Transcription:
Breast Cancer: The Latest Information From UVA

Melanie Cole (Host):  In the United States, breast cancer is the second most common cancer in women after skin cancer. My guest today is Dr. David Brenin. He is the Chief of Breast Surgery at UVA Health System and Co-Director of both the UVA Breast Care Program and High Risk Breast and Ovarian Cancer Clinic. Welcome to the show, Dr. Brenin. So, are you seeing a rise in breast cancer today?

Dr. David Brenin (Guest):  Well, there is a trend towards an increased number of patients being diagnosed with breast cancer today. That is true.

Melanie:  Are you seeing that more women are coming in for screenings and do we think that that's why we are seeing more breast cancer because there is more awareness for screening?

Dr. Brenin:  That's certainly part of it, but sadly, enough women probably aren’t being screened today. It depends on where you live in the country, the proportion of women who do undergo screening. In Virginia, sadly, it ranks kind of in the middle of the field when we look across the United States for women who have reported undergoing a mammogram. So, we really need to do more to educate women about breast cancer screening and its benefits.

Melanie:  So, then, let's talk about breast cancer screening. When do you advise women to start their first mammogram?

Dr. Brenin:  Well, that's a very complicated subject right now and there are several points of view. At UVA, what we recommend is that when women approach the age of 40, that they sit down with their primary care doctor and evaluate their risk of developing breast cancer and also sit down and think about what their goals are in terms of risk reduction and how they feel that breast cancer screening would fit into their lives.

Melanie:  So, what do you tell women every day about getting their first mammogram--that baseline to see where they stand--and then also self-exams. Do you think women should be doing this on a regular basis as well?

Dr. Brenin:  Let's first talk about breast imaging and mammography. So, when a woman should start mammography, probably should grow out of that discussion that I mentioned earlier with their primary care doctor. For women who are high risk--in other words, women who have many family members with breast cancer or perhaps have received radiation therapy as a child or who have had previous breast problems-- it makes sense, clearly, to start routine screening and mammography at age 40 and to undergo that test once a year. Certainly, if not starting at 40, they should start at age 45. For young women, for women between the ages of 40 and 55, if they are going to have mammography, it makes sense to do it every year. I think that once women reach the age of 55, the types of tumors that are most common in the post-menopausal patient are more slow growing tumors. So, it is reasonable to consider cutting down the frequency of mammography to every other year, but beginning at age 45; whereas, tumors that occur in women between the ages of 40 and 55, tends to be a little bit faster growing. So, it makes sense to catch those tumors when they are smaller with breast imaging and in order to do that, they really need to have the mammogram once a year.

Melanie:  We hear about other types of imaging. There is advanced ultrasound and 3D tomosynthesis. What do you tell women when they ask you if they have dense breasts, which one should they go for? Does insurance cover it? How do they decide which one to get?

Dr. Brenin:  Well, 3D tomosynthesis is a relatively new technique that is available to many patients around the country. The real benefit of the 3D imaging is that it decreases what are called “call backs”, in other words, what we know as false positives, wherein a patient has a mammogram, a routine screening mammogram, and she gets a phone call that says you need to come back for more imaging. That's a very stressful situation and it would be ideal to avoid that and 3D mammography or tomosynthesis decreases the risk of that substantially. In terms of ultrasound, this is something that may be useful for patients who have high breast density or extreme mammographic breast density. This would be in addition to a mammogram or tomosynthesis.

Melanie:  So, then, as women hate that waiting for that call back, as you say. That's just a terrifying feeling for most women, then what? If you see something suspicious, then what goes on diagnostically as the next step?

Dr. Brenin:  Well, typically, there'd be more imaging and if, on the additional imaging, the area that looked suspicious continues to look suspicious, the next step is usually an Image Directed Biopsy, where, most commonly, under ultrasound guidance or under x-ray guidance, a small needle is placed through the skin and into the abnormal area and some tissue is removed for analysis by a pathologist.

Melanie:  So, Dr. Brennin, before we get into some of the advances in treatment for breast cancer, people hear on the media are all over about the BRCA Genes and they don’t understand that these are genes we already have. It's the mutation of the genes that you all are looking for. What do you tell women who ask you, should they get tested for this mutation?

