Double Mastectomies: When Are They Necessary?

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

Deborah Howell (Host): And welcome to the show. I am Deborah Howell, and today's guest is Dr. Jane Kakkis. She is the Medical Director of Breast Surgery at MemorialCare Breast Center at Orange Coast Medical Center. And she's here to talk to us about double mastectomies, including when they're necessary, the benefits and risk factors, and what to expect before, during, and after the surgical process. Welcome, Dr. Kakkis!

Jane Kakkis, MD: Thank you. Thank you for having me.

Deborah Howell (Host): It's our pleasure. Let's dive right in. What is a double mastectomy and who is the ideal candidate for this type of procedure?

Jane Kakkis, MD: Well, what we mean by a double mastectomy is removing both of the breasts. And when we think of an ideal candidate, we actually divide people into two groups, people who have cancer at the current time of decision making and people who don't.

Deborah Howell (Host): Fair enough. And why do you think more women are considering this as a first line of treatment once they're diagnosed with breast cancer?

Jane Kakkis, MD: Well, I think if you think of the group of people who have cancer at the time that they're deciding their treatment choices, it's complicated and they're taking advice from a lot of different people. So frequently in my patient population, patients have already decided to have both breasts removed based on conversations they've had with friends and family. And sometimes the decision is made without enough information, in which case my job is to provide more information to allow them to make a better informed decision.

Deborah Howell (Host): Absolutely. You can get way too many cooks in the broth, right?

Jane Kakkis, MD: Exactly.

Deborah Howell (Host): So what are some of the important questions that patients should ask their surgeons if they're considering a double mastectomy?

Jane Kakkis, MD: Yeah, well I like to start off by explaining to patients the difference between a local treatment, meaning treatment on the breast where the cancer is located, and a systemic treatment where people might get something like chemotherapy to treat cells that might have migrated away. Well we have to break those two apart because patients get confused about surgical treatments and whether they affect those other treatments. So for example, someone might say, please remove both my breasts because I don't want chemotherapy. But those two decisions aren't related like that. So I try to break it down so I can inform them how to make the decision surgically and how it's independent of the decision to have chemotherapy.

Deborah Howell (Host): As if it's not unfair enough to have breast cancer, then you have to make that double decision, right?

Jane Kakkis, MD: Exactly. So when they have cancer, what I like to do is start off by really focusing on how can we cure this current cancer, and what are the types of surgical options? Because the most important thing is not to compromise the cancer cure in order to reduce a future risk of cancer that's perceived by the patient. So we like to start off with really focusing on treating the cancer side first. And then we want to assess what is your risk of a future cancer to decide whether they're going to remove a healthy breast on the opposite side or not. So those kinds of things are super important when we're having a conversation about that.

Deborah Howell (Host): And then that leads to my question, what are the advantages and disadvantages or potential complications?

Jane Kakkis, MD: Yeah, so this is a super important question and this is an answer when I discuss it with the patient is probably the most eye-opening pieces of information I can give patients. When you're considering removing both breasts, and when I say you don't want to interfere with the cancer treatment, when you remove both breasts at the same time, the complication rate is four times the complication rate of removing one breast at a time. So when someone has an advanced cancer or a cancer that requires chemotherapy and you just remove both breasts, one of which is completely healthy, and if they have a complication, you could actually delay the rest of their cancer treatment. So I like for patients to really understand it depends on the severity of the cancer and what kind of treatment they have to undergo to be cured of the cancer, whether they should be allowed to do a double-sided mastectomy at the time, or maybe we do it one side at a time, which actually works out quite well for a lot of patients.

Deborah Howell (Host): Well, I'm sure they're glad to have you on their side with all your expertise and knowledge. How common is it, Doctor, for a patient to request breast reconstruction after a double mastectomy? And the big question, can the reconstruction be done at the same time as the mastectomy?

