An Interview with Dr. Page, Head of Breast Consultants:

Q: Obviously with over 50,000 consultations, you are one of the leaders in the US in your field. What do you attribute your success to?

A: Well, we certainly do more consultations, averaging approximately 4,500 per year for the last 5 years, than other centers whose pathologists have great knowledge in breast disease and do breast consultations in the same manner as we do . However, I think that our consultations have a greater magnitude for several reasons. First of all, I have many capable associates helping me so that there is always somebody here who can provide a result even if I am away, as I am fairly frequently lecturing somewhere else. The other two major reasons I think we’ve been successful are that we have tried very hard to be timely in our turnaround time and that we are willing to discuss treatment options and explain things on the phone to the pathologists who are, ordinarily, inaugurating the consultation. Most of the cases we receive in the morning by expedited delivery are telephoned and faxed that afternoon. We don’t do special stains on very many cases, since it’s the nature of breast disease that you don’t need to primarily. We are also willing to talk to them on the telephone about what it might mean if it’s a problematic case or explain to them why we disagree with them or why we took a slightly different approach to it. We are also willing to talk to clinicians and more and more we are getting cases where we talk directly with patients.

Q: How do you see that evolving as patients become more and more inclined to want to take control over their own healthcare and diagnosis?

A: Well, I think the fact that patients themselves actively seek second opinions is certainly do to that and its not something we expected to see 20 or 30 years ago. Now, however, its fairly common. By the time I talk to a woman on the telephone about her breast biopsy, she has usually sought information from the web and one or two clinicians, trying to decide what are sometimes more than one option, more than one treatment, for a given condition.

Q: In your opinion, is treatment for breast disease in the U.S. too aggressive?

A: Breast disease is terribly challenging at the present time because there are a variety of things we can do. We can preserve a breast with very careful surgery and radiation therapy when the tumor is quite large. In another setting someone will say that they would prefer to have a mastectomy because it is easier and over with more quickly. There is a lot of individual choice in the different treatment options. I’m sure people are under treated occasionally but at the present time, because of the focus on breast disease, I think there is a tendency for minimal disease with very little threat to the patient to be over treated by maximal treatment just because the diagnosis is there.

Q: Has mammography changed how you treat breast disease?

A: Mammography has changed everything in the treatment of breast disease. The major thing that’s changed is the kind of lesions that we see. The mix of lesions that we see, the fact that we see many very, very small lesions that we didn’t have to deal with before, has made the field of breast pathology much more problematic than it used to be.

Q: Do you do any special research here?

A: Our research as related to the consult service certainly merits special discussion because I think it’s a trust that we gain by having all these unusual cases that we have to sort through and see what we can learn new about the unusual - they’re almost orphan diseases. For example, the largest series in the literature on metaplastic carcinomas of the breast is about 50 cases and in our consultation series we have 400. If we can have follow-up and learn more about these cases, we provide new information, not to a large amount of people because breast cancer and breast disease are incredibly diverse and are not well recognized as that as we focus on the dreaded case that can kill in the usual way of an ordinary breast cancer. I will give one specific example that we are actually very proud of. We published a paper some years ago that talks about fibromatosis occurring as a result of a breast tumor or a variant of a breast cancer. Fibromatosis is a condition well known to cause local problems by its invasiveness, but because of its occurring in the background of something that looked like a breast cancer, these cases were being treated with chemotherapy as though they could metastasize and we have identified, perhaps not with absolute certainty every time because some of them may have minimal metastatic activity, 30 to 50 cases that only have local recurrence, can not distally metastasize and , probably, shouldn’t be radiated but rather excised to negative margins by surgery just because of the nature of the process of fibromatosis. That’s a big change because prior to our identification of these cases, most of them were called metaplastic carcinoma and thought to be highly malignant and the woman treated with full therapy for a carcinoma. And picking those 30 cases out of the 400 meant a lot of sifting through. One of our research fellows, Dr. Helenice Gobbi, from Brazil, is the one who did the sifting through the cases before we published.

Q: You are expanding the number of consults that you’re going to be able to do, is that correct?

