About 1 in 8 Americans assigned female at birth will develop breast cancer in their lifetime. But when diagnosed early, breast cancer is highly curable.
Aashini Master, DO, a UCLA Health medical oncologist and director of the High-Risk Breast Clinic, encourages patients to not only undergo routine breast cancer screening, but to understand their individualized risk factors.
In recognition of Breast Cancer Awareness Month, she discussed screening recommendations, new diagnostic technology and what it means to have dense breasts.
Q: What are the current screening guidelines for breast cancer?
Dr. Master: The screening guidelines really depend on age and individual risk. For the average-risk woman, the guidelines are to begin at age 40, but there is some variation amongst major organizations regarding the frequency. In practice, most of us, and most primary care physicians who are often doing the screening, are typically doing it once a year for the average-risk woman.
Screening is different for women who have been defined as high risk. A risk assessment can occur in many different ways, most often patients might see their primary care physician who notes they have a family history and refers them to genetics or to the high-risk clinic to have a formal risk assessment done. For high-risk women, who are defined as having a lifetime risk of breast cancer of greater than 20% or those with a genetic mutation, the recommendation is to get an annual mammogram and an annual MRI, alternating every six months. There is not a single age for when to start screening, as it is different for all high-risk women, depending on their genetic mutation or family history.
Q: What are the latest tools to screen for breast cancer?
Dr. Master: Most commonly, 3D mammograms which replaced conventional 2D mammograms about 10 years ago. It’s more sensitive and improves early cancer detection. At UCLA, that’s all we do.
Breast MRIs for those who are at high risk. Ultrasounds are generally used less for screening and more for diagnostic imaging. Let’s say someone comes in and they have a new lump, that’s when we may want to get an ultrasound. There are instances such as for women with dense breast tissue, that we may recommend ultrasounds for screening. The disadvantage to ultrasound is it can find more benign abnormalities, which could lead to more biopsies, or what we refer to as false positives.
There are some new tools like contrast-enhanced mammography that are less widely available. They’re actually delivering IV contrast. The idea is that cancers tend to be very vascular – they have a good, healthy blood supply and contrast travels to these areas of increased blood flow. With the use of contrast, we could potentially pick up smaller cancers.
In addition, abbreviated breast MRIs are being studied. One of the things about MRIs is they take a good deal of time, usually 30 to 45 minutes. There are studies being done that are looking at a shorter time. This may allow us to accommodate more people easily and do more MRIs in patients who are not high risk by conventional criteria but who have extremely dense breast tissue warranting additional screening.
Q: What does it mean to have dense breasts and what are the screening guidelines for patients who do?
Dr. Master: Every woman gets a letter after having her mammogram that often says, ‘You have dense breasts.’ What breast density is actually referring to is the amount of glandular tissue compared to fatty tissue. It doesn’t mean your breasts are firm or hard or large. It’s something we see on imaging. There are four different categories of breast density, from A through D. A is almost entirely fatty. B is scattered areas of density. C means more areas of density and D is extremely dense.
Dense breast tissue is an independent risk factor for breast cancer. It’s not just the more dense our breast tissue is, the harder it might be for a radiologist to see a cancer; it’s that it has more of the cells that turn into cancer. More than half of women will actually have dense breast tissue either category C or D.
If you have dense breast tissue but are otherwise average risk, the recommendation remains to get an annual mammogram. But sometimes if someone has dense breast tissue and other risk factors, ultrasound or MRI can be considered.
Q: What role does genetics play in breast cancer risk?
Dr. Master: Firstly, most breast cancers are not caused by an inherited mutation, only about 5% to 10% are attributable to a genetic mutation. There are about eight breast cancer genes. The risk of developing breast cancer in our lifetime is variable, based on the mutation. That can range from 20% to 80% depending on the mutation. If we are a carrier of any of these mutations, we are going to be a candidate for high-risk screening with mammogram and breast MRIs.
With certain mutations, we may also have the conversation about pursuing a preventive mastectomy if the risk is sufficiently high in one’s lifetime. We can also offer people to go on a medication to reduce the risk of getting a certain type of breast cancer. These are estrogen blockers that can reduce the risk by 35% to 50%, but not all the mutations increase the risk for hormonally driven cancer.
