Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Understanding Breast Cancer: Prevention, Risks and Screening
Unravel the complexities of breast cancer and arm yourself with essential knowledge during Breast Cancer Awareness Month. Join Dr. Holly Thacker as she breaks down the risk factors for breast cancer - age, race, family, lifestyle and genetics - and delves into groundbreaking research surrounding breast cancer prevention. Learn how lifestyle changes like maintaining a healthy weight, exercising and moderating alcohol intake can significantly reduce your cancer risk.
Later in the episode, Dr. Thacker shares the recent changes in mammography screening, including why breast density matters and how it can obscure cancer detection. This episode will equip you with the tools and knowledge to take charge of your breast health today.
Welcome to the Fit, Healthy and Happy Podcast hosted by Josh and Kyle from Colossus...
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Welcome to the Speaking of Women's Health podcast. I'm your host, dr Holly Thacker, the Executive Director of Speaking of Women's Health, and I am glad to be back in the Sunflower House for a new episode, for a new episode On this episode of Speaking of Women's Health podcast. I'm back in the Sunflower House and it's October Breast Cancer Awareness Month, and this is really fitting that we discuss this very concerning and scary condition for women and there are some men who are diagnosed with breast cancer and do need treatment as well, but it's so much more common in women than men. One in eight women 13% will be diagnosed with invasive breast cancer in their lifetime, with about one in 39 women, or 3%, dying from breast cancer. So we're going to talk about the risk factors and how it varies by age, race, ethnicity, family history, medical history, reproductive history, lifestyle factors, genetic factors, lifestyle factors, genetic factors and I'm taking content that we have on Speaking of Women's Health and I'm also going to talk about breast density and some new legislation that affects how mammograms are reported. So, in terms of breast cancer prevention, I took some information from our graduated fellow, dr Alexa Fithik. She's in her own practice in concierge medicine of Westlake now, in fact, in October she is celebrating her one-year anniversary. She did research on women with BRCA gene and their medical and surgical care, and she posted this a couple years ago about breast cancer prevention, and it's really all very similar to how we approach women.
Speaker 1:So when you have a familial mutation's something that's, of course, out of your hands you can't change your genes, but there's a lot of things that you can do to affect your personal risk on your own. It's estimated that 33 percent of all breast cancer cases are preventable. Okay, so that's good news, but staying healthy takes some work. You do need to know your family history and, if you're adopted, that unfortunately may be out of your hands. If you have a first or second degree relative diagnosed with breast cancer before age 50, that alone doubles the risk of breast cancer. Pathogenic variants or other mutations and high risk genes that are associated with breast cancer can increase the risk of breast cancer up to 85%. This means that you want to find out about your extended and immediate blood relatives, particularly if there's breast cancer, ovarian cancer, pancreatic cancer, prostate or colon cancer, and if you find out that a blood relative has one of these mutations, talk to your physician or your nurse practitioner, family doctor, gynecologist, whoever that you see regularly to see if you can be referred for genetic counseling. Now we've had other podcasts on breast cancer, genetics and just genetics in general, and we will have some other upcoming podcast dealing with some of the legalities and the laws associated with this. Some of my patients are fearful to get genetic testing and if it's indicated, really knowledge is power.
Speaker 1:Now, in terms of screening, there's a lot of national organizations the American College of OBGYN, acog, the NCCN, which is the National Cancer Care Network. They generally recommend breast exams every one to three years, starting at age 25 and doing this yearly at age 40. The clinical breast exam really isn't as sensitive as once thought, but I think it's important for women to be aware of their body and any changes. Now both ACOG and the NCCN recommend starting mammograms at age 40 in average risk women and average risk women. Some guidelines recommend starting at 45 or even 50, but there is a 20% reduction in death from breast cancer in those that start screening at age 40.
