Are you at high risk for breast cancer? An early detection guide with Dr. Thais Aliabadi

Do you really know your breast cancer risk? Many women think they do – trusting family history, regular checkups, and mammograms to keep them safe.

But what if these measures leave dangerous blind spots, leading to later, more aggressive diagnoses? 

Today's episode is a powerful wake-up call. Joining us is globally renowned OBGYN, Dr. Thaïs Aliabadi.

Known simply as “Dr. A” to her global following, she's OBGYN to royals and celebrities, and a leading voice on women’s health featured on The Kardashians, The Doctors, and Dr. Phil.

Today, you'll learn why your lifetime risk may be higher than you’ve been told, how diet and lifestyle could change your trajectory, and the essential steps to take today to safeguard your health. This is information every woman needs - don’t wait until it’s too late.

Unwrap the truth about your food 👉 ⁠⁠Get the ZOE app⁠

🌱 Try our new plant-based wholefood supplement - ⁠Daily 30+⁠

*Naturally high in copper which contributes to normal energy-yielding metabolism and the normal function of the immune system

Follow ZOE on⁠ Instagram⁠.

Add a scoop
of energy*

Delicious. Crunchy. Energizing.

Get Daily30+

Transcript

Jonathan Wolf: Thais, thank you for joining me today. 

Dr Thais Aliabadi: Thank you for having me. 

Jonathan Wolf: So we like to kick off our shows at ZOE with a rapid-fire q and a, with questions from our listeners. So the rules are, you can give us a yes, or a no, or if you absolutely have to, a one-sentence answer. Are you willing to give that a go?

Dr Thais Aliabadi: Sure.

Jonathan Wolf: Alright. Are cases of breast cancer rising in younger women? 

Dr Thais Aliabadi: Yes. 

Jonathan Wolf: Does a mammogram always catch breast cancer? 

Dr Thais Aliabadi: No. 

Jonathan Wolf: Is there an accurate way to measure your lifetime risk of breast cancer? 

Dr Thais Aliabadi: As accurate as it can get, yes. 

Jonathan Wolf: Could the food you eat influence your risk of breast cancer? 

Dr Thais Aliabadi: 1000%. 

Jonathan Wolf: And you get a whole sentence now, what's the biggest misconception about the early detection of breast cancer? 

Dr Thais Aliabadi: I don't have a family history of breast cancer, so I'm not going to have breast cancer. 

Jonathan Wolf: And that's not necessarily true? 

Dr Thais Aliabadi: It's not true at all. 

Jonathan Wolf: Very recently, a close family friend was diagnosed with a very high genetic risk of breast cancer and decided to opt for a double mastectomy as a result. 

That was really shocking to me because it's just not something that I had even considered that someone might do based upon a genetic risk from a test, and it definitely completely changed my view about breast cancer. 

I can see that everything that I thought I'd understood about it, which was probably not very much, is all wrong.

So, today I hope we're going to walk through everything we need to know about early prevention based upon what's going on today and maybe not the outmoded ideas that I might have had, and many of us might have had, because it's clear that the science has really moved on.

So I'd like to start maybe with what the guidance is, and I understand that guidance is different in different countries. So we are here in the states, so maybe U.S. guidance about mammograms and the age at which you should have a mammogram. 

Dr Thais Aliabadi: Well, the general guideline in the U.S. right now says that a woman should start her mammogram at age 40 or 10 years before her first-degree relative with breast cancer was diagnosed with cancer. 

But I'm trying to change that, because that does not include the high-risk patients who fall into a category that might need to start the breast imaging as early as 25 or 30. 

So not all women fall into that age 40 or above category, 

Jonathan Wolf: Even age 40 sounds like it is earlier than what it was in the past?

Dr Thais Aliabadi: Yep. 

Jonathan Wolf: So has that shifted? Did it used to be later than 40? 

Dr Thais Aliabadi: Yes. It used to be 50, and in some countries it still starts at 50. In the U.S., for low-risk patients, it's 40. You can do it up to every two years. 

I think patients need to do it once a year, but I want every single person to know her lifetime risk of breast cancer, and based on that risk, then we go backwards and start the imaging. 

So not all women fall into that 40 and above category. 

Jonathan Wolf: So we're definitely going to talk a lot, I think, in the show, about screening. But this is the first time we’ve talked about breast cancer on the podcast, so what causes breast cancer, and why is it so dangerous that we sort of focus on breast cancer versus any other type of cancer?

Dr Thais Aliabadi: So, first of all, after skin cancer, breast cancer is the number one cancer in women. So it's very important. 

One out of eight women will get diagnosed with breast cancer. On average, every woman has a 12.5% chance of getting breast cancer in their life.

I always use the airline example. If I told you you're about to board a plane that has a 12.5% chance of crashing, you would think twice about boarding that plane.

Jonathan Wolf: I mean, I wouldn't get on the plane for sure. Right? 

Dr Thais Aliabadi: But when I say to patients, you have a 12.5% chance of getting breast cancer. They’re like, Oh, so I'm fine. And that's a starting point. 

Then we don't really know what causes breast cancer. Right? But one thing we know there are different factors. 

We talked about nutrition already. Obesity is a risk factor. Having an early period, late menopause, having dense breasts, having a family history of it, having children after age 30, drinking alcohol, and smoking. 

All of this will add to that risk, and it can push you up from 12.5 to as high as 80% if you have a gene mutation. 

