An evening of breast health, education and awareness to celebrate the launch of the High Risk Breast Program, including a customized risk assessment tool and 3D Automated Breast Ultrasound. A panel of experts joined to discuss advancements in breast health and cancer detection and prevention. In addition, high-risk patients shared their journeys. Watch the video recording
of the panel discussion.
Many event attendees submitted questions for the panel discussion, however there were more questions than time. Dedicated to furthering the conversation and increasing awareness, the expert panel took time to answer the remaining questions below.
Q. How did your facility decide upon the ABUS and why?
A. We have long known that increased breast density can decrease the sensitivity of mammography. We have been interested in ABUS for a few years, and after FDA approval, we decided to implement it.
Q. What can you share regarding Breast Thermography? What are the chances of having it approved by the FDA?
A. We don't believe the technology at this moment has been proven, and the likelihood for FDA approval appears to be low.
Q. How do breast implants affect this whole scenario?
A. ABUS is not offered at the moment for patients with implants.
Q. What is chest wall radiation?
A. Chest wall radiation is for lung or breast cancer treatment. Regular chest x-ray is considered very low radiation.
Q. Can you define "high-density breast" and how does a woman find out if this applies to her (radiologist, primary care physician?)
A. The radiologist is the best physician to determine breast density. They have criteria that they follow to determine the density of a breast. The patient will be informed of their breast density as part of their mammogram report letter sent to their home.
Q. The results/diagnosis ultimately depends on the interpretation of the mammogram or ultrasound. Is the image evaluated by two separate radiologists so that nothing is missed?
A. Ideally, both the mammogram and ABUS should be read by the same radiologist, as it is at the Breast Health Center at El Camino Hospital. Results are also interpreted by a computer algorithm to ensure accuracy.
Q. What other testing is available for women with dense breasts besides regular mammogram? Which medical facility has these tests available?
A. ABUS is the only other screening modality. Breast MRI is reserved for very high risk patients. Currently, El Camino Hospital is the only hospital in Northern California to offer the ABUS.
Q. Is the ABUS a more affordable alternative to MRI screening?
A. Yes, ABUS is a more affordable option to MRI screening.
Q. Do you still recommend that a dense breast patient get a mammogram in addition to the 3-D ultrasound? I am told annually "your breasts are too dense, we didn't find anything. See you next year."
A. The 3-D ultrasound is not a replacement for screening mammograms in women with dense breasts. There are early signs of breast cancer that may be seen on mammograms even in dense tissue that are not visualized by ultrasound.
Q. Do breast cancers "disappear" without medical treatment? Does dense breast tissue develop over time?
A. Breast cancer does not go away without appropriate treatment. In many women breasts become less dense after menopause.
Q. Besides the information of having dense tissue, is the patient informed about the added risk?
A. The new law in California has language indicating that a woman must be informed that she has an increased risk of breast cancer.
Q. Do you know about first warning symptoms based on temperature change in the breast over time?
A. Thermography of the breast can identify women who may be at increased risk of developing breast cancer, but it is generally not a good screening test to identify specific breast cancers.
Q. If you are told you have dense breasts, what do you look for in a self-breast exam? Lumps? Anything else?
A. Lumps are the most important thing, but also skin changes, nipple discharge, or persistent pain.
Q. Should women with dense breasts avoid HRTs?
A. The decision to use HRT is a complex one that requires carefully weighing all of the risks and benefits for an individual person. Though the risk of breast cancer goes up with both dense breasts and with HRT, other life style factors like exercise, avoiding alcohol, having children early and nursing for a long time, may mitigate those risks. Furthermore, use of a low dose of HRT for a short period of time may only add a small risk which may be worthwhile depending on how severely menopausal symptoms are affecting a patient's quality of life. Adequate screening would be important for women with dense breasts who elect to use HRT.
Q. If I have a family history of breast cancer, dense breasts and had a baseline exam (mammogram and ultrasound) one year ago, how often should I be having exams thereafter? (Questioner's age is 30)
A. You would benefit from using our new risk app to estimate your risk of developing breast cancer. This tool would help quantify your risk based on family history and would help your physician in planning the appropriate surveillance.
