Get Well Wednesday: Breast Cancer 101

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Janna Andrews knew at an early age that she wanted to be a doctor. Raised by her mother, Janna’s academic pursuits were encouraged and supported through her mother’s sacrifice. Janna attended Princeton University and majored in molecular biology. She then attended Temple University School of Medicine, after which she specialized in radiation oncology.

Since returning home to New York, Janna joined the staff at NorthWell Health as an Assistant Clinical Professor of Radiation Oncology, at the Zucker Hofstra School of Medicine. Janna specializes in breast and gynecological cancers as well as gastrointestinal cancers. Five years ago, Janna started a nonprofit called “Kicked It In Heels” for breast cancer survivors, focusing on young women and women of color.

BREAST CANCER AND MAMMOGRAMS:

What is the survival rate for breast cancer diagnosis?

Thanks to advances in technology with mammography and improvements in treatment, the death rates for breast cancer have declined by 40 %. There are over 3 million breast cancer survivors nationally because of this. Over 6 million breast cancer survivors worldwide. This decline is attributed to breast cancer being diagnosed at earlier stages in nations where populations have access to medical care and the most current and up-to-date treatment strategies.

What are the current treatments for breast cancer?

Treatments like improved chemotherapy regimens tailored to the patient’s’ cancer profile. Hormonal therapy for patients with estrogen/progesterone positive disease and even tests based on gene analysis to distinguish who would benefit from chemotherapy vs. hormonal therapy. Women that have Her2-nue positive disease can be treated with Herceptin. And there are many second line-targeted therapies to choose from if the cancer does not respond to the first line of treatment.

In terms of mammography, the introduction of 3D mammography has led to a decrease in biopsies of non-cancerous lesions. 3-D mammograms, or digital breast tomosynthesis (DBT), overlays 3-D optical mammogram images with x-ray images. Not every woman benefits from 3 D mammography but for women with dense breast, it is very helpful at distinguishing what may be cancerous from what is noncancerous. Instead of looking at a deck of cards stacked on top of each other, it’s more like looking a deck of cards fanned out.

How many women are at risk for breast cancer?

One out of eight women will be diagnosed with breast cancer in their lifetime. That means this disease touches everyone. It’s rare to meet someone who has not witnessed a friend, a loved one, a mother or sibling go through the treatment for breast cancer.

While the death rate from breast cancer has decreased, the disparity outcomes in women of color have increased. Despite having lower incidence rates, Black women had a 41% higher breast cancer death rate. 10% more Black women were diagnosed at regional or distant cancer stage compared with white women.

For every 100-breast cancers diagnosed, Black women had nine more deaths than white women (27 deaths per 100 breast cancers diagnosed among Black women compared with 18 per 100 among white women).

What are the specific risks for Black women?

Despite significant progress in breast cancer detection and treatment, Black women experience higher death rates even though they have a lower incidence of breast cancer compared to white women.

What are the causes of this disparity? Lack of access to care? Lack of health insurance? Implicit bias amongst health care providers? Cultural nuances? Lack of Black women participating in clinical trials? Employment issues like getting time off of work to go for treatment, or securing childcare, can all impact a woman’s ability to seek care or get the optimal care.

It’s fantastic to see these disparities change for states like Connecticut, Massachusetts, and Delaware. It is probably a reflection of the 2006 legislation passed in Massachusetts that required all state citizens to have health coverage. Massachusetts also has or had a National Breast and Cervical Cancer Early Detection Program that helps women in poverty get the screenings they need.

Do Black women get cancers that are harder to treat?

Black women are 3 x more likely to be diagnosed with triple-negative breast cancers. Triple negative means that the cancer cells do not express the estrogen, progesterone, or the her2-neu receptor.

Because there are no receptors to target, triple negative breast cancer have to be treated with chemotherapy. The outcome for triple negative breast cancer tends to be worse in that recurrences are more common. But that is not to deter women from getting screened. We have multiple treatment options for all of the different types of breast cancer. Triple negative can be treated.

What can be done to help more women get screened for breast cancer?

All of this information can be quite scary to hear and that can keep many women from getting their mammograms. We are working on ways to deliver this information in a less clinical or intimidating way. My non-profit, Kicked It In Heels, did a project this year called the Beauty Shop Initiative.  We asked hair stylists to have the conversation with their clients about screening and what they knew about breast density.

What was poignant for us about this initiative was how many hair stylists were eager and happy to help, but also how many of these stylists broke down crying because they had never been screened themselves and they were too scared. What the stylist told us each time was that having the conversation helped them address their fear and motivated them to get screened.

TEXT TOM QUESTIONS

Q: Why does 3D mammography cost more and insurance does not cover it? 

A: 3D mammography is still relatively new.  It increases the cost of a mammogram by roughly $50-100.  We know that 3D mammography decreases the number of false positives but insurance companies are slow to cover it because there isn’t enough information yet that it will improve outcomes. It decreases the number of callbacks for noncancerous lesions and in a large study of over 450,000 women, the detection of larger cancerous lesions went up by 41%.

Q: We know the females in the family should definitely be tested if there is a high risk. What about the males in the family?

A: Men can get breast cancer, too. This is a great question! Male breast cancers make up about 1% of all breast cancers. There is no screening test for men at this time. Men should be familiar with their bodies and know their family history.  If there is a history of a BRCA mutation or a strong family history then they are at higher risk of developing breast cancer.

What are dense breasts?

