[00:00:00] Adam Walker: This episode of The Real Pink Podcast is brought to you by Intuitive Surgical. Intuitive is a global technology leader in minimally invasive care and the pioneer of robotic assisted surgery. Intuitive has been advancing minimally invasive care since 1995 with the goal of helping physicians improve the lives of people around the world.
[00:00:21] You can learn more at www.intuitive.com.
[00:00:28] From Susan G Komen, this is Real Pink, a podcast exploring real stories, struggles, and triumphs related to breast cancer. We’re taking the conversation from the doctor’s office to your living room.
[00:00:42] If your doctor is recommending that you get a mastectomy, you’ll likely have some choices about how the surgery is performed. Your breast cancer treatment, your body, your breast shape, and your lifestyle affect not only your options, but also the pros and cons of your options. There’s no method that works best for everyone because each person is unique.
[00:01:03] Today we’re going to be exploring one specific type of mastectomy, the nipple sparing mastectomy. This is a skin sparing mastectomy that leaves the nipple and areola intact, and usually improves the overall look of the reconstructed breast. Joining us on the show today are two very special guests, Dr.
[00:01:21] Mara Piltin, a breast and melanoma surgical oncologist and physician assistant Maddie Beiswanger, both from Mayo Clinic. They’re going to tell us more about nipple sparing mastectomy procedures, current research that’s being conducted around the use of minimally invasive robotic surgery to assist in these procedures and the possible benefits that these innovations can provide.
[00:01:43] Dr. Piltin and Maddie, welcome to the show.
[00:01:46] Dr. Mara Piltin: Thank you, Adam. Thanks for having us.
[00:01:48] Maddie Beiswanger: Yeah, thanks for having us.
[00:01:50] Adam Walker: I don’t often get to interview like two people about a topic like this. This is kind of fun. I appreciate you, you being willing to join me on the show and talk about this is important and understanding all the different options is important.
[00:02:03] And so I’d love kind of getting to cover that on the show. So mastectomies are you know, a pretty critical part of a care plan for many breast cancer patients. Can you tell us what nipple sparing mastectomy is, or NSM and why someone might want one?
[00:02:19] Dr. Mara Piltin: So I’ll dive in. So a mastectomy by definition is removal of breast tissue as well as the lining of the pectoralis muscle, but we don’t take any of the muscle itself when we do that.
[00:02:31] So with that kind of underneath the category of a mastectomy, I would include, we’ll talk a little bit, kind of about two of them. So total mastectomy, I’ll just briefly mention. So that’s when we remove the breast. The lining of the muscle, but we also take all of the overlying skin and nipple and we close the patient flat.
[00:02:50] This is a great option for somebody who does not wanna undergo reconstruction, and patients will often opt to wear a prosthetic and a bra if they choose to have the appearance of a breast in their clothes, but they certainly don’t have to. I think today we’re gonna focus a little more about a reconstructive option, so that’s nipple sparing mastectomy. This is an option of mastectomy that involves.
[00:03:10] An approach where we take the breast tissue and the lining of the muscle, as I mentioned, as any mastectomy would, but we preserve the entire envelope of skin and nipple so that the reconstruction can be placed beneath that. And this really gives the most natural appearing reconstructed breast look. So it looks like breast, skin, nipple, but there’s something different than your breast that’s causing it to cause that shape like an M.
[00:03:33] There are other options for mastectomy with, without reconstruction. They’re quite nuanced. But for the purpose of today’s discussion, we’ll just kind of focus on that definition. So, yeah. Yeah.
[00:03:43] Adam Walker: This is, yeah, this is the, yeah, I appreciate that. Yeah. There’s, again, you, to your point, lots of options. I’m curious too, like why did you choose to specialize in this particular procedure?
[00:03:52] Dr. Mara Piltin: Yeah. I gained my experience in nipple sparing mastectomy initially during my breast surgical oncology fellowship, which I did at Mayo Clinic in Rochester, Minnesota. Excellent mentors. And have really just taken on a high volume practice with this approach. Because for the right candidate, I genuinely believe it offers excellent cosmetic results.
