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'breast cancer' posts

Becoming a Breast Surgeon

Surgeons are often Type A personalities, the ones who sit in the front of the class, who volunteer for everything, who stay scrubbed in the OR all day with appendicitis and do a post-op check before checking themselves into the emergency department (yes, that was me.) As such, surgeons are often dismissive of the subspecialty of breast surgery. The surgeries are not as complex as cardiac bypass surgery or Whipple procedures for pancreatic cancer. In fact, it’s often a rotation for interns. I was a Type A personality. I had no plans to do breast surgery.

Then, a funny thing happened. I had my first son during residency. Planned with military precision, of course, to coincide with the beginning of my designated research years, as I had hoped to squeeze another baby in there somewhere. After his birth, I would breastfeed, because that is what Type A mothers do these days. It’s the best! Of course, I would do the best! However, like many mothers out there, we had an incredibly rocky start. Poor latch with inadequate weight gain. Triple feeding with pumped milk. Cracked nipples leading to mastitis. As a Type A person, I threw myself into research in an effort to solve the problems. Not just the many, many baby books out there, but Medline searches on breastfeeding management. I learned more than I ever had in my surgery textbooks about the breast, the physiology of lactation that is both incredibly simple and enormously complex, and most importantly, miraculous. I was reminded constantly in my reading of the importance of preserving this ability to breastfeed my son, for his and my health, and how challenging that could be.

I would sit in my office, working on surgical infections research, as I pumped and read about normal breasts and infected breasts and cancerous breasts. Antibiotic rotations in ICUs and glucose control became less exciting than being able to offer targeted medical advice to a frustrated friend in Boston, whose refractory mastitis was being met with shrugs from some of her local doctors until we correctly identified MRSA as the source. Maybe it wasn’t saving lives, but it saved her breastfeeding relationship with her child. Who knows, maybe in the end it would be saving lives! I read more ....

What should I know about radiation if I have breast cancer?

If you’ve been diagnosed with breast cancer, you may wonder if radiation is an option for you.

Radiation is an important pillar of treatment for breast cancer and has never been safer when designed by an experienced team with state of the art technology. Radiation will be part of a standard treatment plan after breast conserving surgery (also called lumpectomy or partial mastectomy). With the addition of radiation to the breast as an insurance policy, patients will do just as well as those undergoing mastectomy. Even after a mastectomy there are indications when radiation to the chest wall and nodes are recommended for best outcome. After a lumpectomy, radiation to the whole breast is the current gold standard.

How does radiation actually work?

Radiation works by aiming it at a target. Free radicals are produced which kill cancer cells, while normal cells have the capability to repair the damage. Cancer cells don’t.

Having the most advanced technology available to precisely plan and deliver radiation to the target will protect healthy tissue for optimal outcomes and the best possible cosmetic result.

How can I make sure I receive the best radiation?

The radiation oncologists treating you should be part of an interdisciplinary team. I, for example, work closely with the patient, the breast surgeons and the medical oncologists. I then design a personalized radiation plan, tailored to the unique characteristics of the tumor and each patient’s personal preferences. The more personalized the treatment the better.

To allow patients to feel their best during and after treatment, I often work with physical therapists, naturopaths, and other support staff (social worker, dietitian etc).

What type of radiation treatment do I need?

Radiation options after a breast conserving surgery can be very confusing. Here is a list that may help you understand the different options:

What you should know about breast cancer and tips for reading online information

Since October is Breast Cancer Awareness Month, I’ve been paying more attention to online blogs about breast cancer and realize there is a lot of information and misinformation out there. How can you know what’s correct, what’s marketing, and what is just plain wrong? Here are some tips:

  1. Be an aware and questioning reader: Ask yourself some of the following questions. What is the source of the information? Does the author have anything to gain financially from the information? Are there studies that provide data supporting the recommendations? Who funded the studies and were there any potential conflicts of interest?
  2. Investigate more than one source: Healthcare has become very politicized and complicated but you can find reliable sources. But realize even with trusted sources the information provided may be conflicting. Some reliable sources include: Swedish Cancer Institute, Breast Cancer Action, National Cancer Institute, and American Cancer Society.

  3. Don’t be taken in by conspiracy theorists: I have practiced surgery for 30 years in a variety of situations and healthcare institutions and NEVER have I experienced a desire to withhold effective tests and treatments from patients. Physicians and hospital systems are not suppressing tests, treatments, and /or cures in order to stay in business. I don’t know a breast surgeon who wouldn’t be thrilled to have to practice another specialty if there was a way to prevent breast cancer.

