What should we understand first when facing a breast cancer diagnosis?
We should understand that a diagnosis is the beginning of a series of decisions, not the end of the story. We need to learn what kind of cancer we are dealing with, how extensive it is, and which treatments are likely to help. Breast cancer care has changed enormously. We have better ways to detect disease, more precise ways to plan surgery, and more treatment options than we once did. Dr. Armando Giuliano joins Dr. Thais Aliabadi and Mary Alice Haney to discuss the current state of care.
We also need to remember that an early diagnosis and an advanced diagnosis are not the same conversation. The questions we ask, the tests we need, and the choices available to us depend on the individual cancer. That is why we keep returning to two ideas: know our personal risk before a diagnosis, and get the right information after one.
Everything here is educational. Our own screening or treatment plan belongs in a conversation with our medical team.
Table of Contents
- Making Breast Surgery More Precise
- Understanding the Diagnosis
- Risk, Screening, and Imaging
- Life After Surgery and Treatment
- Better Decisions, Better Questions
Making Breast Surgery More Precise
How can we improve the chances of preserving the nipple during a mastectomy?
When we perform a nipple-sparing mastectomy, preserving the nipple is not simply a matter of leaving it in place. It needs an adequate blood supply to survive after the breast tissue underneath it has been removed. Scars, previous radiation, smoking, and other factors that affect blood vessels can make that more difficult.
One option for a patient at higher risk of losing the nipple is a procedure called nipple delay. Dr. Giuliano developed it with plastic surgeon Jay Arthur Jensen after treating a patient whose breast and nipple had extensive scarring. She wanted treatment for her cancer but also wanted a nipple-sparing operation. The concern was that the existing scars had compromised the nipple’s blood supply.
In a nipple-delay procedure, we interrupt some of the blood vessels beneath the nipple before the mastectomy. We then allow time for blood vessels from the surrounding skin to strengthen their supply. After roughly two weeks, we proceed with the main operation. The goal is to improve the likelihood that the nipple survives. It is not a guarantee, but for the right patient it can change what is possible.
The idea draws on an old principle of reconstructive surgery: tissue can adapt when its blood supply is changed in stages. What matters today is that a technique developed for a difficult case may help other patients who strongly value nipple preservation. We should bring that preference into the surgical conversation early, so our surgeon can explain whether nipple-sparing surgery and a delay procedure are appropriate.
What is a sentinel lymph node biopsy, and why did it change breast cancer surgery?
We used to remove many lymph nodes from under the arm when someone had breast cancer, largely to find out whether the disease had spread there. That operation provided information, but it could also carry a substantial physical cost: arm numbness, limited shoulder movement, and lymphedema, in which the arm swells. We wanted a way to obtain the information without putting every patient through extensive node removal.
The sentinel node is the first lymph node, or one of the first nodes, reached by lymphatic drainage from a cancer in the breast. We can identify it by injecting dye or a radioactive tracer into the breast and following where it travels. We then remove the identified node for examination.
Dr. Giuliano performed the first sentinel lymph node biopsy for breast cancer in 1991. The early experiments were not straightforward. Initial attempts did not work reliably, and it took a more organized approach with a young trainee to determine how to identify the node. The team compared the sentinel node with the other nodes removed from the same patients. Their finding was powerful: examining that first node could predict the status of the others.
Instead of routinely removing a large number of nodes merely to stage an early breast cancer, we could often remove far fewer. By around 2000, sentinel node biopsy had become widely used. Later research changed practice again. A positive sentinel node does not automatically mean every other underarm node must be removed. In appropriate situations, radiation or systemic treatment can be used without more extensive node surgery. The exact circumstances matter, so we should never turn that finding into a blanket rule for every patient.
Why does the timing of lymph node evaluation matter?
Sentinel node mapping depends on being able to trace drainage from the breast. If breast tissue has already been removed and cancer is discovered afterward, that opportunity may be lost. We may then need a more extensive axillary node dissection to determine whether cancer reached the nodes.
We know this is not an abstract distinction. After a double mastectomy, Dr. Aliabadi learned she had cancer. Because the breast tissue was gone, sentinel node identification was no longer an option in her case. She needed an axillary dissection and experienced restricted arm movement and cording afterward. Physical therapy became part of her recovery.
