Breast Health: Expert Q&A

According to the American Cancer Society, about 1 in 8 women in the US will develop invasive breast cancer during their lifetime. Now, that's a scary statistic. Today, we'll discuss breast cancer and ways to help you protect yourself, hear from expert radiologist Dr. Kirti Kulkarni about why annual mammography screening is the only method proven to reduce deaths, and from genetic counselor Feighanne Hathaway why it's important that women with a family history of cancer understand the risk and the benefits associated with genetic testing. Our experts will tell you about the latest in care, and they will take your questions live. It's coming up right now on At the Forefront Live.

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And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. We're going to start off with introductions. But before we get too far into this, I have to say one thing, and I totally forgot this. I should have worn my pink tie today.

Yes.

You guys just were talking about that as the show was starting, and I feel really bad about that. So I apologize. I had a pink tie picked out and laid out, and then I didn't wear it. So here we go. So I'm starting off a little bit in the hole here.


So Dr. Kulkarni, we're going to start with you, since you're at the desk. And just have it-- just tell us a little bit about what you do here at UChicago Medicine.

Sure. Thank you, Tim, for having me at the Forefront. And thank you for the lovely panel discussion with Feighanne. And thank you for this lovely mug.

You're very--

My name is Kirti Kulkarni. I'm one of the radiologists at the University of Chicago. We're a team of three radiologists. And what we do is we read the mammograms, the ultrasounds, and the MRIs that the patients take here. We interpret them. Typically, we work behind the scenes. But if we find something suspicious, then we go ahead and do the biopsies of those things that we find.

Fantastic. And Feighanne, you have kind of an interesting position here.

I'm a cancer genetic counselor here at the University in our preventative oncology program. And there's two other genetic counselors in our program, as well.

That's great. And I think just having the two of you here illustrates the team approach that we take with our patients, which, again, we'll talk about that a little bit more during the program, but I think it's very important as we discuss this.

So let's just talk about starting off with prevention of breast cancer, because I think that's one thing that is a natural question from people. What things can a woman do to help protect themselves against breast cancer? Is diet-- does that help, or are there things that-- steps that can be taken?

So October is Breast Cancer Awareness Month. And you're seeing the city is lit up pink, and there's a lot of discussion around breast cancer prevention. But I want to just emphasize that the statistics or the epidemiology behind breast cancer is very harsh. And I know people have heard this, but 1-- almost 1 in every 8 women in the United States are diagnosed with breast cancer. And it's invasive breast cancer. On an average, every two minutes, a woman is diagnosed or is told that she has breast cancer. So prevention and screening is an important step, and we need to take that seriously.

When it comes to prevention, I think the first thing is to find out whether you are average risk or if you are high risk. I know people always think, oh, when it comes to screening, when it comes to prevention or screening, we need to do a mammogram. But sometimes that is not enough. I think the first step is to find whether you are average risk or high risk. If you are average risk, then you need to get a mammogram starting at the age of 40.

How do you find out if your average risk or high risk?

So that is a discussion with your doctor and with your genetic specialist. If you have any family history of breast cancer-- especially if it's your parent, your mother, or your sibling-- if you have dense breasts, if you're from an Ashkenazi Jewish descent, if you have any history of prior multiple breast biopsies, and if you are Black-- a lot of these are risk factors that can consider you as high risk.

So you gave me a pretty good segue way to go to Feighanne to talk a little bit about how people might know that they are high risk. And Feighanne, can you share a little bit about what you do here and how that works in the whole process?

Sure. I see patients of all types, so I can see male or female patients. We don't just identify patients with a family history of breast cancer, but also a family history of unusual cancers. And sometimes that could be ovarian cancer, that could be pancreatic cancer. You can even be at risk for breast cancer if there's a family history of prostate cancer.

So all of these cancers can go together. Melanoma is also one of them. So we see patients of all types, all tumor types. If a patient is diagnosed first with cancer, I can see them. But also, if the patient only has a family history.

Also, age of onset is key. So anything diagnosed under the age of 50 is considered an early age of onset. So we get concerned about any cancer diagnosed under the age of 50. There might be a hereditary component going on.

So it's interesting, I was fortunate enough, I had the opportunity to talk with one of our patients who is a survivor and a fighter. And she's done wonderful. Her name is Erica. We're going to play a sound bite with her in just a moment. But she had a family history, and she didn't-- she wasn't aware of her family history, because they didn't really talk about it, which I think a lot of families do that, including mine.

