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| KimberLee Mudge, M.D. |
Thinking about my own Eastern European shtetl-living and likely mutant-tumor suppressor gene-carrying forebears I quickly respond: “I’m not exactly sure what my ancestors did, but I know they did not do that.” We laughed together, and so began a relaxed and far-ranging interview.
“So, you have a farm?” I asked.
“When I finished my residency at York I bought this little 1881 house and worked to restore it. It was on three acres. I planted an orchard, and that evolved into a woodland hobby farm. I grow sour cherries, apples, rhubarb, potatoes, squash, and blueberries. Also, I have chickens, and a few beehives.”
“Are you getting ready for the apocalypse?”
“That is what my partners Tommy (Dr. Thomas Nicholson) and “Iggy” (Dr. Ignacio Prats) joke about. When something happens, they say, they are coming directly to the compound.”
Not one to sit still, Dr. Mudge has expanded her vision and is now working on an old log farmhouse on the part of her property where she has already set up a “fiber farm.” She raises alpacas, llamas, and sheep (the males are rams and the females, ewes, I was kindly reminded later), and she has a few miniature donkeys (the male is a jack and the female is a jenny, for those interested in such things). She hopes to grow this into an educational tool, as “a way of giving back,” she told me.
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| Freshly-shorn llamas and alpacas in Dr. Mudge's pasture |
“My days never stop. I have zero downtime. But I think it keeps me good,” she said. Her son (she is a single parent) does his chores on the farm before and after school. He was adopted from Siberia, she told me.
(Did she say Siberia?) “Did you have to go there to get him?” I asked.
“Yes, he was almost a year old and institutionalized.” The abandoned children (most are not really orphans) have very limited physical contact and nurturing. “You read about this,” she said, “but until you see it, it is something else. For the first couple of years, Peter did not know how to look into people’s eyes. He smiled on his own terms, but not (in a) reactionary (way).”
“They didn’t hold him or comfort him enough?”
“Not really.”
“Did you know the situation of the orphanages in Russia before you went?”
“I used Bethany Christian (adoption services), out of Lancaster, and they had never gone to Siberia before." (She paused...reflecting...) "Usually, when I am given an opportunity, I think of it as a sign, and that I need to take it. So I did.”
“Go on.”
“It was a nightmare situation,” said Dr. Mudge. But “he was in relatively good health” compared to the other institutionalized kids she saw when she got to the embassy where they and Peter were eventually sworn in as U.S. citizens.
“Did you have times when you wanted to back out?” I wondered.
“No, but the Communist environment was straining,” she replied. “After the first trip, Peter did not come home with me. On the second, they needed a redo of the paperwork that they had already received. This was followed by an appeal, and (I had to) stand before the court, and the sit-in judge was not happy about my request.” Though her attorney pleaded with the judge Dr. Mudge feared that they were going to decline the adoption; she sensed that the process was being “driven by (the quest for) the American dollar.”
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| Russian Orphans (from Ekaterina Loushnokova) |
Two years after finding Peter she started the process of adopting a little girl from China. The Beijing Summer Olympics were approaching, and TV images of children leaving the country would not be good PR. (Remember when we all watched the same three or four networks, remember when the news was a shared experience?) The Chinese government changed the rules again and again and Dr. Mudge was disheartened as her hard work failed, and she reluctantly withdrew her request.
Moving on: “How did you decide to become a doctor?” I asked.
“Everyone in my family (in north-central Pennsylvania) was a school teacher and education was important. It’s weird, as a youth I was terrified of death, but, somehow, I wanted to be a physician. My passion was for science. I wanted to be my own boss. I wanted to make a difference. I thought that in medicine I would have autonomy.”
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| Unspoiled farmland in north-central Pennsylvania |
“Tell me more.”
“I have always tried to push the envelope as a woman,” said Dr. Mudge. “I went to college on a basketball scholarship from Marshall University in Huntington, West Virginia. They also had a young medical school there” (making it especially attractive to her). Before medical school, she got a master’s degree in biology. Altogether, she lived in Huntington for ten years. At that point, family, friends, and her “hometown folk” thought she should be a pediatrician or a family doctor.
But KimberLee the medical student needed “action” and, as a visual learner, surgery was the best fit; the days flew by during her surgical rotations and she was excited by what she saw and wanted to share that.
She graduated from medical school in 1991. When looking for a residency she longed to come back to her roots. She wanted to be close to family, but in a somewhat less rural setting than where she was raised. While a fourth-year medical student, she did a surgical rotation in York with Drs. Steve Pandelidis, Tom Scott, Samuel Laucks, Gil Rothrock, and Vasudevan Tiruchelvam. As she reflected on that formative experience, York seemed to be the ideal setting; she loved the “family feeling” of the York Hospital where everybody seemed to know each other, and where they worked together.
