Breast Cancer Treatment Part 1: Surgery, Radiation and Reconstruction

Dr. Diane Reidy-Lagunes:

Your world shatters when you hear the words, “You have breast cancer.” You are not alone. Breast cancer is the most common type of cancer and is highly treatable. Most patients who receive proper care will live long healthy lives, but the diagnosis can still spark a great deal of anxiety and your first instinct may be to think that aggressive treatment is the best way to go, yet evidence suggests that is not necessarily the case. Let's talk about it.

Hello, I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering Cancer Center and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have evidence-based conversations. Our mission is to educate and empower you and your family members to make the right decisions and live happier and healthier lives. For more information on the topics discussed here, or to send us your questions, please visit us at mskcc.org/podcast.

Today we are so pleased to be joined by Dr. Tracy-Ann Moo, a surgical oncologist; Dr. Mike Bernstein, a radiation oncologist; and Dr. Michelle Coriddi, a plastic and reconstructive surgeon. They are an all-star team that work in our regional care network where they bring MSK's exceptional care to the local community. Tracy-Ann, Mike, and Michelle, thank you so much for joining us and for sharing your expertise today.

Tracy-Ann, can you kick us off with the basics? When a patient is diagnosed with early-stage breast cancer, what are the surgical options and approach that you take when you see the patient for the first time?

Dr. Tracy-Ann Moo:

Most patients who I see initially will come in with a small breast cancer that's very treatable, curable, and they'll go on to live long happy lives. And the treatment options at that point would be either doing what we call breast conservation, which is saving the breast; or doing a mastectomy, which is removing the breast.

Breast conservation usually means having a lumpectomy, which is basically just removing the area of the cancer from the breast, followed by radiation generally. The other option, a mastectomy, which is actually done in the minority of patients – most patients presenting with breast cancer will have breast conservation – but with a mastectomy, we will remove the entire breast. We're trying to remove most of the breast tissue. I would usually work with Dr. Coriddi in those circumstances to reconstruct the breast, and that can be done in various phases. We usually start the process of reconstruction though at the time of the mastectomy.

Dr. Diane Reidy-Lagunes:

With a history of breast cancer in the family and/or genetics that suggest there may be a hereditary syndrome, does that change the algorithm on breast-conserving lumpectomy versus mastectomy?

Dr. Tracy-Ann Moo:

It does. Women who present at a young age with a diagnosis of breast cancer, we’ll usually recommend genetic testing. So we'll have them meet with the genetics counselor, they'll talk about testing, which is usually a blood test or a swab. And we're usually looking for the BRCA mutation, as well as other breast cancer-associated mutations that could predispose a person to getting breast cancer.

If you have the BRCA1 or 2 mutation, we would usually recommend thinking about a bilateral mastectomy in that circumstance because women are generally at a higher risk of getting another breast cancer in the affected breast or in the contralateral breast in the future. So the choices there are not as equivalent as we would normally present to them, to the woman with an average risk of breast cancer.

Dr. Diane Reidy-Lagunes:

Got it. You know, obviously this is a very personal decision. Some people will say, “My breast is just an appendage, I don't care.” And some women, obviously, this is something very, very important to them. But if the fear is so strong where they say, “I just don't want to worry about it, just do the mastectomy,” are there data to suggest that in fact a lumpectomy is still the same in outcomes as a mastectomy, even if you're young?

Dr. Tracy-Ann Moo:

So the data strongly supports that the outcomes are the same, regardless of your age. There's a lot out there on social media, there are a lot of celebrities that have bilateral mastectomies, and so women usually come in with a preconceived notion of what they want to do and that's not necessarily based on the data. So what I try to do is go through the actual data.

A lot of women will be surprised when I say, “Well, a lumpectomy with radiation is the same as a mastectomy.” And they'll say, “Well, that doesn't make sense. If you remove my breast, where is it going to come back?” And I try to explain, “We're leaving the skin for reconstruction, you have your lymph nodes underneath your armpit, and the breast cancer can come back somewhere else in the body. So that's where you get your recurrences. Removing the cancer in the breast won't necessarily prevent you from getting a recurrence somewhere else. That's why we have systemic therapy,” which is I think a whole different conversation. But I usually start with education.

And I think at that point, when even the young patient understands her risk of recurrence, then it becomes more of a conversation about risk benefit. And there are some patients who truly will do better emotionally with a bilateral mastectomy. But there are many patients who don't really understand that it's not necessary medically to do it.

