- Coming up on WTVP's "Docs on Call", it's Breast Cancer Awareness Month.

We're discussing everything, from risk factors to detection to treatment.

(upbeat music) (upbeat music continues) (upbeat music continues) Good evening, and thanks for joining us for WTVP's "Docs on Call".

I'm Mark Welp.

Breast cancer is the most common cancer in women worldwide, and the second leading cause of cancer death in women.

About one in eight women will develop invasive breast cancer in their lifetime.

To give us more information, we have with us Dr.

Rozana Dwyer.

She is a board certified general surgeon with Graham Health System in Canton.

Thanks for coming on, Doctor.

- Thanks for having me.

- Appreciate it.

We got a lot to cover here.

First, let's talk about different kinds of breast cancer, because it's not a one size fits all disease.

- That's right.

There's common breast cancers, which include ductal carcinoma, and other types, including lobular and various other ones.

But in general, breasts are composed of ducts and lobulars.

Basically, one makes milk, and one transports the milk.

And these areas are, you know, hormonally active throughout the woman's lifetime, and, you know, array can happen with the cells that can lead to a type of cancer.

Another kind of fork in the road with these cancers are some are hormonally expressive and some are not, which definitely changes the treatment plan.

- Does the size of the breast have anything to do with, you know, if you have a larger breast, does that mean you're more likely to get breast cancer?

- No, no.

- Okay.

- Yeah, size is not a risk factor.

- [Mark] All right, yeah, we wanna put some of these myths to rest.

- Sure, sure.

- So size does not matter in that case.

And is it true that the older you get, the more likely you potentially are to get breast cancer?

- Most breast cancers are diagnosed in your 60s, I would say, on average, but there's definitely... Some breast cancers are in younger women.

Vast majority of breast cancers are what we call sporadic, which means not genetically inherited.

So that just means, you know, during a cell repair, your DNA went array and started overgrowing, and that's what cancer is, it's just an unchecked overgrowth.

So unfortunately, it can happen in younger women, but vast majority, it's in older.

- And let's talk about risk factors.

- Yeah, risk factors for breast cancer.

One, being a woman, right?

It's one of our hormonally active organs.

So, breasts for women, prostate for men.

The longer estrogen exposure, so early periods, late menopause.

Not having breaks in estrogen exposure, like not having children, are risk factors.

Obesity and heavy alcohol use are risk factors.

The thought process behind those are they induce inflammation, which could lead to those abnormal cells forming.

And then of course, family history is a significant key to your development of breast cancer.

So if you have, you know, mother, sister, aunt, couple generations of women with it, your chances are increased.

- Besides the physical, you know, feeling a lump or something like that, what are some of the symptoms that people who have breast cancer might have?

- Vast majority do not have symptoms.

The lump would probably be the most common symptom mentioned.

Rarely it's pain, but that's where the benefit of the screening mammogram comes in, because it catches these abnormalities really early, where most of the women don't even notice a problem.

Some other maybe symptoms they might notice, if their nipple retracts or starts having bloody discharge, those are some kind of warning signs that there might be an underlining issue.

- So, where do we start when it comes to screenings and things like that?

Is there an age you should start at, or I guess if you do have some of these risk factors, maybe do you start younger than other people?

- Yeah, for the average risk woman, with the main medical societies, there's some disagreement on exact, but vast majority start at age 40, okay?

If you have a first degree relative with breast cancer, you would possibly start 10 years prior from that diagnosis, which could put you under 40.

If you have an inherited genetic predisposition to breast cancer, like BRCA1 or BRCA2, it could be much earlier.

- Okay.

And let's talk about self exams.

Do those start at around the same age, or would that be earlier?

- I would say self breast exam, usually in adult phase.

So I would advise, you know, 18 year olds to start.

Just in general, any abnormality they notice in their own body, they would know more than, you know, the clinician they see once every year, every six months, right?

So that goes not just for breasts exams, but skin abnormalities or lumps or bumps, things that are elsewhere that just weren't there before.

So if you notice it, you should tell your doctor.

- [Mark] And how often do you recommend self exams?

- So for women, I would say once a month, and they would definitely need to pay attention to where they are in their cycle, 'cause the breasts change during their menses.

So maybe before or after menses, just to compare.

So, monthly.

- Okay.

What can women do to prevent it?

I mean, they may not be able to do it totally, but- - Within their control, maintaining a healthy lifestyle, you know, alcohol intake in moderation, avoid nicotine use are two things in their control, as well as, you know, exercise.

- Do you think women in general, do they follow these guidelines well enough in terms of, you know, getting those mammograms when they're supposed to and things like that?

They can't be as stubborn as men and put it off.

- No, no, they definitely... You know, I don't know what the national compliance rate is, but I would presume it's high.

