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OneThousandOne represents the amount of time, verbally, that it takes to count to one second. In this one second of time, a great thing happened at The Nebraska Medical Center. In fact, several great things probably happened. A patient was cured, a researcher found the missing link, a nurse treated an injury, a doctor comforted a family or maybe a child just smiled.
MOMENTS IN MEDICINE at THE NEBRASKA MEDICAL CENTER
Spring | Summer 2010

Revealed by the Past

After discovering a genetic predisposition for ovarian cancer, Mary Bernstein bristled at the thought of surgery. A new robotic procedure for hysterectomy, however, had Bernstein back on her feet the very next day. She now calls it her “miracle surgery," a miracle that was made possible by understanding the medical links to her past.

Researching the family genealogy has been a favorite pastime for Judy Weil for many years. But when she decided to dig deeper, eventually asking family members to send information pertaining to their medical histories, the picture began to reveal much more than what Weil and her family had bargained for.

As the letters trickled in, the crucial pieces of the family’s medical history began to unfold. Numerous stories of cancer on her father’s side — the Schimmels — were revealed: Hodgkin’s disease, ovarian cancer, colon cancer, uterine, prostate and several cases of breast cancer. One cousin wrote back sharing that she had had breast cancer and was a BRCA1 gene carrier - a strong predictor of breast and ovarian cancers. She was able to trace the gene back to her father, a first cousin of Weil and her two sisters.

Kerry Rodabaugh, MD

Weil’s family tree was no longer just a hobby, but it became an important wake-up call to their family’s pending fate. The news hit hard for Mary Bernstein, the youngest of the three sisters. Bernstein had been diagnosed and treated for breast cancer 12 years ago at The Nebraska Medical Center. Not only did cancer appear to be strong in her family, but the Schimmels were also descendants of the Ashkenazi Jews, a group in which the BRCA1 gene is very prevalent. Through further research, Bernstein and her sisters learned that women who carry the BRCA 1 and 2 genes have an 85 percent risk for developing breast cancer and a 45 percent increased risk for developing ovarian cancer.

Anxious to determine if they were carriers, Bernstein and her sisters decided that genetic testing was a must. Bernstein’s sisters were tested first. When the results came back negative, Bernstein expected the worst for herself. “I knew that there was no way that all three of us would not carry the gene,” she says.

Bernstein’s prediction was right. After meeting with a genetic counselor in Omaha, her tests came back positive. Bernstein tried to stay as optimistic as possible. “I wanted to be strong for my children and my husband, Tom, who had lost his first wife to cancer and for her children.”

The first people Bernstein confided in after her husband were Ken Cowan, MD, and Beth Reed, MD, oncologists and researchers at The Nebraska Medical Center, whom she respected and trusted completely. Dr. Cowan happened to be a close friend and Dr. Reed had managed Bernstein’s breast cancer therapy. “Dr. Reed is absolutely wonderful,” says Bernstein. “I would follow her off a cliff.”

Both recommended that Bernstein have a hysterectomy as soon as possible. By having a hysterectomy, she could reduce her risk for ovarian or uterine cancer to 2 percent. They recommended she see Kerry Rodabaugh, MD, gynecologic oncologist at The Nebraska Medical Center.

Dr. Rodabaugh, who grew up in Lincoln, joined The Nebraska Medical Center nearly two years ago to pursue her interest in robotics for the treatment of gynecologic/oncologic conditions, hereditary cancer research and palliative care medicine. She attended medical school and completed a residency at Duke University School of Medicine and Duke University Medical Center in Durham, N.C. She completed her fellowship in gynecology/oncology at Brigham and Women’s Hospital and Harvard Medical School in Boston. Before coming to The Nebraska Medical Center, she was on faculty at the University of Missouri’s Ellis Fischel Cancer Center in Columbia, Mo., and the Roswell Park Cancer Institute in Buffalo, N.Y., where she perfected her skills in robotics.

As technology has improved over the years, the use of robotics has increased, especially in areas such as urology and gynecology. Dr. Rodabaugh is leading the transition to robotics in gynecology oncology at The Nebraska Medical Center.

Today, the use of robotic surgery for endometrial cancer patients should be the standard of care for women who are good candidates for the procedure, notes Dr. Rodabaugh. “With this minimally invasive approach, procedures that were traditionally major interventions are no longer so,” she says. “Robotic surgery minimizes pain and discomfort, reduces recovery time greatly and decreases the risk for complications. Patients can go home the day after surgery.

