Up to 80 percent of adults in the United States will experience some kind of back injury at least once. Low back pain is the second most common reason for visiting a doctor (the common cold is No. 1).

While back pain can be both physically and emotionally draining, most people do recover. Acute pain is usually caused by an activity, movement, or spasm, and lasts a short time. Chronic pain lasts longer than three months and may not be associated with any obvious tissue damage.

Although there is more likelihood of back pain as a person ages, the severity of chronic back pain tends to be lower in older age, according to Matthew Smuck, MD, an associate professor of orthopedic surgery and chief of Stanford Physical Medicine and Rehabilitation Services, who spoke at a presentation sponsored by the Stanford Health Library. Dr. Smuck is a physiatrist, specializing in understanding and improving the body’s mechanical function and analyzing the biomechanics of back pain for better patient outcomes.

“Back pain is a highly individual problem, and there are a lot of reasons for it to occur,” he says. “That makes it challenging to diagnose, and the best course of treatment is different for each patient.”

The most common causes of low back pain are:

• Injury or overuse of muscles, ligaments, and joints
• Pressure on nerves, which can be caused by a herniated disc, repetitive motion, or heavy strain or increased pressure
• Osteoarthritis

Less common causes include:

• Spinal stenosis, the narrowing of the spinal canal, which is usually caused by age
• Fracture, caused by sudden and severe impact from an accident or fall
• Spinal deformities, including curvature problems such as severe scoliosis or kyphosis.
• Compression fractures

Low back pain is extremely difficult to diagnose, in part because there are so many moving parts involved. The spine requires complex muscular support so that it does not collapse and for some people can be difficult to heal. When one component is awry, it can set off a chain reaction through the rest of your body. That means that a problem with your shoulder, hip, or gait could be the source of the pain in your back.

“There’s a complex relationship between the muscles, ligaments, bones, nerves, and discs,” Dr. Smuck says. “Another difficulty is that pain is so personal and individualized. It’s very hard to quantify levels of pain and limitations, since its measurables are so subjective.”

Most people with back problems do not need surgery. Surgery is recommended only in cases where there is a severe structural deformity or nerve damage. In situations that do not require immediate intervention, most specialists recommend that the condition be treated conservatively. Most cases get better over time on their own accord with exercise and/or physical therapy, said Dr. Smuck, who recommends that patients continue to do as much activity as possible.

“Gone are the days of bed rest for low back pain,” said Dr. Smuck. “Twenty years ago, bed rest was common advice, but in fact it is actually harmful. The spine is not a delicate structure—it was designed to be used.”

He pointed out several other myths about back pain, including:

• Disc degeneration is a disease. Degeneration is a normal and unavoidable part of aging, like wrinkles or grey hair.
• A slipped disc requires surgery. Only about 20 percent of cases need surgical intervention
• The greater the pain, the bigger the injury. The severity of discomfort has nothing to do with the amount of physical damage.
• Always lift using good posture. Instead, use common sense to move in a way that is comfortable and natural.
• An MRI will help. Imaging is useful primarily for preparing for surgery or other invasive procedures. Otherwise studies show it can actually be harmful by leading to unnecessary treatments and worries.

“A common problem in treating back pain is the discrepancy between the expectations of the patient and those of the doctor,” he says. “Most patients are looking for an explanation, while the doctor does not always see that as a priority and instead is focusing on treatment. There are multiple approaches and different starting points for each patient. Each person’s back pain is different.”

Still, some principles apply to most everyone with back pain. The most effective way to prevent back pain, and to alleviate it when it does occur, is to move. Exercise is medicine, says Dr. Smuck, and physical activity has been proven to reduce risks of back pain.

A recent study by Dr. Smuck showed  that even one hour of moderate exercise each day lowered the risk of back pain by more than 50 percent—even for people who are overweight. And some studies have suggested that moderate-intensity exercise—like fast walking—is beneficial. Two-and-a-half to five hours of moderate exercise each week provide numerous other health benefits as well, he adds, reducing the incidence of diseases like diabetes, depression, heart disease, and cancer.

Heating pads, ice, muscle relaxers, a new (and firm) mattress, all have the potential to help, but the bottom line is to incorporate physical exercise into your regular routine.

“It’s hard to exercise when you are in pain, but the benefits come on quickly once the first hurdles are passed. Do something that is accessible and that you enjoy, whether it’s walking, biking, swimming, or a treadmill,” he advises. “And for every hour you spend sitting, try to take a few minutes to stand and walk around. The body is not meant to stay immobile for long periods of time.”

