Top Doctors 2006: Profiles

Heart Disease

Harvey Waxman
Penn Presbyterian Medical Center

Cardiologist Harvey Waxman is surprisingly upbeat about American heart health, considering our cheeseburger intake. That’s because Waxman is all about prevention, even as he’s ticking off conditions we don’t even know enough to worry about. “Most Americans believe heart attacks are caused by a 100-percent-blocked artery” that chokes off blood to the heart, Waxman says; in fact, an artery that’s just 10 or 20 percent plugged by plaque can quickly become a fatal episode. “­Artery linings can get irritated, and things like smoking or even stress can cause them to crack,” explains Waxman, 57, chief of cardiology at Penn Presbyterian Medical Center. “The body gets a message to send platelets, and the resulting thrombus [blockage] can close off the artery.” The good news: Hardening of the arteries can be treated with medications and new drug-coated stents that prevent the re-narrowing common with older stents. In the very early stages of research right now are xenografts, trans-species heart transplants that, despite the failure of Baby Faye’s transplanted baboon heart in 1984, could be tried in humans again. Doctors can tailor drugs to specific genetic makeups, and this kind of “designer drug” prescription will only get more specific over time. Researchers working with adult stem cells — usually harvested from the patient’s own blood or bone marrow — are testing whether these cells, injected into the heart muscle or arteries, can re-grow healthy cells to repair damaged ones. No wonder the doctor’s so optimistic, even as we dial for another extra-cheese pie. —Amy Donohue Korman

How to avoid Dr. Waxman:
1. “Don’t smoke, don’t smoke, don’t smoke.”
2. Exercise: Alternate 30 to 45 minutes of aerobic exercise one day with 20 to 30 minutes of weights the next day, six days a week.
3. Eat a Mediterranean diet — whole grains, seafood, fruits and veggies, and olive oil.

Skin Cancer

Stuart Lessin
Fox Chase Cancer Center

Think that deep tan makes you look thin and rich? “A century ago, a suntan wasn’t associated with wealth and leisure,” says Stuart Lessin, director of dermatology at Fox Chase Cancer Center. Tans were for field hands and farm girls. But since bronze became stylish, dermatologists have seen a sharp uptick in skin cancer. Despite all the warnings, Lessin says, “People still want to look tan — and at a younger age.”

Researchers predict melanoma will be the most common cancer in the United States by 2022. It’s the least prevalent but most severe form of skin cancer, because it spreads quickly to other organs, blood and bones. Basal and squamous skin cancers, while more common now, are also more treatable. Lessin, 50, cites topical therapies that treat and prevent, like Imiquimod, which was created for warts but shows signs of goading the immune system into manufacturing healthy compounds as an “anti-tumor response.” Even more exciting are “targeted therapies” — intravenous and oral drugs that find and treat cancer cells and replace toxic chemotherapy. That means some people can live longer with their cancers. Someday, Lessin hopes, his specialty will be viewed “more like a chronic disease” than as a sentence of death.

Meanwhile, you don’t have to become nocturnal, he says: “Just be smart. Put on sunscreen, throw on a hat, or just switch from a tank top to a short-sleeve tee. Any little bit helps.” Check your skin on a regular basis, and remember that a fair complexion, lots of moles, and a family history of skin cancer make you at-risk. Lessin puts in a plug, too, for self-­tanning products: “They’re much better than they used to be. They make you look tan, not orange.” —Ashley Primis

How to avoid Dr. Lessin:
1. Learn the ABCDs of potentially cancerous moles: asymmetry, border irregularity, color variation, and diameter — watch for anything larger than a pencil eraser.
2. Start seeing a dermatologist as a young adult.
3. Be sun-smart: Seek shade, and wear protective clothing and sunblock with SPF 30 or higher.

Alzheimer’s Disease

Barry Rovner
Thomas Jefferson University Hospital

You have trouble expressing yourself. You can’t come up with names as quickly as you used to. You can’t remember which actor was in which movie. And you’re wondering: Is this normal aging, or is this Alzheimer’s? Barry Rovner can answer that question for you. Rovner, 52, a psychiatrist and director of clinical Alzheimer’s research at the Farber Institute for Neuroscience at Jefferson, can test your language, memory and perception to determine whether you’ve “crossed the line.”

