Dense Breasts, Family History and Your Mammogram: How to Know your Real Risk

In part two, Dr. Mary Claire Haver and breast oncologist Dr. Eleonora Teplinsky shift to breast cancer risk, prevention, and early detection: dense breasts, family history myths (only 5–10% of breast cancers are hereditary), risk assessment from age 25, who needs genetic testing, and why previvors in surgical menopause can use hormone therapy without raising their breast cancer risk. Plus life after treatment — bone density, chemo brain, heart health, fear of recurrence, and body image after mastectomy. Guest links: Dr. Eleonora Teplinsky (Website) https://interludecancerstories.com/ Dr. Eleonora Teplinsky (Instagram) https://www.instagram.com/drteplinsky/ Dr. Eleonora Teplinsky (Substack) https://drteplinsky.substack.com/ Dr. Eleonora Teplinsky (TikTok) https://www.tiktok.com/@drteplinsky Dr. Eleonora Teplinsky (Facebook) https://www.facebook.com/drteplinsky/ Dr. Eleonora Teplinsky (LinkedIn) https://www.linkedin.com/in/eleonora-teplinsky-md-fasco-220aa02 Dr. Eleonora Teplinsky (YouTube) https://www.youtube.com/@drteplinsky Dr. Eleonora Teplinsky (X) https://x.com/drteplinsky INTERLUDE: Cancer Stories with Dr. Teplinsky (Apple Podcasts) https://podcasts.apple.com/us/podcast/interlude-cancer-stories-with-dr-teplinsky/id1451816690 Living Beyond Breast Cancer https://www.lbbc.org/ Books: “Beyond the Pink: Navigating Life, Health, and Breast Cancer,” by Dr. Eleonora Teplinsky https://www.hachettebookgroup.com/titles/dr-eleonora-teplinsky-m-d/beyond-the-pink/9781538777145/ “The New Perimenopause,” by Dr. Mary Claire Haver https://thepauselife.com/pages/the-new-perimenopause-book “The New Menopause,” by Dr. Mary Claire Haver https://www.amazon.com/dp/B0CKBZ4K1Z Never miss an episode—sign up for The ‘Pause Life Newsletter: https://thepauselife.com/pages/newsletter Medical Disclaimer: The information, including opinions and recommendations, on this platform is meant for informational and educational purposes only. Mary Claire Media, LLC, the unPAUSED podcast, and The ‘Pause Life are not medical organizations. Medical advice or medical diagnosis cannot be provided to you through the platform, any associated website, or customer portals. Using this platform does not establish a patient-physician relationship.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:03Dr. Mary Claire Haver?

  The views and opinions expressed on UnPaused are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. There was so much ground to cover with Dr. Eleonora Teplinsky that we decided to split the episode into two parts. If you missed part one, I hope you'll go back and listen. But for now, here's the rest of our conversation.

• 0:41Dr. Mary Claire Haver?

  Let's talk about family history. There is just so much misunderstanding there. A woman with a family history of breast cancer is told she can never touch estrogen.

• 0:50Speaker 01

  All the time. And again, it feeds into that fear, right? It comes back to that 26% headline. And so we really have to break down family history. To me, family history is in prime time to understand your breast cancer risk. So first of all, family history is very different. Grandma at 85 with breast cancer is very different than five women in your family under 50 get diagnosed with breast cancer.

• 1:15Dr. Mary Claire Haver?

  Why? Help help our listeners understand that.

• 1:16Speaker 01

  Because to me, many relatives at a younger age is really suggestive of a genetic mutation, or a hereditary cancer syndrome that increases cancer risk. Now, it's not to say that if you have a genetic mutation, you can't have hormones, but it's an opportunity to genetic testing to understand your breast cancer risk, to make the right screening protocol and everything.

• 1:41Dr. Mary Claire Haver?

  So I have patients who, over the years, have not been aggressive about getting their mammograms because they're like, I don't have a family history. It's really not gonna... Is that a mistake?

• 1:53Speaker 01

  100%. Most breast cancers are not hereditary.

• 1:57Dr. Mary Claire Haver?

  So what percentage are?

• 1:58Speaker 01

  Five to 10 of breast cancers are hereditary.

• 2:00Dr. Mary Claire Haver?

  Five to 10%?

• 2:01Speaker 01

  Mm-hmm. And so, majority of patients will not have a family history. And so, it's a common misconception that I can't get breast cancer if I didn't have a family history or a genetic mutation. And so I think as we're thinking about starting hormones, we do want to make sure that someone is up to date with their breast cancer screening, because certainly if there's something there, we don't want to give it then hormones, right? That could fuel the growth. And so, family history, I think, is a great time to think about, okay, what is your breast cancer risk? Are you up to date with screening? Have you... If you're at higher risk, then maybe we should be adding supplemental imaging to your screening. And we use all of that to make decisions and recommendations about hormone therapy.

• 2:45Dr. Mary Claire Haver?

  So who should be having genetic testing?

• 2:48Speaker 01

  Well, really, it starts with having a breast cancer risk assessment. And this really should begin at 25. It's not happening, but it should start at age 25.

• 2:56Dr. Mary Claire Haver?

