Keith W Roach, MD

11/24/2025

DEAR DR. ROACH: I have read about using the immune system’s response as a mechanism to battle cancer (such as brain and pancreatic) and to reduce the devastating impact that cancer and its treatment has on humans. I understand current drug trials show promising results. How do doctors and scientists use the immune system to treat cancer? -- J.W.

ANSWER: The concept of using the immune system to treat cancer is old, but the ability to do so has dramatically improved in the past few years. There are a few specific types of treatments that I’d like to highlight:

Immune checkpoint inhibitors are treatments that release inhibitions on the immune system. (These “strengthen” the immune system, which has beneficial but also potentially toxic effects.) For melanoma, the most dangerous form of skin cancer, these treatments have revolutionized treatment and led to dramatically improved outcomes in people whose melanoma has spread. Response rates are up to 60% in a disease where the prognosis used to be dismal.

The unleashed immune system can destroy cancer very effectively, but it also can attack healthy organs, with many people (between 10% to 60% depending on drugs and doses) developing damage to the skin, lungs, liver, thyroid, colon and heart. These toxicities range from mild to life-threatening.

The body’s own immune cells can be genetically engineered to kill cancer cells. Chimeric antigen receptor T cells (CAR T cells) can be specifically changed to recognize cancer cells. This can lead to complete remission with some cancers, especially some leukemias and lymphomas. Unfortunately, they can also attack the body, leading to neurological damage that can be very serious.

Developing cancer vaccines is a highly promising strategy for personalizing the immune system to attack a person’s own cancer. Although the United States has recently made dramatic cuts to its support of this research, researchers in other countries continue to study this. It can be used in combination with other traditional or immune-based treatments.

The immune system can be used to help treat cancer effectively, but there is still the potential for serious side effects.

The concept of using the immune system to treat cancer is old, but the ability to do so has dramatically improved.

11/24/2025

DEAR DR ROACH: I am 89 years old and doing reasonably well, but I have noticed some loss of energy and a bit of my balance. I try to walk, do some exercises, and then hit the hot tub every day to help relax my joints. I recall reading an article about a study concluding that 15 minutes in a hot tub equated, cardio-wise, to a 15-minute jog. I would really appreciate your opinion on this proposition. -- J.D.

ANSWER: I read the study that I think you are referencing, from Coventry, England, and I think the headline writers overstated the more cautious conclusions of the actual study. Being in a hot tub or sauna does increase the heart rate and the ability of the heart to exert itself when done daily for four weeks in people with heart failure.

Other studies have found that healthy volunteers also get small but significant improvements in their cardiac reserve, similar to (but not quite as much as) what would be expected with exercise.

The benefits of exercise are well-known and large and go beyond the effects of the heart, while the benefits of regular hot-tub or sauna bathing appear to give some but not all the benefits of regular exercise. At age 89, there is a risk of heat-related injuries, including lightheadedness and falling, so I would urge caution for new users not to use too high of a heat or stay in for too long, especially when first starting.

11/21/2025

DEAR DR ROACH: I’m a 79-year-old male in reasonably good shape. I am 6 feet, 2 inches tall, and weigh 210 pounds. During a colonoscopy, the doctor noticed that the head of my pancreas was way larger than it should be. I saw a surgeon who advised that it was precancerous after an MRI and a biopsy. I decided on Whipple surgery and will be getting it done in about a month.

Could you please give me your thoughts on Whipple surgery? I’d mainly like to know the risks of using robotics in the surgery and if it is much better than traditional surgery. But I’d appreciate your thoughts on the whole deal. -- M.D.

ANSWER: In the 1970s and 1980s, a Whipple procedure was a very high-risk surgery, with over 15% of people not making it through the surgery. A Whipple surgery removes the head of the pancreas, part of the duodenum, the gallbladder, and the bile ducts. In the best centers now, the operative mortality is less than 4%, which still makes it a risky procedure that should only be contemplated when there aren’t any better options.

The decision to choose a particular procedure is generally done by the surgeon after a careful evaluation of the patient’s particular anatomy. I suspect that your surgeon gave you other options, such as surgeries that preserve part of the stomach. Even though I have more expertise than most laypeople, I still accept whatever my surgeon said was the best option.

The data on robot-assisted surgery versus traditional surgery show no difference in the success of removing the cancer (precancer in your case), mortality, reoperation, or readmission. But the robot-assisted surgeries have less blood loss, fewer wound infections, and shorter lengths of stay. These are both long procedures (about 5.5 hours for traditional and almost 7 hours for robot-assisted on average), and recovery takes weeks to months.

