Archives for 2014

This past year has seen a long-awaited improvement in the treatment of hemophilia A and B. Regular use of prophylactic clotting factors has made vast improvements in the quality of life of boys and men diagnosed with hemophilia. With this use they can preserve joint health and participate in many sports and activities that were not previously possible. However to accomplish this requires patients to access their own veins and infuse themselves three or even more times a week. This has been improved in 2014.

In the last 12 months the FDA has now approved longer-acting Factor IX(used to treat hemophilia B) and Factor VIII(used to treat hemophilia A). This was accomplished by taking a protein found on antibodies and adding it to the clotting factors. This is much harder for the body to breakdown and the clotting factor now stays in the body for a longer period of time. In best case scenarios the new factor IX can be given as little as every 14 days.

Many other exciting products are still in development and further improvements are expected.

The ribbon is a symbol of awareness and support.  It was originally used in the early mid-1900s in a United States military marching song.  The song “Tie a Yellow Ribbon”, inspired the wife of a hostage held in Iran from 1979-1981 to use the yellow ribbon to show support for hostages and to remind others of their service to their country.  Later, during the Gulf War, the symbol evolved into a reminder of all men and women serving the country abroad.

A decade later, AIDS activists turned the yellow ribbon red.  From then on every charitable health cause had one.  It became so popular that the New York Times called 1992 “The Year of the Ribbon.”  The meaning behind the ribbon depends on its color or colors.   Many causes often share each color.

Ribbon colors representing cancer:

Clear, Pearl or White : Lung                                                 

Blue :  Mouth

Orange : Leukemia                                                                       

Yellow : Bone                                                                        

Lime  : Non-Hodgkin’s Lymphoma                                

Purple : Testicular                                                                     

Periwinkle : Stomach and Esophageal                         

Pink and Blue : Male Breast                                                

Gray : Brain                                                                         

Black : Melanoma                                                           

Pink : Breast                                                              

Green : Kidney                                                                         

Teal : Ovarian                                                                      

Teal and White : Cervical                                                    

Violet : Hodgkin’s Lymphoma                                                                      

Burgundy : Multiple Myeloma                                                                

Red and Orange : Myeloproliferative Disorders           

Burgundy and Ivory : Head and Neck                                            

BRCA1 and BRCA2 are the big bads of breast cancer genes. They’re not terribly uncommon, they make it about even odds (or worse) that a cancer will develop, and they often cause a more aggressive form of the disease.

But having normal BRCA genes isn’t a guarantee of normal cancer risk.

PALB2 mutations, we’ve learned recently, change the way BRCA gene products function. And it appears that PALB2 gene mutations raise the risk of breast and ovarian cancer to the same level as a woman with a BRCA mutation – multiplying the risk five or ten times.

Reported in the New England Journal of Medicine this August, PALB2 testing is already becoming part of screening in select circumstances.

Watch for additional updates as they become available.

ADDENDUM 10-6-14 9:35 am

PALB2 testing is routinely offered (as part of a more extended panel) to all patients seen by St. Vincent Hospital’s medical genetics department, according to medical geneticist Theresa Shuck (who is part of the St. Vincent’s team).

But because the more extensive testing takes 12 weeks to complete (compared to 2 weeks for BRCA testing alone) many patients opt out – especially those who need to make surgical decisions sooner.

These more extensive panels also challenge insurance companies. Every possible medical test and procedure is given a specific identifier called a CPT code, which allows insurers to recognize what they’re paying for. Though CPT codes are updated regularly, “there are no CPT codes for these panels yet,” says Shuck.  “Most labs are eating the costs of the panels at this point.”

‘Palliative’ (p`alle `aytiv) or ‘Palliate’ (p`allee `ayt): the relief of physical, emotional, psychosocial and spiritual symptoms with or without cure of the medical condition. Simply put, palliative care seeks to assist you in living the best day you can live, every day.

