Melanie Cole (Host): If you come face to face with the possibility of breast cancer; you’ll probably feel extremely overwhelmed. But here to discuss and clear up some of the confusion surrounding screening and breast cancer treatment is my guest, Dr. Kathleen Allen. She’s a surgical oncologist in diseases of the breast at BayCare Health. Dr. Allen explain a little bit about breast cancer. What are you seeing as far as incidence and awareness? Do you feel that more women are getting screened?

Kathleen G. Allen, MD, FACS (Guest): Well breast cancer is a common disease among Americans. The average risk is about 12% of women will get breast cancer. So, it’s about one in ten roughly and so, it’s a common disease. In terms of screening, that varies. Most of our breast cancer is over age 50, 80% so sometimes it seems more common as we age because it’s happening to our peers. So, it becomes – it seems to be more apparent to us.

Melanie: Who is at risk? Speak about some of the risk factors involved in breast cancer even if there’s the genetic component, but weight, stress. Speak about some of the risk factors.

Dr. Allen: Yes, certainly. In terms of risk factors for breast cancer; the things that we look at as which you already mentioned is family history. Patients can have immediate family members or even distant family members with breast cancer. Usually two or more relatives in the family with breast cancer would be a signal to consider genetics counseling. And that’s kind of another topic that I’m glad to go into. But so, you are exactly right. Family history can be part of risk factors, a genetic mutation that would predispose someone to breast cancer; that might be detected by another disease process. Other risk factors for breast cancer are age of early first period like prior to age 10, a delayed age of menopause. Typical menopause is age 52. Delayed age of first pregnancy which would be after age 30. Elevated body mass index which is something calculated by the patient’s primary care physician in terms of body weight. Patients that take hormone replacement therapy more than five years after menopause can have increased risk of breast cancer. So, those are some of the leading risk factors for breast cancer.

Melanie: Tell us about screening. Who should get screened? When do we start getting screened and why is there confusion over the current recommendations for screening mammography?

Dr. Allen: Screening is looked at from different perspectives. Some screening is based on population studies and overall cost to the population versus the gain of the screening mechanism. So, we look at risk versus benefits of screening. So, if a screening technique is very risky for a patient; then it’s not a good screening method versus a low risk screening method that would have low risk of complications. Also, they look at in terms of the population, if it’s not likely that you will find a disease; then we don’t want to go looking for it by screening everybody and only having one person out of 1000 with that disease process so, it’s not very helpful. So, that’s some of the criteria for how people look at screening. In terms of breast cancer screening, there are different groups that advocate different methods of screening, typically by age 40. That’s pretty well agreed upon that people should start screening at age 40 that have no risk factors for breast cancer. Screening means no issues, you are just without any symptoms, and therefore we are just screening you to see if you have this disease. So, age 40 is typical. And then most guidelines do recommend an annual mammogram starting at age 50. Between 40 and 50, there are different recommendations from every year to every other year. And that’s because most breast cancer is diagnosed after age 50. The thinking on that is that someone that would have breast cancer earlier than that, would be able to pick it up on self-breast exam or their primary care physician doing a breast exam on that patient would pick up the finding.

So, why there is different screening recommended is it’s based on population study and economics and typically, the three components of screening include self-breast exam by the patient on a monthly basis, an annual breast exam by the patient’s physician, like their GYN or their primary care doctor and then their annual or semi-annual mammogram.

Melanie: Are there some symptoms or signs of breast cancer? You mentioned self-exams. Would we feel something or see something? Speak about how a woman would know that there’s a red flag.

Dr. Allen: Yes. Terrific question. Some of the signs and symptoms of breast cancer include nipple discharge, particularly if it’s from just one breast, that could be bloody or clear discharge. Sometimes people just see it on their bra or on their night clothes. Certainly, a breast mass. It can be a – most like it’s a painless mass that seems to be increasing in size. Generally, that’s a firm mass that can somewhat feel as hard as a marble within the breast tissue. So, if you feel a mass that seems different from the surrounding breast tissue. Other symptoms include skin changes in terms of nodules or redness that appears on the breast and seems to be increasing in extent of redness or the size of the area over time. The symptom of pain is not generally a presenting symptom of breast cancer. So, masses, nipple discharge, skin changes are some of the key things for a patient to look – or for a person to look for when they are doing their self-breast exam.

