Transcription:
Breast Cancer Screening, Risk Assessment and Risk Reduction

Cheryl: Welcome to Stoughton Health Talk. I'm Cheryl Martin. Breast cancer is the second leading cause of death from cancer in women here in the United States. It's more likely to occur as a woman ages. And that's why regular screening is so important. Joining me to walk us through the screening recommendations and more is Dr. Aaron Schwaab, a general surgeon at Stoughton Hospital. Thanks so much for being on, Dr. Schwaab.

Dr. Aaron Schwaab: Thanks for having me, Cheryl.

Cheryl: I know that this topic is one of great interest to you. First of all, talk about your background in breast cancer work.

Dr. Aaron Schwaab: So I have been a general surgeon practicing since 2002. And prior to coming up to Stoughton in 2016, I was down in Woodstock, Illinois. And while I was down there, I was the medical director of the breast cancer program for Centegra Health System. So it was a huge part of my practice. Probably 50% of the patients that I saw were breast cancer patients. And so I treated about a hundred new breast cancer patients a year during my time down there as a medical director over about a decade. I was the medical director down there. So I have a lot of experience with treating patients with breast cancer, but also I found it to be an area of medicine that I really enjoyed.

I think that because breast cancer is such a well-funded and well-researched disease, it's something that is a challenge to keep up with. And there's always new things coming out that make it a very interesting and rewarding practice. And I also find that it's just a rewarding thing to take care of patients who have breast cancer and who have been diagnosed with this disease, because it's such a traumatic event in their life for them and their family. And I just found it to be very rewarding to help women and their families get through that diagnosis.

Cheryl: Well, I'm glad you shared your background. And in fact, you mentioned that there are so many new things coming out, and that's another reason we are glad to feature you on this episode. Do you know which women are more likely to get breast cancer?

Dr. Aaron Schwaab: Well, there's a lot of factors that play into that. And so obviously, there's genetics that are involved. But if you really look at it, we know that about one in eight women are going to be diagnosed with breast cancer in their lifetime. And the majority of those women really don't have significant measurable risk factors. They don't all have a gene for breast cancer. So, we want to know obviously what puts women at risk. And so that's why it's important to know what contributes to that and then also how to screen for it. And also, it's important to determine what women might be high risk. And so basically, we've started here at Stoughton kind of a new community education program to cover exactly those topics. We want to kind of help clarify what are the current screening recommendations because they have gotten confusing over the last several years. Also, we wanted to talk about how do we find out which women are at higher risk. And when you do find out that you are at higher risk, what can we do about it? And also just get it out to the community, what are some of the modifiable risk factors that every woman can look at to help and try and reduce their risk of breast cancer.

Cheryl: So let's talk about the screening recommendations. As you said, they can be confusing. So I'm glad you're here to clarify them.

Dr. Aaron Schwaab: Yeah, so it's interesting, up until 2016, it was really simple. Basically, the recommendations were that all women at age 40 should start screening for breast cancer with yearly mammograms. And then what happened in 2016 is a couple organizations came out with different recommendations. So we had the United States Preventative Services Task Force, which is a federal organization that reviews literature and comes out with recommendations for screening and we also had the American Cancer Society come out with different recommendations that really threw a wrench in it. So, for a long time, it was even hard for me to have a conversation with women and tell them what are the current recommendations. But thankfully, it's kind of come full circle now and we're back to the majority of the societies recommending that women should start screening at age 40 and they should do yearly mammograms until they get to an average life expectancy of less than 10 years. So we don't necessarily need to be screening women who are in their late 80s or 90s. But starting at age 40, it should be yearly after that.

And without going into a lot of detail about it, the reason that there was all this confusion and these other organizations came out with other recommendations, is that just like any tests that is done, there are potential risks that go along with these screening tests. And so you would think that a mammogram is just a simple x-ray and, you know, what could be risky about that, but there are some risks of radiation exposure and false positive tests and false negative tests, which basically mean women may end up getting additional procedures that can have additional risks. And so these other societies that came out with these other recommendations were weighing these other risks heavier than the actual benefit of mammograms, which is saving lives. And what we know is that mammograms do save lives. And so that's where we want to make our focus is that we want to save as many lives as we can obviously.

Cheryl: You mentioned there is some risk. Highlight for us the process for breast cancer risk assessment offered at Stoughton Hospital.

Dr. Aaron Schwaab: Right. So basically, there are several models that have been developed where we can enter a woman's health information and family history and biopsy history and all of these factors. And actually, these models will come out with estimates of what a woman's risk of breast cancer is over the next five years, over the next 10 years, and over their lifetime. And if we look at a woman's average risk is about 14% in their lifetimes, we look at that one in eight, that the numbers say that if someone's lifetime risk, for example, is over 20%, then they're considered higher risk. If they're five-year risk is over 1.7%, then that's a higher risk. So what we do is what we're now offering is a free risk assessment for any woman. And by the way, the recommendations are that all women over the age of 25 should actually have a risk assessment for breast cancer. So we're offering this. On our website, there's a phone number that a patient can call and talk to our screener. And it's about a 30-minute appointment where she will go over their family history, their health history, and plug their information into these models and actually find out if they are at high risk.

Cheryl: And again, this risk assessment is free?

Dr. Aaron Schwaab: Correct. It is free.

Cheryl: Great. Talk then about risk reduction strategies.

