Addressing Facts and Fears in the Face of Breast Cancer

Addressing Facts and Fears in the Face of Breast Cancer


(light music)>>Announcer: Here at Johns
Hopkins Medicine known for groundbreaking researching,
teaching and medical care.>>Welcome to Facebook live
from Johns Hopkins Medicine, I’m Elizabeth Tracy. In recognition of breast
cancer awareness month, this month we are
focusing on breast cancer. We’re privileged to have
three experts here with us in the studio to talk about
your questions and concerns relative to breast cancer, a
condition that unfortunately will affect one in eight
women in her lifetime.>>Hello, I’m Susan Harvey the Director of breast imagining here
at Johns Hopkins Medicine.>>Hello, I’m Lisa Jacobs
I’m a Surgical Oncologist that specializes in breast care.>>I’m Michele Manahan, a plastic surgeon here at Johns Hopkins.>>Women of course start their
journey with breast cancer with imaging so we’re gonna start first with that imaging idea. Tell me, how often should a
woman have her breasts imaged and when should she start?>>So at Johns Hopkins we
recommend that women of average risk begin mammographic screening at age 40 and continue annually.>>At age 40 but you said
women at average risk. So, are there women who
should start sooner than that?>>There are some women who
are at an increased risk and that can be based on family
history of breast cancer, and also genetic history,
whether they’re genetic carriers and so each women who is at
high risk would have a unique recommendation for them to
begin mammographic screening and potentially supplemental screening with other modalities such as MRI.>>There’s more than one technique to image breasts isn’t there?>>There is, that’s a good question. So there is full field digital
mammography or 2D mammography and also digital breast
tomosynthesis or 3D mammography.>>And the differences between them?>>The differences are that with
3D mammography we’re able to reconstruct images in
one millimeter slices, so that the overlap between
tissues and overlap that can hide important findings
such as a cancer are lessened. The radiation dose is the
same for both of those and we at Johns Hopkins are
more accurate when we use 3D mammography and there’s
data that suggests this is true throughout the United
States and also in Europe.>>This is emerging data right now?>>There’s several
publications, some data is still coming out regarding
exactly what populations benefit the most from 3D mammography, but there’s several years
of data suggesting this.>>Would you guess that it’s all gonna go to 3D at some
point in the future?>>I do think that, yes. Because there really isn’t much downside. With the radiation dose being the same and the accuracy improved.>>So when you find a
lesion, what happens then?>>So we would often go on
to ultrasound to assist us and the reason we use
ultrasound is to help define the lesion and also
potentially use that modality to guide a biopsy for
a definitive diagnosis.>>Of all comers, all the
women who come in for this, how often does someone then go forward and have to have these
additional techniques?>>So in the screening population, that is a group of women
who a, symptomatic and at our institution about six percent of women are asked to come back after
screening for additional mammographic or ultrasound evaluation. The majority of those women are fine after that additional
imaging and only about two percent of women who
present for screening end up having a biopsy.>>So that’s pretty good,
only about two percent. Yeah, absolutely, so then
what happens after that?>>So we typically do
image guided biopsies, those are natal biopsies. So women come in, we
use a local anesthetic and a needle is used
to perform that biopsy. So the lesion is not removed, it’s sampled and those samples are
sent to the pathologist and a couple of days
later we have the results from the pathologist whether
they’re abnormal cells or not present in the tissue that we’ve sampled.>>At that point in the
diagnosis there’s an awful lot of information that’s available
about breast cancers now. Gosh, HER2-positive, all kinds of different marketers are used. Is that information
available at that point?>>So that also comes from the pathologist and the techniques for those definitions of the molecular and genetic
footprint of the breast cancer can be obtained by the
pathologist from the core tissue samples that
we get from biopsies. So women do get that information, it sometimes takes a few
days longer than just the pathology whether it’s cancer or not. But it can be, that
information can be obtained from the same samples.>>I would guess that
that kind of information is really important when it
comes to determining treatment.>>It absolutely is and
we call those biomarkers. In fact now, traditionally
we have used the tumor size and lymph nodes status to
really direct treatment, but now the biomarkers are
becoming more and more important so those are the estrogen
receptor, progesterone receptor and HER2/nue being the
three most important. There’s some additional
ones that we find important and other that we use to determine
