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Greenwich Hospital Panel Discussion on Breast Care

The Good News about Breast Cancer
At Greenwich Hospital, a panel of breast cancer experts recently discussed the progress being made against breast cancer and what specifically is being done at the hospital's new Breast Center to address the needs of the women in our community. What follows are excerpts from the panel discussion, which was the first in a series of events to celebrate the opening the Greenwich Hospital Breast Center.

Question: Is there good news about breast cancer?
Answer: Dr. Arthur Rosenberg, chief of oncology: I'm often asked about where we stand in the fight against breast cancer. The numbers can appear daunting - 180,000 new cases each year, affecting one in eight women in a lifetime, with 40,000 women dying. In the 1970s and 1980s, there was an increase in cases, primarily because mammograms were being more widely used and were picking up lots of new cases, but those numbers have now evened out.

In the last decade, the good news is that there has been a significant decrease in mortality from breast cancer at the rate of 3 percent annually. Survival rates increased because of early detection through mammography and because of the use of adjuvant therapy (radiation therapy and/or chemotherapy) after breast cancer surgery. Surgical techniques have also improved greatly from the old radical mastectomies. Lumpectomy is an option for many women.

For the first time, new therapies can now prevent breast cancer in women at high risk of the disease. Down the road, we are looking at better treatments, including angiogenesis inhibitors and vaccine therapies. Hopefully, these will bring a major decline in breast cancer mortality in the next 10 years. With advances in human genome mapping, we will also be better able to predict which women are at risk for hereditary breast cancers and we'll be able to develop drugs based on molecular abnormalities.

Part I: Diagnosing breast cancer

Q: How are most women diagnosed?
A: Dr. Phil McWhorter, cancer surgeon: Some women find a lump themselves or a lump is discovered during a clinical breast exam. Increasingly, however, with the widespread use of mammography, women are presenting with X-ray evidence of a breast problem without a palpable lump.

Radiologist Dr. Laura Hodges: The next step is to find out if the suspicious area is cancerous. As the size of the tumors we are seeing on initial evaluation has decreased, it's become necessary that biopsies be image-guided (either by X-ray or ultrasound) because they are so small you can't feel them. We can do this in three ways.

  • Stereotactic biopsy: Using X-ray images, we use a small suction device to remove a tissue sample. We make only a small puncture hole in the breast, which leaves no scar, and we are still able to get a good sample of tissue to analyze in the lab.
  • For a surgical biopsy, we use mammography findings to map where the calcifications are, then we put in a thin wire into the spot, which the surgeon follows to find and remove the lesion.
  • We can also use ultrasound to guide a needle core device into the lesion. The hand-held needle is guided directly by ultrasound images. Again the advantage that there is only a puncture wound and no incision.

Q: What is the role of the pathologist?
A: Dr. Richard Eisen, pathologist: Pathologists look at the cells under a microscope to determine if breast cancer is present and if so, what type of cancer it is. Is it in situ or an early stage cancer? We'll also determine the grade of the tumor. If it's a low-grade cancer, it's unlikely to spread. A higher grade is treated more aggressively. This information assists the oncologist in the management of the patient.

Q: Does every patient receive a biopsy? How do you decide?
A: Dr. McWhorter: It can be hard to decide who needs a biopsy and who doesn't. We of course want to help people avoid unnecessary medical procedures, but we don't want to miss a patient with breast cancer. So in the end the decision to biopsy is a consensus opinion - if the doctor has concerns or if the patient has concerns. I would never tell a patient she should not have a biopsy if she felt it necessary.

In general, the surgeons get involved in the care of a breast cancer patient very early. It takes some of the terror out of this to have these procedures done ASAP. We sometimes see patients with a suspicious lump in our office and do the needle biopsy right then and get a diagnosis right away or we will try to expedite the in-hospital biopsy procedure. When the diagnosis of breast cancer is made, the patient and her family or any supporting people should be thoroughly educated regarding the treatment options and the rationale for them. Following this education process, and only then, the patient will proceed to definitive cancer treatment.