While there is no one right way to evaluate and diagnose low back pain, Dr. Smuck says that there are several common approaches to determine the source of the pain and to prescribe treatment. These strategies range from advice to ignore the problem to numerous tests to pinpoint the painful tissue to a biomechanical approach that identifies posture, activity, and lifestyle changes to modify risk.

About the Speaker
Matthew Smuck, MD, an associate professor of orthopedic surgery and chief of Physical Medicine and Rehabilitation Services at Stanford, is a physiatrist specializing in spine disorders and back pain. He received his MD from Indiana University School of Medicine, and completed his residency and fellowship in interventional spine medicine at Stanford. He worked for several years at the University of Michigan Spine Program before joining Stanford four years ago. He is board certified in physical medicine and rehabilitation and in pain medicine by the American Board of Physical Medicine and Rehabilitation.\

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

About Dr. Smuck
http://stanfordhospital.org/profiles/Matthew_Smuck/

Physical Medicine and Rehabilitation
http://stanfordhospital.org/clinicsmedServices/COE/orthopaedics/physiatry/

Orthopedic Surgery
http://pmr.stanford.edu

Daya Upadhyay, MD
Assistant Professor, Pulmonary and Critical Care Medicine

Joseph Shrager, MD
Professor of Cardiothoracic Surgery; Chief, Division of Thoracic Surgery

Billy W. Loo, Jr., MD, PhD
Assistant Professor, Radiation Oncology

Heather Wakelee, MD, Associate Professor of Medicine, Oncology Division
Stanford University Medical Center
November 15, 2012

Lung cancer gets less press than many other terrible cancers that affect wide swaths of the population, but, sadly, it is still the number one cause of cancer deaths in both men and women. At a presentation hosted by the Stanford Health Library, four Stanford doctors specializing in various aspects of lung cancer testing, diagnosis and treatment outlined advances that are making screening more accurate, surgery less invasive, radiation therapy more precise and genetics-based medical therapies far more targeted.

The doctors included: Daya Upadhyay, MD, an assistant professor of pulmonary and critical care medicine; Joseph Shrager, MD, professor of cardiothoracic surgery and the chief of Stanford’s division of thoracic surgery; Billy W. Loo, Jr., MD, PhD, assistant professor, radiation oncology; and Heather Wakelee, MD, an associate professor of medicine in the division of oncology.

There is no mystery concerning the most prevalent cause of lung cancer. Nearly 90% of all cancers of this type are related to smoking, although a substantial number of patients, especially in Northern California, develop the disease without a history of smoking. About 226,000 new lung cancer cases are diagnosed every year in the United States; 160,000 lung cancer patients die annually. The rate of lung cancer survival over five years is less than 15%, Dr. Upadhyay said.

“This is why we are so aggressive about diagnosis,” she added. “If we can stop or prevent smoking, certainly lung cancer is preventable for many,” Dr. Upadhyay said. “But early diagnosis is the only factor that can improve survival.”

It is a proven fact, she added. The National Lung Screening Trial, the results of which were published in the New England Journal of Medicine in August 2011, found that with former smokers between the ages of 55 and 74, low-dose computed tomography, or LDCT, screening reduced lung cancer mortality in screened patients by 20%.

To confirm potential lung cancers that turn up in screening, surgery “is the only sure answer,” said Dr. Shrager, who heads Stanford Medical Center’s thoracic surgery division. Yet surgery “hurts, and it’s costly and it does have some small risk,” he added.

If a tumor is detected, the standard method a decade ago — even for removal of the smallest nodules — was a thoracotomy: major surgery involving the cutting of major muscles and the spreading of a patient’s ribs.

Less invasive surgical methods are often not able to detect small tumors. This is true with bronchoscopy, and with trying to get a biopsy by passing a needle through the chest wall.

Advances in surgical technology, however, have led to video-assisted thoracic surgery, or VATS, which involves three small incisions, a video camera inserted into the patient’s lung, and specialized instruments that can remove a suspicious nodule identified on a screening CT scan. .

“If we can do that and prove it’s a cancer, we can then go on at the same sitting and complete whatever full operation is required,” Dr. Shrager said.

Once a tumor is identified, the basic operation in the past has generally been the removal of the whole lung lobe containing the cancer, he said. But that school of thought has evolved too, with smaller portions of the lung being removed, especially for smaller tumors, and usually with VATS technology, Dr. Shrager said.

“We are getting smaller and smaller with the things we do,” he said.

Stanford has been on the forefront of this trend; the center conducts about 50% of its lobectomies using VATS, while the national average is about 20%.

Assuming the cancer has not spread to lymph nodes, using the VATS method “we can do exactly the same operation as we used to do with a thoracotomy, but with much less pain medication, and people can get back to their normal lives more quickly,” Dr. Shrager said. The ease and speed of recovery from this less-invasive surgical procedure also enables adding chemotherapy into the treatment mix when necessary, he added.