the need for chemotherapy that are some additional
testing that can be done. Looking at genomics and
genetics of the tumor, not of the person but from
the surgery perspective most of the treatments
are determined by the size and the location within the breast, whether there’s more than one abnormality within the breast and then
the size of the breast compared to the size of the abnormality, and whether or not we
can actually resect it with leaving a very
normal appearing breast, and if we can’t then we will
involve our plastic surgery colleagues to keep us with a
happy person in the long run. It does direct a lot of what we do, and then we also use those
results at other times to identify high risk lesions. Abnormalities that may
not meet the criteria to be a cancer but are
considered high risk. And what I usually tell
people after a biopsy is that they can get a
completely benign result, a cancer or they can get this in the middle of the road result. And when we get that
one, we commonly still do lymphadenectomy for those
and consider them high risk, which puts them in a different
category for screening.>>So it sound like do you
have enough information then at the time of diagnosis before
surgery in order to perform the surgery or additional
imagining techniques needed?>>So there are times with
specific features of a person and their breast tissue and
at other times when there’s some additional things that
need to be evaluated that the radiologist will need to
do some additional imaging. In fact, our radiologists
are actually very good here and that they pretty much
have the workup completed before they get to us. With the one exception
being whether or not an MRI is appropriate and that
commonly is a joint decision depending on how worried we
are about missing something because of someones breast density, or if there’s another
finding that we haven’t quite evaluated well enough whether an MRI is an appropriate test. We will do that in conjunction
with the radiologist to try to decide. We generally, unless the
person has an advanced tumor don’t need staging like looking
at the rest of the body. It’s really looking at
what’s in the breast because fortunately with screening
most people are diagnosed at stage one or stage two.>>How do you determine
who needs a lumpectomy and who needs a mastectomy?>>We have very set criteria on ones that have to have a mastectomy. So, the T four tumors
which means tumors that are involving the skin or
invading into the chest are larger tumors, or what’s
called an inflammatory breast cancer, those all
have to have mastectomies. The other criteria that
we use is a multicentric, which means it’s in
more than one location. So two tumors in the breast that are separated by a distance. That’s called multicentric,
those have to have a mastectomy and then the other group is,
there’s a group we refer to as large tumor to breast size ratio. So if the breasts are small
and the tumors larger, then we’re not leaving enough
breast volume to have a normal appearing breast and then
we have to do a mastectomy. Most women probably 80 to
90% of women are candidates for breast preservation in most settings. And then the other criteria
is if they’ve had prior breast cancer in that breast
treated with radiation therapy then we generally don’t offer breast preservation at that point.>>How about nipple sparing?>>The plastic surgeons can
give us more information on the over cosmesis. The nipple sparing topic
is primarily related to the cosmetics and it doesn’t
change much the cancer risk, it doesn’t change the cancer
portion of the surgery. The tumor has to be at least
one to two centimeters away from the nipple for us to
be able to save the nipple. But it does absolutely improve
the appearance of the breast. And that has to do with
saving all of the skin, and the nipple and areola. But there are some criteria from plastics that makes a difference in
whether or not the nipple will be in the right
spot, be the right height, a whole host of criteria. The surgery is a little more
difficult from our standpoint because we have to work under a distance, there’s some concerns about
the health of the nipple when the surgery’s finished. But the overall appearance
is just so much better then it’s certainly worth
that extra time and work that it takes to do that reconstruction.>>We heard an awful lot
about lymph node dissection. The lymph nodes that are in the armpit, gosh, what happens if you remove those? A pretty terrible condition that sometimes results in swelling of
the hand and so forth. What about that?>>We have fortunately spent
probably the last 10 or 15 years in the research in surgery,
trying to come up with ways to limit the amount of surgical
treatment that’s required, and that involves
involving plastic surgery to convert some women who
previously would have needed a mastectomy to now doing
breast preservation, but it also involves
preserving the lymph nodes. So, there have been a lot
of research studies done, the studies started in 99,
they were reported probably five or 10 years ago that say
