Therese Bevers, M.D. Hi, I'm Dr. Therese Bevers, professor of Clinical Cancer Prevention at MD Anderson Cancer Center. I'm here with Dr. Abenaa Brewster, also a professor of Clinical Cancer Prevention. And this is the Cancerwise Podcast. Dr. Brewster, thank you so much for being here today.  

Abenaa Brewster, M.D. Thank you, Dr. Bevers.  

Therese Bevers, M.D. We're here to talk about the rise in cancer incidence in women under the age of 50. A study from the American Cancer Society showed that women are now higher than men as far as getting cancer, especially in younger women. What are you seeing in your breast cancer patients?  

Abenaa Brewster, M.D. Well, I would say that we weren't surprised at all to see that data because I think the experience of everyone in clinic is that we are seeing younger women with breast cancer. And so, certainly it wasn't a surprise to see it, but it kind of really confirmed what we were already observing. And yes, Dr. Bevers, there was a study which showed that the incidence of women under the age of 50 has, those rates of breast cancer have been going up. And, you know, I think that it's led to a lot of speculation about why, and some of the explanations have been, there's been a big change in terms of women's reproductive behaviors. Women are having children at a later age or not having children at all, which we know are factors that have protected against breast cancer. There's less breastfeeding, and there's also data, studies showing that women or young girls are actually starting their menarche or their periods at a younger age, which is also a risk factor for breast cancer. And then of course, as we know, there are other lifestyle behaviors, for example, carrying a little bit too much weight, not exercising, drinking alcohol, those are all factors that we think could be contributing to the rising rates of breast cancer among younger women.  

Therese Bevers, M.D. I think this underscores that it's important to get their screenings. So, let's talk about that. Um, what are you recommending to women? 

Abenaa Brewster, M.D. Well, you know, at MD Anderson we've always recommended that women start breast cancer screening at age 40, but now the United States Preventative Service Task Force has also endorsed that recommendation, and has encouraged women to have a conversation with their providers about whether or not they are appropriate to start screening at the age of 40, as opposed to age 50. So, I think that was a really welcome change because now we're able to screen women at a younger age when we know that their incidence of breast cancer is increasing. But I'm curious to know, Dr. Bevers, how are you managing high-risk women? Because I know that the recommendations for screening them are different from average risk women.  

Therese Bevers, M.D. I think it's real important that women get a risk assessment, talk to their physician and find out if they're at higher risk of developing breast cancer by around age 25 because we might start as young as age 25. We add in breast MRI as a supplemental screening in addition to her annual mammogram. So, we may start MRIs at age 25. May start then the mammograms at age 30. It all depends on what their risk is and what that risk pertains to. We typically start 10 years before the youngest case in the family or age 40, whichever is first, but not earlier than 25. So, that's why I like to say get a risk assessment by age 25.  

Abenaa Brewster, M.D. So, I agree. I always say that, you know, women should know what their risk is. And sometimes I ask my friends, "Hey, do you know what your risk is of developing breast cancer?" And I think it should be something that all women should know. Am I at average risk or am I at high risk? And certainly for women who have a

strong family history of breast cancer, ovarian cancer, pancreatic cancer, we would also recommend that those women specifically look for genetic testing and counseling.  

Therese Bevers, M.D. I think that's very important. So, not just breast cancer is higher in young women. We're seeing other cancers like colorectal cancer. We've actually seen that the American Cancer Society lowered their screening recommendation to age 45. Get your first screening at 45. I think, that's important. We see even younger people getting colon cancer. Again, I think it's important to get a risk assessment. If there's a family history, you may need to start even earlier than 45. And this probably underscores, it's important to pay attention to symptoms that may develop. Abdominal pain, a change in your bowel habits, blood in your stool or something like that, unexplained weight loss.  

Abenaa Brewster, M.D. And certainly for breast, we also advise our patients, don't just depend on the mammogram or the MRI if you're at high risk and you're getting a supplemental breast MRI. But know the signs and symptoms of breast cancer. Because particularly in young women who are more at risk for developing aggressive breast cancers, those can occur between the interval of screening. So, we recommend that women just know your breasts. I tell women, you know, I don't even like to use the word "examine your breasts" because it kind of implies that it needs to be done in a certain type of way. And we say, just feel your breast, whether or not you're in the shower, lying in bed, just get into the habit of feeling your breasts. And some of the signs that you really want to look for specifically for breast cancer is feeling something that's a hard rock or a hard mass, certainly looking for any skin changes, specifically swelling of the breast, a redness of the breast, puckering in of the skin of the breast, changes of the nipple or the areola. You know, those are all symptoms that if you experience them, that you should certainly bring to the attention of your physician.  

