From Screening to Survivorship: The State of Breast Cancer in Vermont in 2012
by Roberta Nubile - Photos courtesy of Fletcher Allen Health Care & Rutland Regional Medical Center
Every woman starts out with two good reasons for staying current on breast cancer screening and treatment. You may have worried about headlines on controversies within the medical establishment over the frequency of mammograms and their possible effect. You may have questions about the best preventative methods, or wonder how safe you are if a screening comes back positive—or doesn't. What are current treatments if a tumor is found? Will you have to leave Vermont to get what you need?
The short answer to the last question, according to Dr. Charlene Ives, medical oncologist at Bennington's Southwestern Vermont Medical Center's Breast Care Center, is no. "There is no need for Vermonters to go to New York or Boston for cancer care. We have state-of-the-art treatment and care here, " she says.
SVMC's Breast Care Center is one of several cancer centers or hospitals in Vermont that offer breast health care. Vermont women can and should expect guided comprehensive care in the form of screening, diagnostics, medical treatment options including radiation, oncology and surgery, as well as reconstructive surgery, support services and support groups. Jane Catton, the Director of Process Improvement at Northwestern Medical Center in St. Albans says of NMC's cancer program, "We provide a multi-disciplinary approach and though we don't offer all services on site, we create collaborations and pathways for care that make it easy for our patients to get all their needs serviced seamlessly.
State law requires physicians and hospitals to report to the Vermont Cancer Registry on all cases of cancer (and benign brain-related) tumors they diagnose or treat. All of the cancer centers participate in "tumor boards."
Dr. Allan Eisemann, oncologist of the Foley Cancer Center of Rutland, explains these are multi-disciplinary conferences, which typically include the radiologist, surgeon, pathologist, medical and radiation oncologists, nurses, the primary care physician and other specialists related to any particular client's medical needs.
He says, "We gather weekly to present anywhere from one to 10 newly diagnosed cases, and ask the question, 'What is the most modern way to look at this case? ' We get the benefit of everyone adding their expertise, and immediate synthesis of the most up-to-date information. From there we develop a recommendation for the patient."
Screening and Early Detection
The American Cancer Society currently recommends an annual mammogram for all women, age 40 and up, as long as she is in good health. The Affordable Health Care Act now mandates insurance companies to pay for these yearly screening mammograms.
Other medical authorities question a blanket recommendation. In 2009 the U. S. Preventive Services Task force, which evaluates evidence and publishes guidelines for screening various cancers, stated that women in their 40s should discuss their individual circumstances with their doctor, and then decide on the best screening schedule. It said that women aged 50-73 should consider having mammograms every two years instead of annually, and could stop at age 74. Since its report came out, rebuttal studies have arisen to support the benefits of an annual mammogram.
The government's National Cancer Institute recommends that women age 40 or older should have screening mammograms every one to two years.
The U. S. Centers for Disease Control says, "If you are age 50 to 74 years, be sure to have a screening mammogram every two years. If you are age 40–49 years, talk to your doctor about when and how often you should have a screening mammogram. " Other imaging such as ultrasound and MRI may be indicated for some women with moderate-to-high risk factors.
The government's National Cancer Institute recommends that women age 40 or older should have screening mammograms every one to two years. The U. S. Centers for Disease Control says, "If you are age 50 to 74 years, be sure to have a screening mammogram every two years. If you are age 40–49 years, talk to your doctor about when and how often you should have a screening mammogram. " Other imaging such as ultrasound and MRI may be indicated for some women with moderate-to-high risk factors.
Breast self-exams are not always reliable, and a more empowering practice of "breast self-awareness" is now recommended. Women are encouraged not only to have a tactical feel for what their breasts feel like, but a more general sense of knowing when something just doesn't look or feel "right" in her breasts. She can then see her health care provider for a clinical breast exam and further diagnostics.
