Questions and Experts Session Guide: A Surgical Oncologist Answers Questions about Breast Cancer Surgery

A breast cancer diagnosis comes with so many questions and there never seems to be enough time at appointments to have some of these questions answered. To help address this, we developed a "Q&E: Questions and Experts" series. In this series, a variety of experts spend the entire virtual session answering pre-submitted and live questions from participants. Watching the videos on-demand might be a little difficult to get through. So, we’ve created this guide to help you get right to the questions and answers that matter the most to you.

In today’s post, we provide the questions that were sent in and asked during the live session of our Questions and Experts session held in May 2021. In this session, Dr. Mark Basik, MD, FRCPC, a Medical Oncologist, answered questions about breast cancer surgery. In the parentheses, you’ll find the timestamp of where to find the question in the on-demand video.

Breast Cancer Surgeries and Treatments

Living Flat

1. How can a woman who has decided to live flat, but would like the scars for the surgeries fixed, find a surgeon who would help with an aesthetic scar surgery? What type of surgeon would perform the surgery? Also, is there specific wording that can be used to help have this covered through the public health system? (45:35) 
2. A young woman had surgery 10-15 years ago, went flat and now decides that she wants to have breast implants or corrections to what was done. Is it harder for the surgeon to work on women like her that have been living flat for such a long time?  (48:50) 

Lumpectomy

1. Are all tumors visible during surgery? Can you explain the logistics of a lumpectomy and how you know that you are getting all the cancer? (34:14) 

Radiation

1. This particular patient has a TRAM flap reconstruction on one side and an expander on the other side.  What are some concerns that a patient should be aware of with radiation? Are there concerns or considerations to look for as she starts to receive radiation for both? (43:23) 

2. What happens during radiation if you have implants? (54:15) 
3. Can you speak about the risks involved when whole breast receives radiation therapy versus when it is not the whole breast? Is there a benefit to that or a greater risk? (1:17:00) 

Mastectomy

1. When the doctor and the patient decide to have a mastectomy, do you go in and first do the removal of the tumor or you do the mastectomy and then review the tumor? (36:15) 

2. What is the rate of somebody having a bad situation after removing the surgical tape following a mastectomy? (50:10) 
3. This particular patient has had 5 bouts of breast cancer, all small tumors. A few months ago, an ultrasound showed a suspicious lymph node on the side where she has had a mastectomy which is to be followed up with another ultrasound. Would a surgeon go in to take out the suspicious lymph node? If not, what is the likely treatment? (1:02:50) 

Breast Reconstruction

1. Could you elaborate on the option of doing immediate reconstruction? What are the pros and cons of this, and do you have any recommendations or cautions around different types of reconstructions? (3:30) 

2. Are there challenges for women in some of the smaller hospitals in more rural, remote areas accessing immediate reconstruction? Do you see some of those women looking for immediate reconstruction coming into a city center like Montreal or are they still able to accommodate that coordination at some of the smaller, more remote centers? (10:42) 

Rural and Remote Centers versus Big City Centers

1. Are there challenges for women in some of the smaller hospitals in more rural, remote areas accessing immediate reconstruction? Do you see some of those women looking for immediate reconstruction coming into a city center like Montreal or are they still able to accommodate that coordination at some of the smaller, more remote centers? (10:42) 

2. Can you speak to what type of surgery patients might be receiving in smaller centers and who might be performing those surgeries? (1:06:45) 
3. In a big cancer center, is there a pool of surgeons that are used for breast cancer specifically? Would somebody that is a general surgeon also part of this team if they have specialized in doing breast cancer surgery? (1:07:50)  

Margins and Revisions

1. How does the surgeon decide if they have adequate information about the size and location of the cancer in order to remove it all with a breast-conserving approach? How common is it to require a revision for positive margins and how common is it for the revision to also be unsuccessful? (12:05) 

2. How common is it to require a revision for positive margins and how often do you have to go back because of positive margins? (17:46) 
3. This particular patient’s DCIS cancer was removed with clear (unresolved) edges, but the margin was greater than 1mm. Are there benefits to go for a second surgery to revise the margin? (1:01:00)

Testing, Surgery and Surgery Decision-Making

1. How does the surgeon decide if they have adequate information about the size and location of the cancer in order to remove it all with a breast-conserving approach? How common is it to require a revision for positive margins and how common is it for the revision to also be unsuccessful? (12:05) 

2. Is it standard practice for all patients to have a discussion about their best surgery option when they are seeing their surgical oncologist or a general surgeon? (15:40) 
3. How common is it to require a revision for positive margins and how often do you have to go back because of positive margins? (17:46) 
4. What are the benefits oncoplastic surgery? Are there any drawbacks to this type of surgery? (29:05) 
5. When the doctor and the patient decide to have a mastectomy, do you go in and first do the removal of the tumor or you do the mastectomy and then review the tumor? (36:15) 
6. How do oncologists determine the need for an auxiliary dissection versus a sentinel node biopsy? Would you be able to highlight any key differences between the two and what people about to undergo the surgery should expect? (37:35) 
7. This particular patient has Stage 2B estrogen-positive and HER2-negative breast cancer. Do you recommend the Oncotype DX test to be done? (57:20) 
8. This particular patient’s DCIS cancer was removed with clear (unresolved) edges, but the margin was greater than 1mm. Are there benefits to go for a second surgery to revise the margin? (1:01:00)
9. This particular patient has had 5 bouts of breast cancer, all small tumors. A few months ago, an ultrasound showed a suspicious lymph node on the side where she has had a mastectomy which is to be followed up with another ultrasound. Would a surgeon go in to take out the suspicious lymph node? If not, what is the likely treatment? (1:02:50) 

