From Mammograms to Mindset: Navigating High-Risk Breast Care with a Nurse Practitioner’s Guide

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Welcome to Doc Discussions.
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I'm Jason Edwards and I'm here today with Jill Flores.
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Jill's a nurse practitioner in the women's clinic, specifically in the breast clinic.
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How are you doing today, Jill?
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Great.
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Thanks for having me here today.
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You bet.
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Now, where are you from originally, Jill?
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I grew up in Harvester, Missouri.
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Okay, yeah.
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So just down the road.
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Yeah.
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Very good.
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Um, and so what was your education like to get to this point?
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Where did where did you go to school?
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I knew I wanted to be a nurse when I was in high school, and I went to Missouri Baptist School of Nursing.
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And I it was an associate's degree at that point in time when I graduated and when I was finding a job, I started working at it was Mercy then, um, but it was St.
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John's.
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Sure.
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At that point, um, I did postpartum, anapartum, and then I started doing labor and delivery.
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And when I came back here, I was actually encouraged by my OBGYN to go back to school to become a nurse practitioner.
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And I I did.
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And then I um started working for some OBGYN groups throughout the area.
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And I was working for obstetrical associates here at St.
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Luke's, and I had the opportunity to uh move to the breast center about three years ago.
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Yeah, very cool.
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So you have this kind of long history of women's health.
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And um, and I'm sure that serves you well, and you're probably able to help patients out um, you know, use every once in a while using your um OBIN history too.
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Absolutely.
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And that's kind of the nice thing about being in the breast center and having some GYN experience because with all the concerns with birth control, hormone replacement therapy and the challenges that are faced with do they do these medications and what it could potentially affect their breast health.
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Um, it's good to have that knowledge behind me to hopefully be able to give them a little bit of encouragement and some information one way versus the other.
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Yeah, for sure.
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Um, for sure.
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And so can you walk us through um what you guys do at the high risk breast clinic and and who the patients are that it serves?
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Sure.
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Stephanie and myself, we're the two nurse practitioners in there, and we pretty much so run the high-risk clinic.
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And what that is, um, patients that are deemed high risk, that typically here at St.
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Luke's is started at the time of their mammogram.
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And when women, when the person shows up for their mammogram, they're given a black tablet and it has on there a questionnaire about a cancer risk assessment.
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The cancer risk assessment asks questions about their personal history and their family history.
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Personal history being, for instance, how old they were when they started their menses, um, how old they were when they had their first child, if they've used birth control, hormone replacement therapy, any personal biopsies or things that might put them in an increased risk for breast cancer.
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And then it asks about the personal history, um, I'm sorry, family history and their type of cancer and then their age that they were diagnosed.
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That is put into a model that gives us a percentage of a lifetime risk of having breast cancer.
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The average woman walking around on the street is at about a 12% lifetime risk.
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Anyone who is labeled 20% or greater is considered high risk.
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At that time, the patient is notified, usually by a letter, after their mammogram is completed, and they are encouraged to contact our high-risk services, and then they are scheduled an appointment for a more comprehensive plan of care.
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The comprehensive plan of care would include additional screening interventions, um, you know, not necessarily just the mammogram, but maybe a complete breast ultrasound or an MRI based upon their lifetime risk, lifestyle interventions, maybe some modifications they can do in terms of their diet, exercise, maybe some medications that may help to reduce their risk.
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And then they are encouraged to have you know more frequent exams, uh, maybe even do genetic testing based upon what the family history has told us.
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Okay.
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And so for an example, if say a patient is kind of like a normal patient with regard to mencies and things like that and birth control, which all that's getting at just lifetime estrogen exposure, I would assume is the main deal.
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Um, but their mother had breast cancer.
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Would that alone put them in the high risk category?
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I know I'm kind of asking you to do the model off the cuff here, but does that typically put them in the high risk category?
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Not necessarily.
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It really depends upon the age that their mom was when they were diagnosed.
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Okay.
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Anyone who is diagnosed at age 50 or less, that sometimes can be a red flag, although that might be more from a genetic standpoint versus actual patient risk for breast cancer.
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If they've also had a recurrence of a breast cancer, um, their mom maybe had a you know cancer at 50, but then again had one at 65, that sometimes can be can put them at an increased risk.
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Okay.
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So so um so if somebody's um why is it that it's um you know risky the risk is higher if the patient's younger?
