 Thanks for having me and I'm so glad that you're all joining us for this discussion about breast surgery. So just some information about myself. So I went to college at Virginia Tech and I majored in biology. I then went to medical school at the Edward Vi of Virginia College of osteopathic medicine. I did my residency in New Jersey at UMDNJ in South Jersey, which is now renamed Rowan. And then I did a fellowship in breast oncology at St. Luke's Roosevelt and Beth Israel Medical Center in New York. I've worked at Riverview and Bayshore since 2014 and I'm the medical director of breast surgery at the Bayshore Medical Center. And both of our programs are NAPBC accredited, which is a national accreditation program for breast centers. It's a very rigorous evaluation of the centers of all aspects. So I will talk about that a bit later too. Today we're going to talk about reasons for needing breast surgery, different types of breast surgery, some questions to ask before your operation and coordinating care with your other doctors. So why is this important? Well, it's because breast cancer and breast issues affect a lot of women. And eight women will develop right of your family members or somebody, you know, it's something very common. And saying my internet, are you having any internet issues with me? Caitlin, just let me know. Okay. Okay. So it's a very common issue. So which is why it's such an important topic. So the American Cancer Society estimates that there will be 287,850 new cases of invasive breast cancer diagnosed this year. They estimate over 50,000 new cases of ductal carcinoma in situ will be diagnosed, which is stage zero breast cancer, just in this year. And luckily, most of these women will be diagnosed at an early stage, so stage zero one or two, about 66%. And this is important because it means that there's an improvement in their survival rate and then usually less extensive treatment is necessary for these women. But unfortunately, women are still dying from breast cancer. And so the estimate for this year is 43,250 women. And luckily breast cancer survival is improving. There are now more than 4 million women in the United States alive today who have a history of breast cancer and this number is just increasing every year. The five year survival does depend on the stage when they're diagnosed. So it's a localized disease, meaning early stage breast cancer, located just in the breast, their survival five year survival rate is 99%, which is great. It's a regional disease which is where it started to spread to the lymph nodes. So this could either be a high stage two or a stage three, the five year survival decreases down to 86%. And for women who have distant or metastatic disease, the five year survival is 30%. So what are some of the reasons for needing breast surgery. So just to give you a little background in the history of breast surgery. Up until the 1980s screening mammograms had really just first been introduced, they were only around for a few years, and we're not widely adopted yet. And some of the clinical trials were still ongoing at that point. So not many women were getting their mammograms in the early 80s. The many needle biopsies for breast issues were not available yet. Breast culture sound was not used yet, which is a very common tool for us these days. And the breast surgery that was performed. It was really the main way to diagnose breast issues and so it was performed for a whole variety of breast masses, mainly because they couldn't really figure out the diagnosis until after surgery. The diagnosis was either determined during surgery by having a pathologist look at it or just from the surgeon looking at it, or soon after surgery. So there was a lot of questions of what was going on even going into an operation. And then some women actually went into surgery not knowing if they'd be having a lumpectomy or a mastectomy. And I've had even some of my patients saying that when they had breast surgery back in the 70s and 80s that they they consented for both a lumpectomy and if necessary mastectomy so kind of a scary thing to not know whether or not you'd be coming out of surgery with a breast. Luckily, we can do a lot more with our diagnosis these days so there's a lot more knowledge before even going into surgery. So a lot of advances in the diagnosis of breast cancer and breast issues percutaneous needle biopsies are really performed most of the time and gives us a lot of information before surgery. If a lesion is benign on a needle biopsy then a lot of times this surgery can be avoided. If the if the biopsy shows it to be cancer or malignant, then it really helps to give us a lot of good information to help guide the appropriate treatment. It gives us some information on the staging and what type of surgery to do how extensive the area needs to be excised, whether or not lymph nodes need to be evaluated. It gives us a good idea of whether or not chemotherapy would be necessary. And this is important to know because some women need to have chemotherapy before surgery. So really important to know because often their survival will be improved by having some of that treatment before the surgery. Also it'll help us to know whether or not a patient needs endocrine therapy which targets the hormone receptors on certain cancer cells. And it also helps us to know whether or not a patient will need radiation. So a lot of this information can be determined even before somebody has surgery. So it's really helpful for a patient to know not only are they having the operation but what to expect in a couple months afterwards. Our breast imaging has also greatly improved. We now have digital mammogram and tomosynthesis, which is 3D mammogram, which really gives us great images of the breast tissue and helps to determine the extent