Dr. Armando Giuliano on the Science of Surviving Breast Cancer: Part One

Mary Alice:
Last week, actress Olivia Munn courageously shared her journey with breast cancer. She talked about how Dr. Aliabadi and knowing her lifetime risk of breast cancer saved her life. We felt it very important to do an episode with Dr. Aliabadi and Dr. Giuliano, two of Olivia's doctors, to talk about cancer, your lifetime risk, and the stages of breast cancer. This is a two-part episode, so make sure you watch part two as well. Hi, I'm Mary Alice Haney.

Dr. Aliabadi:
And I'm Dr. Thais Aliabadi. On today's episode, we're having a conversation with a man who I quite literally owe my life to. Dr. Armando Giuliano is a pioneer breast cancer surgeon, clinician and researcher who has spent over 40 years treating breast cancer patients. He was the physician who did my second double mastectomy after my first surgeon had left more than 35% of my breast tissue behind.
Not only did he change my life, but his research has led to advances that have significantly improved the lives of countless women and changed the way breast cancer is treated internationally. I couldn't be more excited to welcome my dear friend and colleague, Dr. Armando Giuliano, to SHE MD.

Mary Alice:
This podcast is for educational and entertainment purposes only. It is not intended as a substitute for a physician's medical advice. You should regularly consult your medical provider in matters relating to your own health.
We have one of the rock stars of the medical world here today. I couldn't be more excited for this episode. He is the premier breast cancer expert. I'm going to give you every single thing about him in two seconds flat, but it's also a very personal episode today because we're going to go through Dr. A's own breast cancer journey and how you are really pivotal in saving her life. Dr. Giuliano, you are the regional medical director of the Cedar-Sinai Cancer Breast Oncology Program. Your research career as a breast surgeon scientist has been dedicated to reducing the short and long-term side effects associated with breast cancer diagnosis and treatment. In the nineties, you helped introduce sentinel lymph node biopsy, sparing many, many, many women the need for major breast cancer surgery. You're a true rockstar in the field and we are so blessed to have you today.

Dr. Giuliano:
Thank you.

Mary Alice:
It really is amazing.

Dr. Giuliano:
Glad to be here with you.

Mary Alice:
Did you guys know each other before you had your breast cancer surgery?

Dr. Aliabadi:
Oh my God, of course. We've worked together for many, many years. I always refer my patients, I mean, the way you introduced him, you can multiply that by a hundred, there's so many more things he's done in his life. He's world-renowned breast cancer surgeon. The reason I wanted him here today, he doesn't like doing these podcasts, he doesn't like going on shows. I forced him because I feel like someone like him needs to share his knowledge with the world, with women around the world so they can be their own advocate as I was my own advocate in my breast cancer journey. But he's just a wealth of knowledge. I don't think there's anyone on this planet who's done as many lymph node dissections research, breast cancer surgeries as Dr. Giuliano sitting across from me today. It is truly an honor. I told him if he wasn't going to show up today, I was going to camp outside of his house.

Mary Alice:
She would have too. She definitely would've done that.

Dr. Aliabadi:
I'm just so honored you're here as a colleague, as my surgeon, so I appreciate you being here and sharing your knowledge with us and with all women around the world today. We have a lot of questions for you, and hopefully by the end of this episode, women will know what to do when they get the diagnosis of breast cancer.
Do you know? I'm a gynecologist, but when someone calls you over the phone and says your biopsy is cancer, your brain shuts down because cancer is always associated with death. It doesn't matter what people tell you. It's the scariest diagnosis. It's the scariest moment I've ever experienced in my life, and I grew up in war with bombs coming on my head. It's a different level of fear, but in reality, breast cancer has good treatment. Early diagnosis and prevention plays a huge role and that's why we need your help today to clarify a lot of that for our listeners. Thank you.

Dr. Giuliano:
Thank you. It's a pleasure to be here. You both exaggerated very much in the introduction.

Mary Alice:
We didn't.

Dr. Giuliano:
But thank you.

Mary Alice:
I think we talked about a little bit in the welcome episode. I think it would be breast cancer journey. I think it would be great just to start with that then. We've got really so many questions for you. Can you tell everybody what happened to you?

