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6 March 2019

The American Society of Breast Surgeons (ASBrS) held their annual meeting in Dallas last week. This meeting usually draws about 1500 breast surgeons (just under half the ASBrS membership) from around the world, for several days of pre-meeting courses, didactic sessions, and research presentations. In addition to the science, the meeting provides opportunities for breast surgeons in all types of practice settings and at all levels of training and practice to network and learn from each other. 

The following covers some highlights from the general session. 

The meeting started off with the Critical Issues in Breast Cancer Forum: Changing Paradigms for Breast Cancer Surgery. Dr. Cary Kaufman presented an update on current clinical trials for cryoablation for breast cancer. Cryoablation is a technique that freezes the tumor, using a small probe placed into the tumor (similar to a needle biopsy) under local anesthesia. There are several types of ablative therapy including laser, radiofrequency, high-frequency ultrasound, and cryoablation. Because cold is a natural anesthetic agent, patients undergoing cryoablation do not need any sedation, and the procedure is performed while they are awake. 

Cryoablation was initially tried with benign tumors (fibroadenomas). In many cases, the fibroadenoma reabsorbed, leaving no mass and only a tiny (3 millimeter) scar. Multiple studies have looked at the use of cryoablation for breast cancer, and most have restricted therapy to patients with small (1.5 cm or smaller) estrogen receptor positive, Her2/neu negative tumors. I participated in a national multi-center trial, the ACOSOG / ALLIANCE Z1072 trial, which was published in 2016 and demonstrated that cryoablation was successful in the majority of these patients. All patients in the ACOSOG / ALLIANCE Z1072 study underwent surgery within one month of the ablation, so that the tumor site could be removed and evaluated. Several subsequent studies have looked at cryoablation for breast cancer without surgery. The longest follow up was from Dr. Fukuma in Japan. After 12 years of follow up, he reported 3 local (in-breast) recurrences in 304 patients. Combining 3 published trials, Dr. Kaufman noted that local recurrence rates range from 0.98 – 1.4%, and he concluded that this is extremely promising technology. He also noted that cryoablation of breast cancer appears to have an immunologic benefit – when the tumor cell membranes are disrupted by the extreme cold, the patient is exposed to tumor antigens, which may prompt antibody formation. It is very premature to determine if this immunologic effect will help reduce recurrence rates.

Dr. William Small presented updates on 3 clinical trials of intraoperative radiation therapy (IORT). An advantage of IORT is that it is delivered at the time of lumpectomy, in the operating room, as a one-time treatment. A disadvantage is that status of the lumpectomy specimen margin and lymph nodes are not known at that time. If it is found on final pathology that there are positive margins, external beam radiation is recommended, and at least one trial noted that approximately 30% of patients who received IORT required additional whole breast radiation. Most studies of IORT have been limited to “low risk” lesions – small, low grade invasive cancers in older women. He discussed that a criticism of these studies is that some of these women may not have needed radiation therapy at all. Dr. Small noted that local recurrence rates are slightly higher (3.3 versus 1.3%) but that statistically, IORT is considered “non-inferior” to whole breast irradiation. He noted that seroma (fluid accumulation) is more common in patients who undergo IORT.  He concluded by stating that there is an “acceptable” toxicity, with non-inferior local recurrence. However, as there is relatively short follow up available in low risk patients, he questioned the applicability of this procedure to a broader patient population. A US registry is planned.

Dr. Antonio Toesca presented the results of his study of 100 patients who underwent robotic nipple sparing mastectomy (NSM) and implant reconstruction, and showed a fascinating video which highlighted the precise and meticulous dissection, along with improved visualization, compared to a standard surgical procedure. The average incision size was a little over 1 inch, and the specimen was removed intact (in one piece). The procedure averaged 1 hour and 18 minutes longer than their standard for a nipple sparing mastectomy and implant reconstruction (3 hours, 36 minutes for the robotic procedure. Patients who underwent the robotic procedure were less likely to have axillary web syndrome and reported Improved physical, psychological and sexual well-being. 

Why could performance of NSM using robotic technology become important? Dr. Tina Hieken presented the results of her study (abstract 580759, page 31) showing that as experience with the procedure has grown, indications are expanding and patients who previously were not candidates for the procedure are now being considered. A NSM is a technically challenging procedure, and it takes a toll on the neck and back of a surgeon. A 2017 study published in JAMA Surgery noted a high incidence of work-related musculoskeletal disorders among surgeons and interventionists. Dr. Katherine Kopkash presented her research (abstract 51837, page 52) using intraoperative electromyography (EMG) on the surgeon to assess muscle strain during NSM. Of course, oncologic safety is the primary concern, and more study on the long-term outcomes (as well as costs) of robotic procedures is required. 

The next session was Emerging Strategies in Breast Cancer Care, which focused on “de-escalation” of surgical therapy. Dr. Anna Weiss provided an update of clinical trials evaluating active surveillance for low-risk ductal carcinoma in-situ (DCIS): COMET, LORD and LORIS. Approximately 60,000 cases of DCIS are diagnosed annually. Patients undergoing active surveillance do not have surgery, some are treated with endocrine therapy, and all undergo regular monitoring. This is a accepted option in select cases of prostate cancer, and Dr. Weiss noted that there is no difference in overall survival in patients with low-grade DCIS who do not undergo treatment. The LORD and LORIS trials are open in the UK and the COMET study is open in the US. (Additional perspective)

Dr. Henry Kuerer presented his research on the percutaneous management of breast cancer in the setting of a pathology complete response (pCR) following neoaduvant (before surgery) chemotherapy. He noted that for survival and recurrence matter most, but side effects and complications are significant concerns for both patients and physicians. I’ve recently covered details of his research on this blog

Some of the twitter conversation related to this talk included patients who noted that they would rather undergo surgery than chemotherapy. It is important to note that the patients involved in this study are those who were going to be treated with chemotherapy regardless of surgical therapy because they have triple negative or Her2/neu positive breast cancer. In these patients, systemic (whole-body) therapy is necessary due to the higher likelihood of metastatic disease. Surgical therapy in these patients, especially the “exceptional responders”, may not improve outcomes, but of course more study is needed. Surgery remains the standard of care for breast cancer therapy.

Dr. Judy Boughey discussed several cooperative group trials evaluating management of the axillary (underarm) lymph nodes, and these studies are also focusing on how we can safely de-escalate axillary surgical therapy after neoadjuvant chemotherapy. This is an area that is rapidly evolving with expansion of the criteria for a less aggressive approach to the axilla.

In a session on Evidence-Based Prevention and Management of Surgical Complications, Dr. Suzanne Klimberg presented on chronic post-mastectomy seroma. A seroma is a fluid collection – fluid normally accumulates after mastectomy which is why drainage tubes are left in place. Normally, drains can be removed after 7-14 days, but about 30% of patients will develop prolonged drainage. This is a frustrating problem for patients and physicians as the persistent fluid can be uncomfortable, may increase the risk of infection, and may delay the start of planned chemotherapy or radiation. She noted that a surgical technique to close the tissue known as “quilting” can reduce the rate of chronic seroma, but that it results in excessive skin dimpling and has a significant impact on the cosmetic results. She stated that additional drainage tubes, various “sealant” agents and compression (such as wearing an ace wrap) are not effective. The area may be sclerosed (scarred) by instilling talc or antibiotics, and in some cases, re-operation to remove the inflamed tissue is indicated. Otherwise she recommended patience and repeat aspirations. She noted that there are no ways to successfully prevent seromas from forming.

