 So thank you, everyone, for listening. This is, as you know, a topic I feel fairly passionate about. And I love giving the information to people in any vehicle I can. So breast surgery is my specialty. It's what I practice on a daily basis. And I thought I would focus today's talk on topics that I or questions that I get very frequently when I speak to patient and families. And I think there are some things that just tend to be a bit misunderstood. So I thought I would focus on that. So and of course, focusing on cancer as it is a breast cancer awareness month. So let's just get started. So here's a little summary of some of the topics we're going to talk about. But I really am happy to take any questions. I don't mind stopping the presentation midway for a question. And I'll certainly try to leave time at the end. So the basic topics we're going to talk about is once you do have breast cancer, how do you make that decision of a lumpectomy versus a mastectomy? And is that always a choice that you have? So we'll talk about that a bit. We'll talk about a list of questions that would be very personalized for each person to ask their surgeon or their team members to help them make the right decisions. We'll talk a little bit about age and how that impacts surgical treatment. And that's especially for the older population. And that's an area that is changing fairly quickly. And we're actually trying to do less to treat cancers in older women because it seems to work just as well. So we'll address that. We'll talk a little bit about breast cancer genetics. I know there was or is a genetic lecture coming up that gets much more detailed about the genetics. But the whole concept of, you know, is a mastectomy necessary if you have some type of genetic mutation. We'll get to that a bit. And then one of my favorite topics is, you know, what is a team, why do you need a team to treat breast cancer? What are all the different components? And we'll go over that a bit. And then the common questions about lymph nodes and why are they important and what is the downside to removing them? So we'll try to get into each one of those things a bit. So first, this is just very basic about breast cancer staging. So all cancers have stages and in breast cancer, the stages range from zero through four. So technically there are five stages. So stage zero, and this is a little bit hard to conceptualize because most people think, oh, great, I have stage zero breast cancer. Therefore it's very limited and I can do very little to treat it. But actually you can have stage zero breast cancer that is throughout the breast and requires a mastectomy. So in-site cancer is the type of cancer cell that will sit in the breast and can spread within the breast but does not tend to go anywhere else. So that is the kind of cancer you tend to find on a mammogram before a lump forms, but there are exceptions to that. Stage one, generally speaking, means you do have an invasive tumor, the type that can spread, but it's small and the lymph nodes appear benign. So generally speaking, that's stage one. Stage two, you get a little mix of a somewhat larger sized tumor, sometimes with limited lymph node involvement and other times with no lymph node involvement at all. Stage three is usually reserved for the larger tumors with a higher volume of cancerous lymph nodes. And then finally, stage four usually implies that the cancer has traveled beyond the breast, probably beyond the lymph nodes and to other parts of the body. So treatment is guided towards the stage but doesn't always correlate with the stage. So stage four often does not mean you need a mastectomy and stage zero doesn't mean you can have a lumpectomy necessarily. So it'll depend on a lot of other features that you need to know about. So some general things you should know about the whole lumpectomy versus mastectomy decision. You have to remember the history of this is that years ago, like in the 50s and 60s, mastectomy was done for every breast cancer. The tiniest one, the largest ones, you remove the breast every time because honestly, surgeons were afraid to do less than that because we had no proof that it worked. But then more research occurred and by the 70s, early 80s, lumpectomies were becoming much more commonplace. So generally speaking, is lumpectomy always an option for every woman or person with breast cancer? No, not necessarily. It depends on several things that we'll get into shortly. So sometimes as a patient, you have a choice about what type of surgery and other times you may not, but I think it's important to know what each option entails and what's attached to that so you don't find yourself regretting your decision four or five years later. So this I hear a lot is mastectomy safer. Is it more complete? Is it more thorough? Well, it does remove the entire breast essentially, although there's always little bits of breast tissue left behind after mastectomy. But mastectomy is not safer in that you don't have a better chance of surviving the breast cancer if you have the breast removed. If you can have a lumpectomy, lumpectomy is a safe option. So I wouldn't choose a mastectomy because you're gonna have a better outcome. Sometimes in some cases you do because it's the only choice, but if you have the choice, it's not necessarily better. The other thing I get asked a lot is people kind of assume