Better Health - October 2019

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Better Health D

TREATMENT OPTIONS: patients select their own path, D2 FINDING A LUMP: next steps you should take, D5 BREAST CANCER IN MEN: rare but more deadly, D7

| SUNDAY, OCTOBER 6, 2019

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Helping breast cancer survivors shape confidence into their journey

After 20 years of being a dental hygienist, Mary Walsh-Aframe decided to switch careers and become a certified mastectomy fitter.

She now helps breast cancer survivors find the right option to meet their post-surgery need whether it be for bras, custom or standard breast prostheses or smaller forms called shapers to recreate the natural shape of their breast.

By Anne-Gerard Flynn

side of and live a full life. It is about had alopecia (hair loss) not related surgery though she does see some feeling confident enough to come to to chemotherapy treatment so I before treatment.

Her switch was made 20 years terms and accept and move on. I see knew about wigs and because I was “Many times, I will see a woman ago this month and over that time it happen every day and I hope I help a dental hygienist, I had a science before surgery so we can sit and talk.

Walsh-Aframe has helped thousands to make that happen.” background,” said Walsh-Aframe There is a camisole that is nice to of such survivors who may have had A Certified Mastectomy Fitter who was thinking of a career switch have right after the surgery as well,” a mastectomy to remove one or both through the American Board for around the time a cancer center Walsh-Aframe said. breasts or lumpectomy that removes Certification in Orthotics, Prosthet- was being built near her children’s “Knowledge is power for women a more limited amount of tissue fit ics & Pedorthics, Walsh-Aframe school. and if they come before the procemore comfortably physically and owns board-certified shops called “I thought I could go back and get dure, they can have a better idea emotionally back into their lives.

The Women’s Image Center in certified in orthotics and prosthetics what their options for bras and “This is not anything anyone Worcester and Leominster, and Mer- and that is how I got the idea to open prosthetics are post-surgery. A lot wants,” said Walsh-Aframe, noting about 12 percent, or 1 in 8 U.S. women, will develop invasive breast cancer over the course of her lifetime.

“Depending on a women’s diagnosis, the treatment in many cases affects the two things that make a woman feel most like a woman - her hair, depending on any chemotherapy treatment, and her breasts,” Walsh-Aframe said.

A majority of women are said to decide on reconstructive surgery to have a permanent breast shape after their cancer surgery, but others for a variety of reasons opt to not have additional surgery.

External breast forms that look to recreate a women’s natural shape can be an alternative to reconstruction, and Walsh-Aframe said such prosthetic options have greatly expanded to help a woman “feel confident enough” to “accept and move on” as a survivor.

“I know when a woman is seeing me that she has a lot more on her mind then coming in for this fitting.

She is worried about her family, her A Certified Mastectomy Fitter through the American Board for Certification in Orthotics, Prosthetics & life, should she keep working, what Pedorthics, Mary Walsh-Aframe owns shops called The Women’s Image Center in Worcester and Leominster and about taking care of her parents, Mercy Medical Center is among the hospitals that have added her services for breast cancer survivors. taking care of kids,” Walsh-Aframe (PHOTO BY ANNE-GERARD FLYNN) said.

“There is a really big emotional piece to this diagnosis. Sometimes cy Medical Center, part of Trinity my first shop.” of times women are very pleasantly women come in to see me and they Health Of New England, is among Walsh-Aframe said survivors surprised when they see we have evcry and I say, ‘This is a safe place to the hospitals that have added her generally make an appointment with erything today. I tell women if there let it out.’ It is a journey but it is a services. her through Mercy’s Breast Care is something you are worried or conjourney that you can get to the other “I grew up with two sisters who Center about six to eight weeks after cerned about, if you communicate Special to The Republican

that we have something for it.”

Post-mastectomy bras are designed to give the support needed for both comfort and symmetry and, Walsh-Frame noted, the prosthetic devices help a breast cancer survivor adjust in a number of ways.

“There is a therapeutic benefit to wearing the prosthetic because it helps with your posture,” she said.

“There are two things that happen when a woman has had breast surgery. She will tend to hide and protect the area, so wearing the prosthesis helps with your posture and your gait.”

Twenty years on, Walsh-Aframe said today’s external breast prostheses are lighter and cooler, some fit into the pockets of so-designed bras, while custom-made ones that can be created with the use of an iPad-based, 3-D scanner and computer-assisted design, are measured to fit onto the recipient’s chest wall, Walsh-Aframe said, “like a puzzle piece.”

“Women want to be comfortable.

This is the top priority, but they also want to be confident,” WalshAframe said.

“They want to look symmetrical.

They want to go, continue on with their life. With the 3-D scanner I can reproduce whatever volume is lost due to a mastectomy or lumpectomy. The material is lightweight and its back will fit the surgical site like a puzzle piece.”

If a woman has had both breasts removed, Walsh-Aframe said instead of being scanned to match a custom-made prosthetic device to the existing breast for symmetry, the woman can try on a few different size bra cups and decide what cup size is best for her in creating the prostheses.

