Chapters Transcript Video Young Women & Breast Cancer: Understanding Early-Onset Risk, Genetics & Fertility Today we will spotlight young women and early onset disease as we break down the latest numbers, who's being diagnosed, trends across communities and outcomes. We'll also explore how the environment and exposures intersect with family. History and genetics will map out who should consider screening earlier, high risk groups, inherited mutations, dense breasts, and which changes to watch for, from new lumps to nipple discharge or skin dimpling and will show how AI is reshaping screening and monitoring from smarter mammograms and ultrasound to tools that flag changes, clear answers, practical steps. Welcome to Baptist Health Doctor Doc, a podcast built for innovation and collaboration by physicians for physicians. Hello, I'm Doctor Anastasia Timas, deputy director of Baptist Health Cancer Care and medical director of the Al and Jane Nahmad Women's Cancer Center, part of Baptist Health. And joining me is Doctor Louis Morrell, chief medical executive of the Eugene M and Christine E. Lynn Cancer Institute, part of Baptist Health at Boca Raton Regional Hospital. Hi, Doctor Morrell, and thank you so much for being here today. My pleasure. So today we're gonna be talking about the latest trend that we're seeing as oncologists as we see more and more women being diagnosed at a young age with breast cancer. Uh, today, since Doctor Morrell is an expert in breast medical oncology as well as genetics, she's gonna give us her expert opinion about the latest statistics on young women with breast cancer. I think the most recent reports on, uh, rates of breast cancer drew a lot of attention to actual data now that supports that there's a rise in the incidence or how frequently we're seeing young breast cancer. But of course, everyone is stunned when we see in our practices women in their late 20s or early 30s with breast cancer, since that's not the age that we would normally screen. Um, the, the key though for everyone to remember is that the, the peak incidence. Or the the time that a woman is most likely to get breast cancer is still going to be between 60 and 80 years of age. That doesn't change. And each of those years is probably 1 out of 24 women who could get breast cancer. And that number is more like 1 out of 1200 when you get into the late 20s and early 30s. So it's still not a common finding, and I think everybody realizes that. But what got attention is that when you look back at about the last 10 or 15 years. There is a slow, gra gradual increase in breast cancer. It is about a 1% per year increase. That doesn't mean it goes from 10% to 11% to 12%, but it's 1% of that, so it's a small number, but the, the line is definitely going up, and we've attributed that for years to the fact that women are living longer and it is a disease that is going to occur even in 80 year olds and 90 year olds. But the rate in young women is higher. It's 1.5% per year. So that is a line, a trend that nobody wants to see and has gotten attention and asking the questions of why. Um, we're gonna talk a little bit, uh, later about the genetics component, which is kind of a steady state, but we're all now looking at what are the risk factors and what is that trend since it's now been going on for about 10 to 15 years. Uh, thank you for that information. When as oncologists, when we see women present with early onset breast cancer, which is women under the age of 45, they always wonder what is it that caused the disease, and there's always a lot of concern about environmental risk factors and how this can contribute to the early onset of breast cancer. There's been a lot of scientific publications implicating multiple causes such as radiation exposure and as you and I both know we see women often who were previously treated. For Hodgkin's lymphoma, they receive chest wall radiation, and these women we follow very closely because they're at such a higher risk for developing a future breast cancer. So radiation exposure is certainly one of the environmental risk factors for developing breast cancer. Um, some other implicated causes are toxins such as BPA and plastic, um, and also some pesticides. So these are exposures that have been scientifically linked to an increased risk of breast cancer. There's also a lot of concern about alcohol consumption. This is something that you and I probably talk about all day every day with patients, and a lot of the recent data has shown that drinking alcohol, even in smaller consumptions does increase your risk slightly for getting breast cancer, but obviously the more you drink, the higher the risk is. Uh, currently we're only recommending our patients drink, uh, at at the minute at the most one drink per day. Maximum of 7 drinks per week, um, and obviously for male patients, um, that that allowed consumption is a little bit higher 2 drinks drinks per day because alcohol is also associated with other cancers, as you know, such as colon cancer and head and neck cancers. Um, so these are some of the, the big environmental links to, to breast cancer. And I think that um you know I, I can't remember a time in my career when we haven't been suspicious that younger women were getting breast cancer at a higher rate so it's, it's not a new observation it's just been a little bit better documented. And the other thing I tell my patients that I'm concerned about is activity levels. I can remember many, many years ago when we were looking at prevention options for breast cancer, there was also a study in Sweden that looked at exercise. It was a really well done randomized trial of women who exercise 3 times. A week versus not that had a 40% lower rate of breast cancer that's in the 90s now so we're many years forward from that and that was well before we were sort of getting into a more sedentary lifestyle. So I think that the combination of those things are leading us to sort of the best we can do for the average risk woman. The, the comment I was gonna make about genetics is that um the. The most everyone is familiar with the BRCA gene by now. In fact, there was a podcast I just listened to from here that um was from um Doctor Matir Negron about the BRCA gene. The BRCA gene only accounts for about 25 or 30% of breast cancers under the age of 40, so in