Moffitt Cancer Center's Cancer in our Community podcast focused this October on the impact of breast cancer in the Black and African American communities. In honor of Breast Cancer Awareness month, this second episode in the series features Dr. Iman Washington. Tune in to hear from the experts working to create health equity.
Welcome back to Cancer in our Community, a podcast brought to you by the Office of Community Outreach, Engagement and Equity at Moffitt Cancer Center and made possible by a generous gift from Dr. Michael Vogelbaum and Ms. Judith Rosman via the TOP Jewish Foundation.
This episode was recorded for the month of October which is nationally recognized as Breast Cancer Awareness month.
In 2020 the American Association for Cancer Research released the “Cancer Disparities Progress Report,” in which they describe how:
Black women are 40% more likely to die from breast cancer compared with White women. Which may be a reflection of how:
- Black women are more likely to be diagnosed at a later stage of disease when treatment is less likely to be successful.
- They are more likely to be diagnosed with triple-negative breast cancer, a more aggressive form.
- Systemic racism on delivery of cancer care results in Black women being more likely to receive incomplete treatment for breast cancer.
To discuss some of these disparities and the research being done to address them, for this episode we had the great pleasure of speaking with physician and breast cancer specialist Dr. Iman Washington.
Dr. Blue: Hello, and welcome to another episode of Cancer in our Community where we're having conversations about Black health equity. My name is Dr. Brandon Blue. I'm an oncologist in Malignant Hematology at Moffitt Cancer Center and I am your podcast host.
Today I have the great pleasure of speaking with one of my colleagues and friends here at Moffitt, Dr. Iman Washington. Welcome to the podcast. How are you doing?
Dr. Washington: I'm good. I'm good. Thanks for having me.
Dr. Blue: Wonderful. It's good to hear that. And, before we begin, I want to tell the audience a little bit about your background. So, for those that don't know, Dr. Washington received her medical degree from Duke University School of Medicine and completed her prelim year of residency at Northwestern in Chicago.
She completed her radiation oncology residency at the Ohio State University Wexner Medical Center in Columbus, Ohio. Dr. Washington is now an assistant member in radiation oncology at the Moffitt Breast Program. Finally, she has also been engaged in the visual arts since adolescence and still enjoys painting with acrylics.
We invited Dr. Washington here today because of her expertise in breast cancer. And of course this is Breast Cancer Awareness Month. So we really want to make sure we focus on breast cancer.
All right. Question number one, Dr. Washington, could you just begin by telling us briefly, what are some things that we know about breast cancer as it arises? What's important for the Black community, especially Black women to know about breast cancer.
Dr. Washington: Yeah. So I think it's kind of helpful to understand what we know about where breast cancer arises in the body. So specifically kind of background in anatomy I think is helpful. So the breast is made of fibro-glandular tissue.
So there's a structural part and then there is the portion that's made up of and lobes where milk is produced and the ducts are tubes that carry the milk to the nipple. So breast cancer arises in the ducts or the lobules. We don't know exactly how it develops. That's something that research is investigating.
However, we know that there are several risk factors related to the development of breast cancer. So there are some major risk factors like genetic mutations the BRCA mutation for instance is the highest risk and probably the one that people are most familiar with. But there are also environmental factors and other biological factors or behavioral factors that have been implicated in increasing the risk of breast cancer.
So that's anything from factors that increase a woman's lifetime exposure to estrogen. So that has to do with age at menopause or when they get their period. There's modest risks associated with that. Obesity has been implicated as estrogen can be made in adipose tissue. And that's more where estrogen comes from in post-menopausal women for instance.
Smoking, alcohol are factors as well. A main risk factor is just age. So as women get older, they're more likely to get breast cancer. Most breast cancers are diagnosed in women over the age of 50. And one in eight women in their lifetime in the U.S. will be affected by breast cancer.
So as far as Black women specifically, there are higher rates of more aggressive types of breast cancer in the Black community. So there's something called triple negative breast cancer where the tumors don't recognize estrogen or progesterone and they're HER2 negative. So these are all terms that help us to describe the cancer and help us determine what some of the best treatment for the cancer would be.