Q. At what age should my 21-year-old daughter have her first screening test for breast cancer? I had breast cancer at age 47, my mother at age 33 and 48. My cancer was not detected on a mammogram due to dense breasts. What should be the order of "events" for her to manage her risk?
A. Your family history suggests the possibility of hereditary breast cancer, and I would recommend discussing this with your oncologist, surgeon or a genetic counselor. If you carry the BRCA mutation this would not only affect you but would help in decisions about surveillance in your daughter.
Q. If a BRCA comes back positive, how do you know how drastic a measure needs to be done?
A. People who are known or suspected to have a BRCA1 or BRCA2 gene change should have more regular check-ups and screening for breast and ovarian cancer. These options may have a mix of potential benefits and risks. It is important for BRCA positive patients to discuss all of the options with their physicians because where a bilateral prophylactic mastectomy might make sense for one woman, for another, doing regular breast screening might be the right choice. It is also important to stay in touch with your physician as the guidelines and recommendations could change overtime.
Medical guidelines for BRCA positive women recommend the following:
- Monthly breast self-exams, beginning at age 18
- Breast exams performed by a doctor or nurse every 6-12 months, beginning at age 25
- Alternating Mammograms and Breast MRI every 6 months, beginning between the ages of 25 to 30
- Pelvic exams every 6-12 months, beginning between the ages of 25 to 30
- Transvaginal ultrasounds with color Doppler every 6 months, beginning between the ages of 25 to 30
- CA-125 blood test every 6 months, beginning between the ages of 25 to 30. (This screening may be recommended to start even earlier depending on the family history)
Screening options may change over time as new technologies are developed and more is learned about hereditary cancer. It is important to talk with your doctor about appropriate screening test for you based on your history.
Since screening methods do not prevent cancer, people who are known or highly suspected to have a BRCA1 or BRCA2 gene change may also consider other prevention measures:
- Mastectomy: Removing breast tissue before cancer develops (prophylactically) can reduce the risk of breast cancer by 90 percent.
- Salpingo Oophorectomy: Removing ovaries and fallopian tubes reduces risk of ovarian cancer by 90 percent and can reduce the risk of breast cancer by 50 percent.
- Birth control pills: may reduce risk for ovarian cancer
- Chemoprevention: Taking medications such as tamoxifen, raloxifene, and aromatase inhibitors to lower the risks of getting cancer<./li>
- Lifestyle changes: maintaining a healthy weight, exercising, lowering alcohol consumption, and not smoking.
Q. Do women with dense breasts have a higher risk for other types of cancer in addition to breast cancer?
A. We don't believe any studies have been done specifically looking at that question.
Q. Given that I had breast cancer at age 47, my mother at age 33 and 48, is it still advised to do BRCA testing? I've been told that my daughter is already at high risk, so why do BRCA testing?
A. This question raises the ever important issue of "Who is the right person to test?" Ideally, BRCA testing should begin with a family member who is most likely to have a cancer-related genetic mutation--this generally means someone who has already been diagnosed with breast or ovarian cancer. Testing someone who has had cancer presents the best chance of identifying a genetic mutation. If a mutation is found in that family member, it is considered to be the explanation for your family's hereditary pattern of cancer. As a result, other family members can have single site testing for the familial mutation. Single site testing is less expensive than full testing (called sequencing), since it looks for just a one mutation. And if the results of single site testing are negative we can say with certainty that someone does not carry the mutation, there are no ambiguous results. So, in this patient's case, it makes most sense for her to undergo BRCA testing first (because she has a history of breast cancer at a young age). If it is negative it would seem that BRCA is not the reason for the family's hereditary pattern of cancer and the daughter would still be at increased risk and should consider additional breast cancer screening and risk reduction strategies. If the patient's BRCA results are positive, a mutation is identified, the daughter would have a 50 percent chance of having inherited it and a 50 percent chance of having NOT inherited it. If she is tested and found not to carry the mutation, her risk for breast cancer is about the same as an average woman.
