Baylor’s St. Luke Medical Center

As we commemorate Breast Cancer Awareness Month this October, it is vital to highlight the importance of awareness, early detection, and treatment strategies. Breast cancer remains the predominant cancer diagnosis among women globally. To provide our readers with a comprehensive understanding of patient management and the latest advancements in the field, “Hospitals” Magazine has secured an exclusive discussion with esteemed specialists from Baylor’s St. Luke Medical Center.

Dr. Sebastian Winocour, an Associate Professor who serves as the Chief in the Division of Plastic Surgery, bringing an extensive background in reconstructive techniques post-mastectomy.

Dr. Alastair Thompson, Professor and Chief of the Section of Breast Surgery, whose expertise lies in surgical interventions and their implications for breast cancer patients. 

Dr. Karla Arabela Sepulveda, Associate Professor of Radiology, with her invaluable insights into diagnostic imaging and its crucial role in early detection and ongoing management.

What are the latest techniques in breast cancer diagnosis?

Dr. Karla: Breast MRI, although not a new technology, has been well established as the most sensitive breast imaging technique for detecting breast cancer. What’s new with breast MRI is the effort to maximize its benefits in detecting breast cancer while shortening the protocol to make it more comfortable for patients and, hopefully, cheaper. This is particularly challenging in the United States given the pressure on costs, as is the case everywhere. In the same vein, the imaging that takes advantage of increased vascularity in breast cancer is contrast enhancement mammography. Its interest and accessibility have grown globally. Certainly, in the past five years, there has been a notable increase in its implementation in breast centers around the world. There’s a lot to consider regarding cost and technical aspects when comparing breast MRI to contrast enhancement mammography; the latter is easier to implement.

In certain countries, they conduct mammograms and ultrasounds simultaneously. What do you think about that?

Dr. Karla: Indeed, to detect cancers that mammography might miss, screenings are often supplemented with ultrasound. If an issue is spotted during these techniques, the patient may be advised to have an MRI. However, if the suggestion is that this should be the first step, bypassing the other two techniques, it isn’t always the case. The MRI should be done in conjunction with the mammogram. We can utilize ultrasound or MRI for supplemental screening or diagnostic purposes if an abnormality is identified on the mammogram, necessitating further investigation. In such cases, we might carry out both an ultrasound and an MRI, leading potentially to a biopsy. Beginning with screening, patients without any complaints come in for their annual exam. Most will have a normal exam and require no additional imaging. If an abnormality appears on the mammogram, the next step usually involves an ultrasound. If the ultrasound detects an anomaly, it guides us for the biopsy. If the ultrasound doesn’t correlate with the mammogram’s abnormality, then we rely on the mammogram for guidance. So, the ultrasound you mentioned is a supplemental screening tool. It’s not recommended for every patient having a mammogram. Ultrasound, in addition to mammography, is beneficial for patients with dense fibroglandular tissue on their mammogram. Dense tissue can obscure small details. Ultrasound helps screen these patients with dense breast tissue more effectively. It’s not appropriate to perform an ultrasound on every mammogram patient. Ultrasound is advisable for those with fatty breast tissue or scattered fibroglandular tissue.

What is the role of a radiologist in detecting breast cancer and then in staging it? I know that your role involves much more than just imaging?

Dr. Karla: We’re fortunate, especially with the images we obtain from breast MRIs. Let’s say a patient has undergone a mammogram and ultrasound and is diagnosed with breast cancer. The views of the axilla and the internal mammary chain facilitated by the breast MRI are unique. It’s the only modality through which we can see these aspects using breast imaging tools. We can observe similar things on CAT scans, but a patient would generally have a breast MRI before they ever get a CAT scan. These are ways we can stage the patient. Additionally, mammograms and ultrasounds are very helpful for surgical planning, giving the surgeon a clear map of the extent of the disease, allowing them to plan the type of surgery the patient should undergo. This is where I believe breast imaging is particularly valuable, not just in caring for these patients and planning their next steps, but also in staging.

Dr. Alastair: I’d like to concur with Karla that imaging is crucial in guiding us, the surgeons, on what and how much to remove. It’s also beneficial when collaborating with the plastic surgeon in planning for aesthetic outcomes. From a surgeon’s perspective, I’d like to point out that mammograms today are vastly superior in quality than historically. In some places, like the Emirates Health Service, two different individuals read the mammograms, enhancing the quality and accuracy of detection. In other scenarios, augmented intelligence, or AI, assists in image analysis – a practice prevalent in the US. Furthermore, the three-dimensional reconstructions from certain mammograms, the so-called 3D or tomographic mammograms – the digitized versions – are incredibly precise in pinpointing locations within the breast. For someone like me, a simple surgeon, imaging has grown complex. That’s why we depend on radiologists to elucidate these details, ensuring I understand what to excise.