that if the cancer got to the lymph nodes that a mastectomy will be necessary and that's actually not the case at all. If you have a localized tumor in the breast and the lymph nodes do not, whether the lymph nodes have cancer or not, doesn't mean a mastectomy is necessary. So you can do a lumpectomy and a complete removal of lymph nodes and the breast still may not have to be removed. So cancer in the lymph nodes does not mean that mastectomy is necessary, but staging of the cancer sometimes relates to the choice of surgery in terms of the extent of cancer in the breast and the extent of cancer in the lymph nodes. So there's a lot of thinking and decision-making that has to happen early on in someone's treatment journey. It's difficult because you just find out you have cancer, you're trying to sort out all this information, you may be given lots of information and possibly some options. So it's quite a lot to process and you don't wanna panic while you're doing it. You wanna kind of keep your head. It's always good, by the way, to have a friend or family member either sit in to a consultation, be present on the phone, someone else to help you sort out the information. So here's a little summary of some of the pros of lumpectomy. Why should you have a lumpectomy? Why is that better? Well, saving the breast obviously is paramount to many women, not all, but many. So it's really hard to quantify what it's like to not have your own breast, how you're gonna respond. Nobody really knows that until you have to go through it yourself. For some women, they can't even picture losing a breast and for others, they basically come in to me and say, you know what, I did my thing with my breasts, I'm done and now I just wanna move on and not have to think about it. So one thing to remember with lumpectomy is for the most part, sensation is preserved. You might get little bits of numbness near the scar, but the overall feeling in the breast is still there. As a matter of fact, sometimes it's actually hypersensitive, like a little uncomfortably sensitive, but you do keep breast and nipple sensation. The second point is probably the most important point of the entire talk is that long-term survival with lumpectomy, assuming you can have a lumpectomy is the same as removing the breast in terms of long-term outcomes. So you don't wanna choose a mastectomy so that you'll add percentage points to your survival because assuming you follow all the recommended treatment, your survival from the breast cancer is gonna be the same whether you choose lumpectomy or mastectomy. And that's kind of a hard point to internalize, but I usually kind of reinforce it multiple times so people understand that. Cosmetic results with lumpectomy that can vary for a lot of different reasons. Partly the size and shape of the breast to begin with and it may perhaps the age of the person and what type of skin they have. And most importantly, cosmetics that depend on the volume of tissue you're removing compared to the volume of the breast itself. So if you have a medium-sized tumor and a really small breast, there's probably gonna be some impact. But an inferior cosmetic result after lumpectomy can often be fixed by a variety of plastic surgery techniques. So you have to be, I guess, a little bit understanding about the fact that the breast may not look perfect when all the treatment is said and done. Another big advantage to lumpectomy is you get back to normal activities a lot more quickly. So mastectomy is just more downtime, drains, more restrictions. With lumpectomy, you do have at least a week or so of reduced activity, but as things heal, you're able to do things a lot more quickly. For some people, that's critical. If you have a physical job, if you have small kids or home responsibilities that require lifting, like that might be a very important point to you. And of course, the balance of the pros of lumpectomy go along with the cons. And as a surgeon, I want every patient to feel optimistic and confident in their choice, but I'm not doing my job unless I give them a kind of a picture of what to expect. So one issue with lumpectomy is you don't always get the whole cancer out with one procedure. And you might think, well, how is that possible? Don't you know how big it is? Can't you see it? And I'm gonna show you a diagram in a minute that kind of shows how you can't always tell what's going on at the edge of the breast tissue. So sometimes cancers are bigger than you think. So there's a small chance that you have to go back and do some additional surgery to get better or clearer margins. Also, and for some people, especially if they're kind of nervous or anxious, you need mammograms essentially for the majority of your life after having a lumpectomy. And that's something you have to make peace with. Like it's just, you know, it's necessary. If you wanna watch for any sign of recurrence, you want to do those mammograms. And they're a little bit more uncomfortable after lumpectomy because of scar tissue, radiation change and that sort of thing. But most women, you know, especially if you go from mammograms anyway, prior to diagnosis, you can deal with the stress of going afterwards. So what about worrying about cancer recurrence in the breast itself? You know, I wrote here excessive worry on purpose because everybody worries a little bit about recurrence, but