There's another aggressive type of breast cancer called inflammatory breast cancer and Black women are more likely to be diagnosed with that. So there's the aspect of what kinds of breast cancer there's a disparity in when it comes to Black women. Being diagnosed at a younger age is also a factor.
So it's really important for Black women to be aware of these risks so that they can undergo appropriate screening and be aware of when to see their doctor and when to undergo an appropriate screening, which may be at an earlier age, depending on their overall risks.
Dr. Blue: So from what I know about this mutation that you just brought up, you know, I know Angelina Jolie kind of made that very popular this B-R-C-A or [pronounced] "BRACA" mutation. But can you tell the people, just for those who weren't aware of that, is this something that like, if your mom has it, if your grandma has it, if your great, great grandma has it, sister has like, like who in your family would have breast cancer that you would be worried about something like this?
Or how should people move if they know that there's a family member or somebody affected? Can you just educate the people and let them know?
Dr. Washington: So the main risks are going to be related to first degree relatives. So that's your, you know, your mother, your sister, your daughter. If there are multiple family members on one side of the family that have breast cancer that's also increased familial risk of breast cancer and women in that setting should talk to their physician about genetic testing. And if they are candidates for or appropriate for earlier screening.
Dr. Blue: So what I hear you saying is that if someone is diagnosed with breast cancer specifically, they should probably tell other members of the family because it possibly could help them.
Dr. Washington: Yeah. Yeah.
Dr. Blue: Good.
You know one of the other things that you brought up were some of the factors that potentially could make breast cancer worse, like I know you said obesity and smoking and some of those things. Do you typically recommend people when they get diagnosed to stop those things? Or do they say? "Well, I got the cancer might as well keep going." Or like if they lose weight or if they stop smoking, could that help them at all?
Dr. Washington: Yeah. So women are going to have better outcomes, if they're smoking, to stop smoking, even after you've been diagnosed with breast cancer women have better outcomes when they engage in regular exercise.
So I talk to my patients, you know, even after treatment about regular exercise and alcohol consumption. There are recommendations for limiting that to, you know, no more than, on the high end, would be one drink a day. And that's important for overall risk as well. And it's important to remember we talk about even after women have been diagnosed and treated for breast cancer to engage in healthy living and continue with routine screening for other cancers. To improve how they do overall.
Dr. Blue: Yeah. Something that I think you would be the excellent person to really help clarify for the audience is, when we hear the word cancer, there's so many different things that come to our mind. One of those things being chemotherapy, you know, another of those things being radiation, but to be honest, I don't think we really have a good idea of like, what is radiation? And in your field, you are a radiation oncologist.
Could you tell the people, what is radiation? Are you going to zap them or something? What's happening there?
Dr. Washington: Like you were kind of alluding to, there's three types of oncologists. I kind of put it in categories. Right? So you have your surgical oncologist who is going to talk to you about removing the tumor. Medical oncology uses medication for the treatment of cancer [like chemotherapy]. And radiation oncology uses radiation therapy.
So most patients with breast cancer are treated with the kind of radiation, just like if they were to go for a chest x-ray. It doesn't hurt to get radiation. They're not going to be radioactive. A question that I get very, fairly commonly is, "Can I still be around my family? Can I pick up my grandkids?"
And, and all of that is fine. All of that is fine. So radiation is directed at an area of interest for breast cancer. We're typically talking about treating microscopic disease after they've undergone surgery, and there are certain settings where that doesn't apply, but for women who are undergoing curative therapy that's what we're doing.
Dr. Blue: There's so many myths and kind of, I think misunderstandings about radiation. Could you maybe give us a couple, like positives and negatives, like, Hey, these are some positive things potentially why radiation actually might help. And then maybe, you know, this might be some of the side effects. So if you are a person going through radiation, Hey, these are some things to watch out for.
Dr. Washington: Yeah, radiation helps to reduce the risk of the cancer coming back for women who are undergoing curative therapy for their breast cancer. When you reduce the risk of cancer coming back, that can improve other breast cancer outcomes.
So they may have lower risk of the cancer showing up anywhere or live longer because of their radiation therapy. So that's the case for most women, particularly women before they get into elderly age, where it improves their overall survival after a lumpectomy and reduces the risk of the cancer coming back.
