Sonia Racco was 35 when she gave birth to her first child, a healthy baby girl named Genna.

Twenty months later, Sonia was diagnosed with breast cancer.

“I found the lump while I was breastfeeding,” says Sonia, “but I didn’t think it was anything.”

She knew that it was normal for breast tissue to change with pregnancy and breastfeeding. She also knew there was no history of breast cancer in her family, nothing to suggest that she might be one of the thousand or so Canadian women under the age of 40 who are diagnosed with breast cancer every year.

When the lump didn’t go away after a couple of weeks, Sonia went to her family doctor. Her mammogram was worrisome enough for a referral to Sunnybrook’s rapid diagnostic clinic.

“I had the mammogram, the biopsy and the diagnosis within 24 hours,” she recalls. “I kind of knew as soon as they did the biopsy on my breast and under my arm. My husband was a lot more overwhelmed than I was when we got the results,” says Sonia.

“But later, when I got home and I was with my 20-month old calling me mommy, I was completely overwhelmed. There were a lot of very scary moments: ‘What is happening to me? What’s the prognosis?’ All the uncertainty.”

But there was also the Young Women With Breast Cancer (PYNK) Program, Sunnybrook’s support and research program for young breast cancer patients.

Because Sonia was under 40, she immediately qualified for the special care provided by PYNK.

Sonia Racco, pictured with daughter Genna. (Photography by Tim Fraser)

It’s a fact that women diagnosed with breast cancer at a young age have lower survival rates and experience poorer quality of life than women diagnosed when they are older. They experience more physical side effects, depression and fear of the cancer returning.

They often sense that they may be facing mortality early, leading to the worst fear of all for any young parent – not being there to see their children grow up. And if they survive, they’ll be dealing with possible premature menopause and infertility related to treatment.

“We’re taking away their hormones and destroying their libido,” says Dr. Ellen Warner, referring to some of the lesser known side effects of cancer treatment. She had these concerns in mind when she initiated PYNK, a groundbreaking team effort to deal with the complicated issues, including infertility, of young women diagnosed with breast cancer.

“We have a nurse navigator*,” she says. “Our women are getting extra nursing care, but a lot of it is also psychological.”

She cites an example: “We had one young woman who was newly married. Sex became very painful and she would bleed. She was dealing with physical symptoms and psychological stress.”

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The critical issue for a high percentage of these young women − after survival − is fertility[/mks_pullquote]

The young patient, sent into early menopause by the cancer treatment, was experiencing vaginal dryness. Fortunately, there was a simple solution, says Dr. Warner. “She wasn’t using lubricants properly. We also have a counselling program online for these young couples.”

PYNK patients range in age from 17 to 40 years old, with an average age of 35. However, the average woman who gets breast cancer is 61, notes Dr. Warner. For those older women, a breast cancer diagnosis brings with it many questions and concerns.

“But for a younger woman, the questions and concerns can be different. Maybe she’s 30 and single, and she’s thinking, ‘Oh my God. I’m going to lose a breast, never get married, go into menopause, never have a baby.’ Or maybe she has young children, a big mortgage, has to quit work and hire babysitters for appointment and treatment days. Maybe she wanted to have another child.”

The critical issue for a high percentage of these young women − after survival − is fertility. Endocrinologist and infertility specialist Dr. Karen Glass has been part of Dr. Warner’s PYNK team from the beginning, harvesting eggs before chemotherapy, offering in vitro fertilization (IVF) and freezing the fertilized or unfertilized eggs for later implantation.

“For young women with cancer,” says Dr. Glass, “it’s now the completely normal, expected thing to do.”

A focus on breast cancer research

Research has always been a major focus of PYNK. Studies have looked at the uptake of genetic testing among women born outside Canada, what percentage of women wanted prophylactic mastectomies and the relationship between young patients with breast cancer and their mothers.

Sunnybrook’s successful PYNK program is the prototype for a new Canada-wide research project called RUBY (Reducing the Burden of Breast Cancer in Young Women).

Co-sponsored by the Canadian Breast Cancer Foundation and Canadian Institute for Health Research, the four-year study will enroll 1,200 women newly diagnosed with breast cancer at age 40 or younger – including PYNK participants – at 29 sites across Canada.

RUBY will build on the PYNK research model developed at Sunnybrook, collecting blood and tumour samples in addition to detailed clinical data and patient-reported outcomes, which are kept in a special PYNK database. The data collected will include detailed information about their family history and other risk factors, treatment, disease outcome and quality of life.

Dr. Karen Glass advises PYNK program patients of their fertility options, such as freezing eggs, before they go through chemotherapy. (Photography by Doug Nicholson)

“Some of it is hereditary,” says Dr. Warner, “but we don’t really know what causes it (at a young age). It’s all part of the research challenge.” She calls RUBY a “PYNK copycat” on a larger scale.

RUBY encompasses several substudies, including genetic testing for abnormalities that may have caused the cancer, and determining the effect of lifestyle factors on breast cancer recurrence.

Dr. Warner and Dr. Glass are guiding research within RUBY that is intended to encourage referrals of young women with breast cancer by breast surgeons to fertility specialists who specialize in this patient population. They are also working on a study to better predict the effects of cancer treatment on fertility.

“Ultimately, we’re hoping that the research will come up with better treatment, that recurrence rates will drop, and that quality of life will be better for young women with breast cancer,” says Dr. Warner.

While Dr. Warner’s and Dr. Glass’s research is helping create a better future for young women with breast cancer, there’s much joy every time a young breast cancer survivor is able to bring new life into the world because of the PYNK program.

“I just found out today that another PYNK graduate is pregnant,” Dr. Glass says, with a touch of pride.

Five years after her lumpectomy, radiation and chemotherapy, Sonia is now celebrating another milestone; she gave birth to her second daughter, Gia, in July, making her six-year-old Genna a big sister.

“Dr. Glass is incredible,” Sonia says. “One of the first conversations I had after the diagnosis was, ‘Do you want to extend your family?’ She took me through the procedure and was with me every step. It was a comforting experience, how she and Dr. Warner worked together.

