Episode Transcript
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Speaker 1 (00:01):
It's now time for Centered On Help with Baptis Help
on use Radio. Wait forty WYJS.
Speaker 2 (00:07):
Now, here's doctor Jeff Tumbler.
Speaker 3 (00:12):
Good evening, everyone, and welcome to tonight's episode of Centered
On Health with Baptist Help here on News Radio eight
forty whas.
Speaker 2 (00:21):
I'm your host, doctor Jeff Tublin, and we're joined as.
Speaker 3 (00:23):
Always by our producer Mache and Send who is on
standby to take your calls for this call and show
to talk to tonight's guests who we are having as
a special guest tonight about breast cancer and breast cancer surgery.
Our phone number is five oh two, five seven one,
eight four eighty four if you want to call in
and be a part of the show. One in eight
(00:44):
women will develop breast cancer in their lifetime, and while
we want to advocate for prevention, there are times when
breast surgery is necessary and a skilled breast surgeon within
our community with who you want to trust. Press surgeons
deal with cancers of the breast as well as non
cancer related issues that we're going.
Speaker 2 (01:02):
To talk about tonight.
Speaker 3 (01:04):
And there's about one hundred and fifty thousand mastectomies and
about one hundred thousand reconstructions done in the US alone.
So tonight we have doctor Thomas Nole who's here to
talk to us about breast surgery and advances in breast surgery.
Doctor Nole recently joined the Baptist Health Floyd Breast Surgery program.
He specializes in breast health and treats a variety of conditions,
(01:26):
including cancer and non cancerost breast diseases. He is a
graduate of the University of Louisville School of Medicine and
residency at University of Missouri Health. In addition, he did
an interdisciplinary breast surgery fellowship at Yale University School of Medicine.
We're so fortunate to have him on the show tonight.
Welcome doctor Nol.
Speaker 1 (01:48):
Thank you, good evening. How are you.
Speaker 2 (01:50):
I'm great. How are you doing tonight?
Speaker 1 (01:53):
I'm doing well, excited to be here.
Speaker 3 (01:55):
Well, we're thrilled to have you, and we know that
you've recently joined our community. So tell us a little
bit about the practice that you've set up and where
you're where you're practicing.
Speaker 1 (02:08):
Oh yeah, So I'm over in New Albany, Indiana. Baptist
Floyd our clinic and hospitals over there, So I work
exclusively in New Albany Baptist Floyd. I do one hundred
percent breast surgery there. I started right at the start
of September. After finishing up my training, I moved back
(02:29):
home to the Kentuckyana area and have been kind of
getting my feet on the ground there and picking up steam.
Speaker 3 (02:35):
Now, well, that's only to our advantage, So we welcome you.
We're excited to hear about your expertise in this area
because of course it's such an important area and we're
going to cover a lot of information tonight, but just
so for our listeners to understand what's the general route
to get to do what you do, Why did you
(02:57):
pick this specialty, and what kind of training do you
have to have to do what you do.
Speaker 1 (03:03):
Yeah, So after college, a typical where I would be
medical school. Four years of medical school which is usually
two years of classroom work, and then two years of
clinical work and then after that a residency. So I
did a general surgery residency, which is five years in
training and all of general surgery. So it included breast surgery,
(03:23):
but also surgery of liver, gallbladder, stomach, kind of the
whole gamut, trauma surgery, and that gives you a really
good foundation of general surgical skills that I think, you know,
anyone doing surgery needs to have. There's a lot of
people who after that go out into the community and
they'll do general surgery and are able to do breast
surgery as well. But I knew that that was really
(03:45):
what I wanted to focus on, so I chose to
do an extra year of training, kind of a focused
fellowship on breast surgery. I interviewed. I think it ended
up being eighteen places across the country because during COVID,
so luckily they were all zooming or views. But I
really liked Eales program. The director, doctor Greenup was amazing,
and I think they really offered the most for the
(04:09):
kind of type of practice I wanted. I was able
to train in the big academic center in New Haven's,
but also I spent time in Bridgeport and Greenwich kind
of community practices, more private practice models, and I think
I was really able to see the gamut of how
to have a breast surgery practice, which is going to
be really valuable for me.
Speaker 3 (04:28):
Absolutely, was there something about specializing in breast surgery that
attracted you?
Speaker 1 (04:36):
I think going into medicine. I really tried to keep
my mind open. I was exposed very early to breast surgery,
even in high school. My dad is a plastic surgeon
and he focused primarily on breast reconstruction. So the first
case I ever scrubbed when I was fourteen was a
breast reconstruction case. But after college, I actually went to
(04:56):
graduate school and chemical engineering for a while and thought
I was going to do that, but I think the
draw of the OAR was too strong. I ended up
coming back and going to medical school, and during that
I really explored all different types of medicine. I really
was drawn to cancer care. I think it's very interdisciplinary,
so you get to work with a whole bunch of
(05:16):
different types of doctors and I think really make an
impact in people's lives. But over my time, I just
really liked being in the OAR, working with my hands
doing surgery. I think I have the mindset where I
like to see a problem and do something to fix
it right away, and that's very much surgery. You know,
you go find the problem and fix it or cut
it out. So I was drawn to that, and then
(05:40):
during my general surgery training, I still had not totally
decided on breast surgery. I was looking at all different
types of cancer surgery or other surgeries, but I really
liked how well the patients do. Getting this cancer diagnosis
can be devastating, scary, but we've advanced so much that
we're able to really do a good job treat patients
(06:01):
and they go on and live full lives afterwards with
really minimal effect after in a lot of cases. I
think that was really satisfying to me to see the
patients do so well after the surgery. I just wanted
to keep doing that after training.
Speaker 3 (06:17):
And we're gonna we're going to talk quite a bit
about what those surgeries are and sort of how how
you decide what surgeries to do. But coming off of October,
which is Breast Cancer Awareness Month, we need to talk
a little bit about before we get to you, which
is sort of the breast cancer screening, so that hopefully
we minimize that our need for you, but.
Speaker 2 (06:42):
That's still important. How are we doing from where you came.
Speaker 3 (06:45):
From and now that you're in Kentuckyana, what are you
seeing as far as how are we doing with our
screening for breast making.
Speaker 1 (06:53):
Yeah, screening is really the foundation, and I think The
reason patients do so well is because our screening is
so good, but we're able to catch if someone develops
the cancer, catch it really early on, treat it really
effectively before it develops into a bigger problem. I think
over time there's been kind of a bunch of different
groups that give guidelines for screening. My association as the
(07:18):
American Society of Breast Surgeons. Their recommendation is after age
forty women get annual screen mammograms, and then for people
who are higher risk, they can start at an earlier
age and sometimes do more frequent imaging or different modalities
such as them are wrong, but I think the screen
(07:38):
is incredibly important, and that's the big reason of why
we're able to have such good results because we catch
things early on. I've been really impressed in the two
months I've been at Baptist Floyd. The radiology department there
is awesome. I spent a lot of time going over
talking with them, looking at imaging. It's really that multidisciplinary
(07:59):
mode of care drew me to bread surgery in the
first place. Being able to really have colleagues and we
have each other's phone numbers and call and talk about cases,
and I think that really facilitates excellent care, you know.
Speaker 3 (08:13):
And it's so important, you know what you're saying about
the mammograms being yearly and then being at a place
that you trust, because part of the issue is probably comparing,
you know, one year to the next and looking for
these very subtle changes that can have major impacts on outcomes.
Speaker 2 (08:29):
When we find them earlier.
Speaker 3 (08:31):
But beyond the standard mamogram, what are some of the
other imaging techniques that are being used and why might
someone get like a different imaging test other than just the.
Speaker 1 (08:42):
MANA Beyond the mammogram, the most common other modality would
be ultrasounds. That's involves kind of sound waves that reflect
through the tissue and allow us to see within the
breast in a different way. The most common reason for
that is women who have denser breasts, so within the
(09:02):
breast there's a lot of fat, fatty tissue, but also
this glandular tissue that's involved in the production and delivery
of milk when a woman breastfeed and for younger women
or some women just at any age, that can be
a lot denser and it can be harder to see
through on mammogram, So ultrasound gives us an opportunity to
see through some of that denser tissue and screen for
(09:24):
issues beyond ultrasound. MRIs the other modality that usually takes
a little longer, and that can be if we've already
done a mamogram and ultrasound and there's still some question
we need another way to look. MRI is an option
or for our younger patients who are at high risk,
(09:44):
if they have some sort of genetic mutation that puts
them at a higher risk, or just their family family
history puts them at a higher risk, train with MRI
can be helpful.
Speaker 2 (09:55):
Absolutely well.
