Hello everyone, welcome to this CUBE Conversation here in Palo Alto, California. I'm John Furrier, host of theCUBE. We've got a great remote guest coming in, Joseph Nelson, co-founder and CEO of Roboflow, hot startup in AI, computer vision. Really interesting topic in this wave of AI, next-gen hitting. Joseph, thanks for coming on this CUBE Conversation. Thanks for having me. You know, I love the startup tsunami that's happening here in this wave. Roboflow, you're in the middle of it. Exciting opportunities.  I think computer vision has been talked about more as just as much as the large language models and these foundational models are emerging. You're in the middle of it. What's it like right now as a startup and growing in this new wave hitting? It's kind of funny, it's, you know, I kind of describe it like sometimes you're in a garden of gnomes. It's like, we feel like we've got this giant headstart with hundreds of thousands of people building with computer vision, training their own models, but that's a fraction of what it's going to be in six months, 12 months, 24 months. So as you described it, a wave is a good way to think about it and the wave is still building before it gets its full size. So it's a ton of fun. Yeah, I think it's one of the most exciting areas in computer science. I wish I was in my 20s again because I would be all over this. It's just so, it's the intersection of so many disciplines, right? It's not just tech computer science. It's computer science, it's systems, it's software, it's data. There's so much aperture of things going on around your world. So, I mean, you got to be batten all the students away kind of trying to get hired in there probably. I only imagine you're hiring regimen, I'll ask that later. But first, talk about what the company is that you're doing. What's it, how it's positioned? What's the market you're going after? And what's the origination story? How did you guys get here? How did you just say, hey, we're going to do this? What was the origination story? What do you do? And how did you start the company? Yeah, yeah. I'll give you what we do today and then I'll shift into the origin. Roboflow builds tools for making the world programmable. Like anything that you see should be rewrite access. So, do you think about it with the programmers mind or legible? And computer vision is a technology that enables software to be added to these real-world objects that we see. And so, any sort of interface, any sort of object, any sort of scene, we can interact with it, we can make it more efficient, we can make it more entertaining by adding the ability for the tools that we use and the software that we write to understand those objects. And at Roboflow, we've empowered a little over 100,000 developers, including those in half the Fortune 100 so far in that mission. Whether that's Walmart understanding the retail and their stores, Cardinal Health understanding the ways that they're helping their patients or even electric vehicle manufacturers ensuring that they're making the right stuff at the right time. As you mentioned, it's early. Like, I think maybe computer vision has touched one, maybe 2% of the whole economy and it'll be like everything in a very short period of time. And so we're focused on enabling that transformation. I think it's, as far as I think about it, I've been fortunate to start companies before, start, sell these sorts of things. This is the last company I ever want to start and I think it will be, should we do it right, the world's largest in writing the wave of bringing together the disparate pieces of that technology. What was the motivating point of the formation? Was it, you guys were hanging around? Was there some catalyst? What was the moment where it all kind of came together for you? You know what's funny is my co-founder Brad and I, we were making computer vision apps for making board games more fun to play. So in 2017, Apple released ARKit, augmented reality kit for building augmented reality applications. And Brad and I are both sort of like hacker persona types. We feel like we don't really understand the technology until we build something with it. And so we decided that we should make an app that if you point your phone at a Sudoku puzzle, it understands the state of the board and then it kind of magically fills in that experience with all the digits in real time, which totally ruins the game of Sudoku to be clear. But it also just creates this like aha moment of like, oh, wow, like the ability for our pocket devices to understand and see the world as better, good or better than we can is possible. And so, you know, we actually did that, as I mentioned in 2017 and the app went viral. It was, you know, top of some subreddits, top of Imgur, Reddit, the hacker community as well as Product Hunt really liked it. So it actually won Product Hunt AR app of the year, which was the same year that the Tesla Model 3 won the product of the year. So we joked that we share an award with Elon or share in blowing titties. But frankly, so that was 2017. Roboflow wasn't incorporated as a business till 2019. And so, you know, when we made Magic Sudoku, we, I was running a different company at the time. Rad was running a different company at the time. And we kind of just put it out there and we're excited by how many people liked it. And we assumed that other curious developers would see this inevitable future of, oh, wow, you know, this is much more than just a pedestrian point your phone at a board game. This is everything can be seen and understood and rewritten in a different way.  