Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And today, we're highlighting mammograms and breast cancer screenings for pregnant and postpartum patients. Joining me is Dr. Georges Sylvestre. He's an Assistant Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medical College-Cornell University. Dr. Sylvestre, it's always a pleasure to have you join us. I'd like you to start by giving us a little overview about breast cancer, what you're seeing as far as incidents, awareness? Are more women getting screened? What are you seeing in the trends?

Dr. Georges Sylvestre: Well, the trends, as you know, unfortunately, is not reassuring with respect to breast cancer incidence. So, the incidence, which means how likely is a woman to have breast cancer in her lifetime, is increasing. And for good news, women are living longer and screening tests have improved with respect to finding lesions very early. So, still one in eight women. That is 12% of women are going to be affected by breast cancer in their lifetime. So, that's super important.

The good news, though, is that if you think 1975, which is not that long ago, survival was 75% overall for breast cancer. Now, it's over 90% in 2024. So, there have been really great strides in the detection and the treatment. So, that's one good reason to detect it and detect it early. So, that's how things have changed recently.

Melanie Cole, MS: Has anything changed as far as risk factors? Speak a little bit about the genetic predisposition, what role inherited trait plays in developing breast cancer, but then also environmental factors and risk, because we're going to be talking about pregnancy and postpartum, and you typically would think, "Oh, nobody's at risk when they're pregnant. They're so young." But that's not the case anymore, is it?

Dr. Georges Sylvestre: It is so true, Melanie. In fact, the incidence rise, the most important rise has been seen in young women. That is women younger than 50 and also women younger than 40 years old. So, that really overlaps a lot with the age that women become pregnant. So, the incidence in the young age group increases.

So, the genetic fix factors have not increased. Obviously, our genetic predispositions have not changed. What has changed is our ways to detect it. So, obviously, genetics have improved a lot in the last decades. It's still budding in terms of how much it can detect. Quite a few more breast cancers have been found to be genetically inherited, and we've identified mutations. So, in fact, the genetic inheritance in breast cancer have not increased, but the ways for us to find who's at risk genetically have improved significantly.

Now, the risk factor that have increased in the last decades is unfortunately obesity. Obesity is a risk factor for breast cancer and, you know, unfortunately, at least one out of two women, these in ages of youth, and men too, but more women. So, that has increased and that's potentially modifiable, and it doesn't pertain to pregnancy itself because we're talking about pregnancy, but having never been pregnant before also increases the risk, and also older age at first pregnancy. So, these two things have increased significantly. So, more women have no children and that's fine, it's the right decision for them. And more men, women who have children, have them later in life. So, those are also risk factors that increase the risks of breast cancer.

Melanie Cole, MS: When do we get screened? Based on these risk factors, based on the prevalence and incidence and the trends that you were discussing, who gets screened and when?

Dr. Georges Sylvestre: What do we mean by screening? There's many ways of screening. So, I think it'd be wrong to equate screening with mammograms, because there's a lot more in screening for breast cancer. It's what we talked about, you and I, right now, identifying women at increased risk for breast cancer and identifying women who are not at increased risk for breast cancer screening is different. But you asked me about screening. So, what is screening? The first of all is know your breast. We used to talk about breast self-examination a lot.

And just before I start discussing this as a disclaimer, American Cancer Society, ACOG, the American of OB-GYN, and the American College of Radiologists, slightly different in their recommendations. But the bottom line of this screening is, first of all, a woman's knowledge of her breast. We don't talk about yearly or monthly breast self exams anymore as much, but we recommend that women know their breasts, to know their breast architecture young. Somewhere between 25 and 35, know your breasts, know the lumps that are there, that are not there. And there's no need to systematically examine your breasts once a month, like at a particular time of the cycle anymore, but do it and know when there are changes in your armpit and your breasts. So, that's the first thing.

And then, at the OB-GYN's office, midwife, primary care's office, have a clinician do your clinical breast exam. And then, the recommendations differ slightly from society to society, but American College of OB-GYN, which is the college I belong to, recommends discussing breast exams sometime between 25 and 35, not being necessarily an absolute, although most people do it out of habit. And women like to have their breasts examined when they go to the gynecologist's office. But more and more in medicine, as you know, Melanie, we discussed shared decision-making. So when you know your patient discuss, like, "Listen, there might be a pro in examining your breast," me doing it every year to three year, but it's not so clear that makes a big difference. So, I discuss with patients, "We've examined your breast last year, last pregnancy. Do I do it yearly? Do you want to do every three years? I'm perfectly fine with it." But I think it's important to involve women in that kind of decision with respect to screening.

Now, with respect to mammograms, again, societies slightly differ from one another. But, clearly everybody agrees that average risk women, not about the high risk women, but average risk women, do not need mammograms before the age of 40. At 40, societies differ with respect to recommending yearly versus every two years mammograms starting at 40 versus 45 versus 50. I think most of us are used in discussing mammograms yearly, but it's totally reasonable to do it every two years, mammograms. But again, I involve my patients. If she's like, "I really want my yearly mammogram. I feel strongly about it. My friend had it or I want to know my breast better, that's fine." But there's no clear evidence that doing it yearly versus every two years makes a huge difference. But mammograms were definitely part of the screening method.

Melanie Cole, MS: What are the conditions for which a pregnant woman might need a screening for breast cancer? Usually, as we said, if you're in your reproductive years, that's a little too young for certain screenings. Speak about when you would recommend a pregnant woman get screened.

