Richard Reitherman, PhD, MD discusses three breast screening methods for earlier and more precise detection and diagnosis of breast cancer.
In addition, he describes the dense breast law, as well as when genetic counseling is recommended.
Some questions he answers are how frequently women should get mammograms and what are the screening methods at the MemorialCare Breast Center at Saddleback Memorial.
Selected Podcast
Advances in Breast Screening Methods and Exploration of the Dense Breast Law
Featured Speaker:
Organization: Saddleback Memorial Medical Center
Dr. Richard Reitherman, PhD, MD
Dr. Richard Reitherman, PhD, MD is the medical director of the MemorialCare Breast Center at Saddleback Memorial and Orange Coast Memorial and a board member of the American Society of Breast Disease. He is well-known for his clinical role in the early adaptation, promotion and refinement of Breast MRI, with more than 20 years of experience in breast imaging and intervention. His special clinical and research interests include improving screening for high risk women less than 40 years of age, multimodality imaging correlation with Large Section Histopathology, and implementation of standardized work flow algorithms for Breast Centers.Organization: Saddleback Memorial Medical Center
Transcription:
Advances in Breast Screening Methods and Exploration of the Dense Breast Law
Deborah Howell (Host): Hello, and welcome to the show. You are listening to Weekly Dose of Wellness brought to you by MemorialCare Health System. I'm Deborah Howell, and today's guest is Dr. Richard Reitherman. Richard Reitherman is the medical director of the MemorialCare Breast Center at Saddleback Memorial and Orange Coast Memorial and a board member of the American Society of Breast Disease. He is well-known for his clinical role in the early adaptation, promotion, and refinement of breast MRI with more than 20 years of experience in breast imaging and intervention. His special clinical and research interests include improving screening for high-risk women less than 40 years of age, multimodality imaging correlation with large section histopathology, and implementation of standardized workflow algorithms for breast centers. Welcome to you, Dr. Reitherman. You sound like a busy man.
Dr. Richard Reitherman (Guest): Good morning. I'm here.
Deborah: We have a lot to talk about today, so let's jump right in. How frequently should women get mammograms?
Dr. Richard: I think the mantra would be, for a normal-risk woman, starting at 40, every year—12-month intervals.
Deborah: Okay. There's been a little controversy about that, but you really can't go wrong if you do that, correct?
Dr. Richard: Correct. There is controversy, and probably not the place to get into it my recommendation is that.
Deborah: Okay, very good. Tell me about the screening methods at the MemorialCare Breast Center at Saddleback Memorial.
Dr. Richard: There are three primary mechanisms or methodologies that we use for breast screening. Just to note the difference, screening is when a woman has no lumps or signs or symptoms of the breast. That's the definition of a screening test.
Deborah: Oh, I've already learned something. Wow. Okay.
Dr. Richard: If they have lumps, we use a different algorithm or paradigm, even though we use the same mechanism or instrumentations. The most standard tool is the x-ray screening mammogram, which has been around for a while. It has undergone multiple improvements with decreased dosage and increased resolution. That is the primary mechanism where we screen normal-risk women once a year starting at 40. The other modality we have for screening is ultrasound. We have the whole-breast ultrasound program, which is automated and interrogates or screens with ultrasound both breast volumes, just like a mammogram would. The difference between the two is one uses x-ray and the other uses sound waves and the latter has no radiation. The ultrasound is used primarily for women that have dense breasts, which we can come back to later.
Deborah: Okay.
Dr. Richard: Third modality is breast MRI, magnetic resonance imaging. That is used for high-risk women—that is, those women with a significant family history in addition to mammography. In general, the high-risk woman would have a mammogram and an MRI every year, a normal-risk woman would have a mammogram, and the woman in the intermediate risk would have a mammogram, and, if she has dense breasts, would have an ultrasound in addition. So that's the complement of screening tests.
Deborah: You really don't get out of having the mammogram if you get the ultrasound, in many cases?
Dr. Richard: Good pick up. The mammogram is the constant feature for each group.
Deborah: Right. Okay. As women, we sort of don't look forward to our mammograms, but we know we need them.
Dr. Richard: I think that's true. Again, we screen all women. Most women will not get breast cancer, so most women have to go through the screening procedures with no benefit other than knowing they don't have breast cancer.
Deborah: Right.
Dr. Richard: But we have to screen everybody because other than those with significant family history, we don't know who is going to develop breast cancer.
