High Desert Pulse - Spring/Summer 2010

SPRING / SUMMER 2010

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D E S E R T

Healthy Living in Central Oregon

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The Dash You can do it Drew Bledsoe Fit after football

Stage zero breast cancer

Is the treatment worse than the disease?

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Healthy Living in Central Oregon

SPRING/SUMMER 2010 VOLUME 2, NO. 2

Treatment of All Foot and Ankle Conditions from Ingrown Toenails to Reconstructive Surgery

Treating Foot and Ankle Conditions for All Ages

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Denise Costa | Editor 541-383-0356 or dcosta@bendbulletin.com • Reporting Bill Bigelow 541-383-0359 or bbigelow@bendbulletin.com Betsy Q. Cliff 541-383-0375 or bcliff@bendbulletin.com Marnette Federis pulse@bendbulletin.com Markian Hawryluk 541-617-7814 or mhawryluk@bendbulletin.com Breanna Hostbjor 541-383-0351 or bhostbjor@bendbulletin.com • Design / Production Sheila Timony David Wray • Letters Send letters on health topics to: E-mail: pulse@bendbulletin.com Mail: P.O. Box 6020, Bend, OR 97708 Limit 250 words.

• Corrections High Desert Pulse’s primary concern is that all stories are accurate. If you know of an error in a story, call us at 541-383-0356 or e-mail: pulse@ bendbulletin.com • Advertising Jay Brandt, Advertising director 541-383-0370 or jbrandt@bendbulletin.com Sean Tate, Advertising manager 541-383-0386 or state@bendbulletin.com Kristin Morris, Advertising representative 541-617-7855 or kmorris@bendbulletin.com On the Web: www.bendbulletin.com/pulse

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Page 4

HIGH DESERT PULSE

Contents | HIGH DESERT PULSE

6

12 17 27

COVER STORY

STAGE ZERO BREAST CANCER How do we know when to treat it aggressively and when to wait and see?

6

FEATURES

JOINT REPLACEMENT: ONCE IS ENOUGH Tracking outcomes has reduced surgery do-overs in a dozen nations; why don’t we chart U.S. statistics?

STAYING FIT: HOW DOES HE DO IT? Drew Bledsoe talks about life in Bend, after football.

THE EFFECTS OF BPA Product advice for reducing your intake as scientists debate just how bad it might be.

12

DEPARTMENTS

20

SORTING IT OUT What all those numbers on your blood test really mean.

22 31 32 34 38

GET READY: THE DESCHUTES DASH Me, a triathlete? You can be, and here’s how.

ON THE JOB: OSTEOPATHS What does a D.O. actually, well, do?

HEALTHY DAY, OUR WAY Ride by day and dance by night.

27

BODY OF KNOWLEDGE Pop quiz: stretching.

LAUGHTER: THE BEST MEDICINE Scale down — weigh down.

COVER PHOTO: THINKSTOCK IMAGES FROM TOP: ROB KERR, ANDY ZEIGERT, ANDY TULLIS, ROB KERR

HIGH DESERT PULSE • SPRING / SUMMER 2010

22 Page 5

Cover story |

STAGE ZERO BREAST CANCER

ANDY TULLIS

We can now detect a breast cancer so tiny it may never harm your health

Connie Stratton was diagnosed with stage zero breast cancer in 2004.

She underwent a double mastectomy among a dozen surgeries to treat the disease and reconstruct her breasts.

To treat or not to treat. You decide.

BY BETSY Q. CLIFF

I

n 2004, Connie Stratton was diagnosed with ductal carcinoma in situ. This information was either vital to her well-being or something she never needed to know.

Also called stage zero breast cancer or DCIS, the abnormal cells are still confined to the breast. It is not life-threatening, though it has the potential to turn into invasive breast cancer, which can be deadly.

The now-55-year-old Bend resident followed her doctor’s recommendation for the most common treatment: surgery to remove the tumor in her left breast and about 6½ weeks of daily radiation.

She also took tamoxifen, which interferes with estrogen, because her doctors thought her particular type of tumor would respond to Page 6

the drug. It didn’t go well, Stratton said. “Tamoxifen made me have tremendous hot flashes. My coat was on, my coat was off. It was terrible.”

A year later, tired of the side effects of the drug and worried about the cancer returning, she decided to have a double mastectomy. “I wanted to make sure I did everything I could not to have a recurrence.”

But the radiation had toughened her skin, making breast reconstruction difficult. “I kept tearing open,” she said. In all, she had 11 or 12 surgeries — she can’t remember the exact number — to try to reconstruct her breasts.

“I was the nightmare reconstructing person,” she said. “That was just ongoing forever.”

As mammography has become widespread, the number of wom-

HIGH DESERT PULSE • SPRING / SUMMER 2010

DCIS INCREASES WITHOUT DECREASE IN INVASIVE CANCER

HIGH DESERT PULSE • SPRING / SUMMER 2010

support the current guidelines, and, in some women, treatment has surely prevented them from developing invasive cancer. Clinicians across the country cite the fact that breast cancer is less likely to come back when radiation is used after surgery. In some groups of women — particularly those with more aggressive DCIS, who have larger tumors or who are young — treatment that includes surgery, radiation and drugs such as tamoxifen likely has significant benefits.

The question is whether everyone needs that kind of aggressive therapy. Though treatment has an impressive success rate, surgery and radiation have real costs. If some, or even most, women could skip parts of treatment, it could lessen the impact of the disease on women’s lives and save precious health care dollars.

“From the doctor’s point of view, being very conservative (by offering aggressive treatment) is the right thing to do,” said Dr.

150 Incidence per 100,000

en diagnosed with DCIS nationwide has increased dramatically. Just a few thousand cases per year, representing a small portion of all breast cancer, were diagnosed in the 1970s; now about 62,000 women find out each year they have the disease, roughly 20 percent of all new breast cancer diagnoses.

Treatment for DCIS is nearly always successful. But, as Stratton experienced, it can be brutal. Surgery often causes pain, swelling, tenderness and hard scar tissue. Radiation can burn the breast, toughen skin, cause fatigue and, in some cases, damage organs near the breast.

Treatment also costs a lot, typically upward of $50,000 for the course of lumpectomy and radiation in Central Oregon, although patients with insurance often get most of that covered. Total cost nationwide for treating DCIS is likely more than $3.1 billion each year.

Women increasingly are choosing even more radical and aggressive treatment. According to a recent study, the number of women who have both breasts removed after a diagnosis of DCIS jumped from 2.1 percent in 1998 to 5.2 percent in 2005.

Against the backdrop of this increasingly aggressive treatment, physicians and researchers are beginning to grapple with an uncomfortable fact: that treatment may largely be wasted. Many if not most cases of DCIS are now being overtreated. The disease may not be as dangerous as we currently conceive it, and might often sit in the breast for years without causing any harm.

That idea, which is beginning to gain traction in the medical community, has led to questions about current treatment for DCIS. Some women may not need radiation.

Some, in fact, may be able to go without any treatment at all.

“Most of these (research) trials, when they look at everybody, there’s 60 percent that would never progress” to invasive cancer, said Dr. Linyee Chang, a radiation oncologist at St. Charles Bend. “Then you are treating those 60 percent for the benefit of the 40 percent. At what point are you overtreating?”

To be sure, there are heaps of data that

Thanks to the widespread use of mammography, the number of women diagnosed with ductal carcinoma in situ, sometimes called stage zero breast cancer, has increased. Experts hoped that, as cancers were caught earlier, there would be a corresponding decrease in later-stage cancers. That has not happened.

120

105.1

90

0 ’75

123

Invasive breast cancer DCIS

60 30

141.1

26.8

19.3

3.2 ’80

’85

’90 ’95 Year

’06

’00

The decrease in invasive cancers in the early 2000s is generally attributed to the widespread discontinuation of hormone replacement therapy.

Source: Journal of the National Cancer Institute ANDERS RAMBERG

COURTESY CENTRAL OREGON PATHOLOGY CONSULTANTS

Dyed for contrast, this slide shows a breast duct, about two-hundredths of an inch across, with DCIS. The purple dots are the nuclei of cells that have developed DCIS. The pink swirl in the center is an area of calcification, related to the cancer.

Page 7

ROB KERR

Dr. Linyee Chang, a radiation oncologist at St. Charles Bend, sits with the hospital’s linear accelerator, a multimillion-dollar device used to deliver radiation therapy to cancer patients.

Robert Boone, a medical oncologist at Cancer Care of the Cascades. “But that puts us in a position where we tend to recommend more than is needed some of the time, maybe most of the time.”

Controversial treatment The issue is spurring debate at the highest levels of medicine. The National Institutes of Health, one of the nation’s most prestigious health bodies, last year convened a panel of experts to sort out what is known and what we need to know about DCIS. The conference was called with the recognition that “there is controversy,” said Dr. Worta McCaskill-Stevens, an oncologist at the National Cancer Institute who chaired the planning committee for the NIH meeting.

With DCIS, she said, “there are large gaps in knowledge, and data we do not have.”

One primary gap is that, unlike most other types of cancer, no one is really sure whether DCIS would become dangerous if left alone.

Back in the mid-1980s, when mammoPage 8

“Most of these (research) trials, when they look at everybody, there’s 60 percent that would never progress (to invasive cancer).

Then you are treating those 60 percent for the benefit of the 40 percent. At what point are you overtreating?”

Dr. Linyee Chang, a radiation oncologist at St. Charles Bend

grams were first recommended on a widespread basis, screening advocates theorized that, because more cancers were going to be detected earlier, fewer cancers would be found at late stages. Certainly that was the hope.

The number of cancers caught early soon skyrocketed. Before 1980, DCIS was rarely diagnosed. It was maybe 3 to 5 percent of a clinician’s practice, said Dr. Gary Frei, a surgeon at Bend Memorial Clinic who often excises DCIS tumors.

These days, Frei said it makes up about a quarter of the breast cancer patients he

sees. “This whole new group of patients sprang up when mammography became more common.”

Yet, the number of people diagnosed with late-stage breast cancer has not gone down.

It has stayed relatively consistent since the mid-1980s, but for a small drop in the early 2000s generally attributed to the reduction in the use of hormone replacement therapy, which was shown in large studies to contribute to the development of breast cancer.

Experts began questioning why, if we were catching more cancers earlier, we were not seeing a corresponding drop in late-

HIGH DESERT PULSE • SPRING / SUMMER 2010

Cover story | STAGE ZERO BREAST CANCER

“This whole new group of patients sprang up when mammography became more common.”

stage cancers. One theory, now widely accepted, is that some of the DCIS found on mammograms would never progress to invasive cancer. Some might stay in the breast and never become harmful; some might even disappear on its own.

