Breast Cancer Surgery

February 22, 2021

Information

February 21, 2021

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

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00:00Support for Yale Cancer Answers
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00:05to advancing options and providing
00:07hope for people living with cancer.
00:10More information at astrazeneca-us.com.
00:14Welcome to Yale Cancer Answers with
00:16your host doctor Anees Chagpar.
00:18Yale Cancer Answers features the
00:20latest information on cancer care by
00:22welcoming oncologists and specialists
00:24who are in the forefront of the
00:26battle to fight cancer. This week,
00:28it's a conversation about breast cancer
00:30surgery with Doctor Melanie Lynch.
00:31Doctor Lynch is an assistant
00:33professor and doctor Chagpar is
00:36a professor of surgical oncology
00:38at the Yale School of Medicine.
00:40Melanie, maybe we could start off
00:43by you telling us a little bit about
00:46yourself and about what you do.
00:48I have just moved to Connecticut
00:51and joined the team at Yale from Northeast
00:54Ohio where I have been a surgeon and
00:57surgical oncologist for 20 years.
00:59My background is all based in Ohio.
01:03I graduated from the Ohio State Program
01:05Medical Scientist program where my
01:07research interest was in molecular
01:09biology and signal transduction
01:11in breast and ovarian cancer,
01:13and then in my third year of medical
01:16school I found that surgery was my calling.
01:19I did my training in general surgery
01:22and surgical oncology at Case Western
01:24Reserve in Cleveland and have
01:26built a practice in Northeast Ohio
01:29where I was most recently the director
01:31of the Breast program
01:33in the Summa Health System.
01:35In that role we helped build a
01:38team where we were able to develop
01:41comprehensive services for women with
01:43breast cancer, including same day.,
01:45next day consultations,
01:47a multidisciplinary clinic,
01:48high risk program,
01:49clinical program based on survivorship
01:51care and a oncoplastic surgery
01:54program to ensure that women had the
01:56option for the best long-term outcomes
01:59from their breast cancer surgery.
02:01Maybe we can talk a little bit about
02:05all of those issues that you
02:07kind of mentioned that you had
02:10developed in your practice in Ohio
02:12and presumably will carry on here,
02:15so I want to start at the beginning
02:17of the breast cancer journey
02:20when people don't even know
02:22that they have breast cancer.
02:24So talk a little bit about screening.
02:27This is one of the areas that I think a
02:30lot of people have questions about in
02:33terms of who should get screened when,
02:36how frequently and with what.
02:39That's an excellent question,
02:42and I think those of us who have
02:44been working in the field for quite
02:47awhile also have those same questions.
02:50The data is evolving.
02:52We have thought about cancer screening
02:54as age based that at a certain age
02:57women would begin to get mammograms
03:00and we would choose that age to
03:02begin screening based upon the best
03:05epidemiological data or the data of
03:07what we know about the population.
03:10Incidence of cancer as a whole.
03:12Overtime, we've really come to
03:15understand that screening should be
03:17risk based that some women are at
03:19increased risk for breast cancer and
03:22that increased risk may put them at risk
03:25at even younger ages than other women,
03:27and so developing guidelines that
03:29take risk into account is complex.
03:32So we have competing guidelines that say,
03:34well, maybe some women should be screened
03:38starting at age 40 or 45 or 50,
03:41but we really should take
03:43all the other components
03:45of risk into account,
03:46including family history,
03:48estrogen exposure,
03:49obesity,
03:50all of these other components of
03:53risk to help define the best age
03:56to start screening and then the
03:58best tools to use for screening.
04:00So as we move towards risk based screening,
04:04an important component of that
04:06is understanding family history
04:07and hereditary risk for cancer.
04:12So tell us more about that,
04:17if you have a relative, maybe your mother
04:20was diagnosed when she was 74 years old,
04:24but nobody else in the family
04:27has breast cancer is that
04:29the same as if somebody's you
04:33know paternal aunt was diagnosed at 35,
04:36how do you kind of wrap your head around
04:41familial risk and how
04:43do you advise patients on
04:45when an individual should get screened
04:48and with what modality that should happen?
