 Welcome and thank you for joining our webinar today. It is always a pleasure to be with you and speaking about a topic that I know is personal for all of us. Breast Health and Breast Cancer has touched the lives of every single person joining the webinar today. I am certain. I'm Dr. Harriet Boropsky, privileged to serve as medical director of breast imaging at both Bayshore and Riverview Medical Centers. So I am a radiologist specialized in early detection and diagnosis of breast cancer. And I thought I would spend this afternoon sharing with you what I have learned about breast cancer that you need to know. And the recent game changers that have really supported our mission to detect breast cancer in its earliest stages. So first and foremost, breast cancer is a global health problem. Why? Because it is the most common non-skin malignancy in women the American Cancer Society estimates that 2.3 million women will be diagnosed with breast cancer in the year 2023. Almost 230,000 in the United States. And for those of us privileged to live in the state of New Jersey, 8,330. That's also a significant cause of cancer related deaths, second to lung cancer. And you can see worldwide, almost 700,000 deaths per year, 40,000 in the United States and 1,250 in the state of New Jersey. And believe it or not, it is the most common cause of cancer related deaths in young women ages 29 to 59. And this is from the American Cancer Society just to point out, these are their breast cancer estimates for 2023. Breast cancer actually surpasses prostate cancer as being the most common cancer. And it is second beneath lung cancer as the leading cause of cancer related deaths. And in the United States, did you know that the state of New Jersey is a hotspot for breast cancer? It's in the top 10 states for the highest incidence of breast cancer for reasons that are uncertain at this time. And the Navy blue states are the other states as well. Breast cancer incidence and mortality is in this bar graph here, which is from the American Cancer Society. And it's a reminder of me to share with you that while white women have the highest incidence, greatest number of breast cancer, black women have the highest death rate of breast cancer. Why is this? Well, it may be multifactorial. And you can see in this graph comparing white women, black women and other races and ethnicities that in white women, 68% of the time, breast cancer is localized, while that number dips down to 57% in black women with more advanced cancers. And I will share with you that black women tend to have more aggressive tumors diagnosed at later stages and have a higher incidence of genetically predisposed. In other words, black women in Osco, Ashkenazi Jewish women have a greater incidence of certain mutations that they inherit that may predispose them to breast cancer. So here's the good news. Here's the optimistic side of me and the reason that I do what I do along with my team is that when breast cancer is detected early, it is highly curable. It is detected early in about 62% of cases. Look at the five year survival rate, 99%. When it is more advanced and in fact distant, that means metastatic breast cancer, the five year survival rate drops down to 27%. So we wanna catch it early. Early detection of breast cancer through screening paltz the natural progression of this disease, increases treatment options, many of which do not have a major impact on women's daily lives and livelihood and are well tolerated. And of course, our ultimate goal is to save lives. What is the screening test in the year 2023? It's still a mammogram, but it is a 3D mammogram. 3D mammograms are now the standard of care. There are few and far between centers that are still doing 2D. When you have your mammograms, certainly make sure it's a 3D mammogram. Mammograms have been proven and it's the only test proven to reduce deaths from breast cancer. Also it's appropriate for screening because mammograms are relatively inexpensive, quick to perform, safe and well tolerated. We're gonna talk about discomfort from a mammogram in a moment and accessible to large populations of women. So how do we prevent discomfort during a mammogram? Because we know women do experience pain and discomfort. And in fact, other women telling women that mammograms are painful may be an obstacle for a woman coming in for her mammogram. So here's a couple of tips that I thought I would share with you. First, if you're still getting your periods, schedule your mammogram during the first two weeks of your menstrual cycle before ovulation. Your breasts are less tender, less edematous during that time because there's less hormonal influence. If you're a woman who has sensitive and tender breast tissue, take Advil, Motrin or Aleve or Tylenol about an hour before your exam. When you get into the room, be as relaxed as possible. Take a deep breath as I did before this webinar and exhale, relax your muscles and be as relaxed as possible. It's really helpful also to wear a two-piece outfit. When you're having your mammograms, you can be covered up on the bottom and feel more comfortable. Trust your technologists. The technologists that do mammograms do it for a reason. They are dedicated and highly trained to do what they do. They're committed to taking care of other women. So know that you're in the best of hands and the new mammography units of which we have a unit at Bayshore and one at Riverview and very soon this year, all of our units have a curved compression paddle which is a bit more comfortable. So just some important tips. How do we know screening mammograms work? There is no other screening tests that has been proven and scrutinized like mammograms randomized control trials comparing large groups of women invited to be screened for a mammogram and those not invited to be screened and then comparing those women over the years to see their death rates from breast