Breast Cancer Risk Factors & Screening: A Radiologist's Perspective

Podcast Transcript

Scott Steele: Butts and Guts, a Cleveland clinic podcast exploring your digestive and surgical health from end to end.

So, hi again, everybody. Welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. Today we're going to continue our line across breast cancer, and today focusing on breast cancer risk factors, prevention, and diagnosis.

Just as a little bit of background, the average risk of a woman in the United States for developing breast cancer sometime over the course of her life is about 13%, which is about a one in eight chance. So with a better understanding of symptoms to be on the lookout for and advances in early detection and treatment, there's fortunately a better chance of survival, more so than ever, and we're excited here today to talk about this topic.

I'm very, very pleased to welcome Dr. Laura Shepardson, who is a staff radiologist here at the Cleveland Clinic. She's also the Associate Director of Breast Imaging. Laura, welcome to Butts and Guts.

Laura Shepardson: Oh my gosh, Scott, thank you so much for having me. This is such a great opportunity for us to spread the word.

Scott Steele: So I like to start off all of these podcasts with just giving a little bit of background about yourself, so if you can tell us where were you born, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Laura Shepardson: So I was born in Syracuse, New York. I went to college at Cornell University and then came out to Cleveland to get my master's in biostatistics. I thought I was going to be a research geek for quite some time, but then I realized that I wanted a little bit more in my life so I decided to apply to medical school, went to Case Western for medical school and came to the Clinic for training. I did my residency and fellowship both at the Cleveland Clinic and I've stayed here ever since. I love working here.

Scott Steele: So we're going to focus today on risk factors and then some of the imaging things, but can you just give us a 50,000 foot view, if you will? What are some of the symptoms of breast cancer and then go into what are some of the risk factors?

Laura Shepardson: The number one symptom for breast cancer is no symptom at all. Many women are diagnosed with breast cancer just based off a finding we see on their screening mammograms, which emphasizes why screening is so important. Early detection is key with breast cancer because it gives you more opportunities for treatment and more chance to cure. When women do present with breast cancer, the most common symptom is a painless lump in the breast, even up under the arms. So I always encourage women and make sure when you examine your breasts, you examine all the way up under your arm because sometimes you'll feel something up there. Women also can present with breast pain or heaviness, thickening of the skin, redness involving the skin, some nipple changes, spontaneous discharge, particularly if it's clear or bloody, or a new nipple inversion.

I don't want to forget about the men in our lives. Certainly men get breast cancer too, and they tend to present with a painless lump as well. And interestingly, they tend to ignore their symptoms a little bit more because you're not thinking breast cancer, it's that much more rare in men, and then present later stage. I emphasize to all patients, any persistent changes should be evaluated by a provider or a physician immediately. You want to know that something is benign or needs further workup.

So you asked me a little bit about risk factors. I like to think about risk factors in three different categories. Number one, there's those factors that are the most serious or increase your risk the most. I'm talking about those that more than quadruple your chances of breast cancer. That's age, breast cancer increases with age and it peaks out in the seventh decade so we see breast cancer drop-off when women are in their eighties. But I don't know if that's more related to less screening or less disease in that population.

People who have had biopsies showing any atypia or lobular carcinoma in situ can have an increased risk, and certainly the big player is genetic variations. So patients who carry the BRCA gene have a very high risk of developing breast cancer, and other genes fall into that category as well.

Then there's the risk factors that I say are in the middle of the group. They more than double your risk, up to four times the risk. These are ladies who, number one, have had high dose radiation to the chest. These are patients that typically have had radiation for Hodgkin's lymphoma between the ages of 10 and 30. You also see an increased risk in women who have had a prior history of ductal carcinoma in situ, sometimes shortened to DCIS, and patients who have mammographically dense breast tissue. We'll talk about that a little bit later.

Another big player is women who have a family history. That's two or more first degree relatives. What is a first degree relative? That's a mother, a daughter or a sister with breast cancer or patients who have a male in their family who have had breast cancer.

