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september 2010

North Carolina Urological Associates Comprehensive and Specialized Care

T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

Also in this Issue

Prostate Cancer

Screening and treatment

Ovarian Cancer State of the art 2010


Beyond Imagination. Working in partnership with physicians for over 50 years to bring the benefits of biomedical technology to patients around the world.


Duke cardiothoracic surgeon Donald Glower, MD, and colleagues help patients look forward to healthier lives. Talk about your unique specialty. I am what you would call a super-subspecialist because of what I do with heart valves. My work focuses upon minimally invasive valve surgery, which didn’t even exist 20 years ago. It’s a very narrow niche—not many people do this. Minimally invasive valve surgery simply minimizes the cuts and allows us to get into the body and disturb a lot less tissue than with other types of procedures, so the recovery is typically much quicker and less painful. You’ve been a surgeon for 30 years. You must have learned a lot about the concerns of a patient facing heart surgery. Yes, and that’s why I think it’s important to have a lot of interaction with patients before surgery. This can be a very scary situation for most people. Giving people some hope is important, and I enjoy this aspect of my work. How does Duke stand out in the field of cardiothoracic surgery? Duke is a world leader in minimally invasive valve surgery, heart and lung transplantation, and endovascular therapy for cardiovascular disease. The Duke faculty are great to work with and it really is true that here at Duke, you can come up with almost any idea and you’ll find someone at Duke who wants to collaborate with you. It’s very exciting—lots of bright people on the leading edge. And Duke is rapidly adaptable. If you have a good idea, lots of people could get behind you and support you. By golly, if it makes sense, the research happens. Why would a patient travel a great distance to come to Duke? Duke is an exciting place with lots of bright people focused on developing new ways to help patients. Whatever problem might arise, there are expert physicians who would love to help solve the problem. There’s a lot of good quality care available elsewhere, but patients who come to us are looking for something unusual—something not available just anywhere. We have world experts who are able to deal with the most complex needs.

Dr. Glower and colleagues are committed to excellence in the treatment of heart disease, lung disease, aneurysms of the great vessels, and disorders of the esophagus.

Duke Heart Center 888-ASK-DUKE dukehealth.org/heart 7242


Contents

COVER STORY

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PHOTO BY JIM SHAW

North Carolina Urological Associates Comprehensive, Compassionate Care

FEATURES

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Women’s Health

Ovarian Cancer: State of the Art in 2010 It’s the fifth leading cause of cancer deaths in women in the United States. Women are living long, but the mortality rate has only improved slightly and remains high.

SEPTEMBER

2 0 1 0 V O L U ME 1 I SS U E 8

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DEPARTMENTS 15 News

Light the Night Walk

Illuminated Night Walk Raises Funds, Sheds Light The Light the Night Walk is the signature Leukemia & Lymphoma Society fund-raiser and it has a mighty local impact to the tune of approximately $4 million annually.

 aising Funds for Leukemia R and Lymphoma

18 Urology

 rostate Cancer: Who Needs to Be P Screened and Treated

20 Business Management

 eimbursement Analysis Establishes R True Cost Per Relative Value Unit

22 Gynecology

Ovarian Cancer: State of the Art in 2010

24 Urology

Greater Precision Makes Radiation a Strong Prostate Cancer Treatment Option

26 Urology

 he Multidisciplinary Challenge of T Prostate Cancer

28 Hospital News

 NC Obstetrics and Gynecology Is in U the News

29 Urology

I mproving Prostate Cancer Mortality in North Carolina

31 Phlebology

What Is Phlebology?

32 News COVER PHOTO: Marc Benevides, M.D. and Stephen Shaban, M.D. discuss clinical operations. Photo by Jim Shaw.

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 elcome to the Area, Upcoming Events W and Clinical Trials


From the Editor

Prostate Health Month hopes to conquer fears T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S

The North Carolina Urological Associates – our cover story this month – is a leader when it comes to providing compassionate, cutting-edge urological care. The practice is comprehensive in its ability to treat the range of urological disorders that affect all ages, male and female. And its approach to treating prostate disorders is of special interest this month. September is Prostate Health Month, as declared by the Prostate Health Council of the American Foundation for Urologic Disease in 1999. Its goal is to heighten awareness of the realities of prostate disease, health and treatment, and the ongoing support of the medical community at-large can help. Thousands of men with prostate problems continue to die each year of fear and embarrassment, or suffer needlessly as a result of ignorance or apathy. The fear is remnant of past generations, when incontinence and impotency complicated treatment. The good news is that today medical advances offer more options in the treatment of prostate disease, without the level of risk that once haunted men in the past. Since early detection is always key, men between the ages of 40 and 70 are advised not to wait until symptoms of prostate cancer appear. Beginning at age 50, men should be screened annually for prostate cancer. African-American men and men with a family history of prostate cancer should be screened annually beginning at age 40. In this issue of The Triangle Physician, numerous contributors openly discuss the many facets of treating prostate cancer. Dr. Hugh Leatherman Jr.’s article sheds light on those who should be biopsied and those who should be treated. Dr. Kevin Khoudary Jr. explores the mystery of one of North Carolina’s scary truths – some counties have the highest death rates in the world for African-American men with prostate cancer. Dr. Scott Sailer discusses the improved precision of radiology and Dr. Cary Robertson offers an overview of the benefits of multidisciplinary treatment protocols. Also, Dr. Andrew Berchuck covers the topic of women’s health in his article on the current state of ovarian cancer. Dr. Lindy McHutchinson reviews the basics of venous disorders and John J. Reidelbach presents part two of his series on medical reimbursement. Finally, check out Durham Regional Hospital’s good news and all the opportunities you can support local charitable events aimed at improving quality of life, such as the Leukemia & Lymphoma Society Light the Night Walk.

Editor Heidi Ketler, APR

heidi@trianglephysician.com

Contributing Editors Andrew Berchuck, M.D.; Kevin Khoudary, M.D.; Hugh K. Leatherman Jr., M.D.; Lindy McHutchinson, M.D.; John J. Reidelbach; Cary Robertson, M.D.; and Scott L. Sailer, M.D. Photography Jim Shaw Photography jimshawphoto@earthlink.net Creative Director Joseph Dally

jdally@newdallydesign.com

Advertising Sales Carolyn Walters carolyn@trianglephysician.com News and Columns Please send to info@trianglephysician.com

The Triangle Physician is published by New Dally Design 9611 Ravenscroft Ln NW, Concord, NC 28027

Subscription Rates: $48.00 per year $6.95 per issue Advertising rates on request Bulk rate postage paid Greensboro, NC 27401 Every precaution is taken to insure the accuracy of the articles published. The Triangle Physician can not be held responsible for the opinions expressed or facts supplied by its authors. Opinion expressed or facts supplied by its authors are not the responsibility of The Triangle Physician. However, The Triangle Physician makes no warrant to the accuracy or reliability of this information.

As always, our gratitude for all you do!

Heidi Ketler Editor

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All advertiser and manufacturer supplied photography will receive no compensation for the use of submitted photography. Any copyrights are waived by the advertiser. No part of this publication can be reproduced or transmitted in any form or by any means without the written permission from The Triangle Physician.


On the Cover

North Carolina Urological Associates Delivers Innovation with Compassion North Carolina Urological Associates was formed in September 1997 with the goal of providing comprehensive urological care to patients in the greater Raleigh area. Since then, North Carolina Urological Associates has been on the leading edge of new urological innovations, while adhering to the traditional values of service and compassion. The formation of North Carolina Urological Associates (NCUA) under the leadership of Douglas C. Leet, M.D., strengthened the practice’s commitment to excellence. Marc D. Benevides, M.D., joined NCUA in 2001; Stephen F. Shaban, M.D., in 2004; Brian C. Bennett, M.D., in 2005; Timothy Bukowski, M.D., in 2009; and Brent A. Sharpe, M.D., in 2010. The physicians of North Carolina Urological Associates care for both adult and pediatric urological disorders. Prostate disease, kidney

stones, infertility, incontinence, bladder disease, hematuria, vasectomy and erectile dysfunction are among the areas of focus for adult patients. Pediatric patients with urinary incontinence, undescended testicles, hydroceles/hernias, hypospadias, kidney stones, vesicoureteral reflux, urinary tract infections and congenital deformations of the genitourinary tract are routinely treated by Dr. Bukowski, a pediatric urologist. North Carolina Urological Associates has offices in Raleigh in the Rex Hospital Medical Office Building and in Cary in the MacGregor Medical Office Building. Both offices offer lab services and state-of-the-art diagnostic equipment. ADULT UROLOGY Urology is a surgical specialty that focuses on the urinary tracts of males and females, and of the male reproductive system. It

is “multidisciplinary” in that it includes management of “medical” (i.e., non-surgical) problems, such as urinary infections, and “surgical” problems, including correction of congenital abnormalities of the urinary/ reproductive systems and the surgical management of cancers involving the urinary and male reproductive organs. “From my perspective, the multidisciplinary approach is what makes this practice so interesting,” says Calvin Cross, MPH, who is NCUA administrator. “We have populations of patients who are followed by our doctors in the office and treated medically, and they may never go to surgery.” Those with benign prostatic hyperplasia, or enlargement of the prostate, and incontinence are among them. Common adult urological problems include infertility, enlargement of the prostate, low

p A pediatric urology patient is content, with parents close by, as Timothy Bukowski, M.D., performs an ultrasound.

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p Brent Sharpe, M.D. and Marc Benevides, M.D. examine a patient X-ray for a renal stone.

testosterone, erectile dysfunction, kidney stones, cancers of the kidney, bladder and prostate, and urinary incontinence. Some common adult conditions are described in greater detail below. INFERTILITY According to the National Institutes of Health, male infertility is involved in approximately 40 percent of the 2.6 million infertile married couples in the United States. One half of these men experience irreversible infertility and cannot father children, and the remaining number of these cases are caused by a treatable medical condition. Infertility is the inability to conceive after at least one year of unprotected intercourse. Since most people are able to conceive within this time, fertility experts recommend that couples unable to do so be assessed for fertility problems. In men, scrotal varicoceles, hormone disorders, reproductive anatomy trauma/infection/obstruction and sexual dysfunction can temporarily or permanently affect sperm quality and interfere with ease of conception.

The sooner the infertility problem is diagnosed, the sooner treatment can begin. However, many people find this a difficult subject to discuss. “One reason people are hesitant to discuss fertility is that social and cultural stigmas are sometimes associated with being infertile. It also often creates problems at home for the couple.” says Dr. Stephen Shaban.

simple intrauterine inseminations or in-vitro fertilization” says Dr. Shaban. He also performs surgical sperm harvesting (also known as TESE, or testicular sperm extraction) for men who choose not to have a vas reversal and for men who have irreversible congenital obstruction. The harvested sperm can then be used in conjunction with IVF-ICSI

Several options, including surgery and radiation therapy, are available to those whose prostate cancer is in the early stages. Hormonal therapy to reduce testosterone levels, surgery to remove the testes or chemotherapy may also be used to treat prostate cancer that has spread. Monitoring the cancer without active treatment may be the preferred approach to avoid the potential for complications. Each option has associated risks. Infertility treatment can be as simple as lifestyle changes. Other infertility treatments include micro-surgical reconstruction of blocked reproduction ducts, microsurgical varicoceles repair and hormone treatment. “In addition, I work closely with the woman’s fertility specialist to coordinate her evaluation, which then might be followed by

(invitro-fertilization-intra cytoplasmic sperm injection) in the female partner. Vasectomy reversals About 500,000 vasectomies are performed annually in the United States, but life has a way of changing and situations, like a remarriage following divorce, may lead to a change of heart about having children. SEPTEMBER 2010

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PHOTO BY JIM SHAW

p Medical assistant Tyhesha Carroll discusses a patient consultation with Marc Benevides, M.D.

