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Steve E. Bishop, M.D.

By: Steve E. Bishop, M.D. on October 29th, 2020

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A PMD Conversation: Breast Cancer

Medical Perspectives | Lifestyle & Wellness | Facebook Live Recap

October is National Breast Cancer Awareness Month. And in recognition of this topic's importance, we hosted A PMD Conversation: Breast Cancer with Dr. Steven Bishop, Dr. Tamara Sobel, and Dr. Susan Scharpf. Over about 25 minutes, they discussed numerous topics related to breast cancer, including prevention, screening, treatment, and what they discuss with their patients regarding breast cancer. Watch the full conversation below, and read on for a transcript. 

Introductions

Dr. Steven Bishop: All right, we are live. Thanks everybody for joining us. I'm Dr. Bishop, the Director of Wellness at PartnerMD. I'm joined today by Dr. Tamara Sobel from our Owings Mills office and Dr. Susan Scharpf from our Midlothian office, to talk about breast cancer from a primary care perspective. Thank you guys so much for joining us.

Dr. Susan Scharpf: You're very welcome. Thanks for inviting us.

Dr. Tamara Sobel: Yeah. Thank you.

Dr. Steven Bishop: Absolutely. I want to give you guys each just a couple seconds to introduce yourselves and just talk a little bit about your interest in this topic, if you don't mind. Dr. Scharpf, we'll start with you.

Dr. Susan Scharpf: Good afternoon. I'm Susan Scharpf. I'm in the PartnerMD Midlothian office in the middle of Richmond, which is right now in the middle of the monsoon. And I do general family medicine here. I've been with PartnerMD going on eight years. I love concierge medicine because it gives us the time to address a lot of questions that people have about specific risks and about preventive healthcare. So breast cancer is on many women's minds, and what we want to do is give you the best chance to protect yourself and take care of things.

Dr. Steven Bishop: Perfect. And Dr. Sobel?

Dr. Tamara Sobel: Hi, I'm Tamara Sobel. I'm an internist here in Owings Mills, Maryland. I've been with PartnerMD almost seven years. And what I love about PartnerMD is it gives you time to speak with patients and focus on keeping people healthy. Breast cancer is important. It's the number one cause of cancer in women in the United States, the second cause of cancer death. So I thought that this is a great topic to discuss and educate folks about screening and early detection. That's really important.

Dr. Steven Bishop: Excellent. Thank you guys so much. So we're going to cover a handful of topics related to breast cancer awareness, prevention, screenings, a little bit of research, and answer any questions you guys … some of the ones you've already submitted and some that hopefully you guys will hop on and ask as we're doing the live.

A couple of quick disclaimers. First of all, we are having kind of a monsoon here in Richmond. So our power has been a little shaky the last couple of hours. So if we suddenly disappear, we do apologize and that's what's happened. We'll try to post a summary of good info after the fact on our page. So that's disclaimer number one.

Disclaimer number two is, just keep in mind as we answer these questions and go through this information that we're primary care doctors, which means we're experts in the general care of people. But sometimes when you get down to the deep nitty-gritty about some highly specific cancer treatments and things like that, some of those specific questions need to be addressed by either a breast surgeon or a breast cancer oncologist who really specializes in focusing just on these things.

So some of our answers may be a little bit general and that's okay. We're, we're trying to make sure you guys get the guidance you need to get to what you need to do next if we can't answer right off the bat.

Breast Cancer Risks 

Alright, so let's start with some basic things. So, Dr. Scharpf, what are some of the most common breast cancer risks you see in your patients?

Dr. Susan Scharpf: Well, number one, all women are at risk for breast cancer. One in eight women will develop breast cancer in her lifetime, but it is not a death sentence. It's something that's very treatable and manageable if we catch it early. Some other risks, smoking, tobacco smoking is a risk for most cancers and is certainly a risk for breast cancer.

Unfortunately, obesity has become a growing risk, literally a growing risk factor for women. And there has been controversy about hormone replacement. And over the years in my practice, we certainly have changed how we recommend hormone replacement therapy to women lifelong because of a possible increased risk of breast cancer over time. Childbearing also, and lifestyle, exercise, healthy diet, those are other factors in breast cancer risk.

Dr. Steven Bishop: Excellent. So, Dr. Sobel, when a patient comes to you and they say, "So what's my risk for developing breast cancer," how do you walk a patient through that sort of risk assessment?

