Breast Health Champions
Learn all about the 2018 American Cancer Society Breast Health Champions and how they are revolutionizing the way we think and care for breast cancer in the hopes of a better tomorrow.
What drew you to breast surgery?
In medical school, I was interested in women’s health and debated between ob/gyn and surgery. I decided on surgery and realized during my residency that I connected best with women, so I pursued breast surgery. The connection I make with my patients is as valuable to me as the challenge of the surgery.
You completed a fellowship in breast surgery. Why is that notable?
Completing a fellowship in breast surgery is very important, because it offers additional, highly intensive training in this specific specialty. I was fortunate to do my fellowship at Bryn Mawr Hospital where I trained under Dr. Thomas Frazier, one of the pioneers in breast surgery. During my fellowship, I was also part of a multidisciplinary team that was made up of medical oncologists, radiation oncologists and other specialists. This gave me a very good understanding of how each facet of breast cancer treatment works.
How do you see your role now?
My job isn’t just to remove a woman’s cancer but to also tend to her mind, body and spirit. My patients are mothers, sisters, wives and daughters… the people who are often the glue that holds their families together. I’ve seen some women postpone or decline treatment because they are worried about the time it will take away from their other responsibilities. So, just as much as the surgery is important, I try to ensure that their minds are in the right place to undergo the treatment.
How, then, do you approach an initial consultation?
I use a lot of illustrations to help patients process what their diagnosis means. And I’ll try to understand their fears and obstacles so that I can provide them with the most appropriate treatment options.
Are you finding that women arrive for their first consultation fairly well-informed about their breast cancer?
Yes, but what they have found on Dr. Google doesn’t always apply to them. I find myself answering a lot of questions and educating women about their disease and treatment. The days of “one-size-fits-all” treatment plans are over. We’re at a point now where we’re creating treatment plans that are tailored to each woman’s cancer. Not her type of cancer; her specific cancer.
Increasingly, treatment plans seem to be factoring appearance into the outcome.
Many women attribute their femininity to their breasts. On the heels of their diagnosis, they may be thinking, “Yes, remove my breasts, whatever it takes to get rid of the cancer.” But a few years removed from treatment, they may begin to feel like a piece of them is missing. So, our goal now is not just to remove the cancer but to restore a sense of normalcy to their lives.
What innovations are happening in breast cancer surgery?
It’s an exciting time for breast cancer care. Through clinical trials and improved technology, breast cancer care and surgery are improving and becoming more personalized. Over time, breast surgery has become less invasive overall. We are becoming better at knowing what needs to be surgically removed and what doesn’t. Breast reconstruction after surgery has also greatly improved, helping patients feel “whole” again after surgery. Finally, surgeons now work more closely with other specialists. This team approach to care provides better service to our patients.
Can you elaborate on how breast surgery has become less invasive?
Previously, if we sampled axillary lymph nodes in the operating room and found cancer in some of them, we would automatically remove all of them. Based on newer studies, we don’t have to do that with many patients, which in turn reduces the risk of side effects like lymphedema. Some patients who have tumors that are too large to be removed by lumpectomy can actually undergo chemotherapy first, which can shrink the tumor down to a smaller size and therefore allow the patient to undergo lumpectomy (removing just the tumor) instead of mastectomy (removing the whole breast).
Is surgery always required for breast cancer?
Right now, yes. Medicine and radiation continue to improve, but surgery is still required for the patient to be cured. Patients do, however, often have options regarding the type of surgery they will have.
How important is cosmetics when it comes to breast cancer surgery?
How patients feel about their breasts is a very personal thing. They can be a part of a person’s identity and they’re something they see every day. It’s important to not only cure the cancer but also to make a person feel as good as they can about themselves. Fortunately, cosmetic procedures and reconstructive techniques can help with this.
Is genetic testing changing the way you approach surgery?
If a woman tests positive for a genetic mutation, she may opt for a different type of surgery than if she is negative. A double mastectomy, for example, may have a role in how the patient wants to manage her risk of developing a second breast cancer.
What should a woman look for in a breast surgeon?
The surgeon should be based at a hospital that is certified by the National Accreditation Program for Breast Centers (NAPBC). Patients should also look for a surgeon who specializes in cancer surgery, because it’s a complex field with a lot of nuances. Finally, look for a hospital that makes the patient a part of the team and values her opinion.
What are some innovative things you’re doing right now?
