Rania Habib, MD, DDS (Host): Besides skin cancer, breast cancer is the most common cancer in women in the U.S. The CDC estimates that breast cancer accounts for nearly 30 percent of newly diagnosed cancers in women each year.

This is Duly Noted, a health and care podcast from Duly Health and Care. I'm your host, Dr. Rania Habib.

In this episode of Duly Noted, we discuss what to expect when you have been diagnosed with breast cancer. My guest today is Dr. Amrit Mangat, a Surgeon. Welcome! It is so nice to have you on the podcast.

Amrit Mangat, MD, FACS: Good morning, Dr. Habib. Thank you very much for having me. And I'm delighted to be here this morning and discuss a topic that is near and dear to me and something that I'm very passionate about.

Host: We cannot wait to hear your expertise and really delve into a very timely topic. During a breast cancer diagnosis at Duly, who will be part of the patient's treatment journey? As the surgeon, you are likely not the first step in a patient's diagnosis. So could you also explain at what point you step in as the surgeon and deliver care?

Amrit Mangat, MD, FACS: Definitely Dr. Habib. So, at Duly, it's often the primary care physician or the gynecologist that sees the patient for a specific complaint regarding the breast, whether it be a lump or breast pain or nipple discharge, something in that line. They then get referred to radiology who does the work up in terms of the imaging.

And if there is an abnormality found on imaging, the radiologists proceed with the biopsies and any workup that's necessary. Once a patient has a diagnosis of breast cancer, then they immediately get referred to one of the surgeons in our group. I practice solely breast surgery, so I do see the bulk of the breast cancer patients here.

And then once I see the patients, then based on what the particular diagnosis is, then it's my job basically to refer them to whichever specialist I deem necessary for their treatment. So, yes, once the diagnosis is made, it is a surgeon. But then I work very closely with the radiologist, the medical oncologist, and radiation oncologist to come up with a comprehensive care plan for the patient.

Host: Now, once that patient sees the gynecologist or the PCP, you did mention that, you know, the next step is imaging. What type of imaging should a patient expect?

Amrit Mangat, MD, FACS: So, depending on the symptoms and the age of the patient typically, mammography and ultrasound are always the beginning steps. So if a patient has a lump, they're typically going to get referred for the mammogram and the ultrasound. They give us a lot of information. Each imaging modality that we use, shows us different things. So we also, in addition to mammography and ultrasound, we have breast MRI in our armamentarium and that also becomes very helpful as well. So there are definitely some excellent imaging modalities that are available to us that we use in assisting in getting the diagnosis.

Host: What are the different stages and types of breast cancer, and how do they impact treatment options and prognosis?

Amrit Mangat, MD, FACS: Excellent question. In regards to breast cancer, there are four stages and in general, the earlier that you are diagnosed, the better chances of doing well long term. So, like I mentioned, the stages go one through four, and stage one tends to be a smaller tumor. And, it's not spread to the lymph nodes.

And then stage four is what we consider metastatic disease, where it has spread outside the confines of the breast or the local lymph nodes under the arm, and you may find it in the bones or the liver or the lungs. So, we do find that staging is very helpful and it does guide us in terms of therapy as well.

Some of stage 2 and stage 3 breast cancers can have lymph node involvement and if that's the case, it does sometimes change what surgical treatment we do in terms of the extent of axillary surgery we perform. Sometimes patients might need radiation and chemotherapy as well.

However, even if one lymph node is positive, for instance, or two, it doesn't automatically mean that the patient needs chemotherapy. So this is where a discussion with medical oncology comes in very helpful as they have other tests that they can send to see does this particular patient need chemotherapy.

Host: And what are the different types of breast cancer?

Amrit Mangat, MD, FACS: The most common breast cancer that we see, it's called invasive ductal carcinoma. I see this roughly 80 to 85 percent of the time and it is definitely the most common one. There's also invasive lobular cancer, which is less common, and then there is a few others which are even less common than that.

The invasive lobular cancers can sometimes be a little bit difficult to detect on mammography or even ultrasound. So somebody may present with a mass, but the mammogram or ultrasound don't show any abnormalities. And this would be an instance, for instance, where MRI could be helpful. But those are the main two types of cancer that we see.

