The care team at the Gundersen Lutheran Medical Center’s Center for Breast Care includes (from left) plastic surgeon Lynn Martin, MD, codirector and radiologist Richard L. Ellis, MD, medical oncologist Leah L. Dietrich, MD, surgeon Jeffrey Landercasper, MD, and (seated) pathologist Susan Wester, MD.

Women suffering from breast cancer and those who are trying to head off a genetic predisposition to the disease through early detection must navigate a confounding system in their search for care. A nationwide shortage of radiologists, particularly those willing to specialize in mammography, concerns about the effectiveness of routine mammograms, and cost constraints imposed by expensive technology and tricky reimbursement schemes can make it nearly impossible for patients to find a cohesive breast cancer treatment team. Yet there are those within this realm of medicine who believe that comprehensive care represents the next era of breast cancer diagnosis and treatment. And there are some who are already offering it, much to the gratification of patients and practitioners alike.

An interdisciplinary approach has long been the hallmark of patient care at Gundersen Lutheran Medical Center in LaCrosse, Wis, and the facility’s Center for Breast Care is likewise founded on that model.

“For an institution of this size, Gundersen was way ahead of the game in terms of promoting an interdisciplinary approach to care when I joined the staff in June 2001,” says Richard L. Ellis, MD, codirector of the center. “In traditional breast cancer care, the patient comes in with a palpable lump and then gets ping-ponged back and forth among doctors in order to get the proper examinations. About 2 weeks later, that patient may have a biopsy, and treatment decisions may not be reviewed for another week. Some 25 days after the initial exam, the patient might have a treatment plan.

“If you look at the interdisciplinary approach, our patients come in for a comprehensive diagnostic evaluation about 2 days after their initial visit,” Ellis continues. “That could mean an additional mammogram and a biopsy on the same day, followed by a correlation of the mammogram and the pathologist’s report.”

The patient is then transferred in a seamless manner to the treatment team, which could include a surgeon, a medical oncologist, a radiation oncologist, and a plastic surgeon. The patient receives a consensus treatment plan from all members of the team. Along the way, the patient may also consult with physical therapists, occupational therapists, social services, clergy members, financial aid experts, and geneticists.

“Traditionally, specialists give patients? recommendations independent of one another, and the patient will then have to go home with her head swimming, not knowing what direction to take,” Ellis says. “At Gundersen, we all work together to determine what is best and most appropriate. Typically, this entire process will take about 7 days as compared to 25 days for the traditional approach, and the level of information we give our patients is light years ahead of what many are used to.”

A cornerstone of such a program is certainly a staff member like Ellis, who, as a clinical breast radiologist, is a member of a small population of subspecializing radiologists. Other building blocks of the program are good communication between all participants, an active and strong tumor board with good attendance, and comprehensive support staff, all of whom function on a schedule that places high esteem on timely, flexible service that eliminates a long wait for the patient.

“The availability of interdisciplinary team members is essential, but timeliness cannot be undervalued,” says surgeon Jeffrey Landercasper, MD. “More than 30 years agoeven before we began calling ourselves a breast care centersurgeons at this clinic established an unwritten policy that we would see new breast cancer patients within 24 to 48 hours of either their request to be seen or their diagnosis for an abnormal mammogram.

“That same policy continues today,” Landercasper says, “and it is common for patients with a lump to see all the appropriate members of the multidisciplinary team, to have their imaging studies completed, and to have their biopsy results available within 48 hours. It is also common that primary therapywhether that is surgery for early cancers or initial chemotherapy for locally advanced cancersis initiated within a week of diagnosis. Outcomes are not different whether the initial treatment starts immediately or a month after diagnosis, but from an emotional standpoint, timeliness is very important to the patient.”

To be able to offer such quick care requires flexibility and a commitment by staff members to carry a beeper, work on their afternoons off, and change their schedules to meet patients’ needs.

“We provide a very personal kind of care that includes a lot of phone calls,” Landercasper says. “Patients often have questions they forgot to ask during their appointments, so we have nurse specialists available to answer messages and take phone calls at home. Our nurses also call patients within 24 hours of hospital or surgical discharge.”

Andrew Meade, MD, chairman of the radiology department, notes that such ancillary personnel are well educated about the disease so they can address virtually any patient concern.

