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Melanie: Thanks for tuning in to Back To Health, the podcast that brings you up-to-the-minute information on the latest trends and breakthroughs in health, wellness, and medical care. Today's special episode is part of our Women's Health Wednesday series, which features in-depth conversations with Weill Cornell Medicine's top physicians on issues surrounding women's health throughout the life course. Listen here for the information and insights that will help you make the most informed and best healthcare choices for you.

I'm Melanie Cole. And joining me today is Dr. Melissa Reichman. She's an assistant professor of radiology at Weill Cornell Medical College and an assistant attending radiologist at New York Presbyterian Weill Cornell Medical Center, and she's here to discuss what's new and exciting in breast cancer imaging and screening recommendations.

Dr. Reichman, it's a pleasure as we get into October. It seems to come around faster and faster every year. Tell us a little bit about breast cancer. What are you seeing as far as incidence, awareness? Are more women getting screened?

Dr Melissa Reichman: Good morning, Melanie. Thank you so much for having me discuss breast cancer and breast health, a topic that is so important to me and near and dear to my heart. I'd be happy to talk a little bit about breast cancer. Breast cancer is the most common cancer diagnosed in women. It is a disease in which cells in the breast grow and multiply abnormally, which can happen if the genes in a cell that normally control cell growth no longer work as they should causing cells to divide uncontrollably, forming a tumor.

In 2021, it's estimated that about 30% of newly diagnosed cancers in women will be breast cancer. While annual breast cancer screening is essential, and we'll touch on that later, we have unfortunately seen a marked reduction in breast cancer screening during the COVID-19 pandemic, which will probably lead to an increase in later stage cancer diagnoses down the road.

Unfortunately, this is a reverse in the trend we have been seeing since widespread screening mammography was introduced in the United States in the late 1980s, since which time we've seen a 40% decrease in mortality due to breast cancer.

Melanie: Well, those are some statistics, and I'm sorry to hear about how COVID has affected really the screening and women's ability to go get screened. So before we talk about those screening recommendations, which can be a little confusing, what are some of the risk factors for breast cancer that you can point to? And is there genetic predisposition? Is there a role for inherited trait that plays in developing breast cancer?

Dr Melissa Reichman: Well, yes. First and foremost, breast cancer risk increases with age. As you know, the percentage of older Americans continues to rise and we can expect to see an increase in the number of newly diagnosed cases of breast case. Also personal history of breast cancer can increase your risk as well. Once you've had cancer in one breast, there's increased risk in the other breast as well. And this risk may be decreased by anti-estrogen drugs used to treat breast cancer and reduce risk of developing new cancers. Also family history of breast cancer in a first-degree relative, that includes your mother, sister, or daughter can increase one's risk of developing breast cancer. There may be links to mutations in the genes BRCA1, BRCA2, and PALB2.

Other risk factors that may be noted are radiation exposure, early menstruation or late menopause, taking oral contraceptives, obesity, and having a first child after the age of 30. As I mentioned there is that genetic predisposition for developing breast cancer, but it's really only seen in five to 10% of breast cancers.

BRCA1 and 2 are probably the most widely recognized gene mutations. The lifetime risk for breast cancer for BRCA1 is around 50% to 85% and BRCA2 is around 45%. BRCA genes and the PALB2 gene normally help cells repair DNA. Typically, you have two normal copies of these genes and therefore one would have a lower risk for developing breast cancer. If a single normal gene is present, that's good enough for not developing cancer. But if you're only left with a mutated copy, then this really compromises the cell's ability to repair its DNA and cancer can then develop.

Melanie: Wow. Excellent explanation. What a good educator you are, Dr. Reichman. Now, let's talk about screening, because this is where the confusion lies in. Different organizations have come up with different kind of like prostate cancer screening, the same, there's a little bit of controversy or indecision about certain things. I'd like you to clear some of that up for us right now. Who should get screened at what age and how often?

Dr Melissa Reichman: I would love to explain some of these controversies. Screening is extremely important. There's decades of evidence proving that mammography does save lives. This leads to, I'd say a 40% drop in mortality rates. Screen-detected cancer can lead to less extensive surgeries and treatment for the patient.

The American College of Radiology recommends annual mammography screening starting at age 40 for women of average risk for developing breast cancer. I also would like to say that higher risk women should start at mammography screening earlier and can benefit from supplemental screening modalities. For women with a genetics-based increased risk with a calculated lifetime risk of 20% or more, or those who have had a history of chest or mantle radiation at a young age, supplemental screening with breast MRI is definitely recommended.

