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Melanie Cole (Host): As the risk for breast cancer has decreased from every one in four women to every one in eight women, early detection is key. The American college of Radiology Guidelines state that annual mammograms should begin at age 40 and continue for as long as the woman is in good health. We know it can seem scary, but breast cancer is scarier. And if you are a woman over 40, it could save your life. Here to discuss early and regular screenings for breast cancer is Dr. Dortha Chu. She’s a breast surgeon and a member of the medical staff at Henry Mayo Newhall Hospital. Welcome to the show Dr. Chu. Explain a little bit about breast cancer. What are you seeing as far as incidence and awareness? Are more women getting screened?

Dr. Dortha Chu, MD (Guest): Thank you so much for having me on the show. I really appreciate it. I do think that what we have out there now in terms of diagnostic and treatment of breast cancer is very encouraging. In terms of the incidence of breast cancer, the numbers haven’t necessarily dropped significantly, but in terms of women developing cancer, we still quote an odds of about one in eight women in her lifetime will develop breast cancer. But the key there though, is early detection. We have been able to diagnose those cancers much earlier and therefore women are surviving their cancers in much greater numbers. Which is really the most important part.

Melanie: Who is at risk and is there a genetic predisposition? So, what role does inherited trait play in developing breast cancer and also speak about other risk factors, weight, stress, smoking, diet; those sorts of things?

Dr. Chu: Sure. So, all cancer is genetic by definition because they are always due to DNA mutations. So, that part, we cannot change. But not all genetic mutations are inheritable, in other words, they are not necessarily all being passed down from one generation to another. So, breast cancer in general, occurs because of these random mutations throughout our lifetime in our DNA. So, not necessarily from a genetic factor that you inherit from your mom or your dad. Now there are a small percentage of breast cancers that are truly genetic where there is an inheritable gene mutation that has been passed down in the families from parent to child. Those are rare and most of those now we are able to identify through actual genetic testing. Certainly, when you have a family history that has multiple family members with breast cancer or other related cancers, it raises a suspicion that there may be a genetic factor that’s at play. Someone who does have a documented genetic mutation that contributes to this kind of increased risk will need additional screening because their overall lifetime risk will be higher. But for the average woman, who does not have any family history, in other words, no significant number of women in their family with cancer; the average risk is only between 10-12 percent in her lifetime. So, the risk of breast cancer actually is quite low, if you look at it from that perspective. And this is just true because you are a woman with breasts. You have that lifetime risk of between 10-12 percent.

But if you were to have other risk factors, certainly that could increase that risk over time. The major risk factors that we know of that are not genetic as I mentioned, are smoking and obesity is another one that are factors that we can to a certain degree control. Smoking really is the biggest one though of these kinds of modifiable factors. Certainly, the longer you smoked or the more you smoked, your risk of breast cancer does go up. Having said that, the minute you stop smoking, that risk starts to decrease. So, it certainly is worthwhile to stop smoking no matter how long you have smoked to overall decrease your risk of breast cancer over time. So, those are factors that you can change. And then there are factors that you cannot, and these are factors related to our hormonal cycle throughout our lives and so those are factors that are more individualized and need to be discussed with your care provider.

Melanie: Dr. Chu, tell us about screening. Who should get screened, at what age, how often and why is there such confusion recently over the current recommendations for screening mammography?

Dr. Chu: That’s a really good question. The issue is really has to do with what is the time when your risk of breast cancer goes up? Now I just said that a woman, just by being a woman, her lifetime risk of breast cancer is around 10-12 percent. But the 10-12 percent doesn’t kick in really, until you have reached the age of 50. Before the age of 50, the risk is significantly lower. So, really when we talk about the average breast cancer and again, not the genetic one, but the average breast cancer, the majority of women who really need to be screened are the women who are older than 50. Between 40 and 50 is where the controversy really starts because the majority of women between 40 and 50 will not develop breast cancer. And so, screening every woman between age 40 and 50 has come under some discussion because we don’t want to over diagnose women and expose them to studies that they may not need. Having said that, those of us who deal with breast cancer on a daily basis, I think our consensus is that unless there is contraindications, we do encourage women between the age of 40 and 50 to at least discuss their risk with their care provider to see what their true risk is. Because not every woman is “the average” woman. And so, you may have factors that would increase your risk enough that it may be worthwhile for you to have more regular screening.

