Introduction

This is the first of a multiple-issue series on Interdisciplinary Comprehensive Breast Centers and focuses on radiology and pathology. The following issues in this series will feature treatment and research and then programmatic components. It is with humbleness and appreciation to Stephen Feig, MD that I am serving as the Guest Editor for the series.

My involvement with breast center development spans over 25 years of hands-on experience as well as consultations with more than 100 hospitals and medical staffs across the country. I have come to respect the complexity of these programs and the overwhelming desire on the part of the stakeholders to “do the right thing – for the right reason.” The selection of topics for this series was based on issues I have found to be critical to creating a high quality breast center – often issues that are difficult to address. The authors were selected because of their recognized expertise. All of them have extensive publication and presentation records. I feel extremely privileged to have worked with and/or taught with all of the authors in this issue and consider them valued colleagues and friends.

Just as breast cancer diagnosis and treatment have evolved and matured over time, so have breast centers. Today, after three decades of organization and program development, there are numerous breast center scenarios – from breast imaging-only centers to comprehensive breast programs with a full complement of breast-related services. There are a few physician-owned breast centers and many academic breast centers, but the vast majority of breast centers in the United States are hospital-owned and usually with a private practice medical staff. This distribution of breast centers reflects in part the fact that over 85 percent of newly diagnosed breast cancers in the United States are diagnosed and treated within the community, not in academic centers. Not only are there significant differences in these breast centers based on ownership, there can be considerable variations within each model. The one common theme, however, is providing high quality and timely diagnosis, treatment, rehabilitation and continuing care for breast cancer patients – and, the common goal is to reduce the mortality and morbidity from breast cancer.

Breast centers are defined in many different ways, but the basic components include support of an interdisciplinary approach to the diagnosis and management of breast cancer, a patient-focused, well coordinated process of care, and the utilization of evidence-based guidelines. The articles in this, and future breast center issues, will demonstrate various aspects of such an organized breast care system. This first issue focuses on breast radiology and breast pathology.

As befits his earned stature and his significant contribution to breast cancer diagnosis and research, László Tabár, MD and colleagues lead off this breast center series. Dr. Tabár is considered the world’s foremost “mammography mentor” with numerous well documented and illustrated books and professional courses presented all over the world. He has been honored with several international awards including the prestigious American Cancer Society Distinguished Service Award, the coveted Gold Medal from both the American College of Radiology and the Society of Breast Imaging - as well as the Impact Award from the National Consortium of Breast Centers. I personally believe Dr. Tabár deserves the Nobel Prize. Dr. Tabár’s landmark, two county, population-based mammography screening program in Sweden represents the most thorough and longest term mammography screening study in the world. It has changed the face of breast cancer – clearly demonstrating a reduction in breast cancer mortality due to mammography screening. All the breast cancers in his mammography screening data base have been prospectively and consecutively documented with imaging follow-up. The 24-year follow-up data presented in this article demonstrates that treatment decisions for small invasive breast cancers should be based on specific mammographic features and disease extent for the individual patient. Once casting calcifications have been separated from the other tumor classifications, there is an excellent 24-year disease-free survival regardless of whether radiation therapy is received. Less aggressive treatment decisions, whether it be surgery, radiation or chemotherapy, requires that interdisciplinary comprehensive breast centers approach the decision-making process in a systematic, organized manner with prospective data collection and analysis and with open, science-based discussions. In this article, Dr. Tabár and his team provide valuable science, based on sound research.

Richard Ellis, MD epitomizes the select group of highly skilled and experienced breast radiologists that truly function as clinical breast imaging consultants. Dr. Ellis is the Co-Director of the Norma J. Vinger Center for Breast Care at Gundersen Lutheran Medical Center in La Crosse, Wisconsin – a horizontally organized, interdisciplinary comprehensive breast care center. He was the Biomedical Research Scholar at the NIH Howard Hughes Medical Institute. Dr. Ellis has several publications in peer-reviewed journals. He is a consultant to several breast imaging vendors. In this article, the pivotal role of the clinical breast radiologist in the diagnosis of early breast cancer and the direction and utilization of the diagnostic evaluation to the treatment team are clearly and completely described. This article delineates the essential elements to be included in that comprehensive diagnostic evaluation including biplanar specimen radiography. The communication of that report to the treating physicians assists in the management of patients with breast cancer. In addition, three years of breast cancer screening performance data from the breast care center are presented and compared with national benchmarks.

G. W. Eklund, MD, FACR is one of the premier, and most highly respected, clinical breast radiologists in this country. Like Dr. Tabár, he has many “followers” within the breast radiology world. Dr. Eklund is an international presenter on breast imaging and a national expert on breast centers. Dr. Eklund is the medical director of the Pacific Breast Center in Beaverton, OR and is Clinical Professor of Radiology, Oregon Health Sciences University, Portland, Oregon and Medical College of Wisconsin, Milwaukee. He received the Faculty of the Year Award (1994-1995) from the University of Illinois College of Medicine at Peoria and the Impact Award from the National Consortium of Breast Centers in 2004. Dr. Eklund is past president of the Society of Breast Imaging. As the first Director of the Susan G. Komen Breast Center in Peoria, Illinois, he established a code of excellence that he has shared with breast professionals all over the country. Part of that code relates to the multi-factorial breast imaging efficiency – the focus of Dr. Eklund’s article in this issue. Breast imaging is typically the only procedural activity in the breast center and is usually the sole source of financial support for the breast center components. The article addresses process and outcome issues – both of which are critical with today’s inadequate mammography reimbursement and too few experienced breast radiologists.

