Doc Discussions with Dr. Jason Edwards
THIS is the podcast you have been looking for! "Doc Discussions" are just what the title says they are: physicians from a wide range of specialties, talking about relevant, up-to-date medical topics, not to mention tips on habits to help you live your best life. Your host, Jason Edwards, MD, is a board-certified radiation oncologist with a PhD in cellular and integrative physiology at St. Luke's Hospital in St. Louis, Missouri. Dr. Edwards explores not only diseases but also suggests techniques to optimize mental and physical health for a long and good life. Real people. Real advice. Real good. This is Doc Discussions, with Dr. Jason Edwards!
Doc Discussions with Dr. Jason Edwards
Innovations in Breast Cancer Diagnosis and Management
What does it take to break barriers in the world of surgery? Join us for an engaging conversation with Dr. Nanette Wendel, an inspirational figure in the medical field, as she recounts her incredible journey from the University of Michigan to becoming the Medical Director of the Women's Center at St. Luke's. Dr. Wendel offers a candid look at the gender dynamics and rigorous challenges she faced during her surgical residency in the midwest, sharing how her career evolved over two decades, with a special focus on breast cancer treatment. Her insights into the complexities of breast cancer diagnosis and the pivotal role of patient education are not to be missed.
Our discussion doesn't stop there. We shed light on the significance of early detection through mammograms, exploring the nuances of screening guidelines and the life-changing impact of community initiatives like Pink Ribbon Good. Dr. Wendel also elucidates the benefits of comprehensive imaging techniques, including MRIs, while stressing the importance of a multidisciplinary approach in cancer management. This episode pays tribute to the relentless dedication of medical professionals who tirelessly work to transform patients' lives. Tune in to gain a deeper understanding of the intricacies of breast cancer treatment and the evolving landscape of medical care.
Hi, this is Jason Edwards and I'm here for another episode of Doc Discussions with my good friend, dr Nanette Wendel. Dr Wendell is the head of the Women's Center. Her technical title is Medical Director Nanette. Welcome, thank you. How are you doing this afternoon? Oh, fantastic, you know. With you I kind of wanted to actually go back in time and start from the beginning of your post-high school education. Where did you do your undergraduate?
Speaker 2:at University of Michigan.
Speaker 1:Very good, Very good. That's one of the public ivies.
Speaker 2:they say You're asking me to dust off some cobwebs here.
Speaker 1:Yeah, I think it's Michigan, virginia, north Carolina are supposed to always at the top of the public schools nationwide. And then where did you go to medical school at?
Speaker 2:Northwestern University in Chicago.
Speaker 1:Very good. Did you have a good experience there?
Speaker 2:I had a wonderful time Probably too good a time.
Speaker 1:Now, are you originally from Chicago? Yes, okay, very good, so you came back home.
Speaker 2:Yes, definitely came back home.
Speaker 1:And then, where did you do your surgery?
Speaker 2:residency after medical school uh, northwestern, and then part of it at university of nebraska how about that?
Speaker 1:how did that work out?
Speaker 2:um, northwestern, uh, back in those days there were what we call pyramid programs, where they start off, uh, the intern class very large, and then pare things down.
Speaker 1:Oh, I saw this later in the show Mad Men where, like every year, they would have like one less.
Speaker 2:They kind of get rid of people.
Speaker 1:And that's not how it is today.
Speaker 2:No, no, it is not like that today, but it was in those days, and Northwestern really didn't get rid of people. But what they did was, if it was there were too many for the next level, they would put you into the laboratory to do research for a year or more until they brought you out. And I did not want to do that, I wanted to get on with things. So my good friend who was a chief resident while I was at Northwestern, we came in attending at Nebraska. He said we have an opening coming over. How about that?
Speaker 1:And so that was University of Nebraska, omaha, yes, okay, and Omaha, I've been there. Nice enough place, not Chicago, correct. And so now the dynamics have changed with gender and medicine in general, but certainly over time, with women in surgery, in surgery training and as their, you know, post-training, their occupation and the pathway to becoming a breast surgeon is you do general surgery as your residency program. I cannot imagine there were a lot of women in your program, were you the only one in your class?
Speaker 2:No, In my class I'd say there were probably three of us.
Speaker 1:Okay.
Speaker 2:But yeah, not many. Yeah, and that was probably out of seven or eight.
Speaker 1:Yeah, and general surgery is kind of known as one of the hardest residencies to go through. Every residency has its own.
Speaker 2:I'll admit it was brutal. I always say I went into it a nice person and I came out not such a nice person. They change your personality.
