Mastectomy Q & A

I was lucky (and blessed) enough to find a surgeon that was empathetic, skilled and down-to earth that fit my personal timeline for surgery.  Dr. Nancy Taft did a great job when I needed to have my duct biopsied a few months prior and she made me feel that whatever my husband and I decided would be right for us.  I can’t say enough wonderful things about her, but read my Q & A below and you’ll see what I mean.

Below is a quick reference of my questions to Dr. Taft.  Scroll down to read the ones that most interest you.

1. What are the surgical ways to diagnose DCIS?

2. What are the current treatment options for DCIS?

3. My primary care doctor says DCIS is not cancer. Talk about your position in the debate of whether DCIS is cancer or not.

4. DCIS patients like me don’t fit into the cancer box neatly, do you consider us breast cancer survivors?

5. How do you see the patient-doctor relationship from your perspective as a surgeon?

6. In a ‘perfect world,’ what role do you see yourself having in the care of DCIS and breast cancer patients?

7.  How do you feel about patients who want to get second opinions?

8. What is the standard of care for a new surgical patient coming into your care until they leave post surgery?

9. What percent of women in my age group with DCIS would have opted for a mastectomy only? 

10. How to you, as a surgeon, build relationships with primary care givers who refer patients to you and to post surgery physicians?

NANCY TAFT, M.D.

 School Fellowships:  

Medical School:  Southern Illinois University School of Medicine, Springfield, IL

Residency:  Medical College of Wisconsin Affilliated Hospitals, Milwaukee, WI

Fellowship:  Lynn Sage Comprehensive Breast Center, Northwestern University, Chicago, IL

FACS – Fellow of American College of Surgeons.

Q & A WITH DR. NANCY TAFT, SURGEON – June 24, 2011

INTRODUCTION
by Britta McKenna

I was referred to Dr. Taft by my OB/GYN for a second opinion.  Ever grateful I am that I took the opportunity to see my disease through a different set of eyes and leave the care of a very qualified surgeon who had done a biopsy a few years prior, but with whom I felt a relationship was absent.  What I admire most about Dr. Taft is her energy, passion and bedside manner.  She truly cares for her patients as people and respects our opinions  Having started as an RN in the intensive care unit, then getting her M.D. and now Fellowship, Dr. Taft is always learning how to be a better doctor for her patients.  She recently completed her fellowship in breast surgery at Northwestern. Additionally, she received the 2010 “Humanitarian of the Year” award at Delnor Hospital in Geneva, IL and at Sherman Hospital in Elgin for her military service in Afganistan (she is a major in the US Army, which is another story). I asked Dr. Taft if she would be willing to sit down with me an answer questions for ‘us.’ Much to my surprise, not only was she willing, but she told me she felt privileged to be asked.  We shared lunch and she even picked up the tab.  I found through the process of taping our conversation that I’m not too found of transcribing, especially when the background sounds of a noisy restaurant compete with one’s conversation.  Chalk one up for being my own reporter. I asked a list of questions and now share the most meaningful ones with you.

1. Britta’s Question: What are the surgical ways to diagnose DCIS?

 Dr. Taft’s Answer:  “The first thing for us clinicians is that we have to be looking for DCIS. There is a very fine line between something that is non-cancerous, like atypical ductal hyperplasia, papillomas and DCIS.  We have better diagnostic capabilities with mammograms, stereotactic biopsies, ultrasound guided biopsies and breast MRI, It is hard to anesthetize the area behind the nipple, which was where your problem was making it difficult to get a core biopsy and there wasn’t enough tissue to do a stereotactic biopsy.  Only in cases where a minimally invasive biopsy cannot be performed should anyone have an incisional biopsy which is done in the operating room.  You had a papilloma with associated DCIS, which was unusual. I quote patients 10-15% chance of this happening.  You unfortunately were in the minority group.  Your case really illustrates why subtle findings just can’t be taken lightly.

