Hoag Presents "Ask the Doctor" for Fall 2015

A:​ Patients with breast cancer deserve to be treated by a physician who addresses the issue with the urgency that such a diagnosis demands. Breast specialists at Hoag typically treat patients with the understanding that their treatment is designed specifically for them based on the nature and extent of their disease, and on the patient’s specific needs and desires.

Today, breast cancer treatment is evolving rapidly and treatment approaches are constantly changing. Both the physician and institution have to be committed to investing time, energy, and resources to provide the latest treatment approaches. Some newer treatments are only available at certain institutions, like Hoag. The following techniques which are available at Hoag require a surgeon with specific training and experience:

Hoag is an institution where the surgical breast specialist is not limited by gaps in the team or by lack of tools. Patients at Hoag receive personalized care from surgical breast specialists who are knowledgeable and have access to the newest and most proven treatments.

​Lincoln Snyder, M.D. is a breast surgeon at Hoag Breast Center in Newport Beach. His approach to patient care is making his patients a priority and providing them a tailored plan to best meet their medical needs. He can be reached at 949-764-8281 at the Hoag Breast Center or at 949-791-6767 at the Newport Irvine Surgical Specialists office at the Hoag Health Center Newport Beach.

A:​ The Hoag Family Cancer Institute is committed to the prevention and early detection of lung cancer, and recommends annual low-dose chest CT screenings for men and women who are 55 - 77 years old with a history of heavy smoking, are still smoking or have quit smoking no more than 15 years ago.

A person is considered to have a history of heavy smoking if he or she has smoked at least 30 pack-years. Pack-years refer to the number of packs smoked per day, multiplied by the number of years an individual has smoked for.

In 2011, the National Cancer Institute released results of its National Lung Screening Trial (NLST) conducted from 2002 - 2009. The study randomized more than 50,000 smokers or former smokers ages 55 - 77 who were high-risk, to screenings by either a traditional chest X-ray or a low-radiation dose spiral CT scan, once a year for three consecutive years. The results showed that low-dose CT scans reduced mortality from lung cancer by 20 percent in patients.

While a chest X-ray forms an image of the chest including the lungs, other structures like the heart and spine may obscure parts of the lungs where cancer might be. A CT scan is performed with a doughnut-shaped camera (scanner) and takes several cross sectional images of the chest, which results in a more complete picture of the lungs.

If you are between the ages of 55 - 77, an annual low-dose CT screening is recommended by the American Cancer Society, National Comprehensive Cancer Network, American College of Chest Physicians, American Thoracic Society, American Society of Clinical Oncologists, American Association of Thoracic Surgeons, the American Lung Association, and the U.S. Preventive Services Task Force.

Some of these organizations also suggest annual screenings for patients who are 50 years or older with a 20 pack-year smoking history, and also have an additional risk factor such as the following:
  • Family history of lung cancer
  • Prior history of smoking related malignancy (head/neck, lung, esophageal), or lymphoma
  • Radon exposure
  • Certain occupational exposures (asbestos, arsenic, cadmium, chromium, nickel, diesel fumes, beryllium)

Hoag has a robust Lung Cancer Early Detection Program in place since 2006 and has provided low-dose CT scans to detect small lung cancers in the earliest stages when lung cancer is most treatable. Many insurance companies currently pay for lung cancer screening in appropriate patients and Medicare has also begun to reimburse for lung cancer screenings.

To learn more about the Lung Cancer Early Detection Program, please call Lung Cancer Nurse Navigator Lilian Reed, RN, at 949-764-6889.

​Daryl Pearlstein, M.D., is the program director for Lung Cancer at Hoag and a board-certified, subspecialist-trained thoracic surgeon.

A: ​For men with testosterone deficiency, it is important to discuss treatment plans with your provider in order to learn about the benefits and the risks of testosterone replacement therapy.

There are various preparations of testosterone replacement available including the gel, patch, injections and pellets. While the action, duration, and frequency of administration may differ, the potential adverse effects are the same.

One of the most important contraindications is personal history of prostate cancer. The majority of prostate cancers grow in the presence of testosterone; therefore, a part of prostate cancer treatment involves testosterone hormone suppression. The patient should discuss this with their urologist prior to beginning testosterone replacement.

