Breast Cancer Surgery: How to Make an Informed Decision

Dr. Marisa Weiss: Hello, I'm Dr. Marisa Weiss, Founder and Chief Medical Officer of Breastcancer.org. Thank you all for joining us for today’s webinar on making decisions about breast cancer surgery. At Breastcancer.org our mission and our passion is to empower every person diagnosed with breast cancer to get the best care possible. For more than 20 years we have provided expert information, resources, and support so you can become your own breast advocate. We hope that today’s program helps you make informed decisions about your own unique situation.

Now I'm going to share my screen with you. There we go. For sure, choosing the kind of surgery and breast reconstruction for your own situation is complicated. There’s a lot of information to consider. After today’s program I strongly encourage you to visit Breastcancer.org/surgery where you will find page after page of easy-to-understand basic information and research news, plus you can connect with others who share their experiences within the Breastcancer.org online community. There’s also information to help you understand how other treatments are paired with surgery, like chemotherapy, radiation, and immunotherapy.

It is important to know that many people may not have choices after a diagnosis. The type, stage, and location of the cancer may leave no room for choice say, between lumpectomy or mastectomy. If this is your experience, we are here for you, too, with a lot of resources available on Breastcancer.org to help you navigate your unique situation.

We are honored to be joined by top surgeons who will share their expertise and advice. Dr. Monique Gary from Grand View Health, she is the Breast Program director, director of the Cancer Genetics and Risk Assessment Program, and medical director of the Grand View Health Cancer program.

Dr. Anne Peled is co-director of the Breast Cancer Center of Excellence at Sutter Health California Pacific Medical Center.

Dr. Scott Sullivan is a founding surgeon at the Center for Restorative Breast Surgery, and the St. Charles Surgical Hospital in New Orleans, and he’s also a member of the Breastcancer.org Professional Advisory Board.

And our moderator is Dr. Donna-Marie Manasseh, chief of the division of breast surgery and director of the Maimonides Medical Center Breast Cancer program. we're so lucky to have Dr. Manasseh on the Board of Breastcancer.org.

Thank you all for being here and for your dedication to helping everyone impacted by breast cancer. We also look forward to talking with Jennifer Meade who is the division President of Breast and Skeletal Health Solutions at Hologic, and a special thanks to Hologic for making today’s program possible, and for all of your support.

There are several key terms you may hear when your doctor is discussing types of surgical procedures. A lumpectomy removes a lump, tumor, or abnormality from the breast while preserving the rest of the healthy breast tissue. Re-excision removes extra tissue after a lumpectomy to get clear margins. Your doctor will know if you need a re-excision if your pathology report shows cancer cells at or really close to the edge of the tissue that has already been removed.

A mastectomy is removal of the whole breast. There are different kinds of mastectomy depending on your unique situation. For example, sometimes the nipple and skin envelope can be saved while the rest of the breast is removed. Lymph node removal or sentinel lymph node dissection is when the surgeon removes some of the underarm lymph nodes to see if cancer has spread there. And reconstruction is rebuilding the breast. There are many options to consider, some of which we will talk about with the panel shortly.

If you are deciding on surgery and reconstruction, you may feel overwhelmed. You may be getting input from others whether you ask for it or not, and you may feel rushed to make these critical choices. There are a few questions you can ask yourself to help like, how important is it to keep your breast, or do you want to limit the number of surgeries that you have, or do you want additional opinions before you move forward with a plan? Write down your thoughts and share them with your doctors so they can guide you based on your priorities.

Reconstruction is a very personal decision. Talking with other women who have been through breast cancer treatment and doing research can be a huge help, but again, ask yourself what matters most to you? There is no right or wrong path to take.

Most people are familiar with breast reconstruction with implants or using your own tissue after mastectomy, but there’s also lumpectomy after reconstruction, including immediate reconstruction that can be done right after the lumpectomy is done in the same surgical procedure.

Nipple reconstruction is optional and some women may choose to get 3-D nipple tattoos rather than reconstruct the nipple with surgery, and some women choose to have both the nipple tattooing and the nipple reconstruction. And some women prefer going flat after mastectomy. Aesthetic flat closure is relatively new and is a good option for some women who don't want reconstruction.

There is a wealth of information about surgeries and reconstruction on Breastcancer.org and we will try to answer questions today through the Q and A feature at the bottom of your screen. Put your questions right in there now.

But it is also extremely important for you to feel comfortable with your decisions by talking with your surgeon. I recommend making a list of your questions to help prepare for your appointment. To get started we have a list on Breastcancer.org/surgery-questions. Things like timing, risk, surgery preparation, recovery, requesting to see before and after photos of women who look similar to yourself, and much more are on Breastcancer.org.

In a moment we're going to play a video featuring women from the Breastcancer.org community who are courageously sharing their experiences going through diagnosis, treatment, and surgery. One of these fierce women said, I remember the morning of my surgery looking at myself in the mirror and saying, I'm never going to look like this again, but that's okay. Be kind to yourself. You can’t unwind the tape and do it over. You're doing the best you can for yourself with the information at hand. That’s all you can do.