of disease. And if there's any other areas of concern, ultrasound is very effective for imaging certain breast lesions and sometimes ultrasound can see something that the mammoth might not be able to see. And also we have breast MRI is a tool which is also very sensitive for detecting breast issues. So, some of the reasons for needing breast surgery are could actually be benign. And it could be very appropriate to have surgery for benign reason reason. One of those reasons would be a fiber adenoma, which is enlarging. Fiber adenomas are very common benign lumps in the breasts really almost every woman has them. Just if you don't feel them we don't go searching around for them because they're really not a risk for developing breast cancer. But sometimes these fiber adenomas can continue to increase in size. You can start to feel lump in your breast or they could grow rapidly and they can sometimes become uncomfortable. If it's a fiber adenoma that's enlarging then often we'll take it out to help to avoid those issues. Or if there's any concerning findings with the imaging appearance of it then we would remove it to make sure there's nothing else involved with the fiber adenoma. Sometimes you could get a breast infection or an abscess which is a fluid collection from an infection. It could happen during pregnancy or breastfeeding or really even other times during your life. And often these infections can be managed just with some minor procedures in the office but sometimes if it's extensive we might have to do surgery for it to help the infection to improve faster. Another benign reason is something called axillary accessory breast tissue. There's a lot of normal variations of anatomy with the breast. One pretty common thing is to have extra nipples located that a lot of women just think they're just like a skin lesion they're really not bothersome. But then one of the other normal anatomy findings is some extra breast tissue that's located in the armpit area so that tends to be the most common area. It almost forms like a lump there and can become very uncomfortable. It can increase in size, especially when a woman's exposed to more hormone variations. So often women will notice this after they've had a pregnancy and then the armpit area will get pretty swollen and it can be difficult to get clothing to fit in that area. And sometimes it gets to the point where we would actually remove it with surgery. So when women come to see me for this we really go over the risks and benefits because it is an operation and sometimes scars can cause discomfort. So we really make sure that they're at a good point to have this area removed. But I found that really once a significant area that the surgery really improves their quality of life. So it's something that you don't hear about too much and a lot of women don't even realize that it's actually part of the breast tissue but that could be removed even for benign reasons. Another benign reason is something called a discordant lesion. So that's when a woman has a percutaneous needle biopsy after either a mammo or an ultrasound or an MRI and the biopsy comes back benign. But then when the radiologist is looking at it, they would have expected it to show something. So either like some abnormal tissue or a cancer or something else like that to describe the finding on the imaging. And so in that case it's considered discordant because the imaging looks very abnormal but the biopsy came back benign so they don't match up. So it doesn't happen too often. I'd say maybe 1 or 2% of the time. But it gives the radiologist, it gives them that extra tool to be able to say you know our needle biopsies are very accurate but sometimes it might not give us the most accurate diagnosis and we really should remove it with surgery. And so this is helpful because a lot of times when we remove it with surgery there's actually something abnormal in the area. So some women come to me with that type of lesion and it's always a confusing situation because the needle biopsy did come back benign. But then I show them the images and I explain exactly why this is something concerning and then after some discussion they understand why a surgery be necessary in that case. And another reason for needing surgery would be this category called atypia or high risk lesions. And so this is something that not everybody hears about but as a breast surgeon I see this very commonly. So this is when the excision of certain lesions is recommended due to the risk of upgrade to breast cancer. So there's certain findings in the breast tissue that we know lead to a higher risk of developing breast cancer in that area. In that case we remove them so that it helps to prevent a breast cancer from forming or if there's a tiny breast cancer hiding nearby it makes it helps us to get it out before it advances too much. So one of those lesions is something called an intraductal papilloma. This is a small polyp that can form an adduct. Often they're very soft so they don't typically form a lump and it's something that we pick up on breast imaging or sometimes it's actually the initial sign could be that a woman's having nipple discharge. So the papilloma can cause irritation of the inside of the duct and that can cause nipple discharge. And then in order for the discharge to stop we remove the papilloma with surgery. There's also something called a radial sclerosing lesion which you might hear called a radial scar. It looks like a scar on imaging and pathology but it's not truly scar tissue. But we can often find these near a breast cancer and so we're very cautious with everything with the breasts. And so if we find radial sclerosing lesions, usually we recommend removing them to make sure there's no breast cancer hiding nearby. Another type of atypia called atypical