In part one of a discussion of breast cancer, Dr. Fox introduces Dr. Christina Weltz, an assistant professor of surgery and surgical oncology at Mount Sinai Hospital. In this episode, they discuss Dr. Weltz’s path to medicine, why breast exams are difficult for doctors, and more.
“Breast Cancer, Part 1: Overview of Breast Cancer” – with Dr. Christina Weltz
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Dr. Fox: Welcome to today’s episode of “Healthful Woman.” A podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. In “Healthful Women,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. I’m joined today by Dr. Christina Weltz who’s an assistant professor of surgery and surgical oncology at Mount Sinai and you work in the Dubin Breast Center doing primarily breast surgery in women with breast cancer, correct?
Dr. Weltz: That is correct.
Dr. Fox: Welcome. I’m so happy you’re here. You and I have busy schedules and, you know, fortunately, you’re taking care of a lot of people very well and you’re unfortunately busy because of what you do. But fortunately, I was able to get you in between operating room cases and patients so we can talk about this really, really important topic. Thank you so much for agreeing to come on.
Dr. Weltz: My pleasure. Thank you so much for asking me.
Dr. Fox: So for our listeners, Dr. Weltz as I first met you, Christina, you were one of my teachers in medical school.
Dr. Weltz: I remember.
Dr. Fox: Way back when. It must have been like your first day out of residency now that I think about it but at the time, I don’t think I knew that.
Dr. Weltz: It could have been. What year did you graduate from medical school?
Dr. Fox: So I graduated in 2001 so I would have been with you probably in, you know, yeah, ’99, 2000 in that range.
Dr. Weltz: That’s exactly when I started, yep.
Dr. Fox: What impressed me so much at the time and this is where I’m gonna embarrass you in front of the whole audience is, you know, when you’re in medical school, you meet all these various people and attendings, and surgeons, and internists, and cardiologists, and, you know, you talk about hundreds and hundreds of people, but there’s a few that always stick out they say like, wow, like, that’s a good doctor, that’s someone who I would send a family member to, someone who I would see. I just remember you were a great teacher, you’re really kind to the patients, you’re a great surgeon. And from that point on pretty much, you know, you’re the person I’ve been contacting when I, you know, need to refer someone for anything related to breast surgery or breast cancer and I appreciate having you around. That’s really where it started, you’re just an awesome, awesome teacher in med school and there you go.
Dr. Weltz: Thank you, that is so nice of you. I mean, it’s possible that one of the interactions that we had, you know, when I started, one of my responsibilities was running the breast clinic and it had been a little bit of a disorganized situation. Previously, we were sort of borrowing space from the OB-GYN clinic down on the E level of that building and it was a great clinic from the point of view of who attended it. We had medical students, we had interns in internal medicine who were going through their outpatient clinic rotation, and we had GYN residents, and we had surgical residents.
And what I was sort of able to do with that clinic is really the model I think for caring for women with breast cancer was to make it multidisciplinary. So we had a brand new medical oncologist at that time who just finished fellowship at Sloan Kettering who joined us and we had a pathologist who was literally on-site reading cytology specimens and that type of thing, we had a plastic surgeon who was attending it. And so it really turned out to be a great multidisciplinary experience. So that was probably the first time that we had met each other.
Dr. Fox: Yeah, it could have been. It’s so important I think that when you go through medical school, you know, as you have to learn a lot and some of what you have to learn is, you know, from a book or a lecture, some of it is just sort of how to interact with patients, you know, talking and thinking. But in terms of like, examination, like using your hands, physical exam, you know, doing a breast exam is such an important part of medical care, and it’s one of these things that many, many doctors need to learn how to do. But number one, just in general, when you need to, you know, learn things you need proper…you know, someone instructing you how to do it, but also, particularly either in the world of breast exams or what we do with pelvic exams, it’s a little bit more charged than maybe listen to someone’s lungs.
And so to have it done in a way where the patient is comfortable with what’s happening that, you know, she doesn’t feel like people are just poking and prodding her, people are like “practicing on her,” it’s done respectfully, it’s done modestly. And to sort of give her that reassurance but also that the learners understand sort of the seriousness of this, and it’s something that has to be done deliberately, it just doesn’t happen, people have to think about it in advance in order to do it right, otherwise, people just they don’t learn how to do it properly.