A vasectomy is a minor surgical procedure in which the sperm duct, or vas deferens, is cut in order to achieve sterility. Vasectomy reversal restores fertility by reconnecting the ends of the severed vas deferens, which is located in each side of the scrotum, or by connecting the vas deferens to the epididymis, the small organ on the back of the testis, where sperm matures. Restoring the passage for sperm to be ejaculated out the urethra is usually accomplished using a microsurgical technique. With more than 20 years of experience performing vasectomy reversals, Dr. Shaban likely has performed more than any other urological surgeon in North Carolina. His referrals to treat “redo vas reversals” and difficult cases come from around the state. URINARY INCONTINENCE Of all the urologic conditions, those concerning leaking urine are often the most neglected, especially by women – who make up 85 percent of incontinence sufferers. In either gender, the condition appears in various forms, involving various parts of the anatomy (the bladder, urethra and sphincter), as well as the central nervous system, and are triggered by various causes. Stress incontinence is common to women and

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frequently occurs in men who have undergone prostate surgery. Stress incontinence Stress incontinence is an involuntary loss of urine that occurs during physical activity, such as coughing, sneezing, laughing or exercise. In stress incontinence, the sphincter muscle and the pelvic muscles, which support the bladder and urethra, are weakened. It is often seen in women who have had multiple pregnancies and vaginal childbirths, and whose bladder, urethra or rectal wall stick out into the vagina (pelvic prolapse). Today’s most common operations for stress incontinence have roots in the 1900s and address a similar theme: to support the bladder neck and urethral junction so that neither organ sags or leaks. The powerhouse operation to treat incontinence in women is the pubovaginal sling procedure. Secured to the abdominal wall or pelvic bone, the sling – made of synthetic or natural materials – lifts the urethra into a normal position Men also suffer from stress incontinence and approaches to control it date back to early 1900, with the use of internal and external devices to compress the urethra or sphincter. First introduced in 1973, the implanted artificial

sphincter has since been the gold standard for post-prostatectomy patients suffering from incontinence. Today’s model works by keeping the urethra closed until necessary. To empty the bladder, the patient squeezes and releases a scrotum pump, which empties fluid from a sphincter cuff (positioned around the urethra) into a pressureregulating balloon. With pressure relieved from the urethra, urine flows freely. As the bladder empties, the fluid of the balloon automatically moves back into the cuff, squeezing the urethra shut and preventing leaks. “Current minimally invasive options for urinary incontinence are available that result in a decrease in recovery time and pain, and offer immediate continence,” says Dr. Brent Sharpe, whose specializations include laparoscopic and robotic surgery. In the past, men had to wait six weeks before the benefits of surgery. Research at the University of Pittsburgh Medical Center on the effects stem cells can have on the growth of new tissue in denervated rat sphincters holds promise. In the future, it could be possible to rehabilitate “worn-out” sphincters and other organs to restore urologic health without implants, pharmaceuticals or surgery.


Surgery is mainly applied to patients with an incompetent urethra. The vast majority of patients, however, suffer from bladder functionrelated incontinence. For them, medical management using medication is the typical treatment approach.

causes embarrassment; and can diminish selfesteem and quality of life.

and causes an obstruction of urine, making it difficult to empty the bladder completely.

Urologists have medications for both genders to expand urine storage, improve bladder emptying or increase sphincter closure and

BPH is normally initially treated medically. This is done through alpha antagonists, such as Flomax, or alpha-1A reductase inhibitors, such as Proscar and Avodart. Alpha adrenergic blockers, such as tamsulosin, impede prostate and bladder muscle tension to promote better urination. Androgen suppressors, such as finasteride, shrink the prostate by blocking the conversion of testosterone into dihydrotestosterone, a player in BPH.

“Because the entire prostate gland is removed with radical prostatectomy, the major potential benefit of this procedure is a cancer cure in patients for whom the prostate cancer is truly localized.” – Brent A. Sharpe, M.D., North Carolina Urological Associates Overactive bladder In people with an overactive bladder (OAB), the layered, smooth muscle that surrounds the bladder (detrusor muscle) contracts spastically, sometimes without a known cause, which results in sustained, high bladder pressure and the urgent need to urinate (called urgency). Normally, the detrusor muscle contracts and relaxes in response to the volume of urine in the bladder and the initiation of urination.

relaxation. Oxybutynin chloride (Ditropan XL) and tolterodine tartrate (Detrol LA) reduce overactive bladders by blocking acetylcholine, the chemical that causes muscle contractions.

People with OAB often experience urgency at inconvenient and unpredictable times and sometimes lose control before reaching a toilet. Thus, overactive bladder interferes with work, daily routine, intimacy and sexual function;

BENIGN PROSTATIC HYPERPLASIA Benign prostatic hyperplasia (BPH), or enlargement of the prostate, is a common condition in men more than 50 years old. The growing organ compresses the urethra

As medical management of BPH improves, the numbers of TURPs have been decreasing. PHOTO BY JIM SHAW

“As urologists look forward, we anticipate more effective drugs, delivered in patches or implantable devices, such as the bladder pacemaker, to control overactive bladder,” says Dr. Marc Benevides.

If medical treatment does not reduce a patient’s urinary symptoms, transurethral resection of the prostate (TURP) may be considered, following a careful examination of the prostate/ bladder through a cystoscope. As the name indicates, the surgical procedure is performed by visualizing the prostate through the urethra and removing tissue by electrocautery or sharp dissection. It is performed using spinal or general anesthetic. The outcome is considered to be excellent for approximately 90 percent of BPH patients. Because of bleeding risks associated with the surgery, TURP is not considered safe for many patients with cardiac problems.

p CT technician Selena Sepka prepares a patient for a CT. SEPTEMBER 2010

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If TURP is contraindicated a urologist may consider a simple prostatectomy, in and out catheters, or a supra-pubic catheter to help a patient void urine effectively, according to Dr. Sharpe. Urologists have made great inroads to treat BPH in the last century, including perfecting the prostatectomy and developing pharmaceutical aids to help alleviate symptoms. “While medications have drawbacks, attacking the symptoms is the only approach. Prevention will be possible, when scientists find the cause,” says Dr. Benevides. PEDIATRIC UROLOGY Pediatric urology is a surgical subspecialty of medicine dealing with the disorders of children’s genitourinary systems. Pediatric urologists provide care for both boys and girls ranging from birth to early adult age. “The most common problems are anatomically based, and thus are well addressed by surgical correction,” says Dr. Timothy Bukowski. In North America, most pediatric urologists are associated with children’s hospitals. Training for board certification in pediatric urology typically consists of a surgery internship as part of a urology residency, followed by subspecialty research and clinical training in

pediatric urology at a major children’s hospital. Common problems such as hydroceles and hernias or undescended testicles require typically straightforward repairs, while conditions such as hypospadias and intersex problems are wide ranging and, thus, can be quite complex to address. “Many children develop a urinary tract infection early in life, which can lead to a diagnosis of vesicoureteral reflux if proper imaging studies are performed,” says Dr. Bukowski. Reflux is important to find, as it can lead to scarring of the kidneys, if associated with urinary tract infections. Sometimes a p Lab technician Olivia Hedgepeth draws a specimen from a patient. urinary tract obstruction can cause an infection because of poor urinary anesthesia care needs to be “tapered to the drainage. Obstruction can also cause loss of child,” with increased use of child-friendly renal function, even if no infection occurs, Dr. inhalation agents and the liberal use of pain blocks to help minimize postoperative pain. Bukowski explains. Recent

advances

p Lab technician Lareshia Ray examines a specimen through the microscope.

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in the treatment of vesicoureteral reflux and hypospadias repairs have helped to minimize hospital stay and speed recovery for children. Almost 98 percent of surgical procedures on children can be performed in an outpatient setting.

According to Dr. Bukowski, the safety of anesthesia has improved dramatically in the last 15 years, with the advent of monitoring devises, such as the pulse oximeter, which measures oxygen amount in the blood using a small surface probe. “Capnometry, or carbon dioxide monitoring using various devices, has improved evaluation of lung ventilation of gases, and thus, minimizes problems caused by poor ventilation.”

One misconception is that children can be treated like little adults, “but there are special requirements for children, including emotional/parental support, warmer rooms, smaller instruments and, in general, ageappropriate discussion on what is going on in their bodies,” says Dr. Bukowski. Pediatric

REFERRALS ARE WELCOME The physicians and staff of North Carolina Urological Associates are dedicated to the continued expansion of their service-oriented practice and the delivery of cost-effective, patient-centered care to the residents of Wake County and the surrounding area. Appointments may be made Monday through Friday from 8 a.m. to 5 p.m. by calling (919) 851-5482. More information is also available on the NCUA website at: www.ncurology.com.


Advancing the Quality of Life

After Prostate Cancer By Heidi Ketler

Prostate cancer is the most common nonskin malignancy in men and is responsible for more deaths than any other cancer, except for lung cancer. The American Cancer Society estimates that about 218,890 new cases of prostate cancer were diagnosed in the United States during 2007. Slightly more than 1.8 million men in the United States are survivors of prostate cancer. According to the National Cancer Institute, about one man in six will be diagnosed with prostate cancer during his lifetime, but only one man in 34 will die of it. With greater public awareness, early detection is on the rise and mortality rates are declining. Additionally, new advances in medical technology are enabling cancer patients to return to active and productive lives after their treatment. Prostate cancer is a disease in which malignant (cancer) cells form in the tissues of the prostate. The prostate is a gland in the male reproductive system located just below the bladder and in front of the rectum. It is about the size of a walnut and surrounds the urethra (the tube that empties urine from the bladder). The prostate gland produces fluid that is one of the components of semen.

dihydrotestosterone (DHT) by an enzyme in the body. DHT is important for normal prostate growth but also can cause the prostate to get bigger and may play a part in the development of prostate cancer. • Folic acid – A 10-year study showed that the risk of prostate cancer was increased in men who took supplements of folic acid (a nutrient in the vitamin B complex). • Dairy and calcium – A diet high in dairy foods and calcium may cause a small increase in the risk of prostate cancer. “We don’t have hard clinical data, but the suggestion is to avoid obesity,” adds Dr. Sharpe. High-potency antioxidants, like pomegranate juice, and medications Avadart and Proscar also may have preventive benefits. Researchers are rigorously exploring prostate cancer prevention through numerous clinical trials currently under

way. They are listed on the NCI website (www.cancer.gov). TREATMENT OPTIONS Treatment of prostate cancer has come a long way, starting with the revolutionary, nerve-sparing radical prostatectomy that Patrick C. Walsh, M.D., debuted in 1982. By defining the periprostatic anatomy, Dr. Walsh showed surgeons how they could remove the gland to minimize disturbance of the adjacent vessels, nerve bundles and sphincter mechanisms. Prior to that, those with prostate cancer faced an unenviable choice: undergo surgical removal of the gland and surrounding tissue but risk incontinence and impotence, or choose a treatment that spared the complications but didn’t necessarily remove the disease completely.

