Dedicated breast cancer experts, compassionate caregivers At the Johns Hopkins Breast Center, our specialists and nurse navigators offer personalized care that focuses on the whole woman, while expertly treating the disease. DISCOVER WHAT’S POSSIBLE.
Call 443-997-1820 or visit hopkinsmedicine.org/breastcenter Johns Hopkins breast cancer services are available across the region, from Lutherville, Maryland (conveniently located off I-83) to Baltimore City and Washington, D.C.
Dear friends and colleagues, Just about every one of us knows other women who have had or who are coping with breast cancer. We wish for their fast recovery, offering our support and prayers, yet inwardly wondering if or when it might be us facing this dreaded disease. Recently I was talking with a colleague and learned that she is going through post breast cancer treatment. Making sure she got her annual mammogram was a priority to her and, fortunately, the cancer was found in an early stage. In recent years, the death rates from breast cancer have declined. That’s good news. Explanations for the reduction not only include the decrease in the use of hormone replacement therapies, but also increased education and awareness, extensive scientific research, medical personnel with specialized training, new equipment and instruments, and improvements in surgical and treatment options. Johns Hopkins, the sponsor of this special insert, is on the cutting edge and is uniquely qualified to help women who have been diagnosed with breast cancer. Their knowledgeable and experienced medical professionals offer their expertise so that anyone who is diagnosed with breast cancer can realize their best outcome. And, to complement their excellent care, patients can take advantage of support programs to help them emotionally. Please take a few moments to learn how they can serve you.
Christianne Rupp, Managing Editor
Inside: 4
Advancements in Breast Health New drugs, treatments, and better detection strategies.
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Retreats Help Survivors Reengage in Their Lives Helping patients transition beyond their treatment.
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Choices for a Lifetime Survivor Story: Pam Vierra
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Genetic Testing for Breast Cancer – Is It Right For You? Determining risk factors and making informed decisions.
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Surgical Options for Women with Breast Cancer Finding the right surgeon and exploring surgical options.
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Dr. Fariba Asrari and a radiation therapist with a patient.
Advancements in Breast Health Written by Leslie Feldman
There used to be a stigma associated with the words breast cancer. It wasn’t talked about much, and many women suffered in silence as they waged a battle for their lives. But now, thanks to years of education and awareness efforts, the whole attitude has changed from fear to empowerment. Still, breast cancer remains common — a quarter-million women are diagnosed annually and more than 35,000 women in the United States still die from it each year. But patients are increasingly discovering that a diagnosis of breast cancer is not a death sentence. New drugs and treatments and better detection strategies are slowly turning the illness into a somewhat less formidable enemy. Hitting the Target — Destroying Cancer and Preventing Recurrence with Radiation Radiation therapy is treatment with high-energy rays or particles that destroy cancer cells. Radiation to the breast is often given after breast-conserving surgery to help lower
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the chance that the cancer will come back in the breast or nearby lymph nodes. Radiation may also be recommended after mastectomy in patients with positive resection margins (rim of tissue surrounding the tumor) or when cancer is found in the lymph nodes. “Radiation oncology is a very high-tech discipline,” says Dr. Fariba Asrari, a radiation oncologist at Johns Hopkins. “In the last 10 years, there has been amazing progress in this field. Current technology allows us to hit the target precisely, providing a higher radiation dose while minimizing exposure to normal tissues. This is correlated in many cancers with better tumor control and less toxicity.” Working as a Team to Fight for Their Patients A radiation oncologist has a critical role in treatment management decisions, such as whether a patient is a candidate for a conservative approach, how different
technique allows visualization of the target before hitting it surgical options affect radiation recommendations and the with radiation. rate of side effects, and which patients benefit from Brachytherapy, also known as internal radiation, is upfront chemotherapy or hormonal therapy. another way to deliver radiation therapy. Instead of aiming “Radiation oncology is a complex process that not only radiation beams from outside the body, requires the expertise of a specialized radioactive seeds or pellets are placed into radiation oncologist, but also a team of the lumpectomy bed using catheters or a radiation dosimetrists and physicists, balloon. Only a limited subset of breast radiation therapists, radiation safety, and cancer patients are proper candidates for radiation nursing teams,” explains Asrari, brachytherapy. who was named a 2012 Top Doctor by There are also promising new data Castle Connolly, Ltd. regarding intraoperative breast radiation “The entire team needs to work in therapy. This approach is currently being harmony to properly treat a patient. investigated in clinical trials. Pathologists, breast radiologists, breast “The best technique to use is site specific surgeons, radiation oncologists, and and cancer specific,” says Asrari. “There is medical oncologists are also key to a ongoing research that will provide more patient’s care.” information, but time is needed. At Johns Asrari reviews the breast imaging Hopkins, we use the proven treatments (mammogram, ultrasound, MRI) of her based on the cancer type, tumor patients with a breast radiologist. A new characteristics, and patient performance. case is always discussed with the breast Dr. Fariba Asrari, Johns “For the treatments still being surgical oncology team and, if needed, Hopkins radiation oncologist researched, we offer investigational trials, with the medical oncology team. which