“They can talk to patients about everything from how advanced the cancer is to whether the patient should be worried about their sisters or their daughters getting cancer as well,” Meade says.

Teamwork In Action

The high quality of patient care? impressed radiation oncologist June Kim, MD, when she joined Gundersen 3 years ago, and she quickly recognized that a structured team approach made that level of care possible.

“Our surgeons approach everything as a team instead of doing whatever they want to do,” Kim says. “They make decisions together before they do anything with a patient.”

That process of joint decision-making begins at the initial patient evaluation, where examination notes are made on a check-off card designed by Ellis. The card includes information about whether a clinical breast examination, ultrasound, or imaging was done and has space for notations about palpable lumps, skin thickening, or focal breast pain. The clinician can indicate the level of suspicion, note the location of any areas of concern on a drawing of the left and right breast, and jot down recommendations for consultative services, an image-guided needle biopsy, or second opinion services.

“This form is extremely powerful because it allows for clear communication between the referring physicians and other clinicians about what problems may exist and what their implications might be,” Ellis says. “The system eliminates guessing and has become an essential component of patient care.”

Referrals are made most often for needle biopsies for reasons of diagnostic accuracy, patient comfort, and cost. Ellis estimates that about 90% of biopsies are done with image guidance, while only 10% are done surgically. Deciding further between stereotactic and ultrasound-guided biopsies depends on the amount of tissue the pathologist needs to make an accurate diagnosis.

“When the patient has indeterminate microcalcifications that we cannot see on ultrasound, a stereotactic biopsy will have a definite edge over a surgical biopsy,” Ellis says. “However, stereotactic biopsies only account for about 20% of all the procedures we do.”

A clinical breast radiologisteither Ellis or Meadeand a staff pathologist review cases on a weekly basis to make sure there is radiographic and pathologic concordance, and the interdisciplinary team members meet each Friday to discuss every case.

Staff pathologist Susan Wester, MD, notes that such consistent communication enables specialists to catch suspicious symptoms early, and to answer any questions that the clinicians may have brought up on the check-off card.

“The correlation I am doing with the radiologist over the breast biopsies is really a great quality control check,” Wester says. “Take the recent example of the woman who was mistakenly given bilateral mastectomies at United Hospital in St Paul, Minn. Even though we have internal quality control checks to prevent that from happening, such a mistake also would have been picked up at the radiology and pathology correlation meeting.”

Even before the correlation is made, patients with suspicious-looking ultrasound scans will be informed about the clinician’s concerns so they can begin processing the possibility of having breast cancer.

“That way it is not an overwhelming surprise to them when we have a confirmed diagnosis from the pathology report,” Ellis says. “Overall, our approach takes what is usually a month-long process and shaves it down to mere days, and this step reduces the patients’ worrying down to less than a week as well.”

“There is plenty of evidence that when patients feel good and take care of their emotions along with obtaining medical care, their outcome is better,” Kim points out. “So, while we are taking care of the medical side, we also have psychologists and social workers helping them with the emotional aspects of illness. This is just another example of how we look at our patients as people, not just patients. And we don’t charge extra for that kind of care; it is part of the package,”

Exploring Areas of Concern

The packaged care at Gundersen comes compliments of the facility itself, which is a multidisciplinary clinic with 430 physicians, none of whom have independent practices. According to Cathy Lechnir, administrative director in radiology, that means patients have “a captured audience of providers and we don’t have to get permission from another practice to go ahead and do all the diagnostic workup in one day, or see a surgeon the same day we diagnose a problem.”

While Gundersen may not charge for each component of care because it is part of the continuum, staff members at the Center for Breast Care are quick to point out that the very nature of that continuum reduces the kind of costs incurred in a more traditional system.

“We get quick turnaround of our laboratory results, and in 3 days our patients are already scheduled for therapy,” Lechnir says. “That cuts out multiple office calls to different physicians, and every service the patient needs is available on the same campus. All of this makes it very convenient for the patient, who is treated in a time frame that is much shorter than any other model of care.”

While the staff may be convinced that such a patient-centric model inherently works well, there are no illusions about the need to prove the effectiveness of the Center for Breast Care’s model. The center is currently in the process of gathering outcome data to establish a reputable record of appropriate diagnosis and treatment, prove performance, and establish guidelines for care. The center also follows published guidelines for appropriate outcomes, such as how many cancers occur per thousand screens and the false-negative rate.

