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At the Office of Dr. Bishara and The Paragon Plastic Surgery & med Spa, we want our male patients to be educated about their health too. In a recent article in MedScape, Dr. David Johnson discusses new breakthroughs in screening for colon cancer

WHERE WE’RE AT WITH SCREENING

Hello. I am Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.
Cologuard®, a stool DNA test manufactured by Exact Sciences (Madison, Wisconsin) has just been approved by the US Food and Drug Administration (FDA). It has received a tremendous amount of attention in the lay press, and recently the pivotal study analyses were published in the New England Journal of Medicine.[1] I will give you an overview of how this test might play out in clinical practice for gastroenterologists, primary care providers, other healthcare providers, and patients.
We are doing better with colon cancer screening, but we still are missing 35%-40% of patients who are eligible for healthcare screening. We have seen a tremendous increase in screening over the past decade, but in the past 3 years, this has leveled off to 60%-62%, and the rate of rise in screening has plateaued.[2] The Centers for Disease Control and Prevention (CDC) set their target for colon cancer screening at 80% by 2018, but the current rate of 62% has been holding for the past 3 years. We have seen a 46% reduction in colon cancer-related deaths over the past decade, primarily from the emphasis on colon cancer screening, but nonetheless, screening rates are flat and we are not making progress. What is the problem?
Colonoscopy is the gold standard for screening, but some patients are resistant to having a colonoscopy for many reasons: the “prep,” and taking a day off work, for example.
When the US Preventive Services Task Force (USPSTF) published colon cancer screening recommendations in 2008,[3] few options were available beyond flexible sigmoidoscopy, fecal occult blood testing, and colonoscopy — the only screening methods that met evidence-based standards. At that time, the USPSTF did not accept CT colonography or even the stool DNA test as screening options, because in 2004, the sensitivity of the stool DNA test was only marginally better than 50% for the detection of colon cancer.[4] It was better than the fecal occult blood test by a margin of 4, and it was not very good at all for detecting advanced adenomas.

THE MULTITARGETED APPROACH TO SCREENING

Fast-forwarding to the present technology, the Cologuard is a new and revised stool DNA test. It detects aberrant methylation markers on 2 promoter genes (BPM3 andNDRG4) as well as KRAS mutations, and beta-actin, which is a reference gene for human DNA quantity. In addition to those 4 biomarkers, Cologuard includes a fecal immunohistochemical test (FIT). This is the Polymedco test, and it is set at 100 ng of hemoglobin per mL of buffer. This is the standard threshold used in screening trials for FIT, and it was added to increase the sensitivity of detection of colon cancer.
Approximately 10,000 patients were enrolled in the pivotal study, all of whom had not had recent screenings for at least 9 years for colonoscopy or 5 years for CT colonography or barium enema. These patients were evaluated with colonoscopy and with FIT as well as the combination Cologuard test. The background prevalence of colon cancer in the study was 0.7%. Advanced adenomas were defined as adenomas with high-grade dysplasia, adenomas with 25% or more villous component, or sessile serrated polyps 1 cm or larger in size. With this new twist on advanced lesions, the background prevalence for advanced adenomas was 7.6%.

HIGHEST SENSITIVITY OF STOOL-BASED TESTS

The sensitivity of Cologuard for detection of colorectal cancer was 92.3% compared with 73.8% for FIT alone.
For detection of advanced adenomas, the sensitivity of Cologuard was 42.4%, and for FIT alone it was 23.8%. Fecal testing has not been very sensitive for the detection of advanced adenoma, but with Cologuard, we are seeing nearly a doubling of sensitivity with stool DNA, a big upswing in advances in stool-based testing. For the detection of high-grade dysplasia, the Cologuard had a sensitivity of 69.2% vs. 46.2% for FIT alone. For sessile serrated polyps, the sensitivity was 42.1% for stool DNA testing and 5.1% for FIT, a huge margin of difference.
Of interest, the stool DNA test did not vary by disease stage (that is, it was as good for stage 1 disease as it was for stage 4 disease) or by location. Fecal occult blood testing was always more sensitive for distal lesions, but that is not the case with stool DNA testing. FIT sensitivity catches up in later stages of disease, becoming equal to stool DNA in stage 3 and 4 disease. Stool DNA is more sensitive for advanced adenomas, especially for more distal lesions — sensitivity was 54.5% (distal) vs 48.9% (proximal) — and for larger lesions.

