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Dr. Jones: Do women with breast implants have a higher risk of cancer? What cancer? What's the risk and what should we know?

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: There are about 300,000 breast implant surgeries performed every year in the U.S. Now, there are a number of reasons for breast implant surgery, but all people requesting breast implant surgery have concerns about risks and side effects. There's a new concern about a very rare cancer that might be more common in women with breast implants.

And today in The Scope studio, we're talking with Dr. Jay Agarwal, who is chief of Plastic Surgery at the University of Utah. He's a plastic surgeon at the Huntsman Cancer Institute, who specializes in breast reconstructive surgery, and he's going to help us think about this risk.

Welcome back to The Scope, Dr. Agarwal.

Dr. Agarwal: Thank you. Thank you for having me.

Dr. Jones: So what did the FDA identify as a possible association between breast implants and a rare non-breast cancer?

Dr. Agarwal: Over the past decade and a half, the FDA, the medical societies, and doctors in general have been paying very close attention to the outcomes of their patients that have had breast implants placed. And so, over the past number of years, we found that there is a very small but significant incidence of a rare lymphoma, and it appears that it's associated with a specific type of breast implant, whether they're placed for reconstructive purposes or cosmetic reasons. And that's ALCL, an anaplastic large cell lymphoma.

Dr. Jones: That's a new one to me.

Dr. Agarwal: Yeah. Most people haven't heard it.

Dr. Jones: Right. Very rare.

Dr. Agarwal: And it's not a breast cancer as we think of breast cancers. It is a lymphoma. It's typically found in the capsule, the scar tissue that surrounds a breast implant. But again, I want to emphasize that it's exceedingly rare.

Dr. Jones: If there's an increased risk, what kind of numbers are we talking about?

Dr. Agarwal: We're talking about really low risk. It appears that patients with breast implants have about a one in 3,800 to one in 30,000 risk of developing this type of lymphoma. To put that in a broader context, you can think that the average woman in the United States, one in eight women will develop breast cancer.

Dr. Jones: In their lifetime, yeah.

Dr. Agarwal: In their lifetime. So this is orders of magnitude lower than that risk.

Dr. Jones: So it's very small or . . . this is where I put it in the teensy when I . . . this is my teensy risk.

Dr. Agarwal: That's correct.

Dr. Jones: However, it's a scary thing because many women who are having implants are maybe not doing it for cosmetic purposes but for reconstructive purposes, and they already have cancer on their brain and their heart. What kinds of breast implants are the most likely?

Dr. Agarwal: So what we've seen, first of all, there have been about 400 to 500 cases of this ALCL reported to the FDA. And after looking back at those patients and the types of implant they've had, it appears that the highest association is with textured breast implants.

Dr. Jones: So tell me about that. I don't get textured. Is textured meaning its outside is kind of rough, or what do you mean by textured?

Dr. Agarwal: That's correct. So breast implants come in a variety of styles. The first you may know is saline-filled implants or silicone-filled implants. And then another characteristic can be whether they have a smooth outer surface or a textured outer surface.

We started using textured implants because there was a thought that maybe it decreased the amount of scar tissue that formed around the implant or what we call capsular contracture. Sometimes we use implants that are slightly shaped, and the texturing helps prevent the implant from turning. But the association with the ALCL is the highest with the ones that have a texture on the outer surface.

Dr. Jones: Well, that has some biological possibility. I mean, it could cause a different kind of reaction than a smooth, slippery one.

Dr. Agarwal: It could. It's possible that the texturing creates more inflammation or an area for bacteria to reside and cause an inflammatory response.

Dr. Jones: You mentioned that it's in the capsule or the area around the breast implant. How does this present? Because quite frankly, when we think about lymph cancer, I think about lymph nodes, I think about armpits, neck nodes. I wouldn't think of looking at the breast itself. So how might it present if I were an OB/GYN or a clinician? What am I looking at?

Dr. Agarwal: Right. So patients who've had breast implants can present to their physician, OB/GYN, general family physician, or their plastic surgeon with a variety of different complaints. The breast is swollen, it's become more painful, or they feel a mass. The most common presentation is fluid around the implant. And about 86 percent to 90 percent of patients who've had this ALCL presented with what we call an effusion or a seroma around the implant.

Dr. Jones: Was it years after their implant or . . . it must have been years because cancer doesn't happen in a day.

Dr. Agarwal: Right. So the average time to presentation of the 400 to 500 patients that have had this has been 8 to 10 years after the breast implant has gone in.

Dr. Jones: Right. So if it's 400 in the U.S., that means the vast majority of plastic surgeons, OB/GYNs, primary care docs, nurse practitioners have never seen this, have never heard of it. But if a patient comes with a new complaint some years after the breast implant should be pretty stable, they should know enough to say, "That's not normal."

Dr. Agarwal: That's correct. Again, to put it in a little bit of context, as you mentioned in your opening, there are about 300,000 to 500,000 breast implants that are placed annually in the United States. It's believed that worldwide there are about 35 million women who have textured implants, and it's believed worldwide about 1.5 million implants are placed annually.

So, again, small numbers, but any OB/GYN, family physician, plastic surgeon should be made aware of this, because as we're learning more about it and as we're observing our patients more closely after they've had implants placed, we're identifying more cases of this. And while the number is small, we don't know where it will end up at.

Dr. Jones: Right. Well, when we're talking about breast cancer, even a very rare one, people think about this being lethal. So, when this presents, is this usually a cancer that's spread already? Do most people die from this cancer? What happens when people find this cancer?

Dr. Agarwal: Most of the time with ALCL that's associated with breast implants, the cancer resides locally in the tissues around the implant. And for most of the cases, removal of the implant and removal of the capsule, the scar tissue around the implant can cure the patient of the lymphoma. In rare instances, the lymphoma can spread to the lymph nodes or elsewhere, but the most common presentation is a local one.

