The road to better breast health

Education / Featured Sliders / Health & Fitness / HER Health / Stories / September 12, 2017

Capital Region Medical Center experts share breast cancer prevention, treatment
and survivorship information research shows one in eight U.S. women, about 12 percent, will develop invasive breast cancer over the course of her lifetime.
In Jefferson City, the staff at Capital Region Medical Center and its Goldschmidt Cancer Center works hard as a team to help patients diagnosed with breast cancer achieve remission through a multi-disciplinary action, survivorship program, innovative procedures and equipment, and a plethora of supportive resources.
In recognition of Breast Cancer Awareness in October, HER Magazine recently sat down with oncologists Dr. Raonak Ekram and Dr. Nolyn Nyatanga, mammographer Kari Fisher and mammography and ultrasound supervisor Sheila Kleffner to discuss breast cancer detection, treatment and screenings, and the road to better breast health.
HER: What signs do women need to be aware of in determining if they need to be examined for possible breast cancer?
Dr. Ekram: The main thing is we want to detect it before people have any signs, which is where mammography comes in and plays such an important role in early detection. There have been lots of different conflicting recommendations of yearly mammography, twice a year mammography, what age do you start, etc. The best way for women to muddle through that is to talk to their doctor, because there is such a big difference in what we recommend (based) on what the woman’s personal history is, her family history is. We take into account all those factors … in addition what the best modality is.
Dr. Nyatanga: To add to that, there is conflicting data on when to start screening, but we have a good number of patients who are diagnosed before the age of 40 where the most aggressive screening recommendations are. They also tend to have the most aggressive tumors and higher risk for cancer. We strongly recommend they … know their breasts, have monthly breast cancer screenings and monitor for lumps, swelling, redness that is unusual, drainage, pain – anything that is abnormal for them.
HER: Why are mammograms so important when detecting breast cancer and ensuring breast health? 
Fisher: Like Dr. Ekram said, they are important to find breast cancer before you are symptomatic. You have a better chance of being able to treat it and have a better outcome with a mammogram. Mammography can catch it early, and we can find tiny calcifications, which are like little grains of salt; we can find things that are as small as 2 millimeters or smaller, which you are not going to feel. We can find it before you feel it, especially with our 3D mammography (which has been at CRMC since 2013, making it the first facility to offer 3D mammography and increased the likelihood of finding breast cancer by about 40 percent). … A lot of people skip out on doing their mammograms for years because they think it is horrible. … With the 3D mammography and the breast cushions that we use and the overall dynamic of the machine, it is so much better. … People come in that have put it off for five years, 10 years, and they say, “Why did I do that; it’s
not that bad.” Don’t put it off. It is 10-15 minutes out of your life, and it makes saving your life much easier.
Kleffner: We also perform 3D breast biopsies. We are the only facility in town that does that. We also perform the upright biopsies for patients who cannot lie down or have obstructions where they can lay on the table, so they
can sit in a chair.
HER: What are risk factors that are in a person’s control and not in their control that can contribute to developing breast cancer?
Dr. Nyatanga: In terms of risk factors, the majority of patients don’t have a family history of breast cancer or any genetic factors. About 10-15 percent are genetically inherited.
Dr. Ekram: Many people don’t know that age is big risk factor. The older you get, the more likely you are going to develop breast cancer.
Dr. Nyatanga: Another risk factor is alcohol intake. If you have more than two alcoholic beverages a day, you are more likely to develop different types of cancers. Smoking and other things like various treatments, chemotherapy, late age of first pregnancy, late age of breastfeeding, obesity … have a higher risk of developing breast cancer.
HER: Once someone is diagnosed with breast cancer, what process does medical staff at CRMC/Goldschmidt Cancer Center have for those patients moving forward?
Dr. Ekram: We have a multi-disciplinary approach to everyone diagnosed with breast cancer. As it begins in the mammography department as an abnormal mammogram that is passed onto biopsy, we are pretty good on turn-around rates on biopsy as soon as we detect abnormality in a mammogram. Once the biopsy is completed, the patient is referred back to their primary care physician for discussion on results of biopsy. If that biopsy is positive for cancer, that patient will be referred to the different modalities that treat breast cancer – surgery, oncology, as well as radiation therapy.
We try to get the patients in within 24 hours of receiving a consult, so we can alleviate some of the anxiety of knowing you have breast cancer. Once that is done, things move forward pretty quickly in terms of our modalities, discussing the case and developing the treatment plan that is best for the patient. We do have a multi-disciplinary conference where we meet as physicians (the oncologist, radiation oncologist and surgeon). We also have the pathologist
who is reading the slides that determine if they have cancer, the radiologist who reads the mammograms and performed the biopsy, the nurses in the patient care. We present the case, discuss the case and come up with a plan as a team in how we are going to approach getting the patient to treatment and survival as soon as possible.
The reason why we involve all these modalities is because they are all involved at some point with the patient. The sequence of how things happen, the duration of how things occur is really determined through each individual case.
HER: I understand CRMC has a survivorship program. What is its role and how do they help breast cancer patients? 
Dr. Ekram: During the conference, our cancer survivorship nurse is present. We have a very strong survivorship program for breast cancer. The nurse is involved at the time of diagnosis and walks the patient through the different steps. She also helps create a document, which records all the different treatments, the times, what sort of follow-up is necessary, up to five to 10 years out from diagnosis. Everything is very clear for the patient, because everything can be very confusing. They are seeing three different doctors, getting mammograms and MRI’s, etc. People are just overwhelmed, not just for the time but also what that means for their overall health in the future. It is great for them and for their providers, because we get that document as well and we are all on the same page. … We are in year three and it has been a program in development. … We just have one nurse so there is continuity. She is not only in charge of those face-to-face conversations, but she also is in charge in developing the document that goes out to physicians and other providers.
Dr. Nyatanga: The survivorship is really critical for patients, because they go from a point of seeing them frequently and anxiety builds with decreasing visits to your doctor if they are doing well. It provides them comfort and shows them a plan for the future.
HER: What are some of the other resources and services you have available to breast cancer patients and their families? 
Dr. Nyatanga: In supportive services, we believe in a holistic approach to patient care. We have nutritionists that are involved in our patient’s care. … Physical therapists help as they are undergoing their treatment course. We have Boost program here (including annual Boost BBQ fundraising event, held Aug. 25 this year, that raises funds to give free Boost and Ensure for patients as they are going through treatment and maintain good nutrition). We also have a breast cancer support group (Encouragement Through Caring) that meets monthly.
Dr. Ekram: We also provide social services. Every patient that comes in receives a distressed screening, and if they are having issues at home with various different things that add on to the big pot of overwhelming situations, we do involve a psychiatrist or psychologist to help patients and families to deal with everything that is going on.
Dr. Nyatanga: We also offer clinical trials. We have the opportunity to offer them in the community setting and give patients access to new treatments that are available. We are able to not only offer more options of treatments for patients, but we also are able to participate in moving the field of oncology forward. That is very rewarding for a lot of patients that they are participating in what may be the next treatment that could associate cancer with a cure one day.
Dr. Ekram: We have access to more than 150 clinical trials nationwide through the National Cancer Institute … In the setting of breast cancer, we have anything from trials that are classified as treatment trials that new to what is standard right now. We also have cancer control trials, which look at control of certain symptoms that are associated with breast cancer (such as hot flashes). We do have a genetic counseling program. … We do try to sort out who is at risk for a genetic predisposition to breast cancer and we offer them counseling through a geneticist that comes to Goldschmidt and coordinates with the oncologist to do the appropriate genetic testing for mutations in genes that might predispose to breast cancer. We do have a high risk breast cancer clinic where we look at patients who might be at higher risk of developing breast cancer, whether because it is family history or a genetic abnormality.
HER: What are some rewarding moments you have had in helping breast cancer patients?
Fisher: I’m a stepping stone for patients. So I see them almost every six months for at least two years, and sometimes five years.  … It is wonderful to see how successful it has been, especially when they hit that five-year mark of being cancer free. You get really close with those patients. When they come back every six months, they get really anxious and are just waiting for those results. We show them to the radiologist while they are there and then we provide them information before they leave. We can say, ‘Yes everything is stable, and we’ll see you again in six months.’ It sometimes it gets to the point where we’ll see, ‘We’ll see you next year.’ We get a lot of hugs for that one.
Dr. Nyatanga: It is comforting for them to know they are in the right place and they have the right team taking care of them. They have people to walk with them through this journey, wherever it leads. They have a place where they can feel comfortable knowing they have the best of care. … That is rewarding.
Dr. Ekram: In general, what is most rewarding is seeing a transformation of a patient that comes in completely anxious, distraught and feeling as though this is worst thing in the world to have happened to them, and helping them navigate through that to realize that cancer is not the end all.  … We do a very good job of getting patients in that process quickly and holding their hands through the process; they need that. Their hands are held not just from one provider, but multiple providers, multiple nurses; we are a team and we are a family. We all work hard together to try to help someone through a difficult time.
For more information, visit or call the Goldschmidt Cancer Center at573-632-4800. For more information about mammography services at CRMC, call 573-632-5265. 

