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Tolnitch Surgical Associates Region’s Premier Breast Specialist
T H E M A G A Z I N E F O R H E A LT H C A R E P R O F E S S I O N A L S
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On the Cover
Tolnitch Surgical Associates Region’s Premier Breast Specialist
By Heidi Ketler
“Women should be familiar with their own breasts, so when something changes they can bring it to their physician’s attention. If the primary care physician is unsure, then the physician needs to refer the patient to a breast specialist.” – Gayle A. DiLalla, M.D., F.A.C.S., a breast surgeon with Tolnitch Surgical Associates
“Today, we find patients that are a little more advanced in their disease, and they still have a good prognosis with appropriate treatment,” says Gayle A. DiLalla, M.D., F.A.C.S., a breast surgeon with Tolnitch Surgical Associates. She credits a conceptual shift over the past 10 to 15 years. “We know now that not every breast cancer is the same, and we’re able to do more to determine the biology of a tumor.”
“I just discharged a patient in her early 40s, who felt an abnormality that was not a distinct mass. She even had a normal mammogram and ultrasound. I’m just really grateful that her primary care physician, ‘A,’ listened to her, because I think it was something that many would have missed,” says Dr. DiLalla. “Since our practice is so focused on breast disease, we pursued it further.” Lisa A. Tolnitch, M.D., F.A.C.S., founder of Tolnitch Surgical Associates, is regarded as a pioneer in breast health in North Carolina. Hers was the first breast-dedicated practice
Using genetic testing on a tumor, physicians can better determine an individualized approach, instead of the same approach for everyone. For instance, Dr. DiLalla says, many patients may not need radiation. “We can delve a lot more into the patient as an individual, rather than as a big statistic.” Leading the way in breast care The physicians at Tolnitch Surgical Associates specialize in diagnosing and treating breast disease. Their heightened focus and awareness give them a greater ability to identify what is and is not breast cancer.
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The Triangle Physician
In 2009, Tolnitch Surgical became one of the first in the country to receive the Master’s of Breast Surgery certification. Studies show that patients being cared for by surgeons specializing only in breast cancer have a high survival rate, according to Tolnitch. The practice was structured from the start to allow for more prompt diagnosis, in consideration for the patient. “Having the answers as soon as possible reduces the anxiety level for the patient. “The faster the problem can be diagnosed and the patient has a plan for treatment, the more determined they are and the sooner they are off and running,” says Dr. DiLalla. “We try to eliminate the wait.” Tolnitch Surgical offers a full range of in-office breast services, from annual breast exams to minimally invasive procedures. They include digital mammography and ultrasound, and ultrasound-directed core biopsy. According to Dr. DiLalla, almost all biopsies can be performed in their office as core needle biopsies, rather than a surgical PHOTOs BY Mitch Danforth
Early detection is still the frontline defense against breast cancer, yet more women are surviving at later stages thanks, in large part, to progress in genetics.
serving the eastern half of North Carolina when it opened in 1991, with the goal of providing the highest quality of breast care in a compassionate setting.
Diana Seward, R.T., prepares for a stereotactic biopsy.
They continue to endorse the previous recommendations that women should perform monthly self breast exams and those of average breast cancer risk should have annual mammograms beginning at age 40. The consensus is the USPSTF recommendation was flawed by inappropriate representation and outdated data, among other things. Strategy for Patients at High Risk A high-risk clinic within Tolnitch Surgical Associates provides a formalized approach to good breast health. Vernita Harvey, R.N., (left) and Alice Pappas, R.N., set up for an ultrasound-guided biopsy.
