Interview with Dr. Armando Giuliano, Breast Cancer Surgeon, on Risk, Staging, and Treatment Choices

A breast cancer diagnosis can leave us trying to understand several decisions at once: What does the stage mean? Do lymph nodes need to be checked? Will treatment begin with surgery or medication? And if we have a high lifetime risk but no cancer diagnosis, what can we do now?

Dr. Armando Giuliano joins Dr. Thais Aliabadi and Mary Alice Haney. He’s a breast surgeon and regional medical director of the Cedars-Sinai Cancer Breast Oncology Program who has spent more than 40 years treating breast cancer. His work includes helping advance sentinel lymph node biopsy, an approach that can spare some patients more extensive underarm surgery. The questions below turn his clinical insights, alongside those of OB/GYN Dr. Thaïs Aliabadi, into a practical guide to breast cancer risk assessment, diagnosis, and treatment decisions.

Medical note: We can use this discussion to prepare questions, but we need our own care team to interpret imaging, pathology, risk estimates, and treatment options in the context of our health.

Table of Contents

• Understanding Our Risk Before a Diagnosis
• Screening and Investigating a Breast Change
• Making Sense of a Breast Cancer Diagnosis
• Reading Biomarkers and Genetic Tests
• Choosing Treatment and Risk Reduction
• Questions to Take to Our Next Appointment

Understanding Our Risk Before a Diagnosis

What does lifetime breast cancer risk actually tell us?

A lifetime risk estimate is the calculated chance that we will develop breast cancer over the course of our lives. It is not a prediction that cancer is present today, nor can it tell us exactly when cancer might develop.

Risk calculators combine information such as family history, breast density, body measurements, and findings from prior breast biopsies. The inputs matter. If a biopsy identifies atypical cells, for example, leaving that result out can produce an estimate that does not reflect what we know about our health.

We also need to distinguish a numerical estimate from a decision. Two people can receive the same risk score and reasonably make different choices about surveillance, preventive medication, or surgery. The useful question is not simply whether a number feels high. It is what that number means for our available options and our willingness to live with each option’s trade-offs.

If we have never had a formal assessment, we can ask a clinician which model is appropriate and review its inputs together. A closer look at how breast cancer risk assessments work can help us prepare for that conversation.

Can we be at high risk without a family history of breast cancer?

Yes. A lack of known family history does not rule out elevated risk. Breast density and certain biopsy findings can substantially change an assessment even when no close relative has had breast cancer.

Dr. Aliabadi’s experience illustrates why the full history matters. She had undergone regular mammograms and had no known family history when a breast biopsy found atypical lobular hyperplasia. That finding is not itself breast cancer, but when she included it and her breast density in a lifetime risk calculator, her estimate rose markedly. Cancer was later found in tissue removed during surgery.

We should not treat one person’s experience as an instruction to choose the same operation. We should take from it a reason to verify that a risk assessment includes every relevant biopsy result and an accurate breast density classification.

What is atypical lobular hyperplasia?

Atypical lobular hyperplasia, often shortened to ALH, describes abnormal-looking cells in breast lobules. The cells are not classified as cancer, but their presence is associated with an increased future risk of breast cancer.

That distinction can be confusing after a biopsy. “Not cancer” is welcome news, yet it does not necessarily mean “no change to our risk.” When ALH or another atypical finding appears in a report, we can ask:

• Was the finding considered fully evaluated after the biopsy or any additional procedure?
• Has it been entered correctly into our risk assessment?
• Does it change the imaging or preventive options we should discuss?

We should bring the actual pathology report to that discussion rather than relying only on a recollection that the biopsy was benign.

Does an older relative with breast cancer count as family history?

We should tell our clinician about breast cancer in relatives at any age, along with the relative’s relationship to us and age at diagnosis. A cancer diagnosed in a close relative at a younger age generally raises greater concern about inherited risk than one diagnosed much later in life. But we should let a clinician assess the complete pattern rather than deciding on our own that a family history does not count.

Screening and Investigating a Breast Change

What should we do if we find a breast lump?

We should arrange a clinical assessment. Most lumps, particularly in younger people, are not cancer. Cysts and common fibrocystic changes can make breasts feel lumpy. Still, touch alone cannot reliably establish what a new or changing lump is.

A clinician can examine the lump and surrounding breast, check under the arm for enlarged lymph nodes, and look for changes to the skin or breast shape. Depending on the finding, the next steps may include a mammogram and ultrasound. A fluid-filled cyst that looks benign on imaging is handled differently from a suspicious solid mass, which may need a needle biopsy.

Signs worth reporting include a hard or fixed lump, a lump beneath the arm, concerning skin changes, or bloody nipple discharge. We should also explain when we first noticed a change and whether it has persisted or grown.

If most lumps are benign, why might we still need a biopsy?