Jonathan Wolf: Are we seeing higher rates of breast cancer today than in the past?

Dr Thais Aliabadi: I am, for sure. We are seeing more cancer in younger patients in general, all cancers considered, but especially breast cancer. 

But part of it is also detection, right? Earlier detection. We've gotten better at doing mammograms, ultrasounds, MRIs, and we can diagnose these cancers a little bit earlier. 

Jonathan Wolf: So we are finding more of them, but you're saying part of it might be that we've got better technology to find them. 

Dr Thais Aliabadi: But I've been in women's health for 30 years, and there's definitely an epidemic of breast cancer. I was diagnosed with breast cancer, and my risk factors were very little. 

Jonathan Wolf: It's rare to have this combination of physician and patient, and I think we'd love to talk about that.

Do we know why there might be an increase in rates of breast cancer?

Dr Thais Aliabadi: I think stress, nutrition, alcohol, sedentary lifestyle. Generally speaking, and I speak for American women, the food we eat, the chemicals we're exposed to, lack of exercise, anxiety. 

I think it's a combination of factors. So we don't really know why someone gets breast cancer, but I can tell you, in my case, it was probably diet, stress, and lack of sleep.

But every patient has a different risk factor. 

Jonathan Wolf: This is real. The food that you eat can increase your risk of cancer? 

Dr Thais Aliabadi: Yes, I believe so. 

Jonathan Wolf: I think I was brought up with this idea that cancer was sort of just this random thing that came from outside, and there was nothing you can do.

But you're describing something where your lifestyle has a real impact on it.

Dr Thais Aliabadi: 100%. In my case, I think if for the past 30 years I had slept eight hours a night, and I had time to exercise regularly, and I didn't have to eat hospital food or swallow my food in three minutes between surgeries, I would've probably had a lower chance of being diagnosed with my breast cancer.

I absolutely believe in that.

Jonathan Wolf: We've mentioned this word mammogram. 

But actually, what is a mammogram, and why is that typically the first step for detection? 

Dr Thais Aliabadi:  So, a mammogram is an X-ray of the breast, and it's the most effective method we have right now. It's not perfect, but it's the most reliable we have right now. 

It basically detects tumors and calcifications in the breast years before we can palpate it.

So you want, when it comes to breast cancer or any cancers, the goal is to diagnose it as early as possible. Early detection is key. If you have an early-stage breast cancer, stages one and two, you are more likely to be cured of it than if you go to higher stages, or if you have breast cancer in the rest of your body.

Gutsy by nature. Smart by science.

Get the deliciously crunchy gut* supplement.

Try Daily30+

So, the sooner we detect it, the better it is. Sometimes patients say, Well, I'll do a breast exam and I'll see if I have a lump. By the time you feel a lump, that mass had been there probably for a few years and could have been picked up by a mammogram. 

Now, the limitation of a mammogram is that for patients who have dense breast tissue, the sensitivity of a mammogram goes down. In women ages 40 to 49, 25% of cancers can be missed on a mammogram. And after 50, 10% of breast cancers can be missed on mammogram. 

So mammogram alone is not enough for patients at high risk or patients who have dense breast tissue. And, it's for that reason that sometimes doctors might order a breast ultrasound in case of a dense breast, or they can order an MRI in addition to mammogram.

Jonathan Wolf: So if I understand this right, what you're saying is the mammogram picks up the cancer when it's much smaller than you would be able to find yourself. That means you're much more likely to treat it successfully because, as it gets bigger, the danger of not being able to treat it gets worse.

And you're also saying the mammogram isn't perfect. 

Dr Thais Aliabadi: I want patients to know that I don't want them to replace mammogram with any other imaging. So as a screening tool, we use mammogram.

For patients with dense breast tissue, instead of a 2D mammogram. We prefer a 3D mammogram. 

So our breast tissue is made out of glandular tissue, fibrous tissue, and fatty tissue. The more of the glandular and connective tissue we have, the less fatty it is, the denser it gets.

As the breast tissue gets more dense, and 50% of women have dense breast tissue, it makes it harder for the radiologist to see or detect any cancers on mammogram.

Basically, on a 2D mammogram, which is a 2D X-ray of your breast, in patients with dense breast tissue, the radiologist will see an area of white, and it's really hard to comment about whether or not there's a lesion in there.

For those patients, we recommended a 3D mammogram. Which is basically imagine flipping through the pages of a book millimeter at a time. You can flip through pages of the breast, and really look, and make sure we're not missing any lesions. 

So, 3D imaging is more accurate, and it's a better option for dense breast tissue. We also add a breast ultrasound for patients with breast tissue that are dense, and basically, the ultrasound can detect lesions that the mammogram can miss.

Jonathan Wolf: Would a woman know if she had dense breast tissue? 

Dr Thais Aliabadi: That's a very good question. So patients touch their breasts, and they're like, I think I have dense breast issue. It doesn't work that way. 

It's an imaging diagnosis. So, if you want to know whether or not you have a dense breast issue, you want to look at your mammogram report or your breast MRI report, and the radiologist will always comment about the density of the breast.

50% of patients have dense breasts. 

Jonathan Wolf: So half the people who are going in for this mammogram have dense breasts. And you're saying that that is where it's a lot harder for the mammogram to pick this up. 

Dr Thais Aliabadi: Bravo. And also, of those 50%, a percentage of those patients have extremely dense breasts. 

