Life-Saving Intel: Amanda's Breast Cancer Surgeon Dr. Lucy De La Cruz

Welcome to We Can Do Hard Things.

Recently, we were talking about some stressful thing going on with the podcast, and somebody said, we have to chill.

It's not like we are curing disease here.

It's not like we are saving lives here.

I think it might have been.

There is no such thing as a podcast emergency, right?

And Jen Hatmaker also said that.

Right.

And then we sat there and immediately thought about,

I think, perhaps the most important thing that this podcast has ever done.

Yeah.

Which is

give the gift of Amanda's transparency through her breast cancer.

People don't use the word journey anymore, do they?

What are we saying?

I think they do.

I think they do.

I do say journey.

I mean

hullaba who?

Okay, so let's use that.

So Amanda's transparency

through her breast cancer hullaba who

or hullabaloo?

We're going with who.

It's not a word, but I just think I liked it.

Okay, hullaba who it is.

And

it's hard.

Well, what we're gonna do today

is

kind of look back on that, hullabahoo, and then the decision to discuss it openly and then the miracles and magic that happened as a result of that decision, which people are continuously stopping Amanda in the street, in the store, in the events.

to tell her that her

decision to share her story led them to become advocates for their own health, which then led them to discoveries they wouldn't have made and were life-saving to them.

So

the theme of this

is

celebration that we are over a year out of the hullabahoo.

That

the decision to

really take care of yourself and become an advocate for yourself is the most loving thing you can do for anyone you love.

And we're going to hear from Amanda about where she is post-halabahoo and what she wants you to know that could save your own life.

Amanda, no pressure.

Go ahead.

No pressure.

No pressure.

Yes.

Yes.

And it is,

I asked if we could do this episode because it is Breast Cancer Awareness Month.

And I feel like a lot of things happen in Breast Cancer Awareness Month, which I love if those feel empowering and wonderful for people and it feels like solidarity, that feels amazing.

I,

for me personally,

it feels like the best thing that you could do with a moment of awareness is

un-gatekeep information.

And it feels

so I feel like the awareness let's just you know double tap on the aware piece of the awareness you know less colored t-shirts more

information is my particular love language and i think that

what's been incredible to me is that you know it isn't me sharing because just sharing information does nothing you know like you could just have information but what is so remarkable is the people who have heard the information and then gone to do something about it, which is

really incredible when you think about

that people

that is within their power to do and they're doing it and that just makes me so excited and it makes me think that it really is the gatekeeping of information that is the problem because when we're hearing from all of these women, they're like Good information.

I can use information.

I can save my own life, but it's the information that is the problem.

That's right.

And that's what I think we should be doing with Breast Cancer Awareness Month.

So I feel excited.

And I just want to

turn the mic and the mirror and the celebration back to the people who are doing this because that feels there's so many of them in the pod squad and they...

are really saving their lives and by extension their families lives for doing that.

So, I would love if we could listen to a few of the voicemails.

That these are just three that have come in, the thousands that have come in from people like this of members of the pod squad.

So, I want you to hear a few.

Okay, beautiful.

And before we do that, can I just say that I think you just articulated why we're all insane right now?

Yeah.

Is like

the more awareness quote quote rises of these problems

with no information, the lower the information, the gap between those two is what insanity is.

Like, if you're not going to tell me how to fix it, then maybe I don't even want to be aware.

Because awareness without a plan equals insanity.

So.

Right.

That's just anxiety.

Awareness without a plan is anxiety.

So I mean, thank you.

That is

what I want to say to that and to give an overview of what we're going to do today is

these are things

if you are a person who is not aware that you are on a breast cancer hullaba who

are things that will help you find out if you actually are

and will equip you to have the information you need to know you are either safe and how to continue to stay safe.

And

if you are

already on the ride

or know someone who is,

my experience was absolutely shocking that I thought that I had a problem and therefore

there would be a solution for it and what I found was I had a problem and four different surgeons give me four very different solutions for it

and that is not

because

there are four different solutions for it that are equally good.

That is because there are four different solutions that those doctors

are good at.

And so, that was what was offered to me.

And so, what we're going to do in the second part of this is: my wonderful surgeon, Dr.

Lucy De La Cruz, is going to come on and I'm going to ask her all of the questions that I had, everything that baffled me during the process, all the decision points that were not made clear to me as decision points.

They were presented to me as answers based on what that particular doctor's bias was.

And that is not a dig.

Everyone has a bias.

I have a bias.

We all have biases.

But they were not presented as biases and therefore their answers.

They were presented as the answer.

And so, what I want everyone to be aware of in breast cancer awareness is: A,

how to find out if you have breast cancer because the screening you're having for 50% of the women is not cutting it.

And number two, if you do have a diagnosis, here are all your decision points that you may not even be aware are decisions.

So that's what we're going to do in the second half.

And

what I want to say about the whole awareness without a solution is breast cancer is highly treatable, highly survivable in the vast majority of cases.

And a lot of people are not getting screened because it's so, you don't want to ask your partner if they love you

because you don't want to know the answer, right?

Like you don't want to find out if you have breast cancer because

that you think that's like a death sentence, right?

It's not.

70 to 80% of breast biopsies come back negative.

Like you, you want to get that information.

That is good for you to get.

And

the key is just finding it as early as possible because as early as possible makes it more treatable and it is imminently treatable.

My life is 0% impacted.

Zero.

Except I have nice, perky, plastic breasts.

You really do.

They're lovely.

They're lovely.

The hullabahoo.

The hullabao.

The booby prize.

It's the booby prize.

It's a booby prize.

Okay.

So I say that a little bit in jest, but I'm saying 0% impacted.

And also, I never have to worry about breast cancer again because I have no breasts.

So another upside that we should not overlook.

All right.

So

this

is some of the responses we have received over the last year.

Hi, my name is Anna, and this message is actually for Amanda.

This is probably not the first call you've gotten like this, and it probably won't be the last.

But when you did your

podcast on breast cancer,

I listened to all of them and I thought, how nice that she is doing this for other people because won't everyone else benefit from this?

And

I did take your information to heart, but I did not imagine that this would be my story as well.

So I also had some indicators of high risk.

And after a clear mamogram, I pushed my doctor to have an MRI.

And I thought I was going in to just check a box.

and be super cautious.

And as it turns out, I have breast cancer.

Thankfully, it's stage one because I caught it so early.

But the surgeon said that it would have been a long time before it showed up on a mammogram, and I wouldn't have felt it for a long time either.

And it probably would have been a lot worse.

So, in addition to saving your life, you probably have saved my life, and I don't know how many other people besides us.

So, thank you so much for all that you did to share that information and get the word out there.

Hi, Glennon, sister, and Abby.

This is Susie.

I had to call and leave you this message, which I hope you hear.

Last summer, I listened to the episodes about Amanda's breast cancer diagnosis and also the episode with the breast cancer expert.

And that fall, at my doctor appointment, I asked if I could be approved for increased screening based on my dense breast tissue and my family history and I was approved for alternating MRI mammogram every six months so I had my first MRI in December

and in early January I was asked to come in for some follow-up based on that MRI and by February I had been diagnosed with breast cancer My surgery will be followed by radiation, but because it was detected so early, I'm not expected to need any chemotherapy.

And all of this will happen

before my annual mammogram would have even been due.

So if I hadn't listened to your message and advocated for myself, I wouldn't even know about this cancer yet inside my body.

I just wanted to call and say thank you

and just make sure that you know what a difference you're making.

And I'm so happy that Amanda is well.

That's it.

Thank you.

Hi there.

My name is Mary Beth.

And I just wanted to thank you, particularly Amanda, for being willing to talk about your process.

I hadn't had a mammogram in 15 years.

when I went last week and had one and then an ultrasound and biopsy and found out I have breast cancer.

So

just wanted to let you know, you saved another life.

Oh, my God.

So how cool is that that people are brave enough to

receive information and

advocate for themselves and get what they need?

And I just think,

I think it's an it's an information hole and that is the thing because that's it's an example, right?

People don't have the information that they need to make the best decisions for themselves and people will make the best decisions for themselves with the right information.

That is what these people did.

It has nothing to do with anyone being like brave or doing anything.

Like all I did was share information.

that I wish I would have had before I had it.

And then the people did what what they did with it.

And I just think that's so beautiful.

And one of the things that I want to

talk about is particularly with those first two messages.

The third woman, that's amazing.

Sometimes when you think you're 15 years out and you're like, that ship has sailed and now I'm scared of what to find, like, God bless her.

That is so brave to face that demon.

And it's so amazing.

And with the first two, I want to just re-remind people, we'll put in all the show notes, all the other breast cancer episodes that we have done so that you have like the full packet of information.

If you know someone's going through, you can send them this episode, and in the show notes, it'll have all the episodes that we've done on breast cancer, just all the information that we have found.

But what they're referring to is

breast density.

And what I want you to know is that three days before I went to go get my

double mastectomies,

I had to, for insurance purposes, go get a mammogram

and

The people doing the mammogram knew that I was going to get double mastectomies and They did the mammogram and they came back and they gave it to me and they said you are a hundred percent clear.

