Deepti Chopra, M.B.B.S. Hi, I'm Dr. Deepti Chopra, an associate professor in Psychiatry at MD Anderson Cancer Center, and today I'm joined by Dr. Puneet Singh, who is an associate professor in Breast Surgical Oncology at MD Anderson Cancer Center. And this is the Cancerwise Podcast. Thank you so much for being here today, Dr. Singh. Our topic is physical changes with breast surgery in patients with breast cancer diagnosis, and I'm so glad to have you here.  

Puneet Singh, M.D. Thank you for having me here, Dr. Chopra. I'm really glad to be able to talk about body image after breast cancer, specifically related to breast surgery. There are a lot of physical and emotional changes that can occur after treatment for breast cancer. And so, I wanted to just start off by talking about the emotional response to their breast cancer diagnosis and how that impacts not only their course of active treatment, but how they look and feel.  

Deepti Chopra, M.B.B.S. So, you know, cancer diagnosis is a life-threatening, life-altering condition, and it creates a lot of anxiety and emotional distress. And patients want to start treatment immediately, and their mind is to get that tumor out. They think surgery is the first step, but that may not always be the case, as you know. So, you know, what comes first? And then not to mention the physical changes with cancer treatment, like with chemo, changes are more gradual, whereas with surgery it's pretty rapid and most of them are permanent. So, you know, if it's surgery first they're thinking about what kind of breast surgery and what will they look like and what can be saved, what cannot be saved. And I don't know if you have patients that come in and express these worries. How do you handle that? 

Puneet Singh, M.D. Yeah. No, I certainly agree. I think it can be very challenging. It's a very vulnerable time for many of our patients. You know, they're kind of navigating this new diagnosis, what it means for them in terms of outcomes such as, you know, their survival and recurrence, but also really all of these changes that you mentioned, you know, the physical changes, the emotional changes. And so, you know, our goal in that first visit is not only to review the diagnosis, everything that we know up to that point, but also then to really kind of navigate these topics of how, for example, surgery in my clinic is going to proceed and how that will impact them in the long run. I think many studies show that quality of life, including, you know, emotional and physical well-being, are significantly impacted by breast cancer surgery and breast cancer treatments. But I certainly think there are ways for us to anticipate those and to talk to patients about those so that we can better prepare them in the long run. 

Deepti Chopra, M.B.B.S. Do you feel that emotional distress is more with a certain kind of surgery, one versus the other, or? 

Puneet Singh, M.D. You know, there's certainly physical changes that are going to be present with both mastectomy or segmental mastectomy, which is the formal term for a lumpectomy. But I do think mastectomy tends to have some more kind of permanent changes. And when I talk about physical changes, we're talking about not only, you know, a scar on the breast, but it can also impact the size, shape, appearance of the breast. You know, after a mastectomy, many women, though not all, will choose to undergo breast reconstruction of some sort. And so, certainly that's not going to be exactly like their native breast. But there's also changes related to sensation, whether they're able to keep their nipple or their areola. And even if they are able to, you know, keep their nipple, it can be different in terms of the sensation that they had from before surgery. So, these are all things that, you know, we try our best to really talk to them about. And certainly, it's not just in our surgical clinic, but also in the plastic surgery clinic that they're really discussing how that will go. And so, we talk about those more permanent types of changes. And then of course, there are the more, you know, typically temporary changes. And that can be things such as, you know, whether they're going to have drains in place or are they going to have some range of motion or limited range of motion of the shoulder or some arm stiffness, etc. And we can certainly address many of these, but it is important for us to not only try to discuss them with patients so that they're aware that we have resources for them if they encounter any of these changes after surgery. 

Deepti Chopra, M.B.B.S. That's great. That's great. And I'm glad you're going over this with the patients. You know, personally, we, I focus on the psychological side, and either of the breast surgeries can be emotionally distressing. It's hard to say, but like you said, you know, sometimes the mastectomy is a larger surgery, more recovery time. So, the adjustment is longer and maybe more distressing from that standpoint. But all in all, you know, the breast surgery makes the cancer diagnosis really real for the patient. So, that's, that I think is important for us to realize. 

Puneet Singh, M.D. Yeah. And I certainly think that, you know, while I say we do our best to anticipate these, I think that we also recognize that sometimes patients do benefit from talking to someone like yourself, Dr. Chopra, you know, and and reviewing these either in the preoperative setting before they've had the surgery, if they're not sure how they can navigate that, but also certainly afterwards. So, I think, you know, really it's important to be a team and utilize all of the resources that we have here to support our patients through this journey and this process. 

