October 20, 2010

Dr. Laura Kruper knows the surgery she’s suggesting is a slim silver lining to an otherwise devastating diagnosis. Nevertheless, she says, when the right patients come in to her office facing breast cancer, she tells them, “We have a great option for you. …”

Kruper is a breast surgeon at City of Hope in Duarte, one of the nation’s leading cancer research centers. The surgery she occasionally suggests is oncoplastic reduction surgery, in which the surgeon removes the tumor from the affected breast, and then reduces the other, noncancerous breast to ensure a post-surgical cosmetic match.

It’s not something that all hospitals are prepared to do: “Some people don’t feel comfortable with it,” she said.

But for women with large breasts, the surgery — in addition to achieving its primary goal of removing cancer — can mean breast reduction, with its relief from a lifetime of stretch marks and back pain. And Kruper is happy to be able to offer it. She is one of hundreds of breast cancer experts in Southern California offering procedures that have not yet hit the mainstream — and oncoplastic reduction is just such a practice. With a little research, women facing a breast cancer diagnosis can find a treatment center that provides care to meet their specific needs.

To that end, Kruper said, having so many facilities in Southern California is good for patients. “It does help having different centers,” she said. “Different centers do different things — having access to [them] allows women to have choices.”

Although the choices can seem overwhelming, if you think you have breast cancer you need to consider your options for diagnosis and treatment. A good place to begin comparing providers is to see whether they meet existing standards of care.

What is the standard of care?

Dr. Larry Norton spent 20 years helping to develop the Memorial Sloan-Kettering Cancer Center in New York. The center is one of the largest and most comprehensive breast centers in the country, and Norton believes that all patients should have access to this level of care.

“What should be offered is the whole comprehensive package,” he said, from prevention to diagnosis to treatment to follow-up.

Hospitals should be equipped with screening tools, including mammography, ultrasound and genetic counseling for women with a family history of breast and ovarian cancer. For higher-risk women, including those with a known BRCA1 or BRCA2 gene mutation — which predisposes for breast, ovarian and prostate cancer and occurs disproportionately in American Jewish women — many facilities offer MRIs, which can detect abnormalities in the breast that might not show up using other screening methods.

Breast cancer treatment begins only after a tumor has been properly classified by stage — classified as I-IV, with IV being the most advanced — and type, including hormone-receptive; HER2-positive, which means that the tumor tests positive for a protein called HER2 and may be more aggressive; or triple negative, which often means that doctors don’t know the underlying cause of the cancer. Each type of tumor may indicate a different course of treatment.

Most breast cancer patients are treated with some combination of surgery, chemotherapy and radiation. In surgery, doctors often try to conserve as much of the breast as possible, and to that end, these days, lumpectomies have replaced mastectomies whenever possible.

To find out whether cancer has spread to the rest of the body, standard procedure has recently dictated testing only the first, or sentinel, lymph node that the cancer would hit once it leaves the place of origin in the breast. If the sentinel node tests positive for cancer, other lymph nodes are tested as well. If not, it’s typically considered contained.

When evaluating a hospital, it’s important to be sure that it complies with these existing standards. Additionally, a 1998 study published in the American Journal of Public Health found that breast cancer patients had a greater chance of survival if they were treated by hospitals that have performed a high number of surgeries.

Some local hospitals are also pioneering techniques that have not necessarily been adopted internationally. Many have been proven safe and effective and simply have yet to catch on, and some are still in trials. Here are some trends in local facilities:

Advances in Minimally Invasive Care

To hear surgeon Dennis Holmes discuss breast-conserving options in cancer care is to understand a driving force in the medical community — compassion. In a calm, patient voice, the young surgeon explains his personal philosophy: “My approach to breast cancer surgery is, I want to provide effective therapy by reducing the burden of treatment as well as side effects,” he said.

Holmes, who serves as the director of intraoperative radiotherapy at The University of Southern California Kenneth Norris Comprehensive Cancer Center and Hospital, is working to institute intraoperative radiation therapy, in which patients receive their entire course of radiation therapy in one dose, while still under anesthesia from surgery to remove their cancer.

To qualify for intraoperative radiation treatment, a patient must be in the early stages of the disease. But women with early-stage cancer aren’t the only patients who may benefit from advances in minimally invasive care.

“We are doing nipple-sparing mastectomy on BRCA carriers,” said Dr. Alice Chung, assistant director of the John Wayne Cancer Institute Breast Center at Saint John’s Health Center in Santa Monica, taking time out to discuss the procedure in a spare 30 minutes between meetings.

The goal of nipple-sparing mastectomy, which leaves as much of the nipple intact as possible while removing the majority of the breast tissue, is to maintain sensation in the nipple, as well as erectile ability, in women whose cancers allow it to be done safely. 

