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The Fullness of Midlife

"Finding out you have an increased risk empowers you."

"Finding out you have an increased risk empowers you."

by Dr. Barb DePree MD

Dr. Jane Pettinga with Dr. Barb

Dr. Jane PettingaDr. Barb: Today our guest is Dr. Jane Pettinga. Jane is a general surgeon at Holland Hospital, specializing in breast cancer treatment, prevention and risk assessment. She is a graduate of Wayne State University and has been practicing medicine for 37 years. Jane and I actually spent some time serving patients together in Holland Hospital’s High Risk Breast Clinic.

Today we’re going to talk a little bit more about women’s health and, specifically, breast cancer and some of the opportunities for risk reduction and prevention and also some screening. So, thanks for joining me today, Jane.

Listen now.

Jane: Pleasure to be here.

Dr. Barb: First I’d just like to hear more about how you ended up being a specialized general surgeon in breast, because that’s a bit unusual, and you might have been one of the early breast surgeons.

Jane: One of the first breast surgeons probably in the countrya handful of us. I was sort of heading towards family medicine, but when I did my surgery rotations, I just had so much fun, and it's so nice to see immediate results. So often in medicine, results come slowly over the years.

Then when I finished my training in surgery, I had one child and one on the way and was married to a very busy surgeon. I really wanted our kids to know their parents, so I looked for something I could do where I could control my time. An opportunity arose for me to join an older surgeon, who was a wonderful man, who was doing just breast surgery. Probably one of the first in the country. And I thought, well, I didn’t do ObGyn because I didn’t want to just take care of women, but I’ll give it a try. And it turned out that it was very challenging and very rewarding, and patients are just wonderful. It’s changed so much over the 30 years that it never became boring, even though it was very specialized.

Dr. Barb: Yes

Jane: It was right for me.

Dr. Barb: It’s interesting you say that. Because as you speak, it reminds me that general surgery was my favorite rotation, and I really aspired to be a general surgeon. But, at the time I was about to be married and a couple of the residencies in the country actually talked about their divorce rate being up to 100 percent. I was very intimidated by what the time commitment might mean and what the ability to, you know, have a successful marriage and start a family. So it’s interesting that you created this kind of sub-specialty within the general surgery field and that I,  in turn, chose ObGyn, so it allowed me to do some surgery along the way too. But, I think we were probably somewhat on the same wavelength back at that time.

So I’m wondering if we can start out talking a little bit about breast screening and if you could review some of the general recommendations, because there’s some conflict in the media about who should be screened and when, at what age, and at what intervals. From your perspective,  (and you’re up to date with what is happening in different fields, not only general surgery), how do you recommend the general, average-risk woman be screened for breast cancer?

Jane: Well, it’s interesting… the U.S. Preventative Task Force came out with recommendations a few years ago that decreased the recommendation for screening and mammography. And I don’t agree with their reasonings, though they have brought up very good points. First of all, on the top end of the age scale, there’s no studies that have included women over 70, so therefore, there’s no evidence that screening helps those women, because the studies simply haven’t been done.

However, the rate of breast cancer goes up as you get older. So more of those women are going to have breast cancer. If a woman gets breast cancer at 95, she’s probably going to survive that and die of something else anyway. But it’s still nice to not have a bigger surgery or need chemotherapy, so finding it early is still helpful to somebody.

The American Cancer Society recommendations are that you keep screening as long as you think you have ten years of life left. And that makes a lot of sense. My mother is 92; she’s very healthy. Her mother and one of my sisters have had breast cancer, so I keep telling her, I think you’re going to make it to 100, maybe next year is your last mammogram.

Dr. Barb: Okay.

