Darrell Rebouche (Host): When you hear the words breast cancer, a lot of questions can come to mind. What are the risks? When should you get a mammogram? What happens if something shows up on that mammogram? And if you're diagnosed with breast cancer, what happens next?

In fact, chances are you know someone who has been touched by breast cancer. A mom, a sister, a friend. There's a lot of information out there, and sometimes it can be difficult to know what applies to you and what doesn't, and that's what we're talking about today on Health on Point, presented by Willis-Knighton Health. Beyond the Diagnosis: Breast Cancer Detection, Treatment, and Team-Based Care.

Hello, everyone. I'm Darrell Rebouche, and our guests for this episode are Dr. Julie Cupp, a breast surgeon at Willis-Knighton Health, and a hematologist oncologist, Prakash Peddi at the Willis-Knighton Cancer Center. Doctors, thank you for being here. Let's start with you, Dr. Peddi. It feels like breast cancer is the most prevalent, prominent, common breast cancer we hear about with the possible exception of skin cancer. Is that accurate?

Prakash Peddi, MD: It is accurate. It's one of the commonest cancers in women. But also, you have to remember that this is also one of the most easily treatable and curable cancers there is

Host: Dr. Cupp, you are one of the people who treats them. I know we're going to get into surgical versus non-surgical, how those decisions are made. But you obviously as a breast surgery specialist, primarily looking at breast cancer, I mean, what are the options that people are typically faced with when they've been given a breast cancer diagnosis?

Julie A. Cupp, MD: The biggest thing that affects their decision-making as far as what surgery needs to happen is how big is the tumor that we're dealing with. Something small can easily be managed with breast conservation, whereas larger tumors are going to need mastectomies. But it gets a little bit more complex because people who have larger tumors, sometimes we can use neoadjuvant therapy. So, we give them medicine before we do the surgery and shrink it to the point where somebody who would've needed a mastectomy can now undergo breast conservation.

Darrell Rebouche (Host): Detection is the key, being diligent. Let's talk about what people can do at home. Breast self-exams. Let's start with you, Dr. Cupp.

There's a lot of confusion out there about self-exams, because there's been a change in the nomenclature, if you will. They stopped saying you need to do breast exams, and they started calling it self-awareness. And I think it's a pretty fair thing to say self-awareness. Because with the word exam, you feel like, "I'm supposed to know what I'm feeling. And if I don't know what it is, I'm failing."

And so, really and truly, it's about getting to know your breast and how they feel normally or how they look normally by feeling, by looking at them in the mirror the same way that you get to know your face. And you just want to check them approximately once a month. If you have menstrual cycles, doing it after your menstrual cycle because things tend to be less tender, less lumpy, bumpy feeling, and so you have a better baseline in which, you know, is your normal.

But if you notice something changing from that normal, that's when you want to meet with your doctor and discuss, "Is this a normal change or is this something that needs more of a workup?"

Host: Dr. Peddi, at what point typically in this self-awareness journey do people come to you? Do they have already—they got something that's suspicious, they have something they already know or worry about? When do people see you and your colleagues?

Prakash Peddi, MD: Most of the times, when patients feel lumps or bumps, the only people who call me or need to be seen by me are my patients who already have been diagnosed with breast cancer and who I've already treated them. But I think the first person to know this should be their primary care doctor or doctors like Dr. Cupp, where they have to get into the breast cancer clinic and get it further evaluated.

Host: Okay. So, you're down the road a little bit. And so Dr. Cupp, mammograms, mammograms, mammograms. That may be next. I mean, I don't think you can preach the gospel of mammograms more consistently. So, tell us, I think some people are afraid of it. People are afraid of the procedure. People may be afraid of being touched. Mammograms are so important, and accessibility continues to grow and become easier and easier.

Julie A. Cupp, MD: Yeah. So, mammograms are our gold standard to make sure we're detecting breast cancers early. We've been doing these forever it seems like, you know? And as early as, like, the 1970s, we were starting to get really good at screening with mammography. And we've come a long way from what used to be just literally an X-ray of the breast to being able to go through the breast tissue almost like you would do for a CT scan with our mammograms, and that's what we call tomosynthesis.

