Achilles tendon confronts ballet; pathologists reach out; cannabis considerations: Upstate Medical University's HealthLink on Air for Sunday, Jan. 8, 2023
Physical therapist Michele Dolphin, DPT, and her student Nicole Harry share research on Achilles tendon injuries in ballet dancers. Pathologist Rohin Mehta, MD, and his student Alexandra Tatarian talk about pathologist-patient consults, Neuroradiologist Hesham Masoud, MD, tells what's important to consider before visiting a marijuana dispensary.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a physical therapist and her PT students examined Achilles tendon injuries in ballet dancers.
Michelle Dolphin, DPT: ... The other unique part about the pointe shoe is the ties. The satin ties cross in an area over the Achilles, where normally the Achilles does not have a good blood flow in any of us. ...
Host Amber Smith: A pathologist and a medical student discuss how they're helping patients with cancer understand their lab reports.
Alexandra Tatarian: ... It was really powerful for them to just hold the microscope slide in their hands and realize that was the outcome of this biopsy procedure they went through and kind of see the whole process and then see the slide under the microscope just puts everything together for them. ...
Host Amber Smith: And a neurologist advises what to consider before visiting a marijuana dispensary. All that, plus The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, we'll explore how pathologists can help patients with cancer understand their diagnoses. Then we'll consider what's important to know before visiting a marijuana dispensary. But first, we'll look at why ballet dancers are vulnerable to Achilles tendon injuries.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." It makes sense that ballet dancers tend to have a higher incidence and frequency of lower extremity disorders, compared to disorders in other regions of their bodies. One of the most prevalent types of injuries involves the Achilles tendon.
A doctor of physical therapy from Upstate published research recently about Achilles tendon disorders in ballet dancers. Michelle Dolphin is here to share her work, along with one of the physical therapy students who assisted in this research, Nicole Harry.
Welcome to "HealthLink on Air," both of you.
Michelle Dolphin, DPT: Thank you. We're excited to be here.
Nicole Harry: Thank you.
Host Amber Smith: Let's start with a description of the Achilles tendon and what its role is. Ms. Harry?
Nicole Harry: Yeah, absolutely. So this is a great place to start. The Achilles tendon is located in the back of the lower leg. Many people think of this region as the calf. The calf muscle actually has two parts, and both of these parts are going to attach to the tendon, which attaches to the heel bone. And so it's really the region of your heel cord.
Host Amber Smith: It's in the region of, what kind of cord did you call it?
Nicole Harry: The heel cord. So it's like the back of your heel.
Host Amber Smith: So this is the tendon that helps us flex and point?
Nicole Harry: Yes, absolutely. So this is going to help point your foot and plant or flex your ankle, is what it's called.
Host Amber Smith: I see. So is that its main role in the body, or is it necessary for ambulating, for walking?
Nicole Harry: Yes, correct. So this is the main role that the Achilles tendon has and is necessary for ambulating and walking and what we call push-off during gait.
Host Amber Smith: Do you know what it looks like or what it feels like in the body? Have you seen one in person?
Nicole Harry: Yes. So, we kind of have a lab that we get to go in and see other people's tendons and see how they function. And then we also can see these in the cadaver lab that we have during our placement in school, in our education.
Host Amber Smith: Is it like a rubber band?
Nicole Harry: Yes. Similar, I would say. Definitely shinier and kind of stretchy.
Host Amber Smith: Now, regarding common injuries I've heard of tendinitis. Can you explain what that is?
Nicole Harry: Yes. So tendinitis, broadly, is inflammation of a tendon, and so Achilles tendinitis is going to be inflammation of the Achilles tendon.
Host Amber Smith: And then tendinopathy, what does that mean?
Nicole Harry: Yeah, so tendinopathy and tendinosis are just a little more common in older adults. They can be non-painful. They can be painful. But there's less of an inflammation and more of a different disease process there.
Host Amber Smith: Now, Dr. Dolphin, why are Achilles tendon injuries prevalent among ballet dancers?
Michelle Dolphin, DPT: Thank you for that question. So from our research and our understanding in working with dancers, the Achilles tendon is what's going to help us get up over our toes. So for dancers that frequently dance, it's known as on relevé, on the toes or the balls of their feet. This is frequently loaded. So we see a greater prevalence of injury among dancers.
Host Amber Smith: Compared with other athletes in other sports, right?
Michelle Dolphin, DPT: Well, that's a great point, too. So we often see this in athletes who jump. So I've worked with patients who have had injuries related to volleyball, to basketball, certainly. You can see some disorders in runners as well. And then, as Nicole mentioned, it also can be in folks who are non-athletic. So it can be, I had a patient who one time was just stepping onto a dock to get into his boat, and this may be likely that there was a disordered process in the Achilles prior to this injury. But to your point, dancers and athletes that do a lot of jumping, it's quite common.
Host Amber Smith: So jumping, or like you said,elevating your, on the balls of your feet or on the point. That's the move that sort of puts you at risk?
