We Can Do Hard Things with Glennon Doyle - Life-Saving Intel: Amanda's Breast Cancer Surgeon Dr. Lucy De La Cruz

Episode Date: October 21, 2025

This life-saving conversation is for anyone who has—or loves someone who has—breasts. It’s what to look for, what to ask, what screenings you *actually need* (not just what is offered), and every decision point you have (even if it’s not offered to you) if you are facing surgery.   This Breast Cancer Awareness Month, Glennon, Abby, and Amanda empower us with the most vital tool we have: information. Amanda reflects on how self-advocacy led her to her own breast cancer diagnosis—and we hear from the pod squad about how Amanda’s transparency helped save their lives. Then, we’re joined by Amanda’s renowned doctor, Dr. Lucy M. De La Cruz, who reminds us that every patient has agency—and shares how to choose the treatment path that’s right for you. And special shout out and thanks to Pod Squader Lori Mihalich-Levin (@mindfulreturn) for being such a special part of this story! If you or someone you love has been diagnosed with breast cancer, please save this episode or send it to the people you love. We love you.  For more on Amanda’s Breast Cancer journey:  - Amanda's Diagnosis and What's Next (Part 1) - Amanda’s Diagnosis and What’s Next (Part 2) - Amanda Returns Post Surgery: Here’s What She Wants You to Know  - What Amanda’s Learned About Life, Love & Community (Post Surgery Pt 2)  - Early Detection, Mammograms & Breast Cancer Care with Dr. Rachel Brem  - Expert Advice on Genetic Testing, Cancer Prevention & Care Disparities with Dr. Rachel Brem  About Dr. De La Cruz:  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. She serves as Chief of Breast Surgery and Director of the Betty Lou Ourisman 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, with a focus on highly specialized single-stage implant reconstruction. Patients describe her not only as a world-class surgeon, but as a fierce advocate and mentor—especially for women navigating the complexities of diagnosis, treatment, and survivorship. 

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's no such thing of the podcast emergency right and jenn 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 transatlantic

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 say journey. I mean, hullabahoo. Okay, so let's use that. So Amanda's transparency through her breast cancer, Hullabahoo. Hullabahoo or Hullabaloo?

We're going with who. It's not a word, but I just think I liked it. Okay. Hullabahoo, it is. And it's hard. What we're going to 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 discover as 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-Hullabahoo and what she wants you to know that could save your own life. Amanda, no pressure. 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 ungate keep 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 that 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 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 and that's what i think we should be doing with breast cancer awareness month so i feel excited and i just want to like you like 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 family's 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. Right. That's just anxiety. Awareness without a plan is anxiety. So I mean, I think 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 hullabahoo, these 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 there 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 our decisions. So that's what we're going to do in the second half. Wow. 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 percent of breast biopsies come back negative like you 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 zero percent impacted.

Zero. Except I have nice, perky, plastic breasts. You really do. They're lovely. They're lovely. The hullabahoo. Booby Prize. It's a booby prize.

It's a booby prize. Okay. So I say that a little bit in jest, but I'm saying zero percent impacted. Right. 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 manogram, 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 Suzy. 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 screaming 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 different for 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 biopause. see 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 whole. 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 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 is 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 and 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 100% 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. Because the contrast. The 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. They're 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 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 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 C 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 and 10 people? And if you're category D, you absolutely cannot rely on your mammogram. So it's kind of this false sense of, well, 50% of the people have it, it can't be that bad because they category 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 heterogeneous. 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 breast had to be removed for cancer because you literally can't see it. And I, 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 is probably thinking right now? So let's just get it out of the way. If you know that a C or D breast is 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, 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? 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 no other anything makes sense there is a certain threshold under which you absolutely have the right to um you 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 a certain threshold of likelihood that you are above 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 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, 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. Okay. 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 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 ten 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 carry out 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 it you're you're 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

um efficacious from a diagnostic perspective for breast cancer so you can act 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 um the only d ever associated with my breasts is density um and i just I'm really excited that Dr. Dela 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 thrown open gates. Gate opener. Gate opener. And what is wild is that, do you remember Lori from our Virginia

event? Yes. 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 just I was just diagnosed with breast cancer and the only reason I got my diagnosis was because of your episodes that um 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 like 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 um 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 who are you working with and um she said Dr. Jela Cruz oh my god that's right and then we crazy both started crying because I was like you're gonna 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 um it it just

felt like like i know there's other like incredible doctors in other virginia i'm not saying not it just felt like it is like connection of that she had found her way there then two weeks later i'm walking into my one-year appointment with delacruz i walk in and i'm i 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 was, 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 the actual operating room it was so beautiful amazing 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 here from Dr. Dela 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 important.

