Breast Health Basics

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On today's episode, we're exploring breast health from everyday habits that support breast wellness to understanding pain, lumps, screenings, and imaging. This is a topic that raises a lot of questions and sometimes a lot of worry. So I'm joined by Dr. Lakshmi Khatri, director of the Medical Breast Center to bring clarity and confidence to this topic. Thank you so much for joining me on the podcast, Dr. Khatri.

Lakshmi Khatri, MD:

Yeah, thanks for having me.

Erica Newlin, MD:

Before we start, can you tell our listeners a little bit about your role in the Cleveland Clinic and your background?

Lakshmi Khatri, MD:

Yeah, sure. So I am an internist and I've practiced internal medicine for a little over 20 years. And within that role, I served as a primary care physician and at least half of my patients were female. And so spent a lot of time taking care of women and women's health issues. And I had the opportunity about three years ago to pivot to our breast clinic. I'm the director of our medical breast center, and we focus primarily on taking care of women who are at elevated risk for getting breast cancer. So perhaps a woman who has a genetic predisposition, family history, so we do personalized risk assessments as well, discuss breast density, take care of women who are coming in with breast issues and take care of survivors as well.

Erica Newlin, MD:

Great. Let's begin with what women can do every day, because breast health isn't just about screening. It starts with lifestyle habits, awareness, and understanding your own body. What does breast health actually mean? And why is it important to think about it proactively?

Lakshmi Khatri, MD:

Yeah, I think this is a great question, and I feel like women are looking for this information now. We know one in eight women in the United States will get diagnosed with breast cancer, but what can you do to prevent it? Really, the things that we know which are most effective in reducing the risk of getting breast cancer are exercising, maintaining a healthy weight, and reducing or eliminating alcohol intake.

Erica Newlin, MD:

Are there any small habits that make a big difference?

Lakshmi Khatri, MD:

Movement is really important. It's quite impactful how much exercise regardless of weight can impact not only reducing your risk for getting breast cancer, but also for women who've had breast cancer, it can significantly reduce their risk for a recurrence. And that is as simple as walking 30 minutes, five days a week. So most of the studies that we've looked at have shown about 150 minutes of moderate type of activity per week, whatever that activity is. It doesn't have to be walking. It can be whatever you like to do, but getting your heart rate up a little bit, so if you're walking with a friend or exercising with a friend, you may be a little breathy while you're talking.

Erica Newlin, MD:

Great. Are there common mistakes or misconceptions women have about maintaining breast health?

Lakshmi Khatri, MD:

Probably a big misconception, something I hear in clinic a lot is a lot of my women will ask me if it's okay to use aluminum containing deodorant. It's interesting, but there is no data to support any risk associated with aluminum containing deodorant. So I tell my women to use whatever works for them, whatever they're most comfortable with. I think women ask a lot about hormones, and it's a much deeper topic than we have time to probably dive into. But it's important to know that while there is some potential risk associated with certain types of hormonal use, in general, having a conversation with your doctor because there's a lot of benefit as well. So for example, birth control, I do see a lot of young women who are at very high risk for getting breast cancer and they're thinking about the use of hormonal birth control.

Lakshmi Khatri, MD:

And really the data shows that the amount of breast cancer risk increase from being on any type of hormonal contraception is really, really, really low. And we know that the benefits of cycle control and preventing pregnancy and preventing the risk of actually ovarian and uterine cancer is much, much higher than any risk that you would obtain from being on that birth control. So I think that's another big misconception.

Erica Newlin, MD:

Perfect. Now that we've covered every day breast health habits, let's talk about something many women experience, breast pain. What causes breast pain and how often is it linked to serious conditions?

Lakshmi Khatri, MD:

Yeah. So this is a very, very common symptom for which women will go see their primary care doctor or their gynecologist or they even see us in our clinic as well. And I think that it's scary when you feel breast pain, especially when it's not in both of your breasts and perhaps not associated with your cycle, because I think most women are familiar with that cyclic type of breast pain, but women can also have non-cyclic breast pain, and that means it's pain that doesn't occur in coordination with their menstrual cycle. And interestingly, it doesn't have to be in both breasts. It can just be in one breast. And again, that is alarming, and it is a reason to talk to your doctor, but it is rarely a manifestation of anything bad, meaning cancer. So what we've found is that in most studies, when women present with focal pain, so there's one spot that's hurting, it's not tender to touch necessarily, but you're just walking around with pain in one area that's persistent, that is the type of pain we'd want to work up with imaging.

