In Margaret Duggan’s waiting room at Faulkner Hospital, it isn’t a nurse who comes to get the patient. It’s Duggan herself.
“Call me Peggy,” she says, and doctor and patient adjourn to a small, unremarkable office looking out on a leafy stretch of Centre Street in Jamaica Plain, Mass.
Duggan (CAS’86, MED’90), a surgeon and clinical director of the hospital’s Breast Centre, encourages patients diagnosed with cancer to bring someone along—a friend, her spouse, her mother. Sometimes they do.
“I once had six people in here,” says Duggan, who earned a bachelor of arts and a medical degree at Boston University and did surgical training at Boston Medical Center, then Boston City Hospital. Sometimes it helps.
“The real problem,” says Duggan, “is once they hear the word ‘cancer,’ they don’t hear anything else.”
Cancer Diagnosis. Sometimes, Peggy Duggan’s patients sit silently in her office, as if more time is needed to make sense of what is happening. “They feel that their body has betrayed them,” she says.
Photos by Cydney Scott
Peggy Duggan took your questions about breast cancer, treatment, and a healing touch. Read her responses below.
Breast cancer is complex. Technically speaking, like all cancers, it is abnormal and uncontrolled cell growth, and it can be hard to define, yet a positive diagnosis changes the way a person thinks of herself: she becomes either a cancer patient or cancer survivor. Patients come to Duggan hoping to find a clear path through a barrage of confounding odds and confusing terminology: lobular carcinoma in situ. Operable stage IIC. Metastatic. Lymph node dissection. Trastuzumab. Bisphosphonates. Tyrosine-kinase inhibitor. Adjuvant therapy.
Duggan takes her time. “I explain the situation in the simplest terms,” she says. “I draw cartoons. It’s important for the patient not to feel like you’re hurrying her. They don’t need to decide anything today. I’ll say, go home and think about it.”
Writing in a medical blog, chick-lit novelist Laura Zigman (Animal Husbandry) describes her consultation with Duggan: “Dr. Margaret Duggan…took me into her office and spoke to me for over an hour,” writes Zigman. “She gave me an incredibly detailed and easy-to-understand mini-course that covered oncology and biology and genetics and surgery and statistics and probabilities and which included hand-drawn diagrams on a pad of paper which I actually understood.”
Sometimes, the women in her office sit silently, as if more time is needed to make sense of what’s happening. “People think they’ve been doing everything right,” says Duggan. “They feel that their body has betrayed them.”
Sometimes the women will ask her what she
would do if she were the patient. “I’ll say, it doesn’t matter,” says Duggan. “That’s an emotional decision, and you want me to be dispassionate.”
Besides, she acknowledges, “honestly, I can’t say I would know what to do.”
Becoming One with a Patient’s Body
Over the course of a lifetime, one in eight women in the United States will develop invasive breast cancer. The
disease—the most commonly diagnosed cancer among women—kills nearly 40,000 people a year, but there are
upwards of 2.5 million survivors. We see these survivors, throngs of them, in
well-organized marches, agitating for a cure. Multiply the emotional ordeal of each of Duggan’s 300 to 350 patients each year by 207,090—the estimated number of new cases of the disease diagnosed this year—and the fear is almost inconceivable.
Detailed Diagnoses Things are improving, says Duggan. “We do much less lymph node surgery than we used to, and we get just as much information.”
While she is attentive to newer studies that shed light on breast cancer prevention, Duggan believes that breast cancer screening is “at the limits of its usefulness.” Tumors can lurk for years before they show up on mammograms, whose value is often overestimated or misunderstood. “There is
no question that diminishing screening in women between 40 and 50 will
lead to loss of life,” she
Although the incidence of breast cancer is low
in this age group, the latest guidelines from a U.S. Department of Health and
Human Services task force, which changed the starting age for annual mammograms from 40 to
50, might lull women into
assuming routine mammography has no impact. “I can tell you many women benefit from mammograms in that age
group,” she says. “So I
would advocate for mammograms starting at 40, and the patient and her MD can decide if she needs one annually or every other year.”
Duggan prefers digital mammography, the new standard in Boston, which is easier to read and exposes the patient to less radiation. If breast cancer is curable, she says, it will be because of a highly nuanced combination of surgery and gene, hormonal, and other drug therapies. She sees hope in targeted therapies, hormonal therapy, and genetic markers—treatments custom-tailored to kill specific cancer cells or stop them from growing.