Then there's the other risk factors that are less severe but still play a part in increasing a woman's risk, and these are the factors that increase hormones in your system. So I like to clump these altogether, so patients who have early menarche, they start their periods before 11 years of age. Patients who get pregnant much later than other patients, and we're talking older than 30 years of age. That's so common now because women tend to delay pregnancy for whatever reasons. Women who've never breastfed, women who've never been pregnant at all, patients who start menopause later, so I'm talking about older than 55, recent hormonal contraceptive use, your risk actually comes back down to normal if you stop hormones, recent or longterm use of post-menopausal hormones. The whole point in thinking about that is anything that increases your exposure to hormones, pregnancy, early periods, late menopause, that all increases the time you're exposed to estrogen and progesterone, which increases your risk and stimulates breast cancer cells to grow.

Then there's the other players that are modifiable, meaning there's something you can do about these. Number one, physical inactivity. Certainly exercise plays a key role in reducing your risk for breast cancer. Obesity increases your risk, and that's because the fat cells in our body make estrogen, and again, that goes back to the hormone player. And then alcohol use, this is really more than two to three drinks per day increases your risk by 20%.

Interesting risk factors that I just want to point out because I know there was a lot of research and patients always ask me, are night shift workers and airline flight attendants. What's the theory behind this? So your melatonin levels are decreased, and melatonin plays a key role in inhibiting growth in new tumors. So if you decrease your exposure to melatonin by working all night or flying across time zones, then certainly it'll slightly increase risk. It's not terribly, but if you factor it in with other factors, it's something to consider.

Lastly, patients always ask... There was research several years ago about bras and underwires in bras increasing your risk. No, there's been no research to corroborate that. And implants do not increase your risk for breast cancer. They make it a little more challenging to read your mammogram and there has been recent research showing that implants are associated with a certain type of lymphoma, but I would urge you to talk with your plastic surgeon about that risk.

Scott Steele: Laura, does it matter the size of a woman's breasts as it relates to breast cancer risk?

Laura Shepardson: No. Great question, but no, size doesn't matter.

Scott Steele: You mentioned the modifiable risk factors and everything, but let's just take in general and let's talk about screening. So I'm a woman out there, that's listening to this, and what are the different screening tests for breast cancer? Can you go into each of those for a little bit?

Laura Shepardson: Of course. So the number one way to screen for breast cancer is with screening mammography. So there's a lot of controversy about when to start, how often and when to stop, and we'll go into that a little more detail later, but it's very important for women to understand the benefits of mammography, which is reducing mortality. Multiple research studies have shown over and over again, screening mammograms reduce mortality from breast cancer by as much as 20%. So it's really important.

The other thing to do is talk with your doctor or your provider about your risk factors, what the benefits of mammography are and what the risks of mammography are, meaning there's a lot of controversy about does mammography over diagnose breast cancer? Meaning things show up that turn out to be breast cancer but that will never impact a lady's life. There's a lot of false positives, so that leads to a lot of what patients might think would be unnecessary biopsies and a lot of patient anxiety. So you have to put your preferences in the same context with your risk factors and talk with your doctor about what's best.

So if it's determined that you're at increased risk for breast cancer, there are other things we can do to screen. So patients who have a greater than 20% risk of breast cancer certainly should have annual breast MRIs, and usually we put them on a schedule of every six months. So every six months they'll have some sort of imaging, mammogram in January, for example, MRI in July, mammogram in January, MRI in July.

The other way to screen for breast cancer is with whole breast ultrasound. Now, that's problematic because lots of findings show up on an ultrasound that, again, warrant biopsy, further workup, further management and follow up. So whole breast ultrasound is not used as often but certainly it is in our arsenal for screening.

Scott Steele: Laura, can you talk a little bit about a self-breast exam? When should patients start that? And for people that are uncomfortable with really understanding, is there a way that you can get taught or some educational items out there?

Laura Shepardson: So the key about self-breast exam is that you really need to know and understand what your breasts normally feel like. So when women develop breast tissue, I encourage them, "It is so great for your own health to start just feeling your breast and understanding and looking for any lumps, any new lumps or any new changes in the breast tissue." You're looking for anything that's firm, solid. I equate it to almost like a little stone you would find in gravel. It should be that hard. Cyst and fibroadenomas tend to move around, they can be soft. Those are benign changes that women have in their breasts.

