Dr. Jeannie Shen is a fellowship-trained breast surgical oncologist. She graduated from UC San Diego School of Medicine in 1998 and completed her general surgery residency at UC San Diego in 2003. She then moved to Houston, TX. where she went on to complete a breast surgical oncology fellowship at the University of Texas, M.D. Anderson Cancer Center. In her in-depth interview, Doctor Shen discusses the breast cancer survival rates for lumpectomy and mastectomy patients. She takes the viewer through the discovery process, prep for surgery, surgery and important issues involved in post surgical recovery. Dr. Shen also talks about how bi-lateral mastectomies are on the rise and why this is happening.
My name is Dr. Jeannie Shen. I'm a breast cancer surgeon. I completed my undergraduate at UCLA and went on to U.C. San Diego where I completed both medical school and a five-year general surgery residency. And during residency I discovered that I wanted to specialize and focus on taking care of breast cancer patients so I then traveled to Houston, Texas, and joined the very elite MD Anderson Cancer Center and I completed a one-year breast surgical oncology scholarship.
So I think that a lot of the fear of being diagnosed is not understanding what else is to come. So my job, really, as a breast cancer surgeon, and the first one to have the opportunity to meet the patient, is to educate her. And I often tell them early on that I am the captain of the ship. I am behind the scenes and I am the captain, so if there's a bump in the road, then they can always feel free to call me, and I work very closely with all the oncologists to make sure that we're all on one page and that the patient is aware and part of that decision-making process.
I first explain the type of cancer, what is the name of the cancer let's give it a name. I spend an average of about an hour to an hour and a half at the first visit. Survival rates are very high. I hope at the very least I can let them take that information home. I write out different possible options and scenarios. I would hope that they can take away maybe 50 percent of it. The rest they will glean as they review the notes from that meeting, and some patients will ask to record the conversation, which I usually give permission to. So as they review the notes; they listen to the conversation; and they talk to their family and friends, then they start to absorb more of it.
Most of the time by the time they see me, we can already start to see different options emerge. Sometimes additional testing is needed and so forth, but nowadays, between the imaging and the information that we gather from the biopsy, already the different surgical options and which one may be better than the other start to become clear. Oftentimes from the biopsy and the imaging alone we can start to determine whether things like chemotherapy or targeted treatment could be needed.
I explain to the patients upfront that most of them will need a combination of local treatment, such as surgery or surgery and radiation, and then systemic treatment such as medications, which will treat both the tumor in the breast and prevent it from spreading. We're just using different tools, so with that being said, it's important to understand the differences and how each of these tools serves different purposes.
Starting with treating the tumor in the breast, we talk about the two general options, one is a lumpectomy, which is just to remove the tumor, with a clear margin, followed by radiation, and the alternative to that is a total mastectomy, which is remove all of the breast tissue. And with mastectomy, while in general you don't need radiation, some women, if the tumor is big or in your lymph nodes, we might still consider radiation.
With mastectomy, we always, legally actually, need to talk about the potential option of reconstruction, and I always emphasize that reconstruction is very safe; it does not increase the risk of cancer recurrence; it does not interfere with our ability to detect future recurrence. Legally it's considered part of breast cancer treatment so it's not elective cosmetic surgery; it's actually treatment for the breast cancer. And if we are into reconstruction, then I discuss the timing of it; it can be done either immediately at the time of mastectomy or at a delayed stage, and most of the time, if we can, we prefer to do it immediately. We get a better cosmetic result. Patients also have better psychological recovery after a mastectomy.
What's the main difference between lumpectomy and radiation versus mastectomy? It is the risk of a local recurrence, which is when the cancer comes back again in the same breast. And of course, if you conserve your breast, you still have all your breast tissue there. Your chance of a local recurrence would be relatively higher. Nonetheless, remember that most women having lumpectomies do undergo radiation which sort of sterilizes the remaining tissue and can significantly lower the chance of a local recurrence by more than at least 75 percent.
