Why Breast Center Teams Attend NCoBC2014

NCoBC2014 Las Vegas: Designed to meet the needs of specialties.

Advances in 3D Mammography

Sunday, March 16 at 11:30 - 12:00pm during Digital Tomosynthesis Pre-Session

Linda Greer, MD
Medical Director, John C. Lincoln Breast Health & Research Center
John C. Lincoln Hospital
Phoenix, AZ

This interactive session will allow attendees to participate in hands-on demonstrations showing some of the latest advances in 3D mammography technology, including Tomosynthesis biopsy, contrast-enhanced 2D and 3D mammography and C-View images (2D images created from the 3D dataset). Experts will be on hand for a more detailed discussion of clinical data and answer questions about the technology.

This session will focus on

  • practical tips for implementing Tomosynthesis and C-View into clinical practice including advantages and disadvantages
  • the resultant changes in workflow
  • the change in how patients are worked up
  • the decrease in call back rates for additional spot compression views and ultrasounds
  • case review
  • assistance with Tomosynthesis interpretation and what different lesions look like in 1mm slices.

The Practical Value of Providing Genetic Counseling in Your Breast Center

Saturday during the "Create a Breast Center of Excellence" pre-conference

Mary E. Freivogel, MS, CGC
Manager, Risk Assessment & Prevention
Invision Sally Jobe
Greenwood village, CO

Genetic counseling is an essential part of comprehensive breast cancer screening, diagnosis, and treatment. It includes the increasingly complex concept of breast cancer risk assessment based on various factors, such as family history, hormonal factors, and breast density. In some cases, genetic testing is appropriate. Outcomes from genetic counseling may include personalized screening and risk reduction options for patients and their relatives. When completed at the time of diagnosis, genetic counseling may also significantly alter treatment choices for the patient with breast cancer.

Ms. Freivogel will

  • Provide an overview of NAPBC Standard 2.16 to increase understanding of the measure.
  • Describe the components of cancer genetic counseling that include pre-test counseling, cancer genetic testing, and post-test counseling.
  • Discuss consideration for two types of patients - those who are affected by breast cancer and those who are not affected but have a high risk of developing the disease.
  • Illustrate possible methods to systematically identify women who can benefit from genetic counseling.

Case Studies will be used to clarify the principles shared in this session.

The Power of Words: Communicating "Cancer" in the Breast Center

Monday, March 17 at 4:15 - 4:45 during Plenary Session

Don Dizon, MD, FACP
Associate Professor of Obstetrics-Gynecology & Medicine, The Warren Alpert Medical School of Brown University
Associate Professor (Pending), Harvard Medical School
Director, Oncology Sexual Health
Member, Gillette Center for Gynecologic Oncology,
Massachusetts General Hospital Cancer Center, Boston, MA

The language of medicine has never been more important than when someone is faced with a potential diagnosis of cancer. Unfortunately, it is a language that can be misinterpreted despite the best intentions of clinicians. Think of how we tell women that screening saves lives. Although meant to highlight the importance of early detection, this is not a useful statement for large swaths of the population, particularly those who are living with advanced or metastatic breast cancer. For them, screening is irrelevant. Other examples abound in the world of oncology, from our conversations of risk factors, treatment, and our approach to survivorship. The bottom line is what we say is often not what she (or he) hears.

More effective communication requires a tool kit, that each of us should possess. It begins with acknowledging the emotion, no matter how easy or hard that is. It means looking someone in the eye when we talk to them, and avoiding technical language from the language of science and medicine. It means being aware of how much information needs to be given, and how much one is actually capable of digesting in one session. Finally, it means asking our patients what they have heard, or will tell their families or friends once they have left (sometimes called a "teach-back"). Studies show that being more thoughtful about how we talk to patients, including acknowledging the emotions in the room, not only helps patients feel better, but helps them retain information we are giving.

In an age where our words can linger long after they are spoken, clinicians must be cognizant of how our words can be interpreted, and even misinterpreted. As clinicians and advocates, we must do our best to ensure our patients hear what we want them to hear, rather than what they think we just said.

MR after Cancer? Pro/Con Debate

Wednesday, 9:00-9:30am during the Plenary

Christopher E. Comstock, MD
Director, Breast Imaging Postgraduate Training & Education
Department of Radiology, Memorial Sloan-Kettering Cancer Center
New York, NY

Steven E. Harms, MD, FACR
Chair and Clinical Professor, Department of Radiology
University of Arkansas for Medical Sciences
The Breast Center of Northwest Arkansas
Fayetteville, AR

Extensive screening trials have uniformly demonstrated significantly improved diagnostic capability of breast MR with a sensitivity improvement of 2-3 times that of mammography. Yet, the role of breast MR for pre-treatment staging of breast cancer remains controversial. The attributes and deterrents for using pre-treatment breast MR will be debated in this session.

Clinical trials that established breast conservation treatment survival to be equivalent to mastectomy were performed before breast MR. The lumpectomy cohorts likely harbored undetected disease that was not resected, yet that disease did not adversely influence survival. It has been argued that despite the improved visualization of disease provided by breast MR, resection of this disease would likely not influence survival.

The Z0011 trial showed that there was no decrease in recurrence rates for women with undissected positive sentinel nodes. The reason that residual disease does not affect recurrence rates is attributed to successful treatment with adjuvant therapy. Similarly, undetected disease also likely exists in the breast; yet, recurrence rates for breast conserving therapy is only 2-4% at 5 years.

Breast MR can detect occult contralateral breast cancer in about 4% of patients. These are lesions that would not be addressed with radiation therapy. Yet, the incidence of contralateral disease is declining—probably due to adjuvant systemic therapy.

