Breast Cancer Supplies

>> the changing concerns of women's health, next "on call with the prairie doc." >> good evening, and welcome to "on call with the prairie doc." most of the time, good medical advice is good for everyone. but, there are differences, important differences, when it comes to certain elements of men's health and women's health. so tonight we'll be looking at some of the science specific to women's health issues, including routine female screening, pap smears, pelvic exams, and mammograms. okay, this week's prairie doc quiz question is about mammograms. the u.s. preventive task force, an independent, volunteer panel of national experts in prevention and evidence-based medicine, recommends starting mammogram

screening at 50 years old and every other year thereafter until 75? true or false. call or email your answer. viewers who call in the correct answer will be entered into a drawing to win a signed copy of "a picture of health." this book was written by me with accompanying photographs by dr. judith peterson. we will announce the answer and the winner at the end of the show. we answer your questions as they are called in or sent to us via facebook or email. call in your questions at 1-888-376-6225. or send us an email. your questions matter to us, so let's hear some questions. in the yeager media center studio tonight i am joined by janell powell of the avera medical group internal

medicine women's and larissa bennis with avera medical group brookings. thank you, both, for joining us. janell, let's hear a little bit about yourself. you are in what field of medicine? >> i am in internal medicine, and i specialize in women's health. >> so, you and i are internallists together. >> we are. >> where did you train? >> i trained -- well, i did medical school at the university of north dakota, grand forks, and then i did my residency at the university of iowa, in iowa city. is there and then you came immediately to sioux falls? >> i started in north dakota. i started practicing in fargo, north dakota. and i was there for about 11 years. and then i was in detroit lakes, minnesota, still with the same health system, but i

just was at a different clinic. and then i've been in sioux falls now for almost seven years. >> and that's been -- you're just coming -- getting warmer as you go south. >> i am, yes. yeah. >> so, i mean, internal medicine and women's health, how different is that from just internal medicine like what i do? >> well, i just see women. so, when i started out, i was seeing men and women, and now since i've been in sioux falls, i've just focused on women. so i basically see 16, 17 years old and older for women. >> everything. >> for everything. primary care for women. >> and do you do a lot -- i mean, is half of it pure women's issues or -- and half of it's stuff that guys would have or is it all women's issues? >> oh, no. i mean, there are the women's issues, but then, i mean, again, with the primary care,

it's dealing with cholesterol, blood pressure, you know, heart issues, lung. >> all internal medicine? >> yes, all of internal issues. but then also, you know, we do take care of women with, you know, gynecologic issues, we do pap smears, we do the breast exams, we schedule for mammograms. you know, and we're really -- we really focus a lot on the preventative care, so, again, making sure they have their mammograms, continuing with their pap smears. mammograms. colonoscopies, bone densities, routine laboratory-type screening as well. >> anything in the hospital, mostly all outpatient? >> we're all outpatient. so if we have patients that we admit, they're admitted to the hospital service. so, we're strictly outpatient. >> but you started doing inpatient?

>> i did. i did inpatient for several years. parts of it, yeah, parts of it i did enjoy, it's nice to take care of your own patients, patients really like when their physician can take care of them. >> in the hospital. >> in the hospital. >> yeah. >> but it does make it easier, just -- [ overlapping conversation ] >> yeah, to be just either working in the hospital or, like, what i do, just in the clinic. you're not having the back and forth. >> okay. well, welcome. thank you for being here. >> thank you. larissa, thank you for being here. >> not a problem. >> my partner in crime, we work together at brookings group. >> correct. >> so tell us a little bit about you, you're from where originally? >> i was born and raised in milbank. i graduated from high school there, i did my undergrad,

well, it used to be augustana college, now augustana university, had done my med school at usd in vermillion, residency in kansas, here i am. >> and, so, we were talking about, to the premed students and pre p.a. students here before the show started, about why you picked ob/gyn, you kind of went through a scenario of what would make you decide to go in different fields. let's hear that again. >> well, we tell medical students when they rotate through with us, what would you rely on as one of the fields is one of the deciding factors, good mix of clinical stuff, o.r. things, we've got kind of the long-term patient care and we have a little bit more of an acute type of thing. if you're the type of person where you're doing your rotation as a medical student and you find that you like all the clinic stuff, you hate spending time in the o.r.,

then maybe you need look at more like an internal medicine type of thing or family practice. if you love being in the o.r., you don't want to be in the clinic, then maybe you need to look at surgery. if you like delivering the babies, and you don't want to give them back to the parents, then maybe you need to go into pediatrics. that's kind of a good way to decide what you really like out of things. >> as you said, it's a field, you do everything. >> yup. there's a good mix of everything. and similar to what you guys were talking about, we see patients from when they're very young to when they're very old as well. so we have the clinic stuff, we've got the surgery stuff, we've got the ongoing kind of complete health care and every once in a while, obviously patients come in for more than acute situation as well. >> i mean, there's a big

