Maggie McKay (Host): Welcome to Wellness in Reach, a Mount Carmel podcast. I'm your host, Maggie McKay. Joining us today is Dr. Shilpa Padia, breast surgical oncologist, to discuss breast cancer awareness. Thank you so much for making the time to be here.

Shilpa Padia, MD, FACS: Thanks for having me. I'm excited.

Host: So, let's start with the basics. Can anyone get breast cancer? And who is most at risk?

Shilpa Padia, MD, FACS: The answer is mildly surprising, but anyone can get breast cancer, even men. The risk of men getting breast cancer is much lower than a woman, but it's not impossible. So, to answer your first question, yes, absolutely anyone can get breast cancer. But the people that are most at risk are, A, being female because we have more glandular breast tissue; but number two, the most common time to get breast cancer is in your 60s and 70s. I feel like there's a big misconception that young women are when breast cancer normally affects people and that's actually the rarity. The vast majority are in your 60s and 70s.

Host: So, what signs and symptoms should people never, ever ignore?

Shilpa Padia, MD, FACS: I'll first start and say that we are really in tune with our own health, and we're probably the best people to know our own health whether you're a man or a woman. And so, I always want to start this—I get this question a lot from patients and I always want to make it known that if you have a concern, you should ever feel uncomfortable to say something. Nothing should ever feel too minor. Does that make sense?

Now, yes, there are a few signs and symptoms that we'll talk about in just a minute that are specific to breast cancer. But have I seen cancers present in non-common ways? Absolutely. So, I think if you have a concern, you should never be afraid to address that to your healthcare provider.

But common things that if you notice in your breasts that could be indicative or more likely a sign of breast cancer, one would be if you have a mass. Now, there are many normal masses in the breasts. Breast tissue is actually made of real lumps and bumps. But if you've noticed a mass that's new, it's definitely something you need to say. And that lump and bump, it feels really hard or irregular, or doesn't seem to move, those are some key factors to get it looked at.

Number two is that sometimes we can get some redness of the skin. It's a very special type of breast cancer, but some breast cancers present more as redness of the skin rather than an actual mass. So, we can't just always think that a mass is going to be the only representation of a cancer for example. Nipple discharge, I get that question a lot. It is not usually related to cancer. But if it's a new finding for you, I would highly recommend it. You want to find a cancer before you can see or feel it.

So, the only way to really try to do that is to get a mammogram every year. Mammograms are meant to find things before you can see or feel them. So, I know we'll probably talk about that a little bit later. But I think from a signs and symptom standpoint, never be afraid to touch your breasts as a man or a woman. If you notice something that's absolutely new, I don't care what it is, I want to hear about it. I'd rather be the one to tell you it's nothing versus eventually it be something and it was put off, right?

So, masses, skin changes, nipple discharge, the last one I will mention is dimpling. Sometimes you can notice like a little pulling of the skin, that can sometimes be indicative of something happening within the breast tissues. So, those would be my four most common signs. But also, if you haven't, if you feel like you have something that feels different or just acts different, never be afraid to say anything to anybody.

Host: Right. Better safe than sorry. Your point about you don't be embarrassed to say anything. And so, what if it's nothing? It could be something. But if you didn't bring it up, you know. So, why is early detection so crucial?

Shilpa Padia, MD, FACS: The earlier it is caught, the less treatment that you need, but also the less impact it has on your survival. So, I see a lot of women, even men, for their pre-biopsy visit. So, you have a mammogram or you feel something, it shows an abnormality, the radiologist is suspicious enough that they want to get a biopsy and so then we get to meet them up front, the way I usually describe it is to kind of talk them off a ledge. Because when you hear you have an abnormal mammogram, then there's a lot of anxiety that comes around that.

And in a very good way, we talk more about breast cancer than we ever did before. So, it's become very popular. So, the unfortunate side of that is you have a story of someone that you've known, a second cousin, someone's been affected by this. And so, there's a lot of anxiety that comes with that.

