Breast Health and Breast Cancer --- January 25, 2008

Katherine Lee, M.D. Staff Cleveland Clinic Department of General Surgery

Preya Ananthakrishnan, M.D. Associate Staff Cleveland Clinic Department of General Surgery

Cleveland_Clinic_Host: Welcome Dr. Lee, and thank you for joining us today. Also joining us today will be Dr. Preya Ananthakrishnan. Dr.Ananthakrishnan, it is wonderful that you join us. We look forward to an interesting chat today. Welcome! Let's begin with one of the questions!

Breast Health

newtonm: Someone told me about breast rash and that it can be cancerous. What exactly is this?
Speaker_-_Dr_Lee: A breast rash can sometimes be a sign of inflammatory breast cancer which is rare.

kelly: Sometimes I have pain in my breasts; especially during my period. Could this be a sign of breast cancer?
Speaker_-_Dr_Lee__Speaker_-Dr. Ananthakrishnan: Pain is pretty normal during your period. Pain is not usually a sign of breast cancer.

newtonm: Is it safe to get breast implants? How about breast reductions?
Speaker_-_Dr_Lee__Speaker_- Dr. Ananthakrishnan: It is relatively safe to have implants and breast reductions. Like any surgery, there are risks of bleeding and infection. Also, implants were not meant to last forever.
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: Before any type of breast surgery, it is important to make sure that you mammograms are up-to-date.
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: Silicone breast implants have been FDA approved. There are also saline implants available. You can have a mammogram even if you have implants.

kelly: I have been having some discharge from my nipple. I was told this was normal, but can this be an indicator of cancer?
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: Nipple discharge can sometimes be a sign of breast cancer especially if it is bloody. Nipple discharge warrants a physician's evaluation. It is important to note if the nipple discharge is on one side or both sides, and if the discharge spontaneous with or without squeezing the nipple.

pleasehelp: It surprised me to hear that men can get breast cancer too. What would be the warning signs, or risk factors?
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: Men can get breast cancer and they present with lumps or nipple discharge too.

Breast Self Examination

sunshine: I do a self exam every month during my menstrual period, but I'm not quite sure what I am looking for. Can you provide some advice or suggestions to assist me in doing the self exam correctly?
Speaker_-_Dr_Lee: I tell my patients to do their self-exams consistently about 3-5 days after their cycle is finished. They are looking for a change in their exam. Most women still present with the lumps themselves. You can refer to our website for step-by-step instruction about how to do a breast exam. http://cms.clevelandclinic.org/breastcenter/body.cfm?id=92

happpymom: During a self exam, I detected a lump in my breast. I have an upcoming appointment, but what percentage of lumps are actually cancerous? I am very worried.
Speaker_-_Dr_Lee: Most lumps detected are not cancer but it is important to have an exam and mammogram if a lump is detected.

Risk Factors

mc: What are the biggest risk factors of breast cancer?
Speaker Dr Lee: The known major risk factors are age, age at your first cycle, age at first live birth, family history and previous breast biopsies.

jbr: What can I do to reduce my risk of getting breast cancer?
Speaker_-_Dr_Lee__Speaker_-_Dr Ananthakrishnan: Again, there are some risk factors that you can change such as alcohol to no more than 1 drink per day, exercising regularly and eating a high fiber and high fruit and vegetable diet.

Family History of Breast Cancer

mary: Breast cancer runs in my family. What can I do to lower my risk?
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: It depends on a few things. You will need genetic testing to determine if you are a carrier. If you are a gene carrier, removal of both breasts is a reasonable option. If not, you could take tamoxifen or raloxifene to reduce your risk by 50%.

dotty: I have a friend who was just recently diagnosed with breast cancer. No one else in her family has ever had it. It is the same with my family history. What are the risk factors if there is no family history?
Speaker_-_Dr_Lee: The vast majority of women, approximately 60%, who are diagnosed with breast cancer have no major risk factors for breast cancer.
Speaker_-_Dr_Lee: Approximately 75% of all breast cancers are actually found after the age of 50.

