Caitlin Whyte (Host): Welcome to the Live Greater podcast series information for a healthier you from the University of Maryland Medical System. You've put in the work and done all the tests and now found out you were at a high risk for breast cancer. So, now what? Today, we will discuss what comes next with Dr. Ethan Rogers, a breast surgeon affiliated with the breast health center at UM St. Joseph Medical Center.

Well, to start us off today, doctor, can you tell us what does it mean to be at high risk for breast cancer and how is this risk assessed?

Dr. Ethan Rogers: The average woman has a risk of about 12.5%. So, that's why we say that there's a one in eight chance that a woman will get breast cancer. So, high risk is defined as greater than 20%. So, it doesn't take a lot to go from that 12.5% average risk to above 20%. We assess it in couple of different ways. You can just go by knowledge of a patient's family history if it seems fairly excessive, but there are also risk algorithms that we use plugging in patient's information to actually spit out a percentage risk over a five-year period or over a lifetime.

Host: Well, what are some common risk factors for breast cancer and how do they contribute to an elevated risk?

Dr. Ethan Rogers: Family history is certainly one of the greatest risk factors, number of first-degree relatives with a history of breast cancer. So, for instance, if you had two sisters who had breast cancer, or a sister and a mom who both had breast cancer, that would automatically put you at high risk for developing breast cancer. Also, in addition to those family history risk factors, there are certain pathologies that when we get on biopsy it automatically puts a patient at high risk for developing breast cancers. Things like atypical ductal hyperplasia or lobular carcinoma in situ. Sometimes those are identified on a pathology after a biopsy. And those are things that put patients at a higher risk for developing breast cancer down the road, not even just in the breast where the biopsy was, but potentially in both breasts.

Host: Well, if someone is identified as high risk, what role does early detection and intervention play in improving outcomes?

Dr. Ethan Rogers: As with mammography in general, any time that you can catch something when it's smaller or less advanced within the breast, patients always do better. So, particularly for patients who are at high risk who wouldn't be normally getting their screening mammogram, so those younger than 40, identifying someone as high risk puts them into the screening paradigm where they wouldn't have been otherwise. You prevent the occurrence where someone's coming in after they feel a lump. Normally under those circumstances, the mass is automatically bigger than what it would have been if someone was having routine screening, either done yearly or twice a year.

Host: Well, on that note, how else does breast care look different once you've been told you have a high risk for breast cancer?

Dr. Ethan Rogers: The screening paradigm changes then from what you would normally have for average screening. So, average screening typically starts at 40 with a mammogram yearly. For high risk patients, we'll typically do two imaging studies per year. So, they might have a mammogram once a year. And then, at a six-month interval, they might also have MRI performed of the breasts as well.

For women who have genetic mutations and they're the cause of the patient's high risk, they might start off with MRIs yearly at 25 or 30. The other thing that might happen with a screening regimen is if someone's high risk, and they've had relatives who have had breast cancer at a younger age, say, early 40s, we might start their imaging 10 years prior to that to try and catch them earlier.

Host: Well, with that, how can individuals proactively assess their own risk for breast cancer? And when should they consider seeking professional guidance then?

Dr. Ethan Rogers: I think everyone has a sense of their own risk for breast cancer just based on their own family and personal history. And with that said, I do feel that people always do potentially think their risk is higher than it might be. So, I really do think if anyone has a question about what their risk is for breast cancer, they should at least start out with a conversation with their primary care physician or gynecologist or whatever physician they're seeing routinely, and kind of pose that question. And typically, those practitioners will have experience with prior patients in the past who have been at high risk and know who to send a patient to, i.e., a breast surgeon like me.

Host: Gotcha. Well, we touched on my next question a bit already, but how does genetic risk play a role and what testing options are available for individuals concerned about inherited risk factors?

Dr. Ethan Rogers: So, about 95% of breast cancers are just random events. So women will often ask, when they're diagnosed with breast cancer, you know, how did this happen? So for the majority of the time, there really isn't an answer, which can be satisfying or not. But there are those 5% of women who will have a genetic mutation as the cause of their breast cancer. And so, there are a number of genes that are involved in DNA repair. And so typically, those are the ones that are associated with the development of cancers, and some of them have high risk for developing breast cancer, like 60-80%. And some fall in the 30-40% range, but they all have a certain risk associated with them for developing breast cancer and other potential cancers. So, there have been occasions where patients have done the commercial genetic testing like 23andMe and all of those different things and it has demonstrated, "Oh, you know, you might have a breast cancer gene." And then, we've done confirmatory testing later on to demonstrate that they actually have a genetic mutation.

So, it might not even be that a patient has a family history of breast cancer. There could be other types of cancers that are associated with those mutations, like an ovarian cancer, or a pancreatic cancer, or melanoma, or even colon cancer. So, I find that it's best to just take a thorough family history. Patients should really know what their family history is in order to assess their risks. They should ask their parents, they should ask their grandparents, whether or not there are any family members who have had breast cancer. I find that a lot of patients don't know because people don't really talk about it. Or they're of a generation that didn't really speak about it, or their parents were of a generation that didn't really speak about it. And it's important to figure out what that risk is. Because I've certainly had patients who have been diagnosed with breast cancer that didn't have a family history of it, and have been surprised when their genetic testing comes back as positive. That's how we approach those patients with genetic mutations.

Typically, we'll send them to the genetic counselor to have a discussion about risks and benefits of doing testing, what to expect, potential costs associated with it, and they work with the genetic counselor to potentially pick out the best testing that's appropriate for them, which genes to look for given their family history of cancers, what potential test to send out given cost and insurance coverage. So, it's a collaborative experience with the genetic counselor. Typically, it's either done as a blood draw, takes about two weeks to come back, or a saliva test.

Host: Right. So, knowing your family history is key, but are there other preventative measures that individuals at high risk take to reduce their likelihood of developing breast cancer? Are there specific lifestyle modifications that high-risk individuals can adopt to further reduce their risk?

Dr. Ethan Rogers: Sure. They're the easy ones to say, but potentially not so easy to do, and they're the things that we'd probably recommend across the board for just maintaining health. So, weight loss and cutting back on alcohol consumption. Particularly in women after menopause, a lot of the hormones that are associated with generating these breast cancers and feeding these breast cancers are produced in fat cells. And so, the more one can head towards ideal weight, potentially the better it is that patients will potentially avoid a cancer.

Host: And as we wrap up here, doctor, for those facing uncertainty and anxiety, what advice do you have for navigating the journey of being at a higher risk for breast cancer?

Dr. Ethan Rogers: I feel like a lot of people avoid genetic testing and avoid having these conversations, because of that fear of breast cancer. And so, the way I frame it is that knowledge is power and it allows you to make medical decisions on your time rather than the cancer's time. And so, all of the things that we do are to put people in a position to have a success and potentially avoid cancer completely, because a lot of women will opt to do prophylactic surgery to avoid a cancer completely, rather than continue to do high-risk screening with mammograms and MRIs yearly. The other component of risk reduction is that surgical component in doing prophylactic surgery before a cancer is identified.

So, I think knowing what the risk is for patients gives people power to make those decisions for themselves as to whether or not they want to do prophylactic surgery to avoid a cancer, or at least know what to expect and do the screening to identify something when it's early. So, it's either risk reduction or early detection. So, those are the two options. Also, it allows other family members to make decisions if they happen to test positive as well. So, knowledge is power.

Host: Well, some really grounded advice and information here, doctor. Thank you so much for joining the show today. Find more shows just like this one at umms.org/podcast and on YouTube. And thank you so much for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media.