Yes, women do tend to seek medical care a little more diligently than men in general.

In fact, they've done studies on this that demonstrate that men who are married live longer.

- You're kidding.

- As opposed to unmarried men.

It's called the marriage protective index.

- Okay.

- The same protection doesn't apply to married women.

But if it's similar to the screening colonoscopy, screening colonoscopy is only about 52%.

So, I don't know.

- But that's a lot harder than a mammogram.

- Definitely.

- Or at least takes more time.

- Yeah, it's more invasive and requires anesthesia, as opposed to a mammogram, which is an X-ray taken in two views of the woman's breast, one facing up and down, and one from side to side.

So that's the most basic X-ray.

It's a two view X-ray of each breast, and it allows the radiologist to compare each side.

And the mammogram is most sensitive for women that are a little bit older, actually, 'cause our breasts are less dense, there's a little more fatty tissue, so those X-rays can penetrate through, as opposed to younger women who have very dense breasts.

Those X-rays kind of retract off that density and kind of obscure the view.

And that's where ultrasound comes in, and other adjuncts like accelerated breast ultrasound or breast MRI, these are all types of different ways to look at those dense breasts so we can kind of get a view.

And that's especially important for younger women where we have a concerning mammogram finding.

- And for those women who, you know, may think, "Oh, I don't wanna get a mammogram, it sounds painful and uncomfortable," kind of walk us through it.

How long does it take?

Is it painful or uncomfortable?

Things like that.

- Yeah, so, usually, most insurances will pay for a screening mammogram.

It's part of the preventative health strategy.

And it's usually ordered by your primary care doctor, but some facilities, like our own, can be walk-in.

The total turnaround is very quick.

Maybe there's more time probably in registering your name and, you know, collecting your insurance and waiting to get it done.

But a mammography technician comes in, has you in a private room where you can undress.

And the actual X-rays are really quick.

It's just two views of each breast.

So, you know, less than 10 minutes.

It is a little uncomfortable for sure.

It's not, you know, terribly painful.

But you do have two plates that are basically applying some pressure to your breasts so we can get a good picture, but very quick.

- Okay.

- So we advise people to maybe take a Tylenol and ibuprofen beforehand, just in case there's any discomfort, but it's not longstanding.

- And on average, what would you say the turnaround is from the time they get the mammogram to when they might find out the results?

- Usually 48 to 72 hours.

Depending on your institution, how many radiologists are reading, you know, it could be pretty quick.

- Okay.

- Yeah.

Rarely longer than that.

- So, kinda walk us through what happens if the radiologist does find something that's concerning on those X-rays.

You know, does the patient talk to, then go to, you know, someone who specializes in breast cancer, how does it work?

- Yeah, so the workup usually goes like this.

You obtain a screening mammogram, the radiologist notes something's off, whether it's a actual mass or calcifications or some asymmetry, 'cause we're comparing both breasts.

So then the next step usually is a diagnostic mammogram with ultrasound.

So diagnostic means there's more, it's an X-ray, but more views.

So they'll do, you know, maybe an oblique view to try to target that area of concern.

In addition to those additional X-ray views, they'll do ultrasound, which is a different technique to kind of parse through that tissue and see if they can, you know, clearly characterize what we're dealing with.

Then the next step is usually based on the characterizations, either seeing or doing an interval short term image in six months if it doesn't look too scary.

And by scary, I mean there's features that give a scoring system.

So if it's a lower score, they might just monitor it.

If it's higher, where they're concerned about a malignancy or cancer, then it's time for a biopsy.

So a biopsy is obtained, and there's different ways based on what we're dealing with, via ultrasound guided or MRI guided or mammogram guided, there's different ways to get that tissue.

But once that tissue's obtained, the radiologist usually leaves a little clip in that area, and that helps guide the surgeon later on where to go after.

So after a biopsy's obtained, then the hormones are tested, the type are tested, and at that point, a surgeon gets involved and an oncologist gets involved, and a radiation oncologist might be involved as well.

Should we go into treatment plans?

(laughs) - Well, yeah, we wanna talk about that eventually.

But I read a study somewhere, and forgive me, I forget where it was, but it said that more women with serious breast cancer, not that any cancer's not serious, but advanced breast cancer are opting to get their breasts removed.

And is that something that... Is that in a very serious case that that happens?

- [Rozana] Like a full breast removal as opposed to partial?

- Yes.

- Yeah, I would say vast majority of early breast cancers... I would say vast majority of breast cancers, especially in the early stages, are done with a partial breast removal called a lumpectomy, and afterwards... Where the tumor or the calcifications or whatever is growing the cancer is removed with the rim of normal breast tissue.

And then afterwards, if it's a estrogen producing cancer, what they do after surgery is take an anti-estrogen medicine for five years, and that reduces their risk of recurrence by 50%.