I also encourage patients when you're doing a self-breast exam, pick the same date each month. So if your birthday is January 19th, always examine your breasts on the 19th, or always on day one of your period if your period's pretty regular, just to get yourself in a routine. Do we all do it every month? No, we don't. But again, it's very important because when you know what your breasts feel like, you can bring any changes to the attention of your provider. Many women in their 40s, 50s, aren't seeing doctors on a regular basis, so to say, "Oh, well, my doctor knows what my breasts feel like", it doesn't really help the situation because you can develop changes within that period between visits.

Scott Steele: Let's talk a little bit about a game we like to play here, and that's called truth or myth. So truth or myth, you need to get a mammogram only if you are over age 40?

Laura Shepardson: Myth, exclamation point. Myth, myth, myth. So women who, again, I keep going back to this risk, and I hope that's a recurring theme in this conversation, is that you need to understand what your risk for breast cancer is. Women who are at increased risk will be put on a mammogram schedule starting earlier. So typically we say, if you have a family member who is a first degree family member who was diagnosed at a certain age, you start screening 10 years before that.
The other reason you would have a mammogram before age 40 is if you notice a lump. If you're 32 and you notice a lump in your breast, we will do mammography because we're looking for any subtle mammographic changes that may be associated with the finding or elsewhere in your breasts. A lot of times we see things that are incidental findings.

Scott Steele: So let's go back to something that you mentioned a little bit earlier just to make sure we circle back and understand what that is, and that can be associated sometimes with younger women, but what is this concept that you mentioned of dense breasts?

Laura Shepardson: We define that as an indicator of the amount of glandular and connective tissue, meaning the tissue responsible for making milk and holding the breast in place and up, for lack of a better description. It's not determined by how firm the breasts feel. A lot of times patients will come in and say, "My breasts feels so dense." That is not density. Density is categorized using a standardized system that was developed by the American College of Radiology that's called the BI-RADS system. We categorize breast density in four ways. One, breast can be completely fatty. That means it's all fat. We don't have any glandular tissue in the breast. Or scattered, meaning 25 to 50% density. Heterogeneously dense is 50 to 75% density, and extremely dense means there's way more glandular tissue than there is fat.

I want to emphasize, dense breasts are common. About 40, 45% of US women between the ages of 40 and 74 have dense breast tissue. So it's important because the risk of breast cancer increases with increasing breast density. Women with dense breast tissue have a one and a half to two fold increase in risk compared to those with less dense breast tissue.

The other problem with it is dense breast tissue is white on a mammogram, and breast cancer is white on a mammogram, and so a lot of times the denser tissue can obscure or hide a cancer on the mammogram and making it harder for a radiologist to pick that up. In 2019, the FDA issued a rule requiring all mammogram reports to include information about breast density so that women can have that conversation with their doctors about whether or not additional screening modalities or screening tests should be performed for that particular patient.

Scott Steele: So let's go back to truth or myth. Truth or myth, a mammogram hurts?

Laura Shepardson: Well, sort of in the middle. It's half-truth, half myth. So it really depends on a patient's pain tolerance, but there is a fair amount of compression on a mammogram, and compression is so key. I tell patients all the time, "I understand it's not comfortable. It's brief." It's about 30 seconds for each view, and we take multiple views of each breast, but you're in compression probably about 30 seconds for each view. The problem is you have to compress the tissue because you want everything to spread out as much as it possibly can. If you think about looking at a patient's breast, things can overlap and it can give the false impression that there is a mass sitting there, and that's when we call patients back and do additional pictures and press right over that specific area and ultrasound, the whole nine yards. Compression is necessary because it spreads out the tissue, reducing the chance that anything can look like a lump and it reduces the amount of radiation we need to use to image the breast.

Scott Steele: So if I'm a woman out there or a man with a concerning symptom, but let's just say, I'm an asymptomatic patient and I'm thinking, "Gosh, in this time of COVID, I don't really want to go in and get screened." Is that a right thought process there? Or tell me what's going on in terms of the process of getting screened, especially during this time of pandemic.

Laura Shepardson: Well, it's interesting because when the pandemic first started, many programs shut down and said screening is a non-essential test that needs to be offered. We continued to offer screening, and I think many places have come back up and they are encouraging patients to come back and to screen as well. If you waited and you delayed your screening at least a couple of months, that's not harming anything. Breast cancer doesn't change that fast. So I want to speak to all those people listening, who postponed, you didn't hurt yourself by doing that. So come on back, we're glad to have you.

