2017 Issue 1, Quarterly Newsletter

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WOMEN’S HEALTH

A Happy 2017 to all our patients, families and loved ones!

A time of new beginnings, we hope everyone was able to start the year rested and excited after the holiday break.

My own maternity leave is coming up next month! As my family is preparing for the arrival of our fourth child, we’re also preparing the office for my leave. This fortunately includes the arrival of Dr. Gupta, the fourth physician to join our office! We’re hoping the transition is smooth and seamless, but ask for your patience during the upcoming three months.

Having reached our long-term goal of four physicians, our only remaining focus for the year is improving the excellent care we pride ourselves on in a welcoming, efficient manner. We always appreciate your feedback and look forward to meeting your expectations.

Barb Dehn, NP also returned from a long trip to Tanzania, Africa where she engaged in very humbling work. We are happy to have Barb back and look forward to her writing about her experiences once she’s settled in.

January is also a time of New Year’s resolutions and hopefully improving your health is at the top of your list. If you’re thinking about incorporating some of the health tech innovations in those resolutions, make sure to read the related topic below.

If you haven’t gotten your flu shot yet, please get one soon, the seasonal peak will soon be upon us.

Best wishes for a healthy, joyful 2017!

Sarah Azad, MD

In this issue:

Welcome Dr. Gupta

Reminders for patients of Dr. Sutherland and Crystal

The 2017 Flu Season

Concerns for Women’s Health Care in light of the recent election

NIPT now mainstream for all pregnant women

Am I at increased risk for breast cancer? More affordable testing and a new test for low risk women

Health Technology: advances in women’s health?

An update from ACOG on delayed cord clamping

Highlights from the Women’s Health Blog

WELCOME DR. GUPTA!

One of our goals in providing excellent, comprehensive women’s health care at El Camino Women’s Medical Group, is to have a team that is small enough to allow that care to be personal, yet large enough to allow us to be available every day, night and weekend. That brings us to the arrival of Pooja Gupta, MD on February 1, 2017!

After completing her residency in Pennsylvania, Dr. Gupta worked in a similar women’s medical group in the suburbs of Philadelphia for over 4 years before moving to the Bay Area. She has a great personality and a sincere commitment to women’s health. We are excited to have her join us and know she will be a great addition to our team. Learn more about her on her page.

As Dr. Azad will be leaving for maternity leave from mid-February until early May, Dr. Gupta will be helping to cover most of her patients while she is out, along with Drs. Balassiano and Teng. For pregnant women who are due in February and March, we will be scheduling your early February appointments with her so you will be able to meet Dr. Gupta before your delivery.

REMINDERS FOR THE PATIENTS OF DRS. CRYSTAL AND SUTHERLAND

It’s been 16 months since Drs. Crystal and Sutherland have closed their private practices. By now most of you have been seen in our offices or established care with another physician. If you have not yet established care in our office or with another office, then you’re overdue for your wellness visit, and possibly other follow ups. We are no longer able to honor prescription refills for patients who have not been seen by us and will be making no exceptions. If you are being seen at another office and need your records, please fill out a Release of Information Form and email or fax it to our office.

THE 2017 FLU SEASON

Before the end of 2016, the CDC announced increasing rates of the Flu across the country. As with every year, we recommend everyone over the age of 6 months get the Flu vaccine. The nasal spray is not recommended for the 2016-17 Flu Season. Children under the age of five, adults over 65 and pregnant women remain the highest risk groups for severe complications of the Flu. If you’re in this group or live with someone in this group, we hope you’ve been vaccinated by now.

The Flu Season usually peaks in late January-early February, so if you haven’t gotten it yet, please do so soon. Our office carries the Flu vaccine for our patients, just call to confirm you can walk in on a specific day and we’ll be happy to keep you protected. The Flu vaccine is also available from your Primary Care Physician or local pharmacy.

This year, the influenza A (H3N2) strain has so far emerged as the dominant strain, this generally indicates a more severe season. This may change and other strains may become the predominant strain of the season, but if this continues, we expect more severe illness among young children and older adults. The four years with the highest flu-related deaths in the last decade had H3N2 as the predominant strain.

And remember, the vaccine is not just for you, but also for those with whom you live, socialize and work!

CONCERNS FOR WOMEN’S HEALTH CARE IN LIGHT OF THE RECENT ELECTIONS

The Affordable Care Act was signed into law in 2010, but the majority of provisions were implemented gradually between 2011 and 2014. Some of the major changes related to Women’s Health Care include: mandatory contraceptive coverage, maternity coverage and coverage of preventative services (including Pap tests, mammograms, colonoscopies and annual Well Woman visits). Other major policy shifts include: allowing children to stay on parents’ plans until age 26, no lifetime caps on cost of medical care, and no exclusion of pre-existing conditions.

