Interview with Dr. Stephanie Akbari

January 17, 2013


Liz Dowling: Welcome to Symphony Sisterhood Breast Cancer Dialogues. I’m Liz Dowling. We’re talking today with Dr. Stephanie Akbari, breast surgeon and medical director of the Center for Breast Health at Virginia Hospital Center in Arlington, Virginia. Welcome, Dr. Akbari.

Dr. Akbari: Thank you.

Liz Dowling: We’ll be talking about some of the first things a woman should consider following a breast cancer diagnosis. Perhaps the first thing anyone diagnosed with breast cancer is thinking is “Why me?” Dr. Akbari, as a surgeon, you’re typically the first doctor a newly diagnosed breast cancer patient sees. How do you begin to help them cope with their diagnosis?

Dr. Akbari: Well, I think the best way to cope with the diagnosis is number one, to understand what your treatment options are, and number two, make a plan in order to take care of the problem. I find that once there is a plan in place and there is some activity towards fixing the problem, there’s much less anxiety and stress regarding the diagnosis.

Liz Dowling: Good. How important do you think it is for a breast cancer patient to educate themselves about breast cancer and its treatment?

Dr. Akbari: I think it’s extremely important and the reason for that is because each person brings to the table certain individual characteristics. So every patient is different. There are many options to treat breast cancer and it’s not one-size-fits-all. We try to individualize our treatment. So the better a patient is able to understand what the choices are and that are able to understand what would meet their needs the best, the happier they are going to be in the long run. So education really is the key in order to make sure that we can tailor our treatment to each individual person.

Liz Dowling: So what do you think would be the first steps that a patient should take to get educated?

Dr. Akbari: Well, I think there are lots of resources on the internet, many websites that are credible. One of the problems with that, however, is that sometimes that kind of viewing on the internet can be very scary for patients and they might not know what applies to them and what doesn’t apply to them. I would really encourage them to use their breast cancer’s treatment team. As a resource, use them to their advantage to get the information that they need. Many breast centers have a group of people that can help educate patients which consists of the surgeon, the plastic surgeons, the navigators, nurse educators. Through those people, through the breast cancer team, I think patients would have a better way of finding appropriate educational information.

Liz Dowling: So you really think it’s a kind of combination effort of both doing self-education through the internet to some degree but also working closely with the breast cancer specialists that are your treatment team?

Dr. Akbari: Absolutely. I would encourage people – patients to write down questions so that when they go to the doctor’s appointment, they can tick off each question and make sure that they get their questions answered. I would also encourage patients to take someone with them to their appointments. I personally take notes for patients and give them to them to take home but not every person does that, not every doctor does that. So if someone brings along a loved one to take notes, then there’s a written recording of what has gone on. There is a lot of information that is delivered at each appointment and it’s impossible for a patient to remember everything. So it’s very important to be able to take notes and have a second set of ears so that all of the information is able to be digested.

Liz Dowling: Very good. One of the things we’re hearing more and more about these days is – and you mentioned it at an answer to one of your other questions – is genomic testing of a breast cancer and personalized medicine or more individualized treatment. Could you tell us a little bit about what genomic testing is and how it relates to personalized medicine for breast cancer?

Dr. Akbari: Well, genomic testing is a way of looking at each individual breast cancer’s behavior. In other words, how angry or aggressive is each tumor and the way that we used to do that is we used to look under the microscope. We would take a ruler and measure the size of the tumor. We would look at various stains under the microscope but we realize that that is not the best way in 2013 to get an idea of how a tumor behaves. So just because two things are the same size, doesn’t mean that they’re going to behave the same way. Molecular profiling allows us to get at the actual behavior of each person’s cancer, not just how big is it, are the lymph nodes involved but really down to the nitty-gritty of how is that tumor behaving so that we can better determine which treatments are appropriate for those patients.

Liz Dowling: Do you think a woman should be educating herself a little bit about this type of testing if she has recently been diagnosed?

Dr. Akbari: Well, I would hope that that would come up in the discussions with the breast cancer team that each person would be seeing. Molecular profiling is something that is part of the Standard National Cancer Network recommendations. So yes, if it’s not brought up by the medical oncologist or the surgeons taking care of the patient, yes, I do think the patient should understand what this is and how it would benefit them.

Liz Dowling: Well, there’s certainly a lot to learn about testing and treatment for breast cancer. It must be pretty overwhelming for most breast cancer patients who have just been diagnosed with breast cancer and they need to learn so much so quickly. What type of support from a – I know there’s this support team you’ve mentioned in terms of your breast cancer specialists, but what kind of support in terms of family and friends do you think is helpful to someone who’s just newly diagnosed?