Just by your being here today you're giving yourself the knowledge and support you need. Remember to give yourself grace, compassion, and self-care, too. Now let’s hear more from Joanne, Ivana, Pam, Christy, and Catherine.

Joanne: I just said, you know, Mommy’s got a lump in her breast that has to be removed. Mommy’s going to be okay but she’s going to need a lot of time to rest.

Catherine: When I got my second diagnosis, that is when actually it hit me and I realized, oh my gosh, I really have cancer.

Pam: I just was in a panic and didn’t know what to do.

Christy: You have to make decisions in a short amount of time.

Joanne: And I just thought, I have to be strong. No one else can be strong for me.

Ivana: I am a registered nurse. I have a daughter who is eight and a son who is five years old. I was diagnosed on January 20, 2021, with stage I invasive ductal carcinoma.

Christy: I’ve been married for 28 years to my wonderful husband, Danny, and we have two children. I was diagnosed with breast cancer at the age of 43 in 2015. My diagnosis was that I had breast cancer stage I in my left breast and breast cancer stage IIb on my right breast.

Catherine: I’ve been married to my husband for 18 years. We have one daughter who is 25, a 20-year-old son, 17-year-old daughter, a 15-year-old son, and two crazy dogs. In October of 2020 I was diagnosed with breast cancer and I was 56 years old. The two tumors that they found were in the right breast.

Joanne: My husband, Rich, and I live in New York where we enjoy different hobbies year-round. It was actually on Valentine’s Day I was diagnosed with DCIS so, a stage 0 breast cancer in my left breast.

Pam: I was first diagnosed in 2008. The second time I was diagnosed in 2020, surgery January of 2021, another IDC. Same breast but different side of the breast.

Joanne: I sat down with my surgeon and I really liked her approach. She laid things out in a very analytical way which is what works with how I think. She literally took a sheet of paper and wrote down options. My decision was to have a mastectomy with no reconstruction. The reason I chose not to have reconstruction is when I looked at the additional risks of the added surgeries, it just wasn’t worth it to me.

Christy: When I was given the choice of a lumpectomy, I decided to go with that at first because at first they didn’t think that my cancer was as invasive as it was and that they could get clear margins, and we tried that option and unfortunately we didn’t get clear margins so, I had to get a bilateral mastectomy. So, my care team when I told them that I didn’t want reconstruction, they were all very hesitant about that and didn’t understand why that this was my decision. that is not a very, as common of a decision as having reconstruction, and they even tried to tell me that I wouldn’t look and feel like a woman. But I had to be firm and I wanted to stick with what felt right for me.

Catherine: So, I chose to have a double mastectomy with reconstruction, just based on the fact that if I'm having one breast removed, breast tissue removed, I wanted to have the same for the other just to have symmetry and not have the fear of breast cancer or cancer showing up in my left breast as well.

Pam: So, I said, lumpectomy, of course, because less surgery. There were no reconstruction options given to me by surgeons. By reconstruction I think more of when you have a mastectomy, but with a lumpectomy I was unhappy with the outcome and the way it looked, and I decided on my own that I was going to get plastic surgery.

Ivana: I decided to have the lumpectomy, mostly because that is least invasive as opposed to removing my whole breast. I would have liked my doctor to mention reconstruction for a lumpectomy because I feel like they only talk about it if you’re getting a mastectomy. Hearing that they got all the cancer out, I just fell to the ground and I just started crying. I just felt a release, just a complete release just of every negative thought I was thinking that day.

Pam: When you find out you have got cancer, go into research mode and find out everything you can.

Joanne: Part of my research started very close to home because my sister had breast cancer 12 years ago.

Ivana: I talked to other breast cancer survivors.

Catherine: I talked to my sister who is also a breast cancer survivor. I talked to other women, friends, and people online about their surgery decisions.

Pam: Oh, Breastcancer.org is one of the very, very best places to go.

Ivana: Being on this journey I have met some pretty amazing women.

Catherine: We're all here to support each other.

Christy: The biggest thing that I would say to women is to be true to yourself. The decision is ultimately yours.

Joanne: Read a lot, ask a lot of questions, make your decision, and then go forward knowing you made the best decision you could.

Dr. Marisa Weiss: Thank you so much to Joanne, Ivana, Pam, Christy, and Catherine for sharing their stories and for being part of the Breastcancer.org community. You all inspire me and our whole team, and all the other members of the Breastcancer.org community, truly.

Now I'd like to welcome my wonderful colleague, Dr. Donna-Marie Manasseh.

Dr. Donna-Marie Manasseh: Thank you, Dr. Weiss. I want to start by saying that going through any type of surgery can feel overwhelming, that video was incredible. No part of it is easy and that is why we're here today. I hope this program plus the educational resources and online community of Breastcancer.org help you feel less alone.

Now, I'd like to welcome our wonderful panelists. Dr. Monique Gary is a breast surgical oncologist and director of the breast program at Grand View Health in Pennsylvania. Dr. Anne Peled is a co-director of the Breast Cancer Center of Excellence at Sutter Health California Pacific Medical Center in San Francisco. Dr. Peled’s background is in both surgical oncology and reconstructive surgery. And Dr. Scott Sullivan is a founding surgeon at the Center for Restorative Breast Surgery and St. Charles Surgical Hospital in New Orleans where his focus is on the most advanced reconstructive techniques for women facing breast cancer. Thank you all so much for being here and sharing your expertise.