Screening breast MRI is recommended for women with personal histories of breast cancer and dense tissue, or those diagnosed by age 50. Other is if they've had a history of breast cancer or those who have had atypia at biopsy should consider additional surveillance with MRI, especially if other risk factors are present. Ultrasound is another tool that can be considered for those who qualify but cannot have an MRI.

So again, to reiterate, women should begin at the age of 40. One in six breast cancers are found in women ages 40 to 49. And the ten-year risk for being diagnosed with breast cancer in a 40-year-old is one in 69. It's really important to see that greater than 70% of the women dying from breast cancer in their 40s belong to the 20% not being screened and that the incidence rate for ages 40 to 44 of breast cancer is twice that for ages 35 to 39.

I'd like women to know, especially black women and those of Ashkenazi Jewish descent, they should be evaluated for breast cancer risk no later than 30, so that if they are at higher risk, they can be identified and can benefit from supplemental screening.

Now, the American Cancer Society and United States Preventative Service Task Force have issued guidelines promoting less frequent screening over a shorter period of life and beginning at age 50, screening every other year. Now, this recommendation is quite controversial in our field and in our institution. And there are a number of reasons for this.

It makes judgements on behalf of women about how benefits and risks should be valued. There's no medical evidence of physiologic change to support screening beginning at the age of 50 and the cancer rate increases gradually as a woman ages, as I said earlier, with only slightly more women diagnosed in their 50s compared to their 40s.

The USPSTF uses limited older data that basically underestimates our mortality reduction gained from screening. So the American Cancer Society and USPSTF count one benefit, mortality reduction. And they ignore all the other benefits of screening. They include risks, which are non-lethal and all studies acknowledged that this screening mammography does reduce mortality in women. And that screening every year starting at age 40 would save the most lives.

So remember if you remember one thing from this conversation, the goal of screening is to find cancer as early as possible, and to save as many lives as possible. And the task force says harms of screening 40 year olds, such as false positives or painful biopsies outweigh the benefits. We need to understand a woman's point of view. Women are highly tolerant of false positives, and most women would be willing to undergo a benign biopsy to extend their life. I know it's a lot to digest, but in some, yearly screening at age 40 reduces breast cancer mortality and saves approximately 13,770 more lives each year versus screening every other year from age 50 to 74.

Melanie: Well, I can attest to everything that you're saying. Dr. Reichman. As an Ashkenazi Jew descent and a woman past menopause who had her first child at 36, I've been doing my mammograms. And I'm glad of it. And it doesn't hurt, ladies. I want to point out it's not a big deal. It takes minutes, mere minutes.

Now, Dr. Reichman, 3D mammography tomosynthesis is now something that's being used at many medical institutions. How's that different from the conventional film mammography? And is this a pretty exciting thing?

Dr Melissa Reichman: That's a great question. It's an exciting thing. And it's a great tool and women benefit greatly from 3D mammography. 3D mammograms also known as breast tomosynthesis is an imaging test that combines multiple breast x-rays taken at different angles and creates a three-dimensional picture of the breast. This is compared to the conventional mammogram, which is a 2D picture of the breast. Tomosynthesis can decrease recall rates and the need for followup imaging, can detect slightly more cancers than a 2D mammogram and really improve breast cancer detection in dense breast tissue.

Melanie: So tell us a little bit about the process itself, because back in the day you had to wait in the waiting room when you first got it. And you just mentioned followups or have to do it all again. And we hated that. And we also hated getting that letter saying you need to come back in for that followup. So what happens now? What is it like now after a woman gets her mammogram? Does she just leave or does she have to sit and wait until you tell us the pictures came out good? What's it like now?

Dr Melissa Reichman: Well, for a patient who comes in, they can have a screening mammogram and leave and get their results the next day, or they can have a same-day screening read where they have their screening mammogram and they wait for the doctor. I would say it's pretty quick. And they can get their results at that moment. And if they need any extra pictures, they don't have to come back for a recall. We can give their results and get those extra pictures as needed, which will decrease the patient's anxiety, which is a great process of Weill Cornell Medicine.

Melanie: Rock on. It certainly is. Because that anxiety of waiting for those results is just something no woman likes to deal with. Now, what about referral? Do you have to have a referral for a mammogram?

Dr Melissa Reichman: Yes. Most practices require prescription from a referring provider, just so that results and patient care can be managed.

Melanie: And what about dense breasts, Dr. Reichman? I mean the listeners are going to hear me talk about stuff, but I'm in that category. And so as a result, I get checked with a little bit of a deeper technology and we pay more attention to it. But tell us about dense breasts and why that's something women need to know about themselves.

