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1 Providence SAINT JOSEPH MEDICAL CENTER Burbank Valley RADIATION ONCOLOGY Center Providence HOLY CROSS MEDICAL CENTER Mission Hills Providence HOLY CROSS HEALTH CENTER Santa Clarita

2 TABLE OF CONTENTS 2005 PSJMC Cancer Program Annual Report with a statistical review of 2004 data PSJMC Cancer Committee Membership Message from the Oncology Service Area Director 2 Tamara Sutton Message from the Medical Director, Providence Saint Joseph Medical Center 3-6 Raul Mena, MD Breast Cancer 5-Year Survival Rates Statistics - PSJMC vs. NCDB 2004 Cancer Site-Stage Distribution Report 8-9 PSJMC PROVIDENCE SAINT JOSEPH MEDICAL CENTER (PSJMC) PROVIDENCE BREAST HEALTH CENTER Medical Oncology: Treatment of Breast Cancer Herbert Duvivier, MD Breast Cancer: Treatment and Outcomes Raymond Shofler, MD Radiation Therapy in Breast Cancer Care Marc Botnick, MD Plastic Surgery and Breast Cancer George Orloff, MD, F.A.C.S. Providence Breast Health Center: Digital Technology, CAD and Gail Model 23 Albert Lee, MD The Surgical Pathology Report Jose Esteban, MD Personal Appearance Rehabilitation Center 27 Bebe Tamberg, RMF, CMF Report on Cancer Data Services 28 Lupe Llamas, CTR Cancer Research 29 Susan Garate Cancer Web Site Links 30 P ROVIDENCE C ANCER C ENTERS 2005 Annual Report i

3 PSJMC Cancer Committee Membership 2005 Herbert Duvivier, MD Chair Raul Mena, MD AcOS Liaison/Medical Director Cancer Beth Boyd Spiritual Care Nancy Loporchio, RN Manger, Oncology Unit Marc Botnick, MD Radiation Oncology Robert Simon, MD Family Practice Tamara Sutton Oncology Services Line Director Margy Brown, RN Quality Improvement Director Richard Friedman, MD GYN Oncology Scott Sligh, MD Colorectal Surgery Cheryl Cook, RN Short Stay/GI Lab Cindy Ludwig, RN NE Med Surgery Michael Hyman, MD Urology Chester Wilson, MD Co-Chair Radiation Oncology Susan Garate Research Fred Plessner Physical Therapy Edwin Jacobs, MD Medical Oncology Carl Winberg, MD Pathology Anne Gammariello Pharmacy Diane Voss, RN Surgery Albert Lee, MD Breast Center/Radiology David Yerzley, MD Radiology Don Pederson Spiritual Care Teresa Lee-Yu, PHd Pharmacy Sharon Adell, RNNP Clinical Care Coordinator Lupe Llamas, CTR Cancer Data Services Russell Kieffer Palliative Care Karen Roberson, LCSW Clinical Social Work Jacqui Steltz-Lenarsky Continuing Medical Education Bebe Tamberg Personal Appearance Sherry Howard, CPHQ Professional Staff Office Brenda Lopez Quality Improvements Stephen Stroup, LCSW Trinity/Care Hospice P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 1

4 Message from the Oncology Service Area Director Tamara Sutton Tamara Sutton Oncology Service Area Director I am proud to have recently joined the Cancer Program team at Providence Saint Joseph Medical Center. As you review this report, you will gain a sense of the fine work that drew me to Providence. I have been impressed by both individual team member s efforts and the work of the team as a whole. Much work has already been done and much remains to do. I now have the pleasure of being a part of this great team. I will join in leading us toward our next level of achievement with the development of the Roy and Patricia Disney Cancer Center on the campus of Providence Saint Joseph Medical Center. This year s annual report focuses on our efforts in the diagnosis and treatment of Breast Cancer. For the past 20+ years, breast cancer has been a particular interest of mine. It is a great opportunity for me to work with an institution that has achieved and maintains such outstanding outcomes in this disease. Throughout the next year, we will work to further understand the data related to these impressive outcomes. As we look forward to our new Disney Cancer Center home and begin the complicated planning process, it is comforting to know that we have both strong core values and a set of well thought out guiding principles to light our way: Healing Environment in the Interior and Exterior Areas Use of Human Touch and Human Interaction Spirituality and Nurturing Spaces Inside and Outside Employment of the Arts Mind, Body & Spirit Approach Wellness Program State-of-the-Art Technology Empowerment of Patients through Information and Education Safe Environment for Patients, Visitors, and Staff Recognition of the Importance of Family, Friends, and our Community Emphasizing the importance of Nutritional and Nurturing Aspects of Food Recognizing the Importance of our Donors Above all, each of our patients is and will continue to be valued and treated as a whole person. It is this principle of treating the patient s mind, body and spirit, in addition to our outcomes, that differentiates us from any other cancer program in the San Fernando Valley. Not only the building design and materials but also the elements and structure of the programs will stay true to the vision so well articulated by our cancer program and medical center leaders. We will offer the most advanced technology with a compassionate touch. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 2

