Podcast with Dr. Irina Stefansky

Dr. Stefansky:

In many cases, there are no clear symptoms at the early stage.That’s the difficult part.Breast cancer is often detected during screening — before anything is felt.This is why mammography plays such a central role.But sometimes there are signs.A small lump that wasn’t there before.A subtle change in the shape of the breast.Skin that looks slightly different — thicker, or pulled inward.Occasionally, there can be discharge from the nipple.Now the question is — does this always mean cancer?No. Most of the time, it doesn’t.

But if something changes… and doesn’t go away — that’s usually the point where we recommend checking it properly.

Dr. Stefansky:

Most often, it starts with mammography.

It’s the standard screening tool.It can detect very small changes — sometimes long before they can be felt.But it doesn’t always give the full picture.

That’s where ultrasound comes in.It helps us understand the structure — whether something is solid, fluid-filled, or something in between.MRI is different.It’s more sensitive, but we don’t use it for everyone.Usually in higher-risk patients.Or when we need to better understand the extent of the disease.So it’s not about one test being better than another.

It’s about choosing the right combination — for the right patient.

The final diagnosis is made through a biopsy.And it’s worth slowing down here for a second, because “biopsy” can mean different things.Sometimes it’s done under ultrasound guidance.
Sometimes with mammography.
And in certain cases — MRI. We take a small sample of tissue.
Send it to pathology.And that’s where things really begin.Because the answer is not just “cancer or not cancer”.We get much more than that.The type of tumor.
How it behaves.
And, in many cases, the first clues about how we’re going to treat it.So in a way, biopsy is not just a diagnostic step.It’s the start of decision-making.

Dr. Stefansky:

This is where things can get confusing.Because from the outside, it sounds simple — “breast cancer”.But clinically, it’s not one disease.It’s several.We look at whether the tumor is sensitive to hormones — estrogen or progesterone.
We check if HER2 is overexpressed.
And we assess how quickly the cells are dividing — that’s where Ki-67 comes in.Why does this matter?Because treatment depends on it.A hormone-positive tumor is treated very differently from a HER2-positive tumor.
And both are very different from triple negative disease.So we’re not treating a label.We’re treating biology.

Dr. Stefansky:

Yes, this comes up almost every time. And honestly, it’s a very reasonable question. Because on paper, it may look the same: “breast cancer”. But when we look closer — it’s often very different. The size of the tumor.
Whether lymph nodes are involved.
The molecular profile. Let me give you an example.One patient — a small, hormone-positive tumor, no lymph node involvement.
In that case, we might do surgery first, followed by hormonal therapy.

Another patient — HER2-positive or triple negative disease.
Here, we often start with systemic treatment before surgery. Why?

Because these tumors can respond very well to therapy upfront.Sometimes even disappear completely.So the goal is not just to remove the tumor.It’s to choose the right sequence.
For the right patient.

Dr. Stefansky:

For many years, the default was simple — surgery first. Remove the tumor.
Then decide what additional treatment is needed. But that’s no longer always the case. In certain situations, we intentionally start with systemic treatment before surgery.
What we call neoadjuvant therapy.

Why do we do that?

First — to shrink the tumor.
Sometimes that allows for a smaller surgery. But that’s not the only reason. We also learn how the tumor responds. And that tells us something very important. For example, with HER2-positive or triple negative disease, we often see a very strong response to treatment before surgery. Sometimes even a complete response. And when that happens, it gives us confidence that the chosen therapy is effective.

Dr. Stefansky:

In most cases, our goal is to preserve the breast. If the tumor is relatively small and localized, we can remove it with clear margins — and that’s enough. This is what we call breast-conserving surgery. But it usually comes with radiation afterwards. To reduce the risk of local recurrence. Now, there are situations where mastectomy is the safer option.

For example:

If the tumor is large relative to the breast.
If there are multiple areas involved.
Or if there is a genetic risk — such as BRCA mutations.

And there’s one more thing that patients often don’t realize. Surgery today is not just about removing tissue. Reconstruction is often part of the plan.
Sometimes immediately. So even when mastectomy is needed,
we still think about the long-term outcome — not just the cancer.

Dr. Stefansky:

Not anymore. In the past, lymph node surgery was much more aggressive. Today, we try to be much more precise. Most patients undergo what’s called a sentinel lymph node biopsy. This is the first lymph node that would likely be affected. If that node is clean — we usually stop there. No need for extensive surgery. If cancer cells are found, then we reassess. Sometimes additional surgery is needed. Sometimes radiation is enough. And this is important. Because removing too many lymph nodes can lead to complications — like lymphedema.

So again, it’s about balance.

Oncologic safety.
And quality of life.

Dr. Stefansky:

Radiation is not something we add automatically.

It has a very specific purpose.

To treat what we cannot see.

Even when the tumor is completely removed, there may still be microscopic cells left behind.

That’s where radiation comes in.

After breast-conserving surgery, radiation is almost always part of the treatment.

Because it significantly reduces the risk of the cancer coming back in the same area.

After mastectomy, it’s more selective.

It depends on the size of the tumor.
Lymph node involvement.
Margins.

Sometimes we recommend it.
Sometimes we don’t.

It’s never a one-size-fits-all decision.

Dr. Stefansky:

This is probably one of the hardest questions for patients.

And the first thing I usually say is — chemotherapy is not needed in every case.

We look at several factors.

Tumor size.
Lymph nodes.
But most importantly — biology.

For example, in hormone-positive tumors, especially when they are smaller and less aggressive, we can sometimes avoid chemotherapy.

There are genomic tests that help us estimate whether chemotherapy will actually add benefit.

But in more aggressive types — like triple negative or HER2-positive disease — chemotherapy is often an essential part of treatment.

So the goal is not to give more treatment.

The goal is to give the right amount.

Dr. Stefansky:

A lot has changed.

But not just in terms of drugs.

The way we think has changed.

We no longer treat all breast cancers the same way.

We look deeper.

At the biology.
At the behavior of the tumor.
At how it responds.

There are more targeted therapies today.
In some cases, immunotherapy.

Better combinations.

But maybe the most important shift is this:

We are trying to avoid unnecessary treatment.

And at the same time — not miss the cases where we need to be more aggressive.

So it’s becoming more precise.

And more personal.

Dr. Stefansky:

The first thing is — you don’t have to understand everything at once.

It’s a lot to take in.

And it’s normal to feel overwhelmed.

But breast cancer is not one disease.

There are different types.
Different behaviors.
Different treatment options.

And in most cases, there is more than one possible approach.

Decisions don’t have to be made in a rush.

There is time to ask questions.
To understand.
To think.

And this is where having the right medical guidance really matters.

Not pressure.

Clarity.