With both a traditional Whipple and robot-assisted procedure, the experience of the surgeon and institution is critical. You really want to be in a hospital that performs many of these procedures.

Pre-cancer in this patient's pancreas has his surgeon recommending the Whipple procedure.

11/21/2025

DEAR DR. ROACH: About a year ago, a test revealed that I had an 8-mm stone in my kidney. My kidney doctor was not worried about it. I have had no infections or symptoms, and I have normal kidney function. My general doctor recommended a urologist.

All three doctors thought that it was 50-50 whether it would just stay there forever and that there was really no issue waiting for it to dislodge. But if it did try and pass, it would take surgery. Now less than a year later, over the phone, my urologist is telling me at 74 years old that I should immediately get the surgery; otherwise they will have to put in a temporary stent and have to replace it every three months for as long as I live.

I am going to get a second opinion. My real issue is being 74 years old. I am in very good health. I exercise regularly. I felt pressured to have the surgery due to a fear of replacing the stent every three months versus removing the stone now. What are your thoughts? -- M.A.R.

ANSWER: Kidney stones are common. The goals of treatment are to relieve symptoms and prevent infections as well as the loss of kidney function. Since you have not had an infection, have no symptoms, and have normal kidney function, there is no need for acute intervention that I can see.

It is possible that the kidney stone is in a location where it looks like it could potentially cause an obstruction, so I can’t say for sure that there will never be a need to treat the kidney stone. But I agree with you that a second opinion is wise.

11/21/2025

DEAR DR. ROACH: I had a complete knee replacement. Now when I go to the dentist, he insists that I take a one-time dose of clindamycin (600 mg) on the day of the visit. (I am allergic to penicillin.) My orthopedist laughs and says that this is old-fashioned; he recommended that I don’t take it. Any advice? -- S.M.

ANSWER: Although I don’t advocate laughing at any of our fellow professionals, your orthopedic surgeon is correct that antibiotics prior to a routine dental visit is no longer recommended for people with orthopedic hardware.

Several large studies have been unable to find any reduction in the already low risk of developing a prosthetic joint infection by using antibiotics prior to a dental procedure. This is true for gastroenterological procedures (such as a colonoscopy) or other medical procedures (such as a cystoscopy).

On a related note, people with some cardiac issues should get antibiotics before a dental procedure, but this includes far fewer people than we used to recommend it for.

People with a prosthetic valve, a vascular-assisting device, or an artificial heart; people with a history of infective endocarditis (an infection of the heart valve); those who have had a heart transplant and have valve disease; those who had a left atrial appendage occlusive device (such as the WATCHMAN) within the past six months; and some people with congenital heart disease should speak to their physicians as they are usually indicated for antibiotics prior to a procedure.

Is this advice outdated?

11/21/2025

DEAR DR. ROACH: I am struggling with a decision process due to a lack of consensus among various physicians. I was fortunate back in January at 66 years of age to survive bilateral pulmonary emboli with syncope when my wife successfully performed CPR. The underlying cause is undetermined as multiple tests have been negative.

I’m now on blood thinners (Eliquis), and I have one cardiologist who says that this must be the case for the rest of my life, while another disagrees. I had a hematologist say that it is not worth determining the root cause because blood thinners are the outcome regardless. Yet my long-time cardiologist disagrees and plans to refer me to a different hematologist.

My reading suggests that long-term blood thinner use is not favorable. Recent blood work with my general physician was good, and he tends to lean toward finding out the root cause. Any suggestion on how to referee when there’s a lack of consensus from physicians? -- T.W.

ANSWER: In my opinion, the medical evidence is on the side of the first cardiologist and the hematologist. A single life-threatening blood clot event is a usual indication for lifelong anticoagulation when a reversible cause cannot be found. Yours was not merely life-threatening; it would have been life-ending if not for the heroic action of your wife.

The hematologist is also right that lifelong anticoagulation is the correct treatment even if a genetic cause could be identified. It is very unlikely that a reversible cause will be found after an initial diligent search. However, there still may be a reason to try to find the cause as it may bear on other members of your family, even if it doesn’t affect your treatment.

While it is true that there are risks to lifelong anticoagulation, especially bleeding, you may not be lucky enough to survive another blood clot in your lung. In my estimation, the benefit of anticoagulation greatly outweighs its risks.