If you have? In the early ’80s, doctors didn’t know exactly what Alzheimer’s was doing to the brain, so they only treated the depression, hallucinations and other psychotic symptoms it brought about. Today, doctors understand the disease much better. They know, for instance, that amyloid is the problem protein that destroys the brain’s cells. (Why and how? Farber is the leading institute trying to figure that out.) They know that the risk increases with age starting at around 65, though Rovner just treated a 52-year-old with the disease. They know more women are affected, in part because women live longer. There are drugs that slow the progression of Alzheimer’s, and new ones being tested may slow it significantly more. So far, though, no drugs can prevent Alzheimer’s. “But to a certain extent, you can prevent it,” says Rovner. “That’s what most people don’t realize.” —Vicki Glembocki

How to avoid Dr. Rovner:
1. Treat high blood pressure, diabetes and high cholesterol, since all increase the risk of Alzheimer’s.
2. Exercise your body three times a week (walk, garden, swim) and your mind every day (play memory games like the one shown, read the paper, play bridge).
3. Drink a glass of red wine every day (some studies say it helps reduce the risk).

Diabetes

Stanley Schwartz
Hospital of the University of Pennsylvania

Just last year, endocrinologist Stanley Schwartz realized he was showing signs of diabetes, a disease he’d spent the past three decades fighting. When diabetics had no options besides injections (and one pill) to help them manage their insulin, that diagnosis could mean a grim prognosis: blindness, amputation, kidney failure. In the ’90s, though, breakthroughs in research led to a rush of new medications designed to curb appetite and regulate blood sugar — two essential concerns with this illness. With even more such drugs on the verge of FDA approval, living with diabetes is more manageable than ever.
Type 2 diabetes, which accounts for 90 percent of all cases, can be avoided or delayed significantly, Schwartz says, just by maintaining a healthy lifestyle and being aware of genetic predisposition. (African-Americans and Hispanics are at high risk.) If diabetes runs in the family, everyone, kids included, should monitor diet closely and see a doctor for what Schwartz, 59, calls the “combination theory” of prevention — making sure blood sugar, blood pressure and lipids (including cholesterol) all stay within safe ranges.

Today, Schwartz worries that NIH funding cuts and the furor over stem-cell research will hinder more medical advances for America’s 20.8 million diabetics. He’s working for the day when the only panic after diagnosis is over what he feared most: injections. “I was just as scared as my patients,” he says of administering the needle himself. “But once you get the first shot out of the way, it’s fine.” —Richard Rys

How to avoid Dr. Schwartz:
1. Exercise — at least three weekly 20-minute sessions of fast walking.
2. If diabetes runs in your family, drop sweets, simple sugars and bad fats from your diet.
3. Get a checkup and blood tests every year through your physician.

Stroke

Rodney Bell
Thomas Jefferson University Hospital

Quick — what’s a stroke? If you’re not sure, you’re not alone. Though 700,000 people in the U.S. will suffer strokes this year, that’s not the statistic that worries Rodney Bell, director of the Acute Stroke Center at Thomas Jefferson University Hospital. He’s more focused on this one: Thirty percent of Americans think a stroke is a heart problem, when it’s actually a rupture or obstruction of an artery in the brain.

Public understanding of strokes hasn’t advanced as quickly as treatment options, says Bell, 60, who’s been studying them for 25-plus years. When he was a resident, medicine offered zero help to stroke victims, whose ruptures or obstructions can result in loss of brain functions: “We sent them home.” Today, the outlook is much sunnier if patients receive “clot buster” drugs or surgery to remove the obstruction within three hours of the onset of symptoms. But in the U.S., only two to three percent of victims recognize the warning signs — drooping facial muscles, slurred speech, the inability to lift your arm — and get the care most likely to save their lifestyles and lives.