Given all the advances that have been made in treatment, a woman undergoing lumpectomy and radiation can expect a 20-year risk of local recurrence at no more than 5 to 10 percent. So given that the majority of women having lumpectomy and radiation do not recur in the breasts and so survival is the same, most patients and doctors do choose to try to conserve and that is generally my preference.
So, interestingly enough, mastectomy rates are on the rise, and that's been published, and the reasons for it have been hypothesized and discussed at multiple national meetings.
Nowadays women will have breast MRIs, and about three percent of women will be found to actually have cancer in both breasts. So certainly I think the increasing use of MRIs has contributed to a rise in mastectomy rates.
Also, the increased use of genetic testing has improved beyond the standard BRCA one and two genes. We have these big gene panels now that are being tested. So, as more women are being identified as having a heredity predisposition, that will also prompt them to choose bilateral mastectomies.
A third reason, I believe, is that the availability and the quality of breast reconstruction. If they choose mastectomy now, they understand that we can still restore a breast's appearance for them. Sometimes it can look as natural if not more natural and a little bit younger than their own, so at least it becomes a more palatable option for them.
Ultimately when it comes to the decision of lumpectomy versus mastectomy it's a very involved discussion and it varies per patient. Most women are diagnosed with breast cancer in one breast. That's why I always emphasize to patients that removing the other breast has no survival benefit.
Now, how do we decide? Sometimes the doctor decides. Sometimes the patient decides. I always try to decide it with my patients. For me, I'm looking at, as a surgeon, what is my ability to get rid of all the cancer and still leave a nice pretty cosmetic result. Is the patient willing to accept radiation? And also importantly are we going to be able to follow this patient for recurrence reliably with imaging in the future?
And so if they meet all those criteria, then generally I will recommend lumpectomy And also importantly, for some women and their family, even understanding the statistics, they just have better peace of mind with a mastectomy. Then that ends up being the right decision for her. That's what I tell them. I can tell you from a medical perspective what is safe for you and what I think is best; you know, a lumpectomy has a much easier recovery and quicker, but I'm not the one that has to live with it every day, and so if you're going to wake up after a lumpectomy every day and think, my god, is today the day my cancer comes back; what is that twinge; what is that pain; is that something, then perhaps for you a mastectomy is the better choice. So what's going to give you long-term peace of mind, which is what we want for our patients.
So, lumpectomy is the most common procedure women choose for breast cancer. About 60 percent of women with breast cancer choose lumpectomy. Most of the time it can be done at an outpatient surgery center, or if it's done in an inpatient hospital, you won't stay overnight. It is, however, still done under a light general anesthesia so you are completely asleep for the procedure, but it's very safe. The general anesthesia is just enough medication to help you sleep. On average a lumpectomy will take about an hour and a half in the operating room, but the total time can be longer as we get you ready for surgery.
For most women undergoing lumpectomy their day of surgery will start at a breast imaging center because the surgeon needs some help during the surgery in finding the tumor and/or in finding that special sentinel node. So if a woman has a cancer that was detected on a mammogram, and it wasn't felt on exam, then at the breast center the radiologist will oftentimes identify the lump and then, under local anesthesia, put a little guide wire in and localize the area.In addition to that we ask the radiologist the morning of surgery to inject some dye, either around the tumor or in the breast, and that dye will flow through the lymphatic channel and end up sitting in the sentinel node that helps me detect it, so the radiologist will often help the surgeon the morning of surgery by targeting the area of the lump, as well as helping them find the lymph node.
The concept of the sentinel node, the word sentinel means guard, is that we figured out that if and when the cancer cells spread to the lymph nodes, they don't typically shock all the lymph nodes at once. They have to pass through first what are called sentinel nodes, and people have on average one to three of them, the average being two, so that the cancer has to go through those sentinel nodes before they can go on to the other lymph nodes beyond.
