Love Your Breasts
When was your last mammogram? Even though it is February, if you are still trying to decide on a New Year’s resolution, or want to add another one to your list, getting a mammogram is a great addition.
This is because breast cancer is the number one cancer a woman will face in her lifetime, although “the 5-year relative survival rate for localized breast cancer in the U.S. is 99 percent.” So protect yourself and your health and commit to getting a mammogram every year if you are 40 or older and of average risk.
Today’s issue is an enlightening conversation with Dr. Maria Nelson, MD FACS FSSO, Associate Professor of Clinical Surgery, Chief, Division of Breast, Endocrine and Soft Tissue Surgery and Associate Program Director of USC-Hoag Breast Surgical Oncology Fellowship. In our conversation we cover the difference between benign and malignant breast disease, risk factors for breast cancer, screening recommendations, treatment options for breast disease, and more.
I learned so much from this conversation and I know you will too.
Karyn: Your specialty is benign and malignant breast disease. Which is most common? And what are the main characteristics of each?
Dr. Nelson: While I see patients with every kind of breast complaint, about 20% of the patients I see have some form of benign breast disease. Benign breast disease can range from masses to abnormal imaging findings with or without benign biopsies to simply breast pain.
The typical patient in this category is a high risk woman with no specific complaint but who wants to do more surveillance or talk about risks. Or it can be people with benign lumps/masses or biopsies which may or may not confer risk but who are seeking more information. I also see men with gynecomastia (male pattern breast tissue) who are nervous and want to learn more.
The other 80% of people I see have some form of breast cancer. Typically, we see abnormal imaging which leads to a biopsy of the cancer, but the cancer can also present as skin changes, nipple discharge, or palpable masses.
Karyn: Midlife brings many changes for women and their health. How does perimenopause and menopause impact breast health and a woman’s risk for breast cancer?
Dr. Nelson: Most breast cancers are diagnosed in post-menopausal women, after age 50 and most often in their 60s. This is because a woman’s risk for breast cancer increases as she gets older. Breast cancer is the number one cancer a woman will face in her lifetime, but it is not the number one cancer a woman will die from. Lung cancer has the highest rate of mortality for both women and men.
The best action someone can take is to pay attention to any changes in their breasts and to seek help if they notice any changes. The success of a good screening program is that a patient will not notice any changes on a physical exam but with regular imaging small changes can be found. This is why it is so important to get a yearly screening.
Catching breast cancer early means less treatment and the possibility to avoid chemotherapy and a bigger surgery.
Karyn: What are the current screening recommendations for women between 40 and 60?
Dr. Nelson: The screening recommendations vary depending on the source. I agree with both the American Society of Breast Surgeons (ASBrS) and the American College of Radiologists who both endorse screening for average risk women (average means you do not have a genetic mutation which confers elevated risk, have never had chest wall radiation, or have never had history of atypical breast biopsies to name a few) to start at age 40 with annual mammograms.
In comparison, the American Cancer Society recommends women 45 to 54 should get mammograms every year. Women 55 and older can switch to a mammogram every other year, or they can choose to continue yearly mammograms. Screening should continue as long as a woman is in good health and is expected to live at least 10 more years.
And the USPSTF recommends that women who are 50 to 74 years old and are at average risk for breast cancer get a mammogram every two years. Women who are 40 to 49 years old should talk to their doctor or other health care provider about when to start and how often to get a mammogram.
Average risk implies approximately 12% lifetime risk, while high risk is associated with over a 20% lifetime risk. Insurance companies look at high risk women differently, and usually cover additional imaging in the form of a yearly MRI on both breasts.
At what point a person stops getting screenings depends on the individual and can sometimes be impacted by their insurance company. Often insurance coverage stops covering screenings at a certain age, usually in someone’s 70s. But as women begin to live longer, this may not make sense.
For women where this is the case there are a couple of options. A lot of hospitals have community outreach programs which offer deeply discounted mammograms for women who want to keep getting imaging. In addition, I also would encourage women to have a conversation with their doctor to express their concerns and to see if continued screening is warranted.
Karyn: What are the different types of screenings a doctor might order?
Dr. Nelson: Mammogram is the basic x-ray with 2 views. There is also 3D technology, called TOMO (i.e., tomosynthesis, or DBT - digital breast tomography). Digital breast tomography essentially takes 1 mm slice pictures through the breast and assembles them into a stack of images whereby the radiologist can see more clearly through the breast. There are 3 benefits to using 3D technology. One, it is good for dense breast tissue (tissue which is more glandular v. fat). Two, it increases the detection of smaller cancers. And three, it decreases the callback for unnecessary additional pictures because you start with better quality pictures.
Screenings are moving in this direction, but it will take a while as the machines are expensive and not available everywhere. If a potential concern is identified, an ultrasound can also be used.