Speaker 3 (09:56):
We are talking tonight with doctor Thomas and all. We're
talking about advances in breadth cancer, breast cancer surgery, and
other conditions of the breast.
Speaker 2 (10:03):
We're going to take a short.
Speaker 3 (10:04):
Break and we're going to come back and start talking
about some of the surgeries that you do. Our phone
number is five oh two, five seven one, eight four
eighty four.
Speaker 2 (10:13):
It is like to call in and ask a question
of doctor Nol.
Speaker 3 (10:16):
This is News Radio eight forty w h as you're
listening to Center on Health, we'll be right back. I
(10:40):
want to welcome everybody back who's Centered on Health. With
Baptice Health here on news Radio eight forty whas. I'm
your host, doctor Jeff Publin, and we're talking tonight with
doctor Thomas Nole, who's a breast surgeon here in the
Kentuckyana area, who's talking to us tonight about breast surgery
advances both for breast cancer and other conditions of the breast.
(11:01):
Right before we took our break, we were talking about
the importance of screening and the different types of modalities,
and so you're just joining us. We emphasize the importance
of staying on top of all of those screenings. But
doctor Nole, talk to us a little bit about the
process from the point of view of how the patient
(11:24):
gets a diagnosis or comes to you. Do you usually
get them from a primary care that's found something on
one of these screenings. Do you often make the diagnosis?
When does the biopsy take place? Talk to us a
little bit about that process.
Speaker 1 (11:40):
So in a lot of cases, patients have already had
a biopsy when they make it to my clinic, our
radiology department, they really do a good job. If they
see something on the screen im the gene, they'll do
more imaging to really look at that spot and evaluate it,
which would be diagnostic imaging, and then if needed, biopsy.
(12:01):
Sometimes patients come to me before the biopsy as well,
and we can kind of go through imaging and talk
about that, but usually that biopsy is the next step
to really kind of get a true diagnosis of what
the issue is. That's something done by the radiologists using
either the ultrasound or mammogram for guidance to take place
a small needle in the area of concern and take
(12:23):
a little bit of tissue that our pathologists look at
and give us a diagnosis in either case. You know,
once the patient go go ahead, no, no, go ahead,
And once we have that diagnosis, then we can really
talk about options for treatments and you know what next
steps are.
Speaker 3 (12:44):
And speaking of kind of the options, you know, I
think most of us are familiar with a lot of
the terms that we hear oftentimes get associated with breast cancer,
but maybe we could just spend a few moments kind
of defining some of what these terms actually mean so
that when you talk to us about what you recommend,
(13:06):
we kind of understand them. So, for example, talk to
us about the difference between a lumpectomy and a mass them.
Speaker 1 (13:13):
To me, Yeah, certainly. A lumpectomy is when we remove
a lesion in the breast of concern and a little
bit of normal tissue around it, but we leave most
of the breast tissue in place and don't remove that.
With a lumpectomy, we remove that small amount test it,
make sure we have what we call negative margins, so
(13:35):
no issues extending to the edge of it we took out,
and that helps us ensure that we got everything we
need to and with that, a woman's able to keep
their breast. In a lot of cases, if it's a
small amount of tissue, there's very minimal cosmetic change, no
in terms of size or caught tour of the breast,
and I did a lot of work in terms of
(13:57):
issue rearrangement to really try to minimize any change and
fill in that little defect where we remove. On the
other side, a mast ectomy is removing almost all of
the breast tissue. I say almost all, because we can
never remove one hundred percent of anything, so there's always
a few cells left, but it's ninety nine percent of
(14:17):
breast tissue. In a lot of cases, we remove some
of the overlying skin, including the nipple, but we've found
that doing nipple sparing mass dectomies are safe and that
becomes an option for some women to preserve the nipple.
And with a mass ectomy, we can do that either
with or without reconstruction, which would mean bringing in a
(14:40):
plastic surgeon who would recreate the breast after tissues removed,
typically with some sort of saline or silicon I implant.
Without reconstruction, we remove some more skin and we can
do something called an aesthetic flat closure where we close
the skin flat again the chest wall for a nice
(15:02):
smooth closure. And then there are options of Proust thecs
women can wear or just forgo that.
Speaker 2 (15:09):
So speak.
Speaker 3 (15:11):
Going along, So with these sort of terms we hear,
we hear the term reconstructive surgery, and so is that
what you are kind of just referring to in terms
of bringing in the plastic surgeon, Like, how often when
you're doing your surgery do you bring.
Speaker 2 (15:25):
In a plastic surgeon at the same time?
Speaker 1 (15:28):
Mm hm. So in if a mass ectomy is being
done in a patient once reconstruction, I would always try
to bring in a plastic surgeon. You know, I think
I'm I'm pretty new here, so I think my number
of those cases is still pretty small. But in Fellowship
it was very common to do reconstruction with the mass ectomy,
(15:48):
and a lot of times it depends on women's personal choice.
Sometimes health can affect that it is more surgery for
material being placed in the body so high risk for
infection complications. So we always have to look at what's safest.
And my job as a cancer surgeon is always to
do a really good cancer operation, and that's always the
(16:12):
first priority, but not the only priority.
Speaker 3 (16:17):
And then in terms of kind of rounding out sort
of our understanding of the terminology, you know, we hear
a lot about lymph nodes and lymph node dissection and
sentinel node, Like, what.
Speaker 2 (16:31):
Is the role of the lymph node here?
Speaker 3 (16:32):
Why is that so important when you are evaluating the patient.
Speaker 1 (16:40):
So really I do two different types of surgery for cancer.
I do surgery on the breast and surgery on the
lymph nodes. A breast cancer starts in the breast, but
if it spreads elsewhere in the body, the most likely
first place it would go are the lymph nodes. These
are small glands that help drain fluid from all around
our body, but the breast primarily drains to lymph nodes
(17:01):
under the armpits in an area we call the axilla.
So anytime a woman has breast cancer, we always think
about should we sample some of those lymph nodes to
check if any cancer spread. So that would be a
sentinel lymph node biopsy and a study where we take
the first few lymph nodes that drain the breast and
(17:22):
check them for cancer. We're able to do that by
injecting two different types to die in the breast. One's
radioactive and one is blue, and we're able to trace
that down and find the first few lymphodes to evaluate.
Speaker 2 (17:37):
And go ahead.
Speaker 1 (17:40):
I think the one thing I'd say is lymph node
surgery is probably the place that's changed the most over
the last twenty years in breast surgery, and we found
in some cases women don't we don't have to do
that surgery to look at lymphodes. With older women over
seventy with very early stage breast cancer, we have really
good days that it's safe to omit that study and
(18:03):
avoid some of the potential morbidity of it. It's an
extra incision can cause pain, and also in the exilla
there are limp vessels that help drain the arms, there's
always some risk of disrupting those and potentially causing some
swelling of the art. So we're always very mindful to
if we're able to avoid doing unnecessary surgery, to not
(18:25):
do that.
Speaker 3 (18:27):
Absolutely, So speaking of that, and you know, as you
remind me, as you're educating us here, obviously your training
is geared towards being up on these advances. So as
a patient who might receive this diagnosis that obviously nobody
wants to receive, how do you recommend as they're kind
(18:49):
of processing this information, how do you recommend them evaluating
the type of surgeon they need to see. I mean,
as you mentioned earlier, general surgeons oftentimes do this type
of surgery. Like when they're sitting down and thinking about
finding somebody like you, how how do they find you?
Speaker 1 (19:08):
I think, you know, you can always look at surgeons
on the internet, but really talking to doctors you trust,
getting referrals is the best way. You know, talking to
other people who have had surgery surgeons they have had
good experiences with I think that's important. And then just
finding someone that you know, you get along with, you
(19:28):
know that you feel like understands you, hear's you, and
explains things in a way that makes sense. I think,
you know, there are a lot of general surgeons who
are excellent. My partner has general surgery training, he's been
doing breast surgery for eight years, is excellent. But I
think finding someone who has a true desire to focus
(19:49):
on breast surgery and a special interest in it is important.
Speaker 3 (19:55):
And you mentioned this earlier about and we said it
in the introductory or mark about you that you did
an interdisciplinary breast surgery fellowship. What does that mean and
why is that approach so important for a patient to.
