0:03 
Hello and welcome to breast cancer conversations podcast brought to you by survivingbreastcancer.org. I'm Laura Carfang, breast cancer survivor and founder of survivingbreastcancer.org, a nonprofit organization providing community, education, and resources to empower those diagnosed with breast cancer and their caregivers from day one and beyond. Our podcasts are made possible thanks to our sponsor Store My Tumor. Your preserved tumor contains the most important information about your cancer. Store My Tumor provides live tumor preservation and coordination of advanced diagnostics and personalized immunotherapies. Thank you so much for supporting us. Hello, my friends. I'm so happy to be connecting with you this week on breast cancer conversations. I'm your host, Laura Carfang. And if you're joining us for the first time, be sure to subscribe to our podcast and receive notifications each time we come out with a new episode. To all of you who tune in every week. Welcome back. I'm so glad you're here.

0:59 
Molecular breast imaging is a little bit different, we acquire the images in the same plane. So in the horizontal plane and another 45 degree, molecular breast imaging, the way that this works is we inject you with a radioactive material called technetium. The detectors that we use are much better than the way they used to be. And that's really why this is such a great modality. The most important thing is to just get this information out to everybody.

1:30 
Welcome to the conversation. I have two guests here tonight for my listeners. I'm so excited that you guys are joining us today. We have Leslie Jaeger and you're calling in from the Chicago land area. Okay, excellent. So glad to have you and you have a great story because we overlapped through our breast cancer diagnoses. And I think immediately like you submitted a blog for us and you were telling us how you walk 500 miles and what you were raising money for. And so I'm going to kind of leave the cliffhanger there for our listeners and they will have to kind of stay tuned to hear a little bit more about that. And you spearheaded this partnership in collaboration that we are able to bring Dr. Ha on the show today as well, which I'm also very excited to have because, you know, as survivingbreastcancer.org, as a nonprofit, as we are growing, we definitely rely on our community members to say, Hey, here's a great topic, or here's something that I'm interested in knowing more about, or here's something I think we need to push out to the community, and how we can use our own networks to kind of bring in these amazing guests onto our show. So Dr. Ha, I'm very grateful and thankful that you have the time to spend with our community today. So thank you for joining us as well.--Well, thanks for having me.--Yes. And you are calling in from New York. Correct?

2:43 
Correct. I am actually the director of Radiology and women's imaging at Mercy Medical Center in Rockville Center in New York. We are in Nassau County. And our hospital is part of a larger network. We're part of the Catholic health system of Long Island. Currently I am running a molecular breast imaging program. We are the only molecular breast imaging program in New York State.

3:10 
Leslie, I would love for you to kind of take us back to maybe a little bit of how you and I overlapped in the blog that you shared. Because if you are listening to our podcasts and haven't checked out our website, we do publish blogs every week. And sometimes there are blogs that I write as well as blogs that our contributors from our community submit as well. So it's a really great way to give people kind of that overarching view of like, what is breast cancer, right? We know that no one's diagnosis is exactly the same and same with people's experiences. So I love being able to represent and kind of that gamut.

3:44 
Yeah, so it was back in November 2017. And I was doing just, you know, regular healthcare checkup things and one of the things that my doctor suggested that I do is to get a baseline bone density scan since I was newly postmenopausal just to sort of check, have something to check against and see if you're losing bone, you know, later on in your life. If you don't have a baseline, then there's really no way to know. So that came back with suspicious things in it. And, and mind you just a couple months before that I had had a mammogram and ultrasound that came back all clear, fine you know, yeah. And so, we began to investigate what was happening in in the in the bones and got to the stage of a bone biopsy and found out that it was stage four, lobular breast cancer. And, so lobular is a sneaky type of breast cancer, and that it's it's harder to see in the technologies that we're currently using, and so you can understand how confusing that was to get that diagnosis and so I went to the Mayo Clinic for a second opinion. And the diagnosis was certainly confirmed. But through my time at the Mayo Clinic, I began to learn about this new breast cancer screening called molecular breast imaging, that finds many, many more breast cancers in women with dense breasts, which I have. So I became interested in that technology, and hoping to get the word out to more people about it. Since you know, there's a good chance it could have found mine if had it been available. You know, there's no way to know that for sure. But what I do know is that there are a fair amount of best customers cancer is not being found right now, through the technologies that we're currently currently using as standard and so that's kind of become the job that I've given myself as a way to give back to other people.

5:54 
Wonderful. Well, thank you for sharing that story. And I'm just curious if you don't mind sharing you know, I think when we think about different diagnostics, I don't necessarily associate a bone density scan with finding cancer, right? Like, that's not necessarily one of the normal modalities. And I hear these stories a lot where people are going in for one ailments, they get a CT scan or they get an X ray and something looks suspicious and then immediately it escalates into something else. And, you know, I, my experience, prior to breast cancer has been like just going for like routine one year checkups. I've never broken a bone. I never had any problems. I consider myself very healthy. So the more that I'm talking and hearing women's stories about how they're discovering their cancers and discovering it at a very late stage as well is very shocking. And so, you know, I every time I go to the doctor's now to or someone's telling me, Oh, don't worry, I'm just going in for X, Y, and Z tests. My heart immediately skips a beat because, you know, we're discovering things all the time about our bodies. Can I also ask, you know, when they did the bone biopsy did they know right away that it was breast cancer?

7:03 
No, not at all. It actually looked like multiple myeloma in in the CT scan and the and the x-ray. So that's kind of what we were fishing for. Even though there was a blood test on a urine test that came back negative, so we were kind of everybody was kind of confused as to what it was at that point. So no, we didn't particularly weren't looking for breast cancer, especially since, you know, we I just had a mammogram and an ultrasound and that came back fine. And so, you know, I don't know if my story is is, you know, a common story, but there are cancers that are being found later than they should be. So even a stage one or zero is better than a three, right? Regardless of whether you got you got to four or not like I did so. So I think that's really the the bigger story here is, hopefully there are ways that we can move to that. We can find breast cancers a lot earlier than we are now. That’s kind of what I've dedicated my working life to now.