Drug treatments for lung cancer have come a long way too, said Dr. Wakelee, a clinical investigator who focuses on researching drugs that target particular mutations in lung cancer.

“We have a much better understanding of the biology behind lung cancer,” Dr. Wakelee said.

As a result, the list of drug treatments that have shown promise in treating cancerous tumors has been growing. Many of them were developed for patients whose lung cancer had advanced to the metastatic stage; now these successful drugs are being used in earlier stage cancer treatment, she said.

For example, so called VEGF (vascular endothelial growth factor) inhibitors, which block the growth of blood vessels that help small cancer cells grow into tumors, have improved survivability in patients who received this drug in conjunction with chemotherapy, Dr. Wakelee said. An effort is underway to use the VEGF inhibitor bevacizumab as part of a clinical trial in early stage lung cancer patients who have had surgery, she added.

Yet with the successes come more challenges. Patients with particular genetic mutations in their tumors have responded dramatically well to some targeted drugs, such as gefitinib and erlotinib. Yet, on average, these patients’ tumors “figure out how to become resistant, the cancer starts to grow again and we have to come up with a new plan,” Dr. Wakelee said. Research is underway to come up with new drug combinations to overcome this resistance, she added.

Despite the advances in drug therapies and surgery techniques, “chemo is still a very important part of therapy,” Dr. Wakelee said. Dr. Loo, whose clinical specialty is radiation treatment of lung and head and neck cancer, added that while surgery remains the standard of care for early stage lung cancer, with a cure rate of about 70%, roughly 20% of early stage lung cancer patients cannot tolerate surgery because of risks due to old age or poor health.

The major alternative to surgery has been conventional radiation therapy, Dr. Loo said, but the unsatisfactory results from this mode of treatment has driven the development of new, more targeted radiotherapy techniques.

One such technique is stereotactic ablative radiotherapy, or SABR. It incorporates many highly focused beams of radiation that enable the accurate delivery of high doses of radiation.

“SABR allows us to concentrate the radiation on the tumor with less damage to the surrounding organs,” Dr. Loo said.

The technology is impressive. Using scanning equipment, SABR can either follow a tumor with its beams as it moves with a patient’s breathing, or switch on the beam when the breath of a patient returns the tumor to the target area.

The technique has been proven effective. A recent U.S. study focusing on cancer patients too ill to have surgery found a 98% tumor control rate over three years when they were treated with SABR. The overall survival rate was 56%, an impressive statistic for patients too stricken with other illnesses to undergo surgery, Dr. Loo said. Most of the mortality in this this group of patients was due to causes other than cancer, he added. More clinical trials on the efficacy of SABR treatments are underway at Stanford and across the globe, Dr. Loo said. The medical center’s tradition of innovation, with its invention of the medical linear accelerator and the CyberKnife (a robotic radiosurgery system), continues with its latest advances in radiation therapy.

For More Information:
Stanford Health Library can do the searching for you. Send us your medical questions.

Dr. Upadhyay
http://med.stanford.edu/profiles/pulmonary/frdActionServlet?choiceId=facProfile&fid=6147

Dr. Shrager
http://thoracicsurgery.stanford.edu/people/shrager_bio.html

Dr. Loo
http://med.stanford.edu/profiles/Billy_Loo/

Dr. Wakelee
http://med.stanford.edu/profiles/Heather_Wakelee/

Watch the video

A diagnosis of breast cancer used to imply a terminal condition. But new understanding of the molecular and cellular processes behind the disease has led to more effective diagnostic tools and vast improvements in treatment. The result is that breast cancer now is considered more of a chronic condition rather than a terminal disease.

“In the 1970s there were about 3 million cancer survivors in the United States; today those numbers have grown to more than 12 million. In fact, more than half of the women diagnosed with breast cancer tend to die of something else rather than the cancer.

“Survivorship is growing,”said David Spiegel, MD, associate chair of Stanford’s Department of Psychiatry and Behavioral Sciences, director of the Center on Stress and Health, and medical director of the Stanford Center for Integrative Medicine, who spoke at a presentation sponsored by Stanford Hospital Health Library. “But that’s a good problem to have.”

But with these positive changes come some different challenges. How do you maintain a good quality of life while living with the uncertainty of a cancer diagnosis? How can survivors learn to deal with the stress associated with the disease and live well?

“It’s important to take care of your total health,” Dr. Spiegel said. “Follow Grandma’s advice: Eat well, sleep well, and get plenty of exercise.”