Speaker 1 (20:09):
Have Because all cancer care is interdisciplinary. There's never one
modality to treat cancer. So I work with radiologists, pathologists,
medical oncologists to treat cancer with medicines that treat the
whole body, radiation oncologists who can treat local disease with
(20:30):
radiation therapy, and all those modalities are important and almost
everyone gets some combination of multiple therapies to get the
best result for their cancer. In my training in general surgery,
we spent five years essentially only doing surgery. There was
so much to learn and that's all we could spend
time on. But the real advantage of my fellowship was
(20:53):
I spent four months out of the year with people
who weren't surgeons, with the medical oncologists, the radiation on colleges, radiologists, pathologists,
and other people too. When the DEEMA specialist, genetic counselors,
high risk doctors, the plastic surgeons. I think that really
(21:14):
set me up well to understand the full gamut of
this multidisciplinary care and really be able to be a
lynchpin with all the different providers.
Speaker 3 (21:25):
You know, And I think that you know, what you're
saying is so important, and I hope people are you know,
are listening that you're you've embraced this interdisciplinary approach in
your practice, because one of the things we hear all
the time is that medicine be so siloed and one
part isn't really.
Speaker 2 (21:41):
Talking to the other, and it can be very confusing
for the patient.
Speaker 3 (21:45):
But to have this coordinated care, I would imagine not
only you know, makes the care better, but probably puts
the patient at ease knowing that all these things are
being done together.
Speaker 1 (21:59):
Certainly, and I think it's it's important that everyone in
the care team kind of understands everyone else's role and
has an idea what they do too, and that can
help us really streamline care and make sure we get
people appropriate referrals and get to the right place.
Speaker 3 (22:18):
Yeah, and we had a we've had a couple actually
nurse navigators on our show.
Speaker 2 (22:23):
One of them was a breast.
Speaker 3 (22:24):
Nurse navigator, and you know, her description of the role
in all of this really, you know, shed a light
to me on just how important having those resources are.
But we're going to take us another break here and
when we come back, we're going to talk about the
actual surgeries and the advancement that that.
Speaker 2 (22:41):
You're going to tell us about.
Speaker 3 (22:43):
So we are talking tonight with doctor Thomas Noel about
breast cancer surgery, advances in breast surgery. This is Centered
on Health with Baptist Health, News Radio eight forty WHAS
on doctor Jeff Helm.
Speaker 2 (22:54):
There's still time to call in and.
Speaker 3 (22:56):
Ask the question five oh two, five seven one, eight
four eighty four and we'll be here.
Speaker 1 (23:01):
Right after the break.
Speaker 3 (23:18):
Welcome back to Center It on Health with Baptist Health
here on news radio eight forty w h AS. I
am your host, doctor Jeff Publin, And if you're just
joining us or you've been sharing this hour with us,
we are talking with doctor Thomas Nole, who is a
breast surgeon with the Baptist Health Floyd Breast Surgery Program.
He's talking to it talking to us tonight about breast
(23:40):
cancer surgery and advances, and we.
Speaker 2 (23:42):
Appreciate all this information that you're giving us. Doctor Nol,
Welcome back.
Speaker 3 (23:47):
I have a bunch of things I want to ask
you about in terms of the surgeries, but I want
to pivot for just a second because one of the
things that's really exciting.
Speaker 2 (23:59):
Is when we have an advances in these surgeries, and.
Speaker 3 (24:02):
I want to have you talk to us a little
bit about wireless localization and what does that term mean
and why is it so important in what you do.
Speaker 1 (24:16):
Yeah, So when we do a lumpectomy removing just a
small part of the breast that has a concerning lesion,
but leave the rest, it's often difficult to find where
that issue is. Some tumors are palpable and very clear,
but in a lot of cases there's not a palpable
tumor and the tissue really doesn't look any different to
(24:36):
the naked eye normal breast tissue. It's really microscopic issues.
So the surgeon I need some way to help me
find that spot that I need to remove and make
sure that I get the correct part of tissue. Traditionally,
that was done with a wire. Before surgery, one would
go into the radiology suite and a wire would be
placed under imaging guidance into the lesion that was concerning,
(25:01):
and then in the operating room we would be able
to track down along that wire to the lesion and
use that to find the spot to remove. That's a
tried and true method, it works well, but there's been
a whole lot of new technologies that have come out
to put markers in the lesion that don't involve a
wire being placed a day of surgery or a wire
(25:21):
coming out of the breast at all. He's used a
variety of different methods to signal where it is, be
it radio frequency, magnetism, radioactivity. But in any case, there
are a small little biopsy clip or seed that can
be placed at any time before surgery up to a
(25:41):
month before and doesn't have anything extending out of the breast,
and that option gives us a lot more choice during
surgery on where to place incisions, allows us to zero
into the specimen, remove less tissue and more precisely, and
a lot of just makes the day a lot smoother
(26:03):
for a patient without all these different places to go
the day of surgery. And we're working on trial in
a few different technologies that Baptists fully define the best
one that works for us and hope to really incorporate
that into our practice soon.
Speaker 3 (26:19):
So by doing it the way you're describing in these
advantage do you feel like that does it get you
to the lesion easier or does it minimize kind of
other tissues that you don't have to disrupt in order
to find it?
Speaker 2 (26:32):
Like, what do you think that particular advantages are.
Speaker 1 (26:36):
I think the big advantages are in terms of getting
to the lesion. It allows us to place our incision
wherever is the best for our surgery, be that for
best cosmesis or closest to the lesion. When a wire
is placed, a lot of times we have to account
for where the wire enters the skin, and that kind
(26:58):
of helps or forces us into some incisions at some point.
Speaker 2 (27:01):
Got it.
Speaker 1 (27:02):
And also with these clips, I think it gives us
a more precise idea of exactly where that lesion is
and lets us take less tissue because with any lumpectomy,
we want to get the whole lesion and then a
rim of normal tissue. But in most cases the most
we need is two millimeters of normal tissue around the lesion.
We really don't need any extra. So being able to
(27:24):
know exactly where the lesion is would facilitate us taking
smaller specimens, causing less volume loss to the breast, and
having better cosmetic outcomes with equivalent of onco logic outcomes.
Speaker 3 (27:40):
And so you may be aware that before every show
like this, we run an ad that says what we're
talking about. And this is the first time I've gotten
this much feedback about what does oncoplastics mean? Because I
said it in the promo that that's what we're going
to talk about. So for all my colleagues and friends
(28:00):
that have talked to me all week about what is
ongo plastics, doctor nol, what is oncoplastics?
Speaker 1 (28:08):
So really the two words onco has to do with
treating cancer and plastics. If you think about plastic surgery,
has to do with the more aesthetic or cosmetic part.
And that's a really important part in breast surgery because
we realize that removing the cancer isn't the only thing
we're doing. That's always our first priority to do a
(28:30):
great cancer operation and really try to cure a woman
of cancer, but we don't want to do that in
a way that's disfiguring or causing lasting issues. So any
breast surgery we're thinking about how do we do the
best cancer operation possible but also have a great cosmetic
outcome in terms of oncoplastics. If we do a lumpectomy,
(28:52):
I often do some tissue rearrangement, move around a little
bit of breast tissue to fill in the defect where
I remove tissue, try to minimize any sort of volume
loss and maintain the normal or the natural contour of
the breast. And that's something that through my training has
really been incorporated in all aspects. We're always thinking about that.
Speaker 3 (29:17):
And are you able to do that at the point
of the original surgery. I mean, I'm thinking about, you know,
women having this surgery and then leaving and being you know,
not symmetrical on both sides, and are you able to
do this at the time of the original surgery.
Speaker 1 (29:40):
Everything I would do would be at the time of
the original surgery, So that's usually the best time to
do it. You know, with one operation, right after you
remove some tissue to do any sort of rearrangement you
need to do to minimize any sort of change. I
think after surgery, if there is still a significant cosmetic
(30:03):
defect that begins to get outside of my skill set,
it might require a plastic surgeon who can do kind
of more advanced reconstructive procedures.
Speaker 3 (30:18):
And how often we had this question sent in and
you know we don't want to not mention this.
Speaker 2 (30:25):
How often do you see men with breast cancer?
Speaker 3 (30:29):
I know you're early here, but in your training and
through Yale and everything, what is that some have you
had to operate on male breast cancer?
Speaker 1 (30:39):
I have over my year at Yale, thinking aback, I
think I had at least five men who had breast
cancer that I operated on. And it's certainly more rare,
but it is possible, and it can be a little
trickier because men aren't getting screened for it. So usually
it's kind of found either when there's something palpable or incidentally,
(31:02):
but certainly something that can occur men men to have
small amounts of breast tissue as well, certainly not as
much as a woman's with it. It's something that does
come up. The treatment is very much similar to how
we would treat a woe with breast cancer. There's really
no reason to treat it differently. We can still do
(31:25):
a mass dectimy, which functionally looks a little different, or
in some cases we can do a lumpect to me
to not remove as much tissue and create a conto
or change to a man's chest either.
Speaker 2 (31:39):
Well, I do want to pick your brain.