Unfortunately, for many people, it is synonymous with hospice and, therefore, death. Whether speaking to patients, families or other health care providers, the reaction to the word ‘palliative’ is often the same: hands up, step back, shake head and an emphatic, “no-no, it’s not time for THAT.”

Consider for a moment that palliative care (relief of symptoms whether or not the underlying condition can be cured) has become a medical specialty, just as cardiology, neurology, nephrology and many others are. Palliative care has taken the concept of holistic symptom relief, combined it with a team approach and is focused on the prevention and relief of suffering while supporting the best quality of life for patients (and loved ones) facing a serious illness.

Unlike hospice, palliative care does not require a terminal prognosis. Palliative care seeks to provide the physical, emotional, psychosocial and spiritual care that is often needed throughout the course of a serious illness, diagnosis to conclusion. Palliative care can and should be utilized while receiving aggressive treatment to prolong life, as well as to ease the symptoms of dying.

Studies have shown that people who receive palliative care can live longer, with greater quality of life than those who do not receive palliative care. Before you step back, shake your head and say “it’s not time for THAT,” ask yourself why you wouldn’t deserve the very best YOU-based care that WE can provide.

Opioids are effective pain relievers, but commonly cause changes in your bowel habits.  Why does this happen?  These medications increase the amount of time it takes stool to move through the gastrointestinal system.   They are also able to partially paralyze the stomach so that food remains in the stomach for a longer period of time.  Additionally, opioids reduce digestive secretions and decrease the urge to pass stool.  Often, laxatives and/or stool softeners are prescribed/recommended at the same time as the pain killers.

How can you prevent this from happening?  You can make changes in your lifestyle by:

• Increasing your dietary fiber (whole grain breads/cereal, fruits, vegetables, nuts, and seeds)
• Increasing decaffeinated fluid intake to at least 8 cups/day
• Increasing exercise or physical activity (15-30 minutes/day)
• Increasing time and privacy for toileting

What options are available for treating constipation if lifestyle changes are not possible or effective?

• Colace (docusate sodium) 100mg 1-2 capsules once or twice daily
• Miralax (polyethylene glycol) 17 GM (1 capful) once or twice daily
• Milk of Magnesia (MOM or Magnesium Hydroxide) 30 ml once daily
• Senokot 1-2 tablets once or twice daily

Always contact your healthcare provider’s office if you have not had a bowel movement in 3 days.  Occasionally, rectal interventions are recommended if the above measures are not effective.  Rectal interventions are as follows:

• Suppositories
• Enemas
• Rectal irrigation
• Manual evacuation

The goal of good health care communication is to build a trusting relationship between the patient and the health care team. A trusting relationship allows for sharing of information and defining of patient expectations. 

Cancer is a life-threatening illness. When diagnosed with cancer patients feel fear and anxiety about prognosis and treatments. A general sense of loss of control occurs for nearly all patients. Open communication with the patient and provider fosters many positive results:

 -More informed patients

-Patient’s expectations clearly defined to the health care team

-Patients more satisfied with care

-Patients and families with more control of medical decision making

-Better able to make the change from active treatment to palliative care

Patients and their families should define their expectations for communication to and with the physician. This allows the provider to tailor communication to that family’s and patient’s needs. Some patients and families want a lot of detailed information. Others want less detail. The need for information may change as the patient moves through diagnosis and treatment. There will be key times when information will need to be discussed in detail. These key decision times include:

 -When the patient is first diagnosed

-Anytime new decisions about treatment need to be made

-After treatment, when discussing how well it worked

-Whenever the goal of care changes

-When discussions about advance directives, such as a living will, need to occur 

Cancer is an overwhelming diagnosis. Patient-provider communication, for multiple reasons outlined above and more, is the basis for quality cancer care and cancer outcomes.

All nurse practitioners (NPs) must complete a master’s or doctoral degree program in nursing, and have advanced clinical training beyond their initial professional degree as a registered nurse. Green Bay Oncology now employs seven nurse practitioners. As a nurse practitioner, I view myself as an extension of my collaborating physician. Each physician here at Green Bay Oncology is paired with a nurse practitioner to be an integral part of the care team. The NP is skilled to examine and treat patients independently as a part of the care team.

