Dr. Alexander Miller is a surgical oncologist who specializes in treating breast cancer and people at high risk of the disease. Currently at the START Center for Cancer Care in San Antonio, Texas, he trained at MD Anderson and the Mayo Clinic. Dr. Miller has received awards for excellence in research, education, and patient care. He has been lead or collaborating researcher for several studies on breast cancer treatments, prevention, genetic testing, and the psychosocial experiences of people receiving cancer care.
Listen to the podcast to hear Dr. Miller explain:
- the most common side effects of both mastectomy and lumpectomy and how to manage them
- why the risk of lymphedema, while still a concern, has gone down in the last 10 years
- steps people can take before surgery to reduce the risk of side effects
Running time: 31:48
Show Full Transcript
Jamie DePolo: Hello, everyone. Welcome to this edition of the Breastcancer.org podcast. I’m Jamie DePolo, the senior editor of Breastcancer.org. Our guest today is Dr. Alexander Miller. He’s a surgical oncologist who specializes in treating breast cancer and people at high risk for the disease. Currently at the START Center for Cancer Care in San Antonio, Texas, Dr. Miller trained at MD Anderson and the Mayo Clinic. He has received awards for excellence in research, education, and patient care.
He has been lead or collaborating researcher for several studies on breast cancer treatments, prevention, genetic testing, and the psychosocial experiences of people receiving cancer care.
Today he’s going to talk to us about managing the side effects that can happen after breast cancer surgery. Dr. Miller, welcome to the podcast.
Alexander Miller: Thank you very much.
Jamie DePolo: So to start, are there common side effects? Or can you tell us a little bit about the most common side effects after breast cancer surgery and whether they’re common for both mastectomy and lumpectomy, or are there certain side effects that you see more often with each particular type of surgery?
Alexander Miller: Okay. So you’re right to distinguish between mastectomy and lumpectomy. Lumpectomy is removal of the breast cancer with a normal rim of tissue that’s not affected by cancer, and then usually we’ll remove lymph nodes through a separate incision. That’s usually a less significant procedure. Most of the time it’s an outpatient surgical procedure, but certainly there are some side effects that are associated with it.
I usually tell patients to expect some pain, some swelling of the breast. It’s important to note that the breast or any tissue that’s under the skin, when you remove tissue, the body will produce some fluid. And so it’s very normal to have some fluid in the cavity that’s created by removing breast tissue. In the course of a normal lumpectomy, this is perfectly to be expected and usually doesn’t cause any problems, and in fact helps the contour and the appearance of the area of surgery in the breast for a long period of time. But it’s worthwhile to let patients know to anticipate it. Sometimes if they get up abruptly or change positions, they’ll actually feel sloshing of fluid. So that fluid is very normal. We don’t want too much, but a little bit will be absorbed by the body in time.
Under the arm where we remove lymph nodes, again, you can develop some fluid there. Most of the time there’s no need to remove it or drain it, but it’s important to let patients know that there can be the occasional risk of infection of the skin, which would be noted by redness or warmth of the skin or an enlarged amount of fluid to the point where it almost feels like a small piece of fruit is under the arm. And that would denote enough fluid that maybe we might have to drain it. Not surgically necessarily; most doctors can do this in the office or have a radiologist they work with who can do it with an ultrasound machine.
So the main complications from lumpectomy would be the possibility of swelling or this fluid, the possibility of infection, although the chance for that in most practices is probably 5% or less. There’s also a small risk of bleeding, but again, most of the time when we do a lumpectomy and remove a lymph node or two, the amount of tissue removed is so small and our incisions are so small, there’s not a lot of room for blood to accumulate. So that’s very fortunate.
And then there will be times, especially with lymph node removal, when the arm that’s just beyond the shoulder toward the elbow might feel tight or feel some pulling, sometimes even some numbness at the back of the arm, which hopefully is temporary. Those things can occur as well. And so most patients, like I say, could be treated as outpatients, and they might take a couple days’ worth of prescribed pain medicine and then usually can transition to something like Advil or Motrin or Tylenol.
That’s in distinction to a mastectomy. So again, everybody’s practice is different and every patient’s condition is unique, but a mastectomy can be done either at the time of an immediate plastic surgical reconstruction or separate from that. And the complications and things that we look for are much different depending on what else gets done at the time of mastectomy.
