Episode 3 : Breast cancer 101

Dr. Sophia:
Hello everyone. Welcome to the Doctor Sophia podcast. I'm an ObGyn practicing for over 15 years in my native New York City, and I love to help women learn about their bodies, empower them and embrace themselves. On this podcast, we will talk openly and with heart about all things affecting women from pregnancy, menopause periods, sexual health, fertility, and so much more. Disclaimer, this is general medical information based on my professional opinion and experience. For specific medical advice, please refer to your physician. Hello everyone. In light of breast cancer awareness month, October. Welcome to episode number three, breast cancer. I'm joined with my co-host and very good friend,
Touseef Mirza.

Touseef Mirza:
Hi everyone. It's good to be back. And we are here now with episode three. I feel like we're on a roll now, and after doing the two first ones, we're really excited to continue going down all the different topics. So just so everybody knows why I'm here, I'm gonna be asking some questions in terms of what I hear from all of you. Also since we're good friends, we chit chat about all different aspects of women's health. So let's start Dr. Sophia with just a very general overarching question, which is, how would you describe breast cancer?

Dr. Sophia:
Breast cancer in the simplest form is just the out of control growth of breast tissue that creates a cancer, and cancer being the concept of the out of control growth of tissue.

Touseef Mirza:
What is the risk of women having breast cancer

Dr. Sophia:
In general, in our country, we would consider a woman's risk of developing breast cancer over her lifetime as one in eight women, or somewhere around 12, 13% over your lifetime. And it's interesting because though a high number, I like to think of it in relationship to other things that affect women. And one of those being, let's say heart disease or lung cancer. So the number one cause of cancer related death in women is actually lung cancer. And the number one cause of death period for women is actually heart disease. And so breast cancer is the second leading cause of cancer death among women, but overall, one in three women will die of heart disease versus one in eight women who will be diagnosed with breast cancer. And that doesn't even mean will die of breast cancer. So that's one in eight women that will be diagnosed over their lifetime. And when we think about breast cancer mortality, it's more like one in 40 women overall that will die of breast cancer.

Touseef Mirza:
So are we saying that obviously all of these different types of cancers are serious, but that women have a tendency to focus more when it comes to their health on breast cancer versus the other types of cancers? Has that been kind of your experience?

Dr. Sophia:
I would say that breast cancer creates a very visceral response in women, whether you hear about it because it's your own personal diagnosis or the diagnosis of a family member or the diagnosis of a friend. When we think about breast cancer, we are automatically in tune with our femininity, and with the concept of the feeling of loss somehow more so than if we are told, oh, you have high blood pressure.

Touseef Mirza:
Okay. Or you have lung cancer-

Dr. Sophia:
Even if you have lung cancer.

Touseef Mirza:
Okay. Even if that's actually more severe in terms of the stats, the actual emotional aspect seems to be greater with breast cancer.

Dr. Sophia:
My feeling is any diagnosis of cancer will give us pause. But, breast cancer gives us an uncontrollable sense of emotion, loss, impending doom.

Touseef Mirza:
It feels more severe somehow for women/

Dr. Sophia:
When we think about breasts, it automatically gives you the idea of a woman. Even just saying the word gives us a sense of-

Touseef Mirza:
Of womanhood. Right.

Dr. Sophia:
It gives us a sense of the basic concept of being a woman. Like I said I think any diagnosis of cancer can be very emotional. But I definitely feel that the possibility and the diagnosis of breast cancer can be even more deafening.

Touseef Mirza:
So considering that, would you say that women have a tendency to take, for example, breast screening more seriously, or you haven't really seen that and what does screening look like?

Dr. Sophia:
So I wish it made us even more excited about getting screened. But not necessarily.

Touseef Mirza:
Okay.

Dr. Sophia:
And I think it's because of the modality for which we have for breast cancer screening, which is mammography. Women talk, we talk to each other and for the most part, you know, there's nothing exciting about going for your mammogram. The assumption is, and can be that there's a level of discomfort that's associated with it. And many of us fear that. And so, with that fact, yeah, I, I think oftentimes some of us can be very scared and not wanna go through the screening though it is the best preventative measure that we have,

Touseef Mirza:
The technology from mammograms hasn't really changed over the years that much, right? In terms of pressure, in terms of the actual process, has it pretty much stayed the same?

Dr. Sophia:
It has definitely stayed the same in many ways. Though the interpretation of mammography has changed, the actual modality of how it is performed has not changed dramatically. No.

Touseef Mirza:
Since we're talking about screening, what is the screening, recommendation for women in terms of age and oral frequency?

