Melanie Cole (Host): Welcome. Joining the show today, to discuss regular and early screenings for breast cancer and the treatment options available is my guest Dr. Peter Blumencranz. He’s the Medical Director of the Oncology Service Line and a Surgical Oncologist at BayCare. Dr. Blumencranz, it’s a pleasure to have you with us today. Explain a little bit about breast cancer as we get started. What are you seeing as far as incidence and awareness? Are more women getting screened?

Peter Blumencranz, MD, FACS (Guest): I think the incidence of screening is going up but the biggest issue with increased number of patients we see lately is that all of the baby boomers are getting old enough to get breast cancer. So, there’s been a major population shift. We also have better means of screening so sometimes we can catch stuff earlier than we used to but that evens out over time as you might understand.

Host: Well it certainly does. So, what are a woman’s chances these days, it seems to go up and down of getting breast cancer?

Dr. Blumencranz: Well overall, getting breast cancer is very common, about one out of eight women if you take lifespan up to age 80, it’s about a chance of one in eight. But it does vary based on other risk factors. That’s just average. It’s kind of like with men getting prostate cancer, If you live long enough, you might get it. But there are other things. Some patients may have a genetic risk but that actually only accounts for about five to ten percent of all breast cancer patients.

Host: Well let’s speak about that for just a brief moment. Tell us about that genetic predisposition and what role the inherited trait plays in developing breast cancer.

Dr. Blumencranz: In certain patients, they have inherited a harmful or what we call in the trade a deleterious mutation in one of their chromosomes that predisposes them to breast cancer. The most common of those that people hear about are the BRCA 1 and 2 or BRCA 1 and 2 as they are commonly called. Those tests have been around since about the mid-90s and in fact, we’ve learned in more recent years that there are other genes that may predispose to breast cancer not quite as common as those two. Those are the most common but risks of getting breast cancer in that situation if you have a BRCA 1 mutation, your risk may be as high as 65 to 85% of getting breast cancer by age 70. So, a remarkable difference. But there is testing we can do for that.

Host: So, what about some other risks? Women who are of a certain age and we hear about hormone replacement therapy. I mean there’s a lot of myths floating around, but what about hormone replacement?

Dr. Blumencranz: Well hormone replacement therapy is something that in general, is not a good idea so the issues here that estrogen dependency is true of most breast cancers, that is what we call estrogen receptor positive so it doesn’t necessarily mean that estrogen causes breast cancer, but the majority of breast cancers can be fed by it. and long term women’s health studies that have been done, the combination of estrogen with progesterone, which is typically when the uterus is still in place; in the postmenopausal woman definitely has increased risk for breast cancer. For estrogen alone, not as bad but there is increased risk for strokes.

So, the current recommendation for hormone replacement therapy and we’re talking typically postmenopausal woman would be try to take this for a relatively short time, perhaps three to five years to alleviate going through the menopausal changes but not meant to be taken as a lifetime medication.

Host: Well thank you for clearing that up for so many women. So, let’s talk about screening and who should get screened. There’s been some controversy and we hear one from the US Preventive Task Force and another from ACOG. What do you want to tell us about screening, when we should start getting our first mammography.

Dr. Blumencranz: It’s an excellent question when to start screening and I think the current concept which I think is really the best one is given that there are many societies recommending annually starting at age 40 or maybe at age 50 or maybe every other year and then how long do you do it. do you stop when you are 70 or 75? I think the concept that’s really important is what I would term and it’s not my term, but a term for this is risk adjusted screening. Meaning, you really need to look at the patient’s risk of getting breast cancer because for example, someone who has a BRCA mutation who is not going to take the step of considering possibly having their breasts removed; needs a different level of high risk surveillance and started at a much younger age. Those patients who are high risk should start with an MRI at 25 then annual mammograms at age 30. Way different than the general population.

If you have no increased risk then starting at 40 or 50 can be debated, but I will tell you that in our breast program, probably close to 20% of our patients with breast cancer are under age 50, so in our program right now; we tend to want to start with annual at age 40. But if a patient feels that they’d rather not start until 50 and they have no risk factors, I think that’s acceptable.

Host: Thanks for clearing that up. So, let’s talk about the screening technologies out there. We hear mammography. Women have had a mammogram and it’s really not as bad as everyone thinks and now, we hear about 3-D mammography, tomosynthesis and whole breast ultrasound. When do we use which one and is there a reason for that?

