Ask Dr. Rosen

What is Oncoplastic Surgery?

“I am completely aligned with the mission of Learn Look Locate to help educate and inform people regarding all the options available for breast cancer treatment: one size fits one.” It is extremely important that we give patients the opportunity to be heard and connect with other survivors going through treatment to feel emotionally understood and informed.”
-Barry Rosen, MD Breast Surgical Oncologist

One Size Fits One

Breast Cancer is not one disease; it varies a great deal from one person to the next. Likewise, we all come in different shapes and sizes. Most importantly, we all have different priorities and goals. Therefore, treatment needs to be individualized considering one’s unique biology, anatomy, and preferences. Every breast cancer patient needs to be empowered to explore all the options available to them and choose what’s right for them. That’s why its critical to find the right surgeon to help navigate through the transition from diagnosis to treatment. People need to listen to their inner-voice: if they are uncomfortable with their options, they need to seek out a second-opinion.

Q: Who is a candidate for genetic testing?

A: I think the short answer is “everyone”. Imagine if we could give every breast cancer patient the power to prevent breast cancer in a loved-one—this is precisely what genetic testing can offer for every breast cancer patient. Approximately 10% of all women with breast cancer will test positive for a mutation linked to breast cancer. Their 1st-degree relatives have a 50% chance of having that very same mutation; by offering ‘cascade’ testing to their relatives, we can then potentially prevent their cancer or, at the very least, find it at its earliest stages. Moreover, finding this mutation may impact surveillance and/or treatment options for all newly diagnosed women. Historically, cost has been a major deterrent; however, the test is now covered by insurance for most cancer patients, and, if it isn’t, it can be done for ~$250. If you were tested in the past for a BRCA mutation, please return for MULTIPANEL GENETIC TESTING—we have discovered many more mutations other than BRCA associated with breast cancer. Many women fear discrimination if ‘labeled’ with a mutation. There is a national law (GINA Act, 2008) that protects people with mutations from being denied medical coverage. While obtaining life insurance may be more difficult, I would choose ‘life’ over ‘life insurance’ any day. In short, please ‘pay it forward’ and get tested if you or a close relative have had breast cancer.

Your tumor- What is Genomic Testing

Every cancer has its own unique fingerprint which is determined by the presence or absence of certain proteins in the cancer cell. This information often guides what type of systemic treatment a breast cancer patient can benefit from. There are a number of different molecular profile tests available, of which Oncotype-dx, Mammaprint, and Endopredict are the most common. If you have had breast cancer, ask your doctor for a copy of this report and read it front to back.

What is Oncoplastic Surgery-Hidden Scar Surgery

What is Oncoplastic Surgery?

Oncoplastic surgery is the application of plastic surgical principles to a breast cancer operation to provide the most aesthetic result without compromising the cancer treatment.

Oncoplastic surgical principles are applicable to every breast cancer operation. This could be a simple as hiding the scar and closing the cavity or it could be as complex as performing a compensatory lift and reduction on the opposite breast to provide symmetry.

The most important thing to recognize with oncoplastic surgery is that this isn’t about vanity; this is about recovery. Every woman can have an excellent aesthetic result and not have a daily reminder of the cancer operation that they had.

What is IORT?

IORT is an alternative to traditional radiation therapy. This novel therapy is administered at the time of a lumpectomy and may replace the 4-7 weeks of radiation therapy that is often required following surgery.

This technique allows physicians to administer the necessary dose of radiation within the region of the breast most prone to recurrence, and simultaneously avoid exposure to healthy breast tissue or adjacent organs such as the heart and
lungs. By delivering the dose in a more precise manner, women are spared the common side effects of radiation including skin burns and lethargy.

Unfortunately, not all women are candidates for this treatment and there are only a limited number of hospitals in the United States which offer this. I hope that, by sharing this information, this alternative may be more accessible to women faced with a breast cancer diagnosis; people have a right to know all options available.

What is MBI ? How does it help if you have dense breasts?

Molecular Breast Imaging for Dense Breasts:
Dense breast tissue can mask cancers on standard screening mammograms. “As many as 25% of cancers can be missed,” “Every woman with dense breasts should have additional screening beyond mammography.”