“My husband and I decided to freeze embryos. And last winter, we decided, let’s give it a shot. And it took. And everything is going great,” she says. “Having a second child was a hope. A hope of a possibility.”

*In 2023, PYNK changed models from Nurse Navigator to Physician Assistant as the lynchpin of the PYNK program.

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Geriatric psychiatrist Dr. Nathan Herrmann has dedicated his career to treating and researching Alzheimer’s disease and dementia

When Dr. Nathan Herrmann was a medical student, he intended to specialize in orthopaedic surgery.

Instead, he became the “Memory Doctor,” specializing in geriatric psychiatry and dementia.

While geriatric psychiatry is not a popular specialty for physicians, Dr. Herrmann explains this area of medicine fits his interests perfectly.

I have an affinity for older people,” he says. “I grew up with my grandmother living in our home and had a very close relationship with her. I appreciate the wisdom of the elderly and I’m fascinated by the amazing stories they tell about their lives and experiences.”

About 25,000 Canadians are diagnosed with dementia every year and more than 600,000 Canadians are living with the disease.

“The risk for Alzheimer’s and other dementias increases significantly after age 65,” notes Dr. Herrmann, “and people are living longer.”

With what Dr. Herrmann refers to as “the silver tsunami” upon us, his expertise and insights are more valuable than ever.

Dr. Herrmann also consults on a regular basis at Sunnybrook’s Veterans Centre and the Dorothy Macham Home, a facility that supports veterans with challenging dementia-related behaviour. The average age of the 475 resident veterans is 95.

“I work with the staff at the Veterans Centre on diagnostic issues and the treatment and management of neuropsychiatric symptoms,” he explains, “and on a weekly basis with staff at the Dorothy Macham Home, where residents’ dementia is more advanced and the symptoms are more severe.”

“We have a complex team,” notes Dr. David Shergold, an attending physician at the Veterans Centre and at the Dorothy Macham Home. “And we wouldn’t be as effective without Dr. Herrmann’s leadership and his expertise in looking at some of the dementia behaviours as expressions of war-related stresses.”

According to Dr. Herrmann, visual and auditory reminders of the war, for example, can exacerbate symptoms of post-traumatic stress disorder. “Veterans may become anxious, agitated [or] depressed and [may] experience sleep disorders or withdraw,” he explains.

Dr. Shergold adds, “We all benefit as staff members from Dr. Herrmann’s wisdom. The veterans benefit even more.”

They also benefit from Dr. Herrmann’s research, which focuses on drugs to control dementia symptoms. He has co-authored dozens of papers based on results of clinical trials at Sunnybrook.

This summer, at the Alzheimer’s Association International Conference in Chicago, he presented evidence that nabilone, a synthetic cannabinoid, “demonstrated a significant reduction in agitation and aggression…and a significantly greater reduction of overall behavioural problems.”

The risk for Alzheimer’s and other dementias increases significantly after age 65, and people are living longer.

Dr. Nathan Herrmann,
geriatric psychiatrist

Dr. Herrmann also consults with physicians in the community and is well known online as the Memory Doctor. His blog answers questions about dementia and offers advice about brain health.

“The issues I deal with are questions that come up with every single patient and family,” he says. “I saw a need to educate the community about issues related to dementia. There are things people can do to reduce the risk of cognitive decline.”

His recommendations include exercise, a Mediterranean diet, stimulating activities and good medical care for things like high blood pressure.

The 60-year old psychiatrist practises what he preaches. He eats very little red meat and plenty of fruits and vegetables, and he goes to the gym three times a week. On other days, he cycles or walks through the paths and gardens surrounding Sunnybrook.

And while he may do his daily walk at a comfortable pace, his mind is often racing. “Sometimes, as I’m walking, I’m thinking about patients or writing papers in my mind,” he says.

“It’s very important to keep mentally active. For some people, that means working. Work gives structure, schedule, social interaction and mental stimulation. But there are lots of ways to keep mentally active. The research does not provide great clarity on the best way to do mental stimulation, but we recommend doing as many mentally stimulating activities as possible.”

Dr. Herrmann finds the enigma of dementia – the fuzziness surrounding the diagnosis, cause and treatment of the disease – both stimulating and challenging.

“There is so much work to do, so much research needed to understand the basic components and the causes and how to treat it. It’s a gratifying area to be in.”

But he concedes that finding a cure for dementia has been slow going. “When I started my career in the late 1980s, I’d tell audiences that I was confident there’d be a cure in 10 years. I stopped saying that 10 years ago.”

Nevertheless, Dr. Herrmann maintains a positive perspective. “There is a lot we can do to improve the lives of people with dementia by treating symptoms and treating aspects of the disease that need to be addressed to help families deal with it.”

The post Meet the Memory Doctor appeared first on Your Health Matters.

On a wall of the intensive-care burn unit where Sonia Whyte-Croasdaile was a patient for six weeks – her skin sloughing off her face and body – was a full-size photo of Sonia taken when she was healthy.

“I had to bring in a picture, so they could see who she was,” says her husband, Joseph Croasdaile.

Sonia’s illness began with flu-like symptoms. Less than a week later, her body was fully covered with burn blisters.

The results of a skin biopsy confirmed the suspected diagnosis. Sonia was one of the two in a million people struck by the little-known but life-threatening Stevens-Johnson Syndrome (SJS), a rare condition, often triggered by an adverse drug reaction.

“The term SJS is used for several similar diseases,” explains Dr. Neil Shear, head of Dermatology at Sunnybrook. “Some are viral-induced and mostly involve the eyes, mouth and genitals. Some are drug-induced and can involve the body skin as well as the mouth, eyes and genitals. SJS in any of its manifestations is a horrific disease.”

When the disease becomes even more severe, as it did in Sonia’s case, with a mortality rate as high as 40 per cent, SJS is referred to as toxic epidermal necrolysis spectrum (TENS).

According to Dr. Shear, early diagnosis and treatment by an interdisciplinary medical team, “people with experience who understand the nuances of the disease,” is key for a positive outcome.

The challenge in treating TENS is that every surface of the body is affected, including all the mucous membranes – mouth, throat, airways, eyes, nose, genitals. It can also affect the kidneys and cardiovascular system.

