Health Chats
Innovations in surgical and non-surgical treatment for breast cancer
Tuesday Oct 06, 2009, 12:00PM - 01:00PM (EST)
Director of Breast Services, OB/GYN and Women’s Health Center
Cleveland Clinic
Breast Center, Cleveland, OH
While there are many surgical and non-surgical treatment options for breast cancer, it can be difficult to know which one to choose? Join Joseph Crowe, MD, for a live web chat and get the most up-to-date information on innovations in treatment for breast cancer from one of the nations top cancer programs.<br><br> The Cleveland Clinic Breast Center offers a multidisciplinary team of highly skilled specialists who provide comprehensive care to patients with breast cancer. Here, you will find a full array of services, from initial screening and diagnosis to innovative breast cancer treatment and supportive counseling.<br><br> Joseph Crowe, Jr., MD, is Director of the Breast Center at Cleveland Clinic and Director of Breast Services, Cleveland Clinic Health System and Ob/Gyn & Women's Health Institute. He is a board-certified surgeon with more than 25 years of experience in treating breast disease, and has a longstanding interest in the use of minimally invasive techniques for diagnosis and treatment. Dr. Crowe pioneered the development of nipple-sparing mastectomy and offers the most up-to-date surgical procedures including breast conservation techniques and immediate reconstruction options not widely available. <br><br> The focus on this Health Chat will be on innovations in breast cancer treatment.<br><br> This year 180,000 women will be diagnosed with breast cancer and approximately 43,500 will die. Although these numbers may sound frightening, research reveals that the mortality rate could decrease by 30 percent if all women age 50 and older in need of a mammogram had one. Additionally, if detected early, breast cancer has a five-year survival rate of over 95 percent.<br><br> Breast cancer treatment is the number one priority of our physicians, through a full range of services from prevention, to detection, to surgical and non-surgical breast cancer treatment as well as breast reconstruction.
Joseph Crowe, MD:
Welcome to Innovations in surgical and nonsurgical options in Breast Cancer Surgery with Dr. Joseph Crowe, MD.
Joseph Crowe, MD:
Dr. Crowe is the Director of the Cleveland Clinic Breast Center.  He is a board-certified surgeon with more than 25 years of experience in treating breast disease, and has a longstanding interest in the use of minimally invasive techniques for diagnosis and treatment.  Dr. Crowe pioneered the development of nipple-sparing mastectomy and offers the most up-to-date surgical procedures including breast conservation techniques and immediate reconstruction options not widely available.
Good Afternoon and welcome to Innovations in Surgical & Non-Surgical Treatment for Breast Cancer.  We are very pleased to introduce Dr. Joseph Crowe who is the Director of Breast Services, OB/GYN and Women’s Health Center at the Cleveland Clinic in Cleveland, OH.  Welcome Dr. Crowe and thank you for answering our questions today.
Dr. Crowe: For very large breasted post-mastectomy, post-chemo patient about 60 years old; would you recommend breast reduction surgery or prophalactic mastectomy for the remaining healthy breast?&nbsp;&nbsp;Thank you, Karen
Joseph Crowe, MD:
The breast reduction surgery is likely to help with your comfort and also possibly with symmetry, however, prophylactic mastectomy has the advantage of reducing the chance of a new breast cancer developing on that side over time.  The chance of a new breast cancer is between 0.5% and 1% per year from the time of your original breast cancer.  It is certainly an individual decision that is made by different women which approach if any they would choose.  It is always advisable to discuss your situation with your surgeon and medical oncologist.
Hi - thank you so much for answering our questions today! What is the difference between a screening mammogram and a diagnostic mammogram?  Should I have an MRI instead?
Joseph Crowe, MD:
A screening mammogram is the mammogram performed for women who do not have any breast problems or symptoms.  A screening mammogram is recommended every year after age 40. A diagnostic mammogram is one that is performed when a symptom such as a lump or mass has been found and/or a screening mammogram is found to be abnormal.  A diagnostic mammogram is focused specifically on the area of concern in an effort to further characterize it.  A breast MRI would not necessarily be recommended for breast cancer screening unless you have a very high risk of developing breast cancer such as a BRCA mutation.  Sometimes breast MRIs are helpful in better evaluating a breast mass or abnormal mammogram, however, this recommendation is best made by a breast radiologist.
