Dr. Susan Tannenbaum

Handled With Care

The breast cancer journey is a delicate one. The breast team at UConn Health strives to guide each patient through every step of their individual path with an unmatched level of attention and comfort.

 

By Kim Krieger
Photos by Peter Morenus

UConn medical oncologist Dr. Susan Tannenbaum initiated the multidisciplinary focus of the breast program, connecting patient care to research and bringing accreditation through the American College of Surgeons, before handing the reins to surgeon Dr. Christina Stevenson.

UConn medical oncologist Dr. Susan Tannenbaum initiated the multidisciplinary focus of the breast program, connecting patient care to research and bringing accreditation through the American College of Surgeons, before handing the reins to surgeon Dr. Christina Stevenson.


Some people need no urging to get medical screenings. These are the people who see their dentist twice a year like clockwork, who make that annual preventive care appointment, and who don’t put off a colonoscopy.

But most people are not like that. Even a mammogram can be a tough sell. Getting your breasts squeezed between two cold plates and X-rayed while wearing an ill-fitting gown is nobody’s idea of a good time. And when a patient has already found a suspicious lump, there’s an extra layer of stress.

The radiologists and staff at UConn Health’s Beekley Imaging Center, part of the Women’s Center, do their best to dispel that stress. Good service and a relaxing atmosphere go a long way toward evoking a spa-like ambience. There’s comfortable seating, private changing rooms, warmed gowns that fit, appointments that start on time — and cookies.

The patients appreciate it.

“I’m always in and out,” one woman says to another as they ride the elevator up to the imaging center. “I stay for the cookies and juice,” says the other. They both laugh. The first woman proclaims, “It’s really nice up there!”

Indeed it is. And if a woman cares to linger over her cookies and juice, she can get her results on the spot.

“One woman, here in 2013, 2015, 2017, 2019, always reports the same symptoms. Lumps, terrible breast pain. She wants our attention. She is worried about breast cancer,” says Dr. Alex Merkulov, head of women’s imaging and a radiologist in the Imaging Center. “Our job is to remind her of the prior years and assure her that everything is OK this time, too. We treat people the way we would want to be treated.”

Merkulov is intensely attentive when you talk to him, and although his phone dings constantly, he gives you the feeling that all his focus is on you. However much time you need. He says working with each patient “is a personal relationship.” And he means it.

All a woman needs to start this relationship is an order for a mammogram from her primary care doctor. She makes an appointment and fills out a short questionnaire when she arrives. Does she have a lump? Pain? Have any family members had breast cancer? Depending on her answers to the questionnaire and the results of her mammogram, the radiologists may recommend she come in for more frequent screenings or have a consultation with one of the genetic counselors.

After her low-dose mammogram, the woman dresses, gets her cookies and juice, and hears her results within 15 minutes. If she’s in a hurry, she can leave immediately and get a phone call within two days letting her know if she needs any follow-up tests.

Most of the time, those results are A-OK. The radiologist gives the all-clear and says, “See you in two years.”

Dr. Alex Merkulov

“We treat people the way we want to be treated,” says Dr. Alex Merkulov, head of women's imaging and a radiologist in the Beekley Imaging Center. The large screens in the Center's imaging suite allow radiologists to show patients exactly what they're seeing after a mammogram and explain why they are or are not concerned.

Intimate, Holistic Care

Only about 10% of women have something in the mammogram that might indicate a problem. When that happens, the radiologist recommends a follow-up ultrasound or a special mammogram to detect the calcium deposits that can signal early breast cancer.

“I’m a frequent flyer” at the Beekley Imaging Center, says a patient named Patricia. Because she’s at high risk for breast cancer, she’s had tests often over the last 10 years. At some places she’s had mammograms, “you go in a basement, you don’t talk to anyone, you get a letter a week later,” she says. But UConn Health is completely different.

When she first started going, they modeled her risk. Patricia’s was off the charts, so they had her meet with a medical oncologist at the Carole and Ray Neag Comprehensive Cancer Center who specializes in breast cancer to discuss preventive options. After examining Patricia’s history in detail, the oncologist, Dr. Susan Tannenbaum, advised her that actually, she didn’t need to proceed with preventive medical oncology. On other visits, the radiologist has invited her into his office to view the mammograms displayed on big screens so he can show her exactly what he sees and explain why he is or isn’t concerned.

“They give you a lot of information in a caring way,” Patricia says. “I have too much going on to have my primary care doctor and OB/GYN booking appointments randomly — I need a team treating me holistically. This feels like intimate care from really great doctors.”

That focus on intimate, holistic care is evident even when a woman has a benign breast condition. Women with breast pain, breast infections, fibroadenomas, and other lumps that aren’t cancer see Dr. Dana Scott, an OB/GYN who specializes in benign breast conditions. The benign breast disease program she leads is unique in the area.

“I try to really listen to my patients and spend the appropriate amount of time with them to hear all their concerns,” Scott says. Sometimes the women need treatment, sometimes even surgery. But just as often, it’s the care and attention they get that is the most valuable. For “a lot of patients who are really worried they have breast cancer and they don’t, having someone who can listen to them, examine them, and provide follow-up is really important,” Scott says.

Not All Women Are the Same

But what if a woman’s breast condition isn’t benign? If the follow-up scans reveal something that looks suspicious, the radiologists discuss the findings with the woman and advise her to come in for a biopsy, scheduled at her convenience for some time in the next day or two.

The tissue from the biopsy is evaluated by Dr. Poornima Hegde, a UConn Health pathologist who specializes in breast disease. A cancer diagnosis is only as precise at the pathologist who evaluates the suspicious cells, and Hegde is an expert. She looks at breast tissue all day, every day, and can make the call between cells that are just a little weird versus cells that mean malignancy.

