The Journal - Spring 2017

Spring 2017
The Journal
Focus on Breast HealtH
INSIDE:
Breast Cancer Screening
New Imaging Options
Hidden ScarTM
Advances in Radiation Treatment The Medical Oncologist’s Approach
a publication of Cape Cod Health News


Good Health.
On the Go.
The Journal
AdmInIstrAtIon
Michael K. Lauf
President and CEo
mArkEtIng
Patrick Kane
senior Vice President marketing, Communications and Business development
EdItor
Robin Lord
Communications director
Art oPErAtIon
Deb Barnes
Art director & graphic designer
dEsIgn
95 North
PhotogrAPhy
Julia Cumes
ContrIButors
James Ylisela Jr.
ragan Consulting group
Jan Aubrey, RN
director Physician outreach/referral
Kelly Ahern
digital and social media specialist
Julie Badot
marketing director Emerald Physicians
Patricia Pronovost
marketing Program manager
Mary Pumphery
Administrative Assistant
Jeanne Sarnosky
regional director
Michael Seeley
Web & digital specialist
Cape Cod healthcare
88 Lewis Bay road, hyannis, mA 02601 p: 508-862-5177
e: [email protected]
on the web at www.capecodhealth.org
members of the Cape Cod healthcare system are Cape Cod hospital, Falmouth hospital, Cape Cod healthcare Foundation, the Visiting nurse Association of Cape Cod, CChC Lab services, Bourne health Center, Fontaine outpatient Center, rogers outpatient Center, stoneman outpatient Center, Wilkens outpatient medical Complex, oppenheim medical Building, Clark Cancer Center, davenport-mugar Cancer Center, heritage at Falmouth, JmL Care Center, Centers for Behavioral health, Cape Cod health network, medical Affiliates of Cape Cod and Emerald Physicians
on thE CoVEr
Anne morris, md, radiologist at Cuda Women’s health Center in hyannis
Download the Cape Cod Health News app from www.capecodhealthnews.com/mobile-app or from the App store.
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HEaltHcarE IN tHE fIrSt PErSoN
Michael K. lauf
President and cEo, cape cod Healthcare
Welcome to the inaugural issue of e Journal, an in-depth, sophisticated look at some of the most important and pressing health issues
facing our community. We created e Journal as an extension of our health news site, Cape Cod health news, in order to take you one step closer to the information and give you a detailed look at the science of healthcare from our experts and others in the eld.
In this edition, you will read about women’s breast health and the Cape Cod healthcare doctors who work with the latest technology to provide evidence-based care and treatment for women on Cape Cod. We chose to highlight
this service in order to demonstrate, through interviews with our physicians, nurses and patients, as well as through in-depth, informative articles, that women on Cape Cod can receive the best screening, diagnoses and treatment right in their own backyard.
here at Cape Cod healthcare, we are pushing the boundaries in terms of outcome-based medical care. leading the charge is our incredible team
of physicians, who are trained and experienced
in the latest procedures and treatments, and constantly stay informed about new treatment options for our patients.
nowhere is this expertise more evident than in our women’s breast health program at Cape
Cod hospital and Falmouth hospital. our radiologists, assisted by our technologists, nurses and support sta at Cuda Women’s health Center in hyannis and at Seifer Women’s health and Imaging Center in Falmouth, have some of the best training and skills in the state and are equipped with the latest technology to accurately screen and diagnose problems. e radiation and medical oncologists at Davenport-Mugar Cancer Center in hyannis and Clark Cancer Center
in Falmouth are second to none and provide academic medical center-level care right here on the Cape.
In this issue, you will read how Cape Cod hospital breast surgeons Kathryn Dalton, Do and Jill oxley, MD, FaCS are two of only three surgeons in the state who are currently trained in and performing the hidden ScarTM technique – part of an emerging eld known as “oncoplasty” – which preserves as much of the breast during cancer surgery as possible, while achieving the same outcomes.
also inside, medical oncologist Jennifer Crook, MD explains the exciting new therapies that are tailored to the type of cancer a woman may have. and radiation oncologist Molly Sullivan, MD describes how far radiation treatment for breast cancer has come in recent years.
I hope you enjoy this issue of e Journal, and that a er you are done reading it, you are better informed about women’s breast health and the tremendous advancements that have been made in the eld that we are using right here at Cape Cod healthcare.


105.0-116.5 123.3-125.8
116.6-123.2 125.9-135.3
135.4-148.4
Nationwide, 232,511 cases of invasive breast cancer in 2013 were diagnosed in women–an age-adjusted rate of 123.7 cases per 100,000 population.
In the state’s 12 counties with more
than 70,000 residents*, Barnstable County (Cape Cod) ranked No. 1 in 2013, with 156.4
135.1
1999
125.3 123.7
2009 2013
145.4 137.5 137.2
cases per 100,000 population.
156.4
In 2013, Massachusetts recorded 137.2 cases per 100,000 population, ranking 8th highest among the 50 states and the District of Columbia.
16.9-18.6 20.8-22.2
18.7-20.7 22.3-24.0
U.S.
Since 1999, mortality rates have fallen 22 percent nationwide and 33 percent in Massachusetts.
26.6
1999
22.2 20.7 2009 2013
U.S.
27.1
1999
22.4
18.3
2009 2013
Mass.
In 1999, Massachusetts ranked 16th highest among the 50 states and the District of Columbia, with 27.1 deaths per 100,000 citizens. In 2013, the state dropped to the sixth lowest in the nation, at 18.3.
1999 2009
Mass.
2013
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Breast cancer on the Cape: Too many cases, but fewer deaths
The ght against breast cancer in the U.S. is a tale of stubborn resistance yet signi cant progress. Both stories play out prominently in Massachusetts and, speci cally, on Cape Cod – one of many reasons Cape Cod Healthcare has taken a leading role in early detection and the latest advances in treatment.
16.3
In the state’s 12 counties with more
than 70,000 residents*, Barnstable County (Cape Cod) ranked 6th in 2013, with 20.2 deaths per 100,000 population.
20.2
18.1
Sources: Centers for Disease Control and Prevention, National Cancer Institute, State Cancer Registry. Notes: Female breast, invasive cancer, age adjusted. 2013 data latest available. Mortality rates by county are for 2009-2013. Cancer rates: Data for the U.S does not include Nevada. *The two other Massachusetts counties–Nantucket and Dukes–recorded higher mortality rates because of their signi cantly smaller populations.
By Bob Zeni
119.6
126.6 131.6 129.2
129.6
137.8 139.9
126.0
144.9
125.3 139.2
156.4
181.7
116.5-123.2 123.3-125.8 125.9-135.3 135.4-148.4 148.5-164.0 164.1-184.0 184.1-204.0
198.0
Incidence rates declined after peaking in the late 1990s, but have remained largely unchanged since then.
Breast cancer mortality rates have fallen steadily since 1999, with signi - cant declines in Barnstable County.
17.4 22.2 20.7
21.7 18.1
19.8
21.0
19.9 20.5
16.3-18.1 18.2-19.9 20.0-20.5 20.6-21.0 21.1-22.2
20.2


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any woman will tell you that breast health is of utmost concern throughout her life. Breast cancer is the most common cancer
in women in the United States, and one in eight will be diagnosed with it during her lifetime. on cape cod, the issue is particularly acute, due to our older demographic (breast cancer occurs mostly in older women) and our highest-in-the-state rates of the disease. But, there is also much reason for optimism. New, targeted therapies and treatment mean that women (and men) diagnosed with breast cancer have a much greater chance of cure and/or management of the disease.
at cape cod Healthcare, a multi-disciplinary team of highly skilled physicians, nurses, technologists, social workers
and others are providing the latest and best breast health care. turn the page to learn how.


coNtENt
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raDIoloGY
SUrGErY
GENEtIc tEStING
1
Picture [near] Perfect
Next Generation imaging technology reduces false positives for breast cancer and improves detection.
4
rethinking Breast cancer Screening
Ultra FAST Breast Magnetic Resonance Imaging gives a clearer picture.
9
can You Predict Your
risk of Getting cancer?
A new test can calculate your risk.
11
Not Your average Board Meeting
Weekly tumor board draws doctors, nurses, technicians and others to devise a battle plan for ghting cancer.
12
Hidden Scar Surgery
A new surgical trechnique helps women beat breast cancer while minimizing the disheartening impact on their appearance.
16
a Surgeon finds Her calling
Cape Cod Hospital surgeon Kathryn Dalton, DO fell in love with breast surgery during her medical residency program.