Speaker 1:One of the most important things that you can do to reduce cancer risk, including breast cancer, is maintain a healthy body weight. Unfortunately, obesity and diabesity are just really exploding Out of women older than 20 years of age, more than 41% of them had a body mass index in the obese range. Now, the BMI is not everything. Some people can have dense muscles and dense bones and still have adequate body fat. Other people can be skinny fat with a normal BMI but not much muscle mass and central organ. Adiposity Body roundness index. Correlating your waist to your hip ratio. Your waist to your hip ratio. Doing body mass index assessments or other ways to assess this. A large study found that for every 11 pounds gained during adulthood, postmenopausal breast cancer increases by 11%, and obesity increases many other different types of cancer besides breast ovarian, endometrial, uterine, colon, rectal, thyroid, stomach, pancreas, prostate and men, gallbladder cancers and multiple myeloma. So you might ask yourself, why does obesity have such a negative impact on cancer risk? Well, the answer lies in how our body responds to extra fat tissue. Fat tissue influences inflammatory cytokines that decrease the body's ability to fight off cancer cells, and it can even increase the likelihood of DNA changes which promote cancer when cells divide.
Speaker 1:Exercising regularly, soon as I'm done this podcast, that's exactly what I'm going to do. We have been touting the good effects of exercise on the body for quite a long time, not only for heart disease prevention, mood improvement, reduction in diabetes, but also cancer reduction. The American Cancer Society recommends 30 to 60 minutes of moderate activity five days per week to reduce postmenopausal breast cancer. Don't use tobacco products. There's 70 different carcinogens in tobacco products. There's 70 different carcinogens in tobacco products. Women who start smoking 10 years or more before the delivery of their first child have an 18% higher risk of being diagnosed with breast cancer than those who never smoked. Some data shows less than 10 years of smoking is not associated with an increased risk. But for lung reasons, skin aging, emphysema so many different reasons it's recommended to never smoke.
Speaker 1:Limiting alcohol Alcohol is a carcinogen that is attributable to about 6% of all cancers, including breast cancer, colon cancer, mouth cancer. Even using alcohol mouthwashes we discourage throat cancer, laryngeal, voice box cancer and esophageal cancer, as well as stomach and liver cancer. So 12% of breast cancer cases and 11% of all breast cancer deaths can be linked directly to alcohol. There's really no safe level of alcohol, I'm sad to say, and really I am concerned when a woman ingests more than three to five drinks per week. And for those who do do some social alcohol use, we certainly want you to get adequate folic acid or folate ingestion.
Speaker 1:So how do we prevent breast cancer? During the timeframe of 2015 to 2019, the median age of breast cancer diagnosis was 62 years of age, so that means half of all women were younger than that. The median age of diagnosis is younger for Hispanic women, asian, pacific Islander, black, American, indian and Alaskan Native, compared to Caucasian females, partly reflecting the differences in population age structure as well as age specific risks. So we do like to prevent cancer and, if not able to prevent it, to pick it up early, although a good percent of the reductions in death rate from cancer is actually better treatment once it's clinically identified. So if you do have a lump and a physician ignores you or someone tells you oh, you're too young for breast cancer, go get another opinion. And if you do have breast cancer, you do want to undergo treatment.
Speaker 1:So there's a lot of different guidelines about screening mammography. If your average risk, starting at 40, is reasonable, some women want to delay till 50, although most breast specialists say start at 40 and to continue to age 75. And to continue to age 75. Certainly, there are false diagnoses of breast cancer and the older one is with biopsies, the more likely to be diagnosed with something that looks like cancer but may not affect your lifespan. So cancer screening is not without risk. Now, in those women that have had breast cancer or have strong family histories of breast cancer or chest radiation or known genetic mutations, that's a different story and you really probably need to be seen by a high risk team. Now, usually it's recommended for average risk women between 45 and 54 to do yearly mammogram, but once you're 55, going to every two years if you don't have symptoms or any increased risk. That is helps to reduce these false positives.
Speaker 1:In the past I would never prescribe any hormonal contraceptives or hormonal menopausal hormones if a woman didn't have a screening mammogram. And now I don't do that because the mammogram is far from a perfect test, but it is something that we do have and does help and reduce death rates in some women. Usually we stop screening at 75. It can be continued longer than that if the expected lifespan is going to be more than a decade. That being said, if a woman has no symptoms and she's on unopposed estrogen because she's had a hysterectomy, which reduces breast cancer risk, I've just seen a lot of healthy women with no symptoms get mammograms at age 80 or 85, and they find something that quote looks like breast cancer, and then they're taken off their estrogen and then they do poorly. So there are some risks with screenings. Even though it is, medically considered the standard of care.
