< Previous18 MD-UPDATE Sarah Todd, MD, Joins Gynecologic Oncology Team at UofL Physicians LOUISVILLE A Louisville native, Sarah Todd, MD, has joined UofL Physicians – Gynecologic Oncology at UofL James Graham Brown Cancer Center. Todd specializes in the treatment of benign and malignant gynecologic conditions, including cervical and vulvar dysplasia, ovari- an cysts, fibroids, endometriosis, and tumors of the female reproductive tract (ovaries, uter- us, cervix, vagina, or vulva). She is trained in robotic surgery utilizing the da Vinci® Xi sys- tem. This state-of-the-art technology provides surgeons with exceptional vision, precision, dexterity, and improved access to the treat- ment site. Benefits include smaller incisions, less pain, and a faster recovery, which often means a shorter hospital stay. Todd also brings HIPEC – heated intraper- itoneal chemotherapy – as a treatment option for select advanced ovarian cancer patients. HIPEC is known as “hot chemotherapy.” It involves circulating heated chemotherapy with- in the abdominal cavity for 90 minutes follow- ing complete surgical resection of tumor, which can reduce the risk of cancer recurrence. “HIPEC allows a higher dose of chemo- therapy to be delivered in one treatment,” Todd said. “Since the chemotherapy con- centrates within the abdominal cavity, it minimizes the rest of the body’s exposure to chemotherapy and improves absorption of the drug and susceptibility of cancer cells.” Todd graduated from UofL School of Medicine in 2011 and continued residency in the Department of Obstetrics and Gynecology, training under Daniel Metzinger, MD, gyne- cologic oncologist and head of robotic surgery. She completed fellowship training in gyneco- logic oncology at the University of South Florida/Moffitt Cancer Center. She graduated summa cum laude from both Bellarmine University and Assumption High School. Sarah Todd, MD, is trained in robotic surgery utilizing the da Vinci® Xi system and in HIPEC – heated intraperitoneal chemotherapy for advanced ovarian cancer patients. PHOTO PROVIDED BY UOFL SPECIAL SECTION OB-GYN-ONCOLOGYISSUE #124 19 The Naked Truth about Skin Cancers With skin cancer on the rise, having a Mohs micrographic surgeon readily available is more important than ever BY DONNA iSON BOWLING GREEN Dermatologic surgeon Wilfred Lumbang, MD’s career path has taken him around the world, but he is pleased to have landed in Bowling Green, Kentucky. “I grew up on a tiny little island in the Pacific, and I love smaller communities. I thought I would be more useful here than anywhere else. I feel very fulfilled at Graves Gilbert Clinic,” he states. Lumbang received his earliest education in Guam. While he had his eyes initially set on graphic arts and architecture, he says, “Great teachers and mentors opened my eyes to math and science, and I became intensely focused on academics.” This dedication garnered him a full scholarship to the University of Guam. He then received his medical degree from the University of Vermont College of Medicine. While in medical school, he was commissioned as an offi- cer in the United States Navy. Lumbang went on to complete his medicine internship and residency in dermatology through the Naval Medical Center San Diego. Prior to residency, he spent three years traveling the South Pacific as a battalion surgeon for the United States Marine Corps. From 2007 to 2010, he served as the head of the Dermatology Department at the Naval Health Clinic Great Lakes, Illinois. After completing ten years of military service, Lumbang headed to Vanderbilt University Medical Center in Nashville, Tennessee to further his training on skin cancer surgery. He states, “I was really drawn to Vanderbilt because it was a very intensive program on Mohs micrographic surgery with emphasis on complex skin cancers that devel- op among solid organ transplant recipients.” Upon finishing his fellowship in Mohs micro- graphic surgery and cutaneous oncology, he ran the transplant dermatology clinic and PHOTO BY MORGAN HARRiS Wilfred Lumbang, MD SPECiAL SECTiON SKiN CANCER/DERMATOLOGY20 MD-UPDATE trained both residents and surgical fellows on skin cancer surgery from 2011 to 2015. Then, once again, he knew it was time for a change. Lumbang explains, “When work- ing for big institutions, like the military and then Vanderbilt, you lose yourself somehow in administrative duties. I’ve always been a people person. I want to talk to people, not paper and pencils.” He also recognized the need for his specialty in smaller communities. “No matter where you go, there is always a shortage of dermatologists.” After researching various facilities, he found Graves Gilbert Clinic to be a