Prevention “Every man is concerned about reducing their risk of prostate cancer,” says Dr. Brent A. Sharpe, a urologist with North Carolina Urological Associates (NCUA). According to the National Cancer Institute (NCI), those risks include: • Age – Prostate cancer is rare in men younger than 50 years of age. The risk increases as men get older. • Ethnic background – African-American men are more likely to develop prostate cancer and die from it. • Hormones – The main male sex hormone is testosterone, which is changed into

p Stephen Shaban, M.D. confers with medical assistant Frances Emory. SEPTEMBER 2010

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Today, treatment options and prognosis depend on the stage of the cancer, the Gleason score, and the patient’s age and general health. The Gleason score is a system of grading prostate cancer tissue based on how it looks under a microscope. The score ranges from 2 to 10 and represents the likelihood the tumor will spread, with 10 being the greatest likelihood. Several options, including surgery and radiation therapy, are available to those whose prostate cancer is in the early stages. Hormonal therapy to reduce testosterone levels, surgery to remove the testes or chemotherapy may also be used to treat prostate cancer that has spread. Monitoring the cancer without active treatment may be the preferred approach to avoid the potential for complications. Each option has associated risks. SURGERY Surgery to remove the prostate gland is often recommended for prostate cancers that have not spread. The improved ability to prevent nerve damage may significantly minimize the potential side effects of incontinence and impotence. Surgical options include open radical prostatectomy, laparoscopic prostatectomy and robotic-assisted prostatectomy. Traditional prostatectomy Of the 200,000 men newly diagnosed with prostate cancer each year in the United States, about one-third will undergo this surgical treatment in which the cancerous prostate gland and certain surrounding structures are removed. According to the American Urinary Association, 91 percent of prostate cancer diagnoses in the United States are clinically localized (confined to the prostate with no regional lymph node or distant metastasis, also referred to as stages T1 or T2) when first detected. “Because the entire prostate gland is removed with radical prostatectomy, the major potential benefit of this procedure is a cancer cure in patients for whom the prostate cancer is truly localized,” says Dr. Sharpe, whose specializations include laparoscopic and robotic surgery.

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Traditional open urologic surgery – in which large incisions are made to access the pelvic organs – has been the standard approach when surgery is warranted. Common side effects of this procedure include significant blood loss, postsurgical pain, a lengthy recovery and an unpredictable, potentially long-term impact on continence and sexual function. “The vast majority of patients who undergo a radical prostatectomy see a return of urinary continence and sexual function after a recovery period post-surgery, though there is no guarantee that these benefits will apply for every patient. The length of this recovery period depends on a variety of factors and patients should discuss what recovery they should individually expect with their doctor,” says Dr. Sharpe. Laparoscopic and robotic-assisted surgery – with or without robotic assistance is becoming more common. The challenge with laparoscopy alone is its reliance on a two-dimensional surgical camera and rigid instruments, which are not conducive to delicate urological procedures, like prostatectomies. So, few urologists offer it. “Robotic-assisted surgery is ideal for surgery in which millimeters matter,” says Dr. Marc D. Benevides, an NCUA urologist, specializing in robotic surgery. “Nerve fibers and blood vessels are attached to the prostate gland. To spare these nerves, they must be delicately and precisely separated from the prostate before its removal. Robotics gives the surgeon a better tool to spare surrounding nerves, which can enhance patient recovery and clinical outcomes.” A urologist controls the robotic-assisted surgery by manipulating wristed instruments with seven degrees of motion and threedimensional, intuitive visualization. “Robotic surgery dramatically enhances visualization, precision, control and dexterity, and overcomes the limitations of traditional laparoscopic technology,” says Dr. Benevides. While there are no definitive comparative studies to support the benefit of roboticassisted surgery over open surgery, Dr.

Sharpe points to the dramatic increase in the use of robotics to perform prostatectomies. “In 2009, 75 percent of prostate surgery in the United State was done robotically. In 2007, the split was 50-50. So in one year, robotics gained 25 percent, which is to say, it’s a well-established treatment option and not experimental,” Dr. Sharpe says. PENILE REHABILIATION PROTOCOL While recent advances in surgical procedures have reduced complications, there is a continued risk of interference with sexual desire or performance on either a temporary or permanent basis. Research also shows that, at least in the short term, there is no difference in return of erectile function in robotic versus open prostatectomy. “We have probably maximized our surgical approach,” says Dr. Sharpe. “Even with a high degree of magnification, microneural damage at the time of surgery results in a neurapraxia and possibly a secondary myogenic or muscle injury. The problem is, as in any other neuromuscular injury, if the muscle is not rehabilitated after the nerve injury, many times, if not all the time, the muscle undergoes some degree of atrophy and fibrosis.” Several studies indicate that penile rehabilitation using pharmacologic intervention during the recovery phase may be worthwhile in improving the return of erectile function. “The principle of penile rehabilitation is to maintain penile health through various therapeutic options. Erections are induced while the nerve is healing so the erectile tissue and tunica albuguinea will be functional once the nerve integrity returns,” says Dr. Sharpe. It can take the nerve up to 18 months to heal. The protocol for patients concerned about postoperative sexual function begins early after surgery, as soon as the urinary catheter is removed, generally within two to four weeks. The course of action commonly includes: Phosphodiesterase type 5 inhibitors, also known as PDE5, (Viagra, Levitra or Cialis). These agents prevent the breakdown


of cyclic guanosine monophosphate in cavernosal tissue, which plays a role in the prevention of cell death and fibrosis, and may exert a protective effect on cavernosal smooth muscle. Studies have shown that about 20 percent of men respond to such drugs within three months of surgery, while 60 percent respond at approximately 18 months. Penis pump. Using a penis pump may be a good option if erectile dysfunction medications don’t work and penile implant surgery isn’t a good choice. A penis pump may also help maintain penis size after surgery. Alprostadil urethral suppository (Muse). Alprostadil relaxes blood vessels and muscles in the penis. This increases blood flow into the penis, causing an erection. The injectable form of alprostadil is injected into the side of the penis. The transurethral form is a very small suppository (pellet) that is inserted into the urethra. Penile prosthesis. Penile prostheses are devices surgically implanted inside the penis when the erectile dysfunction is unlikely to resolve or improve with other medical treatments. Sometimes a penile prosthesis is implanted during surgery to reconstruct the penis when scarring has caused erections to curve (Peyronie’s disease). Beyond the usual surgical risks, such as infection, satisfaction rates with the prosthesis are very high, with 80 percent to 90 percent of men satisfied with the results. About 90 percent to 95 percent of inflatable prosthesis implants produce erections suitable for intercourse. RADIATION THERAPY Whether radiation is as good as prostate removal is unclear. The decision about which treatment to choose can be difficult. In patients whose health makes surgery too risky, radiation therapy is often the preferred alternative. In men with advanced disease, radiation therapy can help to shrink tumors and relieve pain. Radiation therapy to the prostate gland is either external or internal. Incontinence and impotence are possible side effects.

External beam radiation therapy is done in a radiation oncology center by specially trained radiation oncologists, usually on an outpatient basis. Before treatment, a therapist will mark the part of the body that is to be treated with a special pen. The radiation is delivered to the prostate gland using a device that looks like a normal X-ray machine. External beam radiation therapy is usually done five days a week for six to eight weeks. The treatment itself is generally painless. Prostate brachytherapy, or internal radiation, involves placing radioactive seeds directly into the prostate. A surgeon inserts small needles through the skin behind your scrotum to inject the seeds. The tiny seeds can be temporary or permanent. Because internal radiation therapy is directed to the prostate, it reduces damage to the tissues around the prostate. Prostate brachytherapy may be given for early, slow-growing prostate cancers. It also may be given with external beam radiation therapy for some patients with more advanced cancer. Urinary incontinence is a potential complication after radiation therapy. MEDICATIONS Because prostate tumors require testosterone to grow, reducing the testosterone level using medications (hormone manipulation) often works to prevent further growth and the spread of the cancer. Hormone manipulation is used mainly to relieve symptoms in men whose cancer has spread. (It may also be done by surgically removing the testes, a procedure called orchiectomy.) Possible medication side effects include osteoporosis, reduced sexual desire, impotence and erectile dysfunction. Drugs are used to temporarily shut down the production of testosterone, such as Lupron and Zoladex, are often called chemical castration, because they have the same result as surgical removal of the testes. However, unlike surgery, it is reversible. The drugs must be given by injection, usually every three to six months. Other medications used for hormonal therapy include androgenblocking drugs (flutamide), which prevent

testosterone from attaching to prostate cells. Chemotherapy is often used to treat prostate cancers that are resistant to hormonal treatments. An oncology specialist will usually recommend a single drug or a combination of drugs. After the first round of chemotherapy, most men receive further doses on an outpatient basis. Side effects depend on the drug, and how often and how long it is taken. They include blood clots, fluid retention, hair loss, low blood-cell count and weight gain. MONITORING Monitoring to ensure the cancer does not spread may be advised. “This option is always presented to a patient,” says Dr. Sharpe. “Our philosophy is to present all options to the patient. Watchful waiting is a reasonable option and well studied and also what I consider for low-risk, low-volume, clinically localized prostate cancer.” Typically, this protocol involves routine doctor check-ups and may include: • Serial PSA blood test (usually every three months to one year). • Bone scan or CT scan to check whether the cancer has spread. • Complete blood count (CBC) to monitor for signs and symptoms of anemia. • Monitoring for other signs and symptoms, such as fatigue, weight loss, increased pain, decreased bowel and bladder function, and weakness. “The appropriate treatment for prostate cancer is not clear. The key is that patients with prostate cancer talk openly with their urologist about reasonable expectations for recovery,” says Dr. Benevides. Appointments may be made with North Carolina Urological Associates, Monday through Friday from 8 a.m. to 5 p.m. by calling (919) 851-5482. More information is also available on the NCUA website at: www.ncurology.com.

SEPTEMBER 2010

13


SPECIALISTS IN UROLOGIC CARE

The six urologists with North Carolina Urological Associates treat all urological conditions within general urology, adult urology or pediatric urology, and have advanced training in subspecialty areas.