[00:04:10] But as you mentioned, ultimately the surgical choice is the patients, and we do a lot of every kind of breast surgery within our practice so it becomes a really patient driven discussion.
[00:04:18] Adam Walker: Okay. Maddie, anything you want to add to any of that?
[00:04:22] Maddie Beiswanger: Yeah, I guess, you know, in terms of why somebody might want a nipple sparing mastectomy in comparison to their other options, there’s kind of two main things that I think about.
[00:04:33] Usually for both cosmetic and psychological reasons. So, For one, we’re still safely treating the breast cancer. But nipple sparing mastectomy also emphasizes preserving the natural aesthetics of the breast. So this approach kind of allows us to hide the scars within the natural folds, either under the crease or at the side of the breast.
[00:04:58] Which ultimately really creates natural looking results with pretty minimal scarring. So the breast after surgery looks the most similar to the patient’s breast prior to surgery. And for many people that can create kind of a sort of sense of normalcy after being treated for cancer. And then on the other hand,
[00:05:19] from a psychological perspective, keeping the natural nipple and areola can help patients feel more confident and comfortable in their body after surgery. So this can positively influence self-esteem and postoperative body image, and sometimes sexual wellbeing as well.
[00:05:38] Adam Walker: Gotcha. Okay. That’s actually a really helpful perspective.
[00:05:42] So who’s a candidate for NSM and how, I mean, how does it improve outcomes for eligible patients? I mean, Maddie, you’ve already spoken a little bit to that, but talk a little bit more to that as well.
[00:05:52] Dr. Mara Piltin: Yeah, so you know, I’ll just say I guess initially when nipple sparing mastectomy started to gain popularity, there was data and studies suggesting kind of relatively strict criteria actually for who might be a candidate for nipple sparing mastectomy, as you would think, with any new adoption, wanna make sure we have the right patients and the right fit.
[00:06:10] I’d say at this point in the adoption of the procedure I would just kind of encourage patients to have a candid discussion with their surgeon regarding goals of care and the surgeon’s comfort with that. Patient’s eligibility for this procedure, because it’s really multifactorial. There’s so many things that go into this.
[00:06:25] You know, we used to limit to things like certain cup size, certain nipple position. Different practices have different cutoffs for BMI still, and so it’s important to just remember that like if we as a surgeon are not recommending a nipple sparing mastectomy approach, there’s typically a good reason for that…
[00:06:39] see it too much risk. So either risk of the skin or nipple not getting good blood flow or you know, concerns about a patient’s particular ability to heal or a high infection risk. And oftentimes if there’s a cancer located too close to the skin or nipple, we wouldn’t feel safe to remove that with this approach.
[00:06:57] And so, like I said, lots of things and lots of considerations that go into this decision. But I will say our sort of inclusion or eligibility for this approach have expanded vastly since we started doing them.
[00:07:10] Adam Walker: Gotcha. Okay. So let’s talk more broadly about kind of surgery in general. What innovations happening in the surgery field for the treatment of breast cancer right now?
[00:07:22] Dr. Mara Piltin: Yeah. I’ll say breast surgery is a field within the surgical community that tends to be respected for how rapid the research is evolving, but a lot of that research is in… outside of the surgical space. So what I mean by that is, you know, we’re doing incredible things with chemotherapy, immunotherapy, things like that, and making really rapid advancements.
[00:07:45] However, we’ve been doing open mastectomy for over a century, and while we’ve certainly made surgical advances over that time, especially in collaboration with our plastic surgery colleagues, to me one of the most exciting more recent innovations is robotic assisted breast surgery, specifically the nipple sparing mastectomy.
[00:08:02] Adam Walker: Gotcha. Okay. And let’s talk more about that.
[00:08:07] Like what is robotic assisted surgery? How is it performed and how does it relate to, you know, this nipple sparing mastectomy?
[00:08:17] Dr. Mara Piltin: So robotic assisted breast surgery is not currently yet FDA approved in the United States. So I guess I’ll just kind of umbrella that start, but we’ll get little bit into in a moment.
[00:08:27] We’re investigating this approach as part of a clinical trial. Okay. So because of that, I can’t really share what we found in the US about pros and cons of assisted approach. Yeah. Compared to traditional, however a number of our surgical colleagues in Europe and Asia have adopted robotic nipple sparing mastectomy.