perfect fit because of its patient-focused philosophy. Treating Skin Cancer in Western Kentucky With the sobering skin cancer statistics, he could not have arrived at a better time. In this country, approximately 9,500 people are diag- nosed with skin cancer every day. “It is now the most common cancer in the United States and worldwide. About one in five Americans will develop skin cancer by the age of seventy. More than two people in the United States die of skin cancer every hour,” Lumbang states, “And, if you look at the data between 1994 and 2014, the diagnosis and treatment of non-melanoma skin cancer within the United States has increased by seventy-seven percent. That’s significant.” The majority of Lumbang’s patients are referred with biopsy-proven skin cancers. Many of his patients from Nashville have followed him to Bowling Green. “As a Mohs surgeon, I perform three roles for a patient. First, I remove the skin cancer in stages. Second, I am the pathologist that looks at the margins and makes sure the margins are all clear. And, then third, I reconstruct the defect created after I’ve removed the skin cancer.” Aside from surgery, Lumbang considers edu- cating both physicians and patients to be a large part of his job. For physicians, he wants to impart the efficiency and effectiveness of Mohs surgery. He states, “It is a single visit, outpatient surgery. You don’t need to be in the hospital. We only use local anesthesia, so we do not expose the patient to prolonged general anes- thesia. And, we can clear the margins on the same day. The lab work is done on-site, on the same day, so patients don’t have to wait for the results for days or weeks. And, it also offers a very high cure rate—up to ninety-nine percent for tumors that have never been treated before.” He also stresses the importance of screen- ing, early detection, and counseling. “About ninety percent of non-melanoma skin can- cers are associated with ultraviolet radiation from the sun.” He adds, “Most skin cancers can be prevented. I think part of general counseling in the primary care setting should be about sun protection—about avoiding tanning beds, using sunscreen, and protective clothing. A great deal of focus should be on prevention through public education.” In closing, Lumbang offers a positive perspec- tive on screening and survival. “It is much easier to screen for skin cancer than any other cancer. All you really have to do to screen for skin can- cer is to look at and examine the skin. And, skin cancer is very much treatable; the earlier skin cancer is diagnosed and treated, the better the chances that patients will survive.” SPECiAL SECTiON SKiN CANCER/DERMATOLOGYISSUE #124 21 Stimulating the Immune System to Attack Cancer UofL Researcher tests “checkpoint inhibitors” to stop cancer cells from spreading LOUISVILLE Jason Chesney, MD, PhD, is the director of the UofL James Graham Brown Cancer Center (JGBCC) and associate VP of health affairs at the University of Louisville. Chesney’s research into immunotherapy for treating cancer has propelled the JGBCC into a leadership role in testing cytotoxic T cells and “immune checkpoint inhibitors.” In a global study of 700 melanoma patients at 113 sites, JGBCC was the lead center world- wide. It finished accrual of patients in March 2018. “Cytotoxic T cells have two brakes, CTLA4 and PD1, that turn them off,” says Chesney. These brakes likely exist to prevent excessive inflammation and autoimmune dis- orders. Antibodies that block these brakes, which Chesney calls “immune checkpoint inhibitors,” allow cytotoxic T cells to become activated against cancer cells. Several of the immune checkpoint inhib- itors are now FDA-approved for multiple cancers, including lung cancer, breast cancer, head and neck cancers, malignant melanoma, Merkel cell carcinoma, cutaneous squamous cell carcinoma, hepatocellular carcinoma, and advanced renal cell carcinoma. In July 2019, Chesney spoke to a group of Louisville area residents at the monthly “Beer with a Scientist” program coordinated by Levi J. Beverly, PhD, associate professor at UofL and co-leader of the Experimental Therapeutics program at JGBCC. According to Chesney, the human body has 100 billion cytotoxic T cells whose job it is to kill virus-infected normal cells AND cancer cells. Both of these cells express non-self or foreign proteins that allow T cells to see them. Unfortunately, cancer cells develop ways to avoid detection by T cells, allowing the cancer cells to grow into tumors and spread to vital organs. Cancer immunotherapies work by activating cytotoxic T cells against cancer cells through a variety of mechanisms. Chesney says that immunotherapies