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Dr. Mike Smith (Host): In 1969, dedicated mammography units became available for use around the world. And mammograms continue to play a key role in early breast cancer detection. Welcome to The GW Hospital HealthCast. I’m Dr. Mike Smith and today’s topic: Mammography Saves Lives. My guest is Dr. Rachel Brem. Dr. Brem is Professor of Radiology and the Vice Chair of Radiology at the George Washington University School of Medicine and Health Sciences. She’s also the Director of Breast Imaging and Intervention at the George Washington University Hospital and the GW Medical Faculty Associates. Dr. Brem, welcome to the show.

Rachel Brem, MD, FACR, FSBI (Guest): Thank you very much.

Host: So, the title, right, mammography saves lives. Can you tell us a little bit about how many lives have been saved, at least maybe an estimate of how many lives throughout the years mammography has saved?

Dr. Brem: So, currently, in the United States, there are about 230,000 new cases of breast cancer every year and about 45,000 women die of their disease. Over the past two decades, there has been a 30% reduction, almost one in three women now survive, that wouldn’t have survived two years ago. So, the numbers that are saved as a result of mammography are enormous and are very real and the other thing to remember is that the women – the age that women get breast cancer in the United States is decreasing so, more and more often, women in their 40s and 50s are getting breast cancer. And so, we are finding early curable breast cancers in these younger women that are in their prime of their lives, career wise, raising children and of course every life is important. But now, with this enormous impact on survival from breast cancer; we have the opportunity to save so many life years as a result of screening mammography.

Host: How has mammography evolved over the years, right? I know for instance digital mammography is something that you kind of hear here and there. Can you just tell us a little bit about where the technique was and where we are at today and where is it going?

Dr. Brem: Yes, okay, terrific question. So, when mammography started out in the 70s when we really as you said late 60s early 70s, we were using the same kind of x-rays that we used to get chest x-rays and now, we are looking for things that are on the order of 50 microns, teeny little things, the absolute earliest sign of breast cancer. So, we went from dedicated analogue mammography units to digital units and now we have 3-D mammography. Up until the availability of 3-D mammography, also called tomosynthesis, we would image a three dimensional object, the breast, in two dimensions. And now, we have the opportunity to basically look at the breast slice by slice so that we can find both more cancers, smaller cancers and have less false positives because we can appreciate whether some of the findings are normal breast tissue that are just lying on top of itself because now, we can really peel through the breast, image by image.

So, increasingly, 3-D mammography is available across the country. Here at GW, we were among the first in the country to have it. And all of our mammograms are done with the latest and most sophisticated technology of 3-D mammography or tomosynthesis.

Host: Right. You know more and more women are asking about alternatives to mammography and we can get into why or why not that might be wise, but there are other options out there for imaging the breast. Can you just kind of review what techniques besides mammography are out there and available?

Dr. Brem: So, that’s a great question. There is nothing that replaces mammography. Mammography is the standard of care for screening for breast cancer. But there are other technologies that help compliment mammography particularly in situations where mammography may be less effective. And in particular, we know that 85% of breast cancers are seen on a mammogram but in women who have dense breast tissue; mammograms are not as effective and not only are mammograms not as effective, but women who have dense breast tissue, have a much higher risk of developing breast cancer.

So, it’s kind of like a perfect storm. So, women with dense breasts should definitely still get mammograms because we find some cancers on mammograms that we can’t find any other way. But in these women with dense breast tissue, they should also have screening breast ultrasound because we can find 25% more cancers and it’s important to remember that the cancers that we find with screening breast ultrasound are really important cancers. And what I mean by that, is they are invasive, small, node negative cancers. So, these are potentially killer cancers but with ultrasound we can uncover them early when they are only in the breast and they are curable.

So, for women – and the other thing to remember is although your density decreases as you age; and 70% of women in their 40s have dense breasts, 30%, a third of women in their 70s have dense breasts. So, across the United States, almost half of women have dense breast tissue and as a result of efforts on the part of the physicians at GW, as well as the Brem Foundation to defeat breast cancer; there is a law that has recently been passed in DC and will go into effect April 4^th that will require all women in DC to be told what their breast density is, at the time of their mammogram. And also, be told that additional imaging can find these additional cancers.

And for women who have a much higher risk than average women or women with dense breasts; that is, women who have a personal history of breast cancer, women who have something called atypia, unusual cells that were found at the time of biopsy or women who have a genetic mutation that results in a much higher risk of breast cancer; we have both magnetic resonance imaging, MRI at GW as well as we are the only institution in this region that has molecular breast imaging, a very exciting new technology that allows us to ask the question what does breast cancer function like as opposed to what does it look like and allows us to find cancers that can’t be seen with mammography or ultrasound as well.

So, here at GW, we are very fortunate to have the absolute latest technology and the largest armamentarium of technology to help us detect early curable breast cancer. And the other thing is that we believe as so much of medicine is going to individualized and personalized medicine; here at GW, the diagnosis and treatment of women with breast cancer is very personalized as well. So, we developed personalized screening protocols for women as well as those women who are diagnosed with breast cancer. We have personalized therapeutic and surgical options to optimize their technology.