Dr. Karla: It’s also noteworthy to mention that radiologists are the ones performing biopsies. In the United States, the vast majority of breast centers have biopsies performed by radiologists. This, in part, is because, as Alastair pointed out, the imaging technology has advanced to such an extent that it makes biopsies easier with image guidance. Being able to see in real-time ensures we’re biopsying the correct target. This level of precision instills confidence that we’re obtaining the necessary tissue for diagnosis. I’m truly grateful that breast surgeons trust breast imagers to execute these biopsies.

We know that breast cancer treatment requires a multidisciplinary approach. When someone is diagnosed with breast cancer, they will be referred to an oncologist who determines the treatment. This oncologist will also coordinate with a surgical oncologist and sometimes a plastic surgeon. Can you explain the process of managing a breast cancer patient?

Dr. Alastair: First and foremost, it’s a multidisciplinary team that cares for the patient. This team includes imaging doctors, pathology doctors, and surgeons from various disciplines: a breast surgeon who removes the cancer, a plastic surgeon who reconstructs, as well as medical oncologists who administer drugs, and radiation oncologists who apply radiotherapy. It’s a comprehensive team centered around the patient. Addressing your question about whether to opt for surgery first, drugs first, or even radiation first: historically, the approach was to surgically remove the cancer and then follow up with drug treatment and/or radiation therapy. However, this approach has evolved. If a cancer is 2 centimeters or larger, especially if it’s a subtype for which we have potent treatments or if it has spread to some lymph nodes, initiating drug treatments first can test the cancer’s sensitivity to the medication. This means that in some cases, the cancer can be completely eradicated from the breast, and sometimes from the lymph nodes also, by the time surgery is performed. This gives us different surgical options. The surgical oncologist removes the cancer, and the reconstructive surgeon restores the patient’s natural shape and size. Thus, initiating drug treatments first can give more surgical options for the patient and we can learn more about her specific cancer.

If the cancer is entirely eradicated before surgery, how do you determine which part of the breast should be excised?

Dr. Alastair: This is where radiologists, like Dr. Karla and her team, play a vital role. When they perform a biopsy, they leave a small marker at the cancer’s location. They can mark both the breast cancer and the armpit’s axillary lymph nodes. Thus, during surgery, using these markers, we can precisely remove the location that previously had cancer or locations where cancer cells were present. We’re not guessing; we’re being precise and accurate.

Who decides if the patient should have a mastectomy or lumpectomy, and what is the difference between them?

Dr. Alastair: That question regarding the choice between mastectomy and lumpectomy is a challenging one for patients. There are some rare circumstances where we would recommend a mastectomy, usually if the patient has multiple tumors in separate areas of the breast or a very large tumor that has spread to the skin and lymph nodes. However, for many women, probably around 3/4 of the women we serve with breast cancer, there is a choice between lumpectomy, which involves breast conservation by preserving the breast while still removing the site of the cancer, or mastectomy, removing the entire breast.  At the end of the day, in consultation with the plastic surgeon, myself, and the rest of the team, we discuss the options and then the patient can decide. What’s very exciting in breast cancer treatment currently is the move towards more breast conservation in many women where it might not have been considered. A trial published in the past year showed that multiple smaller surgeries can be performed with similar recurrence-free survival rates after the surgery. It’s an exciting time for women in terms of treatment options and surgical treatment options.

Regarding breast surgery, if we discuss reconstruction, for instance, if a patient had one of her breasts removed, is it advised to remove the other one to achieve symmetrical breasts?

Dr. Sebastian: The decision to remove one or both breasts is made collectively by the medical team and the patient. While many patients have a risk of cancer recurrence similar to the general population, those with genetic abnormalities face a higher risk. In terms of reconstruction, bilateral mastectomy often provides easier symmetry, especially for those considering implants. Autologous reconstruction, using one’s tissue, typically sources from the abdomen, limiting tissue for future procedures if only one breast is removed. Some women choose double mastectomy for peace of mind against future screenings. The choice is deeply personal.

What are the benefits of opting for immediate reconstruction surgery post-mastectomy or lumpectomy, and under what circumstances do you recommend delayed breast reconstruction?

