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Join Now: For Ask Me Anything with Dr. Axelrod

Join Now: For Ask Me Anything with Dr. Axelrod

Ask a breast cancer expert anything. Join the conversation by replying to this post.

Our Ask Me Anything (AMA) with Dr. Deborah Axelrod is starting now.

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Hello everyone and thank you for joining "Ask me Anything" with Dr. Axelrod. Dr. Axelrod please tell us about yourself.

Thanks Danielle and to SHARE for inviting me. I am a surgeon who specializes in breast diseases and breast cancer and have been in practice since 1988.

Hi, looking forward

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A friend of a friend was recently diagnosed with metaplastic breast cancer. Could you explain what that is, and is surgery a possible option for this type of breast cancer?

Metaplastic breast cancer is a rare variant of breast cancer and constitutes less than 1% of all breast cancer. Usually chemotherapy is indicated. This form of breast cancer does not preclude having lumpectomy vs mastectomy. You will want your friend to get a medical oncologist involved in the early stages of diagnosis since sometimes, chemotherapy may be indicated first rather than surgery.

Has there been any innovation that can prevent lymphedema after breast surgery?

Do you have any opinions about reconstruction, so many women have had issues with implants. What's your personal take?

I think implants and autologous flaps are all good choices for reconstruction after mastectomy. But you must see a plastic surgeon who can do all of the choices so you will get a rounded discussion and then be able to make a decision.

Some issues arise with both- ie hardened implants, implants that can migrate, flaps that have hardened areas from dead fat (aka fat necrosis). Nothing is perfect. Make sure you have the time to recuperate from each one- the recovery from implants (or first using expanders) is quicker than the other choice.

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Even removing one or 2 nodes can cause lymphedema though it is unlikely and less than 5%.

It is difficult to prevent lymphedema. You can reduce the risk by removing less nodes.

If an axillary lymph node dissection is indicated (when you know lymph nodes are involved prior to having surgery), it is sometimes possible to have lymph node transfer surgery performed (ie plastics surgeons do this at our institution) where some lymph nodes are transplanted from other sites and also blood vessels and lymphatics are joined together ("lymphaticovenous anastomoses"). This helps with formation of new channels where the lymph can drain. Some people have reported that their lymphedema has reduced and has become more manageable.

Since age 18, I've had fibroadenomas in one breast and several biopsies. Is there a way to monitor them without the biopsies? I have a lot of scars.

Fibroadenomas are the most common tumors in women under age 40. They can occur as multiples or be just solitary. They can grow during pregnancy. Whether to remove fibroadenomas depends on ie size, multiplicity (having many that look the same and that are small speaks more for observation). I remove fibroadenomas that have grown. It is also important to know how long they have been there. If you've had the fibroadenoma for many years without change, it is possible your doctor will want to just monitor it.

There are ongoing studies in the country looking at freezing the fibroadenomas (cryoablation). There is a size cutoff for this.

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Follow Up recommendations for ILC seem to vary, especially when it comes to what type of scans to have. What are the current recommendations? And what should be done when the type scan/test recommended did not initially detect one’s ILC? Also, should Follow Up continue for a longer period for ILC, say 10-20 years?

ILC is invasive lobular cancer. There are essentially 2 cell types of invasive breast cancer- ductal (more common) and lobular (less common). Lobular is more insidious and grows in sheets so its sometimes harder to detect but be that as it may it has the same prognosis as ductal. Breast cancers not seen on a mammogram or sonogram may be seen on a MRI and you may be able to get a better look at these especially in dense tissue so it's worth asking you doctor about the indication for a MRI in this instance. I would follow invasive lobular and ductal the same way- every 6months for the first 5 years and every year until 10 years. With higher risk patients, ie node positive, the follow up may be extended.

With DCIS, is a double mastectomy my best option to ensure that it doesn’t advance into cancer?

DCIS has an excellent prognosis. I would offer lumpectomy or mastectomy. Mastectomy could be indicated where the DCIS is in more than one quadrant or after repeated attempted the margins can't be cleared or in someone with a history of prior radiation. Bilateral mastectomy is not "better" than lumpectomy for DCIS.

hi, there. what do you think of radiation therapy after mastectomy? do you recommend?

There are certainly instances where PMRT (post mastectomy radiation) is indicated. For instance if the tumor is >5cm, positive nodes or involved/close margins.

thank you.

If a woman has a skin-sparing and/or a nipple-sparing mastectomy is there an increased risk of recurrence because these procedures leave some breast tissue intact?

All mastectomies leave some breast tissue. The local/chest wall rate of recurrence is not statistically different with either of these procedures.

I'm 36 with a strong family history of bc. What other screening should I ask about besides mammograms?

It is important to look at the family history and the different types of cancers (are there others?) and whether affected relatives are alive- they would likely be the ones tested for genetic mutations (blood test). If they tested positive then you would test for the mutation too.

It is more difficult if the relative is not alive. If the history is very strong and there's no one to test than a MRI may be indicated.

Sonography of the breast is like a extension of a physical exam and I would recommend in someone who is young with a dense breast.

I would send you to a physician/genetic counselor who does "risk assessment".

What are the questions one should ask and have answered when deciding whether to have a mastectomy or lumpectomy?

You should find out about the cancer- ask you doctor. There are questions you can get from plwc.org (an ASCO website for the lay public) that gives you a list of questions which are very good to look at before your doctor visit.

- am I a candidate for lumpectomy ? and if not why not?

- if I am being recommended to have a mastectomy, what type, can I save my nipple ? spare most of my skin ? have a reconstruction ?

- will I need radiation after lumpectomy (ie with DCIS some may forego this) and will I likely need it after mastectomy ?

What do you think has been the biggest breakthrough in breast cancer treatment or research recently?

The results of a new study called the TAILORx study was just reported on today in which thousands of women with invasive estrogen receptor positive, Her 2 negative and node negative disease were studied. The question was looking at the genetic profiling of their tumors and numbers that are assigned to reflect risk of cancer returning at distant sites in the body - could you predict who would benefit from chemotherapy and who could forego it. What they found was that many patients did not need chemotherapy.

A 70-year-old woman, with a family history of breast cancer, who is 15 years out from her own diagnosis called our Helpline because she has had a few calcifications biopsied recently. She found the biopsies to be very painful and she is concerned about recurrence so she is considering a bilateral mastectomy with DIEP reconstruction. If she were your patient, what would you advise?

Frst off- what were the results of the biopsy ? If they were benign, I would not proceed with breast surgery. Bilateral mastectomy with DIEP (tissue from your belly) flap is a big recovery and is not indicated, especially as a prophylactic surgery here.

Thank you for inviting me and I hope this information will be helpful to you.

Thank You Dr. Axelrod for contributing to our Ask Me Anything. At this time the questions and answer period is over.

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