Breast cancer is no stranger to women. Whether you’ve lost someone to it, or supported a loved on their healing journey, women worldwide are too familiar with the disease.

To help raise awareness about the importance of prevention and routine screening for the early diagnosis of breast cancer, Dr. Cassann Blake, head of breast surgical services at Cleveland Clinic Florida, recently participated in a virtual interview hosted by Hope Sealey of Diane Phillips & Associates to shed insights on breast cancer, treatment, and reconstruction options. Here’s the Q&A discussion from the interview:

Q: What type of breast cancer do women typically have?

A: Eighty percent of breast cancers are from a ductal origin and the ducts are a conduit for breast milk. The second most common type of breast cancer, accounting for 10-15% of cases, is lobular breast cancer (also called invasive lobular carcinoma). This is breast cancer that starts in the milk-producing gland, or lobules, of your breast where we make breast milk, and has spread into surrounding breast tissue. The cells in those regions are the two most common types that become cancerous. Occasionally we see cancer in the nipple that flourishes on to the areola, but that’s a rare type of cancer, around 1%, called Paget’s. Despite originating from different areas, they are treated the same, however the treatment will differ based on additional features on each type of cancer. Cancer of the breast usually doesn't start in the lymph system, it can travel from the breast to the lymph system, to the lymph nodes, and that has an impact on the stage of breast cancer.

Q: At what age do you typically see women getting breast cancer?

A: Women ages 50-70 years pose the greatest risk for developing breast cancer. However, we do see women developing breast cancer in their 20s and occasionally in their 90s as well. So, everyone should be aware that if you find a lump, it should be evaluated.

Q: If one finds a lump when doing a self-breast exam does the size of the tumor matter? Should one immediately get a mammogram or ultrasound?

A: If you do find a lump you should let your doctor know you’ve identified a lump. If it’s a woman over the age of 30, then a mammogram and ultrasound is typically recommended. If it is someone under the age of 30, then the evaluation starts with an ultrasound. It doesn’t matter the size of the lump you are feeling; once you feel a lump you should then have an evaluation to determine if it’s a cancerous lump or a non-cancerous lump.

I usually suggest to my patients to do a monthly self-breast exam, and if you find a lump, then it’s our job as physicians to find out what it is. Don’t stay at home and self-diagnose based on whether the lump is big or small saying, “well, the lump is small so it's probably nothing or it's big, so it's a cyst.” That’s the job of your physician. Bring it to our attention and let us do the evaluation and help guide you through the process of figuring out what’s going on with your breast.

Q: Is death imminent if the cancer spreads to the lymph nodes? What are treatment options?

A: Not necessarily. Stage 2 breast cancer can be in the lymph nodes, so we treat it with the intention or the purpose of curing it when the cancer does not appear to have traveled to other parts of the body, like the bones, brain, liver, or lungs. At that point, cancer in the lymph nodes is still considered a local and regional disease and can be treated with the intention of curing it. So, death should not be viewed as eminent. However, that being said, prompt breast care or treatment is important. We're now learning that if somebody waits beyond two months to have something done about their cancer, whether it's surgery or sometimes chemotherapy or sometimes a pill, the prognosis may be changing. The cancer cells aren't waiting for us. They're going to continue to try to march on the more time it takes to do something about them. So doing nothing is not an option. And even if the cancer has spread, there are good treatment options that we're learning more and more are able to prolong life.

Q: How do doctors determine the stage of cancer, i.e., Stage 1, Stage 2…Stage 4, etc., and what are the implications of each stage? Is the stage of my cancer the same as the “grade” of my cancer?

A: The stage of the cancer initially is based on a clinical evaluation, meaning what does the imaging show, what does your physician feel in your breast, do they feel any lymph nodes? Stage zero typically is only found on imaging. The implication for stage zero is that if you've been diagnosed with stage zero breast cancer, this is a type of cancer that does not have the ability to spread, and the prognosis is 99% of people are going to be fine. The reason why this does need to be treated, however, is that if nothing is done, eventually at some point in time, these cells, like I mentioned before, aren't going to wait for us. They then may become an invasive breast cancer, move up to a stage one, move up to a stage two, move up to a stage three, and so forth. Your prognosis of cancer is very dependent on the stage. Stage, again, is the size of the tumor, whether or not it's a lymph node and whether or not it it has traveled to other parts of the body. Treatment is based on the stage and the features of a cancer. Your oncology team is going to look at this tumor to see if its sensitive to estrogen or progesterone, or if there’s a protein overgrowing on the cells called HER2. That will help to determine should your treatment involve chemotherapy, or should it involve what we call endocrine therapy, which is basically we're manipulating your hormones because your tumor may love estrogen and we can try to starve it, so to speak. Whether or not surgery should be first or treatment of the whole body with chemotherapy first, these are all decisions that are made based on the stage of the cancer and the features of the tumor.

