Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. October, as many of you know, is breast cancer awareness month. Breast cancer is the second leading cause of cancer deaths for women in the United States. An October 1 report from the American Cancer Society has good news and bad. It says death rates from the disease overall, are going down, but there has been a rise in breast cancer deaths among Asian American and Pacific Islander women, and there's been a spike in the diagnosis of the disease overall in women under 50.

Let's ask why. Joining us now to help make sense of the study is Doctor Lisa Newman, surgical oncologist, chief of the section of breast surgery at New York Presbyterian Weill Cornell Medical Center, and one of the co-authors on this recent American Cancer Society study. Thanks for being here, Doctor Newman, welcome to WNYC.

Lisa Newman: Thank you so much, Mr. Lehrer, it's such an honor to be on your show, and we so appreciate you joining forces with us to disseminate information about breast health awareness. Very important topic. Thank you.

Brian Lehrer: Thank you. Listeners, we know so many of you out there have dealt with or witnessed this disease. If you're a younger woman who's been diagnosed with breast cancer, or know a younger person who's been diagnosed, give us a call now to share your stories and questions. Navigating breast cancer at an earlier-than-expected age, we know, can be tough, of course, at any age, but you probably had to advocate for yourself or you've dealt with the complexity of the insurance system. Help us report this story in any way, and help others by telling yours.

212433 WNYC. 212-433-9692 or of course, if you have any questions for our guest, Doctor Newman, we can always take those. 212-433-9692. The report finds that breast cancer mortality rates overall are declining in the US, but the disease is turning up more often in women under 50 and in Asian American and Pacific Islander women. Can you break down the magnitude of this increase?

Lisa Newman: Yes. Thank you so much. I'd love to delve into this a bit further. We have indeed seen declining death rates from breast cancer over the past three decades. Actually, the death rates have declined by about 44%. That was great news. Very assuring to us that we have achieved many successes, made great progress in breast cancer, largely through improvements in early detection, women are more aware of issues with their breast, and so they're more likely to present with earlier-stage disease when the disease is more highly treatable and curable.

We have many more successes with screening mammography, the imaging has gotten much more effective at early detection, and we've also made wonderful advances in the treatment of breast cancer. We have improved surgical treatments that have fewer side effects. We have a better medical, or what we call systemic therapy for breast cancer, which can prevent metastatic disease. We have better radiation treatments and plastic surgery for women that require breast cancer surgery. This is all the good news.

Brian Lehrer: Let me follow up before we even go on to the bad news, just to linger on this for a second, all of those different tools to reduce the death rate from breast cancer. I mean, that number that you cited that I know is in the study, a 44% drop since 1989. A 44% drop is huge in a leading cause of death.

Lisa Newman: Yes, absolutely. We are thrilled to see these improvements in outcome. It is indeed wonderful news and definitely evidence that we are going in the right direction with breast cancer early detection, and the improved treatments that I mentioned, but we do also have to acknowledge some of the disturbing patterns that we observed in this report related to increases in incidence of breast cancer. This is going to be a major threat to the ongoing progress that we're making in terms of declining mortality rates.

As you also correctly noted, the increasing incidence is being seen disproportionately in younger women, in women that are younger than the premenopausal age, a surrogate of 50 years. For the younger women, the steepest increases in rate were in the Asian American and Pacific Islander women. We don't understand why this is the case, and unfortunately, we have a major handicap in understanding the breast cancer burden of Asian American women, because that label, Asian American, encompasses such a very diverse group of the population.

We really need to disaggregate that term Asian American to try to hone in on why some of these alarming increases are being seen in that population's burden of breast cancer. [crosstalk]

Brian Lehrer: Why in women under 50, overall? I think that's probably the biggest question on a lot of listeners minds. Is this from environmental pollutants that weren't as prevalent generations ago? Is this from lifestyle factors like diet? How much do you know?

