When Care Goes Virtual: The Surprising Benefits of Video Visits

One thing Jillian Worth, MD, ABFP, can count on with teenage patients is their hesitancy to talk about serious subjects in the exam room. For teens coping with mood disorders, typical in-person appointments can feel artificial and discourage conversation. When the COVID-19 pandemic suddenly replaced office visits with video sessions, Dr. Worth noticed something remarkable: her young patients were opening up like never before.  

“What I’ve seen is kids on virtual visit in their bedrooms are more likely to talk about what they’re feeling, in the space where they have those feelings,” says Dr. Worth. “They’re willing to jump right into what they’re struggling with, instead of needing lots of warm-up.”

Another big benefit of video for young patients is flexible scheduling. Arranging an in-person appointment can delay care, when a quick video check-in has the power to turn things around for a teen. Adding a 15-minute virtual visit to the end of her day, says Dr. Worth, is much more doable than a regular visit, and takes care of the patient’s problem when it’s happening.

As a family medicine physician, Dr. Worth sees patients of all ages and backgrounds and surprisingly, video visits have proven beneficial across her diverse practice. Instead of having a patient seated in an exam room, video can offer a little window into their world, revealing the important objects, pictures and even people in their lives.    

“With longtime patients, at some point you stop asking social history questions, like who they live with,” says Dr. Worth. “But maybe you’ll see a grandkid running through the room on video and ask about them, and find out that family has moved in.”

Dr. Worth has discovered that asking her patients new questions that come up through video can lead to better patient care. Patients light up, she says, because they want to tell you more about who they are. They can also feel comfortable enough in their homes to admit problems they’ve never considered discussing in the office. If a patient reveals they feel unsafe in their relationship, for example, the care plan can include steps to address the situation.  

For elderly patients, occasional home visits can be a necessity, but before the pandemic they were usually limited to severely ill and homebound patients. Now that Dr. Worth sees most of her older patients on video, she looks out for them in new ways, such as noticing something in their environment that needs attention.

“I can have them pan around the room and see they have a loose area rug, or a dangerous step going down to their living room,” Dr. Worth says. “Maybe they use a walker and there’s a little dog running underfoot. Things I would never have known from an office visit.”

Then there are the patients who struggle more than others to even get to a provider’s office. Chronic conditions that involve regular appointments for care or medication management can be a challenge for those with debilitating illness, or for those who can’t get time off work. Visits using a patient’s smart phone can happen on a work break. People dealing with chronic pain can avoid a car trip and navigating a medical office building.

Another way virtual care boosts more equal access is the prevalence of smart phones across a diverse patient demographic. “It’s difficult for many working families to get themselves or their kids in for care, but most people have some version of a smart phone,” says Dr. Worth. “The flexibility and the capability of video on their device means they can hop on for a visit wherever they are.”

What’s clear is being able to see a patient when a visit might otherwise not have happened can change the course of illness and recovery. One elderly patient became bedridden and was considering hospice care. A family member held up her phone for a virtual visit with Dr. Worth from the patient’s bed.

“To see her in the office would have been impossible, but I was able to observe how it felt for her when she tried to move around,” says Dr. Worth. “I could see her pain and talk with her. Now we’ve got her in physical therapy at home and I see her sitting up in the living room.”  


Jillian Worth, MD, ABFP, is board-certified in Family Practice and currently practices at the Virginia Mason Bainbridge Island Medical Center. Dr. Worth specializes in family medicine, primary care, pediatrics, preventive medicine and transgender health.

How to Ensure You Get the Health Care You Deserve

**By Jane Dunham, MD**

While your health care team does everything in their power to provide appropriate care, the fact is, nobody knows your body better than you. Therefore, it’s important to be a partner in your medical care: speak up about your needs, concerns, and desires, particularly if something feels off or you have lingering questions.

We know that seeking health care (let alone playing an active role in it) can sometimes feel intimidating, especially if you’re not quite sure about the specifics of your condition. Below, we’ve outlined some tips to help empower you to get the health care you deserve, on your terms.

Educate yourself on your condition or diagnosis

Patients equipped with the proper information regarding their diagnosis may have an easier time playing a role in the care they receive. If you’ve received a diagnosis that’s new territory for you, we encourage you to read about it and ask questions as they arise. Ask your doctor if they can point you toward resources that will help you understand your diagnosis and what to expect. The same goes for medications you are prescribed: Know what you are taking and why you are taking it. Keep an updated medication list with you for reference and be sure this includes any over-the-counter medications or supplements that you take. This information can help to avoid harmful interactions with food or other medications that you may be prescribed.