We’re now able to identify breast cancers as high or low risk using molecular profiling and genomic assays. Many women with early stage breast cancer can safely forego chemotherapy based on genomic assessment of their tumors. This has allowed us to lessen therapies and avoid unnecessary toxicities. We’re also using targeted therapies in combination with hormonal therapies for advanced hormone positive breast cancer, which has made a huge impact on the disease, lessened toxicities, and helped them avoid chemotherapy for more than two years. Finally, precision medicine is a genomic revolution that is impacting the lives of many patients. Identifying actionable mutations and targeting them with suitable drugs in certain subsets of breast cancer like Her2 positive or in BRCA-mutated patients are helpful.
Chemotherapy remains a common treatment for breast cancer. How has it evolved over the years?
Chemotherapy is one of the treatments necessary for some but not all women with breast cancers. Individualizing treatment and identifying those who do not benefit from it is important. Today, we closely monitor and attend to all the side effects from therapy, use a whole-body approach, and help patients maintain their quality of life throughout their treatment.
Is it important for a woman to know her risk level for breast cancer?
It’s very important. There are tools available to identify a woman’s risk level and take appropriate precautions. Prevention remains the key, along with adopting a healthy lifestyle, dietary changes and regular exercise. Screening with mammograms helps identify early stage cancers and saves lives.
How do you approach your first appointment with a patient?
I find that explaining to a patient about their disease in great detail and discussing all of the treatment options helps them better understand their condition, alleviates their fears, and empowers them to make appropriate decisions about their care.
How much does hope matter to patients?
We are in an incredible time with a lot of advances in breast cancer care. Women are generally more knowledgeable about breast cancer today than in the past. Still, fear can grip them and make it difficult to think logically about their care. It’s very important to walk with them in their journey, instilling hope and a positive attitude.
Beyond the scientific advances that have been made, why do you enjoy working in this field?
The personal connection I make with every patient is invaluable. I’m fortunate to work at this incredible organization that treats all patients like a family member, allowing me to make a difference in someone’s life. I learn from each patient, which helps in my growth and brings perspective.
What role are cosmetic procedures playing in treatment plans?
We’re now able to offer more women immediate reconstruction at the time of the mastectomy. We have also expanded the use of nipple-sparing mastectomy, providing the most natural appearance after mastectomy and reconstruction.
What do you consider to be the most meaningful developments over your 31-year career?
Our increased use of lumpectomy instead of mastectomy to conserve the breast is certainly one. In the past, we determined who was a candidate for lumpectomy and breast conservation. Today, we ask who is not a candidate. For women who are not candidates for lumpectomy initially, we can offer chemotherapy before surgery to shrink the tumor and then offer lumpectomy.
How much more effective has screening become over the years?
Today, a woman with breast cancer that’s detected during a routine mammogram has a 95 percent chance of being alive in five years. This very positive statistic is due in part to improvments in mammography and the development of breast MRI, both of which help us better detect small tumors and start treatment earlier.
Have there been similar strides in preventing recurrence, too?
Yes. Some of that can be attributed to new surgical techniques, some of it to more precise radiation, and some to improvements in chemotherapy. Three decades ago we gave chemotherapy after surgery only for advanced cases and most chemotherapy for breast cancer was given for metastatic disease. Clinical trials over time have clarified which women with earlier stage breast cancer will benefit from chemotherapy in lowering their risk of recurrence.
What’s the most innovative thing you’re doing in the operating room right now?
Intraoperative Radiation Therapy. At the time of lumpectomy, we’re able to administer a single concentrated dose of radiation to the tumor site, which ends up being all the radiation the patient needs. It’s intended to destroy microscopic tumor cells that may be left behind. The precision of this therapy helps us spare healthy tissue, the skin and nearby organs that can be damaged with other techniques.
In the past, a woman’s quality of life once she was finished treatment was rarely discussed. What changed?
Women are living longer than they ever have with breast cancer, and, in many cases, they’re dealing with physical and psychological changes caused by their treatments. There needs to be a survivorship plan in place so women know what to expect early in their treatment and years down the line. Ongoing surveillance plans, possible late sequelae of chemotherapy or radiation, and screening for other cancers are important parts of a survivorship plan.
What does a breast care nurse navigator do?
I work with women who have breast cancer, providing them with emotional support and navigating them through the complexities of their treatment plans with as little stress as possible. I meet at the time of their initial cancer discussion with the surgeon to establish a relationship. I may also assist them with scheduling an appointment or finding resources.