In terms of potential side effects of treatment. So one thing that I like to remind patients of is it's important for them to have a conversation with their radiation oncologist about their case in particular. Because depending on what the treatment is that will kind of depend on, what their side effects may be. And it's also important to remember that radiation is a local regional therapy. So side effects are all related to what's nearby.
So they can't extrapolate what someone who is undergoing a head and neck radiation, what their side effects are, or if they're going undergoing radiation to their pelvis, they're completely different. So for breast cancer, if say we're just treating the breast after a lumpectomy, which is just an excision of the tumor in the breast and keeping the rest of the breast, the main side effects are going to be fatigue or having a reduction in energy, skin irritation and feeling achy or tender in the breast. That's going to be it for the most part. So most women are kept comfortable with over the counter pain medications, if they need it like Advil or Tylenol and skincare. So I ask women to moisturize, you know, three to four times a day in the area that we're treating. And women do well with that treatment.
Dr. Blue: One of the common things or questions that I get a lot of times is, you know the appearance of the breasts. So does radiation change the appearance of the breast?
Dr. Washington: Yeah. Yeah, it certainly can. So the main things in terms of appearance, so radiation can cause a. So if you tan to the sun, you're more likely to tan to the radiation therapy. It doesn't have to do with whether you burn to the sun or not. The tan after treatment fades with time, but may not go away completely. So patients can have a residual tan that tends to be faint or mild for most patients by the time we get to a year.
The texture of the breast can change. So it can feel different than the other side. So it can feel thicker, doughier or firmer. It can get a little smaller, sit a little higher, look a little fuller. Those kinds of changes.
When we look at studies that have evaluated, what's the cosmetic outcome or the appearance of the breasts after whole breast radiation therapy, for instance, about 85% of women will have good or excellent cosmetic outcome.
Now there are, for women who have low-risk early stage estrogen receptor-positive breast cancer, they may be eligible for just treating part of the breast after a lumpectomy, which is called partial breast radiation. And there are less cosmetic side effects to some of those treatments.
Dr. Blue: Okay, perfect.
So, you know, you've told us a lot about kind of what you do in your day to day job as a doctor, but as you know there are so many disparities with Black women and with breast cancer in general. One of the ways that we improve those disparities is through research.
And so, we'd like to know, are you involved in any research at all? And if so, what kinds of things are you doing help us out?
Dr. Washington: So, one project that I've started is looking at women with triple negative breast cancer that have tissue samples that have been genomically profiled and using their data for their local-regional recurrence, or the likelihood that the cancer comes back in the same breast or the regional lymph nodes associated with the breast. And looking at White and Black women in that study. So it was a very small study, but we did see that Black women had a higher local-regional recurrence risk and that there were genes that were expressed differently associated with that risk between Black and White women. So, it's something that I'm looking forward to exploring further in a larger patient population.
It's unclear how genetics interact with environmental and other biologic factors.
Dr. Blue: We call that nature versus nurture.
Dr. Washington: Yeah. And so kind of exploring that further, I think, is gonna be something that's important for the Black community, in terms of understanding risk of breast cancer further.
Dr. Blue: You know, one thing when we always bring up research, one of the important things that we think about is what they call clinical trials.
Are there any clinical trials that you know about, maybe even here at Moffitt, that would potentially help patients with breast cancer.
Dr. Washington: We have a lot of clinical trials in the Breast Department. One trial that I'm involved in leading at Moffitt, that's a national trial is a de-escalation study. So basically what that means is, what are the clinical situations where we can do less radiation or omit radiation entirely and still have good outcomes. So there are women with estrogen receptor positive disease that have one to three [positive] lymph nodes. There's a lot of data suggesting that these women benefit from radiation, but there's a group of women who may have a very low recurrence risk without radiation.
So this study is looking at randomizing women between the standard arm which is getting radiation, per standard of care. And the investigational arm is reducing radiation therapy. So a randomized controlled trial just means that I don't choose as a physician and the patient doesn't choose which treatment group they're in, but it's decided kind of randomly so that it's fair to everyone enrolled and is equally distributed amongst the patients.