5 Message from the Medical Director, Cancer Program, PSJMC Raul Mena, MD Raul Mena, MD Medical Director, Cancer Program, PSJMC It is with great pride and pleasure that we present the 2005 Providence Regional Cancer Centers annual report. While the American College of Surgeons Commission on Cancer mandates this report, we appreciate the opportunity to share information about our comprehensive cancer program and the accreditation we maintain. The Providence Saint Joseph Medical Center cancer program have been fully accredited by the commission on cancer since April 01, We use this mandate as part of our quality improvement process and as part of our educational outreach for our medical staff, nurses and the community that we serve to help us achieve the goals of the Sisters of Providence. In this report, we describe some of the many programs related to breast cancer care. We strive to treat the whole person at all stages in the disease process. These stages include the identification of a person s personal risk of developing breast cancer. When a patient develops breast cancer, we use the latest technology for early detection, including digital mammography, ultrasound, MRIs of the breast and computer-aided second opinions. From a breast cancer treatment perspective, we employ minimally surgical techniques such as breast preservation and sentinel lymphadenectomy. For those patients who require a mastectomy, we have breast reconstructive surgery available. Our radiation oncology group uses computerized radiation treatment planning to achieve the best cosmetic results with the least amount of toxicity. Our radiation oncologists also employ a new technology known as partial breast irradiation. Medical oncologists use chemotherapeutic agents, hormonal agents and other tools, such as monoclonal antibodies, in the prevention of breast cancer for women at high risk as well as in the adjuvant and the systemic treatment of their breast cancers when appropriate. We also offer patients the opportunity to participate in clinical trials, for both the prevention and treatment of breast cancer. Our hope is that this research will improve our patients quality of life as well as their survival. Although Providence Saint Joseph Medical Center is the largest hospital in the San Fernando Valley, we serve a population that extends far beyond this geographic area. The hospital has 405 acute care beds and 93 skilled care nursing beds. In 2004, we cared for greater than 1600 new cancer patients. Improving cancer care for our patients is our main focus. Education is the main tool we use to achieve this goal. We conduct a weekly tumor board where 98.7% of all the cancer cases are presented in a prospective manner, before definitive treatment is given. We also have weekly treatment planning conferences to ensure both second opinions for our patients as well as better integration between the different specialties treating breast cancer. We identify patients who may benefit from participation in clinical trials. The third educational conference follows the more traditional didactic presentation. These conferences have included the following: P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 3

6 MESSAGE FROM THE PSJMC MEDICAL DIRECTOR continued PSJMC s state-of-the-art inpatient tower January 14, 2004: Highlights from the San Antonio Breast Conference by A. Garcia, MD February 18, 2004: Update on the 2003 San Antonio Breast Cancer Conference by M. Pegram, MD May 17, 2004: The Use of PET in Oncology by R. E. Coleman, MD August 4, 2004: Post-ASCO 2004 update on Breast Carcinoma by S. Jones, MD September 29, 2004: Post-ASCO 2004 update on Breast Carcinoma by V. Valero, MD November 10, 2004: Hormone Therapy for Breast Cancer by R. Chlebowski, MD December 15, 2004: Adjuvant Treatment of Early Breast Cancer by S. Tang, MD April 21, 2005: Breast Cancer Prevention by R. Chlebowski, MD July 26, 2005: Post-ASCO 2005 Update on Breast Cancer by R. Chlebowski, MD October 18, 2005: Genetic Predisposition by W. Grody, MD All of the above conferences were open to members of the medical staff, nursing staff and other members of the health-care community. We feel our educational conferences and the skill and interests of our medical staff, as well as the foresight and commitment of both our hospital foundation and administration in acquiring the latest technology, have resulted in dramatic improvements in the care of our breast cancer patients. OUR ACCOMPLISHMENTS In early 2005, Providence Saint Joseph Medical Center opened a new state-of-the-art inpatient tower resulting in dramatic upgrades to our surgical suites, diagnostic imaging area and nursing floors with patient centered, single care rooms. The medical oncology unit is on the 6th floor. The care provided by our oncology nurses is second-to-none, resulting in a long list of accolades: 2001: N. Loporchio, RN received an Excellence in Pain Management Award from the Southern California Cancer Pain Initiative 2002: The Oncology unit was awardd Staff Nurses of the Year by the Greater Los Angeles Nurses Society 2003: J. Niega, RN was awarded Staff of the Year by the Greater Los Angeles Oncology Nursing Society 2004: J. Niega, RN was recognized for her work as a bedside nurse by the Philipino American Nurses Association 2004: Frances Farrand, RN was recognized as Staff Nurse of the Year by the Greater Los Angeles Oncology Nursing Society 2005: J. Koch, RN received an Excellence in Pain Management award from the Southern California Cancer Pain Initiative 2006: A group of oncology nurses received the Rose Recognition Award from the Greater Los Angeles Oncology Nursing Society 2006: Cindy Mark, RN was named Staff Nurse of the Year, by the Greater Los Angeles Oncology Nursing Society These nurses are a group of highly dedicated and gifted people who are an integral part of our cancer program. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 4