At Sunnybrook, patients with TENS are treated in the Ross Tilley Burn Centre, where the multidisciplinary medical team is led by Dr. Shear and the centre’s medical director Dr. Marc Jeschke.

Dr. Neil Shear, head of Dermatology at Sunnybrook, developed the first Canadian protocol for dealing with the often fatal disease SJS/TENS.

The Sunnybrook team includes not only dermatologists and burn specialists, but also ophthalmologists, respirologists, gynaecologists, urologists, ear, nose and throat specialists and plastic surgeons.

Dr. Shear and his team of specialists have developed the Sunnybrook Protocol for SJS/TENS. The first Canadian protocol for dealing with the disease, it’s been published in the Journal of Cutaneous Medicine and Surgery.

“We would like to share our management, experience, and present our treatment protocol to help guide treatment of these complex patients, not only in Canada but also worldwide,” Dr. Shear and his colleagues explained in the protocol document.

The protocol is designed to prevent further decline, heal debilitating symptoms and provide supportive care.

Recommendations for supportive care include increasing the temperature in the patient’s room to 30-32°C, applying white soft paraffin to the lips every two hours and a topical steroid four times daily, along with oral rinses, including lidocaine for pain.

Fluids are replaced intravenously, along with pain medication, while appropriate nutrition may be provided through a feeding tube through the nose.

Involving an ophthalmologist and a gynaecologist or urologist as soon as the diagnosis is made is also important.

According to the protocol, daily follow-up by an ophthalmologist is essential. Eyes are treated with artificial tears, lubrication, topical antibiotics and steroids and, when necessary, daily sweeping of the inside of the eyelid with glass rods to prevent it from sticking to the eye itself.

“It is a miserable thing to see. I can’t overstate how horrible this disease is,” says Dr. Shear. “It’s a burn from the inside out. It looks like a burn, but it’s the immune system causing it, as opposed to high temperature.

“What happens is the immune system gets fired up and starts attacking the outer layers of skin, the eyes, genitals, throat, lips. It’s like a flesh-eating disease with cell digestive enzymes eating the skin.”

Of the 300 patients treated every year at the Ross Tilley Burn Centre – the largest burn centre in Canada – up to 10 are admitted with SJS/TENS. These patients spend about four to six weeks at the centre.

“It’s a very challenging patient population,” says Dr. Jeschke. “But for the patients who do survive, healing is quite good. The organs recover, and [there is no] scarring of the skin.”

Unlike temperature burns, SJS/TENS affects only the epidermis, the upper layer of the skin. The dermis, or structure of the skin, which is damaged with third-degree temperature burns, remains intact with SJS/TENS.

Sonia’s skin is now smooth and luminous. “The blisters dried up miraculously and disappeared,” says Sonia, now 50 years old. But seven years after her diagnosis, she is still bothered by bright lights and wears dark glasses day and night. “The normal feeling in my eyes is like when wind blows grit in your eyes on a hot summer day,” she explains.

She also lacks energy and can no longer eat the spicy food she used to enjoy because it burns her mouth and throat. “Before, she used to eat the hottest peppers,” recalls Joseph. “Now we give away most of the ones we grow.”

The scars of TENS, according to Dr. Shear, are actually on the inside. “Patients rebound but become very anxious. Almost always, survivors suffer from post-traumatic stress disorder, and it’s also traumatic for the family.”

He adds, “There is a tremendous sense of fear of future illnesses and the potentially frightening prospect of the unknown risks from any drug. This affects the survivor and their loved ones.”

For Sonia, rebounding from the disease has taken a positive direction. With encouragement from Dr. Shear, she has become a crusader for SJS/TENS awareness and support for patients.

“I want to mobilize the survivors and bring hope to SJS/TENS patients,” says Sonia. “They can heal. They can be beautiful again.”

All photography by Kevin Van Paassen

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At Sunnybrook’s Accessible Care Pregnancy Clinic, women with physical disabilities are cared for from pre-pregnancy consultation to weaning.

When Dalia Abd Almajed’s smartphone disappeared, she knew her 18-month-old daughter must have taken it and abandoned it somewhere in the house. But where? The ringer was off and Dalia was too busy with her newborn son to hunt for the phone.

Most people would be frustrated, maybe frantic. But for Dalia, it was no biggie, barely registering in a life full of challenges. Dependent on a wheelchair for mobility, the 38-year-old mother has managed two pregnancies and the birth of two healthy babies in the past couple of years.

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“Everyone is unique in terms of needs”

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Coping with the logistics of pregnancy – transportation to medical appointments, transferring from a wheelchair to the examination table, coordinating meetings with specialists – poses a huge challenge for mobility-disabled women like Dalia, who immigrated to Toronto in 2014.

And that’s before labour and delivery and bringing a newborn home. “My medical condition is complicated,” explains Dalia, who practised as a physician in her native Iraq before developing transverse myelitis, a disease affecting her spinal cord. “Pregnancy itself, for everyone, is complicated. So my pregnancy, [because I’m] in a wheelchair, was a very complex case. I needed many referrals, many specialists – respirologist, hemaetologist, neurologist, dietitian, anesthetist.

“I was afraid. I was thinking, How will all this be arranged? Will they be able to care for me?”

Fortunately for Dalia and other women in Ontario of reproductive age with disabilities, the Accessible Care Pregnancy Clinic opened recently at Sunnybrook. North America’s first clinic caring for pregnant women with a wide range of physical mobility disabilities. It was the idea and the passion of Dr. Anne Berndl.

Dalia Abd Almajed had a healthy pregnancy and delivery of son Abbas in May 2017. (Photo by Doug Nicholson)

“It’s been my personal project since I started here,” notes Dr. Berndl, a maternal fetal medicine specialist and director of the clinic. “Before I became a doctor, I worked in a home with foster children with disabilities. It gave me a lot of insight. Everyone is unique in terms of needs. There’s no standard approach to people with physical disabilities.”

Dr. Berndl was already caring for pregnant women with disabilities as part of her practice as a high-risk obstetrician at Sunnybrook. She became Dalia’s obstetrician halfway through her first pregnancy. By the time the Accessible Care Pregnancy Clinic officially opened in May, Dalia was well into her second pregnancy.

