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Choosing a hospital for labor and delivery

Courtney Collen (Host): Hello and welcome to Her Kind of Healthy, a health podcast series brought to you by Sanford Women’s. I’m your host, Courtney Collen with Sanford Health News. We want to start new conversations about age-old topics from fertility and postpartum depression to managing stress, healthy living and so much more. Her Kind of Healthy is designed to bring you honest conversations about self-care, happiness and your overall wellbeing with our Sanford Health Experts.

In this episode, we are focusing on what to look for when choosing where to have your baby. It’s a really special conversation. I have Elizabeth Miller, M.D., joining me now. She is a Sanford Women’s specialist in obstetrics and gynecology, and I want to welcome Dr. Miller to the podcast. Welcome!

Dr. Elizabeth Miller: Thank you, Courtney, for having me. This is such an important topic, and I think people get really excited because this is one of the first big decisions that they’re making as parents.

Host: Yeah, let’s talk about that for a moment. How special is this time? And some big decisions to make for a new mom or parents-to-be.

Listen: Health and Wellness by Sanford Health

Dr. Elizabeth Miller: Absolutely. This is a very exciting time. They’re thinking about who’s going to be taking care of them throughout their pregnancy, where they’re going to deliver, who’s going to take care of their baby afterwards and all of the care that they’re going to receive during that time. So, I see pregnant patients even from a preconception visit when they’re thinking about getting pregnant and all of the things that go into that. And then I see women throughout their entire prenatal journey. I deliver babies here in the hospital and I also see them for their postpartum care.

Host: How much do you love what you do?

Dr. Elizabeth Miller: It’s a pretty special job. I don’t think that a lot of people can say that they’re a part of that.

Host: Yeah, let’s dive right in. What should patients or parents look for in a facility or hospital system when selecting their birthplace?

Dr. Elizabeth Miller: It’s really important to look for a place that’s going to provide safe evidence-based care and also a place that can support women in the decisions that they want through the whole birthing process.

Host: Let’s talk through some of those things that Sanford offers. First, who is here to provide that care?

Dr. Elizabeth Miller: So patients here have a decision to make about the provider they would like to see during their prenatal care and for delivery. We have a group of OB/GYN physicians, and we work really closely with midwives that are part of our group too. And then there are also family medicine doctors who will do deliveries.

Host: Can we talk quickly about the difference between an OB/GYN and a midwife?

Dr. Elizabeth Miller: Yes. So an OB/GYN is a physician who has completed medical school and a residency specific in OB/GYN training. All our midwives who are with our group are certified nurse midwives, which means that they have extra training and are advanced practitioners before they get their midwife training. So they have a very high level of care with a nursing background as well.

Host: What are some of those important things women should consider when planning the birth process?

Dr. Elizabeth Miller: One thing that I think is really important for women to consider is what type of birth they would like to have and here at Sanford, we can support women, whether they want a low intervention birth all the way to, if they need a C-section delivery for any reason. So what a low intervention birth could look like is different ways that we can support women who might not want to use things for pain medication who might want to labor in the tub, be able to move around during labor. And we have water birth suites which is kind of unique in this area. And some of our midwives do water births, but even if patients aren’t interested in a water birth, they can still labor in the tub and water can be very therapeutic, especially in the early labor process.

We then have wireless monitors. So while women are in the early phases of labor, or even later on, we can still watch mom and baby and they can move around freely.

So traditionally all of our fetal monitoring would have to be connected to a wall and you would have maybe three or four feet to be able to move around with these wires and you’re always getting kind of hooked up in them as you’re trying to move around. And if people want to try different positions beyond the birthing ball, we can support that with these wireless monitors. They can also go in the tub, which is pretty incredible.

Host: Yes, amazing. But women don’t have to have a low intervention birth, right?

Dr. Elizabeth Miller: Absolutely. Women don’t have to have a low intervention birth. We have women who really want their epidural and we have great anesthesiologists who can help provide excellent pain relief during labor with epidurals.

We also have other options for pain management here at the hospital with IV pain medications, nitrous oxide, which is gas that you can breathe in during contractions to help take away some of that pain during contractions and women can choose any of those options while they’re here having a safe delivery.

So we are watching mom and baby, we have nurses who are trained to be looking for anything that would be outside of the norm with that so that we can intervene or help at any point. And that’s the other really important thing when looking for a hospital: it’s great to have all this support for low intervention, but you also want a place that has a safety net for anything that goes wrong.

So one important thing that we offer here at Sanford are VBAC deliveries, which stands for a vaginal birth after cesarean. So this is for moms who have had a C-section before, and usually it is one or two prior C-sections and there’s, you know, other criteria that makes in the candidate for this or not. But for women who are interested in trying for a vaginal delivery after a C-section. And this is a little bit unique because there are increased risks associated with that. And so we perform continuous monitoring of mom and baby throughout the process. And we have anesthesia and OB available at any time if there was an emergency.

So, frequently, we will see people who are referred to our clinic to discuss TOLAC, which is trial of labor after C-section for patients who are wanting to try for a VBAC delivery. And we meet with them in clinic, we talk about why they had the C-section in the first place, what things make them a good candidate for trying for a vaginal delivery and how we support them through that process.

We also talk to women if we think that it would be safer for them to have a repeat C-section and talk about the risks and benefits of both. Not all hospitals are able to provide a VBAC for patients, but this can be really important, especially if patients want the vaginal birth experience or if they’re planning on having a lot of other pregnancies to be able to have a vaginal birth and then set them up for other vaginal deliveries in the future is really important.

I like to share with my patients that I’m a VBAC mom and I had my VBAC here at Sanford with my son, and it was such a great experience. And I knew that I was in good hands. And if anything were to change during the labor process, I knew that my team would be ready to step in and help my son.

Host: How old is your son now?

Dr. Elizabeth Miller: He’s 15 months old.

Host: Oh, congratulations!

Dr. Elizabeth Miller: Thank you.

Host: When do women start to make those decisions as part of what their labor and delivery might look like?

Dr. Elizabeth Miller: I highly encourage patients to talk with their OB provider, who is giving their prenatal care, about their options during the prenatal visits. The OB provider is the one who knows the patient the best. And usually patients will fill out a birth preference or birth wish sheet for us so that we know some of the things that they’re looking for and then we can talk about those in more detail with them.

Host: Talk about the importance of having pediatricians rounding in the hospital labor and delivery units to check on baby and maybe perform procedures that might be needed.

Dr. Elizabeth Miller: Sure. So the pediatricians that come to see the babies are getting to know their newest patients and they get to know them from the very beginning. And they can identify if there are any extra needs that the babies have and start to address those right away in the hospital. They can also help the parents kind of understand some of those early cares if there’s any procedures that are needed such as a circumcision that that’s desired, those can be performed at that time too.

Host: It sounds like a pretty seamless transition from prenatal care or care with an OB GYN to a new baby. And now it’s time for baby’s care journey to begin.

Dr. Elizabeth Miller: Yeah. That’s our goal.

Host: That care will continue between mom and her OB/GYN. Is that right?

Dr. Elizabeth Miller: We still see our patients in the hospital for their postpartum cares and also for their postpartum visits too.

Host: We expand more on that transition from postpartum to parenting and add additional expertise and insights from Dr. Jennifer Haggar as Sanford Health pediatrician, joining Dr. Miller in another episode of this podcast series as well.

Dr. Miller, what types of pregnancy parenting newborn education options are there here at Sanford? And, and why is it important to have those options available?

Dr. Elizabeth Miller: We’ve already talked about this being a really exciting time. It is also such a huge transition. You are preparing to take home a baby and learning about the actual care of the infant, but there’s also so much learning that goes into the birthing process. And I feel like if patients take the time to do some of these classes, they’re going to feel more comfortable and more confident with that. Here in our clinic, we have birth navigators who are nurses that are specifically trained in OB care and helping women kind of through the prenatal process and connecting them in with classes. They also give tours of our labor and delivery.

And I think this is a really important opportunity for patients to take advantage of because when you can see where you’re going to be giving birth, I feel like that takes away a lot of the unknown and can make you feel a little bit better when you’re able to visualize them.

The classes that we have are all available on the Mom2Be website. And there are online courses and in-person courses, and then also a combo of the two. So they really try and work with people’s schedules to make this an easy thing to do. There’s a Birthing with Confidence course that has both online and in-person parts. And they talk about things like positioning during labor, massage from your partner, different comfort me measures, how to relax and how to support people in labor.

There is also an Understanding Birth online course, and they share birth stories and go through what is labor because a lot of people don’t really understand that. And that’s understandable that they don’t know if they haven’t been through this before.

There’s a WebEx course called Birth Basics. They teach people what the signs are for labor, how to time your contractions at home, when to call or when to come in for evaluation. And when I see patients in clinic, that’s one of their biggest concerns. When do I come into the hospital? And how do I know if I’m in labor? So that’s a great course to kind of go over those basics and also reiterate that patients can just call us with any questions or concerns. And they don’t have to make that decision to come in, in a vacuum. We will help them with that process.

One thing that’s kind of unique here is that we have a Spinning Babies parent course, and this really works with optimal positioning and using balance, gravity and movement throughout labor to help babies kind of come down the right way in the birth canal and to ease the birthing process. And that’s a really fun class.

And then for patients that are looking for extra support and relaxation during labor, our midwives teach a hypnobirthing (now Hypnobabies) course. This is a longer course that does have some practice that they need to do outside of the course, too, to get the full experience. But it uses guided imagery, visualization, and breathing to help during labor.

One of the most underutilized visits is what I consider a preconception counseling visit. And this is for patients who are considering pregnancy and they can come and talk with us about ways to optimize pregnancy, optimize fertility, starting a prenatal vitamin. We talk about any labs that are needed beforehand. And it’s a really great way for them to get to know what type of care we provide during pregnancy then, and answer some really important questions that people have about that. So I encourage anyone who’s considering pregnancy to schedule a visit with us. We love to chat with people even before pregnancy to go over all this stuff.

Host: A lot of questions I’m sure women have before the process. There’s so much great information. Dr. Miller, thank you for giving us an overview. It’s a lot to think about. How important is planning for the unexpected and what are some of those options at Sanford?

Dr. Elizabeth Miller: This is one of the things that I like to talk to my patients about during their prenatal visits, because birth can be unpredictable. Our favorite thing is when we can have a healthy vaginal delivery for mom and baby, but there are times when things change, and our plans change and you want to be in a place that can change those plans quickly and support mom and baby.

When something happens during birth, minutes count for delivery.

So here at Sanford, we have OB/GYN doctors in house 24/7. We have anesthesia here 24/7, and we have operating rooms that are right in our labor and delivery suite. So that we don’t have to move down a floor or across the hospital to deliver baby. We can just go right across the hallway to deliver baby quickly.

The other important thing is we have an excellent NICU team. So they come to any of our deliveries for preterm babies when we are expecting babies are going to need extra care, and they also come to our C-section deliveries and they are there to provide extra support if needed. They can also come immediately after delivery if there’s anything that we notice with baby, where baby is going to need extra care.

Last night, I was on night call on labor and delivery. And I knew that I was going to be doing this podcast in the morning.

So I went straight to the source and surveyed a couple of our night labor and delivery nurses. And these are an awesome crew of people. They are so great at taking care of their patients. They provide a lot of one-on-one support during labor. And I said, why would you recommend for someone to come and deliver at Sanford?

And the biggest things that they were emphasizing were our support of lower, low intervention births. They talked extensively about using water, using water births, and also their support of different positions and movements during pregnancy. And again, I want to emphasize the wireless monitoring that we have available for patients and they were saying that that makes their job so much easier too, because they have the confidence that they still know what’s going on with mom and baby, but people can move around. People can walk around and that’s awesome.

The other thing that they talked about was how quickly our team assembles when needed if there is any type of emergency, whether with a vaginal delivery or with a C-section delivery, we are ready. We practice this with drills. We have excellent communication as a team and we are set to help take care of mom and baby.

Host: It sounds like the care journey is really tailored to each woman. It could be as hands on or hands off right here in the hospital. Dr. Miller, thank you so much for your insight and expertise in this space and all that you do here at Sanford.

Dr. Elizabeth Miller: Thank you, Courtney.

Host: Before we go, I want to mention that many of the services and care options mentioned during my conversation with Dr. Miller are available at the Sanford USD Medical Center in Sioux Falls. For information or to find what options are available near you, call your provider, clinic or visit sanfordhealth.org.

I’m Courtney Collen. Thanks for being here.

Learn more about this topic

• Sanford Health helps navigate fertility options
• You can have a happy and healthy plus-size pregnancy
• America’s Best Maternity Hospitals include 3 Sanford centers

Get more episodes in this series

Mammogram callbacks: Should you be worried?

Ariana Mount (Host): Hello, and welcome to One in Eight, a podcast series brought to you by the experts at Sanford Health. I’m Ariana Mount with Sanford Health News. One in Eight is a podcast geared toward increasing breast cancer awareness as one in eight women will be diagnosed in their lifetime.

Today we’re discussing mammography and the topic of callbacks. What does it mean? And what should someone know when this happens? To explain these important questions is Dr. Chris Johansen, a radiologist specializing in breast conditions and breast cancer. Dr. Johansen is part of the physician team at Edith Sanford Breast Center. Dr. Johansen, welcome and thank you for being with us.

Dr. Chris Johansen: Thank you so much for having me today.

Ariana Mount (Host): So first things first, what is a diagnostic mammogram?

Dr. Chris Johansen: Well, we do diagnostic mammograms for lots of reasons. The most common is when someone has a screening mammogram that isn’t completely normal. Now that doesn’t mean that person has cancer, but it does mean that we need some more information to make a determination. Other reasons for a diagnostic mammogram include a physical finding such as a lump, nipple discharge, perhaps pain or anything that concerns your clinician. Other very specialized situations can also end up in a diagnostic mammogram like a history of cancer or an abnormal study say six to 12 months ago that needed another mammogram performed to figure out if there was anything important going on.

Ariana Mount (Host): If I get a diagnostic mammogram, should I immediately be worried?

Dr. Chris Johansen: Absolutely not. You know, diagnostic mammograms, again, are performed for many different reasons. And one really important thing to remember is that needing a diagnostic mammogram, including in the setting of a screening mammogram that was interpreted as BI-RAD 0, which is what got you to a diagnostic mammogram. It does not mean that you have cancer. It just means we need more information, and we need to take some more pictures and maybe even do a different kind of test called an ultrasound to get that information.

Ariana Mount (Host): How many people get these callbacks for a diagnostic mammogram?

Dr. Chris Johansen: In general, the rate of callbacks on a screening mammogram varies from around 3 or 4%, up to about 10%, with many of the factors that influence precisely the callback rate being based on the demographics of the population. The most important one that the person can control is getting an annual mammogram. If you get mammograms less than once a year, your chance of being called back for a diagnostic evaluation goes up. If you’re getting a regular screening mammogram, your chance of getting a diagnostic callback goes down.

Ariana Mount (Host): I want back up a little bit. You kind of just touched on it, but these callbacks come from a normal screening mammogram, is that correct?

Dr. Chris Johansen: They come from a screening mammogram or a typical screening scenario. If the screening mammogram is interpreted by the physician to not be completely normal, again, not meaning that you have cancer, that’s why we would ask someone to return for further imaging.

Ariana Mount (Host): So when should women start scheduling those routine mammograms?

Dr. Chris Johansen: For the majority of women, age 40 is the perfect age to start screening mammograms. There are exceptions. If you have a first-degree relative who had breast cancer at an early age or if you have some genetic syndromes – in situations like that, you can talk with your family provider, family practice provider, and see if you fit into those categories. But for the vast majority of women, age 40.

Ariana Mount (Host): And how often should women be getting them?

Dr. Chris Johansen: The best timeframe to get a mammogram is once a year. That’s also what tends to be reimbursed by insurance. So most women can get a screening mammogram with no copay once a year. That’s also a good period of time to look for cancer because it’s long enough for there to be meaningful change if the person has an abnormality, but it’s not so long that you start missing opportunities to act on any findings.

Ariana Mount (Host): And you guys screen men as well for breast cancer. Is that right?

Dr. Chris Johansen: We actually don’t screen men, but we do diagnostic workups on men. The rate of breast cancer in men is about 1% of what women’s rate of breast cancer is because men have breast tissue, but only about 1% of the amount of breast tissue that women have on average. So if you have a symptom as a man, you’ll talk to your doctor and it’s very likely they’ll send you for a diagnostic evaluation. But if you’re asymptomatic, other than very rare exceptions, we won’t do a screening mammogram.

Ariana Mount (Host): For someone who’s never had a mammogram, can you explain what the process is or what they can expect when they come in?

Dr. Chris Johansen: Sure. For a screening mammogram, you would come to a mammography office, like the Edith Sanford Breast Center. You would check in with some of our folks out at the front desk and shortly thereafter, they would call you back. And a technologist would perform four images, two of each breast.

The images are painless. They do involve light compression on the breast, and they need to be very carefully positioned, so as to see all the breast tissue and cover the entire area that we want to evaluate. You’ll want to not wear deodorant that day. Many deodorants actually have metal in them, and we can see that on the mammogram and that causes an artifact, which can be in some cases, confused with cancer. So we would ask people not to use deodorant. The actual test itself takes only a few minutes, and for a screening mammogram at the end of the test, you’re free to go. We’ll contact you either with a letter or through your My Chart app to let you know what the results are.

For a diagnostic mammogram, the process takes a little longer because you’ll get the results the same day. You’ll check in, and a technologist will take your pictures. Once that’s done, they’ll be immediately reviewed by one of the fellowship-trained breast imagers at Edith Sanford or at your breast center. And at that point, a determination will be made either that everything is normal or that we need to do an ultrasound. Pending the results of the ultrasound, you’ll talk with the doctor, and either be scheduled to have a biopsy or be told that everything is fine and return to annual screening mammography.

Ariana Mount (Host): That annual screening. Why is it so important?

Dr. Chris Johansen: Breast cancer is the most common cancer that women get. Particularly if women don’t smoke, overwhelmingly breast cancer is the most common cancer. Breast cancer is also highly treatable when it’s caught early. Small breast cancers, early breast cancers, like those detected on a screening mammogram, as opposed to a cancer that’s grown large enough to actually be palpable or felt by a patient or clinician has a cure rate, very close to a hundred percent. And that’s without using chemotherapy.

Most women that are treated for very small or early breast cancers will never even spend a night in the hospital. The only way to fall into that category, if you have a breast cancer is to have it detected with a screening mammogram. Unfortunately, larger or later-stage cancers, those rules don’t apply. Oftentimes we’ll have to use chemotherapy, you may be hospitalized, surgeries tend to be more invasive and the whole process is more unpleasant and more expensive.

Ariana Mount (Host): So when we talk about just how important those annual screenings are, is there anything women should be doing in between those annual screenings? I hear “self exam” a lot.

Dr. Chris Johansen: Right. You know, if you’re getting an annual screening mammogram, you’re already getting enormous benefit. Some people will do self-breast exams on a regular basis, even as commonly as once a month, although there is some research that shows if you’re getting a screening mammogram done in an accredited center, they’re finding cancer so early, that the chances of you having a cancer that develops to the level where it’s palpable between a screening mammogram is incredibly small. There’s no problem with doing self-examination, but if you’re getting an annual mammogram, it probably adds little if any benefit. You’ll also likely have a breast exam when you see your regular clinical provider once a year.

Ariana Mount (Host): Another term we hear a lot is breast awareness. Can you explain the difference between that and a self-exam?

Dr. Chris Johansen: You know, breast health is actually, it’s complicated. There’s more to it than simply feeling for lumps. People can have things like discharge, they can have pain or other symptoms, and there’s a lot to breast health that doesn’t specifically pertain to cancer. Some people can have breast pain and it can be really severe. And there are things that they can work on with their clinician to make sure that if they have pain, it doesn’t keep them from living the life they want to live or doing the things they want to do.

So really for breast awareness, even though we, of course, focus on breast cancer because it’s horrible, and we want to make sure that that’s always at the forefront of our minds, there’s a lot of other aspects to breast health that can be important for women in improving their day-to-day living.

Ariana Mount (Host): For a lot of women, it may be time for them to get a mammogram whether they just turned 40 and it’s their first one, or they’re over 40 and their last was more than a year ago, or if they’ve just simply never been screened. For someone who fits in one of those categories, who is putting off getting screened, what’s your advice to them? Or why is it important that they go ahead and schedule it?

Dr. Chris Johansen: For lots of people there’s apprehension about going in to get any medical test. You don’t know if it’s going to be painful. The results can be anxiety producing. The thing I would tell them is you’ll have a great experience really, which is hard to think about that. Most people don’t think about their mammogram as a great experience, but especially here, our technologists are amazing. They’ve all been through screening. They all know exactly what the experience is like. And they’ll go out of their way to make sure that everything is explained thoroughly.

At the end of it, you’ll be really happy that you did it. It’s like many things in life that are good for your health. You just have to take that plunge and go ahead. And in this case, call and schedule the appointment. And once you do it, you’ll feel really good and happy that you did.

Ariana Mount (Host): So for those listening who are ready to schedule a mammogram, where do they start?

Dr. Chris Johansen: So the first and most important thing to think about is, do I meet the criteria for a mammogram? You want to be female, over the age of 40 and not have had a mammogram within the last 12 months. If you fall into those criteria, call your regular doctor, they’ll be an invaluable source of information and guiding you to a quality center that will do a good exam and let you know about the results in a timely fashion. They’ll also be a center that can help you if you do need any more imaging to complete that imaging locally and in a timely fashion.

After you talk with your clinician, they’ll likely direct you to a center like the Edith Sanford Breast Center, where you can call and schedule an appointment. Oftentimes screening mammograms only take a few minutes. So it’s very likely that you’ll be scheduled soon and can come in for your appointment.

Ariana Mount (Host): Is there anything else you would like people to know about mammogram callbacks, diagnostic mammograms?

Dr. Chris Johansen: The most important thing I can say about being called back from a screening mammogram is even though your first instinct may be to feel anxiety or even to panic a little, know that most likely you don’t have anything wrong, you don’t have cancer, but we want to make sure. In the unlikely event that you do need any further workup or even a biopsy, or even if you’re found to have cancer, if it’s found on a screening mammogram, it’s likely to be a very early cancer and you’re in a great spot. You’re very, very likely to be treated and cured and again, never spend the night in the hospital or have to undergo chemotherapy. Screening-found breast cancers are typically treated highly, effectively and efficiently. So you’re in a good spot.

Ariana Mount (Host): Dr. Chris Johansen, very valuable information. Thank you for your time today.

Dr. Chris Johansen: Thank you so much for having me. I really appreciate it.

Ariana Mount (Host): One in Eight is a podcast series and one of several from Sanford Health covering a variety of topics and featuring Sanford Health experts. Find Sanford Health podcasts on Apple, Spotify and news.sanfordhealth.org. For Sanford Health News, I’m Ariana Mount, and thanks for listening.

Sanford fertility expert helps same-sex couples

Courtney Collen (host):

Hi there. Welcome to our “Health and Wellness” podcast by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. Well, this series starts new conversations and continues the important ones, all designed to keep you well, physically and mentally, featuring our Sanford Health experts. We’re so glad you’re here. In this episode, we’re talking about the fertility journey for same-sex couples. And to do that, we have board certified reproductive endocrinologist, Dr. Keith Hansen at the Sanford Fertility and Reproductive Medicine Clinic in Sioux falls, South Dakota. Dr. Hansen, welcome. Thank you for being here.

Dr. Keith Hansen:

Well, thank you, Courtney. Appreciate it.

Courtney Collen (host):

Sanford Health provides some pretty high quality, compassionate fertility reproductive medicine care that is appropriate for all patients who come in right with various needs and concerns, no matter their sex or sexual orientation.

Dr. Keith Hansen:

That’s very right. We take care of, you know, any couples that are having difficulties conceiving or carrying a pregnancy. We’re happy to evaluate them and help them on our journey to hopefully to have a baby.

Courtney Collen (host):

Are you seeing same-sex couples in this clinic who are looking to grow their family?

Dr. Keith Hansen:

Yes. We see really any couples that want to have a baby or are trying to increase the number of babies they have, you know, whether they’re same sex, opposite sexes, you know, we will see those and help them to hopefully conceive and have a baby.

Courtney Collen (host):

For two men or two women that journey to parenthood looks a little different because they’re missing at least one essential piece to that puzzle. So Dr. Hansen, let’s talk through some of the hurdles that they might face.

Dr. Keith Hansen:

Basically they have the same hurdles as anyone else with a similar type of issues, but they do have some unique hurdles also, in terms of trying to help a couple who are trying to have a baby, no matter who or what their sex or sexual identity is, there are a number of factors that we try to help them with. You know, first of all, we always evaluate a couple to try to determine, you know, to make sure that there’s no underlying disease that could complicate a pregnancy or complicate an issue for a little baby and try to fix that before they get pregnant. So one of the issues we always do is we like to make sure that the couple, that the person who’s gonna be carrying the pregnancy, is taking a vitamin with folic acid, because that’s been trying to reduce the risk of neural tube defects by 70 to 90%. We also like to make sure that their thyroid is functioning normal. And then we check labs that may have an impact upon pregnancy, which could be very important and lowering the risk of the pregnancy and hopefully helping them to conceive and carry a natural pregnancy to term. We also like to do an in depth, you know, history, looking at their past medical history, surgical history, looking at their family history to determine are they risk of any sort of genetic illnesses that might be passed on to the infant?

Courtney Collen (host):

How can Sanford Health help same-sex couples conceive? I know the patient journey obviously looks different from males to females. So let’s start with females.

Dr. Keith Hansen:

In same-sex, female couples where there’s no male, well, they have to use a donor sperm, you know, or the possibility of donor embryos, but usually it’s a factor of donor sperm where what happens is you have to go to an to a cryo bank, which there’s multiple cryo banks throughout the country they look on. And in the old days we used to have piles and piles of books that people had to go through and this was for any couple with severe male factor infertility. And what we would do is they would go through the books, find a donor that met the criteria that they wanted, select the donor, and they’d ship the sperm here. Now it’s all online. So they can actually go online, look up the donor that they would like to pick, select, and then pick that donor and have the cryo preserved sperm sent here where we can keep it cryo preserved and then when ready to be used, we can do intrauterine insemination, hopefully that’s how they could conceive.