procedure. Their stereotactic biopsy services are accredited by the American College of Radiology. Additionally, Drs. Tolnitch and DiLalla, along with breast surgeon Nancy J. Crowley, M.D., F.A.C.S., have extensive training and experience in all advanced breast cancer treatment modalities, including breast conservation procedures and sentinel node biopsy. They also are the most experienced practice in MammoSite five-day targeted radiation therapy (also known as accelerated partial breast irradiation), having taken the lead in piloting the MammoSite balloon approach to accelerated partial breast irradiation in the Triangle. “We have well over 200 patients to date who have completed treatment with excellent results,” says Dr. Tolnitch. Physician collaboration enhances patient care Strengthening its commitment to excellence in patient care, Tolnitch Surgical collaborates regularly with pathology, radiology and oncology colleagues for case review. “This approach allows patients to often have imaging and office visits in a coordinated and seamless fashion, with the goal of a quicker road to diagnosis and treatment,” says Dr. Crowley. Since November 2004, Wake Radiology Diagnostic Imaging physicians and staff have provided screening, and diagnostic mammography and ultrasound in an attached wing of Tolnitch Surgical Associates. Tolnitch Surgical also maintains a collaborative relationship with the Rex
Healthcare pathology group. “We feel collaboration has helped increase the understanding among, and quality of, all our specialties,” says Dr. Tolnitch. Advocates for early detection “Early detection is key to successful treatment,” says Dr. Tolnitch. “When a woman who receives regular screenings and mammograms is diagnosed with breast cancer, she has a 95 to 96 percent chance of surviving. In contrast, cancer in those who are not routinely screened is generally more advanced, dropping the survival rate to 50 to 60 percent.” “Women should be familiar with their own breasts, so when something changes they can bring it to their physician’s attention. If the primary care physician is unsure, then the physician needs to refer the patient to a breast specialist,” says Dr. DiLalla. She adds that “there are still far too many biopsies, but not in our practice. We have the experience and technology to make the best determination to reduce the risk of false positives and needless biopsies.” The physicians of Tolnitch Surgical Associates are among all those who challenge last year’s breast screening recommendations by the United States Preventive Services Task Force. They are allied with “every major organization associated with breast cancer,” says Dr. DiLalla – the American Cancer Society, the National Breast Cancer Foundation, the Association of Breast Surgeons and the American Society of Breast Disease, to name a few.
It emphasizes lifestyle modification and may include recommendations for increased screening, such as starting annual mammograms earlier than 40 or more intensive surveillance. “We try to determine the right amount of surveillance, so we can find problems earlier,” says Dr. DiLalla. “These visits take more time, because we try to cover it all,” she says. Among the risk factors discussed during the patient visit are: • Delayed childbearing or no childbearing; • Family history; • Race and age, to some degree; • Early start of menstruation for certain types of cancer; • Weight, especially around the abdomen, due to higher circulating estrogen levels; • In-vitro fertilization or hormone injections, to some degree; • Proliferative breast disease identified in previous biopsies; and • Lifestyle factors, such as smoking, diet and exercise. Some indications may be approved for the use of tamoxifen. “Traditionally, tamoxifen was used for those diagnosed with breast cancer, and now it is approved for postmenopausal women at increased risk to prevent breast cancer,” says Dr. DiLalla. If prophylactic therapy becomes an option, the physician will help the patient weigh the risks and benefits. “Hopefully, at the very least the patient will make lifestyle modifications,” says Dr. DiLalla. She calls the recent popularity of prophylactic mastectomy, particularly for women with a mutation of the BRAC1 and BRAC2 genes, “interesting,” since the trend JANUARY 2011
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Meet the Breast Specialists at Tolnitch Surgical Associates
Lorna Ethier (left) and Mary Ann Denton welcome a new patient.