Dr. Brenin:  So, there are very clearly articulated indications from the various cancer societies about which patients should undergo genetic testing for BRCA 1 and 2 mutations. Typically, what we are looking for is women who have multiple breast cancers within the family, usually over several generations. Most often, these cancers occur in relatively young women, in other words, pre-menopausal. We also look for any patient family history of ovarian cancer and, to a less extent, pancreatic cancer and melanoma. So, we have to look at the entire family history for these types of malignancies and, if we see a preponderance of these malignancies within the family, we will usually recommend genetic testing. Often the genetic test includes, today, more than just BRCA mutation testing, but panel mutation testing. So, we look at some other areas that we know that genetic polymorphisms may impact on breast cancer and other malignancy risks.

Melanie:  And, I know that it depends on the patient and it's certainly individual, but as far as surgical interventions or first line of defense if a woman is diagnosed with breast cancer, what are you seeing most often, Dr. Brennin?

Dr. Brenin:  Well, still today, breast preservation or lumpectomy is definitely the most common treatment that women select to treat their breast cancer as long as they are candidates for breast preservation. Mastectomy is the other option and it is true that we are seeing a little bit of an uptick in women who are eligible to save the breast, who choose to have a mastectomy. But, right now, still the preponderance of women do undergo a lumpectomy or breast conserving therapy.

Melanie:  And, then, for after the fact, are they going on to Tamoxifen or are there different medications out there today? What about after a lumpectomy or a mastectomy?

Dr. Brenin:  Well, after a lumpectomy, we are going to do several things. The first thing after a lumpectomy is the patient's going to receive radiation therapy to the breast as an adjuvant treatment. But, in terms of systemic treatment like pills or chemotherapy, I think that perhaps that really is your question and Tamoxifen is used a little bit less frequently today. We have newer agents called “aromatase inhibitors” that are a little bit more effective than Tamoxifen and also have a little bit of a different but more preferable range of side effects. Chemotherapy is also something that is very commonly given to patients who have breast cancer, although fewer and fewer people today are having chemotherapy after surgery for breast cancer because we have very good techniques to try to identify which women will benefit the most from chemotherapy, based on certain molecular characteristics of their tumor. We can now do a test on the patient's tumor, which will help us determine what that individual patient's risk is for the tumor coming back elsewhere in the body and what the impact on chemotherapy would be to lower that risk.

Melanie:  And, as far as advancements in what women can look for in the future, are you doing immunotherapy, targeted cell therapy for breast cancer? Tell us about some of the latest advances.

Dr. Brenin:  So, it's the hope of the community that immune therapy is really going to be the next step in our treatment of all types of cancers. To date, there has been some evidence in certain selected groups of women who have breast cancer that immune therapy may be effective. But, at this point in time, it really is the very beginning of the evaluation of immune therapeutic techniques to treat breast cancer. Most of the immune therapy that has been shown to be very effective has been against cancers that are, in themselves, more immunogenic; in other words, that the immune system can detect them. One of the problems with breast cancer is that it has the ability often to fly under the radar of the patient's immune system. So, that is not very immunogenic as compared to something like melanoma, which is one of the most immunogenic cancers that we see. Breast cancer is often undetected from the body. The hope of using immune therapy to treat patients with breast cancer is to wake up the patient's immune system so that they can detect that cancer that is sitting there; that, prior to giving an immunotherapeutic drug like a checkpoint inhibitor, that the tumor was not seen by the patient's immune system. Some of the breast cancers that we are seeing today, it is effective in, but the vast majority to date, that has not been the case.

Melanie:  It's absolutely fascinating what's really going on and so, in just the last few minutes, Dr. Brenin, tell us about your team at the UVA Breast Care Program.

Dr. Brenin:  The UVA Breast Program is a true multidisciplinary team that takes care of all of our patients who are seen with breast cancer at UVA. When you come see us at the UVA, you are not only seeing a surgeon, but your case is evaluated at our weekly tumor board where all the breast surgeons will be there; all of the medical oncologists--the doctor's that give chemotherapy; all of the radiologists--the doctors that look at your mammograms; the pathologists--those are the doctors that look at the slides from the biopsies; as well as radiation oncologists; and the entire care team of care coordinators, social workers, as well as all of our trainees. Each Friday at UVA, every breast cancer that's treated here is reviewed by a group of at least 30 individuals and the patients really do benefit from that shared experience.

Melanie:  Thank you so much for being with us today, Dr. Brenin. You are listening to UVA Health Systems Radio and for more information you can go to www.uvahealth.com. That's www.uvahealth.com. This is Melanie Cole. Thanks so much for listening.