And it's an important reminder I think that if you do have this happening in your family, it's best to share that information. And Feighanne, I would imagine a lot of people aren't comfortable with that, but it is important.

Absolutely. The other important thing is that you can-- even if you think that you don't have a family history, knowing how many people are in your family, what ages they are, what age were they when they died, because a family can be an uninformative family. So you don't realize you're at risk because maybe dad actually had four brothers, and so actually, your family history is not informative. It's not that it's not there, it's just it's uninformative.

I gotcha. So John, let's go ahead and play Erica's first sound bite. This is when she actually finds out she has cancer. We've got a series of soundbites we're going to play throughout the show as she kind of goes through her journey. And this illustrates, I think, what a lot of women probably do go through in this process. So let's play that first soundbite when she finds out she has cancer.

I remember some of her exact words, but not verbatim. But she says, it is cancer. And then instantly, of course, everybody's-- my waterworks start, my daughter's waterworks start. It's just-- but she's still talking to me. And then she says, you're going to need a mastectomy. And after she said that, I didn't hear a word she said.

And Erica, by the way, is a competitive bodybuilder. You probably saw some of the trophies beside her. And throughout the whole process, I think she kind of used that in part, because she's a fighter and she takes care of herself, and she wanted to get back to that. So it was interesting to talk to her. And she relates some of the emotion there, too, with what she goes through. And I imagine you see that with a lot of patients.

Absolutely. I mean, it's not easy to explain to a patient the biopsy results. It's not easy to talk to the family members. We have to show compassion and empathy and help them through this process. Sometimes the questions are about what to do next, sometimes the question is why me, sometimes the questions are, was it not seen on my mammogram? Sometimes a question is about what happens to my daughter?

So I think when it comes to prevention, there's no one formula that fits everyone. I think mammograms are recommended starting at the age of 40. I highly recommend a 3D mammography, which is called tomosynthesis, and which gives us not just-- which is similar as getting a mammogram, but you have multiple angles in which the images are obtained. So from a radiologist perspective, we just don't see one, but multiple images. And I think that helps us especially in patients with dense breasts.

Well, and it's interesting with her story, too, which I think illustrates a lot of things and people can learn from this. She's young. She's in great shape. She takes care of herself. Did not know she had a family history. It did turn out she had a bit of a family history, and so she didn't really think about that at first.

And then she noticed the lump. She was actually getting ready for a competition, so she was on a very strict diet. And she had-- she said she didn't have a lot of body fat, which you can tell looking at her, she doesn't have a lot of body fat. And so it was a little bit more pronounced in her situation. But she immediately went to seek help then, which, again, smart thing to do.

Absolutely. There are certain signs of breast cancer that we always say have a discussion with your primary care physician or do consult a breast expert right away. If you feel a lump, or if there's any nipple discharge, or if there's any focal pain in the breast, any changes in the skin, those are-- any changes in the nipple, dimpling, those are certain signs to be aware of. But also, it's important to ask for help right away.

Yeah. Yeah. And that was one of the smart things that she did. She got right in and saw someone and got to here, actually, at UChicago Medicine, where she was pretty happy with her treatment.

Feighanne, can you talk to us a little bit more about the genetic aspect? Because this was an interesting situation in Erica's case. She had some family members, I believe on her father's side, like for example, an uncle or somebody who had prostate cancer. She had a few different family members that had cancer, but nothing that really stood out to her as something to be aware of.

Yeah. So genetic-- we know that all cancer is genetic to begin with. So in order for you to get cancer, you have to have these random genetic changes occur in one particular cell. But we're also all born with these mechanisms to protect us against cancer. And the genes responsible for that are actually called DNA repair genes and tumor suppressor genes.

And so the big question becomes, are yours actually working or are they not working? So in high-risk individuals, it turns out that you're actually born with a copy not working. And the most common ones that we know are BRCA1 and BRCA2. And then another very common one that-- or, actually, that's less common-- is TP53 is another genetic mutation. But that puts you at very high risk for breast cancer, as well.

PALB2 has been in the paper more recently. It's a pal of BRCA2, so it looks a lot like BRCA2. And then there's some moderate risk genes called ATM and CHEK2. There's a whole slew of genes now that we can do genetic testing for, all of which can put you at increased risk for breast cancer. So it's important to know whether you carry that. And again, just because you don't have a family history doesn't mean that you don't carry a genetic mutation.

