Transcription:
What to Expect During a Mammogram and After

Intro: Duly Noted, a health and care podcast, is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners re-imagine and better understand an extraordinary health and care experience.

Bill Klaproth (host): Welcome to another episode of Duly Noted, the official podcast of Duly Health and Care. I'm Bill Klaproth. And today, I'm very delighted to be joined by Dr. Jennifer Yilk, a board-certified radiologist who specializes in breast imaging high-risk breast patients in cancer guidance. And our topic today is a big one, is breast cancer awareness month. And the latest breast cancer data shows that one in eight women in the United States will develop breast cancer during her lifetime. Breast cancer is the most commonly occurring cancer in women and the most common cancer overall. In fact, in 2020, there were more than 2.26 million new cases of breast cancer in women. Despite this, there is hope. So let's find that out as we talk with Dr. Jennifer Yilk. Dr. Yilk, thanks for being here.

Dr. Jennifer Yilk: Thank you so much. I'm really excited to be here.

Bill Klaproth (host): Well, we're very happy to have you here, Dr. Yilk. And before we get started, I know you wanted to share some quick thoughts on this.

Dr. Jennifer Yilk: Yes, I would love to. You know, I just wanted to reiterate, you were absolutely right. One in eight women will develop breast cancer in their lifetime. And basically, we have shown that mammograms have decreased mortality, especially starting at the age of 40. For example, if we did not allow any woman right now from 40 to 50 to get a mammogram, we would have 100,000 deaths a year. I mean, it's pretty incredible, right? The incidence of breast cancer does go up every year, it has been proven, from the age of 40 to 75. And guys do ask me, "Do men get breast cancer?" How much do you think? I mean, it's more than you think.

Bill Klaproth (host): I think it would be very rare because I don't have any male friends that talk about this at all. But I would imagine guys probably keep it to themselves and it's probably more widespread than I know.

Dr. Jennifer Yilk: Yup. So it is actually 4%. And I usually tell these, you know, gentlemen, "Listen, I know you're not getting mammograms." So I advise them, "Listen, learn your family history and you should do self-breast exams," because there are 4% that do get breast cancer.

And then, one other huge topic that I wanted to talk about is this myth of radiation, right? I don't know if you've heard women talk about it, "Oh, I don't want to get my mammogram because it's radiation" and you will be exposed, right?

Bill Klaproth (host): Yes, absolutely.

Dr. Jennifer Yilk: So basically, I want a lot of people to understand that mammographers, we are physics-boarded. And radiology has two sections that is governed by the FDA and mammogram is one of them. So we have to answer to the government. So Bill, let's say, if I asked you, "Hey, I buy you a free flight from here to Denver and, you know, you can go skiing for the winter." What would you think?

Bill Klaproth (host): I'd be like, "Let's go. I got the skis. Let's hit it."

Dr. Jennifer Yilk: Exactly. Let's go hit the slopes. So, what I want women to understand is that that one mammogram that you get, that screening mammogram that could save your life, has the same radiation dose of a flight from Chicago to Denver.

Bill Klaproth (host): Right. So anybody concerned about radiation, really not a big deal

Dr. Jennifer Yilk: Right. It puts it in perspective, right? And that's why I do say to a lot of these women, "Listen, knowledge is power and it could save your life," right?

Bill Klaproth (host): Yeah, absolutely. So it's not worth saying, "I'm not going to get it because of the radiation risk," because it's non-existent basically.

Dr. Jennifer Yilk: Basically, I mean, if you think about it, no one has a problem getting on a flight, especially if it's free, right? And you're not even concerned. I don't even think people understand that as you fly closer to the ozone layer, which is your flights, you are at increased risk of radiation, which is the same amount as that lifesaving screening mammogram.

Bill Klaproth (host): I see. This is why we love you, Dr. Yilk. I never even knew that.

Dr. Jennifer Yilk: I know, I think it's pretty cool if you put it in perspective for daily life, you know, events.

Bill Klaproth (host): Yeah. You know, thank you for sharing those thoughts with us. I think those are really, really important as we talk about this. And I come from a family of four with three older sisters. And so I'm pretty versed on this, if you will, for a guy. So, let's talk about this. What can someone expect the first time they undergo a mammogram?