Dr. Amal Khoury presented on chronic post-mastectomy pain, and noted that persistent pain occurs in 25-60% of patients undergoing any type of breast surgery. It is thought that this chronic and at times severe pain is due to damage to and neuroma formation of the cutaneous (skin) branches of nerves that run along the 4thand 5thribs, which are roughly at the inframammary fold (bra line below the breast). These cutaneous nerve branches are often not visible at the time of surgery. She noted that the pain syndrome it is often not recognized, and when recognized it is often not treated effectively. She stated that injections with a combination of long-acting local anesthetic and steroid (in a very small dose) at the trigger points is more effective than taking pain or other medications, and in their study at UCSF, 91% of patients required only one injection for lasting relief.

The next session was Practical Considerations for Systemic Treatment. Dr. Judy Boughey reviewed the I-SPY2 clinical trials, which utilize an innovative “adaptive randomization” approach in patients who are undergoing neoadjuvant chemotherapy for triple negative, Her2/neu positive, or other high risk breast cancers. pCR rates are assessed, and drugs that are successful move up higher in the randomization algorithm. This study and its flexible randomization protocol have accelerated the use of some novel agents. Patient reported outcomes assessing quality of life, fear of recurrence, symptoms and side effects are being assessed. If drug response rates are similar, the “winner” may be the one associated with fewer side effects. Dr. Barry Rosen discussed specific strategies to identify the previously involved axillary lymph nodes when chemotherapy is performed prior to surgery. Dr. Elizabeth Mittendorf presented on breast cancer immunotherapy and surgical implications of these treatments. She noted that one agent, atezolizumab, is currently approved for use in patients with metastatic triple negative breast cancer. She noted that there are concerns about wound healing complications with these agents but unfortunately the clinical trials did not specifically assess for this. In addition, she noted that some immunotherapy agents are associated with development of adrenal insufficiency – this complication has only been reported in a small percentage of patients, but it is an important consideration in any patient who is going to have surgery.

A session was held on breast imaging. Dr. Molly Sebastian presented on the impact of breast density on breast cancer risk, noting that it is more difficult to screen patients with dense breasts, and that these patients are also at increased risk for developing breast cancer. The associated breast cancer risk increases with the level of density. Approximately 50% of women in US are considered to have dense breast by mammogram, and she cited a 2010 study that found that 30% of breast cancers could be linked to highly dense breast tissue. Contributors to increased density include younger age, use of hormone replacement therapy, race (Asian), diet (Western), alcohol use, and hereditary factors. She did stress that the presence of a germline genetic mutation (such as BRCA 1/2) conveys a much higher level of risk (regardless of density) than breast density itself. 

Dr. Brigid Killelea discussed balancing high-risk screening (which usually includes MRI) with the concerns about gadolinium toxicity. Gadolinium is a “rare earth heavy metal”, and is used in the contrast material that is administered (using an intravenous line) when breast MRI is performed. Acute allergic reactions are uncommon but as gadolinium is excreted through the kidneys, there are concerns about the potential for kidney damage especially in patients with pre-existing renal insufficiency. Nephrogenic systemic fibrosis (NSF) is an unusual condition that results in progressive deposition of gadolinium in the skin. It has also been found that the number of exposures to the linear form of gadolinium (as opposed to macrocyclic, which is what is most commonly used with breast MRI) correlates with increasing deposits in the brain. More research is needed to determine if this leads to an increased risk of Parkinson’s or other diseases. Studies evaluating “fast” MRI protocols are ongoing but they still use gadolinium contrast. Some work is being done with non-contrast MRI and Dr. Killelea noted that it shows some promise in detecting certain lesions. 

In the session on Ethical Issues in Breast Cancer Surgery, Dr. Rachel Greenup discussed how to manage the situation when the principles of respect for patient autonomy conflict with the standard of care. She noted that patient autonomy allows for us (as physicians) to educate but not to decide care for patients, and that poor physician-patient communication is a key factor in patients opting for non-standard care. Factors associated with patients declining standard therapy include a negative first experience, an uncaring / insensitive / unnecessarily harsh oncologist, fear of side effects, and belief in the efficacy of alternative therapy.  In regards to endocrine therapy for breast cancer, she noted that unmanaged side effects are a significant contributor to stopping therapy. She also presented data showing poorer outcomes in patients who declined standard therapy, and that many, when faced with disease progression, did then opt for conventional treatment. She recommended that physicians review and present evidence to their patients in an understandable way, taking time to acknowledge fears and address patient barriers to treatment, provide time to adjust to diagnosis, suggest a 2ndopinion, and avoid abandonment or fear tactics. She also suggested that physicians be more open (when medically safe) to the combination of alternative and standard therapy. She stressed that patient autonomy is the priority, and that open communication can help align patient-centered care with evidence-based care. 

Dr. Terry Sarantou discussed the ethical issues of obtaining informed consent when performing a new surgical procedure, noting that there is FDA oversight for new drugs and surgical devices, but not for surgical procedures. He stressed that informed consent is a communication process, not a form to be signed. 

Recognizing the role that surgeons play in the current opioid crisis, Dr. Sarah DeSnyder discussed proper prescribing of narcotics in breast surgery. There was also an abstract presentation by Dr. Betty Fan (abstract 5808940, page 27) on this subject. She noted that women who expected postoperative pain or those who reported higher preoperative distress used more postoperative opioids for pain management. She stressed that physician and trainee education about proper prescribing is critical as is setting patient expectations for postoperative pain and providing non-narcotic options. The use of nerve blocks, long-acting local anesthetic agents, acetaminophen (Tylenol) and ibuprofen were also discussed. 

Photographs are an important part of breast and reconstructive surgery to document results both for patient and physician education as well as for quality assurance, and Dr. Toan Nguyen reviewed some of the ethical, legal and technical considerations to protect patient confidentiality and privacy. The ASBrS statement on this issue has been published in the Annals of Surgical Oncology.

In the session covering New Perspectives on Old Problems, Dr. Lee Wilke noted that with improved surgical techniques, breast conservation is now appropriate for select patients with more than one tumor in the breast. She did note that in up to 20-30% of patients with more than one tumor in the breast, the tumors are different subtypes, which may have implications for therapy – so pathologic analysis needs to be performed on all lesions. Dr. Stephen Grobmyer reviewed the current literature on local (in-breast) recurrence, noting that repeat breast conservation may be appropriate in some patients. However, if repeat radiation is performed, there is a higher risk of skin toxicity and potentially unacceptable cosmetic results. In addition, for left-sided breast cancers, repeat radiation raises concerns about cumulative radiation damage to the heart. Repeat lumpectomy without radiation is associated with a 20-40% risk of local recurrence. IORT may be utilized in some patients, but studies are ongoing and data is limited.

Dr. David Euhus discussed that genetic testing does not only potentially impact the surgical procedure that is recommended, but may influence the decision for radiation therapy as well as systemic therapy. In addition, results of genetic testing may impact surveillance for additional breast or other cancers in the patient as well as recommendations for family members. The ASBrS recently updated their genetic testing guideline, recommending that genetic testing be considered for newly diagnosed breast cancer patients. (Additional perspective)

In the session on Benign Breast Disease, Dr. Jane Mendez reviewed breast fistulas (persistent drainage through the skin) and infections, and Dr. Vincent Reid reviewed some of the non-malignant masses that can develop in the male breast. Dr. Katrina Mitchell, who is a breast surgeon as well as a certified lactation consultant, provided recommendations for management of post-partum patients who develop mastitis or breast abscess. One of the key recommendations was that patients should continue breast feeding (better than pumping for keeping the breast empty) and that patients do not need to “pump and dump” the milk while on antibiotics. 

