Breast Cancer Surgery Options with Dr. Andrea Abbott

Breast cancer survival rates are higher than they’ve ever been. For patients requiring surgery, high-quality breast reconstruction that is both aesthetic and safe can be crucial to long-term well-being. Advances in technology and surgical techniques at MUSC are leading to more natural options for reconstruction, allowing women to look and feel more like themselves following surgery.

Joining the show is Dr. Andrea Abbott, a surgical oncologist at MUSC Hollings Cancer Center. She specializes in advanced surgical techniques for breast cancer patients that improve cosmetic outcomes without compromising care.

“I want women to feel empowered to say: ‘This is what I need. This is a crucial time in my life. These are critical decisions that I have to live with forever. It's OK for me to be selfish. It's OK for me to think: what do I want my body to look like?’”

Andrea Abbott, M.D., MSCR

Topics Covered in This Show

•  There are essentially two options for the treatment of breast cancer through surgery. First, a lumpectomy involves removing the cancer and some normal tissue surrounding it but preserving overall the size and shape of the breast, including the nipple. Second, a mastectomy involves removing the breast entirely, with or without reconstruction.
• Dr. Abbott stresses to patients that removal of both breasts doesn’t necessarily improve a patient’s survival. Deciding which surgery is safest depends on the size of the tumor, family history and other factors.
• Mastectomies can include skin-sparing as well as nipple-sparing procedures in which a patient’s skin or nipple is preserved when removing the majority of the breast. However, the safety of the procedure is determined on an individual basis.
• Dr. Abbott is passionate about breast cancer survivors feeling and looking their best, which means minimizing scarring. She is certified in a special technique where surgical incisions are made in inconspicuous areas.
• In some surgical procedures, such as the nipple-sparing procedure, loss of sensation can be a risk. However, it’s possible to strategically graft nerves to preserve sensation.
• While an increasing number of younger women are being diagnosed with breast cancer these days, Dr. Abbott stresses that this might simply be due to a greater frequency in the number of screenings.
• When a patient decides that she wants to have breast reconstruction, she meets with a plastic surgeon, who is part of MUSC’s multidisciplinary team. The surgeon thoroughly reviews her options with her depending on her personal goals, such as size, the type of implant she wants, and other factors.
• Often reconstruction must be completed in a second surgery after the initial surgery in which the cancer is removed. For those who receive implants, this can be strategic in that it provides time for the skin to stretch to accommodate implants.
• When it comes to reconstruction Dr. Abbott often sees women who don’t want to burden others or feel “vain” by having reconstruction surgery. But she encourages women to feel empowered in asking for what will truly make them feel like their best selves.
• Dr. Abbott encourages women to not hesitate to look for a second opinion when it comes to both their diagnosis and reconstruction options.

Transcript

[00:00:00] Erin Spain, MS: Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Women are surviving breast cancer longer than ever before. And for many, high-quality breast reconstruction that is both aesthetic and safe can be crucial to long-term well-being. Advances in technology and surgical techniques are leading to more natural options for reconstruction, allowing women to look and feel more like themselves following surgery. Dr. Andrea Abbott is a surgical oncologist at MUSC Hollings Cancer Center, who specializes in advanced surgical techniques for breast cancer patients that improve cosmetic outcomes without compromising care. She joins me today to discuss these offerings available to MUSC Health patients. Thank you so much for being here today.

[00:01:03] Dr. Andrea Abbott: Thanks for having me.

[00:01:04] Erin Spain, MS: You are passionate about helping breast cancer patients and survivors at every phase of their journey with this disease, from diagnosis to treatment, and survivorship. Tell me about your work in this area.

[00:01:16] Dr. Andrea Abbott: You're right. I love, love my job. I feel so appreciative and grateful that I get this chance to be part of someone's life during this very critical time point. And I just think it's my responsibility to help patients navigate such difficult decision-making and help them not only think about, ‘How am I going to live,’ but also ‘How am I going to thrive, and make sure that I am really enjoying my life and I'm happy with the decisions I made.’

