Innovations in Breast Cancer Surgery

Intro: This is Weekly Dose of Wellness brought to you by MemorialCare Health System. Here's Deborah Howell.

Deborah Howell (Host): Hello and welcome to the show. You're listening to Weekly Dose of Wellness, brought to you by MemorialCare Health System. I'm Deborah Howell and today's guest is Dr. Anna Houterman, board-certified breast surgeon and medical director of the breast care program at the MemorialCare Breast Center at Saddleback Memorial. Today we're going to be talking a little bit about innovations in breast cancer surgery. Welcome, Dr. Houterman.

Anna Houterman, MD: Thank you, good morning.

Deborah Howell (Host): Let's get started. Now, when a patient is diagnosed with breast cancer, at what point do you refer her for surgery?

Anna Houterman, MD: So generally what happens, you know, a patient goes and gets a mammogram and, you know, an abnormal spot is seen, patient has a biopsy performed and gets a diagnosis of breast cancer. And then at that point, usually the first consultation that the patient has is with the breast cancer surgeon. And you know, sort of go over the plan, and you know, the plan may or may not include chemotherapy, radiation therapy, and the patient will generally have appointments to see those specialists as well. But usually the first thing that happens in this plan is that the patient has her surgery performed. That's not always true; there are some patients that have more advanced disease that may not have surgery up front, but the majority of patients do have their surgery up front.

Deborah Howell (Host): Okay, so this is the point where we're at. So there are many different kinds and types of surgery used to treat breast cancer. Maybe you could elucidate us on that.

Anna Houterman, MD: Right. So in general, when someone gets a diagnosis of breast cancer, in general they have a choice between two - two options for surgery. One option is the mastectomy, which, you know, means removing the entire breast plus or minus reconstruction. The other option is lumpectomy, which means, you know, just removing the tumor only and leaving the rest of the breast alone. And if you choose that option - if you choose lumpectomy - it's sort of a package deal and you have to have radiation therapy to your breast afterwards also. And so when you're - when you're looking at these two options and trying to decide between them, there are a couple of sort of important things to know. The first thing is that whichever option you choose, whether it's mastectomy or lumpectomy and radiation, your survival is equal.

Deborah Howell (Host): Really?

Anna Houterman, MD: Right. So a lot of women come in thinking, "Well, I'm just going to have a mastectomy so that I can live as long as possible." But in actuality, whichever surgery option that you choose, you're going to live equal number of years basically.

Deborah Howell (Host): That's amazing, I did not know that. And I can't even imagine - it's sort of like a Sophie's Choice, isn't it?

Anna Houterman, MD: So the main difference between these two options is what is the chance that the breast cancer could come back, you know, years down the road? So if you choose mastectomy, the chance of breast - of a cancer coming back in your breast years afterwards is not 0%. You think it might be because, you know, we're removing all the breast tissue, but we can't actually, you know, remove every single little cell underneath the skin. So the risk is, it's not 0%, but it's, you know, it's very, very low. If you choose the lumpectomy and radiation, because you are leaving breast tissue behind, there is a risk, you know, that a cancer could develop again. But that risk is also quite low. We used to say around 14%, but nowadays it's probably even lower, maybe around 6% chance. So, so still good, you know, good odds that, that the cancer won't come back in your breast. If the cancer did come back in your breast years down the road, then at that point you would have to undergo a mastectomy because you're only allowed a maximum amount of radiation that you're allowed to receive in a lifetime. And so if you've gone through lumpectomy and radiation once and need treatment a second time, then the choice at that point is a mastectomy.

Deborah Howell (Host): Boy, just in the three or four minutes we've been talking, you've really made me eager to go in and get my next mammogram.

Anna Houterman, MD: Oh good, good. I'm glad. Well, mammograms are so important because, you know, they identify tumors when they're very small before we can even feel them. And you know, the smaller you can catch your tumor, the better your prognosis.

Deborah Howell (Host): Absolutely. Now, if the patient would like to have reconstructive surgery, during what part of the treatment process is reconstructive surgery performed?

Anna Houterman, MD: So reconstruction after a mastectomy can really be performed at any time. So for example, you know, if you have a mastectomy and decide not to have reconstruction and then a year later you change your mind, you know, reconstruction can be performed then. But it's nice, most patients like to begin the reconstruction process at the same time as their mastectomy. I think from a psychological standpoint, it's sort of nice to, you know, at the time of your mastectomy to have some fullness, to not see yourself completely flat. And even though the reconstruction process does take a long time, ideally what can happen is, you know, you go in to the operating room to have your mastectomy performed and then while you're still asleep, the plastic surgeon will come in and place what's called an expander and begin the reconstruction process.

