Selected Podcast
Breast Cancer Surgery Options
When you receive a breast cancer diagnosis, you may be faced with different surgical options. Dr. Michelle Ribas, Chief of Surgery at Twin Cities Community Hospital, discusses breast cancer surgery.
Featuring:
Michelle Ribas, MD
Dr. Michelle Dulude Ribasis a general surgeon with a broad spectrum of general surgery andextensive knowledge of emergency general surgery, trauma, critical care and wound care. She iscurrently Chief of Surgery at Twin Cities Community Hospital in Templeton, California.Dr. Ribas earned her Doctor of Medicine fromthe University of California at Davis. She completed her general surgery residency at Kern Medical Center in Bakersfield, California.After completing hertraining, she joined Associated Surgeons of San Luis Obispo. Dr. Ribas is a member of the American College of Surgeons, Society of American Gastrointestinal Endoscopic Surgeons, American Society of Breast Surgeons and the American Board of Wound Management.Dr. Ribas and her husband have three young sons. Transcription:
Alyne Ellis (Host): Breast cancer. These two words strike fear in so many hearts and suddenly you are thrown into talking with a specialist about your surgical options and putting the date on your calendar. I’m Alyne Ellis. This is Healthy Conversations, a podcast from Sierra Vista Regional Medical Center and Twin Cities Community Hospital. Let’s talk with Dr. Michell Ribas, Chief of Surgery at Twin Cities Community Hospital in Templeton, California. Dr. Ribas, when you sit down with your patient to discuss what kind of breast cancer surgery options are available and best for them; what medical factors do you consider?
Michelle Ribas, MD (Guest): The first thing I do is review the patient’s chart and find out like what type of cancer they have. So, there’s two main types of breast cancer. One is in the ducts. So, the ducts that carry the milk to the nipple and if that’s the most common breast cancer. The second type is the lobular cancer that arises from the glands that make the milk. So, after explaining to the patient which kind they have; the second part is what have we found on the imaging biopsy. So, the size of the tumor and the grade of the tumor.
The third thing that we always review is the hormone status of the tumor. So, we want to know if the are estrogen positive, progesterone positive and the HER-2 protein. And those are three – the hormones and the protein that we want to know in order to treat. Because depending if they are positive or negative, the treatment might change. After that, we go ahead and do a physical exam, see how the breast, if there is any changes including the axilla and then we can talk about the different treatments.
Host: So, I know there are a lot of different choices, relatively speaking, of breast cancer surgeries. Why don’t we go in a little bit to what those choices might be. I know there are two different types pretty much; a lumpectomy and a mastectomy, is that correct?
Dr. Ribas: That’s correct. So, the lumpectomy is what we call a partial mastectomy, so it involves removing the tumor and a healthy tissue around it. that’s the most common surgery we do now a days, but it depends on the size of the tumor and the size of the breast. The second option is a mastectomy where the whole breast tissue is removed.
Host: And with a mastectomy, there are quite a few choices within that category everything from sparing the nipple to doing something more radical.
Dr. Ribas: That’s correct. So, through the history of breast cancer, the surgical treatments have changed a lot. It used to be where we went in and took all the breast tissue including the skin, the nipple, the muscles and now we try to do the least amount of excision to the breast. So, the sparing the nipple is very significant for the patient because nipple is part of how we visualize the breast. So, it tends to have better psychological outcomes. And we now can make smaller incisions to get all that breast tissue.
Host: And if you were to go on and have to do more such as taking the nipple and the areola, does that mean that after the patient has recovered, you can have that tattooed on or something, I know it’s not – it doesn’t necessarily feel the same, but at least it’s something that psychologically may help.
Dr. Ribas: Yes, that’s correct. So, now we also try to do surgery and at the same time do a reconstruction and there are different types of reconstruction. But the goal is to try to have the patient wake up and not have just any breast and like you said, usually with reconstructions, it might be multiple surgeries and one of the final stages of that reconstruction is tattooing the nipple.
