Are you at high risk of breast cancer? Follow this early detection guide | Dr. Thaïs Aliabadi

26:08At this point, can you believe it? And I'm just one patient. And I'm like, what are you talking about? Two radiologists on Friday told me my breast tissue was completely clear. There's no breast tissue left. He takes me to a third radiologist who says, you have breast tissue here, here, here, here, here, here. Long story short, I don't want to give you a headache, but I had to, I begged for a second double mastectomy because I had a lot of atypical cells in my breast. And now I also had breast cancer and he was going to do my lymph nodes anyway. And I begged him, I'm like, Dr. Giuliana, can you do another double mastectomy on me?

26:41It took six hours. They did my lymph nodes. They removed my implants, did another double mastectomy, put my implants back in. And when I woke up, he came to me. He's like, I'm so glad you're so stubborn. I'm like, why? and he said they had left 35 % of your breast issue behind. My understanding is this lifetime risk assessment number was basically the thing that made all of that happen, right? Otherwise, you would not have found out about this cancer until much later. And I think you have another story that you can tell us about, which is a patient of yours who's gone public about her story, which is actress Olivia Munn.

27:14And I understand that for her also, this lifetime risk assessment number was critical. Could you maybe give us a high-level outline of that? And then we'll talk through into what this can mean for people who are listening today. And I have so many stories like Olivia Munn, but I'm so proud of her because she used her platform to bring awareness to it. Someone like me or my patients, we don't have a voice, but she obviously does. And she made a huge difference. Basically, she just had her baby. She was done breastfeeding. I did genetic testing. She didn't have any gene mutations. I sent her for a mammogram and ultrasound.

27:51Her mammogram was negative. Her ultrasound was negative. I calculated her lifetime risk of breast cancer because of her family history, dense breast, age at first child, the whole list that I just mentioned. And her risk was about 37, 38%, similar to mine. So I called her to my office and I said, you fall into the high risk category. You have to do an additional MRI. And she said, of course, she's, you know, she's so smart. She's just an amazing woman. So she went, she did her MRI, and of course, they called her. They're like, we saw something. They biopsied it. It came by cancer. Then I sent her to Dr.

28:28Giuliano. Dr. Giuliano had the MRI reread, and they found another cancer in the other breast with a second read. So at this point, she had multiple breast cancers, small but very, very aggressive, negative mammogram, negative ultrasound, negative genetic test. She's had a standard mammogram. She's also had like a genetic test for whether she's at high risk. All of that says it's fine. But you then run this lifetime risk assessment and said, actually, your lifetime risk assessment is really high. So I want to go and do this other test, this MRI test. And that has picked up this like very early cancer, but also this like, you know, very dangerous cancer.

29:09Right. So everything would have been completely different had we not done the MRI. Unlike me, she had a very aggressive cancer. But because we caught it so early, she came to my office and she's like, what would you do? And I said, listen, at your age, I just delivered your baby. You have a tiny little child at home. You have bilateral breast cancer, very aggressive. You have family history of it. Take your breasts off. And she's like, I want to do what you tell me. I'm like, if I were you, obviously I did it for myself, but that's what I recommend. And thank God she did it. She had amazing results.

29:45Dr. Giuliano did her mastectomy. She had reconstructive surgery. You know, it took her a minute to recover from the trauma. Again, you have a little baby at home. Someone tells you you have cancer when your mammogram and ultrasounds are all negative. But I think in spring of last year, she decided to share her journey, which basically, I think, honestly, she started a revolution, not only in this country, but around the world, basically bringing awareness to early detection, this lifetime risk assessment, genetic testing, and all things breast cancer related. So I'm so proud of her. You know, everything happens for a reason in life.

30:23And I always say when something traumatic happens to you in life, go down that path and you'll see why you were placed on that path. And I think both, you know, Olivia and myself, we found our calling. Thank you for sharing both of those stories, which I think are very powerful. before we we move to talking about how you do this lifetime risk assessment i just want to ask about the genetic risk because this is the this is experience that happens my family friend where there was a very high genetic risk which was what triggered the decision to have this mastectomy because in your both these stories the genetic test wasn't positive like how important is genetic testing very very good question so less than five percent of breast cancers are associated with a genetic mutation, less than five.