Can fibroadenomas or cysts turn into cancer or put you at a higher risk for cancer?
Joseph Crowe, MD:
There has been much discussion over the years concerning whether or not benign breast findings such as a fibroadenoma or a breast cyst increases the chance of developing breast cancer.  The agreement is that neither of these benign breast findings clearly increases one's chance of developing breast cancer.  Breast pathology findings that would be considered those that would increase risk would be atypical ductal or lobular hyperplasia.
I was diagnosed with DCIS, stage 0, estrogen and progesterone negative, and not tested for HER2.  I had a lumpectomy and radiation.  Should my tissue be tested for HER2? Thank you in advance for your medical opinion.
Joseph Crowe, MD:
Estrogen and progesterone receptor testing is helpful in women who have ductal carcinoma in situ.  For those women found to be positive for these receptors Tamoxifen is often recommended, particularly when local treatment has been breast conservation.  HER2 testing is not usually performed for DCIS.  HER2 testing is helpful for invasive breast cancer to decide about recommending Herceptin, a therapy that is not used for DCIS.
I had lumpectomy and now must do rads.  Now I am thinking it would be better to have a skin sparing mastectomy instead of doing rads.  Would this be a better choice if I was worried about recurrence?  I have triple negative, stage 1.
Joseph Crowe, MD:
Lumpectomy and radiation (breast conservation therapy) are standard recommended treatments for early stage breast cancer.  An important consideration for the success of breast conservation is the ability to remove the cancer with negative margins.  Some women will choose mastectomy and not breast conservation even when the latter is possible based upon personal preference. This is an individual decision.  Local recurrance is less with mastectomy compared to breast conservation, however, the overall survival of patients with either is similar.
I was diagnosed with lupus in 1994.  I was diagnosed with breast cancer in August 2009 and had a mastectomy.  I am now considering reconstruction.  My question is, will having lupus, mild and well under contol, affect the type of reconstruction I can have?  Thank you!
Joseph Crowe, MD:
In general, the decision about breast reconstruction is made with the plastic surgeon.  Implant breast reconstruction is often a good choice and has not been found to be related to an increase in autoimmune and or collegen vascular disease as thought at one time.  The second type of reconstruction uses your own tissue.  It is a more extensive type of reconstruction.  The advisability of this type of breast reconstruction needs to be made on an individual basis with your plastic surgeon.
My nipple was not saved from the mastectomy. I have friends that have had their plastic surgeon make them a nipple after their implant, however they tell me that after a year or so the nipple expands out and they more or less lose it.  My remaining natural nipple is fairly large and on the long side.  Is there any type of nipple implant or procedure that would give me a new nipple that will last???
Joseph Crowe, MD:
There are different approaches to nipple (reconstruction) after mastectomy.  The simplest approach is tattooing a nipple without any surgery and this approach is acceptable to many women.  Surgical nipple reconstruction can be done using various approaches, many of which will allow for excellent nipple shape and projection for many years.  Your best option would be to consult a plastic surgeon who specializes in breast reconstruction to learn about all your options.
I had a mastectomy of the left breast in May.  They weren't able to spare the nipple because of the size of the tumor (grapefruit sized).  They saved as much tissue as they could so that I can have reconstructive surgery.  I have an aggressive form of breast cancer (metaplastic carcinoma) and plan to have a prophylactic mastectomy on the right side the same day the reconstruction takes place on the left (both at once).  My question is this:  how long after chemo do I have to wait before the reconstruction can be done and is there a chance for recurrence in the reconstructed breasts?
Joseph Crowe, MD:
In a situation such as yours, many women complete all the cancer treatment before beginning breast reconstruction.  The length of time between cancer treatment and reconstructive surgery varies from as little as several weeks to many years, however, many women wait at least 6-12 months.  The breast reconstruction does not increase the chance of recurrance.  With implant reconstruction, a clinical examination is the recommended follow-up after breast reconstruction without mammography.  For autologous reconstruction (using your own tissue) both a clinical exam and mammography are advised for follow-up of recurrance.