Speaker 1:For sure, and just the sheer amount of hours and the stress, it's just a lot to carry.
Speaker 2:At that time there weren't shifts or anything like that. I mean, there were some rotations like vascular surgery, cardiac surgery. I would be home. Were some rotations like vascular surgery, cardiac surgery? I would be home one night a week. Yeah, that was it.
Speaker 1:Yeah, you were called a resident because you were a resident in the hospital. Yeah, and so, and it's. You know, I think, I'm sure no doubt it was extremely difficult to go through that program. But on the backside I think most people are thankful for going through a difficult program because it does make you a stronger person and physician, a hundred percent, yeah, and then, and then did you go to Florida after that?
Speaker 2:Yes, I went to Florida to practice and lived there for 18 years.
Speaker 1:Very good. And then you when did you come to St Luke's here? It's been nine and a half years already.
Speaker 2:Nine and a half years, very good. And then, when did you come to St Luke's here? It's been nine and a half years already. Nine and a half years, how about?
Speaker 1:that, and so you're the head of our breast program here at St Luke's and you treat almost exclusively patients with breast cancer. Is that accurate?
Speaker 2:Yeah, we do see some benign disease as well High risk lesions that may or may not be a breast cancer, lumps and things like that but the vast majority is breast cancer.
Speaker 1:Okay, and you and I full disclosure we work together frequently, which is excellent, and so the kind of algorithm is somebody comes in for their annual screening mammogram, they see a spot on the mammogram and then they typically get a diagnostic mammogram, an ultrasound.
Speaker 2:Correct me if I'm wrong.
Speaker 1:No, that's correct, because you're more familiar with that. And then, if it continues to be suspicious, they will have a biopsy. Yes, to be suspicious, they will have a biopsy. And if the biopsy is positive for malignancy or ductal carcinoma in situ, then they see you and you discuss their treatment options at that point. Correct, and what are their options as far as surgery?
Speaker 2:As far as surgery, the options are lumpectomy, which is what we call breast conservation therapy, where you're only taking out the cancer with hopefully negative margins or edges and saving the breast. That does require generally radiation afterward, but is a very quick recovery. And our other option is mastectomy, that's removal of the entire breast, and what most people don't realize is that basically the survival for both are the same.
Speaker 1:Yeah.
Speaker 2:And so that's a lot of. What I do is education.
Speaker 1:Yeah.
Speaker 2:You know, people always have something in mind, but my job is to fully educate them and help guide them as to the the right procedure.
Speaker 1:Yeah, you know, when you say mastectomy, immediately I thought of our, um, our plastic surgeons, um, because, um, a lot of patients, if they do have a mastectomy, we'll have reconstruction and um, and I've seen a lot of um, uh, reconstruct reconstructions, breast reconstructions at multiple institutions and I really feel like we have two of the best plastic surgeons around 100% agree.
Speaker 2:I tell my patients that because I've been doing this about 30 years and so I've seen many plastic surgeons in my day and worked with several in my day. These are two of the best I've ever worked with hands down.
Speaker 1:I couldn't agree more. I've seen at multiple universities, big, big places and patients from other institutions and and it's a breast reconstruction is different than a breast augmentation. Yes, and it's a difficult thing to have a good cosmetic outcome.
Speaker 2:Yeah.
Speaker 1:But I feel like we're really lucky.
Speaker 2:We're very lucky and the unfortunate thing is that, you know, I don't want to say too much about other places, but the people from other institutions who aren't happy come here and try and do the best we can. But yeah, I've seen a lot as well and I'm just so thankful for the two we have.
Speaker 1:Darrell Bock, and so those two are Dr Scott Geiger and Dr John Holson. Dr John Holson, Correct. And so I'm going to back up and go kind of to the start of the algorithm. If somebody has a suspicious lesion, roughly what percentage of those and we're going to biopsy it. Roughly what percentage of those biopsies are going to be positive for malignancy?
Speaker 2:It's actually lower than you think. Usually about 20%. Yeah, usually about 20%.
Speaker 1:Yeah, and so I think that's a really useful number because I've had friends and coworkers who've had suspicious lesions and saying they're going to get a biopsy. And I tell them you know, odds are it's negative, which you think immediately. You think if I'm a candidate for a biopsy, you know 90% it's going to be positive, and so your mind just goes there and emotionally it's a, you know, very difficult path and it's good to know that the pretest probability is about 20% and that's the way we want it. We want to biopsy a lot more patients. You know that actually have cancer.
Speaker 2:You have to biopsy that many to catch the 20%.