debate about whether primary care, primary care is definitely family physicians and internal medicine, and pediatrics and ob/gyn is part of that primary care group, too, but they're also surgeons, and they're also -- >> yes. >> so, you have it all. >> wear lots of hats. >> so, let's talk about the preventive screening kinds of things that women need to have. there's a lot of debate about how often mammography should be done, for example. let's talk about mammography. what's your take on the recommendations that are out there for how often mammography needs to be done? >> well, i guess i disagree with the task force recommendation. i recommend to women to start at 40 and to do them annually. rather than waiting until 50. >> and what about pap smears?

what do you recommend for pap smears? >> well, you know, when i first started practicing, we were doing them, you know, starting when they were sexually active or with initiation of birth control. now i follow the guidelines, starting at 21. >> and larissa, your comment about pap smears, let's hear your comments about pap smears? >> so i would totally agree with what you were saying. we usually also follow the guidelines. so we start doing pap smears at age 21, and not before then. women age 21 through 30 should have a pap smear done once every three years, assuming that all of those results come back normal. once you turn 30, we recommend doing what we call co-testing, so we'll do the pap, like we would normally do, and then we'll also add in testing for h.p.v., the human papillomavirus.

and we usually say at that point in time, if both of those results end up coming back negative, that we can recommend stretching that screening out to once every five years. with that being said, for all of those results, we always recommend that women come in for the other parts of the well woman exam, so the best exam, the other parts of the pelvic exam, i would say it's not an uncommon confusion for women to assume that any time they have a pelvic exam that they're having a pap smear and those are two very different things. we can do a pelvic exam without necessarily doing a pap smear. so, we always still recommend that women come in yearly for the other parts of the well woman exam. and then we usually recommend continuing with the pap smear

screening until age 65, or if a woman has ever had a history of an abnormal pap at one point in time, we want them to continue those screenings guidelines until they're 20 years out from that episode. >> so you're saying that you follow the u.s. preventive health services? >> the asccp. >> which is who? >> american society for colposcopy and -- i can't remember the other -- >> the other thing? >> yes. >> and then for mammography, you recommend and you follow the american college of -- >> correct. so i would concur with what she was saying about that. >> which is what? >> recommend having a baseline screening mammogram at age 40, and then usually yearly thereafter. >> here's the controversy. it needs to be said clearly, people need to hear it because it's pertinent to the quiz.

i might be breaking the rule about the quiz. but the u.s. preventive health services suggests different. they suggest 50 and every other year after that. what's your take on that? why is there disagreement? >> i think there has been some thought lines for things that there's the one aspect of the patient safety and having the most fair guidelines to make sure you're catching things as early as you can and at as treatable of a stage as you can and there's also the thought process of looking at things for the larger society as a whole and making sure that all of those services that you're able to provide are able to be spread out evenly so everybody can have them and at a cost-efficient rate. >> so your take on that, too? i mean, i'm thinking, you

know, annals of internal medicine supports the u.s. idea of 50 but you say 40. >> i agree. i think starting -- i think 50 is too late. there are many women who are diagnosed with breast cancer before 50. so i think that 50 is definitely too late. and every other year i think is too long as well. you know, i've had women that have had manual breast exam at their well woman with me, have had their mammogram, everything looks fine, they come in, three months later, they found a lump. so, again, i just think that it's -- two years is too long to go. things can happen too fast. they can change, you know, very quickly. >> right. but i'll just say it, you know, just to make clear so the audience hears it, the u.s. preventive health services are saying 50 and every other year. okay. now, let's look at the prevention ideas that are very important.

and that is vaccination for the papaloma. >> um-hum. >> you talked about that a little bit. what do you think about that? there are some people who say, don't give my kid the vaccination for papilloma because that will just make it free wheeling and she'll go out and have sexual activity or he'll go out and have sex now that they feel protected. what's your take on that? >> you know, actually, i guess that argument i haven't heard. you know, the majority of my patients, you know, have concern with their daughters that they want them protected. you know, you know, because you just don't know, i mean, their partner, who, you know, if they do -- you don't know, that person may not know that they have it to pass it on. so, again, i think it is important to have that protection.

