Cancer Update November 2021

NOV E MBE R 20 21 Issue No . 43

cancer update

Breast Center

– specialists devoted exclusively to breast care, diagnosis and treatment

Reshaping silhouettes to transform lives: The Center for Breast Reconstruction offers women facing surgery a full range of options including Delaware’s only center for advanced microsurgery Perforator flap breast reconstruction uses women’s own tissues to create a more natural look

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fter treatment for triple-negative breast cancer that included a total mastectomy, Chastity Jones, 45, was ready for a new look and a new chance for a healthy life.

A bad implant infection caused Jones to rethink her options and when she finally healed, her oncologist suggested the Center for Breast Reconstruction at the Helen F. Graham Cancer Center & Research Institute.

Chastity Jones and Stephanie Caterson, M.D.

“What started out as my cancer nightmare turned into a dream,” Jones said. “I look better now than I did before my cancer, when I called myself healthy. I feel beautiful.”

IN THIS ISSUE

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Reshaping Silhouettes Patient Guides Life-like Tattoos Radar Guided Tumor Localization

Director Stephanie Caterson, M.D., an experienced plastic surgeon who specializes in microsurgical breast reconstruction, offered Jones one of the most advanced procedures available called DIEP (deep inferior epigastric perforators) flap surgery.

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Genetic Counseling Radiology Imaging Mastectomy Pillows News Briefs

Cover image: Stephanie Caterson, M.D., Zohra Ali-Khan Catts, MS, LCGC, Shannon Hostetter, BS, Dawn Johnson Leonard, M.D., Jennifer P. Rowland, M.D.

Dr. Caterson took skin and fat from Jones’ lower abdomen below and around the belly button along with some tiny blood vessels (perforators) to reconstruct a more natural looking breast completely from her own tissue.

“Extensive training in microsurgical techniques is required to perform such an advanced procedure,” said Dr. Caterson, who did her fellowship at Harvard in 2006.

“We are the only center in Delaware performing microsurgical flap reconstruction,” she said. “Across the country, this level of expertise is largely confined to major academic institutions.”

For Jones, the experience was life changing.

“At our very first meeting, Dr. Caterson set the tone for a level of care that was exceptional,” Jones said. “She understood my entire cancer journey before she ever touched me, and her hands are truly magical.”

Women with breast cancer who are not eligible for breast-conserving surgery or who have a genetic risk for breast cancer may request breast reconstruction following mastectomy.

Although implant-based reconstruction is still a popular choice, for a woman who qualifies, using her own tissue for breast reconstruction creates a natural looking and feeling breast that is healthy and long lasting.

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“What started out as my cancer nightmare turned into a dream, I look better now than I did before my cancer, when I called myself healthy. I feel beautiful.”

Chastity Jones

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“DIEP flap surgery can also be a lifeboat to bring in healthy tissue to remove scarring and replace tissue damaged by radiation treatments,” Dr. Caterson said.

With perforator flap surgery, recovery time is longer than traditional breast implant surgery, usually five to six weeks, but reconstructing the breast using tissue from the abdomen, inner thigh or buttock has advantages.

Unlike an implant, the reconstructed breast adjusts with body changes associated with aging or weight fluctuations, for example, to maintain lifelong symmetry on both sides of the chest. The aesthetic effect of a tummy tuck or inner thigh lift from where the tissue is taken can be an added benefit.

“At the Center for Breast Reconstruction, we offer a full range of techniques to help women facing breast surgery reach their goals,” said Dr. Caterson. “We have the experience to fully evaluate our patients and to help them develop a personalized plan to achieve the absolute best outcome.”

Being part of an entire cancer care community like the Graham Cancer Center makes it more viable for patients who are good candidates to choose advanced microsurgical options.

“There are a lot of components that must work well together for patients to have successful microsurgical breast reconstruction,” said Dr. Caterson, who has performed almost 2,000 perforator flaps in her career.

The procedure involves working collaboratively across disciplines, including medical, surgical and radiation oncology. Radiology plays a key role in producing imaging studies essential for pre-operative assessment. The breast reconstruction team works seamlessly with

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“This is such a big operation,” Dr. Caterson said. “My component is important, but we have to integrate with all the other aspects of patient care to achieve successful outcomes.”

