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#278 ‒ Breast cancer: how to catch, treat, and survive breast cancer | Harold Burstein, M.D., Ph.D.

The Peter Attia Drive

Sun Nov 05 2023



Breast Cancer Risk Factors:

  • Early puberty and prolonged menstruation, associated with increased breast cancer risk.
  • Improved nutrition leading to early onset of menstruation contributes to higher breast cancer rates in developed societies.

Breast Anatomy and Development:

  • Breast development begins during puberty due to hormonal changes, enabling milk secretion upon pregnancy.
  • Embryologically, the breast is a gland primarily composed of fat and non-specific stromal elements. The volume of the breast determines its size.

Types of Breast Cancer:

  • Most prevalent types are estrogen receptor positive (ER+), human epidermal growth factor receptor 2 negative (HER2-) tumors.
  • Triple negative tumors lack ER, progesterone receptor (PR), and HER2, more common in younger women and African-American women.

Pre-Cancerous Lesions and Screening:

  • Atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia (ALH) indicate slightly greater risk for developing breast cancer.
  • Ductal carcinoma in situ (DCIS) is stage zero breast cancer that may progress into invasive cancer if left untreated.

Treatment Options for DCIS:

  • Lumpectomy followed by radiation therapy reduces the risk of recurrence significantly.
  • Anti-estrogen therapies like tamoxifen or aromatase inhibitors further lower the risk of recurrence but come with potential side effects.

Natural History of ER+ DCIS:

  • Majority of DCIS cases are estrogen receptor positive.

Breast Cancer Treatment:

  • Neoadjuvant therapy is used for larger tumors to shrink the tumor in the breast and chest area, allowing for a lesser operation with less morbidity.
  • Pathologic complete response after neoadjuvant treatment is a favorable prognostic finding, indicating lower risk and better outcomes.
  • Tailoring drug therapy based on how well the tumor responds to neoadjuvant treatment can improve prognosis.

Hormone Therapy and Side Effects:

  • Anti-estrogen medicines like tamoxifen and aromatase inhibitors are commonly used for ER-positive breast cancer, causing side effects such as hot flashes, night sweats, bone/joint stiffness, hair thinning, vaginal dryness, and increased risk of osteoporosis.
  • Supportive care has improved significantly with powerful anti-nausea medications, white blood cell boosters, cold caps to prevent hair loss during chemotherapy, etc., minimizing some side effects.

Genetic Testing and Hereditary Risk:

  • Approximately 8% to 10% of all breast cancer diagnoses are related to specific hereditary gene mutations.
  • BRCA1 and BRCA2 mutations account for about half or five percent of all hereditary breast cancer cases. They increase the lifetime risk of developing breast or ovarian cancer significantly.
  • Genetic testing for these mutations has become standard practice. Identified patients may consider mastectomy, prophylactic oophorectomy (removing ovaries), or more intensive screening if they choose to retain their breasts.

BRCA1 and BRCA2 Gene Mutations:

  • BRCA gene mutations increase the lifetime risk of developing breast cancer, highlighting the evolving management of cancers.
  • The mutations are autosomal dominant, transmitted equally by men and women, leading to a deficiency in DNA repair mechanism and accumulation of mutations that predispose individuals to various types of cancer.

Other Genetic Mutations Related to Breast Cancer:

  • Other genetic mutations, such as PALB2, CHEK2, and ATM, contribute to about 10% of breast cancer cases.
  • With increased genetic testing following a breast cancer diagnosis, these other mutations are being identified more frequently.

Importance of Multidisciplinary Care:

  • Multidisciplinary care brings together surgery, radiation therapy, medical oncology management with drug therapy, pathology expertise, genetic counseling, and imaging teams under one roof for effective collaboration.
  • Effective communication and collaboration among the multidisciplinary team members ensure comprehensive and coordinated care for breast cancer patients.

Access to High-Quality Pathology Review:

  • Quality pathology review is vital for accurate diagnosis and treatment planning in breast cancer care.
  • Collaboration between radiologists and surgeons ensures precise diagnostic decisions while pathologists play a crucial role in determining tumor characteristics and guiding treatment strategies.

Male Breast Cancer:

  • Men can develop breast cancer but at a much lower incidence compared to women. The risk factors include genetic predisposition and certain hormonal conditions.
  • Treatment principles for male breast cancer align with those for female breast cancer, emphasizing the importance of specialized care programs tailored for men.