Maggie McKay (Host): Welcome to the Kirby Connections Health Podcast, where we help you nourish your wellness journey with Kirby Medical Center. I'm Maggie McKay. On this episode, we'll talk about breast cancer screening with Dr. Arlene Sussman, Medical Director of Virtual Radiologic and fellowship-trained in Breast Imaging. Thank you so much for being here today, Dr. Sussman.

Arlene Sussman, MD: Thank you for having me.

Host: So, let's just get right into it. What do we need to be aware of when it comes to getting screened for breast cancer?

Arlene Sussman, MD: I would say the most important factors are to know that you should begin annual screening at the age of 40. If you are a female, begin at the age of 40. If there are specific risk factors in your family, say a first degree relative was diagnosed with breast cancer before the age that would bring you at 40, you would subtract 10 years from the age at which they were diagnosed, and then you would start screening. But for the general population, begin at 40 and do it every year. Is there an endpoint? No, not in my opinion. The beginning point is the age of 40, if you're female, symptomatic or asymptomatic.

Host: Just so I make sure I understand, so let's say your mom had breast cancer at 40, so you'd start getting them at 30?

Arlene Sussman, MD: Exactly.

Host: Okay. What are some of the differences among different racial groups?

Arlene Sussman, MD: Well, we do know, unfortunately, that there are disparities at the diagnostic level of breast cancer for different racial groups. We do know that African Americans are usually diagnosed at a later stage than other racial groups. We're not entirely sure why that is. It may be a compliance issue. It may be a fear factor or maybe an access issue, but we do notice that and we try very hard to work through that disparity.

Host: And what if you've been told you have dense breast tissue, how does that affect the screening process?

Arlene Sussman, MD: So if you're diagnosed with dense breast tissue, it's sometimes hard to see through that breast tissue on a mammogram. Even what are called three-dimensional or tomosynthesis mammograms, which are like slices through the breast, pictures of the breast through individual slices, it can still be difficult to see through that tissue, especially in dense breasts.

So for women with dense breasts, it is considered an additional risk factor for the development of breast cancer in as much as it is more difficult to read your mammogram if the breast tissue is dense. Now, why is that? Because breast cancer really shows up as the white part of the mammogram or the picture. And dense breast tissue is also white on a mammogram. That's why it can be difficult to discern. So in cases of women who have dense breast tissue, we sometimes think about additional studies that might help us see through, if you will, that dense breast tissue.

Host: So, are there specific screening tools that you use for people with dense tissue?

Arlene Sussman, MD: Indeed. So for women who have dense breast tissue, particularly women who also have other risk factors, say for instance, a family history as we spoke of a few moments ago, that coupled with a dense breast tissue, not only we may suggest, but the American College of Radiology suggests adjuvant studies such as either contrast-enhanced mammography, ultrasound, or sonograms of the breast to see through that breast tissue a little better and their most recent recommendations of breast MRI, which we feel is the most sensitive test for detecting breast cancer.

Host: So, what's the profile of somebody most at risk for breast cancer?

Arlene Sussman, MD: The first is being female, that puts you at significantly increased risk over males. A family history and what is a significant family history? A significant family history is a first-degree relative who was diagnosed with premenopausal breast cancer, a mother, a sister, a daughter, that puts you at significantly about 25% increased risk over the general population of developing breast cancer.

If you yourself have a genetic predisposition, you have a genetic marker such as breast cancer or BRCA1 or BRCA2 gene, if you identified as one of those individuals, you are at sign, significantly increased risk for the development of breast cancer later in life. Those are probably the most important factors. There are other lesser factors, and they come and go in and out of fashion. But I will tell you that obesity has been linked to breast cancer. Heavy alcohol use has been linked to breast cancer. Caffeine gratefully has not been linked to breast cancer as I consume at least two cups a day. But those are the main risk factors, most of which you cannot control.

Host: Dr. Sussman, can you talk a little bit about BI-RADS and what that is?