The younger you are, the more dense your tissue. The older you get, the more fatty your breast tissue becomes, so it gets easier and easier to detect, usually, as patients get older. 

That's why we don't like to order mammograms in a 25-year-old, because you're not going to see anything. Their tissue is so dense that an ultrasound or an MRI would be a better method of imaging, unless they have a gene mutation like the BRCA gene mutation.

Jonathan Wolf: I think what you've told us is a mammogram is essential, but it doesn't necessarily tell you everything. 

And you've also already shared that you have your own personal story about this. I wonder, actually, if having sort of provided some of that context, you'd be willing to tell us about your own story of diagnosis of breast cancer.

Dr Thais Aliabadi: Of course. So I was 48 and I had gone for my mammograms every single year, and every time I would go, they would find something. 

I had a biopsy maybe when I was 40 years old, and even when I was younger, and it was always benign, benign, benign. 

When I got to age 48, I went for my mammogram, and they picked up some calcifications. They had me go back for a biopsy. They did a biopsy, and this time my biopsy came back with atypical lobular hyperplasia. 

These are basically atypical cells in the breast that can increase your lifetime risk of breast cancer, but they're not cancer. So, my doctor said, Well, we're going to remove it. She did an excisional biopsy. They take a lump out of your breast and she told me to go and come back in six months. 

Mind you, at the time I was 48, I had been a vegetarian for five to seven years. I've never smoked. I've never done drugs. I rarely drink alcohol. I had no family history of any cancers, let alone breast cancer. I had no gene mutations. I was never on hormones. 

So in my world, I was not going to get breast cancer. At that point, in 2017, I had started basically calculating everyone's lifetime risk of breast cancer through this tool that I used in my office that is public. 

So when they told me I had this atypical tissue in my breast, I sat behind the computer, and I started calculating my own lifetime risk, which I had no reason to do before because I knew I was in that range of 12.5. 

I started answering the questions and it's a tool we use, basically it asks for your height, your weight, your family history, your density of your breast, whether you've been on hormones, what age you had your period, what age you had your first child, and the list goes on and on.

So I answered all the questions, I pressed calculate, and this number came on my screen: 37.5%. I almost fell off my chair. 

Here I was thinking I'm never going to get breast cancer. Because I'm the poster child of someone who's not supposed to get cancer. I did everything right in my life, well, except sleeping at night. 

I called my doctor, and I'm like, you know, you told me to go and come back in six months, but 37.5% is a very big number for me.

Jonathan Wolf: 37.5% is your risk of getting breast lifetime risk of cancer at some point in your life. So that's four in 10. 

Dr Thais Aliabadi: For sure, one in three. And I called my doctor. I'm like, listen, I have three little kids at home, I love my husband, I love my life, I have the best job. I just, I have everything. I don't want to get breast cancer. And 37% is a very big number for me to swallow. Is it possible to remove my breast? 

And she's like, No, you're crazy. One thing you learn in women's health is that everyone always calls us crazy every time we comment. My doctors were women, and they still called me crazy.

Because I didn't have a family history and because I didn't have any gene mutation and because I was so healthy, they're like, no, don't worry, this is crazy. Why would you remove it? 

She said, You know what? Worst case scenario, come back when you're 50, we'll talk about this again, but right now you're 48, you're going to lose sensation. 

I went home, and I just couldn't deal with it. It's that example, right? Would you board a plane that has a 37.5 % chance of crashing? I wouldn't. I would run away.

So, anyways, I started asking a lot of people, and everyone called me crazy. Finally, after a year, I found a surgeon at a different facility from my hospital who was willing to do my surgery. Against her advice. 

I remember the day before surgery, she's like, this is crazy. Are you sure you want to do this? I'm like, Well, I'm doing it for my children. I don't have time to get breast cancer. And you know what her reply was to me? She said, why are you so worried? We have really good chemo for breast cancer. I was like, you know what? You can't even argue with that. I said, I really want my breasts off.

Jonathan Wolf: We are listening. We're not doctors. Why was that answer not so good enough? What were you thinking when you explained that that didn't make you feel comfortable. 

Dr Thais Aliabadi: As a physician, as a gynecologist in medicine for many, many years, until you are diagnosed with cancer, or you have a loved one diagnosed with cancer, you have no idea the trauma that goes with that.

It's not just this word you can throw out there and say, Oh, you have cancer, Oh, we have good chemo for it. It's a trauma that you will take with you for the rest of your life. It shakes you to your core. 

So, for me to have someone tell me, Well, if you get breast cancer, we have really good chemo, as a mother of three children, I couldn't even listen to that.

The whole point was, I didn't want to get cancer to go down the path of needing chemo. And if you're lucky, the chemo will work. It's not easy when someone tells you you have cancer. 

So at this point I didn't know I had cancer. I begged my doctor to just do it and not to argue with me anymore. So they did a double mastectomy to remove all my breast tissue and replace it at the same time with an implant. 

This was a prophylactic double mastectomy, meaning I didn't have cancer. I wanted to do this to reduce my risk of breast cancer significantly. So basically you go from 37.5%, which was my lifetime risk to less than 5%.

So I did that. I bled out during surgery because, unfortunately, my surgeon was not very experienced. And I did my reconstructive surgery. I was really, really sick when I woke up. My blood pressure, I think, at some point was 70/30. 

