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Oncology Data Advisor: Welcome to Oncology Data Advisor. In this interview, Lillie Shockney, Professor of Surgery at Johns Hopkins University, will be discussing the prevention of breast cancer. Thank you for joining us.

Lillie S. Shockney, RN, BS, MAS, HON-ONN-CG: Thanks for having me.

Oncology Data Advisor: So what are some of the known risk factors for the development of breast cancer?

Lillie S. Shockney: There are quite a few. One is if a girl begins menstruating under the age of 12, which is more and more common today. It's not unusual to see girls actually beginning at the age of 10. Another risk factor is not going through menopause until after age 55; we're seeing an increase in that, as well. Additional risk factors are alcohol consumption, smoking—as we know, smoking causes many kinds of cancers, not just breast cancer— and sedentary lifestyle, so kind of a couch potato type of a person. High-fat diet has also been linked to an increased risk of breast cancer, as has family history. Some people think if they have any family history—like my great aunt had breast cancer in her eighties—that is really not a risk factor. We're talking about significant family history. If your mother was diagnosed in her thirties and died at age 40, and your mother's sister was diagnosed in her mid-forties, that's a significant family history.

We do pay attention to grandparents on both sides of the family, mother's side and father's side, and of course, parents. We do consider aunts and uncles and cousins, but we really pay a lot of attention when it is an immediate relative. When there are several of them or we see them coming down the familial chain on the same side of the family, whether that be your brother's side of your father's side, then we need to really take a serious look and say, "Hmm, there does look like there's a familial link, and therefore, there may be a genetic link. There could be a gene mutation at work here." I will also say that 70% of women diagnosed today have no known risk factors other than the last risk factor, which is being female. With 70% of individuals not having any risk factors, that tells us that there are some significant risk factors out there that we have not been able to identify yet. People should stay tuned and keep themselves abreast of what's new happening in the land of science and research related to breast health and breast cancer.

Density of breast tissue is one of the newest risk factors. The challenge with density is that density on a mammogram looks white, and tumors are white, so we can't see the polar bear in the snowstorm, which makes it much more difficult. Density also is usually a sign of relatively high estrogen levels in the bloodstream. This is one of the reasons why it's not standard of care to be doing mammograms on women under the age of 40, because they've usually got a lot of estrogen in their bodies and their breast tissue is going to look very white on mammogram. Mammography is not very helpful at all for screening purposes when it comes to women under the age of 40, but density is considered a risk factor. It isn't how the breast feels physically; it's how it looks on a mammogram. The radiologist—hopefully a breast imaging radiologist, someone who specializes in mammography—will actually state the degree of density in the report. They're supposed to measure that density, which is also helpful in determining to what degree that density is officially a risk factor.

Oncology Data Advisor: Are there any ways to prevent or reduce your risk of getting breast cancer?

Lillie S. Shockney: There are several. Ideally, however, we really do want to start these in childhood. We want our children physically active and not sitting in the house, playing with their thumbs on some computer game. Because they're not outside playing baseball or basketball or jogging or doing anything physical, they're only exercising their thumbs, which also means that they're usually a heavier weight than we would like to see them. Our bodies store estrogen in our body fat, so this is also one of the reasons why girls are menstruating under the age of 12. As I said earlier, it's not unusual to see them start at age 10. You need a fair amount of estrogen in your body to jumpstart your ovaries. If they've got some extra weight on them, they've probably already started menstruating, which increases their risks. So physical activity is a type of risk reduction—preferably starting that young, though it's never too late to start.

The greatest benefit, though, is that the earlier we begin, the better benefit we will reap—for example, no alcohol, no smoking (including exposure from secondary smoke, since we should never underestimate its impact on our lungs and other organs), and a low-fat diet (30 grams of fat or less, very high in fruits or vegetables, preferably seven fruits or vegetables a day). Additionally, paying attention to our breasts is important. There's been some controversy as to whether or not breast self-exams are helpful or not. As a Johns Hopkins faculty member, I do believe that they are helpful. We know that over 40% of the time, a woman who is under the age of 45 finds her own breast cancer by doing a breast self exam. So why should we be discouraging that? That wouldn't make a whole lot of sense to be saying, "Oh no, don't do that. We'll wait until your lump can be seen on a mammogram without you touching it and feeling it," when it could, in fact, be smaller. We also want to encourage participation in clinical trials for individuals that may be at high risk of breast cancer based on having those risk factors. That's going to inform us today, and in the future for the next generations too, as to what other risk factors there might be.

Clinical trials are not just tied to chemotherapy, as most people think they are. Clinical trials are for prevention, early detection, genetic mutations, surgical interventions, chemotherapy, immunotherapy, radiation therapy, survivorship care, and imaging. It goes on and on. I'm an avid believer in clinical trials. I want others to feel as I do. I participate in them whenever possible. I'm a 29-year breast cancer survivor. I seek them out, not just at Johns Hopkins, but other places too, so that perhaps I can provide something—whether it be a sampling of blood drawn from me, or an X-ray, or whatever, to further this kind of research. When it comes to prevention, one method that does work, although it's a dramatic method, is prophylactic mastectomies. This is not done for women of general risk or those who have a slightly elevated risk. This is usually done, or we certainly have a serious discussion about it, when a patient has been diagnosed as having a breast cancer gene mutation.

