Maggie McKay (Host): Getting diagnosed with breast cancer can be overwhelming to say the least. So, the more knowledge you have, the better. Today, Dr. Sabine Manoli, breast surgeon at St. Joseph Hospital Breast Care Center, will tell us how to navigate this journey.

Welcome to Wellness First, a St. Joseph Hospital podcast, where we hear and learn directly from the experts on all things health and wellness. I'm your host, Maggie McKay. Thank you so much for joining us today, Dr. Manoli.

Sabine Manoli, MD: Hi, how are you? Thank you for having me.

Host: Great. Yes. Great to have you. Let's start with what are the USPTF or U.S. Preventative Task Force recommended guidelines for breast cancer screening?

Sabine Manoli, MD: Well, they were just updated a few months ago for 2024, and the U.S. Preventative Task Force has finally gotten on board with a little bit closer alignment with what the American College of Surgeons and the American Society of Breast Surgeons recommends for breast screening. So, for someone of average breast cancer risk, and we'll kind of talk about what average risk means later, but for average risk, the recommendation is to start screening at age 40.

The one thing that I disagree with, and I kind of represent the American College of Surgeons and the American Society of Breast Surgeons in this, is that the U.S. Preventative Task Force recommendation is starting at age 40 and doing a mammogram once every two years between age 40 and 74. The societies that I belong to and the recommendations that I've held to for all of my career are beginning screening at age 40 for average risk women, but doing screening annually. And I have seen plenty of patients who developed breast cancer in their 40s. So, I agree that they needed to move the age from 50 to 40. And the U.S. Preventative Task Force did that this year, but they still are holding to the every other year, and our recommendation from the physician side is every year, beginning at age 40.

Host: Do women with a family history of breast cancer need to start mammogram screening earlier?

Sabine Manoli, MD: It depends. So, if their female relatives were diagnosed with breast cancer before the age of 50, we generally say that relatives of that person should begin screening 10 years younger than the age of diagnosis of their family member. So, if your mother was diagnosed at 44, you, as the daughter, should begin screening at age 34. And that means the annual mammograms begin at that 10 years minus the age of the affected family member. If your family members were diagnosed postmenopausally in their 50s and 60s, then it's okay to begin your screening at 40, just like the U.S. Preventative Task Force recommends.

Host: And I know a lot of women think, "Oh, I'm going to put off my mammogram," or "I'm not going to do it because it's painful." Is it painful to undergo a mammogram?

Sabine Manoli, MD: It's not painful for most women. I think most of that concern about that comes from the fact that it's the unknown, first of all, if you've never done it. It's kind of a scary concept to think that someone's going to compress your breast. I think some of the discomfort comes from the position because they will put your breasts onto the mammogram plates and then the plates start to compress rather slowly. So, that part doesn't hurt, but you have to hold that position for a while. And it sort of feels like your breast is being pulled away from your body and you're trying to stay still and your breast is being pulled into these plates. It sounds awful, but it really isn't.

And you know, one thing I would say is talk to your female relatives, your girlfriend, somebody who's been through it before. And I think you'll find, generally, most people will tell you it's not painful, it's just a little weird. There's maybe some discomfort, but it's not pain. It's just odd. It's just an odd thing to go through, but it's so, so vital for diagnosing breast cancer. You know, most of my patients are diagnosed early via mammogram. It's something that you're not feeling, the doctor can't feel it. It's so small, but you can see it on the mammogram. And that's why we really highly encourage people to get their mammograms. They're just a great test. And you can pick up these cancers really early so you have the most optimal options for treatment.

Host: I just say to my friends who haven't had them, it's just uncomfortable. It's not painful. It's just awkward and uncomfortable, but to not do it when you have that opportunity, it just doesn't make sense to me. So, what happens if they do find something wrong on the mammogram?

Sabine Manoli, MD: You know, typically, when you have your usual mammograms yearly, they're considered screening mammograms, because it's a screening test looking for a problem. So, if they find a problem, they're then going to set you up with a diagnostic mammogram and potentially also a breast ultrasound. And those are additional tests done to investigate the area that looks unusual on your screening test.