Dr. Stephanie Valente discussed breast pain, which is a common problem that frustrates both patients and physicians. Pain is a symptom of breast cancer in less than 2% of cases.  Suggestions for treatment include decrease caffeine, nicotine, and dietary fat intake, and consider supplementation with essential fatty acids such as evening primrose oil (EPO) or vitamin E. However, she noted that that some studies show that EPO and vitamin E are no better than placebo. Both flaxseed and chasteberry have shown to be effective. Diclofenac (a non-narcotic pain medication) gel can be effective but it needs to be used for several weeks before improvement is seen and it is expensive. In severe cases, danazol (an androgen hormone) or tamoxifen can be used but are associated with significant side effects.

There were several sessions on oncoplastic surgery. Oncoplastics refers to combining oncologic (cancer) surgery with attention to cosmetic outcomes. Basic principles include placing the incision in the least conspicuous place and closure of as much of the breast tissue once the tumor has been removed as possible to minimize, or preferably avoid, a depression in the area. More advanced techniques include rotation flaps and mastopexy (lift) that may be performed by breast surgeons or breast surgeons collaborating with their plastic surgical colleagues. There was also a session discussing some of the advanced microvascular procedures that are being studied to treat lymphedema as well as a video session showing some basic techniques to perform a better (flat) closure for patients undergoing mastectomy without reconstruction. 

The keynote address was delivered by the actress Kathy Bates. Ms. Bates underwent a bilateral mastectomy for breast cancer and has bilateral arm lymphedema. She is a spokeswoman for the Lymphatic Education and Research Network, working to educate, support, and advocate for patients who have lymphedema. She delivered a moving and unique address to the group, combining science and her personal patient perspective. An abstract (abstract 581304, page 22) presented during the meeting demonstrated that postoperative surveillance with bioimpedence spectroscopy compared to tape measure resulted in a 10% decrease in the number of patients requiring complex decongestive physiotherapy. However, these results, which were a planned interim data analysis, did not reach statistical significance.

The new ASBrS screening mammography guidelines were released at the meeting. They recommend formal risk assessment starting at age 25 and a risk-based approach to screening, as well as annual mammography starting at age 40 for average-risk women. (Additional commentary)

All of the research abstracts and posters can be found here. There were many interesting and thought-providing presentations, but it is important to remember that abstracts represent incomplete data and have not been subject to the peer-review process. The oral abstracts that were presented will be published in manuscript form later this year. The poster gallery can be found here (not all posters have been uploaded by the presenters).

As usual if anyone is interested in one of the articles referenced but does not have access, or wants additional information, please send your email address to me: contact at drattai dot com and I will be happy to respond.

This post has not been endorsed by the American Society of Breast Surgeons.

3 May 2019

The American Society of Breast Surgeons (ASBrS) has updated their screening mammography guideline, recommending that women of average risk begin annual screening mammograms at age 40. This update brings the ASBrS guideline more in line with those of the American College of Radiology and the Society of Breast Imaging, and are a departure from their previous guideline, which called for screening to start at age 45. The American Cancer Society recommends annual screening from age 45-54, followed by biennial screening with the opportunity for annual screening. The US Preventative Services Task Force recommends biennial screening starting at age 50.

The updated ASBrS guidelines recommend as a first step that all women undergo a formal risk assessment starting at age 25. Risk assessment involves using any one of a number of models to estimate 5-year and lifetime risk of breast cancer development. These models take into account age, family history, menstrual and pregnancy history as well as history of prior biopsy and racial / ethnic background. Some models take into account body mass index and breast density. The ASBrS guideline has additional recommendations, outlined below, depending on risk level. The recommendations listed for women at high risk of breast cancer are consistent with those of the American Cancer Society and National Comprehensive Cancer Network.

When to start and how often to perform screening mammography has been the subject of much debate over the years. The primary issue is the number of lives saved balanced against the harms of screening mammography. Harms include false negatives (cancer is not detected by the mammogram), false positives (suspicious areas that turn out to be benign) and recommendations for additional imaging (added cost and concerns about the potential effects of cumulative radiation). There have also been concerns raised about over-diagnosis and over-treatment: finding cancers that would never pose a threat to a woman’s health or life – but the patient is exposed to the potential harms of cancer therapy.

The goal of screening is not to detect all cancers – otherwise we would recommend complete body imaging for everyone. The goal of screening is to improve the survival from the cancers that are detected. An ideal screening test is relatively inexpensive and performs equally well in the patient population undergoing the screening. Mammography is acknowledged to be an imperfect screening tool – while relatively inexpensive and safe, it simply does not perform the same in women with breasts of different ages and densities. Approximately 1000 women need to be screened to detect 2 – 7 breast cancers, and mammography performs best in women age 50-74. In younger women, a few cancers will be detected, and there may be a survival benefit. However, because breast cancer is less common in younger women, a larger number of women need to be screened to find a single cancer, increasing the likelihood of a harm. The benefits of screening do not always outweigh the risks – at least for an individual patient.

It is also important to note that some of the new ASBrS recommendations, such as 3D mammography as the preferred type of mammogram, supplemental ultrasound in women with dense breasts, and MRI for all women with a history of breast cancer, are still undergoing investigation and are not always covered by insurance. We know that these studies will find additional cancers, but we do not yet have data on improved outcomes. My patients know that I am fond of saying “the more we look, the more we find, but not everything we find needs to be found.”

Two ongoing studies will hopefully provide additional information regarding 3D mammography and screening interval:

  • The TMIST trial is a national multi-center study assessing the performance of 3D compared to 2D digital mammography. This study will assess rates of cancer detection, callbacks and benign biopsies as well as biology of the tumors detected and outcomes.
  • The WISDOM study is evaluating a risk-based screening approach. After a comprehensive risk assessment, genetic testing, and assessment of risk tolerance, patients are assigned annual versus biennial screening. Women can self-enroll in this study (disclosure – I am not involved with the study team but I am enrolled in the study as a participant) and do not have to change mammography facility.

Until we are at a point when an individual woman’s level of risk can be accurately predicted, there is no definitive “best” screening guideline to follow. Recognizing the potential harms of screening mammography, it is no longer appropriate for physicians to simply hand out an order for an annual screening mammogram for all women starting at age 40. A balanced discussion, taking into account an individual woman’s risk and level of risk tolerance as well as the absolute potential benefits and harms of mammography is indicated. These discussions are nuanced and take time. Various genomic assays are being evaluated and it is hopeful that we will at some point have a test that can accurately predict a woman’s risk of breast cancer – which can then be used to provide more tailored guidance regarding imaging. Until that time (and I hate to end this way…), talk to your physician and medical team about what screening option is right for you.

12 February 2019

The American Society of Breast Surgeons has issued updated genetic testing guidelines for patients who have been diagnosed with breast cancer. The new guidelines recommend that genetic testing to include BRCA 1/2 and PALB2 mutations (and other genes as appropriate based on clinical scenario and family history) be made available to all newly diagnosed breast cancer patients. They also recommend re-evaluation and consideration of updated testing for patients tested prior to 2014.

Traditional guidelines for genetic testing have focused on age at diagnosis and family history of breast, ovarian and other cancers. However, recent studies have demonstrated that a percentage of patients who do not meet testing guidelines will be found to carry a deleterious mutation that may change surgical and other treatment recommendations. This information could also be helpful to family members who could participate in enhanced screening protocols or consider prophylactic surgery.