Speaker 1:And so, yeah, the sensitivity is high of the mammogram, and so we're going to catch most cancers Right, and for most patients it's a yearly mammogram that they're getting correct, and then some patients will be high risk. What are the typical things that puts a patient into the high risk category?
Speaker 2:The typical things are family history, strong family history, history of a previous biopsy that was abnormal, say some atypical cells or what we call I hate this word but lobular carcinoma in situ, which is not a cancer, it's high risk. Those are the main factors.
Speaker 1:Yeah, usually it's a young lady whose mother or aunt or grandmother had cancer, Right?
Speaker 2:and we do have computer programs where the patients when they come in for their mammogram annually, they fill out a tablet and it takes in all the information and goes into an algorithm type software and then spits out a percentage of what their risk is. So anything above 20% is considered high risk. But it's several factors At what age you had your first child? If you had children, what age was your first menstrual cycle?
Speaker 1:weight, all those sorts of things come into play, yeah okay, and a lot of that stuff looks at just your lifetime. Estrogen exposure is a big piece because the majority of these tumors are estrogen receptor positive. Correct, yeah, and that's actually a good thing. Yes yes. Patients with an estrogen receptor positive cancer have a better long-term prognosis than those with estrogen receptor negative.
Speaker 2:Yep definitely.
Speaker 1:How has the surgery changed over time, whether it's the surgery of the primary breast or lymph node dissection? How has that changed, you know, from the start of your career to now?
Speaker 2:I'm going to date myself, but at the start of my career we were still doing what we call radical mastectomies. I mean, I was at the very tail end of that era where the mastectomy took place. But also the muscle was removed all the way down to the ribs, very disfiguring, and it was just horrible.
Speaker 1:Is that the Halstead mastectomy?
Speaker 2:Yes, and all the lymph nodes were removed. Then it progressed to a mastectomy and the muscle was preserved. Then over time it's progressed more and more towards lumpectomy because we know the outcomes are just as good. So it's less and less surgery as well as underneath the arm for the lymph nodes. It was routine up until the late 90s to remove all the lymph nodes from underneath the arm. Even if it was a tiny tumor didn't matter. But then came along what we call a sentinel lymph node biopsy, where we can pinpoint the first lymph nodes in the chain underneath the arm and have special techniques for that. And now that's all we remove for the vast majority of cases.
Speaker 1:And so the cosmetic outcome of the breast and the rate of lymphedema, which is the swelling of the arm, has gone down dramatically.
Speaker 2:Yeah, everythingedly improved.
Speaker 1:Yeah, everything's improved and the cure rates are just as good, but the side effects have gotten less and less, so it's been, in a way, a de-escalation of care with no penalty for the cancer cure rate.
Speaker 2:Right, right, and so, yeah, that's been— and we continue as the years go by. Over the past several years, even it's progressing very quickly to where we're finding out we need to do less and less.
Speaker 1:Yeah, and I would say that's one of the positives about breast cancer is we have a lot of data, and it's data from different eras and different countries, and that becomes very powerful just to have these large numbers of patients that you can kind of tease out who needs what and how to treat them. And then some patients, if they have some high-risk features, we will order an oncotype test and that tests the genes of the cancer cells and that lets the medical oncologist, who's the chemotherapy doctor, decide whether the patient needs chemotherapy after their surgery.
Speaker 2:Right, that has really made a big difference, because it used to be you'd look at the pathology, you'd kind of look at the patient and go well, I think chemo would benefit you or I think it might not benefit you, kind of thing, and now it's based on biology of your tumor and science, and I think that's been an amazing step forward, because so many people were probably overtreated.
Speaker 1:Yeah, it saves people from having to go through chemotherapy, and every once in a while somebody will have pathology that looks fairly non-aggressive for a cancer, but their oncotype score comes up high. It doesn't happen often, but you get surprised sometimes.
Speaker 1:Yes definitely, and that data is pretty solid. They came up with the nomogram or the algorithm with the genes and then they said this should work like this, and then they tested it again and found out that it validated the study, and so that's been powerful. I think there's been change up to this point and there will continue to be improvements in the care of our patients with breast cancer, but in general, compared to most cancers, they have relatively speaking good outcomes as far as cure rate yes, outcomes as far as cure rate.
Speaker 1:But breast cancer is the most common cancer in women and still there's still a lot of breast cancer specific deaths. Just to the sheer number you said with the high risk patients, if their risk is over 20%, what's the average in America for a woman? Is it 1 in 7, 1 in 8?
Speaker 2:1 in 8, yeah, and the 20%? What that means is that is your lifetime risk to age 80.
