Close
Saving...
DrAttai (Physician - Surgery - Breast (Verified) )
Communities: Breast Cancer Thank You's: 36
Member Since: Jun. 2011 Top Answers:  44
Questions:  3 Answers:  83
Ask DrAttai a question:
0    Cc:
Twitter
Facebook
Professional Statement
I am a breast surgeon in Los Angeles, CA. My private practice is dedicated to providing the highest quality care in a comfortable, supportive setting. I treat patients with both benign and malignant breast disease, and recognize the anxiety that both conditions can cause. Patient education plays a key role in maintaining health as well as in treating disease, and I strive to provide as much information as possible so that patients have a good understanding of their condition and of the treatment options.

I am an active member of the American Society of Breast Surgeons, and am currently a member of the Board of Directors, as well as Chair of the Communications Committee. I also serve as a faculty member for our annual meeting and for ultrasound and technology courses, educating other physicians on some of the latest devices and procedures. In addition, I am frequently invited to speak to community groups and I welcome these opportunities to provide education to those looking to lead healthier lives. I am also a member of the Board of Advisors for Circle of Hope, a nonprofit organization which provides financial, emotional, and educational support for breast cancer patients and their families in the Santa Clarita Valley.
Professional Info
Credential: MD
Primary specialty: Surgery - Breast
State Licenses: CA
Languages: English
Gender: Female
Age: 47
      Medical school: Georgetown University School of Medicine
      Residency: Georgetown University Hospital
      Internship: Georgetown University Hospital
Board certifications: American Board of Surgery
Professional memberships: American Society of Breast Surgeons, American Society of Breast Disease
Areas of expertise: Benign and malignant breast disease, cryoablation for benign fibroadenomas and breast camcer, accelerated partial breast irradiation, risk assessment, lifestyle modification
Research interests: Cryoablation, accelerated partial breast irradiation, minimally invasive diagnosis and treatment for benign and malignant breast disease
Hospital affiliation: Providence St. Joseph Medical Center, Providence Tarzana Medical Center
Practice name: Center For Breast Care, Inc
Practice address: 191 S. Buena Vista #415 Burbank, CA 91505
Practice phone number: 818-333-2555
Webpage: www.CFBCI.com
Personal Bio (My story)
Breast Surgeon, Advocate, Teacher, Author
DrAttai Activities
Unfortunately, a lot of the studies are either looking at either DCIS or invasive cancer; many of the studies looking at invasive cancer do not necessarily differentiate between size of the cancer (except for T1 tumors <2cm or T2 tumors 2-5cm) and many of the older studies did not stratify for the biologic behavior of a cancer, such as ER/PR and Her2/neu status. In addition, you are correct that modern use of anti-estrogen medications such as tamoxifen and aromatase inhibitors will further reduce the risk of recurrence. The NSABP B-06 trial, published in 1984, demonstrated no difference in survival in women who underwent modified radical mastectomy (removal of the breast and underarm lymph nodes but not the pectoralis muscle), lumpectomy, axillary dissection, and postoperative radiation, or lumpectomy without radiation therapy. However, the lumpectomy alone group did have a higher rate of local recurrence (39% compared to 14%), which gives the rational for our current practice of post-lumpectomy radiation (http://www.clinmedres.org/content/1/4/309.full). Some overview analyses have demonstrated that local recurrence does result in an increased mortality over a long period of follow up (http://www.ncbi.nlm.nih.gov/sites/entrez/16360786?dopt=Abstract&holding=f1000,f1000m,isrctn). The NCCN guidelines do discuss certain subsets of women that may be able to avoid radiation therapy (http://www.nccn.com/files/cancer-guidelines/breast/index.html#/68/). There is no doubt that radiation therapy, surgery, and our other treatments cause harm and unfortunately, we are not always able to predict (in terms of radiation-related complications) who will develop a firm fibrotic painful breast, who will develop lymphedema as a result of the therapy, and other potential complications. As we learn more about the biology of an individual woman's specific cancer, we should be able to provide more detailed counseling to a woman regarding HER specific tumor, HER risk of recurrence, and then make decisions about what treatment will provide the best option for long-term disease free and overall survival with a minimal or acceptable risk of complications.
DrAttai (Physician - Surgery - Breast (Verified)) replied to answer by member1136 (Caregiver)
The American Cancer Society has a publication "Exercises after breast cancer surgery" - it's a booklet with diagrams of exercises that I find to be helpful. The link is here: http://www.cancer.org/Cancer/BreastCancer/MoreInformation/exercises-after-breast-surgery
New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) Health, Surgery Recovery, Exercises, Work, Breast Surgery, Lumpectomy, Exercise, Fitness, Mastectomy
I use the HALO test fairly often in my practice. It is true that approximately 50% of women will produce fluid. Those that do not produce fluid are considered to have had a normal test, and it is unlikely that they have any abnormality of their milk ducts. If fluid is produced, it is sent for cytology evaluation to see if there are abnormal cells present. Some studies have suggested that if a condition called atypia is present, it has the same significance of atypical ductal hyperplasia found on needle biopsy, which leads to an increased risk of breast cancer in the future.