It’s important, I think, to realize that males who give, you know, that cryo preserved sperm is very carefully evaluated before releasing it for use. First of all, the males that donate it, undergo a thorough history and physical examination, including family history. And a lot of them have screening to make sure that they don’t have any underlying genetic illness such as that they’re not carriers of a disease like cystic fibrosis or spinal muscular atrophy, or one of these other devastating genetic illnesses.

When the couple goes online, they can actually find that information out about that individual and then decide to, you know, like if the only donor they can find is a male who carries cystic fibrosis, then we can go back and make sure that we screen the person who’s given the eggs, the wife, or we can screen her to determine are her, you know, does she carry that same genetic mutation or not? And if she does, then they, we have to sit down and talk about that and their options that are available, including at that point in vitro fertilization, with biopsying the embryo and making sure it’s normal before we put it back.

So in same-sex, female couples, once they picked out the donor, they ship it up here. The easiest way for them to get pregnant is to do in insemination. And so what we do is if the woman has regular periods, what she’ll do is ovulation predictor kits. When it turns positive, she’ll give us a call. And like, if it was positive today, which is Friday, we’d have her come in tomorrow on Saturday, thaw out one vial of sperm and inject it up inside the uterus. And then we’d have her come back on Sunday and do the exact same thing. In San Francisco, they did this large study where they compared single insemination versus dual inseminations and they had a higher pregnancy rate with dual insemination when you’re using frozen sperm. So we really like to do that.

If that doesn’t work, you know, like if let’s say they’re not pregnant after three to four cycles, then at that point, we usually start to look at things like, are her fallopian tubes open? We’ll do a hysterosalpingogram to make sure the tubes are open. How do her ovaries look? Is there any evidence of like premature menopause or anything like that? So usually for couples who have severe male factor or same-sex female couples, usually we try to help them to conceive with, intrauterine insemination to give them the best chance of having a successful pregnancy.

If that doesn’t work, then we can do further testing and we can move on to other therapies. One of the things we do offer, you know, like, we’ll talk with them about if there’s a factor, like let’s say if one of the gals that’s planning to carry the pregnancy, if she’s had a history of like a ruptured appendix, then we’ll do an HSG before they do the IUI to make sure that the tubes are open before we pursue that. Or if we have a couple that say, look before we invest any money in donors sperm, we wanna make sure those tubes are open and the ovaries are working good. Then we’ll test those before they proceed. But a lot of people like to try before they do any further testing and that’s fine.

Courtney Collen (host):

Now what about male couples?

Dr. Keith Hansen:

Their journey is a little bit more difficult mainly because we have to get an egg. And then we also have to have someone carry the pregnancy. So there’s really two factors involved there.

In the past, the only way we could get eggs would be to have a woman, you know, undergo the same like ovulation test to see if she was ovulating and then do intrauterine insemination with one of, with a person’s sperm that was gonna father the pregnancy. And that was what’s called traditional surrogacy where you would just take, and then she would get pregnant and carry the baby to term.

Nowadays, with in vitro fertilization, most people have turned to donor eggs and a gestational carrier, and they don’t have to be the same person. For donor eggs, in the past, the way we would do it is we would have, the couple would find a donor who’s willing to go through the stimulation. We’d stimulate ovaries, take the eggs out, fertilize it with the sperm, and then put the embryo up inside her uterus or a different, or a gestational carrier’s uterus. It doesn’t have to be the same person.

Nowadays though, they actually have donor banks for eggs, just like they do for sperm. And actually a couple can go online, look up the donor, you know, find a donor that’s consistent with what they want, they pay for it. And of course they ship the eggs up to us. We thaw out the eggs and then we can fertilize them. Or the other option is we can take the sperm and ship it down to them and then they can fertilize it and ship the embryos up here. And there’s different reasons for doing it both ways.

And then once we have the embryo, we can place it into a gestational carrier which is, you know, is a little more complicated mainly because the person has to go through so much when they, you know, we have to see the gestational carrier, do a history, physical examination, testing based on what’s going on. And then we have to, you know, prepare her uterus and put the embryo back up inside her uterus.

There is, you know, testing that’s required also, you know, for both people who use donor sperm and people who use donor eggs. And it’s the same. I mean, they have to go through, you know, a battery of tests to make sure that there’s no potential infectious diseases that could be spread. We usually require the American Society of Reproductive Medicine has come out with guidelines, like for gestational cures, they have to go through extensive screening with psychological consultation. You always want to check with your insurance company and make sure they cover pregnancies that conceive from that method.

Courtney Collen (host):

Are there any additional support services that the clinic offers alongside the fertility treatment? Be it, you know, emotional support, financial support to … kind of talk through some of that.

Dr. Keith Hansen:

That’s a great question. We do. We offer pretty much the same services to all of our couples. I mean, we do suggest, you know, a counselor. They can be very beneficial and help with some of the stressful situations because a lot of time it’s kind of like being on a roller coaster, you know. First of all, the hormones go up you know, and then they come crashing down and that can be kind of like a roller coaster of emotions. On top of those of the hormones, acupuncture has been trying to improve blood flow of the uterus. And I don’t know why, but a lot of gals tell me it’s very, very relaxing, even though, you know, they’re sticking needles in you. So I don’t know how that’d be relaxing, but they swear to God it is. And then it also, one of the kind of sad things is a lot of times insurance does not cover infertility. And so, you know, it is a lot of it is up front, which is, you know, I wish we could get more support for it and stuff, because we’re just trying to help them have a baby.

Courtney Collen (host):

If a patient or a couple listening, doesn’t live near a Sanford Health fertility clinic like this one with our reproductive endocrinologists, where do you suggest they begin? If they’re looking to grow their family?

Dr. Keith Hansen:

Well, that does make it difficult, especially in you know, a rural area where people can be a long distance away from a clinic that actually offers these services. And so a lot of times, you know, nowadays with telemedicine, we can actually connect with people over a long distance. We can do a lot of the discussion and work out a lot of the details and then really have minimized the number of times they have to travel to like Sioux Falls or to Fargo. Yeah. Or one of the other facilities where they do this and then have them come in and do the actual procedures here because we really don’t have the option of doing it in other places, but we can reduce the number of times they have to travel nowadays and try to minimize it and maximize their chances of getting pregnant.

Courtney Collen (host):

That’s always a win.

Dr. Keith Hansen:

It is.

Courtney Collen (host):

If couples listening are shopping around for fertility clinics, what would you want them to know about the care experience that they can expect here at Sanford?

Dr. Keith Hansen:

One of the nice things about Sanford is we do offer our care to really, to any couple that wants to expand their family or have their first baby. And we try really hard to offer compassionate care to these couples to hopefully achieve their dream, which is to not sleep well for at least two years.

Courtney Collen (host):

<Laugh> More than that.

Dr. Keith Hansen:

Yeah. It’s actually, I’d say 18 years, but it even goes beyond that, believe it or not. Well, we are here to help couples to conceive and achieve their dream. And we have, you know, a really dedicated staff from the front office all the way, you know, through to our nursing staff, the doctors, everybody is dedicated to trying to help couples achieve their dreams of having a successful, healthy baby and a healthy mom.

Courtney Collen (host):

Or dad.

Dr. Keith Hansen:

Or dads. Yeah. Moms or dads at the conclusion of their visits and, help them achieve that. The other thing is, is both Dr. Von Wald and I are board certified in reproductive endocrinology and continue to maintain certification. We try to stay up on all the newest and latest technology to try to achieve the best outcomes for our patients.

It’s a long, complicated journey, but you know, it’s a very – for us, it’s a very rewarding experience. And for the couples, it helps, you know, to really, to achieve their dreams of having a lot, you know, having more children and increase or having their first child. And it’s very rewarding in terms of that. And we try very hard to be compassionate and try to help them to achieve that dream you know, as fast as we can, of course it takes a while, but we try, you know, we’re very open to all those couples and try to help them through this many times complex and highly technological process that in the past was not highly technological at all and you know, sometimes there can be little bumps in the road or sometimes big mountains in the road, but we can hopefully help them to get around those, those mountains and achieve their dream.

Courtney Collen (host):

Yeah. Well, appreciate all that you do to help in that process to be a part of couple’s journey from the beginning, guiding them through the process and then ultimately helping them hopefully welcome a new baby. What is that like for you?

Dr. Keith Hansen:

Oh, it’s, it’s really rewarding to be able to help couples to achieve their ultimate dream of having a baby. And just so they don’t bring ’em back. There’s, there’s no returns, you know, especially if you have more than one, <laugh> no return, especially when they get to be teenagers.

Courtney Collen (host):

No returns. For sure.

Dr. Keith Hansen:

Yeah. None. <laugh>

Courtney Collen (host):

Well, Dr. Hanson, thank you so much for your expertise. When we talk about couples going through fertility treatments and hopefully having a baby appreciate all of your time and thank you for all that you do.

Dr. Keith Hansen:

Oh, you’re welcome. Thank you so much, Courtney. It’s great to chat with you and hopefully we can help more couples out there to achieve their dream.

Courtney Collen (host):

This was another episode of the “Health and Wellness” podcast by Sanford Health. I’m Courtney Collen. Thanks for being here. We’ll see you soon.

Learn more about this topic

• LGBTQ+ patients can find high-quality care at Sanford Health
• When to refer to fertility, reproductive specialists
• What’s it like to go through fertility treatments?

Get more episodes in this series

Renowned thought leader visits Sanford Health

Courtney Collen, Sanford Health News:

Welcome to this episode of our Innovations podcast series by Sanford Health. Dr. Eric Topol is a renowned American cardiologist, scientist and author. He is the founder, director and professor of molecular medicine at Scripps Research, and he is senior consultant at the division of cardiovascular diseases at Scripps Clinic in Southern California. Dr. Topol oversees a multimillion dollar grant on precision medicine, and he’s the principal investigator for an NIH grant, focusing on innovation and career training in medicine. Our moderator for this episode is Dr. Luis Garcia.

Dr. Luis Garcia (Host):

Thank you, Dr. Topol. I’m going to tell you, there are people that wait all their lives to have an opportunity like the one I’m having right now and they never get it. So I’m blessed and honored to be here today.

You know, you have been one of the most influential physicians in our industry, excellent clinician involving drug development, device development, molecular medicine research, one of the top 10 cited scientists in the world, three books. You advise the UK government on their national health system and all those accolades that I could take the hour that we have here to talk on that.

But I want, because we want to hear from you, but one of the things that I want to tell you is that what I have learned from you today is that besides all that you are a great human, you have great character and you have a great integrity. That’s what I learned today. So that leads me to my first question. Who is Eric Topol?

Dr. Eric Topol:

Well, first, let me say, how kind are you to say these things and I’m very appreciative and humbled. I try to reckon with this question, I’ve never had it before. Who am I, you know. But basically, you know, I as you might expect I have a wife now, 43 years as of yesterday. I have two great kids and three grandchildren, and then there’s what I do at work, which tends to get overemphasized. But as you say, I identify as a physician and as a person who’s trying to improve medicine. I’ve been working out for a long time. And sometimes many days I feel like I haven’t gotten very far, but I won’t keep, I won’t stop. I’ll just keep working until I can’t anymore.

Dr. Luis Garcia (Host):

Well, thank you. And I think the product of your efforts are, it is very tangible for us. I mean, it’s very notable and we appreciate that. You know, you, you mentioned family as a first description of you, and I know you’re a family man. Who was Eric Topol as a child, you know, as you’re growing up? Tell us about your family and your dreams about becoming somebody influential.

Dr. Eric Topol:

Yeah, well I didn’t come from medical family. My mother was a schoolteacher, my father, an accountant. And I really didn’t know that medicine was going to be in the cards until actually in college at University of Virginia. I worked at night shift just trying to make ends meet.

And I happened to be in the night shift as a respiratory technician. And those were the days where, you know, these were very primitive ventilators compared to what we had now, but I saw people in the intensive care unit, almost like a Lazarus, you know, resurrection, I thought they were to die and then they were, they would make it. And I said, “Wow, this is – this medicine thing is amazing.”

So that basically pushed me from what I was planning to do in life to become a physician. But I never really had aspired to be, you know, a leading-edge type force. It was more as a natural pushing hard on things that I believed in or worked hard to try to advocate.

Dr. Luis Garcia (Host):

And you know, a lot of young physicians-to-be, or a lot of children perhaps find themselves or will find themselves in a situation like yours, where you get the opportunities to seize an opportunity and you do it, and then you become really influential.

What would you tell those children right now that are the future of our country and of our world? What message would you tell them of encouragement of why is it important to get an education? Why is it important to take advantage of those opportunities and capitalize on them?

Dr. Eric Topol:

Well, I think the idea that is a limitless, what you can do, if you are really driven to what you’re passionate about that, you know, everyone has the talent and it’s the real matter of applying it, too. It doesn’t have to be kinds of things that I’ve worked on, or you’ve worked on, Luis, but many other people don’t ever find their niche in life. They don’t find the matchup of where they have something to offer. And that’s, I think unfortunate. That alignment of what you can do, that’s special and help people and make a difference.

You know, we’re lucky when we find those, but there’s too many people that have that latent or not-so-latent capability, that’s extraordinary, but they don’t really come to that realization or sometimes they do, but it’s, you know, much later in their life. So the sooner you can find what you are excited about, what you think may be a talent to nurture a particular quality that is burning inside you, go for it.

Of course, it doesn’t happen by accident. It’s not something that’s a natural gift. It means work. You have to really work at it, as well. So it’s a pairing of finding that kind inclination quality and then really going after it.

Dr. Luis Garcia (Host):

I appreciate that that insight, Dr. Topol. Yes, I’ve got to tell you, I feel so lucky that I’m in the medical field and that I love what I do. Right. Oftentimes we find somebody doing a job just because it is a job and not because it is a passion, right? So, realizing what your passion is and executing on it with hard work … I appreciate those comments.

When I talk to great leaders in this world, oftentimes they can identify a moment of uncertainty on their lives in which they had to make a decision. And that decision put you in a much different spot than you would have been if you would’ve taken the other side of the road. Did that ever happen to you?

Dr. Eric Topol:

Oh, actually several times. I live in uncertainties really. But the one I can recall, particularly since we’re talking about a kind of career path, I was at UC-San Francisco in my medical training. And I actually was planning to be a diabetologist because my father had type 1 diabetes and had gone blind by age 49 and I wanted to dedicate my life towards that. And in fact that was one of the reasons I picked UC-San Francisco. They had a first-rate diabetes division.

Anyway, my wife said when I was doing rotations and intersecting with cardiology said, “That’s what you’re really excited about. Can’t you tell?” And so she was the first one to note that I wasn’t at all excited about what I had purported to be. She helped sway me towards cardiology and that was a big, important decision where I was certain, but I was basically realigned with her support and insight.

Dr. Luis Garcia (Host):

Let me change up a little bit, the topic here, Dr. Topol. Sanford Health, we say that we aspire to be the premier rural health care system in the nation. We’re driven by the values that I’ve heard you reinforce and talk so much like restoring humanity in medicine, being about the patient, not being about compensation or reimbursement and really finding again the value and the art of being a physician and taking care of people in need. You articulate that very eloquently in your books. Do you want to share your thoughts about that?

Dr. Eric Topol:

Well, because I’m older, I’ve seen medicine change over the many decades and unfortunately it’s mostly for the bad. That is the emphasis on the patient-doctor relationship has been lost in most respects and the business of medicine has become the center so that term patient-centric is really useless compared to what is the reality.

Especially, as I got older, and naturally I became more frequently a patient and realized even from firsthand experience how this attrition has become so extraordinary. And that is, I think, ignited me to try to get us back and find all the other people that are willing to work together towards getting medicine back to where it was, which was that precious relationship that you had with your doctor, which was the person who had your back, the person who you should trust and whenever you talk, there was an attentiveness, there was just a real presence and you could relate your deepest concerns. Whereas now, of course, that is a rarity.

So I hope that in the future, that’s our biggest deficit right now that I think accounts for why there’s a global crisis of burnout and such severe depression among clinicians. And we can do this, we can get it back. I’m confident of that, but it isn’t going to be without a lot of effort and without solidarity in the medical community.

Dr. Luis Garcia (Host):

Well, one of the things Dr. Topol that I got out of your books was obviously the physician and clinician perspective is very important in patient care. But what about the patient perspective? And to your point that somehow, that art of medicine has been lost for the wrong incentives and oftentimes as physicians will say, “Well, my patients love me and I provide the best care in the world.” And interestingly, in one of your books, you bring the “word cloud” concept. Can you talk to us a little bit about that?

Dr. Eric Topol:

Yeah. I think the perception that our patients, “my patients love me” may be a little off because while there may be some physicians who truly have that, most don’t, and we saw that the word cloud you mentioned is from one leading medical center.

What are the two words that you think of from right coming out from your visit? And the words were not pretty you know, hurried and rushed and unconcerned and just devoid of the humanistic qualities that we need to exude. And that I think is the real problem.

That used to be the case that there was a love. It was bilateral. I mean, there were a lot of patients I just adore. I mean, no question about it. But the time that we have is so compromised that we don’t even have time to listen to a patient no less to do a proper exam and cultivate a relationship.

What I’m excited about with Sanford is that you could be the leader and pioneer reestablishing the care of the patient is about caring for the patient because there isn’t a health system in the United States that exudes that, or is the exemplar. And you can do that here.

Dr. Luis Garcia (Host):

Dr. Topol, thanks for pointing that out to us. And let me be honest with you. As I mentioned earlier in the podcast we’re driven by values. And during the pandemic, we took a special interest on learning how what our patients thinking of us as a health care system, and turns out that we are the most trusted health care system in our regions. And people understand by default that we have the greatest talent, but it is about that trust and it is about that relationship that that really makes the difference.

And the last couple of years have been so difficult for clinicians and health care providers. Right now, they feel that they’re devalued and the sense of being devalued comes precisely from what you’re seeing from their patients, perhaps not trusting their opinion, not trusting their insight because of all the myriad and amount of information that we get from untrusted sources. What are your thoughts about that?

Dr. Eric Topol:

Well, the bigger picture is there is more blurring of truth and lies and, you know, facts and fabrications than ever before and we have done as a country, little to ante up with the forces that are making this, that are consciously trying to blur and, you know, all the fake stuff.

And we have to work hard to get that trust back. And it’s across the board. I mean, all the revered institutions, including medicine has suffered from this. But we have a very strong anti-science faction in this country, more so than most other industrialized parts of the world. And we haven’t done anything really to cope with it, to counter it and take control and unfortunately it’s just gotten worse through the pandemic.

In this time of crisis, this would’ve been ideal time to really work against it. And in fact, knowing it was going to be an issue you could tell early on. But you know, it’s never too late. And I think that because there’s so much unreliable source of information for people because people get their punitive facts and news that often is questionable through so many varied sources. We have to have a central source that is known to be trusted that everyone can rely upon and that’s going to take effort. And we have no such thing, no such force at this point.

Dr. Luis Garcia (Host):

And I don’t want to miss the opportunity to speak about two instances in which your determination in which your adherence to science really have made a difference. And I have to ask you about your participation in COVID, that’s one thing and your participation with the UK government, with the United Kingdom government. But let me just ask you, how does it feel to get called on your personal phone by somebody telling you we want you to come and redefine the national health care system for the United Kingdom? That must be a super honor. How does that feel?

Dr. Eric Topol:

Well, yeah, it was kinda interesting that it happens, you know, from another country, rather than in your own country at the time. I was actually, I was thrilled to get that call and invitation. I didn’t know exactly what I was getting myself into, that I would go and have these, you know, 50 different people assigned to this for this review to help me. And it was obviously a big part, not just planning the national health service, but how well it would be received by the public, how would it be seen as a political, you know, football sort of thing? And so, it was a fascinating learning experience for me and made a lot of, you know, new friends from it.

But, you know, these days in the pandemic, it’s been gratifying because now there are people in our own government that are making contact and, you know, asking for input and it’s great to have a voice to have a chance to weigh in. I think that when you have at least a way, a channel, what you, you know, sometimes in the bubble that our government sits, they don’t really have enough insight about what is the problem out there. I think right now you know, the chance has increased throughout the pandemic of being able to give some, at least thoughts. Sometimes you could consider it advice and it’s fun for me.

Dr. Luis Garcia (Host):

And it’s just amazing. You shared a story with us earlier of how once again, your determination and your input really influenced the release of the vaccine and all the research that what’s going on behind the COVID vaccine. Do you want to share some thoughts about that?

Dr. Eric Topol:

Well, it’s interesting. I never realized the power of social media for me, at least, until I exercised it during the course of the pandemic. It started with the vaccine trials were, we knew they were ongoing, but the companies Pfizer, Moderna, J and J, AstraZeneca, and none of them would release their protocols, like they had something to hide.

So I basically started tweeting at these companies, “When are you going to release your protocol?” And finally, I got them, or whatever that happened, and one did it, you know, and then they all did it because they were all basically you know, undressed about this issue. And once you saw the protocols, then you started to see, “Oh my gosh, there’s a chance that these trials could be stopped early, really early before we knew the truth.”

And then of course there was a concern that the FDA was being subverted. And then the company’s interest was to get the vaccine. So you basically had alignment of the current administration that subverted the FDA and the companies all wanted to get the vaccines approved and get hundreds of millions of doses out there sold as quickly as possible but they didn’t have a plan to do it right.

So by social media, basically exposing the protocols and making them public and also for the research community to see, that was basically the ticket to, we cannot let this happen. If these trials stop after 30 patient events, and we are going to start giving vaccines to billions of people, something is going to be off here.

I think the extraordinary part of this knowing the protocols, being able to have precise readout that if this were to happen as the companies wanted, and as the administration wanted, we could be looking at premature dissemination of vaccines that were not proven, and this could be not knowing the results, but this could be a real setting for mistrust and also a backfire. I mean, we could have really good vaccines, but without validation, we could really see trouble. So, fortunately this got all fixed in the nick of time in October of 2020.

And we were very lucky. We had vaccines that had 95% efficacy, at least against the original strain. And we had it done right. The trials were finished and in just a mid-November, you know, we started to see the results. The companies acted properly and everything kind of fell into place. And we’re lucky about that. It could have gone a whole different route and whatever accusations people have made about “it was rushed.” They don’t have any idea about what rushed could have meant.

Dr. Luis Garcia (Host):

You know, on behalf of so many patients that needed, there’s so many patients that needed that. And there’s so many people that needed your leadership. Thank you for standing up for the right thing. So we appreciate that.

You know, Dr. Topol, in your books, you talk a lot about the future of medicine and how will augmented intelligence, machine learning and all that would influence medical care in the future? Where do you see medicine in 5, 10, 15 years down the road?

Dr. Eric Topol:

Well, one thing I’ll preface that by is that, every time I try to think where it’s going to be an X number of years, it’s multiplied by about three or four times – if not more. It doesn’t move like it should. And this is another flagrant example is that if we were to embrace AI (artificial intelligence) and go after it, in terms of doing the proper vital validation work, we could get there faster. But we’re not. We’re more – the medical community, more afraid of it than they are seeing the extraordinary potential.

But over time, we will see keyboard liberation. We will see reestablishment of really good communication during encounters between patients and clinicians. We will ultimately see remote patient care with much less use of hospitals than we do today. That will take longer, of course, because we have all sorts of reasons in this country to rely on hospitals that we shouldn’t be as much.

At any rate, there will be more changes ahead or at least opportunities for change. Whether we in the United States will adopt them as compared to other countries that are better poised because of their health systems –  that remains to be seen. But this is the most exciting time for medicine rather than certainly the last couple decades where we’ve seen degradation. This is the potential for an extraordinary turning point if we work at it.

Dr. Luis Garcia (Host):

Yeah. I love that last sentence, Dr. Topol. At Sanford, this is reassuring because we are investing a lot on the virtual aspect and the digital aspect for patient care for the right reasons. I’m going back to your comment of “this is exciting, and medicine is still beautiful, medicine is still good.”

We have so many people that have left the workforce and they might decide to come back or not, or so many people that are considering getting into the workforce of health care, but they’re hesitating because of what the last two years had done.

This is my last question: what would you tell those kids that are considering getting into medicine? Why should they get into our field and what is so precious about it that it should be their calling?

Dr. Eric Topol:

Well, there isn’t any question that the best is yet to come. I mean, we’ve hit a bottom that will only can get better now. But moreover there’s no profession that is more exciting, more rewarding than medicine.

The fact that you can truly care for another person for the most important part of their existence, their health, and you can help promote that. And you can have the trust of that person for a lifetime. I mean, there’s nothing like this. There’s no other profession like this. We are privileged to be part of it.

I think once we start to get this turning point established where the humanity is brought back in, it won’t happen. Like a light switch it’ll happen in phases. There will be a surge of interest to be part of this like never before.

Dr. Luis Garcia (Host):

I started my conversation with you highlighting what a great human being and leader you are and to all our listeners, I think they will agree with me that after the thoughts that you shared with us, that is exactly who you are. Thank you for everything you have done until now. I hope that you live until you are 200 years old, so we can continue to have your leadership and if not somehow, with the future of polygenics, and everything that we can clone you. So, but thank you for being here with us.

Dr. Eric Topol:

Thank you. You’re much too kind, but I really appreciate the chance to speak with you today.

Courtney Collen:

And our thanks to Dr. Eric Topol for his time. Find and hear more Sanford Health podcast series and episodes by clicking the link in the show notes, Sanford Health podcasts are also available on Apple, Spotify, or wherever you listen. For Sanford Health News, I’m Courtney Collen. Thanks for being here.

COVID and the important connection to heart health

Alan Helgeson (host): Hello and welcome. You’re listening to the Health and Wellness podcast brought to you by Sanford Health. I’m your host Alan Helgeson with Sanford Health News. Our conversation today is about COVID-19 and the long-term effects on the heart. Our guest today is Dr. Tom Stys with Sanford Heart. Dr. Stys, as we get started today, why don’t you give us a little bit about your role and your background with Sanford Health?

Dr. Tom Stys: I believe it’s almost 20 years since I started at Sanford Health. It was my first job, in fact, after coming out of fellowship training in New York when I remember we came out with my wife, from New York, Long Island. And we came out to South Dakota for the first time ever in January. We did go ahead visit some small towns, USA, South Dakota middle of January, went blowing snow and …

Alan Helgeson (host): Knew you needed a coat.

