Dr. Armando Giuliano on the Science of Surviving Breast Cancer: Part Two

Mary Alice:
Hi, I am Mary Alice Haney.

Dr. Aliabadi:
And I'm Dr. Thaïs Aliabadi. Today's episode is part two of our conversation with Dr. Armando Giuliano, a world-renowned breast cancer surgeon.

Mary Alice:
If you weren't able to tune into part one, Dr. Giuliano is the surgeon who performed Dr. A's second double mastectomy. He was also one of Olivia Munn's doctors. We got into Dr. A's relationship with Dr. Giuliano in the last episode. And in this one we'll talk about exactly what happens when a patient gets a breast cancer diagnosis.

Dr. Aliabadi:
Thanks for watching SHE MD.

Mary Alice:
This podcast is for educational and entertainment purposes only. It is not intended as a substitute for a physician's medical advice, you should regularly consult your medical provider in matters relating to your own health.

Dr. Aliabadi:
Going back to the nipple-sparing mastectomy, it's an important question because so many women struggle with this. I remember before my double mastectomy, they did a procedure on my nipple. Because as you explained, if during a mastectomy you take a lot of tissue from underneath the nipple, you are at risk of losing that nipple after surgery. There is a procedure they do 10 days prior to that, which is an outpatient procedure that basically they detach the nipple and allow vessels to come, new vessels to come and feed the nipple before doing a mastectomy. Can you explain that for us?

Dr. Giuliano:
You make me very happy because I invented that procedure.

Dr. Aliabadi:
There you go. How come you're not talking about it then? I to pull that out of you.

Mary Alice:
I told you we had a rock star.

Dr. Giuliano:
Jay Arthur Jensen and I, Jay Art is a plastic surgeon.

Dr. Aliabadi:
Nipple delay, they call it.

Dr. Giuliano:
We did the nipple delay. So it's based on a very old concept. The father of plastic surgery is Gaspare Tagliacozzi, who worked in the 16th century. And men would get their nose cut off in a sword fight, so they had no nose. So what Tagliacozzi did is he made a tube of flesh from their arm. He sewed one end to their nose and he put their arm on a cast. And this is the emblem of the American Society of Plastic Surgeons. This medieval man with his arm up like this and this tube going into his nose.
Tagliacozzi in his textbook in 1560, described how you make this flap and how long you have to leave it attached before you can cut the other end, when blood vessels would grow. And he says in his textbook, don't wait too long, it gets too old. Don't do it too soon. Wait about 10 days or two weeks. So Art and I had a patient about 25 years ago who had scars all over her breast and around her nipple, and she said, I'm not going to treat my cancer unless you can do a nipple sparing mastectomy. And I said, you can't do it because you won't get any blood supply to your nipple. The scars have destroyed it. And we said, well, if Tagliacozzi could save a nose, maybe we can save a nipple. And we decided to do a delay. You traumatize the nipple, you cut the blood vessels from under it, forcing the blood vessels from the skin and around it to increase in size. Mother nature must say, this is bad, I'm going to die. Let's get more blood to this nipple. Then you wait two weeks and you do the operation and it greatly increases the chance of the nipple surviving. So in high-risk women who have a lot of scars or smokers, had prior radiation, things that hurt the blood vessels, you would want to do a nipple flap. Or some women say, look, I really don't want to lose this nipple, can you guarantee or ensure or increase the likelihood that it won't die? That would be the way to do it.

Mary Alice:
So I just want to be really clear. You saved the nipple. You actually saved the nipple for women. I'm literally sitting in a room with the man that saved the nipple. This is incredible. I love my nipples, they're amazing. So that's great. That's so crazy.

Dr. Aliabadi:
Dr. Giuliano. Can you tell us how you got involved in the sentinel node biopsy and staging of breast cancer?

Mary Alice:
And tell us what that is?

Dr. Aliabadi:
Yes.

