Hi, I'm Dr. Deepti Chopra, an associate professor in
Psychiatry at MD Anderson Cancer Center, and today
I'm joined by Dr. Puneet Singh, who is an associate
professor in Breast Surgical Oncology at MD Anderson Cancer
Center. And this is the Cancerwise Podcast.
Thank you so much for being here today, Dr. Singh.
Our topic is physical changes with breast surgery in
patients with breast cancer diagnosis, and I'm so glad
to have you here.
Thank you for having me here, Dr. Chopra.
I'm really glad to be able to talk about body image
after breast cancer, specifically related to
breast surgery.
There are a lot of physical and emotional changes that can
occur after treatment for breast cancer.
And so, I wanted to just start off by talking about the
emotional response to their breast cancer diagnosis
and how that impacts not only their course of active
treatment, but how they look and feel.
So, you know, cancer diagnosis is a life-threatening,
life-altering condition, and it creates
a lot of anxiety and emotional distress.
And patients want to start treatment immediately, and
their mind is to get that tumor out.
They think surgery is the first step, but that may not
always be the case, as you know.
So, you know, what comes first?
And then not to mention the physical changes with cancer
treatment, like with chemo, changes are more gradual,
whereas with surgery it's pretty rapid and most of them are
permanent.
So, you know, if it's surgery first they're thinking about
what kind of breast surgery and what will they
look like and what can be saved, what cannot
be saved. And I don't know if you have patients that come
in and express these worries. How do you handle that?
Yeah. No, I certainly agree.
I think it can be very challenging.
It's a very vulnerable time for many of our patients.
You know, they're kind of navigating this new diagnosis,
what it means for them in terms of outcomes
such as, you know, their survival and recurrence, but also
really all of these changes that you mentioned, you know,
the physical changes, the emotional changes.
And so, you know, our goal in that first visit is
not only to review the diagnosis,
everything that we know up to that point, but also then
to really kind of navigate these topics of how,
for example, surgery in my clinic is going to
proceed and how that will impact them in the long
run. I think many studies show that
quality of life, including, you know, emotional and
physical well-being, are significantly impacted
by breast cancer surgery and breast cancer treatments.
But I certainly think there are ways for us to anticipate
those and to talk to patients about those
so that we can better prepare them in the long run.
Do you feel that emotional distress is more with a certain
kind of surgery, one versus the other, or?
You know, there's certainly physical changes
that are going to be present with both mastectomy
or segmental mastectomy, which is the formal
term for a lumpectomy.
But I do think mastectomy tends to have some more
kind of permanent changes.
And when I talk about physical changes, we're
talking about not only, you know, a scar on the breast, but
it can also impact the size, shape,
appearance of the breast.
You know, after a mastectomy, many women,
though not all, will choose to undergo breast
reconstruction of some sort.
And so, certainly that's not going to be exactly
like their native breast.
But there's also changes related to sensation,
whether they're able to keep their nipple or their
areola. And even if they are able to,
you know, keep their nipple, it can be different
in terms of the sensation that they had from before
surgery. So, these are all things that, you know,
we try our best to really talk to them about.
And certainly, it's not just in our surgical
clinic, but also in the plastic surgery clinic that they're
really discussing how that will go.
And so, we talk about those more permanent
types of changes. And then of course, there are the more,
you know, typically temporary changes.
And that can be things such as, you know, whether they're
going to have drains in place or
are they going to have some range of motion or limited
range of motion of the shoulder or some arm stiffness,
etc. And we can certainly address many of these,
but it is important for us to not only try to discuss
them with patients so that they're aware that we have
resources for them if they encounter any of these
changes after surgery.
That's great. That's great. And I'm glad you're going over
this with the patients.
You know, personally, we, I focus on the psychological
side, and either of the breast surgeries can be emotionally
distressing. It's hard to say, but like you said, you know,
sometimes the mastectomy is a larger surgery, more recovery
time. So, the adjustment is longer and
maybe more distressing from that standpoint.
But all in all, you know, the breast surgery makes
the cancer diagnosis really real for the patient.
So, that's, that I think is important for us to realize.
Yeah. And I certainly think that, you know, while
I say we do our best to anticipate these, I
think that we also recognize that sometimes patients do
benefit from talking to someone like yourself, Dr. Chopra,
you know, and and reviewing these either in the
preoperative setting before they've had the surgery, if
they're not sure how they can navigate that, but also
certainly afterwards.