Lakshmi Khatri, MD:

However, only about 2 to 7% of the time will that end up being because of a cancer. So it's very, very rare for breast cancer to present as pain. Most of the common causes of breast pain are really hormonal. And even that week before your cycle, when we expect to have more breast pain, there are still other hormonal fluctuations, as you know, that can cause pain. And our diet has a big impact on it as well. We also know that a low fat diet can reduce your risk of getting breast cancer, but can also significantly reduce your risk of getting pain. There's something about the ratio of fatty tissue in the breast that can actually increase a woman's sensitivity to pain in the breast. Caffeine can definitely increase the breast pain, but it doesn't increase your risk of getting breast cancer. So as long as you know, and we know that your pain is of a non-cancerous cause, it's okay to have your caffeine.

Lakshmi Khatri, MD:

But if pain is causing distress and is uncomfortable through the day, I do tell women to remove caffeine. But probably the number one reason for women to have pain is because they don't have a proper fitting undergarment or bra, and it's not easy to find always that they can be very expensive. And I don't know how accurate this is, but I was told by somebody that normal wash and wear with a bra, it loses its elasticity and support at about six months. And I can tell you, I don't think most of us are getting new bras every six months.

Erica Newlin, MD:

They’re too expensive for that.

Lakshmi Khatri, MD:

Definitely. And it's definitely like bathing suit shopping. Nobody really wants to do that, right? So most of the time breast pain is of a benign reason. We can't always identify it, but it should be worked up. If you're coming in with a area that is focal and it's persistent, you need to see your doctor so we can make sure that we're not missing something, knowing that reducing caffeine, getting a proper fitting bra, and then talking about other things that can help reduce breast pain. There's a supplement called evening primrose oil that's actually been shown to be pretty effective and it changes that sort of ratio of the fatty acids in the breast tissue, which can reduce that pain and sensitivity.

Erica Newlin, MD:

And then pain can certainly raise questions, but finding a lump can certainly raise immediate concerns for people. Let's walk through what to do and what steps happen next.

Lakshmi Khatri, MD:

Sometimes women will find a lump because they just accidentally feel it, but I think that it's important to talk about breast awareness or doing a self-breast exam. There has been some data that suggested that doing a monthly self-breast exam might increase the risk of coming in and false alarms, but we still know that a significant number of women will find their own breast cancer. And so I think it's important for all women to know what their breast tissue feels like, what is normal, because breast tissue's pretty lumpy. What's normal for you so that you know when something is different and you can seek medical attention. So regardless of how you find a lump, whether you're feeling in the shower or laying down, or you just incidentally find something accidentally, you should definitely seek care either from your primary care doctor or your gynecologist to start with a clinical breast exam in the office and then they can help decide if you need imaging, which is typically in women over the age of 30, it's going to be a mammogram and an ultrasound. And in women under the age of 30, we start with ultrasound alone.

Erica Newlin, MD:

When someone does feel a lump, what kinds of lumps might be generally benign? What characteristics would concern someone more?

Lakshmi Khatri, MD:

If you're feeling your own breast tissue and you feel something that's out of the ordinary, do not hesitate to get it checked out. But what we find is that lumps that are very smooth and kind of softer, like you can kind of compress them are often related to cysts. And cysts are really common in women who are of reproductive years. And even if I felt that in a woman in my clinic, if it was distinct, I would still be evaluating it because I really cannot know with a hundred percent assuredness that it's nothing. But that's what I'm looking for is sort of very smooth and kind of squishy, really. What I tell women to feel for is something that is obvious because women will often say to me, "Well, I don't really know what I'm feeling for. " You're feeling for something obvious. It may feel like a BB, it could feel like a pea, like a nut.

Lakshmi Khatri, MD:

It could be mobile and it could be just stuck. All of those things would need to be evaluated. And I describe the texture of the breast to women as sort of like a cobblestone feeling. There's lots of little nooks and crannies. And again, that's why the next time you're in to see your doctor and you're having a breast exam, talk about it with your doctor and actually go and do an exam on yourself after so that you know, okay, this is the normal texture of my breast.

Erica Newlin, MD:

That's funny. I do almost a very similar counseling with the cobblestone in the GYN annual visit. I'm like, "Feel it now. It feels like a cobblestone that's normal." But anything that really is feeling like a, I say marble or a pea is what we're looking for.

Lakshmi Khatri, MD:

That's exactly what we tell our patients too. Yeah.

Erica Newlin, MD:

Besides lumps, what other breast changes should prompt a medical visit?

Lakshmi Khatri, MD:

Yeah. So skin changes on the breast. So whether it's a thickening of the skin that could look a little dimpled or like the surface of an orange, so almost pitted, can indicate that lymphatic channels are maybe being blocked by something. Redness, so any focal redness or rash on the breast or on the nipple should be evaluated. Women do experience a lot of eczema on their breasts, and especially on the areola and the nipple, you can sometimes have some peeling or dryness, but if it's something new for you, you should definitely have your doctor take a look at it. You can get a type of breast cancer called Paget’s disease, which involves specifically the nipple, and it would typically cause a lot of peeling and redness and almost erosion of the skin. But again, I would never hesitate if you had some peeling in the areola area around the nipple to have your doctor take a look at it, but it's often eczema.

