Surgeon Seeks To Help Women Navigate Breast Cancer Treatment

Transcript

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. The survival rate for women with breast cancer is higher than ever, approaching 90 percent. We're going to talk about recent improvements in diagnosing and treating breast cancer and in breast reconstruction with Dr. Elisa Port, author of the new book, "The New Generation Breast Cancer Book." She's chief of breast surgery at Mount Sinai medical center in New York and director of its Dubin Breast Center. Dr. Elisa Port, welcome to FRESH AIR. What's the most cutting-edge development you're currently using?

ELISA PORT: There's a variety of different things going on. The cure rates from breast cancer have never been better. And while, of course, it is still a potentially lethal disease, we're doing better than ever before with all different subtypes of breast cancer. And that's mostly related to research advances and so, obviously, drug development targeted at very, very specific tumor - tumor types. We can look at a woman and her individual tumor and try to customize and personalize treatments for her particular case. I can give you an example of that. There's a test that's commercially available called the Oncotype test. And that's a test that we frequently do for subsets of women with breast cancer to help us decide. It's basically a tumor profile test. We take a snippet of their tumor, and a genetic profile is run on that tumor to tell us a little bit more about how it's behaving biologically. And, for example, it can give us very personalized information for a woman that looked like she had a relatively indolent cancer, telling us, no, it's really behaving more aggressively than we would expect. And perhaps we want to treat that person more aggressively in turn with chemotherapy, that sort of thing. And alternatively, it could give us the opposite information. So some of these tests are really almost standard-of-care and more widely available. Some of them are being done at only the top-tier centers.

GROSS: When you are profiling a tumor, do you then test it with different forms of chemo to see which chemo can effectively attack the tumor?

PORT: This is definitely the wave of the future. We actually do that. We take snippets of tissue from women who have a more biologically aggressive form of breast cancer. It's known as triple-negative breast cancer. And we're taking actually a snippet of that tumor and trying to grow it out in animal models and in cell models where we can potentially try out different types of chemotherapy to see what the response rate is before actually giving that to the person.

GROSS: Mammograms have become a little more confusing because there are choices now. There's more than just the conventional mammogram X-ray. There's now 3-D mammograms. There's the options of MRIs and possibly even sonograms. Can you just give us an overview of when you might want to do something other than the conventional mammogram?

PORT: Sure. I think this is a real hot-button issue because there are so many mixed messages that are being sent to women across this country. Mammograms are definitely the most effective way to pick up breast cancer for the general population. And that's why the current recommendations are that every woman gets screened with a mammogram starting at age 40 - period, end of discussion. OK, that said, every person is different. And their risk factors are different. And there absolutely may be a rule for adding on to the mammogram - not instead of - for women depending on their risk level, their breast density, and again, their underlying health. So...

GROSS: Why don't you describe what the 3-D mammogram is?

PORT: Sure.

GROSS: It's a relatively new option for women.

PORT: Yeah.

GROSS: And it's not being prescribed for everyone. It's select women.

PORT: So 3-D mammography is kind of a software update to conventional imaging where basically, for a slightly higher dose of radiation, it takes multiple pictures through the breasts. And you have to envision it - the way I explain it to them is it's almost like it's different paging through a book. So rather than generating one image in one direction and a second image in the other direction, you get multiple images, slices through the breast. And the thing that it's most helpful with is reducing the risk of what we call false positives - so saying there's something there when there really isn't - based on tissue overlap. So if you see a dense piece of tissue on one part of the breast and a dense piece of tissue in another part of the breast and those lay over each other in one view, it may look doubly dense. When you take these - these sheets of tissue...

GROSS: In other words, it may look like a tumor, is what you're saying.

PORT: Yes, it absolutely can mimic looking like a tumor. And then what 3-D mammogram can help with is separating out these pieces of tissue. So as you look at them individually, you realize it was just a summation effect of all these things overlapped. And really, there's nothing there. In some cases, it can pick up cancers that mammograms miss. And overall, it's probably better than a regular mammogram or what's called a digital mammogram.

GROSS: Now, what about an MRI? When do you think...

PORT: Yeah.

GROSS: An MRI of the breast is called for?

