breast cancer awareness

Dedicated breast cancer experts, compassionate caregivers

At the Johns Hopkins Breast

Center, our specialists and nurse

navigators offer personalized

care that focuses on the whole

woman, while expertly

treating the disease.

DISCOVER WHAT’S POSSIBLE.

Call 443-997-1820 or visit hopkinsmedicine.org/breastcenterJohns Hopkins breast cancer services are available across the region, from Lutherville, Maryland (conveniently located off I-83) to Baltimore City and Washington, D.C.

Dear friends and colleagues,

Just about every one of us knows other women who have had or who are coping with breast cancer. Wewish for their fast recovery, offering our support and prayers, yet inwardly wondering if or when it might beus facing this dreaded disease.

Recently I was talking with a colleague and learned that she is going through post breast cancer treatment.Making sure she got her annual mammogram was a priority to her and, fortunately, the cancer was found inan early stage.

In recent years, the death rates from breast cancer have declined. That’s good news. Explanations for thereduction not only include the decrease in the use of hormone replacement therapies, but also increasededucation and awareness, extensive scientific research, medical personnel with specialized training, newequipment and instruments, and improvements in surgical and treatment options.

Johns Hopkins, the sponsor of this special insert, is on the cutting edge and is uniquely qualified to helpwomen who have been diagnosed with breast cancer. Their knowledgeable and experienced medicalprofessionals offer their expertise so that anyone who is diagnosed with breast cancer can realize their bestoutcome. And, to complement their excellent care, patients can take advantage of support programs to helpthem emotionally.

Please take a few moments to learn how they can serve you.

Christianne Rupp, Managing Editor

3912 Abel Drive • Columbia, PA 17512 717.285.1350 • www.BusinessWomanPA.com

4 Advancements in Breast Health

New drugs, treatments, and better detection strategies.

6 Retreats Help Survivors Reengage in Their Lives

Helping patients transition beyond their treatment.

7 Choices for a Lifetime

Survivor Story: Pam Vierra

8 Genetic Testing for Breast Cancer –

Is It Right For You?

Determining risk factors and making informed decisions.

10 Surgical Options for Women with Breast Cancer

Finding the right surgeon and exploring surgical options.

Inside:

A supplement to BUSINESSWoman magazine

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http://www.BusinessWomanPA.com

4 Breast Cancer Awareness – United in Hope for a Cure

There used to be a stigma associated with the wordsbreast cancer. It wasn’t talked about much, and manywomen suffered in silence as they waged a battle for theirlives. But now, thanks to years of education and awarenessefforts, the whole attitude has changed from fear toempowerment.

Still, breast cancer remains common — a quarter-millionwomen are diagnosed annually and more than 35,000women in the United States still die from it each year.

But patients are increasingly discovering that a diagnosisof breast cancer is not a death sentence. New drugs andtreatments and better detection strategies are slowlyturning the illness into a somewhat less formidable enemy.

Hitting the Target — Destroying Cancer and

Preventing Recurrence with Radiation

Radiation therapy is treatment with high-energy rays orparticles that destroy cancer cells. Radiation to the breastis often given after breast-conserving surgery to help lower

the chance that the cancer will come back in the breast ornearby lymph nodes.

Radiation may also be recommended after mastectomyin patients with positive resection margins (rim of tissuesurrounding the tumor) or when cancer is found in thelymph nodes.

“Radiation oncology is a very high-tech discipline,” saysDr. Fariba Asrari, a radiation oncologist at Johns Hopkins.“In the last 10 years, there has been amazing progress inthis field. Current technology allows us to hit the targetprecisely, providing a higher radiation dose whileminimizing exposure to normal tissues. This is correlatedin many cancers with better tumor control and lesstoxicity.”

Working as a Team to Fight for Their Patients

A radiation oncologist has a critical role in treatmentmanagement decisions, such as whether a patient is acandidate for a conservative approach, how different

Advancements in Breast HealthWritten by Leslie Feldman

Dr. Fariba Asrari and a radiation therapist with a patient.