Prevention

nell: Is there anything that I can do to prevent breast cancer?
Speaker_-_Dr_Lee: Again, as in an earlier question, there are risk factors that you can change. One option is chemoprevention for women who would like to prevent breast cancer but there is no 100% guarantee. The medications used for this are tamoxifen and raloxifene.

asreinig: Does alcohol consumption affect the incidence of breast cancer?
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: Studies have shown that alcohol consumption of at least two drinks per day (which is considered moderate alcohol intake) can increase your risk by 20%.
Speaker_-_Dr_Lee: Breast cancer risk is dependent on how much you drink.

Mammograms

sf: What are the current recommendations for mammograms? I heard there were some changes.
Speaker_-_Dr_Lee: We at the Cleveland Clinic recommend baseline mammograms at 35 and then annually starting at age 40. If you are at high risk, mammograms may be performed earlier.

kpmistress: What is the difference between a screening mammography and a diagnostic mammography?
Speaker_-_Dr_Lee__Speaker_-_Dr_Ananthakrishnan: Screening mammograms are your standard 4 views: two of each breast. Diagnostic mammograms are performed when you have a problem and usually indicate more specific imaging at the area of concern.

barb: I've been told that both ultrasound and mammography can be used as screening devices for breast cancer. What is the difference? Is one method more effective?
Speaker_-_Dr_Lee: Mammograms are tests using x-rays to detect breast cancer. Ultrasound is a sound wave test used to determine what type of lump you have. Ultrasound is not usually used for screening but instead for diagnostic purposes.

jackiem: Can you tell me more about the use of MRI’s in breast cancer detection?
Speaker Dr_Lee: MRI’s are 3 dimensional tests which have a high sensitivity for detecting breast cancer. It looks at blood flow and can pick up cancers not seen on mammograms. Currently, they are used as a screening tool in women who carry the genes for breast cancer. Speaker_-_ Dr. Ananthakrishnan: First and foremost your health is most important. Different facilities have different options for imaging capabilities. Definitely seek a 2nd opinion and take your previous mammogram films with you for the appointment.

Calcifications

hammetm: Can calcifications in the breast turn into cancer?
Speaker_-_Dr_Lee: Most calcifications are benign. About 20% can be a sign of an early breast cancer.

hammetm: How do you make the determination if the calcification are benign or an early sign of breast cancer?
Speaker_-_Dr_Lee__Speaker_-_Dr. Ananthakrishnan: The radiologists are trained to look at both the type of calcifications, configuration of the calcification and also whether they are new.

Fibrocystic Breasts

asreinig: If you have fibrocystic breasts, are you more at risk for developing breast cancer?
Speaker_-_Dr_Ananthakrishnan: Not necessarily, but dense breasts can make it more difficult to detect abnormalities on a mammogram.

Hormone Therapy and Breast Cancer

kelly: What do I need to know about taking the Pill and breast cancer? I took the Pill in my 20’s and 30’s, and am now in my 40’s. Should I be concerned?
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: The relationship of birth control pills and breast cancer is controversial and the original studies looked at higher dose pills than those being taken today. If a woman is taking them in her 40’s and has taken them for a long period of time, there may be a link with breast cancer.

stacy: Is there a relationship between hormone replacement therapy and breast cancer?
Speaker_-_Dr_Lee: The Women’s Health Initiative Study did reveal a relationship with HRT and breast cancer and saw a 26% increase in breast cancers in women taking HRT for 4 years. The HRT was the combination of estrogen and progesterone. Women are currently being advised to not take HRT indefinitely.

newtonm: If HRT is known to increase your risk of breast cancer, what should be considered before deciding for or against taking it?
Speaker_-_Dr_Lee: If considering taking HRT, one should evaluate her own risk for breast cancer looking at the major risk factors and determining if the benefits of HRT outweigh the risks. Also, the length of time she is considering taking HRT should be factored in her risk.