Dr. Giuliano:
Well, it's a story I'm very proud of actually. I did the first sentinel node biopsy for breast cancer in 1991, many years ago. We were investigating trying to minimize the amount of surgery women with early breast cancer would have. So prior to acceptance of that operation, if you had a breast cancer, "all," because you can't remove all the lymph nodes, but all the lymph nodes under your arm would be removed to see if it's spread. The consequences of that were often frozen shoulder, patient couldn't use her arm very well, numbness in the arm, lymphedema, which is dreadful, and patients are horrified by lymphedema. Where the arm would swell up, sometimes greatly swell up. So it was an operation that had a lot of consequences. So we looked at ways to minimize that and we decided if the breast cancer is here in this one place in your breast, the lymphatics from that place might just go to one lymph node. So we started injecting a dye into the breast cancer and to see if it would go to one lymph node. And we did it. We had no idea of how to do it. My colleague was doing it in malignant melanoma and that seemed to work very well. And I did it in breast cancer and it didn't work. And I think I'm the first person who said this will never work in breast cancer. And then I had a young trainee come on my service. He said, let's do this in an organized scientific way. And we devised some experiments, and in fact if you inject the dye or a radioisotope into the breast cancer, you can find one lymph node under the arm that turns blue, because the dye went to that one lymph node. And we showed that if you remove that one lymph node and remove them all from the same patient, all you had to do is remove that one, it would predict the status of them all. If the cancer spreads, it spreads to this one lymph node, the sentinel, the guardian lymph node.

Mary Alice:
So before that, all your lymph nodes were taken.

Dr. Giuliano:
All of them.

Mary Alice:
That is incredible.

Dr. Giuliano:
So we then started removing just this one. And I started doing that in the mid-'90s. And by the year 2000, this operation was so successful. By the year 2000, it was a fairly common operation in this country and around the world. So then we did some experiments to show that even if it was involved, you didn't have to remove more.

Dr. Aliabadi:
What does involve mean?

Dr. Giuliano:
It had cancer in it.

Dr. Aliabadi:
The lymph node?

Dr. Giuliano:
Yes. When we first did it, if there was cancer in the sentinel node we would remove more lymph nodes to make sure there wasn't cancer. And then we showed in a study that we published in 2011, that even if the one lymph node had it, you didn't have to remove more. And that has now become standard practice at all major centers around the world.

Dr. Aliabadi:
And is that because you would treat that patient with radiation or chemotherapy?

Dr. Giuliano:
Exactly. Radiation or chemotherapy seem to be as effective as surgery in that situation.

Dr. Aliabadi:
I just want to make it clear. You need to have a breast tissue in order to identify the sentinel nodes, they need to be able to inject the dye into the cancer inside the breast tissue for that lymph node in your armpit to light up. If you're a patient like me, where you do your double mastectomy, they remove the breast tissue, and then they realize you have cancer and they want to go after those lymph nodes. The chance for identifying that sentinel lymph node, the first lymph node that the cancer from the breast is draining into, that option is gone. So someone like me needed an axillary node dissection, which means like old school ways, you have to go in and take bunch of lymph nodes out to see if you have cancer in it or not. And that's a very high risk procedure. And Dr. G is one of the best in the world at it because of all those risks that can come up with it, like lymphedema, numbness. As amazing as he is, the first few months I had a cord, I couldn't raise my arm, then I had to go to physical therapy because everything contracts, you add mastectomy to it. So doing these sentinel lymph nodes and taking these lymph nodes out while you have breast tissue is very, very important.

Dr. Giuliano:
It's a great point. Sometimes we do it on patients who don't have cancer, but may have cancer. So if you had a mammographic abnormality and atypia, I probably would do the sentinel node. Because once the breast is gone, you can't do the minimal operation.

Mary Alice:
You have to have the breast tissue to do it.

Dr. Aliabadi:
You would've saved me a lot of heartache.

Mary Alice:
What's the most common breast cancer caught during early screening?

Dr. Giuliano:
An ER positive stage 1 breast cancer.

Mary Alice:
And what does that mean?

Dr. Giuliano:
So screening detects the earliest cancers, either stage 0 or stage 1. Typically, these early cancers have hormone receptors on them, so they're more favorable. Early detection is the single best thing you can do after prophylaxis prevention.

Dr. Aliabadi:
Dr. Giuliano, is it true that when it comes to different types of breast cancer, correct me if I'm wrong, I love having you here, the most common... So if you look at the breast tissue, we have ducts and we have lobules. You have lobules that have milk in it for breastfeeding, and then you have the ducts that take the milk to the nipple and out the nipple. The most common type of breast cancer is ductal carcinomas. These are cancers that start in the ducts of the breast. The second most common type of breast cancer is lobular breast cancers, which comes from the lobules of the breast. Generally speaking, ductal cancers are diagnosed very easily on mammograms. The lobular ones tend to be a little bit more sneaky and it's hard to diagnose them on mammogram. And that's why the benefit of MRIs come in. So someone like me, my mammograms were fine and it was on MRI that my lesion showed up. In my case, it was read as benign even though it was cancerous, which can happen, it's not... But that's why we add that MRI. So I would say the most common type of breast cancer would be ductal. The second most common is lobular.

