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Breast Cancer: Making the Right Choices for You
Features of a Breast Center
You will note that I chose to say "breast center." I guess that is my own
bias. I believe that you have a better opportunity of having a truly integrated
and comprehensive program for diagnosing and treating breast cancer if the
facility has chosen to invest in developing a "center" for breast health
and treatment of breast cancer. Tagging the word "center" onto a title though
doesn't mean it is one. There are certain features of a breast center that
you should expect to be offered as part of their program if they are in
fact truly a comprehensive breast center. I've listed some of them below
for you.
Easy access
If you have been advised to see a surgeon due to an abnormal mammogram
or lump discovered on examination you will want an appointment as soon
as possible. Until you are seen by a surgeon and answers known about your
clinical situation, your anxiety and stress level will remain high. Most
breast centers, in acknowledgment of this, will ( and should) schedule
you for an appointment within 48 hours of your call or doctor's referral.
Fear of the unknown is the worst fear of all. Even if the news you receive
is bad you can take comfort in knowing that now you can begin working
with the doctors to plan what will be the best treatment choices for you.
Patient empowerment
It is important that you be given the knowledge you need to enable you
to actively participate in decisions about your care and treatment. Some
physicians are reluctant to empower women in this way. It is a patient's
right and should be a key factor in deciding where you want to receive
your treatment.
Patient education
Not only do you need to be educated about breast cancer, the treatment
options, and what to expect each step along the way but so do important
members of your family. This requires an investment of time and resources
by the health care professionals taking care of you. You want to receive
and be educated about your treatment plans as thoroughly as possible.
You need to have easy access to someone in the breast center who you can
ask questions of and feel confident in the responses as well as comfortable
asking the question. By doing so you will come to understand what is happening
to your body and what needs to be done to get you well again. Your family
members who love you and need to support you benefit from this education
too because they worried about you. They need to understand what is happening
so they can devote their time and energy in emotionally supporting you.
Multi disciplinary case conferences
A key advantage to having a Multi disciplinary team approach is the
special expertise each health care professional offers to each patient's
unique situation. Centers who hold on a routine basis case conferences
to discuss in detail a patient's clinical condition, diagnostic findings,
and recommendations for optimal treatment are beneficial to the patient's
overall well-being and clinical outcome. This is a way to help ensure
that the patient is being given individualized attention and care by utilizing
maximum breast cancer knowledge, experience and expertise by the breast
center team.
Special mammography services
Appointments right away
If a woman is being referred by her family doctor or gynecologist for
evaluation of a suspicious lump she wants to know right away if it is
cancer. For that matter , if she finds the lump herself she doesn't want
there to be any delay in getting answers about her situation. Mammography
facilities should offer appointments for such patients immediately. Ideally
the patient would be seen the same day or at the latest the following
day. Often times radiologists are not readily available to read the films
and talk with the patient about what the mammogram showed. You want to
go to a facility that has radiologists available to read the films while
you are there and most importantly tell you what they show. Be sure to
call and ask whether they offer this type of clinical service. It is one
additional way to reduce your anxiety and speed the process along for
you to get answers and proceed with treatment if it is determined to be
cancer.
Percutaneous biopsy-- Minimally invasive stereotactic breast biopsy, core biopsy, and fine needle
biopsies
These are four types of biopsy procedures that can now to be done in
mammography if the facility has the technology and medical expertise.
This method of doing breast biopsies enables the patient to have a sample
of tissue removed without having an open biopsy requiring an incision.
Having the biopsy done this way required special equipment and devices
that not all mammography facilities currently have. It also required special
credentialling for the radiologist doing this type of procedure. Learning
about these programs and services is an additional way to judge how up
to date the facility it that you are considering going to for your care.
Inform the patient and referring physician of the findings right
away
Once you have had a biopsy you want to know the results as soon as possible.
Check to see what the "turn around time" is for pathology results. Many
facilities can tell you or your doctor the results of a biopsy within
24 hours. The sooner you know what you are dealing with the sooner you
can begin to makes plans about the best treatment options for you to pursue.