  Okay. What does that look like? Is this one of the like, computer things you go online?

• 3:00Speaker 01

  Some of them, yes. So there are a number of different ways to assess breast cancer risk. The most publicly available and talked about is the Tyracuzic model. This is free and publicly available. Anyone can Google it, log on, and you start inputting the questions that it asks you. When did you start getting your periods? Your family history? Some of the questions are a little bit outdated, but dense breast. It goes through all of this to really try to understand your breast cancer risk. It's not perfect by any means. It misses people. It doesn't take into account lifestyle. But it does at least identify those that are at higher risk. Again, it misses people, but if it picks up that you have

• 3:43Speaker 01

  a lifetime risk of 20% or greater for being diagnosed with breast cancer, then you're considered higher risk. And what that really means is that we should be thinking about your screening a little bit differently. So maybe mammogram alone is not sufficient. Maybe we're going to add MRI or ultrasound to that.

• 4:02Dr. Mary Claire Haver?

  Who makes that decision? I don't make that decision in OB-GYN.

• 4:05Speaker 01

  It's generally going to be a high-risk breast surgery program. So if you are sitting with the patient, they do a risk assessment. And again, Tyracuzic is one of them. There are many available. And Tyracuzic isn't really for that 25-year-old woman. For that 25-year-old woman, we're thinking of, is there a very strong family history? For patients who had childhood radiation, for lymphoma, for example, they may be at higher risk. So we're kind of thinking through a little bit, and then we reassess that risk. So if you're sitting with the patient and you have determined that they are at higher risk of breast cancer, we recommend referring them to a high-risk breast cancer program.

• 4:44Dr. Mary Claire Haver?

  Where would you find one of those?

• 4:47Speaker 01

  Most institutions will have them.

• 4:48Dr. Mary Claire Haver?

  Like a big academic center?

• 4:50Speaker 01

  Not even. Most places that have a cancer center will have a high-risk program. But if you are not sure, if you're listening to this and you're a patient and you say, "Well, I just went online and did my risk, and it's 20%, and I don't know who to turn", easiest place is to call, ask for referral to the breast surgeon in the practice and in the group. And then the breast surgeon can help take it from there.

• 5:12Dr. Mary Claire Haver?

  So what are the... Just for our listeners, what are... I know BRCA. What are the big genetic risks?

• 5:22Speaker 01

  So BRCA mutation is going to be the most common, but there are other genetic mutations that increase cancer risk. Some of them include CACH2, ATM, PALB2, among others. This is not a comprehensive list. But the goal is, so if you go, first of all, is, do you need genetic testing? And that really is, what does your family history look like? And thinking about family history more than just your mom and your sister, because some will say, "Oh, my mom didn't have breast cancer. I'm good." But maybe there are men on her side of the family that had prostate cancer at an early age, could suggest a hereditary cancer syndrome. So when we think about family history, both mom and dad's side, multiple

• 6:04Speaker 01

  generations, multiple degrees of relatives. And if there is a concern, we go for genetic testing, which would look to identify if you've inherited a mutation that increases your breast cancer risk, or other cancer risk. Based on that mutation, each mutation carries its own cancer risk, you'll be guided on what do you do from here? Do you need to have a conversation about risk-reducing surgery? Do you need to have a conversation about high-risk screening? Do you need to talk about other screening for other cancers, like ovarian, or melanoma, or pancreatic? And so, think of all of this as information gathering, to help you make an individualized plan for yourself.

• 6:46Dr. Mary Claire Haver?

  So you talked about the most common, the BRCA gene. How would you counsel a patient who has this gene? What does that conversation look like?

• 6:54Speaker 01

  So depending on, there's BRCA1 mutations, BRCA2 mutations, depending on which one, there's going to be a slightly differing risk of cancer risk. But carrying a BRCA mutation has an up to 80% risk of being diagnosed with breast cancer. And because that risk is very high, we do recommend a risk-reducing mastectomy, or at least a discussion of that. For women over 65, that benefit of mastectomy is not as strong. So for some patients, we don't do it. We'll do high-risk screening with mammogram alternating with MRI. But it's a conversation. So everyone needs to have a conversation of what your breast cancer risk is, and then how can we lower that risk, whether through risk-reducing surgery,

• 7:37Speaker 01

  or higher-risk screening. And everyone makes different choices based on that. Now, not all genetic mutations are going to have such high risk. So not all genetic mutations require a bilateral mastectomy. Some people listening to this will say, "Oh, I have a mutation, but it was never discussed with me."

• 7:56Dr. Mary Claire Haver?

  Yeah.

• 7:57Speaker 01

  And that may be because you don't have one of these very high-risk genetic mutations, where it would be recommended.

• 8:02Dr. Mary Claire Haver?

  I got an advertisement for Function Health. Seems like a great program. Specifically, they talked about ordering a Pernuvo scan, which is a full-body MRI, not ordered by a doctor, just for screening purposes, and something called the Galleri test. And given my family history, I'm curious, right? And where does that fit into breast and gynecologic cancers?

