Dr. Mike Anderson (Host): Hello, everybody. This is The FortCast Podcast. I am your host, Dr. Michael Anderson, physician and currently serving as President and CEO of Fort HealthCare. On this episode of the FortCast, we will talk about breast cancer, awareness of breast cancer, and how to proceed if a mass is found within the breast. I'm very excited to have my special guest today, Dr. Marc Erickson, one of our general surgeons here at Fort HealthCare. And I know, Marc, I've been part of Fort HealthCare for roughly 20 years. And how long have you been part of Fort HealthCare?

Dr. Marc Erickson: I hate to admit it, but I've been here 29 years going on 30. So, it's been a long run.

Host: Well, Marc, we've been very fortunate to have you part of our medical staff for decades at this point. And given your longevity, I have to say, you still can drive the ball far away. Marc and I have done a lot of golfing together, so I appreciate that too.

Dr. Marc Erickson: We've had some great rounds and happy to be your colleague, Mike.

Host: All right. Thank you, Marc. And so, October is Breast Cancer Awareness Month. And we take that very seriously here at Fort HealthCare, and it's such an important issue in today's healthcare landscape. And a lot of people, myself included, will hear mammograms being promoted, especially during this time of year as we roll into fall. And Dr. Erickson, how important is it for a woman to have a mammogram as part of their screening regimen as they age?

Dr. Marc Erickson: I think it's crucial. I wouldn't let my wife miss one. I think the best way to think about this is that something like one in eight women get breast cancer. And your chance of curing it, your survival and everything else is directly linked to the stage. So, the earlier we could pick up a breast cancer, the better chance you have of being cured. If we get this when it's in even a pre-cancerous stage, a stage zero cancer, which is called DCIS, the vast majority of those are cured. So, mammograms are incredibly important pieces of the puzzle. Everybody should be getting them.

Host: Well, that's great to hear. And it's so important that as we think about our significant others, our spouses, our loved ones, our friends and family, mammogram is the key to early detection for breast cancer. Now, Dr. Erickson, maybe you can educate us on the path for woman or a man. I think one in 100 breast cancer cases occur in men. But when a woman has a mammogram and a lump is discovered, oftentimes that patient will get referred to you or one of your colleagues. Can you take us through the process of what happens then when a lump is discovered?

Dr. Marc Erickson: Yeah. So, I guess I would first say I wouldn't use the word lump because the vast majority of breast cancers that come to my office are not lumps that are palpable, they're abnormalities that are seen on imaging. So, yeah, some do come in, say, "Hey, I feel a lump." And generally, they go to their family doctor first, their primary care doctor, and then they get imaging and then they come to us. So, our approach is we understand this is an incredibly anxiety-filled time when you have an abnormality. And our goal, my two partners and I, is to get people through this process as quickly as possible and either reassure them that this is nothing or deal with the problem as quickly as we can.

So at Fort HealthCare, when people come in, they generally get a screening mammogram first, and that's what most people are getting when they come in for their mammogram. But if there's anything that looks abnormal on that, our breast radiologists who are board-certified specialists and just reading breast mammograms, they will then order what's called a diagnostic mammogram and most likely an ultrasound. So, a diagnostic mammogram is a little different. It's not a big picture of both breasts where you're just screening for abnormalities. It's a focused picture and sometimes from multiple views, looking at that specific area that looked abnormal. And sometimes when they do this, they'll decide it was nothing which is very helpful. And if it's just calcifications, which are little white dots you see on an x-ray, that would be all you'd get. But if there's anything that looks like a density, then they'll get an ultrasound as well, and the combination of the ultrasound and the mammogram are evaluated by the radiologist.

They then have a scoring system. It's a 1 through 5 scoring system of a 1 is a normal mammogram, a 5 is a very concerning mammogram that's likely a cancer; a 2 is when there's something that we know is benign because it's been there for several years and it hasn't changed or it's been biopsied before or something like that; a 4 is the first one that has any concerning features. And then, we try not to have 3s very often because we want our radiologists to tell us this is nothing to worry about, or this is something that needs to be addressed. So, anything that's a 4 or 5 essentially gets sent to us. And our approach is we want to get them in really to our office within 48 hours if we can and sometimes quicker. So when I see somebody in the office they're pretty apprehensive. They've been told there's something abnormal. And generally, the radiologist has already told them that, given them kind of a high level understanding of what's going on. And they generally meet with our breast coordinator, Laura Jacobson. And she also is really good at helping people through the system. So, she sets them up with an appointment.

