The ABCs of  B-R-E-A-S-T

The ABCs of B-R-E-A-S-T

Scottsdale proving a destination for world-class breast cancer care

by Alison Bailin Batz • photo by Mark Susan

“The diagnosis and treatment of breast cancer is nothing if not a group effort between the survivor, doctors, friends, family and even the greater community. A comprehensive approach is critical,” says Dr. Robert Kuske, co-founder of Arizona Breast Cancer Specialists (ABCS). Dr. Kuske and his ABCS team joined together with Arizona Center for Cancer Care to form a long-term relationship with their colleagues, research partners and fellow patient care advocates at Scottsdale Healthcare’s Virginia G. Piper Cancer Center earlier this summer to ensure the greater-Scottsdale community has the very best care options and doctors in the nation, right at its fingertips.

“Arizona Breast Cancer Specialists, Arizona Center for Cancer Care and Scottsdale Healthcare—not to mention some amazing other partners—are now fighting this war against breast cancer together, a war we intend to win,” says Dr. Kuske. “From diagnosis to aftercare, we are a one-stop shop of full-body care for women and their families.”

The joint focus is to provide innovative treatment approaches unmatched in the country.

Dedicated in 2001, the Virginia G. Piper Cancer Center at Scottsdale Healthcare was the first comprehensive cancer center in metropolitan Phoenix to offer diagnosis, treatment, clinical trials and support services in a single, convenient location.

Imaging

Diagnosis of breast cancer often begins at a woman’s primary care doctor, or even at home, thanks to more women proactively undergoing monthly self-exams.

“Simply put, the earlier the detection, the better,” says Dr. Ronald Korn, medical director of the Virginia G. Piper Cancer Center at Scottsdale Healthcare and a partner at Scottsdale Medical Imaging. “The first step after a woman initially notices an abnormality is to undergo a series of diagnostic imaging exams using mammography, ultrasound and/or MRI.”

In fact, his team was among the lead authors of a New England Journal of Medicine article showing the benefits of MRI imaging in the face of newly diagnosed breast cancer, which is now the standard of care in the breast cancer workup.

Thanks to its partnership with Scottsdale Medical Imaging, Scottsdale Healthcare was the first imaging center in the state—and among the first in the nation—to use breast tomosynthesis 3D mammography, according to Dr. Korn.

“As the name implies, these new technologies allow us to get a very detailed look at the layers of tissue within the breast and even generate a three-dimensional image so we can clearly pinpoint the abnormality and determine the next appropriate steps,” says Dr. Korn, noting the local team led the charge on FDA approval of the technology.

In addition to being able to see in 3D, the doctors at Scottsdale Healthcare are also focused on advanced image analysis using high-resolution MRI imaging, and they can measure the biological activity of a patient’s cancer using Positron Emission Mammography, or PEM. Together with an MRI, PEM gives the most accurate and thorough evaluation of a woman’s breast tissue—with pinpoint accuracy.

“Such technologies like PEM are an especially important option for women who cannot get an MRI because they have pacemakers or are claustrophobic,” says Dr. Korn. “We are also finding it to be especially good for women with breast implants, and because of its higher specificity, it might be effective in helping to evaluate and avoid unnecessary biopsies.”

Rather than resting on their laurels, the team is looking to move research further forward at this stage of breast cancer treatment. Together with the Scottsdale Healthcare Research Institute, the team is also the first to use experimental textural analysis, which looks at the actual architecture of the breast. Early data is promising—showing this new technique may well be a key to predicting a cancer’s aggressiveness over time, no matter how it may look in even its earliest stages.

Pathology

Once doctors are able to see the cancer, thanks to imaging, the next crucial step in a woman’s breast cancer journey is with her pathology team. Tissue samples are obtained through a biopsy, which can be performed various ways depending on the type of mass and the patient’s breast tissue.

