Why a tumor board is critical to breast cancer care

Podcast: Physicians meet weekly to review all cancer cases and plan treatment

Why a tumor board is critical to breast cancer care

Episode Transcript

Courtney Collen (Host): Hello and welcome to One in Eight: a new podcast series brought to you by Sanford Health. I’m your host Courtney Collen with Sanford Health News. We’re so glad to have you here as we continue the conversation about breast cancer and topics from diagnosis to treatment and everything in between, One in Eight women will be diagnosed with breast cancer during her lifetime. We’re sitting down today with Dr. Jesse Dirksen, a breast cancer surgeon here at the Edith Sanford Breast Center in Sioux Falls, and we’re talking about the tumor board process when it comes to caring for patients who have been diagnosed with breast cancer and giving them that best possible care.

Dr. Dirksen, so glad to have you here.

Dr. Jesse Dirksen: Thanks for having me. I’m a breast surgical oncologist here at Edith Sanford, breast cancer surgeon. I grew up in Sioux Falls. I went to high school here, went to college here, and then I did med school at University of South Dakota. And then I left, kind of went throughout the country and did a lot of training. And then I finished up my training at University of Iowa. I did a breast surgical oncology fellowship there. Then I joined Sanford in 2012 and I’ve been 100% dedicated to breast surgery since. So it’s, it’s great to be here.

Courtney Collen (Host): What do you enjoy most about working with patients?

Dr. Jesse Dirksen: You know what initially drew me to breast cancer surgery is kind of the relationship with the patients. I’m a general surgeon by background and, you know, you see a patient and you do surgery, maybe see them once after, and then they’re done with breast cancer. You know, you see them before surgery and after surgery, and then you follow them for many years afterwards and, and you really get to know the patient and their family. You kind of develop a relationship with them. You take them through a very difficult time in their life. And, you know, it’s very rewarding, you know. The great majority of breast cancer patients do very well. We have a great team here and it’s just, it’s just a very rewarding field of surgery.

Courtney Collen (Host): Let’s talk about the tumor board, which is the topic we’re covering today, specifically as it relates to breast cancer. So, tell us what the tumor board process is all about.

Dr. Jesse Dirksen: Well, a tumor board is basically a breast conference or a meeting. And we do it once a week where all of us doctors, we get together in a room and we talk about all the patients for the week. Now, I was talking to my medical oncology colleagues, Dr. Bleeker and Lisa, and they told me that the tumor board actually started at Sanford in 2003. So we’ve been doing it for 17 years and then actually started with lung cancer. And currently at Sanford, we divide up the tumor boards in terms of cancer lines or cancer types. So we have a lung tumor board. We have a breast tumor board. We have GI we have GYN, basically there’s a lot of different types. With breast, we only talk about breast cancer patients. So every Monday at 4;00, all of us get together in a room and we talk about all the new breast cancer patients. The nice thing about that meeting is all the different disciplines are there. So there are surgeons, medical oncologists, radiation doctors, radiologists pathologists, geneticists, plastic surgeons, research people, the nurse navigators are there. There is support staff and tumor registry. So it it’s a large group of people that are reviewing each individual case.

Courtney Collen (Host): What is your role on the board?

Dr. Jesse Dirksen: Well, as a surgeon, I work heavily with Dr. Paula Denevan, a surgeon here too. She’s one of my partners. And typically what happens is the surgeon is the first patient or first person to see the patient. And we review everything with them. We get a tentative plan. Well, then the surgeon goes to the tumor board and we present the patients. We talk about the history, we review the mammogram, we go over the biopsy report. Then as a surgeon, we talk to our partners, our colleagues, and kind of give them our plan and then oncology and radiation, etc., they give their input if they think that’s a good plan, or if we’re missing something or we need to do more imaging, et cetera. So my role as a surgeon is kind of present a patient review with the team and see if they agree with my plan.

Courtney Collen (Host): What is the benefit of talking through these cases?

Dr. Jesse Dirksen: It’s a huge benefit. And I tell patients, it’s not only a benefit to me to make sure I got the right plan and I’m not missing anything, but also it’s a huge benefit to the patient. I know a lot about breast cancer, but I’m humble enough to know I don’t know everything and I can give my input to the patient… but if I can get 30 other people’s expertise on their plan, and if we all agree, then the patient can feel very confident that we do have a good plan for them. And we have the right treatment tailored just to them and their diagnosis.

Courtney Collen (Host): Has to be important to the patient too. I mean, knowing that they are truly getting the best care possible.

Dr. Jesse Dirksen: Exactly. And they’re not just getting the surgeon’s opinion or the oncologist’s opinion, but they’re really getting like 30 second opinions at one time from the whole team. And we do have, what’s called a multidisciplinary clinic here where on certain breast cancer patients, they’ll meet with me, an oncologist and a radiation doctor all at the same time. However, this tumor board is very efficient to. It’d be very difficult to get a patient to come meet with 10 different doctors just because it would take a long time and, and, you know, they live far away. So, if I can just review that case with the whole team in one room at one time, it’s a very efficient process too.

