Maggie McKay (Host): Welcome to Women's Health Perspectives, a podcast from Unified Women's Healthcare. I'm your host, Maggie McKay. Medical advances have reduced the overall risk of death from breast cancer, but the number of people diagnosed with the disease continues to rise. Today, we're sitting down with OB-GYN, Dr. Kathy Richardson, who will discuss her expertise in breast screening, including the different imaging options, the advantages of offering the service onsite, and patient communication. She'll also share her own personal experience as a breast cancer patient. Thank you so much for being here today, Dr. Richardson.

Kathy Richardson, MD: Hi, how are you?

Host: I'm great. How are you?

Kathy Richardson, MD: I'm good. Nice to be here.

Host: Nice to have you. So, OB-GYNs are often the first clinicians to recommend breast cancer screening to women. How do you like to approach that conversation with your patients?

Kathy Richardson, MD: Typically, we start having the conversation with women in their 30s, unless they have other high risk issues. Most women begin screening at 40 years old. Depending on which entity you talk to, it's acceptable to do imaging every two years in women 40 to 50 years old. But I'm a proponent of annual mammograms from 40 to 50. So, we kind of start having that conversation at their annual exam. You know, it's kind of a natural thing to do because we've been doing their breast exams since they were in their 20s, and we have the conversation about family history, about any other risk factors they may have going into the process. And if there's any reason to do that imaging earlier than 40 years old, like a first-degree relative that was diagnosed at a younger age, then we would recommend that.

For the majority of our patients, we start that at 40 years old annually. And it's kind of nice in our office because we have the option to say, "Well, and you can just step down the hall and do your screening mammogram," which is a 3D mammography, which is pretty much standard of care these days.

Host: And breast density is a bigger part of the national discussion now. What should physicians know about it and what do patients need to understand?

Kathy Richardson, MD: Yeah. In the past several years, they actually mandated that breast density be reported on mammograms. And so, that is relayed to the patients now. And it can be a little confusing because most of the radiologists that read mammograms will just put that on the report and say, "Well, your breasts are more dense than usual, which may raise your risk. Talk to your doctor about it." Usually, they leave it there. So, women are like, "Oh, what do I do with this?" So, we try to have that conversation proactively before they have their mammogram report, so it won't be alarming in the first place. But the biggest thing about dense breast tissue that we've learned is that, A, it makes mammograms harder to read, so you're looking through more fibrous tissue. It makes it a little fuzzier for them to see actual abnormalities; and B, having more fibrous breast tissue puts you at increased risk for breast cancer as well. So, it's, you know, a little bit of a dual-edged sword, so to speak.

So when we have that conversation, we then launch into-- there are some options after mammography to try to do expanded screening. In some states, legislation has been passed that requires insurers to cover expanded screening, which looks at different ways in different regions. There's breast MRI, which is very common. There's whole breast ultrasound. And now, the new kid on the block is contrasted mammogram, which is kind of up and coming for dense tissue. And honestly, what I say to patients is we're still figuring it out. These are all new modalities. There haven't really been enough studies to show that we know exactly what to do, when to do it, and how it's going to affect you in the long run.

So, those are things that are still being fleshed out in the radiological world. there's a big study coming out in the next year where they're looking at some of these things and, hopefully, that will clear it up a little bit for patients, which way to go. But certainly, in women who have dense breast tissue and also have risk factors like a first-degree relative with breast cancer or have had a previous biopsy with a little bit of focal atypical hyperplasia, those are women that a hundred percent probably should consider doing expanded screening. And then, certainly, other women can elect to do so if they choose.

Host: Tell us about the advantages of 3D mammography compared to traditional 2D.

Kathy Richardson, MD: 3D mammography has been out some time. And in traditional mammogram, you would get-- it was almost like getting what we call a flat and upright x-ray of your chest. You know, you get two views, you get a front view and a side view. And they would look at that and they might be, "Well, is that something a little hazy right there? I'm not sure. Maybe. I don't know." So, you recall those patients. Or, you know, it just looks like general fuzz and you don't see a whole lot.

So in 3D mammography, they're taking multiple, multiple images of the breast, and then they're reconstituting it to look like an actual 3D model of your breast tissue. So, they can spin it around, they can look at it. And whereas a little spot might not show up on a front or a side view, once you rotate it, you might be able to see that spot, so that can actually pick up things that would be missed on a 2D mammogram. Likewise, if you think you might see a little something, but you're not sure, sometimes you rotate it around and it clears off, you know, and you could like, "Well, that was just an artifact on that one view, but it didn't translate to the other images." So, we know that that's not a true. Anything that we need to follow up, we can just kind of let that go.

Host: What about the role of contrast-enhanced mammography? How does that compare to MRI?

Kathy Richardson, MD: So, contrast mammography, you actually are getting your standard 3D mammogram, that you go in early, they put an IV in your arm and they give you IV contrast, just like if you're going to have your standard CT scan or other imaging. So, they image the breast both before and with a contrast and things that are bad, so active cells, cancer cells tends to enhance with CT scan contrast. So, they'll scan your breast. And if it's something's enhancing on that, it's a little bit more alarming. So, it kind of fades out all that background noise of the dense breast tissue.

