Breast Cancer Program

INCIDENCE AND PREVALENCE

Breast cancer remains the most common cancer in women. One in eight women will be diagnosed during her lifetime according to the National Cancer Institute.

PROGRAM OVERVIEW

Hoag Family Cancer Institute, in collaboration with Hoag Women’s Health Institute, provides the full spectrum of comprehensive breast cancer care from screening to advanced imaging and diagnostics, prevention and high risk services, leading-edge treatment, and complementary supportive care. Every year over 800 new breast cancer patients seek treatment at Hoag, many of whom travel from outside of Orange County. This makes Hoag the largest provider of breast cancer care in Orange County.

Melvin J. Silverstein, M.D., F.A.C.S., is the medical director of the Hoag Breast Center and the Gross Family Foundation Endowed Chair in Oncoplastic Breast Surgery. A fellowship-trained surgical oncologist and internationally renowned breast cancer expert, Dr. Silverstein facilitates Hoag’s multidisciplinary breast cancer team of breast surgeons, breast radiologists, plastic and reconstructive surgeons, breast medical oncologists, radiation oncologists, pathologists, and genetic counselors.

DIAGNOSTICS

January Lopez, M.D., leads a team of nine specially-trained, dedicated breast radiologists who are seamlessly integrated with the overall breast cancer treatment team.

Hoag is one of the largest providers of 3D Mammography (Tomosynthesis) in the nation and offers it at all seven screening sites in Orange County. Hoag Breast Center was one of 11 beta sites that participated in a multi-center clinical trial studying digital tomosynthesis that led to its FDA approval in 2011 and was the first in California to offer it clinically, following the FDA approval. To minimize radiation exposure during tomosynthesis, Hoag uses software that reconstructs a synthetic 2D mammogram from the 3D data set.

Hoag’s program also offers breast MRI and breast ultrasound, providing complete diagnostic services when clinically appropriate. One measure of a high-quality screening program is its callback rate and at 7.2%, Hoag’s exceeds national benchmarks (10.0%) by maintaining a low rate of screening recalls. Hoag’s breast radiologists also recommend fewer false positive biopsies that do not yield cancer as evidenced by Hoag’s Positive Predictive Value of 42%, well above the national average of 23.9%.

MR brain demonstrates enhancing mass at the site of prior treatment indeterminate for recurrent cancer versus radiation necrosis while PET/MR reveals increased FDG activity within this mass confirming pr esence of recurrent cancer.

TREATMENT

Tumor Board

The multidisciplinary Breast Cancer Tumor Board brings together breast surgeons, breast radiologists, medical oncologists, radiation oncologists, plastic and reconstructive surgeons, pathologists, and nurse navigators to discuss patient cases. The Breast Cancer Tumor Board meets every Wednesday at 7:30 a.m. at the Patty & George Hoag Cancer Center in Newport Beach and via videoconferencing at Hoag Cancer Center Irvine. It is moderated by Melvin J. Silverstein, M.D., F.A.C.S.

To submit a case, contact Breast Cancer Nurse Navigator, Michelle Booth, M.S.N., F.N.P., O.C.N., at 949-764-5504 or [email protected] or Rosana Figueroa at 949-764-7044 or [email protected]

Surgery

Hoag’s Breast Cancer Program provides the full complement of breast cancer surgery including lumpectomy, mastectomy, post mastectomy reconstruction with implants or free tissue transfer, and oncoplastic breast reconstruction.

Hoag was the first hospital in Orange County to offer oncoplastic breast conservation surgery, and with over 1,000 major oncoplastic surgeries performed in the last 10 years, Hoag is a national leader in the technique. Melvin J. Silverstein, M.D., F.A.C.S., medical director of Hoag Breast Center, was one of the first surgeons to perform oncoplastic breast surgery and Nirav Savalia, M.D., director of Oncoplastic and Aesthetic Breast Surgery at Hoag has pioneered many new oncoplastic surgery techniques for immediate breast reconstruction. Oncologic tumor removal with plastic surgical reconstruction is a win-win combination; the cancerous tumor is widely excised while the appearance of the breast is simultaneously enhanced. At Hoag, breast conservation is the guiding principle when it comes to breast cancer surgery. The program’s re-excision rates for clear surgical margins with oncoplastic surgery are in the single digits, significantly lower than the national average.