Speaker 1:Not all breast cancers can be detected by mammography, especially in younger women and those young women with dense breasts, and so if you have a breast mass or changes in the physical appearance of your breast or your nipple, it needs to be evaluated. Now, breast physical exams can be challenging because the breasts are sensitive to hormone fluctuations and in women who are having monthly cycles there can be fibrocystic changes, particularly during the luteal phase More breast tenderness, nodularity, thickening, changes in the character of the breast. So it's best to do a breast exam after the menstrual period, and that's probably the best time to get a mammogram. If you're cycling Now, some women don't feel comfortable doing self breast exam, and if it's going to be done, it should be done once a month, not like every day. Fortunately, the vast majority of breast lumps are non-cancerous, and if a painful cyst appears and then resolves, then that's clearly not cancer.
Speaker 1:Dr Rebecca Stark, who's a gynecologist who runs one of our community hospitals, wrotea column on being proactive about breast health and talking about breast self-exams and since this is a cancer that so many women are concerned about, it's good to understand your breast and be aware of any warmth or swelling, dimpling or puckering of the nipples, itchy rash, changes in the appearance or a bloody nipple discharge or localized pain that does not go away. You can examine yourself in the shower or the tub with kind of flattened fingertips to kind of go around concentrically In front of a mirror. You can look to see if there is any asymmetry when you raise your arms or tighten your hands on your hips and flex the pectoral muscles. Certainly when you see your women's health care clinician, getting an exam or instructions may help. So we talked about the risk of breast cancer in terms of advancing age and family history having had breast cancer, having your first child after age 30 or never having children, never breastfeeding, certainly gaining weight and having a sedentary lifestyle and excess alcohol and tobacco and also low vitamin D levels, which are very common. The third podcast in season one in 2023 was all about vitamin D and I cannot emphasize healthy nutrition and having a good vitamin D level.
Speaker 1:Now a lot of women think that hormone therapy is linked to breast cancer and there's no increase in death rates in women who use menopausal hormones. This has been looked at extensively. There may be a slightly, slightly higher rate of being diagnosed with breast cancer for women who take long-term estrogen progestin, but there's overall decreased death rates. So it really doesn't factor into the equation, like so many women and unfortunately, their clinicians think. In fact, women that are breast cancer survivors can go on and become pregnant in many cases if that's what they so desire, and women can even be evaluated for hormone therapy. And what so many people don't know and which has been shown in randomized controlled trials, is that estrogen alone in a hysterectomized woman reduces breast cancer diagnosis even into your 70s.
Speaker 1:So in terms of the genetics of breast cancer, genetics play a role in at least 5% to maybe up to 12% of diagnoses. So if you have a first degree relative, such as a mother, a sister or a daughter with breast cancer, that is a higher risk, like three to five times the general population, particularly if that relative had breast cancer before age 40, or if there's a lot of members with breast and ovarian cancer, or if someone has been diagnosed with bilateral breast cancer or there is male breast cancer or Ashkenazi Jewish descent in the family BRCA1,. Brca1, was the first gene detected that was found to be known to increase a woman's risk for both breast and ovarian cancer. So the presence of this mutation produces greater than an 80% chance of developing breast or ovarian cancer by age 85. But that means 20% are spared. An estimated one in every 600 women carry this gene, and I have several women in my practice who have this gene and who are thriving, living full lives and doing well. So knowledge is power.
Speaker 1:The risk of developing a second breast cancer amongst someone with the BRCA1 gene is 65%, so bilateral breast cancer is common in women who carry BRCA1. The second gene, brca2, also plays a major role in breast cancer and it's associated with a similar risk of developing breast cancer, and it probably accounts for a definite small percentage of male breast cancer. Both BRCA1 and BRCA2 could be inherited from either one of your parents, so your father's family history is also important, and each parent who carries the gene has a 50-50 chance of passing it on to their offspring. Usually, these BRCA genes help prevent cancer by creating proteins that keep the cell from growing abnormally. But if you've inherited an abnormal BRCA1 or 2, you're more susceptible to developing cancer to developing cancer. In addition, women with altered BRCA genes usually have an increased risk of getting breast cancer at a younger age, before menopause. But, it is important to note, not all women who carry these genes will develop cancer. At-risk families can take blood tests to screen for mutations in these genes. Some people do need skin biopsies if they have some blood cell line other condition that makes checking their blood not an adequate screen, and genetic testing may be used to determine if a woman who has already been diagnosed with breast cancer is at an increased risk for a second breast cancer or ovarian cancer. And some have even posited that most women age 65 and younger diagnosed with breast cancer should be considered for genetic screening. So that is really some very interesting information about breast health during the month of breast awareness, but we really want to be aware of general health and cancer prevention year round.
