Approximately one in eight women will be diagnosed with breast cancer during her lifetime.
While the disease can have a profound impact on the patient and her loved ones, it is also one that can be effectively treated with surgery, radiation therapy, hormone therapy and chemotherapy.
Skin and nipple sparing surgeries as well as plastic and reconstructive procedures; individually and combined, can effectively treat breast cancer while minimizing impact to physical appearance.
City of Hope offers the latest advances in the surgical management of breast cancer provided by specialized surgeons. For patients with small tumors and early-stage breast cancer, breast-conserving surgery is a treatment option providing optimal cancer surgery while achieving excellent cosmetic outcomes.
Laura L. Kruper, MD is here to discuss breast cancer surgery and all the latest advancements in reconstruction
Selected Podcast
Nipple-Sparing Mastectomies and the Rising Rate of Bilateral Mastectomies
Featured Speaker:
Laura L. Kruper, MD
Dr. Kruper’s long-term academic and research objectives are to optimize the management of breast cancer through better clinical trials. She believes one way to work toward this objective is to translate current scientific research findings from basic bench research into clinical studies and eventually clinical practice. Transcription:
Nipple-Sparing Mastectomies and the Rising Rate of Bilateral Mastectomies
Melanie Cole (Host): City of Hope offers the latest advances in the surgical management of breast cancer provided by specialized surgeons. For patients with small tumors and early stage breast cancer, breast conserving surgery is a treatment option providing optimal cancer surgery while achieving excellent cosmetic outcomes. My guest today is Dr. Laura Kruper. She’s the co-director of the breast cancer program at City of Hope. Welcome to the show, Dr. Kruper. Tell us a little bit about what’s going on in breast cancer surgery now and this trend towards immediate reconstruction after a mastectomy.
Dr. Laura Kruper (Guest): Okay. At our center and at many centers across the United States, we are able to offer many women nipple-sparing mastectomies. That is a procedure in which we can preserve the whole envelop of the breast—so all of the skin and the nipple—and the patient can have small scars so that we can remove the entire breast through that incision and then the patient could have immediate reconstruction afterwards straight to implant so that the patient can have all their surgery in one day and preserve the whole appearance of their breast. For many women, it’s difficult to even tell that they’ve had surgery, period.
Melanie: What are the advantages to the nipple-sparing mastectomy aside from the cosmetic advantages? Are there any other physiological advantages?
Dr. Kruper: It’s interesting that you ask that. They actually have done studies. There is a great questionnaire evaluating women and their satisfaction with the procedures that they have. Although women may feel that their preserved nipples actually feel the same pretty much as or have the same satisfaction as a woman who has had a nipple reconstruction, the benefits are actually seen in their physiological mood and their sexual well-being. That is the benefit to preserving the nipple for most…
Melanie: How much sensation does it have after this kind of surgery?
Dr. Kruper: For many women, it doesn’t have much sensation, which is why I think many women say that the satisfaction level is about the same as a woman who has a reconstructed nipple. We always tell women that they most likely will not have sensation, but some women actually do regain some sensation to their nipple.
Melanie: Who would be a good candidate for this type of surgery?
Dr. Kruper: The best candidates are people who have smaller tumors, not very large tumors, or tumors close to the nipple. Or there’s something called ductal carcinoma in situ, which is cancer within the ducts. So if a woman has DCIS, which is spread throughout the breast, they are not a very good candidate for nipple sparing. But more and more, we are seeing many patients are eligible for nipple sparing.
Melanie: What’s the healing process with this type of surgery? Is it any different than a full mastectomy without the reconstruction done right at that time? Is it a faster healing process?
Dr. Kruper: It’s actually somewhat longer because if someone had a regular mastectomy without any reconstruction, that recovery time is normally two to three weeks. When you add in reconstruction, that doubles the recovery time anywhere from three to six weeks because of the reconstruction. Then there are really no other further surgeries, and most women are much more satisfied when they have reconstruction. For many women, the prolonged recovery is worth it.
Melanie: Is there any risk, Dr. Kruper, of recurring cancer of the nipple after this?
Dr. Kruper: That’s a good question. Several studies have shown, or if you look at retrospective studies, that if a woman has cancer in the breast, the overall rate of developing another cancer in the nipple would be about 5 percent. And that rate might depend also on the size of the tumor and whether the lymph nodes are involved and what type of systemic therapy the patient receives. In a prophylactic surgery—so women who are genetic mutation carriers and have nipple sparing mastectomies prophylactically—the risk of developing a cancer in a breast that has had no cancer is less than 1 percent. So, a safe procedure.