As the women undergoing the HALO test are often younger than 40 and not undergoing routine mammogram screening, if a patient has atypia found on the HALO test, I would likely recommend that she begin screening, possibly with ultrasound and MRI in addition to mammogram, earlier than age 40. However as pointed out by Dr. Bone, this can open up a whole host of other issues, including radiation exposure and false positive test results.

It is important to remember that the HALO test is not meant to detect breast cancer or to be a screening test for breast cancer. It is a form of risk assessment, meant to help us sort out if a woman should undergo screening when she normally would not. I generally do not recommend that the HALO test be performed on women over age 45.
Thanks for the great question! I always considered myself to be fairly healthy, but the reality is it was not until I got sick a few years ago that I really got the wake-up call. The gluten-free diet was a part of my whole "transformation", which has included a transition to a non-processed, primarily plant-based diet, much of which I (try) to grow myself! It has also given me a real appreciation for the amazing healing capacity of our bodies and spirits, as well a much better appreciation of what my limits truly are. While I still try to push through those limits, I'm much more accepting of my boundaries than ever before. I wrote a little about my dietary changes here: http://www.morrisonhealth.com/blog/health/dr-attais-gluten-free-diet . I also feel that what I've gone through personally has made me a much better physician; dealing with illness and recovery as a patient has taught me things that medical school and 16 years of clinical practice did not even touch!
New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) Health, Physician, Healthy Lifestyle, Clinician
Most breast surgery is performed under general, or total anesthesia. General anesthesia is very safe, but not without some risk of complication. Most commonly, a combination of medications is used - usually an inhalational agent (anesthetic gas), a narcotic (morphine derivative) for pain control, amnestic agent (medications similar to valium), and an intravenous anesthetic agent are used. Using multiple agents that have different mechanisms of action means that lower doses of each drug can be used. Anti-nausea medications are often used as well. The anesthetic medications currently used are all relatively short-acting, which minimizes the "hangover" effect of the general anesthesia. However some patients still will take a long time to wake up, or may have significant nausea after surgery.

Some lumpectomies are performed using local anesthesia with intravenous sedation ("twilight sleep"). Some centers are starting to use regional blocks for mastectomy cases, so that the patient is awake or just lightly sedated, but numb in the area of the surgery - in some studies this has shown to decrease the amount of narcotics used after surgery which may reduce nausea.
New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) Breast Surgery, Surgery, Anesthesia
In general, a lumpectomy (most often performed with a sentinel lymph node biopsy) is done as an outpatient surgery, meaning the woman will go home the same day. The usual time to return to fully normal activities can be anywhere from 1-4 weeks, depending on the patient, underarm discomfort (generally this is worse than the breast discomfort) and various other factors.