Host: So, when we move on to say the total mastectomy which has more to do with taking the skin and the breast tissue; what are you seeing in the patient that means that you recommend that?
Dr. Ribas: One if the tumor has extended to the skin, the recommendation is to remove all that area including the skin and the nipple. Second, would be if they already had a previous radiated breast and we know they couldn’t have more radiation and they had another cancer. Another case where we might recommend that is with a very large tumor and smaller breasts where we think we won’t be able to get all of it. But sometimes when you have that, you could end up on chemotherapy before to shrink the tumor.
Host: And then finally, when you take the whole breast, and that includes the lymph nodes under the arm; I gather there are some tests that you would run to see if it has spread. I am wondering if you could tell us about that?
Dr. Ribas: Yeah, so, the first place where breast cancer can spread is usually the lymph nodes under the axilla. With any type of invasive cancer, meaning it has already come out from itself and started moving out of the cells; we want to sample that lymph node. So, even if we would do a partial mastectomy such as removing the tumor; we want to take at least one lymph node to make sure it hasn’t gone that way. Again, breast surgery has changed a lot. We used to take all the lymph nodes and now we know that the medical treatments we have including chemotherapy and the radiation are so effective that we just try to take the least amount that are positive. And the way we do that is usually injecting the breast with a nuclear dye and during surgery going with a special probe to look for the nodes that take up that nuclear dye. That way we just get the one node called the sentinel node that has the most uptake.
Host: And is that run while the patient is on the operating table? Is that node run through a lab to find out if you’ve gotten everything or if it’s positive?
Dr. Ribas: So, the lymph node usually what you are asking is called a frozen section where they go straight to pathology and they take a look. We tend not to do that because the lymph node gets cut in about one millimeter specimens and it would take too long to run a whole lymph node. They will do a sample really quick and make sure, but again, nowadays, since we don’t tend to take all the lymph nodes together, we just send it for a final verification and we usually within three days we are able to know the answer.
Host: So, how often does a patient come into you and have a choice between the different surgeries that you delineated?
Dr. Ribas: Most of the time I guess I would say. We know that a partial mastectomy with radiation, is almost equal as a total mastectomy in the sense of survival. So, if you come in with a cancer in early stages and your only treatment is going to be surgery; having either a partial mastectomy with radiation and that’s the caveat versus having a total mastectomy gives you the same survival rate. And that was decided on many years ago. So, the patient has that choice. Do you want to go through a simpler surgery in general and undergo radiation versus having your total breast removed which is sometimes very traumatic for a patient.
Host: And so you said that surgery it doesn’t happen every time that someone comes in with breast cancer. Is that correct?
Dr. Ribas: Yes. Sometimes they will need to undergo what we call neoadjuvant chemotherapy so some chemotherapy before having surgery.
Host: But even then, you would still have the surgery after the chemo?
Dr. Ribas: That’s correct.
Host: So, looking down the road and looking backward, you said surgeries have changes so much. What do you see that’s optimistic in the future in the way of the treatment of breast cancer surgery? Are there new things on the horizon that you are curious about?
Dr. Ribas: Yeah, yes. Like I said, breast cancer is one of the diseases that is being studied a lot and now there’s more curable – we are curing it more often due to the new medications and the less aggressive radiation. So, we are doing more – it used to be I think that when we heard breast cancer, we were trying to do everything to have the patient survive. You know take all the breast tissue, take all the axillary tissue and now it’s more let’s have them go through this treatment and feel good about themselves later. So, a lot of the things we are doing, it’s involving less scarring, less surgery and more targeted medications. So, one of the new things we’re excited about here that’s coming soon to the central coast is a new radiofrequency clip.
Most of these cancers are not really palpable. We are finding them a lot earlier due to mammography and routine screening. And they are not really palpable, so we tend to put a wire to go in and take the tumor. And now they are coming up with new things where they have this radiofrequency clip and we’re trying to hide the scar and so even though they have to have surgery for a cancer, then they won’t have this reminder that they went through this.