“For the second pregnancy, I didn’t have many concerns because I knew that they will deal with it very well and they know what I need,” says Dalia. “I felt confidence in the team, in the hospital itself. They were listening to me.”

Just as listening to the heartbeat of the fetus in the womb is the key to caring for the unborn infant, so is listening to the patient, which is at the heart of how obstetrics is practised at the clinic. For several years prior to the clinic’s official opening, pregnant women with disabilities who came to Sunnybrook were invited by Dr. Berndl to take part in exit interviews. They were asked: What do you need? What would you want to see in a clinic tailored for women with disabilities? What should we be doing better at Sunnybrook?

It was from those interviews, notes Dr. Berndl, that Sunnybrook came up with the framework for the Accessible Care Pregnancy Clinic. For example, she made sure there was a scale that can accommodate wheelchairs. Without it, women using wheelchairs tend to not be weighed properly – or even not weighed at all.

Dalia, pictured with Dr. Anne Berndl, director of the Accessible Care Pregnancy Clinic. (Photo by Doug Nicholson)

There’s also a concerted effort at the clinic to meet the special needs of pregnant women with disabilities. “The ultrasound bed was higher than the wheelchair,” recalls Dalia. “The technician was able take the ultrasound while I was sitting on the chair.”

Allowing extra time for procedures, such as Dalia’s ultrasound, and for getting from one appointment or lab test to the next is built into the clinic’s scheduling.

“Logistics is one of the hardest things we’ve been working on,” says Dr. Berndl. That includes allowing extra time for transfers and positioning the patient; for consolidating care, so appointments are coordinated and especially for the TTC Wheel-Trans schedule. “We’re learning a lot about the challenges of transportation,” she adds ruefully.

Nevertheless, Dr. Berndl is determined that every woman’s needs are considered and properly accommodated.

The first tenet at the Accessible Care Pregnancy Clinic, according to Dr. Berndl, is to respect each woman as an individual. Every member of the health-care team, including ward clerks, is coached to treat every patient with dignity and understanding. “These women deserve respect and encouragement just like any other woman,” says Dr. Berndl.

This attitude is light-years away from how society in the past regarded pregnant women with disabilities and, in some cases, even up to now.

“I sensed that these women were feeling highly discouraged from having pregnancies,” observes Dr. Berndl. “They’d feel the negativity, the stigma from health-care professionals as well as from others, when they were pregnant.”

Because pregnancy may affect the health of women with disabilities, the clinic encourages pre-pregnancy consultations. “They can ask about concerns and about what may happen,” says Dr. Berndl, “and then feel good about their decisions.”

The connection that begins with the pre-pregnancy consultation doesn’t end until the baby is weaned. An advanced practice registered nurse (APRN) calls every patient before the first visit, explains Dr. Berndl.

“We ask: What are your needs? What could we be doing to make it more comfortable for you? How is your mobility? Before [the patient] comes, we’re ready,” notes Dr. Berndl.

She also points out that at Sunnybrook, there are a number of subspecialists to see women with disabilities and who go out of their way to adjust to the patients’ needs. “Two weeks ago, a neurologist asked me, ‘Do you mind if I just run upstairs to your office and do the consult there?’ There is so much enthusiasm [here at Sunnybrook] for this clinic,” says Dr. Berndl.

Dalia gets an ultrasound while in her wheelchair.
(Photo by Doug Nicholson)

A lactation consultant is available after the birth. As well, the Accessible Care Pregnancy Clinic connects new mothers with community resources. “[We try] to make those linkages early on,” says Dr. Berndl. “These mothers are exhausted and overwhelmed, especially if there is no one out there to support them.”

For Dalia, all of these support services have made a huge difference. She has no family in Canada other than her husband, Salam, who worked in Iraq as a biologist and is now training as a lab technician. “The social worker at Sunnybrook arranged for contact with the CHC [Community Health Centre] to provide help with the baby and to give me time to rest or sleep.”

While managing the pregnancy and postpartum recovery is routine work at the clinic, the ultimate goal is a comfortable labour and the delivery of a healthy baby, with vaginal delivery whenever it’s possible.

Labour and delivery plans are drawn up with input from the entire interdisciplinary team, and every member of the labour and delivery team receives a copy, including the patient herself.

“She is the leader of her own team,” emphasizes Dr. Berndl. “Even if she comes to the hospital at 4 a.m. on a Tuesday in a triage situation, she comes with the plan. We’re always making sure that everyone knows what is going on. Excellence in communication is another one of the tenets of the clinic.”

Being able to communicate is also important for new mothers. That’s why Dalia finally went hunting for her phone.

“My daughter plays with it and throws it everywhere,” she says. “It was under the bed.”

The post Making pregnancy more accessible for women with physical disabilities appeared first on Your Health Matters.

Which is more difficult: dancing the lead role in Swan Lake with a world-famous ballet company or giving birth?

We asked an expert. “It’s close,” replied National Ballet principal dancer Heather Ogden after a considered pause. “But maybe giving birth.”

Six months after the birth of Leo and still breastfeeding, the preternaturally ethereal ballerina performed the demanding dual roles of the virginal Swan Queen and malevolent Black Swan. The Prince was her longtime dance partner, Guillaume Côté, who also happens to be her husband and Leo’s father.

Ogden credits her speedy and triumphant return to the stage in a role that requires superb physical stamina to the pregnancy care she received with Sunnybrook’s Family Medicine Obstetrics team, which always accepts new obstetrics patients, and to the guidance of Dr. Karen Fleming.

“She knew about my fitness goals from the beginning and was always checking in to see how I was, mood-wise,” says Heather, 36. “I had the goal of maintaining a better level of fitness for this second pregnancy. (The couple have a two-and-a-half-year-old daughter.) “I felt healthier, I had a much better energy level, and my mood was better. The biggest difference was that I stayed at performance level much longer and kept in top ballet form.”

Guiding elite athletes and dancers like Heather through their pregnancies, so they maintain fitness safely and are able to return to peak performance level quickly, is a special interest of Dr. Fleming, division lead of Sunnybrook Family Medicine Obstetrics and interim chief of the Department of Family and Community Medicine.