After a mastectomy, some patients go home the same day, although I think most commonly patients are in the hospital for 24-48 hours. I will also depend if reconstruction is performed and what type - patients that undergo muscle flap reconstruction may spend 3-5 days in the hospital. Recovery can vary from just a few weeks up to 6-8 weeks, again depending on the type of surgery / reconstruction, amount of pain, and other factors. After mastectomy, drainage tubes are commonly left in place and may remain for 1-2 weeks.
New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) Surgery Recovery, Recovery Time, Surgery Recovery Time, Breast Surgery, Lumpectomy, Surgery, Mastectomy
"NED" stands for "no evidence of disease" and is probably the term most often used to describe a patient's status after treatment. Unfortunately, we can never truly say a patient is cured of cancer - the best we can do is say that we find no evidence of it. I will often tell my early-stage (lymph node negative) patients after surgery that they have no evidence of disease, and the medical oncologists will use the term after they've evaluated scans and bloodwork and find no abnormality.

It's important to realize that you can have areas of cancer, not detected by scans or blood tests, and still be considered NED. I'd look at NED as not perfect (very few things in life are), but still a good place to be.
New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) NED (No Evidence Of Disease), Cancer
Usually after mastectomy and reconstruction, imaging such as mammogram is not performed as all or almost all of the breast tissue is removed. MRI is sometimes performed every few years, but primarily to assess the integrity of silicone implants, if they were used for the reconstruction.

There are no standard recommendations for imaging in a patient that has undergone mastectomy and implant reconstruction - usually careful physical exam every 6 months is recommended as a recurrence will most often present as a palpable lump (able to be felt). In cases where it is difficult to differentiate scar tissue from recurrence, biopsy is usually performed.

If reconstruction is performed using a muscle flap, MRI or ultrasound are probably the most helpful tests to rule out recurrence, but again there are no standard recommendations for post-mastectomy imaging.
Thanks for the question - cryoablation is fascinating technology, and involves freezing a lesion and then essentially letting nature run it's course. The freezing destroys the tumor cells, and the body then reabsorbs the dead cells. Cryoablation is not new technology, and has been used for some time for tumors of the liver, prostate and kidney. In my practice, it is a standard option for fibroadenomas, which are bengin breast tumors. While cryoablation is still at this time considered to be experimental for breast cancer, a national trial which hopefully should complete enrollment sometime this year is showing promising results. In addition to destroying the tumor without surgery, some early studies have suggested that there is an immune response to the the ablated tumor - anti-tumor antibodies may form...could this be a type of auto-vaccine? Time will tell, but I am so excited about the possibility to have an option besides surgery for selected patients with early stage breast cancer! Here's a link with more information about the clinical trial: http://www.cancer.gov/clinicaltrials/search/view?cdrid=600976&version=Patient&protocolsearchid=5787655
New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) Breast Cancer, Breast Surgery, Cryoablation, Surgery, Cancer Surgery, Cancer
An excellent comprehensive answer. I'll just reinforce a few points - enlist an advocate, and ask questions. A new diagnosis of cancer or other serious illness is much too much for one person to handle alone, and you don't have to handle it alone! Write down your questions, and don't agree to any test, procedure, or treatment until you feel you've had a good explanation of why the test or treatment is necessary, and what the alternatives are.
New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) Cancer Diagnosis, Newly Diagnosed, Just Diagnosed
I just want to stress that if reconstruction is not performed, or if autologous (muscle or fat flap surgery) is performed, the chest muscles and the muscles under the arm are generally NOT cut. For removal of the lymph nodes under the arm, the muscle is usually stretched to gain entry into the underarm area, but it is not standard to cut the muscle. However, chest wall discomfort still is typical and in some patients can last for several weeks or longer. If reconstruction is performed with tissue expanders or implants, the pectoralis muscle is cut, stretched somewhat so the tissue expanders can be placed under the muscle, and then the muscle is re-sewn back. This definitely leads to significant chest wall pain and muscle spasm; we will often recommend the use of a mild muscle relaxant in addition to pain medication for patients undergoing this surgery. I would reinforce Lockey's recommendation for gentle stretching as soon after surgery is possible - it is extremely helpful in terms of regaining range of motion.
DrAttai (Physician - Surgery - Breast (Verified)) replied to answer by member9744 (Survivor (2 - 5 years))
Unfortunately I don't know of any specific surgical therapy - often the nerve is so small that it is not even known that it was cut. I would seek out the opinion of a chronic pain specialist (if you have not done this already) - usually this is anesthesiologist who specializes in treating patients with chronic pain. Sometimes nerve blocks or other procedures may be effective. Best of luck to you in dealing with this very difficult situation.
DrAttai (Physician - Surgery - Breast (Verified)) replied to answer by member1312 (Survivor (2 - 5 years))
Thanks for the question! The San Antonio Breast Cancer Symposium is one of the largest and most prestigious breast cancer conferences, and often exciting and innovative research is presented. However at the recent meeting, a study was presented by a group from MD Anderson, questioning the safety and effectiveness of accelerated partial breast irradiation (APBI) for early-stage breast cancer - specifically they noted that patients undergoing this treatment have a higher rate of complications and eventual mastectomy. Unfortunately before the study was even presented, it received national media attention, leading to significant anxiety and confusion among women. This stresses the importance of reading the study, not just listening to the sound bite - here are some facts:
- The study used retrospective (after the fact) "claims data" to do their evaluation. That means they took Medicare billing information, not actual patient data, and drew some conclusions. It is NOT possible to accurately determine complication rates from claims data as they are not always reported. It is also not possible (and the authors admitted this) to determine why the women treated with APBI subsequently underwent mastectomy - it could have been for an entirely different cancer, even one in the other breast!
- The absolute increased risk of mastectomy was 1.8% which is quite low, and again we have no way to know why the women underwent mastectomy
- APBI has been the subject of multiple prospective (going-forward) and peer-reviewed studies, and has been shown to have an equivalent or in some cases better rate of breast cancer control compared to whole-breast irradiation; the complication rate is also equivalent.