Therese Bevers, M.D. Gynecologic cancers also account for a number of cancers and certainly you can be screened for cervical cancer with a pap smear, or HPV or a combination of the two tests. And I think that's important, but knowing those symptoms, again like abdominal pain, but even feeling full early or feeling bloated all the time can be a

symptom that you should pay attention to. If there's abnormal bleeding or bloody discharge, pay attention that. Blood after intercourse could be a sign of cervical cancer as well.  

Abenaa Brewster, M.D. Yeah. And you know, we spend a lot of time, certainly in the Cancer Prevention Center, talking about early detection and making sure patients have their risk assessment and they're getting appropriately screened. But another area that we spent a lot time with patients is about prevention. And, you know for prevention clinics, they're called prevention and not screening clinics, because we know that we can prevent a significant proportion of cancers. So, I'm curious, how do you advise patients on prevention strategies around diet?  

Therese Bevers, M.D. I tell them to have a diet that is largely plant-based. I'm not saying vegetarian or vegan. I'm saying that most of your plate should be vegetables, fruits, whole grains, and only a small portion should be animal-based. I think limiting alcohol at the minimum, but it's best to abstain because we know that just any alcohol increases the risk of a number of cancers including breast.  

Right. I think that that's probably the behavior that's the most challenging, is the alcohol. More and more women are drinking socially. And, you know, I always talk about, you know, "girls night out." And and that's where you know the binge drinking where you're maybe consuming, you know, two to three or even four alcoholic beverages. And so, what I advise my patients is really view alcohol, if you are going to drink, as something that you have for a special occasion. It should not be used as a Tuesday night, I'm home after work and I'm using alcohol to relax. It really should be for a special occasion, because then you'll find that you will end up drinking less. And you know, in those moments where you are in social occasions, try to replace alcohol with a mocktail. Yeah. There are great mocktails out now. And so, kind of just being very mindful that not every occasion that you're out and about requires you drinking alcohol is definitely one strategy to try to reduce the amount of alcohol that you're drinking. And the same thing I say with exercise, you know, and I'm curious, what are your tips for exercise?  

Therese Bevers, M.D. Well, I tell them that they want to get 150 minutes of moderate exercise. Or if they do more vigorous, they don't have to have as much. But that's minimums. You can always do more, and do at least two strengthening sessions a week where your weights, things like that. I think that these are some of the areas that are really concerning in the current society is we're seeing more overweight and obese individuals, especially women, sedentary lifestyles, binge drinking. And it's resulting in earlier cancers.  

Abenaa Brewster, M.D. Right, specifically for breast cancer we know that being overweight, drinking too much alcohol and being sedentary, if we were just able to kind of, really address just those three behaviors we could reduce the rates of breast cancer by about 30 percent, which is kind of really remarkable when you think about it.  

Therese Bevers, M.D. It is. And women are empowered to be able to take charge of their life and do something about it.  

Abenaa Brewster, M.D. Yeah. And the exercise is tough, you know, I can't tell you how many times I see women in the clinic and they say, "You know, it's really hard. I come home after work, I've got to get dinner, I've got to get the kids to bed. And I just don't have that time for myself." And I say, "Well you know, in this case it's OK to be a weekend warrior." You know, the data shows that it doesn't matter where you get that 150 minutes. And so, if you can carve out an hour on day and an hour on Sunday to go for a brisk walk, which, you know, maybe you can do that for an hour each day, that you can get very close to checking your exercise box. And then fitting in a quick walk during the week. So, I think that we have to spend, we have encourage women to spend the time to look after themselves. And at the same time, just understand that there are a lot of different ways in which women are being pulled, and how we can help them incorporate some of these strategies into their busy lives.  

Therese Bevers, M.D. Yeah, I think even just being mindful of maybe get off the bus or the train, a stop or two early, and walk that distance, walk it briskly. You can pick up 10 minutes there and 10 minutes back and get 20 of your 30 minutes that you wanted to get that day in, just getting there.  

Abenaa Brewster, M.D. Right, absolutely. Yeah.  

Therese Bevers, M.D. Well, thanks for being here today. This was a great discussion. For more information or to request an appointment at MD Anderson, call 1-877-632-6789 or visit MDAnderson.org.