• 8:28Speaker 01

  Yeah. Great question. These advertisements and direct-to-consumer marketing is everywhere. So we have full-body MRI, and then we have blood tests like Galleri. Then there are others that kind of promise to detect a cancer signal with a drop of blood, or a vial of blood. And these are very interesting technologies. And I get it, right? Why wouldn't you want to know, right? I want to know. But I think we have to be really cautious with it. So for the blood test, they are really looking for a signal that there could be something there. There can be false positives. There can be false negatives. They don't often detect a very early-stage breast cancer, or early-stage cancer that may not be in the blood, that's just confined to the breast. And they should not replace screening. So

• 9:12Speaker 01

  if you take, let's say, do a Galleri, and I've not done it, but if you do one of these tests and it shows a signal, then you kind of have to go hunting. Well, you have to get additional imaging. You might need biopsies. So we really have to understand the limitations, the risks and the benefits. And the same thing with full-body MRI. But I think the bottom line is that they should not replace proven, evidence-based cancer screening, like mammograms, colonoscopies, pap smears, and so forth.

• 9:40Dr. Mary Claire Haver?

  Yeah. I had upper and lower GIs for my brother with esophageal cancer, and...

• 9:47Dr. Mary Claire Haver?

  Um, I did do the gallery test just and, and for me, I knew the limitations. Of course, I'm a physician, but I have to say it just, I slept a little better. You know, and I know it only tells you what's in your blood right now. But it's always a fear in the back of my head. And if it relieves some of that anxiety and I could afford it.

• 10:07Speaker 01

  Exactly. I, I don't think there's anything wrong with doing the test. I think I'm more worried that we're doing it and not that some people are relying heavily on that.

• 10:16Dr. Mary Claire Haver?

  Yeah.

• 10:16Speaker 01

  Without doing.

• 10:17Dr. Mary Claire Haver?

  And then skipping their screening.

• 10:18Speaker 01

  Skipping their screening. Um, and then, you know, I think we still have questions before we can recommend it to everybody. Right? Cost and how often should we do it? But I think for the right person, you know, it could be really helpful. And then also I think what you kind of said, well, you have a very strong family history. Right? That's different. Um, and so I think it's something we should be discussing individually, but we're not there yet. Where we're recommending it to.

• 10:39Dr. Mary Claire Haver?

  Across the board.

• 10:39Speaker 01

  Across the board.

• 10:40Dr. Mary Claire Haver?

  So let's go back to breast cancer prediction models. Tyler Kuzic, which I've gone online and done my own. But there's also the Gale model. What do you use in clinic and, and are there some that are really only should be used by oncologists?

• 10:53Speaker 01

  Yeah, there's not a perfect model. So we used to use Gale for a long time and then we kind of switched to Taricuzic. Cause Taricuzic also includes breast density, which is important because if you have dense breasts, which you can only tell on a mammogram, but if you have dense breasts, that does increase breast cancer risk. Taricuzic may overestimate, um, you know, and, and so there's no perfect model. I, the one I use is Taricuzic, but there are a lot in development. And here is where AI actually may be very helpful.

• 11:24Dr. Mary Claire Haver?

  Okay.

• 11:24Speaker 01

  Um, there's some new technology. One is called Clarity, where they're using AI image based risk assessment to predict your breast cancer risk from a mammogram. So Clarity will be able to give you, they're piloting it right now in Massachusetts. Will be able to give you your five year risk of breast cancer from one mammogram.

• 11:44Dr. Mary Claire Haver?

  From an image.

• 11:45Speaker 01

  From an image.

• 11:45Dr. Mary Claire Haver?

  Wow.

• 11:46Speaker 01

  And the guidelines just changed to say that you, that, um, they would consider, you know, they would cover this or the guidelines would recommend it starting at age 35.

• 11:54Dr. Mary Claire Haver?

  Eleanor, I, you just said something that I was like, wait, that I was under the assumption, and maybe I read this or just assumed it. So correct me, that dense breast made it more likely for your breast cancer to be missed because it was harder to see on mammogram rather than a dense breast increasing your risk of breast cancer.

• 12:14Speaker 01

  Both.

• 12:15Dr. Mary Claire Haver?

  Wow.

• 12:16Speaker 01

  And we don't entirely know how dense breasts increase breast cancer risk. There's a lot of research going on, but it's both. So not only.

• 12:26Dr. Mary Claire Haver?

  So should I be getting an MRI?

• 12:27Speaker 01

  Well, if you have dense breasts.

• 12:29Dr. Mary Claire Haver?

  I do.

• 12:30Speaker 01

  50% of the population does. Then you want to talk to your team about whether you should be getting an ultrasound or an MRI. Cause then we're going to look at to your lifestyle, lifetime risk. It's if your lifetime risk is 20% or higher, we might go with MRI. Cause again, also for everyone listening, it really depends on coverage and everything. The guidelines currently say there's not enough data to broadly recommend.

• 12:54Dr. Mary Claire Haver?

  An MRI.

• 12:55Speaker 01

  An MRI or an ultrasound if you have dense breasts. But I will tell you, we know that they can miss things. You know, mammogram is not perfect if you have dense breasts. So I do really encourage people to have that conversation with their doctor about, I have dense breasts. And the category of dense breasts, dense breasts matter. So if you are category C heterogenously dense, that's about 40% of the population. Category D is extremely dense, which is about 10%. And for category D, we really do recommend that MRI. Category C is going to be, you know, user dependent.

