breast cancer

Cooling Off Chemotherapy’s Side Effects

UConn Health’s Carole and Ray Neag Comprehensive Cancer Center is the only Connecticut institution outside Fairfield County to offer its breast cancer patients optional scalp-cooling therapy to reduce their chances of hair loss from chemotherapy treatments.

“Chemotherapy-induced temporary hair loss is one of the most common and stressful side effects breast cancer patients experience,” says Dr. Susan Tannenbaum, chief of the Division of Oncology and Hematology at UConn Health. “Anything we can do to limit a woman’s distress while she undergoes breast cancer care is essential for the patient’s overall holistic health.”

Research studies have shown that the FDA-cleared DigniCap, made by Dignitana Inc., is nearly 70 percent effective in reducing hair loss by at least half in breast cancer patients receiving chemotherapy.

While a patient undergoes intravenous chemotherapy treatments, the computerized cooling cap system circulates cooled liquid through a tight-fitting silicone cap. The cooling therapy works to limit chemotherapy’s side effects by constricting the scalp’s blood vessels, which limits the drug’s reach to the hair follicles and also slows the rate of hair cell division.

The technology’s arrival was spearheaded by donations from UConn Health professors Dr. William B. White and Nancy M. Petry, Ph.D., of the Pat & Jim Calhoun Cardiology Center, among others, and grant funding awarded to the UConn Foundation by the CT Breast Health Initiative.

A Path With Less Pain

Genetic Clues Show Which Breast Cancer Patients Are Prone to Post-Treatment Agony

By Kim Krieger

woman chooses between two marked paths


Sickness and pain go together. We think of them as a matched pair, a married couple. Pain signals sickness, sickness causes pain. But this is not always the case. Especially in early stage cancer, often there is no pain — until the patient is treated.

UConn Health researchers have discovered genetic clues that could eventually reveal which people might be vulnerable to post-treatment pain, they reported in the June issue of Biological Research for Nursing.

“We’ll hear women say ‘If I knew the pain would be this bad, I’d have rather died of breast cancer,’” says Erin Young, a UConn Health pain geneticist. Young and her research partners wondered: Can we really call such treatment a “cure”? It would be better if we could know in advance which patients might suffer from which treatments.

Young worked with data collected as part of a broader study involving nurse-scientist and director of UConn’s Center for Advancement in Managing Pain Angela Starkweather, neuroscientist Kyle Baumbauer, and colleagues at the University of Florida and Kyung Hee University in Seoul, South Korea. Young’s analysis found that common variants in two genes contribute to certain symptoms during and after chemotherapy treatment for breast cancer. The results could one day help patients, and their nurses and doctors, make informed treatment decisions and prepare for — or avoid — damage to patients’ quality of life.

The researchers looked at the genetics of 51 women with early-stage breast cancer who had no previous chemotherapy and no history of depression. The women rated their well-being both before and after treatment for cancer, reporting on their pain, anxiety, depression, fatigue, and sleep quality. Young and her colleagues then looked for connections between genes and symptoms.

Can we really call treatment a “cure”? It would be better if we could know in advance with patients might suffer from which treatments.

They looked at three genes in particular: NTRK1, NTRK2, and COMT. These genes are already associated with pain from other research. NTRK1 is connected to rapid-eye-movement sleep (dream sleep), and a specific variant is linked to pain insensitivity. NTRK2 is associated with the nervous system’s role in pain, fatigue, anxiety, and depression. And some common versions of COMT are linked to risks of developing certain painful conditions. The researchers also chose these genes because the variants associated with pain, fatigue, and other symptoms are fairly common, making it possible to get meaningful results from a sample size of just 51 people.

After the analysis, a couple results jumped out at them. Two of the genes, COMT and NTRK2, had significant correlations with pain, anxiety, fatigue, and sleep disturbance. The other gene didn’t.

“I always like having a yes/no answer — if we get some nos, then we know the analysis wasn’t just confirming what we wanted to see,” says Young.

Such a quick look at a small sample of cancer patients can’t give all the answers as to who is going to develop postoperative and post-chemotherapy pain. But what they did find is very suggestive. Some of the gene variants were associated with symptoms before surgery. For example, women with two copies of the A variant of COMT reported more anxiety than other women did. COMT was also linked with pain, both during and after cancer treatment: women with one variant of COMT reported more pain, while women with a different variant reported less.

