Latest / Meaningful Medicine with Novant Health / Before the Surgery: Expert Answers

Transcript

Before the Surgery: Expert Answers · Meaningful Medicine with Novant Health

• 0:04
  Amanda Wilde (Host): Meaningful Medicine is a Novant Health podcast bringing you
• 0:07
  access to leading doctors who answer questions they wish you would ask.
• 0:11
  From routine care to rare conditions, our physicians offer tips to navigate medical
• 0:16
  decisions and build a healthier future.
• 0:19
  Our focus this episode is understanding breast cancer surgery, what you need to
• 0:24
  know with breast surgical oncologist, Dr.
• 0:26
  Elizabeth Fish.
• 0:28
  I'm your host, Amanda Wilde, and Dr.
• 0:30
  Fish, thank you so much for being here.
• 0:33
  Elizabeth Fish, DO: Thank you for having me.
• 0:35
  Amanda Wilde (Host): Breast cancer surgeries have become more highly precise
• 0:39
  personalized procedures in recent times.
• 0:41
  Currently, what are the main types of breast cancer surgery, and how do you
• 0:46
  decide which is right for a patient?
• 0:50
  Elizabeth Fish, DO: Yeah, so the main two types are either lumpectomy or breast
• 0:54
  conserving surgery or a mastectomy.
• 0:56
  So very different surgeries, but both great approaches for breast cancers.
• 1:01
  lumpectomy really focuses on taking the actual area of the cancer and
• 1:05
  a, rim of healthy tissue around it or hopefully negative margins.
• 1:09
  so a smaller area of tissue is taken versus a mastectomy, we remove all of
• 1:13
  the breast tissue, underneath the skin on that side or both sides depending.
• 1:17
  those are two main ones, and there's a lot of different things that go into
• 1:21
  deciding what is best for which patient.
• 1:24
  A lot of times it's tumor size and breast size and kinda how those go hand
• 1:28
  in hand, as well as genetic testing.
• 1:30
  So if someone is positive for something like a BRCA mutation, maybe mastectomies
• 1:34
  is the better approach for them.
• 1:36
  or if a patient can't have radiation, then lumpectomy's not always a good option
• 1:41
  because typically with lumpectomy, we like to pair that with radiation to get our
• 1:45
  recurrence risk as low as we possibly can.
• 1:47
  So there's a lot of different nuances that go into picking the right surgery.
• 1:52
  Amanda Wilde (Host): what does the surgical process look like
• 1:56
  for these procedures start to finish, if you can say all of these
• 2:00
  procedures have something in common?
• 2:03
  I guess I'm asking what patients should really expect also the day of the surgery.
• 2:08
  Elizabeth Fish, DO: Yeah.
• 2:09
  So a lot of times leading up to the surgery, obviously they're meeting
• 2:12
  with the surgical oncologist, they're meeting with the medical oncologist
• 2:15
  to make the best plan for them, whether it's surgery first or not.
• 2:19
  and when it's determined that surgery is the better approach upfront,
• 2:23
  usually there's, imaging and biopsies and things like that need to occur
• 2:26
  prior to the actual surgery date.
• 2:28
  If we're doing a lumpectomy or that smaller operation, typically we do
• 2:32
  want to, place some sort of localizing device or have radiology place that.
• 2:36
  Usually that's, like a smart clip or a wire or something that can help
• 2:40
  us target that area, so that usually happens about a week before the surgery.
• 2:44
  typically, if they're having a mastectomy with reconstruction,
• 2:46
  they're gonna be meeting with plastic surgery before that as well.
• 2:49
  the day of surgery, they get there usually a couple hours, prior to
• 2:53
  the actual surgery start time.
• 2:55
  they meet with anesthesia, make sure that everything is
• 2:58
  appropriately laid out for them.
• 3:00
  most patients actually leave the same day, and that's, more so for
• 3:04
  lumpectomies or the smaller surgeries.
• 3:06
  And then if they're having a mastectomy or reconstruction, they
• 3:09
  might stay one night in the hospital.
• 3:11
  that's the process of kinda getting to the surgery and the day of surgery.
