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Dr. Mike Smith (Host): There’s good news about breast cancer. Innovative new technologies have been developed for better diagnosis and better surgery. Welcome to The GW Hospital HealthCast. I’m Dr. Mike Smith and today’s topic: Breast Cancer Innovations. 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, breast cancer, right, a lot of women worry about this. It’s a scary diagnosis. Why don’t we go ahead and start first with – a lot has happened in terms of diagnosis and treatment. Kind of give us a rundown of where we were when it came to breast cancer detection and treatment and where we are today and where we are heading.

Dr. Brem: Absolutely and when you opened up with the good news, that’s a great place to start. So, over the past decade, two decades, over the past 20 years, the death rates from breast cancer has decreased by 30%. An enormous number. And half of that is due to improved screening and half of that is due to improved therapies that we have. So, it’s very important for women to understand that breast cancer is not a killer diagnosis. That most women with breast cancer survive and thrive and really, the goal is to try to find breast cancer when it’s diagnosed, early in the breast. And then 95% of early breast cancer is a curable disease.

So, I think women should approach breast cancer that it is an extremely hopeful outlook in terms of surviving and thriving.

Host: Right, right and of course you said one of the key things there, right? Early detection. Early detection. We can’t say that enough and emphasize that enough. And so, to help the audience, maybe you could run through what are some of the common risk factors for breast cancer and what are some of the symptoms that something might be developing?

Dr. Brem: Okay. So, let’s start with the symptoms. Nobody knows a woman as well as she knows herself. And women should do self-breast exam every month. If they notice anything different, they need to really seek medical attention. And it is really important for women to know that they are their best advocate and they do know themselves the best. So, if they see a dimpling of their skin. If they have new nipple discharge. Of course, if they feel a lump, they should seek medical attention.

With regard to finding early curable breast cancer; in the old days it used to be that a mammogram was everything we had. And a mammogram is really important. It definitely saves lives. But it’s not all we have anymore. And now, just like so much of medicine is personalized; here too, in screening for breast cancer and finding early curable breast cancer; we have different solutions to optimize the opportunity to find early curable breast cancer in different women.

So, if a woman has a mammogram, we find almost all of the breast cancers and it’s important for women to know that you can still have breast cancer and have a normal mammogram. Now that doesn’t mean that mammograms aren’t effective. They are extremely effective. But if you feel a lump and a mammogram is normal; that’s not the end of the story. Then you would need an ultrasound or an MRI or other imaging to detect that breast cancer.

But as we talk about risk factors; one of the biggest risk factors for developing breast cancer is breast density. And what that means is that it’s how much white breast tissue you have on a mammogram. You can’t feel it, you can’t see it, you can be perky dense, you can be saggy dense. It’s really only something you can see on a mammogram and it’s really important for women to know because if they do have dense breasts, it means that they need additional testing like screening ultrasound.

At GW, we are very fortunate that we have the latest technology with automated whole breast screening ultrasound where we can find 25% more cancers in women with dense breasts where a mammogram may be tougher to interpret. And it’s also important to realize that women who have dense breasts not only have mammographic detection of cancer more difficult, but they are at a higher risk for breast cancer.

So, if you do have dense breast tissue and you should ask your radiologist when you have your mammogram if you do, then you should get an ultrasound to be able to catch these important but early breast cancers that can truly be lifesaving with screening breast ultrasound.

Host: Right, so there’s – there’s more than just mammography and I think that’s part of the better diagnosis. That’s part of the good news that there is – there are ways and there are modalities for experts like yourself to tease out what that lump is, is there really a mass by using these different whether it’s ultrasound or mammography, MRI, so that is – that’s very encouraging that we are able to use these tools in early diagnosis. I want to ask you though, about the general guidelines for mammography. If you have a woman who is at low risk, let’s say for breast cancer; when should she start with mammograms?

Dr. Brem: So, I think that’s a great question particularly now, but before we get to low risk women, I just want to extend a little bit about what I said in high risk women. So, in women who don’t have dense breasts, mammogram may be enough, in women who have dense breast tissue, a mammogram and an ultrasound. And in women who are at higher risk for breast cancer, whether it be as a result of them having a personal history of breast cancer themselves or a strong family history or have one of the increasing number of genetic mutations that are being identified that are associated with a very high risk of breast cancer; then we have MRI and at GW, we are very fortunate to also have molecular breast imaging. We’re the only institution here in this area that has this really novel exciting way of detecting early breast cancer by asking the question how does breast cancer function different than the surrounding breast tissue as opposed to what does breast cancer look like.

With regard to screening mammography, what the recommendations should be. I want everyone to really hear this very clearly. No matter who recommends various different screening schedules and there are many different screening schedules; everybody agrees that the most lives saved are by getting a mammogram every year starting at the age of 40 until your life expectancy is five years or less. And the only caveat to that is if you have first degree relatives who have breast cancer, you should start five to ten years earlier than that.

Now, there are many different recommendations. The American Society of Family Physicians, the United States Preventive Services Task force, they start at 50 and get a mammogram every other year. And the answer to that is yes, that will save 81% of the incredible reduction in the death rate from breast cancer that we have achieved. So, raise your hand if you are okay to be part of that 19% that would have had the opportunity to have their life saved but won’t as a result of some of the new recommendations for breast cancer which are later and less frequent.

So, the question is why would anybody do that, right? Why would anybody say get mammograms less frequently if mammography every year saves lives? And the answer is that they talk about the harm of mammography. The biggest harm of mammography is the anxiety that women have by getting called back for either additional views or even a needle biopsy. And I can tell you as a physician who has had the privilege of taking care of women for 30 years; a woman is much more anxious if you tell her that she has metastatic incurable breast cancer than if you tell her that she needs another mammogram.