Caring for Mind and Body

The psychosocial needs of cancer survivors should be an integral part of quality cancer care, he said. While conventional cancer therapy is increasingly effective, interventions such as surgery, chemotherapy, and radiation therapy can cause additional distress. Additional stress can come from dealing with pain and fear, diminished capabilities, changing family roles, a sense of mortality, and multiple other factors.

“For cancer survivors, it’s not a matter of just one source of stress, but a series of stressors. It’s an especially important time to explore your feelings and figure out ways to deal with them,” said Dr. Spiegel. “The key is taking stressors one at a time and developing a plan for dealing with them. Feeling overwhelmed by stressors is yet another stressor.”

While sadness is a natural response to a cancer diagnosis, for some women these stresses can lead to depression—a long-term condition that affects a person’s physical and mental health and sense of worth. Sadness can easily morph into depression, which extends into hopelessness, helplessness, and worthlessness. While about 3 percent of the general population suffers from depression, more than 25 percent of cancer patients deal with the condition.

Depression, Dr. Spiegel said, is neither a normal nor acceptable part of cancer survivorship. It is a serious problem that has been shown to affect longevity—one study, published by Dr. Spiegel’s group in the Journal of Clinical Oncology, showed that breast cancer patients who reduced their depression increased their lives by an average of two years. Another study showed that long-term depression predicted mortality and that depressed cancer patients showed significantly higher mortality than non-depressed cancer patients.

Dealing with chronic stress creates changes in the brain’s neural pathways can be alleviated through a number of therapeutic approaches, including antidepressants, transcranial magnetic stimulation, hypnosis, and various types of psychotherapy. Proven techniques include individual sessions, peer counseling, and cognitive behavioral therapy.

Avoiding Depression
Dr. Spiegel’s expertise is in integrative medicine, which merges conventional and alternative therapies to address the complex and interconnected aspects of health and illness. His 30 years of working with breast cancer patients has shown that mind-body interventions can improve mood, quality of life, and coping skills.

He established a guideline that he calls FACES to help women deal with the stress of cancer survivorship while avoiding lapsing into depression:

• Facing issues—not fleeing from them
• Altering personal perceptions
• Cope actively—find some aspect of the situation that you can do something about
• Express emotions—acknowledge that something is amiss
• Social support—making connections is a critical aspect of mental well-being

Social connections appear to have an especially powerful influence on a person’s mental outlook. “Loneliness is as bad as smoking is for your health, and it’s even worse when you have cancer,” he said. “Social isolation is a key aspect of stress.”

Social Connections
In the 1970s Dr. Spiegel established support groups for women with metastatic breast cancer to create an opportunity for them to share and deal with their emotions. His landmark study found that the women involved in a support group, along with traditional medical care, experienced reduced anxiety, depression, and pain, and survived an average of 18 months longer than women who did not take part in a support group. More recent studies looking at both quantity and quality of life have found similar findings or no change in survival rates, but noted that participants showed less overall distress.

Participants were able to share their feelings about death and dying, express their emotions, build bonds, reorder their life priorities, manage symptoms, and clarify their roles.

“They could learn from other people’s perspectives, so they could understand their own ability to see that they did have some control over how they lived, which was very empowering,” he said. “The goal of group therapy is to help manage their stressors. By changing depression into sadness and anxiety into fear, a person can begin to deal with their stress.”

Dr. Spiegel cited another study that found group therapy helped breast cancer survivors acknowledge their emotions: once they stopped trying to control their feelings, their stress levels dropped dramatically. Dealing with strong emotions allowed them make important decisions to make priorities and redefine their lives. This type of therapy also helped reduce depression and anxiety, and encouraged women to participate more actively in decisions related to their health.

“It’s healthy to feel anger or sadness,” said Dr. Spiegel. “Women who check out by trying to constantly control their emotions are under more stress because they have difficulty figuring out what to do to reduce their distress.”

Self-hypnosis also has been shown to have a positive effect on managing symptoms because it can alter how pain is perceived and modulated.  One study found that women in a support group using self-hypnosis reported half the pain levels as women not practicing self-hypnosis.

“Research has shown that women with advanced breast cancer involved in psychotherapy were less depressed and felt better about facing the possibility of death,” said Dr. Spiegel. “It can help them deal with stress so that they feel better about life in general and also appears to improve survivorship. Stress management remains an important component of treating cancer. ”

About the Speaker
Dr. Spiegel, the Jack, Samuel and Lulu Willson Professor of Medicine and associate chair of the Department of Psychiatry and Behavioral Sciences, is internationally known for his research on the relationship between mental and physical health. He is also the medical director of the Center for Integrative Medicine at Stanford, which provides alternative and complementary services, such as meditation, acupuncture, and self-hypnosis, to help patients cope with cancer and other diseases. Dr. Spiegel has authored more than 475 research papers and chapters in scientific journals and 10 books on the mind-body connection. He is a member of the Institute of Medicine of the National Academies.