Michelle Dolphin, DPT: Yeah. It's due to an inadequate loading cycle. Like any muscle, like a muscle in your arm, if you exercise it consistently, and you don't have any rapid change on training or excessive training, the muscle will respond. But sometimes in dancers there's an inadequate preparation. It could be too little exercise or too much exercise that can put this body part at risk.
Host Amber Smith: Does age or gender affect a dancer's risk?
Michelle Dolphin, DPT: We didn't see in our research a difference between gender, between males or females. But what we did notice is adolescents can experience this based on the frequency of training. So if you think about this time of year in holiday shows, they rapidly increase their rehearsal schedule. So this may put them at risk.
And then again, I think of the weekend warrior, so the athlete that doesn't train regularly. They go out to a family event. They play pickleball. They play volleyball. They may get injured because they're not training as consistently.
Host Amber Smith: So when you see an injury like this, do you typically see it in one leg, or would it ever show up in both legs at the same time?
Michelle Dolphin, DPT: I love this question because I'm surprised by the answer, actually. I would suspect it's both legs, right? You would expect your Achilles. You're training both feet, both legs, whatever the case may be. But it actually seems to show up on one side, which we call unilateral. So it may be your dominant side, the side that you push off with more often. And when I've seen it in patients that have both legs are painful, one is usually worse. But I don't know the reason why that is, other than maybe speculating they're loading that a little differently.
Host Amber Smith: Now with ballet dancers, did you see a difference or did you even look between whether they were in pointe shoes -- those slippers that have the kind of the toe box that's really stiff and firm -- or just the regular ballet slippers?
Michelle Dolphin, DPT: Yeah. What we found is exactly that the pointe shoe itself, not only because you're in a toe box, a constructed toe box. If folks aren't familiar, you load all the way up onto your tippy toes, so not just the ball of your foot. Your entire body weight gets in a straight line over your toes. Then, based on the shape of your foot, the longest toes take the most load. We all have different foot arrangements. But the other unique part about the pointe shoe is the ties. The satin ties cross in an area over the Achilles, where normally the Achilles does not have a good blood flow in any of us. So you're taking two factors -- put them up on your tippy toes, and tie these satin ribbons around a place that has a compromised blood flow naturally. And we did see that that has a greater risk of injury than other types of dance, particularly dance footwear.
Host Amber Smith: Well, that's interesting. And there's no way, though, you have to have those satin ties. You can't really keep the shoe on without them, right?
Michelle Dolphin, DPT: That's correct. Plus, think about ballet being this classical or traditional dance. Like most people would object if we put them in a different type of shoe, like some modern way to take that pressure off. So the classical aesthetic demands are such.
Host Amber Smith: This is Upstate "HealthLink on Air" with your host, Amber Smith. My guests are Dr. Michelle Dolphin, who's part of the physical therapy faculty in Upstate's College of Health Professions, and Nicole Harry, who's a student in the physical therapy program. Now, Ms. Harry, I'd like to hear about the research which was published in the Academy of Orthopedic Physical Therapy. Can you tell us why you investigated Achilles tendon injuries in dancers?
Nicole Harry: Absolutely. So I grew up dancing and still really enjoy being a part of the dance world. And I'm drawn to ballet, and specifically pointe because it's just so beautiful and really, truly an art form, how they can do this for hours on end. And so, you know, I thought they're using their bodies in a different way than the normal population is, just walking and exercising. So I figured it would be interesting to look into the difference.
Host Amber Smith: So how was your research done?
Nicole Harry: So our process was a literature review. We searched multiple databases using very specific search terms, and we found all the relevant articles on ballet dancers, specifically on Achilles tendon disorders that were published in the past 10 years. And so we screened these abstracts and full manuscripts and articles based on the author consensus.
Host Amber Smith: So what were your findings? I know you looked at a lot of things, but what are the most relevant findings?
Nicole Harry: We found so many things of interest. I'll touch on a couple here. The prevalence of Achilles pain in ballet dancers of the collegiate level is six times higher than contemporary Chinese dancers of the same level. And they also found that the prevalence of Achilles tendinopathy was very high as well, and it was ranked as the second most common overuse injury by one of the authors, Sabrina et al. So we also looked a little bit on risk factors in young female ballet dancers. Risk factors they found included maturation, hyper mobile joints and compensatory mechanisms. And so it was really interesting because compensatory mechanisms can occur at any joint. You know, the hip, the back, the knees. And it's just how the body's moving differently that can affect the joints above and below. And so that can beaffecting the ankle and the Achilles, Achilles tendinopathy there.
Host Amber Smith: Dr. Dolphin, overuse injuries in athletes must be tricky to treat because the athlete, I know, wants to train and to get stronger or maintain strength, but not overdo it. So how would you counsel a dancer to avoid developing this injury?
Michelle Dolphin, DPT: Yeah, and Amber, it is such a unique thing. It's unique to every dancer, right? Or every athlete that you might counsel. So it's that gradual loading. We call it graded loading. So start with a little. When your body gets ready, do a little more, and so on and so on. That's important for specificity. So if I need to dance on my toes, I need to train by dancing on my toes. But when we think about someone who's maybe having a little setback or having injury, then we say, well, are you cross training? Have you been in a pool? Have you ridden a bicycle? Have you done other things, because your whole body needs to be strong, flexible, fit, etc. So it's a really challenging, balance act, particularly if somebody has a performance schedule, they have a deadline, or an athlete has a competition. So it can be a difficult conversation with adolescents, with families, with dance teachers, with coaches.
