Cancer Care Connections

Cancer Genetic Testing: A Personalized Approach to Your Health

• Dr. Ranjit Goudar • Season 2 • Episode 18

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What if understanding your genetic makeup could transform your approach to health care? Genetic testing is revolutionizing how we approach hereditary cancer risks, offering hope for prevention and personalized care. Dr. Ranjit Goudar shares insights on the Hereditary Cancer Clinic at Virginia Oncology Associates, emphasizing individualized approaches and the importance of genetic counseling for informed decision-making.

Dr. Goudar's work influences the lives of numerous families, underlining the importance of personalized care with inspiring stories, like that of two sisters who share a BRCA2 mutation but chose different paths for prevention.

Inspired by our personal experiences and driven by a mission to aid patients, we offer guidance and resources to ensure that everyone can make informed decisions about their health. The Virginia Oncology Associates website provides additional support.

Ranjit K. Goudar, MD is a Virginia Beach native and son of a physician. He received his Bachelor of Science degree in chemistry from the University of Virginia, where he was a Jefferson Scholar. He earned his medical degree and completed his residency in internal medicine and fellowship in hematology/oncology at Duke University. He is a graduate of the City of Hope Intensive Course in Cancer Risk Assessment. Dr. Goudar is board-certified in Medical Oncology and Hematology.

 While caring for patients with a broad range of cancers and blood disorders, Dr. Goudar’s particular clinical interests include the care of patients with breast cancer, colorectal cancer, and patients at high risk of cancer due to family history or cancer gene mutations. He serves as the director of the Hereditary Cancer Clinic at the Brock Cancer Center in Norfolk.

Dr. Goudar is the Division Chief of Hematology and Oncology at Eastern Virginia Medical School, where he supervises the training of internal medicine residents. He is the author of several research publications and book chapters.

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Thank you for listening! If you're interested in hearing more from Virginia Oncology Associates, make sure to subscribe to Cancer Care Connections on Apple Podcasts, Spotify, or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com.

Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at VirginiaCancer.com. or find us on Facebook or Instagram at Virginia Oncology Associates.

Intro: 0:05
Welcome to Season 2 of Cancer Care Connections. This season, we will continue to bring you insights from the highly skilled physicians and staff at Virginia Oncology Associates who are changing the landscape of patient care. In 2025, we plan to introduce you to other medical professionals who are vital in the care of our patients, as well as patients and survivors willing to share their journey. On this episode, Cheryl spoke with Dr. Ranjit Goudar, a medical oncologist and hematologist at Virginia Oncology Associates. Dr. Goudar discusses how genetic testing is revolutionizing our approach to cancer risk and offers hope for prevention and personalized care.

Cheryl: 0:50
We are sitting down today with Dr. Ranjit Goudar, a Virginia Beach native and son of a physician. Dr. Goudar has been back in Hampton Roads since 2010. He is the director of the Hereditary Cancer Clinic at the Brock Cancer Center in Norfolk. While caring for patients with a broad range of cancers and blood disorders, Dr. Goudar's particular clinical interests include the care of patients with breast cancer, colorectal cancer, and patients at high risk of cancer due to family history or cancer gene mutations. Dr. Goudar is also the division chief of hematology and oncology at Eastern Virginia Medical School, where he supervises the training of internal medicine residents. He is the author of several research publications and book chapters. Dr. Goudar, great to talk with you today, 

Dr. Goudar
Absolutely, absolutely.

Cheryl: 1:40
We're talking today about genetic testing, something that we know gets quite a bit of interest, and we'll do that in just a minute. I do want to talk with you first about how you got started in medicine. I know you have a family history of that as well but why did you decide to go into this field?

Dr. Goudar: 1:59
So as you mentioned, I do have family exposure to this with my father. But the biggest thing that I wanted when I chose to go into medicine, I knew it was a very diverse field. There are surgeons and pediatricians and oncologists. What I was really looking for was the ability to form a long-term relationship with my patients, so I wanted to really try to move things earlier in the process. It became a question as to why people waited until they had cancer before they were able to see an oncologist. You know, if patients were able to see us sooner, then we should be able to talk about prevention and early detection to help my patients do better and live longer.

Cheryl: 2:43
So you came in 2010, back home, back to Hampton Roads, and at that point, what was happening with the Hereditary Cancer Clinic and what did you do when you had the opportunity to lead it way back then?

Dr. Goudar: 2:57
So it was a very small program back then that was led by Tifany Lewis, our lead genetic counselor. But, over the last few years, our practice has placed a real emphasis on growing the program and being able to see and take care of more patients long-term. As we come into 2025, our current year, we expect to see and take care of approximately 3,000 new patients this year. And that doesn't include the patients that we see for long-term management from previous years. So this is absolutely one of the largest and well-trained genetics programs in the Mid-Atlantic at this point.

