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October is Breast Cancer Awareness Month, a time to spread information about the widespread disease that impacts hundreds of thousands of women every year. According to the American Cancer Society, breast cancer accounts for 30% of new cancer cases in women each year. The average likelihood of a woman in the U.S. developing breast cancer is one in eight, or about 13%.

And, with more than four million breast cancer survivors in the U.S., it’s essential to continue providing support for those who have beaten the disease, and those who are still being treated.

We talked to Kandace McGuire, M.D., surgical oncologist and chief of breast surgery at VCU Massey Comprehensive Cancer Center, to learn more about breast cancer, including when to get screened, treatment options, common misconceptions and how to be your own advocate.

How did your interest in breast cancer begin?

I've always been interested in women's health since college. I anticipated going into gynecology, but had two turning points. My mother got breast cancer when I was in college, and that was pretty impactful for me. Also, when I realized that I liked surgery, I was able to, in my final year of medical school, combine the women's health aspect, the breast cancer interest that I had from my mom, and the surgery part of it, via the mentorship of a breast surgeon who's now a lifelong friend. So it was a nice way to come to a specialty that's really personal to me.

What inspires you to do this work?

Sometimes, it's the personal connection I make with people. Every day, I have an underlying feeling that my job is to get them over this diagnosis, get them to the next step and give them a little bit of hope.

Sometimes, it's the research that really gets me excited, and the opportunity to put people on clinical trials and make discoveries that will affect not only the women of Richmond, Virginia, but women everywhere.

Sometimes, it's the collaboration between me and the other physicians and care providers, here at Massey and VCU. It’s such a good, dedicated group of people.

What You Should Know About Breast Cancer

What are the different types of breast cancer?

Breast cancer is really several hundred different diseases just lumped under one umbrella because they happen in the same organ. There are different components of the breast tissue, and all of them can form cancers.

• The most common type is invasive ductal cancer, which comes from the ducts that take milk from the lobules to the nipple for breastfeeding.
• There is also lobular breast cancer, which originates in the lobules.
• Then there is a pre-invasive, pre-cancerous form called ductal carcinoma in situ.

Those are the three most common types. The lobular and the ductal carcinoma in situ types oftentimes will not show any clinical signs or symptoms until they're very advanced, so that's why screening is very important.

At what age should people start getting screened for breast cancer?

Women of average risk for breast cancer should start getting yearly mammograms at age 40. They should do so until they and their primary care physician feel that it is no longer worthwhile for them to screen, meaning that they are close to the end of life, and breast cancer would not be the reason that they would pass.

Mammograms are the best way to reduce the risk of an advanced breast cancer that'll be life-limiting versus an early breast cancer. So, mammograms are not prevention, but they are early detection, and they are the number one reason that we saw a significant decrease in mortality starting in the 80s.

Women who are at increased risk for breast cancer should be talking with their primary care providers or their gynecologists as young as age 25, so that if they have risk factors in their family, or any personal risk factors, they can be evaluated. Women may be eligible for screening as young as 25, or 10 years prior to when their mom, sister, or someone in their family got breast cancer.

What are the treatment options for breast cancer?

The majority of the time, a newly diagnosed breast cancer patient is going to be seen, hopefully, in a multidisciplinary clinic like the one we have. They are likely going to have surgery to remove anything that we can detect as cancerous in the breast and potentially the lymph nodes. Then they're going to have medical and likely radiation therapy to treat the rest of the body, and to prevent recurrence.

With upwards of 30% of women who have advanced breast cancer or a cancer that's really biologically aggressive, we'll actually do chemotherapy first. These are women who have triple-negative breast cancers, or what we call HER2-positive cancers. We look at estrogen, progesterone and HER2. The women who are going to have cancer most responsive to chemotherapy, also tend to be the faster growers and really get some benefit from getting their chemotherapy ahead of time.

Some women have cancers driven by estrogen-progesterone. Of these women, 85% will never need chemotherapy. So they are likely to be on the more common course. A small minority will get some of their medical endocrine or anti-estrogen therapy upfront.

Would you counsel young women who have a family history of having mastectomies and reconstructions as a preventative measure?

Women in our high-risk program who have a lifetime risk of breast cancer based on family history or a genetic mutation of >50%, who are in otherwise good health, are offered the opportunity to meet with a surgeon to discuss surgical risk reduction with mastectomy. Not every woman gets benefit from this surgery, and most will be better served with medical risk reduction and close follow-up. Women need to consider the risk of surgery along with the benefits and discuss this with a surgeon before moving forward with a preventative mastectomy.

Are there any unique offerings at Massey for breast cancer treatment?

Massey is the only academic healthcare system in Virginia performing resensation procedures, which involves reconnecting nerves that were cut during a mastectomy to allow patients to feel again after surgery.

From a surgical perspective, we do lymphovenous anastomosis, which is a way to reroute the lymph drainage from the arm into veins to bypass any damage created by lymph node surgery. It’s been shown in some smaller studies to reduce lymphedema rates significantly, so we’re offering that to any patient who has a large number of lymph nodes removed during an axillary dissection to help reduce the risk of that. Even with patients who've already had that procedure in the past, we still offer the opportunity to meet with our plastic surgeons to see if they can do anything in a reparative way.

