Breast surgical oncologist Dr. Yara Robertson gets it. 

Dr. Robertson’s experience with cancer extends far beyond the wealth of education and years of practice. As a kidney cancer survivor who is at high risk of developing breast cancer, she intimately understands the importance of patient-centered care. Now serving as CARTI’s Medical Director of Surgical Oncology in Arkansas, she uses that knowledge to help her breast cancer patients make decisions that work for them and their care. 

Dr. Robertson sat down with Breastie Maricia Cole for an IG Live in February to talk about how Dr. Robertson’s own experience as a cancer survivor impacts her practice, why being high-risk for certain cancers doesn’t always mean there is a genetic link, and ways that you can—and should—be an active participant in your cancer care. 

This interview has been edited for clarity and length. 

The Importance of Knowing Your Family History 

Did your family’s history of breast cancer encourage you to become a breast surgical oncologist?

Dr Robertson: I went into surgery wanting to be a vascular surgeon, but we had to rotate through the breast surgical oncology program for about two and a half months and [there’s] nothing like taking care of breast cancer patients, to see someone from the beginning to the end of their treatment. To see how far treatment has advanced in just the past couple of years that I’ve been in breast cancer care is really amazing. 

I do have a personal tie to breast cancer. My grandmother, my great-grandmother, my aunt, and my cousin all have had breast cancer. It’s very strong in our family, but my great-grandmother was the only one who had been diagnosed with breast cancer by the time I became a breast surgeon. 

Does your family carry a genetic variant like BRCA? How did you determine that you are at an elevated risk?

Dr Robertson: I actually carry a mutation for kidney cancer but no, we don’t have a mutation for breast cancer. 

So what does it mean to be high risk [for breast cancer]? It  doesn’t necessarily mean you have a gene mutation for breast cancer. If you have a strong family history of any cancers, you should talk to your provider about being evaluated by a risk clinic or a genetic counselor who can actually calculate your risk.

RELATED: I’m BRCA Negative but Chose a Risk-Reducing Mastectomy Anyway

They look at your age, they look at whether you’ve had biopsies before, if those biopsies showed abnormal cells, if you have a family history of breast or ovarian cancer, when you started your cycle, the density of your breast tissue… All of this goes into a calculator and they spit out a risk score.

If your risk score is greater than 20 percent, you’re considered a high-risk patient. That doesn’t mean you have to have your breasts removed. It depends how far past 20 percent you are. 

For instance, my risk score is 42 percent. I could go and get my breasts removed prophylactically at any time, but I’ve had a gigantic operation for kidney cancer and I’m really not in the mood to have another big operation. But I’m very committed to being screened every six months. I get my MRI, then in six months, I get my mammogram. 

Patients who are greater than 20 percent risk need to talk to their provider about enhanced breast screening. And we are picking up breast cancer a lot earlier, at stage 0 and stage 1 by doing this enhanced screening, but people need to understand that if you have an elevated risk, you need to [have additional screening]. 

We’re trying to get out the word to providers to talk to their patients and figure out what their family history is so that you can get them into the right clinic and be followed.

Why is it important for people to talk about their cancer with their family?

Dr Robertson: I am always shocked when I see a new consult whose whole family has had cancer and no one sat down and talked to them about [their risk]. ‘Everybody’s had kidney cancer. Everybody’s had colon cancer, or everybody’s had breast cancer, or ovarian cancer, or there’s a male in the family with breast cancer,’ which is a red flag.

Just getting the word out that [for patients to realize]: ‘Hey, I have a high risk for developing cancer, let me talk to my provider,’ and to providers: ‘Hey, you need to talk to patients about this.’ 

There is a bias that African Americans have a disparity in genetic testing, and that is really a shame because we should be offered the same thing as our white counterparts. But there is a bias where we don’t get genetically tested or you’ll see someone with a strong family history who’s gone through a surgery for breast cancer but was never tested.

I’ve also noticed there are a lot of generations that are secretive about cancer and no one tells anybody they had cancer. You need to know your family history and people need to be open. If I didn’t tell people I had kidney cancer, nobody [in my family] would get tested for the gene mutation that we have.

How Breasties Can Decide Which Surgery is Right for Them

How can someone figure out what type of breast surgery is right for them?

Dr Robertson: What I want to stress is when you get diagnosed with breast cancer, it is often not a surgical emergency. 

Those cells have probably been there for a couple of years. Some younger people have more aggressive breast cancers, but still, take a deep breath. It’s not a surgical emergency. One of my pet peeves is when I see [a patient for] a second opinion and they’re being pushed into surgery but the patient doesn’t know anything about their cancer. They don’t even know their options. They just were told to take their breasts off. 

It’s really complex. Deciding [what surgery is right for you] is individualized. So when a patient comes to see me, we look at their breast cancer to see what type of cancer it is. A lot of breast cancers are hormone positive, meaning they grow in response to estrogen and progesterone, so some of those early-stage breast cancers don’t need upfront treatment [before surgery].

Other breast cancers, like HER-2 positive disease or triple negative, at a certain size, have to get chemotherapy first before I touch them. So it’s not always surgery first. 

The second thing is we look at the size of the tumor. If it’s a very large tumor, you may need to remove your breast just because of the tumor-to-breast ratio. If your cancer is in multiple quadrants of the breast, you [might not be able to] save your breast. 

The other thing that we look at is whether or not you want to do radiation. I want to stress that doing a lumpectomy, which means just taking the cancer out, with the appropriate radiation has the same survival rate as doing a mastectomy.  

