Breast Cancer Basics and Beyond with Dr. Jame Abraham

Podcast Transcript

Nada Youssef: Hi, and thank you for joining us today. I'm your host Nada Youssef, and today we have Dr. Jame Abraham, director of the Breast Cancer program. Today, we're talking about everything breast cancer. So please make sure you guys are logged in, send us your questions. I'll try to get them live here and get as many as we can in this half an hour. But before we start, please remember that this is for informational purposes only and this does not, in any way, replace your own physician's advice. So, let's go ahead and get started. First of all, thank you so much. I know you're very, very busy. Thank you for coming and if you want to go ahead start by just telling us a little bit about yourself.

Dr. Jame Abraham: Thank you Nada Youssef, thank you for having me. I'm Jame Dr. Jame Abraham, director of the breast oncology program. As a breast medical oncologist, I have the opportunity to take care of a number of women with the diagnosis of breast cancer.

Nada Youssef: Great, okay excellent. Well, let's go ahead and start with our first question. I have a question from Stacy. "When should I get a mammogram? I'm 36 and I have no breast cancer in my family."

Dr. Jame Abraham: That's a really good question and thank you Stacy for asking that question. There's lot of controversy about when to start mammograms. In a person with no risk for breast cancer or average risk for breast cancer, the recommendation from NCCN which is our large oncology group, is to start the mammogram at the age of 40. Starting the mammogram at the age of 40 and continue that once a year. American Cancer Society recommends starting the mammogram at the age of 45 but any person above the age of 40 should have the opportunity to do an annual mammogram. So it's really important for Stacy to talk to the doctor and understand what's the risk for breast cancer, and then plan for the mammogram. So overall, we should say that she should start at the age of 40 then continue every year. But having a conversation with their family doctor will really help them understand how to have the shared decision making.

Nada Youssef: Sure, okay great. Thank you! Okay, and our next question, from Deana. "I've been told I have dense breasts, what does that mean? And am I at a higher risk for breast cancer because of that?"

Dr. Jame Abraham: Right, so there's lot of controversy or conversations about dense breasts, so that's kind of a new term in the past four or five years or so. Dense breasts, that doesn't mean how the breasts feel. It actually talks about the amount of fatty tissue in the breasts versus the breast fibrous tissue.

Nada Youssef: Okay.

Dr. Jame Abraham: The ducts and the lobules .... So the density of the breasts changes as we age. And a person who, let's just say is in their forties or early fifties ... almost 40% to 50% of individuals can have dense breasts. When somebody is in their seventies, it could be about 20%. Usually, we can decide about breast density from a mammogram. If you look at the mammogram, you can say, 'Oh, that individual has less dense breasts or high dense breasts.' Based upon many studies, we know that breast density is a risk factor for breast cancer, about five to six times or so. It increases the risk for breast cancer.

Nada Youssef: As you get older?

Dr. Jame Abraham: When you have dense breasts.

Nada Youssef: Sure.

Dr. Jame Abraham: And some of the medicines we use, like hormonal replacement treatment or some of the medicines, can increase the breast density. So it's important for Deana to talk to her family medicine doctor and then make sure she fully understands what it means for her, after looking at her mammogram.

Nada Youssef: Great, alright thanks. Let's go ahead and go to the next question. We have Britney. "Can having plastic surgery done on your breast cause cancer or increase your risk for breast cancer?"

Dr. Jame Abraham: So plastic surgery, let's just somebody's doing breast plastic surgery for breast augmentation or something of that benign procedure, that should not increase the risk for breast cancer.

Nada Youssef: Okay.

Dr. Jame Abraham: Yeah, any plastic surgery or reconstructive procedure should not increase your risk for breast cancer.

Nada Youssef: It's not like at all?

Dr. Jame Abraham: No, there's no data to support that.

Nada Youssef: Okay, that's good to know. Okay, and then I have a question from Sandy. "Could pain in my breast indicate cancer? If not, what else could cause it?" And I guess I'll add to that, what kind of pain? If it's a lump, if it's soreness. What kind of pain could be causing that?

Dr. Jame Abraham: Right, you're right. So pain by itself, pain is a vague symptom.

Nada Youssef: Right.

Dr. Jame Abraham: You could have pain from many different reasons. So, just because somebody has pain in the breast, that doesn't mean that's breast cancer. But, as you said, it's important to make sure they don't have ... she has a new lump or skin changes, changes in the nipple, nipple discharge. So it's important to make sure there are other symptoms. But, if there's new pain which is persistently getting worse, it's important to get evaluated. But just because somebody has pain, that doesn't mean that's cancer.

Nada Youssef: Right.

Dr. Jame Abraham: But even at the same time, they shouldn't be ignoring a new on-set.

