MedEvidence! Truth Behind the Data
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MedEvidence! Truth Behind the Data
Looking Into Breast Imaging, Part 2 Ep. 325
Radiologist Sue Jane Grosso-Rivas, MD joins cardiologist and clinical researcher Michael J. Koren, MD for Part Two of her Master's Series on breast imaging.
Dr. Grosso-Rivas talks about some of the complications that can occur during imaging, including dense breasts and their surprising prevalence. She also talks about new technologies in the imaging world, including contrast mammography and the use of AI in cancer detection. She finishes the conversation by talking about men's mammography and the increase in young-onset breast cancer in some populations.
This is part two of a two-part series.
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Music: Storyblocks - Corporate Inspired
Thank you for listening!
Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts Hosted by cardiologist and top medical researcher, Dr Michael Koren.
Dr. Michael Koren:Hello, I'm Dr. Michael Koren, the executive editor of MedEvidence! And I've been having a fascinating discussion with my colleague from medical school, Sue Jane Grosso-Rivas, and we've been talking about many issues related to breast imaging. This has really been a masterclass and I want to thank Sue Jane again for being part of it. You mentioned the breast density. Does that change the basic recommendations of yearly mammographies or do you go straight to other imaging forms for those type of folks?
Dr. Sue Jane Grosso-Rivas:Yeah, no. What has happened in the past few years is that density has become something that everybody is talking about, right? First it was get your mammogram, get your mammogram. And then it was, oh, get your mammogram. But you also need to know if you have dense breasts, to the point where now there are laws,
Dr. Sue Jane Grosso-Rivas:There are federal laws that exist that say that you must notify patients about this thing called density. What do you communicate? You have to communicate in there because we send lay letters. We send the report to the patient, but they also get something that's called a lay letter and in that letter there is actually a phrase or two that is mandated by the government that says you may have dense breasts. This is what happens with dense breasts. Dense breasts may obscure, so there's a whole phrase that goes into that. So women now need to be notified about this thing called dense breast. And why is that? Because, yes, dense breast can obscure, sometimes a tumor.
Dr. Sue Jane Grosso-Rivas:You know, mammography is pretty good at detecting breast cancer, but when you start going into the dense categories it starts to lower the sensitivity of mammography for breast cancer. So some of those patients may require supplemental screening and we should start with ultrasound first. Right, because ultrasound is another modality and it's been shown that if you do mammography and you add ultrasound, you will pick up some more cancers that you did not pick up by mammography. The next step would be do you have to go to MRI? Right, because MRI is going to. But if a woman has average risk, should you be, should you recommend MRI?
Dr. Sue Jane Grosso-Rivas:MRI is really more for the patient that is either diagnosed with breast cancer or has an increased risk. Most of the women with average risk. You can stop after the ultrasound. Right, you're done. You've done everything you need to do. But as a radiologist, I still maintain the ability to decide what I think that patient needs. So I may look at a mammogram and I may describe what I would call a complex parenchymal pattern, and what I mean by that is that when I look at her breasts, not only is she dense, but I see nodules here, nodules there, like masses, or I see lines. I just see that she's very complex and I know that I feel that that patient really needs to go to MRI next. So the radiologist always maintains the ability to be able to say what needs to be done next.
Dr. Michael Koren:Approximately what percentage of women have this dense breast phenomenon?
Dr. Sue Jane Grosso-Rivas:Well, according to what you know, the lexicon, meaning the American College of Radiology, and they've done a lot of studies about 40% of the population, oh wow. So there are four categories. It's A, B, C, D. A is completely fatty. B is what we call scattered fibroglandular, which is just 25% of this tissue. Right, that becomes kind of white. C and D are heterogeneously dense, which is 75% of the tissue is there and extremely dense is. You know, almost all of it is white. So when they look at this, they say 40% of women have dense breasts. They're in the category C or D.
Dr. Sue Jane Grosso-Rivas:Now I will tell you that certain communities have more dense breasts than other communities. So if you go to certain parts of the country, right, it could be body habitus, some women, you know, when there is some obesity, right, those women tend to have more fatty breasts. And when you have women, you know, maybe in a population where everybody's exercising, they're on hormonal replacement therapy, you know, they're very thin, they watch their weight those women are not going to have as much fat in their breasts. Now, density is determined by genetics. You're either dense or you're not dense. But it also is affected by whether you have hormones, whether you exercise all the time there's no fat, so on and so forth. But it was funny because when I went from Staten Island and came to where I work now, it was complete. I could not believe how many women were dense. So I would say it's not 40%. In my neighborhood, in my community where I am now, I would say 60 to 70% of women are dense.
