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Constructing Care

Renovation project puts BIDMC breast cancer patients at the center of the best medicine

Tejas Mehta

give nowBeth Healey was mourning the sudden and tragic loss of her 18-year-old son, Matthew, only two months earlier when she came to Beth Israel Deaconess Medical Center in November 2009 for her regular mammogram. She had a history of six benign fibroadenomatas—solid, non-cancerous masses—so she was conscientious about her appointments. BIDMC breast surgeon Mary Jane Houlihan, M.D., and the breast imaging staff had carefully managed these benign growths in Healey’s left breast over 18 years. This time, however, it was different. The radiologist spotted something more suspicious, now in the right breast. The biopsy revealed it was breast cancer. Healey, who has received her care at BIDMC for more than 27 years, began treatment immediately and, thanks to the early detection, was cancer free a year later. “They took unbelievable care of me,” she says. “Not only was the medical care I received top notch, but I was treated with such compassion. That made such a difference in how I dealt with my breast cancer diagnosis and how my family dealt with it. They made a very difficult time a little bit easier.”

Breast cancer is the number one cancer diagnosis among the female population and can affect women of any age, young or old. “Breast cancer is seen in women ages 20 to 100,” says Houlihan, who also notes that occasionally men can develop breast cancer. “For younger women, it can happen when they are most busy raising their family, managing a career, and caring for extended family members.” As any patient wrestles with the normal fear and anxiety that accompany a breast concern ranging from benign lumps to invasive breast cancer, the BreastCare Center at BIDMC is committed to providing comprehensive, compassionate care from imaging through surgery, treatment, reconstruction, and support services. “The kindness, compassion, close follow-up, and collaboration are so much part of the culture and the fabric of care at BIDMC, especially in breast cancer,” says Michael Wertheimer, M.D., chief of breast surgery and director of the BreastCare Center.

Today, with more than 700 patients treated each year, breast cancer is one of the most prevalent cancers at BIDMC. “It has always occupied 18 to 20 percent of the cancer cases that we see,” says Lowell Schnipper, M.D., clinical director of the BIDMC Cancer Center and chief of the Division of Hematology and Oncology. “Not only because, unfortunately, it is a common disease, but also because we have always been seen as a leading organization in treating it properly.” In 2012, the BreastCare Center was awarded a three-year accreditation from the National Accreditation Program for Breast Centers (NAPBC), which has established standards of excellence for breast centers. BIDMC achieved a perfect score for all 27 standards of excellence and was the first academic medical center in Boston to earn this distinction. At the renewal visit in March 2014, the BreastCare Center again received a perfect score from the NAPBC. “It validates our high quality, our excellence, our commitment to patient-centered care,” Wertheimer says.

Building on a Foundation

Michael WertheimerIn an effort to further improve the care provided to this population of patients, the BreastCare Center will undergo an intensive facility renovation over the next two years. The BreastCare Center renovation project, which was designed with input from a diverse committee of patients and staff, will enhance coordination between the BreastCare Center’s breast surgery clinic, on the fifth floor of the Carl J. Shapiro Clinical Center, and the screening and diagnostic imaging service on the fourth floor. “We want to provide the best level of service for our patients,” says Tejas S. Mehta, M.D., M.P.H., chief of breast imaging and co-director of the BreastCare Center. “We want to make them as comfortable as they can be given the circumstances, and we want to provide the best equipment and best resources for the radiologists and the clinicians to do the job that they need to do.”

The $6.2 million project, which has been in a planning stage for the last three years, is expected to be completed in 2016. “This could not happen without philanthropy,” Wertheimer says. “The hospital has contributed a portion of the overall funds, but we need to fundraise the remaining to complete the vision of a fully integrated, patient-centered breast care program. A world-class program deserves a world-class facility.” Last fall, longtime BIDMC donor Thelma Linsey pledged the lead gift to the BreastCare Center Capital Fund to ensure the project moved forward. “That was the difference between a green light and a red light for this project,” Schnipper says. “Our success is dependent on the assistance of donors like Thelma and others who have been mighty generous in giving us the opportunity to grow.” BIDMC still needs to raise $1.6 million to complete the renovations.

At BIDMC, a multidisciplinary approach to breast cancer is nothing new. But the process and technology required for providing that top-level care has changed over the last two decades. The physical space needs to be updated to create a more convenient, private, and calming environment for patients. “I think our multidisciplinary programs in breast cancer far ante-date the advent of this new project,” Schnipper says. “But this project is designed to foster increased interchange between the departments and between the doctors who team up to care for patients.”

Currently, the imaging unit on the fourth floor of the Shapiro building is split into two physically separate areas for screening and diagnostic imaging. In the new space, Mehta hopes to combine these efforts to create a unified area where all the imaging equipment needed to care for a patient—from mammography to ultrasound to MRI—is in close proximity to one reading room which would offer easier collaboration and consultation. “This new space will allow for more cohesive flow for the patients and improve workflow for the radiologists and the technologists,” Mehta says. The renovations will also expand the space in the BreastCare Center on the fifth floor to include additional exam rooms and waiting areas. With these improvements, the project is aiming to streamline care for all patients whether they are arriving for a screening mammogram, following up on a breast concern, involved in ongoing screening due to a strong family history, or dealing with a new cancer diagnosis. “Through planning ahead and working in a collaborative fashion, the breast imagers and breast clinicians hope to develop workflow patterns that will be personalized, sensitive, and more efficient, paying attention to women’s busy lives and schedules,” Houlihan says.