This is going to be so helpful. Okay. So we're going to talk to Dela Cruz now? So what we're going to do is I am, I'm stealing Dr. Daly Cruz to myself. Okay. So she and I are going to get on, and it's basically going to 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 her. Tell Dr. De La Cruz, we love her. My favorite part was right after when after my surgery when I went out. I was like, I was texting you and Abby, and I was like, I think, I think it went well.

And then, and then you both texted back and you were like, it did go well. Delacruz already sent a picture of your breasts to us. Yes, it's the waiting group. I was like, they look great. Okay. We love you. All right. Bye.

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. We live in a culture that treats love like a finish line. You win if you get the relationship, the ring, the picture perfect story. Now listen, you know I love winning, and I will make racing from the car into the grocery store into a game just so that I can win it. But the truth is, love isn't a race.

or a prize. It's a practice. It's something you choose and keep choosing. The way I love you, Glennon, is by seeing who she is, what she does, and respecting the hell out of that so much that I want to contribute as much as possible in our shared life. So she does the laundry in our house. Thank you. And I make sure to take off my socks before I toss them in the laundry and turn them inside out so that she doesn't, isn't that the worst part of laundry having to turn things right side out? And I love her in the million tiny invisible ways choosing to give her more life back, really. That's why I support Bumble's message to its members. It's not about one big moment. It's about the ongoing practice, setting intentions, being

honest about what you want, and creating space for connection that feels real. Listen, You can win a race, but if you're running in the wrong direction, is it really a win? Bumble makes sure you are running in the right direction, supporting you with the tips in the right moment and a dedicated expert-backed advice hub. So it's just designed to get you through every stage of your dating journey. Because love isn't a finish line, folks, it's a daily act of showing up for yourself and for someone else. 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, you know, I've aged since I've been in. 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. Let's really hope there are. We're the minority of the minority of the minority in the surgical field. So 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 her.

So, Dele 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, 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. it did um 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 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 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 going to have to lose your nipples you will have your lymph nodes removed then another doctor which the only reason I had enough 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? 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 surgeon. 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. 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. Lle, Zatowski, she said, Lucy, never stop learning. Because when you stop learning, it's not just you that your career is trumped, but your patients get, 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 oncologically safe, but physically, 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 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, I said, 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, you'll either a lumpectomy or mastectomy. if you have the 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 leaving, you know, that I'm putting cosmetic in front of cancer. No, I'm actually, I think there's no reason to not prioritize conchologic 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 ideas 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 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-niple 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 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 a. 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 can't, 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, my past, you know, when I first started, when I was young and fresh and Bushies Bride,

and I wanted to do everything, you know, kind of like, you know, kind of what every, a lot of, 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 in me. And then you would have said, Lucy, you did everything I, 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 going to have to get an MRI, a mammogram.

Am I going to 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 if 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 lower recurrence rate, but 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, 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 have babies, my body's coming in my 40s, like my body's changing. And then I'm 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 time.

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. 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? Yeah. 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 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 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 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 it's, 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 year. So 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 to like, you know, the end of time. Because we do remove 98% of the breast tissue. There's 2% of breast tissue that it's entangled within your subcutaneous fat and skin.

I would say you have like very little of it because you're, but some women, it just depends on your BMI. It depends on your body habit. the skin flaps thickness is really relative to 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 the subcutaneous fat left

behind. And you're holding up like a millimeter of 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 your skin alive. So patients say, okay, well, for me, that local recurrence risk is too high, and I don't want to live with that.