Dr. Aliabadi:
I was 48 and I had gone to mammograms regularly since I was in my mid-thirties because I had extremely dense breasts. I had no family history of cancer at that time. I've never been overweight, I've never done drugs in my life, I rarely drink alcohol, I had never been on hormones or hormone replacement. Like you said one time to me, I was the poster child of someone who you would think would not get breast cancer. I have lived a stressful life in a way that I've worked a lot and I think lack of sleep and just running around for 30 years probably was one of the causes of my cancer, but I want you to talk about that later. At 48, I had a mammogram that showed some abnormality in my left breast. The radiologist told me it's probably early stage cancer. He did the biopsy and my biopsy came back atypical lobular hyperplasia, which means that there's some atypical cells, but there are no cancer cells. At that point I did an excisional biopsy where they go in and take an area of the breast out like a golf size, and I went back to work the next day. When I followed up with my doctor, I was told to come back six months for a follow-up that week I had a lunch meeting with a genetic rep, and as I was eating lunch, he looked at me, he's like, "Did you ever calculate your own lifetime risk?" At that point, every single woman who comes to my office gets their lifetime risk checked, but I never did it for myself because I had no family history, I had no risk factors. I was like, "No, actually good point. Let me do it." I started doing the lifetime risk calculator. As soon as I checked off atypical lobular hyperplasia, my lifetime risk would jump anywhere from 37 to 50% depending on whether or not I marked "extremely dense" or "moderately dense breast tissue" on the questionnaire. I almost fell off my chair when I saw that number. So I called my doctor and I said, "You keep telling me I'm okay and I should go and come back in six months, but 37% is a big number for me. If you told me I had a 37% chance of getting hit by a car today, I would sit at home. I'm a very conservative person." So I called her and she said, "Don't worry about it. You have no family history. Your risk factors are really low. We're going to watch you. Just come back in six months." I tend to be a more aggressive physician. I don't like watching anything. If you show up to my office with a lump, I put a needle in it. Ignoring 37% was not going to be an option for me. So I asked her to do a double mastectomy, and I remember in response to that, she told me that her own risk was north of 50%, that she had her mom die of breast cancer, but she wasn't going to do a double mastectomy. I remember thinking to myself, "This is a very personal decision and just because 55% or 50% is not high enough for you and you're not traumatized with losing your mom, I might not feel the same way."

Mary Alice:
It's very different. Every woman's different.

Dr. Aliabadi:
I had three little daughters, I love my husband, I absolutely love my job, my patients. I have lived a great life and I didn't want to get breast cancer. That reality of going into a machine every six months and doing breast imaging was traumatizing for me. For me it was.
I asked for a double mastectomy. She told me to come back at 50. That didn't sit well with me. I remember meeting my plastic surgeon. I just went for an appointment and his wife had been diagnosed with breast cancer years prior to that, and he told me that if I was his daughter, he would've done my double mastectomy, he would've recommended a double mastectomy. That reassured me. I finally found a surgeon, I convinced someone to do my surgery. She didn't want to do it, she had only done four mastectomies in her life, but I was so desperate, I let her do it, and I was under for 10 hours. I think I told you, Dr. Giuliano, I was under for 10 hours. I bled out. My hemoglobin was five, which means I lost more than half of my blood volume and my blood pressure post-op day two was 60 over like 25. I don't remember the first two days in the hospital. These are what my husband basically remember... I remember it because he told me the story. Finally, I got two units of blood transfusion. I went home, and even though I felt so sick and so ill, I was so happy. I hired a videographer to videotape my journey because so many people called me crazy when I was doing my double mastectomy. From the head of MRI at my hospital to my breast doctor who was following me to all my friends who were physicians, every single person called me crazy, paranoid, you name it. They called anxious. They called me everything, but it didn't matter to me, when I set my mind on something, I do it. I came home and I was so happy. When I opened my eyes after that 10-hour surgery, the first thing I said to the camera, which I don't remember, but it's on tape. I say, "Go tell my children. I will never come home telling them I have breast cancer." That's how I started my journey. A week after, it was back to school weekend and I was shopping at Staples with my husband and I got a phone call from my plastic surgeon, not my surgeon, my plastic surgeon. As soon as he called me and he said he got off the phone with the pathologist, Dr. G, when someone calls you and says, "I talked to your pathologist," it's always bad news. We don't call patients and say, "I got off the phone with the pathologist." The pathologist only calls when it's bad news. As soon as he said that, I said, "Do I have cancer?" And he said, "Yes." At that point, my brain shut down. Here I was, an OBGYN in one of the best cities in the world at one of the best institutions, and everyone called me crazy. They didn't want me to do half the surgery and a week later, I'm diagnosed with breast cancer. Like any other woman who gets this diagnosis, my brain shut down and I don't remember everything else he told me on that day. Obviously I was devastated. I went home, I was shocked, I started crying. I didn't cry because I was sad, I cried because I was angry. Because when so many people call you crazy, and then it turns out you were right, it's not a good feeling. I get so emotional talking about this.

Mary Alice:
I know, I know, I know.

Dr. Aliabadi:
It's emotional. When you have little children, I always say, "If I didn't have kids, who cares?" I would've been stronger. Most people say you become stronger with kids, I actually think you become more vulnerable as a mom because dying is not an option. When someone says, "You have cancer," my brain just went straight to the cemetery. I thought I was dying. It didn't matter, everything I knew about breast cancer goes out the door. Cancer is death until proven otherwise. At least that's what I experienced. At that point, I realized that they had not removed my lymph nodes.

Mary Alice:
Why did you think that? You just felt it?

Dr. Aliabadi:
No, no, no. Because lymph node surgery is lymph node surgery. They go under your armpit and remove lymph nodes. But because they didn't think I had breast cancer and they didn't want to do this surgery, they just removed my breast. But in order to stage breast cancer, you need lymph nodes, and that's how I ended up in Dr.-

Mary Alice:
What does that mean? "In order to stage breast cancer, you need lymph nodes"?