Dr. Eisen: When surgery is performed, the tumor and often one or more lymph nodes are removed. We can then determine the size of the tumor, if the cancer is present throughout the breast and if cancer has spread to the lymph nodes. This information is used to determine the stage of the cancer. We will also examine the cancerous tissue to look for prognostic markers of breast cancer. We check for the presence of estrogen and progesterone receptors, which are actually proteins in cells under a microscope. Finally, we look at HER2/neu protein status.

Breast cancer will be treated more aggressively if some of these markers like HER2/neu are present, and/or if cancer has spread to the lymph nodes.

Q: How often should a woman have a mammogram?
A: Dr. Hodges: First off, we stress that mammography is the best method of diagnosing breast cancer. The American College of Radiology recommends women start having mammograms at age 40, with an annual exam every year. Some groups recommend a baseline mammography at age 35.

The type of tissue present in the breast will affect the quality of the mammography image. As a woman ages, more tissue in the breast become fatty tissue, which makes imaging easier. Glandular or dense breasts are harder to image. We can use ultrasound to augment the mammography image and will even occasionally do an MRI.

Dr. Rosenberg: I can't emphasize enough the importance of mammography. If breast cancer is caught early, meaning the tumor is very small and there is no cancer present in lymph nodes, the cure rate with surgery is above 95 percent. But because mammography can miss about 15 percent of cancers, it's very important to continue self-exams.

Q: After cancer surgery, are mammograms still necesary?
A: Dr. Hodges: Very much so. Once the patient has had surgery, we will perform follow-up mammography every six months after surgery - even if a woman has had a mastectomy. It's important for a patient to return to the same mammography facility so they can compare the new images with past mammography. We will perform diagnostic mammograms and you see the doctor with the results before you leave.

Part II: Treating breast cancer

Q: If a woman has breast cancer, does she have to have a mastectomy?
A: Dr. Barbara Ward, breast cancer surgeon: No, it's no longer a requirement. Many women with early cancers are cured through using lumpectomy and radiation therapy.

However women still do choose modified mastectomy for treatment either because the disease has spread through the breast or they feel better knowing their chance of recurrence is greatly reduced with mastectomy. For intraductal carcinoma, we still may need to do a mastectomy for multifocal disease even though it is not an invasive cancer.

Younger women think seriously about mastectomy because there is a longer period of time for a recurrence to occur. It may make more sense for them to have a mastectomy.

Q: What about prophylactic mastectomy - when the breast is removed even though no cancer is present?
A: Dr. Ward: Now with genetic testing and counseling, we have the ability to tell if a woman is carrying a BRCA gene. If she is, she has an 85 percent likelihood of developing breast cancer. At that point, she may choose a mastectomy. There are also some patients who don't have the gene, but worry a lot about breast cancer. They may be young with children and have had their own mother die of the disease. In those cases, the patient pushes our hand in doing the mastectomy.

Q: What's the latest news in treating breast cancer?
A: Dr. Dickerman Hollister, medical oncologist: There are many areas that have good news. Thanks to mammography and ultrasound, at Greenwich Hospital we are seeing more women with smaller tumors and less lymph node involvement. Our data is better than the national average, which suggests that people in Greenwich are more health conscious.

Knowing if estrogen/progesterone receptors are present and a patient's HER2/neu status tells us which patients are more likely to recur. Recurrence happens when cells that already left the breast before surgery begin growing in another location in the body. We can take steps to reduce that risk of recurrence.

With chemotherapy, there are new drugs that are coming out all the time. They are more effective and we can now better manage the side effects of chemotherapy. Women who undergo chemo are very motivated to increase their own survival. Hormone therapy and combinations of hormones given to pre-menopausal women are also being used. Monoclonal antibodies such as herceptin are being use in about one third of breast cancer patients. And we will have better treatments in the years ahead.

Q: Why do patients receive combinations of chemotherapy drugs?
A: Dr. Hollister: Cancer begins with a single cell. It makes copies of itself but not all the copies are the same. Some cells will be sensitive to one drug but not another. So combinations of treatments have been shown to be more effective. The goal is to get rid of that very last cancer cell.