Dr. Diane Reidy-Lagunes:

Yeah, knowledge is power, and I think you said that beautifully in terms of trying to use the best available data to guide the right decisions for that patient. Let's hear from patient Beth, who is actually a patient of both Tracy-Ann and Mike.

Beth:

My name is Beth. I was diagnosed with stage 0 breast cancer in December 2023. It was discovered through a routine mammogram. There were some suspicious cells, and after the biopsy it was considered to be contained within the ducts. So when I spoke with my surgeon, Dr. Moo, she gave me the option of a lumpectomy or a mastectomy, and I really didn't even consider the mastectomy. I was very concerned about how my breasts would look after the treatment. The surgeon did a spectacular job going around the nipple. I was concerned about losing sensitivity and that didn't happen. The scar continues to heal and will essentially fade, and you won't be able to see it.

So after about 7 to 10 days from the lumpectomy, through the biopsy it was discovered that there was a microinvasion outside of the ducts. So it was advised that the surgeon go back in to take out a few lymph nodes underneath my armpit to make sure that the cancer did not get into the lymph nodes. Luckily that was clear and clean and because of the small amount of invasion of cancer cells, I did not need chemotherapy. However, it was recommended that I do 30 days of radiation.

Dr. Diane Reidy-Lagunes:

Tracy-Ann, Beth talked about maintaining nipple sensitivity. Can you talk to us about nipple-sparing mastectomy and who would be a candidate for that?

Dr. Tracy-Ann Moo:

That's a really great question, Diane, because a lot of patients now are actually interested in nipple-sparing mastectomy and may not necessarily be a candidate. So a nipple-sparing mastectomy basically is a modification to the traditional mastectomy when we would remove the nipple-areola complex. So in the nipple-sparing surgery, we leave the nipple-areola complex in addition to the entire skin envelope. So we're saving all that skin. So as you can imagine, this is a procedure that you may not be a candidate for if you have particularly large or droopy breasts. The other thing is, if you have a cancer that's really close to the nipple, you may not be a good candidate for a nipple-sparing mastectomy. We typically use a distance of about a centimeter on your imaging.

Dr. Diane Reidy-Lagunes:

Great. Even after surgery, as you all know, a patient may often require additional treatment. We're actually going to dedicate an entire podcast to the systemic therapies, including hormone and chemotherapy. But one of those treatments is radiation. Mike, can you share with us the ABCs of radiation, starting with exactly what radiation is?

Dr. Michael Bernstein:

Sure, thanks. So this question comes up a lot on what actual radiation is, and I usually describe it as an X-ray because that's really all we use. Radiation is just an X-ray. You don't feel radiation, hear it, see it, smell it, taste it. Thankfully you don't lose your hair from radiation, you don't get sick, you don't get nausea, you don't get diarrhea. These are just localized X-rays targeting the affected breast. No other part of the body sees any radiation treatment.

The only difference in the radiation that we utilize from a regular diagnostic X-ray that you're more used to – if you go to the dentist and they take a picture of your teeth or you get a chest X-ray, arm X-ray – is the intensity. So the X-rays that we use are a little bit more intense than the diagnostic X-rays because our purpose is not to just take a picture of what we're targeting. It works to create an unfavorable environment for cancer production and cancer growth.

Dr. Diane Reidy-Lagunes:

Got it. We've taken out the culprit, right? We've taken out the tumor itself. Thankfully, Tracy-Ann's done that for us. Why the radiation? In particular, do you show the treatment plan to your patients of exactly what you're going to be radiating and why?

Dr. Michael Bernstein:

Sure, yeah. I really like my patients to feel very comfortable with the radiation plan, and if they want to see exactly where the radiation beams are going and also just as importantly where they're not going, I'm happy to share that with them. Every patient's anatomy is quite different and so we do take some time to make sure it's perfected and individualized to make sure we're treating what we need to and protecting everything in the vicinity.

The comparison between a mastectomy, versus a lumpectomy plus radiation, has shown equivalent outcomes in protecting the breast from recurrence, protecting it from going to the lymph nodes, protecting it from going anywhere else in the body, and survival rates. So those are all equivalent.

Sometimes I use a silly analogy with my patients of a garden. I tell them that if you have all these pretty flowers in a garden and you have one weed, and Dr. Moo is wonderful at taking out the weed and that weed is gone from your garden, sometimes you still have to come back and do some special treatment to the soil to make sure that we can't grow back, almost in an effort to create an environment where it would be unfavorable for a cancer cell to get the idea to come back and grow again. That treatment is the radiation therapy.