3 respected professional medical societies published responses critical of the MD Anderson study, and I expect more criticism will come. The responses are from the American Society of Breast Surgeons: https://www.breastsurgeons.org/news/article.php?id=122, the American Brachytherapy Society: http://campaign.r20.constantcontact.com/render?llr=kdofiegab&v=001rj64Pj8NTf4ISgwN4cSdZYtZBR53GjAi73j4En_qeygPzWmSUe1qgGI7U-jt8HRV7NouL9sMViv1IOOeGT2QHMAaDWrfEuOApREAHj-8Z60%3D and the American Society for Radiation Oncology: https://astro.org/News-and-Media/News-Releases/2011/ASTRO--APBI-safe,-effective-for-some-breast-cancer-patients.aspx

It is again unfortunate that this poorly designed study with no real valid clinical data was allowed to be presented at such a prestigious meeting, and that it received immense national media attention before the scientific community was allowed to interpret the study and respond. I am hopeful that this will not happen in the future, as many women (and many physicians) were caused unnecessary anxiety regarding their breast cancer treatment options.
Our patients have had a lot of success with Udderly Smooth cream - it comes in a big tub - good for elbows and feet, too!
New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) Aquafor, Mederma, Vitamin E Cream, Radiation, Lotion, Aloe Vera, Radiation Treatment, Skin Cream, Topical Cream, Silvadene Cream, Biafine, Skin Care
The minimum amount of breast cancer that can be detected depends on what type of cancer you are dealing with. In terms of a lump or mass (usually representing an invasive ductal cancer), a tumor as small as 3-4 millimeters (25 millimeters = one inch, so 3-4 millimeters is well under 1/4 of an inch) can sometimes be seen on mammogram, ultrasound or MRI, depending on the density of the breast tissue. DCIS, or in-situ (or noninvasive) cancer often does not form a mass, and typically is detected when microcalcifications are seen on mammogram - again the amount of disease can range from just a few millimeters to a much larger area. Unfortunately both non-invasive and invasive cancers can be present without microcalcifications or a mass on imaging, so sometimes it is very difficult to get a true idea of the extent of disease before surgery. Once the tissue is removed, the pathologist will measure the size of the cancer - it may be larger or smaller than what was anticipated based on the imaging studies.

