Ashlee Williams, MD (Host): For many women, getting a mammogram can seem daunting and uncomfortable. When should you start? How often should you go? What can you expect? And what happens if you get an abnormal result? Welcome to the Healthier You podcast. I'm Dr. Ashlee Williams. And today I'm talking with Dr. Ainsley McLean, Associate Medical Director for Diagnostic and Interventional Radiology here at Kaiser Permanente; to explain when and why mammograms are important. How to prepare and what happens during the screening process. Plus, we'll talk about how advancements in technology like AI and 3D mammograms are making screenings even more effective. Dr. MacLean, thank you so much for being here for this important conversation.

Ainsley MacLean, MD: Thank you so much for having me.

Host: So let's just start with why are mammograms so important?

Ainsley MacLean, MD: So breast cancer is very common. In fact, one in eight women will be diagnosed with breast cancer in their lifetime. But the good news is, that it's extremely treatable when we detect it early. And this is why screening for breast cancer is so incredibly important. Believe it or not, the five year survival rate when you catch breast cancer early, before it's spread outside the breast, is about 99%.

However, if it goes undetected and it spreads to other parts of the body, the five year survival rate drops off quite a bit, to 30%. So this is why we need to catch breast cancer early, and why we're so committed to ensuring that mammograms are done, and why they're just so important.

Host: Yeah, that is such an amazing statistic about catching breast cancer early and why screening is so important; 99 percent versus 30%, that's huge. Can you talk about when we should get a mammogram? How often should we be screened?

Ainsley MacLean, MD: Absolutely. So the United States Preventative Services Task Force, which issues standardized recommendations for all screening programs, recommends that women on average, who are average risk for breast cancer, get a mammogram every two years. And this was recently changed to start at age 40 and continue through age 74.

 If you have a higher risk of breast cancer, your doctor may recommend that you start getting mammograms at a younger age or that you get them more often. So it's important really to talk with your doctor about what may be best for you.

Host: Having that conversation early with your doctor is very important. I love here at Kaiser Permanente that we have an amazing genetics team that our patients can meet with and talk about their family history and the risk of developing breast cancer and what kind of screening they should have if they have a higher risk. Can you talk a little bit about what can put you at higher risk for breast cancer?

Ainsley MacLean, MD: Absolutely. And so it is fairly complex. So I'm glad you mentioned, Dr. Williams about geneticists, and it's really good to kind of individualize this to you. But of course, just being a female puts you at increased risk of breast cancer. Males do actually get breast cancer, but obviously women are at significantly more risk due to the amount of glandular tissue we have in our breasts.

If you have a personal or a family history of breast cancer, and the more relatives you have with breast cancer, the higher your risk, right? So that can really increase it. And that's at the point too, where oftentimes a geneticist recommend looking for certain mutations such as the BRCA1 and BRCA2 genes.

And those can really increase the risk of developing breast cancer. Alcohol consumption, obesity, lack of exercise and smoking have also been shown to increase your risk as well. So all of these factors will be taken into account. However, of course, most women are at average risk and therefore would follow average screening guidelines as I discussed earlier.

Host: Okay, so when we know it's time, we've hit the age of 40, we've determined that it's time for us to get our mammogram, how do you tell patients to prepare for the mammogram?

Ainsley MacLean, MD: There's a few things that you can do. So first of all, you know, if you're menstruating, there's times of the month that it can be slightly more painful to have breast compression. So particularly around your period, especially in the week preceding your period, can be kind of a tough time to get a mammogram.

So we generally recommend women, if they can, to avoid sort of that week. Also picking something where it's a little bit earlier in the day because you are going to need to have a deodorant free skin. So we don't recommend any deodorants and a lot of times patients will ask why that is. Believe it or not, deodorant shows up on a mammogram as these little specks and that can sometimes interfere with the interpretation of the mammogram, although as radiologists, we can oftentimes recognize that.

But it just makes it lot more straightforward if we don't have to worry about that and you don't have to worry about that by avoiding that deodorant. Same with perfumes, anything extra kind of try to avoid. I think, you know, in general, when you come in, it's a good idea to bring any information that you think might be helpful to your doctor.

