From routine screenings to biopsies, breast and reconstructive surgery, and supportive survivorship services, the Brookhaven Memorial Hospital Breast Health Services team provides up-to-date, patient-focused care at every point in women’s breast cancer journeys.
David Mangiameli, DO, Program Director of the Brookhaven Memorial Hospital Medical Center Breast Cancer Center, and Nabil Kiridly, MD, plastic surgeon at Brookhaven Memorial Hospital Medical Center, collaborate on the interpretation of patient imaging studies in the Radiology Department.
New York has one of the highest breast cancer rates in the country, according to the Centers for Disease Control and Prevention. For many women, this elevated incidence has led to anxiety about breast cancer risk and when to begin screening, according to David Mangiameli, DO, Program Director of the Brookhaven Memorial Hospital Medical Center Breast Cancer Center.
“Whether the increased number of cases is environmental or related to demographics, we don’t know yet,” Dr. Mangiameli says. “Statistically, however, we do know that New York is a bit above the national average in terms of breast cancer cases, so our patients are often naturally more stressed about it.”
The Brookhaven Memorial Hospital Medical Center Breast Health Services team partners with referring physicians in the community to set women’s minds at ease by offering ready access to screening and helping women with a potentially above-average breast cancer risk develop a customized screening plan. If an abnormal screening and biopsy reveal cancer, women can access a full range of breast and reconstructive surgical options, radiation therapy and chemotherapy through the Breast Cancer Center.
“This is a comprehensive program developed here at Brookhaven Memorial to coordinate and complete the circle of care for our breast health patients,” says Richard T. Margulis, President and Chief Executive Officer of Brookhaven Memorial Hospital Medical Center.
“Located in the heart of Suffolk County, the Brookhaven Memorial Hospital Medical Center Breast Cancer Center offers a high standard of comprehensive, patient-centric and precise cancer care and treatment. Although the Breast Cancer Center is young in comparison to other centers in New York state, our treatments and reconstructive outcomes equal nationally renowned centers.”
— Nabil Kiridly, MD, plastic surgeon at Brookhaven Memorial Hospital Medical Center
Dr. Kiridly spends a few moments discussing follow-up care with staff in the ASU/PACU of the Knapp Center.
A Tailored Screening Plan
Patients can access women’s imaging at Brookhaven Memorial Hospital Medical Center in two ways. Physicians may refer women with an average breast cancer risk to the Women’s Imaging Services Center for routine mammograms. Unless indications warrant further evaluation, these women can continue getting mammograms as recommended and do not need to undergo risk assessment.
Women who are referred to the Breast Cancer Center, however, do receive a risk assessment. Indications for referral include an elevated family history, especially a family history suggestive of a BRCA gene mutation, or changes to the breast, such as breast pain, a breast lump, redness or nipple discharge. The risk assessment these women receive as part of their routine care considers factors such as their genetic history, their family and personal history of breast cancer, and any results from previous breast biopsies.
Based on the assessment, women receive a percentage that represents their lifetime breast cancer risk. Women who have a lifetime risk of breast cancer that is lower than 15 percent are considered average risk, according to the American College of Radiology. Those with a lifetime risk above 20 percent fall into the high-risk category and benefit from annual mammograms and breast MRIs — a combination that the American College of Radiology notes offers a higher sensitivity than the combination of breast ultrasound and mammogram.
“Until you perform risk estimation, you really don’t know how women should screen,” Dr. Mangiameli says. “Because care at the Breast Cancer Center begins with a risk assessment, all recommendations are customized based on each woman’s individual risk.”
Dr. Mangiameli reviews a patient chart to ensure that all documentation, preoperative procedures and orders are up to date.
Once women are referred to the Breast Cancer Center and receive their personalized screening plan, the Breast Cancer Center team facilitates screening in conjunction with providers from the Women’s Imaging Services Center, an American College of Radiology-accredited Breast Imaging Center of Excellence. This accreditation is available to hospitals that provide exceptional care and have already received American College of Radiology accreditation in mammography, stereotactic breast biopsy, breast ultrasound and breast MRI.
“This designation is the highest ranking accreditation available in the nation,” says Nabil Kiridly, MD, plastic surgeon at Brookhaven Memorial Hospital Medical Center. “Having full accreditation with no restrictions means women are not going to find a higher level of care.”