Speaker 1:Okay.
Speaker 2:It doesn't accumulate over the years. Actually, if we were to recalculate it over the years, it would probably go down, because you have less years ahead of you. Therefore, your risk would probably go down. Yeah, but we just do a one-time calculation.
Speaker 1:A one-time and so one in eight is roughly 15%-ish. And so if they're kind of 5% over the absolute number, 5% over the normal, then that puts them at high risk. And then what do you tell patients about breast cancer screening?
Speaker 2:as far as like doing self-exams, well, the ideal would be to do a self-breast exam once a month.
Speaker 1:Okay.
Speaker 2:It's about the same time of the month, especially if you're premenopausal.
Speaker 1:And why that? Why the premenopausal?
Speaker 2:Because things the breast will change at different points in your cycle.
Speaker 1:Okay.
Speaker 2:And so you, and so you want to pick the same point every month to get a good comparison, because if, say, it's a week before your cycle, you start to get a little lumpy and you feel something well, it may be gone two weeks later, sort of thing. Yeah.
Speaker 1:And so the hormones during the cycle can kind of make some of the breast tissue swell and then recede, depending on where you're at.
Speaker 1:Yeah, it can be. You know I do a fair amount of breast exams in my clinic and it can be tough in younger patients but sometimes too in patients who are postmenopausal. They can just have a lot of lumpy, bumpy breast tissue and kind of active tissue and a self-breast exam certainly not as good as a mammogram. But it is important and me and you see cancers every year that the patient actually felt an abnormality. What other symptoms can patients have if they have a breast cancer?
Speaker 2:That initial presentation Thickening of the skin, redness of the skin, uh, nipple retractions. Another one, um, you know pain. A lot of people come to us for breast pain. That I don't really put into it's not very specific. No, no, it's. It's very non-specific. I can almost never find a reason for their pain. But yeah um, I just saw something on facebook the other day that said these are the things that you should watch for, and pain was one of them, and I just cringed A lot of women have breast pain.
Speaker 2:Yeah, breast pain is so common.
Speaker 1:You can sleep on your breast wrong and not really realize it and cause a little bit of trauma, right. And then, once you have pain and you start thinking about cancer, it's hard to get that out of your mind. And so it's okay, you know, to go to your primary care physician and get a good exam and get it checked out Psychologically. If your mind's kind of gone there, it's probably not going to rein itself back in without some sort of objective evidence, that's true. And then bloody nipple discharge.
Speaker 2:Bloody nipple discharge yes, Another one, yeah.
Speaker 1:And yeah, that's. But the vast majority of breast cancers are detected by the mammograms, the screening mammograms. Because they're so good, yes, and they've only gotten better over time, and the radiologists who read those for um, for the most part um, specialize in that area.
Speaker 2:Yeah, they're dedicated breast radiologists.
Speaker 1:Yeah, and then there's been um. To me it seems like there's there's been this um big push from the community, um, which is it's, it's a, a movement really. Um, that's um. Um, that's pro-breast cancer, with the breast cancer foundations and the ribbons and stuff like that, and I think that's been a really positive thing to implement screening programs and get financial support. Now there's a group that you work with in town. It was called Pink Ribbon Girls and they call it Pink Ribbon. Good, now they call it.
Speaker 2:Pink Ribbon. Good, and the reason behind the change of name was well, they wanted to keep the G for the logos, but they found that women felt that when you say girls, it was only for younger women. That the organization was only for younger women, that the organization was only for younger women and so we felt that we were kind of missing a certain population. So they felt they had to change that. For that reason.
Speaker 1:Okay.
Speaker 2:Yeah, it's an amazing organization. It's a nonprofit organization that anyone with breast cancer can be affiliated with and anyone with breast cancer can be affiliated with, and what they do is they provide meals, rides, transportation to and from treatments and then some housekeeping supplies and services. Yeah, all free of charge.
Speaker 1:Yeah, and actually a lot of my patients with gynecological cancers use their service as well, and so I think that's been a really positive group and it's kind of a fun group to be a part of you recently invited me to their gala and it was beautiful. It was a beautiful venue and a lot of patient testimonials which were very moving. So thank you for inviting me.
Speaker 1:That was a lot of fun, but also thank you for your service with that group. Really, really, I appreciate the group and I appreciate you volunteering your time for that cause.
Speaker 2:Thank you.
Speaker 1:Yeah, and so what other things? What are we missing here? What other things do we need to go over, as far as breast cancer or anything else that you'd like to talk about? Have we covered it here? What other things do we need to go over, as far as breast cancer or anything else that you'd like to talk about? Have we covered it here?
