Dr. Kristi Funk, who has treated Angelina Jolie, answers PEOPLE's questions
When Rita Wilson revealed exclusively to PEOPLE that she had been diagnosed with breast cancer, she stressed the importance of early detection and seeking a second opinion as keys to her own recovery.
The actress, 58, also referenced a variety of breast cancer issues on the road to her final diagnosis of invasive lobular carcinoma. To explain the different types of diagnoses and Wilson’s subsequent treatment, PEOPLE spoke with Dr. Kristi Funk of the Pink Lotus Breast Center in Beverly Hills. Dr. Funk is a board-certified breast cancer surgeon who previously treated Angelina Jolie during the star’s 2013 preventative double mastectomy and reconstructive surgery.
For starters, it helps to think of the breast “like a bunch of grapes held by a single stem,” says Dr. Funk. “All of the grapes are the milk-producing lobules of the breasts, and all the little stems that come together are hundreds of tubes called ducts that carry milk from the lobules out the nipple. So those are the two main components that get breast cancer, with about 75 percent of breast cancers starting in ducts and 15-20 percent, like Rita’s, starting in lobules.”
Read on for more of Dr. Funk’s answers to common questions about Wilson’s diagnosis and course of action.
What is lobular carcinoma in situ (LCIS), which Wilson cited as the reason for her yearly mammograms and breast MRIs?
Lobular carcinoma in situ is considered a marker lesion. A marker just says, ‘Hey, there’s something in this breast DNA that might try to make cancer one day.’ The lobules are supposed to have a single-cell lining, where each cell is very orderly, one to the next, but when cells start becoming atypical and crowding on top of one another and fill up that ‘grape,’ that becomes lobular carcinoma in situ. The cells inside are cancer cells, but they have yet to break through the lobule wall so they can’t travel anywhere. That condition, when it’s inside a duct, is called DCIS and is known to be more aggressive locally than LCIS so we always excise it to make sure there’s no invasive cancer.
What is the recommended treatment for someone with a diagnosis of LCIS?
That person should have higher-risk surveillance. They should do screening more frequently, maybe add MRIs. If their mammogram is dense we add ultrasounds and consider taking medications like Tamoxifen that reduce breast cancer risk by half. But it doesn’t necessarily lead to mastectomy, because their chances of getting breast cancer are somewhere around 30%, potentially higher considering family history.
What is pleomorphic carcinoma in situ (PLCIS), which was discovered on Wilson’s biopsy?
Pleomorphic means ‘different shapes.’ These cells are a little wilder looking than your straightforward LCIS. They’re more aggressive and more often associated with a typical treatment associated with breast cancer, like lumpectomy, maybe even followed by radiation. In Rita’s case, the pleomorphic caused more concern and then she had the second opinion where they actually found invasion.
How important is a second opinion in cases like Wilson’s?
It’s a pretty nuanced call from the pathologist between classic LCIS and pleomorphic LCIS and invasive. It’s a continuum almost, so it becomes a matter of opinion as to what is really there. If a person is dealing with a diagnosis that is known to create confusion, then the second opinion might be worth it, especially if it will dramatically alter the choices. She found invasion and ended up with a bilateral mastectomy. If there had been no invasion, she may have just continued on her path of surveillance. So that was a critical fork in the road.
If you’re diagnosed with breast cancer, my suggestion is to ask your trusted physician, whether that’s your surgeon or your medical oncologist, ‘How certain are you in this diagnosis, or should we get a second opinion?’ People ask me that all the time, and about 90 percent of the time, I say there’s no need for a second opinion. It’s called concordant. If the imaging matches what I think on my exam matches the pathology report, it’s all concordant. A horse is a horse is a horse. Don’t keep looking for a zebra. It’s a horse.
Wilson says the first pathology results from the two biopsies showed no cancer. Is that a common result?
‘No cancer’ is not technically true. She had LCIS and she had PLCIS, and those are both cancers. What she really should have written was no invasive cancer. The ‘in situs’ are never treated by chemotherapy; they can never spread to lymph nodes and threaten your life. So doctors and patients will often like to say it’s ‘pre-cancer.’ But what they really mean is, ‘It’s not an ominous threat to my life because it cannot spread.’ But it’s still cancer.
What is the prognosis for invasive lobular carcinoma?
For an early stage diagnosis such as Rita’s, it’s an over 98 percent cure rate. If the cancer had spread to lymph nodes under the arm, the survival rate is 84 percent. If it spread to distant organs, like lung or liver or bone, the chances of being alive five years later are 24 percent.
Once you have breast cancer, if you do a mastectomy the recurrence rate in the skin or muscle or armpit lymph nodes is about 4 to 6 percent. That number can be cut in half by taking an anti-estrogen pill, but it requires some monitoring. If you think about it, every woman walking has a 12.5 percent chance of breast cancer. And so the recurrence after mastectomy is less than a third of everyone else of getting their first cancer.
Why undergo a bilateral mastectomy in such cases?
It’s a frequent choice for a number of reasons: the toll that high-risk surveillance takes on someone’s energy level and their confidence and peace of mind going forward in life can be exhausting. In other words, every six months you’re doing mammogram and ultrasound, with an MRI six months later, with exams by your doctor, and every once in a while there’s some blip on the radar that then needs a biopsy and then you’re waiting for path results. That life is sometimes too much for certain women to desire. They would rather remove the breasts and get rid of the intense surveillance and all of the anxiety that it provokes.
Another reason would be that these cancers that aren’t yet life-threatening, but in the context of a certain person’s life, if a patient’s mom had breast cancer at a very young age or even died from it, this feels like the world whispering to her, ‘Now’s the time. This is bad enough. Why don’t we stop it here?’
What further treatment can Wilson expect to undergo?
After mastectomy, I see patients every six months for five years and then every year forever. I just examine their chest wall with a clinical exam and I always ultrasound the armpit on the cancer side to make sure the lymph nodes are still normal. There’s usually no radiation after a mastectomy. The invasive cancer will have a tumor profile run on it, which looks at what feeds the cancer. If the invasive lobular cancer has receptors for estrogen or progesterone or the HER2 growth factor, she could be recommended to have additional therapy like an anti-estrogen pill. Side effects would be menopause symptoms.
What can women learn from Wilson’s story?
The takeaway is twofold. First, if you are diagnosed with a high-risk marker lesion in your breast, you should be undergoing increased surveillance just like Rita was, meaning adding MRIs and often ultrasounds to the mammogram every year.
Second of all, the second opinion has its appropriate place in certain patients’ lives. With certain conditions, when the diagnosis is leading to an irreversible choice like mastectomy, it would be wise to seek a second opinion if any of your trusted physicians think it’s warranted.