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The Dose Transcript for October 24, 2024

Host: Dr. Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome toThe Dose. It's Breast Cancer Awareness Month, and I daresay most women I know are well aware of breast cancer. What they may not be aware of is that the rules on how to check themselves have been changing. So this week we're asking: What can I do to reduce my individual risk of breast cancer? Hi, Mojola. Welcome to The Dose.

DR. MOJOLA OMOLE: Hi, thank you so much for having me.

BRIAN GOLDMAN: How often do you see patients who are totally or somewhat confused about whether or not to do breast self-examination?

DR. MOJOLA OMOLE: I would say most people are confused because we've gotten different messages. And also, you know, we have different cultures, and so not necessarily has the same information been given to everybody. So most people are not exactly sure, you know, what to do with them.

BRIAN GOLDMAN: Which is a perfect reason to do The Dose on this very important question. But before we begin, can you give us a hi, my name is? Tell us what you do and where you do it. Just ad-lib.

DR. MOJOLA OMOLE: Hi, my name is Dr. Mojola Omole. Most people call me Jola. I'm a breast surgical oncologist and a general surgeon at Scarborough Health Network in Scarborough, Ontario.

BRIAN GOLDMAN: Okay, let's start with the basics. What is a breast self-exam?

DR. MOJOLA OMOLE: A breast self-exam is simple in the sense of it is when you check the breast tissue, but also when you check underneath the armpit. Because that is all part of the self-exam. It involves you looking and feeling.

BRIAN GOLDMAN: So you've started to give the answers of what it's supposed to provide. You've got to get to know what your breasts look like and feel like so that you can observe for changes.

DR. MOJOLA OMOLE: Exactly. Yeah.

BRIAN GOLDMAN: So how effective is a breast self-examination as a measure of breast health?

DR. MOJOLA OMOLE: So as a measure of breast health, there is no studies have been done regarding that. I do think it's important. I think it's important that we all destigmatize and also desexualize breasts. Like, they are an organ. People check to make sure that their blood pressure is normal. You should also check to see if your breast is normal and not necessarily just view it as a sexual organ. There is no data that shows, when it comes to breast cancer, it changes your outcome with that. I like to talk -- it's because I talk to students. I'm like, it's just a way for you to become more comfortable with yourself. So therefore you will feel open to actually go to your primary care practitioner and be like, um, this doesn't feel normal. Because I do think that oftentimes, because of the way we view breasts as a sexual organ, people just, they're ashamed to talk about it. I do think it's a way to also normalize people being able to talk about it. I talk to young people so they can talk to their aunts and they can talk to their moms, you know, other people in their-- the adults in their family, so that they could also be aware of checking their breasts. Because a lot of people also are very scared of doing mammograms and they're scared of finding something. So the more we normalize breasts, the more people will be forthcoming if they see something or feel something that's off.

BRIAN GOLDMAN: Let's go into the science a little bit. Let's unpack why it is that the breast self-exam has been called into question.

DR. MOJOLA OMOLE: There have been some studies that have looked at it, and it's not shown to change your overall survival. Mainly because what changes your overall survival is, when do you detect the breast cancer? The caveat I would put with those studies, though, is that it doesn't look necessarily at a diverse population. A lot of it is just based on retrospective studies. Many patients that I see -- I deal with a younger population and a racialized population -- they found the breast cancer themselves.

BRIAN GOLDMAN: So clearly there is some value in being self-aware and checking yourself.

DR. MOJOLA OMOLE: 100%. And let's be honest that, you know, when we look at Canada, especially in Ontario and Alberta, there is a lack of family practitioners. For many people, even being able to access, let's say, a mammogram or to see a physician in a timely manner, is not the same as it was, you know, maybe 30 years ago or even ten years ago.

BRIAN GOLDMAN: There's a big clinical point here that pertains to the studies that's worth emphasizing. When doctors say that systematic, routine, regular breast self-examination doesn't save lives, what they're talking about is every woman doing it, no matter what, at a prescribed interval. But there's a world of difference between that and feeling your own breasts and noticing a lump.

DR. MOJOLA OMOLE: Exactly.

BRIAN GOLDMAN: Are there groups of women for which the old guidelines may still be valid?

