Practice English Speaking&Listening with: Surgical Management of Breast Cancer

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Good morning. I'm Jennifer Baker. I'm a breast surgeon at UCLA Health.

Welcome to my webinar titled "Newly Diagnosed with Breast

cancer: Understanding your diagnosis and treatment plan." I wanted to do this

webinar because when a patient is newly diagnosed with breast cancer, there's a

lot of information to process, and it's difficult to understand all of your

treatment options in a single visit with your physician, so I wanted to provide

our resources for my patients to watch at home that just reviews basic

information about breast cancer and an overview of breast cancer treatment.

The webinar will just go over basic principles, so it will not be

personalized to your case. However, I do feel it's a good tool to gain a better

understanding of the disease to become more familiar with your treatment

options and ultimately feel more empowered to make the correct treatment

decisions that are right for you. So, we'll be streaming live, so if you

have any questions throughout the webinar, just feel free to post them at

Twitter at hashtag #UCLAMDChat. So, a couple of

key points before we get started, first being that breast cancer is very common,

but not all breast cancer is the same. So, there are three subtypes of breast

cancer: estrogen receptor positive, HER2 positive, and triple negative. Now, these

cancers are very similar in that they arise in the breast. However, they behave

very differently, and thus we treat them differently. So, your treatment plan will

be personalized, and it is very likely that you may know someone else who has

been diagnosed with breast cancer, you may be familiar with their treatment

plan and experience. However, understand that your treatment plan may look very

different from theirs, and it will be personalized based on the biology of

your cancer, or the breast cancer that you have, whether it's spread outside of

the breast, and other factors that are specific to your situation. The other

thing to keep in mind is that most women have excellent long-term prognosis,

and thus, we never want the treatment to be worse than the disease. Today, we are

doing more and more targeted therapy, and that means we use drugs and surgeries

that are effective for your specific cancer, and we're able to avoid

medications and surgery that you don't need. And finally,

treating your cancer will take a team of doctors. So, often, the first doctor

you'll meet will be a breast surgeon like myself. However, a medical oncologist

will be part of your your care, and sometimes a radiation oncologist as well

as a plastic surgeon, and we'll describe their respective roles as we get going.

So, how common is breast cancer? This is a graph of the breast cancer incidence in

the United States between 1975 and 2015. You can see that between 1980 and 2000,

there was a huge increase in rates of breast cancer. This corresponds to when we

were using routine screening mammogram, so we were detecting more cancers simply

because we were looking for them, but if you look over the last 15 years, there's

been a high but relatively stable incidence, and we estimate that 1 in

8 women in the US will experience a breast cancer diagnosis at some point in

her life. And in 2020, we'll see 276,000 new

breast cancer cases in the US in women, and we'll see 2,700 new cases in men. Now,

despite the high incidence over the same time period, we see that the death rates

related to breast cancer have significantly declined. We've seen a 40%

decrease in mortality related to breast cancer since 1990, and this is related to

detecting breast cancer at earlier stages as well as more effective

treatment strategies, so fortunately, most breast cancer that we see today is very

treatable, and if you look at women diagnosed with breast cancer between

2009 and 2015, at 5 years, there was a 90% survival. And if the disease was

localized to the breast only, there was a near 99% survival at 5 years. Your

specific prognosis will depend on, again, your stage at diagnosis and the biology

of your tumor, which we will cover in detail. So, "Why did I get my breast cancer?"

This is the question that everyone wants answered, and most of the time, the answer

is that we don't know exactly why you developed breast

cancer. We do know that there are risk factors that increase your chances of

getting a breast cancer, one being family history, especially multiple family

members on the same side. We've also identified genetic mutations, so

mutations in genes that are passed down from your parents that are significantly

associated with breast cancer, the most common of these are BRCA 1 and BRCA 2,

but this only explains 5% to 10% of the breast cancer cases that

we see. We also consider hormone factors, and this is total lifetime exposure to

estrogen, so the more estrogen over a long time period that you're exposed to,

that will increase your risk of getting a breast cancer. There's other things

that I've listed here, but still, the number 1 and number 2 risk factor

for getting the breast cancer is simply being female and getting older. And 85% of

the patients that are diagnosed with breast cancer will have no family

history of breast cancer and no major identifiable risk factor, so while we

can't tell you exactly why your cancer developed, we I think it will be

important to review the basic principles behind a cancer development and

the difference between how a normal cell behaves and how a cancer cell behaves. So,

this is a normal anatomy of the female breast, and you can see it's a fatty

gland that sits on top of the chest muscle, and if you look at it in

cross-section, the yellow area--this is fatty tissue and support tissue of

the breast--and the major structures are these lobules and ducts.

