Introduction: You are listening to another episode of Living Well with Eisenhower Health. Healthcare as it should be.
Prakash Chandran: About one in eight women in the United States will develop breast cancer in her lifetime. So it's really important to have regular screenings because early detection can help save lives. But what exactly do you need to know about these screenings and what should you do to stay healthy? We're going to talk about it today with Dr. Paul Sylvan, the Medical Director at Eisenhower Schnitzler Novak Breast Center. This is Living Well, the podcast from Eisenhower Health, I'm Prakash Chandran. So Dr. Sylvan, it's great to have you here today. You know, we're talking about screening and I'm curious as to why it's so important for women to get screened and what type of screening is available to them?
Dr. Sylvan: So, screening mammography has been demonstrated unequivocally to show reduced mortality from breast cancer. And that is the main reason to get screened. There have been a number of studies done randomized control trials, as well as observational population studies and all have demonstrated significant mortality reduction with screening mammography.
Host: And so, you're saying mammography and that as I'm assuming for the lay person, just a mammogram, maybe you can tell us a little bit more about what it is and when, or what age a woman should start getting them?
Dr. Sylvan: So, a mammogram is an x-ray examination of the breasts. It usually consists of for a screening mammogram, two views of each breast taken in different projections. And as far as the age at which screening should begin, there is some controversy about it. So it's a little difficult, but I will tell you that my opinion and that of the American College of Radiology and the Society of Breast Imaging, as well as other organizations, is that screening should begin at age 40 and should occur annually in order to get the highest mortality reduction from breast cancer from the mammograms. So again, screening should begin at age 40, and we're talking about average risk patients. I'm not talking about high risk screening, that's a separate topic, but for an average risk patient annual screening beginning at age 40.
Host: Okay. So the recommendation is annual screening starting at the age of 40. I want to unpack a little bit what you said about average versus high risk. Does high risk mean that there has been cancer in the family before and they should start screening sooner?
Dr. Sylvan: A high-risk is not just a matter of having cancer in the family. Obviously a family history is one of the risk factors for breast cancer. But when we talk about high risk, you're talking about greater than a 20% lifetime risk of breast cancer. And these can be calculated by various models that do risk analysis, but other risk factors for breast cancer that would put someone into the high risk category are one of the breast cancer genes. So genetics, not just a family history, but having a specific gene that makes one more likely to get breast cancer. And then other factors such as if someone had had radiation of the chest as a young person, for instance, for Hodgkin's disease, that would put that person at significantly higher risk for breast cancer. So there are a number of factors that would cause someone to go into a high risk group and the recommendations and the way we screen is different for those high risk patients.
Host: Okay. Understood. And just one more question about that. You mentioned if they have a specific gene, is this something that is told to them during, for example, an annual you know, just checkup or is this something they have to specifically get tested if they have that gene?
Dr. Sylvan: So, you wouldn't know if you had that gene, unless you got tested for it and not everybody routinely gets tested for it. So the recommendation to get tested for that gene is usually based upon if there's a very strong family history of breast cancer and in particular breast and ovarian cancer. So if both of those exist in a family, then that would make one more likely to have the gene, but routinely it's not a test that's done for the average patient. There have to be factors that drive someone to do that test to see if a woman has that gene.
Host: Okay. And what is that gene called?
Dr. Sylvan: That's I'm talking well, there are a number of genes, but I'm talking to the most common ones that people are aware of are called the BRCA gene, B R C A, and there's a BRCA1 and a BRCA2 gene. Separate from that, there are another, a whole other group of genes that put one at higher risk of breast cancer, but the ones that are best known are the BRCA genes.
Host: Okay, thanks for that clarification. So we talked about women should start in their forties and get mammograms annually. Is there a time when they should stop? For example, when women reach their sixties, should they continue getting annual mammograms?
Dr. Sylvan: So, the sixties is not even a question to talk about. I mean, the fifties and sixties are actually the highest incidence of breast cancer. And so nobody recommends stopping screening before a woman reaches age 70. So if you look at the, at the data on the randomized control trials that have been done, they screened women up to the age of 64. So the information that's available is that women should be screened definitely up until the age of 74. Beyond 74, so if you look at the American Cancer Society recommendation for screening American Cancer Society recommends that screening should continue. As long as a woman is in good health and has a life expectancy of at least 10 years, the American Society of Breast Surgeons makes that same recommendation. As long as the woman is in good health with a life expectancy of at least 10 years. The American College of Radiology Society of Breast Imaging, National Comprehensive Cancer Network, all recommend screening to continue as long as a woman is in good health and has a life expectancy of at least five to seven years.
