I am Dr.
Lucy Maria de la Cruz, and I'm the chief of breast surgery,
as well as the director of the Betty Lou Ourisman Breast Center at MedStar
Georgetown University Hospital.
The type of patients that I normally see are patients who have been diagnosed
with breast cancer
or patients who are considered high risk or have benign breast disease.
Patients who are high risk are usually those who have a strong family history
or have a deleterious mutation who have been tested for such
I also have an interest in male patients who have breast cancer
as well as other benign disorders such as gynecomastia or breast pain.
My philosophy when it comes to patient care is very much in tune
with the philosophy of MedStar Georgetown University Hospital,
which is cura personalis, and it has to do with taking care
of the whole person.
One of the things that I really, truly value about our field
is that we're able to treat the person in a multidisciplinary approach
and make sure that their journey is a unique journey.
An individual journey and not, you know, one size fits all.
And when I became a resident, I met a patient
in my first year who had breast cancer, and she really touched my life.
She made me realize that I can be a surgeon,
treat women, and also create bonds that were lifelong
bonds with patients and be a crucial part of their journey.
And so I find that this is a very special field,
and I couldn't see myself doing anything else.
A lot of things excite me about the future
of breast cancer surgery.
There are so many advances that we're doing things to research in
not only the medical field as far as medical oncology,
immunotherapy, drugs, vaccines, potentially in the future,
but also as far as the radiation oncology field.
There's a lot of new technology that's coming out that we have here
as well available at MedStar
Georgetown University Hospital
and as well as surgical management of the breast cancer.
You know,
when I graduated from medical school, the way that we treated breast
cancer is very different than what we are treating today.
And so as I see the evolution of the treatment of breast cancer,
I get very excited because ultimately I hope that one day we won't be treating
breast cancer, but we will be preventing breast cancer with treatment.
Patients should come to MedStar Georgetown University Hospital, first and foremost,
because it's an NCI-designated comprehensive cancer center.
And what that means is that we are held to higher standards
across the board compared to other cancer centers.
It is the only one in the region and we have a multidisciplinary,
comprehensive center for breast cancer treatment
which entails breast radiologists, medical oncologists, radiation oncologists,
plastic surgeons, all who specialize specifically in breast cancer treatment.
We have state of the art
and cutting edge technology in and outside of the operating room
as well as we have great supporting staff such as our nurse navigator,
our social worker who will help the patient navigate the system
as well as providing them access to other services, such as support groups,
other services, such as transportation that they may need along the way.
Aside from that, our staff here provides personalized care
for patients day in and day out.
I was intended to do this.
So, when you do what you love it's not work.
I always tell my patients
that I get a lot more from them than they could do from me.
When they tell me, 'thank you.'
You know, it's truly a blessing, what I do
The difference between lumpectomy
and mastectomy is the amount of tissue that we remove.
When patients have a lumpectomy.
It's essentially removal of the area of the cancer
with a rim of tissue around it, which we call a margin.
A mastectomy is the removal of 98% of your breast tissue.
But we're not removing skin or chest wall,
we're just removing breast tissue.
The reason
why someone would have a lumpectomy versus a mastectomy is really done
based on patient to patient.
We look at a lot of things in order to make a surgical decision.
The first thing is tumor size and the breast size.
So, depending on the patient's breast size, whether they have a small breast
or a larger breast, then they are more options.
So, if someone has a big tumor in a small breast,
obviously those patients we normally or would try to recommend a mastectomy.
If a patient has a big tumor in a big breast,
those patients, sometimes we can do a lumpectomy or a mastectomy.
And obviously, there's different scenarios that we go by.
But that's something a decision that patients usually do with the surgeon.
And it's very personal to them.
So, the difference between a lumpectomy and a lumpectomy
with oncoplastics is essentially, lumpectomy alone,
I remove the area of the cancer by myself and I take a rim of tissue around it.
There are some patients who are large breasted who are benefiting
from having oncoplastic surgery and oncoplastic surgery is essentially
me removing the cancer part, which is the onco part,
and then a plastic surgeon doing the reduction and the lift.