Q. If a woman has received HRT, is the breast cancer risk greater for estrogen related cancer or any/all types of breast cancer?
A. The increased risk is specific for estrogen receptor positive cancers.
Q. Does one have to have gene test to have ultrasound if determined to be a high-risk patient?
A. You do not have to have a gene test to have the ultrasound. Genetic testing is typically done for those with a family history of cancer(s). The Automated Breast Ultra Sound (ABUS) is a screening tool, when used along with an annual mammogram, greatly enhances your doctors' ability to detect cancer. When breast tissue appears dense on a mammogram, small cancers are difficult to see. In addition, dense breasts have more glandular and connective tissue, where most cancers may take hold. Dense breasts alone are associated with a higher risk of breast cancer, four to six times that of the normal population. This new technology creates a 3-D view of each breast, making cancers easier to see and without increasing your exposure to unnecessary radiation.
Q. Why wouldn't a doctor go ahead and tell their patient they have dense breasts without needing legislation to do this?
A. Some doctors have been providing this information, but it has not been consistent. Now, with the legislation, all doctors will be required to provide this information to their patients.
Q. Will insurance cover ABUS testing now that the legislation will begin?
A. We believe many local carriers will cover ABUS testing; our top insurers have told us it will be covered.
Q. If ultrasound is not covered by Medicare, how much does it cost on a private pay basis?
A. The private pay cost will be $400, which includes the facility and physician fees.Q. I was advised to have the BRCA test based on my family history. The cost was high and my insurance company would not cover it. Based on health insurance industry, do you see more of them covering this cost in the future?
A. Unfortunately, the cost of genetic testing is high. However, as technology advances, we do see the cost decreasing. The health insurance industry as a whole is difficult to generalize with regards to coverage for BRCA testing as each carrier has slightly different personal and family history requirements before testing will be approved/covered. Some carriers have lower thresholds for when they will do testing. Insurance companies also update these policies regularly. There are several things someone in this position can try.
- You can work with your physician and/or genetic counselor to appeal the insurance company's decision. If you attempted to get testing done a few years ago it is possible that your insurance company's policy has changed since then.
- If you ever change insurance try again for the testing as each plan has a slightly different policy.
- Work with your physician and/or genetic counselor to determine if there is someone else in the family who it may be better to test (see above answer regarding testing the right person). If you have a known mutation in the family almost all insurance companies will cover that testing and if they don't the out of pocket cost is not as exorbitant.
- You can continue to work with your physician to manage your risk for breast and other cancer based on your family and personal history and once the price of BRCA testing goes down, pursue the testing then.
General Women's Health
Some primary care physicians are more experienced and comfortable in the area of women's health than others. Likewise, some OB/GYNs are more experienced and comfortable with basic primary care issues than others. Whether a single physician can meet all the health needs of an individual woman will depend on the woman's age, risk factors, and health status.
Q. Why do some women develop dense breasts and other women don't?
A. Breast density may be related to family history much as height or body shape is related to family history. It is also influenced by environmental factors. For example, use of estrogen hormones can increase breast density.
Q. If you feel something hard under your breast--what should I have done, other than mammogram? Breast is sore in that area and when wearing a bra, it hurts more.
A. You should see your physician for a careful breast exam. He or she will help guide you as to what type of imaging should be done. If a lump persists, it may require a biopsy even if a mammogram is negative.
Q. What are lifestyle changes?
A. Lifestyle changes are those things that we can do for ourselves to lower our risk of breast cancer. We have the ability to:
- Stop smoking (cigarette smoking has been linked to almost every type of cancer)
- Limit alcohol (even moderate drinking of one drink per day increases your risk)
- Exercise (225 minutes per week lowers estrogen levels and your risk for breast cancer)
- Watch your fat intake (weight gain and obesity as adults raise your risk)
Family history of cancer, early menstruation and late menopause are factors that we cannot change. Let's empower each other to change the things we can!