Transcription:
Breast Cancer Awareness

Melanie Cole (Host):  Welcome. Today, we’re discussing early and regular screenings for breast cancer and treatment options that are available. Joining me is Dr. Amy Bremner. She’s a Breast Dedicated Surgical Oncologist at City of Hope and a member of the Medical Staff at Temecula Valley Hospital. Dr. Bremner, I’m so glad to have you with us today. Tell us a little bit about breast cancer awareness. Are you seeing more women get screened? Is there more awareness? Kind of tell us a little bit about the trends right now.

Amy Bremner, MD (Guest):  As I just deal with breast cancer on a daily basis, and that’s pretty much all I’m seeing, every day, all day to me the incidence I haven’t noticed any necessarily increase in incidence, but I do know that yes, more people are being screened. There’s much more awareness in the community as far as getting your mammograms and when to get your mammogram. There is actually some confusion on that, what the best age is to start but we know that there are lots and lots of women getting their screenings on an annual basis and the incidence of breast cancer remains about the same which is one in eight women about 12% of the standard population is at risk for getting breast cancer. Of course, there are other risk factors as well.

Host:  Well let’s talk about some of those then. Because we hear about the genetic predisposition and the BRCA gene. Tell us just briefly about some of the other risk factors including the genetic component and what women are at higher risk.

Dr. Bremner:  Okay so we really discuss breast cancer risk for three different groups. So, there’s the sporadic group which is patients who do not have any family history, they don’t have any genetic predisposition to breast cancer but are at risk for getting breast cancer and that’s the one out of eight women. There is the other risk group which is what we call hereditary which is what you were referring to patients who have an actual genetic mutation that leads to a very, very high risk of breast cancer for example, with BRCA mutations, women can be upwards of 87% chance of breast cancer in their lifetime. And that’s considered the hereditary group of breast cancer risk. And then finally, is the familial group, which is a group that has family history however, no identified genetic mutation but we know that they have an elevated risk of breast cancer due to their family history. So, when I see patients, every patient, new patient gets evaluated, their risk is identified, we do what’s called a lifetime risk of breast cancer and we put them into a category, one of those three categories and then screen them accordingly.

But overall, as far as the genetically related breast cancers, those only account for about five to ten percent of all breast cancers. So, when I have patients coming in with a new diagnosis of breast cancer, they are always kind of surprised that they don’t have a genetic predisposition, but I tell them that yes, only five to ten percent of all breast cancers actually have a genetic mutation. So, it’s more common not to have a genetic mutation. But clearly, we identify those patients and test those patients that qualify for genetic testing.

Host:  It’s so interesting and such a huge topic Dr. Bremner. Before we get into some of the treatment options, and things that you see every day; let’s talk just a little bit about screening. There are many different methods now out there and 3-D tomosynthesis and ultrasounds and tell us a little bit about mammogram screening and why there’s some controversy or confusion over when you should start these.

Dr. Bremner:  You’re right. There are many different breast imaging modalities and by far the most common and most effective way of imaging the breast is your mammogram, your screening mammogram. And there has been some debate out there as far as what the best time, what the best age is to start your mammograms and across the board for most of the societies including the American Society of Breast Surgeons, American College of Radiology; we all agree that beginning routine annual screening should begin at age 40 and should be done on a yearly basis. Now we do discuss this topic at our annual meetings and there has been some discussion about perhaps in a low risk patient being able to start maybe later, maybe at 45. But those recommendations are not yet made. We kind of use those on an individual basis but every patient that I see I recommend starting annual mammograms at age 40. And there was a task force that came out a few years ago stating that women should start mammograms at age 50 and every other year after starting at age 50 and then stopping at age 74. The data that was used in those recommendations has since been disproven. We really agree that screening mammograms should begin at age 40 and should happen on a yearly basis.

There’s a few different types of mammograms, 2-D versus 3-D, the tomosynthesis which is what you referred to is a 3-D mammogram and it’s actually very, very effective in patients who have dense breast tissue. Because it allows you to get multiple slices of the breast and therefore better visualization. In patients who have dense breast tissue, sometimes the tissue can overlap and in your traditional two dimensional mammogram, sometimes things can be missed. So, a 3-D or three dimensional mammogram is ideal in patients who have more dense breast tissue.

So, that’s out there and available and most insurances do cover the 3-D technology. I don’t necessarily get 3-D mammograms on every single patient. For example if they have fatty breast tissue and a two dimensional mammogram can see just as well because it’s a great study as well, then I stick with the two dimensional. And it’s like I said, a great technology and works very, very well. So, not everyone has to have a 3-D mammogram but it’s something to talk to your provider about. It has slightly increased amount of radiation exposure but still well under the threshold that’s acceptable as far as the radiation exposure, which is really, really low. I think women get a little bit anxious about radiation exposure with a mammogram but it’s very, very low and safe.

As far as additional imaging modalities that we use in addition to mammogram include ultrasound, MRI of the breast and we don’t routinely – a screening mammogram is something that should be done on all asymptomatic women on a yearly basis. If patients have dense breasts, then we can sometimes add on screening breast ultrasound to that to increase the sensitivity of detection. In patients who are at higher risk we add on MRIs on an annual basis depending on their lifetime risk of breast cancer. So, we have a lot of different modalities to image the breast to really get a great look at them and we oftentimes do combine mammograms with other imaging modalities.