Another one of the I think really important lessons is to be aware of your body and be aware of changes in your body. And she obviously found a lump, but she had a few other things going on that she kind of attributed to other things, and in fact, they were connected with the cancer. So just be aware and be in tune with what's going on with yourself. If you have any questions, always see a physician. I mean, honestly, what's the worst that can happen then you go in and have a little checkup and then you go home? And that's--

I would like to add to Feighanne's point about women who are high risk. We have different tools or different tests available for them. So mammography is one of the screening tools, but we have other tools.

The other one is ultrasound, whole-breast ultrasound, and MRI. MRI is the big one. And especially women who are high risk, we recommend that they should be tested with breast MRI.

Breast MRI is not a CT scan. It is not something where you get radiation. It is safe. And we have a lot of research studies going on as well, especially one is called CAPS research study, Chicago Alternate Protection Study. And that is what we do at University of Chicago that are newer MRI techniques that are used by which we can pick up small invasive cancers that matter.

So it's a little bit easier for you to see, then, what's happening?

Absolutely.

Great. So we do have a comment from one of our viewers that is from Leslie. Says, thank you Dr. Kulkarni-- so maybe a patient, I don't know. But we appreciate the comments. And if you do have any questions also for our experts, just type them in the comment section. We'll get to those when we can.

So let's talk about risk factors that could actually boost your opportunity to-- or your chance of getting cancer. And these are things, obviously, that people would want to avoid. But there are things you do that you probably shouldn't that make you a little bit more susceptible.

Yeah, I think having a good, healthy diet, something where you're eating less processed food and less trans fat, less sugar, more fruits and vegetables, I think is a better-- it's good for your body. 85% of breast cancers are not because of family or inherited genetic mutations. They're actually random genetic mutations that happen due to external factors. It could be the food that we're eating, or it could be the stress that is in our life, or the cells that are going through-- are not going through the repair as they're supposed to. It might be the aging process associated with the cell.

So to combat that, I think it's nice to be doing daily exercise, even if it's a moderate exercise, for 30 minutes. It's-- ideally, avoid alcohol, or up to five drinks a week, no smoking, no tobacco. Just having a good, healthy lifestyle is important.

Yeah, don't smoke. Or, if you're smoking, please stop. That's a big one, with everything.

A couple of questions from viewers. This is a similar question from two different viewers. Susan asks, is there a relationship between prostate cancer in men and breast cancer in women? And then Tina said, I'd like to know this, as my dad had prostate cancer. I don't know which one of you want to take that one?

So I could take that one. So the answer to that is, yes, there is a link. BRCA2, in particular, can cause breast cancer in women and also can cause breast cancer in men. But then it also can cause prostate cancer in men, as well.

ATM is another one that can cause prostate cancer. BRCA1 has been shown also to cause prostate cancer, as well as PALB2. There's a couple of other prostate and breast cancer genes, too. So, yes, the two are linked. And it's important to know our father's family history just as much as our mother's.

So if your father does have prostate cancer, would you suggest that a woman come in for genetic testing? Or what would you say?

So usually, we like to start with the person who has cancer. That gives us the most information. If we can identify what's causing the cancer in the individual themselves, then it's easier to offer other family members their risk assessment. However, there was a study about three years ago that said that all men with a prostate cancer with a Gleason score of 7 or greater had about a 20% likelihood of being positive on a genetic test.

Interesting. So Kathy has a question. And she wants to know, is there a more comfortable MRI for breast cancer, one that is more open for someone who is potentially claustrophobic?

So there are some institutions that have open MRI. We don't have an open MRI, but our gantries are now-- you know, MRI machines have evolved in the last few years. The gantry, or the hole, is much bigger. You don't feel claustrophobic. We give headphones and you can play whatever genre of music you want and feel comfortable. And the time that you have to be in the scanner is shortened, especially if you're part of one of the research studies that we're doing, like the CAPS or the abbreviated MRI study.

Also, I would like to talk about another research study, which is the WISDOM trial. WISDOM trial is-- it's all around the United States, and U of C is one of the collaborators. I think 100,000 women will be eligible to participate in this study. And I think it's not something which is-- anyone can go online and look up. It's going to be a very good study, because we will get to know which test is appropriate for which individual.

Because there are multiple factors-- there are some women who get mammograms every year, but they still have a interval cancer that develops that is aggressive. Whereas, there are some women who get mammograms every year diligently, or might skip a few years, but still are OK with a small, in-situ cancer. So we really haven't figured out what would be the perfect or the correct strategy when it comes to screening, and WISDOM trial could be one trial that I can think that will make a difference. So it has a personalized trial arm, and it has a regular screening mammogram starting at the age of 40 arm.