I was diagnosed with DCIS by core needle biopsy, less than 1 cm, moderately aggressive, ER +, PR +.  The pathology from the lumpectomy noted LCIS.  A doctor from Sloan Kettering stated during a webcast, which I replayed several times to be sure I understood correctly, that mastectomies are sometimes used to treat DCIS because RT doesn't work as well as with invasive cancers and chemo is not effective.  Would you address this, please, as bilateral mastectomy is a serious consideration for me, in order to eliminate as much risk as possible, as well as to avoid radiation and Tamoxifin (my doctor's drug of choice for me).  I am 65 years old.  Thank you.
Joseph Crowe, MD:
Breast conservation (lumpectomy and radiation) is a common approach for the treatment of DCIS.  Recurrances following breast conservation for DCIS can be invasive recurrances in up to 50% of cases. However, many women do choose breast conservation with an initial diagnosis of DCIS.  If you wanted to avoid radiation and Tamoxifen, mastectomy is the best choice.  Mastectomy for the other breast would be for prevention and this is an individual decision often related to breast reconstruction options and symmetry considerations.
Hi - my mother died from breast cancer a few years ago.  Now my sister wants to have a mastectomy to prevent her getting breast cancer.  Is this common practice and is it REALLY necessary?
Joseph Crowe, MD:
Those women who choose prophylactic mastectomy are generally from families where there is an identified inherited breast cancer risk such as BRCA mutations.  It would be very uncommon for an individual who's mother had developed breast cancer as her only risk factor, to choose prophylactic mastectomy.  I would advise that she consult with a center/ team of breast specialists before deciding to proceed with the surgery.
I had a sterotactic biopsy in August. It came back atypia cells and now they want to go back in there to clean it out even though the biopsy came back non cancerous. I really dont understand all about Atypia. Would you explain? Have a great day
Joseph Crowe, MD:
A stereotactic biopsy removes only a small sample of tissue for analysis.  Whenever atypical hyperplasia is found on a stereotactic (core) biopsy an excisional (surgical) biopsy is recommended so that more tissue can be analyzed.  It has been found that between 30 and 50% of women with atypical hyperplasia on core biopsy will be found to have either DCIS and/or invasive cancer on subsequent excisional biopsy.
I was given the diagnosis of breast cancer on March 24, 2009.  I was told I had comedo type which was very aggressive.  A mastectomy was performed on April 6.  The cancer was placed at stage 1.  The Oncotype DX test was done with a recurrence risk of 13.  I have been told that I have fibroids in the uterus, but that they are not related to the breast cancer.  Should I be concerned about the fibroids?  With the advice of the Oncologist and Surgeon there was no chemo or radiation treatments.   I am on Tamoxifen until I've gone one year without a period and then the Oncologist plans to switch me to an inhibitor.  Is one inhibitor better than the other?
Hello everyone. Dr. Crowe has experienced a temporary loss of internet connection. He will resume answering questions as quickly as possible. Thank you for your understanding!
Joseph Crowe, MD:
The fibroids in the uterus are not related to the cancer and you would not need to be concerned about them. In terms of the best inhibitor I would follow the advice of your oncologist.
Hello everyone! Dr. Crowe is back and will answer one final question.
If I have to have a mastectomy, is it better to have reconstruction right away, or to wait?  What type of implants would you recommend after mastectomy?  Also, what is a "nipple sparing" mastectomy?
Joseph Crowe, MD:
The decision about the timing of breast reconstruction is best made together with your breast surgeon and your plastic surgeon.  Many women have immediate reconstruction. For those who have reconstruction with implants, an expander implant is used at the time of mastectomy with the permanent implant placed several months later.  Permanent implants may be either saline or silicone implants.  The recommendation will be made by your plastic surgeon.  If silicone implants are possible, usually a newer cohesive silicone gel is used that does not have the concerns of the older liquid silicone.  Nipple sparing mastectomy is a full-mastectomy that leaves the skin of the nipple and areola and usually is accompanied by some type of immediate reconstruction.  This procedure is gaining more widespread use but is not possible for everyone.
Joseph Crowe, MD:
Thank you for participating in the web chat on breast cancer and treatment options.  Our team of breast center specialists offer a unique approach to the diagnosis and treatment of breast cancer.  The Cleveland Clinic Taussig Cancer Institute has been ranked #1 in Ohio by the U.S. News & World Report's Best Hospitals Survey since 2007.  To schedule an appointment with one of our breast specialists, call 1-800 223-2273 x 43024 or visit us online at