Melanie: There’s been a lot of news in the media of double mastectomies even if there is not breast cancer in both breasts. Can you tell us about this rise in this trend? And what does it mean? Why are women doing this?
Dr. Kruper: That’s a very good question. Yes, there has been a very large increase in the number of women who are requesting contralateral prophylactic mastectomies. We call them CPM, when there’s no cancer in the other breast. The majority of these women who are requesting CPMs are not people who have either familial risk factors or genetic mutation. There are multiple reasons behind this increase. One is there have been studies that have shown that genetic testing—not even a positive genetic test, just actually being sent to a genetic counselor to have testing—will increase the rate of a woman requesting contralateral prophylactic mastectomy. Obviously, a strong family history of breast or ovarian cancer increases that rate. Also, women who undergo an MRI. One of the problems with MRI is although they are a very good tool for detecting cancer, they do have a high false positive rate. And for a lot of women, if they are being worked up for a breast cancer with an MRI and there are other findings, that makes them pretty concerned about cancer in the other breast. Then other factors that are associated with a higher rate of CPMs are higher education and a woman’s baseline anxiety or worry about recurrence. We have noticed that there is a trend. There have been several papers that came out last year looking at the increased rate of bilateral mastectomies, so mastectomy for the cancer side and then the other side. We certainly see that trend is very high in women who are young—and young being defined as age 40 or below—and you could understand why that would be because a woman who is diagnosed under the age 40 is going to live a very long time and obviously is going to be very concerned about another cancer. What’s interesting is that other studies have shown that the rate of developing what’s called a contralateral breast cancer is actually very low, but many women will foresee that that risk is higher. There are so many factors for why we are seeing this increased rate. Then another reason is, quite honestly, the reconstruction. The reconstruction nowadays that plastic surgeons are doing are really beautiful, and the different kind of techniques that they use. A lot of women know a friend who has had both the breasts removed, and soI think there are a lot of factors coming in to play.
Melanie: When you have a mastectomy or a bilateral mastectomy prophylactically, can you get cancer in the breast?
Dr Kruper: Yes, you can. That rate is very low and unfortunately for a patient who’s had cancer and we do a mastectomy, I always tell them that we can’t get down to zero. There are such things as called chest wall recurrences. That means anywhere along the muscle but also within the skin flap. As hard as we try as surgeons to remove all the breast tissue when we are doing surgery, sometimes you can’t tell the difference between a fat cell and a breast cell. It’s true that cancers can come back. In the prophylactic side, that risk is very, very, very low.
Melanie: Dr. Kruper, what advice would you have for women who have either previously had breast cancer or have a family history about getting that genetic test and that risk that you discussed about, the anxiety, and then considering a bilateral mastectomy?
Dr. Kruper: I think especially since Angelina Jolie came out saying she was a genetic mutation carrier, that really has increased the rate of people asking about genetic testing. The reality is that most breast cancers are spontaneous and they are not related to family history or a genetic mutation. Genetic mutations make up approximately 10 percent of all breast cancer cases, and there are certain things to look for that make some women more at high risk than others. Multiple generations of women with breast cancer in a family, other kinds of cancer as well such as colon cancer, prostate cancer, a young age. Any woman under the age of 45 qualifies for genetic testing. So I do try to counsel patients because a woman who has no family history of breast cancer is the first one in her family and presents at age 65 with a breast cancer, I am going to reassure her that she most likely does not have a genetic mutation and does not really qualify for genetic testing. But if she wants, we could send her to a genetic counselor. A lot of people, I think everybody now or many people think that if they have breast cancer, they have a genetic mutation, whereas it’s actually the reverse. I do try to reassure people. The decision to have a contralateral prophylactic mastectomy is one that really should be a shared decision between the physician and the patient. I really try to counsel my patients that all the studies have shown that if you remove a contralateral breast that’s unaffected, it actually does not improve survival. I tell this to my patients. And for most patients with breast cancer, the risk of distinct cancer or cancer coming back somewhere else in the body, like the bone or liver, is higher than developing a breast cancer in the other breast. But even giving all of those facts, many women will make up their mind one way or another based on whether they have friends who have done this, their own personal concerns. I try to talk them through the whole process.
Melanie: In just the last minute or so, Dr. Kruper, tell listeners why they should come to City of Hope when they are considering breast cancer reconstruction surgery.
