How Radiology Helps Diagnose and Treat Disease

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X-rays, CT scans, MRIs, ultrasound …. for many people, using technology to see inside the body or treat disease might evoke fears of being exposed to harmful radiation. Donna Plecha, MD, chair of Radiology at University Hospitals Cleveland Medical Center, discusses improvements made in recent years to ease those fears, as well as how radiology plays a vital role in the overall treatment process.

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Podcast Transcript

Macie Jepson

It's got to be a huge understatement. A scary medical diagnosis will stop you in your tracks. Coming face to face with your own mortality is a moment in time that one never quite shakes.

Pete Kenworthy

Yeah. And then come the next steps, really getting to the best course of treatment can certainly be daunting. Today we're talking about radiology because it can be confusing. Sometimes it can be scary. And sometimes it can be lifesaving. But people can tend to focus on that scary part, too.

Macie Jepson

You know, we think of cancer treatment. We think of radiology as a diagnostic tool. For me, that was the case, at UH, in fact. When I was five months pregnant, I was extraordinarily ill. Doctors could not figure out why. And the lowest moment for me is when they came in and said, we have to run scans. I laid on the table, and I cried throughout the entire procedure. Yeah, forget about what was happening to me, even what was making me sick. All I could think about was harm to my baby.

Pete Kenworthy

So, what happened?

Macie Jepson

So, it was ugly. Gangrenous appendix twisted off by my daughter's foot. I will spare you the details. But I can honestly say a month in the hospital, emergency surgery, the thing that scared me the most were the tests.

Pete Kenworthy

Is fear of radiology legitimate? I'm Pete Kenworthy.

Macie Jepson

And I’m Macie Jepson. And this is Healthy @ UH. Heck yeah, the fear is legitimate. At least it was for me. But the person with a science behind radiology and the real answers is Chair of Radiology at University Hospitals, Cleveland Medical Center, Dr. Donna Plecha. Thank you for joining us today, Doctor.

Dr. Donna Plecha

Thank you for having me.

Macie Jepson

So, let's start with how radiology is used. I mean, it sounds like it's all phases of the medical journey. I mean, screening, diagnosis, treatment.

Dr. Donna Plecha

Yes. So, we have really a large part of diagnosis of any kind of medical condition. We do screen for cancer. We screen for breast cancer. We screen for prostate. We screen for lung cancer, pancreatic cancer. And at times if a colonoscopy isn't successful, we actually even screen with a virtual colonoscopy using a CT scanner. So, we're very good at screening and trying to find cancers or abnormalities very early on so that we can catch it at a very early stage. It not only impacts mortality and decreases the amount of death, but it also decreases morbidity. You might be able to avoid some of the more toxic treatments for cancer. So, in addition to the screening, which is a big part of what we do, we also help diagnose in patients who are symptomatic. We're very instrumental in treatment of cancer and other diseases. We help with pain management. And we also are part of the survivorship of cancer patients’ journey after they've been treated for cancer.

Pete Kenworthy

So, a huge part of, of a lot of medical conditions. Let's start with that screening and diagnosis part though, which is a huge part of the care. What really kind of piqued our interest when we started talking about this topic is how critical it is to get that diagnosis right the first time, right? How big is that? And what's the data say about that? The necessity to get that right and get that treatment on the right path to begin with.

Dr. Donna Plecha

Well, I think it's really important to have specialists reading your scans so that you get the best read you can. We also are really good at doing noninvasive biopsies of anything that we think is suspicious. And we work very closely with our pathologists to make sure we get the right diagnosis early so we're not wasting therapies on somebody that's not going to respond, and we're using very targeted therapies. I mean, if you look today compared to 10 years ago, there were two types of lung cancer, let's say, small cell and non-small cell. Now we have more than 40 types of non-small cell cancer, and the top 10 have 10 different ways to treat them. So, working hand in hand in a multidisciplinary team with the pathologists, with the oncologists, with the radiation oncologists and surgeons, we can help participate in planning that patient's treatment early on and treating as soon as we can.

Macie Jepson

When I think of treatment, I think of radiation. Radiation and radiology are different. Could you explain that for us?

Dr. Donna Plecha

Absolutely. So, we're actually two incredibly different departments, and the doctors that do radiology have five years of training that are incredibly different than the five years of training that the radiation oncologists have. So, we use radiation in x-ray. We use radiation in CT scans to help see inside the body, to make a diagnosis or to track disease. We also in radiology use things like MRI scanners and ultrasound scanners that have absolutely no radiation. So, we deal in imaging that does have radiation. And we also use imaging that does not have radiation.