Dr. Tom Stys: Yes, no question about that. And then, you know, we did see I that that’s, yes, it was an opportunity, opportunity for us to have our family, kids grow up in a Midwestern environment, culture that we very much appreciated, which is awesome. And I personally had an extremely successful career here as an interventional cardiologist, meaning that I found Sanford’s resources, and ambition, completely in pair with mine. We evolved in the Cardiovascular Institute, affiliated ourselves with Sanford School of Medicine, USD. In fact, we hold the chair position for the division of cardiology for USD School of Medicine. Five of our cardiologists are the core faculty. We have introduced anything that was innovative and permissible in the field of interventional cardiology, electrophysiology, and other areas of cardiology and brought it to the region. And I believe I can very confidently say that we have created the leading program in the Dakotas.

Alan Helgeson (host): So now being here 20 years associated and affiliated with Sanford and a big anniversary, a 10-year anniversary for the Sanford Heart hospital. So in that 10 years prior, you had a hand in really helping lay that foundation and what that looks like and building the program, correct, Dr. Stys?

Dr. Tom Stys: That’s correct. That’s correct. We are very blessed and fortunate to be sitting in our new heart hospital. Well, 10 years. So maybe I should not be using that, that term “new.” It’s, we’re so used to it now, but it’s a beautiful facility. I remember planning, designing with administration. I remember doing procedures with visiting interventional cardiologists and heart surgeons from, quite honestly, all over the world and I have not run across a single one of them that would not be most impressed when they came out here and saw our institution.

Alan Helgeson (host): Well, congratulations to you and your team and the program that you’ve built. And we’re talking about something today. There isn’t any part of medicine that over the last year, two years, that has not been touched by COVID-19 or coronavirus, and things that we’ve heard way too much about the last couple of years, and in interventional cardiology, you’re no different. Our topic today, we really wanna talk about the connection between COVID-19 and heart health, as we’re hearing that there are short and long term effects that COVID-19 can have on the heart. Can we just jump in right there and just from your expertise let’s talk about that, Dr. Stys.

Dr. Tom Stys: Yes, of course. It is most important to talk about COVID and how it affects patients with cardiovascular disease in many different ways, in fact. And, very early, in fact, in the pandemic, we realized that the fear among our patients and community was huge and appropriately so. However, there was too much of lack of recognition of cardiovascular disease and the scope of an issue that it carries it with itself, if not addressed, taken care of treated properly. And so statistically speaking, heart disease, cardiovascular disease, heart attacks, stroke are still number one cause of death, period. And that’s talking about last – that’s our COVID year. COVID emerges number three cause of death.

We very quickly learned early in the pandemic that we will have patients that will be failing to come and seek attention. They will be having symptoms, which sometimes I feel patients are a blessing because at least those patients do get early symptoms of heart disease have a warning sign that allows them to identify an issue, seek attention and help, and perhaps prevent a severe disease that otherwise could be growing with, ultimately its consequences, unnoticed until it’s too late.

So very quickly early in the pandemic, we initiated a campaign of advising our patients, not to neglect cardiovascular disease. And I think that’s the first monitoring, which we very quickly recognized that COVID affects cardiovascular disease.

Our patients initially were afraid to come and seek attention that frequently was lifesaving. We started seeing many more patients coming with advanced forms of heart disease, coming in with advanced heart attack situations, where patients have coming in with warning signs of a heart attack. We fix things. They go home next day, all of a sudden show up with cardiac arrest going into cardiogenic shock. And that’s a completely different story.

My colleagues in cardiology, the division at their institutes, we very quickly identified and appropriately addressed where we even worked with departments of health and the state to make sure that we all had the same message. So then there are other ways where there’s no question COVID affected us. And the pure disease of COVID itself includes effects on heart/cardiovascular system.

And so indeed COVID does create circumstances in our body that can lead to increased frequency occurrence of clot formation, increased occurrence of heart attacks, some arrhythmias, inflammation of the heart muscle, and heart failure. So, there is a number of ways that the disease process itself also affects the hearts and results in bad outcomes.

COVID can affect us in many different ways. Too often, we do not link COVID disease syndrome with cardiovascular disease that COVID can cause directly. Not only COVID can affect outcomes of conventional atherosclerotic coronary artery disease, stroke disease syndromes, by, as I mentioned earlier, neglecting to get help, attention in a timely fashion, but also COVID itself affects cardiovascular system and can be a cause of exacerbation in the form of cardiovascular syndromes.

And for instance, yes, we can have an increased incidence of inflammation of heart muscle, myocarditis, heart failure. We can have increased incidence of stroke. We can have increased incidence of arrhythmias. We have a lot of patients that, after they recover from COVID, have long-term symptoms. And, sometimes it’s even tough to say is it’s relating COVID lung disease, it’s related to heart and consequences of the COVID syndrome associated with cardiovascular disease. Sometimes it’s tough to differentiate. Nevertheless, there’s clear association between COVID and cardiovascular disease. So COVID does affect the cardiovascular system directly.

But I believe that it’s, it’s also very important to recognize that COVID will affect our cardiovascular system in different indirect ways and we very well know that cardiovascular disease for instance, is a lifestyle disease. It’s lack of exercise, our extra weight, smoking, poor diet that are responsible perhaps for majority of cardiovascular disease. Interestingly, it’s a very preventable disease with that in mind, because how easy is it to eat less and exercise more and weigh less? Well, it’s easy to say, tough to do nevertheless, at least theoretically, it’s a very, a preventable disease, but it’s tough for us to do.

Now in COVID pandemic, unfortunately with the isolation, with the lack of outdoors activities, with lack of opportunities to socialize, go out and spend time in many diverse ways that would be perhaps healthier from heart’s perspective. Well, we ended up isolating ourselves, not only physically at home but also psychologically, much less interactions with others in the society.

Well, as by not going out for a routine walks to the mall, shopping, theater, movies, restaurants that stripped us from an opportunity that’s extremely important as far as healthy living. Unhealthy lifestyle behaviors that we have actually observed during the pandemic are increasing incidence of bad diet and extra weight, obesity.

I have to say that that just about every other patient comes to see me currently in the clinic, unfortunately when they step on the scale, the weight is in the wrong direction. They gain weight and it is always the same excuse. Well, I don’t go anywhere. I don’t do anything. I sit at home, watch TV. And the only thing to do is grab snack after snack and, which is sad, right? But very true. And that is a way in which COVID affected us last year. That’s not minor.

Another unfortunate, bad habit that we’ve noticed increased, increased incidents is alcohol consumption. You know, alcohol is not heart healthy. And there’s a clear association between the COVID pandemic and increase in the alcohol consumption that then leads to mental issues, more social issues, more problems, and definitely in a less heart healthy lifestyle than otherwise.

Missed medical visits is another way that COVID affected us very objectively. When we study our population here in South Dakota, there’s a big, big noncompliance you could say with otherwise necessary medical follow-ups. You know, whether you call it noncompliance or just, you know, not understanding the situation, definitely not a positive thing from cardiovascular disease. As I mentioned earlier, cardiovascular disease is still number one cause of death. So if I’m afraid of getting COVID and dying. You know what, I should be just as much or even more so afraid of having a heart disease. And so the fear of COVID should not really prevent me from getting attention, from cardiovascular perspective.

There has been an observed fear of hospitals. So no, I will not go to hospital and I’m not feeling well because that’s where I can get COVID more so than anywhere else. Again, the very false assumption, you know, and we very early in the pandemic made a big effort to make sure that it’s very clearly publicized in media across our state that no, it is probably one of the safest places where everybody’s compliance precautions are taken special, units are organized. And if anything, I think that you should feel safer going to see your doctor or be admitted to hospital for other, perhaps not COVID related issues, then going shopping to a grocery store. So, so it’s very interesting, but that fear of hospital was real. And it did I believe impact outcomes as far as our cardiovascular patients.

So as you can see, COVID also affected our patients from heart disease perspective indirectly.

Alan Helgeson (host): Is age impacting some of those effects that you’re seeing?

Dr. Tom Stys: Definitely age is a very pertinent factor, as far as outcomes of COVID. We find that that’s older patients have poor outcomes. Patients with established cardiovascular disease have worse outcomes. Well, our cardiovascular patients are the elderly patients. We very well have observed that younger populations, especially the teenagers, young people when they do get the COVID infection, their illness is not as severe. And again, whether it relates to us to the age itself or other comorbidities, tough to say, but as a cardiologist, I have to say that yes, age is very clearly recognized as a risk for worse disease course and worse outcomes.

And at the same time, yes, it is our elderly patients that have more cardiovascular disease, preexisting cardiovascular disease, such as coronary artery disease, hypertension, diabetes, stroke history, those cardiovascular diseases themselves, if preexisting will make COVID disease worse.

Alan Helgeson (host): As a person that has been vaccinated, can you still be affected with heart health and heart issues through COVID even if you’re vaccinated?

Dr. Tom Stys: Yes, you can. It has been very clearly proven, however, that patients who have been fully vaccinated undergo much milder disease course and are much less likely to be hospitalized, are much less likely to die. Nevertheless, they can still be affected by COVID and have an acute illness. And so that’s where the recommendation has been. That even though you’ve been vaccinated, you still have to be cautious and careful.

Alan Helgeson (host): What kind of lingering symptoms are you seeing for people that already have existing heart issues?

Dr. Tom Stys: So, first of all, I would say that, as I mentioned earlier, you know, the symptoms of COVID too often mimic heart disease. And sometimes it’s tough to tell quite honestly in patients with preexisting cardiovascular disease, once they recover from COVID, are these still the symptoms lingering from COVID or are these symptoms really more relating to worsening of their underlying cardiovascular disease by COVID? So that’s a very challenging issue for us currently.

We see a lot of people coming to get rechecked after they had COVID with one of our cardiologists in the office. And, the reason is that the symptoms are frequently similar. Each time we had a wave of acute infections in the community, a few weeks later, we have a wave of patients who’ve recovered from COVID and coming for cardiovascular checkups. In those instances, we check patients very thoroughly.

I think it’s extremely prudent to be thorough and not miss progression of cardiovascular disease in patients that have recovered from COVID because as I said earlier, still cardiovascular disease is number one cause of death, and if you’re concerned with COVID, you should be concerned just as much or even more so from cardiovascular disease perspective.

Alan Helgeson (host): What advice do you have for someone who may be under a cardiologist’s care or has had heart concerns for some time that is maybe just recovering from COVID-19? Are there some specific things that you would say to this audience?

Dr. Tom Stys: Definitely. It’s a very good and a very important question. Symptoms of COVID frequently mimic symptoms of cardiovascular disease. COVID itself affects cardiovascular system. So not only you could say that in a way it is also a cardiovascular disease, but at the same time, the fact that you have COVID does not mean that nothing else coincidentally might be going on in your body.

So my advice would be to be aware of too easily, assuming that it’s COVID, I don’t need to worry about my cardiovascular health. Have a very low threshold to pick up the phone, call your doctor. There is nothing wrong, even if you’re on isolation, with having a phone conversation with a doctor, cardiologist, especially with preexisting cardiology condition, cardiac conditions. Discuss the symptoms and see if you need to be concerned or not neglecting symptoms that otherwise may be early signs of something bad happening with your heart, may result in your having not only COVID, but also presenting with a heart attack. And then it’s a very challenging situation.

Alan Helgeson (host): What can a person do to help prevent or lessen the possibility of long-term heart effects from COVID-19?

Dr. Tom Stys: I think I would resonate the CDC recommendation of getting vaccinated. That is the best way to, first of all, hopefully avoid the infection and disease altogether, but at the same time avoid the otherwise possibly grave consequences of severe illness and even dying of COVID. So get vaccinated.

Alan Helgeson (host): We’ve talked about, you know, people staying out and not getting routine appointments. Can you just share a little bit from your perspective as a cardiologist, the importance of heart and vascular screenings?

Dr. Tom Stys: Getting early attention in the course of cardiovascular disease is lifesaving. As I always say, it’s a very preventable disease, first of all, so you can prevent it altogether. And even if you start getting some atherosclerotic disease, plaques, mild plaques here, or there at that stage, you can still intervene and treat it very effectively where you might not even have any consequences of that plaque formation process throughout your life.

Cardiovascular diseases are very preventable and very treatable. The worst thing to do is not get attention when you’re affected. And that’s exactly where our community cardiovascular disease screening program fits. We have very effective, accurate, simple ways of identifying patients that’s a high risk of developing severe cardiovascular disease, whether it’s heart attack, whether it’s other forms of cardiovascular disease. So we should be using those tools. And that’s our screening program.

Alan Helgeson (host): Dr. Stys, thank you for taking time to join in this conversation about heart health and COVID 19. This episode is part of the Health and Wellness series by Sanford Health. For additional podcast series and topics, please click the podcast link on Sanford Health News. I’m Alan Helgeson. And thank you for listening.

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Colon cancer awareness and the importance of screenings

Simon Floss (Host): Hello, and welcome to the special podcast brought to you by the experts at Sanford Health. I’m your host Simon Floss with Sanford Health News. Today, we’re talking a serious disease that affects thousands each year, colorectal cancer. Here’s a few grim statistics about colorectal cancer before we get going. According to cancer.org, the lifetime risk of developing colorectal cancer is 1 in 23 for men and 1 in 25 for women. Colorectal cancer is the third leading cause of death in the United States. Researchers predict it will cause nearly 53,000 deaths in 2022. Joining me now is Dr. Jacob Quail, a surgeon for Sanford Health in Vermilion, South Dakota. Along with providing a wide range of surgeries, Dr. Quail offers colon cancer screenings among many other services. Thanks for joining me today.

Dr. Jacob Quail: Well, thanks for having me. It’s a really awesome topic. Those stats you just read out are real. This is something that we’re dealing with all the time. As we come on March, March is Colorectal Cancer Awareness Month. So it’s something I love to talk about. And I’m sure my family and friends are enjoying me talking about it with someone else, not with not just with them. So I’m happy to be here.

Host: Yeah. And like you said, March, very timely that we’re talking about this, very important discussion as we just said, it affects thousands of people. And just talking about that coming off of hearing those statistics, what’s kind of your reaction? I mean, these are things that you know, but what would you say to people who are listening, hearing that for the first time, not knowing how serious this is?

Dr. Jacob Quail: I would just say, start having that conversation with folks that have been screened and to be aware of the statistics. So, the big change that has happened this past year – the guidelines of when to be screened for colon cancer has changed. Now we recommend screening at age 45, not 50.

Host: Instead of 50. Yeah.

Dr. Jacob Quail: Yep. So, that’s a big deal. Because what we’ve found is that since 1994, the rate of colon cancer has increased 51%, that’s CDC data. So, in the age of less than 50, right? And so, if you’re less than 50, we found that the rates are increasing. That’s significant. So, that’s why we think it’s super important that folks start getting screened at age 45. The range, the age range is now 45 to 75, and we recommend everyone get screened. From that 75 to 85 range, you really need to have that discussion with your provider, whether the risk and benefits still make sense for you. After the age of 85, colon cancer screening is no longer recommended, but again, the big change is that we want folks to start getting screened for colon cancer answer now at age 45.

Host: And you said that we’re seeing an increase in rates. Do we know why or anything like that?

Dr. Jacob Quail: It’s still too early to tell, but it may be secondary to some lifestyle changes that are happening. Some of the risk factors that we’ll talk about for colon cancer: eating highly processed foods, smoking tobacco, drinking unhealthy amounts of alcohol, or obesity, not exercising. These are all important risk factors for colon cancer. They don’t necessarily change when you need to be screened, but they may have something to do with it. But I think time will tell.

Host: Sure. And so one thing that we want to talk about is myths versus facts. What are some typical myths that you hear and what are some facts that people should know?

Dr. Jacob Quail: So, I think one of the myths I hear is colorectal cancer screening is embarrassing.

Of course, for the folks that work at this field all the time, of course it’s not embarrassing. So, it’s a myth for us. But, I can see how some folks would say that it’s embarrassing. The bowel prep having the colonoscopy, they may think it’s embarrassing, and that’s OK. So what do we have to do about that? Well, at least I encourage folks to have a conversation with their primary care doctor, or their doctor that’s going to be doing the procedure just to have answer any questions that you may have about the process, because it’s not something we do all the time. Right? And also, there’s other ways to get screened. If you say, ‘nope, I still don’t want to get screened with the colonoscopy,’ well, there’s some stool-based test that can also be used to screen folks.

And, we say the best screening test is this test that gets done, especially in the rural setting. That’s a setting that I work with every day and we just want the screening test to get done. So, I would say that quality cancer screening is embarrassing, is a myth. Another myth versus fact that we deal with is colorectal cancer screening is expensive. Well, colorectal cancer screening is a screening test. These are tests that are covered by insurance, which we’re very thankful for because we know colon cancer screening decreases the risk of developing colon cancer. That’s the whole purpose, right? That’s why we do it. So, insurance companies cover these procedures, these screening tests. Also, with the age changing to 45, they’ll also be covering those folks as well. So, that’s super important for our patients to know.

Another myth versus fact is colorectal cancer screenings are painful and that’s a myth.

We do colonoscopies under sedation. So, what I tell folks is you’ll come to the procedure room, you’ll meet our CRNA or anesthesia provider. You’ll get some sedation, you’ll be sleepy and you won’t remember anything. And then you wake up. So, of course it’s a myth that it’s painful, but if you’re still nervous about it, there’s another option, right? We talked about there’s two options for colorectal cancer screening. One is that direct visualization with the colonoscopy and the other then is with the stool-based studies that we can talk about a little bit later.

This is the big myth versus fact: I don’t need to get screened if I don’t have symptoms. These are exactly the folks that we want to get screened. We want to get those healthy folks screened so they can stay healthy for the rest of their life. We know colorectal cancer screening works and that’s why we lower the age to 45, per guidelines. So, it’s just something that we want to get the word out that if you don’t have symptoms, we want you to be screened for colon cancer. If you meet the age requirements.

Host: And piggybacking off of that, the earlier that you detect and catch something, obviously the better. Can you maybe speak to that a little bit?

Dr. Jacob Quail: So, that’s a super important point. There is two benefits of colorectal cancer screening. One, it detects polyps that may be pre-cancerous during the colonoscopy. We can take those polyps out and prevent their progression to colon cancer. Now not every polyp leads to colon cancer, but some do. And that why we do it. That’s reason number one.

Number two (reason) why do we do colorectal cancer screening, we are able to detect colon cancer at an earlier stage, maybe when you don’t have symptoms yet. And, at this point it’s easier to treat once detected. So, there’s really those two big benefits for colorectal cancer screening.

Host: One thing that we need to talk about is risk factors and family history. So who is at risk for developing colorectal cancer? Or is it anybody?

Dr. Jacob Quail: Yeah, that’s a great question. The average risk patient needs to gets screened at 45. That’s the average risk.

Now, how about what are the risk factors that change that time when you need to get a screen for colon cancer? Well, number one, family history, right? So, that’s why it’s super important to have that discussion with your family. Around the kitchen table, I knew I grew up in a small rural farm that’s a discussion we did not have. OK, but you need to be having that discussion. So, we’re specifically talking about colon cancer or colon polyps in our first degree relatives. Now who’s the first degree relative? We’re talking about our parents, our siblings, or our children.

So, if they have a history of colon cancer or what we call advanced polyps, you need to start screening at age 40, or 10 years before they were diagnosed. So, that’s super important that family history, personal history, if you have a personal history of colon cancer or colon polyps, you have an increased risk.

Another risk factor is if you’ve ever been told you have inflammatory bowel disease. Now, what is that? That is Crohn’s disease or ulcerous colitis. If you’ve ever heard those terms around the kitchen table, that’s something maybe you have a conversation with your primary doc about.

Host: There are a lot of people that are diagnosed with that.

Dr. Jacob Quail: Yes, there’s a fair amount of folks that are diagnosed with that. So, if you have that diagnosis, you need to be screened for colorectal cancer earlier. OK. There’s other specific genetic syndromes that have an increased risk of colon (cancer). One of them is called Lynch syndrome. I was a Navy surgeon for 11 years, and my last year in service, we had a 24-year-old patient who came in with belly pain. We worked him up, he was found to have colon cancer, (at) 24. It turns out his mom had Lynch syndrome and they never had that discussion. I like to use that example. It is something that we just have to make sure we’re talking to our family members about for this preventable disease.

So those are the three big risk factors, family history, personal history and presence of inflammatory bowel disease. That changes when you need to be screened, what age you need to be screened, for colon cancer. Earlier, we talked about those other risk factors that don’t really change the age when you need to be screened again, that’s like eating highly processed food or smoking, unhealthy alcohol use, obesity, not exercising. Those are important of course, for your general health, but we know they also increase your risk of colon cancer.

Host: Now you alluded to it earlier, but talking about what screening is and what patients can expect. Like you said, there’s really nothing to be afraid of. It can seem a little bit frightening at first, but again, nothing to be afraid of. So, what can patients expect when they come to any of the Sanford facilities?

Dr. Jacob Quail: So, that’s a super important question. So, the big thing we always hear about at least if they’re getting screened with the colonoscopy, (is) the bowel prep. Yes, you have to drink this stuff to clean your bowels all out. And why is that important? That’s important because we want to make sure you’re cleaned out good so we can see if you have polyps or not. If you don’t have a good bowel prep, if we can’t see, we may have to repeat the colonoscopy sooner rather than later. And then, you have to do the bowel prep again and the whole process, right? So, you do the bowel prep in general. You start at the night before, or they’ll tell you to what time to be here in the morning of your colonoscopy date. You’ll get an IV. You’ll meet the anesthesia or CNA provider, if that facility is using those providers. I always say the procedure takes half hour, 45 minutes.

You recover for half hour, 45 minutes, and then you go home. Now, you need someone with you to drive because you get sedation, right? Remember, it’s not a painful procedure. So, you get sedation. So, always helpful to have something lined up because you can’t drive afterwards. I always say no signing any important papers. No doing anything important the rest of the day. You just recover and you go back to a normal thing the next day. That’s important to remember for colonoscopies is in general – you take the day off of work. So, you kind of expect that going into it. So, that’s the colonoscopy experience.

If you have a polyp it’s important that you get the information down the road a couple days later about what type of polyp it is, because that’s important for you to know, because they’ll tell you then when your next colonoscopy should be.

If you have a polyp, you have a colonoscopy repeated sooner than 10 years. That’s really important. Not only for yourself, but we talked about how family history is important. So, you want to let your family members know as well.

The other screening tests that we use then, is there’s some stool-based studies. If you decide to use a stool based study, maybe you heard about a Cologuard or a FIT test, that’s something you don’t do a bowel prep for, but that’s something you can do at home. What’s important about that though, is let’s say your Cologuard or your FIT test is negative. OK? Then you have to repeat the FIT test every year. Remember the colonoscopy. We said, if it’s normal, you have to repeat it every 10 years. The Cologuard, if it’s normal or negative, you get repeated in three years. So, the frequency of when you need to do those stool-based tests is more frequent than if you had to do the colonoscopy.

Now this is the kicker with the stool based test. Let’s say they’re positive. And what does positive mean? Well, they detected either some abnormal DNA or maybe some blood coming from your GI tract. And that means you have to get a colonoscopy because maybe we have a polyp or an early stage colon cancer that we really need to take a look at with the colonoscopy. At that point, it’s called a diagnostic colonoscopy, not a screening colonoscopy. So, it’s a little bit different, but you’ll still do the bowel prep. So, just be mindful of that. If you do the stool study and it’s positive, we recommend the colonoscopy to take a look. So, those are the big screening tests, the colonoscopy, which we talk about that procedure a little bit, the stool based studies, Cologuard or FIT tests and how they’re different.

Host: Lastly, you talked about it earlier, but as Midwesterners, we sometimes tend to not have the uncomfortable discussion or sweep things under the rug. But, these types of things obviously need to be talked about. There has been a lot of growth in this field in the last few years, but there’s still a ton of work to do. So, how do you encourage loved ones to get screened?

Dr. Jacob Quail: And I love that question because what I always say is first you need to have the conversation. We need to have the conversation around the community at home, around the kitchen table, because we know that colon rectal cancer screening works. It decreases the risk of developing colon cancer, colorectal cancer in the future. And if they’re still hesitant, at least talk to your primary doc or talk to the procedure list. I’ll be doing the procedure if you decide that colonoscopy is the best thing for you. And I just think it has to start with that, having the conversation because that’s not something that I know I didn’t have with my family. Now we do. And as we talk about it more, it gets easier to talk about. And I always talk to patients about now, OK, you go be an advocate out there in the community because we know it works and everybody’s important in this community. We want to make sure everyone gets screened. So, that’s what I usually tell folks.

Host: Awesome. Well Dr. Quail, anything wrapping up? I know this is a huge topic that we want to make sure that we cover, but is there anything that you think is important that, wrapping things up, people need to know about?

Dr. Jacob Quail: I think one of the other challenges that we face is some folks – ‘we’re all busy.’

Host: Yeah. Yeah.

Dr. Jacob Quail: ‘I don’t have the time.’ And I think that’s a real challenge for everybody. And one of the good things about colorectal cancer screening is that you don’t have the time, there’s other options. Maybe you, a stool-based study is the best study for you. Maybe this didn’t decide to do the colonoscopy, so there’s options. So I know you don’t have the time, but if you just get it done, I know you won’t regret it down the road because we know it works. So that’s just one of the other challenges that I, that we face that is super important. Especially as we kind of ramp up our efforts in March here with Colorectal Cancer Awareness Month is super important topic and I’m so happy we’re having it.

Host: And quickly, how do you schedule it?

Dr. Jacob Quail: Yeah. So, if you decide, ‘yes, I want to get this scheduled,’ I would touch base with the primary doctor. OK. And they can even put an order in to start the process. You’ll be contacted and you’ll get the bowel prep instructions. That’s always a really important thing. And they’ll tell you what time and where to be. Also, there’s a specific order you can place to get a stool-based test, and that’s something you can do at home. So there’s pathways out there. And they’re ready to be used. Thank you.

Host: Awesome. Thank you so much for joining us today.

Dr. Jacob Quail: Thanks.