raDIatIoN tHEraPY
MEDIcal oNcoloGY
19
24
Getting Personal
Oncotype testing and other advances allow oncologists
to design speci c treatment for each breast cancer patient.
targeted treatment
Innovations in radiation oncology deliver more precise therapy, reducing risk for breast cancer patients.
features
29 Patient Experience
30 Q & A with Pat Ryan-Blanchard, NP
31 The Last Word
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––––[ Radiology ]––––
Kenneth L. Caswell, MD, chair of the radiology department at Falmouth Hospital


PIctUrE [NEAR] PErfEct –––––––––
Next generation imaging technology reduces false positives for breast cancer and improves detection.
By Claudia Dolphin
e facts are in. Since the practice of routine mammo- grams began in the early 1990s, the mortality rate in the united States has decreased by more than 30 percent.
Despite this good news, mammography is under new scrutiny. e gold standard two-dimensional (2D) technology has been criticized for producing too many false positive ndings in women with normal breast tissue, and for missing some cancers, particularly in women with dense breasts.
e technology also has been faulted for causing emotional harm to women who must undergo addi- tional testing. is is especially true in younger women, whose dense breast tissue makes detection di cult.
“about 10 percent of women who get mammograms are called back for additional follow-up. of these,
1 to 2 percent goes on to have biopsies,” said Cape Cod hospital radiologist anne Morris, MD.
Two advancements in imaging technology o er newer ways to more accurately diagnose true cancers, especial- ly when used in combination with traditional 2D mam- mography: three-dimensional (3D) mammography, or tomosynthesis; and FaST Magnetic resonance Imaging (MrI). Patients at Cuda Women’s health Center in hyannis and Seifer Women’s health and Imaging Center in Falmouth have access to both technologies.
an extra Dimension
Tomosynthesis is a next-generation digital mammo- gram technology. like conventional 2D screening,
it uses X-rays to produce images of breast tissue. however, unlike 2D mammography, the 3D machine moves around the breast, taking more pictures at di erent angles.
Similar to a CT scan, the array of pictures creates a multi-layered, in-depth view. e extra dimension helps to uncover abnormalities in a way that a at image cannot, said Dr. Morris.
Women undergoing routine screening with tomosyn- thesis may not notice any obvious di erences from conventional 2D mammography. Preparation for the test is exactly the same and breast compression is still used to capture breast tissue images. e exam takes a bit longer to capture the additional pictures.
With the added dimension, however, tomosynthesis reveals subtle changes in breast tissue that might have previously eluded detection.
“Tomosynthesis is really great at detecting calci cations and distortion (abnormally appearing tissue), which can be signs of cancer,” said Dr. Morris. “It is also better at nding cancer in women with dense breasts.”
In 2015, Massachusetts enacted a law that requires all providers of mammography services to inform a patient in writing if, a er the mammography is interpreted, it is determined that the patient has dense breast tissue.
“Cancer can look like normal breast tissue. When you have really fatty breast tissue, we can easily pick out
a new little patch of tissue because it wasn’t there be- fore,” said Dr. Morris. “But when you have really dense breasts, a new little wisp is hard to detect.”
Dense breast tissue, in particular, raises the risk for breast cancer, because abnormal changes hide inside the layers of tissue, making it hard to detect using conventional 2D screening mammography.
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“Studies have demonstrated that 3D mammography increases the detection rate of cancer, while reducing the number of false posi- tives,” said Salvatore Viscomi, MD, chairman of the Department of radiology at Cape Cod hospital. “It picks up the cancers we want to pick up, at a much earlier time, which is our goal.”
It also reduces false positive nd- ings so fewer women are being called back unnecessarily.
not only is tomosynthesis more accurate in detecting abnormalities, it will also determine the size, shape and location of them. It makes it easier to distinguish more serious cancer from non-invasive ones like ductal carcinoma in situ (DCIS), as well.
How mucH Better?
a study published in a 2014 edi- tion of the Journal of the American Medical Association summarized the work of investigators seeking
answers to that question. a er reviewing data collected from 13 di erent sites across the country, they observed a 29 percent increase in the overall cancer detection rate despite a 15 percent decrease in recalls. In other words, there were fewer false positive ndings and a signi cant increase in detection of actual cancer.
e study was designed to compare the performance of breast can-
cer screening before and a er the introduction of tomosynthesis. an analysis of 454,850 examinations looked at the:
• Recall rate
• Cancer detection rate
• Positive predictor value (PPV) for recalls a er screening or biopsy. PPV measures the accuracy of a test in nding cancer.
Metastatic cancers, or those that spread from another part of the body, were not part of the analysis.
is tomosyntHesis rigHt For every woman?
Cape Cod healthcare now uses tomosynthesis as the standard protocol for screening mammog- raphy. however, there are a few circumstances where conventional 2D mammography may still be preferred. Women who have a tremor or older women who are unsteady on their feet may do better with a conventional 2D mammo- gram, Dr. Morris explained.
“Tomosynthesis takes more pictures than conventional 2D mammogra- phy. is means having to stay on your feet a little longer,” she said.
and, unlike a conventional 2D exam, tomosynthesis is a bit more sensitive to motion.
Finally, some women may nd that their insurance company may limit coverage of screening to conven- tional 2D mammography. In the rare instance that this happens, Cape Cod healthcare only charges an extra $50 for tomosynthesis.


Fast mri
Breast imaging with MrI has been available for some time, but it is rarely used as a screening tool. Despite being the most sensitive test there is, the test takes a long time to administer and is expensive.
But an abbreviated version of MrI, recently developed, is now available upon request at Cape Cod health- care for breast screening. Known as FaST MrI, it is rarely covered by insurance, so women considering this exam should understand how it works and how it di ers from the traditional full-length version.
MrI uses magnetic energy and contrast to create images. unlike mammography, which focuses on anatomical density, distortion and secondary changes (calci cations), MrI detects vascular activity and in ammation that are associated with cancer.
In contrast to mammography, which uses radiation to generate a picture based on breast density, MrI creates a blood ow map using magnetic energy.
“Tumors need blood to thrive and grow, so when they are present, they come with a blood supply that isn’t ordinarily there,” explained Dr. Morris. “ e contrast used
in MrI gets taken into the blood vessels within the breast, where
it is traced. e image reveals the uptake of the contrast into the blood supply. When it shows up in unexpected places, it is a sign
of cancer.”
a traditional screening MrI study takes 20 to 30 minutes to admin- ister. It is typically reserved for women with an elevated risk for breast cancer due to:
• Family history
• A genetic mutation
• Chest radiation from lymphoma treatment at a young age
• If it has been determined that your lifetime risk of developing breast cancer is greater than
20 percent
FaST MrI is an abbreviated version of the standard MrI, taking less than ve minutes to complete a er contrast is injected. only essen-
tial image sequences are included, which accounts for the reduction in time.
“For screening, other sequences are needed to characterize what you are seeing. FaST MrI shows you if there is any enhancement (uptake of contrast),” said Dr. Morris. “If there is no enhance- ment, then you are done. however, if there is enhancement, we may order additional testing, including a full MrI.”
Most insurances will pay for a full MrI if there is evidence of cancer found on FaST MrI.
For women with dense breasts, the knowledge of the limitations of conventional mammography in nding cancer can be unsettling. receiving a noti cation of density, as required by law, may be more than one can bear. Without insur- ance coverage, the out-of-pocket cost for a full MrI exam is o en out of reach.
“For the FaST MrI, we are able to o er it to more women, which is the goal,” said Dr. Morris. “We charge $450 which, for some women, is less than the deductible for a full MrI.” | tJ
––––[ Radiology ]––––
“Studies have demonstrated that 3D mammography increases the detection rate of cancer, while reducing the number of false positives.” - Salvatore Viscomi, MD
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rEtHINKING BrEaSt caNcEr ScrEENING
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Ultra faSt Breast Magnetic resonance Imaging gives a clearer picture.
By Elizabeth A. Morris, Memorial Sloan Kettering Cancer Center, New York, NY
Breast cancer screening is once again controversial. It is hard to miss headlines stating that mammography is an imperfect screening test, missing biologically aggressive cancers and picking up indolent cancers that do not need treatment.
We, who have devoted our lives to ghting breast cancer, have long been aware of the limitations of mammography, especially in women with extremely dense breast tissue. Mammography, for all its limits, is still the only test proven to decrease mortality in multiple randomized controlled trials and through experience with population-based screening. Detect- ing small cancers on imaging before they are palpable improves survival, as well as treatment options. Yet, questions persist. Does the test pick up too much and still not enough; is it wrong too o en?
Perhaps relying on anatomic density, distortions, and secondary byproducts (calci cations) of cancer on mammograms is not enough; we need a better test. as with oncologic treatment, oncologic imaging these days relies more on functionality than anatomy. Screening for breast cancer needs to catch up to this paradigm to better image clinically signi cant malignant changes. e quest for improvement in sensitivity and speci city of breast cancer screening is precisely why new tests are being developed by the radiology community.
Traditional two-dimensional digital mammography is being supplanted by three-dimensional digital breast tomosynthesis (DBT), and contrast-enhanced digital mammography (CeDM) is a test that images vascular- ity as well as anatomic abnormalities. Screening breast ultrasound is an increasingly requested supplemental test in women of all breast densities.
luckily, we have had the most sensitive test for breast cancer detection at our disposal for decades: breast magnetic resonance imaging (MrI). and it rarely misses invasive breast cancers. Breast MrI can tell us functionally how a lesion is behaving as the images re ect the tumor’s molecular/genetic characteristics. Breast MrI does not use radiation, cannot induce can- cers, and is exceedingly safe even though it does require intravenous contrast.
unlike mammography, which generates images based on the density of tissue, MrI creates a “blood ow map,” detecting tumor neovascularity and peritumoral in ammation; this explains its high sensitivity. ere- fore, unlike mammography, MrI relies on alterations that correlate with proliferation and possibly metastatic potential. as medical oncology moves into new thera- pies based on oncogenetics and greater understanding of cell biology, the evolution in imaging is similarly a function of our new understanding of tumor biology.
Breast density legislation is now present in many
states in the united States. Women and their physi- cians are requesting supplemental screening above
and beyond mammography. It has perplexed many of us in the breast imaging community how screening breast ultrasound appears to be accepted for supple- mental screening whereas breast MrI is not. ere is not a single study that shows ultrasound detects more cancer than MrI. In fact, studies show that a signi cant number of cancers are missed on screening ultrasound but are readily found with MrI. Importantly, false posi- tives are much greater with screening ultrasound than with screening MrI. In fact the likelihood of nding a cancer at biopsy performed on the basis of ultrasound screening is less than 10%, whereas it is approximately
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––––[ Radiology ]––––
Salvatore G. Viscomi, MD, chair of the radiology department at Cape Cod Hospital.


