Melanie Cole, MS (Host): According to a recent story in the New York Times, death rates are declining among U.S. women with breast cancer, but the disease is turning up more often in women under the age of 50. What's the story behind these statistics? We're talking about that today on It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. And joining me is Dr. Amanda Woodworth She's the Medical Director of Breast Health for the Henry Mayo Newhall Hospital and Keck Medicine of USC Cancer Program. She's a fellowship-trained breast surgical oncologist and certified in Cancer Genetics and Risk Assessment with a focus in high-risk screening.

Dr. Woodworth, thank you so much for being with us today. I'd like you to start, before we get into the topic, telling us about yourself and your expertise in this topic, because you have a lot to share.

Amanda Woodworth, MD: Thank you very much for having me, Melanie. And yes, this is a topic I'm extremely passionate about. I've been treating breast cancer exclusively for almost 15 years and really have gotten to see what a lot of the trends are that are happening in breast cancer and diagnosis. And the longer I've been in it, the more my goal is to hopefully be out of a job someday. I would love if we could prevent breast cancer altogether. And a lot of my work has actually led me to ultimately become part of the American Cancer Society National Breast Cancer Roundtable since its inception in 2022. Just recently, I was actually named as the chair of the Risk Assessment, Risk Reduction, Prevention, and Early Detection Task Force. So, this is something that I'm really trying to work on, on a national level to really get to the bottom of what's going on and how can we prevent it.

Host: How cool are you, Dr. Woodworth! My goodness. So, you're truly the expert. And as we discussed in the intro there, as I said in the intro, there's a rise in incidence of breast cancer. But there certainly has been a decrease in deaths from breast cancer. But when we talk about the rise, a lot of that is in women younger than 50. So, I'd like to start, before we get into that, about screening. Speak to us a little bit about how screening has evolved and changed over the years. Are more women getting screened? Has awareness campaigns-- have they really made a big difference?

Amanda Woodworth, MD: Oh, I'm so glad you asked that because the most recent data actually just came out from the American Cancer Society and really looking at a lot of this. And a lot of what we've looked at is disparities in breast cancer treatment. And one of those largest disparities in the past has been African American women compared to everybody else being diagnosed with more aggressive later stage breast cancers and actually having a higher mortality rate.

And what we've seen is because of the campaigns that have been out there, actually now African American women are better than any other racial group at getting their mammograms. As a result, the mortality is actually decreasing in Black women. So, right there is proof that as long as we do raise the awareness and make sure that women are getting their mammograms, then we can actually do much better in preventing breast cancer deaths. That recent data also just showed us that although we've seen great improvements with Black women, actually we're seeing a rise in Asian American women as well as, Native American women. And the Native American women are the ones that are not getting their mammograms. So really, we really need to be raising this awareness throughout so that women are getting screened appropriately.

Melanie Cole, MS: We could do a whole podcast just on those disparities and access and even the cultural norms that might be looked at as a reason for some of those disparities. But setting that aside for just a minute, let's talk about risk and how we are looking at high risk as an earlier screening tool, really tell us a little bit about risk and you have a focus in cancer genetics. So, speak about risk and when you see a mother that's had or the BRCA gene mutation, how that might inform some of the clinical decisions about treatment and looking at the rest of the family members.

Amanda Woodworth, MD: Absolutely. So, first of all, it always never ceases to amaze me the moment that a woman is diagnosed with breast cancer, she's immediately worried about her children every single time. And so really, this discussion about genetics becomes very, very easy because that's what women, the moment they're diagnosed is what they're thinking of is, "Oh, no, what is the risk for my children?"

When it comes to cancer genetics, we've really come up very, very far ways. It used to be only if you're under the age of 50, at the time of diagnosis, could you even be offered genetic testing? And now, those indications have blown up. In fact, the American Society of Breast Surgeons believes that all women who have been diagnosed with breast cancer should be offered genetic testing. Those are actually guidelines that I've been working with for over the last decade. Even the other guidelines are all changing all the time. So for women out there who were previously diagnosed with breast cancer or have a family history of breast cancer that had been told in the past that they don't qualify for genetic testing, talk with your doctor again, because you may very well qualify for genetic testing.