“We try to reduce the ambiguity: either you’re OK, or you’re not,” says Merkulov, the radiologist. “Poornima is a godsend.”

If Hegde and the radiologists agree the woman has a cancerous mass, they spring into action. They contact the breast cancer nurse navigator and, often, the team’s social worker and bring them in to discuss the results of the biopsy with the patient. The nurse navigator will call the patient and answer any preliminary questions she has. The navigator also tries to identify any hurdles or barriers the woman might have to overcome to get treatment.

“You need to understand where people are coming from: people may have the exact same diagnosis but very different resources,” says Wendy Thibodeau, RN, one of the nurse navigators who works with breast cancer patients. Thibodeau speaks plainly, and intuitively grasps what you’re really asking with a question. Her role as a navigator is to coordinate care for the patient, offer her emotional support, evaluate any barriers to treatment, and help her get to the next step. She gives every patient her cell phone number and tells them they can call her anytime. Often, they call her to ask her to remind them what the doctor said, what they need to do. But other times, she must talk them down.

“Sometimes we have a patient whose first instinct is ‘Cut it off! Cut it out of me!’” Thibodeau says. “I have to call her and explain you can’t just cut; you need to do lots of tests to understand what we need to do to treat this.” Sometimes a woman will need chemotherapy before surgery to shrink the tumor. The nurse navigator can fit the woman for a cold cap to preserve her hair and meet her on the first day of chemotherapy for support. Or she might need other tests or treatments, and the nurse navigator can explain those and help her through them. Not all breast cancers are the same.

And not all women are the same, nor do they have the same needs. Both these points were highlighted during a tumor board meeting this summer.

The tumor boards are weekly meetings between the medical oncologist, the surgeons, the radiologists, pathologist, the nurses, and the social worker. Radiation oncologists, plastic surgeons, genetic counselors, and any others involved in the patients’ care also join. They discuss their cases that week. Typically, the radiologist will start off, to show the extent of the cancer in the breast and whether they believe it has spread. The pathologist will share and confirm with the team what she’s found.

The medical oncologist will discuss the best approach, the type of treatment this cancer responds to best, whether the patient will need chemotherapy. The surgeons consider the type of excisions they can offer the patient. The discussion about treatment is often collaborative, with the surgeons, radiologists, medical oncologist, and geneticists all weighing in. They also discuss cases post-surgery; did they find what they thought they would? Should treatment change
in any way?

Dr. Christina Stevenson

Dr. Christina Stevenson, surgical oncologist and breast program head, in the operating room.

The Road to the 'All-Clear' — and Beyond

And then there was a patient we’ll call Deborah. She was a 43-year-old single mother. She needed to come in for surgery, and soon. But she had no one to take care of her children for the 24 hours or so she would need for surgery and recovery. Everyone was worried about her.

Dr. Christina Stevenson, the surgical oncologist and head of the breast program at UConn Health, was the first person to bring up Deborah’s childcare predicament. She’d seen her the day before.

Typically, when Stevenson meets with a patient who needs surgery, they discuss surgical options: just the lump, or the whole breast? Perhaps the woman wants a reduction done at the same time, or implants put in for reconstruction, or her own tissue used instead of implants. Stevenson often consults with a plastic surgeon, and she does what is called oncoplastic surgery.

“I always try to preserve the breast in a lumpectomy to have the same size and shape we started with,” she says. “People worry they’ll have a divot. But we can move tissue around to help with the appearance.” She also has a few technological tricks, like the Biozorb sitting on her desk. It looks like an inch-long spring made of clear plastic. It’s actually resorbable suture material, studded with little metal clips. The sutures give a scaffold for the tissue to regrow upon, while the metal clips show up on a CAT scan or mammogram and help to focus radiation treatments, as well as follow-up in the future.

Stevenson is very calm describing all this; talking to her about breast surgery is almost soothing. Above her desk is an excerpt of a Christian prayer often attributed to Mother Teresa: “Dear Lord, Give skill to my hand, clear vision to my mind, kindness and meekness to my heart. Give me singleness of purpose and strength to lift up a part of the burden of my suffering fellow man.”

Stevenson brought up Deborah’s case at the tumor board. The social worker and nurse and community navigators stepped in. Although it’s more common for the community navigators to set up rides to appointments, provide gas cards, or fit patients for a nice wig, their goal is to make it possible for women to get treatment. The social worker focuses on psychosocial needs, and here was a woman with very limited social support. The social worker spoke with Deborah often, exploring who could care for her children within her family and community. Eventually Deborah worked past her anxiety and began to make concrete decisions. After much discussion, she found it in herself to speak with her sister and ask for assistance in caring for her kids while she was in recovery. Her friend drove her to and from surgery. Thanks to everyone stepping up, Deborah was able to successfully complete the initial phase of her treatment.

After surgery, Stevenson follows up with the patient at 1.5 weeks, then three months, then every three to six months for two years, often alternating visits with the medical oncologist. Then, if all is well, the patient comes back for yearly mammograms for life. She comes in for her scans and her cookies and juice and, hopefully, gets the all-clear. And if not, then Stevenson and the rest of the team at UConn Health’s breast program will help her take care of it.

“Because breast cancer is fairly easy to treat, typically. Especially when we catch it early,” Stevenson says. “And when we do regular mammograms, we catch it early.”

Nurse navigators and nurses like Minal Dave, RN, often offer patients emotional support.

Nurse navigators and nurses like Minal Dave, RN, often offer patients emotional support.

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.