So a patient who is having a mastectomy without reconstruction, they do have a lot more tissue removed because then we’re removing all the breast tissue rather than just the area around the tumor. So there’s a larger area that we operate on and, consequently, a larger area that might be prone to developing fluid or blood or the possibility of infection. So in this case, most surgeons will leave a plastic drain that will drain fluid out after the surgery, and that drain will usually be in place for at least a week or two. Patients are instructed before surgery to anticipate that this drain will be in place, and then after surgery, we talk with the nurses about how to take care of the drain, record how much comes out, empty it at least twice a day. And in most communities, there is the option of having a visiting nurse or health worker to come to the home and actually assist with this. You can still take a shower with the drain in place, but it is sort of an added item to be aware of.
Most of the time now with mastectomies, we don’t make a separate incision to remove lymph nodes. So the lymph nodes, if they were removed, will be removed using the same incision, but patients still might feel that pulling or tightening under the arm or, on occasion, this numbness in the back of the arm. The reason for numbness in the back of the arm is that there are nerves that go from the chest wall to the arm that are right -- almost like high wires that we might see on telephone lines -- and those wires are in between and around where the lymph nodes are. So sometimes those nerves get irritated or damaged. In most cases with the type of surgery we do where we don’t remove many lymph nodes anymore, if there is damage to them, some numbness in the back of the arm just below the shoulder can occur for about 2 to 4 weeks and then usually gets completely resolved.
Occasionally, if there are lymph nodes involved that do have cancer in them and they need to be surgically removed, sometimes these nerves are sacrificed and then that might cause permanent numbness of the back of the arm. This was something that was very common 15 to 20 years ago when almost all women had full removal of lymph nodes, but now that we do selective lymph node removal, or what’s called sentinel lymph node mapping, this is much less common, hopefully.
So, in addition to the other things I mentioned, you know, there’s always a risk of an infection developing, and in some practices antibiotics are provided after surgery and other antibiotics are only given if there is a concern for infection, which, again, might be noticed by the patient with redness of the skin or warmth of the skin.
And bleeding is a little bit higher risk in a mastectomy or after a mastectomy without reconstruction because as I mentioned, there’s a much larger area that’s operated and there’s a lot more room for blood to accumulate. The drains that we placed can help remove this blood, but if we notice, especially in the first day or two after surgery, that a patient is accumulating blood under the skin where we have operated, then sometimes it’s necessary to remove that blood with a second surgery. Again, this shouldn’t happen in most practices more than about 10% of the time, but more and more of our patients are coming to us on blood thinners either because they’ve had blood clots in the past, an irregular heart rhythm in the past, or some other condition that causes them to be on blood thinners. And so because of that, I think there is a little higher risk of bleeding after a mastectomy than there used to be.
There’s also the situation of having a mastectomy but then having immediate reconstruction at the same time. In most practices, and certainly in mine, this is done in collaboration with a plastic surgeon where I will remove the breast tissue and the lymph nodes and the plastic surgeon will perform a reconstruction during the same surgery. And there are many types of reconstructions that are possible, but essentially the biggest difference is either placing a tissue expander and then later on exchanging that for an implant or using the patient’s own tissues, such as the abdominal flap, it’s called, or perhaps the tissue or the muscle of the back.
When these reconstructions are performed at the time of mastectomy, then there can be other complications that can occur. There might be a little more pain. When our plastic surgeons use the abdominal tissue, there’s actually a lot more pain, but on the other hand, many measures are taken in the operating room to reduce that, and we give longer-acting injectable pain medicine and also pain medicine during the recovery period.
And certainly when there’s more surgery involving more locations, then there’s also the risk for bleeding or infection or swelling in these other operative sites. But in most practices, the plastic surgeons will specifically review the possible side effects and complications of their portion of the procedure, and in most practices, again, where there are very experienced surgeons involved, usually these are kept to a minimum.
So I think that sort of at least loosely describes the main complications and things that we recognize in the first several days to weeks after surgery.
Jamie DePolo: Okay. Thank you. I do have a couple questions on that. You mentioned bleeding as a possible side effect. And when you were describing it, it sounded like this would be something that the body is doing, producing fluid or blood because of the tissue that’s been taken out, and it should be taken care of with the drain. But how common and serious is it that the person is actually bleeding from an open vessel that was perhaps missed during surgery?