Lisa Newman: I think that all of the factors that you cited are probably relevant and contributing. We definitely suspect that lifestyle factors such as childbearing play a role in the United States. Women tend to have fewer pregnancies compared to women in other parts of the world. Women tend to delay initiation of their childbearing until later years, and these factors can both increase the risk of the most common type of breast cancer, which is a pattern that we refer to as estrogen receptor-positive breast cancer. Diet also plays a factor, and the increasing obesity rates that we're seeing in the United States in women of all ages is also playing a role.

We are, unfortunately, increasingly pursuing a more sedentary lifestyle with less activity, and this can also increase breast cancer incidence.

Brian Lehrer: Explain if you know the mechanism, why delaying childbirth, having kids at later ages, would increase a woman's risk of breast cancer.

Lisa Newman: It probably contributes to breast cancer burden because of the number of estrogen cycles, menstrual cycles, resulting in the breast being exposed to hormonal surges associated with those estrogen menstrual cycles over longer periods of time. Women that do not have any pregnancies or women that start their pregnancies at later ages, the breasts in those women are being exposed to more estrogen cycles. We hypothesize that this is playing a role in the breast developing these cancerous tumors.

Brian Lehrer: Haley on Long Island, you're on WNYC with Doctor Newman. Hello.

Haley: Hi, Brian. Big fan of the show. I just want to say that I'm so grateful that you guys are having this conversation. I'm 35 years old. I'm a breast cancer survivor. I was diagnosed in 2021 when I was 31 with stage three inflammatory breast cancer. I have to say that it's very common to be misdiagnosed when you first start to realize that something is wrong, mostly because people don't think you have breast cancer when you're 31. The fact that you guys are talking about this and bringing awareness to it is really touching because a lot of women just don't get the voice, especially when you're young.

I also find that a big thing that happened for me was there's a lot of existential issues you have to deal with when you get a diagnosis like this, mostly because when you're a young person, there's things that you have to deal with that maybe somebody who's over the age of 60 doesn't have to deal with when they get breast cancer. For example, fertility stuff. I was automatically asked, do you want to freeze your eggs? Things like that, things that I never really had to think about before getting diagnosed. Once again, I'm just so happy and grateful to hear you guys having this conversation. Thank you.

Brian Lehrer: Haley, thank you for sharing your story. Anything there you want to reflect on, Doctor Newman, maybe the fertility issues for younger women who are diagnosed who never had to confront that before, like Haley is saying or anything else.

Lisa Newman: Yes, Haley, I'm so glad that you're doing well and so pleased that you did advocate for yourself in getting this breast cancer diagnosed and treated. Congratulations on doing well, and please keep spreading the word to other young women. Currently, we do recommend that average-risk American women start their screening mammograms at age 40 and should continue them thereafter.

Mammograms, however, are not perfect, and so all women at all ages need to be aware of the potential danger signs of breast cancer, such as a new lump in the breast, lump in the underarm, a bloody nipple discharge, changes in the skin appearance of the breast, such as redness or inflammation, which is probably what Haley noticed with her inflammatory breast cancer, or if you develop a rash on the skin of the breast, especially if that rash is near the nipple.

Now, all of those changes can be caused by benign findings, but you should never make that assumption. You should seek medical attention and have those symptoms evaluated. If you have those symptoms and you're younger than age 40 and haven't been getting mammograms, please seek medical attention. If you have been getting routine mammograms and you were told that they were normal, but you develop any of those symptoms, you still need to get checked out because mammograms can miss some cancers.

It is very wonderful to be able to say that for young women who get breast cancer at premenopausal ages, we can protect their fertility with a number of different programs. As Haley mentioned, the possibility of freezing the eggs is a possibility. There are different ways that women can protect their fertility because, unfortunately, many of the treatments that are necessary for breast cancer, treatments such as chemotherapy, or treatments such as special hormonally active cancer-fighting pills, these can all interfere with the ovarian function.

