What is high risk breast cancer?
One out of eight women will be diagnosed with breast cancer, but the risk is not the same for all women. Medical oncologist Joe Stephenson, MD, explains how women who are at high-risk for breast cancer can reduce their risk.
Amanda Wilde (Host): You’ve probably heard the statistic that one out of eight women is diagnosed with breast cancer, but the risk is not the same for all women. Today, we’ll sort out the facts of high-risk breast cancer and risk reduction with Dr. Joe Stephenson, medical oncologist and the medical director of the Center for Integrative Oncology and Survivorship at Prisma Health.
This is Flourish, a podcast brought to you by Prisma Health. I’m Amanda Wilde. Dr. Stephenson, thank you so much for being here today.
Dr. Joe Stephenson: Well, thank you, Amanda. I appreciate the opportunity to speak.
Amanda Wilde (Host): What exactly is the definition of high-risk breast cancer?
Dr. Joe Stephenson: High risk breast cancer is a term that’s used for patients who have certain criteria, both in their family history, their lifestyle, interactions and some of the radiographic findings. And so it’s a compilation of all of that, that together can put someone in a higher risk category that may require intervention. And so that the key is to try to identify who is at high risk and how do we define high risk as you mentioned. So we’ve got some criteria for that, that we use.
Amanda Wilde (Host): How do doctors assess a patient’s breast cancer risk?
Dr. Joe Stephenson: Well, we haven’t done very well historically. And so the statistic that you mentioned at the beginning of the podcast of one in eight has not changed in my 24 years of practice. And I’m a medical oncologist, with 85% of my practice is mainly breast. And so that number has not changed at all. And as a matter of fact, if you look at it’s going closer to one to seven than it is one to nine. And that’s despite having information at our disposal in terms of how to go about identifying these patients, but it’s not been necessarily well-adopted within the front line of defense of primary care with OB/GYN, internal medicine and family practice in particular. They have so many things that they’re juggling, that sometimes this gets sort of lost in the shuffle. And so, we’ve set up this clinic to try to lean into that a little bit and come alongside our colleagues in terms of trying to make those patients identifiable and then begin to have some sort of interaction to hopefully change that one to eight number to a much greater number.
Amanda Wilde (Host): How does someone get connected with your clinic?
Dr. Joe Stephenson: The funnel that we have is through mammography. And so everyone knows about mammograms and how important they are for early detection and, obviously in treating breast cancer. The earlier it’s detected, in general, the better the outcome. And so mammography has been a staple for screening and early detection of breast cancer. And so we have changed things at our institution in the last four or five months to try to tie our risk stratification with the mammography report, in a way that then we do the identification at the time that they receive their mammogram. And if they have certain criteria that are met, then there’s a note that goes back to primary physicians that if they would like, they can have a consultation with the breast cancer prevention, our risk reduction clinic. in addition to our doing it, even within their own scope of practice, depending on their level of comfort and time.
Amanda Wilde (Host): So with this early detection, what might you see in that mammogram that might be concerning that gives you that heads up?
Dr. Joe Stephenson: So in terms of just the radiographic findings, the one that is most notable is high density breast. So patients who have very dense breast tissue, those patients are notified and that’s now a state law, that those patients have to be notified about their density of their breast. So that’s one risk factor for developing breast cancer. And that may then turn into a broader discussion on certain elements that we have that help us further define their risk. And so what I mean by that is essentially there are certain modeling, if you will, that’s been done over many years now, specifically the Gail score. And the Gail score is asking patients a certain number of questions, very easy to ask and most patients know the answer in terms of their prior history of biopsies. Had they ever had a biopsy of the breast before? Are they still in the menstrual period? When was their first menstrual period? When was their last menstrual period? Do they have a family history of breast cancer? These sorts of questions then calculate in a statistical modeling that then can give us a threshold number. And if that threshold number is exceeded, then that patient should be considered for referral for how can we intervene to reduce the risk of developing breast cancer so that it’s never detected on a mammogram.
