Measles re-emerges; caring for caregivers; preventive mastectomies: Upstate Medical University's HealthLink on Air for Sunday, Jan. 22, 2023
Pediatric infectious disease specialist Jana Shaw, MD, explains new concerns about measles. Social worker Lauren Angelone tells about her focus on caregivers. Breast surgeon Lisa Lai, MD, discusses when mastectomy may help reduce breast cancer risk.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a pediatric infectious disease specialist explains the concern behind measles.
Jana Shaw, MD: ... We have recently heard of outbreak in Ohio, which is not all that far, and there have been other outbreaks in the country in recent years. The risk of measles in our communities really depends on the level of vaccination coverage. ...
Host Amber Smith: ... A social worker tells about her focus on health care workers.
Lauren Angelone: ... Stress is not just inherently based on the role itself, but also the perception of that stress. ...
Host Amber Smith: And a breast surgeon discusses how mastectomy reduces cancer risk.
Lisa Lai, MD: ... If a patient does have a prophylactic mastectomy, they're probably looking at a 5% chance or less of having breast cancer. ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll talk to a social worker about caring for the caregivers. Then a breast surgeon explains why some women at high risk for breast cancer are choosing mastectomy. But first, some timely information about measles.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Measles was declared eliminated from the United States in the year 2000, thanks to better measles control, including a highly effective vaccination program. But today, measles outbreaks among children are being reported, and the presence of the disease is becoming more of a concern.
Here to talk about this is pediatric infectious disease specialist Dr. Jana Shaw. She's a professor of pediatrics and of public health and preventive medicine at Upstate.
Welcome back to "HealthLink on Air," Dr. Shaw.
Jana Shaw, MD: Thank you for having me, Amber.
Host Amber Smith: Do we in Central New York have reason to be concerned about measles right now?
Jana Shaw, MD: That's a great question. It's a timely question. As you mentioned, we have recently heard of outbreak in Ohio, which is not all that far, and there have been other outbreaks in the country in recent years. The risk of measles in our communities really depends on the level of vaccination coverage.
We have a very effective and very safe measles vaccine that's routinely given to children at young ages, and once children are fully vaccinated, the risk of measles is very, very, very small. So, in our communities, as long as we are surrounded by people who are fully vaccinated, the risk should be very low. The only way to establish how many children were truly vaccinated is really to look at records of vaccination. And those are typically available through schools.
As you know, measles vaccine is required for school entry, and schools keep careful records of all those children. So before we started with this talk, I took a quick look at some of the schools in the surrounding area because that's the easiest way to really inquire how at risk we might be when it comes to measles, and most of the major schools in our communities have children fully vaccinated, so that's great news.
Host Amber Smith: So that's great news. But if this disease was supposedly eliminated in 2000, why is it coming back?
Jana Shaw, MD: It is coming back because we, as Americans, we like to travel. We travel abroad. We go to places where measles continues to be transmitted, and those who are not vaccinated get infected and bring it back to our communities.
And unfortunately, we have seen a rise of vaccine hesitancy and vaccine refusal that not only affected COVID vaccines but also affected measles vaccines or other childhood vaccines. So we do see pockets of children who are not vaccinated. Those children are typically geographically clustered, meaning we see schools and communities where we see large numbers of children without measles vaccination. And those are communities where we will see outbreaks. Those travelers who came from abroad will bring the infection unknowingly and will transmit it to communities without pre-existing vaccine immunity.
Well, so what is important for us to know about measles? Measles is a very contagious virus. Humans are the only hosts. It is a virus that, typically, when we talk about the level of contagiousness, one infected person can easily infect up to 18 people around them who are not vaccinated. So one of the highest rates that we've seen is for measles.
It is a respiratory virus. So, nowadays everybody probably knows what that means, as we've gone through COVID. Similarly to COVID, this virus is transmitted through respiratory droplets, but it can also be transmitted via airborne mode of transmission, which means it carries through the air. It can stay in the air for a couple of hours, even if the infected person left the area. So it makes it a very challenging virus to contain because it infects a lot of people who are not immune and also transmits really easily.
Host Amber Smith: How long after someone is infected will they develop symptoms?
Jana Shaw, MD: So, there are two terms that we use. One of them is incubation period, essentially a period between exposure and development of symptoms. And for measles it can be anywhere from one to three weeks. So let's say you are exposed to someone with measles, you are not vaccinated. You can expect developing symptoms between one to three weeks.