Not all genetic mutations are alike. Abnormalities in the BRCA 1 and 2 genes are the most common mutations associated with an increased risk of breast cancer. Mutations in other genes, such as PALB2, CHEK2, PTEN, ATM and others do not convey as high a risk. Treatment decisions in these patients needs to consider family history and other risk factors.

Another important factor to consider is that not all mutations are meaningful. Genetic testing may find a “variant of uncertain or unknown significance (VUS)” – this indicates that there is a mutation in the gene, but there is not sufficient evidence to classify it as harmful or not. Many VUS cases will be re-classified over time to reflect no impact on cancer risk. A smaller number may be re-classified as harmful.

Finally, treatment recommendations and decisions based on genetic testing status need to take into account the individual patient – their age, other medical problems, and their personal preferences.

There are currently several companies that provide comprehensive genetic testing, and costs have come down considerably. It is hoped that other national organizations, such as the National Comprehensive Cancer Network (NCCN) will update their testing guidelines, and that insurers will broaden coverage for testing. Despite some cautions, these new guidelines are an important step to help ensure that breast cancer patients, their treatment team, and their families have the information necessary to make more informed decisions.

Additional Information: Washington Post

10 May 2018

The American Society of Breast Surgeons held their Annual Meeting in Orlando, FL from May 2nd – 6th. As usual, it was well attended – the meeting is known for being very practical and full of information that breast surgeons can bring back to their practices to help improve patient care.

I’ve picked a few topics to highlight in this post: Genetics, Imaging, Local Therapy, Systemic Therapy, Immunotherapy, Liquid Biopsy, Diet and Hormone Therapy, and Changing Paradigms. The following are comments expressed by the meeting speakers. My own comments will be noted in bold italics.

Genetics:

  • BRCA 1 mutation carriers are more likely to have triple negative breast cancer.
  • BRCA 2 mutation carriers are more likely to have ER positive, Her2/neu negative breast cancers.
  • The risk of a 2nd breast cancer in BRCA mutation carriers on average is about 2% per year depending on the specific mutation and the age of affected relatives. It can approach 60-80% in some patients. This increased risk of a new breast cancer is why bilateral mastectomy is often recommended. Removal of the opposite breast may result in improved overall survival but results from studies are mixed.
  • For BRCA mutation carriers, it is recommended that clinical breast exam (breast exam by the physician) be performed every 6-12 months. From age 25-29 annual MRI is recommended, and from age 30-75 annual mammogram (3D mammogram or tomosynthesis was recommended) along with MRI was recommended. It was stated that this screening regimen has not been shown to improve survival, but the screen-detected cancers were less likely to have lymph node involvement. No specific recommendation was made for imaging or exam after bilateral mastectomy.
  • MRI every 6 months has been suggested by some, but there are concerns about gadolinium (a heavy metal material which is the contrast agent used for breast MRI) buildup.
  • Removal of the ovaries is recommended around age 40.
  • In patients with BRCA mutations who undergo salpingo-oophorectomy (removal of the ovaries and fallopian tubes), estrogen replacement therapy has not been shown to increase subsequent breast cancer risk. However, combined estrogen / progesterone therapy may increase subsequent breast cancer risk. It was suggested to consider removing the uterus at the time of ovary removal, so that estrogen alone could be used (if the uterus is not removed, estrogen alone could increase the risk of uterine cancer).
  • There are many other genetic mutations that have been identified that have a variable association with increased breast cancer risk. It was stressed that family history and other factors need to be considered when these less common mutations (such as CHEK2, ATM, PALB2 and many more) are present, before recommending mastectomy.
  • It was stressed that the presence of a variant of unknown significance (VUS) should NOT prompt aggressive surgery.
  • A study was presented that demonstrated that current breast cancer genetic testing guidelines exclude almost half of high-risk patients, and a recommendation was made for testing of all breast cancer patients regardless of age, family history or other factors.

Breast Imaging:

  • Dense breast (as determined by mammogram) reduces the sensitivity of mammograms, and also is associated with an increased risk of breast cancer.
  • It was stressed that determination of breast density is subjective and studies have shown significant variability in grading of breast density. Automated methods of assessing density are being evaluated.
  • 34 states have dense breast notification legislation. Some have supplemental screening (such as ultrasound) legislation (California does not).
  • An advantage of tomosynthesis (also known as 3D mammogram) in patients with dense breasts is that it decreases the likelihood of callbacks and improves the cancer detection rate
  • Abbreviated (3 minute scan) MRI shows promise for screening.
  • There is an ECOG/ACRIN study planned which will evaluate abbreviated MRI versus tomosynthesis in women with dense breasts.
  • Contrast-enhanced mammography is superior to digital mammography but it requires an IV contrast dye, and there is currently no ability to biopsy lesions seen only with this technique.
  • It was stressed that automated whole breast ultrasound (ABUS) should not replace mammography.
  • Molecular breast imaging has a much higher radiation dose due to the need to inject a radioactive material and cost is higher than other imaging modalities. There are only about 100 units in the US.
  • In addition to BRCA mutation carriers, patients who have a history of chest wall radiation at a young age (most commonly for treatment of Hodgkin’s lymphoma) or those who have a lifetime risk of breast cancer over 20% (assessed by various computer modes) should have annual MRI in addition to mammograms for surveillance.

Loco-Regional (breast and underarm lymph nodes) Therapy:

  • Recurrence of cancer in the breast (known as a local recurrence) was previously thought to be related to “disease burden” – the amount of tumor and size of clear margins. According to Dr. Monica Morrow, this has led to an “obsession” with margins, wider surgical resection than necessary, and the overuse of MRI.
  • Due to improvements in systemic therapy (chemotherapy and endocrine therapy), local recurrences have decreased over time.
  • Local recurrences are largely a function of tumor biology – more aggressive tumor types are more likely to recur. Bigger surgery does not overcome bad biology.
  • The rates of contralateral (opposite side) new breast cancer have been decreasing in the US; currently <1% at 5 years for patients who do not have a genetic mutation.
  • Updated 2018 ASTRO guidelines endorse hypofractionation (a shorter course of radiation therapy) in a larger group of patients.
  • There are 3 trials that will evaluate whether or not radiation therapy can be avoided in selected patients – LUMINA, IDEA and PRECISION.
  • ~30% of patients undergoing “direct to implant” reconstruction (no temporary tissue expander) need a second surgery. One of the plastic surgeons that I work with notes that “reconstruction is a process not a procedure!”
  • Managing expectations of the reconstruction process is important so patients don’t get frustrated and feel like their reconstruction has “failed.”
  • Post mastectomy radiation worsens outcome from implant reconstruction; severe capsular contracture occurs in about 30% of patients.
  • If radiation is performed on the permanent implant instead of the tissue expander, the rate of reconstruction failure goes down by 50%.
  • Many plastic surgeons prefer that autologous (patient’s own body) reconstruction be performed after radiation to avoid shrinkage of the flap. A tissue expander could be placed at the time of mastectomy which will be removed after radiation when the flap procedure is performed.
  • Lymphedema risk is about 25% with axillary node dissection versus 6-8% with sentinel node biopsy. In certain patients over age 70 with ER+ breast cancer, sentinel node biopsy can be avoided – this was also covered in the Society of Surgical Oncology’s Choosing Wisely statements. However, it is also important to take into account whether or not the patient will be treated with radiation and/or endocrine therapy. Sentinel node biopsy is also not recommended for most patients undergoing lumpectomy for DCIS. The SOUND trial is evaluating the use of axillary ultrasound to try to determine if this can help select patients who do not need sentinel node biopsy.