• 3:15
  then there's obviously, recovery time and stuff after that as well.
• 3:19
  Amanda Wilde (Host): during the surgery, it's really common to remove lymph
• 3:22
  nodes and test them during surgery.
• 3:24
  How do you determine if lymph nodes need to be removed?
• 3:28
  and what role does the sentinel node biopsy play?
• 3:32
  Elizabeth Fish, DO: Yeah, so that's actually a very nuanced and even more
• 3:35
  personalized, part of our care at this point as well because of the multiple
• 3:39
  surgical trials that have come out.
• 3:41
  But we're actually omitting that part of the procedure in a lot more
• 3:44
  patients now than we ever were before.
• 3:46
  for patients that, already have disease in their armpit, that's
• 3:50
  a whole different ballgame.
• 3:51
  but in terms of the sentinel lymph node procedure, really the idea behind that
• 3:55
  is if cancer, breast cancer is gonna go anywhere first, typically the place that
• 4:00
  it will go is the lymph nodes under the armpit because they drain the breast.
• 4:04
  now typically what we do here is use dual tracer, which is a blue dye as
• 4:08
  well as a nuclear medicine tracer to help amp up the ability to find those
• 4:12
  first couple draining lymph nodes.
• 4:14
  it's a small incision, usually underneath the armpit for the smaller breast
• 4:17
  surgery, and we physically take out those lymph nodes that either turn
• 4:21
  blue or, for lack of better words, beep at us because of the tracer.
• 4:25
  In, women that are 70 and above with early stage hormone positive, estrogen positive,
• 4:30
  I should say, breast cancers, can omit that part of the operation because
• 4:35
  there's really not a, much of a benefit or much of a change in their treatment
• 4:39
  plan, from doing that, and it really doesn't change their survival or their
• 4:43
  risk of it coming back in the future.
• 4:45
  so it's usually in the younger, age bracket, that we're doing
• 4:49
  more of these procedures.
• 4:51
  and it depends on the receptor status of the breast cancer too.
• 4:55
  So it's a little bit different if it's hormone positive versus maybe a triple
• 4:58
  negative or a HER2 positive breast cancer.
• 5:01
  a lot of nuances with the sentinel lymph node procedure, but it is,
• 5:04
  really just a way of finding more information and giving the patient
• 5:07
  more information of has the cancer spread and what is the next best step.
• 5:13
  Amanda Wilde (Host): Thanks for explaining that.
• 5:15
  What are some of the most common side effects or risks of breast cancer surgery,
• 5:20
  and how can patients prepare for that?
• 5:22
  Elizabeth Fish, DO: the most common side effects are, some swelling, maybe
• 5:25
  a little bit of pain or soreness.
• 5:27
  There's honestly not too much pain with that just because it's more numbness
• 5:31
  around that area where the surgery is done, which can also be, a risk.
• 5:35
  other risks included are cosmetic deformity, so that's why making sure
• 5:39
  we pick the right surgery for the right patient is very important.
• 5:43
  we don't wanna have a big cosmetic defect from a lumpectomy in
• 5:46
  a small breast, for example.
• 5:48
  some other risks, especially with the lymph node procedure we
• 5:50
  just talked about, is lymphedema.
• 5:52
  So there is a small risk of chronic arm swelling, otherwise known as
• 5:55
  lymphedema, from that procedure.
• 5:57
  Although it is much less with that operation than with the full axillary
• 6:00
  dissection, which is, removing all the lymph nodes underneath the armpit.
• 6:04
  those are some of the more common.
• 6:05
  There's, some risks of mobility issues or tightening and scar
• 6:09
  tissue and things like that.
• 6:11
  but typically we, refer them to physical therapy or, show them
• 6:15
  some different exercises to help prevent things like that.
• 6:19
  Amanda Wilde (Host): is how you manage pain, swelling, and
• 6:21
  changes in mobility after surgery.
• 6:24
  Elizabeth Fish, DO: typically with, pain, it's really just some ice.
• 6:27
  A supportive bra is really one of the biggest things that people overlook.
• 6:31
  and then Tylenol and Motrin.