Dr. Michael Koren:Really, and that's in New. Jersey right
Dr. Sue Jane Grosso-Rivas:Yeah New Jersey.
Dr. Sue Jane Grosso-Rivas:When, of course, sometimes you may have heard New Jersey supposedly has a higher incidence of breast cancer, because that's the other thing. It's like going to different parts of the country you find different incidence of breast cancer and the population in New Jersey is very large; a lot of breast imaging centers in New Jersey.
Dr. Michael Koren:And the epidemiology of breast cancer when I was doing internal medicine was that if you had your first child later in life, you're more likely to get breast cancer. Is that still considered to be accurate?
Dr. Sue Jane Grosso-Rivas:Yes, they still use that and this risk assessment that I told you about. That's some of the questions that they ask. They will say have you had children? When did you have your first child? Right, so if you had your child younger although they say like less than 20 is is most protective, I mean most women are not going to have it at that time. But, um, so what? Also, when did you have your menstruation, your first menstruation? It's like the earlier you had the menstruation, the more risk. Uh, when did you have menopause? The later you have menopause, the more risk. So those questions are all asked in the risk assessment. So that's still all part of it, but the single most important thing is just being a woman and getting older.
Dr. Sue Jane Grosso-Rivas:I mean that's why you need to get checked out.
Dr. Michael Koren:So this is fascinating. I'm loving all this information. Thank you for sharing it. So there's two more things on my mind that I want to cover. One is AI that's what everybody talks about, and the other one is men. We'll make that last, but hopefully not least. So, lets jump into AI, and certainly AI is the buzzword, and it has affected different areas of medicine.
Dr. Michael Koren:I like to tell my staff here that for every incidence of AI I see an incidence of AS artificial stupidity, and I don't know if you want to comment, but we've heard that it is having a big effect in imaging overall and maybe particularly breast imaging. So tell us a little bit about what's happening with AI.
Dr. Sue Jane Grosso-Rivas:Sure, you know, Mike. What's interesting is I met with a colleague the other day and her son happens to be in medical school right now and she's a radiologist. So she thought that radiology would be a wonderful field for her son and her son said no, mom, AI is taking over, I'm not going to go into radiology, I won't have a job.
Dr. Sue Jane Grosso-Rivas:So very interesting for me to hear that that is what they are possibly hearing right At that stage of medical school where it's affecting whether people go into radiology or not, because they're so concerned that AI is going to take over. So artificial intelligence, right, what is it doing? Well, look, is it good. There's good and there's bad, always right. So with AI and we had something before AI we had something called CAD, which was computerized assisted diagnosis, right, or computerized assisted detection, and we now have CAD. We've had CAD for years, years, and what the CAD does is it helps to point out, for example, where there are calcifications, because calcifications may be the sign of early cancer, ductal carcinoma in situ it's only in the ducts hasn't invaded. So, as a radiologist, one of the things we look for is calcifications, but sometimes they're very tiny, they're very difficult to see. So the software will pick up where there are calcifications and it puts a mark around it and it says look here, look here. And that saves you sometimes, right, because the radiologist somehow didn't see it because it was so tiny. So we've had that for a while, because it also even picks up masses or distortion. But now AI is around and there are quite a few radiology practices that have it already.
Dr. Sue Jane Grosso-Rivas:So I just want to talk about the breast imaging part. So tomosynthesis right, that's the one I told you about that slices through the breast and there are several images. Now one breast could have 80 something images. Like we don't realize. We went from four images of the breasts to now having, you know, 80 images of one breast, 80 images of the other breast. I mean it gets to be almost too much all the slices that you have to look at.
Dr. Sue Jane Grosso-Rivas:So AI for us, what it does, it's got an algorithm that has been developed over time. Right, these companies make them better and better with time because they feed them with information of you know, this is what a cancer looks like. You feed them all this information and now this algorithm comes along, looks at the images, those 3D images, and it says here it is, there's a cancer right there. There's a cancer right there. Look here, look here, look here. And there have been some studies that are saying that AI is picking up some cancers that the human eye has not picked up.