In addition to that pill, they'll do whole breast radiation, which also reduces their risk another 50%.

So, that is called breast conserving therapy.

So, partial breast removal, radiation, and anti-estrogen pill, okay?

If it's a large tumor or there's multiple cancers or they're higher risk in terms of they have a BRCA1 gene or some other genes that predisposes 'em to, you know, from 40 to 60% lifetime risk, they might opt for a complete mastectomy on both sides, even if there's not a cancer on the other, which would be called risk reducing mastectomy.

And that's a personal decision, a very reasonable decision.

And the decision to then do reconstruction at the same time or not is also a personal decision.

That's usually done with a plastic surgeon.

- Sure.

So, yeah, let's talk a little bit about treatments, and kind of walk us through treatment, maybe, for, I don't know, a small mass, and then let's work our way up.

- Yeah, one of the forks in the road that we mentioned earlier is if it's hormone expressing or not.

So hormones we're looking for are estrogen and progesterone, which are the women hormones, if you will, okay?

And another protein that we look for something called HER2.

And if the protein and the hormones are not expressed, meaning the cancer's just not producing those hormones or protein, it's called triple negative, and sometimes we hear that in the, you know, on advertisements for advocacy for breast cancer.

Usually depending on the size, sometimes chemotherapy is done first, or immunotherapy is done first before surgery in those cases.

And surgery is done afterwards, and then based on the result of the pathology from the surgery and the lymph node testing, that would give a final stage, and that will determine if there's more treatment after surgery.

So that's kind of a broad view of that.

If it's hormone expressing, usually you go to surgery first.

So if it produces estrogen and progesterone and not HER2, usually surgery's first.

- What are the most common types of, you know, we talked about different types of breast cancer, what are the most common ones?

- Estrogen, progesterone producing, HER2 negative breast cancers.

That's the most common type.

And ductal carcinoma is the most common type.

So, in the ducts, in the milk ducts.

- I didn't realize this was all so complicated.

Is that why breast cancer is so prevalent in women?

Because there's so much going on in the breasts when it comes to hormones and everything else?

- Absolutely.

It's our hormone active organ, you know, from starting the period to menopause.

So there's over, you know, it could be 40 years of hormone exposure, so.

Our defense mechanisms also, you know, as we age, are not as strong as when we were younger, so our ability to repair those cells are is not as great.

If we have underlying comorbidities that can make us sicker, like, you know, if we have morbid obesity or excessive alcohol use, nicotine use, these are all things that go against our ability to fight kind of, or to be healthy.

But yeah, breast cancer is definitely our number one cancer for women.

And it is one of the most well studied cancers because it's so common.

And with the advocacy of Susan Komen, of course, and just advocacy in general, there's been a lot of money put into research, and that's where, you know, it can get kind of complex.

Literature's always changing.

And I've noticed even in the last 10 years, 11 years since I've graduated medical school, it's really changed, you know?

For instance, removing lymph nodes has become less and less because the medicine's so good.

They see that a benefit of removing more lymph nodes does not offer a patient a longer, cancer-free life.

So there's definitely certain scenarios where we wouldn't be as aggressive.

For instance, in the lymph node removal.

That wasn't the case just 10 years ago.

- Let's talk about men.

- Yes.

- Men can get breast cancer.

- Men can get breast cancer.

Men have breast tissue.

Men can have breast cysts and fibroadenomas, which are benign tumors, just like women.

Overall, not common.

The higher risk men are those in the family, in the families that carry BRCA1, BRCA2.

And in those cases, they will undergo screening, mammograms, just like women do.

Men can get mammograms.

It's obviously not as much breast tissue as women, but it's the same deal.

X-ray, top, bottom, and side to side.

- Yeah, I guess, you know, like we were kind of joking about earlier, men don't take care of themselves as well as women do.

That's just a fact, I think.

But, you know, a man could potentially have to get a mastectomy too, right?

- Yeah, and in fact, in men, because their breast tissue tends to be smaller, their option is just a mastectomy.

Doing a partial in their case would deform the chest, like, cosmetically.

So, most do have a mastectomy.

- Sure.

- Yeah.

- It seems like, you know, you talked about Komen, and then there's so much attention paid to breast cancer these days, do you think that, you know, we're making significant strides in terms of helping keep women alive, you know, after they've been diagnosed and treatment and things like that?

- Yes, I do, because the mammogram, the screening mammogram push, and advocacy for insurance approval, even, this is early, you know, back in, you know, where there was some barriers to getting that, and the interval of mammograms being approved catch these cancers early.

So we're getting these little abnormalities caught really early, where maybe it would've taken a few years to manifest into a larger mass, right?

So we're catching 'em earlier.