04:53That's an excellent way to frame
04:55the question because we know breast
04:57cancer is a very common disease,
04:59so we expect one in eight women
05:01in the United States will develop
05:04breast cancer in their lifetime,
05:06so it's in most families, there will
05:08be a relative who's had breast cancer.
05:11It's when there are multiple relatives in the
05:14family with breast cancer or ovarian cancer,
05:17and when those relatives are diagnosed at
05:20a relatively young age less than age 50
05:23that we begin to have a suspicion
05:25that there may be a hereditary risk
05:28for cancer in those families.
05:30A good rule of thumb is what I teach
05:34my residence, the 3-2-1rule.
05:36If there are three or more relatives
05:39with breast or ovarian cancer,
05:41if there are two primary relatives,
05:43mother, sister,
05:44daughter with breast cancer,
05:46or if there is one relative with
05:48breast cancer at a young age,
05:51cancer in both breasts, or
05:53breast and ovarian cancer,
05:55that's kind of a quick sketch of
05:58what a high risk family might look like,
06:00and so most of us have had patients
06:03who've come to our office that might
06:05have a mother with breast cancer,
06:08but she was the only relative and
06:10she was diagnosed after menopause
06:12and that would be kind of the
06:15baseline risk of cancer that we
06:17see in the population as a whole.
06:20And we know 75% of breast cancer cases are
06:23unrelated to family history,
06:24it's the 10% of breast cancer cases
06:27that are related to hereditary risk
06:30that we can help identify by
06:32taking a detailed family history
06:34and that women themselves can begin
06:36to sort out as they talk to their
06:39relatives and figure out what
06:41their extended family looks like.
06:45So, let's breakdown those two groups then.
06:48So for the people who are at, as you
06:52called it, baseline or average risk,
06:54maybe there's nobody in their family who
06:57has history of breast or ovarian cancer,
07:00maybe their mother was
07:02diagnosed post menopause,
07:03what do you recommend for
07:05them in terms of screening?
07:07When should they start screening?
07:10How frequently should they screen and with
07:12what modality?
07:15The American Cancer Society guidelines tend to be
07:17a good balance between the
07:20competing guidelines from different
07:22professional societies and the
07:24American Cancer Society says to
07:26consider screening starting at age 40,
07:28but certainly start screening
07:30by the age of 45.
07:33That mammography is the best
07:35screening modality that women
07:37should be screened of average risk
07:40to be screened every other year.
07:46And with the consideration for screening
07:48every year for women who might have
07:51increased risk or have dense breast tissue,
07:54so those guidelines seem to be the best.
08:03And when should people
08:05stop screening?
08:07I mean should should people continue
08:09to screen well into their 80s and
08:1290s or is there a point at which
08:15you say you no longer need to get
08:17that annual or every two year
08:19mammogram?
08:23Very interesting question,
08:24because the general guideline
08:26is to stop screening within the
08:29last 10 years of life and for the
08:31average woman in the United States,
08:34the life expectancy is at 84.
08:37So we would say stop screening
08:40somewhere in your mid 70s.
08:43It's hard to predict what the
08:45last 10 years of life are though,
08:47so that's often a discussion
08:48that a woman should have with
08:50her primary care physician.
08:52And what about clinical breast
08:54exam and self breast exam?
08:56Do you recommend that to your
08:59patients or has that fallen out of
09:02favor?
09:03I do recommend that to patients
09:05because many breast cancers are
09:08identified by women themselves
09:10on their self exam and the large
09:12trials that have been done looking
09:15at self breast exam and clinical
09:17breast exam have not been able to
09:20show a benefit in overall survival
09:22by using those as screening tools,
09:24but we know that they do have
09:26value in that women will often
09:29identify cancers on their self exam.
09:31So I recommend patients continue to
09:33do self breast exam to be familiar
09:35with their breasts and changes in
09:38their breast and that women who are at
09:40increased risk for breast cancer have
09:42a clinical breast exam every six months.
09:46And so let's talk about that
09:49population who are at increased
09:51risk aside from the clinical
09:53breast exam every six months.