Melanie: Are there different types of breast cancer? Explain a little bit about diagnosis and how you stage a particular type of breast cancer so that women understand if they have to go back for a diagnostic mammogram; what it is they are being told.

Dr. Allen: Yes, there are two types of mammograms. There’s a screening mammogram and a diagnostic mammogram. The screening mammogram four views are obtained, two on each breast and they are generally read in batches in that the patient gets their mammogram and they go on their way and then that’s read later by a radiologist after they have left. Diagnostic mammogram however, shows the same four views but if there is some issue like nipple discharge or a mass or a concern; then they will take additional angles of the mammogram and may even add in an ultrasound to try to answer the question of what’s going on. And the patient is kept there at the imaging facility until the imaging is read, until further recommendations are made at that time. So, there’s quite a big difference between a screening mammogram and a diagnostic mammogram.

In terms of your question regarding the different types of breast cancer, we tend to designate breast cancer into different cell types based on where the cancer seemed to originate. About 70 to 80% of our breast cancers form from the milk ducts cells of the breast tissue. So, that’s called ductal cancer. There’s another part of the breast called the lobules that are part of the whole milk system and they can also form breast cancer and that’s called lobular breast cancer. So, that gets up to about 90% of our breast cancers and then from there, there is a mixed bag of different kinds of breast cancers and you can have other diseases that can happen to arise in the breast like melanoma or sarcoma or other types of cancers that just happen to be in the breast.

You asked a very good question regarding staging. Staging has to do with several components of a patient’s cancer. In staging, the size of the tumor is considered, the number of lymph nodes that appear to be involved in the process. Breast cancer tends to travel through the lymph nodes before it goes to any other place in the body. So, lymph nodes are important in staging. Any distant disease, like liver, lung, bones. So, those three things are key to staging. Also, we consider the biologic properties of the tumor. In breast cancer, we look at estrogen and progesterone receptor status as well as HER-2 receptor status. Those are very key prognostic indicators because we have medicines to target those receptors and really help improve patient’s long-term outcome. And then the final component of staging is grade or how disorganized the tumor cells are compared to normal breast tissue and that helps give us an idea of in some ways, how aggressive the tumor is. Staging is helpful – the whole point of staging is for prognosis to help us know how far along the cancer is and then we can then address our therapy and tailor it to that patient’s prognosis.

Melanie: Dr. Allen, is it possible to prevent breast cancer and as you summarize this segment for us and explain as a surgical oncologist a little bit about what you want women to know about breast cancer, about possible prevention, living a healthy lifestyle, hormone replacement. Kind of wrap it up for us and explain what you would like them to take away from this segment about breast cancer.

Dr. Allen: In terms of breast cancer and keeping it low impact in any of our lives; screening is the most important in terms of catching something early, keeping an ideal body weight and good nutrition just like we are told otherwise and low stress. All those things help with any kind of cancer prevention. So, exercising at least twenty minutes three times a week, eating our fruits and vegetables, being mindful of our stress levels affective our lifestyle so that we are balanced. Those all things help with our decreasing risk of cancer. I mean there are surgical means to decrease risk of cancer, such as removal of the breasts, but we really – that’s not recommended for patients that are of average risk for breast cancer. That’s held for patients that have a genetic predisposition to getting breast cancer. So, that’s not a feasible option for most people. Most people we just need to take care of ourselves and follow recommended guidelines that they would discuss with their primary care doctor as to how to stay healthy in general and then be aware of self-breast exam, the clinical breast exam and the imaging.

Melanie: Well it really is about awareness and thank you so much Dr. Allen for being with us today and explaining some of this to help clear up some of the confusion surrounding breast cancer and screening and what kinds of prevention options a woman might possibly have. Thank you so much again. You’re listening to BayCare HealthChat. For more information please visit www.baycare.org, that’s www.baycare.org. This is Melanie Cole. Thanks so much for tuning in.