There is a lot of uncertainty about what is coming in the next few years. Our congressmen and women have assured us that for 2017, there is little chance of any major changes for patients with commercial insurance plans (health insurance through companies like Anthem, Aetna and Cigna). Everyone should have insurance contracts in place and any legal changes would affect new plans/plan renewals for 2018. MediCal patients are at some risk if the federal government stops funding for expanded coverage, but the California congress is already working to ensure that there is adequate funding from state resources should this occur.

2018, however, is another story. We are working with our local state congressmen and women to make sure California keeps in place the excellent gains made in access to women’s health services over the last 6 years and are hoping there will be no loss of services in the future.

If you have any specific concerns related to your own health needs, please bring them up at your next appointment or send a message to your physician.

NIPT NOW MAINSTREAM FOR ALL PREGNANT WOMEN

Non-Invasive Prenatal Testing (NIPT) has been available for nearly 4 years. A huge advancement in prenatal care, this blood test (performed on the pregnant woman’s blood sample) is able to analyze fetal DNA that is present in maternal blood after 9 weeks of gestation. Current technology enables us to rule out major genetic abnormalities, like Down’s syndrome, and also to assess fetal gender with 99+% accuracy in the first trimester.

Until this year, most insurance providers only covered this test for women over the age of 35 or with a personal or family history that put them at high risk for genetic abnormalities.

At El Camino Women’s Medical Group, we found NIPT testing to be the most logical replacement for first trimester genetic screening. It’s more accurate (99+% vs 85%) and has less false-positives (<1% vs 20) and with the arrangement we had with Natera, more cost-effective than traditional screening. We’ve been recommending this test for all women since 2015. Fortunately, NIPT testing is becoming more common and most commercial insurers now cover it for women of all ages in pregnancy.

This means that 95% of our patients find their insurance will cover the test—though it may go towards your deductible—and the average, in-network cost is around $800. This is still cheaper than the previous cost of first trimester genetic screening.

For patients with MediCal or HMO plans, NIPT is still limited to women considered at higher risk of a genetic problem, but we still recommend NIPT testing, given its accuracy and low false-positive rates, and Natera offers our patients from the Physicians Medical Group of San Jose a maximum out of pocket of $350. We hope by the middle of 2017 to see complete coverage of NIPT by all insurance providers, including MediCal and HMO patients. There are manyongoing lobbying efforts from NIPT labs as well as patient advocacy groups.

AM I AT INCREASED RISK FOR BREAST CANCER? MORE AFFORDABLE TESTING AND A NEW TEST FOR LOW RISK WOMEN

Since 2009, the American College of Obstetrics and Gynecology (ACOG) has encouraged OB/GYNs to routinely screen every woman for her risk of hereditary breast and ovarian cancer syndrome. At ECWMG, we do this at your very first visit in our office and every year at your Well Woman exam. For women who did need testing for this syndrome, to see if they carried the BRCA 1 or BRCA 2 genetic mutations, testing was $3000-4000, even when the test was approved by her insurance.

Fortunately, in June of 2013, a Supreme Court ruling opened the field of BRCA 1 and BRCA 2 genetic testing to other companies and the price of testing has since come down. There are several labs now offering testing and insurance coverage has markedly improved. Most tests are now in the $1500 price range, when covered at in-network rates. We also work with some labs that can offer the test at the cost of $350 when a patient’s insurance will not cover the test.

During this time, advances in the field of hereditary cancer genes has exploded, there are now over 20 different gene mutations (including BRCA 1 and BRCA 2) that greatly increase a woman’s risk of breast, ovarian and other cancers. Comprehensive cancer screening for women with significant family histories of cancer is becoming the standard of care and the cost is roughly the same, around $1500. We’ve been offering this expanded testing for over a year to all our patients to help separate who needs more aggressive screening to be able to catch cancer earlier.

There is also now a test for women without a family history of breast cancer significant enough to qualify for BRCA testing. 85% of breast cancer diagnoses are in women with no family history. Data from clinical studies have resulted in clinical risk factors that increase a woman’s lifetime risk of breast cancer over the general population, obesity and tobacco use are two such examples. With genetic testing now in its prime, we’ve now learned of several genetic markers that can help predict a woman’s lifetime risk. These markers, called SNPs, in large population studies are associated with both increased and decreased lifetime risks. We have just started offering this test in our office and are using a test called BrevaGen Plus. As the field is still growing, the test is currently validated and available only to Caucasian, Hispanic, or African American women who are age 35 or older. If you qualify, you may be offered this test at your next Well Woman exam. Out of pocket costs to most of our patients are $100 or less.