Patient guides extend a warm welcome to visitors at the Helen F. Graham Cancer Center & Research Institute Kevin Frazier knows the power of a warm welcome and a helping hand. As a patient guide, he is often the first to greet patients as they enter the Helen F. Graham Cancer Center & Research Institute.

“My job is to make our patients and visitors feel comfortable and taken care of,” Frazier said. “I know that my interactions with them can make a lasting impression.”

operating room and infusion staffs.

Post-operatively, coordination with nursing education, rehabilitation, counseling, nutrition and other support services is essential.

“This is such a big operation,” Dr. Caterson said.

“My component is important, but we have to integrate with all the other aspects of patient care to achieve successful outcomes.”

For Jones, having her care at the Graham Cancer Center also meant never having to travel elsewhere for essential services like genetic counseling and testing, nutrition, psychosocial oncology, social work and more.

Frazier is tasked with assuring safe passage for patients crossing the walkways or transferring in and out vehicles and wheelchairs while making their way to the triage nurse or appointments inside.

As the COVID-19 pandemic continues, Frazier is also the first check to ensure that masks are on and worn properly by everyone entering the building.

patients, their family members and care givers,” said Cancer Program Clinical Director Cindy Waddington, MSN, RN, AOCN, NE-BC. “Patients know our greeters by name and look for them upon arrival,” she said.

“At a time when they may feel anxious and vulnerable, our patients report they feel reassured when they drive up and see our patient guides at their station ready to assist them.”

Frazier has earned commendations from patients and nurses alike.

“As a former Navy man, I am all hands on deck,” Frazier said. ‘”I love my job because I know our patients need me.”

“Our patient guides often develop lasting and meaningful relationships with our

“I did get a second opinion in Philadelphia, but I know I made the best decision to stay closer to home,” Jones said. “I not only received excellent care, but my doctors, the staff and even the other patients were always compassionate and encouraging.

“The beautiful people at the cancer center were an avenue of hope when I felt most hopeless; they were an inspiration and a lifeline.”

Cindy Waddington, MSN, RN, AOCN, NE-BC and Kevin Frazier

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Life-like tattoos and 4D nipple reconstruction help breast cancer survivors feel whole again after surgery

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fter her mastectomy and breast reconstruction surgery, Teri Diaz, 40, was on her way to recovery, but she didn’t feel quite finished yet.

For many women like Diaz, who undergo surgery for breast cancer, nipple-sparing mastectomy is not an option, and this part of the breast must be removed.

Having their nipples reconstructed or tattooed can be an important final step to complete the breast reconstruction process.

Nipple reconstruction and tattooing made a world of difference to me,” Diaz said. “I look at myself in the mirror now, and it feels good. I have my breasts back.”

The Center for Breast Reconstruction, under the direction of Stephanie Caterson, M.D., offers women who have had breast cancer surgery a full range of options, including the latest microsurgical flap reconstruction procedures to restore the natural appearance of their breasts.

After reconstruction, once the breast tissue has healed, women may choose either 3D tattooing of the nipple and areola (the dark area around the nipple) or 4D nipple reconstruction with tattoos to complete their look.

About three months after microsurgical reconstruction of her right breast, Diaz returned as an outpatient for her 4D nipple reconstruction. It took about 30 minutes for Dr. Caterson to create a new, life-like nipple in the front of the breast by folding over and sewing a small bit of skin.

A few months later, Diaz sat down with Physician Assistant Kerry Gregory, PA-C, at the Center for Breast Reconstruction, to complete the finishing touches.

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Gregory is certified to perform nipple and areola tattooing, having trained in the most advanced techniques available to medical professionals with some of the world’s most renowned tattoo artists. She uses her color pallet and perspective to help women feel whole again after breast reconstruction surgery.

She applies the tattoos the traditional way using needles to insert pigment into the skin. Newly reconstructed breasts have little sensation, so the procedure is virtually painless.

Teri Diaz and Kerry Gregory, PA-C

Women who do not choose nipple reconstruction can have 3D nipple tattoos that lie flat but with color and definition that looks like a natural nipple.

“We spend a lot of time choosing just the right pigments to create a natural looking tattoo that matches the patient’s skin tones and characteristics,” Gregory said.

“When our patients look in the mirror, they no longer see the scars of their experience.

They see something that makes them happy. They feel complete.”

