One in eight women in the United States will get breast cancer at some point in her life. It is the most common cancer diagnosis, followed by lung cancer. The sooner doctors identify breast cancer, the better the chance for a positive outcome.
Breast cancer screening recommendations are constantly changing. It can be hard to know which guidelines to follow. Jennifer Manders, MD; Julie Specht, MD; and Corrie Fabelo, LGC, discussed in a recent webinar what women need to know about breast cancer.
What is breast cancer?
All cancers are named for where they start. Breast cancer occurs when cells in the breast grow out of control. Most breast cancers start in the ducts or lobules. Cancer that has spread to other parts of the body is said to have metastasized.
What are the recommendations for breast cancer screening?
There are several governing bodies that provide guidelines for breast cancer screenings, says Dr. Manders. Each governing body has their own recommendations for when to start mammograms, either at age 40, 45 or 50.
Black women are encouraged to talk with their doctors about starting breast cancer screenings even earlier. The American Cancer Society has found that Black women are 40% more likely to die from breast cancer than white women.
"There are more aggressive sub-types of breast cancer that are more common among African American women," Manders said. Family history, personal health history and density are all risk indicators.
The governing bodies also have different recommendations for how often to get screened. But they all agree that there isn't great data to guide women about mammograms after age 75.
“It's hard to predict how long somebody's lifespan is after 75," Dr. Manders says. “It's really individual, based on other medical problems you might have."
Guidelines often say to stop mammograms when the patient's life expectancy is around 10 years. That's a difficult prediction to make, Dr. Manders says. Although many people have chronic conditions and other medical problems, advancements in technology have made it possible for people to live longer. Women should talk to their primary care provider or gynecologist to decide how long to continue getting mammograms.
Starting in their 20s and 30s, women should understand their personal risk and family history of breast cancer. Different factors, such as lifestyle modifications or quitting smoking, can reduce risk. Plus, knowing your risk factor can help your doctor determine what screening method to use.
What are the benefits of early screening?
Breast cancer is highly treatable in the early stages. Early screening can detect cancer before it becomes invasive. That means less extensive surgery or chemotherapy to treat the disease.
There is disagreement about when to start screenings because breast tissue is denser when you're younger, Dr. Manders says. That makes it harder to identify abnormalities and can lead to a false positive result.
Breast density does carry an increased risk of breast cancer, but that risk does not necessarily make it deadlier. Density does make it harder to see abnormalities on a typical mammogram, so your provider may recommend other forms of imaging based on your individual risk factors.
What are the different types of breast screenings?
Several methods are available to help detect breast cancer, including:
- 2D mammogram—Detects four to five cancers per 1,000 average risk women screened.
- Tomosynthesis (digital mammography)—Detects an additional one to three cancers compared to mammography alone.
- Ultrasound—Detects an additional two to three cancers in high-risk women, and one to two cancers in average risk women, compared to mammography alone.
- MRI—Detects an additional eight cancers in high-risk women, compared to mammography alone.
Doctors use MRI in addition to mammography for women who have a lifetime risk greater than 20 percent, Dr. Manders says. The average woman's risk for breast cancer is about 12.5%, or 1 in 8.
Abnormal findings aren't always cancer, but they may lead to a higher risk for cancer. For example, someone who was exposed to radiation as a child might have a higher risk of breast cancer in the future.
What therapies are available for breast cancer?
Chemoprevention is an anti-estrogen therapy that can help reduce the risk of developing invasive breast cancer.
“The majority of breast cancers are driven by estrogen or progesterone," says Dr. Specht. “About 80 percent of the breast cancer we see in postmenopausal women and about 60 percent of the breast cancer we see in premenopausal women are driven by estrogen or progesterone."
Chemoprevention medications include:
- Tamoxifen—Reduces breast cancer incidence in high-risk women by 49 percent and is also used to treat breast cancer
- Raloxifene—Reduces breast cancer incidence by about 24 percent
- Exemestane—Reduces invasive breast cancer incidence by 65 percent
“Why isn't everyone taking these? There are side effects, and a lot of women don't want the tradeoff of having the side effects of not having estrogen in their body to prevent a cancer that might never happen," Dr. Specht says. “That tells us we need to find other therapies that have a more acceptable side effect profile for women."