Dr. Jones: Well, that's actually great news for a rare cancer, for it to be actually mostly curable with the surgery, just remove the implant and capsule. To me, as a provider and as a woman, that's very reassuring to me.

Dr. Agarwal: Yes. Nobody wants to have an increased risk of anything if they're having a medical device placed. The good news is (a) it's very rare, and if caught within an early period of time, it can be cured by removing the implant and the capsule. If there's something good about it, I'd say.

Dr. Jones: That's right. I think that's good news about bad news.

Dr. Agarwal: Right. I will say that at the University of Utah and Huntsman Cancer Hospital, we have placed a moratorium on textured breast implants. We no longer place any textured implant until the medical community and the FDA learn more about this ALCL, and until we feel confident or have some better understanding of what the true association, if there's really a cause and effect association.

I think you want to ask all the right questions as a patient. What type of implant am I having placed? What are the risks of the surgery? What are the risks of the implant?

From the physician side, it's important to do a full physical exam when your patient comes in for their annual visit. That includes a full breast exam, particularly in patients who have had breast implants. If a patient notices anything suspicious or a change in the shape, size, or feel of their breast, they should bring it to the attention of their physician. And if an OB/GYN or a family practice doc has concerns, they should then have the plastic surgeon involved.

The FDA at this point recommends that either an ultrasound or an MRI can be done as a screening tool. Anyone who has symptoms should go directly to MRI. Anyone who has an implant placed, particularly a textured implant, should have a screening MRI after five or six years after the implant was placed.

Dr. Jones: Well, for many women who are making the choice about breast implants, only they will be able to balance the risks and benefits in their own bodies. But we try to give them the best information that we have and help support them with their decision. Thanks, Dr. Agarwal, and thanks for joining us on The Scope.

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Recently the Food and Drug Administration (FDA) has identified a possible association between textured breast implants and development of a rare form of cancer called anaplastic large cell lymphoma (ALCL).

The majority of the data suggests the cancer risk is associated with breast implants that have textured surfaces rather than those with smooth surfaces. The risk is low and thus far only a small percentage of patients with textured implants have been found to have ALC in the United States. Nevertheless, out of an abundance of caution the FDA has recalled a specific brand of textured implants.

The Division of Plastic Surgery at U of U Health has stopped using all brands of textured implants in light of the recent concern of developing ALCL. Please note that the recall of these implants does not mean that the implants need to be removed. If you have concerns or questions regarding the recall please refer to the FDA website or speak with your doctor.

For More Information About the FDA’s Ongoing Status on Breast Implants and ALCL

Interviewer: It can be a little confusing sometimes because there are actually two different types of mammograms. There's a diagnostic mammogram and then there's a screening mammogram. We're going to try to figure out the difference between the two of them so you can decide which one it is you might need.

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Interviewer: Dr. Anna McGow is a radiologist at University of Utah Health. Let's break down the difference between the two different types of mammograms. First of all, what is a screening mammogram and who needs that?

Dr. McGow: Right, yeah. Thank you very much. So a screening mammogram, those are performed in women generally who are over the age of 40, 40 and above, who have no breast symptoms. So they do not have symptoms such as focal breast pain, they do not feel a lump, they have no breast skin changes, no nipple discharge, no skin retraction, no lumps in the armpits. Those particular types of symptoms would require a diagnostic mammogram and/or a breast ultrasound.

Interviewer: Okay. So just to be clear, you're going in for a screening mammogram if you have absolutely no symptoms of breast cancer, and that's the one that you just do every year, just so you can get a picture and see what's going on inside.

Dr. McGow: That's right, yeah, just to screen for breast cancer.

Interviewer: And if you have symptoms, then you're going to want to make sure that you're getting a diagnostic mammogram. What's the difference?

Dr. McGow: Yeah, no, that's a great question. So we have women who come in all the time just for a screening mammogram when in fact they should be getting a diagnostic mammogram. To get a diagnostic mammogram, again, a woman has breast symptoms that need to be evaluated and they need additional evaluation beyond the four standard pictures that we usually do for a screening mammogram.

The diagnostic mammogram and/or ultrasound requires a physician order, so from your regular family doctor or other physician. And when a woman comes in for the diagnostic evaluation, a radiologist physician, such as myself, needs to be present for that evaluation. As opposed to a screening mammogram, where a woman would just come in and get the standard four pictures and leave.

Interviewer: And that does not require a physician's order?

Dr. McGow: Those usually do not in Utah.

Interviewer: Yeah. That's just you go into your doctor and you'd say, "It's time for my regular screening mammogram."

Dr. McGow: Yes.

Interviewer: Got you. So it's important to know the difference. You say that there are times that a woman with symptoms will come in and will have been scheduled for a screening mammogram. How can they make sure that that doesn't happen?

Dr. McGow: So the first thing that they need to do is realize that they have a symptom and then call their regular physician's office and tell them about the symptom and request an order to be placed for a diagnostic mammogram.

Interviewer: Okay. So they might not even need to go in and visit with the doctor. They might have to.

Dr. McGow: Exactly. Usually, their physician will like to see them to evaluate the symptom, of course. But if not, if it's something urgent that the woman is very concerned about, they may go ahead and schedule that diagnostic mammogram evaluation with us first.

Interviewer: Okay. I can see how it can get a little bit confusing there at times.

Dr. McGow: Yes, yes. For sure. And so we just want to avoid women getting scheduled for screening mammograms when in fact they have symptoms and then being sent away if a radiologist physician is not there to evaluate them properly.

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Dr. Miller: Self-breast exams can be a very important part of preventing breast cancer, at least detecting it early enough that it doesn't become as big of an issue as it might. We're with Jenna Andrus and Karen O'Toole from Huntsman Cancer Institute. They're in the Patient and Public Education Department, here to talk about an app called Check Yourself. I think that the app says it all, but let's talk about it a little bit further. Jenna, what is Check Yourself?

