Breast Cancer Program: Surgical Treatment for Breast Cancer

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Dr. Austin: Welcome to an MUSC Health Podcast. I'm Dr. Linda Austin, and I'm interviewing Dr. Megan Baker, who is a surgical oncologist with a specialty in surgery for breast cancer. She is Medical Director of the Breast Program here at Hollings Cancer Center at the Medical University of South Carolina. Dr. Baker, I know we're doing some very, very exciting work here in the area of surgery for breast cancer, and you have patients coming from all over the United States because of the very special services and approach that you offer. What is unique about the work you're doing in this area?

Dr. Baker: In general, breast cancer surgical treatment typically revolves around the choice between breast conservation therapy, , plus radiation therapy, which is removal of the entire breast. And traditionally, mastectomy's been done by removing the breast tissue, the breast mound itself, including the nipple and the complex of the breast, and that includes the colored area of the nipple. More recently, we've been doing quite a bit of nipple sparing mastectomy technique, one in which that whole nipple complex is preserved, and in about sixty to seventy percent of patients this also preserves the sensation of the nipple. This technique isn't appropriate for every patient, but for many this is certainly a very viable, aesthetically and functionally preferred option. This is paired at the same time with immediate breast reconstruction, and this can be paired with various types of reconstruction. It can range anywhere from implant reconstruction to more complex autograft meaning using your own tissue to remake your breast

Dr. Austin: So Dr. Baker, let's walk through that process then that you just outlined. A woman, let's say a woman here in South Carolina, or a woman in Idaho or wherever goes and gets her mammogram, she gets a call that there is something suspicious. And a biopsy is done, let's imagine, and in fact the diagnosis that there is carcinoma is made, what is the next step?

Dr. Baker: Well, the next step really revolves around education, and it's very important for patients to realize that they have options. And so the education comes not just from talking to physicians and nurses, but also doing some research on their own. As breast cancer treatment has gotten more progressive and more advanced, the choices have become far more in number. And the choices, although attractive, are often very confusing. And so it's very tempting, given the anxiety that comes with a breast cancer diagnosis, to rush to a surgical decision, or rush to a treatment plan, and I really encourage patients to make a thoughtful decision. And that thoughtful decision will require doing some research on their own, speaking to at least one physician, ideally getting a second opinion when possible, and seeing what the options are. Again, from the surgical perspective those options may be breast conservation, or maybe some form of mastectomy and not one mastectomy fits every woman anymore. So even within the realm of removing the breast there are even more options that are there. But what's very important, and something that you mentioned shouldn't be taken for granted, is getting that diagnosis first before you go to the operating room. The days of going to the operating room to get a diagnosis just because are long gone. And that's important because it really affords a woman an opportunity to know what the diagnosis is so they can consider their options, whereas if you're going to the operating room because you have a lump and you're not sure what it is, it will change what you do in the operating room, and it may burn a bridge and not allow you to do something later. So when technically possible and physically possible, having a minimally evasive biopsy first typically either done by either a surgeon or a radiologist is really a standard of care that we encourage. \par Dr. Austin: That's really helpful to know, and that really is a change from the old days when women would go to the operating room not knowing if they would wake up with a breast or not

Dr. Baker: Exactly. A woman should go to the operating room and wake up knowing exactly what the plan is from the very beginning. I encourage patients that what happens in the operating room should be boring, and there shouldn't be any surprises, because they should come out getting exactly what they planned for. And so that's where the planning really takes so much time for breast cancer. And when I say time and thoughtfulness to it, I don't mean to suggest weeks to months, but even just taking several days to a week or two to sort out what plan is best for you can really ensure a higher quality of care as well as a higher level of confidence in that care. And I'm a very firm believer that if a patient gets the very best of care but doesn't feel confident in the plan, then it really adversely effects their recovery. So it's not enough to have the right treatment, you have to believe that it's the right treatment, and that's where preparation ahead of time is really essential.