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Is it or if their patients, if their if the patient's um the high-risk patient's mother was younger at the time of diagnosis, why does that um does that uh correlate higher with like a genetic, like a gene mutation?
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Yes.
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Sometimes we'll see the cancers be a little bit more aggressive and they will be a little bit I think more detrimental to their health because they're diagnosed at uh usually a later stage if it is more from a genetic standpoint.
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But we have I have a lot of patients who have genetic mutations that can increase their risk for breast cancer, and it doesn't mean 100% you're going to get cancer.
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It's just that you're more likely than the average person.
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So there are certain genes that might recommend having like prophylactic surgeries.
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Um, you don't have to do that, but you know, that certainly is an option for certain women at certain ages once they've completed childbearing.
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And I have some patients that are very for doing anything prophylactic they can do, and other patients, you know, are very um cautious about surgeries or any other interventions that we offer.
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Is that um the patients who would get like a prophylactic surgery, meaning that they get a surgery before the diagnosis of any cancer, is that typically just the BRCA patients, or are there other mutations that feed into that?
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Yeah, that's a good question.
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Um it really kind of depends.
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Um, there are several.
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Um, of course, BRCA is the most known, and that BRCA1 and two is about a 60 to 80% lifetime risk of having a breast cancer.
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Although I've got several patients now who are BRCA1 and two who have never had cancer at all and haven't done the surgeries.
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But there are certain other ones like ATM, Check 2.
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Those aren't which the guidelines like NCC and the you know um National Cancer Coalition.
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Yeah, yeah.
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They um they will certainly they they don't recommend it, but they don't say you can't do it either.
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So a lot of times it's a patient contacting their insurance company to see if the insurance company will cover it or not.
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And we've had several patients.
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I've got several with the um check two in particular who have done the um prophylactic surgeries just because of that.
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And most of those people have a strong family history of cancer as well.
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Yeah, and and whether it's BRACA or CEC 2 or ATM, these are all genes that um we all have, but if you haven't, and they all are involved in the gene editing and and DNA repair or sorry, DNA editing and repair um pathway, I believe.
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And um and so if you have a um a mutation in these, um you can get other cancers aside from just breast cancer, right?
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Absolutely.
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We do more of a comprehensive panel.
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So if we know somebody comes in and they have a family history of BRCA per se, they will get tested for that one, but it it's really in the whole entire gene panel.
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The breasts, the genes are not specific to just breast and ovarian.
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Um in we do a myriad, which is a 48 gene panel, and in that panel there um it would cover like kidney, endocrine, um, skin, uh, colon.
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So some genes that are, you know, can produce breast and ovarian cancer can also lead to those other cancers as well.
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So obviously in the breast center, we would manage the ones that increase the patient for breast, but I have had to refer patients to other providers, such as dermatologists or um or you know, GI doctors to manage that specific gene mutation.
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Yeah, yeah.
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Um, do you see any men in the breast clinic?
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Because you know, some men can have uh like a BRCA mutation and have an increased incidence of male breast cancer, or is that not very common?
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I mean, I know it's uncommon in general, but Yeah, we do.
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We do see um male um patients in our clinic, not very many, but we do.
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Um, some of them are referred from their primary cares with a breast mass, and then at that point it's just specific to the patient on what imaging we would do at that point in time.
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Um we also will, if we have a male with a breast cancer, you know, usually it's BRCA.
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Um and then we would do genetic testing on them.
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Um we don't we don't really see a lot of men, if even if they are BRCA-positive, we typically don't do the high-risk screening on them that we would do on a female patient.
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But but yes, there are certain surveillance measures that we still need to have um based upon their individual care.
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Yeah, yeah.
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For a male, you know, it's it would be extraordinarily difficult to do a mammogram.
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You could by clinical exam and maybe ultrasound.
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We do.
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Um we can do mammograms on them.
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Sometimes if they have some gynecomastia um, you know, going on too.
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And if there's a mass there, you know, we need all the imaging we can get.
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Typically we would then refer them for an MRI because then we can we can find the um and see a little bit more of the tissue.
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Yeah.
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Um and so are there any uh so we know for the screening, like you said, that there's mammograms and ultrasounds and MRIs of the breasts.
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Um do they do any screening with uh not just screening for with um blood work at all in these patients or not really?
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Not really.