Dr. Ward: Sometimes we give chemotherapy prior to surgery. This is called neo-adjuvant. This is used for inflammatory breast cancer or for very large masses in the breast or in lymph nodes. It may allow us to then proceed with a lumpectomy instead of a mastectomy.

Q: Who is eligible for breast reconstruction?
A: Dr. Keith Atkiss, plastic surgeon: Virtually any woman having a mastectomy is a candidate for reconstruction, performed either at the time of the mastectomy or later on. There is an emotional advantage to knowing that much of the reconstruction can be done by the time she wakes up. For some women, handling the burden of cancer is enough at first and the reconstruction options are too much to consider initially. For these women, the reconstruction can be done at a later date.

Reconstruction is done either by using an implant or the TRAM (transverse rectus abdominis muscle) method. The implant is a two-stage method. First, an expander is placed under the skin and under the chest muscle and filled over weeks or months to recreate the shape of the breast. The expander is then replaced with an implant. The TRAM method was developed in the 1980s. It uses the woman's own skin and fat tissue from the abdomen to reconstruct the breast. The advantage is that the breast is softer and has a more natural appearance than an implant. However, the TRAM method is a lengthier procedure with a longer recovery period.

The ultimate satisfaction with the reconstruction depends a lot on a woman's expectations at the start. During an initial consultation with a patient, I make sure she understands that although her body won't be exactly the same as it was before surgery, we can get her to where she feels comfortable in clothes or wearing a bathing suit. It is important that she understands these procedures take multiple steps over time and that it requires a commitment on her part as well.

Q: What is the role of radiation therapy in treating breast cancer?
A: Dr. Daniel Fass, therapeutic radiology: Radiation has been used for 100 years in the management of cancer patients. We've had good success using radiation therapy after lumpectomy in the treatment of breast cancer. Without the radiation, the tumor would come back 30 percent of the time; following radiation recurrence is less than five percent. Mastectomy and radiation is coming back into use as well. While chemotherapy is usually given over several months, radiation therapy usually lasts just a few weeks.

Q: As we can see here by the presence of so many specialists, treating cancer really requires a team approach.
A: Dr. Hollister: Yes, that's very true. Each breast cancer patient requires the input of each member of our team. One advantage we have here at Greenwich Hospital is that we have a small group of specialists who communicate easily. Patients can get in to see us easily.

Dr. Ward adds: The ability to work together as a cancer team is good for physicians as well as our patients. We all meet around one table - the diagnostic radiologist, the surgeon, the therapeutic radiologist - everyone. It facilitates the care for our patients. We make them feel at home. I'm equally excited about the next step beyond medical care where patients have integrated approaches to care - in nutrition, rehabilitation, supportive care. We're going to be able to bring all of these services together.

Part III: Recovery, rehabilitation and alternative medicine

Q: We've been hearing more about integrative medicine. Can you explain what that is?
A: Dr. Barry Boyd, oncologist and integrative medicine specialist: From 30 to 90 percent of cancer patients search out other methods to help in their cancer treatment. By this I mean everything from nutritional supplements to support groups to herbal therapies. The problem comes in when patients don't tell their physicians about these methods. But at the same time, we know these same patients are anxious to have physician guidance. Integrative medicine provides that bridge.

Traditional therapies such as chemotherapy or surgery have most definitely led to an increase in survival but they can lead to anxiety or even depression. Integrative medicine combines the physical care with emotional/psychological/supportive care to help the patient get through this period of fear, grief and physical changes.

There's evidence to show that many alternative modalities we've used do work - spirituality and the use of prayer; mind/body techniques, such as relaxation and visualization; and support groups. But there are other areas, such as herbal therapy, which can be potentially dangerous, so patients need guidance and physicians themselves need to learn where these modalities fit in.

Q: Are there ways to improve a cancer patient's psychological and emotional well being?
A: Psychologist Kim Fraioli: Each person is affected differently by cancer. First I may do an overall assessment that will screen for depression, and assess the patient's anxiety level and coping skills, such as the ability to manage anger or stress.

Treatment can vary tremendously and is based on the patient's needs and individual personality. Some benefit greatly from being in supportive psychotherapy to grieve their losses. Others might do relaxation training, visualization work where they visualize their body's cells recovering. I also offer hypnotherapy for pain management.