Dr. Austin: We had been talking about the nipple sparing procedure that you do. Who is a good candidate for that procedure, and who is not a good candidate for it

Dr. Baker: We typically will recommend nipple or areola sparing mastectomy for women who are considering prophylactic or preventative mastectomy. So women that are considered in that group are women who have been diagnosed with inherited breast cancer gene syndromes something called BRCA one or two. And we know from research those women are at extremely high risk for breast cancer, so much so it justifies removing the breast before they get cancer. Similarly though, there are actually women who have cancer, would like to reduce the risk of having a local recurrence as aggressively as they could, and would be a candidate for this. If their lesion or their tumor is located directly behind the nipple or is involving the nipple, then that certainly would be a contraindication, a reason not to consider this therapy. If they had a specific type of breast cancer ductal carcinoma in situ, which has a proclivity for traveling along the ducts which finish their tracts at the nipple itself, then doing this procedure certainly wouldn't always be appropriate. So nipple or areola sparing mastectomy is a wonderful option but only for a selected group of patients. And so that's where having a lot of preoperative information, particularly an MRI of the breast can be very helpful

Dr. Austin: You mentioned also that oftentimes in that first operation you often do the reconstruction of the breast after mastectomy, is that correct?

Dr. Baker: Mmhhmm.

Dr. Austin: Can you explain the procedure that you use there?

Dr. Baker. Sure. Some women who undergo mastectomy are candidates, meaning that it's safe to undergo immediate reconstruction. So they go to sleep with a breast, and wake up with a newly reconstructed breast. And that's certainly appealing for many reasons, the least of which is the psychological impact of going to sleep and waking up still with a breast. Having that sense of that physical and aesthetic symmetry can never be underestimated. When you're reconstructing the breast at the same time there are several options, the most simple of which would be an implant, the most complex of which would be using your own fatty tissue from other parts of your body, and bringing it up and sewing it into place using microsurgical technique to remake the breast. We're replacing fatty tissue with other fatty tissue, whether it comes from the tummy tuck area, or from someone's bottom. And this is very technically challenging surgery, that I'm very proud of our plastic surgery team that they do quite a bit of it, and the results are very impressive. It's certainly attractive for many young women who are physically active and are young, because this type of reconstruction doesn't take any muscle, and if you're not taking muscle from your six pack area, your rectus, or you're not taking muscle from your back, your latissimus, you don't have the resulting muscle weakness or potential hernia that's there. So you're replacing like with like, not at the expense of any functional unit of your body.

Dr. Austin: So just to clarify that a little bit, are you saying then that another approach that is done by other surgeons or at other centers might be to take muscle

Dr. Baker: Sure, and we will do that too. It's commonly called a tranflap, that comes from the rectus muscle, the six pack muscle of someone's abdomen, or the latissimus flap, coming from the back area just behind the arm. And for some women that's the best option for reconstruction, and our team offers that as well. But for other women that muscle weakness that results is very meaningful, and can make them uncomfortable or make them at risk for problems down the line. So one of those bits of research that I encourage women to do if they're thinking about reconstruction at any time, whether it be immediate or ten years after their mastectomy, that they really research the surgeon that they're going to see, make sure that what they're being offered isn't limited by that surgeon's repertoire but is only limited by what they're body will allow them to do. And not every surgeon can do every technique, and that's fine, but it's important that if they're interested in something that they know what their options are.

Dr. Austin: So who is the ideal candidate for the reconstruction using fat versus the ideal candidate for reconstruction for the muscle flap reconstruction

Dr. Baker: Sure. It's almost easier to talk about who's not the ideal candidate. Really nowadays, women who are getting the muscle reconstruction are women who are too thin, or who have too many other procedures on their abdomen to take that fatty tissue. So women who don't have that fatty tissue but still want to use their own body's tissue will use muscle, borrow muscle from an area to make a new breast mound, rather than using fatty tissue to do that. If a woman has enough ample fat to remake the breast, than it's preferable to just use that fat to remake the breast because they don't have the weakness.\par \par \par Dr. Austin: Plus they have a slimmer waistline then, don't they

Dr. Baker: That's the silver lining to each woman's difficult time through cancer. If they can get a tummy tuck or a lift on their backside that's certainly a major plus.

Dr. Austin: How about saline implants, are those also used, or are they used in addition to the muscle flap

Dr. Baker: Very rarely are they used in combination. For some women that may be an augmentation to their breast, meaning enlarging it to a size larger than what the muscle volume will allow them. You might do a combination of implant and muscle flap. More commonly, women who choose implants are choosing implants are choosing it because it's a less involved operation. And so the recovery is more straightforward, the recovery's not as difficult, and the time in the recovery room is significantly less. We use both saline as well as silicone implants, although historically that's been very controversial. However, we always reassure patients with the best research available, and to date there's been no high quality research that's demonstrated a problem with silicone based implants. Depending on what size a woman is trying to reconstruct their breast and what the rest of their body habit is, there are better choices, silicone versus saline for each woman, and that's where having a careful conversation with the plastic surgeon is very important.

