Breast Cancer Diagnosis

M. D. Anderson Cancer Center
Cancer Newsline Audio Podcast Series
Date: August 18, 2008
Duration: 0 / 12:13

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Leonard Zwelling, M.D:

Welcome to Cancer Newsline a weekly series of podcasts from The University of Texas Cancer Center M. D. Anderson cancer center in Houston Texas. The goal of Cancer Newsline is to help you stay current with the news on cancer research and the rapidly changing advanced in cancer diagnosis, treatment and prevention. We also hope to provide you with the latest information on reducing your family’s risk of being diagnosed with cancer. My name is Leonard Zwelling; I’m a professor of medicine and pharmacology here in M. D. Anderson and today we will be talking with Dr. Banu Arun and associated professor from the Department of Breast Medical Oncology at M. D. Anderson and Dr. Therese Bevers an associated professor of Clinical Cancer Prevention and Breast Cancer Diagnosis here at M. D. Anderson and well focus on the issue surrounded breast cancer diagnosis and most importantly breast cancer screening.

This discussion was inspired by a few recent news items. The first was a study done here at M. D. Anderson published online in the Journal of Clinic Oncology. The first to specifically access the screening of women older then eighty. It’s estimated that approximately 17 percent of breast cancers are diagnose women older in eighty and only about one fifth of women in this age group actually have routine mammography. The second a recent story in CancerWise where Dr. Arun was cited as the source. The story was about a patient with a family history of breast cancer and our use of MRI for detecting her early stage breast cancer.

So our guest Dr. Bevers and Arun and we will start with Dr. Bevers. I would talk first about screening. What is screening and why do we do it in breast cancer?

Therese Bevers, M.D:

Screening is where we are looking for evidence of disease in this case cancer. Before it prevent with symptoms. So when a patient actually presents with symptoms we are no longer in screening mode we actually try to diagnose the problem. Screening is before symptoms present. And actually one of the frequent cited reasons for not screening is because they don’t have any symptoms and that the exactly time we want to do the screening.

Zwelling:

What is the logic behind screening? What the thinking why would you try to catch a disease before it’s even symptomatic?

Banu Arun, M.D.:

There has been studies and reports indicating that you can cure cancer and that not only true for breast but for some other solid cancers as well. That is you catch the disease early you have the highest chance of curing the disease. You still might have to undergo some aggressive treatment. However, staying alive after the treatment is higher if you diagnose the cancer earlier.

Zwelling:

So the next obvious question is who needs to be screened? When do you start? Who needs it? And are there groups of women that need it at different times then most women?

Bevers:

Certainly, for women of course breast cancer is of concern we typically talk about average risk women beginning there breast bancer screening at forty. With annual breast exams that are provided by health care provider and annual mammograms. Certainly if a woman at increased risk she may need to initiate her breast cancer screening at an earlier age and may need to do it more frequently then once a year.

Zwelling:

How do you determine if you are average risk or not? I’m sure people would want to know.

Arun:

That’s a very good question. So they are certain criteria by which we go to determine if a women should perhaps go screening earlier then age forty. I think that the most known risk is familiar risk. So if a women as a family risk of breast cancer and of course the highest risk would be in first degree relative if a women had two first degree relatives.

Zwelling:

First degree relatives means?

Arun:

It means mother, sister or daughter and if a woman has two first degree relatives the general knowledge of rule is that woman’s risk to get breast cancer is about a two to three fold increase. It is also important to take into account the paternal side the father side. I think many many people even health care providers have a tendency just to quote the risk on the mother’s side but father side counts as well so having a paternal aunt with early onset breast cancer is certainly a risk factor and families should be evaluated.

Zwelling:

Are there any other common things that people should be aware of that are also risk factors for breast cancer?

Arun:

There are some other general risk factors for example woman having started menstruating early, late menopause. Having a history of previous breast biopsies especially if the biopsies show a-typical hyperplasia or lobular carcinoma in situs. These are all term as benign lesions but not all benign lesions are really benign in terms of subsequent breast cancer risk. So those women should I think discuss those benign results with there physicians and see if any of these lesions could increase subsequent breast cancer risk and then we start screening earlier.

Zwelling:

So most women who find a lump in there breast and have a biopsy. Most of the time it’s going to be benign. Is that correct?

Bevers:

Majority are going to be benign it’s estimated that about eighty percent of abnormalities end up being benign.

Zwelling:

But of some of those benign tumors they do put you at increase risk so you have to be more vigilant with those women.