Dr. Gary, I'd like to start with you. What factors should someone consider when deciding between mastectomy versus lumpectomy?

Dr. Monique Gary: Thank you so much for the question. Thank you for inviting me to be a part of this amazing conversation, and it really is a very complicated and multifactorial discussion that a patient needs to have with their doctor, with their family, and first and foremost with themselves. But there are some considerations for patients who are thinking about lumpectomy versus mastectomy, and that is your question, correct?

Dr. Donna-Marie Manasseh: That is right.

Dr. Monique Gary: And so, I think the most important things are going to be questions about and consideration for where the tumor is, how many tumors are within the breast, whether or not the nipple is involved. Certainly a patient needs to understand that radiation may very well be required, especially after lumpectomy, sometimes after mastectomy as well, and so, understanding when radiation is indicated is another important consideration for patients.

Genetic factors such as having BRCA mutations or other high-risk mutations that make a patient at increased risk for a second breast cancer or a cancer in what we call the contralateral or the opposite breast, as well.

Other considerations would include things like connective tissue disorders like lupus or scleroderma, and how well a patient might do after radiation, and what are some of the contraindications for radiation if they opt for breast conservation or a lumpectomy. Inflammatory breast cancer is another really important consideration because we know that lumpectomy or breast conservation really is not indicated in that situation, and also things like pregnancy as well.

So, there’s lots of different considerations and I think I’ve covered probably just some of the highlights.

Dr. Donna-Marie Manasseh: Thank you so much, and Dr. Peled, research shows that mastectomy rates are increasing among women who are eligible for breast conserving surgery. Why do you think that might be?

Dr. Anna Peled: So, I think Dr. Gary addressed the things that women go through and things that they are thinking about when trying to decide between mastectomy and lumpectomy, and there are a lot of women who actually have both options and I think it can be really difficult to try to decide what is the right choice for them, and there are so many factors that go into it. I actually went through breast cancer treatment myself a few years ago and was really surprised how hard it was to make a decision about those two.

And I think a lot of it is the quality-of-life issues that come into it, both on the kind of short-term factors about recovery, reconstructive options. Lumpectomy may seem to be an easier, faster recovery but in many cases you may then have to be followed up with imaging which for some women can be incredibly stressful.

I think there’s also the question of family history and so, for many of my patients, even if their genetic testing comes back negative, if they have seen a family member go through breast cancer treatment, especially they have seen someone die of breast cancer, a double mastectomy often feels like the very best choice, and I think for many women it really is. And so, I think a lot of times the decision-making around mastectomy comes from some of these quality-of-life factors, some of the peace of mind that is real and makes a big difference.

The other thing is we have better reconstructive choices now so, with nipple-sparing mastectomy, with better autologous reconstruction, with better implant choices, we really have better things to offer people. I think that makes a big difference for women as well.

Dr. Donna-Marie Manasseh: I couldn't agree with you more. I always say to my patients that what you decide and how you come to your decision will ultimately make you feel comfortable with your decision as long as you’re not doing it because of fear or being convinced into it. So, I couldn't agree with you more.

And Dr. Gary, I'll go to you now. What would you say to women who are considering mastectomy to reduce the risk of developing breast cancer again in the future?

Dr. Monique Gary: Again, I think it is a, that is a personal decision. I think that is an important one to have with your doctor about what the risk of recurrence is based upon the type of cancer that you have, based upon your personal risk factors, things like atypia and lobular carcinoma and in situ and other high-risk lesions. I think looking at the surveillance and the issue of surveillance as Dr. Peled mentioned, you know, many patients have such severe anxiety surrounding surveillance that they would like to reduce their risk in that contralateral breast.

And so, I think it is a great option for the right patient, but it is a conversation that really needs to be revisited more than once because many patients do think of mastectomy as the easier option to reduce risk, not understanding that the risk is not zero after mastectomy, and that there are quality of life issues and that there is still surveillance required, even after a mastectomy. I continue to see my patients every six months for the next several years, up to even five years and we talk about the risk of recurrence in the skin flaps and under the implants and on top of the implants if they have reconstruction, or if they choose to go flat.

And so again, I think that is a really in-depth conversation but it can certainly reduce the risk in that contralateral breast and in the, in the affected breast as well. So, important conversation for a patient to have if they are desiring to reduce that risk.

Dr. Donna-Marie Manasseh: Thank you. Thank you, and Dr. Peled, what short and long-term quality of life factors should women consider when choosing mastectomy versus lumpectomy, such as recovery time, reconstruction options? What are your thoughts on that?

Dr. Anna Peled: So, surgery in general we think of lumpectomy as a less-involved process from a recovery standpoint. I usually tell my patients we're thinking about a week of decreased activity and they may want an additional week of taking it easy from an exercise standpoint, and then after two weeks you can pretty much get back into your life.