Nowadays women who present with invasive breast cancer, as long as their lymph nodes look normal before surgery, they feel normal, then at the time of surgery we'll start by checking just the sentinel nodes first. If there's no cancer in it, we feel reasonably reassured that there will be no cancer in the other lymph nodes. If there is cancer in it, then sometimes we'll take additional lymph nodes. Another realization was that if we found cancer in the sentinel node, most of those women were going to go on and get some type of medical therapy, whether it be hormone-blocking pills or chemotherapy. Many of those women undergoing lumpectomy, they would get further radiation in that area. So even if we didn't do surgery, we postulated that between chemo and radiation, we could treat any additional lymph-node involvement. We also realized that taking more lymph nodes does not improve your survival; you don't live any longer with less; but it did increase this risk of lymphedema.
That dye, can take a couple hours to get to the lymph node, so most patients will start their day several hours before their actual surgery time in the breast imaging center. Once the wire and/or the dye is placed in the breast, they then go the breast center; they get registered; they get checked in; and they start their IV; they sign their consent forms; they will meet with the anesthesiologist. I usually will always come by to see my patient before surgery, to review the plan one more time, make sure there aren't any last-minute questions; and then we go into surgery.
The surgery is about an hour and a half. Patients often ask how invasive is it. How big is the incision? It often depends on how big of a lump you need to take out. But, again, the goal of breast surgery or lumpectomy is to not only remove the tumor but to try to conserve the cosmetics, so to try to ensure that the breast shape stays natural and the shape and size are mostly maintained. Most patients will have one incision on their breast where the lump is being removed and a separate incision under their arm where the lymph node is checked. So there's always two incisions. Most women will not have a drainage tube after lumpectomy. Most surgeons use stitches that will absorb themselves over time so patients don't have to come back for removing their stitches or taking out any staples.
Once the surgery is completed, then patients go to recovery; they spend usually about an hour in recovery before going home. I recommend patients stay home to rest. Mainly the first evening we worry about nausea. Studies do show that patients that don't wake up in pain actually will not have a lot of pain in your arm because we block the pain cascade and inflammation from every beginning.
So during surgery I use a lot of local anesthesia, even though the patient's asleep, and that way, when the wake up, they don't have any pain, and those local anesthesia’s will last four to six hours, and when that wears off I tell my patients you may or may not experience any pain. There's very few nerves in the breast. Most patients after lumpectomy have really little to no pain afterwards.
The lymph node area is a different story. It's very sensitive, so I usually warn them, if anything it's the lymph node area that will bother them. I send them home with an ice pack. I send them home with a small prescription just for a few pain tablets. I will tell you that about 50 percent of my patients take zero pain medicine at all. Maybe about a quarter of them will take plain Tylenol, and only a quarter of them will ever use one or two pain medications that are prescribed. So pain generally is not a major problem after lumpectomy surgery.
Patients ask when can I shower; usually it's two days because the top layer of your skin heals within two days; the body is amazing. When can I wear a bra? I tell patients to wear a bra as soon as possible after a lumpectomy; it will really minimize the swelling, the bruising, the bleeding; it usually provides a lot more comfort and support. Patients ask about activity restrictions. Because we're checking the lymph nodes and we don't usually leave a drain, we usually recommend that you don't lift anything over 10 pounds on that side for two weeks and avoid any strenuous household work. Otherwise I encourage walking; that's very good exercise after surgery. Walking will not only help their energy come back sooner, it does boost the immune system, helps them heal faster. It's important not to stay in bed all day. It's important to stay active even through the recovery process. When can I drive? I ask them to wait two days before they drive. And then most patients will ask when they're going to see me again. It usually takes about a week to get the pathology report back, so most patients are scheduled to see us back in the office about seven to ten days after surgery.
The routine follow-up after lumpectomy generally is a clinical breast exam, usually every four to six months for the first three years, and then every six to 12 months for years four to five, and beyond year five is annually. Now, whether that's with your medical oncologist or surgeon or radiation oncologist, it can be any combination of those.
For one-sided mastectomy, the surgeries are often at an inpatient hospital although there is a push towards outpatient surgery, as well. The average length of time to do one-sided surgery is probably about four hours, and to do two sides about five hours.