That experience makes preoperative planning incredibly important. If an abnormality raises concern that cancer might be found after mastectomy, we should ask how lymph nodes will be assessed and whether sentinel node biopsy should be considered at the time of surgery. We cannot decide that from a general article or from age alone. We can, however, make sure the question is asked before the opportunity disappears.
Understanding the Diagnosis
What kinds of breast cancer are we most likely to hear about?
We can begin with the anatomy. Lobules produce milk, while ducts carry it toward the nipple. Most breast cancers are ductal in origin, and a smaller proportion are lobular. Dr. Giuliano describes roughly 80 to 85 percent as ductal and about 15 to 20 percent as lobular.
That distinction can matter when we are trying to find a cancer. Ductal cancers may be easier to identify on a mammogram. Lobular cancers can be more subtle on imaging and harder to feel. They may also affect both breasts. MRI can be useful when a mammogram does not provide the full picture, although no imaging test is perfect. In Dr. Aliabadi’s experience, her mammogram did not reveal her lesion; an MRI showed an abnormality, but it was initially read as benign.
We also discuss inflammatory breast cancer, an aggressive form that affects the skin. It can cause visible skin changes. Its treatment may include chemotherapy and, depending on the cancer’s biomarkers, immunotherapy. The essential point is not to diagnose a cancer from a description of its appearance. It is to bring concerning breast or skin changes to a clinician promptly.
When we catch breast cancer through screening, we are often finding stage zero or stage one disease. Early cancers commonly have hormone receptors, which can open up treatment options. We cannot promise an outcome from a stage label alone, but detecting disease early gives us a much better opportunity to act.
What is the difference between chemotherapy and immunotherapy?
We use these words so often that it is easy to miss how differently the treatments work. Chemotherapy acts against dividing cells. Cancer cells divide, but so do some healthy cells. That helps explain why chemotherapy can cause effects such as hair loss and diarrhea.
Immunotherapy works through the immune system. Certain cancers can take advantage of mechanisms that limit an immune response. Immunotherapy can interfere with those mechanisms so the immune system is better able to fight the cancer.
These are not simply two interchangeable treatments. We choose based on the cancer. Triple-negative breast cancer and some advanced cancers may be treated with both chemotherapy and immunotherapy. For inflammatory breast cancer, biomarkers help determine which approaches may be appropriate. We should ask not just, “Will we need treatment?” but, “Why is this particular treatment right for this particular cancer?”
What happens in the workup after a breast cancer diagnosis?
We start with a careful physical examination. We want to understand what can be felt in the breast, whether lymph nodes are palpable, and whether the cancer appears attached to the skin or chest wall. We also review the imaging that led to the diagnosis, typically a mammogram and ultrasound.
From there, we add tests for a reason, not simply because more testing sounds reassuring. An MRI may help when dense breast tissue makes a mammogram difficult to interpret, when we suspect something hidden, or when we need to look more closely at the other breast. We may use blood tests in some circumstances to look for signs of disease elsewhere. But with an early breast cancer, spread to another organ is extremely rare, and extensive staging scans such as bone scans or PET scans are generally not needed.
We cannot look at one cancer and say exactly how fast it will spread. We can assess how serious it appears by considering its stage, grade, lymph node findings, and biomarkers. Tests such as Oncotype and MammaPrint may also help guide a treatment plan. Then we bring in something no test can replace: the patient’s preferences.
We should leave a treatment discussion knowing what information drives the recommendation, what alternatives exist, and which decisions are time-sensitive. If we do not understand, we should keep asking.
Risk, Screening, and Imaging
Why are we so focused on knowing lifetime breast cancer risk?
“High risk” sounds specific, but without a number it can mean different things to different people. Some of us overestimate our chance of developing breast cancer. Others underestimate it. When we calculate a lifetime risk and discuss what went into it, we have something more useful than a vague impression.
Dr. Aliabadi points to an average lifetime risk of about 12.5 percent for an American woman. A result of 20 percent or more changes the screening conversation substantially. Family history or an inherited mutation may change it further. We can explore how breast cancer risk assessments work before discussing our own result with a clinician.
A risk number is not a prediction of what will happen to one person. It is a tool for deciding what to discuss: when to begin imaging, whether MRI belongs in the plan, whether genetic evaluation is appropriate, and whether risk-reducing medication or surgery deserves consideration. Knowing the number does not take away our choice. It gives us a more informed choice.