Treatment options
Clinical trials
Having the opportunity to have available to you as many treatment options
as possible is important. Hospitals who participate in clinical trials
can offer more innovative treatment options usually. In some cases these
clinical trials are very new and the medical field is still learning about
all of their benefits and value. If you are asked to participate in such
a trial you are paving the way to the development of innovative research
that will make an important impact on other women diagnosed in the future
with breast cancer. You are also being closely monitored throughout your
treatment process so that data can be collected about your experience
with the chemotherapy agents you've been given. You might also be asked
to participate in a study that already has proven to be very beneficial
for treating breast cancer and now different dosages are being tested
to determine the optimal dosage and frequency for you and other patients
treated in the future. These new discoveries not only benefit you today
but will make a big difference in how many lives we save in the future
from breast cancer.
State-of-the-art breast cancer surgery with
minimal pain and nausea free
Most surgeons would say that doing a mastectomy or lumpectomy is not
technically complicated surgery to perform. That doesn't mean however
than any general surgeon does the procedure well. It is very important
to have breast cancer surgery done by a surgeon who has chosen breast
cancer surgery to be his or her surgical specialty and who does a large
volume of breast surgeries on an annual basis. Historically, it was common
for women to experience nausea and vomiting and post-operative pain following
lumpectomy or mastectomy surgery, even those not having reconstruction
done at the same time. There are breast centers who have solved this chronic
problem and now are able to perform this type of surgery with minimal
discomfort and without the GI side effects often times accompanying general
anesthesia. It is important to ask questions related to this. The doctors
who you are considering taking care of you should have quality of care
data that describes their nausea/vomiting rate, pain management, length
of time in the hospital on average for women having breast cancer surgery
with and without reconstruction, complications that occur during or after
surgery, and satisfaction data from prior patient's experience. All important
information when choosing who you want to have take care of you. At Hopkins,
for women who have breast cancer surgery without reconstruction, the majority
of the patients feel so physically well after surgery that they choose
to go home that same day. They are visited by a home health care nurse
that evening and the next morning and are in constant contact with the
nurse practitioner in the breast center for updates. What is nice about
the option to go home is that it is the woman’s choice. She is pain free
and nausea free and able to concentrate on her emotional well-being which
should be her primary focus post-operatively.
Radiation oncology
Patients who undergo lumpectomy surgery for treatment of their breast
cancer almost always receive this form of adjuvant therapy afterwards.
Most hospitals offer radiation oncology services. If the type of treatment
that is advised for you to have includes radiation therapy you will want
to ask questions about the radiation oncology physician's experience with
treating breast cancer patients. Again, it is valuable to go to a facility
that has extensive experience with treating this specific type of cancer.
They should also have a physicist on staff who assists with this type
of treatment to help ensure that the radiation is done in the precise
location where the treatment is needed. As is the case with all your treatment,
you as a patient should be given the opportunity to participate in the
decision making about this type of treatment option. The physicians and
nurses should be forthcoming with information about how this treatment
is done, the risks and benefits of it, and how it will precisely be administered
to you.
Plastic surgery offering the latest techniques
Free flap reconstructive surgery
Most hospitals and breast centers have plastic surgeons who can perform
flap reconstruction by taking tissues from other parts of your body (
usually tummy area) and creating from it a new breast. This in the past
required the surgeon to maintain all of the vascular system (blood flow)
attached during the procedure. There are new techniques now being used
which enables the surgeon to transplant this tissue cutting the vessels
free. By using intricate microvascular surgery the plastic surgeon is
then able to reconnect the arteries and veins in their new location. The
result for the patient is less pain after surgery. There are only a few
facilities however who have a surgeon who has expertise with this type
of procedure. If you are considering having this type of reconstruction
done you may want to ask about this new method. Again, it is also important
that the plastic surgeon you choose be someone who has done a large volume
of flap and free flap reconstructive breast surgeries. Experience is a
valuable asset when you want the very best cosmetic results that can be
achieved.
Skin-sparing mastectomy
This is also a fairly new form of surgery which was developed at Hopkins
and other major cancer centers. The affected breast is hollowed out, then
the tissue from the abdominal area is used to fill the opening and created
a new breast. There are few facilities that have the surgical expertise
to perform this state of the art breast cancer surgery/ reconstruction
combination. Talk with your surgeon about it and discuss the pros and
cons of taking this approach. Again the cosmetic appearance is amazing.
When you are shown photographs of reconstructed breasts, you will be impressed
with this surgical cosmetic effect. Often the patient doesn't look like
she has had a mastectomy procedure done.