A: We’ve been talking for several years and now Dr. Roy Jensen, an important member of this consult service will continue to work with us as he moves to the University of Kansas where he will direct their cancer center. We have another close colleague who has been an author on many of our papers in pre-malignant breast disease, Loyll? Rogers, who is in Long Beach, California, and we’ve been talking about doing it there as well but I don’t know if we’ll be able to effect that, but his expertise is very great. We talked briefly with a few other people as well but its not easy to coordinate services separated across states.

Q: What brought you to the field of pathology?

A: It’s the fact that there is a great amount of diversity. I miss taking care of patients, which I did as an internist for a short period of time, but I do get to be involved in the management of patients and I am involved in training people to do pathology in a way that is targeted toward the end resolute for the patient and not just providing a diagnosis. I think a pathologist should always ask, and mostly they do, but it’s a question you have to have a lot of knowledge of clinical medicine to provide a pathology diagnosis and understand what it means with regard to therapeutic assignment and how it will impact on the patient. So, I have enjoyed doing that. My anatomic pathology division here at Vanderbilt, I lead for 22 years until 1998. I’m still very much involved in the fellowship training there and those fellows rotate through the breast consultation service. It’s a major part of their experience. We’ve had over 80 fellows at Vanderbilt since 1974 and these are people who finish their pathology training and take an extra year to learn surgical pathology more in-depth and some cyto-pathology as well. And I think that’s what -- I thought about being a university history teacher, I thought about being an internist and a surgeon -- and I think pathology has affordex an opportunity to be varied enough over the many decades I’ve now been involved doing it because what I’m doing now is the same and yet different from what I did 20 years ago -- I’m not doing general pathology as much, the consult service with 20 – 25 consults per day keeps us busy.

Q: So why did you start Breast Consultants?

A: Well, that’s actually a relatively easy question. We had to have a way to handle the outside consultations that were coming in and handle them in a preferential way. There are always some problems involved with larger services. We can on a daily basis know what cases are coming into the breast consultation service and we take great professional pride in knowing that our clients get a consistent kind of service. It’s been a challenge and I’m thankful that I’ve got a great team that has been very supportive along the way. Having it be analogous to and parallel with the rest of the Dept. of Pathology at Vanderbilt University and yet noticeably, but slightly different in the way that the material comes in directly to us and not into general surgical pathology.

Q: How has pathology changed over the last decade in your opinion?

A: One of the most exciting things to me personally about pathology is that we don’t decide how to change things. We have to be consistent with and reactive to the clinical needs so it the clinical setting that mostly changes what we do. That’s why mammography has changed us, radiation therapy has changed us. When I started in 1972, there were only two professionals involved with breast disease, the surgeon and the pathologist, and that interaction was so close that a lot of the pathology of breast disease was written by surgeons and done by surgeons. And now, of course, the number of people involved is sometimes hard to even follow, as there are people beyond medical professionals who get involved in how to handle breast cancer and the various aspects of breast cancer.

Obviously the pharmacology has also changed, the whole idea of estrogen receptor positivity as a major type of breast disease impacted on us very quickly after 1972. The result is that we now have medical oncologists, radiation oncologists, surgical oncologists, radiologist who do diagnostic mammography. At times, it’s too big a group to ever act together as a team. People talk about this promise of having all of these professionals talk together to decide what to do. It’s not possible, even in situations where there is a monthly or weekly conference where they talk together, there is a difference of opinion that has to be resolved by the primary care giver to the patient and the patient herself. That’s what’s gotten to be very complex and I think many patients accept the challenge that they have to be involved in making the decision where as other patients don’t want to have to be involved in making the decision and want somebody to make it. That is the dynamics of the practice of medicine and that is not going to change.

Q: Tell us more about your highly skilled colleagues here at Breast Consultants, PC.

A: My colleagues, of course I feel very close to them and hope that they’re own careers are being helped and aided and made richer by this experience -- they certainly helped me a lot by being involved in it. They certainly have become experts in breast pathology and as I stated, there simply are not enough people who are experts in breast pathology. But the major thing I want to say about my colleagues is none of them work only on the breast service. They are pathologists who are doing research in other areas much related to breast but not always related to breast - Dr. Roy Jensen is very much basic science as well as practical pathology. That’s also true for Dr. Melinda Sanders-Obermeier. Dr. Mary Edgerton has special expertise in informatics. She’s internationally known for her knowledge of informatics. So it’s a question of breast pathology interacting with pathology and medicine in general and not becoming a closed box.