As we recognize Breast Cancer Awareness month in October, host Dr. Jonathan Fialkow welcomes Jane Mendez, M.D., chief of breast surgery at Miami Cancer Institute to talk about early detection and a unique new approach to prevention.
Miami Cancer Institute's Breast Prevention Clinic is aimed at identifying women with an increased predisposition to breast cancer and providing them with specially tailored prevention plans so that instead of becoming a breast cancer survivor, they can remain 'previvors' who do not ever develop the disease.
Baptist Health South Florida is offering special pricing on mammograms during October for patients with no insurance Schedule your mammogram at BaptistHealth.net/BreastHealth
As we recognize Breast Cancer Awareness month in October, host Dr. Jonathan Fialkow welcomes Jane Mendez, M.D., chief of breast surgery at Miami Cancer Institute to talk about early detection and a unique new approach to prevention.
Miami Cancer Institute's Breast Prevention Clinic is aimed at identifying women with an increased predisposition to breast cancer and providing them with specially tailored prevention plans so that instead of becoming a breast cancer survivor, they can remain 'previvors' who do not ever develop the disease.
Baptist Health South Florida is offering special pricing on mammograms during October for patients with no insurance Schedule your mammogram at BaptistHealth.net/BreastHealth
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At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist HealthTalk Podcast, where our respected experts bring you timely practical health and wellness information to improve your family's quality of life.
Dr. Jonathan Fialkow:
Hello, Baptist Health Talk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a practicing Preventative Cardiologist and Lipidologist at the Miami Cardiac and Vascular Institute in Baptist Health, South Florida, as well as Chief Population Health Officer at Baptist Health. Breast cancer is the second leading cause of cancer deaths among women, it's expected to take the lives of more than 42,000 women in the US this year alone. Lifestyle changes, screening, early diagnosis, have all been emphasized, but now physicians are also able to identify those at high risk of developing breast cancer and initiate early measures designed to prevent breast cancer altogether. Here to talk about breast cancer and the latest methods being used to prevent and fight it is Dr. Jane Mendez, Chief of Breast Surgery at Miami Cancer Institute. Welcome to the podcast, Jane.
Dr. Jane Mendez:
Thank you, Jonathan. It is my pleasure to be here.
Dr. Jonathan Fialkow:
So, there's a couple of topics I want to get to specifically regarding lifestyle and prevention, and maybe some of the myths regarding family history or lack of family history, but let's start out by talking about what would be risk factors that would make a woman more likely to get breast cancer, be at risk for breast cancer? What are the things we've identified that we want to pay attention to?
Dr. Jane Mendez:
Yeah. So, the two main risk factors for breast cancer are being a woman and getting older. So, even though we'd like to forget about breast cancer, the older we get, the more concerned we need to be about it. So those are your two main risk factors, to that you can add other factors such as family history as well as some environmental factors, some hormonal factors, and some of those are modifiable and some are not. Of those that are [modifiable 00:01:55] as you alluded to, we have dietary factors, sedentary lifestyle, as well as chronic use of hormonal replacement therapy, exposure to radiation. So, it's multifactorial and that's what is so challenging to identify for patients, what risk factors apply to them so that we can try to prevent breast cancer.
Dr. Jonathan Fialkow:
So, let's start with someone who might not have an identifiable risk factor, other than, as you say, being a woman and getting older. What would the average person be told to do regarding screenings, mammograms, et cetera? Let's start with the low risk person.
Dr. Jane Mendez:
Yeah. So, for an average woman with no significant risk factors, the recommendation is for them to have a baseline mammography, anytime done between age 30 to 40, and then if provided, there are no abnormalities, then have an annual mammography starting at age 40. And we know that the denser the breast tissue, the more important it is to complement that with a breast ultrasound, because we know that the breast density decreases the sensitivity of the mammogram.
