The NewYork-Presbyterian Lawrence Hospital Breast Program — accredited by the National Accreditation Program for Breast Centers (NAPBC) and led by NewYork-Presbyterian Medical Group Westchester (NYPMGW) physicians — integrates leading-edge screening, risk reduction and diagnostic techniques, chemotherapy, radiation therapy, and surgery with psychosocial support and survivorship initiatives that maximize post-treatment health. The result: convenient, local access to state-of-the-art, comprehensive care.
Nancy E. Mills, MD, FACP, Director of Cancer Survivorship at NYP Lawrence, convenes a meeting of the Breast Disease Management Team in the Cancer Center conference room. The Breast Disease Management Team is a multidisciplinary group that provides coordinated cancer care from prevention and screening, to cancer diagnosis, treatment, follow-up, and survivorship.
The New York State Department of Health estimates that 15,000 women in the state are diagnosed with breast cancer each year. In Westchester County, more than 850 new cases are diagnosed annually. Moreover, the county’s incidence rate — 139.9 per 100,000 women — is significantly higher than the 128.5 per 100,000 women diagnosed in the rest of New York state. Thanks to advances in screening and treatment, however, countywide trends for death rates and the diagnosis of late-stage breast cancer are on the decline.
As women diagnosed with breast cancer live longer, healthier lives, the development of comprehensive breast cancer programs that encompass not only screening and treatment, but also post-treatment wellness, has gained importance. The recent opening of the NewYork-Presbyterian Lawrence Hospital Cancer Center, created in collaboration with Columbia University Medical Center (CUMC) physicians who are members of the National Cancer Institute-Designated Herbert Irving Comprehensive Cancer Center at CUMC, has brought the most advanced team-based breast-cancer care to the hospital and the lower Westchester region. The $65 million Cancer Center offers radiation and infusion services with compassionate and coordinated care from a dedicated, multidisciplinary Breast Disease Management Team. Central to the team’s goals is a distinct focus on cancer prevention and screening, survivorship, and genetic counseling, implemented by providers who were recruited for their expertise and talent in those areas.
“Our new Cancer Center equips us to provide the complete continuum of care, in collaboration with Columbia, here in our patients’ community,” says Nancy E. Mills, MD, FACP, Director of Cancer Survivorship at NYP Lawrence, Assistant Professor of Medicine at CUMC and a medical oncologist with NYPMGW, who treats breast cancer and gynecologic malignancies. “The Cancer Center offers services from diagnosis to survivorship and wellness, all in one place, which enables patients to receive high-quality, comprehensive care near their homes and families.”
Carolyn Wasserheit, MD, Director of Breast and Gynecologic Projects and Associate Director of the Breast Disease Management Team at NYP Lawrence, discusses a patient’s care plan with Kate Gutekunst, RN, the oncology nurse navigator. Gutekunst works with the Cancer Center team to ensure coordinated communications to patients and families.
Nationally Accredited Breast Health Program
The journey to breast cancer treatment begins with breast imaging at NewYork-Presbyterian Lawrence Hospital’s Carol H. Taylor Breast Health Center, an American College of Radiology Breast Imaging Center of Excellence. The Breast Health Center offers a variety of modalities, including 3-D screening and digital diagnostic mammography, stereotactic and MRI-guided breast biopsy, breast MRI, and breast ultrasound. The Breast Health Center’s Medical Director, Lynn Chinitz, MD, Assistant Professor of Radiology at CUMC, specializes in the early detection and diagnosis of breast cancer. If Dr. Chinitz finds an abnormality on a mammogram or other screening, she coordinates with fellow team members so further evaluation and, if necessary, cancer treatment can begin immediately.
Advanced Surgical Care
When abnormalities are detected on a mammogram or other screening modality, the next step is for radiologists to refer patients to a breast surgeon for a consultation.
“All of the patients who come to my office are either worried they have cancer or have just been told they do have cancer,” says Michelle Azu, MD, FACS, Director of Breast Surgery at NYP Lawrence, Assistant Professor of Surgery at CUMC, and a fellowship-trained breast surgeon with NYPMGW who specializes in management of benign and malignant diseases of the breast. “No one is sitting in my office feeling great — there is always that worry.”
For Dr. Azu, who bases her practice on collaboration, compassion and expertise, setting patients’ minds at ease starts with team-based, complex decision-making and advanced planning. The collaboration at NYP Lawrence includes Henry J. Lee, MD, PhD, the Hospital’s new Director of Radiation Oncology and Assistant Professor of Radiation Oncology at CUMC, and the breast care multidisciplinary providers, including surgical, radiation and medical oncology, pathology, radiology, genetic testing, and cancer survivorship, as well as nurse navigators. Providers discuss each patient’s case and develop a comprehensive treatment plan at several breast tumor boards and case conferences. With the relationship with the NCI-Designated Herbert Irving Comprehensive Cancer Center at CUMC, clinicians participating in the tumor board also discuss these cases at CUMC’s weekly breast cancer case conference via video chat.