Medical oncology
Most, but not all, patients diagnosed with breast cancer need some form
of chemotherapy as part of their treatment. Again, most hospitals offer
such clinical services. You want to make sure that the medical oncologist
who is overseeing your treatment is specialized in the treatment of breast
cancer. A medical oncologist may treat a wide variety of patients with
various forms of cancer. You want to be cared for by someone who has chosen
to specialize in breast cancer treatment. Someone who treats lots of women
with this disease and has a track record for good outcomes. Ask the doctor
about how many patients he or she treats in a given year for breast cancer
and ask about the patients' experience with complications from treatment.
You want to have a board certified medical oncologist who is readily accessible
in the event you need to talk with him or her urgently while going through
treatment. Ask questions about the doctor's procedure for addressing emergent
calls as well as what type of monitoring will be done while you are undergoing
this type of adjuvant therapy. Ask about the survival statistics for breast
cancer patients treated at the facility you are considering too. All cancer
patients' data is entered into a national database giving cancer specialists
the ability to compare various treatment modalities and clinical outcomes.
Hospitals who treat large volumes of cancer patients also study their
own data and compare it to national statistics. You want to be in the
hands of a team of professionals who have a history of good outcomes.
Whenever possible seek care at a facility which can demonstrate that their
survival rate is better than the national average. (For example at Hopkins,
for women who are pre-menopausal and have positive lymph nodes, the survival
rate is 10% higher than the national average.) You will have a higher
sense of confidence and security being treated in a place which has these
types of results.
Sentinel node biopsy procedures
It was standard practice for decades to perform an axillary node dissection of the lymph nodes as a way to determine if the breast cancer has spread and may therefore have traveled on further to other organ sites like the lung, liver or bones. This type of procedure was necessary because there wasn't a way to indentify which node(s) the cancer may go to first. Today there is. Sentinel node clinical trials began in 1995 and now are considered standard of care for women having breast cancer surgery today. The surgeon uses either a special blue dye or radioactive isotope (or in some cases both) which is injected into the breast cancer tumor itself. The agent used them drains from the tumor bed to the lymphatic system. The first node to turn blue or contain the radioactive material is referred to as the sentinel node. This node and only this node is removed and tested for the presence of cancer, usually as a frozen section in real time in the OR. If it is negative for tumor cells then the remaining lymph nodes are left intact, reducing the risk of lymphedema in the future as well as preserving healthy tissue that doesn't need to be surgically disturbed. As the surgeon about his/her experience with seintinel node biopsy, recognizing that this is the preferred method of evaluating lymph node involvement today.
Genetic counseling
This is a special program for women who have a family history of breast
cancer or have other factors that make them higher risk for developing
this disease. Counseling and genetic testing requires specialists who
not only are experts in this field but also have excellent communication
skills. The choice to have counseling and especially to decide to proceed
with genetic testing is one to be taken seriously and with some caution.
Though it can sound simple to be tested there are many things to consider
before making such a choice. Physicians and nurses who have chosen to
specialize in this field have expertise with helping women make these
choices. Currently only a few facilities offer this type of program now.
It is a growing field however. If this is an area of interest to you or
your family you want to go to a facility that has many years of experience
with genetic counseling and testing for breast cancer. Ask how long their
program has existed and how many patients have been counseled and tested
during that time. This will give you some idea as to their experience
with this specialized type of service.
High risk assessment for breast cancer
Being evaluated for your risk of developing breast cancer or a family
member getting this disease may be important for you to know. There are
health care professionals who specialize in this type of screening and
evaluation. Ask the breast center where you are contemplating going for
your care if they offer this service, who performs the service, and how
many patients they screen a year. The program should be conducted by a
doctor or a nurse practitioner who specializes in breast health screening
programs.