Nada Youssef: Always check with a doctor?

Dr. Jame Abraham: Yeah.

Nada Youssef: (laughs) Great. I have a question from Sammy Lin. "My mom just got diagnosed with breast cancer. What do we do next?"

Dr. Jame Abraham: So, that's a good question. In the US, about 250 thousand women will walk out of the doctor's office with a diagnosis of breast cancer. And that's a question they all ask, 'What should I do next?' As a breast cancer doctor for 10, 15 years, my recommendation will be to find a good team for you. Breast cancer treatment is not done by one person, it's not done by a surgeon or a medical oncologist or radiation oncologist alone. It's a team approach. So if you look at cancer care overall, it's a team approach. And breast cancer really is a good example of how the team works together.

Nada Youssef: Sure.

Dr. Jame Abraham: So, you need to have a good radiologist, given the proper diagnosis, you need to have a good pathologist. Who will look at the tissue and then give you an accurate diagnosis. And then you need to have an excellent surgeon, a medical oncologist, a radiation oncologist and a plastic surgeon. So it's really, really important for her to connect with a team whom they can relate and trust and connect.

Nada Youssef: Great, excellent, thank you! And then I have Mesari. "For someone who has been on breast cancer treatment and declared cancer-free, are there any possibilities to conceive after that, when you're in your early forties?"

Dr. Jame Abraham: That's a good question. Unfortunately, there are a number of young women who get a diagnosis of breast cancer, young women face. They have many unique challenges. Unfortunately, it is one of that. Diagnosis, treatment, having a young family at the same time, balancing work and work life. Fertility is an extremely important aspect of that. To give a one word answer, definitely.

Nada Youssef: Okay.

Dr. Jame Abraham: They can conceive after breast cancer diagnosis. Breast cancer's not an absolute contradiction not to have children after that, definitely. But again, that depends on multiple factors. What's the stage, when they've finished the treatment, what's the type of breast cancer. As I said, because it has many other dimensions of the care, it's extremely important to make sure they have a team who specializes in young women's care.

Nada Youssef: But it's not ruled out.

Dr. Jame Abraham: It's not absolutely ruled out. What we do is, we have a young women's clinic. We have fertility specialists who see young persons with the diagnosis of breast cancer even before we start any treatment.

Nada Youssef: Right.

Dr. Jame Abraham: They can have that conversation early on and plan what they can do in two years from now.

Nada Youssef: Sure, sure.

Dr. Jame Abraham: It's really important for them to get connected to a disciplined young women's clinic.

Nada Youssef: Sure.

Dr. Jame Abraham: And a fortunate expert to have a good conversation.

Nada Youssef: And that's the part of that good team that you've mentioned.

Dr. Jame Abraham: That's right, that's right.

Nada Youssef: Okay, great. I have another question here from Nashwa. "Is hormonal replacement therapy recommended? Many researchers say it might cause cancer."

Dr. Jame Abraham: Right, so hormonal replacement treatment is probably one of the very controversial topics in women's health. Before 2001 or 2002, we used to recommend HRT hormonal replacement treatment for every individual.

Nada Youssef: Okay.

Dr. Jame Abraham: After menopause, that was a standard recommendation. Like Aspirin for heart disease, that's how HRT was.

Nada Youssef: Sure.

Dr. Jame Abraham: But in 2001 or 2002, we had large data come out saying that hormonal replacement treatment can increase the risk for breast cancer. So, in general, that blanket recommendation of 'everybody should take hormonal replacement treatment', we're not doing that anymore.

Nada Youssef: I see, okay.

Dr. Jame Abraham: But again, any medicines we do, we should look at the risks and benefits. If somebody has the family history of breast cancer or high risk for breast cancer, they should be seriously thinking about whether they should take HRT hormonal replacement treatment, because it can increase the risk of breast cancer.

Nada Youssef: Sure.

Dr. Jame Abraham: But at the same time, I don't want to say nobody should be doing HRT hormonal replacement treatment because there are a lot of benefits for hormonal replacement treatment. Like intractable menopausal symptoms, vaginal dryness, [inaudible 00:10:33]. So, they should be talking to their family doctor or gynecologist or oncologist. Then, really look at the risks for breast cancer or risk for other things, like blood clots, uterine cancer, different things. And then we can make informed decisions. As a breast cancer doctor, I'll say that it clearly increases the risk for breast cancer. If you have a risk of breast cancer, probably try to avoid that.

Nada Youssef: Great, alright. And we have Donna. "I turned 40 last year, when should I consider my first doctor visit with a mammogram?"

Dr. Jame Abraham: As I mentioned before, when we were talking about Stacy's question, our recommendation is to start the mammogram at the age of 40.

Nada Youssef: Sure.

