Episode 2: Cancer Prevention by the Truckload

Andrew Becker:  Before we start, a quick note. The content of this episode should not be considered to be medical advice and no physician-patient relationship is implied. It's a wet summer morning in Roxborough, a treelined neighborhood in Northwest Philadelphia. The Fox Chase Cancer Center mobile screening unit idles outside of one story community clinic across the street from a shopping center.

Jennifer Primus: Each time I have you hold your breath, it'll be a three to four second breath hold. I will do two different views of each breast. Now, right up to here, both hands are going to stay down by your side.

Andrew Becker:  It's only 10:00 AM and Jennifer Primus, a mammographer for Fox Chase's mobile screening unit, has already seen her third patient of the day.

Jennifer Primus:  Turn your head towards me. Now, this hand is going to go onto the side of the machine. This hand also, without thumbs. I want you to relax your shoulder. Good job. I think most Americans are. Hold your breath. Patient comes in. I get a brief history. I go through their personal history sheet, make sure there is no acute problem with the breast that they're experiencing today out of the ordinary. They come I and I do a straight shot of each breast. I do a side picture of each breast. I see the images immediately. We are at second generation digital equipment. There is no more running films or anything. It is Hologic Dimensions, second generation, two dimensional mammography unit.

Jennifer Primus: This is the best of the best of a two dimensional mammography unit that's out there. My monitor is right back here behind a leaded plexiglass for limited x-ray exposure, which with the technology nowadays, the amount of scatter and the amount of x-ray that's exposed is minimal. There is a lot of rocking and rolling and shaking, so we have to every single day make sure that the unit is in proper working order for patient exams. After that, I have a schedule. I oversee the intake process and registration process up front to make sure that's flowing smoothly, answer any questions the patients may have, take them back to get changed. They come in, and it is about a five minute exam. Here's what we're going to do now.

Jennifer Primus:  We want to do a side picture of each one. I'm going to continue with the right. Take the right arm out of the sleeve. Now, you have lymph nodes up under the armpit.

Andrew Becker: Jennifer understands that cancer screening can be an emotional experience, and she has a theory about what a successful visit to the mobile unit should look like.

Jennifer Primus:   Do not move a muscle. Relax your shoulders. Anxiety is heightened anyway in the beginning because of this type of exam. It's the nature of the beast. What separates an adequate technologist from exceptional is getting... As soon as they walked through my door into my exam room, bringing down that anxiety level tenfold. I educate them as to what to expect, how to hold their breath, why I am positioning the way I'm positioning, what I am gaining by doing this type of view and positioning the way I position it, answer any questions. During that whole five minute exam, I am talking while I'm actually doing it. Subconsciously, they don't even realize it that their anxiety is already coming down.

Andrew Becker:  Local resident Joanne Cashman hadn't had a mammogram in nearly three years. But after a friend was diagnosed with breast cancer, Joanne made an appointment with the mobile unit.

Joanne Cashman:  My niece had breast cancer at 40. She lost both breasts. She has new breasts, but she's good. I mean, I feel that she had a second chance at life and she has a different outlook. She's appreciating like more today because she's here, she's alive. For women who are reluctant to get this exam, for 15 minutes of your life to be uncomfortable than to have to go through having breast cancer. I myself have to say that to me too because I was one of them women that said, "Oh, I'm not going to do it. I'm not going to do it. I don't have breast cancer. It's a no brainer really." I'm very happy that I did it today.

Andrew Becker:  Everyday our waiting rooms, laboratories, clinics and the mobile screening unit fill up with people searching for something, to take care of others, to find the next big breakthrough, or maybe just to feel like themselves again. This is Connected by Cancer, the podcast of Fox Chase Cancer Center, which is all about that search. I'm Andrew Becker. In each episode, we explore these connections together. Today, we'll be talking about one of the most potent weapons against cancer, prevention. Since 2001, Fox Chase has been sending an oversize RV loaded with medical equipment and professionals into communities without easy access to screening. For a mammographer Jennifer Primus, who we met earlier, bringing screening out into the community is almost a higher calling.

Jennifer Primus: Many patients that come on and most patients that come on are doing this as a preventative measure to ward against breast cancer. The awareness is out there greatly and has been increasing over the past 25 years that I've been in this field. It's phenomenal. We go all over the general Philadelphia area up to I believe a two hour drive, 120 mile limit. It's just incredibly rewarding in that fact, yeah, especially going to the inner city clinics.

