Smilow Shares: Breast Cancer Awareness Month: Screening, Genetics, and Prevention

Name: Smilow Shares: Breast Cancer Awareness Month: Screening, Genetics, and Prevention
Uploaded: 2025-10-03T12:26:40.43Z
Duration: 1 h 7 min 19 s
Description: October 2, 2025 Presentations by: Parisa Lotfi, MD, Tracy Battaglia, MD, MPH, and Melinda Irwin, PhD, MPH

October 03, 2025

October 2, 2025

Presentations by: Parisa Lotfi, MD, Tracy Battaglia, MD, MPH, and Melinda Irwin, PhD, MPH

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00:06Alright. Welcome, everyone.
00:08This is Milo Shares Breast
00:10Cancer Awareness Month. This is
00:11the first of three presentations,
00:14and this one is called
00:15understanding breast health, screening genetics
00:18and prevention.
00:20And I'm John Lewin. I'm
00:21the moderator for this session,
00:24and we have
00:26three
00:31experts.
00:40So we have doctor Pris
00:42Salafi,
00:42who's my colleague in the
00:44department of radiology and biomedical
00:45imaging,
00:47and she will be talking
00:48about
00:49screening,
00:50and Tracy Battaglia,
00:52who is professor of medicine
00:54and associate director community outreach
00:56and engagement for the Yale
00:57Cancer Center,
00:59and Linda Erwin,
01:01who's associate dean of research,
01:03and Susan Dwight Bliss professor
01:05of epidemiology,
01:07deputy director of the Yale
01:09Cancer Center, who will be
01:10talking about
01:11risk modification.
01:14And so without any further
01:16ado, I will stop sharing
01:17my screen, and doctor Lottie
01:19can start her presentation.
01:25Okay.
01:31I hope everyone is having
01:32a good evening.
01:34I'm gonna briefly talk about
01:35breast cancer, current screening recommendations.
01:43We all are aware or
01:44have heard of the US
01:46Preventative
01:47Services
01:48Task Force.
01:50This is a task force
01:51that is,
01:53assigned by the government
01:55to look at medical data
01:58and make recommendations
02:00for screening
02:01different,
02:02types of
02:04diseases.
02:05But specific to breast cancer
02:07screening, they just modified their
02:10recommendation,
02:11recently last year,
02:13and they lowered the start
02:16age for screening.
02:17Now they recommend women aged
02:19forty to seventy four get
02:21screened. However, their recommendation says,
02:24every two years.
02:26And, women seventy five years
02:28or older,
02:29they said that there isn't
02:31sufficient,
02:32evidence to assess the balance
02:34of benefits and harms of
02:36screening mammography in this population.
02:38They also recommended that women
02:40with dense breast,
02:42that there isn't enough evidence
02:44to assess the balance of
02:45benefits and harms.
02:47Now
02:48we can talk about an
02:50hour about the data they
02:51looked at and
02:54what they considered harms and
02:56benefits. But one thing they
02:58considered a harm of screening
03:00was anxiety of women and,
03:02potential callback rates.
03:05Briefly, I just wanna say
03:06that when
03:08screening mammography is the standard
03:10of care, and this is
03:11going back decades, and we
03:13have,
03:15extensive research proving that screening
03:17mammography
03:18saves lives.
03:20Women who had a screening
03:21mammogram compared to women who
03:23didn't definitely live longer, and,
03:26that's how we know.
03:29Everything else, ultrasound
03:31and MRI
03:32and other modalities that I
03:34will talk about, like contrast
03:36enhanced mammography,
03:37we don't have enough data
03:38to know decades worth of
03:40data to know if these
03:42are actually
03:43making women die less of
03:46a breast cancer.
03:49So current
03:51guidelines,
03:52this is a table that
03:54is talking about the different
03:55societies, medical societies talking about
03:58screening guidelines.
04:00I talked about the,
04:02task force. It says start
04:03at forty every two years.
04:05And then different societies like
04:07ACOG is the OB GYN,
04:09society, American Cancer Society, American
04:12Medical Association,
04:14they all pretty much are
04:15recommending
04:16starting at forty. And for
04:17the most part, annual screening
04:19is recommended.
04:21For women older than seventy
04:22five, it's based on shared
04:24decision making. If people are
04:26in good health, if women
04:28are in good health and
04:29they have at least ten
04:30more life, years ahead of
04:32them,
04:33it's a good idea to
04:34continue with mammography. But that's
04:36a personal choice, and it
04:37can be discussed with,
04:40their primary care physicians
04:42and, come to a decision
04:44that's appropriate for that individual.
04:47I am a radiologist, so
04:48I'm gonna talk about American
04:50College of Radiology and Society
04:52of Breast Imaging recommendations,
04:55which basically says start at
04:57forty.
04:57Every year, get a mammogram,
04:59and there is no age
05:00limit.
05:01But, obviously, we do consider
05:03individual health status.
05:06So,
05:07American College of Radiology
05:09recently,
05:10in the last few years,
05:12changed their recommendations
05:13in terms of,
05:15breast
05:16care. And,
05:18they brought to light the
05:20importance of having a risk
05:21assessment
05:22for women,
05:23and they're recommending that women
05:25get a risk assessment
05:27by age twenty five. Every
05:28woman should know if they're
05:30high risk, low risk, if
05:31they're average risk, discuss as
05:34far as they know,
05:36discuss that with their primary
05:37care or, their gynecologist
05:40so that they can
05:41appropriately
05:42be screened starting at that
05:44age.
05:46So
05:47high risk women, as determined
05:49by the risk
05:51assessment models, are deemed high
05:53risk.
05:55If they desire anything more
05:56than a mammogram,
05:58because they're high risk, they
06:00should get some other supplemental
06:02screening.
06:03So MRI has been our
06:05traditional screening tool for those
06:07women. If for some reason
06:08they can't undergo MRI screening,
06:11and there could be the
06:13different reasons for that,
06:15definitely ultrasound and,
06:17institutions that have contrast enhanced
06:19mammography,
06:21they should undergo that,
06:23procedure.
06:24I will talk a little
06:25bit more about that, in
06:27a bit.
06:28Women who have dense breasts
06:30and are not necessarily
06:32high risk, but they want
06:34supplemental
06:35screening,
06:36they can get a breast
06:38MRI. However, sometimes insurances don't
06:40cover that. Most insurances don't
06:43or the they're cost prohibitive
06:45or there's a contraindication
06:47for getting an MRI.
06:49It's important that these women
06:50know they have options. Ultrasound
06:52or contrast enhanced mammography
06:54should be considered.
06:56If someone is intermediate risk,
06:58and, again, these are calculated
07:00lifetime risks with which my
07:02colleagues will talk about,
07:04in a minute.
07:07The and and have dense
07:09breasts.
07:09Of course, they should continue
07:11with mammography but also get
07:13MRI or, ultrasound.
07:17So just to talk about
07:18mammographic density,
07:20mammograms are black and white
07:22and gray. And, basically,
07:24anything that's gray or black
07:26is good.
07:28This is the opposite of
07:29real life,
07:30and white is glandular breast
07:32tissue. However,
07:33cancer,
07:35cysts,
07:36benign masses, anything else that
07:38is not tracked will also
07:39be white.
07:41So when we are going
07:42from left to right, we
07:44are seeing an increase in
07:45the breast tissue density.
07:47This, the right side is
07:49considered an extremely dense mammogram,
07:52and you can see that
07:53the majority of this breast
07:55is white. And if
07:57this breast had a small
07:59cancer in it, it would
08:00be very difficult to see
08:02it because it's gonna blend
08:03in with the adjacent breast
08:05tissue. And this is why
08:07it's important that women who
08:09have extremely dense breasts
08:11should consider additional supplemental
08:14screening. This is a fatty
08:16breast,
08:17and,
08:18you can see that if
08:19there was a mass this
08:21is a normal structure here.
08:22But let's say there was
08:23a mass, it would be
08:24white, and it would be
08:25extremely
08:27easy to appreciate it.
08:30About
08:31of the four categories, half
08:33are dense and half are
08:35not dense. And about half
08:37the population
08:38has dense breasts and half
08:39the population doesn't.
08:42The last one, the extremely
08:43dense,
08:45category is about ten percent
08:47of women. So not very
08:48common, but extremely important.
