Dr. Howard’s Ongoing Quest for the Best Possible Breast Cancer Care

By Aug 15, 2019 September 12th, 2019 News, Surgeon Spotlight

Photo courtesy of The Paducah Sun

With 30 years in practice, Dr. Daniel Howard, a General Surgeon at Mercy Health — Lourdes Hospital, can still define exactly what attracted him to surgery. “It was the binary choice,” he confided. “I like the surgical thought process. You either need surgery or you don’t. And if there’s a problem, you fix it. I like these kinds of clean decisions.”

But one aspect of surgery Dr. Howard is glad to leave in the past is the old, oversimplified, one-size-fits-all approach to breast cancer treatment. “Decades ago, every patient was typically treated with a modified radical mastectomy followed by chemotherapy,” he stated. “Then the lumpectomy came along and we said to ourselves, ‘Wow! We don’t have to do this to people anymore.’ That’s why for the last 20 years, I’ve really tried to stay on the forefront of the latest breast cancer treatments.”

Staying ahead of the curve

True to this mission, Dr. Howard was practicing neoadjuvant chemotherapy years before the treatment received widespread adoption. “If you think about most of the people you’ve ever known receiving chemotherapy, they got it after their surgery and they took it hoping it’s going to do something of value,” explained Dr. Howard. “But when you identify the people that will need chemotherapy in advance, you can treat them first and actually watch the tumor melt away. You can get a complete or near-complete pathologic response and your patients can get on with their lives. With this treatment, we’re now seeing no evidence of disease after 5 years in 95 percent of patients.”

Dr. Howard is also a leader in providing oncoplastic surgery to improve both cosmetic and health outcomes for his patients. Utilizing plastic surgery principles, oncoplastic technique re-approximates breast tissue to fill in the void where cancer was removed, thereby preserving the appearance of the breast. Key to the success of oncoplasty is clear margins during the first surgery. Because breast tissue has been rearranged, in the event of a positive margin, it is unclear where the additional tissue needing removal may be. “When we started doing this a decade ago, the nationwide average for clear margins was somewhere between 20 and 45 percent—it ranged all over the place.” 

In response to the issue, Dr. Howard started using routine ultrasound 25 years ago, ahead of other providers, which pushed the clear margin rate for his patients under 10 percent. But then a new tool came on the market to drive this rate even lower—MarginProbe.

MarginProbe® maximizes the potential for clear margins

Recent years have seen a dramatic improvement in clear margin rates across the country and, according to Dr. Howard, the national average is now hovering approximately between 15-20 percent. But Dr. Howard’s practice at Mercy Health continues to lead in this area, with a positive margin rate now as low as 2 percent, thanks in part to the introduction of MarginProbe. 

“MarginProbe has been very helpful in further putting the math in our favor, particularly with tumors you cannot see such as DCIS and invasive lobular cancers and identifying their exact location and extent,” the physician explained. “Clear margins are one of the single most important ways to provide a good cosmetic outcome during the first, and hopefully only, surgery, particularly if you’re going to use intraoperative radiation. The positive benefits of intraop radiation will be negated if you don’t have clear margins. And if you have positive margins then you worry about having to go back and performing more surgery that can ruin your cosmetic work and then you need to redo everything. That’s why MarginProbe has been a very helpful device over the last couple of years. While we were already doing well, this device has given us another approximate 3-5 percent improvement in our clear margin rates, which pushes us down from 5-6 percent overall to 1-2 percent. That’s a really good thing and it’s why we use MarginProbe on every single lumpectomy we perform.” 

Dr. Howard’s practice at Mercy Health is the only facility in the state of Kentucky to take advantage of MarginProbe, and it’s leading the state, and the nation, in many other areas of breast cancer treatment. They are one of the few practices in the country using intraoperative ultrasounds routinely, and intraoperative radiation which can result in “one shot, one treatment,” in appropriate cases. The practice is also utilizing axillary reverse mapping for lymph nodes to help preserve arm lymphatics. All taken together, the 5-year survival rate for the practice is 97 percent across all types of breast cancer cases.

Looking ahead

Even with these significant results, Dr. Howard continues to look forward to even more robust treatments for breast cancer that are just on the horizon. The physician feels that medication trials with drugs such as Keytruda® and Opivo® are demonstrating possibilities for patients that are not responding to more traditional treatments, and that neoadjuvant endocrine therapy also holds great promise for the future.

“This is a big deal, as these treatments work through a different mechanism,” added Dr. Howard. “It will take some time to determine who can benefit the most, but it will also enable us to get more specific and more personalized in our therapy—especially when you compare it to the ‘one-size-fits-all’ approach of 30 years ago.”

Daniel Howard, MD

Dr. Howard was born in Heidelberg, Germany and grew up in central Kentucky. He moved to Paducah in 1988 and joined Mercy Health in 2011. He performs all aspects of general surgery but with a special interest in breast cancer surgery, always engaging with the latest breast cancer workshops and events.

Education:

  • University of Louisville Hospital
    Residency, Surgery, 1988
  • University of Louisville Hospital
    Internship, Surgery, 1984
  • University of Louisville School of Medicine
    Medical School, Surgery, 1983

Certifications:

  • AB Surgery
    Board Certification

Mercy Health — Lourdes Hospital

This organization serves as a regional referral center for a wide geographic region, including more than a dozen counties in western Kentucky, southern Illinois, southeast Missouri, and northwest Tennessee. Mercy Health — Lourdes Hospital offers an extensive array of medical specialties and technologies typically found in much larger urban settings.

Awards and Accreditations include:

  • Breast Imaging Center of Excellence by the American College of Radiology
  • Centers for Medicare & Medicaid Services (CMS) Five Star Agency
  • Level 3 Patient-Centered Medical Home (PCMH) status
  • Rehab CARF Accreditation (2018 – 2021)
  • Wound Care Center of Distinction (2017)
  • Blue Distinction® Center for Maternity Care
  • American Academy of Sleep Medicine Accreditation