Disclaimer: This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

Cheryl Martin (Host): Screening mammograms can help reduce the death rate from breast cancer among women. But who's most at risk and what are the benefits of 3D mammography? Those answers and more coming up next.

This is Be Well with Skagit Regional Health. I'm Cheryl Martin. And on this episode, I'm pleased to have with me Dr. Michal Whiton, radiation oncologist and Medical Director of the Breast Institute at Skagit Regional Health; and Dr. Aaron Yu, a radiologist and Medical Director at Skagit Imaging Pavilion. Let me begin with you, Dr. Whiton. Who is most at risk for breast cancer?

Dr. Michal Whiton: Well, breast cancer is the most common cancer that we see in women, and it's actually the second most common cause of cancer death in women. The statistic that is quoted most commonly is one in eight. So one in eight women will develop breast cancer in their lifetime. But not all women have the same risk of developing breast cancer. So who is most at risk is a question that many seek answers to.

There are certain factors that increase the likelihood that a woman will develop breast cancer and some of these can be modified and controlled and some cannot. The risk factors, the two strongest risk factors, are being a woman and advancing age. So the older we get, the more at risk we are of developing cancer, not just of the breast, but of other cancers as well. Having a family history of breast cancer is also a common risk factor and one we can't control or having a personal history of benign breast disease or a history of already having a malignancy in the breast. Anyone who has had prior radiation to the chest, most commonly given as a younger adult for a lymphoma or having a history of lymphoma that required radiation to the chest increases risk. And then, how much estrogen a woman's body is exposed to in her lifetime is also of great importance in the risk of developing breast cancer. And a less commonly known, risk factor is drinking more than one alcoholic beverage a day. So these are the risk factors that we know of. Some, again, can be controlled and some cannot.

Cheryl Martin (Host): Dr. Yu, what are the early signs or symptoms of breast cancer?

Dr. Aaron Yu: The early signs and symptoms of breast cancer that we frequently encounter would be if somebody feels a new lump in the breast or armpit. It may or may not be tender or you may feel enlarged lymph nodes in the armpit. Some other potential findings would be you may see some skin changes such as dimpling or even thickening. Other things that may occur would be you may notice that the nipple turns inward, that you can't get it to come out with pressure or squeezing it. And also, nipple changes whether you may see some redness of the nipple itself, some associated scaling or even thickening. And one of the other things besides having these symptoms is that if a patient ends up getting treated for this and it doesn't get better. Those are some red flags to keep an eye out for when you have these types of findings and it just doesn't respond to your typical treatment.

Some other things that patients may notice would be blood or discharge from the nipple or focal breast pain. And then, one other thing that sometimes may be a little bit harder to detect, but if you notice that one of the breasts becomes larger than the other, or if it starts getting smaller. Those may be some findings that somebody should go in and get it checked out by their primary care provider.

Cheryl Martin (Host): Is breast cancer preventable, Dr. Whiton?

Dr. Michal Whiton: You know, as I mentioned, we know what the primary risk factors are for breast cancer. Some again, we can control and some we cannot. The risk factors that we have some control over relate to our estrogen exposure. So, when a woman starts menstruating, the monthly bursts of estrogen in our system begin and they last until menopause. So, if someone has an early onset of menstruation and very late menopause, that would increase the exposure of estrogen in their system over their life.

In a similar realm when a woman becomes pregnant, that turns off those bursts of estrogen monthly and helps reduce a lifetime of estrogen exposure. So if someone has their first pregnancy early in adulthood as opposed to late in adulthood or not at all, that can affect their estrogen exposure over time. Once menopause occurs, if a woman chooses to use estrogen replacement to mitigate the symptoms of menopause, again that's a risk factor for breast cancer and one that we can control. So, whether or not to use hormone replacement at the time of menopause is something that needs to be discussed with a patient's physician to determine if it's appropriate for them because of the increased risk. But again, that's a way to prevent that particular risk, is only using hormone replacement if necessary.

One thing that is not well known is having fatty tissue in our body is also a source of converting estrogen precursors in our body into actual estrogen. And so, there's an enzyme in our fatty cells that converts those precursors and that is our primary source of estrogen production after menopause. So keeping body weight to a healthy level, reducing excess fatty tissue on the body, again that's a risk factor we can control and it reduces the amount of estrogen that the body is just producing in the fatty tissue. Some studies have been done looking at estrogen levels in patients who are overweight in the post-menopausal area as opposed to being lean in the post-menopausal time period. And the levels of estrogen can be 50% to 100% higher in overweight women as opposed to lean women. So again, that's one of the risk factors that help control our risk of just exposure to estrogen over time.

And there have been studies looking at regular exercise and maintaining a healthy weight. There was a study in Norway done about 20 years ago that queried over 25,000 women. And the outcome of that study was they found that women who exercise regularly at least four times a week had a 37% reduction in the risk of breast cancer. So, exercise, maintaining a healthy weight and attempting the control that we do have over our weight to minimize our fatty tissue, all help reduce the risk.

Again, just to note about alcohol, there is clearly a link between alcohol consumption and the risk of developing breast cancer. And the risk is highest for women who consume three or more drinks per day. So the American Cancer Society recommends that women really limit alcoholic beverage consumption to no more than one alcoholic drink per day. And of course, the less, the better. So those are some ways to control the risk.

Cheryl Martin (Host): And when should women get their first mammogram, Dr. Yu.

Dr. Aaron Yu: So there are actually multiple recommendations from different medical societies as to what age women should start their screening mammography, how often they should get them and when to stop. And it's important to note that the research did not specifically address these questions. And so this has led to various interpretations of the research data and then that resulted in some varying recommendations, which ultimately leads to a little bit of confusion.

