September 23, 2008
Cleveland_Clinic_Host: Welcome to Innovative Options in Breast Cancer Surgery with Joseph Crowe, MD.
Dr. Crowe is the Director of the Cleveland Clinics Breast Center. He is a board-certified surgeon with more than 25 years of experience in treating breast disease, and has a longstanding interest in the use of minimally invasive techniques for diagnosis and treatment. Dr. Crowe pioneered the development of nipple-sparing mastectomy and offers the most up-to-date surgical procedures including breast conservation techniques and immediate reconstruction options not widely available.
During the next hour, Dr. Crowe will answer your questions about breast cancer surgery. Before we begin taking your questions, Dr. Crowe will answer some of the most common concerns women have when it comes to breast cancer.
Breast Cancer Overview
Cleveland_Clinic_Host: How common is breast cancer?
Speaker_-_Dr__Joseph_Crowe: This year, more than 183,400 women will be diagnosed with breast cancer, and approximately 40,500 will die. While those statistics are sobering, research shows that the mortality rate could decrease by 30 percent if every woman 50 and older who needed a mammogram had one. What’s more, breast cancer has a five year survival rate of more than 95 percent when it is diagnosed early.
Cleveland_Clinic_Host_: Who is at risk of developing breast cancer?
Speaker_-_Dr__Joseph_Crowe: All women are at risk. But women who carry the breast cancer genes, women with a history of breast cancer themselves or a family history of breast cancer, and women who have certain pathological findings are at increased risk.
Cleveland_Clinic_Host: What are the current recommendations for breast cancer screening?
Speaker_-_Dr__Joseph_Crowe: Monthly self-exams have been under fire lately, but the truth is, most women find breast lumps themselves. The best time to examine your breasts is after your menstrual cycle is finished. Have your breasts examined by a healthcare provider at least once every three years after age 20, and every year after age 40. And have a baseline mammogram at 35, and a screening mammogram every year after 40. If you move and/or go to another health care provider, take the film (mammogram) with you.
Cleveland_Clinic_Host: Does it matter where a woman has a mammogram done?
Speaker_-_Dr__Joseph_Crowe: Not all mammograms are equal. The technology continues to improve. It’s also important to have a mammogram that will be read by a radiologist who has been subspecialty trained in breast imaging.
Cleveland_Clinic_Host: If a woman has breast cancer, what services does Cleveland Clinic have available for care?
Speaker_-_Dr__Joseph_Crowe: At Cleveland Clinic, we have a comprehensive Breast Center that offers patients the latest technology and an unmatched team of physicians, nurses and technologists who specialize in breast care. Our radiologists use state-of-the-art equipment and all are subspecialty trained in breast imaging. We utilize the latest medical and radiological treatments and give patients access to clinical trials. Our breast surgeons are pioneers in breast conservation techniques and offer innovative options for plastic and reconstructive surgery. And we’re available to you at our Main Campus at our Family Health Centers throughout the region.
lmisencik: I am an avid runner/triathlete who has just been diagnosed. Will I still be able to run & stay active during treatment?
Speaker_-_Dr__Joseph_Crowe: There is no reason why you could not be active during treatment. There are considerations though. If you have surgery, the surgeon may recommend that you delay training until healing has occurred. With chemotherapy and radiation there may be a fatigue factor that you would need to be aware of. It does not preclude your training, it just may alter it.
maurino: I want to know if having my ovaries removed may help prevent reoccurrence of breast cancer. I had a 1.4cm lump, which was removed in a double mastectomy procedure. Also, I had one lymph node test positive with a 2mm size area of cancer. I am receiving 6 rounds of chemotherapy with Herceptin.
The tumor was 90% estrogen positive and was a grade III. I had an aunt (father's side) who died from breast cancer, diagnosed at the same age (42) 13 years ago (was with the Cleveland Clinic, as am I). My father also had colon cancer and has been 12 years free of the disease after receiving treatment. I am not concerned with having more children, just living to raise the ones I have now, who are still young. Thank you for your consideration in this matter.
Speaker_-_Dr__Joseph_Crowe: This is a very involved question and should be discussed with your medical oncologist about the advisability of having your ovaries removed. This decision needs to be put into context of everything else: age, resuming periods after chemotherapy, etc.