Host Amber Smith: For a dancer who suspects they may have a problem with their Achilles tendon, can you describe or walk us through what the diagnosis and treatment might entail?
Michelle Dolphin, DPT: Yeah, absolutely. So first of all, in New York State you can see a physical therapist directly without a referral for 30 days, up to 30 days or 10 visits. So PTs are very well trained to do medical screening, if additional imaging or anything else would be warranted. The diagnosis is based on history and clinical exams. So the patient tells you the story of their problem and then you observe specific movements -- walking, sitting, standing, balancing. And then go to a very specific look at the ankle -- range of motion, strength, tenderness. And the exam is really very easy to make in a clinical exam, by a therapist.
Host Amber Smith: So I'm assuming physical therapy is part of the treatment.
Michelle Dolphin, DPT: Absolutely. I would recommend if someone's having problems with this, go see your movement specialist. And the movement specialist is a therapist, physical therapist. Here at Upstate, we have a specialty service group called the performing arts service group, so we see patients throughout our outpatient offices, and a group led by Chris Rieger. We've been going out to local dance schools and doing some screening of young dancers. So definitely it's an area of interest and expertise here at Upstate.
Host Amber Smith: Are there ways that dancers can stay strong while they're recovering from an Achilles injury?
Michelle Dolphin, DPT: Yeah, we will teach them a variety of exercises. Some may be done in sitting. Some may be done with elastic bands and various exercise equipment.
Host Amber Smith: Let me ask, Ms. Harry, in your training so far, have you learned about ways to keep the tendons healthy?
Nicole Harry: Yeah, absolutely. I would emphasize proper training is really the most important factor. So a dancer and their dance teachers really should be aware of the most effective training. In terms of our research, the opportunities we found were linked to volume of training and then endurance and strength of the Achilles. So choreography might entail a limited number of jumps or relevés, which we said before was just going on your toes. But a dancer really should be as fit and as strong as they can be to perform the choreography. Dr. Dolphin previously mentioned changes in training demands, such as increased dance at a summer camp or no dance while students are on break. And so that could affect the dancer's ability to really fully participate and perform and load their Achilles.
Host Amber Smith: Dr. Dolphin, is there any way to predict whether someone has a vulnerable tendon? Can you sort of anticipate that a certain person might have, might develop problems? I know that ballet dancers in general are at higher risk, but can you get down to individual level?
Michelle Dolphin, DPT: Yeah, I think, amber, it's not just based on a physical presentation. You know, there are requirements in terms of, you have to be able to fully point your foot, like get the top of your foot in a straight line with the front of your shin. It has to be completely vertical. So there is one physical capacity component to get into a toe box, which is to be up on pointe. Let's say you've met that physical criteria. The rest comes down to training. There's nothing I can look at, "Oh, this one's too lean, or this one's too that" to decide what is a risk factor. It's about the training, which is actually pretty exciting because that's something we can change and influence.
Host Amber Smith: What about other types of injuries for ballet dancers? Aside from the Achilles tendon, are there other injuries that you see commonly among ballet dancers?
Michelle Dolphin, DPT: Yeah, it's primarily lower extremity and low back. So legs, hips, knees, ankles. And while I have this quick moment, I want to thank our co-author, Liz Janowitz, another student PT who helped us on this paper. And we have another paper in review right now looking at anterior knee pain in dancers as well, because that is very common in dancers.
Host Amber Smith: Well, dancers are not unique to sort of a rigorous training schedule. All athletes, I mean, you think about football players, soccer players, karate. So I don't, I don't know if there's any general advice. I mean, hopefully you have a good coach who's attentive and isn't going to ask you to do things that'll injure you.
Michelle Dolphin, DPT: Yeah.
Host Amber Smith: But how does the, how does an athlete learn their limits?
Michelle Dolphin, DPT: You know this. This is another really great point, and this was not from our research, but from being a clinician and being an educator. We talk about external load, which is how you work out. Are you sleeping? What's going on? And internal load, your stress, your emotional health, your mental health. We can show when people are under increased mental stress, they're more likely to have an injury. So that athlete that's having a really bad day, had a poor exam, had a fight with a parent, that actually increases their risk. So for our coaches and parents and loved ones to recognize, it's not just about the workouts, it's how are we sending ourselves or our family members out to do these activities? Is it a good time? Should we pull back a little bit to protect them from that injury risk? So external and internal factors are at play for all of us.
Host Amber Smith: So being attuned to that maybe would help reduce the risk too.
Michelle Dolphin, DPT: Absolutely. Absolutely.
Host Amber Smith: Well that's really good to know, and I appreciate both of you making time for this interview.
Nicole Harry: Thank you so much.
Michelle Dolphin, DPT: It's been a pleasure. Thank you.
Host Amber Smith: My guests have been doctor of physical therapy Michelle Dolphin, from Upstate's College of Health Professions, and physical therapy student Nicole Harry.