ductal hyperplasia. You'll hear that abbreviated ADH and that's a precursor to breast cancer. It's where an abnormal cells start to form inside the ducts. And when we find that on a needle biopsy, there's about a 20% chance that there could be a breast cancer nearby. And so I almost always recommend surgery for these lesions just because the risk of breast cancer nearby is pretty high. There's also a category called lobular carcinoma in situ which is somewhat similar to the atypical ductal hyperplasia where it also has a high risk of there being breast cancer located nearby. And this LCI is it has carcinoma in the name but it's not truly cancer. It's a high risk lesion. It's just something that wasn't quite discovered when they, when they initially found it as a pathology term they thought it was more like a breast cancer but as we've studied this over the years we found it doesn't exactly act like a breast cancer but more of like a precursor to breast cancer so we're very careful with both of these types of lesions. So having biopsy showing either the atypical ductal hyperplasia or the lobular carcinoma in situ, not only do we have to address it when we find it at those spots, but then going forward it means you have a higher risk of getting breast cancer in either breast in your lifetime. So then we start high risk screening to help to detect something else that might come up or that way we can catch it at an early phase. And then another reason for breast surgery is from malignancy or for cancer. So, surgery is often used to treat someone who's initially been diagnosed with breast cancer. It can also be used to treat a breast cancer recurrence. So there's a small chance that a breast cancer can come back to the same breast or somewhere nearby in the breast or to the lymph nodes and so we can remove that with surgery also. Surgery can also be performed more in a palliative fashion where a woman has advanced breast cancer but it's starting to cause some issues. So I can start to cause a wound when it gets very advanced so surgery could help to fix that. Or also surgery could be used to help obtain more tissue to get a more accurate diagnosis which will help to guide treatment. Those are decisions that are made in close discussion with the patient's medical oncologist because the timing would depend on coordinating with their medical treatment. So what are some of the different types of breast surgery. So the main types of breast surgery are an excisional biopsy, a lumpectomy, a mastectomy which is removal of all the breast tissue, a central lymph node biopsy and an axillary lymph node dissection. So an excisional biopsy is performed to excise a lesion in order to obtain a full diagnosis. So very similar to a lumpectomy but the patient does not have breast cancer is not known to have breast cancer. So usually the diagnosis that we have going into surgery is either something unknown so like a discordant lesion. It could be something benign like a fibratoenoma. It could be one of the different types of atypia, or it could be a high risk lesion. A lumpectomy is very similar performed very similarly just for a different reason to the excisional biopsy so lumpectomies performed when we know there's a breast cancer. So, this is usually an early stage breast cancer that's localized within the breast. The tumor needs to be small in relation to the breast size. If it's covering a wide area in the breast, then it'd probably be better to do a mastectomy to remove more of the breast tissue to make sure we get the breast cancer out. Also it's important that there really should be pretty minimal change the shape of the breast after a lumpectomy. So if removing the lumpectomy causes significant distortion to the breast tissue a lot of scarring in order to obtain good margins, then it might be better to do a mastectomy. And typically with a lumpectomy in order to protect the remaining breast tissue on that side, usually radiation is recommended. And so the patient does need to understand that upfront that they that the radiation will likely be recommended so it's important that they agreed to that step in the treatment, which luckily is well tolerated. But if they were refusing to do radiation and a lumpectomy might not be the best choice for them. A lumpectomy can also sometimes be performed after a patient has had neoadjuvant chemotherapy, which is when they've had chemotherapy prior to surgery. Often this type of medical treatment can shrink the size of the tumor. And so if there's signs of a very good tumor response, then something that initially was very large and would have required a mastectomy, it might be possible to have a lumpectomy. But not all the time I usually try to tell the patient upfront whether or not this could be a possibility, because sometimes even if they have a good response, we might still have to do a mastectomy for various reasons. But if it's a possibility then it's another good reason to have that that chemo upfront. So it's important that the patient understands that after surgery they'll be going for additional imaging so definitely their annual mammograms, but often will perform imaging every six months for a bit depending on how the scar tissue looks and if there's any areas of concern. Sometimes they'll also be getting MRIs in addition to the mammogram or maybe ultrasound. So it's important for them to know that that'll be a part of their treatment and monitoring plan. And I also let patients know that we're very sensitive to any slight changes in the breast tissue. And so they might need some more biopsies over the years to help make sure that something's okay that helped to confirm its scar tissue. Or just if anything slightly changes we want to make sure if it is a recurrence that we catch it sooner than later. And then another