Who's in Your Pod? Mary Barnhart, MD: The Breast Surgeon

Tina 0:00

Welcome to episode 43 of the Cancer Pod. In this episode, we talk with Dr. Mary Barnhart, a retired breast surgeon with a lifetime interest in nutrition and wellness. After attending medical school in the 1970s, Dr. Barnhart trained as a general surgeon, then went on to specialize in breast surgery for the rest of her career.

0:16

So stay tuned as we discuss integrative cancer care and her approach to patient centered medicine.

Tina 0:22

I'm Dr Tina Kaczor and as Leah likes to say I'm the science-y one

Leah 0:26

and I'm Dr Leah Sherman and on the cancer inside

Tina 0:30

And we're two naturopathic doctors who practice integrative cancer care

Leah 0:34

But we're not your doctors

Tina 0:36

This is for education entertainment and informational purposes only

Leah 0:41

do not apply any of this information without first speaking to your doctor

Tina 0:45

The views and opinions expressed on this podcast by the hosts and their guests are solely their own

Leah 0:51

Welcome to the cancer pod

Introduction

Tina 1:10

Hey Leia. How's it going?

Leah 1:12

Oh, hey Tina. Oh, you know,

Tina 1:14

another day, another podcast, another day, another podcast. And another guest. And another guest. This is very exciting. So today we have Dr. Mary Barnhart, who is a retired surgeon, I should say retired breast surgeon. But she came to surgery by way of first being a dietician, then a general surgeon, and then a breast surgeon. And she had her own practice up in Gresham, Oregon, And I will say it was the most amazing surgical suite when I got a tour of it many, many moons ago when you were there, there was a beautiful view of Mount Hood out the window of the operating room. That's what I remember best, besides the fact that there, you know, it was a lovely waiting room and.

1:59

Patient centered, but that operating room was pretty cool view. So anyways, um, the experience counts whether you're the surgeon or the patient. So, so we're gonna have a lot of questions for you around surgery, specifically around breast surgery, around general surgery,

Leah 2:16

around being female and being a breast surgeon. I mean

Tina 2:19

yeah,

Leah 2:20

you're, you're a pioneer.

Tina 2:22

Yeah. Blazing trails and you didn't even know you were doing it.

Mary 2:25

Well, thank you both Tina and Leia, a very gracious and, very kind introduction you bring up so many, um, memories as you're, talking between yourself, things that just were part of my life, walking along day by day.

2:44

You forget that perhaps there were some barriers that were broken down along the way, and because it was part of your. It was difficult to look at those at the time and say, Hmm, that's pretty interesting. And looking back in hindsight now, you realize that indeed there have been so, so many changes specifically in looking at the care of breast cancer patients. What a revelation, what a revolution. Both of those just. Really a wonderful positive change for patients today. Yeah. And so when

Tamoxifen

3:22

you first started, do you remember was, was Tamoxifen already approved for breast cancer when you started? Yes. During my training in, general surgery, which would've been in the 1980s, we were starting to use Tamoxifen as an adjunct to our breast cancer treatment with surgery and chemotherapy and radiation. So it was just coming into fairly common usage at that time. Okay. Yeah, I was curious cuz I know it became standard of care somewhere in there in the eighties or so, but uh, prior to that, it. Known to be effective. Correct. The discovery of Tamoxifen is a whole nother story that maybe we'll get into in another podcast, but you know, they were looking for birth control and kind of stumbled on it.

Tina 4:08

So that's a whole nother story for another day.

Mary 4:10

Absolutely.

Tina 4:12

So, so yeah, What took you from saying, I'm gonna do general surgery to, you know, I just wanna specialize in. Surgeries. What went on to have you land with a specialty?

Mary 4:23

Very interesting. Thinking back on that all of our life experiences coalesced together to make us what we are, and sometimes the path just opens up in front of us.

4:36

And going through my surgery training as a general surgery resident, there was definitely some pushback against me being a female in a man's world at that time. In fact, I was the second woman resident to go through and complete the general surgery residency and some of the things that the male surgeons would say to you during that training. Um, would've gotten them all thrown in jail these days. But we as women just, kept trudging along. So some people would say, Well, if you end up being a general surgeon, you're just going to, you know, do girl type surgery, maybe breast surgery. And it was almost an insult. And I thought, that's not right. These patients that have breast issues and breast cancer, yes majority of them are female, but they deserve someone who is very well trained and equally, if not more important, that really deeply cares about them, has compassion, is willing to deal with the emotional aspect. And I have previously shared with you that I made a big mistake. Getting too close to my patients, and I've lived to celebrate that. Not to regret

A patient lost, a career found

6:03

that there was one particular patient in my last year of surgical training who was such a fabulous patient. She did the surgeries that were recommended. She had chemotherapy. She did everything she was supposed to, and she did not survive her breast cancer. And I was so devastated by losing her. I took it as a personal loss that I had not done enough for her. And even though I had a job already waiting for me in Portland, Oregon. I called those two partners to be and asked them if I could expand upon the training that I had and do a breast fellowship because I was so curious about what did we miss? And even though it was one patient, in my mind, she represented thousands of potential patients and she was the one who, changed my life path.