Dr. Blumencranz: So, the gold standard for screening is still the mammogram and these days digital, not analog which was the old film screen when they would take a picture and develop it on film. Digital mammograms even 2-D were a quantum leap better than the old analog films. And now we have 3-D. one of the advantages for 3-D is that if a woman has denser breasts or larger breasts; if you are doing the 2-D picture you are looking at a three dimensional object in two dimensions and so the density can mask things in front of it or behind it. With the 3-D mammogram, this allows the radiologist to manipulate images and essentially take slices through the breast so you can unmask that density and see through it. So, that’s a great tool especially in the dense breasts or younger women who have higher risk getting 3-D should be the preferred not just 2-D digital.

As far as whole breast ultrasound, that is not meant to be a substitute for mammogram. One of the things I often hear is I don’t want someone squeezing my breast, I don’t want a mammogram, can’t I just have an ultrasound or just have an MRI for that matter. And the answer is no. That ultrasound and MRI will not be the way to find the earliest signs of breast cancer. That’s a standard mammogram.

Host: Do you recommend that women do their own checks? Do you think that leads to unnecessary anxiety? Should we be doing that?

Dr. Blumencranz: I usually coach my patients to just have a self-awareness. You are taking a shower, you are going to wash your breasts, don’t make a big fuss over it, but be aware of any new lump or something that doesn’t feel like it used to. I think the age of that monthly breast check and have your breast buddy that’s going to remind you it’s time for your monthly has gone by the wayside.

Host: Okay so, what else would you like us to know because when we’ve gotten that mammography or tomosynthesis and then we wait for that letter or the phone call saying you need a follow up. Tell us a little bit about the difference between a diagnostic and a screening mammogram.

Dr. Blumencranz: Screening mammography is basically done the same way everywhere. It’s two views of the breast called the craniocaudal view and the mediolateral oblique or kind of angled view from the side. And those are standard views that give the radiologist the best initial impression of the breast and you can have a tech do those two standard views, go home you get a call back. The call back for diagnostic is not a different mammogram machine. Often that’s confusing. It’s really taking different angles and views to try to elucidate a problem. Sometimes they will do what’s called a magnified view where they try to focus in on the troublesome spot that was seen on the screening.

So if they magnify it perhaps see it better. Or maybe in magnifying it something that is an overlapping shadow spreads out and goes away. So, the diagnostic is a workup and often supplemented then by ultrasound to see if there is something cystic or solid that might match the mammographic finding. And following that, beside ultrasound there is MRI so not meant for routine screening, but MRIs are very sensitive and for screening would have too many false positives, so many unnecessary biopsies, but can be a very useful tool when standard mammogram and an ultrasound fail to resolve something.

Host: Wrap it up for us Dr. Blumencranz with your best advice as the expert that you are; what would you like women to know about mammograms, the importance of screening and knowing our risk factors whether it’s genetic or lifestyle or any of those reasons. What would you like us to know about the importance of early and regular screenings?

Dr. Blumencranz: Well there’s no substitute for it. if we can find cancer early, we are finding it at a time when the cure rates now are in the range of 95% and you can have a simple outpatient procedure like a lumpectomy with a lymph node sampling, not radical surgery, in and out of the hospital the same day. So, clearly an advantage with way better survival. I think the other thing I like to tell patients though is how do you modify your risks? Some things you can’t change. If you have mutations, well that’s just in your genes. Other risk factors that you can’t change are when you have your first period or when you start your menopause. All of which relate to hormonal levels and how long you are expressor exposed to hormones.

But there are some things that one can do, and this is for both patients who haven’t had breast cancer as well as breast cancer patients. One of the big ones is obesity. There is a clear linkage between being overweight and both getting breast cancer and breast cancer recurrence. Physical activity, that is getting your target zone, good physical activity can lower risk very nicely. Alcohol consumption. You need a low alcohol consumption for the link to increased risk. Smoking cigarettes, increased risk. We touched on hormone replacement therapy, not meant for long-term use. And then some of the things would be environmental exposure whether it’s to some type of radiation or chemicals which you might be able to modify. The other issue just to mention briefly is that some patients for some reason like having maybe a lymphoma had radiation to their chest wall area when they were young, and they do have high risk for breast cancer some 25 years later and we need to know that important history.

Host: Do you have any final thoughts you’d like us to know?

Dr. Blumencranz: I think this is a good chance for women to take care of themselves and hopefully they will live a long and healthy life even if they get breast cancer, most patients survive and that’s the best take home message. Most patients survive it.

Host: That is an excellent hopeful take home message. Thank you so much Dr. Blumencranz for joining us today and sharing your incredible expertise. That wraps up this episode of BayCare HealthChat. Head on over to our website at www.baycare.org for more information and to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other BayCare podcasts. Until next time, I’m Melanie Cole.