A newer technique, molecular breast imaging (MBI) can help distinguish tumors in dense breasts otherwise masked by tissue. With MBI, a specialist injects a small amount of radioactive tracer that attaches to breast cancer cells and shows up on imaging.

Compared to mammography and ultrasound it causes less uncertainty, says Sumit Chhadia, MD, a radiologist at Advocate Good Shepherd, which plans to start using MBI in 2021. “It gives us a little more cut-and-dried answer of whether it’s suspicious and should be pursued or let go and considered benign.”

Ultimately, the goal is to match patients with the appropriate screening regimen, based on risk factors and breast tissue density.

Who is a candidate for genetic testing?

A: I think the short answer is “everyone”.

Imagine if we could give every breast cancer patient the power to prevent breast cancer in a loved one—this is precisely what genetic testing can offer for every breast cancer patient. Approximately 10% of all women with breast cancer will test positive for a mutation linked to breast cancer. Their 1st degree relatives have a 50% chance of having that very same mutation; by offering ‘cascade’ testing to their relatives, we can then potentially prevent their cancer or, at the very least, find it at its earliest stages. Moreover, finding this mutation may impact surveillance and/or treatment options for all newly diagnosed women. Historically, cost has been a major deterrent; however, the test is now covered by insurance for most cancer patients, and, if it isn’t, it can be done for ~$250. If you were tested in the past for a BRCA mutation, please return for MULTIPANEL genetic testing—we have discovered many more mutations other than BRCA associated w/ breast cancer. Many women fear discrimination if ‘labeled’ w/ a mutation. There is a national law (GINA Act, 2008) that protects people w/ mutations from being denied medical coverage.

Can breast cancer come back after a mastectomy?

Microscopic deposits of cancer cells may be left behind following breast cancer surgery which over time may grow and become evident as a LOCAL RECURRENCE. This occurs more commonly after a lumpectomy than a mastectomy and is the basis behind why radiation therapy is often recommended after surgery. This is why yearly surveillance is critical and why self-examination should continue even after a double-mastectomy . These cancer deposits typically grow adjacent to the scar or attached to the chest wall muscle. If an implant is present, this will typically occur in front of the implant. Less commonly, a NEW CANCER may develop after a mastectomy in residual normal breast tissue that was left behind. This is especially pertinent in women who have a hereditary predisposition and is why the preventive surgery is called a risk-reducing operation rather than a risk-removing one.

What is Neoadjuvant Therapy?

Certain breast cancers are best treated by chemotherapy followed by surgery, Neoadjuvant Chemotherapy (NACT). This can shrink a tumor to facilitate avoiding a mastectomy, provider the most important treatment first, prove that the CT is effective at shrinking the person’s cancer, and buys time to help make better decisions. This can also be done with hormonal therapy—neoadjuvant endocrine therapy.

Can Women with Implants Get Radiation?

Approximately 1 in 20 women in the US have breast implants. Therefore, its inevitable that many women with implants would develop breast cancer. Historically, radiation therapy has been frowned upon for women who have implants due to the scarring that occurs around the capsule of the implant, forcing women to choose mastectomy for their cancer treatment. However, modern techniques have overcome many of these obstacles-lumpectomy remains the best option for many women and the radiation that is usually necessary after surgery can still be given in most cases.

SINGLE VS DOUBLE MASTECTOMY?

If a woman requires a mastectomy to treat their cancer, a double mastectomy is typically frowned upon in the absence of a hereditary predisposition, as this does not lead to a higher survival rate. However, women should be empowered to be given this option as there is often a tremendous emotional value to lower the risk of a second breast cancer developing, as well as the freedom to never have a mammogram. Furthermore, if undergoing a simultaneous reconstruction, a double mastectomy will often lead to a more symmetric result.

What is a nipple-sparing mastectomy?

Traditionally, removal of the breast included removing the nipple. This dramatically affects the shape of the breast which limits reconstructive options. The reality is that breast cancer rarely involves the nipple; most women who require a mastectomy can avoid removing the nipple.

As larger-breasted women age, the nipple is drawn downward, a process called ptosis. Ptosis can dramatically compromise the aesthetic outcome of a nipple-sparing mastectomy. Therefore, surgeons may first perform a breast lift and/or reduction (mammaplasty) prior to the nipple-sparing mastectomy.

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