Sunday Interview with Dr. Kenneth L. Smith: 'We haven't found the actual source for the cause of it'

As a breast surgical oncologist at the John B. Amos Cancer Center, Dr. Kenneth L. Smith handles between 100 and 120 breast cancer cases a year.

Smith also serves as medical director of breast surgery at the center and tries to stay on the cutting edge of breast cancer research and treatments.

Smith sat down with reporter Alva James-Johnson and talked about his career, breast cancer, genetic testing and preventative surgery.

Here are excerpts from the interview, with the content and order of the questions edited slightly for length and clarity.

Tell me a little about your background growing up.

I’m the youngest son of three. My mother was a cotton mill worker in Opelika and my father was a truck driver. No one in my family had been to college or even considered going to college until I came along. My mother’s older sister was a nurse down in this little town called East Tallassee. So that was about my only exposure in terms of medical mentors.

I’ve sort of always been interested in science as a kid. I think I got a chemistry set when I was about 10 or 11, and a microscope a few years after that, and telescope. This was all during the time of the moon exploration events and so forth. So a lot of science was on television and things that interested me. From there, I sort of decided, actually fairly early on, that medicine was something I wanted to pursue through high school and then into college. I  actually nearly flunked freshman chemistry and thought about changing fields, but one of my colleagues encouraged me to continue.

At what point did you choose a speciality?

... Before I even got accepted to medical school. ... At that time in my hometown there were no resident-trained surgeons. All the surgery was done by (general practitioners). I had that kind of in my mind, to perhaps go back to a small area and practice medicine and do surgery on the side. But as things progressed on, it became evident that residency training for a surgeon was increasingly important. So I focused my efforts on the surgical field rather than on a general practice field.

Why breast cancer?

... In the early ’90s, the approach to diagnosing breast disease shifted from an open surgical procedure, which we were all doing at that time, to a minimally invasive approach using ultrasound to pinpoint lesions, making little tiny incisions and putting little biopsy drills in to drill out samples of tissue. ... I was the person appointed to develop that program and recognized that a lot of what we were doing with breast disease and breast cancer, particularly, was a changing field of focus.

It was very interesting and challenging to me that there were options short of mastectomy, which had been the standard approach for nearly a century before the reports in the late ’70s and early ’80s that you could accomplish the same survival with lumpectomy. ... One of my interns when I was a resident in Ochsner was one of the first breast fellows at (Memorial Sloan Kettering Cancer Center in New York) and actually went on to be their director of breast surgery services for a while. And my conversations with him at meetings and conferences around the country again sort of re-affirmed that this would be an interesting area for me to pursue.

How did you end up coming to Columbus?

When I went to Stanford, the idea was that we would eventually transition to a practice of strictly breast disease, and that requires a certain population to be able to have enough patients that require your services.

While we were busy in Anniston, I didn’t anticipate that there would be a volume that would allow me to practice specifically breast. When I was interviewing in different positions, one was offered here in Columbus. Frank Starr is a retired surgeon now, but by longevity he had developed a bit of a breast practice, and they were looking for someone to kind of take over his practice and also hopefully expand breast offerings in the area. I interviewed here and decided that it was the place we wanted to be. It’s a nice community to raise a child and not too far from my mother, who still lives in Opelika.

You started here at the John B. Amos Cancer Center?

Originally with Surgical Associates of Columbus. And then about two years ago, Columbus Regional bought the Surgical Associates practice and moved me to this facility to do strictly breast disease.

What are the chances that the average woman in Columbus will develop breast cancer?

There are a number of factors that affect that. National statistics waver somewhere between an 11 percent and 12 percent lifetime risk. There are a number of factors that increase that risk — family history being one of those, age of onset of menses, age of onset of menopause, postmenopausal hormonal exposure, age at first birth, whether you breast fed, a number of factors that seem to affect that. Alcohol intake has a one-to-one relationship. Diet is still one of those areas that we’re trying to figure out where it plays, although just a week or so ago there was a study reported from Spain, I believe, suggesting that the so-called Mediterranean Diet, whatever that might be, seems to be breast-healthy as opposed to just cardio-healthy. So there are a number of factors that play a role. But for the average woman, about 10 to 12 percent.

Please explain the four stages.

