About the Episode

In the United States, one out of eight women will be diagnosed with breast cancer in her lifetime which, for many patients, can be a devastating thoughtHowever, in the past two decades, treatment for breast cancer has come a long way, and breast surgeon Dr. Barbara Smith has been at the forefront of thmovement to disrupt and improve care for these patients.  

Dr. Smith has been a pioneer in nipple-sparring mastectomies, a technique that removes the breast tissue but leaves the skin and nipple intact. In this episode, find out how Dr. Smith broke the mold to give new hope and better outcomes to breast cancer patients.  

About the Guest

Barbara Smith, MD, is the director of the Breast Cancer Treatment Program anco-director of the Women’s Cancer Program at the Massachusetts General Hospital Cancer Center.  She has devoted her career to saving women’s lives through treating breast cancer

Dr. Smith’s research has focused on three major areas: reducing the extent of surgery and radiation required to treat breast cancer, diagnosis and treatment issues in young women with breast cancer and three dimensional breast anatomy as it relates to breast surgery and pathologic analysis of specimens.  

In addition to serving as an associate professor of surgery at Harvard Medical School, Dr. Smith has also assisted in the development of multidisciplinary breast cancer programs and clinical research activities at Sun Yat-sen University in China, where she has been a visiting professor since 2006. 

Dr. Smith received her undergraduate degree from Massachusetts Institute of Technology where she was encouraged to disrupt and innovate in her study field. She received her medical degree from Harvard Medical School’s Harvard/MIT Division of Health Sciences and Technology and her PhD from Harvard University Graduate School of Arts and Sciences.  

Dr. Smith was named one of Boston Magazine 2019 Top Doctors in surgery and was honored by the Massachusetts Medical Society in 2016 with the Women’s Health Award.  

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Treatment for breast cancer has come a long way, particularly in the past two decades as advances in imaging, genetics and technology have enabled doctors and scientists to understand and treat the disease more precisely. Dr. Barbara Smith, director of the Breast Cancer Treatment Program in the Mass General Cancer Center, has been at the forefront of much of that change. As a young surgeon, she had many women coming to her in the hopes that she could help save their breasts.

When she began examining the data, she saw that survival outcomes were the same with lumpectomy and mastectomy. This inspired her career focus on reducing the extent of surgery and radiation treatment for breast cancer. Barbara has become a leader in nipple-sparing mastectomy, a procedure that removes the breast tissue, but unlike traditional mastectomy, leaves the breast skin and nipple intact. Today, the breast program has done over 3000 of these procedures, the most of any center in the country, and has yet to find any recurrence in the nipple.

Barbara and her team have taken a treatment that was once considered taboo, if not impossible, and made it the standard of care, giving breast cancer patients better outcomes in the long run. 

So welcome, Barbara.

BARBARA: Great to be here.

Q: Barbara, I know that you entered medicine, and particularly, surgery, when there weren’t a lot of women who were doing that. I wanted to start by talking about what it was like to be in that group of women who were breaking barriers and breaking into this area where they hadn’t been many women before.

BARBARA: Well, I was lucky. A lot of the things I did in my career were just at the beginning of the wave of when women could do them. And it even began in college; I went to MIT as an undergraduate. It was unusual for women to go to a science and engineering school. My class was 14% women at that time, which was the highest ever. And surgery was the same way; there weren’t a lot of women. But it quickly changed, and I remember when I was a young attending and we hired our first intern who had a baby.

And so in my career, I went from it being a rare thing for a woman to be a surgeon to be it being routine to have women with their own families as well. 

I think one of the things I learned doing this that’s helped me along the way is that when you're in a situation where you're new in that field, it helps to look at what's going on around you as something that’s not necessarily set up against you, but it’s something that’s just not used to you being there. And I think one of my lessons in college about this came when I was trying to figure out exactly how I would run my major and what courses I would take. And MIT will have a framework and requirements of what you have to do and what the expectations and what the routines are. 

But one of the most valuable things I learned there was their attitude that although these are our routines, if you can think of a better way to do something, and if you're willing to do the legwork to organize it, it’s fine with us. So that played into how I did my undergraduate experience, and that’s been a great lesson along the way. 