I'm Amber Smith for Upstate's. "HealthLink on Air."
Medical lab reports can be confusing. How pathologists are trying to change that -- next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Dr. Rohin Meht is a pathologist at Upstate who offers consults with patients who are facing a cancer diagnosis because lab reports can be difficult to understand. He'll also be studying the impact of this consult service on the patient's care journey.
Dr. Rohin Mehta is an assistant professor of pathology At Upstate and the medical director of pathology and clinical pathology at the Community campus, and he's here to explain how this will work, along with Alexandra Tatarian, who's a third-year medical student who works with Dr. Mehta. Welcome both of you to "HealthLink on Air."
Rohin Mehta, MD: Hi, good afternoon.
Alexandra Tatarian: Thank you for having us.
Host Amber Smith: It seems like it's becoming more and more common for patients to see the results of blood work or lab tests before their doctors do, and I'd like to ask each of you whether you think this is a good thing.
Dr. Mehta, you can recall a time when patients never saw reports and had to wait until the next appointment with their doctor to learn the results of tests. Have things changed for the better?
Rohin Mehta, MD: So I think with the initiation of MyChart, where patients can, are able to look at the results before seeing their clinician, there's pros and cons to that. On one side, I think it's good because the patients are able to get the information, where it may take some time for the clinician to give it to them, whether it be lab work, et cetera. However, on the flip side, if there is a diagnosis, there may not be a positive one, i.e., a cancer diagnosis. In some senses that may not work to people's benefit because they get it, and then they'll have to wait some time before they see the clinician, and obviously the anxiety that that brings along is not the best thing.
Host Amber Smith: Miss Tatarian, you're of a generation growing up that expects all of this information to be available ASAP. Even though not everyone can make sense of a pathology report, is it helpful to have access to what can be confusing or anxiety-provoking?
Alexandra Tatarian: I think it's certainly important that patients, when they receive all this information instantaneously, have somewhere to go for interpretation, especially if they won't hear from their clinician. And sometimes they may not get a full explanation from their clinician of what the report actually means. There's a lot of detail that goes with the pathology report. And so, this service offers the opportunity for patients to really sit down and take the time to go through the report line by line if they want and really understand what is behind just the diagnosis the clinician might share with them.
Host Amber Smith: So this is an interesting project that you're working on here. Are professional pathologist organizations offering solutions or things like this? Are you aware of any efforts that are underway?
Rohin Mehta, MD: Well, it is funny you say that because actually, the president of the College of American Pathologists, which is a renowned organization for pathologists, came across our consultation service on Twitter. So he reached out to us, and he's a big advocate of patients and pathologists being consultants. And he reached out to us after reading (about) our unique program, and he featured our facility in the Archives of Pathology, which is a prestigious journal. And he seems to really want to move forward with having pathologists as consults.
Host Amber Smith: That's interesting. Ms. Tatarian, I want to ask you, with three years of medical school under your belt, do you feel confident that you could decipher any sort of pathology report yourself?
Alexandra Tatarian: I've certainly studied a lot in the last three years. And I didn't realize how much learning medicine would be like learning a foreign language. So I would feel comfortable at least understanding what the words on the paper mean, but in terms of their interpretation for the patient's prognosis and the clinical context of what the treatment plan would be, I think that would be something that would be in my residency, where I would figure out the full meaning. So I think it also just goes to show how much training it takes to truly and fully understand the pathology report.
Host Amber Smith: Right. And the importance of what Dr. Mehta began a few years ago. You started offering patients with breast cancer assistance with making sense of pathology reports after they had a biopsy or a surgical procedure. And are you now expanding that to other types of cancer?
Rohin Mehta, MD: Well, we'd like to. We try to put it out there, but you know, during COVID, it kind of halted, because a lot of people were not able to come into the hospital. So, you know, it kind of took a hiatus. And, now with the help of Alex, we are trying to get the word out to all clinicians. Alex has reached out to a lot of the clinicians with emails saying, "We're offering this service; it'd be great to have more people." So just to show them how informative it can be and how helpful it can be. So yes, we would like to offer it to all types of patients, and I think there's a move for pathologists to be seeing patients, because pathologists serve as clinical consultants to all health care professionals, and now we're beginning to do it. It should be expanded to patients and their family to answer specific questions and to help bridge the gap in their understanding of laboratory tests and pathologists' diagnosis.
Alexandra Tatarian: And going off that, we've met with a number of oncologists and radiation oncologists at Upstate, as well as even a breast cancer support group and talked to patients directly. And part of what we're trying to figure out is when is the best time to set up this meeting in a patient's treatment course and just kind of get people involved, but at the right time, when they're ready to process the report.
Host Amber Smith: So is this mostly patients who are getting their care from Upstate?