Breast Cancer Awareness – United in Hope for a Cure 5

surgical options affect radiation recommendations and therate of side effects, and which patients benefit fromupfront chemotherapy or hormonal therapy.

“Radiation oncology is a complex process that not onlyrequires the expertise of a specializedradiation oncologist, but also a team ofradiation dosimetrists and physicists,radiation therapists, radiation safety, andradiation nursing teams,” explains Asrari,who was named a 2012 Top Doctor byCastle Connolly, Ltd.

“The entire team needs to work inharmony to properly treat a patient.Pathologists, breast radiologists, breastsurgeons, radiation oncologists, andmedical oncologists are also key to apatient’s care.”

Asrari reviews the breast imaging(mammogram, ultrasound, MRI) of herpatients with a breast radiologist. A newcase is always discussed with the breastsurgical oncology team and, if needed,with the medical oncology team.

“I believe that there is a great value to upfrontinvolvement of expert physicians in multiple disciplinesprior to making final treatment recommendations,” shesays. “The fact that the decision is not made by only onephysician provides a strong safety net. We treat a largevolume of breast cancer patients at the Green SpringStation campus of Johns Hopkins, so our entire radiationteam has a vast experience in managing and treating breastcancer patients.

“We also have a multidisciplinary breast consultativeclinic at Green Spring Station where patients can be seensimultaneously in the same clinic and at the same time bymultiple specialists. This clinic provides convenience andsaves time in getting proper recommendations and movingto the treatment phase.”

New Treatments Offer Hope

The latest radiation techniques are three-dimensionalradiation therapy, intensity-modulated radiation therapy(IMRT), stereotactic radiation therapy (SRT), andstereotactic radiosurgery (SRS), which deliver preciseradiation to the target, sparing organs and tissues around it.

These can be delivered with different equipment, such asthe linear accelerator, tomotherapy, and a type ofstereotactic radiosurgery known as CyberKnife. Protontherapy, which uses ionizing radiation to damage the DNAof the tumor cells, is also becoming more available.

Radiation delivery is being performed more frequentlywith image-guided radiation therapy (IGRT). This

technique allows visualization of the target before hitting itwith radiation.

Brachytherapy, also known as internal radiation, isanother way to deliver radiation therapy. Instead of aiming

radiation beams from outside the body,radioactive seeds or pellets are placed intothe lumpectomy bed using catheters or aballoon. Only a limited subset of breastcancer patients are proper candidates forbrachytherapy.

There are also promising new dataregarding intraoperative breast radiationtherapy. This approach is currently beinginvestigated in clinical trials.

“The best technique to use is site specificand cancer specific,” says Asrari. “There isongoing research that will provide moreinformation, but time is needed. At JohnsHopkins, we use the proven treatmentsbased on the cancer type, tumorcharacteristics, and patient performance.

“For the treatments still beingresearched, we offer investigational trials,

which provide the opportunity for our patients to get thepotential new promising treatments in a controlledenvironment, while we gather information to prove theefficacy and safety. Many of today’s research trials will beour future standard treatments.”

Possible Side Effects of Radiation

The main short-term side effects of external-beamradiation therapy are swelling, heaviness and slighttenderness in the breast, sunburn-like skin changes in thetreated area, and fatigue.

Your healthcare team may advise you to avoid exposingthe treated skin to the sun because it may make the skinchanges worse. Most skin changes get better within a fewweeks. Changes to the breast tissue usually go away in sixto 12 months, but in some cases can take longer.

Get a Consultation

According to Asrari, breast cancer patients who intendto undergo lumpectomy need to consult with a radiationoncologist. Recommendations are based on the patient’sage, tumor characteristics, and other factors. There is asubgroup of elderly patients who have the option offorgoing radiation therapy.

“The decision regarding post-mastectomy radiation iscomplex,” says Asrari. “I strongly believe that the majorityof newly diagnosed breast cancer patients benefit from anupfront radiation oncology consultation.”