7 MESSAGE FROM THE PSJMC MEDICAL DIRECTOR continued BREAST CANCER TREATMENT OUTCOMES Let us now review our outcomes in the treatment of breast cancer. We compared our results for the previous five years with the National Cancer Data Base (NCDB), which is supported by the American College of Surgeons Commission on Cancer (Figure 1). At Providence Saint Joseph Medical Center, we diagnose and treat a large number of patients. This does not mean that we have a larger number of breast cancer patients in our area; rather that patients with breast cancer diagnosed elsewhere, throughout Los Angeles County, come to our cancer center for definitive therapy, thus skewing our statistics (Figure 2). Figure 1: Major Cancer Sites vs. PSJMC vs. California vs. USA How do we justify the influx of cancer patients to our hospital? The simple answer is the quality of care delivered by our doctors and nurses combined with the latest in technology results in demonstrable superior outcomes. Figure 2: Class of Cancer Patient Distribution P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 5

8 MESSAGE FROM THE PSJMC MEDICAL DIRECTOR continued For every stage of breast cancer at diagnosis, we surpassed the expected survival outcomes when compared with the NCDB (see page 5 for Stages I, II, III, IV and aggregate Figures). These remarkable outcomes were achieved with one of the highest breast preservation rates in the country. These results also were due to the cooperation and pretreatment planning by surgeons, medical oncologists and radiation oncologists at Providence Saint Joseph Medical Center. The future looks bright. We are currently in the process of planning a free-standing Roy and Patricia Disney Cancer Center. The fundraising for the project is twothirds completed. We will be better able to integrate all aspects of cancer care, not only the traditional, medical oncology and radiation, but also rehabilitative therapy, physical medicine, pain control, spiritual care, behavioral medicine and complementary and alternative medicine. We will feature a patient-based learning center where patients can go, and with the help of a medical librarian and the American Cancer Society, receive up-to-date and accurate medical information with pamphlets or via the internet regarding their disease as well as access to clinical trials. We have some exciting times ahead and with the continued support from the community that we serve, we certainly will continue to improve the quality of life and the survival of our patients afflicted with cancer. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 6

9 Breast Cancer 5-Year Survival Rates 2004 Statistics - PSJMC vs. NCDB Stage I: 5-Year Survival Rates Stage III: 5-Year Survival Rates Aggregate 5-Year Survival Rates Stage: II 5-Year Survival Rates Stage IV: 5-Year Survival Rates P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 7

10 2004 Cancer Site-Stage Distribution Report Providence Saint Joseph Medical Center 1 of 2 ALL Sites SITE GROUP SITE 0 I II III IV UNK NA Total % Total Head and Neck Tongue % Salivary Gland % Floor of Mouth % Gum / Other Mouth % Nasopharynx % Tonsil % Oropharynx % Hypopharnyx % Pharynx / Other Oral % % Digestive System Esophagus % Stomach % Small Intestine % Colon % Rectosigmoid Junction % Rectum % Anus % Liver % Intrahepatic Bile Duct % Gallbladder % Other Biliary % Pancreas % Retroperitoneum % Peritoneum Omentum / Msntry % Other Digestive % % Respiratory System Nose/Nasal Cavity / Mid Ear % Larynx % Lung-Small Cell CA % Lung-Non-Small Cell CA % Lung-Other Types % Pleura % % Bone Bones / Joints % % Soft Tissue Soft Tissue / Heart % % P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 8

11 2004 Cancer Site-Stage Distribution Report Providence Saint Joseph Medical Center 2 of 2 ALL Sites SITE GROUP SITE 0 I II III IV UNK NA Total % Total Skin Melanoma-Skin % Other Non-Epithelial Skin % % Breast Breast % % Female Genital System Cervix % Uterus % Ovary % Vagina % Vulva % % Male Genital System Prostate % Testis % % Urinary System Bladder % Kidney / Renal Pelvis % Ureter % % Eye Eye / Orbit % % Brain/Nervous System Brain % Other CNS % % Thyroid/Endocrine Thyroid % Endocrine % % Hemic and Lymphatic Hodgkin s Lymphoma % Non-Hodgkin s Lymphoma % Plasma Cell Tumors % Leukemia % % Other/Unknown Other / Unspecified % % P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 9