Courtney Collen (Host): I can imagine a lot of the cases are very different and the opinions from all of these different surgeons, radiologists, all these physicians and providers are there times when you’re kind of going back and forth with, okay, whose opinion should we go with here?

Dr. Jesse Dirksen: Absolutely. You know, the great majority of time, it’s, I don’t want to call it straightforward, but we all follow cancer guidelines, NCCN, et cetera, and a lot of things are very well-studied and there’s clinical trials and  protocols we follow. But you’re exactly right, with breast cancer, a lot of times there can be different paths we go down, you know, generally we don’t always do surgery first. But there’s getting a lot more instances now where sometimes we do chemo first, you know, with certain types of cancers, sometimes younger patients sometimes have cancers made it to the lymph nodes, you know, sometimes surgery first, isn’t the right answer. So yeah, there are some times where some oncologists, don’t quite exactly agree or surgeons or radiation doctors. But in the end we always come down to an agreement and we follow strict protocols and in cancer guidelines based on robust clinical trials. Sometimes there are two options and I always contact the patient after tumor board and I let them know, ‘this is what we said, this is what we want to do’. Or sometimes this is what we said, you have two options, you know, and I kind of, obviously we want to make the patient part of this decision process too.

Courtney Collen (Host): I was going to ask you before, what, what cases qualify for discussion with a tumor board, but you mentioned all cases?

Dr. Jesse Dirksen: All cases. So the earliest smallest non-aggressive breast cancer will be discussed. The most advanced aggressive breast cancer will be discussed. Part of our accreditation with the COC and the NAPBC and et cetera, et cetera, is we always try to present cases prospectively prior to surgery. So we always want to have that review prior to any treatment, because we don’t want to start any treatment without having the whole team review the case.

So to answer your question, every breast cancer patient’s case is presented.

Courtney Collen (Host): Are there certain cases that are more common that you review than others?

Dr. Jesse Dirksen: Yeah. You know, you know, fortunately our imaging has gotten so good. We’re catching things earlier and earlier and earlier. And fortunately here at Edith Sanford, we have five fellowship trained breast radiologists. They’re the only ones in the whole region. We have five experts that are very good at finding things on mammogram ultrasound and MRI. So for the most part, cancers are early, very treatable, very curable and we kind of have set plans for them. Now we still see patients who find their own lumps. Maybe they weren’t getting mammograms. Cancer has made it to the lymph nodes, maybe elsewhere in the body. Unfortunately, we’re seeing a lot more younger women with breast cancer. It’s very common for me now. I shouldn’t say very common, but it’s getting more common where I see women in their twenties and thirties with breast cancer. I just saw a very nice lady who was 27. I just saw another one who is 32. As a general rule though, sometimes those cancers tend to be a little bit more aggressive and it really takes a team to figure out the best plan for some of these atypical patients.

Courtney Collen (Host): Why are we seeing younger and younger patients diagnosed with breast cancer?

Dr. Jesse Dirksen: That’s a great question. I think it’s multifactorial and that’s what a lot of research is focused on right now. You know, why is a healthy 27 year old getting breast cancer? Why are 30 year-olds? Why are 40 year-olds? I think we’re understanding more and more about DNA and genetics. Genetic testing and counseling literally changes from month to month. Five years ago, we only really knew about one breast cancer gene it’s called BRCA. But now we have tests that can look at 30, 60, 90, over 100 genes that can deal with breast cancer. So we’re understanding more about genetics. I think there’s probably something in the environment that we just can’t quite figure out that maybe we’re exposing ourselves to and the problem with that, it’s so multifactorial to try and narrow it down to food preservatives or who knows what, but there’s probably something in the environment that might be leading to this too.

Courtney Collen (Host): So it’s all about the research.

Dr. Jesse Dirksen: Yes. About the research and unfortunately, breast cancer is a very passionate area of medicine and rightfully so. And fortunately there’s a lot of dollars that go towards breast cancer research. It is constantly changing and I joined Edith Sanford eight years ago and things are so different now, even over eight years, I don’t do now what I did eight years ago. And chemo is better, surgeries are better, better radiations, you know, genetic testing is better. And that’s what I love about it. It’s constantly changing.

Courtney Collen (Host): Yeah. I’m constantly amazed by the advancement in science and, and medical technology for treatment really from diagnosis to treatment. Absolutely. Do other health systems have a tumor board?

Dr. Jesse Dirksen: As a general rule? Yes. Fortunately here at Sanford, we do have a very robust tumor board. Again, we service about seven or eight cancer lines, which is kind of unusual. A lot of hospitals will just lump all cancers together and that’s fine. It’s better than nothing, but here at Sanford, you know, for breast for instance, you know, our numbers can really vary from week to week, but I mean, it’s not uncommon that we spend over an hour, hour and a half each week talking just about breast cancer and we have the breast cancer experts in that room. So, it’s a really tailored, focused concentration just on that cancer line.

