SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y
Sexual health and fertility Cancer, Fertility, and Sex Heart Disease and Sexual Activity Managing the Risks
Male Infertility Treatments
The Great Prostate Screening Debate
Contraception Update
How Good Are They?
SPECIAL INSERT Intimate Partner Violence A Practical Guide for Clinicians
VOL. 85 NO. 10 DECEMBER 2012
“ I have been very impressed by the personal attention MIEC has shown to my practice needs. They are always available to work proactively with me whenever a risk management situation arises.” Dr. Paul Abramson Family Medicine - Insured by MIEC
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IN THIS ISSUE
SAN FRANCISCO MEDICINE
December 2012 Volume 85, Number 10
Sexual Health and Fertility
FEATURE ARTICLES
MONTHLY COLUMNS
12 Male Infertility Treatments: How Good Are They? Paul J. Turek, MD, FACS, FRSM
4
Membership Matters
6
Ask the SFMS
9
President’s Message Peter J. Curran, MD
14 16
Assisted Reproduction: Advances and New Frontiers Liyun Lee, MD
To PSA or Not to PSA: The Great Prostate Screening Debate Justin Quock, MD
18 Cancer, Fertility, and Sex: Improving Quality of Life for Men with Cancer James F. Smith, MD, MS 20 Contraception Update: A Survey of Various Methods Lily Tan, MD
22 Menopause and Sexual Health: A Transition from the Reproductive Years Sashi Amara, MD
28 Hospital News 29 Classified Ad
33 In Memoriam Nancy Thomson, MD 34 Crossword Puzzle Ernest Lampert, MD
24 Heart Disease and Sex: Managing the Risks Richard Podolin, MD 25 Breasts: A Book Review Erica Goode, MD, MPH
OF INTEREST
11 SFMS Election Results 30 Medical Policy Making 2012: The CMA Annual Meeting’s Mix of Issues and Solutions Stephen Follansbee, MD, and Steve Heilig, MPH
Editorial and Advertising Offices:
SPECIAL INSERT
Intimate Partner Violence A Practical Guide for Clinicians PAGE 27
1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.
MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members
Medicare Finalizes 2013 Physician Fee Schedule CMS released the final 2013 physician payment rule, which sets payment rates and related policies for next year. Some of the notable changes affecting physicians include: • Increase in payments for primary care to 7 percent for family physicians and 3 to 5 percent for other primary care providers. • New “transitional care” CPT codes to reimburse physicians for coordinating patient care within thirty days following a discharge for a hospital or skilled nursing facility.
• Two to six percent cut in Medicare fees for a number of specialties, including cardiology, nuclear medicine, ophthalmol-
ogy, pathology, physical medicine, and vascular surgery. • Rules for value-based payment modifier to take effect in 2013 (using 2013 data) with groups of 100 or more physicians. • Plans to streamline physician reporting programs (e.g., EHR meaningful use, Physician Quality Reporting System, eRx programs). For more information about the final rules, please visit http:// bit.ly/UllvuF.
Anthem Blue Cross Amends Physician Contracts to Include Individual/Exchange Product; Resources/Assistance Available to SFMS Members
Anthem Blue Cross sent a notice to 8,345 physicians who are part of the Blue Cross Select PPO network announcing its intent to participate in the California Health Benefit Exchange, the state’s new insurance marketplace called for under the Affordable Care Act. According to the notice, Blue Cross will be creating a new provider network called the “Anthem Individual/Exchange Network,” which will serve both individuals who purchase coverage through the exchange and individuals who purchase coverage from Anthem Blue Cross in the individual market outside of the exchange. It’s important to note that Blue Cross is amending the
physician’s Blue Cross Prudent Buyer Agreement to automatically include the new individual/exchange network, effective January 1, 2014. The new fee schedule associated
with this product was included with the notice.
Physicians can opt out of the individual/exchange network by notifying Blue Cross of their intent to opt out by December 31, 2012. Opt-out notices should be in writing
and sent via certified mail, return receipt, to the address specified in Section VI of the amendment. Sections VI and VIII of the contract amendment provide instructions for physicians who wish to opt out of the individual/exchange network. Physicians who did not receive a letter and are unsure whether they are affected by this change, or those who have 4 5
San Francisco Medicine December 2012
general questions about the amendment, can contact Blue Cross’s Network Relations Department at (855) 238-0095 or networkrelations@wellpoint.com. SFMS members can receive one-on-one assistance by contacting CMA staffers Mark Lane at (916) 551-2865 or Jodi Black at (916) 551-2863. For more information about Anthem Blue Cross Contracts, please visit http://bit.ly/QlvW07.
Medi-Cal Requiring Physician Reenrollment
The California Department of Health Care Services (DHCS) will soon be notifying physicians that they must reenroll in MediCal as one of the provisions of the Affordable Care Act (ACA). The ACA requires every state Medicaid program (Medi-Cal in California) to revalidate provider enrollment information at least every five years beginning January 2, 2013. Notices of revalidation will be mailed beginning the second week of January 2013. Notices will be sent to business locations on file with DHCS. Anyone receiving a notice must complete and return the requested form(s) and required attachments within thirty-five working days of the date of the notice. Failure to do so may result in payment delays. SFMS/CMA will be hosting a live webinar training course with representatives from DHCS to walk attendees through the Medi-Cal enrollment process for both individual providers and groups. For more information, or to register for the January 16, 2013, webinar, please visit http://bit.ly/SITCYl.
Kaiser Permanente San Francisco Receives National Recognition for Quality and Safety
Kaiser Permanente San Francisco Medical Center has been recognized by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) for achieving exemplary outcomes in surgical procedures. It was one of only
twenty-eight hospitals in the nation to be lauded for “exemplary outcomes” in inpatient and outpatient surgical procedures. The ACS NSQIP recognition program commends a select group of hospitals for exhibiting high quality and safety standards in five clinical areas: DVT (deep vein thrombosis, thrombophlebitis, and pulmonary embolism), cardiac incidents (cardiac arrest and myocardial infarction), pneumonia, surgical site infections, and urinary tract infections. The twenty-eight hospitals cited attained exemplary results in two or more of the five areas. “This accolade is well-deserved recognition of the fine work our physicians and staff do every day in delivering the best care for our surgical patients—before, during, and after their procedures,” said Robert Mithun, MD, SFMS member and physician-inchief at Kaiser Permanente San Francisco Medical Center. www.sfms.org
December 2012 ACS NSQIP is the only nationally validated quality improvement program that measures and enhances the care of surgical patients. The goal of ACS NSQIP is to reduce infection or illness related to a surgical procedure and surgical mortality, and to provide a firm foundation for surgeons to apply what is known as the “best scientific evidence” to the practice of surgery. When adverse effects from surgical procedures are reduced or eliminated, a reduction in health care costs follows. ACS NSQIP is a major program of the American College of Surgeons and is currently used in more than 500 hospitals.
Physician Preceptors Needed at USF
As the promise of team-based care and interprofessional practice evolve across health care settings, the School of Nursing and Health Professions at the University of San Francisco is looking to appoint a number of Bay Area physicians as affiliate faculty who would be linked to our health professions programs. USF is seeking physicians who would be interested in precepting nurse practitioner students. USF nurse practitioner students complete coursework in advanced pathophysiology, advanced pharmacology, and advanced physical assessment before they begin their precepted practice rotations. Because they are all registered nurses, they have experience working with patients and their families and understand much of the culture of the health care system. Interested physicians can contact Judith F. Karshmer, dean and professor of the School of Nursing and Health Professions at the University of San Francisco, at (415) 422-2334 or jfkarshmer@usfca.edu.
SFMS Membership Expires December 31; Renew Your Membership Today
SFMS would like to thank our 1,500-plus members for their support of the local medical society this year. Because of your support and participation in organized medicine, SFMS continues to be the preeminent physician organization championing the case of physicians and their patients as we face the many challenges of these changing times. Please take a moment to renew your support of SFMS by remitting payment for your 2013 dues today. There are three easy ways to renew your dues this year: Mail/fax in your completed renewal form, renew online at sfms. org using your credit card, or enroll in the Easy Pay (quarterly installments) Automatic Dues Renewal Plan by contacting SFMS at (415) 561-0850 or membership@sfms.org.
ICD-10 Impacts All Medical Providers
The transition to ICD-10 is one of the most daunting regulatory requirements ever imposed on physicians. Not only will the number of diagnosis codes dramatically increase from 16,000 ICD-9 codes to 68,000 ICD-10 codes, but new formatting and documentation requirements will impact numerous medical office processes and personnel. While the compliance date for ICD-10 implementation of October 1, 2013, may seem far away, physicians are encouraged to start planning for ICD-10 and 5010 transition immediately. Learn more about ICD-10 at http://bit.ly/SRbSit.
Complimentary Webinars for SFMS Members
CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events. January 10, 2013: Essentials for ICD-10 (Part 1) • 12:15 pm to 1:15 pm January 16, 2013: Successful Medi-Cal Provider Enrollment • 12:15 pm to 1:15 pm January 17, 2013: Essentials for ICD-10 (Part 2) • 12:15 pm to 1:15 pm January 23, 2013: ARC & CARC Revenue Code • 12:15 pm to 1:15 pm www.sfms.org
Volume 85, Number 10 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay
EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD Sashi Amara, MD SFMS OFFICERS President Peter J. Curran, MD President-Elect Shannon Udovic-Constant, MD Secretary Jeffrey Beane, MD Treasurer Lawrence Cheung, MD Immediate Past President George A. Fouras, MD SFMS STAFF Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Coordinator Lauren Estrada
BOARD OF DIRECTORS Term: Jan 2012-Dec 2014 Andrew F. Calman, MD Edward T. Melkun, MD Roger S. Eng, MD Kimberly Newell, MD John Maa, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD
Term: Jan 2010-Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD William T. Prey, MD Joseph Woo, MD
Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Adam Schickedanz, MD Rachel H.C. Shu, MD
CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate
December 2012 San Francisco Medicine
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SFMS experts answer practice-related questions
Get answers to your important practice-related questions with the help of SFMS experts. SFMS’s Ask the SFMS feature connects members with SFMS physicians and partners who can answer questions on a wide variety of topics dealing with the practice of medicine, ranging from practice management, patient education, and EHR assistance to health policy, legal/malpractice, financial management, and more! If you would like to submit a question to our experts, please email info@sfms.org.
When Can Physicians Discharge Patients? Physicians can end a doctor-patient relationship for many reasons, including a determination that the patient requires the services of a different specialist. Doctors also may discharge patients who are uncooperative, do not follow medical advice, do not keep appointments, do not pay their bills, or are disruptive or unpleasant to the staff. Caveat: Some managed care plan (MCP) contracts limit a physician’s ability to terminate doctor-patient relationships. Read managed care contracts carefully to determine if you are able to discharge assigned patients and, if so, what form of notice you must give to patients and to the MCP. If you leave a MCP that assigned patients to you, even if the plan sends its own letter advising patients, you should send a letter to each patient yourself and indicate what arrangements you have been told the MCP will make to assign the patient to a new doctor. Physicians can terminate a doctor-patient relationship for virtually any nondiscriminatory reason, provided they give the patient proper notice and do not withdraw from caring for a patient who is in the midst of a medical crisis. The decision to end a doctor-patient relationship should be made by a physician and never by office staff. 6
San Francisco Medicine december 2012
Remember to take the proper steps when discharging a patient in order to avoid a claim of abandonment. MIEC has put together a step-by-step reference guide on its website (go to miec.com and select Resources—>Publications—>Managing Your Practice #2). Claudia Dobbs is the loss-prevention manager at MIEC. MIEC is a not-for-profit professional liability insurance company, owned by the policyholders it protects. Contact her at (800) 227-4527 or claudiad@miec.com.
Should I Sign the New Blue Shield Agreement? Blue Shield is recontracting with physicians across California. The new agreements were rolled out in phases across a majority of California’s counties. According to Blue Shield, the reason for the recontracting initiative is twofold: 1) Blue Shield has not done a large-scale recontracting with physicians in more than a decade, so the new contracts will ensure consistency and compliance with new laws and regulations; and 2) Blue Shield is offering various tiered networks based on price point in anticipation of possible participation in California’s Health Benefit Exchange and other new delivery models. Exhibit A of the new Blue Shield contract allows physicians to designate which products they are willing to participate in by product type. Blue Shield has also indicated that if a physician chooses not to sign the new agreement, his or her current participation status with Blue Shield will not be affected. Blue Shield has advised SFMS/CMA, however, that physicians who do not sign and return the new agreement will receive follow-up calls and letters from Blue Shield representawww.sfms.org
tives encouraging them to sign the agreement and return to Blue Shield. It’s important that physicians understand that if they do not wish to participate in the new tiered networks offered in anticipation of the Exchange, or any other product types offered, they are not required to sign and return the new agreements. Their current participation status will not change. Physicians who want to participate in the new tiered networks will need to decide whether they wish to opt out of any product types and affirmatively do so by checking those product type boxes in Exhibit A number 2, then sign and return the
agreement to Blue Shield. As indicated in Exhibit A number 2, by checking the box the physician is stating he/she does not agree to participate in that product. A box left blank indicates the physician agrees to participate in that product. SFMS has also prepared answers to the most common questions received from physicians about the new contracts. See http://bit.ly/TRejpU. If you are an SFMS member requiring assistance with Blue Shield contracting, please contact our toll-free reimbursement helpline at (888) 401-5911 or email economicservices@cmanet.org.
2013
Attend the biggest membership event of the year Cocktail Reception 6:30 PM Dinner & Program 7:30 PM
SFMS Annual Dinner Thursday, January 31, 2013 NETWORK WITH COLLEAGUES, MEET SFMS LEADERS, AND CELEBRATE 145 YEARS OF PHYSICIAN ADVOCACY AND CAMARADERIE AT THE SFMS ANNUAL DINNER! President-Elect Shannon Udovic-Constant, MD and the San Francisco Medical Society request the pleasure of your company at the
Concordia - Argonaut 1142 Van Ness Avenue , San Francisco Special Guest Speaker: Catherine R. Lucey, MD Professor of Medicine/Vice Dean for Education - UCSF School of Medicine
RSVP Required For more information www.sfms.org/events.aspx
www.sfms.org
December 2012 San Francisco Medicine
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Expanding your expertise with ours.