Oh my god, we would never have suggested that you do any kind of further screening we would have cleared you completely and the reason that is the case is because I have extremely dense breasts.

So I'm going to take two minutes and go through breast density because this is something you really do need to know about yourself.

There are four categories of breast density, A, B, C, D.

Okay, half of people with breasts are A and B, half are C and D.

Okay, A and B.

A is the least dense.

This is, congratulations, you hit the lottery.

Most of your breast tissue is fatty.

The reason this is important is because when you do a mammogram, fatty breast tissue comes up black on the mammogram.

Any kind of tumors or masses or cancer come up white.

So the reason that that is great is because a mammogram will cover you.

You will know

that something has occurred through a mammogram.

Category B.

Contrast.

The contrast.

Contrast.

Right.

Because the rest of your breast tissue is black.

Problem spots turn out white.

Your doctors can say, look, I see something.

Great.

Mammogram all day.

You're set.

Category B is also considered low density.

There's scattered areas of what they call dense granular tissue, but also fiber and fibrous tissue.

So you're going to have some white spots in there, but generally

someone reading a mammogram will be able to detect that you have something concerning happening.

Okay, so if you're in A or B, you are

50% of the people, 10% in A, 40% in B.

If you're doing that and you are doing your regular mammograms, you will likely be detected.

and Amanda is there do they tell you that like is that something that all women can go in and say I need to know whether I'm a B C or D okay great question so your if you are getting mammograms your mammogram will tell you whether you have a dense tissue or not dense tissue it's written there in fine print the problem is they do not tell you whether you're a b c or d so if if they tell you you don't have dense tissue you know you're a or B.

Okay, and the mammogram is likely sufficient for you.

If they tell you you have dense tissue, you don't know if you are C or D.

And that's really critical, and I'm going to tell you why in just a second.

But every mammogram tells your health care person

whether you are C or D.

So you need to,

if you know that you are dense, your first question needs to be, am I category C dense or category D dense?

So do I just have dense breasts like 40% of the population who are in category C?

Or do I have category D, extremely dense breast, which is one in 10 people?

And if you're a category D, you absolutely cannot rely on your mammogram.

So it's kind of this false sense of, well, if 50% of the people have it, it can't be that bad because they categorize C and D together and call it dense.

So category C is most of the breast tissue is comprised of dense granular and fibrous tissue.

So, that means most of your tissue will be white.

So, it will be harder to see if you have

some concerning mass there.

So, that is something it's called a heterogeneously dense.

If you are, if you're hearing those words, you are C.

Okay,

that

you might want to get ultrasound, 3D mammography, or MRI.

My category D friends, okay,

this is

likely the friends that we heard the first two on the voicemail.

This is me.

I have extremely dense breasts.

This means that I, like one in 10 people, one in 10 people with breasts, will,

my breasts will appear completely white on the mammogram.

So that is why I was cleared and said you're all set, you bet, go home, you have no problems.

Three days before my breasts had to be removed for cancer because you literally can't see it.

And I had a 3D mammography for that, and it was still cleared.

So the important

thing to know is that mammograms miss between 50 to 60%

of cancer in those with dense breasts.

So it's a flip of a coin.

And that's just dense breasts, not extremely dense breasts.

So if you are category D,

what you need to do, like the other callers, is you need to say,

I have extremely dense breasts.

I need to have an MRI.

The MRI is a completely different scanning tool that can go in and see things that your mammography cannot see because your breasts are extremely dense.

Can I ask you one question that I think the pod squad's probably thinking right now?

So, let's just get it out of the way.

If you know

that a C or D breasts, especially a D, cancer cannot be seen inside of that.

So there must be another test given to protect the woman or the person with breasts from the cancer that could be inside of them.

If you know that and you have to advocate for that, why the hell are the doctors

not knowing that and advocating for that?

Like that's a everything you've said is factual.

So why is it that the person has to be a detective and say these things when we're trusting medical professionals.

Why do it can't be possible that they don't know this?

Correct.

This is for sure, like anything else, a money issue.

This has to do with additional screenings costing additional dollars.

Like, there's, there's,

there's no other

anything makes sense.

There is a certain threshold under which you absolutely have the right to

absolutely have the right to have insurance pay for an MRI.

In my experience, if you go to your doctor and you say, I have extremely dense breasts and I am advocating for myself to have the MRI,

they usually, to cover their ass, will approve it.

And therefore, your insurance will approve it.

There's also several scores that you can take.

Like, if you have a family history, of any cancer

together with dense breasts, then it will reach a certain threshold of likelihood that you are above the average chance of getting cancer than the average bear, and that will allow you to have insurance cover it.

I need you to also know that I have heard from two people who said, who had dense breasts, they told their, they listened to our last podcast episode about this.

Their doctor said, you don't need an MRI.

They sent the link to the podcast episode to their doctor and said, if after you listen to this, you still don't need an MRI, you still think I don't need an MRI, then I'm cool with it.

And the doctor approved the MRI.

So it is agitating enough and advocating for yourself enough.

It shouldn't have to be the case.

It's bullshit that it is, but it is bullshit.

So now we just have to advocate for ourselves.

The other really critical thing that you need to know about dense breasts is it is not just that it makes breast cancer so difficult to detect.

If you have

category D

extremely dense breasts, it is both, number one,

almost impossible to find in an MRI, but number two, you have an independent increased risk for breast cancer.

Okay, so we're taking a population that has an independent risk for breast cancer, regardless of whether they could find it easily,

and giving them a test that can't detect it.

Unbelievable.

So, that is why it's important.

It's important to know if you're category D, you are already at risk

more than

others.

So, both of those things are true.

People with this highest density breast, this category

D density, it's called extremely dense, are four to six times more likely to get breast cancer than any other category.

So,

one in 10 people, you need to find out.

And

what we're doing is

they're going to offer you ultrasound first.

They're going to offer you 3D mammography.

You're going to say, thank you so much.

And also,

I will be getting an MRI.

And you're just going to push until they do and make sure it's on record that you have asked for it, that you have said you've needed it, that you have all the rest of your risk factors calculated so that they know

and have on record that they have been alerted, that you know your risk.

And when they know that that is the case, they will approve your MRI.

Okay.

Wow.

It's almost like it would be nice to have a place where we could report doctors who don't approve the MRI, but that's different.

Okay.

Carrie.

You do know what I mean?

Like that, maybe that would scare them to do the right thing is like some public shaming form.

Well, if it all goes back to money and it's all like, then they're also going to be equally scared of getting sued

for having an MRI requested that they disapproved and then you ended up with stage four cancer.

So like

you're using that to your advantage.

That's right.

Just like it's to our disadvantage that they don't automatically prescribe.

these MRIs.

And the last thing I want to say is if you are running into a lot of difficulty and you're trying and you're trying, there is something called a mini MRI.

It's still quite expensive and out of reach for a lot of people.

But if you go in for a full MRI, it is thousands of dollars, right?

And that's what your insurance covers.

There is a thing called a mini MRI that is about a $500 out of pocket.

That if you are facing so many hurdles and you're in a position to do that, it is equally

efficacious from a diagnostic perspective for breast cancer.

So

you can elect to do that yourself if that is within your capabilities to do that.

So

that is

the review of density and category D.

The only D ever associated with my breasts is density.

And

I just

am really excited that Dr.

De La Cruz is coming to talk to us about

all of the things because she is a straight shooter and is the opposite.

What's the opposite of gatekeeping gate letting she's just she's just throwing open gate opener yeah gate opener gate opener and um

what is wild is that do you remember lori from our virginia event

okay

so this woman on the tour that we went on this woman lori she

She was like in the first few rows and she stood up during our event and she said, hi, my name is Lori.

I was just diagnosed with breast cancer and the only reason I got my diagnosis was because of your episodes that educated us on it.

And she had a question.

She had a couple of kids and she was going through it and she was trying to figure out, she was asking questions about how to...

how to deal.

And so I was able to jump down and give her a hug.

And after the show was over, she said she was having,

in the question in front of everyone, she said she was having her surgery the next week.

Yeah,

and I was upset because I was like, damn it, I don't, I wonder who she's having her surgery with.

You know, I've basically taken meetings with every single breast surgeon in Northern Virginia.

Like, I was like, oh no, that ship has sailed.

And I, after, I like jumped off the stage and to talk to her and I said, you know, where,

where are you getting your surgery?

Who are you working with?

And

she said, Dr.

De Dayla Cruz.

Fine.

Oh, my God.

And

then we

both started crying because I was like, you're going to, it's, it's

like meant to be.

She's so great.

And you ended up exactly where you should be.

And then she started crying because she didn't know that she was my doctor.

Anyway, I just,

it just felt like, like, I know there's other like incredible doctors in Northern Virginia.

I'm not saying that.

It just felt like this like connection of that she had found her way there.

Then two weeks later, I'm walking into my one-year appointment with De La Cruz.

I walk in and I'm haven't been there for six months.

I walk in and Lori is sitting there

in the waiting room.

She has just finished her first post-op appointment.

And she's the only other one in the room.

It was so wild.

It just felt like ordained.

And then De La Cruz sent me a picture of the operating room the day that Lori had her operation.