Grade is different from stage. Grade is telling us when the pathologist looked under the microscope, how aggressive the cells look. With that being said, it does not mean that a low-grade cancer should be assumed to not have the ability to spread and do bad things, versus a tiny high-grade cancer can also sometimes do aggressive things. We factor grade in our evaluation, but it is not the be-all, end-all in your treatment.

Q: Looking at generational diseases, how many generations back should we go to find out if we're genetically predisposed to cancer? One is usually asked on a questionnaire whether your parents, siblings or close relative had cancer, but how far should we look back? And is there any way we can improve our chances of not getting cancer based on generational transfer of the disease?

A: We recommend that you talk to your family and try, to the best of your ability, to be aware about three generations on both sides of your family. That includes your parents, your grandparents, your aunts, your uncles, your cousins, your siblings, your nieces, and nephews. So going up three generations and down three generations is very helpful in determining who should have genetic screening to help determine their risk for breast cancer. Now, there's somebody who may have a very strong family who has breast cancer. We may not find a genetic reason for it, but that does not mean you're not at risk. So, seeing a specialist or someone dedicated to breast health can help a patient or help a woman understand where her risk lies, regardless of whether she is gene positive or gene negative.

Q: Regarding mastectomies, should both breasts be removed when we're looking at mastectomies?

A: The only time that we recommend someone really consider removing both breasts is if somebody has a genetic predisposition such as a BRCA mutation or some of the other mutations we know puts a woman at high risk for developing cancer again in the future, or if there's a very strong family history. Those are the two scenarios that we recommend considering removing both breasts. If there isn't cancer in both breasts, it is a conversation, it is not mandatory that both breasts are removed. Even if you have cancer in one breast, the decision to remove that breast is based on the stage and the conversation with your doctor. Roughly 70 to 80% of women who have a Stage 1 breast cancer can save their breast. Some women choose to remove their breast for various reasons. But the prognosis is exactly the same, meaning your odds of being cured of cancer is the same whether you choose to remove your breast that has cancer or keep the breast that has cancer as long as it has been completely removed surgically. Meaning the tumor is removed, we've obtained negative margins, we've done a good job of removing the tumor and you've kept your breast. The prognosis is the same as somebody who's opted to remove one or both breasts.

Q: So, the treatment going forward is not more aggressive if you choose to keep the cancer breast?

A: Correct, when you meet with an oncologist, they're not going to look at you and say, you saved your breast, I now must be more aggressive in my chemotherapy recommendation. Or they're not going to say, you have opted to remove one or both breasts, I'm not going to recommend chemotherapy, I'm maybe just going to recommend a pill. Ultimately, it is the biology of the tumor that dictates additional treatment. How big is the tumor? Did it go to the lymph nodes? What are the receptors? Is it estrogen receptor positive or negative? Is it HER2 positive or negative? Those factors are not changed by how the tumor is removed from your breast, but those factors dictate the risk of the cancer traveling throughout your body. Ultimately, and sadly, when somebody loses their battle to breast cancer, it is because the cancer traveled elsewhere in their body. The oncologist is not looking at the surgery that you've had, provided the surgery has been done well and appropriately, to make recommendations for treatment. Now, the difference between saving someone's breast and removing it is that if you have opted to save your breast, you may need radiation therapy to help sterilize the rest of the breast that is there. But radiation therapy has evolved significantly over the years. It used to be that women got six weeks of treatment. Now many women can effectively have their breast treated with radiation therapy in just five days.

So instead of six weeks, if the whole breast needs to be treated, many women are now having three or four weeks of treatment. But a lot of our women, who don't have nodal involvement or very early breast cancer, are being offered five days of treatment where appropriate.

Q: How many mastectomies do you perform annually at Cleveland Clinic, and do you see a lot of Bahamian women coming there for surgeries of that nature?