When you refer your patients to John Muir Health, you can be confident they will receive exceptional care from a dedicated team of experts. Our highly experienced medical specialists provide a comprehensive, multidisciplinary approach that offers a continuum of clinical expertise across a full range of services. • Behavioral Health Center • Cancer Institute • Cardiovascular Institute • High-Risk OB • Inpatient Rehabilitation Services • Level III NICU
John Muir Medical Centers, Concord and Walnut Creek, California 9
San Francisco Medicine December 2012
• Level II Trauma Center • Neurosciences Institute • Orthopedics Institute • Pediatrics • Surgical Services • Weight-Loss Surgery
johnmuirhealth.com www.sfms.org
PRESIDENT’S MESSAGE Peter J. Curran, MD
A Year in Reflection, and Then What? Trying to summarize the last twelve months in organized medicine initially felt like New Year’s resolutions: more good intentions than positive results. The unsustainable Sustainable Growth Rate and the looming annual Medicare cuts (now reduced to a footnote beside the Fiscal Cliff) are still with us. The San Francisco Board of Supervisors continues to put good reason to the test, from reinstating a fallen sheriff to seemingly prioritizing a city nudist ban over getting a new hospital built. But then I read an op-ed on an unrelated topic from Harvard history professor Niall Ferguson that made my jaw drop and gave me renewed hope. Ferguson believes that the production of natural gas and oil from shale formations via the process of “fracking”—forcing open rocks by injecting fluid into cracks— will revolutionize energy production in the U.S., creating millions of jobs in the energy and supporting sectors and kicking off a renaissance in manufacturing in this country because of cheaper energy. A couple weeks ago the International Energy Agency predicted that the U.S. would pass Saudi Arabia as the world’s largest oil producer and would achieve near energy independence by the 2030s. Although some real environmental concerns remain over fracking, and alternative clean energy development should remain a focus in national energy policy, the U.S. energy situation has improbably gone from dependence and deficits to an economic game changer. A similar scenario is achievable in organized medicine over the next few years. Congress now realizes that it will need physicians’ input to finally achieve the “SGR fix.” On October 15, the American Medical Association and other medical groups wrote a letter to Congress outlining core principles of increased beneficiary choices, infrastructure investments, and physician pay that reflect costs to physicians, as Medicare moves away from a one-size-fits-all, feefor-service payment delivery system. Will organized medicine, in the process, transform from being simply reactive to threats of reimbursement cuts to being an integral part of the solution through health care delivery innovation— opening a new golden age in medicine? The SFMS and CMA have already made a substantial investment in the future by providing dues-free membership to all medical students and residents, and the CMA has started scholarship programs at UCLA and UCSF. While the overall membership has been greying at the CMA over the past couple of decades, the next term of officers at the SFMS is younger than ever. The future of effective health www.sfms.org
care policy depends on tapping the potential of these nextgeneration game changers. What do I see in the crystal ball for health care in San Francisco? Yes, a new hospital will be built, with a business plan that starts and ends with embracing the communities it serves. Health care organizations will continue a consolidation frenzy, rivaling the banking industry of a decade past. The Bay Area will be a model of high-quality, lowcost health care for the rest of the country to emulate. And your San Francisco Medical Society will be ready to meet all of the challenges and opportunities in health care reform head-on. Thank you for the privilege of serving as president of SFMS this year.
December 2012 San Francisco Medicine
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Practices affiliated with Hill Physicians Medical Group retain their independence while enjoying the support of a large, well-integrated network of providers. Hill’s advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,700 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians one of the nation’s leading Independent Physician Associations. Get more for your practice and your patients by affiliating with Hill Physicians Medical Group. Get more information at www.HillPhysicians.com/Providers or contact: Bay Area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com
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Anthem Blue Cross, Blue Shield,2012 CIGNA, Health Administrators (San Joaquin), Health Net, United Healthcare WEST andwww.sfms.org San Francisco Medicine December Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt in.
2013 SFMS ELECTION RESULTS 2013 Officers (one-year term) President Elect Lawrence Cheung, MD Secretary Man-Kit Leung, MD Treasurer Roger S. Eng, MD Editor Gordon L. Fung, MD
2012 President-Elect, Shannon Udovic-Constant, MD, will automatically succeed to the office of President. 2012 President, Peter J. Curran, MD, will automatically succeed to the office of Immediate Past President.
Board of Directors Seven elected for three-year term 2013-2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph W. Woo, MD
Solo/Small Group Practice Forum Delegate Two-year term 2013-2014 Eric Tabas, MD
www.sfms.org
Nominations Committee Four
Delegates to the CMA HOD
elected for two-year term 2013-2014 Izumi N. Cabrera, MD Justin V. Morgan, MD Calvin S. So, MD Yanling Xu, MD
Two-year term 2013-2014 Delegates Elizabeth A. Andrews, MD Lawrence Cheung, MD (serves automatically as President-Elect) Gordon L. Fung, MD Adam Schickedanz, MD Andrea M. Wagner, MD Alternates Peter J. Curran, MD Mihal L. Emberton, MD Steven H. Fugaro, MD Robert J. Margolin, MD H. Hugh Vincent, MD
CMA Trustee Three-year term Oct., 2012–Oct., 2015 Shannon Udovic-Constant, MD
December 2012 San Francisco Medicine
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Sexual Health and Fertility
Male infertility treatments How Good Are They? Paul J. Turek, MD, FACS, FRSM
The care of human infertility is unique in clinical medicine. Treating infertile couples addresses both biologi-
cal and medical needs, with equally dramatic effects on quality of life. Well-heeled in the “know after you go” philosophy, infertility medicine is relentless in its grasp of new technology, well before any rigorous research has shown efficacy or cost effectiveness. Add to this the increased delay in childbearing by reproductive-age women and, voilà, a newfound “urgency” becomes part of the reproductive equation. Flush with this mindset, many consider technology, such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), to be the ideal treatment for male factor infertility, regardless of cause. To a hammer, everything is a nail. On the other hand, others (like myself) view technology as a craftsman might: different tools for different solutions. My job is to convince you that in the era of IVF-ICSI, classical treatments for male factor infertility are not only worthwhile and cost effective but also uphold the medically revered concepts of “healing” and “prevention.”
Male Factor Evaluation: Short, Sweet, and Cheap
I am amazed that insurance companies have not caught wind of this yet: Male factor infertility accounts for 30 to 40 percent of couple infertility and costs only a fraction of what a female evaluation costs to perform. This pillar of cost-effective care is well known to socialized medicine plans in most European countries, but it somehow escapes us here in the U.S. Yet there are other, more compelling, reasons to begin with the male in the evaluation of the infertile couple.
Male Infertility and Concurrent Disease
Approximately 1 to 5 percent of male infertility is caused by a potentially life-threatening disorder (Table 1). Although uncommon, this has led to current thinking that male infertility, and the semen analysis in particular, may be considered a 12 13
San Francisco Medicine December 2012
“biomarker” of men’s health. Indeed, this concept is highlighted in the recently issued white paper on reproductive health issued by the NICHD in 2011, which sought to develop a scientific vision of reproductive health research over the next decade.1 Reason one for the male factor evaluation: Make sure that he is healthy!
Male Infertility and Future Disease
The concept that male infertility might be associated with the development of diseases later in life stemmed from basic science research on DNA mismatch repair. Animal models in which mismatch repair genes were knocked out were noted to be infertile, and most were completely sterile. These same animals also developed certain cancers, such as retinoblastoma, melanoma, and colon cancer (nonpolyposis), at much higher rates than wild-type controls. It is now theorized that this may in fact be the first hit of the “two-hit” theory of carcinogenesis: the inability to repair the second hit and the increased propensity to develop cancer. Since then, we and others have published compelling data garnered from large (50,000-subject) long-term (25 years) epidemiologic studies that a history of male infertility characterized by low sperm counts is associated with the development of both testis cancer (threefold higher risk) and high-grade prostate cancer (2.5-fold higher risk) later in life.2,3 Although needing further confirmation, an infertility history is one of the strongest risk factors yet described for these cancers. Reason two for the male factor evaluation: Make sure that he stays healthy!
Male Infertility Is Often Curable
Admittedly, the condition of varicocele, the dilated veins in the scrotum that occur in 40 percent of infertile men, has its proponents and detractors in the field. Some call it “the most common correctable cause of male infertility known” and others ignominiously consider it “the male endometriowww.sfms.org
sis.” Regardless, it is simple to treat and, in the right setting— clear of other causes and with adequate maternal reproductive potential—such treatment can entirely reverse infertility at two to three times placebo rates. And families are created at home rather than in the IVF laboratory. Witness, too, the utter reversibility of infertility-inducing environmental exposures such as hot tubs, baths, and medications such as calcium channel blockers, sulfasalazine, and finasteride. Reason three for the male factor evaluation: Make sure he is rid of poisons!
Male Infertility Treatments Are Cost Effective
Even eliminating the expense factor, is it difficult to carry out prospective, randomized, controlled clinical trials in reproductive medicine. Similar to the proliferation of robots and lasers in medicine, the latest and greatest gadgets meet with doe-eyed acceptance by both clinicians and patients in our technology-gilded culture. I, for one, believe that, in many cases, classical treatments for male infertility outperform IVFICSI in terms of cost benefit and cost effectiveness. A far cheaper and faster alternative to a randomized study of surgical treatment or assisted reproduction for male factor infertility is to apply decision analysis and Markov modeling.4,5 Decision models are constructed with predefined assumptions and serve as useful tools for estimating outcomes when complex medical treatments are available. Thousands of theoretical “patients” are entered into the algorithm and outcomes assessed. To study the value of varicocele repair and vasectomy reversal, we used outcome probabilities derived from institutional and published sources, performed sensitivity analyses to determine which elements were most important, and calculated threshold values. Overall, varicocele surgery was found to be more cost effective than IVF as long as pregnancy rates of greater than 14 percent were achievable with surgery (we typically see 30 to 35 percent pregnancy rates after surgery) and that there was adequate female maternal potential. After a similar analysis of vasectomy reversal, we concluded that it is often more cost effective than assisted reproduction, especially if vasectomy reversal patency rates (i.e., achieving motile sperm in the ejaculate) are above 79 percent. We then performed a more sophisticated decision analysis that incorporated changes in health states over time, using Markov modeling to investigate the influence of maternal age on cost effectiveness of male infertility treatments. Lo and behold, and maybe not unexpectedly, the impact of female partner age on cost effectiveness of male surgical treatments was large—actually very large—and influenced outcomes more than the surgeon’s ability to improve semen quality. In summary, these decision science studies suggested that for classical surgical treatments to best assist reproduction in the treatment of male infertility, reproductive surgeons must be good at what they do and a serious dollop of respect must be accorded to female age and reproductive potential. The intrinsic value of classic medical and surgical treatments for male infertility has recently been challenged by assisted reproduction. However, the evaluation and treatment of male infertility is still vitally important to keep young men healthy, both now and in the future. In addition, cost-benefit www.sfms.org
analyses, decision analysis paradigms, and Markov models have shown that classic treatments for male infertility still retain value in the era of IVF-ICSI. Maybe this is why we are now witnessing a patient-driven trend toward less technology and more “home conception”-friendly therapies for male infertility.
Paul J. Turek, MD, is director of the Turek Clinic (www. TheTurekClinic.com), a men’s health clinic in San Francisco. He is a former professor of urology, obstetrics, and gynecology at the University of California, San Francisco, where he held the Academy of Medical Educators Endowed Chair in urology. An SFMS member since 2007, he is an active clinician and recognized international authority on men’s health issues. He is past president of the American Society of Andrology and the Northern California Urology Society, and he is president-elect of the Society of Male Reproduction and Urology. Dr. Turek is the editor of the Reproductive Volume of Netter’s Images, second edition. He maintains an active blog at www.TurekonMensHealth. com. He recently helped found a volunteer medical clinic, powered by retired physicians, for the working uninsured (www. ClinicByTheBay.org).
References 1. http://www.nichd.nih.gov/vision/comments/whitepapers/NICHD_Reproduction_Vision_White_paper_030511.pdf. 2. Walsh TJ, Schembri M, Chan JM, Croughan MS, Turek PJ. Increased risk of testicular cancer among infertile men. Arch Int Med. 2009; 169(4):351-6. 3. Walsh TJ, Schembri M, Turek PJ, Chan JM, Carroll PR, Smith JF, Eisenberg ML, Van Den Eeden SK, Croughan MS. Increased risk of high-grade prostate cancer among infertile men. Cancer. 2010; 116: 2140. 4. Meng M, Green K, Turek PJ. Surgery or assisted reproduction? A decision analysis of treatment costs in male infertility. J. Urol, 2005; 174: 1926-31. 5. Hsieh M, Meng M, Turek PJ. Markov modeling of vasectomy reversal and ART for infertility: How do obstructive interval and female partner age influence cost-effectiveness? Fertil Steril. 2007 Jun 1; 88: 640-6; 2007 [Epub].