Until a friend of mine visited me, who was a physician, and basically got really upset and had them give me a blood transfusion. And that's when I perked up. 

So many people called me crazy that I hired a videographer to follow my journey. So that videographer came to every office visit. I don't remember this, but when I opened my eyes from 10 hours being under anesthesia. The videographer was there, and the first thing I told him was to go home and tell my children, I will never come home telling them I have breast cancer. Tell them, Mommy did it. 

I was so proud of myself. As I was getting a blood transfusion. My patient goes into labor, and I forced my husband to drive me to Cedars, and I delivered that baby with the help of the midwife. But that's another story on the side. 

Jonathan Wolf: That says something about your work-life balance.

Dr Thais Aliabadi: Baby Monty was born on the same day as my blood transfusion. 

Anyways, a week later, I was so happy, I felt like this heavy weight was off my shoulder. And I get a call from my plastic surgeon, not my surgeon. I don't know if you know this, but doctors do not call with pathology reports.

If your doctor calls you and says, I just got off the phone with a pathologist, I can guarantee you, 9 out of 10, you're dealing with cancer. So as soon as my plastic surgeon called and said I just got off the phone with a pathologist, the first thing I said was, do I have cancer? 

And he said, yes. In three little areas of your right breast. And mind you, all this time they were biopsying my left breast, and my cancer, three areas were in my right breast. 

For all of the people on the planet who've been diagnosed with cancer, when someone tells you you have cancer, your brain shuts down, and you stop listening.

There's so much you don't know, but the word cancer means you're going to die, right? It doesn't matter if you're a doctor, if you're a surgeon, if you've treated cancer, doesn't matter. 

When it comes inside your home, all I could think [about] were my children, how I fought for a year to have someone remove my breast, and for all the times, my friends, my colleagues, my doctors, the radiologists at different centers, they all called me paranoid and anxious and crazy.

At that moment, I was so angry at them, because the first thing I told myself is these people went out of their way to kill me.  I'm just talking now as a patient, not as a doctor. 

I'm a doctor. I understand now everything that happened, things get missed on MRI. We're not gods. We all make mistakes.

The one thing that really upset me was the number of times people called me crazy for wanting to remove my breast. It's my body. It's my breast. It's not going to affect you. I'm paying for it. Remove it. 

That's how women get treated in medicine. I've dedicated my life to saving women. I've practiced for 23 years. I have never lost a patient under my care to cancer. You can't tell me that's luck. 

But, yes, I tend to be aggressive. Call me aggressive, I take it as a compliment, but I never call someone crazy ever. If someone comes to my office and says, Doctor, something's wrong with me. I don't feel well. I never dismiss them.

I guess the lesson learned here is that you have to be your own advocate. It doesn't matter if you're a doctor. 

So my mission in life now is to educate. The first step of becoming your own health advocate is to educate yourself. I always say, if you know your name, your last name, your date of birth, you also need to know your lifetime risk of breast cancer. 

It's a must. You cannot go through life not knowing what that number is. 

Jonathan Wolf: So, firstly, Thais, thank you so much for sharing that story. It's very powerful to hear it, and I appreciate you sharing it with me and with everyone who's listening. 

How does the story finish? Was everything okay because you'd had this, were you still at risk? 

Dr Thais Aliabadi: Usually, when you have breast cancer surgery, they need to sample your lymph nodes. As part of staging for breast cancer, you need to know if cancer is in the lymph node. 

Because they didn't think I had cancer, obviously, my lymph nodes were not examined, so I had to go to Dr. Giuliano, who I absolutely love and adore. One of the top breast cancer surgeons in the world. 

I made an appointment with him to go and get my lymph nodes checked two weeks after my surgery. At this point, I had removed my breast tissue, and they had put implants, my breasts looked really good. 

I was looking at myself in the mirror, and I called my husband, and I'm like, I don't look like I had a double mastectomy. I look like I had an augmentation, meaning, you know, having an implant and with some breast tissue. 

He's like, What are you talking about? I'm like, I feel breast tissue everywhere. He's like, There's no way you were under for 10 hours. There's no way. 

I called my doctor, I'm like, Are you sure you removed all my breast tissue? She said, Of course, but we leave 5%. I'm like, I understand, but I'm a gynecologist,  I can grab it, this is not 5%. 

The crazy doctor that I am, the aggressive doctor that I am, I put myself in an MRI machine two weeks after my surgery. The same MRI doctor who called me crazy the day before my mastectomy for why I was doing it, comes in and she's like, Why are you here? 

I'm like, I had my double mastectomy, I feel like there's breast tissue left. She's like, No, I reviewed it, it's perfect. So I looked at her, I'm like, I'm sorry, but you also missed my cancer on my MRI. So you can understand why I'm nervous right now. I want a second opinion. She's like, of course. 

I go get a second opinion from another center. They said, your MRI's completely negative, there's no breast tissue left. My husband looked at me and said, You're going crazy, let's just go home. It was a Friday afternoon.

On Monday, I go to Dr. Giuliano. I'm sitting on the exam table. He walks in, he's like, Tais, I'm really sorry. I'm like, Why? He says, All that breast tissue they left behind.

At this point, can you believe it? And I'm just one patient. I'm like, What are you talking about? Two radiologists on Friday told me my breast tissue was completely clear. There's no breast issue left. 