The pathologist then examines the biopsy sample and creates a pathology report to determine the diagnosis and staging of the cancer. “A pathology report includes a wealth of information and is what the surgeon and oncologist will use to determine the best plan of action,” says Dr. Kuske.

With newer genomic-based tests, the pathologist may be able to provide critical information regarding the chance of recurrence and need for additional therapies. “It’s really the starting point of a patient’s journey through treatment and remission,” he adds.

Medical Oncology

Now, it’s the medical oncologist’s turn to step in. “A medical oncologist is typically at the center of it all,” says Patrick Donovan, M.D., oncologist with Arizona Center for Cancer Care providing care at the Virginia G. Piper Cancer Center at both Scottsdale Healthcare’s Osborn and Shea Medical Centers. “We coordinate and oversee a patient’s care, explaining the diagnosis and staging, discussing treatment options and recommending the best course of treatment to the patient.”

It’s increasingly common for cancer treatment to involve several modalities—surgery, radiation, chemotherapy, hormonal, targeted and/or biological therapy—together or in sequence with another. Medical oncologists oversee the chemotherapy and hormonal, targeted and biological therapies, and create a treatment plan based on each patient’s cancer characteristics.

“The ‘one-size-fits-all’ approach to cancer treatment is really becoming a thing of the past. Even among patients with the same type of breast cancer, the underlying genetic makeup of their cancer may react differently to the same drug,” says Dr. Donovan.

The idea of customizing a treatment plan for each individual patient is not a new one. For example, it’s been known that certain hormonal therapies for breast cancer are most likely to be effective when the cancer cells contain estrogen or progesterone receptors.

“What is new, on the other hand, is that we’re now looking at the bigger picture and identifying the genetic abnormalities within the tumor that makes the cancer grow,” says Dr. Donovan. “Taking this into account, we are now able to select specific anti-cancer drugs that target those specific mutations. In essence, a drug that works for one patient by targeting certain genetic abnormalities won’t work for another patient whose cancer has a different genetic makeup.”

Surgery

Treating breast cancer almost always involves surgery, and for years women were left with basically two choices—to either remove the lump or remove the whole breast—and be happy to be alive. Luckily, new advancements in surgical techniques, along with the realization that reconstruction of the lost breast significantly improves the psychological outcome of the survivor, has dramatically changed this old way of thinking.

“Women have many more options these days. It’s not like when their mothers, or even friends just a few years back, were diagnosed and facing surgery,” says Dr. Linda Liu, breast surgeon with Comprehensive Breast Center of Arizona operating at Scottsdale Healthcare. “Advances in the way these operations are done are giving women more choices, faster treatment, smaller scars, fewer long-term side effects and better cosmetic results.”

Most women can have their breast cancer treated by just having the lump removed, but this typically requires radiation for weeks afterward to kill any stray cancer cells in the breast, plus frequent mammograms to watch for a recurrence. Many women don’t want the worry or the radiation, and they choose mastectomy even though they could have less drastic surgery.

Mastectomy rates have been rising, thanks to advances in federal laws that now mandate health insurance coverage for reconstruction of both the involved breast and the opposite uninvolved breast to achieve symmetry.

Newer ways to rebuild breasts have also made mastectomy a more appealing option for some women. Many even have the option of immediate reconstruction at the same time the cancer is removed rather than having to undergo several operations, which was the standard for many years.

“We actually send our patients to see our plastics team in advance of their surgery with us. In mastectomy cases especially, we want our plastics team next to us each step of the way,” says Dr. Liu. “But even with lumpectomy, there can certainly be holes left from where the tumor is removed that need to be addressed via plastic surgery. It’s much better to have a plastic surgeon address this at the time of surgery to prevent a problem rather than try to fix it later when the tissue is altered by radiation.”

In fact, some women have a cosmetic appearance that is significantly improved after a lumpectomy when breast surgeons work with a plastic surgeon at the onset, adds Dr. Liu. “The unexpected aesthetic improvement can transform a traumatic experience into one in which the patient can be pleased with her appearance, all while accomplishing the most important thing—removal of the cancer.”

