Breast Cancer Surgery Program in Jacksonville

Amy Degnim, M.D., General Surgery, Mayo Clinic: We are able to achieve really wonderful cosmetic results with this procedure.

Jeff Olson: Breast cancer surgeon, Dr. Amy Degnim says the first phase of this team procedure is nipple-sparing mastectomy, to remove cancerous breast tissue but if possible save all the skin including the nipple and areola.

Dr. Degnim: So that after a reconstruction the result looks as natural as possible.

Jeff Olson: The natural look is furthered during the second phase of the surgery: Pre-pectoral reconstruction.

Valerie Lemaine, M.D., Plastic Surgery, Mayo Clinic: Once we know that clear margins have been obtained, then I'm called into the operating room.

Jeff Olson: Plastic surgeon Dr. Valerie Lemaine says unlike traditional reconstruction with the implant behind the chest muscle, in a pre-pectoral procedure the implant goes in front.

Dr. Lemaine: The main advantage is the implant is positioned where the breast used to be anatomically. Also, when we do surgery without manipulating a muscle, there is definitely less pain.

Dr. Degnim: We want women to know that this is an option for many of them.

Jeff Olson: For the Mayo Clinic News Network, I'm Jeff Olson.

James W. Jakub, M.D., Surgical Oncology, Mayo Clinic in Florida: My name is Jim Jacob. I'm a surgical oncologist with a primary focus on breast cancer and melanoma. Patients undergoing mastectomy now have the option of combined reconstructive procedures and in doing that for a group of patients, we can actually preserve everything that's seen on the outside, the entire breast skin and the nipple, the areola complex and combine that with the plastic surgeon performing a reconstructive procedure that is an excellent option for specific patients. It can give an excellent cosmetic result and make patients feel restored or whole terms that are frequently used.

As a high volume breast center, we have breast surgeons who are focused on all aspects of surgical management of breast cancer, from lumpectomy and oncoplastic surgery and reconstructive procedures with the plastic surgeon such as nipple sparing mastectomy, and we have a combined team and we can perform operations under one anesthesia combined with the cancer removal portion, as well as prioritizing and optimizing the aesthetic outcomes whether that be an oncoplastic lumpectomy with a breast reduction or a lift, a mastopexy, or a nipple sparing mastectomy in which all of the skin and the nipple areola complex are preserved simultaneously with implant or autologous reconstruction.

Clinical trials allow us to offer tomorrow's treatments today. I think patients who have a cancer diagnosis really should explore the clinical trials available. Most clinical trials are giving the best treatment compared to what we think is going to be the future best treatment.

James W. Jakub, M.D., Breast Surgeon, Mayo Clinic: Patients with a genetic mutation that increase the risk of developing breast cancer have many options to consider. Options include one) more intensive screening, two) preventative medications, and three) risk-reducing mastectomies.

I would like to spend the next two minutes addressing the specific question regarding saving one's nipple during a risk-reducing mastectomy. Risk-reducing mastectomies offer the highest method of prevention against future breast cancers for patients who have a gene mutation. Although mastectomies do not completely eliminate the risk of breast cancer, they provide risk reduction in the range of 90 to 95%. It is important to note, however, that it has not been established that risk-reducing mastectomies improve survival compared to intensive screening. Whereas mammograms, MRI's and other imaging approaches have the goal of early detection, mastectomies are actually a risk-reducing approach intended to prevent the development of ever getting a breast cancer.

There has been an increased interest in preventative mastectomies by patients, primarily because of the improved and sometimes exceptional cosmetic results that can be achieved. One of these techniques is referred to as a nipple-sparing mastectomy with immediate reconstruction. This procedure is discussed in greater detail in some of our other videos, but the point I wish to highlight is a nipple-sparing mastectomy should be discussed with patients who are considering risk-reducing mastectomies.

A nipple-sparing approach allows an individual to keep all of her skin, including her nipple and areola, and the procedure is performed combined with a plastic surgeon in which the reconstruction is started at the same operation.

One major concern among providers and patients has been, is it safe to keep the nipple in cases of a genetic mutation. The short answer based on a recent study led by Mayo Clinic is yes. It does appear to be safe. In our recent multi-institutional study of 548 risk-reducing mastectomies performed in 346 patients with BRCA mutations, zero cancer is developed in three to five years of follow up. It would have been expected that approximately 22 of these high-risk women would have developed breast cancer in this time period without any intervention.

Although no prevention strategy is 100% protective, and we are looking forward to having longer-term follow up from our study and others, nipple-sparing mastectomy is one option women at elevated risk of breast cancer should discuss with their physicians if they are considering a risk-reducing mastectomy.