Many of Vermont's imaging centers have private areas just for women, and technologists and staff in imaging centers are trained to deliver compassionate care. Dr. Sally Herschorn, medical director of Breast Imaging at Fletcher Allen's Vermont Cancer Center, says she teaches her staff how to interact with clients' anxiety or anger, and tells her staff, "For us, we may be having a bad day. But for our patient, who is afraid she may have breast cancer, it's the worst day of her life. "
Herschorn frequently consults with other centers, and is well versed on the issues and questions of the day surrounding mammograms. She says mammography technology is improving. FAHC's recent acquisition of the FDA-approved 3-D mammogram is exciting, says Herschorn, because evidence to date shows it results in "more cancers detected and fewer false positive recalls. " However, critics say it also delivers twice the radiation, is more expensive and has not yet been shown to save lives.
Being called back from a screening mammogram can be stressful, and while Herschorn says most women are relieved to receive good news after the inconvenience of returning, research is ongoing to improve screening methods.
Dense Tissue Issues
Another screening conundrum is dense breast tissue, Herschorn says. "In women with dense breast tissue, tumors may be hard to detect, and women with dense breasts are at higher risk for developing breast cancer. Some women may need additional screening tools such as ultrasound or MRI. "
Several states have introduced or enacted "density notification legislation. " Herschorn admits that methods of classifying tissue density are subjective and prone to inconsistencies. But she is not yet convinced that legislation is the ideal way to provide women with dense breasts the information they need to take charge of their screening. She does encourage women to find out about their breast density from the mammogram report, and to bring up the subject with their doctor. It's valuable to ask about your personal risk factors for breast cancer.
Herschorn recommends that women educate themselves and refers them to the website www.areyoudense.org to learn more about this topic.
And Bigger Questions
While annual mammograms continue to be the gold standard for early detection of cancer by those we talked with in the field, controversy exists over frequency. Ultimately, the decision of when to start her baseline screening, and how often to screen, is a discussion between a woman and her healthcare provider, with consideration of her own risk factors and values. Other issues warrant further study. These include: missed detection of fast-growing tumors, issues around detecting tumors in dense breast tissue, false positive and false negative results, over-treatment of slow-growing benign tumors, cumulative exposure to radiation increasing one's cancer risk, and whether there is improvement in mortality rates relative to early detection.
When a Mass Is Found
If the mammogram is abnormal, further diagnostic tests may be ordered. These include ultrasound scans, MRI (magnetic resonance imaging), CAT (computed axial tomography) scans, PET (positron emission tomography) scans and blood tests. All are non-invasive methods for examining a tumor more closely, although PET and CAT scans do use radiation.
The next step is typically to evaluate the mass via biopsy to determine if the tissue is cancerous or benign. Previously, many Vermonters needed to travel a distance from their local communities to a larger hospital for this step.
At Gifford Medical Center in Randolph, Terri Hodgdon is the lead mammography technician, and has lived in her community for 21 years. Hodgdon describes how Gifford's acquisition of a stereotactic biopsy machine in the last year has increased its ability to deliver comprehensive care.
Says Hodgdon, "What we found is people in this community would prefer to be treated in their community by people they know. It used to be people had to go to Fletcher Allen or Dartmouth, and had to wait to schedule an appointment. We thought we weren't going to do many [biopsies], this being a small community—maybe one per month. This last April, we did 27. "
More than Guided Care
At the stage where needle biopsy is indicated, most Vermont cancer centers offer support services that can help patients coordinate the many tests and appointments that may follow, understand their insurance coverage, or help under- or uninsured patients access funds. Often called a "patient navigator, " the key support person may have a better overall view of the client's needs than any one medical specialist assigned to her case.