Deepti Chopra, M.B.B.S. Yeah, absolutely. I agree with you and I'm happy to see them. I actually like to see them before the surgery so that I can understand where they are and kind of prepare them, you know, because the amount of physical change that comes with surgery is so much for patients to absorb that I try to kind of prepare them in advance. Things like, you know, like you mentioned, the range of motion, let them know that you, you know, you may not be able to do certain things at home that you were normally doing. I also like to mention that, you know, with surgery the most common thing is the breast swelling and pain. Especially, like you said, if you have drains and tissue expanders, that hurts. So, going over all this with the patient really, I think prepares them as much as we can, but also kind of reminding them, like, you know, this is not permanent. With time, these changes kind of slowly die down and things will start getting better. And then the other thing I encourage patients to do is to understand where the scar will be made. So, I don't know what are your thoughts when patients ask all these questions before surgery? How do you, how do you take them? 

Puneet Singh, M.D. Yeah, I, I definitely encourage questions. You know, I think usually, I, when I'm meeting patients for the first time, there's a lot of information to certainly get through. So, we'll go over, you know, mastectomy versus lumpectomy in terms of, you know, the cancer outcomes of survival and recurrence. But then, you know, once we kind of establish that, it's really delving into not only the things that will impact them in the long term as well, like quality of life, but really addressing their questions because those are the things that are going to be most important to them based on their values and their preferences and their goals. And so, that gives me an idea of how to kind of tailor the conversation. So, I actually really appreciate when patients come in with questions. They're prepared. But certainly, you know, we're here as a resource to give patients as much information as possible so that they can feel confident in their decision and, and be informed. And so, specifically, you know, when you, we're talking about scar placement and whatnot, we talk about the typical location or placement of that scar. In other cases, you know, there are lots of different nuances to this question. And so, sometimes it's about discussing that with the plastic surgery team if the patient's going to undergo breast reconstruction. And so, we try to give them an idea of what the scars will look like and what they can do to heal them. But there are, you know, a number of other questions that I'm also asked, you know, related to sensation or can they keep their nipple or not? And, you know, regardless of whether, for example, we can save their nipple as part of the mastectomy, for example, we do offer other options for nipple reconstruction if we do have to remove it. So, you know, we try to navigate the questions that patients have and provide them information, again, so that they feel confident in their decision. It's all about being a team and making a shared decision, for sure. And you know, that reminds me, there's often, you know, a lot of googling that's done in anticipation of their visits. And so, how do you kind of advise patients on, you know, googling their care and treatment for breast cancer? 

Deepti Chopra, M.B.B.S. Yeah, that's absolutely a very important question now. In this world of information overload, there's so much stuff out there that it can be overwhelming and sometimes misleading for patients. So, I try to explain that to them that, you know, take the information with a grain of salt. And if you have any concerns or questions, try and go back to your treatment team, because your team has your information and all your medical needs that need to be addressed. So, they would be in the best position to guide you with all your questions. 

Puneet Singh, M.D. Once a patient undergoes breast surgery, what are coping strategies that you recommend? 

Deepti Chopra, M.B.B.S. Immediately after surgery, you know, patients have to see themselves in the mirror, and there's only one first time to see yourself in the mirror. And it's important to, you know, prepare for that. So, that's what I go over with the patients, especially in the pre-op visit. One simple thing that every patient can do is start with a small mirror, then move to a mid-sized mirror and then a full-length mirror. There are also other strategies that we use to kind of go through the exercise and I go over that with them in detail, because whatever works best for that patient. We have this as a tip sheet on our MD Anderson Patient Education form, if you ever want to look at it, but it's definitely available for our patients. 

Puneet Singh, M.D. That's great. And I think those are really, really helpful strategies. It's certainly something that my patients bring up to me. And, you know, I think it's great to have a resource, as you mentioned, but also being able to refer as appropriate to you. So, thank you for that. I guess I wanted to talk a little bit more also about, you know, how you think after surgery that impacts their body image, you know, in more in detail. 