Doctors are people too

Tina 7:06

I think that brings up something that we, we need to emphasize more often, and that is, um, Behind the medical degree behind the md, no matter what that person is, medical oncologist, radiation oncologist, in this case, surgical.

7:18

We have to remember that's a person and that, you know, there, there might be a hierarchy when people walk in the room, but it's a person. So giving people the grace as a patient or the caregiver or whatever to see the, see the doctor as another human being that goes home to a family and has, you know, inner conflicts that we all face as humans. Um, I think that's really important. And I know, I know that sometimes it can be hard because the system is set up to almost dehumanize the interaction and make it more of a technician. But I think that's really important for all parties to, to keep the humanity and the compassion in the interaction. And, and that relationship, that healing relationship is so important to patient's care and outcomes. That is, um, so, so important. And when you're discussing breast cancer with a patient, it doesn't just involve her, but it's her family, her friends, her support system. There's a huge emotional component and you need to be there as a fellow human being to not only discuss the. Issues related to potentially surgery and things might be involved with that. But you need to meet them where they are, whether they're frightened, whether they're brave, whether they're just putting on a brave face. Wherever they are, you need to be there with them. And while you cannot walk in their footsteps, you need to be there beside them to help them in any way that you can.

Does surgeon's gender influence care?

8:47

Totally agree.

Leah 8:48

Are there differences that you've seen in your, in your practice between how, and I don't wanna get into, you know, anything specific or like male against female, but just in terms of how you approached your patients versus how. Maybe a male breast surgeon approach patients. I mean, I have my own personal experience with, with the surgeon that I had, but I was just curious as to, um, whether, you know, like steering them one way or the other as to the, you know, the surgery that you thought was best versus, you know, hearing what they were saying and honoring their request.

Mary 9:25

What an insightful question. And their, in my experience was sadly a glaring, far too often glaring difference. I can remember hearing surgeons talking to a female patient, and I'm referring to a male surgeon talking to a female patient on the phone. This was not even face to. And I remember him saying, Well, if you were my wife, I just, um, you know, take that breast off, have a mastectomy. And, uh, and then he's flipping around in some pages and he said, Oh yeah, we can just fit you in next week. And I was horrified. I thought, first of all, to have that discussion over the phone, you need to be there in person. You need to be reading how they're taking that information in. Are they understanding it? Are they in a, a mess of tears? Are they surrounded by people who care about them? And to make that decision for them, was just heartbreaking to me. Although long before I heard, um, that conversation, I had seen that in action many times. In fact, in thinking back to. breast cancer surgery.

From whence breast surgery came

Mary 10:45

When I was a medical student, this would've been in 1970s, and then on into my general surgery training, I vividly remember that the patient would come in with a breast lump, we would say, Okay, we need to find out what's going on. So we'd do mammogram, possibly an ultrasound, say You need to go to the operating room, and we're just gonna take this lump out. So we would do an excisional biopsy, would take the entire lump out, send it to pathology. So here in the operating room, and these were done at under general anesthesia, we would all be waiting for the pathologist to cause back with the rapid frozen section diagnosis, basically. Was it cancer or was it. The patient sadly had to sign ahead of time that if that was cancer, she needed to grant us permission to move forward with a modified radical mastectomy at that time. So while the patient is asleep, her family friends are out in the waiting room. We were making decisions for her. Yes, she had quotes consented already. But that was a decision that ultimately we as her surgeons would make. And I remember it was so tragic walking into the recovery room after surgery and as the patients were waking up, coming out of general anesthesia, they would be reaching up and patting their chest. And I knew what they were doing is to find out if their breast was still there. So here they are groggy with anesthesia and they're looking up at the recovery room nurse and saying, Did they have to take my breast? and it would just break my heart. In fact, brings tears to my eyes now just thinking of that. that was how they found out what surgery they had, that's how they found out they had cancer. So it was such a tragic world to see that. And now to fast forward to where we are today, you can sit down with a patient and, and you should, in my opinion, sit down and carefully go through their options, never telling them what thou must do. But these are the options. Let me help you to make your best decision. This is not a decision that I'm going to make. This is not a decision that you have to make by yourself. We will talk this through however long that takes, however many visit it takes. That is the way for patients to make the best choices for themselves, not only emotionally, but long term in terms of their outcome and their survival. So to me, doing a quick little consult over the phone or injecting into the conversation, what you personally would do is not right.

What if it were you, Dr. Barnhart?

Mary 13:53

And over the years, I had many patients that would say to me, Okay, you've given me several options here. What would you do And that was such a common question and my answer. Was always the same frame differently for the situation. But I said to them, Your life experiences are very different than mine. I've had patients from age 18 up into their nineties, and they come from all walks of life, many different socioeconomic situations, many personal goals that they were on their way to achieve. So I would always share with them, Your life experiences are very different than mine. I have not lived your life. I am here to help you in this experience to make your best choice so that your quality of life and hopefully quantity of life going forward is the best that we can, um, provide for you. But I might make a very different decision for myself than you might make for yourself. And it's not fair for me to take away your personal choice. And I always told them, I said, After you have firmly made your choice. I will tell you if I felt it was a good choice. And I always did. I never broke that promise. If they asked, I always told them. And patience, if you give them the proper tools, you spend the time and you care, they will make fabulous decisions. When it comes to breast cancer treatment, very, very rarely would I find a situation where I felt a patient made a decision that was wrong for themselves. And in truth, they make the right decision. If you give them the tool they need and you're there for them, they're too smart, you know, they know what to do.

