“Breast Cancer, Part 3: Diagnosis and Treatment” – with guest 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. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. I want you just to take sort of, like, the last [inaudible 00:00:24] I wanted to talk about is, you know, we talked about screening. What would it be like in terms of logistically if a woman either she finds a lump or maybe she has her screening mammogram and there’s a concern? Who would she see? What would happen? And, you know, again, we can talk about if it comes back benign, good news, versus it comes back cancer, not good news. But just, first, what would be the evaluation of either of those?
Interviewee: The major thing, and this has been a major, major change is that the vast majority of these diagnoses are made by radiologists because, since the 1980s, the development of needle biopsy, as opposed to surgical biopsy, has revolutionized everything. So, the day in which a woman found a lump in her breast and went to see a breast surgeon and was taken to the operating room, put under general anesthesia, had the lump removed, sent to a frozen section pathology intraoperative analysis, and if that showed cancer, she would wake up having undergone a mastectomy, thank goodness, those days are long over because now the optimal way to make a diagnosis of benign or malignant breast disease is with the needle biopsy. And the majority of those are done by breast radiologists using the appropriate imaging.
So, for example, if a woman goes for her annual screening mammogram and an abnormality is detected on the mammogram, or perhaps on a screening ultrasound or what we call a diagnostic ultrasound, the next step would be for the radiologist to explain that there is something of concern and that the best way to determine what it is is with the needle biopsy. And the needle biopsies are what we call core biopsies, where it’s an outpatient procedure done in the radiologist’s office. So, it’s just done with local anesthesia, but it’s a large-bore needle that is put into the lesion and pulls out a sample of the lesion. And even though it’s a small piece of tissue, the pathologist, particularly a pathologist who specializes in breast pathology, is able to tell us a huge amount about what’s going on. And if it’s cancer, the type of cancer, whether it’s estrogen-positive or negative and many other features of the malignancy, and flip side, if it’s a benign lesion, we can very reliably be able to trust that it is, in fact, a benign lesion.
So, you know, the radiologist becomes the key person in that regard. And it’s a real change for radiologists because, historically, they were sitting in a dark room, not communicating with patients, and just sending reports to referring doctors. And with the advent of these needle biopsies, they are the ones who are getting women through this very difficult situation and making those phone calls saying, “This is what you’ve got.” Their role has really become hugely important.
Once the diagnosis is made, if it is something that is malignant, or atypical, or something that either way requires the attention of a specialist, it’s really then that the breast surgeon gets involved that the women would be referred to a breast surgeon. And at that point, working with the patient, and her family history, and her personal history, and the nature of her cancer, it’s determined whether genetic testing should be done, whether further screening should be done, are more biopsies necessary to learn everything there is to know about the current state of the cancer? And at that point, a determination would be made as to the appropriate treatment, you know, surgically, chemotherapy, etc. So, that’s the normal course of events.
Dr. Fox: Right. So, for most women, they’re either going to the radiologist sort of routinely, annually, whatever it is, or maybe their doctor felt a lump, or they said they felt a lump, they say, “All right, we’ll go get some imaging,” and the radiologist will usually determine, do you need just a mammogram, mammogram plus ultrasound? Again, what they see sometimes may determine if they recommend, you know, a next level of testing or something as, “I’ll call you back for more images and a mammogram.” But if she or he suspects something, they’re going to do the biopsy either same day or schedule for the next day based on, you know, I guess, whatever factors go into that. And if it comes back benign and say, “Oh, it’s just, you know, this or that, whatever,” and they’ll say, “Okay, you know, let’s look again in three months,” you’ll never see them, right? Typically.
Interviewee: I typically would not. Sometimes I do just get advice or there are many benign things that for various reasons women do want to have surgically removed, so I would get involved at that level. But usually, like you said, yes, it’s a communication between the radiologist, the primary doctor, whether it’s the internist, or gynecologist, and the patient herself. Yeah.
Dr. Fox: Right. And I think there’s a couple of really important points in there that I want to highlight. Number one is that, again, for most women, when they go to get their screening mammograms, ultrasounds, combination, whatever it might be based on what’s appropriate for her, they’re going to, you know, a person who’s going to take care of them potentially. And the reason that’s important is we recommend women go to the same place. Like, it’s one of the few times someone in their adult life is going to have a relationship with a radiologist, right?