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Salvatore G. Viscomi, MD, chair of the Cape Cod Hospital Radiology Department, recognized the value of FAST MRI
for women on Cape Cod, and was instrumental in bringing the technology to Cape Cod Healthcare.
30% with MrI. a much higher per- centage of biopsies from screening MrI turn out to be cancer.
False-positive rates are important in the choice of a screening test. With experience and training, it has been shown that the false-positive rate of MrI can be lower than mammography.
of course no technology is perfect, and not all cancers are detected on MrI. It is exceedingly rare for MrI to miss an invasive cancer as most are associated with neovascularity. Invasive lobular carcinoma that may not be highly vascularized may be missed (although the vast numbers of invasive lobular carcinomas are indeed detected). Furthermore, the invasive cancers that are detected on MrI are small and mostly node negative.
although it is impossible with our current knowledge to know which of these invasive cancers is bio- logically aggressive and potentially metastatic, most breast experts would err in favor of treatment. e type of cancer that MrI most o en misses is DCIS, although it seems that most of these are also MrI detectable. MrI may not detect DCIS that presents as calci - cations on mammography because the DCIS may not have associated vascularity. DCIS is controversial and has been targeted as one of
the problems with mammography causing unnecessary treatment. Previous studies have shown that MrI sensitivity for DCIS detection increases from 80% for low grade to 98% for high grade, whereas
the sensitivity of mammography actually decreases as DCIS grade
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increases, dropping from 61%
for low grade DCIS to 35% for high-grade DCIS without necrosis. an interesting theory is that MrI appears to pick up the more biolog- ically relevant DCIS, whereas mam- mography is geared for detection of the less biologically relevant.
e decision makers in detecting, preventing, and treating breast can- cer are the patient and her physi- cian. ey know that screening can save lives. e preponderance of evidence says so. e breast cancer death rate was virtually unchanged until the 1990s when regular mam- mography was introduced and mortality dropped by 30%. Despite this, too many women—mothers, sisters, daughters, and friends—are still dying of breast cancer, even when screened. We are not picking
up some of the biologically relevant cancers with mammography.
another test that builds on the success of mammography and that relies more on tumor biology and functionality, not just anatomy,
is called for. abbreviated FaST breast MrI is a huge step forward in breast cancer screening and
may pave the way for future tests based on functionality rather than anatomy, and with better patient access, such as contrast-enhanced digital mammography. FaST breast MrI, with its ability to detect early neovascularity, could potentially make a big impact on identifying biologically relevant cancers that are fatal and currently missed by screening. Data clearly demon- strates that FaST breast MrI could be the standard for breast cancer
screening: it is safe, does not induce cancers, and can nd more can- cers than mammography. We can and must do a better job of linking women with the screening test that can save their lives. | tJ
Reprinted with permission 2014 American Society of Clinical Oncology. All rights reserved. Morris, E et al: J Clin Oncol Vol. 32 No. 22 (August 1, 2014): pp 2281-2283
Cuda Women’s Health Center in Hyannis
Seifer Women’s Health and Imaging Center
in Falmouth
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––––[ Genetic Testing ]––––
Kathryn Dalton, DO, director of breast services, Cape Cod Healthcare


caN YoU PrEDIct YoUr rISK of GEttING caNcEr?
–––––––––
With just a simple saliva sample, a new test can calculate the danger for you—and your family.
By Claudia Dolphin
angelina Jolie made headlines in 2013 by revealing she had tested positive for the BrCa1 mutation, which put her at high risk for developing both breast and ovarian cancer. She chose to have both of her breasts, ovaries and fallopian tubes removed as a preventive measure.
as a result of her candor, today BrCa1 is one of the best-known cancer genes. But there are many others, and a new genetic test can now calculate your risk for breast and other cancers with a certainty of 99.92 percent.
Together, BrCa1 and BrCa2 mutations account for about 20 to 25 percent of hereditary breast cancers, and 5 to 10 percent of all breast cancers, explained Kathryn Dalton, Do, a surgeon who is also director of breast services at Cape Cod healthcare. In addition, BrCa1 and BrCa2 account for about 15 percent of ovarian cancers, overall.
“ ere are 28 di erent genes that we look at that are associated with eight di erent cancers to determine a person’s individual risk of developing cancer,” she said. “What we are looking for are harmful mutations, or changes in the genetic code, that have been linked to the development of certain cancers.”
Cape Cod healthcare’s high risk Cancer Genetic assessment program began in october 2015. Since then, more than 16,000 patients have been referred to Dr. Dalton and her associates for screening and monitoring.
Some of the patients have undergone preventive breast or ovary surgery. Most of the results have been nega- tive. But many of the patients are still considered high risk, depending on their personal and family history, and need close follow-up.
“not all people with a mutation develop cancer,”
Dr. Dalton added. “But when one is identi ed, we can monitor and screen the patient more closely, identify cancer earlier and prevent cancer from happening in the future.”
Maritess Seymour, a 36-year-old woman from Chatham, had a positive result for BrCa2. She had previously been diagnosed with breast cancer and undergone a bilateral mastectomy.
“Dr. Dalton recommended that I be screened for genetics,” Seymour said. “She helped me learn what might happen to me in the future. e biggest concern was my risk for developing ovarian cancer. I also wanted to know what it meant for my 8-year-old daughter’s risk.”
Seymour’s positive test raised her lifetime risk of developing ovarian cancer by 40 percent. She opted for the same course of treatment as Jolie: surgical removal of her ovaries and fallopian tubes.
For hereditary cancers, or ones that run in families, knowing your risk can help guide preventive treatment options and future care. It can also help inform your family members about their own potential risk.
eight cancers have known mutations linked to increased risk: breast, colorectal, endometrial, gastric, ovarian, melanoma, pancreatic and prostate. Inherited mutations account for 5 percent to 10 percent of all cancers.
Dr. Dalton predicts other cancers will be added to the list in the future, as genetic research continues.
––––[ Genetic Testing ]––––
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all women who come to Cuda Women’s health Center in hyan- nis and Seifer Women’s health
and Imaging Center in Falmouth are screened for the possibility of genetic cancers, which includes a consultation to review their family history. red ags, where there is a personal or family history, include:
• Cancer diagnosed at age 50 or younger
• Multiple cancers that have occurred independently in the same person
• Cancer that occurred in both sets of paired organs, such as both breasts or ovaries
• Several close blood relatives diag- nosed with the same cancer (for example, grandmother, mother and daughter with breast cancer)
• Rare cancers, like breast cancer in a man
“We try to make the process as easy and painless as possible,” Dr. Dalton said. “our o ce will do an individ- ualized risk assessment, and if there is ample concern, we will do all of the necessary paperwork.”
Insurance may cover all or part of the $4,000 cost of the test in many cases, especially where the risk criteria has been met, and Dr. Dalton said her o ce will even write a letter of necessity to a pa- tient’s insurance company.
Medicare currently will not cover the cost of testing in the absence of a cancer diagnosis, she said.
Genetic testing results become part of your medical record, but they re- main private under the 2008 federal Genetic Information nondiscrimi- nation act, known as GIna. and there are additional state protec- tions, including in Massachusetts.
Seymour had detected her own cancer through a self-breast exami- nation, but she didn’t immediately seek treatment. She sees genetic testing as one way for her to take a positive step at preventing an additional cancer from developing.
“ roughout the experience, I am sorry that I waited so long to go
to the doctor,” she said. “I initially ignored the symptoms, which is something I now regret. But, having a genetic test to understand my fu- ture risk is something positive that I could do for myself and my family.
“My advice to anyone with con- cerns is don’t wait until it’s too late. You have nothing to lose. It is a positive step you can take for your own health.” | tJ
––––[ Genetic Testing ]––––


