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Dr. John Leonard (Host): Welcome to Weill Cornell Medicine, CancerCast: conversations about new developments in medicine, cancer care and research. I'm your host, Dr. John Leonard. And today we'll be talking about breast cancer imaging and mammography. I'm really happy to have our guest for this episode, Dr. Geraldine McGinty. She has many hats and a lot of expertise. Dr. McGinty is a diagnostic radiologist who specializes in women's imaging at Weill Cornell Medicine and NewYork-Presbyterian Hospital. She has served a number of leadership and policy roles in radiology organizations nationally and internationally. And that's a great part of her contributions to the field.

And additionally, she serves as Senior Associate Dean for Clinical Affairs at Weill Cornell Medicine, where she has a very important role as a leader in our clinical activities here at the medical college. Dr. McGinty is an expert in interpreting a variety of imaging modalities, including mammography, breast ultrasound and MRI. And in the clinic, she performs breast interventional procedures, such as stereotactic and image guided breast biopsies. So today I'm very excited to talk to Dr. McGinty about breast cancer screening, a very important topic and in particular to hear insights on the latest techniques, technologies, and best practices. So, Dr. McGinty, thank you for joining us today. It's great to have you here.

Dr. Geraldine McGinty (Guest): Thank you for having me.

Dr. John Leonard (Host): So I'd like to start by getting a sense for the audience. How did you find yourself drawn to the field of radiology and particularly women's imaging? And then I want to also ask you how you got into some of your leadership and policy and administrative roles that take up a big part of your efforts?

Dr. McGinty: Well, I loved an anatomy in medical school and I loved the idea that radiology is the place where we solve the diagnostic problems. So I think it was that combination of technology and patient care that attracted me. Women's imaging though for me, was an opportunity to have an impact on population health. I loved the idea that we were able to think about screening large populations and improving care at that scale. And then breast imaging is one of the subsections of radiology, where you do still get to spend a lot of time with patients. And there are some fields of radiology where you don't get so much patient care. So, that was appealing to me too.

The policy piece of it was the way in which we finance care and the way in which we pay for care has a huge impact on how care gets delivered. And having witnessed a lot of the work that many organizations – patient organizations, the American Cancer Society, the American College of Radiology – did to ensure that mammography screening would be covered by insurance. And then to potentially see that being eroded because there was a lot of skepticism, misinformed skepticism about the value of screening, was really important to me as much as I could to be at the table where decisions were being made on how we pay for care to make sure that our patients got the right care.

Dr. John Leonard (Host): I think many people would say, well, of course mammograms are important. Of course women need to have access to them. But I understand the perspectives might be a bit more complicated than that. So we’ll come to that a little bit later. But let's start with the basics for our audience, which may include women who are going in for either their routine screening, or they may have a history or a particular risk profile where they need to have breast imaging performed.

As I understand it, there are a number of different technologies or techniques or procedures that are done. Maybe you can give us just a quick description of mammography, and then the other kind of second layer such as ultrasound or MRI, and when might these different techniques be done?

Dr. McGinty: Well, let's start with what we mean by screening. When we are screening, we are taking people who don't have any symptoms, don't have any problems. And we're looking to find disease before it's clinically apparent. We want to pick it up while it's early enough to be more easily treated and cured. So mammography is the test that we use for breast cancer screening, and it has been proven through massive randomized control trials to really save lives and diagnose breast cancer earlier so it can be treated more effectively.

And mammography is basically an x-ray technique. It has a very, very small dose of radiation. Certainly comparable to the kind of radiation we get just from living in the world. Over the years we've seen mammography evolve a lot. It used to be that when I trained, we read mammography on films and now it's all digital. And more recently we've introduced a technique called digital breast tomosynthesis or 3D mammography. What that allows us to do is really see more cancers and find more cancers, especially in women who have dense breasts.

