Breast cancer is the second leading cancer among women, behind non-melanoma skin cancer, and is also the second leading cause of death among cancers in women, behind lung cancer. However, mortality rates for breast cancer among women have been decreasing since the 1980s, due to more widespread screening, breakthroughs in genetic research resulting in improved early diagnosis, and more effective treatments.
In this episode of Kentucky Health, host Dr. Wayne Tuckson welcomes a cancer control specialist and an oncologist to discuss types of breast cancer, screening recommendations, and methods of treating the disease.
Janikaa Sherrod, MPH, is a cancer control specialist with the Kentucky Cancer Program and is the program coordinator for Kentucky African Americans Against Cancer. Dr. Mounika Mandadi, MD, is a medical oncologist with the James Graham Brown Cancer Center and is an assistant professor of medicine at the University of Louisville School of Medicine.
Mandadi says that breast cancer in women most often originates within the milk ducts and glands. Like other cancers, breast cancer is diagnosed in stages, from 1 to 4, with advanced Stage 4 indicating that the cancer has metastasized or spread to other organs. “The treatment depends very much on what stage the cancer is picked up,” Mandadi says.
Diagnosing Breast Cancer and Options for Treatment
“The screening for breast cancer is basically done with what’s called a mammogram,” Mandadi says. “A mammogram is essentially an X-ray of the breast. There are two different views of X-rays which are taken. One X-ray is taken from the top to the bottom of the breast, and one X-ray is taken of the side. And a radiologist then looks at these pictures and tries to pick up if there are any new masses that have formed in the breast.”
If anything abnormal is found, the patient will consult with her oncologist to determine a plan of action. “Early stage breast cancer is more curable,” Mandadi says. “When I say early stage, the breast cancer is confined to the breast, and if it has spread, it has only spread to the lymph nodes on that side of the breast within the axilla (armpit). When that’s the case, it can be diagnosed as Stage 1, 2, or 3.”
If the cancer has spread beyond the breast and the axillary lymph nodes on the same side and is found in other organs, the cancer is classified as Stage 4, and is treatable with medications but not curable.
About 1 in 8 women will get breast cancer in their lifetime, roughly a 12 percent chance. However, certain groups of women have a higher than average risk of getting the disease, Mandadi says. Women who have already had breast cancer, or have a family history of breast cancer, or have had abnormal mammograms before that weren’t cancer, have an elevated risk of getting breast cancer. Other risk factors are having an early menarche (onset of menstruation) and late age of first childbirth, Mandadi adds.
Genetic testing for breast cancer has become more prevalent in recent decades, but Mandadi says that it’s not offered for every woman. Only 5 to 10 percent of breast cancers are genetic, but screening is required for those who have been identified as having a higher risk of getting the disease.
This elevated risk is determined by examining family history and in particular documenting whether family members with breast cancer carried specific genetic mutations. “The most well-known mutations to all of us or most of us are the BRCA-1 and BRCA-2,” Mandadi says. “These are called high penetrance mutations. What that means is that if a woman has this mutation, there is a very high chance of the woman developing breast cancer, such as 50 or 60 percent lifetime risk.”
If a patient is found to carry the BRCA-1or BRCA-2 mutation, they may be referred to a specialist like Mandadi, who operates a high risk breast cancer clinic at the Brown Center. The specialist runs different probability models to assess the patient’s lifetime risk and then consults with them about strategies for treatment.
“As we know, breast cancer can be treated by just removing the tumor if it’s small enough, not having to remove the whole breast,” Mandadi says. “And sometimes women opt for what’s called a mastectomy, or removing the whole breast, or we may have to do it just because of how big the tumor is.
“People who have BRCA-1 or BRCA-2 mutations have a higher risk of developing a second breast cancer or a contralateral breast cancer, meaning breast cancer in the opposite side,” she adds. “So we do discuss what’s called prophylactic mastectomy of the other breast as well as mastectomy of the side which is affected by the tumor, so that’s a big difference. We would not offer bilateral mastectomy to every woman who’s diagnosed with breast cancer.”
Improving Screening for Breast Cancer in Kentucky
As mentioned above, nationally 1 in 8 women will be diagnosed with breast cancer. But Sherrod says that incidence rates in Kentucky are slightly higher overall than the national average, around 125 in Kentucky versus 124.7 per 100,000 people. In recent years, Kentucky’s incidence rate has dropped to more closely align with the national rate, Sherrod explains – but for certain population groups, such as women living in eastern Kentucky and African American women in the state, incidence rates, and mortality rates as well, are still troublingly high.
Access to health care is a primary reason for this, Sherrod says. “For example, in eastern Kentucky, we know that people do not have as much access to screening mammography facilities,” Sherrod explains. “And even if they do, they may have to drive for hours to be able to access those facilities.” As for people living in metro Louisville, Sherrod adds that while they may have more mammography centers nearby, low-income patients still struggle with scheduling appointments and navigating public transportation in order to visit the clinics.
Sherrod says that women have the option to begin breast cancer screening at age 40, but they need to confirm that their insurance will pay for that screening before having it done. “After the age of 45, we do encourage women to get regular screenings – by regular, I do mean annual mammograms,” she says.
Mandadi adds that if a person has a family history of breast cancer, they should start getting mammograms earlier. “The recommendation would be to start at least 10 years earlier than the youngest family member with breast cancer, as long as it’s not under 30,” she says.
Sherrod’s work with the Kentucky Cancer Program includes public outreach and education. One of the initiatives they promote is the Kentucky Women’s Cancer Screening Program.
“For women who feel they might not be able to afford a mammogram, or if they’re uninsured, we’re so fortunate to have this,” Sherrod says. “What that program does is provide free or low-cost breast and cervical cancer screening and diagnostic services for women who need to be screened.”
To be eligible for this program, a woman needs to be over age 21, and either uninsured and/or have a personal income at or below 250% of the poverty level.
“If these women are eligible, they can get their screenings through this program, they can receive any kind of follow-up diagnostic exams through this program,” Sherrod says. “And, if anything comes back positive on these exams or diagnostic tests, they can actually receive treatment through this program. They will receive a Medicaid card, and their treatment will be covered.”
To learn more about the Kentucky Women’s Cancer Screening Program, call 1-844-249-0708.
Sherrod says that, through her outreach, she has found that some women are apprehensive toward getting screened for breast cancer because they have heard that getting a mammogram is painful.
“What we try to tell women is that it’s not necessarily about the pain – you fell some discomfort,” she explains. “A slight amount of discomfort for a short amount of time, but for that 15 to 30 minutes, it can save the rest of your life.”