BREAST HEALTH

By Marte Wasserman, MD, Mayo Clinic Florida; The Society of Healers, Jewish Federation & Foundation of Northeast Florida

What You Need to Know about breast health

Greetings and L'Shana Tova! As you may know, clinically apparent, thereby allowing the greatest possibility of October is Breast Cancer Awareness Month. For a cure. 3D mammography, or digital breast tomosynthesis, is those of us who work in breast health, we spend a technology that not only improves breast cancer detection this month educating our communities about the but also decreases false positive rates and has become latest recommendations regarding breast health. This includes mainstream. This technology obtains cross-sectional images screening mammography, risk reduction strategies and through the breast, helping to uncover small masses and encouragement of funding for breast cancer research and tissue abnormalities that would otherwise be obscured by patient support organizations. My interest in breast health is surrounding breast tissue on a conventional mammogram. two-fold. Professionally, I am a breast radiologist at the Because of the advantages provided by 3D mammography, Robert and Monica Jacoby Center for Breast Health at the insurance companies are increasingly providing coverage for Mayo Clinic in Jacksonville. Personally, I am the daughter of their customers. an advanced-stage breast cancer survivor, and I am, therefore, a high-risk patient myself. I certainly understand the It is important not to panic if you receive high stakes involved with a breast cancer notification of an abnormal screening diagnosis and how this disease affects mammogram. A "recall" simply means patients and their families. As someone who has seen how breast The goal of annual that an area of the mammogram requires further imaging to be cancers emerge in a multitude of screening mammography is adequately evaluated. Actually, most patients, family members, and to find cancers as early as recalls do not end up as a cancer friends over the years, I am grateful to be given this opportunity to share my insights and take-home points about breast health. possible...allowing the greatest possibility of a diagnosis. Even among lesions that require a biopsy, only a small percentage are ultimately diagnosed as a breast cancer.

For average-risk patients, annual cure. Screening mammograms are only screening mammography starting at age intended for patients without symptoms. 40 saves lives and is the foundation of breast A diagnostic appointment is required in the health. Robust data collected over many years supports this setting of breast-related concerns. Screening recommendation. Initiation of screening at age 40 results in mammograms are composed of standardized mammographic the most significant mortality reduction. The National views, and after completion, the patient usually leaves the Comprehensive Cancer Network, the American Cancer department. However, a diagnostic workup typically involves Society, the American College of Radiology/Society of Breast special mammographic views targeted to an area of concern Imaging, and Mayo Clinic recommend this screening and possibly includes an ultrasound. In addition, during a protocol. diagnostic appointment, the radiologist may do a physical

Screening mammograms are better than ever, but like all a diagnostic appointment is to address a patient’s symptoms medical exams, they are not perfect. False negatives can or to further investigate findings from screening happen when mammograms do not demonstrate any signs of mammography. malignancy even when cancer is present. False positives can examination to confirm the imaging findings. The purpose of happen when suspicious findings on a mammogram turn out Ultimately, the radiologist will discuss further management to be benign. The goal of annual screening mammography is recommendations with the patient, including whether the to find cancers as early as possible, before they become patient can return to screening or if there is any need for 27

follow-up imaging, biopsy, or surgical referral. Suspicious breast symptoms include a palpable lump or thickening of the breast or underarm region, nipple discharge, retraction or "pulling in" of the nipple or skin, change in the shape of the breast, redness or "orange-peel" appearance of the skin, and new rash or skin changes of the nipple. Know your breast tissue and be an advocate for your own breast health. Trust your instincts and make sure you get a diagnostic workup when you feel something is different or concerning.

Having access to prior mammograms and any other breast imaging is crucial. Because each patient’s mammogram has a unique breast tissue pattern, it is important for the radiologist to compare to prior imaging studies to determine whether abnormal changes have occurred over time. For this reason, a patient is more likely to be recalled from the first (baseline) mammogram because the radiologist must establish what is normal for that patient. The likelihood of being recalled is significantly lower if the radiologist has prior mammograms available. We routinely make a point to ask every patient for their prior exams, and we have patients sign a release of information form in order to quickly obtain imaging studies from other institutions for comparison.

Breast cancer in men, while rare, can occur in those who are genetically predisposed or have other high-risk factors. Men should alert their physician if they experience any of the breast-related symptoms previously described so that they can be scheduled for urgent breast imaging and evaluation. Men who are at high risk should be managed by a breast specialist for tailored cancer screening.

There are ways to reduce the risk of breast cancer. Lifestyle modifications, including incorporation of an exercise regimen, optimizing diet and body weight, and limiting alcohol consumption have been proven to decrease risk. For high-risk patients, breast specialists can discuss indications for risk-reducing medications that are available.