Arun:

Exactly, even thought those lesions are excised and are taken out just having had them increases later risk of breast cancer. 

Bevers:

Another risk category that is really something that we are seeing now we are being more successful in the treatments of cancer. The pediatric population are those who receive radiology treatment to the chest area, we know that they are at much higher risk of developing breast cancer and there screening should begin earlier.

Zwelling:

Along with the familiar risk are there specific genetic abnormalities that can put women at a higher risk?

Arun:

There are indeed. Lucky, only ten to fifteen percent of breast cancers are only hereditary. Out of the eighty five percent are caused by mutation in the BRC1 or BRC2 gene. So if we see in the family in the genetic trend these two genes are the most common and we see and we test for it. Then we also have some of the rarer syndromes causes by mutations in P53 and P10. Just as a general rule if there is a family with multiple female members with earlier on-set breast cancer meaning pre-menopause. Before age 50 and certainly before age 40 and if there are individuals with ovarian cancer and male breast cancer. Those patients or individual should consider genetic counseling and testing. Cause if positive there screening guidelines are really different from the rest of the population.

Zwelling:

Ethnic groups? Any ethnic groups have a more propensity for having these genes?

Arun:

At this point not that there are certain mutation in the BRC1 and BRC2 especially in Ashkenazi Jewish individuals.

Zwelling:

Let’s talk about how you do screening. I think that one of the things I learned in preparing for this is that breast self exam may not be as good of an idea as we thought it was. You want to talk about that?

Bevers:

Well I don’t think that is not that good of an idea. What we have learned from large studies that have been done in China is that there is no right or wrong way to do a breast self examination. Women don’t need to be taught a technique and that gets kind of away from this concept of an exam. But have a woman to be more aware of her breast. We in fact find that a majority of women that find there own breast masses were not doing so during a breast self examination rather just in the course of activity of daily living. Showering or dressing so we want women to be aware of what their breast normally feels like and if they feel a change to seek evaluation promptly.

Zwelling:

The other question I guess that’s coming up is there is now newer things that obviously Dr. Arun that your involved in that should be more sensitive and more theoretically be better screening techniques. What might that be. 

Arun:

The MRI screening for breast is now really considered the main screening tools especially for woman who has genetic family history. Again being more specific woman with BRC1 and BRC2 or P53 mutation are now eligible to have yearly MRI bi-lateral breast screening in addition to mammograms. So we do not stop the mammograms they get their mammograms as well. One interesting approach is that studies have shown that in the mutation carriers the breast cancers can be interval cancers they are picked fifty percent can be picked up between mammograms. So you have a mammogram six months later the physician or the patient feels the mass. To over come that what we and many other institutions do we alternate MRI and breast mammogram every six months. So that we have them once a year but the patient is under going screening every six months and we see our patients in the clinics as well. This is very new they are now, early studies showing several rounds of these screening methods in high risk individual and it is indeed more sensitive.

Zwelling:

One of the questions I’m sure that people want to hear the answer to is in those women will the insurance company pay for the MRI?

Arun:

For the mutation carriers, “Yes”.

Zwelling:

They will!

Arun:

They will. The American Cancer Society Guidelines came up last year and they are very good guidelines.

Zwelling:

The last thing I would like to talk about is something that is also the news a lot which is prophylactic mastectomy. In those women that are at significant risk for developing cancer. You will hear stories about women who actually undergo total mastectomy both breast removed. Without any demonstrable disease, what’s the wisdom behind that? What’s the current thinking about that?

Bevers:

If I may, we discuss prophylactic mastectomy as a option. A number of patient when they have mutations come to the clinic thinking that we will tell them that they have to have it. It’s one of the options it’s an aggressive option but it’s one of the most effective options. Removing bi-lateral breasts in the genetic high risk woman reducing the incident of cancer by 95%. So it’s very effective. But there are alternatives again MRI and mammograms screenings is an alternative. And the other important issue is that the patient doesn’t have to do it right away. The patient has time to think and do a few round of screening and then decide whether she would like to do the preventative mastectomy. But it’s very effective.

Zwelling:

Thank you Dr. Arun and Dr. Beavers. Thank you for listening this episode of Cancer Newsline. Again this is a weekly series please tune in again next week for our next episode of this series. You can do so by visiting www.mdanderson.org/newsroom and click subscribe from the menu. Or subscribe for free through Apple iTunes and the M. D. Anderson iTune’s university page you can get there directly by typing www.mdanderson.org/itunes . Thank You. 

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