About the Series
The Ernest Rosenbaum Cancer Survivorship Lecture Series is named after the noted oncologist who established the cancer supportive care program at Stanford and the comprehensive cancer care program at UCSF’s Mount Zion Hospital. He wrote more than 25 books on cancer, most of them about living through treatments and life after cancer. The series is sponsored by the Stanford Supportive Care Program.

For More Information:
Stanford Health Library can do the searching for you. Send us your medical questions.

About Dr. Spiegel
http://stanfordhospital.org/profiles/frdActionServlet/David_Spiegel.profile?choiceId=printerprofile&&fid=3789&profileversion=full

Cancer Supportive Care
http://www.cancersupportivecare.com

Stanford Center for Integrative Medicine
http://www.stanfordhospital.com/clinicsmedServices/clinics/complementarymedicine

Eating disorders are abnormal behavior patterns that compromise physical health and mental well-being. These behaviors include anorexia nervosa (self-starvation), bulimia nervosa (binge eating and purging), binge eating disorder, and other non-specified conditions.

Anorexia affects 10 times more females than males while rates of binge eating are 1.5 times more common in females than males. The National Institute of Mental Health estimates that 5 to 10 percent of the U.S. population has an eating disorder of one type or another.

Though eating disorders affect relatively few people, the impact on those suffering from them is severe. Anorexia has the highest mortality rate of any psychological disorder.

“Eating disorders are not about vanity, or choice, or needing attention,” said Debra L. Safer, MD, co-director of Stanford’s Eating and Weight Disorders Program, who spoke at a presentation sponsored by the Stanford Hospital Health Library. “Nor are they a phase. They are serious mental illnesses with dire consequences, so they need to be taken seriously.”

Growing Numbers
Eating disorders affect primarily females and are most common among teens and young adults. About 86 percent of eating disorders patients say they developed the condition before age 20, and there appears to be a higher risk of anorexia nervosa among Caucasians, people from higher socio-economic levels, and from subcultures that put a strong emphasis on appearance, such as models and athletes.

“The numbers appear to be growing in all populations,” Safer said, “but it’s difficult to assess anorexia because there are often inadequate numbers of patients who will participate in studies. Only about .5 to 1 percent of the population has anorexia and the dropout rate from studies by adult anorexics is often about 50 percent.”

Anorexia nervosa causes people to obsess about their weight and the food they eat. They will attempt to maintain a weight that’s far below normal, and to prevent weight gain or to continue losing weight, they may starve themselves or exercise excessively.

People with bulimia may secretly purge, trying to get rid of calories by forced vomiting or excessive exercise. While most people overindulge now and then, there are strict criteria for defining a binge, Safer said, that include consuming an excessive amount of food in less than two hours. Bulimics are preoccupied with weight and body shape and may also misuse laxatives, diuretics, or enemas.

Binge eating involves rapid and uncontrolled consumption of excess food, usually in solitude, followed by feelings of guilt or self-disgust. Unlike bulimia or anorexia, binge eaters do not purge their food, exercise excessively, or eat only small amounts of only certain foods. Because of this, binge eaters are often overweight or obese.

Anorexia usually manifests around age 1214, bulimia around age 1416, and binge eating at age 1822, but many patients report having some symptoms much younger, she added. Almost 40 percent of American 9-year-olds report that they been on diets and/or already started on risky behaviors.

Multiple Complications
“Anorexia is associated with lots of medical complications. They tend to be multisystem, affecting all the organs,” Dr. Safer said. “There are many long-term effects because it interrupts the adolescent growth spurt. In severe cases, the body goes through a ‘hibernation response,’ which is a physical shut-down with low blood pressure, lowered body temperature, and abnormal heart rhythms that can be fatal.”

Other consequences include bone loss, which increases the risk of early-onset osteoporosis; hormone imbalances that cause the absence of periods in girls and decreased testosterone in boys; and gastrointestinal problems, such as constipation and bloating, which make it even harder for patients to want to eat. Purging depletes the body of nutrients, leading to low potassium levels that can cause heart arrhythmias.

There are also neurological consequences. With reduced blood to the brain, eating disorder patients really do think and respond more slowly than their peers and tend to suffer short-term memory loss.

“The cognitive changes associated with malnutrition affect their sense of self and distort their self-assessment,” Dr. Safer said. “The disease causes an actual change in brain chemistry that can perpetuate the cycle. Happily, the effects of malnutrition in the brain can be reversed.”