So, there are some individualities that can be built in in terms of how often you screen. But certainly, my recommendation to my patients is if you are over the age of 50, you really should be getting at least an annual mammogram because mammogram right now is still our best test when it comes to breast cancer detection and it can find breast cancers in such an early stage that you are never going to feel it, there is no physical change, no symptoms, but if we catch it at that stage, it is essentially completely curable. And so, we really want to try to capture it at that early stage if possible.

If you are between the ago of 40 and 50, and you don’t have any other significant risk, you may be able to do every other year in terms of getting a mammogram. But again, I would really advise the patient to speak with her care provider and really assess their risks. Younger than 40, the risk is so low in general, that we do not recommend routine screening because that’s exposure to screening tests without significant benefit. So, if you are younger than 40, without any other major risk factors, we do not recommend routine screening. But if you do have a significant family history or are concerned that you might have a significant family history, then again, I would advise you to speak to your care provider to really discuss that and figure out if that is something that you need to consider at a younger age because of your true genetic history.

Melanie: What about self-exams? Do you encourage women to get to know their breasts and what should we be feeling? What should we be looking for?

Dr. Chu: Well, right now especially, the recommendation is that breast- self-breast exams may not necessarily contribute significantly to the detection of breast cancer. That’s really where imaging can play a much bigger role because again it can find things before you actually feel anything. But my advice to my patients and actually to all women is I think you should do a self-exam every month, not because you are specifically looking for anything, that’s not your job, so to speak, that would be my job as the physician. But I think it is very important for a woman to know what her breasts feel like normally, in other words, what is normal for the individual woman? The breast is not the same for everybody. My breasts are different than everybody else’s. In fact, your left and right breast in the same person might feel a little different, might look a little different and these are normal variabilities and normal variations. But if you are not aware of them, then it can be harder for a provider like me, a doctor like me to be able to distinguish a normal variant versus something that we need to be concerned about. Because it may be a signal that there is something going on.

So, I certainly encourage every woman to do a self-exam every month and the key is just to get to know your breasts. Feel them, look at them, see what they look like, the shape of them, the skin; is it uniform, is it soft, are there any funny discolorations, are there different textures, does the skin look pinched in, are there funny discharges, do you feel a lump that feels different than previously. And these are only changes that you can monitor if you know what they look like on a daily – not daily but on a routine basis. I stopped myself from saying daily, because you don’t want to examine the breasts daily because there may be hormonal changes, especially for premenopausal women that can occur during the course of a month that can be confusing.

So, really you want to examine the breasts if you are premenopausal and still having regular periods; is to examine the breasts at the lowest hormonal point which is typically a day or two after your period ends. That’s the best time to examine the breasts with the least amount of hormonal influence. So, once a month at that time, I think is great because then you will get to know your breasts at their sort of basic level and if something were to change from that, then that’s an alert that you should have it looked at. Now it doesn’t mean that there is something bad happening. Most changes in the breast are not cancer. But certainly, any real change needs to be evaluated and that may be an early sign that something is going on that needs to be addressed. And so, I would encourage a woman to do a breast exam every month.

If you are post-menopausal, you don’t have regular periods, that’s okay, that means your hormonal levels are pretty much the same throughout the course of the month, then that timing is less important and so just pick a convenient day and every month on that day, do a breast exam. Now once a month is plenty, because again, you are monitoring for stability. You are not monitoring for change or looking for a specific item. You are just monitoring to make sure that the breasts feel and look the same. As long as they look the same, you have done your job. If there is any change, don’t panic. Go see a physician.