So, the diagnostic mammograms, they're going to take some magnified views of the concerning area. They may do some additional positioning to really take a good look at whatever they saw on your screening test. And ultrasound is a secondary way of looking at the breast tissue using sound waves that penetrate through the tissue, so it doesn't hurt, it doesn't require any special positioning. It's just like having an ultrasound if you're pregnant. The sound waves go through the breast tissue. And, if they come upon something solid like a mass, the sound waves will bounce back to the ultrasound transducer and tell that transducer that there's something in the way. The sound waves can't go through that. Similarly, the ultrasound can also distinguish between a solid mass and a fluid-filled mass, which a fluid-filled mass is usually a cyst, which typically in the breast is a benign process. So, if you have an abnormal screening mammogram, they'll have you come back, which is called a recall mammogram, and then you have your diagnostic tests, and that's the diagnostic mammogram and the ultrasound, just to look at that spot that they're seeing a little bit more closely.

Host: Dr. Manoli, once somebody is diagnosed with breast cancer, what happens next?

Sabine Manoli, MD: Picking up where we just finished on the last question, if you do have a finding on the diagnostic workup, it'll usually prompt a biopsy. And then, if the biopsy comes back as a cancer, you're typically going to meet with somebody like me who is a breast cancer surgeon. You're going to have a nice long consultation. That doctor is going to examine you and see if there's anything in your breast that they can feel or anything that looks unusual or anything that you're having symptoms of. And then, they have a long conversation with you about potential treatments for breast cancer.

The majority of newly diagnosed breast cancers are treated with a surgical excision first, meaning that the cancer is removed from your body. There are a few subtypes of breast cancer that are treated with chemotherapy before surgery. So, when you meet with the surgeon, they usually know which subtypes need to go to chemotherapy first, and they'll get you referred to a medical oncologist who manages chemotherapy. But I would say by and large, probably about 75% or more of newly diagnosed breast cancers are treated with surgery first. So, you meet with the surgeon and you hear about what that entails. And most people are ready to have their surgery the minute they meet with me, want it out of their body, which is of course understandable, so we get them scheduled as soon as we can.

Host: Are there any other different treatment options or approaches for managing breast cancer that we need to know about?

Sabine Manoli, MD: Usually, breast cancers are treated in what we call a multimodality approach. So, surgery is not typically a stand-alone treatment. By multimodality, we mean that, of course, surgery is part of that package. Chemotherapy is another potential option and, again, not all patients need that, but it does go into the possible list of treatment options for breast cancer depending on types and depending on the aggressive nature of the cancer or lack thereof.

Radiation is another treatment for breast cancer that's typically used, most often with a lumpectomy where we're removing just a portion of the breast, not the whole breast, but sometimes also needed after mastectomy. And then, there's endocrine therapy or hormonal therapy is another name for it. And it's not the same as hormone replacement therapy, which some people have heard of after menopause, taking estrogen replacement. That's not the same as the hormonal type therapies we use in breast cancer. But those are basically the options: surgery, chemotherapy, radiation therapy, and endocrine therapy. And not every breast cancer needs all of those things. It's kind of a combination of things, and it depends on the specifics of the cancer, the subtype, and the person's age, and if the cancer has certain aggressive features or not.

Host: And you have talked about this a little bit, but I'm just wondering if there's anything else we need to know about various surgical approaches for treating breast cancer, like do they do robotic?

Sabine Manoli, MD: No. Breast cancer is not treated robotic or laparoscopically. It's typically an open incision to access the tumor. Most breast surgeons use something called hidden scar surgery where we try to hide the scar in a cosmetic location. For example, around the areola, where there's already a pigmentation shift between the edge of the areola and the skin of the breast. If we can access the tumor through that point, that position, we try to do that. Or in the inframammary fold, which is the fold underneath the breast, if we can access it through there, that's another place that's nice and hidden. When you look at yourself in the mirror, you won't see the incision underneath your breast. But sometimes in a larger breast or depending on the tumor position, if we're doing a lumpectomy, we have to put an incision right over where the tumor sits. So, we do try to hide the scar if we can, but if we can't, we'll place it where we need to get to.