Courtney Collen (Host): How proud are you to see Stanford really leading the way with his cancer care?

Dr. Jesse Dirksen: I’m very proud. To have such a dedicated, robust cancer service in Sioux Falls, South Dakota is quite amazing. We do live in a very rural area and to have a health system like that with a very dedicated focus to cancer, it is quite remarkable. We have some amazing talent here. Our medical oncologists, radiation, oncologists, surgeons, they’ve trained at some very large cancer centers throughout the country. And to take that education and knowledge back to Sioux Falls, South Dakota is quite remarkable.

Courtney Collen (Host): How has COVID-19 impacted those weekly meetings and the tumor board process?

Dr. Jesse Dirksen: It has and it hasn’t. We are still presenting patients. We are still talking about them. We’re still reviewing the cases. Fortunately, our tumor boards have been able to go as planned. The only thing that has changed is obviously we want to protect the physicians and the staff and also the patients. And a lot of it is virtual now. We all used to meet in a room and, you know, sometimes there could be up to 30 people in that room. Well, now what we do is the dedicated people, who are actually presenting the cases will be in the room, like the radiologist to review the films, the pathologists, to look at the biopsies, the surgeon that’s presenting the oncologist, radiation doctors, but a lot of the other people will log on online and they’re able to Skype in so they can still see the films, they can still see the biopsies, they can still get on the mic and give their input. So like the rest of the world right now, a lot of it is virtual. But it hasn’t affected patient care.

Courtney Collen (Host): Talk about how important it is to, to get that annual mammogram example.

Dr. Jesse Dirksen: It has been scientifically proven that mammograms improve or decrease mortality. And now what I mean by that is mammograms truly save lives. There’s few things in medicine that can usually say that… we know colonoscopies can do that, pap smears, things like that. The earlier the detection, the better. We cannot express enough how important it is for women to get their mammogram. Unfortunately, there’s a lot of different recommendations out there right now for mammograms. Every different society has a different recommendation, which is very confusing to the general public. Currently at Edith Sanford, what we’re recommending is women beginning at age 40 get a once-a-year mammogram. And fortunately I think 95% of our footprint even more has 3D mammograms, which gets a better look at the breast tissue, especially dense breast tissue than a traditional mammogram. And like I said, fortunately, here at Sanford, we have five fellowship trained breast radiologists that are very good at this. Now with COVID, you know, understandably women kind of have to weigh their own personal risks and benefits at Sanford. We did stop screening mammograms, which means a regular mammogram for about six weeks, because we cared about the health and the exposure of the patient. But right now, if, if women do feel comfortable, we are encouraging them to come in and get their mammogram. We’ve put safety protocols in place. And it’s a very safe thing to do. Obviously if a woman has a lump in the breast, they have breast pain, they have bloody nipple discharge. If they have any concerns, even during COVID, we would want them to come in and get some imaging and figure out what’s going on. So, yes, I can’t stress enough how important it is even during COVID time for women to get their mammogram. And right now fall 2020, women can get their mammogram. There’s no limitations on that.

Courtney Collen (Host): So back to the tumor board for a moment, as we wrap up for any patient in the future, who would come in to get that care, when she or he hears the word, you have breast cancer or you have cancer in general, it sounds like you guys are ready to really care for that patient, right?

Dr. Jesse Dirksen: You’re absolutely right. In, in what we preach here at Edith Sanford is the team, the team approach, and what patients need to realize that at Edith Sanford is not just me. It’s not just a surgeon. It’s the oncologist, it’s the radiation doctors, the radiologists, it’s the pathologists, it’s the support staff, the nurse navigator… It’s an entire team that is focused on you and it’s focused on your specific diagnosis. It’s focused on your tailored treatment plan and it’s focused on you after treatment. There is a higher emphasis now on what we call survivorship. Patients get their diagnosis, they have their treatment, doing great and then x amount of years afterwards, they’re kind of like, well, what’s now? And we have really focused on still paying attention to those patients, what to look out for, support groups, how you’re doing emotionally, physically, sexual health, you know, their psychological wellbeing. And we focus on all that after treatment too. So it really, truly is a team here.

Courtney Collen (Host): Well, Dr. Dirksen, thank you so much for your time and your expertise. We appreciate all that you do.

Dr. Jesse Dirksen: Thank you. And thanks for having me.

Courtney Collen (Host): I’m Courtney Collen, catch the next episode of One in Eight, our cancer podcast coming soon. Stay well and have a great day.

Posted In Cancer, Cancer Treatments, Expert Q&A, Imaging, Leadership in Health Care, Physicians and APPs, Specialty Care, Virtual Care, Women's