• 6:32
  Not a whole lot of opioids or any other pain medicines are really needed for
• 6:36
  really the mastectomy or the lumpectomy.
• 6:39
  for the swelling, it's a lot of compression and making sure
• 6:42
  we're supporting the breast with a, good supportive bra.
• 6:45
  those are the biggest things.
• 6:46
  But yes, if we're noticing a lot of these things, at the post-op visit
• 6:50
  or a couple weeks later, physical therapy is one of the, mainstays
• 6:54
  Amanda Wilde (Host): And what does recovery look like in those first
• 6:57
  few weeks, and when can patients return to normal activities?
• 7:01
  Elizabeth Fish, DO: for the lumpectomy or that smaller surgery, usually it's
• 7:03
  only about a week or two weeks recovery.
• 7:05
  getting back to work and things like that, it kinda depends
• 7:08
  on what they do for a living.
• 7:09
  I tell my patients, "Don't lift more than about 15 to 20
• 7:12
  pounds for about two weeks."
• 7:14
  they're allowed to shower the next day, that sort of thing.
• 7:17
  That's for the smaller surgery where we don't have drains or
• 7:20
  anything like that involved.
• 7:21
  for the mastectomy, recovery is more like four to six weeks,
• 7:24
  depending on reconstruction or no reconstruction, and really depends on
• 7:29
  when those drains come out as well.
• 7:30
  Typically, if a patient's had reconstruction with plastic surgery,
• 7:34
  the plastic surgeon will really lay out, "This is what you can and can't do,
• 7:38
  after your surgery and for how long."
• 7:41
  Amanda Wilde (Host): since you brought it up, let's talk a little
• 7:43
  bit more about reconstruction.
• 7:45
  How do patients weigh the pros and cons of breast-conserving surgery
• 7:49
  versus mastectomy, first of all?
• 7:52
  Elizabeth Fish, DO: So it really comes down to tumor size as well as breast size,
• 7:56
  and what are they a candidate for, right?
• 7:58
  So are they a candidate for the small surgery, and does that align with maybe
• 8:01
  what they want from a recovery standpoint?
• 8:04
  Maybe their goal is to get back to work or to, be able to play
• 8:07
  with their kids or whatever it is.
• 8:09
  so maybe the lumpectomy is, right for them.
• 8:12
  Maybe they have a genetic predisposition to breast cancer and they're higher
• 8:16
  risk in the future, so maybe the mastectomy is better for them.
• 8:20
  a lot of it does end up being more personalized.
• 8:23
  so those are some of the big things.
• 8:25
  Amanda Wilde (Host): How do reconstructive options factor into
• 8:27
  surgery planning, and when is it best to involve a plastic surgeon?
• 8:32
  Elizabeth Fish, DO: it's best to involve them as early as possible.
• 8:34
  So if we know someone is contemplating, mastectomies with
• 8:37
  or without reconstruction, I'll go ahead and place the referral
• 8:39
  for them to speak to plastics.
• 8:41
  the type of reconstruction really depends on body habitus and maybe
• 8:46
  the quality of their tissue and other medical comorbidities.
• 8:49
  tobacco abuse is a big one.
• 8:51
  It's, difficult to have a reconstruction someone is smoking and using tobacco
• 8:55
  products because we know their healing is not gonna be as good.
• 8:59
  so those are some of the things to think about.
• 9:01
  Now, there's implant reconstruction versus, maybe autologous, using
• 9:05
  their own tissue, such as flaps.
• 9:07
  So a lot of that is discussed with the plastic surgeon,
• 9:10
  pretty early in the process.
• 9:13
  a lot of that is more with mastectomy patients, whereas if
• 9:16
  we're ... there's, also a role for plastic surgery even with lumpectomy.
• 9:20
  So say a patient was interested in a breast reduction at the time
• 9:24
  of their lumpectomy, we can always entertain that, depending on their
• 9:27
  pathology, and have them see a plastic surgeon as early as possible, just
• 9:31
  so we can make it really seamless
• 9:33
  Amanda Wilde (Host): you mentioned smoking, I'm thinking
• 9:35
  about lifestyle factors.