So, I think, you know, really it's important to be a
team and utilize all of the resources
that we have here to support our patients through
this journey and this process.
Yeah, absolutely. I agree with you and I'm happy to see
them. I actually like to see them before the surgery so
that I can understand where they are and kind of prepare
them, you know, because the amount of physical change that
comes with surgery is so much for patients
to absorb that I try to kind of prepare them in advance.
Things like, you know, like you mentioned, the range of
motion, let them know that you, you know, you may not be
able to do certain things at home that you were normally
doing. I also like to mention
that, you know, with surgery the most common thing is
the breast swelling and pain.
Especially, like you said, if you have drains and tissue
expanders, that hurts.
So, going over all this with the patient really,
I think prepares them as much as we can,
but also kind of reminding them, like, you know, this is
not permanent.
With time, these changes kind of slowly die down
and things will start getting better.
And then the other thing I encourage patients to do is to
understand where the scar will be made.
So, I don't know what are your thoughts when patients ask
all these questions before surgery?
How do you, how do you take them?
Yeah, I, I definitely encourage questions.
You know, I think usually, I, when
I'm meeting patients for the first time, there's a lot of
information to certainly get through.
So, we'll go over, you know, mastectomy versus lumpectomy
in terms of, you know, the cancer outcomes of survival
and recurrence. But then, you know, once we kind of
establish that, it's really delving into
not only the things that will impact them in the long term
as well, like quality of life, but really
addressing their questions because those are the things
that are going to be most important to them
based on their values and their preferences and
their goals. And so, that gives me an idea of how to kind
of tailor the conversation.
So, I actually really appreciate when patients
come in with questions.
They're prepared.
But certainly, you know, we're here as a resource to
give patients as much information as possible so that they
can feel confident in their decision and, and
be informed. And so, specifically, you know, when you,
we're talking about scar placement and whatnot,
we talk about the typical location or
placement of that scar.
In other cases, you know, there are lots of different
nuances to this question.
And so, sometimes it's about discussing that with
the plastic surgery team if the patient's going to undergo
breast reconstruction.
And so, we try to give them an idea of what the
scars will look like and what they can
do to heal them.
But there are, you know, a number of other questions that
I'm also asked, you know, related to sensation or
can they keep their nipple or not?
And, you know, regardless of whether, for example,
we can save their nipple as part of the mastectomy,
for example, we do offer other options for nipple
reconstruction if we do have to remove it.
So, you know, we try to navigate
the questions that patients have and provide them
information, again, so that they feel confident in their
decision. It's all about being a team and making
a shared decision, for sure.
And you know, that reminds me, there's often, you know,
a lot of googling that's done in anticipation
of their visits.
And so, how do you kind of advise patients on, you
know, googling their care and treatment for breast cancer?
Yeah, that's absolutely a very important question now.
In this world of information overload,
there's so much stuff out there that it can be overwhelming
and sometimes misleading for patients.
So, I try to explain that to them that, you know,
take the information with a grain of salt.
And if you have any concerns or questions, try and go
back to your treatment team, because your team has
your information and all your medical
needs that need to be addressed.
So, they would be in the best position to guide you with
all your questions.
Once a patient undergoes breast surgery, what are coping
strategies that you recommend?
Immediately after surgery, you know, patients have to
see themselves in the mirror, and there's only one first
time to see yourself in the mirror.
And it's important to, you know, prepare for that.
So, that's what I go over with the patients, especially in
the pre-op visit.
One simple thing that every patient can do is start with a
small mirror, then move to a mid-sized mirror
and then a full-length mirror.
There are also other strategies that we use to kind of go
through the exercise and
I go over that with them in detail, because
whatever works best for that patient.
We have this as a tip sheet on our MD Anderson Patient
Education form, if you ever want to look at it, but it's
definitely available for our patients.
That's great. And I think those are really, really helpful
strategies. It's certainly something that
my patients bring up to me.
And, you know, I think it's great to have a resource,
as you mentioned, but also being able to refer
as appropriate to you. So, thank you for that.
I guess I wanted to talk a little bit more also about, you
know, how you think after surgery
that impacts their body image, you
know, in more in detail.
Yeah, absolutely. So, when it comes to breast surgery
and breast cancer treatment, you know, depending on where
women are in their lives, you know,
loss of breast would mean different things for different
women. Sometimes it's feeling less whole, feeling
less feminine, or sometimes it's, you know, their ability
to maintain or start
romantic relationships.
