Scott Webb (Host): In part two of our series with Dr. Marina Feldman from the Elliott Breast Health Center today, we'll continue our discussion on the importance of screening mammograms and address the anxiety that some women may feel about mammograms in general, and especially if they're called back for a diagnostic mammogram.

This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Doctor, it's so nice to have you back again in part one of our two-part series here on how to sort of avoid or reduce the risk of breast cancer. We talked about the prevalence of breast cancer, how to limit risk, especially through screening mammograms, the importance of mammograms, knowing your family history, all that good stuff. So, if folks didn't hear that and they kind of just jumped right into part two, please go back and listen to part one. We talked about all the good reasons why women should have screening mammograms; it's the gold standard, all of that, but is there ever a time when a woman shouldn't have a mammogram or it's not recommended?

Dr. Marina Feldman: In terms of shouldn't have a mammogram, the recommendation that I have for my patients is if there's ever a time in your life where should we find something, you would not want us to act on it, so let's say you are 80 years old, and you have a bunch of other ailments, and you do not want us to do anything about anything we find, whatever it is, it is, then it doesn't make sense to come in. The recommendation, the standardized recommendation, is if the lifetime expectancy is less than 10 years, then you should stop screening mammography. Having said that, I want to go back to that 80-year-old that I mentioned, because I definitely have patients that have no patience for me when I say I need additional views because they're late to a tennis lesson or they're late to a book club. They have a very robust social life and they have no time for nonsense.

And they also don't want to be slowed down should anything come up. So, those women absolutely should come in for screening mammograms. So, my recommendation is for as long as you would want us to do something about it, you should come in. 

Host: Okay. 

Dr. Marina Feldman: Actually, there are many reasons that I hear from my patients and other women as to why they don't want to come in for a mammogram. There are three main ones. Number one reason that's cited is that mammograms are uncomfortable. And they're not, it's true. Women say, "I don't like how it feels." And I say, yes, but it's something that's necessary for your health. Similar to dental cleanings, right? We get six-month, 12-month checkups, pap smears or colonoscopies. Those are not necessarily comfortable procedures, but they are in the same category of screening procedures that are important for your health. Some of it, I think, has to do with the mindset 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, right? We carry all of our experiences with us. At The Elliott, we get that. We have a team of seasoned, experienced, kind, and really gentle, very professional technologists. And for anyone who has had a bad experience, I would absolutely recommend giving them a try. Because it's not really so much where you get screened, but that you do get screened, as far as I'm concerned. So, you want to find a spot where you're comfortable. 

The second reason that women might be reluctant to come in is misunderstanding their family history. So, I hear women say often, "Breast cancer is scary, but it does not run in my family." So, in part one that you alluded to, we talked about how one in eight women develop breast cancer. Those are women that do not have family history of breast cancer at all. That's why it's important to have annual screening when you do not have family history starting at 40 every year. Because even if breast cancer does not run in the family, some of the mutations that cause it are sporadic, which means they just happen on their own for no good reason. So, that's the second reason, is the family history component. 

And the third reason that I hear is the concern about radiation. So, that risk is there, and we should certainly address that. It is true that mammography uses x-ray, which is ionizing radiation. But it's important to recognize that we live in a society where there's a lot of background radiation in our lives, cell phones, laptops, Wi-Fi routers, Bluetooth devices. Almost everyone I know uses one, and they're not really concerned for the dose of radiation, at least that's not what they're mentioning to me. I recently learned that even smart meters such as electric and gas meters outside of our house, those emit radiation too, right? microwaves, TVs, it's everywhere. 

So, let's say you get sick and you go to a doctor. And the doctor orders a chest x-ray. The amount of radiation in that chest x-ray is roughly the same if you were to get on a plane, let's say in New York or Manchester, since we're in New Hampshire, Manchester, New Hampshire, and you fly across country to Los Angeles and then you're coming back. That round trip on the plane is the same dose of radiation as a chest x-ray. Mammogram is a fraction of that dose. So, women should know that and they also should know that because mammography uses radiation to screen the population, 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 and permissible by FDA, Food and Drug Administration. As a matter of fact, we run QA (quality assurance) on our machines every single morning. And we are routinely audited by a slew of government agencies, including the FDA that come with inspections. And this is of course to keep everyone safe, to keep the public safe. So, in general in medicine, we always talk about the risk-benefit analysis. So, while, yes, mammography uses radiation, given how small the dose is against the background radiation of our lives, clearly the benefits outweigh the risk.

Host: Yeah, they do indeed. And I was thinking as you were saying all the things that we're exposed to- my cell phone is here to my left. I'm looking now at my Wi-Fi router, right? So yeah, it's all around us. It's everywhere, of course. And yeah, I'm sure there's lots of questions. So, it's good that we have you here today and last time and just in general, a lot of medical professionals to help answer those questions. And I'm also sure there's a fair amount of anxiety. I just want to maybe address that, what women, you know, what they think is going to happen versus what actually happens when they go in for screening. What can they expect?

Dr. Marina Feldman: So, there are different workflows in the Breast Center. If a woman comes in for a screening mammogram, screening mammogram versus diagnostic mammogram, we'll get into that in just a second. But screening mammogram means a woman does not have any symptoms. She's just coming in once a year for a screening. So, when she comes in for a screening mammogram, the imaging is done. The woman leaves, and the images are interpreted at a later time. She does not have the results right away. This is called a screening mammogram, like I said. Sometimes a woman is called back from a screening mammogram for additional imaging. And this can be very concerning and very anxiety-inducing, of course. So, let's talk about what to expect in that scenario. When the woman is called back, that's called diagnostic mammogram. 

Host: Okay. 