because, again, if there's anything that you can do to try and reduce the risk of any type of cancer -- >> here's a vaccination that would prevent cancer of the cervix. >> and i actually have had patients that have come in and had those concerns for things. so what i usually tell them, the goal of the h.p.v. vaccination is not to -- >> h.p.v. meaning? >> the human papillomavirus. >> same as a wart on your hand, except it's down there. >> there's a couple different versions for things, there's over 100 different kinds of h.p.v. and they kind of are divided into high risk and low risk type. >> some turn to cancer, some don't? >> the high-risk h.p.v. types have a high prevelance or known association for leading to cervical cancer changes. the low-risk types are more associated with some of the

genital wart types of appearances for things. and what i usually tell patients is that the goal of the h.p.v. vaccination is to try to catch people before they become sexually active, to give them the best protection against ever being exposed to those viruses. >> so it's for women at the age of? >> it's actually f.d.a. approved for ages 9 through i think it's 26. >> 26, yes. >> and now they're saying, guys, too, right? >> um-hum. >> why not guys? and, so, there's no reason why it shouldn't be -- it's the same age for guys then? >> right. >> yup. so ideally you want to try to catch patients before they become sexually active. >> all right. cancer of any kind can take a heavy toll on a person. one brookings nurse survived breast cancer and the ordeal of surgeries, chemotherapy, and radiation to be cancer-free.

she now works with people who have recently been diagnosed to help them through what lies ahead. >> i was in my 30s, so had not had a mammogram, had no reason to have a mammogram. had no family history. i had no risk factors for breast cancer in any way. but because i was a nurse in the operating room, we did breast biopsies or lumpectomies all the time so i was very aware of how common it was. that's how it started. i was 38, 39 years old. and after the diagnosis, then, we got the result of that lump being removed, then the decision was what do we do now? and he felt and i chose a lumpectomy at that time, which is removing some of the breast but leaving as much as possible. so, i had that done. and i had the lymph nodes under my arm report. and when that path report came back, i had nine out of ten lymph nodes positive for cancer.

and all of the characteristics of my breast tumor after they came back from pathology, every characteristic of that tumor was the worst that it could be. i wouldn't think -- i didn't think i'd live very long, really, when you look at the information out there, especially at that time. so, after the lumpectomy, and the removal of lymph nodes, i had six months of hard chemotherapy and six and a half weeks of pretty deep hard radiation to my chest. and i finished those treatments on valentine's day in 2000. so, here it is, fast forward to 2015, i am free and clear, i've had no reoccur once, honestly, i'm doing better than i should be. i'm happy. i'm very very lucky. so i have had everything you can really have done to adjust, but in all honesty, i really think that that's helped keep my free and clear so long.

i had chemo, radiation, initial lumpectomy, follow-up, double mastectomy, and i am also on a cancer pill for the rest of my life. well, i definitely feel breast exams are huge, and don't forget the boys and men for those of us that have sons and husbands, absolutely they should be doing self-exams of their breasts and all kinds of self-exams. for the fellas as well. it's very important. it's how i found my lump. and, really, i was very diligent, because i worked in an atmosphere where i saw tumors and cancer every day. or weekly. so, very -- i really encourage that, obviously, and really get to know your body. some women say, i just don't know if this feels like anything, how do i know? you'll know because you'll be

familiar with yourself, enough to know when something new does show up that you'll say, this wasn't there last month. >> that's a very important lesson that she just gave you. by the way, i want to thank her especially for her, it's not easy to think about having to go in front of a camera and talk about your cancer. and she joins us tuesday evenings for our hopeful spirit choral and we go sing for people who -- many of whom have cancer. so it's a way of giving back, so, thank you, mary, for that. she emphasized the importance of early detection. what's your take on that, janell? how important is it that you catch it early? >> oh, very important. i mean, just like with anything, the earlier you catch it, the earlier stage, the better the outcome. and, like she said, you know,

that's what i really stress to women, you need to do your self-breast exams. you know, women can be intimidated by the feel of their breast tissue, they say, it's lumpy, i don't know how i would ever know, that's what i tell them, the more you do it, the more diligent you are about doing them, you'll learn and become very comfortable with the feel of your normal lumps and bumps so, that way if something abnormal would ever develop, you would know that that feels very different. so, very important, very important. >> now, i have read in the annals of internal medicine, you and i are reading regularly, here's the picture of the breast, i would say this is where the lymph nodes are positive for mary, drains the breast in this area. but they say to do a proper

breast exam, now they say going back and forth like you're mowing the lawn in that manner, instead of the old method of triangulating around the breast. do you have a recommendation about that, larissa? >> i usually kind of tell patients when i'm doing exams, i will usually go back and forth across the tissue. i've also told them, i said, you can start at the middle of the nipple and kind of work your way out, almost make a wagon wheel pattern. i guess i don't usually specify the best method to do the exam, but i usually just tell patients, exactly what you were saying, make sure that you do the exam frequently enough so that you're familiar with your own breast tissue. i usually say things that i recommend looking for, anything that seems like it's new, different, changing in