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• 15:52Dr. Mary Claire Haver?

  What about concerns? I see this online about radiation from mammograms.

• 15:56Speaker 01

  Yes, very, very common, lots of misinformation about that. And I think that's why there is such an interest in like alternative, you know, uh, test to mammogram. But the, it's really the equivalent of walking, their radiation from a mammogram is the equivalent to about six or seven weeks of the background radiation you get exposed to just from walking around the street.

• 16:21Dr. Mary Claire Haver?

  Right.

• 16:21Speaker 01

  The neighborhood. So it's, it's there, it's not, you know, but it's, it's low. And we think about the, what you get, the benefit, right? We do feel generally that the benefit outweighs.

• 16:32Dr. Mary Claire Haver?

  The risks. So for the pre-viver, so a pre-viver, let's define that for our audience. Cause I don't know if everybody understands it's a carrier who's never had cancer.

• 16:40Speaker 01

  Yeah. So it's really, it's either for somebody who's, it's, they've never been diagnosed. They either carry a mutation or they have a very strong family history.

• 16:48Dr. Mary Claire Haver?

  Okay.

• 16:49Speaker 01

  Of cancer.

• 16:50Dr. Mary Claire Haver?

  So she has elected to remove her ovaries at 38, right? Everybody agreed this is your best course.

• 16:58Dr. Mary Claire Haver?

  What are the real options for managing her menopause now?

• 17:02Speaker 01

  Yeah.

• 17:02Dr. Mary Claire Haver?

  Cause we have put her into surgical menopause prematurely.

• 17:06Speaker 01

  Yeah.

• 17:07Dr. Mary Claire Haver?

  Which is a very high risk condition.

• 17:11Speaker 01

  And I will tell you that so many women are delay their life-saving, risk-reducing surgery or avoid it because they're afraid of this very thing. But here's the thing, pre-vivers can absolutely use hormone replacement therapy.

• 17:27Dr. Mary Claire Haver?

  Explain that. I don't think women understand this.

• 17:30Speaker 01

  Yeah.

• 17:30Dr. Mary Claire Haver?

  And when Corinne Men told me that she was going, you know, like, I just assume once a breast cancer patient, always a breast cancer patient, no hormone therapy. Like this is me.

• 17:40Speaker 01

  Yeah.

• 17:40Dr. Mary Claire Haver?

  Five years ago. And that she had gone on hormone therapy and I was like, what?

• 17:47Speaker 01

  So pre-vivers, and we have data, this actually very new study. Let's say you have a BRCA mutation. Okay. Cause we'll just kind of highlight the ones who have a 38 year old woman. She has a BRCA mutation, her breasts are still intact. She's not had a mastectomy and she goes and has her ovaries removed to reduce her ovarian cancer risk. And she's plunged into menopause. We can absolutely use hormone therapy. There was a recent study by Katsopolis, Joanne Katsopolis, I believe, that they had over 600 women who, um, these were all, you know, pre-vivers, higher mutation carriers, BRCA mutation carriers who had this very same thing. They were in menopause because it's ovaries removed. They had their breast tissue intact. So they had not had a mastectomy and they had about over 600 women who were given hormones.

• 18:32Speaker 01

  And then they had six, over 600 women who were not. And the ones who used hormones had, if they were on estrogen alone, they actually had a lower risk of breast cancer. But if they were on estrogen and a progestogen, they did not have a higher risk. So that's a little bit different than what we've seen.

• 18:49Dr. Mary Claire Haver?

  So it was equal risk versus, versus protective.

• 18:52Speaker 01

  Exactly.

• 18:53Dr. Mary Claire Haver?

  Why would a woman take out her ovaries and not her breasts?

• 18:58Speaker 01

  Great question. You know, I, I think we generally do recommend having the discussion for both. But everyone is different and some people say, you think about how much goes into risk surgery. Right? Being a pre-viver is so hard. We don't talk about this nearly enough. You have to make these crazy decisions, these hard decisions about surgeries.

• 19:21Dr. Mary Claire Haver?

  Fertility.

• 19:22Speaker 01

  Fertility, menopause, cost, insurance. And, and then there's always this, this voice, people get told, why are you doing this? You don't even have cancer. There's so many people that get told that. So these are hard decisions to make and a mastectomy is not, you know, it's a hard surgery. Reconstruction is hard. And so there's, it's very common to kind of say, um, maybe I'm going to do this and I'm going to do the mastectomy in a few years. But the point being is that that study really showed us that you can be at higher risk for breast cancer due to a genetic mutation and.

• 19:56Dr. Mary Claire Haver?

  Keep your breasts.

• 19:57Speaker 01

  Keep your breasts and not have a, you know, higher risk of breast cancer.

• 20:01Dr. Mary Claire Haver?

  And so these women also kept their uteruses.

• 20:04Speaker 01

  So we don't know, but the ones that presumably the ones that had estrogen alone had their uterus removed. And we don't know about the ones that were on a progestogen. We also don't know what kind of progestogen they were on.

