Scott Webb (Host): A diagnosis of breast cancer can be devastating to patients and families. And joining me today to tell us more about breast cancer and the various diagnostic and treatment options and share some very positive news about survival rates is general surgeon Dr. Bernadette Guiroy from Salinas Valley Health.

This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to talk breast cancer surgery, but we'll lay a little foundation here for listeners before we get there. So, let's just start there. I think the most obvious one, of course, you and your expertise, what is breast cancer?

Dr. Bernadette Guiroy: So, thanks for having me. And the definition of breast cancer is that breast tumor cells in the breast can grow and out of control and form tumors. And these tumors can then spread outside the breast to the lymph nodes and other parts of the body. And there are two main types of breast cancers. So, one is called a ductal carcinoma, which starts in the milk ducts, and the other one is a lobular carcinoma, which starts in the glands producing the milk.

Host: Okay. Yeah, and that's a good baseline there to just get us started in this conversation and makes me wonder, between females and males, is breast cancer different? Does it present differently or is it more or less the same?

Dr. Bernadette Guiroy: So, the main difference between females and males is that females have a way higher risk of developing breast cancer than males. The lifetime risk of a woman to develop breast cancer is one in eight women or 13% of all women are at risk to develop breast cancer versus in males, the risk is much less. It's one in 800 or less than 1% of breast cancers occur in males.

The presentation, however, is very similar. Now, women are more attuned with their breasts than men, and men would not necessarily expect to develop breast cancer. That also means that the breast cancer in males is often detected at a later stage, not as early as in women. That then translates into a lesser cure rate, for example.

Host: Interesting. Yeah, we're going to talk about detection in a bit, but I wanted to have you maybe kind of go through either breast cancer during pregnancy or just in the young versus the aged population. Like, give us a sense of the numbers.

Dr. Bernadette Guiroy: During pregnancy, the breast undergoes many changes with the hormone changes, with the milk production. And every so often, we see women who developed breast cancers during their pregnancy but did not bring it to the attention of their providers, because they thought, "Oh, it's just a clogged milk duct, and we'll take care of that after the pregnancy." So, they often present with a larger, more advanced stage of the breast cancer than a woman otherwise would. So, the diagnosis often gets delayed. That's the main takeaway there.

The treatment is very similar with some exceptions. The young, which is defined as women less than 40 years of age, can also have breast cancer, but the occurrence of breast cancer is much less common. For example, only 0.65% of women less than 30 years of age have breast cancer. Translating into, if you imagine there is a room full of women, there are 2,500 women of young age, only one will develop breast cancer. On the other hand, if you have women who are older than 65 years of age, one in 126 will develop breast cancer.

Host: Oh, that's a big jump. Yeah

Dr. Bernadette Guiroy: Yeah. So, the aged. As we all get older with modern medicine, there has been much discussion in the breast cancer community how to treat and evaluate these patients. Do we let go? Are we aggressive? Is there a happy medium? And it really depends on how the physiological fitness of a patient is, the current or foreseeable future quality of life, and also the life expectancy and comorbidities. Does she have any heart problems, incapacitating lung problems, or other things going on in her life? So, that would be the evaluation there.

Host: Yeah. And you gave us a sense there of frequency and some of the risk factors. Wondering too about like signs and symptoms. You mentioned that, you know, women are a bit more attuned and diligent about sort of maybe self-exams than men would be. But just in general, like, do people know that they have breast cancer?

Dr. Bernadette Guiroy: Some of the symptoms are that a patient might find a lump behind the nipple or elsewhere in the breast or nipple retraction, or the nipple is fixed to the underlying mass or a lump, skin retraction or skin dimpling. Also, asymmetry of the breast, or one breast is all of a sudden bigger than the other breast. So, those are typically signs of presentation, and they can occur in men or women at any age. So, these symptoms are very similar throughout.

Host: Yeah. And I know this is the case with all forms of cancer, that early diagnosis is key to treatment, survival. So, let's talk about detection of breast cancer, breast cancer screening, and the different options that you recommend.

Dr. Bernadette Guiroy: So obviously, a breast self-examination is very important. Twenty-five percent of breast cancers are detected by breast self-examination, and patients often don't know that. So, patients will often say, "My breast feels lumpy and I'm not quite sure what I feel." But I tell them, "You will feel a difference if it develops." Also, patients often think breast cancer is painful. That is unfortunately not the case. We all wish it would be, but only 1% of the breast cancers will present with breast pain.

So as far as diagnostic imaging is concerned, fore and utmost is the mammogram, bilateral screening mammogram. We're looking for cancers. A diagnostic mammogram is we found an abnormal area, and that is often followed by an ultrasound to confirm and do a biopsy of the abnormal area, send that to the pathologist who will give us some answers, regarding whether the tissue diagnosis is benign or malignant cancer or not. And there are other modalities, for example, MRI or a CT scan and bone scan, PET scan, there's more.

So. We typically start at age 40. That's the recommendation, but that varies. Let's say a woman found something in her breast and she's only 30 years old. So, we typically start with an ultrasound because the young breast is very dense and somewhat difficult to read if you do a mammogram, and it's easier to read with an ultrasound. And if a patient is older, when to stop, there is really no set age. As I mentioned before, the aged are more and more treated very much like the younger patient population.

Host: Give us a sense, doctor, of who's on the breast cancer team, right? I'm assuming radiologist, breast surgeon, and so on, but just give us a sense who all is working with and behind the scenes with patients and families.

Dr. Bernadette Guiroy: So, receiving a breast cancer diagnosis is often devastating to a woman, and she feels alone with this diagnosis and does often not know where to turn first. But just remember, I tell my patients, "We are here for you. We are your team, and we will help you with the evaluation, treatment, and to become cancer-free."

