Bill Klaproth (Host): The thought of breast cancer can be a worrying experience. One way to reduce your worry and anxiety is to understand the successful efforts to reduce deaths from breast cancer by catching it early and/or preventing it from occurring or reoccurring. On this episode of Outer Banks Health, we'll talk with the team at Outer Banks Health that is doing just that.

This is Outer Banks Health. I'm Bill Klaproth. And with me is an esteemed panel today. We have Dr. Charles Shelton. He is a radiation oncologist with Outer Banks Health. Welcome, Dr. Shelton.

Charles Shelton, MD: Thanks, Bill, for having us here today.

Host: You bet. We also have Dr. Christina Bowen. She is the ECU Health Chief Wellbeing Officer and Medical Director of the Outer Banks Health Center for Healthy Living. Welcome, Dr. Bowen.

Christina Bowen, MD: Thanks for having us, Bill.

Host: And we have Dr. Antonio Ruiz. He is a breast surgeon and Director of the Breast Center at Chesapeake Regional Healthcare. He is affiliated with Outer Banks Health. Dr. Ruiz, welcome.

Antonio Ruiz, MD: Thank you, Bill. Glad to be here.

Host: You bet. Well, thank you all for your time today on a very important topic that we're happy to discuss and help to educate women more about breast cancer and the successful efforts that are happening certainly to reduce the risk of breast cancer.

Dr. Shelton, let's start with you. Can you speak about your work to become an accredited cancer program, helping to establish Outer Banks' risk assessment protocols to identify those with a predisposition to cancer?

Charles Shelton, MD: Yes. And thank you, Bill, for having us all here today to talk about this very important issue. So, we are a small community hospital in rural North Carolina. And unfortunately, in rural parts of America, we see a lot of access to services that are not what you might find in urban America. So when we started our cancer program about a decade ago, we began to notice that there were some risks in our population that were not being really looked at properly or being assessed properly, mainly due to the fact that we were rural.

So, one of the first things we decided to do was become an accredited program, which requires a lot of work and effort to meet a lot of standards and metrics that are national standards, and we did so in 2016, and then later became also accredited in breast care in 2019.

Now, as part of an accredited program that focuses on quality breast care, we realized very quickly that most of our primary care doctors in our region were not screening patients based on high risk assessment. In other words, they weren't identifying risks in our population that need to be looked at separately. Instead, we were using what I call older age-based screening recommendations, where after a certain age, you know, a certain percentage of patients are screened just sort of normally, not accounting for any of those risks. So, we created essentially a process to help look into our population and identify risks that might put that person at a higher than normal risk for developing breast cancer.

Host: That's really important to try obviously to understand that someone may have a predisposition to this before they even know it. So, this is really important work. So, that leads me to genetic testing. Can you talk more about genetic testing?

Charles Shelton, MD: For sure. So, we first we studied our population. And we noticed that a lot of our patients with breast cancer indeed have a family history of the same cancers. And that led us to conclude that perhaps we should develop a program to look at that genetic risk, which you just alluded to. And so, we've trained several of our local personnel to be genetics counselors and to provide on-site counseling as well as testing. In doing so, we've really recognized there were no different rurally in America than you would be in urban America. We have about a fixed population of cancer patients, around 10% to 15%, who do carry, unfortunately, a risk that is inherited. And those patients, once we identify that risk, we can offer strategies to further reduce that risk.

The other more relevant and probably larger percentage of the population are patients who have risks that they may not know about. They might be lifestyle risks. They might be environmental risks. Things that perhaps are in our diet, things that perhaps are in our lifestyle that we haven't really had conversations about in terms of how those things increase our risk for certain cancers.

Host: So, you mentioned lifestyle and environmental risk. Dr. Bowen, we'll get to you in a second when we talk about prevention. Dr. Shelton, back to genetic testing, how many people opt to get genetically tested.

Charles Shelton, MD: So, we are lucky. We have a physician champion of genetics testing that's right in front of you. That's Dr. Antonio Ruiz, who has really pioneered genetic testing in our region, not just in North Carolina, but also in Virginia. Essentially, we offer testing to 100% of breast cancer patients when they walk in the door. Now, do all women agree to that? No, I would say we probably are lucky if we get 95% of patients who agree to that per year. But we are one of, I'd say, the leading cancer programs in the country in terms of what percentage of our patients are offered and agreed to genetic testing.

Host: So, you ask everyone that comes in, "Hey, do you want to be genetically tested?"

Charles Shelton, MD: Correct. And so, the guidelines really suggest that indeed we do that. So, what we found is that a lot of patients when you rely on their family history don't have adequate histories to be able to use some of the older guidelines to establish whether they need to be tested or not. The society that Dr. Ruiz is associated with, what's called the American Society of Breast Surgeons, has realized for years that all women really need to be tested to ascertain these risks once they're diagnosed with breast cancer.

