eRounds – Fall, 2012

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PSA: Yes, No or Maybe

Will your patients benefit from PSA screening? Some say yes. Some say no. There are good arguments on both sides. But Cleveland Clinic’s top-ranked Urology program believes that for many patients, PSA testing can be a lifesaver.

Prostate specific antigen (PSA) screening exploded all over the media recently, with the release of a report from the United States Preventive Services Task Force (USPSTF) finding that PSA testing may be more dangerous than helpful for men who have not been diagnosed with prostate cancer. The USPSTF cited the risk of biopsy and unnecessary treatment caused by the high rate of false positives.

Most PSA testing is done in men over 70 years of age. This group is the least likely to benefit from surgery or radiation treatment. Many have slow-growing cancers that pose no danger during the patients’ lifetimes. The story may be different for younger men, however.

“I think there’s a substantial amount of evidence from randomized clinical trials that shows that among younger men, under 65, screening saves lives,” Eric Klein, MD, chair of Cleveland Clinic’s Glickman Urological & Kidney Institute told The New York Times.

Dr. Klein believes that PSA testing is also of benefit for men with higher-risk tumors.

The debate is similar to the ongoing controversy over mammograms to screen for breast cancer — who should have them and how often. As with breast cancer screening recommendations, primary care physicians may feel torn between the desire to spare patients from unnecessary treatment and the reluctance to allow them to skip a potentially lifesaving test. So what should primary care doctors be recommending to their patients who are concerned about prostate cancer?

“The urological community has long recognized the issues raised by the USPSTF,” says Dr. Klein. “We are aware of the potential for risk involving biopsy and treatment. But the data supporting benefit to younger patients and those with higher-risk tumors is substantial. We continue to recommend a baseline PSA for men in their 40s. This helps us separate out the men who are at highest risk of developing cancer, so we can follow them more closely. Those who are at lower risk probably don’t need to be screened yearly, and those at higher risk should be followed more closely. There is also data to show that men with a PSA of 2 or lower at age 60 have a minimal chance of developing metastatic prostate cancer and probably can stop being screened at all.

“We continue to recommend PSA screening, and encourage management by active surveillance rather than treatment for those with low-grade tumors that are unlikely to progress and curative therapy for those with aggressive tumors.”

To refer a patient, please call 855.REFER.123 (855.733.3712).


Congenital Heart Disease is a Lifelong Journey

Childhood treatment for congenital heart problems shouldn’t end the relationship between patient and cardiac specialist.

Adults with congenital heart disease need lifelong attention from specialists with expertise in these complex conditions.

Treatment of congenital heart defects underwent drastic improvement in the latter half of the 20th century. Almost a million adults born with congenital heart defects in the U.S. are alive today as a result. While some of these people will go on to enjoy lives that are free from symptoms or further evidence of their disease, many others will be vulnerable or subject to an array of consequences throughout adulthood. All should be regularly monitored for potential complications of their congenital malformations.

“Adults with congenital heart disease fall into two general groups: those who are newly diagnosed and those who were diagnosed and treated as children,” says Richard Krasuski, MD, co-director of Cleveland Clinic’s Center for Adult Congenital Heart Disease. “The second group is growing larger because of improvements in pediatric congenital heart disease treatment. These people face unique challenges. Many mistake the alleviation of symptoms, as a result of childhood treatment, for a cure.”

The Defect Often Remains

“As patients get older, they may outgrow replaced valves, and conduits and valves may degenerate and become increasingly leaky or stenotic, and the patients are likely to experience problems ranging from atrial fibrillation to heart chamber enlargement and heart failure,” Dr. Krasuski says.

Dr. Krasuski and co-director Gösta Pettersson, MD, PhD, collaborate with pediatric and adult cardiologists, electrophysiologists and cardiovascular surgeons to care for the frequently complex problems of adult congenital heart disease patients. They treat more than 1,200 patients a year. Among the most frequent referrals are former “blue babies” — born with Tetralogy of Fallot, the most common cyanotic congenital heart disease.

The Center for Adult Congenital Heart Disease brings the full treatment armamentarium of Cleveland Clinic’s No. 1-ranked cardiac program (U.S. News & World Report) to bear on aortic aneurysms, valve issues and arrhythmias that their patients develop. This includes experimental percutaneous procedures, aortic stenting and reconstruction.

