What’s the surgeon’s role in breast cancer treatment?

Breast cancer treatment is a team effort that typically starts with the surgeon. In most places, the radiologist will hand off to a surgeon, who then thinks about the most appropriate first step. That may be surgery, but sometimes, it may be chemotherapy, targeted immunotherapy or endocrine therapy.

How can a patient vet a breast surgeon?

Ideally, go to a breast center, which will have specialists who focus on breasts. If that’s not an option, look for a surgeon whose practice is at least 30% breast surgery–focused. Also, ask whether the surgeon is fellowship trained in breast surgery; it’s not the only factor, but it’s helpful to know.

How can patients choose the best surgical approach?

Nationally, 60% to 70% of patients undergo breast-conserving surgery, also called lumpectomy, and 30% to 40% undergo mastectomy. Most surgeons will go over the risks and benefits. In a lot of cases, mastectomy is just not necessary. There’s this thought that if you remove more, it should be better, but that’s typically not the case.

What about reconstruction?

If someone is having a mastectomy, we routinely recommend a visit with a plastic surgeon.  Reconstruction is either implant based, with silicone or saline implants, or autologous, where a patient’s own fat and skin is used. We do occasionally have women who choose not to have reconstruction—more often older women, although I am now seeing more younger women choose this approach.

What’s the best preparation?

After a lumpectomy and sometimes even a mastectomy, you’ll need radiation, which requires putting your arm behind your head. So I recommend exercises to increase the range of motion of your shoulders. I tell patients undergoing mastectomy with reconstruction to do a core strengthening program because you don’t want to put a lot of pressure on your arms. You may not realize how much you push off with your arms when you get up off the couch or the bed. So start getting up without using your arms to push off. Also, arrange your home so you won’t do a lot of lifting post-surgery, and get button-down shirts [as opposed to pullovers] so you won’t need to lift your arms up. And ask what pain to expect and what the pain management plan is. We’re finding that fewer of our patients need narcotics, which is good.

Do men get breast cancer?

About 1% of breast cancer is in males, and it’s just as treatable, stage for stage, as breast cancer in females. It’s key to be aware that men do get breast cancer. If you feel a lump, get a workup.

What inspires you?

The research that is continuously ongoing. Since I’ve been practicing, I’ve seen so many changes. For example, we used to routinely remove all the lymph nodes underneath the arm, even if there was a small amount of cancer there. We no longer do that because we recognize it’s not necessary, and when we remove fewer nodes, there is less lymphedema, nerve pain and numbness and a better range of motion.