Not YoUr avEraGE BoarD MEEtING
–––––––––
Weekly tumor board draws doctors, nurses, technicians and others to devise a battle plan for ghting cancer.
By Susan Moeller
at 7 a.m. on a Wednesday, the conference room at Cape Cod hospital is quickly lling up with about 15 doctors, a nurse practitioner, lymphedema rehab thera- pist, ultrasound technician, and administrative sta .
at 7:05, their eyes turn toward one of two large, 42-inch TV screens in the room that displays a mammographic image of a woman’s breast, a so ly rounded black and white hillock that hosts a 10-millimeter cancerous tumor.
e breast belongs to a 63-year-old woman who came to the Cuda Women’s health Center in hyannis for
a routine mammogram. She remains nameless during the meeting. But her future treatment rests with
these members of the breast tumor board, a mix of medical sta who will consider how best to treat her particular cancer.
e breast tumor board is one of several tumor boards at the hospital and meets weekly. e various medical disciplines represented at the table read like a cancer center directory: radiology, pathology, surgery, reha- bilitation and lymphedema therapy, medical oncology, radiation oncology, plastic surgery and research.
also at the table is hester Grue, who organizes the tumor board meetings and runs the tumor registry, required for reporting state and national cancer statistics and for research. She is the keeper of more than 10,000 tumor cases of all kinds going back to 1975 and is the rst contact physicians have with the board.
Cases usually reach the breast cancer board a er a woman has had a mammogram and core biopsy and has a positive identi cation of cancer.
“ e board brings a di erent perspective on manage- ment that might not be thought of if everyone operated in an isolated way,” said James Chingos, MD, FaCP, who started the tumor board in the late 1980s.
Cases that come before the tumor boards are rst pre- sented by the clinician who is taking care of the patient, or a nurse practitioner from Cuda Women’s health Center in hyannis. next, the radiologist – in this case Charles Williams, MD – shows all relevant imaging ndings, including any mammograms, ultrasounds or MrIs that may have been done.
Jill oxley, MD, FaCS, a breast surgeon and the board’s moderator, adds that the tumor is in ltrating the woman’s milk duct and that it’s estrogen- and proges- terone-positive, meaning it thrives on hormones. She also notes that the patient has a history of breast, colon and pancreatic cancers in her family and that she wants “breast conservation,” meaning, a lumpectomy rather than a mastectomy.
e discussion ends with a recommended lumpectomy followed by radiation and then endocrine therapy, meaning the patient will probably be given tamoxifen or an aromatase inhibitor to lower the levels of hor- mones that have been feeding the tumor.
and then it’s on to the next case, and the next patient’s battle plan. | tJ
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HIDDEN Scar SUrGErY
–––––––––
a new surgical technique helps women beat breast cancer while minimizing the disheartening impact on their appearance.
––––[ Surgery ]––––
By Nick Lanyi
Kathryn Dalton, Do and Jill oxley, MD, FaCS save lives without leaving much of a mark.
Dr. Dalton, who is director of breast services for Cape Cod healthcare, was the rst physician in Massachu- setts to be certi ed in hidden Scar SurgeryTM – a type of oncoplastic surgery that uses traditional plastic surgery techniques combined with breast surgical oncology – to minimize the cosmetic impact of surgery.
Fellow breast surgeon Dr. oxley has also received hid- den Scar certi cation. Together, she and Dr. Dalton represent the rst hidden Scar Center of excellence in Massachusetts.
until recent years, the standard of care for many breast cancer tumors remained a mastectomy. now the trend is moving towards “breast conservation,” in which even large or multiple tumors can be safely removed with a lumpectomy, retaining most of the breast, followed by radiation to destroy any remaining cancer cells.
even so, many surgeons still take the most direct path to the tumor, which can leave unsightly scars and deformity at whatever part of the breast held the cancer.
oncoplastic-trained surgeons look for ways to remove tumors while restoring the natural appearance of the breast shape and maximizing cosmetic e ects of these o en life-saving operations.
“Breast cancer is now so treatable. People are going to live for many years a er their breast cancer diagnosis and treatment,” Dr. Dalton said. “I want them to not only survive but to feel happy about their body... I tell my patients they’ll be ‘beach ready.’ and they love that.”
among the oncoplastic techniques used by Dr. Dalton and Dr. oxley are methods of rearranging and sculpt- ing the tissue inside the breast to close the holes le a er the tumor is removed. Without such techniques, surgery tends to leave a sinking or dimpling appearance on the surface of the breast.
Deborah Young-Kroeger, who lives in South Dennis, was one of Dr. Dalton’s oncoplastics patients at Cape Cod hospital. a mammogram and an MrI scan found two lumps in Young-Kroeger’s le breast. Doctors at Dana-Farber Cancer Institute recommended following protocol: remove the entire breast.
Dr. Dalton proposed a di erent course.
“She said, ‘no, I can do this. I can get both lumps and save the breast and give you a mini-reduction. Worst case scenario we would do mastectomy but we can at least give it a try,’” Young-Kroeger recalled. “She gave me a choice. I said, ‘If you can save the breast and not have me look hacked up, I’d love that.’
“I didn’t want a reminder of this for the rest of my life.”
Young-Kroeger’s november 2015 oncoplastic lumpec- tomy involved axillary and periareolar incisions. She’s more than pleased with the results. “I have a nipple.
I have something that looks, without a lot of close scrutiny, like a regular breast. It healed up beautifully, no issues at all.”
HiDing tHe scar
using hidden Scar, when the incision heals it’s di cult to see where it was. using oncoplastic techniques the breast’s shape, size and contours are close to normal, and the nipple, areola and surrounding breast tissue are una ected.


