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Scott Webb (Host):   October is breast cancer awareness month, and it’s a great time to have on a couple of experts to talk about breast cancer risk factors, the importance of early screening, and the latest imaging technology. I'm joined today by breast surgeon Dr. Victoria Van Fossen and my radiologist Dr. Keristen Brantley both of whom work for Summa Health. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Dr. Van Fossen, I'm going to start with you. We’re talking about breast health. So let’s talk about some of this. What are some of the concerns or concerning signs that a woman should be aware of when it comes to breast health?

Victoria Van Fossen, MD (Guest):   I think a woman should be familiar with her breasts and know what is normal for her. Her breast may change during the month prior to her period and afterwards. So anything that seems abnormal is important to note, especially a breast mass or a lump that wasn’t there before. Any type of nipple discharge, especially if it’s bloody; any type of skin thickening or reddening of the skin, it may even look like an orange peel; any type of skin or nipple retraction; and then any type of lump in the armpit area that would be like an enlarged lymph node is important to be aware of.

Host:   Right. So it sounds like things that would stand out that are out of the ordinary that are new or emergent, anything like that. Those are some concerning signs, of course. So let’s talk about risk factors. What are the risk factors for breast cancer?

Dr Van Fossen:   Well, there’s several different categories of risk factors. The most important probably is your family history. It’s important to note that you should look at both your mom’s history and your dad’s history. So things to be aware of would be if a first degree relative, which would be like your mother, your sister, your daughter had breast cancer and especially if she was under the age of 45. Any family member that has had bilateral or breast cancer on both sides is a red flag. Then any male in the family that has had breast cancer. We know that male breast cancer is pretty rare. It’s only about 1% of all breast cancers. So when we see that that’s sort of a red flag that maybe there's a hereditary component. Also a family history of any type of ovarian cancer, pancreatic cancer, uterine, colon, melanoma, or prostate cancer that runs in the family may also indicate that breast cancer may be a part of that.   Patients that are of Ashkenazi-Jewish ancestry may have a higher likelihood of a hereditary breast cancer, especially BRCA-1 or 2. Actually, they have about a 1 in 40 chance of carrying an abnormal gene that causes or predisposes to breast cancer.

Besides family history, there's other things such as reproductive factors or basically the lifetime exposure of a woman to estrogen. So that would include having an early first period or a late age at menopause as well as a late age for their first pregnancy, not having children, or the use or hormone replacement therapy for a long time. Then the most important risk factor which we cannot help is age. So advancing age is a risk factor for breast cancer. We know that 1 in 8 women will get breast cancer during their lifetime which is about 12%. Breast density, so women that have what we call extremely dense breast tissue which is greater than 75% glandular tissue. They have a higher risk of breast cancer which may be four to five times higher. So it’s less fatty, more glandular. Then there's also importantly lifestyle factors that can include their risk of breast cancer such as obesity. We know that 70% of Americans are either overweight or obese, which is a BMI over 30. That’s actually an independent risk factor for breast cancer. Alcohol use, as little as three to four drinks per week can increase the risk of especially what we call estrogen receptor positive breast cancer. Then inactivity or a sedentary lifestyle also has a higher risk for breast cancer. The other risk factor is if there is a history of an abnormal biopsy. So if there was a breast biopsy done that showed any type of atypical cells or atypical hyperplasia, that may increase that woman’s risk for breast cancer. Then any type of radiation to the chest wall at a young age like for lymphoma in their teen years. That would increase the risk for breast cancer over her lifetime.

Host:   Yeah. You can see why it’s so important for women to know what their risk factors are. Obviously, they may need some assistance with this. So what is Summa doing specifically to help identify women who are at higher than average risk for breast cancer?  

