Breast Cancer Diagnosis: Who Do You See First and What Comes Next?

After a breast cancer diagnosis, what happens first—seeing an oncologist, having surgery or starting chemotherapy? And how do doctors decide between a lumpectomy and a mastectomy?

In this episode of Baptist Health Talk, host Johanna Gomez sits down with Dr. Mehran Habibi, Deputy Chief of Breast Surgery with Baptist Health Cancer Care, to answer common questions patients search online about breast cancer surgery and treatment.

They discuss:

•  The difference between a medical oncologist and a surgical oncologist 
•  Who patients typically see first after a breast cancer diagnosis 
•  How doctors decide whether chemotherapy or surgery comes first 
•  Why chemo first does not automatically mean the cancer is more aggressive 
•  Whether chemotherapy can be shortened when a tumor responds well 
•  Why second opinions and breast cancer specialists can matter 
•  The truth about the myth that surgery or biopsy can make breast cancer spread 
•  Why treatment may still be needed after a tumor is removed 
•  How doctors and patients choose between lumpectomy and mastectomy 
•  Why feeling fine is not a reason to delay recommended treatment 
•  How lymph node involvement affects staging and treatment 
•  Options for immediate or delayed breast reconstruction 
•  How AI is beginning to support breast imaging, surgical planning and treatment decisions 

Subscribe to Baptist Health for more expert conversations on health, wellness, prevention and treatment.

Host:
Johanna Gomez
Award-Winning Host & Journalist

Guest:
Mehran Habibi, M.D.
Deputy Chief of Breast Surgery 
Baptist Health Cancer Care

If you found this episode helpful, we recommend these links for additional information:

Diagnosed With Breast Cancer: What's Next?

Breast Cancer in Young Women: Signs, Screenings, and When to Speak

Life After Breast Cancer: Fear, Healing, and Hope

Transcript

SPEAKER_00 0:00

But again, because of the tumor characteristics, we can sometimes recommend the systemic therapy first and then do the surgery. So it doesn't necessarily mean that if somebody is going to get a chemotherapy that has a very high stage or very aggressive tumor. It means that their tumor happens to be sensitive to the chemotherapy, so we take advantage of that.

SPEAKER_01 0:20

Welcome to Baptist Health Talk, a podcast on all things healthcare, powered by Baptist Health South Florida, your trusted source for healthcare prevention and wellness. Hi, everyone.

SPEAKER_02 0:39

Today we're unpacking the exact questions people search on the internet about breast cancer surgery, but rarely get clear answers to put it in plain language. From who do I see first to does surgery or chemo come before anything else? We're getting straight answers from the expert who knows it best. We're joined by Dr. Maran Habibi, Deputy Chief of Breast Surgery with Baptist Health Cancer Care. Thank you so much for being with us here today. Looking very sharp in your bow tie. Thank you so much. We appreciate you taking your time out and talking to us. So we're going to start off with the basic questions. Can you explain the difference between an oncologist and a surgical oncologist?

SPEAKER_00 1:25

Sure. An oncologist usually refers to a medical oncologist that treats the cancer patients with medications. The surgical oncologist is a general surgeon that usually does an additional training to subspecialize in management of the cancer patients. So then become surgical oncologist.

SPEAKER_02 1:49

Okay, so when someone first gets diagnosed, there's a lot of obviously emotions that just come through. You have a lot of questions, but you don't really know exactly what is the first step that you have to do. Is it first seeing an oncologist or a surgical oncologist?

SPEAKER_00 2:02

So in the in the case of breast cancer, usually the first person that the patient sees is a breast surgical oncologist.

unknown 2:10

Okay.

SPEAKER_02 2:10

And obviously, I know with every patient it's all different, but does surgery come first? Does chemo come first? Or it doesn't really matter.