Dr. Blue: So, if someone listening either has breast cancer themselves, their loved one may have breast cancer and they say, Hey, that might be a clinical trial that I'm interested in, or maybe even other research that they want to make sure that they improve breast cancer for other people. How would they know about that? Or how would they get involved? Or can you give us some information and for the listeners if they're interested?
Dr. Washington: Yeah. So it's always appropriate to come in for a consultation or an opinion when talking to your physician, asking if there's any clinical trials that would be appropriate for you. It's also something that we bring up in our tumor boards, or the multidisciplinary discussions of more difficult cases, where we discuss clinical trials in patients that may be well-suited for that.
Dr. Blue: Now, I appreciate you giving us that information. And, you know, clinical trials are very important to make breast cancer, really any cancer better. But I know a lot of people are a little bit hesitant about actually being enrolled in clinical trials.
You know, we hear the [terms] guinea pig a lot and experimentation, and we like to protect people from those kind of things. And so, do you know if there's any kind of safe guards in place to kind of make sure that, Hey, if a woman is involved in this breast cancer trial, that we actually have her best interests at heart and we really won't be, you know, exposing her unnecessarily.
Dr. Washington: Yeah. So one thing that I like to do is explain what the standard of care is, what treatment off of a trial looks like, and where there are gaps in knowledge, where we think that treatment could be better, but we need to do a study in order to prove that essentially. We always think that what we're offering on a trial, we're hopeful, that it's better or it's the same with less side effects or, you know, improves care in some other way. There are a lot of people involved in emphasizing what needs to be in place, in order to make sure patients are safe and that there is not more risk to them than would be acceptable.
There are boards of people who review trials at Moffitt, and in a greater sense for national trials, to make sure that safety is of paramount concern. Patients are watched very closely on trials and often even more closely than when they're off trials as well, so that's also something that's important and in place.
Dr. Blue: Yeah. So what I hear you saying is that having empathetic doctors like yourself, having a lot of rules in place are really some of the kind of foundations that really makes research safe. Is that right?
Dr. Washington: Yeah.
Dr. Blue: Wonderful. Wonderful. So I wanted to just say, thanks for taking the time out, for joining us today. I know you have a busy schedule.
But before we let you go, before we end the podcast, we wanted to talk to some like practical advice, some stuff that people can kind of take home. So in this case with breast cancer let's talk about screening, for example because, kind of on the forefront of people's minds, people hear about it in commercials and those kinds of things.
Can you tell us about breast cancer screening, like who should be screened and when, and does that matter if you're Black or White? Can you give us any kind of information?
Dr. Washington: So generally speaking, women should start screening with annual mammograms at the age of 40. It's encouraged for women to talk to their physician at the age of 30 or so about what their risk is and are they of higher risk and should start screening earlier. Black women are considered higher risk and should have those conversations to see if that would be appropriate. Patients with certain genetic mutations like BRCA undergo earlier screening. And that may include a breast MRI in addition to a mammogram, for instance.
There are also nomograms that can be used, which essentially is utilizing different aspects of patient health history to calculate what their lifetime risk of breast cancer is. And if the lifetime risk of breast cancer is greater than 20% they should consider earlier screening for instance.
Dr. Blue: As a minority woman yourself, how would you talk to your family members? You know, your cousins, your sisters, your aunts, like, how would you advise them on getting breast cancer screening?
Dr. Washington: Yeah. So, you know, I ask them if they have been screened, right? And inform them, if there's any, you know, lack of understanding of exactly why we do screening.
So, less women are dying from breast cancer now than they were decades ago in part because the implementation of screening and catching breast cancer early. So when we catch it early, women do very well with their treatment and they often require less treatment than if it's caught later. And the risks related to screening are small and the benefits are big.
Dr. Blue: Now, excuse my ignorance on this. But you mentioned the way that we screen is through a mammogram. I'm not really sure what that is. Can you just help the listeners to say, like, what is a mammogram?
Dr. Washington: Yeah. So so a mammogram is where you're having essentially an image taken of the breast tissue.
And it allows us...
Dr. Blue: So a mammogram is not surgery.