Speaker 1:Now on the second part of this Speaking of Women's Health podcast, which you've been listening to and I'm your host, the executive director of Speaking of Women's Health is. I want to go over some information that was recently posted on our speakingonwomenshealthcom site by Dr Laura Leopold, who's contributed several contributions. She's at the Cleveland Clinic. She is a primary care, family medicine trained physician who has had some extra training in women's health and she has had an integral role in educating and training physicians at APPs and primary care related to women's health. She's headed up courses in women's health and she provided an excellent update to our group at the Center for Specialized Women's Health and posted this article that published in October of 2024 on our website and she talks about effective as of September 10th 2024.
Speaker 1:There's a new requirement that all mammography facilities include one or two breast density statements on the screening mammogram in terms of no density or density, and this is in addition to whether or not they see any other abnormal findings on the mammogram, like any concerns for breast cancer. So when you start looking at your mammography reports, ladies, you should be looking for this, and I think it's very important to keep hard copy results of important tests and medical records and not just rely on your doctor's office or the electronic medical system having it, and it's important to follow up on any questions that you have or any abnormalities and not just expect someone to contact you. You really wanna be proactive, to be healthy and be in charge and to be strong, and education helps in this arena. So what do these breast density statements mean? Well, a no density comment means that the breast tissue can either be dense or not very dense. If you do have dense breast tissue, it makes it much harder to find breast cancer on a mammogram and it means that there might be a higher risk of developing breast cancer. I tell women who have dense breasts that they mainly have more breast tissue as opposed to fat tissue, and fat in the breast does not develop into cancer. It's the breast tissue that does so. If there's no density, it means your breast tissue is not dense, so that's great. It's important to have a conversation with your healthcare clinician about breast density, risk for breast cancer and your individual situation. Now, density means that the breast tissue can be dense and much harder to find cancer.
Speaker 1:So if you have very dense breast tissue, other imaging tests in addition to your screening mammogram may be needed. So a screening mammogram is just two views of the breast. It doesn't get extra views unless there's something abnormal. And a lot of women ask to get diagnostic imaging because they want everything done at the same time. But that's actually if you have no symptoms. It's insurance fraud. But a lot of times two views is not enough, especially if there's a lot of breast tissue that needs to be spread out. So if you get that, call back, do not jump to any conclusions.
Speaker 1:So breast density determination is done via breast imaging. So a mammogram, which is basically an x-ray of the breast tissue, is not based on your breast size or your bra cup size or physical exam findings. We know that the breasts are composed of fat and that fibroglandular breast tissue, and so dense breasts have a certain amount of fibroglandular tissue relative to the fat tissue, and the more fibroglandular tissue there is compared to fat, the denser the breasts are. So at least 50% of all people who have a mammogram are identified as having dense breasts. So it's not an uncommon finding and breast density can change over time. Common finding and breast density can change over time. So be sure to read each mammogram you report to see how your breast density is classified. So women that have higher breast density have a higher risk of breast cancer and the fibroglandular tissue appears whiter on mammogram compared to fatty tissue, which is darker. And because the denser breasts have more white areas it's so much harder to see at early cancer, which also could appear white. So you may ask what's the best breast cancer screening test to have if I have dense breast.