Jenna: So Check Yourself is a free app that you can download onto your phone that basically provides some instruction on how to perform a self breast exam and then will establish some reminders to do it on a monthly basis.

Dr. Miller: And Karen, tell us a little bit about the app that you know. Did women seem to like it? Is it an effective app? Is it a good app?

Karen: I think it's a very easy, simple app to use. It shows you at the very beginning mirror mirror. So one of the most important things to do is to look at yourself in the mirror, and if you're not going to do a breast exam . . . But at least look at yourself and know your breasts.

Dr. Miller: And it tells you what to look for?

Karen: Yes, it does.

Dr. Miller: Okay, great.

Karen: I think most women find a lot of lumps in the breast and I think that's really frightening. And this doesn't go through what you're looking for. It just shows you how to do it. And that's the whole point of the app, is to get to know your breasts.

Dr. Miller: And how about the reminder portion? That sounds like that could be really useful because a month can go by pretty quickly.

Jenna: Yeah, you're right. It's amazing how you can just quickly forget how time flies. So the reminder, you can set it up to email you every month or also to text you, so you have both of those options there. And it's pretty nonintrusive so you can set it up pretty easily.

Dr. Miller: One of the things about any app is, is this legitimate? Is it based on actual science, best information? Karen, is this app based on those things? What's your feeling on that?

Karen: Yes.

Dr. Miller: It is.

Karen: Yes, it certainly is.

Dr. Miller: Yeah, so it's an app that a woman could trust.

Karen: Yes.

Dr. Miller: What would be the most important thing to take away from this conversation? I'm going to start with you, Jenna.

Jenna: Yeah, I think just to be aware of your body overall and, like we've mentioned, be aware of your breasts and changes in them and then particularly to talk to your doctor if you are concerned about something, which the app does clarify at the end. If you do have something that is concerning, please talk to your doctor because we know that not all lumps mean that it's breast cancer.

Karen: I think what Jenna said is right on, just becoming familiar with your own breasts and know the lumps and bumps and which breast is bigger than the other and what's normal for you. And that's going to be different.

Dr. Miller: Do you find a lot of women don't know these things? I would think that they would.

Karen: No, I think a lot of women are frightened or they just forget. And I think this app is good for that reason.

Jenna: It's really important to talk to your doctor about it.

Karen: Yes.

Jenna: So if you're not comfortable doing it, be sure that you see your doctor once a year to have them perform just the exam in their office to help do that screening for you. And of course, if they see anything that is concerning, they're going to refer you to some further diagnostic testing.

Dr. Miller: So whether it's you or somebody else, this is just something that you should be doing.

Jenna: Yeah, yeah.

Karen: And with all the screening guidelines out there, again, it's really important to talk to your doctor because a lot depends on your family history. And if you do have a history of breast cancer, it changes as far as screening goes.

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Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: Women get a lot of different information and they get a lot of different opinions about when they should start mammography. Some group of advocates which include OBGYN's and includes radiologists and includes the American Congress of OBGYN and the American College of Radiology says women should start having regular mammograms at 40. Mammograms at 40 vs. 50 Now the people who do science and actually look at how many women have to be screened for how long to save a life from breast cancer say that, in fact, we should probably start at 50 and that's what they do in Europe.

Now there are people who are in between that say, "Well, what you ought to do is just see what your breasts look like at 40, so get a baseline mammogram." So the concept of the baseline has never been adequately tested scientifically to see whether having that baseline and then not having another mammogram until you're 50 actually makes a difference. So in fact, I don't think it's a bad idea to get a baseline mammogram, but I don't have any evidence that it's going to save a life. And at 40, there are lots of things in an active, young breast - when I say that to 40-year-old women they don't, they say, "My breast isn't young." I say, "Oh, honey, you just wait till you get older. You still have a young, dense breast." So even that baseline mammogram, the nature of what makes a breast a breast at 40, when there are lots of hormones around makes it harder to see through and you end up getting called back. So even your baseline ends up causing a bunch of extra investigations and maybe some extra biopsies.

Having said all that, it ends up being a very individual choice because the science doesn't support routine mammography at 40 for everyone. The culture does. So the culture of regular mammography between 40 and 50 is such that, your girlfriends are getting mammograms and it's recommended by your doctor, so the culture in the United States is to get mammography. But the science actually doesn't support it, when you look at how many women have to be screened and how many lives are saved from screening compared to how many lives are disrupted with extra x-rays and extra biopsies and maybe even not very necessary chemotherapy. It's a tough call for women to know what to do.

Here's my take on it. I have women who come to me and say, "My girlfriend had breast cancer and I want a mammogram today." And my answer for that is you're 45. You haven't had a mammogram before. I think that's a reasonable thing to do. But remember breast cancer isn't catching and you can't catch it from your girlfriend, but if you don't feel safe right now and a mammogram will make you feel safer, then that's something that's okay. But remember mammography in the 40s, you find stuff that you have to investigate that isn't necessarily cancer.

I have women who come to me and say, "You know, my family we're down winders." Those are people who are exposed to nuclear radiation from the atomic bomb testing in Nevada and they are really anxious about radiation and they say, "You know what? I really don't think I want to do any extra radiation until it's really recommended." And for them I say, "You know what? I'm going to do your clinical breast exam even though there's no good evidence that doctors doing breast exams saves lives either, but if you feel better saving till 50, that's fine."

And then I have a few patients who say, "You know, my mom had mammography all the time and she still got breast cancer and died and I'm never getting a mammogram." That's a tough sell, because for them I think some screening is good in the 50s and 60s. On the other hand, I think it's going to be up to them and I don't want to make them feel like they're bad people because they choose not to have a mammogram, but every time I saw them I'd remind them and say, "What do you think about this year? How about a mammogram this year?"

So I think women are getting lots of different messages and I think it's a discussion. But I let women drive the agenda about how often they're going to have mammography within the parameters of either the advocates or the scientists.

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Interviewer: You just got home after your breast cancer surgery. What should you expect and what should concern you? That's next on The Scope.