Table 1: Medical Conditions That Underlie Male Infertility
Prolactinoma Testicular cancer Diabetes mellitus Multiple sclerosis Hypogonadism Retroperitoneal tumors Sexually transmitted diseases Obesity Varicocele Anabolic steroids Undescended testicle Occupational exposures Organ failure Chronic opiate use
December 2012 San Francisco Medicine
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Sexual Health and Fertility
Assisted Reproduction Advances and New Frontiers Liyun Lee, MD On July 25, 1978, Louise Brown was born in England, the world’s first baby conceived via in vitro fertilization (IVF). Her mother, Leslie, had been trying to
conceive unsuccessfully for nine years due to fallopian tube blockage. Thirty-two years later, Sir Robert Geoffrey Edwards, the British physiologist, was awarded the 2010 Nobel Prize in Medicine in recognition for his work in the development of IVF; more than 60,000 IVF-conceived infants were born that year in the United States. The past three decades have seen refinements in ovarian stimulation protocols and laboratory techniques that have improved success rates. Embryo cryopreservation, egg donation, and intracytoplasmic sperm injection (ICSI) have revolutionized the field of assisted reproduction technologies (ART) so that we can now successfully treat infertility diagnoses that had previously been untreatable. The U.S. live birth rate per IVF cycle using fresh autologous eggs, including all female age groups, has increased from 19.6 percent when first reported in 1995 by the CDC to 29.9 percent in 2010, and from 30 percent to 55.6 percent in cycles using fresh donor eggs. The pregnancy rate for women under the age of 35 years now approaches 50 percent. Despite those significant ART advances, only one in three women undergoing IVF using her own eggs will deliver a baby. The chances are even lower in women ≼ 40 years old: more like one in five to one in ten. On the other hand, multiple birth rate remains high (30 percent of all live births in 2010 from fresh nondonor cycles), leading to complications for both mothers and infants, including high rates of cesarean section, prematurity, low birth weight, and infant disability or death. While seemingly opposite, the two problems actually stem from the same underlying issue: The majority of eggs harvested in IVF are of poor quality. To compensate for this reproductive inefficiency, multiple embryos are routinely transferred, thus leading to multiple gestations. The key to overcoming the above-mentioned challenges is twofold: to select for high-quality embryos with accuracy and precision so that we can transfer one healthy embryo at a time; and to minimize or prevent age-related fertility decline that is at the root of this reproductive inefficiency. Fortunately, in recent years the field of ART has made significant strides in both areas.
Comprehensive Chromosome Screening: Selecting Healthy Embryos
Selecting the best embryo for transfer has traditionally been performed using developmentally specific morphologic criteria. Yet 40 to 90 percent of morphologically normal em14 15
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bryos are in fact abnormal genetically, i.e., having incorrect chromosome numbers (aneuploidy). The rates of embryonic aneuploidy increase with maternal age. In addition to implantation failure, aneuploidy accounts for 60 percent percent of first trimester miscarriages and up to 5 percent of live births in women older than 40. Therefore, the successful implementation of comprehensive chromosome screening (CCS) of embryos prior to implantation has brought tremendous excitement to our field. The concept of genetic testing of preimplantation embryos has been around since the early 1990s, with sex determination for X-linked diseases. However, attempts at aneuploidy screening had been disappointing. Single cell embryo biopsy was performed at the cleavage stage (day 2 to 3 of development), when embryos have a 30 percent chance of being mosaic, meaning that not all cells within the same embryo will have the same chromosomes. Adding to low accuracy is the test itself. Fluorescence in situ hybridization (FISH) was only possible for 13 out of 23 pairs of chromosomes, when it is evident that aneuploidy occurs across the entire chromosomal complement. Lastly, taking 1 to 2 cells from a 6- to 10-cell cleavage embryo is harmful and dampens its developmental potential. Fortunately, techniques have evolved with the times. Genetic testing platforms such as single-nucleotide polymorphism (SNP) microarray, metaphase or array-comparative genomic hybridization (CGH), or quantitative real-time polymerase chain reaction (RT-PCR) have made it possible for highly sensitive and specific comprehensive chromosomal testing. Further improving the predictive values of CCS, multicell biopsies are now performed on more advanced-stage embyros called blastocysts (day 5 to 6 of development) that have much lower rates of mosiacism (3 percent ) and are more resilient to the traumas of the biopsy. A highly efficient embryo cryopreservation technique called vitrification, rapidly cooling of the embryo to avoid ice crystal formation, allows the embryos to be stored safely while waiting for the diagnostic results of CCS. Multiple studies have demonstrated superior outcomes in IVF cycles with CCS compared to those without CCS. The implantation rates of tested euploid (having the correct number of chromosomes) blastocysts range from 41 to 72 percent, depending on the maternal age.1 The miscarriage rates are low at 10 to 18 percent , even in the 40-and-older group. At Pacific Fertility Center (PFC), we started performing CCS in 2011 using blastocyst biopsy and SNP microarray with Parental Support (Natara, Redwood City, California). We believed that CCS could improve implantation, reduce first trimester miscarriage, and lower the risk of having a baby with Down syndrome. CCS would also be a powerful embryo sewww.sfms.org
lection tool to encourage elective single embryo transfer for the prevention of multiple gestation. From January to August 2012, we transferred 38 euploid embryos tested by CCS in 33 frozen embryo transfer cycles where a majority of patients elected to transfer only one embryo. Our overall implantation rate (including all age groups) is 73.7 percent (88 percent to 33 percent, from <35 years to ≥42 years). Comparatively, the implantation rate of untested frozen embryos was 54 percent overall (66 percent to 25 percent ). This represents a 28 percent improvement and is statistically significant (relative risk 1.28, 95 percent confidence interval 1.02-1.61).
Fertility Preservation: Combating AgeRelated Fertility Decline
Because eggs are endowed during fetal development and undergo irreversible decline without regeneration, age is therefore the most powerful predictor of fertility. Age-related fertility decline is the diagnosis that accounts for the majority of IVF cycles in the U.S. (43 percent in 2010), and perhaps even more so in the metropolitan Bay Area. At PFC, 64 percent of our cycles in 2010 were in women ≥37 years. Despite the recent excitement generated by a group of Japanese scientists who have reported the reprogramming of mouse somatic cells to become egg stem cells, regeneration of human eggs remains elusive. Without genetically manipulating our skin cells to become eggs, which can carry unforeseen health risks, egg freezing is a much simpler and safer way to preserve a woman’s fertility. The world’s first baby born from a frozen egg was reported in 1986. However, historical success rates with respect to survival, fertilization, and pregnancy have been low using the slow-freeze method. Mature eggs are harvested after supraovulation, when they are arrested in metaphase II of meiosis. The meiotic spindle apparatus are fragile structures that can easily be damaged by intracellular ice crystal formation during freeze and thaw. Vitrification, the rapid cooling of eggs from a liquid to glass state, minimizes ice crystallization. This technique has significantly improved egg survival and pregnancy rates. Randomized controlled trials (RCT) from Europe comparing vitrified (n=3578) to fresh (n=3692) eggs from both donors and infertility patients <43 years old have demonstrated a survival rate of 89.9 percent to 96.8 percent, a fertilization rate of 71 percent to 79.2 percent (fresh: 72.6 percent to 83.3 percent ), a clinical pregnancy rate (CPR) per transfer of 35.5 percent to 60.8 percent (fresh: 13.3 percent to 100 percent ), and a CPR per egg of 4.5 percent to 12 percent.2 Retrospective studies from the U.S. with smaller numbers reported similar results with a CPR per egg of 4 to 5 percent. PFC’s unpublished data showed a live birth rate of 6 percent per vitrified donor egg, which is on par with the published literature. Not surprisingly, pregnancy rates with frozen eggs decrease with increasing maternal age, similar to fresh IVF. A 5 to 10 percent live birth rate per egg may seem small, but it translates to a real and respectable chance of having a baby if one considers that 10 to 20 eggs are likely to be harvested from one treatment cycle. Although safety data are limited, reviews of more than 200 infants born from vitrified eggs www.sfms.org
and 900 infants from slow-frozen eggs showed comparable risks of congenital abnormalities and birth weight compared to the general U.S population. Given the data, both the European Society of Human Reproduction and Embryology (ESHRE)3 and the American Society for Reproductive Medicine (ASRM) have announced in 2012 that egg freezing is no longer considered experimental. ESHRE went even further to recommend that egg freezing should be available not only to women facing the loss of fertility from cancer treatment but also to women who want to “protect their reproductive potential against the threat of time” and who want to postpone childbearing regardless of motive.
The New Frontier
The progress made in the field of ART in the past 35 years is staggering and has helped millions of patients build the family of their dreams. CCS and oocyte cryopreservation have added to the ranks of ICSI and oocyte donation as practicechanging breakthroughs that have already started and are certainly going to shape the way we treat fertility care in the future. However, as clinicians we must exercise caution when promoting new technology to our patients, and we must be able to provide appropriate counseling regarding the lack of long-term safety data. In the case of fertility preservation, it is paramount that we do not raise false hope for women seeking to delay childbearing, especially those who are older. While we have come a long way, much more work is ahead on our path to help men and women reach their reproductive potential, one healthy baby at a time. Dr. Liyun Li graduated Phi Beta Kappa with a bachelor of science degree from the Massachusetts Institute of Technology (MIT) and received her medical degree cum laude from Harvard Medical School in the Harvard–MIT Division of Health Sciences and Technology (HST) program. She completed her residency in obstetrics and gynecology at the University of California, San Francisco, and her fellowship in reproductive endocrinology and infertility at Columbia University Medical Center, New York. An SFMS member since 2011, she is currently a practicing reproductive endocrinologist at Pacific Fertility Center in San Francisco.
References 1. Schoolcraft W, Fragouli E, Stevens J, Munne S, Katz-Jaffe MG, Well D. Clinical application of comprehensive chromosomal screening at the blastocyst stage. Fertil Steril. 2010; 94:5, pp.1700-6. 2. The Practice Committees of the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology. Mature oocyte cryopreservation: A guideline. Fertil Steril. 2012 Oct 12. 3. Dondorp W, de Wert G, Pennings G, Shenfield F, Devroey P, Tarlatzis B, Barri P, Diedrich K. Oocyte cryopreservation for age-related fertility loss. ESHRE Task Force on Ethics and Law. Hum Reprod. 2012; 27(5):1231-7.
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Sexual Health and Fertility
To psa or not to psa The Great Prostate Screening Debate Justin Quock, MD Prostate cancer is the second most common cancer in men and the second cause of cancer death in the United States. For this reason, there is a need to
detect it in its early stages, thereby increasing the chance of cure and thus a patient’s longevity. Since the late 1980s, PSA testing has been ordered by physicians. It was originally used in following already diagnosed or treated cases. Because it was helpful in prostate cancer management, this practice led to a trend in using it as a preventive tool. However, such practice was not supported by large randomized studies. Observational evidence showed a drop in mortality in prostate cancer in the 1990s that was considered related to PSA testing. Unfortunately, large studies in both the United States and other countries could not consistently reproduce the absolute mortality improvement that supported observational and intuitive findings. Since October 2011, the U.S. Preventive Task Force Initiative has recommended against prostate cancer screening. After scouring the available data, the group could not find strong enough data to support PSA testing as part of the routine annual preventive care examination. For example, by the late 1990s, it was already known that elevated PSAs did not always prove prostate cancer after biopsy or prostatectomy. Men were sent for unnecessary testing that could lead to procedure-related side effects like bleeding, infection, and, in worst cases, a procedure-related hospitalization. In addition, the potential long-term consequences on sexual function or chances of urinary complications were very real. Another concern was the overdiagnosis of prostate cancer. Retrospective studies on autopsy cases showed that men who had prostate cancer confined to the gland alone died of a cause rather than the disease itself. Thus, an elevated PSA may have led to an earlier diagnosis of cancer, but it didn’t have any bearing on the patient’s life expectancy.
Other professional societies have also weighed in with their recommendations.
The American Cancer Society stresses the need for men to make an informed decision prior to PSA testing. For those who decide to test, a man at fifty years may get a PSA with or without a digital rectal exam. Annual testing is recommended for men with a PSA of 2.5 ng/mL or greater and, if lower, testing every two years is reasonable. For patients with high-risk features (family history of a first-degree relative with prostate cancer diagnosed before age sixty-five or African-American), testing is annual and a referral for prostate biopsy should occur if the PSA is 4 ng/mL or greater. 16 17
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The American Urological Association recommends that annual screening include both a PSA and digital rectal exam starting for the average-risk male at age forty if life expectancy is greater than ten years. When to stop screening and when to undergo a biopsy depends on each individual case.
The American College of Physicians emphasizes the importance of a discussion explaining both the risks and benefits of prostate cancer screening. If accepted, it is reasonable to start PSA testing between fifty and sixty-nine years of age. Black men and men with a family history of prostate cancer should be informed of their higher likelihood of recurrence, but they should also know that the available evidence does not support the need to be treated differently from men with average risk. In summary, the above professional societies all stress the importance of informed decision making. They also emphasize considering the following points during the patientdoctor visit: • Make the decision of whether to be screened or not. • Prostate cancer screening may reduce the chance of dying from the cancer, but not all studies repeatedly support this finding. • If an elevated PSA leads to a workup that confirms cancer, such a diagnosis may not affect a patient’s lifespan. • Following prostate biopsy-confirmed cancer, the decision for treatment of early-stage disease can lead to treatment plans, i.e., surgery or radiation therapies that can lead to effecs on urinary, bowel, and sexual function. • Currently, no study can accurately determine which men with cancer found by screening are likely to benefit from aggressive treatment. Most men with prostate cancer will die from other causes. • If a foreseeable cure is expected after early detection of prostate cancer, then in order to achieve a benefit, one may need to proceed with aggressive therapy.
Once PSA testing has been agreed upon, the following are guidelines for the primary care physician: • For the general population with no family history of prostate cancer, testing can occur at fifty years of age, but it is not recommended for patients who may have other comorbidities that could limit their life expectancy to less than ten years. • African-Americans and men with a family history of prostate cancer, particularly those with the BRCA1 or BCRA2 mutations, should first discuss screening at age forty to fortyfive. www.sfms.org
• Routine PSA testing can be done at intervals of every two to four years for the average-risk individual. • An elevated PSA (>4 ng/mL) should be referred to urology for potential biopsy. • An abnormal digital examination of the prostate should be referred to urology.