And one final thing about at GW how fortunate I feel to be here; is if we look at the cancers that are diagnosed at GW, although the age of the women are younger, which tends to be a more aggressive cancer; we find because we have these newest technologies and because we use this individualized screening strategy; the cancers that we find are earlier, are more curable than the national average and we are very proud of that. And we are also very proud of this extraordinary dedicated multidisciplinary team for all women screened for breast cancer, treated for breast cancer so that we can optimize the diagnosis and treatment of breast cancer for each individual woman with a level of expertise that is unrivaled in this area.

Host: Right, that’s fantastic Dr. Brem. Can you run through the mammography guidelines now. When should a woman start with mammography?

Dr. Brem: Yeah, that’s a great question. And it’s particularly great question now because over the past year or two there have been so many different recommendations. The United States Preventative Services Task Force says start at 50, every other year. The American Cancer Society says women should consider getting screened at the age of 40 but should definitely start at 45 to 54 every year and then every one to two years after that. The American College of Radiology and the ACOG American College of OBGYN says start at 40 and get a mammogram every year. And sometimes, the thing that’s so – the worst consequence is that sometimes all these recommendations are so confusing that women just throw up their arms and say I’m not going for my mammogram because it’s so confusing.

It’s important to remember that no matter what the recommendations are, the one thing that’s agreed upon by everyone is that more lives will be saved if women go for annual mammograms every year starting at the age of 40. And that’s really important because the USPSTF says you know you can start at 50 and go every other year and we’ll still maintain 81% of the advances that we’ve had in decreasing the death rate from breast cancer. But that’s not okay for the 19% of women who could have been saved who now will lose their lives as a result of decreased screening. And some people say you shouldn’t start screening until the age of 50 because breast cancer doesn’t happen that often for women in their 40s. Well more than 25% of breast cancers occur in women in their 40s and breast cancer in women in their 40s usually is more rapid and more aggressive. So, in that population of women, we really must, we have an obligation to find these early cancers and so women in their 40s absolutely should be going every year for lifesaving screening mammography.

And often women in their 40s will have dense breasts and therefore they should have screening breast ultrasounds as well. So, the recommendations vary, but the bottom line and the most important take home message is, no matter what the recommendations are; everybody agrees, that more women’s live will be saved if you start screening at the age of 40. So, you might ask well why would anybody recommend anything else, right? If we are saving more lives, isn’t that wonderful. And the answer is that the harms of mammography are discussed.

And the two biggest harms that are discussed is – or the three biggest issues are the anxiety that women feel as the result of a mammogram that might show something that will need additional testing or even a needle biopsy. The radiation associated with it and so let me address those two things first.

The anxiety is something that we know that everybody gets a bit anxious if they have a positive medical test. But we know that it’s transient and women will go back to not being anxious once everything is worked out. And the other thing is it’s very important to realize that if a woman is told that they have incurable metastatic breast cancer that they will be infinity more anxious than if they get told that they have a mammogram that needs another mammogram or even a needle biopsy.

And finally, this is 2019, where women should have the opportunity to make decisions for themselves and have the opportunity to decide if they want to be anxious to find an early curable breast cancer and it should not be mandated by other organizations or associations. So, I think that’s absurd. Sometimes I feel like we live in the middle ages where don’t worry, your little mind will take care of you. The answer is no, get your mammogram, find early curable breast cancer and if you do unfortunately have breast cancer, become one of the over three million women in the United States that both survive and thrive after a diagnosis of breast cancer.

And so, women should get their mammograms and absolutely no matter what the recommendations are; women in their 40s should absolutely get mammograms every year. And in fact, some of the consequences are that the USPSTF are generally are the body that decides if under the ACA, the Affordable Care Act, a screening examination is covered without a deductible or a copay. So, gratefully, the women across the aisle in Congress have now twice passed a law called the PALS law that allows women to have mammograms free, meaning a screening mammogram has no deductible and no copay. So, cost should not be an issue in getting lifesaving screening mammograms every year.

Host: Right. What about the radiation issue? How do you address that for women that are concerned?

Dr. Brem: Yeah. Great, thank you for asking that. The radiation exposure in mammography is regulated by law. And the law only allows the lowest level of radiation. Every facility, every mammography facility in the United States has to have an inspection every year and prove that their radiation is below the standard, the national standard. In addition, there’s never been a cancer that’s been shown to result as the consequence of the radiation exposure of mammography. And finally, radiologists are extremely sensitive to minimizing the exposure to radiation but like so many things, whether it’s getting in your car, or flying in a plane, it’s always a risk: benefit and the data is compelling that the benefit of a mammogram far outweighs the risk of radiation.

Host: Right. Dr. Brem, you are just full of so much information. I know the audience is soaking all this up. Just in summary, what would you like people to know about mammography?

Dr. Brem: I’d like people to know that mammography is lifesaving, that regardless of what the noise in the media is these days and please go get your mammogram, starting at the age of 40, every year unless you have a first degree relative that had breast cancer at a younger age and then you should start five to ten years earlier. It would be such a tragedy and travesty if after all this headway that we’ve made in saving lives from breast cancer, we now move backwards, and more women die from breast cancer who could have been saved because women don’t get their lifesaving mammograms.

Host: Dr. Brem, I want to thank you for the work that you are doing and also thank you for coming on the show today. You’re listening to The GW Hospital HealthCast. For more information, go to www.gwdocs.com, that’s www.gwdocs.com. I’m Dr. Mike Smith. Thanks for listening.