Transcription:
Breast Cancer - Lumpectomy vs. Mastectomy

Amanda Wilde (Host): Welcome to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical system. We put knowledge and care within reach. So you have everything you need to live your life to the fullest.

This podcast is sponsored by UM Capital Region health. I'm Amanda Wilde. Today, we're talking about breast cancer treatment with Dr. Katerina Tsiapali, happily breast surgeon at UM Capital Region Health. Dr. Tsiapali, good to talk with you.

Dr Katerina Tsiapali: Good morning. Thank you.

Amanda Wilde (Host): I imagine treatment of breast cancer varies a lot according to the pathology of the tumor and also the stage of the breast cancer. What are those different stages of breast cancer?

Dr Katerina Tsiapali: So breast cancer, stages go from zero to IV. For stage zero, we classify DCIS, which is ductal carcinoma in situ. It's a very early form of breast cancer that is contained within the breast and doesn't have the ability to spread. So that's why it is a stage zero. And then stages I and II are considered early stages. Stage III is more advanced, but still contained within the breast and lymph nodes around the breast. And then stage IV is when the breast cancer has spread outside of the breast and lymph nodes to other organs away, such as the liver, the lungs, or the brain or the bones.

Amanda Wilde (Host): So the stages of breast cancer are dependent on how much spread, from no spread to spread outside of the breast?

Dr Katerina Tsiapali: Correct.

Amanda Wilde (Host): At which of these stages would someone undergo a lumpectomy or a mastectomy procedure?

Dr Katerina Tsiapali: So for some advanced cancers, especially those that involve the skin of the breast, we may not have other options other than mastectomy. For early stage breast cancer, so stages zero, I and II, both lumpectomy and mastectomy are good options, equally effective. And then it depends on the size of the tumor, compared to the breast size and whether the patient can receive radiation. For lumpectomy to be equally effective as the mastectomy, it has to be combined with radiation after surgery. And there are certain patients who cannot receive radiation mostly because they have had it before in that area or they have certain medical conditions where radiation, comes with increased complications and it's not a good option for them. For those patients, mastectomy is best, but for everybody else, both the lumpectomy and a mastectomy are good options.

Amanda Wilde (Host): And sometimes do you do radiation first to shrink a tumor before doing the surgery?

Dr Katerina Tsiapali: That is extremely rarely done. Usually, if we need to shrink the tumor, we use medication, most frequently chemotherapy, to shrink the tumor and give the patient the option of breast conservation to preserve the breast and just have the cancerous lump removed.

Amanda Wilde (Host): I want to talk a little bit about the pros and cons of each procedure. Sounds like mastectomy is the safest because it gets rid of all the potentially cancerous breast tissue. But then what happens after the mastectomy? What are the options for closures, either no rebuilding of the breast or rebuilding of the breast? What happens after the surgery?

Dr Katerina Tsiapali: I would say that both options are good if it can be done. If a lumpectomy can be done, it's a very good option as well. So I would say my personal bias is to prefer a lumpectomy because it's smaller surgery. So the patient can recover faster from it. And also, it allows the patient to keep their breasts. The natural breast has sensation; whereas the reconstructed breast is numb, there's no sensation to it and that definitely creates some difficulties for the patient. And I think it's hard to imitate nature sometimes and make something that is equally pretty and matches the other side.

That being said, for patients who need a mastectomy, there's definitely a lot of options for reconstruction if they wish to go that way. Using implants and also their own tissue that is transferred, usually either from the belly or the back, and that tissue is used to recreate the breast. A lot of women choose to go flat, as we say, after a mastectomy, not have any reconstruction, and that is totally a personal preference. The mastectomy, especially if it's combined with reconstruction, tends to be a larger surgery, and that may need a few more weeks to recover as opposed to one to two weeks with the lumpectomy.

Amanda Wilde (Host): So the pros of the lumpectomy are less surgery, less invasiveness, a quicker recovery and breast conservation. Are there any cons to the lumpectomy?

Dr Katerina Tsiapali: Not really from a cancer standpoint. As long as we are able to get around the tumor and remove the whole thing and then add the radiation, the results are equally good to having a mastectomy. I know sometimes that seems a little counter-intuitive. A lot of patients think that, "Oh, if I remove the whole breast, then the risk of the cancer coming back is less." But that has not been proven. We've been tracking these results for decades, and we know that the lumpectomy plus the radiation has an equally good chance of the cancer not coming back when compared to the mastectomy.

Amanda Wilde (Host): So circumstances under which you would get a mastectomy are if the cancer has invaded further. And what about genetic predilections?

Dr Katerina Tsiapali: Yeah, absolutely. Those are very good points. So usually we choose a mastectomy if the tumor is very large and we have no way to shrink it; if the tumor is in multiple areas of the breast that are all connected, so again, if it's a very large area that we can not clear otherwise. And then for certain patients, like you said, that carry a genetic mutation, that makes them very susceptible to having more cancers develop in the future, there is an advantage to removing both breasts, as a prophylactic, as a preventative method as well.