PORT: MRI is a test that is very sensitive for picking up breast cancer. It's a test that's done with an IV injection, where you receive a dye called gadolinium that circulates through the body. And it's picked up by areas of high blood flow. And one of the things that cause high blood flow is cancer. Cancer cells are growing and dividing very rapidly. And those involve increased blood flow in general. So MRIs are exquisitely sensitive to pick up cancer. So the question arises; why not MRIs for everyone? And the answer is because they are associated with a substantial risk of false positives. You do an MRI. You know, 14 things light up in the breast. And that generates a lot of anxiety, a lot of unnecessary biopsies and so forth. And so MRIs are generally reserved for screening women at the highest risk for breast cancer. We have to be really judicious with the ordering of MRIs. And those of us who do this for a living just have seen this play out time and time again. You know, you don't want to order an MRI as a knee-jerk kind of response. And you want to think through what the possible outcomes are in each individual patient.

GROSS: Because you don't want it to lead to a lot of unnecessary testing.

PORT: Correct, right. And...

GROSS: And scaring of women.

PORT: Of course.

GROSS: Yeah.

PORT: And unnecessarily when there's very little added benefit.

GROSS: Yeah.

PORT: So obviously, in the women who are at the highest risk for breast cancer, we worry more in those women about missing a cancer. And so the bar is much lower for doing these imaging studies, etcetera. And so we do. Again, it goes back to our theme, and it's one of the themes of the book, you know, of it's not a one-size-fits-all world anymore. And we - you know, those of us who do this for a living know, or try as best we can, to customize approaches for each individual person.

GROSS: One of your specialties as a surgeon is the sentinel lymph node biopsy.

PORT: Sure.

GROSS: And you've written about it too, in papers. So why don't you explain what the lymph node biopsy is in relation to breast cancer.

PORT: Sure. Finding out if breast cancer has spread to the lymph nodes is one of the single most important pieces of information. So in the old days, the only way of finding out if the lymph nodes were involved was to make a big cut under the arm and remove the nodes under the arm. So as tumors got smaller and smaller, that led to some very smart people saying, gosh, I wonder if there's a way to check the nodes under the arm without actually removing them all. Maybe we can just remove a couple of the lymph nodes and that would be a good indicator as to whether or not the rest are involved. And then, if those nodes are OK, we can leave the rest alone. So what sentinel node involves is that prior to surgery, a woman undergoes an injection of dye into her breast. And that dye travels to - along what's the called the lymphatic pathways - to a couple of nodes under the arm. And what that dye travel shows us is if this cancer's going to spread, here's where it's going to go first. These node or nodes - and it's usually one or two or three - are the gatekeepers for the rest of the lymph nodes under that - under that arm. And if you make a little cut - not a big one anymore - and pluck out those select nodes and those are OK, the rest are OK too. And you've basically reduced the degree of surgery that you have to do.

GROSS: If you're just joining us, my guest is Dr. Elisa Port. She's the author of the new book, "The New Generation Breast Cancer Book." She's the chief of breast surgery at Mount Sinai medical center in New York and co-director of its Dubin Breast Center. Let's take a short break. Then we'll talk some more. This is FRESH AIR.

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GROSS: This is FRESH AIR. And if you're just joining us, my guest is Dr. Elisa Port. She's the author of the new book "The New Generation Breast Cancer Book." She's chief of breast surgery at Mount Sinai medical center and also the co-director of the center's Dubin Breast Center. Let's talk about mastectomies. A lot has changed with mastectomies. I would ask you about who should get a lumpectomy versus a mastectomy, but I think that's so specific probably to each individual patient. I'm not sure how useful a more general discussion of that would be. You tell me.

PORT: Well, I think the long - there are long and short answers for this question. And I think the most important thing that women know is that there are both medical reasons why a woman needs one or the other and personal reasons why a woman could choose one or the other. And that is the epicenter of my job on a daily basis is working with a woman and giving her sort of the medical input and then saying, these are your safe options. And women don't always have all of the options open to them.

GROSS: So are there specific guidelines for when a mastectomy is absolutely required?

PORT: Sure. To give you a couple of general examples, you know, a woman who has a large amount of cancer in her breast, where from a technical standpoint it would be very difficult to do a smaller operation - make a small incision, get an area out, get what we call clear margins, the whole area out - and leave her with a result that she's happy with, that's one very, very common reason why we would recommend a mastectomy. Another, and this is a little bit more of a moving target, is in general, a woman who has - even if the areas are small, in general, when more than one area of cancer is found in the breast, a mastectomy is usually recommended. Although, in selected cases, people are starting to do what we call double lumpectomies, although generally, it's not the standard of care.