important thing to know about a lumpback to me is that typically a patient's able to maintain their normal breast sensation. There might be a little bit of numbness near the incision but overall, they're able to maintain that sensation. So mastectomy, several reasons why this would need to be performed. Sometimes it's performed in patients that have not had breast cancer. And so there's pretty specific reasons when this would be appropriate. And so one you've probably heard about is for women who carry a BRCA1 or BRCA2 genetic mutation. And so this is important because women who have these genetic mutations have up to an 80% chance of developing breast cancer in their lifetime, which is very high. And the breast cancers that women with these genetic mutations tend to develop tend to be pretty aggressive requiring chemo, radiation, a lot of treatments. And so it's definitely a very reasonable option for them to have prophylactic mastectomies meaning removal of the breast tissue before a cancer forms in order to help prevent the cancer to begin with. And so it reduces the risk by over 90%. So I tell patients that after they've had the mastectomies, pretty much the risk of getting breast cancer is only like one or 2%, which is a drastic decrease from 80%. And then the other time that mastectomies can be performed when women do not have breast cancer is when they have reasons for being very high risk of developing a breast cancer. And so I'd like to think of it as kind of similar to having a BRCA mutation so like close to the 80% risk would make it worth going through such a major surgery. And so it's important to have a very long discussion with the patients if this is something that they desire. So if for some reason they have multiple family members who've had breast cancer, especially if they're diagnosed at a young age, even if their genetics are negative, that's something to consider. I say, typically, at least three to five family members so not just one or two. Also, if they keep on having biopsies showing different specific types of atypias, so atypical ductile hyperplasia and lobular carcinoma and situ are pretty concerning. And if they just keep having biopsy after biopsy showing these atypias, then the chance that one of these is going to actually be a cancer just increases as time goes on. And so especially if they have a combination of the family history and multiple atypical biopsies, then if a patient doesn't want to do the high risk screening anymore, we have a long discussion about whether or not a mastectomy so be an option for them. Which is very important to understand and go through all the details of surgery and the risks involved, possible additional operations in the future to really determine what the risks and benefits are, comparing surgery to high risk screening. So of course mastectomies are also performed for patients who are diagnosed with breast cancer. This would be recommended when the tumor size is large. In relation to the breast size, especially if a lumpectomy would result in an abnormal shape to the breast, or a lot of scarring, because also you have to keep in mind that women have when they have lumpectomies that they also have the radiation which can add a little more scarring also. And so that combination, when usually more than a quarter or a third of the breast tissue is removed. That's when it's best to start to consider a mastectomy. So if a woman has multi centric breast cancer, which is where breast cancer is found in more than one quadrant in the breast. If there's several areas close to each other in one quadrant, then that could be removed with a large lumpectomy. But if it's spread out throughout the breast, then the risk of there being other areas in between those that could have cancer that we can't quite see yet is higher. The risk of a recurrence after multiple lumpectomies at the same time is higher. And so it's better to remove the breast tissue to reduce that risk of recurrence. Also, if multiple operations have been performed to attempt to keep doing a lumpectomy. And so, due to positive margins. So what that means is that when a lumpectomy is performed, the pathologist looks at the margins, which are the edges of the lumpectomy. And you want to make sure there's no cancer near the edge. If there's any cancer near the edge, that means there still could be cancer in the breast. And so if that happens, then a second surgery is performed to remove additional tissue at whichever margins involved. And after this has been performed multiple times, if you're still getting more tumor at those edges, then then at some point it might be a good idea to do a mastectomy. Because really usually with the first surgery, the whole imaging abnormalities removed. And so what's found at the edges, we usually can't see an imaging we can't feel as a lump. And so it just shows us that this cancer is being very tricky and that's more extensive than what was originally thought. The lumpectomy is an option if a patient really doesn't want to undergo any further breast imaging. Like I explained earlier that breast imaging can often be every six to 12 months for years with different types of modalities. And some patients just really prefer not to have to do any more imaging or risk doing additional needle biopsies. And then patient preference of course factors in. So I tell patients that, you know, if they have the option to have a lumpectomy because not everybody has that option. They also have the option to have a mastectomy. And that as long as it's treating the cancer and that they understand the risks and benefits and how that might change additional treatment. You know, my main goal is to treat the cancer. And so some women decide that a mastectomy is the right decision for them. And then that would be fine as long