09:55Two questions. First,
09:56when should those clinical
09:58breast exams start and second,
10:00what other modalities do you
10:02use in that high risk population
10:05to screen for breast cancer?
10:08So the women who are at increased
10:10risk for breast cancer will often
10:12have a family history of cancer.
10:14They may have a history of radiation
10:16to their chest at a young age for
10:19the treatment of another disease.
10:21Or they may have other
10:24risk factors like obesity.
10:25Those all increase your
10:27risk of breast cancer,
10:28and by using statistical models,
10:31if we think that their lifetime
10:33risk might be greater than 20%,
10:35those are the women that we would
10:38recommend high risk follow-up,
10:40which would include this clinical
10:42breast exam every six months and
10:45screening both with mammogram and
10:48possibly with breast MRI as well.
10:51And so for my patients that
10:53fall into that category,
10:54I often see them twice a year,
10:57or I'll alternate that clinical exam
10:59with their primary care physician and
11:02then screen with both mammogram and MRI.
11:05We will recommend starting high risk
11:07screening at an age that seems to be
11:10either reflected in their family history.
11:12For example,
11:12if they have a number of relatives who
11:15develop breast cancer in their 40s,
11:17well,
11:17then we should begin screening
11:20at 10 years younger or begin
11:22screening in their 30s.
11:24So the age at which we would start
11:26this high risk screening is really
11:28based upon a family history can give us
11:30some clues as the best time to start.
11:33Great, so moving on to think about
11:36patients who have gone through screening.
11:40And let's say they've been
11:42diagnosed with breast cancer.
11:44The other thing that you had mentioned
11:47at the top of this show was this
11:50move towards oncoplastic surgery.
11:53Can you define that term for us?
11:57Oncoplastic surgery is using
11:59the best surgical techniques,
12:00including techniques that are borrowed
12:03from our plastic surgery colleagues
12:06to achieve a complete resection of a
12:08tumor and then to achieve an optimal
12:11cosmetic outcome for the breast.
12:15So how do you do that exactly?
12:19I mean, is this for people
12:23who are undergoing partial
12:25mastectomy or lumpectomy?
12:28Or are we really talking about
12:31reconstruction after mastectomy?
12:33Both techniques, and so we
12:36know that most women with breast
12:38cancer are going to survive.
12:40This is a very curable disease,
12:43and so as we plan our operations
12:46we want to achieve two things
12:48we want to achieve cure of course,
12:52but we also want to achieve a good
12:55functional and cosmetic outcome for our
12:58patients and so these operations include
13:01both breast conservation,
13:03where we're doing a lumpectomy
13:05and only removing the area where
13:07the tumor is and approaches to
13:09mastectomy with reconstruction.
13:11An example of an operation we might
13:14do for someone who is undergoing
13:16breast conservation or a lumpectomy
13:19would be an
13:21operation where we remove
13:22the area where the tumor is,
13:24and we reshape and maybe we
13:25reduce the size of the breast.
13:27We make sure that the nipple areolar
13:30complex is in the middle of the breast
13:33if we've removed a certain quadrant
13:35then that will give a better
13:37outcome in a better shape to the
13:39breast and also make sure that
13:41the tumor is removed completely.
13:43Terrific, we're going to pick up
13:45and learn a lot more about all
13:47of the different techniques that
13:49you use in oncoplastic surgery
13:52right after we take a short
13:54break for a medical minute.
13:56Please stay tuned to learn more
13:58about surgery for breast cancer
14:00with my guest doctor Melanie Lynch.
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14:12This is a medical minute about survivorship.
14:16Completing treatment for cancer
14:17is a very exciting milestone,
14:20but cancer and its treatment can be a life
14:23changing experience for cancer survivors.
14:26The return to normal activities and
14:28relationships can be difficult and
14:30some survivors face long-term side
14:32effects resulting from their treatment,
14:34including heart problems,
14:36osteoporosis, fertility issues,
14:37and an increased risk of 2nd cancers.
14:40Resources are available to help
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14:46More information is available
14:48at yalecancercenter.org.