Rohin Mehta, MD: As of this point, it is, but I mean, I wouldn't mind seeing patients from anywhere. Again, the main thing is even if they don't understand the jargon per se of what we're saying, we can try to explain it to them in layman's terms. It's so good for them to see what they're fighting against. And that, to me, is the main thing. Some of the patients we've seen, it's mainly they see it, and then they can wrap their head around it. That's how I like to put it. Some people actually are more informed than you would believe. They get on Google, and they come in here, and they ask me all this terminology, and I'm like, "Wow, did you go to med school?" They're like, "No, you know, I just Googled it." So I'm like, "Wow, that's pretty exciting that they can do that these days."
Host Amber Smith: So I wanted to understand how this works, and I know that Covid changed some things, but ideally you want to work with these people in person, face-to-face, is that right?
Rohin Mehta, MD: Yes, ma'am. I feel that that's the best way to do it. You know, there's something not as personal if you are doing it online or on a TV. I think when they're there and you can see them in the eyes, they can ask questions. And, you know, body mechanics, you can work off of that, sometimes. If you start talking about something, and you could sense that they're not really comfortable, you can kind of back off a little bit. And sometimes they can come with their significant others or their family members, and that makes it much easier for them.
Alexandra Tatarian: I was also fortunate to attend one of these sessions with a patient, and it was really powerful for them to just hold the microscope slide in their hands and realize that was the outcome of this biopsy procedure they went through. And kind of see the whole process and then see the slide under the microscope just puts everything together for them.
Host Amber Smith: Now, what are you doing in terms of studying the impact of this service on a cancer patient's journey? Do you have a clinical trial underway?
Rohin Mehta, MD: I'll let Alex answer that one.
Alexandra Tatarian: So we recently received IRB approval to study the impact, and how we're doing that is with a survey afterwards that the patients can fill out -- just questions gauging whether or not they thought it was helpful, whether or not they feel more comfortable with their treatment plan and just understanding their diagnosis. And we're also trying to figure out what cancer severity levels patients might feel more inclined, or less inclined to have this consultation. Because if it's not as good as a prognosis, it might be something that people don't want to see under the microscope per se, but we're just trying to figure out exactly what patients might find the most helpful.
Host Amber Smith: And you mentioned IRB. That's the Institutional Review Board. But can you explain to our listeners what that is?
Alexandra Tatarian: Yes. It is an organization at Upstate, and I think most institutions around the country have it. And you basically put in an application saying all the data that you'll be studying because you need permission to go into patient charts to see what diagnoses they have, and just make sure that people are OK with how the research is being done, just making sure it's clear what we're studying, how we're studying it and what our goals are.
Rohin Mehta, MD: So also making sure that we are, there's a lot of HIPAA regulations (relating to privacy and personal information) and this and that. So collecting their data, we need to make sure that we have their permission and know what and what we cannot look at in their charts. Because a lot of this is kind of gathering information from the charts, educational status, socioeconomic class, all these things. Because it's so novel, it's never been done, maybe there is a certain genre of patients that would be more inclined, as Alex was putting it, to come see us. And some may say, "You know what, I don't want to know." And that's why I think breast cancer patients have this camaraderie that I have not seen. You know, you have all these pink ribbons and these things that a lot of other cancer patients you don't see as much of anymore. I think that pendulum is swinging the other way, and they're starting to do that. But it's good to just gather this information. It may be we can see if there's some sort of trend that we can utilize to get other patients to come in.
Host Amber Smith: And this will help you determine whether this is making a difference for people?
Rohin Mehta, MD: Absolutely. I mean, in the end that's what was our goal, to make sure that people are making sense of their pathology report.
Alexandra Tatarian: And just looking at what research is already out there, there's really not that much on this type of service. There's very few programs even around the country that will offer pathology consultations. And when the published papers that we've seen so far have very small patient pools, maybe around 20 or 30 patients, and I know Dr. Mehta has already met with many, many more than that. We're hoping to get even more patients. We're welcoming all patients who want to come review their pathology reports. And the more information we have, the stronger our understanding of this service's impact will be.
Rohin Mehta, MD: Yeah, I think we've seen now about 61 patients thus far, which is according to the president-elect of the College of American Pathology is the most in the country. And now we've sent out these questionnaires to these patients after we had the IRB approval. And, we've gotten a lot of feedback already. And, the president of the CAP (College of American Pathologists) said he wants to collaborate with us and put this in a national spectrum to maybe galvanize other pathologists around the country to consider utilizing this as a form of treatment, if you will.
Host Amber Smith: How would you advise someone if they're listening to this and they'd like to connect with a pathologist for some help understanding their report? Do you have a website or a way for them to reach out to you?
Rohin Mehta, MD: We do actually. On the Upstate pathology website. Right now it's just gauged toward breast cancer patients. So you go under "patients" and "patient care," there is a link to us. We also have a pamphlet that we have that was created, and Alex has been kind enough to go around the cancer center and put it around to other clinicians, so people can get more exposure to it. I think the thing about it, people would like it if they knew about it, but because it's such a novel thing, nobody really knows that they can see it. And the other thing about it -- we offer this completely free of charge. There's no charge to it. It's mainly for the benefit of the patient.
Host Amber Smith: We'll return to Upstate's "HealthLink on Air," after this short break.
Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith, and my guests are Upstate pathologist Dr. Rohin Mehta and third-year medical student Alexandra Tatarian.