Marc D. Benevides, M.D. Education Undergraduate School - University of North Carolina Medical School - University of North Carolina School of Medicine Internship, Urology - University of North Carolina, Department of Surgery Residency, General Surgery and Urology University of North Carolina, Department of Surgery Memberships Board Certified, American Board of Urology North Carolina Medical Society Specialization Adult urology Robotic surgery Laparoscopic surgery

Brian C. Bennett, M.D. Education Undergraduate School - The Pennsylvania State University Medical School - Vanderbilt University School of Medicine Internship - University of Pittsburgh Medical Center Residency, General Surgery and Urology - University of Pittsburgh Medical Center, Department of Surgery Memberships Board Certified, American Board of Urology North Carolina Medical Society Wake County Medical Society American Urological Association Southeast Section, American Urological Association Specialization Adult urology General urology Urologic cancers Incontinence Renal stones Erectile dysfunction

Timothy Bukowski, M.D.

Stephen F. Shaban, M.D.

Education Undergraduate School - Georgetown University Medical School - State University of New York at Buffalo School of Medicine Internship - General Surgery, Wayne State University School of Medicine Residency, Urology - Wayne State University School of Medicine Research Fellowship, Pediatric Urology University of Cincinnati College of Medicine Clinical Fellowship, Pediatric Urology - Children’s Hospital of Michigan Associate Clinical Professor, Urology - University of North Carolina at Chapel Hill

Education Undergraduate School - University of Pittsburgh Medical School - Mount Sinai School of Medicine Internship, General Surgery - University of South Florida Hospitals Residency, Urology - University of South Florida Hospitals Fellowship, Male Reproductive Medicine and Microsurgery - Baylor College of Medicine

Memberships Board Certified, American Board of Urology Specialty Certificate in Pediatric Urology, American Board of Urology Fellow, American College of Surgeons Fellow, American Academy of Pediatrics, Section on Urology Fellow, Society of Pediatric Urology Southeastern Section, American Urologic Association American Urologic Association Society of Fetal Urology Society for Urology and Engineering Inc. International Fetal Medicine and Surgery Society North Carolina Pediatric Society Board Member, North Carolina Pediatric Society Foundation Specialization Pediatric urology General urology

Douglas C. Leet, M.D. Education Undergraduate School, Michigan State University Medical School - University of Chicago, Pritzker School of Medicine Internship - General Surgery, University of North Carolina at Chapel Hill Residency - Urology, University of North Carolina at Chapel Hill Memberships Board Certified, American Board of Urology Fellow, American Fertility Society Fellow, American Cancer Society (1978) Fellow, Genitourinary Reconstruction Society North Carolina Medical Society Wake County Medical Society Raleigh Academy of Medicine Womach Surgical Society American Urological Association Southeastern Section, American Urological Association American Lithotripsy Society Specialization Adult urology General urology Incontinence

14

The Triangle Physician

Memberships Board Certified, American Board of Urology American Urological Association Society for the Study of Male Reproduction (past chairman, Strategic Planning Committee) Society for Male Reproduction and Urology (past member, Executive Committee) American Society for Reproductive Medicine American Society of Andrology Carolina Urological Association (past president) North Carolina Urological Association Southeastern Section, American Urological Association Durham-Orange County Medical Society (past president) Specialization Adult urology Infertility Vasectomy reversal Erectile dysfunction Laser surgery

Brent A. Sharpe, M.D. Education Undergraduate School - University of North Carolina at Charlotte Medical School - East Carolina University School of Medicine Internship, Surgery - Texas Tech University Residency, Urology - Emory University Memberships Board Certified, American Board of Urology Specialization Adult urology General urology Prostate cancer Erectile dysfunction Laparoscopic and robotic surgery


Community Outreach

Illuminated Night Walk Raises Funds, Sheds Light on

Leukemia and Lymphoma As many as 3,000 are expected to participate in the 12th annual Light the Night Walk in Raleigh Saturday, Oct. 9 at Halifax Mall. Approximately 500 are expected for 10th annual Greensboro walk Saturday, Oct. 9 at Country Park. Another 1,000 will join the fourth annual walk in Durham Thursday, Oct. 21 at the American Tobacco Campus. Light the Night is the Leukemia & Lymphoma Society’s (LLS) signature fund-raising campaign to celebrate cancer survivorship and commemorate lives touched by cancer. Proceeds support the LLS mission to cure leukemia, lymphoma, Hodgkin’s disease and myeloma, and improve the quality of life of patients and their families. Since the first funding in 1954, LLS has awarded more than $680 million in blood cancer research funding.

LOCAL IMPACT Last year, Light the Night Walks raised $439,000 in eastern North Carolina. The North Carolina Chapter of LLS raises approximately $4 million annually, according to Emily Blust, special events director. With these proceeds, the chapter is funding 16 active research projects at Duke University and the University of North Carolina-Chapel Hill totaling $6.5 million. Both institutions are sponsors of the Light the Night Walks. The North Carolina LLS chapter also funds patient services, such as free educational materials, support groups and peer counseling. “So, essentially 100 percent of what we raise benefits our local community,” Blust said.

p Kevin Penn and Family

HUMAN FACES There were an estimated 3,770 new cases of blood cancers in North Carolina in 2009. Nationally, there are nearly 1 million Americans living with a blood cancer. There is a new diagnosis every four minutes and someone dies of the disease every 10 minutes. Every year, Honored Heroes of the Light the Night Walks give the fund-raising efforts a human face. This year, five-year-old Lena

p Lena Thompson

SEPTEMBER 2010

15


Thompson, five-year-old Karson Dickens and 38-year-old Kevin Penn are the Honored Heroes for the Durham, Greensboro and Raleigh walks, respectively. Lena was diagnosed with acute lymphocyte leukemia when she was two years old. Today, she is at the halfway point of her chemotherapy and is in the long-term maintenance phase. Karson was diagnosed with acute lymphoblastic leukemia on April 27, 2009. She received chemotherapy and about a month later the cancer went into remission. Karson will receive maintenance therapy through summer 2011. Kevin was diagnosed soon after his 37th p Karson Dickens birthday with acute myelogenous leukemia. After intensive chemotherapy for six months, the cancer went into remission, only to relapse within a few months after treatment. Kevin was matched for a bone marrow transplant, and his cancer has been in remission since then. Members of the medical community are expected to be among the walkers, including 19 from Family Medical Associates of Raleigh, which is participating for the first time. The walk is the inaugural activity of the practice’s community outreach committee. “A couple of people within the committee have a personal connection to (blood cancers),” said team captain Carlyn Brown, Family Medical Associates medical assistant and clinical research coordinator. Brown first walked in Light the Night several years ago. CASUAL FITNESS EVENT This casual walk has no fitness requirements and all are welcome to participate. Participants who help further the LLS mission by raising $100 or more will become Champions for Cures. Champions for Cures help light the night with hope by carrying illuminated balloons: red for supporters, white for survivors and gold for teams walking in memory of a loved one lost. Five Night Walks are being coordinated across the state: • Winston Salem – Sept. 25, Salem College • Raleigh – Oct. 9, Halifax Mall • Greensboro – Oct. 9, Country Park • Charlotte – Oct. 16, Symphony Park • Durham – Oct. 21, American Tobacco Campus LLS is one of the only voluntary health organizations to offer direct patient financial aid. A small stipend is available annually to anyone diagnosed with a blood cancer. In addition, the Leukemia & Lymphoma Society’s Co-Pay Assistance Program offers financial

16

The Triangle Physician

support toward the cost of insurance co-payments and/or insurance premium costs for prescription drugs. For more information on Light the Night Walk or to register, visit www.lightthenight.org/nc. For more information about any of the LLS patient services, visit www.lls.org or call (800) 955-4572.


Triangle Neurosurgery, PA A Complete Spine Care Center Triangle Neurosurgery provides a unique blend of personalized attention to each patient with the latest advancements in state of the art technology. This results in compassionate and comprehensive care delivered through conservative management or surgery. Our emphasis is patient centered and we recognize the importance of helping patients return to an active and healthy lifestyle.

Dr. Dennis E. Bullard MD, FACS is a Board

in cervical spine surgery. He has been

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honored with the Patients’ Choice Award

in the American College of Surgeons. He is a

and has been elected continuously to the

neurosurgeon who has been practicing for

lists of America’s Top Rate Physicians and

28 years and is always striving for the most

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current and effective care for his patients.

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Urology

Prostate Cancer Who Needs to be Screened and Treated By Hugh K. Leatherman Jr., M.D.

The prostate gland is normally the size of a walnut and is located at the base of the bladder and in front of the rectum. The urethra (the water channel through the penis) passes through the center of the prostate. The prostate is a reproductive organ that supplies nutrients and enzymes to the semen to enable the sperm “to do their thing.� Other than skin cancer, prostate cancer is the most common cancer of men in the

18

The Triangle Physician

United States, with about 220,000 new cases diagnosed each year. It accounts for about 35,000 deaths per year, or about 12 percent of all male cancer related deaths. No one knows exactly what causes prostate cancer, but we do know that prostate cells have to be exposed to the male hormone testosterone for a man to develop prostate cancer. There are some definite risk factors related to the development of prostate cancer.

Advancing age is the strongest risk factor. Race, with African-American males at higher risk, family history of prostate cancer, obesity and a high-fat diet are just some other possible risk factors. Screening for prostate cancer increased dramatically starting in the early 1990s, with the discovery of the prostate-specific antigen (PSA), a protein produced by prostate cells. Screening consists of PSA determination


Dr. Hugh K. Leatherman Jr.’s private practice, Capital Urological Associates, has been in existence since 1986. He earned his undergraduate degree from North Carolina State University and his medical degree from the Medical University of South Carolina. He completed general surgery and urology residencies at the University of North Carolina Memorial Hospital and served as chief urology resident in 1986.

and digital rectal exam. Of note is that the PSA is not infallible and there are many instances of false positives. Subsequently, some men without prostate cancer will undergo needless biopsies with possible attendant complications. False positives can be associated with benign enlargement of the prostate, infection, recent transurethral surgery or even infarction of the prostate.

Generally, if a man’s PSA increases more than .75 during a 12-month period, this should be a red flag. Who should receive a biopsy? So, which men should be biopsied? Those with a life expectancy of greater than five years with one of the following criteria: • Those with an abnormal absolute PSA greater than 4 when no other cause for the elevation can be found, • Those with a prostate nodule, and/or • Those with a PSA velocity of greater than .75 in a 12-month period. Who needs to be treated and how? OK. Now the diagnosis of prostate cancer has been made. Who needs to be treated and which treatment modality is best? This is the tough question. Generally treatment depends on the patient’s age, general health, Gleason score, PSA value and stage of the cancer. The Gleason score is the tumor grade determined by the pathology

Successful treatment outcomes are better for patients with Gleason scores of less than 7, stage T2a or less and a PSA of less than 10. Who should be screened? Remember, there are no symptoms of early prostate cancer, so do all men need to be screened? Men between the ages of 80 and 85 without a strong family history or men with a life expectancy of less than five years due to other medical issues, regardless of age, likely do not need to be screened. At what age should screening begin? Men with multiple risk factors, as stated above, should start screening at age 40. All other men should start screening between ages 45 and 50.

exam of the biopsy material. The Gleason score runs from 2 to 10, with 2 being the least and 10 being the most aggressive tumors. A Gleason score of 6 is the most commonly reported. Prostate cancer stage is from T1 (least advanced) to T4 (most advanced). T1c is the most common presenting clinical stage, which means the cancer was discovered because PSA issues prompted the biopsy. Successful treatment outcomes are better for patients with Gleason scores of less than 7, stage T2a or less and a PSA of less than 10.