spite of the fact that it is an important risk factor, um, it is, is still not explaining everybody or not the only way we're going to be able to identify early onset breast cancers that gene is. Going to be identified in women who have a family history, young breast cancers, ovarian cancer, Ashkenazi Jewish ancestry, um, some other cancers like pancreas may also be associated with it. Anybody who has those family history factors ought to get tested and the reason we're saying that now is because testing has become easy. It used to cost. Thousands and thousands of dollars take months to get a report, and you could only test one gene at a time. It is now something that's really available to everyone as a result, most insurances are covering it and the self pay rate should be no more than $250 which is not, not nothing, but it's not more than a chemistry profile and you only need to do it once in your lifetime. The problem we have is that the women we would like to do genetic testing on and identify with the gene. Aren't coming for mammograms yet. They're 25 years old to 40 are not women we would normally um do screening on, but we want to if they have the BRCA genes. So we have to count on our colleagues, our history taking, our outreach, uh, physicians to recognize that they can do this test one time and get it answered. So if they have a family history, it's, it's not difficult to get testing done anymore and it gives us the opportunity to identify those women who should be screened. And remember that those genes can cause as much as an 80% lifetime risk of breast cancer or a 3% per year risk in a woman who's 30 years of age compared to a 0.2% or something, so. It's really an important risk factor for a very small subgroup, and we're very, um, um, much looking for opportunities to offer that testing so we can identify the women who could do screening and who could do, uh, early diagnosis and then prevention of ovarian cancer in the future. So when you have a young patient who presents with the BRCA gene, how do you recommend that she screen herself every year and at what age do you recommend that she start screening? So in general it's, it's like the other rules if there's a cancer that's young in the family 10 years younger than the youngest cancer but we never start before age 25 and for the BRCA patients in in many parts of the world, uh, we start doing mammogram and MRI at 30 and um if it's BRCA1 or in some BRCA 2 we'll start MRIs between 25 and 30 so it's a, it's a 15 year earlier or at least a 10 year earlier screening. Um, and we have to use breast MRI to, to count on those early detection, um, in those young women cause the breasts are so dense on the mammogram. And, and I am much more of an advocate for screening, but we certainly have all the conversations about what their options are for managing that around pregnancy and, um, and risk reduction if they wanna do that. And then the ovaries really need to be addressed by age 40. Um, so it doesn't have to be scary in terms of you want to have natural childbirth and go through that because it's really just saying let's not plan to have our children at 45. And can you share with our listeners, because a lot of patients who are in their 20s will ask for a mammogram, and some of them are also have some concern about radiation exposure at a young age. Is there any data showing that we shouldn't do mammograms at a very young age because of radiation exposure? I think there is room for caution in exposing the breast that's still developing in a 20 and 25 year old to radiation, and there is uh a reason probably to try to avoid it in in in less it's in a case where you have to do an evaluation of something you feel, but on a routine basis I would prefer. Not to expose younger women to radiation of mammograms. Yeah, I completely agree. And you and I both know that mammography is not a perfect tool, and it can miss up to 10% of breast cancers, especially in a dense breast and a young woman. How do you think that AI is gonna reshape the way we screen and monitor patients? Well, AI in in imaging is one of the most um impressive results I think that we're seeing and the Baptist uh mammogram centers and um up at Lynn Cancer Institute and Women's Institute AI has been an early part uh we've been early adapters to that in fact have been um publishing data on. And and and I think what I tell patients, and I've observed it is that this is not AI reading the mammogram. This is the radiologist reading the mammogram and then the artificial intelligence tool is assisting them or being a second reader. And it's particularly good because the, as any doctor, as any person, you're gonna focus in on an abnormality or a density, what AI can do is. Look at all the tissues around it that are normal. Is there some kind of vessel? Is there some kind of other activity in the environment of what we're seeing? It's led to a 23% improvement in the detection rate in breast cancer, um, when AI is added to, uh, the radiologist and so and and that's without extra biopsies so that's something that is being incorporated across the system and and it is a a a. Really helpful tool because if mammogram is better, then early detection is better, then everything is better. A lot of the advancements and outcomes for breast cancer for all ages has come, um, over the years from early detection. And so having this tool available is, is, uh, really an advancement. Yeah, absolutely. I think it's gonna be transformative. It's actually gonna make the, the, the job of the radiologist a lot easier, you know, much more efficient. So we we also get in addition to the BRCA patients which have a very clear guideline of how they're screened and when they start screening, we also get a lot of questions about how do you screen women that don't have the gene for breast cancer and when they should start screening, say a patient who has a strong family history of breast cancer and a first degree relative like a mother or a sister, what do you recommend to them for early breast cancer screening? So when we do genetic testing on women, especially for family history, we know that probably 90% to 95% of them are gonna have a normal result. I mean it depends on the scenario, but the vast majority, far more of them, even with the family history, are not gonna find the