GROSS: When you're performing a mastectomy and your patient wants reconstruction, you're working with a plastic surgeon. What do you have to do as the breast surgeon to make sure that the cancer is gone, the breast is removed, but the breast is ready for reconstruction?

PORT: Yeah. You know, that's the years of training, which is walking the fine line between, of course, the number one priority, which is making sure all the cancer's out. No one wants to go through that extent of operation and recovery and so forth and then risk leaving cancer behind or an appreciable amount of breast tissue behind that could then form a new cancer. So of course, the number one goal is cancer. But, of course, we want to balance this with the aesthetic concerns. And this is often - you know, this is often a battle in terms of making sure that we do the first but also maximizing the chances of a good cosmetic result. For sure, my job is to remove as much breast tissue that I can. Often, we try to make our incisions really strategically located and as small as we can. And obviously, it's our job as breast surgeons to make sure that we're not compromising the results of cancer removal. You know, when you make a really small incision, it can make it more difficult to remove the breast tissue that's far away from that incision. You just can't reach. And so we have to be really clear about what our goals are and really stick to our guns sometimes about making sure that we're not compromising the cancer part or the cancer priority.

GROSS: So when you - when your patient is having reconstructive surgery and they're doing it with an implant, you keep the original breast skin to...

PORT: Yes.

GROSS: Cover the implant?

PORT: Yes, absolutely. So in general, most mastectomies that are done, especially those with reconstruction, are what are called skin-sparing mastectomies, where we can make really relatively small incisions. If we are removing the nipple, we go above the nipple and below the nipple with our small incisions and remove the small of ellipse of tissue, remove all of the breast through there. We can even check the nodes through that incision and leave the vast majority and preserve the vast majority of the skin envelope, where then, at the same surgery, a plastic surgeon comes in with an implant or a smaller version, a temporary implant - what we call a tissue expander - and can inflate that to a degree that fills out that remaining skin envelope.

GROSS: And that requires coming back several times for further surgeries?

PORT: Yes. So in general, you know, it can be challenging for the plastic surgeons, although many are able to do it. And it's obviously, again, on a case-by-case basis. It can be challenging to put the full-size implant in at the same time as the mastectomy surgery, and that's for a couple of reasons. You know, the skin - after you do a mastectomy, the skin needs to heal. And it's somewhat traumatized from, obviously, removing the breast tissue beneath it because that is the source of a large amount of its blood supply. And one of the things that can put further tension and pressure on that skin and affect wound healing is if you put a full-size implant under there; that puts a lot of tension on the skin. So in many, many cases, putting the smaller tissue expander is advantageous because it really gives the skin a chance to recover without being under tension. And then, over time - two, three weeks after surgery - an injection of saline into that temporary expander fills it out a little bit. And gradually, the skin is stretched so that it can adapt every step of the way.

GROSS: When you have successful reconstructive surgery through the more standard procedure, which is with the implants, how sensitive is the breast tissue to the touch following healing?

PORT: Right, you mean the overlying skin because theoretically...

GROSS: The overlying skin.

PORT: There shouldn't be...

GROSS: Right.

PORT: Yeah, there's - it's a really important point. And it is whether - I think one of the main points - you know, we're doing more and more nipple-preservation mastectomies now. But I think the key point that I have to make sure I inform women of is that whether you save the nipple or you don't save the nipple, most of the sensation is gone. And that's because the nerve endings that come through with the breast tissue are, by and large, removed. So for the most part, there is a lot of numbness in that area. And for every woman, it's sort of very gradual. When you start out, for example, touching the clavicle, they can feel that, which is your collarbone. And as you move down the chest after a mastectomy, it varies from person to person as to where the sensation ends and the numbness begins. But it's a really important part of my kind of - you know, the consultation. Women - you know, it would be natural to assume that if you save the appearance of the nipple, you'd be saving sensation when you really aren't in most cases.

GROSS: I know some women who have cancer in one breast and need a mastectomy wonder if they should have a mastectomy of the other breast because they fear that the cancer will spread to the other side. How frequently does that actually happen, you know, that the cancer jumps to the other side?