And she's sitting there.

Her are the other surgeon, the plastic surgeon that did the reconstruction, Dr.

Van and Dr.

De La Cruz.

And Lori is holding her We Can Do Her Things book in.

In the actual operating room.

It was so beautiful.

And I'm like, this is just amazing.

The intertwining of all of the lives is just, it's such a beautiful thing.

We're so proud of you.

Yeah.

Sister.

We're so proud of you.

Okay, so we're going to go hear from Dr.

De La Cruz now and get all the answers that anybody else might need.

And I just want to say, the way you just described that in the first, I feel like

it was so clear.

Yeah, really.

It's going to be so helpful.

Okay.

So we're going to talk to De La Cruz now.

So what we're going to do is I am,

I'm stealing Dr.

De La Cruz to myself.

Okay, um, so she and I are gonna get on, and it's basically gonna be anything you are, you've been diagnosed and you're staring down the tunnel of what does surgery look like.

You don't know what questions to ask of doctors that you are meeting with, you don't know what your options are, you're being presented with A, but you've heard that maybe B, C, and D are things.

How do we know what questions to ask, what

places to push on, where to advocate for ourselves, and

what actual decision points we have, even if they are not being presented to us?

Amazing.

And then you're going to send this episode to every person that you know that has breasts

as a gift to them.

Okay, yes.

Me personally or our listeners?

You are.

And then we're going to relax.

Okay.

Okay.

No, our listeners.

Say hi to De La Cruz for us.

We love

tell Dr.

De La Cruz we love her.

My favorite part was right after when the after my surgery when I went out and I was like, I was texting you and Abby and I was like, I think it went well.

And then and then you both texted back and you were like, it did go well.

De la Cruz already sent a picture of your breasts to us.

I was like, they look great.

Okay.

We love you.

All right.

Bye-bye.

And now it's time to thank the companies who allow you to listen to We Can Do Hard Things for free.

Today's segment is brought to you by Bumble, the app committed to bringing people closer to love.

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All right, Pod Squad.

As I promised you, we now have the joy and honor of being with Dr.

De La Cruz.

I'm turning this phone off because not a damn person is going to bother us for the next while.

De La Cruz, we're getting this done.

Okay, let me do your fancy bio because you are quite fancy.

Okay.

Dr.

Lucy M.

De La Cruz is an internationally recognized breast surgical oncologist and the youngest Latina chief of breast surgery in an academic institution in the United States.

Maybe that has changed because I've aged since I've been here.

Well, no, I'm saying it's in the bio.

That position.

Yes.

If there are more, that's good.

That is actually good.

You're right.

I'm the order of the minority of the minority in the surgical field.

So it definitely.

Well,

let's hope that stat is off.

But she serves as chief of breast surgery and director of the Betty Lou Orsman Breast Health Center at MedStar Georgetown University Hospital, a nationally ranked center of excellence in breast cancer care, Dr.

De La Cruz specializes in nipple-sparing mastectomies with structural preservation and resensation.

Don't worry, we're going to talk about what the hell all these things mean.

With a focus on highly specialized single-stage implant reconstruction.

As an associate professor of surgery at Georgetown University School of Medicine, she has, thank you, baby Jesus, trained the next generation of breast surgeons.

She is not only a preeminent trailblazing breast surgeon, she is my beloved doctor and friend.

And she is an absolute beast who just came 10 minutes from surgery and is here to join us because she can do hard things.

So.

Daylight Cruz, thank you.

Thank you so much.

And by the way, we can all do hard things, right?

And so, you know, I operated this morning, I took a shower, got here, and set up a computer, which by the way, way, was the hardest thing of my morning.

I feel like with doctors and stuff, it's like you can be in there with organs, but you're like a power switch on a computer.

I know.

I was like, oh my God, how am I going to set up this podcast on my computer?

And oh my God, is this going to work?

And so I did.

And so I'm pretty proud of myself right now.

Pretty proud.

I did.

Tell me how you feel about this.

I told the pod squad a bit ago that my goal for our time together, and you tell me if we should have different goals in addition to this, is that like,

if you're on this journey where you are just like, okay, I have a diagnosis, I'm going to be facing a surgery, and there

either seems to be no decisions because someone's just telling you this is your choice and you have to take it, or so many decisions.

Or sometimes a mix of both where you're just being offered one thing, but you're hearing a lot of noise about, but so-and-so is getting something else.

And I'm reading reading online that there's three other things I could be doing.

And so I think it would be great if we just went through, and I can tell a little bit about how it worked for me, but just get to a place where we can talk about

here are all the decision points.

And here's like the different options that you have, because it feels like

for me,

At the very beginning,

I went to one doctor and I got one set of answers and it was you're definitely gonna have to lose your nipples you will have your lymph nodes removed then another doctor which the only reason i had enough

um capacity emotionally

this is putting aside the fact that i have like the privilege and financial freedom and time to be able to research these things but i didn't even have the emotional capacity to

even face finding a second opinion, right?

Because it was just because Glenn and Abby were here and they were like, that didn't feel so right.

Are you sure?

And then the next person, okay,

maybe

you can keep your nipples, but you're going to have two surgeries.

You're going to have one surgery to get rid of the cancer and another surgery for reconstruction.

And so it's going to be like this year-long process of things.

Then a third surgery.

Then

I meet you.

And then this is where my love story ends

or begins, as it were.

But the whole time, and I didn't have a complicated diagnosis.

I didn't have a complicated situation, but so it was shocking to me to go to four different surgeons and hear four different answers as if they were definitive and the end of the story, as opposed to

here are all the things that could be the case.

I do this one.

And so here's what I would offer you.

So

that's what I want to kind of help walk people

through because it feels like there's a kind of gatekeeping around this information that we

should open the gates a little bit.

So I think it just, you know, one of the things that I always tell patients and I tell my fellows when I teach them is that I was very fortunate to be taught very early on in my residency by someone who was a breast surgeon who instilled in me the idea that a woman deserves a choice when they have it.

There are some women that don't have choices surgically.

And if they do have a choice, you should present it to them and understand that they are going to be, you know, part of the process.

And one of the things that she also instilled in me, Dr.

Lesnikowski, she said, Lucy, never stop learning.

Because when you stop learning, it's not just you that gets,

your career is trumped, but your patients don't get the best of the best.

And so with that in mind, when I became a breast surgeon, I always said, I'm going to push the envelope here.

And knowing that it's it's oncologically safe, but physically I can do it for my patients.

And so, you know, I think it's just part of my mindset.

It's also part of my belief that when women come to me, I want to make sure that this is almost like that they look back as this and this is not a defining moment that makes them feel like they lost something.

We all lose something through breast cancer.

My mom had breast cancer and even I lost something as a family member because obviously now I'm at higher risk of breast cancer.

So, you know, I'm now having to get screening and all that stuff.

But patients who go through breast cancer, they don't sign up to have breast cancer.

They don't sign up to have surgery.

They don't sign up in some cases to have chemo.

So what am I here to do?

I'm here to let them know that my job is to make sure that when they're done surgically, that they still are able to recognize themselves and that I can minimize that.

kind of shock to their body.

Also, there's decision fatigue.

So you're asking someone in a very stressful stressful time of their lives to make the most significant decision that they may do as a woman for their quality of life, their sexuality.

You know, some of us are defined by our nipples.

I sure am, you know, and I wouldn't want to lose my nipple if I didn't have to lose my nipple.

And so,

and sometimes, you know, we talk to patients about it and you're like, oh, it's, well, no, I have one and I want to keep it if I could, if I could avoid it.

So yeah, it's just talking about the patients, giving them the options, either a lumpectomy or mastectomy.

If you have a mastectomy, how can we minimize the trauma?

How can we expedite the healing and do it all oncologically safe?

You know, I've been doing this for 12 years.

It's not that I'm leading, you know, that I'm putting cosmetic in front of cancer.

No, I'm actually, I think there's no reason to not prioritize concologic outcome with cosmetic outcome and build that bridge, which is called oncoplasty.

The Europeans have been doing it for years.

We've been doing it here in America for years.

And there's a vast, vast, vast

number of literature to support that to be offered to our patients.

You know, it's so interesting because I know that doctors have this, the idea is you have to have informed consent, right?

Like, but what's really interesting to me is how do you have informed consent for a procedure if you're not informed that there are...

are alternatives to that procedure.

And let me just give you an example, which is that we're going to get to like the decision points being, you know, mastectomy versus lumpectomy, the direct to reconstruction,

you know, the breast surgery to reconstruction versus a kind of delayed reconstruction where you're having two surgeries.

We're going to get to nipple sparing versus non-nipple sparing, nerve grafting and resensation versus not,

and then the whole lymph node issue, which people need to know about.

So we're going to get to all those.

I want to assure everyone we're going to get to them.

But I want to like my

you just brought up all the nipple sparing stuff.

And

when I went to the first surgeon I went to and said, you are going to have to,

she said, you're going to have to lose your nipples.

And I

was in survival warrior mode.

And I was just adjusting to all of these things and said, and just kind of like buckled down and went dead inside and was like, okay.