provide the opportunity for our patients to get the “I believe that there is a great value to upfront potential new promising treatments in a controlled involvement of expert physicians in multiple disciplines environment, while we gather information to prove the prior to making final treatment recommendations,” she efficacy and safety. Many of today’s research trials will be says. “The fact that the decision is not made by only one our future standard treatments.” physician provides a strong safety net. We treat a large volume of breast cancer patients at the Green Spring Station campus of Johns Hopkins, so our entire radiation Possible Side Effects of Radiation team has a vast experience in managing and treating breast cancer patients. The main short-term side effects of external-beam “We also have a multidisciplinary breast consultative radiation therapy are swelling, heaviness and slight clinic at Green Spring Station where patients can be seen tenderness in the breast, sunburn-like skin changes in the simultaneously in the same clinic and at the same time by treated area, and fatigue. multiple specialists. This clinic provides convenience and Your healthcare team may advise you to avoid exposing saves time in getting proper recommendations and moving the treated skin to the sun because it may make the skin to the treatment phase.” changes worse. Most skin changes get better within a few weeks. Changes to the breast tissue usually go away in six to 12 months, but in some cases can take longer. New Treatments Offer Hope The latest radiation techniques are three-dimensional radiation therapy, intensity-modulated radiation therapy (IMRT), stereotactic radiation therapy (SRT), and stereotactic radiosurgery (SRS), which deliver precise radiation to the target, sparing organs and tissues around it. These can be delivered with different equipment, such as the linear accelerator, tomotherapy, and a type of stereotactic radiosurgery known as CyberKnife. Proton therapy, which uses ionizing radiation to damage the DNA of the tumor cells, is also becoming more available. Radiation delivery is being performed more frequently with image-guided radiation therapy (IGRT). This
Get a Consultation According to Asrari, breast cancer patients who intend to undergo lumpectomy need to consult with a radiation oncologist. Recommendations are based on the patient’s age, tumor characteristics, and other factors. There is a subgroup of elderly patients who have the option of forgoing radiation therapy. “The decision regarding post-mastectomy radiation is complex,” says Asrari. “I strongly believe that the majority of newly diagnosed breast cancer patients benefit from an upfront radiation oncology consultation.”
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Retreats Help Survivors Reengage in Their Lives Written by Neil A. Grauer and Elisa Wise
With so much focus on diagnosis and treatment of breast helping patients in the ways intended. The retreats are free. One retreat is for couples; the other is for women who cancer, it became clear to Lillie Shockney, administrative are not in a relationship but bring a female caregiver — a director of both the Johns Hopkins Breast Center and Cancer Survivorship Programs, that there was an unfulfilled mother, sister, daughter, or best friend — with them. The two-and-a-half-day, two-night retreats offer participants the need for helping patients transition beyond their treatment. opportunity “to candidly speak with others in the same For more than a decade, Johns Hopkins has provided situation,” says Shockney. retreats for breast cancer survivors, supporting their efforts Some discussions are separated by gender. to “transform” themselves from feeling like patients to “I think the men-only group is one of the most powerful getting on with their lives, says Shockney, a nurse and things that we do,” University Shockney says. “Men Distinguished Service are thirsty to find Associate Professor of other men in the same Breast Cancer. situation. There is a Each year, Johns sense of relief when Hopkins hosts two they hear a husband retreats — one in the say, ‘This is how I’ve spring and one in the been dealing with this: fall — called I get in my car and Transforming to scream and cry and Survivorship for curse.’ And they find women who have been out that all of them get diagnosed with breast in their cars and cancer, completed scream and cry and treatment within the The Labyrinth is located at the Bon Secours Spiritual Center and curse — that they’re past three years, and are is a contemplative path based on ancient designs to promote the not alone.” seeking help to integration of spiritual, mental, and physical well-being. A 21-year breast emotionally reengage in cancer survivor herself their lives and become and administrator of Johns Hopkins’ Breast Center since psychologically healthy again. The retreats range in length 1997, Shockney says the metastatic cancer couples retreat from two days and one night to three days and two nights, “is probably the most profound thing I’ve ever done. We depending on their location and agenda. have been helping other breast centers to begin to replicate When Shockney began receiving inquiries from women with stage IV metastatic breast cancer, she realized that there this program by providing them a resource and planning guide. More than 150 have been distributed so far. It is also was also a need for women who were not going to ever be exciting to see these retreats being offered now at Johns done with treatment and were eventually confronting the Hopkins for patients with other types of metastatic end of their lives. They too wanted help coping with what cancers.” the future held for them and their loved ones. They also wanted to spend time with others in the same situation. In 2006, Shockney launched the Metastatic Breast Funding for the Johns Hopkins Metastatic Breast Cancer Cancer Retreat, the only one of its kind in the nation, to Couples Retreat has been generously provided by The Salisbury address those needs. Held twice a year at the Sisters of Bon Family Foundation since its inception in 2008. A video about Secours retreat and conference center in Marriottsville, the retreat, filmed on location and featuring recent Md., the retreats have served many patients and their participants and Shockney, can be seen at families and garnered wonderful feedback that they are http://bit.ly/JHBreastCancerRetreat.