Pete Kenworthy

My mind went to this place of when we were talking about making sure you get that diagnosis right the first time, you really want to be in a place that's got the top latest up to date equipment, right? I'm sure we do here at University Hospitals. But I guess I just was curious as how important that is, and is that something patients should even think about or look at, or are they just, you know, to trust their doctor and wherever they go we'll have the latest equipment to give you the best results, to give you that best diagnosis?

Dr. Donna Plecha

Right. I think the equipment is important. Technology is very important, and it changes all the time, right? So, you want to go somewhere that has the latest and greatest up to date scanners. And you also want those scans read by people who are subspecialized in that particular area. We actually have a little group or a subgroup of radiologists here at University Hospitals that specialize in cancer imaging, right? We have a certain group that specializes brain imaging. So, we try to have as many of the higher end scans read by the highest end subspecialty readers.

Pete Kenworthy

And that's important because then that's the only cancer they see so they're used to seeing little idiosyncrasies within that,

Dr. Donna Plecha

Correct. And there's, you know, the oncologic imager or the radiologist that specializes in cancer imaging, when they get an image, let's say of a certain trial drug that we have going on right now, they can read that image, and they will know what the side effects of that trial medication looks like. And they won't confuse it with recurrence of tumor or growing tumor because they know exactly what they're looking for with that specific drug. And they work hand in hand with the oncologist who's giving that medication, and they work together as a team to track these patients and to make sure we know if the patient's responding to that therapy.

Macie Jepson

As we sit here and learn more about this, I'm reminded that I also received radiology during the treatment when I was pregnant. So, they used that to help scan the delivery of the treatment, if you will. There was an abscess.

Dr. Donna Plecha

Yes.

Macie Jepson

And so they had to use the radiology to find that abscess and to treat it. But I have to know…was my fear legitimate? I mean, and, and how common is that?

Pete Kenworthy

What were you… you were afraid of getting radiation or you were afraid of the procedure itself?

Macie Jepson

No. Forget the procedure. I couldn't have cared less. I was afraid of harm to my unborn child. And I was afraid of radiation.

Dr. Donna Plecha

So, I think the fear is real, but you have to be educated on what kind of scans you're getting. So, when you had a drain placed for your abscess in your abdomen or pelvis, ultrasound was used. There was no radiation used. We could see very well where our catheter is going as we're putting it in so that we get it in the exact right place. We do image guided procedures such as that to take care of a problem. We do image guided procedures to diagnose something, to take a biopsy of something, to take little pieces of tissue out. We do that in the breast. We do that in the liver or the lung, the kidneys. You know, we do it all over lymph nodes so that in the old times you would have to go to surgery to have that abscess drained. In the old times, you'd have to go to surgery to get your liver biopsied or your lung biopsied or whatever. Now, we can do it as an outpatient and do it very precisely. And there's a very small incision, just big enough to get a needle in there. And the patient has a much better recovery now with our noninvasive image guided procedures.

Pete Kenworthy

So, before we move on to the treatment world of radiology, let's back up a little bit to screening. And there's lots of things that fall under this umbrella, right? We're talking about x-rays and CT scans and MRIs and ultrasounds. And what, are the differences there? What are those tests used for? And then what are the legitimate concerns there, right? Maybe with x-ray and CT, people are worried about some small dose of radiation. Is that fair? And then with MRI and ultrasound, is there any sort of inherent risk there, too? I know it's a lot of questions in one.

Dr. Donna Plecha

OK. So, screening, first of all is very important because you want to catch cancer at the earliest stage you can, before it’s spread to lymph nodes, before it's spread to the rest of the body. That's number one. The tests that we do that use radiation or x-ray and CT scan. An example of an x-ray screening exam is a mammogram. It's an incredibly low dose of radiation. It's actually equivalent to taking a round trip flight to Florida, between Cleveland and Florida. And people, I don't think, think twice about getting on that flight about radiation. The radio sensitivity or the breast tissue is not--   the dose that you give to the breast tissue is not going to cause cancer that we know of. It's a very safe dose. We don't even line the rooms, because it's such a low dose, with lead. And it definitely outweighs the risks. The benefits are much greater. If you look at patients who actually get screened with mammogram, you can decrease death rates and mortality by up to 40%. So, we think that starting at the age of 40 and screening yearly is very important for women for preventing death from breast cancer. If you move on to CT scan, we use CT scan really to screen for lung cancer. We also use CT scan to screen for cardiac disease, coronary artery scoring. We do these in certain patients. When you're doing a mammogram, you’re doing it on all women 40 and older. When you're doing a CT scan for lung cancer, you're doing high risk patients, patients who have history of smoking so many pack years. They've actually decreased the threshold for sending patients for CT scans of the lung. And so the radiation there, because they are at such high risk, is again, worth the risk benefit ratio. So, those tests use radiation. If you look at MRI, there's no radiation. So, we do prostate MRI scanning and pancreas MRI scanning to scan for cancer. Again, certain populations of patients get those scans. Those don't have any radiation. And also those two scans for those particular cancers do not have any IV contrast.

