Advice from Veteran Breast Cancer Specialist, Dr. Johnson-Miller

Recently, I had the privilege of talking to Dr. Denise Johnson-Miller, medical director of the breast program of El Camino Hospital in Northern California. As a leader in her field for more than thirty years, Dr. Johnson-Miller has practiced as a surgical oncologist, professor, and program director at many distinguished programs across the country including Rutgers and Stanford.

I asked Dr. Johnson-Miller what she would like people to know about breast cancer and her short answer is “it is right to have hope.” We’ve made tremendous progress in the early detection and treatment of breast cancer over the past decades with new innovations and insights into the disease. Earlier diagnosis means more treatable cancers, and treatment has advanced considerably with shorter-duration, more individualized and effective therapy.

“In the last thirty years, we’ve reduced the overall breast cancer mortality rate by over 40%,” Dr. Johnson-Miller says. “Improvements in testing and genetic screening is making a huge impact. If women get regular mammograms and treatment right away, survival is expected.” As treatments get less invasive, women can return to their lives sooner and more completely. However, we still have a long way to go to ensure that everyone has access to regular screening and a quality cancer care team. The mortality for Black women is some 40% higher than that of white women, even with a 4% lower incidence rate of breast cancer overall. Clearly, there is critical work to be done to identify and address these disparities. 

Detection

It is now expected that primary care physicians and OBGYN’s offer breast cancer risk surveys to calculate patients’ risk for developing breast cancer. They are also available for free online. By learning about personal and family health history, we’re able to determine if genetic testing and more proactive breast cancer screening is needed — which can lead to earlier detection if a tumor does develop. Organizations like The Lynne Cohen Foundation, are helping to lead the way in early detection and prevention with their clinics at NYU. Bellevue Hospital, and USC Keck.

Genetic testing involves a simple blood or saliva test and assesses more than eighty gene mutations that can severely increase the lifetime risk for developing breast and other types of cancer. If a patient learns she has one of these mutations, it will help her, and her high-risk cancer team make decisions about screening and prophylactic management. It is recommended that all patients with a newly diagnosed breast cancer undergo genetic testing to help develop a treatment plan that mitigates the risk of a tumor returning and gives insight into other members of their family who may also be at risk of developing cancer.

Advances in screening have made it possible to diagnosis tumors earlier, before they have a chance to grow and metastasize to other areas of the body. Especially for women with dense breast tissue (about 50% of the population), this technology has made all the difference. To digitally recreate a comprehensive image of the breast for radiologists to review, we use 3-D screening mammograms (or 3-D tomosynthesis) which combines many low-dose X-ray images, automated breast ultrasound (ABUS), which utilizes sound waves, and for those considered high risk for breast cancer, there is breast MRI, which uses powerful magnets with minimal radiation exposure to generate the most comprehensive image.

Treatment

While fully destroying a tumor and preventing its recurrence is not without side effects, treatment has gotten more tolerable over the years. Dr. Johnson-Miller says, “When I first started thirty some years ago, everyone got mastectomies and total axillary lymph node dissections, and almost everyone received chemotherapy, as well.” Now, most people can undergo breast-conserving lumpectomies, which allow a much easier recovery and quicker return to normal life. Also, we’ve learned to be more discerning about who needs lymph nodes removed and how many, which has spared countless women the damaging effects of lymphedema (arm and shoulder swelling) down the road. Lymphedema has a profound negative impact on patients’ lives, so a great deal of effort has gone into finding ways to prevent it with change in surgical techniques, and to manage it early with intensive physical therapy. Also, with genomic testing, we can most accurately predict the effect chemotherapy will have on a specific tumor, so we are more discerning about the medical therapy patients receive, as well.

Now the goal for breast surgeons is to completely remove the cancer while leaving as much normal breast tissue as possible. Often the breast surgeons work in tandem with reconstructive plastic surgeons to achieve an effective and aesthetically pleasing outcome. In a lumpectomy, breast surgeons excise the tumor and margins surrounding it, as opposed to removing the entire breast, as in a mastectomy. To identify the exact location of the tumor within the breast, radiologists place clips and markers at the tumor site prior to surgery and with specialized instruments in the operating room, these trackers lead surgeons to the exact location of the tumor and are removed with the tumor during the surgery.

When total mastectomies- or removal of all breast tissue- are required, in the case of especially large tumors or prophylactically for genetic mutations, there are new, reconstructive options that help plastic surgeons achieve more natural-looking breasts.

As far as medical oncology therapies go, we now have more and better tools to destroy cancers and prevent them from recurring. We’ve learned that most breast cancers are hormone-sensitive (estrogen receptor (ER+) or progesterone receptor (PR+)) and so we can use hormone therapy in management and recurrence prevention. We also test cancer cells for a protein mutation called HER2/neu, and have targeted therapies for that, as well, and there are now immunotherapy drugs that target and boost the immune system in the body to fight cancer cells.

“Decades of research and clinical trials changed the way we treat invasive breast cancer,” Dr. Johnson-Miller says. “We used to prescribe chemotherapy and anti-estrogen therapy for anyone with an (ER+) tumor and cancer cells in the lymph nodes, but now we determine the Oncotype DX of the tumor to determine if chemo is necessary.” While anti-estrogen therapy is still beneficial to all these patients, it turns out “only about one-third of women with early-stage breast cancer (and with three or fewer positive axillary lymph nodes) benefit from chemotherapy.” This obviously had made a huge difference in the lives of many patients.

Almost all patients who undergo a breast-conserving lumpectomy then require a course of radiation therapy to ensure that all the cancer cells have been eliminated. Radiation therapy has gone through many advancements over the past few decades, as well. Now radiation can be focused specifically on the lumpectomy site, thus minimizing the effect on the local skin and other healthy breast tissue and precautions are taken to avoid exposure to the heart and lungs. These more targeted treatments mean fewer long-term side effects for patients.

Hope for the Future

Dr. Johnson-Miller feels hopeful about the future of breast cancer management. As we continue to better identify those at risk and find tumors earlier and treat them more effectively in less traumatic ways, it is reasonable to expect patients to not just survive, but to thrive long after a breast cancer diagnosis. There is no one-size-fits-all solution when it comes to breast cancer as everyone’s genetic makeup, health, history, and social, emotional, and financial needs are unique.

Dr. Johnson-Miller’s advice to all of us is to get regular breast screenings, advocate for our health, know our personal and family risk factors, and take good care of our heart health. This includes exercising twenty to thirty minutes a day, avoiding smoking and excessive alcohol consumption, eating a diet high in leafy green vegetables and fiber, avoiding a lot of red meat and processed foods, and taking a multivitamin and Vitamin D. Equally importantly, she emphasizes the need for a strong network full of compassionate, caring friends, family, and healthcare providers as compassion and hope go a long way toward health and healing.

Sarah Zimmerman is a freelance writer in Northern California and is working on her first novel. In past lives,, she has been a Physician Assistant in Women's Health and the owner of a vegan ice cream business. Sarah writes about marriage, sex, parenting, infertility, pregnancy loss, social justice, and women's mental and physical health, always with honesty and humor. She has written for Ravishly, Cafe Mom, Pregnant Chicken, and more and can be found at sarahzwriter.com and on Medium, Twitter, Facebook, Instagram and TikTok at @sarahzwriter.