And so, we see everyone for these biopsy appointments upfront so we can go through what would happen? What, A, do I think this really looks like; B, if this is worst case scenario, what does that mean? Not only what does that mean for treatment, but also what does that mean long term? But my conversations about early detection are so much better because the earlier breast cancer is caught, it actually does not impact your long-term survival. It's amazing that we've gotten so good—and thank you to all the researchers out there that have worked so hard to find it—but breast cancer is a survivable disease. I mean, living 30, 40 years after your diagnosis is the standard now where not even that long ago, about 25, thirty years ago, we were concerned women weren't going to live five years past their diagnosis.

But the earlier it is caught, the less treatment you need, meaning not all cancers need chemo. Even cancers that would traditionally get chemo, if they're caught small enough, they don't need it. So, you're saving yourself potentially from some other treatments such as chemotherapy, radiation, doing a lumpectomy where maybe if it was waited too long, we might have to do a mastectomy instead. But the two sides of that coin are less treatment, but also the long-term effect of having it caught early means that it won't impact your survival.

Host: Thank goodness for mammograms. My goodness. If you stay on top of it once a year...

Shilpa Padia, MD, FACS: Yeah, and that's my soapbox for sure.

Host: Right. I mean, thank goodness, because just think when they didn't even have those. A big question a lot of us have, I think, is when should people start getting mammograms, and how often?

Shilpa Padia, MD, FACS: This is a really good question, because good or bad, there is a lot of information out there and a lot of information from actual medical societies that seem to differ. And so, it's very understandable that patients can have a little bit of confusion on when to start this, because you're getting different recommendations.

So, the thing I will say is that despite all of the different societies that are out there: the American Society of Breast Surgery, the Society of Breast Imaging, American College of Surgeons; all of the main people—American Society of Clinical Oncology—all agree that starting at 40 for the average woman and then annually thereafter.

And so, if you have hit 40, we need to be getting your mammograms. Because if something ever were to be found although 40 is not the most common time, a mammogram has been proven to improve your survival or basically save your life, because it was caught early enough where it won't impact you long term.

So, I would say absolutely 40. Now, women that have a family history or potentially considered to be higher risk, genetics things like that some women actually are recommended to start not mammograms but at least screening at age 25. So, I just basically behoove women that if you have a family history talk to your provider to say, "You know I might be young, but am I at risk at life to do this? Do I need to do something sooner?" But if your average risk for Americans, like we all are than I would say starting at 40 annually.

Host: And are mammograms the only screening tool available, or are there situations where other imaging tests are recommended?

Shilpa Padia, MD, FACS: No screening mammograms are actually not the only test. From a screening standpoint, there are three types of screening modalities. One is a mammogram, two is an ultrasound, and three is an MRI. But there's a very big difference between a screening mammogram, ultrasound, MRI versus a mammogram, ultrasound or MRI that is being done because you found something. That technically is called a diagnostic mammogram or diagnostic ultrasound.

So from a screening standpoint, there has been many studies looking at what combination is going to give us the best view of a breast to ensure that if something were caught, it was caught early. And in the average individual, a mammogram alone is actually all you need. But if you have dense breast tissue; in 2014, it became federal law and state law, it was federal before but became a state law, that you have to alert women if they have dense breast tissue. And that is actually very important. The problem with that, when that happened, was that it didn't have any follow up. It just said you have dense breast issue. And then, people were kind of left on an island to say well—there was nothing to say it was good or bad. It just said "you have it," black and white. That's new. So, how do we know what to do? And so, I spend a lot of time educating women that 50% of the population has dense breast tissue. It's totally normal.

What we know is that dense breast tissue can sometimes hide cancer cells. So for lack of being too simplistic, mammograms are black and white, but there are varying levels of black and white, right? Like, there's gray and soft shell white and eggshell white, all the things. And those varying levels actually matter. But cancer technically shows up white, and dense breast tissue shows up white. So, I've heard one of my favorite radiologists say it's like finding a snowball in a snowstorm. So, how do you do that?

And so, there are new technologies that are getting screening ultrasounds and screening MRIs that are used to help improve visualization of dense breast tissue. And so, what I would say is that traditionally for most women, a mammogram is enough. But if you have dense breast tissue, then we need to consider adding an ultrasound or an MRI, which are done at the same time as your mammogram, read by the same radiologist so that you get the best, most accurate, read and evaluation.

If you're younger, for example, like we talked about in 25 group, mammograms are not recommended till you're at least 30. So in the higher risk group, they are getting MRIs because they can't get a mammogram. I don't know if that makes sense. But the algorithm here—not to be complicated—but is very specific to what age group you fall into.