You’re a breast cancer survivor yourself?
I am. I’ve been a survivor 13 years. I’ve had mastectomy, reconstruction, chemotherapy, radiation therapy and hormonal therapy over the course of 10 years. I was scared. I didn’t know if I was going to survive. I felt like I was bargaining for more time to raise my child, who was 10 at the time. I was given some great advice from one of my nurses. She said, “Go ahead and cry, but then do something about it.” I use that advice in my job today.
How does your experience affect how you interact with patients?
In me, they see someone who has been through what they’re about to go through and I’m still standing. I can identify with their fears, which helps build trust between us and enables me to motivate them not to curl up and hide from the world, the way I wanted to. Hearing you have cancer takes away all of your control. But you start getting some of it back when you begin forming your treatment plan.
How did you get involved in breast health?
I’ve been with Einstein Medical Center Philadelphia for the last 29 years and involved in breast health for the last 25 of those. For much of that time, I was going out into the surrounding community and educating women about the importance of getting regular mammograms and supporting those here at the medical center as they moved from their screenings to their diagnoses to their treatments. So in a way, I guess I was doing patient navigation before it was even called that.
What’s a typical day like for you?
It’s never boring. I introduce myself right after a woman is diagnosed with breast cancer, and I try to reassure her that I’m her personal resource center for the hospital and the healthcare system. I can help her resolve an insurance issue, schedule an appointment and even set up transportation to and from that appointment. Most importantly, I want her to know that she won’t go through this journey alone. It’s natural for women to be frightened and overwhelmed when they are in this position so I tell them, “Let’s take it a step at a time.”
How would you describe your role?
I’m not an oncologist. I’m not a nurse. I’m coming from a personal place, and I always try to be genuine with patients. My sister was diagnosed with breast cancer at 34, and my aunt was as well at a later age, so it’s touched my life, too. There’s a fair amount of listening in my work. But I also want to make sure my patients are getting the care they need. There are so many resources that they’re usually unaware of.
You’re interested in healthcare disparities. What disparities do you see in breast cancer care?
There are many, but first on the list is access to care. Not everyone has appropriate access to health care or is aware of how and when to get screened for breast cancer. Lack of insurance is another big problem. To overcome these barriers, we need a strong commitment to cancer care equity. Patient navigators and robust use of electronic tools can help women get to their screenings and appointments. Clinicians also need to work with the patient community to implement strategies that work so everyone receives high-quality care.
You are an expert in telemedicine. What advantages does it offer?
It has tremendous potential to improve access to care. I’m not a techie. I am interested in using technology to bridge geographic and access challenges. For example, tele-mammography can bring the service to the patient in a remote or urban setting. The images can be transmitted to the radiologist for interpretation. It’s not always possible for patients to come to us, so if we’re serious about preventing cancer we must figure out ways to go where the patients are.
What excites you about breast cancer care today?
Prevention. Being able to prevent illness is very important. I’ve noticed that it’s incredibly empowering for patients when they can make changes in their lives that have a positive impact on their health. We have a lot of data that show the benefits of physical activity, a plant-based diet and mind/body connection. Get to know your body, learn about your family.
What has changed in the field of chemotherapy compared to a generation ago?
The biggest difference is the number of medications available to help manage the side effects of chemotherapy. Many women still receive chemotherapy, which can cause side effects, but now we can better support them and reduce the impact of those side effects. Additionally, we now have many more targeted medications available which can cause fewer side effects.
How is chemotherapy contributing to the concept of personalized care?
What we try to do today is target therapy with medications that have the best chance at success based upon tumor biology. We can do this because we can test tumors for specific genetic abnormalities and cellular markers. As a result, therapies are more individualized. Additionally, genetic testing of tumor tissue can help identify who may or may not need chemotherapy.
Is it ever too soon for a woman to start thinking about her breast health?
No. Healthy eating and exercise can both influence a woman’s breast cancer risk. The earlier those habits are formed, the better off they will be later in life. Early detection is also important. I encourage all women to report any changes they noticed, especially if something new is identified in the breast area. There’s so much fear tied to cancer, but women shouldn’t worry in silence. If you notice something new or different, contact your medical provider so it can be evaluated.
As someone who spends considerable time in the research lab, how do you see breast cancer treatment evolving?
It’s exciting. I’m able to do the research and then immediately apply the results to our patients, so we’re seeing the benefits of what we’re discovering. It lifts the whole team.