DR. MOJOLA OMOLE: Yeah, for sure. And I would say younger people, also. Racialized women tend to have, the studies have shown... in the U.K. and the U.S. have shown that they present at an earlier age. At an age where, up until last month in Ontario, you can have mammograms. And so for this population, I actually think it's very important. Because we know when you present at a younger age with breast cancer, you tend to have more aggressive tumors and it tends to be worse. And also, just anecdotally, what I've noticed is that, you know, growing up, lots of people have, you know, cysts and fibroadenomas and just other benign things in their breast. And then during pregnancy, they just think, oh, it's the same one. Right? But sometimes you can have breast cancer in pregnancy. So that's why I always say, you know, if you feel anything that feels different, even if you think, well, maybe it's not different, it's just best to get it checked out, get an ultrasound, just to make sure.

BRIAN GOLDMAN: Describe how to do a proper breast self-examination.

DR. MOJOLA OMOLE: Great to do over an audio medium. What I tell my patients is that, pick a time, you know, when you're done-- if you're still menstruating, when you're done your menstruation. If you're not, pick your favourite day of the week and do it the same day every month. Stand in front of a mirror with the hand-- your hand over your head. And then the opposite hand, pretending your breast is a clock, we'll then start at 12 o'clock. You can go counterclockwise, you can go clockwise. Just do the same thing each time. And you start all the way from the outside and then work your way in, feeling just slightly. And then the second time you go a little bit deeper to feel. Before this, you should also look to see if there's any skin changes. Oftentimes when we talk about skin changes and breast cancer, we're talking about lighter skinned people. And we say that, oh, you know, you might notice some redness. If you're darker-toned you won't notice redness, but you might notice like a ruddiness, like a change in the skin tone. Also, it's important to know that you might also notice something called peau d'orange, which is basically like the skin of the orange. And so that kind of, like, dimpling on the skin. So you look for that. And then after you check the breast, you check underneath the armpit. If you're someone who has larger... I always call them 'grandma boobs' that hang a little bit more, make sure to lift underneath to check underneath it there to make sure there's nothing there also.

BRIAN GOLDMAN: We know that breast density affects a mammogram in dramatic ways. Does breast density in any way affect the ability to detect cancers on our breast self-examination?

DR. MOJOLA OMOLE: I would say that it does, because in the sense of, everything feels lumpy when you have a dense breast. You know, it's just because you just have a lot more breast tissue. And so oftentimes people would think, oh, you know, that's just normal, and not think that that something is new. But if you're checking something over time, like over two, three months, you'll have a better idea. You'll be like, you know what? Yeah, this doesn't feel the same as it felt last month. And that hopefully could be the impetus for you to go and see a primary care practitioner.

BRIAN GOLDMAN: You are the breast surgical oncologist among us. Who should be doing a breast self-exam?

DR. MOJOLA OMOLE: Anyone who has breasts. It's also important to know that those who are cisgendered males also can get breast cancer. If you have a family history of breast cancer, ovarian cancer and prostate cancer, there could be a gene that increases your risk, and that gene could increase the risk of those who are cisgendered males to have breast cancer. So, all of those people should also do a breast self-exam.

BRIAN GOLDMAN: How small a size cancer can you detect with a breast self-examination, say, compared to a mammogram?

DR. MOJOLA OMOLE: So for you to detect breast cancer by physical examination, it usually has to be around two centimetres in size. That said, some people can detect it smaller, but most of the time it's two centimetres. For it to be picked up on an ultrasound, usually around one centimetre. And then mammographically, we're picking up clusters of, you know, calcium deposits, which show us that cells are turning over fast, which is a signal of something abnormal happening in the breast.

BRIAN GOLDMAN: If you have implants, can you detect a change.

DR. MOJOLA OMOLE: 100%, yeah. Most breast implants are inserted beneath the muscle. Some now can be in the breast. But you can 100% still detect an abnormality, both with physical exam and also with imaging.

BRIAN GOLDMAN: Turning more generically, what else can women do to reduce their risk of breast cancer?