But the United States Preventive Services Task Force, which makes recommendations for screening and has become a well-known for that, not just for screening breast cancer, but other cancers as well. Their conclusion is that they said there's not enough evidence to recommend for, or against screening after the age of 74. So they're not saying not to screen after 74. They're saying that the evidence doesn't exist to say one way or another, whether screening should continue past 74, but all these other organizations that I already mentioned recommend that screening continue as long as health is good. And the life expectancy is at least five to seven or 10 years.
Host: Okay. That's helpful. And just a clarification here, I'm assuming that this annual mammogram should be coupled with self-examination on a frequent basis, is that correct?
Dr. Sylvan: Well, that's an interesting question. So going back to the United States Preventive Services Task Force, when they came out with their most recent recommendations which were updated in 2016, they specifically recommend against breast self-examination. They say that the harms of breast self-examination are greater than the benefits.
Host: Wow. I've actually never heard of that before. Can you explain why it's something that women shouldn't be doing?
Dr. Sylvan: Well, I don't personally believe that that's the case, but I'm just telling you what came out from the United States Preventive Services Task Force. That was their recommendation. And they've, you have to understand that in a group like that, the USPSTF, when they talk about harms, they're not saying that it's necessarily bad for you, but they're saying that you might do a breast self-examination and find something that really is not anything important, but then it leads to all kinds of other tests and therefore it's bad, but that's their opinion. Most organizations would recommend that women do continue with breast self-examination and also clinical breast examination by one's physician.
Host: Okay. So let's talk about the technology and the latest technology in breast diagnostics. Can you talk a little bit about it specifically, potentially tomosynthesis or 3D mammography?
Dr. Sylvan: So, yeah, so digital mammography was first approved by the FDA in the year 2000, and then in 2011, 3D mammography or tomosynthesis, those are the same thing became available. And what tomosynthesis does instead of just taking a picture of the breast of the entire breast with all of the overlapping tissue and overlapping structures, it actually is able to take slices through the breast tissue in one millimeter thickness. So multiple slices that go through the breast in one millimeter slice thickness. And then the computer at the end is able to synthesize an image of the entire breast from those slices that it acquires. So as a radiologist, we look at the picture of the whole breast, but we also have the ability to look slice by slice through each of those one millimeter thick images. So it gets rid of a lot of the overlapping breast tissue and lets you see things more clearly that would be difficult to see without that.
Host: Yeah, absolutely. I'd heard about dense breast tissue and before this technology existed, it was just a little harder to spot if there was something going on that needed attention. And so with this new technology, it's much easier wouldn't you say?
Dr. Sylvan: Yes. It's much easier. It's very good for looking at dense breast tissue. But interestingly in the studies that had to be done before this was approved by the FDA, it was also just as useful in women who did not have dense breasts as in women who do have dense breasts.
Host: And I'm curious if most insurance providers cover tomosynthesis, including Medicare?
Dr. Sylvan: Medicare does cover tomosynthesis. Most of the payers cover tomosynthesis, but not all of them. And so a woman would have to check with her own insurance company to make sure that it's covered, but most payers do cover it.
Host: Does Eisenhower have additional testing such as ultrasound and MRI if needed?
Dr. Sylvan: Yeah. So those are really standard adjunct procedures to mammography that we have, and that most facilities should have if they're doing breast imaging. So yes, ultrasound is done very frequently in addition to mammography in specific cases. And then MRI again, can be used as a tool for problem solving, but also as a screening tool in women who fall into that high risk category that we talked about before.
Host: So just to close here, you know, we've, we've covered a lot here today. The importance of that annual screening starting at the age of 40 and all of the technology available to help make it as comprehensive as possible. Is there anything else that you'd like our listeners to leave with?
Dr. Sylvan: Well, I think that the most important thing to know is that, I mean, some women are reluctant to have mammograms because they can be uncomfortable and I'm not saying they're not uncomfortable. They're not, nobody likes them. They're not pleasant. But the bottom line is that breast cancer is a very prevalent disease within our society, as you opened up saying that one out of eight women in our country will get breast cancer in the course of our life. And the one modality that we have that has had randomized control trials that have proven a mortality benefit from screening is mammography. So mammography remains an essential thing to do. We get asked by some women, if they can have ultrasound only or MRI only. And the bottom line is those are adjunctive studies, but mammography is really the number one study that's still should be done to look for breast cancer and reduce mortality
Well, Dr. Sylvan, and I think that is the perfect place to end. Thank you so much for that comprehensive advice and explanation today. We truly appreciate it. That's Dr. Paul Sylvan, the medical director at Eisenhower Schnitzler Novak Breast Center. Thanks for listening to Eisenhower's Living Well Podcast. For more information, visit Eisenhowerhealth.org/breast. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks, and we'll talk next time.