Duggan knows the forecasts she delivers daily can be confusing and infuriating, awash in percentages and probabilities, each number pregnant with hope or despair. The
more state-of-the-art the treatment, the more a clinician struggles for clarity and absolutes, with diagnoses ranging from dire to concerning, from tumors that have metastasized to the bones to ambiguous early cell change known as carcinoma in situ, which may or may not become cancers.
There are six standard treatments for breast cancer, some offered in tandem. These are surgery—from breast-conserving lumpectomies to mastectomies—sentinel lymph node (the first lymph node to which cancer is likely to spread) removal and biopsy followed by surgery, radiation therapy, chemotherapy, hormone therapy, and cutting-edge targeted therapies, including monoclonal antibodies such as Herceptin, which blocks a cell growth factor protein and has none of the distressing side effects of chemotherapy.
Breast care at Faulkner involves a squadron of clinicians playing a role in diagnosis, treatment, and recovery, but among all these clinicians, it is the surgeon who is most hands-on, navigating the tissue and excising the actual, palpable cancer, which, Duggan says, is usually rock hard. In Abraham Verghese’s epic Cutting for Stone, a surgeon is described as becoming one with a patient’s body, which is the doctor’s “text, and he sounded it for the enemy within.” Such operating room intimacy is, thankfully, unavailable to patients. But in the time leading up to surgery, Duggan earns her patients’ trust and often their affection. She does 400 procedures a year, steering a clinical team that includes breast surgeons, medical oncologists, radiation oncologists, plastic and reconstructive surgeons, nurse practitioners, clinical nurse specialists, a social worker, and support staff. They all report to Duggan, who is beloved by her staff, according to her boss, chief of surgery Pardon Kenney, and equipped with both an Irish sense of humor and an Irish temper, and almost always prevails.
“She’s at home in a room full of surgeons, and though she does breast surgery, she’s kept up her interest in general surgery,” says Kenney, who considers Duggan, chosen one of Magic 106.7 radio’s Exceptional Women of 2011, a role model for women in surgery. “She shows them how to get it done.” Duggan herself is less likely to toot this particular horn, and both her sister, Mary Duggan, who works in Faulkner’s clinical education department, and Kenney say that while Duggan is tough, she hasn’t got much of an ego. She is not shy, and not above some old-fashioned mischief. One of Kenney’s favorite images is of his star surgeon whipping down Loon Mountain in a nun’s habit clutching a briefcase, along with similarly attired colleagues who make up the Nuns on the Run Team in the hospital’s annual Briefcase Race fundraiser.
A Never-Forgotten Gift
Family Photo The youngest of five children, Peggy Duggan grew up in a housing project in Chelsea, Mass., where her father was a cop for 30 years.
The youngest of five children, Duggan grew up in a housing project in Chelsea, Mass., a small, struggling city across the Tobin Bridge where Boston proper’s gentrification screeches to what appears to be a permanent halt. “Our parents faced a lot of adversity,” says Duggan. “Both of them valued hard work of any kind. They encouraged us to go to school and become educated, and also to contribute to the world in a positive way. Somehow, they were always there for us, even though they both worked so hard.”
Theirs was a close family, and it was “a great experience growing up there,” Mary says. “Everybody knew each other.” Peggy “was an excellent student who did well in everything—a smart, smart girl,” and the children were “raised to be people who cared about other people.”
Their father was on the Chelsea police force for 30 years. Now widowed, he still lives there. Mary, the next to youngest, recalls a 10-year-old Peggy declaring, “I want to be a doctor.”
When it came time for college, her father didn’t want Duggan to leave Boston, but he didn’t have to worry: his
daughter won scholarships to BU and Boston College. She chose BU, and landed a work-study job in the financial aid office. “The director at the time took an interest in me,” says Duggan, who worked hard in the office and managed great grades, too. “After the grades were released, he called me into his office and granted me room and board. It was a gift I’ve never forgotten.” She was one of 15 undergraduates accepted in a six-year medical program, beginning in her junior year. Duggan says she planned to become a primary care doctor, but a third-year rotation in surgery changed her mind. “I completely fell in love with the operating room,” she says. “I loved the culture there, and the types of diseases that were treated there with surgery.”