Surgical Oncologists, Plastic Surgeons and General Surgeons

1. Is it standard practice for all patients to have a discussion about their best surgery option when they are seeing their surgical oncologist or a general surgeon? (15:40) 

2. Can you speak on the different roles of a surgical oncologist and a plastic surgeon, how they work together and what a patient should be discussing with their surgical oncologist versus their plastic surgeon? (23:45) 
3. How can a woman who has decided to live flat, but would like the scars for the surgeries fixed, find a surgeon who would help with an aesthetic scar surgery? What type of surgeon would perform the surgery? Also, is there specific wording that can be used to help have this covered through the public health system? (45:35) 
4. Is it standard care that both the plastic and surgical oncologist be there during surgery? (47:3) 
5. This particular patient had a surgery done by a general surgeon 1 year ago. What is the difference between a surgical oncologist and a general surgeon, and can this patient be confident in surgery that she received? (1:06:30) 
6. Can you speak to what type of surgery patients might be receiving in smaller centers and who might be performing those surgeries? (1:06:45) 
7. In a big cancer center, is there a pool of surgeons that are used for breast cancer specifically? Would somebody that is a general surgeon also part of this team if they have specialized in doing breast cancer surgery? (1:07:50)  
8. What direction do you hope to see surgical oncology go in the next 20 years and what changes would you love to see? (1:10:30)  

Implants and Expanders

1. What are the dangers of implants?  Is one type better than another? (21:20) 

2. This particular patient has TRAM flap reconstruction on one side and an expander on the other side.  What are some concerns that a patient should be aware of with radiation? Are there concerns or considerations to look for as she starts to receive radiation for both? (43:23) 
3. A young woman had surgery 10-15 years ago, went flat and now decides that she wants to have breast implants or corrections to what was done. Is it harder for the surgeon to work on women like her that have been living flat for such a long time?  (48:50) 
4. Can you speak to how tissue expanders work, their failure rate, and what you can expect when getting expanders? (51:15) 
5. How often do patients end up with expanders being in longer than they wanted because they are back on the waiting list for another implant? (52:22) 
6. What happens during radiation if you have implants? (54:15) 

Surgery Risks, Risks of Recurrence and Other Considerations

1. Could you elaborate on the option of doing immediate reconstruction? What are the pros and cons of this, and do you have any recommendations or cautions around different types of reconstructions? (3:30) 

2. Can breast density increase the risk of developing contralateral breast cancer? (25:35)  
3. What are the benefits oncoplastic surgery? Are there any drawbacks to this type of surgery? (29:05) 
4. This particular patient has a TRAM flap reconstruction on one side and an expander on the other side.  What are some concerns that a patient should be aware of with radiation? Are there concerns or considerations to look for as she starts to receive radiation for both? (43:23) 
5. What is the rate of somebody having a bad situation after removing their tapes following a mastectomy? (50:10) 
6. Can you speak to how tissue expanders work, their failure rate, and what you can expect when getting expanders? (51:15) 
7. If you have had an oncoplastic surgery, does this mean a higher risk of lymphedema or is there really no risk or impact? (1:05:25) 
8. Can you speak about the risks involved when whole breast receives radiation therapy versus when it is not the whole breast? Is there a benefit to that or a greater risk? (1:17:00) 

Scaring and Side-Effects Following Breast Surgery

1. After the surgery, would too much scaring be a concern for an accurate reading of a mammogram? (33:15) 

2. How can a woman who has decided to live flat, but would like the scars for the surgeries fixed, find a surgeon who would help with an aesthetic scar surgery? What type of surgeon would perform the surgery? Also, is there specific wording that can be used to help have this covered through the public health system? (45:35) 
3. Do you have any insights into side effects after surgery such as shoulder pain? How do you mitigate this? Who could you see about this, and do you go back to their surgeon to discuss some of these complications? (54:45) 

Lymph Nodes and Lymphedema

1. How do oncologists determine the need for an auxiliary dissection versus a sentinel node biopsy? Would you be able to highlight any key differences between the two and what people about to undergo the surgery should expect? (37:35) 

2. Is there a measurement of cancer cells in the lymph node and who measures this? (41:55) 
3. Is there less lymphedema because of the sentinel node? (42:35) 
4. This particular patient has had 5 bouts of breast cancer, all small tumors. A few months ago, an ultrasound showed a suspicious lymph node on the side where she has had a mastectomy which is to be followed up with another ultrasound. Would a surgeon go in to take out the suspicious lymph node? If not, what is the likely treatment? (1:02:50) 
5. If you have had an oncoplastic surgery, does this mean a higher risk of lymphedema or is there really no risk or impact? (1:05:25) 

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