Since we are living longer, our risk of developing cancer and dying from it increases. PSA testing for the screening of prostate cancer did show improvements in prostate cancer mortality, but unfortunately this is not consistently reproduced through randomized studies. On the other hand, there does not appear to be evidence to support against prostate cancer screening. Subsequent workup and treatment of cancer following an elevated PSA can have concerning side effects that harm quality of life, such as affecting voiding, bowel movements, and sexual function. Such issues could be avoided, especially among the very elderly, whose life expectancies are less than ten years. Certainly a new, more reliable test in the screening for prostate cancer will need to be developed, followed by a test that can help determine its aggressiveness. In so doing, it will provide more valuable information to help both patient and doctor about how to proceed. For example,
does one opt for watchful waiting or for treatment? But for now, it is agreed that the decision to screen will be up to the informed consent of the patient, following a detailed dialogue with his physician.
Online Resources
U.S. Preventive Services Task Force: www.uspreventiveservicestaskforce.org/index.html American Cancer Society: www.cancer.org American Society of Clinical Oncology: www.asco.org/pco/psa American Urological Association: www.auanet.org/ American College of Physicians: www.acponline.org UpToDate: www.UpToDate.com Dr. Quock practices internal medicine and medical oncology in Chinatown. He is a graduate of St. Ignatius College Preparatory and the University of San Francisco. He received his medical doctorate from the Chicago Medical School and returned to his roots after he did his residency at U.C. Davis Medical Center and his fellowship training at U.C. Davis Cancer Center in 1999. He currently serves as vice chief of the Department of Internal Medicine at Chinese Hospital.
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December 2012 San Francisco Medicine
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Sexual Health and Fertility
Cancer, fertility, and sex Improving Quality of Life for Men with Cancer James F. Smith, MD, MS John, a twenty-three-year-old man with a history of testicular cancer, presented to his oncologist in early 2012 with a solid mass in his left testicle. He had previously undergone a right orchiectomy in 2008, four cycles of BEP chemotherapy, and, later, a lymph node dissection for retroperitoneal masses. Since his initial diagnosis and treatment, his primary care doctor and oncologist had monitored him closely for recurrence of his testicular cancer. Unfortunately, his cancer did recur. John was unmarried, but he had a strong desire to have a family in the future, making fertility preservation a crucial component to his care. Between 2003 and 2007, almost 375,000 new malignancies were diagnosed among men in California.1
Significant advances in cancer treatment over the past several decades have led to dramatic improvements in survival, allowing these cancer survivors to shift their focus from battling cancer to addressing important quality-of-life issues. Although survival and disease cure remains their top priority, effects of treatments on their ability to father children and have normal sexual relations are critical considerations for these men.2 Unfortunately, one of the primary side effects of nearly all cancer treatment is temporary or permanent sterility3 and, in some cases, concurrent declines in sexual function.4,5 Cancer treatments including chemotherapy, surgery, radiation, and novel targeted therapies can have significant reproductive implications. Chemotherapy is often associated with defects in sperm production that can permanently impair fertility.3 Some surgical interventions such as pelvic, back, or retroperitoneal procedures have the potential to eliminate the ability of a man to ejaculate.6 For men with testicular cancer, radical orchiectomy removes one source of sperm production and testosterone; however, usually the remaining testicle is able to produce enough sperm and testosterone to minimize the impact on fertility. Radiation therapy has the potential to cause permanent injury to sperm and testosterone production, depending on its dose and location. Novel targeted therapies such as tyrosine kinase inhibitors have led to advances in treatments for a range of malignancies, including chronic myelogenous leukemia, gastrointestinal stromal tumor, hepatocellular carcinoma, and metastatic renal cell carcinoma. 18 19
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Although a few case reports suggest impaired sperm quality, very little is known about the reproductive effects of these agents, despite their growing use against a wide range of malignancies. From a fertility-preservation standpoint, the most important factor is to acknowledge its importance to patients very early in the cancer diagnostic process. Fertility preservation for most post-pubertal men is straightforward and involves banking sperm. This highly effective technique requires advance planning and needs to be done before initiating most cancer treatments. In many centers, fertility preservation counseling by urologists can facilitate any needed treatment.7 For the 5 to 10 percent of men who are unable to produce adequate semen samples or have azoospermia,8 outpatient surgical procedures can preserve testicular tissue directly. The biggest challenge in fertility preservation is for prepubertal boys. While many cancer treatments have the potential to cause permanent sterility for these children, no established technique can preserve their fertility.9 The only fertility preservation option that exists for these boys is to perform a testicular biopsy with long-term cryopreservation of this tissue. Ethical concerns exist about performing this procedure, given no currently demonstrated benefit in humans.10 Despite these concerns, success in animal models11 suggests strong future potential benefit for these children. Furthermore, the risk of testicular biopsy for these patients has been shown to be low.12 John was offered sperm cryopreservation and attempted to produce a semen sample. Unfortunately, as for some men who have had spinal or retroperitoneal surgery, he was unable to ejaculate. Modern template or â&#x20AC;&#x153;nerve sparingâ&#x20AC;? retroperitoneal lymph node dissections are associated with a very low risk of anejaculation; however, for men who have had chemotherapy, this nerve-sparing approach is not always possible, rendering 25 percent or more of these men unable to ejaculate.13 As John is about to have his remaining testicle removed for recurrence of testicular cancer, his only fertility preservation option was to have a TeSE (testicular sperm extraction) at the same time as his orchiectomy. This procedure was performed for John and sperm was successfully found. This sperm was frozen and will be available to John and his future partner to achieve a pregnancy using advanced reproductive techniques (ART).8 After cancer treatment, if men do not have enough sperm for spontaneous pregnancy, ART such as intrauterine insemination (IUI) and in vitro fertilization (IVF) can be highly effective even with dramatically lower sperm concentrations. Men who continue to have low sperm concentrations may www.sfms.org
be candidates for using IUI. For men with zero sperm counts (azoospermia) as a result of chemotherapy or radiation treatment, outpatient surgical sperm retrieval can obtain sperm in 50 percent or more of men.14 These techniques are even more effective (95-plus percent) for men who are unable to ejaculate after surgical cancer treatments. This surgically obtained sperm is used in conjunction with IVF to conceive a pregnancy. Relieved to have banked sperm, John feels reassured that his ability to father children in the future has been preserved. However, he reports that since his orchiectomy, he has had a declining interest in sex and worsening ability to achieve an erection. Cancer treatments can impair sexual function. The stress of treatment can impair libido, decrease penile sensation, and cause erectile dysfunction. Narcotic medications given during or after treatment can impair a man’s ability to achieve an erection or climax normally. Surgery and radiation therapy for pelvic malignancies (e.g., prostate cancer or bladder cancer) can lead to temporary or permanent erectile dysfunction. Bilateral orchiectomy eliminates a man’s ability to produce physiologic levels of testosterone. Low testosterone is strongly associated with a decline in libido and is likely a primary factor in John’s sexual dysfunction. Several treatment options exist to treat low testosterone. Creams, gels, and a transdermal patch require daily application. Patients can give themselves testosterone injections on a weekly or biweekly basis. For many men, implantable forms of testosterone are becoming popular. This option requires a minor office procedure every three to four months. John has elected to start with testosterone injections and finds that his interest in sex is returning, along with normalization of his testosterone levels, but he reports continuing difficulties achieving a rigid erection. Fortunately, a range of medical options is available to treat erectile dysfunction. First-line therapy includes oral phosphodiesterase inhibitors (i.e., sildenafil, tadalafil, vardenafil). Younger patients are almost always treated adequately by these methods. As the stress of treatment declines, particularly in supportive relationships, sexual function in many cases can return to normal. For some treatments (e.g., prostate cancer surgery or radiation), recovery of sexual function is a slow process and can take a year or more. When oral medications and supportive measures are ineffective, second-line treatments are often effective: vacuum erection devices, intraurethral suppositories, or penile injections with vasoactive medication. For the small number of men in whom these treatments do not achieve adequate results, the surgical implantation of a penile prosthesis provides excellent results. Happily for John, low-dose treatment with oral PDE5 inhibitors was effective. Although cancer treatments have a big impact on fertility and sexuality, a number of successful options exist to improve the quality of life of these patients. Promising research on the horizon offers hope for patients in the future. Given advances in cancer treatments, John is likely to be cured of his cancer. Improvements in fertility treatments and the management of sexual function are instrumental to improving his quality of life. www.sfms.org
James F. Smith, MD, MS, is assistant professor and director of male reproductive health in the UCSF Department of Urology, specializing in the treatment of men with fertility problems, erectile dysfunction, and hypogonadism. His primary research seeks to understand socioeconomic disparities in fertility treatment and the effect of cancer treatment on male reproductive and sexual function. He received a bachelor’s degree in molecular and cellular biology from U.C. Berkeley, a master’s degree from the U.C. Berkeley Joint Medical Program, and a medical degree from UCSF. He completed a urology residency at the University of Utah and a sexual medicine and reproductive urology fellowship at UCSF.
References 1. SEER Cancer Statistics Review, 1975-2008. Accessed 2011, at http://seer.cancer.gov/csr/1975_2008/. 2. Schover LR, Brey K, Lichtin A, Lipshultz LI, Jeha S. Knowledge and experience regarding cancer, infertility, and sperm banking in younger male survivors. J Clin Oncol. 2002; 20:1880-9. 3. Ragheb AM, Sabanegh ES Jr. Male fertility: Implications of anticancer treatment and strategies to mitigate gonadotoxicity. Anticancer Agents Med Chem. 2009; 10:92-102. 4. Aksoy S, Harputluoglu H, Kilickap S et al. Erectile dysfunction in successfully treated lymphoma patients. Supportive Care in Cancer. 2008; 16:291-7. 5. Bessede T, Massard C, Albouy B et al. Sexual life of male patients with advanced renal cancer treated with angiogenesis inhibitors. Annals of Oncology. 2011; 22:2320-4. 6. Large MC, Sheinfeld J, Eggener SE. Retroperitoneal lymph node dissection: Reassessment of modified templates. BJU Int. 2009; 104:1369-75. 7. Sheth KR, Sharma V, Helfand BT et al. Improved fertility preservation care for male patients with cancer after establishment of formalized oncofertility program. J Urol. 2012; 187:979-86. 8. van Casteren NJ, van Santbrink EJ, van Inzen W, Romijn JC, Dohle GR. Use rate and assisted reproduction technologies outcome of cryopreserved semen from 629 cancer patients. Fertil Steril. 2008; 90:2245-50. 9. Aslam I, Fishel S, Moore H, Dowell K, Thornton S. Fertility preservation of boys undergoing anticancer therapy: A review of the existing situation and prospects for the future. Hum Reprod. 2000; 15:2154-9. 10. Murphy TF. Parents’ choices in banking boys’ testicular tissue. J Med Ethics. 2010; 36:806-9. 11. Sato T, Katagiri K, Gohbara A et al. In vitro production of functional sperm in cultured neonatal mouse testes. Nature 2011;471:504-7. 12. Wyns C, Curaba M, Petit S, et al. Management of fertility preservation in prepubertal patients: Five years’ experience at the Catholic University of Louvain. Hum Reprod. 2011; 26:737-47. 13. Heidenreich A, Pfister D, Witthuhn R, Thuer D, Albers P. Postchemotherapy retroperitoneal lymph node dissection in advanced testicular cancer: Radical or modified template resection. Eur Urol. 2009; 55:217-24. 14. Schrader M, Muller M, Sofikitis N, Straub B, Krause H, Miller K. “Onco-tese”: testicular sperm extraction in azoospermic cancer patients before chemotherapy—new guidelines? Urology. 2003; 61:421-5. December 2012 San Francisco Medicine
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Sexual Health and Fertility
Contraception update A Survey of Various Methods Lily Tan, MD Birth control, the use of medicines, methods, or devices to prevent pregnancy, has been in use for all of recorded human history. Yet unintended preg-
nancy remains a common problem in the United States. According to a study released by the Guttmacher Institute, a nonprofit organization focused on sexual and reproductive health, 49 percent of the 6.7 million pregnancies in the U.S. in 2006 were unintended. About 5 percent of reproductive-aged women had an unintended pregnancy that year, comprising 3.2 million pregnancies total. Forty-three percent of these unintended pregnancies were terminated. In fact, by age 45, more than 50 percent of all American women will have experienced an unintended pregnancy, and 30 percent will have had an abortion. These alarming statistics are all the more bewildering when one considers that most women are very aware of birth control options and the majority report actually using some form of contraception.