being developed at the UofL Brown Cancer Center involve various approaches to activate cyto- toxic T cells. These include: • Antibodies that “turn off the brakes” of cytotoxic T cells, allowing them to become activated against the cancer cells. • Viruses that help prime cytotoxic T cells against the cancer cells as well as a combination of these brake-blocking antibodies and priming viruses • Cytotoxic T cells simply expanded from patients’ tumors • Cytotoxic T cells genetically mod- ified to attach and kill cancer cells, which are called CAR T cells Is TVEC the Answer? TVEC, Talimogene laherparepvec, is an oncolytic virus engineered to express GM-CSF which leads to CD8+T cell activation. The ques- tion and goal of current research underway at the UofL Brown Cancer Center is to determine the efficacy and safe- ty of TVEC in combination with immune checkpoint inhibitors. Will TVEC improve the efficacy of immune checkpoint inhibitors? Chesney recently pub- lished a landmark article showing that adding TVEC to the immune checkpoint inhibitor Ipilimumab increased regressions of non-in- jected visceral metastases. These data are the first to indicate that oncolytic viruses can improve the clinical activity of immune checkpoint inhibitors and save lives. More Research Investment “For every dollar we spend on national defense, we spend one penny fighting cancer,” says Chesney. “In the last 100 years, begin- ning with World War I through Vietnam, both Gulf wars and Afghanistan, there have been 1.8 million combined military deaths, whereas there have been more than 60 million U.S. civilian deaths due to cancer. Moving 1% of the defense budget to the NCI, the National Cancer Institute, would double the U.S. budget for cancer research and reduce cancer-related deaths not just in the U.S., but worldwide.” PHOTO BY GIL DUNN “Moving 1% of the defense budget to the NCI, the National Cancer Institute, would double the U.S. budget for cancer research and reduce cancer-related deaths not just in the U.S., but worldwide” — Jason Chesney, MD, PhD Jason Chesney, MD, PhD, is the director of the UofL James Graham Brown Cancer Center (JGBCC) and associate VP of health affairs at UofL. SPECIAL SECTION ONCOLOGY4123 Dutchman’s Lane, Suite 414 • Louisville, KY 40207 • 502.897.2144 • ivfkentucky.com Twenty years of caring for patients. PROVEN EXPERIENCE, PROVEN EXPERTISE AND PROVEN EXCELLENCE IN FERTILITY CARE Miriam S. Krause MD, FACOG Kit S. Devine DNO, WHNP Robert J. Homm MD, FACOG NOW OFFERING... Preconceptual genetic screening to determine carrier status Preimplantation genetic screening for aneuploidy Preimplantation genetic diagnosis for specific conditionsISSUE #124 23 Hope for A Cure Hope Scarves’ Colors of Courage BY LAURA ROSS LOUSIVILLE Cancer can be a numbers game. It’s full of statistics no one wants to face, like the troubling fact that one in eight women are at risk to receive a breast cancer diagnosis during their lifetime. About 20 percent of those diag- nosed with breast cancer will receive a second diagnosis of metastatic breast cancer (MBC), which has no cure. A Stage IV diagnosis puts numbers – months, days, and way too few years – to a life. In the rush of the “pinkness” of October, many cancer advo- cates prefer to push away the “pink” and instead, focus on finding a cure through funding for research that can save lives. Lara MacGregor knows that too well. The Louisville resident and native of Wisconsin founded Hope Scarves in 2012, which shares scarves, stories, and hope with people facing cancer, as a personal reaction to her own battle with the deadly disease. MacGregor was preg- nant with her second son when she learned she had breast cancer. After several years of treatment, in 2015, MacGregor learned her cancer had progressed to Stage IV. Despite the diagnosis, MacGregor and her team at Hope Scarves have sent over 12,000 Hope Scarves to people ranging in age from 2-97, to every state and 24 countries, and have invested $600,000 for Stage IV, meta- static breast cancer research. Hope Scarves raises much of those research dollars through the organization’s annual Colors of Courage event, which will be held Saturday, November 9 th at Mellwood Arts and Entertainment Center in Louisville. The event was named the “most meaningful event in Louisville” by area media. Colors of Courage features dinner, live music, an auction, and a popular bourbon pull (which always sells out in minutes), but the most meaningful part of the evening comes in the powerful stories shared by survivors, patients, and families facing cancer. Each year, thousands of dollars are raised specifically to fund met- astatic breast cancer research. Colors of