There are actually five. Stage zero is DCIS (ductal carcinoma in situ). That’s when the cancer cells are contained within the duct. They’ve not had an ability to break out of the duct and spread into the surrounding tissue, which gives it the opportunity to spread to other places. Stage I, as are stage II and III, is based on tumor size. Usually those tumors are two centimeters or smaller. Stage II is usually tumors from two centimeters to five centimeters, or they have positive lymph nodes. Stage III is even bigger than five centimeters or greater than three to four lymph nodes. Stage IV is when there’s metastatic spread outside of the breast and auxiliary area.

What demographic groups are most vulnerable?

Increasing age is obviously the No. 1 occurring risk factor. About 6 percent of breast cancers occur under age 40. Probably about 50 percent occur in women 60 and older. The numbers begin to significantly increase in their 50s. About 10 percent of breast cancers have an identified genetic mutation as a source for their basis, and those tend to occur more frequently in younger women. BRCA1 and BRCA2 are the most frequently identified genes, but increasingly recently there’ve been a number of other genes that have been pinpointed as having an increased risk for breast cancer development, and we’ve actually begun to incorporate those more in genetic testing for certain women.

Does size of breasts have any bearing on breast cancer?

Really not. The difference in volume of tissue is probably more fatty than it is actual breast tissue. Every woman has 12 to 15 lobules of breast tissue within each breast, so the difference in volume is not so much the difference in the amount of breast tissue. Even in women who’ve had reductions, they still have a significant amount of breast tissue left behind, so you can’t get away from doing mammography, even in reduction cases.

What is the rate of survival, typically?

Overall, the survival has improved significantly. There’s been actually about a 30 percent improvement from the 1990s through to the current decade, partly because of earlier detection, partly because of improvements in systemic therapy, chemotherapy, anti-hormonal therapy. For the average woman — early stage breast cancer — the five-year, disease-free survival is in the 85 to 95 percent range. If you detect it when they have DCIS, it’s virtually 100 percent curable.

When you started, was breast cancer as prevalent as it is today?

It’s actually been increasing steadily from the time that I was in training in the early ’80s on through to the early 2000s. In 2002, a large trial called “The Women’s Health Initiative” reported that combined hormone therapy increased breast cancer incidents by 28 percent. So there was a sudden drop across the country, although we didn’t see that drop in this area for some reason. But the numbers have started now rebounding back up. ... In the time that I’ve been here in Columbus, we’ve gone from about 100 cancer cases a year to over 300 to 350 cancer cases a year that come through the John B. Amos facility.

Why are we seeing the increase?

Part of it is the increasing age of the population. Part of it is increasing detection, with improved techniques for finding cancers. Part of it is we’re probably capturing a greater degree of the market. ... Years ago when I was in Anniston, Ala., we had patients that had breast cancer issues. They wanted to go to Emory or Birmingham or somewhere else. ... But I think with improvements in recognition of what’s available here, a lot more people are staying in town rather than making the drive to Atlanta or other places.

There’s been some debate in the past about mammograms and whether or not they’re really effective for early detection.

Yeah, and that’s a complex issue. I think certainly in the story for ductal carcinoma in situ, we clearly have seen a significant increase in the number of cases detected basically because of mammography. ... There are certainly a number of cancers that I see in young women that would not be detectable either because of the degree of breast density or the small size of their tumor, recognizing again that mammography is challenging in young women because they tend to have more dense tissue. Breast tissue shows up as a big white blob on the mammogram and cancer is a little starburst white blob or little white calcifications. So they all kind of blend in together, making it more challenging. ... The question becomes, “Well, how many women have to get screened in order to make it beneficial to find the cancer?”

Are there any risks associated with the mammogram?

Sure. The biggest ones they claim are, No. 1, you may well over-diagnose... leading to additional workup, which adds additional expense, leading to additional worry from the patient from their perspective because they’re told they have something funny going on that needs to be evaluated. A certain number of those will end up with a biopsy that they may not necessarily have benefited from, other than getting the knowledge that they don’t have cancer. Any procedure, even with the minimally invasive procedures, has a risk for complications — bruising, bleeding, whatever else along that line.

So where do you lean? It seems there are good arguments on both sides.

I still tend to favor the American Cancer Society’s recommendation for the average woman to start mammography on an annual basis at 40. That does need to be coupled with a physical exam because there will be lesions that are only palpable, that are not evident on mammograms. In women that have a strong family history, particularly of early onset breast cancer, we recommend that they start screening 10 years younger than the family member’s age at diagnosis. If the mother had breast cancer at 42, we would suggest that they consider starting at 32.