But besides lumpectomy, where this is a procedure where we're just removing a portion of the breast, that means the remainder of the person's breast is healthy and can stay behind, some people either prefer to have a mastectomy where we remove the whole breast, or they need to have a mastectomy because either their tumor is large in comparison to their breast size, or they have multiple areas of cancer in the same breast. So, typically, those are the two approaches for dealing with the cancer site itself, either lumpectomy or mastectomy. And then, usually, there's also a procedure done in the underarm of the side that the cancer is located on, and that's to evaluate lymph nodes. We know breast cancer metastasizes, it wants to. All cancers can move or metastasize in the body. And the first place that breast cancer will move to is the lymph nodes under the arm on the same side of that breast. So, during breast cancer surgeries, we look to see if those lymph nodes are clear or not. And that procedure is called a sentinel lymph node biopsy. So, we do that hand in hand with either the mastectomy or the lumpectomy. The approach in the breast, whether we choose lumpectomy or mastectomy, really depends on the patient's preferences and, again, whether or not we can get around the tumor with a lumpectomy. But the sentinel lymph node procedure in the underarm is not dependent on the size of the cancer. It really just depends on the fact that we're operating for cancer, and we need to see if the lymph nodes are clean or not.

Host: What does the alphabet soup mean, ER, PR, HER2?

Sabine Manoli, MD: Yeah. So, that's some of the subtypes of breast cancer, and they have a very important role in terms of determining treatments that come after surgery and sometimes before surgery. When we talk about ER, PR, and HER2, we're talking about receptors that are on the cancer cells. And every single breast cancer cell derive from one of a person's normal body cells, so a normal breast cell. Normal breast cells have estrogen and progesterone receptors on them as part of your body's way to communicate with your from cell to cell. For example, like if you became pregnant, your uterus and your ovaries are going to send out estrogen and progesterone to kind of tell your breast cells that they need to get ready to make milk. So, the cells receptors on their surface are a way for cells to communicate with each other. If a normal breast cell gives rise to a cancer cell, sometimes those receptors get maintained on the cancer cell surface. And if so, that cancer cell would have estrogen and progesterone receptors, or would be called ER/PR positive, versus if that cancer cell did not maintain those normal cell receptors, it would be ER/PR negative. HER2 is a receptor that's generally not found on normal breast cells, but we do see it sometimes within the tumor cells. They will give rise to this new receptor, and it portends a more aggressive type of breast cancer. So, HER2-positive means that that person's breast cancer cells have a HER2 receptor on the cell surface. HER2-positive cancers generally are treated with chemotherapy. Again, not in exclusion, but you still need to have surgery and then the timing will depend on the size of your cancer, but HER2-positive will generally receive chemotherapy at some point, whether before or after surgery.

There is also a subtype called triple-negative breast cancer. Triple-negative is probably one of the most aggressive variants of breast cancer, and triple-negative means it does not have estrogen receptor, it does not have progesterone receptor, and it does not have HER2/neu receptor, so ERPR is negative, HER2 is negative, hence triple-negative. And those folks also always receive chemotherapy as part of their treatment, because their cancer is more aggressive.

Host: What if no one in my family has breast cancer? Do I need to worry about getting it?

Sabine Manoli, MD: Worry is probably a strong word. We always, you know, have to have it in the back of our mind. But if you have an average risk, your average risk is about one in eight women, so out of 12%, 12.5% lifetime risk. For some people, that's enough to make them worry. And for some people, that's a low enough number that they're not worried.

You should get your screening. Like we talked about, mammography once a year, starting at the age of 40. You should do breast self-exam to check and see if there's anything you can feel, and that's good to do in between mammograms. I think sometimes people get this false sense of security that, "Oh, my mammogram was fine, I don't need to check myself." you always should, and you should look in the mirror and make sure that your two breasts look the same, there isn't some puckering or some skin color change or something that looks different on one side. And if you notice those things in between having mammograms, you should definitely let your physician know, go see someone, have them evaluate.

But having said all of that, even though our risk for general population is 12.5%, 75% of breast cancer patients who are newly diagnosed do not have a family history. So, that means that just because you have a family history doesn't mean you're going to get it, and just because you don't have a family history doesn't mean you're in the clear. Seventy-five percent of our breast cancer not just here, but nationally and internationally, do not have a family history. So yeah, you do need to, I wouldn't say worry about it, but you need to be vigilant and you need to do the screenings and you need to take care of yourself if something's out of whack.

Host: And in which breast cancer patients is genetic testing recommended?

Sabine Manoli, MD: Typically, if somebody is diagnosed at a young age and doesn't have a family history, but they've now developed a breast cancer, let's say at, 38 or 40 or even younger, I would highly recommend that they consider genetic testing. Someone with a genetic mutation that leads to cancer needs to get a bad copy of the gene, and they need to get a bad copy from either mom or dad. So, sometimes mom and dad will carry a bad copy and not have a disease, but then their child will.