Elizabeth Cole (CAS’86), Duggan’s closest friend since sophomore year and now chair of women’s studies at the University of Michigan, says she owes her accomplishments in large part to her determined, focused friend. “I was the person who was more likely to get into trouble, and Peggy put an end to that,” recalls Cole. Peggy set strict schedules for studying and for fun, with studying getting the lion’s share.
“She always had a plan,” Cole says. Duggan lived in Towers and headed for the library every night after dinner. “She always knew what she wanted and she brought structure to my life.” The two were inseparable, says Cole, and still manage a visit at least once a year.
A Sea Change in the Last Decade
After a brief stint as a general surgeon in a private practice in Maine, Duggan returned to Boston to do a breast surgery residency at Boston Medical Center. One day she was asked out by a nurse named Joe.
“He made dinner for her,” Cole recalls. “He’s an ambitious cook and bought special place mats and place settings for the occasion.” Their courtship went fast, and they were engaged a year later. “But that’s how Peggy is,” says Cole. “She knows what she wants. She has a really correct internal compass, a real sense of herself.”
The couple had a fall wedding at Marsh Chapel, followed by a reception at the Castle. These days Joe works as a substitute school nurse, but is mostly home caring for their three adopted children, including twins from Cambodia. Close in age, the children were all toddlers together, which was “pretty intense,” says Cole. Now, she adds, “it’s a party.”
Duggan arrived at Faulkner, a leader in breast cancer research as well as treatment, in spring 1999. She was signing on with “the oldest breast center in Boston,” says Kenney. Started in 1987 by Susan Love, a breast specialist whose books and high media profile made her synonymous with breast cancer awareness, the clinic draws patients from other states, even other countries. Duggan, who is serving a two-year term as president of the Faulkner medical staff, spends one day a week at Boston’s Dana-Farber Cancer Institute.
Taking the position at Faulkner, the hospital where she was born, meant Duggan could remain in the city she loves, with family all around, and make a difference as an administrator and a clinician. The field has undergone a sea change in the last decade alone, she says. Today’s research focus is completely different from the way it was in her early days as a clinician, and she finds the transformation encouraging.
“It used to be that the guys in the lab were separate from the patients in the clinic,” she says. “The tissue samples would go to the guys in the lab, who you didn’t talk to. But now there’s a translateral reach. Every step of the way, the question is, how will the results affect this particular woman. The research now has the patient in mind. We have people in the lab who spend days with me in the clinic.”
Duggan’s repertory company of doctors, nurses, and counselors works in tandem to get the best results in the three areas of concern: morbidity, survival, and selective therapy. Her personal bias is the less surgery the better. “We do much less lymph node surgery than we used to, and we get just as much, if not more, information,” she says.
There are still many miles to go. “I’d love to tell women after surgery that we’ve excised their cancer completely and not have to wait” for the pathology report. And it’s unnerving to oncologists and surgeons that with carcinoma in situ there is no way to know which women will get cancer and which will not. Duggan knows that they could be overtreating many women, doing procedures that harm the body but don’t prolong life, but for now at least, she is unwilling to gamble on patients’ futures.
Cancer of the breast, which can be surgically removed, doesn’t kill people: it’s the spread of cancer to the lungs, liver, and bones that kills people. Duggan and others are working to fine-tune systemic treatment to prevent breast cancers from spreading. They’re on a mission to locate targets in the many subtypes of breast cancer. And lately they’ve got a promising ally in the drug Herceptin, a custom-made antibody that blocks the effects of a protein called HER2, which signals breast cancer cells to reproduce. Nearly a fourth of breast cancer patients have tumors that respond to Herceptin treatment combined with standard chemotherapy. In and of itself Herceptin “has no chemotherapy side effects, with a 10 percent increase in survival,” says Duggan. “But in oncology we say, for 2 percent we’ll change everything.”
At the Unitarian Meeting House in Wayland, Mass., where Duggan has served on the board for three years, she has another circle of admirers. They see the same intelligence, wit, and willingness to pitch in despite her crazy schedule that impress colleagues at Faulkner, but they also see something else.
