Dr. Julia Smith what do we know now about Breast cancer that we didn't know when you first entered the field? A lot, we know an enormous amount, in fact this is one field prevention and screening of Breast cancer is one field that has advanced by leaps and bounds. In 1995, the BRCA or BRCA genes were first identified and described. These are genes that everyone carries but mutations in these genes put women at high risk for developing Breast cancer. So we knew that there were plenty of women who are at a higher risk than the average women for developing Breast cancer. They had a family history that was suggestive, they had personal diseases that were suggestive, but we didn't know why? This helped to explain a lot. It doesn't explain everything, but it help to explain a lot and since that time the science has just leapt forward, and we know have a much better understanding of the factors that contribute to developing Breast cancer, the risks for developing Breast cancer and why there are just these families that seem to be prone. If you were living in New York and you have the opportunity to be treated at the NYU Cancer Institute, you must much better suited to be treated than if you are living in other parts of the country? Well, if you are living in New York you are really fortunate in this respect as in others, because there are major academic institutions and researches going on and there are specialists and there is a screening and prevention program that you can go to get your risk identified and get help and deciding what are the proper decisions for you and the and what options exist. But, you can do that no matter where you are in the country now. There are scattered screening and prevention program across the country and all the major academic institutions now and for places if you live somewhere were you don't have that, you can easily find in most cases some one who is interested in this and who will help you understand what do you need to think about to determine your level of risk. What factors contribute to one's risks? Well, when you think about it on your own you should consider things like your own personal hormonal history. In general Breast cancer is an Estrogen driven tumor and that's why you see it much more in women than in men. Breast cancer can occur in men. Men have Estrogens as well as Androgens just as women have Androgens as well as Estrogens, its just the balance is different so, you can see Breast cancer in men and you have to think about that, but it's most common as we all know in women. So, you think about these things you have to do with your Estrogen development. Your own personal hormonal history, think about for instances how old you were when you started to menstruate, because your ovaries are not producing Estrogen until you go through puberty, on the other end think about if you have gone through menopause how old were you when you went through menopause because once you go through menopause the ovaries have basically shutdown and they no longer producing Estrogen and then there are things that also contributing your own personal hormonal history like when you had children whether their early life how many of you have had, whether you breast fed, whether you took oral contraceptives. Because if you think about this you know, there is an old wives' tale that has a lot of truth, it's not 100 percent true. But it is said that if while you are breast feeding you cannot get pregnant and so that's because you are not going through the normal cycling, monthly cycling of Estrogens when you are breast feeding, you are not going through the monthly cycling of Estrogens when you are pregnant. So if you take a woman for instance just to make the point, if you take a women who got her period when she was nine she had no children, so she had no pregnancies, no breast feeding, and then she underwent menopause when she was 54. If you think about the number of months that woman has gone through cycles month after month after month of cycling Estrogen. Compare that to a woman who got her period first time when she was 15 or 16 have four children, each child was breast fed for a year and then she underwent menopause when she was 40-48-47, something in the mid forties think about all that time when she was pregnant, when she was breast feeding before she went through puberty and after menopause during all of that time tuberous was not exposed to monthly-monthly cycling. She is a very has a very different hormonal profile than the first woman we discuss, so that's the first thing to think about. The next thing to think about is family history, very, very important. You think about your family history and try to understand, ask family members was there any Breast cancer in the family, if there was Breast cancer in the family the key is to understand whether it was in woman who were premenopausal that tends to be much more of the red flag than for a familial gene or a familial tendency to Breast cancer, then for woman who are postmenopausal and get breast cancer. So think about whether there are women, how many relatives had Breast cancer, how many were premenopausal, another red flag is whether is any of them had Bilateral Breast Cancer meaning they got Breast cancer in one breast and then they got it in the other breast, that's also a red flag. Think about whether anyone in the family had had a relative who is a male who got Breast cancer, as I said it can occur in men but it is rare, so if you see a relative who is a male oh you know, no there is no Breast cancer in our family, oh except my my uncle your great uncle had Breast cancer that is a red flag and you need to take that very seriously because it is unusual. Also think about whether there is a ovarian cancer in the family, again a relatively rare cancer in our society but can be linked to Breast cancer. So now we have hormonal history, family history. Think about ancestry, there were certain groups of the ancestors in geographic locations that predispose, one to have a higher incidence of carrying the BRCA gene. So it was discovered in the Ashkenazi Jewish population. In the United States if you pluck a woman of the street randomly she has one in 800 chance of about carrying a mutation in this Breast Cancer Predisposing Gene, which is also linked to ovarian cancer. If you take a random Ashkenazi Jewish woman she will have a one in 40 chance compared to one in 800, and Ashkenazi Jewish population is not by any means the only population that's affected this way, it was discovered in that group but you see it in the Irish and the English and in the Mediterranean, there are many groups where you can see this. So think about ancestry and finally think about your own personal breast history if you ever had Breast biopsies what they have shown even if they weren't cancer, they can give the clue to whether you are at a increased risk if you had any other medical diseases or there any other cancers in the family, they may be related, that's something that's important to know and life style counts to. Let's talk about that, what impact does lifestyle choices have on Breast cancer? Well, lifestyle choices are relative risk factors, meaning that you can do all the right things and still get Breast cancer or you can do none of them and never get breast cancer, but in general it's very important not to smoke cigarettes that we know. Cigarettes raise the risk of Breast cancer, there are many other reasons not to smoke cigarettes most importantly being heart disease, which is actually what the vast majority of women in our society die of not cancer but heart disease, so remember you shouldn't smoke cigarettes, lung cancer predisposes emphysema but it also predisposes