[00:08:46] And so there are publications out there. There certainly is literature to quote and some of the common themes that we see throughout those publications, highlight that robotic nipple sparing mastectomies are safe and feasible.
[00:08:58] Many studies have shown lower rates of complications including risking the blood flow to the skin or nipple like wounds, kind of dead areas of the skin, for lack of a better term. A few studies have highlighted improved patient reported outcomes. So some of those things that Maddie was talking about earlier, like psychosocial wellbeing, physical wellbeing, sexual health, those sorts of things, patients have reported favorable results for robotic approach.
[00:09:22] So we do know that robotic assisted surgery has a learning curve. We’ve seen that over and over again as robotic assisted surgery is adopted in more parts of our surgical community.
[00:09:31] So I guess to that point, we’ve seen robotic surgery in abdominal surgery or rectal surgery, hernia surgery, urology, gynecology, and so on. So robotic surgery is by no means new. And so speaking to the learning curve, some of the data suggests that at least in the beginning, this approach can take a little longer than the traditional approach as we’re getting used to it.
[00:09:59] In my perspective, wonderful, is that it allows us to have excellent visualization, retraction, and dexterity. And that can happen through a really tiny incision compared to what we can do with our hands. And so you know, I’ve noticed that my patients get really excited about the length of the incision for this approach.
[00:10:17] It’s really small. It’s located off to the side of the breast and it offers beautiful cosmetic outcome, in my opinion.
[00:10:24] Adam Walker: What, what is the length of the robotic versus the non, like as far as that goes?
[00:10:30] Dr. Mara Piltin: I can share that the robotic length is 3.5 centimeters. Okay. So that’s a little bigger than a quarter. So to think about an entire mastectomy and the reconstruction being done through an incision that’s a little bit bigger than a quarter.
[00:10:44] Adam Walker: That’s wild.
[00:10:46] Dr. Mara Piltin: Cool to wrap your head around, like when you said that I immediately thought inches and I thought, well, that’s actually like 3.5 I and then my brain went wait. No. She said centimeters, like, whoa, whoa.
[00:10:57] I always laugh about this because, you know, we do a lot of medical measurement in centimeters, but most people converse in the United States and in inches and so Yeah.
[00:11:05] Right to put that into context. You know, I think we, I kind of tend to see our open nipple sparing hovering between 12-15 centimeters depending on the breast size and the patient’s BMI, so it’s a big jump.
[00:11:19] Adam Walker: Wow. So, I mean, it’s four, four times almost smaller. Really?
[00:11:22] Dr. Mara Piltin: Yeah. Yeah. And we take the our open approach is a, is underneath the fold of the breast. So an infra memory fold incision, this we put off to the side of the breast is still along the natural curve. But, you know, Maddie can speak to the size of the incision.
[00:11:35] Some days we, neither of us can believe we’re doing this through this hole.
[00:11:39] Adam Walker: That’s wild.
[00:11:41] Maddie Beiswanger: It really is impressive to see, especially, you know, I work with Dr. Piltin very closely on both open and robotic mastectomies. So comparing them firsthand is, it’s really impressive.
[00:11:52] Adam Walker: That’s and with a, like, forgive me for asking like a very silly question, but with the robotic surgery, like you’re manipulating the robot that’s doing the actual
[00:12:05] surgery part? Is that like, give, give me more details on that if you don’t mind. Just like, like I’m a, like, I’m a five-year-old for a second. Yeah.
[00:12:11] Dr. Mara Piltin: So I, no, it’s a good question because I always tell my patients this when I counsel them. The robot does nothing independently and it’s very well designed to be able to stop if we’re not in control of it.
[00:12:21] Right. Right. And so we’re in the operating room with the patient. We are sitting at a console adjacent to the patient’s bed. And this is where Maddie and I collaborate really well, because Maddie’s actually physically at the bedside, and I’ll let her speak more to this in a moment, but yeah.
[00:12:35] So the robot does nothing independently. We entirely move the robotic arms through this console. The console has high, highly magnified 3D high definition view of the surgical area. We’re seeing really well.
