BREAST CANCER REPORT: 2013 DATA

CAPABIL I T I ES AND OUTCOMESPictured above: Geetan J. / BREAST CANCER SURVIVOR

The Commission on Cancer (CoC) of the American College of Surgeons (ACoS) has granted a Three-Year Accreditation with Commendation to the Cancer Center at El Camino Hospital.

The El Camino Hospital breast cancer program employs a multidisciplinary team approach to provide comprehensive treatment strategies customized for each patient. The team includes pathologists and radiologists, medical oncologists, surgeons, radiation oncologists, nurse navigators, nutritionists, physical therapists, genetic counselors, and social workers. Patients are treated and diagnosed in a comfortable setting, using the most advanced technologies. In our data from the past five years, the benefits of our integrated approach can be demonstrated for every stage of breast cancer.

Breast cancer is the most common malignancy in women,

affecting 1 in 8 women over the course of her lifetime.

The incidence of newly diagnosed breast cancer decreased between the years of 2000 and 2003 and has since stabilized. The American Cancer Society estimates that there will be 232,670 new cases of invasive breast cancer in women in the United States in 2014. Estimates for early-stage (in situ) lesions that have not spread amount to about 62,570 new cases for the same period. In California, the incidence of 122 new cases per 100,000 women is slightly lower than the national average of 123.8 new cases per 100,000 women. The mortality rate for breast cancer has decreased by 34 percent since 1990, which can be attributed to both improved treatment and earlier detection.

Breast Cancer Report: 2013 DATA

Breast Cancer 5-Year Survival

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%Stage 0 Stage I Stage II Stage III Stage IV

El Camino Hospital

National Cancer Data Base

Compared to the national data from thousands of breast cancer

cases, the five-year survival at El Camino Hospital matches or

exceeds the national trend.

This chart compares our outcomes against those from the National Cancer Data Base (NCDB) covering the five years from 2009 to 2013. The NCDB tracks nationwide oncology outcomes for more than 1,500 CoC-accredited cancer programs in the United States and Puerto Rico.

The Breast Health Center offers state-of-the-art digital mammography, which has been shown to improve cancer detection rates. We offer the MammoPad® to make the mammogram a more comfortable experience. A radiologist with specialized mammography training interprets the films with the help of computer-aided detection. At the time of mammography, women are also screened for breast cancer risk using the Hughes Risk Identifier Model. All women are evaluated for family history as well as for breast density, a recently identified risk factor for breast cancer.

Early detection of breast cancer is important not only to improve survival but also to optimize treatment options. The latest data available in California (2011) shows 84 percent of women diagnosed with breast cancer were early stage (Stage 0, I, II). By comparison, in 2013, of the 189 analytic cases evaluated at El Camino Hospital 84 percent (N=158) were diagnosed in early stages (Stage 0, I, II), in keeping with the current data available from the state of California.

The Breast Health Center at El Camino Hospital offers a range of imaging studies for screening and diagnostic tests including mammography, full breast and traditional ultrasound, MRI, and minimally invasive needle biopsies.

Computer-aided Detection: Computer-aided detection (CAD) technology works like a second pair of eyes, reviewing a patient’s image after the radiologist has already made an initial interpretation. If the computer software detects any additional breast abnormalities or “regions of interest” on the image, it marks them. The radiologists can then go back and review the image to determine whether the marked areas are suspicious and require additional imaging or biopsy.

Automated Full Breast Ultrasound (ABUS): This new tech-nology is a screening tool used along with the screening mammogram for women with dense breasts and/or other high-risk factors. High breast density is a recognized risk factor both for developing breast cancer and for breast malig-nancies that are undetected by mammography. While not a substitute for mammography, ABUS is a useful adjunct for women with high breast density. Early experience suggests that this approach could potentially double the number of cancers detected in patients with dense breasts.

Diagnostic Mammograms: Diagnostic evaluations are recom-mended for women who are symptomatic. The entire eval-uation is performed in one visit. The radiologist reviews the imaging studies while the patient waits for her results.

Ultrasound: A breast ultrasound uses sound waves to evaluate palpable lumps and detect cysts and solid tumors that can’t be found by mammogram alone. Ultrasound may be per-formed at the time of a diagnostic mammogram evaluation if the radiologist determines it will add valuable information. Ultrasound also provides guidance for cyst aspirations.

Magnetic Resonance Imaging: For the best quality MRI results, we use breast MRI using a 3 Tesla magnet, Invivo breast MRI coil, and CAD software to aid in detecting lesions.