some people are simply obsessed by the idea of recurrence, even if their numeric risk is only 5% or 10% or something like that. So if you're gonna constantly worry about the breast and mentally you would feel better if the breast wasn't there, then mastectomy might be a better option. But most women after, oh, I say six months or a year, you make peace with that fear. And you just kind of, you know, a few years go by, you have a few normal mammograms and you put it in its proper place in the background somewhere. In terms of pain and sensitivity in the breast after lumpectomy, you know, most people have a little bit of altered sensation like a little discomfort, little stinging, especially sensitivity with the mammogram, but most of the time it's very mild. But every once in a while, someone has a lot more pain than someone else. It could be a nerve irritation, it could take a very long time to go away. But that's actually also true of mastectomy patients. So the chance of a persistent pain or sensitivity situation can be true no matter what surgery you have. The cosmetic thing we talked about a little bit and most breast surgeons are really good at balancing the need to get the cancer out properly with wanting a good cosmetic result. And we take a lot of pride in things like incision placement and removing the appropriate amount of breast tissue. We used to think actually that getting a big wide margin was better than just kind of staying close to the tumor itself. But now there've been recent studies showing you don't really need that big cuff of normal tissue. So where many of us are doing slightly smaller lumpectomies, not taking as much extra tissue out and having very, very good results. So, but again, a poor cosmetic result or what I think, I may think it looks pretty good and the patient might think, oh, this is not how I wanna look. So we have plastic surgeons who can offer a wide variety of ways to help improve the appearance of the breast after lumpectomy, if necessary, but most women actually don't ever need to do that. Except for maybe something like getting a reduction on the other side. So if you have a tumor in a large breast and you do a lumpectomy, the breast ends up smaller afterwards. Many times all you have to do is a limited lift or reduction on the other side. And that helps even things out quite a bit. And then finally with lumpectomy, for most women, radiation treatments are necessary after lumpectomy. And radiation treatments are not particularly difficult. They are a bit annoying as you have to go, usually over a four week period. But overall you can do radiation and have a normal day, go to work, do all your normal responsibilities, but women need to know that if you're going to have a lumpectomy, except in some selected circumstances, you have to expect a need for radiation after lumpectomy. And so here's just a little, I thought I'd put in a little diagram about just some of the basics of lumpectomy. So hopefully you can see my cursor here. So on the left hand side, you see one little example of a tumor and these little green things here are lymph nodes. And lymph nodes are, they can rain, they can be on the side of the breast, they can be up towards the armpit and they can even go up under the collarbone. So most, and we'll talk about lymph nodes shortly, but most tumors will spread to one or two lymph nodes under the arm first before they go anywhere else. So this shows some of those little drainage patterns. But if you can remove that small lump, leave the breast intact and check the lymph nodes, you've accomplished a nice goal without having to remove the breast itself. These other pictures I think are just different locations of where the tumor can be and where the lymph nodes can be located. And on the right here, this tumor happens to be situated towards the back of the breast. Not a problem really, it's just the surgeon has to know where they're going and what area they have. So here you might have to take out a little bit of muscle behind the lump to make sure you get it out completely. But if you take out a lump towards the back of the breast, usually cosmetic results is good because you don't see that deficit quite as much as if we're more forward or like underneath the skin. This is a little diagram of what a lumpectomy might look like after you take it out. So when a breast surgeon does a lumpectomy, we remove the tissue by a variety of means, which we're not really gonna get into too much today. But once that tissue is out, you take an X-ray picture of it to show how the tumor is centered. So ideally you're not looking at the cancer at all because the cancer should be encased in normal tissue. So this diagram here on the left that says negative, you can see the yellowish tumor in the center, you can see pinkish normal tissue around it. And this shows that you have cancer cells in the middle, normal tissue around, and this brown line represents the edge of the lumpectomy. And you have to keep in mind though, it's a three-dimensional piece of tissue, it's not flat, so you can't quite see all the surfaces. On the right side, you see, this would be an example of a positive lumpectomy margin because even though this tumor is in the center, it has like an extension that goes to this edge, which may or may not be visible to the surgeon at the time of the lumpectomy. Some of this