cancer. Not one, not two, not three, but seven of those studies have shown a reduction in deaths from breast cancer in women screen in the 25 to 52% range. Those are big numbers in the field of medicine. Very impactful. The estimated reduction in deaths from breast cancer due to screening in the United States is about 41% based on a meta-analysis study. Mammograms aren't perfect. No single screening test is perfect. What makes them so challenging? Unlike a chest X-ray or a head CT, there is no normal mammogram. There is an enormous variation of normal. I even recognize some patients just from their mammograms alone. A mammogram is like a thumbprint. No one has the exact same pattern and while we're screening for changes due to breast cancer, there's normal changes due to our ongoing cyclical, proliferative and involuntial changes that happen to our breasts. There's a marked variability and even subtle way in which breast cancers can show up on a mammogram. There are so many different types presenting in different ways. There's an overlap in appearance of normal benign changes and lesions in the breast and what could be the earliest start of breast cancer because we have pushed that threshold for early detection so low. Having dense fibrous breast tissue can obscure lesions and mammograms can be limited by that dense breast tissue and how complex the mammographic pattern is. And this is just an example of what different mammograms can look like from fatty tissue, where most of the tissue under the skin is dark, to average wispy breast tissue, to heterogeneously dense, patchy areas of fibrous white tissue, to extremely dense. So that's how variable mammograms can look. There's also limitations of screening. You might have heard mammograms being criticized due to false alarms. Women get recalled, many of us have, me included, and many women have biopsies that can lead to stress, anxiety, and cost, most of which are benign. You should know that if you get recalled because something's been found on a mammogram and that recall rate is 10 to 16%. So that's how many women we call back. The chances you will have breast cancer if you've been recalled are only 6.5%. Most of the time everything is normal. So that's a lot of anxiety. The chances you will have a breast cancer diagnosed if you have a biopsy is only 20%. So that's why mammograms are criticized and that's the price we pay for early detection. Of course, mammograms don't show everything and a missed breast cancer on a mammogram can lead to a delay in treatment. That does happen about six to 10% of the time you can have a normal mammogram where a breast cancer is not seen but you develop breast cancer within the year. That is the highest in women who are high risk and have dense breasts. About 20 to 30% of breast cancers may not be seen on a mammogram and these cancers tend to be the most aggressive. So I do wanna stress to everyone that having a negative mammogram is great news but it does not mean you do not have or will never have breast cancer. It means nothing concerning has been detected. So what are the current screening recommendations for those of us women at average risk? And by average risk, I mean being a woman and getting older with no major additional risk factors. There are different screening recommendations from different governing bodies and organizations putting value into the anxiety and stress caused by those false positive mammograms. And so that's why screening recommendations are slightly different, but here's the consensus. Here's what everyone agrees on. Having mammograms every year beginning at the age of 40 saves the most lives. That is a scientific proven fact. High risk women need to consider earlier screening and screening beyond a negative mammogram and some of the highest risk women are those with a family history of breast cancer in a first degree relative, those women who have had breast cancer themselves, those women who have had prior biopsies with atypia, those women who have had radiation of their chest due to Hodgkin's disease at a young age. And a risk assessment should be performed on all women at the age of 25, especially in women of Ashkenazi Jewish descent and in black women, why? Because as I told you earlier, there's a greater probability of a genetic predisposition for breast cancer. And we wanna start screening way earlier than 40. The American College of Radiology, the National Comprehensive Cancer Network, the American Society of Breast Disease, ACOG, American College of OBGYN, all recommend annual screenings starting at age 40. What percentage of women in New Jersey are up to date on their mammograms? I was curious about that and this is data from the New Jersey Department of Public Health. And you can see in the state of New Jersey, 23% of women are not up to date. They have not had a screening mammogram in a year or two years. And in mom of county where we all live, that number is 22%. We could do some improvement on that number. So tell your friends, your relatives to have their mammogram once a year. How do we break down obstacles and barriers and disparities to women coming in for potentially life-saving screening mammogram? You should all know in the state of New Jersey, you do not need a prescription for a mammogram because that's a barrier. You may not have a doctor. You may have a doctor, but you can't get an appointment for six months. And so you don't need a prescription. You can come in for a screening mammogram without one. We have started online scheduling this year because we're busy, we're working. We might not have time to be on the phone for 30 minutes to schedule a screening mammogram. You can now do it online at HMH. We have convenient hours so that women can come in before they go to work early in the morning, after work in the late afternoon and on Saturdays. For those women who don't speak English, we provide translation services. I