WFSB interviews Dr. Kristen Zarfos, who is the Director of The Breast Health Program at The Hospital of Central Connecticut.
WFSB: How do you define the connection between family history and breast cancer?
DR. ZARFOS: For women who are diagnosed with breast cancer or looking at women who are at increased risk, we are looking at both sides of the family. We look at first degree relatives: mothers and sisters ... second-degree relatives ... and patterns. And in the last few years, we're learning so much more about not so much the association of breast cancer and ovarian cancer from a genetic standpoint or family standpoint ... pancreatic cancer, colon cancer and other cancers. So ... when we first see a patient, we ask them for a thorough history of their family members with cancer. We expand that then if we see patterns where we think a patient may have a genetic predisposition or an abnormal gene for any of these cancers. Then we would refer those patients on for genetic counseling.
WFSB: Family history includes looking at your mother and your sister ...
DR. ZARFOS: Yes, but we also look at the father's side as well. And what's very interesting is if there is any man on either side of the family, even two or three generations removed, who has had breast cancer, which occurs in about 2600 men a year, then those women should be tested for the gene mutation.
WFSB: What about second tier relatives, like a grandmother or great aunt?
DR. ZARFOS: We look for patterns. So if there are multiple family members, even second tier - second degree or third degree - with a pattern of a lot of members with ovarian and/or breast cancer, then again it's time to take a patient like that and talk about what is your risk? Because we want women to know their health and to know what their risks realistically are. And that patient might be someone who would sit down with a genetic counselor. Before seeing the counselor, they're screened to see if their insurance will cover it or not. And whether it's an appropriate measure. But I think you raised a very good question because if you have a lot of relatives with cancer, you might think your risk is higher than it truly is. Or you· might think 'well, they're a couple generations off and it's not that important.' But we're learning so much more that it's important to not ignore any family members with any cancers.
WFSB: And again, there are other cancers that are linked to breast. It doesn't have to be breast.
DR. ZARFOS: Doesn't have to be breast: ovarian, colon cancer, pancreatic cancer.
WFSB: And if a woman's mom has it, does that mean she's destined to get it?
DR. ZARFOS: It's very important to know that 70% of women who have breast cancer have no family members with breast cancer. First and foremost. And that's not the question you're asking me, but it's important when a woman finds a lump who just ignores it because there's no one in the family. So that's fact number one. If a woman's mother has breast cancer, it's not an automatic that she's going to develop breast cancer. But then she should look at the rest of her family history and she should actively embrace some strategies to decrease her risk. She shouldn't consider herself a time, bomb, but she should be vigilant. Now, vigilant would mean tests for early detection: mammography and maybe in collaboration with the insurance industry, MR is if they'll cover it. And I must say, the insurance industry is very good at covering MR is in patients who have known mutations or multiple family members who do have cancer: breast cancer and/or ovarian. So a woman whose mother has breast cancer, we would want her to embrace strategies to decrease her risk: early detection and lifestyle strategies. For example, there are some women who have a family history' of breast cancer who would qualify to have chemo prevention. And she could talk to her physician about going on a medication that could decrease her risk by 50- 85%.
WFSB: How often does that happen? I hadn't heard about that.
DR. ZARFOS: There is a drug called tamoxifen that has been studied in Pl - the first prevention trial ... and the second trial. And women who carry the gene mutation qualify to go on that medication. Women who have premalignant biopsies should be referred for consideration of chemo prevention. And if you have a very strong family history ... in the original trial that came out in 1998 - it's called Pl Trial - it showed that women who entered in the trial simply many because they had a strong family history can decrease your risk of developing breast cancer by 50 - 75%. And one of the criticisms in this country is that not enough physicians look at women who are at increased risk and offer them that opportunity to decrease their risk by 50-85%. Other strategies are lifestyle. We know, there's strong data that if you're physically active four hours a week, you can decrease your risk of developing breast cancer by 37% whether you have a family history or not. Avoiding obesity post-menopausal is clearly an important factor. And keeping alcohol intake less than three to six a week can decrease your risk. So, we want women to know what the risk is - and their physician can guide them as to whether they should take the next step to genetic counseling. A genetic counselor will chart out the family history and say 'yes, you're a candidate for testing or not'. Once you know your risk, whether you carry a gene mutation or not, you can employ these lifestyle strategies. Consider chemoprevention. And there are surgical options for women who do have the BRCA mutations in their gene profile. But surgery is not the only option. And the program at the Hospital of Central Connecticut encourages women to know the risk- truly what the risk is -, employ these strategies ... and surgery is something to consider at the bottom of the list. Know all your options. Be informed so that you're making a decision that's right for each individual women.
WFSB: How strong a risk factor is family history?
DR. ZARFOS: Well, if you have a primary relative with breast cancer - a mother, sister - then you're at a four times increased risk of developing breast cancer. You may or may not also be at risk for developing ovarian cancer whether your family member or you have a mutation in one of the genes that's an indicator for that.