Imaging helps identify the characteristics of a lump, but a suspicious finding often requires tissue to establish a diagnosis. In a needle biopsy, a sample is taken from the area and examined by a pathologist. The result helps separate a benign condition from cancer and, if cancer is present, provides information that guides treatment.

We can ask the care team to explain whether an imaging result and biopsy result agree. We can also request copies of both reports. Keeping those records together makes it easier to discuss the findings with a breast specialist or seek another opinion when something remains unclear.

What does it mean to have dense breasts?

Breast density is an imaging finding, not a description of how firm our breasts feel. A radiologist assesses the relative amounts of dense glandular and fibrous tissue and fatty tissue on a mammogram. Dense tissue appears lighter on a mammogram, which can make some cancers harder to distinguish. Greater density is also associated with higher breast cancer risk.

Density is common and often changes with age as breast tissue becomes fattier. What matters for an individual decision is the density stated in our imaging report, our other risk factors, and whether an additional imaging test is appropriate. We should not assume that a normal mammogram settles every question when we have a concerning symptom or substantial risk.

When might MRI or ultrasound be added to mammography?

The tests provide different kinds of information. Mammography remains important; ultrasound can help characterize a finding such as a lump, while breast MRI may be useful in selected higher-risk patients or when dense tissue complicates evaluation. MRI can also help a care team assess the extent of a known cancer and look for findings elsewhere in the breasts before treatment.

More imaging is not automatically better for everyone. We should ask what specific question an added test will answer and how its result could change our plan. Ultrasound complements rather than replaces mammography, a distinction worth understanding when considering whether breast ultrasound belongs in a screening plan.

Making Sense of a Breast Cancer Diagnosis

What information do we need after a biopsy confirms cancer?

We need more than the word “cancer.” Breast cancer is not one uniform disease, and treatment depends on both where it is and how its cells behave.

At an early consultation, we can ask the team to walk through:

• The pathology diagnosis: What type of breast cancer was identified?
• The imaging: What is known about the size and location of the cancer, and is more imaging needed?
• The lymph nodes: Do examination or imaging findings raise concern about spread under the arm?
• The biomarkers: What are the estrogen receptor, progesterone receptor, and HER2 results?
• The grade: How abnormal do the cancer cells look under a microscope?
• Inherited risk: Should we discuss genetic testing before settling on a surgical plan?
• The sequence of care: What information is still needed before deciding whether treatment begins with surgery or medication?

We do not have to understand every term immediately. Asking a clinician to mark the key results on a copy of the pathology report can make later discussions more manageable.

What do breast cancer stages 0 through 4 mean?

Stage describes how advanced a cancer is. It helps guide treatment and provides information about prognosis, but it does not tell the whole story. Tumor biology matters too.

• Stage 0: Cancerous cells are confined within a duct rather than invading surrounding breast tissue. Ductal carcinoma in situ, or DCIS, is an example. It is considered noninvasive, though it still needs an individualized management discussion.
• Stage 1: An early, generally small invasive cancer. Details such as tumor size and lymph node findings determine its more specific classification.
• Stage 2: A more extensive cancer than stage 1, which can reflect a larger tumor, involvement of nearby lymph nodes, or a combination of findings.
• Stage 3: More advanced disease in the breast and/or nearby lymph nodes, without the distant-organ spread that defines stage 4.
• Stage 4: Cancer has spread to a distant part of the body, such as bone, liver, or lung.

We should ask for our specific stage and the findings behind it, rather than assuming that everyone with the same stage receives the same treatment. Biomarkers and other features can affect both prognosis and the recommended plan.

Why does the care team pay so much attention to lymph nodes?

Breast cancer can spread to lymph nodes in the axilla, the area beneath the arm. Knowing whether cancer has reached those nodes helps determine stage and can affect recommendations for treatment beyond surgery.

That does not mean we should assume every diagnosis calls for extensive lymph node removal. Sentinel lymph node biopsy is one approach used to evaluate the first nodes most likely to receive drainage from the breast. It has helped reduce the need for more extensive underarm surgery in appropriate patients. Our surgeon can explain whether lymph node sampling is needed in our situation and, if so, which approach is planned.

It is especially important to clarify the plan if cancer is discovered unexpectedly after an operation originally performed without a known cancer diagnosis. In that situation, we can ask whether enough information is available to determine stage and what, if anything, still needs to be evaluated.

What is the difference between cancer stage and grade?

Stage describes the cancer’s extent, including its size and whether it has spread to lymph nodes or distant organs. Grade describes how abnormal the cancer cells look under a microscope. Grades commonly run from 1 to 3; higher-grade cells tend to look less like normal breast cells and may behave more aggressively.

Neither measure should be interpreted alone. A small cancer can have concerning biological features, while a tumor’s size does not, by itself, settle which medications are likely to help. We get a clearer picture by considering stage, grade, receptor status, and any appropriate tumor testing together.