Atrial fibrillation ablation is among the treatments now being used for patients with adult congenital heart disease. Although the experience is still small, results have shown success rates that are nearly as good as for patients without congenital anomalies.

There are rare cases of patients with Tetralogy of Fallot who survive into adulthood without surgical treatment. Adult surgery to correct Tetralogy of Fallot is highly complex.

Co-director Dr. Pettersson says, “Patients with more complex congenital heart disease have often undergone one or several operations in childhood before presenting with new problems as adults. Therefore it is important to go to an experienced center with these problems.”

Surgery for Adult Congenital Heart Disease

Most congenital malformations of the heart are surgically addressed in childhood, but corrections are not necessarily permanent. Many patients require frequent, increasingly complex reoperations over the course of their lives.

Mitral valve prolapse and bicuspid aortic valve are also congenital heart defects — although, as Dr. Pettersson points out, “In spite of [the condition] being congenital, many of these patients will not require any operations before they are adults or even late in life.” Nonetheless, Cleveland Clinic does have the nation’s largest valve practice, with among the best outcomes, for when these patients do require surgery.

The 2008 American College of Cardiology/American Heart Association Task Force on Practice Guidelines recommends that all patients with adult congenital heart disease have a primary physician and that they be evaluated by a cardiologist with advanced training and expertise in adult congenital heart disease. Frequency of follow-up is based on the patient’s condition. In addition, patients who require interventional and/or surgical cardiovascular procedures are best served at centers with a specialized multidisciplinary adult congenital heart program — such as Cleveland Clinic.

Pediatric Cardiology

Dr. Krasuski and three other pediatric cardiologists are also seeing patients in the Center for Adult Congenital Heart Disease. They work alongside adult cardiologists and cultivate expertise among specialists in nephrology, hepatology and other disciplines involved in treating conditions secondary to congenital heart disease. “We’ve tried to incorporate the best of both pediatric and adult cardiology to provide the complex care these patients need and deserve,” says Dr. Krasuski.

For more information about the center, visit clevelandclinic.org/adultcongenital or call 216.445.7430.


Full Speed Ahead with Lung Cancer Screening

The data is in. Your patients at high risk of lung cancer could benefit from low-dose CT screening. Cleveland Clinic is well-qualified to draw correct conclusions from screening and address any issues that may be uncovered.

The subject of lung cancer screening using low-dose computed tomography (CT) is controversial. There is a danger of overtreatment when a CT scan reveals nodules that may or may not develop into dangerous tumors. For this reason, Cleveland Clinic has been cautious about recommending CT screening for lung cancer. But the results of the 2011 National Lung Screening Trial (NLST) tipped the evidence in favor of screening. That study showed that in a high-risk population, CT screening can indeed lower the number of deaths due to lung cancer.

“This is the first time that a lung cancer screening study has been able to show a reduction in lung cancer mortality,” says Peter Mazzone, MD, MPH, director of the Lung Cancer Program at Cleveland Clinic. “A 20 percent reduction is exciting news.”

Lung cancer kills more people in the United States than do the next four most lethal types of cancer combined.

It is curable if found early in its course. Unfortunately, most people who develop lung cancer feel no symptoms early on, and therefore the cancer is too often diagnosed at a late stage. Treatment for late-stage lung cancer is effective, but it is rarely curative.

Screening refers to testing people at risk of developing a disease before its symptoms or signs have appeared. The goal of screening is to reduce the disease-specific mortality rate. For this to happen, the disease must be detectable in a preclinical form, and treatment must be more successful when applied early.

The NLST documented a 20 percent reduction in the rate of death from lung cancer with low-dose CT screening compared with chest radiography screening. This was in a population at high risk (age 55-74 with a smoking history of one pack a day for 30 years or two packs a day for 15 years).

Based on this and other evidence, Cleveland Clinic has launched a comprehensive lung cancer screening program, using the same selection criteria as the NLST. The program is offered through the Respiratory Institute.

We need your help to bring this beneficial screening technique to the patient group that needs it most. Patients may only enter the lung cancer screening program with a referring physician’s order.

When you refer a patient for screening, his or her CT scan will be read by board-certified radiologists with expertise in chest imaging, who will send you a report in a standard format. As the ordering physician, you will choose to manage the evaluation of any nodule that is detected or refer the patient to a specialty lung nodule clinic within the Respiratory Institute.

