When the doctor delivers the news that you have breast cancer, the tectonic plates that make up the foundation of your life begin to shift, creating a seismic earthquake that turns your world upside down. Regardless of what kind of cancer you have or how advanced it is, receiving a cancer diagnosis marks an indelible moment that leaves you and your loved ones questioning the future.
Behind the scenes, there’s a team of women at Capital Health’s Center for Comprehensive Breast Care who are already working on your behalf, reading the diagnostics and marshaling your cancer plan to give you the best outcome. They are weighing the options and determining the best strategy for attack. While the cancer fight belongs to you, it is choreographed by a team of experts across a variety of disciplines who are also the kind of people who will drop just about anything on a moment’s notice to be there for you. They are there to devise a plan to remove the cancer from your body with as little pain and upset as possible. They are there for the long-term treatment plan. For the recovery. And even for the emotional and physical pain you never saw coming.
From diagnostics to radiation, chemotherapy treatments to mastectomies, “everyone has her role and when you put us all together, it makes for great patient outcomes,” says Lisa Allen, MD, Director of the Center for Comprehensive Breast Care.
The team is made up of diagnosticians, radiologists, oncologists, radiation oncologists, surgeons, genetic counselors, and breast navigators who have the tools and the passion to provide state of the art care. “This team loves what they do and it is never about egos,” says Rona Remstein, Director of Oncology Services at Capital Health. “We all feel the pain of our patients and never minimize what they’re going through.”
While their résumés and skills as medical professionals are top-notch, the fact that the team is made up of women “enhances our ability to understand our patients and what they’re experiencing from a female perspective,” says Erica Linden, MD, Director of Breast Medical Oncology at Capital Health. “We recognize that women with breast cancer are not only fighting to regain their health, but also to preserve their femininity and a desire to maintain their central role in the family structure. As a predominantly female oncology team, we are able to discuss issues involving hormonal changes that may impact intimacy or sexual dysfunction in a comforting manner.”
What made you decide to specialize in breast cancer, and why do you love what you do?
As a third-year medical student, I was lucky enough to rotate with a plastic surgeon whose practice concentrated on breast reconstructive surgery. I especially enjoyed working with the breast cancer patients. I was impressed with everything from how they handled their diagnoses and faced their surgeries and chemotherapy sessions, to how they kept going on with their lives and continued taking care of their families, all while battling a life-threatening disease. I already knew that I wanted to be a surgeon, but I came out of that experience knowing that I wanted to help women diagnosed with breast cancer shoulder their burden and guide them through their cancer treatments. —Lisa Allen, MD
I thought I was going to become a pediatrician when I started medical school, and then my father developed multiple myeloma. Around the same time, my grandmother was diagnosed with colon cancer. To learn more about these cancers, I did a radiation oncology internship and ended up loving it because the work is so fulfilling and cancer patients are so appreciative of what we’re able to do for them. Sometimes, I’ll get patients who are scared at the beginning and don’t know what they’re going through. I love being able to help them. I think I get more from my patients than they probably get from me, emotionally. Because it’s just so wonderful to accompany them on their treatment journey.
—Shirnett Williamson, MD, Medical Director of Radiation Oncology Services
In oncology, you meet people at the most vulnerable time of their lives. It’s not like working in the ER, where patients get treated and go home, ending your interaction with them. With cancer, you get to know the patient as well as the patient’s family, because they’re going through it all together. That’s why I enjoy working with cancer patients—I know we’re starting a long-term relationship at the time of diagnosis. And when it comes to breast cancer, we are involved with caring for them forever. Patients return for follow-ups or I run into them, and it makes me feel good to interact with them outside the initial treatment phase. I have friends that I worked with 15 years ago when they received their initial diagnosis. I see that they’re still doing well, and it makes me happy. —Trish Tatrai, RN, Breast Navigator at the Center for Comprehensive Breast Care
How does the oncology team work together?