And then those are divided into different subtypes, depending on what the receptors are on the breast cancer cells. The receptors that we do test for with breast cancers are estrogen, progesterone and then HER2. And these results of the receptors can come back positive or negative. And based on what they come back as, tells us about the biology and behavior of the cancer as well as how is the oncologist going to treat this particular patient.

Host: Now, a diagnosis of breast cancer can be obviously very scary to a patient and to their family. How do you as a surgeon approach discussing a breast cancer diagnosis with patients? And what kind of emotional support is provided during this very difficult time?

Amrit Mangat, MD, FACS: In terms of helping the patient with emotional support, it is truly one of the most difficult times in a patient's life when they have this diagnosis of breast cancer Here at Duly, we have nurse navigators who reach out to the patient very shortly after the diagnosis is made. They assist with appointments, helping the patient navigate through the system and provide emotional support as well.

In regards to our offices, our support staff is also there to assist the patients and of course the physicians that I work with and I think this is also a time where it's important for patients to have a good support system in terms of family or friends.

Host: Absolutely. And how do you as a surgeon approach that initial discussion to give the diagnosis of breast cancer?

Amrit Mangat, MD, FACS: Yes, so when the patients come and see me, they have already heard their diagnosis. It's usually by the radiologist or the primary care physician. And so, they have had some time to absorb the results when they come and see me in the office. So, when they do come to see me in the office, I try to put the situation in perspective. Thankfully, most patients will do very well long term and live their normal lifespan once the treatment has been done. So, in every patient, I try to explain to them, it's their particular cancer is unique and individual to them and most people can overcome the diagnosis and go on to live a normal life. Unfortunately, some patients do have more aggressive disease and we have to explain it to them in such terms as well. And my particular philosophy is we are fortunate to have access to many different forms of treatment so I try to explain it to the patient in a more positive manner so that they realize that there are definitely excellent options available to them.

Host: Absolutely. It's really important, like you said, to provide that emotional support and give them a reality of the prognosis based on their stage, as you had mentioned before.

Amrit Mangat, MD, FACS: Correct, and patients come in and naturally they're all very fearful of what's coming, what the situation looks like to them in the long term and I really try to put it in perspective and make them understand what exactly we are dealing with.

Host: That open communication is so important. And I do love that at Duly, you have that emotional support that's provided by the nurses so they can navigate sometimes a very scary process, to get from through the different modalities of treatment.

Amrit Mangat, MD, FACS: Definitely. It's very easy to get lost in the healthcare system on occasion and the help of the nurse navigators that work with us very closely, it really makes a big difference to the patients.

Host: Oh, absolutely. Because they feel, I'm sure they feel that they're not alone and that's really important.

Amrit Mangat, MD, FACS: Yes, I think that's really crucial. I think the staff that's here makes a big impact and difference and that quick access to somebody on the other end of the line is really good for the patients and easing their anxiety.

Host: Absolutely. When we were discussing stages and types of breast cancer and the treatment options, you did mention surgery, radiation, chemotherapy. What are the typical treatment options for breast cancer and how do you determine the most suitable course of treatment for each patient?

Amrit Mangat, MD, FACS: Great question, Dr. Habib. It's definitely multimodality therapy. Often patients think that surgery is the initial option and then once that's done, I'm not going to need anything else. However, we all work together very closely and what I explain to the patients is each treatment modality that we have works in its own way.

So many patients are candidates for breast conservation therapy and many of those patients will go on to proceed with radiation therapy. And what radiation therapy does, it reduces the risk of breast cancer recurrence within the breast. Now, in addition, some patients will go on to need chemotherapy.

Many patients don't, but there are a select few that will benefit from what we consider systemic therapy. And how I explain to the patients is, surgery and radiation work locally at the breast level and then any other therapy such as chemotherapy or endocrine therapy, they work systemically. And what those systemic treatments do, they reduce the risk of a distant recurrence.

So if a patient goes on to have a lumpectomy, which is breast conservation, many of them will proceed to radiation therapy. Now based on the type of the breast cancer that they have, they may or may not need chemotherapy and this is where the oncologist comes in. There are certain subtypes of breast cancer such as triple negative breast cancer or HER2 positive breast cancer.

Some of those patients will indeed need chemotherapy and in terms of what sequence we recommend the treatment, sometimes chemotherapy is given upfront before surgery to downstage the disease. And then we operate. And so it's very variable in terms of what we recommend and we really individualize it. So that's how we explain all the different types of treatment that are out there.

