Caitlin Whyte: Breast health is so important to us here at UAMS and our MammoVan is out on the streets regularly traveling the state, offering efficient and quick screening mammogram services on the go. To tell us more about this innovative service is Heather Kindy, the supervisor of the UAMS Mobile MammoVan.

This is UAMS Health Talk, the podcast by the University of Arkansas for Medical Sciences. I'm Caitlin Whyte. Well, let's start off, Heather, with a bit about the history of the MammoVan Program. What is the mission and purpose of this initiative?

Heather Kindy, BSRT (R) (M) CN-BI: Well, our program originally started back several years ago. Our original unit actually was like a larger van with equipment that rolled on and off. And so, it would have to be set up at the clinic we were at or whatever our location was. That program stopped in 2007 and I was not involved with that. I joined in 2010 when we kind of revamped our program. And now, we have a true RV that's outfitted, so we're completely self-independent. We don't have to have, you know, access to any type of facility, which is really nice. It kind of makes it a neat experience for patients to come on and off.

And our mission is just to help the entire state. We are trying to help provide easier access to screening mammography. Our state of our 75 counties, about 25 of them do not have a mammogram facility within that county, so around a third of the state. Those, of course, are our target counties that we try to reach most frequently to give more accessibility. But we also realize that some of our counties that do have a facility, you know, that facility may be on one side of the county or the patient may have had a poor experience or a family member may have. And so, they just don't want to use that resources that are local in their county. And so, that's where we come in as another option there for the patients to be seen for their screening mammograms.

Aside from accessibility, our mission is also just to help promote breast health, to make sort of a fun event out of your mammogram. A lot of ladies will come to us in groups, friends together, or senior citizen group come in together and try to make it a little more fun and relaxed versus that main hospital setting.

And then, we also try to help the financial barrier as well. We work directly with a wonderful program here in our state called Breast Care, and that's something that we're able to directly sign patients up on. It's just a few extra questions with the registration that we do, and that program provides coverage for the screening mammogram that we're performing as well as any followup that could come. It also provides patients with a Pap smear. Any of your local health departments would accept it, or some practitioners do. So, you will also be able to get a mammogram coverage with your Pap smear. And then, the same thing with the Pap smear, it covers any followup that is needed as well.

Caitlin Whyte: Wonderful. Well, let's talk about mammograms for a second now. What age should people with breast start getting them and what frequency? What are some of the basics people should know?

Heather Kindy, BSRT (R) (M) CN-BI: We do still have mammograms starting at age 40, and that is for your screening annual mammogram. At any age, if you happen to have any type of lump or breast concern, no matter what your age is, you always want to visit with your practitioner about those concerns and have a breast exam. And it may be that you need a different type of exam. You don't need your annual screening, but you may need that lump followed up with a diagnostic or with an ultrasound. So, the golden rule for screening mammography is 40. But if there's ever any difference, just always make sure you're seeing your practitioner.

The only exception to that rule is if you have had a immediate first-degree relative diagnosed with breast cancer. So, that would include your mother, your sister, or your daughter. If any of those have been diagnosed with a breast cancer, you want to be sure to start your screening mammography 10 years prior to when they were diagnosed. So, if you had a mother diagnosed at age 50, you would still start at 40. But if you had a mother diagnosed any younger than 50, then that would put you, you know, starting your screening mammography in your 30s. So, history of your family's breast cancer is a really big factor that, you know, as much information as you can know about your family history, the better, and that would be something to visit with your practitioner about to make sure that you're starting at the appropriate age if you've got that first-degree family relative.

Caitlin Whyte: Now, I know every time I go to see my OB-GYN, I actually did a few days ago, you know, they always bring up the importance of the self-breast exam. Tell us why those are so important and how they work with the in-office clinical exams we get annually.

Heather Kindy, BSRT (R) (M) CN-BI: Yes, we call it the trifecta, and it is your self-breast exam that should be done monthly; your physician's breast exam, that should be done annually, along with your screening mammogram that should be done annually. Self-breast exams are very important. We always want to know our whole body, but we want to pay attention to our breasts. We want to visually look at them in the mirror as well as doing that self-breast exam. We have one piece of literature that we try to give to especially our newer patient. And it's a shower card that you can actually put in the shower, so it's waterproof. It shows the steps of doing a good self-breast exam. At the bottom, there's a little punch out that you can punch out each month to help keep you on track. And that's a resource that's pretty readily available online if you did any kind of search for those, but that's a great literature. But that's what we recommend, annual mammograms after 40. Self-breast exams can start even in your 20s. And then, that annual physician breast exam also can be, you know, when in your 20s and 30s.