Depending on if you have reconstruction with mastectomy and what type of reconstruction if you have it, we really sometimes are looking at more like four or even six weeks of recovery. So, I think that is really important to think about, you know, what are the factors in your life that are going to impact your recovery. For some people the thought of having a six-week recovery let’s say for a flap reconstruction is just not doable with their family or with their being a caregiver or what their situation is at home, and a lumpectomy really is a better choice because they are ready to get back. Other people really do want to go through that extended recovery knowing that there are major benefits for them on the other side.

The other thing to think about is overall kind of body image and long-term functional impact that we see, and we have a buddy system in our practice where people get paired up with women who are similar situations to theirs in terms of cancer or prophylactic surgery, but to really get a sense of how does it feel to go through this procedure, and they know hearing the stories in the video you get a real sense of from these women what might it be like to have these functional changes, to have body image changes, do you still feel like yourself? And I think having those conversations really helps people understand the long-term impacts of the choices they make.

Dr. Donna-Marie Manasseh: Thank you, and Dr. Sullivan, I'll go to you. What’s the best way to find an experienced surgeon who is qualified to perform the procedure that a woman wants?

Dr. Scott Sullivan: Good question. First I want to appreciate the opportunity to participate with such esteemed colleagues. Appreciate everything that they have done.

The worldwide web is a great resource, just as one of the earlier young ladies in the videos talked about as time to strap on your boots and start to do your research. So, start there. Understand your disease, understand your options. You’ll need to consult or suggest consulting with a number of physicians with which you trust. There are very, very good platforms and venues and support groups that can help validate a doctor’s experience, in particular the perspective of the patient, which is very important.

So, that is what I would suggest doing. Be the smart shopper, understand what you have. that is a great deal of trust that you put in the physician, I think most recognize that. There are many options available, then that can make things a little bit more difficult to make the decision, but the web is a good place to start, your trusted physicians locally, and then the support groups that, that such as Breastcancer.org.

Dr. Donna-Marie Manasseh: Wonderful. Thank you, and Dr. Gary, back to you. How long is it safe to wait while you’re trying to find a second opinion or find an opinion to make a decision about surgery while you’re getting a second opinion and doing your research?

Dr. Monique Gary: Great question because I know many patients do often seek a second opinion and sometimes a third opinion, and sometimes even more than that, but there is data that suggests that a patient really should be looking to undergo some first-line treatment within approximately 30 to 45 days after the diagnosis. So, I tell patients really that, you know, we have about that 30 to 40-day window, 45 days, and then we’d like to get going because we know that some of the outcomes and the mortality can be decreased the longer we delay important things, and that depends on things like your tumor type as well.

And so, if patients are considering those options, they really want to talk to their cancer programs about navigation. So, for example, I have a navigator who helps to facilitate patients getting opinions through, through Penn Medicine as we're a Penn cancer network hospital, and so, sometimes there can be easier ways to facilitate those things in order to, to circumvent some of the time delays that we see so that patients can get treatment faster.

Dr. Donna-Marie Manasseh: Wonderful, and there’s a relatively new approach to lumpectomy that is becoming increasingly available in the US called oncoplastic lumpectomy. This involves plastic surgery techniques to prevent certain cosmetic issues like dents and visible scarring. Dr. Peled, who is a good candidate for a lumpectomy with this type of a reconstruction known as oncoplastic lumpectomy, and could someone get reconstruction after years after a lumpectomy?

Dr. Anna Peled: So, literally everyone is actually a candidate for oncoplastic lumpectomy so, what we try to do with oncoplastic lumpectomy is basically try to place scars in an area of the breast where they’re well hidden, and oftentimes at the beginning people think oh, I don't care about my scars, I just want to get my cancer out, but fortunately so many people are doing so well from a breast cancer standpoint that you are going to see those scars every day for the rest of your life. So, we do try to hide scars, and we try to reshape the breast with the tissue that is inside there to try to avoid any divots or defects.

Fortunately this doesn't add much time to a surgery so, eventually if someone is safe to have a lumpectomy, in almost all cases they can have this, a hidden scar with a tissue rearrangement approach that works really well.

In terms of coming back after the fact, ideally we do try to avoid divots in the first place, especially before radiation. But for people who have had lumpectomies already and do have divots or poor scars, there actually are a number of options. Sometimes we can take fat from other parts of the body and add it to the lumpectomy divot that is left, and that can be really helpful in some cases. We can revise scars, we can do kind of a delayed tissue rearrangement to help fill it in.

So, I think a lot of people don't know that there is this ability to go back after the fact and that is a really good thing to ask your surgeon about to see if you might be a good candidate to help yourself move past your cancer.

Dr. Donna-Marie Manasseh: Wonderful. And Dr. Sullivan, for you. For women who choose to have a mastectomy, are there distinct pros and cons between an implant reconstruction, or reconstruction using their own tissue, or just going flat?

Dr. Scott Sullivan: Yes, there are. A lot of patients come in and they already have a bias towards one or the other, but to educate them for that, the individual that is undecided, implants are an easier operation to do. Implants come in a box so, there’s no donor site, there’s no donor site recovery. The implants are much, much better than they were in the past. They still are a foreign body and can create some potential issues. They can still have some mechanical failures or other problems that will require surgery down the road. But certainly it, you know, acquire a nice aesthetic outcome without having a donor site at user recovery.