 Systemic Therapy:

  • The use of genomic tumor testing could avoid the use of ineffective (for the specific patient depending on tumor profile) chemotherapy in up to 50,000 patients per year.
  • Neoadjuvant (before surgery) chemotherapy is most commonly used to decrease tumor size so that patients have a higher likelihood of being able to undergo lumpectomy instead of mastectomy.
  • About 50% of patients who have positive lymph nodes before chemotherapy are converted to node-negative due to chemotherapy prior to surgery, and they may be able to avoid full axillary node dissection.
  • Response to neoadjuvant chemotherapy varies by tumor subtype. Her2/neu and triple negative breast cancers are more likely to respond compared to ER+ and Her2/neu negative tumors.
  • Technical considerations to improve the accuracy of sentinel node biopsy after neoadjuvant chemotherapy including the use of 2 dye agents to map the nodes and removal of at least 3 lymph nodes.
  • A multidisciplinary approach for management of patients who are being considered for neoadjuvant chemotherapy was stressed.
  • Recurrence patterns are different for ER+ versus ER- disease. Patients with ER+ breast cancer are at risk for late recurrence, even 20 years after treatment – the highest risk is in patients with multiple involved lymph nodes. Patients with ER- disease tend to recur earlier (within the first 2-5 years), and then the likelihood of recurrence decreases.
  • Recurrence in the breast is a marker of increased risk for development of metastatic disease.
  • Premenopausal patients who have “low risk” disease could consider stopping tamoxifen after 5 years. It is recommended that patients with “high risk” disease consider 10 years of tamoxifen therapy.
  • Postmenopausal patients who are considered “high risk” could consider 10 years of an aromatase inhibitor, although there is not currently data that shows this approach improves survival. Prolonged therapy in these patients does reduce the likelihood of developing a new breast cancer and reduces the likelihood of breast cancer recurrence.

Immunotherapy / Liquid Biopsy:

  • A brief session was held covering immunotherapy and liquid biopsy.
  • Immunotherapy for breast cancer has not had the success seen in melanoma, lung cancer, colon cancer and bladder cancer.
  • The combination of chemotherapy and a modified herpes virus has shown some promise in patients with triple negative breast cancer.
  • It is likely that immunotherapy treatments will vary depending on tumor subtype.
  • Circulating tumor DNA may predict metastatic disease 8-12 months before evidence of tumor spread – but we are not yet able to improve patient outcomes based on this information. Therefore, circulating tumor cell and circulating cancer cell DNA assessments are not recommended for routine clinical use.
  • It was predicted that “liquid biopsy” will eventually be used routinely to help manage breast cancer patients.

 

Diet and Hormone Replacement Therapy:

  • A low fat diet improved the likelihood of death from breast cancer only in obese women.
  • Currently there is more information regarding the impact of dietary fat versus dietary sugar on breast cancer risk. Dr. Rowan Chlebowski, who has been a lead author on the Women’s Health Initiative studies, stated that due to an increasing number of reports suggesting that sugar may impact breast cancer development, they plan to look more closely at this.
  • Insulin resistance is associated with cancer specific and all-cause mortality in postmenopausal women.
  • One of Dr. Chlebowski’s conclusions was to “avoid body fatness.” Unfortunately, specific guidance on how to best accomplish this was not discussed!
  • The risk of breast cancer associated with hormone replacement therapy (HRT) is greater if it is started around the time of menopause versus 3-5 years later.
  • Breast cancer risk in women taking HRT is higher in women with extremely dense breast versus fatty replaced breasts. The biggest risk from HRT is in lean women with extremely dense breasts. The lowest risk from HRT is in women with a body mass index (BMI) > 35 with fatty replaced breasts.
  • Combination estrogen / progesterone HRT should be avoided in lean (BMI <25) women especially if they have dense breast tissue.
  • The Black Women’s Health Study found no increased breast cancer risk if HRT use was <10 years, but cancer risk was increased if use was >10 years. Other studies showed either no risk or no association of risk from HRT with race.

 

Changing Paradigms – Avoiding Surgery for DCIS and Neoadjuvant Patients

  • Active surveillance is being evaluated for ductal carcinoma in-situ (DCIS). Over 60,000 cases of DCIS are diagnosed per year in the US. Not all cases of DCIS will progress to invasive cancer, and the likelihood of progression is lowest in low grade DCIS. In these patients, less than 10% develop invasive cancer in the same breast after 10 years and over 20% die from other causes within 10 years of diagnosis.
  • There are 3 ongoing clinical trials are evaluating active surveillance for low risk DCIS (LORIS, LORD, and COMET). The COMET trial is the only study open in the US. DCISOptions.org has additional information about DCIS and the COMET trial.
  • Some patients who undergo chemotherapy prior to surgery are found to have no residual tumor after the area has been removed, termed pathologic complete response (pCR).
  • Prompted by patients asking “why do I need surgery?” if it appears that all cancer has resolved after chemotherapy, researchers at MD Anderson Cancer Center are evaluating whether surgery can be omitted in patients who appear to have a pCR after chemotherapy. Patients who have no apparent tumor based on post-chemotherapy imaging (including MRI) undergo core needle biopsies. If these biopsies show no tumor, patients taking part in the study will undergo radiation without surgery.
  • Similar studies are taking place in the Netherlands, Germany, and the UK.
  • Henry Kuerer from MD Anderson stated that “surgeons have an obligation to study possibility of no surgery – and we must ensure safety and efficacy with well-designed trials.
  • Several types of ablative therapy (destroying the tumor without surgery) are being evaluated including cryoablation (freezing), laser, and transcutaneous (no needle puncture or scar) high frequency ultrasound.

Lifetime Achievement Award

Dr. Ernie Bodai, the breast surgeon who spearheaded the Breast Cancer Research Stamp, was honored with a lifetime achievement award. It was fascinating to hear his story and how one man (with a little help) got congress to change a law.

This post has not been endorsed by the American Society of Breast Surgeons

8 May 2017

As a past-president of the American Society of Breast Surgeons I am probably more than a little biased. However, as always, the annual meeting held April 26-30th in Las Vegas was terrific. Topics including the full spectrum of breast disease, including benign and high risk lesions, genetic testing, breast cancer diagnosis and treatment including medical and radiation oncology updates, and metastatic disease.

The press briefing highlighted 3 abstracts which showed that:

  • Modern therapy for inflammatory breast cancer is associated with better outcomes than historically seen
  • Post-treatment lymphedema is related to a combination of treatments including surgery, radiation therapy, and chemotherapy – not just from surgery
  • Patients with DCIS have a 5 year risk of developing a cancer in the other breast of 2.8% and a 10 year risk of 5.6%, and patients should be discouraged from undergoing bilateral mastectomy for this condition. Developing a new cancer in the previously treated breast was twice as likely as developing a new cancer in the opposite breast, and the use of tamoxifen reduced the likelihood of any recurrence.

Dr. Nathalie Johnson moderated a pre-meeting course on Building a Breast Cancer Survivorship Program. I was invited to speak on Traditional Versus Virtual – Options for Patient Support and Education. Just as it can be challenging to choose between cake and ice cream (2 really good things), patients note advantages to both in person and online support and education. It doesn’t have to be one or the other – do what works for YOU! My slides are posted on SlideShare.

During the general sessions, a few topics stood out to me:

Dr. Shelley Hwang from Duke University spoke on DCIS subtyping and overtreatment. She noted that DCIS now comprises over 20% of all mammographically detected breast cancer. It is considered a “non-obligate precursor” of invasive cancer – the rate and likelihood of progression to invasive cancer are not clearly known. However, it is clear that some patients will never exhibit progression to invasive disease, and she discussed this in the context of thyroid and prostate cancer – two situations where we know that treatment in some patients will not provide the patient any benefit. The challenge is to sort out which patients will benefit from treatment and which ones will not. The COMET study is currently enrolling patients with low grade DCIS to in an attempt to help answer these questions.