to Breast cancers, so if you are smoking you should quit, find a way to get help, and quit, and if you haven't smoked don't start that's very important. Alcohol is a slightly different story, what we have seen in the studies thus far is that alcohol in moderation does not raise ones risk of breast cancer. The only catch here is that moderation word that for us, for doctors, medical moderation means these studies were done with two to three glasses of red wine per week, so you are fine if you were in that ballpark and that's important not to go much over that. Exercise is clearly important, no question about it, Estrogens are stored in fat and body mass and body fat index is important everyone should be trying to exercise three times a week at least 20 minutes each time, where during that entire twenty minutes your entire heart rate is above baseline and more is better. And the last thing that has been shown now in very convincing studies to be absolutely critical in lifestyle is diet. A low fat diet, a diet that has a lot of fresh fruits, fresh vegetables, it's good to have high fiber, whole grains and not a lot of animal fat, not a lot of red meat, not a lot of junk food or processed food, these things definitely make a major difference. At what point is one consider genetic testing for BRCA mutations; is that something that you would do with young children? Well, the you know, it's a complicated decision to decide to decide to do a genetic test. So for any individual, I would be absolutely sure that you got into the hands of someone who could help you understand what the implications of the test results are because this is not like getting, it's a simple blood test. You would send of a tube with blood. But it's not like sending of hemoglobin. You know, am I anemic, yes or no? Am I pregnant, yes or no? It's not like that, there can be very unclear answers, when the test comes back and it can have psychological and emotional effects. So it's really important that you will be in the hands of someone who knows what they are talking about, who can help you understand and interpret the results and who can then help you see how that can be useful for you as an individual in making your decisions. So not everyone should get this test, but it can be very, very empowering. First of all there are many things that can need you to be able to do to modify your risk and secondly you may find that you are not in fact at increased risk. When you come to the second part of your question, the young children, there is the BRCA gene mutation, the test that is determined by this blood test has no effect on young children. In fact, you don't even start screening young women who are who might be had increased risk until they are in their mid 20s. You know, at least you would wait until 24. So because you can't do anything medically and they are not going to be affected, there is a young breast cancer but not in young children. It's not advisable to start doing testing on children when it won't affect anything they do medically, it won't all it can do is put a burden on them. They you have to decide and this is a very personal decision and again you should find someone who you can call on to to help you with this as a professional. But you have to decide, if you find that you are at an increased risk and you carry a mutation, how you want to handle that information with your children. And it's powerful information for the children. But especially with young children, things will change; this field has changed very rapidly. And by the time children who are young now become of the age where it will they will need to think about it and it will affect them, things would also be very different. And what could be done, if one finds that they have a BRCA mutation? Well, now there are really medical options that one can you know, exercise. So there are drugs that people can take to reduce their risk. Tamoxifen, the most widely used, the most proven drug, and you know, patient who has an elevated risk taking five years of Tamoxifen once a day will reduce their risk by about half about 50 percent. Other drugs have been looked at as well and studied. And then there is risk reducing surgery that one can undergo. There is Bilateral Prophylactic Mastectomies which reduces one's risk by greater than 90 percent. Probably greater than 95-98 percent in the right hands, and there is Bilateral Salpingo Oophorectomy which means removal of both ovaries and the fallopian tubes. That, just taking out the ovaries in a woman who is at increased risk would do the same thing as giving her Tamoxifen. It will reduce the risk by 50 percent. But obviously if you are talking about a young woman who has a long way to go until menopause, that sounds something you want to do right away because it will have other ramifications that will affect her lifestyle. And her ability obviously, fertility, she won't be able to have children if you take out the ovaries. And then things like bone health are very much affected. So you have to tailor each of these things to the individual women, in addition to risk reducing surgery and medication that one can take to reduce ones risk there is intense of high risk surveillance, with the advent of the MRI, this test that will allow you to look at the breast tissue much more sensitively than with a mammogram. We can follow women who were at high risk and hope to catch any disease which would occur at a very early stage. So your key advice for someone who through their life wants to be involved in a good screening and evaluation program what are the cardinal rules? Lets think about your lifestyle, and do what you can move toward, don't try to do every thing all at once, but think about the things I said and slowly move toward affecting modifications that will help you fall into a low risk group. Think about your family history, and figure out whether it looks to you from some of the things I have said about, ancestry, family history, hormonal history, personal breast history or medical history whether you think you might be at increased risk, if you think so don't assume you are, because you might not be, go seek out some one who knows about these things, get a consultation, talk to them about you know, what you think the risk factors are, get the information, find out whether it's appropriate for you to do any further studies or testing, whether you should be in any clinical trials or protocols and whether you should have any of these risks reducing options. And finally here at NYU and other academic centers what work has been done that what work has being done that you are most hopeful about further future of treatment of Breast cancer? Well, here at NYU, and the NYU Cancer Institute at Lynne Cohen Breast Cancer Preventive Care Program as well as literally across the country, there are many exciting things going on to in clinical trials and experimental protocols, to try to advance this field. So, there are radiologic studies, new ways to look at the breasts that have less and less inconvenience and risks, to determine earlier and earlier whether there are changes that could predispose the breast to breast to Breast cancer. There are drug trials that are being used that may prevent Breast cancer in women who are at high risk. There is a great deal of science going on to understand the molecular changes in the cell that make that cell start to behave in an erratic way when it should be just sitting as a breast cell, it starts to divide and once we have then understanding of those changes, we can figure up the measures we need to affect them. Thank you very much Dr Smith. You are very welcome.
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