Speaker 3 (31:41):
A little bit about how the decision is made between.
Speaker 2 (31:45):
Lumpect to me and mass dect tomy.
Speaker 3 (31:47):
I mean, I'm sure these are very difficult choices sometimes
for a patient to think about.
Speaker 2 (31:52):
So we're going to.
Speaker 3 (31:53):
Talk about that when we come back, because we're going
to take our final break before we delve into that topic.
I want to remind everybody you are listening to Centered
on Health with Baptist Health here on news radio A
forty w h as. I'm your host, doctor Jeff Publin.
I want to remind everybody to download.
Speaker 2 (32:10):
The iHeartRadio app free. It's easy to use, and it'll
give you access to tonight's show and everything else the
app has to offer. You'll be right back.
Speaker 3 (32:35):
I want to welcome everyone back to Sundate on Health
with Baptist Health. Here on News Radio eight forty whas.
I'm your host, doctor Jeff Cubln. We're talking tonight with
doctor Thomas Noel who is at Baptist Health Floyd Prest
Surgery Program, who's one of our breast surgeons, and he's
been talking tonight about advances and surgery of the press. So,
(32:56):
doctor Nol, once a patient received the diagnosis and needs
surgery as part of their treatment plan, how is the
decision made about whether a lumpectomy is done or a
mass sectimy is done? Who makes that choice? Is that
something you present to them or the oncologists? How does that?
Speaker 2 (33:16):
How does that work?
Speaker 1 (33:20):
That's usually a discussion I have with the patients. The
first thing we have to do is assess if both
options are reasonable for the patient. So some patients, unfortunately
have large tumors or areas that need to be removed
where there really isn't going to be enough breast tissue
left after removing that for an acceptable cosmetic result, And
(33:43):
in those cases, lumpectomies just really aren't a good option
just because of the nature of the disease. In most cases,
we catch things so early that they're small and patients
are great candidates for lumpectomy. In any case, this is
one of the few areas in medicine where patients really
have a lot of personal choice in what surgery they have.
(34:06):
I always present mass dect tom and lumpect to me
to patients, and we talk about the benefits and downsides
of both. We did really a bunch of really large studies,
you know, decades ago that showed that the long term
outcome from mess dectomy or lumpectomy with breast radiation after
(34:28):
is equivalent. Women live the same amount of time after that,
so we know either operation is safe and doesn't offer
a big survival benefit between the two. So really it
kind of a lot of it comes down to personal choice.
Some women just never want to have to have a
mammogram again and really just want to proceed with a
(34:50):
mass dectomy, and that can be kind of an empowering
choice to treat. A lot of women don't want to
have a mass dectomy. They really want to preserve their
breast and we can we can that with a lumpectomy.
Speaker 3 (35:03):
But you mentioned something important, So when the lumpectomy is done,
there's other treatments that need to be done, whereas with
the mass sectomy.
Speaker 2 (35:11):
It's just surgery.
Speaker 3 (35:12):
Is that fairly a universal differential between those two things.
Speaker 1 (35:18):
In a lot of cases, you know, like everything in medicine,
there's no no absolute some cases, after a mass ectomy,
you know, women still need radiation to the chestwall or axilla.
But a lumpectomy for cancer in most cases comes with
breast radiation, which helps treat the rest of the breast
(35:39):
and prevent any recurrence in the tissue that remains. There's
some studies that show for women over seventy it can
be safe to emit radiation. In some cases, we do
that selectively in really ways of risks and benefits, but
a full traditional treatment with olympectomy would be some form
of breast radiation as well. Well.
Speaker 3 (36:01):
What is the what's the healing difference is between having
the full math dectamy and then them.
Speaker 1 (36:10):
That can be a big point of decision for patients too.
A lumpectomy is an outpatient surgery, so a woman will
come in the morning, not if we do surgery. She
goes home the same day, usually a store for a
couple of days, two or three days, but often back
on her feet pretty quickly. You know, if someone has
surgery on a Thursday, and they have a kind of
(36:32):
lower activity job. They could be back at work the
next week. Even in terms of post operative pain, a
lot of times women don't need narcotics, just tile and
all ice packs. Ibuprofen is really all they need. We
inject a lot of dumbing medicine as well. On the
other hand, maths ectomy it does require more recovery. Patients
(36:53):
are usually in the hospital overnight because we're removing so
much more tissue. We lead drains these kind of rubber
two tubes that help drain fluid from the cavity that
remain in for a week or two and then are
able to be removed in the clinic.
Speaker 2 (37:07):
But that's a.
Speaker 1 (37:08):
Surgery that can take two or four weeks to really
recover from.
Speaker 3 (37:14):
So and I realized this could be seventeen different hours
worth of you know, conversations and topics, but in general,
what would be the factors that might go into removing
the other breasts. Also, even if there's not a cancer
there or prophylactic mas sectomies that we hear about where
(37:39):
one might have a math secondy even before they have
developed a cancer. And again I know that's an enormous topic,
but just to kind of give us a little flavor
of what might go into those kinds of decisions.
Speaker 1 (37:53):
Yeah, the big picture, women who are at elevated risk,
either from family history or genetic mutation, we would consider
a prophylactic mastectomy. You know, that's the discussion after genetic cascine,
looking at risk factors, about timing if it doesn't have
cancer yet. We also think about these contralateral prophylactic mastectomy,
(38:15):
So if a woman has cancer in one breath, sometimes
they'll elect to have a mass dect. To me on
the other side as well, that's also a very personal choice.
We have a lot of data that says that that
does not extend a woman's life, and we know it
doubles the amount of surgery we're doing. So whatever risk
(38:36):
there is with surgery, that doubles risk of issues with healing,
all that doubles time and the OAR, So that's something
we always take into account. We want to make sure
we're doing that this is a healthy patient who can
tolerate double the amount of surgery. But the reasons for
that can include symmetry, not wanting to do imaging anymore
(38:58):
of the remains the contra colateral breast, or just peace
of mind. Peace of mind is a big thing we
talked about in my fellowship. For some women, peace of
mind means still going in and getting a mammogram on
the other breast to check and really being engaged in imaging.
For other women it means I can't go get another mammogram,
it's too stressful. I'm just really worried waiting for the results.
(39:21):
So that's a very personal and individualized thing.
Speaker 2 (39:26):
Wow, that's well said.
Speaker 3 (39:28):
And I have left you just tons of time, almost
too whole minutes to talk to us a little bit
about non cancerous breast things. So maybe I'll just throw
it out there in our final a couple of minutes.
What are the most common non cancerous reasons that you
would perform breast thos?
Speaker 1 (39:50):
So they are small benign tumors called fibroidinomas that women
can develop. They don't necessarily have to be removed, but
sometimes they're large, painful bother some, so sometimes that's a
surgery where we would remove that. And then also there's
a lot of high risk lesions things we see on
(40:10):
imaging or biopsy that aren't actually a cancer but raise
our suspicion, and sometimes we need to do small excisions
just to gain more information and make sure there isn't
a cancer. Those other issues. Women can develop abscesses in
the breast, Clogged milk ducts can cause issues, and that's
something I treat as well, cellulitis, infection of the skin,
(40:35):
or just general issues with the skin.
Speaker 3 (40:41):
So are these things that typically, you know, people find
when they're doing self press.
Speaker 2 (40:46):
Exams and then they don't know they don't know what
it is. Is that how they get to you in
the first place.
Speaker 1 (40:53):
I think either through screen imaging or feeling a new
lump and then being worked up more. Sometimes they come
to me for sometimes they've already had some imaging, and
we can always go to the work up, find out
what actually is going on, and come up with a
plan for different options to treat it well.
Speaker 3 (41:10):
Doctor Nol, thank you so much. I know this is
an enormous topic to try and cover in one hour,
but you have given us so much information. We welcome
you to the community. We are so excited to have
your services here.
Speaker 2 (41:22):
Thank you.
Speaker 3 (41:22):
I want to thank everybody for listening. That'll do it
for this week's segment of Centered on Health, I'm your host,
doctor Jeff Pumlin. Thank you doctor Nol, and thank you
to our producer.
Speaker 2 (41:31):
This is Joon Tend and.
Speaker 3 (41:33):
We will see you every Thursday, and I hope everybody
has a great, safe and healthy regain. This program is
for informational purposes only and should not be relied upon
as medical advice. The content of this program is not
intended to be a substitute for professional medical advice, diagnosis,
or treatment. This show is not designed to replace a
physician's medical assessment and medical judgment. Always seek the advice
(41:57):
of your physician with any questions or concerns you may
have related to your personal health or regarding specific medical conditions.
To find a Baptist health provider, please visit Baptistealth dot com.