It’s not for me to push you into surgery. My job is to give you all your options. Some patients with big tumors can do chemotherapy or endocrine therapy—the hormone blockers—to get it smaller so we can conserve the breast if they choose to do so. There are multiple options. 

I always tell patients the very first time you meet with a surgeon, you shouldn’t just jump to doing surgery. You need to understand your tumor pathology while we’re offering you the things that we’re offering you so that you can make an informed decision because an informed patient is their best advocate.

Are there any additional tests or screenings someone should do before deciding on a particular surgery?

Dr Robertson: Once you’ve been diagnosed with breast cancer, number one, you need to make sure that if you have a strong family history, you’ve done the genetic testing, because if you’re positive for a gene mutation, you really should consider removing both breasts.

The second thing is the density of your tissue. Dense tissue means it’s hard to see through your tissue. Not everyone needs an MRI before surgery however, if you have very dense tissue, often we have found surprise cancers in there. 

Not everybody needs the same test. So that’s why I say breast cancer is individualized. So you should talk to your particular surgical oncologist to decide [and ask], “Hey, what is the best test before I decide on surgery?”

Who’s On Your Care Team?

What does someone’s medical team look like after receiving a breast cancer diagnosis?

Dr Robertson: It’s multidisciplinary. So when you’re diagnosed with breast cancer, the surgeon often sees the patient first.

So we’re the captains of the ship, as I say, but our job is to make sure we load the ship with the appropriate people: the nutritionist, the geneticist, the lymphedema specialist, your oncologist, your radiation oncologist. Everybody needs to come to the table to discuss what that patient needs.

Not everybody needs the same treatment. What I do is local control. It does not protect the rest of your body like the chemotherapy and just because you get diagnosed with breast cancer doesn’t mean you need chemotherapy.

How do surgical oncologists and plastic surgeons work together during breast reconstruction?

Dr Robertson: When my patients want to be considered for reconstruction, we actually send them to a plastic surgeon—not a cosmetic surgeon—a board-certified, fellowship-trained plastic surgeon that does breast reconstruction.

I’d make sure that their cancer is safe to reconstruct the breasts and then we decide what type of mastectomy we were going to do for those patients. The plastic surgeon evaluates them to make sure their skin is good, that they don’t smoke, all the different things to minimize complications.

And we work together. I will remove the breast and the plastic surgeon will usually come in and then put an implant in or do some type of tissue reconstruction for the patient. We do it on the same day if we can, and sometimes it’s temporary.  We call it immediate delay, meaning they immediately get something in the breast, like an expander, but it’s temporary until you finish your treatment and they take you back later to put the final thing in.

It’s still relatively a new technique, but one of the plastic surgeons I work with, we actually work simultaneously looking for those nerves to re-implant them with grafts on the nipple so that people can hopefully get their sensation back.

RELATED: What You Should Know About Post-Mastectomy Sensation Loss

How can patients work with their team to have the best outcome possible?

Dr Robertson: Be an advocate for yourself. 

Make sure you take somebody with you to these meetings. Before I was diagnosed, I’ve always been sympathetic, because I take care of breast cancer patients but once you’re given the diagnosis, the patient’s eyes glaze over. They’re not hearing you anymore. They’re still stuck on [being told they have cancer]. 

I got this experience first hand, where I sat there while I’m thinking, “He’s going to tell me something’s benign,” and he’s starting to talk about how he had to take something off my kidney, and how I may have to have chemo. 

I wasn’t looking to him anymore and I’m sure my patients have the same look. Have someone come with you and take notes and ask to have your pathology so you can review it for yourself.

Write those questions down before you come in [to see] the surgeon, the medical oncologist, anybody. Don’t let them leave until you get your questions asked. 

Now one thing we don’t like is Dr. Google. I want you to be informed but don’t just bring everything off the internet. Try to be informed so that you can understand about your breast cancer. Ask questions and if [you need], get a second opinion. I got a second opinion and if I hadn’t, I would never have known I had a gene mutation or a second cancer that required me to have a different type of surgery where they found two more cancers.

You don’t need to have a third, fourth, fifth, and sixth opinion because too many will make you get crazy, but if you’re not getting what you need out of your team—or even if you are and you just want to—get another opinion. 

Make sure you know all your options. Don’t rush into a surgery until you understand why you need it. I believe in what we do. I believe in Western medicine. I believe in chemotherapy. I believe in not alternative, but complementary medicine. Ask your doctor about all the things you can do to help boost your survival, meaning you do your chemotherapy, but, “Hey, can I also do yoga or can I do acupuncture? Hey, what kind of veggies do I need to eat? Or can I juice?” 

There’s no magic bullet diet for preventing breast cancer, but you can do things to boost your immune system. Get the nutritionist on the team. 

If you don’t understand something, make the doctor stop. Or if you feel like you’re being pushed to something, make them stop and have another discussion with you. Don’t just sit there like a bump on the log. You need to be an active participant in your cancer care. You have to advocate for yourselves.

Maricia: What would your message be to someone who doesn’t feel like they are supported by their care team? 

Dr Robertson: Unfortunately, Black physicians—especially Black female physicians—account for less than three percent of all physicians. Chances are, you’re probably not going to find someone that looks like you taking care of you, and that’s okay. 

When I had my surgery, my doctor looked nothing like me but he understood where I was coming from. Make sure you have someone that relates to you, who’s going to talk to you as a person. You don’t need somebody dumbing down the words or talking real slow. You have to make sure someone can speak your language and explain it intelligently to you so you make a good decision. 

They may not look like you. However, you can find someone that’s going to take care of you.