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Melanie Cole (Host): According to the American Cancer Society, breast cancer is the most common cancer among women except for skin cancers. About 1 in 8 women in the U.S. will develop invasive breast cancer during their lifetime. My guest today is Dr. Brian McKinley. He’s a surgical oncologist with Greenville Health System. Welcome to the show, Dr. McKinley. Are you seeing the rates of breast cancer rise just now or are they coming down?

Dr. Brian McKinley (Guest): Actually, the rates of breast cancer are not rising at this point. They seem very steady at this point. So, there are no alarming increases in the rate of breast cancer right now.

Melanie: What do you recommend and what are the general recommendations for screenings? At what age and how often should a woman get screened for breast cancer?

Dr. McKinley: That’s a great question. There have been a lot of pronouncements in the lay press about scientific studies and recommendations from governing bodies and things like that. I think the punchline answer is that no one woman should think there’s no one answer for all women. So that, when is the right time to start breast cancer screening test? That’s really a discussion that should take you back to your medical home and your primary care doctor so that you can learn your risk levels and see how they compare to average. You mentioned in the intro that 1 in 8 women would get breast cancer throughout the course of their lives, but not every woman has a 12.5% chance of getting breast cancer. So, figuring out if your risk is average or above-average is very important in guiding those recommendations.

Melanie: Let’s talk about risk factors. What are some of the risk factors for breast cancer?

Dr. McKinley: It’s not too simple to just remind everyone that the main risk factor for breast cancer is a woman’s gender, and the second most important is age. So, if you’re a woman and you plan on staying around, you’re at risk for breast cancer. Some additional risk factors that help us sort out whether your risk is average or higher than average have to do with your family history. So, if there is a family history of multiple individuals with breast cancer or multiple individuals with ovarian cancer, or if there is an early onset of those types of cancers, those are some clues that there might be an inherited component or risk for breast cancer. We also know that things like breast density, as the breast appears on a mammogram, increases the risk for breast cancer. And then, there are a host of factors that have to do with reproductive and menstrual history that add into the risk equation as well.

Melanie: Let’s back up to the genetic inherited gene. If somebody has a family member that had breast cancer and there are tests now for the mutation of the BRCA gene--everybody has that gene, Dr. McKinley, but people are confused about whether it’s the mutation of the gene or the gene itself. So, speak about that inherited genetic component.

Dr. McKinley: First of all, there are two genes called “BRCA”. There’s BRCA1 and BRAC2. Together those genes account for the majority of what we would call inherited cancer predisposition syndromes when it comes to breast cancer. The normal function of the BRCA1 and BRCA2 gene is essentially to keep a cancer from happening. They’re what we call ‘tumor suppressor genes’. So, when everything is functioning properly these genes function to keep a tumor from evolving and developing. When the genes are mutated or altered or essentially broken in some way, they can’t do what they’re supposed to do. So, the suppression of tumors is less effective and, therefore, the development of tumor is much more likely and much more common among folks that have defective BRCA1 and BRCA2 genes.

Melanie: Based on the risk factors and what you’ve determined, when do you recommend a woman has her for a mammogram?

Dr. McKinley: If you are at average risk, and, again, that risk assessment needs to be done by either your medical home or sometimes a subspecialist in breast care, such as myself or one of my colleagues, if you’re at average risk we recommend that a woman start screening for breast with regular mammograms at the age of 40, regular physical exams once a year at the same time, and regularly or promptly reporting any new symptoms.

Melanie: Do you recommend that women conduct a self-exam every month?

Dr. McKinley: We’re not as stringent on the requirement for women to do a self-exam. The reason is that studies that have compared big groups of women that do a breast self-exam to women that don’t do a breast self-exam, those studies fail to demonstrate that doing your self-breast exam actually saves lives. We do stress, however, the importance of breast self-awareness. In other words, if you want to do a breast self-exam, you can, but even if you don’t, if you noticed something that’s new or different, that’s out of the ordinary, that you don’t really remember happening before, that you bring that to the attention of your primary care provider or your surgeon promptly.

Melanie: And, you mentioned dense breast tissue as a risk factor for breast cancer. If you have that, and now there’s laws in some states that you have to be notified that you have dense breast tissue. Are there special screenings for that?