Ask questions about your care plan

It’s well within your rights as a patient to fully understand any care being prescribed to you. Having a clear understanding of the details of your care plan helps you ask informed questions, aids your care team in setting goals that are realistic and achievable, and helps you provide specific feedback to your care team about how things are going. If you’ve asked a question and still don’t understand, don’t be afraid to ask again. Ask for a written copy of your care plan whenever possible so that you can refer to it as needed.

Consider asking a friend or family member to be your advocate

You don’t have to manage your health care alone. Ask a trusted friend or family member to assume the role of your advocate. Having an advocate can provide incredible support, particularly if you are anxious about your diagnosis or are experiencing any sort of issue that might make it difficult to advocate for yourself. Advocates can attend appointments to help ensure that you get all the information you need and make certain that you don’t forget any questions or important areas to address. It’s not uncommon to forget something when you feel nervous or anxious, and an advocate can help ensure you’re receiving the best care possible.

Participate in every decision regarding your health care

Of course, your medical professional is considered the expert, but YOU are the expert on yourself. If your provider suggests a course of treatment you don’t feel comfortable with, let them know and inquire about other potential treatment options. If something doesn’t feel right to you, we encourage you to speak up rather than just going along with things and feeling uneasy or unsure.

Remember, you are the most important person when it comes to your health. The right health care professionals understand this and will help in any way they can to ease your concerns and ensure your experience is positive. Never be afraid to ask questions. Advocate for yourself and always speak up to receive the health care you deserve.


Jane Dunham, MD is board-certified in internal medicine. She practices at Virginia Mason Medical Center and specializes in preventive medicine and primary care.

A Smile is Worth A Thousand Words: The Benefits of Virtual Health Care

**By Nicholas Moy, MD**

Virtual care is changing the way we think about health care. According to the CDC, there was a 50% increase in the number of telehealth visits in the first three months of 2020 as compared to the same period in 2019. As an internal medicine doctor at Virginia Mason Franciscan Health, I see the benefits of telehealth firsthand as we continue to weather the pandemic. In particular, my patients who have been concerned about leaving home have appreciated the convenience and the security of getting the care that they need.

There are other, more surprising benefits to virtual care. Video visits allow faster access to care in some cases. When I or one of my colleagues has an opening for an appointment, we can quickly invite someone into an appointment without having to worry about travel time, check-in time, traffic or other reasons for being late. In some cases, patients have forgotten about their in-person appointments, and instead of rescheduling them to come in weeks later, we can send them a video invite that very minute and complete the visit.

“Video visits allow faster access to care in some cases.”  –Dr. Moy  

Telehealth proves that not all care has to happen in-person. Any visit where I don’t need to physically examine a patient makes sense to start out as a video visit appointment. We have even been able to complete Medicare Annual Wellness Visits. If I feel during a video visit that there is a need for a physical exam, or something more in-depth is needed to further diagnose or treat a patient, we can schedule tests and an in-person follow-up. 

If you haven’t experienced a telehealth appointment before, no need to worry – it feels just like an in-person doctor’s appointment, just over a video call. A few tips I have for someone looking to schedule their first virtual appointment with Virginia Mason Franciscan Health would be to:

  • Mom and child on computerCheck to ensure you have Virtual Mason (our app for virtual care) downloaded onto your phone or tablet. If using a computer, make sure to use Google Chrome as your web browser.
  • Confirm the best phone number and email address for us to get ahold of you. We will call you if we don’t see you in the virtual exam room at the time of your appointment in case you need help!
  • Make sure you have a camera, microphone and speaker or headset. 
  • Make sure your Wi-Fi is working. 

There are a few routine or common screenings that aren’t available to do via telehealth. These include Pap smears, mammograms and colonoscopies. If you need blood work done, contact your provider to complete blood work before your visit or you can always stop by the lab after your video visit.

Just because there is a pandemic doesn’t mean routine check-ups or health problems should be ignored. Telehealth and video visits have been a productive way to connect patients and providers, especially in a time of high stress and the unknown. Despite all the fears and concerns, it is so worth it to see my patients’ smiles once the video connects. Those smiles are worth a thousand words!


Dr. MoyNicholas Moy, MD is a primary care physician and the Associate Chief Medical Informatics Officer at Virginia Mason Hospital and Seattle Medical Center. He is certified by the American Board of Internal Medicine.