If the nodule is large enough or is deemed a high-enough risk, adjuvant testing with diagnostic imaging, guided bronchoscopy, transthoracic needle aspiration or minimally invasive resection will be offered. All patients with nodules believed to require biopsy will be discussed at a multidisciplinary lung cancer tumor board before biopsy.

“We are entering a new era of lung cancer screening,” says Dr. Mazzone. “The NLST has shown that lung cancer mortality rates can be reduced through low-dose CT screening in a high-risk population. Many challenges remain, such as managing the nodules that are discovered, determining cost-effectiveness of treatment and minimizing radiation exposure. Advances over time will help us optimize our program to offer the most benefit to patients and referring physicians.”

If you have questions about our Lung Cancer Screening Program, please call 216.445.3800.

Screening and Smoking

The NLST showed that low-dose CT screening can reduce lung cancer mortality rates by 20 percent in a high-risk group. A 50-year-old active smoker who quits smoking reduces his or her risk of dying of lung cancer by more than 50 percent. Entry into a lung cancer screening program provides an opportunity for education and assistance with tobacco dependency.

Cleveland Clinic has an active Tobacco Treatment Center within its Wellness Institute. All lung cancer screening participants who are identified as active smokers will be given a program brochure and will be offered a consult in the program.

For more information on Cleveland Clinic’s Tobacco Treatment Center, please call 866.857.1916.


When Stroke Runs in the Family

No one likes walking around with a ticking bomb in his or her head. Yet that’s what it may feel like for your patients who have close relatives who’ve had cerebral aneurysms.

A ruptured cerebral aneurysm can lead to subarachnoid hemorrhage or hemorrhagic stroke, resulting in (40 percent) or permanent brain damage (66 percent). Predicting or anticipating these events is difficult to impossible. The most valuable piece of data for predictive purposes is the fact that up to 20 percent of patients who have ruptured aneurysms have a strong family history of the condition: two or more blood relatives who also suffered ruptured aneurysms.

Patients who have a familial history of cerebral aneurysms should be assessed for personal risk. Cleveland Clinic has set up a Familial Aneurysm Clinic where staff will meet with and evaluate your patients whose family history suggests that they might benefit.

The Familial Aneurysm Clinic offers at-risk candidates a complete history and physical, neurological assessment, and lifestyle risk assessment. Appropriate imaging and laboratory tests may be ordered, such as a CT or an MRI. In some cases, a referral is made to the Genetics Center.

Once examination and test results are complete, patients will work with their Familial Aneurysm Clinic medical team to determine the best surveillance and management options. It is recommended that patients with no symptoms or evidence of aneurysm follow up approximately every three years for continued monitoring.

“Every decision to treat a brain aneurysm involves weighing the risks vs. benefits for each patient,” says Peter Rasmussen, MD, director of the Cerebrovascular Center in Cleveland Clinic’s Neurological Institute. “The location, size and shape of the aneurysm matter. So do the patient’s personal and family health histories. Some small brain aneurysms can simply be monitored.”

Depending on the patient’s health and other factors, minimally invasive techniques may be used to prevent rupture. Specially trained neurovascular surgeons can guide a catheter containing coils or stents into the intracranial artery. Coils and balloons can be placed within the aneurysm to stimulate scarring that prevents blood from entering. Stents can also be placed at the base of the aneurysm. As they scar over, they seal off the aneurysm from the circulation.

Even the most challenging aneurysms can be treated using new technology. Giant aneurysms and aneurysms with a broad base often recur after initial treatment with coils and stents. Pipeline embolization is a technology showing promise for these aneurysms. An extra-long, flexible, stent-like device is guided through a catheter and placed along the base of the aneurysm and on either side. As healing occurs, the device scars over and forms a new channel through which blood can flow, bypassing the aneurysm.

The value of these high-tech treatments is incalculable. Straightforward lifestyle counseling is also important. Patients must know that they can lower their risk of aneurysm formation and rupture and stroke by quitting smoking, controlling hypertension and avoiding drug use (cocaine is the worst offender), heavy alcohol use and binge drinking.

For an appointment with our Familial Aneurysm Clinic, call the Cerebrovascular Center Rapid Consult Line at 216.445.1587 or toll free at 800.CCF.CARE, ext. 51587.

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