Saint John's Second Annual Pink Ribbon Lectures - Part One

On October 20th, 2011, Saint John’s Health Center, in collaboration with the American Cancer Society and a generous grant by the Harold McAlister Charitable Foundation, held its Second Annual Pink Ribbon Lectures at the Santa Monica Public Library.

A Woman’s Health – Breast Health and Cancer 

Breast Conserving Surgery Mastectomy and Reconstruction, Dr. Leslie Memsic, Surgical Oncologist

Dr. Leslie Memsic – Up Close and Personal

Dr. Leslie Memsic is a surgical oncologist, who specializes in breast cancer at the Margie Petersen Breast Center at Saint John’s Health Center. Her other areas of interest are liver cancer and immunosuppressant therapies. Impressively, she was the third woman to graduate from medical school at UCLA, and says, “now half of medical school classes are women, and slowly but surely, more women are specializing in surgery.” When Memsic walked into the auditorium, not only did she look dynamite as though she had just stepped off a modeling runway, but her personality was a skyrocket of positive, genuine energy. To top it off, this extraordinary surgical oncologist is also a wife and mother of two, “although it feels like I have more,” she laughed.

Memsic became a surgical oncologist because it involves both human and intellectual elements. She is not only passionate about operating, in a minimally invasive way, but loves connecting to her patients. Her focus is to give as much information as possible, be available, and walk the patient through the process in a compassionate way. Memsic’s cohesive approach makes the patient aware of the choices available under all circumstances, ultimately empowering the patient, and highlights the patients as a vital member of the team.  Her philosophy is that physician/patient teamwork is key to getting the patient well.  From an intellectual standpoint, cancer is interesting because there is always new research, new drugs, new technologies, and new surgical techniques to learn.

When asked how she does it all: balancing career and family, Memsic said, “I have a lot of energy. I used to take my kids on rounds when they were younger because I wanted them to see what I did was important so when I couldn’t make a PTA meeting, it was not because I didn’t love them, but that I have other priorities, which at that moment, took precedence. They forgave me,” she said with a smile. “I used to get the kids to bed and then go back to the hospital. It takes a special man to live with me. Women can have it all,” she assured me, “but juggling is required.”

Breast Conserving Surgery Mastectomy and Reconstruction

The lecture began with Memsic saying “surgery is frequently the first line of diagnosis and treatment for breast cancer, the most common cancer in women. More and more women are becoming proactive that there will be less women dying from this disease every year. Breast cancer has a whole set of implications, however. It has major psychological issues of how good we feel about ourselves so it’s a very important aspect to minimize deformity, while we optimize cure.”

Have breast cancer cases increased?

Worldwide new cases of breast cancer have decreased for the first time in the last few years because of the recognition that hormones in the postmenopausal period may increase your risk of breast cancer.

What countries have the lowest risk of breast cancer?

The lowest risk of breast cancer is in Korea and Japan. Although it may be genetic, but when they move to the United States, the risk starts increasing. We know that some of it is environmental and we think that at least part of it is fat in our diet. Even our lowest fat diet is much higher than a typical Asian diet.

What causes breast cancer?

It’s not clear cut. If it was really easy to know exactly what caused breast cancer, we could eliminate it. But it is a combination of a patient’s genetics, hormones, and environment: which is what we eat, drink, and breathe.  I believe as we clean up our world, all cancers will go down.

Breast cancer staging

Staging is a way of identifying how advanced the cancer is and how aggressive we have to be to treat it. That forms a basis of the treatment planning. If breast cancer is confined to Stage I, it’s a more favorable prognosis.

When do you recommend a screening?

I generally recommend a screening at 35, assuming they have no family history and concerns, and a mammogram every year starting at 40. If they have family history, then I change that and recommend at least ten years earlier than when their mother had it.

What is the age range of your breast cancer patients?

Breast cancer increases as you age, but I have more and more younger patients with breast cancer and the problem with young women, in some cases, is they tend to present it late because they’re not paying attention and they’re not getting mammograms at their age. Doctors aren’t thinking it is breast cancer so they are unaware that they are at risk because it’s not common. I have patients younger than thirty.