So if you've had a prior screening mammogram, maybe at somewhere else that you haven't been before. You know, it's good to bring that information. And also, oftentimes you'll be asked to fill out a form about what your risk factors may be, your family history. Within Kaiser Permanente, we have access to all of that information prior to your mammogram, which is really helpful, so there's no need to bring anything to our appointments, but it is helpful to just make sure, especially if you move, to always kind carry that history of your mammograms with you because when radiologists have the prior mammograms it really helps us interpret the study and so something that, we think may look like it's something new may not be new and that can be helpful information to us and then also impact whether we have to have you come back.

Wearing something that's kind of easy to remove is always just a good idea because you are going to have to take off your top and put on a gown, and then, you'll also be asked to remove all jewelry, so in general on the day of exam, I would just avoid the jewelry, but you don't have to do anything differently in terms of what you eat, what you drink, it really should be a pretty straightforward and quick appointment.

Host: Yes. I love that you mentioned that. I think one of the biggest things when my patients come in, even if they're coming in for knee pain and they're due for their preventative mammograms, we try to get them scheduled. And they'll say, oh, but I'm wearing deodorant. Our technicians here are so amazing. I love that they're so prepared, they can wipe that deodorant right off. We have things to help you even if you come unprepared. Right?

Ainsley MacLean, MD: Absolutely, and I think that that brings up a great point too Ashlee, which is just that there shouldn't really be any barrier to having a mammogram. So, all the things we said are, sort of great ideas, but it's way more important that you actually get a mammogram and you fit it into your schedule whenever that may be, because it's really one of the best things that you can do for your health, and for those, of course, who love you as well.

So, nothing should be a barrier to having it done. And, and a lot of times women actually ask about, well, I can't find my priors. Does that matter? No, a radiologist can interpret your mammogram without any priors and that also shouldn't be a reason to not get a mammogram.

Host: Agree. I also get a lot of feedback that's like, oh, you know, I heard that it hurts really badly. Like I'm really nervous about getting a mammogram. Can you talk a little bit about what a woman or a man should expect if they need to get a mammogram?

Ainsley MacLean, MD: Yes. Absolutely. So that's something that I do tend to take a little ibuprofen before I get my mammogram. I don't know Ashlee if you ever recommend that to your patients. It can definitely be a little bit painful and that's just something that I try to tell myself, you know, it's a good thing if there's some pressure there, because that's what's flattening out that breast tissue, right?

That's how we're actually seeing through that tissue to look for cancer. So I kind of tell myself that as I'm getting my mammogram. And in general, what will happen is you'll come into the room and you'll see the machine and the machine is great because it's really open, right? And you can look around.

It's not like some of our other imaging equipment in radiology where where you have to go into a tube or anything like that. So you'll be able to stand, you can look around, you'll there's no issues with claustrophobia. You will put on a gown and the technologists that do mammograms are incredibly experienced.

So they do, you know, dozens of these a day and our technologists have been doing it for many, many years. And so their main job is to position your breast in a way that they can get the best possible image. And they're going to do that in a very specific way. So the first thing that they're going to do is they're going to have your breast flattened on the machine, from top to bottom.

And that's one of the really important ways radiologists look at the breast. And then they'll do the same thing, but sort of sideways so that they're able to compress it from side to side. And both of those images are really important, for our radiologists to look at. And of course, now what we also have is 3D mammography, where the breast is put in those same positions, but instead of just taking two pictures of the breast, the machine is actually taking a whole 360 degree sort of picture of the breast so that the radiologist can scroll through images and get even a more detailed look at your breast as well.

Interestingly, for a 3D mammo and a 2D mammogram, which I just talked about, there's not really any difference in what the patient does, or really in the speed of the machine as well. So, there's not a huge difference there. And right now, both are recommended and are both are totally appropriate for breast cancer screening. One isn't recommended over another. So there's no wrong answer, whether you have a 2D or a 3D, and we offer both at Kaiser Permanente.

Host: Yes. Thank you for mentioning that because I think it's super exciting that we have access to 3D mammograms at our medical centers. Can you talk a little bit about the technology and advances of mammograms? And are mammograms more accurate now than they have been in the past?