We have seen why this matters when age-based screening alone overlooks someone with elevated risk. Dr. Aliabadi described a patient with family history and an estimated lifetime risk of about 38 percent. After a change in care, she went several years without the imaging previously recommended for her and returned with advanced breast cancer. We cannot know from that story exactly what earlier imaging would have shown. We can know that her risk information needed to travel with her when her care changed.
How do we match mammograms, ultrasound, and MRI to our risk?
We begin by separating general screening guidance from an individualized practice approach. Dr. Giuliano recommends annual mammograms beginning at age 40 for someone at average risk. Dr. Aliabadi also starts annual mammograms at 40 for her average-risk patients, while often obtaining a baseline mammogram at 35. Dr. Giuliano considers that baseline reasonable but notes the tradeoff: breast cancer is uncommon at 35 across the general population, so many mammograms would be needed to find one cancer.
Breast density is another part of the conversation. Dense tissue can make a mammogram harder to interpret. Dr. Aliabadi commonly adds a screening breast ultrasound for patients with dense breasts. Ultrasound can provide additional information, but it is a complement to mammography, not a replacement. We should learn our density result and ask what, if any, supplemental screening makes sense for us. More detail on that decision is available in this discussion of breast density after mammograms.
For someone whose lifetime risk is 20 percent or higher, both doctors describe adding breast MRI and alternating imaging at roughly six-month intervals. Dr. Aliabadi’s approach is to begin higher-risk breast imaging as early as age 30. For patients with a BRCA1 or BRCA2 mutation, she discusses starting even earlier, around age 25. Those starting points require an individual plan with the treating team.
Dr. Aliabadi also describes an intermediate group, with lifetime risk between 15 and 20 percent. In her practice, that can mean mammography from age 40, ultrasound when dense breasts warrant it, and consideration of an MRI every few years. We should not treat those intervals as a universal prescription. The point is to ask why our screening schedule fits our risk rather than accepting a schedule based on age alone.
When should we ask about genetic testing or ways to reduce risk?
If breast cancer runs in our family, we should raise it with our doctor rather than assume someone else has already accounted for it. Genetic testing may be part of the discussion, particularly when an inherited risk such as BRCA1 or BRCA2 is a concern. We also need help understanding what a result means. A positive result can affect decisions about screening and prevention; a negative result does not make every other risk factor disappear. We can learn more about the process through this guide to genetic testing for cancer.
We have choices beyond surgery. Enhanced imaging is an option for some people who do not want a risk-reducing mastectomy. We may also discuss medication. In the conversation, tamoxifen is offered as an example of a medicine that can substantially lower breast cancer risk for an appropriate high-risk patient. Whether it is suitable depends on the person and the type of risk being addressed.
One woman with a BRCA1 mutation told Dr. Aliabadi she did not want intensive imaging or breast removal. The medical team’s responsibility was to explain the risk and the available options. The decision remained hers. We can disagree with a recommendation or decide against a preventive operation, but we deserve the chance to make that decision with clear information.
Life After Surgery and Treatment
Can we take hormones after breast cancer?
This question is difficult because the symptoms are real. Dr. Aliabadi takes an estrogen-blocking medication following her breast cancer diagnosis and describes frequent hot flashes and severe vaginal dryness. As a gynecologist, she had treated vaginal dryness for years; living with it gave the problem a new dimension. We need room to speak frankly about quality of life during treatment, not only about the cancer itself.
We must distinguish local vaginal estrogen from systemic hormone replacement therapy. Dr. Giuliano describes research supporting the use of vaginal estrogen for dryness in people with a history of breast cancer. Systemic hormone replacement is a different question because hormones circulating through the body may be a concern after a breast cancer diagnosis. His general answer is not to prescribe systemic hormone replacement for breast cancer survivors.
These decisions should be made with the clinicians who know our cancer and our treatment. We should tell them exactly which symptoms are affecting us and ask which options they recommend. Hot flashes can be particularly frustrating: a treatment that helps one person may do little for another. We should not have to pretend the side effects are easy simply because the cancer treatment is important.
There is also an important distinction between having had breast cancer and having had a prophylactic mastectomy without a cancer diagnosis. Dr. Giuliano says systemic hormone therapy may be possible in the latter situation, including for someone with a BRCA mutation who has undergone preventive surgery. Again, the decision is individual. Our surgical history and cancer history are not interchangeable.