“Robotic surgery is reducing recovery times for women, minimizing pain and discomfort and decreasing the risk for complications.”
Kerry Rodabaugh, MD

“My goal is to do the most effective oncology surgery in the least invasive way possible without compromising outcomes,” says Dr. Rodabaugh. “The literature shows that robotics is now equivalent to traditional open surgery in some gynecologic cases such as endometrial carcinoma in women that qualify for the procedure.”

Robotic surgery combines robotics and computer-enhanced technology to provide surgeons a greater degree of accuracy and precision. The enhanced images provide a 3-D image rather than the 2-D image provided by laparoscopic surgery and magnify the image 10 times its normal size. Robotics allows surgeons to perform more complex procedures than were possible through traditional laparoscopy because of the wristed-action instruments. The robotic instruments have the ability to bend like the human wrist, allowing the surgeon to move more naturally and freely within the body.

“They allow me to move around just as I would in an open surgery,” says Dr. Rodabaugh. “This provides more flexibility and precision and causes less pain for the patient because we are making fewer large movements within the surgical area.”

Mary Bernstein

Dr. Rodabaugh also uses robotics to perform hysterectomies, remove tumors during the early stages of ovarian cancer, and to remove lymph nodes in the staging of gynecologic cancers. Cancer staging involves determining how far cancer has spread anatomically, which helps doctors develop a prognosis and an appropriate treatment regimen. However, not all patients are candidates for robotics due to other co-existing medical conditions. She expects to soon be using robotics for radical hysterectomies in the treatment of early stage cervical cancer patients.

Before determining what type of surgery is appropriate, women should be evaluated by a gynecologic oncologist to determine the most effective care regimen, notes Dr. Rodabaugh.

News that she would need a hysterectomy was frightening, recalls Bernstein. She envisioned the worst: major surgery, lots of pain and being away from her business for several weeks. As president of Events, Inc., a business that plans weddings, conventions and corporate parties such as the opening of the Holland Performing Arts Center and the Omaha World-Herald Freedom Center, Bernstein couldn’t afford to be inactive that long.

So being the planner that she is, Bernstein immediately went into autopilot. Within several weeks, she was in Dr. Rodabaugh’s office discussing her options and had even penciled in a surgery date on her calendar. “I wanted to get it scheduled immediately so it wouldn’t interfere with my upcoming events or with a family vacation,” she says.

“When I met Dr. Rodabaugh, she asked me why I was there,” recalls Mary. “I told her that I had tested positive for a mutation in the BRCA1 gene and needed an oophorectomy (removal of ovaries). Her response was, ‘I want to do more than that. I also want to do a hysterectomy (removal of the uterus in addition to the fallopian tubes and ovaries).’ She explained that because of my Ashkenazi Jewish ancestry, my uterus was also potentially at risk of developing a cancer. I didn’t need any of these organs anymore and this would eliminate the possibility of getting cancer in any of these organs.”

But the best news, says Bernstein, was that Dr. Rodabaugh suggested doing the surgery robotically. “This meant that she would make five small incisions instead of one large incision from the pubic bone to the chest. I would be in very little pain and I could go home the following day,” says Bernstein. “It was definitely an offer I couldn’t refuse.”

I remember telling my husband, ‘I can’t believe it – I have no pain!’ It was unbelievable.”
Mary Bernstein

And even more amazing, says Bernstein, is that it all unfolded just as Dr. Rodabaugh said it would. She checked into the hospital at 6 a.m. and was back in her room by 2:30 that afternoon. “I woke up from surgery as they were wheeling me to my room,” recalls Mary. “I remember telling my husband, ‘I can’t believe it — I have no pain!’ It was unbelievable. How could it have been so easy and how could I feel so fine? I even got up to use the bathroom.

“I woke up the next morning and they said I could go home as soon as I was ready. I got out of bed, got dressed and I literally walked out of my room, into the elevator and to my car. And I still hadn’t even had a single pain pill.”

In fact, Bernstein says she never filled the prescription for pain pills that was sent home with her. Her daughter came to town to spend the weekend with her so she could help, but Bernstein says as it turned out, she never needed anyone’s help. By Friday, just three days after surgery, Bernstein was driving. On Saturday, she and her daughter had manicures and pedicures and then went out to dinner. “My daughter was in disbelief,” says Bernstein. “She kept asking me if I was OK and I kept telling her that I felt great.”