Dr. Washington: Mammogram is not surgery. So it's completely non-invasive and it gives a detailed image of the breast tissue and allows us to look for anything that may be abnormal.
Dr. Blue: So where do people get these mammograms? Like, is this something that they ask a primary doctor for? Do they have to come to Moffitt for this? Where, where can people get these done?
Dr. Washington: So there's a lot of places to get mammograms done. Yes, at Moffitt, or at general imaging centers, they don't have to be at a cancer center, and their primary care physician can write them for a script to go get a mammogram. They don't have to see a cancer doctor or anything like that.
Dr. Blue: You know, one of the cool things that I see is that they actually have these mobile mammogram vans that go around, like I saw one at the Bucs football game one time when I was there. And so, sometimes the mammogram will come to you! So I think that's really awesome.
So, you know, we're talking about breast cancer and screening, and those things are very important, but you know, I think for the people at home, one thing that is very confusing is, should they give themselves breast exams? Do they not give themselves breast exams? If they should do it, when should they do it? Or maybe not at all.
So being a breast cancer expert, give us your advice.
Dr. Washington: So I think the good thing about doing breast exams is that it allows women to get comfortable with what's normal when it comes to their breasts. So breast exams are often done at their annual appointments with their primary care physician.
But when they're doing breast exams themselves, if they find anything abnormal then it allows them to, you know, follow up with their physician sooner to get that checked out. So that's a benefit of doing breast exams.
Dr. Blue: And when should people do it? Should they do it in the shower or just when they're getting dressed? Or does it matter? Or should they be laying in a certain position? How do women do those things?
Dr. Washington: So it varies on where they're comfortable. A lot of women do it in the shower or when they're moisturizing or they just pick a time, you know, once a month or so to do breast exams. So there's not kind of a right and wrong way to do it. It's really getting comfortable with what's normal for your breasts.
Dr. Blue: All right. So no right and wrong way to do it, as long as you do it, you feel comfortable, you know, what's normal for your breasts. So as soon as you feel something abnormal, Hey, let me tell my doctor. I feel something, not sure what it is, but let's get it checked out.
Dr. Washington: Yeah.
Dr. Blue: Wonderful.
Dr. Washington: And some women have lumpier breasts and, you know, they have changes in their breasts that fluctuate with their menstrual cycle and that sort of thing. And so, something that is persistently different, they should talk to their physician about.
Dr. Blue: Yeah, probably even more so a reason to say like, Hey, I know that this time of month, I should be feeling this, but I'm feeling something different. Or, you know, I know what's normal for me, and clearly this is something abnormal. For sure, I think that's definitely something that hopefully the people at home listening can pay attention to.
Do you have any final thoughts? We really appreciate your time today, but is there anything that you wanted to leave our listeners with as a final thought?
Dr. Washington: Breast cancer is the most common cancer in women, so I just think it’s really important for women to understand what they can do to be proactive. And Black women in particular should know, we’re now considered to be a higher risk group and that’s related to higher rates of breast cancer related deaths, being more likely to be diagnosed with more aggressive breast cancer, so early detection of breast cancer is very important. And it’s important to understand that when breast cancer is found early, it’s easier to treat successfully and often requiring less therapy, so I strongly recommend that women do their annual breast cancer screening. Most women should start getting annual mammograms at 40, but some women are at higher risk than average and may benefit from additional testing or earlier screening. So women should talk to their doctor by age of 30 about their individual risk and see if they may benefit from other screening recommendations. And along with their screening imaging, women can engage in healthy habits to help reduce the risk of breast cancer. So that would be staying physically active with regular exercise of moderate or high intensity, eating a well balanced diet, maintaining a healthy weight, limiting alcohol, and refraining from smoking. So get your screening imaging, and do your best to make healthy lifestyle choices.
Dr. Blue: Well I know, I learned a lot today. I really appreciate your time and we really appreciate you for joining us today. Thank you so much. And again, like I said, we want to do this for breast cancer awareness month. And so everyone out there who is listening, please make sure that you are screened for breast cancer. And if not we hopefully will have taught you something today of why it's so important and please share this with your family members and we appreciate your time.
Dr. Washington: Thank you.
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