And I really stress to the patients that it's not just surgery. We have to do these other treatments to give you the greatest chance of success long term.

Host: How do side effects of treatments like chemotherapy, radiation, or surgery vary from patient to patient? And what can individuals do to manage these side effects?

Amrit Mangat, MD, FACS: Yeah. So treatment definitely has side effects associated with it, but it does vary significantly from patient to patient. In terms of radiation therapy, many patients are naturally fearful when they hear the word radiation. Nowadays, many of the radiation courses are three to four weeks long. It is Monday through Friday daily.

Now when the patients go in for the radiation treatment, it doesn't take that long to deliver the radiation to the breast. So initially the patients actually won't feel any symptoms and the vast majority will go on to do very well and not really have any significant symptoms. Sometimes patients might feel a bit fatigued towards the end of radiation therapy.

Sometimes the breast does get red and sometimes a bit more severe reaction, but that's not that common. So side effects do exist, but I think it's not as common as patients are anticipating. Now, in regards to chemotherapy, of course, it depends on what kind of agents they're getting, how frequently. It depends on the age of the patient, their medical comorbidities, and some patients, believe it or not, are fairly asymptomatic when they are going through chemotherapy, but some unfortunately do experience some significant side effects hair loss, and fatigue, dehydration. So there are numerous side effects that can occur, but the oncologists are very good at managing a lot of these symptoms and it does make a big difference.

Host: Hmm. And what about the surgical side effects? Yeah.

Amrit Mangat, MD, FACS: Yeah, so in terms of surgery, if a patient is undergoing breast conservation and a sentinel lymph node biopsy, those patients actually do go home the same day and in terms of what they experience post-op, of course there's going to be mild to moderate incisional pain and there's a small risk of lymphedema which is swelling of the upper extremity but that doesn't happen immediately, that happens down the road. But the chance of that happening is less than 2 to 5 percent in patients who undergo a sentinel lymph node biopsy.

There can be some numbness around the incisions but by and large after breast conservation, patients do heal well and don't have any significant long term sequela from that particular surgery.

Host: And what about for the few patients that might need a mastectomy? What should they expect?

Amrit Mangat, MD, FACS: In terms of mastectomy, it's definitely more involved surgery. I work with plastic surgeons who often will do immediate reconstruction. And that is very frequently done actually. And in terms of mastectomy, some patients will need a unilateral mastectomy. Some people will proceed with a bilateral mastectomy.

And how they decide depends on family history, their level of anxiety, and if they need a mastectomy on the other side or not. In terms of how patients recover from that surgery, it's definitely a bit more than the standard breast conservation therapy, which most patients do undergo. Sometimes there's a hospital stay involved overnight and the pain in these particular situations is typically more than if someone's undergoing breast conservation. When they do have a mastectomy, I always counsel the patients that you are going to be numb on the chest wall. And that, I think, is important for patients to understand and realize that because it is a very different look and feel when you have reconstruction compared to a natural breast. So I'm very careful in counseling the patients in that regard so that they understand that this is not breast augmentation, it's breast reconstruction. So it's definitely very different to an augmented breast or a natural breast. So it's something for them to be aware of.

Host: Absolutely. Now you've discussed the different types of treatment that patients can undergo, but how does a patient's age, their overall health, and other medical conditions affect treatment decisions and outcomes?

Amrit Mangat, MD, FACS: I mean, it definitely does. For instance, I've recently had a fair number of patients who are in their 80s. Some of them have significant comorbidities and medical problems and some don't and some patients are not able to undergo surgery or tolerate chemotherapy.

So, many of these factors do have implications on what we are able to offer or recommend and also what the patient wishes to undergo. I had a lady the other day who was in her 80s for instance and she has a small malignancy but very reluctant to have surgery. So we have to look at all these factors and then decide what's the best treatment for that particular patient because it's not one thing for everybody.

We have to really tailor it to what the patient is comfortable with and what we feel like that they would be able to tolerate.

Host: Now how does breast cancer treatment impact a patient's daily life, including work, family, and their overall wellbeing?

Amrit Mangat, MD, FACS: That's an excellent question, Dr. Habib, because as I mentioned earlier, this really is one of the most stressful times in a patient's life and they start to think how am I going to manage doing everything that I normally need to do as well as take care of myself during this treatment for breast cancer.