Part of that is because oftentimes the breast surgeon and the plastic surgeon will work at the same time on their own side. So we have at some point two surgical teams, one taking care of finishing the breast cancer surgery; the other one beginning reconstruction. So by overlapping we can then keep the length of surgery as short as we can which, in the end, is much better for the patient to minimize their anesthesia. From there they go to recovery and spend about an hour in recovery and then they go to their room. Again, patients can expect to stay one or two nights in the hospital, and the length of stay, I tell them, depends on how quickly they recover.
For me, there are three criteria for discharge. One is, are the patients comfortable with oral pain medication. Two is, can she eat; can she keep food down, keep liquids down. And three is, is she able to get out of bed and do the basic activities of daily living on her own? So, can she get out of bed; can she get to the bathroom; do basic functions.
So, I tell patients there are some things we can do during the surgery to reduce the amount of pain that they have after surgery. Most of us will also use what's called an on-cue pump, which is a little pump connected to a catheter that actually will then deliver local anesthesia inside the surgical field for about 72 hours after the surgery. Using these techniques, actually we can at least minimize the amount of pain patients have afterwards. I always tell patients, on the scale of 1 to 10, 1 is no pain, 10 is the worst of your life, my goal is to keep you at a 2 to 3.
What I tell patients, most of their discomfort will be a result of their reconstruction, and so, if you're having immediate breast reconstruction, the most common type is to place tissue expanders under the muscle, we don't remove the muscle with a simple mastectomy. The implant is ultimately placed under the muscle. The plastic surgeon will actually lift that muscle and create a pocket and place the temporizing tissue expander and then stretch that muscle out. So oftentimes patients will tell me it's not painful per se, but I feel sore; I feel very tight; and they'll say I feel pressure; I feel that there is a block of bricks sitting on my chest. Some patients will say it's like I have two little elephants or a Mack truck ran over me a couple of times; it's just very sore. And I liken it to if you are not someone that exercises regularly and you suddenly went and did a hundred push-ups, in about a day and a half that kind of tightness and soreness, with movement, that is what I think most patients are experiencing early on.
But the amount of pain varies. I have patients that have little to no pain and go home the very next morning, and others where they have to stay a couple extra days to get their pain under better control. Nowadays, because we're using these on-cue pumps I have noticed that some patients do great the first two to three days, and then once the local anesthesia wears off, then they start to experience it, so it can vary for different patients a bit. It should not be something that is so excruciating that they can't get out and function with. If that's happening, then oftentimes perhaps the tissue expander has been over expanded, so if patients are feeling this tightness and pressure and pain, then I'll often ask the plastic surgeon to remove some of the saline and decompress it and that will often relieve it. We just give a little bit of extra time before we re-expand them.
Another question is how quickly can they get out of bed. We want patients out of bed as soon as possible. Patients who stay in bed after surgery, they get blood clots; they get pneumonia; so we want our patients out of bed to a bathroom and walking around the hallway by the very next day. I encourage the same thing when they go home. Three 10-minute walks a day once they go home. Most patients are back onto a regular diet when they go home. Even if they're not eating a lot, they're eating some regular food.
Another question, when can they shower. There's little tips that we can teach them how to get the drains with them into the shower, so you can shower even with the drains in place.
After mastectomy, we will usually recommend that you don't lift anything over ten pounds for up to six weeks, and you can't lift that affected side over shoulder level for about six weeks. So there is some restrictions in mobility and activity for the first six weeks. Oftentimes patients will need physical therapy after that six-week period to regain full use of their arm. But I do expect that most patients regain normal function of their arm. With mastectomy, you usually can drive once all your drains are out, so I tell patients expect two to three weeks before you're able to drive.
Drains become very important after a mastectomy because you're operating on a much larger area, and when you're operating on a large area, you're creating trauma and damage to the tissues in that area, so your body will be developing inflammatory fluid, proteins and white blood cells, to help you deal with this controlled trauma that's been inflicted. This fluid needs to be drained out; otherwise, it will accumulate around the reconstructed breast.