Dr. Virginia Herrmann from Washington University in St. Louis spoke on non-genetic breast cancer risk factors. This is an important topic and I believe one that doesn’t get covered enough. She noted that hormone replacement therapy does increase risk – although the incremental risk is small and is seen only after about 5 years of use. However, longer term use does result in higher risk. Increased body mass index (BMI) is associated with risk – the risk of breast cancer is 30% higher in patients with a BMI greater than 31 kg/m2 compared to a BMI of 20 kg/m2. She noted that there is a linear relationship between alcohol intake and cancer risk, noting a 10% increase in risk for each 10 gm/day (for wine this is a little over 3 oz) increment in alcohol consumption. The risk is most associated with post-menopausal breast cancer, although in the study she quoted, only alcohol intake during age 50s was associated with an increased risk of postmenopausal breast cancer. She noted the association of ionizing radiation and breast cancer, and young women who received mantle (chest area) radiation for Hodgkin’s lymphoma have a markedly increased risk for developing breast cancer. She noted that breast cancer risk is increased in smokers, correlated with smoking intensity and duration. Finally, she noted the increased risk of breast cancer among soldiers stationed at Camp LeJune related to contaminated drinking water (tetrachloroethylene and trichloroethylene).

Dr. Tiffany Traina, a Memorial Sloan Kettering medical oncologist, gave a brief presentation about triple negative breast cancer: Searching For the Magic Bullet. There are several promising treatment strategies including targeting androgen receptors, the use of PARP-inhibitors in patients who have BRCA gene mutations, antibody-drug conjugates, immune modulating approaches, and targeted therapies based on tumor genomic profiles. Stay tuned – much more to come over the next few years related to this aggressive breast cancer subtype.

Dr. Lisa Newman, from the Henry Ford Health System in Detroit, spoke on Breast Cancer Outcomes: Disparities versus Biology. I have heard her speak on this topic multiple times over the years and always enjoy her excellent presentations. She noted that the incidence of breast cancer in black women is increasing, now close to that in white women. However, mortality rates for black women are higher than those for white women. There is an increased frequency of triple negative breast cancer in black women. She is involved in a research initiative evaluating the association between African ancestry and high risk breast cancer in white American women, African American women, and women in Ghana, including studying novel aspects of tumor biology and breast cancer stem cells – she is asking the question “are there differences in the oncogenic potential of mammary tissue that are associated with ancestry”? She concluded with what I felt was a powerful slide – 60% – 43% – 20%. Those were the survival rates for passengers on the Titanic who were in 1st – 2nd – 3rd class. She noted that healthcare outcomes are often dependent on access to care, and ended with a quote from Dr. Martin Luther King, Jr.: “Of all the forms of injustice, inequality in health care is the most shocking and inhumane”.

Dr. Stephen Edge, from the Roswell Park Cancer Institute, gave an update on the new American Joint Commission on Cancer staging system (AJCC 8th edition). Currently we stage breast cancer based on tumor size and lymph node status. However, it is recognized that that tumor biology plays an important role in prognosis and in some patients it may be more important that tumor size. The new staging system will incorporate tumor grade, Her2/neu status, ER/PR status, and Oncotype Dx status (if available) and should more accurately reflect prognosis. There are 422 lines in the new staging system – it will be impossible to memorize! Thankfully, he noted that the AJCC is working on a staging app.

The last day of the meeting held some great sessions, and the meeting room remained packed up until the very last minute. Dr. Ann Partridge from Dana Farber discussed special considerations in the young breast cancer patient. She noted that the disease is different, the patients are different, and the treatments should be different. Younger women have a higher likelihood to have more aggressive subtypes such as Her2/neu over-expressed and triple negative, and have lower survival rates than older women – even in those with the ER positive breast cancer. However, she cautioned not to over-treat patients based only on age. She noted that young age is not a contraindication for breast conservation, and that there is no clear improvement in mortality in patients who undergo more extensive surgery. She noted the need for improvements in treatment and support, including focused research and guidelines, which should lead to better outcomes.

Dr. Irene Wapnir from Stanford spoke on fertility preservation issues. She noted the various fertility options including medications and procedures. She also reviewed the POSITIVE trial, which will be assessing the risk of breast cancer relapse in patients who temporarily stop endocrine therapy to permit pregnancy, as well as to evaluate factors associated with successful pregnancy after interruption of endocrine therapy. She also stressed that fertility preservation should be discussed with any woman of childbearing age, whether or not she has had a prior pregnancy or a child – physicians won’t know what is important to their patients unless we ask!

Dr. Katherina Zabicki Calvillo from Dana Farber discussed breast cancer in pregnancy. She noted that 0.2-4.0% of breast cancers are diagnosed in pregnant patients – about 1 in 3000 pregnancies. She also noted that given the overall delay in childbearing (and the association of increasing age with breast cancer), the incidence of pregnancy-associated breast cancer will increase. Delays in diagnosis are related to hormonal changes which affect breast tissue making the exam more challenging, and that many patients and physicians assume that masses are related to pregnancy. She stressed that pregnancy termination is usually NOT required, but a multidisciplinary team approach is required. Many of these patients present in more advanced stages, but stage-for-stage, the prognosis is similar to non-pregnant patients with breast cancer. Chemotherapy can be given after the first trimester, but hormonal and Her2/neu targeted therapy should be avoided. She noted that mastectomy should be performed in the first and early 2nd trimester, and discussed the challenges of immediate reconstruction. Breast conservation could be considered in the late 2nd or 3rd trimester with post-lumpectomy radiation planned for after delivery.

Dr. Kevin Hughes from the Massachusetts General Hospital reviewed research studies that have found that in women over the age of 70 with early stage breast cancer, radiation therapy after lumpectomy may not be necessary.  The CALGB 9343 study showed that survival rates were the same whether women received radiation therapy or not. Radiation therapy did reduce the likelihood of cancer returning in the breast (local recurrence) from about 4% in the untreated patients to about 1% in the treated patients (after 5 years of follow up). However it is important to realize that the majority of women in that study were treated with endocrine therapy, which can help reduce the risk of local recurrence. As with many decisions regarding breast cancer treatment, a careful discussion of the risks and benefits of each option is necessary.

Dr. Tina Hieken from the Mayo Clinic gave a very interesting talk on the microbiome and the impact on breast cancer. We normally co-exist with many bacteria – we have ten times the more microbial cells compared to human cells. These microbes carry out metabolic reactions that can be essential to human health. The genetic material (genome) of our microorganisms is called the microbiome. She and her colleagues studied breast tissue from women with and without breast cancer and found that the background breast microbiome is different in women with breast cancer compared to those with benign conditions. She concluded by noting that the future may involve using a microbial pattern to predict breast cancer risk, exploiting the microbiome to enhance treatment response, and that there may also be implications for a cancer prevention vaccine. The Washington Post recently covered her research – definitely worth a read for more information.

Dr. Anthony Lucci from MD Anderson discussed the “Ongoing Saga of Circulating Tumor Cells”. We would all like to see the day when a blood test can tell us with certainty if cancer has developed or returned – but we’re not there yet. After reviewing several studies evaluating both circulating tumor cells (CTC) and circulating “cell free” DNA, he concluded that this information does provide prognostic information in both metastatic and non-metastatic patients, but is not in the current ASCO or NCCN guidelines for guiding treatment. Combining the CTC status with response to preoperative chemotherapy may identify a low risk subset of patients, but noted that additional studies are needed before we can reach the ultimate goal which is improving outcomes by monitoring and responding to CTC and cell free DNA levels.

