S2E3 | Managing cancer risk: Screening and prevention
S2E3 | Managing cancer risk: Screening and prevention
For Marnee Spierer, MD, fighting breast cancer is more than a job. It’s also a family legacy that’s impacted at least three generations of the women in her family. So, when her sister became the latest to be diagnosed with the disease, Dr. Spierer—Radiation Oncologist and Chief of Staff and Chief of Radiation Oncology at Cancer Treatment Centers of America® (CTCA), Phoenix—was faced with some very personal decisions. In today’s episode of Focus on Cancer, Dr. Spierer joins our host, Pat Basu, MD, MBA, President and CEO of CTCA®, to talk about her experience with genetic testing and counseling, what led her to decide to undergo a prophylactic mastectomy and learning firsthand—as an oncologist and a woman—about the importance of managing your risk of cancer.
Marnee Spierer, MDChief of Staff & Chief of Radiation Oncology, CTCA Phoenix
Dr. Pat Basu: Hi, I'm Dr. Pat Basu, president and CEO of Cancer Treatment Centers of America and the host of Focus on Cancer. I am just so delighted for today's episode because we're going to welcome Dr. Marnee Spierer on as our guest on the show today. Dr. Spierer is a world- renowned breast cancer doctor who has unbelievable experience and things to share around breast cancer screening and breast cancer treatment. But she just underwent a very big and bold decision herself to prevent her future risk of breast cancer, and just a really powerful story that I want her to share with all of you. So Dr. Spierer, thank you so much for taking time to be here and share your story with us.
Dr. Marnee Spierer: Hi, Pat, and hi, everyone. Thanks so much for having me. And yes, I'm quite open with my story, and I hope that by the end of our time together, I'll be able to communicate just kind of the bigger picture and the broader picture about screening and prevention and risk. For me, personally, like you said, I'm a breast cancer doctor, so it is not only my passion, or I should say, it's not only my profession, but it's my passion. And I love taking care of breast cancer patients, and I have been doing that for at least two decades now. And so, the irony is that I come from a family of potential breast cancer risk. So my grandma on my mom's side, who was this extraordinarily healthy, active, exercised before it was trendy to exercise, was diagnosed and died of an unknown female cancer when I was young. And then my aunt, so her daughter, my mom's older sister, was diagnosed with breast cancer in her forties. And she ultimately died from it in her fifties, so far too young. I watched the emotional toll that that took on my family. So between those two events, becoming a breast cancer doctor was somewhat natural for me. And then the irony of irony, that last year, my older sister was diagnosed with breast cancer, so for me, specifically, it became personal. I love being on this side of the doctor- patient relationship. I like being on the doctor side. And so, yes, just last month, I underwent bilateral prophylactic mastectomies, which means I had my breasts removed in order to reduce my risk of breast cancer.
Dr. Pat Basu: Wow. Well, thank you so much for sharing that story, and I want to get a little bit deeper into it. But again, I'm so sorry to hear about the way in which breast cancer has affected your family, and certainly, probably influenced your decision to becoming a breast cancer doctor and fighting this horrible disease. So there's been a lot of news around prevention and prophylactic surgeries. I think in the lay press, one of the first celebrities to maybe go down that path was Angelina Jolie, based on some genetic information that she had. There's some testing or certain information that might lead to patients having a significantly higher risk of developing breast cancer. But given that breast cancer is such a prevalent disease, given that it is... Sadly, I believe the latest statistics are, one in eight women developing breast cancer. Even if one were to not have a genetic mutation that has positively or further positively linked to developing breast cancer, it certainly doesn't mean that somebody is not going to have that. And so, in your case, you basically said," The risk of developing breast cancer is still significantly high, that the risks of going through surgery certainly outweighed the longterm... held the risk of potentially developing breast cancer." Is that accurate?
Dr. Marnee Spierer: Yeah, so I'm glad that you mentioned Angelina Jolie because it's so important, Pat. As you mentioned, she carries the gene for breast cancer, and like many women, they are counseled about their risk if they carry the gene. But it's not that black and white in terms of breast cancer risk, Pat. There are gene carriers that we know have a high risk for breast cancer and ovarian cancer and others, but then there's a whole group of women over here that are not gene carriers, but also carry a more than average lifetime risk and even a very high risk of developing breast cancer. And for me, that is where I fell.