Not Your Granddad’s Disease: Here’s What to Know About Gout

Gout. Unless you’ve suffered it firsthand, you could dismiss it as something your grandfather might have had. Despite its fuddy-duddy name, gout – a type of arthritis that occurs when extra uric acid in the body forms crystals in the joints – affects more than 8 million people in the United States. Sufferers have likened the pain of a gout “flare” to glass chards or needles pressing in and out of the affected joint, often at the base of the big toe (though other joints can be involved). The immune system’s attack on the crystals in the joint causes redness, swelling and extreme pain, often while the victim sleeps, and can last several days.  

You may have heard gout referred to as the “disease of kings,” stemming from its long association with a diet heavy in red meats, shellfish and alcohol: all foods high in purines, which prompt the body to make uric acid to break the substance down. Purines, it should be noted, also occur naturally in our bodies. But gout cases are rising in current times, as the population ages, gains weight and consumes more of what is linked to the disease. Yet studies show us that several genes may also play a role in the development of gout, including those that regulate the body’s processing of uric acid. This might explain why some people can have hyperuricemia, or too much uric acid in their body, but never suffer the symptoms of gout.  

Given that gout is here to stay, despite its antiquated image, I talked with Virginia Mason rheumatologist Erin Bauer, MD, about how to reduce flares for those who have gout, and the red-flag signs that it may be causing more serious health problems.

According to Dr. Bauer, the first line of defense against dreaded flares includes:

  • Diet mindfulness. Though diet does not play as big of a role as once thought, there are some foods that increase the risk for flares due to high levels of purines – the compounds in animals and plants that our bodies convert to uric acid. These foods include potatoes, poultry, red meats, seafood and drinking alcohol (especially beer) or beverages containing high-fructose corn syrup.

  • Targeting helpful foods. There are some foods that may slightly lower uric acid levels in the body, including eggs, peanuts, non-fat milk, whole grain breads, cheese and non-citrus fruits.

  • Drinking more water. Keeping adequately hydrated is extremely important, as any decrease in your kidney function will prevent your body from getting rid of uric acid and could lead to the formation of crystals. Studies have shown that increasing water consumption is associated with significantly fewer gout flares.  

  • Dropping those extra pounds. Losing weight will prevent flares over time, though losing weight too quickly or on a diet that is too high in protein may actually cause more flares.

  • Medication consistency. If a uric acid reducing drug is prescribed, such as allopurinol or febuxostat, it’s very important to stay on it regularly. Stopping and starting these medications often causes flares. To prevent this for people starting the medication, another medication is often added for a short time to protect patients as much as possible.
Which gout symptoms say it’s time to see the doctor?
  • Count your flares. Dr. Bauer points to the most recent guidelines, which indicate that having two or more flares of gout in a year could be damaging your joints. Work with your doctor to determine what lifestyle changes or treatments might be appropriate for your repeat flares.

  • Lumps could mean trouble. Deposits of urate crystals (called tophi) can make visible lumps under your skin and tend to appear in the hands, feet, elbows, or the outer edges of the ear. Large ones are easy to spot, but smaller ones may only show up with imaging. Tophi can be painful if they are infected or pressing on a nerve. However, another threat of tophi is they can damage joints and lead to bone erosion.

  • Arthritis seen on X-ray. The longer you have gout, the higher the chances are for joint damage, or arthritis. X-ray evidence of arthritis in the joints affected by gout warrants further evaluation.

  • Beware of stones. The same urate crystals that cause painful gout symptoms can also invade the kidneys, interfering with kidney function and causing severe pain. Uric acid-lowering medications are often recommended for gout sufferers who also have kidney disease.

  • Check your medication. If you’re already on medication to reduce flares but are still having them, talk with your doctor about increasing your dose. Also, taking diuretics tends to increase uric acid levels. Lowering the dose of diuretics or switching to a different medication may be something to try.

Dr. Bauer says gout can be initially managed by a primary care provider, while more complex cases can benefit from evaluation by a rheumatologist. The good news is if diagnosed early, most people with gout can live normal, productive lives. Even if gout has advanced, lowering uric acid levels, with medications and lifestyle choices, can improve joint function and reduce the frequency and severity of flares.


Erin Bauer, MDErin Bauer, MD, is board-certified in internal medicine and rheumatology, specializing in general rheumatology, inflammatory myopathies, inflammatory arthritis and lupus. Dr. Bauer practices at Virginia Mason Seattle and Virginia Mason Federal Way locations. 