It's now time for Centered On Help with Baptis Help
on use Radio. Wait forty WYJS.
Speaker 2 (00:07):
Now, here's doctor Jeff Tumbler.
Speaker 3 (00:12):
Good evening, everyone, and welcome to tonight's episode of Centered
On Health with Baptist Help here on News Radio eight
forty whas.
Speaker 2 (00:21):
I'm your host, doctor Jeff Tublin, and we're joined as.
Speaker 3 (00:23):
Always by our producer Mache and Send who is on
standby to take your calls for this call and show
to talk to tonight's guests who we are having as
a special guest tonight about breast cancer and breast cancer surgery.
Our phone number is five oh two, five seven one,
eight four eighty four if you want to call in
and be a part of the show. One in eight
(00:44):
women will develop breast cancer in their lifetime, and while
we want to advocate for prevention, there are times when
breast surgery is necessary and a skilled breast surgeon within
our community with who you want to trust. Press surgeons
deal with cancers of the breast as well as non
cancer related issues that we're going.
Speaker 2 (01:02):
To talk about tonight.
Speaker 3 (01:04):
And there's about one hundred and fifty thousand mastectomies and
about one hundred thousand reconstructions done in the US alone.
So tonight we have doctor Thomas Nole who's here to
talk to us about breast surgery and advances in breast surgery.
Doctor Nole recently joined the Baptist Health Floyd Breast Surgery program.
He specializes in breast health and treats a variety of conditions,
(01:26):
including cancer and non cancerost breast diseases. He is a
graduate of the University of Louisville School of Medicine and
residency at University of Missouri Health. In addition, he did
an interdisciplinary breast surgery fellowship at Yale University School of Medicine.
We're so fortunate to have him on the show tonight.
Welcome doctor Nol.
Speaker 1 (01:48):
Thank you, good evening. How are you.
Speaker 2 (01:50):
I'm great. How are you doing tonight?
Speaker 1 (01:53):
I'm doing well, excited to be here.
Speaker 3 (01:55):
Well, we're thrilled to have you, and we know that
you've recently joined our community. So tell us a little
bit about the practice that you've set up and where
you're where you're practicing.
Speaker 1 (02:08):
Oh yeah, So I'm over in New Albany, Indiana. Baptist
Floyd our clinic and hospitals over there, So I work
exclusively in New Albany Baptist Floyd. I do one hundred
percent breast surgery there. I started right at the start
of September. After finishing up my training, I moved back
(02:29):
home to the Kentuckyana area and have been kind of
getting my feet on the ground there and picking up steam.
Speaker 3 (02:35):
Now, well, that's only to our advantage, So we welcome you.
We're excited to hear about your expertise in this area
because of course it's such an important area and we're
going to cover a lot of information tonight, but just
so for our listeners to understand what's the general route
to get to do what you do, Why did you
(02:57):
pick this specialty, and what kind of training do you
have to have to do what you do.
Speaker 1 (03:03):
Yeah, So after college, a typical where I would be
medical school. Four years of medical school which is usually
two years of classroom work, and then two years of
clinical work and then after that a residency. So I
did a general surgery residency, which is five years in
training and all of general surgery. So it included breast surgery,
(03:23):
but also surgery of liver, gallbladder, stomach, kind of the
whole gamut, trauma surgery, and that gives you a really
good foundation of general surgical skills that I think, you know,
anyone doing surgery needs to have. There's a lot of
people who after that go out into the community and
they'll do general surgery and are able to do breast
surgery as well. But I knew that that was really
(03:45):
what I wanted to focus on, so I chose to
do an extra year of training, kind of a focused
fellowship on breast surgery. I interviewed. I think it ended
up being eighteen places across the country because during COVID,
so luckily they were all zooming or views. But I
really liked Eales program. The director, doctor Greenup was amazing,
and I think they really offered the most for the
(04:09):
kind of type of practice I wanted. I was able
to train in the big academic center in New Haven's,
but also I spent time in Bridgeport and Greenwich kind
of community practices, more private practice models, and I think
I was really able to see the gamut of how
to have a breast surgery practice, which is going to
be really valuable for me.
Speaker 3 (04:28):
Absolutely, was there something about specializing in breast surgery that
attracted you?
Speaker 1 (04:36):
I think going into medicine. I really tried to keep
my mind open. I was exposed very early to breast surgery,
even in high school. My dad is a plastic surgeon
and he focused primarily on breast reconstruction. So the first
case I ever scrubbed when I was fourteen was a
breast reconstruction case. But after college, I actually went to
(04:56):
graduate school and chemical engineering for a while and thought
I was going to do that, but I think the
draw of the OAR was too strong. I ended up
coming back and going to medical school, and during that
I really explored all different types of medicine. I really
was drawn to cancer care. I think it's very interdisciplinary,
so you get to work with a whole bunch of
(05:16):
different types of doctors and I think really make an
impact in people's lives. But over my time, I just
really liked being in the OAR, working with my hands
doing surgery. I think I have the mindset where I
like to see a problem and do something to fix
it right away, and that's very much surgery. You know,
you go find the problem and fix it or cut
it out. So I was drawn to that, and then
(05:40):
during my general surgery training, I still had not totally
decided on breast surgery. I was looking at all different
types of cancer surgery or other surgeries, but I really
liked how well the patients do. Getting this cancer diagnosis
can be devastating, scary, but we've advanced so much that
we're able to really do a good job treat patients
(06:01):
and they go on and live full lives afterwards with
really minimal effect after in a lot of cases. I
think that was really satisfying to me to see the
patients do so well after the surgery. I just wanted
to keep doing that after training.
Speaker 3 (06:17):
And we're gonna we're going to talk quite a bit
about what those surgeries are and sort of how how
you decide what surgeries to do. But coming off of October,
which is Breast Cancer Awareness Month, we need to talk
a little bit about before we get to you, which
is sort of the breast cancer screening, so that hopefully
we minimize that our need for you, but.
Speaker 2 (06:42):
That's still important. How are we doing from where you came.
Speaker 3 (06:45):
From and now that you're in Kentuckyana, what are you
seeing as far as how are we doing with our
screening for breast making.
Speaker 1 (06:53):
Yeah, screening is really the foundation, and I think The
reason patients do so well is because our screening is
so good, but we're able to catch if someone develops
the cancer, catch it really early on, treat it really
effectively before it develops into a bigger problem. I think
over time there's been kind of a bunch of different
groups that give guidelines for screening. My association as the
(07:18):
American Society of Breast Surgeons. Their recommendation is after age
forty women get annual screen mammograms, and then for people
who are higher risk, they can start at an earlier
age and sometimes do more frequent imaging or different modalities
such as them are wrong, but I think the screen
(07:38):
is incredibly important, and that's the big reason of why
we're able to have such good results because we catch
things early on. I've been really impressed in the two
months I've been at Baptist Floyd. The radiology department there
is awesome. I spent a lot of time going over
talking with them, looking at imaging. It's really that multidisciplinary
(07:59):
mode of care drew me to bread surgery in the
first place. Being able to really have colleagues and we
have each other's phone numbers and call and talk about cases,
and I think that really facilitates excellent care, you know.
Speaker 3 (08:13):
And it's so important, you know what you're saying about
the mammograms being yearly and then being at a place
that you trust, because part of the issue is probably comparing,
you know, one year to the next and looking for
these very subtle changes that can have major impacts on outcomes.
Speaker 2 (08:29):
When we find them earlier.
Speaker 3 (08:31):
But beyond the standard mamogram, what are some of the
other imaging techniques that are being used and why might
someone get like a different imaging test other than just the.
Speaker 1 (08:42):
MANA Beyond the mammogram, the most common other modality would
be ultrasounds. That's involves kind of sound waves that reflect
through the tissue and allow us to see within the
breast in a different way. The most common reason for
that is women who have denser breasts, so within the
(09:02):
breast there's a lot of fat, fatty tissue, but also
this glandular tissue that's involved in the production and delivery
of milk when a woman breastfeed and for younger women
or some women just at any age, that can be
a lot denser and it can be harder to see
through on mammogram, So ultrasound gives us an opportunity to
see through some of that denser tissue and screen for
(09:24):
issues beyond ultrasound. MRIs the other modality that usually takes
a little longer, and that can be if we've already
done a mamogram and ultrasound and there's still some question
we need another way to look. MRI is an option
or for our younger patients who are at high risk,
(09:44):
if they have some sort of genetic mutation that puts
them at a higher risk, or just their family family
history puts them at a higher risk, train with MRI
can be helpful.
Speaker 2 (09:55):
Absolutely well.