Brian Lehrer: Let's take another call. Anna in Litchfield County in Connecticut, you're on WNYC. Hi, Anna.

Anna: Hi, Brian. Thank you for having me. I wanted to talk a little bit about the importance of self-advocacy. I was diagnosed with triple-negative breast cancer at 39, and I first felt it through a tingling sensation in my left breast. I was told by many people, doctors, the Internet, that you don't feel cancer, but after self-advocating, really digging in deep to find something that was off, I was diagnosed and I went through a full year of radiation, chemotherapy, a lumpectomy, the whole nine yards.

Because I was only 39, people really weren't giving me the benefit of the doubt, and so I think the importance of self advocacy cannot go underappreciated. I also think that given the numbers that we're seeing, I'm curious, why is 40 and why it wouldn't even grow to 30, and why the health insurance system is preventing people from getting the mammograms that they might need at a younger age.

Brian Lehrer: Such an important set of questions, Doctor Newman.

Lisa Newman: Yes, very important questions that you've raised. I'm not going to have answers that will be completely satisfying, but I'll take a stab at it. Now, in terms of the age at which a woman should initiate mammographic screening, there is a lot of controversy and debate ongoing because we are seeing declining rates. There are many of us who would like to see women be able to initiate those screening mammograms at younger ages. We do know that for women who have--

Brian Lehrer: You mean declining rates of death, right? Because the earlier screenings help prevent the death of people who have breast cancer, is that what you're saying?

Lisa Newman: That is correct. Because we are seeing increasing rates of breast cancer in younger-aged women, I apologize if I misspoke, but because we are seeing these increases in breast cancer risk in younger women, we would like to see women be able to avail themselves of screening mammograms at younger ages. However, if you look at the actual population-based incidence rates of breast cancer, they do rise significantly after age 40. Even though breast cancer can and will afflict many younger women, the overall rates are still relatively low compared to the older-aged women.

Again, since it's rising for young women, that's a very legitimate argument in favor of starting mammograms early. Now, we do know that some women absolutely need to start those screening mammograms at younger ages. It's important to know your family history. If you have evidence of hereditary predisposition for breast cancer, you may need to start your mammograms at younger ages, and we recommend that the mammograms start at 5 to 10 years younger than the youngest age at breast cancer diagnosis in the family.

If you have a strong family history, you should consider genetic testing, because you might want to consider prevention surgery to avoid breast cancer if you have hereditary predisposition. Some women that are at high risk for breast cancer because of breast biopsy findings showing overactive breast tissue, these women may also need to get supplemental screening for their breasts tests such as breast magnetic resonance imaging or MRI, or they may need to supplement their mammograms with breast ultrasound.

It's important to know the details of any benign breast biopsy that you have. It's great if a biopsy was negative, but you need to know if that biopsy showed overactive cells indicating that you are at higher risk for breast cancer.

Brian Lehrer: Thank you for your call, Anna. I hope that was helpful. Listener texts this question in response to what you were saying earlier about the heightened risk for women who haven't had any children or had children later in life. Listener writes, if a heightened number of estrogen cycles might lead to higher incidence, does hormonal birth control offer any protection?

Lisa Newman: That's a great question, and there have been a lot of studies with conflicting data regarding the correlation between birth control pills and breast cancer risk. Birth control pills have changed dramatically over the past several decades in terms of their content and modality of it being delivered to a woman. Overall, we do not think that there is any significant correlation between birth control pill use and breast cancer risk. I would recommend that a woman decide the optimal birth control that she wishes to use in conjunction with discussions with her gynecologist.

Brian Lehrer: Another listener texts a question about access to screening. Listener writes, breast cancer screening and race ethnicities differences, for example, Black, white, Asian women, etcetera. Please ask. I think they're talking about screening rates, not incidence rates. If there are higher incidents among Asian American and Pacific Islander women, which your study found, is it because they're not getting screened as much as white women? Same thing for Black or Latino women?

