PEDIATRIC EP IL EP SY Continued from cover UCLA Breast Health and chief of the Division of Breast Surgery. The guidelines reflect an effort to balance the benefits and harms of mammography for women in their 40s, who need to weigh the chance of finding cancer against the greater possibility of a result that leads to additional imaging, and perhaps biopsy, for an abnormality that does not pose harm. On the other hand, “younger women have dense breast tissue, so the chance of a false negative” — a mammogram that looks normal even though breast cancer is present — “is much higher for this population,” notes Merja Clegg, MD, a UCLA primary-care physician in Marina del Rey. Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer deaths among American women. The ACOG revised mammography guidelines acknowledge that mammography starting at age 40 has been shown to reduce breast-cancer mortality. When advising their patients about mammography, physicians look at the patient’s risk for breast cancer. Factors that influence risk include the patient’s age, family history of cancer, age when beginning menstruation, age at menopause and previous breast problems. The new guidelines allow physicians to factor their patients’ feelings about risk versus benefit into the equation. Ultimately, the best decision results when patient and physician make a shared decision, says Giovinetza Hasbun, MD, a family-medicine physician in Santa Monica. “It’s all about education. Our job is to be educators and have open discussions with our patients to address their questions and concerns.” For information about the UCLA Breast Center and locations, go to: breastcenter.ucla.edu For information about breast-imaging radiology and locations, go to: radiology.ucla.edu/breast-imaging-clinical Surgery Options Help Quiet Pediatric Epilepsy Seizures Dr. Fallah notes that the consequences of pediatric epilepsy extend beyond seizures and can include learning disabilities, development and cognitive delay, and behavioral and psychosocial problems. “We are talking about a growing and developing brain,” Dr. Fallah says. “The treatment decisions that we make today are to prevent psychosocial and developmental deficits tomorrow as a consequence of untreated epilepsy.” A pediatric neurologist may be able to adjust a child’s medication to control seizures, but if two different medications have been tried and fail to stop seizures, a presurgical evaluation at a comprehensive epilepsy center is warranted, says pediatric neurologist Rajsekar Rajaraman, MD. Surgery, when an option, can provide dramatic results. “For children who are appropriate candidates, epilepsy surgery can offer the best opportunity to reduce, or even eliminate, seizures, lessen the need for medication and improve cognition and their quality of life,” Dr. Rajaraman says. Young children generally experience the greatest benefit from targeted surgeries or hemispherectomies, in which the surgeon removes half of the brain. “The younger the child is, the greater the brain’s ability to take over function that is lost from surgery,” Dr. Fallah says. “Their brains have a remarkable ability over time to rewire.” While surgery is a possible option for a child at any age, “once the child is older than 2, we don’t do those radical operations as much because the benefits are less.” Dr. Fallah says that surgery cures the epilepsy in about 80 percent of cases. In 10-to-15 percent, surgery slows the seizures but does not eliminate them. After surgery, “we often simplify the medical regimen, which may mean fewer medications as well as more modest doses,” says Raman Sankar, MD, PhD, chief of the Division of Pediatric Neurology. Whether or not to completely discontinue medication is decided on a case-by-case basis, involving pathological reports as well as “how completely the surgeon was able to remove the brain abnormality while minimizing deficits that may follow the surgery,” Dr. Sankar says. A new technology that Dr. Fallah is employing is laser interstitial thermal therapy, in which the surgeon makes a tiny incision in the skull and inserts a wire deep within the brain to locate the area causing seizures. “With thermal energy, we heat that area to destroy the tissue. We don’t need to open the skull, and the patient can wake up after surgery feeling great and go home the same day or the next with minimal pain and minimal recovery time.” To view a video of Dr. Aria Fallah talking about pediatric epilepsy surgery, go to: uclahealth.org/ pediatricepilepsysurgery Dr. Fallah recognizes that surgery presents a difficult choice for parents. “Parents struggle with the idea of epilepsy surgery,” he says. “But if they see their child deteriorating — maybe their child could speak before and all of a sudden he or she is losing speech — then they may decide that surgery may give their child a better quality of life.” Vital Signs Fall 2017 Vol. 76 7