In recent years, the topics of breast tissue density and supplemental screening for high-risk patients have gained more attention. Breast tissue density refers to the amount of glandular tissue seen on a mammogram and is independent of breast size. Dense breast tissue is considered an independent risk factor, and patients should be aware of their breast density. The mammogram report is required to classify breast density into one of four categories. Screening mammography is less sensitive for those with "heterogeneously dense" or "extremely dense" breast tissue.

These patients may benefit from supplemental screening with MRI or MBI (molecular breast imaging). On average, one in eight women will develop breast cancer in their 28

lifetime. However, some of us are at increased risk based on family history, genetic mutation carrier status, increased breast tissue density, and other factors. The Ashkenazi Jewish population is at increased risk to carry BRCA genetic mutations. These high-risk groups should be referred for risk-based supplemental breast cancer screening and many will require initiation of screening before the age of 40.

Every breast cancer experience is unique. Breast cancer is a catch-all term that includes a wide variety of subtypes, all with different receptor profiles and clinical behavior, so one patient should not compare their disease with that of others. However, receiving support from others who have a similar diagnosis can be incredibly beneficial, empowering, and informative. There are various support groups available locally. Sharsheret is a wonderful support organization for those dealing with breast and ovarian cancer diagnoses in the Jewish community.

The First Coast is incredibly fortunate to be home to several high-quality health care facilities. I am proud to work with outstanding and compassionate colleagues at Mayo Clinic in Jacksonville, where world-class breast care specialists and researchers from all disciplines work together to manage each breast cancer patient as a team and provide tailored screening protocols for high-risk patients. We are constantly learning more about breast cancers and how to improve methods of detection and treatment. There is more reason than ever to be hopeful in the face of a breast cancer diagnosis. May you all be blessed with good health, peace, and happiness in the new year!

Dr. Wasserman has been a proud member of Federation’s Society of Healers for several years. The Society of Healers provides a unique opportunity for healthcare professionals in Northeast Florida to connect to a cause they care about and to each other. They host industry-related programs, through a Jewish lens, that are open to all healthcare professionals. To find out more about how you can be involved with this group, contact Faye Hedrick at fayeh@ jewishjacksonville.org.

October is breast cancer awareness month

Breast cancer is the most common, and the second HOW CAN I REDUCE THE RISK OF GETTING BREAST leading cause of death, among women in the United States—approximately 40,000 deaths each year. According to researchers at the Hadassah Medical Organization (HMO), women of Ashkenazi Jewish descent have at least a 10 times greater prevalence of BRCA1 gene mutations, leading to increased incidence of the disease. It has also been discovered that founder mutations (a genetic alteration observed with high frequency in a group that is or was geographically or culturally isolated) increases the risk of breast cancer in CANCER? Know your family history and ask your doctor if additional genetic testing is right for you. You can also reduce your risk of cancer by making healthy lifestyle choices like eating right, staying physically active and not smoking. It is important to follow recommended screening guidelines (many which can be found on the CDC and Hadassah websites). Being informed and sharing any concerns you may have with your doctor can help detect certain cancers early. Women of Ashkenazi Jewish descent have at Sephardic Jewish populations as well. The importance of continued breast cancer research cannot be emphasized enough and, together with education, awareness and advocacy, there are many ways you—and the women you know —can live longer, healthier lives. And one last important message: at the onset of the COVID-19 pandemic, elective medical procedures, including cancer screening, were largely put on hold to prioritize urgent needs and reduce the risk of the spread of COVID-19 in healthcare settings. One consequence of this has least a 10 times greater prevalence of BRCA1 gene mutations. WHAT IS BREAST CANCER? Breast cancer is a disease in which certain cells in the breast become abnormal and multiply uncontrollably to form a tumor. been a substantial decline in cancer screening. If you are due for a mammography, or other cancer screening, contact your health care provider to ensure their use of appropriate safety protocols and don’t delay your regular cancer screenings. For information about breast cancer research, IS IT HEREDITARY? Most cases of breast cancer are not caused by inherited check out hadassah.org/health-medicine-in-us/breastcancer-awareness.html genetic factors and do not cluster in families. What is hereditary, however, is the way that cancer risk is inherited, dependent on the gene involved.

HOW DO I KNOW IF I CARRY THE GENE?

Know your family history and ask your doctor about your risk of genetic counseling and if testing is right for you. The Center for Disease Control & Prevention (CDC) recommends that women with specific patterns of breast, ovarian, tubal, or peritoneal cancer in their family history consider genetic counseling and testing for BRCA gene mutations.