So if we see breast cancer developing at a young age, that's usually a red flag. Somebody who has breast cancer bilaterally, both breasts at the same time or at different times in their life, that would be somebody to consider genetic testing. If you have a huge amount of relatives who have breast cancer or ovarian cancer, those would be good reasons to get genetic testing. Or if you're family members who have been affected, we're young at the time of being affected. That would be a good reason to get genetic testing. Or, of course, if you have a family member who's already had genetic testing and tested positive, by all means, you should get yourself tested, if you're so willing.

I do have patients that say all the time," I don't want to know, I'm scared." But, you know, truthfully, it just helps us take care of you better if we know things ahead of time. And same for the person who might have that genetic mutation, it just helps us do, you know, more surveillance and be, you know, a little bit more vigilant with that individual. So, yes, of course, nobody wants to know too much, but knowledge is power, as they say. So, it's good to know.

Host: Better safe than sorry, right?

Sabine Manoli, MD: Yeah, absolutely.

Host: Dr. Manoli, what about men and breast cancer? How common or rare is it in them?

Sabine Manoli, MD: It's far more rare than obviously in women, but it does happen. And it's typically driven by a genetic risk. So, you know, if you have male breast cancer in your family history, it's a very good reason to consider genetic testing. It's a very good reason to be ultra vigilant as a woman, because you're more than likely to have had something passed down from your dad's side if he's the affected individual. But male breast cancer, we always take it very seriously for family history, because it's a huge red flag for genetics.

But yes, it does happen to men. And, you know, I think since men don't have screening, and they typically don't check themselves, unfortunately, when they do find a lump in themselves, it's already kind of far gone. It's had time to be there. It's had time to potentially metastasize, and they do tend to present at later stages of cancer, because it's just not been found when it was small, like women who get mammograms where they have a little tiny thing that nobody can feel, but the mammogram is identifying it.

So with men, you know, we take it very seriously. We tell male patients all the time, if you feel a lump, come in, have someone check it because maybe it's nothing, but you just don't want to sit on it and not know. Like you said, better safe than sorry. My philosophy is always to my patients, I'd rather check you too many times than not check you enough and have you have something that's going unchecked and causing problems that we could have intervened sooner.

Host: Absolutely. Is there anything in closing that you'd like to add that we didn't cover or you would just like to state again?

Sabine Manoli, MD: Really, just the plug for get your mammograms. I have seen so many lives saved because of early detection and it just cannot be emphasized enough. If you're scared because you think it's going to hurt or something like that, just talk to the mammogram technician who's doing your test. Let them know what you're feeling. They're very sensitive to emotional needs, concerns. They deal with a lot of that every single day. And I think you'll find that they will work with you to try to make it not an unpleasant experience. It's just such an invaluable screening test. It's just, you know, I don't want to say it's wonderful. It's not wonderful, but it's wonderful in terms of what it accomplishes for people to save their lives and to not have to deal with breast cancer in the long-term.

For me, as a surgeon, people say, "Well, how do you do this all day, taking care of this awful disease?" Because more than 90% of my patients are survivors, and it's a wonderful thing to see them in the long-term for their annual checkups and to know that 10, 15, 20 years later, they're still fine. And it's because we found their cancer early, we got it out, and they're doing okay. It's scary when you get diagnosed, but then the scariness passes and you just become okay. If you get treatment, everything's going to be okay. And finding things later typically limits the amount of options we have for treatment, and it certainly affects your prognosis. So, finding things early is always better.

Host: That's so encouraging. Ninety percent survive, I've never heard that of your patients.

Sabine Manoli, MD: Most of my patients, thankfully, are stage I or stage II when they're diagnosed. And yeah, the survival for that is greater than 90%. So, modern medicine is awesome. You just have to use it the way it's meant to be used.

Host: Right. We just have to do our part and get in there and get the mammogram. Well, thank you so much, Dr. Manoli. This has been so informative and helpful.

Sabine Manoli, MD: You're welcome. Thank you. Have a great day.

Host: Again, that's Dr. Sabine Manoli. To find out more, please visit stjosephhospital.com/services/womenshealthmaternitybreastcarecenter or just stjosephhospital.com. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Wellness First, a podcast from St. Joseph Hospital.