When a patient is diagnosed with breast cancer, she is presented to a multi-disciplinary team of clinicians that includes a radiologist, a pathologist, a breast surgeon, a medical oncologist, a radiation oncologist, and a reconstructive surgeon. Along with the physicians, we also have nutritionists, geneticists, clinical researchers, a breast cancer navigator, and an occupational therapist rounding out the team that recommends a care plan for the patient. So, it may seem to the patient that one physician is caring for them, but it’s really the entire team that is participating in treatment decisions. —Rona Remstein, RN
While the patients don’t initially know the extent of the team behind them, each one of us has our role and we work well together. Sometimes, when I see a patient, she won’t realize that she’s already been the topic of discussion at our tumor board, where I shared the imaging and someone else shared the pathology, and then the oncology and surgery teams worked through the best treatment approaches. It’s an honor to be part of this team because we all help each other assemble the pieces to the puzzle necessary to care for each patient.
—Anne Moch, MD, Capital Health radiologist specializing in breast imaging
How important is early detection when it comes to treating breast cancer?
The earlier we can detect cancer, the better the outcome for the patient. With the addition of 3D mammography or tomosynthesis, for example, we are better able to detect smaller, invasive cancers that have not yet metastasized to the lymph nodes. 3D mammography gives us a clearer picture of the breast particularly in patients with dense tissue. So often we see young patients with young children and full lives ahead of them. Now that we are able to detect these cancers earlier, the treatment becomes less harsh and more effective. The impact of breast cancer on our patients’ lives and on the lives of their families is less severe. —Anne Moch, MD
Patients now have higher survival rates and are living longer with a cancer diagnosis. When I first started in oncology as a chemotherapy nurse, the side effects from some of the treatments were so harsh that patients got really sick afterward. Today, we have supportive medications to prevent side effects, rather than dealing with them afterward. This allows patients to complete chemotherapy without some of the more common side effects, like nausea and vomiting. Also, due to imaging advancements, we’re finding cancer earlier, rather than diagnosing advanced cancers with a poor prognosis. Women in their eighties never had mammograms in the past and now they’re more informed and start at an earlier age, which is a good thing. —Trish Tatrai, RN
What should women know about breast cancer screening?
The guidelines for breast cancer screening can be confusing for women because there are many groups offering differing recommendations. But every major physician organization—the American College of Radiology, the Society of Breast Imaging, the American Society of Breast Surgeons, and the American College of Obstetrics and Gynecology—all recommend women should begin annual screening at 40-years-old. Screening for normal risk patients should be with a mammogram, not any other tool that you see advertised. In terms of technology, we now have 3-D mammography, which allows the radiologist to actually scroll up and down through the breast tissue instead of only seeing the breast in 2 flat views. Using 3-D mammography, we can detect 40 percent more cancers in patients with dense breast tissue. —Lisa Allen, MD
Widespread screening mammography began in the 1980’s. In the past 30 years, 35 percent fewer women die from breast cancer. Keep in mind that all of the other imaging modalities that we have available such as ultrasound, MRI, and MBI (molecular breast imaging) are used in conjunction with mammography but do not replace mammography in screening for breast cancer. They are definitely helpful, however, in furthering the diagnosis or clarifying abnormalities we see on a mammogram. —Anne Moch, MD
How has cancer treatment changed since you’ve been in oncology?