And so at Skagit Regional Health, a multidisciplinary panel of specialists involved with breast health, we met to basically review these recommendations, and then all the supporting data. So, at Skagit Regional Health, our consensus recommendation is that by age 40, the primary care providers will have an opportunity to meet with their patients and have a shared conversation to discuss what a patient is comfortable with based on the factors like individual risk factors for breast cancer, the likelihood that a mammogram will detect cancer, balancing the differences between the benefits and harms of mammography, and also patient preference, their past experiences and their priorities. We recommend that patients until their life expectancy is less than 10 years to have yearly mammograms or they can consider every two years depending on the patient's risk factors and preference.

Cheryl Martin (Host): Talk to us about 3D mammography, what it is and what the benefits are.

Dr. Aaron Yu: So, 3D mammography or digital breast tomosynthesis is the latest advancement in imaging technology versus the conventional two-dimensional mammography in the past. And the 2D mammography, you're basically taking pictures of the breast from two views. And all the tissue of the breasts are overlapped on each other, so it makes detection of certain things more difficult, especially with women with dense breast tissue.

With 3D mammography, the technology allows us to look at the breast with multiple slices through the breast so you can see different layers and it kind of decreases the overlapping effect and so helps detect breast cancer more easily. And it overall results in better cancer detection and also lower callback rates. And so that's the basic benefits of 3D mammography. And the bottom line for all screening examinations is to try to detect the cancer as earliest and smallest stage as possible, and so that the treatment options and outcomes are significantly improved.

Dr. Michal Whiton: I would love to underscore how important the development of 3D mammography has been for early detection and also reducing stress for patients. And that fewer callbacks for patients, it has been such a gift really to our community because it's very stressful to get a callback after a mammogram is found to be abnormal. So if there's a technology that can reduce that for patients, it's a fantastic thing to embrace. And that when you do get a callback, you know, that the best technology has been used to look closer at what was found initially, and that's just reassuring, I think, for everyone getting mammography.

Cheryl Martin (Host): Are there any other tools that can be used to detect breast cancer?

Dr. Aaron Yu: So, just going back to screening mammography, it's been shown to decrease cancer mortality in women with some studies showing that it can actually decrease it to about 40%. And this is across all age groups, especially the younger patients in their 40s. Screening mammogram recommendations are made for women of average risk, but sometimes patients do have an elevated lifetime risk of breast cancer, which is defined as greater than 20% lifetime risk. And these patients may benefit from additional screening using screening breast MRI.

Cases of a symptomatic patient or in a setting that's not related to screening, for example, if a patient comes in with a palpable lump or nipple abnormality, the workup will also include targeted ultrasound if it's appropriate at that time. And then, the basic workup for trying to detect something in the breast and would be a targeted ultrasound and also a mammogram.

Cheryl Martin (Host): How often should a breast self-examination be done?

Dr. Aaron Yu: Current recommendations by the American Cancer Society is to not perform clinical breast examinations or breast self-examinations. But the patient should be familiar with how her own breasts look and feel. And also they should seek evaluation if there's any changes to their baseline. They should be aware of the signs and symptoms of breast cancer that we discussed earlier.

Cheryl Martin (Host): Do you know why this recommendation that you should not do a breast self-examination?

Dr. Aaron Yu: When the patients see a doctor once a year, the physician or the clinician doesn't really have a sense of what's normal for the patient, because there's going to be something that they may feel that it's bit that's there for the patient and they may draw attention to something that's actually normal. And so to do one once a year, they've shown that it has not been beneficial. And then, in terms of teaching patients self-breast examinations, it kind of goes along the same line of thought. What they did recommend, as I said earlier, is that women should be familiar with what's normal for their own breasts. And when there is a deviation from that or a change that doesn't go away in a short period of time, that should draw attention and they should seek evaluation with their primary care provider.

Cheryl Martin (Host): Okay. Is breast cancer treatable, Dr. Whiton?

Dr. Michal Whiton: Yes. Breast cancer is treatable in every stage. Breast cancer is treatable. In the earliest stages, meaning if a tumor is found in the breast in its smallest stages, it is most curable, before a tumor in the breast has had the chance to spread into either the lymph nodes, in the armpit area or beyond into the body. So the goal of mammography and reducing risk is to be on the earlier side of detection, so that the situation is curable, not just treatable.

Breast cancer, even in its very earliest stages, involves treatment by multiple different specialists. So, surgeons, medical oncologists who may prescribe chemotherapy or hormone-blocking agents and radiation oncologists like myself, who treat patients after surgery or chemotherapy is performed. In some cases of more aggressive cancers, immunotherapy can be used, which are newer therapies aimed at amplifying the immune system's response to certain aspects of tumors. And because of these different specialties involved in the treatment of breast cancer, coordination between these specialties is critical. And at Skagit Regional Health, we have a multidisciplinary team, which is called the Breast Institute, that meets weekly to determine the appropriate sequencing and which modalities of treatment should be used for each individual patient. And we strongly believe prevention and early detection are key to reducing the mortality of breast cancer.

Cheryl Martin (Host): Well, Dr. Michal Whiton and Dr. Aaron Yu, such great information on breast cancer and the advantages of breast cancer screening. Thank you so much for your time.

Dr. Michal Whiton: Thank you for having us.

Dr. Aaron Yu: Thank you.

Cheryl Martin (Host): For more information, visit SkagitRegionalHealth.org. That's SkagitRegionalHealth.org. And if you found this podcast helpful, please share it on your social channels, and thanks for listening to Be Well with Skagit Regional Health.