Courtney Collen (Host): Hello and welcome to One in Eight, a new podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford health News. We are eager to kick off this series all about breast cancer awareness because 1 in 8 women will be diagnosed with breast cancer during her lifetime. Today, we’re talking with Dr. Andrea Kaster, a family medicine physician in the breast clinic in Fargo and our topic today is breast cancer risk.
Dr. Kaster, thank you so much for joining us.
Dr. Andrea Kaster: Thank you very much for having me.
Courtney Collen (Host): We’ll kick things off by getting to know you. Tell us about your role as a physician in Fargo.
Dr. Andrea Kaster: I began my training and went through family medicine and had about 10 years of general family medicine practice before coming over here and joining the Edith Sanford Breast Center. And now I’ve been here for about six years working in the high risk breast clinic. At that clinic, we do a combination of screening for women who are high risk. And then we also do a lot of diagnostic workups for women who have problems or have abnormal imaging at multiple outside facilities and then get referred into our clinic. So it’s a combination of both a screening and a diagnostic clinic. It’s very overwhelming. Of course, anytime you get the diagnosis of cancer and with breast cancer, I think especially, it’s one of those where most people have known somebody who’s gotten breast cancer. A lot of us know people who got breast cancer and probably didn’t think they should have, because despite a lot of there being hereditary cancers, there’s also a lot of breast cancer that isn’t hereditary breast cancer and seems to affect people who would otherwise not be at risk. So it’s really, it’s a scary one for a lot of women. And like you said, 1 in 8 women two in the United States develop breast cancer in their lifetime. So it’s, it’s very common. And so, yeah I think it, it does become more recent for people.
Courtney Collen (Host): So you mentioned risk. Let’s talk about that. What is a risk factor?
Dr. Andrea Kaster: So when you’re talking about risk factors for breast cancer you know, there are both risk factors that are – what we call – modifiable risk factors, and then there’s or ones that we can try to help prevent development of breast cancer. And then there’s some risk factors that are, that, that are out of our control. So some things we know lead to putting us at higher risk of developing breast cancer are a sedentary lifestyle. So as we become more and more technology dependent, we tend to be less and less active so increasing activity is very important to help keep your breasts healthy. And so just to sedentary lifestyle will increase your risk of breast cancer and other cancers as well.
Another one that is what we would consider a modifiable risk factor is alcohol intake. For women really less than one alcohol beverage a day is what’s recommended and minimizing alcohol intake. And it just has to do with alcohol being along a precursor to estrogen. It has to do with keeping your estrogen levels stable. So, minimizing alcohol use is important for women to help reduce their risk of developing breast cancer and then maintaining a healthy body weight. Especially this is important after menopause for women who have that midlife weight gain that can increase their risk of developing breast cancer as well. Related to the fat cells that will help change precursors of estrogen into estrogen effective hormones that can increase your risks. So when it comes to breast cancer, of all of the information out there, those are the real, the three really big ones that you want to focus on that women can do something about on their, on their own. There’s other, a lot of other areas of, of things that are, you know, we can’t really control that, do increase your risk and put you at maybe a higher risk of developing breast cancer. And so risk assessment basically is done for women initially with their primary care provider. And then sometimes if they’re concerned or if they show up our, our clinic, we will do a formal risk assessment on them and that includes factors such as family history and genetics testing in the family. Have they had biopsies done? Did they receive radiation therapy to their chest wall at a young age? Those types of things go into calculating a risk assessment on a woman. Then, that helps us determine if someone is at higher risk of developing breast cancer or not.
Courtney Collen (Host): So when a woman is high risk, what does that mean?
Dr. Andrea Kaster: So we have different risk assessment models that we use, but in general, if you use a risk assessment model and include this type of information also when they had their first period, if they’ve had children, how old they were breastfeeding, those types of information, then also the density of their breast tissue on the mammogram. So we include all this information that I’ve talked about, and then it will give us a risk estimate for a woman for their lifetime risk of developing breast cancer. And for women who have a lifetime risk of 20% or higher, they are considered a high risk. And women who are at around 12% is considered average risk. So that’s the one, and that’s the 1 in 8 number. For women who between 15 and 20% are in the moderate risk category.
Courtney Collen (Host): And who determines that risk?
Dr. Andrea Kaster: That is a big part of what we do at our clinic is risk assessment. So we will have referrals come in for women who have maybe a family history and dense breast tissue. And they just want to determine what their risk is at. And so we will run several of those models, the geneticists and the genetics department do a lot of risk evaluation for women as well. They will run an extensive, you know, kind of pedigree and we’ll run several models there too. So that would be probably the two most common places where women go to kind of get an formal assessment. Primary care providers absolutely can vary. I mean, both of the models we use most commonly, which are the Gail and the IBIS model those are both just available by Google’ing them and any provider can fill in that information for people. So it can also be done in your primary provider’s office, as well.
Courtney Collen (Host): If a woman was deemed high risk, what changes to her lifestyle might she need to make versus somebody who is at a lower risk for breast cancer?
Dr. Andrea Kaster: Really, it’s the same as the prevention ones. There’s staying active and doing more than you’re doing now: technically 30 minutes, five days a week. And I always tell people, it does not have to mean you have to start training for a marathon. Cause I think for a lot of people it’s overwhelming. They think, ‘oh, I have to be active. It means I have to start going to the gym. I don’t like going to the gym’. It really just means you know, mowing the lawn gardening going for walks, all of those types of things. It’s easy to forget how sedentary we are. So many of us are with our current jobs, so just getting out there and being active, same with limiting your alcohol intake and then trying to maintain a healthy body weight throughout adulthood is very important.