Fatigue also seems to have a genetic component. Women with one copy of the T variant of NTRK2 reported more posttreatment fatigue than others, and women with two copies reported much more.

Surprisingly, the genes linked to various symptoms worked independently, and didn’t work together to increase overall pain and discomfort. In other words, they weren’t synergistic; they didn’t make each other worse.

The gene variants predicted pain and fatigue above and beyond any differences explained by treatment effects.

The genes’ effects were also independent of the type of treatment the women received; the 51 women followed a number of different types of treatments: different surgeries, different chemotherapies. The gene variants predicted pain and fatigue above and beyond any differences explained by treatment effects. Other experiments by other researchers have shown the COMT variants are connected to the development of skeletal muscle pain.

“So it’s not just our study but the entire literature that suggests COMT could be playing a role in how sensitive you are to many different types of pain,” says Young.

“We are focusing on how we can identify women who are at risk of experiencing persistent pain and fatigue, as these symptoms have the highest impact on reducing quality of life after treatment,” says Starkweather. “It’s a great example of how we can make progress toward the goal of personalized health care. The next piece of the puzzle is to identify the most effective symptom-management interventions based on the patient’s preferences and genetic information.”

Young, Starkweather, and their colleagues say further research, ideally looking at a person’s whole genome, is needed to refine the connections between genetic profiles and the risk of pain. With that knowledge, patients could work together with their care team to develop individualized symptom-management plans. Properly prepared patients would feel more control and less suffering. And perhaps the cure would no longer hurt worse than the disease.

The Power of MRI

A UConn Health physician is seen reviewing an MRI brain scan.

A UConn Health physician is seen reviewing an MRI brain scan. At UConn Health, doctors are pioneering ways to use MRI technology to diagnose and monitor a range of conditions affecting many parts of the body Photo: Peter Morenus


Magnetic resonance imaging (MRI) has come a long way since the technique was first used in the U.S. in the late 1970s. UConn Health is now taking this powerful, non-invasive imaging tool to the next level.

UConn Health physicians in a variety of specialties are using the technology — which captures images of the inside of the body using a large magnet rather than radiation — in new ways to detect and monitor illnesses.

Prostate Cancer

Dr. Peter Albertsen, chief of UConn Health’s Division of Urology, currently follows 100 patients with localized prostate cancer, which is slow-growing, using advanced multiple-parametric MRI imaging. The technology has now replaced ultrasound as the imaging method of choice for prostate cancer. The technique yields multiple imaging sequences of the prostate, providing information about the anatomy, cellular density measurement, and vascular supply.

There is growing evidence to support the idea that the best treatment plan for low-grade prostate cancer is “watchful waiting” to monitor its progression, instead of immediate surgery or radiation. Albertsen’s practice of active surveillance, and not intervention, for localized prostate cancer was reinforced by a recent long-term study published in September in the New England Journal of Medicine, on which Albertsen served as a consultant.

The technology is extraordinarily helpful, allowing us to avoid invasive biopsy testing and associated risks of bleeding and infection.

Liver Disease

UConn Health is the first in Greater Hartford to use MRI to measure the stiffness of patients’ livers to reveal disease without the need for biopsy. Its MR elastography technique involves placing a paddle on a patient’s skin over the liver during MRI to create vibrations and measure the velocity of the radio waves penetrating the organ. This can indicate a stiffer liver and help diagnose fibrosis, cirrhosis, a fatty liver, or inflammation associated with hepatitis. The initiative is led by Dr. Marco Molina, radiologist in the Department of Diagnostic Imaging and Therapeutics.

“The technology is extraordinarily helpful, allowing us to avoid invasive biopsy testing and associated risks of bleeding and infection,” Molina says. “Plus, with the obesity epidemic, patients developing nonalcoholic steatohepatitis (NASH), or fatty liver, can receive earlier diagnosis and take action to reverse their disease’s progression with diet and exercise.”

Breast Cancer

The new Women’s Center at UConn Health has opened its state-of-the-art Beekley Imaging Center, featuring advanced breast cancer screening. Dr. Alex Merkulov, associate professor of radiology and section head of women’s imaging, and his team are conducting research to test the effectiveness of using an abbreviated, five-minute MRI scan to confirm or rule out a breast cancer diagnosis. Typically, an MRI test takes 20 minutes, but researchers are seeing that a briefer MRI scan of just a few minutes can help provide a definitive answer to whether an abnormal breast growth is cancer or not — and potentially help women avoid the biopsy process.