Committing to use your own tissue, which would be a life-long result, a more life-like result as well, that is a little bit more of a commitment but it takes care of the problem for the rest of your life. You have a donor site so, there’s a donor site scar, a donor site recovery. The technicality of the procedure is a little more sophisticated than putting the implant in. Some of the procedures are not readily available in patient’s geographic area which sometimes would be an incumbrance to it, however, there is the benefit for those people who may have a little extra fat hanging around off of them somewhere that they would like to relocate, they could have a much nicer overall body aesthetic outcome by committing a little bit more to their own tissue reconstruction.

Dr. Donna-Marie Manasseh: Awesome. And Dr. Peled, an audience member asks, do breast implants deteriorate over years and do they need to be replaced?

Dr. Anna Peled: So, in general when we're placing breast implants we tell people that they are really not made to be lifetime devices and so, depending on how old you are when you get them placed, there is a very good chance you are going to need to have them replaced at some time. Fortunately our implant technology is much better now so, the old adage of every 10 years you have to switch your implants out, we certainly don't tell people that any more. We also have kind of a new philosophy that if your implants feel okay you don't have to automatically switch them out.

So, new implant technology, we're talking 20, 25 years with the implants that you have. Certainly there are some situations that make implants need to be switched out more quickly. Having radiation can be one of them, and infection can also affect how the implant heals. But in general certainly we are getting longer times, even though you probably will have to get them replaced at a younger age.

Dr. Donna-Marie Manasseh: Great. Great, and Dr. Sullivan, another question from the audience. Is using my own body tissue more safe than getting breast implants?

Dr. Scott Sullivan: Sorry, there’s an ambulance that came by, I had to mute. It, it depends on what safe means. Safe in that the implants are safe, however, they have certain risks affiliated with them in which they can encapsulate requiring further surgery, which they can rupture, which they can potentially create other issues. There’s implants illness syndrome. You have the lymphoma associated with texture though, that is a very, very low percentage.

So, those are the issues. Using your own tissue takes a technical skillset different than putting an implant in. There’s a failure rate that is associated with it, it certainly is not a perfect result in itself. Aesthetically it can be another very good outcome, as it is a little bit more lifelike result, but you have the risk of the failure, you have the risk of scars from the donor site in that recovery as well.

So, there are risks with all of the procedures including the oncoplastic type. The patient needs to kind of understand what their disease is, what their risks are, understand the preferences, the risk and benefits of each, what fits their lifestyle, where they are socially not only in their marriage but also professionally and how it could be integrated into their life at that time. It is kind of a complex decision to make and it is totally individualized.

Dr. Donna-Marie Manasseh: Awesome, and so, Dr. Peled, what are some of the reasons some women would choose to go flat instead of having reconstruction with implants of their own tissue, and what should these women know about procedures known as aesthetic flat closure?

Dr. Anna Peled: So, fortunately this is something that we're talking about a lot more now and I find we really have basically given people another option for reconstruction with a discussion of aesthetic flat, flat closure. There are some women that don't want to have implants as Dr. Sullivan mentioned. There are some women that don't want to go through flap surgery.

And so, if you are in a situation where you don't want to have other type of sort of more formal reconstruction, aesthetic flat closure is a really lovely option to make sure that you don't have abnormal tissues, you don't have lumpiness or bumpiness on your chest. If you are someone that wants to wear a prosthetic, you really do want to have a nice smooth surface for that to sit in, and so, with aesthetic flat closure the whole goal is to try to have a flat chest that still looks good, and again, let’s people move past their cancer.

I do think that is really important that people ask their surgeon about their experience with flat closure and ideally ask to see pictures. Unfortunately, I think a lot for people really haven't received training in how to make mastectomy look good if you’re not doing a formal reconstruction, and that is really helpful to ask in advance so you have expectations about how you might look.

Dr. Donna-Marie Manasseh: Thank you. And Dr. Gary, how can women have an informed discussion with their surgical care team and make sure that they arrive at the best decision for them?

Dr. Monique Gary: This is a great question, and I think that is really important for women to first understand where their tumor is, where their, what their tumor biology is and understand their disease. that is very hard to make decisions when you don't understand the full nature of what you’ll need. For example, patients who have early-stage disease may still require things like chemotherapy. Patients who opt for mastectomy may still require things like radiation, and so, patients truly try to, they try to compartmentalize the treatment, not understanding that something treats the breast and something will treat the entire body, and what determines those things many times is largely their tumor biology. So, first understanding their disease.

Bringing someone with them is one of the most important things that you can do as a patient, making sure that you have a good advocate and someone who can listen, who can jot down questions, who can ask interesting and intelligent questions. Making sure that your doctor spends that time with you and that you’re able to mirror back that discussion and start from the gaps in your knowledge. You know, I always ask patients, what do you understand about what’s going on, and let them speak for themselves in their own words so that we can then proceed from there, and one, it builds trust and so, making sure that you trust the team that you have chosen, that you have researched that team, that you feel comfortable with their skillset, their expertise, and with their care, their bedside manner as well, and making sure that you understand what’s going on and what all of your options are.

