Mammography has advanced significantly in recent years. What sets 3D mammograms and the use of artificial intelligence apart from standard mammograms? What questions should you ask when looking for a mammography center? And can someone clear up the confusion when it comes to changing guidelines about when regular screenings should begin?
Kathy Schilling, M.D., medical director of the Christine E. Lynn Women's Health and Wellness Institute at Boca Raton Regional Hospital, cuts through the confusion in this information-filled discussion with host, Jonathan Fialkow, M.D.
Mammography has advanced significantly in recent years. What sets 3D mammograms and the use of artificial intelligence apart from standard mammograms? What questions should you ask when looking for a mammography center? And can someone clear up the confusion when it comes to changing guidelines about when regular screenings should begin?
Kathy Schilling, M.D., medical director of the Christine E. Lynn Women's Health and Wellness Institute at Boca Raton Regional Hospital, cuts through the confusion in this information-filled discussion with host, Jonathan Fialkow, M.D.
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Dr. Fialkow:
Welcome Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Baptist Health's Miami Cardiac & Vascular Institute, where I'm also chief of cardiology at Baptist Hospital and chief population health officer at Baptist Health. Mammograms are low dose x-ray images of the breast, and they're used to detect lumps and other changes that are too small to be felt during a clinical breast exam. And mammograms have long been an instrumental weapon in our efforts to avoid preventable deaths, in this case, from breast cancer. Early detection of breast cancer is vitally important in increasing survival and improving quality of life. And in the decades since it was introduced, mammography has come a long way, with advances like 3D imaging and the application of artificial intelligence. My guest today brings a wealth of expertise and experience in women's breast health. I'm happy to welcome Dr. Kathy Schilling, medical director of the Christine E. Lynn Women's Health & Wellness Institute at Boca Raton Regional Hospital, a part of Baptist Health South Florida. Welcome to the podcast, Kathy.
Dr. Schilling:
Thank you for having me. It's my pleasure to be here, particularly in this month of October, which is breast cancer awareness month.
Dr. Fialkow:
Certainly a very valuable opportunities to educate women and the general community about breast cancer and preventive strategies. So let's dive into mammograms. We use the term screening tests, sometimes, and this is true certainly to cardiovascular area as well, you take a person, looks well and say, "We're going to do something to you to find out if you had something." Talk about the purpose of screening and what makes for a good screening test, and then, of course, why mammography is a good screening test.
Dr. Schilling:
So mammography screening, we've been screening in the United States since the late 1980s. And the purpose of it is to take a look at the patient's breasts through x-ray and see whether we can find a small, early breast cancers. We know that with early detection we're able to improve patient outcomes. When cancers are detected on mammography, we know that greater than 95% of patients will be alive and well five years after the diagnosis is made, we also know that there'll be fewer mastectomies performed, more treatment options and less aggressive therapy. So what the purpose of mammography screening is to find a patient who's asymptomatic and find a cancer which may not become clinically evident for several years in the future.
Dr. Fialkow:
I think that's a great response and I appreciate it, and the key word is asymptomatic. A screening test isn't someone who shows no signs of a problem, but it's possible and you're doing the test to find out they have it, and the second point you made, which we'll dive into, is based on the results of the screen test we can make positive impact, which is in this case by finding a breast cancer early we can improve survival and quality of life. So when we're talking to them about breast cancer screening and mammography, mammography has been around for decades. What's advanced in mammography? Is it the same exact test and technology that was going on 30, 40 years ago? Where's the innovation occurred?
Dr. Schilling:
It's a totally different test than when I was back in training. It's like if you think about cameras and how we've changed with cameras, we used to use film to take pictures of our environment or people, and everything has gone digital, everything is computerized. We really have been impacted over the last 40 years by the advancements in computers, in particular. We currently have 3D mammography. We know that the breast is a three dimensional organ. In the past, when we were doing 2D mammography we were looking at it only from two different sides. Now, the mammogram is done in 3D.