“At church we are our whole selves, not just a doctor, not just a mother,” says Ann Gordon, chair of the church board. “Peggy brings her whole self on Sundays, which means opening herself up to absorb and reflect the emotions of any given moment.” It’s during those Sunday services, her friend notes, that Duggan sometimes does something her patients never see. She weeps. ■
You Asked, We Answered
Readers took advantage of our invitation to ask Peggy Duggan about breast cancer, treatment, and a healing touch. Here are some of those questions, along with Duggan’s responses.
QAfter losing my mother to stage IV cancer less than two months ago, I found this article to be touching and inspiring. I appreciate your approach to the women who undergo such devastating experiences. It’s an honor to know that a fellow BU alumni is helping to shape the approach to cancer. I would love to know if you plan to expand your approach to other hospitals and medical care facilities.
Andrea, Thanks so much for your thoughtful comments. I am so sorry to hear about your mom’s battle with breast cancer. It can be such a devastating disease. Fortunately I think the tides are turning as far as compassion and caring for women with breast cancer, but disease-specific centers as a whole have more success with this approach because this compassionate care is not only valued but given resources. To answer you directly, though, I am not planning on directly expanding the breast center itself, but we do have an active role in training medical students, surgical residents, and breast and oncology fellows. I am always sure to include the education of patients and compassion as a major part of the curriculum.
Perhaps you could make a comment on the topic of vitamin D and breast cancer prevention and adjunct treatment for breast cancer, and current research in this area. I’ve seen recent findings that patients with higher initial blood levels have better outcomes, and understand that there is evidence of prevention of developing the cancer in the first place.
Vitamin D deficiency is a common problem now in a world where we spend so much time indoors. Since breast cancer is a disease of developed nations, by and large epidemiologically it makes sense. There is good supporting data that vitamin D deficiency in developing years (adolescence) is a risk for developing breast cancer. It does make sense that vitamin D should be of adequate levels both for absorption of calcium, which is needed for prevention of osteoporosis, and for potential benefits in breast cancer risk. This has recently become a focus of primary care in women’s health. I am not aware of treatment protocols for breast cancer that rely on vitamin D, but primarily as preventative health.
I have an elevated risk for breast cancer—no BRCA1, but my mother and all her sisters had breast cancer. I would like to know your opinion on the risks (excluding gynecological cancers) of taking an anti-estrogen drug. Or, if there is a really good review article, that info would suffice.
Suzanne, The risk of hormonal therapy for prevention of breast cancers is actually quite low. The serious risks are GYN cancers as you mentioned and increased blood clotting, which can lead to deep vein thrombosis (DVT), pulmonary embolis, heart attack, and stroke. These risks are about the same as with oral contraceptives or hormone replacement therapy. The risk of DVT is less than 2 percent but increased in smokers and women who themselves have developed a clot in the past or have a family history of clotting disorders and obesity. The risk of the other serious conditions was even less. The data strongly favors the safety of tamoxifen and other drugs like it in breast cancer prevention. Here is a reference addressing your concerns.
I appreciate this opportunity to ask your opinion on two procedures, because I am uncertain of the best choice for me in the current situation. I have been diagnosed with DCIS in one breast. One surgeon suggested mastectomy with simultaneous preparation for reconstruction, while the other indicated that lumpectomy and radiation would be appropriate. Please indicate the pros and cons of the two procedures for a 73-year-old woman with long-lived female ancestors who were cancer free and died in their late 80s. Are there any specific questions I should ask to arrive at the best decision? I thank you in advance for providing me the information to make an intelligent choice.
The two options you state are both reasonable treatment options for DCIS. Prior to the 1970s, the only local treatment for all forms of breast cancer was a mastectomy with lymph node removal. In the 1970s it became clear if we could remove the entire tumor from the breast and the lymph nodes from under the arm, the addition of radiation therapy would make the option of breast preservation as effective as mastectomy in regard to overall survival. The 10-year local recurrence risk is slightly higher in the lumpectomy and radiation group (breast preservation), but since overall survival is the same, both options can be offered to most women with similar results.
Because you have DCIS you do not need to have lymph nodes removed, but all of the cancer needs to be completely excised. Sometimes with DCIS it can grow extensively in the breast and be hard to excise with a lumpectomy only. So if you have extensive calcifications on your mammogram this may indicate extensive disease. Short of that, my personal feeling is less surgery is usually better and, unless you preferred mastectomy, would recommend lumpectomy. I will add two other caveats, first with lumpectomy: it is impossible to be sure the entire amount of disease is excised until final pathology is back, and so patients sometimes need to return to the OR for a re-excision of the area. Second, if you choose or need a mastectomy, reconstruction is a personal choice. I have seen many women advised to have reconstruction who really are not interested in the procedure. It adds a lot to recovery and risk, which is acceptable only in patients who will are truly motivated for it.
