By Lexi Gray Steacy
Discussions about breast cancer risks in the media and through various outreach groups have led to a higher public interest in accessing screening methods and technologies that identify and treat the illness. Health care providers in Northern Virginia are meeting the needs of their patients by continuing to add new and effective technologies that target the prevention and treatment of breast cancer.
3D Mammography Provides Increased Accuracy of Breast Cancer Screenings
For many women, breast cancer screening is an important part of their overall healthcare maintenance—and options for early detection continue to improve throughout the years. 3D mammography is a relatively new technology that visualizes each layer of the breast tissue, providing radiologists the ability to review certain details that are not captured by older mammography tools.
“3D mammography does three important things, including: decreasing the mammogram recall rate; increasing the positive predictive value for whether a lesion is cancerous; and decreasing the benign biopsy rate,” says Deborah Blair, M.D., chair of the Department of Radiology at Invoa Mt. Vernon and a member of the medical staff of Ultrasound Associates in Alexandria.
The improved visibility that comes with 3D mammography may be of special interest to women with dense breast tissue, according to Stephanie Akbari, M.D., medical director of the Reinsch Pierce Family Center for Breast Health at Virginia Hospital Center in Arlington, where the technology has been offered since late 2012. Traditional mammography may be unable to detect cancerous cells if a woman has dense breasts—which is what happened to Nancy Cappello, Ph.D., founder of the breast cancer awareness organization Are You Dense. Cappello was diagnosed with advanced stage breast cancer in 2004, after a decade of annual mammograms that failed to detect the illness, due in part to the density of her breasts.
Since Cappello’s story became public, Virginia and several other states have adopted laws that require radiologists to send notification to women about the density levels of their breasts. The technology is a viable add-on even for those women who do not have dense breasts, says Akbari, who adds that 3D mammography can be performed at the same time as traditional digital mammography.
While there is a slightly higher amount of radiation emitted with 3D mammography, there is a lower chance of being called back for a repeat test, which may occur more frequently with traditional digital mammography. “A decrease in recall rates with mammograms also means a decrease in the patient’s anxiety level related to their health,” says Blair. “The benefit of identifying cancer earlier and more accurately outweighs the risk of being exposed to a slightly higher amount of radiation.”
New Technology Improves Outcomes of Lumpectomies
Members of the radiation oncology team at Virginia Hospital Center (VHC) in Arlington, express an awareness of the opinion that most people would define a positive healthcare experience as one that leaves them feeling informed and aware of all available options.
When patients have access to clear and complete information about treatments, it creates a more positive and trusting healthcare environment.
VHC recently expanded its list of tools available to breast cancer patients with the addition of the Margin Probe System, which is designed to lower the need for additional surgery following a lumpectomy. Lumpectomy surgery seeks to remove only the malignant tissue from a patient’s breast, and is one of several surgical options available to breast cancer patients. After a lumpectomy is performed, samples of the excised breast tissue are examined under a microscope to determine if the edges—or margins—contain malignant cells. When malignancy is discovered, the patient must undergo additional surgery, when possible, in an attempt to remove the rest of the cancer. Despite careful planning and attention from the surgical team, a chance exists that malignant tissue will remain in the breast following the procedure. And, the prospect of additional surgery can cause considerable stress for the patient, both mentally and physically, says VHC’s Akbari.
Surgeons at VHC have recognized the benefits of the Margin Probe System for several years, since receiving an opportunity to use this tool during its clinical trial phases. When this technology received FDA approval earlier this year, VHC was able to officially integrate the Margin Probe System into its lumpectomy procedures. “We planned for a year so that we could permanently bring this technology to VHC as soon as possible. It’s important for us to have access to the most effective tools for improving patient outcomes,” Akbari says.
When a patient is informed that more surgery is needed following the initial lumpectomy, it can be traumatic for the patient. “The patient wonders why the surgeons were unable to remove all malignant tissue the first time around. We do everything we can to get it right the first time, but unless a patient undergoes a mastectomy, there is a risk that cancerous tissue remains in the breast,” Akbari adds.
Recognizing the importance of minimizing additional surgery, the team at VHC saw the Margin Probe System as useful tool that can be used in the operating room to help lower the incidence of re-excision following a lumpectomy. During the initial lumpectomy, this tool provides a way for surgeons to perform an immediate assessment of tissue that has been removed from the breast. Samples of the excised breast tissue are still sent for microscopic examination following the surgery, but the Margin Probe offers an additional assessment technique that occurs before the first surgery is finished.