DR. MOJOLA OMOLE: So in terms of reducing risk, major one is smoking. Smoking increases your risk highly, probably close to the level of genetic risk. And so it's really important that if you smoke -- vaping also counts as smoking -- that you should look into stopping smoking to help reduce your risk of breast cancer. The other one that has been linked is the amount of alcohol you consume. Consuming more than three units of alcoholic beverages a week increases your risk of breast cancer. Knowing your family history, just so you know whether or not you have a genetic risk factor for breast cancer. So, you know, talking openly to your family about family risk of breast cancer. Ovarian, prostate, pancreatic -- those ones kind of cluster together for a gene. Also doing daily exercise. People like to say, well, you know, it's body mass. But I actually think it's more about just movement. Movement is medicine, so making sure that you're vigorously walking 30 to 45 minutes every day is important for your overall health, but also does reduce your risk of breast cancer.

BRIAN GOLDMAN: What breast symptoms and signs should prompt a visit to your primary care provider?

DR. MOJOLA OMOLE: So any changes to the skin that you notice. Any new lumps that you see in the breast and also underneath your armpit. All of those things are things that you should draw attention to your primary care.

BRIAN GOLDMAN: Are there special issues and challenges that are faced by marginalized and racialized women who are seeking breast health care?

DR. MOJOLA OMOLE: I would say that one of the major ones is that neighbourhoods and areas where there is already systemic barriers to health, also have a lack of primary care practitioners. So, you know, our primary care practitioners are literally the backbone of our health-care system. And the way that most provincial governments are funding them has become an issue, and it disproportionately affects those who are racialized, marginalized. Whether it's because of being unhoused, whether it is because of, you know, ethnicity, refugee status. So that, I think, is one of the biggest barriers to it. And I think there's other systemic issues that, you know, have to do with bias. But really, it's just actually being able to see somebody. You know, it's hard to go to a walk-in clinic saying, oh, I think there's something wrong with my breast. But not having primary care, I think is the biggest barrier.

BRIAN GOLDMAN: And, you know, there are many provinces in which you can't even get a mammogram unless you've got a primary care provider who's referring you.

DR. MOJOLA OMOLE: For sure. Yeah.

BRIAN GOLDMAN: I would say... I wonder if you would agree with this, that one of the other barriers is a lack of awareness and recognition by health-care providers that there are certain subgroups -- for instance, racialized women -- who would be at greater risk of more serious forms of breast cancer at a younger age.

DR. MOJOLA OMOLE: Yes, I do think that, you know, that is it. I try not to... I don't necessarily put the onus squarely on our colleagues. We don't teach these things in medical training or in postgraduate medical training. However, you know, and I think this is really important in Canada. Because we don't talk about these topics, the fact that there are differences based on ethnicity, it's just not widely known. You know, certain groups present younger, certain groups present with more aggressive disease. And so, like I say, if you have someone who is... Race is a social construct, but genetic variation does exist in different parts of the world. So people from West Africa are very different than East African in terms of breast cancer. So it's important to have that conversation if you have patients who originate from West Africa, which will include those who are from the Caribbean because of the transatlantic slave trade. You should have conversations with them regarding breast cancer very early on, probably in their early 30s, about, okay, what is your family history? Do you know your family history? Do you have any questions? Even just engaging in those conversations is the starting point that, you know, you can talk about screening at an earlier age for them.

BRIAN GOLDMAN: And where do you go if you're worried and you don't have a primary care provider?

DR. MOJOLA OMOLE: That is a tough question. I always say... And you're an emerg doc, so. I would say -- this is terrible -- emergency departments at centres who have breast diagnostic assessment centres are great. You know, I get referrals because someone comes in and they're like, you know what? They just refer them to the breast diagnostic centre. And usually I see them within a day or two. They just, you know, plug them in. And that allows them to actually get the workup that they need. Is this a waste of our system because we're clogging up the emerg? 100%. However, I have to look at it from the individual person. I always say, you know, it's good to go to... obviously, because I work at Scarborough, Scarborough. Mount Sinai, Women's College, Michael Guerin. All of these that have diag-- I'm also very Toronto-centric, because that's where I live. But if a place has a breast diagnostic centre, it's best to go there.

BRIAN GOLDMAN: I'll tell you that I made just such a referral last week.

DR. MOJOLA OMOLE: Yeah.