So we drain that out by placing these little silicone plastic tubes called drains. Most patients will have one or two drains on each side that they're having mastectomy. The drains are connected to a little bulb. The bulb is compressed to create a negative pressure so actually it can suck the fluid out. We take care of the drains for patients while they're in the hospital but we actually do also teach them how to take care of it when they go home. We usually can arrange with their insurance to have our home visiting nurse come in and check on them once a day. The drains have to be emptied three times a day. So the patient and/or her family members and caregivers need to understand how to take care of the drain. It's very simple, but, you know, I think for people who are not used to blood and fluid and tissue, it can be very daunting, and it's a real test of family and friends who come and help out. And the drains will usually stay in on average one to two weeks and usually no more than three weeks. And they can be removed in the office either by the breast surgeon or the plastic surgeon.
You know, we talk about recovery mostly in terms of when can we get you back to your normal functions, your normal family life, back to work is an important part for many women, and that time will depend on the type of reconstruction you have. With the most common type of reconstruction where you're using this tissue expander process, I usually say six weeks.
After mastectomy it's not a guarantee that you can't get breast cancer again; you can get what's called a chest wall recurrence. For stage zero through stage one, recurring breast cancer risk is about one to three percent after mastectomy. For stage two, it's about three to five percent. For stage three patients, it's as high as five to ten percent.
After mastectomy there's no breast tissue to squeeze so we don't ever do a mammogram. Studies actually show that routine ultrasound doesn't seem to be of much value. The easiest way to detect it actually is a physical exam. Patients will either notice perhaps a it looks like a pimple that doesn't heal in the skin, okay, or they'll feel a lump like a little pea or a little nodule, so if they feel that, they bring it to our attention.
I do actually follow my patients long term, even after a mastectomy, if I feel that they're not going to get a good breast exam otherwise. If their oncologist or their primary is not routinely doing exam, then we need to make sure that someone is following up on the small chance that they develop a chest wall recurrence.
Sex and breast cancer, most patients don't talk about it and most doctors don't ask. But it is very important. After a mastectomy, there usually is a loss of a sensation. Whether we are able to conserve the nipple or we have to remove it and reconstruct it, even a nipple that's been conserved with mastectomy has no sensation to it. So if that is part of the stimulation process, then couples need to find either other methods or spend longer in the build-up to sexual intercourse. For many of us, and I say us because I think that if I was in that situation I think it would change how I felt about how I looked myself. It is a part of our own body image and part of how our sexuality, how we feel about ourselves and even if your partner tries to reassure you it's all in our heads and so addressing that I think it is very important. I think that an open dialogue with the partner is the most important thing. It also depends on how much that was important as part of their lives before this all began. For many patients, I'll be honest, that don't have a lot of those issues afterwards, they say it was never really a big thing for them before. That was where they were, so they don't expect it now. In others it was a very important part for them, and changes in how they feel about themselves or how they think their partner feels about them can affect that and then if that leads ultimately to, their overall recovery from the cancer treatment.
One of the biggest issues for breast cancer patients, when it comes to sexual intimacy and intercourse, is not only the mastectomy part but, the hormone-blocking medications we give them, and that can cause changes in libido; it can cause dryness down there; it causes pain with intercourse. That's something we can often help our patients with so I think that having that dialogue, not only with your partner, but with your doctor, is very important. It's just important to not only talk to your spouse, but definitely talk to your doctor about changes, difficulties, and we definitely have ways to help most of our patients.
For breast cancer, screening methods continue to improve. One of the newest things coming that's very exciting is 3D mammograms. We're going to have increased sensitivity and lower call-back rates so lower false-positives for women who have dense breast tissue, which plagues 50 percent of us. And once you get diagnosed with breast cancer be confident that your cancer will be treated successfully, and I think that's the message to take home. Treatments are less and less invasive. We are trying to do less and less surgery. The treatments are more and more targeted, like radiation, and even more personalized with decisions about chemotherapy or hormonal therapy. So, as we look towards the future, the treatments will be less invasive; they'll be more targeted; there'll be less toxicity. So there'll be more survivors, hopefully with a lot less side effects.