Dr. Giuliano:
Absolutely.

Dr. Aliabadi:
And the lobulars tend to be more bilateral, affecting both breasts. And then the worst type of breast cancer, probably the most aggressive, as a gynecologist for me, the inflammatory breast cancer, which affects the skin, it turns, peau d'orange they call it, your skin turns orangey color.

Mary Alice:
That happened to you?

Dr. Aliabadi:
God no. That's the most aggressive form of breast cancer. How is the treatment right now for inflammatory breast cancer?

Dr. Giuliano:
It's chemotherapy, immunotherapy, depending on what the biomarkers are. But you're absolutely right, about 80% or 85% of cancers are ductal in origin, and 15% to 20% are lobular. And as she said, the lobulars are very sneaky, hard to detect, hard to feel.

Mary Alice:
What's the difference? And I know this, but maybe people don't. This seems like it might be a good question. What's the difference between chemotherapy and immunotherapy?

Dr. Giuliano:
Chemotherapy works to kill dividing cells. It's a poison in essence for dividing cells. That's why patients get diarrhea. That's why you lose your hair, because those cells are dividing rapidly and are very affected by this chemotherapy that affects cell replication, cell division. Immunotherapy stimulates your immune system to fight the cancer.

Mary Alice:
And how does it do that?

Dr. Giuliano:
It affects certain blockers that turn off the immune system, so it decreases the ability for the immune system to turn off, is the most common way.

Mary Alice:
And when you have a patient that is diagnosed with breast cancer at a certain stage, do you do both?

Dr. Giuliano:
Triple negative breast cancer, we'll get both now.

Mary Alice:
Okay.

Dr. Giuliano:
And certain advanced cancers we'll get both.

Mary Alice:
And you're excited about immunotherapy?

Dr. Giuliano:
Immunotherapy has been miraculous for inflammatory cancers, for triple negative breast cancers. Many cancers actually.

Mary Alice:
You're diagnosed with breast cancer. What's the workup that you give a patient?

Dr. Giuliano:
Well, first you do a physical examination and see if you can detect the extent, because if you can feel lymph nodes, that's a more serious problem. Or if it's fixed to the skin or the chest wall. So the patient gets a good physical examination. Then we've had a mammogram and ultrasound, I assume for the diagnosis. Then you can do an MRI, if there's breast density, making it hard to read a mammogram or might be something hidden or in the contralateral, in the other breast. You may do some blood tests to see if there's any signs of it spreading to another organ. But for early breast cancers, that's extremely rare. Most staging is not necessary for early breast cancers. Bone scans, PET scans are not needed for early breast cancers.

Mary Alice:
How do you know how fast a cancer will spread or do you?

Dr. Giuliano:
You cannot tell how fast a cancer will spread. You can tell from the staging, from the biomarkers how serious it is, what's the prognosis. So if you know that a patient has a triple negative breast cancer, large one with positive nodes, her prognosis is not as good as a small ER positive breast cancer. But again, if the survival or the cure rate is 10% or 15%, you want to be in that 10% or 15%. So you do everything that's possible and be treated correctly.

Mary Alice:
And how do you come up with a treatment plan for your patients?

Dr. Giuliano:
It depends on the stage, on the grade, on these biomarkers, on these tests, Oncotype and MammaPrint, and the patient's preference.

Mary Alice:
Are you hopeful about anything? Is there anything new on the landscape that you're really hopeful about right now with breast cancer?

Dr. Giuliano:
Well, I think we've seen tremendous advances in the surgery and radiation and chemotherapy and immunotherapy. Things just continue to get better, more and more effective drugs. The survival for breast cancer keeps increasing. The detection is getting better.
So our mammography equipment is better. 3D mammograms or it's what's really called tomosynthesis, more effective than the old type of mammograms. So many different changes have occurred in detection and prevention and treatment that I remain hopeful.

Mary Alice:
What about AI? The big question.

Dr. Giuliano:
Well, maybe AI will help in diagnosis, but it still can't do the operations.

Mary Alice:
It can't. It can't do. No, no, no, we still need geniuses like you doing that. And what do you wish every woman listening to this would know?