Or we were talking about some retail use cases of automated checkout. Like anything can be seen and observed. And we presume that that would kick off a Cambrian explosion of applications. It didn't. So you fast forward to 2019, we said, well, we might as well be the guys that to start to tackle this sort of problem. And because of our success with board games before, we returned to making more board game solving applications. So we made one that solves Boggle, you know, the four by four word game. We made one that solves chess. You point your phone at a chess board and it understands the state of the board and they can make move recommendations. And each additional board game that we added, we realized that the tooling was really immature. The process of collecting images, knowing which images are actually gonna be useful for improving model performance, training those models, deploying those models. And if we really wanted to make the world programmable, developers waiting for us to make an app for their thing of interest is a lot less efficient, less impactful than taking our tool chain and really seeing that externally. So that's what Roboflow became. Roboflow became the internal tools that we used to make these game changing applications readily available. And as you know, when you give developers new tools, they create new billion dollar industries, let alone all sorts of fun hobbyist projects along the way. I love that story. Curious, inventive, little radical, break the rules, see how we can push the envelope on the board games. That's how companies get started, great story. I got to ask you, okay, what happens next? No, okay, you realize this new tooling but this is like how companies get built. Like they saw their own problem because they had, because they realized this one but then there has to be a market for it.   And like, okay, wow. Were you guys conscious of the wave coming? Was it one of those things where you said, look, if we do this, solve our own problem, this will be big for everybody. Did you have that moment? Was that in 2019? Or was that more of like, it was obvious to you guys? Absolutely. I mean, Brad puts this pretty effectively where he describes how we lived through the initial internet revolution, but we were kind of too young to really recognize and comprehend what was happening at the time. And then mobile happened and we were working on different companies that were not in the mobile space and computer vision feels like the wave that we've caught. Like this is a technology capability that rewrites how we interact with the world, how everyone will interact with the world. And so we feel we've been kind of lucky this time, right place, right time of every enterprise will have the ability to improve their operations with computer vision. And so we've been very cognizant of the fact that computer vision is one of those groundbreaking technologies that every company will have as a part of their products and services and offerings. And we can provide the tooling to accelerate that future. Yeah. And the developer angle, by the way, I love that because I think, you know, as we've been saying on theCUBE all the time, developers of the new de facto standards bodies because what they adopt is pure, you know, meritocracy and they pick the best if it's self-service and it's good and it's got open source community around it. They're in, it's all in and they'll vote. They'll vote with their code. So, and that is clear. Now I got to ask you, as you look at the market we were just having this conversation on theCUBE in Barcelona at recent Mobile World Congress now called MWC around 5G versus Wi-Fi. And the debate was specifically computer vision that facial recognition, someone was, we were talking about how the Cleveland Browns were using facial recognition for people coming into the stadium. They were using it for ships in international ports. So the question was 5G versus Wi-Fi. My question is, what infrastructure or what are the areas that need to be in place to make computer vision work? If you have developers building apps, the apps got to run on stuff. So how do you sort that out in your mind? What's your reaction to that? A lot of the times when we see applications that need to run in real time and on video they'll actually run at the edge without internet. And so a lot of our users will actually take their models and run it in a fully offline environment. Now to act on that information you'll often need to have internet signal at some point because you'll need to know how many people were in the stadium or what shipping crates are in my port at this point in time. You'll need to relay that information somewhere else which will require connectivity. But actually using the model and creating the insights at the edge does not require internet. I mean, we have users that deploy models on underwater submarines just as much as in outer space, actually. And those are not very friendly environments to internet let alone 5G. And so what you do is you use an edge device like an NVIDIA Jetson is common, mobile devices are common, Intel has some strong edge devices, the Movidius family of chips for example. And you use that compute that runs completely offline in real time to process those signals. Now again, what you do with those signals may require connectivity and that becomes a question of the problem you're solving of how soon you need to relay that information to another place. So that's an architectural issue on the infrastructure. If you're a tactical edge warfighter for instance you might want to have highly available and maybe high availability. I mean, these are words that mean something. You've got storage, but it's not at the edge in real time but you can trickle it back and pull it down. That's management, so that's more of a business by business decision or environment, right? That's right, that's right. Yeah, so I mean, we can talk through some specifics. So for example, the Roboflow actually powers the broadcaster that does the tennis ball tracking at Wimbledon. That runs completely at the edge in real time in technically to track the tennis ball and point the camera, you actually don't need internet. Now they do have internet of course to do the broadcasting and relay the signal and feeds and these sorts of things. And so that's a case where you have both edge deployment of running the model and high availability act on that model. We have other instances where customers will run their models on drones and the drone will go and do a flight and it'll say, you know, this many residential homes are in this given area or this many cargo containers are in this given shipping yard or maybe we saw these environmental considerations of soil erosion along this river bank. The model in that case can run on the drone during flight without internet but then you only need internet once the drone lands and you're going to act on that information. Because for example, if you're doing like a study of soil erosion you don't need to be real time. You just need to be able to process and make use of that information once the drone