Andrew Becker: Tucked away in a back office aboard the mobile screening unit, Fox Chase's director of cancer screening, Linda Hammel, reviews the medical records for the 20 women who are scheduled for screening this morning.

Linda Hammel:  I'm just trying to get it in order in terms of who's coming. We have scheduled 20 women today. In fact, I'm getting my mammogram done today as well. I always use the mobile unit for my mammograms. My day will consist of greeting women starting at about 9:00 AM, assuring that their paperwork is completed, explain to them what to expect once they go onto the mobile unit, and escort them from door to door. What we have this morning is, I see you filled out all your paperwork. You mentioned to me that the last time you had a mammogram was about two or three years ago, which is pretty good. Really. You're not bad at all.

Linda Hammel: It can be scary. We also have not the best weather today. Sometimes anything can be a deterrent, but we're going to make sure that the 10-15 minutes that they're with Fox Chase they're going to get the best service possible. When you go inside, you will then sit along the bench. Antoinette will take your paperwork. She'll also take your insurance.

Andrew Becker:  For Linda, the mobile unit is a bridge of sorts to the community outside the hospital and to people who might otherwise not get this kind of care.

Linda Hammel: When we talk about providing the service to the community, we are talking about the community outside the doors of Fox Chase Cancer Center. We'll meet them at the door when they get their mammogram. We'll escort them, provide them transportation service to and from. We'll sit with them while they get their mammogram. We'll just make sure that the whole process goes smoothly. We are providing a service and breaking down barriers that otherwise would have prohibited the woman from getting a service like ours and then navigating them back to Fox Chase. We're breaking down that barrier. We are saying to them, "You are uninsured, we'll hold your hand through that process. We'll cover you for that process. There's state funding for those kinds of services."

Linda Hammel:  We also provide an interpreter, so it speaks their language, so that an interpreter can explain the forms the format, what to expect when they go back and get their mammogram, instructing them to get undressed, to put the gown on, and then stays with them through the process so that they can be that link to the technician to ask the questions on behalf of the patient. That's the type of individual that we are honored to be able to screen. It's those that for financial reasons, because of a language barrier we just mentioned, or for behavioral issues, are not getting regular mammograms either because they're fearful of perhaps what they may find. How will I manage that? How will I get to treatment?

Linda Hammel:  How can I pay for that? Who's going to help me? Fox Chase has been fortunate to partner with the Susan G. Komen Foundation to provide mammograms specifically to Hispanic women in the Philadelphia area and for African-American women in the Philadelphia area. So these women are primarily uninsured and not compliant to annual screening. Through the Komen grant of which we have been the recipient for the past five years, funding has been provided so we could put a focus on this population of women who are underserved. you also experience women who don't take the time from their job to go get a mammogram. I can tell you of several stories where a woman was scheduled to get a mammogram and forgot about her appointment.

Linda Hammel: Our staff on the unit gave her a quick telephone call and said, "By the way, Mary, you've missed your appointment. We're still here. Would you like to come down now?" She said, "Oh, yes. Thank you so much." Because of something like that, they've caught their breast cancer. They said, "If Fox Chase had not reminded me, had they not been here, had they not taken that time and courtesy to call me to say, "We will wait for you. Come down," I may not have been diagnosed with that cancer. It may have gone on for another year. Fox Chase did save my life."

Andrew Becker: We'll be right back.

Dr. Richard F.:  With cancer, where you start your treatment is crucial because each of us is unique, because every cancer is different. Curing it requires novel approaches, the latest research, specialists in your specific type of cancer. At Fox Chase Cancer Center, we know that the best chance to beat cancer is with the initial therapy. Where you start matters. I'm Dr. Richard Fisher, president and CEO of Fox Chase Cancer Center.

Andrew Becker: This is Connected by Cancer. I'm Andrew Becker. If you're wondering where this passion for prevention comes from, it's the life's work of this man.

Dr. Paul E.:  Hi, I'm Paul Engstrom.

Andrew Becker: Dr. Paul Engstrom spent nearly 50 years at Fox Chase Cancer Center trying to figure out how to stop cancer before it even starts. He founded one of the nation's first cancer prevention and control programs and was a giant in both cancer screening and tobacco cessation. Dr. Engstrom's impact on the world as far as people avoiding cancer is immeasurable and it all started way before he became Dr. Engstrom.