[00:01:45] Erin Spain, MS: You meet a lot of women on this journey when maybe they're getting a second opinion and they've come to you. Tell me about those conversations that you're having when women are coming to you from regional hospitals, other places, and how you're able to get them on a different course and offer treatments they can't get in other places.

[00:02:03] Dr. Andrea Abbott: First of all, I strongly encourage women, men, and anyone to get more than one opinion when you're faced with a diagnosis such as cancer. The very first time you hear, "You have cancer," your mind shuts off. You don't hear a lot of what follows because in that moment, the only thing that you're thinking about is your loved ones. And how am I going to survive? And for women who are often caretakers of other people, they may immediately think, OK, I'm just going to remove both of my breasts, that's how I'm going to live the longest. And so being able to sit with that, hear the information, maybe visit a second opinion may help you kind of come to terms with, OK, I do have options. What are those options? How can I just take a minute and really consider what's actually truly going to be best for me?

[00:02:54] Erin Spain, MS: Yeah, walk me through some of those different options out there and who are the candidates for the different types of surgery.

[00:03:01] Dr. Andrea Abbott: So there are essentially two options for the treatment of breast cancer through surgery.

One is a lumpectomy, which is removing the cancer and some normal tissue around it, but preserving overall the size and shape of the breast and leaving the nipple and the areola in most circumstances. So, we would consider that breast conservation surgery.

The second general option is a mastectomy, and there are a lot of different ways a mastectomy can be performed based on a patient's desire to have breast reconstruction or to have an aesthetically flat closure, which is another option for patients who don't want reconstruction.

So, how you make that decision is rather complex, and this is where it is crucial for you to meet with someone who specializes in breast surgery. A lumpectomy is not necessarily straightforward. There may be surgeons who are very comfortable doing a lumpectomy, while others may be very narrow in their criteria. And what I mean by that is often the decision is based on the size or extent of disease. And this is where coming to a center where you have lots of options, you have a breast surgeon who also can work with a plastic surgeon, may take a patient who would otherwise be offered a mastectomy at one institution and we could step back and say, actually, we have options for you. You are still a breast conservation candidate.

[00:04:31] Erin Spain, MS: Tell me about these conversations that you're having with patients when you're sitting down for the first time and explaining these options. These women are oftentimes very scared. They're worried about going into surgery for a variety of reasons. How do you approach these conversations and explain things in a way that they can really understand?

[00:04:49] Dr. Andrea Abbott: So I say, we're going to talk about three things. We're going to talk about how we're going to treat your breast. What we're going to do about the lymph nodes, and then what's the treatment for the rest of your body. And so we start with the breast and we say, okay, you have two options for most patients.

Again, there are some patients who walk through my door and they're not going to have an option for a lumpectomy. But again, I say, there's two options, lumpectomy or mastectomy. Now let's talk about your tumor size, your goals, how do you want to look, what's important to you, and then we get into that conversation, which is usually 45 minutes to an hour to really, you know, dissect down at the end of the day, you a candidate for, what are your goals two years from now? What not only is going to keep you cancer free, but also help you go to the beach, be on a boat, wear whatever clothing you want to wear and feel comfortable.

[00:05:43] Erin Spain, MS: Cosmetic outcomes after breast cancer surgery is something that has been studied, and there is a lot here to talk about. This can play a big role in a person's well being. Tell me about that.

[00:05:55] Dr. Andrea Abbott: Like I said, when people walk through my door, often the first thing they say is take them both off. I don't need them. I just want to live. And while I understand that, I also want patients to just take a moment, and I think the thing that they need me to tell them and the thing that they need to hear and the thing that is true, is removing both of your breasts does not improve your survival. And I say that multiple times during the visit. The decision to do a mastectomy or a lumpectomy is based on the tumor size and your personal goals and risks that you may have based on family history or your own personal history. But you don't necessarily have to remove your breast to improve your survival, to live longer, to be there for your children and your grandchildren.

[00:06:43] Erin Spain, MS: Do you think that there is a myth out there that persists, that that is the way to go, that that is the answer?