Dr. Marina Feldman: So, it may include additional mammographic views or ultrasound or both. This is under the diagnostic imaging umbrella. In that scenario, the images are being presented to a breast radiologist right away while the woman is in the center, and they're being interpreted real time while the woman waits. So, in our center, after the imaging is completed and interpreted, every single woman that comes in for diagnostic imaging, again, so that means either she's called back from a screening mammogram or she presents for a workup of a new problem or a new symptom or a lump or something else. She then meets with a doctor for a consultation. All of our breast radiologists meet with a patient at the time of diagnostic imaging, and that is the doctor 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. So, sit side by side and look at the actual pictures, images, pictures, and for the doctor to explain to you what it is that they're looking at and what it is that they're concerned about.

There are different recommendations that a woman can expect at the end of a diagnostic imaging. There could be a recommendation to just return to yearly screening. So, that's great. If we see something that we want to keep a closer eye on, sometimes we recommend that she come back in six months for a mammogram or an ultrasound or both. Or if we see something concerning, we'll make a recommendation for a biopsy to get a definitive diagnosis. In all of these cases, a radiologist at our center will sit down with you and explain all the imaging findings and discuss the recommendation face to face.

Host: So then, doctor, if a woman is called back for a screening mammogram, how worried should she be? I'm sure that she's going to be very worried. How can we kind of put their fears aside?

Dr. Marina Feldman: I'm glad you're asking that question because it is very, very stressful to get called back. Everyone assumes that they have breast cancer when they're getting called back, but that's not it at all. It's really important to be armed with some information, so this is what I tell my patients. The cancer detection rate nationwide is 3 to 4 cancers per 1,000 women screened. So, what the cancer detection rate means is for every 1,000 women that undergo a screening mammogram, so just a yearly mammogram, no symptoms, nothing, for every 1,000 women that undergo a screening mammogram, about three to four will be diagnosed with breast cancer. I'm going to put that information aside and jump to something else. It's called callback rate from a screening mammogram. The callback rate from a screening mammogram is 10%. That's the national benchmark, indicative of best practices. 

So now, if we put these two pieces of information together, what it means is a thousand women come in for a screening mammogram. Ten percent are going to get called back. So out of a thousand, a hundred will be called back for additional mammographic views or ultrasound or both. But what I'd really like to stress is that out of those a thousand women that came in for a screening mammogram and a hundred that are called back, only three to four of them will be diagnosed with breast cancer and have a problem. The rest of them will be absolutely fine.

Host: Yeah, hopefully that helps. As you say, there would be a natural amount of worry, anxiety, and so forth. But as you say, it's such a small number. Not to minimize, you know, the effect on those women and their families, but a relatively small number out of that thousand, three to four out of a thousand will actually be diagnosed with cancer. And of course, the whole point of all of this is about the screening mammography and early detection. So hopefully, it's caught early enough that there's no real dire consequences. And I want to ask about biopsies. When do you recommend biopsies?

Dr. Marina Feldman: We recommend a biopsy when we see something that looks worrisome to us. So, that's not necessarily objective criteria, right? What does it mean, worrisome to us? So, some things look completely benign and it's fine. And the finding on the screening mammogram was just a fake out, and the woman can go on and have yearly screening mammograms. 

Some findings, like I said, we follow at six-month intervals. There are others that don't fit the criteria of benignity, of something that looks benign, meaning not cancerous. And it doesn't fit the criteria of something that would be safe to follow. It still does not mean that it's cancer, but we are obligated to keep the patient safe, right? That's why we do it. So then, sometimes you just need a tissue diagnosis. 

So, in terms of what to expect in that circumstance, if a biopsy is recommended at our center, typically on the day of the diagnostic imaging, so this would be call back or if you're coming in because you feel something, you would meet with a physician assistant after you talk to the radiologist. You'd 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 would have a name and a face to know who to expect 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, with our genetic educator, and our PAs and nurse practitioners. So, we work hand in glove, collaborate closely on every single patient and have a face-to-face discussion. So, we're actually the only center, Elliott Health Breast Center is the only center in New Hampshire that is structured like this, where all the specialists are under one roof, closely collaborating on every patient, every day, face to face.

When you come in for a biopsy, there's so many anxieties and fear, right? Fear of the unknown procedure, fear of the outcome. And then, of course, what if it's cancer? Then what? So first, let's again be armed with information to ease our anxiety. Seventy to eighty percent of biopsies are not cancer, and that's not because we're over-biopsying the population, because sometimes we're looking at things that are the size of chalk dust. And it's just impossible to tell. But if it is something, it is easier to treat it when we find it early. So, this is our statistic at the Elliott, as well as a best practice nationwide. So, we're aligned with other centers. It's important to keep in mind that having this data, even though it's very stressful, may help patients to understand kind of what the probabilities are and what the numbers are.

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

Host: Yeah. Yeah, it really sounds, like one-stop shopping. Everyone's there, right? Under one roof at the Elliott. It's awesome. It's been great, part 1 and part 2 now. I just want to finish up, kind of go back over in case folks skipped over part 1, or just to remind them, in summary, if you will, what can a woman do to limit her risk of breast cancer?

Dr. Marina Feldman: Oh yeah. So, we'll go back to healthy lifestyle. That's important. So, we talk about eating healthy. We talked about being active. We talked about limiting alcohol intake. We talked about trying to quit smoking or not smoking at all. And of course, regular screenings and self-breast exams. That's what we should be doing for all of our health, not just our breast health.

Host: Right. Absolutely. Yeah. Well, it's been great to have you. Great to have your time. I appreciate your expertise, your compassion. Great stuff. So, thank you so much. 

Dr. Marina Feldman: Thanks for having me. 

Host: And if you enjoyed this podcast, please be sure to tell a friend and share on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.