For over 15 years I have worked closely with Dr. Lauren Cassell on breast cancer patients. She is the Chief of the Breast Surgery Service at Lenox Hill Hospital.
When we work together, Dr. Cassell performs the mastectomy and I perform the immediate breast reconstruction. Recently, Dr. Cassell and I were asked some questions about the prevention and treatment of breast cancer. I think you may find it interesting to read the answers.
We discussed the role of prophylactic mastectomies with immediate reconstruction for women who have the breast cancer gene and who are at very high risk of developing breast cancer but who have not yet acquired the disease. Prophylactic or preventive mastectomies with immediate reconstructions are among the operations that Dr. Cassell and I perform together.
Question #1: (FOR DR. BERAKA). How closely do you collaborate throughout the patient's surgery and recovery?
Answer: We collaborate very closely. Once Dr. Cassell decides that a patient needs a mastectomy and explains this to the patient and her family, I see the patient promptly -- typically within 2 or 3 days. I evaluate the patient and recommend the plan for reconstruction. This process makes it much easier for women to accept the need for a mastectomy. The patient and her family are shown postoperative photos of women who have undergone mastectomies and breast reconstruction and who look normal. Both medical offices schedule the patient for surgery together, and we never make the patient wait more than two weeks for surgery.
On the morning of surgery, I meet the patient in the hospital and I place preoperative markings on her chest, designing the flaps and the incisions. The patient then goes to sleep and Dr. Cassell performs the mastectomy with sentinel node dissection. Her meticulous surgical technique leaves the skin flaps and the chest muscles in optimum condition for breast reconstruction.
As soon as the mastectomy is completed, and of course during the same anesthesia, I perform the breast reconstruction. Both Dr. Cassell and I collaborate in the postoperative care in the hospital and during the recovery phase after the patient goes home. Patients are allowed to return to unrestricted exercise three weeks after the mastectomy and reconstruction.
Question #2: (FOR DR. BERAKA) Have there been any significant changes or improvements in breast cancer research and surgery?
Answer: One of the very important improvements in the treatment of breast cancer involves women who do not need a mastectomy and are treated with breast conservation therapy -- that is to say, with a lumpectomy. The improvement is called Oncoplastic Surgery which combines principles of Oncologic Surgery (i.e., surgery to cure breast cancer, the lumpectomy) with principles of Plastic Surgery to leave the breast looking normal and often more attractive than before. Oncoplastic Surgery also is designed to keep the breasts looking symmetrical.
After a lumpectomy a cavity remains in the breast which must be repaired. Dr. Cassell is excellent at this, and she typically repairs and closes the cavity by mobilizing and bringing together remaining breast tissue. With good oncoplastic technique, larger lumpectomies can be performed without disfiguring the breast.
In more complicated oncoplastic surgical procedures, Dr. Cassell and I work together. Dr. Cassell performs the lumpectomy and I perform the reconstruction. The most common oncoplastic surgery case in which Dr. Cassell and I work together is the patient with breast cancer who also has very large breasts. In this case, Dr. Cassell does a lumpectomy and I do a bilateral breast reduction. This way, symmetry of the two breasts is maintained, and the new breasts are actually perkier and more attractive.
Question #3: (FOR DR. CASSELL). How long have you and Dr. Beraka worked together? How did your relationship with Dr. Beraka begin?
Answer: Dr. Beraka and I have been working together for about 15 years. I refer patients to him simply because he is an excellent plastic surgeon skilled in breast reconstruction. Our relationship started because of our mutual respect and because we are both firm believers that breast reconstruction should be an integral part of the treatment for breast cancer. Women should be left looking as good as possible and sometimes they can look even better than before surgery.
Around the time that we started to work together, immediate breast reconstruction (that is to say, at the same time as the mastectomy) became the norm, and we were able to offer it to our patients.
Dr. Beraka has always been able to offer our patients the state of the art options in breast reconstruction, and he is involved from the very beginning. Dr. Beraka is fanatical about detail and about advance planning, and those are the keys to success in our work.
What make a reconstructed breast really look like a breast is the nipple, and I have always marvelled at Dr. Beraka's ability to create the most realistic looking nipples after mastectomy.
Question #4: (FOR DR. CASSELL) Have there been any specially memorable or exceptional cases on which you have worked with Dr. Beraka?
Answer: We think of two patients in particular.
Several years ago we took care of a woman in her late thirties who had the breast cancer gene but no detectable tumor before surgery. We performed bilateral prophylactic mastectomies with immediate breast reconstruction in this patient who, as far as we all knew, did not have breast cancer.
But an early unsuspected breast cancer was found in one of the mastectomy specimens. We feel this operation saved this woman's life, and, incidentally, her reconstructed breasts look great. She could not be happier having undergone significant risk reduction surgery and winding up with a wonderful cosmetic result.