So with the personalized arm, they're taking a lot of other factors into consideration, like the genetics. And I think that's important, because it might tell you whether you need screening mammogram plus MRI every year, or you might need only a mammogram once a year. So I think these are important questions that hopefully will get answered with this trial. And the number of deaths associated with this breast cancer will dramatically reduce in the next decade or so.

I'm glad you brought up the WISDOM study, because Dr. Funmi Olopade, who is one of our superstars here, she's a researcher, physician, is heavily involved in that and promotes that.

She is the PI of the study, yeah.

It's a great opportunity, really, for physicians and researchers to learn more. So let's play our next soundbite with Erica. And this-- John, this is going to be one where she starts chemo. And we'll-- her attitude is what I thought was really interesting in this, and she talks about that. Let's go ahead and play that.

On the morning of, he's driving back into town from work, and his mother and I are here. And I'm upstairs getting ready and I just have all types of war music playing, because I'm getting ready to battle. I actually had on this exact outfit, because, again, I'm ready for war. I'm about to go fight for my life.

So I tried to get myself in a spirit of empowerment, the spirit of I'm not afraid, a spirit of I've got this. I'm going to be victorious at the end of the day. And that's the mindset I went into, I went with on my first day of chemo.

She had just had such a wonderful attitude. And she's a lot of fun to be around, she and her fiance. And you can tell that she just-- she was just going to fight this thing, and did, successfully.

Absolutely. I think Erica had that spirit in her. And I've seen her through her journey with that spirit. But not all patients have that in them, right? There are some patients, based on whatever they are going through, whether it's financial, a toxicity, or socioeconomic, or psycho-social, but those are some things that bog them down. And it's our team that helps them understand that we have a great team of doctors here, we will take good care of you. And we'll direct you as to what the next step is. So yeah, kudos to her.

And the team is so important, because we do have such a large team that work with these patients, anywhere from what you do, what other physicians do, what Feighanne does. We have folks that work on diet with them, we have psychologists that help them through the process. It's a very emotional process and very difficult process, and so there is support there. And that's I think that's important for people to know, that there is somebody there to help support them through this process.

Absolutely. And I've seen the nurse navigation team, the survivorship team. They all seem to take really good-- like, take ownership of this, and help the patient, not just through the screening, prevention, but also with the treatment process.

And I think at University of Chicago, we are focusing on the personalized medicine piece. It has taken a lot more shape and form when it comes to treatment, because we look at the biology of the tumor. We look at the genetics. We understand why this tumor is more aggressive in Black women versus white. Although they have the same incidence, why is it that there is more mortality in Black women when it compares-- when compared to the white women?

And this disparity is where we are trying to answer the questions. We kind of know some of the factors that affect it. Mainly, it is the biology of the tumor, the genetics, and also the availability of health care. But U of C is definitely there for them.

So I've got a couple of questions from viewers that I'm going to combine because they connect a little bit, from Suzette and Tina. Suzette asks if there is an age to get screening if you have family history. Then Tina also just asks, do you teach and encourage self-breast exam? And is it a good way to have early detection?

So self-breast exam is something that is currently not in the federal guidelines. But I usually say you can have your self exam. You know your breasts the best. If you feel that there is any change and you feel a lump, do consult us. We'll do an ultrasound, we'll do a mammogram. If you go meet your primary care physician or OB-GYN, sometimes they do a physical exam first and then they send the patient to us. So absolutely, if that's-- you know your breasts the best.

Feighanne, Suzette's portion of the question, age for screening if you do have family history. Is there a time when you should start thinking about that?

Yeah. So first, it depends on if you have a genetic mutation, because you can start screening as early as the age of 25. But as a rule of thumb, we try to say to start 10 years younger than the youngest breast cancer diagnosis in the family if that happens to be younger than 40.

Great.

So if you have a first or second-degree relative diagnosed at 35, then you would start at 25. If you have one diagnosed at 45, then you would start at 35.

Great. So Erica had a mastectomy. She's done quite well. She's back to competing in bodybuilding. We actually went to the gym with her and shot a little bit of video, which made me feel really bad about myself. But she's fantastic. And one of the things that she said that she learned out of this was really to live life to the fullest. And John, can we go ahead and play that clip?

