Kristine E. Calhoun

More options. Better choices for treating breast cancer

Women facing breast cancer surgery have more options today than ever before, says Dr. Kristine Calhoun, one of SCCA's breast surgeons.

"Unfortunately, sometimes those options can seem overwhelming, particularly as a woman deals with her new diagnosis of cancer,” she says. “I try to help each woman choose the treatment plan that deals most effectively with her specific cancer in the context of her personal preferences."

Dr. Calhoun joined the breast cancer surgery team at SCCA and UW Medicine in September 2005. She was the first woman breast surgeon on the team.

Lumpectomy vs. mastectomy

Not every woman is a candidate for a lumpectomy, also known as breast preservation therapy, during which only the cancer (the lump) and a margin of normal tissue are removed.

“The key,” says Dr. Calhoun, “is getting completely around the cancer with a margin of healthy tissue and still leaving a cosmetically acceptable breast.”

The term "cosmetically acceptable" is very subjective, she says. "Some women are happy if their surgeon can spare their nipple, even if most of the breast tissue has to be removed, while other women who could have a lumpectomy opt for a mastectomy—or even a double mastectomy—for personal reasons."

Women who are diagnosed with DCIS (ductal carcinoma in situ), often can have a lumpectomy, depending on the size of the cancer and also whether the surgeon can get good negative margins. (The margins are important in ensuring that no cancer tissue is left behind.) In some instances, however, mastectomy may still be required for DCIS.

Women who have invasive breast cancer (a tumor) may also be able to have a lumpectomy, Dr. Calhoun says. The decision depends in part on the size of the tumor relative to the size of the woman’s breast, as well as if the cancer involves more than one segment of the breast.

For women who are good candidates for lumpectomy, Dr. Calhoun says the procedure has the same long-term overall survival rate as a mastectomy, as long as surgery is followed with radiation therapy to the breast.

“Someone who refuses radiation is not a good candidate for a lumpectomy, since the two treatments really do go hand-in-hand,” she says.

Although some women are afraid of radiation therapy, Dr. Calhoun says, most women find that they tolerate it remarkably well. Although radiation is given daily for a span of six to seven weeks, each treatment typically takes only minutes. “Skin changes and fatigue do occur, but most women find radiation is an easy therapy to tolerate,” she says.

Not your grandmother’s mastectomy

For some women, mastectomy is their only choice. These include women with certain types of breast cancer, including inflammatory breast cancer, cancers that have advanced and are quite large by the time of diagnosis, and cancers that have spread to more than one-quarter of the breast.

And some women who could have a lumpectomy opt for a mastectomy instead, for “peace of mind,” Dr. Calhoun says. “It is a choice that each woman makes as an individual after I present her with the facts as we know them to be.”

However, even if a woman’s only option is a mastectomy, she still has a number of choices about how the surgery can be done, and these newer procedures are much less disfiguring than the mastectomies of 30 years ago.

She adds that the women she sees are very savvy. “They come in with a list of questions, and they will probably have talked to a couple of different surgeons before deciding what to do and with whom.”

Until the 1970s, Dr. Calhoun says, the most common surgery for breast cancer was the radical mastectomy, which was “very disfiguring,” in that it removed the breast, lymph nodes, skin, and pectoralis muscle.

Then surgery advanced to the modified radical mastectomy, which leaves the muscle and only takes the breast tissue, an ellipse of skin, and the lymph nodes. This procedure is still done for inflammatory breast cancer, as well as for large, locally advanced tumors with known axillary lymph node involvement.

The most common procedure done today is called a "total mastectomy,” in which all the breast tissue is removed. At the same time, a sentinel lymph node biopsy is performed to see if the cancer has metastasized to the axillary nodes. One or two sentinel lymph nodes are removed during the mastectomy and checked immediately for evidence of spread. If these nodes are positive, then the surgeon will go ahead and remove most of the lymph nodes under the arm as part of an axillary dissection.

With this surgery, the woman is left with a scar across the width of the breast and the nipple is removed.

There are alternatives, however, including the skin-sparing mastectomy and nipple-sparing mastectomy, both of which leave the patient with smaller scars. “I was trained to do all of these,” Dr. Calhoun says.

A woman with a small cancer who plans to have immediate breast reconstruction may want to discuss whether she is a candidate for the skin-sparing procedure with both her oncologic and plastic surgeons, she says. In this surgery, an incision is made around the nipple and areola, often with a small cut toward the side. The breast tissue is all removed through this small incision.

The nipple-sparing surgery also uses a small incision, one that leaves the nipple intact. This surgery is typically done for women who are having a prophylactic mastectomy because they are at high risk for breast cancer because of a family history, and generally not for woman with known cancers.

From Tacoma, after a detour south for training

Dr. Calhoun was born and raised in Tacoma and attended the University of Washington for her undergraduate degree and earned her MD at the UW as well.

She did her residency in general surgery in Portland, at Oregon Health and Science University, and then headed to Santa Monica for a fellowship in breast oncology at the John Wayne Cancer Institute.

While in California, she was trained by Dr. Armando Giuliano, often credited with being the “Father of the Sentinel Node” as it pertains to breast cancer, as well as Dr. Nora Hansen, who heads the prestigious breast clinic at Northwestern Memorial Hospital in Chicago.

Dr. Calhoun’s mother was diagnosed with breast cancer during her intern year of general surgery. “Her experience did have an impact,” she says. “She was treated in Tacoma by a great surgeon who kept me in the loop, and she is doing wonderfully now. I think having gone through this with a close family member does influence how I relate to my patients and their families.”

In addition to treating women with breast cancer, Dr. Calhoun also treats women with benign breast disease as one of the providers at the Breast Health Clinic at SCCA. Benign breast conditions are non-cancerous breast problems that may or may not require surgery. They include fibroadenomas, papillomas (which cause nipple discharge), and breast pain. She also sees new patients in the Breast Cancer Specialty Center at SCCA, a twice-weekly clinic where newly diagnosed women meet with a team of breast cancer specialists all at one time.

Dr. Calhoun says she does her best to minimize the scarring caused by cancer surgery, be it a lumpectomy or a mastectomy. Furthermore, she adds that she is sensitive to her patients’ emotions about losing a breast if it becomes apparent that mastectomy is required for control of the tumor.

“As a woman myself, I am very aware that in our society breasts are important,” she says. “I try to weigh the cancer cure with the cosmetic outcome so that [my patients] will be as comfortable as possible with the results they achieve from surgery. This is a big concern for me, as well as the patients that I treat.”