In bulimia, stomach acids can erode both the esophageal lining and tooth enamel. Binge eaters tend to suffer from high blood pressure, high cholesterol, heart disease, and gall bladder problems.

It’s a misconception that eating disorders in adolescents are the fault of controlling parents or the result of a culture that emphasizes lean bodies and unrealistic beauty standards, Dr. Safer said. In fact, the cause may stem from multiple factors, including genetics, environment, and personal psychology.

Researchers are exploring the tie between eating disorders and larger issues of cognition and thinking patterns. They hypothesize that, for some, reduced self-esteem can lead to distorted concerns about appearance and a destructive cycle of behavior (a cognitive behavior model). For others, an emotional trigger may set off a way of seeing control of food as an escape from emotional pain that makes them dependent on their behavior (an emotion regulation model).

“No one chooses to have an eating disorder,” she added. “Many are in denial about the seriousness of their illness or have distorted perceptions about how they really look.”

Early Intervention
Treatment for eating disorders includes family-based, individual, and group therapy, with a majority of patients being treated as outpatients. Fifty percent of eating disorders patients make a full recovery; about 20 percent maintain a chronic condition; and 30 percent keep some symptoms or experience recurrence.

While there are no FDA-approved medications to treat anorexia nervosa, family-based therapy—in which the parents participate as active caregivers—works for many adolescents. Another approach is called cognitive behavioral therapy: It focuses on changing flawed thoughts and beliefs to improve the patient’s emotional state. And interpersonal behavioral therapy seeks to improve underlying interpersonal relationships.

“The goal is first to make our patients medically stable and restore their weight,” said Dr. Safer. “Then we start to address other aspects and look at contributing issues. Early intervention can treat or cure the disease. Over time the habit becomes part of the person’s identity so it’s harder for them to change.”

About the Speaker
Debra Safer, MD, is an assistant professor of psychiatry and behavioral sciences and co-director of Stanford’s Eating and Weight Disorder Program. The program involves staff from the Lucile Packard Children’s Hospital’s Center for Adolescent Health and the Stanford University School of Medicine divisions of Adolescent Medicine and Child Psychiatry. A specialist in adult and pediatric eating disorders, Dr. Safer studies the nature and treatment of these disorders, the development and treatment of obesity, and the relationship between binge eating and the metabolic syndrome. She received her MD from UCSF Medical Center, and completed her internship, residency, and fellowship at Stanford. Dr. Safer is board certified in psychiatry by the American Board of Psychiatry and Neurology.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

About Dr. Safer
http://med.stanford.edu/profiles/Debra_Safer/

Stanford Hospital Psychiatry
http://stanfordhospital.org/clinicsmedServices/clinics/psychiatry/psychiatryBehavioralScience.html

Pediatric Eating Disorders Clinic
http://www.lpch.org/clinicalSpecialtiesServices/ClinicalSpecialties/EatingDisorders/eatingDisorders.html

Eating Disorders Research Program
http://edresearch.stanford.edu/

Stanford Hospital Health Library
http://healthlibrary.stanford.edu

National Eating Disorders Association
http://www.nationaleatingdisorders.org/

Skin is the largest organ of the human body. It serves a tremendous immune defense system designed to protect you from the environment, regulates internal temperature, and keeps out infection. It’s also a window to your overall health.

Because it is bombarded by so many external elements, skin reflects changes that can be noticed and tracked, from innocuous freckles and moles to dangerous forms of skin cancer. In fact, skin cancer is at epidemic levels, says Sumaira Z. Aasi, MD, a clinical associate professor of dermatology, who spoke at a presentation sponsored by Stanford Hospital Health Library.

Skin cancer is the most common form of cancer in the United States. More than 1.3 million cases are diagnosed each year—20 percent of all Americans. It is usually curable if caught early and treated appropriately, she says.

Sun damage is the primary cause of skin cancer, intensified by the depletion of the ozone layer, an outdoors lifestyle, minimal clothing, and a population that is living longer. People most at risk have fair skin, blue eyes, and blonde or red hair. Though genetics and other environmental exposures can also cause skin cancer, unprotected sun exposure is the biggest cause of basal cell carcinoma, squamous cell carcinoma, and melanoma.

“The more exposure to the sun, the higher the incidence,” Dr. Aasi says. “No one wants to think about skin cancer while doing activities you enjoy, but it is really all about sun exposure. The effect is cumulative, so even if you are conscientious about covering up and using high SPF protection now, the damage started years ago, with exposure when you were young.”