And I'm going to take a minute here, John, to talk about what we mean by dense breasts, because it's often a question that our patients ask. Every woman's breast is made up of a combination of fat and the glandular tissue. The glandular tissue is the active tissue in the breast. It's what women use to breastfeed their babies. And when there's a lot of that glandular tissue, it can make the mammogram harder to read. So we know that mammograms unfortunately are not perfect. They've been proven to be effective, but they are not perfect. They will not find every cancer.

One of the things that we now do is we inform women of their breast density. And we tell them that if they have dense breasts, mammography might not be the only test that they need. And often what we'll be offering them as a second line is breast ultrasound. Ultrasound uses sound waves to make pictures, and it can certainly find cancers that we can't see on mammography. So that's a combination that we'll often see our patients having.

Now we also use breast ultrasound and mammography for women who've come into us with a problem. A lump, for example, or a nipple discharge. So when we do mammography and breast ultrasound for a problem we're often doing a different combination of pictures, a more targeted view. So what we'll typically see if you're going for your screening mammography, in a lot of facilities is, maybe you'll come on Saturday morning or in the evening, or when's convenient for you. And the radiologist may or may not read your mammogram when you're there. But if you're coming in with a problem, they will do all the pictures that they need that day. And you'll typically get to speak to the radiologist about the results of your test.

So those, I would say are the two most common imaging modalities. An imaging modality that we're using more often now but in a very targeted way is MRI. And breast MRI is something that is incredibly sensitive for finding cancers, but unfortunately it tends to throw up a lot of false positives as well, which can lead us down the path of having to do unnecessary biopsy. So when we use breast MRI, we want to do that very thoughtfully.

So who do we use breast MRI for? Well, we use it for problems that we haven't been able to solve with mammography and ultrasound. We'll often use it if a woman's been newly diagnosed with breast cancer just to double check that there's nothing else that we need to deal with when she's going to surgery. And then there is a small group of patients who we know have a different risk profile. People who have the breast cancer gene or people who have a really strong family history, and for those patients, their screening regimen will not only be mammography and possibly ultrasound, but will also include MRI.

And then lastly, I'm just going to talk briefly about what we do in terms of biopsies as breast images. And sometimes we will find something on a mammography or an ultrasound or an MRI and we need to know what it is. We need to take a piece of tissue from the breast and send it to the pathology lab. So what we're able to do is use our images to guide a needle and take a sample. We use local anesthetic. We do these procedures in our imaging department and they don't require a hospital stay. The patient can typically go home just with an ice pack and they're usually not particularly uncomfortable procedures, but those allow us without having to go to the operating room to make a diagnosis. In many cases, we see something, we do the biopsy, it's negative. We're able to reassure the patient. But in other cases, we're able to get the patient on the first step towards having whatever it is they're dealing with, taken care of.

Dr. John Leonard (Host): I wanted to ask you about quality in this sort of imaging and screening. I know you've been active in various professional organizations and at the national and international level and certainly you and your colleagues really are among the best around at performing these tests and interpreting these tests. What, for the average woman who's getting screening, are there any concerns or tips or is mammography quality across the country at levels where you can pretty much go anywhere and feel like you're getting a good quality? Or is there something that people should keep an eye out for, or at least think about a little bit more as they decide this? Because obviously there are millions of women getting screening tests done, and I would think that like with anything, there might be some variations.

Dr. McGinty: It's a great question, John. And I would reassure the patients listening to this, that every facility that performs mammography has to be accredited and that accreditation is in general administered by the American College of Radiology, which is our professional organization, but it is overseen by the Food and Drug Administration, the FDA. So there's a rigorous program of quality accreditation, which involves the facility having to actually send pictures in to be reviewed. The training of the technologist, the training of the physician is all reviewed and there are requirements for us as practicing physicians to maintain a certain amount of professional education.

Our patients can be reassured that that quality program has been applied to wherever they're able to get their screening mammography. Now what I would say – and thank you for the kind words about our department. I think we have a terrific group. When you start to get into the problem solving aspects of mammography, I think that's where you really want to be going to a place where you've got breast imaging physicians, perhaps receive specialty training, who work in a group, who work collaboratively with physicians like you, with pathologists. Because getting your screening mammography, and 90% of the time you're not going to need anything else, is one thing. But having to deal with a specific problem, that's when we want to be seeing you in a place where there's a lot of focus on keeping up with the latest developments and collaborating with the team.