Lowell SchnipperIn anticipation of the upcoming renovations, BIDMC has already made a few changes to improve the patient experience. “As we are going through the process, the bricks and mortar will take time,” Mehta says. “But there are other key elements that are important to patient care.” One of the major concerns for patients was the hospital gowns. In response, the BreastCare Center recently ordered new robes—short pink ones and long white ones to accommodate different preferences and needs. There is also a roll out for a new admission form that can be shared by radiologists and the clinical staff in both locations so that the patient only has to fill out the paperwork once.

For any patient who develops breast cancer, the goal is to optimize interactions between all members of the patient’s care team and augment the multi-disciplinary programs already in place. “Breast cancer care is interdisciplinary,” Wertheimer says. “If the clinicians don’t work together, if the systems aren’t well integrated and collaborative, the patient suffers.” The new Center will also be easier for the patient to navigate with an environment that is welcoming, comforting, and respectful of the patient’s time and privacy. “We have looked at many other breast cancer centers around the country to find the optimal way to integrate our services, eliminate duplication, and offer patients the most ideal patient experience,” Wertheimer says.

Coordinating Compassionate Care

For women, screening of a potential mass and the initial biopsy represent the beginning of a journey. “A good breast program starts with a good screening program,” Mehta says, noting that BIDMC is a Breast Imaging Center of Excellence as designated by the American College of Radiology. BIDMC and its community affiliates conduct more than 50,000 diagnostic and screening mammograms each year. For convenience, the medical center offers walk-in exams and exam times before and after work hours. One of 10 expert radiologists who are dedicated solely to breast imaging reads the images. For screening mammograms, this occurs within two to three days. If the radiologist detects an abnormality, the patient receives a phone call with detailed follow-up instructions and a quick appointment. For diagnostic mammograms, patients receive results at the initial visit, and the radiologist offers a same-day biopsy if one is needed. “If you are diagnosed with something that is frightening on a mammogram or ultrasound, the idea of being able to deal with it as soon as possible is an unbelievably wonderful gift to give to a woman,” grateful patient Healey says. “It’s a very stressful time for a woman, but it is such a huge thing to be able to be seen right away by somebody to get information, see friendly faces, and be reassured.”

Last year the BreastCare Center upgraded to the most modern imaging technology. In addition to traditional digital mammography and ultrasound, the Center is utilizing tomosynthesis, or 3-D mammography. This latest technology allows the radiologists to dissect a three-dimensional image of superimposed tissues at different angles to determine if there may be cancer or if it is just normal breast tissue. Other upgrades in equipment include the ability to do contrast enhanced subtraction mammography, which uses an intravenous dye to highlight specific areas of concern in higher risk women.

In addition to its first-rate imaging program, BIDMC has a number of systems in place to best manage breast cancer, especially for high-risk patients. The BreastCare Center program aims to identify those women with strong family histories of breast and other cancers as well as certain ethnic backgrounds that might make them more prone to the disease. Women shown to be at high risk get referred to the Cancer Risk Evaluation Program, led by Nadine Tung, M.D. This program utilizes genetic research to determine patients’ likelihood of developing breast cancer and then offers them the appropriate types of counseling and management options. “We have learned enough about cancer with BRCA mutation to know that they have specific vulnerabilities,” Schnipper says. “Dr. Tung runs clinical trials that are specifically tailored to take advantage of weakness in the cancer cell and are an important piece of the BreastCare Center.”

Mary Jane HoulihanFollowing a biopsy of a new mass or imaging abnormality, a team of clinicians collaborates to review the imaging and pathology. If cancer is diagnosed, a multidisciplinary team, which includes the breast surgeon, radiation oncologist, medical oncologist, social worker, radiologist, and breast pathologist, develops a woman’s care plan based on the imaging, pathology, and evidence-based guidelines as well as the age and current health of the patient. “We are fortunate to have a world-renowned breast pathology group and outstanding breast imagers to help the clinicians,” says Houlihan, one of four BIDMC surgeons dedicated to breast cancer care. She adds that details about the tumor at the microscopic level as well as the gene profile of a tumor help the team to better understand how an individual tumor might behave in the future.

The surgical options for the management of breast cancer range from breast conservation, with or without radiation therapy, to therapeutic mastectomy with an option for breast reconstruction. A risk-reducing mastectomy is an option for breast cancer mutation carriers, women who have a risk profile of a mutation carrier, or high-risk women with breast cancer who are undergoing a therapeutic mastectomy. Immediate or delayed breast reconstruction options are available for women undergoing mastectomies. “Breast surgery may not be as complicated as pancreatic surgery or neurosurgery from a technical standpoint, however, from a decision-making perspective, the field has become much more complex,” says Houlihan. “Helping a woman decide on her surgical choices is often not easy. Our impact on women, their families, and their relationship is quite significant.”

Currently breast conserving surgery with radiation therapy is the standard of care for most women with breast cancer and over the last three decades, the ability to preserve the breast has improved. “Based on our group’s surgical experience and outcomes data from the past 30 years, our goal is to remove the tumor and leave women with a good cosmetic result,” Houlihan says. The surgeons collaborate with the radiation oncologist regarding a recommendation for radiation therapy and the medical oncologists for medicines to help reduce the risk of a breast cancer recurrence in another part of the body.

Breast cancer mortality rates have decreased over the last two decades, and most of that comes as a result of increased use of screening. But there are still a large number of women who are unsuccessful in their treatment. “We have much unfinished business in breast cancer,” says Schnipper. “A nucleus like this gives us a real opportunity to see what works, to identify what doesn’t, and then work with our scientific collaborators to solve this problem for our patients.”

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