Deborah: Right. I noticed that you did say that we've made progress in terms of the dosage of radiology. I think that's what most people dislike, and they are uncomfortable as well. But I think it's the radiology that most women fear. Maybe you can address that.
Dr. Richard: Sure. Being that it's a test that you have every year, it can be of little more concern than, say, a test you have once every so often. The radiation is a little more concerning. The current radiation that's used with the current digital equipment is very low dose, and it's equivalent to taking a plane trip cross-country at 35,000 feet, because we have x-ray radiation coming from the sun all the time. It's not considered a risk in terms of increasing the risk of breast cancer.
Deborah: That brings up another question. I've heard the plane analogy before. What about people who are on planes, women who are pilots and flight attendants? Are they at increased risk?
Dr. Richard: We're not aware of any studies that have been done to test that.
Deborah: Okay. That's all we can answer then until there are some tests. How did these three screening modalities work together to produce the best result for women?
Dr. Richard: The screening mammogram, the x-ray mammogram, is excellent for women who have what we would call non-dense breast tissue. Some women, under mammogram, have essentially, it's all black. It's like a negative that you see of a photograph. Some women on the other hand have totally a white breast. That has nothing to do with the texture, the size, or anything. You're just born with that texture.
Deborah: Okay.
Dr. Richard: In general, the breast density decreases with age. The lower breast density produces the higher sensitivity mammogram, meaning that we can detect cancer more easily in the woman with a not dense breast than we can with a dense breast. So in women with a dense breast, we want to add other modalities which mitigate the dense breast tissue. For example, ultrasound would be the next one. No radiation, no risks, really, in terms of radiation or compression. There's no compression. That test is not dependent on breast density. The sound waves are well suited to interrogate dense breast tissue. The MRI is the most expensive test, and so it's reserved for people that have a very high risk of having breast cancer.
Deborah: Okay. Maybe you can describe the breast MRI a little bit more.
Dr. Richard: Sure. Breast MRI is essentially an angiogram where contrast substances are injected. During the course of the examination and the accumulation of the images by the machine, tumors uptake blood flow, and that's how we detect them. Images are subtracted from each other, so whatever the woman's breast density or if she has augmentation or previous surgery, it's all essentially subtracted out, and so we get an as perfect picture as we can any tumors that are in the breast.
Deborah: Okay. Which leads me to my next question: what is the California Dense Breast Law all about?
Dr. Richard: As we had just discussed, breast density decreases the sensitivity of a mammogram. The denser the woman's breast, the less sensitive a mammogram is, and therefore, maybe a physician would suggest another procedure such as an ultrasound or MRI.
Deborah: Okay.
Dr. Richard: The Dense Breast Law simply states that all women having a mammogram in California must receive a written notice of whether their breasts are dense or not. If they are dense, then it may decrease the sensitivity of mammography, and the patient consults their physician for other imaging modalities. It's basically an informed consent so that the patient having the study actually has the information they need to make an informed decision.
Deborah: Information is power. This is the government working for you, actually, right?
Dr. Richard: Surprise.
Deborah: Yes, exactly. Okay. When is genetic counseling recommended, doctor?
Dr. Richard: There are specific guidelines for genetic counseling. If the patient has a certain history in their family above a certain threshold, in genetic counseling it's recommended. The genetic counseling is not genetic testing.
Deborah: Okay.
Dr. Richard: It's a filter. When you meet certain criteria, you're referred to the genetic counselor. The genetic counselor takes a more exacting family history and personal history of tumors and then recommends blood testing if it needs to be performed. For example, a woman who's 40 years old and she goes in for her first mammogram, and her mother was 40 when she was diagnosed with breast cancer, would be referred to genetic counseling if she met criteria for genetic blood testing. Specifically, we're talking about the infamous BRCA1 gene, BRCA2 gene.
Deborah: Okay. Know your family history, very important. Do you have any other advice for women?
Dr. Richard: I think knowing your family history is very important because it's such a risk, and we base all our imaging and complementary imaging in addition to mammography on risk. For example, if a woman has enough family history, we will start screening her with mammogram earlier than 40 years of age. Everybody that comes to our facility, be it a screening or diagnostic patient, receives an assessment of family history, then the radiologist translates that into whether the woman should have additional testing or genetic counseling. We assess every woman who comes there.