Speaker 3 (09:56):
We are talking tonight with doctor Thomas and all. We're
talking about advances in breadth cancer, breast cancer surgery, and
other conditions of the breast.
Speaker 2 (10:03):
We're going to take a short.
Speaker 3 (10:04):
Break and we're going to come back and start talking
about some of the surgeries that you do. Our phone
number is five oh two, five seven one, eight four
eighty four.
Speaker 2 (10:13):
It is like to call in and ask a question
of doctor Nol.
Speaker 3 (10:16):
This is News Radio eight forty w h as you're
listening to Center on Health, we'll be right back. I
(10:40):
want to welcome everybody back who's Centered on Health. With
Baptice Health here on news Radio eight forty whas. I'm
your host, doctor Jeff Publin, and we're talking tonight with
doctor Thomas Nole, who's a breast surgeon here in the
Kentuckyana area, who's talking to us tonight about breast surgery
advances both for breast cancer and other conditions of the breast.
(11:01):
Right before we took our break, we were talking about
the importance of screening and the different types of modalities,
and so you're just joining us. We emphasize the importance
of staying on top of all of those screenings. But
doctor Nole, talk to us a little bit about the
process from the point of view of how the patient
(11:24):
gets a diagnosis or comes to you. Do you usually
get them from a primary care that's found something on
one of these screenings. Do you often make the diagnosis?
When does the biopsy take place? Talk to us a
little bit about that process.
Speaker 1 (11:40):
So in a lot of cases, patients have already had
a biopsy when they make it to my clinic, our
radiology department, they really do a good job. If they
see something on the screen im the gene, they'll do
more imaging to really look at that spot and evaluate it,
which would be diagnostic imaging, and then if needed, biopsy.
(12:01):
Sometimes patients come to me before the biopsy as well,
and we can kind of go through imaging and talk
about that, but usually that biopsy is the next step
to really kind of get a true diagnosis of what
the issue is. That's something done by the radiologists using
either the ultrasound or mammogram for guidance to take place
a small needle in the area of concern and take
(12:23):
a little bit of tissue that our pathologists look at
and give us a diagnosis in either case. You know,
once the patient go go ahead, no, no, go ahead,
And once we have that diagnosis, then we can really
talk about options for treatments and you know what next
steps are.
Speaker 3 (12:44):
And speaking of kind of the options, you know, I
think most of us are familiar with a lot of
the terms that we hear oftentimes get associated with breast cancer,
but maybe we could just spend a few moments kind
of defining some of what these terms actually mean so
that when you talk to us about what you recommend,
(13:06):
we kind of understand them. So, for example, talk to
us about the difference between a lumpectomy and a mass them.
Speaker 1 (13:13):
To me, Yeah, certainly. A lumpectomy is when we remove
a lesion in the breast of concern and a little
bit of normal tissue around it, but we leave most
of the breast tissue in place and don't remove that.
With a lumpectomy, we remove that small amount test it,
make sure we have what we call negative margins, so
(13:35):
no issues extending to the edge of it we took out,
and that helps us ensure that we got everything we
need to and with that, a woman's able to keep
their breast. In a lot of cases, if it's a
small amount of tissue, there's very minimal cosmetic change, no
in terms of size or caught tour of the breast,
and I did a lot of work in terms of
(13:57):
issue rearrangement to really try to minimize any change and
fill in that little defect where we remove. On the
other side, a mast ectomy is removing almost all of
the breast tissue. I say almost all, because we can
never remove one hundred percent of anything, so there's always
a few cells left, but it's ninety nine percent of
(14:17):
breast tissue. In a lot of cases, we remove some
of the overlying skin, including the nipple, but we've found
that doing nipple sparing mass dectomies are safe and that
becomes an option for some women to preserve the nipple.
And with a mass ectomy, we can do that either
with or without reconstruction, which would mean bringing in a
(14:40):
plastic surgeon who would recreate the breast after tissues removed,
typically with some sort of saline or silicon I implant.
Without reconstruction, we remove some more skin and we can
do something called an aesthetic flat closure where we close
the skin flat again the chest wall for a nice
(15:02):
smooth closure. And then there are options of Proust thecs
women can wear or just forgo that.
Speaker 2 (15:09):
So speak.
Speaker 3 (15:11):
Going along, So with these sort of terms we hear,
we hear the term reconstructive surgery, and so is that
what you are kind of just referring to in terms
of bringing in the plastic surgeon, Like, how often when
you're doing your surgery do you bring.
Speaker 2 (15:25):
In a plastic surgeon at the same time?
Speaker 1 (15:28):
Mm hm. So in if a mass ectomy is being
done in a patient once reconstruction, I would always try
to bring in a plastic surgeon. You know, I think
I'm I'm pretty new here, so I think my number
of those cases is still pretty small. But in Fellowship
it was very common to do reconstruction with the mass ectomy,
(15:48):
and a lot of times it depends on women's personal choice.
Sometimes health can affect that it is more surgery for
material being placed in the body so high risk for
infection complications. So we always have to look at what's safest.
And my job as a cancer surgeon is always to
do a really good cancer operation, and that's always the
(16:12):
first priority, but not the only priority.
Speaker 3 (16:17):
And then in terms of kind of rounding out sort
of our understanding of the terminology, you know, we hear
a lot about lymph nodes and lymph node dissection and
sentinel node, Like, what.
Speaker 2 (16:31):
Is the role of the lymph node here?
Speaker 3 (16:32):
Why is that so important when you are evaluating the patient.
Speaker 1 (16:40):
So really I do two different types of surgery for cancer.
I do surgery on the breast and surgery on the
lymph nodes. A breast cancer starts in the breast, but
if it spreads elsewhere in the body, the most likely
first place it would go are the lymph nodes. These
are small glands that help drain fluid from all around
our body, but the breast primarily drains to lymph nodes
(17:01):
under the armpits in an area we call the axilla.
So anytime a woman has breast cancer, we always think
about should we sample some of those lymph nodes to
check if any cancer spread. So that would be a
sentinel lymph node biopsy and a study where we take
the first few lymph nodes that drain the breast and
(17:22):
check them for cancer. We're able to do that by
injecting two different types to die in the breast. One's
radioactive and one is blue, and we're able to trace
that down and find the first few lymphodes to evaluate.
Speaker 2 (17:37):
And go ahead.
Speaker 1 (17:40):
I think the one thing I'd say is lymph node
surgery is probably the place that's changed the most over
the last twenty years in breast surgery, and we found
in some cases women don't we don't have to do
that surgery to look at lymphodes. With older women over
seventy with very early stage breast cancer, we have really
good days that it's safe to omit that study and
(18:03):
avoid some of the potential morbidity of it. It's an
extra incision can cause pain, and also in the exilla
there are limp vessels that help drain the arms, there's
always some risk of disrupting those and potentially causing some
swelling of the art. So we're always very mindful to
if we're able to avoid doing unnecessary surgery, to not
(18:25):
do that.
Speaker 3 (18:27):
Absolutely, So speaking of that, and you know, as you
remind me, as you're educating us here, obviously your training
is geared towards being up on these advances. So as
a patient who might receive this diagnosis that obviously nobody
wants to receive, how do you recommend as they're kind
(18:49):
of processing this information, how do you recommend them evaluating
the type of surgeon they need to see. I mean,
as you mentioned earlier, general surgeons oftentimes do this type
of surgery. Like when they're sitting down and thinking about
finding somebody like you, how how do they find you?
Speaker 1 (19:08):
I think, you know, you can always look at surgeons
on the internet, but really talking to doctors you trust,
getting referrals is the best way. You know, talking to
other people who have had surgery surgeons they have had
good experiences with I think that's important. And then just
finding someone that you know, you get along with, you
(19:28):
know that you feel like understands you, hear's you, and
explains things in a way that makes sense. I think,
you know, there are a lot of general surgeons who
are excellent. My partner has general surgery training, he's been
doing breast surgery for eight years, is excellent. But I
think finding someone who has a true desire to focus
(19:49):
on breast surgery and a special interest in it is important.
Speaker 3 (19:55):
And you mentioned this earlier about and we said it
in the introductory or mark about you that you did
an interdisciplinary breast surgery fellowship. What does that mean and
why is that approach so important for a patient to.
Speaker 1 (20:09):
Have Because all cancer care is interdisciplinary. There's never one
modality to treat cancer. So I work with radiologists, pathologists,
medical oncologists to treat cancer with medicines that treat the
whole body, radiation oncologists who can treat local disease with
(20:30):
radiation therapy, and all those modalities are important and almost
everyone gets some combination of multiple therapies to get the
best result for their cancer. In my training in general surgery,
we spent five years essentially only doing surgery. There was
so much to learn and that's all we could spend
time on. But the real advantage of my fellowship was
(20:53):
I spent four months out of the year with people
who weren't surgeons, with the medical oncologists, the radiation on colleges, radiologists, pathologists,
and other people too. When the DEEMA specialist, genetic counselors,
high risk doctors, the plastic surgeons. I think that really
(21:14):
set me up well to understand the full gamut of
this multidisciplinary care and really be able to be a
lynchpin with all the different providers.