SPEAKER_00 2:20

Um it does matter. As you mentioned, the breast cancer is a spectrum of disease. So we have different receptors of the breast cancer. And when the patient presents, we have different sizes of the tumor as well as involvement of the lymph node and all that. So all of those elements will dictate whether do we do the surgery first or we do the systemic therapy first. But in the past 10 years, there is a lot of changes in that space that there is a group of patients that we actually do the systemic therapy first and then we do surgery. In the past, most of the time we did surgery first, but now there is a very big group of patients that by giving the systemic therapy, we can decrease the size of the tumor. And then when we do the surgery, it would be a little bit of a better chance of doing a breast conserving surgery, or we can de-escalate the surgery either in the breast or in the axilla.

SPEAKER_02 3:19

Okay, so there's so many different types of breast cancers, and I think a lot of people don't understand that every single one is tackled differently. So am I right when I say that you tackle each cancer the same way, but since there's so many different types, there's so many ways that you tackle each and every single one of them.

SPEAKER_00 3:44

So we have some principles that we apply to the cancer care. Right. So there is a surgical management, there is a systemic therapy management, and there is a radiation management.

SPEAKER_02 3:55

But you follow the same plan, is what I'm asking.

SPEAKER_00 3:57

Everyone's gonna be different.

SPEAKER_02 3:59

Okay.

SPEAKER_00 3:59

For every patient, we really define the plan that best suits their needs, their wants, as well as the characteristics of the tumor. So it is really a personalization based on the several factors. Again, we use the three principles of surgical management, systemic as well as radiation, but there are so many nuances, and then the treatment team will define the best therapy for individual patients.

SPEAKER_02 4:29

What if I want to have surgery first or treatment first? Can I, as the patient, say, as much as you are advising me, like just as an example, to do treatment first? Can I say I would like to do surgery first? And is that something that you guys would do?

SPEAKER_00 4:45

Got it. So what happens, um all the decision making is done in a shared decision making. Okay. As physicians, we give the best advice that we feel based on the characteristics of the tumor, we would achieve the best oncologic as well as cosmetic outcome. Of course, this is done in the very collaborative way with the patients and with the other colleagues. And the patients have a tremendous amount of say in directing the in the therapy for them. Again, there are times that we can do either way. We can do systemic therapy first or we can do the surgery first. And then so the the patient will choose. And again, at the end of the day, but if they have a particular preference, we'll we'll accommodate that. We'll uh we'll we'll give the best advice, but the whole thing is a shared decision making.

SPEAKER_02 5:33

Okay, there's also a lot of confusion when it comes to chemo timing. People think, well, if I do chemo first, that means that my cancer is very serious. And the other way around, if I do surgery first, it means it's probably a very early stage. Does that matter, chemo timing?

SPEAKER_00 5:48

So the the timing of chemo, so what happens is so the breast cancer um gets categorized into several stages. Okay. Usually when we are talking about the systemic therapy first, means that we are talking about the stage two or stage three. Means that if the size of the tumor usually is larger than two centimeters, and or if the lymph node is involved. So it still is considered an earlier stage, but again, because of the tumor characteristics, we can sometimes recommend the systemic therapy first and then do the surgery. So it doesn't necessarily mean that if somebody is going to get a chemotherapy, they have a very high stage or very aggressive tumor. It means that their tumor happens to be sensitive to the chemotherapy. So we take advantage of that.

SPEAKER_02 6:34

Okay, so I know this question is on the internet because I actually happen to be one of the people that searched this as well. I will go and say, and I didn't like the answer to it, but unfortunately, uh it's an answer that I had to live with. Can I cut my chemo timing in half if I have to do 12 rounds of chemo? And if by the sixth rounds of chemo I'm feeling better and we notice that the key the tumor has gone down, can we just cut that in half and I can go on live my happy life?

SPEAKER_00 7:05

Yeah, that's it, that's a great question. So there's a so what happens is in the research side, we are trying more and more, trying to decrease the amount of chemo and the timing as much as we can to get the best therapy, best response, yet least amount of toxicity. So there is an active um you know effort is going for every type of chemotherapy to see whether we can do less, can we do shorter, you know. The ones that are in the clinical setting are the ones that through the clinical studies, through the clinical trials, have shown that this is the most effective way as of now. But if you look at over the past 10, 15 years, yes, we have decreased the uh amount, the we we narrowed the uh the type of chemotherapy as well as the timing. So the protocols that we have as a standard means that they are subject to a lot of clinical trials trying to optimize the best therapy. And so when your medical oncologists recommend that regimen, usually is after consideration of all the clinical trials, and the but that's the optimum therapy that they recommend.