Dr Van Fossen:   Well, we implemented something called a cancer risk assessment about three years ago. This is done at the time of a woman’s screening mammogram. So when a woman has a mammogram, the mammographer will ask a series of questions that looks at a woman’s unique risk factors such as data points, such as age at your first period, your height and weight which is to calculate your body mass index, your personal medical history, and your family history of breast cancer or other types of cancer. Then also those other various lifestyle factors such as the BMI, alcohol use, smoking history, any history of an abnormal breast biopsy. All those things are used to calculate using statistical models that look at lifetime breast cancer risk. We have found consistently over the past three years that we have implemented this that about 10% of patients are deemed to be high risk. Now high risk basically means that a woman has a greater than or equal to 20% lifetime breast cancer risk. So an average woman at average risk has a 1 in 8 chance of breast cancer or a 12%. So a patient at high risk would have a 1 in 5 or 20% lifetime breast cancer risk. That breast cancer risk also will identify whether a woman would need genetic counselling or testing. Then the results are calculated, and those results are sent to your provider along with your mammogram report.

Host:   So doctor, what if a woman’s risk score is high?

Dr Van Fossen:   Well, your provider will have received these results in your report. You and your healthcare provider will work together to develop an individualized plan for ongoing screening. You also may be referred to the high-risk breast clinic, which is a clinic that provides genetic risk evaluation, screening and prevention. It also may include enhanced screening, surveillance, and this is all with a multidisciplinary team including certified nurse practitioners, breast surgeons. We have dieticians, nurse navigators that all work together to take care of you and hopefully help you decrease your risk over time.

Host:   Yeeha. It sounds like a very comprehensive approach, a real team-based approach which is great. Lastly for you today doctor, what can women do to lower their risk for breast cancer?

Dr Van Fossen: There's several things that they can do. One is actually just having an awareness of what their risk is. Then the options for risk reduction should be discussed in a shared decision-making environment with your provider. Some things that you can do are lifestyle modifications. This provides a teachable moment for the promotion of overall health. So we know that almost one-half or 40% of post-menopausal breast cancers can be prevented by decreasing alcohol use, so less than three drinks per week, having a normal body mass index or decreasing obesity factors, and then increasing physical activity. So exercising 30 minutes a day five days a week will reduce the risk for breast cancer. Eating a healthy diet, which is plenty of fruits and vegetables, more of a plant-based diet rather than a lot of processed foods or red meat type of foods. Then getting the regular screenings including the annual mammogram and getting a physical exam from their physician are also important to do.   

Host:   Yeah, definitely. Of course just overall health is such a good thing anytime during COVID or to help reduce the risk of breast cancer. It’s just great for mental and physical wellness. Thanks so much for being on doctor. So Dr. Brantley, let’s shift to you now. Why should women get screening mammograms? If they should get them—and we believe they should—starting at what age?

Keristen Brantley, MD (Guest):   So the reason why we recommend that women receive their screening mammograms is to ultimately detect breast cancer as early as possible. The earlier that is detected typically the easier it is to treat. So we like to catch it before there are any breast symptoms. Before there’s a lump or any skin changes that way if there is a problem, it’s just much easier to treat. We want to start getting our mammograms at the age of 40. Now you may come across some different recommendations depending on the various societies, but as a member of the American College of Radiology, it is our recommendation that women start their annual mammograms at the age of 40 unless there are other compounding factors like an increased risk of breast cancer. In those cases, you may need to present earlier for a screening mammogram. That’s a conversation that you would want to have with your doctor whether that be a primary care physician or your gynecologist about your own individual risk and when you should start.

Host:   Yeah, that sounds right. So when we talk about mammograms, what’s a 3D mammogram and does that cost more?

Dr Brantley:   Sure. A 3D mammogram is very similar to a 2D mammogram. They’re both x-rays of the breast with low dose radiation. The 3D mammogram differs however in that we take more pictures at multiple angles. What that does is it allows the radiologist to get a better view of the breast in more of a 3D setting. So there’s many benefits to that including increased detection of breast cancers at earlier time frames. It also can help cutdown on the callback rate because we’re able to tell if something is real or not more readily with the addition of the additional images. As far as the cost, there may be some increased costs but that is going to be passage onto the insurance company. Most insurance companies including Medicare and Medicaid are covering the 3D mammograms. So the patient should not expect to have any increased out of pocket costs.

Host:   That’s good to know, especially since there's so many benefits to a 3D mammogram. Speaking on mammograms, is there ever a point in which women would stop getting them?

