Expert Opinionby Natalie Jacobs December 29, 2015
Before Thanksgiving, I sent out a very brief survey to female Jewish Journal readers. I was curious how local Jewish women are thinking about breast cancer as things like genetic testing become more common. I also wondered about personal family histories. None of the respondents currently have breast cancer, but their questions reflected a sense of concern about developing the disease and if they’re doing enough to stay on top of their own health. So I took the questions to an expert. Dr. Anne Wallace is the director of the UC San Diego Breast Health Center. She is a surgeon who focuses on breast health, breast cancer and breast reconstruction. Her research focus includes developing better imaging technology to detect breast cancer and melanoma.
Mammograms and other detection tools
San Diego Jewish Journal: How often should women get a mammogram?
Dr. Anne Wallace: If she doesn’t have any additional risk, she’s just a normal woman that’s growing older – she doesn’t have a family member with breast cancer or a history of biopsy – then we’re really going with the new recommendation from the American Cancer Society which is to start at 45 and have one every year until 54. And then consider going every other year.
If she has anything that she’s uncomfortable about, then start a little bit earlier at 40 and go every year. Women are going to have a little bit of a choice in this. There’s no doubt that mammograms pick up cancers earlier than 45, but the risk of having unnecessary biopsies starts to go up. The bottom line is, it’s not an easy thing. They need to know their bodies, they need to know what worries them.
Should women get ultrasounds in addition to mammograms?
DAW: No. In this country, we don’t use screening ultrasounds. They do it in Europe because they’re willing to see a solid mass that they don’t biopsy. In this country, solid means biopsy-able and it would cause too many biopsies. So an ultrasound is a diagnostic maneuver once you have something. If a mammogram shows something, or if you have a pinpoint pain or a pinpoint mass, then you get an ultrasound.
When is a breast cancer MRI necessary?
DAW: That is for very high risk women who carry the gene for breast cancer or if you have something very difficult to diagnose. Even if a woman gets a letter saying you have a dense breast pattern, that doesn’t mean she should go get an MRI, that just means she should be more vigilant if something bothers her. An MRI really, by the time you need an MRI, there should be something striking that you need it for – either BRCA positive, or you have lots of a-typical cells in your breast or something that your doctor is having trouble diagnosing.
Breast cancer is really not that hard to diagnose. That’s what people have to realize – this idea that we have to go looking for earlier and earlier detection, this is what we are getting away from. The big misses that people have is when they have a finding and somebody doesn’t know what the heck they were doing – like the nipple was flat and nobody paid attention. Or there was an asymmetry on their mammogram that somebody read as oh, it’s probably nothing. It’s not that hard to diagnose if you see a good team that knows what they’re doing.
Are there some technologies from Israel that are more accurate and less painful than mammograms?
DAW: I know that part of the world does do more screening ultrasounds. It’s not that we don’t know how to do screening ultrasounds. They’re very good at it [in other parts of the world], and they’re very good at determining that mass they see is 99 percent benign, we’re not going to biopsy it and people are comfortable living with that. That’s a little bit different than we feel here. They don’t screen as much in any other part of the world as we do, because there is no survival benefit in this much screening.
Would you recommend people get BRCA 1 and BRCA 2 screenings?
DAW: I recommend that they know their history and they know everything in their family. Women who don’t have some of the familial [history] then just randomly testing them at this point is probably not worthwhile. It’s getting easier and easier to test people for genetic mutations and it’s not just BRCA. So I think women need to keep up on this and figure out how much they want to know. You can get an over-the-counter test that does a lot of stuff on DNA, but then you need somebody to help you go through those results and explain what they mean. There are other genes that cause breast cancer, there are a lot of other genes that cause other cancers.
So at this minute, the answer is: if you have a family history, then you should talk to your doctor and find a genetic counselor and find out which genes you should test for.
That may change two or three years from now. We may be doing whole genomic testing on everybody to find out what everybody has, in a couple years. It’s kind of scary because we’re all going to have things that are going to show up. But at this point, right this minute, even as the risk of breast cancer goes way up with BRCA, cancer isn’t so hard to find, and we can treat it.
What is the likelihood that a Jewish woman will get breast cancer?
DAW: Five percent of Ashkenazi Jews could carry BRCA.
Will insurance cover the test if the only risk factor is being of Ashkenazi Jewish descent?
DAW: If you’re Ashkenazi Jewish and you have that five percent risk, insurance probably won’t pay for it.
What percentage of breast cancer is genetic?
DAW: Not that much. It’s about five to 10 percent, of the genes that we know about. We’ve started to isolate other genes, so it may go up a little bit – because there’s more than BRCA. We’re going to find out that probably all cancer is caused by some mutation, so that number is going to go up. But a historical number we say is five to 10 percent.