14:49You're listening to Connecticut Public Radio.
14:53Welcome
14:54back to Yale Cancer Answers.
14:56I'm doctor Anees Chagpar, and I'm joined
14:59tonight by my guest doctor Melanie Lynch.
15:03We're talking about breast
15:04cancer surgery and Melanie,
15:06right before the break we were starting
15:09a conversation on oncoplastic surgery,
15:12which you had told us was really
15:15combining oncologic principles
15:17and how we can get breast cancer out of
15:20people with clean margins and so on,
15:23and combining it with the best
15:26practices from plastic surgery to provide
15:29a wonderful cosmetic outcome.
15:32And you started by telling us
15:34that these techniques are
15:37things that you can use in breast
15:40conservation as well as in mastectomy.
15:43So in the last example that you were
15:46talking about right before the break
15:49you were mentioning that you could do
15:52this by making the breast smaller,
15:55which is great
15:56for women who may have large breasts and
15:59who may have wanted a breast reduction,
16:01but I'm sure that a lot of our
16:03listeners may be wondering well
16:05what happens to the other breast.
16:07Nobody wants to be lopsided.
16:11Exactly, so these techniques can be
16:14used for women who have large breasts
16:16to reduce the breast and reshape
16:19the breast with a procedure for the
16:21opposite breast to provide symmetry.
16:23And again, symmetry is one of the
16:26principles of a good outcome from
16:28from one of these operations.
16:30For women who have a size and shape
16:33of breasts that they like and would
16:36like to maintain that we have
16:39ways of performing a lumpectomy
16:41where we can reshape the breast.
16:44Make sure the nipple and the areola
16:46stays in the middle of the breast and
16:49also provide a good cosmetic outcome.
16:51And for women where the amount of tissue
16:54that we need to remove from the breast
16:56in order to remove the cancer with a
16:59clear margin may create a deformity,
17:01a loss of volume,
17:02we can often provide other techniques
17:04to help restore some of that volume,
17:06whether it's using a small flap from
17:09the side of their chest wall or using
17:11something called fat grafting to
17:13help fill in that defect to
17:17restore the volume to that breast
17:20to create a better cosmetic outcome so
17:23we can address all three possibilities
17:26using these oncoplastic techniques.
17:29So the concept of fat grafting
17:32sounds really interesting and I'm sure
17:34a lot of our listeners are thinking,
17:36I've got plenty of
17:38fat to move around. How
17:40exactly does that work so that the
17:43fat grafting is a technique that
17:45uses fat tissue that's harvested
17:47from another area of the body,
17:49just like in a liposuction.
17:51That issue is then processed to remove
17:54all of the other debris and to enrich
17:57it for those fat cells that are viable.
18:00That can act as a tissue graft.
18:03The lumpectomy is performed,
18:05and we'll leave clips to mark the cavity,
18:08so we know where the tumor was.
18:11We will mobilize the breast
18:12tissue to close that defect,
18:14and so the area where the cancer was,
18:20the integrity of that space is maintained
18:22for the focus for the radiation oncologist.
18:25The fat graft is then added
18:27to an area nearby,
18:29not in that cavity,
18:30but in the other surrounding tissue to
18:33help restore the volume in that area
18:36to create a good contour to the breast.
18:41And is that done before or after radiation?
18:44Because many of our listeners who may
18:47have gone through this experience or know
18:50somebody who has questions
18:53about how the radiation can really affect
18:56the cosmetic outcome of the breast itself.
19:00That's an excellent question.
19:01After partial mastectomy or lumpectomy,
19:03radiation is usually part of the
19:06treatment plan to help reduce
19:08the risk of local recurrence.
19:10Radiation itself will shrink
19:11the breast by 10 to 15%.
19:14It can also make the breast be more uplifted,
19:18again creating a problem of
19:20symmetry with the other side.
19:23The initial studies that looked
19:25at fat grafting as a way of adding
19:28volume to the lumpectomy site and
19:31providing symmetry for the breast
19:33the fat grafting was often
19:36done after radiation therapy.