[00:12:47] And it has really great dexterity akin to what we would be doing with our hands. It’s just that those instruments are small and inserted through usually one or multiple small incisions to allow us to get that access.
[00:13:01] Adam Walker: Okay. Gotcha. Maddie, anything you wanna add to that?
[00:13:04] Maddie Beiswanger: Yeah, so like Dr. Piltin was saying, it’s usually as the bedside assistant, so there’s two or three of us that are actually scrubbed in and sterile and at the bedside of the patient.
[00:13:15] And our job essentially is to make sure that Dr. Piltin can operate safely from that nearby console. So that can include things like manipulating the tissue, suctioning, positioning the robotic instruments, things like that.
[00:13:30] But we’re very collaborative in that way.
[00:13:34] Adam Walker: It’s a fascinating and amazing.
[00:13:36] Wow. I thank you for painting that picture that really helps a lot. So like what can a patient expect in terms of recovery after a robotic nipple sparing mastectomy?
[00:13:48] Dr. Mara Piltin: Yeah, I usually counsel my patients that recovery is the same. So despite the smaller incision, I mean, I guess yes, you would anticipate whatever would come along with a smaller incision, would come along a little bit different.
[00:14:00] But I tell my patients that to expect the same recovery that one would expect for any nipple sparing mastectomy, the reason for that is the operation on the inside is the same, and that an important component to uphold since this is cancer surgery. We definitely do not want to shortchange the quality
[00:14:16] of the surgery on account of a small incision. So I typically recommend that patients expect six, six weeks of postoperative recovery with the limitations of activity that we would expect for any mastectomy. That being said, our mastectomy patients go home the same day as surgery, so this is outpatient surgery.
[00:14:31] They can shower one to two days after surgery. And we want our patients up and walking. So while we limit their heavy lifting and repetitive motion just to make sure everything heals in really nicely they’re definitely not, you know, tied up in bed and watching only movies for days and days on end.
[00:14:51] We want them active and back getting back to real life.
[00:14:54] Adam Walker: Wow. That’s amazing. Now, alright. So. Back to the robotic technology. What kind of training is required to be able to do this, and do you see this sort of technology rolling out at more of a wide scale in the near future?
[00:15:08] Dr. Mara Piltin: Yeah, there are really well established training protocols, both through Intuitive Surgical, which is the company that owns the Da Vinci Robotic System.
[00:15:16] And through hospitals themselves. The company has representatives who can walk through surgeons through the training protocol to become confident and comfortable on the robotic system. I was lucky to have excellent robotic surgical training during my general surgery residency. I have the opportunity to maintain those skills as part of my melanoma practice.
[00:15:36] So adoption into breast surgery felt very natural to me. And I would go so far as to say that most general surgeons graduating from surgical training programs in this era have at least some amount of experience on the robotic system to some capacity. I’ve spent a good portion of my career working with our general surgery residents here at Mayo Clinic and developed a robotic
[00:16:00] surgery curriculum here at Mayo Clinic. So that’s definitely happening across the country. And so we’re training robotic surgeons outside of the breast space regularly.
[00:16:10] Adam Walker: I love that. I love that. That sounds, that’s amazing. And so you mentioned earlier that, you know, this is already being used and already approved to be used in other types of cancers.
[00:16:20] Can you talk a little bit about like, what those are and then what, like why now for breast cancer? Like why at this time?
[00:16:28] Dr. Mara Piltin: Yeah. You know, the Da Vinci Robotics Assisted Surgery has been cleared by the FDA in the US for many different areas since really the year 2000. So, I mean, it’s hard to imagine, but it’s 25 years ago.
[00:16:43] Adam Walker: So..
[00:16:44] It’s painful. Right?
[00:16:45] Dr. Mara Piltin: I know. Including cardiovascular, colorectal, general surgery, gynecology, thoracic, urology, kind of really across. Forward. As I mentioned, our colleagues in Europe and Asia have certainly been using robotic assisted mastectomy for a number of years. That’s not to say we haven’t been investigating this project for a similar time, however, in the United States, because
[00:17:08] clinical trials are approved and overseen by the FDA we’re ensuring that we go through all the proper and appropriate steps to have approval of this procedure in the US and, you know, we wanna do the highest level of scientific investigation because that keeps our patients safe. So for that reason, robotic assisted nipple sparing mastectomy in the United States is on trial and it’s actually a randomized trial.