[00:06:50] Dr. Andrea Abbott: Right. I mean, think about it. We always associate aggressive meaning bigger. If you go bigger, then that means that you did everything possible. Wonderfully for us, there are advances in cancer care that have taken us from removing an entire breast, all of the lymph nodes, all of the muscle, to now being able to do breast conservation surgery and radiation and have equivalent outcomes.

[00:07:14] Erin Spain, MS: So you did mention one technique which allows you to preserve the nipple of the breast during a mastectomy. Tell me a little bit more about that. How many of these are you able to do? How many women are candidates and choose to do this option?

[00:07:28] Dr. Andrea Abbott: So the three approaches for a mastectomy is the simple or traditional. You remove the nipple, the areola, and as much skin as possible, and you end up with a flat closure. There's no breast reconstructed.

The second option is skin sparing, and this would be for patients who might have very large breasts, perhaps their nipple already is, you know, in a downward trajectory, or we say they have a high degree of ptosis. Perhaps the tumor is behind the nipple in the areola such that saving the nipple wouldn't be safe from a cancer standpoint. So that's called skin sparing. And then you can put an implant in or the patient's own tissue to reconstruct the breast. And at that point you have a breast mound and no nipple in areola that's natural.

And then the third option is nipple sparing, and this is what's considered the cosmetic gold standard. This is the option that will allow a woman to look the most like herself with an implant or her own tissue, and that's called a flap closure in place. And so in this approach, we make an incision usually on the underside of the breast in what's called the inframammary fold. And we remove all of the tissue from the inside but leave all of the skin, the nipple, and the areola. Now this isn't appropriate for all patients. There are some criteria that have to be met and it's a joint decision between the plastic surgeon and the breast cancer surgeon. From my perspective, I'm looking at it from where's that tumor. How close is it to the nipple and the areola? Am I going to get a clear margin? I'm not going to compromise someone's risk for recurrence to meet a cosmetic standard. That's my job as the cancer surgeon. How do I make sure your cancer doesn't come back? And then, of course, the plastic surgeon's looking at it from, OK, when I reconstruct your breast, is it going to look natural and normal? You know, where is that nipple areola going to end up? If it's pointed towards the ground, that's not OK with the plastic surgeon.

[00:09:24] Erin Spain, MS: Scarring can be a major factor when it comes to patient satisfaction with major surgeries like this, and you're actually certified in a trademarked procedure to minimize scarring during surgery. Tell me about this.

[00:09:38] Dr. Andrea Abbott: I became really passionate about the idea of hidden scar surgery when I began to see patients coming in who had surgery elsewhere, and their incisions covered the entire length of their breast, and that was for a lumpectomy. And the patients felt very uncomfortable wearing certain clothing, going to the beach, they had what they considered to be a disfiguring operation. The hidden scar technique is very straightforward. Why put a scar in the center of someone's chest if you can move it to a place where it's hidden by clothing? Hidden scar is just moving the location of the scar, maybe around the areola, maybe closer to the armpit, maybe on the inframammary fold, so that when a woman is wearing clothing, it's not as visible, and it blends in with the natural skin contour. The whole premise, of course, is to not compromise cancer outcomes.

[00:10:33] Erin Spain, MS: I want to talk about something else, which is loss of sensation. That can be a risk with many of these surgeries, including the nipple-sparing surgery you just described. But techniques to promote nerve preservation through nerve grafting are now possible and MUSC Health is one of the few centers in the country that offer this. Tell me about this procedure and what it entails.

[00:10:54] Dr. Andrea Abbott: I think that's really important to highlight. Regardless of the reconstruction, the sensation in the skin and the nipple-areolar complex is not the same, and that can be alarming because you're looking at a part of your body and you're not able to feel it and for a lot of women the whole point of preserving the nipple and the areola was to keep that sensation that's important for you know who you are as a woman and perhaps your sexual health too, and it's a part of your body. I am working with the plastic surgeon so that during the operation, we are looking for a nerve during the dissection and preserving that so then it can be lengthened and grafted to the underside of the nipple so that hopefully, that nerve will regenerate and grow back and a woman can maintain some sensation.

[00:11:40] Erin Spain, MS: This is a fairly new offering at MUSC Health. How have these been going so far? What's reaction been like from patients?