Dr. Sue Jane Grosso-Rivas:Right, we're only human. Sure, you know we're we could possibly not see a subtle finding. Do I think AI has replaced the radiologist? Not yet, not not at this point. I have AI for one of the offices and what'll happen is it'll point to something for me, but ultimately it is the radiologist that has to look at those images and evaluate it and decide is AI being stupid right now or is it really something? And then you decide whether that patient has to come back or not. So I think we need to learn how to live with AI in our world. Basically.
Dr. Sue Jane Grosso-Rivas:Right.
Dr. Michael Koren:So we're certainly not at a point where a radiologist or a group or a process that doesn't use AI is somehow behind the times. Right, we're not at that point.
Dr. Sue Jane Grosso-Rivas:You have to be with the times, for sure, and you have to learn. You know, with every new technology that comes along and we haven't even talked about contrast enhanced mammography, which you probably probably should mention, but with every technology that comes along, you have to kind of embrace it, you have to look at it and you have to see, well, how does this help me? You know, how can I use this to make me a better physician? What can this do for me? And that's kind of the way that I'm looking at it. I'm towards the end of my career, so I'm not worried that AI is going to replace me.
Dr. Michael Koren:I think, based on the way you look, you're at most halfway through.
Dr. Sue Jane Grosso-Rivas:Yeah, Okay, Okay, Mike, let's just say that that's true. But I mean, I enjoy what I do, so I'm not going anywhere anytime soon. But yeah, no, AI is here and and you know it's. It's going to be interesting to see what happens in the future with AI, because it's also going to be used for magnetic resonance imaging. It's being used in many different areas of radiology at this point, so it remains to be seen.
Dr. Michael Koren:So you mentioned contrast imaging, so go ahead and give us the quick spiel on that.
Dr. Sue Jane Grosso-Rivas:Okay, so we talked about x-rays being static, but you know, contrast enhanced mammography and MRI with contrast is not static, it's more functional, it's more physiologic. You know, with contrast agents, if you put either iodinated contrast IV for contrast enhanced mammography, it's the same IV contrast that they use for CT scans. Or if you use a radio tracer, like for positron emission tomography, all of these types of studies, the agent goes into the body and it goes to a particular place where for positron emission tomography, it's where they're using glucose.
Dr. Sue Jane Grosso-Rivas:With contrast enhanced mammography and magnetic resonance imaging it's about flow. Cancers develop blood vessels. That's what cancer does. Cancer wants to grow, so the vessels are created and it grows. And guess what? The blood flow goes to that cancer and then it shows up. So contrast enhanced mammography means I'm doing a mammogram but I'm giving you some contrast because I want to see the flow. I don't know, I don't want to see white. They're subtraction images and it's going to show me where there is a lot of blood flow. And where there is a lot of blood flow is where there's going to be a cancer, and that's the same thing with magnetic resonance imaging. Contrast enhanced mammography's going to be a cancer. And that's the same thing with magnetic resonance imaging Contrast enhanced mammography is going to take off.
Dr. Sue Jane Grosso-Rivas:That's one of the newest technologies and they have a study going on right now. It's called the CMIST trial. It's basically GE, together with, you know, actually Estee Lauder company. I forgot the name of it. I think it's called Breast Cancer Research Group, I think it's called. So they've come together and they are looking to see if women with dense breasts, with average risk, will benefit from contrast enhanced mammography. And that comes up and shows us that it is a good study. I think we're going to see a lot more of that for sure.
Dr. Michael Koren:Wow, fascinating.
Dr. Sue Jane Grosso-Rivas:Because, it's easier. Contrast-enhanced mammography takes about anywhere from five to eight minutes, whereas magnetic resonance imaging takes more like 30 minutes 35 minutes. And MRI is very expensive. Contrast-enhanced mammography isn't. So there are a lot of pros basically for contrast enhanced mammography. But having said that, nothing beats breast MRI. Breast MRI is still at the top as far as being able to show invasive breast cancer. Abbreviated breast MRI is one of the newer technologies where they've learned that they don't have to do the study for as long. They just have to do one or two images and they get to see what they need to see. So it's much shorter scan time.
Dr. Michael Koren:Interesting.
Dr. Michael Koren:So, last but not least, men and breast imaging
Dr. Sue Jane Grosso-Rivas:oh men, yes, yes, and I do get to see a few men in my practice.
Dr. Michael Koren:The forgotten sex, go for it.