shape or size, anything that seems like it's fixed or not mobile, because everybody, as you said, everybody's going to have some lumps and bumps. most of the time when you do the exam, you kind of push around on them, they'll move around, if they don't want to do that, not a bad idea to have that checked out. >> so you said, fixed, you said new, what else? >> changing in shape or size. >> change. >> yup. and then the other thing that i usually say is anything that changes, the color or the texture of the breast. >> color or texture, change. >> yup. >> okay. [ overlapping conversation ] >> if they start noticing any nipple discharge, too. >> nipple discharge.

>> yup. >> okay. so, we've got all that on the thing. how about -- there was this article, or maybe two articles that said, self-breast exam is not successful, not helpful. going in to see the doctor and having a breast exam is not helpful. and that mammograms are the only thing that's needed. have you heard that? >> i have. and i've had patients come in and tell me that. and i tell them that it absolutely isn't true. and i use examples. and probably the one that continues to stick in my mind was a woman that, again, i saw her for her annual exam, i did her breast exam, she had her mammogram the same day, three months later she came back in and she had found a lump. and it was breast cancer. and fortunately, it was at an earlier stage where, you know, she --

>> 100% cure. >> yes. >> there you have it. catch it early. >> catch it early. so, again, -- and i tell women, you know, even -- you may not pick it up, as a physician, i may not pick it up, and that's where your mammogram comes in. as well. but, again, absolutely, you know, again, the more comfortable you are with the feel of what's normal to you, the more apt that you will be able to detect something that's different and abnormal. and the other thing that i stress to them, too, is, you know, to come in, if you feel anything that doesn't seem right, that seems different, you need to come in. >> just come in. >> just come in. and if i'm not 110% sure that it's benign, then we get a diagnostic mammogram. >> well, then the diagnostic mammograms

have changed, aren't they? they are better than they used to be, and then when something's not quite right, now they're doing ultrasounds all the time. >> all kinds of imaging modalities for things that we can use to hopefully help clarify and either give reassurance that things are normal or if there's more studies that are needed to be able to get those studies done. >> i thought also, when i read the article about, stop breast exam, stop coming in for regular breast exam by the doctor, that i have discovered at least two breast cancers by my exam, two. and i know that, you know, five probably breast cancers came in, the patient found it themselves, said, what do you think about this, doc? i was examining my breast and here's a lump, what do you think?

>> well, to me, it just seems kind of common sense. if you're doing the exam, if someone else is doing the exam, you're also having imaging done, then you've got three different methods to detect things, you've got three times the probability that if there is something going on that you'll find it. like we said, at an earlier stage where it's most curable. >> so it's worth doing. >> yup. >> absolutely. >> i've got a question, an 81-year-old woman from vermillion, at what age should you stop getting a mammogram? now, the u.s. preventive health services says -- has an age. what do you think about that? i mean, the cancer is higher risk as you get older, don't go away, in fact, the risk of cancer of the breast increases as you get older.

what's your take on stopping mammograms? >> it gets a little bit tricky. >> it does. >> i was going to say, so, i know that they recommend kind of stopping age 75. with that being said, i think if we look at the way people's health has changed over the years, we have a lot of patients that are living to be quite a bit older than 75. and, so, like we said, if we're doing imaging and we're able to catch things at an earlier stage, it's an easy enough test to have done. i don't know if i really totally see the benefit in stopping at age 75 because i would say even if you would stop at age 75, if that next year they would have an abnormal mammogram that would not be caught for years, it would still have the potential to affect their quality of

life and their long-term survival. and at this point, 75 is still pretty young. >> it is. and a way that i will put it to my patients, i still have some mid 90-year-olds that are getting them every year, but, you know, when a family member or patient asks me, you know, when is it time to stop, i guess what i tell them is that the reason we do the mammogram is we're looking for cancer, we're trying to detect cancer in early state. and the question is, if we find it, what will you do? and if she says, gosh, you know, i'm healthy, i mean, i want to keep living, i'll do everything that, you know, that's needed. then you know we keep doing the mammogram. if we have other complicating medical problems or you're at a point where you say, you

know what, if you found it, i don't think i'd have the chemotherapy, i don't think i could go through the surgery, then there probably isn't a point of doing a mammogram. >> humane to tell me that we do individual things, i mean, we care for each individual depending upon that person. >> we do. >> yes, we do, don't we? and -- >> individualized decision that i think should take place after a discussion with a health care provider and the patient, where they're able to come to a mutual decision on what's best for them. >> so let's talk about breast cancer surgery, it's different now. we used to do total mastectomies. in fact, i remember them doing total and complete mastectomies and also take the muscles. and then the arm would be

