Amanda Wilde (Host): Meaningful Medicine is a Novant Health podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm Amanda Wilde with hematologist and oncologist, Dr. Sandrine Crane. We're talking about breast cancer, from how to think about risk and prevention to the latest options in care and survivorship. Dr. Crane, thank you so much for being here today.

Sandrine Crane, MD: Thank you for having me.

Host: I want to start out with what are some of the biggest myths or misconceptions you encounter about what causes breast cancer, and what does the science show?

Sandrine Crane, MD: One of the most common myths that I encounter is whether or not sugar contributes to breast cancer. And sometimes it is even phrased as feeding cancer. Anything that we consume, whether carbohydrate, proteins, and even lipids, everything gets broken down to the same level of energy that the cells can use. We use them for our own survival. Cancer cells can also use the same type of energy, but there have not been any studies that shows that sugar can increase risk of having breast cancer or even worsen the outcome of breast cancer. It is usually recommended to eat a healthy and balanced diet and limit processed food as well as added sugars.

Another myth that I have encountered is whether or not deodorant or even antiperspirant can increase the risk of breast cancer. And there have not been any studies that have shown that this is a risk factor for breast cancer. And sometimes usually people will wonder why they are asked to hold or not use deodorant on the day of their mammogram. And this is to prevent particles from the deodorant being seen on a mammogram and making it harder to pick up abnormalities.

Host: So, that's where that one got started. I've also heard that genetics play such a large role. Sometimes people feel like, "If I don't have the genetic factors, I don't really have to worry about breast cancer."

Sandrine Crane, MD: That is also another myth. Only about 5% to 10% of patients who have breast cancer have a genetic predisposition to the breast cancer. And only about 15% who have breast cancer and have a family member who've had breast cancer in the past. So, the majority of patients who have breast cancer have no genetic predisposition and do not have a family history of breast cancer. So, it is always important to undergo screening on time and as recommended.

Host: Well, let's get a little deeper into the risk factors. And then, we'll talk too about how breast cancer care has evolved in recent years and what the options are there. But back to genetics and family history, they do influence breast cancer risk. When should someone consider genetic testing?

Sandrine Crane, MD: It's always a nuanced conversation, but current guidelines do recommend for anybody who is diagnosed with breast cancer before the age of 50 to undergo genetic testing. For family history reasons, if someone has a family member who's had breast cancer before the age of 50, or a family member who's had pancreatic cancer, or who has had ovarian cancer, or even advanced prostate cancer, they are definitely people who should consider genetic testing. There are new treatment options that are available to patients who have specific genetic mutations. So if a treatment consideration are being taken into account, genetic testing is offered on an individualized basis.

Host: You mentioned lifestyle also earlier, like exercise and diet. How meaningful are diet, exercise, and weight management when we talk about affecting breast cancer risk or outcome?

Sandrine Crane, MD: So, we do have studies that show that maintaining an active lifestyle is important to decrease the risk of breast cancer occurrence while maintaining a normal body mass index. And we also know that the same benefit also applies after someone has been diagnosed with breast cancer. So, exercise has been shown to decrease the risk of breast cancer-related mortality, even all-comers mortality. The current recommendation is for moderate exercise of about 150 minutes per week. Weight-bearing exercise is about two days a week. Those are definitely lifestyle changes that can make a difference.

Host: What other lifestyle factors like smoking and alcohol use should patients consider?

Sandrine Crane, MD: So, we do know that breast cancer has a strong association with alcohol misuse in terms of the diagnosis of breast cancer, even outcome after a diagnosis of breast cancer. So, it is recommended to not consume any alcohol. But if it is going to be consumed, to limit to one drink per day.

Smoking also has an association with the breast cancer diagnosis and even the outcome after breast cancer diagnosis. We know that sometimes the carcinogens that are produced from smoking can even affect how certain medications and chemotherapy agents function or help patients and sometimes can actually lead to resistance to medication. So, we are always working with patients if they are smoking or drinking to try and address those lifestyle choices and decrease the risk of breast cancer recurrence.

Host: Another risk that is often brought up is hormone-related. I think hormone-related questions are common. Do birth control pills and menopausal hormone therapy factor into breast cancer risk?

Sandrine Crane, MD: Yes, they do. So for premenopausal women, who use estrogen-based medication, that can increase the risk of breast cancer and specifically estrogen receptor-positive breast cancer. The same also applies for the use of estrogen and combined progesterone hormonal replacement after menopause.

In post-menopausal setting, those hormones are recommended to address the symptoms related to menopause. Sometimes it might be hot flashes. It might be mood changes and even maintaining bone density. If those medication are to be considered, we usually recommend for them to be used in the least amount possible and for the least amount of time that's possible.

Host: How should people think about risk versus responsibility? I mean, how do you balance giving patients actionable advice without making them feel blamed?

Sandrine Crane, MD: It's a balance. Very often, after diagnosis of breast cancer, you might sometimes encounter a patient who's blaming themselves, because everybody always wonders, "What did I do or what did I not do that has led to this diagnosis?" Even though we know that smoking, alcohol misuse, and sometimes use of estrogen-based medication can increase the risk of breast cancer, I think it's best to focus on what can be done in the future to decrease the risk of breast cancer recurring or even improving the outcome of breast cancer treatment. And we know that there are things that we can incorporate, including assistance with smoking cessation, counseling about any lifestyle modifications that can be taken.

Host: So when someone is diagnosed, you will meet them where they are to work on those things. You just mentioned one of the common misconceptions. It might be that "I caused this or the products I used weren't healthy for me." Are there any other common misconceptions you want to bring up about prognosis or treatment once someone is diagnosed?

Sandrine Crane, MD: So, some of the misconceptions, sometimes they have to do with prognosis in general. Breast cancer is still a very common type of cancer in women. Probably one out of eight women will have breast cancer in their lifetime. People might think that it is a death sentence of being diagnosed with breast cancer. There are new medication and therapies that have changed the overall outcome of patients who have breast cancer. I reassure patients that we will walk through this journey together, and we have different ways that we can support them, make sure they know that they're not going to go through this by themselves.

Host: And another reassuring point is that breast cancer care is continually evolving and getting more and more specialized in recent years. What innovations give you the most hope for patients now and in the future?

Sandrine Crane, MD: Research have made significant leaps in terms of improving breast cancer outcomes. There are new medication that are targeted. Some of them have been out for the last maybe 10 years. So, the CDK4/6 inhibitor that have changed the outcome of estrogen-positive breast cancer, both in the metastatic setting, even in early stage of breast cancer. We also have newer drugs that are antibody-drug conjugate that are very well-tolerated and also target and deliver the chemotherapy to the cells. The overall survival of patients, who have early stage, even advanced breast cancer, have improved significantly. And that gives me great hope.

Host: So, a lot of hope now and looking into the future.

Sandrine Crane, MD: Yes.

Host: Well, thank you for this conversation, Dr. Crane. Really appreciate your time and the insights you've shared and all the work you do at Novant Health.

Sandrine Crane, MD: Thank you.

Host: Dr. Sandrine Crane is a hematologist and oncologist at Novant Health. To find a physician, visit novanthealth.org. For more health and wellness information from our experts, visit healthyheadlines.org. If you enjoyed this podcast, please share it on your social channels and explore our entire podcast library for topics of interest to you. This is Meaningful Medicine, a Novant Health podcast.