8:02 
Wonderful. Well, thank you. So I would love to just like jump right in. I think we have, you know, two great survivors here on the call with very different experiences of how they found their diagnosis myself and you, Leslie and Dr. Ha and, you know, without just jumping right into like the fun and exciting question of what is molecular breast imaging. I would like to kind of give our listeners an overview of how complex radiology actually is in terms of breast health. And I'm still learning myself too without like, the medical background, you know, I go in and I have a mammography screening. And, you know, it really took me a long time to understand what the standard of care is versus going in for a diagnostic. So because of my age when I you know, push my primary care doctor to write a prescription for me to be able to go and get a mammogram at 34. You know, they did all sorts of pictures right in different different angles, and I think a lot more than just you know, what, like two on each side or four on each side, or whatever the hospital's practice typically is. So I'm going around talking about all these images that I'm getting thinking that's normal not understanding that this was above and beyond because it was a diagnostic process. And it quickly moved to an ultrasound as well because of the dense tissue. And so just, like one example. I know in our breast cancer community as well. We talk a lot about, you know, being able to advocate for 3d mammography or contrast enhanced mammography, MRIs. So within the field of radiology, there's so many options and technologies available. I would, I would love to hear your opinion on, you know, just big picture overview of all of these options and then utilizing that maybe as an introduction for molecular breast imaging.

9:47 
Okay, so, kind of what you alluded to there's two different types of mammograms right? There is a screening mammogram and the way that we screen is you get two views of each breast. All right. And that was really just basically, that was all we did for screening. But recently with all the literature that's coming out about dense breasts, we've quickly realized that just two views of each breast is not sufficient for screening everybody, right? So we are really quickly learning that everybody, we should be moving toward customized screening programs. And that's actually what we've done at Mercy. That's the program that we've developed, right? So what happens is when you come in, and you have no complaints whatsoever, right, this is for people who have no complaints, and then we're just looking for breast cancer to see if anything is popping up. The first thing that will happen is we have you answer these questions, and everybody hates answering the questions because they're like, why are you being so nosy? But there actually is a reason because what I do with those questions, and I look at every single question or we input the questionnaires into a program that will calculate what your five year risk is and what your lifetime risk of developing breast cancer is okay. So that's the first part. That's the first thing. As soon as you walk in, that's what we're doing. And then the next thing that happens is we take the pictures, right, we take the basic pictures. And once those basic pictures are taken, we actually have a software called willpower. And willpower. What willpower does is it will measure what your breast density is. So it's not me looking at the picture and saying, oh, I think this one looks dense or oh, I think this one looks better. It actually measures percentage wise what your breast density is. And that's really important because that means that's something that's replicable and whether I do it or somebody else does it like that density is pretty much going to be the density that you have, right. So once I determined that you have dense breasts, yes, I'm still screening you right but you now you become a dense breast screening for me, okay. And then the dense part what that means is we will do your four views, but I will also let you know listen, you have dense breasts, and this study alone may not be sufficient, we need to have some kind of supplemental screening for you in the form of ultrasound most commonly, but because we have molecular breast imaging, that's another layer so you could have, you should have your screening mammogram plus an ultrasound or molecular breast imaging. Okay, so that's that's basically the screening program that we have. Let's say that you also have a high risk for developing breast cancer because you've had multiple biopsies or you know, there's, there's things that are involved that you're like, how does that have anything to do with what my risk would be but it you know, it matters when you got your period. You know, when you had your first child, it's all these things that you know, family history, right, first degree relatives, or more distant relatives, history of certain GYN cancers. So we look at all of those things. And if you have an increased risk, as well as having the dense breasts, I may recommend at that point that you add a layer of more protection and possibly get an MRI as well. As an MBI, alright, so that's where, you know, so that's really the basic. One of the questions I often get asked is, well, when should I start screening for breast cancer? And that's really important to also so right now, there's a lot of, you know, there's a lot of controversy as to what's the starting age should be. But I because I'm a radiologist, we go by what the American College of Radiology recommend, and that's age 40. with the understanding that if you have a strong family history, or if you have a first degree relative who has breast cancer, all right, we'd like to start screening you 10 years prior to the time that they were diagnosed with the understanding that we won't screen you before you're like 25. Okay. Okay. So that's really an important bit of information, right? Because everybody, you know, a lot of people say, Well, I'm only 32 or I'm only 35. And, you know, they, they don't think that I should be screened for breast cancer, but we find out that you know, what, you had a sister who was diagnosed when she was 40. Okay, so technically, we could have started screening you at 30, or if you had a mother who was diagnosed at age 45. Okay, so those are all little things. So that's really. So that's, that's step one. Step one is figuring out what your screening program is going to be. And when we're going to start screening you. And then we have all these tools that we can use to figure out how we're going to screen you. And what you were saying is, so molecular breast imaging is yet just another tool. It's the latest thing that we have. We are the only ones in New York who have it. It was very it was, you know, with the unit that we have was supposed to go to Johns Hopkins actually, and somehow we wound up getting it because there was like a little glitch there. I guess. The nice thing about molecular breast imaging really is that if you have a negative if your molecular breast imaging is negative, so there's nothing on the molecular breast imaging. There's like a 99.6 or 7% chance that you do not have breast cancer at the time that we're imaging you. Wow. So more than anything I feel like that is really like such a relief. For so many people, so many women, especially when they have dense breasts, especially when we know that you have like a gazillion cysts and you know, little complex cysts and ducks and things like that. But you know, when you get that negative MBI, you can say, you know what, these things are probably all benign. There's a 99 greater than 99% chance that you're good.

15:21 
That's incredible. So, you know, if I understand this correctly, would that actually decrease the number of biopsies then that you need to perform?

15:29 
Yes. So it could potentially decrease the number of unnecessary biopsies that you would need.

15:34 
Excellent. For me, that was like the most painful part.

15:37 
I have a question for Dr. Hall on the other modalities like that the ones that you mentioned, ultrasound, or or something. If those come back negative, then what are the chances that you would not have breast or that you would have breast cancer? Um, you know, I'm saying what's the same?

16:04 
If you have a negative, you mean if you have a negative mammogram if you have a negative, okay, so let's let's put it this way. I have some I have some interesting numbers. Okay. So let's say that I screen 1000 women, all right, and I use what they were supposed to use the mammogram, but we're not even using the 2d 3d combo, not the tomo, but the regular mammogram, right? If you use a regular mammogram, we will find about three breast cancers per thousand women, on average, okay, when we add the tomo the 2d 3d to it, we add about 1.2 more people, so for a little more than four people per thousand now. Okay, so when we add molecular breast imaging, we add approximately eight to nine more women per thousand. All right, so that's so we started off with three and if you want to add eight or nine to that, right, that's About that's actually almost a 400% increase in the detection rate, right? ultrasound alone. So if we do the mammogram, plus the ultrasound, we will add 3.2 more. So instead of having three, we'll get about six per thousand. Okay. All right. I don't know if that's, you know, that's useful information. I think it is useful information. As soon as we do an MRI, we actually get more believe it or not, so I don't want to knock MRI, we do an MRI, there's almost 15 more that we're going to get, as opposed to the eight or nine. But why don't we just do MRI on everybody? Right? At that point? Well, it turns out that with the MRI, you know, all the ones that we're going to be biopsing because we think these things are positive, right? The false positive rate, so there's a 20 to 25% chance that the one that we're going to do isn't it is not breast cancer. Whereas with MBI, there is about a six to six to six and a half to 8% chance that it's not going to be cancer. So much, much less. Okay.

