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Scott Webb (Host): Early diagnosis and treatment are essential to surviving cancer and breast cancer is no exception. And joining me today for a conversation about the latest screening options, including mammograms, MRIs, and ultrasounds, is Dr. Sean DeSilva. He's the Medical Director and Section Chief of Breast Radiology at Franciscan Health. This is the Franciscan Health Doc Pod. I'm Scott Webb. So, Doctor, thanks so much for your time today. We're going to talk about breast cancer today and early detection and all the screening tools and options that women have. As we get rolling here, who's at the highest risk for breast cancer?

Sean DeSilva MD, CPHQ, DABR (Guest): People at the highest risk for breast cancer would be those individuals with some sort of genetic predisposition for breast cancer. So, the most common one would be a BRCA mutation and BRCA, mutation. Those patients would be at the highest risk. There are other genetic syndromes, but BRCA, p53, Li-Fraumeni, any sort of genetic predisposition that raises your risk of breast cancer, put these women at the highest category.

Host: Yeah. And so when we think about early detection, when should that really begin?

Dr. DeSilva: Premature exposure or unusual exposure to radiation in addition to any kind of genetic susceptibility. So, for example, mantle radiation for the treatment of lymphoma is very common in young women. This is a sort of a childhood cancer that is often treated with radiation, very early on in life. And so those patients, in addition to patients that have some sort of genetic predisposition. Like I mentioned, those patients should have discussions with their primary care doctor very early on, I would say as early as when they're kids, even as young as 18, depending on when they received the mantle radiation for that specific example of lymphoma.

But, I would say as soon as you're an adult, as soon as you're 18, have a discussion with your primary care provider about your risk. Talk to them about if there's any family history of breast cancer. We care particularly of first degree relatives, first degree meaning a mother, a father, a sibling, with breast cancer.

And it doesn't have to just be breast cancer, by the way, it could be anybody with any kind of cancer. We think mainly of breast and ovarian cancer. If anybody in your family has had a premenopausal diagnosis of breast or ovarian cancer, definitely something you want to talk to your primary care doctor about getting screened at an earlier age than is typically recommended. In the United States, we currently recommend that all women beginning at the age of 40, receive an annual screening mammogram. Now I know this is a topic of confusion because some societies in the country actually recommend beginning at 50 and some societies recommend doing mammograms biannually. So once every two years, but every major cancer organization in the United States, including the American Cancer Society, including the American College of Radiology, and certainly any fellowship trained breast imager like myself, would recommend screening mammograms beginning at 40, once a year. Again, in the absence of any external risk factors that elevate one's risk of breast cancer. Those women might need to be screened earlier, but in general, if all women can get screened once a year, beginning at 40, that's a good thing.

Host: Yeah, that's really helpful, you know, to break that down for us. And what is a health risk assessment. And why should women take them?

Dr. DeSilva: That essentially is a comprehensive assessment typically done by a primary care provider or possibly a breast surgeon who has expertise in breast health where they go through your full risk of developing breast cancer over your lifetime. And they come up with a magical percentage and there are various models that are used throughout the world.

The most commonly one used in the United States is the Tyrer-Cuzick model. And this model will give you a number, will generate a number of your lifetime risk for breast cancer, meaning how likely is it over the course of your lifetime that you will develop breast cancer. It's critical to do this because not only does it risk stratify you, it tells you if you're actually eligible for additional supplemental screening techniques.

For example, if your Tyrer-Cuzick lifetime risk of breast cancer is greater than 20% you are eligible for annual screening breast MRIs. Now this is a wonderful technique. It's not perfect, but it is highly sensitive in detecting breast cancer in women that are at greater than 20% lifetime risk of breast cancer.

So, again, this health assessment, it will look at everything. We'll look at your family history. We'll look at your breast density. We'll look at genetic history, et cetera, and we'll come up with a number to determine your lifetime risk of breast cancer. And so when women get this number, they can have a discussion with their primary care doctor about what sort of screening techniques are appropriate for me? Is it just mammography that I need once a year, or is it also a supplemental high risk screening breast MRI. And for some women that let's say less than 20% of lifetime risk, but greater than sort of the general population, these women may be eligible for something called whole breast automated ultrasound, we term this ABUS, automated breast ultrasound.