Host: That’s really exciting. Well thank you very much for talking to us. Dr. Michelle Ribas is the Chief of Surgery at Twin Cities Community Hospital in Templeton, California. If you’d like a referral to a physician or another board-certified provider, call the Sierra Vista Regional Medical Center and Twin Cities Community Hospital’s referral line at 866-966-3680. I’m Alyne Ellis. Thanks for checking out this episode of Healthy Conversations, the podcast from Sierra Vista Regional Medical Center and Twin Cities Community Hospital. We’ll see you next time.
Alyne Ellis (Host): Breast cancer. These two words strike fear in so many hearts and suddenly you are thrown into talking with a specialist about your surgical options and putting the date on your calendar. I’m Alyne Ellis. This is Healthy Conversations, a podcast from Sierra Vista Regional Medical Center and Twin Cities Community Hospital. Let’s talk with Dr. Michell Ribas, Chief of Surgery at Twin Cities Community Hospital in Templeton, California. Dr. Ribas, when you sit down with your patient to discuss what kind of breast cancer surgery options are available and best for them; what medical factors do you consider?
Michelle Ribas, MD (Guest): The first thing I do is review the patient’s chart and find out like what type of cancer they have. So, there’s two main types of breast cancer. One is in the ducts. So, the ducts that carry the milk to the nipple and if that’s the most common breast cancer. The second type is the lobular cancer that arises from the glands that make the milk. So, after explaining to the patient which kind they have; the second part is what have we found on the imaging biopsy. So, the size of the tumor and the grade of the tumor.
The third thing that we always review is the hormone status of the tumor. So, we want to know if the are estrogen positive, progesterone positive and the HER-2 protein. And those are three – the hormones and the protein that we want to know in order to treat. Because depending if they are positive or negative, the treatment might change. After that, we go ahead and do a physical exam, see how the breast, if there is any changes including the axilla and then we can talk about the different treatments.
Host: So, I know there are a lot of different choices, relatively speaking, of breast cancer surgeries. Why don’t we go in a little bit to what those choices might be. I know there are two different types pretty much; a lumpectomy and a mastectomy, is that correct?
Dr. Ribas: That’s correct. So, the lumpectomy is what we call a partial mastectomy, so it involves removing the tumor and a healthy tissue around it. that’s the most common surgery we do now a days, but it depends on the size of the tumor and the size of the breast. The second option is a mastectomy where the whole breast tissue is removed.
Host: And with a mastectomy, there are quite a few choices within that category everything from sparing the nipple to doing something more radical.
Dr. Ribas: That’s correct. So, through the history of breast cancer, the surgical treatments have changed a lot. It used to be where we went in and took all the breast tissue including the skin, the nipple, the muscles and now we try to do the least amount of excision to the breast. So, the sparing the nipple is very significant for the patient because nipple is part of how we visualize the breast. So, it tends to have better psychological outcomes. And we now can make smaller incisions to get all that breast tissue.
Host: And if you were to go on and have to do more such as taking the nipple and the areola, does that mean that after the patient has recovered, you can have that tattooed on or something, I know it’s not – it doesn’t necessarily feel the same, but at least it’s something that psychologically may help.
Dr. Ribas: Yes, that’s correct. So, now we also try to do surgery and at the same time do a reconstruction and there are different types of reconstruction. But the goal is to try to have the patient wake up and not have just any breast and like you said, usually with reconstructions, it might be multiple surgeries and one of the final stages of that reconstruction is tattooing the nipple.
Host: So, when we move on to say the total mastectomy which has more to do with taking the skin and the breast tissue; what are you seeing in the patient that means that you recommend that?
Dr. Ribas: One if the tumor has extended to the skin, the recommendation is to remove all that area including the skin and the nipple. Second, would be if they already had a previous radiated breast and we know they couldn’t have more radiation and they had another cancer. Another case where we might recommend that is with a very large tumor and smaller breasts where we think we won’t be able to get all of it. But sometimes when you have that, you could end up on chemotherapy before to shrink the tumor.
