Breast Cancer Braclets

i'm dr. shawna willey, and i'm the director of the betty louourisman breast health center at georgetown university hospital. i'm a breast surgeon which means that i see patients who have both benignand breast cancer, and i also see patientswho are high risk. that means that they may have a higher risk for developing breast cancer and need advice about howthey should be managed,

what kind of imagingthey should have and ongoing evaluation. i've been in practicefor 23 years now. i started my surgical training27 years ago, even maybe longer agothan that, so i have seen a lot of changesin the breast cancer world. now every patient has their ownindividual treatment plan. there is not a recipe -if you get breast cancer this is what happens,it's very individualized.

it's becomemuch more personalized, we have much more varietyof treatments and we're able to tailor treatmentto what patients actually need. we don't overtreat themor undertreat them. i found that i enjoyedthis field because it's intellectuallystimulating. this personalized approachmeans that every single patient, you have to think about what is going to be right for her. another thing that i findincredibly rewarding

is that now,at the age that i am, i have patients that i have followedfor 20+ years. i have one lovely patientwho loves to remind me that she's known me longerthan two of my children have, and that to me is rewarding. i see someone who has had cancerthat long ago, and i still get to see her,we succeeded. she won, and that to meis what it's all about. and it makes me cry.

i do the whole gamutof breast operations. that means thatthere are many women who need surgeryfor benign disease. they might havea nipple discharge, they might have a benignbreast lump. those patients don't have cancer but they need to havesome kind of breast operation. but the majority of what i dois breast cancer surgery. that means women who have beendiagnosed with breast cancer

and need to havethe tumor removed, perhaps in the wayof a lumpectomy, which means that justthe tumor is removed but the rest of the breastis saved, or they may need to havea mastectomy. i also do a fair number of operationson women who are high risk. they may be gene mutationcarriers or they may have a very strongfamily history. they may have had prior surgery

that shows that they haveabnormal cells in their breast, and we do an operation to removetheir breast in a prophylactic way to try to preventbreast cancer from forming. well, almost anybodycan have breast surgery. one of the nice thingsabout breast surgery is it doesn't violateany body cavities. so even if someoneis very sick, they might have other health problems, if they have cancer,

they generally can stillundergo surgery. so we lookat the whole patient and we try to assesstheir whole medical situation. if they have a needfor a breast operation, for instance have been diagnosedwith cancer, then it's the very rare patient who's not healthy enoughto undergo that operation. that's a really good question because breast surgeons comein very different training pathways.

the majority of breast surgeonsare general surgeons who were trainedfor five to six years in the whole fieldof general surgery, and there are some of us,like myself, who have limited our practicesto breast surgery only. i've done this for the last 12 years where i see only breast patients. well a mastectomy itself takes aboutan hour to an hour and a half and there are some variations

that could make it lasta little bit longer. for instance, if we're goingnipple-sparing mastectomies, those are technicallymore difficult and they can takea little bit longer. many times when we're doinga mastectomy we also need to evaluatelymph nodes underneath the arm if we're doing the mastectomyfor cancer. that can add about another20-30 minutes to the operation. so the mastectomy part of itif a lymph node analysis is added

takes about an hour and a halfto two hours. the reconstruction is addedon to that. it's all done at the same time,same trip to the operating room. we do the mastectomy first and then the reconstructionoccurs. if it's reconstruction with implants or expanders that adds about another45 minutes to hour per side. if it's a type of reconstruction where tissue is takenfrom another part of the body,

that can add two to three hoursper side. so if you, for instance,have bilateral mastectomies, meaning both breasts are removedand bilateral reconstruction, the length of operating time could be four to five hoursto seven to eight hours. a lumpectomy by definitionmeans that you're removing the cancer with a rim of normal tissuearound it, and also need to, in most cases,evaluate the lymph nodes. i reserve the operating roomfor about two hours,

but generally it takesabout an hour and a half. mastectomy with reconstruction, depending on the typeof reconstruction requires a one to three nighthospital stay. if you have an expanderreconstruction, there's no other part of your bodythat's been operated on, generally you're in the hospital24 hours. the first 24 hours can bea little bit rough. you have to get overthe general anesthesia,

we need to make surethat you have good pain control, but once those milestones are hitpeople are able to go home, they're able to be up and around,they're able to eat normal food. they can sit, they don't have to bein bed the whole time, but they generally should not drivefor about 7-10 days, so they need to rely on havingsomeone with them for that period of time. if someone has a reconstruction where they've had tissue takenfrom another part of their body,

they would generally spend three nights in the intensive care unit and then are discharged. after than the recuperationis generally about the same, although keeping in mindthat they have two operative sites that they're recuperating from. they may have drainsin each of those sites, they'll have bandageson each of those sites. and specific instructions wouldbe given to each individual patient that's specific to that patient.