18:12 
Thank you that that makes sense.

18:15 
I do think those are significant.--And also your story was interesting that you said that you had the lobular right. So when I first when we first got this machine A few years ago, one of my first patients that I had, I worked very closely with several other breast surgeons, and he called me he said, I want to send somebody over to your office. He's like, Can you see her you know? And can you do that MBI thing that you just got? And I was like, yeah, we can look and we can, you know, get ready. So we'll schedule her for doing this. And basically, her complaint was that she felt that she had heaviness in one breast. One breast felt heavier than the other. And she went to several other, you know, radiology centers, and basically she had mammograms and they told her everything was fine, right. And she was convinced that she had some things She went to the breast surgeon and he said, You know what? She's right. He goes, one breast feels heavier than the other. And maybe it's just that it's asymmetric but he said, you know, and it looks like there's just more tissue on one side. Maybe he said, could you do this thing? We did it, that entire breast was so hot. You know, and when we saw that, I said, Let's now go back and review the mammogram and do a targeted ultrasound of the area. That looks hot, but it's the whole breast pretty much right. Well, and when we did, I said, you know, it's not a mass, it's just the shadowy area. It's like these shadow areas. And I said, okay, we're going to biopsy the shadowy areas and it became invasive lobular. Right.

19:37 
Yeah. Can you explain to the people listening, why that show why lobular would show up on an MBI and not want it not an ultrasound or an or a mammogram?

19:50 
Right it lobular is very tricky, as you alluded to, because lobular grows in sheets, okay, so when we do a mammogram, right, we're looking at things, something in one plane, we look at it like straight on, and then we look at it at an angle, right? So because it's growing in sheets, if if you're catching it in the, if like in in the plane that it's growing in, right, it's gonna learn nothing, you're not gonna see it. It's only when you tilt it and put it into certain planes that you may see something. And because we're radiologists, we always think you have to see it in two plains to actually think that it's real. So that's what you want. You want to see things in two planes. Right, but lobular so the one that you know, is tricky like that,

20:33 
Right, right.

20:35 
What percentage? I'm not sure if you know this information and I don’t mean to catch you off guard either. Do you know what percentage of women either you Dr. Ha or Leslie have lobular breast cancer?

20:46 
I don't know offhand. It's not one of the more common forms though.

20:50 
I'm going to say I've read 10% and I've read 10 to 15%. So it’s somewhere in there. Yeah, the duct doll is certainly much. That's the one that forms a lot. And that's what we are told to feel for. When we talk about these, you know, manual exams or self exam. Yeah, but lobular does not form a lump, usually. Yeah, usually, yes, you have to be we have to really know what you're doing in order to be able to feel it.

21:24 
And it's also amazing to me how many times you know, I give talks at the local high schools. And, you know, you ask women, it's like, do you do your self exam? And they're basically like, yeah, we kind of do it, but we don't know. It's like, nobody's ever gone over it with us to see what it is exactly that we're feeling for. So I do a little thing where I let them feel the tip of their nose and then I let them feel like the little clavicle bone here. And I say things that are fixed like this clavicle bone here doesn't move right and it feels very hard as opposed to like the tip of your nose that feels a little rubbery. The rubbery things usually are okay, it's when you start feeling things out. are hard and that they kind of don't want to move and you can't move them around. That's really when you have to be more worried. And they said, Wow, this, we never, you know, we've never heard that. And, you know, then you hear about, like, Oh, you should be going in a circle to figure out, you know, feel every piece. I don't believe in that either. I think that the whole idea is to make sure that your palpating the entire breast, and if it means that you're going up and down and sideways, sideways, you know, could do it in the shower, use soap so that's a little slippery. So you really actually can feel things. The most important thing is that you do it on a regular basis so that you will be able to detect any interval change. So you really have a good idea of what your breast feels like. I think I jumped the gun a little bit. So I actually, you know, maybe people may not know what molecular breast imaging actually is. Right? So, you know, most people know what a mammogram is, right? So a mammogram. It's an x-ray. It's an x-ray of your breast and the way that we acquire these images are we squeeze the Rest along the horizon. So from top to bottom, all right, and it's, you know, it's a pretty decent compression, it's about 20 pounds or so. And people don't like it, right, and then we take the x-ray, and we look at those images. And then we also take another one called medial lateral oblique, which is at a 45 degree angle, and it's compressed this way, and we take those images. And again, it's an x-ray, molecular breast imaging is a little bit different. we acquire the images in the same plane. So the horizontal plane and another 45 degree, molecular breast imaging, the way that this works is we inject you with a radioactive material called technetium. And, you know, as soon as I say that people kind of freak out a little bit. They say, Oh, my God, you're injecting me with radiation. But the fact is that it's a very, very low dose. It's extremely safe. The dose that we use is the same dose that you get for if you were to have a cardiac stress test, right but they not the it's the the resting portion of it. Which is like the first portion, very, very small dose. If you want to have an idea of what exactly is this amount of radiation, it is the background radiation of living in the United most parts of the United States for the course of an entire year. So it's it's not that much. It's very small, you know, that we, if I were sitting next to you right now, right, you would be receiving radiation from me. People don't realize that but that's the way it is, right? It's just like it's a one year's worth of background radiation. It's very small. And in terms of the safety of technetium, it's been around forever. It's what we use for cardiac stress test. it you know, we inject it and then it goes away, you you basically pass it out of your body, it's not something that stays in there. The detectors that we use are much better than the way they used to be. And that's really why this is such a great modality. Now in the past the detectors more insulin sensitive, so you would have to use so much technetium that it really you know, outweigh the bad Benefits and now we can use a very small dose because the detectors are so much better. And you know, they're always working on improving even more.

25:08 
What exactly are they detecting? Is it like the activity of the cells or the? What's the?

25:15 
It's actually gamma rays, believe it or not, okay? It's a gamma camera. And you know, so what what it does is things that are active things, tissues, that's active tissue that's dividing more rapidly, like cancer, right will take up the radiate radioactive material more than the regular normal tissue. And that's how we're able to detect what area is more is hotter, let's say right? But the problem is that women who are before premenstrual I mean pre menopausal pre menopausal women, depending on where they're in their cycle, can have active tissue and you know that because we've all experienced it Right, right. You we all know what you know, we all knew when we were going to get our periods because everybody was knocking into our breasts. Because they were in gorge and they were sensitive, so same thing. So we try not to image you during that period we try to image you when your breast is a little quieter. If you're postmenopausal. It's not It's not an issue.

