James W. Jakub, M.D., Surgical Oncology, Mayo Clinic in Florida: My name is Jim Jacob. I'm a surgical oncologist with a primary focus on breast cancer and melanoma. Robotic breast surgery is used in other countries in Asia and Europe. Currently in the U.S. it is not approved. It is being performed on clinical trials. We are fortunate to be one of the sites offering robotic nipple-sparing mastectomy as part of a multi-site, FDA-approved research study. The advantages of robotic surgery are being explored and trying to be determined at this time. Currently, a nipple-sparing mastectomy can offer excellent cosmetic results. It does require a large incision to provide adequate exposure for the surgeon. That's typically a large inframammary incision. Robotic surgery offers an incision about 3.5 centimeters up in the axilla. And so, that is potentially one of the advantages. In Europe and Asia. they do have data suggesting that there may be improved sensation after surgery, potentially improved quality of life. Those findings need to be validated.

When faced with a breast cancer diagnosis, patients' biggest fear aside from cancer recurrence is often the risk of lymphedema, swelling of the arm. There are a number of active research and also now standard practice ways we address that and try to minimize the risk of patients experiencing lymphodema. I think this is really important because 91% of breast cancer patients will be alive in five years after a breast cancer diagnosis. And so, currently, we have approximately 3.5 million breast cancer survivors in the U.S. So focusing beyond the cure, but also on the long term quality of life, I think is really, really important. In terms of lymph node surgery specifically, often we're able to give patients who have lymph node involvement treatment upfront — neoadjuvant therapy — and allow patients who are node-positive to convert to node-negative, thus avoiding lymph node dissection. There are certainly patients who are at low enough risk of having lymph node involvement, even though they have a breast cancer, that we don't even need to stage the lymph node surgically: We don't need to remove any lymph nodes. If we do have to do lymph node dissection, there are a number of clinical trials (and in some cases, our routine practice) where we will do reverse mapping, inject blue dye into the arm, identify the lymphatics draining from the arm, try to preserve those, and therefore minimize the risk of lymphedema. Also, if a lymph node dissection is required to actually reconstruct lymphatics, perform what's called a lymphovenous bypass, and microscopically sew the lymphatic back to the vein, and therefore restore flow from the arm and minimize the risk of lymphedema.

Clinical trials allow us to offer tomorrow's treatments today. And so, I think patients who have a cancer diagnosis really should explore the clinical trials available. Most clinical trials are giving the best treatment compared to what we think is going to be the future best treatment.