#16: Urgent Care For Breasts: It’s a Thing! The Latest on Breast Cancer

Tune in this week as Dr. Barrett speaks with Dr. Janie Grumley M.D., a surgical breast oncologist who has expertise in treating patients with breast cancer and benign breast diseases. She specializes in novel treatments such as oncoplastic breast-conserving surgery and intraoperative radiation therapy.

In this episode, Dr. Grumley talks about breast health clinics. Think of an urgent care for breasts where you can actually be examined by a nurse practitioner and get imaging the same day for any lump that keeps you up at night!

Traditionally, if there's a problem with your breasts and you go at the local Emergency Room, Good Luck!! Learn why it’s so important to find a board certified professional you can trust and one who can deliver specialized care custom tailored to your needs. Dr. Grumley describes trusting relationships and the bond she creates with her patients that can last a lifetime.

Dr. Barrett and Dr. Grumley both explain why surgery should be a risk vs. benefit process in order to reduce unnecessary and possibly invasive treatments and dive into interesting subjects like futuristic technologies and Molecular Markers! Yes, that’s a thing too!

On this episode of The Natural Plastic Surgeon…

Dr. Barrett:..it's much better than, like, dosing our whole body with chemo, you know?
Dr. Grumley: Absolutely, yeah.
Dr. Barrett: Where we're hitting everything and feeling like crap.
Dr. Grumley: Right.
Dr. Barrett: Or same thing with radiation.
Dr. Grumley: So how do we show our bodies that our cancer isn't us, right?
Dr. Barrett: Yeah.
Dr. Grumley: That's how, that’s what we have to do is somehow make it look different.

Dr. Barrett: So I mean, people can't stop getting older, right? So we talk about, like…
Dr. Grumley: Although you try to make them…
Dr. Barrett: We try. We, we're learning about telomerase and all kinds of anti-aging stuff that's out there right now. I take a bunch of supplements about that too…
Dr. Grumley:...there is no surgery like no surgery. Obviously, if you have a breast cancer and we have to do something then we have to, kind of, figure out what's the best way to do it so that we're not, you know, putting the patient at further risk by what we do to them as opposed to what we can do to help.

You are listening to The Natural Plastic Surgeon Podcast. I'm Dr. Daniel Barrett, Board-Certified Plastic and Reconstructive Surgeon located right here in Beverly Hills. I specialize in cosmetic surgery of the face, nose, breast and body. This podcast is dedicated to those deciding if plastic surgery is right for them and revealing all the latest beauty secrets. Let’s get started.
Dr. Barrett: Today we have a very special guest for our October Breast Cancer Awareness Month. We have Dr. Janie Grumley. She is the director at the Margie Peterson Breast Cancer Center at Providence St. John's in Santa Monica, right here in Los Angeles. And she's also the director of breast oncology at the John way, John Wayne Cancer Institute. She's also associate professor of surgery at John Wayne Cancer Institute as well.

01:36 DR. GRUMLEY AND DR. BARRETT WERE TOGETHER AT USC

Okay, so I'm really excited to have Dr. Grumley on here because, you know, we actually got to train together when we were at USC together. And you had, you have a, you make my training look like peanuts compared to all the training that you had. I mean, you went to Pepperdine. You went to, you did general surgery at LA County USC, you became a chief resident there and that's when I, that's when I got to work with you and that was some fun times.
Dr. Grumley: Yeah.
Dr. Barrett: You ran a really tight ship and it was amazing. Then you, then you actually went on and became a surgical breast oncology fellow at USC. And USC, I remember, when I wasn't doing plastic surgery, they were doing, they were coming up with all kinds of great, innovative techniques to deal with breast cancer, versus the, kind of, the old school way of just, kind of, like wiping everything out.
Dr. Grumley: Right.
Dr. Barrett: But so I mean, really, I'm just so excited to have you on here, especially for this month, to talk about breast cancer. Janie, welcome to the show.
Dr. Grumley: Thank you so much. I'm excited to be here. It's been a long time since we've gotten to hang out. And so I'm excited. This is a new position for me. So I'm here, I've been here in Santa Monica for about a year and...
Dr. Barrett: Yeah.
Dr. Grumley:...I think we're building something pretty exciting.
Dr. Barrett: You guys are and it's amazing. Santa Monica is such a very, very big place and there's a lot of need for, for someone to do what you're doing. Can you tell us more about what you're doing specifically there and the Margie Peterson Breast Cancer Center?

02:54 MULTIDISCIPLINARY APPROACH

Dr. Grumley: Yeah, so I think our main goal is really, obviously, to take care of the patients. Breast cancer has become so complex, it is not just about the surgery. It's not just about the medicines. It's everything all-encompassing. And so there's just such a need for multidisciplinary approach to breast cancer. But there's nothing more frustrating for patients, at least from what I hear, is that I have to go here and then I have to go there. And they don't know if my doctors are talking to each other. And they're just this very disjointed approach to breast cancer care.
Dr. Barrett: That's, that's a key concept. And I think a lot of people, a lot of listeners need to understand that. When I, when I was in training at USC, and I remember, we would go to these tumor boards and I'm, like, all right, well, isn't there just like a breast cancer doctor? And that's just one doctor that just does it all.
Dr. Grumley: Right.
Dr. Barrett: No, there's like someone who, who looks at your genetics. There's someone who looks at if you need chemotherapy or some, radiation, these are all different. And then your actual breast surgeon. And then if you need breast reconstruction, your plastic surgeon. And it's like, all of these people have to talk to each other.
Dr. Grumley: Yep.
Dr. Barrett: And it's like, I can't, there's probably very few other disease processes that are as complicated and involved as breast cancer. I don't, I'm sure there are some out there that are just as complicated. But breast cancer is up there in terms of the number of specialties that have to work together...
Dr. Grumley: Absolutely.
Dr. Barrett:...to do the job right.
Dr. Grumley: Yeah. So, I mean, most of cancer is very multidisciplinary, but I think breast cancer lead the way in that, kind of, a team approach to care. It was the first to start neoadjuvant chemotherapy for, so doing chemotherapy before you do surgery, and how do you make those decisions?
Dr. Barrett: And that's, like, to shrink the tumor, right?
Dr. Grumley: Right.
Dr. Barrett: Okay.
Dr. Grumley: So it's not, and sometimes now it's to do, to get a better outcome even for patients. So it's not, kind of, you can't operate in these silos where I'm gonna make a decision because somebody else's decision might affect what you're gonna do. And so for, you know, cancer patients for breast cancer patients, when they call we're, like, well, we're going to have you see all these doctors and they're, kind of, wondering, why do I have to see three different doctors in one day. Because...
Dr. Barrett: Yeah.
Dr. Grumley: If you don't really like the idea of radiation that limits what I can do when it comes to surgery. So we have to get that very clear picture as to what the plan is for that patient. So we try to take out a lot of that confusion.

05:10 WHAT TO DO WHEN YOU FIND A LUMP

Dr. Barrett: So let's, let's break it down. So, so say, woman has a lump, right? She's, she's 45. She's got a lump in her breast, and she doesn't know what to do. What should she do? She has, she, you know, her mom actually got breast cancer, but not, you know, maybe when she was seventy years old.
Dr. Grumley: Yeah.
Dr. Barrett: Yeah.
Dr. Grumley: So obviously, she needs to be worked up, she needs to be seen. And that's probably the first area of frustration for most women...is that if you wake up and you feel something, what do you do with that? So the typical course is that you call up your primary care doctor, they said, okay, I'll see you in two weeks. And then they see you and then they're, like, okay, now I'm going to order imaging. I'm gonna send you over here and then it takes another two weeks to get that.
Dr. Barrett: Yeah.
Dr. Grumley: And the entire time you think you have cancer.
Dr. Barrett: Right. Horrifying.
Dr. Grumley: But the majority of women who have a lump that they feel don't actually have cancer. So, but you're spending four weeks of your time frustrated about it. So the first thing that we actually implemented is something called the Breast Health Clinic. So we actually have a dedicated nurse practitioner that works with our radiologists.
Dr. Barrett: Okay.
Dr. Grumley: So they can actually come in, it's like urgent care for breasts. You don't need a referral from your primary care doctor, you can pick up the phone and call the number and just say, hey, I have a breast lump, I'd like to be seen. Because if you just go to an imaging center, they won't see you.
Dr. Barrett: Right.
Dr. Grumley: You need a clinician to feel and...
Dr. Barrett: To write the order.
Dr. Grumley: And assess you first. And write the order. And so we've taken that out of the loop.
Dr. Barrett: That's incredible. Is anybody else doing that?
Dr. Grumley: Not that I know of here.
Dr. Barrett: Okay.
Dr. Grumley: And that's part of what I brought from Seattle, ‘cause when I went up there, it was a model in which they had actually set up there. And they've actually published on how much more efficient care is.
Dr. Barrett: Right.