08:51Density by itself is also
08:53a risk factor.
08:55So women who have denser
08:56breasts have a higher risk
08:59for developing breast cancer compared
09:01to women who have a
09:02fatty breast. For example, one
09:04and four,
09:06the four, which is extremely
09:07dense breast, has a four
09:09times
09:10more risk of developing breast
09:12cancer compared to a fatty
09:13breast and about two times
09:15higher than an average breast.
09:18So when we have, increased
09:21density
09:22from, again, left to right,
09:24we can see the density
09:25of the breast or the
09:26whiteness is increasing.
09:29That lowers our sensitivity
09:31of mammography and increases the
09:33risk of cancer not being
09:35detected.
09:36I don't like using the
09:38word missing cancer. We're not
09:40missing it. We're just not
09:41seeing it. We're not detecting
09:43it. So as we go
09:44from left to right, you
09:46can see that,
09:48the risk increases for nondetection
09:51of breast cancer, and the
09:53extremely dense breast has a
09:54more than sixty percent risk
09:56of, nondetection.
10:00So in order to look
10:01at,
10:03dense breast and utility
10:05of, additional supplemental
10:08screening,
10:09there were several trials that
10:10were recently published.
10:12One was the DENSE trial,
10:14which is the
10:16the dense tissue and early
10:17breast neoplasm screening. This was
10:19a very good trial. It
10:20was randomized controlled trial. It
10:22was in the Netherlands.
10:24And they added MRI in
10:26a population of fifty to
10:28seventy five year olds,
10:30women, who had extremely dense
10:31breast tissue and had a
10:33normal mammogram.
10:35And they wanted to see,
10:37different things, but one was
10:39they wanted to see patients
10:41who had that added MRI.
10:43Do they have
10:44a lower rate of interval
10:46cancer?
10:47Interval cancers are cancers that
10:49develop in between screening,
10:53timelines.
10:54And for them, it was
10:55every two years. They also
10:57looked at other things. For
10:59example, they wanted to see
11:00what is the detection rate
11:01of MRI.
11:03Are there false positives?
11:05What kind of tumors are
11:06detected by MR and some
11:08other characteristics?
11:10They were lucky. They looked
11:12at forty thousand women, and
11:13about eight thousand of them
11:15had the supplemental MRI.
11:17And what they saw that
11:18the rates of interval cancer
11:21was about half in women
11:23who had MRI compared to
11:25mammogram only.
11:26So it was two point
11:27five per thousand compared to
11:29five.
11:30And,
11:31basically, this was great news.
11:33I should also make a
11:35note that these are average
11:36risk patients, not high risk
11:38patients.
11:39And the women who had
11:40the MRI, they had about
11:42over sixteen
11:44per thousand
11:46rate of cancer detection, which
11:48is great. Again, mammography
11:50alone finds if you have
11:51tomosynthesis,
11:53on average, four or five
11:54cancers per thousand.
11:57Another trial called BRAID breast
12:00Screening Risk Adaptive Imaging for
12:02Density
12:03wanted to see, in addition
12:05to mammography,
12:06other supplemental
12:07screening imaging,
12:10tools
12:11effect.
12:12For example,
12:13ultrasound, contrast enhanced mammography,
12:16and MRI
12:17in detection of breast cancer.
12:19They had about nine thousand
12:21patients. Six thousand completed those
12:24extra
12:25modalities.
12:27And,
12:27the cancer detection rates were
12:29really great,
12:31for
12:32and more abbreviated MRI is
12:34just the shorter version shorter
12:36time version of contrast enhanced
12:38MRI.
12:39And in that population, they
12:41had about seventeen per thousand,
12:43detected cancers.
12:45Contrast enhanced mammography
12:47was even higher, nineteen ish,
12:49and,
12:50ultrasound was only about four
12:52point two per thousand.
12:54You can see
12:55that. And in that population,
12:57the, cancer detection rate was
13:00eight point four per thousand.
13:01So you can actually look
13:02at the numbers and appreciate
13:04that ultrasound was just slightly
13:06better, but MRI and contrast
13:08enhanced mammogram more than doubled
13:10it.
13:12Tumor size was also much
13:14smaller. On the average, it
13:15was about a centimeter in
13:17women who had the MRI
13:19and contrast enhanced mammogram.
13:21And,
13:22ultrasound detected tumors were slightly
13:24larger, about double the size,
13:26twenty two millimeters.
13:27These are averages.
13:29So you can see that
13:30earlier detection
13:32is,
13:33key
13:34with
13:35contrast enhanced modalities.
13:38Now just to say a
13:39little bit about contrast enhanced
13:40mammography,
13:42the premise is that tiny
13:44little tumors, anything more than
13:46two millimeter, will demonstrate
13:48angiogenesis,
13:49and that means that they're
13:51gonna grow new blood vessels.
13:53These blood vessels are leaky.
13:55And when we inject a
13:56contrast material through an intravenous,
14:00access,
14:01they go to the breast,
14:02and they accumulate
14:04in these tumors.
14:06We can detect them with
14:07two two ways. One is
14:09contrast enhanced mammography, and one
14:11is MR.
14:13A lot of people, patients,
14:15physicians know about, MRI. I
14:17won't go into into detail
14:18about that. But contrast enhanced
14:20mammogram is essentially a mammogram
14:23that is obtained before and
14:24after administration of contrast, and
14:26this is an example
14:28of that.
14:30When patients undergo contrast
14:32enhanced mammography, they get a
14:33normal mammogram, which is,
14:36this image here, and this
14:38is another view of the
14:39same. It's labeled left CC
14:40and left MLL.
14:42And then
14:43another image,
14:45mammogram image is obtained. Those
14:47images are subtracted,
14:49and what remains
14:50is anything that picks up
14:52the dye. So in these
14:54two images, you can see
14:55that there's a tiny little
14:57mass that shows up in
14:58the left breast,
15:00and it's completely obscured. You
15:02don't see anything like that
15:04because this is an extremely
15:05dense mammogram.
15:07And,
15:09so contrast enhanced mammography
15:11is a mammogram that is
15:13really not affected by breast
15:14density.
15:18So
15:19let me just oops.
15:21I lost my
15:24chair.
15:33Alright.
15:34What we don't have answer,
15:35there are several questions with,
15:38in general and what these
15:40trials that I mentioned have
15:41not answered.
15:43We know that mammography
15:44saves lives by lowering by
15:47decreasing mortality from breast cancer.
15:50We don't know that about
15:51MRI or contrast enhanced mammography.
15:54So,
15:56there's a lot of research
15:57being done about that. Hopefully,
15:59we'll have that answer at
16:00some point. We also don't
16:01know how feasible it is
16:03to have these,
16:05other supplemental
16:06tests,
16:08in terms of logistics,
16:10cost, capacity
16:12for women who are not
16:14at high risk.
16:15As you know, demand for
16:17imaging is very high. We
16:19have very low, MRI capacities,
16:21and contrast enhanced mammography
16:23is not available at every
16:25institution.
16:27At Yale, we are
16:31increasing our MRI capacity at
16:33different sites.
16:35However, we are sharing with
16:36other body parts. You know,
16:38everybody wants to have an
16:39MR. It's a highly utilized,
16:42test.
16:43And we don't have enough
16:44slots to do diagnostic MRs,
16:46to do high risk screening,
16:47and also average screening of
16:49the women who have dense
16:51breasts.
16:52We will be starting a
16:53contrast enhanced mammography program in
16:56the next six months or
16:57so. We'll be doing it
16:58on both, two campuses at,
17:01Smilo
17:02and at our North Haven
17:04campus. And, that'll be great.
17:06It'll be,
17:08very, very exciting for us
17:10to start that program
17:12and offer women,
17:14additional supplemental screening.
17:21Alright.
17:26Alright. Very nice.
17:28Doctor Battaglia?
17:31I'll pull up my slides.
17:32Good evening, everyone. I see
17:34there's a couple of questions
17:35in the chat, John. I
17:35don't know if you wanna
17:36take one or two while
17:37I'm
17:39If you would like, we
17:40definitely will have time at
17:41the very end for everybody's
17:43question. Well, pretty much. So
17:45one of our attendees
17:46asked, doctor Lottie,
17:48about invasive lobular cancer.