finishes its flight. Well, I can imagine it's a zillion use cases. I heard of a use case interview to a company that does GPU division to help people see if anyone's jumping the fence in their company. Like they know what a body looks like climbing a fence and they can spot it. Pretty easy use case compared to probably some of the other things but this is the horizontal use cases, so many use cases. So how do you guys talk to the marketplace when you say, hey, we have generate AI for computer vision. You might know language models that's completely different animal because vision's like the world, right? So you got a lot more to do. What's the difference? How do you explain that to customers? Like here's what can I build and what's their reaction? Because we're such a developer centric company developers are usually creative and show you the ways that they want to take advantage of new technologies. I mean, we've had people use things for identifying conveyor belt debris, doing gas leak detection, measuring the size of fish, airplane maintenance. We even had someone that like a hobby use case where they did like a specific sushi identifier. I don't know if you know this but there's a specific type of white fish that if you grew up in the Western hemisphere and you eat it in the Eastern hemisphere you get very sick. And so there was someone that made an app that tells you if you happen to have that fish and the sushi that you're eating. But security camera analysis, transportation flows, plant disease detection, really, you know, smarter cities with people that are doing curb management identifying. And a lot of these use cases, the fantastic thing about building tools for developers is they're a creative bunch and they have these ideas that if you and I sat John for 15 minutes and said, let's guess every way computer vision can be used, we wouldn't be able to fill, we would need weeks to list all the example use cases. And we miss everything. And we miss it all. So having the community show us the ways that they're using computer vision is impactful. Now, that said, there are of course commercial industries that have discovered the value and been able to be out of the gate. And that's where we have the Fortune 100 customers like we do, like the retail customers in the Walmart sector, healthcare providers like Medtronic or vehicle manufacturers like Rivian, who all have very difficult, either supply chain, quality assurance, in stock, out of stock, anti-theft protection considerations that require successfully making sense of the real world. Let me ask you a question. This is maybe a little bit in the weeds, but it's more developer focused. What are some of the developer profiles that you're seeing right now in terms of low hanging fruit applications? And can you talk about the academic impact? Cause I imagine if I was in school right now, I'd be all over it.  Is there, is there is the uptaken in both areas of younger pre graduates and then inside the workforce? What are some of the devs like? Can you share just either what their makeup is, what they work on, give a little insight into the devs you're working with. Leading developers that want to be on state-of-the-art technology build with Rubble Flow because they know they can use the best in class open source. They know that they can get the most out of their data. They know that they can deploy extremely quickly. That's true among students, as you mentioned, just as much as industry. So we welcome students and I mean, we have research grants that will regularly support for people to publish. I mean, we actually have a channel inside our internal Slack where every day more student publications that site building with Rubble Flow pop up. And so that helps inspire some of the use cases. Now, what's interesting is that the use case is relatively, useful or applicable for the business for the student. In other words, if a student does a thesis on how to do, we'll say like shingle damage detection from satellite imagery. And they're just doing that as a master's thesis. In fact, most insurance businesses would be interested in that sort of application. So that's kind of how we see uptick and adoption both among researchers who want to be on the cutting edge and publish, both with Rubble Flow and making use of open source tools and tandem with the tooling that we provide just as much as industry. And I'm a big believer in the philosophy that kind of like what the hackers are doing nights and weekends, the Fortune 500 are doing in a pretty good order of period of time. And we're experiencing that transition. Computer vision used to be kind of like a PhD, multi-year investment endeavor. And now with some of the tooling that we're working on and open source technologies, the compute that's available, these science fiction ideas are possible in an afternoon. And so you have this idea of maybe doing asset management or the aerial observation of your shingles or things like this. You have a few hundred images and you can de-risk whether that's possible for your business today. So there's pretty broad based adoption among both researchers that want to be on the state of the art as much as companies that want to reduce the time to value. You know, Joseph, you guys and your partner, I've got a great front row seat, ground floor, present at creation wave here. I'm seeing a pattern emerging from all my conversations on theCUBE with founders that are successful like yourself, that there's two kind of real things going on. You got the enterprises grabbing the products and retrofitting into their legacy and rebuilding their business. And then you have startups coming out of the woodwork, young, seeing Greenfield or pick a specific niche or focus and making that the signature lever to move the market. So can you share your thoughts on the startup scene, other founders out there and talk about that. And then I have a couple of questions for like the enterprises, the old school, the existing legacy, a little slower, but the startups are moving fast. What are some of the things you're seeing as startups emerging in this field? I think you make a great point that independent of Rebelflow, very successful, especially developer focused businesses kind of have three customer types. You have the startups and maybe like series A, series B startups that you're building