26:13 
Can you explain what it's like to get the test?

26:17 
So the way that we do it is you come into a room and we sit you in a chair, if you want to stand you can. And basically, as I said, it's like compression, okay, it's about 10 pounds of compression. And it really is just compression to hold the breast in place so that it doesn't slip around that we can acquire these images. And it takes about seven minutes per image. So we do two cc's and two mlo. So that's about 28 minutes, oftentimes will give you a warm blanket so that it will help the circulation. It helps you may get some aroma therapy and basically we put you in there with two televisions so you could watch the HSN network while you're getting your study and then that's really pretty much it. It's pretty easy. When you come in obviously we will inject you with this technetium  with tiny little needle.

27:09 
Woods. That was your experience.

27:11 
I never got one. Oh, you never got one. Okay. No, I went to Mayo Clinic and you know, they they, we were already on the track. So--Right, right.--Yeah. If I wasn't in a screening program there it was for.

27:27 
You already there for your diagnostic. Yeah.

27:30 
Yeah. And so that's why I was interested to ask you that because, you know.

27:37 
Anytime you want to come and visit us, oh, yeah. more than welcome. I'd like to show it to you. Yeah. Great.

27:44 
Nice. And I haven't heard of this until Leslie, you started telling me all about it. And I was like, Oh my gosh, there's like more technology and so much to keep up on. So this is really great to be able to kind of take a deeper dive into exactly what the MBI is and what people can expect when they're going through. screening. You mentioned that your clinic is the only one in the state of New York that offers this type of screening. And this type of study for for people, and how widespread or I guess in this case, like not widespread is this technology.

28:16 
There really aren't that many units. I think that there are maybe 50 units out the country right now or something like that. Maybe less. You know, we run into several little hiccups, so to speak. The main issue being that the insurance companies don't want to reimburse it. You know, they will reimburse and there are certain insurance companies that actually always reimburse and, you know, we keep a little chart together of who are the ones who always say yes, and who are the ones who almost always say no, you know, if you have Medicare, Medicare, automatically, everybody gets approved. A lot of these other places they'll approve you if you have the doctor, calling But that can be a problem because you know, you have to call you, they put you on the phone, and you're literally on hold for about half an hour. And so you know, there's really just isn't enough manpower to do that, I guess. We haven't. Very great, we have a good program because we work with a surgeon and he actually has a navigator who gets on the phone and will say, this is Dr. so and so's office, and she'll stay on hold until somebody comes, at which point he'll stop doing what he's doing. And he gets on the phone and he tells them what's going on. And almost, you know, we're very good at getting the approval. So.

29:34 
That's really good. I remember the first time that knock on wood first and only time that I got a letter from my insurance company telling me I was not approved for a particular chemotherapy drug. And I was livid because, you know, you put so much trust in your oncology team that you know, this is going to be part of like that plan. And I remember going in for my like weekly checkups and I brought in my paperwork and he's like, Oh, don't worry, we called them were taken care. You can ignore that letter. But you're right is there's a lot of behind the scenes administrative, you know, back and forth and man hours that you're mentioning that go into a lot of this treatment and an access and access with regards to where this technology is, and then also access in terms of finance.

30:18 
Right. So I think so insurance Sure, certainly is one of the main issues that we have. But I think that it's even more multifaceted in some ways of why this technology isn't being adopted so quickly. You know, if you think about I think part of it's, it's everybody has a little role to play, let's say, you know, from the radiology point of view, this is the people who are doing the mammograms usually all they do is mammogram, I'm a little bit different, because I do other modalities that I actually do neuroradiology also, which means that I'm very comfortable looking at CTS and MRIs and you know, I'm not I like doing other modalities, so I do the mammograms, I do the breast MRI I do ultrasound. And when this came up, I said, Sure, it's like, I can definitely do this. But they're like, but it's nuclear medicine. And, you know, people who do mama don't want to learn not only a new modality, but it's a completely new type of imaging. It's not like a different type of x-ray, it's a completely different, you know, modality, right? It's not like, it's an x-ray, and we're doing a different type of view. Right. So I think that really is so we get, it's hard. It's gonna take a lot of education to let people know Yes, this is a nuclear medicine study. Really, it's breast imaging. So don't think of it as a different modality. Think of it as a multi-modality approach to a certain problem. And the problem is breast cancer screening.

31:44 
Yes,I love that multi modality. I use interdisciplinary all the time, but I'm gonna start using multi-mode modality. That's a great one.

31:49 
Yeah. I think that's the best, you know, we have to use every tool that we have.

31:54 
Yes. So, um, Leslie I don't know if you've had this experience. I know that there's a lot of legislation still trying to get passed to require various states in the United States to give women a letter if they do have dense tissue. And, you know, it still blows my mind that this isn't like a requirement across all of the states. But I know in terms of like the advocacy sector for breast cancer, you know, there's a lot of momentum to try and get this law passed in all 50 states. And I think last time I was reading a statistic, it was at 38. I don't know since like the last couple of months if it went up, hopefully it did. And but about 38 states for the last time I was reading about it, were required by law for the radiologist team to give some sort of letter and notify the patient, that they have dense tissue, what continues to baffle me and again, an area for advocacy that we're trying to just make aware and act on is that there's not a standard either of what degree this letter has to inform the patient about what their options are, right? So you could have some states that say, you have dense tissue, and here are the things that you should do next or what you should take into consideration. And then there's some states that literally just give you a letter and you know, it could be very vague and there's no direction or, like follow up. It's really just this my requirement. Here's your letter. I'll see you next year. Can you speak a little bit about like, I just feel like talking about dense tissue in general is such a, I mean, we could talk for hours about it. I think it's, it's very complex. And the more that I'm speaking with women who have been diagnosed and with radiologists, my own understanding and research, you know, I'm trying to make sense of all of the, the statistics out there and we advocate for early screening and early detection. And someone brought to my attention that you know, the mammography in its traditional sense of just like, yeah, the traditional mammogram is only as good as like a percentage of how dense your tissue is. Yes. And so I would love for you to like elaborate a little bit on that because, well, I said this right now to talk to you about it. It's very, it's complex right to understand these ratios and you know, you go in for your mammograms in less than your point like a couple months ago prior, you had clear mammograms. So, you know, it's it's unsettling.

