This interview has been conducted in partnership with the National Breast Cancer Foundation (NBCF). Recognized as one of the leading breast cancer organizations in the world, NBCF is Helping Women Now® by providing early detection, education, and support services to those affected by breast cancer. A recipient of Charity Navigator's highest 4-star rating for 14 years, NBCF provides support through their National Mammography Program, Patient Navigation, breast health education, and patient support programs. For more information, please visit https://www.nationalbreastcancer.org/

Oncology Data Advisor: Welcome to Oncology Data Advisor. In this interview, Lillie Shockney, Professor of Surgery at Johns Hopkins University, will be discussing the surgical treatment of patients with breast cancer. Thank you for joining us.

Lillie Shockney, RN, BS, MAS, HON-ONN-CG: Thanks for having me.

Oncology Data Advisor: What are the types of surgeries that are done today to treat breast cancer?

Lillie Shockney: One of the most common surgeries is lumpectomy, which is the removal of the tumor with a healthy margin of tissue around it, so we have some degree of insurance that we've gotten all of the tumor out. The other is doing a mastectomy, which is the removal of the breast tissue. Sometimes it is done removing most of the skin as well; but more and more today, when mastectomies are done, they are also done with breast reconstruction. This means that if the tumor is far enough away from the skin of the breast and far enough away from the nipple and the areola—the space underneath of those structures—then the surgeon can literally hollow out the breast and then fill it with something healthy, with the help of a plastic surgeon or a breast reconstruction surgeon. That could be an implant, or that could be fatty tissue from elsewhere in her body.

Tummy fat is the most popular when it comes to autologous tissue transfer. Buttocks fat is second most popular, and then inner thigh fat is also popular. The body does not reject having this fat transferred from those locations to fill where the breast tissue was because it is the body's own tissue. More times than I can count, I've had strangers call me and say, "My neighbor has breast cancer. She's coming into Johns Hopkins. She told me she's going to have a mastectomy. She would like to do flap reconstruction. I would like to donate my abdominal fat to her." And I have to say, "Well, thank you very much, but no, you can't do that because it has to be her DNA." The only time we can use someone else's is if she has an identical twin and we have transferred her body fat and put it in her identical twin sister who was having a mastectomy with fat reconstruction.

The original form of fat reconstruction was called transverse rectus abdominis myocutaneous (TRAM) flap. This would take out not just the abdominal fat but also the muscle of the abdomen and the blood supply, severing it and tunneling it up to then land up on her chest. That was good for a starter, shall we say. However, if women are still getting that procedure—which I consider to be very old-fashioned now—they should be told that they cannot lift more than 20 pounds for the rest of their lives because they don't have abdominal muscles to prevent herniation. Within a year, approximately 20% of women do have an abdominal hernia from having forgotten and lifted something. Twenty pounds isn't that much; it's a toddler. She picked up her grandson. Why would we want to take that away from her?

At Johns Hopkins, we started doing these in 1997, but they actually began in Brussels, Belgium. In case you're on Jeopardy! tonight and they have a breast reconstruction column, you'll have the answers to this. The newer, and we think better, method of doing it is called a deep inferior epigastric perforator (DIEP) flap, where we take the abdominal fat but no muscle. The muscle is not taken at all, nor is that blood supply severed either. What we do instead is that we cut the abdominal fat free from her body and use tiny perforator vessels which are the size of pencil lead. Picture how tiny that is. We connect those to the perforators that are resting on her chest wall where her breast tissue was removed. Now she has this hollowed out breast skin, and they reconnect them, which is amazing to be able to stitch around something that's just two millimeters in diameter. That provides the blood supply very quickly, and within literally a matter of days, that newly created breast with those tiny little perforators starts growing more perforators on its own, very quickly. It results in a free tummy tuck; any tummy fat that they didn't need is tossed, and she does not have lifting restrictions because her muscles are still intact.

I think that's pretty super. I've had that procedure done, and it was one of the best things I ever did for myself. It was done 10 years after my second mastectomy, when I was medically cleared to be able to do reconstruction. I like to say it was one of the best decisions I ever made for myself. I would do it again in a heartbeat. I think if more women were aware of what mastectomy with reconstruction looked like, they would fear this disease less. We still have grandmothers and great-grandmothers out there who had the total radical mastectomy done in their youth, which was a very debilitating operation. We removed the entire breast and the skin up to the clavicle. We also removed both chest muscles. Some women also had ribs removed. They removed all of the lymph nodes under her arm right down to her lung—not unusual to also remove them part of the way down her arm.