19:38Newer studies have suggested that it's
19:40both effective and safe to do fat
19:43grafting at the time of partial mastectomy,
19:45and that the cancer
19:47outcomes are still quite good.
19:49Again, we need long-term data
19:51to know know for sure,
19:52but the most studies with five year
19:55follow up data suggests that that's
19:57a very safe way to help provide symmetry
20:04that can come from
20:06removing that much volume in a
20:08breast.
20:11The other question that people may ask is
20:13liposuction for many people's insurance
20:15is considered a cosmetic procedure.
20:17And while people may say you know what,
20:20I've got plenty of fat that you can take
20:23off my hips and my thighs and my belly
20:26and use that for your fat grafting,
20:29in fact, you can take a little bit more.
20:33Many may be asking the question
20:35is that covered by insurance?
20:39This is always something that we
20:42want to address before we do our operation,
20:46and many of these techniques we have pre
20:48certified we sent to the insurance company
20:51ahead of time to make sure that it will
20:53be covered under patients insurance.
20:55So this is a reconstructive
20:57technique like any other technique,
20:59is a reconstruction technique and
21:00those are covered by most insurance plans,
21:03so it's something that we always want
21:05to make sure is covered by insurance
21:08before we go to the operating room
21:11so that people don't have any surprise bills,
21:14because that's certainly something
21:16that we want to avoid.
21:19The other technique that you had
21:21mentioned was that oncoplastics
21:23can also be used after mastectomy
21:26in terms of reconstruction.
21:28So tell us a little bit more about that.
21:33Well, the thought of
21:36oncoplastics and mastectomy is that we
21:38want to have options for reconstruction
21:40after that procedure and initial
21:43reconstruction options included implant
21:45based reconstruction or tissue based
21:47reconstruction where we use the patients
21:50own tissue like from their abdominal
21:53wall to recreate a new breast.
21:56And so our techniques have developed
21:58both in terms of how we do our initial
22:01mastectomy and how those reconstructions
22:03are done to make sure that women
22:05get the best possible outcome.
22:07One of the newer innovations in this
22:10area is nipple sparing mastectomy,
22:12where instead of removing the skin
22:14and the nipple areolar complex at
22:17the time that we do the mastectomy,
22:19we preserve the entire skin pocket,
22:21including the nipple.
22:23This technique developed in the early
22:262000s and we really used it mostly for
22:29preventive surgeries and then started
22:31to use it for cancer patients who had
22:34small cancers that were not near the nipple
22:38areolar complex.
22:38We now will use these for many mastectomies
22:42about half of the mastectomies that I
22:44do when we do immediate reconstruction
22:47are now nipple sparing because we
22:49have found that it's safe,
22:51we're able to very carefully remove the
22:54breast tissue all the way up into
22:56the nipple while preserving the
22:58blood supply to the nipple
22:59to make this be a very effective way
23:02to perform mastectomy and to give the
23:04patient the best possible outcome.
23:06With regards to the reconstruction,
23:08we now have better ways of placing implants.
23:12One example is placing the implant on
23:15top of the muscle of the chest wall,
23:18as opposed to putting it behind
23:20the muscle on the chest wall.
23:23And new types of tissue reconstruction
23:26that create tissue flaps to remake
23:29a breast that don't require us to mobilize
23:32any muscle and the outcomes from those
23:35are much better for patients.
23:37With less disability after surgery.
23:40So let's let's dig a little
23:42bit deeper into that.
23:44So are there patients for whom
23:46nipple mastectomy, nipple sparing
23:48mastectomy is not a good option?
23:50Yes, the extent of cancer really tells us
23:54if we are able to preserve the nipple or not.
23:57So anyone who has a very large tumor,
24:00a tumor that extends close to the nipple
24:03areolar complex, any tumor that pulls on the
24:06nipple and causes the nipple to be retracted
24:09or is associated with nipple discharge,
24:12these are not patients who would
24:14be a candidate for nipple sparing
24:16mastectomy. Certainly patients who
24:18have a very aggressive form of cancer
24:21called inflammatory breast cancer,
24:23these patients would not be a candidate
24:25for nipple sparing mastectomy.