I never really felt like people were obstructing me as a woman doing these things. I had more the sense that they just weren’t used to me being there. So if I did a great job, I showed there's no reason why I shouldn’t do this. I proceeded as if I was oblivious to some of the obstacles. And that actually served very well. And you can start out breaking into something in a confrontational way, and there probably are times when that’s necessary, but in a lot of really smart, great organizations like MIT, like Mass General, people want to help you.

Q: Are there things you did – you mentioned proceeding with maybe willful obliviousness. Are there things that you did to set yourself up for that? 

BARBARA: I think it really helped that each of the steps of my career, I think I was able to focus on what the goal was. So it was getting a great education, it was being a great surgeon and having people think of me as a great surgeon, not a woman surgeon. And so I think if the goals are clear and you accept the fact that things are not maybe exactly the way you want them now, but you can change them – I always felt like things could change, probably growing up in a time and seeing change all around me all the time. And I think that’s true today, too. The world has certain rules, but they're malleable. You can do something with them if you are willing to do the work.

I think it was key for me to recognize that it is natural for people to resist change, not necessarily because they object to it, but because it’s hard. It’s time consuming, it disrupts your routines. But with some gentle pushing and showing that it’s better, you can get things done.

 Q: what I know of MIT is it’s a place where there's sort of a culture of disruption and maybe rule-bending, rule-breaking. 

BARBARA: It was encouraged, yes, which is a good thing.

 Q: Yeah, so I'm wondering how that affected you and your outlook, and if that’s something that has carried over into the other work that you’ve done.

BARBARA: So, I always enjoyed situations where I was the first woman doing something, or where I was in a small group of people who were doing something new or different, regardless of gender, but something new. And so I enjoyed that. I like change, I like new things. And I used to say to myself that inertia is the most powerful force in the universe. The tendency to just keep doing the same thing that you're doing is really compelling. But once you recognize that, you can sort of step back from that yourself and not be afraid to do new things.

 Q: when you began your career you trained as a general surgeon. But you’ve ended up with this really specialized area in breast cancer. So can you tell me a little bit about how you ended up in that area?

BARBARA: As I said, I was at the beginning of the wave of when women went into surgery at all. And I got a job as a cancer surgeon -- and started out doing all different types of cancer surgery and still some gall bladders and appendix surgery, things like that. But within about two years, my practice had become 80 or 85% breast. And that was, I think, the idea of being a woman at a time when it was just becoming possible to avoid mastectomies. 

In my six years of surgical training, I had done three lumpectomies. And all the other breast cancer surgery I did was mastectomies. So I was kind of figuring out how to do this new operation. Approaching the lymph nodes was completely different when you didn’t have an open mastectomy incision. And a lot of other surgeons were doing the same thing.

I was at the point in my career when doing new things, again, was normal, and I expected change. And I think women were very active in promoting the opportunity to save their breasts. There was a lot of activism, public discussions of things, and people were very happy to have a woman who they thought would be more amenable to that kind of change, who would appreciate how hard it is to lose your breast and have some sense of really making an effort to avoid that. The other thing is that since there were relatively few women in medicine in general before that time, the idea of a sympathetic ear, somebody who might be gentle.

But I think that it was a time in breast cancer where it was a community of women changing things for themselves. And I was kind of in the right place at the right time. And it turned out to be the perfect job for me because I really enjoy the technical parts. I like fussing about the cosmetic outcomes. And I also like the ongoing relationship you have with your patients. When you treat them for their breast cancer, you have to keep an eye on them for follow-up. What happened in one breast could ultimately happen in the other breast. So there's a long-term relationship you develop with your patients, and I really enjoyed that part of it as well.

Q: And what timeframe is this that we’re talking about? When is this shift starting to happen?

BARBARA: The first paper that showed, the clinical trials that showed that lumpectomy was the same as mastectomy, there was an early report in 1985. And most people didn’t really believe it. There was thought that the follow-up was too short, there was too much risk involved. And then in 1989, the longer term results were published from the United States studies and similar studies in Europe. And so the idea it was pretty safe came out. 

The operation was still applied very selectively, so only the smallest breast cancers could have lumpectomies initially. There were a lot of concerns. If anything was outside of ideal, you'd still have to do a mastectomy. So when I was starting my practice was when people were pushing the boundaries of who could have a lumpectomy. 