Host Amber Smith: So that's a wide window where you could be infecting other people.
Jana Shaw, MD: Yes, absolutely. There is a slight difference between the incubation period, which is what I just described, and also your ability to transmit, which usually happens four days before the onset of rash, which is pretty characteristic and follows four days after the rash appearance. So there's probably eight days of a window, four days before you really have any symptoms, and four days after the rash onset where you are highly contagious.
Host Amber Smith: Now I've read that during this outbreak in Ohio, about a third, I think, of the children infected have been hospitalized. So it makes me wonder, how deadly is measles?
Jana Shaw, MD: Measles is a serious virus. And you know, before we had a safe and effective vaccine, essentially 3 million to 4 million people were diagnosed with measles every year, and the majority of them would be young children. And among those who were diagnosed, you know, as many as 10 out of 100 would develop ear infection. One in 100 or more could easily develop pneumonia, severe diarrhea, and many would end up hospitalized for those complications, including children who would end up in the hospital and subsequently die. About one in 1,000 children with measles will die from measles or will go on developing a very serious and debilitating neurological complication and infection known as encephalitis.
Host Amber Smith: And why is measles a special concern for pregnant women?
Jana Shaw, MD: Measles is a concern for pregnant women, mostly because pregnant women are vulnerable to infections in general. Influenza, for example, can be severe in pregnant women. COVID was more severe in pregnant women. Measles is more severe as well because the women during pregnancy, their body goes through number of changes. Measles is a respiratory virus, so pneumonias can be particularly challenging for women. And their immune system is also going through adjustments. So combination of those physiological changes along with the aggressiveness and severity of measles virus is particularly concerning for pregnant women. And the infection led to preterm birth, death in mothers and also complications, other complications, during pregnancy.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Jana Shaw. She's a pediatric infectious disease specialist at Upstate. And our topic today is the growing concern about measles.
Now, Dr. Shaw, can you explain how a measles vaccine was developed and what year it was first available in the U.S.?
Jana Shaw, MD: Of course, yes. So measles vaccine has been available in the U.S. since the early '60s. Initially, there was what we call monovalent measles vaccine, which means there was just measles with a single-component, vaccine. The virus was killed. But subsequently we have developed a safe and also effective vaccine that more resembled the live virus, known as a live attenuated (weakened) vaccine. The killed vaccine was replaced with this live attenuated vaccine.
The advantage of using that vaccine is that that vaccine more closely resembles the natural infection without causing the serious disease. So the live attenuated measles vaccine was used for an extended period of time, but over time, in order to ease the administration and provide a better coverage for other vaccine-preventable diseases such as mumps and rubella, which are other two common and serious infections in childhood, those vaccines were combined into one known as MMR -- measles, mumps and rubella vaccine. And later on, Merck (pharmaceutical company) was able to also add a varicella component to it, which is the chickenpox.
So we also have MMRV vaccine that is reserved for older children, mostly because there are just higher rates of fever following that vaccination. But currently there are two types of measles containing vaccine available in the U.S. One of them is MMR, and the other one is MMRV. Both are very effective, very safe.
Host Amber Smith: Now, childhood vaccination -- does that provide lifelong immunity?
Jana Shaw, MD: Childhood vaccination with two doses of the measles-containing vaccine will provide a lifelong protection. Correct.
Host Amber Smith: And if someone's parents did not get them vaccinated as a child, and they're an adult now, can they get vaccinated and get that lifelong immunity?
Jana Shaw, MD: Yes, they can. You know, any individual who thinks they are not immune to measles either because they have not received a vaccine, or they were born close to the period when measles stopped circulating and they were not vaccinated, they should check with their provider. They can have their titers (a blood test to check for immunity) checked, and if they're not immune, they should get vaccinated.
Host Amber Smith: If someone had measles and survived, do they then have protection from getting it again?
Jana Shaw, MD: Yes, they do. Natural infection itself is protective and provides lifelong protection as well.
Host Amber Smith: Well, I'd like to go over the symptoms of measles, the things that parents maybe should be on the lookout for. But fevers, coughs, runny noses, those are so common in children. Is there something that stands out about those symptoms for measles?
Jana Shaw, MD: For a person who has seen measles, it's pretty characteristic when you see a child with measles. I had the privilege to care for a child with measles when I was in medical school. So for me, I'll never, never forget that. There are some characteristic features that make measles stand out, such as the child has runny nose. Children are miserable. They have cough. They have characteristic pink eyes. And they have a rash that typically starts on top of the body, starts on the head, on the face, and spreads down throughout the body.