The Expert Panel

(picture from left to right)

Kari Fisher has worked as a mammographer at Capital Region Medical Center for 16 years. She went into the field after she graduated from X-ray school at Rolla Technical Institute/Center. She has also cross-trained in orthopedic X-ray.
Sheila Kleffner is the ultrasound and mammography supervisor at Capital Region Medical Center. She has worked in the field for 18 years, and graduated from University of Missouri in Columbia.
Dr. Raonak Ekram, M.D., is an oncologist at Goldschmidt Cancer Center, with treating breast cancer patients as a primary part of her practice. She attended medical school at the University of Kansas, doing her residency at the University of Oklahoma Health Services and fellowship at Wake Forest University. In the field for 17 years, she has been with Capital Region Medical Center for eight years.
Dr. Nolyn Nyatanga, D.O., is an oncologist at Goldschmidt Cancer Center. She attended medical school at Kansas City University of Medicine and Biosciences, doing her residency with the Cleveland Clinic Foundation and fellowship with Hofstra – North Shore in New York. She has been at CRMC for two years.

CRMC support services for breast cancer patients

−Survivorship program
−American Cancer Society’s Patient Education and Resource Center
−Cancer Wellness program: CRMC physical therapists and exercise specialists design programs to educate on all facets of diet and exercise to emotional and social support for those with cancer.
−Capital Region Center for Mental Wellness
−Home health, outpatient therapy services and social work services
−Outpatient therapy services and social work services
−Capital Region Sam B. Cook Healthplex and nutrition services
−Encouragement Through Caring (breast cancer support group): meets 6-8 p.m. the second Thursday of each month at Goldschmidt Cancer Center.

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Madeleine Leroux

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