Amanda Wilde (Host): So if you have a genetic disposition, then you know you're more likely to have a recurrence, but it sounds like with other patients, lumpectomy can be enough when there's no genetic factor.

Dr Katerina Tsiapali: Correct. I would say that with the genetic predisposition, there is a bigger risk of getting cancer again. The recurrence depends on the type of the tumor that is already there and the type of treatment that the patient will receive. It doesn't get affected by genetics.

Amanda Wilde (Host): Oh, we're talking about recurrence versus a new cancer. So people who are genetically disposed might get a new cancer also. We're talking about surgery, is lumpectomy or mastectomy the only option for breast cancer treatment?

Dr Katerina Tsiapali: So breast cancer treatment usually involves a lot of different types of treatments surgery with either the lumpectomy or the mastectomy is one of them. But in most cases, it is not enough. Usually, we combine it with, like I said, radiation for the lumpectomy and sometimes for mastectomy, if we're dealing with a very large and extensive tumor that has gone to multiple lymph nodes. And we also use medication either in the form of chemotherapy or in a pill form, or a hormonal treatment that also serves the purpose to prevent the cancer from growing outside of the breast and showing up in other parts of the body. So all of those treatment modalities are very important in treating breast cancer. So surgery is just one of them.

Amanda Wilde (Host): And are there other alternatives for surgery or is surgery really always included in the treatment plan?

Dr Katerina Tsiapali: So most patients surgery is going to be a necessary part of the plan. We are currently looking at patients who have stage zero disease so only DCIS with some favorable features, to see if there's any subset of patients that can avoid surgery. But that is currently undergoing research. So we will not have the results from that trial for several more years.

So at this point, surgery is part of the treatment for the majority of breast cancer patients. Sometimes with stage IV disease when it has spread outside of the breast, the benefit from surgery is not very well documented. So for those patients, we examine each case individually and make a decision whether surgery will be of benefit or not.

Amanda Wilde (Host): It sounds like you have lots of tools to deal with the different stages and grades of breast cancer. Have you seen many changes as other medical fields have in the technology surrounding surgery and breast cancer in the past decade or so?

Dr Katerina Tsiapali: Absolutely. I think as breast surgeons, we're constantly evolving our techniques and, trying to deescalate surgical treatment. That means trying to do lesser, smaller surgery, if we can and avoid the large mutilating, big surgeries of the past. So this day and age, it's very rare that we do any very radical treatments in the breast and lymph nodes, because we have a lot of other good treatment options to shrink the cancer so that we don't have to do extensive surgeries.

We have also developed certain techniques that are called oncoplastic breast surgery. And it is a combination of the oncologic surgery, which aims to remove the cancer with certain plastic surgery techniques. So the goal of these types of surgeries. It's to make more women eligible for breast conservation. So we can apply these for larger cancers and then reshape the breast using the plastic surgery techniques so that we have better cosmetic results. Sometimes we have patients who have large breasts that are very heavy and difficult deal with, and we use the breast cancer surgery as an opportunity to decrease the size of the breast, give them a breast reduction so that they end up with a better result, but it is also better for their back and other issues that can be caused by the weight of the breast.

Amanda Wilde (Host): So you really solve a different issue there. What other factors should patients take into consideration when they're figuring out their treatment plan?

Dr Katerina Tsiapali: Definitely have a thorough discussion with their doctors and surgeons about the options. What is the risk for recurrence with or without a mastectomy or a lumpectomy. And, also what is their personal preferrence? For some women, for instance, really do not want to have a foreign body in their bodies, do not want any reconstruction, do not want any implants, wants to avoid big surgeries, and then lumpectomy is the better option for them.

Amanda Wilde (Host): Are there any other takeaways you would like to share with our audience?

Dr Katerina Tsiapali: I think I would advise the audience, when they are in the situation where they need breast surgery, first of all, pick their surgeon carefully, and make sure they pick somebody that has expertise and experience. And also to go into the conversation of which type of breast surgery is right for them with an open mind. I have some patients that come in and say, "I want to do this," or "I want to do that." I would say keep an open mind, listen to the options, listen to the pros and cons and make a better decision.

Amanda Wilde (Host): Dr. Tsiapali, thank you for helping us understand the treatment options and considerations around breast cancer.

This episode is sponsored by UM Capital Region Health, the largest healthcare provider in Prince George's County, dedicated to enhancing the health and wellness of the community by providing high quality accessible patient care. UM Capital Region Health, changing up healthcare in Prince George's County. Find more shows just like this one at umms.org/podcast. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again. I'm Amanda Wilde. Stay well.