The Breast Center at Montefiore Nyack: Delivering Comprehensive Cancer Care Close to Home

By Josh Garcia
Thursday, April 12, 2018

From genetic counseling to treatment and beyond, the interdisciplinary team at The Breast Center at Montefiore Nyack provides high-level services near where patients live and work.

Pre-op, pictured left to right, Robbi Kempner, MD, FACS; Cyrus Loghmanee, MD; and Lawrence Glassman, MD

For patients seeking screening for breast cancer or facing a breast cancer diagnosis, the time and effort required to travel from Rockland County to large metropolitan facilities for expert care exacerbate stress and can be an enormous logistical burden.

“I call it insult to injury,” says Robbi Kempner, MD, FACS, Medical Director of the Breast and Women’s Health Prevention Services at Montefiore Nyack and breast surgeon with Highland Medical, P.C., Breast Surgery. “However, breast cancer patients who previously needed to drive to Manhattan for comprehensive, multidisciplinary, multimodal cancer services now can receive care from experienced, highly trained clinicians here at Montefiore Nyack.”

Screenings and Genetic Counseling

Montefiore Nyack is home to a Clinical Genetics Program for patients at higher risk for breast cancer due to factors such as age, race, ethnicity or family medical history. These patients can speak with a genetic counselor to discuss those risks, as well as options for tailored screenings or preemptive measures such as prophylactic mastectomy or chemoprophylaxis.

“For those who are diagnosed with breast cancer, the Clinical Genetics Program can help them understand their risk for second breast cancer or cancer in the opposite breast,” Dr. Kempner says.

Dr. Kempner confers with her surgical patient during a pre-op appointment prior to a bilateral mastectomy and DIEP flap reconstruction.

Patients in need of breast imaging and screening services have access to 3-D mammography, ultrasounds and MRIs performed by fellowship-trained radiologists. Advanced imaging technology — especially 3-D mammography — helps to increase the detection rate of cancer, allowing for earlier treatment and improved outcomes. The enhanced detail and accuracy of 3-D mammography also reduces the need for stress-inducing callbacks for further screening.

Screenings can be paired with outpatient core needle biopsy to test any lesions found during imaging. Wait times are kept to a minimum, and patients can return quickly to their daily routine. Additionally, patients diagnosed with breast cancer can receive a PET scan on-site to determine if the cancer has metastasized.

Surgical Treatment

After a breast cancer diagnosis, staff at The Breast Center at Montefiore Nyack work with patients to determine the optimal course of treatment. For many patients, surgery is needed to remove lesions and tumors. Montefiore Nyack offers low-dose radioactive seed localization to help pinpoint nonpalpable abnormal breast tissue for removal.

During this outpatient procedure, a small seed is implanted into the breast where the lesion or tumor is located. The seed emits a low-level radioactive signal that the surgeon uses to locate abnormal tissue, which he or she removes, along with the seed, on the day of surgery. This helps preserve healthy breast tissue and is more comfortable for patients than other methods of nonpalpable lesion removal, Dr. Kempner notes.

The Breast Center at Montefiore Nyack also offers Hidden Scar surgery, which leaves patients with little to no visible reminder of their procedure. Incisions are made in areas where scars won’t be apparent once the patient has healed, explains Dr. Kempner, a certified Hidden Scar surgeon. During a lumpectomy, for example, these incisions may be around the nipple-areola complex or under the arm. Hidden Scar mastectomy that preserves the nipple is available at Montefiore Nyack as well.

The range of surgical options for breast cancer patients sets Montefiore Nyack apart, according to Dr. Kempner.

“We’re the only program in Rockland County offering low-dose radioactive seed localization,” she says. “We’re also unique in the area in offering Hidden Scar surgery.”

Prepectoral Breast Reconstruction

Patients who undergo mastectomy may be candidates for reconstructive breast surgery, utilizing implants or patients’ own tissue. Recent improvements in reconstructive breast surgery have lowered the recovery time for patients while decreasing pain, limiting complications and improving aesthetic outcomes.

Dr. Kempner finishes the bilateral mastectomy portion of the surgical procedure while Dr. Loghmanee observes prior to the start of DIEP flap reconstruction.

“For women desiring implant-based surgery, we now offer prepectoral breast reconstruction,” says Lawrence S. Glassman, MD, Assistant Clinical Professor of Plastic Surgery at Albert Einstein College of Medicine and Montefiore Medical Center. “The shape of the breast is more natural after prepectoral reconstruction, with a lower chance of the implant becoming firm.”

Unlike conventional techniques, prepectoral reconstruction places the implant on top of rather than under the chest muscle. This results in less pain for the patient and no animation deformities, which occur when the muscle flexes under the skin, causing the skin to crinkle or ripple.