The high rate of unintended pregnancy despite contraception highlights the importance of selecting contraception appropriate to a womanâ&#x20AC;&#x2122;s lifestyle. Health care providers must not only have full knowledge of all available contraceptive options and their efficacies, which we will review below, but must also consider factors such as cost, safety, availability, and personal acceptability to patient and partner in order to select a birth control method that will most likely be successful for any given patient. Birth control may be divided into several broad categories, with some methods falling into more than one category. All methods involve preventing union of sperm with egg or preventing implantation if fertilization has occurred. These categories include natural family planning, spermicides, barrier methods, hormonal methods, intrauterine devices, permanent sterilization, and postcoital/emergency contraception. Natural family planning encompasses methods that require abstinence during times when fertilization may occur. These methods, which are not recommended where contraception is strongly desired, include ovulation awareness, mucus inspection, tracking cycle dates, basal body temperature recording, and symptothermal methods that combine several aspects of these natural methods. Most studies demonstrate a 20
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failure rate of about 24 percent with natural family planning or withdrawal use. There is no financial cost to these methods, but they may be time-intensive and require a relatively higher degree of responsibility. Spermicides are contraceptive substances that kill sperm, the most well known being nonoxynol-9. They may be used alone, which is associated with a 20 to 50 percent failure rate, or to boost the efficacy of other contraceptives, such as the sponge, condom, or diaphragm. The CDC does not recommend spermicide use alone, citing studies that demonstrate increased risk of HIV transmission with spermicide use. Spermicides have also been shown to shorten the shelf life of condoms and to increase the risks of female urinary tract infections. The sponge, a pseudo-barrier method that relies on spermicide, has a 16 to 32 percent failure rate. Barrier methods of contraception are physical barriers that prevent the passage of sperm into the uterus. They include condoms, cervical caps, and diaphragms. Major advantages of male and female condoms include their ready availability, affordability, and efficacy in protecting against STDs, including HIV, gonorrhea, chlamydia, syphilis, trichomoniasis, and hepatitis. Regular use of latex condoms appears to decrease the risk of HIV infection only by about 69 percent, however, and they are much less reliable for protection against genital herpes or warts. Patients should also be advised that oil-based lubricants, like petroleum jelly, weaken latex condoms and lower their effectiveness against STDs; water-based lubricants, like K-Y Jelly or Astroglide, are safe. Overall, condoms have about a 14 to 15 percent failure rate. Diaphragms are soft latex or silicone domes that create a seal against the vaginal walls to provide a physical barrier between the sperm and the cervix, while cervical caps provide a similar barrier over the cervix alone. Both are designed to be used in conjunction with spermicides. These barrier methods require insertion prior to intercourse and should remain in place for six to eight hours after the last sexual act, but not more than twenty-four to forty-eight hours total. Additional spermicide should be used for repeated acts of sex during this time period. Women must be fitted for diaphragms and cervical caps, and refitting is advised with any weight change of more than ten to twenty pounds or after pregnancies of greater than fourteen weeks. Diaphragms and cervical caps have the benefit of cost effectiveness, as a silicone diaphragm may last up to ten years. However, they may increase the risks of vaginal irritation and urinary tract infections. They also require formal fitting and training to use and have a relatively high failure risk of up to 40 percent. Hormonal methods of contraception include the Pill, the www.sfms.org
mini Pill, NuvaRing, the Ortho Evra patch, Depo-Provera injections, the Mirena IUD, Implanon, and postcoital emergency contraception. All use the hormones estrogen and/ or progesterone, either in combination or with progesterone alone. They differ in the type, amount, and mode of delivery of the hormones. The combination pill is used daily for twenty-one days followed by a seven-day break, although longer usage or continuous usage regimens of active pills exist as well. Women who desire combination contraception but have difficulty complying with the daily dosing of the pill may be better served with NuvaRing, a flexible ring that is inserted intravaginally for three of four weeks, or the Ortho Evra transdermal patch, which is replaced weekly for three of four weeks. The mini Pill contains progesterone only and is taken daily within a three-hour window. The mini Pill, like other progesteroneonly contraceptive options (the Depo-Provera injection, implantable subcutaneous Implanon rod, and Mirena IUD), is given to those women who may have higher risks or side effects associated with the combination contraceptive options. All hormonal contraceptives have perfect-use failure rates of less than 1 percent per year. However, typical use failure rates are much higher, with options that rely on more frequent patient self-dosing having the highest actual-use failure rates. Thus, Contraceptive Technology reports a typical yearly failure rate of 0.05 percent for Implanon, 0.2 percent for the Mirena IUD, 3 percent for Depo-Provera, and about 8 percent per year for the other user-dependent hormonal methods: pills, patch, or ring. Emergency contraceptive pills contain higher doses of the same hormones found in regular oral contraceptive pills. The most commonly used one-step regimen, known colloquially as “the morning-after Pill” or “Plan B,” provides postcoital high-dose levonorgestrel treatment to reduce the chance of pregnancy when taken within seventy-two hours after unprotected sex. It is not an abortion pill and purportedly does not affect or terminate an existing pregnancy. Plan B is available over the counter without a prescription and is reported by the FDA to have an 89 percent effectiveness rate. There are also several implantable methods. Along with the implantable Implanon rod and the progesterone-containing IUD, the ParaGard IUD rounds out the options for longterm, highly effective contraceptive devices that are inserted by the health care provider and require essentially no reliance on patient motivation for contraceptive compliance. Implanon is an etonogestrel implant about the size of a matchstick that is inserted under the skin of the inner side of a woman’s upper arm. It provides contraception for up to three years. Both the levonorgestrel-releasing Mirena and the copper ParaGard IUDs are soft, flexible, T-shaped devices that are inserted into the uterus. The Mirena IUD provides contraception for up to five years, the ParaGard for up to ten. Typical use failure rates within the first year of use for Implanon, Mirena, and ParaGard are 0.05 percent, 0.2 percent, and 0.8 percent respecwww.sfms.org
tively, making these devices the most reliable and longest-lasting forms of contraception available. Because of these considerations, the American College of Obstetricans and Gynecologists recommends the implant of IUDs as the first-line contraceptive option for teens. The CDC concurs, citing a recent study in the May issue of the New England Journal of Medicine that found that compared to women using IUDs, unplanned pregnancies were twenty times more likely among women using birth control pills, the patch, or the ring. For patients or couples who are sure they do not desire to have children, sterilization provides the option of maintenance-free, permanent birth control. Vasectomy is the only sterilization option for men, but women are now able to choose between the traditional tubal ligation, a surgical procedure, or the office-based Essure procedure, which involves placement of coils into the tubes for permanent occlusion. Despite the abundance of options for effective contraception, since 2001 the United States has not made any progress at all in reducing the unintended pregnancy rate. The U.S. Department of Health and Human Services has now established the Healthy People 2020 project. Its family-planning goals are aimed at improving pregnancy planning and preventing unintended pregnancy. A main objective is a 10 percent decrease in the proportion of pregnancies that are unintended, down to 44 percent. Family planning efforts that can help reduce unintended pregnancy include better education of the public and increased access to contraception, particularly to the more effective and longer-acting reversible forms of contraception. Health care providers need to be fully aware of all available forms of contraception in the context of each patient’s unique individual needs in order to best progress toward the Healthy People 2020 goals. Lily M. Tan, MD, is the director of minimally invasive gynecologic surgery at Kaiser Permanente in San Francisco. She is a longtime member of the SFMS and has served on the board of directors for the past six years. A native San Franciscan, she has also served on the medical staff for CPMC, St. Francis Hospital, and Chinese Hospital, as well as Kaiser Permanente. She volunteers regularly in free community health clinics, including the API Wellness Center, which provides free medical care, STD testing, and contraceptive counseling.
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Sexual Health and Fertility
Menopause and sexual health A Transition from the Reproductive Years Sashi Amara, MD Menopause is a normal, natural event in a woman’s life that marks the end of menstrual periods. Menopause affects every woman, and an estimated 6,000 U.S. women reach menopause every day (more than 2 million per year). Menopause is considered to occur if a woman misses twelve months of menstrual cycle, with no other pathology. It represents progressive aging of a woman’s reproductive system. During the transition from the reproductive years through menopause and beyond, a woman experiences many physical and emotional changes, and they are a consequence of aging and menopause. The psychological and biological changes that accompany menopause and perimenopause can cause her to question how she has lived her life and whether she should make changes in how she should live. Also, this time of a woman’s life many times coincides with kids leaving to go to college, taking on the responsibilities of aging parents, and so forth. How women confront these problems is variable and somewhat dependent on their attitudes and perceptions of lifestyle and aging. That said, thanks to the higher education and incomes and increasing experience of being able to juggle multiple roles, a lot of us are able to cope and take this in positive stride.
There is always some ambiguity surrounding the terminology of menopause. The term menopause is defined as absence of menstrual cycle for twelve months, and it reflects natural diminution of ovarian hormones. The terms premenopause, menopause transition, and perimenopause are all somewhat different, but it is reasonable to say that these are the years prior to menopause, lasting as long as four to five years. They also correspond to the highly symptomatic years of menopause. Finally, there is both natural and induced menopause, the latter usually a consequence of surgery or chemotherapy. A woman’s body undergoes changes during menopause. Some of this may be related to hormonal changes and some related to the process of aging itself. The classic symptoms of hot flashes, considered the hallmark of menopause, usually peak during the first two years of menopause and 22 23
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then decline over time. They are usually described as waves of heat, predominantly in the upper body and face, and they are associated with sweating. Many women gain weight during menopause, and unfortunately they are less likely to lose this weight than weight gained during pregnancy. Changes in skin, such as dark spots, dryness, acne, and loss of bulk, could be a result photoaging, hormonal imbalance, and loss of muscle mass. Psychological symptoms around menopause are very variable. Some women transition without any symptoms, but 23 percent of perimenopausal women experience a myriad of distressing symptoms such as sadness, irritability, tearfulness, insomnia, fatigue, and decreased memory and concentration. Women who have experienced significant PMS and postpartum mood disorders are more likely to have psychological symptoms as compared to others. Causes for these mood changes could be multifactorial and include hormonal changes, preexisting mood disorders, smoking, lack of exercise, interpersonal stress, etc. The most predictive factor for depression in midlife and beyond is prior history of clinical depression. Insomnia occurs in 40 to 50 percent of women during menopausal transition, and it worsens the symptoms of depression, anxiety, and stress. The jury is still out regarding the direct effect of hormones on perimenopausal symptoms. Some propose that the change in hormone levels, compounded by sleep disturbances and hot flashes, create an environment that triggers psychological symptoms. Psychological symptoms have a profound impact, since even minor depression or anxiety can result in significant social dysfunction and may interfere with daily activities. Most women present to their primary care provider before they seek help from a mental health professional. Office-based tools such as PHQ-9 or PHQ-2 questionnaires will serve as good screening mechanisms. Gathering a thorough medical, social, family, and substance abuse history and information about prior response to psychotherapy and psychopharmacological medications is very helpful. It is important to rule out other potential diagnoses, such as anemia, hypothyroidism, and medication-induced side effects, before attributing symptoms to mood disorders. Nonpharmacological modalities such as paced breathing, muscle relaxation, group therapy/psychotherapy, yoga, and other activities that enhance quality of life should be explored. Herbs such as Saint-John’s-wort or omega 3 FA are used to treat depression. Saint-John’s-wort (Hypercium perforatum) is used extensively in Europe to treat mild to moderate depression. A Cochrane review was done of twenty-nine trials involvwww.sfms.org
ing Saint-John’s-wort in the treatment of mild to moderate depression, and it was found to have clinical benefit with significantly fewer side effects compared to SSRIs. A combination of black cohosh and Saint-John’s-wort has been shown to be more effective in treating hot flashes and mood symptoms. Another herb, valerian (Valeriana officinalis) is shown to be effective in treating nervousness and to improve sleep quality without significant side effects. SSRIs and SNRIs are highly effective in treating depression and anxiety in perimenopausal and menopausal women. Recent studies have indicated some correlation between SSRIs, bone mass, and fragility fractures. Because menopause is associated with low bone mass, SSRIs should be used judiciously. Estrogen therapy has been shown to be effective early on, when there is a fair amount of hormonal fluctuation. This antidepressant effect of estrogen seems to wane in late menopause when the hormone levels stabilize. Psychological symptoms should be managed collaboratively between GYN, PCP, and psychologist. Doctor and patient should take a multipronged approach that includes lifestyle changes, behavioral therapy, and consideration of complementary modalities versus hormonal versus SSRIs, all tailored to the individual woman’s needs and beliefs. Sexual concerns are common in women in their midlife and beyond, although they are not frequently reported. The PRESIDE (Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking) study, one of the largest done to evaluate sexual dysfunction in women, found 43 percent prevalence of sexual dysfunction. Sexual issues could take different forms, including lack of sexual desire, impaired arousal, or pain with sexual activity. Low sexual desire was the most common sexual problem in women, reported by 39 percent of women, and was associated with distress in 10 to 14 percent. The causes for sexual dysfunction are often a result of several factors and may include psychological problems such as depression and anxiety, fatigue, lack of privacy, medications, or physical problems that make sexual activity uncomfortable. Although all sexual problems increase with advancing age, the prevalence is highest in women aged forty-five to sixty-four, lowest in women sixtyfive years or older. Menopausal status correlates closely with age, and the likelihood of sexual dysfunction worsening at menopause could be related to increased vaginal dryness and inadequate lubrication in addition to age-related decline in drive and desire. Menopause-related estrogen loss results in vaginal dryness, thinning, and pain during intercourse. In addition, hot flashes and sleep disturbance leads to increasing fatigue, resulting in low sex drive. Treatment of sexual concerns is complex, and it should start with a thorough evaluation, including a detailed history, and it should be confidential and nonjudgmental. There are several validated questionnaires, such as the Watts Sexual Function Questionnaire or the North American Menopause Society (NAMS) Menopause Health Questionnaire, to clarify the sexual dysfunction. Following this, medical practitioners will usually complete an exam to look for any physical barriers and lab tests to rule out other causes. www.sfms.org
There are a variety of pharmacological and nonpharmacological treatment choices for female sexual dysfunction, and they vary based on the cause and specific situation. Nonprescription vaginal lubricants and moisturizers (Astroglide, long-acting K-Y Jelly, Zestra) can help with mild to moderate vaginal dryness. Sex education and counseling regarding normal age-related changes in both women and men is helpful. Although estrogen has been helpful in treating vaginal dryness and lubrication, its benefits on libido are uncertain. Underlying depression and anxiety should be treated, although we need to be mindful of SSRI-induced sexual side effects. Bupropion is an alternate agent to SSRIs and is associated with many fewer sexual side effects. Use of androgens for sexual dysfunction is receiving a lot of attention. Currently, there are no FDA approved androgen- containing products for treatment of female sexual dysfunction. Androderm and Testoderm, approved for male hypogonadism, are not approved for use in women. Custom-made compounded topical 1 percent or 2 percent androgen creams are popular. Even though anecdotal evidence supports the use of this compound, there is no safety or efficacy data to support this.
Fortunately, menopause is now better understood and more openly discussed than ever before. Rather than being perceived as an event that marks the decline of youth, it is increasingly viewed as an event that presents an opportunity for women, working with their health care providers, to evaluate personal health and improve quality of life. Sashi Amara, MD, FACP, NCMP, is a board-certified internist and menopause practitioner at St. Mary’s/Saint Francis Medical Group of the Dignity Health Medical Foundation. A SFMS member since 2011, her special clinical interests include women’s health, preventive medicine, and chronic disease management. Dr. Amara completed her internship at Sacred Heart Medical Center, and residency at Virginia Mason Hospital and Medical Center.