There’s other things that women can do. It’s, you know, if you breastfeed your baby for an extended period of time, that’s very helpful. You want to try to avoid unnecessary radiation exposure and also avoid ex extended period of exogenous estrogen. So for women who are, post-menopausal taking hormone replacement therapy you know, of us have heard, that’s not what we recommend in most situations. It doesn’t mean you can’t use it for maybe a short period of time. But, certainly by age 55 or, you know, depending on obviously specifics about your risk factors you know, certainly trying to take the lowest dose possible to manage your symptoms and getting off of that medication as soon as you can.
Courtney Collen (Host): We talk a lot about early detection and getting that mammogram. How important is this screening? Remind us how often we should be getting that exam.
Dr. Andrea Kaster: Yeah, for sure. So with breast cancer, with a lot, most cancers, and in particular this is true with breast cancer finding it early, you have more options for treatment when you find a breast cancer early and use usually less invasive treatment. So for someone who finds an early cancer ductal carcinoma where the cancer is still within the duct and has not become invasive you know, in those situations you don’t need to use chemotherapy. You would just need a surgical excision and sometimes radiation therapy. And so you can avoid chemotherapy altogether in those situations for the most part.
The earlier we can find it certainly, the better, and then the smaller it is, the better outcome we have for that as well and the more surgical options you have and just more treatment options overall. So early detection helps improve outcome. The higher survival rate, the earlier you find it, and then also just more options that way. And so that is kind of a key behind the recommendations that Sanford Health has maintained, which is to start getting an annual mammogram at age 40 and continuing annually after that there are definitely organizations out there that have changed their recommendations. And so they’re depending upon who, you know, if say American Cancer Society or the United States Preventative Services Task Force both have different recommendations on when to start and how frequently to screen, but everybody agrees that you get the most benefit out of annual screening mammograms. The most years of life saved by doing that way. And also decreased mortality by doing an annual mammogram starting at age 40. And so we just feel with that as our top priority, that is the way to continue our practice. There are downsides. There are, you know increased biopsy rates you know, increased stress associated with that. That’s why some of the recommendations have changed. But overall we like to keep our eye on the survival and the decreased mortality.
Courtney Collen (Host): And correct me if I’m wrong, but we should still be getting that annual mammogram regardless of whether we are high or low risk, right?
Dr. Andrea Kaster: Correct. Annual mammograms starting at age 40 and talk with your doctor that you can definitely, obviously there’s a much more shared decision-making in medicine these days. And you want to talk to them about the potential harms of having an annual mammogram. Say you are very, very low risk and don’t have any family history of cancer. You have your lifestyle, you know, you’re meeting all those goals and you have one mammogram and you find out you don’t have dense breast tissue. If all of those things are lined up and you say, I don’t want any extra radiation exposure. I would like to have one every two years, you know, and to make an individual decision based on your preferences with your provider is very important. But we don’t feel that everybody needs to follow the ‘don’t start till 50’ or, you know, those types of things, because we’re going to miss miss cancers when we do it that way.
Courtney Collen (Host): So what advice would you have for women about what we can do now to make sure we’re staying on top of our health?
Dr. Andrea Kaster: Well, you just want to make sure that you are talking to your doctor and staying up on all of your screening recommendations. So, making sure that you’re getting your wellness exam and your pap smears when you need to colonoscopies when you need to start screening for colon cancer screening, that’s another one that goes can get, be very hard to detect early on. And so just making sure that you’re keeping up with all of your screening is so important. Especially we have seen with COVID people are avoiding coming into the clinics for good reason that, you know what, in the beginning, we didn’t know you know, how the virus was spread and what type of what type of activities put you at higher and lower risk. But you know, in general, our clinics and hospitals that are, you know completely masked centers, everybody’s wearing a mask everybody’s being screened and everybody’s washing their hands.
So we feel like it’s very safe to continue now knowing what we know with your screenings and make sure to keep up on that. And then immunizations of course, one of the best inventions of modern medicine and especially important this year with flu vaccines coming out, that everybody gets their flu vaccine. So if a woman is curious about whether she’s high risk or low risk, or just once more information, where should she go and what should she do? I would also say that if you are at elevated risk, so for women who do come in and they have a lifetime risk, that’s over 20% we can do more screening for you. So those women actually will potentially qualify to have a breast MRI in addition to a mammogram on an annual basis. And so we can do that and that improves our screening dramatically.
For women who are afraid of coming in and having finding out they’re at elevated risk, it’s important to know that because we actually can offer more screening. There’s also medications out there that we can use to help lower your risk of developing breast cancer. Those medications are reserved for people who are in the high risk category because of potential side effects, of course. But that is another option for women in the high risk category. And so and then also just making sure you’re doing clinical breast exams with your provider and just being aware of your breasts at home. So for everybody in all risk categories just being, we don’t recommend that detailed you know, linear breast exams like we used to, but we do strongly recommend that people pay attention to their breasts, know what feels normal for them, know what looks normal for them and to report any changes right away.
Courtney Collen (Host): Dr. Kaster, it was great having you as our guest. Your expertise about risk factors when it comes to breast cancer was so valuable as we continue this conversation about breast cancer awareness. And we really appreciate all that you do for women in our communities all over the region. Thank you so much for your time.
Dr. Andrea Kaster: Thank you so much for having us. I appreciate it.
Courtney Collen (Host): I’m Courtney Collen with Sanford Health News. Stay tuned for the next episode of One in Eight, our breast cancer podcast series coming your way soon. Stay well, have a great day.