Other investigational therapies for breast cancer include:
- High-dose vitamin D
- Metformin (diabetes medication)
- Polyphenon E (green tea)
Breast cancer treatment is multimodal and multidisciplinary, Dr. Specht says. “You can't go to one person and think that you're going to get all your treatment for breast cancer because it's such a complicated disease to treat. You need experts in every part of it," she says.
Experts who can help treat breast cancer include:
- Surgical oncologists
- Radiation oncologists
- Medical oncologists
- Genetic counselors
- Physical therapists
- Plastic surgeons (for breast reconstruction).
What is the intent of breast cancer treatment?
One thing Dr. Specht does whenever she has a new patient with breast cancer is to make sure everyone understands the intent of treatment. The goal of treatment depends on whether the cancer is in an early stage or if it is more advanced.
“When you're looking at an early-stage breast cancer and you're looking for a cure, patients will sometimes accept more toxicity of treatment if the goal is curing cancer for the rest of their life," Dr. Specht says. On the other hand, curing early-stage breast cancer can leave patients with chronic health issues for the rest of their life. There needs to be a balance between curing cancer and preserving quality of life.
It's also important for women to keep in mind that there is no one-size-fits-all approach to treating breast cancer. There are targeted therapies for different types of cancer, and the goal is to give patients the best chance of survival once it has been treated.
Echoing Dr. Manders' sentiment, Dr. Specht emphasizes the importance of getting a second opinion. The Christ Hospital has partnered with the Dana-Farber Brigham Cancer Care Collaborative—the first and only hospital in Ohio to become a collaborative member with this prestigious cancer treatment and research organization.
“What that really does is allow us to give patients access to individual treatments, the best patient experience, best-in-class clinical research, and second opinions right here. They never have to leave Cincinnati," she says.
Dr. Specht also says the hospital tries to look at all aspects of the patient to make sure their journey is as successful as possible throughout their treatment.
How do genetics affect breast cancer risk?
Most cancers, including breast cancer, happen spontaneously due to age, environmental factors or chance. However, about 5 percent to 10 percent of breast cancers are hereditary.
These cancers are caused by a genetic mutation that runs in a family. Genetic testing can identify specific variations or mutations that increase the risk for certain cancers.
“It's not to say that everybody with that mutation will develop cancer, but it's a risk factor that puts you at a higher risk for breast cancer and maybe others that we need to manage moving forward," says Fabelo.
A genetic counselor can help you decide on what type of genetic testing is right for you based on your personal family history. Some tests only look at genes associated with specific types of cancer, like breast cancer, while comprehensive testing may look at genes associated with many different types of cancer.
Results from genetic testing may take several weeks to get back. They generally fall into three categories:
- Negative for a mutation or variant in the genes tested
- Positive for a mutation or variant that increases the risk of cancer
- VUS – or “Variant of Uncertain Significance" – which means it is unknown at this time if a genetic mutation or variant identified in the testing is harmful or benign.
Genetic testing through The Christ Hospital Precision Health not only provides results, but genetic counselors will also help you interpret those results so you can make informed decisions about the next steps in your care.
For high-risk cancers, your genetic counselor can refer you to specialty providers for advanced care or make recommendations for more frequent screenings or prevention strategies.
If it's been more than five years since your last genetic testing, re-screening may be recommended for you. Advances in genetics may allow more comprehensive testing to be done or testing may reveal new information that was identified when the previous test was run.
Getting started with breast cancer screening and treatment
Detecting breast cancer early is critical for treatment. But with so many different recommendations and options for screening, it can be difficult to know where to start.
The Christ Hospital Health Network's breast health navigators are nurses who are available to you throughout your journey. They can help you set up screenings, appointments, coordinate referrals, and facilitate any support services you may need.
You can reach our breast health navigators by calling 513-588-0608.