The benefit is that if a patient is more psychologically sound, she or he will be more compliant with treatment. One patient was not complying with medical therapy so with her I used the "bubble technique." She practiced being in a relaxed state. She was then able to use the bubble technique to complete her treatments.

I can also work with a patient's family or significant others. Cancer is a disease that affects a whole family.

Q: What role does physical therapy play in helping breast cancer patients?
A: Dr. Linda Grant, physical medicine: There are three reasons why a breast cancer patient may want to consult with a physical medicine specialist:
a limited range of motion in the upper arm that interferes with normal activities, lymphedema (swelling) of the extremity after axillary node dissection, or difficulty with general mobility, such as walking or getting in and out of bed and activities of daily living, such as getting dressed or eating that only occurs with advanced disease.

Q: What role does a support group play in helping cancer patients?
A: Jackie Zimkin, RN: Life changes forever at the moment a woman is told she has cancer. She has so many questions. Which doctor should I see? Which hospital? What treatment will I have? Will I lose my job? Will my husband find me attractive? It's more than a person can bear to face cancer alone and it's awfully hard for families to discuss. So for many patients, the answers come in the form of a support group. You can share your deepest fears and meet people who have been through this. Support groups can be educational or supportive or a combination of the two. There are several cancer support groups offered through Greenwich Hospital and other organizations.

Part IV: Education, prevention and early detection

Q: How are genetics used in assessing the risk of getting cancer?
A: Ellen Matloff, MS, cancer genetic counselor: Genetics is certainly part of the wave of the future in the prognosis, diagnosis and treatment of cancer patients. We are currently able to use genetics to assess who in a family is at greatest risk of getting cancer and take steps to reduce their risk of ever developing cancer. People who come to see me often have a family history of cancer and have long assumed they will get breast cancer.

We take a complete history of family cancers to determine if there really is a pattern of cancer on both the person's mother's and father's side. We also do a detailed risk assessment to determine a patient's actual risk of developing cancer. In some families, we can test for the BRCA 1 and BRCA 2 genes linked with hereditary breast cancer. Sometimes we provide patients with good news that they do not carry the gene - better news than they expected.

Q: Is breast self-examination still important and how is it done?
A: Pat Sullivan, RN, Community Health at Greenwich Hospital: Absolutely. Despite the increase in the use of mammography, there are still women alive today because they found a lump during a breast self-exam. It's important for a woman to be comfortable with her breasts. Look at them to see what they look like so you can check for changes over time. Breasts change throughout the menstrual cycle. Aside from these regular changes, if you notice something new or different, have your doctor check it out. The American Cancer Society recommends a woman perform an exam monthly, ideally after she has just finished menstruating. For post-menopausal women, you might want to get into the habit of doing a self-exam the first of every month.

To do a self-exam, using the palms of your fingers, place three fingers together. Start at the center of the breast and work around to the edge. Or do the opposite and work from the outside in. Check the nipple for any discharge. If you perform the exam while in the shower when you are soaped up, it's easier to feel any changes. And again, if you feel anything, get it checked out. Most lumps are not cancerous.

Q: Greenwich Hospital has benefited from the support of its community and people like Cheryl Zeldin and the Breast Cancer Alliance. Cheryl, tell us your story.
A: Cheryl Zeldin, breast cancer patient and hospital supporter: Well, I got involved with supporting Greenwich Hospital after my husband, Bert Zeldin, died of lung cancer. I wanted to do something in his memory so I used my contacts in the television industry and organized the first Bert Zeldin Golf Classic to benefit Greenwich Hospital in 1999. Our goal for this year is the raise $100,000. While I was working on the golf classic, I myself was diagnosed with breast cancer through a routine mammogram. I saw Dr. McWhorter and had surgery followed by radiation therapy and I'm doing great. It made me even more committed to helping all the wonderful doctors, nurses, staff and volunteers at Greenwich Hospital.