Melanie: So, what are the different types of mammography? We hear about digital. We hear about screening and diagnostic mammograms. We hear about 3-D tomosynthesis, whole breast ultrasound. Explain a little bit about what you’re doing and the different types of screening that are available for women.

Dr. Chu: Sure. So, mammogram in general, is our best test when it comes to detecting breast cancer. Because a lot of early cancers, before they are large enough to be felt, or cause any other physical changes in the breast; may have some changes on x-ray, which is what mammography is. It is using x-ray technology that we can actually detect and distinguish from the surrounding normal breast and that can give us a clue that there may be something going on that we need to evaluate further. So, any mammogram is better than none. Having said that, the technology has gotten better. We used to do x-rays just like a chest x-ray on an x-ray film, you see those things that doctors hold up in old TV shows. So, mammography used to be done on film and it was good, but film does not allow us to be able to fine tune any areas that might look a little fuzzy, just because of the exposure on the film.

So, that is where digital mammography took a step forward, because that has allowed us to be able to manipulate the image to get a clearer image and so the areas that look a little funny, we can actually kind of refine it a little bit and figure out is it just a technological problem or is there something really going on in that piece of the breast. So, certainly digital is better than film. For a long time, what we had, in terms of the x-ray technology and then the mammograms that people know about is what we can now call two-dimensional. In other words, the breast gets squished so to speak, between two plates and in two different dimensions and an x-ray is taken of all that condensed breast tissue; that compressed breast tissue. And so, the pictures can sometimes be a little misleading because if you have very glandular or very young breasts, or dense breasts is the technical term we use these days; sometimes that image can again, be a little fuzzy and then harder to interpret.

So, a newer technology is the 3-D tomosynthesis or 3-D mammography and the difference is physically the same. There is no difference with the patient. It is the same amount of x-rays, it’s the same amount of time, same amount of compression, generally, of the breast; but the machine itself is different. Instead of taking just that one picture in each direction; it actually takes virtual slices, kind of like a CAT scan for those people who may have had one. It’s like a little virtual sort of slices through the breast in three dimensions and as a result, the computer can take all of those virtual slices and generate a three-dimensional image for us of the breast, so that the tissue is no longer compressed, and we get a clearer image. So, that can allow us, especially in women with a younger or denser breast to be able to distinguish some of those areas that might be confusing because of the overlapping breast tissue. So, it allows us to be more precise and allows us to be able to identify potential problems a little bit easier. So, for some women, that’s a good technology to take advantage of if you can find it in your community. Not every woman needs it, but certainly for those who as I mentioned, with younger breasts or with denser breasts, this could be a really good technology for them to have.

The diagnostic versus screening mammogram really refers to the overview of the breast. The screening mammogram uses a little bit less x-ray just to get kind of an overall picture. So, that is what we use routinely just to kind of get an overall picture of the breast to see if there are any areas that jump out at us. So, it uses slightly less x-ray because the picture is a little less defined. It’s a little less refined. So, it doesn’t allow us to be able to magnify anything. If we see an area that suspicious or I we know that there is a potential problem, like a lump that we can feel or some other changes in the breast; then we go to what is called a diagnostic mammogram. And all that means is that – it is the same technology, but we use a little bit more x-ray, and again these are minimal amounts, please keep in mind, these are very minimal amounts, but still just a fraction more x-ray and what that allows us to is get again a more detailed picture. One that we can then magnify using a computer and be able to target specific areas to get a more precise picture. So, those are really tools to help us refine our ability to identify areas that might be problematic versus again, normal variants that women can have in their breasts.

Ultrasound is great technology. We love ultrasound because it is a much less invasive. It doesn’t have any x-rays and, so it is very, very safe. However, the x-ray technology right now only allows us to scan a little bit of the breast at a time with a little probe instrument. So, it doesn’t give us that overall picture that the mammogram provides. So, it is not really great as a screening tool because of that limitation. The other limitation for ultrasound is that some of those changes that we see on mammogram, those early changes, are not seen on ultrasound. So, you are not going to find cancer “as early” potentially as a mammogram would have detected. So, it’s a good technology as a companion to your mammogram if something is suspicious on a mammogram, but it is not yet good enough by itself.