Dr. Liu and her team work closely with many plastic surgeons in the community, including Dr. Robert Bajnrauh of Advanced Aesthetic Associates (AAA).  He is a plastic surgeon with specialized training in microsurgical breast reconstruction techniques, including the most advanced form of breast reconstruction available today: the Deep Inferior Epigastric Artery Perforator Flap (or DIEP Flap). Dr. Bajnrauh’s specialized training in microsurgical DIEP flaps makes him one of only a few surgeons in the entire Southwest using this technique

“Without trying to overcomplicate it, this method allows us to reconstruct a breast by using our patient’s own skin and fat after mastectomy without harming the abdominal muscles—and patients actually get a tummy tuck as a side effect of the procedure,” says Dr. Bajnrauh. “It is somewhat similar to the more common TRAM flap procedure, where there is some muscle at risk.”

Of course, they also take great pride in the more common reconstructions, including a proactive approach to tissue expansion, a key to an effective breast reconstruction.

“During your actual cancer surgery, a balloon-like expander is placed under the chest muscle, and filled with saline over several weeks to expand the skin and soft tissue. This expander is ultimately replaced with a silicone or saline implant, when appropriate,” says Dr. Bajnrauh.

With so many choices these days for breast surgery and reconstructive surgery, Drs. Liu and Bajnrauh recommend choosing a surgeon who can offer a variety of options and will work with you in determining which is best for you.

Radiation Oncology

One of the first clinical lectures Dr. Kuske attended in medical school was led by oncologist and breast cancer researcher Dr. Bernard Aron. “He actually brought a breast cancer patient on stage and lectured while interviewing and examining the patient with all the care and compassion in the world,” remembers Dr. Kuske.

As Dr. Aron concluded, Dr. Kuske literally ran up to the podium and told his future mentor, “I want to be just like you!”

After spending the rest of the day picking Dr. Aron’s brain about all things patient care, Dr. Kuske would study under the respected specialist for many years before eventually mentoring his own generation of cancer specialists as the chairman of Radiation Oncology at the famed Ochsner Clinic in New Orleans as well as lead the breast cancer program at the University of Wisconsin.

“In 2003, I set my sights on solely treating breast cancer patients,” says Dr. Kuske.

His vision evolved to establishing the world’s first radiotherapy center where its physicians, staff and equipment focus exclusively on women fighting breast cancer.

“In 2008, amid the credit crunch and worst recession since the Great Depression, we put a plan into action to open ABCS, focusing our equipment, techniques, technology investment and fellow partners solely on treating breast cancer with radiation,” says Dr. Kuske. “By 2010, we had three centers, six partners and technologies allowing minimal collateral damage to normal tissues during treatment.”

Among their proudest investments—when Dr. Coral Quiet partnered with Varian Medical Systems to offer the Pivotal treatment solution for prone breast cancer care, an innovative technology for large-breasted women that allows them to obtain treatment in the prone, or face-down, position.

“And of course most recently, there is this partnership with Arizona Center for Cancer Care and the new relationship with Scottsdale Healthcare,” says Dr. Kuske, whose team has installed new technologies in the Virginia G. Piper Cancer Center on the Scottsdale Healthcare Shea Medical Center campus, and is now looking toward upgrades and updates at the Scottsdale Healthcare Osborn Medical Center campus this fall.

The ABCS team is able to offer breast brachytherapy, advanced radiosurgery, whole breast radiation, breast implant-preserving radiation treatments and much more from its new campus office.

“I think Dr. Aron would be proud,” says Dr. Kuske.

Research & Clinical Trials

At Scottsdale Healthcare’s Virginia G. Piper Cancer Center Clinical Trials, community physicians join forces with leading physician-scientists and clinical teams to develop new and unique therapies for improving the health and quality of life of patients all over the country and even the world.

