I met Dr Emília Vieira, a general surgeon, at the Associação Amigas do Peito building located on the campus of Santa Maria Hospital in the Northern Lisbon Hospital Centre, which she founded. In this space, with lots of colour, especially pink, very comfortable and with a cheerful atmosphere, we had a conversation about what it means to have breast cancer, what has changed over time and how today there is a lot of life beyond the breast cancer diagnosis. Dr Emília Vieira is optimistic regarding the development in cancer treatments over the last decades, and she undoubtedly lives to improve the conditions of breast cancer patients, to take care of women far beyond the disease .
What has been your life path, and why did you choose this specialty?
Emília Vieira: All my life I have always wanted to be a surgeon. And I initially thought about gynaecological surgery. In the 1980s, this division of specialties as there is now did not exist. I remember the emergence of urology, vascular surgery and orthopaedics, among others, everything was contained in a big cauldron named general surgery. Out of it all surgical specialties were born. I chose general surgery but, in the meantime, I started to become interested in breast pathology.
For some reason in particular?
Emília Vieira: Maybe because I had a lot of female patients, maybe because I opened my eyes to different things in terms of breast treatment, with stimulating innovations and maybe that was what made me become interested in this pathology. It turns out that my tutor was a woman, one of the first surgeons in Portugal, and perhaps that is why, in a world ruled by men at that time, we had many women patients, because they felt more at ease. That's the reason why we had a lot of breast disease. Both benign and malignant. Whenever there was some problem, a pain, an infection, they came to us. It is obvious that today we have much more malignant pathology than in the past. And maybe that's also why I started to find this pathology interesting. And then, especially in the 1990s, there was a big boom. In the 1980's... when I started, any woman who had a tumour, regardless of its size, had her breast removed. A mastectomy was performed. Mastectomy was known to cure 60% of women. Then, however, the widespread use of radiotherapy began and it was found that it was not necessary to remove the entire breast. As long as part of the breast was removed, followed by radiotherapy, it was as safe as having a total mastectomy.
When you talk about safety you mean survival?
Emília Vieira: Survival and disease-free survival, in terms of longevity and disease-free time. Regarding safety, it is known that a quadrantectomy (partial breast removal) followed by radiotherapy is as safe and has the same survival rate as a mastectomy. And that opened up a completely different world for us. Up to then, women were forced to have their entire breast removed. From the end of the 1980s, early 1990s, a completely different world opened up. And breast cancer started to be seen not as something that amputated the woman in some way, but as something that we were able to overcome, the same applying to the patient, who survived the disease and died as a result of something else. Almost simultaneously, chemotherapy adapted to breast cancer began. The patient was hospitalized for chemotherapy. We contacted the oncologist, who was asked to collaborate with a patient with the characteristics of the tumour referred for chemotherapy. The patient was hospitalized, underwent treatment and then was discharged. I am talking about 1986, 1987, 1989. Today, this type of treatment is performed on an outpatient basis. With radiotherapy and chemotherapy, the evolution of breast cancer was different. Just like with hormone therapy. Chemotherapy consists of intravenous, cytostatic drugs that destroy malignant cells and has a curative and prophylactic attitude. As for hormone therapy, it is an oral medication and is only important for tumours that are hormone dependent, which have positive hormone receptors. The most well-known drug is Tamoxifen, which everyone has heard of. With this medication, "tumour cells fail to recognize hormones and die because they do not feed". As such, it is a drug that has radically altered the prognosis of this type of tumours. Then three fundamental elements emerged, radiotherapy, chemotherapy and hormone therapy, for the breast. It was a boom. And breast cancer, despite being the most frequent tumour, and it continues to be, in women is not what kills the most. What kills the most is lung cancer. And regarding the breast, we have Tamoxifen to thank for. Since the 1980s, mortality has fallen by 25%. A tumour discovered at an early stage may have a 90% chance of cure. What is an early stage tumour? It is a tumour discovered by screening and not because the woman felt it. A palpable tumour is at least 2 years old. A tumour that is not yet palpable can be 6 months to a year old. Of course it depends on the woman's breast size. A small tumour on a large breast is more difficult to palpate than if it is on a small breast. A palpable tumour is no longer a tumour at an early stage and although it may be a more indolent and not so aggressive tumour, it has had an appreciable time of existence. For this reason, in the 1990s, there was a great incentive for screening to discover tumours before they were palpable. And from then on, the first women races started in Boston, and everything started to become generalized. We currently have Pink October, a month dedicated to the prevention of Breast Cancer. So, it was a golden age, and I lived through that golden age, I almost missed its emergence. I felt I was making a difference and that was a great incentive. I usually tell my patients that the time in which they live and the place where we are born are very important, because if it were 30 years ago, most women affected by this pathology would have undergone a mastectomy. Nowadays, most women have kept their breast, and on the occasions when we have to remove it, immediate reconstruction can be performed in the same surgery. Therefore, in terms of breast cancer, however aggressive it may be, in most cases we have a positive view given the therapeutic weapons at our fingertips, whether cytostatic drugs, hormone therapy, various types of radiotherapy or surgery. Perhaps because it is the most frequent cancer, there has been a lot of investment.