31:12So majority of people who get breast cancer do not have a genetic mutation. So please don't tell me, I don't have it in my family, I'm not gonna get breast cancer. That's completely false. Two, if you have any kind of cancer in your family, if it's pancreatic cancer, if it's prostate cancer, if it's colon, uterus, ovary, breast, ask your doctor for a genetic test. In the United States, the genetic tests are about$249. That's it. You know, I always compare it to going to Disneyland. You go to Disneyland, every ticket costs that much. I'm saying one genetic test, one time in your life can save your life.

31:53Why am I saying this? For example, if you have a parent with pancreatic cancer or ovarian cancer, you could have a gene mutation. Most people recognize the BRCA gene that's associated with pancreatic, breast, and ovary, and melanoma. So some members of the family could have a melanoma. Others could have the pancreatic cancer. Do the genetic test. It doesn't always have to be breast to do a genetic test. Are you saying that everyone should do the genetic test? If you have family history, you'd be pushed. If someone in the family has it, you're saying you should definitely do it. Absolutely. But if you don't have it in your family, it doesn't mean you're not going to have breast cancer.

32:35You still need to calculate your lifetime risk of breast cancer, especially if you've had a breast biopsy that showed atypia. And atypia means? Atypical cells in the breast that are not cancer yet. If you're a man listening to this, is the story about genetic tests only relevant for women? Or is it something that you would be saying that men should be doing as well? Absolutely. It's for men and women. And for example, if you told me I have three daughters at home and my mom had ovarian cancer, I would ask you to do genetic testing. Because if you don't have it, then your children are protected, at least from your side.

33:11But then we have to also ask your partner's, you know, family history. So it's for men and women. In that case, it sounds like the man himself is not likely to get risk. So today, if you're a man worried about your own cancer risk, do these genes make a meaningful difference? So you're saying for either side? Absolutely. It can cause prostate. It can be pancreatic cancer. It can be colon cancer. So it can be all sorts. Melanoma can affect all of us. And majority of the time in the US, believe it or not, insurance will pay for these patients to do genetic testing. I think in my practice, 93 % of patients are covered annually.

33:52So I'd love now to get into this lifetime risk assessment, because I think you've definitely provide a whole new perspective on sort of taking more control over this yourself and understanding what you can do. So I imagine there's a lot of listeners right now who are saying, okay, how can I calculate my lifetime risk assessment? So the best formula to use that I use all the time, it's probably the most accurate, easy to use. Women can do it at home. It's the tire Cusick risk assessment tool. I actually put a copy of it free of charge on my SheMD podcast page. People can go there. They can calculate their lifetime risk.

34:32You basically have to enter some personal information about yourself, height, weight, age at first period, age at first pregnancy, whether or not you're menopausal, if you've been taking hormones, family history, density of the breast. And once you answer all the questions, you hit calculate and it'll tell you what that risk score is. And I have videos explaining what each category is and what kind of imaging they need to do. Well, firstly, we will put a link in the show notes, both to the assessment tool and also to your site to help to understand that. Is this something that generally anyone listening to this can do themselves?

35:07I heard you mention things like the breast density, and you've also told me that I can't figure that out for myself. But if they can pull their mammogram images and ask, I would say if you are young, you probably have dense breasts, right? Younger patients have dense breast tissue. I want everyone to calculate their lifetime risk of breast cancer by age 30. 30 is when we start imaging. If you have strong family history of ovarian, pancreatic, or breast cancer, two of the 48 cancer-causing genes are BRCA1 and 2. Those patients need to start breast imaging at age 25. So you calculate your lifetime risk of breast cancer.

35:44And if you can't do it, ask your doctor to do it. A lot of times, believe it or not, especially in the US, the radiologists will do that for you. The problem is the radiologists don't sometimes get all the information about you, like, you know, first pregnancy or, you know, some personal history they don't have, but they try to calculate that tyrocusic risk score for you. But it's something patients can absolutely do on their own. It's pretty simple and straightforward. Once you calculate that risk score, then, you know, we talked about average risk being 12.5. Low risk category is anyone under 15%.

36:26So if your lifetime risk of breast cancer is less than 15%, you fall into the low risk category. In America, you can start your breast imaging at 40 or 10 years before your first degree relative was diagnosed with breast cancer. And if you have dense breast tissue, you have to ask your doctor for a breast ultrasound. So that's for 15 % and below. From 15 % to 20%, that's the intermediate risk category. This is when basically in my practice, I treat every patient differently. But knowing that they fall into that intermediate risk, I might start their mammogram a little bit earlier, maybe get a baseline at 35.