• 20:18Dr. Mary Claire Haver?

  What do you think in IUD, the progestin-containing IUDs have a place here?

• 20:23Speaker 01

  Well, I think, you know, what's interesting is that there, the conversations also around risk-reducing surgery are changing. So it used to be everyone had their ovaries and fallopian tubes removed and that was it. And I think there's much more of a conversation now about, is there a role for hysterectomy? Um, you know, because there's some data, it's very early, it's very observational. But for some BRCA mutations, there could be a higher risk for uterine cancer. Again, very premature, but it's something.

• 20:49Dr. Mary Claire Haver?

  For endometrial.

• 20:50Speaker 01

  For endometrial. So we should be thinking about that or at least having the conversation. But yes, a progestin, you know, an IUD could be an option as well. So I think the point though, is that women need to have counseling on about these options before they have the surgery, right? Have a very clear plan of you're going to have your ovaries removed. What are we doing when you come out of the OR?

• 21:11Dr. Mary Claire Haver?

  Yeah. Okay. And they're not getting that. Just quickly, and I don't want to scare our listeners, but if she doesn't get that conversation and she is sent off into the world in premature menopause, what is she at increased risk for outside of recurrence?

• 21:25Speaker 01

  Absolutely. I mean, there are going to be impacts on both short and long-term health. You know, we know that if you go into premature menopause, especially before the age of 45, you are higher risks of cardiovascular and cognitive and musculoskeletal health. But I always see this message. And so for that pre-viver, even if you weren't put on hormones, it's never, you know, you can go on them later.

• 21:46Dr. Mary Claire Haver?

  It's never too late.

• 21:47Speaker 01

  It's never too late. But for our listeners who, you know, maybe have decided with their team that hormones are not the best option, I always want to stress that you're not doomed if you can't go on hormones because hormones are just one part of comprehensive menopause care.

• 22:00Dr. Mary Claire Haver?

  So she can protect her bones, you know, through weightlifting, there's other medication, you know, like, but that, but it needs to be addressed, right?

• 22:07Speaker 01

  Exactly. And you need to have a preventive plan, you know, are we doing our bone density? How are we screening for the heart? How are we addressing brain health? That comprehensive plan for everybody, hormones are not, needs to be discussed.

• 22:20Dr. Mary Claire Haver?

  Okay, let's talk about women of color. Are genetic testing outcomes different for them? Do they deserve the same tests?

• 22:28Speaker 01

  Well, what's interesting is that access and conversations about genetic testing differ for women of color. And they're often not being offered it when they, you know, qualify and are eligible. And then the, the other part is that most of the, most of the databases for which the genetic testing is based on are Eastern European ancestries. And so women of color have historically not been well represented in the databases that, you know, the genetic testing is based on. And so we can have more what are called variants of uncertain significance, meaning where you sequence the gene and there's a change in it, but we don't know if that change is actually responsible for, you know, increasing

• 23:12Speaker 01

  cancer risk or not. And so you may see more VUS reports. And it's really, it's so important that we are really thinking about access and eligibility for everybody.

• 23:24Dr. Mary Claire Haver?

  So a woman tested negative, but her mother and her sister had breast cancer and the negative test does not have, she's still not average risk.

• 23:33Speaker 01

  Exactly. This is based on a new study where they actually showed that. And we've known this for a long time, but the, if your mother had a genetic mutation, so let's say she had a BRCA mutation and she didn't pass it on to you and you're negative, that's different. But if mom was negative, her mom was never tested, which is often what we see, and you're negative, it does not mean that your risk is back to that of the average woman, because having a family history, even in the absence of a genetic mutation, still increases risk. And so these are things that go into our risk assessment predictions.

• 24:07Dr. Mary Claire Haver?

  Okay, let's talk about bone health and cancer treatment together. I guess Shapiro had published in 2001 that chemotherapy induced ovarian failure drops lumbar spine density 4% in six months. And aromatase inhibitors then are going to run an additional 2% a year on top of that. Are women being adequately counseled about this?

• 24:33Speaker 01

  I don't think so. Really, every single person who's getting cancer treatment is going to be eligible for a baseline bone density scan.

• 24:42Dr. Mary Claire Haver?

  Yeah. So you would get it on a 35-year-old with breast cancer before she started treatment?

• 24:47Speaker 01

  Well, I, I will say, I usually actually get it after they're done with chemo to get a baseline, because we won't get coverage to do a pre and post.

• 24:56Dr. Mary Claire Haver?

  It's $99.

• 24:57Speaker 01

  So I usually do it after, although we're applying for a grant now that would allow us to get really much better, like granular level of our bone density and body composition. But let's say, you know, for average, so she finishes chemo, because we're, for 35-year-olds, we're going to give, you know, chemo is going to be important if recommended. So we get that baseline bone density. I always get a baseline bone density before starting any sort of endocrine therapy.

• 25:25Dr. Mary Claire Haver?

  Okay.

• 25:26Speaker 01

  Before Tamoxifen, before aromatase inhibitors, before, you know, Lupron for ovarian suppression. And where I see a little bit of a gap is in people who are hormone receptor negative that don't need hormone blocking medications. They often don't get that bone density. But chemotherapy can cause skeletal muscle atrophy. And even if you only had chemo, in the absence of hormone, you know, blocking meds, really, if you've had chemo, you should also be getting a baseline bone density.

