” Nolan says. “He has incorporated this new diet and this new exercise, and is just as robust now as before his heart attack—but just doing it differently. “A lot of people end up embracing their situation with such vigor; it’s really quite amazing,” she adds. “People who were couch potatoes before and never paid much attention to their diet, and who maybe had this belief that they were invincible, they come out of this with a new appreciation for life and embrace the knowledge about how to keep themselves healthy.”  n

Williams is looking to an increasingly popular area of cardiovascular research: blood platelets, and a particular protein stored within and used by platelets called brain-derived neurotrophic factor (BDNF). People who have depression also have

the gender conundrum lower levels of BDNF, and given that depression has a clear linkage to heart functioning, Williams is considering whether the protein is a potential culprit. “If a depressed patient’s platelets can’t uptake and use BDNF, it circulates in their arteries, where it can contribute to plaque instability and rupture,” she says.

Recover and Renew!

Watch and listen to Johns Hopkins physicians discuss the invaluable benefits of cardiac rehabilitation. Visit bit.ly/recoverandrenew. For more information, appointments or consultations, call 800-547-5182.

“Maybe that is why there is an increased incidence of heart attacks in people who are depressed. But what we want to see now is whether there is a difference in the amount of platelet BDNF in men and women.” Having recently received funding associated with the Marianne J. Legato Research Scholar Award in GenderSpecific Medicine, Williams and her colleagues will examine differences in platelet function and depression among men and women with and without heart disease. With government research funding on the decline, studies in gender medicine have similarly shrunk, making this investigation all the more valuable for patients as well as for the field as a whole. For more information on the study, including possible enrollment, call 410-550-5128.

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firstperson

Match Maker John Cosby couldn’t donate a kidney to his son. But, with the help of Johns Hopkins, he made a donation possible

Photo by Scott Suchman

When we found out

our 19-year-old son, Sam, was in end-stage kidney failure, my wife and I felt as if we’d been hit by a truck. We didn’t want our son’s life to be limited by being on dialysis for the rest of his life. When physicians at Johns Hopkins told us a kidney transplant was an option, I said right away I’d be a donor. I went through all the blood tests and everything and was devastated to learn I wasn’t the right match for my son. Then they told us about their paired donation program. It’s for people like me who are willing to donate a kidney but aren’t a match for a particular recipient. I agreed to donate a kidney to someone I was a match for, and someone else agreed to donate a kidney to Sam. I’ll never forget walking into Sam’s hospital room after his transplant and seeing him with this big smile on his face. He was already doing better, and he’s been in great shape ever since. He’s now an active 22-year-old who is back to doing what he loves: snowboarding. I donated my kidney later, when it was needed for someone else. The operation wasn’t that big of a deal for me. I went into the hospital on a Tuesday and was back at work the following Monday. Most parents would do anything to help one of their kids. I do have a certain sense of pride knowing that Sam is thriving because Johns Hopkins enabled a stranger and me to give my son the kidney he needed.  n

To watch a video of John Cosby telling his story, visit hopkinsmedicine.org/mystory. For more information, appointments or consultations, call 800-547-5182.

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Life-Changing Expertise The Johns Hopkins Comprehensive Transplant Center has one of the largest, most well-established kidney transplant programs in the country. About half of its 225 yearly kidney transplants are from live donors, and a program for living liver donors is rapidly expanding. Live kidney donations are optimal for the recipients, and much easier on the donors than they used to be, thanks to minimally invasive surgical procedures. To find out whether you are a match to a particular recipient, you’ll start with an evaluation that includes blood and tissue tests. If the results are positive, you’ll meet with a transplant physician to discuss the surgery and risks. Donors are given the same care and considerations as recipients.

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secondopinion MINIMIZING YOUR RISK

Johns Hopkins recommends that most men and women get their first colonoscopy screening for colorectal cancer at age 50. There are, however, certain factors that can place younger people at higher risk and necessitate earlier screening: ◗

Early Warning Despite its reputation as an older person’s disease, colorectal cancer is increasing among young people

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he rise of poor eating and exercise habits permeates the news these days and, as a result, many illnesses traditionally affecting older people are now appearing in the young. One startling example is colorectal cancer; doctors are seeing an increase in cases among people younger than 50, which is the typical age to begin screening. “Nobody knows for sure why,” says Sandy Fang, M.D., a colorectal surgeon at Johns Hopkins, “but it’s probably a combination of things.” Fang points to many culprits as possible risk factors: a family history of colorectal cancer, inflammatory bowel disease, and lifestyle patterns such as low-fiber diet, excessive intake of red meat, obesity and lack of exercise. Colorectal cancer rates have been declining in older populations, but the disease is on the rise in people ages 18 to 49, with rates having gone up more than 2 percent between 1998 and 2007, according

to the National Cancer Institute. Fang says younger people are often misdiagnosed because the symptoms of colorectal cancer—rectal bleeding, abdominal pain and change in bowel habits to name a few— can point to many other disorders, and doctors don’t always consider colorectal cancer because of the patients’ age. When the disease is diagnosed it is usually advanced, because the younger person hasn’t sought care quickly or because symptoms might not have been recognized or acknowledged. Thus, the treatments are more extensive and costly. Fang urges people who have signs of colorectal cancer, regardless of their age, to be proactive with their care. When she sees symptoms in people who have a family history of the disease, Fang says she tends to do colonoscopies sooner rather than later. ■

Rectal bleeding, abdominal pain, diarrhea, changes in bowel movements, or anemia. Talk to your doctor about when to start screenings. A family history of colorectal cancer. Start screening 10 years before the diagnosis of the youngest affected family member. Lynch syndrome. If you are at risk for this hereditary cancer of the digestive tract, start colonoscopies at age 21 and continue every one to three years. Familial adenomatous polyposis. This disease is characterized by benign growths that will likely develop into cancer. Get a colonoscopy every one to two years, starting as early as the teen years.

FREE ONLINE SEMINAR

COLON CANCER: KNOW YOUR RISK

Thursday, March 21, 7–8 p.m. Awareness of symptoms and risk factors are important in detecting colon cancer early. Join Johns Hopkins colorectal cancer experts, gastroenterologist Francis Giardiello, M.D., and colorectal surgeon Susan Gearhart, M.D., as they discuss risk factors, symptoms, the importance of early screenings and current treatment options. To register, visit hopkinsmedicine.org/healthseminars.

For more information, appointments or consultations, call 800-547-5182. hopkinsmedicine.org | 800-547-5182

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