Dr. Pat Basu: Even with your knowledge, even with you being a world expert in breast cancer, I'm sure it was still difficult, and obviously a big decision for you and maybe even for your family. So specifically, when did you begin thinking about it? What did members of your family say? Walk us through maybe some of the emotional decisions. Were you always knowing this was the right path, or did you come to that decision? I'm sure there's millions of people around the country, and certainly around the world, that probably fall into a similar bucket and are potentially contemplating similar prophylactic surgeries.
Dr. Marnee Spierer: Yeah, so my sister was diagnosed at the very end of 2019. Once she was on her path to getting treatment, I thought, it's time for me to evaluate my risk, right? So now, I have an older sister, an aunt, a grandma, and my mother had tested BRCA- negative. My sister had done a more extensive panel that's now available to us, and she was negative. And so, I didn't think I carried the gene, Pat, right, because my sister who has breast cancer, didn't. My aunt didn't have the opportunity to test. She was diagnosed before it became a thing. So at the time, Pat, you remember, we launched an online risk assessment tool here at CTCA and it was brand new. And I just entered in my information, and what popped out at me was, you are considered high risk, you should speak to a specialist. And that wasn't super surprising for me, but I kind of filed that information. COVID had hit us, we were all struggling with what that meant, to be cancer doctors in the face of the pandemic, so I just mentally filed it. Eventually, I decided to speak to my colleague, who's a breast surgeon, and we just talked about the next steps, and she suggested I meet the genetic counselor. And to be clear, Pat, meeting with a genetic counselor doesn't equal genetic testing, right? So I want to be clear on that. It means understanding risk and filling out form after form about risk factors. And this is the road. Modeling for breast cancer risks is all about lifestyle and family history, so I thought I had the lifestyle one beat, and just in terms of cancer prevention in general, maintaining a healthy body weight, exercising, don't smoke, eat well, limit alcohol intake. I'm checking off those boxes and I'm thinking, I am in the low- risk category. And then other stuff that matters for risk, early age of menses. So were you young when you got your period? Yes. What age were you when you had your first baby? Were you a little older? Yes. Ashkenazi Jewish ancestry, yes. So I'm filling out these forms that are required of a genetic counselor appointment, but I'm feeling confident that my lifestyle factors are going to put me in a low- risk category. And then when I met with him and we went over my result, I was very surprised to see my number in bold red, very high risk.
Dr. Pat Basu: Wow, wow. Incredible to have you, somebody who I know so personally, walk me through that experience. What I did not know, Dr. Spierer, was that you actually did the CTCA risk assessment tool as a precursor to meeting with the genetic counselor. And I'm glad that you made that distinction because I know, in this world, and you know so well from talking to so many of your patients, that there's so many terms that sound the same, genetic counseling versus genetic testing, and it can be so hard for people to navigate that. But hearing your story and the way that you've progressed, it certainly raises several things for me. One is, you recapped several of the risk factors to develop in breast cancer. And to be clear, you did such a great job of not only listing the things that should have made you healthy because you lead such a healthy lifestyle, and those are things that are going to reduce one's risk, but at the same time, there are other risk factors that you mentioned, in family history or other things. What are things that everybody should be doing to generally reduce the risk of cancer, knowing that there's some things, family history and the like, that we cannot change?
Dr. Marnee Spierer: Lifestyle factors, as we talked about. And I know, Pat, we both know that we have lived in a world where healthy behavior, healthy living, leading this heart- healthy life has been all about heart disease, right? This is how you prevent heart disease. And it turns out it's also how you prevent cancer. So all the things that, again, I thought were in my column, and I'm not suggesting that you shouldn't have them in your column, because of course, you should - So eating healthy, exercising, right, all of that is super important, limiting the amount of alcohol. Some folks think that smoking only prevents lung cancer, but that is actually not true. Smoking is implicated in many cancers and it's implicated in disease in general, so smoking is a lifestyle factor that can... Giving up smoking or not smoking at all, helps. I live in Arizona, where sunscreen is the Holy Grail. We have SPF in lip balm and facial moisturizer, and we don't go outside without it. And again, there are some skin cancers that are mild and easily treatable, but there's some that are not. And so, easy ones, smoking and sunscreen, absolutely cancer prevention. And then the other ones are more about lifestyle factors that we all can do to reduce our risk. This is not about eliminating risk, this is about risk reduction.
