Devising a battle plan for fighting cancer
At 7 a.m. on Wednesday, the conference room at Cape Cod Hospital hardly looks the place for battling alien invaders.
The early morning sun barely peeks into the room. Coffee and bagels are on the counter. A sign advertises an upcoming holiday party. About 15 doctors, a nurse practitioner, lymphedema rehab therapist, ultrasound technician, and administrative staff banter and tease as they settle into chairs around the table and at the edges of the room.
Some are dressed in traditional white coats, others wear surgical scrubs and a few are in shirtsleeves. At 7:05, their eyes turn toward one of two large 42-inch TV screens in the room that displays a mammographic image of a woman’s breast, a softly rounded black and white hillock that hosts a 10-millimeter cancerous tumor.
The breast belongs to a 63-year-old woman who came to the Cuda Women’s Health Center for a routine mammogram. She remains nameless during the meeting. But her future treatment rests with these members of the breast tumor board, a mix of medical staff who will consider how best to attack her particular cancer and wrestle it into remission.
The breast tumor board is one of several tumor boards at the hospital and meets weekly at 7 a.m. The thoracic board meets at noon Thursdays. There are also boards for neurology and gynecology, as well as occasional special boards for, say, hematology, held when collaborating experts from Dana Farber Cancer Institute come to the Cape.
“It’s a multi-disciplinary conference, a model where all those who interact in the diagnosis and management are at the same table,” says James Chingos, MD, now a primary care physician. Dr. Chingos has long been involved with cancer care at Cape Cod Healthcare and started the boards in the late 1980s.
The disciplines represented at the table read like a cancer center directory: radiology, pathology, surgery, rehabilitation and lymphedema therapy, medical oncology, radiation oncology, plastic surgery, and research.
Also at the table is Hester Grue, who organizes the tumor board meetings and runs the tumor registry, required for reporting state and national cancer statistics and for research. She is the keeper of more than 10,000 tumor cases of all kinds going back to 1975 and is the first contact physicians have with the board.
Cases usually reach the breast cancer board after a woman has had a mammogram and core biopsy and has a positive identification of cancer.
“The board brings a different perspective on management that might not be thought of if everyone operated in an isolated way,” Chingos says. That’s particularly important with breast cancer, he says, because of the wide range of therapies and the way therapies are constantly changing.
Many community hospitals have tumor boards but they don’t tend to specialize, he says. “Our knowledge base of cancer management has grown at a very rapid rate…. Consequently, the people who might deal with, for example the breast, may not know much about what’s going on with gastrointestinal.”
The current case before the board – one of three that morning – is first presented by radiologist Charles Williams III, MD. He runs through the details, including a comparison of films from previous years’ mammograms. Notes on the case are passed around the table.
“She’s an annual screener, which is good,” Dr. Williams says of the patient.
Jill Oxley, MD, a breast surgeon and the board’s moderator, adds that the tumor is infiltrating the woman’s milk duct and that it’s estrogen- and progesterone-positive, meaning it thrives on hormones. She also notes that the patient has a history of breast, colon and pancreatic cancers in her family and that she wants “breast conservation,” meaning, a lumpectomy rather than a mastectomy.
The discussion ends with a recommended lumpectomy followed by radiation and then endocrine therapy, meaning the patient will probably be given tamoxifen or an aromatase inhibitor to lower the levels of hormones that have been feeding the tumor.
And then it’s on to the next case, and the next patient’s battle plan.
By 7:45 a.m., the room is clearing. Some grab a last cup of coffee or snatch a bagel. The 63-year-old woman and her medical record will now be part of tumor history, her case tracked through electronic records and available if anything else should happen in the future.
Her medical team, now armed with a plan, head back into the fight.