Dr Brantley:   There’s no set age when you stop getting mammograms. It really depends on the health of the patient. As long as the patient is healthy and they desire to remain healthy, then you continue to have your screening mammograms. Up until the point where you reach and age or a health condition where if you did find a breast cancer, you wouldn’t be inclined to do anything about it anyway. If that’s not the case, we just recommend that you keep being screened as long as you're in good health.

Host:   What’s the difference between screening and diagnostic mammograms?

Dr Brantley:   The difference between a screening mammogram and a diagnostic mammogram is that the screening mammogram is done on asymptomatic women who are not experiencing any breast problems. No lumps, no pain, no discharge. The diagnostic mammogram comes into place when the patient is experiencing a breast problem and we need to workup that problem further. Say you feel a new lump or changes in the breast. That is when we would take the next step to do a diagnostic exam. What we would do is bring you into the breast center to do additional special images that allow us to see more specific areas of the breast than we do just on a standard screening mammogram.

Host:   I see. So if women are having symptoms, that’s sort of the breaking point there. Screening is for early detection, let’s say, and diagnostic would be if women are actually having symptoms.

Dr Brantley:   Exactly.

Host:   So when is ultrasound used?

Dr Brantley:   Ultrasound is usually used as a supplement to our diagnostic mammogram. Say you come in for a breast problem. We would typically start out with a diagnostic mammogram to get a bigger picture of the breast. Then once we identify a specific area that we need to evaluate further, that is when we would proceed with ultrasound because it’s the focus test that looks at specific areas of the breast.

Host:   Dr. Van Fossen touched on this earlier, but I want to have you go into some more detail Dr. Brantley about dense breasts.

Dr Brantley:   Our breasts are typically composed of two main types of tissue. There is fatty tissue and then there is glandular tissue. The fatty tissue we’re able to see through it more clearly so that if there is something new or growing in the breast, it’s more readily apparent. When you have dense breast tissue, you have more glandular tissue. The reason we’re concerned about that is because the glandular tissue can sometimes obscure masses or other changes in the breast. So it’s important to look more closely in those areas to make sure that we are not missing anything.

Host:   Is that when a breast MRI would be indicated?

Dr Brantley:   We typically don’t do the breast MRI just because you have dense breasts. That’s where the 3D mammograms are really helpful that we spoke about a little earlier. Those typically suffice for dense breasts. When we do a breast MRI, there’s typically two indications. One would be you have a high risk which would be determined by your doctor where you typically have an increased lifetime risk of breast cancer greater than 20%. Then you would qualify for a screening breast MRI. The second instance that breast MRIs are typically done are when you have a known problem like a breast cancer usually. We would do that to further evaluate the breast and do a pretreatment workup. That’s two reasons why we typically do breast MRIs.

Host:   The natural follow up is then how is a breast MRI actually done?

Dr Brantley:   MRI stands for magnetic resonance imaging. It is basically a big machine that we use to image the body, and it uses magnetic technology. So for the breast you would come in. You would be screened and have a questionnaire. Then typically our breast MRIs are done with contrast administration. So you would get an IV and we would administer contrast during the exam. You lay on your stomach and you go onto the table, and we take several images several sequences through the breast. Then the images are put together on a machine and then interpreted.

Host:   Okay. Got it. As we wrap up here today doctor, anything else you want to tell women about your area of expertise whether it’s mammograms, 3D mammograms, ultrasound, MRI. We’ve covered a lot of territory today. Hopefully, this is helpful. Anything else?

Dr Brantley:   Yeah. I just want to continue to encourage the women. There's also men out there. Male breast cancer is very uncommon. 99% of the time it’s in women. Men do get breast cancer. So it’s important for both women and men to know their breast so that they can recognize when changes do occur. We do stress that our women start their mammograms at 40 and annually thereafter. So just take care of ourselves, love ourselves, and get our screenings.

Host:   Absolutely. You know during COVID-19 it’s always great to stay mentally and physically well. Great during breast cancer awareness month to have you both on. Thank you so much and you stay well. For more information on today’s topic, go to summahealth.org/thinkpink. If you found this podcast helpful and informative, please share it on your social channels and check out the entire podcast library for additional topics. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Stay well and we’ll talk again next time.