My role on the breast cancer team is to treat patients with whole-body or systemic therapy. If breast cancer recurs, it often comes back in other organs, such as bone, lung, liver, or brain and is no longer primarily treated with surgery and/or radiation, but rather a chemotherapy or hormonal therapy. What has been so amazing is that new therapies can drastically alter the life expectancy of breast cancer patients. Recently, a young patient with a BRCA-1 genetic mutation and estrogen negative metastatic disease responded to a new therapy called Lynparza (or olaparib). She had no evidence of disease within 1 month of starting this oral therapy. She is incredibly positive for her overall prognosis with this novel agent now 4 months into therapy. A situation that would be deadly in a few weeks or months has now become treatable with pills. —Erica Linden, MD
Over the past several years, we’ve been able to reduce the number of lymph nodes that are removed at the time of cancer surgery. Previously, we would remove all the lymph nodes from underneath the arm to check for the spread of cancer cells, but this would leave the patient at risk of developing permanent swelling of the arm called lymphedema. In the mid 90’s, we began to only take out lymph nodes that mapped with a dye, as long as those nodes were negative. In the last few years, we learned that a patient with positive lymph nodes who gets chemotherapy before surgery and has a good response to it (the tumor shrinks and the nodes are no longer palpable) may also have only nodes removed with dye versus taking out all the nodes, which significantly reduces the chance of developing lymphedema. Fortunately, this has worked for quite a few of my patients. —Lisa Allen, MD
There are several advances that allow us to apply targeted radiation directly to the smallest tumor, all of which deliver better results for our patients. Advanced imaging allows us to define cancers more precisely so we are able to use targeted therapy to treat just the tumors. That helps because toxicity is minimized, and the patient has a better quality of life. Back in the day, the medical team would get exposed to radiation because we were directly inserting radioactive sources into patients. Now, we connect patients to use High Dose Rate (HDR) machines to directly treat tumors on an outpatient basis. Even for something like skin cancer, we can put treatment plaques directly on a patient’s skin using HDR. Technologies like CyberKnife allow us to treat very small tumors in the brain or body. In the brain, we can even treat non-tumorous conditions like trigeminal neuralgia and arteriovenous malformations (AVM’s) because we can target high doses and avoid surgery. —Shirnett Williamson, MD
How has genetic testing changed breast cancer care and prevention?
A decade ago, when it used to take more than six weeks to get results, genetic testing wasn’t as useful as it is today. Now we can get a result in anywhere from 2 to 3 weeks and integrate it into our decision making. Panel testing, which can test for 2 genes or 27 genes using the same blood specimen, has revolutionized what we do. We use it to help us figure out a patient’s preventive care and it may sometimes affect the cancer treatment. It can provide us with a roadmap of other cancers that we should screen or provide preventative surgery for. For example, the panel may show a PALB2 mutation, which indicates a moderate to high risk for breast cancer and can also predict for a higher risk of developing pancreatic cancer. We now also have targeted therapies for BRCA mutation carriers for ovarian and breast cancer, with the potential to help other BRCA cancers like pancreatic and prostate cancer. —Rona Remstein, RN
Over the years, which patients have been the most memorable?
As a surgeon, the relationship you develop with breast cancer patients is different than those with other surgical maladies because of the long-term follow-up. After a while, the patients become a part of our lives, so much so that even when they aren’t sitting in front of me or on the phone, I still find myself thinking about them. I can’t walk away from their physical and emotional needs. Sometimes, I’ll look at my patient schedule and there will be someone I haven’t seen in months or years and I’ll get excited because I know she’s doing well and I look forward to catching up with her. Unfortunately, there are also the times I see a patient on the schedule who I know isn’t doing well, and I need to do my best to keep her spirits up. —Lisa Allen, MD
I remember a woman I was treating for head and neck cancer. It was maybe at the beginning of my career and every time she saw me, she hugged me, she kissed me, and said, “I love you.” And I was like, “Oh, boy.” Well, it turns out she finished her radiation, she was having additional chemotherapy and then one day she brought us cupcakes made in the shape of angels—angel cupcakes. A week later, she died unexpectedly, which broke my heart because I had fallen in love with this person—we had bonded. That really hurt. That really hurt. —Shirnett Williamson, MD
There are times I sense a patient’s overwhelming fear at the same time knowing that she will survive and overcome her diagnosis. She may not believe it yet, but she is stronger that she knows. While we can’t take away the disease, we can help the patient through it. Over the course of her battle with cancer, each patient will reach deep into herself to find the strength necessary to get through to the other side. I love witnessing this transformation. Often, patients are different than they were before diagnosis. They have learned to fight, to live, and to value the little things that they may not have before. —Trish Tatrai, RN