Often during my day as an NP at Green Bay Oncology, I am asked, “Wow, this job must be really hard? I could never do this job.” I open the discussion with my patients as viewing this job as a gift, a window into a person’s life, often into his or her most vulnerable state. It is a very personal, emotional, and rewarding position to be in. I am given the opportunity to be a part of my patient’s and their family’s journey through treatment. It is my job to assist them in any way I can; whether it be with a physiologic, emotional, or social need. I always try to find out what is important to my patients. Is it their job, their family, a special event? By doing this I can individualize each and every patient’s overall plan of care.

The nurse practitioners at Green Bay Oncology help facilitate care at all of the outreach sites, provide care at the Saturday clinic at our east side location, and are dedicated to giving back to our community by speaking at and supporting many local events.

By having nurse practitioners at Green Bay Oncology it has allowed the group to take a more holistic and collaborative approach. We truly do look at each interaction as a group effort. As a group, we continue to focus on how our patients’ needs can best be met. The NP is a key component of the communication that occurs not only between the staff here at Green Bay Oncology, but also with our partnered local and state providers. Here at Green Bay Oncology, rest assured we are here for you, and look forward to being a part of your care team.

 What could go wrong if you never get around to end-of-life planning? Plenty.

“I’ll wait until I have to.”   That’s a huge gamble, since somewhere between 28-68% of patients at end-of-life lose the ability to make medical decisions for themselves.

No POA? You and your family are at risk. If you become unable to make medical decisions for yourself, and haven’t chosen a legal Power of Attorney for health care, Wisconsin law requires the court to appoint a guardian for you. This requires 3-5 business days (at best), costs about $1500 in legal fees (at best). Any family conflict? Well then, let’s make that more like a month’s delay and $5,000 in legal fees – and all this on top of an already upsetting situation.

Patients without end-of-life plans don’t do well. They suffer more. They don’t live as long. And their care costs much more.

Families suffer without advance directives. “My family knows me, and they know what I’d want.” Are you sure about that –I mean REALLY sure?

Have you ever bought a house jointly with anyone? Did you ever feel nervous about making an expensive decision without consulting your partner?

How often does someone you love call to double-check something trivial? Maybe I’m the only one, but my wife Sara calls me to double-check about a lot of things that: a) we’d already discussed, and b) aren’t very important. And I do, too.

Most of us don’t want to make the wrong decision on behalf of someone we love. How confident would you feel making end-of-life decisions for a loved one who’d given you only the most general instructions. Here are some examples of unhelpful directives:

• “No heroic measures”
• “If I’m going, let me go”
• “I wouldn’t want life support if things got too bad”

Making these kinds of decisions without guidance puts loved ones in a terrible position. No matter how well you know someone, it’s hard to feel confident you’re choosing correctly if you’ve never discussed their wishes. So it’s no surprise that families of patients without advanced directives suffer higher rates of depression and complicated grief.

You can’t afford not to think about dying-about the kind of medical care you would and wouldn’t want at the end of your life. And you can’t afford not to tell your loved ones about your wishes.

As a clinic, Green Bay Oncology has an obligation to follow the HIPAA rules set by the federal government. HIPAA is a federal law that protects the privacy of personal health information. It stands for the Health Information Portability and Accountability Act. It gives patients control over who, outside of necessary medical professionals and insurance companies, has access to confidential medical information. Physicians can share medical records with other physicians and clinics when referring a patient to them or communicating with other physicians already involved in the patient’s care. Insurers require basic information to process claims and approve procedures and medications.

When a patient completes the initial paperwork at the first appointment, a notice of privacy practices is given to let patients know that Green Bay Oncology will use and disclose health information for treatment purposes, payment activities and healthcare operations without written consent or authorization. This also explains patient rights related to protected health information. Patients are then asked to sign an acknowledgement of receiving a copy of these practices. Patients also receive a copy of the HIPAA form whose purpose is described below.