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Interviewer: When it comes to getting home and after your breast cancer procedure, what's normal and what's not normal and what should you expect? Hopefully we'll make this next part of your journey a little less scary. Dr. Cindy Matsen is a breast cancer surgeon at Huntsman Cancer Institute. She's going to help give you some idea of what to expect after you get home after your breast cancer procedure. So a woman gets home, what's normal? What's not? Let's start with what's normal.

Dr. Matsen: So what is normal is that regardless of the type of procedure you have, whether you have a mastectomy or lumpectomy, you will have some pain. That's a fact of surgery. So we make sure that we send you home with some pain medication to help with that. You should take the pain medication if you're feeling like you're having more pain than you can handle with something like Tylenol or ibuprofen. If you're ever having a dramatic increase in your pain, we want to hear about that, because that could be a sign that something abnormal is happening and we want to hear from you.

Interviewer: Generally, is it just a couple of different possibilities if you're getting a lot of pain? I mean, what is that abnormality?

Dr. Matsen: So usually if you're getting a lot of pain, it's a sign of bleeding or infection. Early on, it would typically be if you have a lot of swelling and pain we would be worried about bleeding. If you're having a lot of redness and swelling and it's further out from surgery, then we would be more worried about infection.

Interviewer: Everyone experiences pain differently. On a scale of one to ten, I mean how do you even determine if the amount of pain I'm feeling is abnormal?

Dr. Matsen: Right. So what I tell most women if they have a lumpectomy, is that they will probably be sore, not necessarily out of control pain just soreness, for a couple of days. In fact, they will only need the narcotic pain medication for a day or two at most. If women have a mastectomy, especially with reconstruction, they will need pain medication for a longer period of time because that's a much more painful procedure.

Interviewer: Because it's a lot more invasive, you're doing a lot more stuff.

Dr. Matsen: Right, it's a bigger surgery. It's a bigger incision, and it's not necessarily the bigger incision that hurts but just the surface area that is involved. And with reconstruction, especially if it's an expander that's placed behind the muscle, that's quite painful because it's stretching the muscle. So most women, that's where most of the pain is from. It's not actually from the mastectomy, but actually from the reconstruction.

Interviewer: I would imagine that of course, you should always consult your doctor and in this podcast here we're just talking about possibilities, but if there's ever any concern, probably pick up that phone. Is that what you would recommend?

Dr. Matsen: Absolutely, and we always provide women with phone numbers that give them access to someone 24/7, so if you're ever concerned, you wake up in the middle of the night and you feel something really abnormal, we have someone available to talk to you about that.

Interviewer: All right, so we've talked about pain, what are some of the other considerations?

Dr. Matsen: So the two main considerations that we have after surgery are the two things I mentioned with the pain are bleeding and infection. If you ever have an abnormal amount of swelling, we want to hear about that. Typically, if you call us and you say, "I'm having a lot of pain and a lot of swelling," we're going to say come in so we can take a look and see what's happening. If you're ever having fevers and swelling and redness, those are signs of infection and we want to hear from you then too because we're going to have you come in so we can take a look and possibly start you on antibiotics.

Interviewer: And are there differences if you've had a lumpectomy or a mastectomy as far as other things that you should be concerned about?

Dr. Matsen: There are differences. The main difference is that with a mastectomy, you go home with drains in and those drains have to be emptied a couple of times a day and you have to keep track of how much is coming out. If you ever see changes in the fluid, either in what it looks like or how much is coming out, we want to hear about that as well because that could be a sign that something has happened or changed that we need to hear about.

Interviewer: What are some common misconceptions when women get home? Like kind of like false alarms, if you will.

Dr. Matsen: I think the biggest thing is most women with a mastectomy and the drains get very concerned about the drains and the drain output is supposed to go down over time, but they'll be concerned that if it's going down that something bad is happening. And that's actually not, that's a normal part of the process. Your body makes fluid after surgery and as your body heals and those spaces closed down, the fluid will decrease with time.

Interviewer: All right, any final tips or any final thoughts on this topic?

Dr. Matsen: The biggest thing is that for most women, they've never had surgery before. They have no idea what to expect. We try to give you an expectation for the things to look out for, but if there's ever anything that you're concerned about, ever anything that you feel like may not be normal, we want to hear from you.

Interviewer: Better to make that phone call than go on the Internet and try to find out for yourself.

Dr. Matsen: Absolutely.

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Interviewer: What's the better option for breast cancer treatment? Is it a mastectomy or a lumpectomy? Turns out it is a very personal and it can be a very difficult decision to make. We'll look at some of the reasons why on The Scope.

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Interviewer: By the time you have to make a decision whether you should have a mastectomy or a lumpectomy to treat your breast cancer, you've likely to have already been on quite an emotional journey, so things can be pretty scary and confusing. I'm going to try to add some facts to the equation. I'm going to try to help you make the decision that's right for you. We're with Dr. Cindy Matsen. She's a breast cancer surgeon at Huntsman Cancer Institute. So when it comes to breast cancer, is it always a surgical procedure. Is it going to be the mastectomy or lumpectomy or is there something else somebody needs to consider?

Dr. Matsen: So for the majority of breast cancer patients who have been diagnosed with cancer that has not spread to other parts of their body, surgery will definitely be a part of their treatment.

Interviewer: Okay, so that's just going to be a part of it. No way around it at that point. What's the biggest struggle a woman faces when making this decision between the two procedures?

Dr. Matsen: So there's a lot of different things women take into consideration when they're thinking about what type of surgery they would like to have for their breast cancer. One of the first things to emphasize is that there are certain women who will not have a choice. The majority of women do, but about 20% of women will require a mastectomy just based on how big their tumor is or based on other factors related to their disease. So for those women, we tell them upfront, "The option for you is very limited." But for that 80% of women, there is a choice.

Interviewer: Okay, is it usually a difficult choice for most women or is it pretty simple? What's your experience been with that?

