Breast Cancer Awareness Month: Debunking Breast Cancer Myths With Jason Mouabbi, MD

Oncology Data Advisor: Welcome to Oncology Data Advisor. Today we have an interview for Breast Cancer Awareness Month, and I'm joined by Dr. Jason Mouabbi. Dr. Mouabbi, thanks so much for coming on the show today.

Jason Mouabbi, MD: Thank you for having me. I'm very happy to be here.

Oncology Data Advisor: We have a pretty fun session planned today. We're first going to start off with a Q&A session and then go into a myth busting session. To start off, we're going to go over some frequently asked questions surrounding breast cancer. Before we begin, would you like to introduce yourself and share a little bit about what your work in breast cancer focuses on?

Dr. Mouabbi: I would love to. My name is Jason Mouabbi. I'm a Breast Medical Oncologist at the University of Texas MD Anderson Cancer Center. I see a wide range of breast cancers, but I'm dedicated to seeing only breast cancer patients. My area of research focus is invasive lobular carcinoma, which is an understudied but important type of breast cancer. Hopefully, we'll get to discuss it a little bit today during our questions.

Oncology Data Advisor: Definitely. So, the first frequently asked question is, what exactly is breast cancer and how does it develop?

Dr. Mouabbi: Yes, it's very important to first give a definition to the cancer itself. Breast cancer is a type of cancer that starts in the cells of the breast. It occurs when normal breast cells undergo changes that cause them to grow uncontrollably, leading to the formation of tumors and then cancer. When cancer cells start growing, they start invading nearby tissues, and in some cases, they start invading the lymphatic vessels and can reach the lymph node. From there, they can have access to the bloodstream and can spread around the body.

Usually what happens is an error, what we call a mutation in the medical field, that happens at the DNA level in a single cell that causes this cell to start growing uncontrollably. I always tell my patients, cell growth is normal; however, it's highly regulated. When you lose this control for cell growth, that's when we have cancer. Those mutations can either be inherited from our parents or they can be acquired by environmental factors, sometimes by hormonal influences, sometimes by lifestyle choices like smoking. Sometimes they can arise sporadically because every cell, at some point, has a shelf life and has to divide to give way for a new cell. As it's doing so, errors can be acquired at the DNA level that can cause cancer.

Oncology Data Advisor: In addition to mutations, what are some of the other common risk factors for breast cancer?

Dr. Mouabbi: This is a very important question, and before I start answering it, there is a big disclaimer here. A lot of people, when they hear the term risk factor, they think, "Oh, this is what's causing my cancer." Risk factors and causality are different things. Risk factors do not directly cause cancer. That is very, very, very important. Having a risk factor does not mean that you will develop cancer. Some patients with multiple different risk factors never develop cancer, and others with no risk factor do develop cancer. Risk factors are just what the name implies; they're just risk factors, so they increase the risk for breast cancer but do not cause it. This is very important for everybody to know.

There are two categories of risk factors. There is the non-modifiable risk factor. These are things that we have and that we have to deal with. And then there are the modifiable ones; these are the ones that ideally we can change. Of the non-modifiable, one of them is gender, so females are at a higher risk for breast cancer than males. The other one is age. The older we get, the higher the chances are that we might get cancer. That's not only for breast; it's also true for other types of cancer. The third one is family history and genetics. Having a first-degree relative with breast cancer increases the risk of having breast cancer. Also, having a predisposing mutation that inherited from parents can be a risk factor to getting breast cancer.

The fourth one is a very important one, and I always highlight it to my patients, especially when they go into their survivorship phase—that having a personal history of breast cancer is one of the highest risk factors to developing another breast cancer. And the last non-modifiable is breast density. Some females have dense breasts; other have more fatty breasts. The denser the breast, the higher the risk factor for breast cancer.