Screening is really important and there's no set timeline. There's a lot of discussion about how often you should screen, so all the way up to every other year in certain populations. So again, it's not harming you if you waited. But I will say this, the Cleveland Clinic, and certainly I'm sure most breast imaging centers, are taking every precaution, every precaution to protect their patients, screening at the doors, wearing face masks, social distancing, everything everybody's been hearing for the past couple of months. And we're trying to stagger our appointments so that there aren't multiple patients sitting in the waiting rooms. I still think it's important to come on back and get back into that normal routine of screening, whatever schedule you are on, and looking for breast cancer that way.

Scott Steele: Let's say something is found during a mammography, what are some next steps that could potentially happen?

Laura Shepardson: I want to, again, emphasize here, the vast majority of things found on a screening mammogram are benign, but there's only so much we can say about it because it's a screening test. We're just looking, is there anything that looks different or abnormal on a mammogram? There's plenty of benign things that are abnormal looking on a mammogram.

So what would typically happen is patients would be called to come back in and we may do additional mammogram pictures. I mentioned we can compress over certain areas, we might magnify certain parts of the breast, we may also recommend an ultrasound, and that's just another way to look at the breast tissue. We may also recommend that you be seen by a breast specialist, whether it's a surgeon or a medical breast specialist for further clinical exam or risk assessment.

Scott Steele: How does somebody schedule a mammogram if they want to get one at the Cleveland Clinic?

Laura Shepardson: So the best way to do it is to go online, and it's clevelandclinic.org/breast. And then when you do that, I practiced this last night, there's a pink box on the bottom right of the screen, it lists all 32 sites where we perform screening mammograms, including seven sites around Northeast Ohio, where patients can walk in without an appointment. They can just show up and we will do their screening mammogram.
Please know also that the Cleveland Clinic allows you to have a mammogram without a prescription if you don't have a doctor. So we think screening is so important, patients can come in, they don't need to have a doctor's order and let the scheduler know, and she will assist you with scheduling and how the followup is going to occur.

Scott Steele: Well, that's fantastic stuff. As people who listen to Butts and Guts know, we always like to end up with some quick hitters for our listeners to get to know you a little bit better, Laura. So first of all, what's your favorite food?

Laura Shepardson: I'm going to go with a nice salad with a lovely vinaigrette dressing.

Scott Steele: Fantastic. So what is your favorite sport?

Laura Shepardson: Running.

Scott Steele: What is the last non-medical book that you've read?

Laura Shepardson: Let's see, Leaders Eat Last by Simon Sinek.

Scott Steele: Okay. And finally, name something that you like about living here in Northeast, Ohio in Cleveland.

Laura Shepardson: So I love a couple things. I love the weather, I love the change of seasons, I'm all about the deciduous change, whatever it's called, and I think the park system... I'm really an outdoorsy person. I love the park system in Cleveland.

Scott Steele: Great stuff. So why don't you give us a final take home message for our listeners out there regarding the topic of breast cancer and screening risk factors today?

Laura Shepardson: Number one, know what your risk factors are. Number two, talk about it with your providers about what's the best way to screen for breast cancer for you. And number three, COVID has certainly wreaked havoc in 2020, everywhere you go people are talking about it, they're wearing their masks, maintaining social distance, but it's also important to remember there are still other diseases that certainly deserve our attention. So at Cleveland Clinic, we're committed to protecting the health and safety of our patients and our caregivers. We are here for you.

Scott Steele: Really, really well said. So in times like these, it's important for you and your family to continue to receive medical care. For your empowerment and your peace of mind, take the time to schedule a mammogram. Visit clevelandclinic.org/breast. That's cleveland clinic.org/breast, to view all mammography locations, hours, and phone numbers, including those offering walk-in screening mammograms for women with no breast symptoms and even without an order. Rest assured here at the Cleveland Clinic we're taking all the necessary precautions, sterilize our facilities and protect your patients. Laura, thanks for joining us on Butts and Guts.

Laura Shepardson: Thank you so much for having me.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.