37:08If they have dense breasts, I do an ultrasound with it. And if they have any family history, I start the imaging 10 years before the age of that family member who was diagnosed with breast cancer. And the most important group for me are patients who fall into the high-risk category, which is 20 % or higher. 20 % or higher patients need to start their breast imaging as early as 30. By the way, this will never happen in your country, in the UK. That's the problem, right? Early detection. So everyone gets pushed like, you know, much, much later, forgetting that we're missing these high risk patients at a very young age.

37:52And that's why sometimes people are shocked that so-and-so at age 38 got stage four breast cancer. And, you know, sometimes when I watch TV and I see these actresses at a young age getting diagnosed or dying from breast cancer, someone probably didn't do genetic testing on them and didn't calculate their lifetime risk. So that's how important it is. And so one of the things I guess I'm taking away from this is, in a way, the progress of science and medicine today is meaning that we can be more personalized about this than before. You're not saying every single woman should be being screened at 30.

38:25You're saying we can really differentiate now low risk and high risk. And then if you're in this high risk group, you should be screened really aggressively. And indeed, you're talking about the fact that your, you know, your own decision was my risk is so high that I'm going to take this like very serious preemptive surgery because of your confidence in that level of the personalization and understanding of the risk. So this is quite a profound shift in terms of something I guess that Zoe, we're really passionate about, which is this ability to sort of take control of your health and personalize it before you're really sick.

38:57And you're saying that actually we are now able in this area to use this information and everything that we've learned over decades to be able to no longer treat everybody in exactly the same way. Absolutely. And for the high-risk patients, when they start as early as 30, we usually alternate mammogram and ultrasound with an MRI a few months later. Because in high-risk patients, mammogram alone can miss breast cancer. So you You add MRI to make sure you basically bring that 80 % detection to much, much higher, especially for high-risk patients. What are the things that tend to push somebody into this high-risk?

39:36Because you said that you were really high-risk. And now I'm hearing, you know, your number was 36%. You're now saying even at 20%, 37%, I apologize, even 20 % was high-risk. But you also said, I haven't been drinking and I haven't been smoking. So what were the things, you know, somebody's listened to this. The most common reason why people get pushed above 20 % is family history. That's probably obesity, early period, late menopause. Patients who don't have children are at a higher risk. Pregnancy is protective. Breastfeeding is protective. If you have children after 30, that gets affected. Genetic mutations, dense breast tissue.

40:18Patients who have extremely dense breasts, it pushes it way high. There's so many different factors. In my case, it was just that atypical lobular hyperplasia, which is the atypical cells. That pushes your lifetime risk really high. Every person's risk factors are different. The last thing I want to add is for very high risk patients, which in my world, that's 35 % and above. Sometimes, you know, I had a patient yesterday, her lifetime risk is 30%. but every single woman in her family had breast cancer. So someone like her, I would be more prone to treat and reduce that risk. If you have a very high lifetime risk, let's say 30 to 35 % and above, you only have three options the way I look at it.

41:03Number one, you alternate mammogram and ultrasound with an MRI every six months, and you do a lot of praying, and you pray that you don't get breast cancer, and you pray that your doctors will diagnose it, Breast imaging, I'm really excited about artificial intelligence reading these images because hopefully we're going to have more accurate reading so someone like me where my lesion was sitting on my MRI doesn't get dismissed. That's number one. Number two, patients have the option of taking a medication like tamoxifen. I don't know if you've heard of it, but once you get diagnosed with estrogen-receptive positive cancer, a lot of us have to take tamoxifen to basically block the estrogen receptors.

41:44and taking tamoxifen every day for five years can significantly reduce your risk of breast cancer maybe by 50 % in the next 10 years. So that's an option. And the third option, which is what I opted for, is a double mastectomy if you don't really wanna do that imaging every six months, which is pretty tough to go through. MRIs are not easy to do. Breast MRIs, you need a contrast. Mammograms are not easy. And honestly, to go through it and have to wait for the results and be anxious twice a year about it is pretty challenging. And that's why, you know, it's a very, very personal decision. I never tell someone do it or not do it.

42:29I just tell them what I would do if I were them. But with a strong family history or a high lifetime risk, I think double mastectomy is a good option. The problem with double mastectomy is, A, having access to a doctor. Not everyone can afford it. Not everyone has access to a good reconstructive surgeon. So I understand those limitations. It's not for everyone. But at least I want them to know that there are medications they can take for five years to reduce that risk significantly. Do you know a woman entering her 30s or 40s? Or someone who might benefit from learning more about detection of breast cancer?

