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Breast Case Scenarios


Breast cancer is like a story," says Dr. Alan Stolier, a surgical oncologist at Omega Hospital. "There are so many parts to the story — the hereditary part, the (breast) reconstruction part — that you have to try to get a big picture."

  The sagas that play out in Stolier's office involve a heroine (the patient), a nemesis (breast cancer), a team of helpful allies (primary care physicians, radiologists, surgeons, breast reconstruction surgeons, support groups, friends and family) and a series of events that involve weighty decisions (e.g., is a lumpectomy or a mastectomy the right choice? What are the best reconstruction options?). The story unfolds for more than 230,000 women in the United States annually, and each woman's experience is different. Because of the gravity and quantity of treatment-related decisions, it is crucial for women to equip themselves with information so they can collaborate with their doctors to decide what treatment plans are right for them.

  "Treatment should be a conversation between the patients and their treating physicians," says Dr. Hope Rugo, a medical oncologist at the University of California, San Francisco. "When the patients partner with the physicians, you end up with a better situation."

  Every woman should know her body and her risk for breast cancer. According to the American Cancer Society, women should schedule clinical breast exams every year and annual mammograms after age 40. During their 20s and 30s, women should have clinical breast exams performed as part of their annual checkups.

  "If you notice something that concerns you in your breast, don't delay going to your doctor," says Dr. Thomas Cosgriff, an oncologist at Cancer Care of Louisiana. "The earlier we catch breast cancers, the more curable they are."

  Because breast cancer tissues are sensitive to estrogen, any uninterrupted estrogen exposure caused by having children later in life (after age 30) or not at all, or not breast-feeding increases the risk of breast cancer, Cosgriff says. Other risk factors include a family history of cancer, smoking, moderate alcohol consumption and a high-fat diet. Women with a family history may have a mutation of the BRCA1 or BRCA2 (breast cancer type 1 and breast cancer type 2) genes, and these women comprise up to 10 percent of diagnosed breast cancer cases. Cosgriff advises women with a strong family history of breast cancer to see a physician and get tested for the mutation.

  "These genes account for a majority of hereditary forms of breast cancer," Stolier says. "Women who carry a gene mutation have more than an 80 percent risk of developing breast cancer in their lifetime."

  "If you have a family history of breast or ovarian cancer, it is a done deal. You know you should get tested (for the gene mutation)," says Ponchatoula resident Pam Crimmins, 60, who got tested for the gene mutation after her mother, aunt, sister and niece were diagnosed with breast cancer. Crimmins tested positive for the gene mutation. She and her sister Susie Stoulig, 57, who also tested positive, both opted for a double mastectomy and hysterectomy, even though they had not been diagnosed with breast cancer.

  "Being a nurse in oncology, I have lost way too many patients to breast and ovarian cancer, and I knew I didn't want to go through this," Stoulig says. "So I opted to have the surgery, and it has been one of the best decisions I have ever made in my life."

  The decision of whether or not to have a prophylactic (preventative) mastectomy is a highly personal one, but in the event of a breast cancer diagnosis, surgery almost always becomes inevitable. "Surgery is usually — not always — the beginning point," Stolier says. A team of doctors — usually consisting of a surgical oncologist, a medical oncologist and a radiation oncologist — work together in the diagnosis of breast cancer and in the decisions regarding its treatment, she adds.

  "After an abnormal mammogram and an ultrasound that shows a solid mass, women should have a tissue diagnosis and then see a surgeon who may ask for an MRI scan," Rugo says.

  Considering multiple factors, including the tumor's size and aggressiveness, the risk of recurrence, the stage of the cancer and whether it has spread to the lymph nodes, as well as the patient's age and whether she is trying to maintain her fertility, physicians formulate a treatment plan.

  "Everybody's breast cancer is individualized," says Dr. Roy Kite, medical director of radiology at Lakeview Regional Medical Center. "Depending on how big the lesion is and the type of cancer you have, you can go all kinds of different directions in the way you can treat it."

  Chemotherapy or hormone therapy may be used to shrink the tumor prior to surgery, Rugo says. If the cancer is detected early, a lumpectomy (removal of the tumor) followed by six to seven weeks of radiation treatment may be a substitute for mastectomy, Stolier says. Other situations may be better treated with mastectomy. In addition to lumpectomy and mastectomy, "we almost always sample the auxiliary lymph nodes to see if there is any cancer there," Cosgriff says. Every treatment option has drawbacks and benefits, and women should feel comfortable discussing different plans with their doctors.

  "There is not one operation that fits everyone," says Dr. Scott Sullivan, co-founder of the Center for Restorative Breast Surgery. "If there is any level of discomfort with the plan, get a second opinion. Patients need to seek the best care for themselves."

   Sullivan points out that more than 70 percent of women who have undergone mastectomies are not informed of their options for breast reconstruction, according to a study by the American Society of Plastic Surgeons.

  "We try to help educate patients on what their options are," he says. "It helps them handle a very adverse situation in a better way."

  Once considered the "bastard child of plastic surgery," Sullivan says reconstruction techniques have become more refined, with an increased focus on the aesthetic outcome. Performed at the time of the mastectomy, breast reconstruction is covered by insurance and takes one to one-and-a-half hours if implants are used, or three to four hours if the breast is reconstructed from the patient's tissue via a microsurgical technique.

  "We can take fat from any part of the body and transfer it to the breasts," Sullivan says. "The breast will be warm, soft, supple, and it moves naturally and changes its volume as (the woman's) weight fluctuates, and it lasts their entire life."

  However, this approach also involves a longer hospital stay (three to four days versus an overnight stay) and recovery process than implants. Implants, though, run the risk of capsular contraction and infection. "Some people have the misconception that (implants) will look like an augmentation. That's not true. You just have skin laying over the implant, so you see the imperfections in the implant, and the breast always feels cool," Sullivan says. Sullivan also addresses lymphedema, a side effect of lymph gland removal that results in chronic swelling of the arm.

  Though very few women would choose to cast themselves as the heroine of a breast cancer story, those who find themselves in this role can take comfort in the fact that frequently, it's a story with a happy ending. "Eighty percent of women treated for breast cancer today will be cured of their disease," Rugo says.

  Sisters Crimmins and Stoulig urge women to be proactive with their health, to know their bodies, get tested for the BRAC1 and 2 genetic mutations if they have a family history of breast cancer, have regular mammograms and find doctors they trust. The support of family, friends and other women can be invaluable for those dealing with breast cancer.

  "(Susie and I) did the surgery at almost the same time, and (our sister) Deedee took care of us," Crimmins says. "It strengthened us. We were close before, but we are extremely tight now. We know we can live a long life laughing."

For more information and breast cancer resources, Dr. Rugo recommends the websites of National Comprehensive Cancer Network (www.nccn.org) and Living Beyond Breast Cancer (www.lbbc.org ).

Sisters Pam Crimmins, Susie Stoulig and Deedee King (left to right) share a strong family history of breast cancer.

Make sure you know your treatment options, and discuss them with your physician.

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