And is this reality a strength given to breast cancer patients, who know that there are several "weapons" to fight the disease?
Emília Vieira: As I said earlier, we have many weapons at our fingertips. The same does not apply to pancreatic cancer. And that is quite perceptible, but not regarding the breast. There are many things and a lot of research in terms of prevention. There is now a new research whereby blood cells can detect circulating cancer cells. I am already being asked what this analysis is like and when it will come out. People are all too aware regarding new ways of being able to detect tumours as early as possible.
And people can also have the cells and not develop the disease…
Emília Vieira: Exactly, and there is a lot of breast research about exactly that. What causes a cancer cell to be asleep for 20 years and suddenly wake up and bone or lung metastases appear? After 20 years, a tumour that has been dormant for 20 years wakes up. The cells were there, what made them trigger? What makes them fall asleep? What made them wake up?
We don’t know yet. I have patients who have been well for 20, 25 years and then have bone metastasis. The armpit is where it "goes" first. Therefore, when the breast was removed, the axial ganglia were also emptied. However, metastasis, in a low percentage, can also be done through blood circulation. Thus, in a 2 or 3 year old palpable tumour, there may be cells in circulation. And we know which tumours have the most likely characteristics for this to happen. Therefore, when the probability is greater, we have to counterattack with chemotherapy, which in addition to being curative is also preventive, in the sense of destroying the circulating cells, decreasing the probability of having distant metastasis later.
Is there a difference between patients in the 1980s, and now?
Emília Vieira: Women are more interested in their disease. They want to get to the bottom of the issue. They want to understand their tumour and that is why in October I published a book . The title is “O QUE FAÇO? TENHO CANCRO DA MAMA” (WHAT DO I DO? I HAVE BREAST CANCER). The aim was mainly to try to provide some answers, or, to put in simple words, to answer the questions that the patients ask me. They want to understand every characteristic of their tumour. What does it mean, why did they do this to me, why do I have to undergo chemotherapy and the other woman did not. Nowadays, with the molecular and genomic study of tumours, we know about 72 subtypes, so the term breast cancer is very broad. And this is to show patients why there can be 10 women together and none of them have had the same treatment. I usually say that it is a very feminine tumour and that is why it is so varied (laughs). As for men, the percentage of occurrence is 1%, so for every 100 women there is a man. It may be related to hormonal circumstances. It is uncommon, the risk factors are the same as those for women, men who smoke or consume alcohol have lower immunity, have a greater lability of the liver and cardiovascular system issues. As such, they are more likely to have tumours. Regarding the breast, there is not exactly a cause effect in men. What we do know is that in a man with breast cancer a genetic study is always conducted. A man with breast cancer often has a genetic mutation. When that happens, the whole family has to be studied. I have, for example, a patient with breast cancer who has two adult sons and both have the BRCA mutation. The BRCA mutation in men does not only give rise to breast cancer, it can lead to pancreatic cancer, bowel cancer, stomach cancer, thyroid cancer. Therefore, these mutated men always have to be monitored regarding the likelihood of having cancer in those places, regardless of their age. In women, only about 10% of cancers have genetic and family characteristics. I have dozens of women who are daughters of women with genetic mutations and who have to be monitored. Some have it, others don't. When there is a mutation, short-term treatment for prophylactic breast and ovarian surgery is performed. The person who has the tumour is studied, and if she has a mutation, descendants, collaterals and ascendants will be investigated. And people want to know. It is very different, today people want to prevent it, "if there is a possibility of not having the disease by not having breasts, why should I be in this anguish and suffering"? It is a complicated process, but it is a question of survival. If you are not going to use your breasts in terms of breastfeeding, if you are very likely to get cancer, why keep your breasts? Women who have their breasts removed prophylactically because they have a BRCA mutation are women who don't mind doing it. They want prevention. Those who, due to the disease, undergo a mastectomy and then have their breasts reconstructed often say that they do not feel them as their own. Psychologically, it is different. It's about choice. I have patients with beautiful breasts and they say “these are not mine, it's a foreign body that I have here”. They still feel amputated, they feel that something has come out of them. Even if no one else notices. It's in the mind. It is like, for example, not having a breast, having a prosthesis and feeling the phantom pain, their breasts still hurt. And I ask: “What hurts? The skin?”, And they say “No, it hurts inside”.