How about those that refuse surgery?

Tina 16:04

So here's a question cuz you're a breast surgeon. By the time they're coming to you, is surgery a given or did anyone ever say, Well I'm not gonna do surgery at all?

Mary 16:13

Yes, as a breast surgeon, I strongly feel that surgery when it comes to breast cancer is our very best tool. And that is not to underestimate the value of other treatments, terms of adjuvant chemotherapy, radiation therapy.

16:36

Um, I'm a huge, huge proponent of nutrition and lifestyle things that people can do and those can go on forever. But as far as a big blow to breast cancer, taking that tumor out of the breast is a really excellent, and in my mind, the very best way to attack it from the beginning. So patients, of course, always get to make the ultimate decision. And yes, there were a few patients over the years that decided that surgery of any type, even the most minimal excision, was not for them. And I recall one patient who made that decision not to do any surgery. And she continued to come in, see me. I said, That would be fine. I'll follow you along. And as you can imagine, um, things progressed and not in a good way. And she came in, in fact, this was the very last time I saw her. She had a Polaroid picture that she had taken. It was a picture of her chest. And she said, Mary, I want you to have this picture. I want you to promise me you will show this to any patient who in the future comes in and says, I do not want to have surgery. And I kept that picture in my top desk drawer. I never had to show it to anyone. I told patients in the future about it, but I never had to bring that picture out and show them, because as they thought about that, they got the message that this was a patient who had made an alternative. Choice. And not to say that there's not good roles for alternative medicine, but I think you have to do a more holistic approach. Everybody has to come to the table and contribute, and her body did not have the tools to combat that tumor and left unchecked, she ultimately succumbeded to her breast cancer. And fortunately, those patients are very few and far between. But again, a very sad reminder that we all need to work together. Yeah, and and the reason I ask is I. Many years ago, there was a small study by another surgeon in the Portland area who went on to track the people who refused surgery. Basically tracked them for years and reported on what happened, and some of 'em changed. Their mind ended up getting surgery when there was some progression, some had metastasis. It didn't bode well basically. So I think surgery for breast cancer is a given. What people do after that, you know, there's a lot of decisions, a lot of pros and cons to look at, but I do think. In my opinion, and I've always said this to anyone who came to my office, if they have biopsy, proven breast cancer, something in their game plan should be surgery. Yeah, I was, That's why I was curious. I, I'll put a link to that publication. Excellent advice. I totally agree with you that whatever is done before and after that surgical excision, that's up for good conversation. And there can be many, many approaches to maximizing quality of life and quantity of life. Again, get the tumor out if at all possible.

When did biopsies become routine?

20:17

What I find interesting about, when you're talking about the process, how you brought the patient into the operating room and then you excised. You know, what you thought, you know, would be the whole tumor. When did like core needle biopsies start happening where a patient can learn about their diagnosis before going into the operating room? I mean, that seems kind, I mean, that is standard of care. It's, you know, it's rare I think that somebody says, Oh no, don't biopsy it. Just pull the whole thing out. But, um, that seems like a really, I don't wanna say dramatic way of finding out you have breast cancer, if we're gonna put you out and when you wake up, you're gonna find that's like a game show. You know, like, you're, you're not quite sure what door you're gonna go through. Um, very well put Leia and truthfully, not an approach that any person would want to replicate, but sadly enough that stayed in place for a long time. And when the idea of separating your diagnostic procedure from your therapeutic procedure, um, came about, then patients at least had the option to say, Okay, um, if we're going to the operating room, we can do an excisional biopsy, which completely removed the tumor, or an incisional biopsy where we will remove a piece of it. And so we would then say, Okay, we're going to the operating room. We're going to find out what's going on, but we are not going to act upon it. And that stood for many years, probably through the. Eighties and nineties. And then this struggle came about between surgeons and radiologists because the radiologist had become very skilled at breast ultrasound and it was quite easy for them to take a small piece or a core of the lumper mass they were looking at and could then send that to pathology. So when the patient found out about their breast cancer was usually from a primary care physician, there was not a full team of breast. Oncologist involved at that time. And so when they would come to the office, in my particular situation, that was usually referral from the primary care physician and the patients had that four knowledge that they had quotes, a breast cancer. They knew very little about it other than the cell type. And so because there's so many factors and features of the tumor, that will dictate what surgical options might be available. That was where we started our discussion. But the initial diagnosis when the radiologist was working with primary care was something that the patient knew already and in some situations that was helpful. because patients had gone through the initial shock so were better able to understand what we were talking about. for others it was just a torrent of emotions that they could not deal with. And if someone had not helped them through those initial, several days, it was, really difficult to deal with them. But for most patients, doing that core biopsy was helpful because they were, again, forearmed with that information.