Caitlin Whyte: That early detection is so, so important. Just remind us why it's so critical to our healthcare.

Heather Kindy, BSRT (R) (M) CN-BI: So, breast cancer is a very treatable and is a disease that we like to do early detection for. You want to find your breast cancer as early as possible. That's why the mammography part comes in. That's very, very key. You really don't want your breast cancer to be large enough to feel. You want to catch that earlier on a mammogram. There are also different types of breast cancer that don't always come associated with a bump, and those are cancers that you would never feel. They're what we call calcifications in the breast. And they show up on mammograms, kind of like little white grains of salt or sugar, and those can be an early sign of a breast cancer. They can also just be calcium in our breast, that's normal. But that's why it's very important to get your mammogram. Those types of cancers would not just be on a self-breast exam or a physician's breast exam, so that's why it's very key for all three to be done.

Caitlin Whyte: And I'd love to take a moment to discuss the breast care program, which helps people without insurance. Obviously, such a difficult issue to overcome when it comes to healthcare. Tell us about that program.

Heather Kindy, BSRT (R) (M) CN-BI: So, it is a wonderful program that we have here through the Arkansas Department of Health. They have some very minimal requirements. They ask about how many are in your household and your average monthly income. They also will ask just a few other demographic-type questions, you know, for sign up. And they will even provide coverage for patients that do have insurance, but maybe don't have preventative services with their insurance. So, it's not just for patients without any insurance. They also can help to step in for those that, you know, you may have only like emergency-type coverages. So, being able to provide that service to those, it really helps to eliminate that financial burden. Because, you know, if you have to choose between, you know, "I need groceries this month or gas" or "Am I going to go spend $200 or $300 on a mammogram?" That can be a deciding factor for some women. So, we're very fortunate to have this program in the state. It's been around for several, several years, and we're just so pleased that we get to work directly to be that line in between the patient and that coverage.

Caitlin Whyte: And wrapping up, Heather, where do you see these outreach programs like Breast Care and like MammoVan going in the future? How will they continue to grow and help the community?

Heather Kindy, BSRT (R) (M) CN-BI: Well, like I said, this program has been started since 2010. We've really reached kind of max capacity with our one van and the staff we have. And our facility realizes that, and they are looking at taking steps to get another new unit with some new mammography equipment as well as a second unit with mammography equipment. And that would really, really help to open our reach to the state because, you know, we realize that there are some areas that we go to once or twice a year that we could probably go back three or four times. And then, we're very fortunate to, almost daily, at least for sure weekly. We have new facilities, you know, calling in, wanting to see how can we get you guys to come down.

Another thing that we do that I think has been a big help is we will set up at larger facilities or work corporations to do employees. And so, that's helping patients not have to take off work. They can just come over. We typically get patients in and out in about 15 minutes, so they're not having to miss work. Their employers are not having to have as many people off work and the patients are using their coverages and staying healthy.

So, you know, for our future, we definitely want to see our program grow and reach more in the state and continue to work with breast care to help provide that barrier of financial problems.

Caitlin Whyte: Well, some really wonderful things are happening in your department. Heather, thank you so much for telling us about them today. For more information or to make an appointment, you can call 1-800-259-8794 or visit uamshealth.com/location/mammovan. And thanks for listening today. This has been UAMS Health Talk, the podcast by the University of Arkansas for Medical Sciences. I'm Caitlin Whyte. Stay well.

Scott Webb: As is the case with all cancers, the early diagnosis is key. And when it comes to breast cancer, genetic testing for hereditary mutations might be the best option for some women. And joining me today to tell us about genetic testing, who's a good candidate and the many benefits is Denise Jeffery. She's an adult nurse practitioner, specially trained and certified in breast health exams with over 20 years of radiation oncology and medical oncology experience.

This is your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of Solution Health. I'm Scott Webb. Denise, thanks so much for your time today. We're going to talk about genetic testing and a whole bunch of stuff related to this. As we get rolling here, and this is a really fascinating topic, who should have genetic testing?