And you know, I counsel patients that if they don't fully understand what all their options are, if they are feeling emotional, or if they are feeling overwhelmed, we have options to remove the tumor, and then discuss further reconstruction. You know, we don't have to do everything all at once, right? We can do our lumpectomy and then we can opt for later double mastectomies if we need to down the line, and we don't burn any bridges there by taking care of the cancer first. Also, if we find that time and anxiety, women were having a difficult time making those decisions.

But you know, I think that that helping a patient to understand all of those things, their quality-of-life issues, their issues regarding their breasts, the size, the sensitivity, whether or not they would benefit from things like reductions, how important their nipples are to their intimacy and their sensation. Having all of those conversations with patients really helps them to make informed decisions, and it can be challenging to do so during that office visit and at the time of giving a diagnosis.

So, making sure that patients have really detailed material to read, and a great team of nurses and navigators and people to ask those questions, and then connecting them with great resources online like Breastcancer.org is another great way to make sure that they feel that 360-degree support and that they have people they can ask for reliable information.

Dr. Donna-Marie Manasseh: Fantastic. Thank you, and now we have a few more audience questions. Dr. Sullivan, does age influence which surgery is best?

Dr. Scott Sullivan: I would say numerical age does not, but physiologic age does. I did a couple of flaps not that long ago on two 78-year-old very spry women who looked like they were about 60 years old and they cruised through it. We have others who may have been long-time smokers, who have other physiologic problems, are on anticoagulants or have other multiple medical problems that may make them not an ideal candidate for the more complex-involved hyper surgical or autogenous reconstructions, and those, then you’d start to encourage them to think of the simpler things which may be implants or maybe going flat.

So, that is more for me physiologic age as well as other comorbid medical issues that more direct the patients to in regards to the exclusion of one or the other.

Dr. Donna-Marie Manasseh: Great. And Dr. Gary, a popular question I also get, can I avoid chemo/radiation by doing a mastectomy?

Dr. Monique Gary: Again, really speak to making sure you understand your tumor’s biology and your diagnosis because we know that breast conservation really does need to be coupled with radiation in order to see the same survival for invasive disease. And for chemotherapy, you know, patient’s tumor biology dictates whether or not they might need chemotherapy.

So, patients who have triple-negative disease that is larger than 5 millimeters, patients who are HER2-positive. You know, it doesn't necessarily matter the size of the tumor, you can have a very small tumor but still need something like chemotherapy, and patients who have, you know, larger tumors who opt for mastectomy because of that, or have node-positive disease still may need things like radiation. So, understanding fully what their disease is and what those treatment courses are that, you know, that we would outline for them is, is such an important thing.

And then the last thing is really the timing of those things because our job is to help a patient execute their wishes and if their wish is for breast conservation, nearly in any circumstance excepting inflammatory breast cancer, we're able to do that through a combination of things like, chemotherapy in the neoadjuvant or the before surgery setting. So, there’s lots of tools that we can use, but patients should understand that that is not just a menu that they can choose from but that their tumor biology and their disease dictates what type of treatment they should get.

Dr. Donna-Marie Manasseh: Great. Thank you, and Dr. Peled, does preventative mastectomy remove the possibility of tumors forming on the chest wall?

Dr. Anna Peled: So, I wish that preventative mastectomies were perfect, but they are not, and so, even though our goal is to try to take every bit of breast tissue we can see, we know that we're also leaving cells behind. So, we do talk about the possibility of cancer coming in the future, either along the chest wall or in the skin about 2-4, 2-5%, depending on the site. So, that is so much better but not perfect.

Dr. Donna-Marie Manasseh: Awesome, and Dr. Sullivan, how do surgeons make a single reconstruction match the other breast?

Dr. Scott Sullivan: Though unilateral mastectomies are more uncommon than they were, far less uncommon than they were a decade or so, but we still get occasionally some that come through, I find the best way I could replicate the match is make the composition similar to the contralateral side. For instance, if they choose to do an implant reconstruction to get a better match on their natural side, incorporating implant as an augmentation to get the projection that implant reconstructions provide the reconstructed side.

If someone doesn't want to have incorporated implant, then using their own tissue to match the natural tissue of a contralateral side is best. If someone has an augmented breast and then goes through a mastectomy, I can get a better result by using a flap with an implant underneath it.

So, trying to match the composition of the contralateral side I find gives us the best opportunity to do that. One thing we can’t match, though, is the effects of radiation. The radiation does make that radiated side much more perky for their whole life. In fact, seems that patients loved the radiated side better, longer because it remains perky. Non-radiated tissues just will droop a little bit.

But overall if you can match the composition it can be effective.

Dr. Donna-Marie Manasseh: Great, and I want to ask both Dr. Peled and Dr. Sullivan this question from the audience. What is the role of breast surgery and reconstruction for people diagnosed with metastatic breast cancer stage IV? I'll start with you, Dr. Peled.

Dr. Anna Peled: So, I think this is really an evolving field and we're wonderfully seeing more research on trying to understand that not everyone who has stage IV disease is the same, and so, we're trying to figure out if there are people who have stable disease or don't have any evidence of disease and are doing really well, then in fact, putting them through mastectomy and reconstruction does make sense and is a fair and ethical thing to offer, where I think some other situations offering that to someone may not be the right choice, depending on their clinical scenario.

