Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. Today, we're highlighting breast cancer screening at AHN. Joining me is Dr. Matthew Miller. He's a radiologist and the division Director of Breast Imaging at AHN.

Dr. Miller, it's a pleasure to have you join us today. As we get into the imaging, which there's so much going on in your field now. Start by explaining a little bit about breast cancer. What are you seeing as far as incidents awareness? Are you seeing more women getting screened?

Dr. Matthew Miller: Hi, Melanie. First of all, thanks for having me on. And so, it's always a battle to get awareness out there and make sure that women have the knowledge and the power they need to get the appropriate screening that they need. And that extends beyond breast care, it extends through all health fields, right? But for breast cancer screening especially, we have definitely seen an uptick in the screening adherence over the last 20 years. And subsequently, we've also decreased the mortality rate of breast cancer by 50% over the last 20 to 30 years. And so, you know, those two facets have really corresponded with each other. So with increased screening, we've saved more lives.

Melanie Cole, MS: Well, that's certainly true. So, what's changed, Dr. Miller? How has breast cancer screening evolved over the past decade or so. There's so many more advanced imaging options today beyond a mammogram. So, speak a little bit about what's changed in your field. What's exciting?

Dr. Matthew Miller: Yeah, I mean, there's a lot of exciting things. It is one of the reasons I got into the field, right? Because it's ever evolving. I mean, today, breast cancer treatment. Screening, basically the whole gamut is completely different than it was when my mom was diagnosed with a high-risk lesion when I was in high school, right? So, nothing takes the place of a mammogram. The number one thing you can do to give yourself the best chance of surviving a breast cancer diagnosis is getting a mammogram every single year. And that hasn't changed for the last 30 plus 40 years.

Patient adherence to that has changed, it has gotten better. And the quality of mammography has improved over especially the last decade. So back in the '90s, we had plain film mammography, just like any x-ray. You know, they put it up on the view box, right? And then, we converted the digital mammography where it was on a computer. And it was more mobile and the dose had decreased and whatnot.

And then, in the late two 2000s, early 2010s, tomosynthesis, 3D mammography, same thing, became the next game-changer. And so, 3D mammography has really, really revolutionized the way we're able to detect breast cancers and treat it early. It allows us to detect one to three more breast cancers per thousand screened. And it also allows us to be more accurate. So, less people are getting called back for false positives. So, it's really been a great tool, a great revolutionary thing in breast cancer detection.

Melanie Cole, MS: Yeah, 3D tomosynthesis really did change the landscape for you. Now, speak about some of the other technologies we hear about MRI, whole breast ultrasound, all of these other ones. Where do they come into the picture? If we're using 3D, then where do these others come in?

Dr. Matthew Miller: Absolutely. And you mentioned the big ones, right? So, MRI and ultrasound and there's even more we can talk about going forward. But the big one is MRI. Just like an MRI people get MRIs of their back, of their brain, of their shoulder, whatnot, we can do an MRI of the breast. MRI of the breast with contrast is very, very good at detecting breast cancer. And the use of MRI has also evolved over the last 20 years. So, we do MRI primarily for screening for high-risk patients. So, patients that have a greater than 20% lifetime risk of developing breast cancer. And so if you fall into that high-risk category, MRI doesn't take the place of a mammogram, but it works in adjunct to a mammogram and helps us to detect more breast cancer.

And it's also evolving in patients with dense breasts. So, everyone has different quality of breast density. So, breast density, you can think of it as like clouds in your breast. So, some people don't have many clouds in their breasts. A lot of people have a lot of dense clouds in their breasts. And so if you fall into that more dense, that heterogeneous or extremely dense category, still get your mammogram. But then, you also potentially would qualify for an MRI as well. And that helps us to detect any enhancing breast cancer.

