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Prakash Chandran (Host): When it comes to cancer of any type, perhaps the best defense is to be armed with the most accurate information. COnsidering breast cancer, though there have been amazing strides in outreach for funding and education, there still are misconceptions about how to proactively identify the disease and get it treated.

Here with us to discuss is Dr. Barry Rosen. He's a Breast Surgical Oncologist in the northwest suburbs of Chicago, where he has been in practice for over 25 years. A nationally recognized expert in Oncoplastic Surgery, Dr. Rosen has been Program Director and Faculty Training other surgeons throughout the US.

This is AMITA Healthcast, the podcast from AMITA Health. I'm your host, Prakash Chandran. So, Dr. Rosen, thank you so much for joining us today. You know, there's so much we could potentially talk about here, but I wanted to focus on three topics that you have a lot of knowledge in. The first two topics are breast density and genetic testing as it relates to screening, and then finally oncoplastic surgery when it comes to reconstruction. So, why don't we get started with breast density and dense breast tissue? Can you talk about what this is?

Barry Rosen, MD (Guest): Thank you Prakash. Dense breast tissue, there's a lot of myths about breast density. And I think it's very important to clarify that you can't feel dense breast tissue. The way that we define breast density is when a radiologist interprets a mammogram, they will separate out women based upon how dense the breast tissue is.

And we have a very simple system of ABCD. And about 40 to 50% of all women in the United States have dense breast tissue that would be categorized either as category C, heterogeneously dense or category D extremely dense. The reason why density is so important, is that women with dense breast tissue are actually at an increased risk for breast cancer.

So we need to follow women with dense breasts, more closely than the average person. The other fact about breast density is that the more dense your breast tissue, the more likely it is that a screening mammogram alone will not identifya cancer. So, if a woman has a breast cancer and is going in for a screening mammogram, there's a 25% chance that the radiologist will not be able to see that cancer because of dense breast tissue. The reality is, that we can do supplemental imaging in women with dense breasts to overcome the masking effect of density. So, there are many different tests out there that can be used to supplement, not replace mammography. So, mammograms are still very useful even if you have denses breasts. But if you have dense breasts, you need to do an additional test.

It could be as simple as a screening ultrasound, or it could be as complex as a screening MRI. And those are the two most common tests that are being done right now in the United States. A screening ultrasound, perhaps more commonly for those that average risk for breast cancer or category C heterogeneously dense breasts. Screening MRI for those women who have extremely dense breast tissue and, or at are at high risk for both.

Host: Okay. That's very helpful. So you mentioned mammograms, I've heard of different types of mammograms, like 2D mammograms, and 3D mammograms, and especially the 3D mammograms being better at identifying dense breast tissue. Can you speak to this a little bit?

Dr. Rosen: Sure. There are 2D mammograms and 3D mammograms, and 2D mammograms are a very good test, but 3D mammograms are better. And if you can go to a facility that has 3D mammograms, I always advise my patients to preferentially choose a center that has 3D mammography, but even with 3D mammograms, you still can't see through dense breast tissue.

And so the supplemental studies could be, again, as simple as a screening ultrasound or as complex as a screening MRI and the supplemental studies all have different pros and cons. The best thing that I can say to your audience is that know your density ABCD. It's on every mammogram report that it will include density information.

And then the second thing is, if you do have category C or category D, the dense breast tissue, please talk to the physician who ordered your mammogram, what other testing needs to be done.

Host: So, along the lines of being proactive and getting tested, I wanted to move on specifically to genetic testing. So, one of the things that I've heard is that if you have a family history of breast cancer, that you should get tested, I think the number is 10 years before your family member had breast cancer.

But I know that there are people that say, if there is no family history of breast cancer, that they don't need to get screened and they're fine. So, can you speak broadly to genetic testing, who should get it and when they should get it?

Dr. Rosen: Sure. I think what's important to recognize is that most women who get breast cancer have no risk factors for breast cancer. And so there's a common myth that if you don't have any family members who've had breast cancer, you are not at risk. And that's absolutely untrue. The reality is probably about 75% of all cases of breast cancer occur due to environmental risk factors, not hereditary risk factors.

So, every woman in the United States should undergo screening studies beginning at age 40. Women who are at higher risk, include those who've had family members who've had breast cancer because again, probably about one out of four breast cancers occur in women who have inherited from either their mother or their father, a predisposition to breast cancer. What we have available now, which we didn't use to have, is something called multi-panel genetic testing. Right now, for any woman who is diagnosed with breast cancer, in my practice, I offer genetic testing and we'll find a mutation about 10% of the time, meaning that woman has inherited from either her mother or father, a predisposition to breast cancer.

Now that's going to be very pertinent for that woman because she may choose to have a double mastectomy rather than a lumpectomy, for example, if she's at a prohibitively high risk for developing a second breast cancer in her lifetime. If she doesn't choose to do a double mastectomy, we can watch her more closely.

