Michael R. Anderson, MD (Host): Hello everyone and welcome to this episode of the FortCast, the official podcast for FortHealthcare. I'm your host, Dr. Michael Anderson, President and CEO of FortHealthcare and practicing ENT doc, and I am very excited for our guest today. We're going to be covering two big topics in the realm breast care and health.

And my guest today is Dr. Jamie Clementi. Dr. Clementi, thank you so much for joining us today on this episode of the FortCast. We are extremely excited because Dr. Clementi is joining us and is going to be starting her practice in October. And it is just a wonderful opportunity to bring in a breast surgeon specialist onto our medical staff.

As most people know, I've been, I start to count my time here at FortHealthCare in decades now but Dr. Clementi is just starting her practice. It's wonderful to have you, Dr. Clementi. Can you tell us a little bit about yourself?

Jamie Clementi, MD: Hi, Dr. Anderson. Thank you so much for having me on the podcast. I'm really excited to be here today. I grew up in the Chicago suburbs, did my general surgery training down in Kansas City, and was actually back in Chicago to specialize in breast health, did training in breast health and recently moved to the Jefferson County area. And I've been looking forward to starting my practice here.

Host: Well, it's wonderful to have you and really just to build on that, I think it's important for our listeners to understand. So Dr. Clementi did a full general surgery residency and then went on to do a breast surgical fellowship. So she has really done that extra training that is required in order to be an expert in breast health.

It's very exciting today because we want to talk about a couple different topics in the realm of breast care and health. So the first thing I would like to talk about, Dr. Clementi, is the breast lump. Now I'm an ear, nose and throat physician, so I'm going to be learning along with our listeners. But when I hear breast lump, I think breast cancer.

But in reality, a breast lump, how, first of all, how often does it happen? And is it always a cancer?

Jamie Clementi, MD: Yeah, that's a great question. So as far as a breast lump or a breast mass, about 1 in 4 women, so 25 percent of women, may find a breast lump in either one of their breasts at any time in their life. And the majority of these breast lumps are not cancerous. Of course, there are various things that go into determining what this lump could be but more often than not, they do end up to be benign.

Host: Well, that's wonderful to hear. One in four, boy, that is a huge number. So if, you're a woman and you discover a lump in your breast, what's typically their first step? Do they go see their family physician or their primary provider, and then get referred to you? Can you tell us a little bit about that process?

Jamie Clementi, MD: Yes, so, oftentimes people do have, women do have a relationship with a family practitioner and those family docs do see these problems often. And so it's a good idea to go, once you find a lump that's new to you, to go to your practitioner to have an examination. You need a physical examination, they're going to ask you some questions, and then, of course, I'm happy to, as a breast specialist, I'm happy to assess patients as well.

So, if they're referred to me or however you want to get to my office, I'm also happy to do an examination as well, and we'll talk about how long the lump has been there, does it hurt, has it changed in size, just various questions that I would ask. And then the next step, so after doing an examination, would be to get some imaging.

Depending on the age of a woman, so it could be young women in their early 20s, and up to age 90, women can find a breast mass, but depending on the age, you'd get a mammogram plus or minus, or an, and an ultrasound to evaluate this lump. Our radiologists then will look at the imaging and they can look at the features of the lump that they see and better help us decide if it looks like it's a benign mass or if it's something concerning.

And then depending on how it looks on imaging in the exam, we may proceed with a biopsy as well. So a needle biopsy of the lesion.

Host: So, if I could just ask a couple follow up questions there. So, obviously, symptomatology is very important. Does the mass hurt? Has it gotten larger or smaller since it's been discovered? When you get the diagnostics, clearly the radiologists with the mammogram and the ultrasound, they can really help define characteristics of the mass that can point you in the direction of benign versus malignant.

How do you see that, Dr. Clementi, and what do you look for in order to say, hey, this is probably a benign mass, and if it's benign, what are the most common types of benign masses versus, hey, I'm a little bit concerned about this, I think we need to go to the next step. Can you take us through that thought process?

Jamie Clementi, MD: Yeah. So features that would be leaning more towards benign would be, is the mass smooth edged? Is it well circumscribed? Meaning, does it look like a nice circle or a nice oval? Is it filled with fluid? Typically, if it's filled with a fluid that's all of the same density or consistency; that's a cyst and those are usually benign.

Often, most commonly in younger women, so age 30 and younger, they could have something that's a bit firmer of a mass, but it's rubbery, it's more mobile, it's moving around. That would be consistent with something called a fibroadenoma. That is a benign, not cancerous mass that is an overgrowth of the breast supporting ligaments. Very benign.

Host: So when you see a, or when you're suspicious of a benign, so if we could just focus on the cyst, does that require further treatment?

Jamie Clementi, MD: Typically no. So a fluid filled cyst can remain in the breast. Oftentimes they do go away on their own especially as the breast changes with aging. If it is big, if it's bothersome, or if it's really distressing to the woman, we can aspirate it. So we could do a needle aspiration. That's something I can do in the office.