You know, like, okay.

This is the whole mentality we have around this is warrior.

You're a, you're a breast cancer warrior you're fighting you're battling and so when you're in that mode you're like okay you're telling me something that i'm going to have to accept and i am doing my job of accepting it and then after i talked to you and then i went back and said

wait i'm confused because now i'm hearing from a couple of other surgeons that i that I can find out if I need to lose my nipples after

and have it confirmed rather than preemptively losing my nipples.

And she said

the following.

She said,

well, you didn't seem that upset

when I told you that you had to lose your nipples.

But if it's that upsetting,

we can talk about it.

And this is what, this is just feels so important, not to bash that doctor, although I do think that was bullshit for sure.

But like,

but this is, we are going into it as women and survivors and like battle mentality being like, if you tell me something that I have to do, I'm going to take it on the chin and I'm going to keep fighting for my life and I'm going to adjust to it.

But the idea being, had I burst out crying in that office and thrown a fit and shown I was upset about that, you would have given me other options.

Yeah, that's insane.

I mean, I can't attest to that kind of

recommendation from anybody because usually, you know, as a surgeon, we all look at the imaging and we kind of, I mean, I do tell patients, you may lose your nipple if I go in there and your margin is positive.

We may have to go back and take it out.

I have done enough of these that I feel like we have removed, I mean, in my past, you know, when I first started, when I was young and fresh and bushy's bright, and I wanted to do everything, you know, kind of like,

you know, kind of what

a lot of other people were doing, which was removing nipples in the setting.

And I would look at the final pathology and notice that the nipple was not involved.

And I kind of felt like, this is not right.

This doesn't feel good.

And so I was like, you know what?

I'd rather remove it after

because it's a smaller procedure.

You can do it in an office.

It's, you know, if you need it, then the discussion with you and I would have been a different discussion.

I would have been like, Amanda, you need to have this nipple removed.

And then you would have said, Lucy, you did everything you could.

And I'm, and that's usually the kind of response that I get from losing a nipple because they're positive, right?

The patient will be like, you know what, at least we gave it a shot.

And so I feel that in my mind, there's no harm by doing that.

We test it, we sample it in the like, you know, in the pathology department, the pathology comes back.

My plastic surgeon will take you back a week later.

And usually they'll either do it in the office or they'll do it in the operating room, but it takes like 15 minutes to remove that nipple that's been affected.

It's really, you know, incredible how many young women are getting diagnosed with breast cancer.

And I mean, I've been in practice for 12 years, and I remember when I went to medical school and I graduated in 2004, we learned that breast cancer was a disease of the aging.

And I think the counseling today for women is a completely different counseling than maybe the one that my mom got as far as her breast surgery.

And, you know, she had a small tumor, she had a lumpectomy, she's 75 you know the younger women who have a longer life expectancy they want to reduce that risk of local recurrence although there is no survival difference right but they're always worried they're like well I'm gonna have to get an MRI a mammogram am I gonna have to do more biopsies and a lot of the biopsies and a lot of I mean the mastectomies that we do are not really for oncologic reasons they're really because the patients want peace of mind patients want symmetry and patients don't want to have a six-month follow-up with then followed biopsies and things like that because oncologically there's no difference.

A lumpectomy and a mastectomy oncologically have the same survival.

They have a slower, a lower recurrence rate, but the survival is not impacted by my surgery by doing bilateral mastectomy.

Now, when we talk to younger, and we'll talk about that if you have, if you want to talk about it, but when we talk to younger women, what they want to do is, if I'm going to have a surgery, I want to look symmetric.

I want to be able to get naked and have intimacy without feeling like I have to explain myself or be unsure or be shy.

I mean, you know, I remember when I got divorced, I was like, oh my God, how am I going to date again?

You know, I just had babies.

My body's, I'm in my 40s, like my body's changing.

Imagine going through that and then also like having to make this decision or being single or being, you know, in a relationship and having, I mean, I don't know, just insecurities about your like your sexuality after and dealing with all of that.

These are things that we talk to patients about.

And I significantly feel that that's one of the things that I thank my mentor for because she brought that to light to me.

She would talk to women about it, she would talk to me about it.

She said, You know, we are touching women's lives, and make sure that that touch that you do is the best touch that you will ever do because it's the one touch that will be there in their lives forever.

But if they have great outcomes, that's the biggest satisfaction and the biggest gift that I can do to a patient to give that to them, you know, to give them that opportunity to be cancer-free, to look and feel good.

Yes, yes, uh, okay, you just touched on a big part of, and I'm going to try to

speak in late people terms and then you tell us, you tell me where I'm getting it wrong.

Okay, so your first decision, which may or may not be a decision for some people, it was not for me, but if you're going to have to have breast cancer removed, your first decision is

this one.

Is it going to be mastectomy or lumpectomy?

Okay, as I understand lumpectomy, it is lump, right?

We are going to go in, we're going to physically remove the part of your breast that is cancer, and we are going to leave the rest intact.

So, you may have that as an option, or you might not.

I did not because my breasts are not big enough to have anything left over if that were to have happened.

But depending on the size of your breast, depending on the relative ratio of breast to cancer, that's a very different

analysis

also impacted by that is what you just touched on which is even if i was a candidate for a lumpectomy i don't think i would have chosen it because

i

really appreciate the peace of mind i have now in terms of take all the breast tissue out I don't have to be have it hanging over the back of my mind.

I am going to need to go for MRIs every year, and I'm just going to kind of be waiting for this

fearsome threat to descend upon me again.

And so, are those, what are the other considerations?

Because since I have no breast tissue left, I don't even get mammograms or MRIs anymore because there's there isn't anything left for me to be looking at.

So, other than the like ratio of cancer to total breast tissue

and

the continuing monitoring that needs to be done to the extent you have a lumpectomy and therefore you still have breast tissue to monitor.

Are there other considerations that people have when they're making that decision?

So I, when I see patients in the office, I see patients who come just first for me and then they come second, third, fourth, fifth opinion.

And I think one of the things that they go by, and I'm very data driven, you know, I like numbers, I like percentages.

So, normally, what I tell patients is that a lumpectomy patient obviously has residual disease, I mean, residual breast, and the risk of cancer coming back to the breast is 0.5 to 1% per year, and it's cumulative.

So,

0.5 to 1% per year.

So, it's like compounding interest.

It's like

the first year, so you have 1%, the second year, it goes up and up, but that's a pretty low number.

If you get all of that out, 0.5 to 1%

each year compounding.

Okay.

Compounding over the years.

Some women feel like that is too much for them.

And the risk of local recurrence from a mastectomy is up to 8% in your lifetime.

So that's from now till like, you know, the end of time, because we do remove 98% of the breast tissue.

There's 2% of breast tissue that is, it's, it's entangled within your subcutaneous fat and skin.

I would say you have like very little of it because you're but but some women it just depends on your BMI it depends on your body habit is these the the skin flaps thickness is really relative to the the thickness of your skin with your subcutaneous fat so women like you and I would have like smaller pretty thin flaps and then some women have a little thicker flaps ideally you don't want them to be like if you didn't have a mastectomy but you know most women have I would say about this much breast tissue like a subcutaneous fat left behind

and you're holding up like a millimeter of yeah something yeah okay so this is actually you cut off all the breast tissue.

This is the tissue that's basically connected to your skin

so that you can save your skin.

Yeah, keeping it clean.

So patients say, okay, well, for me, that local recurrence risk is too high and I don't want to live with that.

I'd rather have a mastectomy and lower that risk.

I still tell them, listen, there's no survival benefit because patients don't die of breast cancer in the breast.

Breast cancer recurrence doesn't mean that you're going to die of breast cancer.

Actually, most patients who have a recurrence

don't have metastatic disease.

They just have a recurrence that happens in the breast and nowhere else in the body, right?

So try to educate patients like that because they feel like if they have a recurrence, this is it.

The cancer has gone to other parts of the body and not necessarily.

So you, in that case, if you have a recurrence, you'd go back and do another lumpectomy or mastectomy at that point.

Probably a mastectomy.

That would be the indication.

So then the third thing is some patients are like, well, I'm going to have to get radiation.

In most cases, patients will get radiation after lumpectomy.

And some patients don't want to have radiation.

There's some downside to having radiation.

There's skin toxicity.

Now, there are patients that are going to have radiation when they have mastectomy because they have lymph nodes that are positive.

Their tumor is large.

And in those cases, I feel like a lot of those patients, they make the decision of a lumpectomy versus a mastectomy really based on that information that I just told you.

They want symmetry.

They want peace of mind.

They don't want to have MRIs.

They don't want to have any more mammograms.

So they make that decision, even though they're going to have radiation.

It's not the driving.

The driver is that kind of thing that they feel like it.

I mean, we counsel patients, say, listen, this is your risk with, this is your risk without.

This is what we would offer you with a lumpectomy.

This is what we would offer you with a mastectomy.

It's in my prevy to say, okay, where do you feel comfortable?

You don't have to make a decision today.

Go home, think about it.

Take my little sheet of paper that I write down with all the designs and the drawings.

Take it home, call me, and we can have another conversation.