Bell has experimented with everything from free radical scavengers to membrane stabilizers to literal “brainwashing” that rinses out harmful materials. But he says doctors need to treat strokes with PowerPoint slides as well as MRIs: “The big research question is, how do you minimize the damage of a stroke? But we also need to ask, what more can we do to educate people about strokes?” —April White

How to avoid Dr. Bell:
1. Don’t smoke (cigars count).
2. Watch your salt intake. It’s linked to high blood pressure, a risk factor for strokes.
3. Lose weight. Obesity, especially abdominal obesity, has also been linked to strokes.

Breast Cancer

Monica Morrow
Fox Chase Cancer Center

Breast cancer is rife with ambiguities, says Monica Morrow, chair of the department of surgical oncology at Fox Chase Cancer Center. Case in point: In a recent study, breast cancer patients who felt more involved in making treatment decisions were more likely to end up getting mastectomies. But research shows that the less radical option, lumpectomy accompanied by radiation therapy, has the same survival rate. Though most surgeons offer this option, women still feel a mastectomy is safer. So Fox Chase is studying how to communicate the risks and benefits of different courses of treatment based on a patient’s personality style. “Some women want to know everything there is to know,” says Morrow, 52, “but others get overwhelmed by too many details.” The goal is to keep the patient focused on genuine issues so she can ask the right questions.

One tool helping patients make decisions is genetic testing. “I’m always surprised at the number of patients I see who tell me they have five relatives with breast cancer, but they’ve never been evaluated genetically,” says Morrow. There’s hope drugs may prevent cancer even in high-risk women: Tamoxifen and raloxifene have produced encouraging results. And Fox Chase is studying whether five days of radiation therapy could replace the standard six-week course. —Erica Levi

How to avoid Dr. Morrow:
1. Be born male.
2. If you’re over 40, have a yearly mammogram.
3. Get to know your breasts, so you can distinguish between normal and abnormal lumpiness for you — and if you notice a change, see your doctor right away.

Lung Cancer

Larry Kaiser
Hospital of the University of Pennsylvania

Larry Kaiser was only six when he nagged his mom into giving up cigarettes. Small wonder he became a thoracic surgeon, carving out tumors from lungs. Though lung cancer is the most common cause of cancer deaths in the U.S., it doesn’t get the attention or research funding of other cancers, for a simple reason: “People think, ‘Oh, they brought that on themselves,’” explains Kaiser, 53, the chairman of the department of surgery at Penn. “But not every case can be blamed on smoking. Look at Dana Reeve.”

Still, the prognosis is improving. Nodules are being spotted earlier, and smaller. New imaging techniques help: “If a PET scan on a spot in the lung comes up positive, it’s a good sign that spot is malignant,” Kaiser says. Chemotherapy after surgery means patients live longer. Identify lung cancer early enough, and you can cure it, Kaiser says. The trouble is identifying who has the disease while it’s still treatable. He’s convinced genetic triggers and molecular fingerprints will someday explain why nonsmokers sometimes get lung cancer and why some smokers don’t, producing a susceptibility test. Meantime, he suggests smokers and ex-smokers look less at the forest and more at their personal trees: “Studies in the ’70s of high-risk patients didn’t show any value to screening with chest x-rays. But the new scanners may catch lung cancer earlier. If I’d smoked for 30 years, I’d get a chest x-ray.” They cost from $200 to $600. Your doctor should provide a referral; if not, your peace of mind may be worth paying the price yourself. —Sandy Hingston

How to avoid Dr. Kaiser:
1. “Never smoke.”
2. Test your home for radon. Order a do-it-yourself testing kit from the National Safety Council, 200-767-7236.
3. If you’re high-risk, get a chest x-ray.

Prostate Cancer

Alan Wein
Hospital of the University of Pennsylvania

When Alan Wein graduated from Penn’s medical school in the 1960s, prostate cancer was a grim diagnosis. By the time a doctor spotted a problem, it was often too late — the tumor was large, or, worse, had spread to other parts of the body. Four decades later, Wein — now HUP’s chief of urology — says that’s changed drastically. With improved screening techniques, such as the PSA blood test and the dreaded DRE exam (uh, how was it for you, doc?), prostate cancer is being caught earlier, and the mortality rate is steadily dropping.