• 9:37
  Are there lifestyle changes like exercises or physical therapy that can help patients
• 9:44
  prepare for surgery and recover faster to protect their chest and shoulder mobility?
• 9:51
  Elizabeth Fish, DO: Yeah, there are certain exercises.
• 9:54
  and, if we know a patient is gonna need a bigger axillary surgery and
• 9:57
  they're at higher risk for, arm issues, mobility issues, swelling,
• 10:02
  that sort of thing, sending them to physical therapy preemptively,
• 10:06
  so more of a prophylactic approach, is, something of importance as well.
• 10:09
  They will show them different massage techniques and, fit them with a
• 10:13
  compression sleeve and things like that.
• 10:15
  So that's more specific to lymph nodes.
• 10:17
  in terms of just overall health, making sure that they're eating, a well-balanced
• 10:22
  diet that's high in protein, making sure we're getting outside, we're getting, our
• 10:26
  steps in each day, being really just as healthy as we can be before undergoing
• 10:30
  any sort of surgery, not even just breast surgery, is, really important.
• 10:34
  so I try to focus on that at, at all of my, pre-surgical visits as well.
• 10:40
  Amanda Wilde (Host): of things we can do before surgery, what questions do you
• 10:44
  wish patients would ask before surgery just to feel more informed and confident?
• 10:49
  Elizabeth Fish, DO: my patients honestly ask a lot of really good
• 10:51
  questions at, their first visit with me, which is always really nice.
• 10:54
  We have great conversations about, pretty much everything
• 10:57
  they could potentially expect.
• 10:59
  But, I do always want my patients to ask about recovery.
• 11:03
  What does that really look like?
• 11:04
  What does it really feel like?
• 11:06
  That sort of thing.
• 11:07
  what can they anticipate from a, medical oncology or radiation
• 11:11
  oncology standpoint after the surgery?
• 11:14
  realistically, can they then pick up their children, or can they drive their car?
• 11:18
  Can they really get to work?
• 11:20
  Because, this day and age, we all got to get back to work as quick as we can.
• 11:23
  And, so I really wish, a lot of patients would have more of a candid
• 11:27
  discussion about that and, not be afraid to ask those questions.
• 11:31
  one other thing is, what is the impact of whatever the breast surgery
• 11:36
  they're choosing potentially on their sexual health or, things that
• 11:39
  we don't always want to talk about.
• 11:40
  Those are important things to think about when deciding
• 11:43
  lymphectomy versus mastectomy, body image issues, things like that.
• 11:47
  so I really wish the patients would ask about that and feel like they've
• 11:51
  really gotten the, most information they can from those aspects.
• 11:56
  Amanda Wilde (Host): it's really good if you can imagine a very detailed future
• 12:00
  together with your breast surgeon.
• 12:03
  Elizabeth Fish, DO: Yeah, exactly.
• 12:04
  Exactly.
• 12:05
  And I follow my patients pretty much every six months indefinitely.
• 12:09
  I, do enjoy building relationships with my patients.
• 12:12
  And, and I think that's something that's really beautiful about
• 12:15
  breast surgical oncology
• 12:17
  Amanda Wilde (Host): Yeah.
• 12:18
  It is really reassuring to have the same person by your side through all the
• 12:23
  procedures before, during, and after.
• 12:25
  Dr.
• 12:25
  Fish, thank you so much for sharing your valuable insights
• 12:29
  on breast cancer surgery today.
• 12:31
  Elizabeth Fish, DO: Thank you.
• 12:32
  Thank you so much for having me.
• 12:33
  This was great
• 12:34
  Amanda Wilde (Host): Dr.
• 12:35
  Elizabeth Fish is a breast surgical oncologist with Novant Health.
• 12:39
  To find a physician, visit novanthealth.org.
• 12:42
  For more health and wellness information from our experts,
• 12:45
  visit healthyheadlines.org.
• 12:48
  If you enjoyed this podcast, please share it on your social channels and explore
• 12:52
  our library for topics that interest you.
• 12:54
  This is Meaningful Medicine, a Novant Health podcast