BREAST CANCER IN THE 21 st CENTURY. The Carolinas Medical Center NorthEast Experience. Garry Schwartz, MD

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1 BREAST CANCER IN THE 21 st CENTURY The Carolinas Medical Center NorthEast Experience Garry Schwartz, MD The American Cancer Society's most recent estimates for breast cancer in the United States for 2009 include 192,370 new cases of invasive breast cancer and 40,170 deaths from breast cancer. Breast cancer is the most common cancer among women in the United States, other than skin cancer, representing 27% of cases and 15% of deaths. It is the second leading cause of cancer death in women after lung cancer. The chance of a woman developing invasive breast cancer some time during her life is approximately 1 in 8 (12%) with a median age of 61. Breast cancer death rates have shown a gradual decline by about 2% per year since the early to mid 1990 s, and has been most noticeable over the past decade likely due to better screening techniques and reduction in the use of hormone replacement therapy. Five year survival has markedly improved from 75% in the mid-1970 s to 79% in the mid-1980 s, and now nearly 90% from Currently there are more than 2½ million breast cancer survivors in the United States. Risk factors for developing breast cancer include the female gender (male breast cancer represents 1-2% of cases), age (37% of diagnoses are in women over the age of 65), genetic (5- mostly due to BRCA1 and BRCA2), familial, personal history of breast cancer, race (Caucasians have the highest risk, Asians, Hispanic and Native-Americans the lowest), dense breast tissue, LCIS, alcohol (approximately 2-3 drinks/day), obesity/lack of exercise and early breast irradiation (especially seen in Hodgkin s disease). Hormonal exposures (exogenous and endogenous) include early menses, late menopause, nulliparity or having children later in life, OCPs and postmenopausal hormone replacement therapy (combination much more than estrogen alone). Uncertain or unproven risk factors include not breast feeding, high fat diets, antiperspirants and bras, breast implants, pollution, smoking and night work. Our experience here at Carolinas Medical Center NorthEast seems to mirror the above facts and figures and our hospital continues to strive to provide comprehensive care throughout the breast cancer continuum. CMC-NorthEast has a comprehensive dedicated breast imaging center that provides digital mammography, diagnostic ultrasound, magnetic resonance imaging and CT-PET imaging. The Breast Health Center, a Breast Imaging Center of Excellence, supports breast cancer patients by providing comprehensive breast cancer services including prevention, screening, diagnosis and treatment. The Breast Imaging Center of Excellence is accredited in mammography, stereotactic breast biopsy, breast ultrasound and ultrasound-guided breast biopsy. This accreditation is given by the Commission of Quality and Safety and the Commission on Breast Imaging through the American College of Radiology. Our center has been very active in promoting breast cancer prevention to include a mobile mammography van, advertising through magazines and billboards, screening clinics that are open until 7 pm and on weekends, in addition to promotion through the usual healthcare channels (primary care clinics, subspecialty clinics). Our current fundraising campaign headed by the NorthEast Foundation's Board of Directors has pledged to raise $5.5 million over 3 years to continue to support and further develop the Breast Health Program, including the Breast Health Center, purchasing digital mammography equipment and the mobile mammography van, and to provide additional support for breast health community outreach programs. The Board

2 has invited community leaders and volunteers to assist in this important project and created a campaign cabinet and committees to conduct the campaign activities. These funds will be raised to continue to support ongoing activities as well as help meet the ever changing needs of this community as new or unmet needs continue to be recognized. A summary of several of these services are outlined below: Breast Health Center - a spa-like environment that focuses on reducing stress. With leading-edge digital mammography diagnostic equipment - the "gold standard" - radiologists are provided the tools necessary to make a more accurate diagnosis. Multi-Disciplinary Breast Health Conference - On a weekly basis, the best minds in breast cancer treatment gather to discuss options and determine the plan of care for each patient. Every facet of a patient's treatment plan is coordinated to deliver maximum results in a minimum amount of time. From the oncologist, to the radiologist, to the research and breast nurse navigators, and more - all disciplines work as a unified team to treat the patient as a whole person. Breast Nurse Navigator - an experienced oncology nurse who helps the patient and family understand options and what to expect during treatment. Together, they will review pictures of patients who have had lumpectomies, mastectomies and reconstruction, and discuss the physical and emotional aspects of such a decision. The breast nurse navigator addresses concerns the patient may have about side effects, recovery and more. She can also refer the patient to resources such as financial assistance, insurance experts, support for family members and more. Most importantly, the breast nurse navigator gives the patient the emotional support needed along the way. Rejuvenation Center - for the woman whose vitality is drained emotionally from fear, anxiety or anger because of their illness. The Rejuvenation Center uses specific strategies or therapies such as guided-visualization, relaxation techniques and hands-on-healing to provide relief. Additionally, it offers cosmetic support, wigs, scarves and haircutting. Support Networks - connecting newly diagnosed women with other cancer survivors. Here, we know that a woman with cancer wants to talk with other women who have already traveled the journey. Patients will also have access to a variety of other resources, including a library of materials on related topics, as well as support groups, breast cancer Web sites, and much more. Mobile Mammography Van - a part of the CMC-NorthEast community outreach program, the van helps busy working women take the first step towards early breast cancer detection. Featuring digital mammography and equipped with dressing rooms and a seating area, the van will travel within a thirty-five mile radius of the main campus