well, a lumpectomy is a much more limited operation than a mastectomy. it generallyrequires two different operations, or two different incisions,one on the breast and one in the axilaor under the armpit, and that's becausewe have to take out both the tumor and we needto evaluate the lymph nodes if the tumor is an invasive tumor. but these incisionsare much smaller. the breast generally lookspretty normal afterwards

except for the scar itself. patients do not have to spendthe night in the hospital. they do very well going homethe same day because we put local anestheticin both the incision areas. so when they wake upfrom anesthesia they have not only the medicationsthey've gotten from anesthesia to relieve pain, they also havethe local anesthetic. again, they can go home,they can act normally, they can do normal activities,

however we recommend thatthey not drive, they not drink alcoholic beverages, use pain medicationas they need to. generally a lumpectomywith sentinel node biopsy is a very well toleratedoperation. people do very well with it and it's very reasonablefor them to go home the same day. with a mastectomy the limitationsare really from the incisional area. there's no muscles that are removed,

there are no musclesthat are even cut so it's all more or lessskin level surgery so it heals pretty well. it takes about 7-10 days until people get drains out because there's drains put into drain any fluid, and until they'recomfortable enough to go without narcoticpain medications, and to be moving aroundsomewhat normally. it takes two to three weeksuntil they can start to feel

like they're getting backto their usual activities, and it's at about that time thatpeople are able to return to work. if somebody has an autologous or a diep flapkind of reconstruction that does prolong the healinga little bit, again because they havetwo different incisions and it might have affectedabdominal muscles or muscles on the back if they've had tissue takenfrom those areas.

so in those patientsit might be three or four weeks until they feel like they can go back to work, sometimes as longas four to six weeks. with a lumpectomy,again this operation is a little more limitedthan a mastectomy, however you have hada general anesthetic, you may have a drain in,probably not, the majority of the timeyou don't have a drain in, but there's the emotionalaspect

of having been treatedfor breast cancer. you will be comingfor a post-operative appointment roughly a weekafter the operation so i generally advise patientsto wait until that post-operativeappointment to see how they feel, to see whenthey want to go back to work. for some womenwork is a good distraction. they feel better if they're working, if they're in their usual routine.

for some womenit's hard to go back and face their co-workers and all the questions about theirdiagnosis and their operation. and it's also hard to have,again, the stamina that they needfor their usual workday. so i would say for a lumpectomy patient one to two weeks is reasonable, more towards the two week mark. if you have a lumpectomy

generally the incisionsare relatively small and the contour or the form of the breast can be maintained in most cases. but that's something thatthe surgeon should discuss with you based on how large the tumor is,how large your breasts are. a large tumor in a small breastdoesn't get as good a cosmetic result as a small tumor in a large breast because you're removing a smallerpercentage of the breast tissue. when we do a mastectomy we try to create breast

that will either matchthe other side if it's a one-sided mastectomy, or if you're having bilateral mastectomies, both breasts being removed,we try to match up both sides. again, we keep working on tryingto improve that cosmetic outcome by doing what we call skin-sparing mastectomies where we save your own skinso it looks normal, it has normal color,it matches the other side, and in some cases you might be a candidate

for what is a nipple-sparingmastectomy where no skin at all is removed, so you can save the nippleand the areola, your breast can look very muchlike it did before surgery. it might be a slightly different sizebut it's familiar to you, it looks like you. any operation, when you makean incision in the skin there are nerves that are severed. almost anybody who has hadan incision will tell you

that they have a littlenumb area around it. of course when you havea mastectomy in most cases you havea longer incision. and so it is very commonand it should be expected that you have a numb areaon the breast itself. if you've had to have surgeryunderneath the arm to remove lymph nodes, it's possible that you mayalso notice numbness on the back of your armor on your back,

or even when you're shavingyou may notice that you're numb. it's a bothersome thing to peoplebut it's not dangerous. well there's two different thingswe need to talk about. one is the cancer coming backin the breast itself, and the other is the canceroccurring somewhere in your body. so when we talk about the cancerrecurring in the breast itself or in a mastectomy site, the ways that we canreduce that risk is first by doing a good operationwhere we look and evaluate

to make sure that we have clear margins. the margin is normal tissuethat's outside where the cancer was and we want to ensurethat those margins are clear. we do that by lookingat the pathology report. the pathologist reports backto me as a surgeon whether or notthere's any cancer cells that's on the surface of the tissuethat i took out. if there's no cancer cells therethat means the margin is clear and that certainly decreasesthe risk of recurrence.