Dr. Sebastian: Immediate reconstruction, whether post-lumpectomy or mastectomy, generally yields superior aesthetic outcomes, as substantiated by numerous studies. From a logical standpoint, when you immediately replace the void left after a mastectomy with an implant or tissue, it helps maintain the breast’s natural contour. In lumpectomy cases, this can be complemented with procedures like breast reduction for those with larger breasts, further enhancing the results. Immediate reconstruction not only preserves the breast’s shape but also prevents potential deformities that might arise, particularly post-radiation therapy. Correcting such deformities at a later stage can be more challenging and typically necessitates another surgical intervention. Handling reconstruction immediately, during a single surgical session, often results in optimal and more satisfying results for the patient.

But is there a risk for patients due to extended surgery time? The duration of the surgery would be much longer if they have both surgeries at the same time. Is it risky, or does it depend on the patient’s general health?

Dr. Sebastian: The simple answer is no. Many of these procedures, particularly plastic breast reductions and contralateral breast reductions for symmetry, are done simultaneously with the breast surgeon. While the surgical oncologist performs the cancer removal, I work with a separate surgical team and set of instruments, operating in parallel. This doesn’t significantly increase the operative time. While the margins are being evaluated by the pathologist intraoperatively, I’m also working. For example, during a lumpectomy paired with a bilateral breast reduction, we often complete the entire surgery within two hours. This is almost the same amount of time it takes me to perform a breast reduction on a patient without breast cancer. It highlights the advantage of working with an experienced team in a comfortable setting.

As for delaying reconstruction, in certain mastectomy cases where we may not know the need for radiation or adjuvant therapies, we often place a tissue expander in at the time of the mastectomy. This acts as a placeholder, ensuring the patient wakes up with a breast shape. This placeholder is useful during the interval treatment time, pending pathology results and treatment, allowing patients to feel more like themselves post-op. For instance, if a patient chose or needed a mastectomy, we would put in a tissue expander at that time. Immediate reconstruction can then wait until the patient has completed all necessary post-op treatments. If radiation is needed, it would proceed, and we typically wait six months after radiation before proceeding to the final reconstruction. This is usually recommended to be autologous reconstruction using the patient’s own tissue.

After the medical treatment of the patient, before the surgery, do you usually conduct other imaging or testing?

Dr. Karla: Dr. Alastair mentioned that some patients receive chemotherapy before surgery, which we call neoadjuvant therapy. It can be very informative in terms of the potential for disease-free survival and overall survival. It’s essential to document with imaging how the patient has responded to the therapies. Particularly with a breast MRI, there’s significant interest in examining the difference between pre-treatment and post-treatment but pre-surgery images. You can also use ultrasound, but the breast MRI is such a powerful and sensitive tool for breast cancer. It’s an excellent way to see how the patient has responded and if there’s residual disease.

Usually, after the chemo and immunotherapy, how long should a patient wait for the surgery? We know chemotherapy can weaken the patient, and their immune system becomes very low. So, how long should they wait before undergoing surgery?

Dr. Alastair: You’re right; we like to give patients the chance to recover from the effects of the neoadjuvant chemotherapy. Typically, there’s about a three-week practical minimum between the last chemotherapy session and the surgery. Sometimes we might extend this period up to five to eight weeks if we need extra time for the patient to fully recover, especially if we’re planning major reconstructive surgery. So, a three-to-six-week window would be ideal.

Is it possible to have a nipple-sparing mastectomy?

Dr. Alastair: Absolutely. As Dr. Sebastian and I know, many women we operate on prefer to keep their nipple and the central part of the breast, which we call the areola, and the skin envelope. If the cancer isn’t affecting the areola or the skin, we can make a hidden incision underneath the breast. Through this incision, I can remove all the breast tissue and perform any necessary armpit surgery. This procedure retains the nipple and the breast skin, allowing the plastic surgeon to proceed with the desired reconstruction, either using tissue from the patient’s body or some type of implant.

So, if a patient discovers they have breast cancer at an early stage, they might be able to keep their nipple? Or does it depend on the type of breast cancer?

Dr. Alastair: Yes, but it’s very individual. It depends both on the subtype of the breast cancer and the patient’s preference. The shape and size of the breast are also factors. Without delving into overly complicated details, it’s essential to have a strong team—a skilled plastic surgeon, a competent breast surgeon, and imaging support—to make the best decisions for the patient and guide them effectively.

What are the types of breast reconstruction surgery?