Ainsley MacLean, MD: Absolutely. So the technology just keeps getting better and better. y now, many years ago, there was what was called analog mammography, which I think would be kind of similar to a film photograph. Now, of course we use digital mammography, which means that you can zoom in and there's a really high resolution

that our radiologists can do, and just overall, you can take the image a lot faster. Once you get the images taken, they go immediately to our radiologists who are reading all across the Washington, D.C. area, and they can be read within 60 minutes, whereas if you'd had film like we used to have before, a radiologist would only be able to read at the speed of, that that was developed.

With the 3D, it's interesting. It's something actually we were really proud and are so proud to participate in a large trial from the National Cancer Institute called the T MIST trial, which is seeking to define are there certain patients who would do better with a 3D mammogram versus a 2D mammogram?

We are very fortunate, as Dr. Williams said, to have a lot of 3D mammography. Both within Kaiser Permanente and within our area, but many parts of the country don't have access to this technology. And so it's really important, since screening is something that's recommended for all women over 40, that we make a decision, you know, as a country, in terms of what we're going to be recommending and be clear cut about it.

And so really the jury is still out and we're excited to be participating in, in the research that's going to help define that. We do know that 3D mammography has improved detection rates. What hasn't really been shown, in a randomized control trial outside of T MIST is whether it actually saves lives more than 2D mammography.

And we know that 2D mammography, which is the most common form of mammography, does save lives by detecting breast cancer early as does 3D. One of the things we're also looking at now, and I think a lot of women are hearing about in the news, is just around artificial intelligence.

And, one of my other hats is as our Chief AI Officer. And one of the actual areas in which I'm most excited about artificial intelligence is in the realm of screening for breast cancer. And I think for those of you who have been following the news, you can understand why that might be, because whenever you're looking at large volumes of data, that's where artificial intelligence really shines.

And it would always be as an assistant to a radiologist. I don't see artificial intelligence ever replacing, even in mammograms, the role of the radiologist and their experience because, there's a lot of things you have to take into account when you're looking at a mammogram and you see an abnormality.

But we are participating in a research study in 2025 looking at whether that augments and picks up additional breast cancers above and beyond radiologists. Because we do know that radiologists anywhere, just like all humans can't pick up everything and there is the potential for AI to detect breast cancers before they even can be seen with the human eye.

So I'm really excited about that. And really looking forward to hopefully seeing how we can redefine the landscape of breast health.

Host: Yeah, that all sounds very exciting. I think, one of the tough parts about mammograms is getting past the discomfort. But I think another difficult part is the wait for the results. And I can't give enough props to you and your team. The wait time here at Kaiser Permanente getting your results back is so amazing. I mean, a lot of times it's within an hour and I know you've done a lot of behind the scenes work on making sure that happens. Sometimes I have patients that go get a mammogram and then come see me after and I already have the results ready and that feels like a huge weight lifted off their shoulders that they can have the results so quickly.

Can you talk a little bit about results and what people should expect when they get them?

Ainsley MacLean, MD: Absolutely. So I think, first of all, thank you so much, and I'm really incredibly proud of our radiologists and our mammography technologists and the work they do. I think many of them are patients themselves, right, and have had mammograms. And we know that the second you are due for your mammogram, you see it on your calendar, you sort of you know, even if you haven't had a personal, or family experience with breast cancer and start wondering is it going to me? I think the good thing to remember is if for some reason you become one of those women, 99 percent treatable, incredible advancements.

And so, we really help guide you if that ends up being your path. But the reality is that 90 percent of women that come in for a mammogram have a totally normal result, right. And even of the 10 percent of women who don't, and they get called back for additional imaging, the vast majority of those women end up being found to have nothing.

And so the good news is that your chances of having an abnormal mammogram and an abnormal follow up are very small, but the role of a screening study is to catch those women who may have something abnormal. Now, interestingly, first time women who have never had a mammogram before, so women who are 40, have a slightly higher callback rate, meaning they have a slightly higher rate of abnormal, what's called an abnormal mammogram at the time of screening.