Leah 24:03

Mm-hmm.

Do biopsies spread cancer?

Tina 24:04

So I'm gonna tread into some territory the idea that biopsies may spread a cancer or, seed the cancer cells as the biopsy needle is pulled out of the tumor, or in some ways spread it

24:18

in lay language the idea is you're poking a was nest like, should we be doing this? So I I'm gonna put that out there cuz I feel like that's a common question and I think it's understandable. People are like, do I really wanna disrupt this? And you've been practicing as a surgeon before that was used and after that was used.

Tina 24:39

And what's your experience and your opinion on this?

Mary 24:42

That's a really interesting question and was actually at the core of this, controversy between the radiologist and their core needle biopsy gun and the surgeon scalpel. Because, as surgeons, we had always been taught and believed that if you can do no touch technique, you don't want to, cut through a tumor if you can, possibly avoid that.

25:10

So stay around that. Keeping your margins clear and a core biopsy was the opposite of that. Like you said, it was, attacking the W nest. And so lots of controversy and many, many studies, were done looking at that. And ultimately it was found that while intellectually you might question that happening, it didn't ultimately prove to be true. so we were then able to, move forward in that fashion and truthfully, All the surgeons began to understand that as well and say, Yes, this is fine for the radiologists to do that. And many of us as surgeons became, quite used to doing breast ultrasound and frequently used breast ultrasound in terms of diagnostic tools and then actually in the operating room to do our surgical excisions. And so the radiologist didn't like the surgeons learning how to do ultrasound, and the surgeon didn't like the radiologist doing core biopsy. So, you know, the, the controversy is kind of calmed down by now. Everyone's gone back to their corners, but it was an interesting era to live through. That one's for sure. it's kind of funny. There's territories isn't there? Oh, turf wars. Turf wars.

What were reconstruction options?

Leah 26:40

For the women that would wake up having had a mastectomy, what were the reconstruction options at that time? Because now, the plastic surgeon comes in after the breast surgeon and either places an expander or does immediate reconstruction or whatever.

26:58

You know, the patient has chosen as their, as their result, after surgery. So were there the options for reconstruction, for placing an implant or anything like that? At the time

Mary 27:12

when you were moving directly from an intraoperative excisional biopsy, weight on pathology, and move directly to a mastectomy, reconstruction was never an option.

27:27

In fact, in the. A transition of moving away from radical mastectomy to the modified radical mastectomy to skin sparing mastectomies. There was, a lot of transition that was occurring, and I always used to think of this as an involvement of progressive surgeons and brave women because the women with breast cancer pushed a lot of this. And some of the things that we ended up doing between patients and surgeons was because those, brave women said, Well, why don't we try this? In fact, I remember in the early 1990s, we had our. Ambulatory surgical center, and we had done an excisional biopsy on a patient she was found to have breast cancer on her diagnosis. And so in talking about her options, she said, I've decided I'd like to move forward with a modified radical mastectomy, which was an appropriate choice for her. And she said, But I wanna do it back in the surgery center. And at that time, as I said, this is the early nineties, I said, Well, that sounds nice, but you know, I've always done mastectomies in the hospital with, at least an overnight stay, maybe even a few days. Afterwards and she goes, No. She said that surgery center is very nice. I, I wanted do it there. So she talked me into doing it. So I talked with our anesthesiologist, our surgery team, and we thought, well that's probably fine. And she was in her sixties, pretty frisky little gal. And so we went in on Wednesday, did her surgery, and she goes trotting home. Within a couple hours after surgery. I was checking with her, you know, that night and every day and she was doing terrific. And, when I saw her back in the Austin next week, she says, Oh yeah, I went church on Sunday. I was bragging all my little friends what I did. So she was so influential in, you know, all of us, looking at this and saying why that was impressive, how well she had done. So I thought her whole experience was so different than when she was in the hospital. We had to carefully make sure that her anesthesia. Deep enough to be, you know, having her completely out during the surgical procedure, but light enough that she could wake up and go home in a couple hours. And we also did a lot of local blocks within the surgical site. So she had a lot of long term local anesthesia, but short term general anesthesia. And so when she left for um, home, she was in no pain whatsoever. She had no nausea, she was feeling fine and with judicious use of pain medication afterwards. She did extremely well and we found that over and over. And I remember from her, Particular situation on, I would start adding that to my options for patients. So we would talk not only about all these surgical options available to them, but would you like to do this inpatient? Would you like to do it outpatient? And so that was another way that patients, again, could be empowered to take control of what was happening to them because in any kind of medical emergency, patients feel like they've lost control, as we all know. Mm-hmm. And so anything that you can do to put them back in the driver's seat and let them be the one in charge, everyone else is, um, just coming along for the ride, but hopefully helping them with that. And so having that option to do. Um, procedures in the outpatient setting was something that progressed over time. And I remember again, progressive surgeons and, um, brave women. We would continue to push the envelope safely, of course, with procedures that we could do very safely with good patient selection, education of the patient and their family, to let them know you would be an excellent candidate for outpatient surgery. And so we became adept enough at that, that we would often do bilateral both breast mastectomy with immediate breast reconstruction. Now this would be tissue expanders or implant. We would not do the tissue transfer flap. Those were always an inpatient procedure, but, the, um, routine, um, breast conservation procedures, mastectomies with or without breast reconstruction. Those patients that opted for those surgical treatment would do very, very well in the outpatient setting. And I was a huge proponent of that because those patients tended to do so much better than those that were in the hospital and nothing against the hospital team. But there was no motivation on part of the anesthesiologist to keep the anesthesia very, very fine tune because they knew they were gonna quote, sleep it off overnight anyway. And so it was just a different approach and the patients being able to do their own pain control at home was often. Superior to waiting for a nurse to come in and maybe bring them some, um, pain medication. And also patients at home tended to be up rang around and being more active than those in the hospital. It was just a different experience, and again, patients taught us about that. They pushed us to do that because the experience had been so positive. And so as we shared that with them, many of them embraced it and were so, so happy with their outcomes.