There are some technologies that are coming down the pipeline. For example, scanning ultrasounds, whole breast ultrasounds, robot mediated ultrasounds that try to address some of these issues, to try to get a better picture, a more precise picture of the breast. Right now, those technologies are not yet ready I think for prime time, so to speak. There are very few institutions that are using them right now because I don’t think the technology is refined enough yet where I would say that it’s a good substitution; companion yes, not yet for a substitution. For some women, it may be an option if they have access problems to other types of technology, but certainly it’s something I think down the line, we may see more improvement and they may be more of a potential substitute for a mammogram.

There is one other one I just want to quickly mention which is breast MRI. That is also something that a lot of women think about. MRIs are extremely sensitive. They are on par with the mammogram, but the problem with MRIs is that they can be a little too sensitive and they are very much dependent on where you get it both in terms of the facility as well as the radiologists that are employed by the facility to be able to interpret the MRI appropriately. So, it is a little bit more limiting in terms of being able to access and obtain a good breast MRI. Plus, it is more expensive, so insurances tend not to want to include it because the technology isn’t necessarily better than the mammogram and certainly a mammogram Is much less expensive as an option and easier to access. And again, the same problem. The things that we see on mammogram that could alert us to a cancer, are not seen on an MRI. It looks at the breast in a completely different way and so it’s not really something again, that I would say would be an absolute substitute, at least not at this moment in time because accessibility is still such an issue. If there comes a time when the MRI is more easily obtainable then it might be good as a substitute as well for a mammogram. But for now, mammogram, mammogram, mammogram. Is the key.

Melanie: And in just the last minute, Dr. Chu, wrap it up for us with your best advice about early and regular screenings for breast cancer; what you really want women to know at this month and really all the months of the year and why it is so important that they speak with their physicians about these screenings.

Dr. Chu: Absolutely. The key about our success right now in being able to treat breast cancer and women are surviving their breast cancers more and more; is early detection. There is no question that the earlier we find a breast cancer, the higher the cure rate and the more potential that you will have a long and fulfilling life afterwards. And the less you have to go through in order to get there in terms of treatment. And the best test that we have are mammograms at this moment in time as well as other companion technologies that may be necessary to help with the diagnosis. So, it really is key to go in to do regular testings so that if there is a problem, it is picked up as early as possible.

So, my advice to all women is be your own advocate. The self-exam I think is one way to start, get to know your breasts, get to know your own body, because sometimes, it’s about change. If you find that change, you may be able to help yourself before anything else alerts you. So, certainly being aware of your own body is a good place to start. And then having good open communication with your care provider, whether that’s a primary care doctor, a gynecologist, whoever you see on at least an annual basis or semi-annual basis. Someone who can help sit down with you, go over your family history, go over your risk assessment and really come to an understanding of where your potential risk is for breast cancer so that you can better decide how often you need to be screened, how often you need to have mammograms, are mammograms the best option for you, do you have other alternatives that you need to take advantage of. I think that conversation is really the key so that you can better understand where you fall in the spectrum of risk, so that you’re not scared too much for something that may never happen to you, but on the other hand that you’re being assessed appropriately so that if there is a problem, we catch it early.

So, that would be my best advice for women. Be proactive. Take charge of your own body. You’re the only one who can do that and if you don’t do that, then my job becomes limited because I can’t help someone who doesn’t come to me. So, please, go see your primary care doctor, or your gynecologist. Have a good conversation with them and take care of yourself.

Melanie: Thank you so much. That’s really great advice. You’re listening to It’s Your Health Radio with Henry Mayo Newhall Hospital. For more information, please visit www.henrymayo.com . That’s www.henrymayo.com . This is Melanie Cole. Thanks for tuning in.