Dr. Matsen: My experience with it is that most women struggle with that.

Interviewer: Why is that?

Dr. Matsen: I think it's because they get a lot of different information from a lot of different resources and it's a hard time processing what's going to be valuable for them. And it's very difficult when you're given a cancer diagnosis, "Okay, well what's going to happen 5, and 10 and 15 years from now?" And how do I make a decision that I'm going to be happy with at that time because right now the only thing that most women are thinking about is that they want to be cured. The good thing about the options for surgery are whether you have a mastectomy or a lumpectomy which is also called Breast Conservation Surgery, the outcomes, meaning that the likelihood you are going to survive your cancer, is the same regardless of which procedure you cho0se.

Interviewer: So neither one is going to offer a benefit in outcomes?

Dr. Matsen: Right, in terms of survival.

Interviewer: So I scratch my head, why would a woman want a mastectomy? Why would a woman want to go to that extreme at that point is both of them are the same.

Dr. Matsen: Well, let's first just describe what the procedures are so we have a good understanding of what it is that it means to have a mastectomy or a lumpectomy. A mastectomy removes all of the breast tissue, and if you don't get reconstruction, it leaves you with just a flat chest wall. Now women who get a mastectomy obviously have reconstructive options, but it is important to understand with breast reconstruction, that simply creates a breast shape. It doesn't recreate a breast. So it doesn't function like a breast. It doesn't feel like a breast. But it does help with body image, and it does help with how your clothes fit and how you feel with losing a body organ.
A lumpectomy on the other hand retains most of the breast tissue, but removes the tumor and a rim of normal tissue around it. Even with a lumpectomy there will be some changes with what your breast looks like, so there will be a scar. There will be some changes in the contour of the breast and almost always for breast cancer, lumpectomy is followed by radiation, and radiation can also have a significant impact on what your breast looks like afterwards.

Now the reason why women may chose to have a mastectomy versus a lumpectomy is that there is a slight difference in what we call the risk of recurrence and that means cancer coming back within the chest wall or the breast. Even with a mastectomy, it's not perfect. So even if you get a mastectomy there is still a chance that cancer can come back in the chest wall. That chance is low. It's around 1 to 3%. That's what I typically quote patients.

Interviewer: Do you feel that is statistically low.

Dr. Matsen: Yes it is. The ranges can vary depending on what study you are looking at. In general, it's around 1 to 3% and that's at 10 to 15 years out from your surgery.

Interviewer: Oh okay.

Dr. Matsen: And that's based on data that is about 30 years old now, so that's very mature data that we feel very confident about. For breast conservation surgery, we know that in modern data, meaning that in the last 10 years or so, with the kind of radiation we give, with the kind of medications that we use for treating breast cancer now, that the risk of recurrence after 10 to 15 years is probably somewhere in the 5 to 7% range, and that's much lower than what it was with older data. So there is a difference, but it is very small. So you're look on the order of 4%.

Interviewer: Is that a factor that should be considered into a woman's choice at that point? It is a small difference. Are they essentially equal in your mid?

Dr. Matsen: In my mind, they are essentially equal.

Interviewer: Okay.

Dr. Matsen: However, there is sometimes a psychology benefit that women feel to getting a mastectomy because it reduces the risk maximally.

Interviewer: Sure.

Dr. Matsen: One of the interesting things when you look at surgical choice, is that what happens in America is quite different than what happens in other parts of the world. America seems to be more driven to bigger surgery and this belief that bigger may be better. We don't necessarily feel that, as breast cancer providers, feel that's true. But there is a misconception, that by having a mastectomy, you're doing more to treat your cancer.

Interviewer: So, I'm finding myself confused. I can only imagine at this point, a woman who has to face this decision, what she is going through. Because still there is that slight chance, and what's the impact on the mental, and then there's the visual and the appearance. How do you help a woman make the right decision for her?

Dr. Matsen: That is one of the most difficult challenges we face. When a woman comes in to see me, one of things I tell them is that every woman feels differently about their breasts. And every woman approaches their decision making and breast cancer differently. I can't be the one who tells them the right or wrong thing to do. And like I said from a medical point of view, these things are equivalent in my mind. So it has to come down to other factors that are important to them.
We haven't mentioned this yet, but a lot of women are concerned with the other breast. What we are typically seeing nowadays is that people are not necessarily choosing between just having the cancer side taken off, but they are actually making a decision between having both breasts taken off versus just having a lumpectomy. The conversation gets very complicated because we have to talk about things that are outside of what we are concerned about medically.

What we are really talking about is, what are the concerns psychologically. What are the sexual, physical, psychological implications of having your breasts removed? How are you going to feel 10 or 15 years from now? If the cancer does come back, are you going to feel responsible because you feel like you maybe should have had more surgery even though we are telling you that's not the case.

So, it's a really difficult decision for women to make. We try to provide them with the best information possible to help with that, and help identify the values that are most important to them in deciding. But in the end, the woman really has to go home and contemplate on her own what information we've given her and what's important to her. It's a very difficult decision, and I think there are a lot of good resources out there, but you do have to be a little bit choosey about which ones you look at.

The Komen Foundation tends to have some very good resources. The American Cancer Society has some very good resources. There are a lot of support groups out there for women with breast cancer. And some of these decisions are very different based on a woman's age, too. If you are a younger woman, the decision might be very different if you're a younger woman.

There are support groups that are age specific, and some of those can be found through social media. Every woman, like I said, approaches this differently. A lot of women talk to a lot of other patients and people who are around them because breast cancer is a very common disease. There are a lot of people, when a woman is diagnosed, who come out of the woodwork that tell them their story.

Interviewer: Do you have a team approach Huntsman Cancer Institute? Do you have someone to help with that mental aspect of it?

Dr. Matsen: Absolutely. We actually have a social worker in all of our clinics who is incredibly helpful with helping to identify the other concerns that patients have outside of just the medical concerns, and helping to address those and give them resources to help with some of those decisions.