Cancer Development
Exposure to the sun’s ultraviolet radiation causes mutations in the DNA of skin cells. Normally your immune system is programmed to get rid of mutated cells, which is what happens when you get a sunburn and the skin peels—your body is getting rid of the damaged skin cells. As we age, however, the immune system does not register these changes as well, and some mutations slip through the protective system. The mutations cause the cells to grow out of control and become cancerous cells.

“You may not think you have sun damage, but take a look at your arm and compare it to a part of your body that is seldom exposed, like your inner thigh or the underside of your arm,” Dr. Aasi says. “It’s an obvious demonstration of how much you have been exposed to the sun.”

Skin cancer develops primarily on areas of sun-exposed skin, including the scalp, face, lips, ears, neck, chest, arms, and hands, but it can also form on areas that rarely see the light of day. Look for a bump or mark that bleeds, changes color, doesn’t heal, or gets bigger over time, Dr. Aasi says. “No one knows your body as well as you do, so be your own best advocate and keep track of any changes.”

Basal cell carcinoma is the most common form of skin cancer. It’s slow growing and rarely spreads, so it is rarely fatal but can be highly disfiguring if allowed to grow. Look for a red, scaly patch that gets bigger or a pimple with small blood vessels.

Squamous cell carcinoma is the second most common form of skin cancer. It starts off looking like a scaly patch, flat lesion, or red nodule. Actinic keratosis are precancerous growths that also result from sun exposure and can sometimes develop into squamous cell carcinomas. These can be treated very easily in the office without surgery.

Melanoma is the most dangerous form of skin cancer because of its ability to spread into the lymph nodes. Melanoma arises from melanocytes, the cells that provide color to the skin, so it often appears black or brown but can be red or pink as well.

Skin Cancer Treatment
Usually a physician will biopsy a skin sample to determine if a lesion is a skin cancer. If it is cancer, there are multiple treatment options depending on the location and size, such as simple scraping (curettage) and burning (electrodesiccation) and as well as surgical excision. Typically surgery involves cutting the growth, along with a margin of nearby skin to make sure all the cancer cells are removed.

In certain situations an option called Mohs micrographic surgery allows surgeons to remove the cancer while sparing healthy adjacent tissue and examine the margins right away under a microscope while the patient waits. The procedure is used mostly for basal cell and squamous cell carcinoma, and has a 99 percent cure rate for most first-time cancers.

“The technique offers the highest cure rate for skin cancer removal while minimizing the size of the resulting scar,” says Dr. Aasi. “It allows us to be extremely precise, so we can preserve surrounding healthy tissue and save as much skin as possible.”

The procedure requires a special laboratory for analysis of the skin, and Dr. Aasi advises that patients check to make sure the dermatologist using Mohs has been trained through a fellowship. Stanford’s Redwood City dermatology clinic is home to one of the leading Mohs surgery programs in the region.

Cancer Prevention
The most important step to prevent the development of skin cancer is to protect your skin, Dr. Aasi says. Use sunscreen with an SPF of 30 or higher, with broad spectrum UVA and UVB protection. Use sunscreen before you go outside, and be sure to use enough.

“Most people think they are protected but they have not used the proper amount or reapplied it sufficiently,” she says. “Use about a shot glass full and remember to cover your feet, back of neck, ears, and near your eyes. There’s no such thing as waterproof sunscreen, so reapply it when you get wet or sweat. Think of it as paint —apply and then reapply a second coat to get good coverage.”

Cover yourself with loose, lightweight clothing, use a broad-brimmed hat (baseball caps do not provide coverage to the back of the neck or ears), and try to do outdoor activities in the morning or late afternoon—not during prime midday sun.

“There’s no such thing as a safe tan,” she adds. “Artificial radiation from tanning beds is as bad or worse than natural sunlight. The sun might feel good, but it is dangerous.”

Dr. Aasi also suggests you start seeing a dermatologist in your 30s to establish a baseline to track any changes in your skin and to be diligent about doing self-exams on a regular basis.

About the Speaker
Sumaira Aasi, MD, is a clinical associate professor of dermatology specializing in skin cancer and Mohs surgery. She received her MD from Northwestern University Feinberg School of Medicine and did her internship at the University of Chicago Hospitals and her residency at Northwestern University’s McGaw Medical Center. She completed her fellowship in Mohs micrographic surgery and advanced cutaneous oncology at Yale University. Dr. Aasi is Board Certified by the American Board of Dermatology.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

About Dr. Aasi
http://stanfordhospital.org/profiles/Sumaira_Aasi/

Stanford Hospital Dermatology Clinic
http://stanfordhospital.org/clinicsmedServices/clinics/dermatology/

Mohs Surgery Clinic
http://stanfordhospital.org/clinicsmedServices/clinics/dermatology/clinics/mohs.html

Stanford Hospital Health Library
http://healthlibrary.stanford.edu

We know that genes play a crucial role in influencing how we look and act, as well as our susceptibility to disease. Now scientists are trying to use that knowledge in exciting new ways, such as preventing and treating health problems based on therapies tailored to an individual’s unique genetic makeup.

