Transcription:
The Importance of Breast Cancer Screenings

Prakash Chandran (Host):  About one in eight women in the United States will develop breast cancer in her lifetime. So, it’s really important to have regular screenings because early detection can help save lives. But what exactly do you need to know about these screenings and what should you do to stay healthy? We’re going to talk about it today with Dr. Marina Feldman, a Breast Radiologist and Medical Director of Breast Imaging at Elliott and Co-Director at Elliott Breast Health Center.

This is the SolutionHealth Podcast from SolutionHealth. I’m Prakash Chandran. So, Dr. Feldman, it is great to have you here today. Let’s just get right into it. Why exactly should women screen for breast cancer in the first place?

Marina Feldman, MD, MBA (Guest):  Hi Prakash. Thanks for having me on the program. So, you raise a very good question. Why is it important to screen? As you said, one in eight women will be diagnosed with breast cancer. That’s 12% of all women. And we know that breast cancer can be deadly, but breast cancer death rates declined 40% from 1989 to 2016. And the progress is attributed to improvements in early detection. And we know it as mammography. However, despite the presence of this tool and its proven track record; breast cancer is still the second leading cause of cancer deaths in women in the United States. And that’s why we need to have the conversation about the importance of screening mammograms.

Mammography is the gold standard for screening the population. And it’s really the best method we have to diagnose breast cancer early. So, what does early mean? If God forbid a woman is to develop breast cancer, we want to find it when it’s still in its infant stage, the size of chalk dust as opposed to having been allowed to develop into a lump that a woman herself can feel and brings to the attention of her doctor. Early detection could be the difference between a woman moving on with her life and thriving after the diagnosis or possibly losing her life to it. That’s why we talk about screening and that’s why it’s important.

Host:  Okay, that makes a lot of sense. When we talk about early detection, I’m curious as to what age women should actually start the screening and how often they should be screened.

Dr. Feldman:  So, we recommend yearly screening mammograms starting at age 40. A lot of academic bodies are in that boat. American College of Radiology, Society of Breast Imagers, American College of Breast Surgeons, American College of OB-GYNs and NCCN. NCCN is the National Comprehensive Cancer Network that all of the oncologists follow their guidelines for what the appropriate treatments and screenings are. And the American Cancer Society all recommend starting at 40. And it’s really important that we stress this as there is some confusion out there about this. And I tell all of my patients not to get confused.

Starting screening mammograms at 40 as opposed to 50 is extremely important. One in six diagnosed breast cancers occur in women in their forties. That’s 16% of all diagnosed breast cancers are diagnosed in women in their forties. And women that develop breast cancer in their forties tend to have more aggressive disease. So, this is really the population of women that we as a society cannot afford to overlook in screening guidelines and really cannot afford to wait until they turn fifty to start screening them.

Host:  So, is there ever a case where someone should get screened before forty? I’ll give you an example. My mother-in-law got diagnosed with breast cancer at 42 years old and I’ve heard that you should go in I believe or get screened ten years prior to the diagnosis of your parent and so, is there ever a case where you might want to go in earlier?

Dr. Feldman:  That’s definitely one of the school of thoughts that you need to go in ten years before the diagnosis of a first degree relative. But notice that there are a lot of qualifiers there. So, for anyone that has family members with breast cancer or even with other cancers because some of them are genetically linked and we know that now. What we encourage them to do is to go in for a genetic consultation. Consultation is just a conversation where they assess what your overall lifetime risk is and then they make a recommendation on whether you should start screening before 40, whether you should start screening at 40, whether you should start screening just with mammography or for some patients that are younger than 40, sometimes we start screening with ultrasound or with an MRI but this is all very, very unique. The key to all of this is going in and learning what your overall lifetime risk is and what you risk profile is and what your genetics are potentially.

So, consultation is not a genetic test, but you would have an option of doing one if you so choose. The reason this is so important is because information is power and so, I tell my patients I don’t want you walking around thinking there’s a black cloud over your head when there might not be one and just be anxious about possibly getting breast cancer or another cancer down the line. But at the same time, if we know that you’re at increased risk, well there is something we can do about it. We can proactively offer you a more robust screening protocol than just a yearly screening mammogram, whatever is appropriate give you risk stratification.

Host:  Absolutely. One of my favorite quotes is the price of peace is eternal vigilance and part of that is just being in the know so you can work with your doctors and your team to make sure that you have the best care possible. I’d love to talk about the screening itself and that is a mammogram. Are there any reasons why women might not want to have one?