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ChristianaCare breast surgeons specialize in cutting-edge protocols to find and remove cancer First in Delaware to offer new radar guided tumor localization technology

very stressful surgical day for the patient,” said Dawn Johnson Leonard, M.D., chief, Division of Breast Surgery.

In the operating room, with the reflectors activated, Dr. Leonard used non-radioactive, radar guidance to precisely locate and remove Godwin’s cancer, limiting the amount of healthy breast tissue removed.

“For appropriate patients, wire-free tumor localization makes lumpectomies easier and safer,” she said, “particularly in areas where sensitive structures, around lymph nodes, for example, could be damaged easily.”

At the Graham Cancer Center, breast surgeons are part of an entire breast cancer treatment team that includes medical, surgical and radiation oncologists, and other specialists who work collaboratively with patients and loved ones to develop individualized treatment plans for the best possible outcomes.

“As members of this multidisciplinary team, we want our patients to know that breast cancer is a survivable disease, and we expect to cure the majority of the patients who walk through our doors,” said Dr. Leonard. “For those we can’t cure, we have hope, because we still have many treatments that can help control their disease.”

Elaine Godwin and Dawn Johnson Leonard, M.D.

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he ChristianaCare Breast Center at the Helen F. Graham Cancer Center & Research Institute is the first in Delaware to offer SAVI SCOUT® tumor localization technology prior to breast conserving surgery for women with earlystage breast cancer.

The new technology made it possible for Elaine Godwin, 63, of Newark, Delaware to have important pre-operative tumor mapping a few weeks before her lumpectomy to remove the cancer.

“My best friend died from breast cancer, so I was feeling anxious and overwhelmed about the entire experience,” Godwin said. “I was

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glad to have one less thing to worry about on the day of my surgery.”

Tumor localization helps surgeons plan the best route to approach and remove the cancer. Traditional wire localization, usually on the day of surgery, uses actual wires that stick out of the chest to mark tumor location.

Instead of wires, the radiologist mapped Godwin’s tumor by inserting a nonradioactive reflector about the size of a grain of rice. The reflectors are inactive and can be inserted up to 30 days before surgery.

“Wire-free localization reduces discomfort and simplifies and shortens what is often a

In addition to traditional mastectomy, sentinel node biopsy and lymphatic mapping, breast surgeons specialize in a variety of breast conservation and reconstruction techniques, including nipple and skin sparing mastectomy. They work collaboratively with the Center for Breast Reconstruction to identify appropriate candidates for leading edge, microsurgical breast reconstruction as well as oncoplasty, breast reduction, implants and lifts.

Breast Center surgeons serve as principal investigators on national clinical trials through the National Cancer Institute’s Clinical Trials Network, bringing the latest cancer treatments and technologies close to home. Locally, the Breast Surgeons Practice has initiated studies in operating room safety and efficiency, pain management and post-surgical recovery.

They also participate in studies initiated by The Cawley Center for Translational Cancer Research at the Graham Cancer Center.

Two nurse navigators work with the Breast Surgeons’ Practice to provide support for patients as they move through their cancer treatment experience.

“Our aim is to be an extra layer of support for our breast cancer patients from diagnosis and throughout treatment and to help connect them with the appropriate supportive services they may need," Nurse Navigator Kathy Coward, BSN, RN, OCN, CCM.

As members of the Cancer Care Management team, nurse navigators and social workers offer information, support and solutions to the many concerns that arise during the course of cancer treatment. One quality performance initiative tracks high-risk patients after discharge to help them avoid the need for hospital readmission.

“I feel very fortunate to have Dr. Leonard and her team working to cure my cancer,” said Godwin. “With each step, I feel more confident and reassured. I am so glad I chose the Graham Cancer Center. Everyone has made me feel so much better.”

“With five breast surgeons onsite who comprise a multigenerational team of specialists, we are able to offer our patients more surgical options than ever before,” said Dr. Leonard.

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At the ChristianaCare Breast Center, comprehensive breast health care includes integrated genetic counseling and testing services At the ChristianaCare Breast Center, boardcertified, licensed genetic counselors collaborate with a multidisciplinary team of professionals to ensure that every eligible patient has access to timely genetic counseling and testing services.

“Breast cancer that runs in the family is an important risk factor, as well as the presence of other cancers in the family,” Ali-Khan Catts said. “We want to make sure every woman diagnosed with breast cancer has the opportunity for genetic counseling and testing.”