Now let's go on to the modifiable ones. These are the ones that we have the power to modify. One of them is long-term use of hormone replacement therapy and/or oral contraceptives. Again, I hear this all the time. Patients come to me and say, "I caused my cancer because I took hormone replacement therapy" or "I caused it because I took oral contraceptives. I should have known better." I always tell them that they do not cause the cancer. These are risk factors for cancer. Basically, if there's already a precursor lesion for cancer, these things can grow them into cancer, but they cannot cause the mutation at the genetic level. These are, again, risk factors and not causative agents.

The third one goes along the lines of childbirth and menopause. Basically, having your first child at an older age increases the risk for breast cancer. Never having given birth to a child also increases the risk. Early onset of menstruation and late menopause are also risk factors. Now, some other risk factors, as well, are alcohol consumption, obesity, and physical activity—the less active somebody is, the higher the risk—diet, exposure to radiation, and the last one is breastfeeding. Women who do not breastfeed have a higher risk factor for breast cancer. That's why a lot of the time, you hear that breastfeeding is protective against breast cancer. When they studied it, they found that patients who breastfed had a lower chance of getting breast cancer than those who did not.

Oncology Data Advisor: With all of these different potential factors, what are the signs and symptoms that people should look out for?

Dr. Mouabbi: Very important question. There are six cardinal signs and symptoms to look for, but before going into them, it's very important to note that every patient is different. Sometimes you might have signs and symptoms, sometimes you might not have any of them, and sometimes you might have one. These are not set in stone. There are just six cardinal ones to keep in the back of your mind, just in case you experience one of them, to know that you need to seek medical attention. The first one is a breast lump, and this is the most common sign or symptom of breast cancer. However, again, it's the most common, but it's not guaranteed to have a breast lump, and we'll talk about that later. The second one is change in breast size and shape, meaning breast swelling.

The third one is breast pain. Now, this is very important because I also tell my patients that most breast cancers are not typically associated with pain. If breast cancer was painful, we would catch it very early. However, it's not usually painful, so it's not usually one of the signs and symptoms of breast cancer. However, if it happens, you shouldn't disregard it. You should get evaluated by health care professionals to see what's going on. That's why I say that although it's not one of the main breast cancer signs and symptoms, it's just something to keep in mind that it's unlikely to be breast cancer, but it has to be checked anyway. The fourth one is skin changes. Here we talk about skin thickening or skin dimpling. What they call the orange peel feel to the skin is an overlaying of the breast and a color change. Also, along those lines, if you notice a rash that's not going away, that's another sign that you should go seek a health care professional's opinion on what's going on.

The fifth one is nipple changes. Here, we're talking about something that's happened suddenly and quickly over a short period of time. It's a change in the appearance or position of the nipple, such as turning inward. That's what we call nipple inversion. There is also flattening of the nipples. These are two signs, if they happen suddenly over a short period of time, to seek a health care professional for a better professional opinion. The last one is enlarged lymph nodes, especially under the armpit. Some patients start complaining of discomfort under the armpit and then they can feel a ball under the armpit. This is also a sign to let you know that you should seek health care professional's help.

Oncology Data Advisor: Next, what is the role of genetics in breast cancer, and when should someone consider getting genetic testing?

Dr. Mouabbi: Genetics plays a very significant and important role in breast cancer risk. Again, it's breast cancer risk. It's not guaranteed if you have a mutation that you are going to get breast cancer, but it does definitely increase the risk for that. Whenever we talk about genetics in breast cancer, we're talking about inherited mutations. These are something that we inherit either from our mom's side of the family or the dad's side of the family. There are two genes of special interest in breast cancer, and these are the BRCA1 and BRCA2 genes. There are other genes that are associated with breast cancer as well that are important to know of, such as TP53 and PALB2. These four genes usually are the bulk of the genes that are associated with breast cancer. There's also another one called the CHEK2 mutation that sometimes is associated with breast cancer.