If no one is treated, “maybe roughly 50 percent of people who have DCIS will go on to have invasive cancer,” said Dr. Arpana Naik, a surgeon and medical director at The Breast Center at Oregon Health & Science University. “Probably 50 percent or so would never have that DCIS turn into anything and might die of other causes.”

Others put the percent of DCIS that will become dangerous at closer to 30 or 40 percent. But no one knows for sure. Studies on what happens when DCIS is left alone are either old, from the days before mammography was common, or small, from those women who were diagnosed with benign breast tumors that were later found to be DCIS. Today, virtually anyone diagnosed with the disease has it removed from her body.

“There are likely indolent cancers that may

Dr. Gary Frei, a surgeon at Bend Memorial Clinic

ROB KERR

Dr. Gary Frei removes many of the DCIS tumors found in women in Central Oregon.

541-322-CARE (2273)

Cover story | STAGE ZERO BREAST CANCER

BREAST CANCER TREATMENT RESULTS

When 100 women have radiation in addition to surgery to treat DCIS, it prevents, on average, eight cases of invasive breast cancer.

ANDERS RAMBERG

Source: National Surgical Adjuvant Breast and Bowel Project

This mammogram shows a new suspicious cluster of calcifications, later confirmed as DCIS by biopsy.

COURTESY CENTRAL OREGON RADIOLOGY ASSOCIATES

disappear by themselves over time,” said Chang. But, she said, lacking data about which tumors would go away, “it’s hard to just say you don’t need treatment.”

Does radiation help?

We do have lots of data that indicate who benefits from various types of treatment for DCIS. Though several studies are beginning to look at not treating patients at all for DCIS, the more common question is whether radiation is necessary after surgery. Several large and well-designed research studies have explored that question.

So far, most physicians have concluded that radiation offers benefits. Two large studies “could not find a (group in the study) that didn’t benefit from radiation,” said Dr. Thomas Julian, director of breast surgical oncology at Allegheny General Hospital in Pittsburgh Page 10

and a director in the project that performed one of those studies.

That study, part of the National Surgical Adjuvant Breast and Bowel Project, concluded that women who received radiation were 45 percent less likely to have a recurrence of DCIS or develop invasive breast cancer than women with surgery alone. Another large trial, by a group in Europe, found about the same results.

Doctors across the country have for years cited these studies to tell patients that radiation will cut their risk of having the cancer return by half. If you have DCIS, that sounds convincing, doesn’t it?

But look at the raw data in another way and a different picture emerges.

The study out of Pittsburgh compared women who had surgery alone for DCIS with women who had surgery and radiation. It found that women had a 32 percent chance of having their cancer return after 12 years if they did not have radiation and a 16 percent chance if they did.

Think about what the numbers mean. If you have 100 women with DCIS who are treated with surgery but without radiation, 32 will likely develop either DCIS or invasive breast cancer within 12 years. If that same group were given radiation, 16 would likely develop DCIS or invasive breast cancer in that same time period. So the number of cases of cancer prevented by radiation is the difference between the two groups, 32 minus 16, or 16 cancer cases.

We can take the math a little further. In that group of 100 women, 16 will benefit from radiation and 84 will not, either because their breast cancer would return anyway or because surgery alone was sufficient to prevent it from coming back.

Of the 16 cancers that return, about half will be invasive breast cancer. Clinicians often argue that this is the relevant outcome, because it is more serious and, unlike DCIS, not always curable.

Seen in that light, radiation would prevent the development of eight invasive breast cancers. More than 90 percent of women given radiation treatment see little, if any, benefit.

“We know there is a group that will not need (radiation),” said Julian. Though Julian is often characterized as a leading advocate for radiation treatment, he acknowledged that the group that does not need radiation is in the majority.

The problem, said Julian and many other breast cancer experts, is that we cannot distinguish the minority who will benefit from radiation from the majority who will not. “We still haven’t been able to hone in and identify that group that poses a problem,” he said.

In Bend, oncologists face the same problem. “There are people who have DCIS that is basically removed with their biopsy that are never Continued on Page 35

HIGH DESERT PULSE • SPRING / SUMMER 2010

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Quality control | JOINT REPLACEMENTS

Once is enough National registries of joint replacement surgeries have reduced do-over surgeries in a dozen countries. Why don’t we have one in the U.S.?

BY MARKIAN HAWRYLUK

T

here’s a debate raging among orthopedic surgeons about hip replacements. During the past five years, many have turned to artificial hips with balls and sockets made of metal. These metalon-metal implants are thought to last longer than artificial hips made with plastic or ceramic sockets, making them a popular choice for younger patients.

But word is slowly filtering out about problems associated with the devices. The metal-on-metal joints, it now appears, have a tendency to leave behind microscopic debris of cobalt and cadmium metal, creating a host of health problems for patients. Many patients have to undergo a second surgery within two years of the original procedure to replace the joint again. An editorial in a prominent joint replacement journal earlier this year called for doctors to rethink their use of the devices, saying such implants should be used “with great caution, if at all.”

A study released at a conference of orthopedic surgeons in March found that pregnant women who have received the implants may be passing those bits of metal on to their unborn children. “The next step is to find out what, if any, effect metal ions have on fetal or infant development,” said Dr. Joshua Jacobs, a professor of orthopedic surgery at Rush University Medical Center in Chicago, and the lead author of the study.

The best way to do that, Jacobs said, would be through a national joint registry that logs hip and knee replacement surgeries, allowing doctors to track their outcomes.

Page 12

JOINT REPLACEMENT REGISTRIES These countries have established joint registries: • Australia • Canada • Denmark • Hungary • Norway • New Zealand

• Romania • Scotland • Slovakia • South Africa • Sweden • United Kingdom

But the United States has no such registry.

Despite performing more hip and knee replacements than any other country, U.S. surgeons have less data about the success of their procedures than doctors in at least a dozen countries, including Sweden and Australia, that have already created joint replacement registries. And so questions linger — such as the safety and longevity of metal-on-metal joints — that could be quickly answered by tracking results in a registry. It is akin to running a huge clinical experiment, orthopedic surgeons say, and paying no attention to the results.

“Decisions really should be data driven. In the United States, consumers and physicians don’t have the benefit of that data, and that’s really unfortunate,” said Dr. Knute Buehler, an orthopedic surgeon with The Center: Orthopedic & Neurosurgical Care & Research in Bend. “Essentially, we’re flying blind.”

Early warning system A joint registry is simply a database in which joint replacement surgeries, mainly hip and knee replacements, are recorded. Most

include just basic information, such as the patient’s name, date of the surgery, implant used, surgeon and facility where the surgery was performed. If that patient requires another surgery because that hip or knee joint fails, the registry can then link that revision surgery to the initial procedure, giving doctors an idea of which implants, techniques or even surgeons or hospitals are doing better or worse.

The registry acts as an early warning system, pooling results from multiple locations to provide evidence of problems much earlier than any single doctor or facility would notice on their own.

“Clinicians and scientists frequently deal with retrospective data that typically lags at least three years behind when the surgery was actually done,” said Dr. William Maloney, a professor of orthopedic surgery at Stanford University. Maloney spoke at an American Association of Orthopaedic Surgeons roundtable discussion on registries in 2008. “Problems have to be almost catastrophic for us to recognize them as they are occurring.”

Ten years ago, for example, a batch of artificial hip implants made by Sulzer Orthopedics had been contaminated by oil, causing them to break down. Some 17,500 contaminated hips were implanted in the U.S. before surgeons caught on to the problem. But in Sweden, where surgeons established the world’s first national joint registry in 1976, doctors were tipped off to the unacceptably high failure rate after only 30 of the contaminated hips had been implanted. Doctors in the U.S. continued to implant the hip for six months after Swedish doctors abandoned the device.

The success of the Swedish registry has

HIGH DESERT PULSE • SPRING / SUMMER 2010

JOINT SESSION Replacing joints, known as arthroplasty, has been one of the great medical breakthroughs of the last century. As joints deteriorate with age or injury, they can be a source of great pain as well as drastically reduced mobility. Implants are engineered to replicate the damaged parts they are replacing. They are intended to be strong yet flexible and to provide smooth, painless function for their recipients. The latest designs for replacement implants feature titanium Knuckle and chromium/cobalt-based alloys and Wrist high-density plastics, biocompatible Elbow materials that reduce the chance of rejection. Here’s a look at some of the most common arthroplasties.

Shoulder

SHOULDER AND SMALL JOINTS Although hip and knee replacements are by far the most common joint arthroplasties in the U.S., several others are popular. For example, more than 23,000 Americans have

shoulder replacement surgery each year.

Several companies also make specialized joints for knuckles, wrists, elbows, ankles and even artificial spinal disks.

HIP

Basic components Pelvic cup Replaces the worn-out hip socket

Hip replacement is one of the most common orthopedic surgeries in the world, with more than 193,000 total hip replacements performed each year in the U.S. alone. Most patients are 60 to 80 years old, and each patient is evaluated by a surgeon to decide whether replacement surgery is the best treatment.

Patients should plan on a recovery period of three to six weeks, during which they will require substantial assistance.

KNEE More than 581,000 total knee replacements are performed each year in the U.S. The knee is the largest joint in the body and is involved in almost all daily activities. The surgical procedure takes about two hours, followed by a hospital stay of several days.

Most patients are able to resume normal activities within three to six weeks, following a medication and exercise regimen prescribed by the surgeon.

Ball Replaces the spherical head of the femur Femoral stem Fits into the femur

Hip

IMAGE COURTESY THE CENTER: ORTHOPEDIC & NEUROSURGICAL CARE & RESEARCH

Basic components Patella (kneecap) A dome-shaped piece of plastic

Knee

Femoral resurface Metal and plastic, curves around the femur Tibial platform Flat metal platform with a plastic cushion IMAGE COURTESY FPJACQUOT

By 2030, the demand for hip replacement surgeries alone is estimated to nearly triple to 572,000 procedures.

The demand for knee replacement surgeries is projected to grow by more than sixfold to 3.48 million procedures.

Sources: American Academy of Orthopaedic Surgeons; Small Bone Innovations Inc.

HIGH DESERT PULSE • SPRING / SUMMER 2010

Disk

Ankle

ANDY ZEIGERT

Page 13

Quality control | JOINT REPLACEMENTS

COURTESY THE CENTER: ORTHOPEDIC & NEUROSURGICAL CARE & RESEARCH

Fractures can occur around a hip implant as a result of excessive wear of the implant, the implantation or process, or a fall. Joint registries can help identify which implants or procedures are more likely to cause fractures or other complications.

made it the model for the rest of the world.

In 1979, just as the registry was hitting its stride, the revision burden — the percentage of all hip and knee replacements that were do-overs — stood at 17 percent in Sweden.