You can also live life more abundantly after a diagnosis. Like, your life doesn't have to stop with your diagnosis.

Not at all.

I honestly feel I'm living life better today than before I was diagnosed.

Does-- OK. So again, a great attitude. Another question from a viewer, do dense breasts-- are you more likely to have cancer if you have dense breasts?

So dense breast is something that you can find when you get a mammogram. So we the radiologist are the ones who diagnose whether the patient has dense breasts or not. There are four categories of breast density. And a lot of times, we do mention it in the report, but patients sometimes get confused with dense breast and firmness of the breast. Sometimes they get confused with dense breast and the cup size of the bra. But the A, B, C, D of the breast density is not related to that.

So the four categories are A being mostly fatty, and D being very dense. So breast is made up of glandular tissue, which is what we call the milk factory, the fat, which is what composes the breast, and the Cooper's ligaments, or the fibrous tissue that holds it all together. Depending on the ratio of the dense and the non-dense is what we categorize the mammogram as to be A, B, C, or D. And if you have category C or D breast density, we recommend adjunct screening.

No one test can replace the other test. So if you get a mammogram, that doesn't mean you cannot get an MRI. These are complementary tests. And mammograms, people a lot of times have fear of mammograms. And that's why they feel maybe I could get an ultrasound instead. But I think no test can replace the other tests. The ultrasound or MRI are complimentary tests to it.

So mammogram, I know people have heard of their breast get squeezed, and there is a lot of discomfort associated with it. But I want to emphasize that the reason we minimize the thickness of the breast is just so we can minimize the radiation that goes through the breast. And we can get better pictures to find the cancer.

When it comes to category C and D breast density, the white is the dense tissue, and cancer also looks white. So it could potentially mask on a mammogram, and that's why we recommend additional complementary exams. And the insurance companies cover these additional tests, because there is a density law that has been passed in Illinois--

Interesting.

--since 2000-- in 2019.

So technology has changed a little bit in that area, as well as far as just comfort levels with the test. It's gotten better, hasn't it?

Absolutely.

Great.

At some of our offsite locations, we also have smart-curved panels that are more-- better-- they are like a shape of a breast and are better with the compression of the breast.

Just make it a better--

Experience.

--experience, yeah. You know, it's interesting, because where I met you was it River East.

That's right.

And that's where we have the new suite there where that happens. And it's a very nice set up there.

I think getting mammograms should be done with girlfriends, go get your manicure, pedicure, and go get your mammogram. And you know, like it's a check for the year.

Make it a day.

Make it a day.

So should people have them yearly, then? Or--

Yes.

--is there an age--

The recommendation is starting at the age of 40, every year. I recommend 3D mammography, especially for category C and D breast density. There will be adjunct screening tools, either a whole-breast ultrasound or a breast MRI.

And that age has changed in recent years, as well, because I remember we always used to talk about mammograms at the age of 45 or 50.

The American College of Radiology and Society of Breast Imaging, all of the organizations follow screening starting at the age of 40.

Great.

There has been a tremendous shift. I know there have been discussions in the past, but the interval cancers that we've seen could lead to a lot of-- those are more aggressive cancers, too, and in younger women, so we prefer starting at the age of 40.

Fantastic. We are out of time. That went fast. You all were great. We really appreciate it. I don't know if you want to leave us with a closing thought. In particular, for maybe a woman who has been diagnosed, what would you tell her?

That we are here to take care of you. We're here to tell you the next steps. Make sure you ask the right questions. I feel sometimes people get bogged down by this is not the end, the live life to the fullest, just like Erica said. And empower yourself, ask the right questions.

Feighanne, any closing thoughts from you?

And don't panic. We're in this with you. We'll be there every step of the way.

Great. And it is really a wonderful team. So that's great.

We are out of time. As special thanks to our physicians and experts for being with us today. And a big thank you to those of you who watched and participated in the program today. Remember to check out our Facebook page for our schedule of programs coming up in the future. To make an appointment, you can go online at uchicagomedicine.org or you can call 888-824-0200. We will leave you today with a message from one of our Chicago Sky players. I hope you have a great weekend.

You know we're all about staying healthy. Getting an annual mammogram is an important part of maintaining good breast health. Mammograms can help detect breast cancer and other issues. New, state-of-the-art, smart-curve and 3D technology has made getting mammograms more comfortable, convenient, and compassionate. This is not your mama's mammogram. To learn more and to find locations, visit the University of Chicago Medicine website. Be healthy and stay in the game together.