So, the lobules are the balloon-like structures here. Their job is to make

milk, and then the milk is carried out through ducts out the nipple, and we call

those the milk ducts. So, if you look at those under a microscope

under very high power, and you're looking at just a single lobule and a duct, you'll

see that the lobules and ducts are lined by a single layer of cells, and if we

look at this even closer, you'll see that there's a dot in the middle

every single one of those cells. So, that is the cell nucleus, or the control

center of the cell. That nucleus contains all of the DNA and information that

instructs the cell on how to behave, when to grow, and when to die. So, normal

cell growth would be that a cell would get a signal to grow; at some point, the

cell would be instructed to copy itself or replicate itself, and during this

process, all of the DNA is copied, and then once a successful cell has been

copied, the original cell is signaled to die, okay, and that is very regulated, and

it's a normal process in cell growth, such that these cells are constantly

turning over, but as long as they're behaving appropriately, by and large,

there will be a single layer of cells. So, what happens in a cancer cell? In a

cancer cell, there is a problem. There's damage to the DNA, okay. We don't always

know why the DNA damage occurs--it could be because of a carcinogen or an

external influence, it could be because of a genetic predisposition in the cell

itself, but whatever the reason, if this DNA damage is not caught, a cell can be

made with mutated instructions, okay. So the nucleus of the cell now has DNA

that's not going to give the instructions that the cell needs to grow

properly, and instead, it's going to tell the cell to grow and divide too fast, or

not listen to the normal cell, the signal to undergo cell death, and what that

causes is uncontrolled growth. So the cell is now being told to replicate and

grow, and each time it replicates, it's going to replicate the same mutated copy

of itself. Now, when the cancer cells are stuck in

the duct--as in you see in this picture, the cancer cells are growing, and they're

multiplying, but they're stuck in the duct--we call this ductal carcinoma in-

situ, or stage zero breast cancer. At this stage, the cells may form a mass or a

local problem, but they don't have the ability to spread outside the duct. So, an

invasive cancer, which is what we're concentrating the webinar on today, the

cancer cells have learned to get outside of the duct, and the reason why this is

important is because just outside of the milk duct in the fatty and support

tissue of the breast is also where the blood vessels and lymphatics live, and

these cancer cells could be carried away by the lymphatics and the blood vessels

to other areas of the body, and this is the danger of breast cancer. So, if the

breast cancer cells stayed in the breast, they may cause a mass, they may

cause a local problem, but they would never take your life. The danger to your

life becomes when these cancer cells learn to leave the breast and go to

places that you need to live, like your liver or your lungs. So, when we plan your

treatment, and when we think about your prognosis, we're going to think about

your tumor stage, and we do that by what's called TNM staging. So, T--what is

the size of the tumor in your breast, N-- has a tumor traveled to nearby lymph

nodes, and if so, how many, and then M--this is metastases, or travel to distant sites,

and this is when the cancer is spread to distant organs, such as your liver or

your lungs, and we call this stage IV breast cancer. The other thing that we're

going to think about when we plan your treatment, and that is very highly

associated with your prognosis, is something called your biology of your

breast cancer, and this is a very important concept to understand, and

basically, it's when we look at your cancer cells under the microscope, and we

try to learn about how they're behaving and what's driving their growth. So, we

know they're not listening to normal growth signals, they're growing too fast,

but how abnormal are they behaving? And we're going to look at two things. We're

going to look at tumor grade and tumor biomarkers. So, tumor grade is

saying how abnormal does a cell look under the microscope, okay, we grade it

I, II, and III. In grade I, we see the cell looks abnormal, but it looks

pretty much still like a normal breast cell. These are not very

aggressive. They tend to grow slowly, and they're less likely to spread. Now, on the