So 100% of these women got lymphedema. This arm wasn't going to function anymore because of not having an intact lymphatic system. We had to take skin from her back to close her chest wound. It was unbelievable. I was a student nurse when we were still doing these 50 years ago. It was horrific. As long as there are women alive today that have seen that image, then we're still going to have women that are going to fear this disease. They're going to assume they're going to look like their grandmother or their great-grandmother, when that's not the case anymore, thank heavens.

Oncology Data Advisor: Why are lymph nodes usually sampled when breast cancer surgery is done?

Lillie Shockney: When we're doing surgery, whether that be a lumpectomy or mastectomy, we need to know whether or not the cancer has traveled beyond the breast. It uses 2 ways to get there. One is the lymphatic system traveling through the lymph nodes. The other is the bloodstream traveling through the vascular system. One of the things that the breast pathologist is going to be paying attention to in the biopsy specimen and also in the surgical specimen is whether or not there was any lymphatic invasion or vascular invasion. Did he or she actually see, in the tumor itself, a sign that there were lymphatic vessels present? Were blood vessels present? Oftentimes there are. We need to see how far this breast cancer got. Though an ultrasound may have been done of the armpit area to take a look at her lymph nodes before her surgery, we can't see disease that is microscopic. Only a pathologist can by using that powerful microscope.

Whether it be lumpectomy or mastectomy for invasive disease, the breast is injected with either a radioactive isotope or a special blue dye. In some cases, the surgeon will prefer to use both. They wait to see what happens when the blue dye travels from the breast where that tumor was, to the lymph nodes, or when that radioactive isotope travels from that breast tumor up to the lymph nodes. In the operating room, the surgeon uses a Geiger counter and holds it up to the armpit. When the first node beeps, that is the sentinel node, also known as the guard node. That's also the first node that's going to turn blue, if the surgeon chose to use the blue dye.

That node is removed because if cancer were to have traveled to the lymphatic system, it's got to go through that node first. Now, we've been doing sentinel node biopsies since about 1995 or 1996. Prior to that, we still were removing all of the lymph nodes because we didn't know which one it went to first. This is wonderful news for women. It's because of women who participated in those clinical trials of having a node removed compared to all their nodes removed, that we're able to do this today. It dramatically reduces the risk of getting lymphedema. Dramatically.

If we don't see any cancer in that sentinel node, we can feel relatively sure that this cancer has not spread from the breast onto other organs. It's a little trickier though to figure out if it used the bloodstream. We're not sure. If we see that it had vascular invasion in the tumor itself, in that breast, we're going to worry about that some. That's going to up the odds of a doctor saying, "I want to do more treatment. I probably do want to do chemotherapy. I may also want to do hormonal therapy and other systemic therapies to treat the entire body, just in case some rogue cells traveled somewhere and set up a little home in her bones, in her liver, in her lungs, the most common areas where breast cancer will spread."

Oncology Data Advisor: What is a prophylactic mastectomy? When is this procedure recommended?

Lillie Shockney: Prophylactic mastectomy, also known as a preventative mastectomy, is the removal of the breast. Most of the time today, it will be done as a skin-sparing mastectomy, keeping all of the outer skin of the breast, also saving the nipple and areola and then filling it with something healthy. This is usually done when we learn that a patient does not have breast cancer but does carry a breast cancer gene mutation and therefore has a considerably high risk of developing breast cancer in her future. We also do preventative mastectomies of the opposite breast at the request of a patient. A patient may say, "I know my breast cancer is only in my left breast, but I also want to have the right breast have a mastectomy, as well." She may want to do that because she wants to ensure symmetry so they match.

She may want to do it because she never wants to get a mammogram again, because she's frightened of post-traumatic stress disorder (PTSD), which certainly does happen. There's a fear factor when you've had breast cancer once, and now you're going to go back in that mammography room. Anxiety is too much for some women to want to deal with for the next few decades. Other times, it is because the patient had a biopsy done on her breast and it did not show breast cancer, but it showed atypical cells, cells that are one stage away from becoming non-invasive breast cancer, and even a further stage before it becomes invasive breast cancer. If women say, "I don't want to deal with chronically having biopsies and chronically having mammograms done several times a year. This is just more than I can deal with," then we will also discuss with her if she wants to do preventative prophylactic mastectomies. I always want to make sure that the patient is doing this for the right reason, for an accurate reason.