Biopsies: The Center offers the following minimally invasive procedures:• Stereotactic core needle breast biopsy• Ultrasound guided core needle biopsy• MRI-guided core needle biopsy

TECHNOLOGY AND DIAGNOSTIC TESTS

OVERVIEW OF BREAST CANCER PROGRAM AT EL CAMINO HOSPITAL

Stage 0

Stage I

Stage II

Stage III

Stage IV

Stage Unknown

29

72

57

20

6

5

Analytic = 189

Non-analytic = 82

TOTAL CASES = 271

Analytic cases are those diagnosed here. Non-analytic cases were diagnosed elsewhere, but patients came here for treatment.

Our High-Risk Breast Program was established to promote early breast cancer detection and prevention. There are numerous risk factors for developing breast cancer, beyond gender and age, including the following:

• A mutation in the BRCA1 or BRCA2 genes

• Family history of breast cancer

• Atypical hyperplasia on a breast biopsy

• Early menarche

• Late first pregnancy

• Late menopause

• Post-menopausal estrogen and progesterone use

• Radiation therapy to the chest at a young age

• High breast density

The appraisal for our High-Risk Breast Program evaluates a woman’s five-year and lifetime risks of developing breast cancer, as well as her risk of carrying a mutation in the BRCA1 or BRCA2 genes. Although most patients who develop breast cancer do not carry a BRCA1 or BRCA2 mutation, these genetic mutations confer the highest risk for developing breast cancers.

Inherited mutations play a major role in the development of an estimated 5 to 10 percent of all cancers. If the physician has concerns about a familial link to breast cancer, genetic counseling may be recommended. During the patient’s first

appointment with the genetic counselor, the counselor deter-mines whether genetic testing is indicated, based on family history. The patient is given a detailed explanation of testing options and their implications. If the patient opts to be tested, the counselor either swabs the patient’s cheek for a DNA sam-ple or accompanies them to the outpatient laboratory for a blood draw. The counselor also packages the sample, completes the necessary paperwork, and arranges delivery to the right laboratory. Once results are received, the genetic counselor meets the patient again (and family if appropriate) to explain results and recommend next steps. Everything is documented in the medical record and a letter outlining findings and rec-ommendations is sent to the patient and referring physician.

While nurse navigators are increasingly common in cancer treatment, our program also uses navigators in cancer preven-tion, contacting high-risk patients to explain their test results and offer initial counseling. The navigator serves as a single point of contact for the patient. Her role is to be an educator, support person, and liaison to improve communication between all the patient‘s healthcare providers. A multidisciplinary team, including genetic counselors, nutritionists, breast surgeons, medical oncologists, and plastic and reconstructive surgeons is available to discuss risk reduction and prevention strategies. In order to help patients make informed decisions and/or navigate multimodality therapy, the navigator provides infor-mation about the disease process, body image and sexuality, genetic testing, clinical trials, treatment(s), surgical options, postsurgical recovery and survivorship.

JANE G., BREAST CANCER SURVIVOR.

First patient in the Cancer Center appreciated truly first-class treatment.

HIGH-RISK BREAST PROGRAM

GENETIC COUNSELING

NURSE NAVIGATOR

When she first discovered the lump in her breast in October of 2007, Jane was understandably anxious. Jane was working in a healthcare setting, so she reached out to coworkers for a physician referral. She was directed to Dr. Shyamali Singhal, who scheduled Jane for a consultation and biopsy almost immediately. The news was not good, but the way it was delivered was incredible. “Dr. Singhal called me on Saturday morning to tell me it was malignant. She knew I was terrified and didn’t want me to have to wait another minute — either for diagnosis or treatment.”

Jane’s tumor was too large to go right into surgery, so she was referred to Dr. Shane Dormady for chemotherapy. Dr. Dormady also acted quickly, and Jane was in treatment less than two weeks from her initial appointment. Accelerated treatment like this is almost unheard of at most cancer programs, but it is a cornerstone of El Camino Hospital’s patient-centered approach. “Even though I was scared, the doctors gave me an

amazing sense of confidence. They explained everything and collaborated on my treatment every step of the way. The Center was new, and the paint was barely dry, but they were there, working together, doing everything they could to help me.” Jane completed chemo and then had surgery, followed by radiation. Today, she is happy, healthy, and cancer free.

SURGERY: Surgeons at both El Camino Hospital campuses are trained in oncoplastics, which uses plastic surgery techniques to achieve the best oncologic approach while optimizing cos-metic results. There are two options for surgical therapy for early stage breast cancer (stage 0, I, II): Breast conservation and mastectomy with evaluation of axillary nodes. Outcomes are equivalent for both approaches.