How can I or my loved ones obtain my information?

When a patient completes the initial appointment paperwork, a HIPAA release form is completed. This form allows patients to indicate who can receive verbal information from our clinic. This allows someone other than the patient to call into the clinic to get medical information, appointment information and/or billing information as indicated by the patient.

Patients have the right to obtain their written medical information from our facility. They also have the right to release their written medical information to family members, friends or others. In order to have information released, a patient must sign an authorization allowing this transaction. A medical records associate will then verify the information is complete and process the request. This form can be mailed or faxed for completion. In rare circumstances, a verbal authorization can be obtained via phone call with two Green Bay Oncology employees. This is only allowed by exception.

What happens if my loved ones need my information after I pass away?

Any rights granted by the above forms ends when a patient passes away. If records are needed from a deceased patient’s chart, the personal representative of the deceased patient’s estate must present the paperwork that gives him or her the authority to act on behalf of the deceased and then request the needed records.

The exception to this is if records are requested by a physician to treat another family member. The records would be released directly to the health care provider who is treating the surviving relative. Authorization for releasing records of a deceased patient are also not required when releasing health information to funeral directors, medical examiners, law enforcement and for research purposes.

While many of us are used to seeing the HIPAA paperwork in all of the healthcare facilities we go to, we often forget the reason for these laws. It is more than just paperwork to complete. At its essence, HIPAA protects each of us as individuals and gives us much tighter control over our healthcare information.

Lung cancer kills more people every year than breast cancer, prostate cancer, and colon cancer combined.

Unfortunately, lung cancer has historically been diagnosed at a more advanced stage; individuals typically do not have symptoms in the earlier stages of lung cancer. Up to 60-70% of people diagnosed with small, early stage lung cancer could be expected to be alive five years after the diagnosis; only about 10-20% of patients with more advanced lung cancer would be expected to be alive five years after the diagnosis. The United States Preventative Task Force 2013 recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in persons at high risk for lung cancer based on age and smoking history. This new recommendation came from the results of the National Lung Screening Trial (NLST). The NLST identified that screening current and former heavy smokers with low-dose CT scanning at least once yearly for three years resulted in 20% fewer deaths from the disease compared with a yearly chest x-ray. It is important to recognize that there are still potential risks that come along with the screening–a high potential for false positives (a screening test that is positive, but ultimately the abnormality is found to NOT be cancer); unnecessary follow-up procedures (with a risk of complications); radiation exposure; and anxiety related to an abnormal test result.

Green Bay Oncology is committed to the community and we are happy to provide a comprehensive High Risk Lung Screening Clinic, where individuals at high risk for developing lung cancer are able to receive the necessary education on the NLST data and make an informed decision on low-dose CT scanning.

Individuals at risk would include all of the criteria below:

• Between the ages of 55 and 80 
• Have a significant smoking history (30 pack/years). The formula is number of packs per day multiplied by the number of years smoked. For example, 1 pack per day times 30 years equals 30 pack/years; 2 packs per day times 15 years equals 30 pack/years. 
• Currently smoking or have quit smoking less than 15 years ago

The High Risk Lung Screening Clinic offers an appointment with one of our nurse practitioners. The appointments are offered at all of our locations. At this visit, the nurse practitioner will discuss the program and evaluate the individual.  If it is decided to proceed with a low-dose CT scan of the lungs, this will be ordered for a convenient date and time at the Prevea Radiology Department, Webster Avenue Site-Green Bay. A dedicated radiologist with knowledge specific to lung screening criteria will interpret the scan. A follow-up appointment with the same nurse practitioner will be scheduled to review the low-dose CT results and further outline an individual screening plan. All of the individuals entering the screening program will, at minimum, have three yearly screening scans.  This can vary based on the individual results.

To make an appointment or referral call 920-884-3135.