Courage regularly sells out to a crowd of more than 500 guests. MacGregor describes Colors of Courage as a night that brings together kindred souls, families, friends, and those facing cancer to celebrate the power of stories and living life over cancer. “Until 2015, Hope Scarves was like many other cancer organizations celebrating survi- vorship,” said Lara MacGregor. “But, when my Stage II breast cancer progressed to Stage IV, I felt like these celebratory campaigns no longer reflected my experience. After careful consideration, we wanted to do more than celebrate the happy stories and those who ‘beat’ cancers.” “We were touched by how many people appreciated this shift in perspective,” she added. “We added a research component to our work because though scarves and stories are inspiring and practical, they aren’t going to save anyone’s life. If we are truly going to live out our mission to change the way people experience cancer, we must help find more treatment options for those living with advanced cancer.” PHOTO BY GiL DUNN Lara MacGregor, founder of Hope Scarves COMPLEMENTARY CARE24 MD-UPDATE • Premium Banking Services • Personal Cash Management • Specialized Personal Lending • Doctor’s Mortgage Program* • Strategic Planning for protecting , growing & transferring wealth WesBanco Private Client Services — Customized financial solutions for all of your banking and investment needs The banking needs of medical professionals are sophisticated and quite diverse. WesBanco’s Private Bankers can develop customized depository and lending solutions, and provide personalized financial planning to help you address the financial needs of your practice, as well as your personal financial goals. Contact one of our Private Bankers today, and gain the peace of mind that comes from getting the help you need. Rebecca Hern AVP & Private Banker (859) 244-7255 Lexington Andy Mayer SVP & Private Banker (502) 569-4283 Louisville Karen Watson AVP & Private Banker (812) 981-7370 Louisville Caroll Perkins AVP & Private Banker (270) 986-0901 Elizabethtown WesBanco Private Client Services may recommend insured deposits or non- deposit investment products. Nondeposit investment products are not FDIC insured, not bank guaranteed, not insured by any government entity and are subject to investment risk, including possible loss of principal investment. *Subject to eligibility requirements WesBanco Bank, Inc. is a Member FDIC | wesbanco.com | In addition to funding research and shar- ing the scarves and stories worldwide, Hope Scarves brings that glimmer of hope to those it serves. As the organization grows, it is also growing partnerships with hospitals and cancer treatment centers in several states. MacGregor is a fervent and sought-after speaker at conferences and in the media and is determined to live her life over cancer. Hope Scarves’ Colors of Courage event will once again bring hundreds together to raise needed research funds, but the need is there year-round. MacGregor recently wrote, “I am reminded that loving life is what it’s all about. I don’t know what the next chapter holds, but I am one of the lucky ones. Daily, I hold friends in my heart who are spending summer get- ting rods in their legs to strengthen breaking bones, and those who are starting new chemo, and enduring full brain radiation. I don’t know when this will be my reality, but this I know – there is no greater story than a life well loved.” Second Saturday Workshops have been presented nationally since 1988 by WIFE.org Every Second Saturday of Each Month 8:30 - Noon at the University of Louisville Club, 200 E Brandeis Ave., Louisville, KY Learn from experts dealing with financial, legal, and emotional issues. Go to SecondSaturdayLouisville.com for full details. UNTYING THE KNOT? Contemplating or in the middle of divorce? Find help at Second Saturday Louisville Divorce Workshop COMPLEMENTARY CAREISSUE #124 25 While I was going through my messy divorce, I was stunned to run across a book called The Good Divorce. Hello? Who does that? No matter how you cut it, divorce is not an easy solution. It’s not easy emotionally, and the stakes are high financially and legally. In fact, divorce is the second most stressful life event on the Holmes and Rahe Stress Scale. The most stressful life event is the death of a spouse or child. So my question is … if you choose to kill your spouse, wouldn’t the death of the spouse be less stressful than divorcing the spouse? I don’t generally harbor homicidal tenden- cies, but early in the divorce process I found myself wanting to strangle my therapist, too. Her too-lofty observation, “Jan, you’re now in a place of exquisite vulnerability,” was