converse, grade III looks more abnormal under the microscope, and these are more

aggressive cancers that tend to grow more quickly and are more likely to

spread. Grade II is intermediate, and this is

the most common type of breast cancer that we see. The other thing we're going

to look at is tumor biomarkers. Tumor biomarkers are proteins that are

expressed by the tumor cells that inform us about what is driving their growth,

and it can also direct treatments, so we will look at your cancer cell

for 3 proteins--the estrogen receptor, the progesterone receptor, and

HER2 overexpression. So, if we look at all the breast cancer cases we see in the

US, about 60% to 65% will be hormone positive, and we'll just group

that and say estrogen positive. And about 20% to 25% will be HER2-neu

overexpressing, and the remaining 16% to 18% is something we call triple

negative, so they don't express the hormone receptor, and they

are not overexpressing the HER2 protein. So, let's go into a little bit more

detail about each kind--each of these subtypes. So, estrogen

receptor positive, again, is the most common type of breast cancer. What that

means is that your cancer cell is expressing the estrogen receptor, and

that means that estrogen, which normally floats around in your body, can bind to

this receptor, and it's signaling the cancer cell to grow. Think of it like

estrogen is feeding your cancer cell. This also means we can block estrogen,

either by blocking the estrogen in the body or blocking the estrogen receptor, and we

can starve the cancer sell, and that can be an effective

way we can treat estrogen receptor positive breast cancer.

The next is HER2-positive. So, the HER2 protein is a growth factor that fits on

some cells, actually sits on a lot of normal cells, and it basically will be a

signal to the nucleus to grow, and this can be a normal situation for a cell,

where we have one or, you know, a few HER2 receptors on the cell surface.

But HER2-positive breast cancers overexpress the HER2 protein. They

overexpress this growth receptor such that the cell center, this nucleus, is

constantly being told to grow, and this is a very aggressive subtype of breast

cancer, and this historically had a poor prognosis. However, now we have drugs to

target this receptor that are very effective, the most well-known one being

Herceptin, and that has drastically improved survival for these patients.

The next is triple negative. So, triple negative cancers do not express the

estrogen receptor and do not overexpress the HER2 protein, so that means

there are no direct targets for us to hit. However, we do have effective

chemotherapy drugs, and chemotherapy drugs target rapidly dividing cells. And

these triple negative cells are rapidly dividing, and so oftentimes, they're

effectively treated with chemotherapy. So, taking a step back. When we treat breast

cancer, we have to think about 2 things. We have to think about the locoregional

treatment and the systemic treatment. So, the locoregional

treatment is removing the cancer in the breast and staging the cancer by

evaluating the regional lymph nodes, and that will be done by a surgeon like

myself, and then sometimes a radiation oncologist will give radiation therapy

after surgery, and that's to reduce the risk of cancer recurrence.

Now, systemic therapy is treatment to your whole body. It's protecting the body

from any cancer cells that may have left the breast, and this is treatment that's

driven by those biomarkers that we just went over

and could include an anti-estrogen treatment, chemotherapy, HER2 directed

therapy, or immunotherapy, and this will be directed by your medical oncologist.

So, which do we do first? Well, usually surgery comes before the

systemic therapy. However, there are some exceptions. For example, not all breast

cancer is operable, so some patients that present with stage 4 disease, where we

already have cancer cells at distant organs, we need to prioritize the

systemic treatment, and there's less of a role for surgery in that case.

Additionally, sometimes we give systemic therapy before surgery even when we're

dealing with operable cancers, and we might--we call this the neoadjuvant

approach--and we may do that if someone presents with a large tumor or already

has palpable lymph nodes in their armpit, and we want to shrink the disease before

surgery, and that would allow us to do less surgery. There are other times when

we want to monitor the response of your tumor, and if we keep the the tumor in

the breast while we give the systemic therapy, that gives us a good window into

how the cancer is responding, and that's generally done more in the HER2-positive

or triple negative disease. So, what is the role of surgery? So, we need to remove