Deborah Howell (Host): I have learned so much. For some reason, I thought you had to wait until all the cancer treatment was done and then wait a year and then have your reconstructive surgery. I had no idea it could be done at the same time.

Anna Houterman, MD: And there are some situations where that's recommended, but I'd say the majority of patients that have reconstruction, we do like to begin the process at the time of their initial surgery. And it is a process, and so, you know, you don't wake up from your operation with sort of a finished product in terms of reconstruction. The reconstruction is a process that can take, you know, even up to six months before you really look the way that you want to look. Because these expanders are placed, and the expander - you could think of an expander as sort of like an empty implant. It's sort of like a place saver. And so that is placed at the time of your mastectomy by the plastic surgeon. Then during the course of the next few months, the plastic surgeon will see you in his office and slowly start to fill up these expanders sort of as an in-office procedure. Fill up the expanders with saline gradually and in doing so, the skin is stretched out little by little so that the skin is at a size where it can accommodate an implant. And then you go back and have a second operation where the expander is removed and your final implant is placed.

Deborah Howell (Host): I see. Okay. And why is it done that way? I mean, does the breast area cannot handle that sort of weight while it's trying to heal, or...?

Anna Houterman, MD: Yeah. So, you know, when the breast tissue is removed, the skin overlying the breast, you know, is very delicate and fragile. And it’s just like you say, it'd be sort of too much for it to be able to hold an implant right away. And there are times where we want to - part of the skin is removed during the time of the mastectomy, too, and so there may not be enough skin to hold an implant that's the size that the patient wants, and so it needs to be stretched out a bit more.

Deborah Howell (Host): It sounds like breast cancer surgery has really evolved.

Anna Houterman, MD: It really has. If you think back, you know, if you go all the way back to the 1970s actually, prior to the 1970s, the only operation for breast cancer that was performed was something called a radical mastectomy. That had been performed probably for a good century before that. And a radical mastectomy is different from what we think of a mastectomy today. The modern-day mastectomy that's performed is removing the breast tissue and the skin that overlies it. But the radical mastectomy involved removing the breast tissue, the skin, but also all the muscle along the chest wall. And so you can imagine it must have, you know, been a much more debilitating operation for these patients and really affect, you know, their mobility. And so there was a lot of research that was done that showed that the radical mastectomy - the more aggressive operation - actually didn't confer a greater survival advantage compared to the modern-day mastectomy that we do today. So that operation is actually no longer done. And then shortly after that - also in the - sort of in the late '70s - research was done on lumpectomies. And prior to that time, a lumpectomy - lumpectomies were not performed. So you could have, you know, a very large tumor or a very, very small tumor, and no matter what size your tumor was, you had to have a mastectomy prior to this. So lumpectomies, you know, originated at that time and really gave women options. And since that time now, more recently, we've had a lot of new advances also. Nowadays we do things called skin-sparing mastectomies and nipple-sparing mastectomies where the patient is able to preserve their own nipple and areola and really have a more natural look and outcome after their reconstructive surgery. We use incisions that are sort of in locations that are much less noticeable. We do what's called oncoplastic surgery, which is basically something that applies to lumpectomies usually, but it's a concept basically using plastic surgery techniques to perform cancer operations. And of course, the number one goal with a lumpectomy is to remove the entire cancer. But then after that, the secondary goal needs to be, "Let's - we want to try and make the breast tissue look as nice as possible basically." So thinking about aesthetics and the cosmetic result. So those are a number of ways that breast surgery has evolved recently. We've also been looking at trying to select patients that can have fewer lymph nodes removed. Because we, you know, normally will remove one or two lymph nodes in the - under the arm to see if the cancer has spread. And so more recently there's been a lot of research done to see if there are certain patients that can have fewer lymph nodes removed and in so doing, sort of avoid all the risks and complications that go along with lymph node surgery.

Deborah Howell (Host): Okay. Wow, we've come a long way and certainly each patient is kept in mind and for the best and the whole patient. Anna, it's a much better day to be a breast cancer patient these days. Thank you so, so much, Dr. Houterman. It's been great to have you on the show today.

Anna Houterman, MD: Hey, thank you very much.

Deborah Howell (Host): To listen to the podcast or for more information, please visit memorialcare.org. That's memorialcare.org, and we thank you for listening today. I'm Deborah Howell. Join us again next time as we explore another Weekly Dose of Wellness, brought to you by MemorialCare Health System. Have a fantastic, healthy day.