PORT: Yeah, this is really one of the most important - a great opportunity to clarify what risks a woman have - has - and, of course, the reasons for - both for and against removing the other breast. So to answer your question, the most important thing for a woman to know is that when she has breast cancer on one side, breast cancer can spread. It can spread to other parts of the body. It does not spread to the other breast. So women can develop a new, separate cancer in the other side, but for most women, that likelihood is extremely low. And most women do tend to overestimate their risks of getting a new cancer on the other side. Also critically important to know is that the removal of the other, healthy breast in no way reduces a woman's chances of the cancer that they have - particularly an invasive cancer - spreading. So - so there's really no difference in survival between removing the other, healthy breast and not.

GROSS: My guest is Dr. Elisa Port, author of "The New Generation Breast Cancer Book" and chief of breast surgery at Mount Sinai medical center in New York. After we take a short break, we'll talk about who should get genetic testing to see if they're at high risk for breast cancer. Then we'll listen back to an interview with Jack Larson, who played Jimmy Olsen on the 1950s TV series "The Adventures Of Superman." He died Sunday. I'm Terry Gross, and this is FRESH AIR.

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GROSS: This is FRESH AIR. I'm Terry Gross back with Dr. Elisa Port, author of "The New Generation Breast Cancer Book." She's chief of breast surgery at Mount Sinai medical center in New York and co-director of its Dubin Breast Center. Who would you recommend get genetic testing to see if they have the BRCA gene that would mean they face a higher likelihood of getting cancer?

PORT: Right. It's - you know, it is kind of a moving target. The groups of people, like the red flag situations where we think genetic testing may be appropriate, keeps expanding. But here are some of the big ones, women who are diagnosed with breast cancer premenopausally - usually, you know, in their 20s, 30s, 40s especially - who have a family history of other premenopausal breast cancers, women who have combined family histories of both breast and ovarian cancer, any family where there's a history of male breast cancer. And I think one of the important things to know is not that it's exclusive at all, but the gene is way more common in what's called Ashkenazi Jewish women, so women of European descent. So nowadays, pretty much any Jewish woman diagnosed with actual breast cancer can and should be tested. You know, and the number of Ashkenazi Jewish women who have the gene, which is shocking to some people, is actually 1 in 40. So a full 2 percent of the Ashkenazi Jewish population actually has the BRCA gene, whereas in the general population, it's, like, more like 1 in 400. So it's 10 times more common. So as you can imagine, any Ashkenazi Jewish woman diagnosed with breast cancer is getting tested. There's even some initiatives afoot to test Ashkenazi Jewish women even if they don't have breast cancer, with the idea being that if 1 in 40 are going to be found to have this gene, there may be options for those women for prevention that they would not have known about.

GROSS: But what kind of tough choices do you have to make if you've tested positive for the gene, but you don't have cancer?

PORT: In general, there are two main options over the course of time for those people. And it's very, very individually based. One option is what we call surveillance. Remember, we talked a little bit about MRIs, et cetera. This is a group where MRIs are critical. And in general, most of these women - BRCA-positive women who have possibly an upwards of 80 percent chance of getting breast cancer in their lifetimes - would be screened very aggressively. Usually, we do mammograms once a year, and we do MRIs once a year. And we split them up. So for example, a mammogram could be done every January, and an MRI could be done every July. So they're getting tested twice a year. We do physical exams on these people so that, you know, God forbid two months after a mammogram they develop a lump - what's called an interval cancer - we ideally could pick that up early. Unfortunately, the only other option is really on the complete other end of the spectrum, which is what we call bilateral mastectomy or risk reducing mastectomy. The only true way of preventing breast cancer in BRCA mutation carriers is by removing the tissue at risk. And so these are two diametrically opposed options and obviously need to be weighed on a case-by-case basis. And, you know, timing for - one of the things we talk about in the book is ideal timing for one woman may be too early or too late for another. And it can have a lot to do with where women are at in their lives, et cetera, and how they feel about themselves and so forth.

GROSS: Do you lean toward the let's-watch-carefully-and-monitor-you-direction as opposed to the double-mastectomy direction?

PORT: No, I definitely don't. You know, there are two genes, the BRCA1 and the BRCA2. In general, for those women who develop breast cancer with BRCA1, the tumors can be quite aggressive. Even the earliest, smallest cancers can be aggressive and life-threatening. So sometimes when a woman says to me, you know, I'm going to just have mammograms and MRIs, and then, when something develops, you'll pick it up early, right? And I turn around and say, you know, the problem with these BRCA genes is that early detection is a goal. It's not a guarantee. And even the earliest cancer detected in a BRCA mutation carrier can be something that is, A, associated with the risk of death, B, may need chemotherapy and, C, you know, may be associated with all kinds of other downstream effects. So for the woman who is interested in the watchful waiting approach, these are all important considerations to make.