Walsh-Aframe said most insurances cover this newer procedure of a

SEE CONFIDENCE, PAGE D8

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D2 | SUNDAY, OCTOBER 6, 2019

THE REPUBLICAN | MASSLIVE.COM

Breast Cancer patients

select their treatment path A MASTECTOMY WAS ONCE CONSIDERED THE ONLY OPTION FOR A WOMAN DIAGNOSED WITH BREAST CANCER.

same time ensuring that they receive state-of-the-art breast cancer care. When a patient understands their diagnosis, treatment options (including potential side effects) and alternatives, they are empowered to make educated decisions that suit their individual situation. We understand that people are different and share a unique blend of cultural,

By Dr. James L. Frank Patients are welcomed to social and religious influencAdvances in surgery and our center by Ivette, our Navi- es that shape their orientation cancer care now present a gator, and Jackie, our Medical to their disease. wider range of treatment Assistant. They begin buildWe focus on controlling the choices to women facing this ing the framework of care tumor where it began in the significant health crisis. At and support that continues breast. We understand that the Mercy Breast Care Center through the journey. breast cancer has the potenour priority is to listen to, The Mercy surgeons tial to spread to other parts educate and partner with emphasize compassion and of the body, often (first) the women as they enter a jourpatience in helping women lymph glands in the armpit ney and decision-making choose a treatment plan but then other organ systems. process. that best suits them, at the We assess the whole person

including their risk of the cancer spread and then tailor the approach based on that analysis.

Surgery and radiation therapy treat the breast (and sometimes the lymph glands) while hormonal blockers and chemotherapy are directed at the whole body, although they have effects on the tumor in the breast as well.

Recent advances in the analysis of the human genome (the molecular make-up of humans and cancer) have produced an armamentarium of breakthrough medications, so-called “targeted” therapies, that prolong life and control cancer, often with fewer side effects.

We supplement our counselling with educational

OCTOBER IS BREAST CANCER AWARENESS MONTH

Mercy Medical Center’s Breast Care Center The technology you expect, The care you deserve.

materials so that our patients may understand these aspects of their care. In this way they are able to make informed decisions as we guide them through this process.

Breast cancer patients are routinely evaluated by three specialists; a surgeon, medical oncologist and radiation oncologist. Their care plan is then discussed at our weekly breast cancer conference so that a consensus amongst professionals may be achieved and then integrated into the individual patient’s care.

Until the 1960s the treatment for any kind of breast cancer was a radical mastectomy. This involved the removal of the breast, the lymph nodes from the armpit, and the muscles off the chest wall.

What is truly “radical” is the evolution of surgery over the past five decade, the result of randomized clinical trials conducted by surgeons all over the world. We have learned that “less is more”- and this gives women freedom from the often crippling and disfiguring side effects that once accompanied standard breast cancer treatments.

We have learned that breast cancer is best approached as a disease that potentially effects the whole person, physically, mentally and

emotionally. The focus on the breast cancer patient has thus drawn in other highly-trained professionals including physical therapists, geneticists, social workers, navigators (the “mother hens” of the process), nutritionists and behavioral health counselors.

Breast cancer incidence and death rates have significantly declined during the last three decades, due in large part to early detection through mammography and better awareness among women of their breast health. Still disparities in breast cancer care exist and threaten patients in underserved areas and communities.

The Women’s Choice Award named the Breast Care Center at Mercy Medical Center one of America’s Best Breast Centers this spring.

Mercy Breast Care Center is the only facility in Springfield accredited by the National Accreditation Program for Breast Centers, a branch of the American College of Surgeons.

During October, we offer free screening mammography exams on Wednesday afternoons by appointment on a first-come, first-served basis by calling (413) 7489101.

Dr. James L. Frank

If you or someone you love is concerned about breast

We provide streamlined access to all

disease, the Mercy Breast Care Center is a one-stop

the services you need, including:

resource for screening, diagnosis and treatment for cysts,

• State-of-the-art diagnostic imaging

lumps, breast pain and breast cancer.

including 3D mammography, breast

Our center is accredited by the National Association for

MRI and ultrasound

Programs in Breast Cancer (NAPBC) of the American

• Image-guided breast biopsy

College of Surgeons, so you can be assured that we

• Surgical and non-surgical treatments,

meet the highest standards of care for patients.

including radiation therapy and med-

Please call the Breast Care Center at Mercy Medical Center

ical oncology

at 413-452-6600. To make a routine appointment for a

• Breast reconstruction

mammogram, please call 413-748-9729.

• Supportive services such as coun-

is medical director of Mercy Medical Center’s Breast Care Center, attending surgical oncologist and director of surgical oncology at the hospital that is part of Trinity Health Of New England. He is the Massachusetts Chairman for the American College of Surgeons Commission on Cancer. He will speak about breast cancer prevention and treatment Oct. 23 at 6 p.m. in the medical staff room in the Deliso Conference Center on the lower level of the hospital.

OAKDALE DENTAL ASSOCIATES, P.C. .C. Early detection is so important..

For us at Oakdale Dental Associates – it is personal.

seling and support groups • Genetic testing and counseling • Second opinions and information about treatment options • Community resources for transpor-

Breast Care Center (Next to the Sister Caritas Cancer Center.

Please park in the Cancer Center parking lot.)

Suzanne Williams On July 9, 2015 we lost part of our family.

