Mammographic Screening for Breast Cancer – Who, When, and Why?

Mammography for screening of women older than 35-40 years of age was considered a no-brainer for many years and was advocated by all of the major support groups. Screening mammograms have always been felt to decrease the chances of dying from breast cancer by as high as 30% and when state governments have implemented stronger screening programs after approximately 10 years, mortality from breast cancer has decreased. Breast cancers discovered by mammography are smaller and of lower stages when compared to those cancers discovered on examination by patients or their doctors.

Recently more scrutiny has been applied to routine screening and its opponents have become more vocal. The US Preventative Services Task Force  (USPSTF) created a huge stir by suggesting the literature recommended screening with mammography for women between the ages of 50 and 74 be changed to every two years, selective screening before age 50 years, and no obvious benefit for older women. Switzerland upped the ante by not recommending mammographic screening at all (although I’ve heard it is still common for women there to do so).

The problem with mammograms (other than the discomfort) is that they are only 80% sensitive at finding breast cancers and often recommend biopsy for abnormalities that are not cancer (benign). Every biopsy recommended produces a cascade of fears and emotions that can have lasting effects often leading some women to forego any type of screening in the future. Mammography also exposes women to radiation which we know predisposes women to increased risks of brain cancer and leukemia.

The true answer to the mammography dilemma is that we need a better screening tool. Breast MRI is too expensive and nonspecific and breast ultrasound is useful as a supplement to screening but not so much by itself. Coming soon to a breast center near you is 3D-Mammography, Breast Scintigraphy, 3D-automated Ultrasound, and Contrast-enhanced Ultrasound. All of these techniques as they are developed now have too many problems to stand by themselves but are promising in selective cases.

In the near future we will be tailoring screening for each patient based upon breast density, age, prior biopsies and overall risk. This will will have benefits of cost-reduction and less unnecessary biopsies but will still leave some women feeling vulnerable. The good news is that the mortality from breast cancer is continually improving with more effective, less destructive therapies being developed each year. Its a very promising time for breast cancer care as more patients are being cured than ever.


One-third of Breast Cancer Patients Unemployed After Treatment

Recently published in the journal Cancer is a survey study of 1026 women with breast cancer under age 65 . After a follow-up of four years, 30 % of women who had been employed before their diagnosis of breast cancer were now out of work. Most of these women wanted to work and 31% were looking for employment. Getting chemotherapy was most related  to a woman being unemployed after a diagnosis of breast cancer.

The authors of this study state that the risk of post-treatment unemployment should be considered in giving chemotherapy, especially in low risk breast cancer patients. I would add that this has implications for women with a high risk of breast cancer from family history or other factors. If a high-risk woman is the sole care-giver for her family without other resources, a diagnosis of breast cancer might lead to a situation that could impoverish her and her family. This study’s findings also improves the economics of taking risk-reducing medicine and undergoing risk-reducing mastectomies for high risk women.

New study suggests that Tamoxifen needs to be taken for 10 years for improved survival.

A recent study published in Lancet medical journal has shaken up the breast cancer field. Traditionally, in order to prevent recurrences and extend longevity, we have treated early breast cancer patients who have  hormone sensitive tumors with 5 years of the hormone blocker Tamoxifen. However, a recent study shows that 10 years of treatment results in improved rates of living longer without breast cancer.

The study involved 6,846 women with hormone sensitive breast cancer who had completed 5 years of Tamoxifen therapy. They were randomly chosen to either stop taking Tamoxifen or to continue with an additional 5 years, for a total of 10 years of Tamoxifen. The results showed that those women in the 10 year Tamoxifen group had less breast cancer recurrences and less breast cancer deaths. By year 15 breast cancer deaths had improved from 15% to 12.2% by the additional Tamoxifen treatment. The risks of taking more Tamoxifen included increased rates of uterine cancer (3.1% versus 1.6%) and pulmonary embolism [blood clot to the lung]. Overall though the amount of women dying from any causes were significantly smaller in the 10 year Tamoxifen group (639 versus 722).

Since this study has been presented, there has been much discussion about how to apply these results. Here are some thoughts:

Is the benefit of 3% (15% t0 12.2%) worth the additional 5 years of medicine. Our thoughts are that it depends upon how a woman tolerated Tamoxifen. If she barely noticed taking the medicine, then yes it makes sense. If she had side effects then 5 years would be fine.

What do we do with women who have DCIS or those who are taking an aromatase inhibitor? The real answer is that we don’t know.

Most people are leaning towards increasing the length of time for all hormonal medication because we know that hormone sensitive cancers can recur years after a diagnosis. In fact, half of all recurrences occur 8 years from initial treatment. We are also giving Tamoxifen for a few years followed by an aromatase inhibitor for a total of 5-8 years of treatment. This allows women to be exposed to less of the side effects of both drugs.

Should we extend it to 10 years, 15 years, forever…?

One of our patient’s testimonials.

“Before coming to the Cancer Center at Hudson Valley I spoke to a surgical oncologist at another hospital. All the right words were said but it didn’t make me feel better. I decided to go for a second opinion. When I walked in and met Dr. Pond Kelemen for the first time he looked at my charts, looked at me with such warmth, smiled and took my hand and said you’re going to be ok. From that moment on I truly believed that I would be. That’s patientology.”

– Kimberly Gerosa Ashikari Breast Center patient.