• 25:54Dr. Mary Claire Haver?

  And that's anybody receiving chemo.

• 25:56Speaker 01

  Yeah. Yeah. That's not just limited to breast or GYN cancer. And get that baseline bone density. I mean, bone densities are only one part of the story, but it's a starting point. And that can help us figure out, you know, it also can help us kind of predict where we go from here and what your trajectory might look like.

• 26:16Dr. Mary Claire Haver?

  What can she do about her bones that costs nothing?

• 26:19Speaker 01

  Go for a walk. You know, put on a pair of sneakers, go outside, go for a walk. Movement is really foundational. And then we add, you know, when we think about, okay, let's break down that movement, right? Are we doing weightlifting and strength training? Are we getting cardio? Are we doing balance and flexibility? Right? I think what's really important is that we're having a movement plan that encompasses all of these, because where is the risk in poor bone density, the fall. And if you lose, so now it's a perfect storm. You've had, let's say we have a 60-year-old woman, 65-year-old woman who's had chemotherapy. She's suffering from neuropathy, so impact to the nerves in her hands and feet. And so her gait's a little off, balance is off. She has osteoporosis and she goes for a walk

• 27:04Speaker 01

  and she trips on a curb. And now she sustains a fracture because of that. Right? It's this perfect storm. And so thinking about being proactive rather than reactive, knowing the bone density, knowing what we're at risk for, recommending exercise that's going to think through that, calcium, vitamin D, and then, you know, for some people, bone medications.

• 27:26Dr. Mary Claire Haver?

  Yeah, bone building meds. What is chemo brain?

• 27:30Speaker 01

  So chemo brain is really part of the category of cancer-related cognitive impairment or CRCI. And many treatments, not just chemotherapy, we call it chemo brain kind of colloquially, but a lot of our cancer treatments can impact our cognitive health. And it can present in all sorts of different ways. For some people, it's memory issues or word finding difficulties.

• 27:54Dr. Mary Claire Haver?

  Same as menopause brain.

• 27:55Speaker 01

  Same as menopause brain. And it's really compounded also by all the other side effects. So you have a lot of, you know, you have fear of recurrence and you have anxiety from diagnosis, you're having trouble sleeping. And then when you do finally fall asleep, you've, you know, woken up by your night sweats that are not controlled yet. And you're waking up, you've gotten poor sleep, right? And that worsens chemo brain. And the same thing that we see in, in the menopause, in the menopause world. And maybe now you have estrogen deprivation on top of it, right? So it can present in all sorts of different ways. And the challenge with this, and we see this a lot, is that when people go for testing, you know, on formal cognitive testing, they don't have any abnormalities. And they're told, you're fine. It's just, it's fine.

• 28:38Dr. Mary Claire Haver?

  Well, Moscone explained it to me, we have tests for dementia.

• 28:42Speaker 01

  Yes.

• 28:43Dr. Mary Claire Haver?

  But we don't test for someone who has a PhD, you know, like someone who was high functioning, it doesn't matter what degree she has, who now can't do her job.

• 28:53Speaker 01

  Yeah.

• 28:54Dr. Mary Claire Haver?

  But she's not, she's not qualified for dementia.

• 28:56Speaker 01

  Exactly.

• 28:57Dr. Mary Claire Haver?

  Like, we don't test for this. We don't even have an ICD-9 code.

• 28:59Speaker 01

  Well, I think that's the problem is that because we don't test for it, we don't know what to do with it. People, again, it's like.

• 29:04Dr. Mary Claire Haver?

  We don't test baseline cognitive function.

• 29:06Speaker 01

  Yeah. And we don't really, in the oncology world, we don't really have a good test for that. That's also part of the problem. Like, and so a lot of it is really thinking through what are the contributing factors and can we make some of those better? And, you know, thinking about exercising our brain, just like we do all other muscles, but it's hard. And our patients really, you know, think about it, they finish chemo, they're expected to go back to work and function, and they're suffering with all of these things. And there's no, the expectation's like, you're fine now, right?

• 29:39Dr. Mary Claire Haver?

  Yeah. Congratulations, you don't have cancer.

• 29:42Speaker 01

  You rang the bell.

• 29:43Dr. Mary Claire Haver?

  Yeah. Let's talk about heart disease and cancer treatment specifically. Their New England Journal, published in 2013, Darby, I think, found major coronary events rose about 7.5% after radiation. You know, what's going on there?

• 30:01Speaker 01

  Well, a number of cancer treatments.

• 30:03Dr. Mary Claire Haver?

  Again, because your breasts sit right in front of your heart.

• 30:06Speaker 01

  Right in front of the heart. Exactly. So radiation is one of the treatments that can impact cardiovascular risk. The radiation oncologists have really been very cognizant of this for a long time. And there are ways, so if you do need left-sided radiation, because you have a left-sided breast cancer, there are ways that they have you breathe and position during radiation. One of them is called the deep inspiratory breath hold, kind of moves the heart out of the way a little bit with radiation. So there are ways that we can protect the heart. But radiation is only one impact of cancer treatment on your heart. Chemotherapy can impact the heart, depending on which agent you're getting. Premature menopause can impact the heart. Aromatase inhibitors.