“We’ve learned that women can preserve their upper-body strength when the implant is on top of the muscle,” Dr. Glassman says. “Women who are athletic or play sports will notice that their strength is like it was before surgery.”

In addition, patients who are unhappy with previous breast reconstruction due to pain, animation deformities or weakness in their muscles can undergo this procedure for improved results.

Prepectoral reconstruction can take place immediately following mastectomy during a single session of surgery.

“Patients who are on the borderline in terms of circulation or who want bigger breasts after a mastectomy may have a prepectoral expander inserted in order to safely expand the breast skin,” Dr. Glassman says. “In these cases, the expander is filled with air, which is lighter and results in less pain for the patient.”

The expander stretches the skin as circulation to the area improves, leading to better outcomes once the final implant is placed.

Demonstrated Results

Independent analysis indicates The Breast Center at Montefiore Nyack outperforms other programs, both regionally and nationally, on a wide range of accountability and quality-improvement measures. Just two examples from calculations released by the Commission on Cancer (CoC) in 2017 based on National Cancer Database numbers:

  • Montefiore Nyack had a 100 percent rate of recommending or administering tamoxifen or third-generation aromatase inhibitor no more than one year after a woman received a diagnosis of AJCC T1c or stage IB-III hormone-receptor-positive breast cancer. The average rate among all CoC-approved programs was 92 percent.
  • Among patients having at least four positive regional lymph nodes, The Breast Center at Montefiore Nyack achieved a 100 percent rate of recommending or administering radiation therapy after any mastectomy performed within a year of breast cancer diagnosis. The average for CoC-approved programs was 88 percent.

“The comprehensive nature of the care we provide at Montefiore Nyack ensures that treatments are administered quickly,” says Robbi Kempner, MD, FACS, Medical Director of the Breast and Women’s Health Prevention Services at Montefiore Nyack. “If we can ensure that patients have biopsies, screenings, surgeries and other care they need in a timely manner, they can move on to adjuvant treatments.”

DIEP Flap Reconstruction

Some patients prefer breast reconstruction that uses their own tissue, rather than implants, to reconstruct the breast. One such advanced procedure offered at The Breast Center at Montefiore Nyack is deep inferior epigastric perforator (DIEP) flap reconstruction.

“There are strict criteria for DIEP flap reconstruction, but for patients who don’t want prosthetics that may need to be changed out over time, a DIEP can be an appealing option,” says Cyrus Loghmanee, MD, plastic surgeon on staff at Montefiore Nyack. “Candidates for DIEP flap reconstruction can be determined by the plastic surgeon to assure successful outcomes: Patients cannot be morbidly obese, have had extensive abdominal surgery in the past nor be active smokers. There needs to be enough tissue in the abdomen to transfer to the breast in order to have an ideal outcome.”

During DIEP flap reconstruction, tissue from the abdomen is used to form a new breast without sacrificing abdominal muscle. Tiny blood vessels from the chest — only millimeters in diameter — are connected to the blood vessels supplying the flap from the abdomen to restore blood flow and create a new breast. This delicate procedure demands a high level of skill and knowledge.

“Microsurgical expertise is required to perform DIEP flap reconstruction,” Dr. Loghmanee says. “This usually requires an additional year of microsurgery training after plastic surgery residency in order to provide enough experience to have ideal outcomes, and the procedure should be performed extensively during practice for the surgeon to be considered an expert in the field.”

Dr. Loghmanee performs a DIEP flap reconstruction, in which tissue from the abdomen is used to form a new breast without sacrificing abdominal muscle.

Dr. Kempner works to finish the patient’s bilateral mastectomy while Dr. Loghmanee prepares for DIEP flap reconstruction.

Once the tissue is connected, the abdomen is closed in a fashion similar to that of abdominoplasty (tummy tuck). The new breast feels more natural, looks more natural, and grows or shrinks with the patient if her weight changes. As with prepectoral reconstruction, the procedure can be performed immediately following mastectomy or may be performed years later in a delayed setting.

If any abnormalities or changes in shape need to be addressed after either prepectoral reconstruction or DIEP flap reconstruction, fat grafting is an excellent option to help refine the breast reconstruction and address small asymmetries and contour irregularities.

“Fat grafting involves transferring fat from other parts of the body in small amounts using liposuction to help restore the shape and contour of the reconstructed breast at a second stage,” Dr. Loghmanee says. “We can also use fat grafting to create better symmetry or add thickness between the skin and an implant if a patient undergoes prepectoral implant-based reconstruction.”

Navigating Treatment

The Breast Center at Montefiore Nyack connects patients with a breast health navigator who serves as a single point of contact to address any questions or concerns they may have about their cancer journey.

Once patients finish the acute phase of treatment, they receive a written survivorship care plan that helps them know what to expect in terms of side effects and follow-up care. Support groups are also available for patients to draw strength, insight and encouragement from others who have survived breast cancer.

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