Dr. Schilling:
The patient is positioned the same in the mammography unit, but the tube moves in an arc over her head, and attains multiple images at different angles. These images are then reconstructed at one millimeter thick intervals. So we get a good look at the interior, the internal aspect of the breast, as we are looking at it in three dimensions. And studies have shown that we are able to find more cancers when we use 3D mammography compared to 2D, and we have fewer false positive results. So certainly if 3D mammography is not available to women, I would recommend instead of not having mammography at all, you get a 2D mammogram. 2D mammogram is better than nothing at all, for sure. Particularly when we're talking about early detection.
Dr. Fialkow:
Let's dive into that false positive for a second. It's a term we use, and sometimes people in the community don't really understand that. Again, as a cardiologist, quite frequently people say, "Do all the tests you want to do." And we have to temper it by saying, "A good test is reliable, accurate. There's a risk if you do a test that it might show something that's not real." And in the mammography area, do you find that the 3D imaging creates less false positives? Speak to that particular point. You mentioned it. So speak to the importance of that a little bit, if you could.
Dr. Schilling:
So a false positive mammogram means that we are recalling a patient to come back for additional imaging because we think we see something. And this occurs about 10% of the time. When we image patients, recall rate is about 10% nationally, and this can result in increased anxiety for patients when they are recalled, it can be added radiation dose to the patient because we're getting more images and it can be also an added cost to the patient. In our center, we read all of our mammograms while the patient is here.
Dr. Schilling:
So if she needs additional testing, she'll have it while she's at this one visit. So I think that there's a little bit less anxiety. The patient knows right away what's happening. She doesn't have to reschedule. She doesn't have to make a second trip to have the answers, find out what the answers are, and typically when we recall about 10% of our women, the vast majority of them, probably six out of 10, will be released with no findings. So it's a false positive. We think we see something, but with the additional testing we find that really there's nothing there, there's no cancer there. And perhaps two out of 100 will have to go on to biopsy. So the vast majority of them turn out to be nothing.
Dr. Fialkow:
And again, just to emphasize the wonderful points you're making, the improvement in the technology, the use of AI to help interpret the skill of the interpreter, the physician who reads the mammograms, it's to pick up things that might otherwise be missed. But also not to say there's a problem here where there's no problem, which as you just elaborated on... And I'm sure many of the listeners have had those experience of that anxiety of oh, wait a minute, it wasn't normal, I got to come back and the additional stress and testing and whatnot.
Dr. Fialkow:
So as we get more accurate, we'll wind up certainly providing a better service in the mammography area. So you clearly brought up the benefits of 3D mammography, having the interpretation at the time of the mammogram so decisions can be made at that point. When a woman decides that they're going to go to mammography center, and clearly not everyone can come to centers with 3Ds, do you have any recommendations what they should look for to make sure that they will get a good result, which means not missing something that's there and not saying something's there that's not there? What recommendations would you give towards looking to know it's a high quality mammography center?
Dr. Schilling:
I think it's all about expertise and it's about focus. And I would recommend that women, if they can, seek out a center where the commitment is 100% to breast imaging, such as our center, that's all we do here. We see 65,000 women a year. We have 10 dedicated breast radiologists. That's all they do. They're not doing CAT scans. They're not doing other tests to distract them. And we also have dedicated technologists. So they're purely doing breast imaging. All they do is mammography all day long or breasts ultrasound all day long. And so I think it's about the commitment and it's about the breadth of services which are offered. We not only provide mammography screening and ultrasound, MRI, and many other tools, but we're focused on personalizing the care for women. We are moving from a period of time where we recommend screening just based on patient's age, but we're moving now towards more risk based screening.
Dr. Schilling:
So if we determine what patient's level of risk is, maybe some patients at low risk, we can do a little bit less and don't have to be so anxious about screening and getting them in every 12 months. And patients at higher risk, we're going to offer additional screening above and beyond that with just mammography alone. So it's that commitment to say that, "You are important to me, I'm not going to just screen you once a year and not worry about your level of risk, I care about your risk, and I'm going to tailor your screening to what your level of risk is." And that's the commitment that we have at this center.