as I agree with that from their cancer treatment standpoint. So the decision for whether or not to do a mastectomy is also sometimes related to different factors related to radiation. Some patients are unable to have breast radiation and radiation is important because often it's used after a lumpectomy. And so when a woman's pregnant she cannot have radiation because the the dose is very high. And even though it's targeted to the breast tissue there can be some scatter within the breast within the body, which could therefore get to the baby. And so radiation is not performed during pregnancy. Even if the belly shielded it there's still a way that it's possible that that could get to the baby so we definitely would not want to risk that. So the timing of when a breast cancer is diagnosed during someone's pregnancy is important. If it's near the beginning of the pregnancy depends on if they need any other treatments that would get them through the end of the pregnancy. Because we really try to maintain the pregnancy as much as possible it's very, very, very rare that we would ever recommend terminating a pregnancy, even due to a breast cancer diagnosis. But a mastectomy can be performed during a pregnancy. If a patient's near the end of the pregnancy when they're diagnosed and it's something that can be removed with a lumpectomy. There's often about four to six weeks between the lumpectomy and radiation. So if it's within that timeframe, then they could have the lumpectomy, deliver the baby and then have radiation so just a lot of factors on the timing for that, but that's something to keep in mind that could sway what type of surgery we do for a patient. There's also certain connective tissue disorders that sometimes these patients cannot have radiation. And it really depends on the severity of the patient's disease. So I would have them meet with the radiation oncologist to see if the radiation would be possible. One of those is scleroderma, and one is systemic lupus erythematosis. One factor with radiation is whether or not they've already had radiation to that same breast. And so, typically a patient receives the full dose. And so if they receive additional radiation to the whole breast, it could cause some issues with the normal breast tissue wounds irritation. And so, typically we would not recommend having whole breast radiation done to the same breast twice. We previously had mantle radiation for Hodgkin's lymphoma. Some of that radiation overlaps the radiation field for lumpectomy and for the breast. And so we would try to obtain those previous records and coordinate that to see if that would interfere with the radiation, but that's important to keep in mind also. And also, if a patient does not desire radiation for various reasons, it's typically well tolerated, but I've had some patients who saw people go through radiation, especially a long time ago, who had a lot of issues, and they just can't, sometimes just can't get past that, so they just have decided that they wouldn't want to have radiation. And so if it's an early stage breast cancer, the radiation can often be avoided if they have a mastectomy. So for surgery on the lymph nodes, so surgery is performed on the axillary lymph nodes, which is the area the lymph nodes underneath the armpit. This helps us to determine whether or not a breast cancer is trying to spread. And so it tends to be the first area that a breast cancer would spread to. And there's different ways that we can determine if that is occurred and, and different ways we determine how many lymph nodes to remove. So the central lymph node biopsy is the most common type of axillary surgery performed. And this is usually performed on patients who have early stage invasive breast cancer. So stage one or stage two with no signs of lymph node involvement before surgery. So we evaluate the patient in the office and check their lymph nodes on exam to see if I feel any, if I can feel any lymph nodes, then we would do imaging to determine if I feel any lymph nodes to be involved with lymph node, but then ultimately it's confirmed with imaging and needle biopsy ahead of time if necessary. So the central lymph node biopsy looks at the first few lymph nodes in the chain usually it's only between one and three lymph nodes. You have about 30 to 40 lymph nodes under the armpits is just checking the first few. And we found that if we look at the first lymph nodes in the chain that this can accurately predict whether or not any lymph nodes have gone further up the chain. And so if those lymph nodes are negative, then we know the cancer has not passed that point. And so we don't have to look at any more lymph nodes. This was not always the case. This just started like in the early 90s. And so before that point women had full axillary dissections for every breast surgery with cancer, which led to side effects. And so that's why we tried to do less extensive surgery yet still come up with the best diagnosis and treatment for the patient. And luckily the central lymph node biopsy was able to be adopted. And then this is especially important for obtaining accurate staging. And so as a woman's going through the breast cancer treatment process we're looking at the staging the whole time with the imaging and the biopsies. Then we get the lymph node result that further confirms the staging and really that that staging is confirmed after surgery with the full pathology diagnosis. So excellent axillary lymph node dissection is performed still performed when we know that the cancer has spread to the lymph nodes. And then this helps us to determine how many lymph nodes have cancer in them, which again helps us to determine the difference between the stage two and a stage three breast cancer. And so typically between 10 and 20 lymph nodes are