Yes, there is compression that happens with it, and yes, there is radiation exposure. The compression though, it's uncomfortable, yes, it can pinch, it can even hurt, especially if you already have breast pain. So, one of the ways to combat that is taking some Tylenol and ibuprofen about 30 minutes before you have your mammogram to try to decrease the amount of inflammation that's in the breast already, and so kind of stop the pain before it even starts. And then, if you're in the mammogram and the pinch is too much, you can tell the tech, "Hey, back off a little bit," and they're going to.

But then as far as the radiation's concerned, there is more radiation exposure getting on a trans-United States flight than what you're going to get in a mammogram. So, the radiation exposure is actually very minimal, and there are criteria for screening tests to be able to say, you know, "Is this something that we can safely do as a screening mechanism, or is there too much radiation exposure?" And radiation exposure in a mammogram is so minimal that it definitely is well underneath that threshold and is likely less than what you're experiencing just in the environment on a day-to-day basis.

Host: You don't have to have symptoms to want to seek a mammogram, right? That's something that you just should do routinely. And if you do that, what can someone like you or some of your colleagues detect before a patient is symptomatic?

Julie A. Cupp, MD: So before a tumor gets to the point where we could feel it on our self-awareness checks is about the size of a quarter, so over two centimeters in size. With a mammogram, we can catch masses down to around 3 to 4 millimeters in size in comparison. So, we're getting much, much earlier breast cancers.

Then, we can also catch earlier signs such as distortions or microcalcifications that start showing earlier signs of breast cancers. Even with the microcalcifications, you start seeing that those are most likely going to be associated with the non-spreading kind of breast cancer called ductal carcinoma in situ, which is our stage 0 breast cancers, which have 100% survival. So if we can find breast cancer at stage 0, we're doing great, because that's the best we can do.

Host: One hundred percent survival. That sounds fantastic. Dr. Peddi, let's talk about people who tend to be at risk for breast cancer. Can you characterize the people who are at greater risk than average?

Prakash Peddi, MD: The most important thing is age. Post-menopausal women, the 50 to 60 bracket, continuing age is always going to be a risk factor. But some women are born into families where there is a mother or grandmother, aunt, uncle, always with some kind of breast cancer. So, genetics are important along with family history. People sometimes make a mistake that genetics are equal to family history. We find sometimes that there is a big prevalence of cancer in some families without proper genetically positive mutation seen in these families. So, genetics and family is one.

And other risk factors are obviously environmental based. Some things that which you can control, some things that we can't. Altitudes, vitamin D exposures, chemical exposures, food exposures are all some things some people can control it, and sometimes it is beyond their control.

Host: What about behaviors, lifestyle choices?

Prakash Peddi, MD: I think the biggest things were alcohol and the smoking, and we were struggling to actually make a linkage between alcohol and smoking for a while. But now, the data is very clear, saying some exposure to alcohol at certain moderate amounts can put you at a risk of breast cancer.

Smoking does put you at in risk of breast cancer. High obesity rates, more overweight, obesity rates, lack of exercise can put you at risk. So yeah, definitely, there are a lot of things that we also do, as a part of day-to-day routine, which can put us at risk of breast cancer.

Host: There are variances in how the things go, but as Dr. Peddi explained to us, generally you will see him if you have to, after you see somebody like Dr. Cupp or your primary care provider. So, let's go back to Dr. Cupp for a few minutes. Dr. Cupp, we've got them in the door. They're going to have their mammogram. And then, oh my goodness, we see something that's suspicious, something that's worrisome. can you walk the patient through kind of the average process? What happens next?

Julie A. Cupp, MD: So if this starts with a screening mammogram and it comes back as, "Hey, we see something, we need to do more imaging." Twenty percent of all screening mammograms are going to get called back to get additional pictures taken to see if what we were seeing is even real or not. it could be simply a wrinkle in the breast tissue. It could be a cyst that is completely normal and nothing to be concerned about. It could be deodorant that got left on the skin that we're seeing, and we just needed to wipe it off a little bit better, and everything is completely fine, and there are no problems.