By 1997, Sweden had cut its revision rate to 7 percent, about where it stands today.

The U.S. revision rate remains at 17 percent.

With the volume of joint replacements done in the U.S. each year, reducing revisions by only one percentage point could save as much as $100 million in health care costs. If the U.S. matched Sweden’s 10 percentage point reduction , it could save $1 billion a year now, and many times that much down the road.

Joint registry data could also help doctors figure out which procedures work better for which patients. For example, hip resurfacing — an alternative to total hip replacement and another example of a metal-on-metal joint — underwent a resurgence in the 1990s, particularly for younger women. Analysis of data from the national joint registry in Australia, however, showed that women who had resurfacing were twice as likely to require revision surgery as those who had total hip replacements. Digging further into the data, researchers uncovered that the problem occurred in patients with smaller bones. That allowed doctors to improve patient selection for the procedure.

Similarly, the Swedish registry identified a hospital where 4.8 percent of patients who

received artificial hips suffered dislocations that required revision surgery, more than three times the national average for that type of revision surgery. It prompted the hospital to review its procedures and implement quality control measures to reduce the number of dislocations.

“This represents one of these unique opportunities where we can do the right thing to improve care, reduce the overall cost for the system and improve the job that we do for patients,” said Dr. David Lewallen, a professor of orthopedic surgery at the Mayo Clinic. “We know that we can never eliminate all of them, but small reductions in that revision burden will have a huge impact.”

And the impact stands to be even greater as the nation deals with an aging population and an obesity crisis. U.S. surgeons performed about 750,000 hip and knee replacements in the U.S. in 2005, a 70 percent increase from five years earlier. The number of hip replacements in the U.S. is expected to more than double by 2030, while the number of knee replacements is expected to grow more than six-fold.

Establishing a U.S. registry Lewallen is heading the American Association of Orthopaedic Surgeons’ push for a national joint registry, which may be coming to fruition.

The American Joint Replacement Registry was incorporated in July 2009, and stakeholders hope to begin collecting data at pilot

Major joint replacement surgery was the most expensive short-stay inpatient hospital procedure paid for by Medicare in 2006. Joint replacements and revision surgeries totaled $5 billion in Medicare costs that year. Revisions represent about 17 percent of the total, or close to $850 million. sites by the end of this year. If the group can get the American registry up and running, it could look much different from other national registries. In other countries, those registries are primarily government-funded or physician-run. The American effort is emerging as a collaborative venture of doctors, hospitals, insurance companies, manufacturers and patient groups.

“Each of the various groups flourishes, does better economically, does better in terms of reputation, if there are a higher proportion of good outcomes,” Lewallen said.

“The opposite is true if there is a higher proportion of bad outcomes.”

The group has set a goal of getting 90 percent of hip and knee replacement surgeries reported to the registry within three years, but faces tremendous hurdles. The effort has been more than 10 years in the making and has yet to secure ongoing funding. Initial start-up costs of $1 million, Lewallen said, came from orthopedic surgeons’ groups as well as manufacturers and insurers. But the registry could take up to $25 million a year to run.

The registry will also depend on significant commitment from hospitals and surgeons who must submit the data. In some countries, surgeons are legally required to report to joint registries, while in other countries

government-run health care may capture the necessary data. It is unknown if a voluntary registry can get near universal participation.

The voluntary Canadian registry, for example, captured only 41 percent of hip and knee replacements done in 2006 and 2007.

A statewide registry organized by orthopedic surgeons in Virginia has had trouble getting doctors to participate.

On the other hand, Kaiser Permanente launched a company-wide registry in 2001 and within six years had recorded 95 percent voluntary participation rates among more than 350 surgeons in more than 50 hospitals.

“I think it will be an effort to participate in the registry. Will everyone participate?

No,” said Dr. Robert Shannon, an orthopedic surgeon with Desert Orthopedics in Bend. “I think many orthopedic surgeons would do it, because we all want to see better outcomes for our patients.”

Shannon said he could envision Medicare requiring surgeons to report replacement surgeries to the registry as a condition of getting reimbursement. Medicare has a long history of driving reporting of quality improvement data though such measures.

Medicare could also reap huge benefits.

Medicare paid more than $5 billion for hip and knee replacements and revisions in

2006, and is expected to pay an estimated $50 billion per year by 2030.

In 2006, Medicare paid $11,000 for each primary surgery, and $14,000 for each revision, with the cost of the implanted device accounting for about half the cost. Any data that could show which devices tend to fail and which had better long-term outcomes could result in massive savings for the program.

“There’s a myriad different implants that we see from multiple manufacturers, and I think we get the best data on those implants from these long-term registries,” Shannon said. “I have based many clinical decisions off of those registries. So I think by adding a U.S. registry we would get even more data on implants.” U.S. doctors can access registry information from studies published in medical journals, but there is a time lag before those studies are published.

Liability, privacy concerns While there is broad support for a national registry in the U.S., progress has been slowed by concerns that plaintiffs’ attorneys will mine registry data to bring lawsuits against providers and manufactures.

“People are concerned about the liability issues that it brings to the forefront both for hospitals and physicians, and also product

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Registries might also face challenges from federal privacy laws that require patient consent for reporting data and from hospital boards that oversee data collection for research purposes.

Lewallen acknowledged those concerns but believes the hurdles can be cleared.

“This is really what boils down to a quality improvement and patient safety initiative, and there is precedent for bona fide well-intentioned efforts to improve patient care being granted confidential status so it can be used,” he said.

Lewallen also cited the cases of other health registries in the U.S., such as one tracking cardiothoracic procedures. “As far as we know, there has not yet been a single action for discovery or subpoena of data from such registries for any class action lawsuit,” he said.

Manufacturers, meanwhile, could have plenty to lose. Currently there are plenty of options for hip and knee replacement parts, but a shortage of long-term outcomes data. A U.S. registry could help to weed out the weaker products.

Joint registry data, for example, identified an implant involved in a full 20 percent of revision surgeries in Australia, countering a company-backed study concluding the device was 98 percent effective.

“It is outrageous that medical devices are being made available in America that are so lousy they have been withdrawn in markets

overseas,” said U.S. Rep. Bill Pascrell, a New Jersey Democrat who has become an avid proponent of a national registry.

Last year, Pascrell and Texas Democratic Rep. Lloyd Doggett introduced the Knee and Hip Replacement Act of 2009, which would direct the federal government to establish a national registry within five years. But Congress has yet to consider the bill.

“It would reduce the number of costly and complicated do-over surgeries and save taxpayers billions of dollars,” Pascrell said. “As Congress seeks to reform health care and reduce Medicare costs, bringing higher standards to the medical device industry would be a good place to start.”

Last year, the Agency for Healthcare Research and Quality solicited bids from health care institutions that would agree to collect very detailed data on joint replacement procedures. But those would serve more as sentinel sites than a full joint registry. The FDA is also working on a joint registry initiative.

Lewallen said orthopedic surgeons are already working with electronic medical record vendors to create reporting systems that could collect much more detailed joint replacement data in the future. But for now, even having a basic record on every surgery could represent a quantum leap forward.

“I think it’s going to make a difference in the quality of health care that people receive,” Lewallen said. “The most expensive total hip or total knee is the one that fails, because the system pays twice and patients suffer twice.” •

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How does he do it? | DREW BLEDSOE

Trading the gridiron for the great outdoors

Bledsoe is big on Bend

BY BILL BIGELOW PHOTOS BY ROB KERR

S

ometimes, Drew Bledsoe misses the old days.

“Back when I could sit down in front of the TV with a big bowl of ice cream,” he reminisces. “When I was younger, I could eat forever. But I can’t get away with that now.”

Which is not to suggest that staying fit is a problem for the former NFL quarterback, who says he and his family came to Bend in 2004 in large part because of Central Oregon’s get-out-and-do-it lifestyle.

“If you like to be outdoors and active,” Bledsoe says, “this is like Disneyland.”

And Bledsoe’s favorite attractions at this HIGH DESERT PULSE • SPRING / SUMMER 2010

High Desert amusement park include skiing, cycling, golf, and playing basketball in a local adult recreation league.

He is able to do all of those things, he observes, because he got out of pro football with his sturdy 6-foot-5-inch frame pretty much in one piece.

Bledsoe retired from the NFL in 2007 after 14 seasons, mostly as quarterback of the New England Patriots, with whom he became a Super Bowl champion. He was a four-time Pro Bowl selection and, including shorter stints with the Buffalo Bills and the Dallas Cowboys, he compiled statistics that put him among the league’s career leaders in pass completions, passing yardage and touchdown passes.

He also was sacked — tackled for a loss

Former star quarterback Drew Bledsoe, photographed along the Deschutes River Trail, says he exercises now for recreation and health.

of yardage by bloodthirsty defensive foes — 467 times. That’s an incredible pounding.

“Football is a pretty violent game, played by big people,” Bledsoe says. “I played 14 years in the NFL, and to walk away healthy … I count my blessings.”

Bledsoe, who recently turned 38 years old, looks as if he could still be playing today. In fact, several teams have called over the past couple of years, trying to coax him out of retirement.

The offers, he admits, are tempting.

“I honestly loved every minute of it,” he says, remembering the exhilaration of pro football. “Nobody can ever replace that feeling. … I will always miss the game. But I have no regrets. I got out at the right time.”

The right time for him, he says, because he had plans for his future.

Life beyond football for Drew Bledsoe has meant more time with his family: wife Maura and their four children, sons Stuart, 12, John, 10, and Henry, 9, and daughter Healy, 6.

Staying fit is still important to Bledsoe.

But his approach to fitness, he says, has Page 17

How does he do it? | DREW BLEDSOE

“If I wake up in the morning now and I’m sore, I want it to be because I’d spent the whole day before on the ski slopes or on a long bike ride.”

Drew Bledsoe

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changed dramatically.

For football, he explains, “I had to be strong. There was lots of heavy lifting, intense cardio, sprints — lots of uncomfortable things.

“Now,” he continues, “I exercise for two reasons: recreation and health. And with four kids, I can’t help but be active.”

Bledsoe and his family belong to the Athletic Club of Bend.

“I try to get in and lift once in a while,” he says, but he adds that he is “not on a specific regimen right now. … I had my fill for 20 years or so (in football) and have allowed myself to take a break.”

At home, Bledsoe has what he describes as “a small home gym” that includes an elliptical machine and a treadmill.

“I try to get in there a few times a week and do 45 minutes of cardio and some pushups and sit-ups,” he says.

His preferred exercises, however, are done outdoors.

“I try to ski as many days as I can when the snow is reasonably good,” says Bledsoe, noting that he skied upward of 65 or 70 times this past season.

And during months more favorable for cycling, he says, he makes it a point to get out for a bike ride three or four times a week.