We're talking about how pathologists can help patients understand their pathology reports.
Now, let's simplify if we can, what types of information a patient can expect to find on a pathology report if they went for a tissue biopsy to find out whether they have cancer. What sorts of things would they expect to see on the report?
Rohin Mehta, MD: So depending on the type of neoplasm or non-neoplasm we see, there can be numerous things that can be on it. So we have a gross description. So let's say for a biopsy, we describe exactly what's coming out of the patient. For instance, if it's just a biopsy of a lesion, it'll say "small piece of tissue," give dimensions and the dimensions of it and the color, the texture. And then from there we have a final diagnosis, what we see under the microscope, whether it be a neoplasm, such as a carcinoma, or whether it's just something benign like chronic inflammation. For big resection specimens, it gets a little bit more complicated. We have describe what the neoplasm is, whether it's a carcinoma or a sarcoma. We describe what it looks like under the microscope, which is called a microscopic description. Then we have what's called a synoptic report, which the oncologist can use to determine margin status, meaning is the tumor completely excised? Is there any residual tumor? We have certain immunohistochemical stains that we can use to help us determine how aggressive it can be.
Nowadays there's something called targeted therapy. So certain stains we can use for instance, in breast cancer, HER2/neu Herceptin utilization is due to a stain of HER2. So they can gather a lot of information. Some of it is mainly meant for the surgeon and the oncologist, but the patient obviously sees it, so they may have questions on it. So it all depends on what type of neoplasm it is, what part of the body it's from. These reports can actually offer a ton of information.
Host Amber Smith: Now you used the word tumor, and I'm pretty sure that can either be cancerous or not, but what does the word neoplasm mean? Is that a synonym for tumor or...?
Rohin Mehta, MD: It is a synonym for tumor. I mean, neoplasm is something that doesn't really belong there, if you will. Tumor is a growth of tissue.
Host Amber Smith: Are there words that are reassuring that a person might see on their pathology report? I mean, the word "benign." Does that mean you don't have cancer anywhere?
Rohin Mehta, MD: It means you do not have cancer. Benign means benign. It is not a neoplastic, nothing malignant. Other words, such as chronic inflammation, as long as they don't see, and then we will delineate it in our report, saying if it is something that's a malignancy, it will be very obvious to the patient.
Host Amber Smith: And you were talking about like with breast cancers, you can tell a lot about whether they're hormonal, if they're fueled by hormones or not. Are you seeing a lot of use of the genetic testing for breast tumors, the oncogene and that type of stuff?
Rohin Mehta, MD: Absolutely. Yes, we do. We do the oncotype score. Foundation Medicine is something we use. Nowadays, with this targeted therapy, you can get the genetics of a tumor, and some of these tumors may express certain receptors that oncologists can utilize to form what's called targeted therapy. And that is going to revolutionize cancer treatment. I think we're just in the infancy of this. And down the line, it's going to be, I think it's going to be the new wave of medicine. You get a piece of tissue, put it into a machine, get the genetics of it, and then we can say how to treat the patient.
Host Amber Smith: But that's a whole another level of confusion for a patient trying to understand, "What does that tell me?"
Rohin Mehta, MD: Oh, it's confusing for me, not being a molecular pathologist, too. That's why I say pathology is great because we have, it's such team work. It's not like one pathologist doesn't do everything. Everyone has their specialty. Here at Upstate, we have a phenomenal cancer center and phenomenal molecular genetics, and everybody here, we work together. And that's why this group approach is why I love this institution. Other institutions, they'll send things out, and you'll have other institutions working with the same patient. In our place we have, everyone is in one area. That, I think, is what's great about Upstate.
Host Amber Smith: Now, what if a patient has several samples taken in a single biopsy? I'm thinking about prostate biopsies where they take a bunch of different samples at once, and some of them say "cancerous" and some of them say "benign." How does a patient make sense of all of that collectively?
Rohin Mehta, MD: Specifically with prostate, they take biopsies from different areas of the prostate. If one of them says cancer, then you have cancer. Some areas may not, it may not be as diffuse as it could be, but if there's one or two biopsies in certain parts of the prostate that say it's carcinoma, then you have carcinoma. So you have a malignancy.
Host Amber Smith: Now, what additional kinds of information would a person be looking for if they already had a biopsy that detected cancer, and then they went for surgery to have the mass removed? What sorts of things would they look for on that report?
Rohin Mehta, MD: I think the main thing that they will look for is how high grade or low grade it may be. The main thing for everybody is that make sure that the tumor is completely out, or the carcinoma. That margin status is the biggest thing. And from there, there's other entities that's put in the report, again, such as hormone receptor status or certain stainings that may indicate that they can utilize a targeted therapy. Those are the main things for a patient that would be important for them to know. Other things like, from a pathology perspective, how proliferating it is, that's nothing that the patient really, in my opinion, wouldn't really, doesn't need to know about because they have enough to deal with than to know about all these little semantics of it. So, the main thing is, is it out? Is it high grade or low grade? And the biggest thing is, has it metastasized anywhere? And that's a big factor, which most people know about when they think about cancer. Has it "mets" (metastases -- places where it has spread to) anywhere or not? Is it localized, or is it diffuse?