Who's on the integrative care team?

Tina 34:14

So on the integrative care team side, because obviously as a surgeon you're instrumental what ancillary or integrative care. did you find most useful for people going through surgery for recovery and for, you know, everything people want afterwards, which is to feel as best as they can and to prevent recurrence? Like who did you work with and what types of professionals do you think are most appropriate

Mary 34:42

a very broad spectrum?

34:45

And I of course have to, give recognition to the role of a medical oncologist who could be involved, of course, with the administration of chemotherapy or hormonal therapy. And whether that was done before surgery, after surgery, neither or both. that of course, was a very big part of the breast cancer team. A radiation oncologist might similarly be involved. We would look at the timing. Of when radiation therapy would be instituted in relationship to surgery. Surgeons tend to be rightly so, a little selfish. It was kind of me first, me first. and the reason being potentially having to operate on radiated tissue or skin flaps can be challenging. Not necessarily impossible, but those are issues again, that have to be very, very carefully addressed. So giving kudos to my medical oncology and my radiation oncology colleagues. in addition to that, the team could be quite varied and if we had the ability to have naturepath oncologists such as yourself, that was a gift. And while not all patients were open to that, the patients that were gained a huge amount of benefit. And so in addition to what I was always promoting of, you know, let's look at the big picture here. a nature path and specifically if you had a nature pathic oncologist could be extremely helpful. And we also had the privilege of often working with specialty rehab therapists The ones that I worked with during my career were all trained as physical therapists and had gone on and had specialty training so could be very instrumental. In working with scar tissue that would develop after surgery and patients are all different in terms of how their body will respond to surgery and or radiation. so having a specialty rehab therapist is very, very helpful. so I advised almost universally my patients to see a specialty rehab therapist in the rare event that they develop some lymphedema, which is swelling of the arm related to lymph node, either surgery or radiation therapy. That again, would be a really helpful person to have a specialty rehab therapist help you in. um, an acupuncturist, chiropractor, massage therapist. Those are all critically important partners to the whole experience. And so you want to be respectful to the patient's time and their energy and not overwhelm them with so many visits and so many things on their calendar that they feel overwhelmed. And so being judicious in terms of your recommendations and being sensitive to the timing of all of it, and, the expense because things can, um, add up. Even those who are well insured will still encounter copays and the cost of the whole cancer journey and all of the treatment can become very costly, not only in terms of time and emotion, but um, dollars. And so you always wanna be sensitive to that, but the team should be, in my opinion, personalized to that patient. What makes sense to them and what would be the most value

Did you weave in nutrition advice?

38:47

to them.

Leah 38:47

So as a surgeon who was a dietician, how did your training in nutrition. Influence what you talked to your patients about in terms of either preparing for surgery, did that come into play or recovering from surgery?

39:04

Did you weave in that, that diet, you know, knowledge, with your patients?

Mary 39:10

Absolutely. No one got out without, hearing about that in one way or another. And, um, it's interesting that you asked in terms of, how that might influence patients in preparing for surgery and of course, afterwards and. I was, um, very open with my patients from the get go. So they knew from their first consultation with me that this was gonna be part of the package. And you know, if they go, Oh no, no, no, we don't want anything to do with that. You know, I kind of, you know, tone it down. But the ones who embraced it, we just had so much fun with it because I'm not exaggerating when I tell you that group of patients that really embraced the holistic approach, they just did way better than all the others. And it's because they were their own little doctor. They were doing the doctor thing too, because they were treating themselves with their, um, fork and knife and spoon. Every time they ate, or, you know, with their legs and arms every time they were out, exercising, and, you know, all of those aspects, they became the one that, that was their oncology contribution. And so in terms of, um, preparing for surgery, obviously you would want to make sure that, um, they weren't smoking. fortunately, not too many patients or smokers anymore, but you sometimes had to have the big talk with some of them and said, You are going to have a really challenging time, not only with anesthesia, but with your, um, healing after surgery. And there were some patients, if they were unsuccessful in quitting smoking, there were procedures that were not safely available to them. Like some of the types of breast reconstruction were just off the table because they would not heal. We knew they wouldn't heal. And so that was a big one. and always with, their medications, we would want to be sure that the medications that they were taking, taking would not interfere, say with, the whole, um, bleeding aspect because in surgery there's blood and so we would be very careful and judicious in stopping any blood thinners an appropriate amount of time for surgery. And, um, also if patients could adopt the most healthy diet that they could without upsetting them or, upsetting their family. And so I would encourage them even before surgery. Okay, let's work on increasing your fiber. Let's get those fruits and veggies in there. The best you can, the more of the, Cancer fighting veggies you can include the better. So you're gonna start this whole cancer journey on the right

Cancer Hates Cabbage!