And then, a second model, if you will, is something called the IBIS or Tyrer-Cuzick, which is a little more complex, but it is a series of questions that are asked that then if a threshold is met, those patients would be, available to have an MRI of their breast as a part of their overall management. And so, it’s a compilation of the Gail score, more for intervention in regards to some things that we do here, behavioral intervention. Do you drink alcohol? If so, how much? Maybe that’s a risk modifier that you can control. Is there a role for medicinal intervention, like tamoxifen or aromatase inhibitor? These are medications that we give, and I can go into that in more detail, if you like. Is there a need for dietary changes, exercise programs and these sorts of things? It’s all of that together that we think, when we lean into it, we can change the course of their risk and reduce it. And the risk reduction is significant. It can be as much as 50%. So you’re talking about a 50% reduction in the risk of developing breast cancer in patients who receive intervention if they’re identified.
Amanda Wilde (Host): How do we know that?
Dr. Joe Stephenson: We know that through two studies that were complete in the mid-’90s, published around 1998, maybe 2000, 2001. And they were the P-1 study and the P-2 study. And these are two very large studies where patients were randomized to receive a pill called tamoxifen, which has been used to treat breast cancer versus a placebo. And that medicinal intervention in patients who met and exceeded the Gail score, those patients then were able to be randomized to either tamoxifen or placebo for five years. And now, fast forward, 20 years later, and you see a sustained 50% reduction in those patients who receive tamoxifen in terms of their risk of developing breast cancer. And then, there was a second study that basically validated that using a different medication in comparison.
But all of that backs up to when we first were treating patients who had breast cancer and those patients were treated with tamoxifen in the ’60s and ’70s. And what you noticed was that the patients who received tamoxifen back when it was in what we call adjuvant setting after surgery, no evidence of disease. And you gave them this pill to try to reduce the risk of that breast cancer coming back. And what you notice was not only did it reduce the risk of those patients not having a relapse of that primary breast cancer, but also the contralateral breast, those patients did not develop a second primary in the opposite breast. And that was about a 50% reduction in the risk of patients on tamoxifen, did not go on to develop a second primary in the opposite breast. And so it was an observation that then was placed into a proactive, if you will, lean forward into patients who were at risk, but had not developed breast cancer. Could we change that outcome? And not unlike a lot of things that we do, but in medicine, this one actually followed exactly what we had hoped it would, which was the 50% reduction in the observation, turned out to be exactly the same in the prospective randomized study for prevention or risk reduction.
And the corollary I like to use is cholesterol medication. I mean, a lot of people take cholesterol medications to reduce the risk of developing heart disease or coronary artery event. And yet that risk is around 9% or 10% reduction, but everyone is on a cholesterol medication, you know. This is about a 50% reduction in risk of developing breast cancer. And so if we can get that into the vernacular and make it more adopted across the country, then, hopefully it’ll change that mindset. But I think that because tomoxifen originated from a cancer treatment place that is kind of thought of in a different light in terms of using it in a preventive way.
Amanda Wilde (Host): Yeah, that makes sense. But once you change the mindset, it sounds like you feel like you can change that statistic as well, the one in eight statistic.
Dr. Joe Stephenson: I use the analogy with my children. So there’s two analogies with my kids, right? So one is, I’m 58 years old, okay? So I didn’t start out wearing a seatbelt. we just didn’t do it. But now, my kids, I mean, when they’ve gotten in the car all the way through life, I mean, it’s just an automatic thing for them. They just put that seatbelt on. They always have to remind dad, “Hey dad, don’t forget your seatbelt.” And it takes time to change that behavior, but eventually you do. And the other one is smoking. When I was growing up, it was kind of an edgy thing to do. But didn’t have quite the weight of long-term complications that it has now. And so my kids, as they’ve come along, that’s just something that they don’t want to be around, deal with at all. It’s just not even contemplated, We can change that culture, change that sort of thinking. ultimately, I think it’ll have a positive outcome and we can get that number from one to eight to maybe one to 16, one to 20, who knows.
Amanda Wilde (Host): Now, there’s one thing we haven’t touched on that you always hear hand in hand with high risk, which is genetics. And there have been a lot of advances in determining genetics and their role in breast cancer. When is it time to get genetic testing and, who’s at the highest genetic risk of breast cancer? I suppose if you have a family history, you look there. But some people don’t even have that and have genetic risk.