Finally, the noninvasive status of your cancer makes your prognosis excellent. I imagine you will follow your ancestry into your late 80s and healthy.
I’m interested in using yoga, specifically inversion poses, to ease or reduce lymphedema (swelling) in Cancer Athletics teammates. It’s not an easy thing to study, and some of the things that I have read were not written in English; much is lost in the cultural and language translation. Thank you.
— David Dorfman, Cancer Fitness Coach
David, The data on lymphedema is limited and not well done, but we have significantly changed our view on prevention and management over the years. I strongly encourage patients to return to their activity prior to their cancer treatment and increase their activity in order to maintain mobility and control Body Mass Index. Yoga is a wonderful approach to increasing mobility, and I would agree likely decreases risk for lymphedema. Thanks and keep helping these women get back to their normal lives.
I was diagnosed with DCIS in 2000 at age 69, followed by 6 weeks of radiation. My doctor suggested tamoxifen, but I decided against it. I’ve had intense followups for several years and I’m fine. There has been no breast cancer in my mother and three sisters. My assumption is that I am lucky, and that it is unlikely that the cancer will return. Would you agree that the odds are against it?
Helen, I agree with you that you were successfully treated for DCIS 11 years ago and it is very unlikely to recur. Like all women though, you continue to carry risk to develop new breast cancer in either breast, so you should continue with annual mammography.
I went for routine mammography at a local radiology center in my hometown last week. Results came back requesting I have additional views of my breasts
done. I had digital mammography along with ultrasound. Both seemed clear, but they advised me to come back in six months to repeat the process. Should I be alarmed, or ask to speak to a radiologist or my internist? Who is getting the results of the mammography and ultrasound? How can I be assured the validity of these results?
Janet, It is not unusual to be told to return in six months for a diagnostic mammogram. In general it is because of a benign-appearing nodule or calcifications that the radiologist wants to be sure are stable. It is reasonable, though, to speak to a physician about exactly what is being watched. Either your primary or the radiologist would be reasonable.
I am 43 years old and recently underwent open surgical biopsy with wire localization due to two separate microcalcification clusters of BIRADS class 4C suspicious for malignancy of the right breast. Path report shows one cluster as benign microcalcs and the second cluster as adenosis with benign microcalcs, non proliferative fibrocystic changes, and a 2.5mm adenomyoepithelioma. I am currently awaiting a second path report due to the rarity of adenomyoepithelioma. Most professionals I have spoken with have heard of, but never dealt with this diagnosis. If the second path report confirms this diagnosis, what are your general recommendations?
Terry, This is a rare finding. First off, most are benign and so complete excision is all that is warranted, but they can recur locally, and complete clear margins are need to be obtained. If the margins of your tissue resection are not clear of the adenomyoepithelioma, then you should have more surgery to ensure this. In the cases of malignant lesions, they can spread via the blood stream and consultation with a medical oncologist is needed, although based on the size I think spread of this lesion is very, very unlikely. Second, please be sure your second opinion is at a large academic medical center and is being looked at by a breast pathologist. This can be critical in clearing up the diagnosis.
My 50-year-old daughter was diagnosed with stage 0-1 breast cancer late last year. She had the tumor removed at a local hospital and has completed radiation treatments. She has been told that she is now cancer free but that she is triple negative. I feel that the early detection of my daughter’s cancer at stage 1 was miraculous, but wonder whether the triple negative diagnoses, even at stage 1, complicates things. I thank you for any information you can give me about this diagnosis.
Indeed, you are right. Triple negative breast cancers can be difficult to manage and have high risk of metastatic spread even in the case of negative lymph nodes. There are many clinical trials looking for the best treatment options, since triple negative tumors do not have any of the markers (estrogen, progesterone, and Her2neu) that allow us to easily direct systemic disease to prevent the spread of breast cancer. Even for small node negative breast cancers when they are triple negative, chemotherapy is often given in addition to surgery and radiation to prevent metastatic spread.
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