Dr. Sebastian: After a mastectomy, which is the complete removal of the breast, we have two categories: either using implants or using one’s own tissue. The quality of implant-based reconstruction has improved significantly over the last few decades due to advances in technology. Silicone implants have stood the test of time and are considered safe. They ripple less, and we can also use special materials to wrap the implants, allowing them to be placed in the natural position of the breast, which is in front of the pectoralis major muscle. In the past, we placed it behind, which sometimes caused negative symptoms that we’ve now overcome. The alternative is using your own tissue, and with the evolution of microsurgical techniques, we can transfer tissue from the abdomen (the gold standard being the DIEP flap) to the breast. We also have advanced techniques using other donor sites, including the thigh and buttock. These advances in microsurgical techniques have also improved treatments for lymphedema and other issues related to breast cancer. Lastly, I believe the next frontier, especially for reconstruction, is advancing in neurotization to reconnect nerves and provide sensation to the incision site.

Dr. Karla: That’s interesting. This is a really important point. From my perspective as an imager who deals with these women and follows up on them, one of the primary dissatisfaction points they face is the loss of sensation. So, these advances are crucial for patients.

Dr. Karla, one last question: do imaging techniques with an implant yield the same outcome? Or is there a risk of missing cancer cells?

Dr. Karla: I often have patients with implants come for checkups, and they frequently ask if the implants will interfere with imaging. The limitation often depends on the implant’s position. As Dr. Sebastian mentioned, the implant can be placed in front of or behind the pectoralis muscle. If it’s behind the pectoralis muscle, we still have good visualization of the breast tissue. However, when it’s in front of the muscle and covers a significant amount of tissue, imaging becomes more challenging. One breast imaging technique involves specific implant-displaced views for patients with implants, which helps us maximize the tissue within the field of view. That said, imaging will never be as good as with a breast without an implant. But, when women ask if getting an augmentation will interfere significantly with detecting breast cancer in future exams, I don’t think it’s a significant limitation. If they’re adamant about breast augmentation, we can still do an MRI, especially to evaluate the integrity of a silicone implant and ensure it’s not ruptured. But having implants is not, in itself, a reason to be screened with a breast MRI.

Doctors, we know that early detection is key in breast cancer. Could each of you discuss how you participate in raising awareness amongst women about early breast cancer detection?

Dr. Karla: I’m fortunate because radiologists often help women get their annual screening and detect early signs of breast cancer. Early detection is satisfying because we can save lives by identifying the cancer when it’s small and hasn’t metastasized. It’s essential for breast imagers to promote the benefits of screening and for radiologists and cancer centers to make access easy for all populations.

Dr. Sebastian: May I add that as a plastic surgeon, I also have responsibilities. When I see patients without cancer or those with benign, non-cancerous diagnoses—like breast reductions for macromastia or aesthetic surgeries—I ensure that I order appropriate imaging for them to avoid any surprises during surgery.

Dr. Alastair: I’d like to add, and I mean no disrespect to my colleagues, that you, as the journalist, are likely the most critical among us. You have the power to inform, educate, and provide accurate information to the public. This empowers individuals to undergo the right tests, make early diagnoses, get treated, and ultimately prevent breast cancer from reducing the lifespan of both women and men.

Do you have statistics on the recurrence percentage of breast cancer?

Dr. Alastair: Given that one in eight women in many countries will develop breast cancer, if it’s detected early and treated effectively, it’s likely that the woman will live a long and healthy life. The risk of breast cancer returning in the breast is about one in 200 each year. The risk of breast cancer returning elsewhere in the body greatly depends on how early we diagnose the original breast cancer. Thus, early diagnosis and treatment of breast cancer significantly reduce the chances of any recurrence in the future, especially when we deliver effective treatments.

How does Baylor’s Cancer Center distinguish itself from other cancer treatment facilities?

Dr. Alastair: What’s unique is that we have a fantastic group of people who work together in a patient-centered manner. We boast the most modern facilities, techniques, and drugs. Together, in our beautiful brand-new building, we ensure that we offer the very best for our patients.

Dr. Karla: I’d like to add that what I find particularly gratifying about working with this group is the focus on evidence-based practice. In my previous private practice experience, the approach wasn’t necessarily driven by the latest information or research. It’s refreshing and beneficial for the patients to be in an environment that genuinely emphasizes evidence-based care. I appreciate this type of atmosphere where we prioritize patient care over an economic-based practice model that focuses on billing as much as possible.

Dr. Sebastian: I echo those sentiments. We all work very closely as a team, ensuring utmost efficiency for our patients. We frequently communicate directly, often squeezing in patients to see them promptly. We participate in weekly discussions with patients, pathologists, and other colleagues to ensure we provide optimal, advanced treatments. Our commitment to multidisciplinary care ensures the best outcomes for our patients. The feedback and results from our patients affirm why we continue our work at Baylor St. Lukes Medical Center.