The rash is somewhat characteristic. It actually has a morbilliiform appearance, which means it's red, it's flat, but it can become bumpy. And, once you see the constellation of the symptoms along with understanding the tempo as those signs and symptoms develop, one cannot forget about measles.
Fever is a common symptom as well. On the other hand, there are a number of other infections that we see during childhood that can mimic or mask or look like measles, and those are times when it can be particularly challenging to diagnose measles or think of measles if one really is not tuned in to that condition. And because most providers nowadays have not seen measles, it's understandable that they will not think of it. So, a really, really important point for both parents and providers to remember: always check the vaccination status. If your child is not vaccinated, please remind the provider who's taking care of your child that your child has not received measles vaccine, so proper steps can be taken to take care of your child.
Host Amber Smith: Is there a specific treatment for a child who has measles, at home?
Jana Shaw, MD: We really don't have any specific therapy. We use what we call supportive care. So we help the children to get through the infection, especially those who end up seriously ill, end up in the hospital with pneumonia, severe diarrhea, let's say. We provide oxygen, fluids. Vitamin A has been used, particularly in developing countries where malnutrition is common, to assist in mitigation of some of the seriousness of measles infection. But it's really not much more one can do once children are infected and end up seriously ill.
Host Amber Smith: Well, I appreciate you making time for this interview and sharing this information, Dr. Shaw.
Jana Shaw, MD: Thank you, Amber. Thank you for having me.
Host Amber Smith: My guest has been pediatric infectious disease specialist Dr. Jana Shaw. She's a professor of pediatrics and of public health and preventive medicine at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Focusing care on health care workers -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air."
Even before the pandemic, wellness in the health care workforce was identified as important, but then the pandemic ratcheted up the pressures and stresses of the job in ways that maybe weren't anticipated.
Today, I'm talking about staff wellness with a social worker who recently joined Upstate. Her name is Lauren Angelone, and a big part of her job is caring for the caregivers.
Welcome to "HealthLink on Air," Ms. Angelone.
Lauren Angelone: Thank you for having me.
Host Amber Smith: Now, when we talk about wellness, what does that really mean?
Lauren Angelone: Wellness is an interaction between your personal needs and your environment at any given time.
It's intersectional. Wellness will vary depending on the person, their circumstances, their culture, their belief system, politics, morals, values, religion. So wellness is not just about any one dimension, it's a combination of actions in multiple dimensions. It's not just how you feel, think or say you're doing. It's about all of that and more.
And furthermore, when we look closely at the relationship between the individual and the workplace environment, we know it's not only intersectional, but it's also reciprocal, almost on a continuous loop. The work environment affects the individual and their well-being, and then the individual's well-being can affect productivity and organizational performance, and people feel anxious or depressed. Quality, pace and performance of their work tends to decline.
But truly, there are several domains of wellness, emotional, physical, social, financial, spiritual, environmental and professional. They're interdependent and influence each other. And when one dimension is out of balance, then the other dimensions are affected.
Host Amber Smith: It sounds like wellness is going to be different for each individual, though, because all of the things you listed matter to people to different degrees.
Lauren Angelone: Absolutely.
Host Amber Smith: So there are certain stressors that are unique to health care. I'm thinking about dealing with life/death situations, working odd hours or around the clock.
But people who are entering the profession, they already know that, and there's not really any way to change those things because that's medicine. That's the way it is.
So how do you, as a social worker, focus on staff wellness and deal with situations that create stress but are inherent?
Lauren Angelone: We focus on what is within the locus of control, and my priorities are creating a culture of wellness, normalizing and reducing the stigma that's associated with mental health. Building a team of support and promoting awareness of that support system. Allowing space to feel and share truths and really looking at policy and how that truly informs and impacts practice, not just in theory, but in reality.
A common vision and mission statement is a wonderful place to start, but where the rubber meets the road is what truly drives wellness.
Host Amber Smith: There's so many different jobs in health care. Is that going to be different depending on whether you are a surgeon or a lab technician or a nurse or a food service worker?
There's different aspects that you might have control of in those different jobs, right?
Lauren Angelone: Certainly, you know, each role carries varying job demands. And then, there may be nuances within those roles that could predispose an individual to a greater level of stress.
