Scott Webb: The Nancy Ausonio Mammography Center at SVMH is celebrating its 10th anniversary. And since October is breast cancer awareness month, I'm pleased to be joined by radiologist, and Medical Director at the center, Dr. Amy Lantis Stemerman and registered nurse and clinical manager at the center, Bernadette Lucas-Burch, both of whom are here today to discuss the center, the importance of screening mammography, 3D imaging, and so much more. This is Ask the Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Thank you both for being here. The Nancy Ausonio Mammography Center just celebrated its 10th anniversary. So Bernadette, I'm going to start with you. Tell us about the center. Where is it located and what services do you provide?

Bernadette Lucas-Burch: The Nancy Ausonio Mammography Center is located at 240 San Jose street in Salinas, California, and we are a comprehensive breast health screening and service line for women. Also men, there are occasion where men too need to come to our center. So services that we provide to start with certainly screening and diagnostic mammograms. We do have Hologic 3D equipment. So we offer the genius 3D mammography exam. We also performed screening and diagnostic breast ultrasound, stereotactic biopsies, which are also computer aided with our 2D and 3D capabilities with that. Also we perform ultrasound guided biopsies and bone density scanning, or also known as DEXA scans. Part of our service line includes also breast MRI. So those can be screening and diagnostic as well. The other services outside of that without imaging are things such as performing high risk assessments on individualizing women's care and allowing them to understand what is the optimal screening for them. That's in partnership with our nurse navigator and also genetic testing so that women can further understand their risks.

Host: Yeah, definitely. We're going to talk more about this, especially the 3D mammography and genetic testing. We've got a lot to cover today, but I want to ask you to walk us through the process of coming in for a mammogram in the time of Coronavirus, which of course is just unprecedented for all of us. I'm guessing women are nervous as it is to get the screening and now they have to think about COVID-19. So what precautions are you taking?

Bernadette Lucas-Burch: As you mentioned, it's definitely a place where women are anxious to come in to be screened for breast cancer. So we understand that. So in addition, what we've added is triaging questions. We do that on our confirmation calls. So that way we can hopefully avoid anyone showing up that may be ill at our door, they also are asked the same triaged questions. A temperature is taken. We have a patient go ahead and remove any mask that would be coming in from the outside. We give them a nice clean procedural mask to place on them. They also will clean their hands at the front desk. Our seating has been lessened. So, all of our seating of course is six feet apart. And we expedite the women from the front door to the registration process, again, to just in a timely manner, get them through the center. So they're not sitting around as much and minimizing exposure with other patients. We are cleaning regularly. Seats are being cleaned, any surfaces, the registration Bay, as well as the dressing rooms. And of course, all of our equipment and exam rooms are being cleaned extra careful. And we've allowed a little bit additional time in between exams so that that can be completed.

Host: That's really great. And I know that SVMH has really been on the cutting edge from the start trying to be as prepared as possible for COVID-19 of all the expected and unexpected things, you know, that may come because of the Coronavirus. And I want you to tell me about the spa. I was reading about this in preparation. I thought, well, that sounds pretty fantastic and pretty relaxing. So I'm hoping the spa is still open, but you tell us?

Bernadette Lucas-Burch: Yes, the spa is still open. Again, we've had to minimize the amount of women that can sit in that area. We're fortunate enough to have these beautiful French doors that open up with a water feature and chairs outside as well. So with this beautiful weather, women are still enjoying being able to sit in the outdoors. And that's very important to us that women kind of have that little bit of a reflective downtime in between registering and going back for their exam because we think that helps them better prepare themselves for the time of anxiety. It's important in our center to think about that whole woman or whole person in our care, and really be sensitive to perhaps their fears, spend a few moments, our technologists, our physicians, our nurses, everyone is pretty much tuned in because we want to make sure that we're comforting our patients. And I think the spa is just kind of that initial segue before you're called back for the exam. So we're really glad that we can still allow women to sit there. And there's a beautiful, soft music playing, with a scenery of different landscapes sceneries, so that they can kind of mindlessly put themselves out there and not have to focus on the worry or the concern that they may really have going on.

Host: And Dr. Stemerman, I haven't forgotten about you. We've got some questions for you. When should women start to get mammograms? What's the earliest age for mammogram?

Dr. Stemerman: So, we recommend screening mammography for average risk women to begin at age 40. And we follow the guidelines from the National Comprehensive Cancer Network or the NCCN guidelines, as well as the guidelines put forth by the American College of Radiology. And so, although there's been some controversy over the years about when to start and how often to perform a screened mammography, we really do recommend a yearly mammograms beginning at the age of 40. And this is to get the most benefit of screening mammography.

Host: Yeah, definitely. And what type of mammograms do you perform there? 2D, 3D? And with the 3d, if you've got that there, why is that better than today?