Cheryl: 3:38
Well, I definitely want to hear more about that, but I'm hearing 3,000. How do you look at that number? How do you feel when you think about the growth, the change in that program over the years?

Dr. Goudar: 3:51
I think there are two sides to that. The first side is a significant increase in the resources that our practice places in this program and the number of trained staff that we have. We've grown from one genetic counselor, Tiffany Lewis, into three different genetic counselors. And now we are hoping to find a fourth genetic counselor that's a good fit for our program. We also have a set of highly trained nurse practitioners and physician's assistants that help focus on these high-risk patients as well. To me it's not just the number of patients that come in to see us, it's more about the number of families that we're able to evaluate and screen. So that number of 3,000 patients in our offices probably affects more like 15,000 or 20,000 family members. Those could be here, local in the area, or in various places across the country, even around the world in some cases.

Cheryl: 4:50
Man, I hear in your voice just the feeling of pride to be able to reach that far out. You mentioned earlier about the long-lasting vision you have. You like having that long-term relationship with patients, and this really is part of that, isn't it?

Dr. Goudar: 5:09
Absolutely, because if we see a patient who's at high risk, the best case scenario for us is being able to screen that patient appropriately, to follow them with changing and evolving guidelines over time, and ideally help them live a very long, happy and healthy life.

Cheryl: 5:27
I would love to hear some success stories since you've been in charge of the Hereditary Cancer Clinic; stories of people who maybe didn't think the power of genetic testing was as powerful as it is. Do you have any that you can share?

Dr. Goudar: 5:44
Absolutely. I'll give you an example of a young woman in her 30s who was diagnosed with fairly advanced breast cancer and the standard of care at that point was to test a very young woman for specific inherited cancer genes, most specifically BRCA1 and BRCA2. This young woman was found to carry a BRCA2 mutation, and that led to what we'd call cascade testing of various other family members. Her sister, her full sister was found to also carry the same mutation. Many patients, many people in the community, are somewhat hesitant to pursue this kind of testing because they feel that it automatically will lead to risk-reducing preventative surgeries. But we need to point out that individual family members have the ability, and in some cases choose, to have different treatment and different screening than other family members. So the sister, who was diagnosed with breast cancer, knew there was a very high rate of finding a new breast cancer on the other side in the future, so she chose to have surgery mastectomies to remove breast tissue on both sides, whereas the sister who carried the same mutation chose to pursue high-risk screening with breast MRI scans alternating with x-ray mammograms. So these are very closely related patients. They carry the same mutation. We suspect they have similar risks of cancer, but individualized screening is of the highest importance.

Dr. Goudar: 7:24
We cannot and do not treat every member of a family in the exact same way. We see one patient at a time. Certainly, relatives can come for information and support, but we need to make sure that our plan, the plan that we form together with the patient, fits with their goals and their wishes at this current point in time and to follow them long-term, because that can certainly change.

Dr. Goudar: 7:51
I'll give you another example of a patient who was found to carry a high-risk CDH1 mutation, which can lead to a very high risk of a specialized type of stomach cancer called diffuse gastric cancer. So some years ago that mutation was felt to eventually cause stomach cancer in almost every patient who carried it, so the standard recommendation several years ago was for patients to have preventative stomach surgery, a gastrectomy to remove the entire stomach gland, and reduce their risk of cancer to nearly zero. The patient's daughter, very young, in her early 20s, was also found to carry that same mutation. Several years later, but based on newer research, we found that the actual rate of these patients developing stomach cancer was lower, and so we had to have a complicated conversation about screening, which is not terribly effective in detecting this type of cancer versus preventative surgery. Eventually, the younger patient, the original patient's daughter, chose to also proceed with preventative surgery.

Cheryl: 9:07
Incredible that the knowledge you were able to share helped inform their decision to go one path or another. So let's talk about that. Let's talk about how the Hereditary Cancer Clinic can help patients and their families live long and better lives. What is the process?