Since long-term survival is equal in early stage breast cancer patients undergoing a lumpectomy or mastectomy, the bias of the medical profession is that the majority of patients would be best served by undergoing breast conservation surger y. At El Camino Hospital, the rate of breast conservation is 48 percent. Although a higher number of our patients would have been excellent candidates for breast conservation, we are seeing the same trend that has been reported nationally. More women are choosing bilateral mastectomies for their primary surgical treatment. This includes high-risk women with a BRCA mutation but many others as well.

BREAST CONSERVATION: When breast conservation is the goal, a lumpectomy is performed. This involves removing the breast tumor and the small area of normal tissue surrounding it, called the margin. Where appropriate the surgery may include evaluation of the axillary nodes for spread of tumor. Postoperative radiation is usually required.

MASTECTOMY WITH EVALUATION OF AXILLARY NODES: Patients undergoing mastectomy are eligible and are offered immediate reconstruction in most cases. Among the advan-tages of this approach is the ability to perform the oncoplastic techniques of skin sparing and nipple sparing, if appropriate. All patients undergoing mastectomy at El Camino Hospital are offered reconstruction. Oncoplastic techniques minimize deformities in lumpectomy patients and allow for skin and nipple-sparing techniques. Plastic surgeons at both campuses are experienced in all of the alloplastic and autologous recon-struction options, including the new deep inferior epigastric perforator (DIEP) flap technique.

SENTINEL LYMPH NODE MAPPING: To evaluate whether cancer has spread to the lymph nodes, El Camino Hospital physicians use a technique called sentinel lymph node map-ping, an intense evaluation of the first lymph node that drains the cancer. Traditionally, if the lymph node contained cancer cells, all the lymph nodes under the arm were removed. However, removing only the sentinel nodes results in a faster recovery period and decreases the risk of l ymphedema, a painful swelling in the arm. In patients who choose breast conservation, lymph node treatment options are individualized. Recent evidence-based medicine suggests that a complete axillary node dissection may not be necessary in all patients.

National quality measures include the use of the sentinel node technique. Our statistics show a use of this surgical approach in 78 percent of patients (N=101 of 129 patients). It is important to note that some patients may not require axillary node evaluation due to advanced age or medical comorbidities. Others may have had a needle biopsy of an enlarged lymph node prior to surgery.

LYMPHEDEMA: Over the last 20 years, the main complication of breast surgery has been the development of lymphedema. Lymphedema is arm swelling that occurs after lymph node surgery due to blockage of the channels that carry lymph fluid out of the arm.

Although the era of sentinel node dissection has markedly reduced the risk of postoperative lymphedema in breast cancer patients, it remains a significant side effect of breast surgery. We are proactive about treatment options for patients who are at risk for lymphedema. El Camino Hospital physical therapists have undergone extensive training to manage lymphedema complications through a regiment of manual lymphatic drainage, compressive therapy, exercises, and education. Lymphedema treatment typically requires a very individualized approach built around each patient’s particular situation.

TREATMENT

BCS

Mastectomy

No Surgery

2013 Breast-Conserving Surgery Rate

47%

48%

5%

Information drawn from the El Camino Hospital Cancer Registry — A collection of data about cancers that are diagnosed and/or treated at El Camino Hospital.

2013 Sentinel Lymph Node Biopsy

78%

11%

11%

Sentinel Lymph Node Biopsy

Axillary Dissection

No Lymph Nodes Evaluated

MEDICAL ONCOLOGY: Chemotherapy may be recommended in addition to breast surgery. Although most patients receive chemotherapy as an adjuvant treatment after surgery, there may be a role for chemotherapy before surgery.

This is referred to as neoadjuvant chemotherapy. This may benefit patients by shrinking the tumor to facilitate breast conservation, or in cases where the multidisciplinary team decides that there is an urgency in starting chemotherapy. Multiple factors enter into each chemotherapy treatment plan, including the following:

• Stage of disease

• Patient’s age, medical condition, and general health

• Presence or absence of estrogen and progesterone tumor and other markers (in patients who have receptors for estrogen and progesterone, anti-estrogen therapy is usu-ally prescribed either as the sole drug therapy or following chemotherapy)

Depending on the patient and the treatment protocol, chemotherapy treatments are administered in the infusion suite on an inpatient or outpatient basis. In addition, clinical trials are made available to patients who consent to partici-pating in clinical research. These trials include studies that focus on prevention, quality of life, adjuvant therapies, and metastatic research.

RADIATION ONCOLOGY: Radiation therapy is part of com-prehensive treatment for most patients undergoing breast conservation surger y, as well as for some post-mastectomy patients with higher stage cancers. El Camino Hospital has a robust radiation therapy program with a variety of advanced technologies, including the following:

• Varian Trilogy™ Tx Linear Accelerator with IMRT, IGRT, and RapidArc® capabilities. Where appropriate, radiation may be administered with a modern Trilogy linear accelerator and conformal three-dimensional planning techniques. This approach focuses highly targeted radiation on the breast daily for a period of four to seven weeks, avoiding high-dose exposure to the underlying organs.