Dr. Sue Jane Grosso-Rivas:Yes, well, for the men, only 1% of all breast cancers are in men, you know, whereas women, the number of invasive breast cancers that may be shown this year maybe, you know, greater than 300,000,. Let's say a man, the men will have breast cancer, maybe 2000, you know of all the breast cancers. So it's not common. It happens as they get older. So most of the breast cancers you see in men are over the age of 60. Men do not get screening mammography. Okay, that hasn't been instituted. The way that men present is that a man will feel a lump. When they feel a lump on clinical, or if the doctor feels a clinical on clinical exam, they feel a lump. That's when they end up coming to me. I will do a mammogram on a man. Okay, they have enough breast tissue to be able to do a mammogram and we're looking for cancer. Generally. The difference, you know, or what we're looking for basically in men, is they feel a lump. Is the lump cancer or is it something benign, like gynecomastia, which is the development of breast tissue which does happen with a lot of men as they get older. Also, many men that have prostate issues. They're on certain medication that affects the breast tissue, they start to develop breast tissue, just like women. Okay, so that's usually what I'm trying to evaluate. And you know, sometimes doctors will send the man for an ultrasound, but the ultrasound is not what we need. We need the mammogram. You have a lump, you get mammography.
Dr. Sue Jane Grosso-Rivas:Now what if a man has a genetic mutation? Because this is the other thing. People used to think that your mother's history was the only history that was important. That's not true. Now we want to know your family history on your mother's side and your father's side, because your father could have the mutation.
Dr. Michael Koren:Yeah, makes sense.
Dr. Sue Jane Grosso-Rivas:If the father has the genetic mutation, then that's going to increase his risk for breast cancer, as well as his children. So, yes, and men don't get screened, but men do well If their breast cancer is identified. They usually get identified early because men don't have a lot of breast tissue, so it's very easy to feel you know the cancer basically. So men do tend to do well.
Dr. Michael Koren:Yeah, In the cardiology world we use a drug called spironolactone quite a bit that causes gynecomastia and if we identify that, is that a reason to get a mammogram or just get them off the spironolactone?
Dr. Sue Jane Grosso-Rivas:What ends up happening is that they, you know it doesn't feel comfortable for a man when they start, you know, because what happens is they develop breast tissue and they'll develop tenderness, which is uncomfortable. So sometimes what ends up is you'll have to get them on something else, some other medication, basically you know,
Dr. Michael Koren:But they don't necessarily need to be imaged, I guess, is my question.
Dr. Sue Jane Grosso-Rivas:He has to be imaged.
Dr. Michael Koren:he has to be Okay. Oh, interesting,
Dr. Sue Jane Grosso-Rivas:If you, if you feel a lump and he's on spironolactone, there's no way to know if the lump is because of the spirono lactone, with gynecomastia, or is there cancer.
Dr. Michael Koren:Or if there's no lump, just enlargement of the breast. Do you still recommend a mammogram?
Dr. Sue Jane Grosso-Rivas:I would still do imaging. I would do imaging, yeah.
Dr. Michael Koren:Yeah, well, I'm going to be sending you some referrals then in the near future, all right, that sounds good.
Dr. Sue Jane Grosso-Rivas:So you know
Dr. Sue Jane Grosso-Rivas:one thing I do want to mention, because you're a cardiologist what about arterial calcifications on a mammogram? Have you heard about that?
Dr. Michael Koren:I've heard of them. I'm not sure exactly what I would do, but I do get a lot of referrals from other imaging to cardiology because of concerns about coronary calcium. But go ahead. I'm sure you see that as well, yeah.
Dr. Sue Jane Grosso-Rivas:I mean it's very interesting because when I look at a mammogram and I'm looking for calcifications, sometimes I see vascular calcifications, so breast arterial calcifications. Now, let's say it's a woman, that she's in her 40s and I see a lot of calcifications in her. You know vessels. I do report it. Not all radiologists necessarily report it, but we all know that there does seem to be some association with, uh, having vascular calcification seen in your breast. There seems to be some association with cardiac disease and also the potential for developing a stroke. So you know, as a woman gets older, you'll see vascular calcifications more right, because basically she's developing calcifications everywhere, which includes the breast. So it is something to mention and maybe it's an opportunity for the primary care physician to sort of look at that patient and start assessing. You know, how is this person's cardiac health? Because ultimately we're talking about breast cancer, right? But the leading cause of death in women is still cardiac disease right.
Dr. Michael Koren:So A lot of women forget that, unfortunately.