Dr. John Leonard (Host): I'd like to get into the guidelines. And anytime we have a guideline, it seems in medicine, number one, it ends up being controversial. Number two, it changes over time. And at least from my vantage point, which is from a little bit of a distance, it seems like breast imaging and screening guidelines, vary a bit.

So, I'll first ask you, why does it matter? In other words, for an individual patient it may be, well, why don't I start getting screened at an early age and why don't I do it until I'm a hundred years old? Why would there be variation and different perspectives on when and who should be screened?

Dr. McGinty: We are talking about screening half the population at some point in their life, right? So we want to make decisions that give us the most benefit with the least harm. So we are talking about a test that carries a small amount of radiation. We always, always want to be thoughtful about that. And we want to make sure that we are deriving the maximum benefit for women who are screened. So we start with that. So that means we are impacting the lives and the care of millions of women. So it's important that these decisions are well thought out.

From a policy standpoint, there are unfortunately questions of cost. So how do we do this in the most cost effective way? And I think that one can be a little cynical and wonder if some of the questions about screening are more focused on the cost. But the science definitely shows that there is a benefit to screening women and that the most benefit is derived when we start by screening women at 40. This is something that we do in the US. Other countries choose to start screening later, not to screen every year.

And again, these are policy decisions, benefit versus risk, but in the US, we realized that most lives are saved when we start at 40. We want to save all women, but we want to start where we're really going to have maximum benefits. So right now, the American College of Radiology, the American College of Obstetricians and Gynecologists, the American Cancer Society, the National Cancer Care Network, all agree that screening should start at 40 and should be every year.

The American College of Radiology is currently recommending that as long as you're in good health, you should continue to keep screening. Because we still prefer to detect disease while it's easily treated or cured. There are definitely people who think that we should be tailing off as we get older, but right now our philosophy is: if you're still healthy, you should still get screened.

Dr. John Leonard (Host): Are there specific groups of women that should have a different screening strategy, either based on their family history, their other medical problems or other risks, both based on timing as well as what tests you do to provide them with screening.

Dr. McGinty: Thank you for asking that question. It's really important. Obviously, if you have a strong family history, so what we call a first degree relative mother, sister, with premenopausal breast cancer, that puts you in a different risk category. If you have the breast cancer gene, or if your heritage is Ashkenazi Jewish or one of the other groups where there's a higher risk of breast cancer, then you are going to need to pursue a different screening regimen.

And what we are recommending now is that all women at the age of 30 have a conversation with their primary care physician about what's appropriate for them in terms of their screening regimen to understand how they should pursue this. For some women, women who have that very strong family history or the breast cancer gene, or sometimes women who've had perhaps radiation therapy to their chest for a malignancy. Those women are going to need to add in MRI to their screening regimen. So it's a conversation that we think women should be having with their doctor at the age of 30.

Dr. John Leonard (Host): Maybe you could just walk us down the different possibilities. It seems like often hopefully it's everything looks good, come back in a year for most women. But what are the other kind of outcomes that a women might experience where things need a little more follow up to resolve? What are the different pathways one might follow in those hopefully less common situations?

Dr. McGinty: So when you walk in for your mammogram as a screening, you don't have any lumps or bumps, you don't have any other problems, there's a 90% chance that you are going to get a perfectly normal result and see you next year. 10% of women are going to require, and that's an average, but 10% of women are going to require some additional pictures. Maybe there's an area that we need to press out a little bit more or the pattern looks slightly different than last year and we want to just take another look.

But of those 10% of women who we call back, the vast majority, probably eight or nine out of the 10, are then going to get a normal result. Whatever we saw turns out to be nothing. And we just needed to get that closer look. One or two in a hundred is going to need additional testing to clear up or find something. And that typically means the biopsy. Most of the time, we're able to do that biopsy under local anesthetic and needle biopsy that we do in the department.