How likely is it that a woman will get breast cancer if her mother had it?
DAW: If it’s just your mother, and you don’t carry a gene, a normal woman has about a 12 to 13 percent risk of getting breast cancer. One in eight is about 12 and a half percent. Using a mathematical model, say you’re 35 and you had your kids in your 20s and your mother was 60 when she got her breast cancer, that percent goes up very very little.
If you’ve had a lot of biopsies and your mother was 35 when she got her breast cancer, then it probably goes up to about 20 percent. So there’s a mathematical model that you can put in there.
If your mother had it really elderly, there’s almost no risk increase.
Is thermography a good alternative to mammography?
DAW: No, not at this point. The FDA has had warnings against it because we don’t have the correct technology. The idea is very interesting, looking at increased blood flow, but we don’t have the imaging agents yet to make it accurate – it has high false negatives and high false positives. It won’t hurt you to do it, but it’s not recommended at this point.
What are some natural approaches to treating breast cancer?
DAW: When you say natural, that kind of means…a lot of our drugs that we have are actually natural things. The biggest thing that’s advancing cancer is the biologics. In breast cancer, if your cancer is what’s called HER2-positive (on about 20 percent of cancer cells), adding [a specific agent] is getting unbelievable pathologic responses. It’s a hormonal antibody, so the take-home message is that the
medical side of breast cancer is getting such huge advances that we are seeing complete pathologic responses in tumors that we never would have been seeing before.
That’s where we need to be. We need to figure out what cancers are never probably really going to be bad. And which ones are going to be bad and need to have really certain biologic treatments to save lives. So what women should come away from this is – I’m a surgeon and I’m saying this and it could put me out of business – women need to get away from thinking always that cutting more is better.
What is changing a lot in breast cancer is the remarkable progress that our oncology colleagues are doing – amazing things with not new chemotherapy drugs but new biologic drugs that work on the specifics of [each] cancer. The other thing we’re doing is molecular profiling of the cancer. So if a woman comes in with advanced disease, at UCSD we will send her tumor for molecular profiling to see if there is any pattern in the genes that are being expressed in her tumor and then we look for drugs across the world that are being marketed for that abnormality in the tumor. It’s still in the infancy of being really effective, but that’s where we’re going – individualized care for the tumor.
Causes and Prevention
Does hormone replacement therapy put a woman at risk for developing breast cancer?
DAW: Yes. The data is really clear on that. When you take hormone replacement therapy at the normal time of your life – so when you’re going through menopause – and you stay on it longer than a few years, your risk gradually increases. So we don’t put women on it anymore and have them stay on it forever.
What about hormonal birth control?
DAW: Because birth control is usually given before natural menopause, we don’t really have any good data to say that’s harmful at all.
Is there actually a way to prevent breast cancer?
DAW: Yeah, definitely. We have two classes of drugs that prevent breast cancer – estrogen receptor modulators that show about 50 percent reduction in breast cancer, and in certain high-risk women with a-typical cells already it was up to an 80 percent reduction. The other class of drugs is called aromatase inhibitors, used for post-menopausal women and they prevent breast cancer as well. But it’s really harsh taking a drug, because it makes you feel more menopausal and there are symptoms and things. But for our very high-risk women, many of them are on those things.
There’s other very interesting things being looked at – some of the anti-diabetes drugs may reduce breast cancer risks and there’s studies going on with that. The bone sparing drugs like Fosamax may prevent breast cancer as well, and there’s some studies going on with that.
Then, of course, bilateral mastectomy will decrease your risk by 90 percent but that’s a drastic measure and there’s no survival advantage when you do it. That’s what some people don’t realize – there’s never been any data that says preventing breast cancer actually prevents death from breast cancer. You’re preventing something that would have been really treatable, so the death rate doesn’t actually change.
In Europe, nobody is going to even allow you to have a bilateral mastectomy. But if you’re a BRCA patient who is really at risk of getting breast cancer, and you’re having to get screened every six months and you’re constantly getting biopsies, that will drive you crazy so women will choose mastectomy so they can lessen the burden in their life. So they’re making the choice for that. Like Angelina Jolie made that choice because it made her life easier in the end, but it didn’t make her life longer because of it.
Can external factors really cause breast cancer?
DAW: We do know that women who keep their weight low and who exercise regularly have a decreased risk of breast cancer. So exercise four hours to seven hours a week, and keeping your weight about where it was in high school, and lowering your fat content, and limiting your alcohol – so no more than four alcoholic drinks per week decreases your risk. These are active things you can do.