Upon arriving at Hoag in 2008, Dr. Silverstein established the Hoag/USC Breast Surgical Fellowship Program; it is considered one of the top training programs in the country. 32 fellows have been trained to date, completing rotations at Hoag, USC County Hospital and USC Norris Comprehensive Cancer Center. After completing the fellowship, Hoag/USC fellows go on to lead or join breast cancer programs at top institutions including Cleveland Clinic, Johns Hopkins, Georgetown, Rush, Drexel, Virginia Mason, University of Chicago, and more.

Medical Oncology

Medical oncologists specializing in breast cancer are closely integrated with the program. Their experience in treating breast cancer patients and continuous focus on the latest scientific advances and newest systemic therapies are important distinctions of Hoag’s program. Patients seeking care at Hoag also have the benefit of a range of clinical trials, including phase I and II trials, when clinically appropriate.

Radiation Oncology

Hoag was among the first to offer Intraoperative Radiation Therapy (IORT) for the treatment of early breast cancer. IORT is a revolutionary approach that delivers the total planned radiation dose directly to the tumor bed at the time of breast cancer surgery, sparing the patient 4-6 weeks of traditional radiation treatments. Over 1,150 IORT procedures have been performed at Hoag (as of June 2018), more than any single hospital facility in the United States. Clinical outcomes are being tracked, analyzed and published to contribute to the demonstration of IORT’s clinical utility for the treatment of breast cancer. Hoag’s first 1,000 IORT patients were published in the Annals of Surgical Oncology in 2018. The Hoag IORT group reported a projected local recurrence rate of 3.9% at 4-years of follow-up.

In addition to IORT, Hoag Radiation Oncology offers the full complement of external beam radiation treatment including intensity modulated radiation therapy (IMRT) and conformal radiation therapy, given in standard or accelerated daily fractionation protocols.

CLINICAL RESEARCH

Offering clinical trials and research sets Hoag’s Breast Cancer Program apart. Through Hoag Family Cancer Institute’s Developmental Therapeutics Program, in alliance with USC Norris Comprehensive Cancer Center, breast cancer patients are able to access experimental clinical trials not typically offered at community hospitals. The clinical trials below have opened at Hoag for patients with breast cancer. For an up to date list of open trials, please contact Leila Andres, M.S., at 888-862-5318.


(101-10) NCT01189851 Intraoperative Radiotherapy (IORT) for the Management of Carcinoma of the Breast: Use of Mammography, Ultrasonography and Contrast-Enhanced Magnetic


102-15) Data Registry for Early Stage Breast Cancer: Prospective Data Collection and Analyses of Wide Local Excisions and Intraoperative Radiotherapy


(131-17) 0C-16-8: A Phase ½ Safety Study of Intratumorally Administered INT230-6 in Adult Subjects with Advanced Refractory Cancers (Phase 1 clinical trial appropriate for patients with solid tumors)


(152-17) OC-14-9: A Modular Phase I, Open-Label, Multicenter Study to Assess Ascending Doses of AZD6738 in Combination with Chemotherapy and/or Novel Anti Cancer Agents (Phase 1 clinical trial appropriate for patients with advanced solid malignancies of the breast)


(155-17) 0C 17-1: Phase I Multicenter Study of the Safety of Pharmacokinetics and Preliminary Efficacy of CBT- 101 in Subjects with Advanced Solid Tumors and C-Met Dysregulation (Phase 1 clinical trial appropriate for patients with advanced solid malignancies)


(187-17) 0C-17-11: Phase 1 trial of ZW25 in patients with locally advanced (unresectable) and/or metastatic HER2- expressing cancers(Phase 1 clinical trial, appropriate for patients with HER2 expressing cancers.)