17:51How would that show up
17:52on a contrast enhanced mammogram?
17:54So similar to MRI,
17:56it will show up,
17:58because lobular cancer
18:01also has, neovascularity.
18:05As you know, lobular cancer
18:07is not a very common
18:08cancer. It's about ten percent
18:09of our cancers. And, occasionally,
18:12it may not enhance. It
18:14may not take up the
18:15dive similar to MRI.
18:17And that's why
18:21screening mammography, the two the
18:22actual mammogram portion of it
18:23is super helpful. We read
18:23those
18:35based on a
18:37previous biopsy or diagnosis
18:39or whatever,
18:41we can either do contrast
18:43enhanced mammography
18:44or MRI for extent of
18:46disease and,
18:48other diagnostic workup.
18:51Alright. Very good. Let's move
18:53on to the next talk,
18:54and I will promise we'll
18:56get to everybody's questions at
18:57the end. Okay. Great. Thank
18:59you so much. Good evening,
19:01everyone. It's great to be
19:01here with you all to
19:02kick off breast cancer awareness
19:04month. I see,
19:05only one of
19:06our panelists has pink on
19:08today. So, Melinda, you you
19:10have it on. You have
19:11it on. So I'm here
19:12to, take you, through an
19:14overview of high risk breast
19:16health care. I'm gonna talk
19:18a little bit about risk
19:19assessments,
19:20risk assessment that was alluded
19:22to in the
19:23the first presentation on breast
19:25imaging
19:26and, our approach to risk
19:28reduction strategies for those who
19:29do have high risk.
19:31My background is I'm a
19:33general internist, women's health provider,
19:35and preventive medicine,
19:36physician. And so I'm a
19:38practicing clinician in our high
19:40risk breast practice.
19:45So, you know, what we've,
19:47historically
19:48approached breast cancer screening is
19:50using age based screening.
19:54And so
19:56many of us are familiar
19:57with recommendations for screening based
19:59on age alone.
20:00And we know now that
20:02age based screening really ignores
20:04the range, the very sort
20:05of broad range of risk
20:07factors that,
20:09influence our individual risks for
20:11future cancer.
20:12And as we sort of
20:14have advances
20:15in cancer diagnosis
20:17and treatment,
20:18we are,
20:20increasingly providing personalized care to
20:22patients based on their individual
20:24presentation. And so the age
20:26based sort of screening ignores
20:28sort of where we are
20:29in our understanding of cancer.
20:33Twenty twenty two was the
20:35first year that one of
20:36the,
20:37professional organizations called the National
20:39Comprehensive Cancer,
20:42Cancer Center recommendation
20:44made the recommendations for the
20:45first time
20:46for individual risk assessment by
20:48age twenty five, and then
20:50the American College of Radiology,
20:51as we heard, followed suit,
20:53I think, the following year
20:54in twenty twenty three.
20:56So high risk guidelines
20:58now exist from several professional
21:01organizations,
21:02and they promote the use
21:03of risk prediction models to
21:05estimate an individual's
21:06patient's risk. So we're gonna
21:08talk a little bit about
21:09that.
21:10When we think about
21:12high risk breast health care
21:14in general, I think about
21:15sort of four general areas.
21:17The first is
21:19identifying whether or not a
21:21patient is at high risk.
21:25High risk
21:26assessment
21:27can be made through the
21:28identification of pathogenic variants through
21:31genetic testing. So, we need
21:32to,
21:33in the process of identifying
21:35risk, ask ourselves if patients
21:38are eligible
21:39for genetic testing based on
21:41a threshold of potential risk
21:44based on family history.
21:47We also utilize, in the
21:49absence of a pathogenic variant,
21:51these risk prediction models, which
21:53really give a calculated estimate
21:55based on a comprehensive
21:57list of risk factors for
21:58an individual patient.
22:00But there's many nuances to
22:02this model, so I'm gonna
22:03introduce you to a few
22:04of them.
22:05And then based on this
22:06information, we can provide risk
22:08reduction strategies to a patient
22:10based on what thresholds that
22:12they have in their personal
22:14risk.
22:16So we already heard in
22:17the previous presentation
22:19the definition of what is
22:20considered high risk.
22:22So a lifetime breast cancer
22:24risk greater than twenty percent
22:25is considered to be in
22:27the high risk range. So
22:29we're gonna hear more about
22:30that.
22:32So how do we determine
22:34who is at high risk?
22:36In order to do that,
22:37we need to take a
22:38comprehensive
22:39review of an individual patient's
22:41risk factors,
22:43including
22:44inherited gene mutations. And so
22:46we're gonna walk through that
22:47in a moment.
22:48But I just wanna point
22:49out that while we place
22:52a large emphasis
22:53around genetic pathogenic variants or
22:56carrying the gene that puts
22:57you at risk for breast
22:58cancer,
23:00these pathogenic
23:01variants
23:03are responsible for a very
23:05small percentage of breast cancer
23:07cases. So the estimates are
23:08somewhere between five and ten
23:10percent
23:11of these harmful variants. And
23:13many of us are familiar
23:15with
23:16the high risk penetrance genes
23:18of the BRCA1 and the
23:19BRCA2 mutations,
23:21but the field of genetics
23:23is rapidly expanding and evolving
23:25and we now know about
23:26many other pathologic variants. And
23:29so
23:30when we, pursue genetic testing,
23:32we often do a sort
23:33of expanded panel looking at
23:36a number of different variants.
23:38The high risk penetrance genes
23:40listed here,
23:42confer a risk of,
23:44a high risk a risk
23:45of lifetime risk as high
23:47as sixty to eighty percent.
23:50Whereas these moderate risk penetrance
23:52genes listed on this slide
23:54confer risk more in the
23:55twenty to thirty percent range.
23:57So it helps us sort
23:58of categorize a patient's future
24:00risk.
24:03So as a clinician, one
24:04of the first things we
24:05do when we're caring for
24:07patients, whether this is in
24:08primary care or in a
24:10specialty practice, is we ask
24:12ourselves, is my patient eligible
24:14for genetic testing?
24:16And because this field is
24:17so rapidly evolving and
24:20the professional guidelines
24:22change rapidly
24:24in response to what we
24:25understand about genetics,
24:27we have tools in our
24:29electronic health record that support
24:30our providers in making decisions
24:33about who might be eligible.
24:35And I share this because,
24:38I think it's important to
24:40know,
24:41as a patient that this
24:42is a really complex field
24:44that not all providers are,
24:48skilled at, and there are
24:49tools like this that support
24:50our providers. And you can
24:51see here that we have
24:53tools that have a have
24:55a a tab for each
24:56disease because the indications for
24:58testing
25:00differ based on the cancer
25:01disease.
25:02So, from a breast cancer
25:04perspective, if you have a
25:06known mutation, there's no need
25:07to refer you to a
25:09genetic,
25:10counseling or testing.
25:13But if you've had genetic
25:14testing, for example, greater than
25:16ten years ago, you may
25:17benefit from repeat testing because
25:20of the advances in the
25:21extended panels.
25:24So, this slide,
25:25lists for you,
25:28the professional
25:29organization
25:30recommendations
25:31around who should be tested
25:33or considered for testing for
25:34a pathogenic variant.
25:36And so I draw your
25:37attention to,
25:39the underlying text that says
25:40personal history and of breast
25:42cancer and.
25:44So if you have a
25:46diagnosis of breast cancer and
25:48meet any of the criteria
25:49on this list, you should
25:50receive genetic testing, ideally, before
25:53you initiate any treatment to
25:55inform
25:56your treatment decisions.
25:58So,
26:00having breast cancer at a
26:01young age under the age
26:03of fifty is a red
26:04flag for a potential
26:06pathogenic variant. So every woman
26:08under the age of fifty
26:10diagnosed with breast cancer should
26:11get tested.
26:14There are other indications
26:15of genetic,
26:17variants, and that also includes
26:19the type of cancer that
26:20you have. So if you're
26:21diagnosed with a breast cancer
26:23that is what we call
26:24triple negative
26:26or hormone negative,
26:29then that that is also
26:30an indication for testing.
26:32If you have a family
26:33history
26:34of a male breast cancer
26:36in your family, that's an
26:37another indication.