“Margin Probe is a valuable tool in the operating room that can evaluate the breast tissue for malignancies during surgery and potentially eliminate the chance that a patient will need additional surgery. Lumpectomies walk a fine line between taking out too much breast tissue or not enough—and the Margin Probe helps to clarify the correct amount,” Akbari says.
Based on clinical trials on the efficacy of Margin Probe, Akbari expects this technology will dramatically decrease the need to re-excisions following a lumpectomy. In one particular study, the technology lowered the rate of additional surgery by 56 percent. “While the results from the microscope will still be the final determining factor for whether a patient needs an additional surgery, the Margin Probe provides another assessment that is better than the surgeon’s eye alone,” Akbari says.
Robert L. Hong, M.D., medical director of radiation oncology at VHC, says he is excited that his hospital is able to provide a confluence of technologies that rely on one another, each working in parallel to provide the most advanced care for breast cancer patients. Hong adds, “We are working daily to stay on top of possible developments and advances that may be viable additions to the hospital. This requires careful and deliberate consideration, and the search is constant for ways to improve cancer outcomes and quality of life for our patients.”
Sentara Northern Virginia Medical Center began offering a new technology to treat patients with early-stage breast cancer through its 2013 introduction of the Xoft Axxent Electronic Brachytherapy System. The Xoft system is used during intraoperative radiation therapy (IORT) to deliver a targeted dose of radiation directly to a malignant tumor, which minimizes radiation exposure to healthy surrounding tissue.
David Weintritt, M.D., of Sentara and the National Breast Center in Lorton, says the Xoft system “allows a full course of radiation treatment to be delivered in just one dose during the lumpectomy procedure.”
Sentara will also participate in a clinical study (“A Safety and Efficacy Study of Intra-Operative Radiation Therapy (IORT) Using the Xoft Axxent eBx System at the Time of Breast Conservation Surgery for Early-Stage Breast Cancer”) regarding the Xoft system, and is currently seeking participants. [clinicaltrials.gov]
Improved Options for Post-Surgical Complications
Physicians from the Inova Breast Care Institute were able to drastically improve quality of life for an Alexandria woman suffering from painful lymphedema—the result of lymph node removal during a previous mastectomy. In early 2013, Viola Karbo was the first patient in the Northern Virginia region to undergo a lymph node transplant, a procedure designed to provide relief from the daily discomfort of lymphedema. Healthy lymph nodes were transplanted to Karbo’s affected underarm during the seven-hour surgery in order to recreate the lymphatic flow that existed prior to her mastectomy.
The lymph node transplant was performed by A.N. Mesbahi, M.D. and Mark L. Venturi, M.D., both of the National Center for Plastic Surgery in McLean and the Inova Breast Care Institute in Falls Church. The planning period to perform the lymph node transplant included traveling to Barcelona, Spain for an international meeting on lymphedema, and then to New York City to observe a colleague perform the procedure, according to Mesbahi. Karbo was later referred to the doctors as an ideal candidate for this surgery.
In order to be considered a good candidate for lymph node transplant, says Mesbahi, an individual must have severe lymphedema that is not alleviated through other measures such as lymphatic drainage, massage and compression wraps. The individual must also otherwise be in good health. Prior to her surgery, Karbo had tried a number of methods to improve her lymphedema, without success.
“Lymphedema can really impact a person’s overall quality of life—there is discomfort, dependence on compression wraps, and it can be aesthetically disfiguring. Patients may not be able to wear jewelry like rings, bracelets or watches,” Mesbahi says. “Lymphedema doesn’t have a cure—unfortunately it’s a surgical complication that many people have to learn to live with and manage long-term.”
The ultimate measure of success for Karbo was a significantly increased quality of life that has provided improved hand mobility and less swelling, says Mesbahi. Since Karbo’s surgery was performed, the physicians have heard from a number other individuals throughout the country who are suffering from lymphedema and are interested in pursuing a lymph node transplant; additional lymph node transplants are currently being planned at Inova.
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Tags: A.N. Mesbahi, Are You Dense, Arlington, David Weintritt, Deborah Blair, Falls Church, Inova Breast Care Institute, Invoa Mt. Vernon, Lorton, Lymphedema, Margin Probe System, Mark L. Venturi, McLean, Nancy Cappello, National Breast Center, National Center for Plastic Surgery, Reinsch Pierce Family Center for Breast Health, Robert L. Hong, Sentara Northern Virginia Medical Center, Stephanie Akbari, Ultrasound Associates in Alexandria, Virginia Hospital Center, Xoft Axxent Electronic Brachytherapy System