And so, like I said, 20% of all screening mammograms are going to get called back for those kind of things. So if this is a screening mammogram and you get called back, don't jump to, "Oh my gosh, I have breast cancer. And this is going to be bad." Because of the 20% that get called back, only 20% are going to even need a biopsy. So, the vast majority of people who get called back are completely ruled out just with that recall imaging.

If they need a biopsy, only five patients will turn out to have cancer. So, the vast majority are going to get biopsies for things that turn out to not be cancer, and they can be any kind of normal fibrocystic changes that happen because women have breasts and these things are in there, all the way up to abnormal cells but not cancer. And then, like I said, about five of those people, will end up with having a breast cancer diagnosis.

Host: People who have been around cancer patients or people who have been cancer patients know that B word you said is scary, biopsy.

Julie A. Cupp, MD: Very scary.

Host: All right. So is it fair to say that when you hear the word biopsy, that doctor thinks I might have cancer? And the second part of that question: is the process, the procedure itself scary or painful?

Julie A. Cupp, MD: So from the standpoint of if we're recommending a biopsy, there's around at least a 20% risk that there could be a cancer. Now, that's an average. It's anything that we think has greater than a 2% risk all the way up to we're pretty much certain it is kind of cancer. And when the radiologist and people like myself talk to each other, we use a classification system to say what is the level of concern that we have for this turning out to be a cancer, and that's the BI-RADS system.

So if it's a BI-RADS 4A, that means the risk is like 15% or less; whereas if it's a BI-RADS 5, it's a 95% likelihood it's breast cancer. So depending on what the classification that's indicated for it is the level of risk that it's going to actually be something bad. So, the majority of the things we're biopsying though, fortunately, are in the BI-RADS 4 region. So, the risk is on the lower end and still a pretty good likelihood that we're not going to end up with a cancer.

The biopsy itself is what we call a core needle biopsy, in which case, we numb up the skin and the tissues inside the area of the breast that we're worried about the lesion. We make a small nick in the skin to allow for a thicker needle to go in. And then, we core out a piece of tissue through the center of the mass or the calcifications or the distortion or whatever it is that we're worried about to get samples of it.

And we take multiple samples in that area. And then, we put a small little titanium clip in there to say, "We did a biopsy here." So that way, in the future, the radiologists don't keep biopsying the same spot over and over again. Now, these clips are so tiny that women have more metal in their ear for an earring than they do in their breast. So, it's not something that's going to cause any kind of problems or anything like that.

And so, after that clip is in, they remove the needle and the procedure's done. So, it takes about five minutes to get everything done, once everything is positioned and set up the way it's supposed to. Now, the entire procedure can take longer depending if we're using guidance with an ultrasound versus a mammogram versus an MRI. So, the setup can take a while, but the actual procedure itself is pretty quick once we get everything lined up and where we need to be. If you have a really great physician who's doing your biopsy and is very generous with the numbing medicine, then the discomfort is really just getting that initial shot for the numbing. And after that, it's really not that bad.

And you can always, again, advocate for yourself. And if you're feeling things that don't feel good, you can ask for more numbing medicine to try to make sure it's as pleasant a procedure that you can possibly have.

Host: Well, I'm not a doctor, just a podcast host in this context, but here's what I'm hearing: a 20% chance that it might be cancer tells me there's an 80% chance it's not, and that's one one way frame it. So yeah, you got to go with it. So, we talk about Dr. Peddi, all the people who the patients see before they see you, and Dr. Cupp has alluded to a few of those. And I think that goes to a broader issue, which is a very good thing, that at Willis-Knighton, the system is so well-integrated that there's a huge team of people, including yourself and people around you and people who come before you, who help patients identify what their issue is, treat it, and deal with it. So, can you talk about kind of the team-based concept that comes into play?