06:45 GENETIC COUNSELORS

Dr. Grumley: And how we can actually reduce the inappropriate imaging that gets ordered. Because it's somebody that's a specialist, that knows what they're feeling. But you can also take a full genetic history of that patient. We have genetic counselors right there in the clinic.
Dr. Barrett: Yeah.
Dr. Grumley: That can actually get the genetic testing sent off right away. It's about getting them to the end of whatever resolution they need, right? And so we can just do it all at one time. So patients aren't running around, aren't scared, aren't feeling, like, where do I go next? And so they can come see, like, the nurse practitioner, we actually have it pre sel, set so that there are imaging slots for those patients. So they can, typically, if insurance will allow us, do imaging the same day. And then most of the time, if you do imaging, you can actually tell that it's benign, there's nothing we need to worry about.
Dr. Barrett: Yeah.
Dr. Grumley: And we can just ease their minds.
Dr. Barrett: Yeah. Okay.
Dr. Grumley: So that's kind of the first step of getting in to, you know...
Dr. Barrett: Which is a total game-changing thing, because it's, like, I don't know how you are, but I'm, like, I've got, like, a toothache I want to go to the dentist, like, this afternoon.
Dr. Grumley: Yeah.
Dr. Barrett: And I want it taken care of, you know? It's like, and, and then, if I have to go to, like, two different appointments and it's, like, across town or whatever else, there's no parking, I'm like, screw it. I'm not gonna deal with it, you know? So it's just like...
Dr. Grumley: Well, even the primary care docs love it. Because when somebody calls them, they're, like, well, it's so much easier if I just send them to, to somebody who's a specialist and get the imaging done right away. And then we communicate back to their doctors and, and there's usually resolution in a lot shorter period of time.
Dr. Barrett: Okay, so there's a lot more we want to talk about, but I just, what's the information of someone that's here in LA and wants to go get a lump checked out? What, what number do they call or what's the name of the place that they go to?

08:11 HOW TO CONTACT THE BREAST HEALTH CLINIC

Dr. Grumley: So you can just call up the Margie Peterson Breast Center.
Dr. Barrett: Okay.
Dr. Grumley: It’s 310-582-7100.
Dr. Barrett: Okay.
Dr. Grumley: And let them know that you have a lump and need to be seen. And we can take care of the rest of it.
Dr. Barrett: All right. So put that, you guys, put that in your phones. And keep that for. for a rainy day. If you feel a lump and you're not sure what to do. There you go. Give them a call.
Dr. Grumley: Yeah.
Dr. Barrett: K. All right. So now, let's dive in a little more because I really love your approach to breast cancer and the things you're doing--this team approach--and I want to dive in a little bit more so that listeners can, kind of, understand if they, if they do develop breast cancer. Let's say the lump comes back as something suspicious with radiologists.
Dr. Grumley: Yeah.

08:50 BIOPSY OF A LUMP

Dr. Barrett: What is it, and it, and it's like, you know what, this is suspicious enough that we need to biopsy it. What do, how do you handle that as a oncoplastic surgeon? So you’re a breast surgeon, but you, you've learned plastic, kind of like, what we call plastic surgery techniques. And that limits the scarring and disfiguration for breasts. Tell us more about that.
Dr. Grumley: So if a woman is diagnosed with a breast cancer...
Dr. Barrett: Yeah.
Dr. Grumley:...we sit down and talk about all their options. And that's important for women to understand is that there are options. It's not, you have to do this, or you have to do that. It's not a one choice for every single person. And we have to take into consideration who they are, what their genetic background is, and what their genetic risk is, and what are their desires? I know women who have a very small cancer and they're so scared, they want bilateral mastectomy and we walk through all of the reasons why and why not to do that. And then there are those that really don't want to go down those, that avenue and, and do a bilateral mastectomy. So we do have oncoplastic surgery available. I, kind of, explain it to patients as when we do a lumpectomy or a partial mastectomy, we can't see the actual cancer cells.
Dr. Barrett: Yeah.
Dr. Grumley: Like, you remember back in breast? You open it up, it just all looks yellow, and you, how do you know what to take out? And that's, that's the scary part is that you want to take out all the cancer. But the more you take out, the worse it looked with our old traditional incisions which is just a little incision over the cancer.

10:15 DIFFERENT TYPES OF LESIONS

Dr. Barrett: Yeah. And, and let's dive into this a little more. There are differing levels of suspicious lesions, right? So it's, like, you know, I think people really need to understand that, like, precancerous types of lesions are not breast cancer, certain things that are not invasive or not, like, it's not like, you're going to die. You know what I mean? And it's, like, people need...how, how do you communicate that to, to women because it's, I feel like they, they, they're so worried. They have families, they have their children, they're, like, I don't want to risk breast cancer, screw my breasts. I don't want to...but you know, it's, I deal with making...I do some breast reconstruction, but a lot of cosmetic breast surgery and breasts are really, a really important part of a woman.
Dr. Grumley: They are, yeah.
Dr. Barrett: And to just kind of overreact and get rid of that and so like, let's talk about some of these different levels and how do you, how do you break that down to...I mean, I know it depends on the patients and what the findings are and so forth. But how do you deal with that?
Dr. Grumley: So, I spend a lot of time, kind of, walking through what the actual pathology, what they actually have. Right?
Dr. Barrett: Yeah.
11.12 PRECANCEROUS CELLS
Dr. Grumley: What does it mean to have DCIS 2 or precancerous cells?
Dr. Barrett: Yeah.
Dr. Grumley: And how is that not life-threatening? ‘Cause if you look at the statistics, people who have precancerous or DCIS have nearly 100% survival.
Dr. Barrett: Yeah.
Dr. Grumley: Right? So it's not a life-threatening disease. But we just have to get rid of it so it doesn't become anything concerning.
Dr. Barrett: Right.
Dr. Grumley: And we even know now that some don't even become an invasive cancer ever. So there are even studies out there that...
Dr. Barrett: What’s the percentages on that?
Dr. Grumley: So...
Dr. Barrett: DCIS converting into...
Dr. Grumley: So DCIS, depending on the grade, so high-grade DCIS is more likely. Larger span of DCIS is more likely, but that's probably going to change in the next couple years. I mean, research is going, kind of, at lightning speed right now, because there are molecular markers. We used to base it on how it looks.
Dr. Barrett: Yeah.
Dr. Grumley: Like, grade, estrogen to positivity, size...those are the only things that we used to, kind of, use to determine how risky a cancer is. Now we're actually doing molecular markers, right? So we're actually molecularly looking at the cancer to say, okay, are there things that were making this cancer cell more likely to become an invasive, or are they more aggressive? There are things that we have never had, you know, even in our residency, we couldn't do molecular markers on DCIS, where as we can do that now. And we can decide whether or not radiation is even needed...
Dr. Barrett: Yeah.

12:28 PERSONALIZED CARE

Dr. Grumley:...in these types. So I think we're personalizing care a lot better now that we can do these molecular markers. And so those all needed to be taken into consideration.
Dr. Barrett: Yeah.
Dr. Grumley: When you're making decisions about what to do. It's not you have breast cancer, you have to have surgery, you have to have radiation, you have to have chemo.
Dr. Barrett: Yeah.
Dr. Grumley: Right. And it's not, it's not an absolute. I always tell patients, we never tie you down and force you to have chemotherapy, or tie you down to force you to have anything. It's understanding what's the risk and what's the benefit.
Dr. Barrett: Right.
Dr. Grumley: I know sometimes when you hear from doctors, they say, oh, well, this is a 50% benefit, you know, if you do radiation. But 50% of what? If your risk is 2%. And you reduce it by 50%? You're only reducing it to 1%.
Dr. Barrett: Right.
Dr. Grumley: Is it worthwhile? And so those things have to be, definitely, taken into consideration.