Dr. Weltz: I totally agree. And I would also add that, you know, I gave a lecture a couple of weeks ago to our fellows, the breast surgery fellow, and the radiology fellow, and the pathology fellow all in the field of breast cancer, and the lecture was on the topic of benign breast disease. And I started out by telling them that doing a clinical breast exam is still, after 20-plus years in practice, the hardest part of my job. And I actually spoke to them about it in the context of how difficult it is for gynecologists who are doing breast exams on a routine basis on women of all ages, including young women with extremely dense fiber glandular fibrocystic breasts.
And the difficulty in discerning normal density from something that could be worrisome, something that could even potentially be malignant is so incredibly challenging. And so I totally agree with what you’re saying both in terms of the sensitivity of it but also the extreme difficulty of it. And I really admire people like you who practice gynecology and are doing breast exams and need to interpret meaningful findings versus just normal density and it’s really, really challenging.
Dr. Fox: It’s hard. Fortunately, there’s so many options for imaging nowadays when there’s uncertainty and sort of what we call minimally invasive things like biopsies and whatnot, which again, they’re invasive, but they’re, you know, less than surgery there is that to, sort of, you know, fall back on. But it’s hard because it’s hard to get trained well in doing anything that involves a physical exam because so many people just walk in with imaging, but certainly, in these situations where it’s you can’t line up eight medical students like you would do for, you know, looking at a knee in the same way, you know. I could tell a patient, you know, “I want these six people to look at your knee.” “All right, fine, whatever, you know, okay.”
But, you know, you can’t do that in these circumstances so it takes a lot of…you know, a way to train people. And a lot of doctors stopped doing them because they’re just like, you know what, I’m not comfortable doing them, or I’m not good at them anymore, and so they get funneled into either OB-GYNs or, you know, they just go to you. How did you get into this in the first place? You know, what’s your background that brought you to go, you know, into medicine and then after that ask you about, you know, surgery and breast surgery, in particular?
Dr. Weltz: Medicine was an absolute complete fluke and was totally the last thing that I ever thought I would be doing.
Dr. Fox: I thought it was a dental school, hey, it turns out it’s a medical school.
Dr. Weltz: No, no, it’s even worse, it’s even worse, I was going to go into politics. I grew up in New York City, not far from the hospital. My passion was constitutional law and politics. And I had worked, in high school years, both in city and state politics and all of that sort of culminated in my senior year of high school where I was very fortunate to be given the year off, if you will, and spent the year in Washington working on Capitol Hill for a newly elected U.S. senator, and it was an incredible experience.
Dr. Fox: Oh, my God. Wow.
Dr. Weltz: It was just an extraordinary experience. One of his committee assignments was the judiciary committee, and he was also assigned to be on the subcommittee for the constitution. So this was 1978, ’79. And I was searching and writing memos and attending hearings related to things like abolishing the Electoral College, which, you know, would have been nice if we could have accomplished that then, I don’t know if we ever will. But that was really my passion and that was my intention.
So I went to college with that intention and I was actually accepted into kind of an interesting situation at college. I was offered the ability to do two undergraduate years and then go straight into the law school, which I decided not to do because I didn’t want to rush college. But as an undergrad, I thought the best way to end up as a good policymaker was to study humanity, to study history. So I majored in history and literature, that was an incredible experience. And I was literally in my senior year, I would have been starting law school a few months later, and out of the blue, I decided I wanted to volunteer at a children’s hospital just to do something off the campus, something that was meaningful to me, and I love kids.
So I ended up once a week at Boston Children’s Hospital volunteering. And I found myself one day playing cards with a nine-year-old boy who had been born with a very significant hip abnormality and he had just undergone major surgery to correct this condition. And while I was playing Go Fish with him, his orthopedic attending surgeon came into the hospital room and I was there while this child stood up and walked for the first time in his life. And I was moved beyond belief and I found myself in a janitor’s closet sobbing my eyes out, basically.
I went back to my dormitory room, picked up the phone, called my parents and said, “I’m going to take a pass on law school, I have to be a doctor,” and that was it, I never looked back. So I stayed on a little bit extra to do all of the pre-medical courses and went to medical school thinking I would go into pediatrics. As soon as I started doing clinical rotations, my first rotation was GYN followed by a month of obstetrics. And the first time I was in the operating room was scrubbing on myomectomy, big, huge fibroid, and they let me staple the closure and that was it. I knew I had to be a surgeon.
Dr. Fox: You knew two things, I had to be surgeon and I had to not be an OB-GYN?