Dr. Feldman:  Oh there are plenty of reasons that I hear from my patients and from other women why they don’t want to come in for a mammogram. The number one cited reason is discomfort. So, they say well I don’t like it, it doesn’t feel good. And to that, I say, yes, mammograms are not fun but it’s something that’s necessary for your health similar to dental cleanings and check ups and PAP smears and colonoscopies. Some of it has to do with the mind set that you’re walking in with. The more relaxed you are when you come in, the least uncomfortable it is. But some of it also has to do with prior experiences that women have had with mammograms.

At Elliott, we get that. We have a team of seasoned experienced kind gentle and extremely professional techs and for anyone who has had a bad experience elsewhere, I would definitely recommend giving them a try. The other reason why women might be reticent to come in is like you said, misunderstanding about family history. So, I hear women say yes breast cancer is scary, but breast cancer does not run in my family. And it’s important to recognize that most of the breast cancers detected are in women with no family history. So, genetics absolutely play a role but the recommendation for yearly screening mammograms starting at 40 is not for women with family history but rather just for the general population with average overall lifetime risk.

The third thing that I hear all the time is well there’s radiation with mammography. And so that risk is there. And we should certainly address that as well. We should talk about that. So, it’s true that mammography uses an x-ray which is ionizing radiation. We live in a society where there’s a lot of background radiation in our lives. Cell phones, laptops, Wi-Fi routers, Bluetooth devices. I recently learned that even Smart meters such as electric and gas meters placed outside of your house can emit radiation. Microwaves and TVs can do that. And you also can get radiation exposure from air travel. So, let’s say you get sick and you go to your doctor and they order a chest x-ray. The amount of radiation in that chest x-ray is roughly the same as getting on a plane in say Manchester, flying across country to Los Angeles for example and coming back. Mammography is a fraction of the dose of radiation from a chest x-ray. And the chest x-ray is that round trip air flight.

So, also what women should know on the topic of radiation is that mammography uses radiation to screen the population and because of that, there are many rules and regulations that we are subject to. This is to ensure that the equipment is calibrated properly, and the dose of radiation emitted is aligned with what is permissible by the FDA. So, as a matter of fact, we run QA on our machines every morning and we are routinely audited by a slew of government agencies and they come in with inspections and it’s to keep everyone safe including the FDA. In general in medicine, we always have to do the risk benefit analysis. So, while yes mammography use radiation, given how small the dose is against the background radiation of our lives; the benefit of early cancer detection clearly outweighs that risk.

Host:  Absolutely. And I’ve never heard anyone articulate it as clearly as you before. So, thank you so much for that. I think people are really going to understand just how small the radiation dose is. Like you said, it far outweighs the benefit that you’ll get from doing the screening itself. So, I do want to talk about what happens when women come in for the screening. Are the results given right away and if women are called back from a screening, what should they expect?

Dr. Feldman:  So, there are different workflows but there are different things that happen when someone comes into a breast center. So, let’s say someone comes in for a screening mammogram. The imaging is done, the woman leaves, and the images are interpreted at a later time. This is called screening imaging or screening mammogram. Sometimes, a woman is called back from the screening mammogram for additional imaging. And this can be very concerning. So, I want to talk about to know what to expect with that. This additional imaging if the woman is called back is called diagnostic imaging. It may include additional mammographic views or ultrasound or both. In this scenario, the images are being presented to a breast radiologist right away and in contrast to screening mammogram, they are being interpreted real time while the woman waits. In our center, after the imaging is completed and interpreted; every single woman that presents for diagnostic imaging, so that’s either she’s called back from a screening mammogram or she presents for workup of a new problem; she then meets with a doctor for a consultation. The doctor is the breast radiologist that interpreted her imaging. They discuss what the imaging showed, what the follow up recommendations are, and the patient can always review her imaging with the radiologist as well.

There are different recommendations that the woman can expect based on diagnostic imaging. The recommendations could be just to continue with yearly screening mammograms, if we see something that we’d like to keep a closer eye on; then to return in six months for a mammogram or ultrasound or both or if we see something concerning, we make a recommendation to have a biopsy to get a definitive diagnosis. In all of these cases, a radiologist will explain the imaging findings and discuss the recommendation with the woman face to face.

Host:  Yeah you know I think that there’s just so much apprehension and fear when getting called back after a screening and from what I’m hearing from you, it doesn’t necessarily mean that they have cancer, it just means that the radiologist wants to talk about their findings and what options might be, is that correct?

Dr. Feldman:  Yes, you’re absolutely right Prakash. There’s no question that being called back is very stressful. So, it’s really important to be armed with information like realistically how worried should a woman be if she is called back from a screening mammogram? So, here’s the data. Cancer detection rate nationwide is about three to four per 1000 screened. That means for every 1000 women that undergo screening mammogram about three to four will be diagnosed with breast cancer. Callback rate from a screening mammogram is 10%. Again, this is a national benchmark number indicative of best practices, 10%. So, of a 1000 women screened, 100 will be called back for additional imaging. Like we said, some additional views or ultrasound or both. What I’d really like to stress here is 1000 women go in for a screening mammogram, 100 of them are called back, but only three to four of those per 100 will be diagnosed with breast cancer. The rest of them will be totally fine. I find that when I share these numbers with women, they find it easier to stress less about being called back.