By Monday, Bernstein was back at work. “Ninety eight percent of my friends never even knew I had surgery,” she says. “The scars are so small you have to look for them to find them.” Bernstein says she is now a firm advocate of this “miracle” procedure. “Anyone who can have surgery robotically should sign up for it,” she says.

Dr. Rodabaugh says this type of recovery is typical of patients who undergo robotic surgery. “It truly is the way to go whenever the surgery allows,” she says. “My patients are always amazed at how little or no pain they experience afterwards.”

Dr. Rodabaugh also performs a procedure called single incision laparoscopy (SILS) for patients who need only their ovaries removed. SILS is one of the newest advancements in minimally invasive surgery and is being performed at just a few medical centers in the country. Unlike laparoscopic surgery that typically involves three tiny incisions, SILS requires just one incision — through the belly button — leaving virtually no visible scar on the body.

SILS is performed by making a small incision in the umbilicus or belly button where an access port is placed. Through this port, a flexible scope, a camera and tiny instruments can be slipped through and moved around inside the body. Images are produced from almost every angle and allows the doctor to repair or remove organs or tumors.

Dr. Rodabaugh says she hopes to be able to assist in applying this procedure to other gynecologic surgeries in the future such as tubal ligations and other standard laparoscopic procedures.

The recovery period for both SILS and robotic surgery is absolutely incredible, says Dr. Rodabaugh. “Patients go home either the same day or the next day and are back to work within a week. With open surgery, patients are in the hospital for three to four days, have a recovery that lasts four to six weeks and are usually in a lot of pain.

“Today we are putting more focus on improving quality of life for our patients. Robotics is one way in which we can make life easier for women who need gynecologic surgery.”

Bernstein never dreamed that her family genealogy would confront her with such a challenging medical dilemma. Neither did she imagine that, through the miracles of medical science, she could have a robotic hysterectomy at UNMC one afternoon and walk out of the hospital pain free the next morning!

Getting it Right the First Time

Getting treatment from a trained specialist in gynecologic oncology can dramatically impact a woman's outcome and survival.

The use of minimally invasive and robotic surgeries are just a few of the advances that have been made in the field of gynecologic oncology. While advancements have evolved slowly, they are making a difference, says Steven Remmenga, MD, gynecologic oncologist at The Nebraska Medical Center.

Steven Remmenga, MD

Gynecologic cancers are those that originate in the female reproductive organs. The most common and serious of these includes cancers of the cervix, ovaries, uterus, vagina and vulva. If not found early, gynecologic cancers can be aggressive and fatal. This year, more than 78,000 women in the United States will be diagnosed with a gynecologic cancer and more than 28,000 women will die from the cancer.

Ovarian cancer is one that is seeing improved outcomes as a result of new treatment regimens. Considered one of the most lethal of gynecologic cancers, ovarian cancer ranks number seven in terms of cancer prevalence among women, but it ranks number five in cancer mortality.

“Women with ovarian cancer are now living longer than ever before as a result of better chemotherapies, new regimens like targeted therapies and better surgical techniques,” says Dr. Remmenga. “Ten years ago, women may have only survived for a couple of years. Now many patients are living for five to 10 years or more with the disease in a chronic state.”

One of the biggest challenges in the treatment of gynecologic cancers, says Dr. Remmenga, is ensuring women get the right treatment from the right specialist.

“Having your surgery done right the first time can dramatically increase your survival and outcome,” he says. “Recently accumulated research shows that getting treatment from a trained specialist in gynecologic oncology can dramatically impact the outcome and survival for these patients, especially for ovarian and uterine cancers.”

Gynecologic oncologists are cancer specialists who have training in obstetrics and gynecology. This is followed by three to five years of specialized training in the treatment of gynecologic cancers, including surgery, radiation therapy, chemotherapy and experimental treatments, as well as the biology and pathology of gynecologic cancer. This additional training provides these doctors with the knowledge and experience needed to provide their patients with the most effective mode of therapy or combinations of therapy that will provide the most successful outcomes.

“Gynecologic cancers generally involve very complex and difficult surgeries,” says Dr. Remmenga. “Your first chance at surgery is your best chance to have a positive outcome. If you have to come back a second time around because the first treatment regimen wasn’t complete or effective, it becomes increasingly more difficult to treat and puts the patient at increased risk for complications and recurrence.”