Dr. Kruper: I think there are many great centers, but I think one of the benefits of our center is that we are a cancer center. All of our doctors here, we only focus on cancer. We have a multidisciplinary team. A medical oncologist, the surgical oncologist which is me, and then our plastic surgeon. Our plastic surgeons here pretty much only do breast reconstruction. They do beautiful work and they can offer different types of reconstruction for different patients. When a patient comes here, they’re going to get all of their care, and we can offer many state-of-the-art therapies given that we are a national comprehensive network cancer.
Melanie: Thank you so much. It’s great information. You are listening to City of Hope Radio. For more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Nipple-Sparing Mastectomies and the Rising Rate of Bilateral Mastectomies
Melanie Cole (Host): City of Hope offers the latest advances in the surgical management of breast cancer provided by specialized surgeons. For patients with small tumors and early stage breast cancer, breast conserving surgery is a treatment option providing optimal cancer surgery while achieving excellent cosmetic outcomes. My guest today is Dr. Laura Kruper. She’s the co-director of the breast cancer program at City of Hope. Welcome to the show, Dr. Kruper. Tell us a little bit about what’s going on in breast cancer surgery now and this trend towards immediate reconstruction after a mastectomy.
Dr. Laura Kruper (Guest): Okay. At our center and at many centers across the United States, we are able to offer many women nipple-sparing mastectomies. That is a procedure in which we can preserve the whole envelop of the breast—so all of the skin and the nipple—and the patient can have small scars so that we can remove the entire breast through that incision and then the patient could have immediate reconstruction afterwards straight to implant so that the patient can have all their surgery in one day and preserve the whole appearance of their breast. For many women, it’s difficult to even tell that they’ve had surgery, period.
Melanie: What are the advantages to the nipple-sparing mastectomy aside from the cosmetic advantages? Are there any other physiological advantages?
Dr. Kruper: It’s interesting that you ask that. They actually have done studies. There is a great questionnaire evaluating women and their satisfaction with the procedures that they have. Although women may feel that their preserved nipples actually feel the same pretty much as or have the same satisfaction as a woman who has had a nipple reconstruction, the benefits are actually seen in their physiological mood and their sexual well-being. That is the benefit to preserving the nipple for most…
Melanie: How much sensation does it have after this kind of surgery?
Dr. Kruper: For many women, it doesn’t have much sensation, which is why I think many women say that the satisfaction level is about the same as a woman who has a reconstructed nipple. We always tell women that they most likely will not have sensation, but some women actually do regain some sensation to their nipple.
Melanie: Who would be a good candidate for this type of surgery?
Dr. Kruper: The best candidates are people who have smaller tumors, not very large tumors, or tumors close to the nipple. Or there’s something called ductal carcinoma in situ, which is cancer within the ducts. So if a woman has DCIS, which is spread throughout the breast, they are not a very good candidate for nipple sparing. But more and more, we are seeing many patients are eligible for nipple sparing.
Melanie: What’s the healing process with this type of surgery? Is it any different than a full mastectomy without the reconstruction done right at that time? Is it a faster healing process?
Dr. Kruper: It’s actually somewhat longer because if someone had a regular mastectomy without any reconstruction, that recovery time is normally two to three weeks. When you add in reconstruction, that doubles the recovery time anywhere from three to six weeks because of the reconstruction. Then there are really no other further surgeries, and most women are much more satisfied when they have reconstruction. For many women, the prolonged recovery is worth it.
Melanie: Is there any risk, Dr. Kruper, of recurring cancer of the nipple after this?
Dr. Kruper: That’s a good question. Several studies have shown, or if you look at retrospective studies, that if a woman has cancer in the breast, the overall rate of developing another cancer in the nipple would be about 5 percent. And that rate might depend also on the size of the tumor and whether the lymph nodes are involved and what type of systemic therapy the patient receives. In a prophylactic surgery—so women who are genetic mutation carriers and have nipple sparing mastectomies prophylactically—the risk of developing a cancer in a breast that has had no cancer is less than 1 percent. So, a safe procedure.
Melanie: There’s been a lot of news in the media of double mastectomies even if there is not breast cancer in both breasts. Can you tell us about this rise in this trend? And what does it mean? Why are women doing this?
