On this week’s 51%, we recognize Breast Cancer Awareness Month. We tune into a virtual conference on women’s health at the University of Vermont Cancer Center, and speak with Albany Medical Center’s Dr. Lynn Choi about what you can do to reduce your risk for the disease.
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You’re listening to 51%, a WAMC production dedicated to women’s issues and experiences. Thanks for tuning in, I’m Jesse King.
We’re bringing you another trio of healthcare stories today. October is breast cancer awareness month — and while, of course, the point is to better inform the public about breast cancer, many of us are already well aware of it. According to the National Cancer Center, it’s the most common type of cancer in the U.S., with 284,000 new cases expected nationwide in 2021 — so odds are, you or someone you know has been affected by this disease.
Luckily, compared to other cancers, it has a pretty good survival rate (the American Cancer Society put the relative five-year survival rate at 90%) - but that depends on how early it’s caught. The problem is, for the past year and half, the coronavirus pandemic has forced many people to postpone or cancel their regular check-ups and screenings, including mammograms.
Now, doctors and health officials are urging the public to resume their recommended care schedules — and they’re discussing ways to improve detection and treatment on their end as well. The University of Vermont Cancer Center recently held its 24th annual Women’s Health and Cancer Conference. The meeting, held virtually due to the pandemic, brought together experts on cancer detection and prevention, wellness and survivorship. WAMC's Pat Bradley has more on the conference here.
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So the way doctors look at and approach cancers is constantly in discussion — but in the spirit of awareness, let’s get into detail about what breast cancer looks like, how it’s treated, and how you can reduce your risk of the disease. Dr. Lynn Choi is a board-certified breast surgeon at Albany Medical Center with years of experience in cancer-related surgery and surveillance of high-risk breast cancer patients. To be clear, she says just about all women — and some men, let’s not forget — have at least some risk of developing breast cancer, particularly as they get older. But some factors can put certain people at more risk than others, and when you should start to more closely monitor your body depends on your personal risk level.
What made you want to become a breast surgeon?
So I did a general surgery residency, and as I was realizing I was becoming a mother, I became very interested in women's health. I did go to a women's college, I was surrounded by a strong support system of women. And the fact that breast cancer affects one in eight women – you're in a room full of people, there's going to always be a handful of women who have breast cancer. And the main reason I want to go into this is, with surgery, there's two types of surgeries: there's surgeries where you operate, the patient gets better, and then they go on their own path – but with a woman who has breast cancer, you're their doctor for life. Patients really become your family.
During the pandemic, a lot of people were letting their routine appointments slide. Now that the vaccine is out, are you seeing more women come in for mammograms, and for tracking for stuff like this? Or are people still hesitant?
People are getting much better. There's always still a hesitancy, but it's much better now that the vaccine’s out. When the vaccine was not out, at the height of the pandemic, mammograms were down by 40 percent. That's a significant number. That's an issue because the beauty of the mammogram is [that] you catch these breast cancers early. If you catch a breast cancer early, it's actually a very treatable disease. Excellent prognosis. Now, we're seeing an influx of women trying to catch up with the mammograms that they did miss during the pandemic.
At what point should women start thinking about getting mammograms? And how often should they get them?
So the general guideline that we follow – the American Society of Breast Surgeons, which falls under the American College of Surgeons – is 40 you should start getting your annual mammogram. However, if you think you have a higher risk, whether your aunt had breast cancer, your mother had breast cancer – when you start having these questions, see a doctor, whether it's a general practitioner, or they can refer you to a breast doctor, to figure out if you're at a higher risk for breast cancer.
It's a pretty straightforward algorithm that we have on our computers, that we plug in different risk factors. And if you end up being at a high risk factor, meaning greater than 20 percent lifetime risk of breast cancer, we may suggest earlier imaging. There's also a genetic aspect. So five to 10 percent of all breast cancers are due to a genetic mutation that your family might carry. If you have that, imaging can be done even earlier starting at 25. But we do encourage clinical breast exams on an annual basis earlier, before you get your breast imaging.
OK, so genetics can play a role in calculating someone's risk for breast cancer. When determining that risk. What are some of the other things you're looking at?