So, patients after surgery, they wake up and they have their cancer removed,
but they also have a reduction and a lift in both breasts.
So, the person who gets lumpectomy versus
a lumpectomy with oncoplastics is technically based on patient decision.
But also there are some patients that we need
the oncoplastic or the plastic part to be able to preserve
the shape of the breast after taking a larger area of cancer.
So, if a patient has really large breasts and they have a larger cancer,
we are able to still do press conservation
while giving them a lift and a reduction.
And this is very exciting.
Most people, you know, when I started doing surgery
when I was a medical student,
most patients who had a tumor larger than four centimeters
were recommended a mastectomy. Thankfully, due to oncoplastic surgery,
and the creation of this idea in our breast surgery world,
we're now able to do breast conservation in patients who otherwise would have been
recommended a mastectomy
Here at MedStar Georgetown
University Hospital, we offer three different types of mastectomies.
We offer nipple-sparing
mastectomy, skin-sparing mastectomy, or modified radical mastectomy.
So, the difference between them is essentially a nipple-sparing mastectomy is
where we remove the breast tissue through an inframammary fold or an incision
in the inferior portion of the breast where we remove 98% of the breast tissue.
But we do not touch anything of the skin.
We leave everything intact.
Not all patients are candidates.
There are some patients that unfortunately are unable to have this procedure
due to the location of their nipple; if it's too low.
Now, the skin-sparing mastectomy is the one
that is the most common, and those are for patients...
any patient can have that, but it's with the removal of the nipple.
And there is the modified radical mastectomy, which is for patients
who have more locally advanced disease like inflammatory breast cancer,
or patients who have lymph nodes that are extremely involved, who require
a removal of all the lymph nodes underneath the armpit, plus the breast tissue.
The patients today
that we make the decision for nipple-sparing mastectomy are mostly
based on the location of the tumor not being invading the nipple
or of patients not presenting with nipple discharge that is bloody.
And the other criteria is
if their breasts are too large or their nipple is located
below the inferior border of the breasts, which is called ptosis.
Here at MedStar Georgetown University Hospital, we work very closely
with our plastic surgeons to create a personalized treatment plan
and surgical plan to be able to provide most of our patients
with nipple-sparing mastectomies if it's considered oncologically safe.
Reconstruction for breast cancer
patients has truly evolved in the last decade or so.
When we used to talk about reconstruction,
we only thought about patients who had mastectomy.
Now, when we talk about reconstruction, we also talk about patients
who have breast conservation with oncoplastics.
So, if I was to divide the two different patients,
the one that has mastectomy with the one who has oncoplastic
with breast conservation or the patient who has a mastectomy has several options.
They can have something called a deep, which is an autologous,
meaning your own tissue from your belly is used for reconstruction.
This is done by plastic surgery.
I do the cancer procedure and the plastic surgeon
comes into the operating room at the same time
and does the reconstruction at the same time
that we operate on the patient and remove their cancer.
Now, the autologous or your own tissue reconstruction is very natural feeling.
Patients are able to feel like their tissue is their own.
They don't have an implant in.
And a lot of the times, you know,
I tell patients that if they gain weight or they lose weight, it changes with time,
you know, the reconstruction.
Now, not everybody's a candidate for that,
and we do have the option of an implant reconstruction or a tissue expander.
The difference between a tissue expander and an implant reconstruction or direct
to implant, which it's called, is really based on the plastic surgeon's decision
or there are some other criteria which is patient driven,
meaning if the patient's having radiation or if the patient had previous radiation
or the decision is sometimes made in the operating room.
Now a tissue expander, it's essentially a bridge
after mastectomy to be able to put an implant at a later date.
An implant is essentially the same that you would get for breast
augmentation, but it's done at the same time of the reconstruction.
Now, for oncoplastics,
when we talk about reconstruction in the breast conserving world,
we talk about oncoplastics which is usually a reduction and a lift,
or meaning closing of the defect that we've created by removing a larger
area of the breast.