extension is totally microscopic where you can't really see it. So something like this would cause the need for a possible additional surgery to take more tissue out at that edge to make sure you have all the cancer out. But most surgeons, we do what we can to try to avoid the need for a second surgery because it's so emotional, it's emotionally distressing for the patient and honestly, it's emotionally distressing for the surgeon too. So we have to watch out for our own mental health a bit. So a little bit about mastectomy. With mastectomy, the reason some women cite for wanting a mastectomy is that they no longer need mammograms. So for some women, that's a huge plus. They hate mammograms, they get stressed every time they go, they don't trust them because the mammogram maybe didn't show the cancer well in the first place. So we do not do mammograms after mastectomy, except in extremely rare cases when you wanna do a mammogram of a reconstructed breast. Radiation, so radiation is generally needed with lumpectomy, but sometimes also needed with mastectomy. So just because you're removing the whole breast doesn't mean that radiation won't be necessary. You might need radiation because the tumor went towards the chest wall or towards the skin or more often, what if the cancer got to several lymph nodes, you might need radiation for that reason. So I wouldn't necessarily pick a mastectomy to avoid radiation when that is a possibility. So number three here on the list. So if you have multiple areas of cancer in different sections of the breast, like one in the upper part, one in the lower part, behind the nipple, then you really can't do multiple lumpectomies in a breast like that. Oh, let's put it this way. We have no clinical studies that show that doing multiple lumpectomies is a safe thing. There was one or two limited studies years ago, but the recurrence rates were quite high. So except in rare circumstances, multi-centric cancer requires a mastectomy. But for example, if you have two cancers close to each other in the same quadrant or section of the breast, you can do a lumpectomy for that. So that's something to discuss obviously with the surgeon. Breast reconstruction, so many women choose to have breast reconstruction with a mastectomy, but not everyone does. And there is an interesting kind of movement lately that it's called going flat, it's called a few different things, but there are many women who are eligible for mastectomy who are saying, you know what, I just don't really want to do it. And you don't have to do it. If it's something that you feel that you can have a nice, happy, full life without having reconstructed breasts, it's certainly not something you have to do. But there are some wonderful options for breast reconstruction. I'm gonna show you a few diagrams for that. And that's something you wanna have a good discussion with a plastic surgeon. Don't only get your information from the internet because the decision for what type of reconstruction to have depends on your breast type, your body type, the type of surgery you need, your health, your age and a variety of things. So I usually tell people to try to keep the open mind to reconstruction and you can have it along with the mastectomy or sometimes it's actually a delayed procedure where we do it later. So that's something to certainly look into. And then, you know, with mastectomy, many women have a sense of reduced future risk. They feel like they've done everything to reduce the risk of breast cancer. But it's really more of a sense than a fact because removing the whole breast does not eliminate the risk that the cancer will come back in the residual lymph nodes in other parts of the body. So it's really more of a personal sense of completeness rather than really having a major impact on your risk of distant recurrence. Of course, if the breast isn't there, then the cancer won't come back in the breast but it could come back somewhere else. So these are the things that often get considered, you know, when you're deciding or thinking about doing a mastectomy. So I just put up a few very basic diagrams. I didn't wanna do photos. I thought it would be a little bit too graphic. But for example, this is what a woman might look like after she had a mastectomy without reconstruction. So usually the incision or the scar from mastectomy goes from the center of the chest to the side. The funny thing is with these diagrams, they always show women who are very slender. They don't have like little fat rolls and excess tissue. So you know, it can be hard to smooth all that out. But in a thin person, this is the appearance you would get without reconstruction. This diagram's a little bit of an example of a couple of different things. So here on the patient's right is two examples of incisions you might use for something called a nipple sparing mastectomy. So when I do, and what that means is you can actually remove the whole breast but save the entire outer skin pocket. So you can take out all the breast tissue without removing any skin at all. And when you do that, one of the best incisions I think to use is this infra mammary fold incision, this incision under the breast itself because it's a hidden scar, you don't really see it and there's no scar on the breast itself. But it is a bit of work for the surgeon because you have to reach all the way up to the