Amanda Wilde (Host): Meaningful Medicine is a Novant Health podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Our focus this episode is understanding breast cancer surgery, what you need to know with breast surgical oncologist, Dr.

Elizabeth Fish. I'm your host, Amanda Wilde, and Dr. Fish, thank you so much for being here.

Elizabeth Fish, DO: Thank you for having me.

Host: Breast cancer surgeries have become more highly precise personalized procedures in recent times. Currently, what are the main types of breast cancer surgery, and how do you decide which is right for a patient?

Elizabeth Fish, DO: Yeah, so the main two types are either lumpectomy or breast-conserving surgery or a mastectomy. So very different surgeries, but both great approaches for breast cancers. lumpectomy really focuses on taking the actual area of the cancer and a, rim of healthy tissue around it or hopefully negative margins.

so a smaller area of tissue is taken versus a mastectomy, we remove all of the breast tissue, underneath the skin on that side or both sides depending. those are two main ones, and there's a lot of different things that go into deciding what is best for which patient. A lot of times it's tumor size and breast size and kind of how those go hand in hand, as well as genetic testing.

So if someone is positive for something like a BRCA mutation, maybe mastectomies is the better approach for them. or if a patient can't have radiation, then lumpectomy's not always a good option because typically with lumpectomy, we like to pair that with radiation to get our recurrence risk as low as we possibly can.

So there's a lot of different nuances that go into picking the right surgery.

Host: And what does the surgical process look like for these procedures from start to finish, if you can say all of these procedures have something in common? I guess I'm asking what patients should really expect also the day of the surgery.

Elizabeth Fish, DO: Yeah. So a lot of times leading up to the surgery, obviously they're meeting with the surgical oncologist, they're meeting with the medical oncologist to make the best plan for them, whether it's surgery first or not. and when it's determined that surgery is the better approach upfront, usually there's, imaging and biopsies and things like that need to occur prior to the actual surgery date.

If we're doing a lumpectomy or that smaller operation, typically we do want to, place some sort of localizing device or have radiology place that. Usually that's, like a smart clip or a wire or something that can help us target that area, so that usually happens about a week before the surgery. typically, if they're having a mastectomy with reconstruction, they're going to be meeting with plastic surgery before that as well.

the day of surgery, they get there usually a couple hours, prior to the actual surgery start time. they meet with anesthesia, make sure that everything is appropriately laid out for them. most patients actually leave the same day, and that's, more so for lumpectomies or the smaller surgeries.

And then if they're having a mastectomy or reconstruction, they might stay one night in the hospital. that's the process of kind of getting to the surgery and the day of surgery. then there's obviously, you know recovery time and stuff after that as well.

Host: during the surgery, it's really common to remove lymph nodes and test them during surgery. How do you determine if lymph nodes need to be removed? and what role does the sentinel node biopsy play?

Elizabeth Fish, DO: Yeah, so that's actually a very nuanced and even more personalized, part of our care at this point as well because of the multiple surgical trials that have come out. But we're actually omitting that part of the procedure in a lot more patients now than we ever were before. for patients that, you know already have disease in their armpit, that's a whole different ballgame.

but in terms of the sentinel lymph node procedure, really the idea behind that is if cancer, breast cancer is going to go anywhere first, typically the place that it will go is the lymph nodes under the armpit because they drain the breast. now typically what we do here is use dual tracer, which is a blue dye as well as a nuclear medicine tracer to kind of help amp up the ability to find those first couple draining lymph nodes.

it's a small incision, usually underneath the armpit for the smaller breast surgery, and we physically take out those lymph nodes that either turn blue or, for lack of better words, beep at us because of the tracer. In, women that are 70 and above with early stage hormone-positive estrogen-positive I should say, breast cancers, we typically can omit that part of the operation because there's really not a, much of a benefit or much of a change in their treatment plan, from doing that, and it really doesn't change their survival or their risk of it coming back in the future.

so it's usually in the younger, you know age bracket, that we're doing more of these procedures. and it depends on the receptor status of the breast cancer too. So it's a little bit different if it's hormone-positive versus maybe a triple-negative or a HER2=positive breast cancer. So lot of nuances with the sentinel lymph node procedure, but it is, really just a way of finding more information and giving the patient more information of has the cancer spread and what is the next best step.

Host: Right Thanks for explaining that. What are some of the most common side effects or risks of breast cancer surgery, and how can patients prepare for that?

Elizabeth Fish, DO: some of the most common side effects are, some swelling, maybe a little bit of pain or soreness. There's honestly not too much pain with that just because it's more numbness around that area where the surgery is done, which can also be, in your a risk. other risks included are cosmetic deformity, so that's why making sure we pick the right surgery for the right patient is very important.

we don't want to have a big cosmetic defect from a lumpectomy in a small breast, for example. some other risks, especially with the lymph node procedure we just talked about, is lymphedema. So there is a small risk of chronic arm swelling, otherwise known as lymphedema, from that procedure.

Although it is much less with that operation than with the full axillary dissection, which is, removing all the lymph nodes underneath the armpit. So those are some of the more common. There's, some risks of mobility issues or kind of tightening and scar tissue and things like that. but typically we, refer them to physical therapy or, show them some different exercises to help prevent things like that.

Host: And that is how you manage pain, swelling, and changes in mobility after surgery.

