There have been many significant advances in the treatment of breast cancer that have helped patients to diagnose cancer earlier and to provide a range of treatment options. But patients still have many questions about what’s best for them.
In this Q&A, Michael Zeidman, MD, Assistant Professor of Surgery at the Icahn School of Medicine at Mount Sinai and a breast surgeon at Mount Sinai Brooklyn, answers some of the most common questions he gets from patients, including why it is critical to get regular mammograms, how doctors determine the stage of disease, and, if you are looking for a second opinion, the importance of visiting a leading medical center such as Mount Sinai.
Michael Zeidman, MD
How do mammograms help patients and doctors?
Mammograms are the only imaging method that’s been proven to save lives. If we go back to the early 1970s, before screening mammograms were widely implemented, the only way that a patient could discover that she had breast cancer is if she felt it. Now that we have the capability to diagnose breast cancer before it becomes symptomatic, we’re catching it much sooner. So it’s not surprising that survival rates have dramatically improved, while at the same time, we’ve been able to significantly cut back on the amount of treatment needed, which results in a better quality of life after breast cancer.
Why is it important not to delay a mammogram because of concerns about COVID-19?
We are only now starting to see the effects of the public’s general hesitancy of getting mammograms during the pandemic. It’s unfortunately increasingly common for patients who were normally very regular about getting their screening mammograms to skip getting one last year, and now they’re presenting to me with breast cancer that’s likely at a later stage than it would have been if it were discovered a year earlier. If there’s one message I want to get across is, come in, get your screening. The sooner we catch this, the sooner we can deal with it, the less treatment you need, and the better your prognosis will be.
How do you determine what stage breast cancer a patient has?
A very common question that I get from patients with a new diagnosis of breast cancer is “What’s my stage?” I explain that I can’t tell you your stage until after surgery. Determining the stage is made up of a three items: the size of the tumor, whether or not the cancer has spread to the lymph nodes under the armpit, and whether or not the cancer has spread to a distant part of the body. The pre-operative imaging does a fairly good job of estimating the size. But we won’t know the precise size of the tumor until it’s been removed. In fact, unfortunately sometimes the imaging can significantly overestimate or underestimate the true size of the tumor. The only way to tell whether or not the cancer has spread to the lymph nodes is to actually sample a few of them during the operation. We do that with a technique called a sentinel lymph node biopsy. In the operating room, we are able to determine if cancer were to spread to the lymph nodes, what are the few lymph nodes that would be the first to receive that cancer. So we identify and remove those nodes. And if the pathologist tells us that there’s no cancer in those nodes, we can safely assume that there’s no cancer in the rest of your nodes.
What do I need to know about the different stages of breast cancer?
- Stage one breast cancer means that the tumor is two centimeters or less, and there’s no spread to the lymph nodes. Our goal is to catch breast cancer at this stage, because the five-year breast cancer specific survival from stage one breast cancer approaches 100 percent, which means that nearly all of those treated are alive five years after diagnosis. Also, the amount of treatment that a patient would need with stage one is much less than for later stages. It may result in smaller surgery, and patients at this stage are unlikely to need chemotherapy.
- Stage two and stage three breast cancer means that the tumor is larger and it has spread to the lymph nodes. If this is the case, patients need more surgery and are more likely to need chemotherapy. Their five-year breast cancer specific survival is between 80 to 90 percent. This highlights the importance of coming in to get your screening mammogram because even though you may survive your breast cancer with a later stage, you’re going to need a lot more treatment to do so.
- Stage four breast cancer is if the cancer has spread to another part of the body, other than the lymph nodes. At this stage, I tell patients that I can no longer cure them of breast cancer. The five-year survival rates drop to less than 30 percent. We can certainly treat it and, depending on how aggressive the cancer is, we can keep the cancer at bay for many years. But this is what we are trying to avoid.
I just had a COVID-19 vaccine. Should I delay getting my mammogram?
You do not have to delay your mammogram if you are receiving the vaccine, but you should make your radiologist aware which arm got the shot. There has been a lot of talk in the news about how the vaccine can mimic breast cancer. This is not entirely true. The purpose of the vaccine is to activate your immune system to produce antibodies that fight the virus. The cells that make these antibodies are located in small organs throughout your body called lymph nodes. The closest group of lymph nodes to where the vaccine is administered is in the armpit. These are called the axillary lymph nodes, and they are the first group of lymph nodes where breast cancer will typically spread. After receiving the vaccine and activating the cells in the axillary lymph nodes, they will grow in size. This may result in the radiologist wanting a closer look at the lymph nodes with an ultrasound to better delineate if these nodes are large due to the vaccine or if they are concerning for cancer.
What is the difference between a biopsy and surgery?
When we talk about a biopsy, we’re mainly talking about a core needle biopsy. This is where we get a small snippet of tissue in the area of concern, as discovered by the imaging. It’s usually done under the guidance of imaging, such as an ultrasound guided biopsy or something called a stereotactic biopsy, which is done under mammographic guidance. Usually the needle biopsy is done before we do the surgery because it helps us guide what type of surgery the patient needs and because it allows us to determine if chemotherapy is the first step, rather than surgery. For surgery, you are actually coming to the operating room and we remove a large area of tissue around the cancer. If we already know that it’s a very large cancer, we may perform mastectomy to remove the entire breast.
If I am looking for a second opinion, why is it important to go a leading medical center like Mount Sinai?
The treatment of breast cancer has become increasingly complex, as we’ve learned more about it, and so it’s now more important than ever to have a team that works in a collaborative way to tailor a specific treatment program for you. The Dubin Breast Center at Mount Sinai is a true multidisciplinary Cancer Center with specialists concentrating on one problem, breast cancer. The facility is beautiful, and that produces a sense of calmness that translates to patient care and to the patients themselves. While I generally recommend that patients go for a second opinion, because of how complex breast cancer treatment is, I think it’s imperative to go to a center where that’s the primary focus, where that’s all they do.