This is not a drive by, I'm ordering,

and then I go home, and that's it.

The decision is made.

This is the big decision.

And so that's why I want to make sure that

I tell women out there that they should advocate to get options, choices.

Yes.

And then,

you know, the surgeon-patient relation, I always call that a marriage.

You date a lot and then you marry the right one.

But it's a long-term relationship that you have, and that you want to make sure that your patients are educated and they're empowered because it is also their body and their choice.

This is such a good point because it isn't because everyone has a bias, and my bias is against

future threats.

Like I want to operate from the lowest threshold of future threats.

And

that isn't to say, like, so in my case, I was like,

mastectomy is what I want.

And it's very clear from where I am.

And there's a thousand reasons.

I mean, that's a really, really solid points for people to consider.

If you are a lumpectomy versus mastectomy,

first of all, your candidacy for that is going to depend on the size of your breast, the size of your cancer.

You're going to want to consider your level of comfort with continuing monitoring and possible recurrence with the idea that the recurrence rate is

slightly higher with the lumpectomy, but we're still talking 0.5 to 1%

compounding per year.

10 years is 10 versus 10%.

20 years is 10 to 20%.

Okay, 10 years, 10 to 20%.

No, 10 years is 5 to 10%.

20,

10 to 20%.

30

is 15 to 30%.

Versus mastectomies is a flat rate, 8% for the rest of your life.

With the idea that if it were to recur, this is not a death sentence.

It is not a death sentence.

Yes.

Yes.

We go and deal with the cancer again

if it recurs.

Oh, I wanted to say this because a lot of people feel like surgeons,

we treat local disease.

We do not treat systemic disease.

The systemic disease treatment is very important for the patients.

The survival benefit is seen with treatment that is systemic disease treatment, meaning systemic, like if patients are invasive cancer,

they may get chemo.

If patients have estrogen progesterone positive invasive cancer, and if they haven't had a bilateral, you know,

they will have estrogen blockers.

If you have DCIS and you have a bilateral mastectomy, you don't need estrogen blockers.

But if you have DCIS and a lumpectomy, you will need estrogen blockers.

This not only impacts local disease, but it actually impacts survival, meaning taking those medications prevents disease from going anywhere else in the body.

and attacks those cells and reduces the risk of it going somewhere else and becoming metastatic, meaning impacting your survival.

And that's kind of one of the ideas that I always say when they see me and they're like, you're, you're, you say, I'm like, well, listen, I operated on you, but the saviors are really the medical oncologists.

They're the ones that actually treat the systemic realm and they're the ones that prevent cancer from going somewhere else with their treatments.

And that's why I'm actually telling patients that, you know, there's for that decision making also to be very educated.

Yes.

Because skipping some of those treatments does impact survival.

And, you know, kind of going out there and reading about it, but also with going to educated sources to make sure that they don't skip treatments that are necessary that will impact their survival.

So that is such an important point.

And for the lay person, the systemic issue versus

the kind of breast surgery issue, you are.

If there's terms like invasive, non-invasive, that kind of thing.

So there in my case, for example, all of the cancer was within the actual breast.

So, if you are then going,

if you have an invasive piece, this means that it either is a threat that it could invade the rest of your body, or

it already has.

And so, this is why this like this, this more systemic approach where you go to the oncologist and you say, I need chemo, I need whatever I need, because you're preventing what originated in the breast from taking over the rest of the body.

So to kind of clarify, so your breast main purpose is for breastfeeding, and you have ducts, which are little like highways.

Imagine little highways kind of like I-95 and then has little streets that end in the lobules.

The lobules are the infrastructure where milk is made.

So when cancer is within the ducts, which is the most common location for breast cancer to happen in those little highways or little streets, that's ductal carcinoma the in situ means that it hasn't broken through the that wall that barrier okay that barrier is called basement membrane but it's really like the bricks in your house and you had termites the termites are within the wall they haven't eaten up your walls invasive cancer doesn't mean that it's traveled anywhere it does have the potential like Amanda said but it just means that in that duct that wall has been eaten up by cancer and has broken through the wall.

And so, and that the same thing can happen in the lobules, where that lobular cells can break through the lobular wall and become invasive lobular cancer, which is less common.

So one of the things that I tell patients is just the decision about surgery is an important one because it's a permanent one.

The decision about systemic disease treatment, meaning estrogen blockers,

like some of you may have heard tamoxifen, aromatase inhibitors, they block estrogen.

What does that do?

It blocks your ability to feed the most common types of breast cancer, which is usually the 80% of women get estrogen, progesterone, and positive breast cancer, which are two hormones.

And the lesser common are the ones that are HER2 positive, estrogen, progesterone negative.

And then the least common, but it's the most aggressive, is triple negative breast cancer.

In those cases, those patients usually require chemotherapy and immunotherapy to treat them, to decrease the cancer that is in the breast from potentially going anywhere else in the body, body, like you said.

Now, in patients, when they see me, they're like, you know, everybody's wanting to take it all out.

And I always tell them, half of your decision is now, half of your decision is when you see the medical oncologist.

And because I do feel like there's people that get decision fatigue, and once they get to the medical oncologist, because they've gone through, like what you were mentioning, you know, how do you make a decision?

And then they're told to make other decisions.

Then they're faced with yet another decision to do.

And some of them are like, okay, I've heard too much.

this is too much information and I think one of the one of the things that I always tell patients is first of all yes ask for what you want you know if you are able to get it make sure that you get it

ask you know you know when Lori said that she had seen you and you know I think one of the things that I talk about is that you know a surgeon operates the community heals

And she found such peace by just hearing you and then realizing that you and I like knew each other.

She texted me that night and she's like, Oh my God,

I can't believe that I'm like going through this and it's you and I feel so relieved.

Not that she didn't feel relieved before, but I think having that, like finding her way in a place where she may have felt lost and finding someone who saw her and someone that she felt like was almost like a someone that took her in and said, you know, you're good, go do that.

That community is also very important.

When patients are facing this decision, exhaustion,

you know, unknown what to go, like what your sister and

Abby did, like

there's something wrong here.

You should go somewhere else, you know, and I see that often.

I see patients who their friends told them that wasn't like a good consultation.

Maybe you should go.

And I have patients that I tell them, listen, if you don't feel this is the right thing for you, go somewhere else.

Come, I'll help you get an appointment because that's the second thing.

A lot of people can't get an appointment with someone.

If they call the regular, it may take them weeks and that again delays their care.

So I'm always like, listen, I will hook you up with whoever.

Who do you want to go see?

Pick a name, I will call them, get an appointment so that you can go see them and get a second opinion and get more empowered with your own decision.

You know, I always say, This is your body, you're you ultimately make the decision about everything, by the way, about from the beginning to the end.

And we're just here to guide you to make you feel like you're heard, you're listened, and that we're giving you what you want ultimately, making sure that obviously it's oncologically safe and feasible.

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Let's talk about the direct implant because that is very uncommon.

Only 11% of the country does that.

Okay, so let me give the layperson's experience of what people might hear.

So

the first several doctors I went to, this is how it was described to me.

Okay, we're going to go in, we're going to do the mastectomies, meaning you're, they're taking away the breast tissue.

Then you're going to

go home and recover from that.

And you will have, because I wanted, you also can have, you know, flat,

you can just go with flat,

which is they call a flat closure.

You can go reconstruction, just flat closure.

For reconstruction, right?

No reconstruction, just flat.

But I wanted to have reconstruction.

So, assuming you want to have reconstruction, then they have to prepare for the reconstruction by having, oh my God, what are they called?

Inserts?

Expander.

Expanders.

So then

they can't just leave your skin by itself.

So they put like some expanders under your skin, which are not your

not going to be your permanent breasts, but just like temporary balloonish things.

They are plastic balloons that are placed.

They literally are plastic balloons.

Like silicone, kind of, and they put it in.

Silicone.

Okay.

I don't know.

I haven't seen one in many years, so I can't.

Oh, you're such a show-off.

I'm like, I haven't seen that shit in years.

Okay, so the expanders go in, and that is your body preparing for the second surgery, which is the actual reconstruction, where then they go in, they take out the expanders, they put in the implants if that's what you're doing, or there's also other options.

They can take body fat from the rest of your body and do your reconstruction that way.

So, that was how everyone explained it to me until I got to you.

So, I want to, I want you to tell the people

about direct to reconstruction because basically that means this going home and recovering and coming back for another surgery is not a thing.

I went in.

She did the mastectomies.

She and Dr.

Van did the reconstruction immediately, all part of one surgery, so that when I left that day,

my breasts were gone, my implants were in, and I had one recovery.

So

tell

us about this.

Why don't a lot of people offer it?

Who is candidates for it?

And why do you do it this way?

So I think it's been an evolution of my practice.

When I first started, we were doing like 50% implants, 50% tissue expanders.

And then I was at the University of Pennsylvania.

We did a lot of free flaps, meaning your own tissue reconstruction, like a tummy tuck.

They take the tissue and put it in your breasts.

And we would also do those in single stage, meaning at the time of the cancer diagnosis, we do the mastectomy, we do the free flap, okay, your own tissue.