Here are some things that I think it is important to know about breast cancer:

Do self breast exams matter?

Self breast exams: to do or not to do?

Remember when there were monthly emails you could sign up for to remind you and your friends to do your self breast exams at home? Remember seeing the news anchors talking about their monthly self breast exams in an attempt to remind you to do your breast “due diligence?” What happened to self breast exams and are they still important?

Initially, self breast exams were recommended as a screening tool to help early detection of breast cancer. Unfortunately long-term studies have not confirmed that they actually live up to their hype. Two large studies looking at over 200,000 women in both Russia and China didn’t show any difference in breast cancer mortality after 15 years between the women who were performing routine self exams and those who were not. In fact, the women that were practicing self exams found more lumps and underwent more biopsies for benign reasons. Reviews of several other studies failed to show a benefit of regular breast self-examinations including no benefit of early diagnosis, or reductions in deaths or stage at diagnosis. Hence in 2009, the US Preventative Services Task Force advised that clinicians no longer recommend routine self breast examination as a screening tool for breast cancer detection.

Even though you don’t need to be doing a monthly self exam, you should...

What test is best for breast screening?

I often get asked why can’t a woman just get a breast MRI rather than a mammogram. The imaging tests that we do for breast cancer screening and evaluation of abnormalities have different strengths and weaknesses.

Mammograms are very useful as a screening tool. They can be done quickly and read efficiently by the breast radiologist. They have minimal radiation exposure. They can be done by a mobile coach in locations that are more convenient to patients. They are excellent for identifying abnormal calcium deposits within the breast tissue and for seeing disrupted tissue and masses. They may be less effective in women who have dense breast tissue but the digital techniques have helped some with that. 

Ultrasound is a great tool for evaluating a mass or tissue asymmetry found on mammograms. It can distinguish between a benign appearing solid mass, a fluid filled cyst, a mass that is suspicious for cancer, or normal appearing breast tissue. There is no radiation exposure. It is less reliable as a screening tool because it can be dependent on the skill of the physician or technologist doing the procedure. It is possible to miss abnormalities or to mis-interpret normal findings as abnormal. There are studies underway evaluating using an automated version of ultrasound as a screening test but the results are not conclusive and this is not considered ready for standard practice.

Breast MRI is a highly sensitive test that is very dependent on...

Getting a mammogram

Frequently women will ask me: Where should I get my mammograms? There are several things to think about.

First, you want to go to a Center that is accredited by the American College of Radiology. This means that they have high quality images and well-trained radiologists. It is preferable to have a digital mammogram but if that technology is not available, then film mammograms are better than not having one done. While it is not clear that digital mammograms improve survival, they do allow the radiologist to examine the images more clearly and to use computer assisted diagnostic tools.

The radiologists’ experience is also important. Dedicated breast centers usually have radiologists who are specialized in breast imaging. These sub-specialized radiologists are very experienced in using mammograms, ultrasound, and breast MRI to diagnose breast disorders and are less likely to miss abnormalities.

Convenience is also a consideration. You want to make it easy to get your mammograms. Some Breast Centers will have mobile mammography programs that will bring mammogram screening to your place of work, local community or senior center, or even your church or synagogue. If possible, it is a good idea to get your mammograms at the same Center or within the same hospital system every year. That way the radiologists have easy access to your prior studies and can compare them to the current ones.

Here are some other things to know about getting mammograms:

What you need to know about breast screening

In 2009, the United States Preventive Services Task Force (USPSTF) created significant controversy and confusion for both providers and patients when they revised their breast screening guidelines. (The USPSTF is promoted as an unbiased group that reviews relevant studies and makes guideline recommendations. Specialists may be asked to review the guidelines but no breast specialists (surgeons or radiologists) were on the actual review panel.)

The guideline development process aims to weigh the potential benefit of services against the potential harm, and make recommendations accordingly. For breast screening, the harms considered were “psychological harms,” imaging tests and biopsies in women who were ultimately found not to have cancer, inconvenience, and the possibility of treating a cancer that might not have been life threatening. Radiation exposure was considered to be a minor concern. Regarding benefits – the only benefit considered was reduction in death rates from breast cancer.

These USPSTF guidelines recommend...

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