3 providing screening mammograms. The mobile mammography van will visit businesses, churches and community centers to encourage all women, regardless of their ability to pay, to have a mammogram. Once a patient has been identified or formally diagnosed with breast cancer, our breast health navigator will take the patient step by step through the process of obtaining further imaging and biopsies, insuring consultation with a general surgeon, plastic surgeon, radiation oncologist and medical oncologist, as well as holding their hand for any and all questions that arise through this often difficult journey. All of our physicians are Board Certified in their respective fields to provide the entire treatment spectrum necessary for this complex disease. Our center is very active in clinical trials through the NSABP, CALGB and ECOG in addition to industry sponsored trials to provide cutting edge approaches and treatments in the neoadjuvant, adjuvant and metastatic settings. A link to our active trials can be found at: The best measure of our care is to compare our statistics with those of the state of North Carolina (NC) and the National average. In 2008, 185 patients with breast cancer were either diagnosed or cared for at our institution. The breakdown of their staging in comparison with NC and the United States is illustrated below. Staging differences vary slightly. Despite local annual breast cancer screenings and access to mobile mammogram services, Stage 1 breast cancers in our area are slightly lower than state and national averages: AJCC STAGE GROUP CMC- NORTHEAST N. CAROLINA NATIONAL Stage ,577 Stage ,520 34,913 Stage ,863 Stage ,105 Stage ,795 Unknown ,932 Non- Analytic 6 TOTAL CASES ,185

4 40% 18% 19% 19% 32% 38% 37% 26% 27% 25% 12% 9% 9% 3% 3% 3% 7% 0% 0% 0% Unknown Non- Analytic 35% 30% 25% 20% 15% 5% 0% *If a patient presented with a Right Breast Cancer Stage 1 and a Left Breast Cancer Stage 2 in 2008, the two may be considered separate primary sites and if so, would be counted twice in these statistics. **CMC-NorthEast non-analytic cases are included in our numbers but did not require staging (Class 0 s & 3 s) ***Data is compared with the latest available data (2006) in the NCDB benchmark reports The breakdown of CMC-NorthEast treatment in comparison with NC and the United States is illustrated below. CMC-NorthEast performs fewer breast treatments consisting of surgery alone. Since most breast cancer cases require more than surgery alone, we feel that our institutional numbers more accurately reflect current treatment guidelines. This trend is clearly seen in all categories reflecting the use of hormonal therapy; the standard of care in all patients with estrogen and/or progesterone receptor positive breast cancer. TREATMENT MODALITIES CMC- NORTHEAST N. CAROLINA NATIONAL SURGERY ALONE ,833 SURG & RADIATION ,974 SURG & CHEMO ,975 SURG & HORMONE ,201 SURG, CHEMO, & RAD SURG, RAD, & HORM ,549 SURG, RAD, CHEMO, & HORM ,917 SURG, CHEMO, & HORM ,085 OTHER TREATMENT ,334 NO FIRST COURSE TREATMENT ,315 TOTAL CASES 185 4,042 93,135

5 30% 26% 28% 25% 21% 20% 13% 12% 6% 16% 8% 7% 11% 17% 17% 11% 8% 7% 9% 3% 3% 15% 5% SURGERY ALONE SURG & RADIATION SURG & CHEM O SURG & HORM ONE SURG, CHEM O, & RAD SURG, RAD, & HORM SURG, RAD, CHEM O, & HORM SURG, CHEM O, & HORM OTHER TREATM ENT NO FIRST COURSE TREATM ENT 0% CMC-NorthEast 5 year survival in compared with NC and the United States is illustrated below. Survival for Stage 0, 1 and 2 disease is very comparable to the State and National averages. The graph representing Stage 3 disease reveals improved survival while Stage 4 suggests poorer 5 year survival. Interpretation of these statistics is difficult due to the low number of patients in each category. BREAST CANCER OBSERVED SURVIVAL RATES CMC-NORTHEAST - N. CAROLINA - NATIONAL 100% 90% 80% 70% 93.0% 92.0% 93.1% 90.5% 88.9% 88.1% 77.8% 80.0% 79.7% 72.7% 60% 60.3% 50% 54.9% 40% 30% 20% 0% 24.2% 18.9% 16.7% Stage 0 Stage 1 Stage 2 Stage 3 Stage 4

6 Summary The incidence of breast cancer continues to follow a steady decline and is estimated to be as high as 3.5% per year from alone. The explanation is multifactorial to include public awareness and financial support through numerous campaigns across the country, early detection of pre-malignant disease through mammography, and the declining use of postmenopausal hormone replacement therapy. Other factors in the future will be identifying high risk women (based on family history) before the development of cancer, dietary changes focusing on improved lean body mass and decreased alcohol consumption, and continued avoidance of controllable exogenous factors such as radiation and hormonal exposure. Current trends continue to show increasing absolute mortality in breast cancer and while that seems contrary to the decreasing incidence rate, there is likely a time lag factor given the fact metastatic breast cancer has become a chronic, yet still incurable, disease with women living well beyond 5 years. Efforts to decrease the mortality rate will rely on early detection, optimal surgical, radiation and chemo-hormonal treatment coordinated by a multidisciplinary team dedicated to eradicating this disease. The demographic charts clearly reveal our institution is matching the state and national levels in regard to initial staging, treatment and overall survival. CMC-Northeast has continued to dedicate the time and resources to provide the care and compassion necessary to meet these goals. Through our state-of-the-art facility and equipment, dedicated breast health team, and financial support through our Breast Health Campaign and generous community members, we are confident our facility will continue to meet these goals in the years to come.