Dr. Giuliano:
I think a woman listening to this today heard many different things. One, you might want to get a second opinion. I think if your doctor said they've only done four operations, you might not want to go to that doctor.

Dr. Aliabadi:
Unless you're desperate and nobody else listens.

Dr. Giuliano:
It never hurts to get a second opinion. And if your doctor objects to a second opinion, you definitely need one. I tell my patients, I encourage second opinions, go see what someone else says. Sometimes someone else will just see something differently or have a different approach.

Mary Alice:
We're all human.

Dr. Giuliano:
It never hurts.

Mary Alice:
Yeah.

Dr. Giuliano:
And I think you should get screened and adhere to the screening policy and start as early as appropriate for you. And I think you want to hope that if you get it, it's detected early, then it's very curable. And I think the point of your own risk factors, I think that's a great point to make for women. If it's on your website, that'll be a real contribution. Because women don't know what their risk is. Many of us overestimate our own risk or underestimate our own risk. We don't really know our own risk of things. So it doesn't hurt. Knowledge is power. You can know your risk and decide, okay, I'll take that chance or find your risk in saying, I want to do something to prevent cancer. So I think a lot was discussed and I think there's great hope for breast cancer, and great hope for your patients.

Dr. Aliabadi:
I always tell patients, if you're going to get some type of cancer, breast cancer is the one you want to have, because we have a lot of treatment options for it. Unlike a lot of other cancers like pancreatic cancer, ovarian cancer. So don't panic if you have breast cancer, we have treatment for it. The reason we did this episode is to arm women to know what their lifetime risk is and what to do with it. A lot of times patients come and they're like, yeah, I have a very high risk for breast cancer. I'm like, what is that number? I don't know. But when you put a number to it, it puts it into perspective for them. Because in their head they probably think they have a 20% chance. And when you tell them that chance is 50%, suddenly they're like, what? 50%? So knowing what that number is, is very important. But I also want to say that 12.5%, which is the average risk for an American woman, it's still considered a high risk to me. So it's something you don't want to ignore. You don't want to miss your mammograms after age 40. If you have dense breasts, you want to do your ultrasound. And if you're in the high risk category, you have to ask your doctor to add MRIs. If you have family history, ask for genetic testing. So all these options are available for women so we can diagnose them early. I have two important questions for you. Number one, one of the issues after you're diagnosed with breast cancer and you get your surgery or your chemo, do you ever allow your patients to A, take hormone replacement?

Mary Alice:
This is a really good question. I was just going to ask the same thing.

Dr. Aliabadi:
So it's a problem, because if you ask me, my cancer was stage 1B. It's been rough in a way that I've been taking the medication Arimidex as a hormone blocker, and I was told to take it for 10 years. But one of the side effects that really bothers me is the hot flashes associated with it. I didn't know what hot flashes were. And since my diagnosis, I get maybe 30 of them a day.

Dr. Giuliano:
Wow.

Dr. Aliabadi:
And the other thing is severe vaginal dryness, that no one talks about. For me, the vaginal dryness was a shocker. I'm a gynecologist, I've treated vaginal dryness all my life. The word vaginal dryness has a new meaning to me after my diagnosis. So I know that routinely I treat my patients with vaginal estrogen locally to treat their vaginal dryness. I also do a CO2 laser of the vagina. But what about systemic hormone therapy? We were talking to a brain specialist who was saying for women who carry the APOE4 gene, which is a gene mutation that predisposes you to dementia and Alzheimer's, these women benefit from taking hormone replacement for the first seven years after menopause. While someone like me, I am APOE4 positive. I have one copy of it. So I would've been one of those patients who would've benefited from the seven years of hormone replacement. Not only, I'm not on hormone replacement, I'm on a medication that blocks whatever's estrogen is left in my body, and I have all these side effects. For which group of women who have been diagnosed or who have a history of breast cancer, would you say they're okay to have hormone replacement?

Dr. Giuliano:
The lack of hormones is a tremendous problem. The hot flashes, the vaginal dryness. You're absolutely right, you can give vaginal estrogen, that's not a problem. That's been studied actually. A paper recently came out that showed no difference in outcome with vaginal estrogen. We all believed it for many years, but now it's been proven.

Mary Alice:
For any kind? Women with any cancer can take vaginal estrogen?

Dr. Giuliano:
With breast cancer, correct.

