Amanda Wilde (Host): Welcome to Curating Care, the official podcast of St. Clair Health, where we highlight the people, programs, and innovations shaping exceptional care in our community. I'm your host, Amanda Wilde. And in honor of Breast Cancer Awareness Month, we're exploring how advanced screening and risk assessment our helping women take charge of their breast health long before symptoms appear.

Today, I'm joined by Caroline Pryor Lang, a certified physician assistant who manages St. Clair Health's High Risk Breast Clinic. The clinic takes a proactive approach to identifying women who may be at increased risk for breast cancer. We'll talk about how women are evaluated for risk, what makes this clinic unique, and the ways St. Clair Health is using innovation and compassion to deliver high tech, high touch care right here in our community. Caroline, welcome and thank you so much for being here for this important conversation.

Caroline Lang, PA-C: Thank you. I appreciate you guys having me. Happy to be here.

Host: So, high risk is something that we've known about for a couple of decades and have more tools to research exactly who is high risk. Can you tell our listeners about the high risk breast clinic at St. Clair Health, what is it, who is it for, and how are patients referred to it?

Caroline Lang, PA-C: Sure. So, the high risk breast clinic at St. Clair is designed for patients, people who are at an above average risk for developing breast cancer in their lifetime. Those, for example, who may have a strong family history and increased breast density, use of hormone replacement therapy in their past, or additional other comorbid risk factors that then increase their overall risk of breast cancer in their lifetime.

Our goal is to provide additional screening for these women to estimate and determine what their true risk factor is over that lifetime; and thus, potentially mitigate or identify a cancer that would have then been identified later in life.

Specialties together, including OB-GYN, PCP, medical-oncology, endocrinology even, and thus breast surgery to help these women identify their true risk factors and get them on a customized high-risk screening plan through then my clinic.

Host: The clinic uses a risk assessment model. You'll have to tell me the name of this, and then can you walk us through how that tool helps to identify which women are at higher lifetime risk?

Caroline Lang, PA-C: Yeah. So, the model that we use is a standard insurance-accepted model. And based on our national guidelines, it's called the Tyrer–Cuzick model. It's a risk assessment calculator that uses variables, modifiable and both non-modifiable variables. They all come together in this calculator-based system to then give us a numerical output, an objective value that we can assign to a patient and kind of score them. And anything above that threshold is something that then we consider high risk. Lots of patients score differently. That threshold value is 21% or higher. I have my patients who are at low high-risk even though they meet that threshold. But I do have patients that score greater into the 30s and closer to the 35% and 40% risk lifetime risk.

So, lots of patients have various numerical scores assigned to them and their chart, but each plan is very custom. And then, based on that score, we make different recommendations for imaging, medication, treatment, referral-based treatment including genetic counseling, medical-oncology services, et cetera.

Host: So once someone is labeled high risk, wherever they fall on that continuum, your team takes a personalized approach for a prevention plan.

Caroline Lang, PA-C: Exactly. Yeah. So, we meet that patient and really kind of dive into their family history, personal history, again calculates and go over what their modifiable and non-modifiable variables include. For example, a modifiable variable is BMI, often that's something that you can modify and or change, non-modifiable is something, you know, you're born with. It's hereditary, so your family history, your breast density, things that you can't change. So, each patient gets a customized score and game plan. And then, we reevaluate annually. So of course, things can change. Personal history, family history can change. Breast density even changes, BMI too. So, each year, they get a new annual reassessment and a customized game plan.

Host: And what medical imaging do you use to detect changes in these high risk patients?

Caroline Lang, PA-C: Sure. So, we don't deviate from the standard. Everybody is recommended, again, for mammography, that is the gold standard. That is the standard of care for everybody at average risk. But including mammogram, we can utilize ultrasound. But most readily then available for a patient who is considered high risk is a breast MRI, which is magnetic resonance imaging, so not mammography. Mammography is x-ray. So, using an MRI, we can really evaluate the breast tissue, especially in a patient with extremely or heterogeneously dense breasts. In a-- you could say-- more thorough way, we can, in theory, detect potentially cancers or surgical lesions that may not have been identified by mammogram or ultrasound, because MRI is slightly more sensitive in those type of breasts.

Host: For a patient entering your clinic, how is this team of care coordinated? How do you work with breast surgeons and genetic counselors, radiologists, and other specialists to deliver a unified care plan?