Dr. Fariba Asrari, JohnsHopkins radiation oncologist


Retreats Help SurvivorsReengage in Their Lives

Written by Neil A. Grauer and Elisa Wise

With so much focus on diagnosis and treatment of breastcancer, it became clear to Lillie Shockney, administrativedirector of both the Johns Hopkins Breast Center andCancer Survivorship Programs, that there was an unfulfilledneed for helping patients transition beyond their treatment.

For more than a decade, Johns Hopkins has providedretreats for breast cancer survivors, supporting their effortsto “transform” themselves from feeling like patients togetting on with their lives, says Shockney, a nurse andUniversityDistinguished ServiceAssociate Professor ofBreast Cancer.

Each year, JohnsHopkins hosts tworetreats — one in thespring and one in thefall — calledTransforming toSurvivorship forwomen who have beendiagnosed with breastcancer, completedtreatment within thepast three years, and areseeking help toemotionally reengage intheir lives and becomepsychologically healthy again. The retreats range in lengthfrom two days and one night to three days and two nights,depending on their location and agenda.

When Shockney began receiving inquiries from womenwith stage IV metastatic breast cancer, she realized that therewas also a need for women who were not going to ever bedone with treatment and were eventually confronting theend of their lives. They too wanted help coping with whatthe future held for them and their loved ones. They alsowanted to spend time with others in the same situation.

In 2006, Shockney launched the Metastatic BreastCancer Retreat, the only one of its kind in the nation, toaddress those needs. Held twice a year at the Sisters of BonSecours retreat and conference center in Marriottsville,Md., the retreats have served many patients and theirfamilies and garnered wonderful feedback that they are

helping patients in the ways intended. The retreats are free.One retreat is for couples; the other is for women who

are not in a relationship but bring a female caregiver — amother, sister, daughter, or best friend — with them. Thetwo-and-a-half-day, two-night retreats offer participants theopportunity “to candidly speak with others in the samesituation,” says Shockney.

Some discussions are separated by gender. “I think the men-only group is one of the most powerful

things that we do,”Shockney says. “Menare thirsty to findother men in the samesituation. There is asense of relief whenthey hear a husbandsay, ‘This is how I’vebeen dealing with this:I get in my car andscream and cry andcurse.’ And they findout that all of them getin their cars andscream and cry andcurse — that they’renot alone.”

A 21-year breastcancer survivor herself

and administrator of Johns Hopkins’ Breast Center since1997, Shockney says the metastatic cancer couples retreat“is probably the most profound thing I’ve ever done. Wehave been helping other breast centers to begin to replicatethis program by providing them a resource and planningguide. More than 150 have been distributed so far. It is alsoexciting to see these retreats being offered now at JohnsHopkins for patients with other types of metastaticcancers.”

Funding for the Johns Hopkins Metastatic Breast CancerCouples Retreat has been generously provided by The SalisburyFamily Foundation since its inception in 2008. A video aboutthe retreat, filmed on location and featuring recentparticipants and Shockney, can be seen athttp://bit.ly/JHBreastCancerRetreat.

The Labyrinth is located at the Bon Secours Spiritual Center andis a contemplative path based on ancient designs to promote the

integration of spiritual, mental, and physical well-being.

http://bit.ly/JHBreastCancerRetreat


Can you rememberwhat you were doing onApril 18, 2011? Pam

Vierra remembers itwell.

“It was the day thatchanged our lives,” shesaid. “At 4 p.m., Ireceived a call notifyingme that the breast biopsyI had showed DCIScancer in my left breast.”

She had become thestatistical one in eightwomen who arediagnosed with thedisease.

“After learning asmuch as I could digestabout this diseasethrough reading andtalking to friends in themedical field, I decidedto be in control and kickbreast cancer,” Vierra says.“After speaking to a local surgeon, I went to Johns Hopkinsfor a second opinion — the start of many great decisions.”

Naturally, Vierra was frightened, but she chose to followa multidisciplinary approach offered at Johns Hopkins andmet a “whole team of people who would be involved in mymedical care.” When she met her breast reconstructionsurgeon, Michelle Manahan, MD, she recalls feeling acomforting confidence immediately upon meeting her.