Host Amber Smith: Well, how hard is it to tell whether it has metastasized, because there's not like a full body scan that you can do that'll tell you that the person doesn't have cancer anywhere, is there?
Rohin Mehta, MD: Well, actually, there is. So we use what's called the PET (positron emission tomography) scan, and that doesn't necessarily tell you that it's diffused, but if you have a high PET uptake in certain areas in the context of a cancer, then the oncologist or surgeon or interventional radiologist will biopsy those areas to make sure that there is not a metastasis there. But yes, you are correct in the sense it doesn't, it's not a clear cut. The last line of defense or the definitive diagnosis is a tissue. Radiology plays a big role in this. They see a mass that looks very aggressive, that's eating away at the bone cortex, for instance. Then you can pretty much presume that this may be a metastasis. But until you get the biopsy of it and see the tissue under the microscope, you really can't tell.
But there are some imaging studies, and I'm sure in the future there'll be other things now that we'll be able to tell how far ... There's blood tests that you know, you can utilize certain blood tests that can tell you if it's high. Is that an indication that this may be. And that's how they monitor a lot of tumors in patients that are undergoing treatment. They will use blood tests to determine is has this level gone down or has it gone up, in the context of radiation and chemotherapy. So instead of keep putting the patient through biopsies and biopsies, they can utilize blood tests.
Host Amber Smith: Well, it occurs to me that the majority of patients never meet the pathologists who are analyzing their tissue samples. So I wanted to give listeners kind of a description of what a pathologist is and what their training is.
Ms. Tatarian, what attracted you to this field?
Alexandra Tatarian: That is correct that many patients do not meet their pathologist, and even as a medical student, when I tell peers who are not in medicine what I'm interested in -- and that's pathology -- they haven't heard of it, which is interesting because pathologists do play such a key role in the hospital, and what I love about the specialty is that you're problem solving all the time. You're coming up with diagnoses, looking under the microscope, seeing exactly what's going on, and you're able to describe that and communicate it to the doctors who will be giving treatments. So I think it's exciting to be able to figure out what's happening, look at the cells directly.
Host Amber Smith: And so you do the four years of medical school and then a pathology residency, and then maybe fellowships on top of that, is that right?
Alexandra Tatarian: That's correct. And typically the pathology residency is three to four years, and then a fellowship and maybe a specific part of the body like breast or hematology. But I think the more, once you get past medical school, it becomes more like a job and more learning. But I'm excited because I'll get to do pathology more often as a resident than I get to do it as a medical student, and just really learn in the field that you're interested in.
Rohin Mehta, MD: And pathology is also such a constant growing field, like in the sense that you are always learning, you're always reading and going to tumor boards. Like my specialty, for instance, is GI (gastroenterology) and I enjoy doing breast, but all my colleagues have other specialties, and we go together to consensus conferences, and you learn about it a lot. So some people have their love of a certain type of pathology, however, you can always learn more. That's the main thing. I think that pathologists are no longer just a doctor's doctor. I think pathologists should be become more widely recognized as the patient's doctor, and like directly providing information and counseling the patients for their clinical management and well-being.
Host Amber Smith: Well, before we wrap up, let me ask some advice: For someone who's facing testing that has to do with cancer, can they ask their doctor to see pictures of the tissue samples or the tissue sample itself? Will that help in any way?
Rohin Mehta, MD: So, I mean not the pathologist, the actual clinician?
Host Amber Smith: Either, I guess. Although for most patients, they really are not likely to have access to the pathologist, or can they ask to talk to the pathologist if they want to?
Rohin Mehta, MD: Yeah, I mean this is the galvanization of our service because now they're able to ask. I guess they can. I mean, I don't know how comfortable some clinicians may be to point out the histology, having not gone to pathology residency. However, most doctors go through histology (the study of tissue under a microscope) and pathology in medical school, so they do have a certain amount of knowledge of it, so they can probably point it out. But I think that pathologists, obviously, do a better job at that, due to our experience.
Host Amber Smith: Do you think that trying to read the report is likely to be helpful or informative, or confusing and frustrating?
Rohin Mehta, MD: You know, that's weird because sometimes I've had patients come in here who have done their due diligence and have done research. That's what they call Google, right? Sometimes Google's not a good thing because what happens is they can go down this rabbit hole, and there's certain times people who have, they go to these forums and people, you know, misery loves company. So they'll make it sound so bad, and it's really not as bad as it sometimes is.
So on one hand, it's good because it helps them deal with it. But other hand it could get bad because they're getting these results on My Chart. They haven't seen their clinician yet. They're getting on the internet, Googling all these things, and then their anxiety and cortisol level shoots up because they don't know everything else about it until they see their clinicians. So I guess there's pros and cons to that.
Host Amber Smith: How do you see the field expanding? Because it seems like information is just going to become more and more available, more and more immediately. So do you think that services like the one that you're offering are going to become more common?