It is generally known that the normal range for PSA is 0 to 4. Although a patient’s PSA may fall into that “normal range,” one important consideration is the PSA velocity, which is the rate of change over a certain period of time.

Treatment options include watchful waiting, also known as active surveillance; cryosurgery; high-intensity focused ultrasound; one of several types of external beam radiation therapy; brachytherapy

(radioactive seed implant); radical prostatectomy, hormone therapy alone; or some combination of the above. If watchful waiting is chosen, it is very important that the patient be compliant and have periodic PSA determinations to look at the velocity and PSA doubling time. PSA doubling times of less than six to 12 months are very worrisome. Also as relates to watchful waiting, periodic repeat prostate biopsies may be recommended to look for increasing Gleason scores. As relates to all other interventional treatments, there are different success rates and complications involved with each one. Obviously, it is beyond the scope of this article to go through all of these in detail. Suffice it to say that the tried-and-true treatments for organ-confined prostate cancer historically have either centered around some type of radiation therapy or radical prostatectomy. Once a diagnosis has been made, the patient and family should sit down with his urologist, and if need be, a radiation oncologist to have an open and thorough discussion about all treatment options. One should be wary of a practitioner who only wants to give information or strongly recommends only one type of therapy. Prostate cancer is a complex issue, and the patient deserves to be apprised of all options.

SEPTEMBER 2010

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Business Management This is the second in a two-part series.

Reimbursement Analysis Establishes

True Cost

Per Relative Value Unit

By John J. Reidelbach

Performing a reimbursement analysis in a practice can be an extremely valuable process that should be performed at least every two years. In my last article, we discussed the importance of making certain that contracted reimbursement with payers is contractually correct. More importantly, we need to understand whether or not the rate of reimbursement covers the cost to provide medical services for your patients. In establishing the true cost per Relative Value Unit (RVU), the standard we will use, one must calculate the total RVUs for the practice to determine the payment per RVU as show below.

Charge

rate. As in the example Payer 1 is, by far, the most utilized payer in this example. Payer 2 provides 90 percent less volume to the practice yet the practice is being reimbursed 5 percent less for the same services. With this information in hand, a practice should try to renegotiate a higher reimbursement from Payer 2. After determining the per RVU reimbursement and whether or not rates of reimbursement are satisfactory to cover all costs of the practice, we must determine the

Paid

Accounts Receivable

Reimbursement

any expense item or multiple expense line items. As you can see from this example, the cost per RVU to the practice, based on the current year, is $50 per RVU. When comparing the cost per RVU against the reimbursement per RVU, one can see that Payers 1, 2, 6 and 7 are reimbursing at a lower rate than the cost per RVU. Given this information, it allows the practice to see where negotiation opportunities are based on the contracts they hold.

RVU Total

Reimb/ RVU

% of Medicare

Payer 1

$10,505,999

$2,123,956

$46,393

$2,158,751

50,914

$42

117

Payer 2

$1,620,734

$314,062

$24,263

$332,259

8,211

$40

112

Payer 3

$1,273,511

$657,632

$54,696

$698,654

5,286

$132

365

Payer 4

$1,123,253

$340,160

$4,505

$343,539

5,479

$63

173

$84

233

Payer 5

$1,064,609

$459,120

$7,597

$464,818

5,501

Payer 6

$926,276

$180,664

$22,216

$197,326

4,209

$47

130

Payer 7

$407,961

$88,499

$3,056

$90,792

1,979

$46

127

Payer 8

$394,934

$115,807

$3,943

$118,764

2,008

$59

163

Payer 9

$290,950

$84,315

$2,936

$86,517

1,377

$63

174

Payer 10

$268,298

$98,581

$1,006

$99,335

1,346

$74

204

$17,876,526

$4,462,795

$170,612

$4,590,754

86,309

$65

180

Total FIG 1

As you can see from the above example (Fig 1), the reimbursement per RVU varies from $40 to $132 per RVU, with an average per RVU reimbursement of $65. As discussed in the previous issue, it is not uncommon for smaller payers to reimburse at a lower

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The Triangle Physician

cost per RVU to the practice. This is done in a similar manner as in the table above. The table on the next page (Fig. 2) is a general example of cost per RVU. A practice can break down the cost per RVU based on

When reviewing this type information one must be realistic in the approach. For example, if the practice is exceeding capacity in the schedule, i.e., new patient visits are six to eight weeks out, this would indicate opportunity for renegotiations.


John Reidelbach’s career in health care spans more than 20 years and all facets of administration within physician practices, hospitals and large health care insurers. He founded Physician Advocates Inc. in 1996. Today, he assists health care entities in all aspects of practice management, operation, strategic development and implementation, education, contract negotiations, data analysis and capital funding. His credentials include degrees in engineering and education, and a master’s in business administration. Mr. Reidelbach has designed several health care management entities, including independent physician associations, physician practice management companies, management service organizations and group practices. His experience includes developing equity ownership structures, financial incentives, network administration, and information systems selection and implementation. He also has developed detailed analysis tools for health care providers and product vendors. Mr. Reidelbach can be reached in North Carolina at (919) 321-1656 or in Atlanta at (404) 664-9060; and by e-mail to info@mdpracticeadvice.com.

In developing a strategy for negotiations, the best approach would be to start a dialogue with the payer that would have the least impact to the practice in the event negotiations are not beneficial to the practice. Starting with Payer 7, this only represents 2 percent capacity with the practice. In the event Payer 7 is unwilling to renegotiate, the practice may want to eventually withdraw as a par practice. This would have a minimal impact to revenues, as well as open new patient visits for better reimbursing payers.

Total Expense

RVU Value

Overhead

$2,677,677

$31

Physician Expenses

$1,673,548

$19

$111,570

$1

Net Profit/Loss

is much more information that can be gained from a reimbursement analysis, such as physician production comparisons, reimbursement values as compared to surgical and non-surgical procedures, and assistance in determining growth of the practice as it relates to new providers and ancillary opportunities or whether or not to participate with certain insurance carriers. The simple examples given here only provide a few of the benefits of a reimbursement analysis. There are numerous other benefits once one undertakes this process with their practice.

FIG 2 Performing a reimbursement analysis in a practice can be an extremely valuable process that should be performed at least every two years. Reimbursement analyses also will assist a practice in making certain that contracted rates are being paid as agreed. There

SEPTEMBER 2010

21


Gynecology

Ovarian Cancer

By Andrew Berchuck, M.D.

State of the Art in 2010

Women are living longer, but the mortality rate remains high and has improved only slightly. The lack of effective early detection is a significant obstacle. Ovarian cancer is the fifth leading cause of cancer deaths in women in the United States and 22,000 cases are diagnosed annually. This disease represents the greatest challenge to those of us who practice gynecologic oncology.

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The Triangle Physician

Women are living longer, but the mortality rate remains high and has improved only slightly. The lack of effective early detection is a significant obstacle. Possible detection methods include vaginal ultrasound and testing for the blood marker CA-125. Because these tests have not yet been proven to reduce

the number of women dying from ovarian cancer, they are not used for population screening. An additional concern is that screening tests can result in many false-positive results that lead to additional testing and surgeries, even


Dr. Andrew Berchuck is director of the Duke University Medical Center Division of Gynecologic Oncology and co-director of the breast/ovarian cancer program in the Comprehensive Cancer Center. He is actively involved in caring for women with gynecologic cancers on a daily basis, while also leading a nationally recognized program in translational ovarian cancer research. He holds the Barbara Thomason Ovarian Cancer Professorship from the American Cancer Society and has served as president of the national Society of Gynecologic Oncologists.

when cancer is not present. A large ongoing screening trial in the United Kingdom, to be complete in 2014, is evaluating whether monitoring CA-125 trends over time can improve the ability to catch ovarian cancer earlier – and reduce deaths. Known as “the disease that whispers,” ovarian cancer usually produces few symptoms in the early stages. The symptoms that do eventually appear – abdominal pain and distention, gastrointestinal symptoms, and urinary symptoms – are non-specific. Too often women are told they have irritable bowel syndrome or are put through a gauntlet of tests that target everything but ovarian cancer. Practitioners should have ovarian cancer more in mind when those sorts of symptoms occur. Women who present with concerning symptoms should have a pelvic exam and ultrasound to look for a mass or ascites, as well as a CA-125 blood test. These diagnostic tests represent appropriate medical evaluation when concerning symptoms are present.

Sequencing of the genes can be done when appropriate to determine whether there is a mutation. In view of the lack of effective screening, mutation carriers are strongly advised to undergo prophylactic removal of the fallopian tubes and ovaries after child bearing is completed. This can usually be accomplished using laparoscopic techniques with excellent cosmetic results. The cause of most ovarian cancers remains poorly understood, but it is clear that risk is reduced by exposures that reduce ovulation, such as pregnancy and oral contraceptive pill use. Women who have three children or use the pill for more than five years have about a 50 percent decreased risk. This noncontraceptive benefit of the pill is not widely appreciated. Tubal ligation and hysterectomy are also protective, while endometriosis and infertility increase risk. Women with known or suspected ovarian cancer ideally should be referred to gynecologic oncologists for their special expertise and training in managing this disease. The practice of gynecologic oncology encompasses the comprehensive treatment of women with ovarian cancer, including surgery, chemotherapy, follow-up care and issues related to end of life and survivorship. Surgical management involves optimal resection of the primary cancer and metastatic disease in the abdomen, because survival is longer if most or all of the visible cancer is removed. Patients treated in university-based gynecologic oncology programs also benefit

from the availability of clinical trials that test cutting-edge therapies aimed to improve outcomes. They also are surrounded by a supportive environment and care team that includes nurses and social workers. Gynecologic oncologists are involved in both the surgical management and the chemotherapy treatment of ovarian cancer. Platin and taxane drugs are the most active agents. About 75 percent of patients initially achieve a clinical complete remission, but in most cases the disease recurs. Some studies have suggested an advantage to administering chemotherapy directly into the peritoneal cavity, and this has become one of the standard options for treatment. As we learn more about ovarian cancer at the molecular level, hopefully, this knowledge can be used to develop novel biological therapies that will allow a higher fraction of patients to be cured. One targeted agent that inhibits the development of new blood vessels in tumors (bevicizumab) already has shown some positive effects in ovarian cancer and is being incorporated into first-line chemotherapy trials. Although most patients with advanced ovarian cancer are not cured, contemporary therapy has prolonged the duration and quality of life. Further advances in early detection, treatment and prevention are needed in the future to decrease ovarian cancer mortality.

About 10 percent of ovarian cancers develop in women with inherited mutations in either the BRCA1 or BRCA2 genes. Families with these mutations often exhibit striking numbers of breast and ovarian cancer cases at a young age. The risk of ovarian cancer is about 4 percent in women with BRCA1 and 20 percent with BRCA2. Women with a significant family history of ovarian and breast cancer should be referred to a cancer genetic counselor for genetic-risk assessment.