 

 

Knowing the Signs of Stroke Improves Outcomes, Saves Lives

Many of us have heard the phrase “time is brain” referring to the aftermath of a stroke. The most common type of stroke occurs when an artery in the brain becomes blocked, cutting off the flow of blood and oxygen to part of the brain. After a stroke, up to 32,000 neurons (brain cells) die every second, or about 1.9 million a minute!

brain-scan“After a stroke, every minute counts,” says neurologist Fatima Milfred, MD. “That’s why my colleagues in Neurology work in close collaboration with Emergency Department physicians to rapidly evaluate and treat stroke. The right interventions delivered quickly will save brain function and improve outcomes.”

Know the Signs

Recognizing the signs of stroke is critical for getting emergency medical help as soon as possible. Remember the letters B.E.F.A.S.T. for spotting a stroke:

  • “B” stands for Balance. Sudden dizziness, loss of balance or coordination.
  • “E” stands for Eyes. Sudden changes in vision or trouble seeing out of one or both eyes.
  • “F” stands for Face drooping. The person’s face or smile appears lopsided.
  • “A” stands for Arms. One arm is weak or numb and can’t stay raised.
  • “S” stands for Speech. Impaired or slurred speech; difficulty repeating simple phrases.
  • “T” stands for Time. Even if signs go away, call 9-1-1 and get to a hospital immediately.

Signs of strokePreparing for the Unexpected

“Most people do not plan ahead for a trip to the hospital for an emergency such as stroke,” says emergency medicine physician Joshua Zwart, MD. “But a few simple, proactive steps can help ensure you receive the best care in this situation.”

Dr. Zwart recommends people create a personal health file in advance and update it regularly. It should fit into a wallet, purse or be readily available on a smart device and include:

  • Chronic health conditions and previous surgeries
  • Results of recent medical tests
  • Medication allergies
  • List of current medications, vitamins or herbal supplements
  • Names and contact information for your doctors, family and friends who may need to be alerted in the event of an emergency health issue
  • Advance directives

Highly Coordinated Care

Emergency departments operate on a triage basis, which means the most serious illnesses or injuries are attended to first. If you are brought to an emergency department with a suspected stroke, you will be rapidly evaluated and treated. A team of clinicians, including emergency medicine physicians, neurologists, nurses and others will coordinate getting your medical history and completing a physical exam. Additional advanced diagnostic testing and treatment may include:

  • CT scan of the head
  • CT angiography (special imaging of arteries and veins)
  • Blood tests
  • Oxygen therapy
  • Acute stroke medications, such as tissue plasminogen activator (tPA – a clot-busting drug)
  • Thrombectomy (mechanical clot extraction) for large vessel occlusion, if indicated

An Ounce of Prevention

It is estimated that 80 percent of strokes could be prevented. Here are some ways to reduce your risk of having a stroke:

  • Treat high blood pressure and diabetes – regular follow-up with a primary care provider is a must.
  • Reduce high cholesterol.
  • Maintain ideal body weight. Losing as little as 10 pounds can have a real impact on stroke risk.
  • Exercise regularly – 30 minutes of moderate intensity aerobic activity at least five days per week, under the supervision of your doctor.
  • Stop smoking.
  • Find activities that reduce stress, such as listening to music, taking a walk, calling a friend, or other “time-out” activities.
  • Eat a well-balanced diet higher in fruits and vegetables and lower in red meat, such as the Mediterranean diet.

To get an idea of your personal risk for heart disease or stroke, try this online calculator from the American College of Cardiology/American Heart Association.

After a Stroke Event

Sometimes symptoms of stroke resolve before treatment is implemented. The patient may have suffered what’s known as a transient ischemic attack (TIA), also called a mini stroke. Up to 40 percent of people who have TIAs will go on to have a stroke, which is why immediate preventive follow-up care is needed. Virginia Mason patients who are able to receive outpatient care are referred to the Rapid Access TIA Clinic, offering both medical and lifestyle interventions to reduce stroke risk.

Nurse Assessing Stroke Victim By Raising ArmsFollow-up care following treatment for stroke is extremely important. Your care team will outline a plan to aid your recovery and help prevent a future stroke from happening. Special programs, like shared medical appointments (Virginia Mason offers one called Brain Health Strategies), help stroke survivors connect with each other for extra support during their time of healing.

Virginia Mason’s Stroke Support Group is offered monthly as another resource for patients, with facilitators who cover helpful topics while providing plenty of discussion time during each session for stroke survivors, their loved ones and caregivers.

Patients treated for stroke in other health systems are welcome to explore follow-up care options and programs with the Virginia Mason Stroke Center. For more information visit our website, or call (206) 341-0420.