Dr. Sue Jane Grosso-Rivas:Yeah, no, it's like, you know, breast cancer. And breast cancer is not even the leading cause of death. It's lung cancer still, but breast cancer is still the leading cancer. We should say but so, yeah, so if there are arterial calcifications of the mammogram, we shouldn't totally ignore them, because that may help to determine if she has some cardiac disease.
Dr. Michael Koren:And I'm going to throw my final question out at you a little bit out of left field, but it's something we've addressed here in MedEvidence.
Dr. Michael Koren:What are your thoughts about alcohol and breast cancer risk?
Dr. Sue Jane Grosso-Rivas:Well, I think, like with anything, as far as risk is concerned they always askhow can I , " "Reduce my risk of breast cancer, right? So you're going to hear from any doctor for any cancer, right? Lifestyle you know. Obesity they say with obesity there's an increased risk. You know. You want to eat well, you want to exercise, you know all of these things. But then yet I can tell you about my very good friend who was at the age of 40. She was a runner, right. She drank, you know, green juice or whatever it is she was doing. She had cancer, right. So it doesn't just because you do all these things doesn't necessarily protect you. Alcohol, from what I've heard and actually I was listening to one of your podcasts, I think from Med Evidence, and I did hear you guys talk about alcohol, but everything in moderation is the way I feel. I feel to say to someone don't drink alcohol at all.
Dr. Sue Jane Grosso-Rivas:I don't think that makes any sense, Just like, you know, don't drink coffee, right? If a patient comes into me, she's got multiple cysts. We know caffeine can affect the breasts and they could end up developing more cysts. But are you going to tell someone, well, you've got to stop caffeine. You know completely. Very hard to do, I think if someone's drinking alcohol on a daily basis, that's too much and I do think that that is of concern. So, yeah, no, I would say.
Dr. Michael Koren:All good things in moderation is the lesson.
Dr. Sue Jane Grosso-Rivas:I personally think, all good things in moderation, but we still don't know exactly what's causing the breast cancer. Right, I already told you that most of it is not genetic that we know of, although every year, right, every time, we hear about more genes, more genes, and I, for example, we haven't really talked about stories. I have so many stories of patients, but a friend of mine, his daughter, just passed away at the age of 34 from metastatic breast cancer and there's nobody in the family, just nobody in the family. So why, you know those, those cases that I know of where there's no? And then I have another person who's uh, was a technologist of mine, you know developed DCIS at a young age and no genetics, nothing. And then her daughter, at the age of 31, finds her own, feels her own breast cancer, okay, saves herself, basically. No genetics! So so what's going on, so you know, and and we didn't get into is that we are finding we didn't talk about black women and there's a big problem that's going on. And the ACR has now actually issued some new recommendations and this is very important to say right now which is that all women should have their risk assessment at the age of 25 to 30.
Dr. Sue Jane Grosso-Rivas:And what that means is that when you go in to see your, you should go in to see your primary care physician, because a lot of women don't know that there is this genetic predisposition. We need to know if there is family history. You know how many times I talk to a patient and they don't even know their history and when they find out there's something abnormal, they go back and start talking to all their family members and then they find out oh yes, aunt so-and-so, cousin so-and-so. They start finding out all of these histories. Well, that's what the new recommendation by the American College of Radiology you got to find out by the age of 25 to 30. And why? Because if there is a genetic predisposition or significant family history, that woman may need to start earlier than 40 to get her mammogram. That woman may need to get breast MRI, for example.
Dr. Sue Jane Grosso-Rivas:Right, and what they found is that something is happening within the black women, the ages of some of them, because you can get cancer between the ages of 20 and 29. It's not common but you can, and what they found was that black women are getting the 50% more cancers in in black women from the ages of 20 to 29 than their white women counterparts Right 30 to 39, it's only about maybe 17% increase. Something is happening and many of the black women get the more aggressive type of breast cancer. It's called triple negative, meaning it's ER negative, pr negative. You know, estrogen, progesterone negative and HER2, herceptin negative. They are much more aggressive cancers. So you know, it's almost you know, a warning that's going out there to let everybody know.
Dr. Sue Jane Grosso-Rivas:Hey-
Dr. Michael Koren:Any theories as to why that is? Out of curiosity?