Dr. Fox: And so, you know, there are people with certain conditions who have that, where they have to get CAT scans every three months, six months, whatever. But for women, they should know the people, meaning it’s important, number one, because there’s an issue of trust, right? This is someone who’s seen me before and I trust him or her, but also they have all your prior images, they have all your results they can compare. And so, when people sort of bounce around from place to place, it doesn’t mean they’ll get bad care, but it’s sometimes more difficult for the radiologist to make a determination, and maybe they’re more likely to get biopsies when they wouldn’t if the radiologist says, “Oh, this was here six months ago, nothing has changed. We can keep watching it.” And so, that’s a really…It’s an unusual thing with imaging to have that sort of relationship with the radiologist.
Interviewee: I totally agree. And you’re absolutely right that keeping it as consistent as possible, it literally can be lifesaving. Until we have a system where everything is digitalized in a way that it’s accessible to every radiologist in the country, which, you know, with computer technology, maybe we’ll get there, not having prior imaging for comparative purposes leads to all sorts of problems. So you are absolutely right.
Dr. Fox: Right. And also, when people go for their mammograms, typically, they want to go to a place where they do a lot of mammograms because they’re going to have a radiologist who isn’t spending their day reading 100 different things, six of which are mammograms. They’re reading 100 mammograms and ultrasounds a day. That’s all they do. And most places, that’s how it is, but it’s good to ask, you know, “What kind of volume are you? Do you do this regularly? Does your radiologist only do this?” And that’s an important aspect that, again, in big cities, that’s how it’s usually going to be, but not necessarily.
Interviewee: Oh, yeah. I mean, you’re absolutely right. And, you know, other questions come into play, for example, should a woman have the yearly mammogram and should it be supplemented, for example, with an ultrasound? You know, in women who have very dense breast tissue mammography can only do so much. And we’ve all heard stories, of course, of women who had a cancer that the mammogram simply didn’t pick up. And interestingly, now, in New York and several other states, it is a state law that if a mammogram is deemed by the radiologist to reflect dense breast tissue, that the insurer is obliged to pay for supplemental screening, which most commonly translates into a screening ultrasound. And, you know, there’s extreme importance of expertise in radiologists interpreting both mammograms and ultrasounds. So, you’re right. And across the country, it’s not as good as it is in big cities. And there, we hear stories about radiology offices where hundreds of screening mammograms are piling up waiting for somebody to read them, and it’s a frightening disaster.
Dr. Fox: Right. And then, finally, in broad strokes, if someone is diagnosed with a breast cancer based on let’s say they go through this process, the biopsy shows, and obviously, the exact prognosis and treatment is going to be based on all those variables. But, in broad strokes, how would you decide with the patient whether she should be getting, A, no surgery or not yet surgery, B, a smaller operation, like a lumpectomy versus a mastectomy? What are the things that go into that? Because that’s the big decision I think people think about, “Am I going to need, you know, no surgery, ‘it’s not a minor surgery,’ but less of a surgery versus the big one?”
Interviewee: Yeah. With very rare exception, women who are diagnosed with breast cancer will need surgery. There are exceptions to that. There are women, of course, who are well into their 90s or who have multiple medical issues that would preclude the appropriateness and the safety of doing surgery, where instead of operating, we will treat them systemically, put them…for example, recommend that they take hormone-blocking pills. That won’t necessarily eliminate the cancer, but will keep it from advancing and will often cause it to shrink. But across the board, the vast majority of women do get surgery.
There are a lot of myths, and it’s important for women to understand what the reality is. The most important reality is that a lumpectomy, where we go into the breast and remove the tumor and leave the rest of the breast behind, is equally curative as a mastectomy. It’s not surprising that there is a misconception that bigger surgery means bigger cure. But the fact of the matter is that women who can have lumpectomies should not feel that they’re compromising their care by having that as opposed to having a mastectomy. That’s probably the most extensively studied topic in breast surgery with many studies and many decades of follow-up. And that’s a very important thing for people to know.
Another myth is…and this, again, relates to history and what we were talking about the old days where every woman was told, “Mastectomy is the only treatment that we can offer you.” There is also a myth that in this day and age, no woman should have a mastectomy. And the fact of the matter is that many women do need to have a mastectomy. There are certain situations where no matter what, there is no way that we can remove a tumor successfully with just the lumpectomy. There are women who have several different tumors in the breast that are spatially way apart from each other, where it would be a mistake to try to remove each of them individually. And really, the most common reason for a woman needing a mastectomy relates to what we were talking about earlier, namely ductal carcinoma in situ. So, you know, our obligation as surgeons in treating women with breast cancer is to not only get out all of the invasive cancer, which is what we generically think of as breast cancer, but we also have to get out all of the in-situ breast cancer, which, in a sense, is often the background from which the invasive cancer has emerged. And the tricky thing about ductal carcinoma in situ is that even though it is stage zero and completely curable…
Dr. Fox: It’s all over the place.