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Sexual Health and Fertility
Heart Disease and sex Managing the Risks Richard Podolin, MD Early studies in healthy volunteers showed a marked increase in heart rate and systolic and diastolic blood pressure during sexual activity. But sub-
sequent studies of married couples during sexual intercourse in their own bedrooms found a much more modest rise. During the ten to fifteen seconds of orgasm, when physical stress is at its peak, exertion was in the range of 3 to 4 metabolic equivalents (METS)â&#x20AC;&#x201D;similar to climbing two flights of stairs or walking briskly. The changes in heart rate and blood pressure are similar in men and women. Older patients may have more difficulty achieving climax, and so their physical exertion may be greater. In those individuals 3 to 5 METS may be a more reasonable estimate, equivalent to mild to moderate physical activity. Of course, not all sexual activity entails equal physical and emotional stress. This was perhaps most poignantly demonstrated in autopsy studies of subjects dying during coitus: 75% when having extramarital intercourse, often with a younger partner, a statistic that presumably does not reflect the prevalence of that activity in the society at large.
A number of studies and meta-analyses have shown that the increase in relative risk of myocardial infarction within two hours of sexual activity is 2.1 to 2.7. There is no increased risk after this period. The increase in relative risk is similar for patients with and without a previous diagnosis of coronary artery disease. This fact might simultaneously give comfort to those with CAD and pause to the rest of us, until one realizes that, because the time spent in sexual activity is brief, the absolute risk for anyone is exceedingly small. Even a high-risk patient with an annual myocardial infarction risk of 10% engaging in weekly sexual activity would increase his annual risk to only 10.1%. Importantly, regular physical exercise has been shown to ameliorate even this small additional risk. Clear and thoughtful recommendations for sexual activity in patients with heart disease have recently been published by the American Heart Association (see Levine, Steinke, et al). Patients with coronary artery disease who have no or mild angina can engage in sexual activity, while those with unstable or refractory angina should avoid sexual activity until their condition has been stabilized. Sexual activity is reasonable for patients one week after an uncomplicated MI if the patient is asymptomatic with mild to moderate physical activity. Sexual activity can be re24 25
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sumed several days after percutaneous revascularization, or six to eight weeks after coronary artery bypass surgery, if the sternum is stable. Similarly, sexual activity is reasonable for patients with mild or compensated heart failure (NYHA class I or II) or valvular disease, but it should be deferred in patients with severe or decompensate heart failure (class III or IV) or significantly symptomatic valvular disease until their condition has been stabilized. A similar pattern holds for patients with rhythm disorders. Sexual activity is reasonable for patients with well-controlled arrhythmias, including patients with an implanted ICD in whom moderate physical activity does not precipitate ventricular tachycardia or fibrillation. Patients with uncontrolled arrhythmias, such as atrial fibrillation with rapid ventricular response, spontaneous or exercise-induced ventricular tachycardia, or multiple ICD shocks, should avoid sexual activity until their arrhythmias are stabilized and optimally controlled. Most patients with congenital heart disease who do not have advanced heart failure, severe valvular disease, or uncontrolled arrhythmias can also safely engage in sexual activity. Those for whom the safety of sexual activity is less certain include patients with pulmonary hypertension, cyanotic heart disease, severe leftsided outflow obstruction, and anomalous coronary artery passing between the pulmonary artery and the aorta. Women who have forms of congenital or acquired heart disease associated with a high risk of pregnancy-associated cardiovascular complications should be counseled regarding the advisability of pregnancy and contraceptive methods. Patients with hypertrophic cardiomyopathy may reasonably engage in sexual activity unless they are severely symptomatic. Cardiac arrest associated with sexual activity has not been reported in that disorder. Erectile dysfunction is common in men with cardiovascular disease. Some medications, notably beta-blockers and thiazide diuretics, have been implicated as causes of erectile dysfunction, but more recent studies indicate that their contribution is very small. Drugs that can improve symptoms or survival should not be avoided because of a concern that they might affect sexual function. Phosphodiesterase-5 (PDE5) inhibitors (sildenafil, vardenafil, tadalafil) are safe and effective for patients with stable coronary artery disease and compensated heart failure. The safety of these agents is uncertain in patients with severe aortic stenosis or hypertrophic cardiomyopathy. A patient who is on nitrates cannot use these drugs, and a patient who develops chest discomfort or an acute MI should not be given nitrates for twenty-four hours after the last dose of sildenafil or vardenafil, or for forty-eight hours after the last dose of tadalafil. Women who develop vaginal dryness or dyspareunia can use topical estrogen without increasing
Continued on page 27 . . . www.sfms.org
Sexual Health and Fertility
Breasts A Book Review Erica Goode, MD, MPH BREASTS: A Natural and Unnatural History Florence Williams Norton and Co., 2012
This provocatively titled volume, and one of its reviews by Sandra Steingraber, PhD, captured my attention, as a physician and parent, regarding this essential part of human anatomy. Williams is a science writer and
editor for Outside Magazine. Her well-researched volume should be a resource for all physicians, women and men (note that Carolus Linnaeus named our entire phylum “mammals”), whether internists or other primary care people. I include obstetricians, gynecologists, pediatricians (half of whose patients are “baby women,” as one of Gary Trudeau’s Doonesbury characters states), and the oncologists and plastic surgeons who inform women about reconstructive surgery post-mastectomy. All of us interested in the environmental stressors visited upon our bodies should pay particular attention. To quote Sandra Steingraber, “As a mammalogist and nursing mother, I thought I knew everything there was to know about breasts and their exquisite communion in the ecological world. I was wrong. But I never laughed so hard while learning so much. The true story of breasts, revealed at last!” Williams has included photographs that alone are worth the price of the book. My favorite: Sophia Loren glancing sidelong at Jayne Mansfield’s 41-inch, barely covered, astonishing, gorgeous breasts.
Breast and prostate cancer are the two most common cancers in our population, and not just due to an aging cohort.
Williams began to uncover increasingly disturbing information as she nursed her second child. Fretting over environmental materials getting into what she was feeding her daughter as her sole diet save water, she sent a lactation sample to a renowned German laboratory, only to learn that her infant was getting significant doses of fire retardants and petrochemical isomers, plus perchlorate, a jetfuel additive. This baby girl will, as a future mother, dump a portion into the vulnerable mouths and tissues of whatever children she herself nurses, while her older brother is largely stuck with these substances for life. We should note the sources of what was found in Williams’s milk: the detritus of electronics, furniture, and foods were high— especially flame retardants, which we have stopped using in children’s bedtime wear and have instead put into couch cushions and other furnishings, to delay the time it takes a cigarette ember to www.sfms.org
become a flame from two seconds to twelve. Whatever the dangers of a furniture fire, the price is high for all of us due to exposure to these toxic substances. Williams’s levels of these chemicals were ten to one hundred times those of European women, even though she had spent years in rural Montana, away from the prime sources of such recent additions to our environment.
Endocrine-disrupting substances derived from plastics drives much of my own concern.
Williams quotes Sylvia Earle, explorer-in-residence at National Geographic, who states, “I tell people I come from a different planet because the planet I arrived on is so unlike the planet of the twenty-first century. There were no plastics; there was less CO2. There were more fish in the sea. I come from the pre-Plasticozoic era.” Williams spent years researching and carefully documenting the 313 pages of her book. Topics trace the history of our interest in and knowledge of breast tissue, and she describes the anatomy and physiology of the unique breast and baby “fit,” allowing us to nurse our large-brained infants without neck damage. The attendant anatomic consequences are huge: a distinctly human larynx and vocal apparatus provide us with the astonishing versatility of human speech; song; scat; and the high art of Bobby McFerrin, the throat singers of Mongolia, and tonal languages like Chinese. One chapter is devoted to the odd desire of some women, and perhaps their men, to pursue breast augmentation. This is at once appalling and hysterically funny, as she writes about a Houston Breast Enhancement Clinic she went to as a pseudo-subject for a daylong journey through the potential wonders of morphing from a B to a C+ woman. (Texas women apparently are atypically “enlarged,” relative to the rest of the U.S.) Since the twentieth century, all manner of materials have been placed in women’s breasts, including “glass balls, ivory, wood chips, peanut oil, honey, ox cartilage, and paraffin.” Benign methods of augmentation include air (little tubes to inflate bras, seen in the 1950s), not unlike the inflatable flotation devices proposed when one flies the friendly skies across the mostly waterless U.S. A favorite during my teenage Southern California years were powder puffs. I recall a story told to me by a tenth-grade friend who used these for an evening out with a boy who seemed intent on fondling said breasts/puffs. She became amused, removed them, and said, “Here you go! Have fun!” and left the car. Clearly mortifying for both parties, since each knew the story would make the rounds among those of the opposite gender. Now we use silicon, but it, too, has its unintended consequences: It has aesthetic drawbacks and is, of course, enclosed in plastic.
Continued on page 27 . . .
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The Black Plague was a major pestilence in the 14th century.
kill
Communication Failures more then 50,000 patients each year in the 21st century. *
eVigils.com eVigils™ is a private, closed-loop, and secure “collaborative texting” service which improves on standard texting, e-mail, and paging to prevent common communications errors.
eVigils™ means never again wasting time trying to reach and hear from team members, never again wading through e-mails looking for what you need.
eVigils™ is compliant with HIPAA and the Joint Commission ruling on texting. * Institute of Medicine. “To err is human: building a safer health system.” Washington, DC: National Academy Press; 2000
© MITEM 2012 27 Corporation, San Francisco Medicine December 2012
Artwork copyright © 2012 Dan Harding www.sfms.org
Breasts Continued from page 25 . . .
Heart Disease and Sex Continued from page 24 . . .
Williams quotes the American Society for Aesthetic Plastic Surgery in stating that 289,000 U.S. women had breasts augmented in 2009; unknown numbers went to other countries for these procedures. But beyond questions about the odd dissatisfaction that drives anatomically intact women to pay for surgery, there are other concerns with the current use of encapsulated silicon as implants, including leakage, scarring, unanswered issues about its effect on breast milk, and its linkage to a rare form of anaplastic large-cell lymphoma. Most sobering for those of us who are parents is Williams’s chapter devoted to our unavoidable contact with plastics. Often containing endocrine-disrupting chemicals, plastic is everywhere, from our computer casings to car seats, tables, and utensils. It’s in food wraps and packaging, including bottled water and sweet drinks; refrigerator-water dispenser tubing; and the huge mass hovering in the Pacific Ocean. This leaves me feeling powerless to protect our vulnerable children from its effects. Only if multiple studies demonstrate harm to rapidly growing fetuses and youngsters do we see some substances, like BPA, being removed from baby bottles and nipples. Williams ultimately decided to continue nursing her baby, despite the hazards, since that seemed less problematic than trusting the processing, packaging, and storage of commercial baby forumula. But she raises critical, worrisome questions that should stir all of us to channel Rachel Carson as we actively debate about just what we should do to reverse some of the environmental trends we are creating for future generations of plants, animals, and human society.
their cardiac risk. The vast majority of patients with cardiac disease can be encouraged to resume active sexual lives with minimal additional risk. Moreover, patients can be informed that they can reduce even this tiny additional risk by engaging in regular physical exercise. If concerns remain about an individual patient, exercise testing can be useful for risk stratification. Medications used to treat sexual dysfunction are effective and are safe in the great majority of patients with heart disease. Most important, physicians should take it upon themselves to initiate these difficult conversations with their patients. By doing so, they can take the first crucial steps toward healing this important disruption in their patients’ lives.
Erica T. Goode., MD, MPH, a practicing internist for thirty two years, is currently at St. Mary’s working with post-bariatric surgery patients and those with eating disorder and other complex medical/ nutritional problems. She is teaching, doing talks, and is Emeritus at CPMC . As an associate clinical professor of medicine at UCSF she taught for twenty six years. She is also a longtime SFMS member and member of the Editorial Board.
SPECIAL INSERT
References
Kimmel SE. Sex and myocardial infarction: An epidemiologic perspective. Am J Cardiol. 2000; 86:10-13F. Kostis JB, Jackson G et al. Sexual dysfunction and cardiac risk (the second Princeton Consensus Conference). Am J Cardiol. 2005; 96:313-321. Levine GN, Steinke EE et al. Sexual activity and cardiovascular disease. A scientific statement from the American Heart Association. Circulation. 2012; 125:1058-1072. Moller J, Ahlbom A et al. Sexual activity as a trigger of myocardial infarction. A case-crossover analysis in the Stockholm Heart Epidemiology Programme (SHEEP). Heart. 2001; 86:387-390. Muller JE, Mittleman MA et al. Triggering myocardial infarction by sexual activity. JAMA. 1996; 275:1405-1409. Richard Podolin, MD, is a cardiologist at St. Mary’s Medical Center and serves on the hospital’s Community Board. He is a member of the Board of the SFMS, and a delegate to the CMA for the California Chapter of the American College of Cardiology.