swollen and then they'd have to wear, you know, that whole story. those women are gone now. it's been a long time. and now we're doing lumpectomies and stereotactic surgery. talk about that a little bit. >> well, and i would say, in all honesty, the best surgery portion of things not usually something that i get pretty deep into, just because usually if we find an abnormal result, either on an exam or on imaging, usually we look at doing a referral to more of a breast specialist. >> right. >> with that being said, there are a number of different options for therapies for things. there are some more like neoadjuvant therapy where they can do some treatment before they look at doing surgery, that hopes whatever that mass is to be able to shrink it and make it more easily treatable.

>> i haven't heard that word before. >> there are other options for, as you said, lumpectomy, more of a breast-conserving type of therapy, obviously there will be more invasive procedures, and i would say all of those are going to be very dependent on exactly what type of cancer it is, what stage it's at and what else that individual has going on. >> i remember when there was a raging discussion about whether you do a lumpectomy and radiation or whether you do a simple mastectomy. either way, no matter what you do, you're going to have to do a biopsy or a biopsy of the lymph nodes to make sure it hasn't spread. could you explain what that would be, janell? >> well, yeah, again, looking at the lymph nodes, that would give an indication as to whether or not the breast

cancer has spread out, out of the breast. so, and, again, it depends on -- that's what i tell women, you know, i refer them to their breast surgeon as well, because it depends on the type of breast cancer, they also do testing with hormone receptors, if they're estrogen progesterone receptor positive or negative, they also -- there's other receptors that are tested. and that makes a difference as far as with what the recommendation is, whether they can get by with a simple lumpectomy and nothing further or whether they need, you know, a mastectomy with some radiation and chemo, you know, it really -- there's so much testing and way more testing now of what they can do than before. that makes a big difference. >> the brca gene, do you order that often or do you send them

to -- >> we don't. what we do is -- >> what is the brca gene? >> well, there's a brca 1, brca 2, and that can, you know, particularly in women that are younger to see if there's a genetic predisposition to the breast cancer and then knowing how to advise their daughters, their sisters. so, there's two different brca genes. again, i don't order those and do those. you know, once the women are referred to the breast surgeon, then they see the genetic counselor, and the counselor goes through the history, their family history, and then decides about whether or not that would be something that would be beneficial. to do. >> brca standing for breast cancer and it's a genetic predisposition, these people, it runs -- breast cancer and ovarian cancer, right? >> right.

>> people like angelina jolie had that kind of a thing. so she understanded up with a bilateral, both sides breast, preventive surgery, that type of a thing. >> and there are some patients where we'll talk about some of those -- we'll talk about patients and offer testing to some of them if they are candidates for that. and i've had a number of patients who actually have been found to be brca carriers, so then when you have someone with that, then you have to get into a little bit more of a discussion with them about what they're looking at doing long term for things in patients who are known to have or carry that gene. we'll usually recommend instituting earlier breast cancer screening. i would say mid 20s or ten

years from the earliest family relative diagnosis, and usually we'll look at doing kind of every six-month imaging with mammogram, m.r.i. types of imaging. and then you even get into a little bit more of a discussion long term for things of whether they're wanting to be looking at prophylactic mastectomies, whether they're wanting to be looking at removing of the ovaries after conclusion of child birth to reduce the risk of ovarian cancer, those types of things. >> so it's complicated. very interesting. >> victims of sexual assault seldom want to relive the experience by reporting it to authorities or they may even feel a misplaced feeling of guilt. that is why it is important for people to know the options and resources available to

them in such a terrible situation. >> sexual assaults do happen. and when they do happen, it's a small percentage of individuals that actually will go out and perpetrate sexual offenses. but the small percentage of individuals are not -- the reports don't come in very often. and when those reports fail to come in, we end up with individuals who are out there and they get to be repeat offenders because we don't know that they exist. and, so, unfortunately, if it happens to you, the chances of it happening again to somebody else are fairly high. we do need you to do whatever you feel comfortable doing, there would be no pressure in wanting to report a sexual offense, it's an individual difference, something that people have to consider. but there is that thought that

by reporting, you could stop it from happening to somebody else. i encourage people to report situations to the police department. a lot of local law enforcement agencies will allow victims to come in and report situations and have it documented without maybe a full investigation being conducted, if they're not comfortable with that at the time. but then also to file for a protection order and to document every situation, everything that occurs that might be a harassing text message or unwanted phone calls, to keep that documented with the local law enforcement so that if something does happen, they understand it's not a one-time situation. it's never the victim's fault, however, there are measures that people can take to avoid high-risk environments. one of those is that if