Dr. Aliabadi:
Breast cancer has four stages. In order to know what stage you're at, you need to know if you have cancer in your lymph nodes, in your armpits. That's part of staging. They had not removed my lymph nodes. Well, the number one person in the world to do lymph node surgery is this doctor sitting in front of me. Of course at that point, I'm like, "I'm not going to anyone else." I'm just going to add one more thing, I went to see Dr. Giuliano. Two weeks after my first mastectomy, I still had drains coming out of my chest. I was looking at myself in the mirror and I called my husband. I'm like, "Can you come here?" He comes. I'm like, "I don't think my doctor removed all of my breast tissue." He's like, "What do you mean?" I'm like, "I'm sorry, but I looked like I had these giant breast augmentation." You know how you go for breast augmentation? My breasts were full and big, and I never had large breasts. I told my husband, I'm like, "I can grab breast tissue above my implants." And he's like, "Are you sure?" I'm like, "I swear. I know, I'm a gynecologist. That's what I do for a living." Two weeks after my surgery, I put myself through an MRI machine, the radiologist who had also missed my cancer on my MRI and called me crazy and paranoid the day before my surgery, showed up and say, "Why are you here?" I said, "I'm here because I feel like they left breast tissue. I had mastectomy two weeks ago." She looked at my imaging and she said, "No, this is very clean. There's no breast tissue in your breast." I said, "Okay." And I remember looking at her and saying, "Listen, I'm really sorry, but you also missed my cancer on my MRI, which is acceptable. I understand, we're humans, we make mistakes. But you can understand why as a patient, I want a second opinion." She was completely fine. I got a copy of my CD, it was a Friday afternoon. I went to another breast institution right next to my office. I spoke with their head of MRI there who knew me really well, and I asked him to look at my MRI images. He looked at it and he said, "In 12 years of looking at post mastectomy MRIs," this is the cleanest MRI he's seen and there's no breast tissue left. I remember my husband looked at me and he's like, "You know what? You're driving yourself crazy. Let's go home. You need to go home." I said, "You're right." I went home and I was relieved. That Monday I had an appointment with Dr. Giuliano for my lymph nodes. I remember where I was sitting, he opens the door, he comes in, after he gave me a big hug, the first thing he said was, "I'm so sorry about your MRI," and I was like, "Why? Which MRI?" He said, "The one you just did on Friday." I said, "Why?" He said, "All that breast tissue they left behind." At that point I started crying-

Mary Alice:
Of course.

Dr. Aliabadi:
... because I had nothing else left in me. Here I was, first no one wanted to do my mastectomy, then I was diagnosed with breast cancer, then I told them I had breast tissue. I was told by two top radiologists that I didn't have any breast issues.

Mary Alice:
How does that happen? It is a human error? How is it that you saw it and somebody... I mean, you're not a radiologist.

Dr. Aliabadi:
No, but he took me to a radiologist in his office. He said, "Come with me." We go to a third radiologist who was right next door, and she started pointing out all these areas that I felt on exam with retained breast tissue. I remember we came back to the exam room, I looked at him and I said, "You're doing my... I want another double mastectomy." Dr. G was like, "You're crazy." I'm like, "No, I'm not crazy. I want you to do my double mastectomy." I signed a consent for a double mastectomy. I didn't sign a consent for breast tissue to be left behind, and I have a lot of atypical cells. I don't want to go back into these machines. Honestly, as a gynecologist, I always knew people left breast tissue that it's normal to leave, let's say less than 5% of breasts behind. But this was a lot more.

Mary Alice:
Because they want it to look natural. They wanted to keep it in some-

Dr. Aliabadi:
Yeah. But that's not what I wanted. That wasn't important for me.
That day, Dr. Giuliano told me if I waited six weeks that he would do the surgery for me. And at that time, he would do my lymph node staging, which was required to get a diagnosis. That's my journey. That's how I ended up under his amazing care. He did do my second double mastectomy.
You were apprehensive. You didn't want to do it because I had lost so much blood and my recovery was not easy the first time. Obviously as a surgeon, you don't want to take a patient back again and put them through that. But I remember when I woke up, you came to my bedside and you said, "You're so stubborn, and I'm glad you made me do it," because she had left 35% of my breast tissue behind. 35%.

Mary Alice:
If she had come to you at the beginning, what would you have differently or would you have done anything differently?

Dr. Giuliano:
Well, I view risk very differently now. I think Thais talked about it. 5% may be a lot for someone, 90% may not be a lot for someone else. So it's a very personal experience. I would've explored her sense of risk. 37%, is that a lot? That means two thirds of the time, you won't get it in your lifetime, but one third you will. How important is it to get to close to zero, which prophylactic surgery does? Nothing is zero or absolute in medicine. But good prophylactic mastectomies get your wrist down to under 5%, certainly in good hands, even lower. We would've had that discussion, and she's obviously a very intelligent, informed patient. She said she wanted it, I would've done it for her. I would hope I wouldn't lose a lot of blood and I would hope I'd remove all the breast tissue. This is an unusual story. I have a very intelligent patient who can feel that she has breast tissue and that prompted completion of her mastectomy. I think most people wouldn't have realized that.