SEPTEMBER 2010

23


Urology

Greater Precision Makes

Radiation a

Strong Prostate Cancer Treatment Option By Scott L. Sailer, M.D.

The newest advance is image-guided radiation therapy (IGRT), which enables ultra-precise alignment of radiation beams to within 2 millimeters or 3 millimeters or less of the tumor. In prostate cancer, the position of the tumor can change slightly day to day, and IGRT gives us the precision to minimize these changes, helping lower complication rates.

P

rostate cancer is among the most common malignancies affecting men, and it is very curable. This is borne out by statistics from the American Cancer Society, which estimates that two million men living today in the United States have had prostate cancer at some point. The two widely accepted curative therapies for prostate cancer are surgery and radiation, either external radiation or, for certain patients, internal. In addition, for a subset of low-risk patients, another choice is to receive no therapy at all, but rather to have active surveillance that closely and actively monitors the status of the disease. Recently, the National Comprehensive Cancer Network urged physicians to increasingly offer active surveillance to patients whose prostate cancers are at low risk of becoming life threatening. The selection of one course over another is based on age, overall health and how far the disease has progressed. For certain men who need to be treated, this will come down to a choice between surgery and radiation. In consultation with patients, surgery may be the appropriate recommendation, in particular for healthy men in their 50s and 60s. For others, for a broad range of reasons,

24

The Triangle Physician

surgery is not the best option. For men between the ages of 60 and 70, radiation may be recommended because of other health

concerns. And generally, for men 70 and over, age makes radiation the appropriate recommendation.


Dr. Scott Sailer is co-medical director of Wake Radiology Oncology Services in Cary. He can be reached at (919) 854-4588 or info@ wakeoncology.com.

The good news is that radiation therapy has continued to improve over the past decade and a half. Important innovations have increased the accuracy of delivered treatment and have decreased the amount of radiation dose to normal tissue.

beam radiation therapy and brachytherapy or with external beam radiation therapy only. For these patients, hormonal therapy is often added to radiation.

typically they are 60 or older. In general, they have a Gleason score of 6 or under, a low prostate-specific antigen (PSA) level, and only minimal involvement on biopsy.

In substantive ways, including side effects, surgery and radiation differ. But it is notable that outcomes after 10 to 15 years appear equivalent.

Active-surveillance patients typically get PSA tests several times a year and are biopsied every one or two years to check whether the disease is staying the same or is progressing. For a particular group of men, active surveillance is an important third option, because many prostate cancers are not aggressive and are unlikely to cause harm.

There is a third choice for certain very low-risk patients: active surveillance. Candidates for active surveillance may be any age, although

These improvements began with the introduction of three-dimensional conformal treatment, an advance in external beam therapy that shaped the radiation beams to match the contours of the target. This was followed by intensity-modulated radiation therapy (IMRT), a more elaborate version of conformal therapy that wraps the dose around the prostate very tightly and further decreases the dose to surrounding tissue. IMRT has allowed us to safely increase the dose of radiation, helping to increase the chances for cure and complete recovery. The newest advance is image-guided radiation therapy (IGRT), which enables ultra-precise alignment of radiation beams to within 2 millimeters or 3 millimeters or less of the tumor. In prostate cancer, the position of the tumor can change slightly day to day, and IGRT gives us the precision to minimize these changes, helping lower complication rates. All patients can be treated with external beam radiation therapy that typically is given five days a week for seven to eight weeks. In contrast, brachytherapy, an internal radiation treatment that can be used for patients with early-stage cancers, delivers radiation in a single visit by permanently implanting radioactive seeds. These deliver their radiation over several months. Patients with more unfavorable cancers can be treated with a combination of external Womens Wellness half vertical.indd 1

12/21/2009 4:29:23 PM

SEPTEMBER 2010

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Urology

The Multidisciplinary Challenge

Prostate Cancer By Cary Robertson, M.D.

S

ince the early 1900s radical prostatectomy has been recognized as the “gold standard” of prostate cancer treatment. Refinements have rendered this approach applicable to a wide variety of patients with various stages of prostate cancer, ranging from minimally detected low-grade tumors to locally advanced tumors with significant metastatic potential. Identification of important anatomic landmarks, such as prostatic neurovascular bundle interfaces, have permitted an evolution of technical dissection within the past decade that has increased functionality for the post-operative patient to previously unachievable levels. Incontinence and erectile function may be avoided in the majority of patients undergoing nervesparing anatomical radical prostatectomy. This may be achieved with a standard open technique using a small lower midline abdominal incision or with a laparoscopic technique using robotic assistance. Either technique is acceptable and has unique features that may be applied in patient selection dependent on tumor characteristics and patient body habitus. Prior abdominal surgery is a relative contraindication to the laparoscopic technique. Comparison studies of the two techniques suggest equivalence in cancer control in intermediate or low-grade tumors. Aggressive tumors may be more suited to the open technique, which allows for a wide margin of resection, as well as a simultaneous extended pelvic node dissection. Studies have also shown a correlation between increasing annual surgical volume and decreasing surgical morbidity, therefore it is recommended that radical prostatectomy be performed by surgeons with a specialized interest in this treatment. For patients with high-grade tumor pathology and increased risk for extra capsular extension or nodal involvement, multimodal therapy is

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The Triangle Physician

recommended. This may be in the context of a peri-operative clinical trial, utilizing chemohormonal therapy and/or radiation therapy. A multidisciplinary clinic is an excellent setting to discuss individual patients and to offer participation in clinical trials. Since 2005, the Duke Prostate Center Multi-Disciplinary Genitourinary Clinic has offered simultaneous consultation with physician and nurse clinician specialists in genitourinary medical oncology, radiation oncology and urologic surgery for patients desiring a focused discussion of recently diagnosed prostate cancer. Patients are seen over a two-hour period and undergo in-depth assessment in a standardized format, including group discussion by physicians concerning treatment recommendations. Immediate or delayed decision making allows for a customized approach to each patient. Patient satisfaction has been very high with this approach. This format also fosters collegiality and updating between specialists in current advances in therapeutic approaches. It is very important to recognize that alternatives to surgery are available to patients and this may include active surveillance, radiation therapy, cryotherapy or participation in novel-technique trials, such as high-intensity focused ultrasound (HIFU) or combined radiation therapy/ surgery. These alternatives are a key feature of the multidisciplinary clinic experience. Radiation therapy for localized prostate cancer at Duke is now incorporating GPS (global position system) technology for position tracking and is being tested in clinical trials of short-course one-week therapies versus traditional six-week therapies. Combining external beam radiation therapy with surgery in high-risk patients is employed in preoperative patients selected for clinical trials or more traditionally as an adjuvant to surgery. Primary treatment with

Dr. Cary Robertson is associate professor of urology at the Duke University Department of Surgery, specializing in urologic oncology. A medical graduate of Tulane Medical School, Dr. Robertson served in the National Health Service Corps, a program of the United States Public Health Service, from 1977 to 1980 and completed training in urology at Duke University in 1985. After completing a urologic oncology fellowship at National Cancer Institute/National Institutes of Health, he served as a senior investigator there from 1987-1988. Dr. Robertson joined the Duke faculty in 1988. He is currently a member of the Duke Comprehensive Cancer Center and the Duke Prostate Center. As an experienced radical prostatectomy surgeon, he has incorporated robotic techniques into the surgical management of prostate cancer. As national coordinating principal investigator for the North American Ablatherm highintensity focused ultrasound (HIFU) clinical trial, he has pioneered this novel therapy for prostate cancer at Duke. Currently serving as director of the Morris Center for Urologic Research, Dr. Robertson supports basic research in prostate cancer. Combined HIFU and immunotherapy is under study in collaboration with the Department of Biomedical Engineering at Duke University. As a co-founder of the Duke Prostate Center Multi-Disciplinary Genitourinary Clinic, Dr. Robertson consults with colleagues on an ongoing basis. He has served as director of the annual Duke Prostate Center prostate cancer screening clinic since 1990. He is a member of the Society of Urologic Oncology, American Urological Association, American College of Surgeons, American Society of Clinical Oncology and American Medical Association. Referral to the multidisciplinary genitourinary clinic may be completed online at www. healthview.dukehealth.org and selecting “Request An Appointment” or by calling (919) 668-8108.

radioactive seed implants (brachytherapy) or with external beam technology is offered to patients who are clinically suitable or desire a non-surgical therapy. Radiation therapy is a cornerstone therapy for prostate cancer and is an essential component of any multidisciplinary approach. Cryotherapy is an approved therapy for prostate cancer that is ultrasound guided and delivered by percutaneous needles placed within prostate tissue. This minimally invasive treatment is well tolerated and effective. Recently, a randomized clinical trial comparing cryotherapy to radiation therapy demonstrated similar outcomes in localized prostate cancer patients. There is a higher incidence of erectile dysfunction with cryotherapy, limiting its acceptance by patients. However, focal strategies


are developing using this approach with favorable functional results. The role for focal therapy with intentional partial treatment of the prostate is to date undefined and a topic of intense interest. Recently, clinical trials at Duke have featured high-intensity focused ultrasound therapy for low-grade low-stage prostate cancer patients. This approach offers the advantage of ultrasound-guided thermal ablation of prostate tissue with a precision that allows avoidance of vital structures adjacent to the prostate. Widely available in Europe, this technology is limited to small prostate size, but appears to be very effective in ablating cancerous tissue. Although currently not approved by the United States Food and Drug Administration, this approach may be used in combination with other modalities (chemotherapy, biologic therapy) in future clinical trials. It also may be tested as a salvage therapy for recurrent prostate cancer or as a focal strategy in future clinical trials. Effective prostate cancer management requires not only immediate care but longterm commitment. This includes longterm care with survivorship clinics and specialized approaches to any functionality issues. This personalized medicine from a decision-making standpoint, as well as a therapeutic approach, is reflective of the dedication of Duke Medicine to prostate cancer management in 2010. In summary, prostate cancer is a modern therapeutic challenge. Therapy is evolving at a rapid pace. Emerging technologies for ablation of prostate tissue (focal cryotherapy, HIFU) are challenging conventional wisdom about prostate cancer management. New agents for biologic and chemotherapy are also available. Guidance for prostate cancer patients is best achieved in a multidisciplinary setting. The Duke Prostate Center Multi-Disciplinary Genitourinary Clinic is specifically designed to meet these challenges. The Duke University Health System, Duke Cancer Institute and Duke Prostate Center stand ready to meet the needs of each and every prostate cancer patient.

North Carolina Urological Associates Welcomes to the practice

Brent A. Sharpe, MD Treating all urological conditions and specializing in Minimally-Invasive Laparoscopic and Robotic Urological Surgery ∙ Prostate Cancer ∙ Erectile Dysfunction ∙ Urinary Incontinence ∙ BPH ∙ Pelvic Organ Prolapse ∙ Kidney Stones

Dr. Sharpe completed his residency at Emory University and moved to north Alabama where he started the areas first robotic surgery program and expanded minimally invasive urological surgery. Dr. Sharpe was the only surgeon in Alabama performing certain complex robotic procedures and he has successfully completed over 300 of these cases. Dr. Sharpe has a special interest in treating refractory erectile dysfunction.