Deepti Chopra, M.B.B.S. Yeah, absolutely. So, when it comes to breast surgery and breast cancer treatment, you know, depending on where women are in their lives, you know, loss of breast would mean different things for different women. Sometimes it's feeling less whole, feeling less feminine, or sometimes it's, you know, their ability to maintain or start romantic relationships. And sometimes it's a combination of both of these. So, you know, it's totally very dependent on where women are in their lives and how they perceive the loss of their breast. As a result, people become more self-conscious when they go out in social gatherings, especially. They may switch over to wearing more loose clothes, and then sometimes they feel sad about their inability to breastfeed. The other aspect is that there is a phase that some women, you know, mourn the loss of their breast, and it's okay for a little amount of time. The other thing with breast surgery to keep in mind is the lymphedema, which is the arm swelling. It's something that's visible that has to be taken care of, you know, to limit their choice of clothing. It may also interfere with their daily activity with someone who types a lot or drives a lot. So, you know, the arm may be heavy, the perception changes may be there, and they may not be able to do it as they were before the surgery, and which leads to sadness and decreased quality of life. So, these are the changes that I think of in terms of breast surgery. Now, we all know breast cancer treatment is sometimes more than breast surgery. There is chemotherapy, radiation therapy, hormone therapy, and each one of those has physical changes themselves. So, like with hair loss, skin changes, nerve pain, fatigue, and then general body weight gain,  that's something that many women with breast cancer struggle with. 

Puneet Singh, M.D. And, you bring up really good points. I think there's a number of potential impacts. And, you know, it's really, really been helpful to see not only what our patients tell us, but also, you know, what studies show in terms of, you know, what we call patient reported outcomes: how they feel after they've had not only breast surgery but after various treatments. And I think that can, again, help us tailor our conversations with patients, but also what resources to provide them not only preoperatively, but really postoperatively, as you're mentioning. Whether it's, you know, the first couple of months after surgery or the few years after surgery. And I think, you know, of course, we've often focused in breast surgery on reconstructive techniques, and we have a number of them that we can offer for reconstruction after mastectomy or what we refer to as oncoplastic reconstruction. That's reconstructive techniques after a lumpectomy. So, there's different ways that we can try to address the potential questions or things that our patients want in terms of trying to restore them in some way that seems more normal. And so, these are things that we, we try to discuss with our plastic surgeons, but also, as you mentioned, lymphedema. And we have ways of kind of addressing that at the time of surgery or even, you know, long term for chronic lymphedema. And I think there's other, you know, aspects of this, such as, you know, as treatments have gotten better for breast cancer, sometimes that means longer durations of treatment. And what that can mean is sometimes more delayed time to getting to final reconstruction. And so, recently, you know, myself, along with several of our colleagues in Breast Radiation Oncology and Plastic Surgery, you know, published a study called the SAPPHIRE study. And this looked at actually doing radiation before surgery. And so, then patients were able to get mastectomy and immediate reconstruction, tissue-based reconstruction. And one of the key points from the study is that not only was it safe and feasible to do that reconstruction at the time of mastectomy, but it really overall shortened the time from, you know, when they were diagnosed to kind of that final reconstructive step. So, I think that, you know, we're studying this further and and, you know, hopefully there will be other ways to address, you know, body image and the impact that surgery can have on the patient. I was wondering what your thoughts are on these kind of patients who may have more delayed reconstruction, how to how to navigate those body image issues? 

Deepti Chopra, M.B.B.S. Yeah, you're right, because they have a longer time to get used to those physical changes and may, may need more adjustment. So, I certainly help them out by understanding what their mindset is. How can they, you know, rebuild that connection with their new body? And it's a process. It takes time, but at least it makes patients move more towards acceptance of the new body. And so, that's something that I definitely think will be valuable to all these patients if you can, you know, decrease the time of delayed breast reconstruction for them. 

Puneet Singh, M.D. So, we, you know, were talking about, you know, delayed reconstruction. And I was curious if there are any, you know, new strategies or other kind of resources that you are exploring or can offer patients?

 Deepti Chopra, M.B.B.S. Absolutely. So, the area that is definitely not that studied well is the undergarment option for patients who've undergone mastectomy. And we're looking at having customized undergarments for patients. This is an idea that I'm exploring with Plastic Surgery, and we hope we can study it soon. So, I'm excited about that and hopefully we'll have, you know, much more options for our patients down the road. 

Puneet Singh, M.D. Yeah, that would be great. 

Deepti Chopra, M.B.B.S. Thank you so much for the enlightening conversation today, Dr. Singh. 

Puneet Singh, M.D. This was wonderful, Dr. Chopra. 

Deepti Chopra, M.B.B.S. Thank you for tuning in today. If you enjoyed this episode, be sure to follow or subscribe on Apple Podcasts, Spotify, YouTube, or wherever you get your podcasts. And don't forget to comment or review. For more information or to request an appointment at MD Anderson, call 1-877-632-6789 or visit MD Anderson.org. Thanks for listening to the Cancerwise Podcast from MD Anderson Cancer Center.