Breast Cancer Q&A with Dr. Elizabeth Steiner

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In a one-on-one interview, Dr. Elizabeth Steiner, the Director of the Breast Health Education Program at OHSU's Cancer Institute, talks about breast cancer and what you need to be aware of.

Question 1: What are the causes and risks of breast cancer?

"To some extent we don't know. We do know that there are some things that increase a woman's risk for breast cancer. The two biggest risk factors for breast cancer are being female and getting older. "

"However, there are some things we can change to decrease our risk for breast cancer."

  1. "Watch how much alcohol you drink. Women should not drink more than one alcoholic beverage a day."
  2. "Exercise reduces breast cancer risks"
  3. "Breast feeding reduces breast cancer risk."
  4. "Maintaining a normal, healthy body weight reduces breast cancer risk.
  5. "Those are some of the biggest ones we know right up front. These are things we can change and control."

Question 2: Will taking hormone replacement therapy increase the risk?
"Hormone replacements a real tricky subject. There's a lot of  evidence now that suggest that hormonal replacement therapy, 
especially if you're taking both estrogen and progesterone, the two different hormones, which most women do, does increase your risk of breast cancer somewhat."

"It's kind of a balancing act. It definitely increases risk, but not as much as some things. Alcohol actually increases risk more than hormone replacement therapy."

"Hormone replacement therapy doesn't have as many benefits as we once thought it did. It does not work to reduce risk of heart disease. It does help with Osteoporosis and with the symptoms of menopause. But long term therapy with hormones probably doesn't make sense for most women because of the increased risk for breast cancer and other problems."

Question 3: Will taking birth control pills increase the risk?

"The evidence on this is pretty mixed. On the whole we believe that taken appropriately, birth control does not increase breast cancer risk because the doses are much lower and people are using them in a time of their lives when they normally have normal, internal levels of these hormones."

"One of the issues with hormone replacement therapy after menopause is that we're replacing with different kinds of estrogen than we use in birth control pills and at higher doses. And it's the time of our lives when we're not supposed to have these hormones running around in our bodies."

Question 4: How many different types of breast cancer are there?

"There are a lot of different types. The most common type is called Ductile Carcinoma. That's cancer that starts in the milk ducts of the breast. It comes in a lot of different varieties. When we're lucky we catch breast cancer very early. It's still contained inside the duct. Most of the time it's caught when it starts to spread outside of the duct, which is called Invasive Breast Cancer."

"We can also have breast cancer that starts in the lobials, which are collections of cells inside the breast."

"A less common type of breast cancer is called Paget's disease. This is breast cancer that starts in the skin on the breast. You can see that from having red, scaly skin on the breast. Women should really talk to their doctor if they notice this because it could easily be mistaken for something else."

"Inflammatory breast cancer is very rare but it's gotten a lot of attention recently because it's fairly dramatic and harder to 
diagnose. It often causes significant enlargement of the breast,  redness and swelling, thickening, and changes in the skin."

Question 5: How many stages of breast cancer are there?

"Four. The first stage is confined in the breast. The second stage is a local tumor plus involvement of the local lymph nodes. The third stage is involvement of the lymph nodes and possibly the local chest wall. The fourth stage is when the cancer spreads to distant organs like the lungs, brain, and bones."

Question 6: How would I know if I had breast cancer?
"Most breast cancer is found one of two ways. It's found cause either a health care professional finds a lump on a screening medical breast examination, which is something a woman should do once a year once she turns 20, on a screening mammogram, which usually starts at the age of 40, or by a woman's self breast examination."

"You either feel a lump or there are changes on the mammogram that show calcium deposits from where cancer cells are."

Question 7: Self-Breast Exams: New Techniques

"There's breast tissue over the entire chest wall. Instead of just being the obvious breast bound that we see, we need to examine this entire area. The breast is a 3-dimensional structure. It's very important when we're doing our exam to feel at multiple levels. There are 3 levels of pressure: light, medium, and deep, which is pushing all the way to the chest ribs."