A: So when women are breastfeeding, their breast are very dense so just having a mammogram itself can be very uncomfortable. 3D mammography while breastfeeding is safe, but the mammography reading of a lactating breast can be challenging.  If a woman feels a lump or notices a change in her breast while breastfeeding, she should undergo mammography otherwise some centers suggest a woman wait until she’s been done breastfeeding for about six months.

This year I decided to do the 3 D mammography – this was 2 weeks ago. I have been called back for an enlarged mass in my medial right breast. My question is – why was my regular exam unable to identify this in one year?

A:  Unfortunately, the mass may not have been present a year ago. I think the year and a day rule is interesting and I’ve experienced it myself.  I think that is just the insurance companies trying to control their bottom line in assuring that women are being checked at least once a year, but not more often if not indicated.

Q: My mother was diagnosed with breast cancer at 52. When should I start my mammograms?

A: So this is a controversial question. The American Cancer Society recently changed their recommendations two years ago to say that women should start having annual mammograms at age 45 but with the option of starting at 40.  The US Preventative Services Task Force suggest that women should start having mammograms by age 50.

That being said, the American College of Radiology and the National Comprehensive Cancer Network still recommend that mammography starts at age 40 and I agree. Although the risk of developing breast cancer increases with age, young women, especially young Black women, are often diagnosed younger.

Q: What do you think about thermography instead of yearly mammograms to decrease radiation?

A:  Breast thermography should be used as a tool with mammography, but it cannot replace it. Thermography is a risk assessment tool that can give additional information when used with mammography.

Q: How does the common African-American diet impact breast cancer?

A: Eating a well-balanced diet is a great behavioral risk factor that anyone can change. Ideally, postmenopausal women want to avoid large fluctuations in weight gain in an effort to reduce their risk.  Diet and exercise apply to breast cancer survivors as well, both help to reduce the risk of recurrence.

Q: I had my mammograms every year, which were all normal. I felt a lump, went to the doctor, had another mammogram and ultrasound. Neither noticed the lump, but an ultrasound found irregularities. I had a biopsy and was diagnosed with Stage 3 breast cancer 3 years ago.

A: Unfortunately, breast cancers can grow quickly. It sounds like you were on top of your annual mammograms and were familiar with your body to notice a change, which is crucial.

Q: There is a large amount of cancer in my immediate family – my father died from prostate cancer, my mother had kidney cancer and my brother had throat cancer. They are all deceased. Should I be concerned about my cancer risk and would breast cancer specifically be a concern?

A: There are certain familial syndromes that increase your risk of developing breast cancer; they account for roughly 15% of breast cancers diagnosed.  It may be ideal to sit down with a geneticist and go over your family history.  The geneticist can then decide whether you may benefit from having a gene panel run to further assess your risk.

Q: I think why women delay a second mammogram after an abnormal is because they have to pay for it. Why do they have to pay for an abnormal test?

A: That is a good question. I’m not aware that women have to pay for the second mammogram or further screening if the initial test is abnormal.  Women often have to pay for a second opinion, but should fit any charges that arise from additional screening depending on their insurance company.

Q: I have dense breasts and I have a cyst the size of a nickel. I have yearly mammograms. If the cyst gets bigger, should they remove it?

A: It’s great that you are aware that you have dense breasts.  If the cyst is not painful and it’s not affecting the shape of your breast, it probably does not need to be removed.

Q: I m a 46-year-old African American woman and I’ve been getting diagnostic mammograms for the past 4 years or so, because I have dense breasts and a palpable mass in my left breast. I also had a hysterectomy in 2015 because of endometriosis and fibroids. My aunt just finished radiation for breast cancer. Is my risk higher? What changes can I make now to try to keep my risk low?

A:  Yes, your risk is higher because of your family history and also because you have dense breasts. Speak to your physician  -there are medications that you may be interested in using to decrease your risk but going for your annual mammograms and knowing your family history are key. Maintaining a healthy weight, avoiding excessive alcohol use can also help to decrease your risk.

Q: Are there any lifestyle changes that give us an advantage in staving off breast cancer?

A: Exercising up to 150 minutes a week at a moderate pace or 75 minutes of vigorous exercise is a lifestyle change that will pay in dividends. Eating a well-balanced diet, avoiding excess alcohol, all decrease your risk.

Q: I’m blessed to see 50, but does your breast tissue change with age? I felt a difference with my breast exam and had a mammogram & scan with an all clear, but still wonder.

A: Yes, breast tissue tends to become fattier as women age.

Q: My doctor ordered the 3D mamo for the first time last year and they discovered calcification in the left and said they were not cancers and just to come back in 6 months for a re-check. At the 6-month check all was good, then this year the same finding for the right beast, so I have to go back in 6 months for a re-check, What can you tell me about this calcification, what is it and where does it come from?

A: Not all calcifications are cancer, depending on their appearance, they can just be benign findings.  But some pre-invasive breast cancers called DCIS can present with calcifications and the center is watching the calcifications every 6 months to make sure they don’t change.

Q: If you are diagnosed with a Stage 0, why is there an urgency to do the mastectomy? Is it like the Cesarean epidemic because of the type of insurance the patient has? Why isn’t immunotherapy pushed more in our community?

A: There shouldn’t be an urgency to mastectomy for Stage 0 breast cancer.  Depending on how extensive the cancer is in the breast, a lumpectomy may not be the best option but the advantages and disadvantages of both options should be discussed.

Immunotherapy, or using the immune system as a mechanism to fight cancer, is a promising field but many studies and drugs are still under investigation in terms of efficacy. They are often offered on a clinical trial before they are offered to the general public to prove safety and efficacy.

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