I 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 doesn't mean that you're going to die of breast cancer. Actually, most patients who have a recurrence don't develop, 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 a mastectomy at that way. Probably a mastectomy. That would be the medication. 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 lymphectomy versus 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, and 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 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 5% percent, 20 years is 10 to 20%. Okay, 10 years, 10 to 20%. No, 10 years is 5 to 10%. 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, we go and deal with the cancer again if it recurred. So 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 if 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 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 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 layperson, 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 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 ducks, which are little like highways. Imagine little highways kind of like I-95 and then has little streets that end in the lobules. The lovials are the infrastructure where milk is made. So when cancer is within the duct, which is the most common location for breast cancer to happen in those little highways or little street, that ductal carcinoma.

The inside to means that it hasn't broken to 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, it 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 the same thing can happen in the 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 who 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 positive breast cancer, which are two hormones. And the lesser common are the ones that are hurt too 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, 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 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, 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, like, 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 um that community is also very important when patients are facing this decision exhaustion um you know unknown what to go like what your sister and uh 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 a 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 this is your body you ultimately make the decision about everything by the way about about from the beginning to the end and we're just here to guide you to make you to make you

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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 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.

Yeah, like, you can go 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 do they call? Inserts. 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 plates. They literally are plastic balloons. They're like silicone kind of and they put it in. Silicon. Okay. I don't know.

I haven't seen one in many years. I can't tell you what they're going to show up. 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 and 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 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 breast. 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 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. No, it's 17.

We stopped doing, I stopped, in my patients, we're not getting tissue expanders. They were having immediate reconstruction with directive. implant. And I started to realize that patients' recovery was much better. Obviously, they don't have to pay 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 the tissue expander at that time was patients who needed radiation. if they want to put the free flap, meaning your tummy type.

We changed along the way because I said, 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 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. There's no contraindication for an implant to be radiated. Actually, it's kind of nice because it gives.

the full expansion to the skin towards the outside, and the radiation oncologist can do their mapping and they're 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've 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 breast 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 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. Like I said, I was doing it when I was a fellow. I was doing it. I was a resident. I did it beginning 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 want to have another second surgeon. 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 procedure, right? Deep. D-I-E-P, which is deep and fear epigastropedical. 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. 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 reconnected to a vessel in the chest. We have a large volume of patients that come for that as well for that kind of reconfigure. 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 like 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, 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, 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 cancer patient 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, you know, 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 Yahoo's 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 the younger school of thought like anapel

in san francisco does it every day she just recently came out and said i have a breast cancer a diagnosis after having cancer seven years ago and she went on her social media and said i am having a bilateral nipple spary mastectomy 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 yeah 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 type 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 massage. I don't know if this is true of lumptectomies, 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, like you have anesthesia and you can put your hand on yourself and you know your hands there because you can see it, but you don't actually feel it.

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. 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 Time 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, I continue 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. Like any good coach. 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 bone 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. Delacruz, you had told me about it. You had told me that I was going to have chest bone 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 an appellate like i mentioned to her she's a great pioneer in the recensation 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 um so anyway she started doing we talked about it one day and 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 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 float 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. For a bit of man walk around for 30 minutes without like an implant in. By the way, I was having this conversation this weekend and 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 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 surgeons said, yeah, of course, but let me remind you that our key acting in 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'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 loud. louder and louder. And I, and I, 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 that they don't just kind of stay with the answer and take that as a final answer. They go out there and they do their 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

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anyway. You can start again. Bumble helps people do exactly that. Start your love story today on Bumble. 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're 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. It's like, we do it for everybody. Yeah, which is, which it should be for everyone. If there's 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 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. So you can continue to be the person that you are by, you know, getting dressed in the morning and not thinking about the cancer that you had to change 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 closest thing to potentially regaining that sensation so that when you get dressed, when you're blowdry in your hair and doing a curling iron and your iron falls, you burn yourself and you don't realize you that you did, that you can actually say, oh my God, I burn myself and take care of it. Because some people may not even notice like I've burned. I've had patients who burn themselves, I've burned themselves with curling iron, and they

didn't realize they had to 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 four, which innervates this area here. we try to preserve so this is what the structural mastectomy is we try to preserve the um they're called something called in perforators meaning the vessels that provide blood supply to your skin if you 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 which means the skin basically dies skin dies okay so when we're in the operating, 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 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. 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. 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 portion will preserve the sensation. The nipple and sensation, we can't preserve because obviously we 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 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, their called synaptic signals, meaning it's sending them in the brain. It wants to find it's, I call it always the, it's 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, there's, but they're, 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 isn't cover it, we submit like a special request for it and then try to do it. Well, I have full skin. I, I, 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 like,