Speaker 3 (21:25):
You know, And I think that you know, what you're
saying is so important, and I hope people are you know,
are listening that you're you've embraced this interdisciplinary approach in
your practice, because one of the things we hear all
the time is that medicine be so siloed and one
part isn't really.
Speaker 2 (21:41):
Talking to the other, and it can be very confusing
for the patient.
Speaker 3 (21:45):
But to have this coordinated care, I would imagine not
only you know, makes the care better, but probably puts
the patient at ease knowing that all these things are
being done together.
Speaker 1 (21:59):
Certainly, and I think it's it's important that everyone in
the care team kind of understands everyone else's role and
has an idea what they do too, and that can
help us really streamline care and make sure we get
people appropriate referrals and get to the right place.
Speaker 3 (22:18):
Yeah, and we had a we've had a couple actually
nurse navigators on our show.
Speaker 2 (22:23):
One of them was a breast.
Speaker 3 (22:24):
Nurse navigator, and you know, her description of the role
in all of this really, you know, shed a light
to me on just how important having those resources are.
But we're going to take us another break here and
when we come back, we're going to talk about the
actual surgeries and the advancement that that.
Speaker 2 (22:41):
You're going to tell us about.
Speaker 3 (22:43):
So we are talking tonight with doctor Thomas Noel about
breast cancer surgery, advances in breast surgery. This is Centered
on Health with Baptist Health, News Radio eight forty WHAS
on doctor Jeff Helm.
Speaker 2 (22:54):
There's still time to call in and.
Speaker 3 (22:56):
Ask the question five oh two, five seven one, eight
four eighty four and we'll be here.
Speaker 1 (23:01):
Right after the break.
Speaker 3 (23:18):
Welcome back to Center It on Health with Baptist Health
here on news radio eight forty w h AS. I
am your host, doctor Jeff Publin, And if you're just
joining us or you've been sharing this hour with us,
we are talking with doctor Thomas Nole, who is a
breast surgeon with the Baptist Health Floyd Breast Surgery Program.
He's talking to it talking to us tonight about breast
(23:40):
cancer surgery and advances, and we.
Speaker 2 (23:42):
Appreciate all this information that you're giving us. Doctor Nol,
Welcome back.
Speaker 3 (23:47):
I have a bunch of things I want to ask
you about in terms of the surgeries, but I want
to pivot for just a second because one of the
things that's really exciting.
Speaker 2 (23:59):
Is when we have an advances in these surgeries, and.
Speaker 3 (24:02):
I want to have you talk to us a little
bit about wireless localization and what does that term mean
and why is it so important in what you do.
Speaker 1 (24:16):
Yeah, So when we do a lumpectomy removing just a
small part of the breast that has a concerning lesion,
but leave the rest, it's often difficult to find where
that issue is. Some tumors are palpable and very clear,
but in a lot of cases there's not a palpable
tumor and the tissue really doesn't look any different to
(24:36):
the naked eye normal breast tissue. It's really microscopic issues.
So the surgeon I need some way to help me
find that spot that I need to remove and make
sure that I get the correct part of tissue. Traditionally,
that was done with a wire. Before surgery, one would
go into the radiology suite and a wire would be
placed under imaging guidance into the lesion that was concerning,
(25:01):
and then in the operating room we would be able
to track down along that wire to the lesion and
use that to find the spot to remove. That's a
tried and true method, it works well, but there's been
a whole lot of new technologies that have come out
to put markers in the lesion that don't involve a
wire being placed a day of surgery or a wire
(25:21):
coming out of the breast at all. He's used a
variety of different methods to signal where it is, be
it radio frequency, magnetism, radioactivity. But in any case, there
are a small little biopsy clip or seed that can
be placed at any time before surgery up to a
(25:41):
month before and doesn't have anything extending out of the breast,
and that option gives us a lot more choice during
surgery on where to place incisions, allows us to zero
into the specimen, remove less tissue and more precisely, and
a lot of just makes the day a lot smoother
(26:03):
for a patient without all these different places to go
the day of surgery. And we're working on trial in
a few different technologies that Baptists fully define the best
one that works for us and hope to really incorporate
that into our practice soon.
Speaker 3 (26:19):
So by doing it the way you're describing in these
advantage do you feel like that does it get you
to the lesion easier or does it minimize kind of
other tissues that you don't have to disrupt in order
to find it?
Speaker 2 (26:32):
Like, what do you think that particular advantages are.
Speaker 1 (26:36):
I think the big advantages are in terms of getting
to the lesion. It allows us to place our incision
wherever is the best for our surgery, be that for
best cosmesis or closest to the lesion. When a wire
is placed, a lot of times we have to account
for where the wire enters the skin, and that kind
(26:58):
of helps or forces us into some incisions at some point.
Speaker 2 (27:01):
Got it.
Speaker 1 (27:02):
And also with these clips, I think it gives us
a more precise idea of exactly where that lesion is
and lets us take less tissue because with any lumpectomy,
we want to get the whole lesion and then a
rim of normal tissue. But in most cases the most
we need is two millimeters of normal tissue around the lesion.
We really don't need any extra. So being able to
(27:24):
know exactly where the lesion is would facilitate us taking
smaller specimens, causing less volume loss to the breast, and
having better cosmetic outcomes with equivalent of onco logic outcomes.
Speaker 3 (27:40):
And so you may be aware that before every show
like this, we run an ad that says what we're
talking about. And this is the first time I've gotten
this much feedback about what does oncoplastics mean? Because I
said it in the promo that that's what we're going
to talk about. So for all my colleagues and friends
(28:00):
that have talked to me all week about what is
ongo plastics, doctor nol, what is oncoplastics?
Speaker 1 (28:08):
So really the two words onco has to do with
treating cancer and plastics. If you think about plastic surgery,
has to do with the more aesthetic or cosmetic part.
And that's a really important part in breast surgery because
we realize that removing the cancer isn't the only thing
we're doing. That's always our first priority to do a
(28:30):
great cancer operation and really try to cure a woman
of cancer, but we don't want to do that in
a way that's disfiguring or causing lasting issues. So any
breast surgery we're thinking about how do we do the
best cancer operation possible but also have a great cosmetic
outcome in terms of oncoplastics. If we do a lumpectomy,
(28:52):
I often do some tissue rearrangement, move around a little
bit of breast tissue to fill in the defect where
I remove tissue, try to minimize any sort of volume
loss and maintain the normal or the natural contour of
the breast. And that's something that through my training has
really been incorporated in all aspects. We're always thinking about that.
Speaker 3 (29:17):
And are you able to do that at the point
of the original surgery. I mean, I'm thinking about, you know,
women having this surgery and then leaving and being you know,
not symmetrical on both sides, and are you able to
do this at the time of the original surgery.
Speaker 1 (29:40):
Everything I would do would be at the time of
the original surgery, So that's usually the best time to
do it. You know, with one operation, right after you
remove some tissue to do any sort of rearrangement you
need to do to minimize any sort of change. I
think after surgery, if there is still a significant cosmetic
(30:03):
defect that begins to get outside of my skill set,
it might require a plastic surgeon who can do kind
of more advanced reconstructive procedures.
Speaker 3 (30:18):
And how often we had this question sent in and
you know we don't want to not mention this.
Speaker 2 (30:25):
How often do you see men with breast cancer?
Speaker 3 (30:29):
I know you're early here, but in your training and
through Yale and everything, what is that some have you
had to operate on male breast cancer?
Speaker 1 (30:39):
I have over my year at Yale, thinking aback, I
think I had at least five men who had breast
cancer that I operated on. And it's certainly more rare,
but it is possible, and it can be a little
trickier because men aren't getting screened for it. So usually
it's kind of found either when there's something palpable or incidentally,
(31:02):
but certainly something that can occur men men to have
small amounts of breast tissue as well, certainly not as
much as a woman's with it. It's something that does
come up. The treatment is very much similar to how
we would treat a woe with breast cancer. There's really
no reason to treat it differently. We can still do
(31:25):
a mass dectimy, which functionally looks a little different, or
in some cases we can do a lumpect to me
to not remove as much tissue and create a conto
or change to a man's chest either.
Speaker 2 (31:39):
Well, I do want to pick your brain.