Because the technique requires a certain level of expertise, Chung said, “it’s becoming more common, but it’s not something everyone does.”

Difficult-to-Treat Tumors

It can be hard to get medical experts riled up, even when discussing major advances in their field. To that end, Dr. William Audeh, the medical director of the Samuel Oschin Cancer Center at Cedars-Sinai, is hesitant to get too excited when explaining one of the more promising cancer treatments currently being studied — the use of PARP inhibitors, which target DNA at the root of cancer.

“It seems to be promising,” he said by phone, explaining the phase II trial that he co-authored for The Lancet earlier this year.

But to call it “promising” is a bit of an understatement. PARP inhibitors have shown results that have eluded the most potent chemotherapy combinations in women with very difficult to treat tumors, such as those advanced by BRCA1 and BRCA2 mutations, or triple-negative tumors.

When used in conjunction with chemotherapy treatments — some on women who had already received up to 10 rounds of chemotherapy — PARP inhibitors tripled the tumor’s response rate.

“Tripling the response rate is something you just don’t see very often,” Audeh said.

Cedars-Sinai is now one of several international hospitals enrolling patients in a follow-up trial that will attempt to confirm the benefits of PARP inhibitors.

“We’re hoping that we’re going to find more definitely that it’s working,” Audeh said, “so that it might become available as an approved drug.”

Individualized Care and One-Stop Shopping

One of the most noticeable changes in breast cancer care over the past decade or so, says Dr. Edward Phillips, director of the Center for Minimally Invasive Surgery and director of Endoscopic Surgery for the Department of Surgery at Cedars-Sinai, is that all cancers are not treated equally.

“The real change is the individualization of breast cancer treatment,” he said. “There are a lot of individual decisions — different from your mother, girlfriend, even your sister.”

To address the continually evolving ways in which breast cancer is diagnosed, most local hospitals now examine each case with a full team of experts, including a surgeon, a radiation oncologist, a medical oncologist and a plastic surgeon.

“A coordinated approach is critically important,” Norton said. “The medical oncologists have to be connected to the surgeons” and so on.

Many centers also offer a “one-stop shop,” in which patients can visit with their entire medical team as well as social workers and psychiatrists, and in some instances, alternative health practitioners and purveyors of prostheses, wigs, scarves and clothing, such as bathing suits.

What Southern California Offers

With that in mind, some of the leading hospitals in the country are in the Southern California area.

All are up to speed with the standard. Where they tend to differ is in the goals of their leadership and the direction of their research and clinical trials. In selecting a center for care, these are the details that set one institution apart from another.

Revlon/UCLA Breast Center and Ronald Reagan UCLA Medical Center

Dr. Helena Chang, director of the Revlon/UCLA Breast Center at the Jonsson Comprehensive Cancer Center, took over her current position in 1997, following the departure of the outspoken Dr. Susan Love. By comparison, Chang is quiet and speaks quickly in scientific terms about her research and the center.

But her clinical demeanor masks a deep commitment to her patients. In a Los Angeles Times article announcing her appointment, a former patient called Chang “kind and compassionate” and mentioned that at one point following her treatment, the two spoke on the phone for half an hour.

Chang’s research, and her work at the Revlon center, has included a focus on patients with later-stage or more difficult-to-treat cancers, such as recurring cancers and triple-negative tumors, as well as biomarkers for earlier detection.

“One of the questions is, when the tumor is advanced, what is the best treatment?” Chang said. “We can always give them the chemotherapy, but not everyone responds well.”

Located on the university’s Westwood campus, the center focuses on a comprehensive approach to care. The Ronald Reagan UCLA Medical Center performed 595 breast surgeries in 2009, and the center is ranked 10th in cancer care nationally by U.S. News and World Report.

John Wayne Cancer Institute at Saint John’s Health Center

Founded in 1981, the John Wayne Cancer Institute at Saint John’s Health Center was originally affiliated with UCLA. In 1991, the institute broke away from UCLA and formed an affiliation with Saint John’s Health Center.

The center is headed by Dr. Armando Giuliano, who is internationally recognized for successfully pioneering efforts to standardize the use of sentinel lymph node biopsies. Much of his work with this procedure was published in the mid- to late 1990s, and the practice is now considered the standard of care.

The center also specializes in breast-conserving mastectomies, as well as nipple-sparing mastectomies.

Each year, John Wayne Cancer Institute — a 236-bed facility — performs approximately 150 breast cancer-related surgeries.