(211-17) 0C-17-14: An Open-Label, Non-Randomized, Multicenter Study to Determine the Pharmacokinetics and Safety of Niraparib Following a Single Oral Dose in Patients with Advanced Solid Tumors and Either Normal Hepatic Function or Moderate Hepatic Impairment (Phase 1 Clinical trial appropriate for patients with advanced solid tumors)


(214-17) OC-17-17: A Phase 1/2 First-in-human Study of BMS-986258 Alone and in Combination with Nivolumab in Advanced Malignant Tumors (Phase 1/2 clinical trial, appropriate for patients with advanced malignant tumors.)


181-17/0C-14-2: An Open-Label, Phase 2 study of Neratinib in Patients with Solid Tumors with Somatic Human Epidermal Growth Factor Receptor (EGFR, HER2, HER3) Mutations or EGFR Gene Amplification


157-17/0C-18-2: A Phase I Study of FID-007 in Patients with Advanced Solid Tumors


114-17: A Randomized Phase Ii/Phase Iii Study Of Adjuvant Concurrent Radiation And Chemotherapy Versus Radiation Alone In Resected High-Risk Malignant Salivary Gland Tumors


112-16: NSABP PROTOCOL B-51/RTOG PROTOCOL 1304 - A Randomized Phase III Clinical Trial Evaluating Post-Mastectomy Chestwall and Regional Nodal XRT and Post-Lumpectomy Regional Nodal XRT in Patients with Positive Axillary Nodes Before Neoadjuvant Chemotherapy Who Convert to Pathologically Negative Axillary Nodes After Neoadjuvant Chemotherapy

SCREENING AND HIGH RISK SERVICES

The Hoag Early Risk Assessment Program (HERA) launched in 2014 as a free service to the community to help women ages 35-55 understand and minimize their risk for breast cancer. The program uses the Gail and IBIS models to calculate risk. Women identified at increased risk are contacted by the program’s advanced nurse practitioner and provided a free consultation to help them understand their breast cancer risk. The nurse practitioner also provides information on lifestyle modifications that can aid in risk reduction and may also recommend increased surveillance and imaging, managing MRI authorization when necessary, or genetic counseling.

Patients who test positive for germline mutations that increase their risk for breast or ovarian cancer may choose to enroll in the High Risk Breast and Ovarian Cancer Prevention Program, which was launched at Hoag in 2017. Under the leadership of co-directors Heather Macdonald, M.D., F.A.C.O.G., and Lisa Abaid, M.D., M.P.H., F.A.C.O.G., F.A.C.S., the program addresses the unique needs of previvors and offers a holistic and multidisciplinary approach to their medical management. The team of providers, which includes a breast surgical oncologist and gynecologic oncologist, radiologists, a registered dietitian, a licensed psychologist and certified sex therapist, a certified personal

trainer, a yoga, meditation, and mindfulness coach, genetic counselors, and nurse navigator meet with each patient and develop personalized plans comprised of surveillance with specialty exams and imaging, risk reduction and wellness services. Risk reducing surgery can impact many aspects of a woman’s life including intimacy and fertility and the team supports and guides women through these issues.

Patients at inherited risk for breast or ovarian cancer are also often at risk for other cancers, and the program navigator helps link patients to other high risk cancer programs at Hoag Family Cancer Institute.

SUPPORT AND EDUCATION

Hoag’s Breast Cancer Program features a team of nurse navigators – Michelle Booth, M.S.N., F.N.P., O.C.N., Lisa Fassnacht, R.N., C.R.N., C.N-B.N., and Laura Topp, R.N., C.N.-B.N. – who navigate patients through every aspect of their breast cancer journey. The Breast Cancer Support Group meets monthly and offers patients mutual support for coping with the day-to-day issues of diagnosis, treatment, and survivorship. Hoag Family Cancer Institute also offers a Young Women’s Breast Cancer Support Group, for women with a diagnosis of breast cancer under 40 years of age.

Hoag’s physical therapists have advanced training and certification in the treatment of lymphedema utilizing multiple modalities. A lymphedema specialist is integrated in Hoag’s Breast Cancer Program to assess and educate patients on signs and symptoms of lymphedema and prevention tactics.

Patients also have access to Hoag Family Cancer Institute’s range of workshops, education classes, and other support services in addition to women’s wellness offerings at the Hoag for Her Center for Wellness.

For more information call: 949-722-6237