Dr. Diane Reidy-Lagunes:

Got it. And can you just briefly discuss how you decide on the schedule of that radiation and how often our patients have to come in to get it?

Dr. Michael Bernstein:

Sure. Everyone has told us that radiation is bad and we need to avoid it as best we can. Now all of a sudden, I'm sitting in front of patients telling them that they have to come every single day for several weeks for this radiation treatment. What I've been really blessed to witness is the advancements in radiation treatment over these last several years. The field has been moving towards being much more targeted, still being very effective, and much more safe. The side effects and toxicity that patients used to experience decades ago, we're no longer seeing. That also has translated into shorter radiation therapy courses. Because we are so targeted, we now can abbreviate courses that used to be seven weeks of daily radiation for 33 to 35 treatments, sometimes now as short as five days. And I think that is a testament to the field and the technology, to allow the radiation to be targeted and still be very safe and protective of the surrounding tissue.

Dr. Diane Reidy-Lagunes:

Let's hear from your patient Beth again, because she does want to talk about some of the side effects that she got from her radiation treatment and how that affected her.

Beth:

I was told that I would have a sunburn-like reaction, there'd be some inflammation. It was recommended that I use this sav that was a steroid sav that would help minimize some of the skin reaction. It's Vaseline-like so it was recommended to me that I set aside some clothing and tops that I could stain and get dirty. They did tell me that the effects would be cumulative on my energy and on the impact on the skin. So the lethargy started around four or five days in. It wasn't until one week after the 30 days that I was able to get through the day without a nap and I was awake past 8:00 at night. Being vulnerable at work and not feeling competent and capable was difficult for me, admitting that I needed time and space. It's a journey for me learning how to say I need some help. But my motto has been, “Better not bitter, and freedom over fear.” Being alive and being connected and being on purpose is much more important than a scar or a bad burn or anything else that's temporary.

Dr. Diane Reidy-Lagunes:

I think the skin irritation, that is something that many of our patients have to endure. And like she said, you give some great creams. Anything else that you would recommend to potentially mitigate some of the side effects and things that patients should know that could potentially happen even though we have decreased those risks a lot?

Dr. Michael Bernstein:

Right. I think that Beth said it very well. The two most common side effects that we see during radiation treatment are decreased energy, fatigue, and a skin reaction. Thankfully, as she mentioned, the fatigue is fairly well-tolerated. And I usually describe it as, you know when you spend a day at the beach and you're just in the sun and you didn't really do much, but you come home and you're exhausted? It's on that order of fatigue. We still encourage patients to try their best to continue their normal daily routines, which many of them can. But we do see patients report that they might need a nap in the afternoon and maybe they don't usually require a nap, or they go to bed an hour or two earlier. But thankfully we see the energy level bounce back about a week or two after radiation is done, so these are transient and temporary.

With regards to the skin reaction, thankfully we're not seeing what we used to see many years ago. Now it's more like the gradual development of a sunburn or suntan. So certainly the area that we treat can get red and darkened over time, but again, we also feel like that resolves about a week or two after radiation is done. We do use a prescribed steroid cream that patients apply twice a day in the areas that we're treating. That really seems to help to limit any of the redness and darkness, any of the discomfort or itchiness that they may experience.

As far as other things that we recommend, we try to interrupt patients' lives as little as possible. We want them to continue living their lives, eating well, drinking well, and maintaining their normal daily activity.

Dr. Diane Reidy-Lagunes:

And what about exercise? Are there benefits to exercise during the radiation treatment, or is sweating something that you worry about in terms of the skin irritation?

Dr. Michael Bernstein:

I'm a huge proponent and fan of exercise. I think that there have been many studies to show that patients that are active pre-, during, and post-, even though counterintuitive, seem to have less fatigue and less interruptions in their daily routines than those that might be less active. So I think all within reason – we never want someone to run themselves into the ground – but if they are able to go for a walk and maintain a certain level of activity and exercise, we don't worry too much about sweating, as you mentioned. I think it's an incredibly important point that patients should try to stay as active as they can during treatment.

Dr. Diane Reidy-Lagunes:

And Dr. Coriddi, your part is obviously something that's very personal for the patient and requires an informed decision on the different treatment options. Can you walk us through the different types of reconstruction that you are either advising or recommending for your patients, and how that approach is taken?