Host:  Absolutely. I can definitely understand that. I want to move on to self-examination. I assume that in addition to the annual mammogram that women should be self-examining at home. Is that the case?

Dr. Feldman:  Yes. The recommendation is to do a monthly self-exams – well there are a few things that a woman can do for herself right? Number one, is do monthly self-exams. Number two is see her doctor regularly for yearly breast exams as well. The way I describe to patients in terms of self-exams is you’re not trying to feel for badness when you are starting to do examinations. You’re just kind of trying to get the lay of the land. You’re trying to get an assessment of what your breast tissue feels like. We all know that women’s breast tissue can get lumpy towards the end of their cycle, closer to their period. So, what I recommend for women is the first day of your cycle is when you start bleeding, when your period comes. If you count – if your cycles are regular, and you count to day 14, that’s the day of ovulation. The day of ovulation is when the lumpiness of the breast tissue is the least so, try to mark it on your calendar or just keep track of it and try doing your exams, try to get into a regular habit of doing your exams around your ovulation time.

Again, just understanding what your tissue feels like. And then if you notice a change, once you get into a routine of doing it regularly, then bring it to your doctor’s attention. The other thing is of course to start getting yearly mammograms at 40. Really screening mammograms starting at age 40 is the most important thing you can do for your breast health and that’s how we save the most lives.

Host:  But just to be clear, the self-examination can and probably should start before the age of 40. Is that correct?

Dr. Feldman:  Absolutely. Yes. It should start when you grow breasts period.

Host:  Okay. So, if a woman finds a lump on their breast in the process of doing that self-examination; what are the next steps that they should take?

Dr. Feldman:  Well first of all, she should trust herself. Women tend to dismiss what their bodies are telling them often. She should not dismiss it. And she should bring it to medical attention. Whether it’s her primary care physician, her OB-GYN or scheduling herself with a breast health specialist such as a breast surgeon. All of them will likely refer the woman for breast imaging and that’s the diagnostic imaging that we talked about. So, depending on the woman’s age, it could be a mammogram or an ultrasound or both and then as we discussed at our center, we would meet with the woman, the radiologist would meet with the woman and would explain what the findings and the recommendations are.

Host:  And what happens if a biopsy is recommended?

Dr. Feldman:  If a biopsy is recommended, at our center, typically on the day of your diagnostic imaging, you’ll meet with a physician assistant from the biopsy team. She will schedule you for a biopsy that will be done by a breast radiologist, possibly the one that you’ve already met. So, you have a name and a face that you know. On the day of the biopsy, you may also be scheduled to meet with a surgeon. Our center is unique in that we are a true team of multidisciplinary physicians and providers. We’re located in the same suite with our surgical colleagues and our genetic educator as well. And we truly work hand in glove with them. We collaborate closely on every single patient with face to face discussions. We’re actually the only center in New Hampshire that’s structured like this where all the specialists are under one roof closely collaborating on every patient every day. Often even on the same day as the patient’s appointment regardless of whether the patient has an appointment just with imaging or just with a surgical provider. So, often while the patient is still there.

And of course, when doctors collaborate like this, the patient benefits. When you come in for a biopsy, there are so many anxieties and fears. Fear of the unknown procedure, fear of the outcome, what if it’s cancer, then what. So, first, again, let’s be armed with information to ease our anxiety. Seventy to eight percent of biopsies are not cancer. This is our statistic at the Elliott Breast Health Center as well as a best practice benchmark nationwide. We are aligned with other centers. It’s important to keep in mind that we’re not over biopsying the population that’s why most of them are not cancer. But in fact, we’re often biopsying something the size of chalk dust or the size of a sesame seed. So, we really can’t know what it is just by looking at it. And that’s why we need a tissue sample and that’s what the biopsy is. But even having all of this data, it’s still very stressful and we get that.

After the biopsy, we’ll call you back with the results and a game plan for what happens next. But you should be absolutely assured that whatever the outcome of the biopsy is, at our center, you will be supported and carried through that journey by a team that will root for you and rally around you every step of the way.

Host:  Well Dr. Feldman, I think that is the perfect place to end. Thank you so much for your time today. this has been hugely informative. That’s Dr. Marina Feldman, a Breast Radiologist and Medical Director of Breast Imaging at Elliott and Co-Director at Elliott Breast Health Center. For more information please visit www.solutionhealth.org and if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is the SolutionHealth Podcast from SolutionHealth. Thanks and we’ll talk next time.