Proper staging of ovarian cancer, which is often found in more advanced stages, is critical. To provide the best chance of survival, surgery needs to be very aggressive and complete from the beginning, says Dr. Remmenga. Statistics show that patients treated by gynecologic oncologists have the highest survival rates. For instance, for every 10 percent of tumor removed, there is an additional 5.5 percent increase in survival time. “Someone who performs this surgery regularly can be much more effective, and therefore increase survival, than someone who is inexperienced at this surgery,” says Dr. Remmenga.

“Statistics show that patients treated by gynecologic oncologists have the highest survival rates.”
Steven Remmenga, MD

Studies have also shown that uterine cancers, the most common of gynecologic cancers, are treated most successfully by gynecologic oncologists. “A large study showed that patients who had surgery done by a gynecologic oncologist for endometrial cancer were completely staged 95 percent of the time. If they were only completely staged by a nongynecologic oncologist 50 percent of the time, 22 percent of those patients received more treatment than needed.

“We get referrals on a regular basis for patients who underwent treatment elsewhere and because the surgery and treatment was not performed right the first time, they now are coming to see us because of recurrence.”

The problem – lack of awareness of the specialty and its value among other doctors and the general public. “The fact is, we have the expertise right here in Omaha,” says Dr. Remmenga. “We’re just not getting all of the patient referrals that we should be.”

With that in mind, Dr. Remmenga says it is important for women to be their own advocates for their health and well-being. “Do your own research,” he says. “Learn about your disease. Find out how it should be treated and who is most qualified to treat it.”

Dr. Remmenga has spent much of his career trying to get the word out on the importance of getting care from a gynecologic oncologist, as well as establishing and communicating the appropriate treatment guidelines for gynecologic cancers.

He serves on numerous state and national healthcare boards and committees. He is chairman of the Nebraska Section of the American College of Obstetricians and Gynecologists; secretary for the District 6 American College of Gynecologists (ACOG), which includes Nebraska, Iowa, Minnesota, South and North Dakota and two Canadian provinces; serves on the board for the Society of Gynecologic Oncology to help formulate government regulations, the Cervical Cancer Task Force as well as the state board for “Every Woman Matters.” He is also a member of the National Comprehensive Cancer Network (NCCN) committee, which writes national guidelines for the treatment of cervical, ovarian and uterine cancers.

His background and experience before coming to The Nebraska Medical Center is just as extensive and impressive. Dr. Remmenga attended the University of Nebraska at Lincoln on a U.S. Navy ROTC scholarship. He initially inspired to be a Navy line officer, but his interest in the sciences drew him to medical school. Dr. Remmenga attended UNMC for medical school and completion of his internship. He did his residency in obstetrics/gynecology at the Balboa Naval Hospital in San Diego and a gynecologic oncology fellowship at Bethesda National Navy Medical Center in Maryland and Walter Reed Army Medical Center in Washington, D.C.

Dr. Remmenga then performed research at the National Cancer Institute in the Radiation Biology and Radiation Oncology Division studying the use of antibodies and radioactive sources to kill tumors. His service with the Navy then took him to Portsmouth Naval Hospital in Virginia where he served as the department chair for the Obstetrics/Gynecology Department. During his tenure there, he was named Specialty Leader (consultant) to the Surgeon General of the Navy. The Surgeon General is the highest ranking officer in Navy medicine equivalent to a three-star admiral. Dr. Remmenga’s role involved serving as a consultant to the Surgeon General on OB/GYN issues, and he was responsible for writing healthcare policy for obstetrics and gynecology. He was later transferred to Washington D.C. to the TRICARE Region 1 Military Health System, to serve as medical director of Primary Care, director of Clinical Operations and chief medical officer. During this time, he also practiced at Walter Reed Medical Center and sat on many boards for quality and risk management. In 2002, Dr. Remmenga retired from the Navy as a captain and returned home to The Nebraska Medical Center.

Since coming to The Nebraska Medical Center, Dr. Remmenga has also become more involved in clinical research and bench research in the lab. He is currently collaborating with Harvard Medical School for research in treatment for ovarian and uterine cancers.

For the most part, however, most of his time is spent clinically and in educating women and other physicians about his specialty. “I went into this field because I wanted to make a difference,” he says. “If we can get to these women first, we can have an impact.”

Previous article in the Spring | Summer 2010 issue of One Thousand And One:
Room To Breathe