Interviewer: So it sounds like what we've learned is nobody else can make the decision. Each woman has to make her own decision. It's probably going to be a difficult decision. Best thing to do is talk to other survivors. Get out there. Read some reputable resources. Use a social worker at a place like Huntsman Cancer Institute to help gather all that information to figure out what's important to you. And it's not going to be easy.

Dr. Matsen: It's not easy.

Interviewer: But all the other things aside, I think the important thing too, from what I'm hearing from you, that regardless of if it is a mastectomy or a lumpectomy, they are going to provide the similar outcomes. So at least that's one thing you can kind of push aside and not worry about as much.

Dr. Matsen: Right. In terms of the cancer, similar outcomes. I wish hat I could make it easy, but it's just not. And it's a very vulnerable time period. It's a new diagnosis, and women are scared. It's a very hard time to make a decision like that, and we try to give them the most support possible, so that they can make a decision they are going to be comfortable with in the long term.

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Announcer: Questions every woman wonders about her health, body, and mind. This is "Am I Normal?" on The Scope.

Interviewer: Am I normal? Today we are talking with Dr. Kirtly Jones, the expert on all things woman. The situation is, I have one breast that's bigger than the other. Am I... is that weird?

Dr. Kirtly Parker Jones: Well, it turns out that no woman is completely symmetrical. Even women who have had their breasts enhanced will not be completely symmetrical, just because the nature of who they were before they had the add-ons.

So there are two breast buds, they start growing at the very beginning of puberty. Sometimes one grows faster than the other for reasons we don't particularly understand. Occasionally, there are women, and this is quite rare, where one breast bud won't develop at all. That is not normal.

Interviewer: Okay.

Dr. Kirtly Parker Jones: But being within 20 percent of volume, meaning one breast can easily be 20 percent smaller than the other. Now is this worrisome? One breast may hang a little lower, not that any young woman's breasts hang, of course, but if one breast seems to be a little lower than the other, that's also normal. It's important for adolescents to know that breast development isn't completed until about five years after the period, so no interventions should be taken for "correcting" a disparity in breast size or augmenting breast size until women are at least 17 to 18, because at that point their breasts are relatively developed. Disparity in breast size is common. Fifteen to 20 percent difference in size is common.

Interviewer: How common?

Dr. Kirtly Parker Jones: Ninety percent of women have at least that much.

Interviewer: Oh, okay, so really high.

Dr. Kirtly Parker Jones: A very high percent of women have 10 to 15 percent disparity in breast size. They may only notice it when they are in their bra and notice that the bras, which are designed to be symmetrical...

Interviewer: Of course.

Dr. Kirtly Parker Jones: ...may feel a little differently, one versus the other. Or the cleavage may be pushed over toward the middle a little bit more than one side or the other.

Now what about breast size? What's normal for breast size? Well every woman who walks down the street can tell that the range of normal from A cup to DD cup is all within the range of normal. Now what makes large breasts different than small breasts isn't the amount of breast tissue, isn't the amount of tissue that is able to lactate or produce milk during pregnancy, its how much fat is in the breast. So some women develop and deposit fat in their breast more than others.

It is not common to find a very slender woman, with no hips and big breasts, because we tend to put fat in our breasts and our hips somewhat equally. But very slender women may not have that much breast development either. Breast development is also different based on race. So Asian women will have smaller breasts than Caucasian women. The range of normal from A size cups to DD size cups, that's a very large range, and they are all within the range of normal.

Fashion comes and goes. During the 20s, with those really straight shifts, those really straight dresses that we all saw on Downtown Abby, no DD cups were going into those. Now we all know that Dowager Duchess, who had quite large breasts, and the kinds of dresses that she wore. But the beautiful young women were all A cups and flat as can be, and women also bound their chests so that they could be a little flatter in those really straight dresses.

Interviewer: Okay, so I have a question, and I'm going to ask this for all the ladies out there that have this question. Is there any way I can naturally change the size of my breast? Or do I have to go get them fixed?

Dr. Kirtly Parker Jones: Well, the best way to naturally, and there's a little chuckling in the room, the best way to make your breasts be a little bit larger is to be pregnant, however...

Interviewer: That's not an option.

Dr. Kirtly Parker Jones: Yes, pregnancy and breastfeeding makes your breasts larger. After breastfeeding, though, many women find that their breasts are actually smaller than they were before they were pregnant. Now you can always gain a lot of weight, and hopefully if you have a tendency to gain weight by putting fat in your breasts, your breasts might be getting larger, but at the expense of your hips and your thighs and your belly. I don't think that's worth it.

Interviewer: That doesn't sound like a good idea.

Dr. Kirtly Parker Jones: So although there have been many breast augmentation vitamins or exercises, in fact, exercises just increase the size of your pectoral muscles, which lie underneath your breasts. And women have a difficult time getting huge pecks. So getting pecks that are really big to put your boobs on is not going to be all that delicate. I would say that larger breast size for women who are small breasted, consider it fashionable, spend more time watching Downtown Abby. Spend more time running, in which case you will certainly appreciate your breast size or take up a little archery.

The term "Amazon," which is not just a very large distribution company, refers to a tribe of women who were a mezos, without Scota breast, and they took off the breast that was in front of their arrow so they could be better huntresses, so Amazon was a single breasted group of women hunters who took of a breast so they could hunt better. So for all of you small breasted women, well this is mythological of course—so all you small breasted women, spend some time in Downtown Abby, run a little bit more and you'll appreciate your breast size, or think about taking up archery.

Interviewer: My mom says it's actually nice when you have the smaller breast because when you grow older, your breasts aren't going to sag.