Dr. Michelle Coriddi:

Absolutely. So it's a huge topic. I could talk for hours.

Dr. Diane Reidy-Lagunes:

Exactly. It could be a whole episode.

Dr. Michelle Coriddi:

So this will be just sort of a brief summary over everything, but obviously patients should meet with their physicians to get a lot of details and a more personalized approach, which is most important for any meeting with your plastic surgeon. But in general, you can break it down in terms of having reconstruction after a lumpectomy, which is not usually needed. Usually it's only in cases where perhaps a large portion of the breast tissue will need to be removed, and then sometimes the plastic surgeon might come in to do a little bit of rearranging. But again, very uncommon that reconstruction would be needed in that setting.

What we're mostly talking about is reconstruction in the setting of a mastectomy. There are really two main options: one is implant-based reconstruction, and the other is using your own tissue. So in general, we're seeing patients before they have their mastectomy. Reconstruction is still an option if you've already had your mastectomy and even radiation; there are still choices. But if we're seeing you before mastectomy, then usually the first step for patients would be to have a temporary implant, which we call a tissue expander, placed. And that can either go above the muscle or under the muscle. Again, that's a good question and discussion to have with your plastic surgeon. That's placed at the time of the mastectomy and then afterward in the post-operative period, you'll come to clinic and get your tissue expander filled up. That gives a lot of time for us, Dr. Moo, Dr. Bernstein, everybody, to sort of coordinate what other treatments you might have, whether it's additional chemotherapy or radiation. And if you need to have those treatments, then you'd have those treatments with that tissue expander in, which again is the temporary implant that's kind of holding the breast skin where we might want to do our final reconstruction later.

The second step is usually where patients have the most questions, and that's really where the biggest decisions are made. And that’s: Do we take out that temporary implant and replace it with a permanent one? Or do we take out that temporary implant and put in your own tissue, which usually comes from the belly? There are pluses and minuses to either choice. If you decide to replace with a permanent implant, there are choices of implants, different sizing options and things like that to discuss with your plastic surgeon. If you decide to go with your own belly tissue, if you have enough belly tissue or if you need to use thigh tissue or perhaps even tissue from your back, there are a lot of decisions that go into that too.

Most people like to choose implant reconstruction if they don't want to have another incision on their abdomen, or if they just don't have enough tissue and they'd rather be a little bit larger in size. And then a lot of times people will choose to use their own tissue if they prefer not to have a foreign object like an implant, or they want the most natural appearance, which would be to use your own tissue. And then there are some people who want to get rid of some belly tissue, and that's a perfectly reasonable choice too.

Dr. Diane Reidy-Lagunes:

A little tummy tuck in addition. Get that two for one. And if you're using your own tissue, do you stay in the hospital longer? Is the recovery a little bit longer on that one?

Dr. Michelle Coriddi:

Here at Memorial Sloan Kettering, we're really pushing the bounds on this, optimizing pain control and shortening the length of stay in the hospital. We’ve become so good at pain control and the recovery afterward that for a one-sided reconstruction with your own tissue, you'll stay just overnight in the hospital. And for a two-sided reconstruction, you'll stay for two days. That's also because, for your own tissue reconstruction, it actually involves disconnecting and reconnecting of blood vessels. So pain control is one reason why being in the hospital after surgery for a short period of time is good, but the other reason is actually so we can monitor that blood vessel connection and make sure that when you go home that everything's okay.

Dr. Diane Reidy-Lagunes:

Got it. And importantly, this is all covered, correct? The federal government allows for reconstruction to be part of breast cancer treatment?

Dr. Michelle Coriddi:

Absolutely. Breast cancer reconstruction must be covered by insurance. And in fact, in most cases if we're doing a unilateral reconstruction, the contralateral symmetry procedure – perhaps maybe you need a reduction or a lift or something along those lines – will also be covered by insurance.

Dr. Diane Reidy-Lagunes:

Let's hear from Dina, who is one of your patients and underwent a reconstructive surgery with implants.

Dina:

My name is Dina. I'm 48 years old and I was diagnosed with stage 1 breast cancer two days shy of my 46th birthday. I decided really the best route for me was to have a double mastectomy. I was very nervous about getting implants. It was something that I had never entertained in my life. After nursing two children for two years, it was actually kind of interesting because I definitely knew that I wanted to go a couple of sizes smaller than what I originally was. I worked very closely with Dr. Coriddi and her team to get exactly to the size I wanted to be. But I was surprised after the implant surgery, how natural they felt. Dr. Coriddi did an excellent job along the way of managing my expectations that there most likely wouldn't be any sensation or feeling there. We also worked with an amazing tattoo specialist at MSK to tattoo the nipples. That's something that is elective, you don't have to do that, but it really makes you feel kind of back to your old self as much as you possibly can.