Q: The Breast Cancer Alliance has also been a tremendous supporter of Greenwich Hospital.
A: Mary Michaels: Yes, our mission is to raise funds for breast cancer research at the national level, to raise funds for breast cancer related services in the Fairfield County area, and to educate women on the importance of early detection of breast cancer. Since our inception, we have worked with Greenwich Hospital to provide free mammograms to women with little or no insurance. Most recently, we have been able to fund a stereotactic breast biopsy system for the new Breast Center here in Greenwich. Having been founded in 1996 by Mary Waterman, the Breast Cancer Alliance recently marked its fifth anniversary. Though Mary died in 1997, the mission of the Alliance continues to be fulfilled by survivors, their friends and healthcare professionals. To date, we have funded more than $1.9 million to area cancer centers to support research toward finding and cure and methods of finding breast cancer at its earliest most curable stage.

Glossary (definitions provided by the National Cancer Institute)

adjuvant therapy: Treatment given after the primary treatment to increase the chances of a cure. Adjuvant therapy may include chemotherapy, radiation therapy, or hormone therapy.

aggressive: A quickly growing cancer.

angiogenesis inhibitor: A substance that may prevent the formation of blood vessels. In anticancer therapy, an angiogenesis inhibitor prevents the growth of blood vessels from surrounding tissue to a solid tumor.

biopsy: The removal of cells or tissues for examination under a microscope. When only a sample of tissue is removed, the procedure is called an incisional biopsy or core biopsy. When an entire tumor or lesion is removed, the procedure is called an excisional biopsy. When a sample of tissue or fluid is removed with a needle, the procedure is called a needle biopsy or fine-needle aspiration.

BRCA1: A gene located on chromosome 17 that normally helps to suppress cell growth. Inheriting an altered version of BRCA1 predisposes an individual to breast, ovarian, or prostate cancer.

BRCA2: A gene on chromosome 13 that normally helps to suppress cell growth. A person who inherits an altered version of the BRCA2 gene has a higher risk of getting breast, ovarian, or prostate cancer.

carcinoma: Cancer that begins in the skin or in tissues that line or cover internal organs.

carcinoma in situ: cancer that involves only the cells in which it began and has not spread to neighboring tissues.

chemotherapy: using drugs to treat cancer.

estrogen receptor: ER. Protein found on some cancer cells to which estrogen will attach.

estrogen receptor negative: ER-. Breast cancer cells that do not have a protein (receptor molecule) to which estrogen will attach. Breast cancer cells that are ER- do not need the hormone estrogen to grow and usually do not respond to hormone (antiestrogen) therapy that blocks these receptor sites.

estrogen receptor positive: ER+. Breast cancer cells that have a protein (receptor molecule) to which estrogen will attach. Breast cancer cells that are ER+ need the hormone estrogen to grow and will usually respond to hormone (antiestrogen) therapy that blocks these receptor sites.

genetic counseling: A communication process between a specially trained health professional and a person concerned about the genetic risk of disease. The person's family and personal medical history may be discussed, and counseling may lead to genetic testing.

grading: A system for classifying cancer cells in terms of how abnormal they appear when examined under a microscope. The objective of a grading system is to provide information about the probable growth rate of the tumor and its tendency to spread. The systems used to grade tumors vary with each type of cancer. Grading plays a role in treatment decisions.

HER2/neu: Human epidermal growth factor receptor 2. The HER2-neu protein is involved in growth of some cancer cells. Also called c-erbB-2.

HER2/neu gene: The gene that makes the human epidermal growth factor receptor 2. The protein produced is HER2/neu antigen, which is involved in the growth of some cancer cells. Also called c-erbB-2.

hormone therapy: Treatment of cancer by removing, blocking, or adding hormones. Also called endocrine therapy.

intraductal carcinoma: Abnormal cells that involve only the lining of a duct. The cells have not spread outside the duct to other tissues in the breast. Also called ductal carcinoma in situ.

lymph node: A rounded mass of lymphatic tissue that is surrounded by a capsule of connective tissue. Also known as a lymph gland. Lymph nodes are spread out along lymphatic vessels and contain many lymphocytes, which filter the lymphatic fluid (lymph).

lymphadema: A condition in which excess fluid collects in tissue and causes swelling. It may occur in the arm or leg after lymph vessels or lymph nodes in the underarm or groin are removed or treated with radiation.