another way to decreasea local recurrence is by giving radiation. when women have a lumpectomyif we get clear margins we always send themfor whole breast radiation or some kind of radiationto the breast. those two things go together to get the very lowestrecurrence rate. the other questionof whether the cancer might have had a chanceto spread

and come back elsewherein the body is addressed by what we callsystemic therapy, and that's wherea medical oncologist might discuss chemotherapyor endocrine therapy, a pill that's taken to decreasethe risk of recurrence. let's talk about what kindof breast surgery because if it's breast surgeryfor a benign problem, a small amount of tissueis removed, a benign lump is removed,

that generally does not produceany problems at all. i've operated on many women who have had to havea breast operation, they go on to breastfeedwithout any problems at all. the bigger questionis whether or not, if you had to take outmore tissue or you get radiationto the breast, those are things that could interfereand have a negative impact on your ability to breastfeed.

although i have had patientswho were able to, i think the fair answer is to saythat it may not be possible. well first of all you should geta set of instructions from your surgeon's officeand from the hospital as to when you need to beat the hospital, you'll be told that you shouldn'teat or drink anything after midnight. that includes things likenot chewing gum, not sucking on a mint,not smoking a cigarette because all of those thingscould mean

that your operationwould get cancelled. you'll get specific instructionsabout where you should arrive and what timeyou should arrive. one of the thingsi tell my patients is to come in verycomfortable clothing, not so much before surgery but after surgery you want to havevery loose, comfortable clothing, sweat pants, elastic bands, nothing that you have to puta shirt over your head

because you may have limitedarm motion afterwards just because it might beuncomfortable to lift your arms, not because you can't. so a blouse that buttonsup the front or zips up the front is an ideal garment to wear to the hospitaland therefore to wear home. be sure that you have somebodywho's going to help you. you have to have somebodydrive you home. you have to have somebodywho's going to get

your prescriptions filled for you. you have to make surethat you have food and that you can getto the bathroom and all the things that you willwant to do once you get home. in the hospital of coursethe nurses help with all of those things, but as you transitionto go home you want to make sure that you haveall of those things set up even before the operation

so that there's no delays to you getting out of the hospital. we have certain criteriathat need to be met in order for a patientto leave the hospital. she has to have been ableto eat and drink without any nausea or vomiting. she has to be able to go to the bathroom to urinate on her own. she has to havegood pain control. she has to have normalvital signs meaning that her blood pressureis normal,

her heart rate is normal,her respiratory rate is normal and she doesn't have a fever. when all those criteria are met,i would encourage you to leave the hospitalas soon as you can because you want to get onwith your life and you'll be much more comfortable at home. if you're having a lumpectomygenerally, again, you're having a lymph node analysis, you would havetwo separate incisions.

in that caseyou will have the operation, you'd be in the operating roomroughly two hours, you will go to the recovery roomafterwards. once you wake up enough so thatyou're aware of your surroundings, you can have a sip of water, the nurses are satisfiedthat your vital signs are okay, that your heart rate is okay,your blood pressure is okay, you don't have a feverand you're breathing normally, they will transition you to an areawhere your family can meet with you.

that is the area thatyou will be discharged from. you will get our world famousgraham crackers or saltine crackers and something to drink, just to make surethat you're not nauseated and that you're going to be ableto go home, to have the car ride home. you'll get prescriptions written that will be given to youor your family at that time. you'll get instructions as to what you need to do with the bandage.