I get asked a lot why patients can’t just have an ultrasound rather than a mammogram and there are a couple of reasons. Mammogram is still the gold standard for imaging the breast. Mammogram will detect small calcification changes that ultrasound cannot reliably detect. Ultrasound is used as an additional tool when new asymmetry or masses are seen to better characterize these changes. In addition, an ultrasound cannot replace a mammogram because calcium deposits in the breast are most accurately seen by a mammogram. These fine deposits which can be indicative of an early cancer, like stage 0-DCIS cancers, are 25% of all cancers. The best way to think of an ultrasound is as a complement to a mammogram but never a substitute for one.
Lastly, your doctor may order a breast MRI, as in the case for high risk women.
Karyn: What role does genetic testing play in breast cancer screening?
Dr. Nelson: Selective testing is based on individual risk. We don’t typically test unless someone has a family member with a known genetic mutation. In this case insurance will cover the testing. It is worth mentioning that doctors cannot make decisions based on tests like 23andMe. Genetic testing should be done at the direction your medical provider.
Only 5-7% of newly diagnosed cancer patients are found to have pathogenic gene mutation. This percentage is the same for those with a family history of breast cancer vs those without.
Karyn: How should someone think about HRT and breast cancer?
Dr. Nelson: My perspective comes from someone who focuses on breast cancer. I believe someone should be selective when considering HRT. We tend to see an uptick in breast cancer for women taking HRT for more than 10 years. For high risk women, I would say keep to limited duration of 3-5 years, and use the lowest possible dose. If someone’s main symptoms are vaginal dryness, it might be better to use vaginal estrogen versus oral estrogen or the patch.
Karyn: What risk factors predispose someone to breast cancer?
Dr. Nelson: In terms of risk factors, I like to think about risk in terms of things we cannot control and things we can control. Things we cannot control include:
being a woman
getting older
exposure to prior radiation
family history of breast cancer
genetic mutations
dense breasts
when we start menstruating
Things we can control:
being overweight or having obesity after menopause (extra fat cells convert to estrogen, and the most common cancer is an estrogen driven cancer)
alcohol consumption (over 5 glasses per week, the excess converts to estrogen)
taking hormones post-menopause
Karyn: What lifestyle habits are protective against breast cancer?
Dr. Nelson: Certain lifestyle habits such as controlling your weight, eating a healthy diet and getting regular exercise, and limiting alcohol are all protective. I also encourage people to be active and not sedentary. And while the medical literature is not as robust on this topic, I think eating a plant-based diet is advantageous. I would also encourage people to be mindful of and avoid sugar and processed foods.
Karyn: What are the most common forms of treatment for breast cancer?
Dr. Nelson: Treatment options fall into 3 categories:
1) Surgical
2) Systemic, which is an umbrella term for medications such as Tamoxifen or Anastrozole (both anti-estrogen medications) and chemotherapy and immunotherapy. These depend on the subtype behavior of the cancer and burden of disease.
3) Radiation, which is high energy x-rays targeting the affected breast (usually performed after surgery and may be followed with endocrine therapy (i.e., anti-estrogen medication if indicated).
The benefits of catching breast cancer early are smaller surgery, the potential to not need chemotherapy, and lighter amounts of radiation.
Karyn: What is your perspective on pre-emptive mastectomies?
Dr. Nelson: I think it depends on individual risk. For someone such as a BRCA patient, it is very reasonable as they can have up to an 80% lifetime risk of breast cancer. For someone with a 20% lifetime risk, this may be too much surgery. Additional screening is probably a better plan to follow until something changes.
Karyn: What are you most optimistic about in terms of treating breast cancer?
Dr. Nelson: We are seeing more targeted therapies for breast cancer being developed, including immunotherapies and therapies specific to how cancers grow. This increases the possibility of achieving both a cure and a durable result, by which I mean the cancer never comes back. A lot of the new treatment options are happening in the medical oncology domain, where for example, we can use chemotherapy to shrink tumors first which then results in a smaller surgery.
Parting Thought
A sobering topic to be sure, but like Dr. Nelson, I hope that having this information makes the topic a little less scary. And please, if you are over 40, invest in yourself and get a yearly mammogram!
Maria Nelson, M.D. is a highly accomplished surgeon with a wealth of experience and expertise in the field of breast surgery. She is currently the Chief of the Division of Breast, Endocrine, and Soft Tissue Surgery and an Associate Professor of Surgery at the Keck School of Medicine of USC. She holds a masters and medical degrees from the University of South Dakota and completed her residency training in General Surgery at Santa Barbara Cottage Hospital. Afterwards, she completed her fellowship training in Breast Surgical Oncology at Cedars Sinai Medical Center. Furthermore, Dr. Nelson serves as the Associate Program Director of the USC-Hoag Breast Surgical Oncology Fellowship Program. Her clinical focus and expertise is in benign and malignant breast disease, and her current research interests include the diagnostic role of breast imaging techniques and the complex nature of decision-making in breast cancer care.
To be continued…
