Dr. Jesse Dirksen’s chosen career field probably surprised few people.
With a nurse mom and ambulance paramedic dad, “I grew up at the kitchen table hearing medical stories,” said the Sioux Falls, South Dakota, native.
His chosen location? Not too surprising either. Sanford USD Medical Center was at the center of many of those childhood stories. His mom still works in labor and delivery there, his sister is an ICU nurse, and he knows a lot more people working there, too.
More surprising, at least to Dr. Dirksen, is his specialty. He first dreamed of being an orthopedic surgeon. That stemmed from his interests in construction, inherited from a grandfather and father who built houses, and athletics. “You can combine power tools and the sports together,” he said.
He eventually realized general surgery appealed more to him, though — procedures involving the gall bladder, hernias, the colon and breasts. And during his residency in Pennsylvania, he spent a lot of time with surgeons and patients in a new breast center.
So Dr. Dirksen pursued that particular interest through a breast fellowship at the University of Iowa Hospitals and Clinics before coming to Sanford Health in 2012, in the beginnings of the Edith Sanford Breast Center initiative.
Getting to know patients, families
A first encounter with Dr. Dirksen gives a sense of why everyone, from patients to co-workers, seems eager to praise him. He asks a couple of visitors whether they’ve been waiting long, when it actually isn’t even their arranged meeting time yet. He volunteers to search for a room more spacious than his office for a lengthy conversation. Then, trying several and finding them occupied or locked, he finds the right person with a key to unlock one.
Finally sitting down, he’s eager to list a number of things he loves about his work as a breast cancer surgeon at Sanford Surgical Associates. Rising to the top, though, is being able to develop relationships with his patients and their families.
Surgeons performing other procedures, he said, might meet with a patient once or twice outside of the actual surgery. The approach to breast cancer is quite different. He sees a patient regularly for two years.
Typically, a woman gets a referral to Dr. Dirksen after she goes through the experience of having a questionable mammogram, then diagnostic imaging and finally a biopsy that comes back positive for cancer.
“We really try to do a good job of getting patients in as fast as we can because obviously it’s a very scary time for them — a lot of unknowns,” said Dr. Dirksen, who is one of two Sanford Health breast cancer surgeons in Sioux Falls. “They like to have information. They’d like to get a plan going.”
Forming a plan
As the patient’s first point of contact after diagnosis, Dr. Dirksen spends an hour with them and any accompanying family members.
His first goal is to educate patients. “What is your diagnosis? What does it mean?” He asks questions to learn more about them and goes over their images. He does an exam and talks about all of their available treatment options.
His second goal is to offer hope. The five-year survival rate for breast cancer is greater than 95%, he said. “I never give them false hope, but I want to be positive with them and let them know that this is a doable thing. … We’ve got a great team. We’re going to take great care of you.”
Then a whole team assembles to look at information about that week’s new patients and offer input. Those attending include surgeons, oncologists, radiation doctors, radiologists, pathologists, genetic counselors, plastic surgeons, nurse navigators and even researchers. They could see between seven to 15 new patients a week. Patients may come from a wide swath of the region, ranging from Aberdeen down to Sioux City, Iowa, and from Pierre over to Marshall, Minnesota.
Then Dr. Dirksen calls his patients to let them know what he and the team think would be the best way to approach treatment and to find out what the patient has been thinking. Then they can agree on a plan and set it in motion. Nearly all of his patients are women, but he does see a few men diagnosed each year, too.
Strategies for surgery
Those plans vary considerably among patients as treatments become ever more personalized.
And while Dr. Dirksen has two basic options for removing a tumor, which were established before he entered medicine, his surgeries still are planned and tailored for each patient.
“I like to tell medical students and residents that 70% of breast surgery happens even before we get to the operating room,” he said.
Decisions and strategies abound, largely guided by the type, location and size of the tumor, whether lymph nodes are involved and the patient’s individual preferences to save or remove the breast and whether to have reconstruction.
Fellowship-trained breast radiologists interpret the imaging to help Dr. Dirksen know how big the tumor is, its location and whether lymph nodes in the armpit might be involved. Since tumors frequently get caught earlier now, they tend to be so small that a radiologist often puts a little wire into the breast where the tumor is. Dr. Dirksen uses that as a guide to take out the correct area. He also may X-ray tissue during surgery to be sure he has taken out enough.
Dr. Dirksen really enjoys doing the surgeries. “There’s always more advancements. And I really like pushing the envelope and trying to perfect our surgical techniques.”
These days, those include making smaller, more hidden incisions and preserving the nipple when possible.
Lumpectomy and mastectomy
The two types of surgery to remove a breast tumor are a lumpectomy and a mastectomy.
The less invasive lumpectomy involves a small incision from which Dr. Dirksen removes the tumor and a small amount of healthy tissue around it, then sutures it back together. It takes about an hour. Even with this simpler surgery, which typically retains the size and shape of the breast, there’s some consideration beforehand.
“We really try to hide scars,” by using the aptly named Hidden Scar technique, he said. An incision around the areola or nipple commonly hides the scar well. Other incision locations can include under the fold of the breast or in the armpit.
“Cancer is No. 1,” Dr. Dirksen said. “We’ve got to do a good cancer surgery, but we really care about how the breast is going to look afterwards.”
