Katie Couric missed one mammogram. The next one would prove devastating.

You may remember Katie Couric’s on-air colonoscopy from 2000, 2 years after the death of her husband. Jonathan Monahan, from colon cancer.  Her call-to-action resulted in a 20% jump in national colonoscopy rates.

The University of Michigan dubbed it the “Couric Effect.” Now she’s advocating for cancer screening.

On her website, Couric wrote an essay chronicling her breast cancer diagnosis in June of this year.  During a routine doctor’s visit her doctor informed her she was due for a mammogram, although she believed she had only recently had one, her last mammogram had, in fact, been in December 2020.

She scheduled her appointment immediately.

Katie underwent a 3D mammogram, and because of her dense breasts, a breast ultrasound.  Afterwards, her radiologist, Susan Drossman, MD, told her there was something suspicious in her left breast, recommending a needle biopsy to check it out.

The next day she was diagnosed with stage 1A HER2-negative breast cancer. She underwent a lumpectomy in July, followed by 15 rounds of radiation therapy, and then aromatase inhibitor therapy to lower her estrogen levels.

On October 3 Katie sat down on the set of the Today Show to explain her mission to raise awareness of the need for breast cancer screening, to educate women about dense breasts and how this condition may relate to breast cancer.  Only about 70% of eligible women receive screening (which further declined during the pandemic).

About 45-50% of women have dense breasts, which is diagnosed by mammogram, and having dense breasts makes diagnosing breast cancer more difficult.  That where supplemental screening becomes essential in the form of a breast ultrasound.  Unfortunately, only 38 states have laws that require physicians notify patients they have dense breasts, and even in states that do, notifications may not clearly explain why this is important and what to do.

Additionally, not all insurance plans cover breast ultrasound.  Currently only 14 states and the District of Columbia require insurance companies to cover the test at least partially.

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Breast Cancer

According to the American Cancer Society, breast cancer is the most common noncutaneous (not affecting the skin) affecting women in the U.S., with over 51,000 cases of ductal carcinoma in situ (DCIS) and over 287,000 cases of invasive disease diagnosed in 2022.  Widespread adoption of breast cancer screening has increased the incidence of breast cancer diagnoses, it’s also changed the types of cancers detected, such as lower-risk cancers, DCIS, and pre-malignant lesions.

Numerous therapies are available and often used in combination to treat breast cancer, including surgery, radiation therapy, chemotherapy, and hormone therapy, the selection of which may be influenced by clinical and pathological features:

HER2 overexpression and/or amplification

Histologic type

Estrogen receptor (ER) and progesterone receptor (PR) status of the tumor

Grade of the primary tumor

Stage of the disease

Menopausal status

Through molecular profiling breast cancer is classified into one of the following types:

Hormone receptor positive

HER2+ (positive)

Triple negative (ER, PR, and HER2- (negative))

The status of these receptors is important for determining prognosis and predicting response to endocrine and HER2-directed therapies.

So, what are these receptors?

Receptors are proteins found in or on cells that are able to attach to certain substance in the blood.  Normal breast cells and some cancer cells have receptors that attach to the hormones estrogen and progesterone, needing these hormones to grow.

Breast cancer cells may have one, both or none of these receptors.

Blocking a cancer cell’s ability to attach to these hormones can help keep the cancer from growing and spreading.

Knowing the status of these receptors helps your doctors decide how best to treat it.  Depending on which receptors are detected, hormone therapy drugs can be used to either lower estrogen levels or block estrogen from acting on breast cancer cells.  This type of treatment is beneficial for hormone receptor-positive breast cancers but doesn’t work on tumors that are hormone receptor-negative, both ER- and PR-negative.

All invasive breast cancers should be tested for both hormone receptors as about 3 of 4 breast cancers have at least one of these receptors.  The percentage is higher in older women than in younger women.

Breast density

Breasts are comprised of glandular, connective, and fatty tissue.  Breast density describes the relative amounts of these tissues.  Dense breasts are found to have higher amounts of glandular and connective tissue with lower amounts of fatty tissue.

Breast density is determined via mammography, it can’t be determined through a physical examination.  Although breast density can be inherited, there are other factors that can influence it.  Breast density can decrease with age, childbirth, and use of tamoxifen, while increasing breast density can be a result of postmenopausal hormone replacement therapy and low body mass index.

The American College of Radiology developed a scale to categorize breast density called the Breast Imaging Reporting and Data System (BI-RADS), which assists radiologists in interpreting mammogram results.  The scale divides breast density into four categories:

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A: Almost entirely fatty tissue (about 10% of women)

B: Scattered areas of dense glandular tissue and fibrous connective tissue (about 40% of women)

C: Heterogeneously dense breast tissue with many areas of glandular tissue and fibrous connective tissue (about 40% of women)

D: Extremely dense breast tissue (about 10% of women)

Is there a connection between dense breasts and breast cancer?