And as a plug, I've got to say this, Sheila Veloz has started an amazing program that they've been working for since 2020 now, that all women who come in for a screening mammogram are automatically sent an assessment to see if they qualify for genetic testing. And if they do, they're taken through videos and pre-test education so that when they come in for their mammogram, they can literally, I call it a squish and spit, they can get their mammogram, get squished and then spit in a tube and have genetic testing sent off. So, it's an amazing program that we literally presented at the National Comprehensive Cancer Network Annual Conference last year to talk about the great screening that we've been doing. So, genetics is a huge part of cancer screening.

Melanie Cole, MS: Squish and spit is awesome. Can I just say that that is so awesome? And we're learning more and more about not only the BRCA gene mutation and its relationship to breast cancer, but also to prostate cancer, to other cancers. And boy, we're sure learning a lot. It's kind of an exciting time in cancer genetics. But as we look at the younger generation coming up with some of these cancers, some of them are in their reproductive years. Under what circumstances, Dr. Woodworth, would someone in their reproductive years, maybe even pregnancy, or postpartum, be looking at testing, screening, that sort of thing?

Amanda Woodworth, MD: when it comes to genetic testing, first of all, you are born with the same genes that you're going to die with. So, I really highly recommend that all women should really start to make sure they understand what their family history is. And if they potentially have a family history, not just breast cancer, but any woman with a family history of ovarian cancer, pancreatic cancer, those are automatic qualifiers. It doesn't matter what age that they had those diagnoses. But also, obviously, you know, we always talk about prostate cancer now in addition to breast cancer, and then colorectal cancer. That's a whole 'nother podcast. But any large number of cancers in your family, which by large it's more like two to three family members you could qualify. So, please don't just wait until you're reproductive years because I will tell you, I personally hate doing genetic testing on someone who's pregnant. Because you're not going to do anything about that mutation at the time of their pregnancy, but then they spend the next nine months just thinking about what mutations are they handing on to their child. So, it's always good to think about these things well ahead of time. And I want to make sure, Melanie, that, I tell you, it's not just the BRCA gene anymore. We've really discovered a whole spectrum of genetic mutations that can put people at increased risk not just for breast cancer, but other cancers. Pancreatic cancers become one of my favorite things to screen for because we actually have screening tools available to people that have genetic mutations that can put them at increased risk for pancreatic cancer as well. So, we're really going to be changing the face of many cancers.

Host: So, there's genetic screening, and then there's also mammograms, and tomosynthesis, and ABUS, and ultrasound, MRI. Give the listeners a little lesson here in some of the screening modalities that are available and why you might send somebody for an ultrasound as opposed to just a mammogram.

Amanda Woodworth, MD: Thank you. Yes. So, the American College of Radiology actually recommends a risk assessment starting at the age of 25. So, that, you know, kind of, I had mentioned that we should be thinking about this at an earlier age. So, that really means taking a look at, you know, the family history and when did you start periods, when did you stop, age at first pregnancy, all these things that can really tell us, you know, kind of what was your hormonal exposure to come up with a number for what is your risk for developing breast cancer. We recommend, if you do not have a genetic mutation, that all women start screening at age 40. However, if you have a family history of breast cancer, you should start 10 years younger than the youngest family member with breast cancer. So for example, if mom had breast cancer at 45, you should be starting at 35. Also, if mom had breast cancer at 45, you should be getting genetic testing if she had not had testing to make sure you don't have a genetic mutation.

 if you have a genetic mutation, we have very specific guidelines to that genetic mutation to know when you should start. When I say starts screening, that means with mammograms. So, mammogram is still the best tool that we have for detecting the earliest sign of breast cancer. if we could catch every woman at stage zero breast cancer, no woman would ever die of breast cancer. And before we had mammograms, we didn't know that stage zero existed. So, we really need mammograms.