Mary Alice:
With breast cancer?

Dr. Giuliano:
Any type of breast cancer.

Mary Alice:
Okay.

Dr. Giuliano:
Now, can you take systemic hormone replacement? If you're a purist the answer is no. Because even triple negative breast cancers may have a small amount of estrogen receptors on them and it could encourage its growth. So the correct answer is... The board answer is no. You do not give hormone replacement therapy.
And it's a very tough problem for women. I have a nurse who specializes in telling them various types of treatment for hot flashes, none of which have been proven work, but patients try them and sometimes-

Dr. Aliabadi:
I use magnesium, I prescribe Brisdelle. I had a patient a couple of days ago, clonidine patch, but none of it really-

Dr. Giuliano:
They don't really work.

Dr. Aliabadi:
Helps. As my patients are complaining about their hot flashes I'm sitting there having a hot flash myself. And you learn to just live with it. But it's not easy.

Dr. Giuliano:
It's very difficult.

Dr. Aliabadi:
What about women who are BRCA1 or 2 positive, they had a double mastectomy, they might have some residual breast tissue left and they want hormone replacement?

Dr. Giuliano:
I think you could use it in that situation.

Dr. Aliabadi:
You can use that.

Dr. Giuliano:
Yes.

Dr. Aliabadi:
Okay. And my other question to you is for women who have a prophylactic double mastectomy and they don't have a cancer diagnosis, do you ever repeat imaging on them? Would you do an MRI every few years just because of that residual breast tissue?

Dr. Giuliano:
Great question. We actually looked at our patients who in the past had prophylactic surgery and developed cancer. All of them were detected by palpation.

Mary Alice:
What's palpation?

Dr. Giuliano:
Examination.

Dr. Aliabadi:
Like when you touch yourself and feel a lump.

Dr. Giuliano:
So there's probably no need for imaging afterwards. Many doctors do that though. They will order things. And patients actually like it.

Mary Alice:
It just makes them feel better.

Dr. Giuliano:
They feel better knowing they had a negative MRI.

Dr. Aliabadi:
But what if by the time you palpate something, it's been there for a while, why not do an MRI, for example, in someone like me every three years, just to be safe? Like for myself, I do axillary ultrasounds once a year. It takes five minutes to look at lymph nodes under my armpit. Is there a guideline to follow someone with early stage breast cancer like me with a double mastectomy, or do you just let them be?

Dr. Giuliano:
The guidelines are not to do any imaging. In risk-reward it's not... The expense just doesn't equal the risk of finding something. It's so low. If you've had an adequate operation, the chance of that happening is relatively low. And you will feel it almost as soon as you'll detect it. If you think about what's there, just a tiny layer of your skin and a tiny layer of subcutaneous fat. So even a small thing, it can be felt.

Dr. Aliabadi:
Dr. Giuliano, I've been in medicine now for 30 years. I guarantee you, the woman I see with double mastectomy, who are not your patients, have breast tissue left. So that's what worries me. In this podcast I know you don't see it because you did the surgery. Most women around the world do not have access to Dr. Giuliano to do their double mastectomy. I had my double mastectomy in Los Angeles and 35% of my breast tissue was left behind. There should be guidelines to protect women who don't have access to a Dr. Giuliano. So that's what concerns me. That's why I put my patients through these imaging. When I feel breast tissue... I have patients with double mastectomy, I do imaging on them every year, because I'm convinced that they have breast tissue left.

Dr. Giuliano:
Well, you're absolutely right. If you suspect breast tissue, then it's very reasonable to do one.

Dr. Aliabadi:
That's not uncommon though.

Dr. Giuliano:
I actually saw a patient once who was pregnant. She had prophylactic mastectomy elsewhere and she was lactating.

Dr. Aliabadi:
There you go. I rest my case.

Dr. Giuliano:
She said, I can feed my baby with this.

Dr. Aliabadi:
I rest my case. So to tell those patients go and never get imaged.

Mary Alice:
How often should a woman who has a normal risk of breast cancer get imaging?

Dr. Giuliano:
Well, I say at age 40, once a year.

Mary Alice:
Once a year. If you're normal, again, we're saying if you don't have a high risk, that's what you do. And how often, if you have a high risk, do you recommend?

Dr. Giuliano:
Well, if you have a high risk greater than 20%, it would be every six months alternating with an MRI.

Mary Alice:
Okay.