Dr Melissa Reichman: Okay. Well, dense breasts can be challenging. Women with dense breasts have a large amount of fibroglandular tissue and this includes many components. The breast tissue includes connective tissue, ducts, and the terminal duct lobular units where cancer arises. This tissue is cellular and can block the x-ray beam from going through. And this will appear white on a mammogram. If a patient has a fatty breast, the x-ray beam can pass right through and the breast is not as white. If a cancer does develop, a cancer is made of a lot of cells that aggregate together and stop that x-ray beam from going through and the cancer appears white as well, which makes picking up a cancer in a dense breast a challenge. We get this masking effect where basically dense white tissue surrounds the white cancer and prevents us from seeing the differences in whiteness.

The Breast Density Bill that came out in New York in January 2019, it requires mammography providers such as myself to convey in our mammogram reports that's provided to our patients, that they have dense breasts and that it is very common and it is not abnormal. It can make it harder to find a cancer on a mammogram, and this may be associated with an increased risk of breast cancer. But patients should discuss these risks for breast cancer with their healthcare provider and ask the radiologists and their healthcare providers about supplemental screening tests based on their risk.

Melanie: What great information we're giving today. And before we wrap up, I'd love you to tell us about anything exciting that you'd like to mention as far as research, what's new and interesting in breast cancer imaging. And tell us about your team at Weill Cornell Medicine and offer women really the best advice as self-esteem, peace of mind is all taken into account for women when they're getting screened for breast cancer.

Dr Melissa Reichman: Okay. Well, a woman's self-esteem and peace of mind is always taken into account when deciding treatments and accounting during their imaging. Dealing with a new breast cancer diagnosis can be terrifying as we all know. And our job as a physician is to empower women with information regarding their diagnosis, regarding the different imaging techniques and various treatment options.

Thanks to the advances made in breast cancer research over the past several decades, our team can really provide a variety of treatment options and it's a multidisciplinary management of breast cancer. Our team includes radiologists. It includes pathologists, medical oncologists, surgeons, radiation oncologists, nurse navigators and geneticists, and we all work together each week to discuss every case that comes through to give the appropriate individual patient their management and monitor treatment as they proceed. So our goal is to always help the patient get through this time as quickly and easily as possible and get back to their life and their normal routine.

Exciting things that we've been seeing in breast imaging, I'd say MRI is the most sensitive test available for breast cancer screening, but it's only used for high risk women because of exam length and costs and potential for false positives. So abbreviated breast MRI is a new approach being developed that can maybe replace current digital mammography techniques in the future. And the goal of this abbreviated breast MRI is to reduce the length of time, the number of sequences and the cost associated with breast MRI. And it's been shown that abbreviated breast MRI has found about two and a half times more cancers than 3D mammography.

Another vascular-based technology is contrast-enhanced digital mammography. It shows a similar process that we're really excited about. It's likely to be more available and accessible than MRI at a lower cost. And also shows benefits in detecting cancer in women with dense breasts compared with 3D mammogram.

And I want to leave off with most recently artificial intelligence and machine learning. They've arrived and they've shown great promise. As a radiologist, I don't fear it taking over my job. I just think it will help increase accuracy of screening mammography, decrease reading times. And it's exciting the applications in computer-aided diagnosis and detected algorithms and breast ultrasound and the technologies to watch for it in a constantly evolving field.

Melanie: Can you just give us one last parting piece of advice for women that are hesitant to get screened? They're really not sure, tell them what you want them to know about the importance of screening that could save their life.

Dr Melissa Reichman: Well, screening mammography can detect cancers early, meaning that a patient may be asymptomatic and a cancer can be discovered through these routine screening mammograms. And if we detect it early, there's less of a chance of a later stage diagnosis and a decrease in mortality. Additionally, patients should know that the amount of radiation from a mammogram is extremely small and does not increase your risk for breast cancer.

I would say the dose women receiving a screening mammogram is about equal to that received over seven weeks from natural surrounding background. So I don't want that to be a fear for women. I think it's really important for women to get screened and to find these cancers early so that they don't have to deal with the consequences later on.

Melanie: Hear, hear. I can tell you, women, it is easy, it's quick and painless. And the doctors and radiologists at Weill Cornell Medicine will take great care of you. So go get your breast cancer screening now. It's more important than ever. And to learn more about imaging at Weill Cornell Medicine, you can always visit wcinyp.org. That's W-C-I-N-Y-P.org.

We're so glad that you joined us for Women's Health Wednesday. We hope you'll tune in and become part of a community and fast-growing audience of women looking for knowledge, insight, and real answers to hard questions about their bodies and their health. Please download, subscribe, rate, and review Back To Health on Apple Podcast, Spotify and Google Podcast. For more health tips, you can always go to weillcornell.org and search podcasts. Parents, remember to check out our Kids Health Cast too. That's a great show. I'm Melanie Cole. Thanks so much for listening.

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