Mary Alice:
What stage was your breast cancer?

Dr. Aliabadi:
IB.

Mary Alice:
Can you go through the staging again? You guys are these beautiful medical miracle minds over here and I'm not. I can talk about fashion anytime you have any questions about that. Just talking to someone like me, when you hear, "Staging," we don't know what that means. Can you just go through the staging of breast cancer and what each stage means?

Dr. Giuliano:
Staging is an attempt to determine how advanced the cancer is and look at its prognosis. We start with stage 0, which is in situ cancer. That's confined to the ducts. It hasn't escaped the ducts, it lacks the ability to spread. It's not a lethal cancer, it can become one, most of us believe. But that's stage zero and not likely to spread.
Stage I is a small cancer localized to the breast, which is what she had. Based on the size is IA, IB, et cetera. Stage II is typically a small cancer that's spread to the breast or a larger cancer within the breast that is not spread. Stage III is even a larger cancer with more spread. Breast cancer spreads first under the arms to the axilla.

Mary Alice:
What's the axilla?

Dr. Giuliano:
The armpit. That's where stage I and stage III would be. Stage IV is when it's spread to other organs in your body, liver, lung, typically bone. That's the staging system. Each staging system has a prognosis associated with most people with a O have a hundred percent breast cancer survival. Stage I, favorable stage I, in excess of 90%. So it goes down with advanced stage. It's important for patients to know their stage, and it also affects the treatment. A young woman who had lymph node involvement would usually get chemotherapy, without lymph node involvement for hormone receptor positive tumor, she'd get an anti-hormone. There's staging, survival implications, and treatment implications. It's very important to be accurately staged, and that's why we remove the lymph nodes under the arm to see if it's spread.

Mary Alice:
Can you also walk through, if we were starting at the beginning, Thais comes in, she feels a lump, which you didn't, but I'm just saying someone comes in, you stick a needle in her breast, pulls out, it's breast cancer. Can you walk through what happens to a patient or what should happen to a patient when they come into their breast cancer doctor's office?

Dr. Giuliano:
First of all, most lumps are not cancer, particularly in young women. They get lumpy breasts from, we call it fibrocystic disease, it's not even really a disease. Many people prefer to say fibrocystic condition because it's so common in young women.

Mary Alice:
I had several of those before.

Dr. Giuliano:
That's very common. You get little cysts, little lumps, most lumps that women feel are not cancer. If you come in with a mass, you get a physical examination to feel the mass, to feel the lymph nodes, to look at the skin and shape of the breast, look at skin changes to see if there's any signs that may indicate an underlying cancer.

Mary Alice:
What are some of the signs?

Dr. Giuliano:
Well, first is a bloody nipple discharge, mass that is harder and fixed or fixed to the skin, fixed to the chest wall or palpable lymph nodes under the arm.

Mary Alice:
Like you feel a bump in your lymph nodes.

Dr. Giuliano:
You feel a bump, yes. The first thing you would get would be a mammogram and an ultrasound, and looking at the characteristics of the mammogram and the ultrasound, you get a sense of whether it's benign or malignant. You can often say, "Well, this is benign, don't worry about it. This is a cyst." Cysts are rarely if ever malignant, so you would do nothing for that patient. Now, if it were solid and looked suspicious, then you would do a needle biopsy.

Mary Alice:
Let's say at that point the needle biopsy comes back and it's cancer. The radiologist says, "It's cancer." Then what do you do with a patient?

Dr. Giuliano:
Well, there are many different types of breast cancer. It's not one disease. So you look at the biomarkers, the type of cancer, but still evaluating the patient preoperatively. You might get an MRI if she had dense breasts as our star patient here had.

Mary Alice:
And what does that mean? I have dense breasts too. You've said that.

Dr. Aliabadi:
That density of the breast is not something that's palpable. It's what the radiologist diagnosis on your breast imaging. On mammogram or ultrasound or MRI, they make a comment on how much density... There's a ratio of fibrous tissue versus fat. The more dense you are, the more of those fibrocystic tissue you have. And the less fat, as we get older, we get more fatty breasts. The fat replaces a lot of that dense tissue. 50% of patients have dense breasts. 50% of women have dense breasts. The younger you are, the denser it is. Am I correct, Dr. Giuliano?

Dr. Giuliano:
Absolutely. As you age, the glandular tissue regresses and it's more fat. The X-ray beam goes through fat very well, so it doesn't look white and cloudy. If it's white and cloudy, that's more dense, that's more glandular tissue associated with a higher risk of cancer, also higher to detect a cancer. That's why you would get an MRI. An MRI is not an x-ray. It's based on blood flow and magnetic waves that give a different picture of your breast relating to the amount of blood that's flowing to different parts. It works in a manner entirely different from a mammogram and it works very effectively on dense breasts.

Mary Alice:
So you do both sometimes.

