Coordinated Care in Breast Oncology: Importance of Plastic Surgery & Genetic Counseling

In this episode of OncChats: Coordinated Care in Breast Oncology, Jason Ye, MD, and Daphne B. Stewart, MD, of Keck Medicine of USC, discuss how involving plastic surgeons and genetic counselors early in breast cancer care helps guide personalized surgical decisions—such as breast-conserving options or reconstruction—and ensures safer, more effective treatment plans based on individual risk factors.

Ye: A lot of times, when the surgery happens, maybe it will close the door to certain options. We should also mention that our plastic surgery colleagues and genetic counselors are also a crucial part of this decision. I think you and I agree that for most early-stage breast cancer [cases,] people do okay without mastectomy. Lumpectomy breast conservation therapy is our treatment of choice or preferred option. Still, sometimes it may not be appropriate depending on whether the patient has a certain genetic mutation that may make radiation and other therapies more risky, or they have really high recurrence risk or future breast cancer risk, which might change the decision. That’s where the plastic surgeon colleagues will also come in; if we want breast conservation, [they can talk about how] there are these oncoplastic reconstruction options where you end up with a very symmetrized breast without a more obvious surgical defect. If [a patient] gets a mastectomy, there are various options: nipple sparing, skin sparing mastectomy, implant-based or tissue flap-based reconstruction.

Stewart: And lymphatic transfer is a new technology that we have available that’s really changing things in terms of the risk of chronic lymphedema when you do axillary dissection of involved lymph nodes. So, [this is] really a crucial discussion to have.

Ye: It is, it is. Just because breast cancer outcomes [are] so great these days, and much, much better compared with 10 or 20 years ago, we really are focused on quality of life [QOL] and survivorship after we put the patient into remission, or dare I say, ‘cure’ the patient. And yes, the decision regarding dissection vs sentinel lymph node biopsy and maybe radiation [is important. Also,] if you do the dissection, would the patient be eligible for some lymphatic bypass or repair at the time of surgery so that it lowers the chance of lymphedema? By having all of these discussions, patients also get referred to our physical therapy and occupational therapy colleagues early on, so they then start all the preventive exercises early so that these things don’t even happen to begin with. I always tell patients the best way to treat lymphedema is to make sure it doesn’t happen to begin with. So, all of this really comes down to a multidisciplinary discussion and treatment coordination. None of us can do this alone.

Stewart: And I think that [when they walk in the door,] patients are going to have a strong opinion about [whether they want] their whole breast removed, both breasts removed, [etc.] That’s really what they [tend to] come in [with] but I think [the discussion] opens up their minds to the multiple interventions. You could do breast conserving surgery, and there could be a QOL benefit, and in fact, survival benefits long term. If [a patient has] high-risk disease or a large tumor, [they] are potentially going to benefit from doing systemic therapy with [their] medical oncologist before [they] go to surgery, and that intervention may dramatically alter what [their] surgical planning and even [their] radiation planning might be after that. So again, it leads to a number of pathways. [This] can be very reassuring, [to know] that [they] have choices. [They] don’t just have to make one decision. But again, when you [have] a team of experts who then coordinate [what is decided on] it really helps the patient feel more confident.

Ye: Absolutely, and that’s really one of the things that makes me really proud and happy to work here at USC.

Check back tomorrow for the next episode in the series.