And this is another patient: We recently operated on a beautiful 31 year old woman who had a six month old baby. Her mother developed both breast cancer and ovarian cancer. Our patient and her sister were tested and both were found to be positive for the breast cancer gene. The sister had previously undergone mastectomies with reconstruction elsewhere, and our patient thought the results could have looked better. We performed bilateral prophylactic mastectomies with immediate breast reconstruction on our patient. She went on to heal well and is thrilled with the cosmetic results.
These two cases were thoroughly gratifying to both the physicians and the patients.
Question #5: (FOR DR. CASSELL) With National Breast Cancer Awareness Month approaching in October, what do you think can be done to increase awareness of the importance of early detection?
Answer: We need a publicity campaign to get the word out that early detection of breast cancer saves lives, and there are three key points:
#1. Every woman is at risk. Most women who get breast cancer do not have a family history, but if you do have a family history, you are at increased risk.
#2. In selected patients, we can now do better screening for breast cancer with sonograms and with MRI scans of the breasts.
#3. One of the reasons women avoid early detection is that they are afraid of deformity following surgery. We need to publicize the fact that with good surgery and with attention to detail, deformity following breast cancer can be avoided. Breast conservation (lumpectomy) preserves the shape of the breasts. The results of breast reconstruction done together with mastectomy are consistently good. When we do a mastectomy and reconstruction on one side, we also correct the other breast with either a lift or a breast reduction or a breast augmentation in order to preserve symmetry of the two breasts.
And Oncoplastic Surgery actually improves the look of the breasts (See Question #2).
Question #6. (FOR DR. CASSELL) Have there been any notable cases on which you have worked with Dr. Beraka that best exemplify the importance of early detection?
Answer: A professional woman in her early thirties with two small children had very large, sagging breasts. She decided to have a breast reduction.
As part of the evaluation before the breast reduction, she was instructed to have a mammogram and a breast sonogram. The mammogram was negative but the sonogram picked up two small suspicious lesions in the outer part of the left breast. These suspicious lesions were biopsied and found to be very early breast cancers. She was treated with a quadrantectomy (a large lumpectomy) performed together with a bilateral breast reduction, and she is very pleased with the cosmetic result. (This is called Oncoplastic Surgery -- see answer to Question #2).
If this woman had not had the sonogram, the breast cancer would have been diagnosed later at a more advanced stage.
Question #7: (FOR DR. CASSELL). How do you treat patients with a family history of breast cancer? What advice do you offer those who know that they carry a breast cancer gene?
Answer: First, a family history for breast cancer has to be "significant". This means that the patient has two first degree relatives with breast cancer (such as her mother and her sister), or one first degree relative and several second degree relatives (such as cousins and aunts). You have to look at both the mother's and the father's family.
If the patient has a significant family history of breast cancer, she needs to be examined twice a year. She needs a mammogram and a breast sonogram once a year and an MRI of the breasts once a year on an alternating schedule so that she has at least one test every six months. I discuss genetic testing with the patient and I refer her for genetic counseling if she wants to pursue this type of evaluation.
If the patient is positive for a breast cancer gene, she has an 85% lifetime risk of developing breast cancer. More than one half of these cancers will develop before menopause.
But some women just do not want to know and will not have genetic testing.
If the patient is positive for a breast cancer gene, I advise them to consider bilateral prophylactic mastectomies with immediate breast reconstructions. Prophylactic mastectomies drastically reduce the risk and the cosmetic results are excellent. Some patients choose not to undergo this type of risk reduction surgery. They are then kept under very close surveillance.
Also, if a woman is positive for the breast cancer gene, she should consider having her ovaries removed by the age of 39 or when she has completed her childbearing years because of the increased risk of ovarian cancer. We do not have any good techniques for early detection of ovarian cancer.
Question #8: (FOR DR. CASSELL). Have there been any changes or improvements in breast cancer research and surgery? How far has the field progressed over the past year, and what new developments are expected, specially regarding genetics?
Answer: There are three areas of progress:
#1. The results of nipple sparing mastectomy are being evaluated. In this operation, a mastectomy is performed but the nipple is not removed.
#2. A sentinel node biopsy (the sentinel node is the first draining lymph node in the armpit) has replaced a full axillary dissection which removes most of the lymph nodes in the armpit. This trend towards less axillary surgery has markedly reduced the incidence of swelling of the arm (lymphedema) after breast cancer surgery.
#3. Oncotyping of breast tumors is now performed on selected individuals, where approximately 21 genetic markers are studied in each tumor. This analysis helps to determine which breast cancer patients will truly benefit from chemotherapy, and which patients may do just as well with only hormonal treatment.