Dr. Giuliano:
Usually do both if the patient has dense breasts.

Dr. Aliabadi:
As a gynecologist, when my patients are diagnosed on, let's say, core biopsy or FNA biopsy, needle biopsy of the breast, and they get the diagnosis of breast cancer, usually I refer these patients to Dr. Giuliano, for example. But before I do, in my office, I run a genetic test because, A, you want to make sure these patients don't have an underlying genetic mutation. I just do a full panel on them. Number two, I make sure obviously that their breast imaging is ready for a visit with Dr. Giuliano. Usually these patients need a breast MRI. If they've had a core biopsy that has disrupted that area, then I usually call him and ask him if he wants my MRI right away or he wants to wait for the MRI. But as part of the workup, they want to see if you have lymph nodes that are showing up on the breast imaging and they want to see, let's say if you have a breast cancer diagnosis in one breast, they do an MRI to make sure there's not cancer on the other breast. It's important to know that mammograms pick up four out of five cancers. 80% of cancers, the other 20% you need to add ultrasound or MRI. When someone's diagnosed with breast cancer, we do full imaging and I literally, with genetic testing, with those imaging, I hand my patient to Dr. Giuliano and they, depending on the size of it, the type of cancers, and the biomarkers and the breast imaging, they recommend different treatments for different patients. My question to you is, Dr. Giuliano, one thing people don't understand are these biomarkers. Tell me when you get a breast cancer report, what are the things you look at to make a decision whether you do chemotherapy first or if you do surgery first? But what are those biomarkers? When patients have the copy of their path report, I want them to have a basic understanding of what it is to be estrogen receptor positive progesterone. What are other markers that they should look at?

Dr. Giuliano:
Great question, but before I do that, I'd like to mention the genetic tests that you referred to.

Dr. Aliabadi:
Yes.

Dr. Giuliano:
Many of us think all women who get breast cancer should have a genetic test. Insurance companies don't agree with us. We always order a genetic testing, that is to see if you inherited from your parents, an abnormality that's likely to give result in cancer. If you have a BRCA1, for example, your chance of breast cancer in your lifetime is 80%. Now that's a patient whose risk is so high, you certainly would want to do something prophylactically. That test most insurance companies say should be done on young women. Those with a family history of breast cancer or ovarian cancer, even colon cancer and malignant melanoma are associated with the gene and will impact whether you should have that test. We do do that test very frequently. The test when it first came out was about $4,000, now it's a few hundred dollars. Many women, if their insurance company won't pay, will say, "Well, I'm willing to pay a few hundred dollars to find out."

Mary Alice:
249.

Dr. Giuliano:
Exactly.

Mary Alice:
Dollars.

Dr. Giuliano:
So many women will want that test.

Mary Alice:
And then what's the difference between those in the GRAIL test?

Dr. Aliabadi:
That's completely different.

Mary Alice:
That's completely different.

Dr. Aliabadi:
This is a genetic test we're talking about. GRAIL predicts your risk of breast cancer. This is a gene test, they look in your DNA to make sure there's no abnormalities, and correct me if I'm wrong, less than 5% of women with breast cancer have a gene mutation. Majority of women who end up having breast cancer don't have anything in their DNA, or at least we haven't identified it yet.

Dr. Giuliano:
Right. It's inherited from your parents. It's most common in Ashkenazi Jews, and Northern Italians, and people from Iceland. It's different spots around the world where it seems to be more common. We don't know a lot of the places. The Chinese are just starting to do it, most Asian countries are just starting to do it. Latin America, the Philippines, we don't really know what their risk is. But in the US those are the groups that have the highest risk of having the gene mutation, which is, as said, accounts for about 5% of breast cancers.

Mary Alice:
And are there tests that you can do to show what kind of treatment?

Dr. Giuliano:
We'll talk about the pathology report. There are certain things that we call biomarkers. These are biologic properties of the cancer cell itself. As we know, your breasts are sensitive to hormones. Many women can describe fluctuation in the size or pain in their breasts with different points in their menstrual cycle. A breast cell and a breast cancer cell has hormone receptors on it, little places where the circulating hormone binds and affects the cell growth. The two most common are estrogen and progesterone, two basic female hormones. You also have what's called an oncogene, a gene that relates to replication and cancer called HER2. The HER2 receptor is associated with worse cancers or they used to be worse. Now there's treatments specifically for that type of cancer, making it actually a very favorable cancer to have. These biomarkers determine the biologic behavior of the cancer cell. Its likelihood of spreading. There's also grade. Women will see the grade of cancer. There's grade 1, 2, 3. The higher the grade, the more bizarre the cells are, the more cancerous they look, the more likely they are to spread. Grade is important. The biomarkers are important. Then these tests, these genetic tests like Oncotype and MammaPrint that we heard about are important to determine your stage. The American Joint Commission on staging, five years ago, we changed the staging system to add these biomarkers and these genetic tests because if you have a very favorable oncogene, even though your cancer looked bad, maybe stage 2, it's very favorable. These different biomarkers, these different genes interact and determine the behavior of the cancer and its treatment. These tests on the pathology report are very important to determine prognosis and treatment.