Sara McLaughlin, M.D., Surgical Oncologist, Department of Surgery: The goal is the more targeted things that we can give you, the more things that are really specific to your cancer and to your body, the better the outcome is going to be. We have a large number of really targeted therapies which minimize the damage to good cells, if you will. They target the bad cells. So women come to the office that they're very scared, they don't know what to do, and my job is to really help them navigate the overwhelming amount of data related to breast cancer, what they hear on the internet, what they hear from their friends, what they get from media, and try to help distill that down into what is the right decision for them.

You should meet with all of the members and the providers of the team and understand that as you make decisions, how one decision impacts the next decision. And then how do we create a treatment plan that addresses all of those issues?

What I think is perfect about the Mayo Clinic is that you have all of your providers in a truly integrated, multidisciplinary environment under one roof, in one medical record. There are certain benchmarks that we consider to be the minimum standards of care. So you would want to know the volume of cancer that that institution is treating. All of the providers that patients see are in fact breast specialists. This is truly their passion. Where they focus their research, where they think about, you know, these nuances in the care day in and day out.

The innovations that happen, that are supported and fostered by the Mayo Clinic are really unsurpassed in most other medical centers. And that happens not just from the imaging perspective at the beginning, but the clinical trials that are available with respect to vaccinations and immunotherapy. The data and the science is so robust, it's so dynamic, it's changing all the time. And I would say really where we've gone was from this pendulum of more is better to maybe less is okay with the same outcomes and fewer side effects from the entire gamut of disease.

Sara McLaughlin, M.D., Surgical Oncologist, Department of Surgery: When we think about the treatment of breast cancer, we think about it from a comprehensive strategy of the breast, of what could be going on anywhere else. And then how do we create a treatment plan that addresses all of those issues? We have a large number of really targeted therapies which minimize the damage to good cells, if you will. They target the bad cells. Then in addition to that, we're really able, in a comprehensive strategy, to be able to say, okay, if we do the surgery and we take out the tumor and we take out one or two lymph nodes, then we can actually treat the rest of the body. We have data in women that compare breast conservation to mastectomy with 30 year follow up, demonstrating clearly that there's no difference in survival if you have a lumpectomy and radiation or if you have a mastectomy.

We are one of the few places across the country that does our breast surgery cases under regional anesthetic and you can be very precise targeting only the nerves that affect the area of the breast and the lymph nodes where we're working. That allows us then to do the procedure where you're not awake, you don't remember, and you don't feel anything, but you're still breathing on your own. And there is an increasing body of data that suggests by doing a regional anesthetic approach, where you really localize the anesthetic or the numbing medicine to the place where we're working. That, that may actually decrease the stress response of the body to the procedure and that may have implications on future risks for recurrence.

There are some techniques that we can do to rearrange the tissue within the breast so that when you remove a portion of the breast, you're not left with a large divot, for lack of a better word, within the breast. We're able to rearrange that tissue back into that location, maintain a more normal, cosmetically acceptable breast oncoplastic surgery. We also then take that to a next level, use that with the plastic surgeons may do combined procedures with them where we're able to reposition the nipple or do a reduction at the same time. There's all kinds of new techniques related to nipple sparing approaches where we actually save the nipple and areolar complex, which can really be the hardest part for the plastic surgeon to reconstruct in the future. Especially when they try to match symmetry to the other side and the opportunity to save your native nipple without increasing your risk of cancer recurrence is also a significant contribution. Then even beyond that, there are really advanced reconstruction techniques where we use a patient's own tissue. That really are becoming the gold standard of breast reconstruction. Because as you age, those may gain weight and lose weight naturally as your normal breast would, which in the end, results in a better cosmetic outcome.

I think the future of breast cancer care, if I can start there is getting more and more targeted. The more targeted we can get, the better, the better the outcomes are. The shorter the treatment duration, the fewer the side effects.

James W. Jakub, M.D., Surgical Oncologist: My name is Jim Jakub. I'm a surgical oncologist with a primary focus on breast cancer and melanoma. Approximately 1 in 8 or 12% of females born in the U.S. today will be diagnosed with breast cancer. Part of standard treatment for breast cancer does remain surgical management to remove the tumor.

Surgical management of breast cancer typically consists of either a lumpectomy often combined with radiation, or a mastectomy in which reconstruction can be performed based on patient's preference. It's very natural and intuitive and logical to think that a mastectomy is a better operation, will reduce the risk of recurrence, will reduce the risk of distance spread, improve my survival. The reality is when we follow patients long term and long term, we're talking 20 years, that survival rate, the recurrence rates are very similar with lumpectomy versus mastectomy. There's actually some ongoing research and publications based on population-based studies that actually have some suggestion that patients who have lumpectomy with radiation actually might have an improved survival over patients who have a mastectomy alone.