incred- ibly ill-timed. Instead of strangling her, I fired her, got a new therapist, and bought a copy of Crazy Time: Surviving a Divorce and Building a New Life. Just reading the title of the book was therapeutic. Fast forward a couple of decades and I find myself speaking at nationally recog- nized divorce workshops, describing how to go about making the best decision for your marriage and your life if you’re contemplating divorce, or how to navigate the emotional and family challenges if you’re in the process of divorce. Divorce Is Hard on Kids. Bad Marriages Are Hard on Kids, Too Deciding about divorce can be one of the biggest, most challenging decisions you will ever have to make, especially if children are involved. Virtually all researchers and therapists agree that children are better off when their parents stay together — unless the marital strife has become damaging to the children as well. Study after study on divorce finds that chil- dren have the best chance to turn out okay if you do two things: 1. Don’t ask your kid to choose between you and your ex. 2. Provide a stable home life. Here’s the catch: You’re supposed to pull this off this feat of mature, perfectly-calibrat- ed parenting during what may be one of the most unstable periods of your entire adult life. At the time we most need and want to be strong and supportive of our kids — to be at our best as parents — we are likely to be at our most uncertain, volatile, weak, guilt-ridden, catatonic, or despairing. We’re profoundly, not exquisitely, vulnerable. STAY OR GO? For most people, contemplating divorce is an agonizing “too good to leave, too bad to stay” dilemma. So I’m not entirely surprised that most couples experiencing marital prob- lems wait an average of six years before they seek counseling. My job is to help people figure out what kind of gridlock they have and what they can do about it. What level of stuckness are we dealing with? Stuck, but the Relationship Is Capable of Repair and Revitalization. The remedy is almost always a balance between working on yourself and working on the relationship. The payoff for all that work? Practically every dimension of life happiness is influenced by the quality of your marriage, according to a robust body of research. Stuck, Based on Differences You Can’t Do Much About, at Least for Now. This is tricky territory because it involves evaluating whether you or your partner can change or even wants to change. Getting a clear The Divorce Dilemma How Do I Know Whether To Stay Or Go? BY JAN ANDERSON, PSYD, LPCC “Most couples experiencing marital problems wait an average of six years before they seek counseling.” “No matter how you cut it, divorce is not an easy option.” MENTAL WELLNESS26 MD-UPDATE read can be extremely challenging, because it’s easy to fool yourself in various ways: • Feeling hopeful when you shouldn’t • Thinking it’s all their fault — so getting rid of them will make all your unhappi- ness go away • Thinking it’s all your fault — so if you could just figure out what to do more of or less of, everything would be okay “You may be avoiding the sad reality that your partner doesn’t love you enough to care about your wishes. On the other hand, your angry disappointment may keep your partner so much on the defensive that he or she feels too criticized to want to behave different- ly,” points out Joshua Coleman, author of The Marriage Makeover: Finding Happiness in Imperfect Harmony. Gridlock, Based on Differences You Can’t Do Much About — Ever. Once you have a realistic perspective on what cannot be changed, either in yourself or your partner, the next challenge to navigate is: How do you come to terms with that reality? IF YOU STAY: Regardless of an unhappy marriage, some people decide to stay — for the children, or for financial or other reasons. In this case there are two issues to address: 1. How will you protect your children from the effects of your difficult part- ner, your marital strife, or your person- al unhappiness? 2. How will you manage to stay in an unhappy marriage and still be happy? IF YOU GO: If you decide to end the marriage, the chal- lenges are a little different: 1. Are you the “Leaver” or the “Left?” Depending on your position, the bal- ance of power and the emotional chal- lenges will be quite different. 