Now, you should seek genetic counseling before testing, and that's very important. You're not always going to need testing, but genetic counseling is not wrong if you fall into one of those categories. If there is any family history of those genetic mutations—again, these are BRCA1, BRCA2, TP53, PALB2, or even CHEK2 mutations—if you have a close relative who had those mutation, it's not wrong to go seek genetic counseling, not testing right away, but counseling. They can do a family tree and see what your risk is. If your risk is high, they can test you for it.

The second one is a strong family history of breast cancer, especially when there are multiple family members who had breast cancer at a young—typically meaning before the age of 50. The third one, and this is the most important one, is a personal history of breast cancer at a young age or if you had breast cancer in both breasts. If you had breast cancer and there is a family history of ovarian cancer, that can also suggest that you might need genetic testing. Again, regardless of the reason, I'm always a big advocate for genetic counseling before testing.

Oncology Data Advisor: On this theme of testing, when should women start getting regular mammograms, and how often should they get them?

Dr. Mouabbi: This is a little bit all over the place, to be honest. The recommended age and frequency vary from guideline to guideline and from organization to organization. It's not set in stone, and they keep changing them every few years. But at the end of the day, it should be individualized to the individual risk factor, family history, personal medical history, and so forth. Many organizations, like the American Cancer Society, recommend that women with an average risk of breast cancer begin getting regular mammograms by the age of 40. The frequency of mammogram in most guidelines is every year. However, sometimes they say it can be done every two years. I personally recommend every year starting at the age of 40.

Now, continuing mammograms is another decision that has to be individualized, patient to patient. Many guidelines suggest that women should continue receiving mammograms as long as they're in good health and have a life expectancy of at least 10 years. If somebody has a first-degree relative with a predisposing mutation like BRCA1, BRCA2, TP53, or PALB2, those recommendation can change. A lot of times, the screening can start at a younger age. Again, it has to be individualized, but these are some rules of thumb.

Oncology Data Advisor: Awesome. Well, that was the last of our frequently asked questions, and those were some really comprehensive answers to all of these questions and a really great resource that we can share with people. Now to move on to our second part, the myth busting session, we have five common myths about breast cancer. The first one is that only women can get breast cancer.

Dr. Mouabbi: This is a very common misconception, and it is not true. While it's true that breast cancer is much more common in women than men, men can still develop breast cancer. Now, it is relatively rare and it accounts for less than 1% of all breast cancer cases. However, it's essential to recognize that it can and does occur in men. Men do have breast tissue, and although it is less developed than in women, they are still susceptible to getting cancerous changes. Also, the risk factors that we discussed earlier on about breast cancer for females are the same for men, except of course, the risk factors of having childbirth late in life, menopause and menarche, and breastfeeding. These are of course specific for women, but all the other ones such as age, lifestyle, exposure to radiation and so forth, are all still true for men.

Oncology Data Advisor: Second, if breast cancer doesn't run in someone's family, they won't get it.

Dr. Mouabbi: Again, this is not true. While a family history of breast cancer is indeed a significant risk factor, it is important to understand that the absence of a family history does not guarantee immunity from breast cancer. Actually, the majority of individuals diagnosed with breast cancer do not have a family history of the disease.

Oncology Data Advisor: The third myth is that all breast cancers present as a lump.

Dr. Mouabbi: This is where I can talk a little bit about lobular breast cancer, and the answer is no. While one of the most common sign and symptoms of breast cancer is a lump, , not all breast cancers present with a lump. Here, I'm talking mainly about lobular breast cancer and inflammatory breast cancer, so we can talk about them a little bit. There's also another type of breast cancer called the ductal type, and if it's detected very early, it can be so small that you might not feel a lump. Because of the nature of the disease in lobular breast cancer , those cells do not form a mass, so they don't distort the architecture of breast and you cannot feel them on exam. They usually don't present as a lump. It becomes harder to detect like that.