We just numb up the area and under ultrasound, I'll remove that fluid. Sometimes those can recur though, so they're not necessarily a long term solution, but they typically can go away on their own.

Host: And what about the other entity that you mentioned?

Jamie Clementi, MD: The fibroadenoma. So, that's usually something that's found in, like I said, younger women. And they actually sometimes can go away on their own as well, they, we call it degenerate, so as the breast ages, as the woman ages, they might become less noticeable and kind of degenerate on their own.

If they continue to enlarge, if they're really bothersome, and again, just for peace of mind, that's something we can surgically remove in the operating room with a minimally invasive incision that I generally hide.

Host: And are those two masses, the most common benign masses that occur in the breast?

Jamie Clementi, MD: They are. The third one I would include too is an abscess and an abscess could present as a mass in the breast, but typically they're hot, they're red, they're painful. And it might present with some breast swelling and pain as well.

Host: Breast abscesses, I imagine, present more acutely.

Jamie Clementi, MD: They do, so typically will pop up in a week or two. You can have some, we call them smoldering ones that could be there for a bit. There's some more rare abscesses and of course I can go over that in more detail when I meet the patient in person, but typically they present pretty quickly, pretty painfully, and women who are lactating often deal with these issues as well.

And if it is a big enough abscess, that there's a nice fluid collection in there that I can see under ultrasound that is also something I can remove with a needle versus it might need to go to the operating room for some better anesthetic and a good clean out.

Host: Yeah, I imagine the treatment of that is pretty individualized and there's multiple factors that go into the definitive care for those abscesses. But I can imagine that's gotta be fairly painful when that happens.

Jamie Clementi, MD: Yes, yes.

Host: Versus the other two masses, maybe, not painful or less painful than an abscess.

Jamie Clementi, MD: Correct. Generally those could be more uncomfortable but not necessarily painful.

Host: Gotcha. Gotcha. So if we can switch gears a little bit, Dr. Clementi, when you're concerned about a mass that may have some malignant features on the diagnostic imaging, what goes through your head? What do you typically, do you ask the patient more questions or how do you go about then trying to find the true etiology of that mass?

Jamie Clementi, MD: Correct. Well, it's always good to talk about family history. We want to talk about estrogen exposure, age of menarche, if the patient is still menstruating, pre menopause, post menopausal, all very important information for determining this information, as well as a family history of breast, ovarian cancer, and other cancers are relevant too.

So gathering that history would be important. And then looking at the imaging as well, if there's, we call them more irregular features of the mass. There is a grading system, the BI-RADS system, that our radiologists use. It's a standardized system that they look at the features of these lesions they're assessing, and they'll assign it a score 0 through 5, 6 is a known malignancy, but 0 through 5. And based off of that, we might recommend a biopsy.

Host: Gotcha. So when you counsel somebody that they need a biopsy, how do you explain to the patient? I mean, that's gotta be a very challenging conversation where you're trying to relay the medical information in the most sensitive way possible. I imagine that can be quite challenging. And then how do you go about physically performing the biopsy?

Jamie Clementi, MD: Yeah, so talking about the biopsy, well, generally, I like to start with the reason why we're doing it. We like to do a biopsy so we can actually sample a piece of tissue from the lesion so our pathologists can look at it under their microscope and give us a more definitive answer. I wish we had x-ray vision with our own eyes and even with our imaging, but we do need to confirm it with pathology.

Risks and benefits of the procedure, we'll discuss that too, but I do think it's important to know that biopsies do not spread cancer. So there is a concern some women have that if their lesion is biopsied that it might cause the cancer to spread and it does not. We do hundreds of thousands of biopsies across the nation every year and there's no evidence that it spreads.

And that's not how cancer functions and what we do for the biopsy is, so we'll come back to our, either the office or the imaging center. We will numb up that area, good local anesthetic and then we make a small puncture in the skin and then introduce our needle and do a couple biopsies. We want to make sure we get a good tissue sample.

And then while we're doing that, we'll numb up the area some more as well with the lidocaine just to make sure that it's relatively painless. There is a risk of bleeding after the biopsy. We will hold pressure and we generally recommend keeping a compression bra on and ice helps with that as well.

Host: So it's a fairly patient friendly process to do the biopsy.

Jamie Clementi, MD: Something that can be done in the office.

Host: Thank you, Dr. Clementi. That was wonderful on the workup the breast lump.

We hope to have Dr. Clementi on a future episode of the FortCast to maybe talk specifically more about breast cancer and that process. But I'd like to switch gears and talk about nipple discharge. So, Dr. Clementi, in your practice, how often do you see that? And take us through the patient that comes into your office with that chief complaint.

Jamie Clementi, MD: Yeah I would say, I mean, being a breast specialist, I'd say it's common. I've seen enough women come in with concerns for nipple discharge. Again, similar presentation would be they notice something's changing. They see a stain on their shirt. It's looks, the color, or they can actually in the shower, they might be washing and they notice they're able to elucidate some discharge from their nipple.

