Breast Cancer Surgery & Innovative Rehabilitation with Dr. Kim Stone

In this episode, host Rachel Baker sits down with Dr. Kim Stone, a clinical associate professor in the surgical oncology breast section at Stanford University. Together, they discuss Dr. Stone’s journey into breast surgery, the importance of early mammograms, and an exciting new project utilizing virtual reality for patient rehabilitation.

👉 In this episode, you'll learn:

• Why Dr. Stone chose breast surgery as her specialty and the significance of patient relationships in healthcare.
• The guidelines for mammograms and when women should begin screening.
• How VR is being integrated into rehab for breast surgery patients.

Rachel Baker: [00:00:00] Welcome to Scrubcast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today we're speaking with Dr. Kim Stone. Welcome to the show.

Kim Stone: Thanks for having me.

Rachel Baker: Dr. Stone is a clinical associate professor in our surgical oncology breast section. Why did you choose to do breast surgery?

Kim Stone: So, I was always interested in surgical cancer care throughout my training and had some early exposure as a medical student. I also was always one of those medical students that really looked forward to both the clinic and the operating room. So as a medical student, I started shadowing a breast surgeon, um, and I just loved the relationship she developed with her patients.

She saw them, she got to know them very well. You know, supporting them through a very emotionally challenging time. A lot of discussions around, you know, identity and femininity. So, I was [00:01:00] interested in that as a medical student. Throughout residency I, like, loved everything. I was, like, general surgery was a great fit, because at some point I wanted to do literally every single subspecialty.

Um, and then ultimately when it came down to making a decision, I really did come back to that, like, deep relationship you develop with patients. I really enjoy. Getting to know patients and their families and following them for many, many years. It's a great mixture of cancer care and prevention, um, and as well as working on, you know, issues around lactation medicine and supporting breastfeeding women.

Um, so all of those reasons kind of were the reasons I chose breast surgery. And then the last is it's really collaborative. So, we work a ton with the medical oncologists, radiation oncologists, and then in the operating room, we work. together with plastic surgeons all the time. So, um, it's a highly collaborative field, which I also really enjoyed.

Rachel Baker: Nice. Well, so my sister just turned 40 and went for her first mammogram. Is that the correct guideline? [00:02:00]

Kim Stone: A hard question to answer with a simple answer, but yeah, 40 sounds great. The reason it's hard to answer is because, you know, it's confusing. You can look at lots of different guidelines and see lots of different answers.

So, whether you look at like the US Preventative Task Force or the Academy of OBGYN, or the American Breast Surgery Guidelines, they all have slight nuances that are a little bit different. It's actually led to a lot of confusion for many people. Fundamentally, starting around 40 and getting an annual mammogram is a pretty good guideline to follow.

There are some guidelines that say to get mammograms every other year versus every year. Um, when the guidelines shifted, so they did shift this year to, to recommend starting earlier at 40 and they used to say 45. But there are still some guidelines that say every other year. I think us in the field of breast [00:03:00] cancer treatment recognize that women in their 40s, if they're going to start screening, you should do it yearly because younger women actually tend to develop more fast-growing tumors than post-menopausal older women. Of course, there are exceptions to this rule, but if you just look at the statistics, so if you're going to embark on screening at 40, you should do it yearly, the. Screening regimens that, that space it out and say every other year are more appropriate for older women.

And so some of the guidelines say, well, after age 55, you could think about doing it every other year.

Rachel Baker: Yeah, I think my mom got, uh, she was really excited when she turned like 65. And they were like, you only have to get your boobs smooshed every other year now. And she was like, yay!

Kim Stone: I know. And it, that's a big part of this is because it's actually really uncomfortable and women don't really want to do it. And if somebody tells you something you don't have to, or you can start later, like it's great. I like that recommendation.

Rachel Baker: [00:04:00] It's still less invasive than like your pap smear or a colonoscopy though. So, I mean, on the grand scheme of screening, it's not bad.

Kim Stone: It is technically considered non-invasive screening, but, um, most women would tell you it still feels pretty darned invasive. Um, and another element of the screening recommendations are a baseline assessment of risk. So, of course, there are different guidelines if you're in a, um, average risk category versus a high-risk category.

So within the field of primary care, they should be assessing risk, including understanding your family history and some gynecologic factors like OBGYN history to determine like if you are in a bucket of average risk or high risk because screening recommendations for women who are identified at a higher risk of population average, and that's usually defined as 20 percent or higher, would be offered additional modes of screening.

Rachel Baker: Thank you so much for going into that.

Kim Stone: Of course. [00:05:00]

Rachel Baker: Let's start talking about this super cool project that you're working on using virtual reality. You're using VR to administer rehab and prehab to breast surgery patients. I usually think of rehab for like ortho and abdominal surgery patients, but how does rehab and prehab benefit breast surgery patients?