individuals do choose to drink alcohol, that they consume alcohol at a level that they are not incapacitated and that they make sure that they're with a group of individuals that they trust and that they stay with that group. most sexual assaults that occur do involve alcohol or drugs in some form. also carrying a cell phone that is fully charged is advised. and then not being distracted, be aware of your surroundings and, so, that if there is something that comes up, you can be more alerted to it. >> at sdstate it is on us, all of us to put an end to sexual assault. >> to create an environment where everyone feels and is safe. >> to respect that no means no. >> to know that no one ever deserves to be raped. >> to get in the way before it happens.

>> to make sexual assault unacceptable. >> to stand up, to step in, to take responsibility. >> you know, people talk about mature male, mature male as a person who walks in the room and everybody feels safer. a person who is stuck in a previous earlier phase of their maturity and do not advance in their growing up, they walk in the room and you can feel threatened. and i just -- it just angers me to sense that some grown-up males haven't passed the stage and realize that their job, their purpose, their direction should be to protect and to be -- to make their partners and other women and children and other guys in that room safe. that's my comment about this. and great to see the football coach there saying, guys saying, say no, and then if it happens to you, not to be

reluctant to go get help. janell. >> and i guess i would say from, you know, from what i see, you know, in my clinic, we don't have anybody that comes that's just been raped. we would have to have them probably go to the emergency room. but what i do talk to my, you know, my high school, my college-age girls about is that, you know, particularly educating them with birth control, as far as with, you know, prevention of pregnancy, but not against, you know, sexually transmitted diseases, you know, i stress to them that, you know, if they have an encounter, they're not, you know, -- they don't know that person, to really stress to them, you need to come in, just to be tested, you know, we'll do testing for, you know, stds, h.i.v., you just always want to be on the safe

side of coming in and being tested, not to be embarrassed, not to feel bad, you need to come in, you know, we'll talk about it, we'll do the necessary testing to make sure that, you know, you're not at risk of getting any type of an infection. >> any other comments? >> not usually because i would say -- i would concur with what she's saying as well. usually -- i would say it's preferable for patients who have unfortunately had this type of thing occur to be seen by someone who is specially trained and is making sure that all of the things that are needing to be collected are collected and are done in the exact manner that it needs to be done. both for evidence purposes, hopefully in the future, and, like you said, we can offer

the same counseling about s.t.d. collection and, you know, further testing for all of that, but usually there are people that are specifically trained for some of these types of things, just to make sure that whatever evidence is available is collected and is processed in the exact manner that it needs to be done so that there's not any issues with things in the future. >> my dear internist, donna suite, who cares for all these people with h.i.v. in wichita, kansas, do you know her? >> yeah. >> have you met her? >> yeah. >> donna was up here, we did a show on this, her point, everybody should have h.i.v. testing between the ages of 18 and now people are, thanks to viagra and all the other things, guys are, you know, there's a lot more sex going on between -- and you don't

know, so everybody should have an h.i.v. test periodically. i think that's your point. and certainly after somebody who, you know, -- her comment, too, our person who was just interviewed talked about alcohol being a big part of the problem. certainly, i would echo that. any comments more about that? we have questions. let's take some. 88-year-old woman from sioux falls, what do the doctors know about metaplastic cancer associated with fewer than 1% of breast cancers according to johns hopkins? >> and, again, i would kind of echo what we had said before, at least for my portion of things, as far as the actual treatment of things goes, i would definitely recommend that that patient be seen by someone who specializes in the breast cancer portion of things. so just because it's not

something that i usually specialize in, i would say my knowledge on that portion of things is, unfortunately, kind of limited. >> yeah. do you know much about -- i don't know much about metaplastic cancer of the breast. do you? >> i don't. >> it's just a rare kind. you give that patient to the specialist. and that specialist may say, oh, there's a guy who deals with metaplastic from the mayo or from -- daughter who is 52 years of age had a hysterectomy, ovaries are intact, does she need to get pap smears? >> so, i would say for our ideal answer for that is if she has never had an abnormal pap smear before, then she should be done with paps at that point in time. and if all of the pathology from the hysterectomy had come