SPEAKER_02 8:16

Yeah, you hear a lot of uh, well, the percentage that it will come back or it won't come back. That that's something that a lot of times people will hear. A lot of times you're browsing through the inner and you're trying to figure out who to trust. And I think that that's really a big factor when it comes to picking your team, your oncologists, your circle oncologists, on who you're going to go with, because this is not an easy decision. What are some things that you would say uh as a professional that you would look out for, that we should look out for?

SPEAKER_00 8:45

Yeah, I would say this field has becoming so specialized. Yeah. And with the advancement of the research and the nuances of the research and the fact that the folks that are treating you actually doing the research. So these are all very important. So you really want to seek the care at a place that all they do is, for example, in the form of breast cancer, that's what all they do is the breast cancer. So if somebody is um doing breast and then does the hernia surgery and does the gallbladder surgery and does other surgeries, so they can potentially do the surgery okay, but do they know all the nuances that is going on with the research? That would be a little bit of a questionable. Okay. Or same thing with the medical oncologist or other fields, that the folks that are focused, their work on the breast cancer would be the best that they know the most, you know, current research, they're familiar with the trend of the therapies, as well as they're actually involved in the research themselves. I think that that would be very helpful to find somebody that is really focused in this field.

SPEAKER_02 9:48

Do you recommend second opinions, even third opinions?

SPEAKER_00 9:51

Absolutely. So so a lot of my career um uh was at Hopkins and being one of the you know tertiary centers. So for years and years, I've done a lot of second opinion, third opinion, fourth opinions. So I think uh in for the uh you know um case of breast cancer, the nice thing about it is that for the most part, it's not an urgent situation. So you have time to ask questions, ask the second opinion. And then if you feel that you know your questions are not fully answered or you like to uh seek a second opinion, we always encourage that to do that, get the advice um for the second from the second person that is really deeply specialized in this and has done research on it. So I think to me, we always welcome the second opinions.

SPEAKER_02 10:38

Uh, you know, speaking of questions, I don't think there's ever such a thing as a silly question, especially when it comes to your health. I think if it's something that you've heard, whether it's uh an old wives' tale to a question that you have, if it's crossed your mind, I think it should be asked. So one that we saw all over TikTok. And I'm actually glad that I'm asking you this because I've heard a couple of people actually say this. The question is if I have surgery, the cancer might spread if I have surgery right away because it's being touched and then it just spreads all over. Can you clear this?

SPEAKER_00 11:11

Absolutely. Uh furthermore, uh in even more than surgery, some folks may say even if you do biopsy, they may spread. Yeah. And it's absolutely not the case. Really? Absolutely not the case. Okay. So let me put this. Yeah, clear it up for us to believe it's completely not the case. So we've been doing this for over 30 years now. Millions of percutaneous biopsies means that with the uh imaging guided biopsies, for the cases of the breast cancer is not the case at all. There are some other cancers that are very, very aggressive. And I'll give you examples. For example, in the form of gallbladder cancer, which is an organ in the next to the liver. Yes, yes, yes. So that is an incredibly aggressive form of cancer. And we don't necessarily do the biopsy of the gallbladder cancer. But what happens is sometimes when the patients do a choleysystectomy, means they're removing the gallbladder, it happens to have a cancer inside of it. And there are some studies that show some of those patients will have a recurrence at the like a port site that they had the surgery. So because it's an incredibly aggressive tumor, there has been reports of the an area that the gallbladder, for example, was removed from the abdominal wall, they had a you know site recurrence. For the breast cancer, it's just not the case at all. Either both in the form of the biopsy as well as for the surgery, it does not increase the risk of metastases or a spread to the other organs whatsoever.

SPEAKER_02 12:49

How about the question or the belief, I should say, that if you remove the lump, you don't have to do treatment after that, because right if you think about it, the cancer is gone.