Surgery in the 1990s was shifting, and as a young surgeon, she went through her five-year residency she sensed the push towards subspecialization. Dr. Mudge decided to focus on women’s health and she reached out to one of her valued medical school attendings. She asked if she knew of anyone specializing in breast surgery. Her professor did, and KimberLee contacted Dr. Claire Carman in Norfolk, Virginia.
She spent six months (“with essentially no pay”) shadowing Dr. Carman and learning everything she could, came back to York, and began her practice of breast surgery. “This has been a good fit,” she said. It filled a void, as there were no (local) women physicians dedicated solely to women’s health. And, as an added bonus, “it just felt right” and it was who she was.
“What changes in surgery of the breast have you seen over the past 21 years of practice?” I asked.
Dr. Mudge recalled that when she came to York in 1991 she would scrub in for cases where the woman was about to undergo general anesthesia for a breast biopsy. The consent form included the wording that she would agree to an immediate mastectomy if cancer was found during the procedure. Standing by the draped and prepped patient in the cold OR, and realizing that she was the only person in the room that the patient knew was humbling. Dr. Mudge felt that these women were the strongest people she had ever met, knowing, as they did, that they might wake up missing a breast. Thankfully, that doesn’t happen now, as women almost always know beforehand what to expect.
In fact, by the time she started practice, the simple removal of just the tumor itself, the so-called lumpectomy, was already becoming the standard of surgical care. Routine Identification of what is known as the sentinel lymph node in the axilla (the armpit) allowed for easier staging without the development of the feared permanently swollen arm of lymphedema. The disfiguring radical mastectomy was gone and even the less severe modified mastectomy was fading. Breast conservation was much preferred. But things don’t stay the same.
But KimberLee the medical student needed “action” and, as a visual learner, surgery was the best fit; the days flew by during her surgical rotations and she was excited by what she saw and wanted to share that.
She graduated from medical school in 1991. When looking for a residency she longed to come back to her roots. She wanted to be close to family, but in a somewhat less rural setting than where she was raised. While a fourth-year medical student, she did a surgical rotation in York with Drs. Steve Pandelidis, Tom Scott, Samuel Laucks, Gil Rothrock, and Vasudevan Tiruchelvam. As she reflected on that formative experience, York seemed to be the ideal setting; she loved the “family feeling” of the York Hospital where everybody seemed to know each other, and where they worked together.
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| An old postcard of the stately-looking York Hospital |
She spent six months (“with essentially no pay”) shadowing Dr. Carman and learning everything she could, came back to York, and began her practice of breast surgery. “This has been a good fit,” she said. It filled a void, as there were no (local) women physicians dedicated solely to women’s health. And, as an added bonus, “it just felt right” and it was who she was.
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| Claire Carman, M.D. |
Dr. Mudge recalled that when she came to York in 1991 she would scrub in for cases where the woman was about to undergo general anesthesia for a breast biopsy. The consent form included the wording that she would agree to an immediate mastectomy if cancer was found during the procedure. Standing by the draped and prepped patient in the cold OR, and realizing that she was the only person in the room that the patient knew was humbling. Dr. Mudge felt that these women were the strongest people she had ever met, knowing, as they did, that they might wake up missing a breast. Thankfully, that doesn’t happen now, as women almost always know beforehand what to expect.
In fact, by the time she started practice, the simple removal of just the tumor itself, the so-called lumpectomy, was already becoming the standard of surgical care. Routine Identification of what is known as the sentinel lymph node in the axilla (the armpit) allowed for easier staging without the development of the feared permanently swollen arm of lymphedema. The disfiguring radical mastectomy was gone and even the less severe modified mastectomy was fading. Breast conservation was much preferred. But things don’t stay the same.
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| Modified radical mastectomy (from the National Cancer Institute) |
Since the mid-1990s there have been remarkable advancements in genetic assessment of cancer risk and genomic evaluation of the tumor tissue. Since identifying a number of mutated genes that increase the risk of developing breast cancer, most notably some of the many variants (perhaps a thousand!) of mutated BRCA-1 and BRCA-2 (tumor suppressor) genes located on chromosomes 17 and 13, respectively (discovered by Mary-Claire King, Ph.D.), women are becoming more “empowered” according to Dr. Mudge.
For example, even knowing, as carriers of certain mutations, that their chance of having breast cancer by the age of 80 may be as high as 70%, many of these high-risk women are choosing to have close surveillance and breast-conserving procedures rather than a prophylactic mastectomy. The women will, however, often have their ovaries removed to eliminate the also-heightened risk of ovarian cancer, since monitoring for that isn’t very good, and while treatment options are improving, they are still poor.