At the same time, there was starting to be recognition that you could reconstruct a breast at the same time as a mastectomy. Initially for women who chose mastectomy or needed mastectomy, there was concern that paying attention to the cosmetics and doing a reconstruction would be unsafe, that it somehow might encourage a recurrence or mask detecting a recurrence. And so women had to wait a year or two between their mastectomy and their reconstruction, which was psychologically difficult, and actually technically difficult because by removing all the skin, it was much harder to rebuild the breast than if you could work with the healthy skin that was there right from the beginning.

So all of that gradually changed, and it was very exciting to be seeing one thing after another change. And from my point of view, it was seeing one thing that was an absolute strict rule in the past – suddenly, it’s not true anymore. And then the next thing that was gospel, it’s not true anymore. So it sort of fed into my sense of irreverence about rules or conventions, that if all these long-standing things weren’t correct anymore, that left a lot of other things open for discussion and improvement.

Q: I'm wondering as you're talking about this, was there a similar movement in lots of different kinds of cancers, or are there things about breast cancer that were unique?

BARBARA: There was, but I think for a lot of them, breast was first. And the reasons are breast is just so common. It’s still one out of eight women in the United States will get breast cancer in their lifetime. The survivals are very high, and the recurrences happen over a long time. So that kind of the nature of the disease was really helpful for doing studies and changing things. If you're doing an operation and it’s 99% chance that everything's going well, you're probably doing too big of an operation. You can sort of back off. And I think one of the things that we learned is that one of the hardest things to do in medicine is to do less care. It’s always easy to add an extra treatment.. Everyone likes the idea of more and more.

And so it took actually quite a bit of science to show that these smaller options, lesser surgeries, later on, lesser chemotherapy, more targeted things, that they were just as good. And that’s been a wonderful breakthrough because it’s really informed our thinking about a lot of other medical things. 

So for many cancers, it’s recognized that what works best, particularly as you're doing smaller surgeries, is to have a balance of other treatments.

So in order to do a lumpectomy instead of a mastectomy, you have to have radiation therapy that protects the breast tissue that you leave behind. As you start to think about protecting the rest of the body from metastasis, you have to add medications, and sometimes you add the medications before surgery, sometimes afterward. And there's a lot of thinking that has to go into ordering the treatments, deciding exactly how much treatment and what balance of treatment each person gets. And the way breast cancer treatment evolved, those issues were front and center by about 1990. 

And as Mass General started to think about how to improve their breast cancer program in the ‘90s, how to really be a proactive force for women’s health in a variety of areas, the decision was made to try to organize a breast center. And that’s when I was actually hired in the early ‘90s to come and start this.

And it was the first multidisciplinary clinic at Mass General where the office sessions had a surgeon and a radiation oncologist and a medical oncologist in the same clinic, all seeing the patient the same day, and with pathologists and imagers helping us with understanding the pathology results and the mammograms, and all sitting together with the patient in the same session with us and making decisions and prioritizing things. 

And it was a collaborative discussion with the patient as well, recognizing there are options and quality of life. And your perspective and preferences actually can be taken into account. It was very, very exciting. And it just worked out really well.

We were creating a village of people who all thought about the same thing every day from different perspectives, and it actually made things better for the patient. And you could keep that personal element of how you delivered your care and how patients came to see you, but with all this extra infrastructure that made it better for everyone.

Q: Seems like also made it better for the clinicians. If you don’t have to chase each other around and you just know we’re together.

BARBARA: People here work very hard. One of the things I love about Mass General is for the spirit of the place... you have to be a great doctor first, and you have to really take great care of your patients. You're also expected to be a researcher and a teacher and an administrator, but the central core of everything is about being a great doctor for your patients. So when you have a group of people who think like that, a lot of great things will happen. Again, once you show people there's a better way to do it and let them have input along the way. What worked for us was making it efficient for people so that the valuable time they were committing to come to these sessions were productive. And then providing the really important infrastructure you can’t do on your own as a single clinician. 