13:22 STATISTICS OF COMPLICATIONS

Dr. Barrett: Yes, I, I always like statistics. And I, and, when I talked to patients about undergoing surgery...let's say a, a breast reduction, right? I'm more concerned about the surgical risks, right?
Dr. Grumley: Right.
Dr. Barrett: The chance for wound dehiscence or infection or seroma. These are things that are within the realm of likelihood of happening. But they're always asking me about anesthesia risks. And I'm, like, you know, anesthesia risk is there. But it's so small compared to all of these other things that can happen. And, and it's, it's like, somehow, other things get into people's heads and I get it. Every time I get in an airplane I'm, I’m, I’m frightened. Even though statistically, it's safer than me walking home or driving home
Dr. Grumley: Right. It's the plane crash phenomenon. The disasters is what people think about.
Dr. Barrett: Right.
Dr. Grumley: But once you, kind of, bring it back into that, you know, I do explain to them it's like getting on an airplane.
Dr. Barrett: Yeah.
Dr. Grumley: Right. When a crash happens, it's devastating. But we don't think about all the safe flights that were taking off and landing every single day. And it's just the same as surgery, the amount of anesthesia that's given, you know, the number of people undergoing anesthesia and it's perfectly safe.
Dr. Barrett: Right.
Dr. Grumley: But that is the one thing that they're most worried about, because they're thinking, what if I don't wake up?
Dr. Barrett: Yeah.
Dr. Grumley: Or what if I get anesthetic and I can feel everything? Right?
Dr. Barrett: Yes. But on the contrary, when someone has this very low-grade DCIS, and they want to, they want to jump the gun and do the bilateral prophylactic mastectomy, and radiation, the whole nine yards, and chemo, I’m like, look, you're risking other things.
Dr. Grumley: Right.
Dr. Barrett: For this tiny little breast cancer risk.
Dr. Grumley: Yep.
Dr. Barrett: You're risking, like, so it's, like, you gotta, you have to keep everything in perspective.
Dr. Grumley: You do.
Dr. Barrett: And I think it's important to have somebody like you in your center to, kind of, guide people in...
Dr. Grumley: Absolutely.
Dr. Barrett:...understanding all the data. Because, folks, there is no way…Dr. Grumley is, is learning new stuff every single day, I guarantee because I know she's a very avid scholar and she's learning new stuff everday. There is no way you're gonna be able to figure out all this stuff on your own. You just, kind of, have to, you have to trust people, and trust people that spend their, their careers trying to assimilate all this information.

15:15 BREAST CANCER WILL NOT CHANGE OVERNIGHT

Dr. Grumley: Right and gather that information. Don't just go to, you know, one person and be like, okay, sign me up for surgery because I'm afraid of cancer. The nice thing about breast cancer is that it's not something that's going to change overnight. There's no urgency. There's no emergent operation that needs to be done. You have time to do your homework.
Dr. Barrett: Yeah.
Dr. Grumley: And it's okay to meet a lot of different people.
Dr. Barrett: It’s good for you too.
Dr. Grumley: Yeah, yeah it is good for me. I don’t have any emergent operations.
Dr. Barrett: Yeah, so a little flashback to training. I was like, what, do I, you know, I was like, when I was in med school, I was like, this cardiothoracic stuff is really cool where they're opening chests. But it's, like, these guys have to act quick and it's the middle of the night. And I'm just like, you know, if I'm older and have a family, I don't know if I want to jump into doing that. So that's why, you know, that's, that's one thing. So rest assured that it is, nothing's going to happen overnight. And that's a, that's a great way of putting at it, putting it.
Dr. Grumley: And I always tell patients, if it makes you feel more comfortable, get that second opinion.
Dr. Barrett: Yeah.
Dr. Grumley: It’s okay. It doesn't offend me in any way if you get a second opinion, because sometimes you just need to hear it from somebody else.
Dr. Barrett: Yeah.
Dr. Grumley: And if the two opinions agree, then you're going to feel very comfortable and you need to go with somebody you trust. Because with breast cancer, and unlike most of surgery, we're gonna be bonded for life. I follow them for life. It's not, you know, a one and done, and I never see them again.
Dr. Barrett: And you, and you are already busy, right? So you've been in this position for how long now?
Dr. Grumley: About 12 months.
Dr. Barrett: 12 months, and you, you are, you are filled already. I mean, you're such, you're such in high demand that everybody wants to see you.
Dr. Grumley: We’re ready to hire another surgeon.
Dr. Barrett: Yeah.
Dr. Grumley: So we’re excited.
Dr. Barrett: Yeah, I know. I can't believe it. There's such a need for someone who's just integrating all this together. And I'm so glad that you're there. That's amazing.
Dr. Grumley: Thank you. Yeah.

16:50 BREAST CANCER INCIDENCE AND WHAT EVERY WOMAN SHOULD DO

Dr. Barrett: So, let's, let's talk about there's a lot of myths out there. I want to talk about what's the incidence...we’ll, we’ll, we’ll go back to some common things. What's the incidence of breast cancer and, and how, what should women be worried about? What, what are some things that you recommend every woman should do?
Dr. Grumley: Yeah. So I think everybody's heard the statistics, one in eight women in their lifetime will develop breast cancer. And I think the number one myth that everybody kind of has is that, oh, it must be family related, right? Genetics.
Dr. Barrett: Yeah.
Dr. Grumley: You know, it's ‘cause I have family members that have breast cancer that's why I'm at risk. The number one risk factor for breast cancer is just aging.
Dr. Barrett: Okay.
Dr. Grumley: If you live long enough, you're living past heart disease, you're living past, you know, diet, you know, heart or hypertension or whatever else that other people used to get. You know, you get to an age, it's like prostate cancer for men.
Dr. Barrett: Yeah.
Dr. Grumley: Right? Most of breast cancer are the, kind of, age-related, non-aggressive types.
Dr. Barrett: Okay.
Dr. Grumley: Now, the younger patients are more likely to have genetically linked, you know, BRCA1- and 2-linked breast cancers and they can be more aggressive. And so it's important to understand the difference between the two. Most people don't have a genetic mutation.

18:06 GENETIC ABNORMALITIES

Dr. Barrett: Okay, let's talk about that. Because that's a hot subject.
Dr. Grumley: Yeah.
Dr. Barrett: 10 years ago screening for…well let's, we'll talk, first let's talk about these genetic abnormalities and, and what the risk is for breast cancer and let's talk about should people be...10 years ago, people were taking, getting these tests done at a doctor's advice only. They had a strong family history.
Dr. Grumley: Now they get it for Christmas. 23andMe.
Dr. Barrett: 23andMe And I did it too. And I got, I got, I got mine tested. And I'm like, negative. I'm like, whoo, I don't have BRCA. But it's just like...
Dr. Grumley: It’s not all...negative’s not always negative on a 23andMe.
Dr. Barrett: So let's talk about that. Because these things are so, they're, there are all these different tests like Ancestry DNA, 23andMe, there's a, there's a few other ones, boutique ones out there.
Dr. Grumley: Yeah.