These tests do not diagnose breast cancer and they do not determine if you will or will not get it in the future. They are excellent tools to help us know which women have a low enough risk of developing cancer andare safe to go with the least amount of screening (annual mammograms) and which women really need more frequent and detailed screening (MRIs or 3D mammograms).

As always, if you have questions about these tests, please make an appointment to come in and discuss with your doctor.

HEALTH TECHNOLOGY: ADVANCES IN WOMEN’S HEALTH?

Fortunately, health tech startups are realizing that women have different health tech needs than men and are starting to invest in interesting technologies to help improve our health overall. Some things have been way off mark, like a “smart tampon” that connects to your smartphone and reminds you it’s time to change. Others have been long overdue, like a needle-free tissue expander used by women after breast cancer surgery. There are also a few apps working to make birth control pills easy to access and delivered to your door, helping decrease unplanned pregnancies.

Many women are already using an app to keep track of their periods, many others are using similar apps to know when they are most fertile, to help with becoming (or avoiding) pregnancy.

This field (called “femtech”) had a huge increase in funding in 2016. Femtech is thought to be a $200 billion dollar industry, so expect more apps and developments in 2017, and beyond

It is important for women’s health to be the focus on innovation in every area, as we make up over half the population. But traditionally, medical care has had to go through CMS and the FDA, while the tech industry has been a direct to consumer, profit driven field with few checks and balances. People either buy these things or don’t.

The lab company Theranos fit the perfect Silicon Valley startup model and was successfully funded as one but once the Centers for Medicare and Medicaid Services regulators starting looking into the company, things began to fall apart. This brought out the huge gap between convincing people to buy/use your product and having an effective product in terms of clinical assessment, accuracy, and benefit.

This cautionary tale is an extreme one. But for smaller things, like the FitBit, which has been a huge commercial success, the actual clinical results have been disappointing. They do provide people with a lot of data but as many people find out (including some of us who’ve tried them!) knowing you don’t move enough is not the same as motivating you to move more. Average users stop wearing these types of devices in 6 months or less. The Journal of the American Medical Association (JAMA) published an article last year showing that fitness trackers do not improve weight loss when used in combination with lifestyle modification, if anything, the fitness tracker group lost less weight.

And then there are the fertility tracking apps and websites. In July of 2016, the journal Obstetrics & Gynecology published a study on these technologies concluding “Web sites and electronic apps used by the general public to predict fertile windows are generally inaccurate.” These methods are about as effective as the often used “Calendar Method” where you avoid your “fertile days” to prevent pregnancy. If you consider a couple having regular intercourse without any planning and/or prevention of pregnancy has an 85% chance of getting pregnant, then the Calendar Method does work, these couples have about a 25% chance of pregnancy in that same year. However, birth control pills decrease that chance to less than 3% and IUDs to less than 1%. Most women seeking “birth control” are expecting a lower risk of pregnancy than 25% and should be aware of the clinical results of using these apps, there’s a great blog article on one woman’s hope to avoid traditional contraceptives at Gizmodo.

Hopefully 2017, will be full of better news and more clinically proven uses of health technology in improving the lives of women. There are companies like Materna and Pelvalon which are using technology within the traditional medical device pathway and showing a lot of potential into making real changes in women’s health.

AN UPDATE FROM ACOG ON DELAYED CORD CLAMPING

Something that’s been brewing in the data for a few years now is the question of when to clamp a newborn’s cord after delivery. Traditionally, we’ve been clamping the cord as soon as reasonable, within about 30 seconds of birth. A few years ago some data was published showing the benefits of delayed cord clamp of 90 seconds, which showed significant benefits to premature infants (infants less than 37 weeks) and some less significant benefits for term infants.

We began a standard practice around then of roughly 60 seconds of delayed cord clamping—when safe and reasonable—for all term infants. It’s also incorporated in our suggested birth plan.

We were very happy to see ACOG release a new guideline dated this month encouraging the same: 30-60 seconds of delayed cord clamping in term infants. This is helpful as we can now also provide our cesarean section patients with this as all of El Camino Hospital’s OR and nursing staff are on board.

Of course, there are times when this is not the safest choice for the baby or mother and as with all deliveries, decisions are made very dynamically as circumstances dictate.

HIGHLIGHTS FROM OUR WOMEN’S HEALTH BLOG

Our Women’s Health Blog is a way for us to put out up to date information on various topics. The end of 2016 was very busy for us and we haven’t posted very much, but there’s a great article on the basics of Robotic-assisted hysterectomies. Dr. Balassiano has brought this skill to our practice and we’ve seen amazing results.

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