Facts vs. Fiction with Dr. Dennis Holmes

Today on the show we’re talking about factors that affect your risk for breast cancer. Some factors affect breast cancer risk a great deal and others only a small amount. Understanding the factors affecting your risk can help you work with your healthcare provider to develop a breast cancer screening plan that’s right for you.

To help us learn more about the risk factors for breast cancer, Dr. Dennis Holmes joins the Real Pink podcast. Dr. Holmes is the Associate Professor of Surgery at the John Wayne Cancer Institute in Santa Monica, California. As a world-renowned breast surgeon and longtime supporter of Susan G. Komen, Dr. Holmes has dedicated his career to breast cancer treatment and breast cancer research. Dr. Holmes, welcome to the show.

About Dr. Holmes

Dr. Holmes is an internationally-renowned dedicated breast surgeon and cancer researcher who has held the position of Breast Center Medical Director at several hospitals in Los Angeles County. Dr. Holmes has also served as Chief Breast Surgeon and Medical Director of the Los Angeles Center for Women’s Health and as Chief Breast Cancer Surgeon and Breast Cancer Research Committee Co-Chair at the University of Southern California (U.S.C.) Kenneth Norris Comprehensive Cancer Center.

Dr. Holmes is a 2003 graduate of the U.S.C. Breast Surgery Fellowship Training Program, one of the most progressive breast surgeon training programs in the U.S. Breast surgery fellowship training represents not only the highest level of commitment to excellence in breast cancer surgery but also dedication to understanding the roles of medical oncology, radiation oncology, plastic surgery, and other critical services in the management of breast cancer. Since then, Dr. Holmes has integrated this experience into the training of over 20 breast surgeons in his former roles as Program Director of the U.S.C. Keck School of Medicine and John Wayne Cancer Institute’s Breast Surgery Fellowship Programs.

Dr. Holmes serves in the leadership of several national surgical societies and is a frequent lecturer at conferences internationally. Dr. Holmes is a Fellow of the American College of Surgeons and currently serves as President of the TARGIT Collaborative Group, a national intraoperative radiotherapy research and education organization, and Conference Program Chair of the 20th Annual Meeting of the American Society of Breast Surgeons, the nation’s largest breast surgeon society.

Widely respected by colleagues for his innovative approach to breast cancer care, Dr. Holmes has gained worldwide acclaim for his pioneering research in intraoperative radiotherapy and cryoablation (tumor freezing). He currently serves as National Co-Chair of the TARGIT U.S. Registry clinical trial and as National Principal Investigator of the FROST Trial, a clinical trial evaluating the use of cryoablation instead of surgery for the treatment of early stage breast cancer. In addition, he has been a pioneer in the field of minimally-invasive breast surgery, including intraoperative radiotherapy, oncoplastic surgery, and lymph node-sparing surgery.

Dr. Holmes is a strong advocate for individualized or personalized cancer therapy that adapts the extent of care to the severity of the cancer, minimizing unnecessary side effects. Where many breast surgeons see challenges, Dr. Holmes sees opportunities to optimize cancer control as well as patient quality of life. However, what distinguishes Dr. Holmes most is his high level of commitment to providing women with treatment options that suit their physical and emotional needs while also managing the breast problem effectively.

Most of all, Dr. Holmes believes wholeheartedly that, with proper treatment, most women diagnosed with breast cancer will live a long, fulfilling life—a life both richer and more meaningful than they could have imagined following diagnosis. Let your journey begin.


Adam: [00:03] From Susan G. Komen, this is Real Pink, a podcast exploring real stories, struggles and triumphs related to breast cancer. We’re taking the conversation from the doctor’s office to your living room.

[00:16] Today on Real Pink, we’re going to talk about factors that affect your risk for breast cancer. Some factors affect breast cancer risk a great deal and others only a small amount. Understanding the factors affecting your risk can help you work with your healthcare provider to develop a breast cancer screening plan that’s right for you.

[00:34] To help us learn more about the risk factors for breast cancer, I’ve got Dr. Dennis Holmes on the show today. Dr. Holmes is the Associate Professor of Surgery at the John Wayne Cancer Institute in Santa Monica, California. As a world-renowned breast surgeon and longtime supporter of Susan G. Komen, Dr. Holmes has dedicated his career to breast cancer treatment and breast cancer research. Dr. Holmes, welcome to the show.