Speaker 3 (31:41):
A little bit about how the decision is made between.
Speaker 2 (31:45):
Lumpect to me and mass dect tomy.
Speaker 3 (31:47):
I mean, I'm sure these are very difficult choices sometimes
for a patient to think about.
Speaker 2 (31:52):
So we're going to.
Speaker 3 (31:53):
Talk about that when we come back, because we're going
to take our final break before we delve into that topic.
I want to remind everybody you are listening to Centered
on Health with Baptist Health here on news radio A
forty w h as. I'm your host, doctor Jeff Publin.
I want to remind everybody to download.
Speaker 2 (32:10):
The iHeartRadio app free. It's easy to use, and it'll
give you access to tonight's show and everything else the
app has to offer. You'll be right back.
Speaker 3 (32:35):
I want to welcome everyone back to Sundate on Health
with Baptist Health. Here on News Radio eight forty whas.
I'm your host, doctor Jeff Cubln. We're talking tonight with
doctor Thomas Noel who is at Baptist Health Floyd Prest
Surgery Program, who's one of our breast surgeons, and he's
been talking tonight about advances and surgery of the press. So,
(32:56):
doctor Nol, once a patient received the diagnosis and needs
surgery as part of their treatment plan, how is the
decision made about whether a lumpectomy is done or a
mass sectimy is done? Who makes that choice? Is that
something you present to them or the oncologists? How does that?
Speaker 2 (33:16):
How does that work?
Speaker 1 (33:20):
That's usually a discussion I have with the patients. The
first thing we have to do is assess if both
options are reasonable for the patient. So some patients, unfortunately
have large tumors or areas that need to be removed
where there really isn't going to be enough breast tissue
left after removing that for an acceptable cosmetic result, And
(33:43):
in those cases, lumpectomies just really aren't a good option
just because of the nature of the disease. In most cases,
we catch things so early that they're small and patients
are great candidates for lumpectomy. In any case, this is
one of the few areas in medicine where patients really
have a lot of personal choice in what surgery they have.
(34:06):
I always present mass dect tom and lumpect to me
to patients, and we talk about the benefits and downsides
of both. We did really a bunch of really large studies,
you know, decades ago that showed that the long term
outcome from mess dectomy or lumpectomy with breast radiation after
(34:28):
is equivalent. Women live the same amount of time after that,
so we know either operation is safe and doesn't offer
a big survival benefit between the two. So really it
kind of a lot of it comes down to personal choice.
Some women just never want to have to have a
mammogram again and really just want to proceed with a
(34:50):
mass dectomy, and that can be kind of an empowering
choice to treat. A lot of women don't want to
have a mass dectomy. They really want to preserve their
breast and we can we can that with a lumpectomy.
Speaker 3 (35:03):
But you mentioned something important, So when the lumpectomy is done,
there's other treatments that need to be done, whereas with
the mass sectomy.
Speaker 2 (35:11):
It's just surgery.
Speaker 3 (35:12):
Is that fairly a universal differential between those two things.
Speaker 1 (35:18):
In a lot of cases, you know, like everything in medicine,
there's no no absolute some cases, after a mass ectomy,
you know, women still need radiation to the chestwall or axilla.
But a lumpectomy for cancer in most cases comes with
breast radiation, which helps treat the rest of the breast
(35:39):
and prevent any recurrence in the tissue that remains. There's
some studies that show for women over seventy it can
be safe to emit radiation. In some cases, we do
that selectively in really ways of risks and benefits, but
a full traditional treatment with olympectomy would be some form
of breast radiation as well. Well.
Speaker 3 (36:01):
What is the what's the healing difference is between having
the full math dectamy and then them.
Speaker 1 (36:10):
That can be a big point of decision for patients too.
A lumpectomy is an outpatient surgery, so a woman will
come in the morning, not if we do surgery. She
goes home the same day, usually a store for a
couple of days, two or three days, but often back
on her feet pretty quickly. You know, if someone has
surgery on a Thursday, and they have a kind of
(36:32):
lower activity job. They could be back at work the
next week. Even in terms of post operative pain, a
lot of times women don't need narcotics, just tile and
all ice packs. Ibuprofen is really all they need. We
inject a lot of dumbing medicine as well. On the
other hand, maths ectomy it does require more recovery. Patients
(36:53):
are usually in the hospital overnight because we're removing so
much more tissue. We lead drains these kind of rubber
two tubes that help drain fluid from the cavity that
remain in for a week or two and then are
able to be removed in the clinic.
Speaker 2 (37:07):
But that's a.
Speaker 1 (37:08):
Surgery that can take two or four weeks to really
recover from.
Speaker 3 (37:14):
So and I realized this could be seventeen different hours
worth of you know, conversations and topics, but in general,
what would be the factors that might go into removing
the other breasts. Also, even if there's not a cancer
there or prophylactic mas sectomies that we hear about where
(37:39):
one might have a math secondy even before they have
developed a cancer. And again I know that's an enormous topic,
but just to kind of give us a little flavor
of what might go into those kinds of decisions.
Speaker 1 (37:53):
Yeah, the big picture, women who are at elevated risk,
either from family history or genetic mutation, we would consider
a prophylactic mastectomy. You know, that's the discussion after genetic cascine,
looking at risk factors, about timing if it doesn't have
cancer yet. We also think about these contralateral prophylactic mastectomy,
(38:15):
So if a woman has cancer in one breath, sometimes
they'll elect to have a mass dect. To me on
the other side as well, that's also a very personal choice.
We have a lot of data that says that that
does not extend a woman's life, and we know it
doubles the amount of surgery we're doing. So whatever risk
(38:36):
there is with surgery, that doubles risk of issues with healing,
all that doubles time and the OAR, So that's something
we always take into account. We want to make sure
we're doing that this is a healthy patient who can
tolerate double the amount of surgery. But the reasons for
that can include symmetry, not wanting to do imaging anymore
(38:58):
of the remains the contra colateral breast, or just peace
of mind. Peace of mind is a big thing we
talked about in my fellowship. For some women, peace of
mind means still going in and getting a mammogram on
the other breast to check and really being engaged in imaging.
For other women it means I can't go get another mammogram,
it's too stressful. I'm just really worried waiting for the results.
(39:21):
So that's a very personal and individualized thing.
Speaker 2 (39:26):
Wow, that's well said.
Speaker 3 (39:28):
And I have left you just tons of time, almost
too whole minutes to talk to us a little bit
about non cancerous breast things. So maybe I'll just throw
it out there in our final a couple of minutes.
What are the most common non cancerous reasons that you
would perform breast thos?
Speaker 1 (39:50):
So they are small benign tumors called fibroidinomas that women
can develop. They don't necessarily have to be removed, but
sometimes they're large, painful bother some, so sometimes that's a
surgery where we would remove that. And then also there's
a lot of high risk lesions things we see on
(40:10):
imaging or biopsy that aren't actually a cancer but raise
our suspicion, and sometimes we need to do small excisions
just to gain more information and make sure there isn't
a cancer. Those other issues. Women can develop abscesses in
the breast, Clogged milk ducts can cause issues, and that's
something I treat as well, cellulitis, infection of the skin,
(40:35):
or just general issues with the skin.
Speaker 3 (40:41):
So are these things that typically, you know, people find
when they're doing self press.
Speaker 2 (40:46):
Exams and then they don't know they don't know what
it is. Is that how they get to you in
the first place.
Speaker 1 (40:53):
I think either through screen imaging or feeling a new
lump and then being worked up more. Sometimes they come
to me for sometimes they've already had some imaging, and
we can always go to the work up, find out
what actually is going on, and come up with a
plan for different options to treat it well.
Speaker 3 (41:10):
Doctor Nol, thank you so much. I know this is
an enormous topic to try and cover in one hour,
but you have given us so much information. We welcome
you to the community. We are so excited to have
your services here.
Speaker 2 (41:22):
Thank you.
Speaker 3 (41:22):
I want to thank everybody for listening. That'll do it
for this week's segment of Centered on Health, I'm your host,
doctor Jeff Pumlin. Thank you doctor Nol, and thank you
to our producer.
Speaker 2 (41:31):
This is Joon Tend and.
Speaker 3 (41:33):
We will see you every Thursday, and I hope everybody
has a great, safe and healthy regain. This program is
for informational purposes only and should not be relied upon
as medical advice. The content of this program is not
intended to be a substitute for professional medical advice, diagnosis,
or treatment. This show is not designed to replace a
physician's medical assessment and medical judgment. Always seek the advice
(41:57):
of your physician with any questions or concerns you may
have related to your personal health or regarding specific medical conditions.
To find a Baptist health provider, please visit Baptistealth dot com.
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