The most common side effect of lumpectomy is usually stroma,
which is a fluid collection that happens after surgery.
That is obviously reversible and it goes away with time, but
it's very often seen after surgery about a week or two.
The other side effect that I tell patients all the time is
that sometimes we operate on patients who don't have a palpable finding.
And I see them in surgery,
I see them after surgery in their post-op visit
and they're like, 'Doctor, now I have a lump.'
That is usually scar tissue that forms.
And I always tell them that that's something that happens
right away after surgery, but it also improves with time.
The other complications are bleeding or infection.
Thankfully,
those complications are actually quite low and they're less than 3% of patients.
There's another thing that we normally talk to patients about.
So, when we do lumpectomies, we're trying to do something called
negative margins, meaning making sure that there are no edges
where the cancer is touching.
Now I practice something called cavity shave margins,
which has been shown to decrease the rate of positive margins
and that decreases in itself something called re-excision,
which is meaning a second surgery
to make sure that we go back and clean out the margins so those are
the typical things that we talk to patients about after lumpectomy.
One of the most common side
effects of mastectomy is chest wall numbness.
Now, whether it's partial or complete, it's very hard for us to really determine
pre-operatively and it's something that I really talk to patients about.
The reason is because when we remove 90% of the breast tissue,
we also cut nerves that are close to the skin.
So, I tell patients that after surgery,
to not put ice or heating pads because I have seen
a lot of patients who don't have feeling and they end up getting burned.
And so that's something that we talk to patients about.
A lot of them recuperate some of the sensation.
They still feel touch,
they just don't feel pain,
they don't feel hot and they don't feel cold
because those those nerves are very different.
The superficial nerves versus the deep nerves.
Other common side effects, obviously
other regular complications after surgery, which are bleeding, infection,
you're going to have scars, asymmetry.
You know, I always tell patients, unfortunately,
we can't make perfect, but we can make the closest thing to perfect.
And also there is something called post-mastectomy pain syndrome,
which is not really the pain that you experience post-operatively,
it's almost like a neuropathic pain or a nerve pain that happens
usually within two years after surgery.
It doesn't happen very common, thankfully.
But patients who do develop this benefit from physical therapy.
There are studies that show acupuncture is helpful.
And there are some medications that are given by our pain specialists
that are not narcotics, but they're nerve modulator medication
for this type of pain. The type of pain that they experience
is not the type of pain that goes away with Tylenol.
It's more like a sharp shooting pain or numb or tingling sensation
that they feel in their breast.
The clinical trials that we
do mostly in surgery, are truly about de-escalation of surgery.
So, at the beginning...1970s, we used to aggressively treat breast
cancer with surgery and we've realized that surgery
is an important component, but it's not
the only thing that is needed for breast cancer treatment, right?
In most patients. And so a lot of our clinical trials
have to do with decreasing the amount of surgery, therefore decreasing morbidity
for patients without impacting their survival.
So, a lot of the clinical trials that we do have open
have to do with de-escalation of treatment surgically
and allowing patients to be able to get other treatment options
that are equally successful and not impacting their survival.
The role of genetic testing is actually a crucial
one that we practice here at MedStar Georgetown University Hospital.
All of our patients are recommended genetic testing, and this is based on
the American Society of Breast Surgery expanding the criteria from very limited
to essentially anyone with a cancer diagnosis should be tested
for any mutation, not just BRCA mutation.
There are other mutations that are associated
with breast cancer and other cancers.
So, when we talk to patients, I always tell them
that this is important information that they're going to get
and that it's very important for them to know,
not only for themselves, but their family members and also
to change their screening approach, not just for breast cancer,
but other breast cancers such as melanoma, colon, pancreas.
Patients should
come to MedStar Georgetown University Hospital for the breast cancer treatment
because we are a multidisciplinary center
where you will have treatment by all subspecialties
as well as a supporting staff that will guide you through the journey
from the beginning until the end.