Research has noted that if there's a lack of job autonomy, employees are seemingly trapped by job demands or employees who work on extremely repetitive tasks are likely to experience high levels of stress. Research has also shown that role ambiguity, like lack of clarity, certainty or predictability one expects from a job, conflict and overload, they're all closely related to high intensity of individual stress and low work contentment, low trust and low self-worth.
Workplace stress is the harmful physical and emotional responses that can happen when there's a conflict between job demands on an employee and the amount of control that that employee has over meeting those demands. But when we understand stress as an intersection between environmental variables and how they're interpreted by the individual, you realize that stress is not just inherently based on the role itself, but also the perception of that stress. So, wellness is not just different for different jobs, it's different for individual perceptions.
Host Amber Smith: So the majority of the people that I know that are in health care, they got into the field because they genuinely want to help others.
Do you find, though, that a lot of those people have trouble helping themselves dealing with being able to manage stress?
Lauren Angelone: Well, personal wellness is something that we're all challenged by, but when I speak of that stigma, of mental health, how that plays out in the medical field is unique.
We take oaths to put patients first, and I think it creates this norm and value of setting aside yourself and your own personal wellness. And not only that, there's this culture in the medical world of relentless perseverance, often a desensitization of humanity, because how else can we cope with the volume of demand?
We can't fall apart because we're needed to do our jobs in the very next moment in the room down the hall. So, a challenge that I'm faced with: breaking down those barriers and normalizing the priority of taking care of yourself. It's kind of like when you're on an airplane and they're orienting you to take off and what happens in the event of an emergency, and you're instructed to put on your own (oxygen) mask before you're able to put on the mask of someone else.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Lauren Angelone. She's a social worker at Upstate, and her focus is on staff wellness.
Can you talk about some of the initiatives that hospitals and health care organizations have tried in recent years to help promote well-being and resilience in health care workers? Which have worked well?
Lauren Angelone: There seem to be some common themes, and I think we actually do a lot of it right here at Upstate. These practices include improving input, engaging front-line health care professionals to identify system issues and empowering them to develop and implement solutions. Here at Upstate, we call that "shared governance."
Also by increasing recognition, appreciating and rewarding employees for heroic or above-and-beyond acts that they do on a daily basis as part of their jobs. Here we have the Daisy Awards and Stars Recognition. Cultivating a sense of community, having peer support and mentorship. Here, we do that through the nurse residency program, where we take new nurses and support them for the first year of their career.
We have a clinician peer-support program. We have Schwartz rounds (a seminar on the personal aspects of health care), by offering robust professional development opportunities, offering training and education in mental health literacy, self-help, mindfulness skills. We have such a variety of things that increase resiliency that way. We have the Pathway to Wellness, which offers weekly and monthly events and activities.
We did a series of "writing for wellness" workshops. We have pet therapy (such as visits by dogs) for staff and patients. Mindful Tuesdays. We have The Well-being Index, which is a tool that helps you rate and monitor your own personal wellness level that you can take every month, and it connects you to appropriate resources based on your results.
And we're currently building a hotline for staff to call with any wellness concerns. And from there we will triage staff and provide them with appropriate resources.
Host Amber Smith: So it sounds like there's a huge variety, and they all sound kind of different, from rewards to just a range of things. So maybe what works for one person might not be helpful for another, but then there's something else that would help that person.
Lauren Angelone: Absolutely. It kind of goes back to that interdimensional framework of wellness. it's an individual path, but it connects with the environment. And so it's not a "one size fits all" approach. Different things work for different people.
Host Amber Smith: Does research show a correlation between salary and benefits, and job satisfaction?
In other words, would a pay increase make the job stress more bearable? And if it did, would it last?
Lauren Angelone: Certainly, higher-income earners across the board are more satisfied with their jobs, find more meaning in their work, and they're less likely to consider quitting than those in lower-income brackets. An effort/reward imbalance -- meaning combining high efforts at work and low rewards in terms of wages, promotion prospects, job security -- is associated with an increased risk of depressive disorders, but fair and competitive wages, although they're an essential component to wellness, it's just one factor that influences workers' job satisfaction. The relationship between income and career is complex and certainly raises increase work happiness, but it's only temporary, rather than creating a permanent sense of being valued at work.
Host Amber Smith: Now, during the pandemic, not just at Upstate, but across the country and the world, health care workers dealt with a lot of fear, especially in the early days, which really lasted for months. What techniques do you think worked best for getting workers through the worst of the pandemic?
Lauren Angelone: Well, certainly having positive outlets helped all of us get through those darkest times: Journal writing, exercise, counseling, connections, FaceTime.