Arlene Sussman, MD: Certainly. BI-RADS is a way of organizing reporting. It unifies reporting nationally, and it was a great addition to mammogram reports. If you receive your own mammogram report, you will see it at the bottom. The BI-RADS is categorized from 0 to 6. Zero meaning you need additional imaging. A BI-RADS 1 is negative or normal, we'll see you next year. A BI-RADS 2 is benign; again, we'll see you next year. BI-RADS 3 is probably benign. We will likely want to see you in about six months just to ensure that nothing has changed. And then, BI-RADS 4 is suspicious. BI-RADS 5 is highly suggestive-- both BI-RADS 4 and 5- of malignancy, and that there is some urgency associated with this report and to act accordingly.

And then, BI-RADS 6 is a known malignancy. You have a breast cancer, but you're being treated perhaps with medication as opposed to surgery, and we're following up on your studies. So, it's a way for referrers and patients a quick and easy reference. And it unifies all reporting, like I said, nationally, so that everyone sort of is on the same page as to what next steps should be taken, if any.

Host: So, should somebody be worried if the place that you got your screening calls you back for a second screening just to be on the safe side? I know that happened to me once and I was a wreck for about a week, and it was all fine. But apparently, they thought they saw something and brought me back in. So, what's the story with that when they bring you back in?

Arlene Sussman, MD: That is definitely anxiety-provoking for certain. So for every a hundred mammograms screening, asymptomatic mammograms that are read, approximately 8-10% of those screens will get called back or recalled for additional imaging. The doctor sees something that may be suspicious or is unclear or it's new and they want you to come back for additional images. Most of the time, those additional images will solve the problem. But it is definitely very anxiety-provoking. So, most facilities that call back patients for additional imaging give the patients their results on the spot, they don't have to go home again and wait and worry some more. You've already waited and worried enough. You've come back for the additional images, you should receive those results on the spot.

If the extra mammogram images do not solve the issue, they may add on a sonogram right then and there on the spot. They may ask you to go into the sonogram room so they can see through that spot a little bit better and better define that finding. About 75% of the time, the ultrasound will solve the problem in a benign or positive or good way, and then you're finished.

A small percentage of time, the abnormality persists and the sonogram was the right study to do. They found the abnormality. That doctor should discuss with the patient right on the spot what the options are. Usually, it's to either watch it, which would be a BI-RADS 3 if they thought it was probably not trouble, or to go ahead and take a little sample of it, usually right there and then in the office and put the issue to rest.

Host: What would you say to a woman who wasn't getting her mammograms because she heard that it hurts or she was just too nervous or scared, you know, like a younger woman?

Arlene Sussman, MD: Unfortunately, we hear an awful lot about that. Still a majority of women in this country do not go for screening mammograms on a yearly basis. The most common reason: "Well, no one in my family had breast cancer, and therefore I don't need to go." And the truth of the matter is that most breast cancers are what are called spontaneous mutations. There's no family history involved whatsoever. It's exactly why you go for mammograms every year. We know that they save lives.

So, I urge every woman out there to go get it done, go with a friend, go with a relative, have lunch afterwards. Get it done. Make it part of your yearly routine. Try and make it a passable experience. But by all means, please get it done, because we know screening mammograms, save lives.

Host: It really is not that bad. It really isn't.

Arlene Sussman, MD: No, it really isn't. In today's equipment, you don't even have to hold your breath anymore. You could just breathe normally. The image acquisition is so quick. And it really should be pretty painless.

Host: So in closing, is there anything else you'd like to add that we didn't cover?

Arlene Sussman, MD: Well, I thank you for giving me the opportunity to get on my soapbox and encourage women to go out and get their mammograms done in a timely way. We've come a long way. We really have. For the first time in history, you know, the mortality rate from breast cancer is declining. That means we're doing our job. That means you as the patient coming in in a timely way. And the equipment is better, the detection tools are better. The doctoring is pretty good. And altogether, that makes for a pretty positive experience.

Host: That's very encouraging. So, don't forget, get your mammogram every single year. Thank you so much for your time and for sharing your expertise, because it's such an important topic to everyone.

Arlene Sussman, MD: Thank you so much.

Host: Again, that's Dr. Arlene Sussman. To find out more, please visit kirbyhealth.org/services/diagnostic-imaging/digital-mammography, or you can just visit kirbyhealth.org.

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