Dr. Jame Abraham: At the age of 40, every person with an average risk or a person who has no high risk of breast cancer should consider doing a mammogram once a year at the age of 40. Different groups have different recommendations. It's extremely important to make sure that you talk to your doctor about starting now. I say you should be talking to your doctor because the recommendation for a mammogram can be changed based upon your risk.

Nada Youssef: Right.

Dr. Jame Abraham: And there are multiple risk factors for breast cancer. Family history's one of them, from your mother's side and your dad's side. It's important to understand what's your risk for breast cancer.

Nada Youssef: Okay, great. Okay, and then going kind of general, I think our viewers would like to know, are there just general symptoms for breast cancer? Are there general symptoms that people have? Is that kind of what you said earlier with pain? Is there anything else that we should know?

Dr. Jame Abraham: Right, so there are multiple symptoms and signs which a person can watch for. Skin changes, skin protraction, nipple changes, nipple discharge from one side or bloody discharge, feeling a lump, making sure they examine the lump in the breast, or if they feel a lump under the arm. Lump, new on-set pain which is persisting, skin changes, changes in the nipple, areola area. So those are all really important.

Nada Youssef: Okay, great. Let's see, we have Gregory. "I'm a man and I have a large breast that is causing me a lot of pain. Can it be cancer?"

Dr. Jame Abraham: So that's a good question, Gregory. About 2000 or 2500 or so men get a diagnosis of breast cancer. Again, compared to women, about 250,000 women get a diagnosis of breast cancer. It's less common but breast cancer can happen in men. If it's a new on-set pain on one side, I think it's good for him to at least talk to the family doctor or his predicate doctor and make sure there's no lump or nothing different.

Nada Youssef: Sure.

Dr. Jame Abraham: And if there's a lump or if there's a change, they can always get an ultrasound, ultrasound of the breast. Or even a mammogram. If it's from both sides, probably less chance of being a cancer. But I think it's important for Gregory to know breast cancer can happen in men, and if there's a concern it's good for you to check up with your family doctor.

Nada Youssef: Okay, thank you. And then, let's go to the next one here, Lisa. "I have a triangle-shaped cyst or tumor. Should abnormal shape be immediately removed?" She's 27 years old.

Dr. Jame Abraham: Lisa, thank you for the question. If it's a new lump, it's important to do .... Usually, when we feel or patients complain about a lump, usually we recommend an ultrasound. The radiologists can look at the ultrasound, and if the radiologist clearly said it's a cyst, cyst means collection of fluid, then that's less worrisome and they will say just repeat the ultrasound six months or three months since they make the recommendation. Based upon how this is looking under the ultrasound. I don't think you should ignore it, make sure you have the ultrasound or proper testing. Then, depending upon what's the finding from the testing, they can make the decision of what is the next step.

Nada Youssef: Okay, great. We have Carol. "Can you explain ductal carcinoma?"

Dr. Jame Abraham: Ductal carcinoma. If you look at breast cancer, 80% to 90% of breast cancer arises from the ducts. In the breasts, we have ducts and then we have lobules. 80% to 90% of breast arises from the duct. About 10% arises from the lobule. Ductal carcinoma is the most common type of breast cancer. There are two types of ductal carcinoma, there is an invasive ductal carcinoma. That is the most common cancer and the cancer happens in the duct, it kind of invades the outside. That's invasive ductal carcinoma. I don't know what exactly Carol means. So there's ductal carcinoma inside means the carcinoma happens within the duct, it stays within the duct.

Nada Youssef: Okay.

Dr. Jame Abraham: That's ductal carcinoma inside. Invasive carcinoma is the most common type, which we see, and which is the one which has the potential of going to the lymph nodes. If its ductal carcinoma staying within the duct, we call it a 'stage zero'. So less worrisome spreading that to the other parts of the body.

Nada Youssef: Great, okay and the questions are coming in. We have Becky. "I started my mammograms at the age of 18, I have had five biopsies. So far, they have been cysts. Do I have to worry that it might turn into cancer? I do have a family history of breast cancer. Would you recommend a mastectomy?"

Dr. Jame Abraham: Becky, I'm sorry you're really young and going through all these procedures. But I'm glad you're being proactive and taking it on yourself. Let's just look at the risk for breast cancer. Here, Becky's saying she has a family history. When somebody has a strong family history under the age of 50, multiple family members with breast cancer, or breast or ovarian cancer especially under the age of 50, or it can be from either side. From the dad's side or from mother's side. Sometimes we ignore the dad's side and we just focus only on that. And we see patients saying, 'Oh, my mom is fine, my sisters are fine. But oh, my dad's sister had ovarian cancer at the age of 30.' Then we need to work. So if there's a strong family history, we usually recommend a genetic counseling. About five to ten percent of breast cancers are due to abnormal genes. I'm sure if Becky had a concern of strong family history, at some time, I'm sure their family doctor would recommend her to genetic counseling. If the genetic counseling is done and the test is positive, then we usually recommend doing screening at the age of 25. Usually we do breast MRI for that, breast MRI to try to look for that.