––––[ Surgery ]––––
Jill Oxley, MD, FACS, breast and general surgeon, Cape Cod Healthcare


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Oncoplastic-trained surgeons look for ways to remove tumors while restoring the natural appearance of the breast shape and maximizing cosmetic bene ts of these often life-saving operations.
Traditional lumpectomies involve incisions on the surface of the breast just above or near the tumor. Instead, the surgeon makes an incision at a nearby natural crease or line, then uses surgical tools to li the skin and excise the tumor from that entry point.
e surgeon typically makes the incision in one of three places, depending on the tumor’s location and other factors, such as the density of the breast: an axillary incision near the armpit, a peri- areolar incision at the edge of the nipple, or an inframammary
fold incision where the bottom of the breast meets the chest – “where the underwire would be if you were wearing a bra,” Dr. Dalton explained.
In all three cases, she carefully aligns the incision with the body’s natural contours. When the scar heals, it is visible only at close ex- amination and much more hidden than a scar across the surface of the breast would be.
hidden Scar surgery is made pos- sible by surgical retractors with lights to illuminate the breast cavity under the skin. e lighted retrac- tors help the surgeon see clearly what she’s doing as she takes the longer path from incision to tumor. and that longer path means the surgery isn’t as easy as a traditional lumpectomy. “hidden scar surgery can be more technically challenging and can take a little longer to make it look perfect,” Dr. Dalton said. “But it’s worth it to my patients.”
––––[ Surgery ]––––


––––[ Surgery ]––––
Patients requiring a mastectomy can also bene t from new cosmetic options like the nipple-Sparing Mastectomy. is technique,
which surgeons use in coordination with plastic surgeons, preserves the skin, nipple and areola while the breast tissue underneath is removed and replaced with an implant using a hidden scar incision.
Patients can also opt for a breast reduction (mammoplasty) or li (mastopexy) with their lumpecto- my. ey can also elect for surgery on the una ected breast, to make their breasts symmetric, either at the time of their breast cancer surgery or a er their treatment is over. Surgical planning for these patients is “custom-made” with a multidisciplinary team approach and coordination with plastic sur- gery and breast surgeons.
Patients had to travel to Boston for these more advanced techniques before Drs. Dalton and oxley began applying them on Cape Cod. ross-leidy Tejada said she was grateful to have her treatment in her own community, surrounded by her loved ones. She had a nipple-sparing double mastectomy in March 2016 with Dr. Dalton
and Michael lo redo, MD, a plastic surgeon. anks to their e orts, Tejada says, she feels good when she looks at herself in the mirror.
“It’s part of you as a woman,” Tejada, who lives in West Yarmouth, told Cape Cod health news. “You’re used to seeing breasts on you. It impacts your feelings, the way you see things and how you feel.”
oncoplastic training can also help a surgeon remove more tissue from around the tumor – the sought-
a er “margin” to ensure that all the cancer is excised – because Dr. Dalton knows the dead space can be e ectively and attractively closed a erward, she said.
Studies have shown that oncoplas- tics, and the hidden Scar technique, speci cally, maintain the same oncologic success and outcomes as traditional procedures.
oncoplastics was developed in europe in the 1990s, but it remains the exception among u.S. surgeons.
“For doctors who have practiced a certain way for a long time, it’s hard to change,” Dr. Dalton said. “onco- plastics is still evolving. But more doctors nationally are learning the techniques and becoming comfort- able using them.” | tJ
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Instead of making an incision above or near the tumor, as in traditional lumpectomies, surgeons using Hidden Scar make the incision at a nearby natural crease or line, such as at the edge of the nipple, at the bottom of the breast or near the armpit.
Periareolar Incision Inframammary Incision transaxillary Incision


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a SUrGEoN fINDS HEr callING
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“It’s very rewarding. You see patients ght through their cancer. You see them through their journey from start to nish. I’ve cried with them, and hugged them, and become friends with them.”
By Nick Lanyi
Breast surgeon and director of breast services for Cape Cod healthcare, Kathryn Dalton, Do grew up on the north Shore of Massachusetts and attended medical school at the university of new england. She started a surgery residency at henry Ford Wyandotte hospital in Michigan intending to specialize in cardiothoracic surgery or transplant surgery.
But, as the hospital’s only female general surgeon at the time, she was encouraged to work on breast cancer cases. In her last year of residency, she completed a “mini-fellowship” focusing on breast surgery – and fell in love with the work.
“It’s very rewarding. You see patients ght through their cancer. You see them through their journey from start to nish. I’ve cried with them, and hugged them, and become friends with them.”
She had personal reasons as well. her mother and grandmother were both diagnosed with breast cancer and that made her especially interested in saving women’s lives and helping them feel better about the results.
“I decided I wanted to excel at breast cancer surgery
– to learn the latest and greatest. So I took an oncoplas- tics course and hidden ScarTM course.”
To put what she’d learned into practice, Dr. Dalton wanted to focus the majority of her practice on breast surgery and become an active member of her commu- nity. “I really wanted to make a di erence inside and outside of the or and live in a great place to raise my family. e Cape was a dream come true.”
Katelyn Soares, a third-year medical student at the university of Massachusetts, said she was inspired a er spending two weeks with Dr. Dalton last fall. “She was so invested in her patients, and they trusted her so much – in a way that I hope to inspire people to trust me in the future.”
Soares was struck by the unique way Dr. Dalton helps explain medicine in terms anyone can understand.
“She has some pretty cool ways of describing the surgery and the tumor to the patient,” she said. “In lumpectomies, you want to achieve a certain margin
of cancer-free tissue. Dr. Dalton tells patients that
the tumor is the cake and the margins are icing around the cake. If you don’t have enough icing, it’s not an acceptable cake. You need the icing.”
Word about the hidden Scar technique and the surgeons at Cape Cod hospital is starting to spread: so far, two breast cancer patients have come from o Cape for treatment at Cape Cod hospital.
“I always tell each breast cancer patient, we’re best friends for life,” Dr. Dalton said. “I say, I’m going to keep an eye on you every year until you’re 95 years old!”
In addition to her busy schedule in the operating room and seeing patients (Cape Cod healthcare averages about 350 newly diagnosed breast cancer cases a year), Dr. Dalton teaches hidden Scar techniques to other doctors. She also works with organizations in the community that are working to improve the health of Cape Codders. | tJ
––––[ Surgery ]––––


––––[ Surgery ]––––
“I want them to not only survive but to feel happy about their body...I tell my patients they’ll be ‘beach ready.’ And they love that.”
- Kathryn Dalton, DO
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––––[ Radiation Therapy ]––––
Molly Sullivan, MD, radiation oncologist, Cape Cod Healthcare


tarGEtED trEatMENt
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Innovations in radiation oncology deliver more precise therapy, reducing risk for breast cancer patients.
––––[ Radiation Therapy ]––––
By Nick Lanyi
When Molly Sullivan, MD, was a Georgetown medical student, she read something that changed her life.
“Whenever I went to see a patient and looked over the chart, the radiation oncologist’s note was always the best,” she said.
She soon discovered why. Doctors who treat cancer using radiation therapy need a deep understanding of human anatomy to make sure they know how close the cancer is to healthy organs and tissue. ey typically perform thorough and accurate physical exams. and they combine their knowledge of the human body with an expertise in physics.
Dr. Sullivan was hooked. For the past decade, she’s been a radiation oncologist at the Davenport-Mugar Cancer Center at Cape Cod hospital and the Clark Cancer Center at Falmouth hospital. She is part of a team of specialists using the latest innovations to deliver the most precise radiation treatment, signi cantly lowering the risk to cancer patients.
Since the early 1900s, doctors have been using radiation therapy to kill cancer cells by creating small fractures
in their Dna, preventing those cells from growing and reproducing. But the treatment has always been a two- edged sword; radiation also can harm healthy cells near the cancer and lead to other medical complications.
Dr. Sullivan and her team employ the latest technolo- gies – from CT imaging to a more sophisticated means of shaping the radiation beam – to help them design and deliver treatments never before possible.
“With newer machines, we can change the shape of the beam in almost any con guration,” including curved beams and irregular shapes, donut-shaped e ects and many others, Dr. Sullivan said. “and the machines can deliver from the front, back, le , right and o -axis to hit the target very precisely.”
HigHer Doses, Fewer sessions
radiation therapy is common for patients diagnosed with breast cancer. Most patients have tumors that
are surgically removed and then receive accompany- ing treatment – chemotherapy, hormone treatment or radiation therapy – to eliminate microscopic traces of cancer that may remain, reducing the chance of recur- rence.
irty years ago, post-surgical radiation treatment re- lied on a two-dimensional picture provided by X-rays. When a patient visited the hospital for treatment, she would lie on a hospital bed while technicians slid heavy lead blocks in and out of the machine to shape the beam. e machine itself couldn’t shape the beam; tech- nicians had to change the heavy blocks each time they aimed the beam at the patient from a new direction.
While targeting the proper area as precisely as possible, the process risked delivering toxic radiation to sur- rounding tissue, forcing doctors to use smaller doses and necessitating more sessions. a course of radiation treatment commonly involved six to seven weeks of radiation, ve days a week – a serious disruption for patients.
even with those precautions, healthy tissue o en was irradiated. Patients receiving radiation therapy for breast cancer, for example, tended to have higher rates of lung in ammation; patients whose le breasts were irradiated had higher rates of cardiovascular disease.
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“With newer machines, we can change the shape of the beam in almost any con gura- tion...and the machine can deliver from the front, back, left, right and off-axis to hit the target very precisely.
- Molly Sullivan, MD
e most important innovations
in radiation therapy occurred in
the mid- to late-1990s, when new imaging technology began o er- ing three-dimensional images of tumors and tumor beds. next, more powerful computers and better so - ware created superior algorithms to help doctors compare millions of alternatives instantly to design the treatment plans best suited to a patient’s need. Computers now handle all the calculations, result- ing in far greater precision than in previous years.
In recent years, new technology gave doctors the ability to shape the radiation beam, leading to even more targeted treatments. is new approach is known as inten- sity-modulated radiation therapy (IMrT). en the machines that
deliver the radiation – called linear accelerators – added on-board
CT imaging, so that setting up the patient and delivery are seamlessly integrated. is is called image- guided radiation therapy (IGrT).
Greater precision means lower
risk to healthy tissue, which allows the radiation therapy team to use higher doses of radiation to kill cancer cells. at means fewer sessions are needed, reducing fatigue and stress for patients. at Cape Cod healthcare, breast cancer patients now typically go through this regimen, known as hypofrac- tionation, in four weeks rather
than six – a major improvement
for patients who need to travel to the hospital every weekday from
all around the Cape.
”
––––[ Radiation Therapy ]––––


