Nolan Alexander (Host): In 2025, an estimated 316,950 new cases of invasive breast cancer will be diagnosed in women in the U.S., plus 2,800 men will be diagnosed with breast cancer, making it the most common cancer diagnosis overall.

Today, we'll engage with doctors from Holy Cross Health in Fort Lauderdale in a panel discussion on breast cancer. They'll highlight the latest advancements, treatment options, and preventative strategies.

Welcome to Thrive with Holy Cross Health. I'm Nolan Alexander. And today, joining me from Holy Cross Health in Fort Lauderdale, our breast surgical oncologists, Anouchka Coste and Jessica Burgers. Doctors, thank you so much for joining us today. How are you both?

Anouchka Coste, DO: Great. Thank you.

Jessica Burgers, MD: Good morning. We're doing well. Thank you for having us on today.

Host: Breast cancer has been around since ancient times, but its prevention and treatment continue to progress. I'm curious, what are the latest advancements in breast cancer screening and how have they improved early detection rates? And we'll start with you, Dr. Coste.

Anouchka Coste, DO: Some of the new, I think, technology that's kind of helped us a lot is contrast-enhanced mammography, which is making it easier for women to get imaging. Before, we would have to do MRIs for pretty much everybody if we weren't sure, or we needed to look at the entire breast in its entirety.

So, contrast-enhanced mammography has also assisted us, and earlier screenings, high risk screenings are a couple things. Getting people who are at risk for breast cancer in for screening sooner at an earlier age has also assisted us in diagnosing cancers earlier, and even preventing them with prophylactic mastectomies.

Jessica Burgers, MD: You mentioned the idea of high risk, and I think it's important to define that. We always talk about screening and how important early detection is. And typically, we recommend mammograms once a year. But there are patients who either have strong family history or risk factors from different things related to their hormonal exposure in their life, other environmental exposures that increase their risk compared to the average woman.

Average risk of breast cancer is one in eight women will develop breast cancer in their lifetime, but everybody has an individual risk calculation that can be derived by your physician. And I think that it's important that our women understand that they may have a risk that is higher or maybe a risk that is lower. And by understanding this, we can utilize supplemental imaging studies like contrast-enhanced mammography, breast MRI, blood tests like genetic screening in order to tailor how we improve early detection in these women.

Host: I want to come back to the thought of genes here in just a moment, but I am curious what are new treatment options for breast cancer that have emerged over the past few years?

Jessica Burgers, MD: As surgical oncologists, a lot of our focus is on the operative management of breast cancer, but we work in multidisciplinary settings. And there have been a lot of new treatments and immunotherapies, targeted therapies. But from the standpoint of surgery, I think, you know, we continue to refine our surgical techniques in order to keep patients more whole. Something that is becoming more and more common is the utilization of nipple-sparing mastectomies, or the ability to actually keep the colored portion of the areola and nipple at the time that we're removing the breast.

Another surgical opportunity is oncoplastic surgery. Onco being cancer, plastic being reconstructive or basically like doing a breast reduction at the time of a lumpectomy. This allows us to do bigger lumpectomies or breast-conserving surgeries. And again, the idea with both of these surgical options is to try to keep the patient looking as much like themselves after they've finished the surgical operation or the surgical part of the treatment. Dr. Coste, do you want to add anything?

Anouchka Coste, DO: I mean, I think both you and I utilize oncoplastic fairly often, because having cancer is a pretty jarring thing for most women. And the immediate thought that most women have is that "I have to have a mastectomy," and that's not always the case. We've gotten so much better with our surgical techniques. And with oncoplastics, you know, let's say patient has a cancer in the nipple, we can remove the nipple and do nipple reconstruction, and just preserve the remainder of the breast.