12 Medical Oncology: Treatment of Breast Cancer Herbert Duvivier, MD Herbert Duvivier, MD Medical Oncologist, Cancer Committee Chair Medical oncology therapeutics are evolving constantly. During the last five years, there have been significant advances in the oncologic treatment of breast cancer. From the advent of Herceptin to treat metastatic Her-2-Neu positive breast cancer to the development of dose-dense therapy for adjuvant treatment of early stage, high-risk patients, there seems to be no end to the number of new drugs and combinations available to treat women diagnosed with breast cancer. At Providence Saint Joseph Medical Center (PSJMC), we are at the leading edge of treatment for women diagnosed with breast cancer. A look at the statistics shows us the following: 25% of all cancers treated at PSJMC are breast cancers; 70% of all breast cancers at PSJMC are diagnosed Stage 0 - Stage II 50% of all breast cancers diagnosed at PSJMC are in patients older than 60 years old 80% of all breast cancers diagnosed at PSJMC are treated with some combination of surgery, chemotherapy, hormonal therapy and radiation therapy Stage-for-stage survival is better for those treated at PSJMC when compared to the data from the National Cancer Data Base (NCDB). See survival rate Figures on page 5 for Stages I, II, III, IV and aggregate. In medical oncology, a caveat is that success is dependent upon early diagnosis and aggressive treatment of disease. Additionally, chemotherapeutic intervention which is delivered on time and without dose reduction has been shown to improve outcomes over any other delivery method. At PSJMC, the medical oncologists work hard to ensure that delivery is timely and the dose is adequate to meet the job. In early stage breast cancer (Stage I), treatment often is hormonal (anti-estrogen) therapy. There is, however, a subgroup of patients whose risk of relapse is higher; those in this subgroup would benefit from chemotherapy administration. Until recently, defining this group was more a gestalt as rendered by the physician after interviewing the patient. Now, however, we have in our arsenal a genomics test that can help clarify who may be at increased risk of recurrence and who may benefit from chemotherapeutic administration. Visit and for the Oncodx test studied at PSJMC. For those at high risk for Stage I breast cancer and those with Stage II (node-positive) disease, decisions are made based in part on whether the patient is Her-2-Neu positive. Her-2-Neu protein, when present, confers a more biologically aggressive personality to the tumor. For those 30% of women with this protein present a P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 10

13 MEDICAL ONCOLOGY TREATMENT OF BREAST CANCER continued series of recent articles has shown that the addition of Herceptin to their adjuvant treatment will improve their chances of surviving this aggressive disease. For others, a combination of chemotherapy agents alone will be enough to improve their chances of cure. For women with more advanced disease such as Stage III (large tumor or inflammatory breast cancer), neo-adjuvant therapy (pre-surgical chemotherapy and/or hormonal therapy) may help to improve the possibility of breast preservation (surgical outcomes) as well as overall survival from the disease. Women with Stage IV (disease spread to other organs) are treated as if they have an incurable, chronic disease. Many women often survive years with their disease while undergoing multiple single-agent chemotherapies or hormonal manipulations. Additionally, bone morbidity has been substantially decreased with use of bisphosphonates such as Zometa. One of the major advances in cancer treatment has been the control of chemotherapy-induced nausea and vomiting as the prevention of anemia and infections related to chemotherapy. The advances during the last five to ten years have been the result of thousands of women participating in clinical trials. Although the number of participants has remained stable, as has the percentage of the total number of women fighting this disease, it is still pathetically low. At the Providence Regional Cancer Centers, there are many breast cancer clinical trials available in which patients may choose to participate. The pre-treatment planning that takes place between surgeons and medical and radiation oncologists has helped us in achieving some of the highest breast preservation rates while achieving survival rates higher than the national average. This allows women the opportunity to become breast cancer survivors. Their participation in clinical trials allows for continued improvement in the care of cancer patients and improvement in overall survival. The conbination of a strong, experienced team of specialists and a proactive patient often leads to successful outcomes. Our medical oncologists are an essential part of the strong team of experts here at Providence Saint Joseph Medical Center and they are one of the main reasons breast cancer outcomes here are some of the best in the nation. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 11

14 Breast Cancer: Treatment and Outcomes Raymond Shofler, MD Raymond Shofler, MD General Surgeon Providence Saint Joseph Medical Center (PSJMC) has an outstanding record in the treatment of breast cancer. The cooperative efforts of many physicians have produced statistical evidence clearly showing that women treated at this hospital have better outcomes than the community at large. The National Cancer Data Base (NCDB) statistics demonstrate benefits in survival and the avoidance of complete mastectomy. Women with breast cancer want two things: they want to preserve the form and function of the breast and they want long-term survival following their diagnosis. PSJMC has outperformed national statistics in both of these areas. Let s review the demographics of breast cancer in Approximately 217,000 new cases of invasive breast cancer occurred in the United States, with 21,800 in California. It is the most frequently diagnosed cancer in women (excluding skin cancer). An additional 60,000 cases of ductal carcinoma in situ occurred. Approximately 40,000 women die of breast cancer each year. NUTRITIONAL & PHYSICAL ACTIVITY FACTORS Scientific evidence suggests that one-third of cancer deaths are due to nutritional and physical activity factors. For the majority of Americans who do not use tobacco, these factors are the most important determinants of cancer risk which are under our control. The American Cancer Society recommends: 1. Eating a variety of healthful foods, with an emphasis on plant sources 2. Adopting a physically active lifestyle 3. Maintaining a healthful weight throughout life 4. Limiting the consumption of alcoholic beverages BREAST CANCER TREATMENT OPTIONS The surgical treatment of breast cancer requires removal of the tumor and appropriate lymphatic tissue in a cosmetic manner with the preservation of form and function of the breast. The process of diagnosing and treating breast cancer typically begins with either an abnormal mammogram or a lump or mass in the breast. The new Breast Health Center has state-of-the-art digital mammography as well as MRI and ultrasound available for diagnosis. Sampling of abnormal breast masses can be done with fine-needle aspiration or with mammotome techniques, which avoid open surgical procedures. Once a malignancy is identified then a lumpectomy and sentinel node biopsy is generally recommended. The sentinel node procedure permits sampling of one to two lymph nodes instead of the 10 to 15 frequently required in the past in a more complete axillary dissection. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 12