And then as I progressed in my career, probably like my second, third year, I started to realize that it was unnecessary having the tissue expander.

Actually, my plastic surgeon said, you know, Lucy, I'm I'm going to stop putting tissue expanders because

your patients who we do implants on,

they do fine.

They haven't had issues.

And the tissue expander, it's a second surgery and it's really uncomfortable.

And I actually, you know, I felt like I didn't really have that.

I was taught that that's a decision that the plastic surgeon does, not necessarily a breast surgeon can bring up.

And so we stopped doing that in 2018.

We stopped, no, 17.

We stopped doing,

I stopped, in my patients were not getting tissue expanders.

They were having immediate reconstruction with direct to implant.

And I started to realize that patients' recovery was much better.

Obviously, they don't have to pay a second time to go around to have surgery for co-pays.

They don't have to take time off from work.

And so it was kind of an easy transition for me to come and say, you know, all of our patients are going to get direct-to-implant.

And the only time that we would do delayed with a tissue expander expander at that time was patients who needed radiation

if they wanted to put the free flap meaning your tummy tuck

we changed along the way because i said wait wait we could put an implant in they can get radiated and then if they want to do a deep they can do it whenever they don't they don't have to be like oh have a tissue expander and go back right away they can wait there's more time for the skin to heal from radiation the there's no contraindication for an implant to to be radiated.

Actually, it's kind of nice because it gives the full expansion to the skin out towards the outside, and the radiation oncologist can do their mapping and their planning appropriately.

And so

that's how the evolution of me kind of morphing into just simply our plastic surgeons offering direct-to-implant.

So I think one of the things that I would say is just I pushed the envelope in my own clinical practice to

get patients one surgery, one recovery, to minimize the trauma and make sure that I don't know.

One of the things that one of my patients said, you know, I went in, did surgery, and I look back and I don't have to go back in six months.

I have a scar that I can't see.

I feel like, you know, I like my breasts now better than I did before.

They're bigger because I had lost them with breastfeeding.

And every time I hear that, I feel like, you know, why not?

Why not offer that to patients?

And so, you know, I've been fortunate that my plastic surgeons um are on board and they're all about doing less surgery less trauma minimizing tissue handling and the emotional toll of like knowing that i was coming home from that surgery and being like this is my recovery yeah not i have to get through this recovery just to ramp up for another whole surgery and another whole recovery it's a very different psychological experience i'm sure if you're like well this is the first, this is the first marathon, I'm running another one next month.

Like that's and it's very hard.

And I will tell you, it's very hard.

I, like I said, I, I was doing it when I was a fellow.

I was doing it when I was a resident.

I did it being in my career.

And I think one of the things that I heard from patients was that they felt like it was a lot to go through.

And so even that's why we put implants on patients that are going to have deeps because we have patients that actually never come back to get their tummy tuck because they're like, I look good, I feel good, I'm done, I have an implant,

I don't wanna have another second surgery.

You know, when they first at the beginning came in with the idea of doing the tummy tuck.

Right.

And the tummy tuck thing, y'all, is that if people want to use their own tissue for their breast reconstruction as opposed to having an implant,

often it can be taken from other parts of the body and that is called a deep tissue reconstruction procedure right deep

diep which is deep inferior epigastric pedicle it's essentially named after the vessel where you're harvesting the blood supply and the skin from to move it but it's technically from the outside in what you see is the tummy tuck incision right because that's essentially what it is we're removing the tissue that you would remove in a tummy tuck procedure but with the connection to a vessel and we we reconnect it to a vessel in the chest.

We have a large volume of patients that come for that as well

for that kind of reconstruction.

The patients that don't want implants, but you have to be a candidate, right?

Not everybody's a candidate for a reconstruction.

Some women don't have enough tissue.

Some women have way too much tissue.

So it's almost like you have to have this perfect amount of

tummy to be able to preserve, to be able to do the procedure and to be able to do the reconstruction using your own tissue.

So

if I'm someone listening to this and the direct to reconstruction one surgery option has not been offered to me,

what are the reasons that could be true other than that surgeon doesn't do that or isn't skilled at that?

Like,

is, are there people who are not candidates for that?

And I'm not trying to throw anyone under the bus.

I'm trying to, I'm trying to think, I am a, I am a cancer patient who's, who's awaiting surgery.

I've talked to two surgeons.

No one has mentioned direct to implant.

And now I'm sitting here listening to this wondering why the hell not if

that's available.

So why wouldn't that be?

That's a good question.

I think it just has to do with practice patterns and

what your practice is like.

Okay, so they don't know how to do it is what you're saying.

I think it's just, like I said, it's.

You're being sweeter than I am.

I'm like, those Yahoos don't know how to do this, y'all.

Find someone who knows how to do it.

So I think it's one of those things that there are two schools of thought.

There's an old school of thought and then there's there's the younger school of thought like anna pellett in san francisco does it every day she just recently came out and said i have a breast cancer uh diagnosis after having cancer seven years ago and she went on her social media and said i am having a bilateral nipple spheromastectomy with direct to implant with resensation of my nipple and she is a breast cancer surgeon who does plastic surgery and does breast surgery

if that is what she's having herself.

And if I had breast cancer tomorrow and I needed to have a mastectomy, I would have direct implant.

Hopefully, I'll have a little bit of deep, maybe I'll get a deep, but I don't think I would mostly because I wanted the tummy tech to be done, but I don't think I will have that.

And then with the resensation, because why not?

Why not?

Okay, resensation, y'all.

This is a thing.

Okay, so we need to talk about resensation because this is also something that will not be offered to you likely.

Here is the bad news.

When you

need to have mastectomies, I don't know if this is true of lumpectectomies, but you tell me.

One of the tragedies of that is that you are going to lose sensation on your skin

of your breast and your nipples.

So it will be like

you have anesthesia and you can put your hand on yourself and you know your hand's there because you can see it, but you don't actually feel it.

Like you don't feel the sensation.

And most doctors, by the way, won't even tell you this is going to happen.

Literally, no one told me this was going to happen.

No one said, oh, FYI, when you have your mastectomies, you will lose any sensation around your breast whatsoever.

This is the default, which may or may not be disclosed to you.

There is a world of folks like De La Cruz who are

adamant that as a

just

baseline of care, we should not accept that you will never have sensation on your skin or your nipples again.

So they perform this resensation technique.

Tell us about that and tell us what's wrong with anything I said.

No, everything is right.

So actually, there was a New York Times article when I was probably beginning my career, if not my last year, my year in fellowship from New York Times, that was saying a woman, there was a story about a woman who said something, and that's kind of that pretty much what you explained.

Nobody told me I would be numb, and it was in the New York Times.

And I remember because my mentor, who I just

continued to bring up, because she was so incredible at like engraving all these amazing pearls of wisdom that she had learned through her life.

And I think us as mentors of the next generation, you know, should do the same.

And some of my fellows say, I still hear you screaming in my ear.

it's because I'm like you know my voice is really loud I'm Cuban so I'm very articulate and ornate and animated but one of the things that she mentioned to me it was that she brought it up to me one day she would counsel her patients about chest ball numbness now in that time we didn't do resensation and then I remember reading that paper that article from the New York Times and having one of my patients said you know dr.

Deletouze you had told me about it you had told me that I was going to have chest ball numbness mind you this was in 2016 we were not doing resensation I think it was around 2016 or 2015 that this article came out.

And obviously, I didn't have anything to offer.

And this was born out of Anna Pellett, like I mentioned to her, she's a great pioneer in the resensation.

And she brought up this idea because she had treated thousands of women just like myself.

And, you know, she hadn't been able to reconnect it.

And her husband is a peripheral nerve surgeon.

And so anyway, she started doing it.

We talked about it one day.

I was like, I want to do that.

Absolutely.

Like, I want to be like, I want to be the first.

I want to be the second, actually, because you're the first.

I'll be the second.

And I was like, we need to do this on everybody, but insurance wasn't covering it.

So, insurance initially was saying, Please just, can I pause you for a second, a moment, a moment of misogyny that we like to have during this?

Can you just

freaking imagine a world in which something was going to happen to men's testicles?

Oh my God.

Yes.

And

the standard of care

was: okay, first of all, we don't even need to mention it, that they're going to lose sensation in their testicles.

It doesn't seem relevant to mention it.

By the way, do you want me to really upset you?

You know that they put direct implants to reconstruct orchiectomy patients?

So they don't go around without a ball.

They have like a little ball that they pollute right away.

Oh, my God.

Oh, my God.

Okay, so the whole thing where they said, where like direct to implant on breasts is like this novel thing that very few people apparently do.

It is the standard of care.

I mean, so I've heard

a man walking around.

Or I've heard, so I've heard that they would put like an implant in.

By the way, I was having this conversation this weekend in this roundtable, and we were talking about direct to implant, and, you know, we were asked to raise our hands who did direct implant and who didn't.

In this room, a lot of us did direct to implant, but we have very different practice patterns.

Like we're from all over the country.

So it was very interesting to see where and when people are doing direct to implant versus not and in their practice.

And one of the one of the surgeons said, yeah, of course, but let me remind you that orchieectomy patients get a reconstruction right away.