Jane: On the other end of the scale, there’s more controversy about when you should start. It had always been starting at age 40 and then going every year. A lot of the studies that showed efficacy of screening mammograms actually did every-other-year screening. So then when you look at the evidence, it’s hard to parse out how much more benefit you get from every year. Nonetheless, as a practicing surgeon, I see so many women who one year before had a normal mammogram and, boom, now it’s a centimeter. Well, how big would that cancer be before it was felt? Maybe 2 or 3 centimeters. and then you’re getting into a higher stage. So, I think the interval should still be yearly.

Dr. Barb: Starting at age 40 as a general rule?

Jane: Correct, all the evidence shows that mammography saves lives at all ages. Even in the 40-year-olds. But, 40-year-olds have fewer cancers, because it tends to occur when [we’re] older. And so because you’re not going to find as many, it’s not going to be as helpful, because most women aren’t going to have cancer. Mammograms in young women are also harder to evaluate because they have denser breasts, lumpier breasts on mammograms. The U.S. Task Force was worried about the inconvenience and fear that having an abnormal mammogram causes when it turns out to be nothing. Some people talk about unnecessary biopsies. They’re not unnecessary; there’s something there that we have to find out about and the question is what is your level of comfort with having a possible biopsy that turns out to be benign. That is, about 15 percent of biopsies turn out to be cancer. We could easily make that 50 percent by biopsying only the most suspicious things, but then we miss some cancers at an early stage when it’s mostly... when it’s more curable.

Dr. Barb: I hear that argument as well and that’s always seemed a little bit of a disconnect for me, because I think most patients who understand there’s something in the mammogram that needs follow-up, most women are pretty willing to undergo a biopsy to clarify for them whether that’s benign or cancer. So this idea of instilling unnecessary fear, I think that uncertainty or the not knowing, in my mind, is a greater risk.

Jane: To me, it seems very paternalistic. In fact, there was an op-ed, in what I think was the Washington Post when these came out that said, “Don’t worry your pretty little head about breast cancer.” You know, women, have a lot of pain and worry and suffering in their lives. To mea few women, it really is tough on, but for most women... “Okay, here’s one more thing, I’ll go get it done.” Almost all the biopsies are done with a needle, it’s a little outpatient procedure that has very few consequences from it. It’s just relatively easy, and usually it can be done right away. So it’s usually done within a week, so that fear doesn’t last that long.

Dr. Barb: Yes.

Jane:  And the other thing is, sometimes the biopsies find things that are benign, but show that the breast tissue is at increased risk for developing cancer; so then women can take steps to decrease the risk. To me, yearly, starting at 40 and of course, it’s good to talk to somebody about it. You know, the recommendations are: Well, to discuss this with the patient and let her make her mind up. You always do that, but I mean, when I go to the doctor, I rely on his or her expertise, to say, well, no, what’s your recommendation. I don’t go home and think, oh well which medicine am I going to take?

Dr. Barb: Exactly.

Jane: It just doesn’t make sense to me.

Dr. Barb: Can you talk a little bit about tomosynthesis, which is a newer version...

Jane: Yup, it’s also called a 3D mammography. If you can imagine when your breast gets smashed in that machine, you’re pressing everything together and it all overlaps and you get one view going across, one view going down. So all this breast tissue overlaps and it’s hard to see through that. The tomosynthesis looks at little slices through the breast. It’s like a CAT scan, so that you can see just a small part of the breast tissue without everything else getting in the way. It unfortunately means you still have to get smashed. So to the person having the mammogram, it doesn’t feel any different. But, when you read the mammogram it does two things. It finds more cancers earlierand this is especially helpful in women with more dense breastsbut it even finds more cancers even in women with fatty breasts. And it helps the radiologist figure out the benign things. So there’s fewer call-backs and fewer ultrasounds. They can just sort of figure out just by looking at it the first time around. It’s a win-win situation. It does cost more, it takes longer to read, the equipment is a little more costly. More and more insurances are paying for it, because the additional cost is worth the additional pick up of new cancers.

Dr. Barb: Can you talk a little bit about breast cancer risks and what we understand about what the actual risks are and about what maybe is perceived, but not as much a risk as women might understand it to be?