Lisa Newman: Yes, another great observation in question. Now, for the Asian American population and for the Native American population, that the rates that we are seeing in terms of mortality may be a result of lower mammography screening. Again, we do need to parse out that data better by disaggregating the term Asian American so that we can get a better understanding of screening practices in that population. Now, for the breast cancer burden of African American women, there are a number of patterns that need to be emphasized.

We do indeed see that African American women are more likely to get breast cancer at younger ages. African American women are more likely to get biologically aggressive cancers, tumors known as triple negative breast cancers, as one of your listeners commented on earlier. The breast cancer burden of African American women is partly explained by socioeconomic disadvantages, with higher poverty rates in the Black community, leading to delays in a cancer diagnosis and delays in breast cancer treatment. It's definitely not completely explained by socioeconomics.

Black women actually have slightly higher rates of mammographic screening compared to white American women, although they there are some data indicating that Black women are more likely to get their mammograms at some of the non accredited mammography centers. It's important that women get their mammograms with a reputable radiology facility, a facility that is accredited for performing mammography. There are data indicating that African American women have delays in workup of a problem that is found on a mammogram, and that may contribute.

We are also doing some very exciting research trying to understand some of the hereditary and genetic biologic factors that may be contributing to the breast cancer burden of African American women, such as those triple negative breast cancers that we mentioned, and the younger age distribution. There's also a higher risk of male breast cancer in the African American community, and this may also be related to some genetic factors. For all individuals, we do need to be mindful of the fact that breast cancer can afflict men, but overall, male breast cancer is going to account for only about 1% of the total breast cancer burden in this country, but it is twice as common in African American men compared to white American men.

Some of the research that we've been doing to understand the hereditary and genetic factors related to the breast cancer burden of the African American community appears actually to be linked to the genetics of African ancestry because if you look at the African diaspora, the burden of triple-negative breast cancer in women on the west coast of Africa is quite high. It's even higher than what we see in African American women. That's notable because the transatlantic slave trade, of course, brought the ancestors of contemporary West Africans across the Atlantic Ocean to serve as slaves in the colonies.

As contemporary African Americans, we have quite a bit of shared ancestry with West Africans. We are doing a lot of research trying to understand specifically the genetics of west African ancestry and how it correlates with hereditary predisposition for triple-negative breast cancer. This research will be important for women around the world because if we understand some of the genetic factors associated with what we call the breast tissue microenvironment, the immune landscape, our ability to combat cancers with our own immune system, it's going to take studying the genetics of the disease on a global pattern in order to comprehensively understand all of these hereditary factors that can impact on breast cancer risk.

Brian Lehrer: If you're just joining us, we're talking about the recent American Cancer Society study that found a declining death rate from breast cancer in the United States, but concerningly, an increasing rate of breast cancer among younger women, meaning women under 50, in the United States. We're talking about this with Doctor Lisa Newman, surgical oncologist, chief of the section of breast surgery at New York Presbyterian Weill Cornell Medical Center, and one of the co-authors of that American Cancer Society study. Let's take another phone call. Here's KKathryn in Boston. Kathryn, you're on WNYC. Hello.

Kathryn: Hi. Good morning, and thank you both for having such a timely conversation about this. Just a little bit about my story. I just celebrated my 36th birthday this week, but in June of this year, I was diagnosed with stage two triple-negative breast cancer. At the time of my diagnosis, I was 30 weeks pregnant. Obviously, this was a pretty harrowing thing to hear that I had breast cancer, but also it was just a very scary time, just given that I was also managing a pregnancy at the time, but I was relieved to know that I could receive treatment while I was pregnant because of the nature of my cancer being so aggressive, which is I hear a lot about the word research on your call.