Worth the Distance: Advanced Cancer Treatment Helps Alaska Man After Just One Infusion

**By Hagen F. Kennecke, MD, MHA, FRCPC

The day after Christmas in 2016 brought unwelcome news for Wasilla, AK resident Josh McCool.

McCool, then 26, was diagnosed with a rare tumor of his adrenal gland, called a pheochromocytoma (fee-o-kroe-moe-sy-TOE-muh). But after surgery to remove the tumor, a type that can cause serious complications but is rarely cancerous, McCool’s symptoms returned and got much worse.

“My resting heart rate was very elevated,” remembers McCool. “I was super weak, unable to play with my kids, and spending 16 to 18 hours a day in bed. On top of that, I lost more than 100 pounds over six months. I would be out of breath just walking from our couch to the kitchen.”

A Rare Cancer 

McCool’s pheochromocytoma was a type of malignant tumor known as a neuroendocrine tumor, or NET. There are many types of NETs, some which make abnormally high amounts of hormones that cause many different symptoms. After traveling to the Seattle Cancer Care Alliance and undergoing extensive evaluation, McCool was referred to the Neuroendocrine Tumor program at Virginia Mason Medical Center.

That’s when I first met McCool, who had become very weak and sometimes needed a wheelchair. He was in significant pain and his cancer was secreting adrenaline, which was causing even more symptoms. To help target his treatment we used a specialized PET-CT scan, called NETSPOT®, which identifies hormone receptors on cancer cells.

With the cell receptors identified, McCool became a candidate for an advanced treatment known as Peptide Receptor Radionuclide Therapy (PRRT) with a treatment called Lutathera®. In PRRT, a cell-targeting protein, or peptide, is combined with a small amount of radioactive material. When injected in the blood stream, this new substance, called a radiopeptide, binds to NET cells, delivering a high dose of targeted radiation.

Josh Before and After Treatment

Immediate Results

Amazingly, just one week after his first treatment, McCool noticed his symptoms were improving. A better appetite was followed by markedly more energy, increased activity and a significant decrease in his back pain. The targeted nature of PRRT — binding to a protein only on the cancer cells — greatly minimized side effects.

A total of four treatments were needed, once every two months. Since PRRT is not available in Alaska, McCool arranged travel to Virginia Mason. After only his second infusion, McCool was completely off pain medications, had gained weight and was able to play with his two young sons.

A New Beginning

Josh-McCool_Shannon-and-sonsDespite all the challenges of therapy, McCool feels very lucky. “Getting the green light to move ahead with the treatment was like winning the lottery,” says McCool. “It has definitely been a character building experience and one I couldn’t have gotten through without the amazing support system of family and friends that I’ve been blessed with all along the way.”

McCool finished his treatment this month and is planning a trip to Disneyland with his family next year.

All of us on the Neuroendocrine Tumor Program team who took care of Josh McCool take great inspiration from the remarkable improvement in his health. While PRRT is not a cure, the treatment has the potential for adding years to an active and fulfilling life.


Hagen F. Kennecke, MD, MHA, FRCPC
Hagen F. Kennecke, MD, MHA, FRCPC, has advanced training in oncology and specializes in neuroendocrine tumors and colorectal cancers. He is director of the Cancer Institute at Virginia Mason. Dr. Kennecke practices at Virginia Mason Hospital and Seattle Medical Center.

Staying Ahead of Heart Failure: Janet’s Story

To see Janet Henry now, as a successful Human Resources executive for an international chain of stores, and gracious hostess who loves to entertain, it’s hard to realize all she has been through. In the space of one year, she experienced serious health crises: breast cancer, followed by toxic shock, followed by heart failure.

Janet.heart.failure“Many people don’t realize that heart failure is not the same as heart disease,” explains cardiologist Sara Weiss, MD. “Patients with heart disease experience atherosclerotic plaque, or hardening of the vessels which may lead to a heart attack. Heart failure happens when the heart muscle is weakened and is failing to pump consistently enough to serve the needs of the body.”

Heart failure can be caused by heart attack, alcohol abuse, or, in Janet’s case, a complication of the medication she was receiving to combat breast cancer.

When the cancer therapy began, Janet’s oncologist Nanette Robinson, MD, knew one of the biologic medications (a medicinal preparation made from living organisms and their products) would have to be monitored closely because of its possible impact on the heart. Throughout treatment, she and Dr. Weiss, communicated, overseeing Janet’s treatment to minimize, when possible, any impact on her heart. Then, in the middle of the cancer treatment, Janet contracted toxic shock which added to the stress on her heart. Soon after, she began to feel the extreme fatigue that is an indicator of heart failure.