Once we got the programs going, it also became clear this was a great way to do research, that as we’re seeing new patients and thinking about options for them, we can offer them all sorts of clinical trials in all the disciplines. As we’re discussing a patient, someone might say, “Hey, this person’s eligible for this new study and this drug.” And you might not have thought about that as a surgeon in my own office, but when I'm working with the medical oncologist, we’ll be sure not to miss that opportunity. 

It’s also a great venue for teaching because the trainees and all of the different specialties get to see a senior attending, discussing a problem, talking about options, bringing in data, and reaching conclusions and discussing them with patients.

Q: You talked about the shift from mastectomy to lumpectomy, and now today, I know you’ve become one of the leaders within nipple-sparing mastectomies. So can you talk about the journey from there to here?

BARBARA: So, the world had gotten so that mastectomy is still recognized to be needed for certain tumors and certain prevention cases. And it was clearly recognized that it’s safe to do the reconstruction the same day. And then it was recognized it was safe to actually save most of the skin, that you could save a lot of the healthy skin, and that helps the reconstruction because you have your own skin. The scars are way out of the way, and it’s cosmetically better. But there was this sort of cultural memory that it wasn’t safe to save the nipple, that there had been some preliminary attempts in the past that resulted in an increased risk of recurrence. And that was because it was thought that you couldn’t do a safe cancer operation where you thoroughly removed all the milk ducts and breast tissue under the nipple without cutting off all the blood supply.

And the early attempts to save the nipple left enough breast tissue behind that there was risk associated with that. So we recognized that if we wanted to change that, we had to bring in some science. 

It started actually when one of my patients said to me, “You're not taking my nipples.” So this was giving me a flashback to the ‘80s, and women saying “You're not taking my breasts.” So we said, “Okay, well maybe we don’t have to.” And in her case, we did our best and saved the nipples. And she did beautifully. But it led to thinking about, well, how can we show how this is really safe? How can we test it?

And so we started doing microanatomy studies of the nipple. We collected all the nipples removed in traditional mastectomies for a whole year at Mass General and did very detailed anatomy studies, looking at how often was there tumor in the nipple ducts, where were the ducts that we wanted to take out relative to the vessels that we want to leave behind, and found out there was a way you could do this. And then we started working on the technical details of how to make the operation go smoothly and how to protect the skin and so on.

And once we started doing it, the cosmetic results were just unbelievably good. It looked so much more natural that it really just became our mission to make this available to as many women as possible. And it was really that scientific data of, here's how you do it. And now, we've applied that scientific data and technique, and here are our fantastic results. And it’s now becoming more and more standard of care, not just at Mass General, but around the country.

 Q: That first patient, did she have a scientific or a medical background that made her think this was something that was possible, or was it just sort of her personality?

BARBARA: This was her personality. And there are many wonderful patients you run into along the way. It’s one of the perks of this job is that you need all sorts of wonderful people. And this was someone who was stubborn, and she was right. And it was somebody who was not affected in her own mind by tradition either, so I had to respect that.

Q: Does she know that she's sort of this seminal patient?

BARBARA: She knew she was the first one, yeah. She knew she was pushing us, and I think she was proud of that, too. Appropriately, yeah.

Q: When you started doing that initially, again, you're upending things, you're disrupting the culture, and you’ve mentioned this idea of cultural memory. Was there pushback from the medical community at large?

BARBARA: There was some. I think, again, with breast cancer, we had the other cultural memory of having many of our previous traditions being wrong, that lumpectomy was just as safe, and there were other things along the way, doing less lymph node surgery and other things. So there was a willingness to entertain new things that I think was really helpful. 

However, as I was going around the country and speaking at meetings and discussing this, there were initially some questions I could count on every time I spoke. So each time, you just try to explain, here's the data, here's what we’re doing. And then to answer some critics, you just have to do volume. You have to have large enough numbers of patients. You have to show that it’s not just what you can do but what people at other centers can do. There's more and more data that it’s very safe, and now, it’s really just a technical question of how do you do it in the best way possible, how do you optimize the reconstruction, and how do you extend it to people with other special circumstances, previous radiation, other things that continue to be a place where you can push the borders and do more?

