Prakash Chandran (Host): Breast cancer is one of the most common forms of cancer globally, impacting millions of people. The good news is that detecting breast cancer early increases the chances that treatment will be a success. But how do you know when to get screened and what does the process look like? Joining us to discuss is Dr. Sharon Noori, a breast surgical oncologist with the Health First Medical Group.

This is Putting Your Health First, a podcast by Health First. I'm your host, Prakash Chandran. So, Dr. Noori, thank you so much for joining us today. I really appreciate your time. I wanted to get started by asking, "What exactly are the risk factors that increase your chances of developing breast cancer?"

Dr. Shahrbanoo Noori: Hello. Thank you for having me. So, the main risk factors for a woman to develop breast cancer in her lifetime is foremost gender, being a woman; and then, the second is age. So, most of the risk factors are unfortunately out of a patient's control. It's a multi-factorial assessment. It includes previous GYN history, previous breast biopsies, family history, obesity, alcohol consumption. But for the most part, again, it is out of a patient's control.

Host: Understood. Now, you mentioned gender and age. Out of curiosity, are you just saying that as a patient gets older, they're more susceptible? Or is there a certain age where they become more susceptible?

Dr. Shahrbanoo Noori: We see the rise in incidence of breast cancer in women after the age of 40. And that continues to increase for women in their 50s and 60s. And then, eventually, we do see a decline in patients after their 70s. Although, since we are living longer, we do diagnose breast cancer in women beyond the age of 70s, even into their 90s.

Host: Got it. So, you know, I think we're talking today about screening and testing. What testing options can determine your breast cancer risk?

Dr. Shahrbanoo Noori: There are algorithms or calculations available that we can use if we think that a patient may be at a higher risk of developing breast cancer than the average population. So, the average population, the risk is approximately 1 out of 8 women. If we are screening someone and we think that they may be at an increased risk of that, then we can use these online tools that takes into account their age, their GYN history, their family history, breast density, previous biopsies. And if that calculation yields a greater than 20% risk of developing breast cancer, then that patient is considered a high-risk patient where we offer more frequent or advanced screening or even prophylactic surgeries.

Host: So, we know that given some of the factors that you spoke about, like family history, GYN history, that if you put in those inputs, it'll tell you like, "Hey, are you at high risk?" And if that is the case, then you can be more proactive about help.

Dr. Shahrbanoo Noori: Yes.

Host: I'm curious, like are there certain signs and symptoms that people should be aware of that kind of lead to breast cancer or tell you that you might have an onset of it?

Dr. Shahrbanoo Noori: Well, so physical findings commonly associated with breast cancer are a palpable mass, so a lump; changes in the skin, presence of pulling or retraction of the skin and/or the nipple. However, we prefer that we diagnose on imaging. So once there is clinical or physical evidence of a mass, it's typically a larger mass than we would have preferred to diagnose. So really, the goal of breast cancer screening is to catch it on a mammogram versus an exam.

Host: Okay. And speaking of mammograms, I mean, I've heard this question asked before, you know, when is it too early to get a mammogram? How old does someone need to be? Can you speak to this?

Dr. Shahrbanoo Noori: Yes. So, the average risk woman should start screening mammogram at age 40. And this would continue on an annual basis. Really, we have not set an upper limit age to when you should stop. It really does depend on a patient's other medical problems. If a patient is considered a high-risk patient, so those are typically ones with a significant family history of breast cancer. And when we're talking about family history, we really do focus on first-degree relatives, so that would be mother or sister, or someone who has a known genetic mutation, then those are the ones that we may start earlier than 40.

Host: Okay. Understood. What about people without a family history and they're just kind of concerned, can they elect to get an early mammogram?

Dr. Shahrbanoo Noori: You can choose. However, that the problem with getting images done earlier is that a young woman is expected to have hormonally active breasts. So, that may cause confusion on an image where it would lead to additional and likely unnecessary imaging and biopsies and procedures. So, that's what we would like to avoid.