In Berlin, at Central Vermont Medical Center's National Life Cancer Center, Theresa Lever is the patient navigator. Lever's background in social work amplifies her needed skills of advocacy, education and being a compassionate presence to her clients. With her insight into the big picture, Lever says, "I noticed that clients' insurance did not cover physical therapy for range-of-motion complications from lymphedema, which greatly impacts their quality of life. "
Most often the result of surgery or radiation therapy, lymphedema can result in painful swelling in the arm closest to the surgical site. Lever approached the Susan G. Komen foundation for funds to cover a physical therapy consultation, and this service is now available to CVMC breast cancer patients.
Whether a tumor is found to be benign or cancerous, the next step is for a woman to meet with her surgeon to discuss options. "Breast surgery is not what is was for our grandparents. Surgeries are much less gruesome than they were back in the day, " says Dr. Michelle Sowden, a fellowship-trained surgical oncologist at Fletcher Allen Health Care. "Before we go on the table, based on the imaging tests, I already have a decent idea of what I am dealing with in terms of clinical staging, and how much tissue or lymph node is involved. I don't like surprises. "
Possible surgical options include: the more common lumpectomy, a breast-conserving surgery also known as a partial mastectomy; the more rare modified-radical mastectomy (a less disfiguring mastectomy refined by sparing muscle) ; or lymph node removal or dissection. Prophylactic, or preventive, surgery—including a mastectomy, or ovary removal, to lower estrogen production—may be an option for those with a strong family or genetic history.
Chemotherapy or radiation may be used to shrink the tumor prior to surgery. Any of these surgical options may also include a consultation with an oncoplastic surgeon, whose work can help reconstruct the breast. In some hospitals, they work in tandem with the surgical oncologist in a single operation. New approaches to breast conservation surgery include skin and nipple sparing.
A Team Approach
After surgery, a pathologist evaluates the removed tissue mass, and determines the cancer's stage, from I to IV, with IV being more advanced. A woman may then meet with her surgeon again to discuss whether further treatment is needed, or if there is a risk of spreading or recurrence. She may also choose to meet with her whole team, consisting of her surgeon, medical oncologist, pathologist, radiation oncologist and patient navigator.
Whether or not she opts for a group meeting, all her doctors will meet to discuss her care. They consider her wishes and options, and recommend standards of care, but they leave final decisions to the patient. Generally speaking, while each case is unique, if the tumor is small, radiation and perhaps anti-hormonal therapy will be the likely treatment; if the tumor is large, or there is metastasis (spreading), chemotherapy may be indicated.
No Longer One Size Fits All
The field of radiation oncology has changed drastically in the last 10 years, thanks to new innovations, according to Dr. Ruth Heimann, a radiation oncologist at Fletcher Allen and co-chair of the statewide coalition, Vermonters Taking Action Against Cancer. "There is less harm to the patient than ever before with technologies such as IMRT (intensity modulated radiation therapy) to pinpoint areas in a three-dimensional way, " she says. "We can be more precise in our targeted radiation area, and avoid toxicity to the heart and lung. "
She compares the technology changes to the difference between the artistic styles of Mondrian and his flat grids, replaced by Van Gogh's more layered images. "We can create layers with the radiation, or scoop out around specific organs as needed, " says Heimann, describing radiation tailored to each person's individual anatomy. A mold is made for every patient's optimum position, and is used for subsequent treatments. "This helps us" explains Heimann, "to meet our two goals: to control and cure the disease, and have an excellent cosmetic outcome with less scarring and fibrotic tissue. "
Dr. Kim Dittus is a medical oncologist at Fletcher Allen Health Care and an avid athlete and Dragon Boat racer (see sidebar). She prescribes chemotherapeutic agents to shrink tumors and anti-estrogen drugs to inhibit estrogen production. Dittus has been in the field long enough to see improvement in patient prognoses, or predicted outcomes.
Dittus wants women to know there is not just one type of breast cancer, but many. "Today cancer can be very treatable, " she says, "especially if detected early. And research is so important—it is the only way to advance in the field. "
For instance, approximately one in four women has HER2 cancer, an aggressive, fast-growing type. Dittus says, "It used to be that the drug trastuzumab was only available for cancer metastasis. As the standard of care now, it has revolutionized outcomes. It used to be a diagnosis of HER2 breast cancer was a poor prognosis. Now it is much less scary."