Thanks to the research that's been done in the last 20 years. I knew I could receive chemotherapy safely, and I'm in the middle of my fight. I just crossed the halfway mark of my treatment, and I'll go on to have surgery after that. I think a lot of the things that I hear on this program that I just want to reiterate is for women first to be checking themselves every single month, getting to know their breasts, and understanding what that feels like. I felt my own tumor, and I'm actually high-risk myself. I am a BRCA1 carrier.

I knew I was a BRCA1 carrier before my diagnosis, so I was really all over my screenings, and I had gotten an ultrasound in March just to check my breasts while I was pregnant. Nothing came up, and it really felt like my tumor appeared overnight when I felt it in June. Really advocate for yourself. Take care of yourself. I think you can search. My mother had breast cancer twice. Every woman really, in my side of the family has had it. It's amazing to see how much the treatment and the care has changed in the last 20 to 30 years just because we're understanding the disease.

It's breast cancer awareness month. Everyone is getting sprayed with an opportunity to donate to research. By donating to research, you're really just paying it forward to everyone else who's going to come after us until we finally find a cure for this. I think just stop and take the opportunity to donate to a reputable organization because everything that I'm receiving today is a result of people who've donated to breast cancer research over the last ten years. The treatments are better, the survival rates are better, and I thank everyone who's done that. It's just an opportunity for everyone else to pay it forward. Thank you guys for bringing awareness to this and for this conversation.

Brian Lehrer: Thank you for a wonderful phone call, which I think could help other individuals who might find themselves in a similar position to yours and also to the cause, generally, from what you were saying at the end there. Good luck to you, Kathryn, and to your baby. Alex in West Orange, you're on WNYC. Hello, Alex.

Alex: Hi, Brian. Thanks for taking my call. I just want to reiterate what all these other women have said. I really appreciate you guys covering this topic on the show. I'm at high risk for breast cancer. I have family history. I'm Ashkenazi Jewish. I have dense breast tissue. I've been getting ultrasounds and mammograms, actually, since I was in my early 20s, and I just got an MRI last week for the first time. Luckily, I'm okay. They just want to do a six-month follow-up, but I was hit with a $600 payment and my insurance refused to-- They only wanted to cover part of the cost.

My question is around insurance and how I'm luckily in a position where a $600 credit card payment is not a big deal for me and my family, but there's so many other women that are not in that situation. I don't know if your guest can just speak to any type of advocacy around passing legislation so that if women want to get this imaging, they're not going to go into medical debt as a result of it.

Brian Lehrer: Doctor Newman.

Lisa Newman: Thank you for raising those really important points. Advocacy for on the policy and legislation level is absolutely critical in terms of making sure that women can get screened and monitored appropriately if they have had a breast cancer diagnosis. Now, this month, the governor did sign new legislation for New York state indicating that insurance plans would need to cover screening modalities that the physician deems to be appropriate and based upon national guidelines, and that should make women more easily able to get coverage for studies such as whole breast ultrasound or breast magnetic resonance imaging in addition to mammograms.

It remains true that there's a financial toxicity associated with breast health awareness, breast cancer screening, and breast cancer treatment. We definitely need to advocate as forcefully as possible to make sure that all women can take advantage of the wonderful advances that we've made in screening and treatment.

Brian Lehrer: Alex, thank you for your call. A couple of other things before you go. I noticed that a few people are calling or writing in to ask if alcohol intake increases breast cancer risk. There has been recent research indicating that almost no amount of alcohol consumption, meaning no matter how little, it can increase your risk of various kinds of diseases.

Lisa Newman: Yes, that is a very good point. It is absolutely true that research demonstrates a correlation between increasing rates of alcohol consumption and breast cancer risk. Alcohol can also contribute to other health threats, but it is definitely shown that it contributes to breast cancer risk. Now, I don't think that women should necessarily feel that they have to abstain completely from alcohol. If you want to or need to for other reasons, that's totally fine, but a glass of wine here and there can have some cardiovascular benefits.