Dr. Aliabadi:
Can I summarize something, which is what I do in my office and you tell me if it's too much or not? In my office-

Dr. Giuliano:
We know you're very aggressive.

Dr. Aliabadi:
I'm very aggressive. I'm going to say-

Mary Alice:
Thorough. Thorough.

Dr. Aliabadi:
But can I tell you my aggressiveness, I don't want to jinx it, but I've practiced 20 some years, I have never ever missed cancer in any of my patients. I tend to catch... I catch ovarian cancer stage one. But I think that aggressiveness helps. When you talk about a population, yes, putting a 1000 people through something to catch that one person, it's not cost-effective. But if that one person is your wife, your daughter, your mom, your sister, it makes all the difference on the planet. So here's what I do in my office and I've done it for years At 35, regardless, I get a baseline mammogram. If you're normal, normal means 12.5% chance of getting breast cancer. To me, if I told you, would you board a plane that has a 12 and a half percent chance of crashing, most people would say no, that's a big number. Breast cancer average risk is 12.5%. So if your average risk, for me in my practice means less than 15%, I would do a baseline mammogram at 35 and at 40 I start imaging mammograms every year. If you have dense breasts, I add breast ultrasound. 50% of women have dense breast, so they need breast ultrasound. If your lifetime risk is 20% or more, I start breast imaging at 30, meaning with mammogram, ultrasound, and I also add MRI. If you have a gene mutation like BRCA1 or BRCA2, I start breast imaging at 25. Because those patients are at a higher risk of developing cancer even earlier. If your lifetime risk falls anywhere between 15% to 20%, which it falls into that intermediate category, you're not really high risk, but you're also not really low risk, every two to three years I might add an MRI in addition to mammogram and ultrasound.

Mary Alice:
And this is after you calculate your lifetime risk. Most women don't calculate their lifetime risk. So this is something we're going to try to change. We're going to actually have a risk calculator on our website that women can go to. We really want to try to educate them to know their lifetime risk. And then once you know your lifetime risk and have the knowledge, then those are the guidelines. What do you think about her guidelines?

Dr. Giuliano:
I love her guidelines. I think you could argue about the 35, your lifetime risk doesn't start at 35, your risk of breast cancer at 35 in a large population may be 1 in 5,000 to 10,000. So you're going to do 10,000 mammograms to catch one cancer. But it's a reasonable way to go if your insurance company pays for it. If you're willing to spend the money for a mammogram, it's not going to hurt you getting one mammogram. And as she says, if you're that 1 in 10,000, it's a big difference. And I see plenty of women who are in their 30s.

Dr. Aliabadi:
I had a patient last week, she's been under my care for many years, she is now 38. I diagnosed her. She had a high lifetime risk with a family history of breast cancer. So starting at an early age, I've been imaging her regularly, mammogram, ultrasound and MRI. Beginning of COVID, because I don't take insurance she couldn't afford my office, she left. But she knew exactly what she needed to do. She forgot about it. She went to another doctor. And because of her age, she was never given an imaging order, even though her lifetime risk is about 38%. So she didn't get imaged for the past three years. She showed up to my office a week ago. She has advanced stage breast cancer. So that's why I think because women don't know their lifetime risk of breast cancer, because doctors are too busy or they don't know about this number, having women be their own advocate, know what their lifetime risk score is. When I walk in a party, you think I'm psychotic, but I imagine these people with a bubble above their head with a number. I want to live in a world or I want to leave this world when every single woman walking on Earth knows what that number is above their head. Because that will save millions and millions of lives. And that's why I force my celebrity patients with high lifetime risk. I beg them literally to come on this podcast and talk about it, because I don't have a voice. But they have a platform. They have a voice. If every single woman knows their lifetime risk of breast cancer, they're going to handle it. I had a French woman who came to my office, I diagnosed her with BRCA1, as you know, it's a very high lifetime risk of breast cancer.

Mary Alice:
80%.

Dr. Aliabadi:
82, north of 80%.

Dr. Giuliano:
That's a high percent.

Dr. Aliabadi:
She looked at me, and you know what she said? She said, you American doctors are crazy. I'm not going to do breast imaging. I am not going to remove my breast. If you think I'm going to remove my breast, you're completely nuts. She walked out of my office. But you know what? I didn't feel bad about it. I had done my job. I had diagnosed her. I told her exactly what she needed to do. What you do with that information then becomes your choice. But I also want women to know that there are options for them. If you have a high lifetime risk of breast cancer and you don't want to do a double mastectomy and then know that your doctor needs to order these imaging, insurance companies will approve your breast MRI if your lifetime risk is more than 20%. And like you said, there are hormone therapies that can reduce your lifetime risk of breast cancer. So if your lifetime risk of breast cancer is 40% and you take Tamoxifen, let's say for five years, you can reduce that risk to 20 and a half.