upper extent of the breast tissue here and all the way to the side from that incision. So it takes a little bit of time. It can be difficult if you have a very large or a hanging type breast. But ideally if you have a like AB or a small C breast that might be a very nice option assuming the cancer is not right near the nipple itself. So here on the patient's left, this is an example of an implant that is put in behind the muscle. So obviously you're looking at a cross section here this is all covered up in real life but this whitish thing here is what an implant or something called a tissue expander would look like when it's put in. So in this particular case, the plastic surgeon put it in behind the muscle. I mean, you can't tell here but I'm assuming they're implying that the breast tissue has been removed. It's a little hard to tell from the picture. But this can, if it's in a temporary it can be gradually blown up or it can just sit there as an implant and it provides a nice example of what reconstruction would look like underneath the muscle itself. So this is just a little diagram I'm gonna go over having to do with something called deep flap reconstruction. So one of the newer and increasingly popular forms of reconstruction is where a plastic surgeon takes excess skin and abdominal fatty tissue, removes it and shapes it and reconnects it using microsurgery to a person's existing blood vessels and they can actually make your own breast out of your own skin and excess fat. But in order to do that, number one, you have to have excess fat. So if you're very skinny, this might be difficult but it's a great form of reconstruction. If you've had radiation, for example, it often will still heal very well but it's a longer surgery and it's a longer recovery. And you have to find a plastic surgeon who's skilled and experienced at doing it. So, and there's other examples too other types of reconstruction I just haven't gotten into them here. So there's really a lot of options out there and which one is right for you depends on your body type. And for example, if you've had abdominal surgery previously, this might not be a good idea because if there is a big scar up and down that might have ruined the blood vessels that you have to use to do this type of reconstruction. But I think I find it amazing what plastic surgeons are able to do and you can actually wake up and you have a pretty natural looking breast there which heals well and is with you forever. It doesn't need any special maintenance or once it's healed, it's your own tissue. So it's great. A few cons from mastectomy, the obvious, you're losing a breast and there's no price tag on that but for some women it's something they hardly ever get over and also mastectomy affects not just the person having it but their partner. So women sometimes report a different dynamic sexually. They feel wanna cover it up. They don't let their husband or partner touch the reconstructed breast or the chest wall. So that's stuff that doesn't come out for a while but it's difficult and plus there's numbness where the reconstructed breast is or where the chest wall is. So you kind of lose the sensation. There is a longer recovery time to mastectomy and then numb back to me. And of course, as I've stated a few times already, mastectomy is not a guarantee that the cancer won't come back so I wouldn't choose it for that reason. And also when you remove a breast, whether you have reconstruction or not, you're suddenly uneven. So if you have a large opposite breast, you may need to wear a heavy prosthetic if you don't have reconstruction. If you do have reconstruction, it might be hard to get the two sides to match without some additional surgery. So that's something a plastic surgeon can easily address. And then finally, if complications do happen, like if you have a lumpectomy and you get an infection, you give antibiotics, maybe aspirate some fluid and it clears up. But if you have an infection with a mastectomy and you've had reconstruction, sometimes you have to remove the expander implant, start all over again. So it can be a much longer road to fix the complication. So these are all things you should think about with mastectomy. So in terms of how the staging of the cancer impacts the type of surgery you do, it's not as simple as it sounds because sometimes as I said previously, you can have a whole breast full of stage zero cancer and need a mastectomy, whereas you can have a relatively small stage three breast cancer with a not so big a lump and be able to have a lumpectomy. So these are the type of questions you want to ask when you are going for consultation regarding breast cancer surgery. And most breast surgeons will sit down with you and explain many of the basics of your type of cancer. They'll focus on, okay, how big is the tumor? And the reason that's important, we don't always know exactly how big a tumor is, but we have a general idea. If the surgeon says this tumor is very large, you need a mastectomy, what you might say is, okay, can we shrink it first before surgery? And there may be an option to shrink the lump before surgery happens and make a lumpectomy possible. So if you know to ask the question, but usually the breast surgeon will bring that up. The cell type of the cancer, that can matter. Some cell types are very slowly moving and when they're slowly moving, they're