Dr. Aaron Schwaab: Well, so there's two parts of that. So, let's focus first on high-risk women. So if a woman is found to be high risk, there are several things that can impact that. So, why would that be important if a woman is found to be high risk? So what can happen is, number one, the screening recommendations for those women can be different. So instead of potentially yearly mammograms, they may be recommended to get yearly MRIs, for example, which is a much more sensitive test for breast cancer. Some women who are determined to be high risk may actually even have medical options, which can lower their risk of breast cancer. And by that, I mean, there are medications that they can take that have been proven to lower their risk of developing breast cancer by as much as 50%. There are some women who are at the highest risk for breast cancer who may choose surgical options to lower their risk for breast cancer. And we also want to identify those women who might be at risk for the actual gene mutations for breast cancer. Because again, they're going to be at the higher risk and those women we want to make sure are getting every chance they can to have the most sensitive screening and potentially the most aggressive risk-lowering options.

And then lastly, high-risk women may be more motivated to choose some lifestyle changes that can lower their risk of breast cancer. So that's why the risk assessment itself is important. But the majority of women are just going to be average risk for breast cancer. So, for those women, we look at several modifiable risk factors that they can look at to reduce their overall risk and the four main ones that I focus on when I'm talking to the community is, number one, body mass index or basically their weight, so that's one factor. Another is physical activity. Another is their diet and the last is alcohol consumption and smoking. So if you'd like me to, I can kind of talk about each one of those briefly.

Cheryl: Would you please?

Dr. Aaron Schwaab: Sure. So, we'll start with weight or body mass index. And what we do know is that obesity does contribute to the risk of breast cancer. So for a woman who has a BMI or a body mass index, which basically is a calculation of their weight and their height, if they are in a BMI state of 30 to 35, we know that they may have up to a 37% increased risk of breast cancer. If someone's BMI is over 35, it can be as high as 58%. So, we also see that women who are obese, when they are diagnosed with breast cancer, they're often diagnosed at a more advanced stage. They have a higher risk of surgical complications, higher risk of complications from other therapies that they may get for their breast cancer. They have a higher risk of cancer recurrence and a higher chance of dying from their cancer. And we also have other studies that show that weight loss and, for example, bariatric surgery has been shown to reduce a patient's risk for breast cancer. So, clearly, obesity has an impact.

So then if we look at physical activity, we know that women who are not physically active can have a higher risk of breast cancer. And what I highlight is that there are, believe it or not, physical activity guidelines that have been put out for Americans and the most recent addition, which is the second addition of that, recommends that the adults should do somewhere between two and a half hours to five hours a week of moderate intensity or an hour and 15 minutes to two and a half hours of a vigorous intensity physical activity. And basically, what that equates to is if we're talking about moderate intensity, we're talking about walking at a pace of about three miles an hour. So, effort level of about a five or six on a scale of zero to ten. And vigorous intensity activity would be like running a mile at a 10-minute pace. So again, those recommendations are about two and a half to five hours a week of moderate intensity exercise. And what that does is that for women who meet those guidelines, we see that they can have a risk reduction of about 20% of getting breast cancer in their lifetime. So, that's a significant reduction. So exercise is very important.

If we look at diet, we know that a low fat diet has some benefits for women when it comes to breast cancer. It doesn't necessarily change the risk of getting breast cancer. But if a woman does develop breast cancer, a low fat diet can help reduce their risk of dying from breast cancer. But there is one trial that was really interesting that looked at a Mediterranean diet. So a Mediterranean diet for those who aren't familiar with it basically is high in nuts and olive oil and vegetables, fish and seafood. It avoids things like a lot of added sugar, a lot of trans fats, a lot of like soybean oil, canola oil, kind of refined oils; processed meats, like sausages and hot dogs. In Wisconsin, you know, brots are a popular meal. Those would be foods that you would want to avoid. But the study showed that for women who followed the Mediterranean diet, that we saw a significant reduction in the incidence of them developing invasive breast cancer. So diet can have an impact.

And then lastly, when we talk about alcohol and smoking, smoking increases the risk of breast cancer by a range of about 14% to 25%, depending on when a woman started smoking. And so, you know, we know that smoking has lots of poor impact on lots of different health factors. But up until recently, it wasn't thought that it really had a big impact on breast cancer. But now, we know that it does.

And the other one is alcohol. And we know that alcohol has a significant increased risk of breast cancer. And the specifics on that are that basically the average glass of beer or wine has about 14 grams of alcohol. And for every 10 grams of alcohol that a woman consumes on a daily basis, so a little bit less than a glass of wine or beer, there's a 7% increased risk of breast cancer. So, you know, you can easily figure that out if you're someone who has two or three glasses of wine, you could potentially be increasing your risk of breast cancer by 15% to 20% if you have that on a daily basis. So alcohol consumption is also something that's very important.

So when we look at what do we recommend for women as far as how to modify their lifestyle, to reduce the risk of breast cancer, I like to say try to maintain a positive energy balance, and that means eat healthy, exercise, don't smoke and try and limit your alcohol we say to five or less drinks a week which is going, you know, kind of minimize that effect that alcohol can have. And then we're also obviously encouraging women to have their breast cancer risk assessment so that you can find out if you are someone who's in a high-risk category, so we can hopefully intervene and help lower that risk.

Cheryl: Dr. Schwaab, this has been extremely helpful. Such practical advice for women in being proactive to fight breast cancer. Thank you so much.

Dr. Aaron Schwaab: You're very welcome. And thank you for the opportunity to talk today.

Cheryl: That was Dr. Aaron Schwaab, a general surgeon at Stoughton Hospital. To get more information or to get connected with one of our providers, just go online to stoughtonhospital.com. Thanks so much for listening to Stoughton Health Talk brought to you by Stoughton Hospital. If you found this information helpful, please subscribe to this podcast and share it with others and listen to other episodes of interest to you.