Dr. Kirtly Parker Jones: Absolutely, so that's another thing to... count your little breast blessings all you small breasted women, because you have quite a few breast blessings. And those of you large breast women, count your breast blessings too. It's better to count your blessings than to add or subtract from what you were given. Unless you were well outside the range of normal. So our cup size that are fashionable or desirable depends on your ethnicity, your race, the culture of the times, but between A and DD, ladies, you're all normal.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 15, 2018
originally published: June 19, 2014

Dr. Lee: Good afternoon, everyone. Welcome to the show. I'm your host, Dr. Vivian Lee. I'm the Senior Vice President of the University of Utah Health Sciences. Today, we're going to talk about breast cancer. About one in eight women will develop breast cancer in her lifetime, and it is the second leading cause of cancer death in women.
One of the misunderstandings about breast cancer that we're just starting to understand now better is the fact that breast cancer is not just one disease, but it's actually many different diseases. That's a really important point to understand. Because breast cancer is different diseases, it means we have to have different treatments for women with breast cancer.
My guest today is Dr. Alana Welm, who's a researcher at the University of Utah's Huntsman Cancer Institute. Dr. Welm and her colleagues are making news all over the world because they have found a way to grow pieces of a woman's breast cancer in mice, and that's really going to transform the way we think about breast cancer treatment.
Now, I have read that your research means that we're going to treat women in a very different way where in the past we might try a treatment and it may work or it may not work. The women almost feel like they might be guinea pigs because we don't know how to treat them. Instead, your approach with these mice is almost like making a guinea pig for every patient. Is that a fair description of your work and its implication?

Dr. Welm: That's right. It's a science that's telling us now that breast cancer is probably more, like, ten different diseases. Currently, in the clinic, it's treated as though it were, really, three types of breast cancer. What we're doing is trying to personalize the therapy so that we can grow an individual person's tumor in a mouse and actually use that mouse or that tumor line as a way to determine what are the best therapies for that particular women are.

Dr. Lee: Well, if there are really ten different types and we only know about three, then what does it mean if a woman comes in now? If a woman comes into our clinic at the Huntsman Cancer Institute, how do we treat them now?

Dr. Welm: Currently, breast cancer is heavily over treated, believe it or not. So, we really are treating ten women for the benefit of three. We know that about 30% of breast cancer patients will go on to develop a relapse or a metastasis, and metastasis is what kills patients with breast cancer. Because we cannot determine which three women out of the ten will go onto develop metastatic disease, they are almost all getting treated with really toxic chemotherapies. So one of the goals of our study is to be able to use these tumors grown in mice to determine which ones are the most aggressive ones and then modify treatments according to that particular tumor.

Dr. Lee: One of the most interesting aspects of your work was that when you took these pieces of a woman's breast cancer and you put them into mice, the behavior of those tumors actually was just like when they're in people, right? They not only grew like breast cancers, but they also metastasized. What was it about how you did it that was different from what everyone else had previously tried to do and failed?

Dr. Welm: What we did was expand on an idea that we don't want to culture the tumors before we put them in the mice. So we don't want to put them in the lab on a petri dish like everybody had done before. Instead, we put them directly into the mouse breast tissue or the mouse mammary gland. This environment is so much like the human breast that it allowed these tumors to not only grow, but also to behave very similar to how tumors behave in patients.

Dr. Lee: One of the questions that came to my mind when I first read about this research was, won't it be easier to just take a piece of the breast cancer tissue, look at the DNA of it, and then figure out which of those ten types it is just from that?

Dr. Welm: We are doing that. We're examining the mutations in individual tumors. However, we believe that you have to combine some functional analysis of the biology of that tumor together with the genetic information. So just knowing that there's a mutation in a gene doesn't necessarily tell us about how that tumor will behave in terms of metastasis or in terms of response to therapy. Our idea is to really combine that genetics analysis with a functional assay of tumor biology and tumor behavior in order to make the best treatment decisions.

Dr. Lee: It's sort of, like, that old line that it's not just the genes but the genes and the environment? Just putting some of those breast cancer cells somewhere in the mice, but that didn't work but putting it in the breast tissue itself worked. So there's something about the genes and environment relationship that's important.

Dr. Welm: That's exactly right. The other advantage to using this type of an approach is being able to modify the genetics of a mouse in concert with asking about tumor biology gives us a chance to actually examine the interaction between the genetics, the tumor biology, and the host response to the tumor.

Dr. Lee: We have some questions from some listeners online. Laurie, in the West Valley asks this question. "The women in my family have breast cancer. My mother had it. Two of my aunts had it, and now my sister has it. What does that mean for me, and what does this research mean for people like the women in my family?"

Dr. Welm: We know that cancer is a genetic disease, meaning it can be hereditary. As you probably know, we made the original discovery of the BRCA mutations.

Dr. Lee: The breast cancer genes.

Dr. Welm: The breast cancer genes that are carried through certain families and contribute to a small proportion of breast cancer, but those patients who carry those genes have very, very high risk of breast cancer. That type of inheritance is what seems to be manifested in this family. Partly as a result of these kinds of discoveries in Utah, we have a fantastic high-risk breast cancer clinic that's directed by Dr. Saundra Buys at the University of Utah and Huntsman Cancer Institute. They can test people for these genes. They can provide genetic counseling as to how they might want to modify either their lifestyle or even take surgical precautions for breast and ovarian cancer in the case of BRCA mutation. They actually follow these patients. So rather than that just being the end of, you know, "Okay, here's mutation, and this is what it means for you," we actually want to be able to follow them with high screening.

Dr. Lee: Here's another question from Sandra in Murray. Sandra asks about men. "Can men get breast cancer?"

Dr. Welm: Men do get breast cancer. It's relatively rare. It's only about one percent of breast cancer that happens in men, but it is a problem, and it's not very well recognized.

Dr. Lee: Does it run in families the same way as women? We don't know?

Dr. Welm: We don't know. Yeah.

Dr. Lee: Since it's so rare, we just haven't done enough research in that. Well, Dr. Welm, thank you so much for being my guest today.

Dr. Welm: My pleasure.

