An Empowering Book by Experts Offers an Insightful Look at Breast Cancer Care

It was 1996, and Rachel Brem, MD, a radiologist, was weeks away from her own preventive (also called prophylactic) mastectomy, having learned she was a BRCA1 carrier. She decided to do an ultrasound on herself. That’s when Dr. Brem, now the director of the breast imaging and intervention center at the George Washington Cancer Center in Washington, DC, discovered her own breast cancer and ultimately underwent a double mastectomy and chemo.

It’s this personal experience and her long medical career that inform her new book, No Longer Radical: Understanding Mastectomies and Choosing the Breast Cancer Care That’s Right for You, which she cowrote with her colleague Christy Teal, MD, the director of the breast cancer center and the chief of breast surgery at George Washington University Medical Faculty Associates.

Here, Brem, the inspiration for the Brem Foundation to Defeat Cancer, a DC-based nonprofit focused on education and advocacy, discusses why this book is needed — now — and what future treatments for breast cancer might be.

This interview has been edited for grammar and length.

Everyday Health: Why write this book now?

Rachel Brem: Christy and I have been committed to writing a book and had been talking about it for a long time. My epiphany came years ago when I read a New York Times article by a woman who never had breast cancer and who wasn’t BRCA-positive, yet she recommended that women should never have preventive mastectomy or have their breasts removed. After Christy’s mother passed away from breast cancer she was also committed to writing a book. When the world got quieter during the pandemic, Christy came into my office and said it was time to write the book. We both knew that we had a very unique perspective as caregivers, physicians, and patients.

EH: Speaking of being a patient, how does your experience play a role when you meet with patients?

Brem: I don’t think people need [to have had] every disease to be compassionate physicians. However, it gives us a perspective that people who aren’t in our shoes don’t have, and it gives us an additional closeness with our patients.

EH: In your book, you and Dr. Teal break down the four biggest breast cancer risk factors as: 1. mutation/family history broadly; 2. dense breasts; 3. biopsies with atypical findings; and 4. Hodgkin's lymphoma. Which matter most?

Brem: They matter differently, because certain factors give you an increased risk, and every woman at increased risk doesn't necessarily have the same risk. The biggest risk is BRCA1, but the cancers that women with BRCA1 are at risk for are different from BRCA2. If you’ve had radiation for lymphoma, you have a 50 percent lifetime risk. If you have dense breasts, the risk is four- to sixfold higher than for the general population, so there are a lot of factors to consider.

EH: Are your choices different if you’re in your twenties and learn about your high-risk status rather than delving into your family tree when you’re older?

Brem: There are a couple of answers to that. First of all, why do some families with BRCA1 get breast cancer in their twenties, while another family with that same mutation may get it in their seventies? We know that this exists. It’s important to think about cancer as a complex process that’s likely caused by multiple gene mutations. Also, make sure to tell your doctor how old your relatives were when they developed breast cancer — it’s a factor to consider when thinking about risk. The American College of Radiology recently recommended that all women get a risk assessment at age 25 so that women who are at high risk can be more closely monitored.

EH: What do you wish women with BRCA mutations knew about their options?

Brem: Women with mutations confuse surveillance with preventive mastectomy, but they’re fundamentally different. One is to find cancer early while the other is to change the narrative and hopefully to never have cancer at all.

EH: When it comes to mastectomies, what advance do you think is the most exciting?

Brem: It’s not new, but nipple-sparing mastectomies are a game changer. The cosmetic result is magnificent, and the scar can be no different from the scar women get after having a cosmetic augmentation. My hope for the future is that we’ll be able to create the form of a breast via tissue engineering. It’s not here now, but that’s going to happen.

EH: I read that the Brem Foundation is focused on risk-based screening. This includes an ultrasound and MRI, which can detect 25 percent more cancers. Can you tell us more about this?

Brem: Risk-based screening is critical. So many women don’t know you can have breast cancer with a normal mammogram. And, since 40 percent of American women have dense breasts, we need additional screening to find these hidden cancers. These are important cancers. You might say every cancer is important, but some are more important than others. The cancers we find with an ultrasound are small cancers that, while they haven’t spread to the lymph nodes, are actually most concerning. These are killer cancers. For women at high risk, an MRI every year is reasonable, too.

EH: What are some other initiatives the foundation is working on?

Brem: This year, we are increasing our presence in advocacy and legislation — to open access to screenings and diagnostics for all women — regardless of socioeconomic background. We’re also markedly expanding our focus on the critical impact of healthcare on underserved populations. Through our Wheels for Women program, we’re partnering with Lyft to provide transportation to free mammograms. Transportation is a huge barrier to getting access to care.

EH: Whether it’s personalized medicine that can analyze how well a drug will work for you, the use of AI in analyzing mammograms, shorter MRI time and ultrasound tomography, which future breast cancer innovations are you looking forward to?

Brem: Never have we had quicker and more impactful innovations. As I write in the book, my hope is that my grandchildren and great grandchildren will only know of breast cancer in the history books. My hope is that we will find a cure for this ravaging disease just as we did with polio and smallpox.