Dr. Stemerman: Excellent question. So we perform 2D and 3D mammography. Most of our exams are with tomosynthesis or 3D mammography. And these images are the best images to look at all of the breast tissue, not just a two dimensional view, but the very thin slices all through the breast. And so they're acquired in a very similar way that we have done with mammography over the years, mild compression on the breast in a specific position. We usually do two views of each breast for a screening mammogram and these views for the tomosynthesis, the x-ray tube sweeps over the top of the breast. And we obtain a whole dataset of information about the breast tissue, which allows us to see very minor and small details that can help us find breast cancer in the earliest possible stage.

Host: Really amazing stuff. And since you started using the 3D mammography machines, has there been an increase in early cancer detection?

Dr. Stemerman: Yes, the first year that we went from digital mammography or 2D to 3D mammography, the breast cancers that we found, 74% of them were in stage zero or stage one. And these are the earliest stages of breast cancer when almost all of them are treatable and almost all of them curable in the first five years when we find cancer in this earliest stage, this is when the women have the best chance at a great lifelong survival. And it also minimizes the amount of treatment that we need to do for those women's breast cancers. We did, 74% were stage zero in stage one. The first year we went from 2D to 3D. And previous to that, about 56% were stage zero to stage one. So there was a great improvement in the detection of early breast cancer, which is amazing for our patients. That's why we do screening mammography.

Host: Yeah, that really is amazing and certainly worth the investment in that 3D machine. That's incredible. So Bernadette, we come back to you, what's the recommendation for women who are younger than 40 years of age, who have a history of breast cancer in their family? Should they get mammograms much earlier?

Bernadette Lucas-Burch: What we know is women's risk doubles if there's a first degree relative in their family, such as mother's sister or a daughter. So we, again go back to individualizing care and understanding what that woman's risk is. So we use a Tyra Cusick Risk Stratification Model here in our center, which takes into consideration a woman's breast density, her personal history and her family history information, so that we can come up with a score that will tell us whether or not she should have additional imaging sooner than the age of 40, that might mean mammography. That might mean a breast MRI as well. We also that based on the national comprehensive cancer network guidelines, that screening for women should begin 10 years prior to a family member being diagnosed, but not necessarily prior to the age of 30. So we really try to tailor and partner with women to guide them. So that they'll know whether or not they should be screened sooner.

Host: Yeah. It sounds like it really, you know, tailored and customized to the individual woman and her circumstance and genetics and all of that. So that's really fantastic. And do you offer gene testing at the center?

Bernadette Lucas-Burch: We do. The whole conversation around cancer is about risk. And so we look for that estimated lifetime risk for women. And while that score that I talked about earlier will guide us as to what is the optimal screening for a patient. We know that additional risk can be a part of this woman's life as well, based on a genetic mutation, only about 10% of cancers are linked to a gene mutation, but it's important in a family to know that. One, if you are a cancer patient and you have a gene mutation, then that will certainly weigh in on your treatment options. And for women who are unaffected by cancer, if we can know that information in advance, our hope is that we're going to reduce their risk. Now, while the general population for breast cancer is 12%. So one in every eight women will be diagnosed with breast cancer. Our hope is to get these women with mutations who could be up to 85% risk down as close to the general population as possible, and maybe even prevent breast cancer. So that's why genetic testing in our center became very important to perform because the conversation doesn't stop with the risk from what your family history or your personal history, it goes all the way to what is that DNA telling us and how can we best guide you

Host: And Dr. Stemerman, when cancer is detected in a mammogram or ultrasound, what happens next? Paint us a picture of how your staff, you as a physician and other physicians are really there for the patients.

Dr. Stemerman: We always have the patient in mind, all of our radiologists and all of our staff know that finding out that you have breast cancer is a difficult thing to find out. So we take every measure to try and be there for this patient. So once we know that the patient has breast cancer, the ordering doctor has been notified by myself or the other radiologist. We talk to their referring doctor and we have already gotten referrals for different types of physicians that they will need to see in the coming weeks, a cancer doctor or an oncologist, a breast surgeon, as well as an order for a breast MRI. That's one of the very best things that newly diagnosed women can have is a breast MRI. It's the best way we can determine the entire extent of their known breast cancer and evaluate if there's any other breast cancer in the affected breast or in the opposite breast. We know that when patients are diagnosed, they want to be treated for breast cancer the right way, the first time. And so that's very important. So when we bring the patients in to talk about their results, we have a physician and we have a nurse navigator and we allow them to bring a family member, someone to listen with them as well, and we will walk them through their diagnosis. And explain at that time, the next steps in their treatment. We'll have a breast MRI order scheduled for them as well as some consultations. And then we will introduce them to the team of doctors and nurses and social workers that we have here to help guide them through their next steps in the process, their treatment phase.

Host: Yeah, it sounds like they're really in good hands. And you mentioned a nurse navigators there, and I hear that a lot in the course of what I do here, but, I'd like you to really tell us what does a nurse navigator do? What does that mean exactly. And how does that factor into the continuum of care?