15 BREAST CANCER: TREATMENT AND OUTCOMES continued Occasionally, complete mastectomy is required. In these cases a plastic surgeon is consulted for immediate reconstruction. A new technique known as a skin sparing mastectomy allows maximal cosmetic benefit from the combined mastectomy and reconstruction. A physically active lifestyle can help lower your cancer risk BREAST CANCER STATISTICS Let s review recent statistics at PSJMC. Breast cancer continues to be one of the most commonly diagnosed cancers at our hospital. New cases comprise 26% of total cancer cases. Most of these cases (85%) present as early breast cancer namely in situ, Stage I or Stage II (Figure 1). Approximately 20% are younger than age 50. The NCDB records survival statistics showing clearly superior results at our cancer center compared to the national averages. Stage I survival is nearly 98% vs. 87% for the other hospitals. Stage II shows an even greater disparity between results at PJSMC vs. the national average namely 93% vs 77%. Stages III and IV results reveal the same trends. The overwhelming conclusion: women with breast cancer treated at PSJMC live longer. The combined survival chart of all stages of breast cancer reveals this (Figure 2). Figure 1: 2004 Breast Cancer Age at Diagnosis Figure 1: 2004 Breast Cancer Stage at Diagnosis P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 13

16 BREAST CANCER: TREATMENT AND OUTCOMES continued It s important to maintain a healthful weight throughout life PSJMC has been in the forefront of breast conservation surgery for over twenty years. In the 1980s national trials demonstrated that the combination of lumpectomy and radiation therapy offered equivalent results to complete mastectomy. The National Institutes of Health (NIH) Consensus Conference in 1990 recommended this treatment for the majority of patients with Stage I or II breast cancer. PSJMC has breast conservation rates over 80% compared to 60% in comparable hospitals. A recent article from this hospital reviews our experience from 1987 to This review includes the cases of 521 women with early breast cancer. Our results showed superior rates of breast conservation surgery as well as favorable recurrence rates and survival. In summary, PSJMC has an excellent record in the treatment of breast cancer. This is not simply wishful thinking but is based on statistical evidence comparing our hospital statistics with the NCDB. Women treated here benefit from state-of-the-art diagnostic techniques, an excellent radiation therapy program, skilled surgeons and excellent medical oncologists. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 14

17 Radiation Therapy in Breast Cancer Care Marc Botnick, MD Marc Botnick, MD Radiation Oncologist Breast cancer is the most common cancer among women, except for non-melanoma skin cancers. The chance of developing invasive breast cancer at some time in a woman s life is about one in eight (13% of women). Women living in North America have the highest rate of breast cancer in the world. It is estimated that in 2005 about 217,000 new cases of invasive breast cancer and nearly 60,000 new cases of in-situ breast cancers will have been diagnosed among women in the United States. Breast cancer is the second leading cause of cancer death in women, exceeded only by lung cancer. In 2005, about 40,000 women and 500 men died from breast cancer in the United States. Death rates from breast cancer have been declining. These decreases are believed to be the result of early detection and improved treatment. At Providence Saint Joseph Medical Center (PSJMC), breast cancer represents more than 25% of the malignancies treated. About 40% of breast cancer patients treated have Stage I at diagnosis. 27%, 10% and 4% of patients are initially managed at Stages II, III and IV respectively (in-situ disease, 17%). The five-year survival for these stages is: 98%, 92%, 73% and 40% equaling or surpassing the statistics reported by the National Cancer Data Base (NCDB). See survival rate Figures on page 5 for Stages I, II, III, IV and aggregate. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 15

18 RADIATION THERAPY IN BREAST CANCER CARE continued The integration of radiation therapy into the treatment algorithm for definitive breast cancer care has been longstanding. This modality has been shown to enhance both local control and overall survival over that achieved by surgical and chemotherapeutic regimens. During the past decade, radiation therapy techniques and treatment planning have enjoyed a remarkable refinement that has allowed for a simultaneous decrement in treatment related side effects. Promising new approaches also are under investigation that may further allow improvement in the risk/benefit ratio. Breast Conserving Therapy (BCT), which includes the surgical removal of the cancerous lesion usually accompanied by lymph node evaluation followed by radiation therapy to the entire breast, has become an accepted option for women with early stage breast cancer. At PSJMC between 1999 and 2003, nearly 90% of women with stages I-IIIA breast cancer have been managed with BCT. This compares quite favorably to the 60% levels observed among similar SEER patients. The purpose behind radiation therapy is to eradicate any residual microscopic cancer cells in the remaining breast s tissue contents. The equivalence of BCT to mastectomy in the management of early breast cancer has been established in several prospective, randomized trials. Recently, two original trials investigating the efficacy of breast conserving treatment, NSABP B-06 and Veronesi et al., published 20-year results confirming that wide local excision followed by whole breast irradiation continues to be equivalent to mastectomy with respect to overall and disease-free survival. Our Radiation Department published eight-year control rates are 93%, well in line with these studies. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 16