Dr. Austin: What percentage of the time is that first procedure sufficient versus how often you have to go in and do an additional plastic surgery surgical procedure to really get the effect that you want.

Dr. Baker: Well for women who are undergoing reconstruction, it's rarely a one time procedure. In fact it's often multiple steps, the latter steps of them being much less involved, typically an out patient procedure. So for example if a woman had a mastectomy and had an immediate reconstruction with an implant, they normally go back one other day as an out patient, meaning in and out of the hospital the same day. If they're having a more involved surgery using flap, meaning their own tissue, whether it be muscle based or fatty tissue based, they're typically going to come back three months later to have things revised, what's called a stage two, and they may come back even a third time for a revision or a reconstruction of the nipple complex itself with a tattooing to remake the color of the areola and the nipple. So those procedures can sometimes even be done in the office, so they're much more straightforward, much more simple than the initial procedure. But it does require some fine tuning.

Dr. Austin: Does the initial procedure then usually require staying at the hospital overnight

Dr. Baker: Absolutely. So a mastectomy in general whether you're having reconstruction or not, typically requires one to two nights in the hospital. If you're having implants to reconstruct that breast at the same time, your stay in the hospital is about the same, it doesn't change. If you're reconstructing the breast with muscle or fatty tissue it typically adds two to three additional days, so you're in the hospital for a total of four to five days

Dr. Austin: Because you also have the wound site where the tissue's been harvested, is that right?

Dr. Baker: Exactly. So the recovery's a little more complicated.

Dr. Austin: What is the range of time that the initial procedures take?

Dr. Baker: In the operating room

Dr. Austin: In the operating room, mmhhmm

Dr. Baker: Sure. A mastectomy in general, of course it varies somewhat, but in general a mastectomy in general takes an hour and a half to two hours, if you're just doing that one side. And, if you're going to reconstruct that breast, probably another hour added onto that, reconstructing with an implant. If you're going to reconstruct with a flap, it can add on anywhere from four to eight hours. So it can be a whole day in the operating room, particularly if you're doing both breasts at the same time. So you can see why some patients who don't want a long time under anesthetic would certainly be guided more intuitively towards implant reconstruction because the operative time is shorter, the recovery is shorter. Whereas other women who are willing to undergo a longer operation and a slightly more difficult recovery to gain the aesthetic and functional benefits of an autologous using your own tissue will gravitate towards that direction in spite of the longer operative times.

Dr. Austin: Are you implying that the autologous reconstruction tissue might look a little bit better than the implant, or be softer to the touch than the saline implant

Dr. Baker: I think certainly long-term the aesthetic results certainly are better. In the immediate, you know, first year or two, they certainly are comparable to the visual inspection. Certainly as natural as implants can feel, fatty tissue feels more natural than an implant would. The biggest difference that we really see over time is that an autologous, using your muscle or fatty tissue reconstruction is going to age with you appropriately. So it's very normal for women as we get older for our breasts to fall closer to our waists. And it's something we aren't always happy about, but certainly we don't want an age inappropriate look to our breasts either. And so the autologous reconstruction are certainly more age appropriate over time, and you'll see those kind of gravitational changes, whereas with implants you often don't. And I have many patients who in ten years have to get them revised to kind of shift them appropriately so they look more appropriate to their age.

Dr. Austin: And so that each side, right side matches left side

Dr. Baker: Exactly. Symmetry is really one of the most important things. Many women think of breast reconstruction as an issue of size, where in reality it's an issue of symmetry. And so there's never a more unhappy patient than one who is asymmetrical when it comes to the reconstruction. If you're symmetrical in the way things look, left being equal to right, most women are exceptionally happy. \par \par \par \par Dr. Austin: But that's a challenge, because it's not just getting it right in the beginning, but having it stay right over time

Dr. Baker: Exactly.

Dr. Austin: So that's a real challenge

Dr. Baker: Absolutely.

Dr. Austin: Dr. Baker, thanks so much for talking with us today.

Dr. Baker: You're very welcome.

Dr. Austin: If you have any questions about the services or programs offered at the Medical University of South Carolina, or if you'd like to schedule an appointment with one of our physicians, please call MUSC Health Connection at 1(843)792-1414. That's 1(843)792-1414.

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