Surgery is an important component of the treatment plan. Surgical options for breast cancer treatment available at NYP Lawrence include nipple-sparing and traditional mastectomy, lumpectomy, and sentinel node biopsy.
“The question we ask is, ‘How can we maximize patient outcomes without having to perform a major operation?’” Dr. Azu says. “When it comes to breast surgery, doing less is sometimes doing more, and over the past several decades, we’ve realized we can do smaller surgeries in many cases.”
To promote satisfactory cosmesis, Dr. Azu offers oncoplastic surgery and employs breast conservation techniques when possible. For women with larger tumors who could benefit from breast-sparing surgery, Dr. Azu works closely with the breast medical oncologists to offer neoadjuvant treatments, such as chemotherapy or hormone therapy. This treatment approach helps reduce breast tumor size, decreasing the amount of tissue that needs to be removed during surgery.
Lynn Chinitz, MD, a ColumbiaDoctors radiologist, the Medical Director of the Carol H. Taylor Breast Health Center at NYP Lawrence and Assistant Professor of Radiology at Columbia University Medical Center, reviews a breast ultrasound with Michelle Azu, MD, FACS, Director of Breast Surgery at NYP Lawrence and a surgical oncologist with NewYork-Presbyterian Medical Group Westchester.
“Outcomes are of critical importance, but so is the patient experience. We want the patient experience to be one where patients leave and say, ‘This couldn’t have been better.’”
— Michelle Azu, MD, FACS, Director of Breast Surgery at NewYork-Presbyterian Lawrence Hospital
Comprehensive Support for Patients
For patients diagnosed with cancer, the shared decision-making discussion about treatment options can be overwhelming both emotionally and logistically. During this process, the patient is introduced to the cancer care coordination navigator, who can help make the experience a little easier. The coordination navigator helps facilitate consultations and obtains the patient’s medical records as needed throughout her treatment. The breast program also includes a community-based breast cancer screening navigator and a cancer screening nurse navigator, who serve as liaisons between patients and their primary care physicians, educate women about their screening options, and help schedule their screenings.
Genetic counselor Mary Kay Dabney, MS, who comes to the hospital from CUMC, also works with the breast program team to offer genetic counseling and testing for women whose histories and clinical profiles suggest that they are at increased risk for breast and other cancers. If a genetic abnormality is found, the breast cancer team’s recommendations may include chemoprevention, preventive surgery, or surveillance with breast MRI or other advanced screening modalities.
Dr. Azu checks on a patient in the hospital’s Post-Anesthesia Care Unit following breast surgery.
“The number of breast cancer treatments we can now provide or that are under investigation is amazing. From diagnosis to surgery, radiation therapy and systemic therapy, there has been much advancement in the ways we manage patients.”
— Carolyn Wasserheit, MD, Director of Breast and Gynecologic Projects and Associate director of the Breast Disease Management Team at NewYork-Presbyterian Lawrence Hospital
Enhanced, High-Quality Comprehensive Cancer Services in the Community
NewYork-Presbyterian Lawrence Hospital’s new Cancer Center, which opened Nov. 1, 2016, features an expanded outpatient Infusion Therapy Suite, as well as state-of-the-art technologies, such as a linear accelerator and PET/CT simulator. This equipment enables NYP Lawrence to offer on-site hypofractionated radiation therapy, image-guided radiation therapy and intensity-modulated radiation therapy — a huge advantage for breast cancer patients who otherwise would have to travel to other centers for treatments that are often needed daily for four to six weeks.
NewYorkPresbyterian Medical Group Westchester medical oncologists Dr. Mills and Dr. Wasserheit consult with each other in the new NYP Lawrence Hospital Cancer Center. The two trained together and have worked with and known each other for more than 30 years.
The hospital’s medical oncology services include consultations and second opinions, as well as chemotherapy, immunotherapy and hormone therapy. As with the approach to other cancers, physicians who manage breast cancer utilize targeted treatments that match the molecular signature on each patient’s tumor when identified.
“To perform genetic profiling of each patient’s tumor, we send a sample of the tumor to the hospital’s pathologists, who work in collaboration with CUMC’s pathologists, to analyze and diagnose the cancer,” says Carolyn Wasserheit, MD, Director of Breast and Gynecologic Projects and Associate Director of the Breast Disease Management Team at NYP Lawrence, Assistant Professor of Medicine at CUMC, and a medical oncologist focusing on breast and gynecologic cancers with NYPMGW. “The genomic analysis of the tumor will create a profile to see if the cancer has any targetable mutations. If mutations are present, patients may be candidates for a clinical trial, or we may be able to prescribe a therapy to which their tumor has a better chance of responding.”
An example of such targeted, biologic treatments is cyclin-dependent kinase (CDK) 4/6 inhibitors. These oral therapies, whose side effects are manageable, can be used in conjunction with other drugs and may be especially useful in patients with hormone-receptor-positive breast cancer.