Intimate Partner Violence: A Practical Guide for Clinicians “Family violence reports in San Francisco increase sharply” —Cover story, San Francisco Chronicle, November 11, 2012
Domestic violence, also known as domestic abuse, spousal abuse, battering, family violence, and intimate partner violence (IPV), has been broadly defined as a pattern of abusive behaviors by one or both partners in an intimate relationship such as marriage, dating, family, friends, or cohabitation. Domestic violence, so defined, has many forms, including physical aggression (hitting, kicking, biting, shoving, restraining, slapping, throwing objects) or threats thereof; sexual abuse; emotional abuse; controlling or domineering; intimidation; stalking; passive/covert abuse (e.g., neglect); and economic deprivation. Alcohol consumption and mental illness can be comorbid with abuse and present additional challenges when preswww.sfms.org
ent alongside patterns of abuse. The SFMS developed the attached guidelines on domestic violence screening and intervention for physicians and other clinicians in consultation with some of the most experienced clinicians in this arena. This guideline represents a concise and clinically based approach to this complex issue, distilling knowledge from existing longer documents. The brochure has been widely distributed and well received by clinicians citywide and beyond, and it was cited in the JAMA as one of the best such resources. This second edition was revised and updated in 2011. It is available in this issue of San Francisco Medicine for you to remove and keep on hand and is also available on the SFMS website at http://www.sfms.org/ForPhysicians.aspx. If you are interested in obtaining additional copies please contact the SFMS at (415) 561-0850. December 2012 San Francisco Medicine
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HOSPITAL NEWS KAISER
SFVAMC
Saint Francis
Robert Mithun, MD
Diana Nicoll, MD, PhD, MPA
Patricia Galamba, MD
Dr. Jennifer Gunter, MD, FRCS(C), FACOG, DABPM, guest wrote this month’s column. She is director of pelvic pain, KPSF. “So you know you should never use condoms with spermicide, right?” The red faces around the table were evidence that until now this fact was unknown. I was seated around the dinner table having a detailed discussion about sex with six adolescents. Not about right and wrong, but facts about mechanics and safety. No one texted, tweeted, or checked Facebook for updates. Some of the kids were already sexually active and some were not, but their common bond was that they all wanted to know more. I explained that condoms with spermicide have a shorter shelf life, are more expensive, and that spermicide damages healthy vaginal bacteria, paradoxically increasing the risk of contracting a sexually transmitted infection (STI) if exposed. This isn’t groundbreaking news, but for some reason when it comes to sex, it’s difficult to get facts from Point A to Point B. And not just when it comes to condoms. Myths about orgasm, sexuality, contraception, conception, the HPV vaccine, STDs, emergency contraception, and abortion are not only commonplace but lawmakers across the country have presented misleading facts regarding many aspects of reproductive health care in favor of what can only be described as medically unsound, evidence-baseless agendas. Sexual misinformation affects quality of life, can decimate both self-esteem and relationships, and has serious medical sequelae, such as unplanned pregnancies and STIs. I am incredulous that in this era of information overload, facts about sexuality and reproductive health seem to be coming from everyone but the medical profession. But maybe I shouldn’t be surprised. The only legal measures regarding sex education enacted in 2011 involved expanding abstinenceonly education. Sexuality and sex are part of medical care. We all need to step up to the plate and make sure our patients get the right information, because one of the worst things I think a doctor can hear is, “If I’d only known.” 28 29
The San Francisco VA Medical Center (SFVAMC) serves veterans who live in Northern California, up to the Oregon border. Of 11,000 veterans living in Humboldt County, 5,000 have received care at a contract clinic operated by Dr. Brian Craig and Nancy Craig since 1999. Available services have included primary care, mental health, pharmacy, radiology, home-based primary care, and telemedicine. On October 1, 2012, a new Eureka VA Clinic opened, staffed by VA employees in a fully renovated space, with the addition of audiology, optometry, podiatry, and prosthetics services. Future expansion will add physical therapy services. The new clinic was supported by funding from the VA Office of Rural Health, a national office in Washington, D.C., created specifically to identify and support the health needs of veterans living in rural areas. Expanded use of telemedicine to access specialty care at SFVAMC will reduce the need for Humboldt County veterans to make the 270-mile journey to SFVAMC. On October 25, following the Giants’ victory in the first game of the World Series, SFVAMC patients were visited by Major League Baseball (MLB) representative Will Clark, MLB Commissioner Bud Selig, Hall of Famer Gaylord Perry, Hall of Fame broadcaster Jerry Coleman, and Giants President Larry Baer. This generated a great deal of excitement among patients and staff. The MLB visit was part of the Welcome Back Veterans initiative, launched in 2008 by MLB and the Robert R. McCormick Foundation.
San Francisco Medicine December 2012
As I write this column on October 29, the deadline for this issue, I cannot help but congratulate our fantastic San Francisco Giants for a giant sweep of the Detroit Tigers! It was an exciting season, but the post-season turned out to be the most fantastic baseball I have ever enjoyed in my life. As the official health care provider for the San Francisco Giants, we at Saint Francis take great pride in supporting the team on and off the field. As Dignity Health says, “We are the team that takes care of the team on the field.” Congratulations, San Francisco Giants! Recently Consumers Reports published an article in its August issue titled, “How Safe Is Your Hospital?” This was the first time Consumer Reports rated hospitals for safety, using the most current data available from government and independent sources. Nationwide, 1,159 hospitals in forty-four states were reported on in the results. Here in California, 170 hospitals were scored. Saint Francis was seventeenth from the top. The safety score combines six categories of hospital safety into a score ranging from 1 to 100. The categories include infections, readmissions, communication, scanning, complications, and mortality. We are proud to be the highest-scoring facility in San Francisco and among the highest in California. Just last week Saint Francis was given a five-star rating by HealthGrades for treatment of both stroke and hip fracture. The findings are part of the American Hospital Quality Outcomes 2013: Healthgrades Report to the Nation, which evaluates the performance of approximately 4,500 hospitals nationwide, across nearly thirty of the most common conditions and procedures. The quality outcomes are measured independently, based on data submitted to the federal government. Overall, Saint Francis is feeling very successful these days! On behalf of all my colleagues here, we wish the Medical Society membership and their families a very happy and healthy holiday season and an excellent new year.
www.sfms.org
St. Mary’s
CPMC
Francis Charlton, MD
Michael Rokeach, MD
We are all pleased at St. Mary’s Medical Center to introduce our newly elected slate of medical staff officers for the years 2013– 2014. Peter Curran, who is currently finishing his one-year term as president of the San Francisco Medical Society, will step right into the role of chief of our medical staff on January 1, 2013, to begin his two-year term. Pete has shown outstanding leadership abilities in many capacities in our organization as well as at the SFMS and the CMA. Joining Pete on our executive leadership team will be Bob Weber, who will serve once again as our vice chief of staff. In that role Bob will remain in charge of quality improvement, a job he has expertly performed and a function he has revamped and refocused to the betterment of all. Carl Bricca will step into the secretary-treasurer position. Executive committee members-atlarge will be returning Ken Hsu and the newly elected first-termer John Selle. We anticipate great things from this new team of medical staff leaders, who will, we know, bring us great expertise and a jolt of energy. We recently honored Ken Mills as a Pillar of St. Mary’s. This award recognizes those exemplary physicians who stand out from all others, for having built our foundation of excellence through example and for their unparalleled contributions to St. Mary’s during their professional careers. Previous honorees have been Tony Cosentino, Elias Hanna, Dick Welch, and Stan Yarnell. Ken Mills received this rarely bestowed designation based upon and in thanks for nearly four decades of service and dedication to our mission in myriad roles throughout our organization, and because he is a living personification of our core values of excellence, dignity, justice, stewardship, and collaboration. Congratulations and thank you, Ken.
www.sfms.org
Classified Ad Sutter Community Connect (SCC) is searching for a Regional Medical Director (informatics) position for the Bay Area. The ideal candi-
CPMC’s Liver Disease and Transplantation Program was recently honored for exemplary performance by the U.S. Department of Health and Human Services. Dr. Stewart Cooper, the program’s medical director, accepted the award on behalf of his team at the Health and Human Services ceremony held during the Seventh Annual Learning Congress for the Donation and Transplantation Community of Practice, held in Grapevine, Texas. The program received the HHS Transplant Program Silver Award for superior outcomes, including high post-transplant survival rates and low patient mortality rates on the transplant waiting list. This distinction places the CPMC program in the nation’s top 4 percent, based on these fundamentally important criteria. The accolade reflects the exceptional commitment of CPMC’s incredible team, which includes Dr. Robert Osorio, the program’s chair. CPMC recently opened an innovative new program at its Davies Campus: a Brain Health Center that offers patients and families a unique approach to the treatment of Alzheimer’s disease and other memory disorders affecting individuals of all ages. The new center involves a multidisciplinary team of health professionals who provide comprehensive diagnostic workups, treatment, and referrals to community resources, along with a strong emphasis on giving families psychosocial support. The center was made possible by an extraordinary $21 million gift to the CPMC Foundation by an anonymous donor. To find out more about the Brain Health Center, visit http://www.cpmc.org/advanced/ neurosciences/brainhealth/. This past October, St. Luke’s celebrated the Feast of St. Luke and the hundredth anniversary of St. Luke’s hospital and chapel building. It was a special day for CPMC and St. Luke’s. We celebrated with food and music from our former chaplain residents and a declaration from Mayor Ed Lee proclaiming October 18, 2012, St. Luke’s Hospital Day. There were also messages from community leaders, religious dignitaries, and hospital staff.
date is a physician leader who will provide physician-to-physician interface between SCC and independent practice physicians. Ideal candidate has Epic experience and/or sufficient EHR and clinical informatics experience with another system. Strong working knowledge of the business aspects of medical practice, and excellent communication and relationship building skills are essential. SCC has retained KLKingsley to conduct the search for candidates. Please contact: Kate Kingsley, President, KLKingsley Executive Search, 925.934.4306 or kate@klkingsley.com
CMA Foundation Publishes 2013 AWARE Provider Tool Kit The California Medical Association (CMA) Foundation’s Alliance Working for Antibiotic Resistance Education (AWARE) project has published its sixth annual antibiotic awareness tool kit for physicians and other clinicians. The tool kit contains an array of clinical resources and patient education materials to help reduce inappropriate antibiotic use. The 2013 tool kits were mailed last month to 28,000 providers. Physicians are encouraged to use the tool kit to educate patients about antibiotic resistance.
The tool kit can also be downloaded at www.aware.md Physicians are also encouraged to take a brief survey to let us know what we can do to improve future versions of the tool kit. To take the survey, please visit http:// www.zoomerang.com/Survey/ WEB22GHRJXVCQ4.
December 2012 San Francisco Medicine
29
Medical Policy Making 2012 The CMA Annual Meeting’s Mix of Issues and Solutions Stephen Follansbee, MD, and Steve Heilig, MPH “I would like to convey to all physicians how impressed I am with the democratic process at the HOD. Physicians representing their peers are genuinely concerned with the well-being of patients in California, and represent the interest of all their colleagues in making sure the legislative actions create the best possible practice environment. Physicians at home have no idea of the forces at work. Without the SFMS and CMA, physicians would face a dire predicament.” —Eric Denys, MD (Neurology, CPMC/UCSF)
We had resolutions before each of the hearing reference committees (and some members on the actual committees— Lawrence Cheung chaired one, and Keith Loring and Roger Eng were members of others). Each resolution, some with modification, moved important health care issues forward in the areas of health care delivery, health care mandates, and pharmaceutical industry issues, including medication disposal and insurance coverage. Our roster of policy proposals this year, with outcomes, included:
ing in some form since our state’s Gold Rush era, and looking at their earliest work, we find that some things change, and some, alas, don’t. As noted in the CMA’s official history, CMA and its early leaders started the state public health department in the 1870s, made immunizations compulsory for school children in the 1880s, began looking at ways to fund health care for the poor in the 1930s, performed some of the first cornea transplants, established some of the first organ transplant guidelines in the country, and started California’s first medical schools (which later became the Stanford University and the University of California, San Francisco, Medical Schools). And much more. Thankfully, we do not have a cholera epidemic like the one they faced during the Gold Rush, but too many of these types of challenges remain in some form. For example, during the onset of the HIV epidemic a couple of decades back, CMA again took on a leadership role in guiding a solid and compassionate medical and public health response—in no small part due to advocacy from the SFMS delegation.
CMA supports the development of a fully functional, Webbased prescription drug monitoring program (PDMP), whether it be an improved CURES (Controlled Substances Review and Evaluation System) program or a new one that should be fully funded, including through a fee-per-prescription paid by manufacturers and suppliers of drugs monitored.
The annual meeting of the California Medical Association’s elected House of Delegates has been gather-
“The House of Delegates is a great way to stay in touch with friends and colleagues across the state. You realize we are all in it together in this time of great change in health care. The energy is palpable when 650 doctors come together in one room for a common purpose.” —Roger Eng, MD (Radiology, Chinese Hospital)
The annual meeting is streamlined but as well attended as ever; nowadays, hundreds of elected physician delegates convene for a three-day “festival” of policy making. Almost anything related to medicine and public health is fair fodder. San Francisco (Delegation VIII) physicians can be proud of the collaboration and success of our delegation. We tend to bring a broad range of resolutions that encourage intelligent and often lively debate and reflection, and this year was no exception. Our team is well known and recognized by other delegates and delegations, who look to us for support and suggestions.
30
San Francisco Medicine December 2012
TRACKING PRESCRIPTIONS TO CURTAIL MEDICATION ABUSE (Rokeach, Loring, Turner)
REDUCING OVERUTILIZATION: PHYSICIAN LEADERSHIP (Denys, Fung, Eng)
CMA supports physician-led, evidence-based efforts to improve appropriate use of medical services and will educate physicians, hospitals, health care leaders, and patients about the need for physician-led, evidence-based efforts to improve appropriate use of medical services. This resolution originally referred to the “Choosing Wisely” effort that will be the topic of the January/February 2013 edition of San Francisco Medicine.
“PAY FOR DELAY” PRACTICES RE GENERIC MEDICATIONS (Susens)
CMA will ask AMA to support federal legislation that makes tactics delaying conversion of medications to generic status, also known as “pay for delay,” illegal in the United States. As noted in a recent NEJM piece, that might already be the case!
INCREASING UTILIZATION OF POLST ORDERS (Newman, Schickedanz, Lopato)
CMA encourages physicians to become educated about all aspects of the POLST form and to integrate discussions about, and use, POLST in all appropriate instances where medical services are provided to patients at the end of life. Surprisingly to many, this was perhaps the most hotly debated resolution of the year, as our original allowed for nurse practitioners to fill out POLST forms for physician confirmation, as is done in some other states. www.sfms.org
MEDICAL MANDATES FOR INSURANCE COVERAGE AND MEDI-CAL (Chan)
CMA supports the principle that mandated coverage for private insurers should also apply to publicly financed entities, when appropriate; and will advocate that the state legislature must budget for the increased cost to Medi-Cal and enrollees of the California Health Benefit Exchange when passing mandated coverage.
