today one of our coaches who said to me
so why do you do what you do so the
reason I do what I do is that when I was
going through Medical School I realized
that I was a fixer and I needed to fix
things so he became a general surgeon
and as I went into general surgery more
and more of my patients would say you’re
not a typical surgeon and I’d say what
do you mean by that will you talk to my
to us you talk as if we’re really
important and you’re not here just to
operate and so that’s how I ended up in
breast cancer surgery because my day
starts usually with many worried women
and I’ll give you a little story about
how that goes I walk into an exam room
and there she is
sometimes with a significant other and
sometimes not and she’s sitting on the
table and she’s looking like a deer in
the headlights
and she most of the time at this point
knows that she has breast cancer and the
first thing I have to do is I have to
walk up to her and hold her hands and
say this is curable because breast
cancer is curable and the thing about
breast cancer is that breast cancer is
not just one disease it’s at least four
different diseases and in about the year
2000 and Scientific American there was a
scientific article that said it may not
just be for diseases it may be ten
different varieties of disease and so
what I try to tell them even though
they’re sitting there with a pile of
papers from dr. Google is that we have
to treat breast cancer individually we
have to understand what kind of breast
cancer this particular patient has so
I’m going to take you through a journey
a journey that will look at what breast
cancer has been and where we’ve come
when it comes to surgery
because over the course of time
especially since the late 1970s we’ve
added other treatment options to the
surgical treatment of breast cancer and
those are not what we’re going to talk
about today those include hormonal
treatment and chemotherapy putting me to
guess we don’t have another slide ok I
had a diagram next one these are the
faces of breast cancer these are the
patients who you all see on a daily
basis in your Ladies Home Journal and in
the People magazine these are young
these are old these are the celebrities
they come in African American and Asian
they’re men I swear this was amazed that
Richard Roundtree actually had breast
cancer in 1993 and Peter Criss of KISS
had breast cancer so this is what you
wouldn’t it be great if we actually were
able to take care of breast cancer in a
one-day kind of fashion where did we
come from though
next the picture on your left is a
picture of a very ancient instrument
that was how we used to remove not that
I ever did I wasn’t that old but remove
the breast the picture on your right is
the modern-day giant and surgery dr.
Halstead dr. Halsted did what we learn
to be one of the major reasons that we
could cure breast cancer is the radical
mastectomy the radical mastectomy
actually was everything that we could
find on the chest wall it cured more
patients but the problem is when you
cure more patients we also at that type
of surgery we did a lot more disfiguring
teachers so by the 1970s we realized we
didn’t have to do radical procedures so
in the late 1970s we just left the
muscle in place and we took the breast
we would give the patient a very nice
flat chest and these slides are not my
slides that my latest version so I’m
going to apologize because I had some
really good pictures for you so I know
they’re not going to be here and so it’s
making me Norbit more nervous so I’m
just going to tell you this story when
we do the modified radical mastectomy we
leave the muscle and we take less lymph
nodes
what happened was we realized that we
didn’t have to always take all those
lymph nodes and we could just take the
lower two levels we still did
mastectomies but what we found is that
we could actually reconstruct the breast
and we could reconstruct the breast and
make it look almost like you were born
with well over the last 10 years we
actually realized that we could take the
breast leave the nipple in place in the
correct patient and the patient would
look almost like themselves I wish I had
my slides because I could show you a
patient who gave me permission to show
you what she looks like and she has two
breasts one is fake and the other one is
hers and they look identical but by the
1980s we realized that what we could do
is we could take a portion of the breast
and by taking a portion of the breast
and a little rim of normal tissue we can
make that patient live just as long as
the mastectomy patient but we needed to
do radiation and in the 1980s when we
did this study what we realized was that
radiation had to be the whole breast ten
minutes a day five days a week for six
well that’s fast-forward now about 15 to
18 years ago what we also found is that
maybe we can do less maybe more is less
and so what we did was
we started to use partial breast
radiation techniques where we actually
insert a device into the breast after
the fact and the patient would go to the
radiation facility they’d have this
device sticking out of their breast now
mind you it was bandaged in between so
we didn’t have to make them walk around
with this device fluttering in the wind
and so what they would do is up to this
machine and just radiate the area around
the breast tumor cavity and when they
did that we were able to do it in a
shorter time period twice a day for five
days and the catheter only had to be in
there for a week it decreased the amount
of radiation damage to the rest of the
chest wall but not everybody could have
this but a good portion of our patients
could do this so about 10 plus years ago
some very bright people said why can’t
we do this in the operating room
wouldn’t this be wonderful to have it
done all at the same time so there are
three different types of equipment that
have been used to do this intraoperative
radiation two of them use a low-voltage
type of equipment and one uses electrons
all three are still being used today but
in September the American Society of
radiation oncologists actually published
some guidelines that now makes it that
it can be used outside of an
experimental study because up until this
last month everything that we did
interoperative ly really was under an
experimental study electrons electrons
is the type of radiation that we are
most comfortable with it’s what we’re
used to being able to manipulate to do
treatment for all types of cancer
including breast cancer and so what we
now have at our disposal is the ability
to tell a patient that we can do it all
at the same time not everybody can have
this it has to be a patient with a small
tumor someone who doesn’t have any
cancer in their lymph nodes at the
time and it has to be something that we
can actually do and feel comfortable
about doing so I had a patient she came
to me recently and she walked and I told
you about dr. Google well they also come
in not even knowing what kind of cancers
they have and she said to me before you
even start I will only have an incision
this big I am NOT doing chemo I won’t
take that hormone blocking pill and I
want it all done at one time okay so the
good news is she fit all the criteria
but there was one thing I had to tell
her the machine I do radiation with me
and her incision has to be bigger and
she said well how big and I said I can’t
tell you as big as I have to make it I
won’t guarantee a nice you have to
guarantee me I said I can’t guarantee I
said I can guarantee that you’ll be
happy I’ll do it all at one time
and I’ll try to hide most of your scar
so it took me a while she had to go away
and come back a couple of times just to
get to the point where she could be calm
about her decision but we did it and
even though her incision was not this
big when she came back a week after
surgery she said okay you were right
it’s okay so the take-home message today
really is that breast cancer is curable
and we can do more in a smaller amount
of time with less treatment if we find
it early
yes breast cancer is scary and yes
everybody should have knowledge and
education about what their diseases
before they come in for treatment and
can make that decision and for all the
women in the audience get your
mammograms thank you [Applause]