Nada Youssef: Sure, sure.

Dr. Jame Abraham: Again, that depends on the family members, what age they had the breast cancer. When they say they have a strong family history, it's really important to make sure ... are we talking about a gene, or are we talking about a known hereditary breast cancer?

Nada Youssef: Sure.

Dr. Jame Abraham: Then, she had multiple biopsies. I'm sure, Becky, you're followed by an expert, team in the cancer clinic that can recommend what's the best [inaudible 00:19:00]. Mammogram is good, but in young patients, mammogram can be tough because the breast density. In young individuals with a strong family history, usually we say more than 20% chance of having breast cancer in a lifetime, we recommend breast MRI. And sometimes, we recommend chemosynthesis and different things. It's really important to make sure that she talks to the right team, pick the right screen modality, and then having a regular protocol.

Nada Youssef: Great, excellent. Okay, and let me see here, we have Linda. "If you had a tumor removed that was cancer and it was very small, do you not always have to have radiation?"

Dr. Jame Abraham: You're saying the tumor is taken out, that's her two negative and it's more tumor. If we do lumpectomy, we're just taking only the tumor out, in general the recommendation is to do radiation. After lumpectomy, radiation is what we recommend. But that recommendation can be different based upon other factors. Linda, that depends upon your age, your other medical problems and other features within the tumor. In general, lumpectomy we recommend radiation. But if somebody had like mastectomy, the whole breast is taken out, less chance of radiation. Again, that depends upon what's the stage, what's the type and other features.

Nada Youssef: Sure, great. And I have ... let's see. "My mother died from breast cancer at the age of 58 years old. Other than getting an annual breast examination and mammography, what are the other things I can do to prevent getting this disease and what role does diet play in this diet?" We haven't touched on diet, so I'm glad that I read this one.

Dr. Jame Abraham: Glad, glad. Let me start with the diet. Diet plays major role in many of our chronic diseases.

Nada Youssef: Sure.

Dr. Jame Abraham: Hypertension, diabetes and other things. Diet plays a major role in breast cancer too. Sometimes I say, it's almost like a metabolic disease.

Nada Youssef: Sure.

Dr. Jame Abraham: What happens is, when we consume high fat diet, that can potentially increase the estrogen levels. It's related to the estrogen in our bodies. When there's high estrogen levels, there's high increased risk for breast cancer. Regular exercise, healthy diet and maintaining a healthy weight is extremely important in a person to prevent or cut down the risk of breast cancer. That can be the answer for your question, the things you can do to prevent. You can't change your family history.

Nada Youssef: Right.

Dr. Jame Abraham: You're born into that. When you said your mom died from breast cancer, I'm sorry to hear about that. When you say your mom died from breast cancer at the age of 58, as I said before, it's really important to make sure what other risk factors you have. Let's just say your aunt had cancer at the age 55 or somebody else had breast cancer or ovarian cancer. Then you should probably talk to your doctor, family doctor. See if she should see a genetic counselor. Again, that depends upon that strong family history which I was describing before. So depending upon that recommendation, they can decide if she's a candidate for genetic testing. Again, that's only five to ten percent of breast cancer. If that comes back as positive from the recommendation for screening and prevention, we'll change. If she doesn't have the gene, then again, maintaining a healthy ... all the things which I just mentioned. Exercise and diet and having annual screening mammograms.

Nada Youssef: Great! Well, we're actually almost out of time but I wanted to give you a last few minutes to give us any takeaways for the viewers. Anything that maybe we have not touched on that you would like to say?

Dr. Jame Abraham: Unfortunately, breast cancer is still, if I can say, kill about 40,000 women in the US. That's still a huge number. About 240,000 women will get a diagnosis of breast cancer. But the good news is, the number of patients dying from breast cancer are coming down steadily. Every year, the mortality is coming down steadily. That's because of many reasons. One, an effective and early screening, screening plays a major role. Then, highly active and effective treatment plays a major role. And then, the research. The clinical trials and the research and finding better treatment for breast cancer clearly and it helps. From your side, continue to be proactive and take care of yourself. Continue to maintain a healthy lifestyle, get the screening mammogram as recommended by your family doctor and continue to advocate for breast cancer research.

Nada Youssef: Great, well thank you again so much for coming in today. For more health news and tips, make sure you follow us on Cleveland Clinic, Facebook and Twitter. And we'll see you again next time!