But certainly I have several patients in my practice in the last year that have had double mastectomies with reconstruction who have stage IV disease and are doing really well, and I felt really good about that and they felt really good about making that choice, but everyone’s situation is different.

Dr. Donna-Marie Manasseh: Dr. Sullivan, your thoughts on that?

Dr. Scott Sullivan: Yeah. This is kind of intriguing question. So, that is about 15, almost 20 years ago, there was a young gal, she was in her 20s and she had a mastectomy, and her oncologist, when she had metastatic disease, told her that he didn’t want her to have reconstruction for five years. Well, you know, five years passed and she’s standing at my door and she’s like, "Hey, I'm here, I'm ready to do it." Nowadays we have chemotherapeutics, immunosuppressants, hormone-blocking agents that can suppress the progression of metastatic disease.

And so, it is very common that these women are living with metastatic disease for a number of years, and to provide them, in my opinion which I think confirms theirs, a better quality of life, of being female, of having sexuality, of all of the things that they may feel make them whole and an individual and a woman, denying them that opportunity I think is wrong.

So, I'm an advocate for it, particularly if that is something that is desired for a patient. I'm glad we don't, it doesn't seem any longer that the oncologists are prohibiting the patients from reconstruction when they have metastatic disease. I think that is wrong. I applaud the progress that continues to happen in the treatment of the disease, and also all these new surgical techniques. The oncoplastic stuff is great. The new-style implants are all great. All these new techniques just provide these young unfortunate women an opportunity to overcome such a difficult situation.

Dr. Donna-Marie Manasseh: I couldn't agree with you more. And Dr. Gary, what would you say can be done to reduce scar tissue pain after a lumpectomy?

Dr. Monique Gary: Sure. So, after a lumpectomy I counsel patients about massage of the scar, of the dense tissue as well. We talk a good bit about hot and cold therapy so, I advise my patients to use more heat if they are able to, and there are different, different schools of thought I think on how we can reduce the pain. But looking at where those scars are located and the nature of that scar tissue and really intervening early, which could include things like taping as well and different scar creams, I think Dr. Peled could probably talk a bit more about them. There are so many of them, and not all of them are great, and not all of them are horrible, you know? I think that there are some scar creams better than others, but looking at those techniques to reduce scar tissue for patients really does have to do with massage and with being diligent during radiation therapy as well.

Dr. Donna-Marie Manasseh: Wonderful, And Dr. Peled, does reconstruction with fat grafting obscure future mammograms or make future tumors undetectable?

Dr. Anna Peled: We're still continuing to study that as fat grafting is becoming more common, but in general if fat grafting is done well and you have a surgeon who does it routinely for reconstruction and is able to put the fat under those small areas throughout multiple layers to minimize the chance of what’s called fat necrosis, which is a hard ball of fat, the chance of having issues with imaging should be very low.

Additionally, most breast radiologists are very good at deciding the difference between what could be some fat that was placed into the breast or surgical changes compared to an actual recurrence of tumor.

Dr. Donna-Marie Manasseh: Thanks, and I think I'll open this to all of you, but does having dense breasts make breast surgery more difficult, both in the breast surgery and in the reconstructive arenas. I'll start with you, Dr. Gary.

Dr. Monique Gary: Having dense breast tissue doesn't make it more difficult for reconstruction as far as the oncoplastic technique. I think that having fattier breast tissue can lend itself more to fat necrosis and to some of the challenges there so, you know, breast density is not as much of a concern for me as, you know, as it is I think for others, but no. When surgical techniques are in place, you know, those of us who are trained in oncoplastic breast surgery are comfortable doing oncoplastic techniques on either patients with dense breasts.

Dr. Donna-Marie Manasseh: Okay. Dr. Peled?

Dr. Anna Peled: I think Dr. Gary covered everything. I mean, the reality is that there are many people with dense breasts and whether that is mastectomy or whether that is tissue reconstruction or rearrangement, it really goes fairly well, and in some cases having denser breasts actually makes your reconstruction a little bit easier than a lumpectomy.

Dr. Donna-Marie Manasseh: Okay, and another question, for any of the reconstructive post mastectomy reconstructions, is there any imaging that is recommended as part of their follow-up in any way?

Dr. Anna Peled: So, right now if you’re having a lumpectomy and having reconstruction of lumpectomy, whether that is having an oncoplastic, a small oncoplastic closure which we talked about earlier, or something bigger like, a breast reduction or a breast lift, we typically recommend the standard follow-up as recommended by your team, which could include mammography, ultrasounds, or MRIs, depending on different factors. After reconstruction we don't typically recommend that imaging. We do routine exams typically every six months, and then if something comes up we would recommend imaging at that time, but we don't recommend anything specifically different if you have had reconstruction after mastectomy than if you haven't.

Dr. Donna-Marie Manasseh: Okay, and have any of you addressed intimacy questions with your patients? What, you know, having, they have had a mastectomy with reconstruction like, how do you address intimacy with your patients, and we’ll have to make this the last question.