I actually myself did a contrasted mammogram this past April after my breast cancer diagnosis, because my MRI did not pick up some of my ductal carcinoma in situ. And it was interesting, because it was the same breast that I had that had been affected by breast cancer. And it actually did show a new lesion, but the new lesion did not enhance. So, that was reassuring. Not reassuring enough that I didn't do a biopsy, because I was like, "I probably need to know this is still something." So, I did. But I do think that the nice thing about CT mammography in the future would be that that would kind of roll those studies together. So instead of getting a mammogram and an MRI, you would get one CT mammogram and that would take the place in both of them. There are a lot of people that feel like this might be the future for mammography. It's still to be determined. I don't think that the studies have been put out yet that truly tell us which way to go with it. But I think it shows a lot of promise. And hopefully, in the next years, we'll be deciding one way or the other what to do with that.

Host: That's encouraging. Greensboro OB-GYN Associates offers breast imaging on site. What are some of the key benefits you've seen for patients?

Kathy Richardson, MD: I think that there's a comfort in coming to an office that you have always known. We deliver their children, they're with us through their 20s and 30s and, you know, even new patients also. I mean, when you get used to being in a certain environment, that's more comfortable for you. And it also just logistically takes that extra appointment off the books. You know, in our busy, crazy lives, sometimes it's easy to put yourself on the back burner, especially for moms, you know, they tend to take care of everybody and then we'll get to meet when we get to meet. So, it's really nice if you have somebody lassoed in, and they're here already for an appointment that you can be like, "We can shoot you down the hall, do your mammogram right after your appointment. And that way, you know, it's all taken care of in one day. So, that's good.

Also, we try-- not always-- but we try to do their exam before their mammogram. So if I feel something that I'm concerned about, I'm not going to do a screening mammogram. I'm going to order a different tool. I'll do a diagnostic mammogram in that situation. So, it's nice if we can do that hands-on kind of physical exam close to the time of the mammogram. So, sometimes we don't, you know, have them do a screening and then have to get called back and do a diagnostic afterwards. We just go straight to diagnostic.

Host: Dr. Richardson, would you please share some of the feedback you've received from patients?

Kathy Richardson, MD: Yes, I think that people are grateful to have the option to do mammography at the same time as their appointment. They know that they would probably put it off or get it done less frequently. So, I think that they like to have that option to do it right then.

Host: What about the practice itself? Have you seen workflow or business benefits or challenges? How do you handle internal communication and ensure continuity of care?

Kathy Richardson, MD: So, we were the first care center in North Carolina to do Unified Mammography. You can imagine it was a bit of a learning curve on both sides. So, getting things in place like the system to store the images and communication and figuring out which radiology group to use to read your mammogram. There were a ton of logistics involved. And, you know, one of our partners kind of took the lead role in that. And also, our office manager and the mammography tech that they hired did a lot of that legwork. But, you know, since that time, that has been much perfected. So, I think that now when offices decide to institute an office mammography using Unified Mammography, it really is more of a kind of come in, turnkey, they've got it all figured out, they know how to teach you the logistics and the technology behind it. You know, uploading images, how to send reports, you know, what do you do with the letters? All those things have been worked out by several other predecessors at this point. So, that's nice.

Host: Dr. Richardson, you have your own personal breast cancer story. How did you process your diagnosis and what did your treatment journey entail?

Kathy Richardson, MD: So, I was diagnosed last April, actually did my in-office mammography. I was even a little bit late, I'm ashamed to say, just a couple of months, because, you know, it's right here in my office, I really don't have that excuse. Even with that, I was a couple months late, but I went and did my mammogram.

Our poor little tech at that point, I mean, I knew looking at her face that something was up, but she could nod, did not want to tell me that. So, I was kind of like, "Okay, here we go." But my sister had breast cancer very early, so I think I've always kind of been waiting for that shoe to drop. You know, a lot of women feel that way, but I particularly did for that reason. So, it wasn't honestly that big of a shocking surprise to me. It was small on the mammogram. It looked like it was going to be a stage I. I kind of was getting ready to go to Spain to visit my daughter who was studying abroad, I had never been there. So, I had all this going on. And I went to get my diagnostic mammogram and I was like, you know, "Just go ahead and tell me. I'm sure it's probably cancer. Just go ahead and lay it on the line." My radiologist friend's like, "Yeah, yeah, it looks like it probably is." And I'm like, "Well, you know, let's just go ahead and do the biopsy before I go so you can give me the result while I'm there. So, I can tell my daughter." And she's like, "Okay."

So, I had already wrapped my head around it and had my little life plan. I'll do my little lumpectomy, radiation, move on. That would've been the case had it been estrogen receptor-positive breast cancer, which is the most common type. But mine ended up being triple-negative. And that did throw me for a loop, even thinking that, you know, I had everything under control and all the answers realized very quickly, you do not have everything under control and all the answers. So then, that launched into a whole different trajectory of doing chemo and, you know, having to come out ofclinical practice for a little while. And so, it was a whole different ball game. It just teaches you that, you know, even with all the right tools in place, you only have so much control over what happens to you. And then, you have to kind of be along for the ride a little bit

Host: Wow, that's a good attitude, but it would be hard to take. Was there anything about your experience that surprised you either medically or emotionally?