Dr. Sophia:
So it's interesting. I do think that this is a place where it's important to have a conversation with your physician. Screening should really be based on risk and risk stratification. If we had to talk just in terms of the general population, I would say start having a mammogram at age 40. However, it's important to understand that one's risk may increase due to hereditary or genetic influences, family history. So for example, if a woman in her family, or I should say perhaps her mother was diagnosed with breast cancer at the age of 42. Then she, as the daughter, should start getting screened at least 10 years earlier than the age of her mother's diagnosis. So if she were diagnosed at the age of 42, then her daughter should get screened or begin screenings, or least by age 32.

Touseef Mirza:
Okay. So it can be really on a case by case basis.

Dr. Sophia:
So it can be on a case by case basis. Other women, for example, who have genetic predisposition or increased risk of developing breast cancer over their lifetime. So we already discussed that the risk in the general population is approximately 12 or 13%, but for some women it may be over 20%.

Touseef Mirza):
Okay.

Dr. Sophia:
And when we talk about those women who have greater than 20% risk of breast cancer, they may have a genetic predisposition with genetic mutations known as BRCA1, or BRCA2 or the BRCA genes. And with that, those high risk women should typically get screened at a much younger age and using different modalities, not just mammography for example, they may need the addition of MRI. And so it's the reason why it's important to really know your family history. Which is funny because, for example, in the black experience, and though I don't speak for everyone, I know that we tend to not talk about things that we consider as bad things that may have happened in the family or, you know, or not talking about other people's business. And so more-

Touseef Mirza:
From a general perspective, not necessarily from a breast cancer perspective.

Dr. Sophia:
Yeah. Not from just a breast cancer perspective, but from a general perspective that oftentimes we actually don't know enough about our family medical history, but it's a way for us to be armed with information so that we can better really prevent and protect ourselves. So one of the things that I like to really bring home when it comes to having a di discussion with my patients, for example, is go home and have a start the conversation with mom, with grandma, with auntie, what happened to auntie so-and-so, what happened to grandma?

Touseef Mirza:
Or what is happening?

Dr. Sophia):
Or what is happening?

Touseef Mirza):
Yeah,

Dr. Sophia:
Exactly.

Touseef Mirza:
This is a good point to ask this question. When we say we have family history, whether it's coming from a genetic background, when we talk, when we say family, who are we talking about? Do we need to just talk about the generation above us? And maybe two, or is it if we have the chance to know even higher? And how broader, when you say aunties uncle, like is there a safe sort of circumference of people that you talk to? Or is it like the more you know, the better?

Dr. Sophia:
Honestly, the more you know, the better. Of course, we really wanna know first and second generation meaning, you know, and first and second degree relatives, what does that mean? Your mother, your grandmother, your grandfather, your father, your siblings, your aunts, your uncles. And then we can move on into like cousins and things like that. But when we are talking about family history, the more you know, the better. Because there may be trends that you may not be able to see or establish if you only look at one generation, but actually can speak to a story that can affect how we stratify your risk.

Touseef Mirza:
So I think we're gonna do another episode on this when we're literally gonna be talking about how to approach these conversations when you've never talked about that in the family, you know, unless it's like right in front of you. I had a question in terms of, what if I don't have, so I did my research from my family tree perspective, but what if I had no history after doing all the research?

Dr. Sophia:
So with no family history in general, all women should really start screening at age 40. That's all risk, general risk to the population. Um, I think every one to two years is safe and screening should continue up through age 75. And these are recommendations based on the American College of Obstetricians and Gynecologists. Okay. And there are other colleges or governing bodies that may make recommendations That may be slightly different. And I did wanna make a mention, or a note when we are talking about black women. Not only is the diagnosis of breast cancer actually less common in black women in comparison to white women, but one thing we need to understand is actually the mortality or the deaths are more likely to occur though in black women.

Touseef Mirza:
So the incidence is a little bit less.

Dr. Sophia:
So the incidence of being diagnosed with breast cancer is a little bit less.

Touseef Mirza:
Okay.

Dr. Sophia:
Incidences, the high, those who have the highest incidences are actually white women. But when we think about breast cancer deaths, the incidence of breast cancer death is highest among black women.

Touseef Mirza:
Do we know about how much more?

Dr. Sophia:
It can be up to two to three times more.

Touseef Mirza:
Okay. That's a lot.

Dr. Sophia:
Yes.

Touseef Mirza:
Yes. So is it because they're not seeking treatment or is it because they're seeking treatment and the treatment isn't working as well? Do we know what's the cause of that?