WFSB: If you have the BRCA1/BRCA2 testing and it shows you don't have the mutations, then what is the risk? DR. ZARFOS: It's very important to look at a lot of other factors to determine that risk. So let's look at BRCA mutations. Only 5% of people with breast cancer carry the mutation. So, it's a very small number. However, if you do carry the mutation, you have an 85% chance of developing breast cancer. And an increased risk of developing ovarian cancer. Very important to include that ovarian cancer because if you have the gene mutations, we have a lot of tools: MR is, mammograms, breast exams, ultrasounds to screen and find breast cancer early. It's very difficult to find ovarian cancer early. We have no blood test or routine screening tests, so I really want to emphasize how important it is to think about the ovaries. But ... if you don't have the BRCA mutation, it doesn't mean that you're not going to develop breast cancer. Again, 70% of women who develop breast cancer have no family history. Those who have a family history have an increased risk incrementally depending on how many relatives and which side of the family and what degree of relative and if you have the BRCA mutations present, then the risk is 85%.
WFSB: And you mentioned what side of the family. Does a woman's mother's side have more influence on getting breast cancer? Do we have to pay attention to our dad's side?
DR. ZARFOS: It leans toward the maternal side, however, we see patterns of patients who have family members on the father's side only with breast or ovarian or pancreatic or multiple other cancers who may carry those gene mutations. There's another group of patients that we do recommend genetic testing for who are already diagnosed with breast cancer. So any woman under 50, even if there's no family history, should be tested. Only about 10% of those women will have the gene mutation but it may exist. Women who have a particularly aggressive type of cancer, such as Joan Lunden -the triple negative- anybody under 60 should be tested for the gene mutation. 10And we also see different subgroups of different ethnicities and different ethnic patterns that may have a higher risk of developing or having those gene mutations. Important to know in one family member so that other members in that family will know their risk.
WFSB: Just because you have the gene mutation, it's not an absolute that you're going to get cancer?
DR. ZARFOS: Let's look at the numbers. If you have the gene mutation, there's an 85% percent chance you could develop breast cancer. But a 15% chance that you don't. Now in America today, of the women who have the BRCA mutations, 50% choose to be monitored with annual MR is and 50% might choose prophylactic mastectomies. Based on the study that was done over 25 years ago at the Mayo Clinic when we didn't have MR is and we knew about the genetic mutations and the medical community wanted to do something for those women. And so prophylactic mastectomies seemed to be the only answer. But it's important any woman who has a strong family history, any woman who's BRCA tested and may be positive should know she has options. In a study published in November 2010 in the Journal of Clinical Oncology says that if you're BRCA positive, assuming that you're followed very closely with yearly MR is, you have the same chance of survival from breast cancer as those women who choose prophylactic mastectomies.
WFSB: You can't change your family history, but what can you do to protect yourself against breast cancer?
DR. ZARFOS: So we want all women to be aware of their health. And certainly as the American Cancer Society recommends, women should know their breasts and be very vigilant if there are any changes. Many of us advocate breast self-examination once a month, the last day of their periods and if women don't still menstruate, then once a month, whatever date, but consistently. Seeing your physician once a year or maybe twice a year. Maybe alternating your care - breast exam - by your primary care physician or APRN or nurse practitioner and your gynecology team or with a breast surgeon, whichever a patient feels most comfortable with. Frequent breast exams - clinical exams - twice a year. MR is - if you're BRCA mutation positive, the insurance companies will collaborate with us to do those studies. If you have a strong family history - depending on the insurance coverage and the number of family members and the number of first or second degree, MR is can be a tool also. We - in the community of those who take care of women at increased risk and at the Hospital of Central Connecticut increased risk program, we encourage women to have their mammograms six months from their MRI, so we're using different tools every six months to take a look at their breasts. And in addition to early detection, you know, embracing those strategies that can decrease your risk are really important, as we talked about: physical activity four hours a week decreasing the risk 37%, keeping alcohol less than six a week, avoiding obesity post-menopausal and then the strategies of chemo prevention. But each woman should ask her physician 'is there a role for me to take some medication that can decrease my risk of developing breast cancer, whether i have a genetic mutation or just have a very strong family history of breast cancer?'
WFSB: You said watch the obesity but didn't say 'cut out fat'. Isn't the cancer tied to the fat cells?
DR. ZARFOS: Well, it's interesting. The obesity issue is the fat cells contain a hormone that for post-menopausal women, a hormone is secreted from our adrenal glands- a testosterone-type hormone- that circulates in our body. So fat doesn't convert it to estrogen, but this enzyme that is contained in the fat does convert it to estrogen. And the more fatty tissue you have, the more of that enzyme you have. And so that's why obesity is an important issue for post-menopausal women. It doesn't seem to be an issue for pre-menopausal women, but those of us who are post-menopausal know that if you're overweight pre-menopausal, it's every increasingly difficult to lose weight and correct obesity post menopausaL 2
WFSB: How critical is the mammogram? What do you say to women who are too afraid to have one?