I'll give you an example. A patient may be needing to do a mastectomy because the tumor is pretty big. To do a lumpectomy, she would have such a small amount of breast tissue left. It would be a very distorted looking breast. She would not be happy with the way this looks. Sometimes women will say, "I want my other breast off too." Or "You told me I'm going to have a lumpectomy because this is a small tumor, but I want a mastectomy. I say, "Okay, tell me why you want this." She says, "because I don't want chemotherapy." Oops, that's not the trade. If she needs a mastectomy, it's because of the tumor size or having multiple breast cancers in that breast. It has nothing to do with needing systemic treatment for her cancer.

I give them an analogy of a dandelion in their front yard. We can dig up the dandelion and dig up the root system with some healthy soil around it. That's a lumpectomy. We can dig up the whole front yard to get rid of that dandelion. That's a mastectomy. Whether any seeds blew away from that dandelion and landed in your backyard determines whether or not we think you need weed killer for your lawn. That's going to be chemotherapy. It would be terrible to do such surgery and then have a patient to say later, "Well, I'm not getting chemotherapy because I did a mastectomy." You've got to make sure that their reasoning for wanting to pursue mastectomy is based on something that makes sense and not something inaccurate or assumed, or there's going to be tremendous disappointment later which is impossible to correct.

About Lillie Shockney

Lillie Shockney, RN, BS, MAS, HON-ONN-CG: her name is well known in the cancer field, especially in navigation, survivorship, patient-centered care, preservation of quality of life, end-of-life planning and care, and improving the cancer patient's experience and clinical outcomes. She clinically specializes in breast cancer care. Her public speaking, literary work, and notable roles over the last 40+ years are well known to many:

•University Distinguished Service Professor of Breast Cancer (2016-present)

•Former Administrative Director, Johns Hopkins Breast Center (1997-2018)

•Former Director, Johns Hopkins Cancer Survivorship Programs (2011-2018)

•Professor of Surgery, Johns Hopkins University School of Medicine (2016-present)

•Co-developer and medical advisory of Work Stride: Johns Hopkins Managing Cancer at Work

Program (2012-present)

•Co-founder, Academy of Oncology Nurse Navigators (AONN+) (2009-present)

•Former Program Director of AONN+ (2009-2019)

•Editor-in-chief of the Journal of Oncology Navigation and Survivorship (2012-present)

•Author of 20 books and >350 articles on various cancer topics

•National and international public speaker (1997-present)

A two-time breast cancer survivor, originally diagnosed in her 30s, Lillie has worked tirelessly to improve the care of breast cancer patients around the world. She has worked at Johns Hopkins since 1983. Lillie takes great pride in the AONN+, which as of April 2020, has more than 8,900 members. She has served as a consultant for breast cancer for national ABC News and Good Morning America and has been also consulted regularly by the Today Show and CNN. Lillie serves on 28 medical advisory boards currently. In 2008, the President of The Johns Hopkins University and their Board of Trustees appointed her to a Distinguished Service Faculty Chair. This is the first and only time in the history of the institution that a hospital nurse has been appointed to a distinguished service designation. She continued to climb the academic ladder and in 2016 was promoted to full professor. She is the only nurse at Johns Hopkins to have a primary faculty appointment in the School of Medicine and the only nurse in the country to have reached the highest academic faculty ranking and be appointed to a faculty chair as a University Distinguished Service Professor of Breast Cancer at Johns Hopkins University School of Medicine.

She has received 61 awards—54 national awards and 7 state awards, including being inducted into the Maryland Women Hall of Fame, Women in Business Healthcare Trailblazer Award, Johnson & Johnson's Most Amazing Nurse in America award, National Komen for the Cure's Professor of Survivorship award, and several national lifetime achievement awards. Her research area of focus is preservation of quality of life for patients with metastatic breast cancer. Currently, a documentary is being made about her life and her life's work. She tells people she never forgets where she came from—she will always be "a farmer's daughter."

Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.