Host: And thank you for listening. Before we wrap up, I’d like to remind you that Sanford Health’s podcasts are now available on your favorite podcast apps like Apple and Spotify, as well as our website, Sanford Health News. If you enjoyed this conversation, follow us, give us a thumbs up and share your comments. We love hearing from you and hope that you found this conversation insightful. Thanks again for listening. I’m Simon Floss with Sanford Health News.

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Importance of heart and vascular screenings

Courtney Collen (Host): Hello and welcome. You’re listening to the Health and Wellness Podcast brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. This series begins new conversations and continues the important ones, all designed to keep you well, physically and mentally. In this episode, we are focusing on heart health, specifically heart and vascular screenings and everything you need to know. Ahmed Abuzaanona, M.D., is a cardiologist at Sanford Health in Fargo and joins us now for this conversation.

Listen: Health and Wellness by Sanford Health

Dr. Abuzaanona, welcome. Good to have you.

Dr. Ahmed Abuzaanona: Yeah, thank you for having me.

Host: As we talk about heart and vascular screenings, why are these so important?

Dr. Abuzaanona: Screening, by nature, means that we are getting a patient or an individual who doesn’t really have any symptoms or known disease, and we’re trying to find out if they’re at risk of having a particular heart problem or vascular problem in the upcoming few years. That means if we discover it early in the process, we can do a lot more about it to curb the problem and make sure we don’t progress into a real event, because a heart attack for instance, can be a very dramatic event that can lead to a lot of complications.

Host: Talk about some of the common signs or symptoms that might lead to heart health concerns, heart disease, or may eventually result in a heart attack.

Dr. Abuzaanona: It can be different for different people. We know any discomfort in the chest area or even the upper abdominal area, the upper part of the belly, can be a sign of heart attack. Women can have additional symptoms like maybe nausea, a little bit of vomiting or shortness of breath, rather than the typical heaviness of chest that we were taught as a sign of a heart attack. So, heart attack can have a lot of symptoms. Now, outside of that, heart disease in general can have different symptoms that can be bad lightheadedness, bad palpitations, which means like fluttering sensation and fast heartbeat sensation. It could be shortness of breath, doing things that you are capable of doing weeks before, or swelling in the ankles, or it can be chest pain that maybe not as dramatic, but tends to happen frequently, when an individual is doing things that are their daily activities or exercising. So there are multiple things that the heart disease can present with.

Host: So when we talk about a heart or vascular screening, what’s the difference and how would I know which one I need?

Dr. Abuzaanona: That’s an excellent question. So, the heart screening focuses on the arteries of the heart. Essentially there’s one question we’re trying to answer: What is the likelihood that the person would have a heart attack or a similar event in the next few years? So the way the heart screening answered that question is by checking a few things. That includes an EKG, blood pressure, body weight, and cholesterol levels along with some information about the individual. If the risk is thought to be high enough, we do additional testing that’s called calcium scoring. Now we can expand on this later, but I’ll leave that for the heart part. Now for the vascular part, so vascular, that means blood vessels, and those are the things that run from the heart into the body.

What we’re trying to identify here: do we have high risk of blockages in those arteries? Some of those arteries go to the brain and we call those carotid arteries and those lie in the neck, and if they have problems, they increase the risk of stroke. There is a big artery that goes down our belly called aorta, and that can dilate and cause something called an aneurysm, this is like the Latin word for dilation. So this is something that we want to discover as well. The last thing is the arteries that go to the legs and that can cause issues with the legs, including pain, and sometimes in the most severe form lead to ulcers and amputations and infections. So those arteries also can be studied. Now, if we talk about vascular screening, we’re focusing on the arteries in the neck, the big artery in the belly and the arteries and veins in the legs, and most of the time we just study them with an ultrasound. We can also get some sort of blood pressure measurements in the of legs that help tell us about how healthy those leg arteries are. So they’re a bit different, but as you would imagine, a disease process that affects the heart most likely will also involve those arteries. So, I would say, most people would benefit from screening both things if they’re indicated. So if you have high risk to heart problems, you would benefit from heart screening, and also you would benefit from vascular screening.

Host: Now, if I wanted to move forward with one or both screenings, how does that process work? Where do I start?

Dr. Abuzaanona: There are two ways to go about this. Through the primary care physician or provider they always do a good job evaluating cardiac and vascular risk. When it’s believed at a certain point that the risk is high enough, we tend to discuss the options. That can be just treating directly, giving some medications like cholesterol medication that could help lower that risk, or if we’re not 100% sure we can do additional testing. The other way to do it is through the community and this is what Sanford is doing… trying to keep this open to the community through our screening program. What happens in the screening program is you are met with a technologist from the screening center.

They evaluate the risk based on multiple things, include the age, the sex assigned at birth, the blood pressure. They check an EKG, they also check a cholesterol level, and they put all of this information together and identify the risk in the next 10 years. If the risk is considered to be high and for us here at Sanford, we define as more than 6%, then they would recommend the calcium score test. So there’s multiple different ways to do it. If you are in the community and you want to directly get that evaluated, it can be through the screening center or you can just do it through the primary care physician, the primary care provider.

Host: Now, what can I expect during that screening appointment? Walk me through the process.

Dr. Abuzaanona: Part of that screening is identifying the risk. So after the blood pressure, the cholesterol, the EKG, and the brief conversation to ask about family history, etc., the next big thing that is done – if a patient is eligible – is called calcium scoring. And we’ll talk a little bit about this. Calcium score is essentially a CAT scan and it’s considered a low dose CAT scan. We do it without injecting dye, without even needing IV access. So we don’t use an IV line for this, and it’s a quick process where the patient would go into the CAT scanner. It typically takes seconds to take the picture itself. The whole process might take few minutes. What we do is we look at calcium depositions. So how much calcium there is on those arteries that supply the heart and what that tells us, if someone has some calcium on their arteries, that tells us they have higher risk for coronary problems or, like a heart attack or heart attack-like conditions in the future, and that allows us to start treating them to prevent them from happening.

Now, if someone does not have any calcium, we call that a calcium score of zero. The risk is extremely low and this actually adds up to be less than 1% in the next 10 years. So it would be quite reassuring if someone is concerned about a high-risk, maybe due to family history or due to higher cholesterol or anything else, having a negative or a zero calcium score is very, very reassuring. And even having a positive test where we uncover some early process will allow us to treat effectively and prevent future heart attacks.

Host: Do you recommend these screenings every year? So what about those of us who are not at high risk, assuming a low risk score like zero can be associated with good health?

Dr. Abuzaanona: Yeah, I really like the way you describe it: it’s good health. Even though it’s initially designed to comment on the heart and the risk for heart attacks, it turns out if someone has a low, or like a zero score, which is normal, they actually have lower risk for a lot of other things. So lower risk for cancer, lower risk for chronic kidney disease, lower risk for a lung obstructive disease and even lower risk for hip fractures. There is a comment that we sometimes use is: someone who has, even if they’re in their sixties or their seventies or eighties, if they have a calcium score of zero, we call them healthy agers in general. So, you are aging in a very healthy way, and it’s not just a testament to how healthy your heart and your vascular system is, it is just a reflection of how healthy the entire body is.

How often do you need to repeat this? If it was zero, I would say, not earlier than five years. If it was, it can be three to five years. We don’t really know for sure, but the earliest that we do it three years after maybe it could be delayed up to five years and I would think that’s appropriate. If it was positive, so we found an abnormality, we really don’t need to repeat that anymore, because once we identify someone who is at higher risk, we would just treat [them] and we will essentially do a lot of things to prevent heart attacks. The things we do: we focus on the lifestyle, so diet, exercise, weight loss, we manage the blood pressure. So we try make sure the blood pressure is well-controlled. And we manage the cholesterol and we start typically the patients on cholesterol-lowering medications and make sure the cholesterol is at a good level, a satisfactory level.

Host: When it’s time to look at the results of the screening, where does that information go? Who reviews it? What comes next?

Dr. Abuzaanona: In our screening program the patients will be counseled about their results, and if they’re positive, which means there is some coronary calcium, they get referred to the primary physician and we end up seeing most of those patients. So most of those patients, particularly if the calcium score is high, I would say above a hundred, we end up in cardiology seeing most of those patients. And the goal at that point is to see if additional testing is required, if there is any concern about blockage and those arteries that we need to fix. Otherwise, we just make sure that we’ve corrected all the risk factors and we’re maintaining a good blood pressure, maintaining good cholesterol and treating appropriately.

Host: For our listeners now who might be ready to get their screening, how can they make an appointment?

Dr. Abuzaanona: The heart and vascular screening is essentially a service. So if you’ll go into our website at Sanford, look up the location – because we have multiple locations – look up the location closest to you, and there is a number. You just call and schedule an appointment. You don’t necessarily need to see a physician prior to that, because it’s a well-structured process. So only the things that are considered necessary will be done, and in terms of seeing a doctor, you can see the doctor beforehand to discuss if you need to do that or not if you want a tailored answer depending on your risk profile. But if there is any concern, any issues with the results of the test, you will be referred to see a physician afterwards.

Host: So as a cardiologist, Dr. Abuzaanona, I imagine you’ve seen a variety of patients with varying heart health. If we want to take better control of our heart health, you mentioned lifestyle changes a little bit ago. What are some simple recommendations that you have to get us started?

Dr. Abuzaanona: Yeah, I would say introduce some changes because we all can. If we look in into our diet, there is always something that we can do to improve the quality of our diet. And we can always move a little bit more. So that’s different for different people. What we would recommend in general, like general outlines or general guidelines: in terms of diet, try to introduce more vegetables, fruits and grains. Try to replace some of the unhealthy fat with healthier fat. We don’t say stay away from fat. We don’t say that anymore. We try to replace with healthier fats. Healthier fats are found in fatty fish and extra virgin olive oil and in nuts – unsalted nuts, obviously. The unhealthy fat, as you all know, is probably in the red meat and you know the lard, the butter, etc. And stay away from highly processed food. The more processed the food is, if you look at a package that has 20 ingredients, that’s probably no matter what food product that is, it’s probably not the good choice for you.

In terms of exercise, we recommend about 30 minutes of intermediate intensity. So something that gets your heart rate up, but it doesn’t get it up really high. So you can still talk while you do this. You won’t feel very tired. Walking can be a very good exercise for most people and do that for 30 minutes, about 3-to-5 times a week, and that should be good enough.

The biggest advice I try to give is introduce small changes because small changes are usually the ones you can sustain and over time you’ll find yourself, if you introduce enough small changes over a course of a year, that it becomes easy. If you start trying to adapt a lot of things at the same time, it becomes overwhelming and difficult.

Even for, like on a personal level, like if I want to introduce more than two, three changes in diet or exercise regimen, I usually see it that doesn’t really last that long. So just keep it simple. Give yourself a lot of time. So maybe a year or two, and just say, ‘I want to do this by the end of the year’ and make small increment, small changes, and towards the end of the year you’ll find yourself there. You’ll have a better diet, you’ll have a better exercise regimen. And the other thing is if you have any health conditions, health problems, make sure you address them and stick to the medications. So if you have high blood pressure, make sure that’s well addressed and blood pressure is controlled. If you have sleep apnea, make sure that you stick to the CPAP machine and follow the recommendations of your physician, and just make sure you keep up with appointments. This is how you take good care of your heart and overall good care of yourself.

Host: I love that. Thanks. So much of our overall health aligns with having a healthy heart as well. So, this is such great information, doctor, is there anything else that you want our listeners to know today?

Dr. Abuzaanona: I would say that here at Sanford, we have a strong preventive cardiology program. We’re trying to catch heart disease early. And we take pride in the fact that we prevent procedures rather than just do procedures. And in the future, there is a lot of focus on helping people stay away from the hospital and take control of their health. So, we’re going to expand the preventive cardiology program in the future, and that’s my goal and it’s actually my passion. So hopefully in the upcoming few years we will just continue to provide an excellent service for our patients here.

Host: Wonderful. Heart disease prevention is key all year long. Dr. Abuzaanona, thank you so much for your expertise and all that you do for Sanford Health.

Dr. Abuzaanona: Yeah. Thank you for having me. Appreciate it.

Host: For Sanford Health News. I’m Courtney Collen.

Learn more about this topic

• Coronary calcium screening reveals hidden heart problems
• A healthy diet: Your first line of defense against disease
• Heart & vascular screenings: What’s the difference?

Get more episodes in this series

Importance of getting the HPV vaccine

Host (Vanessa Gomez): Hello and welcome. You’re listening to the Her Kind of Healthy podcast series from Sanford Health. I’m Vanessa Gomez with Sanford Health News. Our conversation today is with Dr. Brooke Jensen, specializing in family medicine at Sanford Health. We’ll learn of the importance of the HPV vaccine and its relation to cervical cancer. Welcome Dr. Jensen and thank you for being with us.

Brooke Jensen, MD: Thank you for having me.

Host (Vanessa Gomez): So first, just give us a little bit of your background. How long have you been here at the 32nd and Ellis clinic location? And tell us more about what you specialize in?

Brooke Jensen, MD:  So, I am going on my second year here at Sanford at getting out of residency and I primarily do broad spectrum family practice along with OB care with that as well.

Host (Vanessa Gomez): Our main focus today is on the HPV vaccine. And when you think HPV vaccine, the conversation tends to go more towards women, young girls. What is the HPV vaccine?

Brooke Jensen, MD:  So, the HPV vaccine is a vaccine against high-risk types of the human papilloma virus that is a common cause for cervical cancer and other cancers for men and women alike.

Host (Vanessa Gomez): So when should people be getting this vaccine? And I mentioned, this conversation really surrounds women in girls, but you mentioned young men as well.

Brooke Jensen, MD:  So, we encourage HPV vaccination between the ages of nine and 12 to start as evidence shows that starting at a younger age improves the immune response and better protection against different forms of cancer. We like men and women to both get their HPV vaccines starting at the nine, if we can, but we also do that clear up to the age of 25. So even if you missed out at that younger age, you can still get it later on for protection.

Host (Vanessa Gomez): Why do we want people to get it when they’re younger?

Brooke Jensen, MD:  So, when they’re younger, they actually have a better immune response and produce greater antibodies. There was a study out in the UK recently that was published that showed cervical cancer rates and those who received the HPV vaccine between the ages of 12 and 13 experienced greatest reduction in cervical cancer at around 87%. There were still high percentages in those other age groups, but they gradually decreased the older ages that they got the HPV vaccine at.

Host (Vanessa Gomez): So bottom line is just get it when you can.

Brooke Jensen, MD:  Absolutely.

Host (Vanessa Gomez): And it’ll help. When parents come in with their kids to the clinic and this conversation gets brought up, what are some of the concerns, the common concerns or common misconceptions that parents have?

Brooke Jensen, MD:  A lot of times parents are concerned that “well, is this part of this school requirements, and if it’s not a requirement, why do I need to get it?” So it’s really educating and showing this benefit, although yes, it does not prevent a spread of other viruses or things that are commonly spread just through the air that often we are concerned about in school, this will prevent cervical cancers, anal cancers, penile cancers, and some head and neck cancers down the road for these young men and women, and to help protect them.

Host (Vanessa Gomez): What are some of the side effects that kids experience when they get the vaccine?

Brooke Jensen, MD:  Common side effects that have been re reported are very similar to the other vaccines in adolescents. The most common reported have been syncope followed by injection site redness, pain, and swelling.

Host (Vanessa Gomez): How can we encourage more parents to get this vaccine for their kids, talk to their kids about, you know, this is why you’re getting it?

Brooke Jensen, MD:  Yeah. So, a lot of it’s just education. Encouraging them to come to the table and ask these questions because often there’s been stigma around this vaccine in the past because people know HPV can be spread through sexual contact. And so there’s always concern that this is just gonna encourage my kid to have sex. And that’s really not the case. The studies show that there has not been any increase in risky sexual behavior in children that have had HPV vaccine than those that haven’t. So just educating on them on this and that this is long term protection. This is not just for right now at their adolescent age. This is protection throughout their lifetime.

Host (Vanessa Gomez): What can you tell us about the safety and efficacy, which the efficacy, we talked a little bit about the beginning?

Brooke Jensen, MD:  Some of the efficacy that we have found, it shows that the estimated efficacy of the nine Valeant HPV vaccine is combined against incidents of cervical, vaginal and vulvar cancers is around 96%. So it has really good benefit data from the vaccine safety data link show that more than 600,000 doses of the four Valeant HPV administered to females when this was studied, showed no statistically significant increased risk of Guillain-Barré syndrome, stroke, venous thromboembolism, appendicitis, seizures, or allergic reactions or anaphylaxis. So that really shows good data for this vaccine.

Host (Vanessa Gomez): And in that study, did you mention just girls were studied in it?

Brooke Jensen, MD:  Of this report that they looked at, the 600,000 doses was just primarily reported on the females.

Host (Vanessa Gomez): So, what can we tell parents about the safety for boys then?

Brooke Jensen, MD:  The other current studies that are coming out, they have not found any statistical difference between males and females that are currently being produced.

Host (Vanessa Gomez): So how can parents schedule these vaccines for their kids?

Brooke Jensen, MD:  To schedule the vaccine, you just call your primary care clinic or provider, and you can schedule a nurse visit to set up for the vaccines, or if you have further questions and would like to discuss further with your doctor, just schedule an appointment, and they’d be happy to discuss that with you.

Host (Vanessa Gomez): Can we talk a little bit about what are some of the limitations that you wouldn’t be able to get the HPV vaccine? And I guess one more time, what’s the oldest age that you’re able to get the vaccine?

Brooke Jensen, MD:  We routinely do it through, up to the age of 26 currently but we definitely encourage to get that at that youngest age to get the maximum benefit of the vaccines. And actually, if you do it at a younger age, between the ages of nine and 14, you only have to get two doses instead of three, compared to if you were at an older age.

Host (Vanessa Gomez): So, for older women, what are some of the limitations that they wouldn’t be able to get the vaccine at a certain time?

Brooke Jensen, MD:  If they were currently pregnant, we do not give the HPV vaccine. It’s probably safe, but we just do not have big enough studies on that at this time. If you have a severe allergic reaction to components of the vaccine, you should also not get it as well. You are allowed to get it during lactation. as it is not a live virus vaccine.

Host (Vanessa Gomez): Are there any ingredients that someone would be allergic to?

Brooke Jensen, MD:  Well, someone would have a severe latex allergy, we actually do not recommend getting the vaccine if it’s from a pre-filled syringe. You would actually have to have the nurse draw it up from a separate and prepare that vaccine.

Host (Vanessa Gomez): I think one of the things that we really need to highlight with the HPV vaccine is that these studies are showing that it prevents cervical cancer and other cancers later on in life. So, it’s not an immediate effect whereas the flu vaccine or the COVID vaccine, we see those immediate effects, but this is protecting kids for the future and it prevents cancer, which is amazing. Do you find that parents are surprised, are they excited for their kids to get it at that point? What are some of the reactions?

Brooke Jensen, MD:  A lot of them, I would say it’s a mixed response. Some are very excited and especially when you can kind of show some of those numbers and the high percentage that the HPV vaccine can really truly have a great change of decreasing cancers. It’s currently 96% of the total efficacy of the combined incidence of cervical, vaginal and vulvar cancers of decreasing that. That’s a huge benefit. So when you’re explaining that most parents are very excited. Usually sometimes the limitation is they just don’t wanna get so many vaccines at once. So, a lot of times I encourage, you know, we can always come back if you don’t want all these vaccines at one time, you don’t even have to have a visit with me, so you don’t get charged another office visit, you just have a nurse visit instead and to get that.

Host (Vanessa Gomez): So, who is at risk of cervical cancer?

Brooke Jensen, MD: The majority of those who are at risk for cervical cancer are those that are exposed to the HPV infection. About, out of the HPV 16 and 18, that are the highest risk of causing cervical cancer, they make up 71% of cases of cervical cancer causes. HPV related risk factors that increase your risk of getting HPV include early onset of sexual activity, multiple sexual partners, a high-risk partner, history of sexually transmitted infections, early age at first birth in increasing parity, history of some other forms of vulvar or vaginal cancers and immunosuppression. Other risk factors that are non-HPV related can be cigarette smoking, low socio-economic status, and genetics as well.

Host (Vanessa Gomez): So how do we screen for cervical cancer then?

Brooke Jensen, MD: Our primary method of screening for cervical cancers through pap smears. We start pap smears at the age of 21, and we used to do them at a younger age, but the evidence now shows that younger women should not be screened regardless of age of their first sexual intercourse or other risk factors because currently adolescents clear most HPV infections within one to two year without any neoplastic or cancer changes.

Host (Vanessa Gomez): So once you start screening at 21, and if someone isn’t sexually active, should they still be getting a pap smear starting at 21?

Brooke Jensen, MD: Yes, we encourage all, anyone, doesn’t matter if sexual activity or not, to all start pap smears at the age of 21, because again, HPV causes the majority of cervical cancers but is not the sole cause of cervical cancers.

Host (Vanessa Gomez): And after you start those at 21, how often should you be getting a pap?

Brooke Jensen, MD: For most women from the ages of 21 through the age of through 29, we do it every three years as long as your pap smears have remained normal. And then once you’ve hit the age of 30 to 65, we do pap smear plus HPV contesting and as long as those are both normal, we do it every five years. We typically discontinue pap smears at around the age of 65 or following a hysterectomy if they remove the cervix fully and you have no history of high-grade cervical changes on previous pap smears.

Host (Vanessa Gomez): So why is it that we only do them every three years because the goal of these screenings is to try and find the cancer, catch it early so that you can diagnose it and start treatment if necessary? Why would we not wanna do that every year to try and catch it early?

Brooke Jensen, MD: Because we know a lot of these changes take time and so if someone would have HPV, this gradually changes over time, and we previously actually used to do pap smears every year and it led to more likely unnecessary treatments because we were probably too aggressive on these cervical changes because women again often would clear them. If you’re at a younger age, you typically clear these changes faster than those at an older age so as long as you’ve had these normal pap smears, it’s very reassuring so we started spacing them out to try to decrease your risk of unnecessary procedures.

Host (Vanessa Gomez): In between those every three years, are there different signs or symptoms that women should be looking for when it comes to cervical cancer in particular?

Brooke Jensen, MD: Typically, cervical cancer, most people do not have any symptoms. So it’s very rare that someone would have symptoms. If someone were to have symptoms, you may have irregular spotting or bleeding or bleeding after intercourse and if this were to happen, that would be something to see your provider for and get a pelvic exam for.

Host (Vanessa Gomez): Are there any other preventive measures that women can take when it comes to cervical cancer, besides the HPV vaccine and getting those screenings,

Brooke Jensen, MD: Other things to kind of look for to try to prevent HPV infection and cervical cancer would be safe sexual practices, such as using condoms, avoiding smoking and trying to limit the number of sexual partners.

Host (Vanessa Gomez): And how do people schedule their screenings for a pap smear if they need one?

Brooke Jensen, MD: So typically, all you would schedule is a yearly wellness exam, or if maybe you have gotten off on your yearly wellness and just need only your pap smear, you can just schedule a clinic visit just solely for the pap smear as well.

Host (Vanessa Gomez): Well, Dr. Jensen, thank you so much for your time today.

Brooke Jensen, MD: Thank you.

Host (Vanessa Gomez): To learn more about the HPV vaccine, cervical cancer and the screening services provided, visit Sanfordhealth.org. This was another episode of the Her Kind of Healthy podcast series by Sanford Health. For Sanford Health News, I’m Vanessa Gomez. Thank you for listening.

Learn more about this topic

• HPV vaccine reduces cervical cancer rates by 87%, study says
• What you need to know about HPV
• Understanding cervical cancer: signs, causes & risk factors

Get more episodes in this series

Blood and bone marrow transplant care at Sanford

Courtney Collen (Host):

Hello, welcome to our medical series Called to Care by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance that they can use in their primary care practice. And information about when it is time to refer patients and families to more specialized care. Joining me for these conversations is Dr. Joseph Segeleon, who is vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. But he’s here as my co-host, if you will, to help us dive even deeper into a lot of these topics and provide the best insight in care for our patients and communities. Dr. Segeleon, good to have you back here.

Listen: Called to Care by Sanford Health

Dr. Joseph Segeleon:

Courtney, it’s wonderful to be here. It’s good to see you again.

Courtney Collen (Host):

In the fall of 2021 at the Sanford Roger Maris Cancer Center in Fargo, a team of specialists completed the first autologous bone marrow transplant where a patient’s own stem cells are collected and stored. It was a major milestone making Sanford Health one step closer to becoming a national destination for cancer treatment. Joining us to tell us more about the bone marrow transplant program is Dr. Seth Maliske. He’s a Sanford physician who specializes in hematology oncology and has unique training in blood and bone marrow transplants. Dr. Maliske, thank you for being here.

Dr. Joseph Segeleon:

Yes. Welcome Dr. Maliske.

Dr. Seth Maliske:

Thank you for having me.

Dr. Joseph Segeleon:

Just as I think about Sanford as a rural health center and the journey that we’re on, you really think about how fortunate we are to have an institution like the Roger Maris Cancer Center. And so I’m excited to learn more about the program that they’re doing in Fargo, as well as the opportunities and the resources that this brings to our patients and our communities and our providers. I think for us to start maybe we should level set with some of the terms that we’ve we use to describe this field. So maybe you could clear, clear up bone marrow transplant versus stem cell transplant, autologous versus allogenic and those type of things.

Dr. Seth Maliske:

Sure. The term bone marrow transplant versus stem cell transplant. They, they get used interchangeably. Really, when we talk about stem cell transplant, we have stem cells throughout our, throughout our body. But with this therapy, it’s specifically stem cells for the bone marrow. We call them hematopoetic stem cells. They’re the stem cells that are at least partially differentiated so that they can evolve into our blood cells. And so it’s not stem cells that help with maybe orthopedic issues or other health endeavors. It’s, they’re strictly stem cells that give rise to our blood cells. And so that’s why you can use them interchangeably. But what we mean are that the stem cells are, are meant to help grow the, the cells that give rise from the bone marrow, the word bone marrow transplant is maybe falling out of favor because most of the time the stem cells are collected off of the blood. And so when you were introducing me, you, we called it blood and bone marrow transplant. So that’s why we use those words is because actually with newer medicines, we can collect the stem cells off of the bloodstream instead of having to access them from the bone marrow environment. As far as the other terms, you mentioned, autologous and allogeneic, those terms define who the donor is. So autologous means you’re your own donor. So it’s a self donor: we’re collecting stem cells from the patient, him or herself prior to giving chemotherapy, whereas allogeneic transplant, we use allo donors, which means it’s somebody else. It’s not the patient stem cells, but a relative or an unrelated person. And those stem cells then are used to treat a cancer as well.