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Survivor Story Choices for a Lifetime Written by Lynda Hudzick
Can you remember what you were doing on April 18, 2011? Pam Vierra remembers it well. “It was the day that changed our lives,” she said. “At 4 p.m., I received a call notifying me that the breast biopsy I had showed DCIS cancer in my left breast.” She had become the statistical one in eight women who are diagnosed with the disease. “After learning as much as I could digest about this disease through reading and talking to friends in the medical field, I decided to be in control and kick breast cancer,” Vierra says. “After speaking to a local surgeon, I went to Johns Hopkins for a second opinion — the start of many great decisions.” Naturally, Vierra was frightened, but she chose to follow a multidisciplinary approach offered at Johns Hopkins and met a “whole team of people who would be involved in my medical care.” When she met her breast reconstruction surgeon, Michelle Manahan, MD, she recalls feeling a comforting confidence immediately upon meeting her. “I decided she was the surgeon I wanted for my breast reconstruction procedures,” Vierra says. Vierra chose to have a bilateral mastectomy, even though the cancer was only in her left breast. “I knew that if I had chosen any other option, I would be always waiting for the other shoe to drop. I wanted the cancer out of my body, so I would have the lowest chance of recurrence,” she says.
With her health having become her No.1 concern, Vierra decided to take charge. “I began walking and exercising, along with eating healthy,” she says. “I selected my healthcare facility and surgeon, and with Dr. Manahan’s guidance, I selected the procedures I would have for reconstruction. I made my choices and I never looked back.” Following the mastectomy, Vierra chose a delayed breast reconstruction with DIEP surgery. “The DIEP surgery and initial recovery was long, but the results are truly amazing,” she said. “This procedure offered me reconstruction that used my own tissue and blood supply from my stomach to shape new breasts. I chose this type of reconstruction because I felt the most comfortable with the process and the end results.” Today, Vierra is cancer free. She gives much of the credit for such a positive outcome to Manahan. “She is a brilliant surgeon who is so passionate about what she does,” says Vierra. “The compassion she gave me throughout my journey was such an important source of strength from the beginning to the end.” Strange as it may sound, being diagnosed with breast cancer, says Vierra, turned out to be “one of the best things that ever happened to me. It motivated me to take better care of my health, and being given the power to make health decisions has made me a stronger person.”
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Genetic Testing for Breast Cancer – Is It Right for You? Written by Leslie Feldman
Do any of your family members have breast cancer? Advancements in medicine have found risk factors that can increase your chance of developing this cancer. Knowing your risks can help you to make better, more informed decisions about your health. These decisions can lead to earlier cancer detection and prevention to change your future.
Who Should Get Genetic Counseling?