Bledsoe says his current weight — 235 pounds, give or take — is about the same as it was during his playing days.

“I like to say that it’s just been redistributed a little bit,” he says with a grin. “I’m carrying

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less in my shoulders and more around the middle now.”

Not that a casual observer could tell. Bledsoe still has a trim, game-ready look to him. He says he is mindful of proper nutrition, but he insists he is not obsessed with it.

“I do try to avoid carbs when I can,” says Bledsoe, who last year discovered what he calls “a minor gluten allergy” that steers him away from foods made with wheat.

“It takes a lot more attention now than when I was playing football,” he says. “I’ve got to pay attention to what I eat. My wife makes sure I take my vitamins and that we have healthy food around the house. But no big secrets; it’s mostly just common sense.”

Bledsoe says he does not count calories.

“I don’t have a strict diet,” he says. “I just try to eat healthy.” (Note: For lunch during the interview for this story, Bledsoe ordered a bowl of gumbo soup and a spinach salad, with water to drink.)

And when it comes to adult beverages …

“I still enjoy beer,” he says. “There’s so many great beers brewed here locally.

“But,” he adds, “a lot of times I’ll choose a glass of red wine over beer. Wine’s good for you; in moderation, obviously.”

Bledsoe’s preference for fine wine goes far beyond its reported health benefits. Among his varied business interests, the former gridiron great is now into grapes: the winemaking variety. His ventures include Flying B Vineyard, in Hermiston, and McQueen Vineyard, located in the Walla Walla Valley of southeastern Washington. That’s not far from where Bledsoe was a high school football star before he went on to become an All-America quarterback at Washington State University and then the No. 1 selection in the 1993 NFL draft.

From there, he embarked on a professional career that many experts believe will one day land him in the Pro Football Hall of Fame.

But that, he adds emphatically, is all behind him.

“If I wake up in the morning now and I’m sore, I want it to be because I’d spent the whole day before on the ski slopes or on a long bike ride,” he says, “not because I was lifting heavy weights and training for football.” •

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Page 20

3 Creatinine levels in the body are related to kidney function.

might mean diabetes.

2 Highly elevated glucose levels

from these tests, doctors say it’s important to talk to your physician about the results. Mike Henderson, an internist with High Lakes Health Care in Bend, says the results of a blood test should always be taken in context.

“Knowing the whole story is the hard part,” Henderson says.

Sometimes physicians will order blood tests as a way to look for a specific disease. For example, McLellan says blood tests can be helpful in finding kidney and liver dysfunctions at earlier stages.

“Kidney dysfunction can be very insidious. You can go years with slowly deteriorating kidneys and not feel any-

-Potassium -Chloride -CO2 2 -Glucose -BUN 3 -Creatinine -AST (SGOT) ( )

1 -Sodium

Result 141 4.5 106 28 102 6 L 0.8 22

Reference 133-145 3.5-5.1 98-110 22.0-32.0 74-106 8-20 0.5-1.0 11-41

The chemistry panel, or comprehensive metabolic panel, checks on levels of glucose, proteins, electrolytes and enzymes. An imbalance in the organs can show up in theMetabolic chemistry panel.

Comprehensive Panel

CHEMISTRY PANEL

1 Imbalances in electrolytes, like

sodium and potassium, can point to kidney disorders, heart disease, diabetes or other diseases.

Patient: Scott Johnson Patient ID: 40531028 Sex: M Age: 30Y DOB: 3/3/79 Physician: Doctor Zaius Collected: 02/15/10

says Dr. Bruce McLellan, a cardiologist with Heart Center Cardiology in Bend.

Doctors say the tests are just one of the many tools they can use to assess a person’s overall health. When making a diagnosis or determining whether a person has health issues, doctors will keep in mind not just the results of a blood test but also the clinical profile, symptoms and family medical history.

“So if you have a high LDL cholesterol, then you are at increased risk for coronary disease. It doesn’t mean you will get it, but you are at increased risk,” McLellan says.

To avoid drawing false conclusions

Here’s a general breakdown of a sample test. It may help you in addressing specific questions about your own test results with your doctor.

YOUR BLOOD TEST AT A GLANCE

eading the results of your latest blood test and knowing what it actually means is like trying to put a puzzle together. Even though the pieces give you clues, the bigger picture can be elusive.

That’s when a doctor’s interpretation is essential. Still, knowing more about the meaning of blood tests could help you ask your physician the right questions.

“It’s good for someone to be interested, it’s good for them to ask questions, but this is not something you can go to the Internet and find your answers to,”

R

BY MARNETTE FEDERIS

Laboratories often give reference numbers that indicate what the normal values for each blood element typically are. These numbers are drawn from the results of 95 percent of a defined “healthy population,” and there could be some slight variations among different laboratories.

Errors can occur, however, so not every abnormal number is cause for worry.

thing, no symptoms, no physical findings, and so the blood test is going to be your only chance of catching that reasonably early,” he says.

According to Henderson, “One common misconception is that we have cancer screening in blood tests. We don’t order for cancer screening. However, we order CBC (complete blood counts) looking for leukemia.”

When ordering routine blood work to check on a person’s general health status, there are three panels (or series of tests) that doctors will pay most attention to.

Take a look at the lab report below for a quick lesson on how to read your own. •

Bloodwork is a window to your health when you know what to look for

Bl d test basics Sorting it out | READING A BLOOD TEST

HIGH DESERT PULSE • S

E • SPRING / SUMMER 2010

Page 21

11 Large increases and decreases in platelets, which help the blood clot, can mean excess bleeding or clotting.

10 Hematocrit represents the percentage of the volume of whole blood that is made up of red blood cells. This measurement depends on the number of red blood cells and the size of red blood cells. Both low and high hematocrit levels can signal a problem.

hemoglobin might mean abnormalities such as anemia.

9 Low levels of red blood cells and

cells might mean an infection, and extremely high numbers could be a sign of leukemia.

8 Elevated levels of white blood

7 LDL, or bad cholesterol, should be low.

the higher the value, the better.

6 HDL is the good cholesterol, and

of fat the body uses to store energy, along with high LDL levels, increases the likelihood of heart disease.

5 Having high triglycerides, a type

4 Enzymes including alkaline phosphatase and bilirubin are found in the liver and can help a doctor monitor the organ.

related to kidney function.

0.8 22 16 72 1.2 6.8 3.7 9.5 3.1 1 >60 >1.0

0.5-1.0 11-41 2-34 35-100 0.2-2.0 6.1-7.9 3.5-4.8 8.6-10.2

Reference 0-149 0-199 35-85 0-129 0.00-3.22 0.00-4.44

Result 100 232 H 48 164 H 3.40 H 4.81 H Fasting

L = Low H = High CL = Critical Low

-MCV -MCH -MCHC -RDW 11 -Platelet -MPV -Neutrophil% -Lymphocyte% -Mono% -Eosinophil% -Basophil% -Neutrophil -Lymphocyte -Monocyte -Eosinophil -Basophil

10 -Hematocrit

-Hemoglobin

8 -White Blood Cells 9 -Red Blood Cells

Reference 4.5-11.0 3.90-5.20 11.7-15.5 34.0-45.0 82.0-99.0 26.5-34.0 32.0-36.0 11.5-15.0 140-450 6.5-10.0 43.0-75.0 19.0-47.0 2.0-12.0 0.0-5.0 0.0-2.0 1.8-7.7 1.0-4.8 0.0-0.8 0.0-0.5 0.0-0.2 # = Abnormal Result CH = Critical High

Result 6.8 4.30 13.0 38.4 89.3 30.2 33.8 14.2 265 10.7 H 62.8 29.6 5.7 1.5 0.4 4.3 2.0 0.4 0.1 0.0

A complete blood count (CBC) can show whether the bone marrow is producing blood cells in reasonable amounts. It also indicates whether a person has disorders such as anemia or infection.

CBC, Automated

COMPLETE BLOOD COUNT

-LDL/HDL Ratio -Cholesterol/HDL Ratio Dietary status

6 -HDL Cholesterol 7 -LDL Chol, Calc

-Cholesterol

5 -Triglycerides

The lipid panel can be helpful in predicting the risk of a coronary heart disease. It can also help a doctor determine if a patient needs to be prescribed medication that will help keep bad cholesterol levels down.

Lipid Panel

LIPID PANEL

-AST (SGOT) -ALT (SGPT) 4 -Alkaline Phosphatase -Bilirubin, Total -Protein, Total -Albumin -Calcium -Globulin -A/G Ratio -eGFR

3 -Creatinine

While an extremely high level of white blood cells can point to leukemia, a CBC is not a screening test for cancer.

In analyzing the lipid panel, doctors will focus on each element and compare LDL and HDL cholesterol levels.

Get ready | THE DESCHUTES DASH

DESCHUT SC U Summer’s at hand

Why not give this a tri?

BY BREANNA HOSTBJOR

M

aybe you’re a runner and you’ve jogged laps or entered a 5K for a favorite charity. Maybe you’re a swimmer and you’ve put in some time at the pool to stay in shape. Or perhaps you saw the Twilight Criterium in downtown Bend last year and it inspired you to dust off that old bike in your garage.

But could you do all three sports? In the same race?

Absolutely.

In fact, if you’re moderately fit and injury-free, there’s no reason you can’t compete in the Deschutes Dash triathlon in mid-July. All it takes is practice, and in a few short months you could be crossing your first triathlon finish line.

First things first Triathlons can be intimidating, especially if you don’t feel particularly comfortable with one or more of the sports. What seems feasible now while sitting and reading a magazine may become daunting a few weeks into your training.

The key here, according to Tom Holland in his book “The 12-Week Triathlete,” is to sign up right away. As soon as you decide to compete, fill out the registration forms and put your money down. Once you’re committed, you’ll be less likely to try to back out.

Page 22

And if it’s the length of the race that worries you, remember that the Deschutes Dash has two triathlons for adults: The Olympic race is a 1,500-yard swim, followed by a 25-mile bike ride and a 10K run.

The sprint course is significantly shorter, with a 1,300-yard swim, 12.5-mile bike and 5K run.

For first-time triathletes, “sprint distance is absolutely the best way to go,” said Joanne Stevens, who teaches a triathlon training course at inMotion Training Studio in Bend.

Does that mean you can’t compete in the Olympic race? Certainly not. But consider your options, estimate your level of fitness, and sign up for one or the other as soon as you can (See “Deschutes Dash Essentials” for details).

Build your base Begin by setting a training schedule, and then stick to it.

Both Holland and Stevens recommend practicing each sport twice per week, and Holland advocates incorporating weight lifting into the swimming sessions to help prevent muscle imbalances.

That means an ambitious six days per week of exercise, though, which could be difficult or impossible for some. If you typically have a busy schedule, acknowledge that now.