SPEAKER_00 12:58

Yeah, so for in the in the form of in the in the case of the breast cancer, that is correct. When we remove the tumor from the breast, that area is out. But when you think about it, we look at the cancer not as a completely local disease. The cancer is a systemic disease. And by removing the tumor alone, if you don't do any additional therapy, like the radiation therapy. So if you do a lampectomy, we usually recommend doing a radiation therapy. So what the radiation therapy does is that it sterilizes, it kills the potentially the live tumor cells that there might be in the surrounding of that lumpectomy cavity, and they will decrease the risk of breast cancer recurrence. Furthermore, when the patient is getting recommendation for getting the systemic therapy or the hormonal therapy, that works systemically, will decrease the chance of any cancer from coming back, either locally or systemically. So we treat the breast cancer both from the local point of view and from the systemic point of view. So the systemic therapy works throughout the body, decrease the chance of recurrence. Surgery and radiation works on the locoregional to decrease the chance of recurrence.

SPEAKER_02 14:17

Is that also how when you look at a patient, you also decide whether that patient should have a mastectomy or a lumpectomy?

SPEAKER_00 14:24

And how do you so the decision between the lumpectomy and mastectomy uh falls into several uh you know and kind of like a factors? Um of course, the patient choice and patient decision, it is very, very important. And we always take that into consideration and we do that. In addition to that, the size of the breast and more importantly, the proportion of the size of the tumor to the size of the breast is very important. So, for example, a two-centimeter tumor on a breast that is, for example, a cup breast, or is it a very small breast, is actually significantly large compared to a three, four-centimeter tumor on a breast cup that is like a double D or triple. So, in that scenario, the proportionality of the size of the tumor and to the size of the breast is important. The location of it compared to the skin or the nipple areolar complex is important. So there are several factors that play into that equation. For nowadays, in the past, you know, 20, 30 years, more and more patients we are kind of like looking, trying to do everything to try to preserve the breast if that they want, and to do a partial mastectomy, not remove the necessarily entire breast. Again, this is a shared decision making with the patient wishes uh into also consideration of the size of the tumor and the proportion of the size of the breast.

SPEAKER_02 15:55

So to clear it up, just so there is absolutely no doubt, there's really then no right way to go, whether you want to do a massectomy or a lumbectomy.

SPEAKER_00 16:04

So there are several, yeah, there are several ways of right way to go. You know, the the um the right way, um there are for the for example, for the case of the again, a two-centimeter tumor, for example, on the C COP breast, for example. You can go either way. You know, and again, that's where the patient's choice comes to play. We usually try to do conservative management. Um, and but but then again, patient choice has the higher priority. There is no difference in the survival between the lumpectomy and the mastectomy.

SPEAKER_02 16:40

That's it.

SPEAKER_00 16:40

That's the important factor. Uh so in both, if you can achieve a good cosmetic outcome with the breast conserving surgery, the survival is the same.

SPEAKER_02 16:50

Okay. That that I mean, no, that pretty much clears up a lot of doubt that people have because I think then it just comes down to how comfortable do you feel for the patient, which is obviously something that is very important as well. We also see patients ask a lot of times, if I feel fine, do I really need surgery at this moment? Can I just hold off?

SPEAKER_00 17:14

Sure. The for the breast cancer, the good thing about it is that it doesn't really have in a way that you don't feel fine. You feel fine. I know. Even you have an aggressive breast cancer, you feel perfectly fine. You know, the the unfortunately, um, if somebody doesn't feel fine means that potentially, God forbid, they have a metastatic disease, they have a systemic disease that is so advanced that they don't feel fine. So the sense of feeling fine is not really something that you need to go with. If somebody has a breast cancer, they need to take care of it.

SPEAKER_02 17:51

Okay, so someone's big diagnosed, they have to go through chemotherapy first, and then they're having a mastectomy after. Can they just hold off, though, on that massectomy? Why jump into it six weeks out after chemotherapy?