insiDe tHe vault
Cape Cod healthcare’s linear ac- celerators each sit in a large room dubbed “ e Vault,” with walls shielded with lead and thick con- crete – two at Cape Cod hospital, one at Falmouth. Made by Varian Medical Systems, the accelerators allow a patient to lie on her stom- ach or back as the steel gantry – the moving part of the machines – ro- tates around her.
linear accelerators work by boiling o electrons from a special la- ment, then shooting them through a vacuum tube using microwaves. If the treatment calls for electron therapy (used for targets on or near the skin), the accelerator can create a beam using electrons. Most ra- diation therapy for cancer calls for high-intensity X-rays, or photons. To generate photons, the electrons are shot through the vacuum tube directly into a thin piece of tung- sten target; the collision generates a beam of photons on the other side of the tungsten.
electron beams are directed by cones; photon beams are directed by a sophisticated tool called a multileaf collimator – an array of 120 “leaves” made of heavy lead. each only 5 to 10 millimeters wide but 6 centimeters thick, the leaves can be stationary or move inde- pendently in a coordinated pattern, like blades in a mixer, to shape the beam coming out of the accelera- tor and hit the tumor precisely. e multileaf collimator has replaced the heavy lead blocks of the past, which produced a slightly less pre- cise beam.
“While the head of the machine is still, the leaves may be changing continuously,” Dr. Sullivan said.
Greater precision means lower risk to healthy tissue, which allows the radiation therapy team to use higher doses of radiation to kill cancer cells. That means fewer sessions are needed.
––––[ Radiation Therapy ]––––
“ at tailors the way the dose is distributed.”
e Varian Truebeam accelera- tors have a gantry that rotates 190 degrees in either direction, provid- ing 360-degree movement around a patient from any direction. e combination of the multileaf colli- mators, the movable couch and the moving gantry allows for delivery of radiation in almost any type of shape or con guration.
“If you have a tumor that wraps around a spinal cord, for example, you can develop a radiation dose that curves around the spine very beautifully,” Dr. Sullivan said.
e vaults are also equipped with cameras that allow technicians
to observe carefully from behind a protective wall to ensure that the patient doesn’t move during the procedure. a surface tracking
camera constantly monitors the skin’s surface. If the patient moves, it shuts o the radiation instantly.
anatomy oF a treatment
at Cape Cod and Falmouth hos- pitals, breast cancer treatment involves a team of doctors, nurses and technicians. a primary care physician usually refers a patient
to a surgeon, because breast cancer treatment generally starts with a lumpectomy or full mastectomy. e surgeon then refers the patient to both a medical oncologist, who prescribes additional therapies, such as chemotherapy and/or hormone therapy, and a radiation oncologist. Many patients’ cases are discussed in a multidisciplinary conference attended by physicians from radiation and medical oncol- ogy, general and plastic surgery, pathology and radiology.
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eresa Pitta was referred to Dr. Sullivan in october 2016. Diag- nosed with breast cancer that april a er feeling a lump in her le breast, Pitta underwent surgery and chemotherapy before arriving in Dr. Sullivan’s o ce to prepare for a round of radiation.
e rst step was a simulation, or mapping session, which included
a CT scan. Pitta received three tat- toos, each the size of a small freckle, to help the radiation therapists accurately locate the treatment site. e therapist asked Pitta to take a breath and hold it – not too deep, not too shallow. Because this rst visit was a simulation – a scan of the area of treatment, rather than radiation treatment itself – the therapists used the CT scanner to take images of Pitta’s le breast.
Clark Cancer Center at Falmouth Hospital
a er a few minutes, the appoint- ment was over. Pitta went home, but the work of the radiation oncology team was just beginning. e CT images were fed into a computer, and Dr. Sullivan outlined the target area, the tumor bed and surround- ing tissue, as well as sensitive organs near it – in this case, Pitta’s heart and le lung.
Dosimetrist Je rey Pohl then looked at Pitta’s images on his computer screen and set up the radiation eld and angle that would be used to reach the target area. all of these calculations are automated, using Varian’s models and accepted protocols established by national cancer boards. Pohl then gave the le of the CT scan and the treat- ment plan to the medical physicist assigned to Pitta.
“ e physicist does a completely independent test of the entire program and how the calculations were done,” said Gabor Menyhart, a medical physicist at Cape Cod hos- pital. “We double-check and verify every detail, then approve the plan.”
When Pitta returned the next day for her rst radiation treatment,
she lay on her back on the treat- ment table in one of the vaults. a technician positioned her in the right spot, pushed a button to move the table higher, and asked her to grab hold of a handlebar-like device above her head, keeping her arms out of the way. ( e machine’s treatment tables can be moved in six directions, allowing techs to position the patient in the precise spot.) Technicians moved the linear
––––[ Radiation Therapy ]––––
Davenport-Mugar Cancer Center
at Cape Cod Hospital