If there is a strong family history of breast cancer — occurrences of the disease in at least three first- or seconddegree relatives (mother, sisters, aunts) — genetic counseling would be beneficial. At Johns Hopkins, the genetic counselors are epidemiologists and geneticists who specialize in this What is a BRCA Mutation? area of cancer genetics. At this BRCA1 and BRCA2 are genes time, DNA tests through blood that help prevent cancer from work are used to determine developing. They repair cell damage whether an individual in such a so breast cells can grow normally. high-risk family has a genetic But when BRCA is mutated, it mutation in the BRCA1 or BRCA2 cannot function normally, and genes. breast cancer risk increases. When someone with a family Most inherited breast cancers are Lillie Shockney, RN, BS, MAS history of breast cancer is found to a result of BRCA mutations, and have an altered BRCA1 or BRCA2 people who have them are at Dr. David Euhus, gene, the family is said to have a increased risk. However, not all Johns Hopkins “known mutation.” For many people with the BRCA mutation breast surgical people, knowing their test results is will develop breast cancer. oncologist important because this information may help to determine future What Other Genes May Cause healthcare decisions for themselves Hereditary Breast Cancer? and their families. David Euhus, MD, chief of Researchers now believe that at breast surgery at Johns Hopkins least half of hereditary breast and medical director of the Johns cancers are not linked to the Hopkins Breast Center, explains BRCA1 and BRCA2 genes. that whenever possible, genetic “There are still likely other breast testing should begin with the relative most likely to carry cancer genes that haven’t been discovered yet. This is why a mutation. genetic counseling is so important,” says Lillie Shockney, “This is usually a relative who has already developed RN, BS, MAS, University Distinguished Associate cancer,” he says. Professor of Breast Cancer and administrative director of Shockney adds that it is also important to know the the Johns Hopkins Breast Center and Cancer Survivorship father’s family tree of cancers. Programs. “If a man carries a breast cancer gene,” she says, “he only “A genetics counselor reviewing the cancer pedigree of a family for three and four generations may see a pattern that has a 6 percent risk of getting breast cancer. However, his children — 50 percent of them — will inherit this gene implies a genetic behavior for the cause of the cancers. The from him. If he has a daughter with the gene, she has a 40 genetics counselor will likely explain that they probably do to 80 percent risk of getting breast cancer.” have a gene, even though there is no way to test for it yet.”
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Work with a team of health professionals to get a complete evaluation of your risk and all of your options.
Interpreting the Test Results Positive test results only provide information about the risk of developing breast cancer. The test cannot tell a person whether or when cancer might develop. Both men and women who inherit an altered gene, whether or not they develop cancer themselves, can pass the alteration on to their sons and daughters. “If the BRCA gene test is negative, but there is no positive test in your family, the test is classified as ‘noninformative,’ which means that it hasn’t told us anything about your cancer risk,” says Euhus. If you have a non-informative result and your family history is highly suggestive of an inherited predisposition to cancer, more extensive genetic testing may be required. In the meantime, Euhus recommends taking full advantage of the wide range of high-risk screening and prevention options available. For those who do test positive for the BRCA1 or BRCA2 gene, mammography, breast MRI, and clinical breast exams can help detect the disease. A woman who tests positive can also consider prophylactic mastectomy or taking the drug tamoxifen, which has been found to reduce the risk of developing breast cancer by almost 50 percent in women at high risk. Another drug, raloxifene, is also FDA approved for breast cancer risk reduction in high-risk postmenopausal women. Prophylactic Mastectomies Reduce the Risk of Cancer There are many difficult decisions ahead if you find out that you are at high risk of breast cancer. One question is whether to have prophylactic
mastectomies — surgery to remove both breasts in the hope of preventing or reducing your risk of breast cancer. Understanding your individual degree of risk can help you weigh your options for risk-reducing strategies, including prophylactic mastectomy. Breast reconstruction techniques have advanced tremendously in recent years, allowing preservation of beauty when a choice is made to undergo risk-reducing prophylactic (preventive) mastectomy. Most insurance companies cover prophylactic operations. An Individual Decision If you find out you are at high risk for breast cancer, deciding what to do can be overwhelming and time consuming. It’s a good idea to work with a team of health professionals to get a complete evaluation of your risk and all of your options. The Johns Hopkins Breast Center is staffed with breasthealth specialists, genetic counselors, breast surgeons, and reconstructive surgeons who work together in your care. Second opinions are recommended for women considering prophylactic mastectomy. When to Share Information with Children Sometimes mothers who test positive for a breast cancer gene want to quickly have their children tested. However, children need to be of age to make this decision for themselves and it is not always an easy decision to make. One of the discussions commonly held with a patient and the genetics team is the timing of when to share results with children.
