The vast majority of breast cancer patients undergo some form of surgery, which serves as the core treatment step sequenced often with other important modalities of treatment.
The breast surgeon helps to define, refine and schedule this care, often working with the medical oncologists and radiation therapists.
The team may support the effectiveness of operative procedures with other treatments that take place before or after surgery.
Malini Iyer, MD is here to discuss all your breast cancer surgical options.
Breast Cancer Surgery Options
From the Show: Lourdes Health Talk
Summary:
Air Date: 3/30/16
Duration: 10 Minutes
Transcription:
Melanie Cole (Host): Surgery may be the first line of attack against breast cancer. Most women with breast cancer will have some type of surgery as part of their treatment. That decision is best made with your physician. My guest today is Dr. Malini Iyer. She’s an accomplished board certified surgeon whose fellowship trained in breast surgery and oncology. Welcome to the show, Dr. Iyer. Tell us a little bit about what happens with a woman at first diagnosis with breast cancer. When do they have an appointment with a surgeon?
Dr. Malini Iyer (Guest): Patients can see the surgeon when they present with a mass in the breast or an abnormal mammogram or they can present after they have had a biopsy as an outpatient diagnosing cancer. So, occasionally, they present with symptoms and the surgeon will be the first person that they see. They get an examination and then they will undergo diagnostic mammography and maybe an ultrasound to decide what we’re dealing with. Usually, if there is concern for breast cancer, a biopsy will be performed usually with some kind of image guidance and then a diagnosis of breast cancer is made. After that, the patient will come back and see the surgeon again to discuss their surgical options.
Melanie: Is there a first line of defense surgery--just removing the mass or a lumpectomy or do some women choose to go right for a bigger surgery? How is that decision made?
Dr. Iyer: It all depends on what we call the “stage” of the cancer on presentation. That is, we look at the size of the actual tumor that the patient might have; we look at whether their nodes or glands in their armpits are swollen and might be involved with cancer; and then, we like to see if they might have symptoms suggestive of further cancer elsewhere in the body. Many patients do present with early breast cancer and all cancer that is localized to the breast and that can be determined on an initial breast examination. Based on that, most women do have options of either going for a lumpectomy or what we call a “mastectomy” which is removal of most of the breast with or without the nipple and areolar complex. Usually, a patient does have a choice to do one or the other. A lumpectomy can be done for localized cancers usually in one quadrant of the breast. If there is cancer in multiple quadrants, the patient requires a mastectomy. Otherwise, a mastectomy is a choice for most patients. Unilateral mastectomy can be done for cancer on one side and there are some women who might opt for bi-lateral mastectomies. Usually, the first conversation with the patient is talking about all her surgical options and then going through the pro’s and con’s of each one. Maybe allowing the patient to decide based on her inclination and maybe guiding her based on the extent of the cancer within the breast.
Melanie: Dr. Iyer, women hear the word “mastectomy” and right away, even though we’re trying to save our own lives, there’s a little bit of vanity that comes into play here and that feeling of losing your womanhood. There is breast conserving surgery. Explain the difference between those two.
Dr. Iyer: Breast conserving surgery refers to a lumpectomy where what you have to do with surgery is remove the actual cancer with a rim of normal breast tissue all around. It’s usually done as a day procedure. The patient comes in and the mass is removed, if it can be felt. If the mass cannot be felt, we will use radiology to help us guide the site of surgery by something called a “needle guided lumpectomy” where the radiologist puts a very thin wire into the breast pointing to the site of the cancer and the surgeon comes and performs surgery around the cancer and around that localizing wire. That is a lumpectomy. A mastectomy is much larger surgery. It does involve the patient coming in and involves removal of the whole breast, including the tumor within whichever quadrant of the breast it is in. Then, after that--at the same time nowadays--we do offer reconstruction for the patient. So, you’re looking at maybe a 3-4 hour operation or sometimes even a much longer surgery with admission to the hospital and a little bit more involved post-operative care.
Melanie: That breast reconstruction after surgery, is that the same physician oncologist? Does another physician come in to do that? What if a woman chooses this option?