Dr. Tamara Sobel: So there's a few different things that I ask. First of all, well, of course we ask about their lifestyle. Do they smoke? Do they drink? Alcohol consumption is a risk if they're drinking more than two units a day. Do they have a family history of breast cancer?

What I think is interesting is, many people will think well, they have a low risk because there's no one in their family with breast cancer. But hereditary breast cancer only accounts for a very small portion of breast cancer. So, that's where I have to say, it starts somewhere. So family history is something. Prior breast disease. If they had a benign lesion that was excised, that can increase their risk.

There's also different models that you can use that some folks use, you can plug it in, you can Google, there's the Gail Model and you can figure out someone's breast cancer risk that way.

But in general, I speak in generality with my patients of lifestyle, family history, exposures that they've had, childhood cancer and they've had radiation, like Hodgkin's Lymphoma, that increases their risk. There's things like that. And then we talk about screening.

Lowering Your Breast Cancer Risk

Dr. Steven Bishop: Great. So, once you kind of have a good assessment of someone's risk, Dr. Scharpf, how do you walk a patient through things they can do to lower their risk?

Dr. Susan Scharpf: General health matters affect breast cancer risk as always. So we are going to promote good, healthy diet, weight control, smoking cessation if that's a problem. We'll look at medications. And then we look at screening. Screening can be individualized depending on what test a woman has had before, as we've talked about.

Previous history changes how often you want to have mammograms. So although mammograms don't reduce our risk of breast cancer, it reduces the risk of harms from breast cancer because we can catch things early. And that's what we want to do. We may not be able to prevent everything, but if we can make you well and help you get through things, that's important. So exercise, healthy diet, not smoking.

Breast Cancer Screening

Dr. Steven Bishop: Excellent. So, talking about early detection and screening, Dr. Sobel, what do you tell patients about screening for breast cancer?

Dr. Tamara Sobel: Typically, we start having a conversation for an average risk person, as someone who doesn't have a strong family history of breast cancer, who hasn't had any other prior breast disease, I would just personally start talking about it around 40.

And depending on which organization you're following, you have the American College of OBGYN, USPF Task Force, depending on who you follow, 40 to 45 is when you start thinking about screening. And I generally recommend 40 for my folks, for my patients. And then I may say from 40 and 44 consider it, and 45 to 54 every year, and then after 55 to get it every two years in general.

But it really depends on the person and their risk and their level of concern. Because a lot of times it's not frightening what someone does have, but it's telling someone what they don't have, and to be assuring them that really helps.

And then breast cancer self-exams. I mean, breast self-exams. We used to always recommend doing breast self-exams and now that the recommendation is really against those, but many people do breast self-exam. So I just try to go over what does normal tissue feel like? So I can educate people on what may be an abnormality that they should bring to my attention earlier. So really breast self-awareness. What do your own breasts look like? What do they feel like? So if you notice a change you bring that up prior to your annual exam because early detection is key.

Dr. Steven Bishop: Awesome. My power flickered there, so I'm back. But I'm confident your answer was amazing. So, we're just going to keep going. Everything is still live and going good. So you guys are good.

Dr. Susan Scharpf: Steven, I'd like to piggyback on to that.

Dr. Steven Bishop: Yeah, go ahead.

Dr. Susan Scharpf: I still do individualize with my patients. She talked about when to start mammography and there is a change in that we used to always do mammography every year after 35.

But there are mathematical models that actually say that we could increase our risk of breast cancer over the lifetime if we're doing so many mammograms, and in younger women, we're tending not to do screening mammograms.

It's different if there's a problem. But when you're a younger woman and you have dense breasts, or you might have more cysts, that puts you at risk of more radiation, but also more procedures that may show just a benign finding or lead to side effects or adverse effects with surgery. So there's not one size fits all for breast cancer screening, as we agree on.

Also, it can be done every other year, which also limits the radiation exposure. But that is the USPSTF recommends that ages 50 to 75. But that again is individualized to my patients. That's a generalized recommendation. And these societies that, we look to their recommendations, but then we talk about how that is for each individual.

So some women have had normal mammograms for a number of years, they're in their 60s and they've had no abnormalities. They have very low risk factors, and an every other year mammogram might be a good choice for that woman, but we decide that together.