MR detects additional foci of disease outside the quadrant of the primary in 2-14% of cases. Adjuvant radiation is adequate treatment in many of these cases, but not all. There are no studies that show which MR detected lesions will become clinically significant.

The positive margin rate for lumpectomy surgery ranges from 40-70%. Improved staging with MR may be used to decrease the positive margin rate to less than 10% in some single center studies. The only multicenter trial to evaluate the effect of MR on positive margin rates, however, failed to show any improvement with MR.

If improved staging works, then we should see a reduction in recurrences. The only studies looking at recurrence rates with breast MR are mixed. Because of the significant selection bias in these studies, little useful knowledge can be gained from this analysis.

Breast MR costs about 7 times more than mammography. Some argue that this cost is too much. The expense of breast MR, however, is insignificant compared with breast cancer treatment costs. One drug, Herceptin, has a cost of over $60,000.

As with all imaging tests there are costs associated with false positives. Recent reports show the false positive rate of breast MR is better than mammography.

Use of breast MR may delay treatment in some centers. When MR is integrated in breast management, there are no diagnostic delays.

Successful use of pre-treatment breast MR depends upon the integration with other breast imaging studies and the coordinated use of extent information by surgeons. In centers without this approach, the use of breast MR will likely be limited to women with high risk such as Paget's disease, occult primaries, and BRCA carriers.

Current Concepts in Breast Cancer Survivorship

Tuesday, March 18 at 1:00 - 1:30pm during Survivorship Track

Balazs Imre Bodai, MD
Director, Breast Cancer Survivorship Institute
Women's Health Kaiser Permanente
Sacramento, CA

The presentation will focus on the importance of dealing with the long term effects of breast cancer treatment. It will also describe the current clinical model which has been in use at the Kaiser Permante facility in Sacramento, CA for nearly two years.

The presentation will cover

  • treatment summaries
  • symptoms of recurrence
  • delayed toxicities of treatment
  • monitoring for other primary malignancies
  • lifestyle changes which may have major effects on recurrence, disease free survival and overall mortality.

Medical-Legal Skills for Breast Center Medical Directors

Monday, 11:45-12:15 in Physician Leadership Track

Gerald Kolb, JD
Chief Executive Officer, Ikonopedia, Inc.
Dallas, TX

Delayed diagnosis of breast cancer is the second leading cause of medical malpractice claims and awards or settlements. More than 20% of breast cancers are not detected on mammography. There is confusion about the role of ultrasound in screening. We are seeing greater emphasis on evidence-based medicine. "And you want ME to be the medical director?"

There is no question that breast centers and their medical directors face many challenges, but in most respects those challenges, at least from a medical legal standpoint, are simply to continue the high profile of medical legal risk that has been the lot of the breast center since their inception in the 1990s. The presenter believes that the only way to manage risk is to understand that risk, and attendees will review where the risks, including compliance risks, exist in breast center operations as a prelude to discussing how to mitigate risk in that environment.

Of course, the easiest way to avoid medical malpractice is to not practice medicine. That is not an acceptable resolution, however, and attendees will learn a number of reasonably simple and straightforward principles that, when followed, will dramatically lower risk. There is no magic here, but you should be able to sleep better after attending this session.

Implementing the Program You've Designed

Saturday, March 15 at 1:30 - 2:00 in the Navigation Pre-session

Sandra Walters, RN, CBPN-IC, CBCN
Director of Patient Navigation, Exempla Saint Joseph Breast & Cancer Center
Executive Director, Andre Center for Breast Cancer Education and Navigation
Denver, CO

Getting administrative support and staff buy-in can be two of the most challenging obstacles to overcome. The lecturer will give examples of the solid framework that has been established nationally to not only support but demand that patient navigation services are offered to patients, with penalties if they are not!

Never before has there been a time when support for patient navigation has been so clearly outlined by top industry organizations in both the public and private sector.

Through experience gleaned in 15 years as a patient navigator, Sandra Walters will share an outline of how to provide patient centered care by showcasing a process flow designed to capture the essence of core navigation services to patients.

"The beautiful thing about creating a truly patient centered approach is that it will benefit staff by creating efficiencies and decreasing their non-productive time, and will most certainly provide a positive fiscal impact for the hospital/program."

Genetic Risk Assessment at Breast Cancer Centers, What Works

March 17 as 2:40 pm as part of the RN Breakout Track Session

Christine B. Weldon, MBA
Director, The Center for Business Models in Healthcare
Adjunct Faculty at Northwestern University Feinberg School of Medicine
Chicago, IL

Are your breast cancer patients being assessed for genetic/familial risk for hereditary cancer genes in time for their surgical and therapeutic decisions?

Studies show that while breast centers consistently inquire about a patient's family and personal history less than half of patients have genetic testing results available in time for surgical decisions.

  • Breast cancer patients with a BRCA mutation are more likely to view mastectomy as the best way to reduce future BC recurrence while avoiding multiple surgeries and radiation (Schwartz, JCO-2004).
  • Patients with a BRCA mutation have a higher risk of breast cancer recurrence.

Clear guidelines exist from the NCCN, the American College of Surgeons - NAPBC standard 2.16 recommends "cancer risk assessment, genetic counseling and genetic testing services are provided or referred" and others on hereditary breast and ovarian risk assessment (BRCA 1-2 and other genetic mutations).

This session will review national guidelines, share case studies of effective and ineffective genetic screening practices, and will review actions YOU and YOUR institution may implement to improve genetic risk screening and access to genetic assessment for your breast cancer patients.