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Surgical Options for Women with Breast Cancer Written by Leslie Feldman
Most women with breast cancer have some type of surgery to remove a breast tumor, and their options include breast-conserving surgery and mastectomy. Breast reconstruction can be done at the same time as surgery or later on. Surgery is also used to check the lymph nodes under the arm for the spread of cancer through either a sentinel lymph node biopsy or an axillary (armpit) lymph node dissection. Seeking Out the Right Surgeon Once you have been told that you have breast cancer or might have breast cancer, you will be referred to a surgeon. Many physicians perform breast cancer surgery but may not specialize in breast cancer. Breast surgeons have one year of breast surgery fellowship training, along with two years of surgical oncology fellowship training and one to three years of fellowship training in breast surgical oncology. Because they perform a high volume of breast cancer surgeries, they tend to have better results. Research shows that patients of breast surgeons who perform a very large volume of breast cancer surgeries have a higher survival rate than patients of lower-volume surgeons performing breast cancer surgeries. “A breast surgeon has specialized training in breast
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surgical oncology and focuses on performing breastspecific procedures,” explains Melissa Camp, MD, a breast surgeon at Johns Hopkins in Baltimore, Md. “Moreover, a breast surgeon is familiar with the multidisciplinary care of breast cancer patients and works very closely with radiologists, medical oncologists, and radiation oncologists, all of whom specialize in breast cancer. “Treatment of breast cancer patients involves many specialties, and a breast surgeon can help facilitate the treatment process, as he or she may be the first physician a newly diagnosed breast cancer patient sees.” Many Surgical Options for Patients Long ago, total radical mastectomy was the only surgical option. This was at a time when most breast cancers were diagnosed in an advanced stage. Total radical mastectomies were a very disfiguring type of surgery and reconstruction was not an option. Such procedures are very rare today. Even having a modified radical mastectomy is becoming less common with earlier detection and the ability to shrink tumors before surgery takes place. Today, there are many options. The type of surgery depends on the type of breast cancer a patient has and the extent of its growth within the breast. This will allow the
Johns Hopkins breast surgical oncologists, Dr. Melissa Camp and Dr. Mehran Habibi
to save the nipple. During a nipple-sparing mastectomy, the entire skin envelope of the breast and nipple and areola is preserved while the gland content is removed, and reconstruction is done after mastectomy. The nipple does not retain sensation, but it does give patients facing mastectomy a better cosmetic outcome. We work closely with plastic and reconstructive surgeons to give women the best cosmetic results and options.” There are many options for breast reconstruction, and not every center offers each option. Johns Hopkins provides reconstruction options that include breast implants or free flaps (taking tissue from other areas of the body). It is important to discuss these options with your surgeon to decide what is best for you.
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patient to choose between a breast-conserving operation (lumpectomy) or a mastectomy. There may be factors that eliminate the possibility of breast-conserving surgery and require a mastectomy. The size of the tumor compared to the size of the breast and the cosmetic result determines whether the patient should have a lumpectomy or mastectomy. Larger tumors may require the removal of so much tissue that a cosmetically acceptable result, even with newer surgical techniques, is not possible. Sometimes chemotherapy will be given to the patient before surgery to shrink a large tumor to allow for a lumpectomy. The factors that influence a patient’s decision must be made against the background knowledge that she is not sacrificing survival rate if she chooses one procedure over the other. “At Johns Hopkins, for women undergoing mastectomy, the skin-sparing mastectomy is the most common type of surgery performed,” says Camp. “This procedure, which preserves the skin during the removal of one or both breasts, allows for a better breast reconstruction result. Some women undergoing mastectomy also have the option of preserving the nipple.” “Most women treated for breast cancer are eligible for breast reconstruction,” says Mehran Habibi, MD, director of breast surgery at Johns Hopkins Bayview Medical Center. “Oncoplastic partial mastectomies are procedures in which we use plastic surgery principles to achieve the best cosmetic outcome for breast reconstruction, while observing oncologic principles. “For some patients undergoing mastectomy, we are able
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Most women treated for breast cancer are eligible for breast reconstruction.
After Surgery — Now What?
At one time, a patient had to stay in the hospital for up to one week following breast cancer surgery. Today, time in the hospital ranges from an overnight stay to just a few days for patients having mastectomy surgery with reconstruction. Following surgery, patients usually come home with a drain that is removed within a week. Pain medications are prescribed as needed. And for those having lumpectomy surgery, they go home the same day, resting comfortably in their own home environment. Depending on each individual’s plan of care, chemotherapy, radiation therapy, biological targeted therapy, and hormone therapy may be required following surgery. The type of treatment is determined by the type of tumor and stage of the cancer.
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