And we're here delaying the reconstruction of women.

And I was like, oh, I didn't know that.

That was, that's actually a good point.

And so you're right.

I mean, I think, you know, one of the things that I think we have as a community of breast cancer surgeons, but also patients, is that our voice, we are getting louder and louder.

And that's why I said thank you so much for your voice, because women need to hear this.

Women need to be educated about this.

Women need to ask for better and more and you know explanations.

There are patients who are coming in and asking questions like you did, asking why not, why should I?

What is the science and the reasoning behind it?

They don't just kind of stay with the answer and take that as a final answer.

They go out there and they do the research.

But for those that don't, One of the things that I say is make sure that if you leave from there and you feel like you haven't been given all the options, you should go somewhere else and get more options that you feel are more in tune with you and aligned with your thought of what your plan should be as far as your outcomes.

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Can you tell us the actual process, just briefly, about resensation, how it works, and is this something that is still a major challenge to have covered by insurance?

Because

I can't imagine, like, you did the resensation for me.

It wasn't even like you were like, oh, you're getting the resensation.

I was like, I don't know what that is, but that sounds real good.

I'd like to have that.

Yeah, I don't think I gave you an option.

I was like, we do it for everybody.

Yeah, which is, which it should be for everyone.

If there is an option by which you can retain sensation of your sexual organs, it should not be only for those who know to ask the question, hey, can I retain sensation of my sexual organs?

So it's interesting.

A lot of this, a lot of this idea of preservation, I think that surgery is moving away from radical surgery to more thoughtful surgery because patients are living longer because our systemic disease is better.

I mean, our systemic treatment is better.

So patients are not dying of breast cancer as much as they were before.

And we have better treatments today.

So we need to make sure that the next 30, 40 years of life that they have, they're good years of life, that you can continue to be the person that you are by, you know, getting it, getting dressed in the morning and not thinking about the cancer that you had that changed your life completely, but that you had cancer and that you survived it and that you're able to do everything you want to do and nothing is stopping you from doing that.

And so I think one of the things that resensation provides it's not a perfect science like nothing in medicine is but it gives you the most

the the closest thing to potentially regaining that sensation so that when you get dressed when you're blow-drying your hair and doing a curling iron and your iron falls you burn yourself and you don't realize that you did that you can actually say oh my god i burned myself and and and take care of it because some people may not even notice i got burned I've had patients who burned themselves, have burned themselves with curling iron and they didn't realize they had a burn in their chest Or they fell asleep with a heating pad and they had third-degree burn.

And so these are things that I,

I mean, these are things that can happen, right?

But the most important thing, I have patients like, I want to feel my kids hug me again.

I want to feel my husband caress my breast again.

And these are things that matter to me.

I'm a mom.

I have a partner.

I want to be able to feel fully as a woman, or at least be given the opportunity.

Because as I mentioned, it's not a perfect science, but if I am not giving you that opportunity, then it's a zero science versus the percent of patients that do regain sensation.

And so, I think one of the things that we're trying to do, I mean, definitely all my fellows get trained when they leave, they're able to provide it to patients.

So, usually, what we do is when we're in the operating room, we find the nerve.

There's a nerve that goes directly from your chest wall to your nipple.

That's usually a branch of the T4, so meaning the level of the thoracic, so the spine level 4, which innervates this area here.

We try to preserve, so this is what the structural mastectomy is, we try to preserve the, they're called something called in perforators, meaning the vessels that provide blood supply to your skin.

If you impact those vessels, they're like the main highway of blood supply to your skin.

If you hit those vessels, you can actually hurt the blood supply and potentially cause something called necrosis.

So when we're in the operating room, which means the skin basically dies.

The skin dies.

Okay.

So when we're in the operating room, I'm very thoughtful to look for those perforators and preserve them.

Right next to the perforators are usually superficial nerves that if we don't touch, you will regain sense, I mean, retain sensation on the lateral portion, okay, on this area here.

Okay, and then there's right under your armpit.

Yes, and there are perforators that come here that you can see them.

If you avoid them and you don't hurt them, you then allow some of the nerve, like superficial nerves, to stay up here in this area.

Okay, like right above your breast.

Yes, we're not leaving tissue behind, we're preserving the breast like blood supply.

And we're taking the breast in its capsule around it.

Okay, the breast has a capsule, almost like a little,

when you see it, you can't unsee it.

It's almost like a way that the body differentiates subcutaneous fat from breast tissue.

And it almost peels off when you're in the correct plane.

When you see that, you'll see usually the blood vessels.

And that's what the structural mastectomy that we perform at Georgetown is.

It's really creating the perfect plane of dissection, preserving the blood supply, not by preserving breast tissue, but really preserving the blood supply that irrigates or provides blood supply to the skin, the nipple, and the lateral and the medial and the medial portion will preserve the sensation.

The nipple in sensation we can't preserve because obviously you have to cut through.

And so what we do is we find the nerve in the chest wall.

And when we find it, we cut through it, cut it, mark it, and then the plastic surgeon comes with a a nerve graft.

That's what the insurance pays for, the nerve graft, which is a cadaveric graft from somebody who's donated to science or to us.

And we connect it to the nipple.

And the nerve itself will try to find its match.

So the moment that the nerve that we've preserved,

the stump, keeps on firing, they're called synaptic signals, meaning it's signaling the brain.

It wants to find its,

I call it always the

its soulmate.

It's trying to find a soulmate.

So it's calling out for soulmate and then eventually it reconnects.

But it takes usually between a year to two years for you to regain the full sensation that you're going to have after surgery.

So it's not a process that happens right away.

But I have patients who have done it and they're like, you know, I have sensation pretty quickly.

And then I have patients that are like, you know, at two years,

but they're able to feel, they're able to have sensations.

Is it completely 100% perfect?

No.

I have patients that have a spot here that say, you know, I have never really regained sensation there, but I do feel in my nipple.

Or I have, you know, a little area here that's like a numb patch.

But in most cases, patients are able to have some sensation that prevents them from getting burnt, from getting cold.

You know, some patients put ice or anything.

I always tell them, don't put ice, don't put heating pad, because if you don't have sensation, you can burn yourself.

And so that's why to me, when this was able to be done, and now that insurance, most of the insurance cover it right now.

there are a couple of insurers that don't cover it.

There always are,

but what we try to do is offer it to everybody.

We do the pre-approval process, we submit it.

I've had some patients who have even gotten it, even if the insurance doesn't cover it, we submit like a special request for it

and then try to do it.

Well, I have full skin.

As of like two weeks after,

every part of my skin, full sensation.

Well, you also have like no subcutaneous fat so that's very good because you have so that's like a double extra you know and I have some yeah that's like a that's a good job put it on your really good thing by the way Amanda a lot of our patients do have sensation you know yeah they have more sensation than if they would have never and by the way it takes 15 extra minutes of our lives 15 extra minutes to give you a whole life of feeling how about that I tell people all the time my patients come through not through the central scheduling They come through social media.

They come through friends of my patients.

That is, I have a grassroots approach to my clinical practice.

And I think if we continue talking about it and opening the conversation with women like myself and Anne Pellett, who talk about it all the time, we try to educate women.

I think the next generation of women who get breast cancer.

will be a different story.

They will all be offered all the options, the bells and whistles, like I call them, of breast cancer treatment as far as surgery goes, which they deserve.

And so I think one of the things that I am very happy about is that the next generation of breast surgeons are learning that.

But I think in the next 10 years, it's going to be, you know, it's going to be a significant progress because a lot of people are talking about direct implant.

We looked at the data, only 11% of institutions do direct to implant in the country.

11%.

11%.

And the revision rates are up to 50%, meaning the amount of surgery women need to have after mastectomy is up to 50% of the time they're getting like revisions.

Is that a question you would ask a surgeon?

What is your revision rate?

I would ask, so I think one of the things that, you know, when we talk to plastic surgeons, when they do a deep, for example,

we always have patients say, well, how many deeps do you guys do here?

a year?

And I think it's a valid question to ask your surgeon, how many nipple spheromastectomies do they do?

How often do they do direct implant?

What is their nipple necrosis rate?

Which is another option, another question to ask, because these are based on outcomes.

And, you know, most of us know our outcomes, and we should know our outcomes.

If we're having a high rate of nipple loss because if they nipple dies, then that's something that we should know, right?

And so, those are questions that are valid questions.

You know, the reconstruction, why you do one to versus two-stage, again, I told you, the minority of people are going to have that discussion and be told tissue expanders.

So go to a place where they do direct to implants.

If you would live near a place or if you can travel somewhere where there is direct implant, I would highly recommend it because you're having one surgery less.

The other thing is, as far as the

experience of the surgeon doing nipple spheromastectomies, right?

We do nipple spheromastectomies, I don't know, 98% of the time in patients and i'm not just talking about the nipple spheromastectomy of a small breast i'm talking about that complex nipple spheromastectomy that i told you about that women who have really large breasts who come to us because they have been told that they cannot keep their nipples because their body habitus and their breasts are big and so we offer that we offer that to these women and i'll tell you they're very happy because they're getting you know, a reduction, a lift, and a mastectomy all at once with one surgery.

