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Melanie Cole (Host):  Receiving a diagnosis of breast cancer can be devastating, but patients with breast cancer have an increasing number of surgical options to treat their disease. My guest is Dr. Shayna Showalter. She’s a board certified surgeon who specializes in treating breast cancer and diseases of the breast at UVA Cancer Center. Welcome to the show, Dr. Showalter. Tell us, what are the most common surgical options available for breast cancer patients?

Dr. Shayna Showalter (Guest):  Good morning, and thank you for having me. What makes breast cancer interesting is that the treatment, especially the surgical options, are actually not defined before you even meet a patient. A lot of what ultimately makes the surgical plan for breast cancer patients is the patient’s preference. The two most common surgical treatments for breast cancer are what we call breast-conserving surgery and also a mastectomy. And so, it's my job as a breast surgical oncologist to sit with a patient, to describe the options in detail the risks and benefits of both of them, and ultimately, the surgical choice is typically up to the patient and their family. 

Melanie:  What factors determine the available surgical options for a breast cancer patient? 

Dr. Showalter:  Well, like I said, a lot of it, the number one factor is patient choice. And then a lot of it has to do with the particular cancer that the patient has. So we look at things like the size of the tumor, the stage of the tumor, meaning, whether or not it has spread to the lymph nodes underneath the arm, whether or not it involves the skin of the breast. We look at things like the patient’s age, their ability to potentially undergo radiation therapy. So a lot of that, those are the main things that factor into the patient’s choice and ultimately choose what type of surgical treatment. One thing that is hard for patients to understand is that the surgical treatment and the options that they choose in terms of surgery for their breast cancer is actually not at all related to whether or not they're going to need chemotherapy or hormonal therapy. So once we explain that to patients, they seem a little bit more free to really choose what works best for them.  

Melanie:  That’s an excellent way of explaining it, Dr. Showalter. Describe a little bit about what breast-conserving surgery is and who might be a candidate for it. 

Dr. Showalter:  Sure. Breast-conserving surgery is a word that implies removing the cancer from the breast. We typically also remove a small rim of normal tissue around that cancer to ensure that there’s no cancer cells left in the breast. But ultimately, the majority of the breast is left intact. There are some newer techniques that we use called oncoplastic surgery that we do at the time of breast-conserving surgery to help basically move some of the remaining breast tissue around to create a great cosmetic result for patients. Oftentimes, patients even with fairly large tumors won’t even realize that they’ve had breast tissue removed at the time of surgery. So breast-conserving surgery, which is also oftentimes called a lumpectomy or a partial mastectomy, it all means the same thing, and it basically means removing the breast cancer and leaving the remainder of the breast intact. Breast-conserving surgery is often basically always followed by the recommendation to undergo radiation therapy.

Melanie:  And patients who have breast-conserving surgery, do they also have some lymph nodes under the arm removed as well, or is that not a part of this? 

Dr. Showalter:  Yes, that is a part of it. So regardless of whether you choose to have a mastectomy or breast-conserving surgery, either as a separate surgery beforehand or at the same time, we do what we call a sentinel lymph node biopsy. That involves removing one or two of the main lymph nodes underneath the arm in order to check to see if cancer has spread to those lymph nodes. Depending on the results of that surgery, that information helps actually all of us on the team in order to guide the rest of the treatment. Sometimes that implies that the patient will then need what we call a complete axillar node dissection, which means removing the remainder of the lymph nodes. But more and more, we’re actually not even doing that. Sometimes having positive lymph nodes will mean that the patient is going to be recommended to undergo additional treatments, including radiation therapy or potentially even chemotherapy. 

Melanie:  Dr. Showalter, after a patient has breast-conserving surgery, then you mentioned that those don't necessarily intertwine with chemotherapy or radiation. How long might they have to wait after surgery to start those other treatments? Is there any interaction there? 

Dr. Showalter:  Yeah. So typically, after breast-conserving surgery, it takes about five days for our final pathology report to come in, which we need to ensure that we have all of the cancer out. Again, that tells us if there’s cancer involved in the lymph nodes. And then, once we have the clear report that all the cancer’s out, the patient will typically meet with some medical oncologists to discuss the risks and benefits of chemotherapy. Then, like I said in the beginning, every time somebody has breast-conserving surgery, the recommendation is always to follow that with radiation. Fortunately, we’ve made a lot of advances in radiation treatment recently and able to shorten the course to make that part of the treatment a little bit more palatable for most patients.

Melanie:  What questions should patients ask their surgeons when considering their options for breast cancer surgery? 

Dr. Showalter:  Well, I think it's very important for patients to really understand the difference between breast-conserving surgery and a mastectomy not just in what that surgery entails -- because of course, that’s a very important question asking about recovery time. Especially with a mastectomy, we oftentimes work with a plastic surgeon, and we’ll do what we call immediate reconstruction. But the patients really need to understand their different options in terms of their plastic surgery options, in terms of their recovery, in terms of the length of time they're in the hospital, but what I think is the most important thing that patients need to understand is that it's the job of the surgeon to explain what these choices mean in terms of patient’s overall survival. What we’ve learned from studying breast cancer patients for decades is that whether or not you choose breast-conserving surgery or a mastectomy, the overall survival is the exact same. I think that’s very hard sometimes for patients to understand because they assume that a bigger surgery will lead to a longer survival, so I really make a point of explaining that to patients. The difference between the two surgeries is that there’s a slightly increased chance of a recurrence, meaning, the breast cancer coming back again, when you’ve left some of the breast tissue intact. But most importantly, the overall survival between breast-conserving surgery and a mastectomy is the exact same. 

Melanie:  What about recovery time between those two surgeries? 

Dr. Showalter:  Well, that, I always say, very much depends on the type of plastic surgery that the patients that are opting for a mastectomy end up choosing. When you have breast-conserving surgery, that is outpatient surgery, so we typically will do the breast surgery and the lymph nodes biopsy at the same time. Patients come in and go home on the same day, and they typically are feeling pretty well within just a couple of days, although I always tell them to take it easy for much longer than that. A mastectomy requires one to five nights in the hospital, which is completely dependent based upon the type of plastic surgery for reconstruction. So for both of them, the recovery is fairly quick. Women typically say that they're up and about probably faster than they should be but feel pretty well very quickly after surgery. 

Melanie:  Dr. Showalter, why should patients come to UVA for their breast cancer care? 

Dr. Showalter:  Well, of course, I’m biased but I think that at UVA, what we very much excel in is our multidisciplinary approach to the treatment of breast cancer. So not only are there breast surgical oncologists, myself and my two partners, but we have a great team of radiologists that are all fellowship-trained. They help us in the screening, the diagnosis, and the staging of breast cancer. We have wonderful radiation oncologists, pathologists, and plastic surgeons, and we all work together as a team to really come up with an individualized treatment plan for our patients. One of the things that I love about working at UVA is that we have things to offer for patients with early and late stage disease. For our late-stage patients, we have a lot of clinical trials, especially with the medical oncologists. And like I mentioned earlier, for the patients with early-stage disease, we have a lot of exciting options for shorter courses of radiation as well as interesting surgical techniques that really help us ultimately enhance the cosmetic outcome of our surgery.

Melanie:  Thank you so much, Dr. Shayna Showalter. You’re listening to UVA Health Systems Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks so much for listening.