Dr. Jennifer Yilk: Well, the first thing to expect is you don't need an order. Especially at Duly, you don't need an order to have your mammogram. We try to simplify it and make it easier for these women. So, you know, you just went through your doctor's appointment, you forgot to ask them for your order. You don't need that. You can literally walk in and get your screening mammogram. I'm a mom. I work full time. It makes life so much easier to be able to know that I can walk in and get this done.

Bill Klaproth (host): Can you specify for us what is it exactly you're looking for during a mammogram?

Dr. Jennifer Yilk: So one of the things that I'm looking for on a mammogram is we're looking for calcifications and, you know, 80% of these calcifications in the breast, they're usually a by-product of normal tissue. And then, 20% is sort of an early or a stage zero cancer. And when I try to explain to these patients, it's a by-product, it is not a mass. And what it actually looks like is little grains of salt on the mammogram. Now, when we pick that up and we deem that it is abnormal, usually in that 20%, whether it's just early abnormal cells or a stage zero cancer, survival is nearly a hundred percent.

The other thing we're looking for are masses, asymmetry or distortion. And so what we do then is we actually bring you back to sort of characterize it, and that means with like additional views. So when we talk about that word diagnostic, so diagnostic means that we called you back for an abnormality or you're feeling something. Basically, bottom line is these three things or four things that we're looking for can save your life

The other thing that I just wanted to let people know is when you do come in for that first mammogram, we tend to ask you, you know, a ton of questions and a lot of women are like, "Why are they asking me these questions?" You know, "Isn't it in my chart?" Well, a lot of these questions such as age, weight, height, family history, we use it to calculate something called the Tyrer-Cuzick score. And basically, it's an algorithm and it's an algorithm that someone created. We put it into our Epic. We put the numbers in, and if you're greater than 20%, we send these women to our high-risk breast program. And so that way, they will be screened much sooner. Basically, every six months, you get your mammogram and then six months later you get your MRI, so they don't go beyond a six-month period of being imaged.

Bill Klaproth (host): So family history has to be taken into account for this as well.

Dr. Jennifer Yilk: Interesting enough, the majority is sporadic, which I mean by that word is no family history at all. So you have a higher risk just being a woman.

Bill Klaproth (host): So even if you don't have a family history of this, don't think, "Hey, I'm kind of in the clear on this."

Dr. Jennifer Yilk: Absolutely. That majority of the one and eight we talked about, the majority of those women do not have a family history.

Bill Klaproth (host): Okay. Well, this is really eye-opening and great information. So thank you for sharing this with us, Dr. Yilk. So if something is found, something suspicious, you mentioned then going to a diagnostic. Can you explain more of how that process works and what are the steps then?

Dr. Jennifer Yilk: So we bring you back. And for those calcifications, we do magnification views where we magnify the area because they are tiny, they're millimeters in size. So when we magnify them, we characterize it. And let me tell you, yes, they don't always characterize the way we want. And if they don't, we recommend something called a stereotactic biopsy. And a lot of women will say, "Oh my gosh, is it that device where I lay down on my stomach and my breast falls?" And I'm like, "Yes, that is one way." But that's how we biopsy it because it is with mammogram, the only way we see the calcification. But I want to reiterate, if you're in that 20% group and we've biopsied it, your survival rate is nearly a hundred percent.

Asymmetries, masses, and distortion, we talked about those things. Those are the things that we are looking for on that mammogram. However, when I do that, I can see the mass. I can see there's distortion. I can see some area that looks asymmetric. But I don't know is the mass solid? Is the mass filled with liquid, which is like a cyst, which is the most common finding and benign. So at that point, we use ultrasound. And ultrasound is sound waves. And when the sound travels through, it allows me to see if it's simple, like a cyst, or a fibroadenoma, which happens to be the number one type of benign mass. So I like to tell my ladies, if you've seen your mammogram, it says mass, it doesn't mean it's a bad mass. We have to characterize it. We need to look at it. And, basically, when I'm looking at this mass, I'm looking at its borders, the blood flow inside of it, whether it's laying correctly or shadowing, which means that the sound waves are not traveling through. One, if we find it abnormal and it fits all those criteria of abnormality, we recommend an ultrasound-guided biopsy.

A couple really cool statistics I'm going to tell you, that even if I find a mass in the breast and it looks cancerous and we biopsy it and it is, the survival rate, I'm talking only in the breast, right? Nothing in the lymph nodes in your armpit or axilla, the five-year survival of that in a full-blown mass is 99%.