18:52 GENETIC TESTS FOR BREAST CANCER

Dr. Barrett: Let's talk about those. What do you think about every woman going out there and getting tested for this?
Dr. Grumley: Well I think information is, is always good to have. But it's what you do with that information. I think what needs to happen is that there needs to be the counseling that goes with the genetic testing. They have packaged it up very nicely so it's really inexpensive to, kind of, send things off, but they're not doing full panel testing, right? They're not doing the full, kind of, there's different arrays, different mutations for each.
Dr. Barrett: So, so if a woman who is, is got a very indicative family history of breast cancer, or so early-onset breast cancer, multiple siblings, multiple, you know, generations, and they do this 23andMe so you're saying that's not enough?
Dr. Grumley: That's not typically enough. So if I saw that patient in clinic...
Dr. Barrett: Yeah.
Dr. Grumley:...who's got a negative testing. We would, you know, send it for further testing.
Dr. Barrett: Okay, so, so if someone is in this category that you would normally test for and they do a 23andMe, and it says it’s negative, you still say that hey, no, we need to do more.
Dr. Grumley: I think we, we do need to do full panel testing.
Dr. Barrett: Full panel testing. Okay, ‘cause that's news to me, I didn't know that. There’s actually...
Dr. Grumley: Yeah. So there’s, so there are different BRCA mutations that are tested.
Dr. Barrett: Yeah.
Dr. Grumley: You know, the 23andMe do the more common types. But I think that somebody like that needs to see a genetic counselor.
Dr. Barrett: Yeah.
Dr. Grumley: Right? It's not just send off a test. And then what do you do with it? What if it comes back as being positive?
Dr. Barrett: And who would that person be? Do you have the criteria that they use now for recommendation of this multi-panel testing?
Dr. Grumley: Yeah. So anybody who has a family history of ovarian cancer.
Dr. Barrett: Okay.
Dr. Grumley: Male breast cancer qualify already, for genetic testing. We typically like to test those that actually has the cancer ‘cause they have a higher likelihood of actually having a mutation.
Dr. Barrett: Okay.
Dr. Grumley: And once you know what that mutation is, then you can test.
Dr. Barrett: So that’s interesting one of my nurses who works here, her father died of male breast cancer.
Dr. Grumley: Yeah.
Dr. Barrett: So would she be one that...
Dr. Grumley: She would be somebody that would be tested, but he would be tested first.
Dr. Barrett: Okay, he's passed away now.
Dr. Grumley: So if he's passed away, then, then she would be tested and, and she would qualify for testing.
Dr. Barrett: Okay.

20:53 GUIDELINES FOR GENETIC TESTING

Dr. Grumley: The guidelines for genetic testing are always Changing and it's become less and less stringent so, and it's also become less expensive to do testing.
Dr. Barrett: Great.
Dr. Grumley: So it's financially, definitely, not as devastating as it used to be. So anybody really with a young breast cancer in their family, obviously, we want to try to test the cancer.
Dr. Barrett: Is that less than 50?
Dr. Grumley: 4, uh less than 50, we would do genetic testing on anybody who's diagnosed with cancer.
Dr. Barrett: Okay.
Dr. Grumley: Obviously, it's nice to have that negative result, then you feel very comfortable that there's nothing to worry about. But it's important if you do get a positive result that somebody interprets it for you because there are variants of unknown significance that can come back.
Dr. Barrett: Oh.
Dr. Grumley: What that means is that you have a variant from normal, but we don't know what that means.
Dr. Barrett: Okay.
Dr. Grumley: Right? We don't know if it's gonna be important. I've had patients sent to me for bilateral mastectomies with an unknown variant and you're, like, no, no, no, no that hasn't been shown to be linked to breast cancer. So why would you undergo a surgical procedure, with its risks and then reconstruction?
Dr. Barrett: Yeah.
Dr. Grumley: When we don't even know if there's risk.
Dr. Barrett: It is no walk in the park.
Dr. Grumley: No. It is not a one and done.
Dr. Barrett: No. That is a, that is a long, and it's never as good as you were before.
Dr. Grumley: Yeah. Well, I've always said there's no surgery like no surgery.
Dr. Barrett: Right? That’s a great quote.
Dr. Grumley: It’s, it’s absolutely true...
Dr. Barrett: Did you come up with that?
Dr. Grumley: Well, no, I think somebody wiser, yeah somebod, one of our wiser attendings, I’m sure, said it.
Dr. Barrett: Yeah.
Dr. Grumley: But there is no surgery like no surgery. Obviously, if you have a breast cancer and we have to do something then we have to, kind of, figure out what's the best way to do it so that we're not, you know, putting the patient at further risk by what we do to them as opposed to what we can do to help.

22:36 SCREENING GUIDELINES

Dr. Barrett: Yeah, so those are some common things is genetic testing, one in eight. What are the screening guidelines, like, what, what, this is all over the place and, and I listen to so many podcasts about health and wellness and...
Dr. Grumley: Yeah.
Dr. Barrett:...people talk about radiation exposure, people talk about overtreatment and breast cancer. What are the official, what are the official guidelines? And what do you think?
Dr. Grumley: Well, it depends on who you ask what the official guidelines are. I think it's become way more complicated than it needs to be.
Dr. Barrett: Yeah.
Dr. Grumley: And part of it is because of this, the US Preventive Task Force report that came out.
Dr. Barrett: Yeah.
Dr. Grumley: What it basically said was that we don't think that there's enough benefit to do it annually from 40 on. And the reason for that is not because it doesn't save lives, it actually states in there that it does save lives, especially in the age 40 to 50 category. But what they're saying is that to save so many lives, so many women get anxious about having to be biopsied.
Dr. Barrett: Yeah.
Dr. Grumley: So I usually tell patients, you know, the guidelines for 40 and annually, are really good. They're there for a reason, because it does save lives if you do that. But what it's also important to, what's also important to do with patients is I actually sit down with them and actually show them the image and, and show them exactly why it's so complicated to read this image. I use the analogy it's like playing Where's Waldo? So a radiologist has basically ten seconds to play Where's Waldo? One big picture of all of these things that are happening, right? Now, are there certain mammograms that are easier to read? Absolutely. The really fatty breast mammogram, really easy to read. It's like Where's Waldo? is right in the center and there's nothing else around it, right? Or you could have a very dense breast. And that's very complicated. There's all of these other figures in there, and you're trying to pick out little areas.
Dr. Barrett: Yeah.
Dr. Grumley: And so what they need to do often is they will call you back because they need a better look at certain areas. And that's what a callback is. It's just they need to have a better look. So don't be anxious because most people will be called back at some point in their lifetime, especially people with dense breast tissue.
Dr. Barrett: Yeah, so we…by the way, we do all, we recommend mammograms for anybody 35 and above getting breast surgery and...
Dr. Grumley: Absolutely.

24:50 MAMMOGRAM BEFORE BREAST AUGMENTATION

Dr. Barrett:...and the main reason we, why we do it is so, if you're 35 and you get a breast augmentation, you have a baseline. So let's say when you do turn 40 if something suspicious pops up, they've got a reference mammogram to, kind of, look back at me. And be, like, hey I see what happened here with the surgery. I can see the implant underneath the muscle.
Dr. Grumley: Yep.
Dr. Barrett: Which supposedly, by the way, makes mammograms easier. If it’s underneath the muscle. It kinda push...
Dr. Grumley: If it’s underneath the muscle?
Dr. Barrett: Yes.
Dr. Grumley: Yeah.
Dr. Barrett: Which is one of the reasons why I go submuscular with, with implants.
Dr. Grumley: Absolutely.
Dr. Barrett: And, and so, you know, we do, we do all of that. We don't, I don't do any breast surgery unless they get that, you know, or if they're over 40 they have a recent one.
Dr. Grumley: Yeah.
Dr. Barrett: And that's just.
Dr. Grumley: That’s smart.
Dr. Barrett: Yeah. And, and that's just for that one in eight scenario, which is probably going to happen, where I...fortunately, I haven't had anybody come back with breast cancer.
Dr. Grumley: Yeah.
Dr. Barrett: So that, but I've had people come back with getting repeat imaging, and they're worried, they're freaked out. They want to cancel their surgery. I’m like no, go back, get your ultrasound, ultrasound negative, right?
Dr. Grumley: Yeah.
Dr. Barrett: Benign.
Dr. Grumley: Right.
Dr. Barrett: Just follow up in a couple years.
Dr. Grumley: Exactly.
Dr. Barrett: And so it's, but, but it's like, that, the anxiety just goes right up.
Dr. Grumley: Right. But if you actually explain to patients that when you go for your mammogram, there's a good chance they're gonna call you back and have a better look.
Dr. Barrett: Yeah.
Dr. Grumley: ‘Cause they just need to have a better look. Then that anxiety, kind of, comes down.
Dr. Barrett: And, and that, and no it’s true. What you, what you mention is, is totally spot on. I remember going into these radiology, these rooms, it was like you're entering Star Wars.
Dr. Grumley: Yeah, you're, like, huh?
Dr. Barrett: You’re looking at, you’re looking at these screens and you look, I feel like you're looking at galaxies. It's so blown up on these screens and you’re looking at these little different star systems. But that's just, I don't know how they, they interpret them so well. They, they’re specialists.
Dr. Grumley: Exactly. But they do it every day. And this is all they do. And, and it's amazing what they can pick up. Now we have 3D mammograms. So tomosynthesis makes it a lot easier for women who have very, kind of, complex imaging. So instead of taking, you know, the breast and, and pressing it and shooting one image through it.
Dr. Barrett: Yeah.
Dr. Grumley: Which can obscure, you know, things can, kind of, be on top of each other. It can be hard to, to interpret.
Dr. Barrett: Right. Because it’s like a basically, like, a simple X-ray.
Dr. Grumley: Right. Now we can actually do 3D in which they take multiple images, kind of like a CT scan.
Dr. Barrett: Okay.
Dr. Grumley: And so that helps because we can actually get rid of some of that background. So it decreases callback. So fewer women have to be called back to have a better look. But it also increases our ability to find tiny cancers in very dense breasts. So it's definitely improved things when it comes to imaging.