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The only screenings we would really do is more of from a genetic standpoint, um, you know, but no, typically we don't do usually do any blood work.
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Yeah, after somebody's already diagnosed.
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Correct.
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Yeah, they they do have some um screening tests out there, the gallery is a common one, um, but it's it's um so often inaccurate that it's probably not ready for prime time.
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Do you have any experience or knowledge of uh of uh the tests like that?
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You know, the where you just it's like somebody wants to come in and make sure they don't have cancer and they get a blood draw?
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Yes.
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I've had a federal several patients that have had that testing done, um, not obviously here at St.
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Luke's, but have reported their testing to me.
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I don't know much about that.
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My question always to the patient is I don't know how often they need to do that, you know, for for reassurance of that.
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And I don't think it's covered by insurance.
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I I don't think so.
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It it's kind of I think it it's in its infancy probably.
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I mean, it's been around, you know, the the the whole thing has been around for a while, but as far as like being available to the consumer, um, it's something you can buy yourself and run.
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But the problem is if it's negative, there's a high probability you don't have cancer.
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But if it's positive, it's still more likely that you don't have cancer than you do, but you have to go down this road and have this you know million-dollar workup, and and there's all this anxiety and everything that kind of goes with it.
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And so I think when so the the specificity is high, but the sensitivity is not great.
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And so hopefully over time they can improve that to where it's kind of a more useful tool, but probably you know, the the the reason the insurance doesn't cover it is not because you know the insurance company's hateful, it's just not that useful of a test currently.
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Um but hope you know, hopefully as time goes by, I'm sure they've made great progress up to this point.
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Hopefully they will continue to make progress on it.
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Um and so we we'll we'll see.
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Absolutely.
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So what if if um so what kind of lifestyle modifications could a person make to decrease their probability of getting breast cancer?
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I usually tell patients it things that they would be told by their primary care, the cardiologist, things for a healthy heart are very breast protective.
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So having a very, you know, healthy diet, lots of fruits and vegetables, high fiber bran.
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Um I think they say like the Mediterranean diet, the DASH diet, different things like that can certainly, you know, be very lifestyle and things that help your your heart can certainly help reduce your risk of all cancers.
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Of course, I focus more on breast.
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Sure.
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Um, and then certainly, you know, regular exercise.
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There's lots of research supporting that you know, exercise, you know, definitely helps.
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Um, our bodies were meant to move, and that's it.
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And I think with um with that, I have a good friend who's a physical therapist, and she said in their in their sayings, it's sitting is the new smoking.
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So inactivity can be just as detrimental to your health as smoking can be.
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And a lot of patients will kind of open their eyes a little bit whenever I say that.
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So I think it's really good to keep them moving in um whatever, whatever fashion they they possibly can.
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Certainly, then we would recommend um, you know, them to, you know, watch any kind of if they're smoking, I definitely recommend that they discontinue smoking, even vaping, um, any kind of nicotine certainly can be uh detrimental to the breast health.
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We see sometimes even recurrent infections with decreased blood flow from the vasal constriction.
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Yeah.
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And then um alcohol too.
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I think the current guidelines are recommending like one drink or less a day.
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So we try to make sure that they're utilizing those healthy lifestyle choices to reduce their risk.
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And is is the the exercise and the diet, does that have to do with the fact that if the more fat you have on your body, the fat secret, you know, fat cells secrete a lot of hormones, including estrogen.
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Is that the is that the mechanism of action kind of at play with that?
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It can.
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And that certainly can be, you know, being overweight can be a risk factor for breast cancer.
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Yeah.
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Um, and but yes, the circulating estrogen, you know, our body produces in that fat tissue uh hormone called estrone.
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You're like, yay, hormone, but it's not the good hormone.
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And in fact, a lot of women when they're coming in with like maybe menopausal symptoms, you know, then I say usually, you know, reducing your body weight by sometimes even 10% can really significantly reduce even your risk for breast cancer, but reducing your your hormones and reducing your uh menopausal symptoms, hot flashes, you know, moodiness, irritability, yeah, things like that.
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Yeah, and it's it's of course it's hard.
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You know, we all we all want to do our best to to stay lean, but it's it's a it's a it's a lifelong battle for sure.
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Yes.
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And with the alcohol, you know, there's a relationship between that and breast cancer.
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And I think as time goes on, medical professionals kind of recommend less and less alcohol.
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Um they used to say two drinks for men and one drink for women a day.