So I think, it's not what it used to be anymore. The surgical treatment becomes more personal, because we have therapies that can shrink the tumor and we can save the breast. and I think, you know, most breast surgeons now are going for saving the breast as much as possible, because there are no added benefits to having mastectomy unless, you know, you as a patient just decide, you know, "I don't want to have to do a mammogram" or "I don't want to have to consider this in the future." So, I think there are just more options for patients now with regards to their care.

Host: We can certainly understand the personal benefits. But most importantly, how are the latest targeted therapies improving survival rates for breast cancer patients?

Jessica Burgers, MD: So, Dr. Coste started to allude to shrinking tumors and you know, our old paradigm with treating breast cancer was that the surgeon usually would be the first step in treatment. But now with better and better therapies and targeting specific features on the tumors, we can shrink these down significantly, which not only improves the surgical outcomes, potentially allowing for less surgery, potentially allowing for less side effects or consequences of the surgery, but also improving overall survival and outcomes in the long term. So again, this is where we work very closely with our medical oncologists whenever we're faced with a patient with breast cancer, looking at all these fine details to decide, you know, is this one where surgery is the first step, or maybe surgery is better as the second step given the advancements that we've made.

Anouchka Coste, DO: To add to what Dr. Burgers just said, there were certain cancers that used to be kind of almost a death sentence to patients, whereas now we have immunotherapies specifically for triple negative disease that can essentially shrink the tumor completely and basically remove the cancer before we even get to the operating room. So that way, patients have better outcomes, longer survival outcomes, and just better all quality of life.

Host: That's interesting. I'm curious more about your thoughts on immunotherapy. What's new for breast cancer and how does it differ from traditional treatments?

Anouchka Coste, DO: Immunotherapy specifically Keytruda is not only used in breast cancer, but it's used in a couple different arenas in the oncology world, but that specifically has improved survival rates for patients. It is given to the patient preoperatively generally, and then sometimes, you know, within a year afterwards for the patients. We have also biologic therapy such as HER2 treatments such as pertuzumab, which also are given preoperatively and adjuvantly after they receive their surgical treatment. So, that has been around for quite some time. But the Keytruda is fairly, you know, new in the past five, 10 years, has come on the scene and kind of changed the outcomes for those patients quite significantly.

Host: Dr. Burgers, earlier you talked about genes. How has the knowledge of genetic factors in breast cancer evolved recently? And what does this mean for family members of patients?

Jessica Burgers, MD: So, the classic genes that we think of being associated with cancer are the BRCA genes, BRCA1, and BRCA2. And the initial genetic linkage that we realized could be a contributing factor to breast cancer and ovarian cancer syndrome. But nowadays, when we do genetic testing, we actually do what we call panel testing. And now, we understand that there are multiple genes that can be associated with a variety of different types of cancers. Genetic testing is looking at the genes that you were born with, basically to see if the genes are abnormal, meaning that our cells are constantly dividing, they're constantly replicating, and we're constantly getting little errors in our cells. We have mechanisms in place in our cells to repair these abnormalities as they come up. But some people, when they're born with abnormalities and these basically repair genes, these errors accumulate more frequently. And in those accumulating more frequently, then these are the errors that ultimately lead cells to behave badly and become cancerous cells.

And so through blood testing, we can see if these genes are not working properly, and we can have a statistical prediction of what we think a patient might develop certain cancers. And from that, we have recommendations, guidelines, protocols on how we can reduce that risk. Sometimes reducing that risk is just being more vigilant, earlier detection, increased imaging, but sometimes reducing that risk could be surgical, removing the breast tissue before it ever has the opportunity to gain these cells that become potentially cancerous.

Host: That certainly seems so advanced. Back to basics, what role do lifestyle and dietary changes have in reducing breast cancer risk? And have there been any recent findings?

Anouchka Coste, DO: I tell my patients the same thing. It's literally the only thing you have control over. There's been major studies that have looked at exercise, even post-treatment, that have reduced the risk of cancer. So, weight training exercises, cardiovascular exercises, reducing the amount of weight also reduces their risk of breast cancer.