Host: Understood. So, what would be your recommendation if someone is like, "I want to potentially elect for this early," do they just go to their primary care? Is there kind of that algorithm calculator that they can go to online? Where should someone start if there's a concern?

Dr. Shahrbanoo Noori: Yes. They would start with their primary care or GYN. But again, we typically do not encourage women to start screening mammography earlier than 40 if they're considered average risk. Now, if a woman presents with a specific problem, a new onset of a mass, again, skin, nipple changes, that's not considered someone who would benefit from screening. That is someone who would need to undergo a diagnostic exam. So, that's a different category. But if a woman has no new breast problems or symptoms and just wants to start screening mammography earlier than 40, that's typically not encouraged.

Host: Okay, understood. I want to talk about the mammogram itself. I have heard before from some of my friends, actually, that sometimes it can be painful. Can you speak to the mammogram and what the process is like?

Dr. Shahrbanoo Noori: Sure. So, the mammogram, a screening mammogram, typically the process will take 10-15 minutes, where they are usually taking multiple images of each breast at different angles. There is compression or squeezing of the breast involved between two plates. And some women have more breast tenderness in general than others. So, those women may consider the exam painful. The compression itself is not for 15 minutes, so you're not under compression for that period. The compression is usually only for about, you know, maybe 20-30 seconds each time. The process takes a bit longer. And just to make sure that the technician has obtained adequate images, sometimes there has to be repositioning of the breasts to include more tissue. So, that's what is involved in the process. You know, I usually say, yes, I can understand that mammogram can be painful, but they are the forefront of breast cancer screening. And it's largely due to advances we've made in imaging why we have been so successful for breast cancer treatment.

Host: Yeah, absolutely. I know it's the gold standard to really bolster that early detection. And 20 to 30 seconds of discomfort, I'm sure, is a lot better than the alternative.

Dr. Shahrbanoo Noori: Right. Well, it's 20 to 30 seconds at a time while they're taking that specific angle. So, it may be longer than that.

Host: Okay, understood. Thank you for the clarification. What about cost? Are mammograms expensive?

Dr. Shahrbanoo Noori: So, most insurances will cover screening mammography after the age of 40, so that's part of the well-woman checkup. I was able to pull up self pay, so that's $125, which is what we quote patients. That's again just for a screening mammogram. So if we have to get additional or diagnostic images, an ultrasound, those are more costly. But if a woman after the age of 40 just wants to go in and get a screening mammogram, she doesn't have access to insurance, then probably that's the written cost, although there's always exceptions where it may end up being cheaper.

Host: Now, you know, I am curious, after a mammogram is done, What are the most common issues or breast health issues that come up? I know there's obviously the range there, but maybe you can speak to that.

Dr. Shahrbanoo Noori: So usually, if a patient undergoes a screening mammogram, especially if it's the first one or it's been a while where we do not have prior images to compare, it may identify a mass or an area of asymmetry or distortion. So then, the next step would be to bring the patient back for diagnostic images. That usually includes focused magnification views of the breast, so more mammograms, and perhaps the use of ultrasound or sonography to better define this area of question. The majority of time when a patient has an abnormal mammogram and they come back for additional diagnostic images, that area ends up being benign, so no additional followup is necessary.

Host: Okay. Understood. In the case that there is a followup and something is detected, you know, what are the next steps? I know that you said there's kind of the diagnostic piece where they go in for more mammograms, magnifications, but if it's determined like, "Hey, there's something here," what happens next?

Dr. Shahrbanoo Noori: If a mass or region of breast is considered suspicious for malignancy, then the next step is typically setting that patient up for a core-needle biopsy, which is typically performed by a radiologist. So, the same type of doctor that will read and evaluate your imaging, your mammogram, is the one that will perform the core-needle biopsy. So, the core-needle biopsy will use image guidance, whether that's mammogram or ultrasound, even MRI, to pinpoint that area in question and take pieces of that tissue out for diagnostic purposes. So, that's the standard of care. We do not typically go straight into surgery. We like to know what it is we're dealing with up front because the management, the surgical options and treatments depend on that pathology.