Host: Well, it's really important that you ask the question when they come in and give them the option if they want to get genetically tested. So Dr. Shelton, thank you for explaining all of that to us. We definitely appreciate that. Let us move to prevention as you mentioned before. Dr. Bowen, let's talk to you about lifestyle behavior modifications and the six key pillars of lifestyle medicine-- I love that phrase, lifestyle medicine-- and how they play a key role in decreasing the chances of gene mutation, which increases the chances of cancer, especially in those predisposed to cancer.

Christina Bowen, MD: Yeah. Well, thank you so much for having us again. And yes, the concept of lifestyle medicine is pretty exciting when you heard the statistics that Dr. Shelton was sharing about our community that are not unique to Dare County. It's what we're seeing nationally that only about 10-15% are actually found to have a genetic mutation. So, what that really says is we are seeing families that are grandmothers, mothers, daughters that are having breast cancer, yet their genetic screen does not show any mutations. And so, what that says to us is likely there's some lifestyle modifications that have been passed down that we can work on.

When we think about decreasing our risk for cancer, that body mass index, so looking at our weight, our BMI, looking at patient's nutrition, looking at their physical activity level, how much alcohol are they intaking and are they smoking? So, those are the big five that we talk about for decreasing cancer risk, and actually decreasing recurrence of cancer.

So, one of the things, I know you want to hear about the pillars of lifestyle medicine, why it's been so wonderful here at the Outer Banks Hospital to have the Center for Healthy Living is that we have board-certified physician, nurse practitioner, and a nutritionist. And lifestyle medicine is really founded on nutrition, it's founded on physical activity, sleep, stress, risky substances, so those could be alcohol or tobacco. And really, the concept of connection and purpose. And so, you can see how that really aligns well. The concept of the pillars of lifestyle medicine align really well with those big five risk reducers that we know about for both prevention of cancer and then prevention of recurrence.

We talk to those patients. Dr. Ruiz and Dr. Shelton are amazing partners. So when we identify someone that might be high risk, no genetic mutation or they might have a genetic mutation. They're referred to our Center for Healthy Living so that we can really partner with them and walk alongside them to decrease those lifestyle modifications that we know will help decrease cancer from ever occurring, hopefully, and then from reoccurring for sure.

Host: Absolutely. So, just trying to take notes here. So, physical activity and exercise, diet and nutrition, stress reduction. You said get rid of the harmful substances, healthy relationships, all of those things are really important factors then when contributing to someone who is potentially putting themselves at risk for breast cancer. Is that right?

Christina Bowen, MD: That's correct.

Host: That's really interesting. And then, you said through the genetic testing, you find that 10-15% of people actually have a predisposition to cancer. So, it sounds like the majority of people that come in don't have a predisposition to it. But potentially, lifestyle is causing them to develop this. Would that be the right way to think about this?

Christina Bowen, MD: Exactly. And so, as we say often, you can change that trajectory, because we'll see patients often that say, "Well, my mother had it and my grandmother had it and my aunt." And we might be able to say, "Well, you've had genetic testing and it shows that it's negative. Let's work on those pillars. You can change this through lifestyle modifications." And for our patients that do have positive genetic mutations, it's really empowering to come and say, "Hey, we know that you have this. And here are some other things that we know decrease your risk of having cancer." And so, we see both. So, you can see where it's really nice to have this comprehensive cancer care here in the Outer Banks.

Host: Absolutely. Well, Dr. Bowen, thank you for that. We appreciate it. And Dr. Ruiz, let's bring you in on this. So, as Dr. Shelton said, you are the pioneer in genetic testing, so very excited to talk to you about this. Can you talk about your role in working with patients in the high risk clinic through your genetic testing and about referrals from Outer Banks Health?

Antonio Ruiz, MD: Certainly. Dr. Shelton was being more than gracious in my role as far as genetic testing goes. We have been doing genetic testing for quite some time. We were involved in some early studies. And actually, a lot of the patients that were in that study were from the Outer Banks. But my role with this team has mainly been, once these patients are identified, they will often be referred to the high-risk clinic. They usually come in with some imaging, usually at least a mammogram. If they're 40, actually, sometimes we'll see some even at 35. Sometimes they've been identified with a high risk already. So, they may have had appropriate imaging even earlier than that. But we review what imaging they have had and then go from there and then discuss enhanced surveillance if needed and then any risk reduction strategies, which we would want to review at that visit as well.

So as far as enhanced surveillance, when these patients come to us with their elevated risk, we then look at their family history, we look at if they have a mammogram, their breast density. And then, using that information decide what other enhanced surveillance imaging modalities may be appropriate. For some, it might be ultrasound, and so on. And for others, maybe MRI. Some qualify for MRI, some don't, but we have to have that discussion. And then, once we get past the enhanced surveillance discussion, then sometimes we get into the risk reduction discussion. As Dr. Bowen already talked about, some risk reduction is just healthy living, whether it's diet and exercise, which we know are so important, adequate sleep, you know, lots of things that contribute to that.