Dr. Joseph Segeleon:

Thank you. That helps clarify those terms, which I think are often confusing. And I suspect since stem cells are obtained peripherally, that is a lot more appealing for donors, such that they do not have to undergo a bone marrow procedure.

Dr. Seth Maliske:

It’s not only appealing. But it also is more effective. We can collect more stem cells from the bloodstream than we can from the bone marrow itself so we can get higher numbers or higher quantities of stem cells, which are beneficial when we use them for transplant.

Dr. Joseph Segeleon:

As we talk about the center up in Fargo, what conditions and what do patients generally have as far as their disease process that you mostly see and that you utilize these procedures for?

Dr. Seth Maliske:

The use of autologous stem cell transplant or autologous bone marrow transplant is commonly used in multiple myeloma. We use it very often in multiple myeloma, either early on in one’s therapy or sometimes we reserve it for later. But it commonly becomes part of the treatment of myeloma patients. Autologous transplant is also used in relapsed lymphoma. So we don’t do it unless the cancer is relapsed, meaning not cured up front. Those lymphomas include B-cell lymphomas as well as T-cell lymphomas. When we talk about allogeneic stem cell transplant, when we have to use a donor, those, those cancers that we use allergenic transplant for include leukemia. So more traditional aggressive leukemias, like acute myeloid leukemia, acute lymphoblastic leukemia. We also treat aplastic anemia as the most common groups of cancers that we treat with allogeneic stem cell transplant.

Dr. Joseph Segeleon:

So if you will for the providers who are listening and to give them a good idea of what their patients will experience, walk us through a typical myeloma patient with a stem cell transplant.

Dr. Seth Maliske:

Myeloma patients are initially treated with multi-drug chemotherapy regimens or anti myeloma therapy regimens. They receive that medicine for approximately three or four months. And then once the cancer is, is debulked more or less, we then can take them to transplant. The transplant process begins by interrupting that therapy so that their bone marrow is healthy enough to collect stem cells. We then mobilize the stem cells from the bone marrow into the blood. And we do that with the assistance of growth factor medicine. It’s a collection of shots that precede the collection by four days. And then the collection is usually a one to three day event where we’re essentially using a dialysis machine. It’s not exactly like a dialysis machine, but the idea’s the same. We basically create a circuit where blood comes out of the patient’s body through the machine.

Dr. Seth Maliske:

The machine is calibrated to collect a layer of the blood where the stem cells sit and then everything else is returned back to the patient through the opposite side of the circuit. And so blood just circulates around this circuit for several hours, probably four to five hours altogether. And then at the end, we’re left with about a pop can full of stem cells. So it’s blood and plasma and stem cells. And then that bag is then sent to our lab where we use special freezing media so that the cells are unharmed as they freeze and then we store them until they’re needed for transplant. We often interrupt the collection or separate the collection of stem cells and the transplant by at least one week. This allows patients to just recover , helps their platelet count recover, helps them feel a little bit better as we then bring them into the hospital for chemotherapy.

Dr. Seth Maliske:

The chemotherapy is given in myeloma, at least, just over one day. In lymphoma, it’s given over six days. And then after the chemotherapy is given, after the chemotherapy is basically metabolized by the body so it can’t harm stem cells anymore, we then give the stem cells back. So that’s usually about 24 to 30 hour break between last dose of chemotherapy and the giving of stem cells. Everything after that’s just a long recovery for patients. So it’s about two weeks in the hospital until those stem cells start to work. The stem cells are just given by gravity through a catheter. So it’s really just like a blood transfusion. Not a whole lot different, any different than the way red cells or platelets are given by transfusion. But then those stem cells go through the bloodstream and are basically recruited back to the bone marrow environment where they engraft and grow and produce normal, healthy cells. And it takes about two weeks for those normal healthy cells to start being made and push back into the bloodstream where the patient’s safe to go home. And then again, they just slowly recover after that. They usually feel a little unwell for about a month. They start to feel more like themselves by the end of the second month. And then really, I feel, I think completely back to normal by the third month.

Dr. Joseph Segeleon:

So since a number of the patients travel to the Roger Maris center for their care, if I heard you correctly, the patient spends two weeks in the hospital, and then is there additional time that they stay within the proximity of Fargo?

Dr. Seth Maliske:

That is correct. Yes. We keep patients in hospital for that two-week period. Once they leave the hospital, once they’re safe to leave, we keep them in Fargo for another seven to 14 days, just to make sure that they don’t have any early setbacks. It’s just a way to, I think, ensure that they’re well cared for through that first month where they’re the most vulnerable.

Dr. Joseph Segeleon:

And I understand a caregiver comes, accompanies the patient then as well. Is that right?

Dr. Seth Maliske:

Yeah. We define a caregiver up front. Kind of the, the person’s yeah, their partner in this endeavor. They, you know, oftentimes it’s a husband or a wife or their spouse. But other times it’s children or a sibling, but that person is with them throughout the whole journey. And they’re a big part of the team.

Dr. Joseph Segeleon:

If I understood correctly, the cell preps are done at Sanford as well?

Dr. Seth Maliske:

So we have our own lab. We have our own machines, so everything is done at Sanford. So when I describe the mobilization and the collection, that’s all done, outpatient, it’s all done here at Sanford. And then the freezing and the thawing of cells are all done here as well.

Dr. Joseph Segeleon:

OK, great. Now, as far as in those two weeks and then as you said, the recovery period, what kind of complications do you look for? And then after discussing what kind of potential complications a patient may have, maybe we could segue into some survival statistics as well.

Dr. Seth Maliske:

So for the autologous stem cell transplant, the toxicity is primarily of chemotherapy. This is what we call ablative chemotherapy. It’s meant to ablate the bone marrow, wipe out the, the bone marrow. So it’s harming what we hope to be all the cancer cells, but will also injure the normal cells of the bone marrow. Therefore patients almost universally need some blood transfusion, whether it’s red cells or platelets. It also renders them very vulnerable to infection. And that’s the main reason they’re in the hospital for that two-week period. They’re at higher risk for infection because of how suppressed their immune system is, but also because the chemotherapy is quite toxic to the GI tract. So everywhere from the mouth to the bottom and the mouth can get sores, or really the bowel wall can kind of have breakdown and that can serve as a portal of infection for bacteria.

And that is why they’re so much more vulnerable than even the average chemotherapy patient. So taken together the bone marrow and the gut being quite affected by the chemotherapy., we watch those two organ systems, the best. Very seldomly do they need like artificial feeding, but we always tell them that their nutrition is gonna be affected because they feel unwell. There are a lot of times lying in bed for not a long time, a few days, but this just makes it so that they’re maybe a little unsteady on their feet before they leave. So we have to make sure they’re eating and drinking, walking strong on their feet before they go. In addition to making sure they’re well protected from infection. That’s the typical story I convey to patients with autologous transplant. Allogeneic transplant creates a whole new realm of risks.

And that’s because when donor cells are used, they’re used to create an anti-cancer effect. We call that graft versus tumor effect. And that’s what we want to see because it’s gonna help treat the cancer. But another part of the person is just the rest of their bodies. So we call that graft versus host disease, and that can affect really any part of the body from head to toe. So skin, bowel, liver, lungs, really anything become affected. And then on top of it to prevent that graft versus host from happening, we have to suppress a person’s immune system, even on top of what it’s already suppressed from the chemo, and that leaves people even more vulnerable to infection. So these competing risks of outcome, beyond cure, include risks of harm from graft versus host, much higher risk of infection, and then there’s other more, I guess, rare side effects that are life-threatening too, but allogeneic stem cell transplant is, is just a whole new, a whole new level of, of care. It really requires a, a huge team to support people through allogenetic stem cell transplant.

Dr. Joseph Segeleon:

And, what about for autologous transplant? What are the survival statistics at this time?

Dr. Seth Maliske:

As far as treatment related harm? And when I describe that to patients, I, what I mean by that is what are the chances me performing transplant actually shortens your life, not necessarily the cancer shortening one’s life. So that’s treatment related harm or treatment related mortality. With autologous transplant, that’s probably 1%. Maybe one in a hundred people may have a really bad infection or a bad bleeding episode or another event at the time of their transplant caused by chemotherapy that could potentially shorten their life. It may even be less than that, but it’s about 1%. As far as chances of curing the cancer, myeloma’s tricky because we don’t think of it as a curable disease. What we’re doing is putting it into a deeper remission so that the cancer stays away for longer. And usually by transplant, in an average patient with standard risk disease, we can keep the cancer away for a number of years, maybe four or five years.

Compared if we don’t do transplant, it’s probably half as long, maybe two and a half years. Something like that. When we look at lymphoma, another cancer that we commonly treat with autologous transplant, we’re probably increasing, we’re doubling the odds of cure as an average guess doubling the odds or increasing the odds to about 50 50. It may not sound as good as patients want to hear, but I think without transplant, we consider it relatively uncurable and we need to use transplant to, to if the cancer’s proven to be sensitive to chemotherapy, I should add in that case, we can cure about 50% of relapse, large B cell lymphoma. So again, a 50% chance of cure with a very, very low chance of cure, otherwise in taking a chance of 1% risk of harm, highly in favor of doing transplants and large B cell lymphoma. And then as far as allogeneic stem cell transplant, it’s very individualized based on the patient, the donor and the disease becomes very difficult, but we talk about treatment related mortality, more on the more on the spectrum of 10 to 20%, and then the chances of cure again, highly variable. So too general to, to comment, I guess, without a patient in front of me.

Dr. Joseph Segeleon:

Well, thank you. Thanks for that. That’s a lot of very useful information. Now for our primary care physicians and providers that are listening. After the patient, the stem cell transplant recipient goes back to their community, are there specific things that the primary care provider has to watch for, has to be aware of?

Dr. Seth Maliske:

I think early post-transplant, we always worry about infection. That’s kind of the first, second and third thing on our minds, to be honest. If we can prove there’s no infection, we, a lot of times it’s just residual chemo toxicity and patients just need time to recover. Otherwise, can the stem cells cause harm? You know, a month or two down the road, generally not. There are some longer term chemo toxicities that are possible. The chemo can sometimes affect the lungs weeks or months down the road. So there are unique events, but for the most part, we worry about infection. Beyond that, I guess we always have to be concerned about blood clots, post-hospitalization and side effects of any subsequent medicines that we’re using. But for the most part, much of the toxicity happens in the first two to four weeks while they’re here in Fargo.

Dr. Joseph Segeleon:

I understand some of these patients will need revaccinated with vaccinations they’ve had in the past. Does that occur at the provider’s office, the primary care providers, or do they come back to the transplant center for those?

Dr. Seth Maliske:

So at least in myeloma, patients do get therapy to maintain remission afterwards. So if they’re seen by a cancer provider say in Sioux falls or Bismarck, Bemidji, et cetera, we have them restart this, what we call maintenance therapy with their local cancer providers. And we have them start the vaccines there. We help guide the vaccines and make sure that they’re done on time. So there’s communication with our nurse navigating team, as well as their teams locally. But for the most part, these vaccines do happen at their local offices. Perhaps, maybe the very first vaccine we do here, not because of risk or harm, but just because I always see patients at that six month mark, just to see how they’re doing. And that’s oftentimes when we start the vaccines, but it doesn’t have to happen with us here in Fargo. Ultimately my goal is to get people through transplant, get ’em out past that first 90 day window, and then try and return as much of their care as possible back to their local oncologists, who they garnered so much trust with before.

Dr. Joseph Segeleon:

1. And so those, those patients do have some vulnerability to some illnesses that prior to the transplant, they perhaps did not. Is that correct?

Dr. Seth Maliske:

Yes, that’s correct. So when I was referencing much of the harm being in the first two to four weeks I’m not trying to describe the risk that their immune system is back to normal at the end of the first month. Really their immune system recovers over an extended period of time. So we have our innate immune system, which is neutrophils and something called natural killer cells. Those things recover first, and those are the things that prevent neutropenic infections, the infections that can really make people sick very fast. And those are the things that the most life threatening early post-transplant. So once those things are, once the neutrophils and natural killer cells are recovered, they’re much safer, but they’re not completely back to normal until closer to two years. And the reason why is because our lymphocytes, our B cells and T cells, they start to function more normally in that three month to maybe nine-month window. And so we delay vaccines until closer to six months. The vaccine schedule happens over a year and a half, actually, and so it’s not really until you’re fully revaccinated that your immune system really functions like it did prior to transplant. This ablative chemotherapy really wipes out our memory cells, as well as our normal innate immune system. And so we have to retrain it to protect against the against the infections that we can vaccinate against.

Dr. Joseph Segeleon:

Great, thank you for that. I know that the Roger Maris Cancer Center had been preparing for this program for quite some time. Tell the listeners the benefit of having a program like this in Fargo.

Dr. Seth Maliske:

So I kind of hopped on board after a lot of the heavy lifting was done. So I was amazed at what the team had accomplished in the years prior. So it’s – to build a transplant program, you have to have a huge team. You have to have a lab. You have to have an oncology program. You have to have an inpatient and outpatient program, and it takes a lot of work and a huge testament to the team at Sanford having built that. I started about a month or two prior to our first transplant. So I got to start really when all the heavy lifting was done. And so even in the last year, being here, it’s been remarkable to witness the stories that patients convey along the way. I knew of toxicity associated with transplant.

I knew of it a lot in the form of chemo toxicity and just how much time it takes to recover. But I don’t think I really appreciated just that, that toxicity of, of just proximity, that not just the time of recovery, but the time people spend going to and from doctor visits or the time people spend just traveling before transplant for the workup. That stuff, maybe I was aware, but become much more aware of as I’ve listened to patient stories over the last year. Patients are so pleased to be able to have their cancer care closer to home. It allows them to, I think, feel more comfortable, but not just comfortable being closer to home, but a lot of times their cancer doctors are other providers here in Fargo. I have a, a group of colleagues that are all malignant hematologists and they may treat the patient’s myeloma or the patient’s lymphoma.

Dr. Seth Maliske:

Maybe the nurses are more familiar. The nurses on the inpatient side become familiar. And then when we can do transplant in that same environment where people have already earned that, we’ve already earned their, their trust. That goes a long way as well. They’re not relocating, they’re not learning new doctors, they’re not learning new rooms. They, they just so feel, feel so much more comfortable just being at home. Now, of course, there are people that come from Bemidji and Grand Forks and Bismarck and surrounding communities. So not all of our cancer patients come from Fargo, but just having that familiarity is a huge aspect that patients appreciate as well. But yeah, I, I think, it’s truly remarkable. How, how appreciative patients have been of this program in just the first year of its existence.

Dr. Joseph Segeleon:

Yeah, I think very, very well put, I mean, the, you know, to have that trust in your environment to have the trust in physicians and nurses and hospitals that you already know, not to mention reducing the anxiety of the travel costs and all of the costs associated with travel and being away from home, it’s really an incredible benefit that we have within our community, a center like the Roger Maris center and the procedures and the cutting edge comprehensive care that you are providing, you and your colleagues. And I appreciate that it takes a team and there’s been a lot of foundational work that has brought you to the point that you are today. Why don’t we close up with two questions. Two questions I wanted to ask is maybe describe current state, what procedures you are currently doing, and then what does the future hold for your therapies and where you would like to see the program go?

Dr. Seth Maliske:

So we’ve spoken a lot about autologous, as well as allogeneic stem cell transplant. We’re well established with autologous transplant. We’ve completed a dozen or more transplants. I think the team’s doing a wonderful job and I look forward to continuing to do good care for autologous transplant. Allogeneic stem cell transplant will begin here in the fall. We’re not too far away, but it’s just a, it’s not just having the infrastructure, now it’s finding the right patient and treating the right disease. So I really expect that to – we’ll probably complete our first allogeneic stem cell transplant, sometime between October and December. I think we’re ready to go just about any time. We just have to find the right team in the right environment. And then as far as the future beyond allogeneic stem cell transplant, we haven’t discussed car T therapy a lot.

Car T stands for chimeric antigen receptor T cells. It’s just a genetically modified T-cell that is trained to fight cancer. We have a lab, we have all the foundation set up for that. We’re just kind of creating a a little bit more electronic medical record build and some education with nursing staff, but hope to bring that on board in early 2023. And then I think beyond just the technologies, I hope to bring a little bit more of a research infrastructure, more clinical trials. I would envision us being able to enroll kind of these advanced phase trials, you know, stage two, stage three, perhaps industry sponsored trials that really will support our patients with need for these cellular therapies such as stem cell transplant and car T therapy. So I think there’s a lot to look forward to, and I think the future is bright here in Fargo.

Dr. Joseph Segeleon:

That’s fantastic. And I certainly appreciate and have enjoyed the time we’ve had to talk about this. There’s great things that you’re doing up there for Fargo that you’re doing for the entire region and for Sanford. And I am looking forward to all that you are doing up there. I’m looking forward to learning more about this. I think it’s great that our patients, families and our providers know that there is this caliber of care that is close to home that we are comfortable with, that we know our colleagues and it really is a fantastic benefit for Sanford patients, families, and providers. So thank you again for your time, and I’m gonna turn it back over to Courtney.

Dr. Seth Maliske:

You’re very welcome. Thank you for your time as well.

Courtney Collen (Host):

Dr. Maliske, Dr. Segeleon, as always, thank you for joining us. This was another episode of our Called to Care podcast series by Sanford Health. I’m Courtney Collen. Thanks for being here and we will see you soon.

Learn more:

Fargo leukemia patient receives bone marrow transplant

First bone marrow transplant patient healing close to home

Sanford Health, NCI connect to study, prevent cancer

Simon Floss (Host): Hello, and welcome to ‘Innovations,’ a podcast series brought to you by the experts at Sanford Health. You’re listening to our 19th episode, ‘a connection to fight cancer.’ I’m your host Simon Floss with Sanford Health News.

The practice of medicine goes far beyond clinic walls. The Innovations podcast looks at the biggest issues facing healthcare today. Each one of these episodes offers the opportunity to see the ever-changing world of health and wellness through new eyes. Our leaders offer out of the box solutions to some nagging questions.

Today we are talking about a disease that’s affected everybody in one way or another: cancer. Recently, Sanford Health has become heavily involved with the ‘Connect For Cancer Prevention Study,’ a research study from the National Cancer Institute aimed at better understanding the causes of cancer, and how to prevent it.

Here to help explain what we need to know is a distinguished panel of guests, Chun-Hung Chan, Deann Witte, and Amanda Mensing. Dr. Chan and Amanda are joining us from Sioux Falls and Deann Witte is joining us from Fargo.

Host: Thank you all so much for being here today. We’ll get right to it because this is a big topic with a lot to unpack Chun, we’ll first start with you. What exactly is the connect study?

Chun-Hung Chan, PhD: The connect study is a new innovative study that the National Cancer Institute has started that basically is looking at causes of cancer and developing a new resource for researchers nationwide to basically look at things like how your lifestyle, or where you lived, your genetics, and other factors might affect your risk for developing cancer. The goal really is to identify these new potential risks and help prevent cancer.

Host: Amanda, if someone was going to ask you why this study is important, what would you say?

Amanda Mensing: Well, I would say that the study is one of the first that enrolls people before they ever get cancer. I know a lot of research studies focus on patients when they get cancer. Whereas this one looks at people before with no indication that they would get cancer.

We’re also looking at, as Chun said, environmental factors, such as where a person grew up, where they currently live where they work, any social factors and their lifestyle choices in terms of how that could lead them to either develop or not develop cancer later.

Host: So, this is just incredibly useful. Deann, in your mind, what’s the most unique thing about the connect study?

Deann Witte: I think for the most part it’s such a large study. They’re looking to enroll up to 200,000 people and it’s a long-term study over the course of, at least 10+ years of healthy individuals. Most of the studies as Amanda said deal with treatments rather than trying to find cause. So this is kind of in my mind, what would be the most unique thing I guess.

Host: Chun, how did Sanford Health become a part of this study?

Chun-Hung Chan, PhD: So, through my work with the Sanford biobank I got to know the folks at the National Cancer Institute, and many years ago, they invited me to present. I presented to them on what we do at Sanford as far as research and bio-banking is concerned. That led to them inviting us to submit an application to participate in this study. And we were successful in being awarded that contract. That’s how we got here.

Host: What was that experience like? I mean, one being asked to present that and then two, just having that direct connection with the Institute.

Chun-Hung Chan, PhD: It was actually an interesting experience in the sense that I was not expecting them to reach out to us. Generally in research, normally we look for the funding opportunities, but in this case, the NCI actually directly approached us which was unexpected, but also quite an honor, I think for us.

I think obviously whatever we were doing here, they were impressed with and, and saw the value of including Sanford Health in this important new study. And I think that definitely having those relationships with the national cancer Institute and the leadership there definitely benefited us.

Host: The old expression ‘don’t call us, we’ll call you.’ They actually called us, you know? So, what’s that say about Sanford Health in general?

Chun-Hung Chan, PhD: I think that basically says that you know, Sanford Health has started to become recognized as a leader in research.

Host: Amanda, how can a person join the study?

Amanda Mensing: So, there’s a few different ways that we’re looking for our participants. If there are, if someone is eligible they may get an invitation from Sanford research through either my chart or also in the mail. Otherwise we do welcome people to go to the website for the study cancer.gov/connect study. And then we’re also going to be placing posters, working on recruitment there. We’re going to be working with some of our Sanford physicians to see how they can get their patients involved as well.

Host: Why would you recommend that someone get involved and join the study?

Amanda Mensing: I think this is a really unique opportunity to be able to input the way a person chooses to, you know, live as far as social life, or location and provide that information and just basically give it out as a bank to try to help our future generations try to find potential causes of cancer that we may not have even thought of.

Host: And speaking of potential causes these, these outliers as far as the study where someone lives, their genetics just a reminder for people listening, what are some of the biggest causes if you will, or just those outer layers that might contribute to a cancer diagnosis later in life?

Amanda Mensing: I think a lot of what people think of right now are causes of cancer are the obvious ones smoking for one. So, this is really looking at, is where you live a potential? Do you have a higher risk depending on what part of the country you live in? Which I think is the main reason that it’s so important that we’re working with so many different locations throughout the country is we can try to determine that.

Host: How many locations? Sorry to interrupt. If you have a ballpark number, too.

Amanda Mensing: We have nine right now, I believe. Am I right on that, Chun?

Chun-Hung Chan, PhD: Sanford is one of nine institutions nationwide that are working together to recruit for this study.

Host: And I’m assuming it’s, like you said, nationwide coast to coast, Midwest, down south?

Chun-Hung Chan, PhD: There is representation from the east coast, the Midwest, the Pacific Northwest. We even have a location in Hawaii.

Host: Well, Aloha. Deann, say a person wants to join the study. What are some things that they need to know? What’s going to be expected of them, and what are the responsibilities of participants?

Deann Witte: After you consent and join the study, you’ll just be asked to complete variety of questions in the form of surveys, answering questions about your health history, environmental questions, about where you work and live among others, of course just all background information that might help assist researchers.

In the long run as far as looking back, you’ll be asked to make an appointment to complete sample collection of blood urine and saliva. And after that first initial round of survey and sample collection, participants will be contacted periodically to complete additional surveys and provide additional sample collection.

Host: And you said this is a long study. 10+ years, what’s kind of the timeframe on that again?

Deann Witte: The timeframe on the biospecimen collections?

Host: No, just the length of the study.

Deann Witte: Chun, maybe you could answer that better than I could. I know a 10 plus years, as far as following people in the most the age group, more likely to develop, I guess?

Host: Sure, Chun if you want to take that?

Chun-Hung Chan, PhD: As designed right now with the study the NCI are hoping to follow participants for at least 10 years with the idea that over the course of those 10 years, and with the age group that we’re actually looking at between the ages of 40 and 65, based on national statistics they would expect a proportion of them to develop cancer during that 10-year period.

(As of February 2024, the NCI Connect study has expanded the eligibility criteria to include ages 30-70.)

However, the NCI have also indicated to us that if this study is a success in terms of recruitment, that they would consider extending it beyond 10 years and possibly up to 20 years in length. And this will really be probably the most comprehensive study for looking at the causes of cancer anywhere in the world because most studies generally do not do a long-term 10 to 20 year follow up.

Host: What information will be collected from a person and then how will it be used?

Chun-Hung Chan, PhD: In addition to the survey questions that Deann mentioned we will also ask participants to give us permission to access their medical records. So, Sanford will provide medical record information to the NCI that will be associated with this, the survey questions, as well as the samples that have been collected. And all of this information will be collated together. Then, they will also draw upon additional information such as geographic location. So, they may look at things like, particularly in the Midwest, they might look at you know the type of industry that occurs around here.

So, obviously in the Midwest there’s a lot of farming. They might look at farming and potential exposures to agricultural chemicals. Then tie that back with where you actually live, and see whether there’s a potential that you were exposed to some sort of pesticide or something like that, and if there’s maybe a link between that and developing cancer. So, really they’re using a variety of different information, as well as the information that we provide and that the participant provides themselves to really get a comprehensive picture of, what is it that the participant may have been exposed to at some point that may result in developing cancer.

Host: This is just fascinating. Amanda, what are the benefits of joining ‘Connect’?

Amanda Mensing: In terms of direct benefits, there’s not really any direct benefits to the participant. But, overall we’re looking at a benefit to the general knowledge of cancer in terms of how it could develop and that could impact future generations and help prevent cancer by determining causes and the risks associated with it. So much of it is a long-term impact looking at doing a study that could impact future generations and the participants, children, or grandchildren.

Host: Deann say that there’s someone with no history of cancer. What would compel them to participate in the study, or why should they still participate?

Deann Witte: More than likely someone has been touched somehow by cancer? Whether it be through a relative or close friend or coworker we all kind of know people that have had to go through cancer treatment. This is a way for, for those people to feel like they’re helping and feel like they’re contributing to the cause. I think it’s a feel-good way of saying, “you know, what. I’m involved in this. I’m going to try to help in whatever way I can.”