that we don’t have to remove all of those lymph nodes, even if the tumor has involved that area. Now, that’s if a person was early stage when they were diagnosed, which is one of the advantages
of screening mammography. If we can catch them when they’re early, even if they have a little
bit of tumor in the node, we don’t have to do that bigger surgery. Which reduces the long term complications associated with the treatment. So, if they have lymph
nodes that we can’t feel, we can only identify them
on pathology as having tumor and it’s only one or two nodes, we don’t remove more nodes. If it’s four or five nodes or it’s a tumor that we can feel in the lymph
nodes when they’re diagnosed then we’re in a little bit of a bind, we can give chemotherapy
first to try to shrink that tumor away from those
nodes, and if we can do that then we get back into the
realm of having some options. But if the tumor doesn’t
shrink from the chemotherapy, then we have to remove those nodes.>>One issue I guess that’s
been largely in the news lately has been Angelina Jolie who
courageously came forward and said look, I have
these mutations and I think I ought to have both
of my breasts removed. How often do women come to
you with that when they get a diagnosis of breast cancer
even though that may not be what you would recommend?>>We do genetic testing on anyone who, there’s certain criteria
we use for that also. So genetic testing is done
in women who are diagnosed before menopause,
there’s certain criteria. Triple negative tumors
diagnosed before the age of 60, a family history that is
suggestive or male breast cancers, or a combination of
breast and ovarian cancer which is what Angelina Jolie’s family had. In that population we will
recommend genetic testing and if you know that
there’s a genetic mutation in your family, then we test
the rest of the family also. The risk of breast cancer in
that case is between 40 and 80% so it’s very very high. We offer to those women if
they choose to do high risk screening they can, and
we follow them along doing high risk screening
which involves mammography and MRI, and physical exams. Many of those women will
decide to go ahead and do preventive mastectomies and in that case, it’s fortunate that we can
offer them the option of high risk screening and
whether they choose to do that or the preventive
mastectomies is up to them. If we are doing preventive mastectomies, then we usually involve
the plastic surgeons to talk about reconstruction options.>>So let’s talk about
reconstruction options.>>In general, we have a variety
of reconstruction options and our goal when we’re
thinking about reconstruction is really first to preserve
and then to restore both form and function of the breast. So the reconstruction options
that we’re thinking of in general are using an
implant based reconstruction or using the patients own tissue, and then when we’re
talking about the situation like Lisa’s been telling
you about in terms of a prophylactic mastectomy,
we may have a few more options available to us in terms of
not just techniques but timing. Because our patients will
often ask us not just what type of reconstruction will I have, but what’s the time span
that I need to think about to have my breast reconstructed, or a portion of my breast reconstructed? And that’s very important
as well when we talk about sort of the overall complexity
of the reconstruction choices that our patients face.>>Would you please tell us then, what are some of those
reconstruction options and the various pluses and
minuses relative to them?>>Well I think what we would
all like is for every patient to be able to have in one
sitting and entire perfect breast reconstructed, but a lot of
times we do need to think about steps to get to that end goal. So if possible, we could try
to reconstruct what’s removed at the time of the surgery
with our surgical oncology colleagues that we work
very closely with as a team. If we’re able to do that,
then we can either use and implant or a patients
own tissue in that situation. If in discussion with the patients and discussion with our other colleagues, we think that it’s better
to do a staged approach to breast reconstruction,
then most of the time we’re starting with a temporary
prosthetic reconstruction that’s under the skin, so
it is a reconstruction, but it’s an implant based
or a temporary implant based reconstruction which is
usually this temporary implant that I’m talking about
is a tissue expander. So a lot of patients when
they’re doing their research before coming to see us in
clinic will have read about these and have a bunch of questions
because there’s a lot of information, luckily,
there’s a lot of information out there for patients to
be able to see what choices they have before even coming
to clinics so that they can come armed with some
questions, armed with some thoughts about what’s important to
them and then we can have a very rich discussion about those things.>>How quickly after
surgery can someone begin their reconstruction process?>>We hope that we can begin
the reconstruction process right at the time of the initial surgery. It may take us until we’re