At that point, when I come in to see them in the office, my goal is to try and bring the temperature in the room down a little bit. Help them with their anxiety by giving them honest information. so that there's not just a million ideas out there of, you know, "I'm going to die from this." We can just focus on what was found and how we're going to identify it.

So, generally, if it's not a palpable thing, it's something that showed up in imaging, I always have the imaging up and I go through it with them and I explain to them what's concerning about it, what's not concerning about it. We generally discuss, you know, is this a 4, is this a 4 A, B, or C, or a 5? I tell them if it's a 4A, this is very unlikely to be a breast cancer, it's just something we have to check out. If it's a 5, I usually tell them, "This is concerning for breast cancer, but that doesn't mean you're going to die from this. It means we're going to get to the bottom of what this is. We're going to deal with it.

Host: So Dr. Erickson, just so I can summarize. patients will start, if I understood you correctly, with what is called a screening mammogram. And if the screening mammogram shows an abnormality, it could be just a radiographic abnormality, it triggers then a diagnostic mammogram, which will sometimes involve ultrasound as well. And it's on that diagnostic mammogram where the radiologist will do the ratings one through five. And then, that's something that you will visit with the patient and go over with them about the ratings. Is that correct?

Dr. Marc Erickson: That is an exact summary. Well done.

Host: Great. So, now, Dr. Erickson, it sounds like the art and the decision making occurs when there's a 4 or 5 level seen on the diagnostic mammogram as you're meeting with the patient, and I'm sure the patient's loved ones simultaneously. So, take us through a little bit of that process.

Dr. Marc Erickson: You're right. We do try to encourage them to bring a spouse or a family member or more with them. And we try to, first of all, clear the air as far as what we're looking at. So if it's just a few little calcifications, I might explain to them the difference between a breast cancer that's stage 0, which is called ductal carcinoma in situ, which is commonly seen with microcalcifications, or I'll explain to them there's some distortion in the shape or the density of a particular area so they understand what we're looking at. And then, I'll try to tell them, you know, "The chance of this being a cancer is..." And I'll give them round numbers. But a lot of times they're thinking it's 90%, and I'll tell them it's probably 5% or 10%, and that immediately makes most people feel better.

Host: Absolutely. So, what's your next diagnostic step if you're truly worried about an abnormality seen on the diagnostic mammogram? What's your next step after that, after you've had the conversation?

Dr. Marc Erickson: So, this is much better than it was a couple of decades ago. First of all, if it's a palpable lump. something I can feel, I'll commonly or frequently biopsy that right in the office at the first visit. We'll talk about it beforehand, but usually what I'll do is we'll just numb it up with a little local anesthetic and then have a little biopsy gun. And we do this, it is painless essentially, but we'll just take a couple little bites of it, put a Steri-Strip and a Band-Aid on, and that'll get us to a diagnosis as quick as it can possibly be done.

But the vast majority of things, as I said, are picked up on mammogram. And those, if they're only on mammogram and not an ultrasound, we will biopsy them in the x-ray department using mammogram as our guide. If they show up on an ultrasound, I find it's easier to biopsy them with ultrasound, so we do that in the X-ray department as well. Those two procedures, when we do it with ultrasound, we call it ultrasound-guided core needle biopsy, or if we do it with mammogram, we call it stereotactic biopsy. They're a little bit different, but we try to do them again within usually 48 hours of when we meet them, depending on x-ray availability.

But if it's goning to e done stereotactically in the mammogram suite, a woman would be in a sitting position in a chair, the same machine that we use for the diagnostic mammogram, which is a three-dimensional machine. We can take little pictures. It's not the big picture, but a little tiny square, maybe a two by two inch area. And we'll try and identify the same abnormality. And it's pretty incredible technology. I can across the room put a cursor on the area that I biopsy. The machine then calculates X, Y, Z coordinates and transmits it to the mammogram biopsy machine, and we can wash up that little square of skin on the breast. We can numb it up by injecting a little bit of local anesthetic, make a little nick with a small scalpel blade. And then, we put this big needle into the breast and position it in the abnormality. And when I put my foot on this little pedal, it opens up a little slide on that side of the needle, sucks in a piece of tissue, and then vacuums it right out and puts it into a little cassette.