Speaker 2:Well, the main thing for me always is you know, the government gets involved with their task forces trying to change the age of when you should have your mammogram and at what age you should stop having mammograms and things like this. But all of us in the field, no matter where you are in the country, feel that you should start your mammograms at age 40 or younger if you're high risk.
Speaker 1:Oh yeah, so there are different groups and different consortiums that have different recommendations. Now the American Cancer Society. Their recommendation is 40 years and it has been for a long time. Is that right? Yes, and then there is this entity that sprung up, I don't know when and where, called the United States Preventative Task Force, and it's a government agency, correct. And so you know the rule if a government agency, correct, and so you know the rule of a government. Whatever their name is, they do the opposite of, and so typically their recommendations, no matter what the cancer type, are less aggressive than the surgeons. And you the? The book Freakonomics kind of taught me this lesson, which was, uh, halfway written by um, a, um, uh, economist from university of Chicago one of your fellow Chicagoans.
Speaker 1:Um, but it was like if you understand the incentives then you can kind of predict behavior. And so their incentive is to pay for less mammograms.
Speaker 2:Correct, it's all about money.
Speaker 1:Yeah, and so our good friend Dave Krakovic. God rest his soul. His famous line was the answer's money. Now ask me the question.
Speaker 2:Exactly.
Speaker 1:But their incentive is to spend less money on mammograms, and the American Cancer Society's goal is to pick up breast cancers at an earlier stage to have a higher cure rate. And so yeah, I think definitely 40. And then implementing these high-risk programs can make a big difference too and give women who kind of have this at top of mind a little bit of peace of mind knowing that they're getting taken care of with mammograms or even MRIs sometimes, right.
Speaker 2:And that's been another thing that I've seen over the years is in the beginning, when we were seeing high-risk patients, you know our guidelines recommend MRI yearly in between your mammogram, and we had a lot of trouble getting that paid for by the insurance companies. A lot of trouble and thankfully we're finding that less and less now that it's become mainstream that if you are high risk you get a mammogram and then six months later you get an MRI and repeat that cycle throughout your life and say do you get an MRI and repeat that cycle throughout your life?
Speaker 1:Yeah, and even there's a girl I went to medical school with named Amy Patel, who's big in the breast imaging world and I think it was her or it may not be, but I think I saw it on her Facebook feed where there's been legislation even saying, you know, like it was passed through the government, saying the insurance companies have to, you know, provide this, and so there's kind of an activist, you know, arm out there as well, trying to make a difference.
Speaker 2:Yeah, we found that with whole breast ultrasound, because that is one of the tools that we use for people who have very dense breasts and don't really need an MRI. And it's whole breast ultrasound. And again, in the beginning, very difficult to have the insurance companies approve it and have it paid for. And now there are laws and Missouri is one of the states that does have a law stating that if this is deemed necessary, that it will be paid for.
Speaker 1:Yeah, that's great. That's great. And the ultrasound, the mammogram, mri and ultrasound they all kind of have different roles, but the ultrasound is the value of that that. It shows blood flow, like if you can see a mass, you can see blood flow in it. Or is there some other?
Speaker 2:Well, you can see blood flow, but the value is say you have a mammogram with dense breasts. All you see is like a white cloud. Yes, okay, and you will not be able to pick up anything small. It has to be very large before you can see it, Whereas the ultrasound if you do whole breast ultrasound, it will pick up the smaller lesions way before your mammogram will.
Speaker 2:Okay, so your signal-to-noise ratio, the mammogram is still important and people ask me this all the time. Why should I have both? Say you have calcifications, which are these little white dots calcium that are deposited. You will not see that on anything but mammogram. And that could also be the first sign of breast cancer. So they all go hand in hand, they don't exclude one another.
Speaker 1:Yeah, your pleomorphic calcifications right. Actually, when I see patients for ocular melanoma, which is a rare type of eye cancer that we actually treat a fair amount of here, I need to image their liver every six months and I go back and forth between ultrasound and CT scan and MRI if necessary, because they each kind of have their role there and it's just another tool in the toolbox to detect cancers. Well, nanette, I want to thank you so much for your time and your work. I appreciate you and our community's indebted for you for the work that you do for our patients with breast cancer. So thanks so much for joining me tonight.
Speaker 2:Well, thank you very much, and we thank you as well because you're our star radiation oncologist and every day the patients tell me how much they love Dr Edwards. You're never as good or as bad as people say you are. Oh, I think you are Thanks so much, nanette, I appreciate you All right, thank you.