And we also know that whatever anxiety women feel as a result of getting these additional tests; it’s transient. It goes away. So, why would anybody not offer women the opportunity to get lifesaving screening to detect early breast cancer? And the other part of this that absolutely drives me insane is aren’t we educated, empowered, informed women? Shouldn’t we have the opportunity to decide whether we want to be potentially slightly more anxious and have a lifesaving small curable cancer found as opposed to sticking our head in the sand and not finding it with possible tragic consequences?

So, the most important message I can send to all women is even though there has been an enormous amount of noise and even the American Cancer Society has changed its recommendations. But the most important thing for everybody to realize is that these great strides that we’ve made in women living with breast cancer are going to go backwards if we listen to these other recommendations because everybody agrees, that more American women will die of breast cancer if they don’t get a screening mammogram every year at the age of 40 onwards.

So, if there’s one message I can send with this podcast; it’s yes, there are many different recommendations. There has been a lot of noise in the media. But if women would please remember that the one common theme is that the best way to save lives and find an early curable breast cancer is to get your mammogram at the age of 40, every year in order to detect early curable breast cancer.

Host: Let me ask you Dr. Brem though, what would you say to a listener who hears that but maybe the concern is the amount of radiation. How would you answer that concern?

Dr. Brem: Well that’s a great question. So, radiologists are committed to as little radiation as possible. But it’s important to realize that the radiation associated with a mammogram is like flying to California four times. And most of us, for the right purposes, would happily fly to California four times. There has never been a documented cancer as a result of the radiation from a mammogram and mammography is the only medical imaging and one of very few medical tests that are regulated by law. Every mammography facility in the United States has an inspection every year to make sure that its radiation is within the allowable limits and is a very low amount of radiation. It’s a risk:benefit and the trade off is well worth it.

Host: Right, right. You mentioned too, the genetic mutations associated with some breast cancers. Can you tell us a little bit about that testing and who should get the genetic analysis done?

Dr. Brem: Well, that’s a great question. So, certain people have genes that are associated with a much higher risk of developing breast cancer. Some of the genes, if you have that gene; 80% likelihood that you will develop breast cancer, 50% by the age of 50. So, you get cancers more frequently and at a younger age. There are certain populations of people who have a much higher prevalence of this gene in their communities. So, for instance, of all Americans, one in four hundred will have one of these genes. Among Ashkenazi Jews; one in forty will have this gene. So, there are those who believe and myself among them, that testing Ashkenazi Jewish people for this gene is very appropriate.

The other people who should be tested are people who have strong family histories of breast cancers in multiple family members particularly if it happens young or if it happens in both breasts. Any woman who has breast cancer at the age of 50 or below or any Ashkenazi Jewish woman who has breast cancer at the age of 60 or below should get tested. And there are other people who should be tested.

Now I want to say two things about that. First of all, the best way to get tested is to see a genetic counselor. They are the ones who will be able to really – they are terrific detectives in finding which genes should be tested for. And they are also sort of the voice of an enormous amount of information. And the other thing is, that it’s a saliva test now, it’s not even a blood test. And as many people know, you can get these tests commercially with companies such as Color or 23 and Me that can test for these genes. So, the testing itself is extremely important and much easier and far less expensive than it used to be. It’s under $200 to get tested for these genes.

But the other thing that people should understand is getting tested for a gene is a very personal thing. And even if you are in this population of people who are at higher risk for having the gene; whether you get tested or not should really be a personal thing of what you’re comfortable with. So, I think it’s important to have this discussion with your physician and all the decisions that people make whether it is to get tested or whether it’s not to get tested; are appropriate decisions as long as you are well informed.

Host: Right. Very, very good answer Dr. Brem. So, part of this podcast is obviously the early detection, how important mammograms are in detecting cancers early. But the other part of the innovative technologies is better surgeries. If somebody does have a lump or does have a cancer, tell us a little bit about how that treatment has evolved as well.

Dr. Brem: Yeah, of course. So, when my mother had breast cancer when she was 33 years old in the 70s; and in those days the surgery was truly mutilating. Today, not infrequently, women who have been treated for breast cancer can go on a topless beach and no one would know the difference. And as I often tell my patients, they don’t have to go to a topless beach, but the comfort level of feeling whole and looking whole whether it be in a gym or in front of your partner in life or in front of your children is really very important. So, whether a woman needs a mastectomy, the reconstructive options are extraordinary or whether a woman has a lumpectomy so frequently the surgery itself is so minimal, that it’s very hard to even appreciate. So, I think the array of options for reconstruction are completely different than they were even several – a decade ago and so I think it’s best to – for women to understand that even after breast cancer surgery; they can and should feel whole and beautiful and the options of what’s available is probably best discussed with their breast surgeon and their plastic surgeon.

Host: You know Dr. Brem too, you know lots of information was just covered and you did an excellent job. I know my audience is soaking all this up, but let’s just end with this. In summary, what would you like people to know about breast cancer?

Dr. Brem: I would like people to know that breast cancer has impacted every American, one in eight American women will develop breast cancer and those that don’t are impacted by their family member or neighbor or colleague at work or someone they love. And every man and woman in America is impacted by breast cancer.

The other thing is that breast cancer is not a death sentence, that there are over three million women who have had breast cancer in our country that are surviving and thriving. And finally, the best way to decrease how intense your therapy is and to assure your survival is to find early curable breast cancer. And so, get your mammogram every year starting at the age of 40. If you are dense, get a screening ultrasound and if you are at higher risk, get an MRI so we can find these small node negative cancers before they become a problem that we can’t successfully handle.

Host: Right. Dr. Brem, great summary. I want to thank you for the work that you are doing and 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.