Alexander Miller: It should be pretty rare. It’s a good question. It should be very rare. Probably the chance of that happening in most practices is no more than 10%, maybe 15%. But like I said, I think the thing that’s changed -- and again, the type of surgery and the techniques we use have also changed over time -- but the biggest change I notice over the last few years is the number of patients who see us who are already on blood thinners. And so we’re always trying to manage the risk of being off or on those blood thinners, and thereby the risk of either making a clot that could travel to the legs, the lungs, or even to get a stroke, versus the risk of bleeding.
So we’re trying to get those blood thinners on and off around the time of surgery as quickly as possible, and yet we recognize that there may be a patient or two who, because we’ve tried to get them back on blood thinners to avoid another complication involving a heart attack or a stroke or a blood clot, they may experience some bleeding from that.
And what happens with blood vessels, normally blood vessels are treated by either heating them, or cauterization, or we have small metal clips that we use at the time of surgery. But occasionally a very small blood vessel will either be in spasm or very tight at the time of surgery and we won’t see it bleeding, and then over the next 12 to 36 hours it might expand again, or dilate, and bleeding might be caused. So the most important thing for a mastectomy patient is that they’re watched very closely, especially in the first day or two. In most practices, women who undergo mastectomy without reconstruction are in the hospital at least overnight, if not two nights, and the nurses in those facilities need to be educated as to what to look for in terms of bleeding.
Certainly blood from the drain that’s profuse would be one indication, but it’s interesting that patients and nurses sometimes don’t recognize that after we perform a mastectomy, the chest wall will look very thin and almost the skin is up against the chest wall, and obviously the breast tissue has been removed. But sometimes with bleeding it will look like not a lot of tissue has been removed, but it won’t look abnormal necessarily, and people won’t recognize for several hours that there might be bleeding. So it’s something that everyone needs to be educated about so they can recognize sooner rather than later. Sometimes if we identify a bit of bleeding after surgery, it can be controlled without going back to the operating room. But if it’s allowed to persist for several hours, then usually we’ll go back to the operating room and remove it.
Jamie DePolo: Okay. That’s very helpful. Thank you. I’m also wondering about women who have mastectomy but do not plan to have any type of reconstruction, so there would be no tissue expander, no microsurgery. And are there any different or special side effects that those particular cases might have or is it the same as a mastectomy?
Alexander Miller: Beyond what we’ve already discussed, the main thing that I recognize -- and I think it’s more of a longer-term issue after they’ve recovered -- is women, especially younger women who choose not to have reconstruction, often, even though they’ve seen perhaps pictures or other images online or elsewhere, they’re really not prepared for what their bodies will look like having not had reconstruction when they recover.
And the first thing that they will look at is their incisions and also how, if there is any extra skin from the breast, where that sits on their body. Many women, especially larger women, will notice that there’s excess skin, especially under their arm. And we used to make large incisions and take a lot of skin to the point where that skin was tight. Rarely in my practice do I do that anymore, either because patients might need radiation even after mastectomy for more of what we call locally advanced breast cancer, or because in discussion with the patient before surgery they explained that while they don’t want reconstruction immediately, they might want it down the road. And our plastic surgeons prefer to have extra skin, if possible, so that will enhance and optimize their reconstruction.
So I think the biggest thing that women notice is the appearance of their incisions, whether or not they’re symmetrical, if they have surgery on both sides or bilateral surgery, and also where the extra skin resides and how that feels to them. And there’s really two groups of women that end up not having reconstruction, at least in my practice. One group are younger, very astute women who have either friends and/or extensive exposure to other materials, including online, and they’ve decided for whatever reason that reconstruction is not important to them. Some of them will go on and have tattooing where the breast tissue was or their chest wall, and they really have very specific ideas about how they want to look afterwards.
There’s another group of women who for whatever reason are just not good surgical candidates for reconstruction. They might have other medical conditions or be somewhat older, less active. And so that’s a different group of patients. That group of patients tends to have more of a problem with that extra skin, and there are some methods for pulling that extra skin in away from under the arm that they can discuss with their surgeons before surgery and even after.