Prakash Peddi, MD: I think, it starts off with the mammogram staff down with our radiology staff, mammographers, then Dr. Cupp, surgical oncologist. And then, I get those patients. The great thing about our team right now is that we tend to have a tight team doing breast conferences all every other week, which includes radiation oncology, radiologists, breast surgeons, and, pathologists, and us as medical oncologists. We come up with this consensus. And most of the patients have very clearly laid out plans so that there is no need for any confusion with these patients. And it is very organized, very ssystematic. I think the wonderful thing about our group right now is that, even with the most complex cases, we tend to have multiple opinions of multiple people, which actually helps us to actually cater to the best of the need for these patients right now.

Host: This is Health on Point, presented by Willis-Knighton Health. Our guests are Dr. Prakash Peddi from Willis-Knighton Cancer Center and Dr. Julie Cupp, a breast surgeon at Willis-Knighton Health. Dr. Cupp, people hear the term stage a lot when they talk about any kind of cancer, and you stage breast cancer, too.

Can you tell us what the stages are and what they mean?

Julie A. Cupp, MD: So, stage is based on how big is the tumor? Has it gone to what we call the regional lymph nodes, so the lymph nodes in the area immediately adjacent to the cancer? And in the world of breast, that means in the armpit. And then, whether or not it's gone anywhere else in the body, which is metastatic disease.

So in breast cancer, we have five stages. There's stage 0 all the way up through stage IV. So in all cancers, stage IV means metastatic cancer, meaning we now see disease beyond where it started from. So if we find that a patient has breast cancer, and we see tumors that are in the liver or the bones or the lungs or something like that, that would be our metastatic breast cancer patients, our stage IVs.

Our stage 0s, as I said earlier, are our DCIS, ductal carcinoma in situ patients. So, they have a non-invasive cancer that is not able to spread to any parts of the other body, so that is what we call stage 0. Now, the rest of them, stage I, II, and III have to do with increasing size in the tumor as well as involvement of the lymph nodes underneath the arm. So, the larger the tumor and/or the more lymph nodes involved, the higher the stage we get.

Host: There are lots of options depending on the stage and many other factors with respect to surgery. And I want to come back to Dr. Cupp on that. But Dr. Peddi, breast cancer is not always surgical, is it? I mean, talk to us about surgical versus non-surgical approaches to treating breast cancer.

Prakash Peddi, MD: Well, it depends upon what Dr. Cupp and what the patients have to say, okay? Like Dr. Cupp was alluding, stages can be 0, I, II, III. We choose either to omit surgery, omit radiation, omit chemotherapy sometimes, and very importantly, based upon patient's preferences. For example, let's say a patient had a stroke and wants to defer surgery and should be deferred surgery immediately. They come to me where medical therapy or endocrine therapy or some form of treatments are initiated.

For example, let's say there is a 90-year-old, patient who is not a right candidate for surgery. They come to us first or Dr. Cupp or the radiation oncology staff funnels us these patients, and that is how we end up with these patients. And there are some patients for various medical complications, even when they're young, chose to have medical therapy. We have patients where we still provide cure by just using bimodal treatments such as chemotherapy and radiation together, and some patients are strongly opposed for surgery. All these permutations and combinations are possible in these patients, yes. Definitely, there are some patients who can skip surgery and who can be maintained on these treatments for a long time.

Host: Dr. Cupp, I suspect that most patients can't make these decisions on their own. They do them in careful consultation with you, Dr. Peddi, everybody else who joins them along the way. So, can you kind of give us the spectrum of surgical options available? I know there's a lot of talk about lumpectomy versus mastectomy and, oh my gosh, and there are different philosophies about it. And Dr. Peddi's already talked about, you know, people just have a wide range of opinions. So, kind of lay out for us what you see and what the typical choices are.

Julie A. Cupp, MD: To kind of piggyback on what y'all were talking about as far as how much does surgery need to be in it, it is the mainstay of treatment of breast cancer. Surgery is part of that. So unless the patient's really a poor candidate for surgery, we're going to think about surgery.