Host: Like you said, cancer truly has impacted everyone in one way or another. Chun, how is this study impacted if a participant develops.

Chun-Hung Chan, PhD: If a participant develops cancer it will actually not impact the study in the sense that you know, the participants can still continue to be part of this study. The sad reality is that out of the 200,000 people that they hope to enroll, a proportion of them will probably develop cancer in their lifetime. That’s actually one of the kind of goals of this study is that they want to look at those people who do go on and develop cancer. Because, then the NCI will actually have kind of like a before and after picture of what does that participant look like before they’ve had the cancer, and then after they develop cancer? What the NCI are really hoping to do is work with Sanford and identify those participants that do go on to develop cancer.

Then, we will provide them with additional information from their medical records treatment information may be some samples from pathology so that they can really study what type of cancer the participant has developed, and link that back to any kind of potential pre-cancer data that they have in terms of exposures, and really see if there’s any sort of link there between what they might be exposed to or genetics, or things like that and the cancer that they end up developing. So, like I said, this is really a comparison of before and after. And they do actually expect a number of participants to develop cancer in order for them to be able to study those risk factors.

Host: Deanna and Amanda, I’ll ask you both the same question and allow both of you to respond. Deann, we’ll first start with you. Why should the study matter to Sanford providers?

Deann Witte: I think that for providers you know, some of our providers work in research and some don’t, but it’s a way for them to refer people to a study that could benefit them and down the road and contribute to their knowledge and maybe changing the course of their treatments or their treatment decisions making changes down the road for people rather than just thinking about the here and now. What are we treating particular cancers with now more so looking like how, how can that change by looking back at these things? And, maybe just making strides to make that better for people.

Host: Amanda?

Amanda Mensing: What we learn from this study could help provide new insights into risk factors for developing cancer, as we’ve said. And, that could definitely help providers in the future by giving them new tools and insights to prevent cancer. It could also assist in new screening guidelines. I know the screening guidelines for particular types of cancers seem to change quite often. And this could kind of give providers a little better direction as far as what the best screening guidelines are.

Host: Awesome. Well, thank all three of you for taking the time and joining us here today.

Before we wrap up, I’d like to remind you that Sanford Health Innovations podcast is now available on your favorite podcast apps like Apple and Spotify, as well as our website, Sanford Health News. If you enjoyed this conversation, follow us, give us a thumbs up and share your comments. We love hearing from you and hope that you find these conversations insightful.

Thanks again for listening. I’m Simon Floss with Sanford Health News.

FDA leader talks cellular therapy with Sanford

Simon Floss:
Hello, and welcome to Innovations. A podcast series brought to you by the experts at Sanford health. I’m your host Simon Floss with Sanford Health News.

Over the last few years, the topic of regenerative medicine and orthobiologics has been subject of many headlines as it relates to treatment of orthopedic joint pain.

Orthobiologics can mean a variety of treatment options based on a patient’s specific needs. As it may seem relatively new, what do we know about these treatments and what oversight is there of these programs to make sure patients are getting the best treatment?

For this episode, we bring you a conversation on this topic. Recently, Dr. David Pearce, Sanford Health president of innovation, research and Sanford World Clinic sat down to talk with Dr. Peter Marks, director of the Center for Biologics, Evaluation and Research at the Food and Drug Administration in Washington, D.C.

David Pearce, Ph.D.:

Dr. Marks, it’s a pleasure to be here with you today. Could you just tell us a little bit about who you are and what you do?

Peter Marks, M.D., Ph.D.:

Yeah, thanks for having me today. I’m the director of the center for biologics evaluation and research at the food and drug administration. We handle the regulation of complex biologic products like cell and gene therapies, blood products, and vaccines.

David Pearce, Ph.D.:

Ok. So obviously right now during the pandemic, lots of approvals with vaccines and treatments for COVID, but we’re really interested in hearing a little bit about what your thoughts are on the way, the direction of what cellular therapies actually encompass.

Peter Marks, M.D., Ph.D.:

I think right now that cellular therapies are a very wide range of products, everything from simple cell therapies or tissues that might be used for local treatment of wounds or issues, to more complex things like cellular products where cells are laid down on scaffolds. And those can be used as a tissue-like thing. There are cells laid down on scaffolds that are like organs and those are under investigation too. So all of those things are under investigation, as cellular therapies, and then there are some of the approved cellular therapies now. Most of those right now are genetically modified cell therapies, the chimeric antigen receptors. So there’s a whole range from simple things to kind of intermediate really complex things, to very complex things.

David Pearce, Ph.D.:

Exactly. I mean, it’s a very booming business. Business is probably not the correct word for it right now, but Sanford as a health system obviously, wants to do the right thing for its patients constantly. So I was wondering if you just tell us a little bit about the approval process for a cellular therapy.

Peter Marks, M.D., Ph.D.:

For cellular therapies, they go through different processes depending on whether or not they meet certain requirements. Some products don’t actually even have to come to the FDA for an approval. They are exempt because they are not manufactured significantly and they’re used in the body in a manner in which they came from another person.

So let me just try to explain what that means. There are products you can imagine, like a skin graft where you take it from skin going onto skin, and one doesn’t do anything more than maybe size it or wash it, or maybe put in some antibiotic solution. Those we don’t even require investigation, new drug applications or biologics license applications. They fall under what I call our tissue rules, which are just a way of making sure that one doesn’t pass along communicable diseases when one uses those products. They don’t have to come in for an approval. One makes them according to these regulations and one is OK.

Then there are products where they are more complicated. They might be a product where one does very significant manufacturing, such as remove cells from a tissue and then grows them in culture and then formulates them and puts them back into a location that’s different from where they came from. And that’s some of what has been done with mesenchymal stem cells or other stem cell therapies. And for those because one can’t say that they’re going to work just the way they worked, because they’ve been manufactured and they’re being used in a different place than where they came from. There, one needs to go through the normal investigation process that we expect, which is an investigator comes to FDA, files an investigational new drug application.

That application is reviewed by the agency. And if everything looks in order after 30 days, we say, OK, it’s fine for you to proceed with a clinical trial. And then once that investigator gets clinical trials data together in a sufficient manner, usually through multiple stages of trials, they come back to the agency. We have another conversation and if everything looks good, they file a biologics license application. If everything looks good there, they get an approval and then they have an approved product. So if it sounds like a lot of work it’s because it is a lot of work, right?

David Pearce, Ph.D.:

Yeah. Forgive me. If I were to do an executive summary here, what it takes to get a cellular therapy approved is it’s a lot of work and there’s a lot of rules and regulations and at Sanford, we’re no different from other health systems where, it’s a complicated process and we’re trying to do right by our patients. The environment we’re in right now, we know there’s many groups offering cellular therapies that are unapproved. Sanford Health clearly can’t be in that group. We obviously want to do the safe thing and we all want to do the efficacious thing. So I’m just wondering if you could comment a little bit about the environment right now out there, what we are calling the wild west and with respect to some of these regenerative cellular therapies.

Peter Marks, M.D., Ph.D.:

I think we actually also sometimes think it’s the wild west out there. We are in an environment now where for a while it’s true, people kind of cite back that maybe FDA wasn’t clear enough in the 2010-2015 period of time, we weren’t clear enough about what was not allowed. And because of that, there were a lot of stem cell clinics that proliferated saying, ‘well, I’m just taking cells from somebody and I’m giving them back.’ And so they meet this kind of exception I told you about, but they weren’t just taking the cells out and putting them back, taking cells out and putting them back – that’s something like doing bone marrow transplantation. There you take someone’s bone marrow out, you give them chemotherapy and you give it back to them. That’s actually, that’s OK. That’s actually legit that way.

On the other hand, if you take cells out, destroy some of the cells, grow the cells in culture, and then formulate them in some mixture with some other chemicals and then give them back, that’s a very different thing. And so, we’re seeing people do that. And they’re doing it without having the normal process of coming in and having an investigational new drug application in place.

But what’s worse is they’re actually charging people for it. And that’s really a problem. It’s bad enough to kind of violate the regulations by not having the right the right paperwork in place. We’ll call it kind of venial sins and moral sense. It’s bad, it’s not good not to have the right paperwork in, but it’s charging is really a problem here because they’re selling products that are unapproved.

And it’s not just unapproved, most of the time they’re unproven, that’s the bigger problem, right? And that means people are paying money for something that we have no idea whether or not it will help them. And in some cases we do know that can hurt them because there have been some pretty bad things that have happened over the years when people got stem cells stuck into their eye or to their kidney or to their spinal column.

So, the goal here would be to try to see people kind of get the wild west under control by having people know enough about what they’re getting into. So they don’t get involved and pay money for things that aren’t going to be effective.

David Pearce, Ph.D.:

Yeah. Education is a huge part of this. I mean, that’s one of the things that Sanford focused on initially, as we started to explore some of these clinical trials. Our focus initially is being, ‘Let’s walk before we can run.’ You alluded to some of the oncology trials, which are really the more advanced areas, but we’ve really sort of focused a little bit in orthopedics right now which is an area where we have people coming into our footprint and basically saying, ‘Hey, we can inject this into your knee and 50% off for the second knee,’ and they’re not really telling people what they’re injecting and they are charging these ridiculous amounts of money. So, our mission is to legitimize and explore the appropriate types of products right now. So, I thank you because I’ve had conversations you with respect to, what Sanford is doing and we’re a champion for the FDA.

Peter Marks, M.D., Ph.D.:

I very much know that. I think to the extent that what you’re trying to do here is the right thing, which is, this is an area where there’s a demand. It’s great, actually people want to get the therapy, but you’re trying to do it the right way by actually letting them get the therapy, but also get the information that you need, that we need to actually understand whether the therapy is safe and that it actually works. Right? And that’s what’s so critical here.

So that at the end of the day, the beauty of participating in a clinical trial is that even if ultimately the product doesn’t work, you haven’t done something for nothing, right. You’ve helped advance knowledge because even a negative trial helps us learn something. And if it’s positive, that’s really great because then you’ve probably benefited some, and society’s benefited as well. So, that’s the reason for hoping that clinical trials like you’re doing people are aware of them and they enroll in them.

David Pearce, Ph.D.:

Exactly. So, we’re particularly proud of that approach. One thing you did mention previously was about people charging, and then that’s one of the things that really upsets me when we have people come in and they say, ‘I spent thousands of dollars on this therapy,’ and they don’t know what they got. But, I was wondering if you could sort of just elaborate a little bit on what cost recovery is for trials.

Peter Marks, M.D., Ph.D.:

If you’re getting an investigational therapy, something that isn’t proven to work, you shouldn’t be paying like retail price for it. Right? What we do allow at FDA is if there is at least some evidence, some manufacturer, someone who’s making it, it has to show us that they’ve done at least some safety studies, that there’s at least some chance that it could work, right? They have to have some good rationale that it might work and they have to have some safety information. The person who’s making it can apply to FDA for something called cost recovery. And what that means, is they provide us with an accounting of what it actually costs to make the product, and then they can charge the patient or the patient’s insurance company for that amount. They can’t charge to make a profit.

They can’t charge for all of the other care that goes in. They can’t charge for the research nurse for the clinical trial, but they can charge to recover the cost of actually making the product. And that’s felt to be fair in that it helps small entities be able to continue to move forward research. So I think that’s kind of the public health benefit of allowing that. But it doesn’t mean that people should be making a profit on this. That’s not what they’re doing. And that’s why there’s this requirement for an accountant to actually certify what’s going on.

David Pearce, Ph.D.:

Absolutely. No, thank you for that. I’m just going to mention what our trial is, and I know you can’t endorse that, but I think for the filming that I’m just going to talk a little bit about what our trial is. Obviously I talked a little bit about Sanford trying to legitimize this space right now in leading in orthopedics.

So we currently have a clinical trial which we like to call a registry where we have five indications. So, osteoarthritis in five joints basically. We’re very much looking forward to sharing the results with respect to that. I can tell you the uptick from just our community and the fact that people are looking for this from outside of our footprint as well is very encouraging. I think there’s a good base of people out there that want to do the right thing and also want to understand that getting the right treatment.

Peter Marks, M.D., Ph.D.:

Look, we are nothing but supportive of this type of work that needs to happen where clinical trials done in a way that’s getting advancing knowledge is exactly what people should be doing. And it’s exemplary of what we want to see happen across the spectrum of this area. It’s only too bad that this isn’t happening more broadly across the country.

David Pearce, Ph.D.:

In closing, is there anything else that you think you’d like to share with them?

Peter Marks, M.D., Ph.D.:

For me, I think this area of regenerative medicine is so exciting. And I think to date, it has not flourished as well as it could because people haven’t done what you’re doing. Which is actually systematically going through and finding out if things work or not. Hopefully you’ll find out that this actually works. It might work in three out of the five. It might work in all out of the five, but you’ll figure out what works and then you’ll improve upon that. And that’s how a field actually grows is you find out what’s working and what’s not working, and then you improve upon what’s working. And so to date, people haven’t been actually really interested as much. Some of these people are just looking to make a buck in advancing knowledge. They’re just looking to make a buck. Right? Whereas this is actually what you’re doing is actually taking the field forward. Which is so important because I think we’d like to believe that there’s a lot there that biology can offer us. Right? And by doing this, we’ll hopefully make those advances.

David Pearce, Ph.D.:

That’s funny you say that. When I talk about these trials, I tell people there’s a lot of biology in there, so I’m going off script. And I just want to ask you one other thing, based on your background. Peter, there’s so much advance in immunotherapies in cancers right now, so much advance in different cellular therapies. I’m wondering where you think that will go? CAR-T engineering advancing, and now we’ve got the NKT cells story that is developing, you know, where do you see things going with this?

Peter Marks, M.D., Ph.D.:

I think a couple things can happen right now. Shorter term, I think we’ll see, hopefully see the autologous CAR-T cell therapy manufacturing that’ll come down in costs, because of some of the automated systems that are beginning to be developed. And whether that will remain at kind of centralized manufacturing, like what’s happening now, or whether it gets to be distributed with places manufacturing locally, I don’t know for sure, but those models will be interesting. So I think in the short term, we’ll see some advances in autologous CAR-T cells.

The reason why that’s important is because I think if the cost comes down, people will use them for earlier stage disease and they actually might be more effective. I’m an oncologist by training and you know, what we’ve done with them is where we always know that if you use any oncology drug in the most advanced setting in metastatic cancer, you don’t get the greatest results always.

And some of the times when you bring it into earlier stage disease and it’s really great and you make a big difference in adjunct therapy, that’s been shown for breast cancer, et cetera. Now here for CAR-T cells, it may be that once you, once you can bring them back to earlier stages of disease, you might, you might actually be able to take people in their second remission, rather than their fifth remission and mop up disease so they don’t have recurrence in the longer run. I think we may really see advances here that might really be transformational.

If we get to allergenic CAR-T cells off the shelf products where, because you can take them off the shelf, they’ll be ready right away for people who need them. The cost should come down and more so, the ability when you’re making these batches where you’re not, it’s just not one-offs, you’re making very large batches, maybe a hundred doses from one donor. You can do the genetic modifications to make these cells start to have the kind of logic where it’s not just, they’re recognizing one receptor, they’re recognizing two or three, and then you can actually start to think about addressing solid tumors. Right? And that would, to me, be really exciting because I think that’s where that to me is the place where so far, we haven’t been able to go with these. People have tried to get CAR-T cells to work for solid tumors, and it hasn’t been an unabashed success yet, but I think we may see that if we can get to allergenic CAR-T’s.

David Pearce, Ph.D.:

Certainly, there’s a lot of work being done on modifying these right now. And again, at Sanford Health the next step for us is actually in-house, making sure we have the cellular processing in the point of care, with respect to that. So one last walnut is, is that some of our medical oncologists are very excited about NK cell.

Peter Marks, M.D., Ph.D.:

The idea here is that here you have something that, I mean, that’s what these things do, right? These are cells that are designed to eliminate things. They have the potential to hone in and kill. And if you can get them to there to understand the right target to kill, to train them to kill the right target, potentially have a very powerful therapy that could also be potentially even off the shelf therapy, which is very exciting.

David Pearce, Ph.D.:

And that’s one of the cellular processing steps that we’re taking right now in partnership with obviously one of the leading groups with respect to that. So, Peter, it was a pleasure. Thank you so much.

Peter Marks, M.D., Ph.D.:

As always. It’s great. Thank you.

Simon Floss: For more information on what Sanford Health is doing in orthobiologics and regenerative medicine, please visit sanfordhealth.org.

Also, a reminder that the Sanford Health Innovations podcast is now available on your favorite podcast apps like Apple and Spotify, as well as our website, Sanford Health News.

If you enjoy this conversation, follow us, give us a thumbs up, and share your comments. We do love hearing from you and hope you find these conversations insightful.

Thanks for listening. I’m Simon Floss with Sanford Health News.

Learn more:

• Ep. 9: Regenerative medicine options for orthopedic pain
• Ep. 12: New treatment options for orthopedic pain
• Cell therapy helps Sanford patient get back to racecourse

Regenerative medicine options for orthopedic pain

Courtney Collen (Host): Hi there. Welcome to our medical series Called to Care by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance that they can use in their primary care practice and more information about when it’s time to refer patients and families to more specialized care.

Joining me for these conversations is Joseph Segeleon, MD, who is vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. He’s here to help us dive even deeper into these topics to provide the best insight and care for our patients and communities.

Welcome, Dr. Segeleon, good to see you.

Dr. Joseph Segeleon: It’s wonderful to be here. It’s good to see you again.

Host: So our topic today really is fascinating focusing on regenerative medicine. Orthobiologics at Sanford Health is treating musculoskeletal injuries through cells from fat, blood, and bone marrow, which can reduce a patient’s pain speed up healing, improve overall recovery. That’s really all I know about this. So I’m excited to dive even deeper with you and with our physician expert, who is joining us, Dr. Donella Herman, who specializes in non-surgical orthopedic conditions, including fractures, arthritis, overuse injuries in endurance athletes and concussions through a variety of treatments.

Dr. Herman, welcome.

Dr. Donella Herman: Hi, thank you so much for having me. It’s a pleasure to be here today.

Dr. Joseph Segeleon: Yeah, I tell you Courtney, I share your perspective on this. When I was prepping for this session, I really came to realize how much I did not know about this subject and so I’m sure our listeners are also quite excited to learn about this. So, Dr. Herman, again, thank you so much for being here. We really look forward to our conversation that’s upcoming.

Why don’t we start off by telling us a little bit about yourself and your training?

Dr. Donella Herman: So I have been working at Sanford Health for the last four years. I kind of took a roundabout way to get into my medical training. I was actually previously an athletic trainer and then did some fetal alcohol syndrome research and then decided I wanted to kind of pursue medical school. I kind of had a natural draw towards sports medicine and research at that point, given my background. So I went to medical school at USD and then I did my family medicine training here in Sioux Falls. After my family medicine training, I did a year fellowship at Duke University in North Carolina. That sports medicine fellowship focused some on research, a lot of ultrasound guided injections, the overall treatment of musculoskeletal injuries, including fracture management, and then also some additional training in the regenerative medicine realm.

Dr. Joseph Segeleon: Great. Well, fantastic. Thank you. We really are so fortunate to have you here in our region. So why don’t we just get to it? What are orthobiologics?

Dr. Donella Herman: So orthobiologics is kind a big fancy word, and it’s an umbrella term that we use in terms of how we can use our body’s own resources in an attempt to provide a better environment for healing. And a lot of times there’s kind of, I don’t know the fancy words that you hear in the news about how we’re going to regrow things and the stem cells. For us, we’re trying to find ways to use cells that we have, that we know are a part of the healing process. Things like platelets, things like mesenchymal stem cells, things that we know help in the healing process when we have an injury and how can we harness that for some of the everyday things that we see in our clinic. So that’s kind of what orthobiologics is as a whole. It’s harnessing the body’s own resources and trying to utilize those to improve an environment and promote healing.

Dr. Joseph Segeleon: So is orthobiologics a part of regenerative medicine or is it different from regenerative Medicine?

Dr. Donella Herman:  It depends on where you are. It’s, it’s kind of a regional term more or less. Some people will call orthobiologics regenerative medicine. Some people will call regenerative medicine orthobiologics. I see it more as orthobiologics is a small area under the umbrella of overall regenerative medicine, because we can use regenerative medicine in cancer treatments. We can use it in other diseases as well. The orthobiologics, we are focusing that on musculoskeletal injuries versus kind of whole body treatment.

Dr. Joseph Segeleon: Okay, perfect. That’s very helpful. Thank you. That really clarifies it for me. In thinking about what’s the best way to sort of unpack this, this topic, perhaps maybe we could start with: what kind of patients come to see you for specifically for this technology and then maybe we can drift into the actual technology itself.

Dr. Donella Herman: Absolutely. I see a wide variety of patients in my everyday clinic. When it comes to the regenerative medicine and orthobiologics portion of my patients, it really is people who likely have a chronic injury. Osteoarthritis is one area that we treat pretty extensively with orthobiologics. But we also have things like chronic tendon injuries, whether it be rotator cuff or achilles tendon. With that being said, you can also use some of this for acute injuries or injuries that maybe we have an athlete that has an acute injury to the rotator cuff or to a muscle. Using these products, we can try to expedite healing, you know, get them better, faster, kind of a, of a mentality, but also do it in a safe way where we know we’re promoting maximum healing.

Dr. Joseph Segeleon: Yeah. I was surprised, when I was prepping for this, in 1939, there was a bone marrow aspirate used for a nonunion fracture. So I don’t know if I was doing a crossword puzzle in medical school during period or what happened, but very interesting. So chronic injuries and I know chronic conditions like osteoarthritis affects something like 50 million people, knee osteoarthritis in the United States. What are the advantages and disadvantages of orthobiologics? Or if you’d like to get right into the usages of whether it be plasma, derived products or stem cells it’s really up to you.

Dr. Donella Herman: Yeah. I think that one thing that we’re focusing on and a lot of people focus on with orthobiologics is it’s a non-surgical option. We’re looking for right now. We have steroid injections or we have lubricating injections, or, you know, we have have things that are, are manmade that we can inject and then we have surgical options and there’s not a lot in between. And so these are kind of seen as conservative measures that aren’t quite as invasive as a surgery. Although I will say that bone marrow aspiration is not an un-invasive procedure. It’s kind of something, if we don’t want to go in and surgically intervene or have a joint replacement, we kind of see these as options of that kind of gray area where… it seems like we go from really conservative stuff and then don’t have a whole lot in between that big surgical intervention. For us, this is hopefully going to help bridge that gap. But there, there are different kinds of, of cells that we can utilize to try to bridge that gap.

The less invasive thing to do is to use a blood product. So, you can have your blood drawn. We spin it down in our clinic, we take platelets and sometimes we add some white blood cells in if we’re going into a tendon. But we use those platelets and we inject that into the injured area, whether that be a joint or a tendon. And the hope is that those platelets who are the first, you know, the first cells at the scene of the accident is how, what I always tell my patients, you know, you cut your fingers and the platelets get there first and signal your body what to do.

Well, we anticipate that these platelets, we put them in a concentrated amount, into a joint space or into an injured tissue and they’re going to signal the body, ‘hey, let’s, let’s have you come in here and bring some healing in’ or bring the products we need to, to promote healing. And it’s really about trying to create that better environment for that joint or for that injured area. And so that’s kind of a less invasive way to do it, but then, okay, the next step, maybe we want to do something more with the regenerative cells that we get from bone marrow from fat. And so for those, we have a little bit more invasive procedure, but we also know that the mesenchymal stem cells also have a lot more signaling power than a platelet does. And so we can go in and do a bone marrow aspirate off the back of the pelvis. And then we have a process where we clean the cells and we count the cells. We make sure they’re alive. Most importantly, we see how many we have. We also make sure that there’s not any toxins in there. And we make sure there’s nothing infectious in there. And those four steps are something important because that’s not something everybody does. And so we make sure that we know what we’re injecting and that it’s a safe product to inject. And then we inject it to the injured area. We can also get those same sort of regenerative cells from fat tissue. And so we can go in and do basically kind of what we call a mini lipoaspirate or a small volume liposuction. And so we do that either off the abdomen or the gluteal areas and we take those cells and they have the same different processing standpoint, but we are looking for the same things prior to injection. We want to make sure they’re safe. We don’t want any toxins in there. We want to make sure that we have live cells and that there’s enough of them that we’re actually gonna get a good response from it when using these cells as the same thing, I’m not going to promise you, oh, we’re going to come in and regrow new cartilage. We just don’t have evidence of that yet. But we do know that if we inject these things, people have improved pain, they have improved function. They’re able to do the things that they enjoy more often. But we’re also following that with all of these regenerative cells. We are following our patients so we know how long they’re having relief for, how much activity they’re doing, if they have improvement of pain and motion. These are the things that we’re following and kind of measuring.

Cause right now we just, we don’t have a lot of information. There’s a lot of people doing it all over the country. You can go anywhere and there’s kind of pop-up shops that are, are offering these stem cells are offering, you know, they’re making a lot of promises that we can’t necessarily say they’re delivering on. And so what we’re trying to do is hopefully in five years, people will come to Sanford and say in a patient with this condition, which product works the best? And we’ll have that information. We’ll be able to say, yeah, we’ve done all three products in, in this kind of an injury or this kind of a population. And this product seems to be working the best. So that’s kind of our overall goal with it.

Dr. Joseph Segeleon: I read I read in prepping the stem cells are viewed as the general contractor coordinating the repair job and the plasma rich or platelet rich plasma is supplies added to do the jobs, or I thought that was or supplies needed to do the job. So I thought that was interesting. So most of these treatments are symptom relief, is that accurate?

Dr. Donella Herman: It’s symptom relief, functional improvements. And so we do generally want to see less pain, but we also want to see improved range of motion, improved strength and improved overall function. And so those are all the things that we follow. We have a way of capturing patient reported outcomes for our regenerative medicine orthobiologic patients. And in doing that, we’re hoping to see maybe we’ll again, in five years, we’ll find out that this, this one helps most with pain. So if their primary problem pain, we should probably go in this direction. But if we’re really looking to get back to doing more high level activities, then you know, we’ll, we’ll hopefully be able to steer ourselves in our patients in the right direction.