43:06Why not share this episode with her right now? you could empower her to be proactive about early detection. It could save her life, and I'm sure she'll thank you. I would like to move to listener questions. So first question is, can the food you eat influence your risk of breast cancer? Absolutely. I think obesity is one of the underlying conditions for breast cancer. So, you know, processed food, animal products, you know, we talked about smoking, alcohol, all of that can affect it. Absolutely. Does taking hormonal birth control or HRT increase your risk? And how big a concern should this be?

43:45It's not a concern. It probably can vary, very slightly, but not significant enough. Having said that, it's individual. Patients need to talk to their doctors. Every patient has a different risk factor that needs to be dealt with. For example, if someone has a lifetime risk of, I don't know, 50 % for breast cancer, For the vast majority of people who are listening to this, it sounds like you're saying that that's safe. It's very safe. It's very safe. It can slightly increase their risk, but not significant enough. Having said that, for example, I don't want someone whose grandmother had breast cancer, whose lifetime risk is 20 % not to take hormone replacement during menopause and have poor quality life with hot flashes and vaginal dryness and all these other symptoms because they're scared of taking hormone replacement.

44:34I think that's really interesting because I know there's a lot of debate about this. And so it's interesting hearing you being so strong about the risks here. I assume you're saying that somehow you view the benefits from these to really outweigh the risks. Yes, especially if anyone's gone through menopause. I mean, I'm sitting here having a hot flash. I can't take hormone replacement. I'm on anti-estrogen, the opposite of it. But if you have the option, it's life-changing. So you don't have to have a hot flash doing a podcast. Well, firstly, thank you for sharing that. One of the things we talk a lot about on the podcast is how much no one is willing to talk about menopause.

45:07So I appreciate it. And you're performing great. So I think you should be feeling good about it. Final question from listeners. Are all lumps, whether you feel them in your breasts or armpit, worrisome? As a patient, I would say you can't decide. Let your doctor decide. Some lumps are concerning. Majority are not. So you can have a swollen lymph node because you got a flu shot on that arm that day, or you got your COVID vaccine. You can have a cyst, which are very, very common. Fibrocystic changes of the breasts are very, very common. Fibroadenomas are benign tumors of the breast in younger women.

45:42But generally speaking, cancer tumors don't really move. They're stuck. So if something is mobile, it's probably nothing. But I would always tell my patients to call me, come in, let me examine, and let me decide if I need to order a breast ultrasound or imaging. The one thing I will tell you, no one is too young for breast imaging. Got it. So even if you feel like you're just too young for this to possibly be cancer, go and see a doctor. I've had a 22-year-old with breast cancer with no gene mutation. Any lump needs to be evaluated by a gynecologist or a primary care doctor. And you're saying that most of the time the doctor is going to tell you you're fine.

46:25So don't immediately panic. But on the other hand, don't ignore it because you can't judge for yourself. There isn't some magic way that you can figure out at home whether this is okay or not. No, I would say trust your doctor. So I'd just like to finish with asking you what advice you have for women who are struggling to advocate for themselves in the doctor's office. Because you're telling a story where you found this hard. And I think it's pretty clear to anyone listening to this that you're a pretty powerful and strong-willed doctor with all this advice and knowledge and all the rest of it.

46:58and you found that hard. And many people listening won't have any of that. They may indeed be in health systems where they've got less ability to just sort of have control. What would you say to anyone listening to this who's saying, well, how can I advocate for myself? I would say, I hear you. I get you. It happened to me. It's not easy. It starts with education. That's why I started my podcast. That's why I'm on this podcast. Basically, you have to educate yourself. In order to be your own health advocate, you have to educate. The problem is once you educate yourself and you empower yourself, and you know what you have to do, and you go to your doctor, you have to find the doctor who actually listens, who has the time, who takes you seriously, who doesn't call you crazy, who doesn't dismiss your symptoms.

47:44If you're lucky enough to find that doctor, the problem with the healthcare system, we're overwhelmed with patients. We don't have time, right? So if you're lucky enough to find a doctor who's listening to you and really taking you seriously, then the next step is being able to afford the prescriptions that they write for. Does your insurance cover your MRI? Does your insurance cover your ultrasound? My MRI after I was diagnosed with breast cancer was$3 ,000. Do you understand that? Being able to afford the treatment is the next limiting factor. So there's so many levels that we get stuck in this healthcare system.