He takes me to a third radiologist who says, you have breast tissue here, here, here, here, here, here. Long story short, I don't want to give you a headache, but I begged for a second double mastectomy, because I had a lot of atypical cells in my breast, and now I also had breast cancer. And he was going to do my lymph nodes anyway. 

I begged him, I'm like, Dr. Giuliana, can you do another double mastectomy on me? It took six hours. They did my lymph nodes, they removed my implants, did another double mastectomy, put my implants back in. And when I woke up, he came to me. He's like, I'm so glad you're so stubborn.

I'm like, Why? And he said, They had left 35% of your breast tissue behind. 

Jonathan Wolf: My understanding is this lifetime risk assessment number was basically the thing that made all of that happen. Right? Otherwise, you would not have found out about this cancer till much later. 

I think you have another story that you can tell us about, which is a patient of yours who's gone public about her story, who is an actress, Olivia Munn.

I understand that for her also, this lifetime risk assessment number was critical. Could you maybe give us a high-level outline of that? And then we'll talk through into what this can mean for people who are listening today, 

Dr Thais Aliabadi: I have so many stories like Olivia Munn, but I'm so proud of her because she used her platform to bring awareness to it.

Someone like me or my patients, we don't have a voice, but she obviously does, and she made a huge difference. 

Basically, she just had her baby. She was done breastfeeding. I did genetic testing. She didn't have any gene mutations. I sent her for a mammogram and ultrasound, her mammogram was negative. Her ultrasound was negative.

I calculated her lifetime risk of breast cancer because of her family history. Dense breast age at first child, the whole list that I just mentioned, and her risk was about 37%, 38% similar to mine. So I called her to my office and I said, you fall into the high-risk category. You have to do an additional MRI.

And she said, of course. She's so smart, she's just an amazing woman. So she went, she did her MRI, and of course they called her. They're like, we saw something. They biopsied it, it came back cancer. 

Then, I sent her to Dr. Giuliano. Dr. Giuliano had the MRI reread. And they found another cancer in the other breast with a second read.

So at this point, she had multiple breast cancers. Small but very, very aggressive. Negative mammogram, negative ultrasound, negative genetic test. 

Jonathan Wolf: She's had a standard mammogram. She's also had a genetic test for whether she's at high risk, right? All of that says it's fine, but you then run this lifetime risk assessment and said, actually, your lifetime risk assessment is really high so I want to go and do this other test, this MRI test, and that has picked up this very early cancer, but also this very dangerous cancer, 

Dr Thais Aliabadi: Right. So everything would've been completely different had we not done the MRI. Unlike me, she had a very aggressive cancer, but because we caught it so early, she came to my office and she's like, What would you do?

And I said, listen, at your age, I just delivered your baby, you have a tiny little child at home. You have bilateral breast cancer, very aggressive. You have a family history of it. Take your breasts off. 

And she said, I want to do what you tell me. I'm like, if I were you, obviously I did it for myself, but that's what I recommend.

And thank God she did it. She had amazing results. Dr. Giuliano did her mastectomy, she had reconstructive surgery. It took her a minute to recover from the trauma. 

Again, you have a little baby at home. Someone tells you you have cancer when your mammogram and ultrasounds are all negative. But I think in spring of last year, she decided to share her journey, which basically, I think honestly, she started a revolution not only in this country but around the world, basically bringing awareness to early detection.

This lifetime risk assessment, genetic testing, and all things breast cancer-related. So I'm so proud of her. Everything happens for a reason in life, and I always say, when something traumatic happens to you in life, go down that path and you'll see why you were placed on that path. 

I think both Olivia and myself, we found our calling.

Jonathan Wolf: Thank you for sharing both of those stories, which I think are very powerful. 

Before we move to talking about how you do this lifetime risk assessment, I just wanted to ask about the genetic risk. Because this is the experience that happened with my family friend, where there was something that's very high genetic risk, which was what triggered the decision to have this mastectomy.

Because in both your stories, the genetic test wasn't positive, right?  How important is genetic testing? 

Dr Thais Aliabadi: Very, very good question. So, less than 5% of breast cancers are associated with a genetic mutation, less than five. 

So the majority of people who get breast cancer do not have a genetic mutation. So please don't tell me I don't have it in my family, I'm not going to get breast cancer. That's completely false. 

Two, if you have any kind of cancer in your family, if it's pancreatic cancer, if it's prostate cancer, if it's colon, uterus, ovary, breast, ask your doctor for a genetic test in the United States. The genetic tests are about $249. That's it. 

I always compare it to going to Disneyland. You go to Disneyland, every ticket costs that much. I'm saying one genetic test, one time in your life can save your life. 

Why am I saying this? For example, if you have a parent with pancreatic cancer or ovarian cancer, you could have a gene mutation. Most people recognize the BRCA gene that's associated with pancreatic, breast and ovary, and melanoma.

So, some members of the family could have a melanoma, others could have pancreatic cancer. Do the genetic test. It doesn't always have to be breast to do a genetic test. 

Jonathan Wolf: Are you saying that everyone should do the genetic test?

Dr Thais Aliabadi: If you have a family history of cancer. 

Jonathan Wolf: If someone in the family has it, you should definitely do it. 

Dr Thais Aliabadi: Absolutely. But if you don't have it in your family, it doesn't mean you're not going to have breast cancer. 

You still need to calculate your lifetime risk of breast cancer, especially if you've had a breast biopsy that showed atypia. 

Jonathan Wolf: And atypia means… 

Dr Thais Aliabadi: Atypical cells in the breast that are not cancer yet.