Dr. McKinley: There are not special screening to determine whether you have dense breasts. Whether you have dense breasts can be determined on a standard mammography and when the mammographers, the breast imaging doctors, read every mammogram, one of the things they’re supposed to do by rule is make a comment on the density of the breast. If the density of breast falls into one of two categories, that’s where the legislation requiring those doctors to tell the patients comes in. So, if you have dense breasts, the imagers have to tell you that you have dense breasts, and that that means your risk for breast cancer is higher than average. Now, one of the ways to improve breast cancer detection in dense breasts is with a special mammogram technique called 3D mammography or tomosynthesis mammography.

Melanie: Tell us about that.

Dr. McKinley: The idea is that on a standard mammogram the breast tissue shows up as white areas. Women that have a lot of very dense breast tissue have very large areas of white on their mammograms. It turns out also that many cancers show up as white areas on the mammogram. So, if you have a very white breast because of dense breasts, sometimes a little white area that’s an area of cancer might hide within that dense breast. So, what a 3D mammogram does is it enables breast x-ray doctors, instead of looking at the whole breast from one direction at a time, they’re able to peel off layers of breast tissue, so minimizing the effects of the dense breast on the ability to read the x-rays. It like a CAT scan for the breast; whereas, a CAT scan of the brain allows us to look inside the brain and see what’s inside, the 3D mammogram allows us to look inside the breast in a more detailed way.

Melanie: Dr. McKinley, every woman fears that letter or phone call that says something suspicious was found. If they get that and they hear that, what do you tell them as the next step?

Dr. McKinley: It’s obviously a very traumatic event when you first get that. What we try to encourage women to do is to take a deep breath and, not in a patronizing way, but to tell them to calm themselves down first because what you don’t want to do is the thing that might be fastest or easiest. You want to seek expert, team-based care for the problem that you have, whether it’s an abnormal mammogram or whether it’s a biopsy that showed cancer. You want to make sure that you get the best treatment the first time around. That’s really our main message is to seek expert, team-based care that is focused on breast disease.

Melanie: And, if something suspicious is noted, do they look toward a biopsy? What do you do for them?

Dr. McKinley: When we see a woman that has an abnormal mammogram and there is something suspicious, usually that terminology indicates that some sort of biopsy will be recommended. Almost every biopsy in 2016 should be done with x-ray guidance and should be what is called core-needle biopsy. So, in our system, our breast imagers who are focused on breast disease do all of our biopsies with image guidance. It turns out with those core biopsies, those special needle biopsies, most of the time an actual surgical biopsy can actually be avoided.

Melanie: Talk to women; give them your best hope. Whether they hear something suspicious or whether they’re just going for their annual mammogram, and we all get nervous at that time of the year, so give your best hope of what you want women to know about breast cancer, about possibly preventing breast cancer, the risk factors, and why they should come to Greenville Health System for their care.

Dr. McKinley: One of my main messages that I try to share with women, and sometimes it sounds a little counter-intuitive during breast cancer awareness month, is that everyone should recognize that while breast cancer is a common disease in our country, as you pointed out, the leading cause of cancer among women in the U.S., most women will not get breast cancer. If 1 in 8 will get it, that means 7 in 8 will not get it. So, taking a measure of perspective is helpful. Now, the fact that most won’t get it doesn’t mean that we shouldn’t look very hard at what we can do to detect it early and prevent it. Prevention and early detection really hinge on the ability for us to determine risk levels. So, risk stratification, which can be done by your doctor, either your primary care provider or at our breast health center, can really help a woman understand what her risk level is and then, based on that, to tailor a plan of physical exams, mammograms and breast awareness toward her needs.

Melanie: Tell us about your team at the breast cancer center.

Dr. McKinley: We’re very fortunate that we have both a breast cancer multidisciplinary center as well as a breast health center. For a woman with needs from benign breast disease all the way through the cancer care, we have multispecialty focused approach. So if you’re recently diagnosed with breast cancer in our system we appointment to our breast cancer multidisciplinary center. At that one appointment, you meet with your surgical oncologist, with your medical oncologist and with your radiation oncologist. Those three doctors will have reviewed all of your x-rays and your biopsy reports and will come and share with you the team-based plan that was developed at the conference. You also meet with our nurse navigators, who really are, by all accounts, the most important folks in our program, because they are able to focus their energies on literally navigating the patient through what is a very scary and sometimes, based on the number of medical terms and tests, a confusing process. So, coming to that team-based, focused clinic where we are we see new breast patients is very helpful for folks that are facing a recent diagnosis of breast cancer.

Melanie: Thank you so much, Dr. McKinley, for being with us today. You’re listening to Inside Health with Greenville Health System, and for more information you can go to www.ghs.org. That’s www.ghs.org. This is Melanie Cole. Thanks so much for listening.