Dr. Iyer: Usually, breast reconstruction is performed by a plastic surgeon working in conjunction with the oncologist in the operating room. So, the mastectomy is done first and then, the plastic surgeon comes in and completes the reconstruction based upon the choice that the patient has made. Reconstructive options are multiple and are available in various forms. Two standard reconstructive options include placement of something called a “tissue expander” behind the muscle in the area of the breast. Usually this involves further treatment for about three to six months when that expander is filled with a saline. At a later stage, the expander will be removed and an actual implant, either a saline or silicone implant, will be placed in that area to substitute for the patient’s native breast. The other reconstruction is called “autologous reconstruction” which involves using another portion of the patient’s body--either the fat in the lower abdomen or the tissue in the upper chest or in other areas of the breast. You use the patient’s own tissue and move it into the area where the native breast was to make a reconstructed breast.
Melanie: If you discover that the cancer has spread to the lymph nodes and they have to have lymph node removal, then what does that add to the surgery and what are the after effects, like lymphedema, that can happen?
Dr. Iyer: All patients with what is called an “invasive” breast cancer must have some kind of surgery done to the lymph nodes in the armpit. The lymph nodes are glands to which the cancer might spread. So, for early breast cancer what we do is a sentinel lymph node biopsy in the armpit where we inject various dyes into the breast and follow them into the armpit and remove nodes into which this dye might migrate. It doesn’t mean these nodes are involved with cancer but these are the first nodes that could be involved and they are tested. If these nodes are negative, the patient does not need any further surgery. On an average, about 1 to 4 nodes are removed. If the patient has an actual involved node, then more surgery is done in the armpit where a lot more nodes may be taken out. That is called an “axillary dissection”. That is a little bit more involved and might require the patient to be admitted for a day or two depending on the circumstance. If the nodes are removed, the patient always has a small risk of some side effects of which is something called “lymphedema” where the arm can swell up because it doesn’t drain appropriately after surgery. In that situation, the patients arm could get swollen, they could have a little pain radiating down the arm and the entire limb might just feel a little thicker than otherwise. Usually, treatment for lymphedema involves physical therapy, various forms of compression garments and sometimes, in late stages, may even need surgery to reverse the lymphedema. Surgery is not always successful but could be used and there are multiple plastic surgeons nowadays that are qualified in lymphovenous anastomosis and this may help the patient. Unfortunately, if you do develop lymphedema, it is a permanent thing and physical therapy and exercise helps in quite a few patients in early stages. Other symptoms and problems because of lymph nodal involvement could be varying degrees of numbness, pain and tingling in the armpit and the upper arm and, occasionally, most of their pain along the arm is what we call “neuropathy”. Vary rarely, with the extensive dissections of the node, nerve injury may occur which might lead to mild weakening of the left shoulder almost akin to a rotator cuff kind of issue.
Melanie: Such great information, Dr. Iyer. Tell us a little bit about your team at Lourdes and what you’re doing that’s exciting there.
Dr. Iyer: We have a wonderful team of surgical oncologists, medical oncologists and radiation oncologists. We also have a nurse navigator and, in my office, I have a wonderful clinical nurse assistant. We also have a great radiology team who helps us with diagnostic mammograms and evaluation of breast cancer. The team really starts with the radiologist who often does the mammograms and detects early cancer. The patient could start their journey in my office where they come with a symptom and something that I can evaluate and then, our nurse navigator gets them hooked into the system so they can see all the other physicians involved in their care in a very timely fashion. We have multi-disciplinary conferences where all the specialists join together and discuss almost every case prospectively, even before they go for surgery, to make sure that all treatments are given in a timely fashion and in the appropriate order according to the patient’s disease. We have very great pathologists who are excellent in diagnosis of the cancer and are able to give us useful information to guide our treatment. In follow up, we have a lot of social programs including a wellness program and social workers who can help the patient deal with their journey through breast cancer and subsequently allow them to be survivors and live well after treatment of breast cancer. I do believe we have a spectacular team and a wonderful oncology program at Lourdes.