So if you are 40, you have your first mammogram, you never had one before, and you get called back, don't think to yourself, oh my gosh, I came in for a screening mammogram. I don't ever want to do this again. I can't believe I have to have a follow up. And why is that? That's because you've never actually had a prior before.

So as you end up coming in for your 40 year old, your 42 year old, your 44, or ones in between, you're building a record of cases that the radiologist can then use to kind of, without, I think the best way to say it is get to know you and the way your breast tissue looks. And so you're going to be a lot less likely to be called back the more regularly you get a mammogram.

And also as you build up that sort of story, your own personal story, with your breasts and your breast tissue. Cause there are changes we see over time as you gain weight or you lose weight, if you're breastfeeding and we just want to get to know you, as much as possible. So in most cases you'll have a normal mammogram.

 As Dr. Williams said, we do result that quickly. And we're able to do that through digital and other technologies that really have been, I think transformative for women to get those results so quickly. Now one of the other questions that comes up is just around dense breast tissue. This is something that's been a really area of intense research and sort of investigation over the last decade or so, as we start to understand more about the different types of breast density.

Many women will see at the end of their mammogram note, even language that we're required to put in by the various states as to what that means to you. By dense breastity, dense breasts, women are into four different buckets. And it's basically just the percentage of your tissue that is either fatty, or glandular, and that ranges from predominantly fatty to, predominantly pretty dense.

And there's nothing to worry about no matter where you are on that spectrum. But we do know that dense breasts makes it a little bit harder to read a mammogram, as well as breast density may also actually independently increase your chances of having breast cancer. So one of the areas of excitment around 3D mammograms really does lie in sort of that more dense breasts, and why is that? We can scroll through the breasts a little bit more. We can see what's an area of overlapping tissue versus a cancer. You know, I'm excited most, I think, about 3D mammography in those women with dense breasts. Oftentimes, an ultrasound will come up as a potential additional way to look at the breasts in women with dense breasts.

And, again, that's a little, an area sort of still of investigation. And we do follow standardized guidelines around breast ultrasound and really recommend doing mammography. And we'll recommend any additional imaging if we feel that it's indicated, but we don't de novo recommend any additional screening studies based on evidence guidelines.

So, you know, again, we really try to prioritize women receiving their mammogram results. And, if they're abnormal, you get a phone call from us and we'll get you in for a follow up quickly, and help navigate you wherever that is in, in your journey, we will be right. by your side.

And, and I think that's really critical and making sure that, we make the whole process, as, painless as possible, but also that we do, what we do best, you know, at Kaiser Permanente, which is diagnose breast cancer early, get you treated and get you on living a really healthy life.

Host: Yes, and there's an amazing team of support that if you do have an abnormal mammogram, everything happens very quickly. If you have a abnormal screening, the diagnostic mammogram and ultrasound is booked very quickly. If that turns out abnormal, there's a process to schedule the biopsy and it's very streamlined, very quick.

Usually happens within a few days, which I think is just an amazing thing about Kaiser Permanente and our integrated care system. Thank you so much, Dr. MacLean. We learned so much about mammograms and what to expect in the process. Here are the top takeaways. 1. Breast cancer is common, but it's easily treatable if it's caught early. 2. Women at average risk for breast cancer get a mammogram every two years, starting at age 40. But those at higher risk, including those who have certain gene mutations or have a family history of breast cancer, should talk to their doctor to see if screening sooner or more often may be appropriate.

3. It's a good idea to avoid scheduling your mammogram around your period, when your breasts may be more sensitive. You'll want to arrive at your appointment with clean, deodorant free skin. But never let these things be a barrier to getting the care you need. 4. The whole procedure takes about 20 minutes. And the actual breast compression only lasts about 10 to 15 seconds for each image. Technology has greatly improved the accuracy and effectiveness of mammograms in recent years. 5. Remember, it's common for patients to get called back after a screening mammogram. Most often, the findings are benign. But if you do need treatment, Kaiser Permanente stands by you with expert guidance and medical care throughout the process.

 For more information about women's health from our experts, visit kp.org/doctor and listen to more episodes of Healthier You wherever you get your podcast. If you enjoyed this episode, be sure to share it with others who may find it helpful. Thank you. And from all of us at Kaiser Permanente, be well.