“Number one, look at how much time you have to train per week and be honest about it,” Stevens said. Scheduling two hours of train-

HIGH DESERT PULSE • SPRING / SUMMER 2010

TESS DASH S PHOTOS (FROM LEFT) BY PETER STRONG (2008), ANDY TULLIS (2006) AND ROB KERR (2009)

ing every Wednesday won’t do you any good if you have only 15 minutes to spare.

Next, Stevens suggests finding your weaknesses. Divide up your time, devoting the most, at least in the beginning, to your weakest sport. If you’re equally comfortable with all three, then spread your time evenly.

If you’ve swum only a few times, you’ll want to work on technique.

Learning good stroke style now will mean faster times on race day, according to Holland, because you can learn to minimize the effects of drag so you can swim more efficiently. Swimming poorly, he states, only reinforces swimming poorly.

Adult swimming classes are available at Juniper Swim & Fitness Center in Bend, and if you already have a basic grasp of swimming technique, they can be a good way to improve your strokes.

For bike training, Stevens recommends starting with trips of about five miles and taking it easy until you become comfortable. Practice is important, and the more you bike, the better your pedal stroke, or cadence, will become.

Both Stevens and Holland caution against practicing in too high a gear, though.

“Someone new to biking tends to push a really heavy gear,” Stevens said. But biking hard doesn’t necessarily make you faster, though it will almost always make you more tired. And tired or injured legs are not what you want when you head into the running stage of the triathlon.

The early acclimatization period of your training is also a good time to carry bike tools and learn to fix flat tires. Facing a flat with no tools and no practice would be a rude awakening in the middle of a race.

When you begin running, make sure you have properly fitted

HIGH DESERT PULSE • SPRING / SUMMER 2010

shoes that support your feet and don’t give you blisters. Then start with short runs, or as Stevens suggests, run and then walk until you can maintain a jogging speed for about half an hour.

It’s also never too early to practice brick workouts, which are biking followed by a run. After the exertion of a bike ride, the transition to a jog can feel extreme.

“Your legs feel like jelly,” Stevens said. “You’ve got to know how that feeling is, because it will go away. And don’t panic. It can be shocking for someone new.”

It’s unlikely that, even with practice, the strangeness of the transition will ever cease completely. But you can learn to anticipate it, and Holland says that, with practice, running after biking will become steadily easier.

Step it up By the end of May, you should have the basics of each sport down and have a solid fitness foundation. This is your base, the first of Holland’s four recommended cycles.

Now it’s time for the second cycle, increasing the intensity of your workouts. This is a build phase, followed by a peak, before the athlete reaches a tapering period.

Begin devoting more time to each sport, lengthening the distances or times you spend in the water, on the bike or on the road. Take a week or two to adjust and then increase the duration again.

The more you train, however, the more prone you may become to burning out, which is one of the pitfalls of taking months to prepare for the Dash. Do what you can to keep yourself interested and motivated.

Stevens suggests adding interval, speed or endurance work to Page 23

Get ready | THE DESCHUTES DASH

14th St.

DESCHUTES DASH Colorado Ave.

Les Schwab Amphitheater

97

Dr.

BEND

Centu ry

Bike out and return

Virginia Meissner Sno-park

Sprint turnaround 41

46

s Hw y.

Cascade Lake

r ive R tes hu sc e D

Slow things down In early July, two weeks before the Deschutes Dash, athletes should begin to taper.

You should have just finished weeks of hard training, and now it’s time to rest and let your body recover.

It may feel strange, even counterintuitive, to scale back now, but this stage is vital for Page 24

Les Schwab Amphitheater

Shevlin-Hixon Dr.

First Farewell aid Bend Park Athlete parking Bill Healy 97

Bridge

Sprint course Olympic course (includes sprint distance)

Source: Deschutes Dash

each training session. Add drills and endurance to your swimming. Vary the courses and terrain that you bike or run.

“The more you mix it up, the fitter you’re going to get,” Stevens said. “You’re not going to get as bored.”

Remember to keep your nutrition and hydration in mind, too. Holland recommends practicing the skill of eating and drinking in the middle of your sports. Using aid stations during the Dash is a good idea, so get used to taking in liquids while biking so that you’ll be prepared when you need to do it on race day.

The Deschutes Dash will serve Gatorade at the aid stations, so consider drinking it during your training. Even if you plan to bring water bottles with you on your biking leg — and you should — you’ll be drinking at these stations as well, so get your body used to consuming the sports drink.

These weeks will cover the most intense workouts of your training, culminating about three weeks before the Deschutes Dash. Keep that in mind and keep hitting the trails and the pool.

. ve oA d a lor Co

Run course Sprint: 1 loop, 3.1 miles Olympic: 2 loops, 6.2 miles Swim course Sprint: 1,300 yards Olympic: 1,500 yards Century Dr.

Simpson Ave. e. r Av Emkay St. Columbia St. ndle a h C Mt .W ash . D Colorado Ave. r.

Olympic turnaround

Run, swim and transition course

Bike course

S O

Swim exit and run to transition

Race finish on footbridge

iver Deschutes R Reed Mk

Footbridge

First aid t. Rd.

Swim start Swim start buoys approximate placement (beach area) O Olympic race S Sprint race GREG CROSS, ANDERS RAMBERG

anyone who wants to arrive at the race with enough energy to compete.

“People tend to have a panic, but you cannot gain fitness in the last two weeks, so there’s no point in doing last-minute fitness,” Stevens said.

Rest instead, and reduce your workouts to a few brief sessions per week. These will keep your body ready without depleting stores of energy.

Holland warns that athletes in this stage may begin to feel tired, lethargic, even crabby.

Not to worry, though. All of that is normal.

Instead of sitting around and chafing from the lack of activity, Holland suggests staging a mock triathlon for yourself. Spend only a few minutes in each sport, but use all of the gear and clothing that you intend to race in.

This way you can find any problems, like clothing that rubs or irritates, while you still have plenty of time to fix the issue.

It’s a good time to get adjusted to wearing a wet suit, which is recommended for the swim segment of the Dash. The wet suit will make you more buoyant and should improve your body’s position in the water. The warmth will also keep you more comfortable in the 62-degree river.

“Wet suits are wonderful,” Stevens said. “But you also have to practice taking them off.”

Holland recommends a “stop, drop and pull” method for wet-suit removal. As you exit the water, unzip the wet suit and pull it from your arms as soon as you reach the

banks. When you reach the transition area by your bike, sit down and pull the suit off your legs. While it may seem that the act of sitting would add a few seconds to your transition time, it’s much easier to do this while on the ground than to try to keep your balance while tugging on soaked neoprene.

Stevens also suggests removing the wet suit quickly after the swim.

“As soon as you exit the water, you start to take that wet suit off because it’s got that water inside it and it helps to get (the wet suit) off your body,” Stevens said.

Finally, spend these last two weeks checking your gear. Tune up your bike, Holland says, because if a mechanic finds anything wrong there will be enough time to order spare parts if needed.

Then gather all your race gear and organize it. You don’t want to realize, two days before the race, that the sunglasses you intended to wear during the biking leg are lost. Running all over town trying to find a replacement will only add to your pre-race stress.

Race day You’ve trained, organized and rested up.

Now it’s time to actually race.

Give yourself plenty of time in the morning to prepare before you head to the Deschutes Dash to set up your transition areas.

Holland recommends making sure that your bike tires are properly inflated; you want them to be full, but not so full that they

HIGH DESERT PULSE • SPRING / SUMMER 2010

burst when temperatures climb later in the day. Then put the bike in a low, or easy, gear so you don’t have to fiddle with it in the madness of trying to leave the transition area.

The Dash also has a “try a tri” swim wave, which Stevens highly recommends for firsttime triathletes. It allows beginners to start the swim segment half an hour before other competitors, so new athletes can avoid the crush of faster swimmers rushing through the water.

Gina Miller, the Deschutes Dash race director, says the early wave was instituted several years ago when it became apparent that first-time triathletes were anxious about the swim wave.

“We wanted to create an environment where they could feel more comfortable,” Miller said. And this wave allows racers not only to swim with other beginners, all of whom are likely to be concerned about the body contact that inevitably occurs during the swim, but also to run and bike among the faster racers who may catch up to them

during the rest of the Dash.

If you opt for a traditional starting wave, or if you’re unable to enter the try a tri — sign ups are limited to the first 75 interested competitors — you’ll be placed into a wave based on your swim speed.

“Be honest about your ability and how comfortable you are,” Stevens said. And if you’re not a fast swimmer, or if you aren’t comfortable, stick to the back so that speedy competitors don’t swim over you.

Once you finish the swimming leg and transition to the bike, temperatures will likely be climbing. Even if you’re nervous, tired or preoccupied with finding your cadence, remember to hydrate.

“By the time you hit the run, it’s too late,” Stevens said. “What you do on the bike leg helps you on the run.”

And most importantly, have fun. After spending months preparing for the Dash, you’ll be ready. In no time at all you’ll be celebrating the accomplishment of finishing a triathlon. •

Deschutes Dash essentials Triathlons can be notoriously gear-heavy, with elite athletes intent on improving their race times. But unless you’re planning on doing a good deal of racing, keep it simple. “If it’s something you just want to try, you don’t need a lot of gear,” Stevens said. Stick to the basics: a wet suit for the swim; a bike, helmet and possibly clip-ons for the ride; and good shoes for the run. Central Oregon has numerous shops where you’ll find what you need; below are recommendations from Stevens and Miller.

Wet suits: You can find a suit at Central Oregon Diving LLC: 541-388-3660. Or try www.

wetsuitrental.com or www.xterrawetsuits.com. All venues both sell and rent suits.

• Central Oregon Diving will rent a triathlon wet suit for about $12 per day. If you decide to buy a suit, most prices will fall between $100 and $700.

Clip-ons: Most people don’t own time-trial bikes, so they use clip-ons, which

attach to the handlebar of a regular road bike and modify the frame so that you can lay your arms down, placing them close together to reduce wind resistance. The idea, said Mike McMackin of Hutch’s Bicycles, is to look like a downhill skier. “That’s the position that a time-trial or triathlon bike is trying to emulate.”

• Clip-ons can cost around $100-$200. • Try Hutch’s Bicycles at 541-382-9253 (west Bend) or 541-382-6248 (east Bend), or Sunnyside Sports at 541-382-8018.

Running shoes: You’ll be logging a lot of miles in these shoes, so make sure they fit

correctly. A good shop will watch you run, or even videotape your stride, to make sure you’re getting the best shoe for your running style.

• Be prepared to pay upward of $100 for a good pair of shoes.

• Try Fleet Feet Sports at 541-389-1601 or FootZone at 541-317-3568.