We also use MRI for screening for breast cancer. We are the first ones in Northeast Ohio to have fast MR, which is less than 10 minutes. We offer that to patients who have dense breast tissue, even if they have no increased risk in their family. That does have IV contrast, but it has no radiation. Again, we think that the risk benefit ratio is in the positive. You know, I think that the benefit is it finds two to three times the cancers of a mammogram. So, if patients want to opt for that, they have that option. We can also use ultrasound to screen for breast cancer in dense breasted women that has no radiation and, again, has no IV contrast, but doesn't pick up as many cancers as the MRI.

Macie Jepson

So, is it safe to say the radiation on some level gets a bad rap? There's a misunderstanding about…

Dr. Donna Plecha

Well, I think, you know, radiation, it depends on the perception, right? CT scanners today have a much less of a dose to patients than they did 10 years ago, especially to the pediatric population. That was brought to our attention in the radiology realm that we needed to concentrate and decrease our doses and come up with new technology that decreases doses for pediatric patients. We then expanded it to all patients. So, we have a much lower dose of radiation than we did in the past. So, that is something we focused on. It is something real. And you know, you, you should ask your doctor when you're getting a scan, you know, is this necessary? I've had this many scans, but usually it's, you have to look at the risk/benefit ratio. And if you need to find out if there's something wrong, that's the best way to look inside. I think it's worth it.

Pete Kenworthy

OK. Let's move on to treatment now. We've recognized here today that radiation and radiology are different, right? Radiation is a form of cancer treatment.

Dr. Donna Plecha

Yes.

Pete Kenworthy

But radiology plays a role in treatment as well, right?

Dr. Donna Plecha

It does.

Pete Kenworthy

Why is that?

Dr. Donna Plecha

There's different ways that it can contribute to therapy of cancer patients. One example is that we make a therapy such as if a patient's going to surgery, and they're going to get a liver tumor removed. If it's a very vascular tumor, before they go to surgery, it can be days before, they can have a catheter put into that artery that feeds that particular tumor. And we can put small little particles in there that embolizes that tumor so when that patient goes to surgery, the tumor may be smaller, and the tumor will be less vascular. So, it's safer for the patient. Another example of that is if a patient's getting radiation therapy for prostate cancer, the rectum lives right next to the prostate, just behind it. So, if we give radiation to that prostate gland, some of that radiation may bleed over into the rectum and cause damage to the rectum and cause problems because of that, and the rectum was in totally normal shape. So, what we can do, we can use our image guidance, our ultrasound guidance that we talked about with the abscess, and we can inject a gel, a safe gel in between the two, the prostate and the rectum, and we can also put markers around the prostate so that the radiation oncology doctor can deliver that radiation in a safer way so we can save the rectum from getting damaged. And we can also focus the radiation treatment to the prostate gland to get better treatment for that cancer. So, those are two ways that we can help our colleagues, the surgeons, and the radiation oncologists treat their patients.

Another way that we help treat cancer is we actually, our nuclear medicine radiologists, treat thyroid cancer by giving them radioactive material that goes straight to the thyroid. We also have what's called theragnostics where we have things that are radioactive material that we can see with imaging and will also go to tumors specifically, such as a neuroendocrine tumor. We can specifically target that tumor. The treatment will go right there and will cause radiation right there and cause damage to that tumor. We have another collaborative team of our interventional radiologists and our nuclear medicine radiologists who work together. There are small microspheres that are radioactive that come from the nuclear medicine world. And they are given to our interventional radiologists who, again, put a catheter into the liver and deliver it straight to that tumor and treat that tumor with that radiation so that that tumor is treated without having to go to surgery. So, we might use those kinds of techniques in tumors that aren't responding to normal chemotherapy or other ways to treat. So, we are good at treating cancers more and more as technology advances.