Pathology services
Patients don't always think about this particular service but it is
a very important one. The pathologist who looks at your tissue specimen
determines what type of breast cancer you have, how fast it is growing,
whether it has spread to your lymph nodes, and provides other important
pieces of clinical information to your breast surgeon, medical oncologist,
and radiation oncologist. Accuracy and completeness is critical. It is
difficult for a layperson to assess whether the pathology services being
provided at a hospital are of good quality or not. One source for this
information is the JCAHO -- Joint Commission for Accreditating Healthcare
Organizations. They inspect hospitals on a tri-annual basis and write
up reports on their findings. Included in their inspection are their findings
for the pathology department. Though they don’t actually look at slides
and determine if they were accurately interpreted, they do look at the
processes used by pathology to determine how effectively they work. They
also review the credential files of the pathologists and other faculty
at the facility. You can see the latest results of the hospital’s inspection
by going to the JCAHO web site at www.jcaho.org
or calling 1-630-792-5800 and requesting a copy of the report. This information
became publicly accessible in 1997. There are some pathology departments
who have made errors in reading the results of a breast tissue specimen.
The worst case is when a specimen is read as benign tissue when in fact
it contains cancer cells. You may wish to consider obtaining a second
opinion about the pathology results by taking your pathology slides to
a second facility that has extensive experience also in diagnosing and
treating breast cancer. The pathologist should be considered one of the
members of the breast center team and actively participate in the case
conferences referenced earlier in this document. The information they
provide serves as the road map for determining the treatment plan options
best for your specific situation. Ask if the pathologist attends these
conferences and what role he or she plays in the actual case discussion.
Patient satisfaction surveys
There are few breast centers who perform patient satisfaction surveys
but all should. It is important to learn from patients how satisfied they
were with their care and how can the center go about improving specific
services and programs offered to make care even better than before. Conducting
surveys is time and resource intensive. Centers who have chosen to survey
their patients are sending an important message-- that the health care
professionals there care about their patients' opinions and want to hear
from them. When asking a breast center whether they conduct surveys or
not also ask what they do with the results they obtain. It is one thing
to collect the data; it is another to do something constructive with it.
Health care professionals need to take their patients' opinions seriously.
All too often a patient may complain about a specific service or aspect
of care she received and her words are not taken to heart. Seek out a
place where the philosophy of the center is to use the results of their
patient satisfaction surveys to determine what initiatives the center
will work on to improve patient care. Go to a facility that considers
the patient's opinions the most valuable-- even more valuable than the
health care professionals taking care of the patient. (A doctor may think
it is acceptable for a patient to wait 2 weeks for an appointment when
she has found a lump in her breast; the patient feels however that she
should be able to get an appointment that same week. The patient is right!)
Breast Centers who truly have the patient's best interest in mind will
demonstrate this philosophy by conducting surveys and acting on the results
in real time.
Continuity of care
As more and more health care services are converted from an inpatient
setting to an outpatient setting the need to ensure effective and efficient
continuity of care heightens. Ask the facility how they go about keeping
your primary care doctor or referring physician aware of your condition
and treatment status. Check to see how they manage to keep track of how
you are doing after you go home following surgery or chemotherapy treatments.
Ask who is responsible for coordinating your care. You need to have confidence
that you are being watched over even when you are not physically at the
hospital. Some facilities have nurse practitioners who stay in touch with
their patients via telephone once they are home. Some offer home health
nursing care after surgical treatment is done. The team of professionals
taking care of you also need to stay in close contact with one another--
that's why they are a team. Ask them how they communicate with one another
and keep each other informed about your progress and needs. You want to
be cared for by a team who stay well connected with you and with one another,
including your referring physician or doctor who functions as your family
doctor. Feeling confident that you are receiving good continuity of care
provides wonderful peace of mind to you and your family.
Urgent care needs services
When an urgent problem arises such as sickness that won't subside following
a treatment you need to have ready access to a professional who can take
care of this situation promptly. Ask what the breast center's procedures
are for handling such emergencies. Also ask how often patients in the
past have needed to utilize this special service. A breast center should
have available for its patients a professional health care provider 24
hours a day, 7 days a week to handle emergencies. In addition to this
the patients should be well informed how to access this urgent care service
and know they can confidently rely on it. You should not have to go to
an Emergency Room to have such this urgent care needs attended. If their
patient education program has been thorough and well done you and your
family will know how to take care of most crises and head them off at
the pass. (For example, taking an anti-nausea drug at a designated time
to preventing vomiting later on.) There are unforeseen circumstances however
that do arise on occasion which warrant prompt intervention by a doctor
or nurse. Knowing and understanding how urgent care needs such as this
are handled is important. Though you may never need to use it you want
to know that such a program is in place and works well.
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