accelerator’s gantry to the le and right of Pitta, very close but not touching her.
as the therapist positioned
Pitta and the gantry, Dr. Sullivan dropped by to verify that every- thing was a go. e therapist then used the automated system to deliver the precise dose in the exact spot. each treatment lasted about three minutes, and the entire visit no longer than 15, Pitta said.
“It wasn’t stressful at all,” she said. “ e hardest thing was keeping your hands in the perfect position. You can’t move once they get you all lined up.”
Pitta returned every weekday, driving 45 minutes each way from Well eet to hyannis. a single mom who works at the Snow library in orleans and also as a home health aide, she was philosophical about the long daily drive. “on my third day, I met a woman from nan- tucket who was ying in every day. I thought, if she can do that, I can drive 45 minutes.”
and she praised her medical team’s professionalism and appreciated their upbeat attitude. “ ey became like friends, seeing them every day.”
Pitta nished her entire course of radiation treatment shortly before anksgiving. By early December, she felt ne – the only remaining side e ect a little discoloration on her breast, similar to a suntan. It will fade over time. | tJ
––––[ Radiation Therapy ]––––
BrEatHING EaSY
Cape Cod Healthcare’s radiation oncology team relies on high-tech equipment – among the most sophisticated of any medical eld.
But some of the most effective patient practices they’ve incor- porated into their breast cancer treatments involve no technology at all.
Because the breast is near the lungs and, in the case of the left breast, the heart, it’s crucial to avoid damage to those organs during radiation sessions. One best practice the Cape Cod team uses is simple yet highly effective: “deep inspiratory breath hold.”
Research shows that asking a woman to inhale and hold her breath during treatment creates separation between the breast and the heart – a small but signi cant difference that reduces the risk of radiation hitting the heart.
“I got pretty good at it,” said Theresa Pitta of Well eet, recalling her daily treatments last fall. “Eventually I was able to hold my breath for 25 seconds.”
Another simple but effective technique helps protect the heart during left breast treatment. Patients lie prone on the treatment table, rather than on their backs. A hole in the table allows the breast to hang freely down, keeping it farther away from the chest wall and signi cantly minimizing the chance of damage to the heart and lungs – especially when the entire breast is being irradiated. | tJ
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GEttING PErSoNal
–––––––––
oncotype testing and other advances allow oncologists to design speci c treatment for each breast cancer patient.
By Nick Lanyi
Tonya Souza had no reason to suspect her routine mammogram would nd anything abnormal. But it did, and her doctor ordered a stereotactic biopsy, a needle biopsy done by a radiologist using mammo- graphy for guidance.
When the lab results came in, they showed that the tissue in Souza’s breast contained atypical cells.
Cape Cod hospital breast and general surgeon Jill oxley, MD, FaCS performed a lumpectomy to remove the area in July 2016.
a er Souza’s outpatient surgery, the pathology revealed atypical ductal hyperplasia – not technically cancer,
but an unusually rapid growth of cells lining the breast ducts. For Souza, this increased her risk of future devel- opment of breast cancer to 40 percent.
For Souza and thousands of other women facing changes in their breast health, the diagnosis and treat- ment options of today are more individualized and customized than in years past. While former treatments weren’t exactly “one size ts all,” doctors now personal- ize their treatment to a much greater degree – based both on the patient and the tumor itself.
Some examples of the change are well known. For example, chemotherapy now is almost always used only a er surgery, to prevent a recurrence of cancer. Better education and screening have helped change the calcu- lus for women diagnosed with breast cancer, too.
But innovations that identify the type of breast cancer, re ned greatly over the past ve years, have received less attention – and they are making an enormous di erence in each patient’s experience.
“Fi een years ago, we saw more women with more advanced disease, which meant lower survival rates,” said Jennifer Crook, MD, a medical oncologist at Cape Cod healthcare. “We also saw a higher risk of relapse down the line, because treatment wasn’t as accurately targeted.”
Today, Dr. Crook’s patients tend to have cancer at an earlier stage, with a greater than 90 percent chance of survival.
“ at’s exciting to me,” she said. “We can tell our pa- tients that this cancer will be a bump in the road, and that you are likely to live a long time. We can reassure them that they will be ne.”
getting speciFic
e term “breast cancer” suggests that one type of cancer exists in the breast. In fact, there are dozens of breast cancers. and doctors treat each one individually.
once a potential tumor is detected by mammogram or MrI, a biopsy is performed to determine whether or not the cells are cancerous. If the tumor is malignant, Cape Cod healthcare’s breast team determines whether or not the cancer has metastasized – for example, whether it has spread to other parts of the breast, or to nearby lymph nodes under the arm.
For each tumor, doctors measure the size and grade – how di erentiated in appearance the cancer cells are from normal nearby cells. ey also determine the type of tumor, based on where it’s found and where it originated.
Most breast cancers are ductal carcinomas. at means they originate in the milk ducts and are either found where they began (known as in situ), or a er they have
––––[ Medical Oncology ]––––


––––[ Medical Oncology ]––––
Jennifer Crook, MD, medical oncologist, Cape Cod Healthcare


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––––[ Medical Oncology ]––––
“I love what I do. I love the education component – the counseling. And
in oncology, the whole family gets involved.
We really get to know patients and walk them through the process.”
- Jennifer Crook, MD
spread to surrounding breast tissue (called invasive ductal carcinoma). Invasive lobular carcinomas, found in the breast sacs that produce milk, account for another 5 to 15 percent of breast cancers. about 5 to 10 percent of cancers are other, less common types.
Pathologic analysis reveals the tu- mor’s hormone receptor status and her-2 receptor status, which helps determine if certain treatments, such as Tamoxifen or herceptin, would help.
another development in the diag- nosis and treatment of breast cancer is known as oncotype testing, which analyzes the activity of a group of 21 genes. It reveals far more detail about a patient’s prognosis and allows doctors to design more per- sonalized treatment options.
Knowing the characteristics of the cancer helps doctors tailor the chemotherapy regimen using the same drugs as in the past, but in di erent combinations.
“oncotype testing changes the course of treatment in about
20 percent of patients,” Dr. Crook said. “We believe it helps eliminate undertreatment and overtreatment.”
Dr. Crook reviewed the results of the pathology report with Souza at Cape Cod hospital and explained that her cancer risk was high. She recommended that Souza begin taking Tamoxifen, a hormone treat- ment that helps slow or prevent cancer growth when the cancer is hormone-receptor positive.
“She explained every little detail about what I could expect in terms of side e ects – and also what might


happen if I don’t take the drug,” Souza said. “She was very thorough and very nice.”
Souza was going through meno- pause and experiencing hot ashes. Tamoxifen can make hot ashes worse, a side e ect that bothers some women. So Dr. Crook pre- scribed another drug that helps combat that issue.
“She said, ‘You’re the same age I am, and if it were me I’d take it. But if you really don’t like the side ef- fects and you call me in six months and tell me you’re not taking it any more, I won’t be angry with you. It’s ultimately your decision.’”
reDucing stress
Dr. Crook set out to become a pe- diatrician. But as a medical student, she gravitated toward working with adults. e rst week of her oncol- ogy rotation, she knew what she wanted to do.
oncology is a specialty that com- bines fast-developing science with a compelling need for one-on-one patient engagement, she said.
“I love what I do. I love the educa- tion component – the counseling. and in oncology, the whole family gets involved. We really get to know patients and walk them through the process.”
new patients tend to be extremely stressed. Dr. Crook spends an hour with them, explaining test results, the prognosis they suggest and the prescribed therapies the breast team recommends.
“When a new patient comes in,
the stress level is at a 10,” she said. “a er that rst meeting, it’s down to a 5 – no matter what the prognosis is. What really frightens people is the unknown.”
at’s another reason oncotype testing is so important, she said. e results help patients under- stand their prognosis and the most e ective course of treatment.
“ ese tests help quantify much more precisely the risk of cancer coming back. Patients can look at
the gene testing report and see the results and a number,” Dr. Crook said. “It’s very clear. Before, they re- ceived an estimate from the doctor; it resulted from good science, but it was really just an estimate.”
Dr. Crook said most patients are pleasantly surprised. When caught early, breast cancer is highly surviv- able. and the side e ects of che- motherapy, hormone therapy and radiation therapy, while sometimes signi cant, are less debilitating than most patients imagine.
“Treatment does not have to be harrowing, as it is o en depicted in the media – based on what hap- pened decades ago,” Dr. Crook said. “ roughout your treatment, we want you living your normal life, and most patients can do that.”
––––[ Medical Oncology ]––––
Oncotype testing, which analyzes the activity of a group of genes, reveals far more detail about a patient’s prognosis and allows doctors to design more personal- ized treatment options.
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tHe longest Drive
ask Mary rogers, of Yarmouth.
She had a routine mammogram and ultrasound exam in Septem- ber 2015, with no sign of cancer. But the following May, she noticed a lump on her breast. her doctor ordered a biopsy, and it came back positive for cancer.
Ten days later, Kathryn Dalton, Do removed the 2.8-centimeter tumor; the surgery went as expected and the recovery was normal.
In June, rogers met with Dr. Crook to review results of the oncotype testing of the tumor ordered by
Dr. Dalton.
“We discussed those results and other factors relevant to me, such as my age – 64 – and other health issues,” rogers said. “I was on the border between someone who would bene t from chemotherapy and someone who might not
need it – right in the middle of the gray area.”
e tumor’s genetic makeup showed nothing unusual, and the surgery had removed the tumor
as well as the desired margin around it. however, Dr. Crook was concerned about the rapid onset
of cancer between September, when the mammogram and MrI were negative, and May, when the tumor was found. Dr. Crook recommend- ed chemo and radiation.
“It was really frightening to think about going through chemo,” rogers said. “But Dr. Crook explained that chemotherapy in 2016 is signi cantly di erent
than chemo of old. You don’t have to have all the terrible side e ects from years past.
“You de nitely will feel tired, and you might walk on the treadmill for half an hour instead of an hour.
But the sooner you try to resume your normal life, the sooner you’ll get back to feeling more normal.”
rogers decided to proceed with chemo and radiation therapy. She had four sessions of chemo, one every third week. She met with
Dr. Crook a day or two before each treatment.
“Dr. Crook went over my blood- work every time so that she knew that I was coming back to where I was before the previous treatment,” rogers said. “She’d explain how
it looked and what would happen next. She was very thorough.”
rogers said the chemo was tolerable, but not without some side e ects.
“I was surprised that I lost my
hair so quickly, between the rst and second treatments,” she said.
“I knew it would happen, but I thought it might take a little longer.”
She also ran a high fever for 24
to 48 hours a er each treatment, which is normal for some patients. She felt more tired than usual, but resumed her normal routine within a few days – including one of her passions, playing golf.
“one time chemo was on ursday and I played in a golf tournament the following Wednesday – and I won the longest drive competition!” she said.
a er nishing the chemotherapy, rogers began radiation therapy, supervised by Je rey Martin, MD. a er 15 sessions – every weekday for three weeks – she was done.
rogers, a self-employed book- keeper who does accounting work for small businesses, said in December that she’s feeling better now. her hair is coming back, and she’s feeling much less tired. She said she appreciates the attention she received from the Cape Cod healthcare team.
“everybody treated me with great respect, concern and care,” rogers said. “While it was not a great ex- perience to go through, the people who were there were incredibly knowledgeable and supportive.” | tJ
––––[ Medical Oncology ]––––