26:40But even patients who have
26:42not been affected by cancer
26:43are eligible for for testing
26:45if any of their family
26:47members who had breast cancer
26:50meet those criteria.
26:53So if a patient meets
26:54those criteria,
26:56their options in our health
26:58system are to go on
27:00and see a genetics counselor
27:03in our Smilogentics,
27:06clinic clinic,
27:08or we have tools now
27:10for our primary care physicians
27:11to do what we call
27:12point of care genetic testing
27:14in their practices,
27:16understanding that while we have,
27:18over
27:20a dozen counselors, we can't
27:22always meet the demand of
27:24all the patients that get
27:25referred to us. So we
27:26have new tools to support
27:27our
27:28primary care providers to do
27:30point of care genetic testing,
27:32which is often a blood
27:33test.
27:35In the absence of a
27:36pathogenic mutation
27:38or if a patient is
27:39not deemed eligible for genetic
27:41testing,
27:43Clinicians rely upon these risk
27:45prediction models, and there are
27:47many of them out there.
27:49This slide
27:51provides a table of the
27:53probably the top five,
27:55most commonly utilized or most
27:57validated and and,
28:01usable,
28:02tools that are out there.
28:05And so when we do
28:06these risk assessment models, they
28:08provide us with two numbers
28:10of of interest that guide
28:11through the professional organizations'
28:15recommendations for risk reduction strategies.
28:17We look at a lifetime
28:18risk and we look at
28:20a five year risk. And
28:22those thresholds,
28:23if you reach a lifetime
28:24risk greater than twenty,
28:26you may be eligible for
28:27supplemental breast cancer screening with
28:29MRI or other modalities as
28:31we just talked about.
28:34If you
28:36reach a risk threshold of
28:38greater than one point six
28:39seven, you may also be
28:41eligible for risk reduction strategies
28:43using medications, what we call
28:45chemoprevention.
28:47There are several drugs that
28:48are available that can
28:51act as,
28:53that can reduce your future
28:55risk of a hormone positive
28:56breast cancer.
28:59So here's a snapshot of
29:01one of the most commonly
29:02used tools that you too
29:04can can go and calculate
29:06on your own.
29:07There is the sort of
29:08website where you can download
29:10this,
29:11this,
29:12risk prediction model,
29:14and this is the kind
29:15of output that you will
29:16get. What I'm trying to
29:18show you on the slide
29:18is several things. One is
29:20the type of information you
29:22need to be able to
29:23answer
29:24the questions to get an
29:25answer
29:27and also showing you the
29:28results
29:29when you change
29:30the race of the patient
29:32from white to black. And
29:34you can see
29:35in the same patient who's
29:37forty two, had their first
29:38menstrual period at ten,
29:40had their first baby at
29:42thirty five years old, had
29:43two prior breast biopsies that
29:45were not cancer,
29:48had no atypia on those
29:49biopsy results,
29:51had one first degree relative,
29:53so that's mother, daughter, or
29:55sister, in this case, one
29:57mom with breast cancer,
30:00and and we calculate that
30:01risk for a black woman.
30:03The results are on the
30:04left of this screen. So
30:06you could see they don't
30:07this particular patient who's black
30:09with those characteristics
30:10does not reach the five
30:11year risk threshold
30:14for chemo prevention
30:15based on this model, nor
30:17do they risk reach the
30:18high risk threshold for a
30:20lifetime risk greater than twenty
30:22for MRI.
30:24But if you change nothing
30:25but the race,
30:27this model actually
30:28suggests that this patient is
30:30eligible for both of those
30:31things.
30:32And some of this reflects
30:34the incidence rates of breast
30:35cancer between races, but it
30:37also demonstrates
30:39how imperfect
30:41the models are that we
30:42have that sometime contribute
30:45to inequities
30:46in our ability to care
30:48for patients. And so I
30:49I I share this
30:51to also give sort of
30:53an abundance of caution that
30:54there are other models that
30:55don't take race into consideration
30:57that may be more appropriate.
31:01So the other model that
31:02is widely used and,
31:05and recommended by many professional
31:06organizations is something called the
31:08Tyra Cusick model.
31:10In parentheses, I have the
31:12word IBIS there because that
31:13in my that is the
31:15way that you can find
31:16it if you Google it
31:17on
31:18if you go and Google
31:19Tyra Cusick, you're gonna get
31:20a bunch of different options
31:22with web based version that
31:24that are really easy to
31:26use because they're pretty
31:28and they seem really easy
31:29to answer.
31:30But those are not validated.
31:32The only validated one is
31:34on this, website that I
31:35list for you here. You
31:36actually have to download the
31:38software, and it's a little
31:39cumbersome to use. And it's
31:41kind of easy to make
31:43mistakes and get the wrong
31:45answer. So,
31:48when I talk about these
31:49risk models, I like to
31:50say it's sort of like
31:51garbage in, garbage out. If
31:53you don't put the right
31:54information in, you're gonna get
31:55an answer that's not really
31:57reflective of your risk.
31:59So in this case, this
32:01model takes into consideration
32:03many more risk factors than
32:05the the breast cancer prevention
32:07tool that I showed you
32:08first.
32:08It takes into account your
32:10height and your weight,
32:12whether you're not you have
32:13an Ashkenazi Jewish ancestral background,
32:16what your breast density is.
32:18We just heard about the
32:19the
32:20how breast density is another
32:22additional risk factor that we
32:23need to take into consideration.
32:26It also takes into account
32:28family members outside your first
32:29degree relatives and family members
32:31with ovarian cancer.
32:33It also allows you to
32:35say whether or not you
32:36or any of your family
32:37members who've been affected have
32:38had
32:39genetic testing.
32:42But you can make mistakes.
32:44If you don't,
32:48use the right age of
32:50die
32:51of the family members when
32:52you enter the information and
32:54asks you for an age,
32:55if you give their current
32:56age
32:57and not the age of
32:58the diagnosis
32:59at the time of their
33:00diagnosis of cancer
33:03or you don't include unaffected
33:05family members,
33:07you can overestimate
33:09risk
33:10or underestimate risk. And so
33:11it's really hard to use
33:13these models if you don't
33:14have experience,
33:16utilizing them.
33:19So I'll share here with
33:20you the results of this
33:21model with that same patient
33:24putting in some,
33:25you know, average sort of,
33:27age of first,
33:29average,
33:30examples of, like, height and
33:31weight.
33:32And this gives this is
33:34a example of what the
33:35printout might look like. And
33:36so you might remember the
33:38last slide, we had a
33:40range of lifetime risk between
33:42sixteen and twenty something percent.
33:44This one suggests the lifetime
33:46risk, if you look up
33:47in that right upper corner,
33:48is twenty six point five
33:50percent.
33:51And the five year risk
33:52on the other was between
33:54one point five and three,
33:56and this five year risk
33:57is two point one. So
33:58it just demonstrates
33:59sort of, you know, how
34:01imprecise these models are even
34:03though they are the best
34:04that we have to give
34:05us guidance.
34:08I wanna make a comment
34:09about polygenic
34:10risk scores, which are risk
34:12scores that you may get
34:14if you get genetic testing
34:15and provide,
34:19if you have genetic testing,
34:20they're looking at multiple
34:22of your genetic variants
34:24to try to estimate a
34:26score for you. And these
34:27often
34:28overestimate
34:29risk and make people really
34:31anxious that they get back
34:32during their genetic testing. If
34:34they have no pathogenic variant
34:36and then they get this,
34:37I think we have to
34:38be really cautious that these
34:41scores actually are overestimate risk
34:44and are not really ready
34:45for prime time.
34:48So I just wanna make
34:49one point about atypia. Atypia
34:52is a finding on breast
34:53biopsy that is another risk
34:56factor for future cancer that
34:57needs to be taken into
34:59consideration.
35:00So if you had a
35:01biopsy, you wanna know whether
35:02or not there was any
35:04atypia present.
35:07This is an additional risk
35:08factor that confers an intermediate
35:10risk.
35:11This is another tool that
35:13we utilize with our providers
35:15to help guide them on
35:16who should go on for
35:17surgery with atypia and or
35:20who might be eligible
35:21for risk reduction strategies.