Registration: Registration for the Dash is online only. Visit www.signmeup.

com/67797 to register, or visit the Deschutes Dash Web site and follow the links to register for other event races, which include a kids’ race and 10K and 5K runs. The Dash’s sprint and Olympic triathlons cost between $75 and $95 each, depending on when you sign up. Contact the Dash at 541-318-7388 or www.freshairsports. com/events/deschutes_dash.

PETER STRONG

David Cooper, of Woodland, Wash., crosses the finish line after completing the duathlon course of 2008’s Deschutes Dash.

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Minimizing exposure | BISPHENOL A

ANDY TULLIS

BPA is a ubiquitous ingredient in everyday items. Can you tell which of the products above are likely to contain it? Check your answers on Page 29.

BPA: In the news and in your food Our exposure is low but constant. What you can do to reduce your contact while experts are engaged in debating the long-term effects.

BY BETSY Q. CLIFF

Y

ou can’t avoid it. You swallow it in canned food. You touch it when you put on your bike helmet or switch a CD. Your kids may drink it down with their juice.

BPA is in our food, our water and the air we breathe.

Bisphenol A is a chemical used in the production of a host of consumer goods, and studies have shown that more than 90 percent of people in the United States have measurable levels of BPA in their bodies.

The chemical is all over the news these days, too, with considerable controversy about how tightly its use should be controlled.

Washington state recently banned it in products made for children 3 and younger, following Wisconsin, Connecticut and Minnesota. In Oregon, a similar ban proposed earlier this year fell short by just one vote in the Legislature.

On a federal level, the Environmental Protection Agency and the Food and Drug Administration this year announced plans to study the chemical’s effects on human health.

On one side are environmental groups and advocates for a BPAfree world who link the chemical to health problems ranging from heart disease to infertility. They say BPA is toxic to the body, even in small doses, and liken industry efforts to downplay the effects of BPA to tobacco industry tactics that covered up the health ef-

HIGH DESERT PULSE • SPRING / SUMMER 2010

BISPHENOL A (BPA) • What is it? A chemical compound made by industrial chemical companies.

Raw BPA often looks like a white powder.

• How long have we used it? Commercial production of BPA began in the 1950s.

• Why are people worried about it? BPA can act like the hormone estrogen and may disrupt the body’s normal processes. Some studies, most of them in animals, have suggested deleterious health effects from BPA, including an increase in heart disease, diabetes or reproductive problems. fects of smoking.

On the other side are manufacturers and the plastics industry, which contend that BPA is safe. They cite decades of use of the chemical and the low level of exposure for most people. It’s one of the best ingredients, they say, for making plastic hard and shatterproof and for keeping canned food from tasting like the can.

With both sides citing science and making seemingly legitimate points, where does that leave us, the consumers?

Sorting the science from the hype can be difficult. Studies conflict and even the same study can have different interpretations. Even if you can draw conclusions, there’s the question of whether to change your behavior. Is the risk high enough to stop using canned food?

Should you change your water bottle? Should you do anything?

Page 27

Minimizing exposure | BPA WHO IS DRINKING BPA WITH THEIR WATER?

What is BPA?

In The Bulletin’s offices, the guy who drinks from the blue Nalgene bottle at right bought his bottle about a year ago; the company said all of its bottles have been BPA-free since 2008. On the other hand, the woman with the gray Nalgene, which is about 6 years old, is using a container containing BPA, the company said.

BPA is a chemical that is used as a “building block” for hard plastics and epoxy resins, such as the linings of food cans that prevent the food from touching the metal. Before BPA became available, canned goods used less effective linings; BPA is credited with protecting food from spoiling and helping it retain its flavor.

Many, many products contain BPA, including tennis rackets, pop cans, eyeglasses, CDs, cell phones, security shields, reusable water bottles and a variety of other household and business products.

It is made in huge quantities. In 2006, nearly 4 million tons of the chemical were produced worldwide. Most of that went into hard plastics, with the rest used for epoxy resins.

Consumers would hardly ever see raw BPA, but if you did it would probably look like a white or tan flaky powder. The Dow Chemical Co., one of the largest manufacturers, says it has a mild odor.

BPA was first discovered by chemists at the turn of the 20th century. In the 1950s, two U.S. scientists discovered how to make polycarbonate plastic, a hard, clear, shatter-resistant plastic, using BPA as the base. Commercial production began a few years later.

Why is there concern?

PETE ERICKSON

As for the stainless steel blue bottle at left, made by the Canadian company Innate, that’s BPA-free, according to the company. Most stainless steel bottles do not contain BPA, though aluminum water bottles are sometimes lined with a substance containing the chemical. The disposable water bottle at right is likely also BPA-free; the chemical is rarely used to make more flexible plastic.

Though BPA is cleared from the human body quickly and doesn’t accumulate like some toxins, we get a new dose every day. So if it is a problem, the effects are likely widespread.

The primary concern, discovered in the 1930s, has to do with BPA’s ability to act like the hormone estrogen. Further research has shown that BPA can mimic and possibly interfere with the normal activity of estrogen and perhaps other hormones.

The fear, said Deana Connors, a toxicologist with the Oregon Office of Environmental Public Health, is that the chemical would “contribute to problems with the endocrine system,” which produces hormones in the body. That could lead to all sorts of problems from earlier onset of puberty to a higher risk of cancer.

Still, the level of BPA that a person is typically exposed to is very

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WHICH PRODUCTS CONTAIN BPA? small, on the order of micrograms per day. Conventional wisdom among toxicologists has been that these low doses would be unlikely to affect human health.

Current research, however, is questioning that notion. Known as the “low-dose effect,” a new controversial theory postulates that low, continuous doses of BPA can have a measurable effect.

“For years, we were taught the dose makes the poison,” said Margie Kelly, communications director at Safer Chemicals, Healthy Families, a coalition that campaigns for a reduction in toxic chemicals.

“BPA is in a class of chemicals that is defying that idea.”

Other groups aren’t so sure. Summarizing a multitude of studies on the topic, the Bisphenol A Global Industry Group, made up of major manufacturers of BPA, released this analysis: “No low-dose effects were found in these studies, thus clearly demonstrating that the low-dose hypothesis is not valid. The weight of scientific evidence clearly supports the safety of BPA.”

What does the evidence say?

The validity of the low-dose theory is the core question, but it’s hard to draw firm conclusions from any research to date.

The biggest problem: It is extremely difficult to do the kind of studies of BPA that would conclusively establish its safety or harm.

Because nearly everyone has the chemical in his or her system, scientists can’t design an experiment that would compare the health of people exposed versus those not exposed. And they really can’t imagine getting people to agree to voluntary doses of BPA, even if they could get it past their ethical review boards.

So scientists have done the next best thing. They’ve looked at populations of people to try to see whether those people with higher amounts of BPA in their bodies have problems with their health.

One of the largest studies of this type, published in 2008 in the Journal of the American Medical Association, found that the higher the amount of BPA exposure (measured through urine analysis), the more likely a person was to have cardiovascular disease and diabetes.

Although the study was not able to determine if higher levels of

From Page 27.

3 4

1

8

5

2

6

15

7

11 9 12 13 10

14 16 17

YES 5, 13 TreeTop Apple Juice, Diet Coke (per Tree Top, North American Metal Packaging Alliance; aluminum cans usually lined with epoxy resin that contains BPA) 6, 9, 12 DelMonte Fresh Cut Green Beans, Campbell’s Chicken Noodle Soup, Progresso Vegetable Classics Soup (per Consumer Reports test; lining of can made with BPA) 11 Similac Advance Infant formula in can (per FDA; BPA is in linings of cans)

NO 1 C&W frozen peas: likely no (no response from manufacturer, but industry group says frozen food containers rarely contain BPA) 2, 14 Sunmaid Raisins, Country Choice Oven Toasted Oats; cardboard container/ plastic lid (per companies; linings not made with materials that contain BPA) 3, 10 Apple, potato (fresh produce is not packaged; does not contain BPA) 4, 16 Playtex sippy cup, Playtex baby bottle (major manufacturers of baby bottles and sippy cups pledged in January 2009 to keep BPA out of products for young children) 7 Eden Organic Black Eyed Peas (Eden Organic has pledged not to use BPA in its canned food) 8 Canada Dry Ginger Ale (per industry group; single-use plastic bottles rarely contain BPA) 15 Trader Joe’s Peanut Butter (per company) 17 Safeway Select Boysenberry Preserves (per company) Sources: Consumer Reports, Food and Drug Administration, Tree Top, Safeway, North American Metal Packaging Allliance, Sunmaid Raisins, Trader Joe’s, Country Choice Organic

BPA actually caused greater risk of disease, authors could not find another explanation.

David Melzer is a professor of epidemiology and public health at Peninsula College of Medicine & Dentistry in the United Kingdom and an author on the paper. He wrote in an e-mail that the research team

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Minimizing exposure | BPA had tested other possible explanations for the high disease rates seen in people with a lot of BPA in their bodies. These tests, Melzer said, had been fruitless, leading to the conclusion that BPA was the likely culprit for the increased amount of disease.

Some researchers have used animals to try to figure out how BPA affects the body.

Results have been shocking: Mice exposed in utero had defects in their reproductive system, including indications of cancer in the prostate or breast. BPA changed connections between cells in the brain of animals tested and, in some, BPA exposure made the animals more aggressive.

Other animal studies have found that BPA increased insulin secretion in the pancreas, interfering with the way sugar is processed in the body and possibly explaining a link to diabetes.

Still, no one knows whether these effects would translate to humans. The level of concern, however, has risen high enough to warrant federal government action, both the EPA and FDA concluded in statements released this year.

The FDA released a statement in January signaling the possibility of harm from the chemical, one of the first such statements by a federal agency. The agency said in a news release that new studies on BPA have “led federal health officials to express some concern about the safety of BPA.” It noted that better research is needed and launched a $30 million project to study

WHAT SHOULD YOU DO? There are several fairly easy steps to reduce BPA exposure.

• Use BPA-free plastics. They exist, though there’s no surefire way to identify them. Look for BPA-free on the label or check the company’s Web site. Typically a number 7 on the recycling label means it contains BPA, but that is not a sure indication of the chemical’s use.

Other recycling numbers rarely contain the chemical.

• Avoid putting plastics that have BPA in the dishwasher or microwave. The chemical is more likely to leach out when the containers are heated, even once those containers have again cooled. Transfer foods to a ceramic or glass dish before heating. Replace plastic containers that have been washed frequently in the dishwasher; damaged or scratched plastic is more likely to leach BPA. • Avoid canned foods, when possible. At least one company, Michigan-based Eden Organic, sells food in cans lined with a BPA-free material, though it costs more to produce. Several Central Oregon stores carry the products, including Whole Foods, Newport Market and Ray’s.