34:07 
Let me see. I don't know if this is going to project for you, but let me actually do a little talk. And let me see if I can show you this. So basically, can you see this? I took this from Wendy but you know, it's the when it's Wendy Bergsaw's image, right basically. So you can see that the the one over here, this is a fatty breast. Okay. And you see it's very dark. And this one is a dense breast. Hmm. Okay. So the difference is, the denser you are the whiter the breast gets, right? Well, it turns out that breast cancer is white. Right? So if you're looking for something that's white, in a background that's completely white, you can imagine that this is very challenging task. Right? Whereas if something is basically dark, and you're looking for something white, that's much easier, right? So That's the first point. The other point is if you think about this at the most basic level, right? your breast is basically made up of fatty tissue and glandular tissue because it's an organ that makes milk so that's going to be a portion of it that's fatty and then this portion that makes the milk, the glandular tissue. Well, it turns out breast cancer is not going to you're not going to get a fatty breast cancer, right? The fats not going to convert into some kind of a tumor like it can, you know, this like liposarcomas, and things like that. But we were talking about breast cancer. So these are things that are really arising from the glandular elements. So if you have more glandular element, you know, you actually are going to have an increased risk because there's more of it. Right? That's really at the most basic level. That and this is really with that realization. I think this is when everybody said we have to have supplement this just doing a mammogram alone is not sufficient. We must have supplemental screening. So it's not it's not a diagnostic test at that point. It's an added layer of screening. So people who have dense breast should have this added layer of screening. And then in terms of detection of cancers, as the density increases, this is part of the studies that Volpara has done the Volpara people, right? When they looked at it, they said that, you know, when the breast tissue is fatty or scattered fiber glandular, the detection rates pretty good, but somewhere in the middle of the heterogeneously dense group, right, so they're like, greater than 50, less than 75%. That area, it's when it's really in there somewhere that the, the in terms of the consistency of picking up small lesions really drops off, because we just can't see it. You know, so in some ways you think about it. Yes, it's a seeing eye test, but should it really be a seeing eye test it shouldn't be right? That's really not fair. You know, and that's really why MBA is so great. I have a great story for you. So we had a woman who came in, she was seen outside. Her dermatologist saw her and they saw a lump. And she said, Oh, did you know you have this lump? She said, No, I didn't notice that this lump. What is this lump? So then they examined her and she had a lump in her armpit also. So they said, Oh, this is really weird of a lump in your armpit. You have something like over here. So they went up by up seeing the lump in her armpit. And it came back metastatic cancer, probably breast. Well, she just had her mammogram a few months ago. Right and she had fatty breasts, how about that?--Wow.--So is it okay, this is really crazy, right? They said How could she have breast cancer and she had mammograms for over five years beyond that, that the mammogram hadn't changed. They brought me the mammograms I looked at them. They were not changed. It's not like we missed anything. Nobody missed anything. There was nothing there pretty much it had not changed. So the surgeon called me and said, oh, I saw you did talk. Do you think that you know, you this MBI could help you because we have this metastatic breast cancer and a fatty breast. And we have no idea where this is coming from. I said, you know, sure, but I said, maybe we'll try it. But she'll said, oh, by the way, she was she had a PET scan that only was hot in the armpit. Nothing in the breast showed up. So I thought, well, you know, we could still do it because the PET scans a big body scan, and this is really targeted study for your breast. So sure enough, we do the study. And there's a tiny little area that's hot. I mean, it's a little specie area that's hot on The MBI. But it happened to be in the breast that had the lymph node. Okay, so now we have to go back and look at the mammogram, go back and look at the mammogram, do a targeted ultrasound of the area, and the only thing that I can find is she has this small cluster of calcifications that hasn't changed in five years. Wow. You know who biopsies these things like you don't? So I said, Well, you know what I said? This is All I see here, oh, maybe we should biopsy this? And she said absolutely. We biopsied. That was her primary. Primary. Yep. And he had already gone to our lymph node. So the tiny little cluster, hard to believe, right? But that's where MBI you know, not not only just for screening things, but it really is a powerful adjunct to diagnosing, it's a powerful tool that we can use to help us diagnose and to problem solve difficult cases. I think that's really my favorite way to use it, you know?

39:31 
So yeah, it's almost like finding like the scavenger hunt backwards, right. Yeah, exactly. advanced stage and trying to figure out its origin. Yeah, I am definitely going to recommend you and MBI to a really good dear friend of mine who unfortunately also got diagnosed at stage four. And to this date, it has not been traced back to her breast. She ended up keeping her breast she didn't because she was already metastatic and I think with all her stickers, leanings and mammography scans and CAT scans, PET scans, etc. To date, so my understanding is that there is just no, it's not in her breast. It's pretty much everywhere else in her body, unfortunately. And so that would be very interesting. I think from.

40:14 
That would actually be a really interesting case. Ah, yeah, absolutely. So she's still metastatic--Yes.--But they don't have a primary on her breast breast for sure.

40:24 
Unless that's why I was asking you some of those questions too, like when they did the bone biopsy. And because for this particular woman, she was very similar. They did a bone biopsy. And they didn't know what it was. They were like, well, and she was, yeah, what type of news is that right, you, you're worried and then your doctors like, well, we don't know. And you start to realize that medicine is not a perfect science, and then it's all these like, investigative you know, trying to find what is that? So you know, I, I can empathize with that experience that you went through as well with, you know, is it one thing is another thing, you do all these tests and you're just kind of waiting.

41:00 
Yeah, it's a harrowing experience. Um, you know to have it that way. But something that Dr. Ha alluded to a couple minutes ago I I've had this thought for a while that it feels like to me really tough on the radiologist to have to have to find things in the in a pictures that are just all cloudy like that that seems I mean seems unfair to me almost expect them to see something that's not really seeable.

41:43 
That's what that's why I said it. I don't think that this should have to be a seeing eye test, you know, on many levels, but it is you know what I'm saying? And from my point of view, this is my job. Okay, my job. My only job is to find breast cancer when I'm looking at these mammograms when I'm looking at breasts. My only job is to find breast cancer. And if it means that I, you know, I'm whatever I need to do. So that's really why like, I feel like I need to know what what's your history, I need to know, you know, if I see that you have a very high risk, right, and I just don't see anything and I'm sure that, you know, I feel like you're going to get breast cancer at some point, you can bet your you know, but that I'm, I'm gonna, I'm gonna do everything that I need to do to make sure that it's not there when I look. And that if it pops up between the time that I see you today, and the next time that you come that I'm going to catch it at the earliest point, I mean, this is the best that we can do. But I have an extra toy that nobody else has, and you know, I use it. And it helps me you know, so I think that when people see that it really is helpful when we get this information out to people. When doctors see how helpful it is when patients realize that there's something else that they can use, and they basically say listen I want this test. I think that you know, with education that we will get better.

