Breast Health Q & A by Anjali Malik, MD
Updated: Nov 14, 2019
In recognition of Breast Cancer Awareness Month, I reached out to Dr. Anjali Malik who practices as a breast imaging and intervention specialist. –Jeanne
What are the various risk factors for breast cancer? There are non-modifiable and modifiable risk factors for breast cancer.
Non-modifiable risk factors cannot be changed. These include the TOP TWO risk factors for the development of breast cancer: being female and aging. The others are family history, known genetic mutation, personal history of breast cancer, age of menarche/menopause, race/ethnicity, mantle radiation to the chest (i.e., for lymphoma, when radiation is delivered to a large area of the neck, chest and armpits to cover all the main lymph node areas in the upper half of the body) and first pregnancy after the age of 30.
Modifiable risk factors are in our control and include obesity, alcohol, smoking and oral contraceptive/hormone replacement therapy use.
What general behaviors are recommended for breast health? Maintaining a healthy weight and avoiding alcohol are the two most important steps women can take to reduce their risk for the development of breast cancer. Knowing the family history of both sides of your family is also important to assess the need for genetic testing, which pertains not only to breast cancer but also to ovarian, colon, pancreatic and thyroid cancers. No specific diet has been recommended for breast cancer, though studies have shown that high-fat diets and diets with processed meat can increase the risk of all cancers. While there have been questions surrounding the phytoestrogens of soy, no studies have shown this to be a risk factor for breast cancer, and rather, some studies have shown it to be beneficial in breast cancer survivors.
What is the recommended surveillance for the general population? Every woman has at least a 1/8 (or 12%) risk for the development of breast cancer over the course of her lifetime. For those women at average risk, studies have shown that annual screening mammograms starting at age 40 reduce mortality by up to 40%. What is the recommended surveillance for those at high risk? Those who are at high risk for breast cancer (a greater than 20% lifetime risk of breast cancer) often have a known genetic mutation, a strong family history, a personal history or have had mantle radiation to the chest. For these women, the recommendation is to begin annual mammogram testing when they are 10 years younger than the youngest diagnosed relative, 10 years after mantle radiation, or no earlier than 25 and no later than 30 years of age. Many of these women will also need an annual contrast-enhanced breast MRI, contrast-enhanced mammogram or another physiologic test which looks for areas of increased activity, such as nuclear medicine tests.
Please discuss premenopausal breast cancer Premenopausal breast cancer is any cancer in a woman younger than 50 years old. It is often found in women in their 20s and 30s. Though some women go into menopause before or after the age of 50, this age is used as a cutoff because breast cancer after the age of 50 is often age-related. While the median age for the development of breast cancer is 62, one-sixth of breast cancers are diagnosed in women aged 40-49. Survival rates are worse in premenopausal women when compared to those in older women, and younger age has been shown to be an independent predictor of adverse outcome. Additionally, side effects from the treatments can include infertility, early-onset menopause and osteoporosis, which have an impact on the overall health of these young women. Why are women with dense breasts at an increased risk for the development of breast cancer? Are women with dense breast parenchyma followed differently? If so, how? Breast density refers to the proportion of fibroglandular tissue versus fat within the breast. For women with heterogeneously and extremely dense breast tissue, this proportion is greater than 75% (very little fat is present). On a mammogram, fibroglandular tissue is white and fat is black. Having fat within the breast makes it easier to identify cancer, which is also white. So, for women with dense breast parenchyma, their mammograms can be difficult to interpret, and small cancers may be obscured. Women with dense breast parenchyma are also at increased risk for the development of breast cancer, up to four to five times that of women with lower breast density—but it is unclear why. To enhance the screening of women with dense parenchyma, breast tomosynthesis (3D mammography) should always be used. In concert, patients and providers can assess a woman’s personal risk and determine the need for additional screening with ultrasound or MRI. Breast density reporting legislation has been enacted in many states so that women are aware of their breast density and can have these discussions with their doctors.
Why are Ashkenazi Jews at an increased risk of breast cancer? Ashkenazi Jewish women do have a higher risk than the average American woman, and while it is not known why, it is attributed to the fact that there is a higher prevalence of the BRCA 1 and 2 genes amongst women of this community. Approximately one in every 40 Ashkenazi Jewish women and men have one of these gene mutations (compared with one in every 400 in the general population), and about 10% of the Ashkenazi Jewish women diagnosed with breast cancer every year have the BRCA 1 or 2 mutation.
Should we do a breast self-exam? If so, how often? How to perform one? I recommend that all women over the age of 20 perform monthly, mid-menstrual-cycle breast self-examinations. Women should become familiar with the normal pattern of their breast tissue so they can better detect any changes. The changes to look for are lumps of the breast or underarm, pinpoint pain, nipple or skin changes and nipple discharge. Exams can be performed with the arm up in the shower using water as a lubricant and with the fingers in a circular motion or lying down with the arm up.
Anders CK, Johnson R, Litton, J, et al. Breast Cancer Before Age 40 Years. Seminars in Oncology. 2009 Jun; 36(3): 237–249.
Boyd NF, Guo H, Martin LJ, et al. Mammographic density and the risk and detection of breast cancer. N Engl J Med. 356(3):227-36, 2007.
Egan KM, Newcomb PA, Longnecker MP, et al. Jewish religion and risk of breast cancer. Lancet. 347: 1645-6, 1996.
Ray KM, Price ER, Joe BN. Evidence to support screening women in their 40s. Radiol Clin North Am 2017; 55:429–439.
Struewing JP, Hartge P, Wacholder S, et al. The risk of cancer associated with specific mutations of BRCA1 and BRCA2 among Ashkenazi Jews. N Engl J Med. 336: 1401-8, 1997.
Yaghjyan L, Colditz GA, Collins LC, et al. Mammographic breast density and subsequent risk of breast cancer in postmenopausal women according to tumor characteristics. J Natl Cancer Inst. 103(15):1179-89, 2011.
American Cancer Society. Breast cancer facts & figures 2015–2016. www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2015-2016.pdf
National Cancer Institute. Genetics of breast and gynecologic cancers (PDQ®) - health professional version. cancer.gov/types/breast/hp/breast-ovarian-genetics-pdq#link/_113_toc
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Genetic/familial high-risk assessment: breast and ovarian, Version 3.2019. www.nccn.org
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Invasive breast cancer, Version 1.2019. www.nccn.org
Surveillance, Epidemiology, and End Results Program website. SEER data, 1973–2014. seer.cancer.gov/data/
Anjali Malik, MD
Anjali Malik is a Breast Imaging and Intervention Specialist at Washington Radiology, serving patients of the DC Metroplex. She received her BA in Public Health/Natural Studies from Johns Hopkins University and her MD from Tulane University School of Medicine before completing her residency at the University of Texas Southwestern Medical Center/Parkland Hospital and Health in Dallas, TX. She was a Brem Fellow in Breast Imaging and Intervention at George Washington University Medical Faculty Associates.
Dr. Malik's passions are breast imaging, women’s and global health, preventive medicine and healthy, eco-friendly living. She serves as the Co-chair for Social Media for the Society of Breast Imaging, on the Breast Economics Committee for the American College of Radiology and as the Chair of Women & Diversity for the District of Columbia Metropolitan Radiological Society. She also serves on the Medical Society of the District of Columbia Advocacy Committee and on the Bright Pink Medical Advisory Committee.
To subscribe to the SOULFUL Insights health and wellness newsletter click here.