Dr. Holmes: [00:59] Hello, Adam.

Adam: [01:00] It’s an honor to speak with you. I’m really looking forward to chatting and just understanding a little bit more about risk factors because admittedly, I don’t have a lot of information. So, I think you’re going to provide our audience with a lot of really good insight here. It’s going to be really fun.

Dr. Holmes: [01:13] I am happy to help.

Adam: [01:15] So let’s go ahead and get started. So what are a few of the common factors that affect breast cancer risk?

Dr. Holmes: [01:22] Well, Adam, it’s important to understand that breast cancer risk factors are physical, lifestyle or historical factors that influence a woman’s chances of getting breast cancer. So it really is a range of things. It can be genetic things, like if you have genetic predisposition, because of maybe a BRCA mutation, it could be due to a family history. For example, if you have a first, second- or third-degree family member on the mother or father’s side with a history of breast cancer or ovarian cancer, those things impact the risk.

[01:57] Breast density is something that we’ve recently learned is an important risk factor. Higher breast density is associated with an elevated risk of breast cancer. Of course, there’s increasing age, there’s issues of delayed childbirth, being overweight, lack of exercise, drinking excessive alcohol, that’s more than two glasses per day.

Adam: [02:17] So let’s talk just a little bit about some of the things that you just mentioned towards the end of your list. So you mentioned several things that are genetically, certainly beyond our control, but what about the things that are under our control? Can you talk a little more about that?

Dr. Holmes: [02:29] Right. So you made a very important distinction there. Some risk factors are changeable and some are unchangeable. Certainly genetics and family history are things that you just can’t change. Your breast density is something that can’t be changed. It’s an individual trait that a woman has and it differs from one woman to the next.

[02:49] But there are things that you can do to reduce the risk. One of those things is exercise, another is maintaining a diet rich in fruits and vegetables. The third is reducing or maintaining lean body weight. If you’re overweight, reducing your weight. These are all things that one can do, including avoiding smoking. We know that hormones, particularly combination hormones that contain both estrogen and progesterone, increase risk of breast cancer over time. So if you can avoid using it, that’s another way to reduce the risk.

Adam: [03:24] So where would someone get those hormones exactly? What would they be in?

Dr. Holmes: [03:29] Women, when they reach menopause, often have side effects of menopause such as hot flushes and night sweats that– it reduces their quality of life. Many physicians prescribe estrogen replacement therapy to women once they reach menopause to improve the quality of life and we also know that the medication has the ability to improve bone density and also may reduce the risk of cardiovascular disease in women as well.

[03:59] So there are some positives related to it, but with extended use of hormone replacement therapy, we do see an increased risk, about 20% increased risk in breast cancer. Specifically, the medication that many people are prescribed are those that contain both estrogen and progesterone, two different hormones and it’s actually the combination of the two hormones that seem to be associated with a higher risk.

Adam: [04:25] I think, just summarizing what I’ve heard you say, so as far as factors that are under a person’s control would be things like exercise, being sort of generally healthy and then just essentially aware of the medicines and medications that you’re on and the potential benefits and the potential repercussions of those medicines. Is that a good summary?

Dr. Holmes: [04:44] Right. Although I listed hormone replacement therapy as a medication that increases risk, everything has sort of pros and cons. So an individual woman has to decide based upon her personal and family history and so forth whether the benefits of taking the medication exceeds the risk of taking the medication. So if she has a low incidence of breast cancer in her family history but she has significant symptoms of menopause, she may decide that it’s worth taking those little extra risk for the benefit of reducing the hot flushes and night sweats.

Adam: [05:17] And just to dig a little bit more on the exercise and healthy side, there’s obviously a large spectrum of very unhealthy to what I would maybe determine as hyper-healthy, and so where on that spectrum would you recommend women consider themselves to be in the more healthy, less risky area?

Dr. Holmes: [05:38] Well, I guess everyone can be a little healthier. From starting from where you are, there’s always some room for improvement, but it’s actually been examined, sort of calculated, like what is necessary in terms of exercise, in order to achieve a measurable benefit in reducing your risk of breast cancer. So for the average woman, exercising two and a half hours a week, doing some sort of cardio exercise, where their heartrate is increased, whether it’s running, walking, dancing, treadmill, whatever, that has been shown to be associated with a 20% reduction in their lifetime risk of breast cancer. So that’s two and a half hours a week. I tell my patients it’s thirty minutes a day, five days a week.