19 RADIATION THERAPY IN BREAST CANCER CARE continued MRI Some women require mastectomy in order to best surgically manage the local extent of their breast cancer. Mastectomy may be necessary because of the size of the breast tumor or due to other factors. In a portion of these cases, radiation therapy directed at the chest wall post-operatively can decrease the possibility of a local or regional recurrence. Appropriate candidates include those who have four or more lymph nodes containing cancer or those whose primary tumor is larger than 5cm. Post-mastectomy chest wall and lymphatic radiation has been proven to diminish recurrences by 30% and to improve overall survival by 10% on an absolute basis. External beam radiation is the usual type of radiation therapy utilized for women with breast cancer. The radiation is focused by a machine (linear accelerator) onto the area affected by the cancer. This area usually includes the whole breast or chest wall and may also extend to the underarm as well as the supra-clavicular (above the collarbone) and internal mammary (beneath the sternum) regions. The treatment volume is typically determined by the tumor size and location and by the number of lymph nodes involved with cancer. Radiation therapy usually is not started until the tissues have been able to heal for about a month after surgery, and delayed until chemotherapy (if recommended) has been completed. Standard radiation to the breast after a breast-conserving surgery takes six to seven weeks. The entire breast is generally treated for 5 weeks, followed by a smaller 1 to 1 1 /2 week radiation boost to the lumpectomy site where the tumor originally was located. Treatment is given daily, Monday through Friday, and a typical treatment will last only five to ten minutes. The radiation beams are similar to ordinary chest X-rays but of much higher energy. The high energy of the radiation damages the cancer cells and leads to their destruction. Normal cells in the breast have a better ability than cancer cells to repair this kind of damage, thus can survive. An important clinical advance in breast cancer treatment has been three-dimensional (3-D) radiation planning using a dedicated CT scanner. Planning the radiation therapy using CT scans helps design safer and more accurate radiation therapy treatment. This may be important in reducing or eliminating the amount of radiation given to lungs, heart or opposite breast. This technology also allows for a boost treatment that is more precise than older techniques. Intensity Modulated Radiation Therapy (IMRT) is another technological advance that may further improve the delivery of radiation for breast cancer while minimizing the side effects and normal tissue exposure. IMRT works by dividing each beam into multiple, smaller beamlets that better target the breast. IMRT is combined with inverse treatment planning to determine the best way to treat a patient. It relies on the patients' computed tomography data that are processed and analyzed by a complex computer system to produce the ideal radiation dose distribution for that patient, improve the uniformity of the radiation dose within the breast and reduce the hot spots (higher dose regions) seen in more tradition treatment plans. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 17

20 RADIATION THERAPY IN BREAST CANCER CARE continued Breast biopsy The rationale for elective treatment of the whole breast stems from pathologic studies of mastectomy specimens that demonstrate the existence of unsuspected foci of carcinoma in up to one third of women at a distance from the resected tumor. The majority of patients included in these studies, however, had tumors 3-4cm in size that were clinically detected; thus this information may not be relevant to contemporary patients. In addition, other studies suggest that the rate of development of new tumors elsewhere in the treated breast is similar whether or not whole breast irradiation was provided. Limiting the radiation field to the region of the tumor bed plus an appropriate margin of surrounding tissue currently is under investigation as a possible option for management of selected low-risk patients. Also termed Partial Breast Irradiation (PBI), this approach may offer the potential advantages of reduced treatment-related side effects due to decreased normal tissue exposure and may provide a logistically easier method for breast conserving therapy. PBI delivers radiation over a much shorter period of time (five days total, twice per day) to only the part of the breast with the cancer. Three techniques are available to achieve such treatment; one method utilizes 3-D conformal external beam radiation therapy, the other two involve placement of multiple catheters or a balloon catheter (Mammosite) directly into the breast and irradiating the tissue from within. It is hoped that PBI will prove to be equal to the current standard whole breast irradiation. Partial breast irradiation, however, is still experimental; clinical research trials are currently under way. So far, the results have been promising, but more experience is needed with this technique before it can be recommended as standard treatment. Appropriate candidates are encouraged to participate in RTOG 04-13, a major national clinical trial of partial breast irradiation that will be available at PSJMC later this year. Still, the success of conventional whole breast irradiation demands a conservative approach to the application of PBI until appropriate data suggest otherwise. Detail and attention must be directed to appropriate patient selection and quality assurance of treatment delivery. The American Brachytherapy Society and the American Society of Breast Surgeons have outlined the eligibility criteria for PBI. Although some differences exist, the general approach is consistent. Extensive intraductal components, young age (<45 years), invasive lobular subtype, DCIS and nodal status, are frequently used as exclusion criteria. Tumor size needs to be <2cm and margins must be 0-2mm at a minimum. Our primary goals remain 1) achievement of excellent clinical outcomes, 2) enhancement of the cosmetic result and 3) investigation of promising new alternatives that may complement the currently available approaches. With these in mind, our patients care will continue to be second to none. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 18