has long been for breast conservation. While she believes that’s still the case, the main message is patients are more “empowered to choose, not like 30 years ago, when they were told this is your only option.” The Increasing Cost of Health Care With almost 20 percent of women in North Carolina uninsured and more than 14 percent living below the federal poverty level, there are many with breast cancer who don’t get treatment because they can’t afford it. Realizing this, Dr. Tolnitch founded the Pretty in Pink Foundation in 2004 to ensure quality care regardless of ability to pay. Her annual goal was to provide financial support for 10 uninsured or underinsured breast cancer patients in Wake County. Since its inception, however, the foundation has helped more than 700 patients throughout North Carolina pay for the surgery, chemotherapy and radiation treatment they could not otherwise afford. Pretty in Pink, which is funded through donations, serves as a client advocate. the staff of Pretty in Pink ensures the efficient use of funds by negotiating reduced fees through a network of physicians and community medical facilities, and helping to manage the care. It also serves as a clearinghouse for breast cancer resources and services for economically disadvantaged individuals and families. In April, Dr. Tolnitch won the 2010 Soroptimist Ruby Award for Women Helping Women, presented by the Raleigh Club of Soroptimist International, recognizing her work through Pretty in Pink. The Pretty in Pink Foundation is now positioned for expansion to every state to ensure no breast cancer patient is denied access to quality care and treatment, says Dr. Tolnitch. Ironically, Dr. DiLalla is concerned that health care reform is actually driving up costs, creating a larger population of underinsured. She says she has observed that “it’s actually more difficult to get things covered.” And she expects it to continue in that direction, as insurance companies restructure and Medicare cuts deepen. This will only increase the need for programs like Pretty in Pink and for physicians to serve as patient advocates. “We (Tolnitch Surgical) spend a lot of time being advocates for patients in working with insurance companies,” says Dr. DiLalla. “I anticipate that whatever the changes are, we need to do the very best for the patient based on the reality of what’s out there,” including educating them about existing patient protections. For more information on Tolnitch Surgical Associates or to schedule an appointment, call (919) 782-8200, or visit www.carolinabreastcare.com.
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The Triangle Physician
Lisa A. Tolnitch M.D., F.A.C.S., first started in practice in 1988 and founded Tolnitch Surgical Associates in 1991. It was the first practice in the area focused exclusively on the treatment of breast disease. She is a key sponsor of, and contributor to, a multidisciplinary conference to keep the specialists involved in breast care current on advances in the treatment of breast disease. Dr. Tolnitch graduated Phi Beta Kappa from the University of Kentucky and earned her medical degree from the College of Medicine at the University of Louisville. She completed her internship and residency at the University of North Carolina-Chapel Hill. Additionally, she was chief resident in 1988. Dr. Tolnitch is affiliated with the American Society of Breast Surgeons and the American Society of Breast Disease, and she is a fellow of the American College of Surgeons. She was a past board member of the American Cancer Society and was also on the steering committee for multidisciplinary breast cancer at Rex Healthcare. Dr. Tolnitch was featured on the Today show in 2009 and is regularly interviewed by regional news programs on advances and issues in the treatment of breast cancer. Nancy J. Crowley M.D., F.A.C.S., has been in the practice of surgery since 1993 and has specialized in breast surgery since 2001. She has published more than 18 peer-reviewed articles on cancer and lymph node dissection. Dr. Crowley graduated Phi Beta Kappa from the University of Wisconsin at Madison and earned her medical degree from Duke University Medical School. She completed her residency at Vanderbilt University. At Duke University, she was a research fellow, senior resident and chief resident in the Department of General Surgery. Dr. Crowley is a fellow of the American College of Surgeons, and affiliated with the American Society of Breast Surgeons, American Society of Breast Disease, Association of Women Surgeons, American Medical Association, North Carolina Medical Society and Wake County Medical Society. She was certified by the American Board of Surgery in 1994. She currently serves on the Breast Care Committee at Rex Hospital. Gayle Ackerman DiLalla, M.D., F.A.C.S, has been in practice 18 years and joined Tolnitch Surgical Associates in 2008. She earned her bachelor’s degree and medical degree from the University of Missouri in Kansas City. She completed her surgery internship and residency at the University of Florida in Jacksonville, and was chief resident in 1992. She began her career in Roanoke, Va., and served as assistant professor of surgery at the University of Virginia. Dr. DiLalla is board certified in general surgery and a fellow of the American College of Surgeons. She is a member of the American Society of Breast Surgeons, Association of Women Surgeons and the North Carolina Medical Society, and serves on the American Society of Breast Disease Advisor Editorial Board. She is a past board member of the American Cancer Society of Charlotte County, and past member of the Board of Trustees at Fawcett Memorial Hospital in Port Charlotte, Fla., and the board of directors of the Virginia Organ Procurement Association teaching hospital.