Mary 42:28

foot. And I used to share with them, I said, Always remember this cancer hates cabbage and all it's friends. Oh my gosh, that's gonna be a t-shirt. Write that down, Tina. That's awesome. Cancer hates cabbage. I love that. I'm using that tomorrow. I must confess I stole that from Dr. William Lee. But um, he had it right in terms of, you know, there are so many things that patients can do and so if you make it fun and you know, we've all heard the eat the rainbow and all of that, there's so many fun ways to start eating a wonderful diet. And while each person needs to. You know, make decisions that make sense to them along the way. Again, patients are really smart and you give them the pearls that they need and they'll make a necklace. And so, in terms of, their eating, we would always encourage them to, you know, do the best you can ahead of time. Try to minimize your alcohol consumption. And as we'd talked about before, you know, you definitely don't wanna be smoking, but make sure that you focus more on whole. Leaving aside, highly processed high sugar foods and maximize your water consumption ahead of time. And then of course, following the, last day or so, specific recommendations that you need to follow prior to surgery. those are all, things that are not only helpful ahead of time, but afterwards too. So once a patient is in the recovery mode, then you have, issues, for instance, um, with pain control. Interestingly enough, most breast surgery that's done for cancer surgeries, especially breast conservation surgery or a mastectomy without reconstruction, is not that painful for the majority of patients. And I used to always share with patients, this will be emotionally more uncomfortable for you than physically. And I found that to be true very often. And so therefore their use of opioids after surgery was not that great. And so they didn't bump into the problems with constipation, but whether they were going to need a lot of pain medication afterwards or not, I was still always on the fruit, veggies and fiber bandwagon with them. And of course, keeping well hydrated, you know, was um, critical. And then walking something so simple or doing some light exercise following surgery, just again to keep them moving. Depending upon the particular surgery that they chose and we ultimately performed, that would dictate the fine points of how active they might be in terms of, um, lifting weights and whether they could pop back into the swimming pool or things like that. And so again, each patient and the surgery she ultimately chose and we did, would dictate those fine points. I think I shared

Leah, every surgeon's dream patient

Mary 46:04

this in a previous podcast, or maybe it's just a story I tell to anyone who will listen. Um, prior to my, mastectomy, I remember I was told, you know, you will have weight restrictions afterwards. And so we had this big hospital. Type scale in our kitchen because my, um, my husband's grandfather was like a small town surgeon. So we have his old scale. And I remember taking everything cuz I was gonna be off work for three weeks. Everything that I could possibly think of, a full pot of coffee I put on that scale. My purse, I put on that scale cause I was like, I was not gonna exceed my, my weight restrictions. you know, and I was gonna follow what the doctor said to a t but, uh, I just remember just weighing everything. Cause I, I would go for walks. Um, squatting was my big. Doing squats. That was like my, my big form of exercise, um, But yeah, scale I think is really important. Not for a patient to weigh themselves, but to weigh stuff around their house. Well, Leia, you are every breast surgeon's dream patient, Um, we wish that they were all as dedicated as you were. Um, and some of them you knew, they were just winging it. And, um, when they would come in for their post-op visits, you would see how faithfully they had adhered or not adhered to your kind recommendations to them.

47:35

So obviously you would be a dream patient and they all should follow your lead. Well, I also didn't have children, and I, that's something I often heard from my patients or hear from my patients is I'm gonna go, how long without holding my child, You know? And so that. I was fortunate in that, that I didn't have, um, have that, you know, on my plate cuz that would be hard, you know, you have a baby and you, you're not supposed to hold your, you know, your own child. So, Very much so. And those special people of your life to know that you'll have to make changes in your interaction with them, hopefully very short term, but, um, that's, that's hard and again, makes it so much. More important to be sure that the patient is making a decision that is going to work for their lifestyle. Um, certainly long term, but short term as best you can, you want to, um, come up with a plan that is one that they can live with literally. Absolutely. And you

Lymphedema, any tips?