Dr. Georges Sylvestre: That's a shared decision. Certainly a woman who is at high risk, that is a known genetic mutation in herself or in her family, a prior biopsy that was "iffy" or suggested a precancerous lesion or a suspicious lesion that was nevertheless not cancerous, she's definitely more at risk. And like I said before, more and more up to have pregnancies later in life. So, a 42-year-old woman who walks in my office pregnant with a high risk of breast cancer and never had a mammogram, I will discuss it with her.

That being said, it's important to note that the screening mammograms are absolutely not dangerous, okay? But the sensitivity might be slightly lesser in pregnancy. So, depending on her risk, she might say, "Listen, I'm here, I have good medical coverage right now. I have good medical care. I can get a referral easily. Let me do it because I'm, say, 20 weeks pregnant, as opposed to postpartum, where I'll be super busy, perhaps breastfeeding, perhaps I'll lose my insurance." So, it's all a matter of risk-benefit and to discuss them with the patient. But certainly if the patient's at higher risk, I recommend a screening mammogram then, especially if she never had any recent or any mammograms in the past.

Melanie Cole, MS: What about postpartum women? Is it basically the same? And you said they're going to be busy, obviously. Is it different if she's nursing? Because, I mean, mammograms are not the most comfortable thing, but they're really not that bad. They only take a few seconds, but I can't imagine if somebody is full, that having a mammogram wouldn't, you know, be recommended.

Dr. Georges Sylvestre: I'll talk about two types of mammograms. The one that I ordered because I find something is suspicious versus a screening mammogram. The screening mammogram is probably the same thing in breastfeeding and pregnancy. It's very safe. There's no question about that, but it's just not as sensitive in detecting lesions. That being said, breast is best. I encourage breastfeeding to my patient as long as they want. Our recommendation is at least exclusive breastfeeding until the age of six months, and I don't want screening to get in the way of that. So if a woman is at higher risk of breast cancer and she wants to keep breastfeeding six months or more, I think it's totally reasonable to offer breast cancer screening with a mammogram.

It's also reasonable to wait if she's not particularly high risk or say she plans to breastfeed for a limited period of time after nursing. The general recommendation is that the sensitivity of the mammogram will markedly improve three or four months after you stop nursing.

Melanie Cole, MS: Okay. So Dr. Sylvestre, you're giving us so much to think about. God forbid, if a woman is diagnosed, especially if she is pregnant or in her postpartum time, what's the next step? Where does she turn? What does she do next?

Dr. Georges Sylvestre: I'll answer that question in different scenarios because I've seen them all, all of them with good outcomes. So, more women survive breast cancer and come to my office wishing to become pregnant or already pregnant. So, that's wonderful because breast cancer is so survivable now that it's totally realistic for most survivors of breast cancer to be pregnant. So, that's not an issue. Every couple of months I treat women or care for women for prenatal care who are getting at the same time treatment for breast cancer.

The good news is that if you do have breast cancer diagnosed shortly before pregnancy or during pregnancy, there are options. Chemotherapy, surgery, maybe safe options in pregnancy. The only thing that's a big no-no because of the proximity of the uterus is radiation, but there are options for breast cancer diagnosed during pregnancy and during postpartum. Obviously, during the postpartum period of breast cancer, if it's diagnosed and chemo is needed, then a cessation of breastfeeding would often be necessary, but that's a different story. But I've seen that several times, but almost always the outcomes are excellent.

Melanie Cole, MS: You've given us so much hope and good information. You know, really upbeat for the state of breast cancer and survivability today. Dr. Sylvestre, as we wrap up, you spoke about shared decision-making a couple of times today. So, I'd like you to speak about that, how self-esteem, reproductive age, peace of mind are all taken into account when we're talking about screening and deciding about treatments and ongoing watching to see what's going on.

Dr. Georges Sylvestre: Yes, that's just an important point. It's important when I see women, which is obviously in my case during pregnancy. I make it a good point at some point to sit down and discuss breast cancer using the postpartum visit. Let's establish a plan of followup based on your age. So, let's identify if you have risk factors, because for important risk factors, we can offer referrals to medical geneticists and surgical oncologists, we can discuss even further methods of screening and treatment. But let's establish if it's high risk or a lower risk. And let's discuss how we want to be screened. How often do you want a breast exam? Not everybody feels the same way about having a clinical breast exam at the GYN's office. So, maybe she wants it once a year, every three years, or wait until she's 35 or 45. In many cases, a decision is the right one. The decision that you make with your doctor may be totally an option for you. And the same thing goes for mammogram. When do you want to start your mammogram? Do you want to start your mammogram at 40 every two years? Every year is at 50, based on your insurance or based on your personal wishes. My personal history, my mother died of breast cancer last year, so maybe I would feel very differently if I were asked that question during pregnancy. And keep in mind also that the pregnancy is a very specific important period where you do have a nine-month relationship with the provider with whom you can discuss the pros and cons of the breast cancer screening. So, I think it's an excellent time to discuss your risk and your wish for screening, the hows and the whens.

Melanie Cole, MS: Thank you so much, Dr. Sylvestre. And thank you for sharing about your mother because that really does tell women how important it is to discuss this with their physician. Thank you again so much. And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, iHeart, and Pandora. For more health tips, go to weillcornell. org and search podcasts and parents. Don't forget to check out our Kids Health Cast. I'm Melanie Cole. Thanks so much for joining us today.

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