Dr. Sophia:
Honestly, I think it's multifactorial. I think it has to do with our access to care treatment and treatment options and institutionalized racism within the healthcare system.

Touseef Mirza:
So we just don't have the same level of care and access when it comes to black women.

Dr. Sophia:
That is correct.

Touseef Mirza:
Okay. Do we know if that has improved a little bit over time or it has stayed?

Dr. Sophia:
I think unfortunately that stayed pretty relatively constant.

Touseef Mirza:
Okay.

Dr. Sophia:
And in some instances, it may have even gotten a little bit worse.

Touseef Mirza:
Okay. Well, it's important to speak about those issues. So maybe that's something we could do on another podcast as well.

Dr. Sophia:
I definitely think we should.

Touseef Mirza:
Okay. So we will talk about that for sure. To go back to, um, the foundations of breast cancer, do we know the main causes of that? Aside from genetics?

Dr. Sophia:
Honestly, the number one risk factor for developing breast cancer is actually age. So your risk of breast cancer simply increases as we age with the most likely diagnosis occurring between the ages of 50 and 60. But age is definitely our number one risk factor.

Touseef Mirza:
For example, if somebody is more overweight or has other types of ailments, such as a heart condition, does that have an increased risk?

Dr. Sophia:
Some of the increased risks of developing breast cancer include things like what we call early monarchy or early your first having your first period, you know, before the age of 12, for example, or having your menopause late, you know, after the age of 55 and not having had any children. All of those are interestingly increasing the risk of potentially developing breast cancer.

Touseef Mirza:
And that's because it has more of a hormonal factor involved.

Dr. Sophia:
Yes. It's considered an increase in the exposure of estrogen, for example, over your lifetime.

Touseef Mirza:
So I'm curious, I had not heard as much about that. Some of this actually is related back to as early as when you started your period.

Dr. Sophia:
So if you started your period very early. And did not have any children, and then ending or going through the transition of menopause very late can actually increase your risk of breast cancer.

Touseef Mirza:
So are you saying that we need all three of them to increase, or even each individual scenario increases the likelihood of breast cancer?

Dr. Sophia:
We are talking about, let's say going what can go together maybe like early monarchy and late menopause, those two things as an independent risk factor.

Touseef Mirza:
Okay. But let's say that I don't have the two first and I just, uh, started menopause really late. That's my only, so that-

Dr. Sophia:
Would be your only increased risk factor.

Touseef Mirza:
Okay. So that is by itself a risk factor. Yes. As well. Okay. And in terms of other diseases, does that increase the risk at all

Dr. Sophia:
Other potential cancers? Others like environmental exposure? And we've already discussed genetic risk factors and the concept of having dense breasts. So women who may have undergone a mammography and then have been told you have dense breasts, dense breasts can be its own independent risk factor, merely because it may make it a little bit more difficult for a diagnosis or to be able to see that a cancer actually exists.

Touseef Mirza:
So it doesn't mean that you have it, it just means that if you have it, it would be hard to detect it.

Dr. Sophia:
It may be a little harder.

Touseef Mirza:
May be a little bit harder.

Dr. Sophia:
Yes. But let's be clear, about 50% of women have dense breasts.

Touseef Mirza:
50%?

Dr. Sophia:
Yes. Up to 50%.

Touseef Mirza:
So, then do we need more different types of machinery then? Like maybe we're not, if there's 50% of women that have this, then don't we need another machine that can see through those, all those dense, dense breasts?

Dr. Sophia:
So again, this is where your risk stratification needs to happen, and that conversation needs to happen with your physician. So not just dense breasts, because it's a very common thing to have dense breasts, but if your conversation with your physician, you know, you realize that you have other increased risk factors. Then it may be that along with having a mammogram, you may need a different modality in order to, aid in the screening process. For example, we may add ultrasound to your screening tool.

Touseef Mirza:
If you have dense breasts.

Dr. Sophia:
If you have dense breasts.

Touseef Mirza:
Okay.

Dr. Sophia:
That can help to further detect if there is a true problem.

Touseef Mirza:
Okay. So can you explain what risk stratification means and what does modality mean?

Dr. Sophia:
Risk stratification means having a conversation where I find out things like, when did you experience menopause? How old were you? Or how old were you when you first got your period? Is there anyone else in your family who has been diagnosed with breast cancer? Are any of those people first degree relatives, mother, sister, and grandparent? Do you know of anyone in that group of women or men in your family who may be a genetic carrier for breast cancer?