Dr. Joe Stephenson: Absolutely. The genetics piece is a part of that risk assessment. And so when patients are being analyzed for should they have some sort of intervention medicinal, behavioral, that sort of thing, one of the aspects that’s really foundational is a genetic piece to that. And so that piece continues to evolve and broaden. It used to be the BRCA1 and BRCA2 genes. And so that’s what we tested for. And everyone kind of knows that, the Angelina Jolie story in Time Magazine and that sort of thing, and it was really the first gene linked to familial breast cancer. And so it got a lot of headline and rightly so. But it’s really a small part, that particular BRCA1 and BRCA2. However, now, there’s CHEK2 and there’s PALB2 and there’s ATM. And these other genes that we did not know about, that we do now and how that then impacts risk of breast cancer, but also other cancers. And so, if your first-degree relative has metastatic prostate, then you are eligible to be checked for breast cancer mutation. Or if you have someone who has pancreatic or ovarian, these then qualify you if you will, to be eligible to be evaluated for a genetic mutation that may then predispose you to breast cancer. And so then, if that’s the case, then how if we can identify, then we can intervene to prevent.
Amanda Wilde (Host): Now, we were talking about how to lower your risk to begin with, lifestyle changes, there might be medicine. Is treatment itself different if you are a high risk individual?
Dr. Joe Stephenson: Yes. So a couple of things, one is the dose of like tamoxifen that we use is a lower dose than that which is used in treating breast cancer. And so in 2018, Dr. DeCensi published an article that basically the same study design as that which was done in the mind-’90s, but at a much lower dose of tamoxifen. And those curves have basically been exactly the same, but the dose is lower and the duration is lower. And so, the medicine that’s used in my clinic is now half of what we used in the, original prevention studies because, in the original prevention studies, we used the dose for which we had seen in the observation for treating active breast cancer. So 20 milligrams was used to treat breast cancer and still is. And so when the original P-1 study was designed, it was designed using 20 milligrams. And so Dr. DeCensi has ordered for years, and it now has confirmed that that’s too much in a preventive strategy. But the treatment is vastly different.
And what also is different is the surgery aspect of it. So, one of the arguments that some have made, you know, when I see patients is, well, if I keep up with my screening, And I get breast cancer, then all probability it’s going to be an early stage breast cancer. It’ll be estrogen sensitive. And I can just get my tamoxifen or aromatase inhibitor at that point. But some believe that, recognize that, number one, is your dose is going to be priced as much and you’re going to have to undergo a surgical procedure and you may have to have some radiation and get into some of these other aspects of treatment so that you can avoid that in a preventive strategy.
Amanda Wilde (Host): Can you talk a little bit about risk reduction versus prevention? And based on your 24 years in the field, do you believe we will ever find a cure for breast cancer?
Dr. Joe Stephenson: Now, prevention in my mind is a very, very strong word. That means that I can intervene and I can prevent a particular disease, much like cure is a very, very strong word. If an oncologist says that you’re cured of your disease, that means you never have to think about that disease again. And so I’m very judicious with the language that we use in how we talk to our patients.
When I first meet a patient after they’ve come to the clinic, the first thing I say is “This is the breast cancer prevention clinic. And you’re here today to discuss the roles of interventions that we can use to reduce the risk of you developing breast cancer.” It really the should be called the risk reduction clinic. But that’s the difference between it’s really a reduction in risk versus an actual prevention of a disease.
Now, the second question was, “Do you think we’ll ever get a cure for breast cancer?” I don’t know. I kind of doubt it. There are many flavors of breast cancer, and I don’t know that we’ll ever get to a point where we can prevent all breast cancer or eradicate it. But I certainly think we can drop it significantly in terms of incidence rate in the population. And in addition to that, really there are certain variations of breast cancer that probably will always be with us, but that would be a very small minority of the majority of breast cancer that we see today, in terms of like 15% to 20% of all breast cancer, is probably going to be with us indefinitely. But the other 80% to 85%, I think is something that we can really change that number significant.
Amanda Wilde (Host): And that is very hopeful, looking toward that, changing that number. This is such helpful information. Dr. Stephenson, thanks for sharing your time and expertise today. Also, I want to say thank you for all the work you do to support breast health.
Dr. Joe Stephenson: Well, thank you. And I appreciate the opportunity to speak with you today.
Amanda Wilde (Host): For more information and podcasts on other topics, visit PrismaHealth.org/Flourish. This has been Flourish, a podcast brought to you by Prisma Health. I’m Amanda Wilde. Be well.Read More
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