Jonathan Wolf: If you're a man listening to this, is the story about genetic tests only relevant for women, or is it something that you would be saying that men should be doing as well?

Dr Thais Aliabadi: Absolutely, it's for men and women. For example, if you told me, I have three daughters at home and my mom had ovarian cancer, I would ask you to do genetic testing. 

Because if you don't have it, then your children are protected at least from your side. But then we have to also ask your partner’s family history, so it's for men and women. 

Jonathan Wolf: In that case, it sounds like the man himself is not likely to be at risk. 

So today, if you're a man worried about your own cancer risk, do these genes affect you? So you're saying for either side… 

Dr Thais Aliabadi: Absolutely. It can cause prostate, it can be pancreatic cancer, it can be colon cancer, melanoma. It can affect all of us.

The majority of the time in the U.S., believe it or not, insurance will pay for these patients to do genetic testing. I think in my practice, 93% of patients are covered annually.

Jonathan Wolf: So I'd love now to get into this lifetime risk assessment. Because I think you've definitely provided a whole new perspective on taking more control over this yourself and understanding what you can do. 

So I imagine there's a lot of listeners right now who are saying, okay, how can I calculate my lifetime risk assessment?

Dr Thais Aliabadi: So, the best formula to use that I use all the time, it's probably the most accurate, easy to use. Women can do it at home. 

It's the Tyrer-Cuzick risk assessment tool. I actually put a copy of it, free of charge on my SHE MD podcast page. People can go there, they can calculate their lifetime risk. 

You basically have to enter some personal information about yourself: height, weight, age at first period, age at first pregnancy, whether or not you're menopausal, if you've been taking hormones, family history, density of the breast. And once you answer all the questions, you hit calculate, and it'll tell you what that risk score is. 

I have videos explaining what each category is and what kind of imaging they need to do.

Jonathan Wolf: Well, firstly, we will put a link in the show notes both to the assessment tool and also to your site to help to understand that.

Is this something that generally anyone listening to this can do themselves? So I heard you mention things like the breast density, and you've also told me that I can't figure that out for myself.

Dr Thais Aliabadi: They can pull their mammogram images and ask. I would say if you are young, you probably have dense breasts, right? Younger patients have dense breast tissue. 

I want everyone to calculate their lifetime risk of breast cancer by age 30. Age 30 is when we start imaging if you have a strong family history of ovarian, pancreatic, or breast cancer.

Two of the 48 cancer-causing genes are BRCA1 and BRCA2. Those patients need to start breast imaging at age 25. 

So you calculate your lifetime risk of breast cancer, and if you can't do it, ask your doctor to do it. A lot of times, believe it or not, especially in the U.S., the radiologists will do that for you. The problem is the radiologists don't sometimes get all the information about you, first pregnancy or some personal history they don't have. But they try to calculate that Tyrer-Cuzick risk score for you.

But it's something patients can absolutely do on their own. It's pretty simple and straightforward. Once you calculate that risk score, then we talked about average risk being 12.5%. Low-risk category is anyone under 15%. So if your lifetime risk of breast cancer is less than 15%, you fall into the low-risk category.

In America, you can start your breast imaging at 40. Or 10 years before your first-degree relative was diagnosed with breast cancer. And if you have dense breast tissue, you have to ask your doctor for a breast ultrasound. So that's for 15% and below. 

From 15 to 20%, that's the intermediate risk category. This is when, basically, in my practice, I treat every patient differently, but knowing that they fall into that intermediate risk, I might start their mammogram a little bit earlier, maybe get a baseline at 35.

If they have dense breasts, I do an ultrasound with it and if they have any family history, I start the imaging 10 years before the age of that family member who was diagnosed with breast cancer. 

The most important group for me are patients who fall into the high-risk category, which is 20% or higher. 20% or higher patients need to start their breast imaging as early as 30. 

By the way, this will never happen in your country. In the U.K., that's the problem, right? Early detection. So everyone gets pushed much, much later. Forgetting that we're missing these high-risk patients at a very young age.

That's why sometimes people are shocked that so and so at age 38, got stage four breast cancer. And you know, sometimes when I watch TV and I see these actresses at a young age getting diagnosed or dying from breast cancer, someone probably didn't do genetic testing on them and didn't calculate their lifetime risk. 

So that's how important it is.

Jonathan Wolf: So one of the things I guess I'm taking away from this is, in a way, the progress of science and medicine today is meaning that we can be more personalized about this than before. 

You're not saying every single woman should be screened at 30, you're saying we can really differentiate now, low risk and high risk, and then if you're in this high-risk group, you should be screened really aggressively.

Indeed, you are talking about the fact that your own decision was, my risk is so high that I'm going to take this very serious preemptive surgery. Because of your confidence in that level of the personalization and understanding of the risk. 

So this is quite a profound shift in terms of something that at ZOE we're really passionate about, which is this ability to take control of your health and personalize it before you're really sick.

You're saying that actually we are now able, in this area, to use this information and everything that we've learned over decades, to be able to no longer treat everybody in exactly the same way. 

Dr Thais Aliabadi: Absolutely. And for the high-risk patients, when they start as early as 30, we usually alternate mammogram and ultrasound with an MRI a few months later. 

Because in high-risk patients, mammogram alone can miss breast cancer. So you add MRI to make sure you basically bring that 80% detection to much, much higher, especially for high-risk patients. 