• Eat fresh foods, which don’t contain BPA. • Choose frozen over canned. Frozen foods are less likely to contain BPA, though a test by the Milwaukee Journal Sentinel found very small amounts in some frozen food trays, such as those used in ready-to-eat dinners. the effects of BPA. It hopes to have the first results of these studies later this year.

The EPA said in March it would study the environmental impacts of the chemical, and whether humans are endangered by their environmental exposure to BPA. Right now, consumers should take a measured response to the government’s warnings, said Kristina Thayer, acting director of the Center for the Evaluation of Risks to Human Reproduction at the National Toxicology Program. “It wasn’t enough for them to

• Throw away scratched baby bottles and cups, as damage could increase the leaching of BPA. Most baby bottles made after January 2009 do not contain BPA; that’s when the six major manufacturers committed to stop using BPA in their products.

• Use powdered infant formula rather than liquid. Both powdered and liquid formula cans are often lined with BPA, but tests showed it leaches into liquids but not powders.

• Switch from BPA-containing hard plastic water bottles to metal bottles, but check the Web site of your bottle manufacturer to be sure your metal bottle doesn’t contain BPA on the inside lining.

• If you drink soda, choose plastic liter bottles rather than aluminum cans, which are lined with BPA. Soft plastic bottles intended for single use do not contain BPA. • If you are concerned about the other products you buy, check the company’s Web site. A good rule of thumb is that hard, clear plastics with the number 7 on them and smooth liners, such as the linings on aluminum cans, contain BPA, and softer plastics or non-plastic containers do not. suggest a ban on BPA or tell people to throw away their BPA, but enough to say, ‘Let’s try to move away from the chemical.’”

Without anything proven, but with strong suggestions of harm, it’s impossible to quantify the risk of BPA for any one individual. Each person, then, must decide how much he is willing to change his behavior to avoid BPA. Overall, the risk level is likely moderate, experts say, so there’s no need to panic. Right now, “nothing’s settled,” said Kelly. “What are you going to do? Not sell canned food?” •

On the job | OSTEOPATHS

Just what does a D.O. do?

Holistic and hands-on

BY BREANNA HOSTBJOR

Y

ou wake up feeling awful. Your head hurts. Your back aches. Your lungs feel heavy.

It’s time to go to the doctor.

But don’t expect to walk in, rattle off your symptoms and have a prescription jotted down. Not if your physician is a D.O. Not if you’re a patient of Dr. Maren Dunn.

Dunn, 34, is a doctor of osteopathic medicine at Pioneer Memorial Hospital in Prineville.

She comes from a background in physical fitness, first as an athletic trainer in college, then as a personal trainer, where she had plenty of physical contact with clients. And when she transitioned to a medical field, she wanted to continue to work and heal with touch.

“Basically (I have had) my hands on people all through my career,” she said.

Dunn practiced in Idaho before personal reasons necessitated a move to Oregon.

And as a rural family practice physician, she found Prineville was a great match. “It was great for their needs for a primary care physician and my desire to continue treating patients who live in a small town.”

Like all primary care doctors, she went through rigorous medical training before she graduated from Kansas City University of Medicine and Biosciences and completed her residency at Idaho State University. Unlike M.D.s, she was board-certified as a D.O. What’s the difference? An osteopath is trained to look at patients from a whole-person perspective. The idea is that illness and injury aren’t just a set of symptoms to be cured; a patient’s well-being, and the restoration of that state, depend on the individual’s health history and lifestyle. So it’s not enough to focus on what feels wrong; the whole individual must be treated, getting at the causes

HIGH DESERT PULSE • SPRING / SUMMER 2010

of illness instead of just the effects.

Part of that healing involves educating patients about how to care for themselves. A D.O. can teach patients about changes they can make that will improve their health, putting the healing process in the hands of the patient as well as the physician.

That’s why a typical visit to an osteopath will involve an initial interview to establish medical history and learn about the individual’s home, work or family life. Those details may contribute to illness or injury. Osteopaths are trained to understand the body’s musculoskeletal system, so most visits will also include a structural exam to evaluate things like posture and balance, and the D.O. will use his or her hands to find and help diagnose the affliction.

What the physician finds in these procedures, and in the myriad other tests common in doctors’ exams, will guide any treatment plans he or she recommends. And for D.O.s, part of this plan may involve osteopathic manipulative treatment, or OMT. That means hands-on care. The osteopath uses stretching or gentle pressure to help treat illness or injury. “I use touch therapy to help people ease their pain and promote healing,” Dunn said. “It can help kids with ADD focus. It can help people with migraines make their headaches go away. … It can help people with asthma get clearer breathing.”

That hands-on approach is perfect for some patients, especially people with chronic pain who don’t necessarily want to rely on medication. She said OMT helps them find relief.

Which doesn’t mean osteopaths aren’t versed in pharmaceutical care — they are — or even that they’re necessarily averse to it. But, in some circumstances, OMT can complement, occasionally even replace, drugs or surgery.

And for some patients, that’s just what the doctor ordered. •

PETE ERICKSON

Dr. Maren Dunn stands in the offices of Pioneer Memorial Hospital in Prineville, which hosts her osteopathy practice.

“I’ve been trained to use a whole-person perspective and listen to (the patient) and not just their symptoms. How a person lives directly impacts their health. Our whole goal is to help the body heal itself rather than just medicate it.”

— Dr. Maren Dunn

Page 31

Healthy day | HEAD OUTDOORS

Hi, warm weather Dining gets casual, the trails are clear — and the nights are young

BY BREANNA HOSTBJOR PHOTOS BY RYAN BRENNECKE

A

fter a mild winter, the arrival of spring can slip by with less fanfare than usual. Sunny days and clear trails seem almost normal, not like the post-snowfall treats they often are when cold weather retains its grip into June.

Still, now is the time to head outside and enjoy Central Oregon as the temperatures start climbing. Get in some hearty, nutritious meals and exercise out in the sun, then head indoors during the cool evenings to heat things up on the dance floor.

Here’s one recipe for a day of healthy play:

1. Grab an early lunch at Cafe Yumm! The casual restaurant

in Bend’s Old Mill District offers a range of healthy options for diners, plus an outdoor patio. Several varieties of Yumm! Bowls (above) include selections of organic brown rice and beans, topped with veggies and sauces.

Small bowls are $5.75, and each bowl increases by a dollar per size.

Or try one of the burgers: The vegetarian option can be ordered to suit vegan diets, and comes topped with ginger Asian slaw. The wild salmon burger is made with line-caught fish from the Northwest. Both cost $7.75. (325 S.W. Powerhouse Drive, Suite 130, Bend; 541-318-9866, www.cafeyumm.com.)

2. Bike Phil’s Trail. After fueling up with a hearty

lunch, drive out to Phil’s Trail, west of Bend. Mountain biking opportunities abound here, so take a side trail or two through the system. Most trails are easy to moderate, especially when you’re near the trailhead. And be respectful of other bikers you’ll see on the tracks; this is a high-use area. That said, there should be plenty to keep you busy and happy for a few hours while you enjoy the sun and the scenery. (From Bend, head west on Skyliners Road. Continue until you reach a road marked with a biker icon. Turn left. The road will intersect with a Brooks-Scanlon logging road, and there will be a parking lot here where you can leave your car. No permits are required.)

4. Go dancing. Get a dance-floor workout once night falls. Plenty of bars and clubs have DJs spinning most nights, and many have no cover charges. You can also be adventurous and strut your stuff at a live-music event. The Blacksmith Restaurant in Bend brings in local DJs on Friday and Saturday nights, usually beginning at 10 p.m. There’s no cover, so head in and let the beats get your whole body moving.

(211 N.W. Greenwood Ave., Bend; 541-318-0588 or www.bendblacksmith.com.) • 3. Refuel at Kebaba. Mediterranean food, rich in fruits, vegetables and olive oil, has

been linked in numerous studies to heart health. And this cozy restaurant serves modern Middle Eastern foods that fit the bill. Try the taboule salad, with bulgur, antioxidant-rich tomatoes, onions, cucumbers and olive oil. Or try the vegetable kebab, with mixed vegetables, tahini, pilaf and salad. Prices are healthy, too: some salads cost as little as $4, and no dish is more than $17. (1004 N.W. Newport Ave., Bend; 541-318-6224, www.kebaba.com.)

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Body of knowledge | POP QUIZ

Stretch your brain Reach for the answers to this little quiz

GREG CROSS

BY BREANNA HOSTBJOR

A

lmost everyone who has participated in sports or taken a physical education class has learned about stretching — bending over to touch your toes, contorting into a pretzel.

What else is there to know?

Maybe more than you think.

The science behind stretching has evolved in recent years, and some of those tips from thirdgrade soccer practice may be out of date. See if you can wrap your mind around these questions and answers.

1.

2.

3.

4.

Stretching before exercise prevents injuries.

True or false?

Ballistic stretching, which involves quickly bouncing through range-of-motion activities, should be performed by which group of people?

A. High-endurance athletes B. Highly flexible athletes, such as gymnasts or yogis C. Anyone 20 to 30 seconds of static stretching, which involves holding a stretch position, before a workout improves muscle efficiency.

True or false?

How long should you hold a static stretch?

A. 10 seconds or more B. 20 seconds or more C. 30 seconds or more

5.

6.

7.

Stretching is more beneficial: A. Before exercise B. After exercise C. Stretching is best when performed independent of exercise.

Stretching before bed is a good idea, but only if the following applies: A. You have no lingering sore muscles from the day.

B. You have been active recently.

C. You haven’t consumed any alcohol in the past two hours.

For maximum flexibility, everyone should stretch at least twice a week.

True or false?

ANSWERS

1. False. A study by the American College of Sports Medicine showed no correlation between stretching and injury rate. Stretching can, however, increase flexibility and range of motion, making it easier to engage in exercise activities.

2. C. Anyone can practice ballistic stretching, though, as with all forms of stretching, care should be taken to make sure it is performed correctly.

Consider seeking out the guidance of a physical therapist or coach to make sure you undertake these stretches safely, because the wrong bounce could lead to injury and muscle damage.

3. False. While some clinical trials have found no difference between stretched and unstretched muscles, most suggest that static stretching — like bending to touch your toes and holding the position — causes muscles to generate less force. It is also possible that repeating the stretches decreases muscle efficacy. On the other hand, dynamic stretching — which uses movement to facilitate a stretch, as during a lunge — seems to have a positive impact on the force our muscles can generate.

4. A. The length of time you should hold a stretch varies from person to person, but most studies recommend holding each position for at least 10 seconds. This should not cause pain, however, and muscles should be warmed up before you begin.