The rate of breast cancer goes up as you get older.Jane: Sure. Average risk for an American woman who lives to be 90 is about 12 percent. So that’s significant. But, it goes up as you get older, so it’s much less than that if you live to be 75, say. The most important risk factor is having inherited an abnormal gene from your mother or father like Angelina Jolie did. It can come from the father’s side, so look at your family. Look at your family. Are there more two or more women with breast cancer, especially if it was a young age; especially if there’s ovarian cancer in the family, or males with breast cancer, early prostate cancer, pancreatic cancer. Those can all be related in to the most common inheritable gene abnormality which is BRCA1 or BRCA2.

You can imagine if you inherit an abnormal gene the BRCA1 and 2 genes code for a protein that’s involved in the cell that lets the cell to recognize when it’s turning into cancer, and it pushes a self-destruct button. If those genes aren’t working the protein isn’t made, and the cell doesn’t recognize itself being cancerous; it keeps growing. For some reason it affects breast, ovary, pancreas, prostate, and more than anything else.

Dr. Barb: So when you speak of two individuals, we’re including grandmothers, aunts, cousins, nieces, sisters, mother...

Jane: Correct. First-, second-, or third-degree relative. First degree is your mother, sister, daughter. Second is aunt, cousin, grandmother, and then the third degree is their kids and mothers. You look at both sides; you have to look at one at a time. If you have an aunt on each side, that doesn’t count.

Dr. Barb: And the other is potentially the age at diagnosis that also plays a role.

Jane: If you can imagine that every single breast cell has this abnormality, it doesn’t take too much to put something over the top and have the cells actually turn into cancer. Therefore we tend to see the cancers at an early agebefore menopause. So that’s a real clue, because breast cancer is so common, it’s not unusual to have one or two women in the family with breast cancer, especially if you have a large family. But, if they were 40 years old, 40 to 50, then you start looking at it differently.

The other important thing is if someone is Ashkenazi Jewish, there are some gene abnormalities that are more prevalent in that community; So if you have one person in your family that had breast cancer and you’re Jewish, you should ask your doctor about it. Because you can have a simple blood test or cheek swab test. The tests have become much less expensive in the last few years. In fact there’s one company now that will do it outside of insurances for $275, and test several different genes at one time.

Having genetic counseling before the testing is important.The important part about genetic testing is that you really need to know what it means. You know, what does it mean for you, for your family. What kind of impact is it going to have? Will it have impact on insurance? There’s just really a lot of things to know. It’s not just what’s my blood sugar or my blood count. It’s a test that has a lot of implications. So having genetic counseling before having the testing is important. And you say, why should I do this? I’m just going to wait for the shoe to drop, why live in fear? The reason is there’s things to do about it. I will get to that in a minute, but before we get into that I should mention a few other risk factors.

Family history genetics is a very important one. Probably the next important one is having had a biopsy of the breast, that wasn’t cancer, but showed something called atypical cells. Either atypical ductal hyperplasia, atypical lobular hyperplasia or lobular carcinoma in situ. It actually has the word cancer in there. it’s sort of like if someone is very fair skinned, they are more likely to get sunburned. If a woman has these types of cells in her breasts, she’s more likely to have a cancer start.

So that gives significant increased risk. Other things are, being overweight after menopause, starting your family after 30, starting your period before 12. Sort of the longer time you have uninterrupted cycles of estrogen, non-estrogen. There’s not a lot of environmental things that we know about. I expect that we will find out about it sometime.

Finding out you have an increased risk empowers you.Breast density is something that is relatively newly talked about. And you can also think about it as the more active your breast tissue is, the more it will show up on a mammogram, and the more likely it is that it will make a mistake. Once you find out you have an increased risk, it empowers you. There are things you can do. Probably the best thing, is to exercise.