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But and and and you know, I I like you know having a beer every now and then too.
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But in in general, a good reframe is that alcohol is poison.
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I mean, it's not it's not good for you, it messes up your sleep, it causes all kinds of issues.
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And so yeah, I agree.
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You want to keep that to a minimum kind of across the board.
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Right.
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Um and so the what what challenges um do you guys find in the breast clinic?
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Um, whether it's um uh with getting patients to do things or current screening, what what are some big challenges that you guys deal with?
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Well, actually, my patients listen to me better than my kids do.
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So, you know, I said that's always uh if I can get my kids to listen to me as well as my patients do, I'd be uh if you figure that out, let me know.
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All right, all right.
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But one of the main challenges that I have mainly is with the MRIs and getting the insurance companies to cover them.
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Um, you know, we I've been on an like an email panel with providers from all the other entities, you know, SSM and um WashU, SLU, Mercy, and we're trying to fight the legislation to get these MRIs covered.
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These people meet criteria 100% to have the imaging done, but the insurance companies don't want to cover it.
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There was a law that came out, was it last year, that said that the MRIs were going to be covered for patients.
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But what we found out is that it's for patients who have their insurance company who is based out of the state of Missouri, which is very few and far between.
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So, you know, and I don't ever want a patient to have to determine do I make my car payment this month or do I have my breast MRI?
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But a lot for a lot of women, and I have I kept keep a list of women that I have who, you know, when I go to fight these legislative people and for them to help us, I'm like, look at all these patients that I have that are more than willing to do the imaging.
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It's just that they don't have the funds or the means to be able to do that.
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And that's one of the main challenges I have.
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I think at St.
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Luke's here, we do a great job with, you know, just staying on top of our patients and offering services and trying to make some accommodations for patients and, you know, even changing our schedules to accommodate their schedules so that we can get these ladies in, get them seen, get them evaluated.
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What I found is that early detection, that is the key.
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If we can catch something as early as we can, there's less interventions and longer survival.
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And that's the goal of any kind of cancer.
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But, you know, specifically, you know, for breast, most of the patients that I see, they have families, you know, their moms, their sisters, their daughters, they're, you know, their teachers.
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They they don't have time for cancer to slow them down.
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So granted, you know, it's a little bit of work on their part to have to schedule the appointments.
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Um, but if we can, you know, get them in a good fashion where we're evaluating them appropriately, then if something does change, we can there again get them in as soon as we can, get them evaluated, get them treated for, you know, for longer survival.
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Yeah, for sure.
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So are there any common misconceptions or any reasons that patients would kind of be hesitant to come in to the breast clinic that you see?
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Usually in discussing that with patients, it's usually a time factor thing.
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Um, in fact, I've seen patients where they have been given the letter after their mammograms that they're high risk or they would like to, you know, have the high risk assessment, you know, performed on them.
00:18:39.670 --> 00:18:43.110
But sometimes it's just a time thing, um work constraints.
00:18:43.269 --> 00:18:55.589
Uh women are so used to taking care of everyone else in their families, their children, sometimes their parents, their spouses, um, other siblings, their work, their coworkers, and they always put their own health on the back burner.
00:18:55.750 --> 00:19:07.750
But so it's very interesting when a woman comes in and I try to explain to them, just like when you're on an airplane, when the oxygen comes down, you know, the flight attendant says, take care of yourself first so you can take care of everyone else in your in your area.
00:19:07.910 --> 00:19:10.789
And that's kind of the way I see this uh too.
00:19:10.870 --> 00:19:12.950
Um, you know, taking care of your own breast health.
00:19:13.190 --> 00:19:17.430
Then if you're healthy, you can help get everyone else on track as well with your family.
00:19:17.750 --> 00:19:18.549
Yeah, for sure.
00:19:18.710 --> 00:19:19.829
That's really good advice.
00:19:20.069 --> 00:19:30.630
I would imagine if if you were a patient and you had a higher risk of any kind of cancer, that there would be some psychological aspect to it, whether it's the worry that comes with it.
00:19:30.710 --> 00:19:35.750
Um, what advice do you have for patients and how to deal with the kind of mental and emotional side?
00:19:36.150 --> 00:19:36.470
Sure.
00:19:36.630 --> 00:19:42.390
Well, and they I always reassure patients when they walk out the door, if there's any change at all in their breasts, just give us a call.