• Intensity-Modulated Radiation Therapy (IMRT) may be prescribed in challenging treatment situations. IMRT utilizes advanced computer planning algorithms to tailor a uniform radiation dose to the tumor’s exact three-dimensional shape, sparing the surrounding healthy tissue.

OUTPATIENT SERVICES

Our medical oncology team provides outpatient services for patients with breast cancer. These services include disease management, treatment, symptom management, nutritional assessments and education, psychosocial evaluations, counseling, and care coordination. Our team members available to see patients include the following:

• Oncology-Certified Nurses to conduct nursing assess-ments and perform injections, blood draws through ports and other venous access devices

• Patient Care Navigators to offer assistance with care coordination and emotional support

• Board-Certified Specialist in Oncology Nutrition to support nutrition needs during and after cancer care

• Certified Medical Assistants (CMA) to perform the tech-nical aspects of patient care within a defined scope of practice, upon authorization and supervision of a nurse

• Genetic Specialist to provide risk assessments and testing

• Clinical Research Coordinator to provide information on available clinical trials

• Social Worker to offer concrete services and medical counseling to all patients

• Lymphedema Therapist (by referral)

• Community Outreach Coordinator to provide integra-tive care options such as concierge services and information on resources and support groups

• Nutritionist to counsel women on nutrition, dieting, and coping with changes in taste and appetite that can accompany cancer treatment.

Minimally invasive CyberKnife® technology enables us to offer a non-invasive option to treating tumors.

BREAST CANCER PROGRAM STATISTICS

Free Mammogram Program: PROMOTING BREAST HEALTH FOR UNDERSERVED WOMEN

Each year the Free Mammogram Program at El Camino Hospital works with the community to provide over 300 uninsured and underinsured women with free mammograms, breast ultrasounds, breast MRIs, and breast biopsies through funds donated by local community groups. In 2013, El Camino Hospital provided a total of 487 free screening and diagnostic tests for this group and provided education to 10,000 women in the community.

AGE AT DIAGNOSIS: At El Camino Hospital, the trend favors diagnosis at an early age, as depicted in the chart below, comparing our data to national data trends. For example, in the 20 to 54 age category, El Camino Hospital percentages are higher than the national trends. This could be attributed to various factors such as access to care, aggressive and well-published early detection programs, and identification of high-risk patients through the High-Risk Breast Program.

RACE: While race is not a risk factor for breast cancer, white women have the highest incidence of breast cancer in the United States, according to the National Cancer Institute. At El Camino Hospital, white women, including Hispanic, account for 62 percent of the patients diagnosed in 2013; Asian women represent 14.9 percent; and Chinese follow at 10.1 percent. By studying the ethnicity of our breast cancer patients, we can see if there are patterns within a particular group.

Age at Diagnosis

30%

25%

20%

15%

10%

5%

0%

ECH SEER*

ECH

SEER*

22.9%25.2%

13.8%20.7%

28.2%22.2%

12.2%14.8%

14.4%9.6%

4.3%5.7%

4.3%1.8%

0%0%

55–64 65–7445–54 75–8435–44 >8420–34<20AGE

*Surveillance, Epidemiology, and End Results Program: A program of the National Cancer Institute, SEER is a source of information on cancer incidence and survival in the United States.

Breast Cancer Diagnosis by Race

OTHER

VIETNAMESE

FILIPINO

JAPANESE

CHINESE

0% 20% 40% 60%

WHITE/HISPANIC

ASIAN OTHER/NOS

Information drawn from the El Camino Hospital Cancer Registry — A collection of data about cancers that are diagnosed and/or treated at El Camino Hospital.

For more information or for referral to one of our specialists, please call or visit our website.

www.elcaminohospital.org/breasthealth 800-216-5556

Some Members of our Breast Cancer Care Team

Front row, left to right: Robert Sinha, MD, Radiation Oncologist; Robin Cisco, MD, General Surgeon; and Peter Naruns, MD, General Surgeon.

Back row, left to right: William Rogers, MD, Pathologist; Tim Lockyer, MD, Hospice and Palliative Care; Imtiaz Qureshi, MD, Radiologist; Shane Dormady, MD, PhD, Medical Oncologist; Lily Servais, Genetic Counselor; Sarah Lamson, RN, Nurse Navigator; and Jiali Li, MD, PhD, Medical Oncologist.