And the technology is pretty incredible in that there's 12 little slots in this cassette. And after each biopsy, we x-ray immediately that little tiny piece and can see if we have calcifications. So within about 15 seconds of me putting my foot on the pedal, we'll have a piece of breast tissue and know if we got the right area, if there's calcifications in it. So, I'll usually go all the way around the clock. You know, it takes about a minute and a half to get 12 biopsies. Then, we leave a little sleeve in that breast, take the needle out, and I put a little metallic marker into the cavity. This is a little bit bigger than a grain of rice or about that size. And we leave that in there and then remove the sleeve and take a followup mammogram. We do that for two reasons. One is if it turns out to be benign, which the majority of things we biopsy are not cancers, then when the patient has a followup mammogram, we can use that as a guide. We'll know that that's a nothing, it's already been biopsied. If it turns out that it's a cancer or a pre-cancerous abnormality, we use that little Marcer as a guide when we do surgery. So, that's the process for if it's done in the mammogram suite.

If it's done under ultrasound, it's even easier. I meet them in the ultrasound department. The ultrasound tech will be there with me along with usually Laura Jacobson, our breast coordinator. And with the woman laying on the gurney, we'll wash up the breast and the tech will hold the probe over it. And while we're watching real time on the screen, I can numb up the breast. I'll put actually numbing medicine right around the lesion. You can watch that and the woman can watch that, what we're doing if she desires. Again, make a little tiny nick. And we have the same type of instrument we use in the stereotactic machine, but it's handheld, so I can kind of Pac-Man man through the abnormality. And then, after I pull that instrument out, we'll put a similar rice-sized little metallic marker into that cavity as well. It doesn't matter how we do it. It's quick and easy, fairly painless. You can drive yourself home, end up with a Band-Aid on the breast, and that's about it.

Host: Well, that is pretty remarkable. The one thing that stood out to me as I was listening, Dr. Erickson, is how fast things happen. In other words, if there was a level 4 or 5 identified on a diagnostic mammogram, you try to get those patients in within 48 hours. Then if it's a level 5, again, within a very short period of time you want to get that biopsied. Because I cannot imagine the amount of stress and worry that the patient and their families go through during this diagnostic process. And I really commend you and your partners for trying to speed this along as quickly as possible for our patients in our community.

Dr. Marc Erickson: We have to put ourselves in the patient's position and the family's position. And I wouldn't want to be waiting around wondering whether I had cancer or not. So, most of my office time is on a Wednesday. Very commonly I'll see someone on a Wednesday, I'll do a biopsy on a Friday and I'll have a result by the next Wednesday. So, we can sit down and talk about whether it's nothing or what we'll do as the next step.

Host: Well, it's very reassuring that the vast majority are benign in nature. I think Dr. Erickson talking about what to do with the cancerous biopsy. That's probably a whole 'nother topic that I'm hoping maybe we can talk about in the future. But I would say that aside, if you see the patient back and their family and you give them the good news that it's a benign biopsy. Take us through that process. How often do you follow up on that? Do you ever have to re-biopsy it? So on and so forth.

Dr. Marc Erickson: That's an excellent question. So, all benign biopsies that we do either stereotactically with ultrasound guidance get a followup diagnostic mammogram at six months. Our concern is that, we're doing this with a needle, it's a large-bore needle, but you could miss something by a millimeter. And we want to make sure that six months later, there's not something else that's developed.

Having said that, when they're calcified, we see the calcifications immediately. So, we know we got the right area. And when they're densities that we're doing with ultrasound, we're watching the biopsy in real time and seeing the density disappear. So, I think the chance of us having a false negative is far below 1%. I can't remember in the last 10 years where we didn't get it early on. Now, having said that, there are occasional times where, you know, it's just a difficult one to isolate, we're not a hundred percent sure. And if that happens and we aren't a hundred percent sure that we got it, then we'll actually do an old-fashioned open biopsy in the operating room. But that's maybe a handful of times a year do I have to do an open biopsy and do commonly more than one breast biopsy a week. So, that'd be a very unusual situation.

Host: Well, that's great to hear that the vast, vast majority of biopsies are done outside of our operating room in a very timely fashion to help our patients. That is really great to hear. Dr. Erickson, just for future podcast, I'd love to go over the different types of breast cancer and maybe that's something we can schedule in the future. But for now, I cannot thank you enough for coming on the FortCast podcast.

Dr. Marc Erickson: Thanks, Mike. It's been a pleasure.

Host: Once again, I wanna thank Dr. Marc Erickson for being part of the FortCast podcast today. And I really want to emphasize, please get your screening mammograms. I am Dr. Michael Anderson, signing off for the FortCast Podcast today. Thank you. Bye-bye.