[00:11:48] Dr. Andrea Abbott: A majority of patients are really excited to have this option. It's not adding a lot of risk to the surgery. It doesn't lengthen the time of the surgery significantly. It is done at the time of the cancer operation, so that hopefully there's a very minimal amount of time between when that nerve is cut and when we're redoing that nerve graft. I think on the whole, this has been a really exciting option for patients.

Something that we haven't touched on but is significant is a lot of my patient population is getting younger and younger. So I have more patients that are in their 30s and 40s who are thinking to themselves, like, I'm in the height of my life and you are telling me, you know, I have to have a mastectomy or I'm choosing to have a mastectomy because I know I have 40 years of life ahead of me. I want to be able to wear whatever clothes I want. And I want to be able to, you know, have sensation in my skin and my body. And the loss of that may really impact my ability to feel like a woman or enjoy my life, and every person has to be able to know what their options are.

[00:12:59] Erin Spain, MS: I would love for you to just talk a little bit more about that phenomenon that is being seen with more and more younger women getting this diagnosis. What do we know about that? Why is that happening?

[00:13:09] Dr. Andrea Abbott: So I think first and foremost, we have to acknowledge that our screening is so much better than it used to be. The mammography quality has just improved significantly, even in the last five years. Now with 3D mammography, our ability to pick up even small cancers is just amazing. And so, early detection means patients are going to have more options. They're going to more likely be candidates for nipple sparing or breast conservation.

The other thing that has really improved is our ability to talk about these things, right? Our grandmother's generation, women went in, they had their entire breasts removed and nobody talked about it. They slipped a prosthesis in their bra, and you didn't know. Thankfully, our mother's generation, they're a little bit more comfortable talking about it. And here we are doing a podcast. So I think as we change our culture of talking about it, of being comfortable talking about women's health, we'll, you know, see that trend of people having more mammograms, earlier screening, doing genetic testing. You know, sometimes we can get misled and think like, Oh, something must be happening in our population. There's more cancer, but maybe it's just that we're detecting it earlier.

[00:14:20] Erin Spain, MS: When it comes to reconstruction, deciding which type and timing can be really crucial considerations. Tell me about the various breast reconstruction procedure options available to MUSC patients and how those decisions are made with your patients and the plastic surgeon.

[00:14:37] Dr. Andrea Abbott: When a woman decides that she wants to have breast reconstruction, I set her up with an appointment to see a plastic surgeon. And that initial visit can be an hour and it's understanding all of the options for reconstruction.

Historically, it was silicone implants. That was it. And then, you know, we went through a period of time where we decided silicone wasn't safe, so then everyone got saline. There have been a lot of improvements. And so now silicone and saline are back on the market as implants, but also the way that we do autologous flap reconstruction and autologous means you're using your own tissue and that tissue typically comes from your stomach.

Again, we've had tremendous advances in the way we do that surgery. So we used to take the muscle and the fat and the skin. Now we're just taking the fat and the skin. So it's a much less invasive procedure than what autologous tissue flap reconstruction used to be. How a patient decides which is best for them, again, is really meeting with a plastic surgeon and going over your goals. Not everybody is going to have enough tissue in their abdomen to reconstruct the breasts that they want. Not every patient is going to feel comfortable using silicone, or perhaps they don't like the way that the saline feels. So again, it's having the opportunity to meet with the plastic surgeon, feel the implants, try them on, what size do I want to be? What are my goals for this operation as well?

So that is usually two visits with a plastic surgeon and really meeting with somebody who you feel like hears you, understands you, and you can clearly communicate what your goals are for your aesthetics. Now that being said, plastic reconstructive surgery is not a one-and-done operation. Unfortunately, the majority of patients are not able to have a bilateral or a unilateral; that means one side, mastectomy, get an implant put in and never have surgery again.

And the reason is because there is a lot going on. The first operation is really about the cancer. How do you take care of the cancer? And then we try to put in an implant if it's appropriate.