35:25I wanna highlight that because
35:27this is such a complicated
35:29area, we get referrals from
35:31primary care physicians and OB
35:32GYNs and self referrals from
35:34patients
35:35to support them in helping
35:37them estimate their own risk
35:38and determine their eligibility for
35:40genetic testing. And if you
35:42were to come to see
35:43any of our providers across
35:44our network,
35:45this is the type of
35:46clinical care and counseling that
35:48we would provide.
35:49We don't have time to
35:50go into to these,
35:53all these different strategies, but
35:55we talk about prevention strategies
35:57and early detection strategies. And
35:59based on the individual
36:00risk
36:02and the patient preferences,
36:04we can talk and counsel
36:05about lifestyle and behavior that
36:07we're gonna hear about from
36:08doctor Erwin,
36:09chemoprevention
36:10or medications to reduce your
36:12risk,
36:13risk reduction mastectomy
36:15for those with lifetime risk
36:16greater than forty percent,
36:19and then their early detection
36:20options are not preventing cancer,
36:22but finding it early. And
36:23that includes self exam, clinical
36:26exam, and the breast imaging
36:27that we just heard about
36:28from doctor Laffey.
36:31So I'm gonna stop there
36:32because I know I took
36:33more time than I should
36:34have, and I'm gonna pass
36:35it to my colleague, doctor
36:36Erwin.
36:45Okay.
36:46Thank you.
36:47And I'm gonna try to
36:52get it into the right
36:54mode.
37:03You could maybe answer a
37:04question while I'm doing this.
37:09Did I freeze?
37:15You're good. You're I think
37:17we see the center mode,
37:18though. Are you you're not
37:20full screen yet?
37:23Okay. Good. Switch your screen.
37:24I was scared. I thought
37:25I froze.
37:28I thought I froze, but
37:29I'm good. I'm not frozen.
37:32Alright.
37:33I was thinking maybe we
37:34can answer some of the
37:35questions in the chat while
37:37I'm presenting just in case
37:38we don't get to all
37:39of the, questions.
37:41Good evening, everyone.
37:43My name is Melinda Erwin.
37:44I'm a professor in the
37:45Yale School of Public Health
37:46and deputy director in the
37:48Yale Cancer Center. And I'm,
37:50going to share with you
37:52breast cancer prevention.
37:54And I'm gonna really focus
37:55on beyond individual risk factors
37:57and more how the environment
37:59and systems shape our risk
38:00for breast cancer.
38:03Also, I wanna first start
38:05with acknowledging that breast cancer
38:07mortality rates have decreased by
38:08forty four percent since the
38:10peak in nineteen ninety. And
38:12much of this success in
38:14reduced mortality rates is because
38:16of what, doctor Laffey said
38:18in our early detection and
38:20our our ability to screen
38:22breast cancer, which results in
38:23an earlier stage at diagnosis,
38:26and then also,
38:27amazing
38:28advancements
38:29in treating breast cancer. And
38:31so those together have really
38:32helped,
38:34reduce breast cancer mortality rates.
38:36But what about preventing breast
38:38cancer
38:39outright so that,
38:41we don't have to deal
38:42with treatment?
38:43So I know this is
38:44a busy slide, but it
38:45highlights many of the risk
38:47factors for breast cancer. And
38:49if you look sort of
38:50at the top going to
38:51the
38:52clockwise,
38:54in purple
38:56are, the non modifiable
38:58risk factors.
38:59And,
39:00Doctor Battaglia mentioned,
39:03germline
39:04mutations.
39:05And while those aren't sort
39:07of modifiable, there are ways
39:08that we can,
39:10be aware from them and
39:11change our screening guidelines. And
39:13then the other non modifiable
39:15are female sex, older age,
39:18certain race and ethnic groups
39:19have a higher risk of
39:20breast cancer,
39:22family history,
39:23breast density, previous history of
39:25breast cancer and age at
39:26menarche,
39:27or a first period, and
39:29then age at menopause.
39:31The green factors on sort
39:33of from the six P
39:35at the bottom to the
39:36top of the circle are
39:37what we call modifiable factors.
39:39And these are primarily related
39:41to lifestyle behaviors.
39:44So our body composition
39:46or, whether we're overweight or
39:48obese,
39:49physical activity,
39:50diet and alcohol,
39:52as well as oral contraceptive,
39:54contraceptives and hormone replacement therapy
39:56in the postmenopausal
39:57years. So I'm gonna focus
39:59on those for the remainder
40:01of the talk.
40:04Unfortunately, over the past three
40:06decades, we've seen a significant
40:08increase in the prevalence of
40:10obesity, not only in the
40:12US but globally. In fact,
40:14every country
40:15across the globe has seen
40:17increased rates of obesity.
40:19Obesity is defined as a
40:21body mass index of thirty
40:23or greater and body mass
40:24index is basically our weight
40:26adjusted for height. It's an
40:28imperfect measure because it does
40:30not take into consideration the
40:31amount of muscle you have
40:33versus adiposity. And we know
40:34muscle weighs
40:35more than body fat, but
40:37on a population level, it's
40:39a pretty good indicator.
40:40And what's concerning is seeing
40:42that,
40:43back in the seventies rates
40:44of obesity
40:46were, in women's seventeen percent
40:48and now they're up to
40:49forty two percent.
40:51And during this same time
40:53period over the last thirty
40:54or forty years, we've seen
40:55a significant reduction
40:57in physical activity levels.
40:58And much of this is
41:00because of technological advances. We
41:02can do our work from
41:03home, from a laptop,
41:05even from an iPhone. So
41:06this has created a society
41:08that is very
41:09sedentary.
41:10So it's not so much
41:11about doing exercise,
41:13but are we sitting too
41:14much and how to reduce
41:16our sitting time?
41:17I present these two slides
41:19to make the point that
41:20this is not something that's
41:21happening on an individual
41:23level, but on a societal
41:25and global level.
41:27And therefore, the interventions
41:29needed
41:30to reverse these trends in
41:31obesity and inactivity
41:33have to be at the
41:35environmental,
41:36societal, and policy level.
41:40And so
41:41discussing that, you you may
41:43have heard the term obesogenic
41:44environment, and this is the
41:46fact that we have widespread
41:47availability and marketing of high
41:49calorie and processed foods.
41:51There is recent research showing
41:53that more than fifty percent
41:54of the foods people
41:56consume per day are highly
41:58ultra processed foods.
42:00This is partly because that's
42:01what available everywhere. It's ubiquitous.
42:05It's cheaper and it's easier
42:06and access is everywhere. So
42:08we have limited access to
42:10affordable,
42:11healthy foods. We also have
42:12an urban design that favors
42:14cars over walking and biking
42:16and work environments with long
42:18sedentary or sitting hours. And
42:21then lastly,
42:22in our free time, we're
42:23consumed with social media, which
42:25is leading to more sedentary
42:28behaviors.
42:30So what are the mechanisms
42:32of how, some of these
42:33modifiable
42:34lifestyle factors related to body
42:36weight, physical inactivity,
42:38poor diet, and alcohol might
42:40increase risk for breast cancer.
42:42Well, we know that they're
42:43primarily through estrogen,
42:45inflammation, and metabolic markers such
42:47as insulin.
42:49Delving down a little bit
42:50deeper, we know in our
42:51postmenopausal
42:52years when women stop producing
42:54estrogen via their ovaries,
42:56they continued
42:57to produce it in their,
42:59adipocytes and their body fat.
43:02And this is from the
43:03conversion of androgens
43:04to estrogens via the enzyme
43:07aromatase.
43:08We know that this is
43:09really important because in women
43:11who have estrogen receptor positive
43:14breast cancers,
43:15they're prescribed a standard of
43:16care and aromatase
43:18inhibitor,
43:19which inhibits the conversion of
43:21androgens
43:22to estrogens.
43:23So this is really showing
43:24that estrogen is a primary,
43:27mechanism
43:28that mediates certain
43:29modifiable
43:30and other factors related to
43:32breast cancer.
43:33So research on trying to
43:35reduce estrogen levels systemically,
43:38as well as reducing
43:39inflammation,
43:41and insulin and other metabolic
43:42markers
43:43is really,
43:45important to better understand the
43:46right type of intervention
43:48for certain types of of
43:50people.