Barney15: What does a 5 year survival rate mean?
Speaker_-_Dr__Joseph_Crowe: Many people who have recurrent breast cancer will recur in a period of 5 years. The definition is the % of people who are still alive after five years. Breast cancer has a 95% - 5 year survival rate when it is diagnosed early. The emphasis is on early diagnosis.
Cleveland_Clinic_Host: Can you explain the differences between a screening mammogram and a diagnostic mammogram?
Speaker_-_Dr__Joseph_Crowe: A screening mammogram is done routinely for individuals who do not have symptoms. A diagnostic mammogram is performed when someone has a particular symptom such as a mass and is focused on that area. The diagnostic mammogram can also be done as a follow-up to a screening mammogram when something is seen on the screening mammogram.
pele2: Are mammograms still reliable after reconstruction surgery?
Speaker_-_Dr__Joseph_Crowe: Mammograms are used and reliable after breast tissue reconstruction (TRAM or DIEP) but are not recommended after implants. The procedure for screening after implant is palpation.
Cleveland_Clinic_Host: What criterion warrants an MRI for breast cancer screening?
Speaker_-_Dr__Joseph_Crowe: An MRI breast cancer screening is usually done for individuals who are at high risk for breast cancer such as those who have a BRCA mutation. BRCA mutation is a gene mutation that indicates that the person has a high risk of developing breast cancer during her lifetime. It is a blood test that is done after a person is evaluated by a genetic specialist and then the decision is made for testing.
nystrom: What are my options if the doctor says I need a breast biopsy because of a lump?
Speaker_-_Dr__Joseph_Crowe: If a breast biopsy has been recommended, there are two types - a needle biopsy and a surgical biopsy. Very often a needle biopsy can give accurate information. If the needle biopsy does not provide enough information, an excisional surgical biopsy may be necessary. A breast biopsy is the only definitive way to make a breast cancer diagnosis.
LucyintheSkies: Would you comment on the advantage of stereotactic biopsy over lumpectomy, especially if the results show no malignancy?
Speaker_-_Dr__Joseph_Crowe: A needle biopsy (stereotactic or ultrasound guided) can be quite accurate in terms of diagnosis. If there is any question about accuracy, then an excisional surgical biopsy may be necessary.
Seeking Second Opinions
nystrom: Should I seek a 2nd opinion if breast cancer surgery is recommended?
Speaker_-_Dr__Joseph_Crowe: Many people are interested in the realm of possibilities regarding their breast cancer and treatment options. Different opinions from different physicians can often be very helpful. Seeking second opinions is all about gathering information to make a wise treatment choice. I encourage individuals to seek as many opinions as they feel are helpful. Click here for more information about Cleveland Clinic’s Second Opinion service.
Breast Cancer Treatment
Barney15: If cancer is found in one breast, what are my options?
Speaker_-_Dr__Joseph_Crowe: Breast cancer treatment consists of local treatment (treating the breast) and systemic treatment. Treating the breast involves either breast conservation (lumpectomy plus radiation) or mastectomy with or without reconstruction. The choice depends upon tumor size, breast size, and personal preference.
In addition, many women benefit from systemic therapy that is using medications that treat cancer cells that have gone beyond the breast. The majority of women who develop breast cancer do benefit from systemic therapy combined with local.
Summertime: Some time ago, a study indicated patients having a lumpectomy have a similar chance of reoccurrence as those who chose a mastectomy. Currently, what is the preferred treatment course now - lumpectomy or mastectomy?
Speaker_-_Dr__Joseph_Crowe: The choice between lumpectomy and a mastectomy depends on the size of the tumor, type of cancer, whether or not the patient can receive radiation, the desired cosmetic outcome after conservation and finally personal preference. Some individuals could have either, but chose a mastectomy. Some may not be eligible for a lumpectomy.
What is Breast Conservation Surgery?
Carol: What do you mean when you say "breast conservation surgery?"
Speaker_-_Dr__Joseph_Crowe: Breast conservation surgery for breast cancer means saving or conserving the breast. This involves removing the cancer by lumpectomy or partial mastectomy. The remaining breast tissue is preserved or saved and treated with radiation.
