 What causes breast cancer? Well, looking for an exact cause is not really available today at this point, though research is going on. What is important is that we know that there are significant risk factors that will increase a woman's risk for developing breast cancer. And some of these are related to estrogen levels because we feel that higher estrogen levels are related to the development of breast cancer. If we look at things such as late pregnancies, late menopause after 55, early menstruation before 11 or 12 years of age, if we look at lack of exercise and we look at being overweight, obesity, we are looking at situations where the estrogen levels are high. Now, the highest risk factor is age. The older a woman gets, the higher her risk for breast cancer. And generally, most breast cancers are picked up after 50 or 55 years of age. But I caution all women that although the majority over two-thirds of invasive cancers are after age 50-55, every woman should be aware of changes in her breasts, whether she's in her 20s, 30s, 40s, or older. Because age is not a protection, it still can happen in young women and does. How is breast cancer detected? Breast cancer is detected either through the patient herself being aware of her breast and the risk for breast cancer and is proactive about her own health or by her family physician and organicologist. Also, we do screening mammography on women from age 40 on. Of course, the mammography is done on younger women depending upon their family history. So, much of following women with breast disease or breast family histories is individualized. But between physical examinations, breast self-examinations, and doctor checkups, breast cancer is detected. When should a woman have a mammogram? There has been a tremendous amount of controversy and so this question is a very good one. I personally treat patients as individuals and I think they should be. Mammographies, the standard today, I think it's acceptable to start at age 40 and do them annually. Then as women get older into their 70s and 80s and 90s, I think mammography can be altered maybe to every 18 months and obviously if somebody's not medically able to go for a mammography when they're in their 80s and 90s, then it can't be done. But I think because women are much younger today, you can't look at the chronological age of a patient. You must look at their history, family history for cancer, and other circumstances to make any adjustments in the intervals between mammograms once a woman is 80 and older. Are some women more likely than others to get breast cancer? Yes, and I like this question because it helps to go along with trying to put in perspective where women stand regarding hereditary breast cancer. Women will think, oh, I don't have a family history of breast cancer. I don't have a family history of other cancers, so I can have that BRCA mutation which increases the risk for breast cancer. But the majority of women who get breast cancer do not have a family history. So it's important that women understand they must go for screening mammographies. They must do those things that reduce their risk for breast cancer. The women who don't have a choice are women who are mutation positive for BRCA1, BRCA2 and now we've identified other mutations that increase a woman's risk for breast cancer. This is why your family history should be known to you so that when you go to your physician they can see whether or not you need to see a geneticist in consultation. There are things that can be done. Please learn your family history. If a woman is diagnosed with breast cancer, will she necessarily have to lose her breasts? No, and that's a very good question because I strongly feel that women delay coming to get examined if they pick up something because they were afraid. And I think being afraid is due to many, many misconceptions. Mastectomies are a choice. There are two ways to treat breast cancer surgically and this is for local control. This is removal of the breast called a mastectomy with or without immediate reconstruction or lumpectomy which is a wide removal of the cancer with a rim of healthy breast tissue around the cancer itself followed by radiation. Radiation has come a long way and now we have available for patients the six-week standard but we also have a three-week program which was developed in the Canadian program in Toronto which is available which is a three-week program. We also have available CyberKnife. So radiation has gone from just one mode to various options for the patient. So when we look at a breast cancer with the diagnosis we have to determine does the woman have more than one cancer in that breast? If she does, she does require a mastectomy. If a woman has a large cancer that measures maybe three or four inches she might be best suited to have preoperative, before surgery, drug therapy. It's important that patients know that the tumors can be shrunk so that they may not have to have the mastectomy. They might be able to have the breast conservation which is the lumpectomy with radiation. In addition to the surgery on the breast which is for local control and neither one of these methods is a hundred percent. They both have the risk, a small risk of local recurrence. Now patients with mastectomy rarely will need radiation but there are certain circumstances where they might. Are other treatments required after undergoing surgery for breast cancer? Yes, breast cancer is and should be approach as a team effort and the people involved would be the medical oncologist, the surgical oncologist, the radiation oncologist and we also have involved nurse navigators. We have social workers involved. There's an entire team that's dedicated to ensuring the patient gets her full treatment. Today particularly since we have such a deeper understanding of the biology of breast cancer we have been able to individualize the treatments for patients. So patients should understand because of what's available thanks to research. Not everyone is required to have chemotherapy. We can do testing of their cancer cell to see if there's a benefit to chemotherapy and we can also test cancer cells to see what type of chemotherapy is to that patient's advantage for their breast cancer and reducing the risk of the breast cancer coming back. So ordinarily I would say the majority of women who have breast cancer will require additional treatment whether it's radiation treatment, if they have breast conservation or the small rare cases of mastectomies that require it, post mastectomy, but also drug therapy which is under the care of the medical oncologist who may or may not start the treatment before surgery depending upon that patient's circumstances. Why do some women have a mastectomy when they don't have breast cancer? Often what triggers a woman to consider having a breast removed is a friend or a relative gets breast cancer and the alarms go on and they decide, wow do I want to go through what they've gone through for treatments? Really not even knowing what the treatments are today which have come a long way. But women who have strong family histories rightfully will come and ask about what we call prophylactic mastectomies. That's the removal of breasts that do not have cancer. And I think that's a very hard discussion to have and it shouldn't be taken lightly. A patient who is considering having a breast removed because of a strong family history needs to understand that removing the breast is not 100% prevention. It's a 90% reduction. There isn't any way surgically that every single ductile cell in the female breast is going to be removed surgically. So it's a 90% reduction, not 100%. And I make it very clear that patients understand that. Now there's a group of patients who really don't have a choice. That's women with the mutations of the BRCA1 and BRCA2 genes which significantly increases their risk for breast cancer and can occur at a younger age and can occur in both breasts. So risk is probably greater than 60% or so for breast cancer. And there are other cancers that there are also increased risk for like ovarian. But those women should have prophylactic mastectomies. Now I am diagnosing BRCA positive women in their 70s and 80s where following them is high risk with mammograms, sonograms and breast MRIs. But younger women who are BRCA positive must or at least strongly encourage them to see a medical oncologist, a geneticist and a breast surgeon. Can a woman take any steps to avoid breast cancer? Absolutely. There have been risk factors identified that are what we call modifiable. When you look at the risk factors of alcohol, you look at the risk factors of lack of exercise, you look at the risk factor of obesity, particularly post-menopausal obesity because post-menopausal obesity and lack of exercise has been identified as a risk factor for estrogen positive post-menopausal breast cancer. So these are things that women can modify, their diets, their exercise, their alcohol consumption, binge drinking particularly is not advised. I also feel that women have to appreciate the things they can't modify and that's our getting older, that's a given. We can't do anything about our hereditary or genetics. We also identify other things that increase our estrogen levels and early menstruation. Now, the average age used to be 12, 13, it's much lower now. So the younger, a young girl starts to menstruate and the later a woman goes through menopause, gives a huge interval of estrogen exposure and having pregnancies after 30 or no pregnancies, leaving the breast cells immature and not fully developed which is what pregnancy does, full pregnancy does. These are things that prepare the breast cells to be stronger against any factors which may try to alter their cell proliferation. For more information on Winthrop University Hospitals Breast Program, please call 1-866-WINTHRUP or visit us online at winthrop.org. Our nurse navigator is prepared to help you through your journey with any breast issues. Thank you.