Touseef Mirza:
So risk stratification, that term basically means that you're looking through all potential risks that you might have as it pertains to breast cancer so that it can be assessed whether you are at high risk or low risk.

Dr. Sophia:
That is correct. Okay. The goal of risk stratification is to understand where you are in terms of how best to do your screening.

Touseef Mirza:
Got it. And then when you say modality in this situation, are we talking about different forms of treatment or does that mean something else?

Dr. Sophia:
When I'm speaking of modality, I'm simply talking about the different options for screening.

Touseef Mirza:
Okay.

Dr. Sophia:
So the mainstay of screening for breast cancer is mammography. We can have additive screening tools such as ultrasound, and for those women who are at very high risk, we may add MRI modality on top of mammography, for example, in order to help with early detection.

Touseef Mirza:
Okay. Good. Thank you for that specification.

Dr. Sophia:
You’re welcome.

Touseef Mirza:
Can I do anything to prevent my chances of getting breast cancer? Or is it kind of out of my control?

Dr. Sophia:
No, nothing is ever out of our control. I do wanna really stress the concept that a healthy lifestyle, for example, eating right, exercising, it sounds so simple, but it can make a difference. Two, understanding your own breast architecture, meaning knowing exactly what your breast feel like or what I like to say, know where all your lumps and bumps are. And the reason for that is the majority of breast cancers will develop before you can, you'll detect it, it can be there for up to two years or by the time you feel the lump, but if you know your breast, you will find that lump before your doctor does. Because if you're only going to see your physician every one or two years, then the likelihood is that you may be the one to feel something that's a little bit abnormal and can bring that to the attention of your physician. I think we take for granted that we know our own bodies and that we can know our own bodies. So if we really take down the concept of I know where all of my lumps, bumps, aches, and pains, then we'll be able to kind of direct our doctors and advocate for ourselves.

Touseef Mirza:
Instead of waiting.

Dr. Sophia:
Instead of waiting

Touseef Mirza:
And seeing if something is wrong.

Dr. Sophia:
Exactly.

Touseef Mirza:
You just become much more proactive-

Dr. Sophia:
Proactive aware We can, and we do have ownership of ourselves.

Touseef Mirza:
What is the frequency that you would recommend for a self-breast exam that we do on ourselves?

Dr. Sophia:
I don't know if I have a specific frequency per say.

Touseef Mirza:
Okay.

Dr. Sophia:
I think it's more so the concept of knowing your own breast. If you do it intentionally once every couple of months. Okay. “Hey, the girls, they still feel the same.”

Touseef Mirza:
Okay.

Dr. Sophia:
And also, you know, in terms of being really specific, I definitely tell women if you're younger and you're still menstruating to wait until about seven days after your period just so that you're not feeling your breasts at a time when you're experiencing hormonal changes can happen. And then thinking that something is happening that may or may not really be happening. So I would say yeah, you would try to do it at a time when you are just feeling the breast tissue for how they are.

Touseef Mirza:
If you do have breast cancer, is there a good chance of remission? Like in terms of where we are with treatments? I think we need to do a whole other podcast on that in terms of breast cancer treatments. But just in general, would you say that it is a promising area?

Dr. Sophia:
Actually, I would say overall, when your breast cancer is detected at a very early stage, the survival rate is very high. And that's with almost all the different types of treatments, whether we go through a very conservative treatment versus a very invasive treatment, the likelihood of survival is incredibly high when it comes to breast cancer. And that's why the importance of having the screening, the importance of doing the screening is so that you have the biggest or the, the greatest chance of detecting cancer at the earliest stage. And I think that it's one thing that we don't actually talk enough about is the fact that yes, one out of eight women may be diagnosed with breast cancer, but it's also understanding that among those one in eight women, the overall majority of those women, if their breast cancer is detected early, will survive their breast cancer.

Touseef Mirza:
One of the biggest takeaways for me, and this is really when we look at breast cancer is early detection. Like that is early detection in terms of knowing your own body and doing your own self exams, but then also doing the screenings. Do you have any recommendations for women who are scared of getting a mammogram? Like are there certain things that women can do or anything like to help sort of alleviate being scared of, like it will hurt and so forth? What would you say to that?

Dr. Sophia:
Well, one thing I wanna clarify, it's not a self-breast exam. Again, I like to really point out it's just a matter of knowing your own body.

Touseef Mirza:
What's the difference?

Dr. Sophia:
When we think of an exam, we're looking for something, it automatically makes you hyper alert and, and then it can provoke a sense of anxiety all by itself. When I say instead, be familiar with all of your body parts, don't be afraid or ashamed or feel weird because you have touched your breast. Hmm. And you know exactly what they feel like.