Adam: [06:20] Yeah. I love that.

Dr. Holmes: [06:21] If you can manage to get up to four hours a week, that reduces your lifetime risk by 40%.

Adam: [06:28] Wow, so it doubles.

Dr. Holmes: [06:30] Doubles. And by way of comparison, for high-risk women, we often recommend to them a medication that’s given to reduce their risk of breast cancer. That medication is called Tamoxifen, for example, which has some positives—it reduces the risk—but also has some negatives. But the magnitude of that risk reduction is only 50%. Now, 50% is a lot, but compared to what you can get from exercise, you can get 50% reduction from taking a medication daily for five years or 40% from just doing exercise without any need for medication and without medication side effects.

Adam: [07:06] Wow, that seems remarkable.

Dr. Holmes: [07:08] It’s not a little difference. It’s actually a significant magnitude. When we add radiation to lumpectomy, that reduces the risk by about 60%, so you can get two-thirds the benefit of that. So, it’s not a small deal to recommend exercise, and it is really a way that people can empower themselves to take control of their risk. Nothing reduces the risk to zero, but you can do a lot to get the risk down to a manageable level.

Adam: [07:34] So Dr. Holmes, I came into this conversation fully recognizing that exercise plays a huge role in our health, huge role in reducing risk for all kinds of things. I never, in my wildest dreams, would have imagined you would say a 40% in risk for four hours of exercise a week. That’s a really good deal.

Dr. Holmes: [07:55] It’s a great deal.

Adam: [07:56] I want that deal a lot.

Dr. Holmes: [07:57] I see lots of anxious women that come in to see me, because they’re concerned about their risk of breast cancer and what they can do. I do my best to try to channel their anxiety into exercise because you can worry about it and do nothing and not [unclear 08:12] your risk but you could also focus on the things you can do, which not only impacts the breast cancer risk, but exercise reduces cardiovascular risk, which is the main killer of women, reduce the risk of diabetes, reduce the risk of colon cancer, improves energy, improves self-esteem. It has so many positives.

Adam: [08:35] Right. Wow, that’s fantastic. You’re making me want to go for a jog right after this interview, so I may do that. Wrapping up this interview, where would somebody go to find out more about, their personal risks associated with breast cancer and just get more information in general?

Dr. Holmes: [08:51] Well they should go to the Komen website. I think it’s komen.org and there’s an area where there’s a list of breast cancer risk factors. It’s also important to know that it’s just not a matter of sort of guessing what your risk is, based upon whether or not you have one of these traits that I mentioned. There are actual formal calculators that someone can plug in their family history, their age, the history of abnormal breast biopsies, and breast density that allows them to figure out on a very individual level what your lifetime risk of breast cancer turns out to be.

[09:29] One of those things that people have heard about and you can access just on the Komen website is the Gail model, which is a commonly used model for estimating your lifetime risk of breast cancer. Often, people overestimate their risks. So having an estimate that’s more precise will reduce a lot of unnecessary anxiety, but some people underestimate the risks. So knowing that you’re high risk can actually motivate you to take control of your lifestyle.

Adam: [09:59] So I think if I can just offer two takeaways from this conversation, it sounds to me like really understanding what your risk is is critical and the calculator on the Komen website is a great way to do that. That’s komen.org. Then secondarily, exercise four hours a week because it’s just great for you all around—

Dr. Holmes: [10:16] If you can.

Adam: [10:17] If you can, and if not, then two and a half hours is still a great start.

Dr. Holmes: [10:21] Yes, it is.

Adam: [10:21] It’s a fantastic start. Well, Dr. Holmes, this has been genuinely fascinating. I really appreciate your time today. I’d love to have you back on the show again sometime, and thanks so much for joining me.

Dr. Holmes: [10:31] I’d love to return.

Adam: [10:34] Thanks for listening to Real Pink, a weekly podcast by Susan G Komen. For more episodes, visit realpink.komen.org. For more on breast cancer, visit komen.org. Make sure to check out @SusanGKomen on social media. I’m your host, Adam. You can find me on Twitter at @ajwalker, or on my blog, adamjwalker.com.


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