Now scheduling appointments at 160 MacGregor Pines Drive, Suite 205, Cary, NC 27511 2800 Blue Ridge Road, Suite 405, Raleigh, NC 27607 919-851-5482 • www.ncurology.com SEPTEMBER 2010

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Hospital News

UNC Obstetrics and Gynecology Is in the News Honors and Awards The recipients of this year’s $5,000 Cefalo/Bowes Young Researcher Award are: • Elizabeth Geller and Barbara Robinson – “Perineal Body as a Predictor of Anal Sphincter Injury at First Vaginal Delivery. “ • Champa Woodham – “The Association of Angiogenic Factors and Vitamin D in Preeclampsia.” A $1,000 Schweitzer Sustainability Grant was awarded to the UNC Horizons Program to support its smoking cessation program. The Smoking Cessation Program includes making nicotine gum or other over-thecounter nicotine-replacement products available to Horizons clients, along with smoking-cessation incentives, yoga and fitness DVDs in order to encourage positive coping skills. The grant money will also provide books on nutritious eating and cooking demonstrations in order to promote comprehensive lifestyle changes.

The UNCOBGYN Twitter site was nominated for Healthcare Twitizen for the week ending July 16. Three of the seven TraCS $10,000 grants were awarded to the following clinical and translational research projects: • Emma Rossi and mentor John Boggess, “Pelvic and Para-Aortic Sentinel Lymph Node Mapping with Robotically Assisted Near-Infrared Imaging After Cervical and Uterine Indocyanine Green Injection.” • Stuebe, “Management of Maternal Symptoms (MOMS) Study.” • Kelly Evenson, Epidemiology, School of Public Health; Center for Health Promotion and Disease Prevention, and Anne Steiner, “Impact of Physical Activity on Achieving Pregnancy.”

In the News USA Today… Dr. John Steege made the chronic pain list in “Top-Notch Doctors: Our Database of Medical Pros.” The Providence Journal… Dr. Dan Clarke-Pearson was quoted in an ar-

ticle on ovarian cancer, entitled “New Hope to Fight Ovarian Cancer.” CNN… Dr. Alison Stuebe talks about her Talent Identification Program days in “Lady Gaga Went to Geek Camp, Too.”

Blogging “Emergency Contraception.” Dr. Mike Evers explains the different types and how they work. “What’s the Deal with Vitamin D and Pregnancy?” Dr. Arthur Baker helps with answers. “New, Less Restrictive Guidelines Issued on Vaginal Birth After C-section.” Dr. John Thorp reviews new VBAC guidelines. “OVA1: Should We Use It?” UNC’s Gynecologic Oncology group discusses its use. “Running a Road Race Without Shoes?” Dr. Alison Stuebe discusses breastfeeding and how to get “equipped.” “Forgettable Contraception.” Dr. David Grimes reveals stats about unplanned pregnancies and offers solutions. “When Lactation Doesn’t Work.” Dr.

Alison Stuebe discusses the realities. “Pregnancy in Women Over 40.” Dr. Bill Goodnight talks about pregnancy in one’s 40s.

In Print Baker AM, Haeri S, Shafer A, Moldenhauer JS. Maternal gastric carcinoma metastatic to the placenta. Eur J Obstet Gynecol Reprod Biol. 2010 Jul 30.

Upcoming Events 20th annual Art of Breastfeeding Conference: “Celebrating the Past, Present and Future of Breastfeeding.” Three-day course for practitioners offering up-to-date information and evidence-based strategies for management of breastfeeding and human lactation. Oct. 4-6, The Friday Center, Chapel Hill. For more information, please call Wake Area Health Education Center at (919) 350-8547 or (866) 341-1814.

• Financial strength – $2.6 billion in net admitted assets and $677 million in policyholder surplus; a Best’s Rating of A- (Excellent) • Unparalleled experience – more than three decades of service to the healthcare community • Aggressive claim defense – nearly 73% of cases closed without an indemnity payment; win rate of more than 93% for those that went to a verdict at trial • Innovative risk management – extensive risk management services and customized, practice-specific programs

THE TIME IS RIGHT TO EVALUATE PROMUTUAL GROUP To learn more about ProMutual Group, please visit www.promutualgroup.com/NC.html or call us at (888) 776-6888.

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The Triangle Physician


Urology

Improving

Prostate Cancer Mortality in North Carolina

By Kevin Khoudary, M.D.

North Carolina has many endearing qualities – mountains, beaches, a high quality of life, excellent academic institutions – the list goes on and on. What many do not recognize is that North Carolina is also a major outlier in prostate cancer death rates. Typically in the top two to three states for mortality from prostate cancer, there are counties in North Carolina with the highest death rates in the world for AfricanAmerican men. The average black male in North Carolina has a death rate of 2.8 times that of an average Caucasian male. The statistics are so profound that the Department of Defense awarded the University of North Carolina $10 million in 2004 to study the disparity between North Carolina and Louisiana in black male deaths from prostate cancer. Results are only now returning with the lack of access to care or a relationship with a physician as two of the most important variables. Delayed diagnosis lending itself to later stages portends a poorer prognosis. One in six men will ultimately be diagnosed with prostate cancer in their lifetime. The diagnosis is typically made through screening with prostate-specific antigen (PSA) and digital rectal examination. However, experts are divided over the benefits of offering widespread screening for prostate cancer. Many believe screening leaves thousands of men who are at no real danger of dying from the disease with erection problems and incontinence. A common belief is that the majority of

men who develop prostate cancer will die from some other cause. This has prompted research into who ultimately will require aggressive intervention and who will not require anything. Unfortunately, we presently have no test to determine this and are left with no concrete recommendations to patients as to their best option.

The goal of the North Carolina Minority Prostate Cancer Awareness Action Team is to increase the number of African-American men screened annually and promote treatment for prostate cancer during its early and potentially curable stages. Recent accomplishments include creation of a Prostate Health Center in southeast Raleigh that will combine the aggressive outreach and expertise of urologists, radiation oncologists, medical oncologists, among other professionals. The newer blood tests for prostate cancer cells and urine for expressed prostatic secretions offer hopeful options for the future, however they are not presently being universally applied due to sensitivity and specificity issues. The problem is further complicated when considering that although prostate cancer kills a minority of men affected, its high prevalence makes it the second most common cancer death for men.

Dr. Kevin Khoudary is a partner with Cary Urology, with offices in Cary, Clinton, Dunn and Clayton. Educated at Johns Hopkins University, University of Medicine and Dentistry of New Jersey, Northeastern Ohio University College of Medicine and Harvard Medical School, Dr. Khoudary’s interests include prostate cancer and microsurgical male infertility.

Therapeutic options Once diagnosed with prostate cancer, clinical staging of the disease is indicated. Depending on the PSA and pathologic appearance, a bone scan or computedtomography scan may be ordered. Most men have clinically organ-confined disease at diagnosis. This typically results in three options: surgery, radiation or watchful waiting. Each of these may be appropriate for an individual patient and decisions are typically made based on the health status and risk tolerance to side effects. Surgery, be it open radical prostatectomy or robotic, comes with the risks of potency and continence. Radiation can be performed as external beam radiotherapy, brachytherapy (seed implantation) or a combination of the two. Burn injuries to the rectum or bladder and potency issues are the most important risks these patients face. Given the length of time it takes to define a benefit of one therapy over another and the lack of statistically significant long-term randomized studies, advising a patient as to the best single option is difficult. The known North Carolina statistics regarding death rates from prostate cancer necessitate action. The Action Team Founded in 1985, the North Carolina Minority Prostate Cancer Awareness Action Team (the Action Team) provides targeted outreach for minority men who are at the greatest risk of developing prostate cancer. The Action Team is comprised of volunteer professionals and community leaders with SEPTEMBER 2010

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NEWSOURCE-JUN10:Heidi

a deep commitment to service. These individuals work in partnership with churches, Greek-letter organizations and others to disseminate information about prostate cancer, in an effort to increase the number of African-American men screened annually and promote treatment for prostate cancer during its early and potentially curable stages. Cary Urology has worked closely with the Action Team to gain attention from the North Carolina Department of Health and Human Services. In 2009, we were successful in having a need declared, and then winning the approval for a Prostate Health Center to be located in southeast Raleigh. This health center will combine aggressive outreach with the expertise of urologists, radiation oncologists, medical oncologists and a host of support professionals. A patient will then benefit from the perspective and care of many different professionals in a single setting. Hopefully our concerted efforts and synergy will help diminish North Carolina’s notoriety for prostate cancer.

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The Triangle Physician

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What is Phlebology? By Lindy McHutchinson, M.D.

What does a Phlebologist treat? a) Varicose veins b) Tired, achy, heavy legs c) Swollen legs and ankles d) Venous ulcers e) All of the above Answer: e Phlebology is one of the newest recognized fields of medicine and is dedicated to the diagnosis, treatment and study of vein disease, which afflicts 80 million Americans or approximately 20 percent of the adult population. Phlebology treats both the medical and cosmetic (spider veins) aspects of venous disease. If a medical problem is present, most insurance companies, including Medicare, will cover the treatments. Venous disorders diagnosed and treated by a phlebologist include: chronic venous insufficiency, varicose veins, spider veins, venous leg ulcers, congenital venous abnormalities, venous thromboembolism and other disorders of venous origin. Venous leg symptoms include: ankle and leg swelling; and tired, achy, heavy, painful, pruritic, throbbing, cramping, burning, stinging, tingling and restless legs. Phlebology is a recognized specialty by the American Medical Association (AMA), American Osteopathic Association (AOA) and the North Carolina Medical Board. Most states even list it as a specialty on the Council for Affordable Quality Healthcare (CAQH) form. This means physicians who diagnose and treat venous disorders, including varicose veins, can now select phlebology as their primary or secondary area of practice. Phlebology also requires a board exam. According to the American Board of Phlebology website, only two physicians in the Triangle area are board certified in phlebology. I am one of them.

Phlebology Dr. Lindy McHutchinson began training with notable physicians in the field of phlebology, first at Duke University as an observational fellow with Dr. Cynthia Shortell, chief of vascular surgery at Duke. Subsequently, she completed an extended clinical preceptorship with Dr. John Mauriello, fellow of the American College of Phlebology and nationally known educator in the field. She also trained with Dr. John Kinglsey in Birmingham, Ala., another nationally known phlebologist. Today, Dr. McHutchinson is medical director of Carolina Vein Center, a practice dedicated to the treatment of chronic venous insufficiency and other conditions associated with venous disease. To learn more about venous disease, visit www.carolinaveincenter.com. Dr. McHutchinson can be reached at lindy@carolinaveincenter.com or (919) 405-4200.