Dr. Tamara Sobel: Yeah. Exactly. Individualized. Way back when, we used to have screening mammograms at age 35, which now we recommend against. And one other thing I was going to say is that, if there is a first-degree relative with premenopausal breast cancer, then that may change, they may get a mammogram earlier than 40.

Dr. Susan Scharpf: Absolutely.

Dr. Tamara Sobel: And then also in certain genetic mutations, radiation can increase your risk of breast cancer. So we may not want to do mammograms, but we will do breast MRIs.

Anxiety from a Mammogram Result

Dr. Steven Bishop: I did want to ask a question. I don't know, you guys may have addressed it while my power was out for a second, but how do you deal, being a primary care doctor that order a lot of mammograms like you guys do, and it's not uncommon to have a slightly abnormal mammogram and need follow-up testing.

How do you help patients walk through the anxiety involved in getting an abnormal result and waiting perhaps for follow-up testing or biopsies, those sorts of things?

Dr. Susan Scharpf: I'll speak to that. Very anxiety provoking. And I get my patients' mammogram reports back and we'll see, "Need additional findings." That's when particularly a phone call to say, "How are you doing? How do you feel about this?" This is what I will … I'm looking at the mammogram report. I'm not looking at the mammogram, but I'm looking at the radiologist's ideas about it and interpretations of it.

And so it may be a more concerning lesion or a less concerning lesion. And if I can say to the patient, "Hey, you have something that's a shadow, we just need another view and let's set that up," and we help set that up. If it looks like it may need to be something that needs a biopsy, of course we'll help work on that.

And I have that personal conversation with my patient. And it's usually on the phone because if I tell somebody, "Oh, come on into the office. Let's talk about your tests you had," that's very anxiety provoking. So a phone call to say, "Hey, I'm here for you."

I have a particular affinity to this because I had breast cancer. And I was that woman who the radiologist called and said, "Oh, we need to have another second look."

And I knew exactly what that meant, and I'm now almost five years out. And so it brings up a little different perspective to what you go through, which is very traumatic at first. And we also of course help pick who I'm going to refer my patient to. I know what centers I'm using for the mammography and their biopsy. I know those radiologists. I can say, "Wow." And sometimes I'll say, "Oh, well, I had mine taken care of here." Or, "This is my surgeon. This is my oncologist."

And it makes me feel comfortable because my patients are very special and also helps me to guide them. And when I was diagnosed, my patients helped me too. They said, "Oh, you can expect this with radiation."

And every case is different, but our explaining, what is the next step? What are your fears? Someone may want to know what's the worst case scenario. What's the easiest thing that's going to happen?

And I'm going to be here for you step-by-step. If you need to talk about it, and I'm going to reach out to you and make sure that, "Oh, yeah, you had that biopsy. How are you doing? I'm going to get the pathology."

We as a family, as primary care doctors, it's important. We have a relationship and women and men, as men can have breast cancer, being there and supporting that person is really, really important.

Dr. Steven Bishop: Absolutely. Thank you. And congratulations for being five years out. Awesome.

Dr. Susan Scharpf: Thank you.

3D Mammograms vs. Mammograms vs. Breast MRIs

Dr. Steven Bishop: That's great. Great. Just switching gears a little bit, Dr. Sobel, I'm just going to go ahead. There's a couple of questions from the live audience. Can you talk a little bit about the differences in some of the different screening modalities? So we've got sort of standard mammograms. Then there's 3D mammograms and MRIs. What's the benefits to the different ones?

Dr. Tamara Sobel: Sure. 3D mammograms are more sensitive. So it would pick up more things, and there's supposed to be less false positives with those. The breast MRIs are reserved for people who are high risk. That's usually folks that are under active surveillance under a breast surgeon... They're not as accurate in a younger person but they are very good in detecting things that are smaller.

Breast Cancer in Men

Dr. Steven Bishop: Okay, great. And, Dr. Scharpf, you mentioned men can get breast cancer too, of course. One of the questions that was pre-submitted was about a male breast cancer survivor, who's five years out. What do you typically … it may not be typical because it is not very common, but what have you told men with breast cancer in terms of follow-up and how to manage that long-term?

Dr. Susan Scharpf: Yeah. There are standards of care that the oncologist will follow and we're taking care of that person alongside. But one of the more unusual factors with male breast cancer is, we've got to look for more likelihood of a genetic link. And the breast surgeons in our community will have a genetic counselor and also PartnerMD has a relationship with VCU and the local university counselors.