I also have a lot of women in their 30’s and 40’s. I think because of awareness, I am getting younger women, catching most of them in Stage I cancer. I have an even amount of pre-menopausal and post-menopausal patients, however.

Do the majority of women who get breast cancer have the gene?

No, the majority do not have the gene. Only about 15% of people who have breast cancer have the gene.  It’s a spontaneous mutation related to everything from environment, pesticides, hormones in meat, high fat diet, pollutants.  However, nothing has been definitively linked.

Should everyone get the gene test?

It’s an expensive test, and if you don’t have breast cancer or family history, insurance companies won’t pay for it. It’s $3200. The majority probably don’t need to get tested for it.  But we do recommend everyone under 50 who is still pre-menopausal and has breast cancer or a family history of breast or ovarian cancer.

We are finding young women with no family history that have the gene.  Young women should not get breast cancer. Not enough people are being tested, but not everybody needs to be tested. The minority of women with breast cancer have that gene.

In vitro (IVF). Does it cause breast cancer?

There is no proof yet, but we are always concerned about hormones. Those women are usually pre-menopausal and most of our evidence suggests that post menopausal hormones are risky. Women getting In vitro are generally younger – pre-menopausal - and are getting a short course of intense hormones. It isn’t over a long period, so the jury is out. We just don’t know, but we are concerned that it may increase the risk of breast cancer and ovarian cancer. We just don’t know yet, so while we are concerned, we wouldn’t tell a woman not to do In Vitro at this point. We would express our concerns, but there is no proof yet.

What does cancer look like?

Different cancers look different, but a breast tumor is gritty. It’s grisly. Normal tissue is soft and floppy. Benign things can be rubbery, but cancer has a distinct feel to it. When you feel a tumor in your breast it can feel soft and rubbery because of all the tissues but when you get it out or do a biopsy on it, it’s not.

Tumor removal

You need to remove the tumor with a rim of normal tissue for clear margins to confirm that no cancer is left behind. If you just remove a lump around the edge, you could have cancer there. There may be tentacles that are invading the normal tissue around it.

Positive lymph nodes removal history

In the past, we’ve removed as many lymph nodes as possible. Then we did sampling, which were the removal of random lymph nodes – and we were never really sure which lymph nodes we may have missed that could be positive.

Sentinel Lymph Node biopsy

This is now the standard of care in breast cancer surgery. We either inject blue dye in the area around the tumor or around the nipple and then we make an incision underneath the armpit and we can see a blue lymph node. It does not say whether it’s cancer or not. It says, ‘look at me; I’m the first draining lymph node of this cancer.’ Once pathology looks at it, if it’s negative, we don’t remove the lymph nodes. We’ve learned that lymph node involvement is step wise, so if you get the first draining one and its negative, you don’t need to take out the rest. If it’s positive, you take out some more.  We check the lymph nodes so we can get a better idea of how hard we have to fight to cure the patient.

Do we need lymph nodes?

Not cancerous ones. In a general sense, you should remove the least number of lymph nodes necessary. From an immune standpoint, you’re fine without lymph nodes in your arm pit because you have lymph nodes throughout your body that’ll pick up the slack, but locally, the lymph nodes are involved with preventing infection and cancer in the area of your arm and your breast, so patients that have a lot of lymph nodes removed, the more likely they can injure a nerve, have swelling or infection.

Radiation therapy after Lumpectomy

If a patient is a candidate for a Lumpectomy, as long as they get radiation and lymph nodes are identified, there is no reason to do a Mastectomy.

If you just remove the lump with a margin of normal tissue – Why Radiation?

There is something environmental, hormonal, or something genetic that makes that entire breast at risk and there’s a 30% recurrence rate within that breast without radiation, so we still recommend radiation if we’re going to do a Lumpectomy – a breast conserving operation.

A benefit of a Lumpectomy

It’s a breast conserving operation and generally the patient retains the natural sensation.

Disadvantages of a Lumpectomy

Radiation required, and there could be some deformity of the breast. I try to make cosmetically favorable incisions.

Who is a candidate for a Mastectomy?  (removal of breast)

1. If there are multiple tumors in the breast (but if they’re in the same quadrant, frequently a larger Lumpectomy and radiation would be fine.) 