11/19/2025

Dear Dr. Roach: I'm a healthy 50-year-old woman. I asked my doctor to test me for Lipoprotein(a) after reading about it. My level was high, at 41 mg/dL. My doctor told me that it didn't need to be treated since I don't have any other risk factors for heart disease. When and how should a high Lp(a) level be treated?

— K.P.

Dear K.P.: Lp(a) (called "lipoprotein little A") is an independent risk factor for heart disease compared to total or LDL cholesterol. It is important to look for Lp(a) when a person has a personal or strong family history of heart disease without many other risk factors.

A level of 41 mg/dL is increased but does not put you at a very high risk for heart disease in absence of other factors. The risk increases as Lp(a) levels increase. Levels above 180 mg/dL place a person at a high risk for heart attacks and strokes.

Lp(a) does not have specific treatments. So far, the treatments that specifically lower Lp(a) have not reduced the risk of heart disease. Statin drugs do not reduce Lp(a); in fact, they can slightly increase Lp(a) levels, but they do reduce heart attack risk in people who are at a high risk for heart disease due to Lp(a) and other risk factors. PCSK-9 inhibitors like evolocumab (Repatha) reduce the risk of heart disease in people with high Lp(a) by about 25%.

A new medicine, inclisiran (Leqvio), is a small RNA molecule that reduces Lp(a) and LDL levels, but it is not yet clear that it reduces heart attacks and strokes. At least one early trial has yielded positive results.

I look at Lp(a) as an additional risk factor when deciding whether a person needs therapy. If a person is at borderline risk based on traditional risk factors, including LDL cholesterol, blood pressure, smoking history, or diabetes, then a moderate to high Lp(a) level will get me to recommend therapy. A very high Lp(a) level, especially in a person with a strong family history of heart disease, might get me to recommend treatment even if a person is otherwise at average risk.

In your case, I agree with your doctor that a modestly elevated Lp(a) level in a person with no other risk factors does not require treatment.

I'm a healthy 50-year-old woman.

11/19/2025

Dear Dr. Roach: I have needed reading glasses for years. I started eating a lot of spinach, and now I don't need reading glasses! My eye doctor didn't believe me.

— R.P.

Dear R.P.: Reading glasses are needed for people with presbyopia (literally "old eyes"). The lens gets stiffer with age, and the eye muscles simply aren't strong enough to pull the lens into a position to focus close-up. Presbyopia is usually treated with reading glasses, which reduce the work that the lens need to do and allow people to see close-up.

Presbyopia can also be treated with eyedrops that constrict the pupils. Any photographer knows that the smaller the lens aperture (the opening that is controlled by the f-stop), the more objects are in focus (called an increased depth of field). The drops work the same way.

Spinach is good for the eyes in that it contains substances like lutein and zeaxanthin, which help prevent macular degeneration and can improve vision in people with retina problems. However, I don't know of any mechanism where spinach can improve the ability of the eye to focus, so I am also at a loss as to why the spinach helped you.

11/18/2025

DEAR DR. ROACH: I have Type 2 diabetes. How often do I need to see my doctor? -- A.B.

ANSWER: When a person is first diagnosed with Type 2 diabetes, a visit every three months is normally recommended. If a person is on a healthy diabetes regimen, including their diet, exercise regimen, and medication therapy if needed, and a person also has good control of their blood sugars, then the visits could be made less frequently.

Personally, I prefer seeing most of my patients with Type 2 diabetes at least every six months, but I have a few people who can only be seen once a year. In these cases, I trust the patient to follow their blood sugar levels, either through fingerstick measurements or a continuous glucose monitor, and know that they will contact me if their sugar goes out of control.

Also: How safe is Evenity for treating osteoporosis?

11/18/2025

DEAR DR. ROACH: My primary care doctor has prescribed the medication Evenity for my osteoporosis. I have been on Fosamax for about three years, but my recent bone density scan went down slightly in the osteoporosis area. I am very concerned about the black-box warning of heart attacks and strokes since this is a very new drug with very little trials. I am hesitant to start it and am very interested to know your opinion on the safety of this drug. -- C.M.

ANSWER: Alendronate (Fosamax) is a bisphosphonate -- the most commonly used initial treatment for osteoporosis based on decades of safety data. When used properly for men and women who are at a high risk of fracture, and when used for an appropriate amount of time (usually three to five years before reassessing), the risks are small. The benefit in preventing a serious fracture outweighs these small risks for most people.