Which essentially uses ultrasound to screen the breast for breast cancer. And this is particularly useful in women with dense breasts, which is something I definitely wanted to talk about here. Something we actually do not talk about often and is not heard in the lay population, or even understood by primary care providers very well, is that if you have dense breast tissue right, the utility of mammography is actually very poor. You really don't hear this very often, but half of women out there have dense breast tissue. Right. And so it is not inaccurate to say that for half of the population, screening mammography, it's not good enough. The reality is, that based on the evidence we have, in a woman with dense breast tissue, it's only about 55 to 60% sensitive. Put another way, we're going to be missing 40 to 50% of cancers in women with dense breast tissue. You know, if you tell a woman, who has dense breast tissue, hey, we're going to do a mammogram on you. And there's a one in two or a one in three chance that I'm going to miss a cancer. I mean, that is terrible odds, even for Vegas. Right?

Host: Yeah. I don't like those odds at all. No.

Dr. DeSilva: And that's why I mentioned ABUS, you know, the automated breast ultrasound, because breast ultrasound does not care about breast density, right? Ultrasound works regardless of your breast density. In fact, it's best in women with denser breast tissue. So, this is something that women should talk to their primary care doctors about.

And if they have dense breast tissue, something they should absolutely consider getting again, not to replace screening mammography, but to supplement it again, I just want to emphasize that all women beginning at 40, in the absence of other risk factors should be screened once a year, beginning at 40.

But, I would say at least half of the population needs a supplemental screening technique to look for breast cancer.

Host: Yeah. As you're saying, you know, one in two, approximately, right. So, let's just take a step back and go through mammograms a little bit. Are we talking 2D, 3D mammography. Just break that down for us. What is a mammogram exactly?

Dr. DeSilva: It is one of the most common ways and the standard of care now in the United States and around the world, to screen for breast cancer. Again, beginning at age 40, done annually, 2D versus 3D. For 2D mammography, this has sort of an older technique that utilizes x-rays that just go in one plane, right, in 2D, in two dimensions. The newer technique, which is now the sort of quote unquote 3D mammography is also known as tomosynthesis, or, you know, tomosynthesis guided mammography.

And what this technique involves is you have those two standard views top to bottom, and then sort of at an angle. The only difference is the breasts are compressed and then multiple pictures are taken 15 degrees above and 15 degrees below. And so it's sort of like a 3D picture where the radiologist can now scroll through the breast.

It's no longer 2D. It's three-dimensional. I can scroll through the breast, in three dimensions and look for cancer in a more accurate way. If you are in any major city, women are being screened with 3D mammography. Unfortunately in some parts of the country, particularly in the rural parts of the country, 2D mammography is still utilized, but the cancer detection rate, has been shown over multiple studies to be higher. So, we find more cancers with 3D mammography. We actually call back less women with 3D mammography. So, things that we might've thought was cancer on a 2D mammography, because we can now scroll through that area; we're able to say with confidence that, oh, this is just overlapping breast tissue, or this is just a cyst or something like that.

And we don't need to scare a woman and have her come back for additional imaging. So, it's actually very beneficial to patients, beneficial to doctors. We like it more. It's easier to evaluate and overall it's just better for everybody. And then, like I said, it is the standard of care and I believe all insurance companies now pay and cover for 3D mammography as the standard of care.

Host: Yeah. Standard of care, and so when we think about insurance, I know this is maybe a little bit outside your area of expertise, but if mammography is the standard of care, and is generally covered by insurance, where do MRIs and the ultrasounds and that higher level of screening, especially for women with dense breast tissue, how does insurance view those, that higher level of screening, which we've identified that you said at least one in two women probably need?