a product as fast as you can to keep up with them. And they're really moving just as fast as you are and pulling the product out of you for things that they need. The second segment that you have might be calling SMB but not enterprise who are able to purchase and aren't as fast of moving but are stable and getting value and able to get to production. And then the third type is enterprise. And that's where you have typically larger contract value sizes, slower moving in terms of adoption and feedback for your product. And I think what you see is that successful companies balance having those three customer personas because you have the small startups, small fast moving upstarts that are discerning buyers who know the market and elect to build on tooling that is best in class. And so you basically kind of pass the smell test of companies who are quite discerning in their purchases plus are moving so quick to pulling the product out of you. Currently, you have a product that's enterprise ready to service the scalability availability and trust of enterprise buyers. And that's ultimately where a lot of companies will see tremendous commercial success. I mean, I remember seeing the Twilio IPO, Uber being like a full 20% of their revenue, right? And so there's this very common pattern where you have the ability to find some of those upstarts that you make bets on like the next viewers of the world, the smaller companies that continue to get developed with the product and then the enterprise whom allows you to really fund the commercial success of the business and validate the size of the opportunity and market that's being created. It's interesting. I mean, there's so many things happening there. It's like, in a way it's a new category but it's not a new category. It becomes a new category because of the capabilities, right? So it's really interesting because that's what you're talking about as a category creating. And I think developer tools, so people often talk about B2B and B2C businesses. I think developer tools are in some ways a third way. I mean, ultimately they're B2B.  However, you look kind of like a B2C company in the ways that you measure product adoption and kind of go to market. In other words, we're often tracking the leading indicators of commercial success in the form of usage, adoption, retention, really consumer app traditionally based metrics of how to know you're building the right stuff. And that's what product-led growth companies do. And then you ultimately have commercial traction in a B2B way. And I think that that actually kind of looks like a third thing, right? Like you can do these sort of funny zany marketing examples that you might see historically from consumer businesses. But yeah, you ultimately make your money from the enterprise who has these de-risk high value problems you can solve for them. And I selfishly think that that's the best of both worlds. Because I don't have to be like Evan Spiegel guessing the next consumer trend or maybe creating the next consumer trend and catching lightning in a bottle over and over again on the consumer side. But I still get to have fun in our marketing and make sort of fun, like we're launching the world's largest game of rock, paper, scissors being played with computer vision, right? Like that's sort of like a fun thing you can do. But then you can currently have the commercial validation and customers telling you the things that they need to be built for them next to provide commercial, to solve commercial pain points for them. So I really do think that you're right by calling this a new category and it really is the best of both worlds. It's a great call out. It's a great call out. In fact, I always joke with the VC. I'm like, it's so easy. Your job is so easy to pick the winners. What do you talk about so easy? I go, just watch what the developers jump on. And it's not about who started it. It could be some of the dorm room to the board room person. You don't know because that B to C, the C is that it's B to D, you know, it's developer because that's a human, right? It's a consumer of the tool, which influences the business that never was there before. So I think this direct business model evolution, whether it's media going direct or going direct to the developers rather than going to a gatekeeper, this is the reality. That's right. Well, I got to ask you while we got some time left to describe, I want to get into this topic of multi-modality, okay? And can you describe what that means in computer vision and what's the state of the growth of that portion of this piece? Multi-modality refers to using multiple traditionally siloed problem types, meaning text, image, video, audio. So you could treat an audio problem as only processing audio signal. That is not multi-modal, but you could use the audio signal at the same time as the video feed. Now you're talking about multi-modality. In computer vision, multi-modality is predominantly happening with images and text. And one of the biggest releases in this space is actually two years old now was CLIP, Contrastive Language Image for Training, which took 400 million image text pairs. And basically instead of previously when you do classification, you basically map every single image to a single class, right?  What CLIP did is you can think about it like the clasp for an image being the Instagram caption for the image. So it's not one single thing. And by training on understanding the corpora, you basically see which words, which concepts are associated with which pixels. And this opens up the aperture for the types of problems and generalizability of models. So what does this mean? This means that you can get to value more quickly from an existing trained model or at least validate that what you want to tackle with computer vision, you can get there more quickly. It also opens up the, I mean, CLIP has been a bedrock of some of the generative image techniques that have come to bear just as much as some of the LLMs. And increasingly we're gonna see more and more of multi-modality being a theme simply because at its core, you're including more context into what you're trying to understand about the world. I mean, in its most basic sense, you could ask yourself, if I have an image, can I know more about that image with just the pixels? Or if I have the image and the sound when