2. If a tumor is in one or more opposite areas of the breast, then it may be safer to remove the breast than do multiple Lumpectomies.

3. Some tumors grow in sheets rather than lumps and sometimes you can’t get a clear margin, so if you can’t get a clear margin, you have to remove the breast.

4. Sometimes cosmetically it’s not a good idea for a Lumpectomy. For example, if there is a large tumor perhaps behind the nipple in a small breast, you’ll not have a good cosmetic result if you just do a Lumpectomy, but if you do a Mastectomy with reconstruction, you may have a better cosmetic result.

5. If you have the BRCA gene mutation, you have a high risk of both breast cancer and ovarian cancer, so ideally we recommend a Bilateral Mastectomy before you get breast cancer. 

6. If a patient has had prior radiation in the chest wall, for example if she has had Hodgkin’s Lymphoma or lung cancer it may be difficult to reradiate a breast that has developed breast cancer.

7. There are selected patients that can have reradiation but in a general sense, we want a patient to consider a Mastectomy rather than taking an additional dose of radiation.

8. A patient has a recurrent malignancy and previously had a Lumpectomy and radiation; we recommend removal of the breast. 

9. Patient's preference. You may be a thirty something year old woman and  have watched your mother die of breast cancer and even though you may be a candidate for a Lumpectomy and radiation, you may feel better if the breast is removed. Ultimately, as long as the patient is explained the pros and cons, and the physician discusses the patient’s fears and addresses them, then some patients will psychologically do better with a Mastectomy and the physician has to respect that choice. 

A skin sparing Mastectomy

We do not have to remove a lot of skin around the tumor in order to get a cure. We can save the skin. Skin sparing Mastectomy is becoming the standard and you have a much better cosmetic result because it’s got a smaller scar. If we can save the nipple, it’s another step forward. You want to remove as much breast as possible but keep the nipple alive. Multiple studies show that nipple reoccurrences are rare. The majority of patients you can save the nipple, but you have to clear the margin and there has to be no cancer under the nipple.

Do I have to get reconstruction?

You don’t have to have reconstruction. There are bras that come with breasts. There are silicone implants with a nipple that fit with the adhesive on your bra or chest wall. And, some women wear their scars as a badge of courage.

What are my reconstruction options?

Implants are most common, either silicone or saline. Silicone breast implants have a more natural feel, the substance is thicker. Saline is salt water and doesn’t feel quite as natural, but when we put a saline implant we go underneath the muscle of the chest and that helps minimize saline’s difference in terms of how it feels.

Can Silicone and Saline implants leak?

Yes. Normally there is scar tissue that covers the implant so if it leaks it usually stays between the hole of the implant and the scar tissue however we have seen little dots of silicone in lymph nodes.

Are Silicone implants safe?

Years ago, there was a lawsuit because of a silicone leak and it was once taken off the market and investigated. Multiple studies that show that there do not appear to be any increased risks of autoimmune diseases in cases of silicone implants. There may be a sub-population who already has an autoimmune disorder such as Lupus or Fibromyalgia and they may be potentially at risk because that’s a small population that gets implants and we may not have picked that up for higher risks.

What happens when Saline leaks?

You deflate and it’s absorbed by the body. It won’t be picked up by lymph nodes.

Which is better: Saline or Silicone implants?

They’re both equally good. You need to do what makes sense for you. Implants are constantly evolving.

Are there any disadvantages to implants?

1. You could develop scar tissue and it could make your breasts perkier.

2. Risk of Infection.

3. Sometimes thin women develop ‘visible ripples’. (you can have fat injections to help)

4. You can develop Lymphoma – although this cancer is rare there is a slightly increased risk in patients that have had implants. (not just breast cancer patients)

5. A rupture or deflation in which case you would need to have another operation.

Do I have any other options?

You can use your own tissue to construct the breast. For example, it can be taken from your stomach, thighs, butt and/or back flaps.

Conclusion

Memsic concluded her lecture saying, “surgery for breast cancer is constantly evolving so that we can save patients with minimal side effects. There is quality of life after breast cancer surgery.”