Elizabeth Fish, DO: typically with, pain, it's really just some ice. A supportive bra is really one of the biggest things that people overlook. and then Tylenol and Motrin. Not a whole lot of opioids or any other pain medicines are really needed for really the mastectomy or the lumpectomy. for the swelling, it's a lot of compression and making sure we're supporting the breast with a, good supportive bra.

those are the biggest things. But yes, if we're noticing a lot of these things, at the post-op visit or a couple weeks later, physical therapy is one of the, mainstays

Host: And what does recovery look like in those first few weeks, and when can patients return to normal activities?

Elizabeth Fish, DO: for the lumpectomy or that smaller surgery, usually it's only about a week or two weeks recovery. getting back to work and things like that, it kind of depends on what they do for a living. I tell my patients, "Don't lift more than about 15 to 20 pounds for about two weeks." they're allowed to shower the next day, that sort of thing.

That's for the smaller surgery where we don't have drains or anything like that involved. for the mastectomy, recovery is more like four to six weeks, depending on reconstruction or no reconstruction, and really depends on when those drains come out as well. Typically, if a patient's had reconstruction with plastic surgery, the plastic surgeon will really lay out, "This is what you can and can't do, after your surgery and for how long."

Host: Well

since you

brought it up, let's talk a little bit more about reconstruction. How do patients weigh the pros and cons of breast-conserving surgery versus mastectomy, first of all?

Elizabeth Fish, DO: So it really comes down to tumor size as well as breast size, and what are they a candidate for, right? So are they a candidate for the small surgery, and does that align with maybe what they want from a recovery standpoint? Maybe their goal is to get back to work or to, be able to play with their kids or whatever it is.

so maybe the lumpectomy is, right for them. Maybe they have a genetic predisposition to breast cancer and they're higher risk in the future, so maybe the mastectomy is better for them. a lot of it does end up being more personalized. so those are some of the big things.

Host: How do reconstructive options factor into surgery planning, and when is it best to involve a plastic surgeon?

Elizabeth Fish, DO: it's best to involve them as early as possible. So if we know someone is contemplating, mastectomies with or without reconstruction, I'll go ahead and place the referral for them to speak to plastics. the type of reconstruction really depends on body habitus and maybe the quality of their tissue and other medical comorbidities.

tobacco abuse is a big one. It's, difficult to have a reconstruction if someone is smoking and using tobacco products because we know their healing is not going to be as good. so those are some of the things to think about. Now, there's implant reconstruction versus, you know maybe autologous, using their own tissue, such as flaps.

So a lot of that is discussed with the plastic surgeon, pretty early in the process. a lot of that is more with mastectomy patients, whereas if we're ... you know there's, also a role for plastic surgery even with lumpectomy. So say a patient was interested in a breast reduction at the time of their lumpectomy, we can always entertain that, depending on their pathology, and have them see a plastic surgeon as early as possible, just so we can make it really seamless

Host: you mentioned smoking, I'm thinking about lifestyle factors. Are there lifestyle changes like exercises or physical therapy that can help patients prepare for surgery and recover faster to protect their chest and shoulder mobility?

Elizabeth Fish, DO: Yeah, there are certain exercises. and, if we know a patient is going to need a bigger axillary surgery and they're at higher risk for, you know arm issues, mobility issues, swelling, that sort of thing, sending them to physical therapy preemptively, so more of a prophylactic approach, is, something of importance as well.

They will kind of show them different massage techniques and, you know fit them with a compression sleeve and things like that. So that's more specific to lymph nodes. in terms of just overall health, making sure that they're eating, a well-balanced diet that's high in protein, making sure we're getting outside, we're getting, our steps in each day, being really just as healthy as we can be before undergoing any sort of surgery, not even just breast surgery, is, really important.

so I try to focus on that at, at all of my, pre-surgical visits as well.

Host: Speaking of things we can do before surgery, what questions do you wish patients would ask before surgery just to feel more informed and confident?

Elizabeth Fish, DO: my patients honestly ask a lot of really good questions at, their first visit with me, which is always really nice. We have great conversations about, pretty much everything they could potentially expect. But, I do always want my patients to ask about recovery. What does that really look like?

What does it really feel like? That sort of thing. what can they anticipate from a, medical oncology or radiation oncology standpoint after the surgery? realistically, can they then pick up their children, or can they drive their car? Can they really get to work? Because, you know this day and age, we all got to get back to work as quick as we can.

And, so I really wish, a lot of patients would have more of a candid discussion about that and, not be afraid to ask those questions. one other thing is, what is the impact of whatever the breast surgery they're choosing potentially on their sexual health or, things that we don't always want to talk about.

Those are important things to think about when deciding lumpectomy versus mastectomy, body image issues, things like that. so I really wish the patients would ask about that and feel like they've really gotten the, most information they can from those aspects.

Host: So it's really good if you can imagine a very detailed future together with your breast surgeon.

Elizabeth Fish, DO: Yeah, exactly. Exactly. And I follow my patients pretty much every six months indefinitely. I, do enjoy building relationships with my patients. And, and I think that's something that's really beautiful about breast surgical oncology

Host: Yeah. It is really reassuring to have the same person by your side through all the procedures before, during, and after. Dr. Fish, thank you so much for sharing your valuable insights on breast cancer surgery today.

Elizabeth Fish, DO: Thank you. Thank you so much for having me. This was great

Host: Dr. Elizabeth Fish is a breast surgical oncologist with Novant Health. To find a physician, visit novanthealth.org. For more health and wellness information from our experts, visit healthyheadlines.org. If you enjoyed this podcast, please share it on your social channels and explore our library for topics that interest you.

This is Meaningful Medicine, a Novant Health podcast