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
From Mastectomy to Tailored Care: How Tumor Boards, Genetics, and New Therapies Shape Modern Breast Cancer Treatment
A breast cancer diagnosis can flip your world in a single sentence—so we set out to restore clarity, calm, and control. Dr. Jason Edwards sits down with breast surgeon Dr. Nanette Wendel and medical oncologist Dr. Meera Rana to map a modern pathway through complex choices, from the first tumor board conversation to long-term survivorship. Together we show how to match treatment to tumor biology while protecting quality of life.
We start inside a multidisciplinary tumor board where surgeons, medical oncologists, radiation oncologists, radiologists, and pathologists collaborate on one coherent plan. You’ll hear why lumpectomy plus radiation can achieve survival equal to mastectomy in early-stage disease, how sentinel lymph node biopsy slashes lymphedema risk, and when MRI tips the balance between conservation and mastectomy. We unpack Oncotype and other genomic tests that separate patients who need chemotherapy from those who don’t, and we dig into the reasoning behind giving chemotherapy before surgery for HER2-positive and triple negative cancers.
Dr. Rana explains the evolving toolkit: endocrine therapy for hormone receptor–positive disease, PARP inhibitors for BRCA mutation carriers, CDK4/6 inhibitors for high-risk and metastatic settings, and immunotherapy’s growing role in triple negative breast cancer. Dr. Wendel brings the human side forward—how cosmetic outcomes and immediate reconstruction buffer the emotional hit of surgery, and why education often shifts patients away from default “double mastectomy” thinking toward evidence-based, confidence-preserving choices. We close with practical advice for the toughest first two weeks after diagnosis: record visits, bring another set of ears, ask for repetition, and lean on a plan that balances cure with the life you want to return to.
If this conversation helped you or someone you love, follow the show, share it with a friend who needs it, and leave a quick review to help others find these insights.
Welcome to Doc Discussions. This is Jason Edwards, and I'm here with Dr. Mira Rana and Dr. Nanette Wendell. Dr. Rana is a medical oncologist, which is a doctor that gives chemotherapy or targeted therapy or even immunotherapy. And Dr. Wendell is a breast surgeon in our breast clinic. Welcome.
SPEAKER_00:Thank you. Thank you. And so we actually work together a lot. Um, and commonly we interact um mostly in our tumor board. Um, Dr. Wendell, do you care to describe to the listeners um about what tumor board is and what the function of it is?
SPEAKER_03:Sure. Um here at St. Luke's we have a weekly conference. It's held every Monday morning, and um it's strictly for breasts. Um there are tumor boards uh for other cancers as well, but uh we discuss only breast cases. And it's a multidisciplinary um uh board where uh people like you, radiation oncologists, Dr. Rana, and her colleagues, medical oncologists are there, surgeons, pathologists, radiologists, and we present cases, um, uh challenging cases, run-of-the-mill cases, uh, just so we can uh all collaborate uh and get um a multidisciplinary plan together for the patients.
SPEAKER_00:Yeah. Um, and so um we we choose kind of uh or we discuss what kind of surgery would be best. And obviously you lead that discussion. And some patients will need systemic therapy or radiation therapy, and so we try to have kind of a comprehensive plan the best we can at that point. Um, if patients have like a very early stage breast cancer, um, you know, they have a couple treatment options, and over the course of time, we've tried to de-escalate the um uh the surgery um for these patients, whether it's the breast or the lymph nodes.
SPEAKER_01:Do you care to discuss that a little bit?
SPEAKER_03:Sure. Um I've been at this quite some time now. So um when I first started, mastectomy was the only option, period. And it was a modified radical mastectomy, which means that all of the lymph nodes were removed as well as the breast. It didn't matter if the tumor was five millimeters or five centimeters. Uh, it was all the same. And Mira uh Dr. Rana can speak to this. Um, a lot of people got chemotherapy in those days. Um, it was very deforming. Uh reconstruction was not really up and running or an option at that time. So, what we've seen over the years is um uh less and less deforming surgery. We are now performing mostly lumpectomies, where uh we call that breast conservation, and um that is mostly for cosmetic reasons. Uh and it's been a tremendous uh move forward. Um, we've also started taking fewer and fewer lymph nodes. Um, in the advent of sentinel lymph node biopsy back in the 1990s. Um, actually, I I was taught myself I was among the first to be doing that. And um, that really has been a game changer in terms of uh morbidity, the lymphedema, and that sort of thing, and uh really has brought us forward. So it's been it's been a great Yeah.
SPEAKER_00:Yeah, we've been able to kind of keep roughly the same cure rates, but have kind of less side effects from the treatment.
SPEAKER_03:That's right. And and I think an important point of that is that the survival uh with somebody who has a lumpectomy, including radiation versus a mastectomy, is the same. And that most people don't understand that. And I think that's a really important point.