5. B. Stretching before exercise inhibits muscle function and may put you at risk for injury because the muscles move with less force. Stretching afterward, however, benefits flexibility without affecting performance. Muscles are also warmed and have good blood flow at this stage, which makes the body more receptive and the stretch more effective.

6. B. To help avoid injury and increase efficacy, muscles should always be warm before you stretch. So if you’ve been sitting on the couch watching TV for a while, be sure to get blood flowing back into your limbs before you try to touch your toes. Try walking around or engaging in other gentle activities first.

7. False. While regular stretching is likely to increase flexibility for most people, injury, weakness or other imbalances can inhibit permanent gains.

And, like all fitness activities, the ideal amount of time you should stretch depends on your body.

— GUIDANCE PROVIDED BY MIKE TOMPKINS OF REBOUND PHYSICAL THERAPY

Page 34

HIGH DESERT PULSE • SPRING / SUMMER 2010

Cover story | STAGE ZERO BREAST CANCER Continued from Page 10 going to have another event,” said Boone. “But it’s still statistics. It’s not actuality. God doesn’t come down and point to the ones that need (treatment) and the ones that don’t.”

Separating cancers Some physicians and researchers say you don’t need divine intervention to determine who should get radiation. Of these, Dr. Melvin Silverstein is likely the most well-known.

As he said, “I have 20 years of experience picking out the people that don’t need it.”

Silverstein is the medical director at the Hoag Breast Care Center in Orange County, Calif., and a professor at the Keck School of Medicine at the University of Southern California. He is a giant in the breast cancer world. According to his biography, he is the founder of the first freestanding breast cancer center in the United States and author of the only textbook on DCIS. Even those who disagree with him do not dispute his expertise. Yet his ideas are still considered by many to be outside the mainstream of treatment.

“From the doctor’s point of view, (aggressive treatment) is the right thing to do. But that puts us in a position where we tend to recommend more than is needed some of the time, maybe most of the time.”

Dr. Robert Boone, a medical oncologist at Cancer Care of the Cascades Silverstein designed a system to classify women with DCIS based on their risk of having cancer return. It takes into account a patient’s age and tumor size, measures of tumor aggressiveness and surgical margins, the amount of normal tissue removed during surgery to take out the cancer. (Wider surgical margins are thought to protect against the return of either DCIS or a more invasive cancer.)

For those with a good score on Silverstein’s system, often called the USC/Van Nuys Prognostic Index after the institutions that sponsored his research, less aggressive treatment is justified. Silverstein takes out

their cancer with surgery and then sends them home without radiation.

Many of his patients, he said, come from areas where less aggressive therapy is not offered. “My whole practice is based on people who don’t want (radiation therapy) and they fly to see me.”

His results are good; patients with good scores on the prognostic index were just as likely to have another bout of breast cancer after 10 years whether or not they received radiation therapy.

Other cancer experts say they respect his success; his data are often included in discussions of treatment options by other research-

Cover story | STAGE ZERO BREAST CANCER

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At Central Oregon Radiology Assoc., PC (CORA), and its hospitals and imaging centers, highly skilled radiologists with advanced training are the only ones reading patient imaging studies.

CORA radiologists have been an integral part of the Central Oregon medical community for over 60 years providing the expertise, technological resources, accountability and connectivity that sets them apart from other radiologists.

ers. The problem is that no one else can achieve his results.

“The data are provocative,” said McCaskill-Stevens, who said Silverstein’s methods were reviewed at the recent NIH meeting.

“But to validate the efficacy of his research, I think it needs to be validated in a large clinical trial.”

Despite several attempts to stratify patients in the same way Silverstein does, no one has yet been able to find a group for which radiation does not add some benefit.

The key, said Silverstein and others, is in how closely Silverstein’s group looks at the biology of each individual woman’s cancer.

Silverstein’s team spends more time and money on pathology than most cancer centers, said Dr. Craig Allred, a pathologist at Washington University in St. Louis who is working on the biology of DCIS. That, he said, allows for a better diagnosis. “It reveals a lot about the underlying structure of the tumor,” said Allred. “I think this issue about pathology evaluation is a big deal.”

Pathologists take samples of the tumor, slice it up like a loaf of bread and examine its features. Typically, pathologists will perhaps study a few dozen slices of a tumor. Silverstein said his pathologists look at up to 60.

That kind of detail, however, is expensive and time-consuming.

Insurance companies do not reimburse well for this kind of work, Silverstein said, and it is likely cost-prohibitive for most of the country. Though Silverstein said his hospital has accepted his methods and agreed to eat the extra cost, many hospitals will not endorse what amounts to unpaid time to evaluate additional pathology slides, even if it could save money down the line in less treatment.

“My hospital won’t support it,” Allred said. “They can’t bill for the extra pathology work.”

Becoming less aggressive In addition to Silverstein’s efforts, both the NIH and other widely respected sources have issued calls for scaling back treatment of the disease. The NIH conference concluded that “the primary question for future research must focus on the accurate identification of patient subsets … including those persons who may be managed with less therapeutic intervention.”

Some women, it said, could likely “be monitored after biopsy without surgery or other therapies.”

There are at least a couple of clinical trials now looking at

WHAT CAN YOU ASK YOUR DOCTOR? If you have recently been diagnosed with ductal carcinoma in situ, here are some things you might want to discuss with your physician.

• What is the recurrence rate for this disease?

• What are the features of my diagnosis that might affect my chance of recurrence?

• What are my options for treatment?

• What are the side effects of each treatment option?

• If my cancer does recur, how will my choices now affect the ability to treat a recurrence?

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HIGH DESERT PULSE • SPRING / SUMMER 2010

STAGING BREAST CANCER

Staging is the way doctors assess the severity of a woman’s breast cancer and helps determine how the cancer will be treated.

Percentage of cancer diagnoses

5-year survival rates

Lumpectomy followed by radiation, or mastectomy

19%

100%

Confined to breast

Surgery and radiation; may involve systemic medications such as chemotherapy or hormone therapy

40%

98%

Stage II

Spread to lymph nodes near breast

Surgery, radiation and systemic medications such as chemotherapy or hormone therapy

31%

86%

Stage III

Surgery, radiation and systemic Spread to area near breast such as medications such as chemotherapy chest muscle, skin or hormone therapy

6%

57%

Description, tumor size

Stage 0 (DCIS)

Has not spread beyond breast ducts, lobes

Stage I 2 centimeters (¾ inch) or less in diameter 2-5 centimeters (¾-2 inches) in diameter More than 5 centimeters (2 inches) in diameter

Stage IV

Tumor can be any size

Spread of cancer

Typical treatment for stages

Confined to breast

Distant spread to bone, lung, liver, etc.

Chemotherapy or other systemic drugs and may include surgery or radiation

Sources: American Cancer Society, Journal of the National Cancer Institute, Breastcancer.org, Imaginis, Dr. Robert Boone

that issue. Several researchers are tracking how women with low-risk DCIS fare when they are treated less aggressively and followed closely by a physician for signs that the disease is progressing.

Cancer experts, for their part, do see less aggressive treatment in the future for DCIS. They just say we’re not there yet.

“When we get to a better refinement of the biology of the disease … (we will be able to tell) who will be able to go home and live a nice, comfy life and who needs treatment,” said Julian.

The last piece is taking the debate out of the medical field and to the women actually diagnosed with the disease. Many women may feel, as Stratton did, that they want to do everything they can to remove the threat of cancer. Surely that’s what has been preached for the past couple of decades.

“We made such a big level of activity of telling women you need a mammogram and you need to intercede when you find something. Now to tell people to go home and have fun?” said Julian. “There will be some women who are OK with that and some women who say, ‘Are you out of your mind?’” •

HIGH DESERT PULSE

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IV III

II I

O 4%

20%

© 2007 MCCLATCHY-TRIBUNE NEWS SERVICE

Laughter | THE BEST MEDICINE

Scale down — weigh down!

I

did it naked, clothed, morning, noon and night. A look at a weighty problem.

When I meet a friend on the street, I’ve never yet had one say, “Hi, Sally. I see you’re 160 pounds today.” Except for my life insurance agent looking skeptically over his glasses, should the scale numbers matter to anyone? Maybe my doctor. But she can calculate it by poking at any extra feminine flesh Velcroed on my hips.

So why an obsession with the bathroom tattletale? It has its place, but, like anything, moderation is key. For 20 years I stood atop Mount Vesuvius — my scale — about six to 10 times a day. I’m not normally stupid, and I’ve never experienced an addiction — except to that oval relic with the peeling padded surface.

I needed to step on in the morning and certainly when I went to bed at night. Even when returning from the grocery store. It’s as if turning down the candy aisle, even though I stayed to the far side, must have added a pound or two.

Why should stepping out of the bathtub change the numbers from what they read before I jumped in, as if any unneeded insulation would wash down the drain? I probably spent more time scrutinizing lines on that round dial than sitting on the flushing thing next to it.

It was hard to tell if the pointer was on the third mark or fourth until I grabbed my glasses. How much did they weigh? Was the thing set EXACTLY on zero? Would standing on tiptoe make a difference?

I’ve stepped on at 2 a.m., sleepily turning on the light to see if three hours of slumber had changed anything. Of course, there was always before and after meals, with or without earrings.

Distractions helped. A bit of romance worked off a little. At least an occasional test didn’t hurt. Thank goodness for three days of flu — 2 pounds, whoosh — but don’t drink a glass of water.

Vacation truly was an escape from the volcanic creature threatening to erupt. Other scales tempted me not. But the minute I walked in the door, it was back — the urge — luring me like dead stuff does a dog.

THEN I DECIDED TO JUST SAY NO. SUBMISSIONS I would never again allow a 2-inchDo you have a funny thick metal object to rule my life, eshealth story you’d like to pecially one that had nothing more share? Send 500 words cordial to say than “flump, flump” or less to pulse@bend when I stepped on and “plump, bulletin.com. Editors will plump” when I retreated. select one submission The first week of my new resolve, for each edition.

I learned the meaning of withdrawal.

That scale reached out to me more

Page 38

than my husband did. The arguments with it were fiercer than those with my politically challenged brother.

But all is quiet now. I’ve upgraded to a sleek digital model that gently tells me when I’m two-tenths of a pound high and doesn’t seem to need my constant attention. When I add the hours I wasted praying to that pompous old icon, I could have been out on the street letting people notice how gorgeous a curvy woman really is. • — SALLY BEE BROWN Brown is a longtime Bend area resident and past active member of the business community. She has been a freelance writer for 16 years, and more than 100 articles of hers have been published in regional, national and international magazines. She has written an as-yet unpublished novel and is contributing editor to PassageMaker Magazine, which caters to trawlers and ocean motor yachts.

SPRING / SUMMER 2010 • HIGH DESERT PULSE