Creating a new primary care clinic for cancer survivors

As a cancer survivor, I know how finishing treatment can feel both happy and unsettling. I was ecstatic to be done with chemotherapy and radiation therapy, but I worried about recurrence and long-term treatment side effects. Whenever I went to a cancer checkup, I wore silly socks to remind myself to smile. And decades later, I still have to be vigilant with periodic screening tests like breast MRIs due to increased health risks from radiation.

Quality survivorship care requires a strong collaboration between oncology and primary care clinicians, particularly as patients complete their treatment. To help patients during this critical time, Stanford is piloting a cancer survivorship clinic embedded in the practice of primary care physician Jennifer Kim, MD. I recently corresponded with her to learn more.

What inspired you to focus on cancer survivorship care?

“When medical oncologist Lidia Schapira, MD, and I met about 2 years ago, we discussed her ideas of integrating primary care into survivorship at Stanford. All primary care practices, including my own, already care for survivors. As this is not a topic that I learned about in training, I wasn’t sure what would be different about calling it survivorship.

I learned more by attending national conferences and reviewing online curricula on survivorship. I also spent clinic days with oncologists as they saw patients. As I started to learn about survivorship, I realized that cancer and cancer treatment changes all aspects of patients’ health — medical, emotional and social — for the rest of their lives.”

How does your clinic work?

“Together with Lidia Schapira, I started Stanford’s Primary Care Cancer Survivorship clinic. I’m currently the only primary care physician doing this at Stanford and I see patients for two half days per week in the Hoover primary care clinic. My visits are consultative, meaning patients come to see me for one to several visits to discuss a complete survivorship plan, which they can bring back to their primary care physician for ongoing care.

The focus of my visits is to detail a full treatment history and make a personalized survivorship plan for issues such as cancer surveillance, potential long-term and late effects of treatment, psychosocial concerns, co-morbidities and preventative care. I create this history and plan together with the patient, so both the patient and their whole care team will understand the content.

Having the clinic embedded in my primary care clinic — a different building and environment than the oncology department — helps us physically and mentally shift gears and transition to a primary care-based survivorship plan.”

What have you learned?

“I’ve learned the most powerful survivorship lessons from my patients and their experiences. I’ve learned not to assume what my patients are struggling with. Instead, by asking about their experiences and listening to their concerns, I can better understand what is really important to each individual. I’ve also found that it is very important to be open about and sensitive to emotional and psychosocial issues, including fear of recurrence, anxiety, fertility and sexual health. These topics are rarely the focus of oncology visits and patients don’t know who to ask.

I now realize that survivors often struggle with the transition from oncology care back to primary care-based care. It’s a challenging, overwhelming and emotional time when many still have significant long-term effects of treatment and multiple specialist visits. Patients often voice a need for a ‘quarterback’ to help guide them through the next phase of recovery — finding health after cancer.”

Do you have any advice for other primary care physicians?

“Primary care physicians can and should be an essential part of survivorship and health after cancer. However, there are currently many barriers to survivorship being integrated into primary care — a knowledge gap, disparate electronic medical records, limited appointment time and patient concerns over whether primary care physicians are able to manage survivorship.

Many primary care physicians aren’t confident in their own survivorship knowledge, as there are so many cancers and so many treatments to keep track of, even in terms of surveillance recommendations and potential long-term effects. This is why shared care with specialists and continuing education can make a great impact in this area of increasing need.

With the help of a great team, Lidia and I are developing an online course with video, animation and text to help primary care physicians gain more knowledge, resources and confidence in their long-term care of survivors. We hope to distribute this widely when it is ready.

We’ve also started to create a patient-facing survivorship course that will focus on self-management, communication and resources. We hope this will help patients better navigate survivorship issues on their own and with their care team.”

Photo by Pamela Williams

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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How does radiation in space affect the brain?

Exposure to deep space poses many potential risks to the health of astronauts, but one of the biggest dangers is space radiation. Above Earth’s protective shielding, astronauts are exposed to radiation from energetic charged particles that increases their risk of cancer, damage to the central nervous system and a host of other health problems.

A new study has now investigated how chronic, space-like irradiation impacts the brain function of mice. To learn more, I spoke with Ivan Soltesz, PhD, a senior author on the study and a professor of neurosurgery and neurosciences at Stanford.

What was the goal of your study?

“Our basic question was ‘what happens to your brain during a mission to Mars?’ So far, only the Apollo astronauts have traveled far enough beyond the Earth’s protective magnetic field to be exposed to similar galactic cosmic radiation levels, albeit only for short durations.

In previous rodent studies, my lab observed that neuronal function is disrupted by low levels of radiation, a fraction of the dose used for cancer therapy. However, technical constraints required us to deliver the entire radiation dose within minutes, rather than across several months as during a mission to Mars. In the current study, we are the first to investigate the impact of prolonged radiation exposures, at Mars-relevant doses and dose rates, on the neurological function. We used a new neutron irradiation facility at Colorado State University.”