Dr. Kruper: That’s a very good question. Yes, there has been a very large increase in the number of women who are requesting contralateral prophylactic mastectomies. We call them CPM, when there’s no cancer in the other breast. The majority of these women who are requesting CPMs are not people who have either familial risk factors or genetic mutation. There are multiple reasons behind this increase. One is there have been studies that have shown that genetic testing—not even a positive genetic test, just actually being sent to a genetic counselor to have testing—will increase the rate of a woman requesting contralateral prophylactic mastectomy. Obviously, a strong family history of breast or ovarian cancer increases that rate. Also, women who undergo an MRI. One of the problems with MRI is although they are a very good tool for detecting cancer, they do have a high false positive rate. And for a lot of women, if they are being worked up for a breast cancer with an MRI and there are other findings, that makes them pretty concerned about cancer in the other breast. Then other factors that are associated with a higher rate of CPMs are higher education and a woman’s baseline anxiety or worry about recurrence. We have noticed that there is a trend. There have been several papers that came out last year looking at the increased rate of bilateral mastectomies, so mastectomy for the cancer side and then the other side. We certainly see that trend is very high in women who are young—and young being defined as age 40 or below—and you could understand why that would be because a woman who is diagnosed under the age 40 is going to live a very long time and obviously is going to be very concerned about another cancer. What’s interesting is that other studies have shown that the rate of developing what’s called a contralateral breast cancer is actually very low, but many women will foresee that that risk is higher. There are so many factors for why we are seeing this increased rate. Then another reason is, quite honestly, the reconstruction. The reconstruction nowadays that plastic surgeons are doing are really beautiful, and the different kind of techniques that they use. A lot of women know a friend who has had both the breasts removed, and soI think there are a lot of factors coming in to play.
Melanie: When you have a mastectomy or a bilateral mastectomy prophylactically, can you get cancer in the breast?
Dr Kruper: Yes, you can. That rate is very low and unfortunately for a patient who’s had cancer and we do a mastectomy, I always tell them that we can’t get down to zero. There are such things as called chest wall recurrences. That means anywhere along the muscle but also within the skin flap. As hard as we try as surgeons to remove all the breast tissue when we are doing surgery, sometimes you can’t tell the difference between a fat cell and a breast cell. It’s true that cancers can come back. In the prophylactic side, that risk is very, very, very low.
Melanie: Dr. Kruper, what advice would you have for women who have either previously had breast cancer or have a family history about getting that genetic test and that risk that you discussed about, the anxiety, and then considering a bilateral mastectomy?
Dr. Kruper: I think especially since Angelina Jolie came out saying she was a genetic mutation carrier, that really has increased the rate of people asking about genetic testing. The reality is that most breast cancers are spontaneous and they are not related to family history or a genetic mutation. Genetic mutations make up approximately 10 percent of all breast cancer cases, and there are certain things to look for that make some women more at high risk than others. Multiple generations of women with breast cancer in a family, other kinds of cancer as well such as colon cancer, prostate cancer, a young age. Any woman under the age of 45 qualifies for genetic testing. So I do try to counsel patients because a woman who has no family history of breast cancer is the first one in her family and presents at age 65 with a breast cancer, I am going to reassure her that she most likely does not have a genetic mutation and does not really qualify for genetic testing. But if she wants, we could send her to a genetic counselor. A lot of people, I think everybody now or many people think that if they have breast cancer, they have a genetic mutation, whereas it’s actually the reverse. I do try to reassure people. The decision to have a contralateral prophylactic mastectomy is one that really should be a shared decision between the physician and the patient. I really try to counsel my patients that all the studies have shown that if you remove a contralateral breast that’s unaffected, it actually does not improve survival. I tell this to my patients. And for most patients with breast cancer, the risk of distinct cancer or cancer coming back somewhere else in the body, like the bone or liver, is higher than developing a breast cancer in the other breast. But even giving all of those facts, many women will make up their mind one way or another based on whether they have friends who have done this, their own personal concerns. I try to talk them through the whole process.
Melanie: In just the last minute or so, Dr. Kruper, tell listeners why they should come to City of Hope when they are considering breast cancer reconstruction surgery.
Dr. Kruper: I think there are many great centers, but I think one of the benefits of our center is that we are a cancer center. All of our doctors here, we only focus on cancer. We have a multidisciplinary team. A medical oncologist, the surgical oncologist which is me, and then our plastic surgeon. Our plastic surgeons here pretty much only do breast reconstruction. They do beautiful work and they can offer different types of reconstruction for different patients. When a patient comes here, they’re going to get all of their care, and we can offer many state-of-the-art therapies given that we are a national comprehensive network cancer.
Melanie: Thank you so much. It’s great information. You are listening to City of Hope Radio. For more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.