43:06 
Right? So my experience has been so far, because some people know about it because I took this walk to raise money for the, you know, for the density matter study at the Mayo Clinic, etc. And so they know my story and they'll ask their doctor. Um, what about this molecular breast imaging test? Because I have dense breasts. And usually the response is oh, I've never heard of that.

43:34 
Correct.

43:35 
So then what can the woman say? So, you know, like, Well, how do we then move on from that?

43:46 
Mm hmm. Okay, so basically, what one of the things that you could do is, there is a website that I think has a list of all of the centers that are currently have molecular breast imaging. Okay. All right. So you can look at that website and say listen in my state, I see that this is where it is and say, this is where I want to go. at our hospital, the patients can actually pay out of pocket if they want. And what we've done is we basically bare bones, you know, as low as we can go as low as I can get the administration to agree to, and that's what it is. That's what we charge. I think that it's reasonable. It's a significantly less than getting an MRI. Most people can afford it. I have other things that are available to me that if you weren't really are somebody who needs it, who doesn't have it, I have grants that you know, will cover you and things like that. So that's how we do it here. But I think that really it is it's terrible, but the onus is on the patient that if you know that you want this thing you have to push, you know, and if your doctor doesn't know about it, you know, call them out on it, and say listen, I need you to research this and I want to get done. I think the main thing is, you know, if you, if you push and say, Listen, I would like to get this done. And if you don't have this available, I'm going to take my things and I'm going to go where they have it right. You know, it's really it's always about hitting people in the pocket. You know, it's terrible, but I think that really does drive a lot of things. I think that's one of the reasons why everybody likes doing MRI, right. And MRI on average, I think the Medicare reimbursement rate for an MRI is like over $1,000, the MBI I think reimburses at about $400. So if you're an institution, I think that you'd much rather do the thousand. I mean, this sounds terrible. And I I don't know that this is true, but I you know, you can kind of read between the lines, I guess, if you can get paid $1,000 for something as opposed to $400 which one are you going to do? You know, and it's and it's certainly especially since the thousand dollar thing is the one that gets reimbursed. You know, all the insurance companies are agreeing to pay for that.

45:58 
About that though is that not only is that not just for the highest risk people.

46:05 
The MRI, it is it is for the highest risk people. Yes. Oh, I like to use it sparingly.

46:12 
Yeah. So I'll take myself as an example. I would I never qualified, I would never have qualified for an MRI.

46:20 
Correct. You would have had to pay out of pocket.

46:22 
Risk. And isn't that true of over half of the breast cancers anyway? Is that?

46:34 
Yeah, absolutely.--About 75% or something.

46:37 
Most breast cancers. It's, uh, you know, you're the first one who has it. It's like, yes, if you have a family member who has breast cancer, you are more at risk, right. But by and large, most of the breast cancers that we detect are with no family history.--Yeah.--Right.--Mm hmm.--You know, and the, I think the other really important thing that we kind of didn't discuss right now. is we talked about your family history, we talked about that sheet that you have to fill out. We talked about your breast density. And I think that the next thing that I actually want to do that I think is very important is genetic genomic testing. Right? I think that genomic testing is going to become a really important thing. And what I'd really love to see is that when you come in, that basically you are offered genomic testing, you know, you come for your mantle, and part of the screening should be that you should be screened genomic, you know, your gene should be screened. And if you have like these variants, or if you have these genes, right, Well, hello, it's, you know, we need to put you in a different category, we need to be a little more aggressive with you as well. We're talking about BRCA. Yes, but BRCA was just, you know, one of the things BRCA is the one that we all hear about, but there are so many others and everyday we're finding more and more things. I mean, there are so they actually found that young women who develop breast cancer after a pregnancy, right, there's actually a variant in the gene that you know, they're finding that more and more common with that. So if you know that you have that, you know, maybe you need to be a little more careful, you know, be very, yeah. If you have a kid that you know you have that gene, then you really need to screen yourself carefully afterwards. Wow.

48:11 
Yeah. There's a lot out there.

48:14 
There's so much out there. There's so much information. It's really hard to keep up.

48:18 
Yeah, yeah, we just have to get it out there and get it used by everybody in the population to really make a dent in what's going on. Right?

48:27 
Exactly. I think this information, like, I get goosebumps every time I have these podcasts and talk with amazing women like both of you, because like you're always learning something new. And it takes time again and again and again, to hear the same content. And what I'm so excited about, related, unrelated, but just to share one of our one of our colleagues, I just did an interview with on just this topic of genomic studies and the whole discussion around you know, precision medicine and you know, genomic testing and trying to really figure out that like specialized medicine, or specialized screening as we started off this conversation was, we are very individual. And, you know, there's all of these factors that play into a potential outcome. So I think that just has to be stressed. I also want to stress to our listeners, the importance that you've been stressing Dr. Ha, of knowing your family history, I unfortunately fell in the cat category of not knowing my family history, mainly because of, it's not something my family talked about. It was very close to the vest. It wasn't something people bragged about. It wasn't something we knew, like aunts and uncles. It was like, we're good. Everything's good. So when I moved to Boston, and I had to find a new primary care, she's like, so what do you have your family history? Like? I think I'm fine. Like, I don't know, maybe like high blood pressure, maybe. Right? Yeah. And it wasn't until post diagnosis. My mom flies out from Chicago. We go meet with a genetic counselor and oh my gosh, like the little gene tree of like, what everybody had was you know, quite, quite telling, but I think she has a story because I didn't know how important that piece was in the puzzle. And I did not test positive for any of the eight genes that I got screamed for. So unfortunately, fortunately, unfortunately, there's no family connection in that regard. And so like, Oh, good, that's great. I don't care the T but wait sporadic and so like, how did I get this? And so it's just I want to let people know to like understanding that family health component can really make a difference, whether it's breast cancer or any sort of, you know, disease, and illness.

50:35 
Right, right. Because there are other cancers that are associated with breast cancer. And again, I said, you know, the time that you had your first period can affect your risk. The age of your first pregnancy can affect your risk. Yeah.

50:51 
The longer the more over

50:56 
Over 30 if your first if your first child is over 30 and I'm like this day and age who has a kid for 30? I certainly didn't. Yeah, yeah. Crazy, right? So we asked you that question and people will get annoyed or not having children also increases your risk.

51:15 
So you either have children or you don't have children. There's a certain age.

51:18 
Yeah, did all these things, all these things play a factor? And you know, it's like, we really aren't trying to be nosy, but really trying to figure out what your risk is. I changed. I changed that questionnaire. It used to say, breast history. And now I told them, I said, change this thing, and I make it really bold and big. And it says breast cancer risk assessment. Yeah, so it's like heads up, ladies. It's like, you know, we're not being nosy.

51:44 
And is breast density, part of that risk? Or is that a separate.