2. Britta’s Question:  What are the current treatment options for DCIS?

Dr. Taft’s Answer:  “There are two options – both are surgical – a lumpectomy followed by radiation or a mastectomy.  The pro of mastectomy, or breast removal, is that you don’t have to undergo radiation, whereas with a lumpectomy you do.  While I think breast MRI’s are often helpful, they are not quite as good with DCIS.  When people are first diagnosed and they are told this is a non-invasive cancer or a pre cancer diagnosis, they get excited because there is less concern with the cancer spreading to the lymph nodes.  With DCIS it is almost tougher because it is a microscopic disease.  You can’t see it, you can’t feel it and you don’t know how extensive it is until you see it under the microscope.  So a patient comes in for a lumpectomy and has positive margins, they have to have these positive or close margins re-excised.  If they are still positive, they really need a mastectomy.   This requires several surgical procedures and is an emotional roller coaster for the patients and their families.  So it is really hard sometimes to appreciate the extensiveness of the DCIS.

3. Britta’s Question:  My primary care doctor says DCIS is not cancer. Talk about your position in the debate of whether DCIS is cancer or not.

Dr. Taft’s Answer:  “There are many ways to label DCIS but the main point is that it is contained within the ducts of the breast making it non-invasive.  It is pre-cancer.  There is often debate whether or not it is actually a cancer but I tell my patients, it requires treatment and long term follow up.  If you have a diagnosis of DCIS and opt for a lumpectomy, your treatment consists of surgery, radiation and in patients who are estrogen/progesterone positive (ER/PR), the drug tamoxifen.  If you have invasive cancer and choose a lumpectomy, your treatment is the same although the type of hormonal therapy may vary depending on the patient’s menstrual status.   The main difference is whether or not the patient will need chemotherapy.  If it is extensive DCIS, like extensive invasive ductal, you get mastectomy, reconstruction.  With the exception of the chemotherapy component, much of the treatment and the follow up is the same.   I like to say it is non-invasive cancer because you are getting some form of cancer treatment, but you will not get any two doctors to agree on this.  I think the way I put it seems pretty reasonable.”

4. Britta’s Question:  DCIS patients like me don’t fit into the cancer box neatly, do you consider us breast cancer survivors? 

Dr. Taft’s Answer:  “I do think you are.  It is non-invasive cancer, it did not move outside the breast.  Your chance of having cancer in the other breast has gone up significantly having a history of DCIS.  You are a patient…just like my invasive breast cancer patients and I will follow you.”

5. Britta’s Question:  How do you see the patient-doctor relationship from your perspective as a surgeon?

Dr. Taft’s Answer:  “I think being a surgeon gives us a unique perspective. I see it as two things:  sacred and a privilege.  If you think of it, when you came in you only knew me to a point before surgery.  You trusted me to put you to sleep, where you could not intervene, defend yourself, or ask questions and do a cancer operation. I am amazed each day with the trust people have in me and my abilities as their surgeon.  This is sacred and I think the day I don’t feel that way about it, I’m out of medicine.  Standing in the operating room, taking cancer out of patients and traveling this journey with them is one of the greatest joys and passions of my life.  I cannot imagine doing anything more meaningful or rewarding.

6. Britta’s Question:  In a ‘perfect world,’ what role do you see yourself having in the care of DCIS and breast cancer patients? 

Dr Taft’s Answer:  “I consider my role is helping the patient make their decision, get the operation and a year from now or five years from now they are happy they had.  Some patients have choices and some patients like yourself really don’t.  For those that have choices, my perfect world is for them to look back and say, ‘thank God I did this.’  For the patient that doesn’t have choices, I think in a perfect world I help get them to the person, the reconstructive surgeon and help build the medical team that will take good care of them and that they’ll have confidence in. I strive to do that with each patient. “

7. Britta’s Question:  How do you feel about patients who want to get second opinions?

Dr. Taft’s Answer:  “I tell the patients that come to me, ‘if you want to go to another surgeon for a second opinion I am not offended.  This is not about my skill, my knowledge or my expertise.  It is about your connecting and trusting the person who is going to take care of you for the rest of your life.  The patient has to go where they have confidence, and a doctor, even if recommended, may not always be a match.’ “

8. Britta’s Question:  What is the standard of care for a new surgical patient coming into your care until they leave post surgery?