Now, even this sort of blew my mind, masses where you have local metastasis, which means it has spread to that same side armpit, your five-year survival is still 86%. Huge. Huge. And then, when it becomes a cancer and it's gone elsewhere, to the bone or the lung, the five-year survival goes significantly down to 29%. I mean, that tells you right there, get in early, do your mammograms, right?

Bill Klaproth (host): Yeah, get in early. I would imagine there's a large percentage of women where it has metastasized and they're like, "God, I wish I would've gotten here earlier. My life was so busy and hectic."

Dr. Jennifer Yilk: I know.

Bill Klaproth (host): "Why did I put it off?"

Dr. Jennifer Yilk: Always tell them, "Don't beat yourself up. We are here now. We've found it. We will take care of it."

Bill Klaproth (host): So a lot of the women that come back for this diagnostic, you're probably able to rule out in a good percentage that anything is wrong. Is that right? You're going to take a look, a closer look, and then, "You know what? Everything looks fine. We'll see you back in a year."

Dr. Jennifer Yilk: Yeah. And I think some of that, you know, I always implore women to find out who is reading their mammograms. Because you go to a specialist, correct? You can go to your orthopedic and your orthopedic might specialize in spine. That's not who you want, right? You want your orthopedic, because you have a knee problem, to be specialized in knees. And you have the right to ask that as a patient, right?

Bill Klaproth (host): Yes.

Dr. Jennifer Yilk: People don't understand because they think we're in the background and they don't understand that radiology now, everyone is specialized. We have neuro people. We have musculoskeletal, which is the bone and muscle. And our mammographers, especially here at Duly, all 13 of us are fellowship-trained, which is really unheard of outside of an academic center. So you're even going to get called back even less, so less false positives and most likely not biopsied when you have specialists looking at your mammograms.

Bill Klaproth (host): Another good point to remember. Make sure you know who's reading that mammogram.

Dr. Jennifer Yilk: And you have the right to ask. They don't know that. You know, they think it's just a radiologist. Yes, they are board-certified and there's nothing wrong with that. But you want somebody who does this day in and day out. That's the only way to be better at a specialty.

Bill Klaproth (host): Let me ask you about dense breasts. How does that factor into this?

Dr. Jennifer Yilk: So dense breasts, they are a high risk. And people are like, "Oh, I have dense breasts." Majority of the women in this country do have dense breasts. And we are now mandating it in their letters to put what type of density is your breast. And the type, we have four types. We've got fatty, we've got scattered fibroglandular, heterogeneously dense and then extremely dense. So the latter two, that is what the majority of our population is made up of. So when people say I have dense breasts, you are correct probably, you know, the majority do. But it makes it harder, even with 3D tomosynthesis, which all of our patients get that 3D imaging, it's difficult to see through dense breasts. So it is a major risk factor.

Bill Klaproth (host): So it's harder to pick up a calcification or as you call it, asymmetries, masses, distortions, harder to pick those things up through dense breasts.

Dr. Jennifer Yilk: Correct. Yup.

Bill Klaproth (host): Do women with dense breasts have to come for mammograms more often?

Dr. Jennifer Yilk: They don't. Actually, unless we deem them to have to come back more often because we found something that was slightly suspicious; however, it is not fitting into my entire category for a biopsy. No, not because they have dense breasts. Absolutely not. Because we will usually do other modalities in ultrasound. If we find them very dense, we will do an ultrasound to make sure there was nothing hiding in there. Or they have an MRI. So, no, they don't have to come sooner than that one year period, unless we tell you specifically that you have to come back in six months.

Bill Klaproth (host): You were just mentioning other modalities. What are some of the other modalities for breast cancer screening?

Dr. Jennifer Yilk: We talked about mammogram. And again, I'm going to reiterate, the only modality that really does pick up that stage zero 100% curability, a.k.a calcifications, is the mammogram. And that's why it is still the gold standard. And I do want people to understand that all of these modalities, they are sort of pieces to a puzzle. And when you put them all together, it creates the entire image. So they're all great, but not always do they solve all of the problems with just one.

The second one is ultrasound, and we talked a little bit about that. It allows the sound waves to travel, allows me to tell me whether it is cystic, which means a balloon filled with water, or a solid mass. And then, what type of solid mass does that look like, right?

And then, the final one is MRI. I do get a lot of women that are like, "Why don't we just go directly to that? It would be wonderful. Let me tell you. But I think a lot of women, we would pick up a lot of things even earlier, even though we are picking up a lot in millimeters in size. However, I am going to tell you, it is wonderful, but what can it miss, Bill? It can miss that stage zero breast cancer, right? So the one that I want the most that will give you a hundred percent curability, it could miss that.