that image was captured or had someone describe what they see in that image when the image was captured, which one's gonna be able to get you more signal? And so multi-modality helps expand the ability for us to understand signal processing. Awesome. And can you just real quick, just define CLIP for the folks that don't know what that means? Yeah, CLIP is a model architecture. It's an acronym for Contrast of Language Image Pre-Training. And like, you know, model architectures that have come before it captures the, almost like models are kind of like brands. So I guess it's a brand of a model where you've done these 400 million image text pairs to match up which visual concepts are associated with which text concepts. And there have been new releases of CLIP, just the bigger sizes of bigger encodings of longer strings of text or larger image windows. But it's been a really exciting advancement that OpenAI released in January, 2021. All right, well, great stuff. We got a couple of minutes left, just I want to get into more of a company-specific question around culture. All startups have, you know, some sort of cultural vibe.  What's your culture like at Roboflow?  And then, hey, we should start a company. Two years later, what, that's kind of like a curious, inventing, building, hard charging, but laid back. That's my take. What's your, how would you describe the culture? I think that you're right. The culture that we have is one of shipping, making things. So every week, each team shares what they did for our customers on a weekly basis. And we have such a strong emphasis on being better week over week that those sorts of things compound. So one big emphasis in our culture is getting things done, shipping, doing things for our customers. A second is we're an incredibly transparent place to work. For example, the, how we think about giving decisions where we're progressing against our goals, what problems are biggest and most important for the company is all open information for those that are inside the company to know and progress against. The third thing that I'd used to describe our culture is one that thrives with autonomy. So Roboflow has a number of individuals who have founded companies before, some of which have sold their businesses for a hundred million plus upon exit. And the way that we've been able to attract talent like that is because the problems that we're tackling are so immense yet individuals are able to charge at it with the way that they think is best. And this is what pairs well with transparency. If you have a strong sense of what the company's goals are, how we're progressing against it and you have this ownership mentality of what can I do to change or drive progress against that given outcome, then you create a really healthy pairing of, okay, cool, here's where the company's progressing, here's where things are going really well, here's a place that we most need to improve and work on. And if you're inside that company as someone who has a preponderance to be a self-starter and even a history of building entire functions or companies yourself, then you're going to be a place where you can really thrive. You have the inputs of the things where you need to work on to progress the company's goals. Any of the background of someone that is just necessarily a fast moving and ambitious type of individual. So I think the best way to describe it is a transparent place with autonomy and an emphasis on getting things done.  Great stuff. Hey, final question, put a plug out there for the company. We're looking to hire what's your pipeline look like for people, what jobs are open, I'm sure you got hiring all around. Give a quick plug for the company, what you're looking for. I appreciate you asking the, basically you're either building the product or helping customers be successful with the product. So in the building cap for other product category, we have platform engineering roles, machine learning engineering roles and we're solving some of the hardest and most impactful problems of bringing such a groundbreaking technology to the masses. And so it's a great place to be where you kind of be your own user as an engineer.  So those are roles that tend themselves to being those that build the product for developer advocacy, those that are account executives that are enabling our customers to realize commercial success and even hybrid roles. Like we call it field engineering where you are a technical resource to drive success within customer accounts. And so all this is listed on roboflow.com slash careers. And one thing that I actually kind of want to mention, John about that's kind of novel about the thing that's working at Roboflow. So there's been a lot of discussion around remote companies and there's been a lot of discussion around in-person companies and do you need to be in the office? And one thing that we've kind of recognized is you can actually chart a third way. You can create a third way, which we call satellite which basically means people can work from where they most like to work. And there's clusters of people, regular on-sites and at Roboflow everyone gets, for example, $2,500 a year that they can use to spend on visiting coworkers. And so what sort of organically happened is heat numbers have started to pull together these resources and rent out like lavish Airbnb's for like a week and then everyone kind of like sends in and works together for a week and makes and creates things. And we call this lighthouses because, you know a lighthouse kind of brings ships into harbor and we have an emphasis on shipping. So. Yeah, quality people that are creative and doers and builders. You give them some cash and let the self-goverting begin, you know, and the creativity goes through the roof. That's a great story. I think that sums up the culture right there, Joseph. Thanks for sharing that. And thanks for this kind of great conversation. I really appreciate it. And it's very inspiring. Thanks for coming on. Yeah, thanks for having me, John. Joseph Nelson, co-founder and CEO of Roboflow, hot company, great culture in the right place in a hot area, computer vision. This is going to explode in value. The edge is exploding. More use cases more develop and developers are driving the change. Check out Roboflow. This is theCUBE. I'm John Furrier, your host. Thanks for watching.


