July 27, 2011 Interview with Babak Mehrara, M.D. Plastic & Reconstructive Surgeon Memorial Sloan-Kettering Cancer Center New York, New York (CL= Cheri Laser, Author/Interviewer; BM=Dr. Babak Mehrara) CL: The purpose of the book I’m writing—Under Construction: A Body & Soul after Mastectomy—is to target newly diagnosed breast cancer patients, to give them a source they can reference that has humor, information, sort of a respite from the fear—something that’s not too technical, a place for them to get started. So, given that target audience, I was wondering—just to start this conversation—if you had one thing to say to a brand new breast cancer patient, what would that be? What would be the first thing you would say? BM: Well, they’re going to be overwhelmed. But there are lots of resources out there to help them—lots of things available to get them through it. They’ll get through it with support from their health care professionals, families, friends, and online communities. So they should not despair. CL: Great. Thank you. That’s the kind of thing people want to hear, because in the beginning, when you first hear you have breast cancer, it’s very frightening. My situation was a little diluted in that I’d already had cancer. So it wasn’t the first time I’d heard it. But even so, it was really terrifying. Now … I’ve kind of divided these questions into two segments. One is about you, and one is about the technical parts of the reconstruction and other pieces of information that I want to include, to help people with their decisions. And then any closing comments. BM: Okay. CL: Do you mind if I read these questions? I tried to memorize them, but I was unsuccessful. BM: Sure. CL: Other than offering your technical skills, how do you approach those first meetings with new breast cancer patients? And you may have already answered this with your first answer, so if you don’t have anything to add, let me know. What do you do to reassure them and help reduce the anxiety that every woman brings into that first meeting with you? BM: Well, I spend a lot of time with them during the first visit trying to gauge … to get an idea of what they are, what their life is about and their social situation, and what the context of the breast cancer is, so it’s not in isolation. So, we do that—and then we go through the various options for reconstruction, then we try and figure out what’s the best method for that particular person. And then I show them lots of different pictures of various options for reconstruction and how they can … what they can expect from them. Then we go through questions, if they have any. So really, just a lot of time trying to tailor the type of reconstruction that we do for the
person, depending on their life circumstances, their oncological issues, and as best as I can glean, their desires for reconstruction. CL: Okay. When women come in for that first meeting, how many have already decided to do a mastectomy and reconstruction versus how many are coming to talk to you to get information to make that decision? BM: I think most people who come to see me have already made that decision. CL: They have. Okay. Thinking back on those first meetings again, was there a particularly challenging first meeting you had that produced lessons you think would be useful to new breast cancer patients? BM: I think breast cancer patients continuously teach me new things. People come up with questions I didn’t expect—things that didn’t worry … that I wouldn’t have thought were issues but were issues to them. And I think I continuously try to figure out ways to get my message out better so that it’s more understandable and less technical, less scary. So, I don’t think there are any specific examples. It’s a continuous process where I can continue to learn. CL: Did they teach you about that first meeting in medical school, or is that something you kind of have to learn as you go? BM: No, they never did that. They never taught me anything about that in medical school. We do have a resource here at Memorial for how to communicate better with patients. I did that, actually, my seventh or eighth year into practice, and it actually did help. I found that I had learned a lot of those techniques by myself through trial and error, but you know there’s actually a fair bit of research that’s done on this. So that was helpful. CL: On the first meeting? Or on that … BM: That’s in general … on talking to patients. On giving them bad news, or giving them good news, conveying information, and trying to get them to remember a particular point that you’re trying to make. CL: Through the fog … the fog of fear. BM: Make the message memorable. CL: Right. Are there usually people in the room with them—family members or somebody who can help them remember those things? BM: Sometimes. CL: Or is the woman more often than not by herself? Trying to hear all of this?