Reading Biomarkers and Genetic Tests

What are ER, PR, and HER2 on a pathology report?

These results describe characteristics of the cancer cells that help the care team choose treatment:

• ER, or estrogen receptor: An ER-positive cancer has receptors through which estrogen can influence cell growth. Anti-hormone treatment may be relevant.
• PR, or progesterone receptor: This result shows whether the cells have progesterone receptors and adds information about the tumor’s biology.
• HER2: This identifies a growth-related feature of the cancer. HER2-positive disease has treatments directed at that feature.

We should ask which results are positive or negative and, most importantly, what each result changes about the proposed plan. A label that once sounded uniformly unfavorable may mean something different when an effective targeted treatment is available.

What does triple-negative breast cancer mean?

Triple-negative breast cancer tests negative for ER, PR, and HER2. Without those treatment targets, its management differs from that of hormone receptor-positive or HER2-positive disease. It often calls for more aggressive drug treatment, and immunotherapy has become an important option for some patients.

We should avoid turning “triple-negative” into a prediction about any one person’s outcome. We need to know the cancer’s stage, grade, and full treatment plan before drawing conclusions. We can ask whether chemotherapy, immunotherapy, surgery, or a combination is being recommended and why.

Is inherited genetic testing the same as testing the tumor?

No. The tests answer different questions.

Inherited, or germline, genetic testing looks for a cancer-associated change we may have inherited from a parent. A result can affect risk discussions, surgical choices, and potentially the care of relatives. BRCA1 is one example of a gene that may be included in such testing.

Tumor testing examines characteristics of the cancer itself. Tests such as Oncotype DX and MammaPrint assess gene activity in the tumor to help estimate prognosis and, in appropriate settings, whether additional treatment such as chemotherapy is likely to be useful. A tumor test is not a substitute for inherited genetic testing.

We can ask whether either type of test is appropriate before making a major treatment decision. We should also ask what a positive, negative, or uncertain inherited result would mean. An overview of genetic testing for cancer can help us prepare those questions.

Does a positive lymph node automatically mean we need chemotherapy?

Not always. Lymph node involvement is important, but it is not the only factor. Age, menopausal status, hormone receptor status, tumor characteristics, and, for some cancers, tumor test results can affect whether chemotherapy is expected to provide a meaningful benefit.

Similarly, a low-risk result on an appropriate tumor test does not mean we can disregard every other finding. We need the care team to explain how the result applies to our cancer. A useful question is: “Which part of my pathology suggests this treatment will help, and how would the recommendation change without this test result?”

Choosing Treatment and Risk Reduction

How do we choose between a lumpectomy and a mastectomy?

A lumpectomy removes the tumor with surrounding tissue while leaving the rest of the breast in place. A unilateral mastectomy removes one breast. A bilateral mastectomy, often called a double mastectomy, removes both.

For an appropriate patient with early breast cancer, breast-conserving treatment can offer survival comparable to mastectomy. That does not make the choice emotionally simple. Keeping the breast, preserving sensation, the possibility of a future cancer in remaining breast tissue, reconstruction, and the burden of follow-up can carry different weights for different people.

We should separate two questions that are easy to blur: What treatment is needed for the cancer already diagnosed? And what benefit might removing an unaffected breast offer? Removing the other breast can reduce the chance of a new cancer there, but we should not assume it improves survival for every person diagnosed in only one breast.

Before deciding, we can ask a breast surgeon to explain the medically suitable options, any expected additional treatment, likely cosmetic and sensory outcomes, and the specific reason one operation might be favored in our case.

When is a double mastectomy considered for prevention?

A risk-reducing bilateral mastectomy removes breast tissue before a breast cancer diagnosis, or may be considered in broader risk-management decisions. It can substantially lower breast cancer risk, but it cannot make the risk literally zero. Surgery also carries potential complications and permanent changes, including loss of sensation.

For someone with a substantially elevated risk, we should discuss the full set of alternatives rather than treating surgery as the automatic next step. Those alternatives can include high-risk imaging and preventive medication. Our preference matters, but it should be informed by a careful discussion of estimated benefit, limitations, surgical expertise, reconstruction, and recovery.

If we feel our concerns have been dismissed, seeking another qualified opinion is reasonable. A second opinion can also help when reports and physical findings appear inconsistent. We can bring prior imaging, pathology, and operative records so the next clinician can review the same evidence.

Does a mastectomy remove every bit of breast tissue?

Not necessarily. A mastectomy aims to remove breast tissue, but the anatomy and surgical technique mean we should not describe it as an absolute guarantee that no breast cells remain. The amount and location of tissue left behind can matter, particularly when a procedure was chosen for risk reduction.