PUTTING COLOGUARD INTO PRACTICE

As we put this into perspective, there are a couple of caveats.
One is that we don’t know what the test performance characteristics will be when this is ultimately rolled out and used in practice. In 6.4% of patients who had the stool DNA test, for whatever reason the samples couldn’t be analyzed. In the context of the baseline prevalence of colon cancer in this population, that means that they lost the results for 689 patients, and 4 cancers could have been missed just because the test could not be done. That can change the statistics a little bit. The number needed to screen to detect 1 cancer is 154 for colonoscopy; for the stool DNA/Cologuard test, it is 166; and for FIT, it is 208.
The recommendation from the multisociety task force and the American College of Gastroenterology guidelines[5] is that if stool DNA testing is used, it should be done at 3-year intervals.
Patients should not view this as an alternative to colonoscopy, and it should be offered to patients only after they have explicit guidance that colonoscopy is the best test that we have for prevention because we can identify more precancerous polyps than we can with any stool-based testing. A colonoscopy needs to be done by a quality colonoscopist. Detection rates will vary on the basis of the adenoma detection rate of the individual colonoscopist, so the better we can define our adenoma detection rates, the better patients can select a colonoscopist by asking, “What is your adenoma detection rate?”

ALTERNATIVE TO COLONOSCOPY, NOT A REPLACEMENT

Will Cologuard become a replacement for colonoscopy? No. It is a test that should be offered to patients who refuse colonoscopy. It will still be an expensive test — the estimated cost is $590. It is money well spent if it brings the people who refuse colonoscopy into a screening program. The cost analysis and cost effectiveness remain to be defined, along with the test performance characteristics, how the test performs outside of a clinical study, and patients’ acceptance of the test. It appears that acceptability is higher than for standard FIT or the fecal occult blood test.
No screening is not an option. Any screening is better than nothing. We have a screening gap of approximately 20%; we are going to need to increase screening rates from 60% to 80% by 2018. Hopefully, this will stimulate discussions between patients and their healthcare providers. Colonoscopy is still the preferred strategy, but for anything that raises the awareness of screening and acceptability of screening, I am all in.
This is Dr. David Johnson. Thanks for listening.
 

In an article in the Prime Dermatology journal, authored by Dr. Chang Jun Huhen, titled “Robotics, Artificial Intelligence, and the Future of Hair Transplantation”, Dr. Huh reviews the evolution of hair restoration surgical options and contrasts that to technological advancements and unique benefits offered by the ARTAS Robotic Procedure.


Over the past 10 years, robotic procedures have enhanced surgical care that doctors give their patients.  Robotic systems help surgeons improve the outcome for patients and help reduce manual and repetitive movements, which ensures more accuracy and precision.  The use of robots has paved the future for surgeries and will help patients have better experiences. The advantages of minimally robotic procedures appeals to doctors and patients, because of decreased pain and increased recovery time.
Restoration Robotics was founded by physicians and engineers to help develop a solution for hair restoration patients.  Robotic technology plays a role in Follicular Unit Extraction (FUE) because it gives patients consistent and safe results, with no visible scarring or long recovery time.  The ARTAS Robotic System enables surgeons to give their patients natural-looking outcomes with fast recovery time.
In the past, hair restoration involved Follicular Unit Transplantation (FUT), where a strip of scalp is surgically removed and individual hair grafts are generated by manual dissection.  This has been common practice FUT method since the early 90’s.  Soon after, manual FUE started, by using small dermal punches to remove single hair grafts directly from donor sites and implant them in the balding scalp area.  This was the beginning of a less invasive technique with faster healing time.
The ARTAS Robotic System is a FDA approved, physician controlled, interactive computer-assisted system that enables harvesting of hair follicles during hair restoration.  It is the first and only technology that allows physician-controlled, image-guided, robotic assisted FUE.  The robot is programmed to be able to do with great precision what physicians can do only with extensive experience.  The robot can harvest follicular units in a random pattern, or as a percentage of the total number of follicular units in a designated area.  The physician can make changes to dissection depths and angles during the process.  Because the robot is making the repetitive actions, it makes the process go much faster.
Benefits of ARTAS Robotic Hair Transplants:

  • Robotically precise and consistent
  • Reduced treatment time
  • Decreased discomfort
  • Faster recovery time
  • No linear scar
  • Undetectable donor area

The robotic system dissect grafts accurately and consistently, thousands of times with acceptably low transection rates of between 4.9%-8%.  The ARTAS system will also soon be able to use sophisticated 3D patient modeling and design to help create recipient sites at the rate of 2,000 per hour.  The addition of the ARTAS system attracts many patients that would be hesitant to try traditional transplant procedure, and allows physicians to take hair restoration to the next level and produce high patient satisfaction.
Please see the attached article for a more in-depth view of the ARTAS System.

What is a Robotic Hair Transplant?