“For a modern interdisciplinary breast center to work, it needs to have a commitment to excellence, which means an institutional review of patient outcomes,” Landercasper says. “In the surgical field, that means knowing local recurrence rates and the accuracy of sentinel lymph node biopsies. To expedite this, we also are working on a program that will allow the respective members of the multidisciplinary team to enter patient data into a common program on a computer or Palm Pilot that can be transmitted to other members.”

If there is a weak link for the interdisciplinary team approach, Ellis readily admits that it is the clinical breast radiologist.

“There are not enough fellowship-trained or equivalent radiologists to fulfill the role of clinical breast radiologists, and I am unfortunately not seeing a rise in interest in the subspecialty,” Ellis says. “Radiologists have been taught to evaluate the pathology they see on films, but breast imaging is a different creature. We truly are clinicians for the patient in terms of early detection and diagnosis. In simplistic terms, we are breast specialists with a good command of breast anatomy, physiology, and pathology, and we happen to use those funny imaging tools to get our jobs done.”

Despite his love of the niche, Ellis recognizes that breast imaging modalities are not nearly as alluring as the newer modalities like CT and MRI.

“Residents also hear horror stories of poor reimbursement and lawsuits, and those things keep many radiologists with potential from going into a fellowship in breast imaging,” Ellis says.

Meade concurs that less funding and a high degree of risk keep radiologists away from the subspecialty, and notes that Gundersen is not immune to the dearth of appropriate personnel.

“We as well as many other breast centers are scrambling to find staff for our facilities,” Meade says. “It really takes a person dedicated to providing optimal service, which is a hands-on approach that is unusual in radiology except in the case of interventional radiologists, and most groups can seldom afford to have full-time mammographers.”

Inspiring Others

Such concerns do not keep proponents of Gundersen’s approach from being hopeful that such centers will someday be a paradigm.

“When the Center for Breast Care advertises, our ads say, The right care, right here.’ But we don’t just say it, we mean it,” Kim says. “Patients are getting first-class care here and I think other facilities can duplicate this model.”

Meade allows that such a model is unusual at this point, “but this is one of the diseases that tends to cross a lot of specialty lines,” he says. “From that standpoint, a multidisciplinary approach is really preferred. It may not be applicable to all medicine, but there are aspects that will help those planning multidisciplinary types of approaches for other illnesses.”

In fact, the Center for Breast Care will physically become part of Gundersen’s cancer care segment when it moves into a center devoted to such diseases in June. The new location will increase access for patients and give the team more room to read screening mammograms and conduct diagnostic examinations, ultrasound, and biopsies. The Center for Breast Care’s present location will be reserved for screening mammography and additional workup.

The center also hopes to one day offer a fellowship in clinical breast imaging, and hopefully inspire more radiologists to enter the field.

“My concern is lack of interest in general,” Meade says. “Radiology groups have a difficult time supporting this concept. Usually they refer patients outside the system, and it can end up being a political mess. Ideally, I believe there should be a breast center in every reasonably sized hospital, but in terms of expense I’m not sure it is practical. The biggest concern is obviously a lack of people being trained in radiology, which gives us a smaller base to attract to this subspecialty. But unequivocally, I think the answer to whether it will be the wave of the future for breast cancer is yes.”

Ellis contends that breast imaging already becomes an evolutionary process for radiology groups once they reach about 20 in size.

“At that point they can decide whether they want to subspecialize or continue with general radiology,” Ellis says. “And I think that institutions and physicians want to be able to offer interdisciplinary breast care, but they can’t without staff resources or the proper technology.”

Meade and Ellis are both nonetheless hopeful that the success of entities like Gundersen will inspire other radiologists and other facilities to invest in a sophisticated model of care for breast disease, even if it means surmounting some initial hurdles.

“What Gundersen does sounds simple, but doing it becomes extremely complex,” Meade says. “It costs a lot of money, and it means hiring people to do a lot of things that are not directly related to treating the biological disease. But it makes patients’ lives ever so much better.”

Elizabeth Finch is a contributing writer for Decisions in Axis Imaging News.