It's important to note that lobular breast cancer accounts for about 10% to 15% of breast cancers. There's also inflammatory breast cancer, which is more rare than lobular cancer. Inflammatory breast cancer comes as a diffuse cancer that takes over the breast, so the breast present as more swollen and heavier than the other breast, but you cannot feel a discrete mass. It's really important to keep in mind that not all breast cancer present as a lump.

Oncology Data Advisor: The fourth myth is that breast cancer is a death sentence.

Dr. Mouabbi: This myth is far from the truth. While we have to acknowledge that breast cancer can be frightening and challenging, it's not a guaranteed death sentence by any means. In fact, in this day and age with the advancement in breast cancer research, early detection, and treatment, they have significantly improved the prognosis and survival rates of individuals diagnosed with breast cancer.

I'm going to give you some numbers, because I'm a numbers man and I like numbers. Every few years, American Cancer Society and National Institutes of Health (NIH) publish their survival rates. The five-year survival rate after a breast cancer diagnosis is close to 91%. That's, again, the five-year survival rate. The death rate is 1 in 39 patients, so that's 2.5%. This number has been steadily decreasing year after year. So, the myth is very far from the truth. Breast cancer is not a death sentence. It's something that should be looked at, managed, and treated appropriately to have the best outcome.

Oncology Data Advisor: And our last myth is that someone can't have a healthy pregnancy after being diagnosed with and treated for breast cancer.

Dr. Mouabbi: This myth, again, is not accurate at all. That's why it's a myth. Many individuals have undergone breast cancer treatment and gone on to have very healthy pregnancies and very healthy babies. However, it's very important to know that there are several factors that should be considered to individualize the care, because it can vary from patient to patient. It's very important if you're getting breast cancer treatment to talk about fertility preservation with your doctor, because some breast cancer treatments like chemotherapy or hormone therapy can affect fertility. Before starting the treatment, if you are interested in having a pregnancy down the line, you should discuss preserving your fertility by undergoing egg harvesting, embryo freezing, or so forth. These are important to discuss before starting any treatment for breast cancer.

Another thing that's very important is the timing of the pregnancy. Sometimes, we ask the patient to delay getting pregnant a little bit after a diagnosis of breast cancer and treatment just so we can do some form of preventative treatment to reduce the risk of this cancer coming back before getting pregnant. We have some studies that were recently published that showed that we can sometimes interrupt therapy for a year or two for a patient to get pregnant. That's really important to discuss and plan ahead of time. Also, medical monitoring is very important, not only by an obstetrician, but also by your medical oncologist, and they should be talking with one another and having the same plan.

Talking about breastfeeding is very important because the ability to breastfeed after cancer treatment may be influenced by the type of treatment received and individual circumstances. For a lot of women, we ask them not to breastfeed after getting pregnant and we give them a pill to prevent milk formation, so these are also important to discuss. Finally, talking about the risk of recurrence, most patients will be okay getting pregnant after treatment. However, some patients are at a very high risk for recurrences. When getting pregnant, sometimes there is a surge of hormones in the body, and those can accelerate their recurrence speed. For some patients, again, it's their choice, but we need to inform them that they are at a high risk and that might be a little worried if they get pregnant. It's really individualized based on the risk of recurrence.

Oncology Data Advisor: Awesome. It's been so informative to hear all of these answers and definitely very reassuring to hear that some of these myths are false as well. Thank you so much for coming on today and sharing all this great information.

Dr. Mouabbi: Thank you, Keira, for having me. It was great to be here.

About Dr. Mouabbi

Jason Mouabbi, MD, is in Assistant Professor in the Department of General Oncology and the Department of Breast Medical Oncology at The University of Texas MD Anderson Cancer Center, where he specializes in lobular breast cancers. His research focuses on the management of breast cancer subtypes and their impact on treatment. Dr. Mouabbi has been the recipient of multiple honors and awards, including the Guiding Researchers and Advocates to Scientific Partnerships (GRASP) Advocate Choice Award in 2022 and the Lester & Sue Smith Breast Cancer Award of Excellence in 2021.

Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.