Dr. Barb: And this would be for those women who we don’t identify even as having increased risk. They may be the average-risk woman, who still have a 12-percent lifetime risk of developing breast cancer. The best way she can try to remain in the 88 percent of women who will not be diagnosed with breast cancer, the most proactive thing she can do, is to maintain an ideal body weight. Is that what you wouldor one of the things you would recommend?

Exercise in and of itself, even without weight loss, decreases the risk for breast cancer.Jane: Oh yes. Statistically, body weight makes a difference for postmenopausal women, not premenopausal women. But, if you’re overweight when you are premenopausal, you’ll likely be overweight when you are postmenopausal, so it's always a good time to keep your body weight in check. Exercise in and of itself, even without weight loss, decreases the risk for breast cancer. It’s hard to put an exact number on it, because you have to rely on people telling you how much they exercise. But it can be as much as a 20-percent decrease in risk, which is fantastic! Because it does all these other wonderful things: decreases your risk for heart attack, stroke, diabetes, dementia; I mean, it’s just the best thing any of us can do for ourselves.

Dr. Barb: And how do you advise women in exercise? Thirty minutes five times a week, forty-five minutes five days a week? Where do you set the ideal standard for exercise?

Jane: The ideal: It’s aerobic exercise that makes a difference. Strength training is great too. But in this case, it’s the aerobic exercise that counts. You don’t have to be dyingjust a little bit out of breath, a little sweaty. Walking is great. It’s ideally four hours a week. Everyone is different, their schedules are different and you have to figure it out. You don’t want to do four hours in one day. That would be too difficult and you wouldn’t get as much benefit. But, if you want to do twenty minutes a day and then more on the weekend; if you want to do forty minutes a day; if you want to do an hour four times a weekhowever it fits into your schedule. And don’t pick something you hate because you won’t keep it up. Get a dog, so you have to take them out for walks. Just figure out somehow to incorporate it. If you have a family, bring them along; it's good for everyone. Everybody go for a walk after dinner.

Dr. Barb: Yeah. As we’ve recently been hearing, inactivity, or being sedentary is the new smoking when it comes to general health. So I think, the good news is that we do have some science behind exercise in reducing breast cancer risk. I think when it comes to women’s health, breast cancer always gets people’s attention, and people are always willing to hear more about it. So, I’m hoping that as we hear more about it and understand the connection, it will encourage women in their wellness to incorporate that as a part of their routine. I think it's an area where we haven’t been bold enough in emphasizing its benefits.

Jane: And it can be done. It seems daunting and especially if you’re busy, raising kids, working. Where do I fit it in? You can find a time to fit it in. Maybe you don’t get up to four hours a week. Anything is helpful.

Don't go on a diet; change your eating habits.Along with that comes your eating patternsyou know; what you eat. And for breast cancer it's a dietlet me step back. For breast cancer, it's even harder to get strong evidence to show the relationship. Again, partly because you have to rely on people’s eating patterns. You can show stuff pretty easily in mice which doesn’t always translate over to humans. But, overall it appears that probably a diet that’s low in animal fats, high in fresh vegetables especiallyfruits, is the best. You know, it's the best for everything.

It can be hard to do thatit's hard at first to figure out. What are my eating patterns going to be like? Don’t go on a diet, just figure out what you’re going to do. Change your lifestyle, change your eating habits so that you’re healthy. Shop around the outside of the grocery store, where all the fresh stuff is. Try to stay away from processed foods. It takes a while to get used to that. But once you do, you can have delicious meals that aren’t going to take hours and hours to make.

Dr. Barb: And the thing that I hear is when women are really able to do that, they just feel better. They have more energy, they sleep better ...

Jane: And it's better for their families!

Dr. Barb:  And we’re talking about breast cancer specifically, but I don’t think we can overemphasize the other areas of their lives that will be impacted by that.

