Photo by Gavin Sisk, University of Washington Health Sciences Photography
Breast cancer is a complex disease, and, as many of its sufferers quickly learn, so is its diagnosis and treatment.
From the time a woman finds a suspicious lump until her treatment plan is mapped out, she may have consulted with as many as four specialists who will verify whether the lump is cancerous, surgically remove the tumor, and design chemotherapy and radiation plans to eliminate traces of malignant cells.
Multi-faceted medical care such as this provides diverse expertise but also can be a logistical burden for patients and doctors.
That's why the Breast Cancer Specialty Center at the Seattle Cancer Care Alliance takes a team approach to patient care, said Dr. Ben Anderson, a University of Washington breast surgeon. As clinical medical director of the UW Breast Care and Cancer Research Program, Anderson oversees the Alliance specialty center and the Breast Health Center at UW Medical Center-Roosevelt.
"With the level of complexity in clinical care and research today, it's not realistic for any individual to become a specialist in all areas," he said. "Only through teamwork and collaboration can we get to the next generation of treatment advances."
The Alliance clinic is known as a multi-specialty center, where a patient with a breast-cancer diagnosis undergoes an integrated team evaluation of her cancer and how it may be treated.
In an initial consult, patients are seen jointly by a breast surgeon, a medical oncologist and a radiation oncologist, all of whom specialize in breast disease, said Anderson, also an investigator in the Clinical Research Division.
Mammography, ultrasound and magnetic resonance imaging (MRI) for diagnosis and disease progression also is conducted by radiologists at the specialty center. Such consolidation of medical services in one location fosters productive collaboration between the specialists and streamlines care for patients.
"It's one thing to get a report sent to you and entirely another thing to walk down the hall and go over a case with your colleague," Anderson said. "I don't think many centers have this level of integration. Very few of them actually see patients as a team. But that's how we work in every case."
Anderson credits colleagues Drs. Roger Moe and Robert Livingston, UW breast-cancer specialists, for their early insight in the 1980s about the value of multi-disciplinary cancer care, which they helped develop at UW Medical Center.
In addition to the Breast Cancer Specialty Clinic, breast care at the Alliance and UW is offered through the Breast Health Center at UW Medical Center-Roosevelt, which provides evaluation of suspicious lumps and abnormal mammograms and refers those needing cancer care to the specialty center.
Another resource, in the outpatient facility on the Day Campus, is the Women's Cancer Genetics & Risk Reduction Clinic, directed by UW oncologist Dr. Julie Gralow. This clinic provides risk assessment and screening for women with family history of breast cancer.
Besides consults with oncologists and surgeons, women evaluated in this clinic meet with a genetic counselor and a gynecologic oncologist, since women with genetic predisposition to breast cancer also are at increased risk for ovarian cancer.
Care for high-risk individuals is a challenging - and increasingly important - part of cancer care, because psychosocial support plays as substantial a role in care as does medical treatment, Anderson said.
New imaging technologies
Another significant focus in breast-cancer research and treatment is the development of new breast imaging technologies that are used to diagnose disease and follow response to treatment.
"This is a very exciting time in imaging," said Dr. Connie Lehman, a UW radiologist and director of breast imaging at the Alliance. "We have new imaging tools beyond mammography which enhance our ability to effectively detect, diagnose, and treat patients with breast cancer."
One function of imaging is to detect and evaluate tumors early with noninvasive methods, Lehman said.
"The earlier we can detect a cancer, the better the chances for a cure," she said. "The first step is to evaluate whether a lump is cancerous. We'd like to do this without unnecessary biopsies. In an ideal world, we'd have very few biopsies of benign tumors."
Imaging also is used for patients with known cancers, Lehman said.
"Once a patient is diagnosed with breast cancer, it is important that we accurately identify the extent of disease," she said. "MRI can identify areas of malignancy that are not seen on mammography or ultrasound. This can help our surgeons and oncologists design the most appropriate treatment for the individual patient."
Lehman said that imaging also can help evaluate a patient's response to therapy.
"Some patients receive chemotherapy before surgery," she said. "We use imaging to monitor whether the tumor is getting bigger or smaller. In the past, mammography and ultrasound were our only choices.
"We are now exploring the potential advantages of MRI and nuclear medicine imaging techniques in evaluating a patient's response to chemotherapy. We hope these new methods will tell us, at a much earlier time point, whether the chemotherapy is working or not."
The primary tools used for breast imaging are mammography, ultrasound and magnetic resonance (MRI).
Although most women are screened and diagnosed with mammography and ultrasound, the group is taking part in two research studies to evaluate the utility of MRI for these purposes.
One of the studies is to assess the value of MRI as a screening tool for high-risk women, Lehman said.
"This is unlikely to be effective for all women because it's very expensive, and a useful screening tool should be fairly inexpensive," she said. "But for genetically predisposed women, this may be a useful strategy. In general, mammography serves this population least well, because these women tend to be younger and therefore have denser breast tissue, which is harder to evaluate by mammography."
The breast-imaging group at the Alliance is the first in the region to perform biopsies under MR guidance.
"When we find a lesion on MRI that is not visible on mammography or ultrasound, we need to be able to biopsy the suspicious region under MRI guidance," Lehman said. "The Alliance is the first to test a new method of vacuum-assisted breast biopsy under MRI guidance."
This instrument, developed by Johnson & Johnson, allows for more accurate sampling. While it is commonly used outside of the MRI suite (under mammographic or ultrasound guidance), until recently it has not been possible to perform this method under MRI guidance.
Private funding crucial
Lehman's work is partially supported by the Avon Foundation, which awarded $2.5 million last year to the Breast Cancer Research Program, a local multi-institutional consortium directed by Dr. Peggy Porter of the Human Biology and Public Health Sciences divisions.
A portion of the Avon award supports research to develop imaging and screening strategies and a fellowship in breast-imaging research.
Although the Alliance itself is not a research institution, Anderson and his colleagues are members of the Breast Cancer Research Program, directed by Porter, and are important collaborators in the program's goal of translational research.
A key aspect of this collaboration has been to establish a system for obtaining patient samples for a breast tissue bank, a critical resource to enable breast-cancer research to move forward, Anderson said.
Each patient treated at the Alliance and undergoing surgery is asked for her consent to donate breast tissue and blood samples for research purposes, optional procedures that do not affect their care.
While research that holds the key to improved cancer care, physicians don't lose sight of their primary roles as health-care providers. "A humanistic approach to patient care is the fundamental core of our program," Anderson said.