A: We do see a fair number of women from the Bahamas who come to Cleveland Clinic for their care. The mastectomy rate is roughly about 45 to 50% of all of our breast cancers that opt to have a mastectomy performed, depending on the year. We do approximately 200 or so mastectomies a year.

Q: How long does a mastectomy procedure typically take to perform and what is the recovery process like?

A: The surgical procedure length varies based on whether you're having one or both breasts removed and whether you've opted to have reconstruction and the type of reconstruction that has been recommended by the plastic surgeon. If someone has had one or both breasts removed without reconstruction, the recovery time is three to four weeks. If they have opted to have reconstruction, it's closer to six weeks.

Q: In the Bahamas, we have one of the highest prevalences of the BRCA mutation in the world, based on studies that were done here. As we look at prophylactic mastectomies which seem to be considered more and more, do you think the prevalence of breast reconstruction surgeries is a factor in women's decisions to have prophylactic mastectomies?

A: I think it does influence a woman's decision to have a prophylactic mastectomy. What we know is that women who have a BRCA mutation are at high risk for developing breast cancer that a prophylactic mastectomy has been shown to prolong life for women who have a genetic mutation up until a certain age. So occasionally we'll have somebody who's been identified as having a BRCA mutation at 70 or 75. We have a harder time saying that removing both breasts is going to help you live longer. We may say, okay, well, let's do higher screening, have a mammogram, and an MRI every year. So, there are options for close monitoring.

Q: I do know some people who've had mastectomies and it was a very unpleasant experience for them, especially if they are thin. Have there been any more recent advancements in the entire process to make this more appealing?

A: So, for appropriately selected women, a nipple-sparing mastectomy is an option. That means that the breasts are removed, sometimes through an incision under the fold of the breast, and it can have a very natural look because you've got to preserve your own nipple and areolas. A lot of women do find that to be appealing to have the ability to have that. I think sometimes the duration of time it takes to complete reconstruction when that surgery is not offered can at times be associated with someone saying, “no, I'm not ready to have a mastectomy because I'm not ready to commit to having reconstruction.” Reconstruction for a lot of women does involve at least three procedures to complete the reconstructive process.

Q: You mentioned chemotherapy and radiation earlier. Can you tell us a bit about that as to when treatment requires chemotherapy versus radiation?

A: Radiation therapy is recommended typically if somebody has nodal involvement. So, if the cancer is spread to the lymph nodes, radiation therapy is going to be recommended. If someone has opted to have a mastectomy and the tumor is found to be greater than five centimeters, radiation therapy, even though you've removed the breast, is going to be recommended. If the margins are involved or very close, meaning the tumor was removed, but there may still be residual cells left behind or we are very close to the edge of the tumor, occasion radiation therapy would be recommended. If someone has opted to remove the breast, the threshold for radiation therapy is lower, like I mentioned before. Some women may get five days of treatment to the area that the tumor started in, or some women may have three to four weeks of treatment based on their stage and nodal involvement.

Regarding chemotherapy, who should get chemotherapy is based on the features of the cancer, the size of the tumor, and whether or not it's involved in the lymph nodes. For women who have hormone-sensitive tumors, and they are HER2 negative, the current treatment recommendation is that if the tumor can be removed successfully, do surgery first and then answer the question if chemotherapy is needed later. There is also genetic testing that can be done on the tumor. Now this is different genetic testing than the one that is used to evaluate for a BRCA gene for example, to determine if the prognosis will be better with chemotherapy versus without it.

If someone has a triple negative breast cancer, a more aggressive form that tends to have a higher incidence in women of color, or if someone has a HER2 positive breast cancer, the tumor can be anywhere from two centimeters or greater or have lymph node involvement, then chemotherapy would sometimes be recommended, or the current guideline is chemotherapy is recommended before surgery. This way we can get a better sense of the response of the tumor to chemotherapy, and if there's residual disease after the tumor has been removed, additional treatment options can then be discussed.

Q: You mentioned earlier that genetic testing is done for the BRCA gene. Can you tell us about the type of testing that is done? Have there been any new developments in the type of testing done for BRCA to detect cancer?