Dr. Jonathan Fialkow:
So, quite frequently, and I even see this in my cardiology practice, if a woman has a mammogram and then they're told, "Oh, you need an ultrasound." That's not necessarily something that immediately they need to be afraid of, or it's a sign of a higher risk situation, it's for more information?
Dr. Jane Mendez:
You're absolutely right, Johnathan. Absolutely. We do it because they help us identify different things, and the gold standard for breast cancer screening is certainly the mammogram, but oftentimes we need to get the ultrasound as well, so we can complement the mammographic findings. For example, if they see something that appears to be a mass, is it cystic or is it solid, and is there anything else associated with the mammographic findings? So, yes, the woman shouldn't be scared, it's just part of doing a more thorough evaluation.
Dr. Jonathan Fialkow:
If a woman has a mammogram and it requires an ultrasound because of densities, can they expect that would be ... Again, every time they have a mammogram, they could expect that would be something that's necessary?
Dr. Jane Mendez:
The radiologists are very good in their recommendations nowadays, they will clarify that and specify that in their reports. And also we have better ways now, so that we can assess the breast density and we can then make those recommendations even from their report. But you're right, some women will need to have both mammogram and ultrasound each time they come for their screening.
Dr. Jonathan Fialkow:
Is there a benefit for a woman having their serial mammograms at the same place or the same centers, is there are benefit in comparing and whatnot when we look at mammograms?
Dr. Jane Mendez:
Absolutely. Absolutely. We know that the sensitivity or specificity of mammogram and ultrasound, meaning how well is this going to help us find out what's going on? Is improved by comparing to older films. So, we can see if something is new, has something changed, has it's been there all along? So, being able to compare to older images is really helpful in trying to better understand what is happening and we can make appropriate recommendations. So, having everything done in one place where they have all your images certainly provides an advantage.
Dr. Jonathan Fialkow:
You had mentioned, again, some of the non-modifiable risk factors, things you can't change, one is family history, which speaks to obviously genetics. Can you speak a little bit to whether the components we would look at as, yes, this is a family history, are there circumstances where women may think they have a family history, that would place them at risk, but it's not true? So, can you unpack that a bit?
Dr. Jane Mendez:
Absolutely. So, turns out, and I just want to make it clear that only 10% of breast cancers occur in women who have a family history of breast cancer. 5% of women have an identifiable mutation or something in the genetic makeup that really predisposes them to their breast cancer. Well, the vast majority of cancers occur what is called sporadically, meaning that nobody in their family has it, and they are the first ones. So, we focus on those that are either the 10% or 5%. What we do is at the time of the initial consultation, or as part of our follow-up, we ask very specific questions about yes, do you have a family history of breast cancer? Who was the relative? Is very important. We're more interested in first degree relatives. So, is this your mother, your sister? Then when it gets farther and farther in terms of, is it your grandmother, is that your first cousin, your third cousin? That helps us to further stratify what might be the genetic risk associated with that family history, so we can put it in perspective.
Dr. Jane Mendez:
Also, we would want to know about any male breast cancer in the family or any other cancers in the family. So, oftentimes we ask about ovarian cancer because that's related to the BRCA genes, which are the most prevalent genes associated with breast cancer, but like that we also ask about colon cancer, prostate cancer, pancreas, stomach cancer, because we know that certain genetic mutations that those other cancers also associated with the gene. So, it helps us to stratify the risk, so we can determine who might benefit from a genetic consultation and actual genetic testing.
Dr. Jonathan Fialkow:
So, first degree relative, mother, sister, most significant. When you start getting to other degrees, outlying, less so, but still part of it.
Dr. Jane Mendez:
Yes.
Dr. Jonathan Fialkow:
How about age? For example, I can tell you in the cardiovascular world, "I have a family history of heart disease," "What happened?" "My 90 year old grandfather had a heart attack." And we could tell them, "Yeah, that's not putting you at too much risk." Is there an age component in the family history as well?