We’ve seen improvements in mammography. We’re not quite there yet. I think there are better methods of screening that are in the process of being evaluated — not just the most recent one, the three-dimensional or tomosynthesis device — but there’s also a look at using a low dose, low-radiation dose CT scan that may be helpful. Other studies have looked at using certain contrast agents, particularly in young women with dense breast tissue to bring out the suspicious areas.

What is available in terms of genetic testing?

... Previously up until just a couple of years ago, there was a single company in the entire country that did all the testing. They sort of developed the process. ... A Court ruling said that you couldn’t patent genes, so after that a number of companies have now gotten into the area. ... Obviously, BRCA1 and BRCA2 are the most frequent cause that we’ve identified for known mutation sources for breast cancer, but increasingly we see other genes such as PTEN or P51. ... Some of those genes, it’s kind of a borderline increased risk and becomes a question for us how aggressively we should manage those. ... For the most part, the focus still largely remains on BRCA1 and 2.

So when is it a good idea to have a breast removed and when is it bad idea?

... No. 1 is genetic mutation that increases their risk — mainly BRCA1 or BRCA2, although there are options for those patients of increased surveillance and then acting if they develop it, because it’s not 100-percent risk. It varies from about 40- to 80- percent lifetime risk. You may well die of something else long before you ever develop breast cancer. ...

The other increased risk that those patients have is obviously ovarian cancer, which is a much more difficult cancer to detect and treat. That needs to be part of their surgical intervention if they’re going to take that approach.

What’s available in terms of reconstructive surgery?

In this community, as across the country, the most frequent reconstruction technique has been tissue expanders — put in a little salt water or saline bag that comes back and replaces with a silicone implant at some point down the road. Autologous flaps, or using part of your own body to reconstruct, is probably the more durable approach. It’s a much more challenging operation, a much more difficult one to recover from.

... A colleague of mine in New Orleans actually does sort of a butt lift. They take part of the fat and skin from the buttocks and transpose it into a new breast mound. Obviously, that’s a significant operation.

Are implants safe these days?

In the early ’90s, there was a concern about silicone gel leaking into the tissue and resulting in connective tissue disorders. Fortunately, in studies from Mayo and other places, there was never shown to be a connection between the connective tissue disorder incidents and this gel leaking into the tissue. Since the mid ’90s, there were federal studies that looked at different implants, and the structure and the nature of implants have changed such that now it’s a much safer process. But as with anything man-made it does have a certain life span.

Now, let’s talk about you personally as a surgeon and how you deal with so many cases. Does it ever take an emotional toll? And if so, how do you handle that?

Obviously, it’s a challenge for some patients versus others. You have to maintain a professional demeanor with all of your encounters, obviously, but you also have to express some degree of empathy. It can be a challenge, but fortunately we usually have something to offer everyone — even stage fours, you can offer them a degree of palliation to try to maximize their quality of life. I think that’s what we have to focus on. It’s what benefit we have to offer patients and help them get through this journey.

Why do you think this disease is still so prevalent in our society?

Well, unfortunately, in spite of all the improvements in the both detection and diagnosis, we haven’t found the actual source for the cause of it.

Are we making any progress in that area?

I think, certainly, we are. And I think eventually they’ll get to it. When that will occur is hard to predict.

Bio

Name: Dr. Kenneth L. Smith

Age: 60

Hometown: Born in Tallassee, Ala., grew up in Opelika

Current Residence: Columbus

Job: Breast surgical oncologist and medical director of breast surgery services at the John B. Amos Cancer Center

Previous Jobs: General and breast surgery, Surgical Associates of Columbus; breast surgery, the Breast Center of Gulfport, Miss.; general surgery, surgical clinic of Anniston, Ala.

Education: Bachelor of Science in biology, Auburn University; Doctorate of Medicine, University of Alabama at Birmingham; chief resident in general surgery, Ochsner Foundation Hospital, New Orleans; Rachleff Fellow in Breast Surgery, Stanford University School of Medicine, Stanford, Calif.

Family: Wife, Magdalene; 24-year-old son, Taylor; and a golden retriever, Thunder.

This story was originally published October 3, 2015 at 11:25 PM with the headline "Sunday Interview with Dr. Kenneth L. Smith: 'We haven't found the actual source for the cause of it'."