And sometimes it's a combination of both of these.
So, you know, it's totally very dependent
on where women are in their lives and how they perceive the
loss of their breast.
As a result, people become more self-conscious
when they go out in social gatherings, especially.
They may switch over to wearing more loose clothes,
and then sometimes they feel sad about their inability to
breastfeed.
The other aspect is that there is a phase that some
women, you know, mourn the loss of their breast, and it's
okay for a little amount of time.
The other thing with breast surgery to keep in mind is the
lymphedema, which is the arm swelling.
It's something that's visible that has to be taken care of,
you know, to limit their choice of clothing.
It may also interfere with their daily activity with
someone who types a lot or drives a lot.
So, you know, the arm may be heavy, the perception changes
may be there, and they may not be able to do it as they
were before the surgery, and which leads to sadness
and decreased quality of life.
So, these are the changes that I think of in terms of
breast surgery. Now, we all know breast cancer treatment is
sometimes more than breast surgery.
There is chemotherapy, radiation therapy, hormone therapy,
and each one of those has physical changes themselves.
So, like with hair loss, skin changes,
nerve pain, fatigue, and then general
body weight gain, that's something that many
women with breast cancer struggle with.
And, you bring up really good points.
I think there's a number of potential impacts.
And, you know, it's really, really been helpful
to see not only what our patients tell
us, but also, you know, what studies show in terms of,
you know, what we call patient reported outcomes: how
they feel after they've had not
only breast surgery but after various treatments.
And I think that can, again, help us tailor our
conversations with patients, but also what
resources to provide them not only preoperatively,
but really postoperatively, as you're mentioning.
Whether it's, you know, the first couple of months after
surgery or the few years after surgery.
And I think, you know, of course, we've often
focused in breast surgery on reconstructive techniques,
and we have a number of them that we can offer for
reconstruction after mastectomy or
what we refer to as oncoplastic reconstruction.
That's reconstructive techniques after a lumpectomy.
So, there's different ways that we can try to address the
potential questions or things that our patients want in
terms of trying to restore them in some way that seems
more normal.
And so, these are things that we, we try to discuss with
our plastic surgeons, but also, as you mentioned,
lymphedema.
And we have ways of kind of addressing
that at the time of surgery or even,
you know, long term for chronic lymphedema.
And I think there's other, you know, aspects
of this, such as, you know, as treatments have gotten
better for breast cancer, sometimes that means longer
durations of treatment.
And what that can mean is sometimes more
delayed time to getting to final reconstruction.
And so, recently, you know, myself,
along with several of our colleagues in Breast Radiation
Oncology and Plastic Surgery, you know, published a study
called the SAPPHIRE study.
And this looked at actually doing radiation
before surgery.
And so, then patients were able to get mastectomy and
immediate reconstruction, tissue-based reconstruction.
And one of the key points from the study
is that not only was it safe and feasible to
do that reconstruction at the time of mastectomy, but it
really overall shortened the time from, you know,
when they were diagnosed to kind of that final
reconstructive step.
So, I think that, you know, we're studying this further and
and, you know, hopefully there will be other ways to
address, you know, body image and the impact
that surgery can have on the patient.
I was wondering what your thoughts are on these kind of
patients who may have more delayed
reconstruction, how to how to navigate those body image
issues?
Yeah, you're right, because they have a longer time to get
used to those physical changes and may, may need
more adjustment.
So, I certainly help them out by understanding what their
mindset is.
How can they, you know, rebuild that connection
with their new body?
And it's a process.
It takes time, but at least it makes patients move more
towards acceptance of the new body.
And so, that's something that I definitely think
will be valuable to all these patients if you can, you
know, decrease the time of delayed breast reconstruction
for them.
So, we, you know, were talking about, you know, delayed
reconstruction. And I was curious if there are
any, you know, new strategies or other
kind of resources that you are exploring or
can offer patients?
Absolutely. So, the area that is definitely
not that studied well is the undergarment
option for patients who've undergone mastectomy.
And we're looking at having customized undergarments for
patients. This is an idea that I'm exploring with Plastic
Surgery, and we hope we can study it soon.
So, I'm excited about that and hopefully we'll have,
you know, much more options for our patients down the road.
Yeah, that would be great.
Thank you so much for the enlightening conversation today,
Dr. Singh.
This was wonderful, Dr. Chopra.
Thank you for tuning in today.
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