Our multidisciplinary breast cancer program is extremely unique. We are the only place in Greater Richmond and most of the commonwealth, that you can walk into your first breast cancer appointment and meet your entire treatment team all at once, which we've demonstrated has reduced time to treatment, and creates a more cohesive message for the patient that we're all on the same team.

What are the side effects of breast cancer treatment?

Medicine is not perfect. Surgery, chemo, radiation and anti-estrogen pills all have side effects. With surgery, you can get permanent pain, permanent numbness and lymphedema. Those are some of the things we see with patients after surgery with chemotherapy. Some women lose their hair in the short term. They will sometimes get numbness and tingling in their fingers, called neuropathy, that can sometimes go away, but sometimes doesn't. Some chemotherapies can affect your heart function, so it puts you at a very high risk for infections. So those are while you're getting treatment, not afterward.

With radiation therapy, the area of the skin which has been radiated, can oftentimes be firmer, which can make one breast firmer and smaller than the opposite breast. There can be some risks to underlying organs, but the way that we do radiation here at Massey attempts to minimize as many of those side effects as possible.

With endocrine or anti-estrogen therapies, some women will get menopause-type symptoms, such as bone and joint pain. Some women will be at risk for uterine issues. Nothing’s perfect, which is why it's important for patients to talk about side effects with their doctors and figure out how to balance risk reduction with the likelihood of side effects.

How can breast cancer survivors monitor their heart health long-term?

The medications that are most likely to affect heart function are a class of drugs called anthracyclines. There are some anti-HER2 drugs, like trastuzumab, that can cause permanent heart issues. So while they're on treatment, women will get scans of the heart, whether it's an echocardiogram or some other functional study of the heart. If there is any evidence of effect on the heart, then that's really important for patients in survivorship to be followed with frequent echocardiograms or scans that will look at that function, because that's something that could then worsen, even though it may not be that bad when you get treated in your 40s or 50s. When you get in your 60s or 70s, you put aging on top of whatever damage you have, and then it can become clinically significant. So it is really important to be followed by a doctor who's either a survivorship or cancer expert, or at least a primary care physician who recognizes what you've been through and where your heart function is, so that it doesn't get left by the wayside.

What are some common misconceptions about breast cancer?

One is that patients can just opt for surgery alone without needing any other treatment. Many patients say, ‘I would like to have a bilateral mastectomy and be done with this.’ Well, that sounds great, but breast cancer is a systemic disease that manifests itself in the breast. By the time you realize that you have breast cancer, you have little cells floating all around your body, waiting to cause trouble, and surgery doesn't do a thing for them. They need medical therapy. There are tumor cells that float around the breast. If you only have a lumpectomy, and surgery didn't get those, that's what radiation is for. And so, with very rare exceptions, breast cancer is a team sport. You're gonna need at least two modalities of therapy. Usually, surgery is part of those two, but it's rarely surgery alone.

Some women think that if they don't have a family history of breast cancer, they're at some amazingly low risk, but the average risk of breast cancer is one in eight, and those are women who typically don't have a family history. Only 5-10% of women who get breast cancer have a family history. Which means 90-95% of women don't have one.  

Another one is that people think men can't get breast cancer. One in 735 men will get breast cancer, so while it's way less common than female breast cancer, it can occur.

Are there any ways to reduce the risk of breast cancer?

Limiting alcohol use to one alcoholic beverage per day or less is super important.

Hormone replacement therapy, which is really important during the perimenopausal time, can be used safely. But we see a lot of patients who are just left on it for years, if not decades, and that significantly increases the risk for estrogen-receptive breast cancers.

Exercise frequently, try to avoid weight gain in menopause. Eat a low-fat diet that's primarily plant-based. It doesn't mean vegetarian, it just means you're eating some plants along with whatever else you're eating.

Is Massey conducting any clinical trials for breast cancer?

We have a very active portfolio of breast cancer clinical trials. We've got about 15 open right now, dealing with all ranges, whether it's surgery, chemotherapy, survivorship; we've got a lot of quality of life studies going on. One of the more exciting trials right now is something called a ctDNA study, where we are following the very specific DNA signature of cancer in women's blood to see if we can detect that in their blood and how that affects their outcomes long-term. It's a technology that's been around for a while, but figuring out how to apply the results is the next step. So we're doing a lot of research, which I think will really be important for future generations.

Is there anything else important that people should know?

Be your own advocate. Occasionally, we have patients who say, ‘You know, I've felt something in my breast for a really long time,’ and people wrote it off, especially young women. Unfortunately, we’re seeing more young women with breast cancer.

Young women who think that something is different in their breasts need to advocate for themselves and find an advocate who will support them to move forward with a workup. Nine times out of 10, it's absolutely nothing, but that one time out of 10 that it's breast cancer, you want to know when it's early, and not when you felt it a year ago and nobody listened to you.

Nobody wants to be that annoying patient who goes, ‘Hey, no, I'm really worried about this, it's not going away.’ Be that annoying patient. It could mean the difference between surviving breast cancer and not.

Written by: Tatiana Del Valle