Dr. Taft’s Answer:  “The workup has to be complete.  Some patients with genetic testing want to have their surgery before all the tests are back.  I try to really put the brake on that since we don’t have all the information. I can’t begin to presume how they feel, but they have a sense of urgency to get the cancer out of their body. I feel like my role is to help establish who needs to have genetic testing completed and who needs to have a breast MRI.  Not everybody needs a breast MRI and only 3-5% of breast MRI’s tell me something I didn’t already know. You really have to identify who is a potential candidate for chemotherapy before radiation, who is a candidate for partial and full breast radiation and identify what is appropriate for them. I look at my patient and all their possibilities and identify what is appropriate for them.  Get them to the right people and get their workup complete in a timely, efficient and respectful fashion, then get them on the operating table.  My fellowship helped me with this in correctly identifying these people – who needs their ovaries out…do we do that at the same time as the breast surgery…and identifying who can handle that and who can’t. Postoperatively, I want to make sure that they have gotten the appropriate referrals to medical oncology (medonc), radiology oncology (radionc) and make sure they are seen appropriately.  If they have had axillary dissections, I send them to see a lymphedema specialist for teaching and monitoring.  I schedule a follow up every six months for the first three years.  Patients think that once the surgery is over they are done with me.  No, I’ve actually called up patients who tell me they are doing great and think they don’t need to come in to tell them they need to get in the office for an appointment. I don’t want my patients to get lost.  That is one thing as a surgeon, THE thing, I am the most paranoid.  I don’t get upset about too much, except something getting missed.  Let’s say I order a mammogram on you and we don’t follow up and get the results, I’ve just done you a huge disservice.  My standard of care to me is that there is good follow up and we are keeping track of the results.  I also document how many false positive margins and how I’m doing and I don’t think most surgeons do that.”  I want to know how I am doing as a surgeon and compare that to the national statistics and make changes as needed.

9. Britta’s Question:  What percent of women in my age group with DCIS would have opted for a mastectomy only? 

Dr. Taft’s Answer: “  Very few although it is often dependent on age and other various factors.  It is almost unusual today for a woman not to schedule reconstruction at the same time.

With you, when you chose a mastectomy only, you were at the time, the only young patient that I have taken care of less than 60 years of age, that didn’t get immediate reconstruction.  And when you chose that I thought ‘Wow, this woman is really committed to her education’ and I instantly admired you for that. You did that and you are smart and confident in yourself and didn’t need that breast to go to school. I really admire you, you have no idea.

Why should we deny women reconstruction at any age?  If they want it, are healthy and their medical team says they can withstand it, why not?  I help run the breast conference at Delnor and Sherman Hospitals and we had an 81 year-old patient who wanted reconstruction.  As long as she is a viable candidate, why not?  Why should we deny these women?

10. Britta’s Question:  How do you, as a surgeon, build relationships with primary care givers who refer patients to you and to post surgery physicians?

Dr. Taft’s Answer:  “One thing, with the radiation oncologists, reconstructive surgeons and other specialists, we all have each others’ cell phones.  I am on the phone every day with multiple doctors discussing patient care.  They see the quality of your work and you see the quality of theirs and that builds relationships.  With the primary care docs the relationship depends on you and what you tell them after having surgery.  If you went back to them with negative feedback, it doesn’t reinforce their referral.  As we treat you well and you are happy, it goes back to the primary care doctor.  I thank them and am always appreciative of a referral.  Most primary care physicians don’t really want to be in charge of your breast cancer. It is one of the most highly litigated areas of medicine.  When I stop and think about it, I feel like a blood vessel among a pond of mosquitos.  I know that I’m doing my job well and I’m conscientious, but in the end,  I will probably get sued at some point and that will break my heart.  I will know that I have done my best with what I had and what I knew at the time.  With primary care physicians, they don’t spend their time immersed in your breast cancer because they have to know about diabetes, hypertension and asthma and every disease their patients may have. They are amazing that they have to know so much about so much!  I on the other hand wanted to be a specialist and want know everything there is to know about breast cancer and benign breast disease too.  Primary care doctors are just want someone to take great care of their patients which helps to build the relationship.