Dr. Goudar: 9:42
So, the first step is trying to identify people in Hampton Roads who do have a higher risk of cancers, and in some cases, the patients certainly know before their healthcare providers. Many patients often know that there is a strong family history of cancer in their family, multiple relatives with the same type of cancer perhaps, or a patient themselves who had a certain type of cancer many years ago at a very young age. So we see probably an equal portion of patients whose healthcare providers raise the red flag and say, "You know what, your family history is concerning to us. We'd like to send you to Virginia Oncology for a further discussion and to determine if you or one of your relatives would in fact qualify for genetic testing." We also have a fairly large set of educated patients who say I'm concerned about the potential of inheriting a high-risk cancer mutation based on recent developments in my family; one of my sisters, my mother, was diagnosed with cancer young. One of my brothers, one of my male cousins. They also, in many cases, ask their primary care provider for a referral or they self-refer for evaluation. That is step one in the process; seeing the patient. Then we try to determine their risk of cancer. In some cases, that first patient is the most helpful or the only appropriate patient to proceed with genetic testing. But in some cases, one of their relatives who has actually had a concerning type of cancer may be the best and most helpful person to test. It's very important to point out that the actual genetic test is really just one point in the overall process. After we determine genetic test results, even if they are negative; if the results are normal, patients may still be at higher risk of certain types of cancer, based on their family history. Using continuously updated and sophisticated software prediction models, we can predict a patient's future risk of breast cancer, ovary cancer, colon cancer, prostate cancer, and then individualize the process, determine what a patient's future risk of cancer is and what their options for increased screening are. In some cases, we can use medication to try to reduce future risk of cancer and then determine which of their relatives may also be at higher risk and may also qualify for genetic testing or increased screening.

Dr. Goudar: 12:16
So it is a process where we tend to follow patients long term. My patients generally either carry a high-risk mutation or have a higher risk of certain types of cancer and require extra screening, which can be arranged by myself or through our office. The most important part to recognize here is that the screening guidelines, the technology, change on a very rapid basis. For example, patients with an ATM mutation. These are very, very common. Up to one in 60 Americans carries one copy of this ATM mutation, and after Labor Day of 2024, four short months ago, our screening guidelines were changed so that every patient who carries an ATM mutation now qualifies for pancreas cancer screening, starting at age 50. And that is the critical importance of being able to follow these patients long-term, even well after genetic testing so that we can make sure that the most appropriate and most updated guidelines are used and discussed with these patients so that they can stay on the cutting edge of their own medical care.

Cheryl: 13:39
One of the questions I had for you was, what do you see as the future of the hereditary cancer clinic, and I think I heard a piece of that there, didn't I?

Dr. Goudar: 13:49
So the biggest thing for us to talk about is, given the high number of patients and families that we follow long-term in our clinic, I think that the future of oncology will be moving ahead earlier in the process of cancer detection and treatment. What we are trying to do here is to use the volume of patients and the number of highly trained staff that we have to offer patients the opportunity to participate in research programs, primarily involving the testing of new medications, to try to reduce the risks of various types of cancer, and also to employ the use of very new, very sophisticated cancer detection testing so that we can help be on the cutting edge of cancer prevention, detection, screening, and treatment.

Cheryl: 14:48
It's all so incredibly exciting, and I can tell how passionate you are about this. And while it is exciting, I think it also might feel a little overwhelming for someone who's listening to this podcast, thinking about their family history, their latest doctor visit, their latest illness. As someone who's listening to this show, it could be a health professional, it could be a patient, it could be a family member of a patient, it could be just someone who's interested in cancer or cancer research. What do you want someone to take away from hearing what you're talking about? Because, as we know, we have family members. There could be disease within three generations of our family, so it could affect a lot of us. What do you want someone to take away from listening to you talk about the options that are available at Virginia Oncology Associates?

Dr. Goudar: 15:42
I think that I would like residents here in Hampton Roads to know that genetic testing is becoming much more common. Many more patients qualify for that now. I do believe at some point the testing will be universally offered to all Americans. Not everyone will choose to proceed with that, but the biggest thing that we need to move forward is to make sure that our residents know the most critical part of their care is individualized and personalized screening and treatment. Handing someone a piece of paper that talks about genetic testing results is a part of the process. It's not a long-term solution. They need to see a clinician. They need to see a physician to talk about their best options at that point in time and to know that we will work with them on the day we see them and every time we see them into the future.

Cheryl: 16:43
You mentioned earlier Tifany Lewis. She is a genetic counselor at your clinic, so for anyone listening to this, interested in more information about the testing and the genetic counseling that comes afterward, check out the episode that she did with us. You can find that in the show notes here for this podcast episode. But can you address what happens after the test results come in? I think that maybe one of the reasons why people don't get more testing is they're afraid. And you mentioned it earlier, you're afraid of what the results might be. So I mentioned Tifany because she had talked with us in a previous episode about how important genetic counseling is after those test results come in. But can you answer that question, what happens once the results are right there in your hands?

Dr. Goudar: 17:31
So the next step will be for us to determine is that individual person; are they still at high risk of certain types of cancer. And that calculation will not be listed on the genetic test report. If they are still at higher risk, then we would talk about laying out their options to proceed with increased screening.