Q: What are some other breast cancer risk factors?
Dr. Master: I like to separate into non-modifiable and modifiable. Increasing age is really the biggest risk factor for breast cancer. A family history, having dense breast tissue, starting periods at a young age or going through menopause at an old age, never having had a full-term pregnancy. Sometimes we get diagnosed with a high-risk breast lesion. Though they are benign, these can increase our risk as well. (Also) therapeutic radiation to our chest, which had been commonly done for certain types of lymphoma.
The potentially modifiable risk factors that we like to counsel women about are alcohol consumption, physical inactivity, excess body weight, particularly when post-menopausal, and some concerns about menopausal hormone therapy. Most women aren’t going to have one obvious risk factor, outside of someone who has a genetic mutation. That’s why population-based screening remains so important.
Q: What are the most common types of breast cancer?
Dr. Master: There are three common subtypes. We refer to these as ER for estrogen receptor positive or PR for progesterone receptor positive; HER2-positive; and triple-negative. The classification is exceedingly important because it determines our treatment, not so much surgery, but the role of chemotherapy, immunotherapy, estrogen blockers and also the sequencing of the treatment.
Q: What are the warning signs of breast cancer?
Dr. Master: The main thing we really think about is a new breast lump. But the other things we certainly want people to be aware of are if we’re seeing skin thickening or firmness of the breasts, change in shape or size, swelling in a part of or all of the breast, if the skin starts dimpling or looking like an orange peel. New nipple discharge, particularly bloody, and nipple inversion, and if the breast is red. We also want to pay attention to the underarm area, if we find a new lump there.
What I think is important to know is how your breasts generally feel and if there is a change from that. By and large, early breast cancer does not have symptoms and is generally caught by screening.
Q: What does a breast cancer lump feel like?
Dr. Master: I typically describe it to my patients as a marble. It’s going to feel hard. It’s generally not going to move. It can be irregular. It might not be super smooth or perfectly round. Sometimes cancer lumps can feel softer and might be tender or painful. It can be difficult to determine whether a lump is cancer sometimes just based on how it feels.
If someone feels a new lump and it’s not going away, we absolutely want it to be evaluated, even if we’ve recently had a normal mammogram. That said, most breast lumps are actually benign.
Q: Is breast cancer treatable and curable?
Dr. Master: Yes, fortunately very often. Certainly, it depends on the stage and biology. For most early-stage breast cancer, the five-year survival rate is 90% to 100%. The majority of women where it’s early stage and not found in the lymph nodes are going to be cured of their cancer beyond five years as well. If it starts to spread to the lymph nodes, so a higher stage, we’re still talking about numbers in the 80% to 85% rate of survivorship with all the most current treatments we have available.
Q: What do you see coming soon to further advance early detection of breast cancer?
Dr. Master: I think that AI is being developed to improve imaging – so, improve mammogram interpretation, reduce false negatives and false positives and provide personalized screening-based recommendations. I think that is one thing that is definitely being incorporated and is going to continue to increase. Risk-based screening – of course, we are already doing that, really looking at one’s individual risk. It is not universal yet but I think it will be much more so.
Imaging technologies with the contrast-enhanced mammogram and the abbreviated MRI might become more standard.
The last thing is still investigational, but blood-based early detection. This is looking at doing blood tests to hopefully detect earlier and less invasively.
Q: Can men get breast cancer?
Dr. Master: It is not particularly common, but men absolutely have breast tissue and can develop breast cancer. More commonly, we see it associated with a genetic mutation or a family history or if they have some underlying condition associated with increased estrogen production. Because we’re not doing routine mammogram screening, a lump or a thickening of the skin definitely needs to be evaluated.
Q: What else is important for UCLA Health patients to know?
Dr. Master: My recommendation is to start screening at 40 with the understanding there are some variable recommendations and guidelines and to know your risk. Know your family history, if possible, your genetics, because that might result in a recommendation to actually start screening earlier than age 40.
Do not ignore changes in the breast even if we’ve recently had a normal mammogram. Know that early detection of breast cancer largely results in a cure.