removed. And then after those are evaluated they see how many of the lymph nodes have cancer in them. The lymph node dissection is more extensive than the central lymph node biopsy so often women have a little more numbness under the armpit compared to the central node. The risk for lymphedema increases to about 12%, which is swelling in the arm on that side. Luckily it's easily treated physical therapy but if we can help to decrease that risk we really try to as long as it's safe from a cancer standpoint. And sometimes the having surgery in that area since it's under the armpits in a sensitive area, it can, especially during the healing process can limit the mobility to the arm a bit. And it can take a little while to regain that mobility with stretching and exercises often physical therapy. So what are some questions to ask before your operation. So, it's important to ask about what you should do to help prepare for your surgery. So of course it's good to try to sleep very well every night and try to get your full eight hours. It's important to eat a healthy well rounded diet. You should make sure to ask your diet doctor if any specific foods or drinks should be avoided, either leading up to surgery or the night before. Oftentimes I'll ask you not to eat or drink anything after midnight the day of surgery but sometimes this can vary sometimes it's important to take your medicines with a small sip of water so it's important to ask the details of exactly what you should eat and drink. It's important to stay active and to exercise, leading up to surgery, you know try to maintain what your normal activity is. But if you don't normally exercise. It is good to help to start to do some light exercise, you know don't do anything too strenuous because you don't want to hurt yourself, but just walking stretching, you know ask your doctor what would be good to help out, leading up to surgery. I found that the more active patients are, and the more exercise that they do the better they're able to handle a surgery so even if you just started a couple weeks ahead that could help out with your recovery. It's also important to ask your doctor if there's any medications, vitamins or supplements that need to be stopped prior to surgery. The main one you'll hear about is blood thinners. So aspirin, Coumadin, Plavix, there's a whole variety of them these days. These often need to be stopped a few days before surgery but the timing really depends on what medication it is and what reason you're taking it. I have some patients who have to take it up until surgery so it's just important that the other medical issues are considered and your other medications. So with diabetic and blood pressure medications sometimes those need to be adjusted right around the time of surgery. Certain blood pressure medications are very important to take before surgery other ones, it's best to skip a certain dose with diabetic medications they're often adjusted because you're not eating or drinking on the day of surgery. You have to keep a close eye on your sugars so your primary care doctor or whoever manages your diabetes will let you know how to adjust those medications leading up to surgery. Also vitamins or supplements are very important because some of those can also have a blood thinning properties to them so they should also be stopped prior to surgery. Before surgery it's really important to make sure your other medical issues are under control and so the breast cancer, the breast surgery is just one component of your whole body. But when you're going through surgery it's anesthesia and the recovery process and whether or not you have other medical issues can factor into all of this and can affect your risk factors. So it's important that whatever medications you're taking that you continue to take them as directed. It's helpful for you to see your primary care doctor for physical to make sure that everything else with your medical history is is going well and is stable and overall if your other medical issues are stable. It'll decrease your risk of having any complications after surgery. So make sure to ask is what's actually performed during the operation. And so your doctor really should be prepared to answer this in a lot of details and I think it's important for my patients to understand almost every step to the surgery I don't want them to be surprised with anything or blindsided. So just starting from what's the name of the operation. So, so I always explain that exactly to the patient that way they know what side we're operating on why we're operating how they're going to be shown to that area. And how will this name for the surgery what will it be anything different than what's on your consent form. So you have to sign a surgical consent prior to the operation that you're agreeing to do the procedure you understand the risks and the benefits. And sometimes the wording can be kind of funny. I think the one that I find the most confusing for patients is something called a modified radical mastectomy. And so it sounds very scary but pretty much what it means is that it's a mastectomy. Plus we're also doing the lymph node dissection at the same time. And so I always spell that out for patients that way they know the different components that are all lumped together in the same term. It's important to ask what type of anesthesia you'll be receiving. Is it a locally anesthesia or twilight will be generally anesthesia. Would you expect there to be a breathing to place with which you wouldn't remember but you might get a scratchy throat afterwards it's just good to know that that's what that could be from. What exactly will be removed during the operation is it just breast tissue is that lymph nodes. It's made size for the lumpectomy and does your surgeon expected to be some type of