“We are working closely with our breast surgeons practice to offer genetic risk assessment services to all of their patients.” said Director of Genetic Counseling Zohra AliKhan Catts, MS, LCGC, at the Helen F. Graham Cancer Center & Research Institute’s Familial Cancer Risk Assessment Program.

Working with a patient’s personal and family medical history, a licensed genetic counselor looks at patterns in the family tree that could suggest a higher risk for hereditary cancer.

Based on this information, the genetic counselor can help patients determine if genetic testing is the right next step.

Typically 5 to 10 percent of breast cancers are inherited. Genetic changes or mutations in genes such as BRCA1 or BRCA2 that are passed down from a mother or father are considered to be the single biggest risk factor for inherited breast cancer.

With just a small sample of blood or saliva, genetic testing looks for changes or mutations in a person’s DNA or genetic makeup to determine the likelihood that a person has or will develop a hereditary cancer. As DNA sequencing technologies evolve, increasing numbers of genes associated with breast and other cancers are beginning to emerge.

Guidelines from the American Society of Breast Surgeons now recommend that every patient who sees a breast surgeon should be evaluated for hereditary risk of cancer and the potential need for genetic testing and/or genetic counseling.

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From left: Paula Furtado; Pawel Pomianowski, M.D.; Brooke Meader, MS, LCGC; Zohra Ali-Khan Catts, MS, LCGC; Bruce Boman M.D., Ph.D.; Kendra Flores, MS, LCGC; Nicole Lester, MS, LCGC 9

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Today’s broader screening map, Ali-Khan Catts says, gives us an increasingly informative picture of a patient’s unique genetic make-up and her risks for developing a particular type of cancer.

“We are seeing as many as 8 to 10 percent of women testing positive for mutations in this larger pool of genes,” she said. “Armed with this information, women and their doctors can make better informed decisions about managing their cancer today as well as their cancer risks for the future.”

Genetic counselors are also partnering with Breast Center radiologists and breast imaging teams to reach out to women during routine screening visits to identify cancer risk factors in their personal and family medical histories.

“We want to make sure that each of our patients at the Breast Center is getting the most appropriate and informative screening right from the start,” said Ali-

Khan Catts. “Genetic modeling based on a woman’s family and personal history can guide us to what screening modalities might be beneficial besides a mammogram such as an MRI for those at high risk or an abbreviated MRI for those at moderate risk.“ Similarly, genetic testing can guide decisions about surgical management or the most effective treatment options.

Genetic counselors are partnering with ChristianaCare medical oncologists and primary care physicians to increase awareness about genetic assessment services among patients diagnosed with three subtypes of breast cancer. These subtypes, known as early onset, HER2 negative metastatic breast cancer and triple negative breast cancer, do not respond well to the standard chemotherapy regimens. Funding for this effort comes from the Association of Community Cancer Centers in partnership with Pfizer Global Medical Grants.

“We are also teaming with ChristianaCare Community Outreach and Education to spread the word about genetic counseling services in our communities,” said Ali-Khan Catts, “where, for example, incidence of syndromes such as triple negative breast cancer are two to three times more likely to occur among African-American women.”

The Familial Cancer Risk Assessment Program at the Graham Cancer Center is one of only three such comprehensive statewide programs in the United States that documents cancer risks that run in families. The program also offers consultations for hereditary cardiovascular disease, adult onset and childhood onset hereditary syndromes, genetic neurological disease, and prenatal risk assessment and counseling.

from Delaware and surrounding communities whose family histories representing in some cases extend back generations. Patients who participate in the genetic counseling program can have their family history data entered into the registry to help scientists learn more about cancer patterns in our community and work toward new discoveries in cancer prevention, diagnosis and treatment. The team is also building similar registries for cardiovascular and adult onset neurological diseases.

“What we know about the genetics of cancer and other diseases is rapidly advancing,” said Ali-Khan Catts. “Our cancer genetics program at the Graham Cancer Center is an important resource for comprehensive and personalized cancer care and risk management.”

The High-Risk Familial Cancer Registry currently houses data on 13,988 individuals and their 496,030 relatives

“With more sophisticated testing methods, we can now examine a much larger panel of susceptibility genes. Currently, we can test for as many as 47 different genes associated with common hereditary cancers. Many of these are associated with an increased risk for developing breast cancer and other cancers as well, including pancreatic, ovarian and colon cancer.”