But what I would say after speaking with people, what I would say helped our health care workers was transparency, support, flexibility from leadership, communication through daily briefings from our director, having adequate supplies, feeling supported by the community, feeling as though the community was rallying behind them, feeling valued and recognized. That helped.
Host Amber Smith: I'm curious whether social workers and others who are focused on staff wellness learned anything from the pandemic in terms of how to look at wellness or how to ensure a health care workforce that's happy and healthy?
Lauren Angelone: That's where we began to look at, look more closely at, wellness as being multidimensional and intersectional.
It's not just a personal crusade, one that you deal with on your own time, perhaps with a therapist, and then you check your baggage at the door. We've realized that the professional is personal and there is a mutual relationship, cost and benefit to establishing a culture of wellness. We realize the stigma associated with health care workers acknowledging mental health struggles and the need to break that stigma.
And we also realized that we simply don't have the resources to support staff entirely, which is essentially what led to the creation of my position.
Host Amber Smith: The U.S. surgeon general said the pandemic brought the relationship between work and well-being into clearer focus, not just for health care workers, but for workers in all jobs.
And he produced a workplace and mental health and well-being report, which I know you've reviewed. I wonder, do you take anything from that report for your role in caring for the caregivers?
Lauren Angelone: Absolutely. I took a lot from that article -- from that report, rather. It's saying that organizational leaders have to prioritize mental health in the workplace by addressing structural barriers to seeking help and decreasing that stigma around accessing mental health support in the workplace, encourages organizations to invest in workplace well-being, as well as local organizations and community development. And the suggestion that that can turn into the development of a happier and healthier, more productive workforce and contribute to the success and economic well-being of an organization.
But something in particular stood out to me. They conducted a national survey, and 84% of the respondents said that their workplace conditions had contributed to at least one mental health challenge, and that 81% of workers would be looking for workplaces that support mental health in the future.
So what I took from that report is that I'm not only needed, but I'm wanted.
Host Amber Smith: It sounds like this is important to workers. Well, thank you so much for making time for this interview, Ms. Angelone.
Lauren Angelone: Thank you again for having me, Amber. I appreciate it.
Host Amber Smith: My guest has been social worker Lauren Angelone from Upstate Medical University. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air," mastectomy reduces, but does not eliminate, breast cancer risk.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Women who are at a significantly increased risk of breast cancer sometimes elect to have their breasts removed in an operation called a prophylactic mastectomy.
Here to discuss how this is done is Dr. Lisa Lai. She's an assistant professor of surgery at Upstate, specializing in breast surgery.
Welcome back to "HealthLink on Air," Dr. Lai.
Lisa Lai, MD: Thank you, Amber. Thank you so much for having me back.
Host Amber Smith: The actor Angelina Jolie chose to have a prophylactic double mastectomy in 2013 after genetic screening revealed that she had a mutation of the BRCA gene, which significantly elevated her risk of developing breast cancer.
After that, did you notice an increase in the number of women who undergo genetic screening and seek out preventive surgery to have their breasts removed?
Lisa Lai, MD: Yes, I know she was very public about her case. And for women, I think that could be helpful.
In general, the trends of genetic testing have been on the rise.
More genes have been discovered. More companies have brought testing forward. I think, in general, people and physicians are more aware now. Her case helped women to put it into perspective, especially if they were thinking about their own family history or doing testing for themselves. But I think a public figure who had a result and did something about it, I think that could have been helpful for those types of patients.
Host Amber Smith: So, which women are the ones that genetic testing might be advisable for?
Lisa Lai, MD: Well, there's a really long list to determine exact criteria, but, generally speaking, those who have family history of certain cancers like ovarian cancer or breast cancer, especially if there's multiple relatives with breast cancer or at particularly young age, we refer to the NCCN (National Comprehensive Cancer Network) guidelines for testing, which are updated about every six months, and use dedicated genetic counselors to determine who's really eligible.
But generally speaking, those with family history of certain cancers may be eligible for testing even if they've never had cancer themselves.
Host Amber Smith: So we've heard about the BRCA, the BRCA genes, but there's others too, right?