A mastectomy involves removal of all of the breast tissue. This can mean something different for each patient, depending on whether they want reconstruction.
For a patient who decides against reconstruction, Dr. Dirksen removes the nipple, skin and breast tissue. Sanford Health has a certified prosthetic specialist to help the patient get a custom-made prosthetic.
For patients, often younger women, who choose reconstruction, that procedure can be performed during the same operation as the mastectomy. Dr. Dirksen makes the incision under the fold of the breast and removes the breast tissue.
“When I’m done, the plastic surgeon comes in, and then they put an implant in underneath the skin,” Dr. Dirksen said. “A lot of times nowadays, we go above the muscle, which is much less sore and has a quicker recovery.”
Mastectomies, particularly if they involve implants on both sides, can take up to four hours, Dr. Dirksen said.
Role of family history and genetics
Dr. Dirksen spends considerable time discussing genetics and family history when he sees patients. That helps with treatment decisions and helps identify women who may have a higher risk of breast cancer.
“Up until about 5 years ago, we pretty much only knew about one breast cancer gene,” he said: BRCA.
“Now we know about 20, 30, 50, up to 90 genes that can cause breast cancer.”
So he asks whether a patient has a lot of breast cancer in the family, or ovarian cancer, or other types of cancers. He asks whether the cancer involves every generation and at what ages, particularly if family members were young.
He suggests that patients who seem at higher risk meet with a genetic counselor. Sanford Health has genetic counselors who specialize in breast cancer, so they can map out a family tree and give their expert opinion about whether the patient should pursue genetic testing, and for which genes.
Putting himself out of a job?
As Dr. Dirksen peers ahead, he sees the role of genetics and genomics growing in prominence — in other words, heredity and the study of all of a person’s genes.
“I think the future of breast cancer will probably be less and less surgery and probably more medicines.”
And medicines already have started to be tailored to the specific gene mutations for tumors. Whether patients receive chemo, radiation and/or immunotherapy — and when — can vary significantly depending on the type of breast cancer they have.
In patients with the HER2-positive type, for example, some studies have indicated that giving chemo before surgery can lead to a better response, Dr. Dirksen said.
“In a lot of these patients, we’ll do chemo first, and then when I do the surgery, when we get that pathology report back, there’s nothing left,” he said. “Chemo has wiped the cancer completely clean.”
So he looks ahead to a day, maybe even within 10 years, when a patient with that type of breast cancer could first have chemo, then have a clean biopsy and avoid surgery altogether.
“Surgery will always have a role with breast cancer, but maybe someday I will be out of a job,” he said. “But I would be OK with that.”
Focus on survivorship
The 20th century saw many advancements to replace the previously uniform treatment of breast cancer with a radical mastectomy.
“Our treatments are getting better. The surgeries are getting better. The medicine is getting better,” Dr. Dirksen said.
And, he added, “the survival rates have skyrocketed.”
But he thinks one part of a breast cancer journey has room for improvement: the emotional impact on patients and their families, especially after medical treatment has ended.
During medical treatment, patients see their surgeon and oncologist regularly, led through the process by a nurse navigator who can answer questions and offer support to patients.
“Then they’re kind of ‘done.’ We graduate them,” Dr. Dirksen said.
“And then a lot of patients have a lot of concerns. ‘Well, what’s next? I’ve been seeing you guys every six months for five years. I’m a little bit worried about being let go.’ And that’s survivorship. And I think at Sanford, we’re really trying to improve in that aspect.”
Support groups, life coaches, lay navigators — these are all types of support Dr. Dirksen mentions that can help women cope with the emotional, physical and spiritual effect that breast cancer may have on them long after their diagnosis.
Sanford Health also offers a daylong retreat, Revive, in three locations every October for breast cancer survivors at any stage of the disease.
Sideline: public speaking
Fall keeps Dr. Dirksen busy every year. Beyond caring for his patients, his speaking skills are especially in demand then.
He speaks about breast cancer awareness and Edith Sanford Breast Center’s services to companies and organizations. He speaks on educational topics to medical staff and residents. And he speaks to the media.
One speaking event he jokes that he can’t seem to get out of is hosting the Revive Retreat in Sioux Falls — despite encouraging the audience to write on the retreat survey afterward that they didn’t like the master of ceremonies and want somebody different next time.
“But I love it,” he said. “It’s really neat being up on stage and looking out in the crowd and seeing hundreds of survivors and seeing hundreds of your own patients.”
Laurie Kruse, nurse manager of the breast imaging department at Edith Sanford Breast Center, is an organizer of the retreat. When Dr. Dirksen is speaking, she has no worries.
“He is so well-versed, and he knows how to put those jokes in there and yet pull back when he needs to be serious. All off-the-cuff,” Kruse said.
He clearly believes in his message.
“Most people who are in the breast cancer world, we do it for a reason,” Dr. Dirksen said. “It’s because we care. We’re passionate about it. We care about our outcomes, and we care, not only about the patient as a name and a medical chart number and a diagnosis, but we care about that patient as a person.”
He treasures being able to help patients move past a time of fear and anxiety.
“Towards the end of their time with me, they’re doing great. They’re living life. They’re going on vacations. It’s just really neat to see that whole process, so I absolutely love my job.”
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