Dr. Goudar: 17:59
That is something that we discuss. It is not something that we certainly force a patient to have. We talk about their options in moving forward and we also talk about the importance of other close family members proceeding with the same type of evaluation. There have been many examples in which we test a patient who does not have some sort of high-risk cancer mutation but one of their close relatives does, and the unaffected patient who does not carry the mutation may still have a higher risk of cancer. They may still qualify for increased cancer screening. And that is something that we work with each individual patient trying to determine their best options. Many people think that if their genetic test results are negative, they won't have to worry about that type of cancer in the future. And that's not true for every person. We need to increase the amount of genetic education here for our residents, improve that screening to try to detect cancers as early as scientifically possible.

Cheryl: 19:02
Dr., what's a newer issue you are seeing that affects people who don't necessarily have a history of disease?

Dr. Goudar: 19:13
So one of the very new and extremely important issues is the fact that over the last couple of years, radiologists who view a woman's mammogram now add a line about the density of the breast tissue. That does not involve how firm the breasts are to the touch.

Dr. Goudar: 19:33
It refers to how well the X-rays go through the tissue and how clear the mammogram images are. So women should know that having dense breast tissue is very normal for a younger woman, especially before menopause. However, the presence of dense breast tissue can be linked with a higher risk of breast cancer, and also denser breast tissue is harder to view with an X-ray mammogram. So a woman who receives a report talking about dense breast tissue should definitely talk with her primary care provider or with her gynecologist and ask does my family history and density rating on my mammogram help me qualify for increased screening with a breast MRI scan. That will not fit in for every woman with dense breast tissue, but it may apply to many of them. So we need to let women here in Hampton Roads know that if they qualify for high-risk breast cancer screening, we would talk to them about their options and help them figure out which type of screening they would like to pursue to try to catch breast cancer at the earliest stage, the most treatable stage, and the most curable stage.

Cheryl: 20:57
Do you find that patients of your clinic are surprised by the results they get and the impact on their health care?

Dr. Goudar: 21:09
So there are two sides to that. The first side is that, in many cases, we are able to tell a patient that their genetic test results are normal, that they are negative, and that their predicted future risk of certain types of cancer is fairly low, closer to the average rate of these cancers in Americans. So we're able to provide that patient with a good amount of reassurance, able to lay out a plan for cancer screening for them, to talk about the importance of testing and screening for other family members. But those patients don't need to stay in our clinic long term, so many folks are very relieved to hear that kind of good news. On the other side, patients may be surprised to find out that even though their genetic testing is negative, they're still at higher risk of these types of cancer. That's certainly a point that I keep returning to in this interview because I think it's the most critical point that many patients are surprised by.

Cheryl: 22:17
Where can people go for more information? You've shared a lot with them and it might be something that people need to process before they pick up the phone to call their physician or to reach out to Virginia Oncology Associates. Where can people go for more information?

Dr. Goudar: 22:35
So our website, virginiacancer.com, carries a lot of important information about the process of genetic testing, how to submit more questions, how to speak with their primary care provider, a referral to our clinic, starting a conversation about what we think the family's risk of cancer is, what we think our individual patient's risk of cancer is, and how we proceed moving forward.

Cheryl: 23:05
Certainly, knowledge is power, especially when it comes to a medical diagnosis, and, as you've been discussing, Dr. Goudar, this is something that comes from your heart. It's a passion for you. Is there anything else you'd like to add about the work that you're doing with the clinic?

Dr. Goudar: 23:24
So I think it's important to note that patients can be overwhelmed by the amount of different options, different screening, different testing, and the number of different family members who may qualify for evaluation. But in the end, we are dealing with one patient and one doctor in a room trying to make the best decisions for themselves. And this comes back to me. At an early age, my father was an internist with an office at DePaul, and his main goal was helping his patients do well for as long as humanly possible. And I carry that mantle. I certainly try to carry that mantle going forward. I wear his watch, I carry his stethoscope in my pocket, and that is how I take care of my patients today.

Cheryl: 24:17
Dr. Goudar, thank you so much, and thank you for all that you're doing. 

Dr. Goudar:
Thank, you.

Exit: 24:26
Thank you for joining us today on Cancer Care Connections. Today we explored how genetic testing is our approach to predicting cancer risk, encouraging patients with a family history of cancer to undergo testing to better understand their risks and options for screening and treatment. Results from genetic testing will allow a conversation to begin about prevention and early detection strategies. If you or someone you know has a family history of cancer, consider speaking with your physician today to learn more about cancer genetic testing. 

Don't forget to subscribe to our podcast via Apple Podcasts, Spotify or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com. Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at virginiacancer.com or find us on Facebook or Instagram at Virginia Oncology Associates.