When bisphosphonates like alendronate don’t work in a person who is taking it as prescribed, it’s worth considering whether it might not have been absorbed by the body well or if the person is getting the necessary calcium and vitamin D for the medication to work. They must be taken very carefully as foods and other drugs (even water with a high mineral content) can cause them to be poorly absorbed.

If no reason can be found, then switching to a different class of drugs is reasonable. Romosozumab (Evenity) is a reasonable choice. In two large trials, one found an increase in the risk of new heart attacks and strokes, but the difference was relatively small. (It was 0.8% in the Evenity group and 0.3% in the Fosamax group.) But the larger trial didn’t find an increase in risk compared to a placebo. Two more trials that were published in the past year, which followed over 20,000 people on Evenity, didn’t find an increase in risk.

Even though there are some reassuring data, I still would not recommend Evenity to people who are at a high risk of heart attack or stroke (such as those with a prior history of having one). Alternatives include parathyroid hormone-type drugs; estrogen receptor modulators like raloxifine, which also reduces breast cancer risk; or denosumab (Prolia), which has the disadvantage of needing indefinite treatment. Further reassuring safety studies could get me to change my mind.

Consultation with an expert may be reasonable. I refer my patients who do not do well on first-line treatments to my colleagues in endocrinology.

I am very concerned about the black-box warning of heart attacks and strokes since this is a very new drug with very little trials.

11/17/2025

DEAR DR. ROACH: I was having hoarseness while taking ibuprofen. A friend got intestinal bleeding due to taking it. My doctor gave me 7.5 mg of meloxicam daily, but I’m not sure it’s OK long-term. I’m 73 with osteoarthritis and osteopenia. I exercise daily and eat a healthy diet, and I have high blood pressure that is controlled with losartan and amlodipine. -- T.M.H.

ANSWER: Ibuprofen is generally a safe drug, but it does have the potential for side effects -- some of them being serious. Gastrointestinal bleeding is a serious one, and it is most common in older women. I would not try a second nonsteroidal anti-inflammatory drug (NSAID) like meloxicam in a person who has a history of serious bleeding with any other similar drug.

Hoarseness could be due to an allergy, due to direct irritation of ibuprofen on the throat, or from the worsening of acid reflux, which can cause hoarseness if acid gets all the way into the throat.

Meloxicam is also an NSAID but is chemically in a different class from ibuprofen (Motrin, Advil and others) or naproxen (Aleve and others), which are closely related. It’s reasonable to give it a try, but if it causes hoarseness again, then an NSAID probably isn’t a good choice for your arthritis. You could consider acetaminophen (Tylenol) or topical NSAIDs, which do not get absorbed enough to cause an increased bleeding risk.

Ibuprofen is generally safe, but there are some potential side effects.

11/17/2025

DEAR DR. ROACH: I am a 76-year-old woman in what I thought was excellent health. On a recent coronary calcium CT scan that was ordered because of my age and slightly elevated cholesterol, an incidental finding was described in the report as “innumerable, tiny noncalcified pulmonary nodules bilaterally.” The largest of these is in the “left lower lobe with multiple additional 2- to 4-mm nodules,” and they recommended “clinical correlation and a consideration of a dedicated chest CT.”

I found the report quite scary, especially considering my mother and grandfather died of lung cancer (although they were smokers and I never smoked). My primary physician has ordered the chest CT but wants to wait four weeks. She says that the nodules could be caused by inflammation or infection and might resolve on their own.

My fear is that they’re actually lung cancer and waiting four weeks might be problematic, not to mention extremely anxiety-producing. I would appreciate your input. -- M.S.

ANSWER: I certainly understand why you are concerned about lung cancer given your family history, but primary lung cancer is very unlikely. Since there are so many of these tiny nodules, I agree with your doctor that these are highly unlikely to be lung cancer, which is generally only a single nodule.

Your doctor is correct that there are inflammatory and infectious conditions that can cause a similar appearance on a chest CT. Some of these infections are serious (including tuberculosis), but people generally have symptoms. So, I think this is unlikely. Exposure to lung toxins, especially silicosis and asbestosis, are generally occupational, but they are another potential cause.

Some cancers can spread to the lungs. While the appearance of nodules on a CT scan in a person with no known cancer would be unusual, if the CT scan in four weeks shows that the nodules are enlarging, then this would be concerning. Getting another scan in less than four weeks might not be enough time to see a change.

I am sorry about the unavoidable anxiety in waiting for the scan, but it’s likely that the scan won’t show a change and you will be able to stop worrying.