A full complement of screening modalities, including digital mammography, 3-D breast tomosynthesis, ultrasound and breast MRI, is available through the Women’s Imaging Services Center. Women in need of a breast biopsy also benefit from the expertise of Arlene Sussman, MD, Program Director of Women’s Imaging Services. Dr. Sussman offers advanced percutaneous biopsy and interventional radiology techniques, such as stereotactic, MRI-guided and ultrasound-guided core needle breast biopsies, as well as fine-needle aspiration and needle localization, which aid breast surgeons in accurately pinpointing lesions that are not palpable but require excision.
“If a patient has microcalcifications of the breast and a biopsy reveals a precancer, for example, I can’t find the lesion simply by palpating the breast,” Dr. Mangiameli says. “Prior to my taking these patients to the OR [operating room], Dr. Sussman places a needle in the breast that guides me to the exact specimen location so I can prove with certainty that the sampling is perfect before patients awake.”
Other advanced diagnostic modalities include terminal duct excision and microductectomy with nipple exploration to evaluate different types of nipple discharge. If women aren’t candidates for needle biopsy because, for example, they have a silicone breast implant that’s located near the nodule, surgical excisional biopsy of the breast is also available.
The Women’s Imaging Services Center features a dedicated patient navigator who guides patients through imaging services and biopsy. In addition to helping women schedule these tests, this navigator helps them obtain insurance authorization as necessary and facilitates screening outreach efforts.
Both Dr. Kiridly and Dr. Mangiameli see patients at the Brookhaven Breast Health Services Center, a comprehensive and fully accredited Breast Center of Excellence.
A Multidisciplinary Approach to Breast Cancer Treatment
Following biopsy, Kenneth Lidonnici, MD, Director of Pathology at Brookhaven Memorial Hospital Medical Center, reviews breast specimens.
“Dr. Lidonnici has a deep role in evaluating tissue and giving us the proper diagnosis,” Dr. Kiridly says. “His findings guide how the entire surgical, radiation and medical oncology team treats the cancer.”
Once cancer diagnoses are confirmed, a multispecialty group of providers, including fellowship-trained breast imagers, specialty interventional radiologists, breast, plastic and reconstructive surgeons, pathologists, and medical and radiation oncologists meet for biweekly conferences, during which they review each case and collaboratively decide upon the course of treatment.
The Breast Cancer Center is accredited by the American College of Surgeons National Accreditation Program for Breast Centers and offers the full spectrum of services. Based on patients’ presentation, treatment plans may include breast surgery, chemotherapy, reconstructive surgery and radiation therapy.
“During our evaluation, we make sure that each patient’s physical and social needs are met and that multiple physician viewpoints are incorporated,” Dr. Kiridly says. “This ensures each patient receives custom-made treatment.”
The cooperative approach also helps improve treatment outcomes.
“Sometimes, patients need chemotherapy to optimize the success of the surgical step,” Dr. Mangiameli says. “In other cases, a radiation oncologist may look at the patient report and ask that we adjust our surgical technique to, for example, go higher on the clavicular side of the breast to make it easier to treat positive nodes after surgery. If that dialogue doesn’t take place before surgery, those opportunities are missed.”
Similar to the navigation function at the Women’s Imaging Services Center, a patient navigator offers guidance and mentorship to women receiving active cancer treatment at the Breast Cancer Center by, for example, educating women about their disease and the things they need to do to remain compliant with their care.
“The patient navigator makes sure patients thrive while going through the treatment process and, at the same time, serves as a resource for patients to find answers as questions arise,” Dr. Mangiameli says. “This navigation is critical to how patients move through treatment and avoid the potential spiral of depression and anxiety.”
Members of the OR team including Ava Fellenz, RN OR; Rocio (Rosa) Carcelen, PNA OR; Yao Ting Hsien (Stanley) PNA OR; Harold Mamuyae, Instrument Room coordinator in the OR; and Carolyn Holecek, RN OR, with Dr. Kiridly and Dr. Mangiameli.
Advances in Breast and Reconstructive Surgery
Breast surgery techniques available through the Breast Cancer Center include unilateral and bilateral mastectomy, nipple-, areola- or skin-sparing mastectomy, prophylactic mastectomy to help women mitigate their breast cancer risk, lumpectomy, lymph node dissection, and chest wall reconstruction. Dr. Mangiameli is fellowship-trained in oncoplastic surgery and employs minimally invasive techniques, including endoscopic-assisted mastectomy to minimize scarring, when possible.
Following breast surgery, women have a choice to receive plastic and reconstructive surgery. This option is available to Brookhaven Memorial Hospital Medical Center patients regardless of their insurance coverage.