Dr. Aliabadi:
Is it true that the triple negative, when your estrogen receptor negative, progesterone negative and HER2 negative, you tend to have a more aggressive cancer?

Dr. Giuliano:
Absolutely. If you think of a normal cell has these ER and PR receptors because it needs it to grow. As it becomes more wild and develops the ability to grow without these hormones, it becomes a worse cancer. The triple negative cancers, those that don't have estrogen receptors, don't have progesterone receptors, don't have HER2 receptors are worse cancers, will grow more wildly, require more aggressive treatment.

Dr. Aliabadi:
And is more aggressive treatment chemo?

Dr. Giuliano:
Usually, yes. And now immunotherapy.

Dr. Aliabadi:
Immunotherapy, I was going to ask you about that.

Dr. Giuliano:
Tremendous rise have been made in triple negative breast cancer with the addition of immunotherapy, the drug Keytruda.

Dr. Aliabadi:
When you look at a path report as a gynecologist, when I see estrogen-receptor positive, progesterone positive, HER2 negative, in my heart, I'm a little happier for that patient. But what is the difference between Oncotype and MammaPrint and when do you order Oncotype and when do you order MammaPrint?

Dr. Giuliano:
They're basically the same concept. They look at the genetic mutations within the cancer, unlike a gene test to see if you have BRCA, which looks at your normal cell mutations, this looks at the cancer. And the difference is they look at different genes. They have slightly different interpretations, but they basically show not only the prognosis but the response to therapy.

Dr. Aliabadi:
It can really literally tell you, "Oh, you've got this stage and this type and this is what you should do for treatment." It's a tool that you use.

Dr. Giuliano:
Exactly. A high risk score on any of these tests would typically mean the patient gets adjuvant chemotherapy. Adjuvant chemotherapy is you've had your operation, it looks like all the cancer is gone, but we know that a cancer can come back. If there are cells somewhere in the body circulating or lodging in your big toe or your liver, we give the patient chemotherapy right after the operation, that's adjuvant chemotherapy. A high risk on the tumor genes means chemotherapy should be given and will be helpful. A low risk score for an positive cancer, it means the patient should get an anti-hormone. A big difference between MammaPrint and Oncotype is you can do MammaPrint on triple negative breast cancers. Most of them are high risk, but there's the occasional one that's not.

Dr. Aliabadi:
I was told that also for MammaPrint, you want to have positive nodes and when you don't, you do Oncotype. Is that true or is it false?

Dr. Giuliano:
You can do for positive nodes now on both.

Mary Alice:
What does positive nodes mean?

Dr. Giuliano:
That has spread to your lymph nodes.

Mary Alice:
Lymph nodes.

Dr. Giuliano:
Before these tests, anyone who had in the lymph nodes would get chemotherapy.

Mary Alice:
Oh, so now you can-

Dr. Giuliano:
Now, these tests have shown that an older woman with one or two positive lymph nodes doesn't need chemotherapy and won't benefit from chemotherapy. But a young woman, a premenopausal woman, a woman under 50 who has even one node would benefit from chemotherapy.

Mary Alice:
And that's because she has so much more estrogen and more... Is that the reason for that?

Dr. Giuliano:
Well, her tumor tends to be more aggressive.

Mary Alice:
Is that because she hasn't gone through menopause yet? What's the reason for that?

Dr. Giuliano:
Probably.

Mary Alice:
Probably. We don't know that.

Dr. Giuliano:
She's younger anyway.

Dr. Aliabadi:
My Oncotype was 11.

Dr. Giuliano:
That's very favorable.

Dr. Aliabadi:
Is it below 15 that's favorable?

Dr. Giuliano:
Below 15 is favorable, correct.

Dr. Aliabadi:
And above 25 is not favorable.

Dr. Giuliano:
Right. Young women between 15 and 25, it's debatable. Other features may be taken into consideration.

Mary Alice:
If somebody doesn't have cancer at this point, but they have a high risk of breast cancer, do you have some tips that you can give women things they should be doing or do supplements work? I mean, is there anything that you would give to women that are high risk for breast cancer?

Dr. Giuliano:
Well, you can take an anti-hormone. If you're a young woman at high enough risk, you can take the drug tamoxifen. Tamoxifen was typically given for women as an adjuvant after their operation to prevent cancer recurrence, but it can be given to prevent breast cancer and it decreases the occurrence of breast cancer by about half. If your risk is 15%, you can knock it down to 7%. If you're an older woman, you can take an aromatase inhibitor, which is like tamoxifen, but for older women who don't have functioning ovaries. You can do chemo prevention, you can take the drug raloxifene. There are different drugs that affect hormone interaction with the cells.
You can do high-risk screening. That's a mammogram, six months later, an MRI because these work on different ways and you have different ways to detect the cancer. Six months later, a mammogram; six months later, an MRI. That's a typical follow-up for a young woman with a BRCA mutation. We say that you should do high-risk screening if the risk of breast cancer is over 20%. Insurance companies will pay for that. It's a valid, reasonable thing to do for women.