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3121733-01

271 Carew Street, Springfield, MA 01104 413-452-6600 • MercyCares.com

tation, childcare or other needs

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SUNDAY, OCTOBER 6, 2019 | D3

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D4 | SUNDAY, OCTOBER 6, 2019

Dietitian’s

THE REPUBLICAN | MASSLIVE.COM

Genetic testing, better breast cancer treatments

Diary women more options give younger

Dr. Holly S. Mason is section chief, breast surgery and surgical oncology, department of surgery at Baystate Health and co-medical director of the Baystate Breast and Wellness Center.

(ANNE-GERARD FLYNN PHOTO)

Zoraida Rodriguez is a Registered Dietitian with the Holyoke Medical Center Endocrinology & Diabetes Center.

As a Registered Dietitian with Holyoke Medical Center (and the mother of two school-aged boys), Zoraida Rodriguez knows a thing or two about burning the candle at both ends. Planning sensible and tasty meals not only helps her maintain her balancing act but allows her to go the extra mile for her parents. Browse her daily food diary for a little inspiration.

BREAKFAST · 1 cup steel-cut oatmeal with walnuts, cinnamon and apples, cooked in water · ½ cup soy milk · coffee I add soy milk to the steel cut oatmeal after cooking it with water. Oatmeal has both soluble and insoluble fiber. Soluble fiber provides satiety because it slows down digestion, while insoluble fiber improves gut health by aiding bowel movement and removing carcinogens. Other days if I am running late, I have 2 slices of whole wheat toast and peanut butter or 1-2 slices of low sodium deli turkey. I never forget my coffee though! I make it with low fat milk and stevia.

MID-MORNING SNACK OPTIONS · yogurt

LUNCH · tuna pouch in oil · canned chickpeas, no sodium added, rinsed with water · spring-mix greens, red peppers and radishes · top with apple cider vinegar, I don’t add additional fats (oil, mayonnaise, olives) because the tuna chosen already comes with oil · pepper, to taste · ground ginger, to taste I combine the first two ingredients and then add it to the spring mix. This is my “canned antioxidant meal” since it’s quick and healthy.

Fish has omega-3 fatty acids, which are good for the heart and help decrease inflammation. These veggies are full of vitamin K, vitamin A and vitamin C, which are antioxidants that help protect healthy cells from the damage caused by free radicals.

Even fumes from cars can cause cell damage from free radicals. These veggies help protect us.

PRE-DINNER SNACK · 6–12 almonds or peanuts · fruit such as a tangerine or apple

· fruit · crackers with peanut butter · carrots with hummus · string cheese and cherry tomatoes I usually don’t have a mid-morning snack because my high-fiber breakfast keeps me satisfied until lunch.

However, if my stomach is growling and lunch is not for 2 more hours, then I choose a snack. Some people also may need a snack if there are four or more hours between breakfast and lunch.

· Kind Bar · string cheese and cherry tomatoes (if at home prior to preparing dinner) Before dinner, I always need a snack. I choose a fruit that’s the size of a tennis ball because it has fewer carbohydrates. Fruits don’t require refrigeration, so these are my go-to choices. Sometimes fruit by itself increases my appetite, so I include nuts with my snack for a feeling of satiety, thanks to their

monounsaturated fat (omega-3), protein and fiber content.

DINNER · chicken thigh, which I had left cooking in the slow cooker in the morning prior to going to work (with various herbs and spices added such as oregano, parsley, garlic, pepper, turmeric, paprika, salt) · I combine it with black beans and brown rice and a side of salad or if the children are too hungry to wait, then I heat up corn taco shells and add lettuce, tomatoes, peppers, cilantro to make a taco salad meal.

I follow the healthy plate method and encourage the family to do so as well.

AFTER-DINNER SNACK OPTIONS · 6 oz. Greek yogurt · glass of 1% milk with cinnamon and a tablespoon of natural peanut butter I often pick one of these two snacks. Greek yogurt typically has more protein and fewer carbohydrates than other yogurts, and natural peanut butter tends to have no sugar or salt added.

I drink water with all meals!

I don’t have a gym membership, but I do park further away, use the stairs at work, and walk in the evening with my husband.

Zoraida Rodriguez is a Registered Dietitian with the Holyoke Medical Center Endocrinology & Diabetes Center. To schedule an appointment, please call 413.534.2820

Advances in Breast Cancer Diagnosis & Treatment

Wednesday, October 9, 2019, 5:30 p.m.

HMC Auxiliary Conference Center According to the National Breast Cancer Foundation, a woman is diagnosed with breast cancer every two minutes – but the good news is that survival rates have been increasing over the last few decades. Join Dr. Mateen and Dr. Dulala, HMC Oncologists, as they discuss the importance of screening and early detection, as well as new treatments available.

Register online at www.holyokehealth.com/events or by calling (413) 534-2789.

HolyokeHealth.com

By Anne-Gerard Flynn

Special to The Republican

Several years ago, Baystate Health surgeon Holly S. Mason noticed a “preponderance” over several months of what she called “very young women with breast cancer in their 20s and early 30s, more than we had typically seen.”

Mason is section chief of breast surgery and surgical oncology in the department of surgery at Baystate and co-medical director of its Breast and Wellness Center.

She and statistician Jane Grub were able to determine, using data from Baystate’s Tumor Registry as well as other sources, that the increase in the Pioneer Valley was not one “to raise red flags” and require further investigation and some type of intervention like added screening.