Caroline Lang, PA-C: So, I am breast surgical oncology-trained. I have been practicing in this office, in breast surgery, specifically for almost six years now. Most recently, probably within the last two, two and a half years, I took the high risk clinic under my, you could say, wing, just because I felt drawn to this population as a young female. And it's very niche and I like customizing those game plans.

So on top of operating and being a surgical PA, I do high risk too. But that also brings me even closer to the breast surgery side of things. So, it's nice, when I meet a patient, I can make it very concierge and explain the surgical side of things. And should a patient of mine need surgery for an atypical lesion, a pre-invasive cancer or an invasive cancer, I get them to surgery right away. I work very closely with plastic surgery. Should my patients who have pathogenic mutations requiring plastic surgery involvement, I can get them seen also right away. I have very well-working, established relationships with gynecology, medical-oncology. And often when a patient comes to me, those specialties have told me that it's really nice that then I own the patient's breast health, they know that I am the reliable provider that will follow up on their imaging, call them with results, do an annual physical exam, even a biannual physical exam. The service that I provide, it's very specific. And obviously, it's just breast-related, but those additional specialties really rely on us. And I think it's very cool.

Host: And I can say on the other side as the potential patient, that it is great to have a guide like you to help us navigate through a system we truly don't understand, which you obviously have a very deep understanding of.

Caroline Lang, PA-C: It's really nice to feel that they feel guided and trusted ultimately.

Host: Someone to bring your questions to is really important.

Caroline Lang, PA-C: Sure.

Host: And speaking of that, in your view in the work that you've done these years, what are the biggest misconceptions about high risk breast health, especially for those women who don't have a family history, and how do you address those when you're counseling patients?

Caroline Lang, PA-C: Maybe the biggest misconception is that maybe people don't think that they're high risk, even if they have a limited family history in breast cancer or gynecologic cancers. Often, patients think, "Well, my mom didn't have it," or "My sister or first cousin didn't have breast cancer. I must be at average risk." And until they really get that first mammogram at 40 or earlier if indicated, they don't know that risk assessment score because it's not been calculated yet. But I think if you're concerned or if you feel like you have dense breasts or if you just have questions, the biggest misconception is like, "Oh, I can't be seen in that clinic." Of course, you can be seen. I see everybody all the time, and I calculate your score. And who knows, you might be at high risk at the time you meet me. And I'd love to meet any young woman who has a desire to act in, I should say, preventative medicine. So, that's what I would recommend.

Host: Caroline, thinking ahead, in these years that you've done this, you've seen a lot of medical advancements, technology keeps advancing. So, there's a lot for you to keep up with. How do you hope the high risk breast clinic will impact breast cancer outcomes in this region over time?

Caroline Lang, PA-C: My goal is to see the effects of high risk decrease the lethal cancers or the later stage cancers that then we diagnose. It's nice to explain to a patient that, yes, this may cause you some anxiety and this additional screening may make you feel some type of way. But the ultimate goal is to act on something surgically that could be super teeny tiny and not require the treatment that often patients are most scared of: the chemotherapy, the drugs that make your hair fall out. So if we can decrease the later stage diagnoses, or the diagnoses that come with those treatment toxicities, that's my goal, is to make a breast cancer easier to comprehend, digest for the patients and ultimately lead to less comorbid life stressors, I guess, because a cancer diagnosis, no matter how big or how small, really affects the patients wholeheartedly. And we are there to be their biggest supporter.

Host: What advice would you give to someone who feels they might qualify for high risk monitoring?

Caroline Lang, PA-C: First, if you think that you qualify the medical-oncology model is available online for free Through a website, I believe called MagView, at least that's what we use. But you could score yourself and kind of identify your baseline risk assessment value. That might not be 100% right. Of course, I can help guide a patient. But if you think that's you, take the test. And if your score is close to that threshold amount, I'd love to meet you.

Host: Caroline Lang, thank you so much for joining us today and helping us understand the vital work happening inside the High Risk Breast Clinic at St. Clair Health.

Caroline Lang, PA-C: Thank you very much. I appreciate it.

Host: Your team's commitment to early detection, advanced imaging, and individualized care is making a life-changing difference for women across the region. To learn more about treatment options available at St. Clair Hospital Breast Care Center, visit stclair.org/breastcare. To schedule an appointment with Caroline or another St. Clair Medical Group breast and general surgery provider, call 412-942-7850. And thanks for listening to Curating Care, a podcast brought to you by St. Clair Health.