(Note to the men who have gotten this far: Males of the species harboring the genetic BRCA2 mutations have about an 8% lifetime risk of breast cancer and a nearly 25% risk of prostate cancer. This genetic information, you see, is not just for women.)
While genetic testing can identify women with an increased risk for cancer, “genomic” testing of the tumor itself can help direct treatment. For example, with a commercial 21-gene assay, a low “score” predicts a 2% rate of distant recurrence at 10 years that is unlikely to be improved by adjuvant chemotherapy (that can, therefore, be withheld). A high score, on the other hand, predicts benefit from chemotherapy. This “preventive” chemotherapy may reduce cancer deaths by up to 70%. Endocrine therapy is now often recommended first for women with hormone-sensitive (so-called estrogen- or progesterone-positive) tumors. Other markers such as HER2 must also be taken into consideration as various new treatments are developed.
Curiously, despite the many advances and options, young women with one-centimeter localized cancerous lesions that are not associated with known genetic mutations are often choosing to have a (simple) mastectomy and breast reconstruction. They don’t want to have the fear of another cancer hanging over their heads for decades. “They want to get on with their lives,” noted Dr. Mudge, as they consider “lifestyle” issues to be paramount.
Decisions, decisions. Education gives women the tremendous advantage of a fully-informed choice. So Dr. Mudge and members of her team spend a lot of time and effort to be sure that adequate information is provided to every woman, and that the women fully understand their options. The management of diseases of the breast is now exceedingly complex; there are benign but suspicious breast masses, clearly precancerous growths, sharply localized cancers, cancer that has spread to regional lymph nodes, and even cancer that has spread distally at the time of initial diagnosis. Patients need time and help to take it in.
“Handling the intense emotions that accompany a breast cancer diagnosis must be difficult for you,” I say.
While there is a little bit of hand-holding, a softening, Dr. Mudge tries her best to be “a straight shooter” and she doesn’t “sugarcoat” things. After the anxiously awaited biopsy is completed the fear and anxiety continue. She knows this and makes sure to call with the pathology results as soon as they are available. Dr. Mudge notes that at the time of this phone conversation the women “are on their own territory” and they can react “on their own terms.” They may “cry or throw things,” but this happens in private. KimberLee then arranges for an office visit within 24-48 hours to work out a plan.
She writes everything down and gives them their reports. They need to be fully informed. And with that information, they are more empowered and, hopefully, less victimized. Dr. Mudge reviews everything, and the woman gets to know her surgeon and the support staff. They need to develop mutual trust and a true partnership.
Some patients have told Dr. Mudge that cancer is “the best thing that has ever happened” to them. She said that “many come out on the other side stronger and more confident.” They have “conquered the beast.” She said that “it is quite remarkable” as some move on, maybe from a spouse that was not right, or gone on to college and become nurses. It is courageous to work through suffering.
Not really knowing why, I ask if she is optimistic about the future of her still-independent practice.
When she came to the York Hospital she was pleased that there was a feeling of family throughout the community. But over the last 20 years, the health systems grew and spread. It seemed to her that “respect for the clinicians” was being slowly eroded, and that physicians were gradually becoming “expendable commodities.”
Countering this trend, Dr. Mudge said, is that her surgical practice has remained unique. She and her partners “have all subspecialized” but collectively they “function as one general surgeon.” And it has been ingrained in them that they have a sacred responsibility to the patient, who always “comes first.”
As the continued autonomy of her practice, “Leader Surgical Services,” is threatened by the large health conglomerates that control patient flow Dr. KimberLee Mudge has needed to expand her vision of the future.
What does she see?
Maybe a bright new facility dedicated to the comprehensive management of diseases of the breast. A place where patients and staff work together seamlessly. Where there is a focus on early diagnosis when suspicious lesions are still small and easily removed. Where the surgical procedure is carefully fitted to the specific needs of the woman. Where postoperative and late follow-up care occur in a peaceful nourishing setting.
Where this setting is dotted by plantings of lavender and sunflowers. And vegetable patches. And fruit trees. Where honeybees flit from blossom to blossom. Where patients and staff can walk on lovely winding paths together. Where there is mindfulness of the needs of future generations. Where sustainability is a guiding principle. Where everything is connected. Where there is family.
That would be a nice vision. Squinting, I can almost see it forming in the distance...
Suggested additional readings (from my husband's bookshelf):
1. Capra, Fritjof. The Web of Life. Anchor Books, New York, 1996.
2. Mukherjee, Siddhartha. The Gene: An Intimate History. Scribner, New York, 2016.
3. Wilson, Edward O. The Future of Life. Vintage Books, New York, 2002.
By Anita Cherry 6/27/19
For example, even knowing, as carriers of certain mutations, that their chance of having breast cancer by the age of 80 may be as high as 70%, many of these high-risk women are choosing to have close surveillance and breast-conserving procedures rather than a prophylactic mastectomy. The women will, however, often have their ovaries removed to eliminate the also-heightened risk of ovarian cancer, since monitoring for that isn’t very good, and while treatment options are improving, they are still poor.