Arthritis

The UConn Musculoskeletal Institute is now researching the use of MRI to assess and map the strength, weakness, and underlying makeup of a patient’s cartilage, especially for those with arthritis. The tool can allow orthopedic experts to identify any thinning or loss of cartilage in the body, which signifies moderate to late-stage disease. In early stages of arthritis, MRI can help pinpoint early morphological and subtle biochemical changes in cartilage.

Neurological Disorders

In neuroradiology, UConn Health is using the power of MRI to differentiate brain tumors, to detect strokes, to assess dementia, to diagnose multiple sclerosis, to evaluate traumatic brain injury, to find the source of epilepsy, and to guide brain surgery. In March 2017, leading neuroradiologist Dr. Leo Wolansky joins UConn Health to advance its research and chair the Department of Diagnostic Imaging and Therapeutics. Wolansky’s neuroimaging research has focused on enhancing understanding of MRI and its contrast agents, especially for multiple sclerosis and brain tumors. He also specializes in the hybrid imaging modality PET-MRI.

“Thanks to the power and advancement of MRI, doctors can see early evidence of disease and seize the opportunity to intervene and improve their patients’ health,” Molina says.

On the Ground for Breast Cancer Awareness

breast cancer screening


Rashea Banks’ first patient at Community Health Services, a federally qualified community health center in Hartford’s North End, was a woman who lost several family members to breast cancer.

The woman, a Latina, said she wanted to get a mammogram, but did not know where to go.

“This woman’s experience, and others, are fueling my determination, ambition, and passion to reach as many women as possible and navigate them through early detection in order to prevent diagnosis at a later stage of breast cancer,” Banks said shortly after she started as UConn Health’s Community Breast Navigator in September 2015.

Visit UConn Health for information on UConn Health’s Breast Cancer Program.

Today, Banks has provided one-on-one counseling about breast cancer and the significance of early detection to more than 300 uninsured and underinsured women. She has referred 120 for breast screenings, resulting in 61 women receiving mammograms and/or ultrasounds at UConn Health.

Banks’ position with The Carole and Ray Neag Comprehensive Cancer Center is grant-funded by Susan G. Komen Southern New England to help raise awareness of early detection among high-risk African American and Latino women. Breast cancer in this population often tends to be more aggressive, more difficult to treat, and more deadly. Fortunately, there have been no breast cancer diagnoses among the women she has helped thus far.

Anyone who visits Community Health Services in Hartford and, more recently, Community Health Center, Inc. in New Britain, has the option to receive free breast cancer counseling and free breast screenings through UConn Health’s Breast Navigation Program. Banks also scans the providers’ schedules every day, looking for patients who have not had a mammogram in the past year, and has the provider tell the patients she would like to talk to them at the end of their visit and enroll them in the program for a free mammogram. Other times, providers will identify patients who do not have health insurance and may have never had a mammogram, and will ask Banks to talk to them.

A lot of women are not aware that they may be at high risk for breast cancer. As a fellow African American woman who was raised in an inner-city community, I think it is so important to raise awareness of breast cancer directly in the community.

For those women choosing to receive breast screenings, Banks tracks their experience and, if any abnormalities are detected, connects them with UConn Health’s Breast Nurse Navigator Molly Tsipouras at The Carole and Ray Neag Comprehensive Cancer Center in Farmington for further access to treatment.

“A lot of women are not aware that they may be at high risk for breast cancer,” says Banks, who is currently pursuing her Master of Public Health degree at UConn. “As a fellow African American woman who was raised in an inner-city community, I think it is so important to raise awareness of breast cancer directly in the community.”

Banks and UConn Health’s Breast Navigation Program continue to do community outreach in the Hartford area at health fairs, walks and races, and expos.

Along with breast surgeon Dr. Christina E. Stevenson, Banks plans to present on the success of UConn Health’s Community Breast Navigation program at The San Antonio Breast Cancer Symposium this December to encourage other cancer centers nationally to do similar outreach in their communities to help further the fight against breast cancer.

