Peconic Bay Medical Center’s Ask the Medical Expert:
Seeing Pink: Let’s Discuss Breast Cancer & What You Need to Know
A Discussion With Dr Susan Lee, Breast Surgeon
with Peconic Bay Medical Center, a member of Northwell Health
Breast cancer is the most common cancer diagnosed in women worldwide which means 1 in 8 women will be diagnosed with breast cancer in their lifetime. According to the American Cancer Society, estimates for breast cancer in the United States for 2018 are as follows:
- About 266,120 new cases of invasive breast cancer will be diagnosed in women.
- About 63,960 new cases of carcinoma in situ (CIS) will be diagnosed (CIS is non-invasive and is the earliest form of breast cancer).
- About 40,920 women will pass away from breast cancer.
- In recent years, incidence rates have been the stable in white women and increasing slightly (by 0.3% per year) African American women. Breast cancer is more common in these women, compared to women of other races/ethnicities.
- Mammography will detect 80-90% of breast cancers in women without symptoms.
- There are more than 2.8 billion cancer survivors in the United States.
According to the National Breast Cancer Foundation:
- One in eight women in the United States will be diagnosed with breast cancer in her lifetime.
- Breast cancer is the most commonly diagnosed cancer in women.
- Breast cancer is the second leading cause of cancer death among women.
- Each year it is estimated that over 252,710 women in the United States will be diagnosed with breast cancer and more than 40,500 will die.
- Although breast cancer in men is rare, an estimated 2,470 men will be diagnosed with breast cancer and approximately 460 will die each year.
- On average, every 2 minutes a woman is diagnosed with breast cancer and 1 woman will die of breast cancer every 13 minutes.
- Over 3.3 million breast cancer survivors are alive in the United States today.
Medical Expert Dr. Susan Lee:
QUESTION: How prevalent is breast cancer in women?
ANSWER: A woman has a 1:8 lifetime probability of being diagnosed with breast cancer which is a 12% lifetime risk. It is 30% of all diagnosed cancers in women. According to the American Cancer Society, in 2018, approximately 266,000 women will be diagnosed with invasive breast cancer and 64,000 women will be diagnosed with noninvasive breast cancer.
QUESTION: What types of breast cancers are there?
ANSWER: There are many types of breast cancers, but the most common type of invasive breast cancer is invasive carcinoma, making up approximately 80% of all breast cancers. The second most common is invasive lobular carcinoma, this is the type that may be missed on mammograms or ultrasounds. The other more rare types of breast cancers make up the remaining 10%. Ductal carcinoma in situ (DCIS), is stage 0, and is non-invasive breast cancer. The number of DCIS diagnosed has increased as more women are getting screened and the majority of the time it is found on screening mammograms. The prognosis for DCIS excellent with over 98-99% survival.
QUESTION: Are there certain demographics which tend to lead to a more prevalent diagnosis? For example, does race or ethnicity play a factor in diagnosis?
ANSWER: Ashkenazi Jewish, Norwegian, Dutch and Icelandic populations have a higher prevalence of the genetic mutation (BRCA1 and BRCA2) which increases the risk of breast cancer. African Americans have a higher risk Her2neu positive breast cancer and the more aggressive triple negative breast cancer.
QUESTION: It is often said that breast cancer ratios are higher here on Long Island than in other parts of the country. Do you agree with that?
ANSWER: There have been reports of 11-13% above the rest of the state and 3-1% above the national average. However there have also even been misquotes of 30%. In 2004 there was a study conducted by the government called the Long Island Breast Cancer project to determine if there were specific factors which were responsible for the reported higher rates of breast cancer on Long Island. The study did not find any environmental (air toxins, electromagnetic fields, water contamination, hazardous waste etc).
However, there was a higher incidence of already known causes of increased breast cancer risk including: positive family history, increased alcohol consumption, having children at a later age, etc. Also, Long Island has more affluence and more women are likely to get screened.
QUESTION: Are men ever diagnosed with breast cancer? If so, what causes them to get breast cancer and is it treated the same way as women?
ANSWER: Breast cancer can be diagnosed in men but is very rare, with a lifetime risk of .1%. According to the American Cancer Society, in 2018, approximately 2250 men will be diagnosed with breast cancer. If a man carries the BRCA2 mutation, he will have a 5-10% life time risk of developing breast cancer.