Deborah: That is great. It's been really a pleasure to have you on the show. I really, really enjoyed hearing about the three different screening methods. I wasn't aware about the screening. Having no lumps is why you're there in the first place, and that's why you get what you get in terms of your mammogram, which we may dread but we really do need, because it can lead us to some very, very important healthy information about our own bodies. Thank you so much, Dr. Reitherman, for taking the time to talk to us today about advances in breast screening methods and so much more. It's been a real pleasure to have you on the show.
Dr. Richard: You're welcome. Thank you.
Deborah: I'm Deborah Howell. Join us again next time as we explore another Weekly Dose of Wellness brought you by MemorialCare Health System. Have a fantastic day.
Advances in Breast Screening Methods and Exploration of the Dense Breast Law
Deborah Howell (Host): Hello, and welcome to the show. You are listening to Weekly Dose of Wellness brought to you by MemorialCare Health System. I'm Deborah Howell, and today's guest is Dr. Richard Reitherman. Richard Reitherman is the medical director of the MemorialCare Breast Center at Saddleback Memorial and Orange Coast Memorial and a board member of the American Society of Breast Disease. He is well-known for his clinical role in the early adaptation, promotion, and refinement of breast MRI with more than 20 years of experience in breast imaging and intervention. His special clinical and research interests include improving screening for high-risk women less than 40 years of age, multimodality imaging correlation with large section histopathology, and implementation of standardized workflow algorithms for breast centers. Welcome to you, Dr. Reitherman. You sound like a busy man.
Dr. Richard Reitherman (Guest): Good morning. I'm here.
Deborah: We have a lot to talk about today, so let's jump right in. How frequently should women get mammograms?
Dr. Richard: I think the mantra would be, for a normal-risk woman, starting at 40, every year—12-month intervals.
Deborah: Okay. There's been a little controversy about that, but you really can't go wrong if you do that, correct?
Dr. Richard: Correct. There is controversy, and probably not the place to get into it my recommendation is that.
Deborah: Okay, very good. Tell me about the screening methods at the MemorialCare Breast Center at Saddleback Memorial.
Dr. Richard: There are three primary mechanisms or methodologies that we use for breast screening. Just to note the difference, screening is when a woman has no lumps or signs or symptoms of the breast. That's the definition of a screening test.
Deborah: Oh, I've already learned something. Wow. Okay.
Dr. Richard: If they have lumps, we use a different algorithm or paradigm, even though we use the same mechanism or instrumentations. The most standard tool is the x-ray screening mammogram, which has been around for a while. It has undergone multiple improvements with decreased dosage and increased resolution. That is the primary mechanism where we screen normal-risk women once a year starting at 40. The other modality we have for screening is ultrasound. We have the whole-breast ultrasound program, which is automated and interrogates or screens with ultrasound both breast volumes, just like a mammogram would. The difference between the two is one uses x-ray and the other uses sound waves and the latter has no radiation. The ultrasound is used primarily for women that have dense breasts, which we can come back to later.
Deborah: Okay.
Dr. Richard: Third modality is breast MRI, magnetic resonance imaging. That is used for high-risk women—that is, those women with a significant family history in addition to mammography. In general, the high-risk woman would have a mammogram and an MRI every year, a normal-risk woman would have a mammogram, and the woman in the intermediate risk would have a mammogram, and, if she has dense breasts, would have an ultrasound in addition. So that's the complement of screening tests.
Deborah: You really don't get out of having the mammogram if you get the ultrasound, in many cases?
Dr. Richard: Good pick up. The mammogram is the constant feature for each group.
Deborah: Right. Okay. As women, we sort of don't look forward to our mammograms, but we know we need them.
Dr. Richard: I think that's true. Again, we screen all women. Most women will not get breast cancer, so most women have to go through the screening procedures with no benefit other than knowing they don't have breast cancer.
Deborah: Right.
Dr. Richard: But we have to screen everybody because other than those with significant family history, we don't know who is going to develop breast cancer.
Deborah: Right. I noticed that you did say that we've made progress in terms of the dosage of radiology. I think that's what most people dislike, and they are uncomfortable as well. But I think it's the radiology that most women fear. Maybe you can address that.
Dr. Richard: Sure. Being that it's a test that you have every year, it can be of little more concern than, say, a test you have once every so often. The radiation is a little more concerning. The current radiation that's used with the current digital equipment is very low dose, and it's equivalent to taking a plane trip cross-country at 35,000 feet, because we have x-ray radiation coming from the sun all the time. It's not considered a risk in terms of increasing the risk of breast cancer.