The first group of women who have these very specific ideas about not wanting reconstruction and how they want to look, sometimes even though we don’t do reconstruction, we will work with our plastic surgeons after the mastectomy and they’ve recovered to refine or alter their incisions in some way if they’re not happy with them. And I’ve certainly seen that happen a couple of times.
Jamie DePolo: So the best thing someone could do is definitely talk to the surgeon beforehand and explore all the options for reconstruction or not reconstruction and ask questions accordingly so that, say, if a woman is very sure she never wants reconstruction, she can have the outcome she wants whereas if she may want reconstruction down the road, then you would probably do different incisions or leave more skin. So it sounds like the bottom line is to definitely talk to the surgeon and explore all the options.
Alexander Miller: It’s really important, and it’s really important that women make choices for themselves. So many times I’ll see women who, either because of their spouses or significant others, are trying to accommodate those people, and all our studies and experience demonstrate that women really have to make the choice that they’re most comfortable for individually and for themselves. They should not feel rushed, either, to make these choices.
Breast cancer is not something that develops overnight, and so they should feel very comfortable taking a week or more to make a decision. And if after they leave the surgeon’s office they decide, “You know what, I’d like to visit with a plastic surgeon,” even though the surgeon may have recommended lumpectomy, no surgeon should be uncomfortable with that decision or request and should accommodate it.
If they have other questions after they’ve left the office, they should, again, recontact their surgeon to ask more questions and they should also feel comfortable always getting a second opinion. Many times surgeons’ recommendations are based on the local community practice. So, for example, if a surgeon is in a community where the plastic surgeons are not able to provide microsurgical reconstruction using the patient’s own tissue, they won’t offer it necessarily. And yet I think it’s important, if patients have questions about this, to ask, “Well, where is the closest surgeon or practice that could offer this option, and is that something that in an ideal world would be appropriate for me?”
And similarly, just with the choice of lumpectomy versus mastectomy, we know based on the medical literature that when patients are chosen appropriately, the outcome or the risk of getting cancer again is very low with either choice: either a lumpectomy, in which case some sort of radiation is needed after, or a mastectomy, when most of the time radiation is not needed. But if these operations are done appropriately, the chance that the cancer will come back in that area, in that breast, are about 7% plus or minus a few percentage points. So the outcomes are equivalent, and yet there’s a lot of pressure in certain practices to really try to do lumpectomies. There’s certain pressure in other practices to recommend mastectomies and in even others to recommend doing bilateral breast surgery.
And all of these decision are very individual. There are several criteria that each decision should be made using, and again, a patient really has to feel comfortable that she’s receiving all the options, and if she’s not a candidate for one of these procedures, she needs to ask her surgeon why and get a very reasonable and appropriate answer. And if she still has more questions afterwards, as I said, feel free to recontact the surgeon or seek out other sources of information.
Jamie DePolo: Excellent advice. One topic we haven’t touched on yet is lymphedema. And I know from our site visitors, many people have that condition, many people are afraid of that condition as they’re going into surgery. In your experience, how common is that, and are there things a woman can do ahead of time, say having her arms measured to see if any swelling does develop, to keep tabs on it, do as much risk reduction as possible? Are there things that you recommend for that?
Alexander Miller: That’s a great question. So again, in the newer era of removing fewer lymph nodes -- and so we have a technique called sentinel lymph node mapping using either a very safe radioactive material and/or a blue dye that demonstrates lymph nodes that would be most likely to have cancer -- we are removing fewer lymph nodes. And in the course of removing fewer lymph nodes, the occurrence of lymphedema has declined tremendously. So whereas it might have been as high as 20 to 25% in the past, now, if women only have a couple of lymph nodes removed, the chance of having noticeable or significant lymphedema should be 5% or less.
However, there are always women who will have some amount of arm swelling. And again, we would hope that most of it is very minimal and can be treated with massage therapy and perhaps physical therapy. But some women still, either because of their disease or certain anatomic features, will have the sort of older type of arm swelling that people might think of that’s very recognizable. Now, there is a new procedure in which lymph node tissue and other types of tissue can be moved under the arm and reconstructed there typically, again, by either microsurgeons or specialized reconstructive surgeons, and that’s something to discuss with the surgeon.