Dr. Jane Mendez:
Yeah. So, we know that it's also important to find out when that relative was diagnosed with breast cancer, if it was in the premenopausal or postmenopausal age, because as I already alluded to earlier, age alone is a risk factor for breast cancer. So, if the relative was diagnosed pre-menopausal, meaning at a younger age, that will be considered to be at higher risk than if developed, it was diagnosed at a postmenopausal age. Another component that is also relevant is ethnicity. We know that certain ethnic groups, such as Ashkenazi Jewish population has higher prevalence of some of these genetic mutations.
Dr. Jane Mendez:
So, when we ask our patients about their family history, it's very important to identify these other potential ethnic groups so that we can make the appropriate referrals. And something interesting, it's even if you're not Ashkenazi Jewish, we know that because of the mixing of genetic makeup, especially with migration patterns around the world, we also have Sephardic Jews that have a Spanish ascendance and also certain African groups from West Africa who came as slaves in the Americas. So, it's really interesting as part of the migration patterns to see some of the other subtleties. But when we do the families, the question, we try to identify any of these potential factors, so we can really stratify the risk and make the appropriate interventions for the patient.
Dr. Jonathan Fialkow:
So, can we talk a little bit ... Again, that is fascinating. I'm sure as much as we've learned, it's going to be interesting to see what we learn more about these patterns, and especially as we starting getting into these genetic testing and such. So, there's a recommendation for what we will, the usual risk woman for the serial mammograms. If someone is high risk, they have that first degree family relative. They have, again, an Ashkenazi Jewish heritage. What would be the next step? What would they do or what would we do differently if they come to us for an evaluation?
Dr. Jane Mendez:
Yes. So, luckily, Jonathan, now we have models to help us calculate. One might be the woman's risk for developing breast cancer in the future, there are multiple models, but the one that is most commonly used is the Tyrer-Cuzick Eighth Edition model, where it takes a lot of these factors in consideration. And it gives us a percentage probability of that woman developing breast cancer within 10 years and during their lifetime. So, that is something that we do and if somebody indeed has such high risk, usually greater than 20%, in addition to the increased surveillance, we will increase and follow that patient with a breast MRI. Because we know that the breast MRI is not a screening test, but it's certainly a good tool to help us further evaluate those women who are at increased risk, so that since it has much greater sensitivity, as compared to mammogram and ultrasound for this specific group, it really provides an advantage.
Dr. Jonathan Fialkow:
So, mammograms obviously don't prevent breast cancer, they detect breast cancer early ostensibly for a better cure rate. Can you speak a little bit towards the data regarding mammogram [crosstalk 00:11:21]?
Dr. Jane Mendez:
You're right. So, nowadays in 2020, when we have an early stage breast cancer, we can quote that we have a 98.5% 10 year survival, with the [inaudible 00:11:32] tool, the advances, the technology, the awareness that has happened over the past 40 years, certainly we're in a much better place than we were before. And there is no doubt that the earlier we can detect that breast cancer, the better the outcome, because certainly we have a lot of options that we can offer to our patients. So, early detection is key for improved outcomes and improved survival.
Dr. Jonathan Fialkow:
Again, this is wonderful information. Can we talk a little bit about the Breast Cancer Prevention Clinic at the Miami Cancer Institute? Obviously, a lot of this is done through there, but the prevention is the new concept as well. Again, not detecting and helping the women survive. What's the unique approach to a woman through the Breast Cancer Prevention Clinic?
Dr. Jane Mendez:
See, we know it is so important to try to prevent, so in this clinic, what we're trying to do is identify a very specific patient population whom are maybe at increased risk of breast cancer, let it be because of their family history. Let it be because they have certain pathologic conditions to increase their risk or because they had previous radiation or because they have been identified to have some of these high risk mutations. So, in this clinic, we will tailor a prevention plan for these patients, including not only if they need to have genetic consultation, set that up, or certainly nutrition as well as exercise plan, so that they can try to monitor all the different components that are critical in order to maintain a healthy lifestyle.