Deborah: That brings up another question. I've heard the plane analogy before. What about people who are on planes, women who are pilots and flight attendants? Are they at increased risk?
Dr. Richard: We're not aware of any studies that have been done to test that.
Deborah: Okay. That's all we can answer then until there are some tests. How did these three screening modalities work together to produce the best result for women?
Dr. Richard: The screening mammogram, the x-ray mammogram, is excellent for women who have what we would call non-dense breast tissue. Some women, under mammogram, have essentially, it's all black. It's like a negative that you see of a photograph. Some women on the other hand have totally a white breast. That has nothing to do with the texture, the size, or anything. You're just born with that texture.
Deborah: Okay.
Dr. Richard: In general, the breast density decreases with age. The lower breast density produces the higher sensitivity mammogram, meaning that we can detect cancer more easily in the woman with a not dense breast than we can with a dense breast. So in women with a dense breast, we want to add other modalities which mitigate the dense breast tissue. For example, ultrasound would be the next one. No radiation, no risks, really, in terms of radiation or compression. There's no compression. That test is not dependent on breast density. The sound waves are well suited to interrogate dense breast tissue. The MRI is the most expensive test, and so it's reserved for people that have a very high risk of having breast cancer.
Deborah: Okay. Maybe you can describe the breast MRI a little bit more.
Dr. Richard: Sure. Breast MRI is essentially an angiogram where contrast substances are injected. During the course of the examination and the accumulation of the images by the machine, tumors uptake blood flow, and that's how we detect them. Images are subtracted from each other, so whatever the woman's breast density or if she has augmentation or previous surgery, it's all essentially subtracted out, and so we get an as perfect picture as we can any tumors that are in the breast.
Deborah: Okay. Which leads me to my next question: what is the California Dense Breast Law all about?
Dr. Richard: As we had just discussed, breast density decreases the sensitivity of a mammogram. The denser the woman's breast, the less sensitive a mammogram is, and therefore, maybe a physician would suggest another procedure such as an ultrasound or MRI.
Deborah: Okay.
Dr. Richard: The Dense Breast Law simply states that all women having a mammogram in California must receive a written notice of whether their breasts are dense or not. If they are dense, then it may decrease the sensitivity of mammography, and the patient consults their physician for other imaging modalities. It's basically an informed consent so that the patient having the study actually has the information they need to make an informed decision.
Deborah: Information is power. This is the government working for you, actually, right?
Dr. Richard: Surprise.
Deborah: Yes, exactly. Okay. When is genetic counseling recommended, doctor?
Dr. Richard: There are specific guidelines for genetic counseling. If the patient has a certain history in their family above a certain threshold, in genetic counseling it's recommended. The genetic counseling is not genetic testing.
Deborah: Okay.
Dr. Richard: It's a filter. When you meet certain criteria, you're referred to the genetic counselor. The genetic counselor takes a more exacting family history and personal history of tumors and then recommends blood testing if it needs to be performed. For example, a woman who's 40 years old and she goes in for her first mammogram, and her mother was 40 when she was diagnosed with breast cancer, would be referred to genetic counseling if she met criteria for genetic blood testing. Specifically, we're talking about the infamous BRCA1 gene, BRCA2 gene.
Deborah: Okay. Know your family history, very important. Do you have any other advice for women?
Dr. Richard: I think knowing your family history is very important because it's such a risk, and we base all our imaging and complementary imaging in addition to mammography on risk. For example, if a woman has enough family history, we will start screening her with mammogram earlier than 40 years of age. Everybody that comes to our facility, be it a screening or diagnostic patient, receives an assessment of family history, then the radiologist translates that into whether the woman should have additional testing or genetic counseling. We assess every woman who comes there.
Deborah: That is great. It's been really a pleasure to have you on the show. I really, really enjoyed hearing about the three different screening methods. I wasn't aware about the screening. Having no lumps is why you're there in the first place, and that's why you get what you get in terms of your mammogram, which we may dread but we really do need, because it can lead us to some very, very important healthy information about our own bodies. Thank you so much, Dr. Reitherman, for taking the time to talk to us today about advances in breast screening methods and so much more. It's been a real pleasure to have you on the show.
Dr. Richard: You're welcome. Thank you.
Deborah: I'm Deborah Howell. Join us again next time as we explore another Weekly Dose of Wellness brought you by MemorialCare Health System. Have a fantastic day.