“I decided she was the surgeon I wanted for my breastreconstruction procedures,” Vierra says.

Vierra chose to have a bilateral mastectomy, even thoughthe cancer was only in her left breast.

“I knew that if I had chosen any other option, I wouldbe always waiting for the other shoe to drop. I wanted thecancer out of my body, so I would have the lowest chanceof recurrence,” she says.

With her health havingbecome her No.1 concern,Vierra decided to takecharge.

“I began walking andexercising, along witheating healthy,” she says.“I selected my healthcarefacility and surgeon, andwith Dr. Manahan’sguidance, I selected theprocedures I would havefor reconstruction. I mademy choices and I neverlooked back.”

Following themastectomy, Vierra chosea delayed breastreconstruction with DIEPsurgery.

“The DIEP surgery andinitial recovery was long,but the results are trulyamazing,” she said. “This

procedure offered mereconstruction that used my own tissue and blood supplyfrom my stomach to shape new breasts. I chose this typeof reconstruction because I felt the most comfortable withthe process and the end results.”

Today, Vierra is cancer free. She gives much of thecredit for such a positive outcome to Manahan.

“She is a brilliant surgeon who is so passionate aboutwhat she does,” says Vierra. “The compassion she gave methroughout my journey was such an important source ofstrength from the beginning to the end.”

Strange as it may sound, being diagnosed with breastcancer, says Vierra, turned out to be “one of the bestthings that ever happened to me. It motivated me totake better care of my health, and being given the powerto make health decisions has made me a strongerperson.”

Choices for a LifetimeWritten by Lynda Hudzick

Survivor Story


Genetic Testing for Breast Cancer –Is It Right for You?

Written by Leslie Feldman

Do any of your family members have breast cancer?Advancements in medicine have found risk factors that canincrease your chance of developing this cancer.

Knowing your risks can help you to make better, moreinformed decisions about your health. These decisions canlead to earlier cancer detection andprevention to change your future.

What is a BRCA Mutation?

BRCA1 and BRCA2 are genesthat help prevent cancer fromdeveloping. They repair cell damageso breast cells can grow normally.But when BRCA is mutated, itcannot function normally, andbreast cancer risk increases.

Most inherited breast cancers area result of BRCA mutations, andpeople who have them are atincreased risk. However, not allpeople with the BRCA mutationwill develop breast cancer.

What Other Genes May Cause

Hereditary Breast Cancer?

Researchers now believe that atleast half of hereditary breastcancers are not linked to theBRCA1 and BRCA2 genes.

“There are still likely other breastcancer genes that haven’t been discovered yet. This is whygenetic counseling is so important,” says Lillie Shockney,RN, BS, MAS, University Distinguished AssociateProfessor of Breast Cancer and administrative director ofthe Johns Hopkins Breast Center and Cancer SurvivorshipPrograms.

“A genetics counselor reviewing the cancer pedigree of afamily for three and four generations may see a pattern thatimplies a genetic behavior for the cause of the cancers. Thegenetics counselor will likely explain that they probably dohave a gene, even though there is no way to test for it yet.”

Who Should Get Genetic Counseling?

If there is a strong family history of breast cancer —occurrences of the disease in at least three first- or second-degree relatives (mother, sisters, aunts) — genetic

counseling would be beneficial. At Johns Hopkins, the genetic

counselors are epidemiologists andgeneticists who specialize in thisarea of cancer genetics. At thistime, DNA tests through bloodwork are used to determinewhether an individual in such ahigh-risk family has a geneticmutation in the BRCA1 or BRCA2genes.

When someone with a familyhistory of breast cancer is found tohave an altered BRCA1 or BRCA2gene, the family is said to have a“known mutation.” For manypeople, knowing their test results isimportant because this informationmay help to determine futurehealthcare decisions for themselvesand their families.

David Euhus, MD, chief ofbreast surgery at Johns Hopkinsand medical director of the JohnsHopkins Breast Center, explainsthat whenever possible, genetic

testing should begin with the relative most likely to carrya mutation.