So, who is the team? Of course, the radiologist, we talked about that, the breast surgeon. There is a medical-oncologist. There is a radiation-oncologist. There is medical support team members, the oncology nurse navigator. There's a social worker, but there's also social support from family members and close friends.

Host: Yeah. Family and friends, for sure. All right. So, let's get into treatment, Doctor, and there are lots of things to cover here. Well, let's just start maybe with the most obvious one, that may be the gold standard. I'm not sure, but you're the expert. Let's talk surgery.

Dr. Bernadette Guiroy: Nowadays, because the breast cancer screening on a regular basis, on a yearly basis, has often led to very early detection of breast cancer. And we have found if we take that breast cancer out with a rim of healthy tissue surrounding it, and that is called a lumpectomy or partial mastectomy, which also includes postoperative radiation, has the same long-term outcome as a total mastectomy, which we did many, many years ago. So, patients do not necessarily lose their breast. If that is the case, if we decide for a total mastectomy, then we work very closely with a plastic surgeon for immediate or delayed reconstruction.

And the reconstruction, it can be what we call oncoplastic reconstruction, which means tissue in the area of the breast, which is healthy, but in the neighborhood, so to say, gets moved into the defect. Or the patient might decide for an implant or a flap, which is often tissue, muscle, skin, subcutaneous tissue from another area of the body, the back as a latissimus dorsi flap, or the abdomen, a TRAM flap.

Host: Yeah. Right. So, the various surgeons working together there, decisions made obviously with the patients, perhaps families, and then possibly involving the plastic surgeon in real time or maybe delayed. And then, I want to talk to you about something I read about neoadjuvant treatment. What is that exactly, and when might patients consider that?

Dr. Bernadette Guiroy: So, neoadjuvant treatment versus adjuvant treatment means that patients undergo treatment with a medical-oncologist first. So, there could be hormone blockade. A well-known medication is tamoxifen or chemotherapy, and that is to shrink the tumor prior to the surgery to downstage the tumor. And that often allows the patient to keep her breast while we are doing a partial mastectomy or lumpectomy, and we don't have to do a total mastectomy. Also, an advantage is that often we don't need to do a complete axillary lymph node dissection where we take the lymph nodes out of the axilla, but we target only a few. It's called a sentinel lymph node dissection.

And there's a big difference because with a sentinel lymph node dissection, patients have afterwards a much lower risk at what is called a lymph edema, swelling of the arm. And the risk with a sentinel node is often 1% to 3% only over time, over a lifetime, versus with a complete axillary lymph node dissection, that risk goes up to, like, 20%, 25%. So, there's a big difference.

Host: Big difference for sure. So then, Doctor, what happens after treatment? Who do the patients work with, medical-oncologist and so on? Give us a sense of, you know, how things go after hopefully a successful surgery.

Dr. Bernadette Guiroy: So, the patient will be referred back to the medical and radiation oncologist. And the medical-oncologist will often prescribe hormone blockade, which is tamoxifen I mentioned before. Very few patients need additional treatment other than hormone blockade, maybe chemotherapy if the tumor went outside the breast to other organs or sometimes also the axilla.

And if patient underwent a lumpectomy or partial mastectomy, we'll do radiation to the remainder of the breast to prevent recurrence of the cancer in the breast. Sometimes the patients also see the occupational therapist and physical therapist. This is more for general well-being. It helps the patients to, in the end, regain control of their lives and see that they didn't lose range of motion and are just incapacitated by the surgery or the chemo or radiation afterwards.

Host: Yeah. And as we talked about earlier, there's a whole team involved. So, you gave us a sense there of who patients and families may work with after surgery, of course. And, Doctor, I know this is not necessarily your area of specialty, but maybe just give us a sense anyway some of the mental health challenges that patients go through.

Dr. Bernadette Guiroy: Yes. As I mentioned before, receiving the diagnosis is often perceived by the patients as devastating, and they respond with anxiety, depression. They have adjustment disorders. And this is where we recommend, in general, stress management, having a positive outlook, being optimistic about what's ahead of them. There's also journaling. There is self-help groups. There's survivorship support. And there is yoga. There is acupuncture. Some of that is actually paid for by the insurance companies also.

Host: I wanted to get a sense from you just breast cancer survival rates by the various stages

Dr. Bernadette Guiroy: So, we typically divide the breast cancer into early breast cancer stage and advanced breast cancer stage. There's a stage 0, I, II, III, and IV. Stage 0 is when the cancer is only in the ducts or in the lobules, the ductal carcinoma in situ or the lobular carcinoma in situ, the very early cancers. The survival is 100% excision and radiation afterwards. Stage I, survival is about 100%. In stage II, the survival is about 95%. Stage III, it dips down to 80%, and stage IV to about 30% because stage four is when the cancer has gone outside the breast, outside the axilla, and seeded other organs.

We have learned over the last maybe decade or so that we are now more and more able to keep patients going and affording them an adequate or satisfying quality of life with ongoing treatment, very much like we treat hypertension or diabetes; thus, turning the cancer not only into an acute disease, but also a chronic disease that we learn to manage ongoing.

Patients want to regain control of their lives and regain quality of life. And I think the most important thing is to be patient with yourself and to listen to your body. There will be days where you won't feel well, and your mind is not in a good state, and you feel pessimistic or depressed. But there will be other days where you will feel better. And over the course of the treatment, things will look up again and be more positive, where you will eventually be able to hopefully resume everything you did before. But give it time. Allow time to pass.

Host: Yeah, allow some time and patience and grace, and all great advice from an expert. Appreciate your time today. Thanks so much.

Dr. Bernadette Guiroy: Oh, you're welcome.

Host: And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.