Cancer Program Annual Report 2016

FEATURE: An Overview of Breast Cancer

Rishi Agarwal, M.D., MSc
Oncology & Hematology

Breast cancer is the most common cancer in U.S. women except for skin cancer. It is second only to lung cancer as a cause of cancer death in women. Advances in research have led to several new effective changes in diagnosing and treating breast cancer, which have led to a gradual decline in the death rate from breast cancer in the last few decades.

Anatomy of the Breast
The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. Lobules end in dozens of tiny bulbs that can produce milk. Thin tubes called ducts link the lobes, lobules, and bulbs.

Breast cancer remains the most common malignancy diagnosed among women in the world, with about 1.7 million women worldwide diagnosed in 2012. The incidence rates are higher in developed countries. In the United States, about 252,710 new cases of invasive breast cancer will be diagnosed in women and about 40,600 women will die of breast cancer in 2017. Also in the U.S., 1 in 8 women will develop breast cancer in their lifetime. Besides invasive cancer, about 63,400 women will likely be diagnosed with Carcinoma in Situ (precancerous or earliest form of breast cancer).

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Click circles below to see 2016 statistics on Breast Cancer.


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UK Markey Cancer Center Affiliate Network

In 2016, The Medical Center at Bowling Green affiliated with the University of Kentucky Markey Cancer Center, the state's first and only National Cancer Institute-designated cancer center, through the UK Markey Cancer Center Affiliate Network. The UK Markey Cancer Center Affiliate Network was created to provide high-quality cancer care closer to home for patients across the region, and to minimize the effects of cancer through prevention and education programs, exceptional clinical care, and access to research.

Digital Breast Tomosynthesis Units

In April 2016, both The Medical Center’s Radiology Department and Western Kentucky Diagnostic Imaging purchased and installed new digital breast tomosynthesis units. The new units will allow each facility to offer the latest technology for screening and diagnosis of breast cancer.

Patient Navigator Program Expanded

In 2016, The Medical Center expanded the program by transitioning the cancer patient navigator to full time status, enabling the navigator to transition from a radiation oncology-based navigator to a more hospital and community-wide service. In doing this, we were able to provide face-to-face service to the community by meeting with patients in physician’s offices or other designated areas. The navigator increased coverage to include patients in the entire 10-county Barren River Area Development District through direct referral to local resources and programs available in the area.

ACR Lung Cancer Screening Centers

In 2016, The Medical Center at Bowling Green, The Medical Center at Franklin and The Medical Center at Scottsville were awarded the ACR Lung Cancer Screening Center designation by the American College of Radiology. This designation is only awarded to providers that achieve accreditation in the chest module and those whose facility meets or exceeds the requirements set forth by the ACR Lung Cancer Screening Committee.

Advanced Neurological MRIs Using 3T Technology

In 2016, our state-of-the-art MRI suite was completed, offering a newly constructed MRI department that contains approximately 3,000 square feet and houses the Philip’s Ingenia 1.5 T (Tesla) and Ingenia 3T (Tesla) “open” wide-bore MRI systems.

MIMS Software

MIMS Software is software specific to radiation oncology planning that performs “deformable registration.” This allows the dosimetrists to more accurately fuse PET scans with treatment planning CT scan, especially if the patient is scanned in different positions. The software also allows the physics team to perform “composite” doses across different treatment planning platforms. MIMS also has advanced contour features that allows for outlining both normal and tumor bearing structures more easily. These are significant enhancements in planning of radiation oncology patients.


Physician Reviewer:
Rishi Agarwal, M.D., MSc,
Oncology & Hematology

Physician Study: Adjuvant systemic therapy practices in node negative (Except N1) hormone receptor positive HER-2 negative breast cancer during 2014-2015.


There is considerable ambiguity in treatment of early stage hormone receptor positive, HER-2 negative breast cancer. Most patients with tumor size > 0.5 cm will benefit from adjuvant hormonal therapy but the selection criteria for patients who would benefit from systemic chemotherapy is still under development. Guidelines are vague and several factors such as age, pathological staging, multigene signature methods, size of the tumor, lymph node status, etc., can play a role in deciding if patients would be candidates for hormone therapy plus chemotherapy or hormonal therapy alone or no systemic therapy.


We reviewed charts of hormone receptor positive, nonmetastatic, T1-T3, N0 - N1, treated in 2014 and 2015. We only included hormone receptor positive patients who were negative for HER-2.


Included in the study were 172 patients with a median age of 62 years (range 25-91 years). Of those patients, 164 were alive at the time of data entry. Pathological staging and grades were as follows:

Pathological staging:

  •           Stage 0 - 24 patients
  •           Stage I - 94 patients
  •           Stage II - 43 patients
  •           Stage III - 2 patients
  •           Unknown stage - 1 patient

Pathology grades:

  •           Low grade pathology - 79
  •           Intermediate grade pathology - 52
  •           High grade pathology - 24
  •           Stage III - 2 patients
  •           Unknown grade pathology - 17

Multigene assays were done in 20 patients, leaving multigene analysis unavailable for 152 patients. Of the patients who had Oncotype DX(n=13), a low recurrence score was found in 4 patients, intermediate recurrence score in 2 patients, and a high recurrence score in 6 patients. Results are not known for 1 patient.

Among patients who had the Mamma-print assay, 4 were low risk of recurrence and 1 was high risk of recurrence. In 2 patients, the type of multigene assay was not available, but both were low risk of recurrence.

None of the 10 patients with low risk of recurrence (n=10) got chemotherapy. Hormone therapy was received by 8 of the 10 patients. Of the 7 patients with high risk of recurrence, 6 got chemotherapy. Among the 2 intermediate grade patients, 1 got hormone therapy and 1 did not get any systemic therapy.

Based on pathological grading, 84 patients had well-differentiated tumors. Out of those 84, 11 received chemotherapy, and 10 of those who received chemotherapy also got hormonal therapy afterward.

Of the 30 patients who had poorly differentiated pathology, 14 patients got chemotherapy and 11 of the 14 did get hormone therapy afterwards. Out of all the poorly differentiated pathology, 18 got hormonal therapy. Out of all poorly differentiated patients, 7 got only hormonal therapy without any chemotherapy.

Fifty-eight patients had moderately differentiated histopathology. Twenty-three of those patients got hormonal therapy. Twenty patients got chemotherapy. Sixteen out of those did not get any systemic therapy or it is unknown.


Although our analysis is limited by several factors, including missing data and retrospective review, it’s evident that significant heterogeneity exists in the use of systemic therapy in patients treated with local modality. Multigene signature methods were either not used or the results were not available in most patients. Recent studies have shown that multigene panels could help identify patients even in high risk pathology group who may not need chemotherapy. More widespread use and reporting of multigene assays will be beneficial, as well as careful selections of patients who would benefit from chemotherapy. Further steps need to be taken to standardize post local therapy treatment in early stage breast cancer patients.


The Medical Center
Cancer Treatment Center for Southern Kentucky
250 Park Street
Bowling Green, KY 42101

(270) 781-7178 or 1-800-745-1213
Cancer Registry (270) 745-1288

Barren River Regional Cancer Center
103 Trista Lane
Glasgow, KY 42141

(270) 651-2478 or 1-877-573-0050