Host:  Well thank you for that excellent explanation. So, a woman gets diagnosed, one of the scariest things that she can absolutely hear. Tell us a little bit about what’s exciting in your field, about what’s going on as far as treatments and whether we’re talking about breast reconstruction after mastectomy, or lumpectomy and lymph node biopsy. Just kind of give us a whole rundown on treatment options now because there are more than there ever have been, yes?

Dr. Bremner:  The standard treatment options for women who are diagnosed with breast cancer is either what we call a partial mastectomy which is also known as a lumpectomy versus a mastectomy which is removal of the breast. So, depending on the certain case that I’m presented with, we decide kind of what option is the best for each patient on a personal level based on multiple factors, size of the tumor, location of the tumor, patient risk factors if they have any genetic predisposition. So, a lot of factors go into deciding which surgical option is going to be the best for each patient. So, we spend quite a bit of time discussing those options in detail, the pros and the cons.

With partial mastectomy or lumpectomy, I was trained in my fellowship to do something called oncoplastic breast surgery which is where we use our oncologic principles at removing the cancer, but also plastic surgery techniques combined with that in order to get the most optimal cosmetic results. So, we can do breast reductions at the time of a lumpectomy if a patient has large breasts. We have tissue rearrangement techniques where we can move tissue that’s present in the breast to fill spaces so that there is no cosmetic deformity. So, there’s a lot of options and when it comes to partial mastectomy and anytime, we can save a woman’s breast, I really prefer to do that.

What we’re doing that’s pretty exciting now at Temecula Valley Hospital is that we’ve just started the intraoperative radiotherapy program and that is where you deliver radiation therapy at the actual time of the surgery. So, the patient then can avoid needing whole breast radiation therapy for anywhere from three to six weeks everyday of the week. So, it’s a great technology that allows us to place a balloon at the time of the surgery, deliver radiation therapy for approximately nine to eleven minutes, remove the balloon and then in the majority of cases, that’s it. Patient wakes up, they’ve had their surgery, they’ve had their radiation. And then they can go on to their normal active lifestyles. So, that’s one of the more exciting things that’s happening right now at Temecula Valley Hospital.

And then as far as mastectomy goes, that’s a really great option as well. Again, pros and cons with each surgical option and many women do choose mastectomy and with mastectomy we offer reconstruction where I work closely with plastic surgery to offer the best reconstructive option possible. And I think the most exciting thing that’s come recently or we’ve been doing for some years now is what we call nipple sparing mastectomy which is where we can actually save the patient’s nipple and areola to allow for the reconstruction to look a little bit more natural and the patients feel more like herself. And if we can do nipple sparing mastectomies, we try to do those as well, if it’s an ideal case for that. So, these are some really great technologies and really great outcomes and so women actually are feeling good about themselves after their treatment. They are feeling happy. They look good and, in some cases, look ten year younger and it’s not a constant reminder that they’ve been through breast cancer treatment. It’s actually a silver lining in a breast cancer diagnosis.

Host:  Wow. What a time to be in your field. Would you summarize it for us please Dr. Bremner and let the listeners know as a surgical oncologist, what you want them to know about breast cancer. There are so many treatments and so much screening options that you’re here for them and let them know what you would like them to know about being aware, about knowing their risk, about getting their screenings. Put it all together for us.

Dr. Bremner:  So, mainly what I need to tell women especially new patients who come into my office or if I’m in the community giving a talk, I think the biggest and most important thing is to get your screening mammogram and to set up your care with your primary physician to make sure that you are getting your annual screening mammogram and you are getting the appropriate mammogram meaning whether you need two dimensional or three dimensional imaging. That’s a start. So, you get your screening mammogram.

I think what’s really crucial is something called risk assessment which is where you are evaluated by your primary care physician or someone like myself where we can take your information including your family history, your age, your weight, if you have had any previous biopsies, lots of different factors so that we can determine what your personal risk is of developing a breast cancer in your future. Standard population, is about 12% risk. We all start out about there. But with family history and other factors; that risk can go up. And for instance if a patient reaches a 20% threshold or above, we add on additional imaging. So, we want to assess everybody’s risk at the first time that we see them and then we do that every single year and update that every year to know are they getting all the imaging that they need.

So, mainly, it’s getting in, getting your screening, also assessing your risk and then finally, knowing what your breast tissue looks like, knowing do you have dense breast tissue, do you not. Do you need additional imaging, even if you are not high risk but you have dense breast tissue. So, it’s really a conversation to be had with your primary provider over okay I get my screening mammogram on a yearly basis, what’s my tissue density, what’s my breast cancer risk, and what further studies may benefit me in the future as far as detecting a breast cancer early.

Host:  Wow, what a great segment. That was so informative. Dr. Bremner thank you so much for joining us. You’re listening to TVH Health Chat with Temecula Valley Hospital. For more information please visit www.temeculavalleyhospital.com and share this show with your friends and family. Share with other women you know. It was very informative and we all are learning together from the experts at Temecula Valley Hospital. And please remember to subscribe, rate, and review this podcast and all the other TVH Health Chat podcasts. Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for action or treatments provided by physicians. I’m Melanie Cole. Thanks so much for listening.