And even then, the majority of those turn out to be normal. So our cancer detection rate is about four in a thousand. So you can see that of every thousand women who come in, it's a very small number who have cancer. Now you could say, well, gosh, you've had to call all those people back and do all those biopsies. What we're looking to do is we're looking to find cancer while it's small and treatable. So we want to be as thoughtful and as careful as possible in hunting that down.

Dr. John Leonard (Host): There are some different techniques, biopsy procedure, the stereotactic or the image guided. Can you give us a high level difference there?

Dr. McGinty: Well, they are different in terms of the process. We use the type of imaging where we see the potential abnormality to guide the biopsy. So if we've seen it on mammography, we use the mammography guided biopsy, which is also known as a stereotactic biopsy. If we see it on ultrasound, we'll use ultrasound. They're all needle biopsies. They all use local anesthesia, but because of the type of imaging that we're using to guide, they're a little different.

So, when you're having an ultrasound guided biopsy, you're lying on the table the same way as you would be for ultrasound. That's probably the quickest one. The stereotactic biopsy on the MRI require a little bit more positioning. And are a little slower because those images are not as real time as ultrasound. But in all of these, I would say that the actual biopsy part of it is probably no more than 10 to 15 minutes.

Anytime we do a procedure, there's a lot of setting up and explaining and consenting and cleaning, but the actual biopsy part of it is quite short. And I also mentioned that our patients go home with steri-strips, little sterile tape on the area and ice pack. We ask them to not shower for 24 hours and not be lifting any heavy weight, to be too active for a day or so, but really no significant down time.

Dr. John Leonard (Host): I would be remiss if I didn't ask you about COVID vaccines and mammography. I know at least at the beginning when people were getting vaccinated, we were seeing lots of swollen lymph nodes and that was creating problems for women getting mammography. What's the latest guideline for women who might be getting their booster or otherwise, and need to get a mammogram, should they wait a while? Make sure they tell the doctor? What are you telling your patients?

Dr. McGinty: We're really just focusing on make sure we know when you last had a booster, when you had your vaccine. As you can imagine, we had to shut down care for several months during the pandemic and shut down screening. And our main focus now is making sure that everyone gets back on track with their screening. We don't want people delaying or waiting. We'd rather see you. We now know what the appearance of those lymph nodes is after COVID. If there's something we have a question about, we might ask you to come back for a follow up ultrasound, just to make sure it clears up, but we'd much rather see you and make sure that you're getting your mammogram back on time.

Dr. John Leonard (Host): I know you interact with a lot of women regarding their breast health issues, their concerns. Just briefly any other key messages you want to let our audience know about from the standpoint of risks or other signs of breast cancer or concerns that may come up that should really lead them to seek medical attention, whether it's imaging or their primary care physician or their gynecologist?

Dr. McGinty: I'm often asked about breast self-exam and it's something that we don't necessarily focus on as much as we used to. If you are somebody who feels comfortable examining your breasts every month, we are more than happy to show you the right technique to do it, but we definitely want you to be seeing your healthcare provider and having your breast examined by them at least once a year. The bottom line is, if anything concerns you, we want to see you. We want to make sure that if it's nothing that we can reassure you and if it's something that we can catch it and that we can start treating it.

The other thing people will ask me, well, what else can I be doing? I'm getting my mammogram every year. The basic things of maintaining a normal weight, minimizing alcohol, exercise is always good. Those are things that I'll often talk to patients about.

Dr. John Leonard (Host): Is there something on the horizon, as far as breast imaging that you're really excited about in five or 10 years? Will we be using new technologies? Will this all happen in a different way? What are some of the things on the horizon that at least have you excited about how things might get better or change in the future?

Dr. McGinty: We spoke about MRI and it's a really powerful tool, but anyone who's had an MRI knows that it's about a 30, 40 minute examination, requires an injection, it's quite an involved test. So there's a specific modification called abbreviated or fast MRI where we're hoping to get that MRI exam down to maybe five minutes. Which means that we could then leverage the power that it has to see more cancers in a way that would actually be pragmatic and reasonable to do for the whole population. So that's exciting.