In Robotic FUE hair transplant procedures, follicular units are isolated using the ARTAS robotic system. The ARTAS system is a computerized, image-guided robot that automates the labor intensive process of extracting grafts. Its advantage over other FUE techniques is due to its precision and consistency in extracting grafts. All FUE procedures at The Paragon Plastic Surgery & Med Spa are performed using the ARTAS robot.
ARTAS is the very latest technology in hair restoration.  Dr. Bishara is using the ARTAS System in his Mansfield and Southlake offices. This interactive, computer assisted equipment employs image guidance to enhance the quality of hair follicle harvesting. ARTAS is the first hair transplant robot to improve the most challenging aspects of Follicular Unit Extraction (FUE).
Hair Transplants | Dallas TX | Mansfield TXThis physician-controlled, state-of-the-art system enables the harvesting of hair follicles during hair restoration procedures. It offers numerous beneficial features, including an image-guided robotic arm, special imaging technologies, small dermal punches and a computer interface. The ARTAS System is capable of identifying and harvesting individual follicular units to implement the FUE technique. The device, guided by cameras and 3-D imaging software, can perform the dissection of hair follicles individually at a rate of up to 1,000 per hour.
Please visit our website at www.MarkBisharaMD.com for more information on robotic hair transplants or call our office at (817) 473-2120.
 

The follicular unit extraction (FUE) procedure consists of four steps: the separation of follicular units from the surrounding tissue, the removal of follicular units from the scalp, the creation of recipient sites, and the placement of follicular units into these sites. The first step is performed by the ARTAS robotic hair transplant system – the part of the FUE procedure requiring the greatest precision and that is most subject to human error.
Q: Is robotic FUE different in the number of follicular unit grafts one can extract compared to manual FUE?
A: We can extract (and transplant) the same number of follicular unit grafts robotically as we can manually.
There is generally less transection of the hair follicles with robotic FUE, since the method is more precise. This enables us to obtain follicular units with less trauma to the grafts.
Second, the robot is faster than the human surgeon, and much more consistent since, unlike the human surgeon, it never fatigues and the accuracy is maintained throughout the entire procedure.
Q: I am an African-American man with tight curly hair. Will the FUE robot be able to work on curly hair?
A: Yes, the ARTAS robot for FUE can be adapted for African-American hair when performing follicular unit extraction.

Q: How many different kinds of robotic devices are there?

A: There is only one, the robot called the ARTAS System for FUE, made by Restoration Robotics. The Neograft machine, occasionally confused with a robotic device, is actually a hand-held instrument that is not robotically controlled and lacks image-based tracking.
This Information is brought to you courtesy of Dr. Bishara and The Paragon Plastic Surgery & Med Spa
 
 

Hair transplant surgery has come a long way since it was first introduced in the 1950s. Back then, Dr. Norman Orentreich started testing a theory that hairs located at the sides and back of the head were genetically “programmed” to resist balding and that when relocated to balding areas, these “donor hairs” would retain this characteristic. It was an idea that was, quite literally, ahead of its time because while the theory was sound, the available surgical techniques were too crude to produce consistently natural-looking results.

The Bad Old Days of Hair Transplantation
In the 1960s and 1970s, hair transplants consisted of removing clumps of donor hairs with a round punch and then transplanting these plugs of hair into regularly spaced rows. Sometimes, if the patient had enough donor hair and dutifully completed all the sessions of hair transplant surgery, a doctor might be able to achieve good coverage, albeit with a very solid-looking hairline and limited ways the patient could style his hair. Too often, however, the patient would run out of donor hair before a good result could be achieved and the result would be the dreaded “doll’s head” look with obvious, evenly spaced plugs of hair. For an entire generation, the words “hair transplant” became virtually synonymous with “hair plugs” and many people, quite understandably, preferred to live with their hair loss than get an obvious-looking hair transplant.
When It Got Better
In the 1980s, hair transplant technique took a giant leap forward with the introduction of smaller grafts. Instead of large plugs of hair, surgeons would excise a strip of hair from a balding-resistant patch and section it into two types of grafts, mini grafts (4-8) hairs and micro grafts (units of 1, 2, and 3 hairs). The mini grafts were placed where fullness was desired and the micro grafts were places along the hairline for a more natural look. More grafts could be transplanted in each session than when surgeons used the “punch” technique and the results were definitely better looking.
When It Got Great
In the 1990s, we finally achieved a truly natural-looking hair transplant method called Follicular Unit Transplantation or Follicular Unit Grafting (FUG) that mimics the way hair naturally grows. The introduction of a new and powerful microscope, called the binocular microscope, made it possible for surgeons to take that same strip of donor hair and section the hairs the way they naturally grow, in units of 1, 2, 3, and 4 hairs. These “follicular units” can be transplanted into very tiny incisions placed very closely together. The result is excellent density, even after just one session. And because the hair is transplanted the same way it grows, there’s never an awkward phase where the patient looks strange or like a work in progress.
A further refinement of the technique, called Follicular Unit Extraction (FUE) does away with the strip. Instead, these follicular units of donor hair are removed one at a time using a small circular punch. There is no incision with FUE and the minimally invasive procedure leaves no visible scars. The donor hairs are placed the same way they would be with FUG and the results of both types of procedure are completely natural. When performed by an accomplished surgeon — no one will know that you’ve had a hair transplant.
Hair restoration product literature, including Propecia information, is available in our office. Please contact us at 817.473.2120 to schedule an appointment or visit our website at www.MarkBisharaMD.com