But helping super-fit women modulate their activity during pregnancy is a small part of Dr. Fleming’s practice. For the most part, she’s doing the opposite – encouraging pregnant women to move more. Being active reduces rates of gestational diabetes and high blood pressure in pregnancy as well as decreasing rates of operative deliveries like caesarian sections. Exercise is also associated with lower rates of post-partum depression.

“Our challenge with the majority of women is that they’re sedentary and tend to reduce exercise during pregnancy, which can contribute to gestational diabetes, excessive weight and high blood pressure in pregnancy,” says Dr. Fleming. “One of the preventative goals is exercise, which improves sensitivity to insulin and helps with pushing the baby out.”

Childbirth, she notes, is “a physically demanding activity, and exercise during pregnancy is like training for a competition.”

It’s also crucial for recovery. “Once you go home with the baby, there’s a lot of carrying and lifting, a lot of physical demands for being a parent,” she emphasizes.

Physical activity is important – whether you’re taking on the role of mother or Swan Queen.

New obstetrics patients are always accepted without referral. The Family Medicine Obstetrics team is comprised of 10 family physicians, located at Sunnybrook and in the community across the GTA.

For more information, please visit sunnybrook.ca/familyob

The post Guiding professional dancers & elite athletes through pregnancy appeared first on Your Health Matters.

The family was packing for a March break vacation, recalls Christina, “and suddenly Adam could barely walk. His whole left side wouldn’t function.”

She called 911 and accompanied him to a local hospital. “Within an hour, the CT scan was done and the ER physician told me he had a lesion on the brain,” she says. “I know now that ‘lesion’ sometimes means ‘tumour.’”

Then Adam had an MRI. “At midnight,” says Christina, “I was told, ‘He’s got glioblastoma and he’s going to die from this. You need to know. Your husband is going to die.’”

A biopsy had confirmed glioblastoma. “It was quite advanced by the time he was diagnosed,” she says. “At the time, they estimated he would have 18 to 24 months.”

Glioblastoma invades the brain quickly and lethally, striking about 1,000 Canadians every year. It’s the most common and most aggressive of malignant tumours that originate in the brain.

Most patients survive less than two years following diagnosis, and the median survival rate is generally 15 months. The average five-year survival rate is 10 per cent.

“The minute they told me, I just burst into tears,” Christina remembers. “I’d lost an aunt and uncle to different types of brain tumours. I knew what the path was going to be.”

At the same time, she couldn’t believe what was happening.

“Adam was so vibrant and healthy. He was the guy who never got sick. He was a picture of health. He ate well, he worked out.”

Christina Turner (pictured with her children) lost her husband, Adam, to glioblastoma in 2013. (Photo supplied by Christina Turner)

So far, researchers have found that hereditary factors may be implicated in a very small number of patients with glioblastoma. But for most cases, there is no explanation for the cause.

What is known is that the tumour originates in the brain’s supportive tissue, or glia – a tentacled network with its own rich blood supply, making it a prime environment for a rapidly growing and highly invasive malignant tumour.

After being diagnosed with glioblastoma, Adam was transferred to Sunnybrook and into the care of internationally recognized glioblastoma specialists, neuro-oncologist Dr. James Perry and radiation oncologist Dr. Arjun Sahgal and their teams at the Odette Cancer Centre.

Currently, glioblastoma is treated with some combination of surgery to remove accessible tumours, with radiation therapy and with chemotherapy. But this cancer is a devious, elusive and deadly shape-shifter, making treatment difficult and outcomes poor.

Adam Turner died just nine months after his diagnosis, exactly one month after his 46th birthday, leaving his wife Christina and their three children, and a close-knit circle of family and friends.

Understanding the unstable glioblastoma

Unlike some other cancers where the cells are clones of each other, when one glioblastoma cell becomes two, the offspring cells don’t look like the parent.

“Glioblastoma is highly genetically unstable, more so than most cancers,” Dr. Perry points out. “Tumour cells in glioblastoma bear no resemblance to each other. We call this tumour heterogeneity, and this poses one of the biggest obstacles to successful treatment because the cells have different DNA mutations.”

A scan of the brain reveals a large enhancing mass in the brain, which causes pressure leading to headaches, nausea and vomiting and an inability to walk properly. After surgery the diagnosis was a glioblastoma.

The offspring of an entire family of glioblastoma tumour cells are all different, with different DNA machinery and different switches.

“Some of these cells respond to treatment, but some don’t, and begin to take over the tumour,” Dr. Perry explains.

That’s what makes treating glioblastoma such a challenge.

As one of North America’s most extensive practices dealing with glioblastoma and other brain cancers, Sunnybrook’s Odette Cancer Centre is, notes Dr. Perry, involved in “research embedded in care.”

The complex, challenging care provided at Sunnybrook for people with glioblastoma combines cutting-edge research and technology, clinical trials and innovative therapies and advances in precision medicine.

The goal, says Dr. Perry, is “to deliver an effective therapy without collateral damage.”

Getting inside the brain

There’s the problem of where glioblastoma is located in the brain.

Researchers have mapped areas of the brain, for example, locations linked to vision and speech. “But with glioblastoma,” says Dr. Sahgal, “everything shifts around to accommodate the tumour and there is only so much you can see with a traditional MRI.”

The neurosurgeon may think she’s cutting into a safe area, but without guided imaging that provides a map of the brain, she may be damaging critical normal tissue.

Doctors need new and better ways to see the tumour in the brain.

New technology – such as Sunnybrook’s new MR-Linac, which gives visual access to the tumour during radiation treatment and provides more advanced monitoring of the tumour as well as normal tissue during those treatments – is improving understanding of the “biomarkers of response” according to Dr. Sahgal.

“In other words, detecting and understanding the unique signals through the MR images during treatment may provide for treatments that are personalized to the patient’s unique tumour biology,” says Dr. Sahgal.

“The MR-Linac has major potential to advance the entire field of radiation response for these tumours and a new field of research,” he adds.