Now, though, patients face an array of confusing decisions upon diagnosis. Should they have more diagnostic tests? Do they need treatment, or will close monitoring be enough, since prostate cancer often grows very slowly? If treatment is needed, should they have surgery or radiation? Which types of each work best? “It’s not like lung cancer,” Wein says, “where you just go in and cut it out.”

Wein, 64, is optimistic that in time, the solutions will be simpler. Though it’s still at least a decade in the distance, for example, research has begun on a vaccine for men with a genetic predisposition for the disease. “Obviously, that’s the dream — that would be on everybody’s wish list,” Wein says. —Tom McGrath

How to avoid Dr. Wein:
1. Get screened. Wein recommends regular PSAs and DREs starting at age 50 — a decade earlier if you’re African-American or have a brother or father with prostate cancer.
2. Consider selenium. Wein has seen enough evidence that he takes a
200-microgram supplement every day.
3. Go Italian. The antioxidant lycopene — tomatoes are full of it — has also been shown to offer protection. Get yours the way Wein does at right: “My wife is Sicilian, and I love her red sauce.”

Kidney Disease

Michael P. Madaio
Temple University Hospital

Admit it: You never spend so much as a moment at the urinal pondering the life-saving work your kidneys do. And yet the United States has one of the highest rates of end-stage renal disease in the world. Uncontrolled diabetes and high blood pressure are the most common — and well-known — causes of kidney failure. But what’s most unsettling about kidney disease are the unknowns: There’s no cure — grueling dialysis and risky transplantation have long been the only end-stage treatments — and doctors still don’t understand much about a common cause: autoimmune diseases, a mysterious category of ailments, including lupus and chronic fatigue syndrome, in which the body arbitrarily attacks its own immune system.

Still, Michael P. Madaio, who left HUP last month to become chief of nephrology at Temple, feels hopeful about the specialty to which he’s devoted nearly three decades of clinical work and research. NIH funding and research are increasing as America’s population ages and becomes more vulnerable. And Madaio, 57, cites the “life-changing effects” of drugs formerly prescribed only for transplant recipients that now are being used to stave off end-stage kidney failure.

Of course, there are steps you can take to keep your kidneys in good shape: “Generically speaking, it comes down to doing all those things no one really wants to do,” Madaio says. Follow the doctor’s orders, and you can go back to flushing without philosophizing. —Jessica Blatt

How to avoid Dr. Madaio:
1. Get your blood pressure and cholesterol levels checked.
2. Limit salt intake; watch out for frozen and canned foods with high levels.
3. Eat a balanced, healthy diet.

Emphysema

Gregory Tino
Hospital of the University of Pennsylvania

Long before Gregory Tino’s father developed pulmonary fibrosis, Tino had decided to become a lung specialist. But seeing his dad struggle for breath after nearly 20 years of smoking gave Tino, the director of HUP’s Pulmonary Outpatient Practices of the Pulmonary, Allergy and Critical Care Division, “a new perspective on what it’s like for families of patients with lung disease.”

Included under that umbrella are asthma, chronic bronchitis, interstitial lung disease and other lung ailments, along with the better-known emphysema. This last involves a loss in the lungs’ surface area — “Holes in the lungs that don’t regenerate themselves,” Tino, 45, explains. It’s largely a disease of smokers, but can also be caused by environmental factors such as air pollution or secondhand smoke. Symptoms include shortness of breath, wheezing, coughing, chest tightening, fatigue, and losing weight without trying. Early detection helps doctors slow the progress and lessen the severity of symptoms. This focus on rehabilitation is relatively new: “Years ago, we didn’t have much rehab for emphysema patients,” Tino says. “Now, we tailor treatments according to the severity of the symptoms.” Exercise helps, especially for patients who’ve led sedentary lives. Since there’s no cure, Tino says, “Treatment is all about creating a lifestyle that’s livable and enjoyable. There’s a misconception that emphysema is no big deal. But it can rob you of your ability to walk, to talk — things we take for granted.” —Blake Miller

How to avoid Dr. Tino:
1. Don’t smoke.
2. Avoid occupational exposures such as air pollution and dust.
3. Ask your doctor to screen you if you have any of the symptoms.