Kim Stone: Well, so most breast cancer surgeries includes axillary surgery. So removal of lymph nodes from the armpits. And so if you look at impact on patient's upper extremity function over time, there's a pretty significant impact. Now, while the risk of significant upper extremity disability is low, the Addition is so prevalent that the total population of patients that are at risk or have some degree of upper arm dysfunction After breast cancer treatment is substantial and you know as we sort of mentioned about the multimodality Treatment [00:06:00] so breast surgery plus radiation together have an additive effect that can cause significant shoulder dysfunction And decrease brain to motion as well as chronic pain.

So the use of PT after breast surgery, you know, most patients don't need to see a physical therapist after breast surgery, and in fact, most patients don't, but there is a known unmet need. It doesn't mean they're not having issues. Um, and if you measure things like grip strength or range of motion and physical, in physical therapy studies that look at, actually measuring upper extremity function, there's an impact from the treatment.

And so that is sort of the foundation. The other is this project started a few years ago when frankly, patients had limited to no access to physical therapists, like during the pandemic, PT offices were just closed. There was really, it was very hard for patients who did need PT to get in to see anybody, let alone on a [00:07:00] benefit standpoint.

Rachel Baker: So is that how you came up with the idea of using VR because of the pandemic?

Kim Stone: Yeah, well it was also one of those, a very Stanford thing. Um, where you have sort of a group of people doing research in a realm that happens to overlap you. You like, you know, your Venn diagrams just overlap. happen to overlap and you start to brainstorm around what kind of a collaboration could we do.

So there's a lab at Stanford on the undergraduate campus that includes like PhD students that's a whole VR lab and they have a wide variety of studies there. Engineers and neuroscientists and computer scientists that were interested in collaborating with somebody on the medical school side and in particular, really excited about trying to do something in the realm of surgery.

So they ended up connecting with Cindy Kin and myself, Dr. Kin, of course, has a lot of research in prehab and helping to prepare patients for surgery. And the reason why they reached out [00:08:00] to me from breast surgery. Well, first of all, I love kind of doing these innovative kind of projects that are a little out there, but then secondly, we really quickly realized that surgical patients wearing a VR goggle, potentially being dizzy, off balance, like, running into walls.

Yeah, that would be really dangerous, and you can go online and you can find all sorts of means GIFs of people wearing VR headsets and running into the wall. Okay, and so kind of early on we recognized that a seated session would be safe. Initially. We're really trying to target an older, more frail patient population who might not typically be able to engage in some of these things.

We wanted, we were trying to think what would actually be helpful because it's limited in a seated environment.

Um, and so that's where we started thinking about upper extremity and range of motion and what could be done to kind of demonstrate as a pilot project using this modality in a perioperative setting.

Rachel Baker: Don't get me wrong, I love the idea of not having to drive to my physical therapist for appointments, but I have used a VR headset all of once in my life, and I'm a millennial, so did you find there was any apprehension to using the device or a steep learning curve?

Kim Stone: I mean, I had never used a device, like, let's be clear.

Um, we have no screens in our household. We own no television. We play no video games. So this is like, not something in my wheelhouse. I personally am prone to motion sickness. It's like, I don't know about this. So we all started this project by all of us trying it out and wearing it. Even our nurses in clinic got a chance to wear it.

And to be totally honest, I feel like some of us as researchers had more apprehension than actually the patients have had. Patients have been pretty excited about it. You have some patients who use it already, like they enjoy gaming or they do exercise with and are excited to use it for something to promote their health.[00:10:00]

And there's another group of patients who are super curious. They're like, oh, that sounds cool. I've never done that. I'd love to do that. Maybe a little bit of healthy skepticism around, really? We're gonna do what? Okay. So I think some of us using it for the first time was like one of the bigger barriers.

Rachel Baker: So does VR rehab have similar results to in person rehab or what are your findings?

Kim Stone: This project is a feasibility pilot, so we are assessing, like, kind of, can it be done? Can it integrate into the system? Our study is not designed to study efficacy. Got it. Um, the truth is, I don't think any of us think it would outperform in person physical therapy.

It's an excellent and very effective modality. I think that we have always envisioned this as an alternative, kind of bridging a gap, because there is not enough physical therapists in the world and patients just don't [00:11:00] go. And so isn't there something better than nothing? So a lot of our study is designed around assessing feasibility and asking, It's actually the questions you asked.

It's like, are patients really willing to do this? We felt like there's, there is a learning curve for how to use it and how to interact with it and, and just the performance of the exercises. While they're very basic, we do have like, little wrist weights they can use to gradually increase, and there's a learning curve.

So we thought it was important that they actually learn to use the device before they've had any surgery, before they have any potential, you know, pain or discomfort. So this is where the prehab comes in is there's like a learning phase where they get the headset, they set up their account, they learn to do these exercises and get comfortable with it.