Dr. Pat Basu: So well said, so well said. Such great points. Number one, I love that you mentioned that there are some of these things that are not just a specific type of cancer. So people always think of smoking as lung cancer only, and make no mistake about it, it will severely increase one's risk of lung cancer, but as you said before, risk of other types of cancers. And that common pathway of what causes cancer is implicated in so many of the things that you mentioned, poor eating that leads to obesity, too much intake of sugar, all of those unhealthy things that we might put into our bodies, obviously, smoking being at the top of the list for those who are smokers, sun and protecting yourself from the sun with sunscreen. These are ubiquitous risk factors, and I'm so glad that you laid those out. I'm also glad that you made that distinction between prevention and screening. And certainly, you laid out the risk factors for prevention. Let's move over to talk a little bit more about screening. And let's talk not only about breast cancer, obviously, but what are some of the ways that you might recommend that people evaluate and work towards in getting screened for cancer?
Dr. Marnee Spierer: Of course. Yeah, so they're very separate, right? They're very separate. The idea of screening is about early detection. We know that cancers that are caught early are more easily treated, and we have a better chance of curing you, right? And that's what we want. Even if you're diagnosed with a cancer, we want you to be cured, and so that's what screening is all about. And the important thing here is that screening is based on guidelines, it's based on data. And as you know, Pat, we have these task forces that are put together by experts and they're constantly updated. So there's a task force around breast cancer screening. How old should you be? Does family history play a role? Similarly, with colon cancer screening, we have colonoscopies, but what age should you be when you start getting your first colonoscopy, and how often should you have them? For women, cervical cancer screening. Cervical cancer is a deadly disease in parts of this world because there is not mass screening. In this country, we have mass screening that allows us to diagnose women with early- stage cervical cancer, and then treat them and cure them. So those are really the big three. There's also lung cancer screening with a certain kind of CAT scan for high- risk patients. But again, these are examples of screening in the literature, but it's gender- dependent, age- dependent. And so, my advice to my patients and their families, my friends, my own family, is, go to your doctor, have a relationship with a primary medical doctor, and make sure that you are getting the screening that is right for your age and gender.
Dr. Pat Basu: Absolutely. There's so much out there. You and I are very close to it. Sometimes, the guidelines are being changed, they're being updated, often appropriately, so as new literature comes in... But for the average human being that flips on the news, there's a dizzying array of information, in terms of an anecdotal news story, all the way to trying to keep up with some of these guidelines, let alone in the day and age of social media, somebody might post something, or God forbid, in the day and age of misinformation, there is a lot of misinformation out there. And I really, really want to echo what you said, contact your doctor, contact us if people have questions about this, because it is so critical. And again, worth restating, catching cancer early is absolutely a key tenant of successfully battling the disease if one gets diagnosed with it. To all of our listeners out there, again, please, please get screened. We've spent a lot of time talking about this notion of the shadow curve during COVID, where people are missing their screenings and that's making a bad problem even worse, meaning that in most cases, from mammograms for breast cancer to pap smears for cervical cancer, colonoscopies for colorectal, and you mentioned a low- dose CT for lung cancer, even prior to COVID, most patients who should be getting screened were actually being disrupted, or who were eligible to be screened, were not getting it done. And it's certainly gotten a lot worse during COVID, so absolutely contact your doctor. If you don't have a doctor, contact any medical professional who can get you in touch with one, because this is the key tenant to battling cancer. So we've talked about prevention and how to mitigate some of the risk factors in that category. We've certainly emphasized the importance of screening. Following a little bit of a distinct progression there, Dr. Spierer, one might move then, from screening to diagnostic examinations. Can you give us a sense of what those entail?
Dr. Marnee Spierer: I am certain that all of our listeners have had family members or friends or acquaintances who went to get their annual screening mammogram, which by definition, means you didn't feel anything right? So it was just a screening test, and they were diagnosed with breast cancer. I have several young women in my life, and they have since had their surgeries, and some had chemo, and they're wonderful, they're doing beautifully now, but they never felt anything. But you can feel something, right? You can have a symptom of a cancer. And for my sister, she had her regular screening mammogram, and then months later, she actually felt a lump in one of her breasts, and that ultimately led to a biopsy and her diagnosis of breast cancer. And there's other examples of that. I mean, breast is an easy one, right? If a woman feels a lump in her breast, not every lump is cancer. However, every lump should be evaluated by a physician who can then tell you how to work it out to ensure you don't, or if you do, get you into treatment, right? Similarly, let's say you have this new onset of shortness of breath, and it becomes harder and harder to breathe, and then you cough up blood. Could that mean you have a run- of- the- mill pneumonia? Absolutely, but it can also be a warning of lung cancer. Go to a doctor. So there's lots of signs and symptoms that we feel. And unfortunately, Pat, many of us, and again, as you alluded to, especially during COVID, we put them off and we say," Ugh, I'm sure that's just a hemorrhoid. I'm sure maybe I just have..." Nowadays, a lung thing is COVID till proven otherwise. But it is very easy for us to dismiss a sign or symptom, especially, we're all so busy, everyone's so busy, but that's a mistake. For my sister, she caught it very early. She felt a lump and she went to the doctor immediately.