Diagnostic evaluation includes H&P and duplex ultrasound. Duplex ultrasound is usually performed in the office by a specialized technician and is considered the “gold standard” to evaluate venous insufficiency. Using duplex ultrasound, the technician evaluates the flow of blood in the leg veins and “maps” the veins. Occasionally, other venous imaging techniques, such as plethysmography, computed-tomography scan and magnetic resonance imaging, are also occasionally utilized. Normally, leg veins have functional, one-way flow valves to keep blood flowing against gravity towards the heart. If these flow valves are defective, absent or other conditions are present, blood flows retrograde or backwards down the leg, causing venous congestion and increased venous pressure. This venous congestion and hypertension are ultimately responsible for most of the symptoms and physical findings of chronic venous insufficiency, which include swelling, varicose veins, skin changes and venous ulcers. Treatments are usually short, outpatient office procedures focused on closing unhealthy veins with either endovenous laser ablation and/or sclerotherapy (injections.) Bulging varicose veins are usually removed via micro extractions, called phlebectomy. Recovery time is brief, and patients usually return to normal activities the following day. SEPTEMBER 2010

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News Welcome to the Area

Upcoming Events

Amy Rebecca Auerbach, M.D.

Robert Douglas Jaquiss, M.D.

September 25, 2010

Internal Medicine University of North Carolina (UNC) Hospitals Chapel Hill

Duke Children’s Hospital and Health Center, Durham

Walk to Fight Diabetes

Arthur Maine Baker III, M.D. Obstetrics and Gynecology Maternal and Fetal Medicine UNC Hospitals, Department of Obstetrics and Gynecology, Chapel Hill

Jennie Baird Buchkovich, P.A. Durham

Esin Cakmakci Midia, M.D. UNC Hospitals Department of Radiology, Chapel Hill

Kevin Anthony Carneiro, D.O. UNC Hospitals, Department of Physical Medicine and Rehabilitation, Chapel Hill

Emily Choi, M.D.

Omkar Karthikeyan, M.D. Pediatrics UNC Hospitals, Chapel Hill

Shujaat Ali Khan, M.D. 812 Red Hawk Court, Fuquay-Varina

Alim Mirza Ladha, M.D. Neurological Surgery Duke University Hospitals, Durham

Sharon Lydia Jacobson Lechner, M.D. Family Practice UNC Hospitals, Chapel Hill

Teng Chun Lee, M.D. Cardiovascular Surgery, Thoracic Surgery Duke University Hospitals, Durham

Neurology UNC Hospitals Electromyography Lab, Durham

Eyob Makonnen, M.D.

Pamela Anne Clanton, M.D.

William Brogdon Messer, M.D.

Internal Medicine UNC Hospitals Division of General Medicine, Chapel Hill

Lisa Renee Cowan, M.D. Emergency Medicine P.O. Box 5942, Pinehurst

Kristine Marie Crimmins, M.D. Pediatrics UNC Hospitals, Chapel Hill

Rachel Marie Crooks, P.A. WakeMed Health and Hospitals, Raleigh

Francis Charindra DeCroos, M.D. Ophthalmology Duke University Hospitals, Durham

Emily Marie Fonteno, M.D. General Surgery UNC Hospitals, Chapel Hill

Megan Kelly Fuller, M.D. General Surgery UNC Hospitals, Chapel Hill

Suchita Bhalchandra Gade, M.D. Boice-Willis Clinic, Rocky Mount

Mitchell Ray Gore, M.D. Otorhinolaryngology UNC Hospitals, Chapel Hill

Hugh Judd Grant Jr., M.D. Gynecology 4414 Lake Boone Trail, Raleigh

Catherine Kizer Hathaway, M.D. Internal Medicine UNC Hospitals, Chapel Hill

Alison Marie Hofmann, M.D. Pediatrics, Allergy and Immunology Duke University Hospitals, Durham

Thomas Lawrence Holland, M.D. Internal Medicine, Infectious Diseases Duke University Hospitals, Durham

Timothy Craig Hudson, D.O. Anesthesiology UNC Hospitals, Chapel Hill

Saundra Alicia Jackson, M.D. Emergency Medicine UNC Hospitals, Chapel Hill

Endocrinology, Internal Medicine UNC Hospitals, Chapel Hill

Infectious Diseases, Internal Medicine UNC Hospitals, Division of Infectious Diseases, Chapel Hil

Simone Renee Mevs, PA Cancer Centers of North Carolina, Raleigh

David Adam Michaels, M.D. ApolloMD, Rocky Mount

Timothy Daniel Murphy, M.D. Orthopedic Surgery UNC Hospitals, Chapel Hill

David Tu Kim Nguyen, D.O. Radiology MLS, Pittsboro

Virginia Carroll O’Brien, M.D. Duke University, Durham

Emmeline Margaret O’Leary, M.D. 5506 Turkey Farm Road, Durham

Philip Andrew Roehrs, M.D. UNC Hospitals, Division of Pediatric Hematology-Oncology, Chapel Hill

Juan Manuel Rojas Balcazar, M.D. UNC Hospitals, Chapel Hill

Adriano Nussa Salicru, M.D. Internal Medicine UNC Hospitals, Chapel Hill

Cassandra Marie Sams, M.D. Radiology UNC Hospitals, Chapel Hill

Janica Evelyn Walden, M.D. UNC Health Care, Chapel Hill

Jared Weiss, M.D. UNC School of Medicine, Division of Hematology and Oncology, Chapel Hill

Lindsay Ann Wilson, M.D. Internal Medicine 514 Copperline Drive, Chapel Hill

Manu Yadav, M.D. Maria Parham Medical Center, Henderson

Li Zhou, M.D. 505 Hallburg Court, Wake Forest

Form a team of friends, family and co-workers for the American Diabetes Association Step Out: Walk to Fight Diabetes Saturday, Sept. 25. The event starts at 9 a.m. at Research Triangle Park. Every step taken and every dollar raised helps the American Diabetes Association provide education programs in the community, protect the rights of people with diabetes and fund critical research for a cure. Once registered, online fund-raising tools are available to create a personal webpage, send e-mails, accept online donations and raise more money to stop diabetes. Two or more people make a team.

The Heart Walk is locally sponsored by Duke Medicine, Quintiles and Wachovia. For more information, visit www.starttriangle.org or call (919) 463-8376.

For more information, visit stepout.diabetes. org and insert your zip code for local information.

October 2, 2010

September 25, 2010 and additional dates

Night Walks for Leukemia and Lymphoma Cure In North Carolina there will be five Light the Night Walks this fall to raise funds in search of a cure for leukemia, lymphoma, Hodgkin’s disease and myeloma, and to improve the quality of life for patients and their families. They events are: • Winston Salem – Sept. 25 at Salem College • Raleigh – Oct. 9 at Halifax Mall downtown • Greensboro – Oct. 9 at Country Park • Charlotte – Oct. 16 at Symphony Park • Durham – Oct. 21 at American Tobacco Campus Light the Night is the Leukemia & Lymphoma Society’s signature fund-raising campaign to celebrate cancer survivorship and commemorate those lives touched by cancer. Those who raise $100 are Champions for Cures, who will help “light the night” by carrying illuminated balloons: red for supporters, white for survivors and gold for teams walking in memory of a loved one lost. These events begin at dusk and the illuminated balloons help create a visual awareness throughout the city. For more information or to register, visit www.lightthenight.org/nc.

September 26, 2010

Start! Triangle Heart Walk The Start! Triangle Heart Walk Sunday, Sept. 26, at the RBC Center in Raleigh will raise funds to fight the nation’s No. 1 and No. 3 killers – heart disease and stroke, respectively. Approximately 100 companies and 15,000 people are expected to participate. Gates open at noon. Festivities start at 1 p.m. and the walk kicks off at 2 p.m. The Triangle Heart Walk is the signature fund-raising event for the American Heart Association. It promotes physical activity and heart-healthy living in a fun family and dogfriendly environment. In addition to the one- and three-mile walk, three exhibit areas focusing on Create Hope,

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Inspire Change and Celebrate Success will: • Pay tribute to lost loved ones; • Honor survivors of heart disease and stroke; • Encourage behavior changes in adults and children, like increasing physical activity and making heart-healthy choices part of daily life; • Highlight the successful fund-raising efforts of individuals and companies; and • Celebrate individuals and companies who have made significant changes to lead a heart-healthy life.

Strides Against Breast Cancer Join the community for the 2010 Making Strides Against Breast Cancer Saturday, Oct. 2, beginning at 9 a.m. at North Hills Mall in Raleigh. Sponsors include Bremner Duke, Channel 11 Eyewitness News, Curves, Foxy 107.3, The Light 103.9, Merck, Qualcomm, University of Phoenix-Raleigh Campus, Wake Radiology and Walmart. For more information, contact Jennifer Lichtneger at (919) 334-5218 or raleigh.strides@ cancer.org, or visit online makingstrides.acsevents.org.

Clinical Trials Do you have patients with any of these problems?

Urology

Wake Urological Associates, PA Currently screening Do you have a sudden and urgent need to urinate? Do you have accidental loss of urine? If you are a male/female, 18 years of age and older you might be eligible to participate in a clinical trial study for Over Active Bladder conducted by Wake Urological Associates. For additional information and qualification criteria please call 919.782.1255 and ask for Clinical Trials Department or visit our web site www.Wakeurological.com.

Gynecology Women’s Wellness Clinic

is conducting a research study . If you are female and 12-18 years old, have regular periods, requesting birth control pills for any reason (OR you can be part of a control group that does not take any pills), You may be eligible to participate in this study. Participants under the age of 18 must have parental consent Study participants will receive at no cost: Birth control pills for 1 year, study related exams, compensation for time and travel is available. For information, please call 919-251-9223.


Pressing This Simple Button Could Save Your Patients’ Life.

Breast MRI (BMRI) has become a popular topic in both the lay press and in peer-reviewed journals recently and has generated unprecedented interest from our referring clinicians and the patients they serve. The American Cancer Society’s latest guidelines supports a BMRI and mammogram once a year starting at age 30 for high-risk patients.* Since 2005, Wake Radiology has been the regional leader in Breast MRI services having performed over 5,400 BMRI examinations to date. Our subspecialty expertise and quality of imaging and interpretation are well known throughout the area. Our experienced Breast MRI radiologists are available seven days per week to address questions and concerns about your high-risk patients or the procedure itself at BreastRisk@wakeradiology.com or call our BMRI Physician Hotline at 919-788-7978.

G. GLENN COATES, MS, MD Body Imaging Radiologist Director, Body MRI Services Co-director, Breast MRI Services

DUNCAN ROUGIER-CHAPMAN, MD Body Imaging Radiologist Co-director, Breast MRI Services

CARMELO GULLOTTO, MD Body Imaging Radiologist Breast MRI Specialist

WAKE RADIOLOGY RALEIGH MRI CENTER | 3811 Merton Drive | Raleigh, NC 27609 | 919-232-4700 WAKE RADIOLOGY CHAPEL HILL MRI | 110 S. Estes Drive | Chapel Hill, NC 27514 | 919-942-3196 *The ACS’s risk factors are available on their website at <www.cancer.org>.

DANIELLE L. WELLMAN, MD Women’s Imaging Radiologist Breast MRI Specialist

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©2010 Wake Radiology. All rights reserved. Radiology saves lives.

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September 2010