Lisa Lai, MD: Yes. I think BRCA is most well known and carries the highest risk of breast cancer in a patient's lifetime. But there are other genes which can still have a relatively high estimated risk of breast cancer and are important to us. They may not have as hard guidelines for when to consider prophylactic surgery. Some of them are dependent on family history, and certainly the patient's personal preferences are considered very carefully, but some of those genes might be like PAL2B2 or CHEK2 or ATM. And the decision to have a prophylactic mastectomy in one of those circumstances is taken very carefully. They don't all necessarily need to have it, or we wouldn't necessarily recommend it for all, but it comes up in conversation.
Host Amber Smith: Well, I understand breast cancer in men is very rare, but are there men who have a significantly increased risk and would they be candidates for prophylactic mastectomy?
Lisa Lai, MD: These genes that increase risk of breast cancer can be found in women or men.
And when found in men, it does increase their lifetime risk of breast cancer higher than an average man. But their risk of developing a breast cancer is still quite low. An average American woman has a risk of about 12% in her lifetime. If you have a man with a BRCA gene, for example, his risk of having breast cancer is probably under 10% in his lifetime, so less than an average woman.
And for that reason, we don't always do the aggressive screening like with mammogram and MRIs in a man who has a breast cancer gene because the risk is still low. So we tend to, do more clinical exams, and not so much routine imaging, routine screening. And for that reason, if a man has a risk of less than 10% of having breast cancer in his lifetime, the prophylactic mastectomies would be excessive.
So we would think that the risk and everything that comes with having a prophylactic mastectomy would probably not be beneficial enough for a man.
Host Amber Smith: I was surprised that prophylactic mastectomy can lower breast cancer risk by 90%, but it doesn't guarantee that a person won't get breast cancer.
Can you explain why not?
Lisa Lai, MD: Yeah, that's a good question as well. And we always discuss this with patients. I would say that it lowers the risk by probably 90 to 95% so that if a patient does have a prophylactic mastectomy, they're probably looking at a 5% chance or less of having breast cancer. And that's because every breast cell is not removed with a surgery.
The breast tissue is mostly removed, but there's a careful plane of dissection that's done between the skin and the fat that needs to remain under the skin and the breast tissue. And it's a matter of trying to get as much as possible while not damaging the skin so that the patient can have good blood flow to the skin and heal well after surgery.
And there's probably a little bit of breast tissue that remains at the surrounding edges of the breast and maybe very scant amount that remains on the chest wall. And I don't know if that perfectly explains it, because there it could be other reasons that it develops down the line, like was there something microscopic there that wasn't known before surgery? But generally speaking, the majority of the breast is removed, but there's always that small chance.
Host Amber Smith: So if the majority of the breast is removed, and then the woman would not be having mammograms regularly because there's not tissue to do mammography with, how would a breast cancer be discovered in the future? If there were some stray cells, like under the collarbone or in the armpit, would it just be discovered by accident?
Lisa Lai, MD: These patients who are undergoing the surgery will usually continue following with us in our practice for at least a yearly exam.
And they may also follow with their regular doctors in GYN (gynecology), too, so clinical exam is still recommended and performed, and if any lump or difference is noted, imaging can be done. We'd never do a mammogram because there's no tissue to compress, but an ultrasound or an MRI could be done to investigate.
Most times we do that, we find scar tissue and postoperative changes. Now, rarely, in some cases we will kind of make an individualized screening protocol of someone after prophylactic mastectomy. So either for something in our judgment that we think warrants an annual MRI (magnetic resonance imaging scan) or a patient who would feel reassured by having an annual MRI, we'll do that sometimes for screening purposes, or an annual ultrasound (another type of imaging test).
And if they've had implant-based reconstruction, we will check the implants every few years with imaging to make sure the implants are still intact, and that allows them some additional imaging.
Host Amber Smith: Are there good alternatives for women who are at significant risk of breast cancer but who don't want to have their breast removed??
Lisa Lai, MD: Yes, absolutely. So, here at Upstate we have a high-risk program that is helping patients follow for clinical exams and imaging, patients who are either not ready for surgery or not eligible for surgery or just not interested in surgery.
Generally speaking, the women we want to capture for a surgery like this are probably between the ages of, I'll say, roughly 30 to 60. Obviously, if you're doing the surgery on much younger patients, they're probably having the surgery too soon in life. They're not at a very high risk at that point.
And then the converse is true. If you're doing this on a 70- or 80-year-old patient, they're clearly going to get less benefit because they have a shorter life span. So, if it's for that reason, or they're just generally not interested, or it's just not good timing in life, we'll recommend a very careful screening protocol, usually mammogram plus MRI each year for imaging and then clinical exams.