“We wanted to see what were the trends and whether what we were experiencing here in the Pioneer Valley was abnormal or was more of a consistent change that other areas were seeing as well,” Mason said.

“We did find an increase but not a statistically significant increase that would raise significant red flags, but certainly as the detection of breast cancer has increased so have the numbers nationwide increase. We had a similar increase but it was not something that would have prompted a significant search and intervention.”

Mason added, “At the time we did the study we collected data on about 6,800 patients who fit into having breast cancer and 6 percent of them fell into what we call early onset.”

“We used the number 40 for the age of early onset,” she said.

“More recent data says 7 percent so not a significant change since we finished the study in 2014.”

Mason said though the review showed “no cause for concern,” it did raise the question, “How do you screen a population that theoretically is at low risk but can be impacted?”

“The problem is young women don’t get screened, they don’t get mammograms,” said Mason of screening that usually begins for women considered at average risk for breast cancer at age 40 or possibly 50.

“You don’t know, depending on what kind of health care they have connected with, whether younger women are getting yearly breast exams or just having conversations.

With cancers found at a later stage, the treatments are more extensive and potentially you could have a worst outcome.”

Mason added that “one thing that has improved” in recent years among both providers and patients is being aware and talking about any family history of any cancer and whether there is a need for genetic testing because of it.

“The public is much better educated about that,” Mason said.

“Many people are seeking out evaluation where 10 years ago it would not have been on their radar. In the end this will help us with these young patients. If someone is identified because of family history, they will get screened earlier. So, if they do develop breast cancer it is caught much earlier and the treatments are not as extensive.”

Mason added that Baystate has streamlined the process for someone looking into whether they need to have genetic testing done to assess their cancer risk because of their family history.

“I commend Dr. Grace Makari-Judson here for the development of the family cancer genetics program because what they have done is come up with the system where if a patient wants to be evaluated, they send the paperwork in and their family history will be assessed before they even have to come in for an appointment,” Mason said.

She said younger people considered at elevated risk for breast cancer could have annual mammograms or be candidates for a breast MRI and also be considered for a low-dose of the breast cancer drug tamoxifen that can reduce risk in patients at increased risk.

She added breasts self-exams among young people are typically the way a lump is detected.

“In the younger population where we are not doing regular screening it does come down to awareness of your body and doing a breast exam,” Mason said.

“We recommend that if you are going to do a breast exam, you do it once a month, you pick the same time of your menstrual cycle to do it because your breasts will feel different depending on the hormone levels in your body. It is important to be consistent, and if you think something has changed get it evaluated.”

She also recommends “keeping up health care with either a primary care physician or another provider like a gynecologist who will do a clinical breast exam.”

“I am a proponent of the clinical breast exam,” said Mason of a procedure that could result in the detection of a lump between screenings or in someone not yet screened.

“There is a lot of controversy in women over 40 who are getting mammograms about the benefit of clinical breast exams although I still believe in it because I see plenty of breast cancer patients who have found their own cancers.”

The clinical breast exam is no longer recommended by the American Cancer Society for women of any age in the United States as mammography screening has improved and become more accessible though it does not oppose women wanting a clinical exam though not as a substitute to mammography screening.

There is disagreement among national societies as to when a woman at average risk for breast cancer should get mammograms with the ACS recommending at age 45 and the U.S. Preventive Services Task Force at age 50.

“Starting at 50 you should absolutely get mammograms,” Mason said.

“Whether every one or two years is a personal preference in how you feel about mammograms and the radiation exposure associated with them that is low, but certainly no further out then every two years.”

She added, “in the 40- to 50-age population it is a conversation to have with your physician if you are at average risk.”

She said that “some women are comfortable with a clinical breast exam while other women would prefer to be screened.”

“If you are at elevated risk due to family history or had a biopsy that showed some abnormal cells that were not cancer or have had other particular risks, start at 40 with your mammograms,” Mason said.

She added, “There are pros and cons about having mammograms in your 40s.

You think about catching cancer early and that is what we want.”

“Women in their 40s have more dense breasts than older women so there is a greater chance of having an abnormal mammogram requiring you to come in for an additional study, and having a biopsy for something that was not cancer,” she said.

“We call that a false positive.”

Mason said that “the thing to remember is that almost 20 percent of patients who are diagnosed with cancer at our breast center are in their 40s.”

“That is a pretty big number so I feel as a breast surgeon I would certainly rather find something early so I can do a small surgery and minimize treatment,” Mason said.

“It is a matter of patient choice today and shared decision making so we need to discuss with our patients the pros and cons of when to start mammograms, and let them decide and we provide whatever assistance can.”

Mason added that treatments have also “changed a lot” in recent years for breast cancer, which can be more aggressive in younger patients.

“We know a lot more about breast cancer now,” Mason said.

“Some of the treatments patients would have gotten at the time of the study are vastly different now than today.”

She added that since coming to Baystate 16 years ago “how we manage patients has completely changed in a good way.”

“We are better able to tailor who needs what, who really is going to benefit from chemotherapy versus who can take tamoxifen and can we downsize the cancer using chemotherapy first so they do not need a mastectomy or could have a lumpectomy,” Mason said.

“So really everything has changed and the young patients really can benefit.”