In the book you wrote, what questions do you ask?
Emília Vieira: There is a little bit of everything. To the famous question "why me?", there is no answer. “What do I do?”, which is the title of the book, I say: First comes the shock of the news, then what is there to do? Let's fight. "I can't be like this". Most women are fighters, some are defeatists, but they are few, and we try to instil the survival instinct in them. Especially because we know that in most cases there is a high probability of surviving. I usually say "you are going to die of something else". And the vast majority die of something else. Of course it depends on the type of tumour, but that is why tumours are so well characterized, so that we can have a limit. Some women think it is not worth fighting for, there are women who refuse doing anything, it is the so-called "disease denial". Of course, we also had two major wars in the past century. Medicine has always evolved after wars and the development of medicine is also important. Anaesthesia became widespread after the first world war, which enabled a breakthrough in surgery. With regard to oncology, it was positively affected by the evolution of medicine, it is not a golden age but it has many possibilities. There is prevention and women are aware of it. In the association we do a lot in terms of prevention. We inform, give talks, go to schools, parish councils and municipalities, and do clinical screenings. Nowadays, women are more informed, they want to know more, everyone knows how to read. We currently have the digital world. I often say that knowledge is power. I write that in the book. The more we know, the more knowledge and power we have over ourselves and the more we are interested in knowing. Knowledge is addictive, the more I know the more I want to know. And the more I know, the more I realize our limitation and this is wonderful, having this ability to know more.
And this association, Amigas do Peito, how did it come about?
Emília Vieira: The patients asked me to create this association. It has been a hard journey, first it was a field I was not familiar with, I am a surgeon, I learn every day. It is not an easy business because it lives off volunteering, mainly conducted by women. They all have a strong character, which is good, but we often have to know how to work as a team. And not everyone has the capacity to volunteer. There has to be a learning curve and now we have an excellent team of volunteers, it is positive. And we have had our facilities since 2016. It was pursuant to the patronage law that we did all this. And now we have the Reception House in the Padre Cruz neighbourhood, in Carnide, which opened in October 2019 with capacity for 5 people. It is aimed at cancer patients, relocated and with economic needs. We really wanted it to be located at the hospital centre, in the physical space of the Pulido Valente Hospital, which has space. It would be something that would make up for a big gap. We receive people from all over the country, and for people who are relocated it would be important. There are people who come for chemotherapy every 3 weeks in an ambulance, or have radiation therapy every day. The IPO has a reception centre and we, as the largest hospital in the country, should also have one.
And the women received here have various activities…
Emília Vieira: We have gymnastic, psychological, psycho-oncological, nutritional, and spiritual support when necessary. Also, sometimes, we have some complementary medicines. And then we have the pink route, which is the possibility of referring any woman who doesn't have an appointment, who doesn't know where to go. Women know our association. For example, a few days ago, students from the Escola Superior de Saúde of Santarém showed interest in selling our gifts and I will be giving a talk on breast cancer prevention. We live on donations and subscriptions, we have no state support, so we have to be proactive. We will also have a concert sponsored by the Cape Verde embassy. We receive many patients from Portuguese speaking African countries and the embassy will collaborate with us in a solidarity concert on 18 March at “LISBOA AO VIVO”, in Poço do Bispo, Lisbon. These people, coming from certain countries, are very needy and we help in what we can.
What message would you like to pass on to breast cancer patients?
Emília Vieira: I think that in terms of breast cancer we are in a positive evolution phase. We are more and more likely to cure tumours, as long as they are discovered early, so people have to be aware of prevention, screening and knowing their bodies too. If there is any change, they should see a doctor. Since we are more and more likely to have cancer, due to age, among other factors, we have an increasing number of weapons to fight it. I think it is a positive phase, although it is the disease of the century, and perhaps because of that, we an increasing number of weapons to fight it. We are living longer, we are investing in prevention and there is so much research, we cannot be discouraged. I want to leave a word of hope. We are in a wonderful time in terms of research and new drugs, and that is a positive thing.