Q: Can you talk to me a little bit about the patient experience of this procedure? I think for me in thinking about it, it’s interesting because it’s not just a technical surgery. It is a woman’s breasts, and not just the inside, but the outside and how she sees herself and how she relates to probably other people and relationships. How does that piece figure in?

BARBARA: Someone wrote an editorial about doing mammograms, titled The Breast is Close to the Heart. And I think that’s – physically, it’s true, but it really is an important part of how women think about themselves. And sometimes people who've had to have some of these surgeries say “I grieve for my breast,” that it is an emotional and a physical adjustment. So as we looked at it, for people who need a mastectomy or choose a mastectomy, we wanted to make things look as good as they could. But it’s also, for some women who are choosing mastectomy, it’s important that they really understand the pros and cons of doing the lumpectomy with radiation if they're eligible for that versus a mastectomy and reconstruction.

So, a large part of what we do is that personal connection with the patient and the serving as kind of an educator and mentor through the process. And so what I do in my practice is really talk about the pros and cons, go over the technical details, show them pictures of what things might look like so they can see. And then be very frank about the data about who’s likely to have regrets if they choose, for example, double mastectomies. What's the risk of recurrence if they don’t choose a mastectomy, and so on. And it is a personal journey for each person.

Q: And is that something that makes it challenging at all scientifically as you're interacting with other clinicians and other researchers, that it is this very sensitive part of a woman’s body, not just physically, but emotionally?

BARBARA: It is, and it’s different from other types of surgery where there can be a really serious or important or technically challenging thing that has to be done. But once it’s done, it’s done, and it’s not likely that the same thing’s going to happen to the patient again, or it’s not part of the surgical care to follow them on. In breast surgery, you're often following the patient and making these decisions over time. 

Having done this for a while, you get to see patients’ experiences over time, and I think that helps me explain to them, when I've seen women make this choice or that choice, how do they feel about it later? 

I think it’s very helpful to have data. We have clinical trials that have tested this versus that and that versus this other thing. And so we can really help patients know what the facts are. And then for most people, I think we talk about, what's the safest thing you could do? And if there's something that’s safer, I tell them I’ll always push you toward that. If there's things that are similar, then we have to go into quality of life issues. So, how would you feel with this versus that? And then help them with the decision-making process, saying “As I see women make this choice or that choice, women who worry about this seem to be happier with this path, or that if this is more critical to you, you might prefer this other option.”

Q: Yeah, and helping set some context, I imagine. As a patient coming in, maybe start from some information or no information, and then you're inundated with information and making sense of that.

BARBARA: It is. And I think one of the things that I hear almost every time we have one of these multidisciplinary sessions – at the end of the day, the patients say, “Oh, I feel so much better. You’ve given me so much more information than I had at my first opinion.” 

And I think that’s the way I look at it. To me, it’s a very rational field. There's a lot of data to help decide about what's the best thing to do. And so it’s communicating that in a way that the patient’s comfortable with it, giving them the context of the other things they’ll be thinking about or dealing with, being very honest, not being afraid to give bad news or to tell them frankly what they have to deal with.

 Q: I know you’ve done quite a bit of work with young breast cancer patients, and I'm curious to hear your perspective, especially right now when there's been so much work with genetics, and many young women are getting prophylactic mastectomies as a prevention measure. 

BARBARA: So breast cancer happens across a range of ages. And the median age for breast cancer’s probably in the early 60’s. And so about a quarter of breast cancer happens under age 50, and about 5% or so under age 40. And the women who are at the youngest ages have the highest chance of having a genetic mutation, where we have a great chance of curing that cancer we've just diagnosed, but we may be telling some of them that their risk of making a new cancer on the other side is 50 or 60%. So these are the women choosing who sometimes will choose double mastectomies even at a young age.

And so early on, we recognized that younger women in the past were treated differently. There were some concerns about the treatments that worked for older women not being as effective in younger women, and one of those main things was Tamoxifen, some of the anti-estrogen treatments. That was discovered not to be true, and it’s a very important part of treatment. 

But we recognized in our own practice that there was a lot of concern that younger women weren’t doing as well. And so we put together a dataset of women who had breast cancer before age 40, and in a fairly short time, we had over 600 women. And we were able to follow them and see that with current treatments, they really did just as well as older women. So it took getting some of the message out for that, but at the same time recognizing there are parts of their treatment that are unique.