Dr. Fialkow:
I think that individualized approach does set the center apart. So, let's start with the basic guidelines. So what's the general guideline out there in the country for the frequency of screening for mammograms? Can you speak to that? And then we'll get a little deeper dive to the individualized approach as you mentioned.
Dr. Schilling:
So the screening guidelines, since when we first started back in late 80s have been to start screening at age 40 and screen every single year. We still follow those guidelines today. We recommend that they continue screening as long as they remain in good health and we'd act on findings should we find something. So if they're going to say, "I don't want to have a biopsy, I don't want to have surgery, then you shouldn't come in for screening." Another important thing which we have recommended for the last several years is that every woman have a formal risk assessment before they reach the age of 30. And what we're trying to do here is identify those patients who may be at risk for familial breast cancer, hereditary breast cancer, like the BRCA1 or BRCA2 patients who tend to develop a breast cancer maybe in their 20s or 30s.
Dr. Schilling:
And those patients, using the 40 age start for screening, would not be qualified for screening in their 20s and 30s. So if we can identify those at risk for familial breast cancer, we're going to start screening them earlier with MRIs and mammograms maybe beginning at age 25. So things have changed over the years. In 2009, the United States Preventive Services Task Force came out and said, "Don't start screening until 50 and only go every other year to 74." This has caused a lot of confusion to people, and we know that 20% or one in five women that we diagnose with breast cancer are in their 40s. And so if we start screening at 50, again, we're going to be going backwards, we're losing the opportunity to find cancers in these young women when they're most important to their families and to their community and their workforce. So we begin at age 40 and go every single year.
Dr. Fialkow:
I love the approach where you take the basic foundational guidelines, which is for the broad populations, but you can do a mammogram every three months, but obviously the cost and the radiation exposure offsets the findings. You can wait every five year, but you'll miss a lot of cancers. So taking those foundational guidelines, but then you individualize them. The person's not just coming in for a scan and leaving, you're doing the intake and going into the deeper family histories of the lifestyles and making that individualized approach. And I think as a listener the take home point for me, it's it takes the burden off of me to know and remember when I have to do this, when I have to do this, what I have to do this, what does this interpretation of this study mean for me? That's part of the whole holistic evaluation that you guys provide.
Dr. Schilling:
We actually tell patients what their level of risk is when they come in, as we are reading these exams real time, before the patient leaves, the technologist can give patient a little brochure that we have that educates the woman as to what her level of risk is and what our recommendations are for future follow up. And so we really are trying to inform that patient so that she can be her own best advocate, should she need additional testing, she can go to her doctor or one of our doctors here and ask that.
Dr. Schilling:
So it's really about just making the patient aware of their own personal risk. And artificial intelligence I think in in the near future is really going to assist us because I believe that the risk can be determined on the mammogram. The artificial intelligence has been able to identify patterns of breast cancer just by looking at the breast density, the presence of calcifications and masses. And it's really about what's going on in that women's personal breast tissue who's going to determine what her level of risk is in the near future. And so it's really going to change everything. Right now, the clinical models that we use to predict risks are really... It's like a toss of the coin. They're really very ineffective.
Dr. Fialkow:
So a woman over 40 year are at risk are the guidelines. And of course we know that women under 40 get breast cancer, but it'll be much more precise to look for things that may say we want to keep a closer eye on you, or maybe even more of an emphasis on lifestyle changes.
Dr. Schilling:
Exactly.
Dr. Fialkow:
I appreciate it. Let's switch gears a little bit and move into some of the public health type realities with mammography. What did you see and what did we see within the Baptist system and maybe even nationally regarding mammography screening through COVID and what are we seeing now compared to the early stages of COVID? Can you speak to that a little bit?