Dr. Jane Mendez:
So, the approach in this case, trying to individualize that plan for the given patient, so that instead of becoming a breast cancer survivor, they can continue as a previvor, meaning even though you have the increased predisposition to breast cancer, we keep it at that. And the word previvor is a very interesting concept, which means, okay, we know you are at increased risk, but what can we do to try to keep you in that state, where you do have the predisposition, where you do not develop the disease. So, that's a great concept.
Dr. Jonathan Fialkow:
Do you find a lot of the women who come to the Breast Cancer Prevention Clinic are self-referred or are they recommended by their gynecologist or primary care doctor?
Dr. Jane Mendez:
It's a combination of different referrals. So, I'm happy to see that because I think the awareness needs to be out there. So, I'm very happy when you see that the primary care physician or the gynecologist ... And again, because women are a lot more aware of the potential interventions, they are calling and making the appointments themselves. So, it's good to see that we can be proactive about breast cancer.
Dr. Jonathan Fialkow:
There's also a Benign Breast Cancer Clinic. Could you speak a little bit about the benefit of that? That seems to be a very innovative approach as well.
Dr. Jane Mendez:
Yes. Yes. So, certainly we want to really cater to all the patients depending on their needs, and certainly we want to improve the access for all the breast cancer patients so that we can expediently provide their care. So, what we do in the Benign Breast Clinic is all the non-cancerous conditions are addressed in that clinic, so that we can focus on their needs and ... Sorry, they interrupted me on the phone.
Dr. Jonathan Fialkow:
It is a real world podcast.
Dr. Jane Mendez:
Yes. Yes. So, this clinic then focuses on these women. We make sure that in their clinical exam, everything is normal as well as everything is normal in their imaging. If it's something beyond what was advertised as benign, then we make sure that it gets escalated to the appropriate clinic, let it be the Breast Cancer Prevention Clinic or the surgeon to exclude a potential breast cancer. But the clinic has helped those ease the access to the breast cancers and at the same time, access to the women who might be having breast pain or might be having cysts or other benign conditions that need to be reassured by an expert so that they can move on, and with the proper follow-up when needed.
Dr. Jonathan Fialkow:
Great. So, in the Cancer Institute they have a whole division or a whole program around benign findings, is very unique as well, but certainly appropriate and well received. Here's our chance to give a little public service discussion. So, at the very beginning of the podcast, you impressed upon our listeners the importance of serial mammograms. COVID we're seeing a decrease in women getting their mammograms, whether it's not wanting to be exposed to going out of their house for the imaging stuff. Can you speak to how important it is to maintain your screening, your routine screening processes?
Dr. Jane Mendez:
Yes. Very important to maintain the screening because as we alluded to already, early detection is key in order to have better outcomes. And in addition to screening, it's also important to know your family history and to know your body. So, I cannot underscore the importance also of breast self-exam and knowing what's normal to you and your body, because certainly if you don't know what's normal for yourself, how can you then seek medical attention, if you don't even know what's normal for you? And I can assure the patients that the imaging centers are following COVID-19 guidelines in terms of safety. So, they shouldn't let them deter them from getting their appropriate screening, because I've already seen the cases where they've postponed the necessary screening, and by the time they come to us six months later, it's a completely different story. So, I encourage all the women to go and seek their mammogram, so that we can then attend to their needs and continue with prevention.
Dr. Jonathan Fialkow:
Thank you for that. We're seeing it across the medical spectrum and certainly the breast cancer screening should not by the wayside, like any other many other processes. Self-examination, how accurate is it, both for finding tumors early or false findings and stuff? Where do we sit right now in our recommendations towards self-examination?
Dr. Jane Mendez:
I think even though the American Cancer Society doesn't really think there's enough evidence to recommend that clinically, in the real world, I think it's really important for a woman to know what's normal for her.
Dr. Jonathan Fialkow:
It does, yeah.