They might talk to their primary care doctor, and usually we get them referred to our breast specialty center that way. And then of course, what's really important with nipple discharge is talking about the presentation, how long it's been going on. Is it both breasts? Is it just one breast? What color is it?

Typically brown, green, tan, white is all more benign. If it's rusty or bloody, that kind of raises a flag that we want to do some more investigation. And if it's both breasts or both nipples, generally, that might not be something concerning, but if it's just one nipple, that's bloody nipple discharge, and this is new, we might, again, that's raising my suspicion that we need to do some more imaging and look to see if there's any underlying mass or lesion, particularly in the ducts of the breast and we can oftentimes find those on our imaging and then biopsy those to make sure there's no underlying malignancy. As far as having, again, talking about the symptomatology of this is important because if it's bilateral breasts, new nipple discharge that's kind of milky, then is there something else going on with the body? It might not be a problem or an issue with the breasts, but something else hormonally, the pituitary gland, medications. So, our discussion is very important.

Host: In your practice, what's more common? Is it more common to have a benign etiology for this, a benign cause, or the more concerning cause?

Jamie Clementi, MD: The most common that I've seen is it does end up being what we call a papilloma or a growth of tissue inside the duct of the breast. And they typically come back benign, but because it's causing symptoms, we do want to biopsy it or remove it to make sure there's not hiding a malignancy. And I have seen a couple that have, we call it upgrader, ended up having an underlying malignancy in that papilloma.

Host: Wow. How often is it infection related?

Jamie Clementi, MD: That's, it can happen. You can have purulent discharge or pus coming out from the nipple. But again, it would be, your breast would be, the breast would be hot and large, it'd be painful. So it can happen, but it's not very common that it's a benign infection, it's just coming out of the nipple. Usually the whole brest would be more involved.

Host: So I imagine when a woman experiences this, it's very concerning. And oftentimes they probably, again, go to their family medicine physician or provider. And then if typical treatments don't work, then they get sent on to somebody like you to be evaluated.

Jamie Clementi, MD: I did want to mention too, sometimes the nipple discharge may be new and we investigate it and we look at it and we don't see any concerning underlying lesions, sometimes as the breasts age, those ducts become a little bit bigger, dilated, and they kind of just collect debris inside the ducts. And then they get expressed out, and that's very benign. I have seen a couple cases of that, it's called duct ectasia and usually does not require further workup. But, again, if it's really bothersome, we can discuss it.

Host: So, if I understood you correctly, Dr. Clementi, the most worrisome symptom, if it's one breast and it's more rusty or bloody in nature, that really is more of a concern.

Jamie Clementi, MD: Correct. My flag is raised when I hear those words together.

Host: And then that's when you would go down the diagnostic path of radiology and going from there.

Jamie Clementi, MD: Correct.

Host: Yeah, it's so important for us to review these, to understand, our listeners to understand, our community to understand those worrisome symptoms that occur. So you seek health out quickly and promptly and then get in to be taken care of. Don't put it off. Make sure you have somebody, a good relationship with a family medicine physician or provider and then ultimately you may need to see somebody like Dr. Clementi.

Jamie Clementi, MD: And then Dr. Anderson, on that note too, I did want to throw out, men can also develop breast lumps in either or both of their breasts and also could develop discharge as well. And if that is happening, again talk to your provider. Please go talk to a doctor and get evaluated for that.

Host: Yeah, and I think that's sometimes lost amongst us males is that, you know, breast problems in males can definitely occur. The last stat I heard, and you can correct me, is that breast cancer cases in men, they, they represent roughly 1 percent of breast cancer cases. Is that accurate?

Jamie Clementi, MD: About, it's less than 1%, that is correct. It is less than 1%. But it does happen and men can also get mammograms depending on the shape of their breast tissue as well. They can also get mammograms and we usually do an ultrasound as well.

Host: Okay. Yeah. So, so don't forget that. All the rules, everything that Dr. Clementi talked about, still apply to men as they do women. It just, it doesn't happen as often as men, but it still can happen. Correct?

Jamie Clementi, MD: Absolutely. Absolutely. So please don't ignore it or put it aside. Just ask. I'm happy to answer questions.

Host: Sure. Absolutely. Well, Dr. Clementi, I can't thank you enough for being on this episode of the FortCast. As an ENT doc, I learned a great deal today. I'm sure our listeners will and our community will when they tune into episode of The FortCast, so thank you for being on here today.

Jamie Clementi, MD: Thank you so much for having me. It really was a pleasure. This was super fun.

Host: Well, good. Hope we do it again in the future, too. Every October is Breast Awareness Month, Breast Cancer Awareness Month, so we're hoping to have you on future episodes of the FortCast.

Jamie Clementi, MD: Yes, and everyone get their mammograms and I will see you all in October.

Host: Sounds great. Well, hey, if you enjoyed this episode of the FortCast, please check out our full library on our website and also share it on your social media channels. We greatly appreciate you tuning in today. This is Dr. Michael Anderson signing off. Thank you and have a great day. Take care.