2. How will you rebuild your life? 3. How will you keep your relationship with your children together as your marriage comes apart? By the way — my apologies to Constance Ahrons. Her book, The Good Divorce: Keeping Your Family Together When Your Marriage Comes Apart, actually has some good stuff in it. When the timing is right. PROVIDING UNIQUE AND EASY SOLUTIONS TO THE MEDICAL COMMUNITY FOR OVER 30 YEARS. Special Home Loan Programs for Physicians Medical Practice Lines of Credit & Equipment Financing RepublicBank.com Member FDIC It’s just easier here. ® Treasury Management Services Remote Deposit Capture Business Online Banking Mobile Banking App* Mobile Deposit* Lockbox Processing EMILY MILLER Private Banking Officer 859-266-3724 emiller@republicbank.com NMLS ID # 419242 Republic Bank & Trust Company Loan Originator ID # 402606. * Message and data rates may apply from your wireless carrier. Usage and qualification restrictions apply for Mobile Deposit. "Practically every dimension of life happiness is influenced by the quality of your marriage." MENTAL WELLNESS27 MD-UPDATE SEND YOUR NEWS ITEMS TO MD-UPDATE > news@md-update.com News Medical Marijuana in Kentucky. Are We Ready for It? Foundation for a Healthy Kentucky brings leaders and researchers together to discuss multiple topics LEXINGTON “Medical Marijuana Fact and Fiction” was the theme of the Howard J. Bost Memorial Health Policy Forum, presented by the Foundation for a Healthy Kentucky on Monday September 23, 2019 at the Marriott Griffin Gate in Lexington. The goal of the forum was to “Elevate the public health voice in medical canna- bis policymaking discussions in Kentucky.” According to its website, the Foundation for a Healthy Kentucky, led by president and CEO Ben Chandler, “is a nonprofit, non-partisan organization that opened in 2001 with a mission to address the unmet health needs of Kentuckians by influencing policy, improving access to care, reducing health risks and pro- moting health equity.” Speakers and presentations at the confer- ence included Shannan Babalonis, PhD, from the Center on Drug and Alcohol Research at the University of Kentucky; Brian Higgins, Esq, with Frost Brown Todd, LLC; Andrew Freedman, co-founder, Freedman & Koski, Lisa Gill of Consumer Reports, and Danesh Mazloomdoost, MD, Wellward Regenerative Medicine in Lexington and a fellowship-trained anesthesiologist in pain medicine. More Research Needed Babalonis referenced a Pain and Opioids In Treatment (POINT) study conducted in Australia, reviewed in Lancet, 2018 that sug- gested that “medical cannabis use may be det- rimental to pain patients taking opioid anal- gesics. Cannabis worsened patient outcomes with greater pain severity and interference in their daily activities.” Her conclusion was that “not enough high-quality studies have been conducted to determine what conditions it may help, and what conditions may worsen with cannabi- noid treatment.” Legal Questions Brian Higgins, an attorney from the Cincinnati office of FBT, has advised health- care systems, senior living facilities, and phy- sicians on medical marijuana use, mostly in Ohio. He presented some background facts such as: 1. Before the 1900s, it was legal to grow and consume marijuana 2. In 1906, the Pure Food and Drug Act said marijuana products had to be labeled with contents and dosage. 3. In the early 1900s, states began to crim- inalize marijuana and its use, associating it with migrant immigrant workers. 4. In 1986, the Anti-Drug Abuse Act cre- ated mandatory minimum penalties for marijuana offenses. 5. In 1996-1998 California, Alaska, Oregon and Washington legalized medical mari- juana. 6. In 2012, Colorado and Washington legalized recreational marijuana. Medical marijuana is currently legal in 33 states plus Washington, DC, and in 11 states plus DC, recreational use is legal. States laws vary, but generally medical marijuana laws require a certified physician visit and certain medical conditions; some home-grown mari- juana is permitted, but possession has limited amounts and time periods for use. Some states allow minors to use. The sticking point, said Higgins, is the discrepancy between the Federal Controlled Substances Act which designates marijuana as a Schedule 1 controlled substance and the vari- ous states’ law. Enforcement of the federal laws is limited, but that could change, said Higgins. Colorado Experience Andrew Freedman of the consulting firm Freedman and Koski, Inc., spoke about some of the practical results that Colorado has experienced since recreational marijuana was legalized. Key points that most people care about are frequency of youth and adult use, hospitalizations, driving while high on THC, and tax revenue. Ongoing and unresolved implementation issues around recreational marijuana include delivery systems, potency, vaping, and health and economic equity, said Freedman. Big cor- PHOTOS BY GiL DUNN Shannan Babalonis, PhD, from the Center on Drug and Alcohol Research at the University of Kentucky Brian Higgins, Esq, with Frost Brown Todd, LLC Next >