For some genetic variants, removing the ovaries may reduce risk, and, similarly, lowering estrogen may reduce risk. Some of these genes are associated with estrogen-fed type tumors, and if you lower the amount of estrogen, you can also reduce their risk of breast cancer somewhat, not as much as surgery, but to some degree.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Lisa Lai. She's a breast surgeon at Upstate.
Now, how do you help your patients prepare for prophylactic mastectomy? Are there tests or imaging scans that are done before surgery?
Lisa Lai, MD: Yes, we'll do a clinical exam. Usually a mammogram and an MRI, maybe an ultrasound if we're looking for something specific, with the goal of making sure the tissue looks as normal as possible prior to surgery. Because if there is an abnormality, if there's a cancer, for example, we want to plan the surgery a little bit differently, in that we would do a lymph node biopsy in a breast with cancer.
But if we think it's a healthy breast, we usually will not do the lymph node biopsy at the time of surgery because it adds a lot of surgical recovery and benefits very few people. That being said, the breast tissue is always looked at by the pathologist once it's removed, but if there is an abnormality, it's always ideal to know about it before surgery and plan accordingly.
Host Amber Smith: Can you describe how the operation is done and how much tissue is removed?
Lisa Lai, MD: There's a couple different ways to do it. Usually when planning a mastectomy, the first thing we plan for is whether or not the patient wishes to have reconstruction, and if they are having reconstruction, how is that being performed?
And also timing of the reconstruction. Is it being done at the time of mastectomy? Is it desired, but not with the mastectomy, maybe desired a few years later for a particular reason?
So I would say that's the starting point, and based on whether they have reconstruction, we plan the incisions and whether skin and nipple are being saved for a reconstruction, or skin and nipple need to be removed because the desire is for the chest to be flat afterwards. So based on that conversation, we usually then start talking about what we think the scars will look like and how the surgical approach would be.
Host Amber Smith: So the patient really has to have a game plan for what they want to do longer term before you start the surgery.
Lisa Lai, MD: Right, yes. Like whether we need a plastic surgeon to be there or not. And, how we plan the incisions and closure. Now, they may not know that at the first meeting, so we can plan for a consult. They can gather more information, then we can meet again to confirm the plan prior.
Host Amber Smith: Do you typically remove muscle along with the tissue?
Lisa Lai, MD: No, we save the muscle. We remove just the outer lining of the muscle, called the fascia, but all the muscle is saved.
Host Amber Smith: And in prophylactic cases where there's no breast cancer apparent at this point, do you remove lymph nodes?
Lisa Lai, MD: Usually not. If we think that the breast is healthy and normal and there's no abnormality on our exam or imaging pre-op, then we will not remove lymph nodes because the chance of finding cancer is so low.
That would just add a lot of extra surgery and probably little benefit.
Host Amber Smith: Now, what is recovery from mastectomy like, and is it different for women who have a cancer diagnosis and have mastectomy compared with those who are doing it proactively?
Lisa Lai, MD: Having the surgery for cancer recovery could be a little more involved because of the lymph node surgery under the armpits, but it generally involves having drains for a couple weeks and coming to the office weekly and not being overly physically active.
In the beginning we were just wanting everything to heal inside, but then gradually increasing activity. Showering usually can happen a few days later, driving a few days later. once the drains come out, after, you know, maybe three weeks or so, then mobility usually increases, pain decreases, and they can slowly start getting back to usual activities.
Host Amber Smith: What are the drains used for? What are they collecting?
Lisa Lai, MD: The body will naturally put fluid into that empty space where the breast used to be, so the drains are helping that fluid get out, so it doesn't build up, and encouraging the skin to stick down and close the empty space.
Host Amber Smith: And then it's just a kind of a gradual ability to get back to your normal physical activities?
Lisa Lai, MD: Yeah, I mean, the really strenuous stuff, we might wait a couple months like for, you know, really heavy upper-body weightlifting and things like that. But, you know, in terms of household activities or return to work, I would say probably within four to six weeks, but there's always exceptions, too.
Host Amber Smith: Are you aware of any studies that show how women feel about their decision, say, 10 years afterward, whether they're glad that they had the operation?
Lisa Lai, MD: Now, I don't know about exactly the 10-year mark, but generally what the studies have shown is that patients are happy with their own decisions.
So, if they were strongly pushed in one direction, versus came to the conclusion themselves and proactively asked for a surgery like this, I think they're generally happy.