––––[ Patient Experience ]––––
PatIENt ExPErIENcE
an overwhelming diagnosis made easier
By Roberta Cannon
anita Caruso has always believed in donating what she can to support health services, espe- cially at Cape Cod hospital. She has su ered the loss of a step-granddaughter and a step-grandson to sarcoma.
“I think it’s necessary to donate to support ser- vices and keep them going,” said Caruso, whose children work in the service sector, supporting health, seniors and homeless families. little did she know that she would one day need the many services she supports to help her through her own diagnosis of cancer.
In July of 2015, Caruso had her annual mammo- gram and received a call-back request. She was told she had calci cations in one breast that were questionable and she needed a repeat mammo- gram. e results indicated cancer and she was referred for a biopsy and treatment.
her next step was to meet with Kathryn Dalton, Do, a general surgeon who specializes in breast surgery at Cape Cod hospital.
“My daughters and I met with Dr. Dalton for an
initial consultation and we fell in love with her right away,” said Caruso.
“It’s a gi for me to help patients through their cancer treatment, I feel honored that they entrust their lives in my hands,” said Dr. Dalton.
Caruso had a biopsy and was diagnosed with invasive ductal carcinoma, Stage 1 cancer of the breast. Following a lumpectomy and sentinel node removal, and a period of healing, she started radiation treatment ve days a week for ve weeks. She completed treatment in october 2015.
Caruso, 80, is not one to sit idle, and has pub- lished two books, “Brayden’s Magical Carousel Horse” and “Brayden’s Magical Forest.” ese are the second and third books in her children’s series, Brayden’s Magical Journey Books, based on the adventures of one of her great-grandsons and his cousins.
Caruso’s positive outlook and her appreciation for the care she received at the Cuda Women’s health Center and the radiation oncology department at Cape Cod hospital has motivated her even more to promote support for Cape Cod healthcare.
“When I found out I had cancer, it was over- whelming, but with the help of the sta at the Cuda Women’s health Center, I felt more comfortable,” said Caruso. “I tell people it’s important to donate because you want the best of care and you want to support the services that you may need yourself one day.”
The Journal
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The Journal
30
From ‘plain lm’ to sophisticated imaging, a nurse practitioner looks back on 30 years of innovation in breast cancer treatment and care.
Pat ryan-Blanchard, nP, has been caring for patients for more than 30 years. She joined Cape Cod healthcare in 1989 and currently works at the Cuda Women’s health Center in hyannis.
In this issue of e Journal she re ects on the changes over the span of her career.
How has breast cancer care changed in your lifetime?
In the ’70s, I was caring for women with more advanced stages. Today, most breast cancers
are detected at an early stage. Back then, people were not necessarily doing mammography on a yearly basis as a screening tool, therefore many women were diagnosed at more advanced stages. When President (Gerald) Ford’s wife (Betty) was diagnosed with breast cancer (in 1974), people started looking at mammography as a screening tool. Back then the technology was plain lm and screens and grids. is is the technology that we had basically through the ’80s and ’90s.
what was the rst signi cant change you saw in the eld?
ings evolved as accreditation organizations began to govern and standardize what breast cancer care should look like. In the 2000s, digital
mammography became available and imaging became so much better. radiologists in training began to specialize as dedicated breast imagers.
How have things advanced since then?
e biggest advancement is that with the evolu- tion of technology, we are able to nd things smaller and earlier with the potential for a great prognosis or cure. We have progressed so that MrI is used for our high-risk patients, those diagnosed with breast cancer, those who test positive genetically and those people who have
a strong family history. We also perform MrI- guided biopsies, targeting enhancements that are potentially cancerous.
recently, the Cuda Center transitioned from digital mammography to 3D Tomosynthesis mammography, which is yet another more detailed way of looking at breast tissue. (See page 1 for more information.)
How have clinical services evolved along with technology?
at the heart of everything is the multidisci- plinary conference that includes a team of incredible people, including our breast surgeons, plastic surgeons, pathologists, medical oncolo- gists, radiation oncologists, nurse practitioners, social services and research sta . every case is looked at by the whole team and the treatment recommendations are individualized to each patient. From that point, they are linked in with our system and really become part of a family in some ways.
what exciting things are on the horizon in breast cancer treatment?
We already do oncotypes on breast surgical spec- imens that help to predict the rate of recurrence. e trend is to gear towards targeted therapy to match the right people with the right therapy. e wave of the future is all in this molecular type of testing to give the clinicians the most precise tools they need.
HoW far WE’vE coME
––––[ Q & A ]––––


––––[ The Last Word ]––––
voIcES of BrEaSt caNcEr
More than 350 women are diagnosed with breast cancer at Cape Cod Healthcare each year, after which their journey of treatment and recovery begins. Here’s what some patients and caregivers had to say about their experiences.
patients
Jennie mitchell of Brewster
“ e best thing people can do if they are diag- nosed with breast cancer is to create a positive environment and bring the people you love into your fold as much as you can. It’s important to realize that even though the cancer can come back, you can still take control and live. at is my strength and my truth.”
Janet russell of Dennis
“I still go for chemotherapy treatments every three weeks but I don’t allow myself to dwell on that.
I consistently stop and think of positive things and believe in my strength. encouraging words from family, friends and co-workers make me feel successful. I don’t know what’s going to happen tomorrow, but I don’t let cancer control me.”
sharon whittemore of Dennis
“I cried throughout these procedures, but the most awesome tech was holding my hand and reassuring me. My doctor even gave me a ride home a erwards, giving me instructions along the way. a core of friends and family also rallied around me.
“Breast cancer took three years out of my life but it made me realize that there are important things and not so important things.”
caregivers
Kathryn Dalton, Do – General Surgeon and Director of the Cape Cod Healthcare
michael Fishbein, mD – Radiologist and Breast Imager at Falmouth Hospital
“If you go to the american Cancer Society website and look at breast cancer mortal- ity in the united States, it has fallen about 2 percent per year for about the last 15 years.”
David lovett, mD – Medical Oncologist at Davenport-Mugar Cancer Center in Hyannis
“We see a better outcome with patients who have a close sup- port system: lots of friends, church support, family, of course. an important thing is being there, understanding. It
is important (for patients) to know that people have their back.”
Je gaudet, licsw, osw-c – Survivorship Program Manager, Cape Cod Healthcare
“ ere are many reminders
of illness, during and a er treatment for breast cancer. Women need the support of family and friends to continue even a er treatment. Support
groups o er an opportunity for people to share ideas and to get support from each other through happy and tough times.”
emily gomes, rn, ocn – Oncology Nurse
at Davenport-Mugar Cancer Center in Hyannis
“We are never too busy to answer a question. We want to give every tool (for patients) to get through this di cult time.”
Breast Services
“It’s a gi for me to help patients through their cancer treatment. I feel honored
that they entrust their lives in my hands.”
The Journal
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