“This is usually a relative who has already developedcancer,” he says.

Shockney adds that it is also important to know thefather’s family tree of cancers.

“If a man carries a breast cancer gene,” she says, “he onlyhas a 6 percent risk of getting breast cancer. However, hischildren — 50 percent of them — will inherit this genefrom him. If he has a daughter with the gene, she has a 40to 80 percent risk of getting breast cancer.”

Lillie Shockney, RN, BS, MAS

Dr. David Euhus,Johns Hopkinsbreast surgicaloncologist


Interpreting the Test Results

Positive test results only provide information about therisk of developing breast cancer. The test cannot tell aperson whether or when cancer might develop. Both menand women who inherit an altered gene, whether or notthey develop cancer themselves, can pass the alteration onto their sons and daughters.

“If the BRCA gene test is negative, but there is nopositive test in your family, the test is classified as ‘non-informative,’ which means that it hasn’t told us anythingabout your cancer risk,” says Euhus.

If you have a non-informative result and your familyhistory is highly suggestive of an inherited predisposition tocancer, more extensive genetic testing may be required. Inthe meantime, Euhus recommends taking full advantage ofthe wide range of high-risk screening and preventionoptions available.

For those who do test positive for the BRCA1 or BRCA2gene, mammography, breast MRI, and clinical breast examscan help detect the disease. A woman who tests positive canalso consider prophylactic mastectomy or taking the drugtamoxifen, which has been found to reduce the risk ofdeveloping breast cancer by almost 50 percent in women athigh risk. Another drug, raloxifene, is also FDA approvedfor breast cancer risk reduction in high-riskpostmenopausal women.

Prophylactic Mastectomies Reduce

the Risk of Cancer

There are many difficult decisions ahead if you find outthat you are at high risk of breast cancer.

One question is whether to have prophylactic

mastectomies — surgery to remove both breasts in thehope of preventing or reducing your risk of breast cancer.Understanding your individual degree of risk can help youweigh your options for risk-reducing strategies, includingprophylactic mastectomy.

Breast reconstruction techniques have advancedtremendously in recent years, allowing preservation ofbeauty when a choice is made to undergo risk-reducingprophylactic (preventive) mastectomy. Most insurancecompanies cover prophylactic operations.

An Individual Decision

If you find out you are at high risk for breast cancer,deciding what to do can be overwhelming and timeconsuming. It’s a good idea to work with a team of healthprofessionals to get a complete evaluation of your risk andall of your options.

The Johns Hopkins Breast Center is staffed with breast-health specialists, genetic counselors, breast surgeons, andreconstructive surgeons who work together in your care.Second opinions are recommended for women consideringprophylactic mastectomy.

When to Share Information with Children

Sometimes mothers who test positive for a breast cancergene want to quickly have their children tested. However,children need to be of age to make this decision forthemselves and it is not always an easy decision tomake.

One of the discussions commonly held with apatient and the genetics team is the timing of when toshare results with children.

Work with a teamof health professionals

to get a completeevaluation of your riskand all of your options.


Most women with breast cancer have some type ofsurgery to remove a breast tumor, and their optionsinclude breast-conserving surgery and mastectomy. Breastreconstruction can be done at the same time as surgery orlater on.

Surgery is also used to check the lymph nodes under thearm for the spread of cancer through either a sentinellymph node biopsy or an axillary (armpit) lymph nodedissection.

Seeking Out

the Right Surgeon

Once you have been toldthat you have breast canceror might have breast cancer,you will be referred to asurgeon. Many physiciansperform breast cancersurgery but may notspecialize in breast cancer.

Breast surgeons have oneyear of breast surgeryfellowship training, alongwith two years of surgicaloncology fellowship trainingand one to three years offellowship training in breastsurgical oncology. Becausethey perform a high volumeof breast cancer surgeries, they tend to have better results.

Research shows that patients of breast surgeons whoperform a very large volume of breast cancer surgerieshave a higher survival rate than patients of lower-volumesurgeons performing breast cancer surgeries.