finally done with everything that we can do with our surgical tools to rebuild the breast. It may take us several months
to sometimes over a year to achieve our end goals.>>How would you compare
and contrast the difference between implants and
a patients own tissue? Who’s suitable for each
of those techniques and how do women choose?>>It’s a tough choice
and some patients are suitable for everything,
other patients are better or worse candidates for different
types of reconstructions. When I talk to patients
about reconstruction choices, I think of the implants and
the patients own tissue. A bit as opposite ends of ones spectrum. So one end, we have an
implant based reconstruction, which is a little bit quicker and easier on the body for each surgery. We don’t need to add new
incisions elsewhere besides the chest where the patient
has to have the surgery anyhow. The downside to an implant
based reconstruction is that the implants aren’t
built to last forever. So there may need to be
maintenance surgery down the road, several years usually down the road. But still, that can be
daunting to patients to think about needing to have
maintenance when they really just like to get this
behind them and move on with the rest of their lives. On the opposite end of the spectrum is the patients own tissue. The advantage to that is once
it’s there and successful, it grows old with the patient. We don’t need to think
about that maintenance, but the downside is that we
do need to take this tissue from somewhere else on the body. So it may mean additional scars, it may mean additional healing, it may mean a little bit more
time in healing investment on the part of the patient early on.>>It sounds like you’re really
positive about it though.>>I think we have good
options for reconstruction, we have a variety of options. So what we’re really happy
about is that we can try to the best of our abilities
to talk to our patients to really get to know them
so that we can understand what their goals are and
so that we can tailor these multiple choices that we have
to what’s best for their lives because we know, this is not
fun, nobody chooses to have this done if they don’t otherwise have to. Our in plastic surgery
is to try to shift things so that it’s a little bit more choice, a little bit more opportunity, a little bit more
independence that the patients can start to feel again about
what they’re dealing with.>>Very good, we do have a
question and I’m gonna turn it back to you from someone who’s watching. What about breast cancer in men?>>Men do get breast cancer,
men have breast cancer, it’s a rare occurrence,
it’s about one percent of all breast cancers. When men have a breast
cancer, they are more likely to be a genetic carrier of the mutation that families can pass on
and that’s about 40% in men, where it’s much much less in women. So, a male breast cancer can
be detected by palpation, we do not screen men, we don’t follow men with screening after a
diagnosis of breast cancer. But can be very helpful
for the family to know for a follow up in planning
for other family members.>>Everyone here has mentioned
genetics and markers. So I’d like to hear from all of you. Gosh, what is the role for those? Do you see it expanding in the
future and maybe can be used as a screening modality in leu of some of these other things?>>Well, we’re very lucky
here to have a whole team of genetics experts and the breast ovarian surveillance service clinic. So that is fabulous, women can get all the information they need and
this is obviously expanding. We used to think of BRCA
one and two genes only and there are many more variants
now that can inform women about how they should be
screened regarding breast cancer, but other cancers as well.>>There are a lot of research
studies looking at trying to for detection that don’t involve imaging or other techniques. Most of them are all purely
in research aspects right now, people have looked at a
whole variety of looking for circulation tumor cells,
looking for DNA in blood. There’s a whole host of things
that actually some of our researchers are also participating
in and sort of driving some of that research. None of it’s ready for primetime yet. So none of it has gotten
us out of mammography, but there’s a number of
other imaging modalities. Ultrasound and things that
are also in research that are looking into trying to find
other ways to detection that don’t necessarily
involve the radiation exposure of mammography which is
minimal, very minimal.>>Mammography is a very good tool. It’s the only tool that
we have has been proven to decrease mortality from breast cancer, and as Doctor Jacobs pointed out. Cancers that are detected
by screening are generally small cancers and early
stage and therefore curable with a less invasive treatments. So mammography is good but it
has limitations particularly in women with dense breast tissue. So we can supplement the
mammogram with a variety of different tools,
including breast ultrasound, and breast ultrasound can be very helpful. It can have challenges with specificity, meaning that there are false alarms. We happen to be working right