Ali-Khan Catts, MS, LCGC

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Radiology imaging onsite is one more reason to choose the ChristianaCare Breast Center

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he ChristianaCare Radiology Department offers the latest in breast cancer imaging at the Breast Center, located onsite at the Helen F. Graham Cancer Center & Research Institute as part of a comprehensive array of personalized breast health services.

“Being onsite to care for our patients in person, allows us to more accurately evaluate breast concerns and enables us to perform breast biopsies as needed,” said Jennifer P. Rowland, M.D., chief of Breast Imaging, and a member of the Breast Center team.

Breast Center radiologists subspecialize in breast imaging interpretation of mammography, breast ultrasound and breast MRI, and performance of image-guided breast procedures. Their in-depth knowledge of breast anatomy, pathology and surgical procedures allows for interpretation of subtle imaging findings. These specialists have experience with unusual presentations of breast cancer and uncommon breast health conditions.

“By focusing exclusively on breast imaging, our radiologists are highly skilled at identifying breast cancer at the earliest appearance on screening mammography,” said Dr. Rowland.

“Finding and treating breast cancer at the earliest stage saves the most lives.”

The breast radiology team is also expert at performing image-guided breast biopsies for tissue diagnosis and image-guided breast procedures, including the latest wire-free tumor localization, to assist with breast surgery.

A robust breast MRI program offers supplemental screening for women with a high lifetime risk of breast cancer. The technology also is used for diagnostic purposes to evaluate breast symptoms or breast implants and to provide pre-operative assessment or post-treatment evaluation.

The team has developed a fast breast MRI protocol to expand availability and access to screening breast MRI for women with dense breast tissue or at intermediate lifetime risk of breast cancer.

Collectively, the breast imaging team has extensive research experience and members have gained national and international recognition as leaders in the field. Team members have contributed to the development and implementation of breast MRI and helped to revise the Breast Imaging Reporting and Data System (BI-RADS), the standardized lexicon and system used by radiologists to assess and communicate breast imaging results and recommendations.

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Pictured: Meghan Fedullo, RT, RM, BS, Shannon Hostetter, BS, Jennifer P. Rowland, M.D.

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At the Breast Center, the optimal patient experience starts even prior to arrival. Preregistration one or two days before a patient is scheduled for diagnostic breast imaging and breast MRI allows the staff to clarify symptoms so that the imaging work-up can be appropriately tailored to address their clinical concerns. This allows time to adjust prescriptions and obtain prior imaging for comparison, as needed.

“Our pre-registration workflow is designed to maximize the patient experience,” said Breast Center Operations Manager Shannon Hostetter, BS. “Our patients tell us they are impressed with the convenience and efficiency they experience when they come for their appointments at the Breast Center.”

Unlike most breast imaging centers where technologists only perform mammography, ultrasound or breast MRI, at the Breast Center technologists are encouraged to cross-train in the different imaging modalities. The staff aims to pair patients with a single technologist during their appointment.

“We have learned that continuity of care fosters increased trust between our patients and providers,” said Dr. Rowland, “and also prevents loss of pertinent clinical information that can occur with a hand-off or transition of care.”

If there is a suspicious finding seen on ultrasound and the radiologist recommends

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a breast biopsy, the patient has the option of having a same-day procedure.

It is likely that the same radiologist will perform the breast biopsy with the assistance of the same technologist while having the patient remain in the same ultrasound suite as used for the diagnostic evaluation.

“Less moving around, less wait time and fewer encounters with different staff means a more personalized, less stressful experience for our patients,” said Meghan Fedullo, RT, RM, BS. “If multiple imaging or biopsy is required, I’ll be right there for my patients, every step of the way.”

All next steps in a patient’s care are coordinated to make the process as easy and seamless as possible. The radiologist will call and discuss the breast biopsy results with each patient, and the breast center staff will schedule the patient for an appointment with a breast surgeon, if needed.

“Having the multidisciplinary breast care team in a single location also helps facilitate collaboration and communication among providers, ultimately leading to better patient care,” said Dr. Rowland. “We have multiple platforms available to facilitate discussion of complicated patient care decisions.”