Now, one exception to that as an area of study is looking at people who have medicine before we get to surgery. If it looks like all of their cancer's gone, we're trying to figure out which of those patients may not benefit from surgery because Dr. Prakash Peddi has gotten rid of all of it for us. And so, doing surgery is not going to be of much benefit other than confirming that.

But for the rest of the patients, surgery is going to be part of their journey through breast cancer. And so, when I talk to patients about breast cancer surgery, we review those two options of mastectomy and lumpectomy. As I said earlier, the biggest thing that decides whether or not we can save the breast is how big is the cancer. So if we have somebody who has a small, less than a one-centimeter tumor, they don't need a mastectomy. And there is no survival benefit in doing mastectomy. Taking off a lot of healthy breast tissue is not going to prevent the cancer from coming back. And even doing a mastectomy, there is always still a chance of recurrence, both in the chest wall and elsewhere in the body. So, that's one of the difficult parts about having the conversation about what should I do surgically because there's a lot of mythology that mastectomies make things better, and removing the breast really doesn't.

So if I have somebody who has a small tumor, a lumpectomy is the only thing that needs to happen. Now, that being said, some women still choose to do mastectomy, and the reasons for that can be just personal preference or even potentially to try to avoid needing radiation therapy. Because if you do a lumpectomy, you are going to need radiation afterwards. And so if radiation is something that is not possible because of other health issues or because of transportation issues, things like that, a mastectomy is the better way to go to reduce the chances of something recurring in the breast area. So, those are the two biggest points in making that decision.

When we do lumpectomies, like I said, we want smaller tumors. But for women who have larger breasts, one of the benefits of having a larger breast in this case is the fact that sometimes we can invite our plastic surgery friends to come along to the surgery and do what we call oncoplastic surgery to be able to get the cancer out and make the breast look normal, in which normally taking out that large of a tumor would've caused a deficit. They can do tissue rearrangement in the form of a breast reduction and make the breast look like you just had a nice breast reduction instead of having a cancer surgery. So, we've gotten to be able to do some really creative mechanisms surgically to be able to conserve breast and make them look the same or even potentially better than what they started. And that does involve in doing surgery on the other side to make sure that they match each other at the end.

When we get into the discussion of having mastectomies, we talk about doing mastectomies where we go flat afterwards. And then, we talk about reconstruction options. And so, reconstructions can be done with a skin-sparing mastectomy, where we leave the majority of the breast skin, but we remove the nipple and the areola. And in a very select set of patients, we can do a nipple-sparing mastectomy, where we actually can keep the nipple and the areola.

Now, in those patients, we need to have typically smaller breasts with nipples where they are supposed to be, kind of in the perky position instead of pointing to the floor. And they also need to have the tumor far enough away from the nipple to be able to get normal tissue in between the tumor and that nipple space.

Host: Cosmetic's clearly a huge factor in decision-making as well. And there's so much emotion that goes into a breast cancer diagnosis. And, you know, It's safe to say that the overwhelming majority of breast cancer patients are female, but not all. Dr. Peddi, I think one of your strengths, knowing you a little bit, is how well you support the patients emotionally and psychologically, and how you help them through the process. I know that's a priority for you. So when you talk to your breast cancer patients, talk to me about how you prioritize their emotional and psychological well-being.

Prakash Peddi, MD: You have to ensure, first of all, the patient who comes into your clinic will stay in the clinic or will be at least following you in the clinic at a later point. There are patients who . where anxiety takes over everything, where depression takes over everything. I always feel that, as medical practitioners, we have very less clue on what is the background story of all these patients. Someone will be having a catastrophe in the at household and still dealing with the breast cancer at the same time.

So, I think definitely I would say it's such a privilege to actually be with these patients and addressing that conflict, because if you don't stabilize that part, your success is only part. Because only when you actually ge-get in the family, the patients and all involved in their care, and also I think you'll have a long-lasting results. I do feel that a big chunk of either depression or anxiety also stems from misinformation.