BM: It’s probably 50-50. CL: Okay. BM: Yeah, I’d say 50-50. CL: So, in your opinion, is it helpful to have a family member in the room to help remember all these things? BM: Well, you know, coming from a big family, I always think it’s good to have people around. Sometimes it can be disruptive, though. Sometimes, if a family member is too vocal, they can end up taking some of the attention away from the patient. They can end up confusing the issue sometimes, or interrupting, and I forget things or they forget things. So I think it can be good and bad. Most of the time, it’s good. CL: Okay, good. Switching gears a little bit, to you … of course, for me, you’re a star. But what led you to the reconstructive specialty in the first place? Was there one motivating moment? BM: Well, I always liked plastic surgery because I thought it was very creative and fun. I thought it was interesting because it was … you don’t sort of do the same thing over and over again. Plastic surgeons are really the last general surgeons left other than maybe pediatric surgeons. We operate on everyone, you know, from babies to ninety-year-olds. We operate from head to toe. So, we don’t just do breast reconstruction. We do all kinds of other reconstruction. So that really is interesting and challenging. So, on a given day, I could do a breast reconstruction, a head and neck reconstruction. Lots of different things. So I like that. I like the challenge. I thought it was better than … to me, it was better than just cosmetic surgery because I thought it was more challenging to repair something as opposed to just sort of tweak something. So those are the things that I like. CL: So that’s what led you into the cancer reconstruction versus the regular cosmetic practice? BM: Yeah, I suppose. I also did additional training in microsurgery, where we transfer tissue from one part of the body to another. And that’s typically used in cancer reconstruction. So that’s the other thing that sort of pushed me in this direction. CL: Okay. How many years have you been here doing that now? BM: This is the beginning of my tenth year. CL: Actually, you answered one of my questions, because I had a question about what percentage of your time is spent on breast reconstruction versus other … BM: Ninety percent. CL: Ninety percent! So ten percent covers the rest of the body?
BM: I used to do other stuff more frequently before. But now most of my time is spent on breast reconstruction. CL: Since you first began your cancer reconstruction work, how much of an increase in breast cancer have you witnessed? BM: Well, there’s definitely more activity now. But I think that may be due, in large part, to the fact that we’re getting a lot more early detection than when I started. And early detection means there are more treatment options available, which means I see more of those patients. CL: Once a woman embarks on the reconstruction path, what is the average length of time for the full reconstruction process to be completed? BM: One year. CL: Since nipple reconstruction is an optional part of the process, what percentage of your patients decides not to proceed with that? BM: Only fifty percent or less opt for nipple reconstruction. CL: Really? Why is that? BM: Well, the reasons can be as varied as the patients, and it sort of comes down again to how the breast cancer fits in context with the rest of the person’s life. For some women, replacing the nipples just isn’t important. Other women are just tired of having surgery. So, there are lots of reasons. CL: What is the most common positive occurrence or development that you observe in your patients as they move through the reconstruction process? BM: Women are clearly more informed and more comfortable with their decisions relative to their breast cancer, their treatment, and their outlook in general than they were even just a few years ago. And that’s probably the biggest positive change I’ve observed. CL: And conversely, what is the most common challenge faced by your patients throughout the reconstruction process? BM: There’s not enough attention paid to the mental and emotional effects of breast cancer on women—the effects on self-image, their personal relationships, sexuality, and the impact that breast cancer has on the whole person. Also, there have always been a lot of myths and rumors about breast reconstruction—and those still exist in rather alarming numbers. CL: Seriously? What sorts of myths and rumors?
BM: Things like breast implants making it more likely that there’ll be a recurrence—or that having implants will interfere with or complicate future treatment should there be a recurrence— neither of which are true. There is no data that demonstrates a connection between recurrences and the presence of implants—and it’s highly unlikely that implants would even need to be touched in order to proceed with recommended treatment. Yet, the myths and rumors persist nonetheless, and they are more prevalent in certain parts of the country. CL: I find that astonishing! I need to research that element of this subject in depth. BM: You should for this book. And there’s something you might want to read as part of your research—a book called Emperor of All Maladies. The author’s last name is Mukherjee. It’s sort of a biography of cancer but with a lot more involved, and I think you might find the information very valuable. There’s another book too—Made to Stick—author is Heath … it’s actually by two brothers. Speaks to why some ideas—or myths and rumors—have longevity when others don’t. CL: Thank you! I will definitely add those to the to-do list. BM: And here’s something that I’m guessing will surprise you—only thirty to forty percent of women who have mastectomies have immediate reconstruction. CL: You’re kidding! I am surprised! So, sixty to seventy percent of the women in those parts of the country you just discussed will live for some number of years with the mastectomies only? BM: Or for the rest of their lives. CL: But why? BM: For a variety of reasons, they are not referred to a reconstructive surgeon. Sometimes we as reconstruction surgeons sort of get the blame—either we hear that we’re not available, or there’s an issue with proximity. But there are other reasons as well. I just saw a patient today, for example, whose breast cancer physician told her that breast reconstruction was cosmetic rather than treatment. CL: I find that unbelievable! In what parts of the country is this situation most prevalent? BM: Well, we do run into this more frequently in less populated, more rural parts of the country where you don’t find large cancer centers nearby. But the challenge is not just there. We run into it here as well. CL: By “here,” do you mean in New York? BM: Yes. The physician in the example I just mentioned from earlier today works here at Memorial.