As a lifelong resident of Cortlandt Manor, Kimberly Gerosa had witnessed Hudson Valley Hospital Center evolve from a nice little hospital to the amazing facility it is today. Kim says she had always had a positive impression of the hospital. Her internist and gynecologist are affiliated with it, but now she knows and appreciates the hospital on a much deeper level.

Kim’s journey with breast cancer began after her routine mammogram in December of 2011 indicated a problem. The radiologists at Hudson Valley recommended an ultra- sound, which confirmed Kim needed a biopsy. Everyone in this imaging department was extremely nice, and very compassionate in helping Kim deal with this news – from the technicians to the radiologists. At this point in time, the Cancer Center at Hudson Valley was brand new. Not knowing much about it Kim went at first to another hospital to speak to a surgical oncologist.

Kim was told she had the early stages of breast cancer. All the right words were said but Kim did not feel at ease with this doctor. Her internist recommended she go and speak to the doctors at the Ashikari Breast Center at Hudson Valley Hospital Center. From the moment Kim met Dr. Kelemen she knew this was the right decision for her. She had a lumpectomy in January of this year. Unfortunately she learned soon after, on her birthday actually, that her birthday surprise was that the cancer had moved to her lymph nodes taking  her cancer from stage 1 to stage 2 .Consultations were arranged with Drs. Azim Ajaz, director of oncology services, and Chika Madu, Medical Director for Radiation Oncology, and Dr. R Michael Koch, plastic surgeon specializing in breast reconstruction. They designed a treatment plan that was right for her, which began with a 5-month course of chemotherapy. Kim said that Dr. Aijaz’ compassion and intelligence helped her get through the treatments.

While going through chemotherapy was a tough time in her life, she said the Hudson Valley Hospital Center team did everything they could to make it easier for her.  In June, after finishing her chemotherapy treatment Kim came back to Hudson Valley to have a bi-lateral mastectomy. She was in the hospital for 3 days and everything was done to make her feel as comfortable as possible. The night of her surgery the nurses were wonderful, checking constantly to make sure she had everything she needed. And even though she was not a candidate for the one-step mastectomy, the doctors were able to perform skin and nipple sparing . Nancy, Dr Koch’s Surgical Physician Assistant, has been there for all Kim’s post op questions and concerns.

Kim’s breast cancer journey is not over, but all indicators point to a full recovery and a healthy future for her. She said going to a comprehensive cancer center like the Cheryl R. Lindenbaum Cancer Center made her journey a lot easier, because every doctor and course of treatment Kim needed was available at the Center. And it’s all right here for her in her own backyard.

Gilda’s Club OPEN HOUSE Feb. 7 at HVHC Cancer Center

Gilda’s Club Westchester, a leader in support for cancer patients and their families, invites men and women who have been newly diagnosed with cancer to a new support group called “Living with Cancer.” An Open House is scheduled for Thursday, Feb. 7 at 6 p.m. at the Cheryl R. Lindenbaum Cancer Center at 1978 Crompond Road, Cortlandt Manor.  The group will meet every first and third Thursday of the month from 6-7:30 p.m. at HVHC’s Cancer Center. For more information,  programs, call  Miranda Dold at 914-644-8844.

More Choices for Breast Cancer Treatment at HVHC Thanks to IORT Grant

Women treated for breast cancer at Hudson Valley Hospital Center will have more choices thanks to a $150,000 grant the Hospital is to receive from New York State with the help of Senator Greg Ball. The money will help to pay for equipment that will allow the Ashikari Breast Center at Hudson Valley Hospital Center to perform intra-operative radiation on women undergoing breast cancer surgery. The procedure will be available to patients starting the second week in November.

“The Ashikari Breast Center at Hudson Valley Hospital Center offers women the best cancer care close to home,’’ said breast cancer surgeon Dr. Andrew Ashikari today at a press conference at the Hospital. “Now women who could benefit from intra-operative radiation don’t have to travel elsewhere to get it. This is a great addition to the Hospital and a victory for women with breast cancer.’’ “Not everyone is a candidate for IORT, but in many women undergoing a lumpectomy it provides a less stressful option to traditional whole breast radiation treatments,” said Dr. Pond Kelemen .

Sen. Greg Ball said he was happy to advocate for his community in Albany.“The stresses associated with battling breast cancer are overwhelming and providing world class services locally, without the additional stress of travel and hardship of leaving the familiarity of their community is exactly why I couldn’t be happier to deliver this $150,000 grant to the Hudson Valley Hospital Center. I am proud to assist in making the Cheryl R. Lindenbaum Cancer Center the destination of choice for cancer patients in the Hudson Valley,” said Senator Greg Ball. “It is a great honor to be able to deliver this money for the hard working doctors, nurses, staff and the entire Hudson Valley Hospital Center community, especially as we embrace the struggles of our

Intra-operative radiation (IORT) allows selected breast cancer patients undergoing breast preservation surgery to receive one dose of radiation while asleep during surgery, compared with 6-1/2 weeks of radiation after surgery. In higher risk patients, it is used to boost the surgical cavity with radiation to reduce the post-op radiation to only 5 weeks. Women who undergo IORT only and develop a recurrence can then undergo a repeat lumpectomy and whole breast radiation, while those who get standard radiation and develop a recurrence are recommended to have a mastectomy. The Ashikari Breast Center has participated in the largest international trial of IORT and will be active in the American trial, which will begin soon.