So when I talk to a patient who doesn't have any medical background, I basically talk about risk factors meaning, “What are the factors that cause you to have your period less?” Those are favorable factors in decreasing breast cancer occurrence. So how many times did you get pregnant? The more times you get pregnant, the less time you have your period. If you breastfeed, the less you'll have your periods. So these factors, we think of as favorable because they decrease hormonal exposure.
OK, so it has a lot to do with hormones.
Absolutely. Other things we can ask is, for some women may have had a hysterectomy – are you put on a hormone replacement therapy? If you're put on that, there's an association: longer use of hormone replacement therapy is associated with a risk factor of breast cancer. So hormones are the big factor. Genetics is another, and then the other one is environmental. How much do you drink? Are you exercising? What's your body mass index? Fat, it's called adipose tissue – that can produce estrogen hormones as well.
What are some of the warning signs of breast cancer?
I always tell women to be aware of their breasts. The younger you are, the more dense their breast is. Younger woman have more lumpy, bumpy breast tissue, so it's a little hard to say, “Oh, is this just my density, or is this a mass?” So I tell them to try to be aware of what your breast is. Also, you know, once in a while, take a look in the mirror when you raise your hands up. Do you see any new dimpling? Is your nipple being pulled in? Do you feel a new mass? Do you have any nipple discharge? So figure out what you think your normal breast is, and anything different is something I would absolutely say bring to your doctor.
And are there different types of breast cancer?
Yes, there are a lot of different types of breast cancer. Just to generalize, the breast is made up of lobules and ducts. So if you were breastfeeding, lobules are what produces breast milk. Ducts is what brings the milk from the lobules to the nipple. 80 percent of breast cancers affect the ducts, the rest are usually lobular. And then within that, you can also differentiate the profile of the breast cancer.
When you get a breast cancer diagnosis, by a biopsy usually – so let's say a woman comes in, they feel a mass, then the doctor sends them for imaging and they actually see a mass, and then they're offered a biopsy that the radiologist performs. It's like a one hour procedure, you go in, they numb the area up, and there's a little pressure, and by the image, they can get a small little biopsy tissue sample – very small, I would say like inchworm-size, very small. If that comes back as breast cancer, there's three receptors that we always look for, for invasive breast cancer. By definition, invasive starts at a stage one. The three receptors you always look at are: two female hormones (estrogen, progesterone), and the last receptor is HER2. We always look at, you know, “Is this receptor positive? Is this negative?” If all three are negative, you have what's called a triple negative breast cancer, and that is one of the most aggressive breast cancers, because there's really no target for medication. The majority of breast cancers that affects postmenopausal women, they end up being hormone positive. And if it's positive, that means you have your candidate for a medication to bind that, and you have medications to decrease your breast cancer recurrence. Does that make sense?
I think so. So when we talk about like lobules and ducts, that's sort of the location, but there can be different types even within those categories.
Absolutely. Based on the receptor status.
OK. What would be the treatment options going forward from there?
Typically, in early breast cancer, you usually have surgery to remove the cancer – usually a stage one and a two. If you have a more advanced breast cancer, or a more aggressive breast cancer based on the profile, you may be offered chemotherapy upfront to try to shrink the tumor and then have surgery after.
If that’s successful, what are the odds that it can come back?
So it depends. Typically, with early breast cancers, we're talking stage one or two, they have an excellent prognosis. We're talking disease free survival in five to 10 years greater than 90%. It's more the later stages or more aggressive cancers, such as if all the receptors are negative, where you can have a higher rate of recurrence.
So say there's a possibility that breast cancer sort of runs in the family. In my own case, multiple women in my family have either had like close brushes with it or have been diagnosed. Is there a way to know whether or not you have a genetic risk for getting breast cancer?
Yes. People who have a family history, I always offer if they would like to see a genetic counselor. Based on the National Cancer Comprehensive Network guidelines – that's the big bible for all types of cancer – they do have certain requirements like, “If this woman is diagnosed with no family history, but is less than 45, they should be recommended to a genetic referral.” There's different guidelines where genetic referral is always recommended. But now we do offer it to all women, or anyone who's interested. If that's the case, we send the referral, then they meet with a genetic counselor, they go through their history and offer it to them. If they would like it, it ends up being a blood test. They test multiple genes to see if you're at risk for one of these breast cancer mutations. About a decade or so ago, the only genes that they did test are the BRCA gene: BRCA 1 or 2. That's a high-risk gene. Now they test the high risk and other genes that are more moderate-risk genes. So if you are curious, I would recommend bringing it up to your doctor or seeing a breast specialist and they would be happy to offer you genetic testing if you're interested.