Mary Alice:
My grandmother died of breast cancer, but she was 83. My question to you is that's not considered really a family risk of breast cancer because she was so much older when she got breast cancer. Is that correct?

Dr. Giuliano:
Correct. The younger your relatives are, the greater your risk.

Dr. Aliabadi:
I like that calculator because you also have to include not only your family history, you have to include the density of your breast, your weight, your height, all of it.

Dr. Giuliano:
And especially atypical lesions. Well, if you have-

Dr. Aliabadi:
Increase it significantly.

Mary Alice:
And what is that? "An atypical."

Dr. Giuliano:
It means your cells aren't quite normal, but they're not abnormal enough to be cancer, they're a little strange. Women with atypia have an increased risk of breast cancer and that greatly increases your risk. As we heard, when you do the score, once you push that button for atypia, it shoots way up.

Dr. Aliabadi:
That was me. That's what I had. I didn't have cancer, but I had atypical cells in my breast. These are cells that look abnormal, but they don't look as abnormal as a cancer cell. My question to you, Dr. Giuliano, is very frequently patients come to my office because they don't know if they should have a lumpectomy or if they should have a double mastectomy. This is a very common question for women diagnosed with breast cancer. It's a tricky one because not only it's a personal decision. For me when it's an early stage and I have a young patient, like I said, I tend to be more aggressive on the most aggressive side of the spectrum. But as a breast cancer surgeon, when do you tell someone they need a lumpectomy versus when do you recommend a double mastectomy?

Mary Alice:
And can you tell us what a lumpectomy is?

Dr. Giuliano:
Okay.

Dr. Aliabadi:
Thank you.

Dr. Giuliano:
The first bilateral mastectomy, or double mastectomy is how patients refer to it, is the operation for prophylaxis prevention. We were talking about things you can do for prevention. That's the most effective prevention.

Mary Alice:
It's a double mastectomy?

Dr. Giuliano:
Correct. I've not had a patient who had bilateral mastectomies ever get a breast cancer.

Dr. Aliabadi:
Because you don't leave breast tissue behind.

Dr. Giuliano:
Maybe. Or I'm just lucky.

Dr. Aliabadi:
No, you're a great surgeon.

Dr. Giuliano:
The treatment for breast cancer can be unilateral mastectomy, bilateral mastectomy, or lumpectomy. And as she said, it's a-

Mary Alice:
What's a lumpectomy?

Dr. Giuliano:
A lumpectomy is where you remove the tumor but keep the breast. You remove the tumor, you want to get a little tissue around it and you keep the breast and the breast looks fairly normal when you do that. Patients who are concerned about how they look, how they feel, their sexuality, will very often want a lumpectomy. The cure rate or the survival is the same as bilateral mastectomy or unilateral mastectomy. But you can get another cancer.

Mary Alice:
Because you have breast tissue.

Dr. Giuliano:
You still have breasts.

Mary Alice:
Exactly.

Dr. Giuliano:
Exactly.

Mary Alice:
And that's why.

Dr. Aliabadi:
When do you decide to do lumpectomy? Single mastectomy or double mastectomy?

Dr. Giuliano:
Well, that's the patient's decision, isn't it? I mean, that's a very personal decision, a very difficult decision. Most young women who want a mastectomy will do the bilateral mastectomy. The advantage is basically symmetry of reconstruction and risk reduction. They're not likely to get a cancer on the other side if they have bilateral mastectomy. Many young women on the other hand want to keep their breasts. They want to keep sensation and they want to look normal. They'll choose the lumpectomy. Unilateral mastectomy is something that you might want to do for an older woman whose risk of a cancer on the other side is relatively low. But again, you have symmetry problems. Women are tending to choose bilateral mastectomy, we feel that it's overdone that they don't get sufficient benefit, but that get a lot of psychologic benefit. They feel better about themselves.

Dr. Aliabadi:
What about nipple sparing versus non nipple sparing? Meaning when you have a double mastectomy, you can choose to keep your nipples or you lose your nipples. I know when you do prophylactic mastectomy, meaning you don't have cancer, you want to prevent getting cancer, like in my case then you have the choice of keeping your nipples just because it looks better. But for someone who's diagnosed with breast cancer, do you always remove the nipple with a mastectomy or do you sometimes leave it behind?

Dr. Giuliano:
Great question. I prefer a nipple sparing mastectomy. The patients look virtually normal, you can hide the incision under the breast. They look like women who had augmentations. They look fantastic. The argument against that, we remove the nipple in the past because the ducts go right into the nipple. Obviously the ducks are where the milk comes out and ducts are where you get cancer. We always thought, "Well, if you leave the nipple, you will get cancer." Then in the late nineties, a paper came out looking at women who did prophylactic surgery and compare that to their sisters who didn't get prophylactic surgery. And they found that the women who had prophylactic surgery with preservation of the nipple did so much better than their sisters. They didn't get cancer and they didn't get in the nipple. It turns out that the ducts in the nipple are large ducts and cancer tends to start in small ducts, so you can leave the ducks in the nipple. The problem is if you come close to the nipple, it can die because you take its blood supply. Many surgeons leave a lot of breast tissue under the nipple and that can lead to problems in the future. I've seen patients who've gotten cancer after nipple sparing mastectomy because a lot of breast tissue is left.