GROSS: Since the BRCA gene is more likely to show up in women who are Ashkenazi Jews, do you always recommend to your patients who are Ashkenazi Jews that they get tested for the gene?

PORT: Many of them, yes. You know, I think one of the most tricky things about the mutation is that the mutation can be handed down on either a mother or a father's side of the family. So imagine, if you will, that I'm an Ashkenazi Jew. And my father - and of course men don't get ovarian cancer. And very few get breast cancer, although some do, of course. And make believe my father had the gene, but it travelled silently in him. And make believe he only had one brother. And make believe the gene came through their father. You could see how I, quote, unquote, "have no family history of breast cancer," and then I develop breast cancer at age 35. And they test me and find out, lo and behold, I'm BRCA-positive. How did that happen without any family history of breast or ovarian cancer? And it happened because I have a family with very few women on that side of my family. And so the gene can be very deceptive and very tricky and travel surreptitiously in families. So I do set the bar very, very low for testing in anyone where it may be traveling.

GROSS: But, you know, that does lead to a lot of potential double mastectomies, probably in some women who never would've had cancer. So you're kind of opening the door to mental suffering and to, you know, very invasive surgery.

PORT: Sure. I mean, I think this is - this is a very controversial area. But understand, with the BRCA gene, it is one situation - no one's advocating - you know, I certainly am not doing double mastectomies on women without the gene. You know, I have never really done that, in any appreciable numbers, preventatively. I mean, the cases are very, very few and far between. But what we're saying is that if you are found to be a BRCA mutation carrier, the likelihood that you will get breast cancer over your lifetime - and keep in mind, we never know with any individual person when that shoe is going to fall. You know, the - and so the timing is difficult to determine as well. The risk of ovarian cancer is also incredibly important. Ovarian cancer is a disease that is usually caught much later than breast cancer. As I like to say, there is no really early detection of ovarian cancer. There's no mammogram for the ovaries. And so at the very least for these women, we can talk about ovarian removal after they're done with childbearing and avoid that very lethal disease.

GROSS: Because the BRCA gene also leaves you more likely to get ovarian cancer.

PORT: Correct. The risk of getting ovarian cancer with the BRCA gene is anywhere from 20 to 40 percent with the BRCA1 and maybe up to 20 percent with the BRCA2, and earlier onset with BRCA1, later onset with the BRCA2.

GROSS: I imagine you've had to tell a lot of women that they have cancer.

PORT: Yes.

GROSS: What does that take out of you, to have to convey so many times such bad news?

PORT: You know, listen. I wish I could say it got easier as it goes along. But it certainly doesn't. And, you know, and there's degrees of it. You know, and it affects me every single time. But it is what we're trained to do. And I think for me personally, the only redeeming part is that that's followed very closely by, and here's what we're going to do to make you better. I think it would be much harder for me as a person to take care of a kind of cancer where there weren't so many amazing options for treatment and there wasn't as much room for optimism. And I think for me personally, that is what keeps me going.

GROSS: If you don't mind my asking, do you worry about getting breast cancer yourself?

PORT: I do, of course, as a woman. I don't think I do obsessively. You know, personally, we - you know, I have a complicated family history. But we don't have a huge breast cancer component in our family. But, you know, the average woman's risk is 10 percent over her lifetime. And I don't think I think obsessively about it. But I do what I have to do to make sure I'm being checked, exactly what I would recommend for - I do for myself what, you know - I do for my patients exactly what I would do for myself.

GROSS: Well, I want to thank you very much for talking with us.

PORT: Thank you so much for having me. I really enjoyed it, and it - I'm so appreciative of the opportunity.

GROSS: Dr. Elisa Port is the author of "The New Generation Breast Cancer Book." She's chief of breast surgery at Mount Sinai medical center in New York. After we take a short break, we'll listen back to an interview with Jack Larson, who played Jimmy Olsen on the 1950s TV series, "The Adventures Of Superman." He died Sunday. This is FRESH AIR. Transcript provided by NPR, Copyright NPR.