So then when they are recovering from surgery and cleared to do these physical exercises. They aren't fussing with the headset trying to figure out how to get it fit to them because we also realized that they probably would never do that. You're not kind of feeling [00:12:00] the greatest anyways. You're, it's not the ideal time to use an entirely new platform like that.

Rachel Baker: Well, so what are your next steps?

Kim Stone: So we'd had a first phase of our study where our first, I think it was about 10 patients, um, was highly exploratory, a lot of interviews with the patients to understand what it's like, surveys about the process, assess their needs, and figure out how to integrate it into the clinical setting.

Right now we're in a phase, so that was kind of our pre pilot phase, um, and those were all patients that actually we had a handful that came into the lab or we did it in person and then we've transitioned to patients. doing it at home themselves. So right now we're in a phase where we're enrolling 30 patients preoperatively.

Some of the patients will be randomized to have physical therapy sessions through zoom actually. So where there's a live physical therapist available to kind of help them and guide them in addition to use of the VR.

So I think we'd like to better understand how could this complement. [00:13:00] A more standard physical therapy setting, and we have structured interviews before and after, and some function assessment of the upper extremity function.

Um, so we're actively enrolling those patients still. Um, so our next step will be to kind of look at the outcomes for this group and consider a larger scale project. So that would be focused on efficacy of the intervention. So a larger scale project taking these feasibility. Aspects and designing a project that's scaled to assess efficacy.

Rachel Baker: Awesome. Well, I look forward to seeing your results. This project was sponsored by a department of surgery seed grant, and you presented some of these findings at our grand rounds in May. So if any of our listeners are interested in watching that video, I will place a link in the description. We are at that point in each episode of Scrubcast where we ask each of our guests the same two questions.

Uh, and the first one is [00:14:00] who is a surgeon you admire and why?

Kim Stone: Well, there are many. Um.

Rachel Baker: It's hard to choose just one. I know.

Kim Stone: It's hard to choose just one, but because this I think is going to air in October and it's Breast Cancer Awareness Month, I thought I'd give a shout out to one of my mentors from fellowship, Dr. Laura Esserman. She's a fairly famous figure in breast cancer and surgery. She's a passionate advocate for women's health, a incredibly robust researcher. And has designed a bunch of very innovative research platforms. Um, but then on top of it, she's like a super dynamic, fun person. She has an incredibly full, enriching life.

She's passionate as a leader. And just a whole bunch of fun attributes. So, she's really fun. You know, to quote Dr. Krumel, she's a tour de force, and she trained in general surgery here at Stanford.

Rachel Baker: hey, I like her [00:15:00] already. The second question is, what is the best advice you have received, in ten words or fewer?

Kim Stone: Does this have to be about surgery? 

Rachel Baker: No, it does not.

Kim Stone: The one that first popped in mind, which I'm just going to go with, because who knows who's listening and needs to hear it, is actually parenting advice that I received. And I think it could apply to a lot of aspects in life, but when we had a new baby, one of the pieces of advice that we found so useful, and we continue to quote it, is, Don't try to make a happy kid happier.

Oh. Because the truth is there's nothing better than a happy kid, right? And you know, your, your son, maybe he's like playing with this little truck and just delighted by it. Why do we go up there and say, don't you want a bigger truck? Oh's?

Rachel Baker: Like you're shooting yourself in the foot,

Kim Stone: You're shooting yourself in the foot.

Like you have this, you're having so much fun with this one truck. How about don't you want a bigger truck [00:16:00]

Rachel Baker: or another truck? Two trucks.

Kim Stone: Or another truck. I think about this in a lot of aspects of life, more than probably this person who gave me this advice intended, but I think it has some pretty profound meaning around how we parent and satisfaction and, you know, just that it's okay to be happy.

Rachel Baker: I can apply this to many things in my life.

Kim Stone: You can apply it to many things. That's why it came to my mind.

Rachel Baker: Well, it has been such a pleasure talking to you. Before we go, I want to ask, what is next for Dr. Stone?

Kim Stone: Literally right now?

Rachel Baker: Yeah,

Kim Stone: It's going to be making dinner. Actually, I'm going to make a slideshow. I'm going to make a work on a presentation for a family medicine lecture, and then I'm going to go make dinner.

Rachel Baker: Awesome. Sounds like a plan. Well, thank you so much for joining us.

Kim Stone: Thank you, Rachel.

Rachel Baker: And that brings us to the end of another episode. If you like Scrubcast, we hope you'll tell your friends and subscribe wherever podcasts. Scrubcast is a production of Stanford University's [00:17:00] Department of Surgery. Today's episode was produced by Rachel Baker. The music is by Midnight Rounds, and our chair is Dr. Mary Hawn.