Dittus' passion is exercise. Her research has studied the effects in cancer patients of exercise for combating fatigue and preventing weight loss. She is part of a team responsible for initiating a new oncology rehabilitation program at FAHC for cancer survivors called "Steps to Wellness. " It offers resistance and aerobic training in a 12-week program, free to all Vermont cancer patients.
"Cancer is a continuum, " says Dittus. "In the beginning, a patient sees many doctors, and the treatments are intense. When it is finished, it's as if they are dropped off a cliff, as they have been in such intense observation for so long. Oncology rehabilitation fills in that piece. " Dittus hopes to increase the availability of the program—now funded by local donations—not just to cancer survivors, but during cancer treatment as well. Insurance already covers the initial evaluation by the physical therapist and physician, but she is now gathering data to persuade insurance companies to cover the cost of the rehab.
Dr. Lorilee Schoenbeck of Mountain View Natural Medicine in South Burlington is board-certified in naturopathic oncology. She offers naturopathic care for breast cancer patients during and after conventional treatment that, she says, "parallels any phase, including support for surgical wound healing to prevent scarring and infection, prevention or treatment of burns during radiation, support of the immune system, and specific naturopathic support depending on the chemotherapeutic agents and the side effects associated with them. "
Shoenbeck explains, "I don't use detoxifiers during this time, or any herbs which are metabolized in the same pathway as chemotherapeutic agents. I am careful during radiation treatment to avoid an excess of antioxidants precisely because radiation does its work by creating free radicals, [which] damage the DNA of cancer cells by flooding the body with high doses of antioxidants. So we time the delivery of naturopathic care—so it enhances the effectiveness of conventional treatments. After the treatments are over, it's very good at cleaning up the damage. "
Schoenbeck receives referrals from several cancer centers, and says physicians today better recognize that naturopathic medicine fills unmeet needs of their clients. "Most oncologists were unfamiliar with any aspect of naturopathic care, " she says, "and used to routinely stop all supplements because they didn't know about interactions. We are starting to move beyond those days into an era of increased collaboration and mutual respect. " Schoenbeck recently presented to medical students at the University of Vermont during "integrative medicine week, " joined by Dr. Dittus, to discuss allopathic and alternative approaches for treating breast cancer.
Wendy McKinnon is a certified genetic counselor and the coordinator for the familial cancer program at FAHC. McKinnon takes referrals throughout Vermont and upstate New York, and counsels clients about the results and implications of genetic testing, if they have a family history of cancer. "Knowing your family history is key, " says McKinnon, and reminds Vermonters that Thanksgiving has been declared "family history day" by the U. S. Surgeon General. Thanksgiving is an excellent time to ask details about diseases and medical records, including ages at diagnosis.
"Only 5 to 10 percent of breast cancer is due to an inherited gene mutation, " says McKinnon. According to breastcancer.org, women with genetic mutations have up to an 80 percent risk of developing breast cancer during their lifetime, and they are more likely to be diagnosed at a younger age (before menopause). An increased ovarian cancer risk is also associated with these genetic mutations.
Survivorship: Connection and Fitness
"Studies show that cancer survivors who connected [with other survivors] live longer lives, " says Linda Dyer of Survivorship NOW. There are support groups throughout the state for cancer patients and survivors, and these can be located through your closest cancer center. Often, the groups are run by cancer survivors who volunteer their time.
As Dittus noted, while cancer detection and care are improving, cancer survivors may need wellness tools to live a healthier life after cancer. Programs such as Steps to Wellness for oncology rehabilitation, and Dragonheart Vermont's Survivorship Now (see sidebar) recognize that need, and strive to fill it. Both are new programs, up and running, and free to Vermonters.
|Roberta Nubile is a Vermont registered nurse and a writer interested in health and social issues.|