Speaker 1:So digital mammograms remain the mainstay of breast cancer screening, even in those who have breast density. Now, tomosynthesis digital mammograms so-called three-dimensional mammogram has been shown in studies to perform a little bit better than the standard two-dimensional mammograms in terms of picking up breast cancer at an earlier stage, and I think the main benefit of the tomomammograms is reducing the chance of callbacks in those that have dense breasts. Not all facilities have the capability for 3D mammogram, so getting a 2D mammogram is still a very good test compared to no screening at all, and it's also less radiation, and that is something to also consider. Supplemental screening in addition to mammography has been shown to pick up some cancers that might potentially be missed on mammogram. In women who have very dense breasts, that might include whole breast ultrasound, not in substitution for mammogram, but in addition, and potentially breast MRI, particularly in those women at high risk for breast cancer. But the potential drawback of having these tests could be false positives, which can lead to unnecessary biopsies and can lead to over diagnosis of some breast cancers, as well as increased costs that may not be bore by your insurance. And these tests are not meant to replace a mammogram. They're just in addition to, or supplemental to, the screening mammogram. Just in addition to, or supplemental to, the screening mammogram.
Speaker 1:So having a conversation with your healthcare clinician, being aware of what your breast cancer risk is and how to reduce it, knowing what your breast density is, and knowing that there are clinical tools to help assess your five-year risk of breast cancer and lifetime risk of breast cancer, can help, and also knowing that there are chemo prevention therapies that are FDA approved. Tamoxifen, in pre and post-menopausal women and high-risk women reduces the diagnosis of breast cancer, and, in post-menopausal women, roloxifen, brand name Avista, which helps the bones. Riloxifan, brand name Avista, which helps the bones, is FDA approved to reduce the diagnosis of ER positive breast cancer. None of these agents, though, have been shown to prolong life, and menopausal hormone therapy is one thing that has been shown to extend lifespan in women, and so I get into this yin and yang discussion with some of my breast colleagues, because they're so focused on breast cancer and that, once you are diagnosed with breast cancer, and even for women who are diagnosed with DCIS, which is ductal carcinoma in situ, which is stage zero breast cancer, and sometimes more aggressive treatment is used for that than actual breast cancer. Many times it means that the woman comes off of hormone therapy, which not only treats symptoms and reduces several diseases but can significantly improve the quality and the longevity of a woman. And so that's why I do not emphasize the end-all be-all with just imaging.
Speaker 1:Imaging imaging, and certainly the breast MRI, which gives us beautiful pictures, is not without risk. Gadolinium is injected into the vein. For contrast, now we're using better types of gadolinium, but it can deposit in the kidney and the brain. It is a more invasive procedure and sometimes it's converted women from having simple lumpectomy and radiation to complete mastectomy, which years ago lumpectomy with radiation was shown to be equivalent to longevity as complete mastectomy.
Speaker 1:So even though it would seem like early screening and early diagnosis is optimal and in many cancers like cervical cancer and colon cancer and skin cancer, this is the case but breast cancer is very complicated and there is a lot that you could do lifestyle wise and if there's red flags that suggest you have a higher risk genetically of cancer, that's important to know because it translates to things besides just the breast, and thankfully we have a lot of innovative and targeted therapies for those women with breast cancer and we have treatments to treat the menopausal symptoms that are not hormonal, if women cannot be on hormone therapy. In fact, the beginning of season one, we had several CMEs for physicians and APPs on non-hormonal options to treat hot flashes, including the new candine neuron inhibitors like fezolinatant. We also have a wide panoply of bone therapies to treat and prevent and manage osteoporosis, which is going to be a higher risk in women who are deprived of estrogen, and we have some local and systemic treatments to help the genitourinary system, which can be really affected when women lose their estrogen. So I really think all of that is encouraging. You should just not rest on your pink ribbon laurel and just get your yearly mammogram and not think about anything else. The mammogram is a tool. It is part of our armamentarium to help us be strong, be healthy and be in charge.
Speaker 1:So thank you so much for tuning in to another episode of the Speaking of Women's Health podcast. We're really grateful for your support. We hope you'll share this podcast with others and leave us a five-star rating. You can even go to our website, speakingofwomenshealthcom, and hit the donate button to our nonprofit and to catch all the latest from Speaking of Women's Health. Please follow or subscribe for free wherever you listen to podcasts on Apple Podcasts, spotify, tunein wherever, because we don't want you to miss any future episodes. Thanks again, and I'll see you next time in the Sunflower House.