• 30:46Dr. Mary Claire Haver?

  LDL, cholesterol, heart glyceride.

• 30:48Speaker 01

  And I will say, for a long time, we only thought of the impact of the heart on the impact of the ejection fraction, right? How effectively does the heart beat?

• 30:55Dr. Mary Claire Haver?

  Like heart failure.

• 30:56Speaker 01

  Heart failure. We weren't thinking about the impact on cardio metabolic health and your cholesterol. And aromatase inhibitors in premature menopause, 100% can impact cholesterol. And so that's something where we really need to be monitoring and have a very clear plan of what are we doing and what are the targets that we should be setting. And so this is where, for anyone listening, I would urge you to ask your medical team, did the treatment I receive or will receive in the future, impact my cardiovascular health from either heart failure, you know, functioning perspective or a metabolic perspective? And what should I be doing? Should I be seeing a cardio oncologist? How often should I be getting my cholesterol monitored? You know, and how often do I need other additional cardiac tests, but really be proactive with your heart?

• 31:47Dr. Mary Claire Haver?

  Let's talk about the mind. So how can support groups and breast cancer communities really help with the mental health component of breast and gynecologic cancers?

• 31:58Speaker 01

  I mean, this is, you know, mental health is so impacted with anyone who's navigating any cancer diagnosis, treatment, and fear of cancer recurrence is, is real. You know, studies say 50%, I don't, you know, I think it's everybody has some.

• 32:14Dr. Mary Claire Haver?

  I mean, there's normal vigilance.

• 32:15Speaker 01

  Yes.

• 32:16Dr. Mary Claire Haver?

  And then there's something that's becoming pathologic. How do you know the difference?

• 32:18Speaker 01

  Exactly. And I think, is it paralyzing you? Is it something where you can't stop thinking about it, right? Everything that you do is really kind of, you know, impacted by that fear. It's normal to have the, the scan anxiety, you know, you're about to have a scan and you're nervous. It's normal to have those.

• 32:33Dr. Mary Claire Haver?

  I have it before a mammogram.

• 32:34Speaker 01

  Everyone does, right? And that's, that's, that's.

• 32:37Dr. Mary Claire Haver?

  What if?

• 32:37Speaker 01

  What if, right? You're worried about that. There's triggers of it's, you know, the anniversary of your diagnosis, or you see someone online diagnosed, you're facing a recurrence, right? It's very normal to have those triggers. But if it's really impacting your everyday functioning, then we, that's a different level. So really understanding what, you know, what are the symptoms that you have and that you face? And how do those, that fear show up in you? Because it looks different in everybody. And then really, how do we address that? And I think that looks different for each person. For some people, it's journaling, it's meditation, it's positive self-talk, it's watching a funny movie, it's

• 33:17Speaker 01

  community, which can be amazing. You know, or it's therapy, it's medication. So it looks different for each person, but really building your toolkit. Community is something that I think really has, is transformative, especially for our younger women who often may not know somebody close to them that's been diagnosed.

• 33:37Dr. Mary Claire Haver?

  Yeah.

• 33:37Speaker 01

  They're the youngest ones in the exam room. People are telling them, you're too young to be here. And they're like, well, here I am. So.

• 33:43Dr. Mary Claire Haver?

  Yeah.

• 33:44Speaker 01

  Now what? So finding a good community, and there's so many incredible support groups out there, you have to find your people. Not all support groups will be right for you. So test them out. See, but don't be afraid to start to reach out.

• 33:57Dr. Mary Claire Haver?

  Engage. You tell a story, and this actually happened to one of my very best friends. After her double mastectomy, she really struggled with her body image. And how do you counsel patients about that?

• 34:12Speaker 01

  Yeah, I think, you know, it's so impacted. You know, people are not prepared for what's going to happen with that first look, you know, after the bandages, you have bruises, you have strains, it's swollen, it's discolored, and that is really hard. And so I think being prepared for all the different steps of the recovery and the impact of cancer treatment and body image as a whole, you know, and for some people, it's really, there was a study looking at something called the mirror program, where you kind of look at smaller mirror, you know, you look at a really small mirror, small part, and then you kind of, you know,

• 34:45Dr. Mary Claire Haver?

  Slowly increase.

• 34:47Speaker 01

  Slowly increase, because it can be very traumatic to kind of look at a full-length mirror, look at yourself. I have some patients who say, I walk by mirrors and I.

• 34:53Dr. Mary Claire Haver?

  Don't look.

• 34:54Speaker 01

  You know, I've gotten rid of mirrors in my bedroom because I don't want to look at it. So I think, again, understanding a lot of, I think, the challenges come from not being prepared. And it's not on the patient, right? It is on our medic, on the medical teams for us to adequately prepare our patients about what to expect, what do things look like, and asking for photos. You know, you can ask your plastic surgeon, your breast surgeon, do you have photos of different steps of the recovery process? At least, I think, knowing what to expect, if you know, I'm going to have really drains and bruises and scars, and this is going to last for five days, whatever it is, right? I think that helps a lot.