00:19:42.470 --> 00:19:43.910
You know, we're just a phone call away.
00:19:43.990 --> 00:19:52.470
I have patients that live in Illinois, southeast Missouri, you know, up in northern Missouri, you know, several hours away, but we're just a phone call away.
00:19:52.549 --> 00:19:58.710
So sometimes they just need that person to hold their hand or just to reassure them that, you know, that this is gonna be fine.
00:19:58.789 --> 00:20:02.710
And I tell patients now, you know, it's like I'm holding your hand now, I'll hold it then too.
00:20:02.950 --> 00:20:04.950
You know, if you end up with that diagnosis of it.
00:20:05.110 --> 00:20:13.350
But there again, the pattern, the fashion that we're doing this, hopefully seeing somebody every six months with doing mammogram and then alternating it six months later with an MRI.
00:20:13.430 --> 00:20:18.069
If there's any change within that six months, then we'll be able to address it at that point in time.
00:20:18.309 --> 00:20:21.029
And, you know, and and women know their bodies.
00:20:21.190 --> 00:20:24.710
And so if a patient calls me and says, hey, there's something going on here, I trust her.
00:20:24.870 --> 00:20:26.630
Like, come on in, let's do some imaging.
00:20:26.789 --> 00:20:41.990
And then if we can put a picture with what we're feeling, sometimes that can help, you know, give them a little bit of reassurance, like, oh, it was just, you know, fibroglandular tissue, or oh, I had a cyst that, you know, is benign, you know, finding, or, you know, I said now we know what we're feeling.
00:20:42.069 --> 00:20:43.430
We now we get your new baseline.
00:20:43.509 --> 00:20:44.870
So this is what we have.
00:20:45.029 --> 00:20:50.150
I tell patients all the time, you know, just like, you know, as we age, our hair changes color, you know, to gray.
00:20:50.230 --> 00:20:52.150
It doesn't mean there's anything wrong with our hair.
00:20:52.309 --> 00:20:55.190
It's just a new finding, and breasts can change as well.
00:20:55.350 --> 00:21:00.549
And a lot of times I'm seeing patients through their 40s, through their 50s, through their 60s, and and and so forth.
00:21:00.710 --> 00:21:05.990
And obviously, our women's bodies have a tendency to change as we age and as we trend towards menopause.
00:21:06.069 --> 00:21:08.630
And so the breast tissue is going to change as well.
00:21:08.789 --> 00:21:12.630
Sometimes it changes for the norm, sometimes it doesn't change for the norm.
00:21:12.789 --> 00:21:22.549
And it's just determining, you know, when or teaching your patient like when there's a problem, when to call, when to notify us, and then when we need to, you know, maybe address it a little bit further.
00:21:22.789 --> 00:21:24.150
Yeah, yeah, I agree totally.
00:21:24.230 --> 00:21:27.910
You know, knowing that somebody's there if you need them, you know, makes a big difference.
00:21:28.150 --> 00:21:41.750
Um, and so how um if a patient had some concern and wanted to get assessed and kind of go through the um risk model to see if they would meet criteria for the high-risk clinic, um, how would they go about getting a hold of you guys?
00:21:42.150 --> 00:21:46.390
We have a high-risk nurse navigator and we can give you that number.
00:21:46.549 --> 00:21:53.110
And what a patient would do is call if she doesn't answer or leave a message because she's probably on the phone with another with another patient.
00:21:53.350 --> 00:22:06.390
But it's a maybe 10-minute conversation and it will ask questions about the personal history and family history, and then it will give us your lifetime percentage of having a breast cancer.
00:22:06.470 --> 00:22:24.069
If patients hit the criteria of 20% or greater, then they would be offered to schedule an appointment with either Stephanie or myself, nurse practitioner, and then we bring the patient in and then they said have that um discussion and get them set up with a great plan to help um evaluate their breasts appropriately.
00:22:24.390 --> 00:22:33.589
Okay, and so if people want to get a hold of Becky, our high risk nurse navigator, the phone number is 636 530 5512.
00:22:34.150 --> 00:22:38.069
Jill, thanks so much for all the good work you do at the hospital and thanks for your time today.
00:22:38.309 --> 00:22:38.630
Thank you.
00:22:38.710 --> 00:22:39.269
Appreciate it.
00:22:39.509 --> 00:22:39.990
You bet.