Interviewee: …it can be all over the place. And so, one of the really tough situations that women face is being diagnosed with ductal carcinoma in situ with no symptoms. Just presenting for their yearly mammogram, having a situation where the ductal carcinoma in situ is extensive involving half the breast and being told, you know, “The great news is what you have is stage zero and completely curable, and you won’t need chemo, and you don’t have to worry about possible metastasis or death, but I cannot get this out with anything short of a mastectomy.” And that is sort of a huge paradox for people to struggle with. And so it makes me a little angry when, you know, some of the press will…particularly the “New York Times,” for some reason tends to do this really dashes the concept that surgeons still tell women that they need mastectomy. How could we do that? It’s brutal, it’s butchery, etc. The fact of the matter is because of these circumstances, many women do need it, and, thank goodness, we can do it in a way that saves most of the skin that enables a very natural-looking reconstructive result and can be completely curative. There are so many different factors and it’s often the absolute opposite of what people might anticipate that an early-stage breast cancer can require a mastectomy, whereas something far more invasive if isolated is very safely treated with a lumpectomy. So, it’s not exactly what people would always think.
Dr. Fox: How common is it that women are sort of presented with a choice where, like, “We can do a mastectomy as option A, and that’ll be sort of your final treatment, most likely, or a lumpectomy, but along with that comes radiation or chemo”? And then it’s sort of like you’re balancing, “Do I rather have a smaller operation plus more treatments or I just want to have a bigger operation and be done with it?” Is that something that’s common, that type of decision?
Interviewee: It is common that we present women with choices. I think a large part of my job is to really explain all of these things, you know, to explain sort of the same thing that I was just talking about with regards to ductal carcinoma in situ, explaining to women why in a situation like that the mastectomy is the only option. And also explaining, for example, overcoming myths that people believe in, you know, namely that the mastectomy is more curative. I would never force someone to have a lumpectomy who just feels more comfortable with a mastectomy. But I think if you spend 15 or 20 minutes telling people about the studies, telling people about the history, showing women, for example, their own imaging and looking at the X-ray, the mammogram with the patient and explaining why the lumpectomy is safe or why the mastectomy is necessary, I think, you know, with education, and explanation, and just good communication, the myths get weeded out and the reality comes home. And I think, at that point, it becomes very clear what the right decision is.
Dr. Fox: What an amazing conversation. I’m so happy we spoke for, you know, the past six hours or whatever it’s been. But it’s one of these things, I guess almost, if not everybody you take care of as a woman, I take care of women, my life, I’m surrounded by women, and everyone is really afraid, you know, about breast cancer, and for good reason. It’s a really scary thing. When someone says, “I have, you know, 1/8 chance getting a cancer in my lifetime,” and it’s freaky. Like, it’s really scary. And I think that…
Dr. Fox: …you know… But the more sort of women realize that, number one, although it’s common, as you said, most people are going to do very well, and particularly if they have screening and that they should be confident that the people doing the screening are now really specialized in this, that they’re good at this. Like, they do this all the time. And if, you know, they do have a problem, whether it’s precancer, or cancer, or even a benign disease, that there are doctors like you who do this all day. This is like, “These are the people who take care of…” You see them, you understand sort of what they’re going through physically, medically, emotionally. I mean, there’s so much that goes into this, and this is what you do, and that women should feel…even though, yes, it is scary, they should feel confident that as long as they’re doing the things that they’re doing, and seeing the right people, and, you know, following whatever, that they’re likely going to be fine in one way or another.
Dr. Fox: And the journey may be hard, it may be easy. Just, you know, there’s a lot of roads people take, but it’s not just this doom and gloom that has to hang over people. And I just think that it’s such an important message and we continue to learn more, and as the therapies get better and screening gets better, this should only improve over time, you know, for our daughters, our granddaughters. It should only get better, not worse, fortunately.
Interviewee: I completely agree. Even when things are tough, and even when it’s a difficult situation prognostically, therapeutically, I’ve always been a believer. There’s no problem that can’t be solved, and working with patients both as a physician-patient, but also as a person-to-person. And I often think…you know, I know more about breast cancer not surprisingly than most of my patients do. That’s what I do professionally. But other than the fact that I know about it and they have it, other than that, we’re the same person. And I think that’s so important, and being there for the person as a human being and not just as a doctor is so incredibly important and so meaningful. It’s what gets me through, and I think it’s what gets so many of my patients through. And it’s really the beauty of the profession.
Dr. Fox: It’s amazing. I totally agree with that sentiment. Wow. Thank you.
Interviewee: Thank you so much.
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 H-E-A-L-T-H-F-U-L-W-O-M-A-N.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 firstname.lastname@example.org. Have a great day.
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