48:25But I would say, educate yourself. If something doesn't feel right, get a second opinion, get a third opinion, find a doctor who specializes in that. If you have a breast lump and you have family history of it, if you need genetic testing, find someone who will take you seriously and listen to your complaint. Thais, thank you so much. We'll always try and end with a quick summary. So I'm going to try and do a summary and I'd like you to just correct me where I got this wrong. When I think back across the show, I think the biggest thing I take away is do a lifetime risk assessment for breast cancer by the time you're 30.

49:00And if you're after 30, like do it immediately. It's I think the biggest story because, you know, your own story is so powerful about this idea that you felt like you're doing everything right. You're low risk. You're literally a doctor who is looking after women who can have breast cancer. And then you suddenly did this and you're like, I'm at 37 % and suddenly that transformed the way you're thinking about it. Then this story is sort of fighting to get the treatment that you're basically saying you feel people at this level should very seriously consider because if not, they've got other very intrusive solutions.

49:36And then when you did it, you're like, thank God I did because actually it turned out you already had cancer. And thank you for telling that story, which I can tell is still, you know, really understandably emotional and raw. And anyone listening to that will have felt that. And I can understand this also, this idea of having one's children and all the rest of it. So it's really powerful. I think the other big takeaway from this is therefore, you need to be more of your own health advocate, because probably in health systems, or in the States or the UK or anywhere, they're not really designed today for this level of differentiation of risk, like the ability to tell that somebody might be this very low risk, right below 10 % or they're above 30%.

50:13And so sort of our screening is designed for sort of this average level. And it's therefore going to probably spend too much time on people who are very low risk and not enough on the people who are high risk. And this is, it seems to me, your big message is that we can really determine a lot more now about who's high risk. And it doesn't require some incredibly complicated imaging to figure out this risk. Actually, you're saying that you can go onto a website and fill in this information and give you this answer. The other thing I took away was this story that if you have any family history of cancer, take a genetic test.

50:48You're like, it costs the same as going to Disney World for the day or something, and it could save your life. And I think you talked about this, this BRCA, this BRCA gene, for example. Which is two of the 48 cancer-causing genes. There are many cancer-causing genes. People say, oh, I've been tested for BRCA. That's not enough. You need the full panel. There is CHECK2 that gives you 50 % chance. It's PALB2 gene mutation that gives you a 50 % chance. So there are other gene mutations that can increase your risk of breast cancer. And then the final thing I took away was you were actually really quite strong that for most women, hormonal birth control or HRT is safe.

51:27Although there is like a statistical increase in the risk to do with breast cancer, your view is that this is on absolute terms is very small. But, you know, opposite of that, I do worry about alcohol. I do worry about smoking. I do worry when patients are overweight. I do worry about lack of exercise. So those factors are so much more important. Sleep, low stress, you know, all of that is much more important than worrying about that birth control pill that you took for two years in your life. And where does food fit in that list? Very important. I let you have a full podcast on gut microbiome and our health in general, right?

52:06Our gut microbiome is linked to our insulin resistance. As we get older, insulin resistance can cause us to gain weight. Weight gain can cause everything is related. So it all starts with food. As you can imagine, hosting this podcast, running Zoe, juggling family life, it all keeps me pretty busy. So I try as best I can to stay energized and show up well in all those parts of my life by fueling my body with the right food by exercising and by adding a scoop of Daily 30 to my meals every day. If you haven't heard of Daily 30 yet, it's the gut supplement designed by our gut health scientists here at Zoe.

52:45It's made of over 30 high-quality, hand-picked plants, including seaweed, fungi, and different types of fiber. Better yet, it contains ingredients that support gut health, digestion, and energy, which is ideal for packed calendars and busy lives. Simply add one scoop a day to any meal for an extra boost of fiber and plant diversity. And because it tastes delicious on just about anything and adds a satisfying crunch, it quite quickly slots into your life, becoming a daily healthy habit you'll always have time for. By the way, whenever we talk about Daily 30 as a good source of fiber, we're required to say that it contains four grams of total fat per serving.

53:27Obviously, that's all amazing healthy fats from plants. so order yours today at zoe.com daily 30 thanks for listening and see you next time