But then, we sometimes discuss what options are available to actually reduce the risk, not just increase our detection rate. And that might be either ovarian suppression or hormone blockade or ovary removal, even breast surgery to remove the breast to decrease the risk. And then if we get into that discussion, sometimes we have to discuss reconstruction as an option. So, we usually start with these topics with the patient, see what they're interested in, what they qualify for, and then try to help guide them into something that they feel fits for them. You know, try to personalize this experience for them as much as possible to get them to do whatever evaluation or risk reduction modality they feel most comfortable with.

Host: So, for someone who comes in with a predisposition for breast cancer, do they automatically qualify then for enhanced surveillance?

Antonio Ruiz, MD: Yeah. Most of the patients that I see in the high risk clinic will either qualify for ultrasound or MRI. One of the things that we do is we do a calculation to see what their risk score is. And we usually use the Tyrer-Cuzick score and anybody who scores above 20% is in the high risk group and they would qualify for an MRI. Anybody below 20% but above 12% is in the intermediate group and those patients would qualify for an ultrasound, but sometimes it's hard to get the MRI approved for that group.

Host: For someone that qualifies for enhanced surveillance, how often do they have to come see you? Is it yearly? Is it now we're a five-year window, a ten-year window? I would imagine you want to continually see them then if they are on enhanced surveillance, if they do have a predisposition to breast cancer?

Antonio Ruiz, MD: So, a lot of these patients, we try to make sure that they get evaluated with a clinical exam, at least, you know, probably twice a year. We try to work with either the other physicians on this team or sometimes their primary care physician or their OB-GYN and utilize them to be part of that group that's going to monitor them so that I don't have to beat them up with a lot of appointments every year. But if I can, you know, get that down to where I just have to see them once a year and then utilize their other physicians for the other exams, that usually works out better for the patient.

Host: So if someone does have a history of breast cancer in their family, at what age should they start coming in for these types of screenings?

Antonio Ruiz, MD: With family history, it depends on what that family history is. But some patients, you know, we tell them at least five to ten years before the age of the family member that was diagnosed. We have patients in their 20s that start coming to the high risk clinic. And then depending on if they've had genetic testing, if they've tested positive for some of the really high risk genes, I mean, imaging can start sometimes as early as 25.

Host: Wow. Okay. Well, thank you for answering that. I appreciate that. That's good to know. So again, early detection is really what is key here and all of your efforts towards that are really valuable. So, thank you so much. This has really been informative. Before we wrap up, I'd like to get final thoughts from each of you. Dr. Shelton, as we wrap up, anything else you'd like to add?

Charles Shelton, MD: I'd love just to emphasize how this collaboration has helped us to really focus on what I call precision medicine. So, each patient is treated as an individual. They come into our hospital and they have an individual risk assessment tool that quantitates their actual risk for breast cancer themselves, which then compares them to the rest of the population. We then empower that patient to have the tools necessary to address that risk, whether it be enhanced imaging, whether it be risk reduction strategies through either genetics or through lifestyle medicine. So, it's truly a model that is powerful in the sense that it is for each individual patient that comes into our hospital. So, we had 5,000 patients last year that were screened in the Outer Banks. Every one of those women had that same tool to assess their risk when they came in that particular year, which I think is phenomenal.

Host: Dr. Shelton, thank you for that. We really appreciate it. Dr. Bowen, final thoughts from you?

Christina Bowen, MD: Yeah, I'll just echo what Dr. Shelton said about the individual nature with which we're able to each of our patients. I've seen that with both of these providers and how they individually care for their patients. And in my role as the Medical Director for the Center for Healthy Living, that's exactly what we do. So, we share with them those prevention strategies we discussed, but then we really partner with them and say, "Hey, what do you want to work on? What feels best to you? Knowing these risk reduction strategies, where do you want to begin?" And really partner with them. And it's truly been incredible to see how our patients respond and change that cancer trajectory for their life, for the better.

Host: Thank you so much for that. Dr. Bowen and Dr. Ruiz, final thoughts from you?

Antonio Ruiz, MD: As you can see, we're real proud of the program that we have down at the Outer Banks, what we have to offer for the community down there. But any good program needs a strong chief, a leader, and the Indians that run around doing the work in the background. And as you can see, Dr. Shelton is the fearless leader of this group. He's really put this thing together and brought it all together for us. Dr. Bowen's service there is phenomenal. What she does for our patients and I can't tell you how I see my patients and follow up after they visited with her and how they feel that has really benefited their experience in general in taking care of their cancers. And also, I thank the Outer Banks Hospital and Chesapeake Regional for the support that they've given us, allowing us to do all this.

Host: Absolutely. Well, I want to thank each of you again. This has really been informative and educational. Thank you so much. And once again, that is Dr. Charles Shelton, Dr. Christina Bowen, and Dr. Antonio Ruiz. And we thank you so much for your time. For more information, please visit outerbankshealth.Org. And if you found this podcast helpful, please share it on your social channels. And please visit outerbankshealth.org/podcasts for our growing podcast library. I'm Bill Klaproth. And this is Outer Banks Health, the official podcast of Outer Banks Health. Thanks for listening.