SPEAKER_00:Yeah, yeah. We have um at least six large randomized controlled trials performed in different decades and different places. So that would um be very close to the truth, as an epistemologist would say. Uh, and so when we um are initially talking about patients in tumor board, sometimes we'll order some tests to see if they're candidates for chemotherapy either before or after the surgery. Dr. Rana, do you care to talk about those tests, like the oncotype test?
SPEAKER_02:Sure, yeah. So the oncotype test is a relatively newer test that's really helped determine who might benefit from chemotherapy. So especially in some of the early stages. So historically we used to kind of, it was actually more of a guessing game based on their pathology and what we thought. And so with the oncotype, it takes the guessing game out of it. So it's saying, what is your risk of recurrence distantly and what is the benefit of chemo? So the nice thing is it really does a better job of telling us who needs it and who doesn't. Now, that don't get me wrong, there are some gray zones that do come up here um every now and then with intermediate scores, but for the most part part has really helped us quite a bit. Um, other testing that we do outside of hormone-driven breast cancers is you know, every time Dr. Wendell is doing a surgery or even a biopsy that's being done by radiology, we're always testing for ER, PR, and HER2. And so some of our patients who might be HER2 positive or triple negative might actually benefit from chemotherapy prior to surgery.
SPEAKER_00:Yeah, you bet. Um, and and the um what is the what is the purpose of giving the chemotherapy prior to surgery or who benefits getting it prior to surgery versus after surgery?
SPEAKER_02:So really that really that actually depends on their marker. So patients who are triple negative tend to have more aggressive disease. So in theory, they will most likely need chemo either before or after. The benefit of giving these patients who are either triple negative or HER2 positive before surgery is that it might make it easier for Dr. Wendell to do surgery for one. So depending on how large their tumor is, if they have lymph node involvement, it might help minimize, you know, needing an axillary lymph node dissection, which is huge for lowering the risk of lymphedema as well.
SPEAKER_00:Yeah. And and so um, so if patients you said if patients have larger tumors, um, it can help Dr. Wendell do the surgery. Um, is there a size requirement that you look at, Dr. Wendell, for patients to see if they're a candidate for lumbectomy versus mastectomy?
SPEAKER_03:Yeah, it's not an absolute number. Um, obviously, breast size comes into it. Um, and it's it's a lot of judgment. Um when we talk about different tests, one thing that has brought us forward is the MRI. Um I find it very beneficial to have an MRI on anybody who has a breast cancer because sometimes the tumor is larger than meets the eye on ultrasound or mammogram, and that may push them from a lumpectomy to a mastectomy. So basically, uh, you know, I look at things, I look at the breast size. If I think that they're not going to have a good cosmetic result with a lumpectomy and it's gonna be very deformed, then we have to discuss uh mastectomy.
SPEAKER_00:Yeah. And how how important is the cosmetic outcome to the patient? And this is not like a scientific thing, but like you see patients and you understand how they think and mentally and emotionally.
SPEAKER_03:Yep. Absolutely. Uh it's it's extremely important because um this is a devastating time. They have breast cancer, and you know, if you can preserve the breast and preserve the cosmetic uh uh outcome, it it's incredibly important for their uh psychological state uh and overall, you know, well-being.
SPEAKER_00:Yeah, I think I think one thing is that that I noticed is you know, the the mental and emotional state of a patient, it it exists on a continuum of of time. And they they're not always going to feel kind of the same way about the cosmetic outcome in the midst of the battle, like right when they're diagnosed, versus how they feel five years later. Right. And I think a lot of times patients um underestimate how important the cosmetic outcome will be for the their whole lives. Um, and so have you have you noticed this too, Dr. Rana?
SPEAKER_02:Yeah, I have. I've actually had some patients really ask me, what do you recommend? And I always say, you want to plan for a better cosmetic result because it tends to make more of a difference than a lot of people realize. You know, especially for women undergoing chemotherapy or losing your hair most of the times. And that really plays a big role in confidence. And on top of that, having to do a surgery, which also can significantly affect that. So we do have a lot of conversations about that.
SPEAKER_00:Yeah, yeah, for sure. And, you know, a couple of people who aren't here right now are um Dr. John Holson and Dr. Scott Geiger are um uh plastic surgeons. And a lot of times if patients do have to have a mastectomy, um I think we're really, really fortunate to have two really good plastic surgeons here to help reconstruct the breast and give them an acceptable cosmetic outcome. Um, how do you work with the plastic surgeons, Dr. Wendell?