If she has, for example, a BRCA1 or BRCA2 mutation—these are the most common known ones, and if she has BRCA1, she has as much as an 80% risk of getting breast cancer and a 40% risk of getting ovarian cancer. Well, we can take that risk down to 1% for breast and 1% for ovarian by getting out her fallopian tubes and her ovaries. Just as a side comment, most ovarian cancers begin in the fallopian tubes and then grow backwards into the ovaries, which is why you've got to get your fallopian tubes out, not just the ovaries, for risk of ovarian cancer. We also do a total simple mastectomy, not removing lymph nodes other than the sentinel node. This is just in case breast cancer were to be found in that breast when the pathologist receives that mastectomy specimen and carefully combs through it. It does happen occasionally that the mammograms and the breast magnetic resonance imaging (MRI) scan we did before the surgery didn't show any signs of breast cancer, but when the pathologist looks much more closely at it under the microscope, they do find some tiny little breast cancer in there. It's important that we have already sampled the guard node, also known as the sentinel node, because if the breast cancer were to travel from the breast to the lymphatic system, it's got to go to that node first.

With total simple mastectomy, we leave the muscle alone, and we can even leave the skin. We can leave the nipple and areola, carving out the inside of the breast and then filling it with something healthy, whether that be an implant or fatty tissue from elsewhere in your body. That's a way to dramatically reduce risk of getting breast cancer during these preventative surgeries, prophylactic mastectomy on both breasts bilaterally. In addition to that, regardless of whether if she carries BRCA1 or 2, we also recommend getting those fallopian tubes and ovaries out. Ovarian cancer is much sneakier than breast cancer. By the time you have symptoms that are recognizable, it's usually already spread to other organs. We don't have a good way for screening for it, which is why we do encourage the more aggressive method of reducing risk of ovarian cancer, which carries a high mortality rate.

Oncology Data Advisor: Are there any other types of cancers that increase an individual's risk of developing breast cancer?

Lillie S. Shockney: There are. Ovarian cancer is certainly a flag for us that she's also at increased risk of breast cancer. Also carried on the BRCA2 gene mutation are pancreatic cancer, melanoma, and prostate cancer in men at a younger-than-average age. If we see a man with prostate cancer in his forties or early fifties, we should be doing genetic testing of him because he may very well carry a BRCA2 gene mutation. When a man carries this mutation as far as breast cancer, he's only got a 6% to 10% risk of getting breast cancer, so we usually don't do mastectomies on men in a preventative way. However, we certainly do test him genetically. If he does test positive, then we want to test other family members: his sons and daughters, his brothers and sisters, and such. Girls are going to be at a much higher risk (40% to 60%) of getting breast cancer and a 20% to 40% higher risk of getting ovarian cancer if they've got a BRCA2 gene mutation. Other siblings and offspring are unfortunately also at risk for pancreatic cancer and melanoma. We want people to be getting screenings done to reduce risk in a high-risk genetically profiled family program with geneticists that follow these families along for the rest of their lives.

Thank you for listening to Oncology Data Advisor. Be sure to check back throughout Breast Cancer Awareness Month for more of this exclusive interview series, all found at oncdata.com.

About Lillie S. Shockney

Lillie S. Shockney, RN, BS, MAS, HON-ONN-CG: Her name is well known in the cancer field, especially in navigation, survivorship, patient-centered care, preservation of quality of life, end-of-life planning and care, and improving the cancer patient's experience and clinical outcomes. She clinically specializes in breast cancer care. Her public speaking, literary work, and notable roles over the last 40+ years are well known to many:

•University Distinguished Service Professor of Breast Cancer (2016-present)

•Former Administrative Director, Johns Hopkins Breast Center (1997-2018)

•Former Director, Johns Hopkins Cancer Survivorship Programs (2011-2018)

•Professor of Surgery, Johns Hopkins University School of Medicine (2016-present)

•Co-developer and medical advisory of Work Stride: Johns Hopkins Managing Cancer at Work

Program (2012-present)

•Co-founder, Academy of Oncology Nurse Navigators (AONN+) (2009-present)

•Former Program Director of AONN+ (2009-2019)

•Editor-in-Chief of the Journal of Oncology Navigation and Survivorship (2012-present)

•Author of 20 books and >350 articles on various cancer topics

•National and international public speaker (1997-present)

A two-time breast cancer survivor, originally diagnosed in her 30s, Lillie has worked tirelessly to improve the care of breast cancer patients around the world. She has worked at Johns Hopkins since 1983. Lillie takes great pride in the AONN+, which as of April 2020, has more than 8,900 members. She has served as a consultant for breast cancer for national ABC News and Good Morning America and has been also consulted regularly by the Today Show and CNN. Lillie serves on 28 medical advisory boards currently. In 2008, the President of The Johns Hopkins University and their Board of Trustees appointed her to a Distinguished Service Faculty Chair. This is the first and only time in the history of the institution that a hospital nurse has been appointed to a distinguished service designation. She continued to climb the academic ladder and in 2016 was promoted to full professor. She is the only nurse at Johns Hopkins to have a primary faculty appointment in the School of Medicine and the only nurse in the country to have reached the highest academic faculty ranking and be appointed to a faculty chair as a University Distinguished Service Professor of Breast Cancer at Johns Hopkins University School of Medicine.

She has received 61 awards—54 national awards and 7 state awards, including being inducted into the Maryland Women Hall of Fame, Women in Business Healthcare Trailblazer Award, Johnson & Johnson's Most Amazing Nurse in America award, National Komen for the Cure's Professor of Survivorship award, and several national lifetime achievement awards. Her research area of focus is preservation of quality of life for patients with metastatic breast cancer. Currently, a documentary is being made about her life and her life's work. She tells people she never forgets where she came from—she will always be "a farmer's daughter."

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