But to understand the future of genetically based personalized medicine, it’s important to understand the basics, says Euan Ashley, MD, PhD, an assistant professor of cardiovascular medicine and director of the Stanford Center for Inherited Cardiovascular Disease, who spoke at a presentation sponsored by the Stanford Health Library.

Human DNA is contained within 23 pairs of chromosomes, one half pair from each parent; genes are segments of DNA that determine specific characteristics, such as hair color or height. Some characteristics come from a single gene, while others come from gene combinations. Humans have about 20,000 genes (and so do worms), and the complete instructions they carry are called the human genome.

Genes hold the instructions for making the proteins that manage cell growth and function. When cells duplicate, this genetic information is passed along to the new cells. The genes may mutate over time, causing disease, and such variants can be passed along from parent to offspring. There are more than 3 billion units of information (letters) in the human genome.

Organizing the Information
But the human genome is not quite that straightforward. When mapping the genome, scientists found that blocks of DNA, called haplotype blocks, tend to stay together. By measuring single letter variants called SNPs in each of these blocks, they were able to look across the whole genome at once.

Using a chip to look at the genes or the cell messages that come from the genes was developed at Stanford and now is used as a tool by researchers worldwide. Over the past couple of decades, using such chips, researchers have identified more than 4,000 single genetic variants associated with disease. Most diseases, however, are caused by a multitude of variants acting together.

“Gene chips allowed researchers to look at large populations and associate a genetic variant with a disease,” said Dr. Ashley. “There was a deluge of strong associations within just a few years. Sequencing (spelling out the letters)  the entire genome has come down in price dramatically: 10 years ago a human genome sequence cost about $100 million; today it runs close to $1,000, making the process accessible to most labs and hospitals, and moving toward the day when the genome is used as a routine part of medical practice.

New Clinical Tool
Another enormous step occurred when a Stanford scientist sequenced his entire genome three years ago. He had a family history of severe heart disease that was reviewed by Dr. Ashley—a genetic heart specialist—which made Dr. Ashley the first physician with access to a patient’s complete genome. He put together a team of Stanford scientists to help analyze it.

“Having the patient’s genome available allowed us to look at the possibility of disease, the clinical risk, and what drugs he would or would not respond to,” said Dr. Ashley, referring to pharmacogenetics. “Access to a person’s genome enables us to look at the genetic information in a way that makes sense for clinical medicine. We can look at a patient’s potential response to medication based on their individual genetic makeup.”

Whole-genome sequencing could identify and help prevent heart problems—and other life-threatening diseases—in patients who seem healthy but may be at risk because of an inherited predisposition, he added. Because he could review his patent’s genome, Dr. Ashley was able to make a list of drugs to avoid based on genetic variations associated with reactions with common medicines. His analysis indicated that the patient would respond well to statins.

“Personalized medicine is about individual risk for disease and targeted preventive care,” said Dr. Ashley. “We are only now taking the first steps toward integrating this information into clinical care, and we still have a lot to learn in terms of interpreting the data.”

For now, he adds, clinical applications for an individual’s complete genome have more potential in challenging cases such as rare family syndromes, and studies are underway for genetic response to stent restenosis and drug resistance.

About the Speaker
Euan Ashley, MRCP, DPhil, FACC, FAHA, is an assistant professor of cardiovascular medicine and director of the Center for Inherited Cardiovascular Disease, a multidisciplinary program that coordinates care for adults and children with genetic disorders of the heart and blood vessels. He is a member of the leadership group of the American Heart Association’s Council on Functional Genomics, deputy director of the Stanford Cardiovascular Institute, and a member of the roundtable on genomics of the Institute of Medicine. An exercise physiology graduate of the University of Glasgow, Dr. Ashley received his PhD in molecular cardiology from the University of Oxford and his MRCP in medicine from the Royal College of Physicians. He joined Stanford in 2003.

For More Information:

Stanford Health Library can do the searching for you. Send us your medical questions.

About Dr. Ashley
http://stanfordhospital.org/profiles/frdActionServlet?choiceId=printerprofile&fid=7578

Dr. Ashley’s Research Laboratory
http://ashleylab.stanford.edu/

About the Human Genome Project
http://www.ornl.gov/sci/techresources/Human_Genome/project/about.shtml