But to answer your question in terms of trying to prevent it, the first step, no question, is removing as little tissue as possible to provide appropriate treatment. And then, once the surgery has occurred, taking care to probably not have blood draws in that arm. But the idea of not being able to have a blood pressure check I think is probably antiquated. There’s really no reason a patient can’t have their blood pressure checked a few weeks to perhaps a month or two after surgery once they’ve healed, because just compressing the arm should not cause lymphedema.
What can trigger lymphedema is something like a scratch or an insect bite or a bite from a pet or some type of wound that’s created in the hand or the arm. And if a patient who’s had lymph node removal undergoes or experiences any of these types of traumatic events, they should contact their doctor. Because sometimes antibiotics will be recommended or special cleansing of the arm will be recommended, because the more lymph nodes that are removed, the more prone someone is to swelling and to infection of the arm, and it’s that infection or swelling, if it’s not corrected promptly, it can lead to lymphedema. So that’s very important.
And again, as with all these things that we’re discussing, very important to discuss that risk or the possibility of that occurring with their surgeon and to find out what the surgeon’s experiences with that and how they manage it. In our practice, we have a dedicated physical therapy group that manages patients with lymphedema. It’s pretty rare that they have to do much more than massage therapy and some other types of exercises, but occasionally a woman with significant lymphedema will be counseled to wear an elastic support garment that gets fitted on their arm. These are not particularly comfortable, especially in the summertime when it’s hot, but on the other hand really can reduce the amount of swelling that women have.
Jamie DePolo: Thank you. All very good points. And finally, I’m wondering, do you give your patients a list of things to do before surgery in the hospital that can help reduce any side effects from surgery or things to do at home afterward? I’m just wondering if there are any tips that people who are getting ready for surgery right now can take away from this?
Alexander Miller: Sure. So the first thing would be, we try to identify if someone is a smoker. And if someone’s a smoker, we really ask that they either reduce the amount that they’re smoking or get into some type of smoking cessation program. There’s clear evidence that smoking interferes with wound healing, probably by interfering with the normal anatomy of blood vessels and circulation. And so if there’s any opportunity to intervene with smokers before surgery, we really try to do that. And, in fact, some of our plastic surgical colleagues will test patients for nicotine in their body, and if the nicotine level is too high, they will not proceed with reconstruction at that time. So that’s very important.
The other things we discuss are healthy eating and exercise and getting rest. These are always challenging, even when life is normal, and when life’s been tilted because of a cancer diagnosis, it’s even more difficult. But it took many years to get very good information on the correlation between recovering from and being treated for cancer and things like a healthy diet, exercise, and sleep. And so we really try to encourage patients to eat healthy -- and by that I mean if they are younger than 65, reducing the amount of animal protein they eat, especially red meat -- trying to exercise at least 30 minutes 3 to 4 times a week, and getting at least 8 hours of sleep a night. It’s not always possible, but these are the goals for which we strive. And that even is recommended after surgery with recognizing that exercise has to be curtailed and altered based on the type of operation that they have.
So these are very important things. We want to know if our patients have any difficulties. For example, when there was a flu epidemic during the fall and the winter, we had to postpone many surgeries because patients had flu-like symptoms, and we don’t want to be operating during that period of time or any other types of alterations in their health. There are times where we will get or identify X-rays and tests that we do before surgery, certain abnormalities, and if we find abnormalities in blood tests or chest X-rays or EKGs, we want to check on all those things before we go to surgery to make sure that the patient is as healthy as they can be before they go undergo these procedures.
In addition, around the time of surgery, many physicians will recommend that patients wash their bodies with very good antibacterial soap to, again, reduce the chance of a skin infection. And so different surgeons will have certain regimens that they will discuss with patients to use certain types of antibacterial soaps, if they’re not allergic to those, that will help cut down on the risk of infection.
Most surgeons do not want their patients to shave, especially under the arms, within about 2 to 3 days of surgery if not more. We might do some shaving around the surgical sites the day of surgery, but our information in medical literature demonstrates that if their shaving is done about 2 days or within 1 to 2 days before surgery, that actually increases the risk of an infection. So the timing of any types of shaving or alteration of the skin is very important. And I think those are probably the most important preoperative considerations.
Jamie DePolo: Thank you so much, Dr. Miller. This has been very helpful, and I think the information is going to be very valuable for our site visitors.
Alexander Miller: My pleasure. Thank you very much.