51:48 
Yeah, breast density is part of the risk. Yes, that's, that's why I said you know, when you come in, I look to see what your density is. I don't do it. With my eyeballs. I do it with the machine. Volpara is excellent. All the studies. On breast density, many of the studies have used that software in particular, some of the other companies are, you know, using different things, but this that's the one they use, I really like it. And I'm not saying that because you know, I have no connection to them or anything like that. I just happen to think it's really a powerful tool. Okay.

52:19 
Great.

52:22 
Wonderful. Another piece of information that I learned in my research was, you know, how we define risk. I would love to pick your brain and, you know, help our myself and our listeners understand, you know, what qualifies as high risk and I know we’re talking about like, potentially family history and all of this assessment that you're doing. And I bring this up in the context of my own experience when I went for a post treatment post breast cancer, annual screening, not a diagnostic so that helped me understand, you know, the difference in that type of screening. I was going in for a, just a regular screening, and then I'm in Massachusetts and they give me that letter that says I have dense, dense breast press. And I'm like, Okay, great. I got this letter. I'm empowered. I started a non-profit and this podcast, like, I know what to ask next, right? And I'm so excited to say, Okay, I want like, whether it's the ultrasound now I know to ask, investigate and learn about potentially that MBI. And the person I was speaking with, told me that I was not high risk. And I was totally shocked to find out that someone with breast cancer is at high risk for recurrence.

53:31 
You are actually high risk. Oh, and once you have a history of breast cancer, so there are certain things so one of the things that I always look for is, you know, you have women who come in and they've had biopsies, right. And I see you know, they've had biopsies right and then I'll say, oh, this you had a biopsy, but that looks like there's little scar tissue there. It looks like there's a little distortion here. And I'll say like, did you have her have a surgical biopsy like an excisional biopsy, not a lumpectomy and excisional biopsy right. They say yes, I had an excisional biopsy. It's not it's not cancer, everything was fine. But then I'll go back and say, okay, so you actually had a needle biopsy, the needle biopsy must have shown something that said, hey, listen, you know what? It was either an intraductal papilloma, it was a radial scar. It could have been what we call ADH, a typical dihyperplasia or a typical lobular hyperplasia. If it's one of those two or the latter, if it's one of the a typical, you know, lobular or ductal hypo, that actually is a high risk lesion. Okay. intraductal papillomas, you know, the jury's still thinking about you know, we're still thinking like, we're not really sure yet but I will tell you that if you have an intraductal papilloma, most surgeons will take them out. All right, that an intraductal papilloma is like it's like a wart in your dock. Right. It's like a wart. It's you know, papilloma virus, right. And even though that in itself is in cancer it we're not sure if it predisposes us to cancer. Or if it's going to be in areas that may have cancer. So that's why we take those out. You know, so if I see that you had surgery after a biopsy, right, I always question you, and I'll say specifically, did you have atypical duct hyperplasia or atypical lobular hyperplasia? Because if you have either one of those things you are put into the high risk category right away. Okay. The other thing is, once you have breast cancer, right, and you have a diagnosis of breast cancer, the protocol that I use, is I want to see you back every six months for the side that has the breast cancer, okay, and you're going to get a mammogram and ultrasound and whatever else I need to do to figure out what's going on with that breast, okay, so you will have a diagnostic and your diagnostic for five years. You've diagnostic imaging for five years after that, from the time that we diagnose, you know, from the time that you have your surgery and that you're diagnosed. So you'll come in six months, you'll come out to the side that has the breast cancer, or had the breast cancer you come in another six months, I'll do that side of the deck, and then we'll screen the other side. Six months later, we'll do the side with the breast cancer and this will go on for five years. Okay, once you're clear for five years now you get thrown back into gen pop, right? You're back to the screening program, but you are no longer a regular screening for the rest of your life because you had that breast cancer. In my book, you were always a high risk screening. Okay, so you will be a high risk screening for me for eternity. So anytime you come in, I know that you had that history, your High Risk Screening and you're going to get extra. But I mean, extra, not in terms of I'm not doing extra views on you, you know what I'm saying? But you're gonna have extra layers ups. So you only have supplemental screening, either in the form of ultra mostly ultrasound or MBI.

56:50 
Yes, that makes sense. And is that particular to you in your practice in your screening after a diagnostic?

56:58 
It's actually a recommendation that That's kind of like an ACR thing. I mean, that's really a recommendation they say you should, you know. Yeah.

57:05 
That's really great to know again, another moment of empowerment.

57:08 
A lot ma many places do it that way.

57:11 
I'm just curious why you think it is, is I do a lot of reading on the internet and what all these organizations recommend for supplemental screening and under what conditions and first of all, I know that they differ in their recommendations. And then they almost always just mentioned ultrasound or MRI. And yet, there's this other modality that is out there that's been FDA approved for a long time and I'm just I'm it confuses me. And I was so surprised to learn about it really, just by accident at the Mayo Clinic. I like I said we never had it so I'm just curious about that. Why do you think that is?

57:56 
I think it's people are, nobody likes change. You know, people are comfortable with what they're comfortable with. When you ask it's and it's really like part of it has to be that the radiologists who are doing the study has to say, hey, I need this thing. You know, but if the radiologist is saying like, you know, what I, what I'm working with is enough, I don't really need anything new, then it's never going to be something that the hospital is going to be interested in purchasing. You know, a lot of the clinicians are depending on what the doctor who's looking at the study is saying, This is what I need to make a diagnosis. And if they tell you, you know, I'm doing the mammogram, I’m doing the ultrasound, it's good enough, then there's no information out there to say that there's something extra. So I guess a big portion of this is that we have to educate radiologists a little bit more to say, Listen, this is we're not saying that what you're, what you're doing is insufficient. You know, we're saying you're doing a good job. It's like we don't want people to think that oh my gosh, you know, you're not doing a good job. You're doing an excellent job. But hey, wouldn't it be so much better to have something to make you better You could do an extra, you could do something extra.--Right? Right--I think that's really what it is. It's really all about education.

59:09 
Right. And how does that happen? Like, how do radiologists get educated on new things? How does that work?