Rohin Mehta, MD: I hope so. I do hope so, because at least the feedback that we've gotten, me and Alex have gotten, through our questionnaires, it's been nothing but positive. It helps people. Now, the caveat to that, there's some people who do not want to know anything about it. They say, "I have cancer. Let me just get treated. I don't want to know about it. Let's just get it over with."
Some people really want to know about it. I guess it all depends on the person, and as Alex has alluded to before, how severe the cancer is. If it's something that's not so bad, maybe they'll have more likely to come and see us or wanting to know about it.
Host Amber Smith: Well, I appreciate both of you making time for this interview. Thank you.
Rohin Mehta, MD: Thank you very much for having us.
Alexandra Tatarian: Thank you.
Host Amber Smith: My guests have been Dr. Rohin Mehta, he's an assistant professor of pathology at Upstate and the medical director of pathology and clinical pathology at the Community campus, along with third-year medical student Alexandra Tatarian.
I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from neurologist Dr. Hesham Masoud from Upstate Medical University. With marijuana now legal in New York state, what should people consider before heading to a dispensary?
Hesham Masoud, MD: I would say be aware that you're dealing with more potent products now. So if you had used recreational marijuana in the past, then maybe now you're entering into a commercialized space now, and so you need to be aware that things are significantly more potent.
CBD stands for cannabidiol, and THC stands for tetrahydrocannabinol. So those are the major components, and the differences is, the CBD is non-psychoactive, and the THC is psychoactive. That relative concentration of THC versus CBD is really what's going to predict for you if you're getting more of a psychoactive component versus one that doesn't have that and has maybe the CBD's effect, which are thought to have anti-inflammatory, antioxidant effects.
Be aware that essentially THC is what's going to have that psychoactive alkaloid that's going to have those behavioral disinhibitions, maybe anxiety, so on and so forth. That's going to be in a higher concentration in sativa plants. So if it says sativa, if it comes from a sativa plant, or they say "sativa dominant," expect that that means it's going to have more THC, so potentially more psychoactive versus CBD.
And CBD is the one that has the anti-inflammatory, antioxidant effect and sort of the body type stuff. And that may have a higher component or higher concentration in a plant called indica. So if it says "indica dominant" or indica, then I would expect not to get as cerebral, but maybe more body. Are you never going to have the cerebral? No. Unless it's like zero THC and all CBD, expect to have some sort of psychoactive component. So that would be something to be aware of. It's this ratio, though, of how much between THC and CBD, and using sativa as your surrogate for THC and indica as your surrogate for CBD, with the knowledge that indica still has THC in it.
And then it's also important to know that this THC or these cannabinoids, if you're ingesting it, are really enhanced by foods that have fat in them. And so if you eat something that's greasy, it may potentiate the effect even more. So it can be a little bit difficult with edibles, because the dose response has to do with, obviously, the time from ingestion, and it's not as quick an absorption as it would be if one were inhaling it through smoking or a vapor.
It's important to know that eating versus vaporizing has a different effect, slightly, that is not as easy to predict in terms of comparing it to smoking. These cannabinoids can have different vaporizing points in terms of temperature. And therefore you can have different ratios between your THC and your CBD than if you had smoked it.
I would say another thing to be aware of is the people behind the counter for the most part, if you're going to a dispensary that has some regulation to it, are going to know a little bit about things. So I would share maybe your history of use because potency is modulated, obviously, by your own intrinsic tolerance. And you can't really say, "Oh, well, when I use alcohol, I am fine, so I'm going to be okay with marijuana." There is really no conversion there, that I've seen. But, just sort of sharing that, "Yes, I'm a heavy cannabis user," or "I'm a very light user," and so on and so forth.
And then when deciding on the way to ingest it, understanding that a vaporizer may be more potent. An ingestible may have a little bit more of a different behavioral effect than what you were used to when you had tried marijuana in the past. That can be in a very delayed fashion, so really give yourself time and plan your day accordingly. I think those are the basic considerations.
Host Amber Smith: You've been listening to neurologist Dr. Hesham Masoud from Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: E.D. Watson is a poet in training at the Institute for Poetic Medicine. She sent us an exuberant celebration of the body and urges us to do so, even as it ages and seems to turn against us. Here is "In Praise of the Body":
So much is made of the soul,
a thing we cannot prove or hold
and yet for this we pray, we sigh
we kill we moan
and damn ourselves, imagining
some place else is home --
but the body
the body is a fact
and I say bless it, bless its appetites
bless it limp and bleeding
each labored breath, the skin gone slack
bless its cavities and hollows
bless the curve at the base of the back
and bless each toe.
Call it friend instead of traitor
for no greater intimacy exists
than to be within its wetness
slickness pulsing, breathing
aching and excreting. Sleeping.
And when we say we love, remember
what we love is this: a mother's veined
and freckled hand, a child's nub of chin
the inside of a lover's thigh
where hairs grow soft and thin --
oh bless it
bless it all
and kiss your friends upon their mouths
that they may feel your lips
press your nose into their scalps
bear witness to what unravels them
the nodules, failing kidneys
gout, each one of us an envelope
of pain and iridescence, each ecstasy
so fleeting. Place your hand
upon your chest and feel your heart there,
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," understanding the microbiome. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.