usually less likely to recur in the breast itself. The more aggressive tumor types may have a little more of a propensity to recur after a lumpectomy. So the surgeon can usually get a sense from the needle biopsy that most women have prior to surgery about how that cancer will behave. Location of the tumor in the breast itself, that can matter in terms of cosmetic. So if the tumor is immediately behind the nipple, for example, there may not, you might have to have the nipple removed to do a lumpectomy. And that's gonna affect the appearance of the breast. So that could be one issue. If the lump is very high up on the chest wall, there might need to be a scar up there. So it's always a good idea to ask about how the location of the tumor might impact the surgery itself. And then in terms of risk for complications. So every person should understand their medical history and how it impacts their surgical risk in terms of length of anesthesia and the scope of the surgery itself. So if you are a uncontrolled diabetic who smokes cigarettes and has heart problems, you're gonna be at higher risk for every complication. Wound healing and anesthesia complications, blood clots, that sort of thing. If you're a healthy person who generally speaking takes care of themselves, your risk is lower. And then simply even being extremely overweight is a big risk factor for any type of surgery. So there are some things obviously that you can't change before the surgery itself. You can't lose 50 pounds, that sort of thing. But you can if you smoke, even quitting smoking a week or two before the procedure can help reduce your risk of infection. So that's important to ask the surgeon how am I considered a high risk person? Am I being realistic about the type of surgery I want to have? And then this last question applies more in a teaching hospital but who's actually gonna be doing my surgery? So you would think that the surgeon you meet is the one actually performing the surgery because usually that's true. But some surgeons work in teams, occasionally surgeons run two rooms at one time. And if you work in a teaching hospital, there may be a resident or a fellow in training who is doing the surgery with the surgeon and at times they're doing parts of it on their own. So it's fair to ask that is probably on your surgical consent that you sign. And it's fine, we all train. So everyone who does surgery was in a training program at one time but it might it's good idea to ask what the usual is the surgeon there the entire time or do they leave the room at times to go on to do something else? And then a few more pertinent questions timeframe. I think COVID taught all of us that maybe not everything needs to be done immediately. So back in April of 2020, we all had to shut down all surgery that was not an emergency. And believe it or not, cancer was not considered an emergency. So for about six or seven weeks, I was not allowed to do breast surgery at all. So in terms of what happened to those patients, luckily most I would say probably all of it. I don't think anybody was harmed by that delay, but if people couldn't have surgery right away some of them could actually wait. Like if you have stage zero cancer that's slowly moving. So that can wait, but it depends on the type of stage zero and the cell type. So that's something you wanna find out. Also in some people who can't have surgery right away, if we know they need chemotherapy, they can do the chemo before the surgery. And that keeps them protected. You're treating the cancer prior to the surgery being done. So that's not a bad strategy there. And then finally, many cancers are estrogen sensitive. So there's actually medication of block estrogen that can help prevent cancer from spreading while you're waiting to do surgery. It's called neo-adjuvant hormonal therapy. It's something we've actually done for a while, but we did a whole lot of it around COVID and it worked just fine. So, but in general, in most people I meet, I like to do surgery within four weeks or so when I first meet them, but sometimes testing takes a while. Sometimes they have family events and other things they have to do. But you wanna ask the surgeon how quickly does this need to move so that I know I'm safe and protecting myself? Second opinion. So there's a lot of, obviously a lot of talk about second opinions. And generally speaking, they're a perfectly fine idea. There's hardly a downside to a second opinion, except there can be a little bit of a delay and a little more hassle in actually setting it up because all your stuff has to go to another doctor and another facility to be looked at. But you know what was there are some people who clearly benefit from second opinion. Primarily if I meet with a patient and they're extremely unhappy with what I'm telling them or angry or defensive or just unaccepting of what I think should be done. I asked them to go for second opinion because they need it. You know, and maybe my way is not the only way and how would they know because they're not an expert in the field? So for those people, second opinion is a wonderful thing. But if you leave a doctor's consultation with a really unclear idea of what to do after completing all your testing, then you want the second opinion because you simply don't know what another doctor's gonna say until they actually say it. So most surgeons