Jonathan Wolf: What are the things that tend to push somebody into this high-risk? Because you said that you were at really high risk, and now I'm hearing, you know, your number was 37%, even 20% was high risk.

But you, you also said, I haven't been drinking, I haven't been smoking. 

So what were the things, if somebody's listening to this….

Dr Thais Aliabadi: The most common reason why people get pushed above 20% is family history. That's probably obesity, early period, late menopause. Patients who don't have children are at a higher risk.

Pregnancy is protective. Breastfeeding is protective. If you have children after 30, that gets affected. Genetic mutations, dense breast tissue, patients who have extremely dense breasts, it pushes it way high. 

There's so many different factors. In my case, it was just that atypical lobular hyperplasia, which is the atypical cells that pushes your lifetime risk really high. Every person's risk factors are different. 

The last thing I want to add is for very high-risk patients, which in my world, that's 35% and above.  I had a patient yesterday, her lifetime risk is 30%, but every single woman in her family had breast cancer. So someone like her, I would be more prone to treat and reduce that risk. 

If you have a very high lifetime risk, let's say 30 to 35% and above, you only have three options, the way I look at it. Number one, you alternate mammogram and ultrasound with an MRI every six months, and you do a lot of praying and you pray that you don't get breast cancer. And you pray that your doctors will diagnose it. 

Breast imaging, I'm really excited about artificial intelligence reading these images because hopefully we're going to have more accurate reading. So someone like me, where my lesion was sitting on my MRI doesn't get dismissed. That's number one.

Number two, patients have the option of taking a medication like Tamoxifen. I don't know if you've heard of it, but once you get diagnosed with estrogen receptor-positive cancer, a lot of us have to take tamoxifen to basically block the estrogen receptors.

Taking tamoxifen every day for five years can significantly reduce your risk of breast cancer, maybe by 50% in the next 10 years. So that's an option. 

And the third option, which is what I opted for, is a double mastectomy. If you don't really want to do that imaging every six months, which is pretty tough to go through. 

MRIs are not easy to do. Breast MRIs, you need a contrast. Mammograms are not easy, and honestly, to go through it and have to wait for the results and be anxious twice a year about it is pretty challenging.

That's why, you know, it's a very, very personal decision. I never tell someone do it or not do it. I just tell them what I would do if I were them. But with a strong family history or a high lifetime risk, I think double mastectomy is a good option. 

The problem with double mastectomy is having access to a doctor, not everyone can afford it. Not everyone has access to a good reconstructive surgeon, so I understand those limitations. It's not for everyone.

But at least I want them to know that there are medications they can take for five years to reduce that risk significantly. 

Jonathan Wolf: I would like to move to listener questions. So, the first question is, can the food you eat influence your risk of breast cancer?

Dr Thais Aliabadi: Absolutely. I think obesity is one of the underlying conditions for breast cancer. So, processed food, animal products. We talked about smoking, alcohol, all of that can affect it. Absolutely. 

Jonathan Wolf: Does taking hormonal birth control or HRT increase your risk? And how big a concern should this be?

Dr Thais Aliabadi: It's not a concern. It probably can very, very slightly, but not significant enough. Having said that, it's individual. 

Patients need to talk to their doctors. Every patient has a different risk factor that needs to be dealt with. For example, if someone has a lifetime risk of 50% for breast cancer. 

Jonathan Wolf: For the vast majority of people who are listening to this, it sounds like you're saying that that's safe.

Dr Thais Aliabadi: It's very safe. It's very safe. It can slightly increase their risk, but not significant enough.

Having said that, for example, I don't want someone whose grandmother had breast cancer, whose lifetime risk is 20%, not to take hormone replacement during menopause and have poor quality of life with hot flashes, vaginal dryness, and all these other symptoms because they're scared of taking hormone replacement.

Jonathan Wolf: I think that's really interesting, because I know there's a lot of debate about this, and so it's interesting hearing you being so strong about the risks here. 

I assume you're saying that somehow you view the benefits from these to really outweigh the risks. 

Dr Thais Aliabadi: Yes. Especially if anyone's gone through menopause, I'm sitting here having a hot flash. I can't take hormone replacement. I'm on anti-estrogen, the opposite of it. 

But if you have the option, it's life-changing, so you don't have to have a hot flash doing a podcast. 

Jonathan Wolf: Well, firstly, thank you for sharing that. One of the things we talk a lot about on the podcast is how much no one is willing to talk about menopause, right?

So I appreciate it, and you're performing great. So I think you should be feeling good about it. 

Final question from listeners, are all lumps, whether you feel them in your breasts or armpit, worrisome? 

Dr Thais Aliabadi: As a patient, I would say you can't decide, let your doctor decide. Some lumps are concerning, majority are not.

So, you can have a swollen lymph node because you got a flu shot on that arm that day, or you got your COVID vaccine. You can have a cyst, which are very, very common. Fibrocystic changes of the breasts are very, very common. 

Fibroadenomas are benign tumors of the breast in younger women. But generally speaking, cancer, tumors don't really move. They're stuck. 

So if something is mobile, it's probably nothing. But I would always tell my patients to call me, come in, let me examine, and let me decide if I need to order a breast ultrasound or imaging. 

The one thing I will tell you, no one is too young for breast imaging. 

Jonathan Wolf: Got it. So even if you feel like you're just too young for this to possibly be cancer, see a doctor.