Dr. Joseph Segeleon: And when you talked about duration of effect, does that vary with product? Does it vary with the injured area? Or can you comment on a little bit of, is there preliminary data that gives you an idea of what the duration of effect is?

Dr. Donella Herman: It’s kind of hard to predict. It’s kind of like the other options we have currently that are widely used, like the steroid injections and the Viscosupplementation. We know that some people get the injection and it may last for years and some people get the injection, it may last for months. And so, it can be a little bit difficult to predict. I think that there’s been some data showing that, you know, six months out people are still seeing improvement with the regenerative cells. I know that there are health systems and health insurance plans that do cover some of the platelet rich plasma injections for joints and they can allow them up to twice a year. And so kind of, again, that six month mark is what we’re kind of seeing for improvement with that being said, anecdotally, I can tell you if people I know that have had the regenerative medicine and orthobiologics and they have had years of relief and have significantly improved their function.

Dr. Joseph Segeleon: Okay. Cause that’s good to know. I know that there are differences with regards to what’s allowed with the cells prepped and the length of time between aspiration and injection. I get the sense that much of this as FDA and legal, that is specific to the United States and then also perhaps different rules or different legalities pertain to outside the United States. Can you comment a little bit on that?

Dr. Donella Herman: Yeah. The FDA has some pretty strong statements in terms of minimally manipulated cells. That’s the term that they like to use. That gives us a window of time of processing these cells and injecting the cells and also what can you mix together and what can’t you. There’s restrictions in terms of, of, you know, taking a couple of products and putting them together and seeing if we mix some, is it better? Well, that’s kind of, we’re manipulating things at that point. And so things have to happen in individual injections. There has recently been some kind of more robust statements from, from the FDA in terms of, they want to restrict kind of the places that are maybe trying to take advantage of the, oh, what’s the word I’m looking for…

The FDA has come out with a lot of some strong statements in terms of one, we obviously don’t want to manipulate the cells. That’s always been the, the rule, but also if you’re doing this, you need to make sure that you’re doing it appropriately, that you’re doing it for the reasons of collecting patient reported outcomes. And, and in ways that the FDA says it’s okay to do that. One interesting thing of the stem cells, of the regenerative cells that we’re utilizing, is that for the fat derived stem cells, we have an FDA registry for that. We’re the only place in the country that has an FDA registry. So really nobody else should be injecting these, these process cells for, for joint pain or for osteoarthritis in the, in the five joints that we have the registry for.

But the reason we have the registry is because it’s something that’s kind of needed right now in medicine, because there are so many other places doing it. We need something that’s controlled, but it’s hard to do a double blind randomized controlled study for every single joint for every single thing. So they’re asking us to kind of start with the registry and then get some preliminary data from that and then see from there, if we can kind of, okay, what can we use for head-to-head studies thereafter, but it’s going to give them a lot of information in terms of what they can be used for in the future. But that also means we have a registry and we’re being watched. And so, you know we have a lot of safety measures in place. We have a lot of rules that we need to follow, especially our processing. This is something that even with the bone marrow derived regenerative cells, you know, we have a window, we want in from the time we start processing the cell to the time we inject it, we want to get that done in less than two hours, because we want to have the highest cell viability. We want as many cells to be alive as possible. We want the least risk of it being, you know, contaminated by something. And so we try to get everything done within a two hour window for the regenerative cells from bone marrow and fat. For the PRP, we inject those within 20 minutes. I mean, it’s a 20 to 30 minutes between when we draw the blood because we do it directly right there in clinic and this blood draw. So it’s a little less invasive.

Dr. Joseph Segeleon: I can certainly see with the huge number of individuals who are affected by osteoarthritis, by injuries, orthopedic problems, I can certainly see where there’s a need for this. And I can also see where there might be some opportunities for people to take advantage of people that are vulnerable and that have chronic pain syndrome. So I’m delighted to hear Sanford is part of clinical trials and really leading the way domestically with this registry. I think that’s fantastic. Let’s talk a little bit about costs and you alluded to earlier that some insurance companies cover this how do most patients afford this or is cost prohibitive?

Dr. Donella Herman: It can be for some patients. I say some health insurance plan, Sanford health insurance covers the PRP injections to the knee. And that’s one of the few that does. They just cover it for knee osteoarthritis at this point but we’re hoping that eventually we’ll be able to expand that to other joints as well. A lot of insurances don’t cover it though because it’s still considered to be an investigational use. And so until we get consistent data and that involves everybody actually collecting the data until we get that insurance companies are really hesitant to cover for it. With us having the FDA registry, we’re not here to make a profit. We can’t make a profit if we have an FDA registry. But, it does cost money to do these. And so for all of the, the orthobiologics procedures, we do what we call cost recovery, which is basically that we have the patient pay for it, but it is basically covering the cost of the procedure and the injection. And so it’s not it’s not anything that is necessarily for profit for Sanford. We’re just trying to cover the cost. If you’re doing it into a joint, oftentimes it requires more than one injection. So we’re doing usually two, sometimes three injections into the joint. So that can add up. For the tendons with the platelet rich plasma, we can generally get by with just doing one. It has a little more restriction afterwards. You know, if we inject into a joint, people usually get back to the regular stuff pretty quickly. With the tendons, we have some restrictions afterwards, but we can generally do that as a one-time injection for the bone marrow aspirate and the, the fat derived cells.

Dr. Joseph Segeleon: Okay. Thank you. I do want to go back a little bit to the physiology and the science of this, if you will. I understand that cartilage – because it has very little blood supply – does not really heal very well. And that’s one of the attractive features of stem cells. Is that correct?

Dr. Donella Herman: That’s one of the attractive selling points for stem cells. I’ll say, I know that there’s been some studies in the past that have shown that there have been cartilage defects that have had improvement after, after stem cells. I don’t think it’s necessarily the same kind of cartilage. You know, we have this, this really robust cartilage at the end of the bones on those weight-bearing bones. We certainly don’t make promises that we’re going to rebuild cartilage because we just don’t have evidence that that’s what it’s doing. For me, I prefer to think of it as we’re just creating this environment where we have these signaling. And, you know, for me to say, if I put a stem cell into your knee is going to regrow cartilage. Well, if I say it can do that, I don’t necessarily think I can say that it won’t turn into an ear. You know, I mean, we have the, if we think that the stem cells can just figure it out that quickly, for me, it’s more that we’re putting the stem cells in there, it’s in this environment and it’s creating a better environment where the body can come in and kind of heal the area. And it’s probably not going to put down this big, robust cartilage, but it may create an environment where there is some protection for where the cartilage has worn through.

Dr. Joseph Segeleon: Okay. Thank you. That’s very helpful. Let’s talk a little bit about what we’re doing here at Sanford. Why don’t we well, let’s just talk about what, what in your practice, what is, what’s your typical day, or how are you applying his orthobiologics to your practice?

Dr. Donella Herman: I love my practice because I don’t have a typical day. But you know, I, I I’ll see a wide variety of you know, young people to, you know, 6, 7, 8 year-olds to 96 year-olds. But when it comes to the orthobiologics a lot of the times the people I’m seeing are people who it’s either a, an athlete who has had an acute injury, and we’re trying to get in there and promote maximum healing quickly, or it is somebody who has had a chronic condition. Who’s looking for a non-surgical option. Generally, what we do, we have them come in. If we need to get some imaging, we do a lot of times they have some imaging. But we kind of look at their underlying issue and talk about all the things that they’ve tried and then kind of talk about the differences in orthobiologics and based on our kind of conversations and their goals and expectations, we decide what the next best step for them is going to be. And whether that’s a regenerative cell or if it’s more of the platelets, we can kind of determine based on, you know, cost. Is that going to be prohibitive? Or is it going to be difficult for you to be laid up for a few weeks if we inject a tendon? Things of that nature. It’s really an individualized conversation with each patient about what their overall goals are expectations and how orthobiologics can assist them in the most meaningful way.

Dr. Joseph Segeleon: I think I heard you say that there were five joints, is that correct? And what are those?

Dr. Donella Herman: Yes. We have five joints that we can utilize. We have the wrist joint, the shoulder, the hip, the knee, and the ankle. When we do the bone marrow derived stem cells. If you have let’s say you have some arthritis in your hand or, or in your midfoot we can utilize those for, for other joints as well. So there’s a little bit broader use for the bone marrow derived cells. We can also use those cells and things like rotator, cuff tears and tendon injuries.

Dr. Joseph Segeleon: Okay. And are these procedures typically same-day procedures?

Dr. Donella Herman: I usually tell people if we’re going to do the procedures for the regenerative cells, either the bone marrow or the fat that you should plan on giving me half of your day. And so we have you come in either early in the morning and we get you out by lunch, or we have you come around lunchtime and we have you out by five. Like I said, we want that kind of short processing window. We don’t want too much time to go by. And so it’s usually kind of an in and out procedure for them.

Dr. Joseph Segeleon: Okay. And what about recovery or the tendon injuries?

Dr. Donella Herman: That’s a little bit longer. We do, we do a little bit more to protect tendons then after the injection, because we create this inflammatory response and we don’t want to start pulling around on that tendon. So for that, I tell people, you know, at six weeks after that injection, we’re hoping to get you back into those higher level activities that you enjoy, or sports specific activities for an athlete. For joints, we tell people, we kind of just, it’s kind of common sense for the first couple of weeks afterwards, just don’t overdo it kind of reduce your impact activities. Or if it’s a shoulder, don’t do a lot of overhead stuff, but if we’re going into a joint, it’s kind of two weeks of, let’s take it easy and not overdo it, and then gradually try to increase your activity after that.

Dr. Joseph Segeleon: Okay. Well, it seems like this field of orthobiologics… I’ve heard so much about it, particularly in the last five years or so. So I’m going to have you do some predictions here. What does the future hold for this field?

Dr. Donella Herman: I’m hopeful that in five years, we’ll be able to say we have other options for people who are either not surgical candidates, cause there’s people with co-morbidities that that just don’t have good surgical options. But that we also, in five years maybe have a better understanding that we’re standing to glean more of that information of: you have this kind of a problem you’re in this age group you’ve, you’ve tried A, B or C … can we start what what’s going to be the best option for you and where you’re at and your life with this condition, I’m hoping in 10 years, we’ll be able to say, you know what, maybe we should be doing this earlier. Maybe we shouldn’t be doing as many steroid injections. Right now, people are getting in as they run out of options. Maybe in 10 years, we’ll realize that maybe this is an earlier option that will kind of give us additional options moving forward. So, that’s what I’m hopeful for is that in five years, we’ll have a better idea of which patients fit where, and in 10 years we’ll be able to say, maybe we need to start sooner.

Dr. Joseph Segeleon: Okay. All right. And finally can anybody refer patients to you and can patients self-refer to you?

Dr. Donella Herman: Absolutely. So if patients have interest in orthobiologics, they can certainly make an appointment. With our clinic, they generally try to funnel them to me so we can, we can have that individualized conversation, but sometimes they come from other people within our clinic, if they have interest in and mention it to another provider, if you’re a provider outside of our clinic, we actually have an orthobiologics referral within the epic system. So if you just type in orthobiologics that referral will pop up, you, you associate the diagnosis and it will get them directly to my clinic for the conversation.

Dr. Joseph Segeleon: Okay. Well, great. Well, I know the time seemed to go quickly. This seems like a topic that we could wait into for hours, but I hope this was a good overview. Is there anything that I left out that you’d like to comment upon?

Dr. Donella Herman: You know, it’s an exciting time for orthobiologics. I’m really proud to be a part of it at Sanford because I do feel like we’re doing it right. And that’s kind of always been our, our mantra within the orthobiologics group is that if we’re going to do this, let’s make sure we’re doing it right. And I think that we have a really unique opportunity to not only provide the best care for our patient population, but also to develop information that can be used across the United States and the world in terms of how orthobiologics could be used and should be used moving forward.

Dr. Joseph Segeleon: Well, I appreciate your scientific integrity and I certainly appreciate all that you do clinically. I really appreciate educating Courtney and I on this topic because I learned a lot. So I’ll turn it back to Courtney.

Host: I learned a lot too, Dr. Segeleon. Thank you as always for being here, again, to help guide the conversation as we speak to our clinician experts in this space. Dr. Herman, wonderful to meet you and learn more about your practice and the healing that you provide for patients with pain. Thank you again for being here.

Dr. Donella Herman: Absolutely. It was my pleasure.

Host: Our Called to Care podcast series by providers for providers continues right here with our Sanford Health experts. I’m Courtney Collen. Thank you so much for being here. We’ll see you soon.

Learn more

• Sanford Health pioneers use of body’s own stem cells
• PRP injection helps patient with chronic ankle injury
• What is regenerative medicine?

New treatment options for orthopedic pain

New treatment options for orthopedic pain

Alan Helgeson (Host): Hello and welcome. You’re listening to the Health and Wellness podcast brought to you by Sanford Health. I’m your host, Alan Helgeson with Sanford Health News. This series begins new conversations and continues the important ones, all designed to keep you well, physically and mentally. Today we’re talking about Dr. Donella Herman, an orthopedic physician with Sanford Orthopedics & Sports Medicine in Sioux falls.

Dr. Donella Herman: Thanks for having me. I really appreciate it.

Host: Well, we’re going to talk about something today we hear a lot about these days and we know we’re all more active than we’ve ever been before and not just young people, but old people and everybody in the middle. What we’re hearing a lot about is regenerative medicine and orthobiologics. Hopefully you can describe what they are and why they should mean something to us.

Dr. Donella Herman: Absolutely. It’s an exciting field that Sanford is approaching right now, where we’re looking at how we can use resources within our own body to promote healing and promote a good environment where we’ve had an injury.

Host: When we’re talking about regenerative medicine and orthobiologics, are they the same thing when we hear those terms or do they mean different things?

Dr. Donella Herman: Regenerative medicine is kind of the larger umbrella. There are a lot of things that fall under regenerative medicine, including things in cardiology and oncology and ortho biologics. So orthobiologics is kind of the orthopedic side of regenerative medicine.

Host: Is this something that’s fairly new in the science that we were hearing so much about it these days, Dr. Herman?

Dr. Donella Herman: You know, it’s something that’s been in the works for a long time. There’ve been some studies in Europe. It’s something in the U.S. that people have been dabbling in. I think that if you go to the coasts, you can find kind of pop-up shops where people have been doing this for awhile. At Sanford, we’ve been doing platelet-rich plasma, which falls under this umbrella. We’ve been doing that for some time, but it’s something that it’s pretty widely found, but not widely studied. And so that’s where we kind of get into trouble is that people are using it, but we don’t really know what it does or if it works. And so it kind of, it can have some negative connotations to it, but at Sanford, we’re trying to kind of change that conversation. We’re hoping to kind of study what we’re doing and, and gather information. So we know what people are getting injected with, and really what the outcomes are in the end.

Host: As an orthopedic physician and working in the clinic and seeing patients every day, how does orthobiologics then compliment what you’ve done or what you’ve seen or traditionally done in an orthopedic clinic?

Dr. Donella Herman: Yeah, great question. In orthopedics, we have kind of some limitations in what we do in that there’s people usually think there’s non-surgical things and surgical things and the non-surgical things, things like physical therapy, therapeutic exercise, corticosteroid injections, something we call Viscosupplementation for joints, these are things that we use quite a bit, but we kind of have a, we have a couple of options and then the next option is surgery. And so orthobiologics we’re hoping is going to compliment that and that it’s going to give us some additional non-surgical options moving forward. Obviously there’s some things that, that have to be surgically intervened on but for, for the person who’s just trying to stay active and maybe isn’t quite ready for the surgery and we can provide them some relief with other options, we’re hoping this will help fill in the gaps.

Host: Right now as the current state is, you may have a menu with several items on it, but with this, this is a much bigger menu of things that you can use depending on whatever the injury is or what your recommendation is and all the things that go into how to decide to use it right?

Dr. Donella Herman: Absolutely.

Host: Let’s talk a little bit about Sanford Health and the role in orthobiologics.

Dr. Donella Herman: Yeah. We really have dedicated ourselves to making sure that if we’re doing it, we’re doing it right. One of the things that we know is that you can go to a lot of different places and get a lot of different promises. You know, we make sure that people know what our expectations are and try to have realistic expectations of what, what the orthobiologics products can do. But we’re also making sure that we’re following patients and we’re learning about if you have one, one kind of injection, like a regenerative cell versus a PRP, like when is that going to be more appropriate? Because that’s what we really don’t know and that’s one of the reasons insurance companies don’t like to cover these is because we don’t have that information about which one really is better than the other. And so at Sanford Health, we’re really dedicated to that. To making sure that we’re looking and following and seeing what, what patterns we can find so, you know, in, in a few years, we’ll be able to say, you know, this is what your knee looks like, or your hamstring looks like, or your Achilles looks like, and this is going to be the best product for you because we’ve looked at it, we’ve studied it and we’ve seen results and this is going to be the best option for you moving forward.

Host: Is it safe to say that really looking at, I don’t know if this is even a term, I’m making this up, but like a conservative pioneering in, in doing it the right way through research combined with the treatment options?

Dr. Donella Herman: Yeah, absolutely. We’ve got a very unique opportunity. The FDA has approved us for a clinical registry and we’re the only clinical registry in the nation and we were using that to study what we call stromal vascular or fat cells and stem cells that we can get from fat or regenerative cells from fat and what we’re doing is we’re, we’re, we have this registry and we’re the only one in the nation that has permission to do this and so we follow very strict guidelines in terms of who can, and can’t get the product, what the product has to look like. We have a lot of safety measures in place and so we make sure that we know how many cells that we’re injecting. We know how many of those cells are alive when we inject. We need to make sure that there aren’t any toxins involved and that there’s no infections involved and so we have that for the registry, but we’re treating all of our products that way, whether it be bone marrow aspirate, or PRP, we’re testing all of our products to make sure that that safety is in place and you’re getting what we say you’re getting. I think that that’s one of the shortfalls of a lot of places is that you can go in and get the injection, but they’re not taking those extra measures to ensure safety and also to make sure that you’re getting what we say, you’re getting.

Host: This is so much good stuff. Dr. Herman., let’s get into now, someone listening to this program and they have joint pain or an issue, who is a candidate for this?

Dr. Donella Herman: It’s kind of a complicated algorithm and honestly, it’s a very individualized conversation. If you have pain, whether it be a chronic tendon pain or an acute muscle injury, or if you have chronic joint pain, those are kind of all areas that, that we’re looking into and we basically have people just come in to talk about their pain and talk about how it’s limiting them and through that conversation, we discuss, you know, what expectations they have, what their overall goals are. And then we think of, okay, what options do we have that are going to be able to allow you to meet your goals, but also be either cost effective, or if you have kind of a manual job, we take that into account. We don’t want lay you up too much from your job or limit how much you can do at work. So it’s kind of a, it’s a very much individualized conversation we have with people in terms of, okay, what are you a candidate for? What would be the most promising thing for you? And I, I often tell patients, you know, ask me in five years exactly what that best product is because in five years, I’ll probably know, but right now we’re just, we’re, we’re studying it and we’re gathering more information. And so we base it on a lot of individualized kind of characteristics of, of not only what your pain is, how long you’ve had it, but where your overall goals are.

Host: Next question, Dr. Herman. What areas of the body can you use the orthobiologics in? Is it just knees, hips? What parts?

Dr. Donella Herman: So for the, for the registry, for our fat derived cells, we have five joints that we’re allowed to use that in and so that is the shoulder, the wrist, the hip, the knee, and the ankle. We can use the bone marrow and those joints as well, but we can also expand the bone marrow option to other joints. So, you know, the CMC joint or the joint of the base of the thumb, toe joints we can use it for, for things like that. The other options we have are also for muscle and tendon injuries. So if somebody has an Achilles injury and, and it’s something that we’re going to try to treat without surgery, we can use the bone marrow cells or rotator cuff tears even have responded nicely to bone marrow cells in the past. For the PRP, it’s kind of the same thing. We can either do joints or we can do tendons. We treat some hamstring injuries, Achilles injuries, things like that.

Host: What sort of time is needed? I know that you’re talking about different treatment options, but in general, are there some times to consider for recovery and healing?

Dr. Donella Herman: Usually when we inject into a joint, regardless of the product, we usually tell people, it, it takes a couple of weeks. We don’t want you to be too active for a couple of weeks. You can still do your activities of daily living. We don’t anticipate that you’re going to need crutches or, or a sling or anything like that. When we get into the ligaments and the tendons, because we’re injecting into that area, we want to be able to rest it afterwards. And so when people have either a ligament or a tendon, we generally ask them that, you know, we’re going to have some limitations probably for the first six weeks. If you’re a higher level athlete, it may, it may take you 10 weeks to get back to that higher level activity. But if you’re, if you’re somebody who has repetitive work at your job, it’s usually about six to eight weeks to return.

Host: Are there some risks or side effects to consider as part of orthobiologics?

Dr. Donella Herman: Absolutely and, and that’s something we also want to be forward about is that one of the risks is that this may not give you complete relief of symptoms. And so that’s a big expectation conversation that we have. But anytime we do an injection, risks of bleeding and infection are kind of the biggest ones. We make sure that we take all the safety precautions. We need to ensure that, that we don’t don’t have any of those injuries. You know, we do a lot of our injections under ultrasound guidance so we make sure that we’re going exactly where we need to go. We can see the injured area and we can ensure that you’re getting the product in the location it needs to be.

Host: Next question, Dr. Herman.  I know that Sanford is a very sprawling health organization with lots of different places to come into. Do I have to be a current Sanford patient to see somebody about this?

Dr. Donella Herman: You know, you can do a self-referral if your insurance allows for it, otherwise you can get a referral from your primary care provider. We’ve been trying to talk to the, the providers in the region and kind of let them know how to get people filtered into the appropriate place. A lot of times, if, if you see another provider and they feel it’s, it’s an appropriate option for you, they’ll, they’ll kind of push you in that direction or lead you to my clinic. But otherwise, if you have questions or concerns, you can just make an appointment in my clinic and we can kind of talk about what your options may or may not be

Host: Dr. Herman. I know that people with joint pain or joint issues, like everybody, and, and I’m sure you see them on a daily basis, people that are already sort of educated, I’m using the air quotes, by going to Google and searching. So people are searching this stuff and they see pop-up ads about these other places doing types of things, what should they be wary of when they see these things and why should they choose Sanford Health?

Dr. Donella Herman: That’s a great question and I always-people get nervous when, when they say, oh, they they’ve researched this on Google. I love it when my patients tell me that. I do. I know that means that they are, they’re truly interested in improving their own health, they’ve taken the time to do research. So for me, that’s a really positive thing when they’ve kind of looked into things. I think if you’re looking and, and they’re making promises that they can build new cartilage, that you’ll have a brand new joint or a brand new tendon when they’re done that, they’re going to get rid of a hundred percent of your pain, that you’re going to be able to climb Mount Everest. You know, I think, I think being aware that, you know, we don’t have all the information of what we’re doing. We’re generally just trying to provide a better environment for healing with these products. And if that means our body can somehow make some cartilage and put it in an empty spot in your knee then great but we don’t know that that’s actually happening. What we know is happening is that we’re creating a better environment within the knee so we have less pain and improved function. So if people were making you promises that if you get this, you’ll never need a knee replacement, or you’re going to feel a hundred percent better, I would be a little leery of that. And the other thing is the cost. You know, we really, we really shouldn’t be making a lot of money on these. So if they’re promising you, the world, and all you have to do is spend $10,000, okay, there, they may be looking to make a profit more than anything. The third thing is, is, is are they looking to see what they’re injecting? You know, are they able to tell you we are injecting live cells? Can they tell you how many? Can they tell you are these a safe product? Are we sure that there’s nothing infectious involved? Those are the, those are other questions that I think are important to ask because those safety concerns are, are the ones that really put people at risk if people are, if other entities aren’t taking those additional safety measures.

Host: Dr. Herman, I’m listening to this program, and I’m really excited about this and I think this might be just what I need, but I live in a community not near a Sioux falls. What are some of those questions they might want to ask my primary care provider about this If I bring this up through a regular clinic visit?

Dr. Donella Herman: I think just asking them questions about all the conservative measures that they’ve tried, and then obviously asking your primary care physician, you know, what they know about orthobiologics. We’re, we’re really making an effort to try to educate primary care physicians within our group because, because we know that they’re the frontline, we know they’re kind of the boots on the ground treating these early. And so I, if it, hopefully we’ve gotten to your primary care physician by the time you have these questions, but if you ask your primary care physician and they don’t have the answers, you know, we have a team within orthobiologics that is available. So, so you can either contact our clinic or ask your primary care physician too, to see if you may be a candidate.

Host: Dr. Herman, last question I wanted to ask you. Let’s say you’re riding an elevator and you’ve got 30 seconds to tell somebody why orthobiologics is important to somebody with joint pain. What would you say to them?

Dr. Donella Herman: I think it’s important because it’s a new option and it’s a, it’s an option that can either delay surgery or give people opportunity for, for healing and better function when maybe surgery isn’t an option for them.

Host: Dr. Herman, it was a pleasure talking to you today. We thank you so much for all of your information and insight into this topic of regenerative medicine and orthobiologics. For Sanford Health News, I’m Alan Helgeson.

Learn more about this topic

• Podcast: Regenerative medicine options for orthopedic pain
• How to find relief for chronic pain of all kinds
• Podcast: What is joint pain and what can you do about it?

Get more episodes in this series

Sanford Health’s commitment to our veteran community

Shawn Neisteadt (Host): Hello and welcome. You’re listening to the Innovations podcast series brought to you by Sanford Health. I’m your host, Shawn Neisteadt with Sanford Health News. Our conversation today is with Captain Paul Weckman, head of military and veteran affairs. Captain Weckman, welcome — thank you for being with us here today.

Paul Weckman: Well, Shawn, thank you for the invite. I appreciate it. This is a great day today. The sun’s out and looking forward to sharing and talking with you about veteran and military programs.

Host: And when we call you Captain Weckman, that’s just not a cute name we’ve come up with around the office for you. You’ve earned that name. Let’s talk about your background before you come here to Sanford Health.