Treatment

motherof3: What is the drug tamoxifen? What are the side effects of tamoxifen, and what are the alternatives to this treatment?
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: Tamoxifen is an estrogen receptor blocker and is taken orally once a day for a period of 5 years. It can be taken for prevention or treatment of breast cancer. There are some serious side effects such as stroke, clotting such as deep venous thrombosis or pulmonary embolus and uterine cancer risk. The risk is small however.

wantanswers: Are there other options, besides a mastectomy?
Speaker_-_Dr_Lee: Absolutely, there are options to having a mastectomy. Lumpectomy with radiation is also an alternative.

marni: How often does breast cancer come back, or metastasize elsewhere?
Speaker_-_Dr_Lee: This depends on the features of the original cancer. Nodal involvement predicts a higher risk of the cancer coming back. Even if the nodes are not involved, over 40% have the ability to come back or spread.

Seeking a Second Opinion

munnybunni: I sent in a question the other day. I am on my fourth mammogram and ultra sound due to the fact that they cannot get two views to do a needle biopsy and I have told me I am too heavy for the stereotactic table until I lose some weight. I don’t want to hurt the physicians’ feelings by going and getting another opinion...my sister died with breast cancer in 2004.
Speaker_-_Dr_ Ananthakrishnan: First and foremost your health is most important. Different facilities have different options for imaging capabilities. Definitely seek a 2nd opinion and take your previous mammogram films with you for the appointment.

munnybunni: Is it possible to call your facility for a mammogram and a visit with a breast surgeon in same day, since I have had three other Mammograms & ultrasound? I was also told I was too big for a MRI table. It seems as though I am overwhelmed with all this...and I guess I am afraid of the answers I might receive.
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: Yes - it is possible to have a mammogram and visit with the surgeon the same day. You would need to indicate that when you make an appointment. The telephone number to call for making an appointment is 1.800.223.2273 ext 43024

munnybunni: I saw where you mentioned about chemoprevention which my Dr. sent me to AGMC to a oncologist there. She sat me down and asked questions. After all the questions she said my risk for heart disease due to family history was higher than breast cancer....she recommended weight loss and walking and going out daily in sun for vitamin D.
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: First you need a thorough evaluation to reconcile the mammogram issue you discussed earlier. Individual risks and benefits vary for everyone. Risk factors for heart disease are extremely important. If you have questions related to heart disease - there is a web chat on our heart centers web site. You can access this at www.clevelandclinic.org/heartcenter

munnybunni: Thus far I would like to thank you and Cleveland Clinic for this chat as I am learning so much from it and never knew something like this existed
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: You are very welcome.

munnybunni: Sometimes you read about drinking or eating things with antioxidants...is that also a good preventative measure?
Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: There have been numerous studies that both support and refute the benefits of antioxidants and cancer. However, there is no clear link with antioxidants and reducing one's risk for breast cancer.

Cleveland_Clinic_Host: We are getting ready to close for today. A large number of questions were received and we apologize if we did not get to your question. We will try to answer as many questions possible in these last few minutes. If you have additional questions, please go to http://www.clevelandclinic.org/health/livepersonchat/to chat online with a health educator.

Cleveland_Clinic_Host: Some participants have asked about upcoming web chat topics. If you would like to suggest topics for 2008, please use our 'Contact Us' link (www.clevelandclinic.org/contactus) to submit your suggestions. In the subject drop down, choose Health/Disease Information, so that we receive your comments. Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Katherine Lee and Dr. Preya Ananthakrishnan is over. Dr. Lee, Dr. Ananthakrishnan, thank you again for taking the time to answer our questions today.

Speaker_-_Dr_Lee__Speaker_-_Dr_ Ananthakrishnan: We enjoyed the format very much and look forward to future chats.

Cleveland_Clinic_Host: If you would like more information regarding breast cancer, please visit the Cleveland Clinic Breast Center web site at http://cms.clevelandclinic.org/breastcenter/. For general health information you may also wish to visit http://www.clevelandclinic.org/health/.

Cleveland_Clinic_Host: Thanks for joining us everyone! Join us for our next live web chat at 12 noon February 5, 2008: Back Pain featuring Dr. Lokesh Ningegowda from Cleveland Clinic Pain Management.