Researchers like radiation oncologist Dr. Stanley Liu are studying biomarkers to provide information about how well tumours will respond to radiation. (Photograph by Kevin Van Paassen)

Meanwhile, drug therapies directed at the brain must get past the blood-brain barrier – the membrane that prevents many substances in the blood from passing into the brain and nervous system.

However, Dr. Perry is excited about an innovative new ultrasound technique – transcranial focused ultrasound – that’s making holes in the brain’s fortress.

Ultrasound energy at low intensity can temporarily loosen the barrier to allow drugs through to attack the glioblastoma tumour.

“We’re in early days of a clinical trial,” says Dr. Perry, “but low intensity focused ultrasound works beautifully and it appears to be safe.”

Getting to the bottom of the genes

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“There are things that are happening now that are so much safer that the quality of life is better for patients,” says Dr. James Perry, neuro-oncologist at Sunnybrook.

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Researchers have been exploring genetic mutations and biomarkers – signs of biological properties or molecules – associated with glioblastoma.

These advances in genomics are also making a difference in the treatment of glioblastoma, providing more information about which tissue and tumours will be more sensitive to radiation therapy.

That has led to the new field of radiogenomics, says Dr. Sahgal, which correlates cancer imaging features and genetic information.

Also, genomic research has made it possible, Dr. Perry continues, “to break down the vast majority of glioblastoma [cases] into four major types and to focus drug development and strategies on each of those four types” – instead of on an infinite number.

“Despite the lack of obvious new medications and therapies, there are things happening now that are so much safer that the quality of life is better for patients,” he adds. “And we’re able to be more aggressive, which is why we’re getting the gains in survival.”

Radiation oncologist Dr. Arjun Sahgal, left, and neuro-oncologist Dr. James Perry. (Photograph by Doug Nicholson)

While research continues into the molecular makeup of glioblastoma and how it can be targeted by using the body’s own immune system (immunotherapy) and other new approaches to bring about long-term remission and possibly a cure, the current goal is to prolong both the length and quality of life for patients.

“When we’re talking about glioblastoma,” says Dr. Perry, “it’s incurable. But the survival time is getting longer. Now 10 to 20 per cent of our patients survive for five years. Until the [oral chemotherapy] drug temozolomide came along, almost no one survived that long.

“We even have a patient who’s a 20-year survivor. Why did she get lucky? What is it about her tumour that’s not like the others? They appear identical. It’s all in the molecular profiling – the pathways that control the tumour. [It’s] just as random as that.

“Those of us who have been around a long time recognize that the effects of our treatment pale in comparison to the effects of the genetic lottery.”

As the research and innovation continue at Sunnybrook’s Odette Cancer Centre, Dr. Perry is hopeful about the future for glioblastoma patients.

“I think the two-to-five-year survival will continue to go up.”

Adds Dr. Sahgal, “There are very few places in the world that can do all of this.”

Learn about the Gord Downie Fund for Brain Cancer Research at Sunnybrook

The post Advances in treating glioblastoma, a virulent and erratic brain cancer appeared first on Your Health Matters.

By viewing the tomosynthesis slices (panels 2 to 4) the radiologist can be assured that there is no cancer present, but only normal tissue structure at that location.

Looking at a regular mammogram, explains Dr. Martin Yaffe, senior scientist at Sunnybrook Research Institute, is a lot like looking through the glass at an aquarium. “You don’t see the little fish behind the others.”

That incomplete view is challenging when the patient is a younger woman who typically has more dense tissue and less fat in her breasts, meaning small cancers may lurk unseen.

Dr. Yaffe and his Sunnybrook colleague Dr. Roberta Jong, a radiologist specializing in breast imaging, are Canadian pioneers in advancing new techniques and technology for mammograms for younger women and those with dense breasts.

They led the Canadian contribution to the landmark study – D-MIST (Digital Mammographic Imaging Screening Trial) – that compared the diagnostic accuracy of film and digital mammography.

They found that, for women 50 years old or younger and for women with dense breasts, the digital mammography was significantly more accurate. Digital mammography has now all but replaced film mammography.

Now Dr. Yaffe and Dr. Jong are again advancing the field, leading the first Canadian clinical trial comparing three-dimensional breast imaging (3-D tomosynthesis, or TMS) with the current standard of digital mammography.

T-MIST (Tomosynthesis Mammographic Imaging Screening Trial), initiated at Sunnybrook, will be the first, large randomized, multicentre study comparing the two techniques.

Dr. Yaffe describes the newer technique as “looking slice by slice.” Instead of taking just two digital views of the breast, TMS takes up to 15 images that are layered into a three-dimensional view. “It’s less likely that structures would be hidden,” explains Dr. Yaffe.

The 3-D view not only finds more abnormalities, but it also reduces the number of false alarms.

Preliminary studies suggest that TMS reduces the chances of false alarms by about 30 per cent.

When TMS finds cancers that may otherwise not have been recognized until later, it can result in less aggressive treatment, meaning breast conservation and increased survival rates, he says.

Or, as is often the case with prostate cancer, testing a tiny malignant tumour found in the breast may indicate that it poses no risk and requires only “watchful waiting.”

The researchers are currently recruiting more than 6,000 women at four sites in Canada for T-MIST, while looking to extend the trial to 148,000 women across 14 more sites in North America.

Images courtesy of Dr. Roberta Jong & Dr. James Mainprize

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State-of-the-art targeted radiation for prostate tumours and metastases is bringing uncommon results to the most common male cancer

Rodney Witz had been cancer free for seven years since his treatment at Sunnybrook for prostate cancer. But a semi-annual follow-up blood test last year showed his PSA (prostate specific antigen) level was rising. Then came the troubling news: An imaging scan revealed that cancer cells had spread to the bone.

“The first time, you worry because you have cancer,” says the 72-year old retired hairdresser. “The second time, when it’s in the bone, it’s getting a little bit on the scary side.”

But regular follow-up by Sunnybrook paid off. “They told me it was just one spot,” he recalls, “very, very small, almost undetectable since it was so small, really early stage.”

Cancer that has spread to only a few spots is known as oligometastases. It meant that Rodney could opt for a technique called stereotactic body radiotherapy (SBRT) for oligometastases.