SPEAKER_00 18:04

That's a that's an incredibly you know important question. So, what happens is the systemic therapy in the form of a chemotherapy when the patient gets um prior to the surgery, it you a lot of times we see a fantastic response in a way that tumor melts away, you can't really feel it at all. But all of those effects we don't have any data at this juncture that you can just do the chemotherapy and do nothing else.

SPEAKER_02 18:31

So because of Is it because we just haven't done it?

SPEAKER_00 18:34

So there are some studies that they looked at it, you know. But but again, and at some point a day may come that you do the systemic therapy and you completely don't do anything after that. But as of now, the standard of care is that if once you do the systemic therapy, then you give a four to six weeks window for the immune system to come back to normal, then you do the surgery. So it is very important that you don't give any chance for if the chemotherapy potentially killed vast majority of the cancer cells, but there are a little bit of them remain that you don't detect them in the imaging.

SPEAKER_02 19:12

That you take the tissue out.

SPEAKER_00 19:13

And you don't take it out, and then they will regrow back. So you you take it right away that before they potentially have a chance of regrowing, you you took care of the problem. Okay, so it's just pretty much that there just hasn't been enough research to show exactly and and probably the systemic therapy, again, there might be some other type of systemic therapy that just completely eradicated. At this juncture, we don't have them yet.

SPEAKER_02 19:37

Right, because I know sometimes then after people have to take some chemotherapy pills after to even help them for that to not happen. Would they be able to delay it or we're just not there yet?

SPEAKER_00 19:49

So usually one once the surgery is completed after the course of the systemic therapy. Again, most of this regimen are done by the protocols because of the research that they did. So depending on the type of tumors, there are times that you're gonna continue a version of the systemic therapy after surgery. There's some port of some form of chemotherapy, once you're done with the surgery, you will stop it. Again, all of those depending on the receptors. So medical oncologists are the experts that they will say, based on that receptor, you're gonna continue afterwards. Based on the specific receptor, you can stop, or you can continue the hormone therapy afterwards.

SPEAKER_02 20:29

How about lymph nodes? How much of that falls into the factor of what your journey looks like to healing from this cancer that someone has been diagnosed with? Whether it's lymph nodes have been affected, or it just shows that maybe they're weakening, let's just say.

SPEAKER_00 20:49

Yeah, so the lymph nodes are very, very important factor in the in this journey. And so if the breast cancer usually wants to travel beyond the breast, usually it goes to the lymph node first. So in surgery, what we do for a lot of patients, we sample the lymph nodes first and to see whether it has cancer has gone to them or not. So if the cancer has gone to the lymph node, it elevates the stage. So it means there's a more advanced stage.

SPEAKER_02 21:18

So that means you could have been a two, but now it's a three.

SPEAKER_00 21:20

So you know if the lymph nodes are not involved and the tumor is less than two centimeters, that is a stage one disease. If this if the size of tumor is less than two, it is more than two centimeters, that's a stage two disease. Or if the lymph nodes are involved but it's a small amount, that's a stage two disease. Stage three is the size is larger and more lymph nodes are involved, or the lymph nodes are matted, means that are fixed, that's a stage three disease. Stage four is that if the other organs beside the lymph node and the breast are involved, like a liver or like a bone. So that's the staging, how the staging works. But the lymph nodes are playing a very important role. Important role in the staging and in the process of the management. Again, if they are involved, we sometimes again, we usually give the systemic therapy, we have to do surgery and then patients have to get radiation. So it's a higher stage, more therapy is given is involved.

SPEAKER_02 22:17

So we really should focus on the stage. Obviously, we know stage four is, you know, it's probably the more critical one, but uh stage one, two, or three, does that factor in how you actually uh give the diagnosis of whether or not you're gonna have chemo first or surgery first, is my question.

SPEAKER_00 22:39

It does. It does. For the stage one disease, for the most part, we do surgery first. The stage two and three are the ones that again, based on the receptors, we go between the surgery first or systemic therapy first. On a stage four disease with a metastatic disease, the systemic therapy is the one that is a mainstay of therapy. So we don't necessarily um uh do a lot of surgery in a stage four disease. There are some exceptions to that. So it's a stage four disease that sometimes for the local control, if the tumor is like a bleeding or is it locally advanced, sometimes we may have to do surgery. Okay. Or so, but for the most part, is the two and three that become controversial that you do the state surgery first or the systemic therapy first, and again, based on the receptor, it it varies.