Dr. Pat Basu: I love the distinction. I tend to think of these two distinct buckets, which is asymptomatic screening, based on, as you stated before, guidelines that might be age- dependent, gender- dependent, other things that we mentioned, go talk to your doctor about. At the same time, those symptoms that we have, and the jargony medical term that sometimes you and I might be familiar with, might be non- specific symptom. And again, to be very clear, these are non- specific symptoms. Having them, certainly can be from a very common cause and a non- cancerous cause. But the bottom line is, don't ignore these. And again, coming back to what's happened in this past 12 months with COVID, is, there's not only been a decrease in the number of screenings that people just get naturally, there's been a tremendous decrease in just the interactions with the healthcare system for some of these symptoms. If somebody has pain, somebody has shortness of breath, somebody loses a little bit of weight and they're not going in, that, coupled with what we all know is a fragmented American healthcare system, is why so many cancers fall through the cracks. And you and I know firsthand from what we do, again, not only how important it is to catch things early, but we've seen cases, sometimes that get referred to us from other providers, where we just wish we could rewind the clock and catch that cancer earlier. So really, really love the way you've laid out the progression for our listeners. I do want to come back to, and although I am so grateful that you shared your story with us, and frankly, the courageous decision that you made, you mentioned in your own journey, Dr. Spierer, when you met with the genetic counselor. So we've talked about prevention and risk- reduction strategies, we've talked about screening, we've talked about the diagnostic exam once somebody has symptoms and the like, but at what point should people get genetic counseling? And can you share a perspective on when that should be done, how that should be done? I'm sure many of our listeners would love to know.
Dr. Marnee Spierer: Yeah, of course. And that, to me, Pat, is, maybe again, one of the most essential take- home points from this exchange between you and me, is that knowing your history and knowing your own story is the most powerful tool. So I'm a cancer doctor, so I knew my story, I knew my family's story, I knew what to ask, but for many women, they might not know. Again, I mentioned earlier that it's this non- black and white world. Oh, I don't have BRCA, breast cancer gene, I don't need to worry about breast cancer, I'm like everyone else. I'm just an average- risk person, versus the huge, gray area of family history and knowing your risk factors. So having a provider, going to a doctor, making sure they understand your risks and your family history and your story, and going to a genetic counselor. And by the way, there's several online tools that we can all use. And I don't know about many of them, but I think the take- home really is, if you Google, or if you do an online tool, or if you think you might be high risk, just go talk to somebody, right? so I met with a genetic counselor, because we have one here and it was easy for me here. But it was about understanding my risk, it wasn't about getting a test for a genetic abnormality. I mean, ultimately, I did that, but it was more like, let's rule it out. I'm sure you'll be negative. So it's really about talking to someone to know your risks. And again, we started, Pat, with me making the decision to do breast cancer surgery to remove my breasts, a bilateral, both- sides mastectomy, taking off my breasts, in order to reduce my breast cancer risk. But as you can imagine, we don't have those surgeries for lots of organs, and so for some women, this seems like a crazy, crazy decision. How could you take a body part off without having cancer? Other women would completely understand. I think another really, really strong take- home point, Pat, is that everyone should know her option and then get to hear treatment options, get to hear options. And they can range from high- risk screening, taking a pill or a medicine to reduce risk, or in my case, preventative surgery. And so, understanding the options is the most important thing here, and so that's the take- home. I think if there's two big take- homes from this part, is it's not black and white. Breast cancer risk is not black and white. It's not gene or no gene. There is a spectrum, and decades from now, we will look back and say," Wow, we didn't have all these other BRCA genes back then, but we do now." So that's part one. And part two, once you know your risk, know your treatment options, because they are not all created equal for each woman.
