Journal News

Estimated printed pages: 6
July 9, 2006
Section: News
Page: 1A

Small hospital, big progress
Melissa Klein
Staff
The Journal News
Patients seek out Dobbs Ferry doctors for breast surgery technique
Melissa Klein The Journal News DOBBS FERRY Rori Clark is not the type of patient you would expect to find at Community Hospital at Dobbs Ferry. Clark is healthy and lives some 1,300 miles away in Parkland, Fla. But she traveled to have surgery at one of the smallest hospitals in New York state that was, until recently, little known outside of the village. An Internet grapevine led her to Community Hospital, and a meeting with the surgical team at its Ashikari Breast Center persuaded her to go through with a difficult surgery she had long contemplated. Last month, she had a double mastectomy to prevent breast cancer. "I just knew that if I was going to do it, it was going to be now, and it was going to be with these doctors at this hospital," Clark said in mid-June, two days after the operation. Clark, a 39-year-old mother of three, and the other women who have come to the hospital from across the country are drawn by a new one-step procedure in which their breasts are removed and then reconstructed, eliminating multiple surgeries. Some have breast cancer and others, like Clark, are at high risk for the disease because of a genetic mutation. "So that was a huge factor, to wake up and have breasts and be done," Clark said. "Be done, be done, be done and get on with my life and not have to do any more surgeries, look great, feel great and have my main thing, which is the breast cancer reduction." The unique approach is a collaboration between breast surgeons Roy Ashikari and his son, Andrew Ashikari, and plastic surgeon Andrew Salzberg. In high-risk women, the Ashikaris use a surgical technique to spare a woman's nipples, and Salzberg pioneered a method that creates enough room for implants to be inserted immediately. The surgeons treat about 250 cases a year at the breast center, which opened in 2004. The center has helped bolster the bottom line of a hospital that struggled financially for years and nearly went out of business. The 50-bed hospital, which was founded in 1893, was sold at auction in 2002 after it failed to make payments on a federal loan used to finance a new building in the 1980s. St. John's Riverside Hospital in Yonkers purchased the hospital and runs it as part of its Riverside Health Care System. After the takeover, some workers were laid off, and, to attract more patients, the hospital added speciality programs such as a sleep center, a program for weight-loss surgery and the breast center. "Normally people go to the hospital based on primary-care doctors," said Ronald Corti, president of Community Hospital. "Here they come for the primary-care doctors and the specialties that we have in place, and the breast center is key in that area." Last year, the hospital showed a profit - $750,000 - for the first time in years. Dr. Roy Ashikari, a well-known breast surgeon who once led the breast service at Memorial Sloan-Kettering Cancer Center, said the hospital's small size was an advantage for treating cancer patients. A woman who has a suspect lump can be evaluated by the surgical team, have a mammogram and ultrasound and a biopsy, if needed, in the matter of an afternoon. "In an hour and a half, two hours, I can tell the patient you have cancer or you don't have any cancer," Ashikari said. Hunting online Most of the patients who have surgery at the breast center have cancer. A small number are at risk for the disease because of mutations in two genes known as BRCA1 and BRCA2. The lifetime risk of developing breast cancer if you carry either of the genes is as high as 85 percent, and having them also puts women at risk for ovarian cancer. Clark has the BRCA1 mutation. She was tested after her sister was diagnosed with ovarian cancer, following the death of their mother from the disease. She had a hysterectomy and her ovaries removed three years ago and continued to be monitored for signs of breast cancer. "Not only is it expensive, it's mentally wearing," Clark said. She began to do research on prophylactic, or preventative, mastectomies and found an organization called FORCE: Facing Our Risk of Cancer Empowered. The group has a Web site, www.facingourrisk.org, where women post messages about their surgical options. It was there that Clark heard about the Ashikaris and Salzberg and a village called Dobbs Ferry. "I didn't know anything about it," she said. "I've been to New York, but in the city." Controversial procedure In women who want preventative mastectomies, the Ashikaris do what's called a subcutaneous mastectomy. They make an incision under the breast, remove almost all the breast tissue and leave the nipples intact. The method leaves the breasts looking similarly as they did before surgery and, in some women, sensation is maintained. But it is not