Dr. Manjeet Chadha from Mount Sinai spoke on repeat lumpectomy after prior lumpectomy and breast radiation. Traditionally, mastectomy has been recommended if cancer returns after lumpectomy and radiation therapy. On average, there is about a 10% risk of “in breast” recurrence after lumpectomy and radiation, but this will vary based on tumor and treatment type. She reviewed several studies evaluating the different types of focused or partial breast radiation that may be used in selected patients who experience recurrence of their breast cancer. She also called for additional studies in this area.

One of the last talks was by Dr. Mehra Golshan from Dana Farber. He spoke about the decision whether or not to operate on patients with breast cancer who present with Stage IV (metastatic) disease. Traditionally, we have not recommended surgery for patients with metastatic breast cancer as these patients were not expected to have long survival, and it was not felt that removal of the main tumor would impact survival. Evaluating existing studies has also been challenging because while some have shown a benefit to removal of the main tumor, the patients who underwent surgery in those studies tended to be younger and healthier. He concluded by noting that surgery in patients with Stage IV breast cancer is not standard of care, but some studies do support this practice. It is recommended that these patients be evaluated in a multidisciplinary forum and that treatment choices be individualized.

 I returned from the meeting exhausted but energized. In addition to the scientific content, the meeting is an opportunity to connect with friends and colleagues across the country. I’m already looking forward to ASBrS 2018!

This post has not been endorsed by the American Society of Breast Surgeons.

27 June 2016

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation. Things Providers and Patients Should Question have been chosen by various medical societies based on review of the evidence-based literature. The American Society of Breast Surgeons (ASBrS) has published their contributions to the campaign (open access) in the Annals of Surgical Oncology.

The 5 ASBrS measures include:

1.) Don’t routinely order breast magnetic resonance imaging (MRI) in new breast cancer patients
2.) Don’t routinely excise all the lymph nodes underneath the arm in patients having partial breast removal (lumpectomy) for breast cancer when only one or two contain cancer
3.) Don’t routinely order specialized tumor gene testing in all new breast cancer patients
4.) Don’t routinely reoperate on patients if the cancer is close to the edge of the excised lumpectomy tissue
5.) Don’t routinely perform a double mastectomy in patients who have single breast with cancer.

Rational for the measures is included in the manuscript, and are posted on the Choosing Wisely website.

As with the other Choosing Wisely lists, these are meant to spark discussions between patients and their physicians regarding the appropriate use of medical tests and procedures. In many areas of medicine, tests and procedures may be performed without good supportive evidence. There may be many valid reasons for straying from an evidence based practice, which is part of the art of medicine. In fact, the Choosing Wisely website specifically states that “these recommendations should not be used to establish coverage decisions or exclusions.” In addition, the ASBrS statement notes that the selections made “are not meant to infer that a test or procedure endorsed in our list is a ‘never should occur’ event.”

Individualizing care as much as possible is extremely important. However, that does not mean performing every available test just because it’s available. Patients and physicians need to realize that there are downsides to unnecessary testing. Physicians also need to remain educated about current practice, and not continue to make outdated recommendations simply because they may have “always done it that way.” A goal of the Choosing Wisely campaign is to ensure that when decisions are made, available evidence is considered and that the process is a collaborative one between patients and their physicians.

21 June 2016

In October, we solicited input a research survey designed to identify how patients prefer to be notified of a new cancer diagnosis and cancer-related test results. The results were presented at the 2016 Annual Meeting of the American Society of Breast Surgeons in April. The full manuscript – What Do Patients Prefer? Understanding Patient Preferences for Receiving a New Breast Cancer Diagnosis – was just published in the Annals of Surgical Oncology.

Our study showed that physicians are not meeting patient expectations regarding mode of diagnosis disclosure (phone versus in person) or timeliness of results disclosure. The majority of patients who responded to our survey preferred to be notified in person, however many commented that they truly preferred the method that was fastest. More patients preferred to be notified of radiology results by telephone, and electronic methods such as email or patient portal were preferred for blood test results.

We included many of your comments in the manuscript, and it is clear that one size most definitely does not fit all in terms of results disclosure. However, from our study it is very clear that we are not meeting patient expectations. System issues should be evaluated to identify areas of improvement in terms of timeliness of results disclosure, and physicians should ask patients how they prefer to be notified, and should make every effort to honor patient preferences.

Thank you to the community for your participation in this study, and for helping to make an important contribution to the literature. This study would not have happened without the support of the #BCSM community, as well as the Dr. Susan Love Research Foundation, Living Beyond Breast Cancer, and the Seattle Cancer Care Alliance. If anyone is interested in receiving the manuscript (and you are not able to download it from the Springer website) please email me: [contact at drattai dot com] and I will be happy to send you a copy of the paper.
Deanna J. Attai MD, FACS
Regina Hampton MD, FACS
Alicia Staley BS, MBA, MS
Andrew Bogert PhD
Jeffrey Landercasper MD, FACS

 

Passing the gavel to Dr. Sheldon Feldman

On April 15, 2016, I passed the gavel of the American Society of Breast Surgeons (ASBrS) to our new President, Dr. Sheldon Feldman. The weeks leading up to the meeting were filled with anticipation, anxiety, and a few nightmares. I had dreams that I slept through my Presidential Address, and that I forgot to prepare my slides. My nightmares stopped when 2 weeks before the meeting, I had the opportunity to speak with Dr. Chip Cody, my predecessor. He is a breast surgical oncologist at the Memorial Sloan Cancer Center in New York and a very experienced and polished speaker. He let me know that he also had nightmares before his Presidential Address – it wasn’t just me! The meeting itself brought many emotions, including a bit of last minute panic before the big talk, joy, and pride. Those words don’t do the emotions justice.

Read more

 

9 November 2015

The American Society of Breast Surgeons Foundation has just launched a patient information website – Breast360.org. The site was developed by breast surgeons, and patient advocates have had input and oversight during the entire process. Please take a look, and feel free to provide feedback if you have a suggestion for additional content.

 

27 December 2013

I was recently featured in the December 2013  issue of Oncology Times, in the Profiles in Social Media section. I was interviewed by Lola Butcher, and in case you are not able to access the article, I have re-posted it here. This explains how I became involved in social media and how this involvement has impacted both my professional and personal life.

Oncology Times:
doi: 10.1097/01.COT.0000441837.24257.46
Lola Butcher

Twitter Bio: Breast Surgeon, #BCSM Co-Moderator, Teacher, Advocate, Author, Organic Vegetable Gardener, and Gluten-Free
Facebook Bio: Dr. Deanna J. Attai is a breast surgeon dedicated to state-of-the-art minimally invasive care for women with benign and malignant breast disease. Areas of expertise include ultrasound, minimally invasive breast biopsy, cryoablation for benign and malignant tumors, and accelerated partial breast irradiation. Dr. Attai is actively involved in research and patient and physician education in addition to her busy clinical practice.

Deanna Attai, MD, a private-practice surgeon in Burbank, Calif., is best known in the social media world for her leadership in the Breast Cancer Social Media community, including her role as co-moderator of the BCSM TweetChat every Monday evening. She is featured in 25-and-counting videos on her YouTube channel. She blogs regularly about breast cancer topics on her website; shares personal reflections on her wellness blog; and promotes breast cancer awareness and knowledge on her Facebook page.