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


Hi my name is Emily. Hi my name's Nick. Hi I'm Koopa. Hi my name's Tamlin. I've got a Japanese curry. I agree with Mexican rice. Some Nasi Goreng homemade with some chicken and some rice. I've got the fajita mix here with the chicken with some veggie. I've brought a partial salad today which has some veggies and some olives and sundried tomatoes and an extra vegetable variety and my favorite cappuccino and this will help me get through the rest of the day. Crosses. My highest protein and high fiber content and it's just like downright delicious. Just for something different because I can't eat the same thing all the time with a variety and yeah I love getting it all in. It's really easy to make and the parcel will keep me full for the last afternoon.


Philip Garcia was taken to a California jail on a Wednesday morning in March of 2017. By Friday, he was dead. Riverside County withheld information about Garcia's death from his family, journalists, and federal monitors. But using public records laws, ProPublica obtained 17 hours of video and thousands of pages of records that shed light on Garcia's treatment in custody. We found that jail staff failed to address Garcia's urgent medical and mental health needs even after determining he was in a psychiatric crisis. The videos show that deputies used violent force against Garcia and then lied about their treatment of him in reports. His death was ruled a homicide, but it didn't lead to any charges or discipline for anyone involved in his custody or care. The records provide an unusually thorough account of a recurrent tragedy, a person in mental crisis dying in law enforcement custody. It began when police responded to a call that Garcia was behaving bizarrely and out of character, throwing things at his neighbor's house. The 51-year-old repairman and father, shown here years earlier, was then arrested for allegedly assaulting his roommate. The police department declined our request for footage of his arrest and transport to the jail, but their reports make clear that Garcia was experiencing a mental health crisis. They say that Garcia was repeatedly banging his head against the barrier in the patrol car and yelling incoherently. We don't know everything about Garcia's health history or the treatment he received in jail. Much of his medical information was redacted and his family declined our request for interviews. But we do know that Garcia's wife told law enforcement at least twice that he suffered from a seizure disorder. Video of Garcia starts as officers lead him into the jail. During the booking process, Garcia appears unable to follow directions. We showed this footage to a mental health specialist who used to work at the jail. He appears to be agitated, obviously, but he's stumbling a little bit. And so your reading into that is like, is that intoxication? We have a seizure and he's coming down from that. What's going on? Is he in the midst of a psychotic break? Deputies are supposed to collect Garcia's medical history and determine if a mental health assessment should be conducted. But jail staff don't write down any information about him. They abruptly stop questioning Garcia, later writing he was uncooperative. They take him to a cell where he remains in isolation for 18 hours. Video from the cell's camera appears to malfunction, showing only fragments of live action and then freezing on a single frame for long stretches of time. In the unfrozen moments, Garcia is behaving erratically. He claws at the light on the ceiling, jumps at the security camera and wraps toilet paper around his body. By six the next morning, there's no evidence that mental health staff have seen Garcia or that he has slept or eaten for the last 18 hours. A sergeant decides to forcibly remove Garcia from the cell because he's damaging the ceiling light and could harm himself. Over the next several minutes deputies use a barrage of weapons and force against Garcia. One would assume that they should be trained to de-escalate a person and not right away try to take them down. But it's been my observation and once an inmate is to that level, it's their will against the inmate's will. The footage in the cell is frozen on a single frame when a deputy fires 30 rounds of pepper balls under the cell door, releasing a chemical that burns his eyes in airways. A few minutes later, a special team of deputies in riot gear prepares to remove Garcia from the cell. This deputy is about to throw a stinger grenade. The device emits smoke, rubber pellets and a loud bang. Garcia runs away from the grenade and is tackled by six deputies. Then smoke fills the cell, obstructing the camera. In their reports, several deputies write that they repeatedly punched Garcia as they struggle to handcuff him. Another deputy tases Garcia. Then deputies move him to an emergency restraint chair to immobilize his limbs and move him to another cell. He would never freely move his arms and legs again. An hour later, while jail staff remove the taser prongs from Garcia's side, a deputy places him in a painful salivary gland hold for 10 minutes. The way his head's being held, like, how can he breathe? How can he swallow? Who deserves that? Nobody deserves that. Should somebody be trying to de-escalate the client? Yeah. We wouldn't think a mental health would not be given an option. They're doing their thing. Around 9 a.m., a clinical therapist determines Garcia is in a psychiatric crisis and should be transferred to the county hospital. She's supposed to talk to Garcia face to face, but instead speaks to him through a hole in the door for just a few seconds.  