Dr. Pat Basu: Wow, that's terrific, Dr. Spierer. I love that. Just to summarize, I think, some of your really, really important points there, again, number one, it's not black and white. Somebody who is, let's just say, BRCA- negative, if they have the testing, does not mean that they're not going to develop breast cancer. Conversely, somebody who is BRCA- positive may not absolutely develop breast cancer, but it is a spectrum. Number two, really, really know yourself, know your history, and talk to somebody. Talk to somebody, don't just ignore the information. Certainly, don't ignore the guidelines, and absolutely don't ignore the symptoms. And then number three is to know that there are options, and to know your options, and that it's a deeply personal decision, but also one that, with great professional guidance, every patient can make the most informed decision that is best for them. And in your case, Dr. Spierer, that decision was a prophylactic or protective bilateral, both- sided mastectomy, a removal of your breasts, so that you could live in a way that gave you peace of mind and a healthy future, free of breast cancer, from your perspective. So thank you for being so courageous. You're a role model in many ways. Let me just conclude by asking you how you're doing.
Dr. Marnee Spierer: So I am doing great. Like we talked about earlier, my surgery was last month, and I feel great. I even played pickleball this weekend. I hope my surgeon is not listening, but I played pickleball this weekend, and I... I mean, pickleball light. Let's be honest, it was pickleball light. But I feel great, and my sister finishes... She gets her last infusion in less than two weeks, so she's been in therapy for over a year now, and so great milestones for both of us. My mom can sleep easier now for both of her daughters. And yeah, I'm feeling great.
Dr. Pat Basu: Fantastic. Well, definitely give your sister my regards, and I was going to share your pickleball story, but yeah, I didn't want to get you in trouble with your surgeon. But I know sometimes, as doctors, we don't make great patients. But the bottom line is, it sounds like you're doing great. You had surgery a month ago, back on your feet, back to living life, and hopefully, with a lot more peace of mind for you and your family. Finally, Dr. Spierer, what final advice do you have for any of our listeners, whether they may be patients... But as we know, there might be millions of people who are not patients, but in a similar boat, that certainly have family members that, sadly, have suffered from this disease. What are your words of advice or wisdom?
Dr. Marnee Spierer: Yeah. So number one, know your story. I'm all about knowing your story, because if you don't know your story, no one else knows your story. And some people can't, right? I have friends of mine who were adopted and they don't know their story, and understandably so. But if you do know your story, know it and share it with your doctor so that you can get the screening that you need, that's applicable to you, your age, your gender, and your background story, your family history, your risk factors. Know the options that come with those risk factors. Some might be losing weight, drink less alcohol, exercise more regularly, consider more of a plant- based diet than a meat- based diet, lifestyle stuff, right, lifestyle stuff that can protect us from everything, not just cancer. Then there is the more extreme approach, right? Know maybe options for something like me, a surgical reduction surgery, but just know that option. And then I'll end with, Pat, because it's hard, right, the elephant in the room, there's this pandemic going on. And it all took us for a loop here, cancer docs everywhere, doctors everywhere. I mean, people everywhere, right? How do you follow guidelines for screening? How do you do something that's elective during a pandemic, right, having the respect for some unknown virus, balancing between what we know is cancer? And I say this to my cancer patients all the time," Cancer doesn't care about you, cancer doesn't care about me, and I can promise you that cancer doesn't care about a pandemic," right? And so, we have so much data on screenings that were missed, cancers that are being found at a later stage, treatment that's been interrupted because of the pandemic, and I get it, we all get it. We understand why that's happened. But now that we're in a little bit of a more understanding place, and now that we're getting vaccinated, and I can say that I've been fully vaccinated at this point, cancer doesn't wait, cancer doesn't care. Do your screenings, get your cancer treatment, find the place where you feel safe, respect the pandemic, respect this virus, but know that cancer doesn't wait and cancer doesn't care, so we really do have to balance both.
Dr. Pat Basu: Well, what a powerful message to end on. And I just, again, want to thank you for sharing your story, Dr. Spierer. So glad that you're doing well. And I think you just shared so many powerful messages for our listeners today, so thank you for sharing your story, thank you for all that you do, battling cancer, and thanks for sharing your time in what I know is a very busy time for you, caring for patients. So great to see you, and we'll talk soon.
Dr. Marnee Spierer: It was my pleasure, Pat. I really enjoyed this conversation, and I hope it helps. I hope we got the message out there. But again, thank you very much for having me.