Lakshmi Khatri, MD:

So a new rash in the breast, thickening of the skin, and nipple discharge. So nipple discharge is very common, and there's some characteristics that tell us this is definitely nothing to be worried about, and some that tell us we should be worried. So it's not uncommon even many years after breastfeeding to have some milky or creamy discharge, specifically like with some stimulation, whether it's in the shower or with squeezing. What we worry about is nipple discharge that is spontaneous and it's typically on one side. You're noticing it on your bra or you might notice it on your nightgown and it's typically going to be clear or bloody. That needs to be evaluated with imaging, typically a mammogram and then an ultrasound that focuses on the area behind the nipple. And it often is indicative of something called a papilloma, but it can be indicative of something beyond that, like a breast cancer, so needs to be evaluated.

Erica Newlin, MD:

For some of these symptoms, as you mentioned, imaging may be needed and there are many different types available. Being asked to get an additional mammogram or imaging can be scary and confusing. Let's go over what tests exist and when they're used to help reduce that stress and anxiety.

Lakshmi Khatri, MD:

Yeah. And I'm so glad you bring this up because I do think that this is a scary thing for women to get called back. So first and foremost, the standard of care for screening for breast cancer is a screening mammogram. And really the gold standard we use is a 3D mammogram. So it's pretty rare that you'll find an institution or a hospital system that doesn't do 3D mammography. So a screening test is a test that is done when there are no symptoms and you're looking for the disease, which would be breast cancer. About 10% of the time you are going to get called back after your screening mammogram. They do two images. So they basically do one where they compress your breast from top to bottom, and then they do one where your arm is up in the air and they're doing an angled view.

Lakshmi Khatri, MD:

But those two views, even with the 3D images, which make it much more clear to see, do not always tell us everything. And there are lots of changes in the breast that might need a deeper dive to know for sure if they're normal or not. So 10% of the time you're going to get called back and they'll ask you to do what's called diagnostic images. Those are images that are done specifically to follow up on a finding, whether it's something that you felt or your doctor felt, that nipple discharge or an abnormal screening mammogram. And that's what diagnostic imaging is. And in the majority of cases, diagnostic imaging will include not just a mammogram, but also an ultrasound to help characterize what we're seeing. Is this benign or is this something that might need to be biopsied? And once you've had a diagnostic image, again, whether it's because you've presented with some sort of symptom or you're doing a follow-up, what we call a callback for an abnormal screening mammogram, there are a couple different categories that you can fall into.

Lakshmi Khatri, MD:

And I think this is where it gets a little bit scary. Our patients are often using MyChart, and so they're reading mammogram reports that I even find are confusing for my colleagues. And before I was working in the breast center, sometimes they were confusing for me. So I can't imagine how confusing they are for the patient, but there are a couple categories that I think we should talk about. You could do your follow-up imaging, that callback or that diagnostic imaging. It could be what they call negative, which means there's nothing going on, or it could be benign, meaning they found a cyst and they know it's benign. But then there are a couple other categories where they'll call something probably benign. Nobody wants to hear probably, especially when it comes to their breasts. But actually what probably benign actually means is that the radiologist's level of suspicion is less than 2%.

Lakshmi Khatri, MD:

So they're basically 99% sure this is nothing. When we see something that's probably benign though, we follow it up in sort of a short interval. So we'll repeat imaging in six months and we'll do it every six months for up to two years until we can be sure that this finding hasn't changed. And that could be like a complicated cyst or something called a fibroadenoma that's a common finding that is a benign sort of tumor or growth of the sort of scaffolding of the breast tissue. So that's what probably benign means and getting called back every six months. So you don't need to be worried about that. You just need to know that we're being extra cautious and this is how the American College of Radiology recommends that we follow breast findings on imaging. And then the next category is the recommendation for a biopsy.

Lakshmi Khatri, MD:

Many women probably who are listening in have had a breast biopsy before. The level of suspicion at which a breast biopsy will get recommended is anywhere between a 2% chance there’s something going on to a 95% chance there's something there. So they will call your finding suspicious and those words are super scary, but often the radiologist knows that I'm 97% sure this is a complex cyst, but I want to be sure and we need to biopsy. So the level of concern at which we would say you should get a biopsy can be very, very low. And I think it's important for women to know what those words mean probably versus suspicious because they're kind of broad, scary terms when you don't know what they actually mean.