CL: But I thought—it was my understanding—that reconstruction is considered part of breast cancer treatment—at least one of the treatment options. BM: Well, sometimes there’s an insurance situation. But, generally speaking, reconstruction is included in the options for breast cancer treatment. So, debunking the myths and rumors about breast reconstruction—even, and sometimes especially, with members of the breast cancer medical community—remains a significant challenge. CL: That must be incredibly frustrating. BM: It can be. CL: Well, I’m definitely adding this subject to the book. I’d really like to reach those women who aren’t hearing the whole story. BM: Good. CL: We are starting to run out of time, so I have one more question, and then I’ll ask you for some closing comments. BM: Okay. CL: Given your experience, do you believe that there are traits and/or circumstances shared in common among long-term breast cancer survivors? And if so, what would those be? BM: Well, from my observations, women who are forced into decisions—forced into having a prophylactic mastectomy, for example, on the breast without cancer—do not fare as well. Women who make their own decisions do the best. And, in terms of overall survival, that is clearly affected by early detection and treatment enhancements that have taken place over even just the past few years. For example, HER2 positive breast cancer used to be a very bad thing. But now there are targeted treatments that are altering the outcomes with encouraging results. CL: Thank you. Now, in closing, what message would you like to convey to the newly diagnosed breast cancer patients who will be reading Under Construction—A Body and Soul after Mastectomy? BM: Well, I think it’s a good idea that you’re writing this book—giving women one more option to consult in order to make the most considered decisions for themselves and their lives. At the point after they’ve received the diagnosis, they need to be listening to the professional input so they can ultimately sift everything down and arrive at the best choice that fits them and their lifestyle and circumstances. CL: So, should they also be educating themselves—using online resources, among others—in order to become more proactive with their care?
BM: No, I personally don’t think that’s a good idea. They need to listen rather than searching the Internet. If you had a complicated tax problem, you’d seek out a qualified tax professional rather than Googling “complicated tax problem.” Likewise, if a twenty-five-year-old single woman, who is into sports, lives in a fifth-floor walkup, and would like to have a family someday, has done a lot of online “research” on trans flap reconstruction versus implants, she might have decided on her own that the trans flap is what she wants because the “research” says it “looks more natural.” But she needs to listen to her doctors about the specifics—the details and realities—of the trans flap option. If she lives alone, she might not have anyone to take care of her during the several weeks of recovery. And the invasive abdominal surgery involved with trans flap might have a major negative impact on her future ability to participate in sports or to sustain a pregnancy. So, these are conversations women need to be having with their doctors rather than trying to find all the answers on the Internet or trying to “control” their own care. The breast cancer patient needs to be guided by her doctor since she isn’t a doctor. And I do my best to tailor my comments and recommendations to the patient’s individual situation and the personal dynamics of her life. She then needs to listen, let everything settle, and then make the best decision for herself. CL: Does “listening” include seeking additional opinions? BM: Not if it’s just for the sake of getting additional opinions. There are some valid reasons to seek additional opinions: if there’s something unusual about the case and some reason to believe that the first doctor might not be the best equipped to handle the situation; if the doctor isn’t listening to the patient’s concerns; if there appears to be some sort of major disconnect between the patient and physician. Otherwise, there can be a substantial risk in delaying treatment for invasive breast cancer just so the patient can wait for a second, third, or fourth opinion. If the diagnosis is fairly standard, routine, straightforward, there shouldn’t be any need for additional opinions, since nothing will be gained. Again … women should 1) listen, 2) distill all of the information, and 3) make a considered decision that’s targeted and relative to the specifics of their lives. And, as I said in the beginning, there are lots of resources available now to help women through the process of breast cancer treatment—whatever those decisions might be—in addition to the support they’ll receive from their families and friends. CL: Thank you so much, Dr. Mehrara, for giving me your time today. I’m deeply grateful. BM: You’re welcome. Good luck with the book.