Touseef Mirza::
It's more like making friends with your body,

Dr. Sophia:
Make friends with your body. Be sure to know your body very, very well. As opposed to the concept of a breast exam.

Touseef Mirza:
Okay. I like that.

Dr. Sophia:
And moving over, when I think about how do I take away the fear, the anxiety surrounding a mammogram, I think it's just being honest.

Touseef Mirza:
Okay.

Dr. Sophia:
We go through as women, many things that are uncomfortable. I'm a gynecologist, and I'll tell you there is absolutely nothing fun about getting a pap smear. And yet we are pretty religious about doing it. It's kind of been ingrained in us that we need to, as it should be, don't get me wrong, but I think it's the reminder that we are all together strong. We can handle it and more than just handle it. I think it's the understanding this is something that's truly gonna benefit me. It's a small moment in time because to have a mammogram done is actually very quick.

Touseef Mirza:
How long does it take? Approximately

Dr. Sophia:
10 to 15 minutes in some instances, if not less. And so it's managing expectations. It can be uncomfortable. There's no sugarcoating that, but definitely it's relatively quick. But-

Touseef Mirza:
The 10, 15 minutes is like the whole thing, the time that you're actually

Dr. Sophia:
Undergoing the actual, what we call the pressing

Touseef Mirza:
Of the breast?

Dr. Sophia:
Of the breast. Yeah. That's moments,

Touseef Mirza:
That's like 30 seconds. Yes. It's momentary. So I think that's a good point though. Like if there's somebody younger that's listening to this podcast, what is actually a mammogram?

Dr. Sophia:
A mammogram is basically having an x-ray of the breast. We put the breast in between two plates and gently press those plates together in order to kind of stretch out the tissue so that we can see and perform the x-ray.

Touseef Mirza::
And then a picture is taken

Dr. Sophia:
And then the picture is taken.

Touseef Mirza:
Okay. So that you can see through the tissues. Okay. And so that sort of pressing, pressing, that's the thing that some women are fearful of, but it's 30 seconds or less.

Dr. Sophia:
And I don't wanna, I don't wanna diminish at all the concept of the fear or the intensity of the fear, of the concept of the pressing. I think regardless for some women, they're like, I didn't feel anything. And for others, oh my God, that was the worst thing that I could have ever gone through. And so I definitely don't wanna minimize that. I want women to simply feel empowered. They can get through a process that is quick and that they can, again, advocate for themselves if they find that their technician is perhaps being a little bit rough or not explaining things well enough, or make the point to say that I'm a little bit sensitive, or, you know, say that. Tell your technician, I know that this can be uncomfortable, please. Is there a way that we can do this in a manner? Please talk to me. Let me know everything that you're doing before you do it so that I can be prepared.

Touseef Mirza:
Communicate.

Dr. Sophia:
The communication tool is key.

Touseef Mirza:
Okay. I think that's important though. I think we don't talk about that enough of having that connection with the person in the room. Also, that can also alleviate some discomfort that you feel you can trust the person doing that and telling them that you are a little bit fearful. And also I think, you know, you said like, it's, it's important to acknowledge what you're feeling, like whatever you're feeling is legitimate.

Dr. Sophia:
Absolutely.

Touseef Mirza:
And, so it's, it's totally fine to voice that.

Dr. Sophia:
Yeah. I think if we voiced it, we can start to liberate ourselves from the fear. If we actually talk about it.

Touseef Mirza:
Right. I think we learned a lot in terms of breast cancer. And I am sure we're gonna be talking about more. I definitely wanna talk more about genes, like BRCA next time. But for now I think thank you Dr. Sophia for asking all these questions and answers.

Dr. Sophia:
Well thank you Touseef for joining me on episode number three of the Dr. Sophia podcast. As we close, I would like to close this episode with an excerpt from the phenomenal. Maya Angelou, her poem. Her poem, Phenomenal Woman.

Touseef Mirza:
Because we are phenomenal.

Dr. Sophia:
We're exceptionally phenomenal.

Touseef Mirza:
So we can deal with all this because we're phenomenal. Maya said, so.

Dr. Sophia:
That is correct. Yes. Pretty women wonder where my secret lies. I'm not cute or built to suit a fashion model size, but when I start to tell them they think I'm telling lies, I say it's in the reach of my arms, the span of my hips, the stride in my step, the curl of my lips. I am a woman, phenomenally phenomenal woman. That's me. Until next time, again, this is general medical information based on my professional opinion and experience. For specific medical advice, please refer to your physician. Thank you.