“When I started doing this, it was you are young, mastectomy that’s it and be done with it,” she added, “and now we can really figure out if they really have to do that and, especially with genetic testing, we can know how serious is the risk to the other breast and there are some medical treatments now for specific gene mutations.”

She called this targeted therapy the “key to breast cancer.”

“It is exciting and great for patients because we can give them better options and choices where they did not have choices and let them weigh in on the decisions,” Mason said.

“Before we had to tell them this is all you have and now it is what do you want? What is going to help you maintain your quality of life and treat your cancer and that is the key to everything.”

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THE REPUBLICAN | MASSLIVE.COM

I Have a Lump in My Breast,

Now What?

It is normal to be scared when you find a breast lump, but not necessarily a finding of concern. Schedule an appointment to be seen by your primary care provider.

Although 80% of breast lumps found by women are not cancerous, it is still important to have any new and persistent breast lump checked out. Don’t ignore a new lump in your breast.

I encourage everyone to know their own bodies and to perform monthly self-breast exams to detect any changes that may need to be evaluated. If that breast lump turns out to be breast cancer, early detection can save your life.

Benign breast lumps usually have smooth edges and move easily when you touch them. They are often found in both breasts. There are several factors that can cause benign breast lumps, including normal changes in breast tissue, breast infection, injury, breast cyst, fibroadenoma, intraductal papilloma, and traumatic fat necrosis. Some of these factors are highlighted below:

1. Normal changes in breast tissue: Breast

tissue responds to hormone changes particularly around the menstrual cycle. During normal monthly menstrual cycles some women have fibrocystic breast changes.

This means that they have lumps in both breasts that increase in size and tenderness just before their periods.

These lumps are normal breast tissue or cysts which have become enlarged or irritated in response to cyclic hormone changes. They usually become less prominent and tender after the period ends.

2. Breast infection: Some-

times a painful lump, with or without redness, is the first sign of infection. Abscess tends to occur in small pockets that are warm and tender to touch. Symptoms usually worsen quickly. Applying warm compresses can be helpful, but you may also need antibiotics to treat this.

4. Simple cysts: Simple cysts

are fluid-filled sacks that are usually found in both breasts. They can vary in size and tenderness particularly around the menstrual cycle.

The number of cysts vary from one to many. Breast cyst development tends to run in families.

5. Fibroadenomas: These lumps tend to occur in women between the ages of 20 and 30. They are more common in African-American women. A fibroadenoma forms when the breast makes extra milk-forming glands.

This causes development of a solid, round, rubbery lump in

Cancer is the most concerning cause of a breast lump. A cancerous mass in the breast will continue to get bigger and ultimately can cause disfigurement of the breast. Breast cancer can also spread to other parts of the body and vital organs making it life threatening.

6. Distortion of the nipple or

50, and annual mammograms between the ages of 50 and 75.

Screening mammograms can identify breast cancer at an early stage, even before it has created a palpable mass or other symptoms in your breast. Early detection saves lives.

other parts of the breast.

7. Nipple discharge that starts suddenly or is bloody.

8. New pain in one spot of

the breast that does not go away.

If you have any of these breast changes, seek care immediately.

Glenda Flynn Advanced Oncology Nurse Practitioner

Mass General Cancer Center at Cooley Dickinson Hospital

Newly Diagnosed with Cancer?

This is Breast Cancer Awareness Month. I encourage you to consider things The good news is that that contribute to breast breast cancer can be found health. Once you turn 20, you in the early stages when should check your breasts evtreatment and cure are ery month, usually the week possible. For this reason, it after your period. In this way is vitally important for you you can become familiar with to watch for the warning your breast tissue and more signs of breast cancer and easily recognize any changes report them immediately to your health care provider. Be that occur. Your health care provider may also recomaware of any changes in the look or feel of the breast, the mend a clinical breast exam nipple, or the development of (done by your provider) every 1-3 years starting at 20. nipple discharge.

As you get older, get The warning signs of a mammogram. Expert breast cancer include: organizations disagree on the timing and frequency of 1. A lump, hard knot or thickening of the breast or mammograms, so it is best to discuss this with your health underarm area. care provider.

2. Swelling, warmth, redness Consider having a first or darkening of the breast. mammogram at the age of 40 (or earlier if you have a 3. Change in the size or family history or a first-deshape of the breast. gree relative developed 4. Dimpling or puckering of breast cancer at a young age), the skin. then a mammogram every 5. Itchy, scaly sore or rash on 1-2 years (www.uspreventativeservicestaskforce.org) the nipple. between the ages of 40 and

Next Day Appointments Now Available

Patients who have just been diagnosed with cancer urgently want to know what happens next. That is why medical oncologists at the Mass General Cancer Center at Cooley Dickinson Hospital now offer next day appointments for people newly diagnosed with cancer.

“We want our patients to have the option of seeing a medical oncologist

as soon as the next day,” said Lindsay Rockwell, DO, medical director of the Mass General Cancer Center at Cooley Dickinson.

“Our teams are ready right away to provide reassurance, answer questions and start creating a personalized treatment plan for each patient.”

To make an appointment or for more information, visit cooleydickinson.org or call the Mass General Cancer Center at 413-582-2900

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3. Breast injury: A bump to the breast can cause bruising or an underlying blood clot (hematoma). These lumps tend to occur in response to a known injury and are associated with the “black and blue” color changes characteristic of bruising.