 Additionally, smoking, drinking, we know, you know, anywhere from one to three drinks a week can increase your risk by 15%. So, minimizing the amount of alcohol consumption. Another big thing I tell my patients is that getting enough sleep actually has also been proven to reduce your risk of cancer. So, making sure you're getting that good R&R time is actually pretty important, believe it or not. because it allows your cells time to regenerate, repair themselves if you don't have that time. Like Dr. Burgers was saying, there are more errors that can be made in gene function.

Jessica Burgers, MD: So, you know, it's the things that we know that we're supposed to be doing in our lifestyles: eating a healthy balance of vegetables, lean proteins, sleeping well. But I think a lot of press has come out recently about the risk of alcohol. I think that we're starting to understand more and more the linkage of alcohol, particularly with breast cancer, but even other malignancies. And so, I think that's, you know, a very hopefully easy lifestyle choice for people to start to implement, is just cutting down the number of drinks per week.

Host: That's all so insightful. Thank you so much. What are the current guidelines regarding mammograms and how might they change based on recent research?

Jessica Burgers, MD: So, there are a number of different societies that implement guidelines for screening mammography. And sometimes this can be confusing for patients depending on which type of physician or specialist they're seeing, because of these varying guidelines. Dr. Coste and myself, we belong to the American Society of Breast Surgeons, and our organization recommends starting mammographic screening at the age of 40.

Up until recently, one of the national guidelines, which was the U.S Preventative Task Force, actually said to start at 50. But they've recently changed their guidelines down to 40 as well. And this is because particularly in minority populations, breast cancers can present earlier. So, 40 years old is usually the age to start, and we would recommend doing mammography once a year. And that is up until a patient has about a life expectancy of 10 years. The idea with mammograms is we're trying to get lead time, and when we can determine when our intervention will impact long-term survival. And so if we can find breast cancers basically 10 years ahead of when they will impact a patient's longevity, this is the thought process behind continuing up until we think that a patient has about 10 years left in their life, and that's when there's continued benefit from screening.

Host: To wrap it up, if there's one thing you would want us to remember or think about when it comes to overall breast health and self-awareness, what would it be?

Anouchka Coste, DO: I would say start at 40 or younger, depending on if you have a family, a first-degree relative that had breast cancer 10 years before they did. Just go see your primary care doctor and let them know you want to see a breast surgeon if you're concerned about your risk of breast cancer, and just keep getting screened.

Every year is good. Every year feels like it's good and everything's normal. So, just keep doing it, because we want to see more of those negatives instead of anything positive. So, the earlier we find it earlier, we can treat it. And like you said about breast awareness, I recommend that. There's a lot of push for self breast exams. But I think more importantly, just women becoming familiar with their breast and knowing when something's different and saying something to their providers about it.

Jessica Burgers, MD: In my previous comment, we were talking about screening in general population. But as I alluded to before, there's this group, the patients who are at hight risk. I echo the sentiment that I think it's important for women to understand that there are different levels of risk and there are ways to actually calculate these. There are programs that exist to the general public. The risk score that we typically use is called the Tyrer-Cuzick score.

There's another thing that's called the Gail model or the NCI model. And these are things, like I said, they're accessible to the general public. But you should meet with either a gynecologist or even better would be a breast surgeon to help translate that for you. But I think understanding your individual risks just empowers patients to be vigilant about their long-term breast health.

Host: Doctors, thank you so much for your insight and your time today. We really appreciate it.

Anouchka Coste, DO: Thank you. No, I appreciate it.

Jessica Burgers, MD: Thank you.

Host: That was Doctors Anouchka Coste and Jessica Burgers. For more information, go to holycrosscancer.com. If you enjoyed this podcast, please share it on social media and check out the entire podcast library for topics of interest to you. And this is Thrive with Holy Cross Health. Thanks for listening and have a great day.