Host: Okay. And, you know, because you're speaking about it, I understood that there's a lot of pre-work necessary before you get into these different treatment modalities. What are the different treatment options that are out there? Maybe you can speak to them at a high level and then we can dig into it.

Dr. Shahrbanoo Noori: Sure. So, breast cancer treatment in general is performed in what we call a multidisciplinary setting where there are multiple individuals involved. So, I serve as the surgical oncologist. There typically is a radiation oncologist and a medical oncologist. So, we each have been given the task of doing a specific job. Sometimes what we offer and do overlaps. But what we have found that when we tackle cancer from different angles, It increases our success rate of treating the cancer, but also reducing the risk of it coming back because it is twofold. You want to get rid of the cancer at the local level, in this case the breast, but you also want to decrease the risk of metastatic potential of it coming back somewhere else.

Host: And what are the positives and negatives to keep in mind when considering some of these different options, especially, you know, breast-conserving surgery versus a mastectomy?

Dr. Shahrbanoo Noori: I think it's really important for the patient to understand that we do not treat every cancer in the same way. Really, we have developed these sophisticated assays and testing to try to individualize treatment. We don't want to overtreat and we don't want to undertreat, so the treatment is really individualized to the patient and their cancer.

The benefits of breast conservation therapy is that we are able to, obviously, save the breast. The cosmetics are much more desirable in most cases than what we're able to do with a mastectomy. But also, what we have proven over decades is that for your early stage breast cancer, a lumpectomy typically with addition of radiation, gives us the same overall prognosis and survival as a mastectomy. So, a lumpectomy with radiation is not an inferior treatment. It's just as good as a mastectomy.

Host: Yeah, that's interesting. Actually, we have a close family friend who at 74 got the mammogram, had been doing it yearly, got diagnosed and, you know, was offered kind of this lumpectomy and radiation. And it was like, "Well, why is a mastectomy not something that they would offer me?" But I think to your point, it's highly individualized and, you know, that combination, it seems to be just as effective. So, I think what people need to understand is that, like you said, there's multidisciplinary, there's a unique approach depending on the type of cancer and you're going to work to really evaluate what's best for the patient.

Dr. Shahrbanoo Noori: Right.

Host: Okay. Now, the last thing I wanted to speak about is just kind of the emotional and just mental state when you are given a cancer diagnosis. There's obviously a lot of anxiety and overwhelm. Are there mental health resources or professionals that you can recommend if someone, you know, needs help processing?

Dr. Shahrbanoo Noori: So, unfortunately, we don't have a specific person as part of our Health First Cancer Institute. That is something that we have discussed over the years to be able to offer that very important piece of the journey. In general, I do give patients names and resources for support groups, because sometimes they're aware of resources that I may not know from a clinical standpoint.

What I will say is that, you know, my team here, I have a fairly large team, and we offer a nurse navigator and we try to be here for the patient throughout each steps because it can be very overwhelming. It's very important to have that support group. But I do advise patients to be careful of all the information that they may get from outside sources, especially the internet, especially social media, because there are a lot of misconceptions out there regarding breast cancer treatment. And so, you just have to be careful of where you go for those resources and that information as well.

Host: Yeah, absolutely. That's good advice. Last thing I always like to end on is, you know, given all of your years of experience, you know, working with patients with breast cancer, what is one thing that you know to be true that you wish more patients knew?

Dr. Shahrbanoo Noori: Getting that mammogram done.

Host: I think that is simple, to the point and really poignant advice, right? Like it's something that really can be this prevention mechanism of really just going in and being proactive really saves lives. So, Dr. Noori, thank you so much for your time. Very much appreciate it.

Dr. Shahrbanoo Noori: Absolutely. Thank you.

Host: That was Dr. Sharon Noori, a breast surgical oncologist with the Health First Medical Group. To schedule an appointment for a mammogram, you can visit hf.org/schedule or you can call 321-434-6100. You can also learn more at hf.org/breasthealth. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library of topics of interest to you. My name is Prakash Chandran. Thanks again for listening to Putting Your Health First. Be well.