So it depends definitely on what kind of treatment is recommended. As I mentioned earlier, most patients when they undergo breast conservation surgery, they do go home the same day and I think that's very beneficial for them so they can rest and recuperate in their own surroundings.

In terms of work, there's obviously time off that's going to be required when you have surgery and sometimes when you have chemotherapy as well. If you have a mastectomy, sometimes four to six weeks are required off work. And when you have breast conservation therapy, perhaps one or two weeks. In regards to radiation, since the radiation treatment on that daily basis doesn't take that long, most of our patients are actually able to continue their work schedule through radiation.

Now, if somebody ends up needing chemotherapy, that's going to be a little bit of a different situation depending on the side effects that the patient experiences. They may be able to continue work and all their other activities, but sometimes they do need to take time off. We do see that, and I think we just need to be aware and diligent and see what kind of symptoms patients are having because they may not be able to work and do all the other things that they need to do on a daily basis.

Host: And what about the impact on their family?

Amrit Mangat, MD, FACS: It definitely does have an impact on the family members, whether they be spouse, children, parents. So it's not unusual that I see family members come into the office with me and they're obviously very concerned about their relative. And we just try to provide support to them and give them some expectations of what the patient may be experiencing and what the patient or may not need.

And we try to guide and counsel them so that they are better armed to help take care of the patient as well.

Host: Absolutely, so important to provide that support because we often forget that the family is going along with that journey and, you know, it takes a huge impact on their mental health as well when they're watching their loved one go through such a rigorous treatment.

Amrit Mangat, MD, FACS: It really does. And honestly, sometimes I have seen that the family is more stressed than the patient. So, I think that once we are all on the same page and discuss prognosis and treatments in a way that makes them realize that I can get through this. I think that's really, really crucial and makes a big difference for the family as well.

Host: At Duly, you seem to have a very well established multidisciplinary team that is taking care of these patients in a very holistic manner. How can patients advocate for their own care and engage in shared decision making with their healthcare team during this breast cancer journey?

Amrit Mangat, MD, FACS: Yes, we do have a team that works very closely together. We have a breast cancer conference where cases are presented by the surgeons, if they have particular questions or recommendations in treatment or additional guidance. And when we do have that breast conference, it's attended by pathology, radiology, medical oncology, radiation oncology. We have dieticians on staff. So everybody comes together and discusses certain cases that we present. In terms of advocating for their own care, I do think it's very important and I think part of this starts with education. We provide patients with some excellent material that they can read on their own.

There are some websites that I inform the patients about and I encourage them to look at that as well. And then, I also say you have the option of getting a second opinion. There's certainly no harm in that at all. And the oncologists are very helpful in guiding the patients in making decisions about other treatment as well.

Now there are occasions where we might recommend a particular treatment, but the patient declines it. And should that happen, then we have to let them know that these are the potential issues that could occur if you decline a certain therapy. But we do try to keep them engaged and make them understand that this is a, these are our recommendations but we would like to make it in combination with your understanding and what that may or may not entail for you.

Host: That sounds like it really empowers the patient to help make the best decision to fit their lifestyle. That's wonderful.

Amrit Mangat, MD, FACS: No question about it. I always say knowledge is power and in this particular situation, I encourage my patients to become well educated about their disease and this will help them guide them to make the best decision treatment in conjunction with their physicians for them.

Host: Well, thank you so much for sharing your expertise on breast cancer diagnosis and treatment. Are there any last keynotes that you would like to share with our audience today?

Amrit Mangat, MD, FACS: Well, first of all, thank you Dr. Habib, it's been a pleasure speaking with you this morning and I think that I would just advocate for screenings and for patients to get help when they feel like something is wrong. It's still not uncommon for me to see patients who have missed mammograms and ignored breast lumps and then unfortunately the disease is more advanced in those particular situations.

So I would just like to push for screenings and if you feel like anything is wrong, please certainly get help.

Host: Absolutely. And thank you again for all of your expertise today.

Amrit Mangat, MD, FACS: My pleasure. Have a good morning. Thank you.

Host: This is Duly Noted, a health and care podcast brought to you by Duly Health and Care. To dive deeper into this topic and many others, or to book an appointment with physicians like Dr. Mangat, please visit dulyhealthandcare.com. I'm your host, Dr. Rania Habib, wishing you well.