“Because I was in the middle of cancer therapy it was difficult to understand what was causing the fatigue,” Janet remembers. “When we determined the fatigue was caused by heart failure, I began seeing Dr. Weiss weekly. She prescribed and adjusted medication strengths until we had the right dosage and I didn’t feel the fatigue anymore.

“I think I’m doing really well with the medication,” Janet adds. “My heart numbers are right where they’re supposed to be.”

“Heart failure is very treatable,” according to Dr. Weiss. “Medication and special pacemakers are the primary treatment. Patients are also encouraged to make lifestyle changes, which include eating healthy food, exercising and maintaining a healthy weight.”

Heart failure can also be experienced as shortness of breath because of fluid buildup in their lungs or abdomen. To prevent heart failure, Dr. Weiss recommends that patients work with their primary care provider to learn what their health numbers are for blood pressure, cholesterol level, body mass index and glucose level. They should also follow a plan to control existing conditions including high blood pressure and diabetes.

Janet is now cancer-free and her heart failure is under control. Along with the medical support she received, Janet credits Team Janet, her family and friends whose “tremendous support saw her through this difficult time.” Janet maintains her health with a low salt diet. She also added a new member to her family, an energetic black lab named Annie, who encourages her to walk every day.

 


A version of this story also appears in the Virginia Mason Health System 2018 Annual Report. 

Exciting Developments for Pancreatic Cancer Care

**By Flavio G. Rocha, MD**

After successful treatment for pancreatic cancer, one of our patients shared her story. Life after cancer is not normal, she said, it’s better than that. She talked of being inspired by the dedication of the Virginia Mason team. As a member of this team, a cancer surgeon and a clinical researcher, I am inspired by the progress we and other organizations are making toward better treatments for this disease. Working together to discover new therapies and the potential for early detection, the future of treating pancreatic cancer has never felt more hopeful.

Today Virginia Mason sees almost a third of all pancreatic cancer patients in Washington state, with decades of experience delivering care as a multidisciplinary team. This collaboration across specialties – along with advances in imaging, surgical techniques, specialized treatment and safety protocols – contributes to a doubling of the overall survival of our patients compared to the national average, as reported by the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program.

researchVirginia Mason is also invested in world-renowned medical research with Benaroya Research Institute (BRI), offering patients access to clinical trials investigating new therapies for all stages of pancreatic cancer. As a BRI affiliate investigator, I see a new wave of disease-fighting possibilities ahead, based on the latest research involving cancer cell microbiology, genetic testing and immunotherapy.

Reach Goal: Early Detection

Despite improvements in treatment, an estimated 46,000 people in the U.S. will die of pancreatic cancer this year. That’s because 90 percent of cases are diagnosed in later stages, when the cancer has already spread to other tissues or organs or requires preoperative therapy to reduce tumors. Virginia Mason, in partnership with BRI and other research collaboratives, is focused on looking inside the pancreatic cancer cell to identify biomarkers that signal a precancerous condition.

A specific protein, for example, was found in a clinical trial to be significantly elevated in the pancreatic fluid of patients known to have premalignant lesions. These results suggest that testing the fluid for this biomarker could detect disease in patients at increased risk, before becoming pancreatic cancer. Other research around early detection focuses on developing special blood tests, diagnostic imaging and other screening tools to find disease at its earliest stages.

Hereditary Cancer Testing

In July 2018, the National Comprehensive Cancer Network (NCCN) issued a new guideline that all individuals with a diagnosis of pancreatic cancer must meet criteria for hereditary cancer testing. Studies suggest up to 10 percent of pancreatic cancer is caused by an inherited mutation in BRCA1 or BRCA2, the so-called breast cancer genes. Other genetic mutations have been linked to an increased risk of pancreatic cancer as well.

Is there a benefit in genetic testing if the patient already has pancreatic cancer? Yes, for two reasons:

  • Knowing about an inherited genetic mutation may help direct treatment decisions. BRCA-associated cancers, for example, are known to respond to certain treatments, including specific types of chemotherapy. This concept of “personalized medicine” is expanding through clinical trials of other agents that target cancers linked to genetic mutations.
  • Identifying a mutation can be valuable knowledge for family members, who can choose to be tested and learn if they are at higher risk for developing certain cancers. That’s because the same mutation that is linked to pancreatic cancer is also associated with breast, ovarian and other cancers. Family members who test positive can engage in screening or risk-reducing strategies for other forms of cancer, as available.