“A breast surgeon has specialized training in breast

surgical oncology and focuses on performing breast-specific procedures,” explains Melissa Camp, MD, a breastsurgeon at Johns Hopkins in Baltimore, Md. “Moreover, abreast surgeon is familiar with the multidisciplinary careof breast cancer patients and works very closely withradiologists, medical oncologists, and radiationoncologists, all of whom specialize in breast cancer.

“Treatment of breast cancer patients involves manyspecialties, and a breastsurgeon can help facilitatethe treatment process, as heor she may be the firstphysician a newly diagnosedbreast cancer patient sees.”

Many Surgical Options

for Patients

Long ago, total radicalmastectomy was the onlysurgical option. This was at atime when most breastcancers were diagnosed in anadvanced stage. Total radicalmastectomies were a verydisfiguring type of surgeryand reconstruction was notan option.

Such procedures are veryrare today. Even having a

modified radical mastectomy is becoming less commonwith earlier detection and the ability to shrink tumorsbefore surgery takes place.

Today, there are many options. The type of surgerydepends on the type of breast cancer a patient has and theextent of its growth within the breast. This will allow the

Surgical Options for Womenwith Breast Cancer

Written by Leslie Feldman


patient to choose between a breast-conserving operation(lumpectomy) or a mastectomy.

There may be factors that eliminate the possibility ofbreast-conserving surgery and require a mastectomy. Thesize of the tumor compared to the size of the breast andthe cosmetic result determines whether the patient shouldhave a lumpectomy or mastectomy.

Larger tumors may require the removal of somuch tissue that a cosmetically acceptableresult, even with newer surgicaltechniques, is not possible. Sometimeschemotherapy will be given to thepatient before surgery to shrink alarge tumor to allow for alumpectomy. The factors thatinfluence a patient’s decision mustbe made against the backgroundknowledge that she is not sacrificingsurvival rate if she chooses oneprocedure over the other.

“At Johns Hopkins, for womenundergoing mastectomy, the skin-sparingmastectomy is the most common type of surgeryperformed,” says Camp. “This procedure, which preservesthe skin during the removal of one or both breasts, allowsfor a better breast reconstruction result. Some womenundergoing mastectomy also have the option of preservingthe nipple.”

“Most women treated for breast cancer are eligible forbreast reconstruction,” says Mehran Habibi, MD, directorof breast surgery at Johns Hopkins Bayview MedicalCenter. “Oncoplastic partial mastectomies are proceduresin which we use plastic surgery principles to achieve thebest cosmetic outcome for breast reconstruction, whileobserving oncologic principles.

“For some patients undergoing mastectomy, we are able

to save the nipple. During a nipple-sparing mastectomy,the entire skin envelope of the breast and nipple and areolais preserved while the gland content is removed, andreconstruction is done after mastectomy. The nipple doesnot retain sensation, but it does give patients facingmastectomy a better cosmetic outcome. We work closely

with plastic and reconstructive surgeons to givewomen the best cosmetic results and options.”

There are many options for breastreconstruction, and not every center

offers each option. Johns Hopkinsprovides reconstruction options thatinclude breast implants or free flaps(taking tissue from other areas ofthe body). It is important todiscuss these options with yoursurgeon to decide what is best for

you.

After Surgery — Now What?

At one time, a patient had to stay in thehospital for up to one week following breast cancer

surgery. Today, time in the hospital ranges from anovernight stay to just a few days for patients havingmastectomy surgery with reconstruction.

Following surgery, patients usually come home with adrain that is removed within a week. Pain medications areprescribed as needed. And for those having lumpectomysurgery, they go home the same day, resting comfortablyin their own home environment.

Depending on each individual’s plan of care,chemotherapy, radiation therapy, biological targetedtherapy, and hormone therapy may be required followingsurgery. The type of treatment is determined by the typeof tumor and stage of the cancer.

Most women treatedfor breast cancer are

eligible for breastreconstruction.(

(Johns Hopkins breast surgical oncologists,Dr. Melissa Camp and Dr. Mehran Habibi

breast cancer awareness

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