The breast imaging team works closely with the breast surgeons, plastic surgeons, radiation oncologists, medical oncologists, pathologists, genetic counselors and other members of

the breast care team. They gather to present and discuss cases during weekly multidisciplinary tumor conferences, converse via secure virtual platforms and through a shared electronic health records system.

“Several times a day, we simply walk across the hall to have a face-to-face discussion or to review breast imaging in person,” said Dr. Rowland. “We respect and value one another’s subspecialized training, knowing that we offer better care for patients with our collective knowledge, experience and expertise.”

The personal, hands-on care that each team member provides helps ease what can become a stressful experience for patients sometimes faced with the unexpected.

Operations Manager Hostetter knows that insurance concerns and billing issues can add to that stress. “From scheduling to check-in to imaging, we want our patients to know the Breast Center experience is truly all about them, their comfort and their convenience,” she said. “Our patients trust our partnership and the role our team plays in their breast health.”

Mastectomy pillows made with

love

Marie Willey knows how hard recovery from breast cancer can be. After her mastectomy, she found comfort and support from a pillow she could get her arms around. “I decided to make a pattern and started sewing pillows myself to share with other patients,” Willey said. She began making and distributing two or three a week on her visits to the Helen F. Graham Cancer Center & Research Institute. There’s a heart inside each pillow and an encouraging note attached. “I think about each person who receives one of my pillows, and I want them to know what is in my heart,” Willey said.

“I don’t know you, but we are on the same journey.

Here is big hug from me.’’

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News Briefs

ChristianaCare breast radiologist addresses JAMA Network Open on the benefits of screening mammography for women over 75 Breast Radiologist Catherine M. Tuite, M.D., in the Department of Radiology at the Helen F. Graham Cancer Center & Research Institute published a guest commentary in JAMA Network Open (Aug. 26, 2021 online) on the potential benefits of screening mammography for women 75 years and older.

“The incidence of breast cancer increases with age, and given that the data support at least a modest association between breast cancer risk and breast density in older women, continuation of screening mammography in healthy women aged 75 years or older may offer a substantial opportunity to avoid morbidity and mortality from breast cancer in this age group,” Dr. Tuite writes.

Dr. Tuite points out that most breast cancers are still diagnosed in women of all ages with no previously identified major risk factors.

She advises caution in restricting screening for women at any age, even for those with lower than average risk.

“Ultimately, the decision of when to stop screening is personal, and each woman deserves the agency to weigh her own wishes, values, and life experiences with an accurate and unbiased discussion of risks and benefits of screening mammography in making that decision,” said Dr. Tuite.

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Graham Center medical oncologists co-author study showing advanced tumor profiling technology means more patients matched to precision cancer therapies In a study co-authored by medical oncologists Michael Guarino, M.D, and Jamil Khatri, M.D., at the Helen F. Graham Cancer Center & Research Institute, findings showed that cancer tumor profiling using advanced next generation sequencing can substantially increase patient access to tissue-based tumor profiling.

The Graham Cancer Center has partnered with Strata Oncology since 2018 to offer next-generation tumor profiling to patients with advanced or rare cancers. Based on test results, eligible patients are matched to the best available clinical trials or most innovative therapy.

Using the StrataNGS test, more than double the number of tumor tissue samples met the minimum tumor surface area requirement for comprehensive genomic profiling, compared to other leading commercial tumor profiling tests, according to research published in JCO Precision Oncology, Aug. 19, 2021.

“We are excited that this study shows that more of our patients can benefit from the opportunity to participate in precision medicine clinical trials without leaving the state of Delaware,” said Dr. Guarino. “This technology can successfully analyze the genome of more tumor tissue samples and that enables us to target more cancers with specific therapies, hopefully resulting in better outcomes for more patients.”

As of June 1, 2021, 2,793 cancer patients at the Graham Cancer Center have had their tumors profiled. Of those, 784 patients matched to a precision oncology therapy and 625 patients had their tumors matched to open clinical trials.

Donation to Cancer Special Needs Fund From left: Nicholas Petrelli, M.D., Kaitlyn Foraker and Holly Foraker. Kaitlyn and Holly delivered cake pops to the staff of the Graham Cancer Center. Kaitlin has been baking and selling cake pops in honor of her late grandmother and patient, Joyce Webber.

She also presented Dr. Petrelli with a check from the proceeds to support the Cancer Special Needs Fund.

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