the cancer in the breast. There are 2 options to do that. We can do that with a

mastectomy or a lumpectomy. A mastectomy is when the entire breast

is removed, and the kind of mastectomy will vary based on how much skin we

remove, whether or not the nipple is preserved, and whether or not

reconstruction is performed. Now, a lumpectomy--this is also called breast

conservation surgery, it's also called partial mastectomy, they all mean the

same thing--and it simply means removing the cancer and a rim of normal tissue

around it--we call that the margin. And then oftentimes--and we preserve the

breast when we do this--so oftentimes, in most cases, radiation therapy will be

part of your treatment plan after surgery. So, which surgery is right

for you? Seems like mastectomy might be the more

reasonable choice since it's a bigger surgery, and so you'd think it'd

be a better treatment. Well, that used to be what we thought, and in the 1980s, you

know, prior to that, most women were getting mastectomies. However, we have

studied this in large trials and asked the question, "Do we need to remove the

breast to be effective treatment for your cancer?" and actually, the answer is

no, that bigger surgery does not mean better survival. So, this is the largest

trial that we did in the US asking this question. It's called NSABP B-06,

and 2,000 women in the 1980s were randomized to lumpectomy versus

mastectomy. And that 20 years follow-up, if you look at their overall survival--so

you can see that mastectomy patients are the squares and the lumpectomy patients

are the triangles--there's absolutely no difference in overall survival. Now, this

is one trial. However, there were other trials going on in other countries

randomizing an additional thousands of women, and all of the trials came up with

the same conclusion, and that is lumpectomy is safe, and the chances of

survival are exactly the same as mastectomy. So, why would you get a

mastectomy, then? Why wouldn't everyone get breast conservation? And the reason

is because not everyone is a candidate for breast conservation. So, we think

about tumor size and breast size, so we want to make sure that if we remove the

cancer that we also leave with you with a breast that has good shape and looks

cosmetically acceptable. So for example, if you have a size A breast and you have

a tumor that's around the size of a golf ball, then maybe we won't be able to

leave you with a breast shape that you would be happy with after surgery, so

sometimes we would consider mastectomy in that situation. The other thing is

tumor location. So, most of the time, the tumor will start in one area of the

breast. However, sometimes, it starts in several quadrants of the breast.

That's called multifocal or multicentric disease. In that case, those patients are

better served with mastectomy. The other thing we haven't really touched on but

was certainly important in breast cancer care

is most women--and it's depending on their age and their family history--will

qualify for genetic testing, and what we're looking for with that is genes

that are passed down from your parents that will significantly increase your

risk of getting a breast cancer. The most well-known ones are BRCA1 and BRCA2.

However, there are at least 7 other genes that are highly associated, and

then a whole other panel of genes that are more loosely associated with a

higher chance of getting a breast cancer. So, once these patients have gotten one

cancer, it's also more likely they would get a second cancer. So, these patients

may decide to do something called bilateral mastectomy, so we would be

doing mastectomy for the side of the cancer, and the other side we'd be

operating on for prophylaxis to decrease their risk of getting a future cancer.

Now, in the absence of a genetic mutation, most patients do not need a bilateral

mastectomy. So, the other thing a surgeon like myself will do is lymph node

surgery. Now, most patients will need some sort of lymph node surgery, and the 2

options are axillary lymph node dissection and sentinel lymph node

biopsy. An axillary lymph node dissection is when most of the lymph nodes and the

lower part of your armpit are removed. Now, this procedure is not commonly done

anymore. It's not usually necessary. There are indications and situations where we

still do it. However, this will be done in a very individualized basis, and most

patients are going to be getting a sentinel lymph node biopsy, which is

simply a staging procedure. And the concept is that if cancer will were to

have spread from your breast, it's actually going to spread to the first

nodes that drain your breast, so we want to identify those first draining nodes,

and in order to do that, we inject your breasts with a dye or a radio tracer

before surgery, and then at surgery, we're able to make a small

incision on your armpit, and we'll remove only the nodes that are blue or

radioactive. So, we have a Geiger counter that we use,

and we can find those those nodes that are hot. And just because we find the

sentinel nodes does not mean you have cancer. What it means is that we're going

to remove those nodes, we're going to send them to pathology, and the

pathologist will look for any microscopic cells that are in those

nodes. So this will be your final node status, and whether or not you have

cancer cells in your lymph nodes versus not can tell us something about your

prognosis, and it can also direct future or additional treatment, such as

radiation or systemic therapy. So, what is the role of radiation? Well, the role of