43:52You've heard a lot recently
43:54about alcohol and how alcohol
43:56increases breast cancer risk. And
43:58the way this works is
43:59alcohol or ethanol
44:01can, when we drink it,
44:03it's more of a focus
44:04on there's a dose response
44:06effect here. So one drink
44:07might be okay and not
44:09much of a risk, maybe
44:10a a lifetime five percent
44:12higher risk, but it's if
44:14you have two or three
44:15or four in a day.
44:16That's where your risk of
44:18breast cancer really increases.
44:20And that's through,
44:21how alcohol or ethanol is,
44:24converted in the enzyme,
44:26that of ADH that then
44:28leads to,
44:29a chemical that can cause
44:31chromosome rearrangement
44:33and mistakes in our DNA.
44:35So,
44:36prudent, you know, wanna be
44:38modest with our alcohol intake.
44:41So I wanna go back
44:42to talking about the lifestyle,
44:45these factors in the environment.
44:46We know that lifestyle risk
44:48factors are shaped by the
44:49environments we live in and
44:51that our lifestyle choices are
44:52strongly influenced by the environments,
44:54the policies and systems,
44:56and that our environments often
44:58promote unhealthy eating and sedentary
45:00behavior, and that access to
45:02places to exercise affordable, healthy
45:03food and supportive policies are
45:03key to
45:04food and supportive policies are
45:06key to prevention.
45:08And I wanna dig deeper
45:09on the the sort of
45:11reducing
45:11sedentary behavior
45:13and making sure you understand
45:15the importance of this. This
45:17figure here is based on
45:18hundreds
45:20of prospective
45:21cohort studies
45:22that have enrolled individuals, let's
45:24say at around age forty
45:26or thirty or twenty and
45:28followed them to fifty, sixty,
45:30seventy, eighty years of age
45:31one and looked at mortality
45:33as the outcome.
45:34Cancer,
45:35mortality, as well as cardiovascular
45:37mortality.
45:38And what's really important to
45:39recognize in this figure is
45:41this drop that going from
45:43nothing, being very sedentary to
45:45just doing something
45:47is where you see
45:49the most bang for your
45:50buck, the biggest,
45:52reduction
45:53in breast cancer risk or
45:55mortality,
45:56implying that just doing something
45:58is better than nothing. It
46:00doesn't have to be training
46:01for a marathon.
46:03The goal, the recommended amount
46:05is two and a half
46:05hours per week of of
46:07moderate intensity, such as brisk
46:09walking, but it's really important
46:10that the research has shown
46:12that really just doing something
46:13can be beneficial.
46:15This same figure comes up
46:17time and again
46:18in studies looking at walking.
46:21And these are from pedometers
46:22from iPhones. When you look
46:24at how much steps you've
46:25taken or Fitbits
46:26showing once again a similar
46:28curve that going from very
46:29little walking less than a
46:31thousand steps per day, which
46:32is only a half a
46:33mile in all of our
46:35steps per day, not in
46:36kind of going for a
46:38walk, but from when you
46:39wait till you go to
46:40bed at night. So going
46:42from a thousand
46:43and trying to increase it
46:44a thousand steps per day
46:46or more,
46:47has a significant
46:48reduction in risk for
46:50all cause mortality, as well
46:51as breast cancer mortality.
46:54Two thousand steps per day
46:55is equivalent to a mile.
46:57So if you can kinda
46:58think about increasing five hundred
47:00or a thousand steps per
47:01day throughout your day, then
47:03that's gonna really help lower
47:04your risk.
47:06What about the dietary guidelines?
47:08There are a number of
47:09guidelines that are listed on
47:11the left here, but overall,
47:13what's recommended is a,
47:15a plant,
47:17based diet
47:18where,
47:20animal products are are maybe
47:22one third of what we
47:23eat in a a day.
47:25We really wanna focus on
47:26increasing our fruits and vegetables
47:28in our fiber, which is
47:29in our fruits and vegetables.
47:32So we now have a
47:33really good food label, as
47:35you can see on the
47:35right, that tells you how
47:37much grams of fiber you
47:38get in various foods, as
47:40well as how much added
47:41sugar, that's new to the
47:42food labels. And that was
47:43a significant
47:45FDA policy change that came
47:47out just a couple of
47:47years ago, requiring that added
47:50sugars be pulled out on
47:52the full food label, because
47:53it was very confusing to
47:55consumers.
47:56For example, if you're drinking
47:57orange juice and it shows
47:58a lot of sugars,
48:00but, it might be that
48:01that's not added sugars to
48:03the orange juice. So more
48:05important to look at the
48:06amount of added sugars on
48:07the food label than than
48:09the overall sugars.
48:11We wanna, maintain or increase
48:13our protein per day to
48:14about one point two grams
48:15per kilograms.
48:17Generally, most people eat plenty
48:19of protein in their diet,
48:21even though there seems to
48:22be a lot of advertising
48:24out there to get more
48:25protein, but most people eat
48:27plenty of protein.
48:28And in thinking about the
48:29type of protein you get,
48:30having it from fish,
48:32and and maybe poultry and
48:34reducing it from processed meat,
48:37which in turn will also
48:38reduce your amount of sodium
48:39and low saturated
48:41fat.
48:44What about supplements? So the
48:46American Institute for Cancer Research
48:48as well as the American
48:49Cancer Society,
48:51and NCI
48:52do recommend that you do
48:54not rely on supplements for
48:55cancer prevention
48:57and, to reduce your risk
48:59of cancer, to choose a
49:00balanced diet with a variety
49:01of foods.
49:02And those diagnosed with breast
49:04cancer or any cancer, it
49:06is critically important
49:08to share the supplements that
49:09you're taking with your provider
49:11because they could interact with
49:13the treatments you're receiving
49:15and reduce the efficacy of
49:16the treatments.
49:17But guidelines are that you
49:19should not rely on supplements
49:20for cancer prevention. In fact,
49:22it's important to recognize the
49:23word supplement.
49:24If you are low in
49:26that level, it helps to
49:27supplement. But if many people
49:29are already,
49:31getting enough vitamins and minerals
49:33from their diet and having
49:34additional
49:35supplements on top of that
49:36is not any added benefit,
49:38and in fact, it could
49:39be harm.
49:41So I just wanted to
49:42quickly highlight,
49:43where the research some of
49:45the studies that we've done
49:46of,
49:48diet and exercise
49:50and weight management interventions
49:52and the effect on breast
49:54cancer risk and outcomes. This
49:56was a trial we completed
49:58about,
49:58ten years ago now, and
50:00it was in postmenopausal
50:01women without breast cancer.
50:03But it was a forearm
50:05randomized trial of diet alone,
50:07of all the recommendations I
50:08just mentioned,
50:09exercise, which was basically
50:12brisk walking for two hours
50:14per week, and then the
50:15combination of diet and exercise.
50:17And really the takeaway here
50:18is all the negative signs
50:20you see in all of
50:21these markers,
50:23biomarkers related to breast cancer.
50:25So higher levels of these
50:26increase your risk of breast
50:27cancer,
50:28except for SHBG.
50:31And so,
50:32these inter the diet and
50:33exercise interventions, significant reductions in
50:36insulin,
50:38in
50:39CRP, a marker of chronic
50:40inflammation, and in our estrogens.
50:42And then the figure on
50:43the right shows estrogen levels,
50:45which is the most,
50:47common,
50:49estrogen in postmenopausal
50:50women, and you can see,
50:53just the significant reduction in
50:54estrogen levels with diet, exercise,
50:57and the combination
50:58of about ten to fifteen
51:00percent. And this was within
51:02three months of a healthy
51:03eating and exercise program.
51:07We just completed a trial
51:08in women who were receiving
51:10chemotherapy
51:11for breast cancer,
51:12and what we were able
51:13to show in working with
51:14the registered dietitian,
51:16on our team, those who
51:17were randomized to receiving
51:19receiving counseling of healthy eating
51:22and exercise over the year
51:24from their diagnosis through chemotherapy.
51:26And at one year, we,
51:28working with our dietitian, they
51:30were able to increase their
51:31physical activity levels
51:32and the,
51:34the diet quality, the quality
51:35of the foods they were
51:36eating during chemotherapy.