widely embraced, because a small amount of breast tissue remains. "That tissue is still there ... for a cancer to (potentially) develop," said Marlene Frost, a professional associate in research at the Mayo Clinic in Rochester, Minn. "That's the major controversy." Frost was a co-author of a large 1999 study that found that prophylactic mastectomy reduced the incidence of breast cancer in high-risk women by 90 percent. Of 639 women in the study who had double mastectomies, seven went on to develop cancer, and all seven had subcutaneous mastectomies. Frost said one cancer was in the nipple and one was above the areola. "It was in that area where there would have been some tissue left," she said. Dr. Andrew Ashikari said his surgical team, which includes Dr. Pond Kelemen, shaves off almost all the breast tissue in the three-hour procedure. "We really leave nothing behind," he said. The Ashikaris, who are both surgical oncologists, also practice at Westchester Medical Center in Valhalla. As of June 26, the team had done 42 prophylactic mastectomies, and no patients had developed cancer. About half of those operations were done with the one-step reconstruction. "What's made it popular has been the plastic surgery part," Ashikari said. One-step plastic surgery In general, there are several ways to reconstruct a breast after a mastectomy, including some that use tissue from other areas of the body. Patients who opt for implants typically undergo at least two operations. The implants have to sit under the muscle in the chest, a space that is usually too small to accommodate them. Surgeons will insert a balloon-like device called a tissue expander under the muscle that is gradually inflated over several months to create enough room for the implant. The woman then has a second surgery to replace the expander with a permanent implant and possibly a third operation to create nipples. "I was trying to figure out a way we could avoid that tissue-expansion process," said Salzberg, whose plastic surgery office is in Tarrytown. "My idea was to just forget the tissue-expander idea, let's go put an implant immediately and try to cover it with some other material besides the patient's own skin and muscle." Salzberg, who is part of the plastic surgery team that runs the burn center at Westchester Medical Center, thought of AlloDerm, a tissue-replacement product created from donated skin. It has long been used in burn care and for other treatments. In 2001, Salzberg began using AlloDerm to bridge the gap in the chest muscle once the implant was in place. "Within six weeks, it's just totally replaced by your own cells," he said. "It's perfectly natural." Salzberg said other doctors were slowly starting to use the technique. He wrote an article on using the AlloDerm method in women with breast cancer, which appears in this month's edition of the Annals of Plastic Surgery. He said there were many women at risk of breast cancer who are candidates for prophylactic mastectomy but have been avoiding it. The operation usually is covered by insurance. "A lot of women who I see didn't want to do it because they thought they'd be deformed and they thought they would be looking terrible and didn't know that this was an option," Salzberg said. Calendar girls Sharon Kulik, a special education teacher from Columbia, Md., had a prophylactic double mastectomy at Community Hospital in February 2005. She said she considered the surgery for five years and spoke with numerous doctors. She said she does not know if she would have gone through with the operation if she did not have Salzberg's one-step reconstruction. "His technique allows women to have breasts like they did before or better, and not something that is so artificial-looking, and yet reduce their risk," Kulik said. She posted her experience on the FORCE Web site, and when other women did as well, it began to catch on. "I call them the `mavens' - these women who basically have just gone out there and been our advocates for doing this, and, honestly, we've never advertised it," Andrew Ashikari said. "We were just amazed how women were coming in from different parts of the country." These "mavens" gave their doctors a gift this year. A dozen of them posed for a calendar, some wearing low-cut shirts and one in a T-shirt that says "Nice Rack." Roy Ashikari showed Clark and her husband, Terry, the calendar when she returned to his office after her surgery. She stayed in New York for a week after her operation while drains remained in place from the surgery. She felt well enough to see a Broadway show and go sightseeing. Now back home, Clark said she felt good and was very pleased with the outcome. She said she was adjusting to life without the threat of cancer. "To not have to worry anymore is just a whole new way of being now," she said. "It's really amazing." Reach Melissa Klein at mklein@lohud.com or 914-694-5063.
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