Dr. Monique Gary: I think that is important to discuss intimacy and sexual dysfunction at every point in that cancer care continuum. So, whether that is as a result of surgery, scarring, pain, et cetera, whether that is issues of libido and vaginal dryness through AI therapy, you know, discomfort after radiation. And so, I talk with my patients about intimacy from the very beginning. Whether they are child-bearing age, we discuss any fertility concerns or issues. We discuss prophylactic, prophylaxis in terms of having intimacy and sex.

And then what are the expectations along the way, whether they opt for breast conservation or for a mastectomy, and how can we achieve those optimal results so, that they are able to have good intimacy despite, you know, how they may be feeling about their breasts or their self-image throughout their cancer journey because I think that is a fallacy for us to, you know, do a surgery and get a patient through their cancer journey and say, "Okay, now, go out and love yourself. Wear pink and have great sex," and you know, "Everything’s going to be okay," when, you know, many of us didn’t love our bodies before breast cancer. We didn’t like how things, we didn’t like the droop, we didn’t like our hips, we didn’t, you know, how we pick ourselves apart as women and so, self-esteem starts from the cell and we really have to work a lot with our patients around that because it can take a hit after breast cancer or we can rebuild it and build it true and real and better than ever.

And then on the surgical side of things, I know talking about things like nerve reconstruction and nerve grafts are really great conversations to have with patients so, that they can understand what their options are after mastectomy to retain some sensation.

Dr. Donna-Marie Manasseh: Awesome. Well, thank you everyone. I want to thank our amazing panel. Unfortunately we're out of time with our questions, but thank you all for the informative and encouraging discussion.

Next I'd like to introduce Jennifer Meade. She is the division President of Breast and Skeletal Health Solutions at Hologic, and talk about some of their current initiatives. Hologic is a generous support sponsor of this event and we thank them for their kindness and generosity. Welcome, Jennifer. You’re Muted, Jennifer.

Jennifer Meade: How is that?

Dr. Donna-Marie Manasseh: That is perfect, thank you.

Jennifer Meade: Wonderful. Thank you so much, and a huge thank you for all of the panelists. This is a very impressive group and it has been very informative listening to the conversation.

Dr. Donna-Marie Manasseh: So, Jennifer, can you tell us about the work Hologic is doing to give more women access and options for breast-conserving surgery?

Jennifer Meade: Yeah. You know, as I think many are aware, a breast cancer diagnosis can be really life changing for a patient and for her loved ones, and we need to ensure that every woman faced with this journey has access to all of the options and, leading edge, pardon me, technologies available, and for many women as we've been talking about over the last hour, there are less invasive options that need to be considered.

Reconstructive lumpectomy procedures are one of the latest advances in care that can also be a unique benefit of pairing the lumpectomy and the cosmetic reconstruction within one procedure. But right now as we’ve been talking about, there’s limited patient awareness which is why forums like this are so important. Patients need to know that this option is available and they need to know that women don't necessarily need to live with the cosmetic imperfections that may come with a traditional lumpectomy or other procedures.

And so, in Hologic we're taking steps to increase the conversations around the procedure, we're working to get the word out via our website, shapeherfuture.com, so that more women know about the full spectrum of options that might be available for them. You know, if they, we heard, rightfully so, that this is really a personal conversation between a woman and her physician and you know, at the basis our goal is simply to arm women with the knowledge that they need to make sure that those are informed decisions and informed conversations.

Dr. Donna-Marie Manasseh: Wonderful, and how do you, how do these efforts fit with the early detection and treatment technologies Hologic has already been focused on for some time?

Jennifer Meade: Yeah. At Hologic our innovation is rooted in what we call the Science of Sure and that is our commitment to deliver exceptional clinical results which help healthcare providers diagnose and treat patients with precision, with certainty, with confidence. In the Breast and Skeletal Health position, which is where I am, we put improving patient outcomes and the patient experience at the forefront of everything we do, and we see opportunities that stay on the full clinical continuum of breast health from screening all the way through to treatment and monitoring.

You know, they were very proud of the impact that we’ve had on breast care which includes the launch of the Genius 3-D mammography exam in 2009 which was really revolutionary in breast cancer screening, as well as major advances in biopsy workflow, physician support, and patient comfort, you know, which are just a few things that we’ve worked on. We continue to lead advancements and invest in this every single day.

The commitment goes beyond the technology itself. We place a really heavy focus on patient awareness and on patient access. It is well established I think as most of us know, that breast cancer detected early is highly treatable and in many cases that treatment can be less invasive and it can be less costly, and regular screening mammography is absolutely critical to support early detection, and there are real barriers out there for women as it relates to preventive health.

There’s been a lot in the press, as an example, about how much this was magnified during the pandemic, right? Barriers to getting your preventive care over the past year. And so, patient and clinician educational opportunities, advocating for payer coverage of breast cancer care, and supporting research and interventions aimed at addressing disparities in breast cancer screening and treatment are just a few actions that we are taking to help remove some of these barriers, and really ensure that more women get access to the care that they deserve.

Dr. Donna-Marie Manasseh: Well, thank you so much, Jennifer, and thank you, Hologic.

And that concludes today’s program. Everyone will receive a recording next week. Thank you for joining us and for being such an important part of the Breastcancer.org community. Remember, knowledge is power. We look forward to seeing you again soon. Take care.