Dr. Diane Reidy-Lagunes:

I think that's a really great example of someone who was able to make a decision based on her own personal choices on that. You want to talk a little bit about that nipple tattoo?

Dr. Michelle Coriddi:

We really try to listen to our patients if they want to change something about their breasts. We try to accommodate whatever we can do for patients so that they feel satisfied and happy with their outcome for their self-confidence and their satisfaction and their well-being. And the tattoo is part of that for some patients. Some patients decide, “I'm happy without having a nipple-areola reconstruction,” which is also a choice. But for a lot of our patients, they prefer to have a nipple-areola complex reconstruction.

Sometimes we can actually create a skin nipple, I guess I would call it, which is something that actually sticks out from the chest and then we tattoo for coloring. But for most patients, a 3D nipple-areola complex tattoo is usually the way to go. I mean, we call it 3D, meaning that when you look in the mirror, it looks like there's a nipple that's sticking out, but it's a tattoo, so it's flat. We have specially trained physician assistants here at Memorial Sloan Kettering in the city and all the regional spaces that offer this and are excellent in creating realistic natural tattoos.

Dr. Diane Reidy-Lagunes:

Is there any additional surveillance for patients that opt for the implants that you wouldn't necessarily need for those who decided to use their own tissue?

Dr. Michelle Coriddi:

Yeah, that's a good question and something that's ever-changing. We stay up to date on all the FDA guidelines. So the two implant choices are silicone- or saline-filled. The implants all have a silicone shell on the outside. It's just a matter of what the filling is. If you pick a silicone implant – which actually most patients do because it feels a bit softer and tends to look a bit more natural – the FDA at this point is recommending that you have an MRI about five years after we put it in and about every two to three years after that, and that's really to detect if it's ruptured.

Dr. Diane Reidy-Lagunes:

Great. And do you worry that that may interfere with the screening for potential risk of recurrence of the breast cancer, with the implant?

Dr. Michelle Coriddi:

The literature that we have to date does not show that any implant placement either above the muscle, below the muscle – even outside of our literature and talking about breast augmentation – actually changes anything in terms of outcome or potential for recurrence monitoring.

Dr. Diane Reidy-Lagunes:

Any advice from any of you that you might want to give to our listeners, or questions that you think may be important for them to ask their doctors as they're going through this part of their journey?

Dr. Tracy-Ann Moo:

Probably the best advice I can give is to stay off Google when you first get that diagnosis because it can really make you crazy. Pick a good doctor and let them guide you through the process because it can be a very complicated process. It's important to go into your appointments, especially your initial appointments, with somewhat of an open mind so you can actually listen to what your doctors are telling you and the options they're giving you. We try to guide you as much as possible, but sometimes that's a little bit harder if you're set with whatever Dr. Google told you last night.

Dr. Diane Reidy-Lagunes:

Well said.

Dr. Michelle Coriddi:

One other thing to mention too: you talked briefly about options for reconstruction – there's obviously a lot more detail on things that go into it, which is important to discuss with your plastic surgeon – but there are also lots of women who choose to have a mastectomy and decide that they'd like to have a flat closure, which is also becoming more popular. For those women, I just want to make sure that everyone is aware that that's also an excellent option if you're feeling not very comfortable or don't really want reconstruction.

Dr. Diane Reidy-Lagunes:

Right. So no reconstruction is absolutely an option as well.

Dr. Michael Bernstein:

Sometimes it's also helpful to bring a family member or a loved one or friend along to the visits. It's a lot of information and it's very new and it can be a very intimidating and scary process, so to have a second set of ears to ask other questions and make sure they hear what your doctor is telling you might also be helpful.

Dr. Diane Reidy-Lagunes:

Thank you for joining us. We learned a tremendous amount from all of you.

Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information or to send us your questions, please visit us at mskcc.org/podcast. Help others find this helpful resource by rating and reviewing it on Apple Podcasts or wherever you listen. Any products mentioned on this show are not official endorsements by Memorial Sloan Kettering. These episodes are for you but are not intended to be a medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Dr. Diane Reidy-Lagunes. Onward and upward.