And then, ultrasound is another tool that we use. So ultrasound, it's the same type of ultrasound that we use to look at babies or look at a gallbladder for gallstones or whatnot. We use it on the breast. And that works in conjunction with mammography. So, it doesn't replace a mammogram. There are still things that a mammogram that can pick up that an MRI or an ultrasound doesn't pick up. But there are things that an ultrasound can help, detect. So we can do a screening ultrasound for people with dense breasts that might not need or qualify an for an MRI, or we can do a diagnostic ultrasound to evaluate something, either a symptom, like a palpable lump or something that we may have found on a mammogram and we want to get a better picture with ultrasound for.

Melanie Cole, MS: Dr. Miller, when we think of providers counseling their patients on getting their mammograms and they're talking to their patients, we hear a lot about personalized medicine. So, you're mentioning these other technologies. For providers that are counseling their patients, how would you advise them to mention these if we think about it in terms of individuality. As you mentioned, dense breasts, high-risk, familial, you know, genetics, BRCA gene, you know, situation. So when they're speaking to their patients, what would you like them to know?

Dr. Matthew Miller: I think every provider should have a conversation about, breast cancer history starting at the age of 25. So, you have patients that come in, they're 25 or older. They should have that conversation of, "Okay, what is your family history? Have you ever been diagnosed with something? Do you have a personal history? You know, did you get exposed to radiation when you were younger?" There's a subset of patients that get diagnosed with lymphoma in their teens. Those patients are potentially high-risk. Having that history starting at the age of 25, going through that, and then developing a personalized approach to screening. So if they are deemed to be high-risk, then they would qualify for mammograms before the age of 40. They would qualify for screening MRIs before the age of 40. Typically, high-risk patients start screening at 25 with MRI. And then, mammography at the age of 30. That's personalized approach to medicine.

And then, once they get the imaging performed, we give a density score. So, we can't really detect a patient's breast density by just looking at them, but we can detect it with imaging. So if you get a mammogram, you get an ultrasound, you get an MRI, we can see how dense your breasts are. And then, that provides even more information. Okay, you might be borderline risk, you might be 15-20% lifetime risk, maybe not above 20, maybe not high-risk. You're intermediate risk, but you're extremely dense. And so, that together should say, "Okay, I think you need something more than just a mammogram. Get an MRI as well or a get a screening ultrasound every year in addition to your mammogram."

So when we talk about personalized approach to medicine, and specifically breast imaging and breast cancer detection, that's the approach to do. Having these conversations and recognizing these risk factors.

Melanie Cole, MS: Dr. Miller, when we think of access and equity, the barriers to screening, the barriers to medical care are quite significant in the country. When we think about barriers to breast cancer screening specifically, how is AHN addressing these?

Dr. Matthew Miller: Absolutely. It is on the forefront of our minds every day. Number one is knowledge. Knowledge and knowing what is appropriate for you to do to give yourself the best chance of overcoming a breast cancer diagnosis. We talked about, number one, is getting a screening mammogram every single year. And that's why you have people like me, you have advocates out there, getting on social media, going to news outlets, talking to different groups about what is appropriate, what do you need to do? When should you get a mammogram? Starting at the age of 40, doing it every single year, that saves the most lives. So, knowledge is power. And it's especially important for breast imaging.

And then, beyond that, finance, right? I mean, everyone, in today's world, everyone has finances to take into account. And I will say that Allegheny Health Network, in partnership with Highmark, have made great strides. So, the state of Pennsylvania recently passed a bill that won't go into effect, I think, until 2027, where diagnostic breast imaging that could be a diagnostic mammogram, ultrasound, MRI is now 100% covered. So traditionally, a screening mammogram is a hundred percent covered if you have insurance. So if you have insurance, you don't have to have a copay, there's no co-insurance. You go in, you get a hundred percent covered. That's by the government. And Highmark AHN goes a step farther and covers any additional imaging even to a biopsy. So, you don't have any financial reason not to get the breast care that you need. And then, beyond that with finance is patients who potentially aren't insured. So, we recognize there's disparities with different socioeconomic classes and whatnot. And that should not be a reason for you to not get your breast care. So, we have partnered with different organizations, and we offer free screening mammography to any patient, insurance or not. So by all means, there's no financial reason for you not to get your breast care.