Dr. Sue Jane Grosso-Rivas:They're looking into the possibility. They want to look at the type of cancers, the molecular basis, but what they have found overall not even just black women, asian women, right, they have a lower incidence in general, but they're finding that the younger women are starting to have more, there's more of an incidence of breast cancer, and people are trying to figure it out. And a lot of these breast cancers are estrogen receptor positive and progesterone positive also, so they tend to be estrogen type tumors, right? So I don't know, we haven't figured out exactly what is going on. But then let's go back to lifestyle. That's what I'm saying. So what is it?
Dr. Sue Jane Grosso-Rivas:So, if you ask me about alcohol, you know, is it related to the way you're living your life, right? Is it related to the way that you're eating? Is it nutrition? Is it the environment? What do we have in our environment? The microplastics? I don't know right. There's got to be. There's something that's happening. The good news is that for the past 50 years, the mortality rate for breast cancer has dropped significantly. So there is no doubt that we are doing a better job with all of the screening, mammography, maybe the new chemotherapies that are out there. Whatever it is that we're doing, it is much better. Women are surviving breast cancer. There's no doubt about it that they are. Whether it's stage zero, stage one, stage two, women can still survive their breast cancers, absolutely so that's the good news.
Dr. Michael Koren:So, Sue Jane, a lot of people are concerned about the cost of health care. Tell us a little bit about what the expectation should be of a woman who needs these screening procedures and what her insurance company should pick up and what the cost should be approximately.
Dr. Sue Jane Grosso-Rivas:Well, you know, at this point, because all of these organizations have agreed that screening mammography should occur, right, they should be able. Their insurance company should be paying for their screening mammography.
Dr. Michael Koren:Zero out of pocket usually?
Dr. Sue Jane Grosso-Rivas:Usually a zero out of pocket, usually. Now they may have, however, a deductible that they have to meet, right? So I shouldn't say everybody, everyone's insurance is different. Let's talk about Medicare, for example, right, medicare. Like most women that come for their mammograms, many of them are older, they're Medicare age. So the woman must know what the Medicare rules are, because you know if they come just a few days too early, you know if it has to be exactly at 12 months that they can get their mammogram. If not, then they will be responsible for the bill, right? So they need to be aware. Some insurance companies will say you don't have to wait a whole year, just do it at some point in the year. So it just has to be, you know, this year, next year, it doesn't matter what month. Every woman has to be aware.
Dr. Sue Jane Grosso-Rivas:Now there are screening programs out there. You know that that will pay for free mammographies. And you know in in New Jersey there's something called the seed program and that seed program will help women get mammograms for free. So there are ways of getting free mammography. But as far as insurance is concerned, yes, you're right, this is something you need to look into because if that insurance company believes that you should only get mammography every two years. They may not pay for every year, right. But what about supplementary screening? Your radiologist reads it and says you need an ultrasound and your insurance company turns around and says, no, you don't, right, that's a problem. So you need to know what state you live in and you need to know what the laws are, because there are states where the law does protect you and the insurance company has to pay for your supplementary study. The only way to know is to speak to your insurance company. Many women go back and fight with their insurance companies if they have to.
Dr. Sue Jane Grosso-Rivas:Breast MRI is another issue. Sometimes you hear breast MRI. Well, we can't get the insurance company to agree to do the breast MRI. So I'm very careful in my reports. I make sure that I make it very clear as to why I am recommending this breast MRI, because that report is going to help determine whether her insurance company will pay for it. But you're right, you have to.
Dr. Sue Jane Grosso-Rivas:And how about this? When should you stop doing a mammogram? And I'm sorry we didn't get to talk about this, but this is important because many organizations will say stop at 74. I mean 74-year-olds say, 75, I mean nowadays people are living much longer, right? So the American College of Radiology says this, and I believe this as well you stop when you are no longer going to be in good health. If you're going to be in good health for the next 10 years, then you should continue to get your mammogram. So if you got a 74-year-old and she's doing very well and she expects you know, the doctor feels like she's probably going to live until 84, then yeah, she should continue getting her mammogram, right. So, but what if the insurance company doesn't pay for it? That's a problem.
Dr. Michael Koren:Well on that. I truly want to thank you for the MedEvidence family for a true tour de force. Thank you, Sue Jane, for a true masterclass on breast imaging. I learned a tremendous amount. I'm sure our audience will share that sentiment quite a bit. And thank you for sharing your story about Ms. Goldberg. And thank you for just a tremendous number of very pragmatic insights that I'm sure will make a difference in people's lives.
Dr. Sue Jane Grosso-Rivas:My pleasure. My pleasure Any opportunity I have to get information out there. I just think it's what I'm here to do.
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