27:07 CONCERNS ABOUT RADIATION

Dr. Barrett: What do you say to the women who are worried about radiation exposure to the breasts from repeat mammograms?
Dr. Grumley: So my...
Dr. Barrett: Or screening mammograms?
Dr. Grumley: Yeah, so I usually tell them, do you carry a cell phone? Do you go on an airplane? Because I can tell you all of that is way more radiation than a simple mammogram once a year.
Dr. Barrett: Right.
Dr. Grumley: Right. When you look at the amount of radiation, it's about a chest X-ray.
Dr. Barrett: Okay. So, like, is that, like, a single airplane flight? Or would it...
Dr. Grumley: So a single airplane flight is probably like 10 chest X-rays.
Dr. Barrett: Gosh.
Dr. Grumley: 15 chest...you know, it's definitely a lot more than a single. So when we take it and put it into context...
Dr. Barrett: Yeah.
Dr. Grumley:….I think it's what's the risk? What's the benefit? Right? So we're not saying we're put, putting them through CT scans every year, right? We're not doing annual CTs or every three month CTs.
Dr. Barrett: Yeah.
Dr. Grumley: It's a very low risk, but it could be a huge benefit. Because not only can we save lives with mammograms, what people don't think about is the fact that if we catch it early, we don't have to do as much treatment.
Dr. Barrett: Right.
Dr. Grumley: Right?
Dr. Barrett: And it prevents it from spreading. In case it does get invasive.
Dr. Grumley: It prevents it from spreading. And a lot of times women don't need to have chemotherapy if it's found early.
Dr. Barrett: Yeah.
Dr. Grumley: You know, we have molecular markers that can actually, you know, decipher who needs chemo versus who doesn't. So, the US Preventive Task Force looked at well, outcomes of patients didn't change with mammograms. So they, it wasn't, like, oh, you know, we could save that many lives. We could save a few but not that many. Well to me, if it was my life, I would think it would be worthwhile. But it doesn't address the fact that how much do you have to do to get to the same survival? Do you need to have chemotherapy? Do we need to be doing more radiation? Are there other things that we need to be doing, ‘cause as treatment gets better, outcomes get better? Right?
Dr. Barrett: So in a nutshell, mammogram at 40, annually is, is beneficial. Yes, it might save a few extra lives, but it might decrease the amount of treatment that you might have to go through.
Dr. Grumley: Right.
Dr. Barrett: Is that what you're saying?
Dr. Grumley: Yeah.
Dr. Barrett: Okay.
Dr. Grumley: Because I think that's, that's the bigger value.
Dr. Barrett: It’s huge.
Dr. Grumley: Given the option, if I screened and found something tiny and I don't need to do chemo versus if I waited...
Dr. Barrett: Yeah.
Dr. Grumley:...and felt it and then, you know, it's definitely a difference.
Dr. Barrett: So we, we live in a, we live in a place--Los Angeles--where people think all kinds of things and a lot of the things are great. And I'm learning new things, like earthing and grounding and organic stuff.
Dr. Grumley: Yeah.
Dr. Barrett: And, and people, but there's, there's, there's talk about, you know, vaccines causing problems and, and mammograms causing breast cancer.
Dr. Grumley: Right.
Dr. Barrett: And, and I remember when I was at Kaiser, I remember, I remember there was one woman who had breast cancer and she didn't want to do anything. And this was like a bad breast cancer and she's just, like, I'm just going to heal it naturally. It’s like, how do you…that, that probably happens more here than anywhere else in the country. So how do you deal with women who are reading this un by, un, unsubstantiated stuff, like on Facebook, or wherever else that's, kind of, fueling these thoughts that, you know, it can, can heal these things naturally and so forth.

30:15 HEALING OF BREAST CANCER WITH NATURAL METHODS

Dr. Grumley: Right. So I usually try to, kind of, sit down and, kind of, walk through why they're thinking the way they do.
Dr. Barrett: Yeah.
Dr. Grumley: A lot of it has to do with fear of what these, and distrust of medical treatments. So if you actually, I've had a couple of patients where they're like, oh, I went to Mexico, or I started doing coffee enemas to treat my triple-negative breast cancer. And you sit and you talk to them...
Dr. Barrett: Coffee enemas? Really? Is this a real story?
Dr. Grumley: Yeah, this is a true story.
Dr. Barrett: Because I know some people that do that for fitness. I’ve never heard of that for breast cancer.
Dr. Grumley: Yes, for breast cancer. She's like, it doesn't stink as much if I do it. And I'm, like, okay.
Dr. Barrett: Wow.
Dr. Grumley: But walking through why she felt that way, it all really stemmed from when she got diagnosed, and they said, oh, no, it's triple-negative, we need to do a mastectomy.
Dr. Barrett: Yeah.
Dr. Grumley: And, like, people just jumped off the deep end with her when it comes to treatment, which totally scared her.
Dr. Barrett: Yeah.
Dr. Grumley: And then she starts reading and then she's, you know, worried about, you know, medical, you know, companies and, you know, doctors in the pockets of, you know, pharmacy, pharmaceuticals, and then it can kind of fuel. And so when we sit down and actually walk through why she is so fearful and why she wants to go down this road, we can kind of alleviate some of the anxiety associated with it. I mean, I got her to surgery, which was amazing.
Dr. Barrett: Yeah.
Dr. Grumley: But, you know, I think it's important to understand the process and why they're thinking the way they do. And then you can sit down and walk through the science with them. I mean, I spend a lot of time with our cancer patients because I want them to understand what is going on, what we know about their cancer, and what can we do and why do we do the things we do? Because none of us want to do anything if you're, if you don't know why you're doing it.
Dr. Barrett: Right, I think that's key. Not, not all cancers are equal. People are, like, why isn't there a cure for cancer? And I'm like, well, a, are we're talking pancreatic cancer? Are we talking lobular carcinoma? Are we talking ductal carcinoma for breast cancer, I mean there's different variants.
Dr. Grumley: There’s so many different...yeah.
Dr. Barrett: And it's, like, to understand cancer, cancer is cells that can't control themselves from dividing.
Dr. Grumley: Right.
Dr. Barrett: And it can…and, and they're all different shapes and sizes.
Dr. Grumley: Right.
Dr. Barrett: And, and so it's just, it's important to understand that too.
Dr. Grumley: Right. Well, I usually tell them cancer is like the word ball. How many different balls are there, right? And how many different ways and, in you, in how it would bounce, and how you would play it, and how the game would go? I mean, it's just like cancer, there are just so many different types. And there's so many different things that you need to do when it comes to treatment. And it differs from person to person too.
Dr. Barrett: Yeah. Let's, okay, so you recommend mammograms starting at 40 every year? Is there a situation where someone should get a mammogram sooner?

32:47 WHEN TO GET A MAMMOGRAM BEFORE THE AGE OF 40

Dr. Grumley: Definitely if you have a family member that had early-onset breast cancer.
Dr. Barrett: Okay.
Dr. Grumley: So I would hope that those patients who have family members with early-onset are being seen by a specialist. They need...
Dr. Barrett: And that’s less than 50?
Dr. Grumley: Right.
Dr. Barrett: Okay.
Dr. Grumley: So we typically, so think of it as premenopausal breast cancer. We typically have what's called a high-risk clinic. So patients who have family history, who don't have a genetic mutation, or even those who do have a genetic mutation, that don't want prophylactic surgery--want to be watched--need to be watched carefully. So we make arrangements so that we will call them when it's time for imaging. We will examine them when it's time for an exam, and so nothing gets missed. But definitely, we would do more stringent imaging, we might do MRIs once a year, in addition to their mammogram.
Dr. Barrett: Yeah is that an option for somebody? If they are really adamant about not getting a mammogram, to just pay out of pocket for an MRI? Would that be as good?