SPEAKER_02 23:28

Okay. So then for a patient who has or is going to go through a mastectomy, and you wait a little bit longer, and then you have to have a reconstruction surgery, how long is that? Can you even delay that?

SPEAKER_00 23:41

Um, the answer is yes, you can do all of that. And whatever you can you can, yes. For we we usually, if somebody goes through the process of mastectomy, we always offer the reconstruction. Yeah, we always have them meet with the plastic surgeon and and and depending on again what they want, we have a lot of times we do reconstruction right away at the same time. And but there is a version of that you do a delayed reconstruction, or you can do them six months later or a year later. So we have all of those options. If somebody for variety of reasons decide not to do the reconstruction right away, they can do the reconstruction later. But but usually we offer the reconstruction right at the at the time of consultation if they are considering a mistake to me.

SPEAKER_02 24:24

Yeah, are expanders even a question anymore if you have to go through expanders at this point?

SPEAKER_00 24:30

So there are several ways to do the uh reconstruction. And there is a um direct-to-implant option, means that you can do it right at the time of first operation. Um, then they can sometimes you can do expander and then transition it to implant, or you can do expander, transition it to autologous flap. So means that, for example, you can use the the your own tissue to do the reconstruction. So there is a the breast reconstruction has a lot of different options that the plastic surgeon in consultation with the with the breast surgeon, and of course, with the consultation, the patient will choose what would be the best uh kind of form of reconstruction for them.

SPEAKER_02 25:10

Dr. Habibi, I was diagnosed in 2017, and I feel like so much has changed. Every time I look, I'm like, oh, there's a new research, there's a new therapy, there's a new way of actually now attacking breast cancer, which is all amazing. Thank God for all of that. Do you feel that it is just continuously changing as much as I do? AI now is part of the factor. Do you think all of this is helping the science to just get closer and closer to making life a little bit easier for women or men who have been diagnosed with breast cancer?

SPEAKER_00 25:46

Absolutely. Yeah, you're you're absolutely right. The amount of research is incredible on it. So, and I'm you know, I am I'm part of that. I I do research all the time in the breast cancer. In the past several years, we've done a lot of research, and and you're absolutely right. AI is playing a huge role now, and it's helping in from the diagnosis, it's helping the breast radiologists to really focus on areas that is not easy to see. It does with the machine learning, it suggests uh what area that they need to focus a little bit more. So it's it's helping radiology very well, it's helping even the surgery in using, for example, the breast imaging and creating volumetric measurements of the size of tumor. And when we are kind of like doing a consultation for on the tumor that you look at the MRI and you say that you need to get the mastectomy, but with the volumetric measurements with the AI, you can look to see, you know what, actually, the percentage of the breast volume that is going to be resected, you can do an oncoplastic lumpectomy and not do the mastectomy. It's amazing. And then when it comes to the oncology, it helps tremendously with defining the right therapy for the patient. So AI is having an impact in pretty much all aspects of the same way that is aspecting the life is aspecting the breast cancer therapies as well.

SPEAKER_02 27:08

You know, I what I can't wait to read and hear about is when we have somehow figured out how someone can go into chemotherapy and the chemo can just target the bad cells and not target the good cells.

SPEAKER_00 27:21

That is the that is the holy grail of the future.

SPEAKER_02 27:23

That is absolutely that would be the goal. And that is, I think, as a society, we all win in this together. Exactly.

SPEAKER_00 27:30

That is the holy grail for sure.

SPEAKER_02 27:32

Thank you so much for uh sharing your knowledge with us. It was a lovely conversation, and I'm glad you answered all the questions that we have. Thank you so much for sharing your insight with our audience or remember viewers. Be sure to hit that subscribe button on our channel here to keep up with the latest health and wellness information and tips from our experts. Thank you so much for watching and be safe.

SPEAKER_01 27:54

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