Hematomas can take a long time to heal.

the breast that freely moves when touched. There can be one or many of them.

Tomorrow, we can start planning your care.

Next day appointments following a new cancer diagnosis If you have just been diagnosed with cancer, you have the option to see a medical oncologist from the Mass General Cancer Center at Cooley Dickinson Hospital as soon as the next day. Our teams are here when you need us, to reassure you, answer your questions, and start planning your personalized treatment.

30 Locust Street, Northampton, MA Medical Oncology: 413-582-2900

cooleydickinson.org

ADVANCING CARE TOGETHER

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THE REPUBLICAN | MASSLIVE.COM

SUNDAY, OCTOBER 6, 2019 | D7

%%SATFOL-%%3MONTH%%2DATE

Breast Cancer in Men is Rare, but

More

Deadly

By Keith O’Connor

an opportunity to raise awareness about the importance October is Breast Cancer of finding breast cancer early Awareness Month. when it is most treatable.

If you are a man, you are “I believe we have done not exempt from developing a good job over the years in breast cancer. getting the word out to womThis year an estimated en about breast cancer and 2,670 men in the United the importance of screening States will be diagnosed with mammography. But, for men, breast cancer and 500 will die not so much,” said Dr. Brady from the disease, according of the Baystate Breast and to the American Society of Wellness Center.

Clinical Oncology (ASCO).

“While the chances are slim, Still male breast cancer is men still need to know that rare with less than 1% of all developing breast cancer in breast cancers developing their lifetime is a possibility. in men. Black men have the Unfortunately, there is a lack highest incidence rates at 2.7 of awareness among men and out of every 10,000 men, as a result they tend to ignore followed by white men with any breast lumps. When they 1.9 diagnoses out of every do finally decide to visit their 100,000 men. doctor, often when the tumor “I have only seen eight cases has grown significantly, and of male breast cancer in the that is why men have a higher past 20 years,” said breast mortality rate,” she added. cancer surgeon Dr. Elizabeth Brady of Baystate Medical Early detection is “key,” Center. noted Dr. Brady, who October is National Breast along with the American Cancer Awareness Month and Cancer Society offers the Special to The Republican

cer is 84%. However, for men a gene mutation that causes following symptoms of breast cancer men should diagnosed with Stage 1 breast the breast cancer, and this gene mutation can be passed cancer, the 5-year survival be aware of:

· A lump or swelling, which is often (but not always) painless · Skin dimpling or puckering · Nipple retraction (turning inward) · Redness or scaling of the nipple or breast skin · Discharge from the nipple.

The standard of care for treatment of men with breast cancer remains mastectomy with lymph node evaluation through sentinel lymph node biopsy (checking 2-3 lymph nodes under the arm). Men may still benefit from chemotherapy or hormonal therapy, depending on the characteristics of their specific breast cancer.

Overall, the 5-year survival rate for men with breast can-

rate is 100%.

Factors that can raise a man’s risk for developing breast cancer include: · Age – most men are

diagnosed with breast cancer in their 60s

· Family history of breast disease – 1 out of 5 men

who develop breast cancer has a family history of the disease

· Inherited gene mutations – men with a mutation in the BRCA2 gene

· Elevated levels of estrogen associated with liver disease, low-doses of estrogen-related drugs, and the rare genetic disease known as Klinefelter’s syndrome

· Testicular conditions.

“A percentage of men with breast cancer have inherited

on to his children. Most breast cancers are not caused by this gene mutation, and researchers continue to work on establishing cause and effect so we can avoid risk factors and prevent the disease,” said Dr. Brady.

may be the key to prevention, such as: · Maintaining an ideal body weight

· Eating healthy · Restricting alcohol consumption

· Exercising regularly.

For more information

on the Baystate Regional Similar to all cancers, leading a healthy lifestyle Cancer Program, visit Bay-

stateHealth.org/Cancer, or to request an appointment call 413-794-9338. Baystate Health will hold its annual Rays of Hope – Walk & Run Toward the Cure of Breast Cancer on Oct. 27. For more information, visit BaystateHealth.org/RaysofHope

Breast Surgeon Dr. Elizabeth Brady of the Baystate Breast and Wellness Center

Imagine a

GENERATION without breast cancer

We walk and run for the survivors, for the fighters, for the research and for those we carry in our hearts. Make the #ROHPinkyPromise, start fundraising, and join the movement on Sunday, October 27 with more than 20,000 others at the Rays of Hope Walk & Run Toward the Cure of Breast Cancer.

BaystateHealth.org/RaysofHope CS11398

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D8 | SUNDAY, OCTOBER 6, 2019

THE REPUBLICAN | MASSLIVE.COM

New guidelines on expanded

risk assessment for genetic mutations linked to breast cancer

include survivors

By Anne-Gerard Flynn

Special to The Republican

Veteran Baystate Health medical oncologist Grace Makari-Judson was joined

by Dr. Dawn Brooks, a new medical oncologist at the Baystate Regional Cancer Program, in being asked here about new guidelines from the advisory panel, the U.S. Preventative Services Task Force, designed to help locate a greater number of women, including survivors of breast cancer themselves, who may be at risk for an inherited gene mutation linked to the disease. In August, the USPSTF updated and expanded its recommendations for risk assessment, counseling, and genetic testing for the BRCA1 and BRCA2 genes whose certain mutations can pose a risk for breast cancer.