21 Plastic Surgery and Breast Cancer George Orloff, MD, F.A.C.S. George Orloff, MD, F.A.C.S. Chief of the Division of Plastic Surgery PSJMC In recent years, great progress has been made in the detection and treatment of breast cancer. Still, over 217,000 women in the United States will develop breast cancer this year alone. Almost all women diagnosed with breast cancer will have some type of surgical procedure to treat their breast cancer. The goal in surgery is to remove as much of the cancer as possible with clear margins. In most cases, women have the option of a lumpectomy with only a small portion of the breast removed. In other cases, a woman may choose or need a mastectomy in which the entire breast or breasts are removed. When a mastectomy is part of the treatment plan, in addition to the physical loss of the breast, some women may experience a psychological loss, leaving her feeling disfigured. Now, however, almost every woman who loses a breast as a result of cancer can have it rebuilt by a plastic surgeon through reconstructive surgery. Breast reconstruction helps many women regain their sense of femininity and sexuality that may have been affected by surgery. It can also help minimize the feelings of loss and helplessness. Breast reconstruction following a mastectomy due to cancer is one of the most rewarding surgical procedures. New surgical techniques and new types of implants have made it possible for surgeons to create a breast that can come very close to matching a natural breast. And, planning breast reconstruction should begin as soon as a patient is diagnosed with cancer. At Providence Saint Joseph Medical Center (PSJMC), the plastic surgeon is part of a team of physicians that treats women with breast cancer. The team includes the primary care physician, medical oncologist, breast surgeon, radiation oncologist, plastic surgeon, pathologist and mammographer. This team works together with the patient to develop the optimum treatment plan. As part of the team, the plastic surgeon makes recommendations for breast reconstruction based upon the patient s age, overall health, anatomy and post-surgical goals. Even with the care of the team, the decision to proceed with breast reconstruction can be difficult and confusing. It can often be hard for a patient to think about breast reconstruction when they are dealing with the challenges of facing cancer. Your spouse, your family and your medical team can help you make this decision clearly. If a patient decides that she wants breast reconstruction, the first consideration is whether to have it immediately following the mastectomy or to have the reconstruction performed at a later date. Breast reconstruction can happen months or even years after a mastectomy. Your physicians will help you in making this decision. Frequently, a patient chooses reconstruction immediately following a mastectomy. In these cases, the reconstructed breast already in place when the patient wakes up after surgery. These women are spared the experience of seeing themselves without a breast. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 19

22 PLASTIC SURGERY AND BREAST CANCER continued Since the long-term prospects of living without a breast or part of a breast affect every woman differently, the choices that are right for one woman won't necessarily be right for another. After a mastectomy, a woman may choose to wear external breast forms, a gel type prosthesis that fits into a special bra, or make no attempt to alter their appearance. Or a woman may choose breast reconstruction, using either breast implants or their own tissue. Continual improvements in plastic surgery techniques offer better results today than ever before and make breast reconstruction an option for most women facing a mastectomy. The decision is a very personal one and often not easy to make. Delayed reconstruction might be preferable for some patients. Women who are overwhelmed by the diagnosis of breast cancer and the discussion of surgical and medical approaches to treat it may not be able to make a sound decision regarding their preferences for breast reconstruction at the time of their mastectomy. For such patients, a step-by-step approach that addresses tumor management first and the reconstructive procedures later may be more appropriate. Once a decision has been made to proceed with breast reconstruction the types of reconstruction that will be considered can be separated into two basic types, implant reconstruction and flap reconstruction. Implant Reconstruction During a mastectomy, the surgeon removes the breast tissue and the nipple and surrounding skin. The patient is left with only skin over the chest muscle. After a mastectomy, the chest is indented, or concave, where the breast used to be. In implant reconstruction, the most common technique uses an expander, a specialized implant, to stretch the remaining skin and create a new breast mound. An expander is a specialized balloon-type device, with an attached valve, that is placed under the skin. Over several post-op office visits, the plastic surgeon fills the expander balloon with saline, or salt water, through a needle painlessly inserted into the attached valve. As the expander fills, the skin over the breast stretches until the implant reaches the desired size. When the desired size is reached, the plastic surgeon, in a subsequent operation, replaces the expander with a more natural, better-feeling, permanent implant. Permanent implants are filled with saline or silicone and are available in a variety of different sizes and shapes. The surgeon can help a patient decide on which is best for her. Some patients do not require preliminary tissue expansion because they have adequate skin for the size breast they desire, and therefore, a permanent implant can be placed as the first step without using an expander. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 20