Because the NYPMGW Breast Disease Management Team has access to the latest cancer clinical trials at Columbia’s NCI-Designated Herbert Irving Comprehensive Cancer Center, their eligible patients are referred there. The NYP Lawrence cancer care team facilitates the patients’ participation in clinical trials at Columbia while coordinating their continued care at NYP Lawrence.
NYP Lawrence recently opened state-of-the-art operating rooms that allow surgeons to view real-time images and other data while they operate on patients.
Prioritizing Survivorship and Return to Wellness
The NYP Lawrence Hospital Cancer Center offers a variety of supportive services to patients throughout their cancer journey, including palliative care, physical therapy and rehabilitation, and nutritional, psychosocial and spiritual counseling. Additionally, Cancer Center patients have access to the NYPMGW and ColumbiaDoctors networks, which consist of community-based primary care and specialist physicians throughout Westchester County. For example, Mona Kennedy, MD, an NYPMGW primary care physician with an additional certification in obesity medicine, is a member of the Breast Disease Management Team. Dr. Kennedy offers nutritional consultations to address weight changes that can accompany cancer treatment and survivorship.
“Some patients may have a genetic mutation that requires a personalized screening protocol. Others may have emotional issues or may not want to meet with a counselor. It’s empowering for patients to know they have options and that someone is looking out for them as individuals.”
— Nancy E. Mills, MD, FACP, Director of Cancer Survivorship at NewYork-Presbyterian Lawrence Hospital
Dr. Mills walks with Aubri Veneruso, PA. Together, Dr. Mills and Veneruso lead the effort to provide critical services to patients who survive cancer. The program includes the development of individualized survivorship care plans to address patients’ ongoing medical and emotional needs, regardless of where they may have received cancer treatment.
Since breast cancer patients comprise more than a third of all cancer survivors, the Breast Program also includes a Cancer Survivorship Clinical Program focused on managing health issues that can arise following treatment. That team includes Dr. Mills, Dr. Wasserheit and cancer survivorship expert Aubri Veneruso, PA, who was recruited from the NCI-Designated Comprehensive Cancer Center at Northwestern University.
“As soon as patients finish treatment, they receive an individualized survivorship plan,” Dr. Mills says. “A copy of the printed document is also given to the patient’s primary care physician and OB/GYN, who use it as a guide to the patient’s well woman care, including immunizations, screenings, and bone, cardiovascular, sexual, reproductive and emotional health.”
The Cancer Survivorship team also regularly collaborates with specialists outside of oncology to ensure patients’ needs are met. For example, hormonal agents, such as aromatase inhibitors often prescribed for many years, can affect bone density, so women taking these medications should have a baseline bone density screening and follow-up screenings every two years. Working with their NYPMGW endocrine colleagues, the team can prepare a treatment and monitoring plan if osteoporosis or osteopenia is found.
Heart health is also important to monitor in patients receiving therapies such as anthracyclines, which can cause cardiac toxicity. Through relationships with NYPMGW and ColumbiaDoctors cardiologists, Dr. Wasserheit is working to analyze risk factors that may put a patient at greater risk for these treatment-related outcomes, and ensure that appropriate medication is prescribed. Similar precautions are taken for patients who take trastuzumab, a chemotherapy agent typically prescribed for patients with early-stage and metastatic breast cancers. Trastuzumab has been linked to the development of congestive heart failure. The risk of trastuzumab-related cardiovascular complications is higher for women who receive the drug in conjunction with an anthracycline. NYP Lawrence patients on these medications are monitored closely and treated accordingly.
Gynecologic health and fertility concerns are addressed by the Cancer Survivorship Clinical Program in collaboration with NYPMGW and ColumbiaDoctors’ obstetricians and gynecologists, who offer a full range of women’s health care, including sexual health and reproductive services.
Dr. Azu in one of the hospital’s new operating rooms
“Chemotherapy can affect the ovaries and decrease a woman’s ability to get pregnant,” Dr. Wasserheit says. “This is an area that previously hasn’t received much attention, but women of childbearing age with breast cancer may want to have these conversations. We can refer patients to specialists for egg harvesting or other fertility preservation techniques. We will work with patients who have been on long-term hormonal therapy and wish to conceive to develop a plan.”
While cancer survivors of childbearing age may decide they need these treatments, often they also join cancer survivors of all ages in their need for emotional support, which is provided through a breast cancer survivor support group run through the Cancer Survivorship program.
“Through our program, patients get a great deal of attention,” Dr. Wasserheit says. “Our goal is to really listen to our patients and connect them with resources as necessary. Our social workers, nurse navigators and all team members are especially involved in community outreach and facilitate participation in beneficial supportive services.”
For additional information about the breast health services available at NYP Lawrence and these NYPMGW physicians, visit www.nyp.org/lawrence.