gene. And so we really put this into the category of breast cancer risk assessment and individualizing imaging and personalizing that. I, I, I take this as a very great opportunity to figure out what should you do so it's not just a prescription for the patient. Now there's a tool it's called the Tyraousic tool and that. Is a good tool, but it takes a a fair amount of detailed data entry to actually get the most accurate version of it. I think it's well worth every woman at one time going through that more detailed version of it, um, and whether that's something they even do themselves online or uh or go to a specialist or a breast center to have this done. Um, that you can get a lot of reports, but it's data in data out, so you wanna have a very accurate assessment and then use the guidelines to say who should have. Ultrasound added who should have additional imaging. We've been using contrast, mammogram or breast MRI in our higher risk women and also to remember that it, it, it, it's something that will change during your lifetime. So your score at 42 is not gonna be your score at 65. And so it doesn't mean that you have to continue to do MRI's the whole time. Your breast density may change. Those calculations can change over time, so. Um, it, it, it's a, it's a useful tool that we use to figure out because I don't wanna expose women to undue fear or undue imaging, and you can combine that, especially in younger women where the decision making is so important. So you have 3 or 4 family members with breast cancer, your risk could be very similar to BRCA if somebody had it at 39, you should start earlier and those tools can help us identify who those are. So it's a risk assessment kind of appointment that's well worth having. Yeah, that brings up a great point because I think there's so much confusion surrounding the guidelines and the American Cancer Society also stresses that if you don't have the gene or if you don't have a strong family history, you should still start screening at the age of 40 and then every year thereafter and I think if you bring up a great point because you have to individualize the risk and if they're at a high risk or if they have the BRCA gene then they obviously go into a different category they start earlier and their screening is more robust um so when we see these patients that are young and that are diagnosed with breast. Cancer, it's such a dilemma because there's so many different factors that these young women are facing. And one of the biggest factors is if they want to preserve their fertility, how do they do that? And we all know that chemotherapy can really affect the fertility and how do we preserve it? And there's so many different options that we have nowadays, luckily, like freezing eggs, freezing embryos, taking part of the ovary to reimplant it later. And the important thing is to to for patients to really work within a comprehensive breast cancer program that has these fertility specialists available to them and if you can share about your program and the specifics of that, yes, I, I think again being aware of what the options are. You know, when a woman, any woman, but especially a young one, because of the unique um impact a diagnosis at 34 years of age, no children yet could mean to that woman. And of course, The, the, the, the kinds of reactions that person most likely gonna have are gonna be, you know, what's gonna happen to me? How do I get rid of this? How do I get past this, you know, is it gonna affect any other family members? or how's it gonna affect my life? Am I gonna need chemo? Am I gonna lose my hair? All those things are racing. And every woman you meet, they probably wanna have their breast off yesterday you know there's a real, there's a, there's such a sense of, of, uh, a universal urgency and there are things that require an assessment right at the time. Is this a person who should have treatment before they have their surgery. And is this a person who would like to have more children because you could lose your window to preserve that fertility if you just don't even address it and if they don't address it and so what's become an optimal way for us at our center is before every patient has that surgery first treatment they're gonna meet with the whole team they're gonna meet with the medical oncologist individually but at one appointment. They're gonna meet with the geneticist, they're gonna meet with um the radiation oncologist, they're gonna meet with the psychosocial person and that. Issues like they need a fertility specialist, let's get that in. Let's get it going. We can get it in. We have a window or no, I'm not interested in it so that we're not missing the opportunity, but it means you have to work with the team. You can't do it on your own. You can't just go straight to this or straight to that. Everybody needs to be engaged. And so for younger women, I think that this is, uh, absolutely essential and really become standard and I, I think that you are and in the South you at Miami, Miami Cancer Institute, you're doing some of this multidisciplinary as well we have a similar multidisciplinary program that you do and it's so important you've highlighted how there's so many challenges and that cause fear and anxiety in these young women and how important it is to have all the specialists there together to see the patient in a timely manner and to really um individualize the best plan and treatment options for that patient. So I really appreciate all your comments today and sharing your high level of expertise and today we've really discussed we've covered screening, um, the environmental risk factors, genetics, AI, how it's shaping the care for our young women in the realm of breast cancer, fertility preservation options, survivorship and how uh we can access patients can access. um all these important contributions that we have for their care and as a team of medical providers at Baptist Health, uh, we are committed to ensuring that our community is educated on all options available to them so the progress is real and it's accelerating and I want to thank you for your time today. Thank you very much. Thanks to everyone for listening too. Thank you. To find out more about the topics covered on Baptist Health. to doc, please visit physiciansources. Baptisthealth.net. Created by