If you're in that case, are there ways you can reduce your risk?
Depending on which gene you have, usually what's offered is you can do bilateral prophylactic mastectomies, or you can have imaging surveillance so you'll get annual mammograms and you will get annual breast MRIs. Breast MRIs are the most sensitive breast imaging that we offer. We do not offer to every woman, because if every woman got this, this would lead to a high rate of false positives. But people who are higher risk, we do recommend it. So every six months, you're getting some sort of surveillance. For just any woman in general, we would talk about lifestyle modifications, exercise on a regular basis, a good plant-based diet, and decreasing hormonal risk factors. Some of them in come in having been on hormone replacement therapy for a decade, and we talk about trying to reduce that.
I heard exercise and a plant based diet. Specifically, how much exercise are we talking here, and which foods?
Well, I tell patients, it's good to have a very colorful plate: more greens, more reds, they have more antioxidants that helps block the various pathways associated with cancer. So a colorful diet, that's what we generally recommend. For exercise, its 150-200 minutes a week. It sounds a little daunting at first, but once you start doing it…How you split that up, that's up to the patient, but at least 115 minutes a week of exercise.
Is it OK if I like run some things that I've heard by you, and you can tell me whether or not there's any legitimacy to them?
Sure.
So I've heard things like, different deodorants can increase your risk.
No.
OK. So that’s a no. What about things like underwire bras or wearing a bra too often?
No, no.
Are there any other myths out there that people should just forget?
Well, a couple years ago, at one of the conferences I went to, there was a question of hair dye and association. There's no absolute association, but they've been looking into this. So I guess for women who, I don't know how often, but maybe ask if they could have a more natural hair dye – there’s no real direct association with that.
As someone who's in the field, who works at an academic medical center, what are some other things that people are researching right now?
So, when we talk about breast cancer, there is an early-stage breast cancer that's a ductal carcinoma in situ, where it’s ducts and hasn't gone out. That's usually a clinical stage zero. There's current research going on now to see if that can be treated medically, and not with surgery. So if a woman has a ductal carcinoma in situ diagnosis, right now the standard of care is to perform surgery. There is active research going on to see if we can actually avoid surgery in early breast cancers. There's excellent research going on to try to do less but have excellent outcomes in our breast cancer patients.
Because it's Breast Cancer Awareness Month, is there anything that I'm missing that you'd like me to know?
The most important thing is women should be getting their mammograms on an annual basis starting at 40 or up. If you think you have high risk, bring this up, maybe you need imaging earlier. Also, younger woman have more dense breasts – mammograms are a little harder to see through dense breast tissue – so we do recommend ultrasounds with dense breast tissues. So we're talking usually the younger woman, they usually get annual mammograms with ultrasounds. Also, if you have a mass, if something is different with your breasts, this should not be ignored, whether you're a male or female.
Also, a lot of patients feel tremendous guilt when they get diagnosed with it. I have [normally] very healthy patients, and patients need to realize this is not their fault. It's one in eight, it's the most common cancer among women here in North America. It's not their fault. That's one of the biggest misconceptions.
Dr. Lynn Choi is a breast surgeon with Albany Medical Center in Albany, New York. Dr. Choi, thanks for speaking with me.
Thanks so much for doing this. It's such an important month. I feel like it should be every month, but I'm happy that we have one month dedicated. If you don't take care of your health, you really don't have anything, you know?
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To wrap things up, we’re going to change gears now, and bring you an interesting story on sex work in New York. Last month, New York Governor Kathy Hochul said she is looking into a proposal to legalize sex work in the state. The move has long been pushed by advocates, who say it would empower sex workers and give them added protections. WAMC’s Ashley Hupfl has more here.
51% is a national production of WAMC Northeast Public Radio. Our producer is Jesse King, our executive producer is Dr. Alan Chartock, and our theme is "Lolita" by the Albany-based artist Girl Blue.