Dr. Akbari: Well, I think everybody is different and everybody has different needs when it comes to this. Some patients take the diagnosis and treat it as if it’s a fight, that they are going to fight this out and be very aggressive. Other patients are very scared and they find that they’re sort of paralyzed and unable to take any action. So the family support network that each patient has would have to take into account how the patient is responding or what their fears are. Some patients need more help than others. Some patients need more questioning, more talking. Other patients need less of that. I think it really is an individualized assessment. Friends, family, any contacts that these newly diagnosed patients have should be used to meet their psychological needs when it comes to dealing with the diagnosis.

Liz Dowling: So what kind of tasks do you think that the family and friends can best provide to the newly diagnosed patient? Are there specific things that the support team can do?

Dr. Akbari: Well, I think just to provide a loving, caring environment where all questions are fair game. Specifically with breast cancer, it is oftentimes felt to be a disfiguring operation. It’s something that affects a woman at her core because of the physical appearance change. Each woman views their breast differently and how they feel about them. So there are a lot of personal reactions to this type of diagnosis. If you have your appendix taken out, it doesn’t carry the same psychological weight as having breast cancer. So I think really, it does boil down to how each patient feels about their situation. I think that conversations are very helpful. I don’t think that scary stories are helpful. There are friends and family who try to share their experiences which may not have been good in the past and I don’t think that’s a helpful thing. Overall, to provide a positive environment would really be the best strategy.

Liz Dowling: Okay. Let’s talk a moment about a woman’s preparation for the first meeting with her breast surgeon. Can you tell us, from a surgeon’s perspective, what is the surgeon trying to accomplish with the patient in the first consultation?

Dr. Akbari: Well ideally, you would be able to, as a surgeon, present all of the options that are available and then comment on which one would be best for the patient based on what they bring to the table. You would outline the general aspects of what parts of treatment are involved specifically chemotherapy and the medical oncologist, radiation oncology, reconstructive surgery, what kind of imaging is needed, do they need an MRI, do they need to do another testing, and really give an overview of the entire process from start to finish. It really is best for that meeting if a lot of the initial emotional shock of the diagnosis has worn off because it allows patients to focus better on the specifics of their treatment. I find that if patients are still in that initial – they just found out this morning or last night, they have much more difficult time listening to the options. I find that they have to have multiple appointments which sometimes can slow things down and become frustrating for patients. So the initial visit ideally would provide an overview of the entire process and then go into specifics, if surgery is the first step about how it’s done, what would be done, risks, benefits, alternatives, that kind of thing.

Liz Dowling: So you mentioned that timing is pretty crucial for the patient and that they should have some length of time to kind of adjust to the diagnosis. In general, what do you find that time period might be? Is that a few days, a few weeks, a few months? What do you think in general works best?

Dr. Akbari: You mean before they’re able to have a conversation?

Liz Dowling: A productive first consultation with the surgeon.

Dr. Akbari: I would think – again, it’s probably different for everyone but the average would probably be two or three days. Breast cancer is a psychological emergency. Everybody thinks that they’re fine one day and then the next day, the phone rings and they’re told that they have breast cancer and all of a sudden, everything is completely different. Most people think that before breast cancer is seen on a mammogram, it’s been there for approximately two or three years. I say this so that patients know that the time that it takes to appropriately tailor their treatment and get the best options for them which sometimes can take two weeks or more, that timeframe is not harming them while we’re figuring out for them what would be best. A lot of times, there is additional testing that’s required, MRIs, consultation with plastic surgeons and the time that it takes to get those things set up is very, very important because we don’t want patients to look back on their experience and feel that they were rushed through it and that they weren’t able to make decisions, that they had to really rush through it and that’s not a good thing.

Liz Dowling: Are there any specific questions that you feel patients ask you during that initial consultation that are particularly good that other patients might think to include on their list of questions for their surgeon?

Dr. Akbari: Well, I think in my experience, most patients’ biggest fear besides dying and patients are not dying from breast cancer the way that it used to happen, many patients are living with breast cancer. So once people realize that they are not going to die from this, the most important general concept I find is whether or not patients are going to need chemotherapy. There are lots of negative associations with chemotherapy. Everybody has heard of somebody who had it and didn’t feel well and they lost their hair. So I think most patients are able to understand the surgical part and they’re not so scared about that. They’re not so scared about radiation but the chemotherapy part is very, very scary for most patients and the most important thing that they want to know besides “Am I going to be okay?” in that initial visit is “Do you think I’m going to need chemotherapy?” They’re all fine with the surgery part but I think there’s a lot that goes into that treatment. I find the patients that come with questions specifically related to what they are afraid of, that allowed us to understand the patient better and meet them where they are so that we can help them best.

Liz Dowling: Wonderful. Thank you so much, Dr. Akbari, for your thoughts about how to help a newly diagnosed breast cancer patient with information and support. That concludes our dialogue for today and we look forward to talking with you in the future. Thank you so much.

Dr. Akbari: Thank you very much.