Like many physicians, she initially was dubious about the benefits of social media and waded in only to support a professional organization. A lot has changed since then.

“If you had told me a few years ago that not only would I be on Twitter, but I would be driving an hour and a half to the funeral of a woman I got to know through Twitter and that I would have this huge following on social media, I would have never believed it because this is so far removed from anything I have done previously,” she said.

“But this has changed me personally, it has definitely changed me professionally, and all for the better. And I can’t imagine practicing without it at this point.”

How did you get involved in social media?
“It’s all the fault of the American Society of Breast Surgeons [ASBS]. I am chair of the communications committee, and in 2011, the staff person I work with and I thought that we might be able to use social media to increase the visibility of our organization and also offer patient education.

“I had to go before the board of directors and explain why, as an organization, we need to be involved in social media. And I can tell you, I got a lot of blank stares at that meeting.

“Before I went to the board meeting, I set up a Facebook page for my practice. And then I opened a Twitter account, and I just started following and listening. I followed a lot of cancer organizations, I followed a lot of news media organizations. I started following some professional organizations. And then, I started noticing the conversations that were going on specifically related to breast cancer among patients and advocates.

“The first time I realized that I really have a role on Twitter was one night when two women on Twitter were discussing one of their friends who had just been diagnosed with Paget’s disease. One said, ‘Her doctor told her she needs a mastectomy, but I also read that maybe she could get an MRI.’ And I just sort of watched these women with a little bit of horror, thinking, why are doctors not answering these questions? So I kind of butted in and said, ‘I’m a breast surgeon, can I give you any guidance?’

“And I ended up doing the same thing that I do day in and day out if a colleague or friend calls me and says, ‘My mother was just diagnosed—what do I need to do?’ I explained the usual workup for Paget’s disease and the surgical options, depending on what the MRI showed. I found out where in the country she was located, and I got on the American Society of Breast Surgeons website to find a couple of ASBrS members in the area in case she wanted a second opinion.

“I got an email from that woman about a month later, saying the patient had the MRI, the cancer was localized, she had a lumpectomy—and thanking me for my help. That was when I realized there are so many patients who are just not getting the information they need from their physician, and they are going online to look for information whether we are there or not.

“So I think it’s part of our responsibility as physicians to make sure that the information is accurate, and that people are getting the answers they need. And even if we just raise a couple of questions that they can take back to their own physicians, then we’ve done our job.”

The #bcsmchat on Twitter is the envy of every medical community that is interested in social media. What makes it so successful?
“Two breast cancer survivors who are very active on Twitter—Jody Schoger [@jodyms] and Alicia Staley [@stales]—started the breast cancer social media weekly chat in July 2011. I missed the first one, but I joined the second, and basically have participated ever since. I came on as an official co-moderator in October 2011.

“The success is due to the integrity and the vision of Jody and Alicia. When they first found each other on Twitter, they realized that no one was really talking about breast cancer in a constructive way. A lot of times the people who are online looking for information about cancer have not had a pleasant experience with their diagnosis and treatment and they need to discuss issues or problems. So Jody and Alicia sought to provide a supportive environment and evidence-based information and avoid perpetuating media hysteria and misinformation.

“The community essentially polices itself. Some people come on to the chat trying to promote their specific agenda and companies come on to promote their products, and that gets shut down very quickly.

“We are having docs join in left and right, and it’s fantastic. The patients absolutely love it because they have this whole network of specialists that are available to them, even outside of chat hours. Patients sometimes send out a tweet asking a question about a study or something they have read, and they will tag a couple of us and we all respond. It provides us a good opportunity to help empower and educate patients.

“Jody, Alicia, and I come up with weekly topics. I tend to take the lead when we are talking about medical things. For example, when we did a chat based on the American Society of Breast Surgeons’ meeting in May and the American Society of Clinical Oncology Breast Cancer Symposium in September, I basically rounded up the docs who were going to be involved, came up with the topics, and I moderated.

“If Jody is leading the discussion on a certain topic, I’ll be the one in the background, fielding the side questions or the things that may not be exactly pertinent. So we often have multiple conversations going on at once. It often takes the three of us to keep it under control.

“One week we had a topic scheduled, and two of the group members, both with end-stage metastatic disease, died that morning, within hours of each other. So, that night we spent most of the chat talking about them—the issues of death and dying, but also honoring our members.

“Jody and Alicia and I all kind of patrol the hashtag (#bcsm) during the week. People will send out tweets using the hashtag—maybe it’s someone who has written a blog post, maybe it’s somebody posting an article, sometimes it’s someone saying, ‘First day of chemo today; I’m scared.’ We call it our ‘bat signal,’ and we tell people if they have any questions or issues during the week, just send out a tweet with #BCSM and we’ll all come running.”

How has social media affected your practice?
“You don’t use social media to get patients. I don’t think anyone will come to me just because I have a good Facebook page or because I’m on Twitter. But Twitter gives me a huge network—just like it does for the patients—of specialists all across the country that I draw from, personally and professionally, for my own education and for what I can provide to my patients. And these are some of the leaders in their field. So I have access to the best and the brightest in medical oncology and surgery and other specialties.

“Also, the interactions I have with patients on Twitter have made me realize just how difficult our treatments really are for them. Of course, we see the patients who come to our offices and we ask them questions, but when we hear these women talking online, it lets us see what happens behind closed doors. It gives us a window into what really is going on with our patients and how our treatments and our words really affect them.

“This has changed the way I interact with my patients. I am much more aware that they are putting on their happy face when they come into the office. The reality is I just have to dig a little deeper to get to the issues that are concerning them.”

What is the #bcsm-LATweetup?
“There are several of us who are in southern California, and one of the #bcsm members came up with the idea that we should all get together. So maybe five or six of us met—that’s a Tweetup—and it was like we were all long-lost high school friends.

“When we scheduled the next one, another member, Donna Peach (@danceswithpens), said she wanted to come. She was a writer by trade and a dancer and such an incredibly warm and loving person that we all really gravitated towards her.

“By the time our TweetUp was scheduled, it was clear from Donna’s blog and her tweets that she was not well and probably towards the end stage. While we were sitting at the restaurant waiting for her, one of our group, Lori Marx-Rubiner (@regrounding) got a text saying Donna’s husband couldn’t find a handicap ramp—Donna was in a wheelchair by now—and they were going to turn around and go home. And Lori got up from the table, ran out, and basically stopped traffic to help get Donna out of the vehicle and wheel her up to the table. And we were all together for about an hour.

“Donna made such an impression on us that when she passed, it was like we had known her all our lives. Three of us drove down to the funeral. We had known her for only a little while, but she was a family member.”

What advice do you have for physicians who have not yet tried social media?
“When I started using Twitter, one of the first things I did was look at organizations like the American Cancer Society and check who is following them and I would start following some of those people. That led me to a few patients and advocates who seemed to have a prominent voice, and I looked to see who was following them and who they were following. And that is how I started figuring how who I need to listen to. There were many I started following initially whom I later un-followed because their voice wasn’t anything I wanted to hear.

“The best way to start is just to go in and look and listen. And you will figure out where your community or where your niche is. Or you may never say a word. You may just use it to soak in the information, and that’s perfectly fine. The whole world is open to anyone, which is incredible.

“Also, don’t be afraid as a physician in social media to humanize yourself. I put a lot of my garden stuff on my blog and on my Facebook page. I’ll get more ‘likes’ when I post vegetables from my garden than any breast cancer story that I post. And the feedback that I get, both from my patients and from the people that I haven’t met but who follow me online, is ‘Oh, my gosh, the doctor is a real person.’”