“The conventional thinking about any solid cancer that has spread,” explains Dr. Patrick Cheung, a radiation oncologist with the genitourinary and lung cancer care teams at the Odette Cancer Centre, “is that it has spread microscopically everywhere, and therefore there would be no point to try to eradicate each spot of cancer that we could see on the scans. Usually, the main treatment for a few metastases is the same as if there were 100 metastases, which would be some type of drug therapy (like hormone therapy for prostate cancer) to slow down progression. Eventually it stops working after a certain period of time.”

At Sunnybrook, “based on promising results, our interest is to be a little more aggressive,” says Dr. Cheung. “In addition to the standard hormone therapy, we’re delivering very highdose, very focused radiotherapy to eradicate the tumours we see on the scans. We’ve learned with this SBRT technique to treat tumours in any organ safely.”

It was used originally for stage one lung cancer. “The cure rates are very good for early stage lung cancer, with results comparable to surgery, for patients who, for one reason or another, cannot undergo traditional surgery,” he says.

Rodney was one of the first patients with oligometastatic prostate cancer to be treated with SBRT at Sunnybrook. Dr. Cheung is leading a clinical trial called CROP that will determine the effectiveness of this targeted radiotherapy approach in improving outcomes for men with oligometastatic prostate cancer.

SBRT could be described as a non-invasive knife. “It’s trying to mimic surgery,” he says, “which is rarely performed when cancer has spread.”

The biggest challenge for the radiation oncologist is avoiding organs adjacent to the area targeted by radiation. The oncologist’s expertise and experience are paramount during the procedure.

“We have to be very careful if there’s a normal organ right next to the tumour,” explains Dr. Cheung, “because these are very intense doses to try to eradicate the tumours.”

In time, after the treatment, new tumours may show up elsewhere, says Dr. Cheung. But studies have shown that in patients treated aggressively with SBRT, the proportion of long-term survivors is consistently higher than expected when compared to most patients with metastases.

“We can’t claim that we can cure all prostate cancers that have progressed elsewhere in the body,” says Dr. Cheung, “but even in those not cured, there’s evidence that progression is delayed. The studies show that 20 to 30 per cent of those with metastases treated in this way are long-term survivors.”

Rodney’s wife, Carol, is hopeful her husband has many more years for them to spend together. Originally from South Africa and now residents of Thornhill, Ont., they often enjoy the winter months in Florida.

“I’m an optimist by nature,” says Carol. “When the cancer came back on Rodney’s pelvic bone, I wasn’t particularly upset. Dr. Cheung said he would get rid of it. He did.”

Sunnybrook, she says, “is an amazing institution.”

More than a year after his SBRT treatment, Rodney is feeling fine.

“They checked me again last summer with a general bone scan and it was all clear,” he says. “The thing I like about the whole team is, if you tell them something, they respond right away, they’re on it right away. I have ultimate faith in these guys. They never make promises they couldn’t keep.”

“I’d bet my life on them, that’s for sure.”

Dr. Gerard Morton and Dr. Patrick Cheung are pioneering advanced prostate cancer treatments, including stereotactic body radiotherapy, high-dose-rate brachytherapy and external-beam radiotherapy. (Photograph by Doug Nicholson)

When Dr. Ihor Popadynec found out he had prostate cancer, he was only mildly surprised. He was having a problem with prostatic hypertrophy (enlarged prostate), a common condition in men as they age.

This condition can hide underlying tumours.

After 45 years as a family doctor, he’d examined hundreds of enlarged prostates in his patients. He’d referred men for regular PSA tests, then sent them to urologists when the results were suspicious.

He knew that one in eight Canadian men would be diagnosed with prostate cancer, most likely after the age of 60. “It’s the most common tumour men get,” he says. “Every male is facing this problem as he ages.”

[mks_pullquote align=”right” width=”300″ size=”24″ bg_color=”#2f56a5″ txt_color=”#ffffff”]“We can’t claim that we can cure all prostate cancers that have progressed elsewhere in the body, but even in those not cured, there’s evidence that progression is delayed. The studies show that 20 to 30 per cent of those with metastases treated in this way are long-term survivors.”[/mks_pullquote]The 72-year-old retired physician realized he was vulnerable, even though his PSA was within normal limits, and there was no history of cancer in his family. What his biopsy revealed was a fairly aggressive prostate cancer.

But what shocked Ihor was not the diagnosis. It was the treatment. “In all my years in practice, surgery was the go-to treatment,” he explains. “It’s what I expected to happen to me.”

Instead, his urologist suggested that Ihor “speak to Dr. Morton at Sunnybrook. He’s got a technique that might be a better way to go.”

Increasingly, men across Ontario are turning to Sunnybrook for a better way to deal with prostate cancer, from diagnosis to treatment.

The technique that impressed Ihor’s urologist was developed at Sunnybrook. It is now being offered as a newer treatment option at major cancer centres all over the world, revolutionizing the way some medium- to high-risk prostate cancers are treated. For patients who cannot undergo surgery due to other medical conditions, or for patients who choose to avoid surgery, the prognosis with this treatment is as favourable as that which follows surgically removing the prostate.

The procedure is a combination of highdose- rate (HDR) brachytherapy, which delivers a short, high dose of radiation internally into the prostate, and a series of external-beam radiotherapy treatments (EBRT), which are directed at the pelvic area from outside the body to target any cancer cells that may lurk beyond the prostate gland.

“We do one treatment with HDR brachytherapy followed by a three-week course of 15 EBRT treatments,” says Dr. Gerard Morton, a radiation oncologist with the genitourinary cancer care team at the Odette Cancer Centre. “This treatment is particularly effective for men who have more aggressive cancers. We recently completed a clinical trial for men with medium- and high-risk prostate cancer. This treatment has been shown to reduce the risk of recurrence by half.”

He adds: “We’ve been following these patients carefully, and we now have patients followed up for 10 years. Over 90 per cent are cancer free after 10 years – and these are men who’ve had higher-risk prostate cancer. The results are equivalent to surgery.”