so that's like a double extra. Yeah, that's for you. Now, and I have some, yeah, that's like a, that's a good. Good job. Put it on your wall. 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 Ann Pellet 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 for... 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 sparemestectomies do they do? How often do they do direct to 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 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 to 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 sparemisectomies, right? We do nipple sparymestectomy, I don't know, 98% of the time in patients. And I'm not just talking about the nipple sparymestectomy of a small breast. I'm talking about that complex nipple sparing mastectomy that I told you about, that women who have really large breast 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 mastectin 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. Oh, two weeks after surgery. I was like, I mean, we wanted to work out.

You were like, I'm ready to work. Let's be. let's be clear delacris 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 what i think maybe i may have confused you with another one of my patients who was like texting me at 10 days my drains are putting out 20 cc's can i do yoga with the drains i was like no you cannot do yoga give it a beat no that wasn't me it wasn't okay it wasn't you then well she reminds me of you because she was like very like i'm running and i'm like listen you have to stop doing what you're doing

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 words and you tell me if this is right. So in my case, 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 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. We are here about margins. They take 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 what 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? And 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 going. 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 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 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, 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, wait, but you did a nipple sparemestectomy, and she had 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 never get rid of her. So there was a lot of, like, fibers that was in the breast from her having breastfed, along with milk that I found in the operating room. But my point is that not everything that is picked up on the MRI, it's cancer, right? And so if we assume that all of these women have a nipple, cancer at the nipple, which is not the most common location of breast cancer, most common breast cancers appear in the upper outer quadrants of the breast, then we are taking unnecessarily these nipples. And does that, is that, because that goes to my last question

about innocent until proven guilty. Is that how you feel about the sentinel lymph? No. Oh, for the D.C. Yes. No. So let me just, I can answer this very quickly or very, specifically. So in olden days, we used to remove lymph nodes for anybody undergoing mastectin. So 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 is not across the barrier, as I mentioned before. It's all within the milk duct.

Those cancers have very, very, very, very low, low, low, low, 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 notes. We used, we never sample lymph nodes for patients with these, I'm not going to say never. Never is a strong word. But we usually don't sample lymph notes for DCIS under a lumpectomy. We'll get a lumpectomy. Because if they have invasive cancer, we could always go back and do a lymph, no, 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 Xylla. 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 lymphidema that's 5%. Lymphidema may be permanent. So once you have it, you may not get rid of it. You could only treat it. Okay. So one of the things that we use at Georgetown is this technique called mag trace. Mag trace 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 to 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. it 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 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 note. And again, like I told you, Amanda, if it comes back that you have invasive cancer, we'll go back and take out lymph notes. 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 mastectin. That's literally one in 10 women or 0.5 women, every 10 women saved them, like needed it. So imagine removing 95% of lymphills that never needed to remove or one out of, you know, 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 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 lymphoma biopsy. It's called the sound trial. Again, these are very much nichey things. I want you to discuss it with your doctor. Still a 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 mag trace injection, which is.

for a deluge sentinel lymph no biopsy. So if you have DTS, your lymph nodes are also innocent until proven guilty. Exactly. So we are going to put the die in. So we have tagged them. If they are guilty, we are ready to take them in. Okay. Amen.

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 didn't, it wasn't. great. But also, you can get numb to the armpit after surgery. Some people develop courting. Some people, you know, like I said, you can develop lymphitis. So it's not a naive procedure to just do a simple, 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 lymphopsy has been really changed. in our practice, practice changing for all of us at Georgetown. De La Cruz, we love you. You're probably late for another surgery. I'm so high. I have 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 for you, Amanda.

Thank you. And I'll tell Dr. Fan that you say hi. Oh, please do. I love it. Bye. Love you guys. Okay. Take care.

Bye. Bye. We Can Do Hard Things is an independent production podcast brought to you by Treat media. Treat media makes art for humans who want to stay human. And you can follow us at we can do hard things on Instagram and at we can do hard things show on TikTok.