Kathy Richardson, MD: Yeah. I've had other interviews. And I think the thing that in the midst of it to me was the most surprising was how lonely it is of a journey. And it's hard to explain that to someone who's not done it. But the reason is not that you don't have good support. Like I had tremendous support from family, from friends, from patients, like, you know, all the people that could possibly support me supported me. But you feel very lonely in that nobody can really fully do it with you. And everything that you had planned in your life is all of a sudden different. You know, your life is going to be different, your work is going to change, your habits are going to change. I mean, just kind of everything's thrown on its ear.

So, it's a really hard thing to give up a lot of that, a lot of the future you had planned for yourself and find a new future, so to speak. So, you're glad that you have the future to plan. So, that's the number one thing. But it also is kind of the hardest.

Host: So being a physician, how did that affect your experience as a patient? Were there times where your medical knowledge helped or maybe added to the stress, because you know so much more than the average patient?

Kathy Richardson, MD: Probably both. I mean, I think that definitely, as I said, you know, finding out that it was triple-negative. You know, the implications of that being more serious. So, that part was hard. I'm sure my sweet oncologist would say that having a physician as a patient is harder, because, you know, we tend to go down the rabbit hole a little more and, yeah, just be a little more challenging on things sometimes as far as the crazy stuff that we think of. So, I think that those things probably made it a little more challenging, going through it as a physician.

Host: For your clinician and medical team peers who are listening, who care for others, but may neglect their own preventive care, like you were saying, we all put it off and maybe especially doctors, I don't know, but what advice would you give now from both sides of the experience?

Kathy Richardson, MD: You know, we do. Doctors are-- you know, you hear the saying-- we're the worst patients, and that's a true story for a lot of us. I won't say all, because I know some doctors who do a very fine job of their healthcare. You know, I think that the thing that I say to patients even that have busy lives, not just doctors, is you can't be the best person that you can be for others unless you are in good health.

So even though it feels like you're taking a little bit of a liberty for self-care and to do things in that way, it's really important. It's hard in that moment to do it. In the physician world, in the provider world, probably all of medicine really, we decide that we are, you know, low on the totem pole and we tend to kind of be all-or-nothing people. So, we throw ourselves into work and forget about all the other stuff. And, you know, you just kind of realize it's important work and it's good. And you care about your patients, but it's not the end of everything. Like, you have to have some balance to all of that. And, you know, I think about when I was a young mom and I was taking call every third night, you know, delivering babies and you miss out on a lot of the stuff with your kids. So, there has to be a little bit better job of doing both. You know, I don't think that women or men should have to choose one or the other. I think that you should be able to enjoy your family and your life and practice medicine and not have to sacrifice so much one way or the other.

Host: For some final thoughts, what's your vision for breast cancer awareness and screening in the future? What developments do you anticipate? And what would you like to see in the next five years or maybe the next decade?

Kathy Richardson, MD: Well, I think in terms of screening, you know, as we were discussing, I think finding a solution for women with dense breast tissue, that increases the likelihood we will not miss cancers early and have that intervention be available equally to dense and non-dense breast tissue women. That is an important story to sort out. We have to figure that out a little bit and we have to decide which imaging modality is going to fix that.

As far as treatment goes, literally, I was so blown away with all the things that are in the pipeline. When I was doing my treatment, I went to a breast cancer conference virtually, just because I could and I had the time to do it. And it was really more for oncologists. So, a lot of it was like way over my head. I was like, "I have no idea what they're talking about." But they did have so many things in the pipeline, both. For estrogen-positive breast cancer and triple negative in particular. The immunotherapies that are now available, a lot of the oral chemo medications that patients with metastatic disease can take that has really prolonged life.

Things that used to be like, "Well, you know, you've got a two to three-year run out and that's really about it. We're not sure we can help you beyond that." That's just not the story anymore. So certainly, women still succumb to breast cancer, and it's awful. You know, I mean, I've had colleagues and patients I've met since I've been in my treatment that were very similar to where I was and you know, they're no longer with us. They've died in the year that I have gone through treatment. So, losing those people is still a tragedy and awful. But it's not overwhelmingly the story anymore. There's a lot more hope that people can coexist for longer, even with advanced cancer, and have a great quality of life. And that's a good story.

Host: That's very encouraging. It's good to know that. Because you know what? You never really hear that when you hear about breast cancer and people who have it. So, thank you so much for sharing your expertise and your own personal journey, your story. We really appreciate it. Such an important topic.

Kathy Richardson, MD: Thank you. Thank you for having me.

Host: Again, that's Dr. Kathy Richardson. Find all Women's Health Perspectives episodes on the Unified OB-GYN intranet site. Just click the tile on your Okta dashboard. To learn more, please visit unifiedhc.com. Thanks for listening to Women's Health Perspectives, presented by Unified Women's Healthcare.