Makari-Judson is co-director of the Rays of Hope Center for Breast Cancer Research, chair of the Baystate Health Breast Network and is professor of medicine at the University of Massachusetts Medical School-Baystate.

Brooks earned her medical degree from the University of Florida College of Medicine. She holds a doctorate in molecular biology from Princeton University in New Jersey and both bachelor’s and master’s degrees in biological sciences from Stanford University in California. She completed a residency and internship at Dartmouth-Hitchcock Medical Center in New Hampshire in 2013 and a fellowship in medical oncology at Oregon Health and Science University in 2015.

Who is the USPSTF now recommending also be assessed for risk of inherited breast cancer and how do these guidelines on BRCArelated cancer apply to breast cancer survivors?

The USPSTF recommends that a woman with a personal history of breast or ovarian cancer as well as a woman with a family history associated with mutations in breast cancer susceptibility 1 and 2 (BRCA½) be evaluated by her primary care provider to determine whether referral to a genetic counselor or other appropriately trained specialist is indicated.

The recommendation to evaluate women based on their personal history is new with this update.

Confidence CONTINUED FROM PAGE D1

custom prosthesis “as long as you have a prescription from your practitioner.”

“Medicare is the only insurer that does not cover this procedure,” said WalshAframe who supports the “Let Her Decide Campaign” for the U.S. Congress to pass legislation for Medicare to cover the custom breast prosthetic that she said is the “only custom prosthesis that Medicare does not cover” and the one she feels “truly does make a woman feel like herself ” in how it can be designed for an exact fit.

“Women of Medicare age are of the age that has the highest rate of breast cancer diagnosis,” she added of the rate for those over 70.

Walsh-Aframe, whose shops carry a variety of wigs,

What is the evidence behind the recommendations and are there any projections on how they could reduce breast cancer mortality rates among the targeted population?

Five to ten percent of breast cancers are linked to inherited mutations in the BRCA1 and BRCA2 genes.

A woman found to carry a mutation in either gene may take various steps to significantly reduce her risk of developing breast or other cancer, or to detect cancer at the earliest possible stage when the chance for cure is greatest.

If she has already been

How does a primary care provider determine who should be given a risk assessment now under these expanded guidelines and what does this involve?

A primary care provider considers a woman’s medical and family history to determine whether or not to pursue further evaluation for a hereditary cancer risk.

A variety of brief questionnaires, as listed in the USPSTF recommendation statement, are available for this assessment. Scoring above the questionnaire-specific threshold prompts a provider to discuss the option of further evalua-

increases her risk for developing breast, ovarian or other cancer.

Such evaluation includes review of the woman’s medical history and ethnicity as well as the medical history of her extended family, focusing on incidences of cancer or known mutations that increase the likelihood of developing cancer.

Such specialists use criteria set by expert groups, such as the National Cancer Care Network and the American College of Medical Genetics, to determine which individuals are candidates to undergo genetic testing.

If a woman or man meets

Genetic test results may be positive, negative or show a variant of uncertain significance.

Meeting with a cancer A positive result tells us that genetic specialist provides a a mutation is identified that woman the opportunity to un- is known to be “pathogenic,” dergo a thorough evaluation meaning it is associated with of her likelihood of having higher cancer risks. inherited a mutation that If a pathogenic mutation

Care, and a rack of sportstype bras.

“I think I had one molded cup like the T-shirt bra. Now, we have so much and we are always getting even more new products,” said WalshAframe, holding a small form of removal soft layers designed to fit over a breast.

“For example, sometimes a woman will have implant reconstruction and when they do that surgery, they put tissue expanders (temporarily under a chest muscle at the new breast site) that are gradually enlarged with saline to create space big enough for the implant (to match the opposite breast.) A woman will sometimes feel she is not even in her shape going through that and so we have this form whose layers we can take away as she gets fills until she just has the one layer.”

External breast prostheses

“Most insurances cover three bras so I may start out with two different ones and say let’s wear them both and see which one is the more comfortable one for you and let that be the third.”

She said the right fit depends on the “women’s surgical site, her size.”

“If you are petite, maybe I will use a petite bra,” WalshAframe said.

“If you a full-figured, we have what we call M frame bras which give a lot of lift and support. If a woman is a few years post-op sometimes I will use an underwire. Each case is different. Sometimes women say, ‘You know what, I just want a comfortable bra.’

I will always ask the woman what type of bra were you wearing before your breast surgery to see if I can get back to that.”

Walsh-Aframe said “each case is different as well” in

(ANNE-GERARD FLYNN PHOTO)

hats and headscarves, is also working with U.S Rep. James P. McGovern on legislation to assist chemotherapy patients and those affected by alopecia on getting Medicare coverage for wigs that most insurers cover. The bill as introduced would allow for such coverage if deemed a medical necessity by a provider as “part of a proposed course of rehabilitative treatment.”

On the morning of this interview, Walsh-Aframe was busy unpacking her off-theshelf products in a room in Mercy’s Breast Care Center.

“When I started, I did not have this selection,” WalshAframe said.