i would encourage youto bring a bra to the hospital so that you can wear it home. after a lumpectomy it's niceto have the support of a bra. it feels good on the incision, it feels good to have thatconstriction and that support. i also tell people to put an ice packon both incisional areas for about 24 hours afterwards. just like if you sprained your ankleyou're going to put ice on it. this is an injury too,even though it was through surgery

and the ice will help decreasethe bruising and the soreness. you can go home that day,you can eat normally. you'll feel tired,you should take a nap. use pain medicationas you need to, especially to go to bedthat night. the next day you'll feel soreness but you'll be able to startresuming usual activities. well i think two thingsfall into that category. one is nipple-sparingmastectomy,

and what that meansis you have a mastectomy where the breast tissueis removed but no skin is removed and we're able to leavethe nipple and the areola in place. this is a relatively new approachto doing a mastectomy and we actually have a registrygoing where we're evaluating to see whether long termit will be safe, because right now we don't havereally long term follow-up to establish the safety of thisin regards to cancer recurrence.

we have short term follow-upbut not 20-25 years, so we're really trying to evaluateto see whether or not this is, from a cancer recurrenceperspective, a safe operation. not all patients are a candidatefor that operation. it's very selective and we reallyhave to evaluate each individual patientto see if they meet the criteria for being eligiblefor that operation. another operation that we're doingor a category of operations is called oncoplastic surgery.

this is generally a termthat's used in women who are having breast conservingsurgery or a lumpectomy where we're trying to preservethe form of the breast but get very good margins. the ideal patientfor this operation may be somebody who hasa relatively large breast who has a relativelylarge tumor. if we were to do a goodcancer operation on her it might require a mastectomy

because the operationwould be too deforming. but we might be ableto combine a lumpectomy with a reduction, and she mighthave a reduction on that side along with her cancer operation. she may also subsequently geta reduction on the other side so that she matches. some of it has to dowith whether you have cancer, and there's cancer characteristics.in other words we would not recommendthis operation

for women who havevery large tumors or have tumors that are centrally located close to the nipple-areolarcomplex. even in that setting we remove the tissuefrom right behind the nipple and we send that to pathologyfor a permanent section. we get the results backfour or five days later, and if that tissuehad cancer cells in it we would tell the patient

that she needs to havethe nipple removed because that's too close. that means the marginsaren't clear. so those are the cancercharacteristics. there's also patientcharacteristics. women who havevery large breasts aren't a candidate for this because we can't constructa very large breast. we don't have prosthesesor implants that are that big.

plus, in many casesthey have too much skin. their breasts are hanging down and their skin has beenstretched out too much. so they're not good candidatesfrom a patient perspective. the ideal patienthas a to c cup breasts and may havea very small tumor or may be havingprophylactic surgery, maybe a gene mutation carrierand is wanting to reduce her risk and yet preserve the usualappearance of her breast.

so it's a very individualizedrecommendation and we have to be honestwith patients about whether it's the right operation for them from a cancer perspective and from their own bodyperspective. well we have at georgetowna multidisciplinary approach. we work with many differentkinds of doctors but the three core doctorsare a surgeon, a medical oncologistand a radiation oncologist.

if you want or needa mastectomy, we would also have you meetwith one of our plastic surgeons to talk about immediatereconstruction which could be doneon the same day with the same trip to the operating room as your mastectomy. in additionwe have lots of other services. we might have you seea genetic counselor if you have a strong family history.we have nutritionists, we often have patients go seeour physical therapists

after their surgery so thatthey can work on range of motion and be educated about of riskof lymphedema which is a swelling of the arm that can occurafter a lymph node dissection. we tag team all of those visits so you don't have to seeeverybody in one day necessarily, however we do have a breastcomprehensive care group where we see patients who havebeen diagnosed with breast cancer who have not yet had treatment,

and in that clinic they can seethe medical oncologist, the radiation oncologistand the breast surgeon all with one visit to the clinic. georgetown university hospitalhas everything to offer. we have breast surgeonswho are trained, specifically trainedin breast surgery, who are national leadersin breast surgery. we have reconstructive surgeonswho are national leaders. we have breast surgery coveredso to speak.

from a medical oncologystandpoint we are participatingin multiple clinical trials. we have excellent medicaloncologists, and many of them. we have five medical oncologists who are dedicatedto breast cancer alone. our radiation oncologistsare focused on breast cancer. they treat breast cancerwith radiation. they generally treatafter surgery is done and in most casesafter chemotherapy is done.

we have the full rangeof things. we have great geneticcounselors, our pathologists are great,it comes as a whole package. every department, every modality,every specialty has to have excellence in itfor us to be able to offer you the very best care possiblefor breast cancer.