24:27The other group of patients
24:29we have to think about are patients who might
24:32require radiation therapy after mastectomy.
24:34These are patients who will
24:36have either very large tumors or
24:38who have positive lymph nodes,
24:40meaning that there is cancer that is
24:43found in their axillary lymph nodes either
24:46before surgery or at the time of surgery.
24:49We know that those women will
24:52be offered radiation therapy.
24:54And we often don't want to perform
24:56an immediate reconstruction and
24:58then radiate that reconstruction.
25:00So it's a complex set of criteria for
25:03those women who would be a candidate
25:06for nipple sparing mastectomy.
25:08These are often women with early stage
25:10disease with tumors that are small and
25:13not near the nipple areolar complex
25:15who will most likely not need radiation
25:18therapy after their mastectomy.
25:20Those are the best candidates for
25:22the operation.
25:24And what about
25:25the size of the breast as well?
25:29I mean when we were
25:32talking about breast conserving
25:33surgery that for some patients they
25:36actually want a breast reduction.
25:38So in a patient who chooses
25:41to have a mastectomy,
25:43but wants the breast to be smaller or lifted,
25:46are those patients ideal
25:48candidates for nipple sparing,
25:49mastectomy or are there other techniques
25:52that you use in that population?
25:55That's a great question.
25:57The initial use of nipple
25:59sparing mastectomy was for women
26:01with relatively small breasts,
26:02A-C Cup or smaller who didn't have
26:05a lot of droop to the breast.
26:07So the nipple areolar complex was
26:09kind of in the middle of the breast.
26:12We know that the important component
26:14for healing from this surgery is
26:17to make sure that there is good
26:19blood supply to the nipple areolar
26:21complex and that blood supply
26:23comes from the top of the breast,
26:25so the farther the nipple is away
26:28from the collarbone,
26:31we know the longer distance the blood
26:33has to move to get to the nipple,
26:37so the bigger the breast and
26:39the more droop to the breast,
26:41the more risky that procedure is.
26:44And so there are things that can
26:46be done to help address that.
26:48For women who have large breasts or
26:50for women who have droop to their
26:52breasts and that includes things
26:54like using a wise pattern incision,
26:56which is a incision that will often
26:58use for a breast reduction and
27:00then performing a free nipple graft
27:03taking the nipple and moving it back
27:05to a better spot that can be used
27:08in the setting of a mastectomy.
27:10So there are a number of
27:13other techniques that can be used to
27:15help reduce the size of the skin pocket.
27:17Make the breast smaller and move
27:19the nipple areolar complex back
27:20to the center of the breast.
27:23So, that sounds like a number
27:26of tools in the toolbox to really help
27:29women to maintain the cosmetic
27:31look of the breast the way that they
27:34would like it to be either the way that
27:38it is now that they are happy with
27:40or even better than it is currently.
27:43But one question that people may
27:46ask is, if you save the nipple,
27:48will it still function?
27:50Or is it really
27:52more for cosmestics?
27:55That's an excellent question
27:58because it's hard to describe to patients
28:01ahead of time what this operation
28:03is going to feel like afterwards,
28:06so the loss of sensation in the nipple
28:09areolar complex is expected about 10
28:12based on the surgical technique used,
28:14about 10% of women 10 to 15% will have
28:18sensation in the nipple after the operation.
28:21Most women will not have sensation
28:24in the nipple.
28:25But the appearance of the breast
28:27is more like their own breast,
28:29and so that is often the
28:32real benefit to this operation.
28:33It feels more like their breast,
28:35so even though they may not
28:37have sensation in the nipple,
28:39they have appreciation that the breast
28:41looks like their breast.
28:43Doctor Melanie Lynch is an assistant
28:46professor of surgical oncology
28:47at the Yale School of Medicine.
28:49If you have questions,
28:51the address is canceranswers@yale.edu
28:52and past editions of the program
28:54are available in audio and written
28:56form at yalecancercenter.org.
28:58We hope you'll join us next week to
29:01learn more about the fight against
29:03cancer here on Connecticut Public Radio.