Erica Newlin, MD:

For sure. I have a fair number of patients who say, "I always get called back for diagnostic mammograms. Should I even bother with the screening mammograms?" What are your thoughts or opinions on going straight to diagnostic mammograms

Lakshmi Khatri, MD:

Yeah, I get that too. And there are some women, especially women in their 40s or women who have dense tissue, so you're having all these hormonal changes already, so your breast tissue might be changing, your tissue may be more dense. We always recommend that if your last image ended up being benign, that you go onto screening mammogram because if you're able to identify that, hey, your breast tissue looks normal on those few images, it's really the best route to go rather than doing an excess number of images. Now, the amount of radiation that we get exposed to when we do a mammogram is extremely low. It's very, very low. It's safe during pregnancy, in fact. It's equivalent to getting on a cross country flight. So four hour flight, you actually get exposed to the same amount of radiation you would if you're getting a mammogram, but nobody wants to do additional images when they don't need to be done.

Lakshmi Khatri, MD:

And so we always recommend going back to your screen if it was determined that your last mammogram was normal. That being said, it often occurs in women with more dense breast tissue. And so supplemental screening is something that can be considered for women whose tissue may be dense and about half of women have dense breast tissue, especially in their 40s and 50s. And all density means it has nothing to do with what your exam is like or what your breasts feel like. It has everything to do with the ratio of the glandular tissue on your mammogram to the fatty tissue on your mammogram. And the more glandular tissue you have, the harder it can be to find something when it's very, very small. So things can hide. And so thinking about other pictures that you can do, so other imaging modalities. So for example, an ultrasound, what we call a whole breast ultrasound, where you actually scan the entire breast to look for something that might have otherwise hidden in that dense tissue, or sometimes we use an MRI.

Lakshmi Khatri, MD:

So we do MRIs of the breast for women who are at very high risk for getting breast cancer, but we can use an abbreviated version of that MRI, so slightly quicker version of that MRI that's almost as sensitive as the full and quicker, so a little bit easier, more economical, and can help find something early that could be hiding in that dense tissue. So for those women, Erica, you might talk to them about these options.

Erica Newlin, MD:

Perfect. And you've alluded to this when you mentioned the MRIs, but can you talk a little bit more about what patients might want to look into for screening if they're at very high risk or have strong family histories of breast cancer?

Lakshmi Khatri, MD:

Yeah. So if you have a family history of breast cancer, you should definitely talk to your doctor, whether it's your gynecologist or your primary care doctor about what your risk might be. And there is a calculator that you can do online. It's called the Tyrer-Cuzick model and you can find calculators online. It's a very finicky statistical model. It is not perfect. And in fact, now here at our breast center, if you get a mammogram here, they automatically calculate it for you. So you will look at your report, although a lot of women haven't looked deep into this report to find this number, but you can find their estimated lifetime risk. The average woman's estimated lifetime risk to get breast cancer is about 12 to 13%, and women at 20% or greater are who we consider to be at elevated risk. And those women qualify for MRI with their mammogram.

Lakshmi Khatri, MD:

And how we manage those women is they do a mammogram once a year and an MRI once a year, and we try to stagger those pictures by about six months. So if you have a family history and you're wondering if your risk is elevated, talk to your doctor, potentially do a risk score yourself online if you've got all the information about your family members who are affected and when. It's important that we start thinking about this very early. It's actually recommended that you have your first sort of risk assessment at age 25. And the primary reason for that is to see if there is any signal in your family history that there may be a genetic cause for your risk for cancer. But the earlier you identify that, then the better you can be at being proactive with screening and management.

Erica Newlin, MD:

Well, perfect. Well, this has been such a great conversation. Before we end today's episode, let's finish with some practical advice for women who want to take charge of their breast health. What's one simple step someone can take today to support their breast wellness?

Lakshmi Khatri, MD:

Just one? Oh, wow. I wasn't prepared for just one, but I think understanding your risk. Again, one in eight women will get breast cancer and many of them don't have identifiable risk factors. So understanding your risk, and that encompasses everything. So that's my way to cheat with this answer, is to talk about your family history with your doctor, understand what your breast density is, and take control of those things that we can modify, which is our lifestyle, minimizing alcohol, trying to move more, and trying to get to a healthy weight, because those are all things that can help significantly reduce our risk.

Erica Newlin, MD:

Dr. Khatri, thank you so much for joining me on the podcast today. For more information on breast health, visit clevelandclinic.org/schedule your mammogram. That's clevelandclinic.org/schedule your mammogram. If you found this episode helpful, subscribe and share it with a friend. Remember, understanding your breast health is one of the most important steps you can take to support your overall wellbeing.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.