QUESTION: Can children be diagnosed with breast cancer?
ANSWER: Breast cancer in children is extremely rare and usually of a different type than adult breast cancer. There is <.1% chance of developing breast cancer in this population.
QUESTION: Is there anything a person can do to prevent a breast cancer diagnosis?
ANSWER: There is nothing that can 100% prevent breast cancer. There can be lifestyle habits which can decrease the risk such as: exercise, eating healthy, avoiding processed food, not smoking, and limiting alcohol consumption. For patients who are “high risk,” there are medications (anti-estrogens) which can decrease the risk of breast cancer but it is important to note that there are side effects and the benefits of taking the medication should outweigh the negatives. Some patients who are extremely high risk, such as the BRCA mutation carriers, may choose to have prophylactic mastectomies to decrease their risk by 90-95%. Angelina Jolie and Christina Applegate are two well celebrities who made this decision.
QUESTION: What are the 2 strongest risk factors for breast cancer?
ANSWER: The 2 strongest risk factors for breast cancer are female gender and increasing age. Other risk factors include no children, 1st child after the age of 30, more than one alcohol drinks per day, obesity, smoking, strong family history of breast cancer, personal history of atypia on breast biopsies, carriers of breast cancer increasing genetic mutations, early menarche and late menopause, prior high dose radiation to the chest (lymphoma).
QUESTION: What new types of procedures and treatments are taking place at Peconic Bay Medical Center?
ANSWER: Peconic Bay Medical Center is the only hospital in the Forks (North and South Fork) that offers DIEP autologous reconstruction (see below) and placement of an implantation device to direct radiation therapy after a lumpectomy and possibly improve cosmetic results.
QUESTION: What is the difference between a lumpectomy and a mastectomy?
ANSWER: Lumpectomy is also known as breast conversation surgery and is removing the cancer only and preserving the breast. Usually, patients who have a lumpectomy also have to have radiation therapy. Mastectomy is the removal of the breast. There are variants of mastectomy: skin sparing mastectomy, nipple sparing mastectomy depending on patient eligibility. Radiation usually is not needed with mastectomy but there are exceptions. Also, reconstruction can usually be offered at the same time as the mastectomy. There are different types of reconstruction and it is important to meet and discuss the options with a plastic surgeon prior to surgery. The current gold standard for reconstruction with the patient’s own tissue is called a DIEP reconstruction and is performed only by plastic surgeons with special microvascular training/experience. PBMC Northwell Health is the only hospital in the Forks (North and South Fork) that offers this type of reconstruction.
Let’s Discuss Genetics
QUESTION: What role does genetics play in breast cancer?
ANSWER: About 5-10% of breast cancers are thought to be hereditary. A diagnosis of breast cancer does not mean a patient has a genetic mutation. Having said that, more than 75% of breast cancer patients have no family history of breast cancer.
QUESTION: Can you tell us a little more about the BRCA genes?
ANSWER: The BRCA genes are human genes which make tumor suppressor genes that help repair damage of cell’s DNA. When these genes have mutations, the protein is not made or is made but functions incorrectly. Damaged cells are not repaired correctly and may lead to increase in developing cancer.
- QUESTION: What could cause mutations on these genes?
- ANSWER: Mutations in genes are changes in the DNA of the genes and causes can be environmental such as radiation, toxins, chemicals or they can been spontaneous, resulting from error that occurs during cell replication and division.
- QUESTION: Are these genes found in both men and women?
- ANSWER: The BRCA gene is found in both men and women. In the general population, it is found in 1 in 400 people but in certain high-risk groups like the Ashkenazi Jews, it is found in 1:40.
- QUESTION: Does a mutation mean that one will definitely be diagnosed at some point of a person’s life with breast cancers?
- ANSWER: Having a mutation is does not mean a person will definitely get breast cancer however the risk of getting breast cancer is increased. Depending on the mutation, for BRCA carriers, the lifetime risk of developing breast cancer is 40-85% and there is also an increased risk of developing a second breast cancer. In addition, there is a 16-44% increased risk for developing ovarian cancer compared to 1-2% for the general population.
QUESTION: Is there a blood test or any other test to screen people for genetic predisposition for breast cancer?