DR. ZARFOS: The mammogram is really very, very important. It's a critical tool and many women we do MR is on say 'well, do i still need to have a mammogram, too?' They work in conjunction with each other. And what i say to women about mammograms is you know, it's about 10 minutes out of 365 days a year that can give you peace of mind those other 364 and a half days. It can be uncomfortable. It's not just the physical pain. I think women are afraid to hear the answer, to hear what the answer is. But i ask women to make a decision that they're not going to be angry with themselves down the road. You know, get your mammogram. If you're going to have breast cancer, we want you to find it early. The mortality rate from breast cancer has gone down 30% ... or let's say the survival rate has improved 30% since the 90s and we started using mammography to a great extent in the 90s. So for those of us who take care of women with breast cancer, if it's going to be a diagnosis, we want to help them find it at the earliest possible stage.
WFSB: And the ultrasound?
DR. ZARFOS: Ultrasound is very important for women who have dense breast. So there are two strategies where we use ultrasounds. If a woman has a lump she can feel, if there's an abnormality on a mammogram that's a specific lump, then an ultrasound is another tool to further investigate it. And this state is the first state to pass legislation that when women have very dense breasts - which is very common in young women, but I see it in women in their 70's and 80's too if they have really dense breasts - an ultrasound is an excellent screening tool. Not uncomfortable. No radiation. So it can see through through the dense tissue in case there's a cancer that's encased in the dense tissue and can't be seen. And we actually have the leading radiologist in the country - Jean Weigert - who has done that research and will be presenting it at the San Antonio Breast Conference in December.
WFSB: Mammography and ultrasound are complimentary, yes?
DR. ZARFOS: The mammogram and the ultrasound compliment each other. They don't replace each other. They work hand in hand. So it's very important for women when they receive the letter about the mammogram that they have dense breasts or if their practitioner tells them that they have dense breasts, to have a screening. ultrasound. We can find cancers that are hidden in that dense tissue.
WFSB: What is the number one reason women give as the reason they won't get a mammogram?
DR. ZARFOS: The number one reason that women will express why they won't have their mammograms is discomfort, but I think part of it is fear. Fear of what they'll find. And if we can just turn that around to say you're more fearful if you don't have your mammogram or your colonoscopy or you do your self-exam or see your doctor once a year. So, again, I think it's important to say 'find out what's going on with your health. Know what's going on with your health. Embrace it. Take care of it. You'll get better.'
WFSB: Where do we stand in battle against breast cancer today? Where can we be in 10-20 years?
DR.·ZARFOS: Well, the most exciting thing is that today compared to the 90s, the survival rate is 30% improved because of early detection. And for those women who don't want to have mammograms? It's because of mammograms! The data is really clear. We started doing mammography in screening programs in the 90s and today far fewer women die from breast cancer because of that. What are we going to know in the future? Well I think understanding our increased risks. So for the women we're talking about today, knowing the risk and embracing early detection and different modalities for early detection and lifestyle changes and perhaps chemo prevention? We should see an ever-improving survival rate for breast cancer.
WFSB: What decade of age are you seeing the most diagnoses of breast cancer?
DR. ZARFOS: The highest incidence of breast cancer occurs in women in their 70's and 80's and so it's very important to take this into consideration when there are some recommendations to stop doing mammograms as early as 70 or 72. The highest risk group are our aunties and our grandmothers ... maybe me ... in their 70's and 80's. Twenty percent of the time, those tumors can be very aggressive, although most older women - 80% of their tumors aren't aggressive and they are well taken care of. So those of us in the breast community feel very strongly that we should not leave our aunties and grandmothers behind, do a mammogram if it's appropriate to the woman's overall health. Taking the context of her social network, her support network, whether she would be a candidate to do something with results. But let's not leave those wonderful women behind because it's the group with the highest incidence, we should find them early and then embark on treatment that's the least intrusive on their quality of life in· the context of who they are as individuals and know their health issues. It's one of my pet passions, actually. I'm hoping that the Hospital of Central Connecticut- we have a program for older women with breast cancer. When I finished medical school, you rarely saw anybody. I mean, thirty five years ago ... Thirty five years ago, you rarely saw a spry 80 year old. Look around you! Look around you! And so many women we devote $4,000-$5,000 a year to cardiac medications. I've actually studied this. And so why would you not spend $88.83 - which is the charge to Medicare- for a mammogram? To find a cancer small. Remove it. Maybe no other treatment necessary. And have them live happily ever after. I have seen patients who are in their 70's and 80's who did not have mammograms. Do not to self-exams. Didn't have breast exams. And we find that their cancer is very large. And then we are forced to do surgery that is much more intrusive and interferes with their quality of life. So this is one of passions: to find these cancers early, again ... in the context of the woman's overall health, mental health and treat it to not to give her the best chance for not dealing with the cancer again, but not impacting her, her quality of life.
WFSB: Once more as we wrap things up, would you lay out the risk of getting breast cancer with 1) no family history 2) family history but no gene and 3) family with genetic mutation?
DR. ZARFOS: So the risk of developing breast cancer for ah average woman in the population with no family history is one in eight. If you have a family history of breast cancer of a first-degree relative, it's a four times increased risk. And if you carry the gene mutations, there's an 85% chance you could develop breast cancer.
WFSB: Please define 1st degree and 2nd degree relatives.
DR. ZARFOS: First degree relative would be a woman's mother or sister. Second degree relative would be a grandmother or an aunt. And third degree is beyond that: cousins on either side.
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