Dr. Weltz: No, no, I loved the specialty and I loved obstetrics, I could not get enough of it. I did that rotation actually at Pennsylvania Hospital. I was a med student at UPenn and it was a fabulous hospital for GYN and GYN oncology and obstetrics as well.
Dr. Fox: Still is, yeah.
Dr. Weltz: Yeah, really amazing. And then in the context of my training, I very much went in the direction of breast surgery, I think largely because I was getting involved with some innovative clinical research in that field that was very exciting to me and that went very well, I really fell in love with this specialty. And it’s a wonderful specialty, including from the point of view of being there to help women during really one of the most difficult experiences of their lives. So there’s not only the medical and surgical and technical and, you know, all of those aspects of it but it’s a very collaborative team approach, which I think is the best way to practice, and it’s also very much of a connection to patients, which to me is really the most important part of the job.
Dr. Fox: Yeah, and I think that’s so interesting and, you know, your time, but you’re sort of draw towards humanities and, you know, law and policy. And it is interesting because, you know, as you know, at Mount Sinai Medical School, so many of the medical students now, I think more than half, come to medical school not through your traditional pre-med program. And that’s something that’s been increasing over time, they push these programs in a good way, and what they’ve come to learn and many people around the country have come to learn, you don’t need a science person to go to medical school, you need someone who’s bright, and caring, and kind and we can teach them whatever chemistry they need to know, which is very little. We need to…whatever biology, we’ll teach you, like, it’s okay, there’s no such thing as…you don’t need like, you know, a chemist or a mathematician to go into medicine because the skills you require aren’t typically scientific, they’re mostly people skills. I mean, if you’re bright, you know?
Dr. Weltz: I couldn’t agree more. And I think if your heart is in the right place and your motivation is there, that’s 99% of the battle.
Dr. Fox: I was just curious, how did breast surgery become like a field in itself because you don’t really hear about, you know, other than maybe like heart surgeons, cardiac surgeons, you don’t hear about people saying like, I’m a pancreas surgeon or, you know, just liver or…Is it something that just evolved because it was very technically complicated or just because it was such a maybe more loaded experience that you needed people who just did this because like you said, they had to work through everything else in addition to just the surgical or medical aspects?
Dr. Weltz: It’s a really good question. I think part of it is that I think so many aspects of general surgery, which is, you know, the field that breast surgeons originally train in, so many aspects of it are becoming increasingly specialized. Early, when I was training, many of my teachers were classical general surgeons, they did abdominal surgery, and they did vascular surgery, and they did breast surgery, etc. And, you know, some specialties, as you mentioned, like cardiothoracic or vascular or pediatric surgery early on became entities in and of themselves because they are so specialized.
And over time, particularly in, you know, places like New York where there’s such a demand for specialization, you know, I think general surgery has become increasingly specialized, which I think is a good thing. I think it’s particularly good with regard to breast and, you know, this also I think relates very much, for example, to gynecologic oncology is that as a surgeon, I have to know what I’m doing from a radiology point of view even though I’m not a breast radiologist, and I have to know what I’m doing from an oncology point of view even though I’m not a medical oncologist, and ditto with regard to reconstruction and with regard to radiation therapy and pathology as well.
And so I think over time, breast surgeons have become less involved with other surgeons and much more working as a team with other breast cancer specialists and I think that really results in the absolute best care that we can give people. I think the evolution has been a very good thing. You know, breast surgery is not everybody’s first choice, a general surgeon, it’s arguably technically not as exciting perhaps as operating on the human heart or blood vessels or laparoscopic procedures or that type of thing. We really only do three or four operations.
But, you know, I think historically it was looked upon as, you know, what’s the big deal? Anybody can take a tumor out of a breast, anybody can do a mastectomy, and we’re coming to learn that that is so much not the case. And when general surgeons who do not specialize in breast surgery and just perform it assuming that it’s no big deal do so both from a management point of view and from a technical point of view, things can go quite wrong. And so the fact that this specialty is becoming an entity in and of itself and that there is fellowship training these days and for the last 10 years or so, patients are getting far, far better care.
Dr. Fox: You know, one of the things that I always learned from the really good surgeons that I got, you know, the privilege to either watch or to operate with or just to learn from is so much of surgery, obviously, is technical, but people don’t realize how much of it is cerebral, meaning the decision of which operation to do is almost always gonna be more important than your hands when you’re doing them. And so, you know, like, yeah, if someone says we’re gonna do double mastectomy but that’s not what she needs, right? And, you know, okay, that’s not a great outcome, or vice versa, they do the opposite. They say, no, we’re just going to do a smaller operation but in fact, she needed a bigger one, or she needed to be offered a bigger one and, you know, discuss what that means. Again, it’s not always the technical aspect of how do you throw a suture, it’s really making the decision about what operation are we gonna try to do?