"When we do a breast exam we want to use what's called the Vertical Strip Three Pressure Method. We want to cover the entire perimeter. The exam should start at the top of the armpit and going in strips all the way down and up. And feel each location with the three levels of pressure."

"The best sensory apparatus we have is in our fingertips. When we do a really good breast exam we can find a small mass, like the size of a pencil eraser, 85% of the time. Do self exams correctly. Second of all, do them regularly. The best time to do one if you're still having menstrual cycles is on day 5-10 of your cycle. You're breasts have the least influence from hormones, so they're less tender and lumpy. It's important to do them at the same time of your cycle every month because you get to learn what's normal for you. Any woman is going to know better than any health physician what her breasts should feel like."

"Women who are more at risk had babies really late, didn't choose to breast feed, are overweight, drink more alcohol, or have a known genetic mutation. These women should learn how to do a correct self-exam by a professional."

Question 8: Are all lumps cancerous?
"No. Absolutely not. The vast majority of the time a lump that a woman finds is not cancer. It's very hard to tell just by feeling 
though. If a woman feels a change, we want to follow that up. No matter what go in and figure it out."

Question 9: What about a mastectomy?

"If we catch breast cancer at stage one it's 98% curable. A woman can then have a lumpectomy to take out the cancerous area and radiation therapy to kill of any remaining cells that are cancerous in that area. OR they can have a mastectomy to take the whole breast tissue off. Sometimes women with stage one are offered chemotherapy, which is a combination of drugs that kill off cancerous cells. Chemotherapy is tailored to each individual woman's needs and her specific cancer."

"Many women take pills for 5-10 years after that have been shown to reduce the re-occurrence and have very few side-effects."

Question 10: What are the treatments for breast cancer?
"In the past a mastectomy not only meant taking off the breast tissue but a lot of the muscles of the chest wall to. That left women with a lot of limitations on how they could physically move like their arm."

"Now we understand we don't have to do that. Mastectomy is aggressive in the sense that it takes off the entire breast, but for many it's the option of choice. For those who have stage one it's either having a lumpectomy and radiation or a mastectomy and being done."

"It's a very personal decision that women have to make themselves. Counselors are available to help women discuss their options."

Question 11: What are the chances the breast cancer will come back?

"It depends on what stage the breast cancer was at when found. Stage 1 has a survival rate of 95-98%. Stage 2 is a little less good. It's in the range of 75-80% and the number's go down from there. It's really important to catch breast cancer early."

Question 12: Can breast cancer be inherited?
" We know that there are certain gene mutations that people can inherit that increase the risk of breast cancer and other kinds of cancer. Two of the most common ones are BRCA1 (breast cancer 1) and BRCA2 (breast cancer 2). These are more common in certain populations. Jewish women from Eastern Europe heritage, certain Asian women, and other small populations that are more at risk. It doesn't mean the women outside these populations don't have these genes."

"The average risk of getting breast cancer if you live to 85 is about one in eight. The average risk if you have this gene and do 
nothing to prevent it is 40-80%. These genes are rare. Only 5-10% Of breast cancer is caused by genetics."

"Genetic testing is not recommended for the vast majority of people. The U.S. Preventative Services Task Force says genetic testing is really only indicated for women who have certain ethnic heritages or women who have certain genetic patterns in their family, such as lots of members getting breast cancer before menopause. This is less common than getting breast cancer after menopause."

Question 13: Should women under 40 get a mammogram?

NO. A mammography under 40 is a bad test. There is no reason to do it. The test has too many false positives, which means it thinks it's found cancer when it isn't there, and too many false negatives, which means it doesn't find cancer when it's there. Women under 40 should have a yearly medical breast examination by a physician and self breast examination on a regular basis."

Question 14: Being cancer-free

"Many times now cancer is a chronic illness rather than an automatic death sentence. It's important to be aware of that. Often times people don't get screened for cancer cause they don't want to know. When in fact, when caught early cancer's a curable disease. We save lives everyday by curing cancer. But we can only fix them if people come see us and help us look for them."