Michael Lagios, MD is considered one of the top breast pathologists in the country and has a highly respected and utilized Breast Cancer Consultation Service in San Francisco, California. He is unique at this level of expertise because he is in private practice. He is affiliated with St. Mary’s Medical Center and is Associate Clinical Professor at Stanford Medical School. He is an internationally recognized expert on duct carcinoma in situ and has written or co-authored much of the pertinent literature in this area over the last twenty years. Dr. Lagios is past president of the American Society of Breast Disease and is editor/co-editor of and reviewer for several international peer-reviewed journals. He has been recognized by Best Doctors in America from 1992 to the present and Best Doctor, Pacific Region in 1995-1996. Dr. Lagios is a Fellow of the California Acadmey of Sciences. His article addresses the difficulty in accurately measuring image-detected T1N0 breast carcinomas. Incorrect calculations can result in a recording of a larger T-size and stage and, therefore, result in inappropriate recommendations for adjuvant therapies. Common errors in tumor size determination are reviewed and illustrated.

Julio Ibarra, MD is a private practice breast pathologist with considerable hands-on experience with community hospital-based interdisciplinary comprehensive breast centers. In the mid 1980s, he developed the on-site, Fine Needle Aspiration Clinic within the Long Beach Memorial Breast Center which was later rated number one of the Top Ten Breast Cancer Centers in the United States by Self Magazine. He is the President Elect of the American Society of Breast Disease. Dr. Ibarra is currently Medical Director at the MemorialCare Breast Center and Pathology Department of Orange Coast Memorial Medical Center. He is Associate Clinical Professor for the Department of Pathology at University of California at Irvine. He was identified as one of the Best Doctors, Orange County in 1998, 2002, 2004, and 2005. Dr. Ibarra’s article presents the strong argument for synoptic pathology reporting so that the information presented is clear, concise and accurate rather than having the relevant information buried within the narrative which then can be easily missed. Synoptic pathology reporting is slowly becoming the standard-of-care in this country for all organ types. Within each institution, however, synoptic pathology reporting is usually spearheaded by the interdisciplinary breast center team because the pathology report contains the information upon which critical treatment decisions are made. The article includes two diagnostic templates: invasive carcinoma and ductal carcinoma in situ. The MemorialCare healthcare system now includes five breast centers within southern California and all utilize the Ibarra format – as do many other breast programs that have read his articles on the topic.

Michael Linver, MD is an outstanding clinical breast radiologist who has successfully complemented his busy private practice in Albuquerque, NM with teaching. Not only is he a frequent invited speaker on breast imaging and the Mammography Quality Standards Act, since 1986, he has been the Director of the only hands-on, interpretive skills course for breast radiologists in the country. Dr. Linver was instrumental in the development of national breast imaging standards as one of only five breast radiologists on the original National Mammography Quality Assurance Advisory Committee to the FDA, from 1994 to 1998. He is a Fellow of the Society of Breast Imaging. He has been listed in Best Doctors in America every year since 1996 and voted Albuquerque’s Top Doctor in Radiology in 2005 and 2006. His numerous articles in professional, peer-reviewed journals, with their emphasis on quality and accountability, have had great influence within the breast imaging and breast center world. His article in this issue on the expanded breast imaging audit addresses the essentials of collecting and calculating the appropriate data for the expanded audit, the importance of separation of screening and diagnostic mammography audit data, and the real and potential impact audit data analysis has on improving radiologist performance and patient outcomes. Limitations on audit analysis by demographic and other factors, impending new federal regulations involving the audit, and pertinent medicolegal issues are also reviewed.

Gerald Kolb, JD has been actively involved with breast imaging since 1994 when he was the Executive Director for Comprehensive Breast Health of Colorado, a vertically integrated breast imaging program. For the last decade, Mr. Kolb has been the CEO of Breast Health Management, Inc in Bend, OR and has worked with over forty comprehensive breast centers where his expertise is business development, managed care contracting, equipment adoption and utilization and work flow – all of which are critical to developing a financially responsible, high quality breast center. He is active with the National Consortium of Breast Centers, is a frequent invited speaker, and has published many articles in trade magazines and peer-reviewed journals. Mr. Kolb is a consultant for numerous manufacturers of breast-imaging devices and products. He is currently the Chief Development Officer of Women’s Diagnostic based in Dallas, TX. Mr. Kolb’s article on digital mammography makes the point that this new modality must be viewed as a system that, in its ultimate iteration, integrates mammography both with other breast imaging modalities, and with the supporting infrastructure that is critical to the entire process of mammography delivery. The article addresses the strategic process required for breast centers which are considering implementation of digital mammography, and also provides a framework for reengineering existing digital programs to provide strategic integration of the various elements of the delivery system.

This group of authors reflects, with distinction, the true meaning of “interdisciplinary” breast care. They are committed to quality breast care. They truly represent the cream-of-the-crop. All the authors have been mentors to me over the years and I am very appreciative of their contribution to this first issue of the Interdisciplinary Comprehensive Breast Centers series.