So taking out the cancer earlier kind of stops it dead in its track and reduces your recurrence rate by a lot.

- And with breast cancer, you know, with the different types of cancer, does breast cancer tend to move around more in terms of if you've got a lump?

I mean, is the worry, I guess, that it's gonna spread to the rest of the body?

- I would say vast majority of cancers in general take a little bit of time.

So when a cell becomes abnormal to a mass, it might take years.

And that's the same for a colon cancer.

When a cell becomes abnormal to the most common colon cancer, they estimate it takes eight years.

- Wow.

- And that's kind of how they gauge the surveillance schedule, so.

Vast majority, I would say, are not fast.

- Sure.

If you do have folks in your family who have had breast cancer, does it... You know, let's say a woman's watching this, and her mother had breast cancer, her grandmother had breast cancer, is there something she should do to get tested to see if... Is there a test to see if, you know, you have a particular gene that can make you more susceptible to getting breast cancer?

- Yes.

You can talk to your primary care doctor, usually that's the good first step, and request something called genetic testing, which is a blood draw.

There's many different companies, there's really kind of bigger names in the game that have been there longer, for instance, like Myriad or Invitae.

And what you do is you fill out a survey from the company, and it includes family history, some personal questions about yourself, your height, weight, your comorbidities, your medical problems, your family history, and they will mark if you're approved or not for.

They have broadened the acceptability for genetic testing, okay?

So, if they see that you're a higher risk, you get approved.

So that means, you know, you'll get a lab draw, which is just a blood draw, and then they'll test for the various genes, including BRCA1, 2, PALB, you know, there's a few different ones, P10, and they'll give you a report that shows your personal risk of breast cancer compared to the average population.

If it's elevated, and that usually means more than 20%, okay, you might qualify for additional screening, which may include, you know, mammogram yearly in addition to a breast MRI, for instance, if you're younger.

So, the primary care doctor's the first step to request genetic testing.

- Is there any kind of a preventative medicine out there?

- [Rozana] For breast cancer?

No.

It's more lifestyle modifications.

- With breast cancer and prostate cancer in men, it's, you know, parts of our body that we don't always talk about, and things like that.

Do you find patients sometimes are reticent to come in because it's too personal of a thing?

- I would say yes.

I think female patients like to have their breasts examined female providers in general, so that's why OB-GYN has a huge role in their training for breast exams, because women feel like it's a female issue, and they might address the OB-GYN as opposed to their primary care doctor, who may be a male, and a very good doctor, but it's just a sensitive part of the body.

Similar to prostate.

Men maybe feel comfortable talking to a male about it as opposed to a female.

I already forgot your question, I'm sorry.

(laughs) - Well, you know, with talking about, for some women, you know, breasts are a big part of their lives or big part of their identity.

- That's right.

- So it seems like some might have trouble talking about it.

- Yes.

I would say there's some hesitation in the unknown.

Some are afraid of maybe what it would show.

So I've had patients that maybe felt a lump or something was off for a couple months, and they thought maybe it'll just go away, and it doesn't.

And then finally, either they tell a family member or it's becoming painful or something, where they actually address it to the doctor.

So that's why I always say, if you feel like something's off in your body, you need to let your doctor know.

- Sure, yeah.

- You know best.

- Is there anything we haven't mentioned yet that you think people should know about breast cancer?

- I would say, you know, the breast cancer in general, when you hear that diagnosis, it can be very overwhelming in general, any cancer, right?

No one wants to hear it that they have it.

But it is treatable, and especially in the early stages.

And there's a lot of forks in the road.

I would always say, bring family members with you to the doctor's appointment, ask your questions, and to trust the process, because this is one of the most well-studied cancers, and it seems like it's only getting better treated.

- Yeah.

Yeah, we don't wanna scare people, but we want to give everybody information they know to keep themselves and their relatives happy.

And I guess that's the other thing, folks out there, if they encourage their female relatives, female loved ones, to take care of themselves, you know, look at those risk factors, and do the self exams and get the mammograms when they turn 40.

Doesn't hurt, I guess, to have a little push in that right direction.

- Absolutely, absolutely.

And a lot of primary care offices have kind of these check boxes for these screenings to make sure that their patients are getting it, too.

- Very interesting.

Well, it is Breast Cancer Awareness Month, and we hope that you share this show with your friends and relatives so they can learn more about this issue.

Dr.

Rozana Dwyer from Graham Health System in Canton, thanks for all the information.

- Thank you.

- Appreciate it.

- You're welcome.

- And thanks for joining us.

You can watch this show again and share it at wtvp.org, and you can find out about future show topics on our Facebook and Instagram pages.

And we always wanna know your questions and topic suggestions, so you can message me on social media or leave a comment.

Thanks for watching, and take care of yourself and your family.

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