Dr. Weltz: Absolutely, that’s become all the more relevant now. Historically, it was always surgery first when it came to breast cancer, largely because there really weren’t other options but in so many situations now, it is far better to treat the patient, you know, neoadjuvantly with chemotherapy or hormonal therapy prior to doing surgery and the nuances of that are also incredibly important to make the right decision.
I can give you, you know, an example, one of the most aggressive types of breast cancer that women get is so-called triple-negative breast cancer, which is a particularly aggressive form of breast cancer which does not respond to hormonal influence, in other words, estrogen which in estrogen-positive breast cancer drives the cells to divide and which can be treated and medications that block that. There are no receptors of that nature in a woman who has triple-negative breast cancer.
These cancers, unlike most breast cancers, can really evolve quickly in a very frightening way. Tumors that are growing quickly, propensity for things to get into the skin causing inflammatory breast cancer, or propensities for things to metastasize far more quickly than other types of breast cancer. And a common mistake that you’ll see people make is to have a woman presenting with a rapidly growing aggressive triple-negative breast cancer and say to her, surgery needs to be done first, it needs to be done right away, and then everything else will follow. And the fact of the matter is that triple-negative breast cancer, despite being so aggressive, also responds amazingly well to chemotherapy.
And given that chemotherapy, for example, is treating the entire body, not just the breast but any potential cells that are systemic, you know, chemotherapy will stop the progression of this disease in its tracks, not only in the breast but potentially everywhere. And it is for that reason as well as some other reasons that chemotherapy in the vast majority of cases of women with triple-negative breast cancer really needs to be given first. And, you know, that type of thing has to be understood, and not only in terms of knowledge, but also in terms of intuition.
When you see a woman who’s presenting with a tumor that is literally growing in a way that you can measure over the course of a month or two, you have to think, you know, in terms of surgery is just not the right thing to do at this point. We’ve got to be attacking this aggressively on a global level, for example, with the use of chemotherapy. Those are the kind of decisions that are life-saving really.
Dr. Fox: Right. What percentage of your time clinically is spent on breast cancer versus benign breast disease? I’m just curious.
Dr. Weltz: It’s probably 65/35, I would say.
Dr. Fox: Is that is that typical for breast surgeons?
Dr. Weltz: Yeah, I think it’s typical. I think, you know, when people are starting out, they tend to take…you know, just to get established in practice and whatnot often start up, you know, treating a lot of benign entities or just doing problem-solving, which is a big component of the treatment of breast issues. And over time, people will sort of go in the direction of only wanting to treat women who have breast cancer and I’ve always felt that, of course, you know, arguably the most important thing that I do is in the treatment of breast cancer, but I very much enjoy taking care of women with benign disease. I love solving problems. And a lot of what you see in the treatment of benign or presumably benign disease relates to detective work and solving problems and making a determination as to whether something is or is not malignant, and I really enjoy that. It’s harder in many ways kind of like what I was saying before that doing just routine breast exams is incredibly hard, you know, seeing women with benign disease is also very difficult.
Dr. Fox: Yeah, I mean, listen, it’s obviously rewarding if someone comes with cancer and you can treat them and hopefully improve their outcomes or cure them, even if it’s impossible to help them get through it, but I’m sure it’s also equally rewarding to tell women, “You don’t have cancer, like, you’re good to go.” That must be a great day, you know?
Dr. Weltz: Very. Women will come in your office with a self-detected mass, and it’s incredibly scary. And, of course, their assumption is that it’s probably malignant, and fortunately, it usually is not malignant, and you check it on ultrasound and put a needle in it and it’s a cyst and in five seconds, it’s gone and it’s great.
Dr. Fox: I mean, obviously, breast cancer is something that, you know, fortunately, gets a lot of attention on the plus end because, you know, there needs to be, you know, awareness and screening and funding and all these things but women are terrified of it, obviously. I don’t think I’ve ever met anyone who’s not terrified of getting breast cancer, and why is that? Is that sort of because of all this attention? Or is it really, you know, appropriate for them to have this fear? Like where does that come from, sort of, in your, sort of, experience?