SPEAKER_03:Oh, we work very closely together. Um I I I will plug them any day of the week. Um, I've been doing it, like again, doing this for a very long time, seen a lot of plastic surgeons, and these two are hands down, I think, the best I've ever worked with. Agreed. Um their cosmetic outcomes are exceptional. And uh we we work very closely together. Um, when I find somebody that is interested in reconstruction, you know, we immediately contact them, get them in. Um, you get the surgery scheduled, and uh it's pretty, pretty seamless. Um they at least uh at the time of mastectomy will have either a temporary implant called an expander or the permanent implant. So when you're waking up, you already have a breast mount. And that again is such a psychological uh has a huge psychological impact. You know, you've you've lost your breast, but you look down and there still appears to be something there.
SPEAKER_00:Yeah. Yeah, I I I do think half the battle as you're going through the treatment is on the mental side, you know, just how how you you're thinking about life, how you think about your body, yourself, and and um and so I I think it having good plastic surgeons and good general surgeons, um, and having really good cosmetic outcomes is uh, you know, really, really important, even though in the midst of the battle you just want to cure the cancer, but in the long run, that becomes a really important um issue. Um so when they when a patient has a genetic mutation, such as a BRACA mutation, how does that change um you know surgically um for the patient? Does that move the needle for you whether you would proceed?
SPEAKER_03:Definitely, definitely. Um there are some mutations that are stronger than others, but definitely the BROCA, the CEC 2, the ATM. Um in those patients, uh again, depending a little bit uh about uh age and things like that, um I would probably counsel more for mastectomy and also consideration for a double mastectomy because there is risk with those uh mutations, and that risk will be for life. So, you know, you really need to consider if you have a breast cancer in one of those genes to potentially do a double mastectomy.
SPEAKER_00:And um which kind of patients do we actually do those testings in? Um like what what would so we don't do like bracket testing in every patient, but but which ones were we be like more prone to do that?
SPEAKER_03:Sure. Uh anybody with with a family history, um especially you know, first degree relatives, um, other uh cancers come into play, uh somebody with pancreatic cancer in the family or melanomas in the family, uh, we would do genetic testing. Uh somebody with bilateral cancers, cancers on both sides, uh, triple negative cancers will all get genetic testing. All men um get genetic testing. So um it's pretty broad. Uh there is a movement to potentially test everyone. Um, I think that's again judgment.
SPEAKER_00:Yeah, that I mean, what is it? Maybe um less than 10% for sure of all breast cancers um have a genetic mutation, right? Right. Um, and and uh Brocco, I would assume is the most comp common. Is that is that what we see? Or or is that actually no, no?
SPEAKER_03:I think I I see more of the CEC2 and the ATMs to be honest, yeah.
SPEAKER_00:Yeah. Um and so the there's been also this emergence of new um systemic therapies um that we use. Can you talk about kind of the old ones for like the estrogen receptor positive patients, but then also um our PARP inhibitors or HER2-directed therapies as well?
SPEAKER_02:Sure. So for um hormone-driven breast cancers, we usually incorporate something called endocrine therapy. And these are medications, usually in the form of pills, to lower estrogen levels one way or another. So whether it's the production or the binding at the receptor level. Um, newer therapies that we're now incorporating also include immunotherapy in the chemotherapy setting before surgery, but then PARP inhibitors have made a huge difference in terms of risk of recurrences for patients. So specifically for those who have BRCO mutations. Um, so we tend to do it on the back end, meaning after surgery, after having had chemotherapy to lower the risk of recurrence.
SPEAKER_00:And then, you know, God forbid somebody ends up having distant metastasis, which means the cancer gets into the bloodstream and spreads to another part of the body, most commonly the bone. Um I've noticed that you guys are using kind of some newer targeted therapies. Can you touch on that a little bit?
SPEAKER_02:Yeah. So for hormone-driven breast cancers, there's a big role of CDK4-6 inhibitor. So that includes a group of three medications that I can think of off the top of my head. But we have been using it in stage four hormone-driven breast cancers and are actually moving it up earlier. So for patients who undergo chemo than surgery and have any residual disease and are at a high risk of recurrence, we will start patients on these in addition to hormone-lowering agents for about two to three years, depending on the medication.
SPEAKER_00:Yeah. And then we've used a drug class called immunotherapy in a lot of different cancers. And it's been really helpful in that it improves outcomes, but doesn't typically cause a lot of severe side effects, although it can in rare scenarios. Um, is there a role for immunotherapy currently or in the future for patients with breast cancer?
SPEAKER_02:Yeah, so we're right now we're using it mostly in triple negative disease. So anyone who has stage four, which means cancer that's spread to any other organs, and it's triple negative, um, we will incorporate it depending on a testing that we do on the tumor. Um, the other situation is for triple negative breast cancer early stage when we're doing it before surgery. So we're combining it with chemotherapy. And actually, most patients are tolerating the immunotherapy really well. It's really more so side effects of chemotherapy that we have to monitor more closely.