[00:17:30] And what I mean by that is the patient meets criteria is seen by a surgeon who is enrolling in the trial or participating In the study and then the patient is randomly selected for either a robotic approach or a traditional open approach. Right. This allows us to have the highest level of evidence, as I mentioned once we’re able to finish collecting and analyzing our data, and it’ll give us the best comparison of robotic to standard open approach.
[00:17:56] You know, it seems a little bit difficult to wrap your heard around, not making your surgical choice, right? If you come in and say, I want robotic mastectomy, you get the traditional approach. But the reality is that’s our tried and true, that’s our standard of care. We are advocates and excited about the robotic approach.
[00:18:12] But it’s still under trial.
[00:18:14] Adam Walker: Right. Yeah, that makes sense. All right. Maddie, question for you in your experience at the bedside with Dr. Piltin, what do you want patients to know about robotic assisted surgeries and how the two of you work together?
[00:18:27] Maddie Beiswanger: Yeah, definitely. I think, you know, like we kind of touched on earlier, it can just be hard as a patient to kind of grasp the concept of their surgeon sitting at an adjacent console, but not necessarily at their bedside, like a traditional non robotic surgery.
[00:18:43] So I think it’s just really important for patients to understand just how much communication and teamwork goes on throughout the entirety of the surgery. So, Dr. Piltin and I are working very well as a team together. Since I’m right there with the patient at the bedside, I’m able to monitor the breast tissue and the skin from the outside while Dr.
[00:19:05] Piltin’s working on the inside. And then I’m also able to see everything that she’s doing on the inside from a screen. Which then allows me to give real time feedback while she’s operating. So we’re in constant communication, asking each other for frequent feedback. So in general, for patients undergoing a robotic procedure, including a nipple sparing mastectomy, they can just have the utmost confidence that there’s seamless communication happening throughout the entire procedure.
[00:19:37] Adam Walker: That’s great. That’s great. All right. Last question here for our listeners. What are next steps that they can take to learn more about these surgical options and how can our listeners talk to their providers about it?
[00:19:49] Dr. Mara Piltin: Yeah, I would definitely encourage any patient who’s interested in this approach or knows somebody who they think might benefit from this information.
[00:19:57] You can look at the institutions nearby regionally to where you’re located that might be offering robotic nipple sparing mastectomy on trial. The clinical trial is ongoing study currently recruiting patients actively at a number of hospitals across the US. And the best way to identify those locations would be through clinicaltrials.gov.
[00:20:16] That includes not only the sites, the surgeons participating, but also the inclusion criteria. So patients or advocates can cross reference breast size, bmi, et cetera. You know, before you book a flight somewhere or travel a distance to see a doctor, sometimes it’s good to just make sure that it’s something you’re interested in after reading more about it.
[00:20:33] So, absolutely, that’s where I end it, yeah.
[00:20:36] Adam Walker: Alright Maddie, anything you’d like to add?
[00:20:39] Maddie Beiswanger: Nope.
[00:20:41] Covered it.
[00:20:41] Adam Walker: All right. Well, Dr. Piltin, Maddie thank you so much for joining us on the show today. It’s been a pleasure to get to talk to you about this.
[00:20:49] Dr. Mara Piltin: Thank you for having us.
[00:20:50] Maddie Beiswanger: Yeah. Thanks again.
[00:20:51] Adam Walker: And thank you to Intuitive Surgical for supporting the Real Pink podcast.
[00:20:56] Intuitive is a global technology leader in minimally invasive care and the pioneer of robotic assisted surgery. For more information about intuitive, visit www.intuitive.com.
[00:21:13] Thanks for listening to Real Pink, a weekly podcast by Susan G Komen. For more episodes, visit real pink.komen.org. And for more on breast cancer, visit komen.org. Make sure to check out at Susan G Komen on social media. I’m your host, Adam. You can find me on Twitter at AJ Walker or on my blog adam j walker.com.