Dr Thais Aliabadi: I've had a 22-year-old with breast cancer with no gene mutation. Any lump needs to be evaluated by a gynecologist or a primary care doctor. 

Jonathan Wolf: And you're saying that most of the time the doctor is going to tell you you're fine. So don't immediately panic, but on the other hand, don't ignore it because you can't judge for yourself.

There isn't some magic way that you can figure out at home whether this is okay or not. 

Dr Thais Aliabadi: No, I would say trust your doctor. 

Jonathan Wolf: So I'd just like to finish with asking you what advice you have for women who are struggling to advocate for themselves in the doctor's office.

Because you're telling a story where you found this hard. I think it's pretty clear to anyone listening to this, that you are a pretty powerful and strong-willed doctor with all this advice and knowledge and all the rest of it. And you found that hard.

Many people listening won't have any of that. They may indeed be in health systems where they've got less ability to have control. What would you say to anyone listening to this who's saying, Well, how can I advocate for myself? 

Dr Thais Aliabadi: I would say, I hear you. I get you. It happened to me. It's not easy. 

It starts with education. That's why I started my podcast. That's why I'm on this podcast. Basically, you have to educate yourself. In order to be your own health advocate, you have to educate.

The problem is, once you educate yourself and you empower yourself, and you know what you have to do, and you go to your doctor, you have to find the doctor who actually listens, who has the time, who takes you seriously, who doesn't call you crazy, who doesn't dismiss your symptoms. 

If you're lucky enough to find that doctor, the problem with the healthcare system, it's over.

We're overwhelmed with patients. We don't have time, right? So if you're lucky enough to find a doctor who's listening to you and really taking you seriously, the next step is being able to afford the prescriptions that they write for. 

Does your insurance cover your MRI? Does your insurance cover your ultrasound? My MRI, after I was diagnosed with breast cancer, was $3,000. Do you understand that? Being able to afford the treatment is the next limiting factor. 

So there's so many levels that we get stuck in this healthcare system, but I would say educate yourself. If something doesn't feel right, get a second opinion, get a third opinion.

Find a doctor who specializes in that. If you have a breast lump and you have a family history of it, if you need genetic testing, find someone who will take you seriously and listen to your complaint. 

Jonathan Wolf: Thais, thank you so much. We always try to end with a quick summary, so I'm going to try and do a summary, and I'd like you to just correct me where I got this wrong.

When I think back across the show, I think the biggest thing I take away is, do a lifetime risk assessment for breast cancer by the time you are 30 and if you're after 30, do it immediately.

Your own story is so powerful, this idea that you felt like you're doing everything right. You're low risk. You're literally a doctor who is looking after women who can have breast cancer, and then you suddenly did this and you're like, I'm at 37%, and suddenly that transformed the way you're thinking about it. 

Then the story you’re fighting to get the treatment that you are basically saying you feel people at this level should very seriously consider, because if not, they've got other very intrusive solutions.

We don't buy the hype — and neither should you

Our new app reveals what the food labels won't, using data from the world's largest nutrition study run by ZOE. (Only available in the US)

Download free

And then when you did it, you're like, thank God I did, because actually it turned out you already had cancer. And thank you for telling that story, which I can tell is still, you know, really emotional, understandably emotional, and raw. 

And anyone listening to that would've felt that, and I can understand this also, this idea of having one's children and all the rest of it. So it's really powerful. 

I think the other big takeaway from this is therefore you need to be more of your own health advocate. Because probably in health systems, whether it's in the states or the U.K. or anywhere, they're not really designed today for this level of differentiation of risk.  The ability to tell that somebody might be this very low risk, right below 10% or they're above 30%.

So our screening is designed for this average level, and it's therefore going to probably spend too much time on people who are very low risk and not enough on the people who are high risk.

This is, it seems to me, your big message is that we can really determine a lot more now about who's high risk, and it doesn't require some incredibly complicated imaging to figure out this risk.

Actually, you're saying that you can go onto a website and fill in this information and give you this answer. 

The other thing I took away was this story that if you have any family history of cancer, take a genetic test. You're saying it costs the same as going to Disney World for the day or something, and it could save your life.

And I think you talked about this BRCA gene, for example, which is… 

Dr Thais Aliabadi: Just two of the 48 cancer-causing genes. There are many cancer-causing genes. People say, Oh, I've been tested for BRCA. That's not enough, you need the full panel. 

There's CHEK2, that gives you 50% chance, PALB2 gene mutation, that gives you a 50% chance. So there are other gene mutations that can increase your risk of breast cancer. 

Jonathan Wolf: Then the final thing I, I took away was you were actually really quite strong, that for most women, hormonal birth control or HRT is safe, that although there is a statistical increase in the risk to do with breast cancer, your view is that this is on the absolute terms, very small.

Dr Thais Aliabadi: But you know, opposite of that, I do worry about alcohol. I do worry about smoking. I do worry when patients are overweight. I do worry about lack of exercise. So, those factors are so much more important.

Sleep, low stress, all of that is much more important than worrying about that birth control pill that you took for two years in your life.

Jonathan Wolf: And where does food fit in that list? 

Dr Thais Aliabadi: Very important. I let you have a full podcast on gut microbiome and our health in general, right? Our gut microbiome is linked to our insulin resistance. As we get older, insulin resistance can cause us to gain weight. Weight gain can cause… everything is related. So it all starts with food.