SPEAKER_00:Are you having any noticing any challenges in medical oncology for patients with breast cancer?
SPEAKER_02:I do. I think probably one of the biggest challenges I see aside of, you know, I think with chemotherapy, people mostly go in with the expectation that this is not going to be great. My life is gonna be difficult, I'm gonna have a lot of side effects, and so it's more expected. What I tend to see, and I think that probably surprises most patients, is really the long-term effects of hormone lowering agents. So, you know, these medications have been around for a long time. They affect estrogen. And on top of everything that most of my patients have gone through, including surgery, plus or minus chemo, plus or minus radiation, to be on a medication that takes away a lot from them can be really difficult. So we're talking about side effects, including weight gain, hair thinning, you're talking about hot flashes, not feeling great, brain fog. So I have a lot of people that say I was able to work really well, think quickly, um, you know, just do all these things very seamlessly, and now I'm having difficulty. So I think that that's probably one of the biggest battles that I see for a lot of my patients is really long-term effects of being on some of the medications that we prescribe.
SPEAKER_00:Yeah, for sure. Um, and Dr. Wendell, how about you? What kind of challenges um do you see in your clinic?
SPEAKER_03:I I think the biggest challenge for uh myself and my patients are in terms of uh educating them to as to uh the outcomes with both lumpectomy with radiation versus mastectomy. Um, very frequently the patients will come in and just mastectomy. I want a double mastectomy, period. And um it's not always the best option. I mean, it's a it is an option, but it's not the best option. So my job, I feel, is to educate um and let them know that we do have different options. They're all excellent options and you know, a different way of thinking. And and I I always feel that when I have left and somebody the room and someone has come in saying, I really want double mastectomies for, you know, again, a very small tumor, and they leave there saying, Okay, I'm gonna have the lumpectomy that I I've really done my job well.
SPEAKER_00:Yeah. I mean, we we all have our own life experience and we've all kind of heard through whether whatever kind of media it is or through uh movies or things, articles we've read, we have these biases. And it it is, you know, I I do appreciate patients putting their trust in us, knowing that, you know, you've kind of got your life experience, but we've all seen literally thousands of patients go through the entire gamut of breast cancer treatment. And um and and in general, I think patients do um give us their trust, you know, and and listen to what we have to say and um and and you know end up making good decisions, you know, for themselves in the long run. Um and and you know, of course, none of us take that trust for granted. You know, we appreciate it. And um and so just in closing, what would you tell somebody if they were just diagnosed with breast cancer? Um, just you know, the the uh do you have any um good good thoughts or good advice that you could kind of um give them off the cuff, Dr. Rana?
SPEAKER_02:Yeah, so I think probably my advice would be take in all the information, ask questions, and ask to have that information repeated. We see a lot of people going through this, you know, day in and day out, and they're being bombarded with information and it's hard to soak in. But at the end of the day, you want to make the right decision for yourself. And then knowing that you've got a team that's gonna help you along the way.
SPEAKER_00:Yeah, for sure. I agree. When patients come in, they're oftentimes shell-shocked, especially, you know, when Dr. Wendell's the one who typically gives them the news. And um, do you find that kind of after you say cancer, there's not a lot that's absorbed after that?
SPEAKER_03:Um actually I'm very fortunate because they are most of them already know their diagnosis. Um they're uh the way the system works is they have their biopsy and then the nurse navigator does call them so they are aware already. So the initial shock is is a little bit worn off so that we can have some discussions. And um, you know, I encourage folks to um record um our consult. I have no problem with that. Take a lot of notes, bring someone with you so that you have another set of ears because it is a ton of information, very overwhelming uh for them. So yeah, I I think that, you know, yeah.
SPEAKER_00:I I think the first two weeks after a diagnosis is kind of the toughest, just because you were kind of flying high and then all of a sudden the floor dropped out from under you, and it takes a little bit of time to reconcile that. And then typically the emotions calm down and the logic kind of kicks in. And and so yeah, just if you can survive the first couple weeks and um try to get accurate information, you know, it typically gets better for sure.
SPEAKER_03:I think too that uh, you know, once they've seen one of us, they at least have some sort of a plan. And that is very reassuring to a lot of people that this is this is not a a death sentence and you know, this is going, we're gonna take care of you, you're going to be fine. It is gonna be a long road, but at least once they feel like they have a plan in place, uh the anxiety is is much less.
SPEAKER_00:For sure. For sure. You kind of feel anchored, you know, once you've talked to somebody who's done it a thousand times and they seem at peace with it. Um well, I want to not only thank you both for coming on today, but I want to thank you for all your work you do for our mutual patience. Um, I very much um respect you and appreciate you both.
SPEAKER_03:Thank you. Thank you. Likewise.