The diagnosis is harder because the breast tissue is dense. So MRIs and some other tools can be helpful with that. You can have women who haven’t finished their childbearing and who have a diagnosis of breast cancer, and in the past, that meant that you could never have children again. And so what we and other groups did was really start to recognize that that wasn’t necessarily true either. And so now when a younger woman comes in and has a diagnosis of breast cancer, as part of their treatment, we also introduce them to the fertility preservation group and have ways for them to bank eggs or embryos if they want because some of the treatment such as chemotherapy may accelerate menopause and reduce fertility. So finding ways to say to younger women, “This isn’t a death sentence, that you are likely to do really well, that we have ways to both treat you and help prevent future episodes, and that we can protect some of the other things that are important to you as a young woman like the ability grow your family.”

 Q: Do you have the sense that this trend with people like Angelina Jolie having that elective mastectomy and talking about it – do you think that’s a trend that’s going to continue, or will we shift away from it?

BARBARA: That’s something that’s talked about a lot now, is that there are women – and Angelina Jolie was one of them where her lifetime risk of breast cancer may have been 70 or 80%. So there is actually some survival benefit for those highest risk mutation carriers to doing preventive mastectomies. So we now have a very proactive program to identify these women at the highest risk, and we do genetic testing at the time of initial cancer diagnosis visits for patients to help them sort themselves.

But I think the concern is about women who have smaller cancers who aren’t that likely to get new cancers in the future who choose double mastectomies for peace of mind. And to me, it still comes down to the woman’s choice about what does she see as an acceptable risk to live with? If her risk of a future breast cancer is ten or 15%, how does she feel about that? Would she rather do prevention surgery and not have to have a second round of breast cancer treatments like the one she may be going through? And so this is where we try to educate women as much as we can about the pros and cons of one approach versus the other. 

Q: Is there advice you would give to young women who know there's history in their family and are thinking about these things?

BARBARA: I think people recognize that knowing your risks and proactively addressing them is probably the best way to do things. And for breast cancer risk, there actually are a variety of prevention options other than surgery. So I think it’s helpful for women to know where they stand.

And I often will encourage people who have a family history or who have a risk gene in their family to think about testing and to find out whether that risk applies to them or not. And if they don’t have the mutation, they go about their business normally, and if they have a mutation, to be able to have a plan about how to do checkups, how to do prevention and so on. 

And so I encourage people to look at it that way, that it’s something that, if you have it, there's ways to address it that can make your life better, and to not be afraid to get that information.

Q: I  know there's been talk recently about the changes in recommendations for mastectomy and for screening of women, what age and how often – what's that about?

BARBARA: So this is a debate that’s gone on as long as I've been aware of breast issues. And that’s that how aggressively do we screen healthy women for breast cancers? And we know that for women who have regular mammograms, the average size at which a cancer is found is quite small. The chance of it having spread to the nodes is low. And so for many women, the treatments can be less because the prognosis is already better. 

The use of mammograms on a regular basis has made it so that we find smaller and smaller cancers. And we now find some cancers that are so small that we’re not sure how dangerous they are. We’re not sure whether you need to even ever know you had that.

So the concern was raised that by doing mammograms, we’re finding things that aren’t medically important and still putting people through treatments. So there's been a lot of debate as people look at the data – some will look at it and say the mammograms clearly have saved lives. They have made treatments easier. The need for chemotherapy has gone down. And other people say maybe you would've died of something else. My own bias and experience has been that a mammogram is a wonderful thing, that finding a cancer when it’s small is a wonderful thing.

I also think we can improve things by continuing to reduce the extent of surgery to make the treatment of the cancers small enough that you're happy to have a small procedure because of a big potential benefit. 

Q: And so what's on the horizon now? Do you have a next disruption in mind?

BARBARA: Yes, we’re in the middle of it right now. So I think the nipple-sparing mastectomy is a problem that’s pretty much solved, and we’re going to continue to fine-tune and tweak how we do it. But I think the data is unquestionable that it’s a great option for most patients. The next thing we’re looking at now is the lumpectomies. 