33:44 MRI’S AND ULTRASOUNDS

Dr. Grumley: Um, the problem is that they're picking up different things. So mammograms are looking for calcifications. Calcifications if it's an, if it's an intermediate grade DCIS or even some high-grade DCIS, will not have significant blood flow to it. And so an MRI won't pick it up. So you, they're really more complimentary.
Dr. Barrett: Okay.
Dr. Grumley: They, kind of, go hand in hand. And so it's not one or the other because you might miss things if you just did one versus the other.
Dr. Barrett: I see.
Dr. Grumley: Right. If you just did mammograms, you might miss small masses if you have a very dense breast. But an MRI would pick that up, typically. So that’s why the, the dual imaging modalities.
Dr. Barrett: And then what about ultrasound, same thing?
Dr. Grumley: So ultrasound has typically been better for diagnostic because it's so user-dependent. It's somebody's hand. That's, you know, and it's even, you remember during residency when one person uses the ultrasound versus the other person that uses the ultrasound, so you need to know where you're looking. It's not a good screening tool. At least it never used to be because it has to be the person's hand and you might miss parts of the breast. But now there's something called ABUS which is an Automated Breast Ultrasound. So it's, like, this big box that you can actually put on the breast...
Dr. Barrett: Okay.
Dr. Grumley:...and it will automate it, it's an automated pattern in which will get all quadrants of the breast.
Dr. Barrett: Cool.
Dr. Grumley: So it's repeatable, it's more reliable, but again, it's not picking up calcifications.
Dr. Barrett: Got it.
Dr. Grumley: So that's, again, a complementary study, but not instead of.
Dr. Barrett: So, really quickly, cancer cells put out calcifications.

35:13 CANCER CELLS AND CALCIFICATIONS

Dr. Grumley: Well, cancer cells can put out calcifications, you can have cancer without calcifications.
Dr. Barrett: Wonderful.
Dr. Grumley: Right. So it's, it's basically, we usually see cancer, or calcifications if they're very fast-growing cells. So there's debris that's, kind of, left behind by necrotic tissue. But you can have calcifications that are not cancer. So you can have atypia that can be calcified. Atypia is a little specks that look, that shows atypical ductal hyperplasia, or it could be usual hyperplasia, which is just normal variant of the breast. So the reason why I like the annual mammograms is because when a radiologist is looking at your mammogram to interpret it, they're looking back to last year to see if there's change.
Dr. Barrett: Yeah. Right.
Dr. Grumley: They literally sit there and count these calcifications. Like, that calcification is here, that is here. And, oh, these are new.
Dr. Barrett: Right.
Dr. Grumley: It wasn't there last year. It's that change that we're looking for when it comes to making a decision about biopsies.
Dr. Barrett: All right. So let's switch gears. Let's talk about prevention. What can people do besides…I mean, people can't stop getting older, right? So we talk about, like…
Dr. Grumley: Although you try to make them…
Dr. Barrett: We try. We, we're learning about telomerase and all kinds of anti-aging stuff that's out there right now. I take a bunch of supplements about that too...but what, what can people do to decrease their risk of breast cancer? I mean, when, I remember when I was at the county, it seemed like every woman that I was presenting at tumor board was obese.
Dr. Grumley: Yep.
Dr. Barrett: And I felt like I, I was, like, I can't remember the last skinny woman with breast cancer that I presented. It was all, I mean, we, we had a certain subset of patient population there. So...
Dr. Grumley: Yes. I can guarantee there are skinny, thin women that have breast cancer.
Dr. Barrett: I know, oh I know totally. Yeah. And I, I remember, but I remember having that thought. I was, like, is this linked? Sure enough.

37:05 LIFESTYLE CHANGES TO PREVENT CANCER

Dr. Grumley: Yes. So definitely, when you think about what are the things that we can do to prevent our breast cancer risk, you want to think about more lifestyle moder, mod, alterations. So the American Cancer Society does a really nice job. It's on their website that actually outlines what women should think about doing. So exercising over 150 minutes a week of actually vigorous exercise, decreasing sedentary time in front of a TV or sitting around, increasing their vegetable and plant-based diet, but decreasing their meat, red meat diets. Now, none of this is saying eliminate anything, right? None of the guidelines tell you you can't do this or you can't do that. It's just living a good healthy lifestyle will decrease your basic body fat.
Dr. Barrett: Yeah.
Dr. Grumley: We know that there's probably alterations in estrogen levels because estrogen can be stored in fatty cells. And so that is something to consider. But even if you do all the right things, you may still develop breast cancer. So I don't want people to be out there thinking oh, I caused my breast cancer by not doing x, y and z.
Dr. Barrett: Right.
Dr. Grumley: Right. It's important to say, okay, well, there are things that we can do to improve it just like diabetes, right? There are things that we can do to decrease our risk of diabetes, but some people will still get it. So you can do, you know, do the things you can but not worry about the things that you have no control over.
Dr. Barrett: Got it. Okay, what's, okay, so healthy lifestyle? Right.
Dr. Grumley: Yeah.

38:34 SMOKING AND ALCOHOL

Dr. Barrett: What about smoking? What about drinking alcohol? What are, what are some other ones that are…?
Dr. Grumley: So smoking is definitely a risk factor. Even secondhand smoke...
Dr. Barrett: Really?
Dr. Grumley:...is considered a risk factor.
Dr. Barrett: Okay.
Dr. Grumley: Alcohol intake--excessive alcohol intake--is considered a risk factor. Now a lot of these studies are, are association studies. As you recall in medical school, association studies are really difficult to interpret, right? Is it the environment that they're in? Are there factors that are not being accounted for that's causing this association? So it's not necessarily a cause and effect, but we know that, you know, smoking definitely has, is a carcinogenic...
Dr. Barrett: Yeah. For a lot of things.
Dr. Grumley: For a lot of things, right? Whether that links directly to breast, it's not quite as clear. But definitely we see these association studies where, you know, patients who are smokers are higher risk. Patients who are around a lot of secondhand smoke are at higher risk. So obviously trying to eliminate that or limit that.
Dr. Barrett: So all right, so, tips. If you're really worried about breast cancer, exercise 150 minutes every week, at least. Avoid alcohol in excess, av, avoid smoking entirely or secondhand smoke. And do you do monthly exams? Do you recommend monthly exams, self-exams?

39:45 MONTHLY BREAST SELF-EXAMINATIONS

Dr. Grumley: So monthly exams I think is, is important. You should know what your breasts feel like.
Dr. Barrett: Yeah.
Dr. Grumley: But, unfortunately, everybody is taught to do those little tiny circles on the breast, right? Because everybody got one of those cards.
Dr. Barrett: Right, you hang in your shower, right? Yeah.
Dr. Grumley: Mm hmm. But the problem with that is that almost everything feels like a lump when you do those little tiny circles, and it freaks a lot of people out.
Dr. Barrett: Right.
Dr. Grumley: So if you're unclear about your exam, definitely come see a specialist. Come to the breast health clinic and we can, kind of, show you how it should be done. Typically, I tell patients, just when you're in the hot shower, put some soap on your hands, run it nice and flat over your breasts. Because, you know, women's breasts are lumpy, bumpy. And you have no idea if it's an actual mass, and so we can actually walk through that whole process with them. But if you know what your breasts feel like, then you'll know when something's different. And that's when it, we need to be brought, it needs to be brought to, you know, medical attention. ‘Cause there are things that you can have a normal mammogram and you can feel something that needs to be taken care of because there are certain types of breast cancer that's just harder to detect.