But then beyond that, for women that have dense breast tissue, dense breast tissue shows up as white on a mammogram and so do masses. So, you could have a small mass that's hidden in dense breast tissue that we may not see. So, we start looking at those women saying, we need something else other than just mammograms. We still need mammograms because nothing else shows microcalcifications, which can be the earliest sign of breast cancer. But we need to also try to look for masses as well. And so, that's a big place where we really look at that risk assessment. For anyone whose lifetime risk is greater than 20%, it's recommended that in addition to annual mammogram, they're getting annual MRI. And we usually like to stagger those so that the breasts are being screened every 6 months. So,. Mammogram maybe in January, MRI in July. And then, they should also be followed by a high risk specialist, which that's what I do, so that they're getting a clinical breast exam twice a year. Then, we also talk about potential risk reduction techniques.

But the most important thing is really understanding what is your risk. And that's actually something that we're currently doing with the American Cancer Society is to figure out what is the best risk assessment tool that we have that we can really make available to the public in a much easier way. And so, that's kind of what we've been doing in the background as well, because not everyone is the same, so we probably shouldn't be screening every woman the same.

Host: Wow. You have so much expertise and so much great information. It's so educational listening to you, Dr. Woodworth. Now, God forbid a woman is diagnosed, what does she do next? To whom does she turn? Because that is a dizzying, confusing, very scary time and those are words nobody wants to hear. So, what's your best advice if someone is freshly diagnosed? What do you tell them to do first?

Amanda Woodworth, MD: and I'll tell you, we are so blessed here at Henry Mayo that we have an amazing nurse navigator that is right there over in our breast center at Sheila R. Veloz Breast Center, that that's usually the very first point of contact that they have that will help them to get set up with an appointment, to be able to see an expert like myself, to really talk them through their diagnosis.

But the most important thing I always say first is don't panic. I mean, fortunately, we have a lot of experience. I guess I should say, unfortunately, we have a lot of experience in the treating treatment of breast cancer, and we've gotten really good at it, honestly. I know it's a terrifying diagnosis, but not every cancer is the same. And as soon as somebody is told that they have a breast cancer, that doesn't necessarily mean that we know every step of the treatment at that time. Once we diagnose someone with breast cancer, we actually look for very specific proteins on their cancer cells. I call it the flavor of the cancer. People may know them as the estrogen receptor, progesterone receptor, or HER2/neu receptor to really know what kind of treatment is that woman going to need. So, I think the most important thing is to get an appointment with an expert so that they can really take a look at your cancer and figure out what is the best treatment course, because it varies depending on the cancer type so much.

And not everybody's cancer is the same. So, you know, you hear things from your friends that tell you exactly what you need, but their cancer may have been different than what yours is.

Melanie Cole, MS: What great advice you're giving us here today. I'd like your final thoughts, Dr. Woodworth, to listeners, viewers. What would you like them to know about screening, especially when there's a hereditary factor going on in the family for younger breast cancer survivors? We're seeing this rise in incidence. Offer your best advice to us here.

Amanda Woodworth, MD: the most important thing is to fully understand your risk. The ostrich effect does not work. Don't bury your head in the sand. Ask to speak to a specialist. There are many providers like myself that have started to work in high risk screening to make sure that we're screening you appropriately. Ask your provider where can you go to get an adequate risk assessment and to know what is the best screening for you because not everybody is the same. And by pretending that that family history doesn't exist or the things that you're afraid of don't exist, it doesn't work. That's not how we work to prevent breast cancer. It's really important to understand your risk, embrace it, and make sure that you're doing the appropriate screening for you.

Melanie Cole, MS: Thank you so much. Dr. Woodworth, what a great guest you are. And if you're due for your annual mammogram, you can always call the Sheila R. Veloz Breast Center at 661-200-1099, or you can visit sheilaveloz.com. You can also always visit the Henry Mayo Newhall online library, which is free, and that's library.henrymayo.com, for so much great information. Thank you so much for joining us on It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole, and I'm so glad you were with us today.