51:39And what is,
51:40quite remarkable is that this
51:42intervention
51:43led to a fifty three
51:45percent,
51:46pathologic complete response rate compared
51:49to twenty eight percent in
51:50the usual care group. Both
51:52groups were receiving chemotherapy, but
51:54those that had were randomized
51:56to the,
51:57exercise and nutrition intervention
52:00had less breast cancer
52:02at surgery. So this was
52:03a group of women receiving
52:05new adjuvant
52:06chemotherapy
52:07and then had surgery. And
52:09at the time of surgery,
52:10those in the intervention group,
52:11there was less evidence of
52:13breast cancer.
52:15What is the mechanism of
52:17that? Well, in this trial
52:19also, with women with breast
52:21cancer,
52:22we showed that really that
52:24this intervention led to favorable
52:25changes in body composition, but
52:27also
52:28reduction in c reactive protein,
52:30which is inflammation,
52:32insulin, and leptin.
52:35So I just wanna, touch
52:36upon anti obesity medications because,
52:40I know that this is,
52:42a lot of patients and
52:43people, people with and without
52:45cancer are very interested in
52:47the role of these medications,
52:48which are remarkable,
52:51really profound in the amount
52:52of weight loss and adiposity,
52:55loss that occurs with these
52:57medications, which are,
52:59now sort of called GLP
53:01one,
53:02glucagon like protein one receptor
53:04agonists.
53:06There's really limited research
53:09on these anti BC medications
53:11and breast cancer risk or
53:12outcomes among those with breast
53:14cancer.
53:15It is being conducted now.
53:16It's evolving. So in one
53:18year and in two, three
53:20years, there'll be more research
53:21out there. But right now
53:22there's very limited
53:24information about these medications in
53:26regards to breast cancer.
53:28We do know that the,
53:30the mechanism is they cause
53:31significant weight loss up to
53:33about twenty, twenty five percent
53:35loss,
53:36and metabolic changes such as
53:38the ones I just mentioned,
53:39all these metabolic
53:40markers.
53:43Most of the studies that
53:44are done are observational,
53:47looking at outcomes except for
53:48the trials of testing the
53:49medication on weight loss. But
53:51in regards to cancer, they're
53:53observational and so there isn't
53:54a cause and effect,
53:57relationship yet established.
53:59Most important, if you are
54:01considering
54:02one of these medications,
54:04discuss it with your provider,
54:06especially if you've been diagnosed
54:08with cancer.
54:12I always get this question.
54:13I think it's really important.
54:15Many people follow the diet
54:17and physical activity guidelines, and
54:18they can still develop breast
54:20cancer, and it's very frustrating.
54:22So it's important to note
54:23that a healthy lifestyle lowers
54:25risk but does not eliminate
54:27it.
54:28Whether you like this analogy
54:29or not, I think it's
54:30simple and can be,
54:32helpful.
54:33It's like wearing a seat
54:34belt, which, lowers your chance
54:36of severe injury in a
54:38car crash, but it does
54:39not guarantee
54:40safety, but it lowers your
54:42risk.
54:43Much like
54:44screening and,
54:45leads to earlier detection and
54:47practicing,
54:49you know, changing some of
54:50the modifiable risk factors, it
54:52lowers your risk.
54:54But most importantly, breast cancer
54:56is influenced by a mix
54:57of factors that are genetic,
54:59reproductive
55:00history, hormones, environment,
55:02and chance.
55:03And that for women already
55:05diagnosed,
55:06these modifiable factors might also
55:09improve treatment tolerance, reduce recurrence
55:11risk, and improve outcomes. So
55:13even if you've been practicing
55:14these healthy behaviors and you're
55:15still diagnosed with breast cancer,
55:18maintaining
55:19a healthy diet and exercise
55:21can help with your prognosis.
55:25Okay. I think my last
55:26slide here, I just wanna
55:28touch upon postmenopausal
55:29hormone replacement therapy because there's
55:31been a lot
55:33of information on this, especially
55:35on social media, and it
55:37can get very confusing
55:39to individuals.
55:41HRT, as you might know,
55:42replaces estrogen and progesterone hormones
55:45that decline during menopause.
55:47And HRT
55:49reduces menopausal symptoms and also
55:51protects against osteoporosis.
55:54Breast cancer risk increases with
55:56longer use of HRT.
55:59Recent
56:00research that came out in
56:01the last couple years showed
56:02that the risk was less
56:04in women from age fifty
56:06to fifty nine than in
56:07women sixty or older. So
56:09many women might take HRT
56:11in their 50s and then
56:12stop it when the menopausal
56:14symptoms subside.
56:15And research recently has shown
56:17that that's a lower risk.
56:20It's also really important to
56:21note that hormone therapy, which
56:23is also called endocrine therapy
56:25for breast cancer,
56:26should not be confused with
56:28HRT.
56:29HRT and endocrine therapy produce
56:31opposite effects.
56:33Endocrine therapy for breast cancer
56:35is a medication to lower
56:36hormone levels
56:37systemically like aromatase inhibitors
56:40or block the action of
56:41the hormone at the receptor,
56:43such as tamoxifen,
56:45which in turn lowers risk
56:46of breast cancer recurrence
56:48and also can be used
56:49in women at high risk
56:51for for breast cancer.
56:54Most important is to discuss
56:56the potential benefits and risk
56:57of HRT with a health
56:59care provider before starting treatment.
57:02So in closing, I just
57:04want to,
57:06kinda remind again that thirty
57:07percent of breast cancers could
57:08be prevented through lifestyle changes,
57:11yet lifestyle is driven by
57:12the world around us, the
57:14food industry, urban design, and
57:16social norms.
57:17We know that changing habits,
57:19especially in a world full
57:21of stress, limited access to
57:23healthy foods and environments that
57:24don't encourage physical activity is
57:26not easy.
57:27So, you know, hoping that
57:29there'll be policies and systems
57:30changes
57:31that can make the healthy
57:33choice
57:33the easy choice.
57:36And important to note that
57:38progress is uneven across populations
57:41and that access to care,
57:43socioeconomic status and environmental exposures
57:46contribute to disparities. And unfortunately,
57:48there are disparities in breast
57:50cancer incidence and mortality.
57:52And so lastly, every step
57:54we take toward healthier habits
57:55matters,
57:56Small changes add up such
57:58as just focusing on reducing
58:00sedentary behavior, and that combined
58:02with community level efforts
58:04will reduce breast cancer risk
58:06and improve overall health.
58:09So with that, I will
58:10stop sharing.
58:16That is great.
58:17Thank you, doctor Arun.
58:19We do have a few
58:20questions
58:21that have been submitted and
58:25couple of the two that,
58:26we've answered a few of
58:27them directly, but, couple that
58:30are out there radiology questions.
58:32So doctor Latvie can take
58:34the first one and maybe
58:35I'll take the second one.
58:37So a questioner asks and
58:38she's a breast cancer survivor
58:40more than two decades ago.
58:42And she says, yes. If
58:43mammogram and ultrasound are done
58:45and compared to past results
58:47and found to be a
58:47change, what is the next
58:49step? So if there's a
58:50change on your mammogram and
58:51your ultrasound, what do you
58:52do next?
58:56And you're muted, Brisa.
58:59There we go. Sorry about
59:00that. If a patient
59:02is found to have a
59:04mammographic or sonographic abnormality without
59:06any other symptoms, that is
59:08called a callback from screening.
59:11Generally, women are asked to
59:12return for additional specific dedicated
59:15diagnostic imaging,
59:17which means additional mammographic views,
59:20targeted ultrasound
59:22with, generally presence of the
59:24radiologist
59:25who can assess.
59:26And,
59:27then the radiologist
59:29can,
59:30determine
59:31if there is a need
59:32to perform a neal biopsy,
59:34follow-up, or do nothing.
59:39Yep. So that yeah. So
59:41that's a great answer. I
59:42hope that answers your question.
59:44You'll get called back, and
59:45we'll do additional workup with
59:46other images. So the other
59:47radiology question is what is
59:50molecular breast imaging?
59:52And so, molecular breast imaging
59:55is a nuclear medicine study.