CANNABIS: DECRIMINALIZATION, REGULATION, AND TAXATION (Fouras, Abrams, Pating, Turner)
This was a follow-up to last yearâ&#x20AC;&#x2122;s much-noted policy paper on cannabis, adopted by the CMA board. As the regulatory issues are largely federal, CMA will request that the California governor petition the federal government to reschedule marijuana to facilitate medical research.
PUBLIC POLICY POSITIONS AND CMA AFFILIATION (Maa, Udovic-Constant, Fung, Fouras, Curran)
SFMS past president George Fouras, MD, at the CMA House of Delegates
Following some confusion and consternation related to the California tobacco tax proposition last year, CMA bylaws or other appropriate rules would be amended to require an individual member of a county medical association/CMA who takes a visible public position on any proposed legislation, proposition, or other public policy and who lists any affiliation with organized medicine to publicly disclose the fact that his or her opinion is not in agreement with the formal position taken by the association, if this is in fact the case.
TIMELY REFILLS OF SIGHT-SAVING PRESCRIPTION EYEDROPS (Calman)
CMA supports requiring health insurers and plans to cover prescription topical ophthalmic agents under terms that will allow for better access to such medications, including administration by officials or agents at a school, daycare, or any other reasonable location where medication cannot be self-administered by the patient or a guardian.
SFMS members at CMA House of Delegates
ADVANCE DIRECTIVES FOR MEDICARE PATIENTS (Follansbee, Leung, Andereck)
CMA urges the Centers for Medicare and Medicaid Services (CMS) to explore options for encouraging every beneficiary to complete an advance directive, and CMA/AMA and CMS will develop benchmark goals for percent of enrollees completing an advance directive, and make the results publicly available.
PROMOTING QUALITY AND TRANSPARENCY IN GRADUATE MEDICAL EDUCATION (Schicke-
danz) CMA supports efforts to urgently address the anticipated imbalance between the number of medical school graduates and available residency training positions; and greater transparency at all levels in the calculation, distribution, and tracking of graduate medical education (GME) funding; and will petition the Centers for Medicare and Medicaid Services to address perceived disparities in the distribution of GME funding.
Continued on the following page . . .
www.sfms.org
SFMS member Dr. Eric Tabas celebrates winning a spirited auction for an all expense paid trip to Paris at the CMA Foundation Gala
December 2012 San Francisco Medicine
31
Medical Policy Making Continued from the previous page . . .
SAN FRANCISCO MEDICAL SOCIETY DELEGATION
MEDICATION TAKE-BACK PROGRAMS (Follans-
bee, Turner) CMA now supports medication collection or “take-back” programs, funded in whole or in part by the pharmaceutical industry, that help keep unused medications out of the environment and out of the hands of potential overdose victims or drug abusers.
Stephen E. Follansbee, MD (Chair) Peter J. Curran, MD Gordon L. Fung, MD Michael Rokeach, MD Andrew Calman, MD H. Hugh Vincent, MD Elizabeth A. Andrews, MD Lawrence Cheung, MD Steven H. Fugaro, MD Man-Kit Leung, MD Andrea M. Wagner, MD Keith Loring, MD Leslie M. Lopato, MD George P. Susens, MD Shannon Udovic-Constant, MD William S. Andereck, MD Gary L. Chan, MD Roger S. Eng, MD George A. Fouras, MD Katherine E. Herz, MD Adam Schickedanz, MD (Resident) Eric Tabas, MD Eric H. Denys, MD H. Hugh Vincent, MD Robert Margolin, MD
CELL PHONE USE IN CARS (Udovic-Constant, Fouras)
CMA will support public education efforts regarding the dangers of distracted driving, particularly activities that take drivers’ eyes off the road, and will ask the AMA to do likewise. Our original was more forceful, asking for more severe penalties and even bans.
OPPOSING THE DEATH PENALTY (Curran, Chan)
This resolution was rejected as not being germane to medicine, even though the California Psychiatric Association has unanimously taken a similar position in supporting prison physicians who feel ethically compromised. But we were unable to convince CMA it was in error.
That was just our list; in addition, some other important positions passed this session were initiated by other delegations but passed with careful input from us. Two come to mind: one on supporting a new policy on blood donation (which has historically imposed absolute restrictions forbidding donation from men who have sex with men) and one on acknowledging the detrimental health effects of laws prohibiting same-sex civil marriage. “It was another fun and productive HOD meeting for the delegation. Though it was just my second year going, it’s clear to me what a valuable opportunity we have each year to be a voice for the patients and physicians of San Francisco. I have no doubt that we’ll continue to be among the most productive local chapters, because we really take that opportunity and responsibility to heart” —Adam Schickedanz, MD (Family Practice, SFGH) Per a resolution last year by Dr. George Susens, CMA also called unethical the pharmaceutical and medical device “seeding” and other pseudo-clinical trials that mix marketing with research and expose patients to inadequate safeguards without true informed consent and without approval and monitoring by an IRB. The resolution also states that it is unethical for physicians to knowingly participate in “seeding” or other pseudo-clinical trials or to accept remuneration for enrolling patients in such trials. There was much more, with something of interest to every specialty, practice setting, and personality. A full list of the new policies adopted is available at http://www. cmanet.org/news/detail/?article=final-actions-of-the2012-house-of-delegates. “It is fascinating how the House of Medicine reinvents itself every year with change in health care policy at the CMA, and I believe this is a lesson SFMS must learn to remain viable to the next generation of physicians.” —Peter Curran, MD (Cardiology, St. Mary’s) 32 33
San Francisco Medicine December 2012
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In Memoriam
Nancy Thomson, MD
William T. Bender, MD
Benson B. Roe, MD
William Tucker Bender was born in San Francisco on December 5, 1926, to William Lee Bender, MD, and Claire Tucker Bender. He graduated from Lincoln High School and thereafter served in the U.S. Navy. He graduated from the University of California, Berkley, in 1948, and from the University of California School of Medicine in 1951, joining Alpha Omega Alpha Honor Society in 1952. For two years he served as a physician at Fairchild Air Force Base in Spokane, Washington. After completing a residency in obstetrics and gynecology, he enjoyed an active practice at 490 Post Street, with privileges at Children’s Hospital. He joined the San Francisco Medical Society in 1954 and served as a delegate to meetings of the California Medical Association. After retiring from private practice, he worked with the State of California Parole Board, Napa State Hospital, and Kaiser Permanente in Richmond. Throughout his life, he was a dedicated physician, husband, and father and a giving friend. He was an avid salmon fisherman, outdoorsman, and world traveler as well. He loved the San Francisco Bay Area, the Pacific Ocean and the Delta, all of which he explored with his family and friends on his beloved boat, the trusty Tappan Zee. He enjoyed dining with his many friends; dancing with his wife, Rosalee; and rooting for the 49ers. In the last stage of his life, he fearlessly faced adversity and passed with dignity and grace on July 16, 2012, aged 85. He is survived by his devoted wife, Rosalee, as well as his daughter Gretchen and son-in-law Scott Stooker of Napa.
Benson Bertheau Roe was born a fourth-generation San Franciscan, July 7, 1918. He died August 6, 2012, at the Villa Marin, San Rafael, age 94, after a long and productive life. He was a graduate of U.C. Berkeley where, as a member of the Cal crew team in the 1939 national championships, he helped set a record that still stands for the four-mile distance. He graduated from Harvard Medical School in 1943 and followed that with five years of surgical training at Massachusetts General Hospital in Boston. He joined the UCSF faculty in 1951. During his long tenure there, he published more than 175 articles and book chapters on his specialty and wrote the basic textbook on thoracic surgery. His autobiography, Maverick among the Moguls, was published in 2002. Early in his career as UCSF professor of surgery, he founded the cardiovascular surgical service and performed the first heart transplant in San Francisco. He became concerned about the frequent early failures of the primitive 1950s pumps designed to circulate oxygenated blood to the body during open heart surgery. Risking his professional standing, he adapted one of the first experimental heart-lung machines (designed for animal experiments only) and used it for successful operations on patients who were near death. By doing so, he proved the usefulness of machines that were ultimately used by cardiovascular surgeons everywhere. Dr. Roe also pioneered the use of “induced hypothermia”— cooling anesthetized cardiac patients to barely 88 degrees by immersing their bodies in ice water to slow their blood circulation. In other pioneering research efforts, Dr. Roe and his colleague Dr. Edwin J. Wylie developed and used synthetic materials for plastic blood vessels and heart valves as early as 1956. In 1972, a Hayward engineer, Paul Davis, came to Dr. Roe with an idea for an artificial heart made of aluminum and Teflon and powered by compressed air. The UCSF team adapted the device and implanted it on a succession of calves until they succeeded with one calf, who lived in frisky health for a week before succumbing to infection. That experiment gave way to more heavily supported research at other institutions, and today so-called artificial hearts are common assist devices for cardiac surgery patients. Dr. Roe’s wife, Jane St. John Roe, died in 2006. He is survived by their son, David, and daughter, Celeste, of Oakland, as well as two grandchildren.
Matt Dickstein
Business Attorney Representing Medical Practices Since 1994 * Medical Corporations * Stark & Kickback / Regulatory Compliance * Employment & Contractor Agreements * Breakaway Physician Competition * Buying & Selling a Practice * Hospital – Group Contracts * Leases for Medical Offices * Multi-Discipline Practices Idea of the Month: I’ve got all the money I’ll ever need if I die by four o’clock this afternoon. – Henny Youngman
39488 Stevenson Pl. #100 Fremont, CA 94539 510-796-9144 mattdickstein@hotmail.com mattdickstein.com www.sfms.org
December 2012 San Francisco Medicine
33
CROSSWORD: Cranial Nerves Ernest Lampert, MD, the author of this puzzle, is a retired General Surgeon who practiced in San Francisco from 1950 to 1982. As a past member of the SFMS, he served on the Medical Review and Advisory Committees. After retirement he turned a hobby of constructing both regular and medical thematic crossword puzzles into a business. He is a regular contributor to Simon & Schuster’s Crossword Puzzle books as well as a freelancer for newspapers and medical publications. His puzzles are currently available on theNerves iPhone, iPad iPodLampert via the iTunes Cranial 21 and Ernest MD App store (search crosswords for commuters or crosswords for doctors). Answers available at www.sfms.org.
ACROSS 1. Detroit financing co. 5. "Hawaii Five-O" nickname 9. Asian cat-like mammal 14. Green surrounder 19. Prefix with space 20. Petri dish filler 21. Makarova of tennis 22. Bum 23. 5 & 12 27. Biases 28. Hordeolum 29. Space shuttle protector 30. ___ inhibitor, used in hypertension 31. Unfair 33. Honeybun 34. 4 39. Cool J and Bean 40. Ming of the Houston Rockets 42. Arctic explorer 43. Italian wine region 44. British jamboree grp. 45. 6 50. Lohengrin's bride 52. Expand: Abbr. 54. Flight segment 55. "How to Hit .300" author 56. 2 & 3 61. Ludicrous 63. Spanish wine 64. Sipowicz's partner on "NYPD Blue" 65. Milk source 67. Plaintiff 69. Bite a little 70. In ___ (going nowhere) 71. It may be a lot 74. Existing 76. Some fire starters 80. Folk singer Griffith 81. 11 & 7 84. Owner of Abbey Road Studios: Abbr. 85. "So long" 87. Apropos of 88. Sundance's Place 89. 8 91. Cardiac bundle that transmits electrical impulses 93. Klutz's cry 96. Fink 97. Where black is white, for short? 98. IV alimentation 99. 1 101. Mrs. Rabin 104. Lines up the crosshairs 108. Donnybrook 109. Maker of footnotes 111. "Misery" star 113. Wine-soaked cake 117. 10 & 9 120. "You ___ right!" 121. Prince ___, Edie Murphy film role 122. Be next to
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DOWN 1. Heaters 2. European thrush 3. Coloratura's piece 4. Napoleon brandy 5. Colleens 6. Near the bottom line of I.R.S. form 1040 7. Bert Bobbsey sib, et al 8. Henry Clay, for one 9. What a cobbler often does 10. Rita's prince 11. Infection 12. Hair net 13. Couple's coup 14. Archer of myth 15. Phd's next hurdle 16. "The Manchurian Candidate" heroine 17. Silver Springs neighbor 18. Av, for one 24. ___-Sketch 25. Reagan aid Nofziger 26. "Candle in the Wind" dedicatee
115
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"___ life!" Hingis rival Its flag has two green stars Biblical peak Big Bang brew
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32. Dis. with a butterfly rash on the nose 34. BlackBerry rivals 35. Fiennes of "The English Patient" 36. Spanish cardinal point 37. Diet follower 38. Japanese aborigines 41. Caesar's pinna 44. 35 to Mendeleev 45. Volume 1 heading starter 46. Hannibal's family name 47. Flamboyance 48. Half of Mork's sign-off 49. It's for the birds 51. Alveolus 53. Intense teaaching programs 54. It's felt on the range 57. Knee ligament 58. ___ and terminer 59. Broods 60. Callas's lover, once 62. Take in 66. "Carmina Burana" composer 68. Run in syndication, maybe 71. First to be chosen 72. Famed orca 73. Home to Phillips University 75. He played Robin and Don Juan
77. 78. 79. 82. 83. 86. 90. 91. 92. 94. 95. 98. 99. 100. 101. 102. 103. 105. 106. 107. 110. 112. 114. 115. 116. 118. 119.
Hot rod propellant Golden Horde member Bluish-gray Coquettish "Oh ___ little faith!" A soldier wears one, and a duplicate Not outsourced Some PCs Far out? In on Look down on Less verbose Warren Buffett, e.g. Skinny English model Hot flowers Finnish lake Satan, at first Country album? Eccentric LAX or JFK General ___ chicken Local theater: slang Experience Like the White Rabbit Jack of "Rio Lobo" Humpback's kin Friction ___
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