As far as the minimum amount of breast tissue removed at lumpectomy - it really varies tremendously - there is no standard. The goal of a lumpectomy is to remove the tumor and a "margin" - a rim of normal breast tissue - and still preserve as best possible the cosmetic appearance of the breast. There remains considerable debate on what an adequate margin is - some will be comfortable with no cancer cells right at the edge of the specimen, and some like to go for a wide margin, as large as one centimeter (10 millimeters) or greater. As in many areas, the truth is probably somewhere in between - usually 2-5 millimeters is generally acceptable for invasive cancer and 5 millimeters or greater for DCIS. But as I mentioned in the paragraph above, it can sometimes be difficult to estimate the true extent of the cancer, which makes it very difficult to give a good estimate prior to surgery of just how much tissue will be removed. In addition, at the time of surgery sometimes areas of adjacent tissue look or feel abnormal - it's sometimes a judgement call how much to remove. We try to balance between not having to return to the operating room due to positive margins, versus the poor cosmetic results of removing too much normal breast tissue.

There are some devices being evaluated that are looking at intraoperative margin assessment - being able to tell during the surgery if breast tissue at the edge of the tumor has cancer cells or not. These devices are under investigation, but do seem promising for providing the surgeon more information during the procedure regarding how much tissue to remove.
New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) Minimally Invasive Breast Surgery, Lumpectomy Margins, Breast Surgery, Lumpectomy, Breast Cancer Detection
I agree with Dr. Feldman's answer - there is no question that complementary techniques can help put a patient in a better physical and mental state prior to undergoing therapy, and can help manage the side effects of therapy. Just as we have come to appreciate the importance of proper nutrition, exercise and sleep in the maintenance of health and prevention and treatment of disease, I think that CAM will also play an increasingly important role in disease prevention and treatment.
New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) Complementary Treatments, CAM (Complementary And Alternative Medicine), Surgeons
It is possible - I would suggest contacting Myriad Genetics through their website (listed above) / customer service and they might be able to make some suggestions based on your prior testing.
DrAttai (Physician - Surgery - Breast (Verified)) replied to answer by DrAttai (Physician - Surgery - Breast (Verified))
The following information is from the site Facing Our Risk: http://www.facingourrisk.org/index.php - a national nonprofit organization devoted to hereditary breast and ovarian cancer.

"Women with a BRCA mutation or other hereditary breast cancer who choose breast conservation to treat their breast cancer are at higher risk for another cancer in either breast than women with sporadic breast cancer. Although the exact risk depends on a woman’s age and other factors, one study found that BRCA carriers diagnosed with breast cancer have a 14% chance within ten years of developing the disease in the same breast, and a 37% chance within ten years of developing the disease in the opposite breast. Another study found a 40% chance for BRCA carriers to develop cancer in the opposite breast within ten years of their initial diagnosis. The risk for a second breast cancer among women who develop sporadic cancer is about 10%."


New answer by DrAttai (Physician - Surgery - Breast (Verified)) in topic(s) Breast Cancer Recurrence, Breast Cancer, BRCA Mutations, BRCA-2, Breast Cancer Risk, Recurrence
DrAttai's Profile


Breast cancer questions and answers.
Personalized, helpful, and accurate health information.
Share TalkAboutHealth
Invite friends to join the Community

Give a 'Thank you' to
Thought for
Close
TalkAboutHealth
Please join TalkAboutHealth and you will be able to ask questions.
Join Now
Close
Your question to DrAttai:
Optional: What context or background information is relevant to this request?
Notes:
The more clear and thorough your request, the more likely you will receive support.
Many of our members are learning from this information or english might not be their first language. Please use standard english and spell out all words. For example, use 'you' instead of 'u'.