48:45

know, before surgery, I know that you've had this conversation probably with every single patient, but before surgery, and this is true of other surgeries, not just breast surgery, but since we have you as a breast surgery, I'm gonna ask you in this sense, lymph nodes can often be taken and that can lead to a higher risk of lymph edema, which is basically congestion of a lymph flow. Is there something that you said always go do this? Was it the physical therapist who does lymph drainage? Was it something else? Was there, was there anything that you thought, Wow, this really makes a big difference in people who do this, have a lot less? Lymphedema later on. You know, the whole issue of, um, lymphedema, I think back when the old radical mastectomy or the, um, modified radical mastectomy in the early days, there was a huge focus on what they call axillary cleanout. So the goal was to remove every single axillary lymph node that you could see or feel. When you do that, you've had a huge disruption to the lymphatic flow from that, um, arm ultimately up through the axilla into the lymphatic drainage. In looking at that, you could almost guarantee that lymphedema would develop. As the transition moved away from that extensive lymph node dissection to with breast conservation, we started doing less and less axillary dissection. We did more sampling. We did sentinel lymph node mapping where you would target the most likely lymph node where those tumor cells had traveled. With that, you were able to, instead of removing 30 or 40 lymph nodes, maybe you know, 1, 2, 3, 4 lymph nodes with those being the ones closest to the breast. And so disrupting the main flow of lymphatic fluids through the axilla was much improved, but that being, With lymphedema. There's a huge variation on the theme in terms of why some patients will develop it and others will not. Even in situations where someone might have had a similar approach surgically and or related to radiation, some patients would have very little effect and others would be severely impacted with that, and some of. It had to do with body habitus. Some of the patients who had a little more, um, weight that they were carrying sometimes had a little bit more problem with lymphedema. But again, that was not universally the case. Oftentimes, patients who were quite athletic prior to surgery and continuing afterwards would not have as much of a problem, but it was never something that you could preoperatively predict. And so in terms of addressing that, was there any one thing that would make a difference? Certainly the specialty rehab therapists were very, very helpful in teaching the patients how to do manual lymphatic drainage so they could themselves. Basically encourage the lymphatic flow and as new little lymphatic channels would develop, they could often get ahead of their lymphedema. Some patients would have it for, um, many years, but were able to control it either with, um, compression garments. There are different degrees of compression with light sleeves and even, um, Puffy little compression jackets that they can, um, wear over their arms, say while they're sleeping. So again, some patients would find that if their salt consumption was too high, that would aggravate the, um, lymphedema humidity and heat would tend to aggravate that. That wouldn't mean you necessarily have to move to Alaska to deal with it, but sometimes being aware of the potential aggravating factors and doing your best to avoid those. And even things so simple as elevation of the arm and, um, not doing undue compression. In fact, it was interesting for years, the practice of avoiding taking blood pressure or starting an IV or even doing, uh, vena puncture in the involved arm was, um, tab. and I remember patients saying, How important is it that, you know, I always avoid, um, having my blood pressure taken head. So it often was, you don't wanna say it was a myth, but it was one of those ideas that had been passed on and on and on with maybe no real understanding of what was going on. So if lymphedema became very, very severe that the, um, lymph flow could not easily flow back through the axilla, then if the arm was really large, yes, you would not want to do a localized compression, even briefly with a, um, blood pressure cuff. But when you stop to think about it, drying blood or even starting an iv, were really leftovers from that potential. If you get an infection in this arm that has lymphedema, you will progress to a, you know, a virulent cellulitis. And so the intent in the beginning was very good, but yet was there really, um, practical significance to that? And now today where sentinel lymph node biopsy is almost always the way that the lymph nodes are addressed and if need be more lymph nodes removed, we don't see the same amount of lymph edema. And so some of those recommendations probably are, um, superfluous and not really needed. But if a patient feels more comfortable, absolutely fine. And hopefully you'll have, um, another good arm that you could use for those. Well, Leah, do you have any other last questions before we wrap it up? I actually do. So

What music played in the OR?

55:45

at the end of some of our episodes, I have come up with an unofficial theme song because we have our theme song that we use for the podcast, but sometimes there are more popular culture type songs that come through my head as we're doing an episode. And that made me think of, this is such a random thing, when I would get wheeled into surgery, the anesthesiologist often asked me, What do you wanna listen to? And I would tell him what I wanna listen to. So I get wheeled in and the music is playing. So, My question to you is, what did you like to listen to when performing surgery? that's a really, um, fun question to answer. And um, just as your experience was one where, um, they asked what you like, we did that as well. And so many times, patients would, you know, have their special, um, tunes that they liked or special types of, music. And as long as it wasn't, um, too wild and crazy, everything was fair game, sometimes there would be, Some of the surgical team, whether the nurses or anesthesiologists that might have a particular aversion or a particular like of some styles of music. And so the anesthesiologist, because they were the one ultimately in charge of the music, cuz they weren't, um, sterile in terms of their garb and so they could turn the music on and off. So the anesthesiologist almost always one out And so funny story, the um, song that um, was one that we all used to, um, join in singing was back in training. Weird Al Yankovich came out with like a surgeon So when that would, and back in those days it was, um, this really dates me, it would be on the radio. And so when like a surgeon would come on, the anesthesiologist would turn that up really high and all of us would start belting out like a surgeon cutting for the very first time. And so most of the time we didn't play that in front of patients, but, um, pretty much all types of music and, um, some of the patients would tell us after surgery parts that they remembered either going to sleep or waking up. And we were always careful when they were, waking up to have really soothing and, um, lovely music. And sometimes patients would say, you know, I thought I must have gone to heaven because the music was so heavenly when I woke up. So you had to be careful that it wasn't too heavenly that they think they didn't make it through their surgery. Yeah. Keep the harps to a minimum Exactly. So now, so that, that was, that was a good little insight because now we know that anesthesiologist is the dj. Yes, yes. Oh, I learned that when I was doing a rotation and, um, sat in on a surgery, I learned that yes, the anesthesiologist has the, at least up in Portland had is very extra large coffee and, and the music that was, that was their thing. I think that's universal Well, they do know their stimulants and depressants, so Yes, absolutely. So, um, as long as you had a good working relationship with, the anesthesiologist, always good.