Dr. Schilling:
The last March, mid-March, we had to cease all screenings, and that was nationwide. So there was no screening mammography, no screening ultrasound, no screening breast MRI. And we saw a precipitous drop by about 95% of screening mammograms across the country. And that lasted until the end of May, so a good period of time that we were closed. We were not permitted to screen, but we were permitted to do diagnostic mammograms. So we did continue to see patients who had symptoms, which may have been related to the presence of breast cancer. So if patients had a palpable mass or they had nipple discharge or pain, we would still see them. But our volume dropped from about 200 cases a day at all our sites to 30 cases once a week.
Dr. Fialkow:
Wow.
Dr. Schilling:
We continued to do biopsies. So we were [crosstalk 00:15:32].
Dr. Fialkow:
Understandably why, but nonetheless, the numbers speak themselves.
Dr. Schilling:
It was traumatic, but the patients who came in, we continued to do biopsies. So we were continuing to diagnose patients with breast cancer, but the operating rooms were closed. Only emergencies were going to the operating room, and breast surgery was considered an elective surgery. So even though we diagnosed patients with breast cancer, they were sent home with a pill to help limit the growth of that cancer until the operating rooms opened up. So, that's pretty traumatic in a period of time where not only was their COVID, but patients had newly diagnosed breast cancer and were found that I can't have the standard of care, but these were the guidelines of the national societies. Everyone nationally had to abide by these guidelines for patients with newly diagnosed breast cancer. But during that period of time, we had a lot of free time to draw together plans for how do we get patients to return to screening safely, how do we keep our technologists safe.
Dr. Schilling:
And so we implemented many, many different processes here. We doubled the period of time that we took with the patient. So she went it from a 15 minute exam to a 30 minute exam so we could limit the number of people in the building at one time. We did not permit any visitors, no guests into the building. Patients were screened when they entered the lobby, they were given masks to wear, and we no longer used our community dressing room or community waiting area. The patients were brought directly into the mammography room where they changed. They had their examination, they redress and went back out to their car to wait for the results. And we guarantee that those results would be available within 30 minutes. If the patient needed to be recalled, she would come back up and we would do the necessary additional testing but overall we wanted to actively recruit our patients.
Dr. Schilling:
We knew that in that six week period of time we fell behind by about 7 or 8,000 women that we didn't screen. So we sent out 15,000 letters and we told the patients that you need to come back to continue to screen, not to put off your mammogram, that the breast cancers continue to grow despite the fact that there's a pandemic. We informed them of all the safety measures that we had undertaken and we also told them that we have funding. Many women lost their jobs, they lost their insurance and we let them know that we have funding to encourage them to come back and just to let them know that it was safe.
Dr. Schilling:
We sent letters to our referring physicians as well. And so we actively went out and tried to recruit patients. So right now, as I said, this breast cancer awareness month, we have reduced costs, imaging tests. We are working six days a week because we're so busy, but overall, the patients satisfaction, it was 99%. Patients are so pleased with the care that they're given. They feel very safe. Our center is not in the hospital, so we have a free standing center so they feel safe and secure and they're coming back to screening.
Dr. Fialkow:
So you've clearly expressed to our listeners the importance of resuming breast cancer screening, and perhaps more importantly, you've assured women of the safety of resuming the breast cancer screening and its important role in preventing breast cancer. Now, I know there's been some discussion in various medical circles recently about the correlation between COVID vaccine findings and mammography results. Can you speak a little bit about what we've learned and what we're recommending right now regard timing of a COVID vaccine and getting a mammogram?
Dr. Schilling:
When we first started getting vaccinated we saw patients come in for their mammogram, that was back in January of this year, and we noticed that we could see enlarged lymph nodes. And with time we realized that it was on the side that the patients had their vaccination, and so enlarged lymph nodes may reflect spread of cancer to the lymph nodes in the armpit area. But we found that we can see in large lymph nodes just related to the normal immunologic response to the vaccine. Initially we did a lot of additional imaging on these patients. We would do additional mammograms or additional ultrasounds, but then as we heard everyone across the country was having the same findings we tended to relax and just say, "These lymph nodes should resolve within a period of three months." And we just let the referring clinician know to monitor the patient.