23 PLASTIC SURGERY AND BREAST CANCER continued It s important to remember that implants are not permanent. They eventually wear out and must be replaced. This can happen sooner than expected if the implant leaks or is distorted by capsular contraction, scar tissue around the implant. Overall, implant reconstruction is a good option for women who have not had radiation therapy as part of their treatment and want a shorter recovery period. Flap Reconstruction The most natural breast reconstruction uses a woman s own skin, fat, and on occasion, muscle to make the reconstructed breast. Breasts made with a person s own tissue feel and move more naturally than those made from implants. However, be aware, that flap reconstruction is more complex and the recovery is longer and more intense. The flap, consisting of skin, fat and muscle, and the blood vessels supplying the tissue, is tunneled beneath the skin to the chest. Often a cosmetic tummy tuck procedure, where the t issue is removed from the lower abdominal region, is combined with the flap reconstruction to make a breast. In these cases, the patient gets benefit of an improved abdominal contour along with a reconstructed breast. Tissue reconstruction is a good option if a woman wants the most natural reconstruction possible and does not want to worry about the possibility of implants leaking or needing replacement. Tissue flap reconstruction is preferred if radiation therapy has been or is planned in the treatment of breast cancer. There are some cases in which a physician may use an implant as well as a woman s own tissue to create the best result. Nipple Reconstruction Regardless of the technique chosen, once the reconstructed breast has settled and softened into its final position, usually about 3 to 4 months, new nipples can be created. For many women, adding nipples to their reconstructed breasts brings a sense of closure to the whole breast cancer experience. Nipple reconstruction is an art. Most surgeons reconstruct the nipple using the skin of the new breast. Once the nipple is created and allowed to heal, a tattoo is added to the area to simulate the color of the opposite nipple. Because the reconstructed breast has little sensation, this procedure can be performed only with local anesthesia. A wide variety of colors are available to accommodate all women. The goal of breast reconstruction is to match the opposite unaffected breast. However, this is sometimes impossible to do without performing surgery on the unaffected breast or the one without cancer. In some women, a breast augmentation or enlargement, or breast reduction or lift may be required to get the best cosmetic and functional result. It is important to point out there are no right or wrong decisions when considering the timing or type of breast reconstruction. It is very important to get as much information as possible about all the available options so one can make an informed decision. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 21

24 PLASTIC SURGERY AND BREAST CANCER continued In the past five years, new designs, especially in breast expanders, the balloon devices that stretch the skin to make room for the permanent implants, have made the reconstructive process more efficient, less painful and far safer. Breast reconstruction continues to improve with more consistent and satisfying results. In the future, we anticipate FDA approval of a new gel implant that will greatly expand a woman s choice in reconstruction. Ongoing research with adult stem cells offers additional hope for improved contour and decreased scarring. Recent studies have affirmed that breast reconstruction does not increase the risk of the cancer s spread or recurrence and does not impede detection of recurrence. As a board certified plastic surgeon, I am proud to be a member of the American Society of Plastic Surgery (ASPS), a major supporter of the Women s Health and Cancer Rights Act (WHRCA). This federal law requires group health plans to provide coverage for breast reconstruction, surgery on the other breast, if necessary, to achieve symmetry, and the treatment of complications from mastectomy or reconstruction. The American Society of Plastic Surgery is proud to have been part of the effort to stop insurance denials for this type of surgery. The members of the Division of Plastic Surgery at PSJMC and I support all women in their fight against breast cancer. For all breast cancer patients and those at high risk for the disease, I suggest the following: Talk to a plastic surgeon who is a member of the ASPS regarding reconstructive and preventative options; and discuss the pros, cons and realistic expectations of those choices. Plastic surgeons that are members of the ASPS are uniquely trained and educated to provide the very best in cosmetic and reconstructive surgery of the face and body. To assist in the decision making process, I recommend visiting the web sites of the American Society of Plastic Surgeons ( the FDA ( the American Cancer Society ( and P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 22

25 Providence Breast Health Center: Digital Technology, CAD and Gail Model Albert Lee, MD Providence Breast Health Center (PBHC) moved to its current location in May 2004 and since then has been using digital technology exclusively. Computer Aided Detection (CAD) has supplemented every screening study, and the Gail Model risk assessment has been incorporated into the reports. sensitivity in detecting breast cancer. To date, it is difficult to conclude that this enhancement is absolute in its findings. There are occasional cases where it detected significant lesions the radiologists overlooked. However, due to a substantial false positive rate, the radiologists dismiss the majority of the CAD markings. Albert Lee, MD Medical Director Providence Breast Health Center Full Field Digital Mammography (FFDM) has many advantages. The acquisition efficiency of the digital format yields an increase in patient volume. In 2005, PBHC performed 18,000 mammograms with three digital rooms as compared to 16,000 in 2003 utilizing four analog rooms. The ability to manipulate images on the workstation, such as changing contrast and magnification, helps radiologists with detection and analysis, especially with microcalcifications and patients with dense breasts. The Digital Mammography Imaging Screening Trial (DMIST) substantiated this experience. Because the images are stored electronically, referring physicians may view the cases on Stentor, the medical center s Picture Archiving and Communicating System (PACS). The images can be accessed easily from physicians offices. CAD is a computer-generated, second-look tool. Theoretically, it is designed to improve the overall PBHC utilizes a risk assessment tool based on the Gail Model to estimate a woman s individual risk for invasive breast cancer. Information obtained during the initial visit is used to identify key risk factors. These risk factors include race, age at menarche, age at first live birth, number of first-degree relatives (mother, sister(s), and/or daughters) with breast cancer and the number of previous breast biopsies (whether positive or negative). After these questions are addressed a statistical result is obtained that provides an individual risk estimate for a five-year period as well as a lifetime risk. These results are incorporated in the reports that are sent to the referring physicians. Based on the results the physician can then identify those patients with elevated risks and who might benefit from some form of chemoprevention. P ROVIDENCE C ANCER C ENTERS 2005 Annual Report 23