Melanie: Thank you so much for being with us, Dr. Iyer. Really, it was great information so beautifully put. You’re listening to the Lourdes Health Talk. For more information you can go to lourdesnet.org. That’s lourdesnet.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Surgery may be the first line of attack against breast cancer. Most women with breast cancer will have some type of surgery as part of their treatment. That decision is best made with your physician. My guest today is Dr. Malini Iyer. She’s an accomplished board certified surgeon whose fellowship trained in breast surgery and oncology. Welcome to the show, Dr. Iyer. Tell us a little bit about what happens with a woman at first diagnosis with breast cancer. When do they have an appointment with a surgeon?
Dr. Malini Iyer (Guest): Patients can see the surgeon when they present with a mass in the breast or an abnormal mammogram or they can present after they have had a biopsy as an outpatient diagnosing cancer. So, occasionally, they present with symptoms and the surgeon will be the first person that they see. They get an examination and then they will undergo diagnostic mammography and maybe an ultrasound to decide what we’re dealing with. Usually, if there is concern for breast cancer, a biopsy will be performed usually with some kind of image guidance and then a diagnosis of breast cancer is made. After that, the patient will come back and see the surgeon again to discuss their surgical options.
Melanie: Is there a first line of defense surgery--just removing the mass or a lumpectomy or do some women choose to go right for a bigger surgery? How is that decision made?
Dr. Iyer: It all depends on what we call the “stage” of the cancer on presentation. That is, we look at the size of the actual tumor that the patient might have; we look at whether their nodes or glands in their armpits are swollen and might be involved with cancer; and then, we like to see if they might have symptoms suggestive of further cancer elsewhere in the body. Many patients do present with early breast cancer and all cancer that is localized to the breast and that can be determined on an initial breast examination. Based on that, most women do have options of either going for a lumpectomy or what we call a “mastectomy” which is removal of most of the breast with or without the nipple and areolar complex. Usually, a patient does have a choice to do one or the other. A lumpectomy can be done for localized cancers usually in one quadrant of the breast. If there is cancer in multiple quadrants, the patient requires a mastectomy. Otherwise, a mastectomy is a choice for most patients. Unilateral mastectomy can be done for cancer on one side and there are some women who might opt for bi-lateral mastectomies. Usually, the first conversation with the patient is talking about all her surgical options and then going through the pro’s and con’s of each one. Maybe allowing the patient to decide based on her inclination and maybe guiding her based on the extent of the cancer within the breast.
Melanie: Dr. Iyer, women hear the word “mastectomy” and right away, even though we’re trying to save our own lives, there’s a little bit of vanity that comes into play here and that feeling of losing your womanhood. There is breast conserving surgery. Explain the difference between those two.
Dr. Iyer: Breast conserving surgery refers to a lumpectomy where what you have to do with surgery is remove the actual cancer with a rim of normal breast tissue all around. It’s usually done as a day procedure. The patient comes in and the mass is removed, if it can be felt. If the mass cannot be felt, we will use radiology to help us guide the site of surgery by something called a “needle guided lumpectomy” where the radiologist puts a very thin wire into the breast pointing to the site of the cancer and the surgeon comes and performs surgery around the cancer and around that localizing wire. That is a lumpectomy. A mastectomy is much larger surgery. It does involve the patient coming in and involves removal of the whole breast, including the tumor within whichever quadrant of the breast it is in. Then, after that--at the same time nowadays--we do offer reconstruction for the patient. So, you’re looking at maybe a 3-4 hour operation or sometimes even a much longer surgery with admission to the hospital and a little bit more involved post-operative care.
Melanie: That breast reconstruction after surgery, is that the same physician oncologist? Does another physician come in to do that? What if a woman chooses this option?