59:21 
I think that's so what happens a lot of times is my experience has been and what I've always advocated for is, you know, what the cases that nobody else wants to do. You know, that it really, it's just like, I don't know what to do with this case. It's like, let me do those cases for you. You know, and if I can prove to you that this is working, you know, prove it to you once, okay, prove it to you twice, prove it to you three times. And at that point, maybe you'll say, you know what, I think there's something to this. So it's, it's a really slow procedure. It's a slow process, but we just have to keep at it. Yeah, you know, there are lots of things are like this. You know, Even in the course of my time as radiology, there was a time when anybody who we thought we had it, they had a kidney stone, believe it or not, we would inject them with IV contrast and do what was called an IVP. Nobody even knows what that is anymore. Because we don't do it, you get a CAT scan, you see the stone and you're done, you know, but in order to get from bad to getting a CT, it was insane. My nephew had, as a kid had it renal stone, and they said, No, it can't be reenlist on his a kid. And I said, Can you do the CT? You know, and they said, No, we're not going to do it. Finally, they did it. They found the stone, you know, but only because I was the radiologist. And you know, we insisted that this was done. Now, this is what's done all the time. You know, so changes really difficult and changes slow, right?

1:00:47 
Okay, you hear that with breast cancer too, right? Like, oh, it can't be breast cancer. You're too young or exactly how you don't have a family history. Like Well, you don't need a family history to have breast cancer. I mean, right. Again, it's just one of those other factors from The risk factor.

1:01:01
Women's imaging review course at the Mayo Clinic is putting on in, I think it's December--December--MBI breakout session. So this is what we were just talking about, right? This is all radiologists, if they're if they're at this event could learn more about this modality at this breakout session.

1:01:18 
Everybody's fascinated by it when they hear the lectures. I hope that a lot of people go to this. I'm certainly going to try to go there I know it's a half day. Mm hmm. Yeah. So I'm going to try to sneak out of dodge and get over there.

1:01:31 
And, you know, just tell all your radiologists friends, but this is in Naples, Florida. Yeah. In December.

1:01:39 
I know as the other day we have one of the women that I work with my other radio, you know, the other member, she's actually going to be there. She's going great.

1:01:47 
Great. Yeah. Yeah. So I think that's, you know, one way that I know that doctors have you know, continuing education is not the word they use. I'm sure it is.

1:01:58 
It is. Yeah, continuing medical education.

1:02:02 
All right, great. I do have a question for you just in concise words. What is the recommendation that Laura I'm doing this really for your organization because everybody is a survivor or thriver. So for the for your audience specifically, what would you recommend that they do in terms of screening for themselves, given the fact that they are survivors? What is the two sentence takeaway that they should take about their screening, given that they have had breast cancer before?

1:02:42 
Five years out? You are High-Risk Screening, okay. Or High-Risk Screening. So mammogram, sonogram, MRI, or MBI. Okay.

1:02:54 
All right. And some of that differentiating between those have to do with your density.

1:03:03 
No, if you were high risk, I want to see you getting everything, everything. Okay, I want you know, maybe you can forego the sonogram. Okay, sometimes sono, you know, with the fatty breast sono was difficult to find things, you know, okay, believe it or not, sono is not great for fatty breasts you know, so I like to target. So if you have fatty breasts, and if you have a fatty breast, instead of doing a ultrasound of the entire breast, I am much more likely to do a targeted ultrasound in any areas that may have areas of dense tissue, rather than to screen the whole thing like that, because it's really difficult. It's difficult. It's it's difficult, laborious for the techs and you know, you don't, again, like I said, it's not a seeing eye test for me. We also don't want to set a punishment for them that they're sitting there, you know, scanning through a triple D breast that's all fatty. They're not gonna find anything unless I tell them listen, I need you to go five o'clock, you know, go about to the pants from the nipple, and you're going to just scan that area like crazy.

1:04:07 
Okay, all right. Okay, that's great to know is that I'm not sure that that's widely known. What do you think, Laura, that you are absolutely high risk after?

1:04:19 
Yes. I mean, it's always in the back of our minds. Right. And--it makes sense.--Yes, it completely does. And yeah, I'm so glad you asked this question. Because, you know, I, there's good days and bad days, I think for us, right, where, you know, we're, we're grateful to be alive. And we went through this rigorous treatment, and we're here. And then there's some days where just even very recently, I'm going to be celebrating my three year survivorship, like, in a couple of weeks. So for my date of diagnosis, and, you know, it's almost surreal that like, I'm technically healthy, like, you know, we feel like we've been sick and going through treatment for so long that it's it's hard to embrace, kind of this new like, No, it's okay. You really do just have allergies. It's not a symptom of cancer like, thanks to clarity, you're gonna be fine you know or I had a tickle in my throat and I was like oh my gosh, I think I need like a chest x-ray like something's just not right. And to your example also Dr. Hot when you know you're talking, I'm sure everyone's situation is slightly different, of course, but you know if the breast cancer has traveled to one of the lymph nodes, and I guess the terminology is a little confusing to you, right? Like, technically it has metastasized outside of like the the local breast area codes, but it's not necessarily classified as stage four, if I'm saying this correctly. And so what keeps me up at night is I'm going in for what's going to be my six months every six months for five years screening and but what if they don't find it in my breasts, like, should we be advocating for CT scans or other type of screenings in the future? Outside of just waiting for a symptom or something that right to show up to say, Do I think I have bone pain in my femur or I think I'm having like severe headaches. And then for them just, you know, all of a sudden I feel like we're just waiting to be diagnosed with a later stage.

1:06:18 
I think I'll some of the places if they know that you have metastatic bone, or you have metastatic disease, they will screen you they'll screen you, I think annually with the PET scan, I don't know that you could. So there are things that you can do, you can get a pet to make sure that there's nothing going on also. So that's, you know, that's another level of screening. One of the things I always tell my patients and it's really getting a diagnosis of breast cancer is can be though is devastating, right? But you know, once you have your lumpectomy, once you go through treatment, and they come back with their six month, I tell them I said Listen, I said so had breast cancer, right? And what that means is now you're going to come and see me every six months. We're going to check you every six months, think of it this way think of breast cancer as that your disease? Okay? I could have told you that day that you had diabetes, right? And if you would said, I'm going to ignore it, I'm not going to check my diabetes, I'm not going to check my blood sugar. You know, your blood sugar could go off the chart, and you could wind up having to have like a toe cut off. You know, people wind up having amputated legs, you know? So if you think of it that way, those people have to check how many times a day do you have to check your disease at that point multiple times, right? With the breast cancer? Yes, this is your disease, you know, you're going to check this and you're going to stay on top of it. My job is to make sure that you keep coming, and that if anything happens that I'm going to catch it for you. You know, but I can't do it alone. It's like we are a team. Yes, we're a team.

1:07:50 
Yeah. I love that. I love that. I'm smiling over here. All right, we got we got like you're ever hitting on one end. we're advocating on the other end. We're coming together we’re. Yes. We take care of ourselves together.

1:08:01 
Yep. We're women. We're strong. And I always tell them I said you could do this. I said, you know, you can do this women are strong.

1:08:10 
Yeah, I agree with that.

1:08:12 
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