Disparities in Breast Cancer

Podcast Transcript

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

Dr. Scott Steele: Hi, again everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery and the President of Main Campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, we're going to talk about a topic we have not talked about before, and that's disparities in breast cancer. And I'm so pleased to welcome our expert, Dr. Anna Chichura, who is a breast surgeon oncologist and benign gynecologist in the Department of General Surgery here at the Cleveland Clinic. Anna, welcome to Butts and Guts.

Dr. Anna Chichura: Thank you so much for having me.

Dr. Scott Steele: So, if you've listened to us you know, we always start out with the same thing with just give us a little bit of background about yourself. Where are you from, where did you train and how did it come to the point that you're back here at the Cleveland Clinic?

Dr. Anna Chichura: So, I'm originally from Scranton, Pennsylvania. I went to undergrad and Medical School in D.C. at Georgetown and then came to the clinic for my residency in OB/GYN. I initially thought that I was going to be a gynecologic oncologist and then realized about halfway through residency that wasn't quite the best fit for me. So, I was really fortunate that a lot of the breast surgeons who were here were really excellent mentors for me and let me work with them. And eventually, I successfully entered Breast Surgery fellowship. I completed my fellowship in Chicago and then moved back here to the Cleveland Clinic after last October. So, being here at the Cleveland Clinic has provided me a really unique opportunity to see patients in both breast surgery and gynecology and really help to provide holistic care to my patients.

Dr. Scott Steele: That's fantastic, and I am sure you're maybe one of the unique people out there that has that opportunity, so that's wonderful. So today, we're going to talk a little bit about disparities in breast cancer. To start, can you first explain a little bit more about how breast cancer forms in the body?

Dr. Anna Chichura: Absolutely. So, breast cancer usually begins when normal cells in the breast undergo genetic changes or mutations that cause them to grow uncontrollably. So, these mutated cells divide, and they can form a tumor, and that can either be non-invasive or invasive, which spreads into surrounding tissue. So, we don't really know why these mutations or genetic changes happen, but we do know that there are some risk factors like family history, some inherited genes, hormonal influences and lifestyle choices that may play a role.

Dr. Scott Steele: So, what are the different types of breast cancer?

Dr. Anna Chichura: There are two main types of breast cancer: ductal cancer and lobular cancer, which are named based on the structures in the breast that they develop from. There are also three different markers that we use to further characterize breast cancers, and these markers tell us not only how the cancer behaves, but also how we can treat breast cancer.

So, there are three main types of breast cancer receptors that we also look at in addition to the two main subtypes of breast cancer. So those receptors are estrogen receptor, progesterone receptor and HER2. So, estrogen and progesterone are both hormones. And so, if a cancer cell is positive for the estrogen receptor, it means that estrogen helps that cancer cell to grow. The third marker that we look at is HER2, and this is a protein that's normally expressed on cells of the breast, as well as other cells in the body. But it can become over expressed by some cancers. So normally each cell should have two copies of this protein on its cell surface. But when cancer cells over express it, they have multiple copies, like eight copies for example. So, when HER2 is over expressed, it sends a signal to the cell to make it divide and grow more quickly, and as a result, it results in accelerated cancer growth. So, these cancers tend to be more aggressive and grow very quickly.

There are also cancers that are referred to as triple negative breast cancers that don't express any of these markers. Those cancers also tend to be more aggressive than other cancers. The most common type of breast cancer that we see, though, is a breast cancer that's hormone receptor positive, so either estrogen or progesterone receptor positive, and HER2 negative.

Dr. Scott Steele: So, one of the things in colorectal cancer, we've had a change in screening dropped for the first time ever to go down to 45. So, at what age should someone get their first mammogram, and how critical is early detection in breast cancer?

Dr. Anna Chichura: So, we recommend that women start getting their first mammogram at age 40, sometimes even earlier, depending on their particular risk factor. So, we start screening imaging for women as early as 25 in some cases. It's extremely critical to diagnose breast cancer in its early stages when it's more contained and has not spread as far throughout the body. We know that we have a higher chance of cure when we diagnose it at earlier stages. Patients require less invasive treatment, including less chemotherapy, less invasive surgery, and they have better overall prognosis and survival.

Dr. Scott Steele: So, "truth or myth?" Truth or myth: Breast cancer mostly affects women over the age of 50.

Dr. Anna Chichura: That is true. So, the risk of breast cancer increases with increasing age, and we know that women who are post-menopausal do have an increased risk of breast cancer as compared to premenopausal women. So, while that is true, though, there are cases of women being diagnosed with breast cancer in their 20s and 30s, so it's important for all women to be aware of their risk factors, undergo breast health screenings, and breast self-awareness.

Dr. Scott Steele: So, I'm not to say that regardless of what age you get breast cancer at, that can be a life-changing diagnosis. So, can you touch a little bit about what we're talking about today; research that has shown, for whatever reason, disparities in the diagnosis of breast cancer?

Dr. Anna Chichura: Certainly. So, some of the different disparities that affect how breast cancer is diagnosed and treated among different groups of people can be linked to different factors like race, ethnicity, socioeconomic status, and access to healthcare, whether that's based on geography, cultural, or language barriers or insurance status.

Dr. Scott Steele: So, is there a demographic that is maybe more likely to be diagnosed with breast cancer after their very first mammogram?

Dr. Anna Chichura: Yes. Actually, researchers at the Cleveland Clinic have found that younger black women, that is women between the ages of 40 and 45, may be more likely to have cancer detected on their first mammogram as compared to other races. And that risk was statistically elevated with every month that they waited after their 40th birthday to get screened.