Pancreatic Cancer

John P. Hoffman
Fox Chase Cancer Center

You don’t want to get pancreatic cancer. Granted, you don’t want to get lung cancer or breast cancer, or a bad cold, either. But you really, really don’t want to get pancreatic cancer, because it’s the Karl Rove of illnesses: inconspicuous, merciless, and ruthlessly efficient. Difficult to diagnose (it’s sometimes called the “silent disease,” because early symptoms — abdominal or back pain, unplanned loss of weight, loss of appetite, jaundice — are seldom recognized) and difficult to treat, pancreatic cancer kills the same number of people each year as are diagnosed with it. “It’s the type of cancer that gives cancer its bad name,” says Fox Chase Cancer Center surgeon John P. Hoffman.

There is some good news. In November 2005, for example, the FDA approved the use of the lung cancer chemo drug erlotinib (under the brand name Tarceva) — in combination with gemcitabine, the standard pancreatic cancer chemo drug — for patients with advanced, inoperable or metastatic pancreatic cancer. The combo shows a small but statistically important increase in survival over the use of gemcitabine alone.

Still, the only way to cure pancreatic cancer is to catch it early and remove it, which is Hoffman’s job. He specializes in the most common surgical treatment, the Whipple procedure, in which parts of the pancreas (which produces enzymes that break down foods and secretes hormones that help metabolism), stomach, small intestine and gall bladder may be removed. In recent years, the operation has become much safer, and post-op chemotherapy and radiation are more effective; even Hoffman, not one to gild the lily, says, “Things are much better than they used to be.” Early detection is key, though, so it helps to know if you’re at risk. While age (most of those diagnosed are between 60 and 80), gender (more men than women get it), race (African-Americans have the highest rates in the world) and a family history of pancreatic cancer increase the chances of getting the disease, the most generally accepted risk factor is one that’s controllable: smoking. —Andrew Putz

How to avoid Dr. Hoffman:
1. Don’t smoke.
2. Be aware of the risk factors.
3. If you’re at risk, watch for the early symptoms.

Colon Cancer

Robert Dean Fry
Hospital of the University of Pennsylvania

The problem with colon cancer is simple: We really don’t want to think about it. But Robert Dean Fry, a colorectal surgeon for 25 years, points out that it doesn’t take all that much thought. If someone in your nuclear family has had colon cancer, you should start getting annual colonoscopies 10 years prior to his or her age of detection. (A benign colon polyp takes seven to 10 years to turn cancerous. If caught in the polyp stage, it can be snipped away via a relatively simple procedure through the anus.) The family connection gives you a one in three chance of developing the disease, Fry says. Overall, a baby born today has a six percent chance of someday developing the disease.

A colon cancer diagnosis isn’t the nightmare it was just 15 years ago. Back then, cancers were removed and analyzed: How deep, how far advanced, what was your life expectancy? Now, colorectal cancers are analyzed before surgery, in order “to defy that prognosis,” Fry says with obvious pride — “to change the natural history of the disease.” If the cancer is early-stage, it gets snipped trans-anally; laparoscopy — surgery using small incisions in the abdomen — has made removing more advanced tumors less traumatic; and new methods of chemotherapy fight the vascular supply of cancers, starving the tumor of blood. In fact, Dr. Fry predicts that within a few decades, surgeons will be reduced to analyzing colorectal cancers simply to see which chemotherapy agent will eliminate them — making the cure medicinal instead of surgical. “And that,” he says quite cheerfully, “will put me out of business.” —Robert Huber

How to avoid Dr. Fry:
1. “Get annual colonoscopies, starting at age 50. Any other advice would detract from that.”