(Note to the men who have gotten this far: Males of the species harboring the genetic BRCA2 mutations have about an 8% lifetime risk of breast cancer and a nearly 25% risk of prostate cancer. This genetic information, you see, is not just for women.)
While genetic testing can identify women with an increased risk for cancer, “genomic” testing of the tumor itself can help direct treatment. For example, with a commercial 21-gene assay, a low “score” predicts a 2% rate of distant recurrence at 10 years that is unlikely to be improved by adjuvant chemotherapy (that can, therefore, be withheld). A high score, on the other hand, predicts benefit from chemotherapy. This “preventive” chemotherapy may reduce cancer deaths by up to 70%. Endocrine therapy is now often recommended first for women with hormone-sensitive (so-called estrogen- or progesterone-positive) tumors. Other markers such as HER2 must also be taken into consideration as various new treatments are developed.
 |
| Women's risk of breast cancer by age and BRCA status |
Decisions, decisions. Education gives women the tremendous advantage of a fully-informed choice. So Dr. Mudge and members of her team spend a lot of time and effort to be sure that adequate information is provided to every woman, and that the women fully understand their options. The management of diseases of the breast is now exceedingly complex; there are benign but suspicious breast masses, clearly precancerous growths, sharply localized cancers, cancer that has spread to regional lymph nodes, and even cancer that has spread distally at the time of initial diagnosis. Patients need time and help to take it in.
 |
| One algorithm for breast cancer (from Onkopedia) (BCS=Breast conservation surgery) |
While there is a little bit of hand-holding, a softening, Dr. Mudge tries her best to be “a straight shooter” and she doesn’t “sugarcoat” things. After the anxiously awaited biopsy is completed the fear and anxiety continue. She knows this and makes sure to call with the pathology results as soon as they are available. Dr. Mudge notes that at the time of this phone conversation the women “are on their own territory” and they can react “on their own terms.” They may “cry or throw things,” but this happens in private. KimberLee then arranges for an office visit within 24-48 hours to work out a plan.
She writes everything down and gives them their reports. They need to be fully informed. And with that information, they are more empowered and, hopefully, less victimized. Dr. Mudge reviews everything, and the woman gets to know her surgeon and the support staff. They need to develop mutual trust and a true partnership.
Some patients have told Dr. Mudge that cancer is “the best thing that has ever happened” to them. She said that “many come out on the other side stronger and more confident.” They have “conquered the beast.” She said that “it is quite remarkable” as some move on, maybe from a spouse that was not right, or gone on to college and become nurses. It is courageous to work through suffering.
Not really knowing why, I ask if she is optimistic about the future of her still-independent practice.
When she came to the York Hospital she was pleased that there was a feeling of family throughout the community. But over the last 20 years, the health systems grew and spread. It seemed to her that “respect for the clinicians” was being slowly eroded, and that physicians were gradually becoming “expendable commodities.”
Countering this trend, Dr. Mudge said, is that her surgical practice has remained unique. She and her partners “have all subspecialized” but collectively they “function as one general surgeon.” And it has been ingrained in them that they have a sacred responsibility to the patient, who always “comes first.”
As the continued autonomy of her practice, “Leader Surgical Services,” is threatened by the large health conglomerates that control patient flow Dr. KimberLee Mudge has needed to expand her vision of the future.
What does she see?
Maybe a bright new facility dedicated to the comprehensive management of diseases of the breast. A place where patients and staff work together seamlessly. Where there is a focus on early diagnosis when suspicious lesions are still small and easily removed. Where the surgical procedure is carefully fitted to the specific needs of the woman. Where postoperative and late follow-up care occur in a peaceful nourishing setting.
Where this setting is dotted by plantings of lavender and sunflowers. And vegetable patches. And fruit trees. Where honeybees flit from blossom to blossom. Where patients and staff can walk on lovely winding paths together. Where there is mindfulness of the needs of future generations. Where sustainability is a guiding principle. Where everything is connected. Where there is family.
That would be a nice vision. Squinting, I can almost see it forming in the distance...
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| Dr. Mudge's animals are watching us... |
Suggested additional readings (from my husband's bookshelf):
1. Capra, Fritjof. The Web of Life. Anchor Books, New York, 1996.
2. Mukherjee, Siddhartha. The Gene: An Intimate History. Scribner, New York, 2016.
3. Wilson, Edward O. The Future of Life. Vintage Books, New York, 2002.
By Anita Cherry 6/27/19