Close at Heart

By Kim Kreiger
Illustration by Yesenia Carrero

Radiation treatment for breast cancer can inadvertently graze the heart, leading to damage and disease years later. UConn doctors are working to change that.

closeatheart


Getting radiation treatment for breast cancer can make you feel vulnerable. Sitting in a machine with radiation pointed directly at your chest, you have to trust that the doctor knows what she’s doing, that the X-rays are aimed right, that the machine is properly calibrated … and then you just sit perfectly still.

But what if you could have some control over the process?

Dr. Robert Dowsett, chief of UConn’s Division of Radiation Oncology, and
colleagues in the Carole and Ray Neag Comprehensive Cancer Center are using a new technique to give breast cancer patients agency in their radiation treatments. And they’re taking better care of the patients’ hearts in the process.

A patient can intentionally increase the heart-chest wall distance by more than a centimeter by controlling her breathing using the Deep Inspiration Breath Hold.

Using the technique, called Deep Inspiration Breath Hold, patients can help control the accuracy and timing of their own radiation dose. The patient takes a breath of specific depth before the radiation machine turns on. Doing this correctly can increase the distance between the heart and the breast by a centimeter or two, lowering the amount of radiation hitting the heart by as much as 50 percent.

Jeryl Dickson, 62, of Manchester, Conn., was one of the first patients at UConn Health to use the technique, from late 2015 through Feb. 2. Her doctors, including Dowsett, prescribed a course of radiation therapy to make sure there were no lingering cancer cells remaining after a lumpectomy removed her breast cancer.

“I practiced deep breathing and breath holds prior to radiation treatment with the radiation oncology staff so I could feel what it would be like,” says Dickson.

Radiation treatment of breast cancer can be very effective, eradicating tumor cells hiding in the chest wall. But breast cancer survivors have a heightened risk of heart disease that shows itself years later. Ironically, the heart disease stems from the radiation that originally saved their lives. Radiation is a type of light, and like visible light, it has a tendency to reflect and scatter. Just as even the sharpest spotlight has blurred edges where it blends into shadow, even the best-aimed medical radiation beam occasionally scatters into tissue outside of the tumor it targets. Sometimes it hits the heart.

Dr. Agnes Kim, director of the Cardio-Oncology Program at UConn Health, analyzes echocardiography images as one way to monitor cancer patients’ risk of heart disease.

Dr. Agnes Kim, director of the Cardio-Oncology Program at UConn Health, analyzes echocardiography images as one way to monitor cancer patients’ risk of heart disease.
Tina Encarnacion/UConn Health Photo

“We worry about heart attacks down the road, 10 to 15 years after radiation treatment of cancer in the chest. We also worry about inflammation on the outside of the heart in the short term. We don’t exactly know how the radiation damages the tissue, but it definitely seems to accelerate damage to blood vessels. It can also cause scarring and fibrosis damage,” says Dowsett.

But the distance between the heart and the chest wall varies from person to person. And a patient can intentionally increase the heart-chest wall distance by controlling her breathing using the Deep Inspiration Breath Hold.

To make the best use of the Deep Inspiration Breath Hold technique, Dowsett and his colleagues at UConn Health combine it with an optical scanning system supplied by C-RAD. The scanning system is essentially a computer with a camera that models the surface of the skin on the patient’s chest. It tracks the patient’s breathing, and coaches her to inhale just the right amount. As the patient, you wear virtual-reality goggles in which you see a bar graph showing your inhalation, with a box at the top. Your goal is to hit the box and then hold your breath for the 20 to 30 seconds it takes to complete the radiation treatment. Some patients can hold their breath that long; others can’t. It doesn’t matter, because if you exhale, or giggle, or cough, the system sees your chest move out of the perfect range and stops the radiation. It won’t restart until you get yourself back in position and inhale to just the right spot again.

“The deep breathing technique was not difficult at all,” says Dickson, “Honestly, I was more focused on my cancer, and heart health never entered my mind. But I am glad I put my trust in my doctors, and I never had any doubts.”

UConn Health is the only hospital using this technology in Central Connecticut. It’s a powerful, precise way to make sure the radiation beam gets the cancer, and to minimize the risk to other organs.

Previously, “the area we treated inevitably ended up being bigger than the target (tumor) itself,” Dowsett says. “Now we’ve expanded this to abdominal targets such as the pancreas and adrenal lesions,” while sparing healthy surrounding organs.