I think, whether you call it as a TikTok, whether TikTok universities or WhatsApp universities or YouTube universities, patients should get a feel. Just like we choose lumpectomy, mastectomy, and every option for them, my job is not to just cater what is written in the book to the patients, but I also see where we can meet the patient to make the right decisions for them. And that takes a lot of investment in terms of time in knowing the patients, what are their realistic goals, what are the family issues that you are facing. And spending quite amount of time, and not just one time, but multiple times, will get you there where you and your own patients are at a unison, and they know that we are actually rooting for the best of their care.

And once the belief is set, most of the patients, their fears will allay, go away. And this is for most of the people. I agree that there are always going to be some nervous patients where it's always a constant challenge for me as well as, you know, any medical practitioner. But barring those, those small subset of patients, many patients do extremely well once they have trust in the system that they're being really taken well care of.

Host: Dr. Cupp, couple of things I want to end with, you and then with Dr. Peddi. First, I think we all know that patients are in excellent hands, world-class hands at Willis-Knighton. Could you elaborate on that a little bit? And then finally, what is the homework that you would give anybody who has been paying attention to this and wants to make sure that they get a quick jump on anything that might be going on?

Julie A. Cupp, MD: The training that we've had, as far as physicians in Willis-Knighton, it's been world-class. I myself, I trained at MD Anderson in breast surgical oncology. Dr. Peddi, he trained over at LSU Shreveport under some of the great giants over there who've been in the business for so many years beforehand, who's taught so many generations of great medical-oncologists, both in our community and across the nation.

Our breast radiologist is one of the few in this region who has fellowship training also in breast imaging. And she's the one who's doing all of our diagnostic studies. So, you have somebody who is specialized in breast from every aspect of this. And then, when you look at our radiation oncology group, they're the ones who are adopting the newest technology for the best outcomes in radiation therapy across the nation. They're a training center for using proton therapy. They actually had proton therapy before MD Anderson did. So, I mean, coming here to Willis-Knighton to get your care, you're going to be getting excellent multidisciplinary care with people who are friends with each other, who talk to each other on a daily basis.

In fact, if Dr. Peddi hasn't heard from me in about 24 hours, I usually get a call going, "Hey, are you okay?" And I have to remind him, like, "Hey, I do take vacations sometimes." So, you know, we are constantly in contact with each other, discussing patients, not just in our conferences every other week, but just on the daily basis, making sure we understand what's happening with our patients, and that they are getting optimal care and nobody's missing a detail somewhere.

And as far as what should patients or potential patients be doing at home is, if you're over the age of 40, get your mammogram every year. If you have a family history, if that family history has breast cancer under the age of 50, and a first or second-degree relative, you should probably even start mammograms at a younger age, but not before age 30. So, that is our youngest age. So if somebody's trying to do mammograms at age 25, we don't need to go there. Now, if we do need screening that young, there is modalities with MRI and things like that, but you should be following with a breast surgeon to figure out if that's the right thing to be doing. But if it was grandma had breast cancer at 80, nobody needs to be doing mammograms at 20.

And then, also, the self-awareness. Get to know how your breasts feel. We have, unfortunately, very poor education in breast health in general in our country, and we've taught pretty much that if you feel something, it must mean it's bad. Well, our breasts have texture to them, just like every other part of our body. And the more you feel it, the more you're going to understand that there is texture. So, texture is okay. It's just if that texture is changing in a way that is worrisome, something's growing, something's become painful, the skin is thickening, it's getting red, something along those lines, we want to know about that so we can figure out, is this normal? Is it an infection, or could it be a cancer? So that way, we're getting on it as quickly as possible, and making sure the right thing's done at the right time. 

Darrell Rebouche (Host): Dr. Peddi, can you think of one thing that everybody should know about breast cancer?

Prakash Peddi, MD: It's curable very much, but get diagnosed in time.

Darrell Rebouche (Host): Dr. Prakash Peddi, Dr. Julie Cupp, thank you for your expertise and your optimism. It's been a great pleasure spending time with you today on a very important topic. And thank you all for being with us for Health on Point, presented by Willis-Knighton Health.