Dr. Kiridly offers comprehensive reconstructive options following lumpectomy and mastectomy, including implant-based reconstruction, flap reconstruction using autologous tissue, and unilateral breast reconstruction with accompanying breast lift, reduction or augmentation surgery on the healthy breast to ensure symmetry.
When using implants, Dr. Kiridly may perform single-stage, direct-to-implant reconstruction or multiple-stage reconstruction. Factors considered in this decision-making include the presence of comorbidities, breast size, smoking status, age, disease stage and patient preference. A 2013 study published in the Journal of Plastic Surgery and Hand Surgery found that single-stage and multiple-stage reconstruction offer similar results in terms of surgical-site infection and reoperation rates, but single-stage reconstruction may raise patients’ risk of complications related to prosthesis failure.
“If patients are candidates for both techniques, they have the opportunity to decide whether they want single-stage or multiple-stage reconstruction,” Dr. Kiridly says. “Single-stage surgery has some limitations in its reconstructive ability, so a lot patients choose multiple-stage reconstruction.”
Physicians usually perform multiple-stage reconstruction in two steps. The first step typically occurs at the time of mastectomy and involves either using a tissue expander or placing an implant to form the breast mound. During subsequent surgical stages, physicians may replace the tissue expander with an implant, as needed, and perform nipple-areola reconstruction using pigmentation.
At the Brookhaven Breast Cancer Center, Dr. Kiridly uses highly cohesive, form-stable breast implants (also known as “gummy bears”). These gel implants offer some advantages over saline implants because they are designed to feel more like women’s natural breast tissue, keep their shape even in the event of rupture and are firmer, which may help reduce the likelihood of rupture, according to the American Cancer Society. At the time of reconstruction, Dr. Kiridly uses advanced autologous tissue grafts or acellular dermal matrix grafts as needed to provide additional tissue support.
“Patient centrism is one of the most special things about the care delivered at Brookhaven Memorial Hospital Medical Center. No patient is ever turned away because of her insurance or financial status. Our physicians are dedicated to ensuring every woman receives the same level of evidence-based care.”
— David Mangiameli, DO, Program Director of the Brookhaven Memorial Hospital Medical Center Breast Cancer Center
Professional and support staff at the Brookhaven Breast Health Services Center outpatient facility include Ashley Zerafa, Ashley Selg, Dr. Mangiameli and Geraldine Burgo.
Following cancer treatment, women must remain compliant with recommended screenings. Women who’ve had a lumpectomy, for example, need a mammogram at least annually, according to the American Cancer Society. Dr. Kiridly recommends that women who’ve received implant-based breast reconstruction have an MRI every two to three years to check for rupture or other problems that might compromise the integrity of the implant.
Receiving follow-up screenings, however, is only one piece of thriving after a cancer diagnosis. The Breast Cancer Center also features a multiple-grant-funded Breast Cancer Survivorship Coalition that provides multiple outreach programs to address survivorship — the process of living well during and after cancer treatment.
“A diagnosis of breast cancer can cause major psychological distress for patients,” Dr. Kiridly says. “Some patients become fearful or retracted. Others are confused and aren’t sure what to do. It’s like they’re facing a dark tunnel. The goal of our entire team is to serve as a torch of light that guides patients through that tunnel in a comfortable, caring way.”
Dr. Kiridly updates charts between patient rounds at a Workstation on Wheels (WOW) in the Knapp Center ASU/PACU.
Coordinator Merilyn Konnerth leads the Breast Cancer Survivorship Coalition. Available programs help alleviate challenges related to treatment and accessing care in several ways. For example, Lend a Helping Hand, a program supported by Pink Aid and LI2Day, coordinates transportation to and from appointments and provides multiple types of financial assistance to women in need. Other programs include the Pink Pearl Program — a program that pairs women in active treatment with mentors who are at least one year out from treatment — and Mondays at the Racine, where women in active treatment can receive free salon services. Finally, Konnerth hosts Breast Cancer and the New Normal, an open support group that is held every other Tuesday evening.
“Our survivorship services steel the loneliness sometimes associated with breast cancer,” Dr. Mangiameli says. “Women who opted for breast conservation may face anxiety and depression due to worries about cancer recurrence. Others may struggle with the concept of having new breasts or with complications from chemotherapy, which can include long-term pain and numbness in the hands and feet. During these meetings, women can come together and talk about what others are doing to cope. It stops people from feeling like they’re alone while adapting to their new way of life.”
To learn more about how the Brookhaven Breast Health Services Center cares for women, visit brookhavenhospital.org.