The thing about this type of surgery is that patients have plenty of time to think about it, so they can. Rather than having cancer, which can happen at any time, these patients have the chance to get multiple consults if they want, or to really, thoroughly research things if they want, or time the surgery for when it seems right in their life or for the right season because obviously no one wants to really put their brakes on in life to do something like this. So there's never really a great time.
But, I think these patients are generally very happy. And again, most of them came to attention for something like this because of their relatives having cancer. And I think they can refer to those experiences that they've seen their loved ones go through to be able to see how they really want to avoid that as much as possible.
And I think to be able to sign up for an elective surgery like this, go through it and get results back that there was no cancer and go on with life, I think that's very reassuring to them.
Host Amber Smith: Let's talk about reconstruction. How do you help a woman decide if she wants breast reconstruction?
Lisa Lai, MD: I'll usually discuss an overview and about the different types of reconstruction and also the timing, like will it be done at the time of the mastectomy, or is it desired later on? And, if there's any glaring concerns, like someone who medically may not be a good candidate, or any other reason, I'll help them.
Generally, I'm very open about referring to a plastic surgeon and gathering information with either good online resources or handouts, pictures, actual patient photos and just generally explaining the options while also guiding them to whoever else they may need.
Host Amber Smith: Do you have patients who are OK with having a flat chest or who prefer a prosthesis instead of reconstruction?
Lisa Lai, MD: Oh, yeah, absolutely. There's a term called "aesthetic flat closure," where the chest is closed nice and flat, without excess skin, avoiding any kind of loose or extra tissue that could be there, so closing it very carefully. And, some really great advocacy groups for that, patient-led groups who've gone through the surgery and chose to have a flat chest. You see them in the media sometimes. They sometimes have fashion shows, and these are women that are very proud to be flat and will very openly share that with others. That group of patients, to me, seems incredibly happy with their decisions, so I think it's a good choice for some, but it's a very specific group of women who felt that desire.
Host Amber Smith: Well, this has been very informative. I appreciate you making time for this interview, Dr. Lai.
Lisa Lai, MD: Oh, thank you so much, Amber. It was my pleasure.
Host Amber Smith: My guest has been Dr. Lisa Lai. She's an assistant professor of surgery at Upstate, specializing in breast surgery. I'm Amber Smith for Upstate's "HealthLink on Air."
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Sharon Pretti is a poet, a teacher and a medical social worker. She gave us two poems that speak to each other. They craft a portrait of a family's strength and love through even the hardest times. First is "Lunch at Sea Level":
My mother sliced her dill into quarters,
forked the rust-edge of an iceberg leaf,
a tower of fries between us. Our talk
didn't stop; fence rot, her leg cramps,
the ghost click persisting under my hood,
then a poem she told me she'd read
in her life-long learning class,
the circle sparring over which word
sang: rock or stone.
Did I mention it was my birthday?
Whorls of gift bag glitter, turquoise tissue
escaping skyward? This piling of decades
and I couldn't say: my brother, your son's chemo is failing.
I spoke about the cliff-side cypress instead,
the red-tails spiraling above them.
She ooohed over the lupine unleashed
below and told me the class chose stone
for how it descends at the end of a line.
The waitress wiped our table clear
of crumbs. And no, there was nothing
more we wanted. We knew better,
but didn't soften, our grief guarded
and me motioning to the wind-topped waves,
how they seemed to ride in from nowhere,
how they swept against rock, fractured like light,
how none of the breaking stopped.
Her second poem is called "Weekend at Rush Ranch":
A grove of oaks to shade us, our feet
propped on a paddock holding the biggest
horse we'd ever seen, daylight pouring
over its flanks, its withers and forelock.
The neck, we wanted our hands there,
the shiver and sway of all things possible.
Dust clouds rose when we walked,
my brother's back to me, a narrowness
that was new, his shoulder blades jutting
like windows cranked into the heat-drunk day.
Fields of needle grass beyond the fence,
bent, then upright. A progression, he told me,
the cancer beetle-burrowing into his spine.
All those summers and we never learned
to ride, never mastered the tension and release
of reins, the weight shifts signaling a beast
toward speed or stillness. How does the body
know when to stop?
Lucky horse, my brother said. braided mane,
a diamond crest. We had to tilt our heads
to meet its eye, that amber globe, its center
flecked with our reflection. What could
this creature know of us? The storm inside
each breath? Our wildness?
We wanted a miracle: limb, cell, bone, lymph. All of it.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," more children are recovering from irritable bowel diseases.
If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.