And we do it all the time.

So it's very satisfying to see these women and to see all women that are able to get reconstruction and feel whole right after surgery.

Like two weeks after surgery, they're pre their, oh, two weeks after surgery, I was like, I went to work out.

You were like, I'm ready to work out.

Let's be, let's be clear, Dealer Chris.

I haven't worked out in five years.

I was, I was doing my regular life.

Oh, that's what you were wanting.

You were like, can I be active?

I was like, I don't know.

Okay, nobody may have confused you with another one of my patients who was like texting me at 10 days.

My drains are putting out 20 CCs.

Can I do yoga with the drains?

I was like, No, you cannot do yoga with the drains.

Give it a beat.

No, that wasn't me.

It wasn't you.

Okay, it wasn't you then.

Well, she reminds me of you because she was like, very like, I'm ready to go.

I'm like, listen, you have to stop doing what you're doing.

Like, you're like doing all these things.

She's like, but I'm home.

I'm like,

I love it.

Okay, I just want to make sure because we've talked for so long about nipple sparing.

I just want to put, I just want to say something in regular people's words.

and you tell me if this is right.

So in my case, my,

by all the scans, it seemed like my cancer was so close to the nipple that the assumption was, you will have to lose that nipple because we are worried that the cancer is going to bleed into the nipple and therefore you'll have to lose it.

Your approach was, and that, so it was kind of preemptive.

It was like, that was the assumption.

It's preemptive.

We're not going to be able to keep it.

Your approach was, you're right.

We might not be be able to keep it but here's what we're going to do we're going to go in we're going to do the surgery we're going to take out the breast tissue then we're going to do the analysis of the pathology of the tissue that is closest to the nipple and this is where a lot of these words come when you're here about margins like they take the the they take little slices of the tissue that are closest to the nipple or to whatever area you're worried about.

In our case, we're talking about nipple sparing, so closest to the nipple and they put it under a microscope and they say, okay, look, here's where the cancer ended.

How much space do we have between where the cancer ended and the tissue that we cut off?

So in other words, if that cancer went all the way up to the edge, that is too scary of a risk that it has already infiltrated the nipple.

Or is there enough margin?

And that's where the word margin comes from.

Is there enough margin there that we see a wide enough gap between where the cancer ended and where we cut this tissue to know that it didn't jump to the nipple and therefore you can keep your nipple?

So, your approach was instead of

preemptively going in and taking it,

we're going to wait

and see what the pathology says.

We're going to look at the data after the case because we can always, if those margins look murky and dangerous, take your nipple after the fact rather than take it preemptively.

And in my case, my margins were clean, and that's why I got to keep my nipple.

Absolutely.

Is that correct?

Absolutely.

Yes.

So I assume everybody's innocent until proven guilty.

Thank you.

What did my nipples ever do to you?

I know.

So all nipples are innocent until proven guilty.

If they're guilty, they're gone.

That's what it is.

That's literally my theory because I will tell you, I have had in the last couple of months, I've had a couple of patients like that.

And one one of them had stopped lactating for months i would say like over

i think it was like about 11 months and when i went in there the the mri had shown stuff towards the nipple when i went in there there was still breast milk and she i was very surprised because she had stopped breastfeeding for 11 months and there shouldn't be that much milk but there was a lot of milk and when i went back in the pathology it there was all the lactational changes that were going to the nipple.

It wasn't cancer.

Her cancer was in the upper inner quadrant of her breast.

And when I reviewed it with one of her other physicians who saw her after for treatment, she questioned that.

She goes, Weep, but you did a nipple spheromsectomy and she had an area of MRI.

I said, Listen, I have reviewed this pathology with the pathologist.

They're all lactation.

I mean, there was milk everywhere when I was operating on her.

So, yeah.

So, they thought the milk was cancer, so they were going to have to get rid of it.

So, there was a lot of like fibrous tissue that was in the breast from her having breastfed, along with milk that I found in the operating room.

But what my point is that not everything that is picked up on the MRI is cancer, right?

And so, if we assume that all of these women have nipple cancer at the nipple, which is not the most common location of breast cancer, most common breast cancers appear in the upper outer quadrant of the breast, then we are taking unnecessarily these nipples.

And is that, is that, because that goes to my last question about innocent until proven guilty, is that how you feel about the sentinel lymph node?

Oh, for the details, yes.

No, so let me just, I I can answer this very quickly or very specifically.

So in olden days, we used to remove lymph nodes for anybody undergoing mastectomy.

If they have

lymph nodes are right under your armpit.

The idea is the road travels, cancer would travel directly from your breast.

Its first stop would be the lymph nodes.

The lymph nodes would feed it to the rest of your body.

So super scared of it being in the lymph nodes because that is how it's going to go systemically to the rest of your body.

Exactly.

And so

for DCIS, which is stage zero breast cancer, it has not crossed the barrier, as I mentioned before.

It's all within the milk ducts.

Those cancers have very, very, very, very, very low, whoa, whoa, whoa, likelihood of going anywhere.

And therefore, the likelihood of them going to the lymph node is really irrelevant.

Like we don't need to sample lymph nodes.

We never sample lymph nodes for patients with BC.

I'm not going to say never, never is a strong word, but we usually don't sample lymph nodes for DCIS under a lumpectomy who get a lumpectomy because if they have invasive cancer we could always go back and do a lymph node because all the road maps all the roads have been you know they are preserved but when we do the mastectomy we remove 98% of the breast tissue including breast lymphatics meaning the lymphatic drainage to the axilla so the breast is a gland that drains all their lymphatic system which is the way that we clean infection and we clean out our immunity is to the axilla

So if the patient doesn't need to have lymph nodes removed, we try to avoid it because there's a risk of arm swelling or lymphedema that's 5%.

Lymphedema may be permanent.

So once you have it, you may not get rid of it.

You can only treat it.

Okay, so one of the things that we use at Georgetown is this technique called Magtrace.

Magtrace is an injection that is a small particle of a metal part, not metal, but it's a fluid that has a small particle that is capable of traveling through these tiny little channels of lymphatic and kind of lodging themselves into the lowest lymph node of your lymphatic chain or lymphatic.

I call it like

the grapes of a vine.

The lowest one is the one that we're trying to pick up with this injection.

Because that would be the first place the cancer would go.

Yes.

So then we stain it with this mag trace, which is an injection that we do when you're asleep, you're not awake, you don't have any pain from it, you don't have to go anywhere to get it done, you get it in the operating room.

And also, we do the same for like when we do lymph node surgery.

We do the injection in the operating room when you're asleep, so you don't have to be awake for it, you don't have to be injecting your nipple, you know, while you're awake, which is really uncomfortable, even though people say that it doesn't hurt.

I would say those are men that say it doesn't hurt because it's not being done to their nipple.

But we do it in the operating room, so we do that, we stain the lymph nodes, and again, like I told you, Amanda, if it comes back that you have invasive cancer, we'll go back and take out lymph nodes.

But why do an operation that you may never need?

Since we've started using the MAGS trace, we've saved 95% of women having lymph node surgery for DCIS after mastectomy.

That's literally one in 10 women or 0.5 women, every 10 women, saved and like needed it.

So imagine removing 95% of lymph nodes that never need it to be removed.

Or one out of, you know, nine, 10 out of 10 women, instead of removing one out of 10 women, that actually need that lymph node information.

And actually, there's now now new clinical trials that show that if you qualify, again, ask your doctor, but not everybody with a very early stage breast cancer may even need a sentinel lymph nobiopsy.

It's called the sound trial.

Again, these are very much niche things.

I want you to discuss it with your doctor.

Still, the standard of care is to getting a lymph node if you have invasive cancer.

For DCIS, if you have a mastectomy, we recommend that you use MAGTRACE injection, which is

for a delayed sentinel lymph nobiopsy.

So if if you have DTS, your lymph nodes are also

innocent until proven guilty.

Exactly.

So we are going to put the dye in.

So we have tagged them.

If they are guilty, we are ready to take them in.

Okay.

But we're going to let them be innocent until we know we have an invasive element and that will save you.

Because honestly, my lymph node biopsy was

terrible.

Like it, it.

it didn't it wasn't great so don't mess with them if you don't need to be armpit after surgery Some people develop cording.

Some people, you know, like I said, you can develop lymphedema.

So it's not a naive procedure to just do a simple lymph node and remove it.

You know, I don't want anything removed from my body if I don't have to have it removed.

And lymph nodes are one of those things that for DCIS with mastectomy, using the MAG trace injection to map the lymph nodes for a delayed sentinel lymphobiopsy has been

really

changing in our practice, practice changing for all of us at Georgetown.

Dayla Cruz, we love you.

You're probably late for another surgery.

I'm so happy.

I have 20 patients in clinic who showed up.

Oh my God, go, go, go, go.

I love you.

I'm grateful for you.

You're the best.

Bye.

Thank you.

Thank you.

Thank you.

Thank you so much.

Period.

Thank you.

And I'll tell Dr.

Phan that you say hi.

Oh, please do.

I love it.

Bye.

Love you guys.

Okay, take care.

Bye.

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