Boosting the Body’s Immune System

Leveraging the power of the body’s own immune system to fight cancer is the science behind immunotherapy, variations of which are already prescribed by oncologists to treat a variety of cancers. While success has been limited using immunotherapies in the treatment of pancreatic cancer, ongoing clinical trials are testing multiple forms of the therapy, including pancreatic cancer vaccines (designed to “program” the immune system to attack cancer cells), and immune checkpoint inhibitors (shown to reactivate immune cells shut down by cancer cells). Other forms of immunotherapy utilize modified viruses to infect tumor cells, or modifications of the body’s own cells to disrupt cancerous activity.

The Future of Research is Now

Virginia Mason is one of 12 clinical trial sites selected nationwide by Precision Promise, the Pancreatic Cancer Action Network’s groundbreaking initiative to improve patient outcomes and double the pancreatic cancer survival rate by 2020. Starting this year, patients will be able to enroll in Precision Promise through the participating sites, accessing trials of multiple novel therapies alongside standard care approaches.

Through Precision Promise, clinical outcomes data will be continuously tracked and analyzed, accelerating findings that can be shared across the trial sites. Analysis methods, including the use of genomic data, will be matched to patients’ responses to therapy to quickly identify effective treatment options. As breakthroughs emerge, Precision Promise will adapt clinical programs to help get successful therapies out to patients faster than traditional research models.

What Keeps Us Going? Our Patients

The pancreatic cancer survivor who shared her story described the joy of seeing her daughter graduate, and teaching her son how to drive. As physicians we are privileged to not only treat disease with our best skills and knowledge, but to nurture hope in our patients that they will return to the lives and people they love. We have seen the pancreatic cancer survival rate increase 3 percent during the last three years, and momentum is building. The time for changing everything we know about diagnosing and treating this disease starts now.


Flavio Rocha, MD
Flavio G. Rocha, MD, has advanced training in surgical oncology and specializes in liver, biliary tract and pancreatic cancer. He is director of research in the Digestive Disease Institute at Virginia Mason and an affiliate investigator at Benaroya Research Institute. Dr. Rocha practices at Virginia Mason Hospital and Seattle Medical Center.

Watchman Device Potential Alternative to Blood Thinners

People with atrial fibrillation – an abnormal, irregular heart rate – are at increased risk of stroke due to blood clots. The abnormal rhythm may cause blood to pool and form clots, mainly in a small chamber of the heart known as the left atrial appendage. To prevent these clots from forming, many atrial fibrillation patients considered at high risk for stroke are treated with blood thinning medications such as warfarin.

But there’s a catch: for many patients, taking blood thinners is problematic, due to bleeding issues or other health problems that interfere with the medication. For the right patient, a new device offers a potential alternative to long-term blood thinners. The device, called the Watchman, is a quarter-sized implant placed in the left atrial appendage of the heart. Once in place, it permanently closes off the appendage, preventing clots from escaping and causing a stroke.

WATCHMAN_device

Watchman Device Implant

The minimally invasive Watchman procedure is performed under general anesthesia through a catheter inserted in the groin. Patients typically leave the hospital the next day and quickly return to normal activities.

“The Watchman device is a great alternative for patients with a history of bleeding, frailty, falls, dementia or inability to maintain their target blood values on warfarin, despite their best efforts,” says Moses Mathur, MD, interventional cardiologist, Virginia Mason Heart Institute.

Patient Selection a Key to Success

While the goal of implanting the Watchman device is eliminating medications like warfarin, patients must be able to take a short course of blood thinners after the procedure until imaging tests show the appendage is permanently closed. After that, patients are transitioned to an aspirin regimen.

Other key criteria for Watchman candidates include:

  • Diagnosis of atrial fibrillation not due to a heart valve problem (such as rheumatic mitral stenosis, or presence of a mechanical heart valve)
  • Increased risk for stroke based on age and other current health conditions
  • Left atrial appendage anatomy compatible with the Watchman device
  • Ability to undergo an ultrasound scan of the heart (transesophageal echocardiogram), to ensure no existing clots are present and to examine the left atrial appendage during and after the procedure

Due to thorough patient assessments and the focus of an experienced team, Virginia Mason has an over 95 percent success rate implanting the Watchman device and eliminating long-term blood thinner regimens for patients.

“By assuming a small procedural risk up front, patients are offered the promise of being warfarin-free for the rest of their lives,” says Dr. Mathur. “And along with that comes fewer side-effects, less bleeding and less cost, year after year.”