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Announcer: Examining the latest researches and telling you about the latest breakthroughs. The Science and Research Show is on the scope.

Interviewer: Researcher Alana Welm, a professor at the Huntsman Cancer Institute investigates the worst cases of breast cancer and has discovered a new way of thinking about how tumors in these patients progress and spread. Her work may lead to new type of cancer screening and new treatments. Dr. Welm, this work focuses on the most aggressive forms of breast cancer. Can you explain?

Dr. Welm: Yes, most patients with breast cancer who die from that disease, die because their disease spreads to other organs and that's called metastasis. So, we are trying to understand the most aggressive forms of breast cancer that are not cured by local therapy, like surgery and radiation but actually have the chance of spreading to other organs.

Interviewer: You were able to gain new insights into metastasis by looking at tumors from real patients.

Dr. Welm: Yeah, for example, we have one particular who presented with metastasis breast cancer. So, in this particular patient, it's a really interesting case in which the therapy was changed to a new combination of therapy and she had a very good response to this therapy and had stable disease for almost an entire year. Unfortunately, her disease eventually became resistant to that therapy and progressed. So what were able to do is, take her cells both before and after that therapy, put it in the model system and then test those exact therapies. What we found was, in fact in the model system, we could show that the first batch of tumors cells was sensitive to that therapy but then eventually became resistant and that matches the batch of tumor cells that have progressed after the treatment. So what this just tells us is that our model system is, at least in this case, faithfully recapitulating the progression of the disease and potentially will be able to predict whether or not a therapy would work for a given patient with cancer.

Interviewer: And this is a new way of researching tumors?

Dr. Welm: It's new in the sense that we are able to do this straight from patients instead of using well established cancer cell lines that have been grown in tissue culture, on plastic dishes for decades.

Interviewer: Either way, so you can use your model system to come up with personalized treatment plans?

Dr. Welm: Yes, we are in the process of designing a clinical trial in which we could grow individual breast cancer patients' tumors in our model system, in order to test the variety of therapies that are available to patients with metastasis breast cancer, and then determine which of those is the most effective in the model system, and then use that if necessary, if in the case of a metastasis relapse in that patient.

This would be initially just limited to people who have very aggressive form of the disease because it's pretty labor intensive and would be expensive, but we think it's a more accurate model of how an individual tumor behaves and so, it should also be more accurate model of how that tumor responds to therapy.

The reason why that's important is because it's very unlikely, given the complexity of cancer, that targeting a single gene, two genes or three genes or some combination of more genes is ever going to lead to a cure for cancer because it's so very complex, and every time you block a single gene function, the cancer finds a way to compensate by [inaudible 00:04:50] another gene. So the reason why we are so excited about this is because we found a single protein that can, by itself, work to activate more than a hundred genes, and we have an inhibitor to block this and we were able to show complete blockade of metastasis in our model system with cells from two different patients.

Interviewer: That's pretty remarkable.

Dr. Welm: It was very remarkable. There are not many things that can cause complete blockade of metastasis, it's a high hurdle. We know that this pathway isn't the only one that drives metastasis, so there is still a lot of work to be done. But one of the things that we have been able to get from this is, in [inaudible 00:05:31] fingerprint of a tumor that will tell us whether or not the pathway is on, and for those patients with pathway on and their tumor cells, they may be good candidates for this new inhibitor that is currently being developed. Interviewer: Do you have any idea of how common this mechanism works in cancer patients?

Dr. Welm: We found that this pathway is activated in approximately 25 percent of all breast cancers that we examined and we looked at around 2000 patients.

The other important thing to note is that, the signature is on more often in the so called triple negative subset of breast cancers. Those that are negative for the estrogen receptor, progesterone receptor and the [inaudible 00:06:13] gene, and this the subset of breast cancers for which we currently have no targeted therapy. The only current therapy there is chemotherapy and radiation, and so, if we can inhibit Ron, we will have potentially the first targeted therapy for triple negative breast cancer. It's also the most aggressive form of breast cancer.

Interviewer: And might this pathway be involved in other types of cancer?

Dr. Welm: The Ron pathway is actually [inaudible 00:06:38] in most solid tumors of epithelial origin. So pancreatic cancer, lung cancer, colon cancer, etcetera, and it has been shown to [inaudible 00:06:50] with poor prognosis. We haven't done the mechanistic work yet to determine whether this exact pathway is driving metastasis in those cancers. It's certainly worth to look at because it again goes with poor prognosis and bad outcome.

Interviewer: So how do you think you can use this new information to help patients?

Dr. Welm: Well, we hope that we can use this information to identify patients who might be at high risk of metastatic relapse because we can identify that their tumors have this pathway active. For me, the most important next step is getting this into clinical trials. So, the inhibitor that we have decided to work with is currently in phase I trials, which are simply to determine safety and dosing regiments for this drug and that trial is being conducted right now in Australia. So, we are working with the company who developed the drug to get a trial going in the U.S., like a phase II setting, so we could try and determine the ability to either shrink existing metastasis or block the growth of new ones.

Interviewer: Do you think finding this mechanism will prompt other scientists to look for epigenetic pathways being involved in cancer or cancer progression?

Dr. Welm: It's already being looked at in many settings. So, I think that's really the new frontier in cancer biology as we are learning that mutations do drive cancer. There are certain mutations for which you can use a targeted therapy and have some success but resistance is always a problem, so with any single mutation that you are targeting, you also will select four resistance populations. So, combinatorial therapy or therapies given in combination are really what's happening now at the forefront of clinical cancer care, but the problem becomes toxicity. If you can identify a pathway like we have, where hundreds of genes are regulated by a single targetable protein, you might have more impact to that disease than hitting a single mediator within a hundred genes.

Of course, I still think resistance will be a problem with Ron inhibitors, if history holds up. That's why our lab is also working separately on understanding all of the signaling pathways downstream the Ron, so that we can anticipate what might be the resistance pathways and preemptively think about combination therapies.