ANSWER: Yes, several different tests are available. If there is a known mutation in the family, targeted testing for specific BRCA mutation can be performed. Currently multigene panel testing is done to look for mutations in several genes that are associated increased breast and ovarian cancer, including the BRCA genes. A blood or saliva sample for DNA is needed for all of these tests.
The Importance of Screenings:
QUESTION: Please tell us about breast cancer screenings and at what age should screening for breast cancer begin and how often?
ANSWER: There are a lot of different recommendations in the media depending on the reported organization about when to start screenings. The initiation of mammogram screenings varies from 40-50 years old and annually or biennually thereafter as long as the patient is in good health and 10 years of life expectancy. Each patient should discuss with their provider which recommendation to follow and it may also be dependent on a patient’s insurance. For patients with dense breasts, an ultrasound may be added. For patients deemed as “high risk,” MRI’s may also be added. If there is any question that a woman is “high risk” for breast cancer, they should see a breast specialist to determine if a different screening protocol applies.
QUESTION: What types of screenings are there? Is there one more effective than others?
ANSWER: Mammograms are our main tool for breast cancer screening. However there are about 10% of breast cancers that are not seen on mammogram. For women who have dense breasts, ultrasounds screenings can be performed in addition to the mammogram. Ultrasounds alone are not recommended for screening and should not take the place of mammograms as there are early signs of breast cancer, such as microcalcifications which may not show up on ultrasound. MRI screenings are not recommended for the general population.
Self-awareness of how ones breasts look and feel may help find changes that may prompt a woman to seek medical attention. However, breast self-exams have not been found to decrease the risk of dying from breast cancer.
QUESTION: If a person is screened and diagnosed with breast cancer are the treatment options the same or does it depend on the breast cancer type they have been diagnosed with?
ANSWER: We have progressed from treating every breast cancer exactly the same way to using size and amount of spread to dictate treatment and now also using tumor characteristics including receptor status: (estrogen and progesterone, her2neu), the genomic testing of the tumor itself and taking the general health and age of the patient into consideration. Some patients may even receive chemotherapy prior to surgery. Breast cancer treatment is complex, constantly changing and the importance of seeing a Breast Specialist cannot be overstressed. It has evolved to involve multiple medical specialties working together to individualize treatment.
QUESTION: What is triple negative breast cancer?
ANSWER: Triple negative breast cancer is a type of breast cancer that does not demonstrate estrogen, progesterone or Her2neu staining, thus “triple negative.” Hormone therapy and targeted therapy with Herceptin cannot be used in this type of breast cancer. This type of breast cancer tends to be more aggressive and the majority of these patients will receive chemotherapy regardless of surgery or radiation. Triple negative breast cancer is 10-20% of all breast cancers. There is a higher incidence in younger women (<40-50 years old), African-American and Hispanic patients and BRCA1 carriers.
About Dr. Susan Lee
Dr. Susan Lee is Chief of Breast Surgery at Long Island Jewish (LIJ) Forest Hills in Queens and see patients at Peconic Bay Medical Center (Riverhead), a member of Northwell Health. Dr. Lee is Board Certified in Obstetrics & Gynecology. She can be reached at (718) 925-6294.
About Peconic Bay Medical Center
Located in Riverhead, NY, Peconic Bay Medical Center is a non-profit hospital committed to providing exceptional care and improving the health of the communities it serves. Peconic Bay Medical Center offers wide-ranging, full-scope services and programs along with state-of-art technology. Peconic Bay Medical Center joined Northwell Health in 2016. For more information, visit PBMCHealth.org.
About Northwell Health
Northwell Health is New York State’s largest health care provider and private employer, with 22 hospitals, over 550 outpatient facilities and nearly 15,000 affiliated physicians. We care for more than two million people annually in the New York metro area and beyond, thanks to philanthropic support from our communities. Our 62,000 employees – 15,000+ nurses and 3,900 employed doctors, including members of Northwell Health Physician Partners – are working to change health care for the better. We’re making breakthroughs in medicine at the Feinstein Institute. We’re training the next generation of medical professionals at the visionary Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and the Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies. And we offer health insurance through CareConnect. For information on our more than 100 medical specialties, visit Northwell.edu.
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