Located within the Scottsdale Healthcare Research Institute and through collaborative partnerships with the Translational Genomics Research Institute (TGen), leading pharmaceutical companies, biotech firms and academic universities, they are accelerating promising new cancer treatments through the study of cancer genetics.

“It is common to see patients, and even their doctors, consider clinical trials to be a last resort in their care plan,” says Dr. Jasgit Sachdev, a medical oncologist and investigator specializing in breast cancer at Virginia G. Piper Cancer Center Clinical Trials. “In order for our patients to benefit from the latest advances in cancer treatment, we as their doctors must advocate that clinical trials be integrated early on in a patient’s treatment course, especially the trials that directly target the unique markers in each patient’s tumor.”

Through innovations in research, clinical trials are quickly becoming a preferred first course of treatment for patients who want access to the latest advances in medicine. Those who seek clinical trials are drawn by the opportunities to be treated by some of the brightest minds in their fields, using the most promising new therapies, technologies and techniques.

There are five active clinical trials specific to breast cancer at Virginia G. Piper Cancer Center, in addition to 30 other studies, many of which are for solid tumors and could include breast cancer patients as well.

“We just recently served as the lead research site for the promising Side-Out Foundation pilot study, which showed that patients with advanced breast cancer had longer disease control when their treatment was based on identification of the abnormal proteins in their individual tumor, as compared to the previous treatments they received without this additional testing,” says Dr. Sachdev. “We’re very excited about the success of the study. Its studies like these that are paving the way for the future of targeted cancer treatments.”

Supportive Care

Every cancer diagnosis comes with questions that need answers, treatments to consider, and uncertainty on how to navigate the healthcare system.

This is where Scottsdale Healthcare’s cancer care coordinators come in—at no cost to the patient or family.

“These masters-level prepared registered nurses have advanced expertise in oncology. They are knowledgeable about cancer and the resources available to fight it,” says Dr. Korn, who notes that a typical day for a coordinator usually consists of spending time with patients, providing referrals to physicians, educating families about treatment plans, and developing lists of questions that new and returning patients should ask their doctors.

Scottsdale Healthcare and the team at ABCS also ensure that women looking for a second (third, fourth or fifth) opinion on their treatment options are also covered—again at no cost—through Arizona Institute for Breast Health (AIBH).

“ABCS co-founder Dr. Coral Quiet launched AIBH back in 1998—and today we are a 12-member strong volunteer team of physicians and medical professionals whose specialties include breast radiology, breast surgery, naturopathic medicine, medical oncology, radiation oncology, reconstructive surgery and breast pathology,” says Dr. Kuske, a long-time volunteer with the program. “Our team, guided by a patient advocate who is a survivor herself, evaluates the best medical and surgical options for the preservation of a woman’s life, body and emotional well-being, as well as the continued quality of her life.”

Any woman interested in being a part of the program simply needs to visit aibh.org and contact the patient advocate. The doctors meet each Wednesday, and are always open to taking on new enrollees. To date, AIBH has worked with thousands of women and their families—and not only to provide second opinions, but also free support, resources and fitness and nutrition advice.

Also within the Virginia G. Piper Cancer Center at Scottsdale Healthcare is Tina’s Treasures Boutique—named in honor of founder and cancer survivor Tina Johnson. This truly unique retail boutique is focused on supportive care to meet the needs of cancer patients, survivors and their families. Whether newly diagnosed, currently in treatment or a longtime survivor, customers of Tina’s Treasures will find personalized services in a private, comforting and positive environment. Tina’s Treasures staff includes board-certified prosthetic and wig fitters, many of whom are cancer survivors themselves.

A unique feature also available is the Virginia G. Piper Cancer Center’s Creative Arts Lifetime Pass. This pass is available to anyone who has ever had a cancer diagnosis, regardless of whether they are currently in treatment or even a patient at the center. Pass holders can participate, free of charge, in any of their Body, Mind and Spirit programs, which include yoga, tai chi, reiki, healing art, drumming circle and nutrition classes.