Dr. Paul E.:  As a youngster in grade school, one of my classmates became ill and actually developed diptheria disease that we don't even see anymore due to vaccinations. I remember her house. There was a sign on the door. You could not enter that house because she had a contagious disease and was very sick, and then she died. I said, Why? Why in the world should that happen? How does that happen that somebody who is well one day playing on the playground and going to school and then becomes ill and sick to the point of death?" That memory stays with me. Then my grandmother died essentially in my presence. I was sitting in an automobile with a friend while she and my mother and a number of ladies were at a get together.

Dr. Paul E.: My grandmother left the a group of ladies and came out and sat in the backseat of the car while my friend and I were talking and listening to the radio, and suddenly turned around and she breathed her last and died right there. A very pleasant death in the sense there was no suffering or anything like that, but a surprising death. Again, I think the acuteness of the death affected me.

Andrew Becker:  Another early inspiration was his dad's small town medical practice. Being the son of the only doctor in a town of 500 helped too.

Dr. Paul E.:  I was interested in his work and he involved me to some degree. Particularly patients that he would see, these are usually trauma patients. Since there was no real emergency room or other medical facility in the community where we lived in, they came into his office and the office was a part of our home. These people would come in. If it was after hours or it was something that he thought I'd be interested in, he encouraged that. He encouraged me. We used to practice when we were traveling in the automobile on trips tying surgical knots. My father was very good at doing superficial or local surgery.

Dr. Paul E.:  He could tie a knot with either hand, and he was teaching me how to do this with thread as we were driving along. Just an example of how I guess he subtly was encouraging me to take up the profession.

Andrew Becker: Following his dad's footsteps, Paul did, but a trip to California would bend the trajectory away from general practice and toward a new kind of medicine.

Dr. Paul E.: As a first year medical student, in the break between the first and second year, I spent two months out in Berkeley, California with State Health Department, so about eight or 10 of us selected from medical schools around the country. My particular job was to shoe leather. I guess you'd call it epidemiologist, where we go out into the field and trace disease. The disease I was tracing that summer was equine encephalitis, a rare condition carried by mosquitoes, a virus that causes encephalitis and can be fatal to children and to elderly. It was my job to go out into the San Joaquin Valley, go to the local hospitals, go to the medical records and try to document where and how patients acquired equine encephalitis and then what the outcome of the of the condition was.

Dr. Paul E.: This involved tracing and missing mosquitoes. We'd go out and collect mosquitoes, bring them into the laboratory, and they'd look for the virus on the mosquito legs. It meant going into the record room at the local hospitals and tracing the cases. This was kind of my first experience of trying to look at disease as a community problem. Then after I got into my interest in cancer, it was obvious that cancer has many of the same issues as equine encephalitis.

Andrew Becker:A meeting with Timothy Talbot, visionary leader of the Institute for Cancer Research set Dr. Engstrom on a course to help revolutionize cancer prevention.

Dr. Paul E.: Dr. Timothy Talbot was the person who hired me. He convinced me in an interview I had with him. What I call my preemployment interview. He convinced me that this is a place where I could bring together basic science and clinical treatment science in a way unique, that can't be done in many institutions because they're either too large, too scattered or don't have the expertise. The thing that amazes me is that we literally cut the death rate from lung cancer by about 50% as a result of a strong public health program and tobacco control and smoking prevention. You can actually make a difference. Yes, Fox Chase was one of the leading institutions in developing some of the first programs of that type.

Dr. Paul E.: I guess if I've accomplished anything in my lifetime, it was becoming the inspiration for a number of cancer centers to develop programs like this.

Andrew Becker:  A final note about the power of prevention. It's estimated that as many as half of all cancer cases are preventable. Cancer prevention includes reducing risk through lifestyle choices such as avoiding tobacco, maintaining healthy weight, and exercising. It's also important to get recommended screenings like mammograms and colonoscopies because these help identify cancer at earlier, often more treatable stages. Connected by Cancer is a podcast at Fox Chase Cancer Center and it's produced and edited by Joel Patterson and me, with help from Jonathan Pfeffer. Thanks to Linda Hammel, Jennifer Primus, Joanne Cashman, and Dr. Paul Engstrom for sharing their stories with us.

Andrew Becker: Thanks also to Blue Dot Sessions who provided us with music and to Rocket Summer Productions. Subscribe to Connected by Cancer in Apple Podcasts on FoxChase.org or wherever you listen. Remember, the content of this episode should not be considered to be medical advice, and no physician-patient relationship is applied. I'm Andrew Becker. Let's stay connected.