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By Lee B. Riley, MD, PhD, FACS and Carol Kachmarsky, RN, OCN, BN

“Call the doctor. You need a biopsy.”

Returning home after a long day, a woman checks the mail and reads these mammogram results. Understandably anxious, she needs to make vital health decisions, and she already feels two weeks behind. Today, more than ever, choosing a highly experienced breast care team is critical to her care and survival. Like most fields of medicine, finding a specialist makes a considerable difference in the treatment and outcomes and breast cancer is no exception. There are several steps a patient should take to help ensure that she receives the best possible care.

Nearly 200,000 women will be diagnosed with breast cancer in the United States this year, and roughly five times that number will need a breast biopsy. Even more women are at increased risk of developing breast cancer and are not aware of it. Although there are numerous books that target the breast cancer audience, none specifically address the early issues around choosing a breast surgeon and breast care team. Before Breast Cancer Surgery is a focused, easy-to-read book written in a question/answer format to rapidly arm the reader with the information she needs to ensure that she receives the best possible care.

Some life-threatening medical situations, like having a heart attack, require immediate action. The diagnosis of cancer, while associated with a strong sense of urgency, allows some time to make decisions and choices. With the rapid and complex advances in cancer care and a wide variance in outcomes by surgeons, a new patient should spend enough time to find a surgeon who has expertise in breast cancer. And yet, finding a surgeon that is up-to-date and has specialty training in cancer surgery can be difficult - particularly when a women is under duress and wants nothing more than to have the tumor removed as soon as possible. However, finding the right surgeon and breast care team can improve one’s chance of survival by as much as 35 percent, a benefit frequently larger than either radiation therapy or chemotherapy.

Choosing the right breast surgeon is just one way to improve a patient’s care. There are many steps that should occur prior to breast cancer surgery. The book provides a simple checklist at the beginning to assist patients. Some examples from this list include:

• Was your pathology reviewed by a second pathologist prior to surgery? Breast cancer provides challenging decisions for pathologists. Pathology errors are found in three to six percent of cancer cases and, while this error rate may seem small, it can make a major difference for some individuals.

• Should your tumor be analyzed for its genomic features? Testing to determine if a patient has inherited a cancer-causing gene (e.g. BRCA1 or BRCA2) is different from genomic testing of a patient’s individual tumor. Researchers and commercial enterprises now have the ability to evaluate a wide variety of genes that have been shown to predict how a specific breast cancer will behave. Using this information, several proprietary analyses can predict the chances of a recurring tumor and whether chemotherapy is indicated or not. Because some of these tests require that the tumor is preserved at the time of surgery, it is important to talk with your surgeon about this possibility before surgery.

• How will your tumor margins be evaluated? The goal of breast surgery is to remove the entire tumor. One way to evaluate this is to make sure that there is a margin of normal tissue surrounding the tumor. Breast surgeons use a variety of techniques to decrease the chance that a tumor extends all the way to the edge of the margin. Which technique is used may decrease the chance that a patient needs to return to the operating room for additional surgery.

• Should you see a genetic counselor and/or have genetic testing before surgery? There are several factors that help predict if a patient has a genetic mutation. Computer programs use basic information to estimate these chances. If a patient is considering genetic testing, it is strongly recommended that they first talk to a genetic counselor, nurse, or doctor qualified to interpret and explain these tests. Because the recommendations from a genetic counselor may change the surgery plan, it is advisable in these cases to get these opinions prior to breast cancer surgery.

Co-author Lee B. Riley, MD, PhD, FACS, is the Medical Director of Oncology and the section chief of Surgical Oncology at St. Luke’s Hospital and Health Network in Bethlehem, PA. Trained at the University of Texas in Houston, he completed a post-doctoral fellowship at the MD Anderson Cancer Center and a fellowship in surgical oncology at Fox Chase Cancer Center in Philadelphia. He served on the faculty at Fox Chase until his recruitment to his current position in 1997. Co-author Carol Kachmarsky, RN, OCN, CBCN, completed her nursing education at St. Luke’s Hospital School of Nursing and obtained certification in both oncology and breast care. For the last several years she has worked with Dr. Riley at Cancer Care Associates, focusing on breast cancer.