Why the Heart Institute at Virginia Mason?

The Watchman procedure requires a heart team with expertise in structural interventional cardiology, where interventional cardiologists, electrophysiologists, imaging specialists and others work together to achieve the best outcomes for patients. This approach ensures every part of the procedure – from patient selection to post-procedure follow-up care – results in fewer complications and an optimal recovery.

Transgender Health Care at Virginia Mason: Providers are ‘Driven to Do This Work’

Longtime Virginia Mason patient Samantha Forney and the nurse caring for her sat down to talk. The nurse had made a mistake by referring to Samantha, who is a transgender woman, with male pronouns. Samantha saw an opportunity for teaching, with a receptive caregiver.

“To me it’s much more important to make something a positive learning experience,” said Samantha. “Getting my feelings hurt or being angry won’t make things better for the next person.”

Samantha.Forney

Samantha Forney

Samantha’s steadfast advocacy for transgender health care first caught the attention of her primary care doctor, who asked if she would join the guiding team working to develop transgender health care at Virginia Mason. Eager to be involved, Samantha applied to become a Patient-Family Partner (PFP), a unique volunteer program that invites patients and families to be active co-designers of patient care. In her new role, Samantha made an impression on the PFP clinical team: would she be willing to share her personal story while presenting to the medical center’s board of directors?

Samantha began work on her board presentation in the summer of 2017, a time when Virginia Mason’s development of Transgender Health Services was well underway. A bolstered strategy to support diversity and the individual needs of patients ignited in 2016, when the organization signed on to the American Hospital Association Equity of Care pledge: a national call for eliminating health care disparities among patient populations. A commitment to providing affirming care for lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) people spawned system-wide changes, from policies and staff training, to new care guidelines across medical specialties.

Virginia Mason’s health equity work was already changing the organization when Samantha presented to the board in September 2017, but sharing her own experience shed light on the human toll of lifelong struggle, loss and fighting for acceptance. It was the compassionate care that Virginia Mason had already given her, she said, that made her certain they could be leaders in providing the support and health services transgender people are often denied.

“Virginia Mason has these wonderful providers who really do care, they are driven to do this work.” — Samantha Forney 

“I told the board about both positive and negative experiences I’ve had,” said Samantha. “But Virginia Mason has these wonderful providers who really do care, they are driven to do this work. I see the team come together for my appointments. It’s a culture, a willingness to collaborate with each other and with other doctors that treat me. It’s so amazing to find that.”

It was Virginia Mason’s destiny, Samantha put forward to the board that day, to welcome a chronically mistreated community into the dignity and safety of comprehensive medical care. Now after more than a year of advising the organization as a PFP and working with the transgender service line (TSL) guiding team, Samantha admits being in awe of what people are doing, both on the clinical and administrative sides. It’s their energy, professionalism and humanity, she says, that motivates her to personally connect with more Virginia Mason providers.

“Every time I see a new provider I say ‘before I go, can I ask you to please consider joining the WPATH [World Professional Association for Transgender Health]?’” says Samantha. “And I also ask them to join the guiding team, because we need them.”

A face-to-face connection can open people to new ideas, a power that drives the TSL guiding team. Providers from across the patient care spectrum – from clinical staff to administrators to physicians and surgeons – join with patient partners to learn from each other as they plan improvements to the care experience.

“Guiding team meetings are a safe space for clinicians and staff members to ask questions beyond their own areas of expertise,” says Maria Rearick, director, Ambulatory Services at Virginia Mason. “It’s a unique forum, to have open discussions across care teams for sharing our progress and where we see opportunities.”

As transgender health care services at Virginia Mason grow across specialties – including primary care, speech-language pathology, gynecology, facial surgery, endocrinology, and urology – the voices of patients like Samantha ensure that awareness and sensitivity toward all LGBTQ patients keeps growing too. Working goals for the TSL guiding team include more staff education through facilitated discussions, creating a welcoming environment with everything from all-gender restrooms to affirming medical forms, and continued outreach to partner organizations and the LGBTQ community.

“This a new frontier in medicine,” says Samantha. “I’m very proud of the giant step Virginia Mason has taken in this direction. They are passionate about equity in health care and making things better for people. It’s an exciting time.”


Transgender Health Services at Virginia Mason offers a range of primary and specialty care services for transgender and non-binary patients. We provide gender-affirming, evidence-based care to meet individual needs and goals in a welcoming and supportive environment.