And also, it also comes with its own repercussions, which is it is invasive, which means that you need to have an IV put in and we cannot see anything without contrast, which is the dye that goes into the vein. And that dye is called gadolinium and that comes with its own issues. We have many, many studies that have shown multiple, multiple MRIs. You can get nephrotoxicity, which means kidney toxicity or buildup in the brain.

So, yeah, it's wonderful, except for that stage zero. It also is unfortunately not cost-effective. And it comes with its own repercussions, missing that's stage zero breast cancer.

Bill Klaproth (host): So I asked you earlier about family history. Can you talk to us a little bit about who is considered high risk?

Dr. Jennifer Yilk: One of the great things, if I can just preface that, one of the great things is here at Duly, we did set up that high-risk breast program, which is amazing because it picks up those people greater than 20% with that big, long name called Tyrer-Cuzick, that algorithm I talked about.

A couple of the risk factors that we don't have control of as women, I have no control over my dense breasts. We talked about that, right? I have also no control really over my family history, which you should implore, I think our children and our family members who are women to know their family history. Ask how many women have died of cancer? What kind of cancer? Another thing is age. Boy, do I wish I could control that, but we can't, right? So you know, breast cancer increases with age. For example, at 40, it's one per thousand. And at 41, it's two per thousand.

And then, you also can't control their age of menstrual cycle when you started it. So you're considered higher risk if you're less than 12. And then, also age of menopause, greater than 50. And the reason for that, you're probably like, "Why?" Right? Cancer is not caused by estrogen. It can be fed. So the estrogen is one of those things that can feed the breast cancer. It's kind of a key hole and the key is the estrogen. So, what happens is these women are exposed way longer than they should be to the key or the feeder.

And so, one of the other things, radiation. Well, we were talking about that, right? There are some women though that are radiated purposefully for like lymphoma less than the age of 30. And at that point, the breasts are not fully developed. I know we think they are, but they're not. So they are very, very susceptible to radiation damage, which is much less because they're purposely when you have lymphoma, right, giving you a dose for cure. Not like a mammogram, but a dose for cure. And so, their breasts are susceptible. So those women, we tend to image them eight to 10 years after they finished radiation.

And then, the last and final one, we've heard a lot about BRCA1 and BRCA2, which are those gene abnormalities? Again, I implore women learn your history. I always tell them to take control and learn their family history. Know what type of cancers are in their family? No, you know, if they have heart issues or if they have diabetes, it's taking control.

And then, some of the risk factors, interesting enough, we can control, right? One of them being, which I know women, this is a tough subject to bring up, especially when they're here for a mammogram and now I'm going to bring up their weight. Nobody wants-- especially me, don't talk to me about my weight. But the women that tend to have BMI, which is your weight factor, that's what we measure., If it's high, the reason why we care is because fat cells store estrogen and make it. So you're exposed again to that key which feeds the cancer way more than somebody that had a BMI that was normal. So that's why. It's for that very reason. Because if you're susceptible, we don't want to make you more susceptible.

The other thing is exogenous hormones, birth control, things like that. Women that take estrogen like Premarin after menopause. Your reproductive history, I think it's minor, but it's still there. Like if you had a child after the age of 30, they consider that high risk or let's say you never had children, or if you didn't breastfeed.

And then the one, which is interesting, is alcohol. You would never think that, but there are studies that show the more alcohol you consume, the higher susceptibility you have.

Bill Klaproth (host): That's interesting. I was going to ask you about lifestyle things like alcohol, smoking, poor diet, lack of exercise, all of those things.

Yep. All of those do. And one really cool thing, I don't know if you mind, I just wanted to digress a little bit, so some of those risk factors that we can't control I wanted to talk about. So women now from the age of 25 to 39, they're not coming in for mammograms, right? Because we said 40. But the group that I'm seeing, the fastest increased rise in breast cancer right now is 30 to 40, which is a little scary.