Dr. DeSilva: Absolutely. Absolutely. It is not an understatement to say that probably close to one in two, at least one in three women need some sort of supplemental screening technique. I mean, it's really a big misunderstanding of the population, and not by the fault of our patients, but I think the doctors, we need to educate patients more and help them understand that, you know, if you have dense breast tissue or if you have a greater than 20% lifetime risk of breast cancer, based on the Tyrer-Cuzick health assessment, I mean, you really need some supplemental screening tool. So, to answer your question with regards to the insurance companies, as far as I'm aware, the high-risk screening breast MRs for women that have a greater than 20% lifetime risk of breast cancer is universally covered by all major health insurance companies, including Medicare and Medicaid. So, the breast MRs for women that are eligible is no problem to get, as far as I understand. With regards to ABUS, you know, the automated breast ultrasound for women that are sort of at that intermediate risk, right, greater than the normal population, which again, we say is roughly 12%.

So, you know about one in six women will develop breast cancer in her lifetime. Right. So somebody you know, is almost certainly affected by breast cancer. So, we say there's a 12% lifetime risk as a woman, just by being a woman, you have a 12% lifetime risk of breast cancer. For those women that fall in between 12 and 20, that are not eligible for high risk screening breast MR, an ABUS would be indicated. It varies on a state-by-state basis. So, I do know for example, I did my training in Boston, in Massachusetts and in Massachusetts, ABUS is actually not covered by insurance companies. And so as a trainee, I did very little automated whole breast ultrasound, but, here in Illinois and in Indiana, where this technology was actually developed and pioneered, insurance companies do cover it.

And so women routinely in Illinois, in Chicago and Indiana, women routinely receive automated breast ultrasound. So, again, I would say that if you live in a state that covers automated breast ultrasound, it is absolutely worthwhile to get it done. And if you are in a state that does not have it covered, I would have a conversation with your primary care doctor and possibly your insurance company about somehow seeing if that would be worthwhile for you, maybe not on a yearly basis, but every other year or something, depending on finances and what you can afford.

Host: Doctor, this has been really educational today, and I've even pushed you outside into insurance, which is definitely not something you do on a regular basis, but you're quite knowledgeable, which is great. As we wrap up here, wonder if you could just talk about value, the importance of self exams for women, especially since detecting breast cancer early is so key.

Dr. DeSilva: That's a great question. And I would say that breast self exams is a sort of controversial topic because if you look at the major societies out there, the American College of Surgeons, the American Academy of Family Physicians, even the American College of Radiology; we actually vary in our recommendations and our guidelines for self exam and so this is an interesting topic. So, I'm going to sort of give you my perspective on this, which is a perspective shared by I know most of the physicians that I work with and the primary care doctors that I work with. At a minimum, women should be receiving an annual screening physical exam, breast exam done by a physician at least once a year.

So, if you are above the age of 18, you should have, at the time of your annual physical exam, a breast exam by a physician. With regards to self exams, I can only speak to what I imagine myself doing as if I was a female. I would want to know my body well. And so what I tell my female patients is that there is no harm in doing routine monthly self exams. So I would say to talk to your doctor about how to do a breast exam and have them show it to you. There's actually a technique that can be done.

And you want to make sure that you cover the breast. You want to make sure you cover also the armpit, right, the axilla to look for lymph nodes. And so my perspective is, if it's not going to do harm and it's only going to add understanding and awareness of one's body, I think it's a good thing.

So I would encourage all women above the age of 18, to do monthly self exams. And again, this is not something that is routinely endorsed by all medical societies, but at a very minimum though, almost all medical societies in the United States will recommend an annual breast exam done by a physician. So, whether it's a gynecologist or your primary care provider, whoever it is, as long as it's being done once a year, that's good.

Host: Yeah, I hear you once a year. And regarding the self exams, none of us are going to hold you to it Doctor. We understand that, you know, opinions vary, but as you say, you know, it probably can't hurt and it can only help, but it's one more tool in the tool belt, if you will, when we think about detecting breast cancer early and everything that everybody can do in pursuit of that. So, Doctor, thanks so much for your time today and you stay well.

Dr. DeSilva: Thank you very much.

Host: For more information, visit Franciscanhealth.org and search mammogram. And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well. And we'll talk again next time.