Do we need routine MRI or ultrasound after a double mastectomy?
We hear a genuine difference in emphasis here. Dr. Giuliano explains that routine imaging is not recommended by guidelines after an adequate mastectomy. In patients his team studied who developed cancer after prophylactic surgery, the cancers were detected by examination. With only a thin layer of skin and tissue remaining, an abnormality may be felt.
Dr. Aliabadi’s concern comes from what she has encountered in practice: some patients still have substantial breast tissue after a reported double mastectomy. She describes having had significant tissue left after her own first operation. If she can feel what appears to be remaining breast tissue in a patient, she is more inclined to order imaging. Dr. Giuliano agrees that imaging is reasonable when residual tissue is suspected.
These statements are not the same as saying that everyone needs a routine MRI after mastectomy, or that nobody ever needs imaging. We need to know what operation was performed, what tissue remains, whether we have a cancer history, and what our examination shows. If we notice a new lump or change, we should bring it to our medical team rather than wait for a scheduled test.
Better Decisions, Better Questions
What gives us reason to be hopeful about breast cancer care?
We have made progress on more than one front. Surgery has become more selective. Radiation, chemotherapy, and immunotherapy have improved. Detection has improved too. Dr. Giuliano points to three-dimensional mammography, also called tomosynthesis, as an advance over older mammography equipment. He expects diagnostic tools to keep developing, while recognizing that technology does not replace a skilled surgical team.
Hope does not mean telling every patient that treatment will be simple or that every outcome is certain. It means understanding how many decisions can now be tailored to the cancer in front of us. It also means staying engaged with screening and seeking help promptly when something is wrong.
We should feel comfortable getting a second opinion. Another clinician may see something different or suggest another approach. If our doctor objects to a second opinion, that is all the more reason to seek one. We should know who is performing an operation, understand their experience, and feel able to ask questions before consenting.
What five actions should we take from this conversation?
We can turn the science into a practical plan without pretending that everyone needs identical care:
- Know our lifetime breast cancer risk. Ask for a risk assessment and discuss the number, our family history, and any changes that could affect our plan.
- Keep up with appropriate screening. For average-risk patients, discuss annual mammograms beginning at 40. Ask whether our breast density or personal risk calls for additional imaging.
- Make a higher-risk plan. If our lifetime risk is 20 percent or more, ask when imaging should begin and whether alternating mammography and MRI is appropriate.
- Ask about genetic evaluation when family history raises concern. Understanding an inherited risk can inform screening and preventive choices for us and our families.
- Advocate for the care we need. Seek a second opinion when appropriate. If our concerns or documented risk are not being addressed, find a clinician who will review them with us.
The most important thing we can give ourselves is not a single test or a single operation. It is the knowledge to participate in our care. We may choose intensive surveillance, medication, surgery, or another course recommended for our circumstances. Those choices are personal. We just want every one of us to have enough information to make them.
Concerned About Your Health? Talk to Dr. Aliabadi
Dr. Aliabadi is an expert OB/GYN who is knowledgeable in all aspects of women’s health and well-being. Dr. Aliabadi and her caring, supportive staff are available to support you through PCOS, endometriosis, menopause, childbirth, infertility, or routine gynecological care. We invite you to establish care with Dr. Aliabadi. Call us at (844) 863-6700 or
Frequently Asked Questions
Does a positive sentinel lymph node always mean we need more lymph nodes removed?
No. In appropriate cases, additional node removal may not be necessary. Our team considers the cancer and the rest of our treatment plan before recommending the next step.
Can a normal mammogram rule out breast cancer?
No imaging test finds every cancer. Dense breast tissue and some cancers, including lobular cancers, can make detection more difficult. We should discuss persistent concerns and our personal risk with a clinician.
Is vaginal estrogen the same as systemic hormone replacement after breast cancer?
No. Local vaginal estrogen and systemic hormone therapy are different treatments. We should discuss either one with the clinicians who know our cancer history.
Should we automatically have regular MRIs after a double mastectomy?
Not automatically. Routine imaging is generally not recommended after an adequate mastectomy, but suspected remaining breast tissue or a new finding may warrant an individual assessment.
