Chances are, you have been impacted by breast cancer. One in eight women will be diagnosed in her lifetime, which unfortunately may be your sister, cousin, friend, or neighbor. It may be you. Or perhaps, concerned about getting the disease, you are considering options to minimize your risk.
What comprehensive care providers want you to know is that breast cancer diagnosis and treatment have been revolutionized over the past two to three decades. What was once a cancer that, more frequently than not, took lives or disfigured women, can now be a “beatable, treatable disease.” This is thanks to modern imaging, therapies, and procedures, according to Gary Tuma, M.D., FACS, director of plastic surgery for Capital Health’s Plastic Surgery Associates of New Jersey, based in Pennington.
From the public’s standpoint, the “spirit” of breast care has recently evolved into an empathetic, individualized patient experience that brings both power and comfort to those battling cancer. Many breast care centers have moved from paper gowns and sterile exam rooms to soft robes and cushy couches. The ominous hum of treatment machines is often masked by calming music. On what may be the hardest days of a woman’s life, care providers have gotten to the heart of what it means to be diagnosed. And they’re giving her all the knowledge and support they can deliver.
Through the Screening Door
Never before have women had such advanced technology so readily available to them. Digital mammography, an effective screening tool, is the gold standard for early detection of breast cancer. “Mammography is, at this point, the only imaging study that has been proven to decrease deaths from breast cancer,” says Anne Moch, M.D., a radiologist with Capital Health Advanced Imaging, while noting that other studies are available for complementary use.
Mammograms, or X-rays of the breast, can detect tumorous tissue and are recommended for women aged 40 and older every year. While the technology has been effective at catching early cancers, it has some limitations, especially for women with dense breasts. “Sensitivity of mammography in a dense breast can be as low as 30 percent,” according to Dr. Moch. Dense breasts are composed of more tissue and less fat, making tumors harder to detect. Dense-breasted women also happen to be more susceptible to breast cancer. (For more on dense breasts, visit areyoudense.com.)
In difficult-to-interpret mammograms, radiologists may turn to other types of imaging to be used in combination with mammography. These options include magnetic resonance imaging (MRI), ultrasound, tomosynthesis, and most recently, molecular breast imaging (MBI).
According to the National Institutes of Health, MBI is a (functional) nuclear medicine study of the breast that relies on the differences in the (mitochondrial) activity of tumor cells vs. normal cells. “Therefore, the density of the surrounding breast tissue is less of an obstacle to overcome,” Dr. Moch explains. Studies with MBI use Tc-99m sestamibi, a radiotracer that accumulates in any tumor that may be present. Tc-99m sestamibi has been used for years in cardiac stress testing. The amount injected for MBI is one-fifth of the dose used for cardiac stress tests.
The Capital Health Center for Comprehensive Breast Care in Hopewell, N.J., was the first institution in the country to acquire MBI technology. Their physicians report great utility when used in conjunction with mammography for women at high risk for breast cancer or hidden cancers. These include women who have had previous biopsies with high-risk lesions and those who have inherited the BRCA1 or BRCA2 gene. New breast-density legislation pending in the New Jersey Legislature will require insurance companies to cover breast evaluations and other medically necessary testing if a mammogram determines a patient has dense breast tissue, and that certain mammogram reports have to contain information about breast density.
“Our goal in the women’s imaging center is to provide state-of-the-art care to our patients, and the addition of molecular breast imaging aids us in our ability to detect breast cancer at its earliest, most treatable stage and further allows us to provide exceptionally high-quality care to our patients,” Dr. Moch says. “We’ve had a tremendous amount of success in our experience so far in detecting small cancers and also in providing other patients with the reassurance that no abnormality is present in their breasts.”
Now What?
Women who receive a positive breast cancer diagnosis are faced with challenging choices regarding optimal treatment. The Center for Comprehensive Breast Care streamlines care by offering nearly all physician offices and services in one building. These cutting-edge services include initial screening and diagnostic exams, biopsies, oncologic surgical services, radiation and chemotherapy, reconstructive surgery, breast navigation services, and more.
Director Lisa Allen, M.D., explains that the center’s employees seek to offer everything a patient needs, including a breast navigator who guides women through the maze of treatment choices, support services, making appointments with members of the healthcare team, and other “emotional” hurdles.
“When you come here, you’re not a number,” assures Dr. Allen. “We really personalize the care you’re getting for the particular cancer you have and the particular person you are. We don’t rush patients in and out. We spend a lot of time to help them through the decision-making process for how their cancer will be treated.”
If surgery is the approach that is recommended, patients may be offered a lumpectomy (segmental mastectomy), which removes only the breast lump and a surrounding margin of normal tissue, or a single or double mastectomy. Recommendations depend on the particular type of tumor, how large it is, how large the breast is, and whether the tumor has spread within the breast, among other factors, explains Dr. Allen. Most patients do not require a mastectomy, and “the data show that recurrence rates and survival rates are actually the same if you have a mastectomy vs. having a lumpectomy with radiation,” she reports.