Host: Dr. Padia, in the last few years when I've gotten mine, they say, "Do you want this extra imaging?" It's like another $40. And I'm like, "Yes, whatever you have, yes, always." But do we all need to do that? And why is that extra and not just part of the mammogram? What is that? It's somewhat new, right?

Shilpa Padia, MD, FACS: that would definitely be like the supplemental screening ultrasound, or the MRI that they were talking about. Most likely your ultrasound because you have—not to be TMI— but that tells me that you have dense breast tissue. And so, if you have dense breast tissue, then yeah, and I do it too. So, I'm part of the 50% of the population that has it. The day of my mammogram, I do my supplemental ultrasound on the same day at the same time; the radiologist reads it live. But no, that doesn't apply to everyone. But again, 50% of the population has dense tissue, so 50% of the population should most likely also be getting that supplemental screening.

Now, the combination of that automated ultrasound with mammogram, with women with dense breast tissue has shown to improve visualization by almost 30% improvement which is amazing. So, the better we are at looking at something, the more accurate we can be in finding something early, which again, early detection is less treatment, less impact on your overall survival.

Host: Speaking of new treatments through the years, how has breast cancer diagnosis and treatment evolved?

Shilpa Padia, MD, FACS: Oh my goodness. So much in like such a short time. You know, when I was in training, which I'm older than I look, but I will say I'm like feel like I'm relatively old here. We did lumpectomies, but I wouldn't be remiss to say that some of my attendings were kind of—you know, women in this situation feel vulnerable, and they want to come to you for what you believe as an opinion, right?

And there were people that would say, "You know, if you were my wife or my mom, I would want you to have a mastectomy." And although that's fine, people listened. But as time has progressed, we very much learned that that isn't always the right answer, and actually having a mastectomy doesn't always mean that anything's ever is actually a better treatment.

You know, one of the biggest myths in breast cancer is that having a mastectomy means that you must have had aggressive cancer or advanced stage. And actually, neither is true; it's personal choice. Women make that decision all the time. And it's based on how they feel in their heart. It's actually very rarely related to anything I have to tell them or any recommendation I have.

But the other side of the coin is that another myth is that having a mastectomy means everything's gone nothing can go wrong, and that's also not true. About 3% to 5% percent of breast tissue is left behind on a microscopic level. So, they are equal whether, you know, one of the advancements has been that we have allowed women to try to save their breasts. We have a way to do that, that isn't less treatment. You know, women aren't making decisions for now, not thinking about the future. It allows them to decide what they want done personally. That's from a surgery standpoint.

From a treatment standpoint, like radiation, radiation traditionally used to be somewhere between six to seven weeks and then went down to four weeks. And now, there's actually certain women that qualify for five days or one week. I mean, it's amazing that we went—and radiation is if, like, for example, six weeks. It's six weeks, five days a week for ten minutes. That's thirty treatments total. To go down to five is really amazing, but that's because of advances in treatment that way too. Same for chemo. Chemo used to be recommended for any woman less than 70 and any tumor that was more than one centimeter, which if we think about a centimeter, that's not very big, right?

So, you couldn't be able to feel that usually. But now, the vast majority of women don't get chemo for any type of cancer. It's just very specific instances. So in general over the last 25 years, there's been huge advancements in surgery, radiation, and chemo. Like, some cancers just seem to advance in one of those three realms, but breast cancer has just like exponentially changed in about 25 years. It's amazing.

Host: That's so encouraging. I know you've mentioned several of them, but just break it down for us, if you would. What treatment options are available today? Just, you know, all the choices.

Shilpa Padia, MD, FACS: No, good question. So, breast cancer treatment is definitely broken down into two main categories: The things that we do to the breast and then the things that we do to the rest of the body.

So technically, the day of surgery is a day that a woman is meant to be cancer-free or a man depending on who we're operating on. But the weird thing about cancer and the unlogical thing about cancer is that even though you can remove it, it can still come back. So, everything we do after surgery is to make sure it never comes back. And we're very good at that, but we really have to be specific on what type of cancer this person has, and then what do we need to make sure it doesn't come back?

