The most important message about breast cancer in 2014 is that, unlike some cancers, the words “survivor” and “support groups” are now associated with it, Dr. Denise Fraser said at a seminar at the Martha’s Vineyard Hospital’s health fair last Saturday.
Currently, about one in eight women in the U.S. get breast cancer, she noted in her presentation. However, success in earlier diagnosis through improved technology has resulted in detection and removal of smaller tumors, which has led to a higher survival rate.
A 75-year-old woman in the audience asked if it was still necessary for her to get annual mammograms, since there was probably a lesser chance of developing breast cancer at her age.
“No, it’s probably more,” Dr. Fraser said. “The older you are, the higher risk there is for breast cancer.”
The odds increase dramatically, as shown on a chart in her PowerPoint presentation on “Understanding Breast Conditions.” The number of women diagnosed with breast cancer from ages 30 to 80 rose by decade: 1 in 5,900 at age 30; 1 in 1,200 age age 40; 1 in 590 at age 50; 1 in 420 at age 60; 1 in 333 at age 70; and 1 in 290 at age 80.
Although changes in women’s bodies occur more slowly as they age, Dr. Fraser said, yearly mammograms are still recommended, with the exception of those who are suffering from another medical condition or multiple health problems.
Although Dr. Fraser performs a variety of surgical procedures in her role as chief of surgery at MVH, she has a special interest in breast cancer. She started her practice in general and trauma surgery at Fairfax Hospital in Northern Virginia, and broadened her experience in laparoscopy and diseases of the breast at the Fairfax, Fair Oaks and Reston Hospitals. Before coming to MVH in 2002, Dr. Fraser served three years as the director of the Breast Health Program at the Roger Williams Medical Center in Providence, R.I.
She said the most important factor in her decision to come to MVH was being able to provide the same level of care to her patients as she did at Roger Williams, which she has been able to do. Among the procedures Dr. Fraser performs are examinations following abnormal mammograms, image-guided biopsies, cyst removals, lumpectomies, breast-sparing mastectomies, and sentinel node procedures.
Imaging studies available at MVH include mammograms and ultrasound. Two radiologists from Mass General Hospital, Dr. Deborah Hall and Dr. Deborah Termeulen, are at MVH once a week to read mammograms and call women whose mammograms indicate they need follow-up with additional films or an ultrasound. Dr. Fraser said she touches base with them often, to find out which patients are of concern so she can arrange to see them.
“After we see something on a mammogram or feel something a physical exam, we may send someone for an ultrasound,” Dr. Fraser said. “It tells us if something is solid or fluid-filled, and that’s a really big difference. Something with fluid is usually a cyst, which is benign.”
Cystic lesions are far more common, especially in younger women, Dr. Fraser said.
“About 80 percent of breast lesions are probably benign; my concern rises according to the person’s age,” she added.
Dr. Fraser said invasive ductal carcinoma, which begins in the milk-carrying ducts and spreads beyond them, is the most common type of breast cancer, making up nearly 80 percent of all diagnoses.
Biopsies are done to determine whether or not a lesion is cancerous, and whether it requires a lumpectomy to remove just the lump, or a mastectomy, to remove all of the breast tissue and some lymph nodes, but not muscle.
At the time of surgery, Dr. Fraser said she injects blue dye that travels into surrounding “sentinel” lymph nodes, so she can identify and remove, on average, about three of them to check to see if cancer cells have spread. If those are positive, the patient would return to have other nodes removed and checked, to determine the stage of the cancer and what follow-up treatment would be required — for example, medication, chemotherapy, and radiation.
If a patient wants to have breast reconstruction, Dr. Fraser said she and a plastic surgeon coordinate their care so that when she finishes the mastectomy, the plastic surgeon follows up with a procedure to prepare the area for the addition of a prosthesis at a later time.
Fortunately for Martha’s Vineyard patients, Dr. Fraser said, MVH now has a hematology and medical oncology team from Mass General Hospital that provides more comprehensive, integrated services for a wider range of some specialty cancers, such as breast cancer. The team rotates visits to MVH, and chemotherapy is administered under their guidance.
The availability of radiation treatments in Falmouth now, instead of having to go to Hyannis as in the past, is also a welcome convenience for Vineyard patients, Dr. Fraser said.
The subject of mastectomies, particularly preventative ones to guard against future breast cancer, has been on many women’s minds since last May, Dr. Fraser said, following news reports that actress Angelina Jolie opted for elective bilateral mastectomies. Ms. Jolie underwent the surgeries after genetic testing revealed she carries a mutation in the BRCA1 gene, with an 87 percent risk of developing breast cancer. BRCA2 gene mutations also carry an increased risk of developing breast and/or ovarian cancer.
Dr. Fraser said since then, she has had women come in and ask her whether they should do the same thing, especially if they have a family history of breast disease.
“I tell them to get genetic testing done, and see if it is truly genetic,” Dr. Fraser said. “Then, if they are positive, they could think about mastectomies. If you have the BRCA1 gene, mastectomy is probably the best prevention for breast cancer. It’s not 100 percent, but it’s about 95 percent effective.”
Dr. Fraser said possible factors that may help lower a woman’s risk of breast cancer include exercise, avoiding a high fat diet and obesity, and hormone replacement. Most breast cancer is not inherited through faulty genes, other than the BRCA1 and BRCA2, she added. However, women with close relatives who have been diagnosed with breast cancer, such as a sister, mother or daughter, do have a higher risk.
For women who want to be proactive in their breast care, Dr. Fraser said the recommendation is monthly self-exams and an annual clinical exam by a healthcare provider and screening mammogram, starting at age 40 — or at 35 for those with a family history of breast cancer.
As for those who are concerned about the risk of radiation from a mammogram, Dr. Fraser said, “If you fly across the country from New York to California, you’re getting more radiation than you do from a mammogram.”