And I think that's something that is more particular to male breast cancer. We want to look for … prostate cancer can be associated with that and other family members. And of course, genetic screening for women, that conversation often comes before a woman has been diagnosed with breast cancer and her relative may be diagnosed.

And so we help a little bit by looking at breast cancer. How many people in the family tree have breast cancer. Is there a male relative with breast cancer? Ovarian cancer and prostate cancer can be part of that genetic thing.

A lot of people are concerned because we've had famous people affected by the BRCA gene. And I'll start into genetics a little bit. There is somewhat more known about genetic risk in breast cancer, but also genetic testing on breast cancer tissue is one of the fields, I know you want to talk about what's next, so I'll just kind of throw that out there.

But particularly in male breast cancer, I think we need to know about that. And men need to know, I don't know that I had that conversation with most of my men, but if someone comes in and they have something going on in the breast tissue, we're going to pursue that because it does happen.

BCRA Testing and Genetics

Dr. Steven Bishop: So, what do you say to folks who come in and are asking about genetic testing, BRCA testing, these sorts of things? How do you walk patients through that sort of decision about whether they need to meet with a counselor?

Dr. Tamara Sobel: Yeah. So I think anyone who's got a strong family history of breast cancer, especially premenopausal breast cancer, and especially men with breast cancer, I definitely refer them to a genetics counselor. And I have used a genetics counselor through PartnerMD and I've been very happy with that arrangement. They've been doing telehealth and it's nice. There's also someone here in Baltimore that I refer folks to for genetics counseling. Anyone who's got that strong family history, I refer.

Closing Comments

Dr. Steven Bishop: Okay, excellent. We're running up on a little bit over 20 minutes here. I want to just give you guys both an opportunity to say anything else you'd like to that we've missed, or that you want to mention about breast cancer. Then we'll kind of wrap up. Dr. Scharpf, any closing words or comments?

Dr. Susan Scharpf: Yeah. Actually in the treatment of breast cancer because, again, we're walking side by side with that patient, kind of explaining what the steps are as the breast surgeon might lay out for the patient, but there are different types of breast cancer, different sizes make a difference.

And the biopsy often goes into maybe a lumpectomy and lymph node surgery, which is much less invasive than 20 years ago. Now we're looking for early spread, but it's a much less disfiguring surgery than it was in my grandma's time or maybe even my mom's time. And the oncologist can now give an idea whether someone would be better served with chemotherapy or not having chemotherapy.

I was one of those early patients and they did a test on the tumor after it was taken out, called a MammaPrint, which they're doing now. It was more investigational at that time five years ago only. And it has a certain type, which I can't get into that, I don't know that, but they'll say, "Well, you're less likely to have a recurrence if you have chemotherapy. And you," fortunately for me, "you don't have that higher risk." So I had the standard treatment. But that's really exciting. And they're coming out with more ways to know what to do that's less harmful. Chemotherapy is big guns, and if you need that, okay, we'll take it. And if you don't need that, that's, I feel very fortunate.

And then follow-up afterwards, how often do you get mammography? A woman or man who's been diagnosed with breast cancer is going to have several ongoing members of the team following her. So me as the primary care doctor, making sure that everything else is going well with her health as much as possible, and her oncologist, and her surgeon, maybe a radiation oncologist.

And then there's a regular cookbook. This is how it's managed to reduce the risk of recurrence. And my patients could be 20 years out. What do we do to make sure that you're not at increased risk of another breast cancer?

Dr. Steven Bishop: Absolutely. Dr. Sobel, anything you'd like to add?

Dr. Tamara Sobel: I think everything you said was awesome. I just want to say, like to any of my patients, we all work together as a team and we just get our patients know that we're here for them. And we facilitate communication between their oncologist and their breast surgeon and come up with a plan for them, and help with screening and surveillance and emotional support. We just here with them every step of the way. And it's just really important to get screened and early detection is key.

Looking for more breast cancer information? We're here to help. 

About 1 in 8 U.S. women (about 12%) will develop invasive breast cancer over the course of their lifetime. For men, the lifetime risk of being diagnosed with breast cancer is about 1 in 833 (or about 1% of all breast cancer cases).

All month, we've shared articles and videos from our health coaches to help you reduce your risk for breast cancer.