Dr. Weltz: It comes from largely the fact that it is such a common cancer. It is the most common…with the exception of, you know, very, very treatable skin cancers, it is the most common cancer that women get. Fortunately, it is not the most common cause of cancer deaths. And that’s a reflection of the fact that we, fortunately, are able to cure most breast cancers.
But I think it largely comes from the fact that it’s hard to find someone who has not had a relative or a friend or a relative of a friend who hasn’t had breast cancer. And I think, you know, women who have seen people go through treatment particularly in older days where diagnoses were made later, treatment was far, far more difficult than it is now. Everybody’s, you know, caught a glimpse of something that’s extremely upsetting and, at times, gruesome, and unfortunately, at times, results in death and I think that’s where a lot of the fear comes from. I hope that over time, as people come to realize that with early diagnosis and better treatment, you know, that most women who get breast cancer are able to be cured, thank goodness, that some of that will alleviate, but I think that’s part of it.
And I think it’s also, you know, a reflection of the fact that even though breast cancer, of course, becomes more common with age, nevertheless, there are women as young as 20s and 30s and early 40s, who get breast cancer. And, you know, having done this for, again, a long time, there is nothing more upsetting and tragic than a young woman, you know, who has young children struggling with this disease. And I think that’s the biggest terror of the whole thing. And I think anybody who has experienced that, or known of someone who went through that, or even seen a movie or television show depicting that, I think that’s where the terror comes from.
Dr. Fox: I think you brought up a lot of really important points. And it is really common. I mean, the number that people quote is that a lifetime risk is like over 10%, it’s like one in eight women will…
Dr. Weltz: Yeah.
Dr. Fox: But as you said, I mean, that’s a pretty scary number for people to process, but as you said, particularly with screening and good treatment, the majority, the overwhelming majority are not gonna die because of their breast cancer, they’re gonna get treated, they’re gonna be well, and you would think those that only improve with time, right? Someone who’s right now 20 or 30, it’s possible that if she’s unfortunate enough to get breast cancer when she’s 50, 60, or 70, you’re talking 30 years from now. Think of the treatments now, if they could have imagined that 30 years ago how differently it is.
Dr. Weltz: Absolutely.
Dr. Fox: And it’s one of these things that it changes the numbers when we look at it but it definitely explains why people are so afraid.
Dr. Weltz: I agree. I think it’s also really important to point out that with more knowledge of breast cancer in terms of how it behaves biologically and prognosis and treatment, we’re really coming to realize that breast cancer is many different diseases, and it ranges from very, very non-aggressive, indolent, strongly estrogen-responsive tumors that are extremely treatable and curable in close to 100% of the time.
And then really on the opposite end of the spectrum are far more aggressive types of breast cancer, things that present in very frightening ways, including inflammatory breast cancer, which is a particularly frightening entity. And, you know, I think as with any disease or any medical condition, the scary ones are going to be the ones that stay in people’s minds or that, again, might be depicted in a book or a movie or a television show. And, you know, that combined with the kind of numbers that you were just talking about, lifetime risk of one out of eight in America, it would certainly bias people to think that if you get this thing, it is going to be absolutely dreadful and fortunately, that’s not the case.
Dr. Fox: Yeah, I think a lot of times, particularly with breast cancer, a lot of women don’t talk to others about it, right, they don’t tell people. Someone has a very early treated breast cancer, her friends might not know about it, her family might not know about it. And so, frequently, the people in their lives that they know have breast cancer are the ones who are more sick and maybe undergoing bigger operations or, you know, out of work or, you know, are undergoing chemo. And so those are the ones that, sort of, you know about but for every someone, you know, you know about in that circumstance, there may be 5, 6, 7 or 10 people you know who had a much “easier,” it’s not easy, but easier course and are doing well and you don’t even know about it.
Dr. Weltz: Absolutely right. That also kind of flips the other way in that when women are diagnosed with breast cancer, and whether it’s through the internet, or through, you know, personal or family contacts, when people do reach out to them, again, the assumption is that this is an absolutely dreaded disease, and oh, you must be so terrified. And, you know, as a breast surgeon, I’m very, very, you know, frequently telling women, realize that every situation is different and that this is a very heterogeneous disease. And, you know, don’t fall into the temptation of listening to people who might have had one experience or known someone who had an experience because everybody’s situation is different, so I think it can sort of go both ways. So a lot of women become extraordinarily afraid because of people talking and giving them advice that that is really not reflective of their particular type of breast cancer.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com, that’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at email@example.com. Have a great day.
The information discussed in Healthful Woman is intended for educational uses only, it does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.