40:50 BREAST IMPLANTS AND CANCER

Dr. Barrett: Got it. Do breast implants cause breast cancer?
Dr. Grumley: So…I get asked that a lot here in LA. So breast implants themselves have not been shown to cause breast cancer. Now that's, that's typical breast cancer. Now there's this, all this talk about these implant related-lymphomas, which is a totally different thing than breast cancer. It’s just a canc, a lymphoma that happens to be around implants.
Dr. Barrett: Yes.
Dr. Grumley: Which is different. So not talking about that.
Dr. Barrett: Yes.
Dr. Grumley: But breast implants itself has not been shown to cause breast cancer. But it can make it harder for us to detect breast cancer. So when you talked about always doing it subpectoral, why? Because we can push it out of the way so we can have a better view of the breast itself.
Dr. Barrett: Right.
Dr. Grumley: As opposed to sub, sub-glandular, which is like between the breast and the, and the muscle.
Dr. Barrett: It’s right in, smack in the middle.
Dr. Grumley: Right.
Dr. Barrett: Yeah.
Dr. Grumley: It obscures a lot of the breast tissue that we really want to have a good look at. And that makes it very hard for us to, kind of, decipher.
Dr. Barrett: Yeah, no the, we actually have a whole podcast with Dr. Ritu Chopra who's a, he works, he, he's been doing some research with Allergan and their textured implants. Who had that one in 3000 risk of the anaplastic large cell lymphoma, which is a lymphoma that develops in the capsule around textured implants. And it happens with the other textured implants as well, but it hasn't been shown to happen with smooth implants. And even in the worst-case scenario, these implants that were recalled, it's one in 3000. Chance of being str...
Dr. Grumley: It’s very, very rare.
Dr. Barrett: Yeah, chance of being struck by lightning in your lifetime is about one in 3000. So I tell people that. But I don't use Allergan. I use Mentor and it's 1 in 86,000 chance if I use texture, but most of time I'm using smooth.
Dr. Grumley: Yeah.
Dr. Barrett: People are more likely to get problems from surgery like infection, capsular contracture, other things.
Dr. Grumley: Exactly.
Dr. Barrett: Versus this rare lymphoma. But it's out there. It's in the news and it's, it’s people are, like, oh, breast cancer! It's not breast cancer, it’s lymphoma. Again, it's a different type of ball, like you said.
Dr. Grumley: It’s, yeah, it’s totally different.
Dr. Barrett: I want to touch on hot topics. Hot topics that are, are going on at your level. And, and you do a lot of research as well as clinical stuff. So you are, you are like, you're completely in the breast cancer world. And it's amazing that you can do, you can balance your three kids, the clinical side of things, the whole surgery, the, the Cancer Institute, and then John Wayne cancer research.
Dr. Grumley: Yeah. Well, I don't do it on my own.
Dr. Barrett: Ok. Well, I know, it’s not, like, yeah.

43:15 RESEARCH PROJECTS

Dr. Grumley: It's not just me, it's a huge team. It’s an amazing team that we’ve put together there. But yeah, so research is definitely important. You know, part of what I loved about medicine was that how things are always changing, right? How can we improve? How can we make it better? And I think what we're looking at when it comes to breasts in the future is the fact that we can, kind of, figure out what a patient actually needs. You know, breast, or cancer treatment in the past has always been, kind of, this buckshot. We'll just try this. Let's try that.
Dr. Barrett: Yeah.
Dr. Grumley: You know, bigger must be better. But what we're actually finding out is looking at molecular levels of the cancer cells to decipher which are which.
Dr. Barrett: What does that mean molecular level? For, like, the listener?
Dr. Grumley: Yeah so you’re looking at genetics of the tumor to see is it a higher-risk cancer? Do they have, you know, patterns in which we would recognize as being higher risk? So a lot of the research that's happening at John Wayne is looking at triple-negative breast cancers. Are they all alike and...

44:09 TRIPLE-NEGATIVE BREAST CANCER

Dr. Barrett: Now what does triple-negative mean?
Dr. Grumley: So that means they're, on the cancer cells themselves they have lost…so cancer cells of the breast is a version of your own breast cells. Your own breast cells has estrogen receptors on it, it, kind of, signals for growth when you hit puberty. So cancer cells that have lost it is an estrogen-negative. So something genetically has altered, so it's lost that estrogen receptor on it. So it doesn't modulate its function. So estrogen receptor-negative. And then progesterone is the other hormone so also negative would...and then HER2 is another, kind of, protein that's typically seen. So if it's also negative, that makes it a triple-negative breast cancer.
Dr. Barrett: Got it.
Dr. Grumley: That's the most aggressive form. At least we've, you know, it's been categorized as the most aggressive form of breast cancer. But as we're starting to find out by looking at the genetic profiles of it is that it's actually not one cancer.
Dr. Barrett: Yeah.
Dr. Grumley: There are different types. There are less aggressive triple negatives, and then there's really super aggressive triple negatives. And then there are those that will respond and those that won't respond to what we have available and those that respond to different things. And so instead of just, kind of, trying one thing for this big bucket of disease, we have to actually look at the molecular makeup of it so that we can better prescribe what's actually needed for that specific person.
Dr. Barrett: Okay.
Dr. Grumley: So I think it's really exciting. I think the future is going to be more personalizing medicine, right? We're not just treating the cancer, we're treating your specific cancer. Just like everybody is different, we have to treat the cancers differently, too.
Dr. Barrett: That's pretty incredible.
Dr. Grumley: Yeah.

45:40 STIMULATING THE IMMUNE SYSTEM

Dr. Barrett: Is there any research going on into stimulating your own immune system to, kind of, go after these aberrant cells?
Dr. Grumley: Yeah. So triple-negative is actually one of the largest areas where they're looking at immunotherapy to help stimulate your own ability to, kind of, fight against cancer. We're actually embarking on a new study, just right now, looking at inter-operative radiation therapy, why does it work so well? If we do one dose of radiation, we think it's such a small amount of radiation. Why does it work?