The success of breast conservation surgery depends on removing the cancer with normal tissue around the cancer (negative margins.) The goal of breast conservation surgery is to have as normal appearance as possible of the breast.
Implants and Reconstruction
Carol: If I have to have a mastectomy, is it better to have reconstruction right away or to wait?
Speaker_-_Dr__Joseph_Crowe: That is an individual decision. It depends on the recommendation of the surgeons as well as the particular treatment plan. Very good reconstruction can occur immediately or be delayed.
Survivor: What kinds of implants are safest after a mastectomy?
Speaker_-_Dr__Joseph_Crowe: A common approach is for the Plastic Surgeon to use an 'expander' implant initially. Once the expansion of the tissue has occurred to the desired size, the implant is exchanged for a permanent implant. The Plastic Surgeon will then advise about saline or silicone filled implants.
What is Nipple Sparing Mastectomy?
Carol: What is a 'nipple sparing' mastectomy?
Speaker_-_Dr__Joseph_Crowe: A usual mastectomy involves removing the nipple and areola. Nipple sparing mastectomy involves saving the nipple and areola. The nipple sparing mastectomy started here at Cleveland Clinic in 2001. It is not appropriate for everyone and depends upon the type, amount and location of the cancer in the breast, the planned treatment of the cancer and also breast size. Our experience at Cleveland Clinic has been very successful combining nipple sparing mastectomy with immediate breast reconstruction for appropriate candidates.
Barney15: During the reconstruction process, does Cleveland Clinic work with a tattoo artist to finish the process?
Speaker_-_Dr__Joseph_Crowe: When a nipple sparing procedure is not performed, there is a technique of using tattoos to create the appearance of a nipple.
Tina: My friend had a mastectomy just to prevent breast cancer. Isn't that going a little too far?
Speaker_-_Dr__Joseph_Crowe: Prophylactic mastectomy has been shown to decrease the chance of developing breast cancer by over 90%. Prophylactic mastectomy (removing both breasts) is generally chosen by women who are at a very high risk (70-85% risk) of developing breast cancer in her lifetime. This risk is usually associated with a BRCA 1 or 2 gene mutation.
TRAM or DIEP Flap Reconstruction
spagle: Where do you get tissue for breast reconstruction and how is it done?
Speaker_-_Dr__Joseph_Crowe: Usually the tissue for breast reconstruction comes from the lower abdomen. It is the same tissue that is removed during a 'tummy tuck' procedure. This tissue can be transferred up to the breast area while still attached to the rectus abdominus muscle - an operation called a TRAM flap.
Or the tissue can also be removed from the lower abdomen completely, not left attached to the rectus muscle and then its blood supply is reattached to the patient using micro vascular surgery. This is called the DIEP flap.
Recovering after Surgery
Maddie: How long does it take to recover from breast surgery?
Speaker_-_Dr__Joseph_Crowe: It depends on the type and extent of the surgery. The breast conservation surgery recovery is typically fairly quick, usually resuming normal activities within a couple of weeks. On the most part, that is also true for a mastectomy even with an implant reconstruction. The difference is that the mastectomy with autologous tissue such as a TRAM or DIEP reconstruction requires a much longer period of recovery.
Preparing for a Surgical Appointment
lmisencik: I was just diagnosed with invasive ductal carcinoma. I have an appt with Dr. Dietz on 9/26. What can I expect?
Speaker_-_Dr__Joseph_Crowe: For your appointment, it is important to be prepared with a list of questions or concerns, and any outside test results. It is also important to bring your mammograms and slides if they were not done here. Finally, you may want to bring a spouse or close friend with you for support.
Seeking Second Opinions
nystrom: Should I seek a 2nd opinion if breast cancer surgery is recommended?
Speaker_-_Dr__Joseph_Crowe: Many people are interested in the realm of possibilities regarding their breast cancer and treatment options. Different opinions from different physicians can often be very helpful. Seeking second opinions is all about gathering information to make a wise treatment choice. I encourage individuals to seek as many opinions as they feel are helpful.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Crowe is now over. Thank you again Dr. Crowe, for taking the time to answer our questions today.
Speaker_-_Dr__Joseph_Crowe: Thank you very much for this opportunity.
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