radiation is simply to reduce the risk of cancer recurrence, and generally, we do

recommend this after breast conservation surgery or lumpectomy. Oftentimes, a

mastectomy is avoided. However, it still may be recommended, and that's

dependent on your tumor size and your lymph node status and, to a lesser extent,

your age. So, moving on to the role of systemic therapy. So, most patients with

invasive breast cancer will need some kind of systemic therapy. Not all

patients will need chemotherapy. And another key point to really keep in mind

is that the amount of breast surgery we perform is not going to change how much

systemic therapy is recommended. So, just because you got a mastectomy does

not mean you're less likely to get chemotherapy. The systemic therapy will

be given based on the biology of your breast cancer. So, going back to the

different subtypes. So, for example, in an estrogen receptor-positive breast cancer,

we'll be offering an anti-estrogen treatment, which is an oral pill that you

can take for 5 to 10 years. Oftentimes, chemotherapy or

immunotherapy can be avoided in these cancers. However, we sometimes

recommend it, and that might be if you have a positive node or your tumor

characteristics look higher grade. And sometimes we send your tumor off for

some additional testing that can help better inform whether or not you'd

benefit from chemotherapy. HER2-positive cancers will always get a HER2 directed

therapy, the most common being Herceptin, but there are other HER2 targeted

therapies that we're using, and this is usually administered in combination with

chemotherapy. For a triple negative cancer, chemotherapy is usually

recommended, and a key point to keep in mind with all of this is that your

treatment plan will be ultimately planned by your medical oncologist, and

it will be based on your unique cancer characteristics and situation.

So, I know I reviewed a lot today, but just in summary, when we treat invasive

breast cancer, we need to think about local therapy and systemic therapy. Local

therapy is removing the cancer in your breast, staging your lymph nodes, and

preventing the chances of getting the recurrence, and systemic therapy is

treatment to your whole body, so protecting--and the treatment will vary

based on the subtype of your breast cancer.

Additionally, prognosis depends on your cancer stage and your tumor biology.

Bigger surgery is not better treatment. Again--and I hope I drove this point home--

that your treatment plans are going to be highly personalized, and it's based on

your stage, the biology of your breast cancer, and multiple other factors that

are unique to you. And lastly, I do want to leave you with this, and that is: a

breast cancer diagnosis feels like an emergency, but you do have time, and you

have time to feel comfortable with your treatment team to understand your

treatment options and ultimately make informed decisions that are right for

you. So with that, I'll take any questions

that are coming in. It looks like we have a couple. So, the first one. "Is surgery

typically the best and only treatment for breast cancer?" Well, I hope we

reviewed that. So, surgery in invasive cancer is not the only treatment for

breast cancer, nor is it the best. It's part of the treatment for breast cancer.

We also have to do the systemic therapy,

and I think if we review the webinar, that we can kind of answer that

question. So, "How long do people typically live after a breast cancer diagnosis, and

what is the usual life expectancy?" So, typically, patients have excellent

long-term prognosis from a breast cancer, but again, it's going to depend on how--if

the cancer has progressed when you present or the tumor biology. In general,

what, 5 years, our survival is about 90% for all comers. However, it's really

going to depend on those 2 things, your stage and your cancer biology. "What should

I look for in a doctor if I have concerns, and where can I find one?" So, the

things you want to look for in your doctor is to make sure that they

specialize in breast cancer, so you want to find a surgeon who has done a

surgical oncology or a breast oncology fellowship and know about the newest

surgery techniques, and you also--you want to find doctors that work well together

because it is such a multidisciplinary approach. You want to make sure that your

surgeon is talking to your radiologist, is talking to your medical oncologist,

because our treatment plan should be cohesive, and we should all be on the

same page, so those are those two things I would definitely look for.

So, is there any more questions? Okay, well thanks for joining me! If you

have any other additional questions, you can reach out to us at

The Description of Surgical Management of Breast Cancer