Denise Jeffery: Well, the criteria for testing have expanded pretty much yearly. And the criteria has gone from being very restrictive to being much more inclusive. And the criteria were just recently updated probably about a month ago. So when we're thinking about women that have a diagnosis of breast cancer, a woman at 50 or under, so if she's diagnosed at 50 years of age or under, then that's a recommendation to have testing.

If a woman has two or more breast cancers that are diagnosed, either at the same time or at different times, that would be another reason for genetic testing. And if there are two or more women in the family regardless of age, then that is also an indication. There are many indications. Some of the other ones are if a woman has a new diagnosis of breast cancer and is of Ashkenazi Jewish ancestry, then that's a recommendation to do genetic testing because the Ashkenazi Jewish population has a higher prevalence of these mutations than the non-Jewish population. So for the Jewish population, their risk of having a BRCA1 or 2 mutation is one in 40 versus the non-Jewish population, which is one in about 250.

Another indication for testing would be a diagnosis of what's called a triple-negative breast cancer at any age. So, triple-negative breast cancers are breast cancers that test negative for estrogen, progesterone, and HER2. So, those are the three receptors that all breast cancers are tested for.

Scott Webb: Right.

Denise Jeffery: If a woman has a diagnosis of breast cancer and she also has a family history of men with prostate cancer, if there's pancreatic cancer in the family, ovarian cancer, male breast cancer, those are all indications to consider doing genetic testing. And then, there's the unaffected women, so women that don't have a diagnosis of breast cancer but have a family history. So any person who has a family history with a close family member who meets any of the criteria that I just mentioned, they would also meet criteria for testing as an unaffected individual.

Scott Webb: Yeah. So, it sounds like lots of different scenarios, lots of indications, so a lot to process. Great to have your expertise. You mentioned family history there related to this, are most cancers hereditary?

Denise Jeffery: No. In fact, most cancers are sporadic events. Only about five to 10% of all cancers are due to an inherited mutation. We do see cancers that run in families, and these are referred to as familial cancers when a hereditary mutation hasn't been identified. And the majority of all cancers are just sporadic events that are due to environment and lifestyle factors.

Scott Webb: Yeah, sporadic events, I hadn't heard it put that way before, but that makes sense. And that it definitely feels like what many of them are. So when folks are trying to decide, women are trying to decide, working with their healthcare providers, how do you decide which genes to test?

Denise Jeffery: Well, historically, the testing for hereditary mutations was very limited. So from the standpoint of breast cancer, prior to 2014, we would test for two genes, BRCA1 and BRCA2. So, those are two high-risk breast cancer genes. If the testing for those two genes was negative, we'd essentially be done at that point. But in 2014, a couple of big things happened. The company that did all of the testing for BRCA1 and 2 lost a patent on the BRCA1 and 2 testing, and that opened it up to many other labs.

In addition, the technology changed at that time. That allowed testing of many genes at the same time. So now, we use these multi-gene panels, and those panels can test for only genes that increase the risk of breast cancer, or we can test for panels that will cover many different hereditary cancer syndromes. And that's more the trend these days, is to test for broader panels.

Scott Webb: Yeah, I see what you mean. And it certainly sounds advantageous both for, you know, those taking care of folks like yourself, but also for all of us, women especially through this lens of breast cancer. So, if a person is diagnosed with a hereditary mutation, is there anything that can be done about that?

Denise Jeffery: Yeah. All genes have specific risks and cancers that they are associated with. So, what happens is that we look at the gene that's found to carry the mutation and the risks associated with that particular gene and make recommendations for management. So from the standpoint of breast cancer genes, let's say if a woman has a hereditary mutation that increases her risk, then there would be a recommendation to increase surveillance with mammogram alternating with MRI. Depending on the gene, there may also be risks of other cancers and potentially screening for other cancers and maybe risk-reducing surgeries.

So, the BRCA1 and 2 genes can increase the risk of ovarian cancer as well. So if a mutation is found in one of those genes, then there's a recommendation to remove the fallopian tubes and ovaries for risk reduction. So, it really just depends on, you know, what gene is found to carry the mutation and the risks associated with that particular gene.

Scott Webb: Yeah, I see what you mean. And I'm wondering when we think about the diagnosis of a hereditary mutation, so if a person has that is diagnosed with that, does that automatically mean that all family members are at risk?