Dr. Aliabadi sought further evaluation after she felt that substantial tissue remained following her first bilateral operation. Another specialist’s review raised concern despite earlier reassuring interpretations, and a later operation addressed retained tissue while allowing lymph node evaluation. Her experience is unusual, but it highlights a practical point: if a post-surgical examination, imaging report, and our understanding of the operation do not seem to align, we can ask the surgeon to explain the discrepancy and obtain an expert review.

Can we keep the nipple during a mastectomy?

Sometimes. Nipple-sparing mastectomy can provide an appearance that some patients value, whether an operation is preventive or treats cancer. Eligibility depends on the individual situation, including the cancer’s location and whether preserving the nipple can be done safely.

The trade-off is more than visual. The surgeon must consider the nipple’s blood supply and how much underlying tissue is left to preserve it. Keeping the nipple does not guarantee that normal nipple sensation will remain; numbness or altered sensation can persist after surgery.

We can ask what tissue is expected to remain beneath the nipple, how the surgeon will assess safety, what sensation changes are likely, and whether preserving the nipple would alter cancer treatment or risk reduction in our case.

What options do we have if our risk is high but we do not have cancer?

We can discuss three broad approaches, alone or in combination:

1. More intensive screening. A high-risk plan may use both mammography and MRI, sometimes spaced so a different test is performed about every six months. Dr. Giuliano identifies a lifetime risk above 20% as a point at which high-risk screening is commonly considered.
2. Preventive medication. Tamoxifen can reduce the occurrence of certain breast cancers in suitable higher-risk patients. Other hormone-directed medications, including raloxifene and aromatase inhibitors, may be options depending on factors such as menopausal status.
3. Risk-reducing surgery. Bilateral mastectomy offers a substantial reduction in risk but is a major, irreversible choice with physical and emotional trade-offs.

We should ask how much each option is expected to reduce our risk, what it cannot prevent, and what follow-up would still be needed. We also need to review medication side effects and surgical risks with the clinicians who would provide that care.

Do breast implants increase our risk of breast cancer?

In the discussion of breast cancer risk, Dr. Giuliano does not identify augmentation itself as increasing the risk of breast cancer. He does point out a practical imaging concern: significant scar tissue around an implant, known as capsular contracture, can make it difficult to obtain a good mammogram.

If we have implants, we should tell the imaging center when scheduling and explain any firmness or other changes to our clinician. The important distinction is between a procedure changing cancer risk and a complication making breast evaluation more difficult.

Questions to Take to Our Next Appointment

How can we make a consultation more useful when we feel overwhelmed?

We can bring someone we trust, keep copies of our reports, and focus on a short list of questions. If we have just received a diagnosis, we do not need to make every decision during one conversation.

• What exactly does my biopsy show, and what is still uncertain?
• What are my stage, grade, ER, PR, and HER2 results? Are any of those results preliminary?
• Do my lymph nodes need further evaluation?
• Will additional breast imaging change the treatment plan?
• Should we discuss inherited genetic testing or tumor testing before surgery?
• Which treatments are medically suitable, and what benefit does each offer me?
• What are the risks of waiting for another opinion or test result before deciding?
• If I choose surgery, what tissue will be removed, what sensation might change, and what care will I still need afterward?

We can ask the clinician to explain a recommendation in plain language and write down the answer. A clear plan should connect each proposed test or treatment to a specific finding and a specific goal.

What should we remember most?

We should know our risk before a crisis when possible, investigate new breast changes rather than guessing what they mean, and ask for the full pathology picture after a diagnosis. Stage matters, but lymph node findings, grade, biomarkers, and appropriate genetic tests may change the plan.

Above all, we can make room for both evidence and personal priorities. The best decision is not necessarily the most aggressive or the least invasive. It is one we understand, made with a qualified care team after the relevant findings and trade-offs have been explained.

Frequently Asked Questions

Can a normal mammogram rule out breast cancer?

No. Mammography is valuable, but a concerning lump or other breast change still deserves evaluation even after reassuring imaging. Breast density and the nature of a finding may lead a clinician to recommend ultrasound, MRI, or biopsy.

Is atypical lobular hyperplasia breast cancer?

No. It describes atypical cells rather than cancer cells. It can, however, raise future breast cancer risk and should be included in a clinician-led risk assessment.

Is stage 0 breast cancer the same as stage 1?

No. Stage 0 describes noninvasive disease confined within a structure such as a breast duct. Stage 1 describes early invasive cancer. We should ask our care team to explain the exact diagnosis and management options.

Does a double mastectomy reduce breast cancer risk to zero?

No. It can lower risk substantially, but no operation offers an absolute guarantee. We should discuss the expected benefit, possible remaining risk, complications, and alternatives before deciding.

Are BRCA testing and Oncotype DX the same thing?

No. Inherited genetic testing can identify a cancer-associated change passed down through a family. Oncotype DX examines features of an existing tumor to help guide treatment decisions in appropriate cases.