Common adverse effects can also include skin irritation with topical preparations, and change in mood/behavior. Skin irritation can be prevented by applying the medication in different locations. In more severe cases, a small dose of topical steroid may resolve the irritation. Testosterone replacement can improve energy levels, but some men can become aggressive and easily angered. If this occurs, the dose of testosterone can be decreased, or preparations that avoid wide fluctuations in the hormone level should be tried.

Other adverse effects include enlargement of the prostate gland, worsening sleep apnea, and an increase in red blood cell production (erythrocytosis). Because of these issues, it is important to be monitored by the prescribing physician every three to six months. In cases of prostate enlargement, the individual may start noticing changes in urinary flow, frequency and sense of incomplete voiding. With worsening sleep apnea, the Continuous Positive Airway Pressure (CPAP) may need to be readjusted. If erythrocytosis occurs, the person may notice redness on the face or itchiness after a hot shower. Some erythrocytosis patients are instructed to donate blood every few months to decrease their red blood cell count.

Some of the long term effects of testosterone replacement include decrease in sperm production and in the size of testicles. Couples that desire fertility should seek consultation with infertility specialists prior to starting testosterone replacement. Unfortunately, gradual decrease in the size of testicles cannot be prevented with the use of testosterone.

Although rare, there are life-threatening adverse effects with testosterone replacement. Clot formation (venous thromboembolism) and cardiovascular events may occur without any warning. In order to prevent these, it is important to not smoke and maintain an active lifestyle with regular exercise.

Overall, testosterone replacement is very important for those with a true deficiency. It improves fatigue, muscle function, libido, and helps to prevent osteoporosis. There are many potential adverse effects and therefore, close monitoring by a knowledgeable physician is the first step.

​Jinsun Choi, M.D. is an endocrinologist with Hoag Medical Group and practices at the Huntington Beach and Irvine – Woodbridge locations. Her approach to patient care is to partner with her patients to provide them with education and the best care possible. She can be reached at 714-477-8038.

A: ​While the term Attention Deficit Disorder (ADD) is commonly associated with children, it is also a condition that affects many adults. If you are an adult concerned about the possibility of being affected by ADD, it is recommended you consult your physician. The following is a checklist for when you visit your physician.

Some common risk factors for people with ADD include:
  1. A lifelong history of attention deficit that begins at early childhood.
  2. A genetic link of family history.
  3. Symptoms such as inattention, distractibility, lack of focus, and difficulty in staying on task.

There are different methods to perform the assessment including:

  1. Using a tool to diagnose attention deficit.
  2. Getting a clinical evaluation to eliminate other possibilities that cause distractibility and inattention, such as forms of mental illness, depression, stress and hyperthyroidism.
  3. Assessing for comorbidity: Learning disability, alcohol and chemical dependency, Obsessive Compulsive Disorder (OCD), depression, anxiety, Tourette's Syndrome and facial tics.

Oftentimes, family members are brought into counseling in order for them to understand the difficulties of the patient and how to deal with their deficit. In adults, attention deficit disorder does not come alone as it is commonly bundled with other mental health issues.

Additionally, the comorbid conditions such as depression or drug abuse may be the most important aspect of the patient's health that need to be addressed immediately rather than the attention deficit itself. Thus, the attention deficit takes a secondary role and is not the primary difficulty.

When it comes to treatment plans, medication has been the mainstay, and typically works best when coupled with counseling. Although medication is the most common form of treatment, it is a stimulant and not ideal for everyone, including patients with heart disease, who are not candidates for such medication. The medication has to be handled with care and has adverse reactions. Insomnia, loss of appetite, weight loss, headaches, and irritability are all side effects. Side effects can be averted with lowering the dose and careful titration is necessary.

The life of an adult patient with ADD can be eased dramatically with the right treatment. Getting to the right physician who understands the different components of the treatment is essential and can be life changing.

​Zwi Steindler, M.D. is a family practitioner with Hoag Medical Group and practices at the Irvine – Woodbridge location. He has extensive experience treating patients of all ages and dealing with complex conditions. He can be reached at 949-791-3103.