Another thing is that I have a real problem with people who say ‘well, the surgeon was a jerk, but I’ll put up with it because he/she is a good surgeon.’ Just because you are good, doesn’t mean you can’t be nice.  If you can’t be empathetic and sensitive to women and where they are coming from, like you, when you decided not to have immediate reconstruction, even when it may not be the decision I would make, it is my role to support you on whatever you decide as long as it is not detrimental to your well being and outcome.  If you can’t be sensitive to that, you shouldn’t be doing the surgery.

Britta:  I remember what you said to me before I had chosen between a lumpectomy and radiation or a mastectomy was, ‘Whatever path you choose will be right for you.’

Dr. Taft: You did the right thing for you.  And you got your degree and you got your reconstruction in the order that worked for you. “

Other thoughts from Dr. Taft:

“You choose the moment to look at your breasts after reconstruction.”

“There should be a silver lining to the dark cloud of breast cancer – go get the breasts you have always wanted…”.


	                	                	

3 Responses to “Mastectomy Q & A” Subscribe

  1. Britta Wilk McKenna April 17, 2012 at 2:07 am #

    Kate, you are right on! Dr. Taft is an incredible breast surgeon and I am extremely blessed to have met her and been in her care. She was not the first surgeon I met with….a reminder to keep looking to find a surgeon or doctor you connect with, who has positive referrals and one you can relate to personally and whom you feel will give you the best medical AND personal attention.

    • Mira June 20, 2012 at 12:52 am #

      I very much admire your hotesny and beautiful writing. This sounds like a horrible ordeal that you have been able to put in the past. I’m happy for you. May you remain cancer-free throughout the rest of a long life!I’m glad to know that even professionals such as you and your husband can be confused by the diagnostic process. It’s certainly not always straightforward, and I have sometimes felt just plain stupid about it all.I’m now living with metastatic breast cancer in my lungs. This was after sixteen years of believing myself to be cancer-free (as you know, Marilyn, but I wanted to share my experience also in this forum). I had what was diagnosed as first stage cancer at that time. I had a lumpectomy, lymph nodes sampled, and radiation. I then took tamoxifen for five years. And I believed this was all in my past. I now understand that it’s not that simple. Cancer tumors can be too small to be detected by mammograms or even CT scans. I’ve had regular mammograms all these years, of course, without detecting any further problem.In my case, I do not have a new primary tumor in my breasts, so even a mastectomy back in the day wouldn’t have spared me this recurrence. I am living with metastatic cancer that has been there since my first diagnosis sixteen years ago. It had already metastasized into my system, but that wasn’t detected.And now, for whatever reason, it has flourished in my system enough to be detected and become a problem. My tumors are still small and slow-growing. I’m on a hormonal treatment. I hope to remain stable for years and years, though never again cancer-free (because it is metastatic).The moral of the story is, I think, diagnostic tools can only go so far. Professional judgment can only be based on the facts at hand. And none of us are stupid about trying to understand these things. There simply is too much that is still unknown.But I praise God regularly for the amazing work that has been done in research and development of new treatments. What is available now is light years away from what was available sixteen years ago. What was available for my friend, who also has metastatic breast cancer and was first diagnosed and treated six years ago, is light years away from what is available today. We both benefit from these advances, and our lives and quality of life will very likely be extended by them.Breast cancer research far surpasses research into other forms of cancer. That is partly because the disease is so prevalent, and by a certain age it seems we all know someone who has had it. But it is also because public attention and fundraising have been focused so heavily on this illness.So, while I certainly understand your unhappiness with the color pink (I think breast cancer is red and purple and black and some awful mix of these things, if a color has to be accorded it, and a pastel pink is ridiculous), still I know myself blessed by whatever means research is funded and continued with such ferocity. This research isn’t pink. But if pink will inspire giving, then I say God bless whoever dreamed up pink.I am deeply in awe of your courage in facing your illness. I am indebted to you for sharing your experience with me and with others on this blog. I think this is impassioned and moving writing. And I appreciate your hand held out to others who have faced and are facing this disease. Thank you very much for sharing this piece.Forgive me, please, for my difference of outlook on the color pink.I’m glad to know you, Marilyn.

  2. Kate F April 6, 2012 at 2:52 pm #

    What an incredible surgeon you have! Great Q & A.

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