Dr. Jane Mendez:
That then they can detect if something has changed. So, certainly a lot of women don't even want to examine their breasts because they're afraid of what they're going to find. But certainly, the earlier you detect something, the sooner you can seek medical attention and the sooner we can get the appropriate imaging and appropriate intervention. So, it's important, not necessarily supported by the data, but every time I get to give a talk on prevention, I think it's step number one, know your body.
Dr. Jonathan Fialkow:
It certainly can't hurt, right?
Dr. Jane Mendez:
Certainly cannot [crosstalk 00:19:04].
Dr. Jonathan Fialkow:
And it's cheap.
Dr. Jane Mendez:
It's free. You can do it at any time, any place and it can make a difference in somebody's life.
Dr. Jonathan Fialkow:
So, the first level of prevention, if you will, would be to stay active, eat a healthy diet, don't smoke. Second level would be get your regular screenings, as you went through. We talked about the higher risk population, whether it's other cancers or family histories and certain genetic abnormalities, which would require workup. I love the concept of previvorship in that prevention component. Last question I have regarding our breast cancer programs, again, Benign Clinic is a great one as well. How about survivorship programs? What are we doing in terms of a woman has breast cancer, gets treated, cured, ostensibly, or a surgical procedure that's cured. Are we just, "Good luck, you're done with us."? Talk a little bit about survivorship programs.
Dr. Jane Mendez:
Yeah. So, survivorship is as important as any of the treatment. And currently in the United States, we have three million breast cancer survivors because of all the advancements, because of all the technology, as told you, women are living long, long lives after breast cancer. So, their survival becomes really critical and important, and the patient's needs change when they go from treatment over to the survivor stage as part of their cancer journey. So, we have a whole set and program of survivorship, everything from psychological support to yoga classes, to acupuncture, to nutrition, and obviously healing, whatever is needed to keep the patient not only cancer-free, with great quality of life, because it's important to maintain that balance.
Dr. Jane Mendez:
It's not only about surviving the breast cancer, but also living your life with good quality and any adjustments. And as you know, a lot of the treatments that we use to maximize the cure have sequela, some acute and some long-term. So, it is really important for the patients to have access to their survivorship program, so that they can continue as their needs change and evolve over time. Continuing not only their fight against cancer, healthy and free of cancer, but also with good quality of life, both mental and physical.
Dr. Jonathan Fialkow:
And as a separate plug, from a cardiology ... As we build our cardio-oncology programs through MCI and MCBI, breast cancer survivors have higher risks of cardiovascular disease as they get older and they concentrate on the breast cancer appropriately, we do want the proper general lifestyle and cardiovascular prevention services [crosstalk 00:21:48].
Dr. Jane Mendez:
Yes. And along with that, along with cardio-oncology, which has been a great asset to our program, we also have great rehab oncology services. So, as the patient's needs, in terms of neuromuscular neuropathies, or other side effects that develop secondary to the treatment, we actually tend to be very proactive and use that as a very effective way, again, to keep the holistic approach to breast cancer.
Dr. Jonathan Fialkow:
I love that word, holistic. I was going to use it as well, and that really is what is the approach to the patient from the Miami Cancer Institute with your services and the others that we mentioned. So, October is Breast Cancer Awareness Month. What messages would you like to emphasize to the listeners as we wrap up the podcast, anything we've left out or anything you want to reiterate? This is your chance.
Dr. Jane Mendez:
No. I think I'd like to encourage all the women when they find something, seek attention, comply with their screening guidelines, do not delay it. And if you feel something, say something because early detection makes a big difference.
Dr. Jonathan Fialkow:
Words to truly live by. I appreciate Dr. Jane Mendez, Chief of Breast Surgery at Miami Cancer Institute. Thank you, podcast listeners. As always, if you have any thoughts or ideas for future topics, please email us at baptisthealthtalk@baptisthealth.net, that's baptisthealthtalk@baptisthealth.net. Thanks for listening. Stay safe, mask up.
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