University of Southern California Norris Comprehensive Cancer Center and Hospital

The USC Norris Comprehensive Cancer Center and Hospital, located on the USC medical campus near Boyle Heights, is one of the few hospitals in the area designated by the National Cancer Institute (NCI) as a comprehensive cancer center, a recognition of cancer facilities for research and patient care. In addition, comprehensive cancer centers educate health-care professionals and the public, and reach out to underserved populations.

Last year, Dr. Debasish Tripathy joined Dr. Michael Press as co-leader of the Women’s Cancer Program at the university. According to a statement from the hospital, Tripathy plans to focus on “increasing the number of treatment and clinical trial options for patients; developing a clinical trials and research program that matches the needs of patients and interfaces with the areas of scientific excellence at USC; setting up community outreach programs and forums” at USC.

The hospital is home to the Harold E. and Henrietta C. Lee Breast Center. USC was unable to provide the number of breast cancer-related surgeries that it performs each year.

City of Hope

As one of the largest cancer research centers in the country, City of Hope is also designated by the NCI as a comprehensive cancer center. The facility offers a number of clinical trials, and in addition to the surgical advances made by doctors like Kruper, advances are being made in the areas of chemotherapy and radiation. 

Located about 30 minutes northeast of downtown Los Angeles, City of Hope is ranked 20th in cancer care by U.S. News and World Report.

The center is also a leader in clinical trials — the National Comprehensive Cancer Network (NCCN) reports that the national average for patient enrollment in trials is 5 percent. At City of Hope, 25 percent of patients are currently enrolled in a trial.

“At a big academic center, everybody works together as a team,” Kruper said, adding that treatment at a center such as City of Hope can be particularly productive for patients with unusual cancers, aggressive cancers or cancers that appear in very young patients.

City of Hope was unable to provide the number of breast cancer-related surgeries it performs each year.

Huntington Memorial Hospital

To stand out as a community hospital among several large, urban academic medical centers is no small feat, yet Huntington Hospital was listed by a representative from City of Hope as a leader in breast cancer care.

Located in Pasadena, the 636-bed hospital performed 2,100 breast cancer-related surgeries in 2009. The hospital offers permission to conduct surgeries to experts from local academic and research centers, including USC, City of Hope and UCLA. All breast cancer surgeries performed on site are done by surgeons affiliated with outside facilities.

To assist patients in navigating their care, Huntington has two dedicated breast cancer nurse navigators on staff who “work directly with the doctors and interface with the patients and the families to help direct their treatment,” said Maury Kulwin, the executive director of the hospital’s ambulatory and cancer services.

For patients who want to explore alternative therapies, Huntington launched a program to provide acupuncture on site in April of this year. Once a week, Dr. Paulette Saddler offers the procedure to patients to help combat the side effects of cancer therapy.

Acupuncture can “help people with the fatigue, help relieve symptoms of nausea, to manage lymphedema, [a chronic condition in which the arm swells as a result of lymph node removal] as well as joint pain from the medications and hot flashes,” Saddler said.

Cedars-Sinai Medical Center

Located east of Beverly Hills, Cedars-Sinai, with its Saul and Joyce Brandman Breast Center, is one of the largest medical facilities in the Los Angeles area, performing more than 3,000 breast-related surgeries each year, with 95 percent of those done on an outpatient basis.

The hospital has upcoming trials that will focus on risk reduction in underserved communities and, separately, molecular breast imaging for early detection.

“We’re trying to identify women at higher risk in underserved areas, and then intervene with a more robust survey” that would “assess their risk and be able to empower them to make lifestyle changes,” Phillips said.

Cedars-Sinai has also recently partnered with the Christina Applegate Foundation to provide MRIs to high-risk women. 

The program hopes to target “women under 45 who have a history of breast cancer, or who carry BRCA mutations, women who aren’t covered by insurance or have a high deductible,” said Cindy Chavira, the breast center program manager. “We look at the need and then will approve these women to assist with MRI.”

Hoag Hospital Newport Beach

Located south of Los Angeles, the Breast Care Center at Hoag Hospital Newport Beach performs approximately 1,000 breast cancer-related surgeries per year and is led by Dr. Melvin Silverstein.

Silverstein is an expert in several areas of breast cancer research, including needle biopsies, oncoplastic reduction and cancer that is contained within the milk duct.

In 2009, Silverstein published an editorial in the Journal of the American College of Surgeons titled “Where’s the Outrage?” expressing his indignation over the fact that so many breast cancers in the United States are still biopsied using open surgery rather than needles.

“Since about 80 percent of breast [tumors] are benign, it’s not a good idea” to open the breast simply for a biopsy, he said.

To that end, nearly 99 percent of breast biopsies performed at Hoag Memorial are done using a needle, as opposed to the national average of approximately 66 percent, Silverstein said. The doctor also trains fellows from USC to perform Oncoplastic reduction surgery.