And then of course there's artificial intelligence. We've heard a lot about the promise of artificial intelligence in medicine, but from mammography, I think that it's really exciting to think about how we could use it to augment the performance of the radiologist so that we could see more patients. And I think that has a really powerful potential application in global health, because think about there are so many parts of the world where there really are not enough radiologists and it's very resource constrained.

How could we potentially bring the lifesaving benefits that we've found from breast screening to parts of the world where we haven't had it. And AI seems to have real potential there.

Dr. John Leonard (Host): So I want to wrap up with having you share a little bit about your efforts nationally on radiology policy. People know that they benefit a lot from the care of radiologists, but they don't personally interact with them very often, except for some specific situations such as with their breast imaging. But tell us about the importance of national policies on care and perhaps how it relates to the radiology field as well as elsewhere. I know that's been a big area where you've had a big impact.

Dr. McGinty: Well, the history of breast cancer screening and detection is one that I think is a fascinating story of how patient groups and physician groups work together because of it was first lady, Betty Ford who really sort of highlighted her own breast cancer journey. And I think made it something that women felt they could talk about. And it was really women becoming active and saying, we want better care. We want the availability of this care, working with physician organizations who then influenced government and regulators to offer mammography screening.

And then importantly, make sure that mammography screening was of an appropriate quality. And I think that the discussions more recently have been about how we can continue to evolve the breast cancer screening program, how we can make sure that we preserve access and increase access to women who haven't maybe had as much availability. And again, we continue to work with patient groups to ensure that we're meeting their needs and moving the field forward. And we've learned so many lessons from how to do this effectively with breast cancer screening that the work we've done on lung cancer screening has benefitted from that.

And again, how we pay for care impacts how care is delivered. We have had an ongoing effort with Congress to make sure that breast cancer screening continues to be paid for. What does that mean? It means we have to tell the story of the benefit of screening and breast cancer screening to lawmakers, most of whom are not physicians. And there's often a stereotype about radiologists that we are sitting in dark rooms and we don't like to talk to people.

But we make it our business to make sure that we are speaking to the people who make policy decisions and payment decisions so that they know. We are the physician experts in breast cancer screening, and we can show them why this is an important way for the government to steward our resources. So, it's all about being in the rooms where those decisions are being made.

Dr. John Leonard (Host): Well, before we wrap up, I want to ask you about your role here at Weill Cornell Medicine as Senior Associate Dean for Clinical Affairs. This is a great chance to hear from you directly as to the big things that are happening on the clinical front at Weill Cornell Medicine for our patients. So maybe if you could just briefly mention some of the key projects you're working on as we accelerate our clinical programs here and our clinical care efforts in collaboration with NewYork-Presbyterian Hospital – what are the big things that you're working on to help us deliver better care for our patients and improve access, etcetera?

Dr. McGinty: Gosh. Well, there's a long list. I'm very honored to support the Dean in the execution of our clinical mission. So, we have three missions at Weill Cornell, care, discover and teach, but our goal is that we link those together in a way that benefits our patients. I am tasked with everything from making sure that our physicians, and our staff are feeling supported and really able to provide the best care to thinking about as we grow our organization, where should we grow? As we look at the need for our services, where are the most appropriate places first to put a new practice?

As you know, we're actively working now on bringing more of our Weill Cornell care to Brooklyn, Brooklyn Methodist Hospital. And I'm also tasked with supporting our leaders in developing new programs and making sure that they have the organizational support to do that. So a lot of exciting things.

Dr. John Leonard (Host): Well, thank you very much. Dr. McGinty, it's been great to have you here. I'd like to invite our audience to download, subscribe, rate, and review CancerCast on Apple Podcasts, Google Podcasts, Spotify, or online at weillcornell.org. We also encourage you to write to us at This email address is being protected from spambots. You need JavaScript enabled to view it. with questions, comments, and topics you'd like to see us cover more in depth in the future. That's it for CancerCast conversations about new developments in medicine, cancer care and research. I'm Dr. John Leonard. Thanks for tuning in.