see a lot of women on Saturdays. We open up Saturdays at Riverview to schedule women to come in for appointments when they need to see a doctor. And sometimes we have all of our Spanish-speaking women come in with our translators. And it's just a wonderful day. It makes them feel so comfortable that they can communicate in their language. I think ethnic and racial diversity amongst our care team members is something we need to work toward because that's how women will feel comfortable in our care. We have a pink fund from our foundation that supports screening mammograms and anything else that may be needed for women who don't have insurance or are underinsured. Of course, we all know it's anxiety provoking to come in to have a mammogram. I'm worried that we're gonna get a phone call and we're gonna be recalled. You can ask for your results. It's called a same-day read. Schedule your mammogram so that you can get your results the same day. I think timeliness of results is so important. We all know after you have a test, you are waiting for your results. You might not be able to sleep. So we try to read our screening mammograms definitely between 24 and 48 hours so you get your results. And we now allow you to schedule your next appointment or your way out the door. So you've already got that on your calendar way in advance. I thought I would share with you something that we've recently launched. We've launched online scheduling, but also we are now using our EPIC, our electronic health record to identify screening age women who need to schedule their screening mammograms and those women who are due for their mammograms, they're getting text messages with a link to our website so that they can schedule a mammogram. I got my text message last week and I scheduled my mammogram and you can see them when we launched that it's called a care gap closure campaign, leveraging EPIC. We had a peak in the women that called to schedule their screening mammogram. So ways in which we are breaking down barriers. I thought I would share with you also the latest advances in technologies for screening for breast cancer that are having the most important impact and that's going to be the next generation of 3D mammograms. I'm sure you've all heard of AI, artificial intelligence, it's everywhere. It's also here in the screening world, we are using AI to help us doctors do a better job detecting breast cancer and we're going to be launching risk reporting. So as I said, 3D mammograms are now the standard of care. Why? They're just a better mammogram at the same radiation dose. We are able to look at the breast, I have a little toggle button at one millimeter thin cuts. It really improves upon the major limitation of mammograms, overlapping tissue, which may obscure important findings or cause us to call back women unnecessarily. And it's really remarkable. I would have to say in my medical career, the 3D mammogram will be the number one, most important and most impactful technology that I will see why. It's led to 15 to 53% increase in our breast cancer detection rate and 15 to 37% decrease in our recall rate. Really remarkable technology. Then next generation is here. We've got units at Riverview and Beishra. And as I said, all of our units will be replaced to this latest technology. Very few centers have this next generation 3D mammography. It's higher resolution, higher contrast images. It's a more comfortable exam because of the curve paddle. And we've got the AI for computer aided detection. So I have to admit, I'm a human being. I'm the doctor reading many of your mammograms along with my colleagues. I am distracted, I get tired, I may miss things. Computers don't get tired. AI is a way of leveraging computers, technology, deep learning to do a very high level second read, marking things that the computer detects is abnormal. We think it's gonna have a really significant positive impact on our outcomes. So we're using that now. There's a new technology we launched at Riverview Medical Center, Contrast Enhanced Mammography. This uniquely combines the very high detailed images of a mammogram with contrast that's given by vein. What does contrast do? Well, when we fail to detect breast cancer, it's usually aggressive tumors and dense breasts. And the way to find those tumors, the most aggressive tumors, first thing they do is bring in abnormal vessels. It's called tumor neovascularity. Many, many vessels come in to provide oxygen, blood flow to rapidly growing tumors and those vessels are also leaky. So if we give contrast, we're able to image that abnormal vascularity. That's how MRI works. So contrast enhanced mammography is an alternative to MRI. Not everyone can have an MRI at a much lower imaging cost and shorter image time. You don't need pre-authorization. It's very inexpensive. It's a diagnostic mammogram with contrast. The radiation dose is very similar to a diagnostic mammogram and it's very well incorporated into our program. And just to give you an example of what a contrast enhanced mammogram looks like. And it's for a specific subset of women, but it's a mammogram and here's the regular mammogram that's given, that's done after a woman receives contrast. There's a low energy and high energy view. The low energy is just like regular mammogram. These, the higher energy shows the contrast enhancement and the subtraction image. And this is this image on the right shows what an abnormal enhancing mass looks like. And this is what a breast cancer would look like on a contrast enhanced mammogram. And you can see how difficult it is to see here and how conspicuous it is on this view. So that's how that works. It's similar to MRI in its diagnostic performance. It does find additional breast cancers about seven to 13 out of a thousand breast cancers compared to mammograms alone. And that's because we're adding contrast. Who should have a contrast enhanced mammogram? A