The problem we have with lumpectomies now is that we care about getting out every little microscopic bit of tumor with our surgery. And we want the edges of this piece of tissue we take out to be microscopically clear. With our current imaging technologies and surgical techniques, even though we do our best surgery taking out everything the mammographer sees, everything we feel, maybe 20% up to 30% of the time, when the pathologist tests the edges of the lumpectomy, there's tumor there and we have to go back and do a second surgery because they can’t do that testing live for us.

So what we’re working on is a technology that would let us see these cancer cells at the edge during the first operation. And this is circling back to my MIT roots. So I've been collaborating for about ten years with a group that’s now a company that’s spun off from MIT that’s developed a technology for seeing cancer cells in the margin of a surgical operation. So we’re now doing this exciting thing of disrupting lumpectomy surgery. And we think that this idea of having image-guided surgery so you can see the cancer as you operate, take just enough and not too much is the next exciting thing to work on.

This approach uses a dye that was developed at Mass General. It’s a dye that’s injected intravenously before surgery. And it is converted from a non-fluorescent to a fluorescent form by the enzymes that are present around almost all cancers. So you're taking the biology of a cancer and forcing it to mark itself. 

And so the patient’s injected with the dye. We do our standard surgery. And then I have a special probe that I put into the cavity that has a glass window that shines the right light frequency to make the fluorescence appear, and reads it out. And then there's software that displays on a monitor a red spot where there's residual tumor, and we take it out. 

Q: Wow, that’s incredible. So what are the steps in getting that to be status quo?

BARBARA: So this has been another very exciting and educational thing because it went from the initial discussions, which was me and three guys about how we might do this and how the equipment might look and work, and how does it get tested? And so we did the first in-human use of the device in the operating room here with a group of 60 women, brave women, again, who are helping us move the field along. And that worked well enough we then had a multi-center study that we finished the first phase of, and then again, the second phase now that’s going to be testing it to see if it’s really ready to be approved by the FDA and applied clinically more broadly and tested more widely.

Q: I assume you're probably reaching the climax or the end of your career, thinking about what's next, but there are any other things that you think “Before I'm done, I want to do this thing?”

BARBARA: Well, it’s wonderful to be in a field where there's always something new you can do. And I think as I look forward to what goes on, I think some of these research things you can do forever. Some of the things where you're helping patients, you can do forever. And I think I really liked to see some of these things continue and with respect to how things are going at Mass General, I'm very excited about the team that we have. And we’re very excited to be able to keep this going and growing and when I finally do retire, have it be stronger than when I left.

 Q: Absolutely. Well, thank you so much, Barbara. This has been really wonderful. Before I let you go, I have my final five questions. What advice would you give your younger self?

BARBARA: I think one of the big mistakes I made early on when we were planning things was that someone actually gave me what turned out to be, I think, some bad advice, that if you want to do something, just get a small group of people and just push it through. And I tried that once, and it alienated people in a way that just didn’t seem worth it to me. So I think what I would’ve told myself earlier is the best way to get things done is with consensus.  And being very inclusive earlier than I was.

Q: What's the best decision you’ve ever made?

BARBARA: I think probably going to MIT. And that was because it was kind of a stretch for me. It was going from a pretty small town that had like one movie theater, and taking a leap of going to a city and trying something that was really hard and seeing that I could do it.

 Q: What was your first job?

BARBARA: My first job was working in a hospital lab. I made $12 dollars and 50 cents a week, and it wasn’t that long ago, so that was just a really bad pay. And my job was to do urine tests and other things in a clinical lab of a hospital. But I got pretty good at it, and I got to move up to doing bacteriology, which was more interesting.

Q: Do you have any guilty pleasures?

BARBARA: I love to read, and I read everything. All sorts of fiction of every kind. I like Lee Child, and I actually read a lot of science-fiction. 

Q: And what are you curious about right now?

BARBARA: I continue to really enjoy thinking about how to improve surgery. I also have a daughter who’s 23 who has found a career that’s harder than surgery. She's doing physics in computational and mathematical engineering. And so I'm really interested in seeing how careers evolve for young women over time.

Q: Thank you so much for being here, Barbara. It’s been an absolute pleasure talking with you today.

BARBARA: Thank you so much for having me.

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