Dr. Schilling:
And if the lymph node don't go away, then yes, you can send them back in and we'll do some additional testing, but we typically have in the past had recommended that patients have their mammogram before they go in for their vaccination and then wait at least six weeks until after the vaccination to come in for their mammographic screening. But certainly if patients have acute symptoms, we had one patient said, "I had a palpable mass, but I heard that you're not supposed to come in until six weeks after your vaccine." So if you have acute symptoms, you need to come in as soon as possible, we'll work through the lymph node issue.
Dr. Fialkow:
So two categories of people you just mentioned, and I think it's important as you did mention that it's an accepted and expected response to have large lymph nodes after the vaccine, that shows your body is developing a, immunological response. It's a good thing, but on a mammogram you can't necessarily tell the difference, what it is, so we don't want to confuse it. But if you have a concern in a breast exam, don't wait because you've had a vaccine, but if you could do the vaccine first. That's very helpful. And it's interesting how no one would've thought of it until we started doing the vaccines and seeing the mammograms and insure, across the country, new policies are put in place. And my last thing is, which, again, I would be remiss to myself if I didn't bring up, talk a little bit about the breast arterial calcification assessment at the center and what it means and what you guys do with that, because it's something we're going to be expanding down here in South [inaudible 00:22:00]
Dr. Schilling:
Now this is a great initiative. We started about in January in 2020, we hired a preventive cardiologist, Dr. Heather Johnson. And I had been reading about this for many, many years and really didn't have a solution, so we waited until we had somebody to provide that solution to initiate this program. And what studies have found is that the breasts have arteries in them just as all organs do in the body. And at times we can identify calcifications within the walls of those arteries. And studies have shown that if patients have calcifications in the walls of their arteries, that there's a high likelihood that they may have calcifications in the arteries in their heart, which may place them at risk to develop cardiovascular disease. So while we are very good at looking for calcifications in the mammogram as a sign of breast cancer, we are very good at finding them also in the walls of the arteries.
Dr. Schilling:
And so it's an incidental finding, but it's something that's important for us to educate, again, our patients about their possible risks to develop breast cancer. And we know that cardiovascular disease is the number one killer of women, and it kills 20 times more Americans than breast cancer does on an annual basis. And we also know that 80% of events are preventable, mostly through lifestyle modification and at times with medications. So why would we not let this as patient know she can prevent cardiovascular disease becoming part of her medical history just by having her mammogram? And it's really these patients are here because they're interested in screening and early detection, so why would we not tell them about their possible risks to develop cardiovascular disease?
Dr. Fialkow:
So you beat me to the punch that cardiovascular disease does remain the number of killer of women. And if we're able to identify, through mammography, through screening, another indication of someone's risk for another problem, we don't just ignore it, we actually say, "Hey, it's an opportunity to address your lifestyle and your risk for cardiovascular disease as well." So, again, appreciate that as you and I are aligned in our prevention of disease and certainly from the cardiovascular standpoint.
Dr. Schilling:
And there's 40 million mammograms being performed on an annual basis here in the United States. We really have the opportunity, if all breast imagers take the time and the effort, to let people know that they may be at risk. It doesn't cost anymore. This doesn't take more time. It's no more radiation to the patients. And I just think that it's something that's the right thing to do. And we want patients to become just as passionate about their cardiovascular health as they are about their breast health.
Dr. Fialkow:
Wonderful. Again, great conversation, tremendous information, love the innovation, the individualized approach, the team based approach, if you will, for women, not just getting the breast cancer screening with the mammogram, but evaluating all the components of what may lead to a higher risk of breast cancer. Great conversation. Again, thanks again. To our listeners, as always, if you have any comments, thoughts, or ideas for future topics for this podcast, please email us at baptisthealthtalk@baptisthealth.net, that's baptisthealthtalk@baptisthealth.net. Thanks for listening. And until next time, stay safe.
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