back normal, she should be good. if she's ever had an abnormal, then she would need to continue to be followed up for an appropriate amount of time. >> and that varies with the individual, age and -- >> yup. >> i do think that the ob/gyn doctors, at least the old ones, years ago, used to do pap smears, the uterus is gone, the cervix is gone, the cancer is gone, and we still want to do this. oh, it was a male ob/gyn, wanting to do pap smears on this lady, she's in her 80s, for goodness sake. >> but, again, i would still stress that even though she does not have a cervix and she does not have a uterus, if her ovaries are still intact, she still needs to have the other parts of the well woman exam. >> so that you can feel. >> in case she would still be

at a risk of having ovarian cancer, those types of things. >> we have a question, when a mom has breast cancer, premenopausally, okay, so the mom had breast cancer before she turned to menopause. when should the daughter get hers? >> i guess i would say with that, i think that's where the genetic counselors come in. you know, with the patient, and, again, depending on what type of breast cancer she has, at that age they would probably do the brca testing. >> that's the question. >> yeah. and then they would do the brca testing, then depending on the results of the brca testing, you know, the age of the daughter, you know, make the recommendation. >> so, if you're positive brca, so, breast cancer in your family, and you have the gene, puts you at risk, it

isn't 50 and it isn't 40, probably, you start mammograms at? >> that's what we were kind of talking about earlier. i would say mid 20s, otherwise ten years earlier, so mid 20s is the earliest, otherwise ten years before the earliest diagnosis of a family relative. or closest family relative with breast cancer. >> the problem with mammograms in younger people, however, is that breasts are much denser. and it's much harder to make the diagnosis. and there's a lot more biopsies done in those breasts. and that's why the u.s. preventive services said 50, not 40. >> but, again, different patient population. >> right. >> right. >> and that's where, you know, some of the different modalities may come in as far as with using the ultrasound. >> yup. >> you know, the 3-d, you

know, maybe something -- may be something, there's the contrast enhanced. again, it depends on, really, on the age. but, you know, that's where, i mean, there are the other modalities, too, particularly with the ultrasound, i think at that age. >> ultrasound is better. and then when do you do the m.r.i. breast -- you mentioned the m.r.i. breast screening. does that -- in these high-risk people, i'm not familiar on -- i don't when -- >> and, that's where, too, i think then that's where, you know, you really kind of rely on your breast radiologist, too, as far as what their recommendation would be. and, you know, again, i've had some, you know, very young patients and i've called them to ask them, you know, based on their age, based on the

family history, what would be the best modality? what is the best way to start? sometimes starting with an ultrasound, then they may make a recommendation as far as with m.r.i. so i really rely on the breast radiologist to help make that decision. >> right. >> because they're the ones looking at the images, so i would say whatever they feel like they need to have or best clarification would be what we would go with. >> 75-year-old woman from sioux falls, what is the testing for polycystic ovarian syndrome? what is that? >> polycystic ovarian syndrome is kind of just what it says, a syndrome that has a number of different things that are associated with it. so usually when you're looking at, we kind of call it p.c.o.s. and i would say one

of the common things that patients will end up with is a, we call it ammenorrhea, so you either have fewer periods than average or you have no periods. it can have a number of different lab abnormalities that are associated with it. some of them can be hormonal changes, it can also have effects on the lipids or the cholesterol types of labs that we can look at. it can have changes associated with an increased propensity to have insulin resistance or some difficulty metabolizing sugars at times. >> and it goes with the obesity, generally is with it. >> yes. >> is it always with it? >> no. >> and then imagingwise we usually will look for certain kind of criteria or certain combination of things. usually transvaginal

ultrasound imaging to make those diagnoses. but, like i said, it's not just one thing that gives the diagnosis. it's a combination of a number of different things. another thing would be what we call hirsutism, having abnormal hair growth patterns in females. some women will have hair growth on the chin, chest, areas that you would not normally see hair growth on a female. >> but there are a lot of women who have hair growth, hair growth alone does not mean polycystic ovarian -- >> again, it goes together with the syndrome. so looking at the question that we had here, i would say, in a 75-year-old woman, i would probably have relatively minimal concern for a pcos type of thing, because at 75, she's likely menopausal, and, so, while there may be some changes associated with, like

we said, the lipids, the insulin resistance, those types of things, the gynecologic complications that can occur along with that, i would say my concern for that portion of things would be pretty minimal. >> so, if we go to the drawing, the -- can we see them under laparoscopy, polycystic ovaries look larger? these are the ovaries. >> i would say you can possibly see some changes with the laparoscope. which where we actually looking at the ovaries with a camera in the abdomen. more often than not, i would say usually prefer to have imaging with an ultrasound. rather than going the more invasive method of an actual surgery for that. >> it's interesting, if you give these people the treatment for diabetes, because they sometimes have prediabetes