She sat surrounded by several dozen stacks of bras with pockets in a myriad of sizes and colors, as well as prostheses in soft, pink suede, zippered-cases from manufacturer American Breast

Are you in agreement with this update to the 2013 guidelines and do you see it as a real step forward in terms of cancer prevention among a certain segment of women at risk?

The updated guidelines emphasize a three-step process.

First, a primary care provider needs to ask about family history.

Second, the primary care provider needs to review an individual’s personal and family history to see if they are appropriate for referral to a cancer genetics specialist for consideration of genetic testing.

Third, the cancer genetics specialist will determine if the individual meets criteria for testing, counseling the individual and then perform testing. Not everyone that is referred for personal or family history ends up meeting criteria for testing.

Because the best person in the family to have genetic testing is the individual who has had a cancer diagnosis, we want to identify breast and ovarian cancer survivors and if they meet criteria, encourage testing.

Reasons that a breast cancer survivor has not had testing may be because some of the criteria have changed since they were diagnosed, but also because family histories change.

Although medical oncologists are very much in tune to thinking about hereditary cancer syndromes, many of these women may no longer be followed by their oncologists.

That is why these recommendations seek to encourage primary care providers to assess individuals for genetic risk and refer them when appropriate.

There are clearly men and women who unknowingly car-

Veteran Baystate Health medical oncologist Grace Makari-Judson is co-director of the Rays of Hope Center for Breast Cancer Research, chair of the Baystate Health Breast Network and is professor of medicine at the University of Massachusetts Medical School-Baystate.

treated for breast cancer, these steps may reduce her risk of developing a second breast cancer or other type of cancer.

More intensive cancer screening may be adopted to detect cancer earlier, and she may elect to take medication or undergo surgery to decrease her risk of developing cancer.

A woman should have the opportunity to be fully informed about the advantages and disadvantages of each intervention in order to make a decision best suited to her own situation and personal values.

is identified, it is important that individuals are counseled regarding strategies for more intensified screening and prevention.

Negative means that no known pathogenic mutations were identified. This doesn’t mean that an individual would never get cancer, so screening is still important.

A variant of uncertain significance indicates mutations that we do not yet know the significance of and so these do not lead to a recommendation to do anything differently.

tion by a specialist trained in genetic testing.

The Baystate Health Breast Network has a straightforward guideline to assist clinicians in determining who to refer for consideration of testing.

What does any recommended genetic counseling involve and when would it lead to a recommendation of genetic testing?

criteria for testing, there will be a personalized discussion about the advantages and disadvantages of proceeding with genetic testing.

What would genetic testing show and what might be indicated as a result of the genetic testing?

today include ones that are weighted with silicone as well as others that are made of foam or fiberfill. Some fit inside the expandable pocket of a mastectomy bra. Others can be worn against the skin and some can be attached to the chest wall with special adhesive.

Most insurance companies cover costs for a certain number of mastectomy bras per year as well as a prosthesis, and Medicare covers some external breast prostheses including a post-surgical bra after a mastectomy. Patients are advised to check their coverage and get a prescription from their provider that states their diagnosis and need.

Walsh-Aframe said she usually sees a woman “a couple of times.”

“The first visit I take a history and I will do the fitting,” Walsh-Aframe said.

ry cancer susceptibility genes and have yet to be identified.

These guidelines are a step in the right direction.

What would you advise breast cancer survivors who were successfully treated years ago in terms of being assessed now for their risk of an inherited mutation? A decision to do so could involve a lot of new anxiety and aren’t such survivors already being followed for recurrence?

At Baystate’s Breast Cancer Survivorship Clinic, women are questioned at each visit regarding any changes to their family history.

If they are identified to carry a hereditary susceptibility gene, this does not impact their risk of recurrence, but does have impact on their risk of a second cancer.

It gives them an opportunity to prevent second cancers and allows family members to be proactive and hopefully avoid a cancer diagnosis altogether.

At the Baystate Family Cancer Risk Program, our team from medical oncology, cancer genetics and breast specialists, review personal and family histories of cancer to determine if individuals referred to us meet criteria for genetic testing.

Guidelines for referral are meant to be broader than guidelines for testing. We cast a wide net so that we don’t miss anyone.

The USPSTF guidelines encourage primary care providers to refer individuals for testing.

Cancer genetic counselors and medical oncologist follow the National Cancer Care Network and American College of Medical Genetics guidelines for determining criteria for testing.

Insurance companies look to those guidelines to determine coverage for testing.

What the USPSTF guidelines recommend, we have been encouraging for a long time.

Cancer genetics has become increasingly complex and there are now many more genes beyond BRCA½ that may be associated with hereditary risk.

We know more now than we did in 2013 about how to watch high risk individuals more closely and lower their cancer risks.

terms of whether a woman needs a prosthetic device to recreate her natural breast.

“Sometimes I can use a molded cup like a T-shirt bra and we don’t need anything,” Walsh-Aframe said.

“But most of the time there is a little something that we will put in there.”

She added, “Women are so grateful and appreciative” to both be properly fitted post-surgery and to have a choice in bras of “at least 50 different styles, different prosthetics.”

“It helps a woman move forward with her life,” said Walsh-Aframe of breast cancer survivors being able to have choice in deciding how they want to handle what has changed.

“You have to adjust to your new skin, and that is paramount to your recovery because you need to feel good.”