46:12 RADIATION THERAPY

Dr. Barrett: So, let's back up a minute. So radiation is, is basically shooting a beam of ionizing radiation that is…it affects dividing cells. Typically dividing cells are cancer cells, right? These are just uncontrolled divisions. Normally, the cells in your body have about, I don't know, 80 or so cell divisions, and then they die. Cancer cells are cells that they don't have a shut-off, and they just keep going like crazy, right? So one of the tricks that we discovered a long time ago is that if you radiate these rapidly dividing cells, it kills them.
Dr. Grumley: Right.
Dr. Barrett: So radiation has been a mainstay of breast cancer therapy in, in certain situations. And I, I remember when my own father had lung cancer, and I remember they’d have this, they’d have these tattoos on his chest. And he'd had these radiation burns where they’d shoot a whole beam right through his whole chest. And they do some, they do similar stuff for breast cancer where they, you know, they, they’ve refined it a lot since then.
Dr. Grumley: Yeah.
Dr. Barrett: But tell us, what is it, this interoperative radiation that, that you guys are doing now that's so different?
Dr. Grumley: Right. So typically, for breast cancer patients, you have to have radiation from the outside. It’s like you said, they put the tattoos on and they, there are beams that, kind of, go through the breast tissue. And it typically takes probably somewhere in the three weeks to six-week range of treatment, depending on the stage of cancer and other factors. So, obviously, there's a lot of fear because what else is getting radiated?
Dr. Barrett: Right.
Dr. Grumley: Just like we said about surgery, there's no radiation like no radiation. Because we're also treating a lot of things that are normal.
Dr. Barrett: And it, and it makes our lives, as a reconstructive plastic surgeon, and it makes our lives really difficult to try and recreate a breast when the, the surrounding tissue has been radiated because it doesn't respond like normal, healthy, non-radiated tissue.
Dr. Grumley: Right. Yeah, so there's definitely lasting effects.
Dr. Barrett: Yeah.
Dr. Grumley: So but what we've discovered is that as we do screening, we're finding smaller and smaller cancers. Do we need to radiate this large area? When you look at the studies where disease recurrence--so that means when the cancer comes back in the future--where does it come back?
Dr. Barrett: Does it really come back? Or is it just left there in the beginning?
Dr. Grumley: Well, we, that's a good arg...we don't know.
Dr. Barrett: Yeah.
Dr. Grumley: We don't know. So even after radiation, even if they come back, where do they come back? They come back right in the vicinity of where the first cancer is. And so that's where we started looking at perhaps we can target the radiation perhaps we don't need to radiate this big area.
Dr. Barrett: Yeah.
Dr. Grumley: Maybe for smaller cancers, we can just radiate a smaller area. Technology became available that we could actually bring radiation into the operating room. So instead of the big linear accelerators that are hidden in the basement somewhere that you can't get to. It's just this little tiny machine that gets wheeled into the operating room. So we can do the lumpectomy or the partial mastectomy. Then I know exactly where the tumor came from ‘cause I just took it out.
Dr. Barrett: Right.
Dr. Grumley: Then we place the applicator for the radiation and we just radiate the tissue around there.
Dr. Barrett: So this is pretty cool because I remember this was just getting started at USC when I was finishing my training. And so backing up, there's full mastectomy where the whole breast is removed. And there's a lumpectomy where we take a little quadrant or a little, little surrounding area where that breast cancer is.
Dr. Grumley: Right.
Dr. Barrett: And it's kind of cool because it preserves the rest of the breast.
Dr. Grumley: Right.
Dr. Barrett: So I remember there's, like, this little balloon and it was like a big marble and you stick it in there and then you wrap the breast up around it, and then it just, it just localized radiation, right in that spot.
Dr. Grumley: Yeah. So radiation is just on the surface of the applicator.
Dr. Barrett: Yeah.
Dr. Grumley: And so it extends for about a centimeter. So it's basically saving the rest of the breast.
Dr. Barrett: Yeah.
Dr. Grumley: Saving the chest wall. And so it's limiting the amount of radiation, but it's really treating well, kind of, the tumor bed, which is the tissue that needs to be treated.
Dr. Barrett: Yeah. And results?
Dr. Grumley: Has been great. So the target trial was first started in 2001. That's the large trial that compared it to whole breast radiation. So in well-selected, so in the appropriate patient, small cancer, early-stage they did just as well, when it came to having this cancer come back in the future.
Dr. Barrett: Yeah.
Dr. Grumley: But what they also found in the later follow-up is in, in that very well selected group of patients, the survival for any disease, any death was actually better in the intraoperative group than the whole breast group.
Dr. Barrett: Interesting.
Dr. Grumley: So, obviously, everything we do has a side effect.
Dr. Barrett: Yeah.
Dr. Grumley: So we definitely don't want to cause problems when they don't have a very high risk of cancer. Right?
Dr. Barrett: Right.
Dr. Grumley: So it's picking the right tool for the right patient. So we just have to have it in our tool belt.
Dr. Barrett: Yeah, I mean, we've all heard those stories and people get horrified at these complications that happen. So-and-so went in for surgery and they ended up in ICU. Something bad happened.
Dr. Grumley: Yeah.
Dr. Barrett: It’s just like...
Dr. Grumley: Yeah.
Dr. Barrett:...you know, it's we, we think that we are doing good all the time. But people make mistakes, infections can happen. You know, we really, radiation can, can hit a part somewhere else that might be developing its own cancer or something. You know and it’s just, like...
Dr. Grumley: Right, there's always things to be considered, that need to be considered. But you have to assess: what's your risk, and what's your benefit that you're going to get from that treatment? If it's worthwhile, you have a really bad disease, then you do want to treat with, kind of, bigger treatments. But if you don't, we don't want to cause problems for you down the road either. So we're looking at, kind of, the effects of intraoperative radiation therapy, and we're actually looking at, like, we were talking about the immune response to it. And perhaps there's something that happens with radiation at the time that can actually alter your immune, kind of, response to that area. Maybe that's why we're getting such...
Dr. Barrett: In a, in a good way?
Dr. Grumley: In a good way.
Dr. Barrett: Yeah.
Dr. Grumley: Right. It's bringing, you know, bringing some immune cells to heal an area and that may be helping fight something. So we're looking into that now and we're really excited to be...
Dr. Barrett: Because I mean, that, you know, our immune system is, like, the more and more I listen to podcasts and stuff about the human body and health, and even though I went to med school, and have a Masters in physiology, I'm still learning, like, it's amazing how complex the human body is and how little we know.
Dr. Grumley: Absolutely.
Dr. Barrett: The immune system is a pretty smart cookie, you know? And it's just, like it, to me, it's, like, if we can, if we can figure out the immune system to work in, in our favor to go after these bad things...
Dr. Grumley: Right. Yep.
Dr. Barrett:..it's much better than, like, dosing our whole body with chemo, you know?
Dr. Grumley: Absolutely, yeah.
Dr. Barrett: Where we're hitting everything and we’re feeling like crap.
Dr. Grumley: Right.
Dr. Barrett: Or same thing with radiation.
Dr. Grumley: So how do we show our bodies that our cancer isn't us, right?
Dr. Barrett: Yeah.
Dr. Grumley: That's how, that’s what we have to do is somehow make it look different than our normal set. Then our own immune system can attack it.
Dr. Barrett: Yeah. Awesome. Well, Dr. Grumley we're, we're, kind of, towards the end here. What, it, what are some key takeaways, or what are some things that you want the audience to, to know about? Or what's the latest and greatest thing or anything else you want to share?

52:40 FINAL ADVICE

Dr. Grumley: I think it's important to understand that breast cancer is not nearly as scary as it used to be. There are just so many choices available.
Dr. Barrett: It's not a death sentence.
Dr. Grumley: It’s not a death sentence. You know, you go to the common walk and you have 30, 40, 50-year survivors. It's important to say, to understand that what your neighbor did isn't what you need to do. You have to make your own decisions.
Dr. Barrett: Yeah, I don't know if you know this. I recently participated in the Malibu triathlon with Dr. Tiffany Grumwell. I don't know if you know who she is.
Dr. Grumley: I do. Yeah.
Dr. Barrett: She does a lot of breast cancer reconstruction.
Dr. Grumley: Yeah, she's wonderful.
Dr. Barrett: And I, I was out there and I did a swim. And she's like, she's like, Dan, we need, we need some more swimmers. I'm like, all right, fine. I'm like, that's my worst part of doing anything. I was, like, I can run really fast, I can ride a bike, but you want me to get in the ocean and swim? What am I, shark bait? I don't know. And so I went out there and I swam, and it was great. But there was like 150 to 200 women, some men too, and they were all running and cycling. And they've all been through surgery. Some of them might have been your patient. I don't know. But it was, it was totally awesome.
Dr. Grumley: Yeah. It's amazing how things have changed. I mean, even when you and I were doing residency, we were seeing women die all the time when it came to breast cancer. But we are really not seeing that. You know, our ability to find things early and the treatments that we have available now is definitely changing things. Now, are there women still dying of breast cancer? Absolutely. So there's still the need for more research and to better hone in on what is needed. But it's definitely not as scary as it used to be. The things that you can do about getting better outcomes is obviously lifestyle changes that they can do. And getting screened.
Dr. Barrett: Yeah. And I, and I think when you do, when you do come across the, the, the unknown and you're, you're concerned about something, reach out to a multidisciplinary center, like the Margie Peterson center, and, you know, go to a multidisciplinary place so that you can get, kind of, a team approach. If you are worried about something. And this, this urgent care for the boobies? I love it. I'm gonna, like, I'm gonna give all my patients this phone number. This is, like, the best idea ever.
Dr. Grumley: Yeah, no, it's been great. She's been so busy since we've opened it. ‘Cause that's what, you know, a lot of women are, like, I don't really have a doctor, like, where do I go and...
Dr. Barrett: Yeah.
Dr. Grumley:...you know, what do I do with it?
Dr. Barrett: I get, I get a lot of patients that ask me to look at lumps too. They’re, like, here for their tummy...oh, can you look at my breasts too? I’m, like, oh god, it's been a while since I've done a breast exam. Let me feel, like, it kind of feels normal, but you should go see your doctor, right? Because I’m not really...
Dr. Grumley: Now you can send them to us.
Dr. Barrett: I'm totally gonna send them to you guys. So that's fantastic. Well, Dr. Grumley, thank you so much for being on the podcast and you are really, you are really bringing, you know, some new things to breast cancer and your dedication and passion is really showing and so thank you for what you're doing.
Dr. Grumley: Well, thanks for having me.
Dr. Barrett: Absolutely.
Dr. Grumley: It’s been fun.
Dr. Barrett: Anytime. Awesome.

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