Bernadette Lucas-Burch: We have a nurse navigator in the breast center, so she is a breast health nurse navigator. And then we have an oncology breast cancer nurse navigators. So their role truly is to be a liaison to enhance support, provide education, coordinate care, ensuring that timely seamless care happens, whether you're a breast cancer patient or you're an unaffected patient who may have just learned that they're a gene mutation carrier. So whatever aspect on that continuum of care from pre risk, reducing strategies, all the way to a cancer diagnosis, a navigator is just kind of at the hub of the team and cancer itself is such a complex journey that we want to ensure that women have the additional support, not just women, their families as well. And so really they are there to address fears, distress, anxiety, LINQ patient, to a social worker who also has access to additional services in the community and ultimately reducing barriers to someone's care financially, emotionally learning how to cope with a diagnosis, a new diagnosis. So they're pretty multifaceted. They are an amazing support. And addition to the care here that we offer at the Nancy Ausonio Mammography Center and within our cancer program at Salinas Valley.

Host: Let's talk about advice for women who may have been recently diagnosed with breast cancer. What advice do you have for the women themselves, their partners, their families, as they embark on this cancer journey, if you will?

Bernadette Lucas-Burch: You are not alone. And we are here as Dr. Stemerman alluded to this multidisciplinary team, and we're all here for the woman, their family, their children, whomever, this impacts. We certainly want to educate them, support them and help them somewhat gain a sense of they can do to continue living when getting that diagnosis is so overwhelming in the beginning. I think our best advice, of course COVID has taken away the fact that we can give nice big hugs to some of these patients, which is very difficult. So somehow just listening, connecting, ensuring that they know we genuinely are here. And sometimes that's all they need just knowing there's someone to listen, a phone number, a business card, here's who you can contact. You can show up, we're going to be here. No matter what.

Host: Men do get breast cancer, not a lot, but they do. So do you see male patients and what types of screenings are done for men? Is it ultrasound? Mammography?

Bernadette Lucas-Burch: Men do develop breast cancer. It is less than 1%. Statistically in 2020, about 2,620 men are expected to be diagnosed with a breast cancer. They do have mammograms and ultrasounds, both performed mutation. Men can also be mutation carriers, which can elevate their risk for various cancers. And one of those being breast cancer. So most of the time it's a diagnostic exam that we're performing because a man has developed a lump or has some symptom. We certainly can also perform those screening exams for them. Should they be in a risk category that we know they are put at a higher risk for developing breast cancer? We do our best, since we are predominantly a women's center, we have a nice process built in where we allow men to have kind of a separate place to be seated. So they're not commingled with the women. And we also offer them the same emotional support, this being male doesn't take away the fact that they also to have fears being here in this center. And so we extend that support and concern to them as well.

Host: So, Bernadette last question for you here, what's the process for making a mammogram appointment?

Bernadette Lucas-Burch: So, we have some of our providers in the community. We're still using paper orders, so a physician to order is needed. And then we have several of our SPMC clinics where electronic orders are being sent to us. So a lot more convenient for our patients and simple call will either be initiated from our center to that woman and or vice versa. The women can call in and simply schedule their appointment. One thing I want to add that I think was important. And so that's how you schedule an appointment, but I also want to remind women and men that there used to be a time where with family history people would think, well, it's not my mom's side, so I don't need to worry. And I think I want to make sure people understand that our DNA or our genetics come from our mom and our dad and both sides do matter. So it is so, so important for people to get that understanding now about what is that family history, what types of cancers ran in the family, so that that's always available, not just for you, but for future generations. That's really, really important to have that information.

Host: And as we wrap up here, Dr. Stemerman last word to you, what's your general advice for women?

Dr. Stemerman: So, I have lots of advice for women. The first being that screening mammograms really do save lives. So please get your screening mammograms. You can do it safely at our center. And I really hope that people will continue with their yearly screening mammograms. This is the best way to get the most benefit and decrease your risk of dying from breast cancer. The other thing is know your risk, make sure that you're getting the appropriate types of screenings. We know that for average risk women, yearly screening mammograms. Those are enough. But for high risk women or perhaps some women who've had breast cancer in the past, yearly mammography plus screening breast MRI is the best way to screen your breasts for breast cancer. And finally, there's a lot of stress out there, a lot of different things going on, but I hope women in general, remember to have their healthy lifestyles; eating, right, exercising, decreasing your stress, all of these things are known to benefit women and men. So I hope people can stay healthy, wear a mask.

Host: Absolutely. Wear a mask and wash your hands and never a bad time to be mentally and physically well, but especially right now during COVID-19. I'm so glad we had you both on this was really a great tag team effort here. You really work well together and I feel like we covered a lot of ground today. Hopefully we helped women and really sincerely you both stay well.

Dr. Stemerman: Thank you. You too, you too.

Bernadette Lucas-Burch: Thank you

Host: For more information or to schedule an appointment visit svmh.com/locations/nancy-auconio-mammography-center. And we hope you found this podcast to be helpful and informative. This is Ask the Experts from Salinas Valley Memorial Healthcare System. I'm Scott Webb. Stay well, and we'll talk again next time.