now on some deep learning and machine learning project
combining mammography and ultrasound to see if we can
really increase the accuracy of cancer detection and
minimize those false alarms. Then there are several
advanced imaging techniques including breast MRI,
which requires an I.V. and an injection of
gadolinium contrast material. That is a very sensitive tool,
it uses expensive equipment that’s not always
available and accessible, and it is an expensive
tool in and of itself. In regards to screening
of the average population, probably not a good choice. We also have contrast mammography, which means that women again
have an I.V. and contrast material similar to that
use for a CAT scan and then a mammogram and that
too is very sensitive. It looks to be very similar
to MRI’s so more accessible using mammographic equipment. Certainly still has the
challenge of being more invasive with the intervenous
injection and there are some downsides to injecting contrast, and then the last tool
that’s sort of considered advanced imaging but highly accurate is molecular breast imaging. Where a radioactive material,
very low dose is tagged to a tracer and then that
is injected intravenously and we can look at the metabolic features of lesions that are in the breast. So that tool actually looks at
the function of breast cancer rather than just the
anatomic appearance on the mammogram or ultrasound. So there are lots of advanced
imaging tools, expensive. Coming along we’re getting there and lots of research that will help us.>>One of our watchers asks
what can we do about prevention?>>So breast cancer prevention
is an important component and it’s actually really interesting to me that we can prevent a cancer. That there is the ability to do that. This all started using
some of the medications that we use to treat breast cancers. So the first studies that were
done looking at prevention were prevention using tamoxifen, which is a treatment for breast
cancer and in those studies where tamoxifen was used for
treatment, it was noted that those women just had few breast
cancers on the other side. So then there was a very large study done in the United States with
about 13,000 women that put compare tamoxifen to placebo. And there was a 50% risk
reduction in women at high risk. So these were all high
risk women and that you can reduce the risk by about
half in the women who just have risk based on family
history or whatever the generic risk factor was. In the population that gets one of these indeterminate results, sometimes when the radiologist do a biopsy and you get something called atypia. Atypical ductal hyperplasia,
atypical lobular hyperplasia, you can reduce the risk
by 85% with tamoxifen or the hormone therapies. So it’s a very significant risk reduction. So I’m talking, so we also
like to define modifiable risk factors and non-modifiable risk factors. So, the modifiable risk
factors are obesity, weight gain after menopause. Many of them that you would think would be related aren’t really. We don’t know that smoking is a risk, we don’t know that birth
control pills are a risk. But exogenous estrogens,
so in women who take hormone replacement for
more than five years after menopause have a little
bit of an increased risk. So those types of things
are modifiable risk factors and exercising and maintaining
a normal healthy weight, low fat diet, those are all beneficial for reducing the risk. Then you have your
non-modifiable risk factors like having a family history,
your genetic risk associated from your family, or you have one of these biopsies that shows atypia. Those are the ones where
we would talk about trying to use chemo prevention, which is the hormone therapy. So we use the hormone
therapy to reduce the risk. It’s actually very
affective in some patients.>>Excellent, we’re at the end
and so I would ask all of you then to give just one positive
message in your expert views of breast cancer right now for women who unfortunately get this diagnosis.>>Our detection tools are
improving and we’re working hard in a lot of ways to continue that trend, and so early detection
can improve survival and also lessen the
invasiveness of treatment should a breast cancer be found.>>I would say we’ve been able
to partner with all of our groups to be able to do both
research and apply clinically reductions in the amount of
treatment that’s required. Partly because we can
have early detection, but also we can partner
with our plastic surgeons who even if we have to do a mastectomy, they can do the reconstruction. But if we don’t have to do a mastectomy, we can do breast reduction and lift, and give them an overall
improvement in their appearance which is the silver
lining on the diagnosis.>>And I just want to say
that we are all here for any patient who needs us. We wished that nobody
needed us and until the time when no one does, we will be
here to do our best for you.>>Thank you so very much for
joining us on Facebook live from Johns Hopkins Medicine.

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