Jane:  Now as far as prevention goes, these lifestyle changeswhich we should all be doing:  exercise, eating well, getting mammogramssome women at high risk we get screening MRIs so they’re getting checked every six months. In addition to all that, a step up from that, for women with increased risk, we do have some drugs for that, that can cut the risk about in half. Which is really significant.

Tamoxifen is the most well known, but we have several drugs. Tamoxifen is the only drug that is approved for premenopausal women; but there are several drugs that can be used in postmenopausal women for this too. All drugs have some side effects, and the side effects vary according to the individual. Again, we have to go over the risk-benefit ratio. It's not appropriate for all women to be on, but for those who are have an increased risk, it can cut their risk by 50 to 70 percent, so it makes sense.

Dr. Barb: And there are some tools to try to help women understand more exactly what their lifetime risk is, taking into consideration...

Jane: Yup

Dr. Barb: A number of the things you mentioned earlier. So for instance, if a woman is 12 percent and for someone they might have up to a 35-percent lifetime risk of breast cancer, you can reduce that risk, nearly back down to an average woman just by considering a medication. And generally these medications are used for a defined period of time?

Jane: Five years.

Dr. Barb: It’s not being on it for life. It's a five-year use of the medication, hopefully giving them, in turn, lifetime risk reduction.

Jane: Right. The easiest time to take it is premenopausally. Because there’s the least side effects and a longer period of benefit.

The last thing is that for women at a very high risk, some women will choose to do what Angelina Jolie did to have the breast tissue removed with immediate reconstruction. That reduces the risk by 90 percent; still not 100 percent, but very significant.

Knowledge is power; it could spur you on to do lifestyle changes.That worry about having that surgery is what keeps some women from having genetic testing. It is a choice. You don’t have to do that. We do have these other things to do. Especially the drugs to decrease the risk, do the lifestyle changes, watch you real closely so that if you do get breast cancer, we should be able to find it real early when it's the most curable. So that fear should notI don’t thinkkeep women from knowledge. To me knowledge is power, and it could spur you on to do some of these lifestyle changes.

Dr. Barb: And every decision along the way as to what might be a consideration is made in conjunction with the patient and a provider. So there’s nothing that says once you know, that you have to follow through with breast surgery. It's all about what makes the most sense and at what particular time of your life that you might consider that next step.

Jane: And even for somebody who has a gene abnormality, you have to look at the family because there’s probably other genes that modulate it... that make a difference. Because some families who have an abnormal gene you should see breast cancer in about half the women in the family, and sometimes there’s only a couple. And you know there’s more women who should get cancer. So it's not 100 percent. It’s somewhere between a 45 and 85 percent chance. If you come from a family where it doesn’t come up as much or it shows up in the 60s or 70s that might make a difference of what your choices are. If on the other hand, half of the women have died of cancer by the age of 50, you probably will be more likely to do the maximum and have the surgery.

Dr. Barb: Be more aggressive in those cases.

As we finish up today, Jane, tell me where do you find richness at this stage in your life?

Jane: Oh, everywhere. [laughs] Certainly in my family, my children, grandchildren, siblings, elderly parents. My siblings are my best friends. And luckily we live pretty close to many of them. I find great satisfaction in my work, with my husband, and I like exploring the world. My last big trip was to climb Mt. Kilimanjaro.

Dr. Barb: I think that when it comes to implementing exercise, you can be a shining star for the rest of us, to look at it in how you’ve really been intentional about incorporating that with your passion for travel.

At a certain age, I have to exercise or I won't be moving.Jane: I like to be active. I’ve always liked to be active. I haven’t always been as faithful in the exercise. But at a certain age, I feel I have to exercise or I won’t be moving. It just becomes more and more important as I get older instead of less important. I’ve really carved out time in my life to make that happen. It's easier with my kids being grown. But it's a very important thing to me, and hopefully I’ll be able to keep it up forever.

Dr. Barb: Thanks Jane, and thanks so much for joining me today.

Jane: Thank you!


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