Garcia arrives at the county hospital's emergency room at about 10 a.m. and waits all day for a bed. Video doesn't start until after Garcia has been moved to a special unit for inmates that night. His arms and legs have now been restrained for 15 hours. He needs medical care and a psychiatric evaluation. In the footage we reviewed, he doesn't receive either one. The standard of care is to assess an individual and to use the least restrictive measures as possible in any situation where you're dealing with a combative agitated patient. And I don't believe the least restrictive measures were used in this case. Deputies call in a tactical team to help move Garcia to a medical bed. One deputy is recording with a handheld video camera, which the jail requires whenever deputies use force against inmates. Another deputy presses a plastic shield on top of Garcia's head and chest as the team moves and restrains him. While the deputies are redoing the restraints, Garcia cries out for help. Seconds later, the deputy pushes down on the shield over Garcia's face with his full upper body weight. Two minutes later, he forces the shield down on Garcia again. In reports, the deputy holding the shield wrote that he didn't apply any direct pressure to Garcia's face and that Garcia was not struggling for breath. When the deputy removes the shield, blood is visible on Garcia's spit hood and his breathing is labored. By now, Garcia has been in custody for more than 33 hours, much of that time restrained and in distress. Persistent agitation comes most often from some type of medical condition that needs to be assessed in a hospital. They should be led from a medical perspective because it's a medical issue. A few minutes later, nurses want to attach a telemetry machine to monitor Garcia's heart. Deputies and medical staff have competing priorities, security versus the patient's health. But the hospital is legally obligated to provide the same standard of medical care for inmates as for any other patient. Given the restraints, it's really important to take vitals. Ultimately, if you're not checking someone's breathing and blood pressure and circulation, that can lead to serious consequences. Not connecting the tele means medical staff did not track Garcia's heartbeat, possibly missing crucial information as his condition worsened. A short while later, Garcia is sweating profusely. Records show that earlier that day, the emergency department diagnosed him with a life-threatening condition brought on by overexertion. It causes the body's muscles to break down and can lead to kidney failure. Restraining against the restraints for so many hours is causing Garcia to destroy muscle tissue, pouring toxins into his bloodstream. By 10.47, Garcia has been restrained for 16 hours. Then the video ends, while three deputies and a state correctional officer are restraining him. It's the last image we have of Philip Garcia alive. He survives for three more hours, but the sheriff's department did not release footage from that time. Shortly after 2 a.m., Garcia stops breathing. Staff perform CPR, but it's too late. We know from the autopsy report that struggling against the restraints contributed to his death. The sheriff ruled that Garcia died at the hands of other people, making his death a homicide. The sheriff's department conducted an internal review of Garcia's death and did not discipline any deputies. Garcia's family filed a wrongful death lawsuit against Riverside County. Their case could have exposed what happened to Garcia, but it never went to trial. The county denied the allegations and admitted no wrongdoing. It settled the suit by paying the Garcia family almost a million dollars, with the condition that the family not speak to the media about the case. When Garcia died, Riverside County was already on notice. The year before, a federal court ruled that the health care at county jails was woefully inadequate and ordered them to improve treatment of inmates. But court records and expert reports show that inmates there are still at serious risk of harm because of a lack of adequate medical and mental health care. When you're taken to jail in the middle of a mental health crisis, you shouldn't be treated like that and you shouldn't end up dying.