• 35:35Dr. Mary Claire Haver?

  Okay. So what is the one thing, or many things about estrogen, cancer, and family history that you want the listener to understand?

• 35:44Speaker 01

  We covered so much. But I would say really is that, one, is everyone deserves a conversation. And I say this in the book as well, you deserve a conversation about your treatment, about your side effects, about your options. Everyone has options. And it should not be a blanket no. It should be having a conversation, a discussion about what is right for each person.

• 36:08Dr. Mary Claire Haver?

  And if a woman listening does two things before her next appointment, what should she do?

• 36:13Speaker 01

  I would say really, one, make a list of the side effects that you are experiencing, and the side effects were systems that you were worried about for long term, right? So go into that appointment with, these are the concerns that I have, prioritize them. And then, two, I think, start to think about what you are already doing for lifestyle or horm, you know, whatever you're already doing to address those side effects, so that you can make a plan about how do we optimize going forward.

• 36:40Dr. Mary Claire Haver?

  So we're going to do some lightning round stuff. Are you down for that?

• 36:43Speaker 01

  I'm down.

• 36:44Dr. Mary Claire Haver?

  So hyper hope, right? All right. Number one, a randomized trial of hormone therapy after breast cancer ever being run again.

• 36:52Speaker 01

  Hope.

• 36:53Dr. Mary Claire Haver?

  Hope. Polygenic risk scores, and we may have to explain what that is, replacing, do you have a family history?

• 37:00Speaker 01

  Yeah, so, so hope, but polygenic risk scores are really looking at individual gene changes, and then trying to combine them together to get a better sense of risk. And we're seeing some studies ongoing, so I'm very hopeful.

• 37:11Dr. Mary Claire Haver?

  Yay. Vaginal DHEA becoming default for survivors instead of a workaround?

• 37:18Speaker 01

  Hope.

• 37:19Dr. Mary Claire Haver?

  Hope. Yeah, we have to get the cost down.

• 37:20Speaker 01

  Yeah.

• 37:21Dr. Mary Claire Haver?

  I would literally prescribe it for everyone.

• 37:23Speaker 01

  Oh, yeah. It's great. After they can afford it.

• 37:25Dr. Mary Claire Haver?

  They have to pay for it. Menopause care written into every survivorship care plan?

• 37:31Speaker 01

  I mean, I'm going to say hope, because I would love to see that happen. I think we have work to do.

• 37:35Dr. Mary Claire Haver?

  Okay. Oncology and gynecology sharing one chart on the patient?

• 37:38Speaker 01

  Oh, massive hope.

• 37:39Dr. Mary Claire Haver?

  Massive hope. Yeah. They're like, bye, you have cancer.

• 37:42Speaker 01

  See you later.

• 37:43Dr. Mary Claire Haver?

  See ya. Come back for your pap smear. Okay, yes or no? And this is usually for social. Okay. A breast cancer history means you can never use any form of estrogen?

• 37:54Speaker 01

  No.

• 37:55Dr. Mary Claire Haver?

  Low dose vaginal estrogen is safe for survivors?

• 37:59Speaker 01

  Yes.

• 37:59Dr. Mary Claire Haver?

  Family history of breast cancer by itself rules out hormone therapy?

• 38:03Speaker 01

  Nope.

• 38:04Dr. Mary Claire Haver?

  A BRCA carrier can at least have a conversation about menopause hormone therapy?

• 38:09Speaker 01

  Yes.

• 38:09Dr. Mary Claire Haver?

  Soy is dangerous for women with breast cancer?

• 38:12Speaker 01

  No.

• 38:14Dr. Mary Claire Haver?

  Most breast cancer is hereditary?

• 38:16Speaker 01

  No.

• 38:17Dr. Mary Claire Haver?

  Chemo brain is real?

• 38:18Speaker 01

  Yes.

• 38:19Dr. Mary Claire Haver?

  Everyone affected by breast cancer deserves a conversation about their options?

• 38:23Speaker 01

  Yes.

• 38:23Dr. Mary Claire Haver?

  What is the best place to start that conversation?

• 38:27Speaker 01

  Read Beyond the Pink. I wrote the book really to put everything into a comprehensive resource that people can take. My hope is that they feel seen, they feel heard, and they can bring that book to their medical team with studies, with evidence, to say, I'd like to start the conversation.

• 38:43Dr. Mary Claire Haver?

  Where can our listeners find you?

• 38:46Speaker 01

  You can find me at Dr. Daplinsky on all social media platforms, and check out Beyond the Pink, Navigating Life, Health, and Breast Cancer, which is really everything we talked about today in a comprehensive, one-stop guide for everybody.

• 38:57Dr. Mary Claire Haver?

  And thank you so much for sharing all of your wisdom and knowledge with our listeners today. I think you've made a huge impact.

• 39:04Speaker 01

  Thank you for having me.

• 39:07Dr. Mary Claire Haver?

  You can find full episodes of UnPaused on YouTube at Dr. Mary Claire. Also, you can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepauselife.com. UnPaused is presented by Odyssey in conjunction with Good Roommate Media and Long Wave Digital.