The prospect of achieving the same result without the need for invasive surgery was good news, and Ihor didn’t have to wait long to hear it. “They rushed the results to Sunnybrook, and Dr. Morton and his resident saw me within three or four days,” he recalls.

He also heard at that meeting exactly what the treatment would entail. “With the patient under general anesthetic, we insert catheters into the prostate and introduce a radioactive source, which moves in and out in a programmed fashion,” explains Dr. Morton. “It takes about 10 minutes and then we remove it. There’s no ongoing radiation.”

Ihor describes it as “multiple hollow prongs inserted into a grid near the treatment area. Inside the prongs there’s a core, like a ballpoint pen, that comes out to do a quick burn [radiation dose] and then it’s retracted again. It’s a matter of timing and intensity. And hopefully they get it all.”

The single HDR treatment is a newer form of brachytherapy. Originally, brachytherapy involved inserting low-dose rate radioactive implants, or “seeds,” which remained inside the gland permanently.

“We do use both procedures,” explains Dr. Morton, “the implant on its own and the HDR combined with external beam for more aggressive cancers.”

When Ihor woke up from the anesthetic, he felt no pain or discomfort, and there was no bleeding. “I went home within two hours of the procedure; I never even spent a night in the hospital,” he says.

“It was,” he concludes − reaching for a word that’s rarely associated with prostate cancer − “elegant.”

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About 75 per cent of prostate cancers that require treatment will be cured by surgery or radiation. The remaining 25 per cent will recur and spread to other places in the body, a process called metastasis. At this stage, prostate cancers are typically treated with androgen deprivation therapy (ADT), also known as hormone therapy.

Androgens (male hormones, including testosterone) help prostate cancer grow. Blocking androgen production slows progression of the disease. But usually, sometime after two years or so, the cancer no longer responds to ADT alone. While Sunnybrook’s Odette Cancer Centre provides care for patients across the spectrum of the disease, medical oncologist Dr. Urban Emmenegger, specializes in much-needed research and treatments for prostate cancer at advanced stages when hormone therapy no longer works on its own.

Conventional hormone therapy impairs the production of androgens in the testicles, the major, but not only, source of male hormones. One of the newest androgen-deprivation drugs used at Sunnybrook blocks production of male hormones everywhere in the body and even inhibits the prostate cancer cells from producing their own hormones.

“When combining this drug with conventional hormone therapy, most patients will respond at first – only for the cancer to again become resistant after a while. However, in some patients, not all of the metastases become resistant,” says Dr. Emmenegger. He looks for ways to strategically tailor novel treatments for men who have a combination of both resistant and treatable metastases.

In collaboration with radiation oncologist Dr. Patrick Cheung, Dr. Emmenegger is conducting a clinical trial on the effectiveness of stereotactic body radiotherapy to stop the growth of such resistant, “rogue” metastases. The high-dose radiation finely targets up to five rogue tumours or progressing tumours, while the continued hormone therapy treats the stable tumours.

This clinical trial was inspired by one man whose prostate cancer had spread to his spine after having been on an experimental treatment for a number of years. “He was treated with radiation while continuing the study medication, and his PSA came down again,” says Dr. Emmenegger. “Now, 18 months later, his PSA is increasing again, and the cancer has further spread. But, in essence, we have gained a year and a half.”

The post Hunting down the most advanced prostate tumours appeared first on Your Health Matters.

“I’m told that I have the prostate of a 20- year old,” says 58-year old Martin S., “which is a great pickup line, except that I’m happily married.”

Martin’s prostate is the subject of more than a quirky pickup line.

Because he has a gene mutation associated with prostate cancer, Martin was invited to take part in the Male Oncology Research Program at Sunnybrook’s Odette Cancer Centre. He has BRCA2, which, along with BRCA1, is a gene mutation that can increase risk for prostate, breast and ovarian cancers. (For privacy, Martin asked that his full name not be used.)

The research program’s confidential registry, database and biobank for men with genetic dispositions for prostate cancer are a collaborative undertaking by several institutions that is led by Sunnybrook.

“Ancestry, family history and known genetic predispositions such as BRCA mutations are important factors in a risk assessment for prostate cancer,” says Justin Lorentz, a genetic counsellor at the Odette Cancer Centre. “We know that men of Ashkenazi Jewish ancestry are 10 times more likely to have a BRCA1 or BRCA2 gene mutation compared to men who are not of Ashkenazi Jewish ancestry.”

“Men of West African/Caribbean ancestry are also known to have higher risks for prostate cancer and more aggressive disease, and men with a family history of prostate cancer are known to be at increased risk,” adds Lorentz.

“We are actively working to engage men of West African ancestry or men with strong family histories, to better understand how prostate cancer is inherited and how best to support these patients,” adds Dr. Danny Vesprini, a radiation oncologist and researcher at Sunnybrook with a specific interest in the genetic predisposition to develop prostate cancer.

“One of our challenges is to get guys into the clinic to participate in this kind of research,” says Lorentz.

Martin, however, was glad to get involved. So far, he’s in good health with the prostate of, well, a 20-year-old. And he knows that not all men with BRCA mutations will develop cancer. Nevertheless, he explains, “my maternal grandmother died from breast cancer, my mother and an aunt died from breast cancer in their 40s. Until I had genetic counselling at Sunnybrook, I hadn’t realized the mutation could be passed on to sons and then passed on by them.”

More recently, research such as that ongoing at Sunnybrook has found that men with BRCA mutations carry up to double the risk for prostate cancer and are more likely to be diagnosed at an earlier age; in addition, the cancer is likely to be more aggressive compared to men in the general population who develop the disease.

“Prostate cancer is often slow-growing, though it can also be aggressive in men in the general population. In the case of men with BRCA mutations or other known genetic predispositions, and those with strong family histories (given their higher risk), we really want to monitor these guys closely for early diagnosis and timely intervention,” says Dr. Vesprini.

He strongly believes other mutations and markers will be found, most likely sooner rather than later. “We’ll likely find something heritable in families with strong family histories,” he says.

Sunnybrook is one of only a handful of hospitals researching men with known genetic predispositions like BRCA1 and BRCA2, and men with a strong family history of cancer or who are of West African/Caribbean ancestry.

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