mammography: The use of X-rays to create a picture of the breast.

marker: A diagnostic indication that disease may develop.

mastectomy: Surgery to remove the breast (or as much of the breast tissue as possible).

metastatic cancer: Cancer that has spread from the place in which it started to other parts of the body.

monoclonal antibodies: Laboratory-produced substances that can locate and bind to cancer cells wherever they are in the body. Many monoclonal antibodies are used in cancer detection or therapy; each one recognizes a different protein on certain cancer cells. Monoclonal antibodies can be used alone, or they can be used to deliver drugs, toxins, or radioactive material directly to a tumor.

pathologist: A doctor who identifies diseases by studying cells and tissues under a microscope.

plastic surgeon: A surgeon who specializes in reducing scarring or disfigurement that may occur as a result of accidents, birth defects, or treatment for diseases.

prognosis: The likely outcome or course of a disease; the chance of recovery or recurrence.

prophylactic mastectomy: Surgery to remove one or both breasts in order to decrease the risk of developing breast cancer. Also called preventive mastectomy.

radiation oncologist: A doctor who specializes in using radiation to treat cancer.

radiation therapy: The use of high-energy radiation from x-rays, neutrons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy) or from materials called radioisotopes. Radioisotopes produce radiation and can be placed in or near the tumor or in the area near cancer cells. This type of radiation treatment is called internal radiation therapy, implant radiation, interstitial radiation, or brachytherapy. Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that circulates throughout the body. Also called radiotherapy.

radiologist: A doctor who specializes in creating and interpreting pictures of areas inside the body. The pictures are produced with x-rays, sound waves, or other types of energy.

recur: To occur again. Recurrence is the return of cancer, at the same site as the original (primary) tumor or in another location, after the tumor had disappeared.

stage: The extent of a cancer, especially whether the disease has spread from the original site to other parts of the body.

stage I breast cancer: Cancer that is no bigger than 2 centimeters (about 1 inch) and has not spread outside the breast.

stage II breast cancer: Stage II breast cancer means one of the following: cancer is no larger than 2 centimeters but has spread to the lymph nodes in the armpit (the axillary lymph nodes); cancer is between 2 and 5 centimeters (from 1 to 2 inches) and may have spread to the lymph nodes in the armpit; cancer is larger than 5 centimeters (larger than 2 inches) but has not spread to the lymph nodes in the armpit.

stage III breast cancer: Stage III is divided into stages IIIA and IIIB. In stage IIIA breast cancer, the cancer (1) is smaller than 5 centimeters and has spread to the lymph nodes in the armpit, which have grown into each other or into other structures and are attached to them; or (2) is larger than 5 centimeters and has spread to the lymph nodes in the armpit. In stage IIIB breast cancer, the cancer (1) has spread to tissues near the breast (skin, chest wall, including the ribs and the muscles in the chest); or (2) has spread to lymph nodes inside the chest wall along the breast bone.

Panelists

Keith Atkiss, MD
Plastic Surgeon
Greenwich Hospital

D. Barry Boyd, MD
Integrative Oncologist
Greenwich Hospital

Richard Eisen, MD
Pathologist
Greenwich Hospital

Kim Fraioli
Psychologist
Greenwich

Linda Grant, MD
Section Head
Physical Medicine and Rehabilitation
Greenwich Hospital

Laura Hodges, MD
Diagnostic Radiologist
Greenwich Hospital

Dickerman Hollister, Jr., MD
Medical Oncologist
Greenwich Hospital

Ellen Matloff, MS
Yale Cancer Center
New Haven, CT

Philip I. McWhorter, MD
Director of Surgery
Greenwich Hospital

Mary Michaels
Breast Cancer Alliance
Greenwich, CT

Arthur Rosenberg, MD
Section Head
Medical Oncology Greenwich Hospital

Pat Sullivan, RN
Community Health at Greenwich Hospital
Greenwich, CT

Barbara Ward, MD
Medical Director
Greenwich Hospital Breast Cancer Center

Cheryl Zeldin
Bert Zeldin Golf Classic
Greenwich, CT

Jackie Zimkin, RN
Greenwich Hospital
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