What part of the brain did you study?

“The hippocampus, which is critical for several important brain functions, including the formation of new memories and spatial navigation. And the medial prefrontal cortex, which is important for retrieving preexisting memories, making decisions and processing social information. Thus, deficits in either of these two brain regions could detrimentally impact the ability of astronauts to safely and successfully carry out a mission to Mars.”

What did you find?

“My lab at Stanford measured electrical properties of individual neurons from mice that were exposed to six months of chronic neutron radiation. We determined that after chronic radiation exposure, neurons in the hippocampus were less likely to respond to incoming stimuli and they received a reduced frequency of communication from neighboring neurons.

Our collaborators at UC, Irvine found that chronic neutron radiation also caused neuronal circuits in both the hippocampus and medial prefrontal cortex to no longer show long-lasting strengthening of their responses to electrical stimulation, normally referred to as long-term potentiation. Long-term potentiation is a cellular mechanism that allows memory formation.

Our collaborators also conducted behavioral tests. The mice displayed lasting deficits in learning, memory, anxiety and social behavior — even months after radiation exposure. Based on these results, our team predicts that nearly 1 in 5 astronauts would experience elevated anxiety behavior during a mission to Mars, while 1 in every 3 astronauts would struggle with memory recall.”

How can these findings facilitate safe space exploration?

“By understanding radiation risks, future missions can plan practical changes — such as locating astronaut sleeping spaces towards the center of the spacecraft where intervening material blocks more incoming radiation — that may help to mitigate the risks associated with interplanetary travel.

However, my lab believes the best way to protect astronauts from the harmful effects of space radiation is to understand at a basic science level how neuronal activity is disrupted by chronic radiation exposures.

One promising sign is that radiation exposures that occur in space rarely cause neurons in the brain to die, but rather cause smaller scale cellular changes. Thus, we should be able to develop strategies to modulate neuronal activity to compensate for radiation-induced changes. Our team is already starting a new set of chronic space-radiation experiments to test a candidate countermeasure drug.”

Would you ever go to space, given how harmful it is on the human body?

“The radiation risks we discovered are mostly a concern for travel beyond low earth orbit, such as months-long missions to Mars. Shorter trips to the moon — such as the Apollo missions — or months spent in Earth orbit aboard the International Space Station appear to pose a much lower risk of radiation-induced cognitive deficits. I would definitely like to go into space for at least a few quick orbits.

I’m also confident that my lab and others will expand our understanding of how chronic radiation impacts the nervous system and to develop the effective countermeasures needed to enable safe missions towards the moon or Mars within the next decade. However, I’m not sure I’m ready to leave my lab unattended for two years while I take a sabbatical to Mars.”

Photo by ColiN00B

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Stanford study shows the power of eco-friendly packaging for cigarettes

My eyes are drawn to eco-friendly packaging when I shop for groceries. It is how I pick my laundry detergent, dish soap and many other products from the litany of options. But I’ve learned to double-check whether these items are actually better for the environment, because there are a lot of misleading labels.

Companies know that pro-environmental marketing works. A new Stanford study shows it is even effective for cigarettes.

The researchers surveyed over 900 adults on their perception of two major cigarette brands: Pall Mall and Natural American Spirit. Pall Mall is marketed as a discount brand, while Natural American Spirit is marketed as environmentally friendly. For instance, the Natural American Spirit’s “Respect the Earth” campaign advertises a “zero-waste-to-landfill” facility and uses a logo with three tobacco leaves that mimics the recycling symbol.

The study participants were a mixture of current smokers, former smokers and people who have never smoked. All three groups consistently ranked Natural American Spirit cigarettes as being healthier and better for the environment than the Pall Mall cigarettes.

“Ecofriendly and natural food products are seen as safer for health,” said the study lead author Anna Epperson, PhD, a postdoctoral fellow with the Stanford Prevention Research Center, in a recent Stanford news release. “That couldn’t be farther from the truth when it comes to cigarettes.”

Both brands are actually manufactured by the same company, Reynolds American. And they have the same health impacts, including a significantly higher risk of heart disease, cancer and chronic obstructive pulmonary disease. They are also commonly discarded, resulting in toxic chemicals leaching into the soil and water supplies.

 “All commercially available cigarettes will kill more than half of long-term users if smoked as intended. Marketing language that obscures these health harms, even indirectly through questionable pro-environment claims, ought to be prohibited,” the study authors concluded.

This warning may be particularly important to the San Francisco Bay Area and other pro-environment and pro-health regions, where Natural American Spirit cigarettes are especially popular according to Epperson.

Photo by webyourlife

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.