So, the reason why treatment is broken down into two major groups is because, after it's removed, we want to make sure it doesn't come back in the breast again. But then, although it's rare, we also have to prevent it from coming back in other parts of the body and that's how we take care of a person as a whole. And so, sometimes radiation is recommended for breast cancer treatment, but that's usually if a woman does a lumpectomy. Because you may not have to remove all the breast tissue, but you at least have to treat it. So, surgery, options in surgery are either removal of the whole breast or a lumpectomy with radiation. They aren't equal like I said one is not better than the other. That's one side of the box is what are the things that we do to the breast.

But then, in order to prevent cancer cells from coming back in other parts of the body, sometimes women are prescribed pills they take a pill once a day for five years. That reduces the risk of cancer coming back. But some very special cancers require some form chemo also to go through their bloodstream. So, some women can get everything; surgery, radiation, chemo, and a pill. Some people, depending on their choice, may actually only get surgery. That's why breast cancer treatment is so different for everyone. There are many algorithms because much research behind it. That is super exciting, because it's not one-size-fits-all. You know, it's great to have a conversation with a woman and lay out your options and say, "You tell me what you feel comfortable with, because you're going to be okay regardless. Just how do we fix this and what makes you feel whole again."

Host: It's so great that there are so many options now, you know? And that you can tailor it to each different person, as you said. What is one fact about breast cancer that you wish everyone knew.

Shilpa Padia, MD, FACS: Mammograms do not cause cancer and are not harmful to you. Because I feel like that right now with social media being as big as it is and a lot of medical advice floating on all of those platforms, I feel like that's the question that I have to answer most now more than I ever have before, is that, "Well, I don't really know if I want to get that mammogram. It's going to cause cancer. Its radiation." Radiation is an umbrella, but it is not the radiation that we think of from Hollywood where its melting you and its like nuclear radiation. That's not it. It's an X-ray. And there has never been a cancer ever to be proven from a mammogram. And the amount of radiation that you get is actually less than flying on an airplane, because there is a lot of radiation in our atmosphere. So, I just have to have some honest conversations. But if there's one thing I would say I wish people knew is that mammograms are not causing cancer and they're also not harmful to your health. They're not that type of radiation.

Host: That is so interesting about the comparison to flying on an airplane. My goodness. Dr. Padia, in closing, is there anything else you'd like to add that you want women and men to know?

Shilpa Padia, MD, FACS: I think the only other thing I would say no one makes good decisions feeling rushed and no one makes good decisions out of fear. Both of those feelings happen when a cancer diagnosis happens no matter what that cancer is. And so, early detection is important, yes, from a survival standpoint for having less treatment needed. But the earlier it is caught, you actually have a minute to take a breath and I think that's also really important because these are life changing decisions that we're making. And that doesn't mean that anything's ever going to be delayed. That's not what I'm getting at. I am just saying that don't matter the situation We need to make sure that there's always a moment to take a breath so that we're not making rush decisions or feeling fearful about our survival. And so, that would be my biggest piece of advice to men and women that are going through any cancer diagnosis, is don't make that decision rushed and don't make it out of fear. Get your questions answered. Ask them. This should be their first rodeo. But it's not our first rodeo. But that's okay. Ask your questions. You don't know what to ask, because you've never been through that. But that's expected. So, never be afraid to ask those questions, but don't ever feel pressured to make a decision feeling rushed or out of fear.

Host: That is such good advice. You can apply that to your whole life actually, right?

Shilpa Padia, MD, FACS: No, right.

Host: Like it. Yeah. Yeah, but especially this. That's great. Well, this has been so informative and insightful and encouraging. Thank you for sharing your expertise today. We really appreciate it.

Shilpa Padia, MD, FACS: Yeah, thanks for having me. I'm open to any questions or anything anybody would ever have. I get really nerdy about it, so I'm sorry.

Host: Not at all.

Shilpa Padia, MD, FACS: I'm passionate about it. And if it's ever going to happen to you, like we're always happy to be there with you in the journey.

Host: That's the kind of doctor you want. Again, that's Dr. Shilpa Padia. For more information regarding breast cancer care, please visit mountcarmelhealth.com/services/breastcancer. Thanks for listening to Wellness in Reach, a Mount Carmel podcast.