Dr. Iyer: Usually, breast reconstruction is performed by a plastic surgeon working in conjunction with the oncologist in the operating room. So, the mastectomy is done first and then, the plastic surgeon comes in and completes the reconstruction based upon the choice that the patient has made. Reconstructive options are multiple and are available in various forms. Two standard reconstructive options include placement of something called a “tissue expander” behind the muscle in the area of the breast. Usually this involves further treatment for about three to six months when that expander is filled with a saline. At a later stage, the expander will be removed and an actual implant, either a saline or silicone implant, will be placed in that area to substitute for the patient’s native breast. The other reconstruction is called “autologous reconstruction” which involves using another portion of the patient’s body--either the fat in the lower abdomen or the tissue in the upper chest or in other areas of the breast. You use the patient’s own tissue and move it into the area where the native breast was to make a reconstructed breast.
Melanie: If you discover that the cancer has spread to the lymph nodes and they have to have lymph node removal, then what does that add to the surgery and what are the after effects, like lymphedema, that can happen?
Dr. Iyer: All patients with what is called an “invasive” breast cancer must have some kind of surgery done to the lymph nodes in the armpit. The lymph nodes are glands to which the cancer might spread. So, for early breast cancer what we do is a sentinel lymph node biopsy in the armpit where we inject various dyes into the breast and follow them into the armpit and remove nodes into which this dye might migrate. It doesn’t mean these nodes are involved with cancer but these are the first nodes that could be involved and they are tested. If these nodes are negative, the patient does not need any further surgery. On an average, about 1 to 4 nodes are removed. If the patient has an actual involved node, then more surgery is done in the armpit where a lot more nodes may be taken out. That is called an “axillary dissection”. That is a little bit more involved and might require the patient to be admitted for a day or two depending on the circumstance. If the nodes are removed, the patient always has a small risk of some side effects of which is something called “lymphedema” where the arm can swell up because it doesn’t drain appropriately after surgery. In that situation, the patients arm could get swollen, they could have a little pain radiating down the arm and the entire limb might just feel a little thicker than otherwise. Usually, treatment for lymphedema involves physical therapy, various forms of compression garments and sometimes, in late stages, may even need surgery to reverse the lymphedema. Surgery is not always successful but could be used and there are multiple plastic surgeons nowadays that are qualified in lymphovenous anastomosis and this may help the patient. Unfortunately, if you do develop lymphedema, it is a permanent thing and physical therapy and exercise helps in quite a few patients in early stages. Other symptoms and problems because of lymph nodal involvement could be varying degrees of numbness, pain and tingling in the armpit and the upper arm and, occasionally, most of their pain along the arm is what we call “neuropathy”. Vary rarely, with the extensive dissections of the node, nerve injury may occur which might lead to mild weakening of the left shoulder almost akin to a rotator cuff kind of issue.
Melanie: Such great information, Dr. Iyer. Tell us a little bit about your team at Lourdes and what you’re doing that’s exciting there.
Dr. Iyer: We have a wonderful team of surgical oncologists, medical oncologists and radiation oncologists. We also have a nurse navigator and, in my office, I have a wonderful clinical nurse assistant. We also have a great radiology team who helps us with diagnostic mammograms and evaluation of breast cancer. The team really starts with the radiologist who often does the mammograms and detects early cancer. The patient could start their journey in my office where they come with a symptom and something that I can evaluate and then, our nurse navigator gets them hooked into the system so they can see all the other physicians involved in their care in a very timely fashion. We have multi-disciplinary conferences where all the specialists join together and discuss almost every case prospectively, even before they go for surgery, to make sure that all treatments are given in a timely fashion and in the appropriate order according to the patient’s disease. We have very great pathologists who are excellent in diagnosis of the cancer and are able to give us useful information to guide our treatment. In follow up, we have a lot of social programs including a wellness program and social workers who can help the patient deal with their journey through breast cancer and subsequently allow them to be survivors and live well after treatment of breast cancer. I do believe we have a spectacular team and a wonderful oncology program at Lourdes.
Melanie: Thank you so much for being with us, Dr. Iyer. Really, it was great information so beautifully put. You’re listening to the Lourdes Health Talk. For more information you can go to lourdesnet.org. That’s lourdesnet.org. This is Melanie Cole. Thanks so much for listening.