But remember, I just did a major surgery. I just took out all of your breast tissue and your veins are clamped down. They're like, what have you just done to me? And so sometimes that blood flow to the skin is not as robust. It's not as healthy as we need it to be to now put an implant in right behind that skin.

So the plastic surgeon's job is to come in and take a look. How does that blood flow look? They have special tools and equipment that they use to look at the blood flow to the skin in real time, and they can make a determination. Is it safe to put an implant in? And that's called immediate reconstruction. If it's not, it doesn't mean it won't ever happen. It just may not happen that day. And so that's called delayed reconstruction. They can try to put in a temporary placeholder, and that's called an expander. And as the name implies, that expander goes into the pocket that's created from removing the breast. And then over the series of the next couple of months, you visit the plastic surgeon, and they fill that expander with air or saline, and as that balloon expands, it stretches the skin slowly, and then eventually, you get to the size that you desire, and you go back for the second operation where the new implant is put in.

[00:18:01] Erin Spain, MS: You are so passionate about staying on top of these latest procedures and technology available. What do you see coming up next? What could we imagine could be in the future for the next generation of women who may be facing these types of surgeries?

[00:18:16] Dr. Andrea Abbott: I think we're going to see an expansion of criteria for nipple-sparing mastectomy. I really do think that we are pushing the envelope of what we can do and for the larger-breasted woman, or for a woman whose nipple areola may not be in the right place so they can immediately be a candidate. How can we do a two-stage approach?

So I think we're going to start to see more complicated decision making in this sense of how do we stage this out? The other thing I would say is, in my, you know, practice, I'm really changing who I say is a candidate for a lumpectomy. And it's a really straightforward number, right? So if your tumor is greater than three centimeters, you need a mastectomy. We don't say that anymore. Now we really say, what is the tumor size? What's your breast size? What can your breast accommodate?

[00:19:07] Erin Spain, MS: What advice would you like to give to women who may be going through this right now and they're about to visit some surgeons and make some decisions about their breast cancer surgery. What would you like to say to them?

[00:19:19] Dr. Andrea Abbott: Women should feel empowered to ask for what they want and desire. So often, women come in and they say, well, I don't want to be vain or I just want to do whatever is safest, or I don't want to be out from work for too long, and they're compromising what they want because they are afraid in that moment to have the center of attention on themselves, and I just really want women to feel empowered to say, this is what I need. This is a really crucial time in my life. These are critical decisions that I have to live with forever. It's OK for me to be selfish. It's OK for me to think about what does my life look like in two years? What do I want my body to look like? And if you're not getting the answers that you think that you want, or you're not being listened to, please see another physician. There are so many of us out there. There is nothing wrong with getting a second or third opinion, and if somebody's feelings are hurt, because you went and got a second or third opinion, that wasn't the doctor for you in the first place.

[00:20:25] Erin Spain, MS: This is a question we ask everyone who comes on this podcast. What do you do to optimize your health and live well?

[00:20:31] Dr. Andrea Abbott: What I try to do for myself is the same thing that I advise patients. The number one question I get is what should I be eating? How can I eat something or not eat something that's going to help me live longer? And so I am really trying to look at my diet and stick to the corners of the supermarket. So it's the fruits, the vegetables, the meats, and if you're nondairy or you're dairy, it's the dairy case, right? The yogurts and things. For me, it's how do I make sure that I'm eating less processed foods, more natural foods. Not everybody can afford organic. I don't buy everything organic either, but I am looking at labels. How do I minimize hormones? How do I try to just pick the foods that are the healthiest for me?

[00:21:16] Erin Spain, MS: That's great advice. The four corners of the supermarket. Well, thank you so much for joining me and having this important conversation that it sounds like you are having with so many patients who come through the door. And I hope that some folks will be listening to this and it will lead them to MUSC Health if they need to have a conversation like this in the future. So thank you so much for your time today.

[00:21:35] Dr. Andrea Abbott: Absolutely. Thanks for the platform.

[00:21:37] Erin Spain, MS: For more information on this podcast, check out advance.muschealth.org.

Learn about breast cancer support — screenings/mammograms, diagnosis, treatment, and more — at MUSC Hollings Cancer Center.