59:57So there's a radioactive
59:59substance called technetium
01:00:01and
01:00:02and it's and a form
01:00:04of it is used very
01:00:05commonly in different medical tests,
01:00:07especially a test of the
01:00:08heart. And what they found
01:00:10when they were testing people's
01:00:11hearts is that breast cancers
01:00:13would light up
01:00:14in this test. So the
01:00:16the substance that they were
01:00:17giving
01:00:18to look at the heart
01:00:19would go to breast cancers.
01:00:20So they realized they could
01:00:21turn this into an imaging
01:00:22test, and it's a it's
01:00:24an imaging test that has
01:00:25good sensitivity.
01:00:27It finds cancers at a
01:00:28similar level
01:00:30to MRI and contrast mammography.
01:00:32It hasn't been studied as
01:00:33much. It has some downsides,
01:00:35though, as opposed to a
01:00:36contrast mammogram, which takes about
01:00:38five minutes or an MRI
01:00:39which takes about
01:00:41ten to twenty minutes,
01:00:42every image
01:00:44on molecular breast imaging is
01:00:45about fifteen minutes, five zero.
01:00:47It has gone down with,
01:00:50better equipment,
01:00:51but it's a longer scan,
01:00:53and it doesn't quite give
01:00:55the anatomy.
01:00:56It doesn't give it doesn't
01:00:57show us the anatomy
01:00:59like MRI or contrast mammography
01:01:01does. So it hasn't,
01:01:03been as widely accepted.
01:01:05But, it's a test. Basically,
01:01:07you get injected with a
01:01:08radioactive substance, and then you
01:01:09get damaged.
01:01:13So we
01:01:15are,
01:01:18there's no more questions on
01:01:19the chat. We can
01:01:21stay for
01:01:23another five minutes or
01:01:25if one of our panelists
01:01:26would like to
01:01:28add something, I'd be happy
01:01:30to listen or I can
01:01:31ask questions.
01:01:37Actually, one of our listeners
01:01:38had a question about
01:01:40the risk models.
01:01:42And,
01:01:42so, Tracy,
01:01:44yes.
01:01:45So,
01:01:46and don't forget to unmute.
01:01:49You mentioned two websites,
01:01:51one of which,
01:01:55you know, that one of
01:01:56which is web based, and
01:01:56the other one you had
01:01:57to download software. Can anybody
01:01:59download that software, or do
01:02:00you have to get permission?
01:02:01It's free.
01:02:03It's free. It's just the
01:02:04interface is not very intuitive.
01:02:06It's kinda complicated.
01:02:08It's not clear
01:02:09exactly what they're asking.
01:02:11So I I think it's
01:02:12easy to make mistakes using
01:02:14that model.
01:02:16There are
01:02:17other,
01:02:18versions of it on the
01:02:19web that are, like, pretty
01:02:21interface and clear questions,
01:02:23but I don't think that
01:02:24they're validated, and so I
01:02:26wouldn't necessarily
01:02:27encourage using them. So, I
01:02:29mean, I think you could
01:02:30go ahead and assess assess
01:02:31your own risk and print
01:02:32out your results and bring
01:02:33it to your provider.
01:02:35Anytime I see a patient
01:02:37and they bring me a
01:02:37risk model
01:02:39result
01:02:40without the information of what
01:02:41went into it, I just
01:02:43repeat it because I don't
01:02:44know what went into that
01:02:45calculation to give the result.
01:02:49So I I think the
01:02:50the message I would give
01:02:51is
01:02:53these are not easy to
01:02:54interpret
01:02:55and don't panic. If you
01:02:56get a very high
01:02:58risk, you should review it
01:02:59with a a a provider
01:03:01who has experience using the
01:03:02models.
01:03:04Yeah. So someone who's used
01:03:06the models, I would definitely
01:03:07concur. There are little things
01:03:08that can make a big
01:03:09difference.
01:03:11Height and weight are one.
01:03:12You have to put those
01:03:13in to be accurate.
01:03:15And if you're so if
01:03:16you're tall, it increases your
01:03:17risk of breast cancer, which
01:03:19is not intuitive, but it's
01:03:20in the model. One thing
01:03:21that seems to drive it
01:03:22for
01:03:23a lot of our patients
01:03:24is having a first child
01:03:26after thirty, which has become
01:03:27extremely common.
01:03:29And so, yeah, then would
01:03:31you like to comment on
01:03:31that, doctor Taglia?
01:03:34Yeah. I mean, I think,
01:03:36you know, we take a
01:03:36lot of,
01:03:39of the reproductive
01:03:42history into account for,
01:03:45breast cancer risk. And the
01:03:46way that I like to
01:03:47think about it is it's
01:03:48really just to sort of,
01:03:50the
01:03:51the amount of time an
01:03:52individual
01:03:53has
01:03:55exposure to estrogen unopposed.
01:03:58And so when you have
01:04:00your period very early
01:04:02and you don't go through
01:04:03menopause until very late
01:04:06and you don't have a
01:04:07child
01:04:08at all or have a
01:04:09child at an older age,
01:04:11you're not opposing any of
01:04:13the natural hormones of sort
01:04:15of your normal cycles
01:04:17that interfere sort of that
01:04:18may sort of be,
01:04:20contributing to breast cancer risk.
01:04:23So having children younger for
01:04:24whatever
01:04:26reason, having any children is
01:04:28protective. Having children at a
01:04:30younger age probably has something
01:04:31to do with the breast
01:04:33development
01:04:33and the opposition of the
01:04:35hormones.
01:04:38Great. And,
01:04:44that's I've yeah. I have
01:04:46no other questions to ask.
01:04:51Oh, and doctor Laffey is
01:04:52typing an answer,
01:04:54looks like, to one last
01:04:55question.
01:04:56Anything else anybody would like
01:04:58to add? Oh, I see.
01:04:59If any if anyone's still
01:05:00on,
01:05:01and does have questions, feel
01:05:03free to email me directly
01:05:04at melinda dot erwin at
01:05:05yale dot edu. I'm happy
01:05:07to answer questions later on
01:05:09as well.
01:05:10And I I have one
01:05:11question, doctor Erwin.
01:05:15So exercise we know
01:05:17and
01:05:19being thinner reduces your risk
01:05:20of postmenopausal breast cancer. Does
01:05:22the same thing apply to
01:05:23premenopausal
01:05:24breast cancer?
01:05:26So for exercise, yes. It
01:05:28lowers your risk from you
01:05:30know, if you exercise childhood,
01:05:32premenopausal
01:05:33years, later on is
01:05:35a significant lower risk for
01:05:36developing
01:05:37breast cancer.
01:05:39The research with obesity is
01:05:40a little confusing because it's
01:05:42related to estrogen and and,
01:05:45whether you have a twenty
01:05:46eight day cycle. And so
01:05:48sometimes if you have high
01:05:50amounts of body fat, you
01:05:51might not have a a
01:05:53menstrual cycle that's,
01:05:54every twenty eight days. And
01:05:56so it kinda confounds the
01:05:57relationship with breast cancer risk.
01:06:00However, with that said, we
01:06:01know that weight gain
01:06:03from adolescence through adulthood,
01:06:06independent
01:06:07of your BMI,
01:06:08is associated with increased breast
01:06:10cancer risk.
01:06:11So I think two messages
01:06:12I always like to to
01:06:14tell people is to try
01:06:15to prevent weight gain
01:06:17and to try to reduce
01:06:18sedentary
01:06:19behaviors.
01:06:23Alright. Well, I'd like to
01:06:25thank
01:06:26our panelists again
01:06:28and,
01:06:30let everyone know that we
01:06:32have two more
01:06:34of these webinars. The next
01:06:35one is October ninth, and
01:06:37it's
01:06:38entitled early stage breast cancer,
01:06:40what patients and families should
01:06:41know.
01:06:42And the one after that
01:06:44is October sixteenth, so these
01:06:45are all on Thursday nights.
01:06:48And October sixteenth is progress
01:06:49in metastatic breast cancer research
01:06:51and treatment. Talk about the
01:06:53ways we are,
01:06:55have improved the treatment of
01:06:56metastatic breast cancer. It's,
01:06:59it's been quite astonishing over
01:07:00the past decade
01:07:01what has the advances we've
01:07:03had. So,
01:07:08that is all. Looks like
01:07:09we're good. Okay.
01:07:12Thanks, everyone.
01:07:14And, Eliza, unless you have
01:07:16any other things, we will
01:07:17say goodbye.