A: As we learn more about the relationship of cancer and genetics, the genes that we're looking for have expanded. Initially, several decades ago, we only looked for BRCA1and BRCA2 if there was a family history of breast and ovarian cancer. Now we know that there are other genes that have a similar risk of developing breast cancer. So now we're looking forPALB2, CHECK2, and ATM. Most women who are having genetic testing are now having panel testing. We're looking for 40, sometimes 70, different genes that are associated with cancer. The genes and the amount of genetic mutations we’re looking for now compared to before have increased because now we are aware of the relationship of certain mutations and the risk of breast cancer. Genetic testing is typically a blood test or a saliva sample that is sent to the testing company and the genetic counselor will communicate the results once available.

Q: If you're genetically predisposed to BRCA gene, it doesn’t necessarily mean you’re going to develop full-blown cancer right away. What can you do to reduce the risk of developing full-blown cancer if you're predisposed?

A: There are some things that can be done, but it's important to highlight that the risk of developing breast cancer if you have a BRCA mutation that is anywhere from 60 to 80%. To be clear, the risk is significant and while there may be things that can be done to lower your risk, to maximally lower your risk by 90-95%, that would be with a prophylactic mastectomy. That is truly how you can have the most risk reduction. Outside of that,

depending on age, sometimes in conversations with your team, moving the ovaries can lower your risk of subsequent breast cancer by as much as 50%. But if your risk of breast cancer is 80% and we're lowering it by 50%, that means that we are only lowering your risk to 40%. So that is how we typically counsel our patients. Now, if someone opts to not have a prophylactic mastectomy, that's acceptable. Everyone must make a decision that's right for them. We usually recommend high-risk screening, as I mentioned before, mammograms and MRIs, so that if a cancer is developing, we are then able to identify it at its earliest stage, which would then hopefully translate to a better prognosis.

Regarding ways to lower your risk, a healthy lifestyle seems to lower risk, meaning limiting red meat, limiting processed meat foods, limiting your alcohol, or eliminating altogether alcohol intake can be helpful. Physical activity, moderate activity, which includes such things as vacuuming or taking a brisk walk. 150 minutes a week can be helpful. If you don't have 150 minutes to commit, then 75 minutes of vigorous activity, such as walking briskly uphill or doing a physical activity where you really can't hold a conversation while you're doing it because you're kind of huffing and puffing, that can also lower your risk of breast cancer. Outside of the things that a woman can do for herself to lower her risk, there are times when considering a medication for five years may also help to lower your risk of developing breast cancer, and that usually should be discussed with a medical oncologist.

Q: Are there any specific gene therapies that are being used to target the BRCA gene?

A: A gene therapy for BRCA mutation is still considered experimental. So, enrolling in clinical trials is encouraged because it's how we answer the question of: can we find new therapies that hopefully will prevent breast cancer from ever developing?

Q: Will a vaccine ever be developed to successfully treat breast cancer? We know there's some testing going on, but do you think we'll ever get a vaccine that really can significantly reduce the risk of it developing?

A: We certainly hope so. The Cleveland Clinic does have a clinical trial exploring the use of vaccines to help decrease cancer recurrence and vaccines do appear to have a future in breast cancer risk reduction and treatment. So, we are optimistic, but right now it's in the clinical trial phase.

A lot of times we have to follow women for several years to know the answers to what our question was. Was our question, did we reduce the risk? Well, that means we have to monitor someone for several years to know if we are able to reduce the risk. Similarly, did we decrease the risk of a cancer coming back? We are hoping that in the future, we can have quicker answers to our clinical trials, but at least we're making strides to try to answer the questions that we have today with women participating in our trials.

Q: We see a lot of robotics being used in surgeries today, but what about artificial intelligence being used to help detect or improve breast cancer treatments? Is that happening with Cleveland Clinic in any area now?

A: In radiology, AI is being used to review mammograms to help determine if there's an abnormality that the radiologist should look at a little bit more closely. So, it is helpful to have another set of eyes, like AI, to look at breast imaging, especially for women who have dense breast tissue. The issue with dense breast tissue is that on mammography, your tissue looks very white, and cancers also appear to be white. So right now, what's being used every day is AI in breast imaging.

End of interview.

In summary, Dr. Blake’s number one counsel to Bahamian women is that “doing nothing is not an option.” Let’s do our self-breast exams, get our mammograms, eat right, exercise, and should cancer appear, embrace the journey with the support of close family and friends.