Paul Weckman: I served honorably for 26 years on active duty in the Navy. And so the ranks of the Navy is a little different than they are in the army Marines and Air Force. So a captain in the Navy is equivalent to a full colonel in the other service.

Host: Well thank you for your service. That had to be a big transition coming out of that in, into what we would call civilian life. But you’re in kind of a familiar area here at Sanford.

Paul Weckman: Yes. Transition is, is one of the, probably most difficult things for a lot of military folks. And that was one things that this job was not only a challenging career, but I’m answering a calling too because a lot of veterans do struggle in trying to get back and transition into not only the civilian world, into the workforce, because completely different cultures, different mindset. That was one of the challenges. But again, to me, it’s almost self-healing to have that ability to kind of speak bilingual as well, and to be able to translate for those veterans transitioning and because I’ve been there and done it.

Host: And that’s one of the areas that your department works in right now is becoming an employer of choice as we call it around here. Kind of tell us what that’s all about.

Paul Weckman: Yeah. Well, when I first took this position, we created it and that was one of the things as military people always ask us is, OK, what’s your desired end state? Or what do you want me to accomplish here? We agreed upon three buckets that I have to fill. And the first one would be being an employer of choice. And with that is how we have veterans, military, guard, reserve members — if they have a choice to work in the civilian workforce, you know, a choice in that, why not make the choice of coming to Sanford health. And at the same time, they feel that they’re either appreciated or recognized for their service in their skill sets. Because a lot of the skill sets they acquire in the military are not even close to being the same as civilian workforce. You know, a tank driver, we don’t have those. I was a ship driver and I’m not driving any ships at Sanford right now. But we have other acquired skill sets that we do want to recognize more leadership skills, and then the ability to be able to do multiple tasking and then just a lot of those different attributes and skill sets that hopefully we can understand, recognize and utilize those working here at Sanford Health.

Host: And there are benefits for those who are veterans or still active with their military careers should they choose to work at Sanford Health or at the Good Samaritan Society.

Paul Weckman: Absolutely. I’m so proud of our leadership. They agreed and understand how important it is, especially for guard and reserve members that are citizen soldiers, as they say, they work here full-time. And then part-time, well either one weekend a month, two weeks out of the year or when they’re mobilized, they’re gone. And so how do we ensure that they have that same type of a lifestyle because unfortunately they, they may be deployed and then their paycheck is lowered. So what we have is what they call differential pay. We make up the difference. And I’m proud to say that we are one of the best or the best throughout the entire United States for having such an aggressive differential pay program that basically covers up to a whole entire year. And there’s not many organizations that do that. And I think that’s one of the reasons, too, that we were recognized recently with the Department of Defense Freedom Award. And that’s one of the things that they weigh heavily on is how well we take care of guard, reserve members.

Host: So speaking of employer of choice, let’s say a veteran is listening out there right now. How should they go about applying for a job here at Sanford Health or at the Good Samaritan Society?

Paul Weckman: Great question. One the things that we have created just recently is it’s a career site — sanfordcareers.com is where they would go once they get to that landing zone, there’ll be a dropdown menu where it’s the, the about tab. And in there we’ll have veterans and you click on that, that tab of veterans and then immediately it will take you to a site where it’s totally designed for veterans. They understand it. For example, if they, we call it a MOS, which is like a military operate, you know, occupational standards code, they can type in that three or four digit code. And within the nanosecond transmit it, interpret it into a civilian skill set that Sanford Health has. If you were a truck driver in the Army, you probably will find a job opening to drive trucks or vehicles for one of our programs. If you’re interested in doing that — if you’re a medic and you type that in, you’re going to be either a certified registered nurse or a certified nurse assistant, or, you know, a BSN nurse.

Host: You often talk about some educational opportunities. I know you and I have talked in the past about scholarships and how we recognize veterans across Sanford Health. Tell us about that.

Paul Weckman: Absolutely matter of fact, this last week, that’s where I was on the road giving out $5,000 scholarships to the individuals that are veterans all over our footprint. You know, I’ve been in South Dakota, North Dakota and Minnesota this last week, and to see the smiles on these veterans — I always do it in front of their peers in the classroom They not only have served, but they have great community service and volunteerism that they really maybe demonstrated leadership skills, but they’re just all around great veterans and also students academically, and they’ve been doing real well.

And so this last week, that was one of the best parts of my job is to be able to surprise them and award them with a $5,000 scholarship. So that, that, that’s one of the programs that we do. And it’s just a great program that we have. Another one is for those employees at Sanford health, we do have what they call a veteran of the year award. And we also have a veteran advocate of the year award. So for those who aren’t even a veteran, it’s what they do to help support veterans can get recognized as well.

Host:  Those are some of the big things, but there’s also little things I notice in the hallways at Sanford Health. And that is if you just pass somebody in a hallway and you look at their badge and they’re a veteran, it says so.

Paul Weckman: That’s one of the cool things that a lot of people don’t understand the importance of being recognized as a veteran, not only as an employee, but my second bucket is we want to be a provider of choice for veterans. So we have found when a veteran comes in to seek medical care and the first person they is the nurse who is screening them, and there’s a veteran across that ID badge right away, that will instantly lower their anxiety level. They can just instantly start relating that, OK, here’s a fellow veteran, here’s our fellow brother or sister that I’ve worked with in serving in arms, and then just, they relax. They open up and they feel more comfortable of being there as a patient. And that’s probably one of the coolest things that I see in comments. I hear of about how we’re not only veteran friendly is as an employer, but then also as a provider.

Host: As a provider, there’s also the veteran ambassador program — which is kind of similar to what you’re talking about. They’re veterans reaching out to veterans.

Paul Weckman: What we do is in the morning when they come in, they can pull the list of veterans because we do track the veterans. We ask them if they are a veteran patient and we have it in our electronic medical record. And there we can track when we know who our veterans are, if they self-identify. So we go visit them in the hospital. A lot of these maybe not have a loved one that can come visit them. If they’re there for a period of say, maybe five days, maybe they had a hip replacement or heart surgery or whatever the case may be is. And then we come in and we visit with them. Along with that, we recognize their services. We provide them a little small token, and it’s a veteran pin. The stories, unfortunately a Vietnam veteran commented when we provided them this pin and pinned him with it, he says, this is the most recognition I’ve ever had since my Vietnam days. And again, that generation had a pretty tough reception coming back home. And to see that is showing that we really are making a difference and recognize these veterans across the board.

Host: Moments like that. How important are those to you?

Paul Weckman: Well, it can be pretty emotional. Tears sometimes do come. The veterans program, like I said, we did a great Sanford Health News story on it. You can always go online and, and, you know, screen for it and look at it, but it’s called the ambassador program, but you will see in every one of those veterans’ eyes, the emotions, the appreciation for just being recognized and just someone even stopping by for a few minutes in. And the other part of it is our volunteers. When they get done at the end of the day, they are so self gratified and humbled to be in this program. And really to them, it’s a healing process, maybe for them as well, definitely a gratifying process where they really feel good about themselves, that they helped a fellow veteran in time of need.

Host: Sanford Health has a veteran information hotline, kind of a one-stop shop for veterans out there, kind of their single point of contact. If they have questions, I’ve got the number in front of me, it’s (800) 949-1848. For any veterans out there who may have questions they can just call in right there. And again, they’re going to be talking to someone who’s going to speak their language.

Paul Weckman: Correct. And it’s one of those things now that we’ve had this up and running for a few years, that it’s great that they can talk to someone. And then they will say, if it’s an employee question, they will go right to that department. Or if it’s a billing issue, we’ll go to, you know, it would go to that department. So it’s pretty seamless operation. And as far as the number of calls, it’s great now that there is one source, you know, for that.

Host: The program and veterans clubs across some of the major medical centers at Sanford Health, kind of tell us about those as well.

Paul Weckman: We decided on this a few years ago, there’s nowhere in the nation that has, but in the military, we call them USO clubs. It’s just a way to get away from everything. And some people say maybe to chill out or just to relax and just do nothing, but it’s exactly what I just said. And so the concept we figured, well, why can’t we do this in the hospital? Veterans are there. And sometimes could be there all day. If they’re doing lab work or they’re waiting for results or waiting for their next appointment. And we live in a rural area. And so in North and South Dakota are both designated rural areas. States people could be driving for hours and for, to get here, why not find a place for them just to hang out? And in addition to not only the veteran, we could also have it for their family members or their healthcare provider.

Basically anybody there that might be a provider or help them get around. And it’s really cool. Even our veterans service county officers, there may be shuttling them. There is a caretaker. They too could stop and use the same facility. So we’re seeing that there is great use out of it. And then it was kind of really cool is when they’re in there and then two families are in there and us, military families, all of a sudden the next thing there, they’re sitting next to each other, maybe share names and you know, they’d always know someone else or this or that, and then their help. And again, we see the anxiety levels come way down because they’re visiting with each other. And we always are there to kind of have each other’s back, always be there to take care of them. And we were always great and resources and try to help them: Hey, do you hear about this or this or that or that?

And so that’s what we’re seeing. If you were to go into the veterans club and I challenge people, if you are a veteran and you go into the club, just read the comments that are in the guest book. That’s the part I can go in there any day. If I just want to get cheered up, I just read the comments because they are so gratifying to see and appreciative of how they have a place. If they just want to hang out, they want to, we have computers in there. If they want to get on the internet, if they want to play board games, we have board games that they want to watch TV. They have TVs, or if they just want to relax, shut their eyes and relax in one of the La-Z-Boy chairs there, that’s great there. And we always have coffee that is always on. And if they want to have a cup of coffee, sometimes we might even have a pastry or something there, but it’s just a great place to go and just forget about most things and just relax.

Host: One thing I want to talk about before we talk about community outreach as well, and this kind of gets into that is the Sanford Chip for veterans that was unveiled here a couple of years ago. Update us on that program, where it is and what that means.

Paul Weckman: Sure. So nationally, we do have a mutual agreement with the VA out of Washington, D.C. When we announced this back a few years ago, in 2019, with generous gifts from Denny Sanford and Sanford, the foundation all came together, came up with a $50 million contribution. It is called the PHASER program — is what the VA has identified is there’s approximately 170 or so veterans hospitals out there. So across the United States, if a VA would get enrolled in this program at no cost to the veteran, they would be able to get a simple blood test. A physician now can prescribe the medication that genetically speaking when metabolized in their body and be effective versus in the past, maybe a physician or someone that was administering medications would just trial by error here, give this a try.

If it works fine, if not come back and maybe we’ll up the dosage or maybe on something else, but this kind of eliminates the dosage and eliminates the trial by error and guessing game. I call it medicine that designed for your body, not mind when it comes to what your body’s metabolizing better. And we’re finding out that it’s saving lives. I mean, you think about, from blood thinning after surgery to prevent blood clotting, after a major heart surgery, we’re finding out that some were not prescribed, they were prescribed maybe a blood thinner, but not the right blood thinner. And so we’re seeing that from the results in the last couple years of that, we’re also seeing, for example, someone that might be on an antidepressant, some of them have post-traumatic stress. Why not get them on the right one the first time? It could save lives.

The suicide rate in veterans is way higher than it should be. And it’s way above the civilian side of things. And so that’s one way that we can help reduce that as well as by getting them on the right dosage in the right meds. Sanford has the same opportunity, no cost for veterans. So if you were a Sanford patient too, you could go in as a veteran and request it and right, it’d still be no cost and you could get those results within a few weeks, and that will go through your primary care. So we’re kind of running two programs, the same thing in parallel, but for those that are not visiting or have in Sanford is our primary care. They’re just going to have to be a little bit more patient, wait for the VA to get us up and running. And like I said, I anticipate it within the next month or so we should be both programs up and running.

Host: Pretty amazing time in history that a little blood test can tell you exactly what you need to take and when and how much. I want to also talk to you about some the community support that is offered from Sanford Health out there for veterans and active military.

Paul Weckman: And that would be my third and last bucket. It would be that community outreach and us being the partner of choice. So we got to take a look at it is what do we have in locally within our footprint as well? The South Dakota Military Heritage Alliance. And it’s the first in the nation to give that I’m aware of where you have a collaboration of like the VFW, the American Legion, all these other organizations under one roof.

And that is one of the things that I was just at down there just a few minutes before here, and to give tours to some people that just first word out of their mouth is wow. We have meeting rooms out there. So we have meetings going on all the time with these veteran organizations that can come out there and gather in place. So it’s kind of like one stop shop and everybody can come there.

We have a lot of veteran owned businesses that rent out, lease spaces there.

Host: It’s not just you tooting your horn and talking about all the great things going on here at Sanford Health and the Good Samaritan Society. There’s been quite a bit of recognition for the work in that space as well.

Paul Weckman: We have now the first in the nation that I’m aware of just south of Sioux Falls in Parker, South Dakota, it’s called Wings of Valor Lodge. And again, I’m very proud to be an employee of Sanford because they came to us first because the community gets it. They understand how we feel about taking care of our veterans because it’s just the right thing to do. And they approached us and they had a concept, an idea about having the first, ever in the nation, again, an idea of having a hunting lodge just for veterans. And, not only is there hunting, but there’s a lot of other things that are going on out there. And it’s usually a three or four day event out there. And I am happy to say that they’re going to celebrate their one year anniversary here coming up next week.

But the outreach we’re having people coming from all over the United States flying in and about every two weeks, there’s another group. It’s fully ADA compliant and also wheelchair accessible. It’s like I said, the first in the nation that I’ve seen where they feel so comfortable being out there because we can accommodate all those. We have wheelchairs with tracks on it, all the rooms have been designed by a 27-year-old Marine that has no legs that, that he stepped on IED in Afghanistan. He designed these rooms while he was in his wheelchair. So he gets it and he designed it that way. And that’s how we built it. And so they’re comfortable. They’re independent out there. They don’t need help. And that’s what they enjoy being out there.

Host: That’s perfect. Captain Weckman, I want to thank you for your time today, and also more importantly, thank you for your service.

Paul Weckman: Well, you’re welcome. And I appreciate that. Thank you, Shawn.

Host: To learn more about how Sanford Health supports veterans visit sanfordhealth.org and search veterans. This was another episode of the Innovations podcast series by Sanford Health. For Sanford Health News, I’m Shawn Neisteadt. Thanks for listening.

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Preparing for your first mammogram

Courtney Collen (Host): Hi, welcome to the “Health and Wellness” podcast by Sanford Health. I’m your host Courtney Collen with Sanford Health News. We are continuing an important conversation all about breast cancer as 1 in 8 women will be diagnosed with breast cancer in her lifetime.

I’m so happy to have Dr. Christina Tello-Skjerseth who is a radiologist at Sanford Health in Bismarck, North Dakota. And we are talking all about that breast cancer screening, the mammogram Dr. Tello-Skjerseth, thanks so much for being here.

Dr. Christina Tello-Skjerseth: Thank you for having me. I’m happy to be here.

Courtney Collen (Host): So let’s start with the most basic. What is a mammogram?

Dr. Christina Tello-Skjerseth: That’s a great question. So a mammogram is a special X-ray of your breast and we do it bilaterally, which means both breasts. Every year, they get that special X-ray. There’s a special machine that takes the images. It’s not just your regular X-ray machine like when you get a chest X-ray. It’s a special unit that’s just for evaluating the breast tissue and taking breast images.

And there is a difference between a screening mammogram and a diagnostic mammogram. A screening mammogram: you come in with no symptoms, whatsoever. You’re not having any breast lumps or breast pain. You’re just there for your normal screening exam. A diagnostic mammogram, however, is different. You come in for that when you actually have a breast symptom. Now it does use the same machine to take the images, but the difference is for a screening mammogram, we’re just taking two images of each breast. For a diagnostic mammogram, you take images, you take usually three or more images of each breast and they’re shown directly to a radiologist and then they guide whether or not you need additional imaging with the mammogram or if you’re going to go on to ultrasound right away. Whereas a screening mammogram, essentially, you get those done, you leave and those images get put into a queue or, you know, essentially a pile of other mammograms and then we radiologists read those in packs.

Courtney Collen (Host): So how do we know when it’s time to come in for that very first mammogram?

Dr. Christina Tello-Skjerseth: Well, there are a lot of guidelines out there. The ones that we follow here at Sanford are the American College of Radiology, the Society for Breast Imaging, the American Congress of Obstetricians and Gynecologists, as well as the NCCN guidelines, which is the National Cancer Comprehensive Network. And they all recommend beginning annual screening mammograms at age 40. And the reason why we support those guidelines is because we have done the extensive research and reading into all of the different literature out there that’s been performed, all of the studies. And we know that when you start screening at age 40 and do it every year, that has the greatest mortality reduction. What that means is the risk of dying from cancer decreases significantly if you start at age 40 and do it every year. So those are our recommendations.

Courtney Collen (Host): OK. That’s great to know. And would there be any reason someone needs to go sooner than age 40?

Dr. Christina Tello-Skjerseth: Absolutely. That’s another great question. These recommendations are for women who have average risk of breast cancer. An average risk is 1 in 8 women in their lifetime essentially will get breast cancer. Now, if you’re at a higher risk, if you have significant family history, like a number of a female relatives or male relatives that have had breast cancer before, maybe specifically, your mother, your sister, close relatives, and even sometimes, you know, those in your extended family, that could possibly indicate that you’re high risk.

There’s also a number of gene mutations out there. Almost everyone has heard about BRCA one and BRCA two or BRCA gene mutations, but there’s about 30+ other gene mutations out there that can be associated with a higher risk of breast cancer, as well as other types of cancer. Another risk factor, if you have dense breasts, meaning that you have more of that glandular breast tissue that can increase your risk. If you’ve had a childhood cancer like lymphoma or Hodgkin’s lymphoma or leukemia, where you’ve had radiation to your chest for treatment, that can increase your risk.

So there are some very specific risk factors out there that insurance companies will follow and that the American Cancer Society and other organizations follow, as well. And if you have more than a 20% increased risk based on those risk factors, you fall into the high risk category and you should probably start screening earlier than 40.

Now, if you have one of those known gene mutations, we recommend you start getting annual screening MRI at age 25 and then you start your annual screening mammography at age 30. So it depends on a lot of different things. As a general rule, we usually say you should start screening 10 years before the youngest close relative of yours had breast cancer. So for example, if your mother had at age 40, you should start mammograms at age 30 and probably also start your annual screening MRI in conjunction with your mammogram.

Courtney Collen (Host): Let’s prepare for that first appointment. Tell us some do’s and don’ts to keep in mind.

Dr. Christina Tello-Skjerseth: Sure. You know, so again, I want to stress the fact that these are screening mammograms, not diagnostic mammograms. So a screening mammogram means you have no breast symptoms. So when you’re getting ready to schedule your mammogram, make sure that, you know, you’re feeling well, you don’t have any of those symptoms like a breast lump, nipple discharge, breast pain, things like that. If you do, then you want to make sure you see your doctor first and get scheduled for a diagnostic mammogram.

Sometimes, you know, based on your age, if you still have your menstrual cycle, there can be certain times of the month where your breasts might be a little more tender or even more glandular tissue so that can change what your breast looks like on the mammogram. Now, there isn’t a set guideline as to when you know you to get your mammogram during your menstrual cycle. It’s usually whenever you want. And then us radiologists, you know, know when you have it and know what to look for on the mammogram, but, you know, personally, if you’re feeling a little more tender or having pain, you might want to hold off until that goes away, based on your cycle.

Another thing to know is if you have had a recent immunization or a shot, like a flu vaccine or a COVID vaccine, that can cause a reaction in your lymph nodes or your glands up in your armpit area, which we call the axilla and we can see those lymph nodes on the mammogram, and they can be enlarged because your body’s reacting to the shot you got in your arm. So you might want to hold off just a little bit if you’ve had a recent shot.

The other thing is, you know, wearing deodorant, we can see the calcifications in the deodorant on the image. If you do wear deodorant the day of your mammogram, we’ll probably ask you to wipe it off with a wipe. So, other than those, you know, do’s, and don’ts as far as what to expect on your first mammogram. Here in Bismarck, our mammogram center is here in the hospital, we have other clinics in the area that also have mammography, but majority will be down here at the hospital.

Courtney Collen (Host): OK. So now it’s time for that first appointment. Walk us through the experience of that first mammogram and what that appointment looks like at Sanford Health.

Dr. Christina Tello-Skjerseth: So you’ll come in and go through your routine check-in procedure. Then you’ll change into a gown that opens in the front, and then you’ll wait in the waiting room. We’ll call you back. That is usually one of our radiology technologists who is specially trained in mammography. They will ask you some questions, you know, how you’re feeling that day, if you have any breast complaints, pain, discharge, lump, anything like that. They might ask you some of your risk factors, if any of your family history has changed recently, maybe a new member got diagnosed with breast cancer or a type of cancer. They’ll ask about how many kids you’ve had, how old you were when you first had your first child, cause all that can affect how much estrogen or hormones in your body and that can affect again, risks of breast cancer and how your tissue looks.

So you’ll be asked some questions as you walk back. Then we take you to our room that has that special mammogram camera to obtain the images. They’ll have you clean off your armpit area, usually, to get all that deodorant off.

And then we’ll take two pictures of each breast during the picture or the image acquiring process. There’s a paddle that comes down and compresses your breast tissue. Now, this is the part where some women will say really hurts and they hate having mammograms because of that pain. It’s very variable and subjective. You know, some people just say it’s a light pressure. Some people cry in pain, it’s very variable. So that’s something to expect.

And the reason why we compress the breast tissue is one, so we can spread all the tissue out as much as possible. So we can look for those tiny cancers if there are any hiding in the breast tissue. We also do that compression so that you don’t move because motion can blur what we’re seeing on the mammogram. And we want to be able to see everything so we can find those tiny early cancers if they’re there.

Now, there are two types of mammograms that are used in the U.S. One is called the 2D mammogram, which is probably what everyone has been used to. There’s also a 3D mammogram, which has been in the news, you know, for years. We call that tomosynthesis. What that means is, instead of just taking a flat 2D image of the breast, we’re taking multiple images of the breast at different angles. Then those images get stacked by the computer and they give us an image we can actually scroll through. So we’re looking at each millimeter of tissue, not just one flat image of the breast. So, that allows us to see through some of that dense tissue that could possibly have hidden the cancer.

So with 3D mammography, which we do a 100% of the time here at Sanford across the enterprise, when we do that, we find those early tiny, more advanced cancers because they don’t hide as much in that dense tissue. So most patients will be getting that 3D mammogram. Insurance does cover it. There are a few insurances that maybe don’t cover it. So if that’s the case, they’ll probably get that traditional 2D mammogram. Now you won’t know a difference between getting one or the other as far as how long you’re in compression or any other differences. Really, the camera does moves above your breast a little bit when you’re getting a 3D, but it doesn’t increase the amount of pain, or how long you’re in compression.

And then after that, we take you out of the machine, make sure you’re okay, and then you go on your way. If it’s a screening mammogram, those images get put into a pile with a bunch of other patients and then us radiologists will read them in packs during the day. And then you’ll get a message when the mammogram final report is ready for you.

Courtney Collen (Host): What are other common questions or things we should know as we prepare for that first appointment?

Dr. Christina Tello-Skjerseth: Yes. So I will tell you if you’re scheduled for your first mammogram and you’ve never had a mammogram before, what that means is we just have those first images. We have nothing to compare it to until you get your next mammogram. So when we don’t have any comparisons, what that means for us as radiologists is that we don’t know what your breast tissue normally looks like. So there is a higher rate of callback, meaning we’re going to, we’re going to find some things that may be abnormal. We don’t know. And that you’ll get called back to take additional images, which is the diagnostic mammogram, maybe even an ultrasound, maybe even a biopsy. So, a lot of people get concerned when they get called back, especially for their first mammogram. So our technologists tend to tell people now, “Hey, if this is your first mammogram, don’t get too excited if you do get called back for something, because we have no other priors.” You know, it was someone who is 65 and who’s been getting mammograms for, you know, 15, 20-some years, we have a lot of priors to go on. But someone who’s 40, we don’t have anything to go on. So there is a higher rate of call back.

The other thing I will tell women in general is, you know, that the recall rate or the callback rate nationwide is about 10%. So 1 in 10 women getting a screening mammogram will get called back for additional imaging, meaning that we’re seeing something that we’re not sure what it is. It could be a cancer. Mostly it’s usually gonna be something benign, but 10% will get called back for more images. And 10% of those that are called back will go for a biopsy. And about 20% of those patients will end up being cancer. So 80% of biopsies are normal. That does change a little bit based on your age. You know, if you’re between 40 and 50 or 50 and 60, et cetera, it does increase the older you get. But I always tell women, don’t get too excited if you get called back for something. Cause again, the chance of it being anything cancerous are pretty, pretty tiny.

Courtney Collen (Host): And finally remind us why it is so important to get this done.

Dr. Christina Tello-Skjerseth: Sure. So I’d like to stress the importance of annual screening mammograms beginning at age 40. So 1 in 8 women in their lifetime will get breast cancer. Now the average age or median age in the U.S. is age 63. However, we do see a lot of women in their 40s, even younger than 40 that do get breast cancer. And honestly the vast majority of them don’t have any high risk factors. So, while we know that the older you get, you know, the more likely you’re at risk of having breast cancer, what we’ve found through decades and decades of well-researched literature and studies is that the greatest mortality reduction for breast cancer occurs when you start screening at age 40 and do it every single year. And that mortality reduction means your chance of dying from breast cancer decreases significantly. That’s because we’re finding them earlier when they’re less aggressive and usually more treatable. So that is the goal of screening mammograms to save lives. We want to do it as soon as possible and as efficiently as possible. So, start at age 40 and do it every year.

Courtney Collen (Host): Wonderful information and a great way to wrap up. Dr. Tello-Skjerseth, thank you so much for this wonderful insight into the mammogram and reminding us when to start, why we’re doing it and we appreciate all that you do at Sanford Health up in Bismarck. Thanks, again.

Dr. Christina Tello-Skjerseth: Thanks so much. It’s my pleasure. Happy to be here.

Courtney Collen (Host): This was another episode of our podcast series One in Eight by Sanford Health. I’m Courtney Collen. Thanks for being here. Stay well.

Learn more about this topic

• Following doctor’s orders: My first mammogram at 40
• Podcast: Most-asked questions on screening mammogram
• Podcast: Mammogram callbacks: Should you be worried?

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