Leah 59:31

Well, thanks for, Thanks for humoring me and answering my question. And we now have an unofficial theme song for this episode. Yeah, I was a big Al Yankovich fan back in the day cuz it was just goofy enough to sing along. That's awesome. Yeah, you have to enjoy the journey. Well, Thank you so much for joining us. This was great. This was great to have a little insight, get inside the surgical suite, find out what's happening there. so thank you for taking the time to join us and, uh, yeah, we may, we may get more questions from listeners and we welcome those if people wanna write to us or reach out on social media at the cancer pod.

Mary 1:00:11

And, uh, we can always gather up more questions and have you back someday. Well, again, that would be my honor, and the two of you are doing such a fabulous service for, humanity in general, and specifically right now in, um, looking at breast cancer patients, a fabulous group of people and so deserving of, what you're doing. So thank you again for letting me play a small part of all of it.

Leah 1:00:39

Well, thanks for, thanks for joining us. you both.

The Wrap Up

Track 1 1:00:43

I loved hearing. her talk about, and I really wanna hear more about her talking about being a surgeon back in the eighties, like I think that's such an interesting time to have been a woman and a surgeon. Like I bet she could write a book.

Track 2 1:00:56

Yeah. Yeah. Are there some kind of jokes where the default pronoun is a he? When they talk about a surgeon? I can't remember the jokes. I'm not so good at that.

Track 1 1:01:03

I don't know. We'll have to look 'em

Track 2 1:01:05

But yeah, it's one of those things where people just naturally Or I should say people did assume. I think the assumption is different now. I think it's more 50 50 in medical school even.

Track 1 1:01:15

No, I think I, I think that it still is assumed that if a female physician walks into a room, unless they have the tag that says, Doctor, I think people assume that it's a nurse. I think that still goes on.

Track 2 1:01:27

Yeah.

Track 1 1:01:27

Mm-hmm. I do.

Track 2 1:01:30

Maybe times are changing though. Maybe it's just because, you know, old guard.

Track 1 1:01:34

Well, there are more women, There are more women in, in medical school. so, but yeah, I, I don't know. I liked your stories. I think, I think it's, I dunno, we're, we're lucky to have been able to speak with her. I think that was great.

Track 2 1:01:49

Yeah. And I've known Mary for quite a long time over 15 years now, and. She's just always been so patient centered. The question is, how do we train more doctors to be that way? Right? I mean, she's that way as a person and she became a surgeon, but how do we institutionalize that person? Centeredness the, the compassion,

Track 1 1:02:12

the empathy. Can you teach someone empathy?

Track 2 1:02:15

Yeah. Or do you just recruit differently?

Track 1 1:02:18

Yeah. That might be, that might be the answer. Yeah. If anyone out there is listening and you're not following us, or you're not subscribed on your favorite podcast streaming app, do so now. follow us on social media. We are the cancer pod. So at the cancer pod, wherever social media may exist. Not everywhere. I'm not everywhere. I have not put us everywhere. But, um, you could send. Email, the cancer pod gmail.com If you have comments that you wanna share with us.

Track 2 1:02:48

Yeah, and there's, you know, I can see the stats on the, on the backside and there are, A good number of people who listen on Apple Podcasts, who don't hit that little plus sign and follow us. So if you could just do that and while you're at it, you may as well scroll down and see where those stars are and give us five because

Track 1 1:03:05

And leave a comment. Leave a comment as to like why you think that we are five star worthy

Track 2 1:03:12

Yes, cuz our little indie podcast needs to find more people and help more people out. And so the only way to do that is to, uh, get bumped up when people are looking for this kind of information.

Track 1 1:03:22

and share and share it. Send. Send an episode to a friend, a loved one.

Track 2 1:03:26

nothing says you care. Like sending an episode of the Cancer Pod,

Track 1 1:03:32

What's our T-shirt again? Cancer Hates Cabbage.

Track 2 1:03:34

Cancer hates cabb.

Track 1 1:03:36

God, I love that. Dr. William Lee. I think I follow him on the Instagram. So on that note, I'm Dr. Lea Sherman,

Track 2 1:03:44

and I'm Dr. Tina Kaser.

Track 1 1:03:45

and this is the Cancer Pod.

Track 2 1:03:47

Until next time

1:03:48

Thanks for listening to the cancer pod. Remember to subscribe, review and rate us wherever you get your podcasts. Follow us on social media for updates, and as always, this is not medical advice. These are our opinions. Talk to your doctor before changing anything related to your treatment plan. The cancer pod is hosted by me, Dr. Lea Sherman. And by Dr. Tina Caer music is by Kevin McLeod. See you next time.