We can do imaging every six months rather than every year, so that if she is destined to get a second breast cancer, we'll find it earlier. The real advantage beyond that, is cascade testing because if a woman has a predisposition that we identify, her family members have, first degree relatives have a 50/50 chance of also having that mutation.

And if I know about that mutation, before they're diagnosed. I actually have a fighting chance at preventing breast cancer. And at the end of the day, we would much rather to prevent cancer than to treat cancer. So, genetic testing is a very important part of my practice now, but admittedly, that only represents a relatively small subset of all women who get breast cancer. The take home message, if you've had one or two relatives with breast cancer, you may very well qualify for genetic testing. And I encourage you to talk to your primary care doctor about this, or you can actually seek out genetic counselors that are present at most major hospitals.

Host: Yeah, that's really good advice. And one thing to note is just what you mentioned around a lot of the cancer that you see is driven by environmental factors. So, can you outline a framework that someone can follow in terms of being proactive around screening?

Dr. Rosen: Well it's, if you're 40 or older, you should be starting screening imaging. And that may just be a mammogram or if you're dense breast tissue, it can include a mammogram and ultrasound or even a mammogram and MRI. You also need to understand your risk, because again, there are risks that are outside of our control and there's risks that we can modify. And one of the risks for breast cancer is obesity. And so to the extent that one can control their fat intake in their diet and try to get to an ideal body weight, that will also lower your risk for breast cancer. Alcohol use is a known risk factor for breast cancer. So, if a woman can moderate the amount of alcohol that she consumes or even avoid alcohol altogether, that will clearly reduce the risk of getting breast cancer. So, there are things that are within our control. Exercise is well-recognized to lower one's risk. Avoiding exogenous hormones, such as through birth control pills or hormone replacement therapy. All of these are known to be risk factors. Now I'm not saying that a woman shouldn't take birth control pills or estrogen replacement therapy, but what I'm saying is that you have to look at your baseline risk.

And if you are at elevated risk for breast cancer due to other factors, maybe you, one can modify some of the other controllable factors.

Host: So, the last topic that I wanted to move on to was something that was mentioned in your bio, which is oncoplastic surgery. I at a high level, understand that's getting the best aesthetic outcome without compromising cancer treatment, but maybe you can speak to it more at a high level and teach us what it means.

Dr. Rosen: Well, thank you. And this is a topic near and dear to my heart because I think all too often, women have equated breast cancer surgery with being left with a permanent deformity. And oncoplastic surgery, actually, it's a very simple principle, which is, as you stated, you apply plastic surgical principles to cancer surgery to get a better aesthetic outcome without compromising cancer treatment.

So, we never compromise the cancer treatment, but all else being equal, if I don't leave a woman with a permanent defect, then it's going to make it a lot easier for her to live and move beyond their cancer diagnosis. It's not about vanity, it's about recovery. And so just can be very simple. For most women it's as simple as hiding the scar in a natural crease such as under the breast or around the areola, or even in the armpit and also closing the cavity after a lumpectomy so that a woman isn't left with a divit in the breast. Sometimes, what we do is we incorporate a breast lift and reduction in the cancer operation so that it allows us to remove as much breast tissue as we need to remove to treat the cancer and then do a compensatory procedure on the opposite breast so that a women can actually look better after her cancer surgery than she did before. So, we can get very sophisticated with this. I also think that oncoplastic surgery extends to mastectomies as well.

Frankly, if I never do a mastectomy and again, in my life, I'd be very happy, but there are some situations where we have no choice. If I have to do a mastectomy, I can often do what's called a nipple sparing mastectomy, which is where we don't remove any of the skin, we just shell out the inside of the breast and replace that with typically an implant. So that while it's not the same as having breasts, if you looked in a mirror, you would never know that the person had a mastectomy. So, we've gotten a lot more sophisticated than we used to. But yet I don't think any breast surgeon will be happy until we do much better on the prevention side so that we don't have to treat breast cancer as often as we do.

Host: Of course. You know, just as we start to close here, Dr. Rosen, you've shared a lot of valuable information here today. But just given all of your years of experience, if you could share one thing with women that are listening what might that be?

Dr. Rosen: Get out there, get your mammograms once a year. It works. If you find a cancer at an early stage, breast cancer is curable an overwhelming majority of the time when you catch it early. It makes a very big difference if you just comply with screening recommendations. And if you're in a category that's at higher risk, then understand that risk, talk to your doctor about that and recognize if you need to go above and beyond the simple yearly mammogram at age 40, or perhaps if you need screening at an earlier age.

Host: Well, Dr. Rosen, I think that is great advice and the perfect place to end. Thank you so much for your time.

Dr. Rosen: Thank you for having me. Take care.

Host: Thanks for listening to AMITA Healthcast, the podcast from AMITA Health.

Prakash Chandran (Host): to learn more about breast cancer treatment that I made a health. Please visit Amita health.org/care. I pre-cost Gendron and we look forward to you joining us again.