specific subset of high risk women as I've talked to you about before, in women newly diagnosed with breast cancer, we're using it to assess extent of disease and those women getting chemotherapy to follow their response, problem solving. If you have a mammogram and it's not quite certain whether an asymmetry needs to be biopsied or not contrast can sometimes help. And as I said, it's an alternative to breast MRI when it's not possible for a woman to have one for various reasons. You have to have normal kidney function to have a contrast enhanced mammogram and you can't have a history of a reaction to the contrast that's given by vein. And I'm gonna talk about knowing your risk for breast cancer. Many women really don't know their risk but risk models are available that can help us actually give a number to a woman's lifetime risk for breast cancer. As you know, when you come in for your mammogram the technologist asks a whole list of questions related to risk. What do we do with that information? Well, right now not a lot but there are models that can incorporate all that data and give us your specific lifetime risk for breast cancer at this point of time when you come in the risk changes every year. So you need to have a risk assessment every year. We are gonna be incorporating this into your mammography report after January at HMH and models incorporate your current age, family history of breast and ovarian cancer, reproductive history. It's important to know if you had children or not at what age? When did you start having your period? When did you go through menopause? This all factors into risk. Your biopsy history, your BMI and your breast density because having more fibrous dense breast tissue is a risk factor for breast cancer. That allows us to report your lifetime risk which can then proactively identify women at high risk. And those are women that have a lifetime risk of greater than 20% and those women who should see a genetic counselor because they have a significant chance of having a hereditary predisposition to breast cancer. It also very importantly informs what I call risk-based personalized screening. For some women having a mammogram alone once a year is sufficient. For some women, particularly those with dense breasts, it may be a mammogram plus an ultrasound. And for our highest risk women, it may be a mammogram staggered with MRI at six month intervals. How do we know? We know based on the lifetime risk. It also informs appropriate referrals for genetic counseling. It complies with new insurance authorization requirements. When your doctor recommends an MRI, the insurance company, in order to authorize it, it wants to know your lifetime risk for breast cancer. And it bottom line, it improves the quality of care in early detection and even prevention of breast cancer. So a risk assessment for breast cancer should be done and it should be performed in all women by the age of 25 because in certain women who have a genetic predisposition, we're screening them with MRI starting at 25 to 30. And at 30, we start doing mammograms and then we stagger MRIs with mammograms. So you gotta know your risk. Can we modify our risk for breast cancer? What can we do to help ourselves? Well, there are certain things you can't change. We can't change that we're getting older. We can't change our family history. We can't change our reproductive history but we can lead healthier lives. We can maintain a healthy body weight. Being obese, particularly after menopause, is a significant risk factor for breast cancer. A study showed that a five kilogram per meter squared increase in body weight is associated with a 12% increase in breast cancer risk and a breast cancer surveillance consortium study that was published showed that breast cancer would be reduced by 16% if all women achieved a BMI of less than 25. So we need to be cognizant about this and body weight is very important for risk. We should also limit our alcohol intake. The 2008 nurses health study showed that there is definitely a relationship between alcohol consumption and breast cancer and engage in physical activity regularly. A meta-analysis of 139 studies found that regular physical activity reduced the breast cancer risk by 22%. So, and there was a recent study published that if you adopt all of these three prevention strategies, if you maintain a healthy body weight, limit your alcohol intake and engage in physical activity, you can reduce your breast cancer risk by 22%. So things we can do. And this is just to brochure that we have what you can do to reduce your breast cancer risk, all of these things that we just talked about. And lastly, I'm gonna end with really important information that you all need to know where you have your mammogram matters. It really does. You wanna go to an ACR, that's the American College of Radiology, designated comprehensive breast imaging center. These are centers that have been accredited for mammograms, for ultrasounds, and for biopsies and MRI. That means they have met the highest criteria for quality. You wanna go to a center like this because the dedicated team, and by that I mean the front office staff, the nurses, the technologists and the doctors are all specialized and experienced in breast imaging and compassionate care. You wanna have access to not just the very breast mammogram, you may need an ultrasound, you may need an MRI, you may need a contrast enhanced mammogram. That's called multi-modality screening. If you need to have a biopsy, these centers do minimally invasive breast biopsies and have access to a team of specialized physicians. If you are diagnosed with something pre-cancerous or cancerous, we've got a wonderful team of genetic counselors, breast surgeons, radiation oncologists, oncologists, and nurse navigators. And very importantly, and not to be underestimated, continuity of care is really important. Thank you very much.