BRIAN GOLDMAN: It's not like it doesn't happen. And certainly, you know, I think the take-home message for people listening to us is if you're worried and you haven't got a primary care provider, if you have no other option, please do go to the emergency department. Because we do have pathways, particularly for examination of breast lumps, to do biopsies, ultrasounds, etc., to see if they're abscesses or if, or heaven forbid, if they're cancers.

DR. MOJOLA OMOLE: Yes, 100%.

BRIAN GOLDMAN: The issue is controversial. We've done a lot of shows on White Coat, Black Art, on our sister show, on this very subject. But when can you start getting regular screening for breast cancer?

DR. MOJOLA OMOLE: B.C. was, British Columbia was way ahead of its time. They have been 40 for a few years now that you can start getting mammograms without needing to have a referring physician. Alberta is 45. Ontario recently has become 40. The middle Prairies are still 50, as of the age. The Maritimes are still 50, and Quebec is Quebec. I think 50 still. And I do think that other provinces would also be working towards, you know, pushing the legislation to make sure that people can start having regular mammograms at the age of 40.

BRIAN GOLDMAN: And if in doubt, check in the province in which you live. You can probably find it on the website of the provincial cancer agency. Is it fair to say, Jola, that the current guidelines don't take into account that Canada's population is a lot more diverse than it used to be?

DR. MOJOLA OMOLE: I would say that it's extremely fair to say, and that's probably why the majority of us who are in breast cancer are not in favour of the Preventive Task Force recommendations. They themselves recognize that these groups have different incidences, different outcomes, however, that there's not enough data. But I'm like, but we don't collect the data. So, if-- Like, you won't see it. If you're waiting on data, you've got to first collect the data. But we have data from the U.K. which has a similar system to us, and that does show that -- and in the U.S. -- that, you know, women who are from African diaspora -- so Black women, Hispanic women and Asian women, and Indigenous women -- present at a younger age with more aggressive disease, and do worse with their breast cancer.

BRIAN GOLDMAN: Well, Dr. Jola Omole, thank you so much for coming on to The Dose to discuss breast cancer awareness and self-examination and other things in this month of breast cancer awareness.

DR. MOJOLA OMOLE: Thank you so much for having me.

BRIAN GOLDMAN: Dr. Mojola Omole is a general surgeon and breast surgical oncologist at the Scarborough Health Network and the president of the Black Physicians Association of Ontario. Here's your dose of smart advice: Breast cancer is the second most common cancer in Canada. One in eight women are expected to develop the disease eventually. Doctors used to recommend that all women do periodic breast self-examination to detect cancers early. That blanket recommendation has fallen out of favour because of research that shows that regular breast self-examination as a universal recommendation does not reduce mortality across all populations. That does not mean that you should ignore symptoms that could mean breast cancer. Many breast problems are first discovered at home. These include breast lumps, sores, redness, unusual discharge from your nipples, as well as a change in the outward appearance or shape of the breast. Lumps are not always due to cancer. Other causes include infections and other benign causes, such as fibroadenomas. The newer concept these days is called breast self-awareness. It means being aware of how your breasts normally look and feel so you're quick to notice any changes. It means feeling your breasts to check for lumps and areas that cause pain when you touch them. It also means checking for those other symptoms I mentioned, such as redness or a change in the shape of your breasts. How you do this and how often is up to you. The best time to check your breasts is one week after your menstrual period starts. That's because your breasts are less likely at that time to be swollen or tender. If you don't have periods, you can check them at any time. Talk to your doctor if you have concerns or notice changes. Depending on your age, regular mammograms or breast exams by your health-care provider may be recommended. Some of these age-related recommendations differ depending on where you live, so check with your health-care provider or provincial cancer agency. There are lots of things you can do to reduce your risk of getting breast cancer. These include maintaining a healthy body weight, staying physically active, reducing alcohol intake and quitting smoking. If you take birth control or hormone replacement therapy, discuss with your health-care provider how that may also affect your risk. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you like this episode, please give us a rating and review wherever you get your podcasts. This edition of The Dose was produced by Sameer Chhabra. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health-care provider. I'm Dr. Brian Goldman. Until your next dose.

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What can I do to reduce my individual risk of breast cancer? - Transcript

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