As part of a lumpectomy, surgeons perform local rearrangement of tissue and fill in any indentations in the breast. If the cancer is just too large, physicians will recommend a mastectomy to be carried out by one of the team’s surgeons. It may be a total mastectomy, during which the entire breast is removed, or a skin- or nipple-sparing mastectomy, during which parts of the breast may be kept. A sentinel lymph node biopsy or an axillary lymph node dissection procedure also may be performed to see if the cancer has spread, and to control regional spread of disease. Radiation therapy, estrogen therapy, or chemotherapy is available if the patient’s specific cancer requires additional treatment.
To determine the best course of action, women are thoroughly evaluated by Capital Health’s multidisciplinary breast care team members, including surgical oncologists, medical oncologists, radiologists, geneticists, radiation oncologists, and reconstructive surgeons, who “treat each patient for her individual cancer,” says Dr. Allen.
Knowledge is power, and throughout these consultations, “women will understand the full gamut of options,” says Dr. Tuma, who works on the reconstructive end of the multidisciplinary approach.
Rebuilding Process
In 2012, the U.S. Congress introduced the Breast Cancer Patient Education Act, seeking to increase women’s awareness about the reconstructive options available to them after a mastectomy. While insurance providers who cover mastectomy are required to cover reconstructive surgeries, a low percentage of women moves forward with reconstruction, despite its effectiveness in restoring breast appearance.
General surgeons in years past did not often recommend consultation for plastic surgery following mastectomy, Dr. Tuma points out. But the specialization of breast reconstruction, a relatively new phenomenon, has made significant strides in the past decade, and more women are exploring options to restore their bodies. “Today, immediate breast reconstruction is pretty much the standard of care,” which can begin at the time of mastectomy, Dr. Tuma says.
“This is a huge advantage psychologically, physically, and emotionally for women, because not only do they not have to live with any significant deformity for any period of time, they are also fully aware that the process to start to rebuild and reconstruct starts right away.”
Capital Health offers an array of reconstructive options in conjunction with mastectomy. Implant-based surgery, which often employs silicone implants, is a popular and extremely safe option, according to Dr. Allen. Tissue-based reconstruction techniques use tissue from the patient’s stomach, back, thighs, or buttocks to rebuild the affected breast.
Traditionally, most breast reconstructions involved only the one breast affected by cancer. Today, it’s not uncommon for both breasts to be treated. If a unilateral mastectomy and reconstruction is performed, a woman may opt for a procedure on the other side to achieve symmetry. This would include a breast lift, enhancement, or reduction.
Most recently, some women are also seeking elective, prophylactic bilateral mastectomies to reduce the risk of getting breast cancer. By having both breasts removed, women who are at high risk for breast cancer reduce their risk to about 2 to 5 percent, Dr. Allen says.
Interest in this surgery has increased since actress, humanitarian, and mother Angelina Jolie announced in May that she underwent a prophylactic bilateral mastectomy after testing positive for a mutation of the BRCA1 gene. Normally, BRCA1 and BRCA2 prevent breast and ovarian cells from growing and dividing uncontrolled. However, when there is a mutation, it can increase the chances of cancer developing.
“My doctors estimated that I had an 87 percent risk of breast cancer and a 50 percent risk of ovarian cancer, although the risk is different in the case of each woman,” Jolie wrote in The New York Times. “Once I knew that this was my reality, I decided to be proactive and to minimize the risk as much as I could. I made a decision to have a preventive double mastectomy … My chances of developing breast cancer have dropped from 87 percent to under 5 percent.”
Actress Christina Applegate, who was diagnosed with breast cancer, underwent a lumpectomy and genetic testing in 2008. After testing positive for BRCA1, she also decided to undergo a double mastectomy.
“Reconstruction options are changing because there are now more bilateral cases, even when there is no cancer diagnosis, but they are considered high risk. Patients who have the gene that puts them at increased risk are pursuing prophylactic options to decrease their risk,” Dr. Tuma says. “Some women, like Angelina Jolie, are opting to move forward with mastectomy and reconstruction, though they have not had cancer, for prophylactic reasons in high-risk groups.”
Insurance coverage for such surgeries is “unpredictable and a bit scary,” Dr. Tuma says, noting that no one really knows how insurance providers will ultimately decide to handle the complex cases of high-risk, prophylactic breast cancer patients.
As a reconstructive surgeon, Dr. Tuma has one important goal: to allow women to feel good about their bodies, especially when in public. “There will be some changes in the body—shape, size, and scarring, which will be evident to you as you’re standing naked in front of a mirror,” Dr. Tuma says. “But in public—in a bathing suit or evening gown—few people will have any idea you’ve had anything done.”
Surgical patients typically respond with “overwhelmingly positive feedback,” Dr. Tuma reports, describing his patients as “comfortable, confident, and happy” with their bodies.
Positive results emerge in tandem with the supportive, patient-centered environment provided by a comprehensive care team. Combined with the array of screening technologies, clinical procedures, therapies, and reconstructive choices, women are presented with comfortable healing environments.
Women battling breast cancer need convenient, comfortable, compassionate care. With life on the line, positive action requires a positive vision.
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