Yes, in two ways.  First, breast cancer is much more difficult to detect in dense breasts.  Dense breast material and some abnormal breast changes, such as calcifications and tumors, appear as white areas in mammograms which can hide cancerous growths.

Second, multiple studies have shown that women with dense breasts have an increased risk of breast cancer, and women with extremely dense breasts have a four- to six-fold higher risk of breast cancer than those with fatty breasts, independent of the effect of breast density on mammogram interpretation.

The big question is, is supplemental testing warranted for women with dense breasts?  That question hasn’t been satisfactorily answered yet.  The U.S. Preventive Services Task Force (USPSTF) in 2016 stated, “current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging (MRI), digital breast tomosynthesis (DBT), or other methods in women identified to have dense breasts on an otherwise negative screening mammogram.”

Couric is currently working with Rep. Rosa DeLauro (D-Conn) on legislation that would ensure that women and their healthcare providers have access to the information about breast density to make informed healthcare decisions.  DeLauro will also introduce legislation this month that would require insurance companies to completely cover the costs for breast ultrasound for women with dense breasts.

How often should you get a mammogram?

That’s a good question, one that still seems to be a subject for debate.

According to the USPSTF, women who are 50 to 74 years-old and are at average risk for breast cancer should get a mammogram every two years.  Women who are 40 to 49 years-old should talk to their doctor or other healthcare provider about when to start and how often to get a mammogram.

However, the American Cancer Society recommends annual checkups for both age ranges, while the American College for Obstetricians and Gynecologists recommends between annual and every two years, depending on your shared decision-making approach.

The other challenge may be your insurance provider, as some companies may only cover mammograms every two years; the specifics depend on your policy, so check your summary of benefits.

Do men get breast cancer?

Yes.

According to the American Cancer Society about 2,700 cases of invasive breast cancer will be diagnosed in men, about 1% of the total breast cancer diagnoses in the U.S.  Of those 2,700 diagnoses, about 530 men will die, about 20%.  By way of comparison, according to the CDC about 264,000 women will be diagnosed, about 42,000 women will die, or about 15%.

Breast cancer is about 100 times less common among white men than among white women, and about 70 times less common among black men than black women.  As with black women, black men with breast cancer tend to have a worse prognosis.  For men, the lifetime risk of getting breast cancer is about 1 in 833.

What are the risk factors for men?

We don’t completely understand the causes of breast cancer in men, but researchers have identified several factors that may increase the risk of getting it.  As with female breast cancer, many of these factors are related to hormone levels.

Aging

Aging is a significant risk factor for the development of breast cancer in men.  On average, men with breast cancer are about 72 years old when they are diagnosed.

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Family History

If other members of the family (blood relatives) have had breast cancer, the risk is increased.  About 1 out of 5 men with breast cancer have a close relative, male or female, with the disease.

Inherited Gene Mutations

Men with a mutation in the BRCA2 gene, the gene that provides instructions for making a protein that ats as a tumor suppressor, have an increased risk, with a lifetime risk of about 6 in 100.

Often mutations in these genes are most often in found in family members with many cases of breast and/or ovarian cancer, they have also been found in men with breast cancer who did not have a strong family history.

Alcohol

Heavy drinking of alcoholic beverages increases the risk of breast cancer in men.  This may be because of its effects on the liver.

Liver Disease

The liver plays an important role in the balancing of sex hormone levels.  In cases of severe liver disease, such as cirrhosis, the liver is damaged and unable to adequately moderate hormone levels, causing uneven levels of androgens and estrogen.  Men with liver disease can also have a higher chance of developing benign breast growth (gynecomastia) and have a higher risk of developing breast cancer.

Obesity

Studies indicate that women’s’ breast cancer risk is increased by obesity after menopause, which is also a factor for male breast cancer as well.  The reason is that fat cells in the body convert male hormones (androgens) into female hormones (estrogens).  This means obese men have higher levels of estrogens in their bodies.

Should men be screened for breast cancer?

Generally, breast cancer screening is only recommended for men at increased risk of breast cancer due to a BRCA2 or BRCA1 inherited gene mutation.  The question is, how would you know if you have the gene mutation in the first place. Generally, if you have a family history of breast cancer, then genetic testing is your starting point.  Talk with your healthcare provider about whether genetic counseling and genetic testing may be right for you.

If it is determined you have the BRCA1 or BRCA2 gene mutation, it’s recommended men should begin breast cancer screenings at age 35.  Have a yearly clinical breast exam, which is a physical exam done by a healthcare provider, and generally can be done as part of your regular medical checkup.

It’s a good idea to learn breast self-examinations, a simple procedure you can do in the privacy of your home.  Women often detect breast cancer themselves, either by self-examination (25%) or by accident (18%).  Despite the increased use of screening mammography, a large percentage of breast cancers are detected by patients themselves, so self-examination, for men and women, remains a key component of early detection and treatment.

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