Denise Jeffery: Well, all first-degree family members will have a 50% chance of inheriting that same mutation, so it would be recommended that all first-degree family members undergo testing. So if a woman, let's say, has a diagnosis of breast cancer and she's diagnosed with a hereditary mutation, and she has a sister who undergoes testing and her sister tests negative for that same mutation. Then, her sister would be considered at population or average risk for breast cancer. But if her sister tested positive for that mutation, then she's going to have the risks that are associated with that gene.

Scott Webb: Yeah, I see what you mean. This is a lot to take in, but you're doing a great job explaining all of this. I'm wondering if you could just take us through, you know, at least on a sort of layman's terms basis, how is genetic testing done?

Denise Jeffery: It's easy actually. It only requires a tube of blood or saliva sample. Some labs are now using buccal swabs, which is a swab of the inside of your cheek. My preference is generally to do a blood draw, just because there's less likelihood that there'll be a failure of the sample in the lab. So with saliva samples, there can be many factors that will affect how much DNA is in the saliva. So if you choose the saliva sample and testing is done, there's a greater possibility that will fail in the lab. Whereas we don't really see that with blood.

Scott Webb: Let's talk a little bit about insurance. We can't talk about anything in healthcare without usually touching on insurance. Will genetic testing affect our ability to get insurance?

Denise Jeffery: So that's a question that I think many people have and why some people will not come in for genetic testing, even if it's recommended is because they're concerned about insurance. But there's legislation called the GINA Act or the Genetic Information and Non-Discrimination Act, and this is federal legislation that protects people from discrimination by health insurers and employers based on genetic information. So your health insurer can't say, "Well, they're not going to cover you" or they can't increase your premium. They can't change the plan based on genetic information. But the things that are not protected by this legislation are life insurance, long-term care insurance, and disability insurances. So for instance, if somebody is diagnosed with a hereditary mutation and they want to purchase life insurance, one of two things would happen, either they wouldn't be offered the life insurance or it would be at a higher cost. But health insurance is protected.

Scott Webb: So Denise, if I had genetic testing through a direct-to-consumer testing company and no mutation was identified, does that mean that I don't have a genetic mutation?

Denise Jeffery: Possibly. But the direct-to-consumer testing labs, it's not a substitute for testing through a genetics laboratory that specializes in testing for hereditary mutations. And the reason is that direct-to-consumer testing labs test for one specific type of mutation in the gene. And there are several different types of mutations that happen in the genes that can increase someone's risk for developing a cancer. So testing through a genetic testing lab that tells you that you don't have any mutations that really hasn't been comprehensive testing of those genes. So, it's definitely not a substitute.

And the converse is true, also that if a person has testing through a direct-to-consumer testing lab, and the lab tells them that they have a likely pathogenic or a pathogenic mutation in a gene, then that has to be confirmed with a genetics laboratory. For instance, I saw a woman recently who came to me with her results from a direct-to-consumer testing lab that had identified a mutation in a gene. And when we did the confirmatory testing through the genetics laboratory, she did not in fact have a mutation. And unfortunately, she had been treated before at a different location as if she did have a mutation.

Scott Webb: Oh, I see what you mean. Yeah, I see the complications there. False positives or false negatives or, you know, however, whatever the right way is to put it. I see what you're saying. This has been really interesting. One of the things I love about what I do is learning from experts, and I definitely have from you today. I'll give you an opportunity here as we wrap up. What are your final thoughts and takeaways? You know, when we think about genetics and breast cancer risk and genetic testing in general, what do you most want folks to know?

Denise Jeffery: There are many people that are probably out there with hereditary mutations that are not having testing. We know that we've only probably nationally identified 1% or 2% of the people that carry hereditary mutations that can increase their risk. And so, I would say that, you know, if genetic testing is recommended, at least go to a place where you can get information that is reliable and make a decision about whether or not you want to pursue testing. And this is a rapidly evolving field. There are changes constantly to what we know about the risks of certain genes and the cancers that are caused by these genes.

If someone's had genetic testing, I would say it's important to keep in touch with the people that have done their testing to determine whether or not there have been any changes in their recommendations for screening or management, because sometimes genes, the risk of cancers with certain genes can go down and they can actually be taken off of genetic panels, or there can be increases in risks. So, it's important to stay in contact with your genetics professionals or the people that did your testing so that you can make sure that you are being cared for appropriately.

Scott Webb: Yeah. That's just great advice from an expert today. Thank you so much, Denise. You stay well.

Denise Jeffery: Thank you.

Scott Webb: And for more information, go to elliot hospital.org/breast health.