Host: And then finally, when you take the whole breast, and that includes the lymph nodes under the arm; I gather there are some tests that you would run to see if it has spread. I am wondering if you could tell us about that?
Dr. Ribas: Yeah, so, the first place where breast cancer can spread is usually the lymph nodes under the axilla. With any type of invasive cancer, meaning it has already come out from itself and started moving out of the cells; we want to sample that lymph node. So, even if we would do a partial mastectomy such as removing the tumor; we want to take at least one lymph node to make sure it hasn’t gone that way. Again, breast surgery has changed a lot. We used to take all the lymph nodes and now we know that the medical treatments we have including chemotherapy and the radiation are so effective that we just try to take the least amount that are positive. And the way we do that is usually injecting the breast with a nuclear dye and during surgery going with a special probe to look for the nodes that take up that nuclear dye. That way we just get the one node called the sentinel node that has the most uptake.
Host: And is that run while the patient is on the operating table? Is that node run through a lab to find out if you’ve gotten everything or if it’s positive?
Dr. Ribas: So, the lymph node usually what you are asking is called a frozen section where they go straight to pathology and they take a look. We tend not to do that because the lymph node gets cut in about one millimeter specimens and it would take too long to run a whole lymph node. They will do a sample really quick and make sure, but again, nowadays, since we don’t tend to take all the lymph nodes together, we just send it for a final verification and we usually within three days we are able to know the answer.
Host: So, how often does a patient come into you and have a choice between the different surgeries that you delineated?
Dr. Ribas: Most of the time I guess I would say. We know that a partial mastectomy with radiation, is almost equal as a total mastectomy in the sense of survival. So, if you come in with a cancer in early stages and your only treatment is going to be surgery; having either a partial mastectomy with radiation and that’s the caveat versus having a total mastectomy gives you the same survival rate. And that was decided on many years ago. So, the patient has that choice. Do you want to go through a simpler surgery in general and undergo radiation versus having your total breast removed which is sometimes very traumatic for a patient.
Host: And so you said that surgery it doesn’t happen every time that someone comes in with breast cancer. Is that correct?
Dr. Ribas: Yes. Sometimes they will need to undergo what we call neoadjuvant chemotherapy so some chemotherapy before having surgery.
Host: But even then, you would still have the surgery after the chemo?
Dr. Ribas: That’s correct.
Host: So, looking down the road and looking backward, you said surgeries have changes so much. What do you see that’s optimistic in the future in the way of the treatment of breast cancer surgery? Are there new things on the horizon that you are curious about?
Dr. Ribas: Yeah, yes. Like I said, breast cancer is one of the diseases that is being studied a lot and now there’s more curable – we are curing it more often due to the new medications and the less aggressive radiation. So, we are doing more – it used to be I think that when we heard breast cancer, we were trying to do everything to have the patient survive. You know take all the breast tissue, take all the axillary tissue and now it’s more let’s have them go through this treatment and feel good about themselves later. So, a lot of the things we are doing, it’s involving less scarring, less surgery and more targeted medications. So, one of the new things we’re excited about here that’s coming soon to the central coast is a new radiofrequency clip.
Most of these cancers are not really palpable. We are finding them a lot earlier due to mammography and routine screening. And they are not really palpable, so we tend to put a wire to go in and take the tumor. And now they are coming up with new things where they have this radiofrequency clip and we’re trying to hide the scar and so even though they have to have surgery for a cancer, then they won’t have this reminder that they went through this.
Host: That’s really exciting. Well thank you very much for talking to us. Dr. Michelle Ribas is the Chief of Surgery at Twin Cities Community Hospital in Templeton, California. If you’d like a referral to a physician or another board-certified provider, call the Sierra Vista Regional Medical Center and Twin Cities Community Hospital’s referral line at 866-966-3680. I’m Alyne Ellis. Thanks for checking out this episode of Healthy Conversations, the podcast from Sierra Vista Regional Medical Center and Twin Cities Community Hospital. We’ll see you next time.