Hello and welcome to Around the World in 8 Minutes by People's Dispatch, where we bring you stories of resistance against capitalist exploitation, state repression and neoliberal onslaught. In today's episode, we will be taking a look at the death of one person and injuries to over 40 in the Israeli attack on Great March of Return protests in Gaza. We will also be taking a look at protests in India as the blockade in Kashmir enters its third month and South African security guard unions raising wage issues with their employers. Before we go into our main stories, let's take a look at the massive protests in Ecuador, which continued for a second day on Friday. Tens of thousands resisted the neoliberal package of President Lenin Moreno. Moreno's so-called reforms seek to remove subsidies on diesel and petroleum, which would increase prices considerably. He has also introduced labour laws, which will attack workers' rights and lead to a decrease in wages. While some organizations have announced an end to the strike, many more will be continuing the actions in the coming days against the betrayal by Lenin Moreno of his mandate and his surrender to the IMF. Here is some footage from yesterday's protests. We now look at the Great March of Return protests in Palestine and Israel's continuing and brutal repression. One protester was killed and over 50 injured when Israeli forces opened fire on protesters at a Gaza border on Friday. The victim, 28-year-old Ala Nizar Hamdan, was killed when Israeli forces fired at demonstrators using live and rubber-coated ammunition. A number of the injured were taken to hospital for treatment and others were given medical attention at the scene. Thousands of thousands of Palestinians have been participating in the weekly Great March of Return protests since March 2018. The protesters are demanding the right to return to their lands and an end to the 11-year-old Israeli blockade of Gaza. Around 313 Palestinians have been killed and more than 5,000 injured by Israeli forces who have resorted to lethal force, including the deployment of snipers and use of tank and artillery fire. For our second story, we look at protests against India's brutal repression of the people of Kashmir, which entered its 60th day on October 3rd. On August 5th, the far-right government of Narendra Modi abrogated the constitutionally guaranteed autonomy of Kashmir and bifurcated the state.  Political leaders remained in detention, a communications blockade has denied Kashmiris even basic ability to talk to each other and a massive military deployment has caused innumerable day-to-day difficulties to the people. Activists across India have been demanding the lifting of the siege on the people, the release of political prisoners and the immediate restoration of all communication lines. They have also expressed solidarity with the people of Kashmir and condemned the use of torture. Here's some footage from a protest in New Delhi in solidarity with the people of Kashmir. Today is the 60th day when Kashmiris have been silenced. They are not being allowed to speak of how they are. And today, CPI MN has called for a nationwide solidarity day with Kashmir and in that context we are having it in Delhi. We demand, we are seeing that our rulers, the ruling government, the ruling party, is claiming that everything is normal in Kashmir, that everything is peaceful and only people outside Kashmir are worried about Kashmir. We want to ask if everything is so normal, everything is so peaceful. Why are not Kashmiris being allowed to speak up? Why are leaders under detention? We have got news how, at the earliest instance of any protest, pellet guns are being fired at people. We have got news how teenagers have died because of the danger. We have got news how people are dying in hospitals and they are not being able to see their nearest relatives because of the locket that is continuing in Kashmir. And this situation cannot happen. Indian Prime Minister goes outside, goes to America and he claims that everything is fine. If everything is fine, why are Kashmiris being silenced? Of course. In our final story, we look at organizing by security guards in South Africa who run the verge of a strike. This is following the failure of talks between unions representing over 150,000 security guards and employers over the last week. The unions have approached the commission for conciliation, mediation and arbitration which will try to intervene in the case, failing which a strike may be called. The unions have been demanding a wage hike which the employers have been resisting. Even the most highly paid security guards or those belonging to grade A get a monthly salary of ran $5,557 that is around $366 which is way lesser than the living wage for an individual which is estimated to be around $6,340. Meanwhile, the living wage for a family is estimated to be nearly $11,300. The situation for grade B and grade C guards is even worse as they earn $4,891 and $4,377 respectively. Moreover, all these are wages before deductions after which the lowest paid security guard earns a meager $3,800 per month. When confronted by the unions, the employer's offer was initially a measly 1%. During negotiations last week, they raised it to 5%. But even this hike will not bring the highest paid workers' salaries to the level of the minimum wage, not to mention those of grade B and grade C. This paltry offer is despite the fact that the unions were ready to accept a progressive increase which would have taken their salaries to the minimum wage level in 3 years. The unions also demanded a health cover to which employers would be obliged to contribute 60% but the latter just ignored the demand. Security guards work under exceptionally difficult circumstances in South Africa where crime rates are quite high. The paltry offer by employers has infuriated the workers who are determined to go on a strike if their legitimate demands are not met and their interests are sacrificed at the altar of profit. That's all we have for this episode of Around the World in 8 Minutes. To know more about these stories, visit our website peoplesdispatch.org and follow us on Facebook, Twitter and Instagram. Thanks for watching. Thank you.