Mary Alice:
Do you think that getting a augmentation gives you a higher risk of breast cancer? Does it do anything to have silicone versus... Women talk about that a lot. "Do I get it? Do I not get it?"

Dr. Giuliano:
Augmentation does not increase your risk of breast cancer. What it can do is if you get one of the complications called capsular contracture. Some women, the implant causes a lot of scar tissue around it and it sometimes gets like a rock. And when that happens, you can't get a good mammogram.

Mary Alice:
Right. It's the preventative.

Dr. Giuliano:
That's the problem. You can't detect it as well if there's capsular contracture, but it does not increase the risk.

Dr. Aliabadi:
I have to say, when you have a double mastectomy, you don't feel your nipples. There are institutions now that are doing nerve sparing mastectomies. Someone like me, when I did my double mastectomy, I just felt a tight band around my chest, I felt nothing else. Sometimes I would feel phantom pains, I would feel this itch in my breast, but it wasn't there. It's just a very weird-

Mary Alice:
Like a phantom limb. But a phantom-

Dr. Aliabadi:
Exactly. But I felt a tight band around my chest. I'm five years out, so the sensation is slowly coming back. But as you get close to my nipple, I still don't have sensation. That sensation, if we keep it's mostly because of the visual effects of it?

Mary Alice:
Well, which is psychological. I mean there's a lot that goes into that.

Dr. Giuliano:
You can look fairly normal. Really, it's tremendous aesthetic result. The nipple innervation, I'm not convinced works, but there are people who are putting the... Innervation nipple comes from your spine through the intercostal nerves. So it's a long run. They're putting nerve grafts and long nerve grafts usually don't work, so I'm not convinced. Not everyone can reproduce the nipple sensation.

Dr. Aliabadi:
Honestly, I'm really happy, I'm an easy patient, though. It's survival versus not having a nipple. So I'm so grateful for what I have. Like I said, the sensation comes back.
I don't know if you guys have heard of EMS, electric muscle stimulation, the suits you wear.

Mary Alice:
Yeah.

Dr. Aliabadi:
Three years ago I started doing that and I had honestly had no sensation. Someone needs to study this. As EMS stimulates your muscles, you wear this suit and basically it contracts your muscle 80 times in a second. You do it for 20 minutes and it's supposed to equal two to three hours of training with a trainer. But for me, I did that for six months and I felt like I was starting to get more and more sensation. That was one of my motivations for doing EMS. I don't know if it was the timing of it or if it was the EMS, but I really started feeling more after doing this. I don't know if there are any studies on that.

Dr. Giuliano:
Interesting. No, I'm not seeing any. But some women will actually describe that they get some sensation back in their nipple.

Dr. Aliabadi:
But I have not in the nipple, but up to the nipple. If you touch me before, I wouldn't feel it. Now. If you touch it, I can feel it, which is more than what I wanted.

Dr. Giuliano:
Interesting.

Mary Alice:
How long have you been in remission?

Dr. Aliabadi:
I did my surgery when I was 48 and a half, and I'm 53 now. Almost five years.

Mary Alice:
Can you tell us what remission versus complete remission is and is there a difference? Is that a dumb question?

Dr. Giuliano:
No, but my answer will sound very cynical. You're cured when you die of something else, aren't you?

Mary Alice:
That is true. That's the one concept that we know we are all going to die of something. It might be a bus, it might be cancer, it might be stupidity. We don't know.

Dr. Giuliano:
What's inherent in that statement is that problem with cancer is it can come back anytime, but most cancers would come back early. We used to say if you were free at five years, you were cured. But we know some cancers could come back late. I saw a woman whose cancer came back 35 years after a radical mastectomy. It's unusual, but it can happen. Triple negatives come back very quickly in the first year or two. ER positives, no.

Mary Alice:
Are you seeing breast cancer rise? It feels to me that it's bigger than it was 30 years ago or 20 years ago. If so, what do you think is the cause of that?

Dr. Giuliano:
Well, the rates increase greatly with the advent of mammography. More and more women who get screened, you find more and more early cancers. Recently there's been a slight dip in the incidence of breast cancer.

Mary Alice:
Why do you think that is?

Dr. Giuliano:
I don't know. I have no idea. We don't know what causes breast cancer. You can come up with the usual suspects, our diet-

Mary Alice:
Stress.

Dr. Giuliano:
... the air we breathe. We really don't know.

Mary Alice:
Thank you so much for joining us today on SHE MD. Dr. Giuliano had so much incredible information to share that we recorded another episode to dive deeper into the science behind treating breast cancer. Make sure you tune in for part two of our conversation with Dr. Giuliano. And don't forget to follow us on social media at SHE MD podcast and subscribe to our show on YouTube or wherever you get your podcast.