cosmetic defect, because if that's the expectation then sometimes some plans can be started ahead of time to, to help to treat that. It's also important to ask about the risks for the operation. Most commonly the risks involve bleeding infection, a poor cosmetic result or reaction in anesthesia. So you can also ask your doctor what the risks are so for patient blood then there's the risk for bleeding increases. For patients who are diabetic or have other issues sometimes the risk for infection is higher than normal. So it's just good to know what to expect and you could even ask what the treatment would be if one of those issues happens to occur. It's just good to ask what's expected during the recovery after surgery. It's typical to feel more tired than usual. It's important to listen to your body and to rest when you need to, but also it's really important to walk very frequently after surgery. This will help you to feel better give you more energy. It's something that's pretty easy for the body to do, but it also greatly reduces your risk for developing blood clots. If you're in a home and don't move around. Unfortunately, you could get a blood clot which is very serious. So that's just a simple way to help prevent that. It's important to expect how intense the pain will be, and what type of medication is typically necessary. Is it something over the counter. Will you get a prescription. How often do they expect does your surgeon expect you to take the medication. Can you use ice packs after surgery. And so for my patients it depends on the surgery so ice packs help a lot with breast pain after a look back to me but if my patients having a mastectomy I don't have them use ice packs because then it can start to affect the blood supply. And then what are your restrictions after surgery. When will you be able to drive again. How much of a lifting restriction will be for how long will this affect your job. And also it's important to ask what type of dressings will be placed on the incision. Will the dressings need to be changed. Will you need help with that. Do they expect to have to place a drain. Will you need a home care nurse, especially if you have a drain placed. And when will you first go for your follow up appointment so typically it's a week or two after surgery when that pathology comes back. So it's best to know when to expect that to be so you can make sure to attend the appointment and you know to bring any of your family who can help to listen to the pathology result also. And also what other specialists do they think that you'll need to meet either before after surgery so this could include plastic surgeon a medical oncologist, radiation doctor, even a genetics counselor, and ask them what the timing would be sometimes this is set up before surgery other times we wait until after the pathology comes back. So next important thing with breast surgeries coordinating care with your other doctors. So this is really improved as as breast centers have increased over the past number of years. So the first breast center was the Van Nuys breast center, which was found in the 1970s out in California by Dr. Milton Silverstein. And before breast centers were developed patients complained that their work up and treatment for breast cancer was very fragmented. There was long delays occurring between each step in the process. And we used about when to do which step. These breast centers help to centralize the diagnostic work up and treatment for breast cancer. So, then in 2008, the National Accreditation Program for breast centers began we call this any PVC. And this is an important program because it has a series of standards that the accreditation focuses on the multidisciplinary treatment of breast cancer. This includes presentation of a patient's case at a multidisciplinary breast conference. Also this leads to improvement in the quality of care and programs who participate in this accreditation program monitor outcomes for their patients. Also, they made sure to make the criteria so that all different types of hospitals could participate, not just major hospital institutions, but teaching hospitals where there's residents and students and then also just normal community hospitals. So that really across the country you can find different types of hospitals that all have this accreditation, and you know that their standards are all equal. So, each of these accredited breast centers have achieved outcomes that meet or exceed the national standards. The standards that are evaluated are that a multidisciplinary team approach is used to coordinate breast care and treatment and the different treatment options available. It helps to improve access to breast specific information education and support. When our data is collected, they look at quality indicators for different subspecialties involved with the breast cancer diagnosis and treatment. There's ongoing monitoring and improvement of care for the patients. And there's also information available to patients about participation in clinical trials and new treatment options available. It's a very extensive application and the reevaluations every three years and includes a site visit with each reevaluation. So you show the surveyor your program and each of your components and explain exactly what your team's doing. So it's a really good way to make sure you're staying up to date and that you've all the best options available for your patients. So some of the specialists that are on the multidisciplinary team include the breast oncology surgeon, which would be myself, a medical oncologist, a radiation oncologist, the radiologist pathologist, a plastic or reconstructive surgeon, nurse navigator, social worker, genetics counselor, nutritionist, physical and occupational therapist and palliative care. Thank you.