What are some of those innovations?
Recent clinical trials have allowed us to understand that shortened courses of radiation therapy can be just as effective as the standard 30-day treatment with early-stage breast cancer. We’re also doing more partial-breast radiation therapy, which allows us to spare more of the healthy breast tissue. And there’s a new clinical trial that’s going to evaluate the treatment of breast cancer with stereotactic body radiation therapy. Basically, it delivers a high but very precise dose of radiation. So, overall, we’re decreasing the time women are receiving radiation during their treatment, as well as the toxicity of that radiation and the area that’s exposed to it.
Can you tell us about the clinical trials you’re conducting to study diet’s effects on various conventional therapies?
We studied how caloric restriction would impact chemotherapy and radiation therapy. Because we had such positive results, we launched a few different clinical trials. In one, we’re investigating the diet’s influence right before surgery, and we’re seeing that it’s not only capable of slowing down tumor growth and improving the cancer-related biomarkers, but we’re also finding that the bacteria in the gut is undergoing a positive change.
What advances have changed breast surgery?
It’s not enough today to just rid patients of cancer; we want to help them feel like their normal selves after surgery. The nipple-sparing mastectomy has become a popular means of achieving that. We’re doing it through tiny incisions in the bra line or just above the nipple. Everything a woman sees in the mirror before the surgery, she sees after. And the shape of her breasts may even improve.
What does the phrase “de-escalation of treatment” mean?
That means we’re now trying to do as little intervention as possible but achieve the same results. For example, I recently saw a patient in her 80s who had breast cancer 20 years ago and was treated very aggressively. She now has breast cancer in the opposite breast, but it’s much smaller because it was caught earlier. This time she’ll get a lumpectomy and hormone therapy. That’s a de-escalation of treatment from the mastectomy, chemotherapy and radiation she received 20 years ago.
What advances are being made in breast surgery?
We are always involved in clinical trials to see if we can improve treatment. We recently wrapped up a trial that studied “shave margins,” which refers to the amount of healthy tissue we remove around a tumor. The idea is, if you take a little extra tissue from around the tumor during a lumpectomy, you can lessen the chances of needing another surgery later on. Nationally, about 30 percent of lumpectomies require a second surgery to get better margins. At Jefferson, we average less than 10 percent.
Breast surgery feels like it’s changing by the week. How is it evolving at Crozer-Keystone?
Much of the innovation happening is in the area of reconstruction. We recently teamed up with Crozer-Keystone plastic surgeons to offer the most advanced breast reconstruction surgical procedures, including nipple-sparing mastectomies. For a long time, implant reconstruction was a woman’s only option. Now, we’re able to use a woman’s own tissue to recreate her breast, and our patients, overall, are happier with the result.
How much of a consideration is the cosmetic side in what you do?
It’s very important. It’s hard enough to have cancer. To have a body part removed on top of that only compounds the physical and emotional distress. Reconstruction alleviates some of that trauma and enables women to begin the healing process in a better state of mind.
Similarly, how is genetic testing influencing your work?
It’s changing not only how we’re doing the surgery but also how we care for a woman. For instance, new studies are indicating that women don’t necessarily need to have preventive mastectomies if they have a genetic mutation. In many cases, putting them under increased surveillance is enough.
How closely do you work with other oncology specialists?
Very closely. I’m in constant contact with our medical and radiation oncologists. We also have a weekly breast panel here at the hospital, which reviews all of our new breast cancer patients. This way, every doctor has input early on, and together, we can develop the most appropriate and personalized treatment plan for each patient.
Would you say that breast surgery is trending toward the less invasive end of the spectrum?
Yes. Here’s a significant example: 20 years ago, axillary lymph node dissection was the standard. Today, it’s a sentinel node biopsy, which enables us to remove less lymph nodes—the more you remove, the greater the side effects—and, ultimately, spare more women from the risk—the lifelong risk—of developing lymphedema, which can be very painful and disabling.
What drew you to the field of breast surgery?
Unlike other areas in surgery, breast cancer patients become your own. I continue to see them long after their surgeries. We become friends. I show them pictures of my son, and they keep me updated on what’s going on in their lives. It’s very rewarding, especially to see them doing well years later.
Do you ever have a routine day?
No. One of the most interesting aspects of this job is that there are so many nuances to it. Every woman is unique. Every breast cancer is unique.