are very open about second opinions. We don't take it personally. I kind of value the information I get from it, but it can just sometimes lead to a little bit of confusion but hopefully not too much. In terms of speeding up your own recovery, this is kind of a hot topic lately and we like to tell people there are things you can do to make sure you heal better and faster. Prior to surgery, you know, if you kind of, oh, let's say try to eat healthy, stay hydrated and exercise that those interventions actually can help you in the recovery period just to be in the best shape you can possibly be in. After the surgery, you really want to follow instructions from the surgeon. If you're told to rest for three, four days, you want to do that because if you do too much the first couple of days, you might be at higher risk for swelling or hematoma or something along those lines. So you do want to be a little bit careful with that. Does surgery have to be done as a first step? I think we figured out already that sometimes chemotherapy and sometimes hormonal therapy can be done as a first step. So this is something to ask your surgeon and or your treatment team. Let's see, God, I am verbose here. I'm gonna try to maybe split by some of these slides just because I think I'm being a little too wordy and we're gonna run out of time. Is age a factor in surgical decision-making? It is, just a little comment here about de-escalation. So what this means is women get older, often the treatment for breast cancer can be a bit less aggressive. So you don't have to do everything for women who are old. The key thing though is how do you define older? And I find that really changes based on what study you're looking at. Some people think older is over 65, everybody agrees older is over 80, but there's different, you know, there's some women who are 70 who are extremely young, appearing and in excellent shape. There are other women who are 65 who have serious medical conditions. So you wanna make sure the treatment fits the situation. But in general, for example, women don't always need to have lymph nodes taken out when they have a lumpectomy if they're over 70. It depends on the type of tumor. And this is all newer information so that the studies have to be tailored to the specific patient. Generally speaking, breast reconstruction can be done after mastectomy in older women, but they may have to accept a somewhat higher complication rate just simply because of their age. So that's something that plastic surgeon will address. And then briefly, non-surgical options. So for example, I have a, there's a woman I saw not too long ago and actually she was in a nursing home and she has dementia, some other medical issues. I believe she's in her early nineties and her caregiver found a lump in the breast. So we did a biopsy, we, you know, found out that it was a type of breast cancer. And we had several discussions about options. And unfortunately that particular lump was not estrogen sensitive. So the two basic options are surgery or chemotherapy. And at 92 with dementia, she really couldn't tolerate chemotherapy. And eventually we decided that surgery was not right for her either. So that's the rare patient who has breast cancer who is not being treated. And, you know, the cancer is probably going to grow. It's just the upheaval of doing a mastectomy and some who can't even really understand what a mastectomy is because of her memory issues was not the best option. But for example, if that same patient had taken medication of block estrogen, that could have kept, that could shrink the tumor if the tumor is estrogen sensitive. And that could keep that tumor from spreading for years. So it really, that's why we do biopsies and older women who may not be surgical candidates so we can find out what would be the best type of treatment. Other things that might be eliminated in older patients, radiation, not always needed after lumpectomy. It's on a case by case basis. And then skip that because we're gonna talk about genetics in a minute. Treatment of younger women, there's some considerations that you really have to keep in mind. Certainly in women who are younger, they have more time ahead of them to need mammograms, possibly MRIs. So we do clearly check genetic status on young women prior to surgery to make sure they're not at particularly high risk. So this is just a fairly busy alphabet type chart, I call it, but I don't know if any of you saw the or attended the genetic lecture, but this is a basic pie chart of the different types of genetic mutations that can lead to breast cancer. So this doesn't mean that everybody has a genetic mutation, only maybe 10% of people have breast cancer caused by a genetic mutation, the other 90% it's random. But in the people who have a genetic mutation, about half of them have either BRCA1 or BRCA2, which are the more common mutations, but then the other half have all these other less common mutations. So, but these mutations are less likely to cause cancer than BRCA1 and BRCA2. So you really need to have full panel genetic testing of all these mutations and then have an individualized discussion with your surgeon about how your genetic test results would impact your surgery. So people talk about this a little bit. So if you have a gene mutation for breast cancer, it doesn't mean you need a mastectomy or like bilateral