It's all about moderation and avoiding excesses. In addition to minimizing alcohol intake, we want women to, who consume a lot of fresh fruits and vegetables and minimize fatty content in their diet, remaining active, avoiding obesity. These are all going to be excellent ways of minimizing the threat of breast cancer.

Brian Lehrer: You mentioned international comparisons before in one context. Is this an area that's been well-studied? I think it's been documented that people in the United States in general have all kinds of what we call chronic diseases, particularly many kinds of cancers, and heart disease, compared to people in other parts of the world that don't live what we consider a western lifestyle with respect to diet in particular.

Lisa Newman: Yes, that is a very important point, Mr. Lehrer. Although we do put a lot of money per capita into healthcare, we don't necessarily reap the benefits in terms of having substantially greater longevity compared to a lot of other countries. As other parts of the world, such as developing nations, start to adopt more of the Americanized, westernized, urbanized lifestyles, we are starting to see dramatically rising breast cancer rates in those other countries.

Brian Lehrer: By the way, you mentioned what Governor Hochul did recently, and my producer looked that up and has just given me something from the governor's press release. I'm going to read this because this is really important and potentially helpful for people to know. It says, this legislation changes parts of the insurance law to require individual, group, and nonprofit, including HMO health insurance plans to cover breast cancer screening and diagnostic imaging. The coverage applies if a doctor recommends it based on nationally recognized clinical guidelines.

The screenings include diagnostic mammograms and breast ultrasounds and MRIs. Just putting that out there in case there's anything else you want to say about that.

Lisa Newman: Thank you so much for reinforcing that message. We do want to disseminate word that, fortunately, in New York State, we are providing more options for women in terms of coverage for these important studies. There is a very unequal availability of insurance coverage for these types of breast imaging modalities in different states. It is important for women to understand the legislation and their own healthcare policies in the state where they live. It is also, I think, important to point out to your audience more comments about the term breast density, which was mentioned by one of your listeners.

It is true that high rates of breast density as reported on a mammogram is relevant for two different reasons. Number one, a lot of density on the mammogram can obscure some of the cancer-related findings that we look for on a mammogram. Many women with a lot of density on that mammogram will require whole breast ultrasound to better evaluate that mammogram, or they might require a breast MRI. Breast density is in and of itself a risk factor for future breast cancer development.

There are regulations on a national basis today that all radiologists have to report on breast density, and so women can get this information from their mammograms, and they can use that information to determine other screening modalities that they may need to take advantage of.

Brian Lehrer: One last thing before you go, I was actually speaking to somebody who works in your field recently who said they would like to move breast cancer awareness month out of October because it's also the season when people are getting flu shots and now COVID shots, which can cause swollen lymph nodes from the normal immune system reaction to a vaccine. Those swollen lymph nodes go away after a few weeks, but they can be mistaken during your breast cancer screening for potential cancer symptoms, and so they cause a lot of unnecessary fear and unnecessary follow-ups. Have you heard this before?

Lisa Newman: That's a really interesting perspective. Now, it is true that particularly with the COVID vaccinations, there can be some confusing findings on ultrasound evaluation of the underarm lymph nodes, in particular, because those underarm lymph nodes or glands can become inflamed. Fortunately, our radiology colleagues who specialize in breast imaging have become very, very skilled at being able to recognize and evaluate the ultrasound images of lymph nodes that are enlarged because of a cancerous problem versus lymph nodes that are enlarged because of a recent vaccination.

They will routinely ask patients about timing of a vaccination relative to the imaging and they will account for this when they're interpreting the studies.

Brian Lehrer: Doctor Lisa Newman, surgical oncologist, chief of the section of breast surgery at New York Presbyterian Weill Cornell Medical Center, and co-author of Breast Cancer Statistics 2024 the report from the American Cancer Society. Thank you so much for joining us. You could tell from the calls how much people appreciated you.

Lisa Newman: Thank you, Mr. Lehrer.

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