Mary Alice:
I didn't know that was half.

Dr. Aliabadi:
It's 50% lower. But people don't know that. Doctors don't know it. At least offer it to the patient and then let them decide. Let patients be their own advocate. Let women make their own decision. Instead of having a doctor make that decision for them, I think women should make that decision.

Dr. Giuliano:
I totally agree with you. I have some very prominent women here in Hollywood who are BRCA1 or 2 positive, who elected not to remove their breasts. And I see them, I follow them very carefully. I'm very anxious for them. They understand what the problem is, and it's their choice. Again, risk is very personal.

Dr. Aliabadi:
Right.

Mary Alice:
I think that's really the most important thing that we're talking about today, which is it's really every woman's choice. But she needs to have the choice. She needs to have the knowledge so that she can make the choice.

Dr. Aliabadi:
Bravo.

Mary Alice:
And like you said, most women in this world can't have access to you or can't go to your office, whether because they can't afford it or because they don't live in Los Angeles or whatever that means. That's why we started this podcast, because it's your life mission to make sure that this knowledge and this knowledge gets out there to all women so that they can make their own choice. And the only way they can make their own choice is if they have the knowledge. And know your lifetime risk. And once you have that, what to do with it. And it's confusing. That's why I'm sitting here a little bit as a layman and trying to ask these very simple questions that most women are so confused about. We are. There's just a lot of information swirling around. So I just really... I couldn't thank you enough for being here today. I've heard so much about you from Dr. A. And to have you here and to be able to share your knowledge to all women is so powerful. So thank you so much for being here.

Dr. Giuliano:
My pleasure, thank you for having me.

Dr. Aliabadi:
Thank you. You know I love you.

Mary Alice:
And at the end of every episode, we like to give our listeners an action plan. Five things that you think that every woman should do.

Dr. Giuliano:
Okay. Get your mammogram appropriately at age 35 if you're her patient, or 40, if you want to adhere to the guidelines. Know your risk. Don't be too afraid if you get breast cancer, because as we just heard, it's a very curable disease with a lot of different types of treatment. Get a second opinion when appropriate. And...

Dr. Aliabadi:
Can I finish it for you?

Dr. Giuliano:
Please. Give me one more.

Dr. Aliabadi:
If your doctor is not ordering the right imaging for you and you know you need it, go to a different doctor.

Dr. Giuliano:
There you go. That's five. Thank you

Mary Alice:
That's five. Thank you for that. Thank you so, so, so much. We really appreciate you being here. It's such an honor. It really is.

Dr. Giuliano:
Thank you. Pleasure to be here.

Dr. Aliabadi:
You are one of a kind. And I hope you never retire. I'm not going to let you retire.

Mary Alice:
Dr. A, can you give us our five action plan tips for today's episode?

Dr. Aliabadi:
Yes. Number one, know your lifetime risk of breast cancer. You can go on our website and calculate that risk. Number two, if your lifetime risk for breast cancer is average, meaning it's about 12.5%, then you need to start breast imaging at age 40. You start that with mammograms, and if you have dense breasts you ask your doctor to order a bilateral breast screening ultrasound. Number three, if your lifetime risk is 20% or more, you fall into the high risk category, which means you need to start breast imaging as early as 30, and that imaging needs to be done every six months. You can alternate mammogram and ultrasound with an MRI of breast every six months. Number four, if you fall into the intermediate category, meaning your lifetime risk is anywhere between 15 to 20%, then I recommend starting breast imaging at age 40 with a mammogram. And you can add a breast ultrasound in case you have dense breasts. But I also recommend adding a bilateral breast MRI every few years just to be safe. Number five. If you have family history of breast cancer, I recommend doing a genetic test. These genetic tests are almost always covered by insurance.

Mary Alice:
Thank you so much for joining us today on SHE MD. If you want to stay strong, healthy, and empowered, follow us on social media at SHE MD podcast and subscribe to our show on YouTube or wherever you get your podcasts. And if you want today's action plan, go to shemdpodcast.com.