Macie Jepson

I wish our listeners could see your face because this is your passion. And I'm just so curious to know, it could have been oncology, but you chose radiology. Why is that?

Dr. Donna Plecha

That's an interesting question. When I was in medical school, I actually did multiple months of dermatology and graduated with honors in dermatology and did research in dermatology. I did a late elective in radiology, and I just realized that radiology touches so many aspects of medicine and helps figure out what's wrong with a patient very early on: pediatrics cancer, Cystic Fibrosis, you know, diabetes complications, heart disease, brain tumors, Multiple Sclerosis. You name it, radiology most likely, not always, might find it. And I just thought that that had the biggest impact on patient care that I saw during my medical school experience. So, I changed my decision and quickly went to the match in radiology.

Macie Jepson

Glad you did.

Dr. Donna Plecha

I am, too.

Pete Kenworthy

OK. So, you talk about having a great impact, and another way that's done, certainly here at University Hospitals, is through research. And my guess is you and the radiology department are very heavily involved in research. Can you touch on that a little bit and kind of where things are going and what we're learning?

Dr. Donna Plecha

Sure. I can talk about some wins that we've had in the past and progress that we've had in the past. We were doing research with the digital breast tomosynthesis 3-D mammography before it was FDA approved. We were the first one in Northeast Ohio to have it. We were also the first one in Northeast Ohio to use the fast MRI for screening for breast cancer. We were one of the early adopters of CT scanning for lung cancer, and we've scanned over 3,500 patients and found quite a few cancers that we otherwise wouldn't have found. We also do a lot of research in MRI. This research has been going on for over 30 years. And some of the things that we have developed here at University Hospitals are now routine around the world. One of the newest things that we've come out with is something called MR Fingerprinting. And it's actually a way to quantitate MR images, as opposed to just looking at a picture of a brain, let's say. And it's a way that we might be able to predict response to chemotherapy after the first dose of chemotherapy. That's something that's important to us because if the patient's not going to respond to that treatment, we'd like to stop it after the first dose instead of continuing on. We have an NIH grant looking at that. We are also using MRI Fingerprinting in the brain and the kidney. So, that's something that we are really interested in using in the near and far future to see what kind of applications we can use that for. We've also been very active in using contrast material with ultrasound. That's something that actually hasn't been widespread used around the country. We use contrast with MRI. We use contrast with CT. But the contrast in ultrasound is actually small bubbles. And it's something that has helped us target exactly where tumors are, which ones have the most vascularity and helps with imaging and treatment decisions.

Macie Jepson

As we start to wind down, Doctor, I think it's, I can't even imagine medicine without radiology now that you've laid it out for us this way. I mean, how would we get these diagnoses without it?

Dr. Donna Plecha

We wouldn't. We can't see inside the body without radiology. And how are you going to make the diagnosis without that? There is absolutely no way you could do that. And I think a lot of patients forget about radiology and forget about the radiologist. Part of radiology is the radiologist. They're the doctors behind those images that are interpreting and have the knowledge interpret and look at those images and try to figure out what's going on. And patients don't think of those doctors. And those doctors are the ones kind of behind the scenes or in the shadows that are reading all these scans and trying to figure out what's going on inside of that patient. And that's what drove me to that subspecialty is because us as radiologists have a very big impact on patients’ journeys, whether it's cancer, whether it's diabetes, heart disease, whatever it is. We are commonly imaging at a very crucial point in that patient's journey to figure out which road to take next. Is it a biopsy? It is a certain medication? What is it? And we're going to help make that decision. And so I'm very proud of what our radiology department has done. And I'm really proud of my subspecialty because we have advanced technology to a point today. We are able to image patients safer, find cancers earlier and make the right diagnosis at the right time so we can treat as soon as possible.

Pete Kenworthy

Dr. Plecha, thanks so much for all this information. We really appreciate your time.

Dr. Donna Plecha

Absolutely. Happy to be here. Thank you for having me.

Pete Kenworthy

Remember, you can find and subscribe to this podcast on iTunes, Google Play Stitcher or wherever you get your podcasts. Search University Hospitals or Healthy @ UH, depending on where you subscribe.

Macie Jepson

And for more health news, advice from medical experts and Healthy @ UH podcasts, you can go to UHhospitals.org/blog.