or early diabetes, start them on metformin, that makes them -- they get more fertile, right? what's the reason for that, do you know? do you have any idea? >> i can't tell you why that is, but i know that's what they do. and, again, that's where, again, kind of with this woman at 75, because probably one of the, you know, the biggest concerns for women that have polycystic ovarian syndrome is the infertility, the issue of infertility. [overlapping conversation ] >> right, right, right. >> do they have thin he were bones or are there problems with osteoporosis in this group or less? >> you know, i'm not even sure. >> yeah, i guess i haven't seen anything. i really don't think that there is. yeah, i guess i haven't seen anything in any of my

patients. >> off the top of my head. >> we've got 30 seconds. quick answer. if someone is menopausal, having symptoms, what's your go-to first treatment for menopausal symptoms, flushing, so on and so forth. >> yeah, that's hard. you know, that usually is a -- can be a lengthy conversation, as far as with menopausal symptoms, as far as with which symptom is it that's really causing the problem. you know, whether it be the hot flashes or the night sweats. i guess as far as with hot flashes again, our goal is to really try and avoid using estrogen. using a fexor is one of the first ones, antidepressant, antianxiety medications are helpful. >> all right. and i'm going to roll on. and now for the winner of tonight's prairie doc quiz.

the u.s. preventive task force recommends starting mammogram screening at 50 years old and every other year thereafter until 75. true or false. the answer is true and we have disagreement in the audience. >> correct. >> in our experts. so get out your mammogram, if you're in that age group, for sure. it was sharon swagerer, thank you, sharon, the book will be in the mail to you soon. we'll be right back after this. >> we have a big problem. and we need your help. >> it's happening on college campuses, at parties, even high schools. it's happening to our sisters, and our daughters. >> our wives and our friends. >> it's called sexual assault and it has to stop. >> we have to stop it. >> so listen up. >> if she doesn't consent or if she can't consent, it's rape, it's assault. >> it's a crime.

it's wrong. >> if i saw it happen, i was taught, you have to do something about it. >> if i saw it happening, you speak up. >> if i saw it happening, i'd never blame her, i'd help her. >> because i don't want to be a part of a problem. >> i want to be a part of the solution. >> we need all of you to be part of the solution. this is not respect, it's about responsibility. >> it's up to all of us to put an end to sexual assault. >> and that starts with you. >> because one is too many. >> i believe that equality of the sexes, both in the workplace and at home, should make our society and our families stronger and happier. although our u.s. society is not quite there, we are a heck of a lot closer than when i was growing up. this is not to say men and women should have the same roles, but i believe the

different perspective each provides is of equal value. say it again, men and women having equal value should not require having the same role. i was interested to hear about a recent study indicating combat units with a mixture of men and women were not as effective as combat units with men alone. i know enough about how study results can be skewed to show the answer the researcher wants, but still it didn't surprise me that combat units with women might be less effective as killing units. my mother and father were quite different in their roles, both in our community and in our family, and yet as far as i was concerned, were of equal value in what they each contributed. my mom's role was as the peace-keeper to compromise when a balance was needed,

while my dad's role was more rigid, standing for a principle without conciliation. mom was emotionally apparent, while dad was more likely to cover his feelings. dad could open a stuck jar lid, while mom was not nearly as physically strong. although she could be brought to an emotional conflict quickly, my mother was also quick to forgive, while my dad was slow to anger, yet once incensed, he could hold a grudge. they were different, each had their weak and strong points, and yet together, in my eyes, they were awesome. i remember how mom's attitude changed after she was hired at the desmet news and her regular income lifted the financial burdens about which our family struggled. it changed her role from staying at home raising children to equal partner in supporting the finances

of the family. it was interesting to see how their arguments lessened and her painting and creative expressive talent blossomed after that. at least in my family, equality of the sexes should not mean equal roles. hurrah! for the difference. [music] >> so we've got 20 seconds for the last question that we've got on atrial fib in women. what do you think? how do you treat it? do you treat it different than men? >> no. >> and the basic principles are? >> anticoagulation, weight control. >> there we are. and that's it. we thank you both so much for being here. i sincerely thank our studio guests, janell powell and larissa bennis, for their willingness to participate in our show.

and, to you at home, thank you for letting us come into your living room again tonight, we appreciate the opportunity. so, from all of us here at "on call with the prairie doc," until next time, stay healthy out there, people. >> no one lives forever, we would like to live a long and healthful life. what are the basic lifestyle decisions we can make to give us the best chance at success? longevity, next time "on call with the prairie doc." >> funding for "on call with the prairie doc" is provided in part by: >> avera is a proud sponsor of "on call" on south dakota public broadcasting. >> larson manufacturing is proud to support "on call television" as it continues to

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