And then, other issues is access. We have over 20 breast centers in Western Pennsylvania. I think it's up to 23 now throughout all of Western Pennsylvania, as high as Erie and as south as Union Town, right? And so, we have all these different brick and mortar breast centers to provide access so that anywhere you live in Western Pennsylvania, there's a accessible AHN breast center to go get the care that you need.

So, we're constantly looking and evaluating for other sites to open up breast centers and provide access, but I think we have a pretty good smattering throughout Western Pennsylvania.

Melanie Cole, MS: Well done, Dr. Miller. That is excellent news really. Because when you think of diverse communities and they hear a diagnostic mammogram costs money, then they're just not going to do it. And then, that's going to raise the mortality rate. And so very well done. That's great to hear. Now when we think of needing that diagnostic, that's because maybe they had an abnormal screening study. What happens after that? You know, it used to be you had to wait in the waiting room, make sure that the pictures were good, and then whatever. And then, God forbid, you got that letter in the mail. But now, how do we know it's abnormal and what happens next? Then, what's the next step?

Dr. Matthew Miller: Electronic medical records has really revolutionized patient communication, right? And nowadays with the volume of screening mammograms, you come in, you get your screening mammogram, and then you leave. And the screening mammogram is usually read within one to three business days. And once you get that result, that result comes to your myChart, which is your own personal electronic medical record. And you see majority of the time you get a, "Hey, your mammogram looks good. Come back in a year." But if you have we call it BI-RADS 0, which is a callback. You'll see that result, and then your physician will call you to get you the order. And then, we, the breast center, will call you to get scheduled. And so, we get you scheduled for a diagnostic mammogram and an ultrasound. And so, those patients will come in. And it's really tailored to what the finding is to the mammogram. You have a diagnostic mammogram, which is different than a screening mammogram. It's specialized imaging to cater to the finding. And then, potentially, you would have a diagnostic ultrasound in addition to that. So, we would evaluate the finding on a mammogram with an ultrasound. So statistically, if you want to talk statistics, about 10% of people who get a screening mammogram get called for a diagnostic evaluation.

And then, of those 10% of people that get the diagnostic evaluation, about a third of those are recommended to have a biopsy. And then, of the third that are recommended to have a biopsy, about a third of them are diagnosed with breast cancer. So, it's not an insignificant number, but still a third of a third of a 10th is a very, very small number. So, we diagnose about four to six breast cancers every thousand screening mammograms that we perform.

Melanie Cole, MS: That's quite the process, and it can be such a scary time for patients. But AHN is different and there are a lot of places that patients can go. What makes AHN different in breast imaging and breast cancer care that you find so unique and so supportive and compassionate for women that do have to go through this?

Dr. Matthew Miller: I think AHN, first and foremost, is such a welcoming medical facility. We pride ourselves in our patient experience. We pride ourselves in the timeliness of our appointments and the timeliness of your experience with us. We want to get you in, we want to get you out, we want to get you the care that you need.

Obviously, there's going to be waits here and there, but I think one thing that we pride ourselves in is the accuracy and comfort of our patients. And so, coming to our breast center, you know that you're going to get the expert care and be comfortable doing so and be able to talk to providers who know what they're doing, who are expertly trained. They're all fellowship-trained breast imagers. So, you know that the person who's taking care of you has spent dedicated time honing their craft and becoming an expert in their field.

Beyond that, we're constantly looking for ways that we can break down barriers to get the care to the patients that might have barriers in front of them. So, I mentioned before about our brick and mortar locations. We offer walk-in screening mammograms. So, eight of our sites every day you can walk in from 7:30 AM to 11:30 AM. Go in, get your screening mammogram. You don't even have to have an order from your physician. You know that you're due for a mammogram, go walk into one of our sites and get it done. So, we provide that flexibility that most other places don't provide. And so, that's extremely important to us, is getting the care that you need on your terms.

Melanie Cole, MS: Very well said. Dr. Miller, thank you so much for joining us today and really sharing your incredible expertise. And to learn more or to refer your patient, please call 844-MD-REFER or you can visit findcare.ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole. Thanks so much for joining us today.