So I just proposed recently to some of our OB-GYNs, you know, because when they come to us, though they already have a palpable. What I mean is they feel something. I'm behind the eight ball at that point as a radiologist. So I'm behind the eight ball. We've already got a mass, so she's at least a stage I, if it is a cancer if we looked at it and we made sure that we characterized it and looked at it. But we're already behind the eight ball. So I proposed to some of our OB GYNs that we maybe start screening in their offices because it is a very easy algorithm to incorporate into our Epic system. You have them ask some questions, like I said, you know, weight, height, family history, all of those. And that way, they will print out that Tyrer-Cuzick for these women, maybe 25 to 39, which will highlight those young women that are at high risk before they present with a mass.

Yeah, that sounds like a great idea. And then, would the physician urge them to make sure they're doing self-examinations as well?

Dr. Jennifer Yilk: A hundred percent. And with that being said, you get this greater than 20% number. Then, your OB-GYN sends you to our high-risk center. And then, they will get imaged and screened appropriately before, so then they will present to me with maybe that stage zero versus a stage I or II already.

Bill Klaproth (host): So are you trying to get a baseline basically?

Dr. Jennifer Yilk: I'm not basing on mammogram necessarily, but, you know, probably that will be incorporated, but at least it will flag these women, yes, probably to get a baseline mammogram and then also annual MRI six months opposite. Also, physical exams by somebody that that's all they do, so they're trained in it all day, everyday. So that way, we flag them before they are at that point, before they're pregnant with a mass, because these are women that are in reproductive age, right? They have young kids. Some of their cancers tend to be a little more aggressive. So, I think we could save many, many, many lives by incorporating that one algorithmic number, like Tyrer-Cuzick. If we can find them. And I think the best way is, you know, they're seeing their OB-GYNs. They're not seeing us, but they're seeing the OB-GYNs. So, we're in the talks with that right now.

Bill Klaproth (host): Well, that only seems to make sense. And as you keep talking about early detection, that seems like it would be a good place to start.

Dr. Jennifer Yilk: Right.

Bill Klaproth (host): So if someone does come to you, what additional resources and information is available in the event breast cancer is confirmed?

Dr. Jennifer Yilk: I first always tell my patients that we, as the docs, whether it's your oncologist, radiologic or pharmacological, which I mean the one that gives you radiation or the one that gives you chemo, or us, the fellowship-trained breast radiologists or the breast surgeons, reach out to us. We are always here. You know, send us an email, do something on MyChart. I always answer, and I know my colleagues do too.

The other thing is we have our nurse navigators. They are amazing and have so much knowledge. And then, the high risk breast center too. I know they field a lot of phone calls. But I'm going to say, "If you're going to look on the internet, my lady, anyone can say they're a doctor." Make sure you go to a reputable site, such as cancer.net, the CDC, the National Cancer Institute, the American Cancer Society or the Susan G. Komen Foundation.

The other thing we do have, which I think women don't realize, is we have access to where the best wigs are, right? Make sure they know they're going to have chemo, they're going to lose their hair. Where do you even look up on the internet, right? Best wigs for chemo patients. No. Or what support group do you recommend? Because you'll pull up, you know, on Google and you'll get tons of all these support groups, but which ones are the ones that we hear back from our patients? We have knowledge of that. Also, I got a mastectomy where my breast is gone, but I would like a nipple tattoo, you know, to make it look more aesthetically like a normal breast. And we have those people too. So, again, reach out to us.

Bill Klaproth (host): Well, that is a nice service that you offer for support and for people that have certain questions and things that they need answered. So that's wonderful. Well, Dr. Yilk, this has really been informative. Thank you so much for your time. Is there anything you want to add as we talk about breast cancer, being that October is Breast Cancer Awareness Month?

Dr. Jennifer Yilk: I just want to say thank you so much. You know, I love teaching. My technologists know and a lot of my patients know that I love teaching because, again, my motto is knowledge is power, right? But I do want people to know that I think all of us that deal with breast cancer, just innately we love what we do. And I know this is Breast Cancer Awareness Month, but I think for us every month is really Breast Cancer Awareness Month.

Bill Klaproth (host): Yeah, that's a great point. Every month is Breast Cancer Awareness Month. Very well said. Dr. Yilk,. thank you so much. This has really been informative and interesting. Thank you so much for your time. We really appreciate it.

Dr. Jennifer Yilk: Oh, Bill. Thank you so much. I'm honored. Thank you.

Bill Klaproth (host): And once again, a big thank you to Dr. Jennifer Yilk and all the providers and team members focused on delivering extraordinary care to people facing cancer in our communities. To learn more about what we're doing to help humans flourish, visit us at dulyhealthandcare.com. Thanks for listening.