Jane Kakkis, MD: Yeah, you know, in my patient population it's extremely common. It's not age-related. We have ladies of all ages who request mastectomy reconstruction and we love to do it at the same time. We get the most optimal outcome, so if patients are a candidate, which is the majority of patients, we will do it at the same time. And I would say over ninety percent of people do request reconstruction. And we do the first part of the reconstruction at the time of the mastectomy, but then the reconstruction usually involves one or two smaller surgeries after to finish it.

Deborah Howell (Host): But still, finally some good news.

Jane Kakkis, MD: Yes.

Deborah Howell (Host): So what's the typical length of stay at the hospital after a double mastectomy?

Jane Kakkis, MD: So interestingly, for the type of reconstruction where we use an implant, it's only overnight in the hospital and it's a pretty easy postoperative recovery in terms of pain and other kind of physical discomfort. So patients usually are able to eat normally and just take pain pills and kind of have a low-key existence at home when they go home for a week or two and then they kind of slowly resume normal activities over the course of another couple of weeks. So it's a pretty reasonable surgery to recover from.

Deborah Howell (Host): Lovely. Now what's the typical length of stay at the hospital after a double mastectomy? I know you said overnight, but you know, the recovery process, returning to work, those kinds of things.

Jane Kakkis, MD: Yeah, so most patients go home from the hospital the next day and then after a couple of weeks they will just resume light duty activity and then probably back to work. Depending on how stressful their work is, probably roughly four to six weeks after the actual surgery date.

Deborah Howell (Host): Four to six weeks. And what about driving?

Jane Kakkis, MD: So most of the patients are allowed to drive once the drains are removed. And that depends on the healing of each patient, but those drains are generally speaking removed between seven to ten days after surgery.

Deborah Howell (Host): Okay. And does it matter if you have a stick or not?

Jane Kakkis, MD: No.

Deborah Howell (Host): Okay. Okay. I'm just sticking up for those people who drive stick shifts.

Jane Kakkis, MD: Yes, exactly. No, I think generally we don't want them to drive with the drain in case they have pain at the drain site that's distracting them from driving. But there's no physical limitation to driving.

Deborah Howell (Host): Excellent. Okay. And you know, you're not gonna do push ups right away, but you could do walking and what other kinds of activities?

Jane Kakkis, MD: Yeah, so normally when people do a gradual return to activities, they'll start with walking and stretching and then maybe some weightlifting on their legs first and then the arms and actually eventually they can get back to all activities they've done before. I've had Olympic level athletes and people who do triathlons and every kind of sport and there will be no limitation after everything is all completely recovered.

Deborah Howell (Host): Well that is excellent news. And what resources and support does MemorialCare Breast Center at Orange Coast offer to patients before, during, and after treatment, Doctor?

Jane Kakkis, MD: Well, you know, we have an amazing center. So we have everything in one place. So we have a cancer center information center where we have lots of information regarding you know prevention and nutrition and things like that. We have a nutritionist that can help with diet. We have a speech therapist who helps with complications after chemotherapy and we have an amazing physical therapy department that will help people if they have some tightness after surgery or if they lost some strength during the treatment, get them back in shape. And we also have psychosocial services because obviously going through cancer is a traumatic experience emotionally as well as physically. And so we have the support there to help people get through that portion of it as well. So we really like to try to heal the whole person and not just the cancer.

Deborah Howell (Host): And the family, the psychosocial services would, I'm assuming involve some of the family members?

Jane Kakkis, MD: Absolutely. The family is always taken to account for all of our services and we even have genetic evaluation which also incorporates the family. So yeah, we definitely like to reach out to the whole family with all our support services.

Deborah Howell (Host): Fantastic. Well, we want to thank you so much, Dr. Kakkis, for coming on the show today and for all the good work you do. And to learn more or to listen to a podcast of the show, please visit memorialcare.org. That's memorialcare.org. I'm Deborah Howell, thanks for listening and have yourself a wonderful day.