preventive mastectomy. So some women tell me they don't wanna get genetically tested because they don't wanna mastectomy. And my answer to that is you don't need, having genetic testing doesn't mean you have to have a mastectomy. It just means we can individualize your follow-up plan based on what you have. So for example, if someone gets genetic testing and they're 75 and they have a BRCA1 or BRCA2 mutation, I'm not necessarily gonna recommend a double mastectomy, but that's information that can help their children or their nieces and nephews or their younger relatives who may want that. Plus I'm gonna follow that patient with MRI as well as mammogram to look more carefully. The type of gene you have impacts your risk, BRCA1 and BRCA2 are the highest, the other ones are lower. And what if you have all these other issues? If you're very overweight, smoker, heart disease, other types of medical issues, you might have a high risk of complications from mastectomy. So I might think it might not be worth it at that point. Maybe if you lose weight and then wanna consider mastectomy, it might be something. So again, very individualized decision. And also you don't look at genetic test results in a vacuum, you look at your family history and see who's actually had breast cancer. So if you test positive for one of these genes and no one in your family's had breast cancer, in some cases that means your risk may not be as high as you think. On the other hand, if you have multiple relatives who have had breast cancer at young ages and you have a gene, that can really mean that you're more likely to get something. Then we consider social issues like work, family. There's never a good time to have a preventive mastectomy but there sometimes are worse than others. So that's something to think about and then you have to make the whole reconstruction decision and whether you're mentally ready to go through a big preventive surgery. It's a whole different thing. When you know you have cancer and have to do surgery, that's one thing versus a preventive operation. So all these things have to be discussed and considered when you're thinking about doing mastectomy for a genetic mutation. So just a couple words on teamwork in breast cancer treatment. So most surgeons are, you're captain of the ship, you're in charge of everything. And that's true for like a very short period of time in breast cancer treatment. So in the beginning, when you first have an abnormality like a lump or mammogram, maybe your gynecologist is in charge of ordering testing. Then your breast radiologist is in charge of doing the mammogram ultrasound needle biopsy. Then you're sent to a breast surgeon and we kind of supervise testing and treatment for the next couple of weeks. And then often you get sent to a medical oncologist who more becomes your treatment quarterback. But all these people listed here on the slide are important in your treatment or can be, not necessarily. Gynecologist, because often the evaluation starts with them. Breast radiologist does the mammograms, the radiation doctors in charge of radiation. So there's, and all these people like physical therapy is critical after mastectomy and sometimes after lumpectomy to getting full function back. And don't forget our nurse navigators who are a wonderful part of the team. Their nurses usually based at the hospital who help with expediting appointments, answering questions and just overall making sure you get the care you need. So this is all clearly teamwork. At the HMH hospital specifically Riverview which is where I practice, we have a multidisciplinary tumor board. We meet weekly, our team meetings are about 90 minutes every week and we discuss anywhere between six and 15 new breast cancer patients a week. And we will discuss, we review pathology slides, we get everyone's opinion, both in person and on Zoom is now a lot of people do call in. And it's incredibly helpful, especially for the more complicated cases. So the tumor board might impact treatment decisions if an oncologist says, I really think chemotherapy should be done first and I hadn't thought of that in that particular situation. Then I have them see the oncologist and we sometimes do chemo first. Plus there are research protocols and clinical studies that can really be discussed and implemented as a result of a tumor board meeting. But at the end of the day, your team members have to communicate with each other and we all do, we talk, we email, we see each other in person and we make sure we're all on the same treatment page because it's really important. So, oh, lymph node removal. You know what, maybe I do, I see there's a couple of questions. I think I'd rather go to that. This is just talks a little bit about, let's skip the lymph node part. And just in summary, there are many options in breast cancer treatment, communication with your entire treatment team is extremely important and ask questions, ask lots of questions. We like it actually, because it shows you're engaged and if you don't feel comfortable asking, you can designate a friend or a family member to ask for you as long as we have your permission then they can be looped in nicely. So, remember breast cancer screening and treatment is for everybody. Still there's still about 20% of women that don't get mammograms you should get them every year. So tell your friends and family.