Dr. Scott Steele: I'm sure this is going to be a hard question to boil down in a few minutes, but what factors contribute to these inequalities in diagnosis and then, ultimately, I guess, survival amongst breast cancer patients?

Dr. Anna Chichura: So, there are a number of factors that have been shown to affect how patients have access to care and their ultimate survival from breast cancer. So, things like race, particularly Black and Hispanic women tend to be diagnosed with more advanced stages of breast cancer compared to White women. We know that women who were underinsured or uninsured have worse access to care. Women who are coming from rural areas who may not have access to healthcare, and then there may be cultural barriers to care, as well.

Dr. Scott Steele: And do you ever see that maybe, also, is it a lack of awareness or in terms of education that we're not getting the word out well as providers? Or is there something we can do more in that area?

Dr. Anna Chichura: I think that is a part of it that, as providers, we may not be getting the word out quite as well. And so, I think there's a number of initiatives from that standpoint, including different community outreach, just raising awareness about breast cancer and advocating for policies that help to improve healthcare for all groups so that women can start to get their annual screenings at an appropriate age.

Dr. Scott Steele: Okay. So, I'm a provider out there that sees women patients, specifically one that either is a primary care internist or whatever specialty it may be. What do I do, my patient's right in front of me - how can I address those disparities with cancer in patient populations that are at a higher risk?

Dr. Anna Chichura: So, the American College of Obstetricians and Gynecologists recommend that women have an assessment by their healthcare provider for their risk of breast cancer in their 20s. So, a basic way that patients can be screened is just by asking, "Do you have a family history of breast cancer? A family history of ovarian cancer? A family history of pancreatic cancer, or any other number of high-risk cancers that may be associated with breast cancer?" But those are our big three: breast, ovarian, pancreatic. So, if they do have a family history of that, then you can delve into that a little bit further and say, "Do you know what age your relative was diagnosed?"

But if they do have family members that have a history of breast cancer, then at that point it may be worthwhile to refer the patient to either a breast surgeon or a medical breast provider like we have here at the Cleveland Clinic who can further assess their risk and then make recommendations about screening.

Dr. Scott Steele: Anna, can you talk a little bit about mammogram versus MRI? Is that dependent on your insurance, is it the size of the breast? I mean, what goes into that factor? Because I've known women that are like, "I don't want a mammogram. I don't want to go through that - for whatever reason. So, can you talk a little bit about that?

Dr. Anna Chichura: Sure. So, mammograms and MRIs give us different information. Mammograms are our standard screening and our first line screening tool that we use. And they work pretty well in most women. We know that they aren't quite as sensitive in women who have dense breast tissue, which is approximately half of the population. So, for women with dense breast tissue, they can consider having some sort of supplemental screening. That's usually in the form of a whole breast ultrasound or an MRI. So, MRIs are used for higher risk patients typically, those who have a known gene that predisposes to breast cancer or who have extremely dense breast tissue and a history of breast cancer among other situations. MRIs are more costly or harder to access, so they're not used quite as much. They also use a contrast called gadolinium, and there's concern that that could build up in the body over time with multiple MRIs.

Dr. Scott Steele: So, let's look into the future now. So, are there any advancements on the horizon when it comes to breast cancer diagnosis?

Dr. Anna Chichura: Absolutely. So, one of the most exciting advances is the use of artificial intelligence and mammography. So, there was a study that was recently published that showed that using artificial intelligence could help to diagnose breast cancers just as well, if not even better, than a radiologist on mammogram. And then there's also some data that suggests that AI may be able to predict who will develop breast cancer in the future by looking back at mammograms over the last several years.

Dr. Scott Steele: Gosh, that's fantastic. So now, it's time for our quick hitters where we get to know our guests a little bit better. And, so first of all, what is your favorite sport?

Dr. Anna Chichura: CrossFit.

Dr. Scott Steele: Fantastic. What is your favorite meal?

Dr. Anna Chichura: Pizza.

Dr. Scott Steele: You get to go on one trip, and you have all the money in the world, where are you going?

Dr. Anna Chichura: I'm going to go to Greece.

Dr. Scott Steele: Yeah, that's fantastic. Santorini is lovely. And so, if you can, you said you were from Ohio, went away, then came back. So, tell me something you like about being here in Northeast Ohio?

Dr. Anna Chichura: I love the fact that it stays bright for so long in the summer. The fact that the sun sets at 9:00 PM is my absolute favorite thing.

Dr. Scott Steele: That's fantastic. So, give us a final take home message as in regard to disparities in breast cancer.

Dr. Anna Chichura: So, there are a number of disparities that affect breast cancer outcomes. And for as many disparities as there are, there's as many efforts trying to address them by improving access to care, increasing awareness, promoting education, conducting research, reducing financial barriers, and helping patients to navigate the healthcare system, as well as trying to make clinical trials more inclusive for patients of different races.

Dr. Scott Steele: That's great and great advice. And so, to schedule a breast cancer appointment or a second opinion, please call our Cancer Answer Line at 866-223-8100. That's 866-223-8100. And to schedule a mammogram, please visit clevelandclinic.org/mammography. That's again, clevelandclinic.org/mammography, M-A-M-M-O-G-R-A-P-H-Y. Dr. Chichura, thanks so much for joining us on Butts and Guts.

Dr. Anna Chichura: Thank you. Thanks for having me.

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